Sabrina Hermosilla

Bypassing primary care clinics for childbirth: a cross-sectional study in the Pwani region, United Republic of Tanzania

OBJECTIVE To measure the extent, determinants and results of bypassing local primary care clinics for childbirth among women in rural parts of the United Republic of Tanzania. METHODS Women were selected in 2012 to complete a structured interview from a full census of all 30076 households in clinic catchment areas in Pwani region. Eligibility was limited to those who had delivered between 6 weeks and 1 year before the interview, were at least 15 years old and lived within the catchment areas. Demographic and delivery care information and opinions on the quality of obstetric care were collected through interviews. Clinic characteristics were collected from staff via questionnaires. Determinants of bypassing (i.e. delivery of the youngest child at a health centre or hospital without provider referral) were analysed using multivariate logistic regression. Bypasser and non-bypasser birth experiences were compared in bivariate analyses. FINDINGS Of 3019 eligible women interviewed (93% response rate), 71.0% (2144) delivered in a health facility; 41.8% (794) were bypassers. Bypassing likelihood increased with primiparity (odds ratio, OR: 2.5; 95% confidence interval, CI: 1.9-3.3) and perceived poor quality at clinics (OR: 1.3; 95% CI: 1.0-1.7) and decreased if clinics recently underwent renovations (OR: 0.39; 95% CI: 0.18-0.84) and/or performed ≥ 4 obstetric signal functions (OR: 0.19; 95% CI: 0.08-0.41). Bypassers reported better quality of care on six of seven quality of care measures. CONCLUSION Many pregnant women, especially first-time mothers, choose to bypass local primary care clinics for childbirth. Perceived poor quality of care at clinics was an important reason for bypassing. Primary care is failing to meet the obstetric needs of many women in this rural, low-income setting.

Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania.

To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.

Tuberculosis, drug use and HIV infection in Central Asia: An urgent need for attention

INTRODUCTION Rates of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant tuberculosis (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan. In addition, rates of HIV infection related to injection drug use seems to be rising as well, thus creating conditions for a potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV which would have terrible consequences for public health in these countries. CURRENT STATUS In many countries of Central Asia, diagnosis of tuberculosis still rests on clinical grounds or simple technologies such as chest radiograph and sputum smear examination. Modern molecular techniques such as GenExpert are being introduced in Kazakhstan and Uzbekistan, and perhaps soon in Kyrgyzstan. Treatment of TB is still often centered around prolonged inpatient stay at TB hospitals. Only a minority of patients with HIV infection are receiving ART, and TB and HIV services are not well integrated. Needle exchange programs are becoming increasingly available, but opioid substitution therapy is rarely used in Central Asia. TB, drug treatment and HIV services are generally not well-integrated. CONCLUSIONS To combat this developing storm, integration of TB services, HIV care, and substance abuse treatment programs is needed urgently to allow efficient and effective diagnosis and treatment of these conditions in a coordinated manner.

Tuberculosis in Kazakhstan: analysis of risk determinants in national surveillance data

BackgroundDevelopment of tuberculosis (TB) is determined by various risk factors and the interactions of temporal and spatial distributions. The aim of this study was to identify the most salient risk factors for TB disease as well as multidrug resistant TB (MDR-TB) at the oblast (provincial) level in Kazakhstan.MethodsCorrelational and descriptive analyses were conducted at the oblast and national level using data provided by the country’s National Institute of Geography (NIG) and the National Tuberculosis Program (NTP). Reported incident case notification rates (CNRs) and prevalence vary by oblast, thus the study investigated which determinants contributed to this regional variation and compared burdens among oblasts.ResultsThe results showed that while tuberculosis CNRs decreased over the study period, MDR-TB conversely increased. Two oblasts -Atyrauskaya and Mangystauskaya - presented especially significant anomalies with large decreases in TB incident CNRs coupled with comparatively large increases in MDR-TB incident CNRs.ConclusionUnderstanding the distribution of TB and MDR-TB cases and associated risk factors, especially the “unknown risk factor” categorization points to the need for future research.

Disaster risk reduction and sustainable development for small island developing states

ABSTRACT In contrast to continental nations, the worlds 52 small island developing states (SIDS) are recognized as a collective of countries that experience disproportionate challenges for sustainable development related to their geography, small size, and physical isolation. These same states also face elevated risks for disaster incidence and consequences particularly in the realms of climate change, sea level rise, natural disasters (tropical cyclones, earthquakes, tsunamis, volcanoes), and marine hazardous materials spills. Cyclone Winstons direct impact on Fiji in 2016 and Cyclone Pams landfall over Vanuatu in 2015 provide case examples illustrating the special vulnerabilities of the SIDS.

