Acting on non-communicable diseases in low- and middle-income tropical countries

Scan With Me: A Train-the-Trainer Program to Upskill MRI Personnel in Low- and Middle-Income Countries

PURPOSE

Access to MRI in low- and middle-income countries (LMICs) remains among the poorest in the world. The lack of skilled MRI personnel exacerbates access gaps, reinforcing long-standing health disparities. The Scan With Me (SWiM) program aims to sustainably create a network of highly skilled MRI technologists in LMICs who will facilitate the transfer of MRI knowledge and skills to their peers and contribute to the implementation of highly valuable imaging protocols for effective clinical and research use.

METHODS

The program introduces a case-based curriculum designed using a novel train-the-trainer approach, integrated with peer-collaborative learning to upskill practicing MRI technologists in LMICs. The 6-week curriculum uses the teach-try-use approach, which combines self-paced didactic lectures covering the basics of MR image acquisition (teach) with hands-on expert-guided scanning experience (try) and the implementation of protocols tailored to provide the best possible images on their infrastructures (use). Each program includes research translation skills training using an established advanced MRI technique relevant to LMICs. A pilot program focused on cardiac MRI (CMR) was conducted to assess the program's curriculum, delivery, and evaluation methods.

RESULTS

Forty-three MRI technologists from 16 LMICs participated in the pilot CMR program and, over the course of the training, implemented optimized CMR protocols that reduced acquisition times while improving image quality. The training resources and scanner-specific standardized protocols are published openly for public use in an online repository. In general, at the end of the program, learners reported considerable improvements in CMR knowledge and skills. All respondents to the program evaluation survey agreed to recommend the program to their colleagues, while 87% indicated interest in returning to help train others.

CONCLUSIONS

The SWiM program is the first master class in MRI acquisition for practicing imaging technologists in LMICs. The program holds the potential to help reduce disparities in MRI expertise and access. The support of the MRI community, imaging societies, and funding agencies will increase its reach and further its impact in democratizing MRI.

Cardiometabolic diseases and associated risk factors in transitional rural communities in tropical coastal Ecuador

BACKGROUND

There is a growing epidemic of chronic non-communicable diseases in low and middle-income countries, often attributed to urbanization, although there are limited data from marginalized rural populations. This study aimed to estimate prevalence of cardiometabolic diseases and associated risk factors in transitional rural communities.

METHODS

A cross-sectional study of Montubio adults aged 18-94 years living in agricultural communities in a tropical coastal region of Ecuador. Data were collected by questionnaires and anthropometry, and fasting blood was analyzed for glucose, glycosylated hemoglobin, insulin, and lipid profiles. Population-weighted prevalences of diabetes, hypertension, and metabolic syndrome were estimated. Associations between potential risk factors and outcomes were estimated using multilevel regression techniques adjusted for age and sex.

RESULTS

Out of 1,010 adults recruited, 931 were included in the analysis. Weighted prevalences were estimated for diabetes (20.4%, 95% CI 18.3-22.5%), hypertension (35.6%, 95% CI 29.0-42.1%), and metabolic syndrome (54.2%. 95% CI 47.0-61.5%) with higher prevalence observed in women. Hypertension prevalence increased with age while diabetes and metabolic syndrome peaked in the 6th and 7th decades of life, declining thereafter. Adiposity indicators were associated with diabetes, hypertension, and metabolic syndrome.

CONCLUSION

We observed an unexpectedly high prevalence of diabetes, hypertension, and metabolic syndrome in these marginalized agricultural communities. Transitional rural communities are increasingly vulnerable to the development of cardiometabolic risk factors and diseases. There is a need for targeted primary health strategies to reduce the burden of premature disability and death in these communities.

Effect modification of diet and vitamins on the association between air pollution particles of different diameters and hypertension: A 12-year longitudinal cohort study in densely populated areas of China

INTRODUCTION

Particulate matter (PM) is identified as one of the exacerbating and triggering factors for hypertension. Diet intake and the consumption of vitamins may potentially moderate the impact of PM on hypertension.

METHODS

A 12-year longitudinal cohort study was conducted on a population in densely populated areas of China. Residual balancing with weighted methods was employed to control for time-varying and no time-varying confounding factors. Stratified Cox proportional hazards models were conducted to examine the moderating effects of diet and vitamins on the risk of hypertension with PM.

RESULTS

There was a significant positive association between long-term exposure to different diameter PM and the risk of developing hypertension. The hazard ratios (HRs) for hypertension were 1.0200 (95 % CIs: 1.0147, 1.0253) for PM1, 1.0120 (95 % CIs: 1.0085, 1.0155) for PM2.5, and 1.0074 (95 % CIs, 1.0056, 1.0092) for PM10. The diet and vitamins moderated these associations, the intake of healthy foods and vitamins exhibited a significant positive moderating effect on the relationship between PM exposure and hypertension risk. Among all participants, the high intake of fruit (PM1 (HRs: 1.0102, 95 % CIs: 1.0024, 1.0179), PM2.5 (HRs: 1.0060, 95 % CIs: 1.0011, 1.0109), and PM10 (HRs: 1.0044, 95 % CIs: 1.0018, 1.0070)) and vitamin E (PM1 (HRs: 1.0143, 95 % CIs: 1.0063, 1.0223), PM2.5 (HRs:1.0179, 95 % CIs: 1.0003, 1.0166), and PM10 (HRs: 1.0042, 95 % CIs: 1.0008, 1.0075)) with lower risk of hypertension than the overall level and low intake of related foods and vitamins, exhibited a strong positive moderating effect on the relationship between PM and hypertension. Similar trends were observed for the intake of fish, root food, whole grains, eggs, fungus food, vitamin B2, B3. However, Na, meat, sugary and alcoholic exhibited opposite trends. The moderating effect of vitamin E intake was stronger than vitamin B and C.

CONCLUSIONS

Diet and vitamins intake may moderate the association between PM exposure and the risk of hypertension in adults.

Sauveur R, Inddy J, Macius Y, Théard M, Lee MH, Mourra N, Rasul R, Nash D, Deschamps MM, Safford MM, Pape JW, Rouzier V, McNairy ML. Neighborhood Social Vulnerability and Premature Cardiovascular Disease in Haiti

Importance

Higher social vulnerability is associated with premature cardiovascular disease (CVD) and mortality but is understudied in low-income countries that have both the highest magnitude of social vulnerability and a growing CVD epidemic.

Objective

To evaluate the association between social vulnerability and hypertension, CVD, and CVD subtypes in Haiti as a model for similar low-income countries.

Design, Setting, and Participants

This population-based cohort study used enrollment data from adults participating in the Haiti Cardiovascular Disease Cohort Study. Recruitment occurred via multistage random sampling throughout slum and urban neighborhoods in Port-au-Prince, Haiti, from March 2019 to August 2021. Data were analyzed from May 2022 to December 2023.

Exposures

A modified Haitian Social Vulnerability Index (SVI-H) was created following the US Centers for Disease Control and Prevention Social Vulnerability Index method. Twelve variables across the domains of socioeconomic status, household characteristics, and social and community context were included. The SVI-H was calculated for each study neighborhood block and then stratified into SVI-H quartiles (quartile 1 was the least vulnerable; quartile 4, the most vulnerable).

Main Outcomes and Measures

Prevalent hypertension and total CVD, defined as heart failure (HF), stroke, transient ischemic attack (TIA), angina, or myocardial infarction (MI). Age-adjusted Poisson regression analysis yielded prevalence ratios (PRs) comparing the prevalence of hypertension, total CVD, and CVD subtypes across SVI-H quartiles.

Results

Among 2925 adults (1704 [58.3%] female; mean [SD] age, 41.9 [15.9] years), the prevalence of hypertension was 32.8% (95% CI, 31.1%-34.5%) and the prevalence of CVD was 14.7% (95% CI, 13.5%-16.0%). Hypertension prevalence ranged from 26.2% (95% CI, 23.1%-29.3%) to 38.4% (95% CI, 34.8%-42.0%) between quartiles 1 and 4, while CVD prevalence ranged from 11.1% (95% CI, 8.8%-13.3%) to 19.7% (95% CI, 16.8%-22.6%). SVI-H quartile 4 vs 1 was associated with a greater prevalence of hypertension (PR, 1.17; 95% CI, 1.02-1.34) and CVD (PR, 1.48; 95% CI, 1.16-1.89). Among CVD subtypes, SVI-H was significantly associated with HF (PR, 1.64; 95% CI, 1.23-2.18) but not with combined stroke and TIA or combined angina and MI.

