No / This article explores options to strengthen environmental law to maximize its health impact in the developing world. A review of environmental treaties, including their domestic implementation, reveals the weak synergies between health and environmental objectives. The article advances adaptive governance as a framework for rethinking international environmental law to improve health in Africa, but argues that it has its limits. It analyses these strengths and limits in the context of evolving regional environmental health governance in Africa, and proposes four principles – environmental justice, multi-sectoral collaboration, evaluation and environmental ethics – to reinforce its potential to improve health and the environment in Africa.

Introduktion: WHO publicerade 2021 nya rekommendationer för fysisk aktivitet, i rapporten inkluderades även rekommendationer specifikt anpassade för personer med funktionsnedsättningar. I rekommendationerna belyser WHO vikten av ökad fysisk aktivitet, minskad skärmtid och minskat stillasittande för barn och ungdomar med funktionsnedsättningar.  Syfte: Syftet med studien var att undersöka om fysioterapeuter/sjukgymnaster (FT/sjg) inom habiliteringsverksamhet i Sverige känner till WHOs rekommendationer om fysisk aktivitet för personer med funktionsnedsättningar. Vi undersökte även hur rekommendationerna implementeras av FT/sjg, samt om de upplever att rekommendationerna är en bra modell för arbetet med olika patientgrupper. Metod: En enkätundersökning genomfördes med totalt 20 frågor. Rekryteringen skedde genom två Facebookgrupper samt kontakter i habiliteringssektionens styrelse. Frågorna var uppbyggda med både flervalsfrågor och öppna skrivfrågor och undersökte fysioterapeutens upplevelser av WHOs rekommendationer. Resultaten redovisas deskriptivt och på de öppna frågorna genomfördes en sammanställning samt indelning i text med citat. Resultat: Enkätundersökningen resulterade i totalt 28 deltagare. De visade att majoriteten av FT/sjg kände till rekommendationerna samt att de används inom vården men även att några inte var bekanta med rekommendationerna och/eller valde att inte använda dem. De kvalitativa frågorna visade även att det finns behov av att individanpassa målen ytterligare. Konklusion: Svaren pekar mot att majoriteten av Ft/sjg känner till målen och använder dem i arbetet med patienterna. Däremot kan de vara för svåra att uppnå och en större individanpassning är nödvändigt. Svaren tolkas dock med försiktighet pga. få deltagare.

Background: Effective communication is key to team working in healthcare. It can be negatively impacted upon by existing cultures, logistical challenges, role confusion, and a lack of collaborative approaches to practice. Clinical guidelines recommend using the International Classification of Functioning, Disability and Health (ICF) to aid communication within stroke teams. Yet no empirical evidence exists on the process or outcomes of such implementation. Aims: This project aimed to explore ways the ICF could be used with an acute stroke service and identify key learning from the implementation process. Methods: Using an action research framework, iterative cycles were used within exploratory, innovatory and reflective phases. Content analysis was used to map patient notes’ entries to ICF categories. Thematic analysis was undertaken, using a model of immersion and crystallisation, on data generated via interview and focus group, e-mail communications, minutes from meetings, field notes and a reflective diary. Descriptive statistics were used to analyse quantitative questionnaire data. Data from all sources were combined to determine key findings. Findings: Participants chose to develop an ICF-based team transfer of care report with an ICF glossary to aid completion. Five overall themes were determined; the need to: (1) adopt the ICF in ways that met local service needs; and (2) adapt the ICF language and format. Once implemented, the ICF: (3) fostered communication within and beyond the stroke team; (4) promoted holistic thinking; and (5) helped to clarify team roles. Conclusions: These are the first empirical findings within stroke services that demonstrate how to make the ICF a clinical reality. Participants needed to adapt and own the ICF to adopt it. When implemented, it enabled specific team communication challenges to be overcome. The use of action research to implement the ICF has facilitated sustained change and improvements to communication, thus benefiting patient care.

