Spurious early ecological association suggesting BCG vaccination effectiveness for COVID-19.

BackgroundSeveral ecologic studies have suggested that the bacillus Calmette-Guérin (BCG) vaccine may be protective against SARS-CoV-2 infection including a highly-cited published pre-print by Miller et al., finding that middle/high- and high-income countries that never had a universal BCG policy experienced higher COVID-19 burden compared to countries that currently have universal BCG vaccination policies. We provide a case study of the limitations of ecologic analyses by evaluating whether these early ecologic findings persisted as the pandemic progressed.MethodsSimilar to Miller et al., we employed Wilcoxon Rank Sum Tests to compare population medians in COVID-19 mortality, incidence, and mortality-to-incidence ratio between countries with universal BCG policies compared to those that never had such policies. We then computed Pearson's r correlations to evaluate the association between year of BCG vaccination policy implementation and COVID-19 outcomes. We repeated these analyses for every month in 2020 subsequent to Miller et al.'s March 2020 analysis.ResultsWe found that the differences in COVID-19 burden associated with BCG vaccination policies in March 2020 generally diminished in magnitude and usually lost statistical significance as the pandemic progressed. While six of nine analyses were statistically significant in March, only two were significant by the end of 2020.DiscussionThese results underscore the need for caution in interpreting ecologic studies, given their inherent methodological limitations, which can be magnified in the context of a rapidly evolving pandemic in which there is measurement error of both exposure and outcome status

The global surgery blood drought: frontline provider data on barriers and solutions in Bihar, India

Background: Limited access to safe, timely banked blood is a critical barrier to providing basic surgical care in resource-limited settings globally. Contextual, locally driven data are required to elucidate country needs, develop effective interventions, and guide policy decisions. Objective: We employ qualitative methodology to describe barriers faced and solutions proposed by front-line obstetric providers in Bihar – a poor, populous Indian state where maternal mortality exceeds the national average. We aim to make locally driven recommendations for ongoing policy work in India to strengthen the country’s blood transfusion system. Methods: From February to May 2016, two researchers conducted semi-structured interviews with 19 obstetric providers across Bihar. Snowball sampling was employed until thematic saturation was reached. Following immersion into de-identified texts and dual codebook development, a primary analyst completed topical coding, and a secondary analyst confirmed reproducibility. Results: Providers report that pervasive banked blood shortages force hospitals to require replacement donation, but patients’ families often cannot or will not donate. Providers wait one to six hours for blood, depending on availability of staff and supplies, blood bank proximity, and the ability of the patient being treated to navigate the system. Providers feel forced to refer their patients, often to distant, poorly equipped centers. Providers identify donor education, improved infrastructure, and improved local coordination as focus areas for intervention. Conclusions: A multi-stakeholder approach that aims to increase blood donation through community education, mitigate limited infrastructure through short-term workarounds, and improve local-level coordination through state support and policy change is required in Bihar. This study generates data to guide policy and future research aimed at generating affordable, contextually appropriate interventions to the blood drought

Provision of surgical care in Ethiopia: Challenges and solutions

With the lowest measured rate of surgery in the world, Ethiopia is faced with a number of challenges in providing surgical care. The aim of this study was to elucidate challenges in providing safe surgical care in Ethiopia, and solutions providers have created to overcome them. Semi-structured interviews were conducted with 10 practicing surgeons in Ethiopia. Following de-identification and immersion into field notes, topical coding was completed with an existing coding manual. Codes were adapted and expanded as necessary, and the primary data analyst confirmed reproducibility with a secondary analyst. Qualitative analysis revealed topics in access to care, in-hospital care delivery, and health policy. Patient financial constraints were identified as a challenge to accessing care. Surgeons were overwhelmed by patient volume and frustrated by lack of material resources and equipment. Numerous surgeons commented on the inadequacy of training and felt that medical education is not a government priority. They reported an insufficient number of anaesthesiologists, nurses, and support staff. Perceived inadequate financial compensation and high workload led to low morale among surgeons. Our study describes specific challenges surgeons encounter in Ethiopia and demonstrates the need for prioritisation of surgical care in the Ethiopian health agenda. Abbreviations: LCoGS: The Lancet Commission on Global Surgery; LMIC: low- and middle-income countr

Macroeconomic burden of firearm-related fatality across OECD countries: an estimate of annual and cumulative gross domestic product losses, 2018–30