Conclusions and Relevance

In urban Haiti, individuals living in neighborhoods with the highest social vulnerability had greater prevalence of hypertension and HF. Understanding CVD disparities in low-income countries is essential for targeting prevention and treatment interventions toward populations at highest risk globally.

Engaging One Health in Heavy Metal Pollution in Some Selected Nigerian Niger Delta Cities. A Systematic Review of Pervasiveness, Bioaccumulation and Subduing Environmental Health Challenges

The Niger Delta environment is under serious threat due to heavy metal pollution. Many studies have been conducted on the heavy metal contamination in soils, water, seafood and plants in the Niger Delta ecosystem. However, there is a lack of clear understanding of the health consequences for people and strategies for attaining One Health, and a dispersion of information that is accessible. The study focused on investigating the contamination levels, distributions, risks, sources and impacts of heavy metals in selected regions of the Niger Delta. Prior studies revealed that the levels of certain heavy metals, including Cd, Pb, Cu, Cr, Mn, Fe and Ni, in water, sediment, fish and plants in most Niger Delta ecosystems were higher than the acceptable threshold attributed to various anthropogenic stressors. In the reviewed Niger Delta states, ecosystems in Rivers state showed the highest concentrations of heavy metals in most sampled sites. Groundwater quality was recorded at concentrations higher than 0.3 mg/L World Health Organization drinking water guideline. High concentrations of copper (147.915 mg/L) and zinc (10.878 mg/L) were found in Rivers State. The heavy metals concentrations were greater in bottom-dwelling organisms such as bivalves, gastropods and shrimp than in other fishery species. Heavy metal exposure in the region poses risks of communicable and non-communicable diseases. Diverse remediation methods are crucial to reduce contamination levels, but comprehensive strategies and international cooperation are essential to address the health hazards. Actively reducing heavy metals in the environment can achieve One Health objectives and mitigate disease and economic burdens.

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study

BACKGROUND

Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life.

AIM

To develop a multidimensional international palliative care goals model in dementia for use in practice.

DESIGN

International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified.

SETTING/PARTICIPANTS

Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study.

RESULTS

Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves.

CONCLUSION

A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Health Facilities Readiness and Determinants to Manage Cardiovascular Disease in Afghanistan, Bangladesh, and Nepal: Evidence from the National Service Provision Assessment Survey

Background

In South Asia, cardiovascular diseases (CVDs) are an increasing public health concern. One strategy for dealing with the growing CVDs epidemic is to make health facilities more ready to provide CVDs services. The study's objectives were to: (1) assess healthcare facilities' readiness to offer CVDs services; and (2) identify the variables that influence such readiness.

Methods

This study employed data from the Afghanistan Service Provision Assessment Survey 2018-2019, Bangladesh Health Facility Survey 2017, and Nepal Health Facility Survey 2021 that were cross-sectional and nationally representative. In Afghanistan, Bangladesh, and Nepal, 117, 368, and 1,381 health facilities, respectively, were examined. A total of 10 items/indicators were used to measure a health facility's readiness to provide CVDs services across three domains.

Results

The mean readiness scores of managing CVDs were 6.7, 5.6, and 4.6 in Afghanistan, Bangladesh, and Nepal, respectively. Availability of trained staff for CVD services are not commonly accessible in Afghanistan (21.5%), Bangladesh (15.3%), or Nepal (12.9%), except from supplies and equipment. Afghanistan has the highest levels of medicine and other commodity availability. Among the common factors linked with readiness scores, we ought to expect a 0.02 unit rise in readiness scores for three nations for every unit increase in number of CVDs care providers. In Afghanistan, Bangladesh, and Nepal, availability of both diagnosis and treatment facilities was associated with increases in readiness scores of 27%, 9%, and 17%, respectively. Additionally, an association was observed between nation-specific facility types and the readiness scores.

Conclusions

Country-specific factors as well as universal factors present in all three nations must be addressed to improve a health facility's readiness to provide CVDs care. To create focused and efficient country-specific plans to raise the standard of CVD care in South Asia, more investigation is necessary to ascertain the reasons behind country-level variations in the availability of tracer items.

The relationship between climate change, globalization and non-communicable diseases in Africa: A systematic review

Climate change and non-communicable diseases (NCDs) are considered the 21st Century's major health and development challenges. Both pose a disproportionate burden on low- and middle-income countries that are unprepared to cope with their synergistic effects. These two challenges pose risks for achieving many of the sustainable development goals (SDGs) and are both impacted by globalization through different pathways. While there are important insights on how climate change and or globalization impact NCDs in the general literature, comprehensive research that explores the influence of climate change and or globalization on NCDs is limited, particularly in the context of Africa. This review documents the pathways through which climate change and or globalization influence NCDs in Africa. We conducted a comprehensive literature search in eight electronic databases-Web of Science, PubMed, Scopus, Global Health Library, Science Direct, Medline, ProQuest, and Google Scholar. A total of 13864 studies were identified. Studies that were identified from more than one of the databases were automatically removed as duplicates (n = 9649). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 27 studies were eventually included in the final review. We found that the impacts of climate change and or globalization on NCDs act through three potential pathways: reduction in food production and nutrition, urbanization and transformation of food systems. Our review contributes to the existing literature by providing insights into the impact of climate change and or globalization on human health. We believe that our findings will help enlighten policy makers working on these pathways to facilitate the development of effective policy and public health interventions to mitigate the effects of climate change and globalization on the rising burden of NCDs and goal 3 of the SDG, in particular.

Examining the referral of patients with elevated blood pressure to health resources in an under-resourced community in South Africa

BACKGROUND

Low-and-middle income countries face a disproportionate burden of non-communicable diseases (NCDs) that threaten to overwhelm under-resourced health systems. Community health workers (CHWs) can promote NCD prevention, reach patients, and connect them to local community health resources; however, little has been done to examine how referrals to these resources are utilized by community members. The purpose of this study is to examine the use of referrals to community-based health resources and investigate the factors influencing patient utilization of referrals connecting them to appropriate health resources for elevated blood pressure (BP).

METHODS

CHWs conducted home visits, which included BP screening and brief counseling, with community members in Soweto, South Africa. Participants with elevated (systolic BP: 121-139/ diastolic BP: 81-89 mmHg) or high (≥ 140/90 mmHg) BP were referred to either a local, community-based physical activity (PA) program managed by a non-governmental organization or local health clinics. The number of participants that received and utilized their referrals was tracked. Follow-up interviews were conducted with individuals given a referral who: (1) went to the PA program, (2) did not go to the PA program, (3) went to a clinic, and (4) did not go to a clinic. Interviews were transcribed and analyzed to identify common themes and differences between groups regarding their decisions to utilize the referrals.

RESULTS

CHWs visited 1056 homes, with 1001 community members consenting to the screening; 29.2% (n = 292) of adults were classified as having optimal BP (≤120/80 mmHg), 35.8% (n = 359) had elevated BP, and 35.0% (n = 350) had high BP. One hundred and seventy-three participants accepted a referral to the PA program with 46 (26.6%) enrolling. Five themes emerged from the interviews: (1) prior knowledge and thoughts on BP, (2) psychosocial factors associated with BP control, (3) perception about receiving the referral, (4) contextual factors influencing referral utilization, and (5) perceived benefits of utilizing the referral.

CONCLUSION

CHWs can successfully increase community members' access to health resources by providing appropriate referrals. However, greater attention needs to address community members' barriers and hesitancy to utilize health resources.