Point-of-care (POC) tests can improve the management of infectious diseases and clinical outcomes, through prompt diagnosis and appropriate delivery of treatments for preventable and treatable diseases, especially in resource-limited settings where health care infrastructure is weak, and access to quality and timely medical care is challenging. Microfluidics or lab-on-chip technology is appropriate for POC tests when general design constraints such as integration, portability, low power consumption, automation, and ruggedness are met. Although many POC tests have been designed for use in developed countries, they might not be readily transferable to resource-limited settings. These new technologies need to be accessible, affordable and practical to be implemented at resource-limited settings to save lives in developing countries. The overall goal of this dissertation is to develop microfluidic diagnostic devices which are practical and reliable for global health. We first focused on immunoassays, an important class of diagnostic tests which utilize antibodies to quantify host immunity or pathogen protein markers. We developed and evaluated a rapid, accurate, multiplexed, and portable microfluidic immunoassay for diagnosis of HIV and syphilis on hundreds of archived specimens (whole blood, plasma, and sera). Our assay exhibited performance equal to lab-based immunoassays in less than 20 minutes. In addition, our technique quantified signals using a handheld instrument, allowing for objective measurements as opposed to current rapid HIV tests which require subjective interpretation of band intensities. We further integrated three important off-chip processes in a diagnostic test - liquid handling, optical signal detection, and data communication – in a low-cost, versatile, handheld instrument capable of performing immunoassays on reagent-loaded (i.e. “ready-to-run”) cassettes at high analytical performance characteristic of ELISA but with the speed, portability and ease-of-use of a rapid test. We also evaluated this immunoassay device in Rwanda on archived samples and achieved analytical performance comparable to that of benchtop standards. To simplify the user interface and reduce the cost of the diagnostic device, we integrated our microfluidic immunoassay with a smartphone to replace computers or high-cost processors for diagnostic devices in low-resource settings. Our low-cost ($34), smartphone-supported device for a multiplexed immunoassay detected three antibody markers from HIV, treponemal- and non-treponemal syphilis from fingerstick whole blood simultaneously in 15 minutes. This device was designed to eliminate the number of manual steps, through the use of lyophilized secondary antibodies and anti-coagulant, preloaded reagents on cassette, and an automatic result readout. A step-by-step user guide was included on the smartphone to make the device simple enough to be used by an untrained operator. The analytical performance of the device was evaluated in Rwanda by local health care workers. We also accessed user experiences for improvement of the device in future. While immunoassays offer rapid and accurate diagnosis for infectious diseases, various infections cannot be confirmed using protein markers. Due to increasing clinical demand for detection of DNA and RNA signatures for diagnosis and monitoring of patients in resource-limited settings, we also explored how microfluidic and nanoparticle technologies can improve nucleic acid amplification test at the point of care. Nucleic acid tests are arguably some of the most challenging assays to develop due to additional steps required for sample pre-treatment (e.g. cell sorting, isolation, and lysis, as well as nucleic acid extraction), signal amplification (due to low physiological concentrations, target contamination, and instability) and product detection. Here we developed a sputum processor to isolate and lyse mycobacteria (M.smegmatis) from a more complex sample matrix, using magnetic beads-based target isolation to replace the need of a centrifuge or other complicated sample preparation technique. We also investigated a technique to detect Mycobacterium tuberculosis using multiplex polymerase chain reaction (PCR) and silver-gold amplification detection.

No description available.

Antimicrobial resistance (AMR) is a growing problem around the world. To meet the threat of a futurewithout effective treatment of infection, WHO and other authorities have published strategies and actionplans. However, it is unclear to what extent they have been implemented. As the seventh wealthiesteconomy in the world, Brazil could serve as a role model for other fast developing countries in the battleagainst AMR. The objective of this study was to investigate if and how implementation of internationalAMR strategies is addressed in literature, and to describe how such guidelines have been implemented inBrazil. The study was carried out as a literature review of scientific articles and of documents published byBrazilian authorities. In the scientific literature great importance was given to a multidisciplinary approachand to surveillance, with a special emphasis on local data. Brazilian documents showed a focus on healthcare settings and on actions concerning surveillance. Many tools were in place, such as networks and legalframework. Using local data, identifying measures most important for the target group and thenimplementing them, was considered most important. Generally, there was a lack of assessments. Brazil stillhas a long way to go, but has started out well with its focus on surveillance.

Thesis (Ph.D.)--University of Melbourne, Centre for Eye Research Australia, Dept. of Opthalmology 2010. / Typescript. Includes bibliographical references (p. 251-274)

