Respiratory Tract Infections in Children with Down's Syndrome

BACKGROUND: Children with Down’s Syndrome (DS) are prone to respiratory tract infections (RTIs), yet there is little evidence to guide clinical practice. AIMS: For children with and without DS, this thesis aims to use routinely collected data to identify RTI-related healthcare utilisation, those most at risk of RTI-related healthcare utilisation, and the effects of antibiotics in preventing RTI-related hospitalisation. METHODS: A systematic review of existing interventions and a retrospective cohort study based on routinely collected primary and secondary care data (CALIBER). KEY FINDINGS: The CALIBER cohort comprised 992 children with DS and 4874 controls. Children with DS consulted their GP for RTIs twice as often as controls, were prescribed antibiotics twice as often, and were hospitalized six times as often. In children with DS, younger age, congenital heart disease and asthma were risk factors for RTI-related healthcare utilisation. Using multivariate analysis, this study found that for infants with DS, the prescription of antibiotics significantly reduced subsequent RTI-related hospitalisation - the number needed to treat is 11.9. Separate analysis, inverse probability of treatment weighting, found that the protective effect for infants with DS was not significant. When prescriptions were analysed by type of RTI, the prescription of antibiotics for upper RTIs did not reduce the risk of hospitalization for children with DS or controls. This was also the case for lower RTIs, although with a small sample. CONCLUSION: For children with DS over the age of one presenting with RTIs to primary care, antibiotic treatment does not prevent subsequent RTI-related hospitalisation. There is conflicting evidence from two separate analysis methods as to whether treating infants with DS with antibiotics prevents RTI-related hospitalisation, so further research is recommended. Further prescribing strategies (i.e. rescue antibiotics) should be explored to broaden the evidence base for this at-risk group

Ethnic differences in multimorbidity after accounting for social-economic factors, findings from The Health Survey for England

BACKGROUND: Social-economic factors and health behaviours may be driving variation in ethnic health inequalities in multimorbidity including among distinct ethnic groups. METHODS: Using the cross-sectional nationally representative Health Surveys for England 2011-18 (N = 54 438, aged 16+), we performed multivariable logistic regression on the odds of having general multimorbidity (≥2 longstanding conditions) by ethnicity [British White (reference group), White Irish, Other White, Indian, Pakistani, Bangladeshi, Chinese, African, Caribbean, White mixed, Other Mixed], adjusting for age, sex, education, area deprivation, obesity, smoking status and survey year. This was repeated for cardiovascular multimorbidity (N = 37 148, aged 40+: having ≥2 of the following: self-reported diabetes, hypertension, heart attack or stroke) and multiple cardiometabolic risk biomarkers (HbA1c ≥6.5%, raised blood pressure, total cholesterol ≥5mmol/L). RESULTS: Twenty percent of adults had general multimorbidity. In fully adjusted models, compared with the White British majority, Other White [odds ratio (OR) = 0.63; 95% confidence interval (CI) 0.53-0.74], Chinese (OR = 0.58, 95% CI 0.36-0.93) and African adults (OR = 0.54, 95% CI 0.42-0.69), had lower odds of general multimorbidity. Among adults aged 40+, Pakistani (OR = 1.27, 95% CI 0.97-1.66; P = 0.080) and Bangladeshi (OR = 1.75, 95% CI 1.16-2.65) had increased odds, and African adults had decreased odds (OR = 0.63, 95% CI 0.47-0.83) of general multimorbidity. Risk of cardiovascular multimorbidity was higher among Indian (OR = 3.31, 95% CI 2.56-4.28), Pakistani (OR = 3.48, 95% CI 2.52-4.80), Bangladeshi (OR = 3.67, 95% CI 1.98-6.78), African (OR = 1.61, 95% CI 1.05-2.47), Caribbean (OR = 2.18, 95% CI 1.59-2.99) and White mixed (OR = 1.98, 95% CI 1.14-3.44) adults. Indian adults were also at risk of having multiple cardiometabolic risk biomarkers. CONCLUSION: Ethnic inequalities in multimorbidity are independent of social-economic factors. Ethnic minority groups are particularly at risk of cardiovascular multimorbidity, which may be exacerbated by poorer management of cardiometabolic risk requiring further investigation

Mapping Two Decades of Paediatric Down Syndrome Research Literature

BACKGROUND: While research has led to significant advancements in the health and life expectancy of children with Down Syndrome (DS), there remains a significant burden of disease and health inequity. Further research, focused on areas of greatest need, is imperative to address this. An understanding of what research has been undertaken, and any existing gaps, helps to guide future academic efforts. METHODS: We utilised an epistemological approach to summarise two decades of paediatric DS literature. Publications were categorised according to the country of origin, methodology, primary health themes and subcategory research themes. RESULTS: Across 5,800 paediatric DS publications we demonstrate a general increase in the number of publications in this field between 2000 and 2014, with a trending decline thereafter. The majority of publications were affiliated with Institutions based in Western countries. The majority of studies utilised a cross-sectional methodology (33.3%), while relatively few were interventional (5.6%), qualitative (2.7%) or mixed-method studies (1.6%). Most publications focused on development & cognition (13.1%), neurology (9.9%) and oncology (9.8%), with fewer focusing on genitourinary health (0.9%), growth (0.9%), mortality (0.9%) and child protection (0.2%). CONCLUSION: These findings highlight areas of relative paucity within the paediatric DS literature which may warrant increased academic attention

