Synthesis of Ce/Ru Doped ZnO photocatalysts to the degradation of emerging pollutants in wastewater

Semiconductor nanoparticles (NPs) and nanowires (NWs) of doped ZnO system with different dopant content have been synthesized by Polyol-Mediated Thermolysis (PMT) process and Vapour-Solid (VS) reaction. The average crystallite size, morphology, specific surface area, and direct band gap have been evaluated. The structural and functional characteristics have been studied by X-Ray Diffraction techniques (XRD), Field Emission Scanning Electron Microscope (FESEM), High Resolution Transmission Electron Microscopy (HRTEM), Brunauer, Emmett and Teller (BET) method, UV-Vis Diffuse Reflectance Spectra (DRS), UV-Vis Spectroscopy, and Photoluminescence measurements (PL). Also, the photocatalytic activities of pure and doped ZnONPs were evaluated by removal rate of Methylene Blue (MB) under UV irradiation (365 nm) at room temperature. XRD patterns revealed the common hexagonal ZnO Wurtzite-type structures with a preferred orientation of (101) plane. Secondary phases as CeO2, Ce2O3, Ce, RuO2, Ru3O4, Ruhave been identified. For both dopant, Ceand Ru, and for all the concentrations in the precursor solution, FESEM and HRTEM showed NPswith morphologies ranging from spherical/ellipsoidal to hexagonal. The size of NPs was observed to decrease (from ~30 to ~16 nm) with increasing doping concentration due to the interaction between the Ce-O-Zn or Ru-O-Zn ions. EDS results confirmed the incorporation of Ce or Ru ions into ZnO lattice.Using the Kubelka-Munk treatment on the diffuse reflectance spectra, the direct band gap energy has been estimated to be slightly lower than 3.0 eV in both, the Ce and Ru-doped samples. Compared with pure ZnO NPs, the PL spectra of the doped NPs showed red-shifted UV emission and an enhanced blue emission with the typical broad green-yellow emission. The results showed that photocatalytic efficiency of doped ZnO NPs was always enhanced

Characteristics associated with depression, anxiety, and stress in university students

Introducción: La presente investigación se enfocó en analizar las características asociadas a la depresión, ansiedad y estrés en estudiantes universitarios en tiempos de pandemia COVID-19. Método: El estudio fue de diseño no experimental, correlacional, prospectivo y de corte transversal. La técnica de recolección de datos fue la encuesta, y su instrumento el cuestionario DASS-21, el cual cuenta con una confiabilidad muy buena de 0.91. Este ha sido aplicado a 385 estudiantes universitarios peruanos, de manera virtual. Resultados: Los resultados indican que de los estudiantes encuestados, un 12% de ellos presentan estrés alto, 7% ansiedad severa y 9% depresión severa. Dentro de los factores que se asociaron al estrés encontramos la edad, la carrera previa, el contar con trabajo, tener enfermedad crónica; la ansiedad tuvo factores asociados como edad, tener una carrera previa, estado laboral y diagnóstico de una enfermedad crónica; la depresión tuvo factores asociados como edad, el tener hijos, con una carrera previa, conexión de internet, tener trabajo, el haber sido diagnosticado con una enfermedad crónica, el tener un familiar o persona cercana con COVID-19 y finalmente el que alguien cercano haya fallecido. Conclusión: Se estimaron 3 modelos de regresión logística con 77.3%, 68.2% y 63.3% de certeza para estrés, ansiedad y depresión respectivamenteIntroduction: The present research focused on analyzing the characteristics associated with depression, anxiety and stress in university students in times of COVID-19 pandemic, Method: The study had a non-experimental, correlational, prospective, cross-sectional design. The data collection technique was the survey, and its instrument was the DASS-21 questionnaire, which has a very good reliability of 0.91. It has been applied virtually to 385 Peruvian university students. Results: The results show that 12% of the students surveyed presented high stress, 7% severe anxiety and 9% severe depression. Among the factors associated with stress were age, previous major, having a job, having a chronic disease. Anxiety had associated factors such as age, having a previous career, work status and diagnosis of a chronic disease. Depression was associated with factors such as age, having children, having a previous major, internet connection, having a job, having been diagnosed with a chronic disease, having a family member or a close person with COVID-19, and finally having someone close who had passed away. Conclusion: Three logistic regression models were estimated with 77.3%, 68.2% and 63.3% certainty for stress, anxiety and depression, respectively