Association between normal-weight obesity and cardiometabolic risk factors among adults in Addis Ababa, Ethiopia

The relationship between normal-weight obesity (NWO)-high percent body fat (%BF) in individuals with normal body mass index (BMI)-and cardiometabolic abnormalities has not been explored in Africa. We determined the prevalence of the NWO and evaluated its association with hypertension, elevated blood sugar and dyslipidaemia among adults in Addis Ababa, Ethiopia. A cross-sectional study was conducted among adults 18-64 years (n = 600). Blood pressure, blood glucose, lipid profile, and anthropometric measurements were completed. As a function of skinfold thickness, body density and %BF were estimated using Durnin & Womersley and Siri Equations, respectively. The relationship between the NWO and the outcomes of interest, assessed using adjusted linear and logit models. The age- and sex-standardised prevalence of NWO was 18.9% (95% confidence interval (CI) 15.8, 22.2%). Comparison between normal-weight lean (normal %BF and BMI) and normal-weight obese individuals suggested no difference in systolic blood pressure (β = 2.55; 95% CI - 0.82, 5.92); however, diastolic blood pressure (β = 3.77: 95% CI 1.37, 6.18) and odds of hypertension (adjusted odds ratio (AOR) = 2.46: 95% CI 1.18, 5.13) were significantly raised in the latter. Similarly, adults with NWO had elevated blood glucose (β = 2.30; 95% CI 1.23, 15.66) and increased odds of high blood sugar level (AOR = 1.68; 95% CI 1.05, 2.67). LDL (β = 8.73: 1.56, 15.90), triglyceride (β = 20.99: 0.78, 41.22), total cholesterol (β = 10.47: 1.44, 19.50), and Cholesterol to HDL ratio (β = 0.65: 0.27, 1.04) were also raised among adults with NWO. NWO is common among adults in Addis Ababa and is associated with cardiometabolic derangements.

Influence of Air Pollution Exposures on Cardiometabolic Risk Factors: a Review

PURPOSE OF REVIEW

The increasing prevalence of cardiometabolic risk factors (CRFs) contributes to the rise in cardiovascular disease. Previous research has established a connection between air pollution and both the development and severity of CRFs. Given the ongoing impact of air pollution on human health, this review aims to summarize the latest research findings and provide an overview of the relationship between different types of air pollutants and CRFs.

RECENT FINDINGS

CRFs include health conditions like diabetes, obesity, hypertension etc. Air pollution poses significant health risks and encompasses a wide range of pollutant types, air pollutants, such as particulate matter (PM), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O2). More and more population epidemiological studies have shown a positive correlation between air pollution and CRFs. Although various pollutants have diverse effects on specific cellular molecular pathways, their main influence is on oxidative stress, inflammation response, and impairment of endothelial function. More and more studies have proved that air pollution can promote the occurrence and development of cardiovascular and metabolic risk factors, and the research on the relationship between air pollution and CRFs has grown intensively. An increasing number of studies are using new biological monitoring indicators to assess the occurrence and development of CRFs resulting from exposure to air pollution. Abnormalities in some important biomarkers in the population (such as homocysteine, uric acid, and C-reactive protein) caused by air pollution deserve more attention. Further research is warranted to more fully understand the link between air pollution and novel CRF biomarkers and to investigate potential prevention and interventions that leverage the mechanistic link between air pollution and CRFs.

Global Burden of Chronic Obstructive Pulmonary Disease Through 2050

Importance

Chronic obstructive pulmonary disease (COPD) is a respiratory condition that is associated with significant health and economic burden worldwide. Previous studies assessed the global current-day prevalence of COPD, but to better facilitate resource planning and intervention development, long-term projections are needed.

Objective

To assess the global burden of COPD through 2050, considering COPD risk factors.

Design, Setting, and Participants

In this modeling study, historical data on COPD prevalence was extracted from a recent meta-analysis on 2019 global COPD prevalence, and 2010 to 2018 historical prevalence was estimated using random-effects meta-analytical models. COPD risk factor data were obtained from the Global Burden of Disease database.

Main Outcomes and Measures

To project global COPD prevalence to 2050, generalized additive models were developed, including smoking prevalence, indoor and outdoor air pollution, and development indices as predictors, and stratified by age, sex, and World Bank region.

Results

The models estimated that the number of COPD cases globally among those aged 25 years and older will increase by 23% from 2020 to 2050, approaching 600 million patients with COPD globally by 2050. Growth in the burden of COPD was projected to be the largest among women and in low- and middle-income regions. The number of female cases was projected to increase by 47.1% (vs a 9.4% increase for males), and the number of cases in low- and middle-income regions was expected to be more than double that of high-income regions by 2050.

Conclusions and Relevance

In this modeling study of future COPD burden, projections indicated that COPD would continue to affect hundreds of millions of people globally, with disproportionate growth among females and in low-middle income regions through 2050. Further research, prevention, and advocacy are needed to address these issues so that adequate preparation and resource allocation can take place.

The Experiences of Community Health Workers in Preventing Noncommunicable Diseases in an Urban Area, the Philippines: A Qualitative Study

(1) Background: Barangay health workers (BHWs) play important roles as community health workers in preventing noncommunicable diseases (NCDs), where the shortage of health professionals is felt more acutely in the Philippines. However, there is little research on the experiences of BHWs as community health workers in preventing NCDs. This study aimed to clarify the roles and difficulties of BHWs in conducting activities for the prevention of NCDs. (2) Methods: Qualitative data were collected from 25 BHWs. (3) Results: The mean age of the participants was 50.4 ± 9.5 years, 23 were women, and the mean length of time as a BHW was 9.1 ± 7.7 years. Three major themes about the role of BHWs in preventing NCDs-"screening for NCDs", "assisting patients with management of their conditions", and "promoting healthy behaviors"-and four major themes about the difficulties-"insufficient awareness of preventative behaviors", "economic burdens", "lack of resources for managing NCDs", and "difficulty of access to medical care facilities"-were identified. (4) Conclusions: Through the findings of this study, focusing interventions aimed at addressing the difficulties for the prevention of NCDs among BHWs may help reduce health inequities.

Global burden of non-communicable chronic diseases associated with a diet low in fruits from 1990 to 2019

Background

The aim of this study was to assess the global burden of disease from non-communicable chronic diseases (NCD) due to diet low in fruits from 1990 to 2019.

Methods

Based on data from the Global Burden of Disease (GBD) 2019, the global burden of disease due to diet low in fruits was analyzed for each country or region, disaggregated by disease type, age, sex, and year. The number of deaths and disability-adjusted life years (DALYs), population attributable fraction (PAF), age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) were calculated, and the average annual percentage change (AAPC) was calculated to describe trends in ASMR and ASDR from 1990 to 2019.

Results

From 1990 to 2019, the number of deaths and DALYs due to diet low in fruits increased by 31.5 and 27.4%, respectively. Among the tertiary diseases, ischemic heart disease, stroke, and diabetes and kidney disease were the top three contributors to the global increase in deaths and DALYs. However, both ASMR and ASDR showed a decreasing trend. The fastest decline in ASMR and ASDR was in stroke, with AAPC of -2.13 (95% CI: -2.22, -2.05, p < 0.05) and -0.56 (95% CI: -0.62, -0.51, p < 0.05), respectively. For GBD regions, high PAF occurred mainly in South Asia, Oceania, and sub-Saharan Africa. Age-specific PAF for stroke and ischemic heart disease death attributable to diet low in fruits was significantly negatively associated with age. Diet low in fruits related ASMR and ASDR showed an M-shaped relationship with the socio-demographic index (SDI), but with an overall decreasing trend.

Conclusion

The number of deaths and DALYs due to diet low in fruits continues to increase. Therefore, early nutritional interventions should be implemented by the relevant authorities to reduce the burden of diseases caused by diet low in fruits.

Association of fine particulate matter and its constituents with hypertension: the modifying effect of dietary patterns

BACKGROUND

Studies have shown that nutritional supplements could reduce the adverse effects induced by air pollution. However, whether dietary patterns can modify the association of long-term exposure to fine particulate matter (PM2.5) and its constituents with hypertension defined by the 2017 ACC/AHA guideline has not been evaluated.