Identifying risk factors associated with smear positivity of pulmonary tuberculosis in Kazakhstan

Background Sputum smear-positive tuberculosis (TB) patients have a high risk of transmission and are of great epidemiological and infection control significance. Little is known about the smear-positive populations in high TB burden regions, such as Kazakhstan. The objective of this study is to characterize the smear-positive population in Kazakhstan and identify associated modifiable risk factors. Methods Data on incident TB cases’ (identified between April 2012 and March 2014) socio-demographic, risk behavior, and comorbidity characteristics were collected in four regions of Kazakhstan through structured survey and medical record review. We used multivariable logistic regression to determine factors associated with smear positivity. Results Of the total sample, 193 (34.3%) of the 562 study participants tested smear-positive. In the final adjusted multivariable logistic regression model, sex (adjusted odds ratio (aOR) = 2.0, 95% CI:1.3–3.1, p < 0.01), incarceration (aOR = 3.6, 95% CI:1.2–11.1, p = 0.03), alcohol dependence (aOR = 2.6, 95% CI:1.2–5.7, p = 0.02), diabetes (aOR = 5.0, 95% CI:2.4–10.7, p < 0.01), and physician access (aOR = 2.7, 95% CI:1.3–5.5p < 0.01) were associated with smear-positivity. Conclusions Incarceration, alcohol dependence, diabetes, and physician access are associated with smear positivity among incident TB cases in Kazakhstan. To stem the TB epidemic, screening, treatment and prevention policies should address these factors.

Mapping the key issues shaping the landscape of global public health.

Abstract A survey of global health experts attending an invited meeting provided a means to map key issues perceived to be shaping emerging global public health agendas. Eighty-five participants proposed three major issues likely to have the most significant impact on the field of global health in the coming years. Six raters grouped the resultant items, with multi-dimensional scaling (MDS) analysis producing a composite two-dimensional map depicting the overall patterning of items. Thematic clusters were incorporated within four major domains: changing health and prevention needs (15% of items), globalisation and global health governance (33% of items), transforming health systems (30% of items) and innovations in science and technology (7% of items). The remaining 15% of items addressed forms of environmental change. The distribution of items across domains was not significantly influenced by the current professional role of participants, their current location in the ‘global north’ or ‘global south’ or their region of focus (although the latter approached threshold significance). The constraints on interpretation imposed by the biases influencing participation in the survey are noted. However, the exercise suggests the potential for coherently defining shared agendas for diverse stakeholders to address emerging priorities. The closer integration of environmental concerns with other global public issues is clearly warranted.

Risks for tuberculosis in Kazakhstan: Implications for prevention

SETTING Four regions in Kazakhstan where participants were recruited from June 2012 to May 2014. OBJECTIVE To examine associations between incarceration history and tobacco, alcohol, and drug consumption, and human immunodeficiency virus (HIV) infection and diabetes mellitus (DM) with TB. DESIGN This matched case-control study included 1600 participants who completed a survey on sociodemographics, history of incarceration, tobacco, alcohol and drug use, and HIV and DM diagnosis. Conditional logistic regression analysis was used to examine associations between a TB diagnosis and risk factors. RESULTS Participants who had ever smoked tobacco (aOR 1.73, 95%CI 1.23-2.43, P  0.01), ever drank alcohol (aOR 1.41, 95%CI 1.03-1.93, P  0.05), were HIV-positive (aOR 36.37, 95%CI 2.05-646.13, P  0.05) or had DM (aOR 13.96, 95%CI 6.37-30.56, P  0.01) were more likely to have TB. CONCLUSIONS The association between TB and tobacco use, alcohol use, HIV and DM in Kazakhstan suggests a need for comprehensive intervention and prevention approaches that also address tobacco and alcohol use, DM and HIV.

An Ounce of Prevention: Deaths Averted From Primary Prevention Interventions

INTRODUCTION The U.S. lags in the nationwide implementation of primary prevention interventions that have been shown to be efficacious. However, the potential population health benefit of widespread implementation of these primary prevention interventions remains unclear. METHODS The meta-analytic literature from October 2013 to March 2014 of primary prevention interventions published between January 2000 and March 2014 was reviewed. The authors then estimated the number of deaths that could have been averted in the U.S. in 2010 if all rigorously studied, efficacious primary prevention interventions for which population attributable risk proportions could be estimated were implemented nationwide. RESULTS A total of 372,054 (15.1%) of all U.S. deaths in 2010 would have been averted if all rigorously studied, efficacious primary prevention interventions were implemented. Two in three averted deaths would have been from cardiovascular disease or malignancy. CONCLUSIONS A substantial proportion of deaths in the U.S. in 2010 could have been averted if efficacious primary prevention interventions were implemented nationwide. Further investment in the implementation of efficacious interventions is warranted to maximize population health in the U.S.