Exploring the third delay: an audit evaluating obstetric triage at Mulago National Referral Hospital

BACKGROUND: Mulago National Referral Hospital has the largest maternity unit in sub-Saharan Africa. It is situated in Uganda, where the maternal mortality ratio is 310 per 100,000 live births. In 2010 a ‘Traffic Light System’ was set up to rapidly triage the vast number of patients who present to the hospital every day. The aim of this study was to evaluate the effectiveness of the obstetric department’s triage system at Mulago Hospital with regard to time spent in admissions and to identify urgent cases and factors adversely affecting the system. METHODS: A prospective audit of the obstetric admissions department was carried out at the Mulago Hospital. Data were obtained from tagged patient journeys using two data collection tools and compiled using Microsoft Excel. StatsDirect was used to compose graphs to illustrate the results. RESULTS: Informal triage was occurring 46 % of the time at the first checkpoint in a woman’s journey, but the ‘Traffic Light System’ was not being used and many of the patient’s vital signs were not being recorded. CONCLUSIONS: It is hypothesised that the ‘Traffic Light System’ is not being used due to its focus on examination finding and diagnosis, implying that it is not suitable for an early stage in the patient’s journey. Replacing it with a simple algorithm to categorise women into the urgency with which they need to be seen could rectify this

The Use of Digital Technology for COVID-19 Detection and Response Management in Indonesia: Mixed Methods Study

BACKGROUND: The COVID-19 pandemic has triggered the greater use of digital technologies as part of the healthcare response in many countries, including in Indonesia. OBJECTIVE: The objective of our study was to identify and review the use of digital health technologies in COVID-19 detection and response management in Indonesia. It is the world's fourth most populous nation, and Southeast Asia's most populous country, with considerable public health pressures. METHODS: This paper conducted a literature review of publicly accessible information in technical and scientific journals, as well as news articles between September 2020 to August 2022 to identify the use case examples of digital technologies in COVID-19 detection and response management in Indonesia. RESULTS: The results are presented into three groups, namely (i) Big Data, Artificial Intelligence and Machine Learning (technologies for the collection and/or processing of data); (ii) Healthcare System Technologies (acting at the public health level); and (iii) Population Treatment (acting at the individual patient level). Some of these technologies are the result of government-academia-private sector collaborations during the pandemic, which represent a novel, multi-sectoral practice in Indonesia within the public healthcare ecosystem. A small number of the identified technologies pre-existed the pandemic, but were upgraded and adapted for the current needs. CONCLUSIONS: Digital technologies were developed in Indonesia during the pandemic, with a direct impact in supporting the COVID-19 management, detection, response, and treatment. They addressed different areas of the technological spectrum, and with different levels of adoption, ranging from local, regional to national. The indirect impact from this wave of technological creation and use, is to provide a strong foundation for fostering future multi-sectoral collaboration within the national healthcare system of Indonesia

COVID-19 & informal settlements: is ‘Stay Home’ safe?

The disproportional burden of coronavirus (COVID-19) and vulnerability to containment measures in informal settlements have been recognised; however, the role of poor housing conditions in propagating these remains neglected. Poor housing conditions makes it difficult to effectively implement social distancing measures. With increased time spent in cramped, dark and uncomfortable indoor environments, water and sanitation outside the home, and no outdoor space, higher exposure to existing health hazards and high levels of stress, with women and children being most vulnerable, are anticipated. Through this commentary paper, we reflect on these interconnections and recommend immediate measures and the long-term need for adequate housing for health and well-being

Participatory learning and action (PLA) to improve health outcomes in high-income settings: a systematic review protocol

Introduction: Participatory learning and action (PLA) is a form of group reflection and learning with documented efficacy in low-income countries to improve social and health outcomes. PLA represents both a learning philosophy and a practical framework that could be applied to a variety of contexts. To date, PLA has not been widely implemented within high-income countries (HICs) to improve health and health-related outcomes. We aim to synthesise the literature currently available by means of a systematic review to form a foundation for future applications of PLA methodology in HICs. Methods and analysis: Two reviewers will independently search predefined terms in the following electronic bibliographic databases: MEDLINE, EMBASE, CINAHL and Cochrane Library. The search terms will encompass PLA and PDSA (Plan-Do-Study-Act) projects, as well as studies using the Triple/Quadruple Aim model. We will include randomised controlled trials that incorporate online or face-to-face components using the PLA/PDSA methodology. Our data will be extracted into a standardised prepiloted form with subsequent narrative review according to the SWiM (Synthesis Without Meta-Analysis) guidelines. Ethics and dissemination: No ethics approval is required for this study. The results of this study will be submitted for publication in a leading peer-reviewed academic journal in this field. Additionally, a report will be produced for the funders of this review, which can be viewed for free on their website

Antibiotic prescribing in patients with self-reported sore throat.