METHODS

We included 47,501 Chinese adults from a nationwide cross-sectional study. PM2.5 and five constituents were estimated by satellite-based random forest models. Dietary approaches to stop hypertension (DASH) and alternative Mediterranean diet (AMED) scores were calculated for each participant. Interactions between dietary patterns and air pollution were examined by adding a multiplicative interaction term to logistic models.

RESULTS

Long-term exposure to PM2.5 and its constituents was associated with an increased risk of hypertension and stage 1-2 hypertension. The DASH and AMED scores significantly modified these associations, as individuals with higher scores had a significantly lower risk of air pollution-related hypertension and stage 1-2 hypertension (P-interaction < 0.05), except for interaction between PM2.5, sulfate, nitrate, ammonium, and AMED score on stage 1 hypertension. For each IQR increase in PM2.5, participants with the lowest DASH and AMED quintiles had hypertension risk with ORs (95%CI) of 1.20 (1.10, 1.30) and 1.19 (1.09, 1.29), whereas those with the highest DASH and AMED quintiles had lower risks with 0.98 (0.91, 1.05) and 1.04 (0.97, 1.11). The stratified analysis found modification effect was more prominent in the < 65 years age group. Consuming more fresh vegetables, fruits, whole grains, and dairy would reduce the risk of hypertension caused by PM2.5 and its constituents.

CONCLUSIONS

Dietary patterns rich in antioxidants can reduce long-term exposure to PM2.5 and its constituents-induced hypertension defined by the 2017 ACC/AHA guideline, especially in young and middle-aged individuals. Compared to the Mediterranean diet, the DASH diet offers superior dietary guidance to prevent stage 1 hypertension caused by air pollution.

Engineered Living Materials for Advanced Diseases Therapy

Natural living materials serving as biotherapeutics exhibit great potential for treating various diseases owing to their immunoactivity, tissue targeting, and other biological activities. In this review, the recent developments in engineered living materials, including mammalian cells, bacteria, viruses, fungi, microalgae, plants, and their active derivatives that are used for treating various diseases are summarized. Further, the future perspectives and challenges of such engineered living material-based biotherapeutics are discussed to provide considerations for future advances in biomedical applications.

Non-self glycan structures as possible modulators of cancer progression: would polysaccharides from Cryptococcus spp. impact this phenomenon?

Invasive fungal infections (IFI) are responsible for a large number of annual deaths. Most cases are closely related to patients in a state of immunosuppression, as is the case of patients undergoing chemotherapy. Cancer patients are severely affected by the worrisome proportions that an IFI can take during cancer progression, especially in an already immunologically and metabolically impaired patient. There is scarce knowledge about strategies to mitigate cancer progression in these cases, beyond conventional treatment with antifungal drugs with a narrow therapeutic range. However, in recent years, ample evidence has surfaced describing the possible interferences that IFI may have both on the progression of pre-existing cancers and in the induction of newly transformed cells. The leading gambit for modulation of tumor progression comes from the ability of fungal virulence factors to modulate the host's immune system, since they are found in considerable concentrations in the tumor microenvironment during infection. In this context, cryptococcosis is of particular concern, since the main virulence factor of the pathogenic yeast is its polysaccharide capsule, which carries constituents with high immunomodulatory properties and cytotoxic potential. Therefore, we open a discussion on what has already been described regarding the progression of cryptococcosis in the context of cancer progression, and the possible implications that fungal glycan structures may take in both cancer development and progression.

Nonalcoholic Fatty Liver Disease in Asia, Africa, and Middle East Region

Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease worldwide. The global prevalence of the disease varies according to the geographical region. Despite having distinct models for the western patterns of NAFLD, Africa, Asia, and the Middle East regions exhibited varying prevalence rates of NAFLD. The disease burden is anticipated to significantly increase in these areas. Furthermore, with an increase in NAFLD risk factors in these regions, the disease burden is expected to rise even more. Policies at the regional and international levels are required to address such growing burden of NAFLD consequences.

Association between Mortality from Chronic Noncommunicable Diseases and Human Development Index in Brazil between 1980 and 2019

BACKGROUND

Chronic noncommunicable diseases (CNCDs) caused more than 734,000 deaths (55% of all deaths) in Brazil in 2019, with an important socioeconomic impact.

OBJECTIVES

To analyze the mortality rates from CNCDs in Brazil from 1980 to 2019 and their association with socioeconomic indicators.

METHOD

This was a descriptive, time-series study of deaths from CNCDs in Brazil from 1980 to 2019. Data on the annual frequencies of deaths and on population were obtained from the Department of Informatics of the Brazilian Unified Health System. Crude and standardized mortality rates per 100,000 inhabitants were estimated using the direct method (Brazilian population in 2000). The quartiles of each CNCD were calculated, where a quartile change, due to an increase in mortality rate, was represented by a chromatic gradient. The Municipal Human Development Index (MHDI) of each Brazilian federative unit was extracted from the Atlas Brasil website and correlated with the rates of CNCD mortality.

RESULTS

There was a reduction in mortality rates due to diseases of the circulatory system during the period, except in the Northeast Region. There was also an increase in mortality from neoplasia and diabetes, while the rates of chronic respiratory diseases showed little variation. There was an inverse correlation between the federative units with greater reduction in CNCD mortality rates and the MHDI.

CONCLUSIONS

The observed decrease in mortality due to diseases of the circulatory system may reflect an improvement in socioeconomic indicators in Brazil during the period. The increase in mortality rates due to neoplasms is probably related to the aging of the population. The higher mortality rates of diabetes seem to be associated with an increase in the prevalence of obesity in Brazilian women.

Growth patterns in childhood and adolescence and adult body composition: a pooled analysis of birth cohort studies from five low and middle-income countries (COHORTS collaboration)

OBJECTIVE

We examined associations among serial measures of linear growth and relative weight with adult body composition.

DESIGN

Secondary data analysis of prospective birth cohort studies.

SETTINGS

Six birth cohorts from Brazil, Guatemala, India, the Philippines and South Africa.

PARTICIPANTS

4173 individuals followed from birth to ages 22-46 years with complete and valid weight and height at birth, infancy, childhood and adolescence, and body composition in adult life.

EXPOSURES

Birth weight and conditional size (standardised residuals of height representing linear growth and of relative weight representing weight increments independent of linear size) in infancy, childhood and adolescence.

PRIMARY OUTCOME MEASURES

Body mass index, fat mass index (FMI), fat-free mass index (FFMI), fat mass/fat-free mass ratio (FM/FFM), and waist circumference in young and mid-adulthood.

RESULTS

In pooled analyses, a higher birth weight and relative weight gains in infancy, childhood and adolescence were positively associated with all adult outcomes. Relative weight gains in childhood and adolescence were the strongest predictors of adult body composition (β (95% CI) among men: FMI (childhood: 0.41 (0.26 to 0.55); adolescence: 0.39 (0.27 to 0.50)), FFMI (childhood: 0.50 (0.34 to 0.66); adolescence: 0.43 (0.32 to 0.55)), FM/FFM (childhood: 0.31 (0.16 to 0.47); adolescence: 0.31 (0.19 to 0.43))). Among women, similar patterns were observed, but, effect sizes in adolescence were slightly stronger than in childhood. Conditional height in infancy was positively associated with FMI (men: 0.08 (0.03 to 0.14); women: 0.11 (0.07 to 0.16)). Conditional height in childhood was positively but weakly associated with women's adiposity. Site-specific and sex-stratified analyses showed consistency in the direction of estimates, although there were differences in their magnitude.

CONCLUSIONS

Prenatal and postnatal relative weight gains were positive predictors of larger body size and increased adiposity in adulthood. A faster linear growth in infancy was a significant but weak predictor of higher adult adiposity.