Valorización de empresas Enel Distribución Perú S.A.A y Luz del Sur S.A.A

El sector eléctrico es un componente muy importante para el crecimiento de todo país pues ello implica que muchas actividades económicas requieran de electricidad para sus procesos productivos logrando impulsar el desarrollo del país. Además, aquellos servicios también son indispensables para las poblaciones ya que generan mejoras en la calidad de vida pues permite una mejor asistencia sanitaria, educativa, de telecomunicación entre otros. De ahí que haya una fuerte relación entre este sector y el crecimiento de un país. En el Perú, este sector tuvo una notable transformación con las reformas de políticas de liberalización de la economía donde el enfoque se centró en regulaciones en el que se logren la eficiencia energética, es decir mercados competitivos con una buena regulación del monopolio natural de este servicio, que incrementen las inversiones privadas y se logren tarifas eficientes para todos los sectores económicos y usuarios finales. Así, el sector eléctrico peruano a lo largo de los últimos años ha mantenido un crecimiento sostenible destacable para el progreso del país. El subsector de distribución eléctrica peruana opera bajo el régimen de monopolio natural y con concesiones de plazo indeterminado, con lo que les permite ejercer inversiones en desarrollos e infraestructura a largo plazo. Para el presente trabajo de investigación se ha seleccionado dos empresas líderes del sector eléctrico en distribución que son: Enel Distribución Perú S.A.A. y Luz del Sur S.A.A., quienes mantienen el respaldo de sus casas matriz que también son líderes en Europa y Asia, con el objetivo de realizar un análisis financiero y valorización comparativa entre las empresas, ambas con cotizaciones en la Bolsa de Valores de Lima. Dicho estudio comprende el análisis de los últimos 5 años y se realizó una proyección del valor de estas empresas. Basado en esa información se establecieron los supuestos adecuados para realizar la proyección de Estado de Resultados y el Estado de Situación Financiera para los siguientes cinco años (2023 – 2027). Asimismo, se utilizó el método de flujos descontados para determinar el valor de cada compañía en base a los estados financieros y finalmente, se realizó un análisis de sensibilidad mediante la evaluación de escenarios pesimistas y optimistas, el cual asumió variaciones en los niveles de consumo de GWh, pues al ser un subsector de distribución de energía se considera como la única variable relevante en el impacto de valoración para ambas empresas ya que estos niveles de consumo están sujetas a las variaciones del mercado.The electrical sector is a very important component for the growth of any country since this implies that many economic activities require electricity for their production processes, thus promoting the development of the country. In addition, those services are also essential for the population since they generate improvements in the quality of life as it allows for better healthcare, education, telecommunications, among others. Hence there is a strong relationship between this sector and the growth of a country. In Peru, this sector had a notable transformation with the policy reforms of liberalization of the economy where the focus was centered on regulations in which energy efficiency is achieved, that is, competitive markets with good regulation of natural monopolies of this service, that private investments increase and efficient rates are achieved for all economic sectors and end users. Thus, the Peruvian electricity sector throughout recent years has maintained remarkable sustainable growth for the progress of the country. The Peruvian electricity distribution subsector operates under a natural monopoly regime and with indefinite-term concessions, which allows them to invest in long-term developments and infrastructure. For this research work, two leading companies in the electrical distribution sector have been selected: Enel Distribución Perú S.A.A. and Luz del Sur S.A.A., who maintain the support of their parent companies that are also leaders in Europe and Asia, with the objective of carrying out a financial analysis and comparative valuation between the companies, both with listings on the Lima Stock Exchange. This study includes the analysis of the last 5 years and a projection of the value of these companies. Based on this information, reasonable assumptions were established to carry out the projection of the Income Statement and the Balance Sheet for the next five years (2023 – 2027). Likewise, the discounted cash flow method was used to determine the value of each company based on the financial statements and finally, a sensitivity analysis was carried out by evaluating pessimistic and optimistic scenarios, which assumed variations in the consumption levels of GWh. Given the fact that it is an energy distribution subsector, GWh is considered the only relevant variable in the valuation for both companies since these consumption levels are subject to market variations

