Malaria Control Strategies in the Kilombero Valley, Tanzania

Malaria is major public health problem in Tanzania and increasing trends have been observed in the last two decades. A significant consequence of repeated malaria infections in high transmission areas is anaemia in very young children. The control of malaria in Tanzania includes both preventive and curative strategies. On the preventive side insecticide treated bed nets (ITNs) are a promising tool. ITNs have been shown to be effective in reducing malaria morbidity and mortality in controlled trials. Large-scale implementation of the technology is currently being initiated in many African countries. We report the impact of a large social marketing programme of ITNs on malaria morbidity through a series of studies, in a population of about 55,000 people in Tanzania. The ITNs social marketing programme resulted in a rapid increase in any net ownership (from 58 to 83%) and an increase in ITNs ownership (from 10 to 61%) in children under two years of age within 2 years of implementation. As a result the overall mean haemoglobin levels increased (from 8.0 to 8.9 g/dl) in the study children during the successive surveys. The prevalence of anaemia in the study population decreased from 49% to 26%. Comparison between children with ITNs and those without nets showed that ITNs had a protective efficacy of 63% (95% CI: 38 to 77) on the prevalence of parasitaemia, and 63% (95% CI: 27 to 82) on anaemia (haemoglobin £ 8 g/dl). These results endorse the wide scale implementation of ITNs in Tanzania. ITNs can only reduce the risk of malaria dis ease but cannot eliminate it. Hence, appropriate effective treatment is required. Chloroquine is a cheap and safe antimalarial and it was until recently the first line drug of choice in the National Malaria Treatment Policy. Resistance to chloroquine has been reported with increasing frequency in Tanzania and has been linked to the increasing admissions with severe disease in hospitals. A comparative randomised, open clinical trial of chloroquine against Co-artemâ (fixed combination of Artemether + Benflumetol) an alternative new antimalarial, showed seven-day parasitological cure rates of 94% for Co-artemâ and only 35% for chloroquine. Generally, Co-artemâ showed a superior clearance rate, successfully cleared higher parasite densities and suppressed new infections over a longer period of time. Furthermore, Co-artemâ suppressed more effectively gametocytes in these children, indicating a potential benefit for reducing malaria transmission. The unacceptably high chloroquine failure rates call for an urgent review of the National Malaria Treatment Guidelines. The decision to change the first line antimalarial and the choice of a new drug depend on a number of factors that include the clinical, epidemiological and social-economical factors, as well as the health infrastructure. Considering all of these dimensions, sulphadoxinepyrimenthamine (SP) was identified as a good interim replacement for chloroquine. Further Phase IV evaluation of Co-artemâ and other combination therapy regimens are required before considering their inclusion in the national treatment policy. Much work is also needed to identify suitable compounds to be used for home management of malaria, within the national treatment guidelines. Experience gained with these studies gives a description of the different methodologies and tools that can be used to evaluate different components of the National Malaria Control Programme. For example, it was difficult to assess the impact of the ITNs programme using the case-control approach. Repeated cross-sectional assessments were found to be more suitable for assessing the impact of ITNs under programme conditions, especially on malariarelated anaemia in this area of high transmission. Specific indicators for programme evaluation may need to be identified for specific interventions. These may be different from the ones used in randomised controlled trials. The use of molecular markers for monitoring and evaluation of antimalarial intervention programmes illustrate the need to develop and validate novel tools and approaches for programme evaluation. Better malaria control is expected by combining ITNs and an effective antimalarial, especially combination therapy. The evaluation, implementation, and monitoring of all these control activities requires a partnership between researchers, policy makers, health managers, in close collaboration with other stakeholders in the public and private domain, including the beneficiaries - the community

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

A multinational Delphi consensus to end the COVID-19 public health threat

Despite notable scientific and medical advances, broader political, socioeconomic, and behavioural factors continue to undercut the response to the coronavirus disease 2019 (COVID-19) pandemic1,2. This Delphi study convened a diverse, multidisciplinary panel of 386 academic, health, NGO, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global public health threat. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry, and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of ragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches1, while maintaining proven prevention measures using a vaccines-plus approach2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust, and engage communities3 in the management of pandemic responses. The findings of the study, which have been further endorsed by organisations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help bring this public health threat to an end

A multinational Delphi consensus to end the COVID-19 public health threat

Abstract Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic 1,2 . Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches 1 , while maintaining proven prevention measures using a vaccines-plus approach 2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities 3 in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end

A multinational Delphi consensus to end the COVID-19 public health threat

Abstract Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic . Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches , while maintaining proven prevention measures using a vaccines-plus approach that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end

A multinational Delphi consensus to end the COVID-19 public health threat

Abstract Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic 1,2 . Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches 1 , while maintaining proven prevention measures using a vaccines-plus approach 2 that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities 3 in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end