Magister Chirurgiae Dentium (MChD) / The World Health Organisation estimated that in 2002 more than 13,772 000 deaths in developing countries were caused by infections. This accounted for more than 45% of all deaths, making up 7 of the top 10 causes of death (World Health Organisation, 2004). Sub-Saharan Africa is the epicentre of the devastating HIV pandemic. The country leading with the highest HIV rate in the world is South Africa, with approximately 5.5 million people infected(UNAIDS, 2008; South Africa Country Progress Report, 2008).The development from HIV to AIDS progressively weakens the immune system, making the individual more susceptible to numerous infections, e.g.various forms of orofacial sepsis (Mindel, and Tenant-Flowers, 2001). HIVpositive individuals are eighteen times more likely to become infected with community-acquired methicillin-resistant Staphylococcus aureus than the general population. (Crum-Cianflone et al., 2006). The management of sepsis is of great concern with regard to human morbidity and mortality, as well as its financial implications, especially in cases of antibiotic resistance (Kimleck et al., 1976; Panlilo et al., 1992; Kirkland et al., 1999). Currently, there is no published peer-reviewed literature assessing the impact of HIV on orofacial sepsis. This study aimed to assess the impact of HIV on orofacial sepsis, investigating the clinical and microbiological profiles of the population. These results were used as a guide in the adaptation of current treatment protocols.The study population consisted of patients with orofacial sepsis (requiring incision and drainage or admission) who were referred to the Maxillo-Facial and Oral Surgery Units at either Groote Schuur or Tygerberg Hospitals. These patients were examined, diagnosed and treated as per standard protocol. The empiric antibiotic treatment was tailored according to microscopy and sensitivity results when it became available. The exclusion criteria of the study were refusal of HIV testing or unwillingness of patients to participate in the study.The ratio of HIV positive patients treated was much higher than the population prevalence (2.4:1.1). Odontogenic infections (71.11%), followed by septic jaw fractures (15.56%) were the most common causes of sepsis. The most common causative teeth were the mandibular posterior teeth (43.75%)(excluding the mandibular 3rd molars). The most common fascial spaces involved in the HIV positive group were the submandibular spaces (36%),followed by the submasseteric and canine spaces (27% each). In the HIV negative group, the buccal (41%) and submandibular spaces (33%) were the most common fascial spaces infected.The HIV negative group had the most multi-fascial space involvement, with 35% having more than one fascial space involved. In comparison, the HIV positive group had only 18% involvement of more than one fascial space. This was also reflected by the HIV negative group, which included five cases of Ludwig’s Angina as compared to one case in the HIV positive group. The Gram Stain showed a predominance of Gram positive cocci for both the HIV positive and negative groups. Gram positive bacilli were significantly more prevalent in the HIV negative group (p = 0.0409). Pre-treatment antibiotics were associated with sterile abscesses in 20% of the cases. No growth on culture occurred only in the HIV negative group (statistically significant with p = 0.00488).A statistically significant increased length of admission was found for the cases with penicillin-resistant bacteria (Wicoxin Rank Sum Test p =0.0072). Penicillin resistance was found in 17.78% (8 cases) with ten strains of five types of bacteria (S. aureus, K. pneumonia, Enterobacter, E. coli,Alpha-haemolytic Streptococcus). Eight percent (5) of these cases were also resistant to co-amoxiclav®.In the HIV positive group the following trends (p>0.005) were found:• The average platelet counts of this group was 112.34 x108/L (lower than the HIV negative group);• The length of admission for the HIV positive group was slightly longer by 0.25 days even though this group had fewer fascial spaces infected;• A larger number of bacteria with penicillin-resistance was more prevalent in the HIV positive group (six resistant bacteria in four cases compared to four resistant bacteria in four cases).Greater numbers of orofacial infections were seen in HIV positive subjects relative to their population prevalence rates. Added to this, was the higher rate of antibiotic resistance and longer hospital admissions.These findings may warrant further investigation of the relationship between HIV positive and negative groups with regard to orofacial sepsis.

Background: The World Health Organisation (WHO) Africa region experiences multiple public health emergencies (PHEs) annually. PHEs have been documented to affect the provision of health services including immunisation. To our knowledge, there is a scarcity of studies characterising PHEs and the performance of national immunisation programmes (NIPs) in countries within the WHO Africa region that have experienced PHEs. This study assessed PHEs (armed conflicts, disasters, and disease outbreaks) and the performance of NIPs in the context of PHEs using global and regional immunisation targets. Methods Countries in the WHO Africa region that were reported to benefit from the African Public Health Emergency Fund (APHEF) were used as case studies. Data on PHEs and immunisation indicators recorded between 2010 and 2019 in the study countries were extracted from different electronic PHE databases (the Emergency Events database, the Uppsala Conflict Data Program, the WHO Emergency Preparedness and Response, and the Program for Monitoring Emerging Diseases Mail) and the WHO/UNICEF immunisation database, respectively. The PHEs and immunisation indicators were stratified by country and summarised using descriptive statistics. The Mann-Whitney U test was carried out to determine the association between the frequency of PHEs and the performance of NIPs in the selected countries from 2010 to 2019. Statistical significance was defined at p-value < 0.05. Results Thirteen countries were included in this study. A total of 175 disease outbreaks, 288 armed conflicts, and 318 disasters were reported to have occurred within the 13 countries from 2010 to 2019. The Democratic Republic of Congo had the highest total PHE count (n=208), while Liberia had the lowest (n=20). Only three of the 13 countries had a median coverage value for the third dose of the combined Diphtheria, Tetanus, and Pertussis vaccine (DTP3) that had attained the target for ≥90% immunisation coverage. Higher counts of armed conflict and total PHEs were statistically significantly (p=0.03) associated with not attaining MNT elimination. Conclusion PHEs are prevalent in the WHO Africa region, irrespective of the level of a country's immunisation maturity. In absence of effective interventions, PHEs have the potential to derail the progress of NIPs in the WHO Africa region. As we enter the Immunisation Agenda 2030 era, this study advocates for the prioritisation of interventions to mitigate the impacts of PHEs on the NIPs.