The Greatest Healthcare Disparity: Addressing Inequities in the Treatment of Childhood Central Nervous System Tumors in Low- and Middle-Income Countries

The antithesis between childhood cancer survival rates in low- and middle-income countries (LMIC) and high-income countries (HIC) represents one of healthcare's most significant disparities. In HICs, the 5-year survival rate for children with cancer, including most brain tumors, exceeds 80%. Unfortunately, children in LMICs experience far worse outcomes with 5-year survival rates as low as 20%. To address inequities in the treatment of childhood cancer and disease burden globally, the World Health Organization (WHO) launched the Global Initiative for Childhood Cancer. Within this initiative, pediatric low-grade glioma (LGG) represents a unique opportunity for the neurosurgical community to directly contribute to a paradigm shift in the survival outcomes of children in LMICs, as many of these tumors can be managed with surgical resection alone. In this chapter, we discuss the burden of pediatric LGG and outline actions the neurosurgical community might consider to improve survival for children with LGG in LMICs.

Imaging blood-brain barrier dysfunction: A state-of-the-art review from a clinical perspective

The blood-brain barrier (BBB) consists of specialized cells that tightly regulate the in- and outflow of molecules from the blood to brain parenchyma, protecting the brain's microenvironment. If one of the BBB components starts to fail, its dysfunction can lead to a cascade of neuroinflammatory events leading to neuronal dysfunction and degeneration. Preliminary imaging findings suggest that BBB dysfunction could serve as an early diagnostic and prognostic biomarker for a number of neurological diseases. This review aims to provide clinicians with an overview of the emerging field of BBB imaging in humans by answering three key questions: (1. Disease) In which diseases could BBB imaging be useful? (2. Device) What are currently available imaging methods for evaluating BBB integrity? And (3. Distribution) what is the potential of BBB imaging in different environments, particularly in resource limited settings? We conclude that further advances are needed, such as the validation, standardization and implementation of readily available, low-cost and non-contrast BBB imaging techniques, for BBB imaging to be a useful clinical biomarker in both resource-limited and well-resourced settings.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level

BACKGROUND

In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services.

METHODS

The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts.

RESULTS

Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care.

CONCLUSIONS

The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.

Opportunities and challenges to non-communicable disease (NCD) research and training in Pakistan: a qualitative study from Pakistan

INTRODUCTION

Most of the global non-communicable disease (NCD)-related death burden is borne by low and middle-income countries (LMICs). In LMICs like Pakistan, however, a major gap in responding to NCDs is a lack of high-quality research leading to policy development and implementation of NCDs. To assess institutional opportunities and constraints to NCD research and training we conducted a situational analysis for NCD research and training at Aga Khan University Pakistan.

METHODS

We conducted a descriptive exploratory study using grounded theory as a qualitative approach: semistructured interviews of 16 NCD stakeholders (three excluded) and two focus group discussions with postgraduate and undergraduate trainees were conducted. A simple thematic analysis was done where themes were identified, and then recurring ideas were critically placed in their specific themes and refined based on the consensus of the investigators.

RESULTS

The major themes derived were priority research areas in NCDs; methods to improve NCD research integration; barriers to NCD research in LMICs like Pakistan; design of NCD research programme and career paths; and NCD prevention at mass level, policy and link to the government. In general, participants opined that while there was an appetite for NCD research and training, but few high-quality research training programmes in NCDs existed, such programmes needed to be established. The ideal NCD research and training programmes would have in-built protected time, career guidance and dedicated mentorship. Most participants identified cardiovascular diseases as a priority thematic area and health information technology and data science as key methodological approaches to be introduced into research training.

CONCLUSION

We conclude from this qualitative study on NCD research and training that high-quality research training programmes for NCDs are rare. Such programmes need to be established with in-built protected time, career guidance and mentorship for the trainees to improve their research capacity in Pakistan.

Lessons to learn from the analysis of routine health data from Moria Refugee Camp on Lesvos, Greece

Background

Refugees in humanitarian settings commonly experience many health needs and barriers to access healthcare; health data from these settings are infrequently reported, preventing effective healthcare provision. This report describes health needs of refugees in Moria Camp on Lesvos, Greece—Europe’s largest refugee camp.

Methods

A set of routinely collected service data of 18 131 consultations of 11 938 patients, attending a primary care clinic in the camp over 6 months in 2019–20, was analysed retrospectively, focusing on chronic health conditions.

Results

The most frequent chronic conditions were musculoskeletal pain (25.1%), mental health (15.9%), cardiac (12.7%) and endocrine conditions (8.9%). In all, 70.4% of consultations were for acute health problems, with high rates of injuries and wounds (20.8%), respiratory infections (12.5%), gastroenteritis (10.7%) and skin problems (9.7%), particularly scabies.

Conclusions

The prevalence of acute and chronic health problems is high in this setting, with some likely attributable to the deplorable living conditions in the camp. Despite its magnitude, the interpretability of routine health data is limited. A research agenda is identified, and a framework for chronic disease management in refugee camps is proposed.

Socioeconomic determinants for diagnosed non-communicable diseases among older people in China: Individual- and regional- level effects

Non-communicable diseases (NCDs) have become the major contributors to premature death and disability in China. This study used the repeated cross-sectional datasets of the 2008, 2011, 2014, and 2018 Chinese Longitudinal Healthy Longevity Survey, with a total number of 44,886 observations, to investigate the association between doctor-diagnosed chronic diseases (DCDs) and socioeconomic status at both individual and province level by multilevel logistic models. Results showed that higher socioeconomic status at both individual and regional level (measured as urbanisation) were associated with higher odds of diagnosed chronic diseases among older people in China. This study also found a "convergent" effect on DCDs between individual income and urbanisation. Meanwhile, older people who can receive adequate medical support and who cannot receive adequate medical support have a "divergent" effect on DCDs by urbanisation. Additionally, older people with different types of public health insurance have a "paralleled" effect on DCDs by urbanisation. The implications of this study may be that chronic disease among older people in lower socioeconomic status was substantially underdiagnosed. Investment in primary health care could be a cost-effective way to reduce the inequalities of diagnosed chronic diseases.

Non-communicable Disease-Related Sustainable Development Goals for 66 Belt and Road Initiative Countries

BACKGROUND

Since 2015, the Global Burden of Disease Study (GBD) has measured progress in achieving health-related Sustainable Development Goals (SDGs) annually worldwide. Little is known about the status and attainment of indicators of non-communicable diseases (NCDs) by 65 countries from the Belt and Road Initiative (BRI) proposed by China in 2013.

METHODS

Data from GBDs were used to estimate 24 NCD-related SDG indicators in BRI countries from 1990 to 2017. Each indicator was scored from 0 to 100 to compare multiple indicators over the study period. The natural log of the annual change in each location and year and weighted annual rates of change were used to generate projections for 2030. National-level estimates were determined by socio-demographic index (SDI) quintiles in BRI countries with more than 1 million inhabitants.

RESULTS

In 2017, the median overall score of NCD-related SDG index for the 66 BRI countries was 60 points, ranging from 29 points in Afghanistan to 84 points in Israel. More than 80% of countries achieved the SDG 2030 maternal mortality (MM) rate target in 2017, and the national skilled birth attendance rate was above 99% in more than 59% countries. However, none of the BRI countries achieved the goal for children's overweight, modern methods of contraception, and universal health coverage. It was predicted that 80.4% of NCD-related SDG targets would be achieved in these countries by 2030. The overall score of NCD-related SDG index were positively associated with SDI quintiles.

CONCLUSION

For many indicators, the achieved progress in many countries is less than the annual rate necessary to meet SDG targets, indicating that substantial efforts need to be made in the coming years. Progress should be accelerated through collaborations between countries, implementation of NCD prevention and control strategies, and monitoring of inequalities in NCD-related SDGs within populations.

Mortality inequalities measured by socioeconomic indicators in Brazil: a scoping review

OBJECTIVE

Summarize the literature on the relationship between composite socioeconomic indicators and mortality in different geographical areas of Brazil.

METHODS

This scoping review included articles published between January 1, 2000, and August 31, 2020, retrieved by means of a bibliographic search carried out in the Medline, Scopus, Web of Science, and Lilacs databases. Studies reporting on the association between composite socioeconomic indicators and all-cause, or specific cause of death in any age group in different geographical areas were selected. The review summarized the measures constructed, their associations with the outcomes, and potential study limitations.

