Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

What is a Free State? Republican Internationalism and Globalisation

This article addresses an underexplored area of investigation within the global justice debate: To what extent does globalisation structurally undermine the freedom of states? And if it does, what type of injustice does this constitute? It is argued here that a republican theory of freedom as non-domination is better equipped than existing cosmopolitan and social liberal accounts to explain the systemic connections between domestic, international and global injustice. The forms of unchecked power that globalisation sets off create new opportunities for the domination of states – by other states as well as by non-states actors. And when citizens live in dominated states, they are themselves exposed to domination. The upshot is a normative analysis of the global arena that attributes a central role to states, yet is deeply critical of the status quo. </jats:p

Correction: Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico.

[This corrects the article DOI: 10.1371/journal.pone.0184540.]

Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico

<div><p>Background</p><p>No study has estimated the potential impact of Human Papillomavirus (HPV) vaccination in Puerto Rico, a population with considerable burden of HPV-related morbidities. We evaluated the health and economic impacts of implementing a vaccination strategy for females and males in Puerto Rico, with the quadrivalent HPV (HPV4) vaccine, under different vaccination scenarios.</p><p>Methods</p><p>We adapted a mathematical model which estimates the direct and indirect health benefits and costs of HPV4 vaccination in a dynamic population. The model compared three vaccination scenarios against screening only (no-vaccination) for three doses of HPV4 vaccine among individuals aged 11–15 years in Puerto Rico: 1) 34% for females and 13% for males (34%F/13%M), 2) 50% for females and 40% for males (50%F/40%M), and 3) 80% for female and 64% for male (80%F/64%M). Data specific to Puerto Rico was used. When not available, values from the United States were used. Input data consisted of demographic, behavioral, epidemiological, screening, and economic parameters.</p><p>Results</p><p>The model predicted decreases in: 1) HPV infection prevalence for females and males, 2) cervical intraepithelial neoplasia and cervical cancer incidence for females, 3) genital warts incidence for females and males, and 4) cervical cancer deaths among females, when various vaccination program scenarios were considered. In addition, when the vaccination percentage was increased in every scenario, the reduction was greater and began earlier. The analysis also evidenced an incremental cost effectiveness ratio (ICER) of $1,964 per quality–adjusted life year gained for the 80%F/64%M uptake scenario.</p><p>Conclusions</p><p>HPV vaccine can prove its cost effectiveness and substantially reduce the burden and costs associated to various HPV-related conditions when targeted to the adequate population together with an organized HPV vaccination program.</p></div

Estimated cumulative incidence costs avoided since HPV4 vaccination program started, by vaccination scenario.

<p>Estimated cumulative incidence costs avoided since HPV4 vaccination program started, by vaccination scenario.</p

Estimated HPV 6/11 related incidence of genital warts among females over 100 years, by vaccination scenario.

<p>Estimated HPV 6/11 related incidence of genital warts among females over 100 years, by vaccination scenario.</p

Estimated HPV 6/11 related incidence of genital warts among males over 100 years, by vaccination scenario.

<p>Estimated HPV 6/11 related incidence of genital warts among males over 100 years, by vaccination scenario.</p

Estimated HPV 16/18 related cervical cancer deaths among females over 100 years, by vaccination scenario.

<p>Estimated HPV 16/18 related cervical cancer deaths among females over 100 years, by vaccination scenario.</p

Estimated HPV 16/18 related incidence of CIN 2/3 among females over 100 years, by vaccination scenario.

<p>Estimated HPV 16/18 related incidence of CIN 2/3 among females over 100 years, by vaccination scenario.</p