Impaired intrauterine growth, inability of the fetus to achieve the required growth potential, contributes to a higher burden of neonatal morbidity and mortality. Intrauterine growth is an inferred process and small for gestational age is considered a rough estimate of impaired intrauterine growth that requires reliable gestational age data. Due to sparse data and measurement errors in gestational age, researchers rely on markers such as birth weight, birth length, and birth head circumference to infer fetal growth. While the etiology of impaired fetal growth is multifactorial, maternal anemia and undernutrition contribute substantially to impaired fetal growth and are prioritized in 2030 global nutrition goals by the World Health Assembly. Nutrition supplements such as lipid-based nutrient supplements, multiple micronutrients, and iron or folic acid during pregnancy are presumed to improve maternal anemia. But the effect of the supplements during pregnancy on fetal growth appears to be small to negligible, which has shifted the researcher’s focus to the pre-conception period. However, prior reviews on the preconception period have either synthesized the evidence from observational studies, or have explored outcomes such as congenital anomalies (e.g., neural tube defects), neurodevelopment disorders, or only birth weight. Hence the evidence from existing randomized controlled trials (RCTs) evaluating the effect of preconception nutrition supplements on maternal anemia and all markers of fetal growth including birth weight, birth length, and birth head circumference has not been systematically summarized and synthesized. We bridged this knowledge gap in the current dissertation (Aim 1). The Women First (WF) Preconception Nutrition Trial found that lipid-based nutrient supplementation started preconception or during pregnancy conferred greater benefits for birth weight and birth length among mothers who were anemic (Hemoglobin (Hb) < 12 g/dL) than among mothers who were non-anemic (Hb ≥ 12 g/dL) pre-pregnancy. However, by dichotomizing women into anemic and non-anemic women, we may miss high-risk women with specific Hb levels who may obtain greater benefits for intrauterine growth associated with the supplements. Assessing the effect of preconception nutrient supplements across a range of pre-pregnancy Hb levels will help us identify women with specific Hb cut-offs who may have the greatest potential to respond to the supplements (Aim 2). Additionally, there are major gaps in understanding the mechanisms of how nutrient supplements, consumed either before or during pregnancy, improve intrauterine growth. A better understanding of the underlying mechanisms would allow for fine-tuning of nutrition interventions for greater efficacy. Here, we examined whether Hb during pregnancy could be a potential mechanism through which nutrition supplements improve intrauterine growth (Aim 3). For Aim 1, we undertook a systematic review and meta-analysis of the RCTs evaluating the effect of preconception nutrition supplements on maternal hemoglobin and markers of intrauterine growth including birth weight, birth length, birth head circumference, and small for gestational age. Additionally, we examined preterm birth as an important perinatal outcome. We searched electronic databases including PubMed, Web of Science, Embase, CINAHL, and Cochrane Central. We computed pooled mean differences and risk ratios (RR) with 95% confidence intervals (CIs) using random-effect models. We employed I2 and Cochran’s Q test statistics to assess heterogeneity. We used the GRADE (grading of recommendations, assessment, development, and evaluations) tool to assess the quality of evidence. For Aim 2 and Aim 3, we leveraged the existing data from a large multi-country Women First (WF) Preconception Nutrition Trial conducted in Pakistan, India, Guatemala, and the Democratic Republic of Congo. Women in the WF trial were randomized to consume a lipid-based nutrient supplement (LNS) at least three months before and during pregnancy (Arm 1- preconception), only during pregnancy (Arm 2- during), or not at all (Arm 3 - control). The outcome was weight, length, and head circumference within 48 hours of birth expressed as Z-scores. For Aim 2, we analyzed the WF trial data on 2443 women-newborn dyads. For each site, we computed adjusted mean differences in these Z-scores between