RESULTS

Of the 77 full texts that met the inclusion criteria, the study reviewed 24. The area level of composite socioeconomic indicators analyzed comprised municipalities (n = 6), districts (n = 5), census tracts (n = 4), state (n = 2), country (n = 2), and other areas (n = 5). Six studies used composite socioeconomic indicators such as the Human Development Index, Gross Domestic Product, and the Gini Index; the remaining 18 papers created their own socioeconomic measures based on sociodemographic and health indicators. Socioeconomic status was inversely associated with higher rates of all-cause mortality, external cause mortality, suicide, homicide, fetal and infant mortality, respiratory and circulatory diseases, stroke, infectious and parasitic diseases, malnutrition, gastroenteritis, and oropharyngeal cancer. Higher mortality rates due to colorectal cancer, leukemia, a general group of neoplasms, traffic accident, and suicide, in turn, were observed in less deprived areas and/or those with more significant socioeconomic development. Underreporting of death and differences in mortality coverage in Brazilian areas were cited as the main limitation.

CONCLUSIONS

Studies analyzed mortality inequalities in different geographical areas by means of composite socioeconomic indicators, showing that the association directions vary according to the mortality outcome. But studies on all-cause mortality and at the census tract level remain scarce. The results may guide the development of new composite socioeconomic indicators for use in mortality inequality analysis.

Diversity regained: Precautionary approaches to COVID-19 as a phenomenon of the total environment

As COVID-19 emerged as a phenomenon of the total environment, and despite the intertwined and complex relationships that make humanity an organic part of the Bio- and Geospheres, the majority of our responses to it have been corrective in character, with few or no consideration for unintended consequences which bring about further vulnerability to unanticipated global events. Tackling COVID-19 entails a systemic and precautionary approach to human-nature relations, which we frame as regaining diversity in the Geo-, Bio-, and Anthropospheres. Its implementation requires nothing short of an overhaul in the way we interact with and build knowledge from natural and social environments. Hence, we discuss the urgency of shifting from current to precautionary approaches to COVID-19 and look, through the lens of diversity, at the anticipated benefits in four systems crucially affecting and affected by the pandemic: health, land, knowledge and innovation. Our reflections offer a glimpse of the sort of changes needed, from pursuing planetary health and creating more harmonious forms of land use to providing a multi-level platform for other ways of knowing/understanding and turning innovation into a source of global public goods. These exemplary initiatives introduce and solidify systemic thinking in policymaking and move priorities from reaction-based strategies to precautionary frameworks.

The niche-specialist and age-related oral microbial ecosystem: crosstalk with host immune cells in homeostasis

Although characterization of the baseline oral microbiota has been discussed, the current literature seems insufficient to draw a definitive conclusion on the interactions between the microbes themselves or with the host. This study focuses on the spatial and temporal characteristics of the oral microbial ecosystem in a mouse model and its crosstalk with host immune cells in homeostasis. The V3V4 regions of the 16S rRNA gene of 20 samples from four niches (tongue, buccal mucosa, keratinized gingiva and hard palate) and 10 samples from two life stages (adult and old) were analysed. Flow cytometry (FCM) was used to investigate the resident immune cells. The niche-specialist and age-related communities, characterized based on the microbiota structure, interspecies communications, microbial functions and interactions with immune cells, were addressed. The phylum Firmicutes was the major component in the oral community. The microbial community profiles at the genus level showed that the relative abundances of the genera Bacteroides, Lactobacillus and Porphyromonas were enriched in the gingiva. The abundance of the genera Streptococcus, Faecalibaculum and Veillonella was increased in palatal samples, while the abundance of Neisseria and Bradyrhizobium was enriched in buccal samples. The genera Corynebacterium, Stenotrophomonas, Streptococcus and Fusobacterium were proportionally enriched in old samples, while Prevotella and Lacobacillus were enriched in adult samples. Network analysis showed that the genus Lactobacillus performed as a central node in the buccal module, while in the gingiva module, the central nodes were Nesterenkonia and Hydrogenophilus. FCM showed that the proportion of Th1 cells in the tongue samples (38.18 % [27.03–49.34 %]) (mean [range]) was the highest. The proportion of γδT cells in the buccal mucosa (25.82 % [22.1–29.54 %]) and gingiva (20.42 % [18.31–22.53 %]) samples was higher (P<0.01) than those in the palate (14.18 % [11.69–16.67 %]) and tongue (9.38 % [5.38–13.37 %] samples. The proportion of Th2 (31.3 % [16.16–46.44 %]), Th17 (27.06 % [15.76–38.36 %]) and Treg (29.74 % [15.71–43.77 %]) cells in the old samples was higher than that in the adult samples (P<0.01). Further analysis of the interplays between the microbiomes and immune cells indicated that Th1 cells in the adult group, nd Th2, Th17 and Treg cells in the old group were the main immune factors strongly associated with the oral microbiota. For example, Th2, Th17 and Treg cells showed a significantly positive correlation with age-related microorganisms such as Sphingomonas, Streptococcus and Acinetobacter, while Th1 cells showed a negative correlation. Another positive correlation occurred between Th1 cells and several commensal microbiomes such as Lactobacillus, Jeotgalicoccus and Sporosarcina. Th2, Th17 and Treg cells showed the opposite trend. Together, our findings identify the niche-specialist and age-related characteristics of the oral microbial ecosystem and the potential associations between the microbiomes and the mucosal immune cells, providing critical insights into mucosal microbiology.

Unhealthy Dietary Habits and Obesity: The Major Risk Factors Beyond Non-Communicable Diseases in the Eastern Mediterranean Region

There are 22 countries in the Eastern Mediterranean Region (EMR) expanding from Morocco in the west to Pakistan and Afghanistan in the east, containing a population of 725,721 million in 2020. In the previous 30 years, the illness burden in the EMR has transmitted from communicable diseases to non-communicable diseases such as diabetes, cardiovascular diseases, and cancer. In 2019, cardiovascular mortality in the EMR was mostly attributed to ischemic heart disease, the first reason for mortality in 19 countries in the region. Stroke was the second reason for death in nine countries followed by diabetes, which was ranked as the second reason for death in two countries. The prominent nutrition-related NCDs risk factors in EMR include obesity, hypertension, high fasting plasma glucose, and upregulated unhealthy diet consumption. Most of the EMR population are unaware of their NCDs risk factor status. These risk factors, even if treated, are often poorly controlled, therefore, inhibiting their existence by changing the lifestyle to proper dietary habits and sufficient physical activity is mandatory. In this review, the epidemiology and nutrition-related risk factors of NCDs in the EMR will be discussed and illustrated, aiming to scale up action and support decision-makers in implementing cost effective strategies to address obesity and NCDs prevention and management in the region.

Japan's development assistance for health: Historical trends and prospects for a new era

The year 2020 marked an important turning point in Japan's global health policy. While the global health community has been suffering serious damage to sustainable health financing due to the COVID-19 pandemic, an independent commission on Japan's Strategy on Development Assistance for Health (DAH) launched an ambitious policy recommendation to double the amount of Japan's DAH during the post-COVID-19 era. This paper examines historical trends in DAH in Japan over the past 30 years based on published literature and comprehensive DAH tracking data and highlights priority areas for discussion on how DAH can be advanced to ensure equitable and efficient use of limited resources to support the achievement of the Sustainable Development Goals, including universal health coverage and pandemic preparedness, in low- and middle-income countries. Priority areas for discussion include: how and where to focus DAH for equitable health gains; how to provide DAH to support health system strengthening, including pandemic preparedness; and clarifying the role of DAH in global health functions.

Revamping of Chronic Respiratory Diseases in Low- and Middle-Income Countries

Low- and middle-income countries (LMICs) endure an asymmetrically high burden of worldwide disease and death caused by chronic respiratory diseases (CRDs), i.e., asthma, emphysema, bronchiectasis, and post-tuberculosis lung disease (PTLD). CRDs are firmly related with indigence, infectious diseases, and other non-communicable diseases (NCDs) and add to complex multi-disease with great impact on the lives and livelihood of those affected. The pertinence of CRDs to health and demographic wellbeing is relied upon to increment in the long time ahead, as expectations of life rise and the contending dangers of right on time youth mortality and irresistible infections level. The WHO has distinguished the counteraction and control of NCDs as an earnest improvement issue and crucial for the sustainable development goals (SDSs) by 2030. In this review, we center on CRDs in LMICs. We examine the early life roots of CRDs, challenges in their avoidance, identification and administration in LMICs, and the pathways to resolve for accomplish valid widespread wellbeing inclusion.

Addressing Severe Chronic NCDs Across Africa: Measuring Demand for the Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus)

Severe chronic non-communicable diseases (NCDs) pose important challenges for health systems across Africa. This study explores the current availability of and demand for decentralization of services for four high-priority conditions: insulin-dependent diabetes, heart failure, sickle cell disease, and chronic pain. Ministry of Health NCD Programme Managers from across Africa (N = 47) were invited to participate in an online survey. Respondents were asked to report the status of clinical care across the health system. A care package including diagnostics and treatment was described for each condition. Respondents were asked whether the described services are currently available at primary, secondary and tertiary levels, and whether making the service generally available at that level is expected to be a priority in the coming 5 years. Thirty-seven (79%) countries responded. Countries reported widespread gaps in service availability at all levels. We found that just under half (49%) of respondents report that services for insulin-dependent diabetes are generally available at the secondary level (district hospital); 32% report the same for heart failure, 27% for chronic pain and 14% for sickle cell disease. Reported gaps are smaller at tertiary level (referral hospital) and larger at primary care level (health centres). Respondents report ambitious plans to introduce and decentralize these services in the coming 5 years. Respondents from 32 countries (86%) hope to make all services available at tertiary hospitals, and 21 countries (57%) expect to make all services available at secondary facilities. These priorities align with the Package of Essential NCD Interventions-Plus. Efforts will require strengthened infrastructure and supply chains, capacity building for staff and new monitoring and evaluation systems for efficient implementation. Many countries will need targeted financial assistance in order to realize these goals. Nearly all (36/37) respondents request technical assistance to organize services for severe chronic NCDs.

Chronic non-communicable diseases considering sociodemographic determinants in a cohort of older adults

Abstract Objective To analyze the differences between the proportions of chronic non-communicable diseases (CNCDs) at two time periods, in a cohort of older adults, based on sociodemographic determinants. Method This is a retrospective longitudinal study with baseline data obtained in 2008-2009 and follow-up in 2016-2017, from the FIBRA Study. The McNemar test was used to compare the frequencies of CNCDs according to sex, age, and education, with a significance level of 5% (p<0.05). Results The sample consisted of 453 older adults (mean age 72±5.2 years old; 69.4% women). There was an increase in the proportions of arterial hypertension (64.4% versus 71.1%) and diabetes mellitus (21.9% versus 27.5%) in the periods studied, and a reduction in rheumatologic disease (43.6% versus 35.8%) and depression (21.7% versus 15.7%). Hypertension increased in older women, in those aged 65-74 years old and those with low education levels. Diabetes increased in older men, in those over 65 years of age and those with low education levels. A reduction in the proportions of rheumatologic diseases and depression was observed in women, in those aged 65-74 years old and those with low education levels. Conclusion The data reflect the need to understand the sociodemographic health determinants involved in the health-disease-care process to reduce social inequities and the burden of CNCDs in the most vulnerable population segments, especially in the older adult population with multimorbidity.

Doenças crônicas não transmissíveis considerando determinantes sociodemográficos em coorte de idosos

Resumo Objetivo Analisar as diferenças entre as proporções de doenças crônicas não transmissíveis (DCNT), em dois momentos, em uma coorte de idosos a partir de determinantes sociodemográficos. Método Trata-se de estudo longitudinal retrospectivo com dados obtidos do Estudo FIBRA linha de base (2008-2009) e seguimento (2016-2017). O teste de McNemar foi utilizado para comparar as frequências de DCNT segundo sexo, idade e escolaridade, com nível de significância de 5% (p<0,05). Resultados A amostra foi composta por 453 idosos (idade média 72±5,2 anos; 69,4% do sexo feminino). Observou-se aumento nas proporções de hipertensão arterial (64,4% versus 71,1%) e diabetes mellitus (21,9% versus 27,5%) no período estudado, e redução nas de doença reumatológica (43,6% versus 35,8%) e depressão (21,7% versus 15,7%). A hipertensão aumentou no sexo feminino, e nos idosos com 65-74 anos e com baixa escolaridade; o diabetes aumentou nos idosos do sexo masculino e nos indivíduos com idade acima de 65 anos e com baixa escolaridade; observou-se redução das proporções de doenças reumatológicas e de depressão no decorrer do estudo nas mulheres, naqueles com 65-74 anos de idade e com nível mais baixo de escolaridade. Conclusão Os dados refletem a necessidade de compreensão dos determinantes sociodemográficos de saúde envolvidos no processo saúde-doença-cuidado para a redução de iniquidades sociais e da carga de DCNT nos segmentos populacionais mais vulneráveis, especialmente na população idosa com multimorbidade.

High performance methylated DNA markers for detection of colon adenocarcinoma

BACKGROUND

Colon cancer (CC) is treatable if detected in its early stages. Improved CC detection assays that are highly sensitive, specific, and available at point of care are needed. In this study, we systematically selected and tested methylated markers that demonstrate high sensitivity and specificity for detection of CC in tissue and circulating cell-free DNA.

METHODS

Hierarchical analysis of 22 candidate CpG loci was conducted using The Cancer Genome Atlas (TCGA) COAD 450K HumanMethylation database. Methylation of 13 loci was analyzed using quantitative multiplex methylation-specific PCR (QM-MSP) in a training set of fresh frozen colon tissues (N = 53). Hypermethylated markers were identified that were highest in cancer and lowest in normal colon tissue using the 75th percentile in Mann-Whitney analyses and the receiver operating characteristic (ROC) statistic. The cumulative methylation status of the marker panel was assayed in an independent test set of fresh frozen colon tissues (N = 52) using conditions defined and locked in the training set. A minimal marker panel of 6 genes was defined based on ROC area under the curve (AUC). Plasma samples (N = 20 colorectal cancers, stage IV and N = 20 normal) were tested by cMethDNA assay to evaluate marker performance in liquid biopsy.

RESULTS

In the test set of samples, compared to normal tissue, a 6-gene panel showed 100% sensitivity and 90% specificity for detection of CC, and an AUC of 1.00 (95% CI 1.00, 1.00). In stage IV colorectal cancer plasma versus normal, an 8-gene panel showed 95% sensitivity, 100% specificity, and an AUC of 0.996 (95% CI 0.986, 1.00) while a 5-gene subset showed 100% sensitivity, 100% specificity, and an AUC of 1.00 (95% CI 1.00, 1.00), highly concordant with our observations in tissue.

CONCLUSIONS

We identified high performance methylated DNA marker panels for detection of CC. This knowledge has set the stage for development and implementation of novel, automated, self-contained CC detection assays in tissue and blood which can expeditiously and accurately detect colon cancer in both developed and underdeveloped regions of the world, enabling optimal use of limited resources in low- and middle-income countries.

Remarkable Uptake of Deoxynivalenol in Stable Metal-Organic Frameworks

Deoxynivalenol (DON), which is known as one of the most harmful mycotoxins, has contaminated food and feed and attracted concerns worldwide. However, the effective adsorptive removal of DON to ensure food safety still is a challenge, which is ascribed to the poor planarity and larger steric hindrance of DON molecules. Here, a new Zr(IV)-based metal-organic framework, entitled BUT-16 with one-dimensional channels and N-atom-decorated pore surface, is designed, prepared, and utilized for the adsorptive removal of DON. It exhibits excellent adsorption ability with an adsorption capacity of 46 mg/g higher than all reported adsorbents until now and a rapid adsorption rate of 0.031 g mg^-1 min^-1. DFT calculation and X-ray photoelectron spectroscopy results of the guest-loaded phase suggest that the record-breaking adsorption could be due to the cooperation of hydrogen bonding and Zr···O interaction between DON molecules and BUT-16 host. Most importantly, BUT-16 can effectively adsorb and remove DON in the simulated gastric fluid, but DON adsorbed on BUT-16 is hardly desorbed in the simulated intestinal fluid. The results demonstrate that BUT-16 has great promising application for the control of DON in foods and feeds.