Valorización de empresas Enel Distribución Perú S.A.A y Luz del Sur S.A.A

El sector eléctrico es un componente muy importante para el crecimiento de todo país pues ello implica que muchas actividades económicas requieran de electricidad para sus procesos productivos logrando impulsar el desarrollo del país. Además, aquellos servicios también son indispensables para las poblaciones ya que generan mejoras en la calidad de vida pues permite una mejor asistencia sanitaria, educativa, de telecomunicación entre otros. De ahí que haya una fuerte relación entre este sector y el crecimiento de un país. En el Perú, este sector tuvo una notable transformación con las reformas de políticas de liberalización de la economía donde el enfoque se centró en regulaciones en el que se logren la eficiencia energética, es decir mercados competitivos con una buena regulación del monopolio natural de este servicio, que incrementen las inversiones privadas y se logren tarifas eficientes para todos los sectores económicos y usuarios finales. Así, el sector eléctrico peruano a lo largo de los últimos años ha mantenido un crecimiento sostenible destacable para el progreso del país. El subsector de distribución eléctrica peruana opera bajo el régimen de monopolio natural y con concesiones de plazo indeterminado, con lo que les permite ejercer inversiones en desarrollos e infraestructura a largo plazo. Para el presente trabajo de investigación se ha seleccionado dos empresas líderes del sector eléctrico en distribución que son: Enel Distribución Perú S.A.A. y Luz del Sur S.A.A., quienes mantienen el respaldo de sus casas matriz que también son líderes en Europa y Asia, con el objetivo de realizar un análisis financiero y valorización comparativa entre las empresas, ambas con cotizaciones en la Bolsa de Valores de Lima. Dicho estudio comprende el análisis de los últimos 5 años y se realizó una proyección del valor de estas empresas. Basado en esa información se establecieron los supuestos adecuados para realizar la proyección de Estado de Resultados y el Estado de Situación Financiera para los siguientes cinco años (2023 – 2027). Asimismo, se utilizó el método de flujos descontados para determinar el valor de cada compañía en base a los estados financieros y finalmente, se realizó un análisis de sensibilidad mediante la evaluación de escenarios pesimistas y optimistas, el cual asumió variaciones en los niveles de consumo de GWh, pues al ser un subsector de distribución de energía se considera como la única variable relevante en el impacto de valoración para ambas empresas ya que estos niveles de consumo están sujetas a las variaciones del mercado.The electrical sector is a very important component for the growth of any country since this implies that many economic activities require electricity for their production processes, thus promoting the development of the country. In addition, those services are also essential for the population since they generate improvements in the quality of life as it allows for better healthcare, education, telecommunications, among others. Hence there is a strong relationship between this sector and the growth of a country. In Peru, this sector had a notable transformation with the policy reforms of liberalization of the economy where the focus was centered on regulations in which energy efficiency is achieved, that is, competitive markets with good regulation of natural monopolies of this service, that private investments increase and efficient rates are achieved for all economic sectors and end users. Thus, the Peruvian electricity sector throughout recent years has maintained remarkable sustainable growth for the progress of the country. The Peruvian electricity distribution subsector operates under a natural monopoly regime and with indefinite-term concessions, which allows them to invest in long-term developments and infrastructure. For this research work, two leading companies in the electrical distribution sector have been selected: Enel Distribución Perú S.A.A. and Luz del Sur S.A.A., who maintain the support of their parent companies that are also leaders in Europe and Asia, with the objective of carrying out a financial analysis and comparative valuation between the companies, both with listings on the Lima Stock Exchange. This study includes the analysis of the last 5 years and a projection of the value of these companies. Based on this information, reasonable assumptions were established to carry out the projection of the Income Statement and the Balance Sheet for the next five years (2023 – 2027). Likewise, the discounted cash flow method was used to determine the value of each company based on the financial statements and finally, a sensitivity analysis was carried out by evaluating pessimistic and optimistic scenarios, which assumed variations in the consumption levels of GWh. Given the fact that it is an energy distribution subsector, GWh is considered the only relevant variable in the valuation for both companies since these consumption levels are subject to market variations

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Economic Burden of Dengue Virus Infection at the Household Level Among Residents of Puerto Maldonado, Peru.

Dengue virus (DENV) was reintroduced to Peru in the 1990s and has been reported in Puerto Maldonado (population ~65,000) in the Peruvian southern Amazon basin since 2000. This region also has the highest human migration rate in the country, mainly from areas not endemic for DENV. The objective of this study was to assess the proportion of household income that is diverted to costs incurred because of dengue illness and to compare these expenses between recent migrants (RMs) and long-term residents (LTRs). We administered a standardized questionnaire to persons diagnosed with dengue illness at Hospital Santa Rosa in Puerto Maldonado from December 2012 to March 2013. We compared direct and indirect medical costs between RMs and LTRs. A total of 80 participants completed the survey, of whom 28 (35%) were RMs and 52 (65%) were LTRs. Each dengue illness episode cost the household an average of US$105 (standard deviation [SD] = 107), representing 24$56, SD = 87), especially lost wages. The proportion of household income diverted to dengue illness did not differ significantly between RM and LTR households. The study highlights the significant financial burden incurred by households when a family member suffers dengue illness