the randomized arms across six pre-pregnancy Hb categories (8-8.9, 9-9.9, 10-10.9, 11-11.9, 12-12.9, and ≥13g/dL) based on Hb distributions. We pooled site-specific effect measures using meta-analysis. For Aim 3, hemoglobin measured at 12 (n=2075) and 32 weeks of gestation (n=2157) was a mediator. We employed causal mediation analysis under a counterfactual approach to estimate direct and indirect effects. For Aim 1, we identified 20 eligible RCTs (n=27,659 women). Preconception nutrition supplements (iron and folic acid, multiple micronutrients, and a lipid-based nutrient supplement) increased maternal hemoglobin by 0.30g/dL ((0.03, 0.57); I2=79%). However, we did not find a significant effect of the supplements on birth weight (12.47gm ((-33.14, 58.08); I2=58%)), birth length (0.15cm (-0.26, 0.56); I2=68%; n=5), birth head circumference (-0.23cm (-0.88, 0.43); I2=84%), small for gestational age (RR: 0.91 (0.80,1.04); I2=31%), or preterm birth (RR: 0.93 (0.69,1.25); I2=57%). Overall, the quality of evidence was assessed as moderate and very low for maternal hemoglobin and three markers of intrauterine growth including birth weight, birth length, and birth head circumference, respectively. In Aim 2, we found that the effect of LNS on birth weight, length, and head circumference varied by pre-pregnancy Hb categories. Pooled mean differences in the Z-scores for birth length (0.60 (0.03, 1.23)), birth weight (0.50, (0.11, 0.89)), and birth head circumference ((0.26, (0.02, 0.51)) were greatest for Arm 1-preconception vs. Arm 3-control women with Hb 9-9.9g/dL. Women with Hb 10-10.9g/dL also benefited from preconception LNS. However, compared to controls, the effects of preconception LNS on birth weight, birth length, and birth head circumference attenuated for women with Hb 10-10.9g/dL. Compared to Arm 3-control, LNS during pregnancy (Arm 2) improved birth length, birth weight, and birth head circumference for women with Hb 8-10.9g/dL. Preconception LNS (Arm1) vs. LNS during pregnancy (Arm 2) improved the three markers of intrauterine growth only for women with Hb 9-9.9g/dL. Women with nearly normal (11-11.9 g/dL) and normal Hb (≥12g/dL) did not appreciably benefit from LNS, offered before and or during pregnancy. For Aim 3, Hb at 12 or 32 weeks of gestation did not mediate the relationship between the LNS and intrauterine growth. Indirect effects of preconception LNS (Arm 1) vs. Arm 3, mediated by Hb at 12 weeks, were 0.02 (-0.02, 0.01), 0.01 (-0.01, 0.02), and 0.01 (-0.01, 0.02) for length, weight, and head circumference Z-scores, respectively. The corresponding direct effects, not mediated by Hb, were 0.18 (0.09, 0.33), 0.12 (0.03, 0.23), and 0.06 (-0.03, 0.20), respectively. Site-specific and gestational age-adjusted data analyses both at 12 and 32 weeks of gestation confirmed the findings of negligible mediation by Hb during pregnancy. All types of preconception nutrition supplements studied to date appear to reduce maternal anemia. However, it is uncertain whether there are beneficial effects of preconception nutrition supplements on markers of intrauterine growth. Low quality of evidence from the RCTs examining the markers of intrauterine growth warrants future well-designed RCTs to produce solid scientific data, particularly on the benefits of a more comprehensive package of preconception nutrition supplements that include both macro- and micronutrients. The findings from the WF trial suggest that the benefits of preconception LNS on fetal growth are mainly confined to women with pre-pregnancy Hb 9-9.9g/dL. Compared to controls, women with Hb 10-10.9g/dL also benefited from preconception LNS, albeit the magnitude of effect on three markers of intrauterine growth was modest for women with Hb 10-10.9g/dL. However, LNS, started during pregnancy, appeared to improve markers of intrauterine growth for women with a wider range of Hb 8-10.9g/dL. Women with Hb ≥ 11g/dL did not benefit from LNS started either pre-conception or during pregnancy. These findings suggest that prioritizing women with specific pre-pregnancy Hb categories for targeted nutrition interventions may be advisable. This would target limited resources most efficiently in LMICs. Lastly, negligible mediation by Hb during pregnancy suggests that alternative pathways that potentially mediate the relationship between LNS and intrauterine growth need to be investigated.