Concessão privatista do saneamento e a incidência da Covid-19 em favelas do Rio de Janeiro

RESUMO O objetivo foi avaliar a relação espacial dos indicadores de saneamento (acesso à água e ao esgoto), considerando a modelagem da concessão da Companhia Estadual de Águas e Esgotos do Rio de Janeiro (Cedae), e a sua possível relação com a incidência da Covid-19, nos bairros com e sem áreas de favelas. Os dados de casos confirmados da Covid-19 analisados foram obtidos no Painel Saúde do Rio de Janeiro. Foi considerado o fracionamento do município em quatro blocos regionais. Nos 163 bairros da cidade, a taxa de incidência média foi de 9,78 casos/1.000 hab. Os bairros com as menores taxa de incidência foram aqueles com predominância de aglomerados subnormais (favelas), baixa renda per capita e cobertura de saneamento, sugerindo maior lacuna de testagem e subnotificação de casos. Reduzir a inequidade e o racismo estrutural deveria ser prioritário. A sindemia da Covid-19 contribuiu fortemente para perdas socioeconômicas e de saúde pública significativas. Em um cenário de reconstrução, é imprescindível retomar o compromisso para com os Objetivos de Desenvolvimento Sustentável da Agenda 2030 das Nações Unidas.

Privatizing sanitation concessions and the incidence of COVID-19 in slums in Rio de Janeiro

ABSTRACT This assessment aimed to evaluate the putative spatial relationship between sanitation indicators (access to water and sewage) considering the Rio de Janeiro State Water and Sewage Company (CEDAE) parameters and the COVID-19 incidence among districts with and without slum areas. The data of confirmed COVID-19 cases analyzed were obtained from the Rio de Janeiro Health Panel. We considered the division of the municipality into four regional blocks. The mean COVID-19 incidence was 9.78 cases/1,000 inhabitants in the 163 city districts. The lowest COVID-19 incidence rate was most reported in slum regions, with lower per capita income and sanitation coverage, suggesting a significant gap in testing and case underreporting. Reducing inequality and structural racism should be a priority. The COVID-19 syndemic strongly contributed to significant socioeconomic and public health losses. Our commitment to the Sustainable Development Goals of the 2030 agenda of the United Nations is pivotal in a backdrop of reconstruction.

A new mathematical approach to improve the original dietary inflammatory index (DII) calculation

Accumulating evidence links dietary intake to inflammatory processes involved in non-communicable disease (NCD) development. The dietary inflammatory index (DII) designed by Shivappa et al. has been shown to capture the inflammatory potential of dietary behavior in a large number of epidemiological studies. Thus, the DII may serve as future tool to assess someone's nutritional inflammatory capacities and hence, the individual risks for NCD development later in life. The calculation method of the DII, however, can benefit from alternative mathematical steps, particularly regarding the transformation from standardized daily food consumption to percentile scores. Here, we provide novel approaches, the scaling-formula (SF) and scaling-formula with outlier detection (SFOD) methods, with the aim to optimize the DII calculation method proposed by Shivappa and colleagues. We illustrate on simulated data specific limitations of the original DII calculation and show the benefits of the SF/SFOD by using simulated data and data from the prospective TEENDIAB study cohort, which supports the application of SF/SFOD in future epidemiological and clinical studies.

Prevalence and co-occurrence of lifestyle risk factors for non-communicable diseases according to sociodemographic characteristics among adults Chilean residents

To examine the prevalence and co-occurrence of lifestyle risk factors for non-communicable diseases (NCDs) according to sociodemographic characteristics in Chilean residents. A cross-sectional study based on data from 5995 adults from the Chilean National Health Survey. The lifestyle risk factors included were physical inactivity, tobacco consumption, alcohol consumption, low fruits and vegetable consumption, and overweight/obesity. The most frequent risk factor was overweight/obesity (75.6%), followed by alcohol consumption (74.8%), low fruits and vegetable consumption (51.7%), physical inactivity (36.3%), and tobacco consumption (27.9%). Only 1.0% of the participants did not present any risk factor, while 9.6%, 30.4%, 34.0%, 20.3%, and 4.7% accumulated one, two, three, four, and five risk factors. Men (OR 1.56; 95% CI 1.18; 2.04), people who have secondary education (OR 1.59; 95% CI 1.20; 2.10), and those with lower household income (OR 1.39; 95% CI 1.09; 1.59) had higher odds of three or more risk factors. Associations were inverse for older adults (OR 0.57; 95% CI 0.41; 0.79) and rural geographic areas (OR 0.77; 95% CI 0.67; 0.89). The prevalence of risk factors for NCDs is fairly high in Chilean residents. Interventions may need to target these co-occurrences rather than emphasizing individual risk factors for NCDs. Interventions could further consider these co-occurrences as a potential target for population stratification.

Dietary Approaches to Stop Hypertension (DASH) diet, Mediterranean diet and blood lipid profiles in less-developed ethnic minority regions

Different from developed countries, there is a paucity of research examining how the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets relate to lipids in less-developed ethnic minority regions (LEMR). A total of 83 081 participants from seven ethnic groups were retrieved from the baseline data of the China Multi-Ethnic Cohort study, which was conducted in less-developed Southwest China between May 2018 and September 2019. Multivariable linear regression models were then used to examine the associations of the DASH and alternative Mediterranean diet (AMED) scores, assessed by modified DASH score and AMED, as well as their components with total cholesterol (TC), LDL-cholesterol, HDL-cholesterol, TAG and TC/HDL-cholesterol. The DASH scores were negatively associated with TC, HDL-cholesterol and TAG. Comparing the highest quintiles with the lowest DASH scores, TC decreased 0·0708 (95 % CI -0·0923, -0·0493) mmol/l, HDL-cholesterol decreased 0·0380 (95 % CI -0·0462, -0·0299) mmol/l and TAG decreased 0·0668 (95 % CI -0·0994, -0·0341) mmol/l. The AMED scores were negatively associated with TC, LDL-cholesterol and HDL-cholesterol. Comparing the highest quintiles with the lowest AMED scores, TC decreased 0·0816 (95 % CI -0·1035, -0·0597) mmol/l, LDL-cholesterol decreased 0·0297 (95 % CI -0·0477, -0·0118) mmol/l and HDL-cholesterol decreased 0·0275 (95 % CI -0·0358, -0·0192) mmol/l. Although both the DASH diet and the Mediterranean diet were negatively associated with blood lipids, those associations showed different patterns in LEMR, particularly for TAG and HDL-cholesterol.

Repeated Annual Health Risk Assessments With Intervention Did Not Reduce 10-year Cardiovascular Disease Risk: A 4-year Longitudinal Study in 13,737 Financial Sector Employees

OBJECTIVE

To determine if repeat annual health risk assessments (RAHRAs) with intervention reduce 10-year cardiovascular disease (CVD) risk in financial sector employees.

METHODS

Retrospective analysis from RAHRAs in 13,737 employees over 4 years. We report changes in 10-year FRS for CVD (%) and risk factors after 1 (GR1), 2 (GR2), and 3 (GR 3) RAHRAs.

RESULTS

Mean FRS increased with RAHRAs (GR1: +0.4%; GR2: +0.7%; GR3: +0.8%) (P < 0.001) and was higher for GR3 versus GR1 (P < 0.001) and GR2 (pairwise: P < 0.0355). RAHRAs were associated with increased inadequate fruit/vegetable intake (GR1: +5.4%; GR2: +9.8%; GR3: +15.8%) (all pairwise: P < 0.001) and overweight (GR1: +5.4% vs GR2: +9.8%) (P < 0.001) and only hypercholesterolemia decreased (GR1: -4.4% vs GR3: -9.6%) (P < 0.001).

CONCLUSION

RAHRAs did not reduce 10-year CVD risk in financial sector employees. Role of RAHRAs in chronic disease management requires further study.