Background: In 2015, firearm-related unintentional injuries, physical violence, and self-harm caused over 36 000 deaths and 100 000 injuries in the USA, and over 250 000 deaths worldwide. Of these deaths, more than 64 000 were in OECD countries. Nevertheless, firearm injury risk reduction remains socially and politically controversial. Although the costs of treating firearm injuries has been estimated, little is known about the macroeconomic impact of firearm deaths. Here, we aim to estimate the future macroeconomic burden of deaths in OECD countries. Methods: Using value-of-lost-output methodology, which estimates the macroeconomic burden of deaths in terms of lost economic productivity, we estimated the annual and cumulative gross domestic product (GDP) lost due to firearm-related fatalities from 2018 to 2030 in all 36 OECD countries. We used mortality data from the 2016 Global Burden of Disease study to project mortality rates from 2018 to 2030. We then applied these projections to an adapted version of the WHO EPIC (Projecting the Economic Cost of Ill-health) model to project GDP losses attributable to firearm-related deaths. Findings: Across OECD countries, we estimated macroeconomic losses from firearm mortality at US$272·1 billion in lost economic output between 2018 and 2030 ($124·9 billion from physical violence, $135·7 billion from self-harm, and$11·4 billion from unintentional injury), with $8·0 billion in annual losses in 2018 growing to an estimated loss of$35·9 billion in 2030. This amount represents 0·051% of total estimated 2030 GDP, or $1 lost for every$1944 of potential economic output. The USA is estimated to lose more than other OECD nations, with annual GDP losses of $24·5 billion in 2030, representing 0·10$180·6 billion cumulative losses from 2018 to 2030. Mexico's estimated loss in 2030 is $6·3 billion, which represents 0·20$50·3 billion cumulatively from 2018 to 2030. No other OECD country had estimated cumulative losses greater than $10·6 billion in the study period, nor greater than 0·04% of GDP in 2030. Considered as a proportion of 2030 GDP, the USA's projected losses were 93·0% higher and Mexico's losses were 290·6% higher than the mean proportional losses across all OECD countries in 2030. Interpretation: Firearm-related deaths are expected to cause disproportionately high macroeconomic losses in the USA and Mexico from 2018 to 2030 compared with other OECD countries. These losses represent an important proportion of GDP, and should be considered in broader social, economic, and health policy decisions about firearm regulation. Future studies might consider cost-benefit analyses that weigh the costs of risk reduction interventions against the potential economic savings of reducing firearm mortality. Funding: None

'We are all serving the same Ugandans' : A nationwide mixed-methods evaluation of private sector surgical capacity in Uganda

Introduction Half of all Ugandans (49%) turn to the private or private-not-for-profit (PNFP) sectors when faced with illness, yet little is known about the capacity of these sectors to deliver surgical services. We partnered with the Ministry of Health to conduct a nationwide mixed-methods evaluation of private and PNFP surgical capacity in Uganda. Methods A standardized validated facility assessment tool was utilized to assess facility infrastructure, service delivery, workforce, information management, and financing at a randomized nationally representative sample of 16 private and PNFP hospitals. Semi-structured interviews were conducted to qualitatively explore facilitating factors and barriers to surgical, obstetric and anaesthesia (SOA) care. Hospitals walk-throughs and retrospective reviews of operative logbooks were completed. Results Hospitals had a median of 177 beds and two operating rooms. Ten hospitals (62.5%) were able to perform all Bellwether procedures (cesarean section, laparotomy and open fracture treatment). Thirty-day surgical volume averaged 102 cases per facility. While most hospitals had electricity, oxygen, running water, and necessary equipment, many reported pervasive shortages of blood, surgical consumables, and anesthetic drugs. Several themes emerged from the qualitative analysis: (1) geographic distance and limited transportation options delay reaching care; (2) workforce shortages impede the delivery of surgical care; (3) emergency and obstetric volume overwhelm the surgical system; (4) medical and non-medical costs delay seeking, reaching, and receiving care; and (5) there is poor coordination of care with insufficient support systems. Conclusion As in Uganda's public sector, barriers to surgery in private and PNFP hospitals in Uganda are cross-cutting and closely tied to resource availability. Critical policy and programmatic developments are essential to build and strengthen Ugandan surgical capacity across all sectors

You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda

Background: Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. Methods: From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis. Results: The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need. Conclusion: Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity

Pearson correlation coefficients between years of implementation of BCG Policy and COVID-19 outcomes among countries with current universal BCG vaccination policy (A) and among countries that previously had universal BCG vaccination policies (B), March-December, 2020.

* Statistically significant Pearson correlation at p<0.05.</p