Objectives: To investigate the predictors of general practitioner (GP) consultation and antibiotic use in those developing sore throat. Methods: We conducted a prospective population-based cohort study on 4461 participants in two rounds (2010-11) from 1897 households. Results: Participants reported 2193 sore throat illnesses, giving a community sore throat incidence of 1.57/ person-year. 13% of sore throat illnesses led to a GP consultation and 56% of these consultations led to antibiotic use. Participants most likely to have sore throats included women and children (e.g. school compared with retirement age); adjusted incidence rate ratio (aIRR) of 1.33 and 1.52, respectively. Participants with sore throat were more likely to consult their GP if they were preschool compared with retirement age [adjusted OR (aOR) 3.22], had more days of sore throat (aOR 1.11), reported more severe pain (aOR 4.24) or reported fever (aOR 3.82). Antibiotics were more often used by chronically ill individuals (aOR 1.78), those reporting severe pain (aOR 4.14), those reporting fever (aOR 2.58) or children with earache (aOR 1.85). Among those who consulted, males and adults who reported feeling anxious were more likely to use antibiotics; aOR 1.87 and 5.36, respectively. Conclusions: Only 1 in 10 people who have a sore throat see a doctor and more than half of those attending get antibiotics. Further efforts to curb antibiotic use should focus on reducing initial GP consultations through public information promoting safe self-management, targeted at groups identified above as most likely to attend with sore throats

Building on health security capacities in Indonesia: Lessons learned from the COVID-19 pandemic responses and challenges

As an active member country of the WHO's International Health Regulation and Global Health Security Agenda, Indonesia, the world's fourth-most populous and largest archipelagic country has recorded the second-highest COVID-19 cases in Asia with over 1.8 million cases in early June 2021. This geographically and socially diverse country has a dynamic national and sub-national government coordination with decentralized authorities that can complicate a pandemic response which often requires nationally harmonized policies, adaptability to sub-national contexts and global interconnectedness. This paper analyses and reviews COVID-19 public data, regulations, guidance documents, statements and other related official documents to present a narrative that summarizes the government's COVID-19 response strategies. It further analyses the challenges and achievements of the country's zoonotic diseases preparedness and responses and lastly provides relevant recommendations. Findings are presented in four sections according to the Global Health Security Agenda capacities, namely epidemiological surveillance (detect capacity); laboratory diagnostic testing (respond capacity); data management and analysis (enable capacity); and the role of sub-national governments. The COVID-19 pandemic has been a catalyst for the rapid transformation of existing surveillance systems, inter-related stakeholder coordination and agile development from the pre-pandemic health security capacities. This paper offers several recommendations on surveillance, laboratory capacity and data management, which might be useful for Indonesia and other countries with similar characteristics beyond the COVID-19 response, such as achieving long-term health security, zoonoses and pandemic prevention, as well as a digital transformation of their governmental capacities

Building referral mechanisms for neonatal care in humanitarian emergency settings: A systematic review

AIM: During humanitarian emergencies, women and children are particularly vulnerable to health complications and neonatal mortality rates have been shown to rise. Additionally, health cluster partners face challenges in coordinating referrals, both between communities and camps to health facilities and across different levels of health facilities. The purpose of this review was to identify the primary referral needs of neonates during humanitarian emergencies, current gaps and barriers, and effective mechanisms for overcoming these barriers. METHODS: A systematic review was performed using four electronic databases (CINAHL, EMBASE, Medline, and Scopus) between June and August 2019 (PROSPERO registration number CRD42019127705). Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was neonates born during humanitarian emergencies. Studies from high-income countries and prior to 1991 were excluded. The STROBE checklist was used to assess for risk of bias. RESULTS: A total of 11 articles were included in the analysis; these were mainly cross-sectional, field-based studies. The primary needs identified were referrals from homes to health facilities before and during labour, and inter-facility referrals after labour to more specialised services. Some of the main barriers included a lack of roads and infrastructure for transport, staff shortages-especially among more specialised services, and a lack of knowledge among patients for self-referral. Mechanisms for addressing these needs and gaps included providing training for community healthcare workers (CHWs) or traditional birth attendants to identify and address antenatal and post-natal complications; education programmes for pregnant women during the antenatal period; and establishing ambulance services in partnership with local Non-Governmental Organizations. CONCLUSION: This review benefited from a strong consensus among selected studies but was limited in the quality of data and types of data that were reported. Based on the above findings, the following recommendations were compiled: Focus on local capacity-building programmes to address programmes acutely. Recruit CHWs to raise awareness of neonatal complications among pregnant women. Upskill CHWs to provide timely, appropriate and quality care during humanitarian emergencies