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

Background Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990–2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals. Findings In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (−28·4 to −2·9) for all diabetes, and by 21·0% (–33·0 to −5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (−13·6% [–28·4 to 3·4]) and for type 1 diabetes (−13·6% [–29·3 to 8·9]). Interpretation Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.publishedVersio

Mapping inequalities in exclusive breastfeeding in low- and middle-income countries, 2000–2018

Abstract: Exclusive breastfeeding (EBF)—giving infants only breast-milk for the first 6 months of life—is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization’s Global Nutrition Target (WHO GNT) of ≥70% EBF prevalence by 2030. While six LMICs are projected to meet the WHO GNT of ≥70% EBF prevalence at a national scale, only three are predicted to meet the target in all their district-level units by 2030

Mapping inequalities in exclusive breastfeeding in low- and middle-income countries, 2000–2018

Exclusive breastfeeding (EBF)-giving infants only breast-milk for the first 6 months of life-is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization's Global Nutrition Target (WHO GNT) of ≥70% EBF prevalence by 2030. While six LMICs are projected to meet the WHO GNT of ≥70% EBF prevalence at a national scale, only three are predicted to meet the target in all their district-level units by 2030.This work was primarily supported by grant no. OPP1132415 from the Bill & Melinda Gates Foundation. Co-authors used by the Bill & Melinda Gates Foundation (E.G.P. and R.R.3) provided feedback on initial maps and drafts of this manuscript. L.G.A. has received support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brasil (CAPES), Código de Financiamento 001 and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) (grant nos. 404710/2018-2 and 310797/2019-5). O.O.Adetokunboh acknowledges the National Research Foundation, Department of Science and Innovation and South African Centre for Epidemiological Modelling and Analysis. M.Ausloos, A.Pana and C.H. are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project no. PN-III-P4-ID-PCCF-2016-0084. P.C.B. would like to acknowledge the support of F. Alam and A. Hussain. T.W.B. was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. K.Deribe is supported by the Wellcome Trust (grant no. 201900/Z/16/Z) as part of his international intermediate fellowship. C.H. and A.Pana are partially supported by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project no. PN-III-P2-2.1-SOL-2020-2-0351. B.Hwang is partially supported by China Medical University (CMU109-MF-63), Taichung, Taiwan. M.Khan acknowledges Jatiya Kabi Kazi Nazrul Islam University for their support. A.M.K. acknowledges the other collaborators and the corresponding author. Y.K. was supported by the Research Management Centre, Xiamen University Malaysia (grant no. XMUMRF/2020-C6/ITM/0004). K.Krishan is supported by a DST PURSE grant and UGC Centre of Advanced Study (CAS II) awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M.Kumar would like to acknowledge FIC/NIH K43 TW010716-03. I.L. is a member of the Sistema Nacional de Investigación (SNI), which is supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT), Panamá. M.L. was supported by China Medical University, Taiwan (CMU109-N-22 and CMU109-MF-118). W.M. is currently a programme analyst in Population and Development at the United Nations Population Fund (UNFPA) Country Office in Peru, which does not necessarily endorses this study. D.E.N. acknowledges Cochrane South Africa, South African Medical Research Council. G.C.P. is supported by an NHMRC research fellowship. P.Rathi acknowledges support from Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India. Ramu Rawat acknowledges the support of the GBD Secretariat for supporting the reviewing and collaboration of this paper. B.R. acknowledges support from Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal. A.Ribeiro was supported by National Funds through FCT, under the programme of ‘Stimulus of Scientific Employment—Individual Support’ within the contract no. info:eu-repo/grantAgreement/FCT/CEEC IND 2018/CEECIND/02386/2018/CP1538/CT0001/PT. S.Sajadi acknowledges colleagues at Global Burden of Diseases and Local Burden of Disease. A.M.S. acknowledges the support from the Egyptian Fulbright Mission Program. F.S. was supported by the Shenzhen Science and Technology Program (grant no. KQTD20190929172835662). A.Sheikh is supported by Health Data Research UK. B.K.S. acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal for all the academic support. B.U. acknowledges support from Manipal Academy of Higher Education, Manipal. C.S.W. is supported by the South African Medical Research Council. Y.Z. was supported by Science and Technology Research Project of Hubei Provincial Department of Education (grant no. Q20201104) and Outstanding Young and Middle-aged Technology Innovation Team Project of Hubei Provincial Department of Education (grant no. T2020003). The funders of the study had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. All maps presented in this study are generated by the authors and no permissions are required to publish them

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication