Global maps of travel time to healthcare facilities

The effect of conflict on damage to medical facilities in Mariupol, Ukraine: A quasi-experimental study

Medical facilities are civilian objects specially protected by international humanitarian law. Despite the need for systematic documentation of the effects of war on medical facilities for judiciary accountability, current methods for surveilling damage to protected civilian objects during ongoing armed conflict are insufficient. Satellite imagery damage assessment confers significant possibilities for investigating patterns of war. We leveraged commercially and publicly available satellite imagery and cross-referenced geolocated facility data to conduct a pre-post quasi-experimental study of damage to medical facilities in Mariupol, Ukraine as a result of Russia's invasion. We found that 77% of medical facilities in Mariupol sustained damage during Russia's siege lasting from February 24-May 20, 2022. Facility size was not associated with damage, suggesting that attacks on medical facilities are not random but instead may have been the result of intentional targeting. This is the first cross-referenced pre-post census study of the effects of an ongoing conflict on specially protected medical infrastructure.

Global Crop-Specific Fertilization Dataset from 1961-2019

As global fertilizer application rates increase, high-quality datasets are paramount for comprehensive analyses to support informed decision-making and policy formulation in crucial areas such as food security or climate change. This study aims to fill existing data gaps by employing two machine learning models, eXtreme Gradient Boosting and HistGradientBoosting algorithms to produce precise country-level predictions of nitrogen (N), phosphorus pentoxide (P2O5), and potassium oxide (K2O) application rates. Subsequently, we created a comprehensive dataset of 5-arcmin resolution maps depicting the application rates of each fertilizer for 13 major crop groups from 1961 to 2019. The predictions were validated by both comparing with existing databases and by assessing the drivers of fertilizer application rates using the model's SHapley Additive exPlanations. This extensive dataset is poised to be a valuable resource for assessing fertilization trends, identifying the socioeconomic, agricultural, and environmental drivers of fertilizer application rates, and serving as an input for various applications, including environmental modeling, causal analysis, fertilizer price predictions, and forecasting.

Travel Time as an Indicator of Poor Access to Care in Surgical Emergencies

Importance

Timely access to care is a key metric for health care systems and is particularly important in conditions that acutely worsen with delays in care, including surgical emergencies. However, the association between travel time to emergency care and risk for complex presentation is poorly understood.

Objective

To evaluate the impact of travel time on disease complexity at presentation among people with emergency general surgery conditions and to evaluate whether travel time was associated with clinical outcomes and measures of increased health resource utilization.

Design, Setting, and Participants

This retrospective cohort study used administrative statewide inpatient and emergency department databases with linkage across encounters, including nearly every inpatient or emergency department encounter in the states of Florida and California in 2021. Participants included adult patients who presented to an emergency department with 1 of 5 common emergency surgical conditions. Data were collected from January to December 2021 and analyzed from June to December 2023.

Exposure

The primary exposure was travel time from the patient's home to the facility where they initially received emergency care.

Main Outcomes and Measures

The primary outcome of interest was surgical disease complexity at the time of presentation to emergency care. Secondary outcomes included inpatient complications, mortality, and indicators of health system resource utilization. Multivariable logistic regression models were used, and adjusted odds ratios (aOR) and 95% CIs were reported.

Results

Among 190 311 adults with emergency general surgery conditions, 7138 (3.8%) lived further than 60 minutes from the facility where they sought emergency care. Longer travel times were associated with higher odds of complex disease presentation for travel time of more than 120 minutes vs 15 minutes or less (aOR, 1.28; 95% CI, 1.17-1.40). Patients with a travel time 60 minutes or more were more likely to require operative intervention (aOR, 1.17; 95% CI, 1.10-1.26), inpatient admission (aOR, 1.41; 95% CI, 1.33-1.50), interfacility transfer (aOR, 1.32; 95% CI, 1.15-1.51), and longer inpatient stay (adjusted mean difference, 0.47 days; 95% CI, 0.35-0.59), and had higher charges (adjusted mean difference, $8284; 95% CI, $5532-$11 035).

Conclusions and Relevance

In this cohort study of patients with emergency surgical conditions, travel time to emergency care was associated with markers of delayed presentation and increased facility resource utilization. As opposed to static measures, such as rurality, travel time may serve as a more useful metric to inform policy efforts aimed at preserving access to care amidst rural hospital closures and regionalization.

Bacteriology testing and antimicrobial resistance detection capacity of national tiered laboratory networks in sub-Saharan Africa: an analysis from 14 countries

BACKGROUND

Accurate detection of antimicrobial resistance (AMR) depends on adequate laboratory capacity. We aimed to document key weaknesses hindering AMR detection at various tiers of laboratory networks in 14 countries in sub-Saharan Africa, and analyse their significance in AMR surveillance and policies.

METHODS

In this analysis, we obtained retrospective data on AMR and antimicrobial consumption from 14 countries participating in the Mapping Antimicrobial Resistance and Antimicrobial Use Partnership between May 1, 2019, and June 30, 2020. We established the number, capacity for AMR detection, and other characteristics from all bacteriology laboratories within the national network from existing national health system compendiums, combined with a self-applied scored survey tool. We calculated AMR detection readiness scores at a facility and country level and analysed the pertinence of national strategies to address system gaps for AMR detection and surveillance.

FINDINGS

Of the 53 770 listed laboratories, 675 (1%) were formally assigned to deliver bacterial testing and invited to complete the survey tool. Of the 504 (75%) facilities that returned the completed survey, 393 (78%) reported antimicrobial susceptibility testing (AST) capacity and collectively provided geographical access to less than 50% of the general population in seven countries. Continuous access to water was reported by 347 (88%) laboratories, power sources by 341 (87%) laboratories, and the presence of qualified laboratory scientist or technologist by 377 (96%) laboratories. By contrast, ISO15189 accreditation was reported by 90 (23%) laboratories and use of an electronic laboratory information system by 54 (13%). Reference laboratories were associated with higher AMR detection readiness scores than were district laboratories (odds ratio 4·7 [95% CI 1·3-10·2; p=0·014). Private, not-for-profit laboratories were associated with higher scores than were government-affiliated facilities (9·2 [1·6-53·8; p=0·014). Designated national AMR sentinel sites were associated with higher scores than were non-sentinel sites (5·8 [2·9-11·8; p<0·001). Laboratories processing between 1001 and 3000 bacterial cultures annually were associated with higher scores than were those processing less than 200 cultures annually (4·8 [1·7-13·7]; p=0·0040). Strengthening bacterial testing and capacity for AMR detection represented less than 20% of the proposed interventions in 12 of the 14 national AMR action plans.

INTERPRETATION

AMR action plans and other relevant national strategies should prioritise the scale-up of bacterial testing services to improve access to care and promote quality AMR surveillance. Interventions that democratise AST to lower laboratory tiers, formally designate AMR sentinel sites, and implement whole-of-network laboratory information and quality management systems are urgently needed.

FUNDING

Fleming Fund, UK Aid, and US Centers for Disease Control and Prevention through the Training Programs in Epidemiology and Public Health Intervention Networks.

Inequalities in tuberculosis control in Ethiopia: A district-level distributional modelling analysis

BACKGROUND

Implementation studies indicate that the addition of tuberculosis diagnosis and treatment services into the community health extension workers' tasks-that is 'task-shifting'-improved case detection and treatment outcomes in Ethiopia. Given resource and operational constraints, only a limited number of areas can be targeted by an expanded task-shifting program. Therefore, we mapped the distributional disparities in tuberculosis services across regions and districts and modelled the equity pathways towards optimising national scale-up of this task-shifting intervention in Ethiopia.

METHODS

We used data from various sources including District Health Information Software 2; demographic, geospatial and topographic data; and previously published implementation study findings. We developed methods to integrate these datasets and to calculate the proportion of health facilities with tuberculosis services, the district population to health centre ratio, and the proportion of district population living within 2h walking distance from a health centre. Equity and disparities were then measured in terms of: tuberculosis services coverage; health centre adequacy, that is the district population served by health centres; and spatial access adequacy, that is the district population with health centre access within a two-hour walking distance. Subsequently, districts were ranked according to these measures to allow prioritisation of the health extension worker task-shifting intervention.

RESULTS

Tuberculosis services coverage varied from 54% in Afar region to 100% in Harari region, and health centre inadequacy ranged from 10% of districts in Benishangul-Gumuz to 87% in Sidama. After spatial access adjustment, health centre inadequacy ranged from 7% of districts in Sidama to 91% in Somali; and tuberculosis services inadequacy from 7% of districts in Sidama to 97% in Afar. Task-shifting implemented in inadequate districts (55% of all districts) could raise national case detection rate from 66% (currently) to 88% and treatment success rate from 93% to 99%; Benishangul-Gumuz achieving the largest increase of all regions.

CONCLUSIONS

Access to effective tuberculosis services presents substantial disparities across districts in Ethiopia, due to both health system and tuberculosis-specific factors. Jointly considering both types of factors would enable prioritisation of districts where health extension workers would be most impactful.

Mapping Drug-Resistant Tuberculosis Treatment Outcomes in Hunan Province, China

BACKGROUND

Drug-resistant tuberculosis (DR-TB) remains a major public health challenge in China, with varying treatment outcomes across different regions. Understanding the spatial distribution of DR-TB treatment outcomes is crucial for targeted interventions to improve treatment success in high-burden areas such as Hunan Province. This study aimed to map the spatial distribution of DR-TB treatment outcomes at a local level and identify sociodemographic and environmental factors associated with poor treatment outcomes in Hunan Province, China.

METHODS

A spatial analysis was conducted using DR-TB data from the Tuberculosis Control Institute of Hunan Province, covering the years 2013 to 2018. The outcome variable, the proportion of poor treatment outcomes, was defined as a composite measure of treatment failure, death, and loss to follow-up. Sociodemographic, economic, healthcare, and environmental variables were obtained from various sources, including the WorldClim database, the Malaria Atlas Project, and the Hunan Bureau of Statistics. These covariates were linked to a map of Hunan Province and DR-TB notification data using R software version 4.4.0. The spatial clustering of poor treatment outcomes was analyzed using the local Moran's I and Getis-Ord statistics. A Bayesian logistic regression model was fitted, with the posterior parameters estimated using integrated nested Laplace approximation (INLA).

RESULTS

In total, 1381 DR-TB patients were included in the analysis. An overall upward trend in poor DR-TB treatment outcomes was observed, peaking at 14.75% in 2018. Deaths and treatment failures fluctuated over the years, with a notable increase in deaths from 2016 to 2018, while the proportion of patients lost to follow-up significantly declined from 2014 to 2018. The overall proportion of poor treatment outcomes was 9.99% (95% credible interval (CI): 8.46% to 11.70%), with substantial spatial clustering, particularly in Anxiang (50%), Anren (50%), and Chaling (42.86%) counties. The proportion of city-level indicators was significantly associated with higher proportions of poor treatment outcomes (odds ratio (OR): 1.011; 95% CRI: 1.20 December 2024 001-1.035).

CONCLUSIONS

This study found a concerning increase in poor DR-TB treatment outcomes in Hunan Province, particularly in certain high-risk areas. Targeted public health interventions, including enhanced surveillance, focused healthcare initiatives, and treatment programs, are essential to improve treatment success.

Geographical accessibility to healthcare by point-of-interest data from online maps: a comparative study

Geographical accessibility is important for promoting health equity, and calculating it requires the locations of all existing healthcare facilities in a region. Authoritative location data collected by governments is accurate but mostly not publicly available, while point-of-interest (POI) data from online sources, such as Baidu Maps and AutoNavi Maps are easily accessible. However, the accuracy of the latter has not been thoroughly analyzed. Taking Baotou, a medium-sized city in China, as aneample, we assessed the suitability of using POI data for measuring geographic accessibility to healthcare facilities.We computedthe difference of geographic accessibility calculated based on POI data and that on authoritative data.Logistic regression and a multiple linear regression model was applied to identify factors related to the consistency between the two data sources. Compared to authoritative data, POI data exhibited discrepancies, with completeness of 54.9% and accuracy of 63.7%. Geographic accessibility calculated based on both data showed similar patterns, with good consistency for hospitals and in urban areas. However, large differences (>30 minutes) were shown in rural areas for primary healthcare facilities. The differences were small regarding to population- weighted average accessibility (with slight underestimation of 3.07 minutes) and population coverage across various levels of accessibility (with differences less than 1% of the population) for the entire area. In conclusion, POI data can be considered foruse in both urban areas and at the level of entire city; however, awareness should be raised in rural areas.

Inequalities in the geographic access to delivery services in Brazil

BACKGROUND

Despite Brazil's recent social progress, access to health services is still unequal. This article analyzes the inter-municipal distances traveled by pregnant women to access delivery services, documenting their magnitude and relationship to socioeconomic and risk factors for over a decade in Brazil.

METHODS

Using data between 2007 and 2017 from the Brazilian Information System of Live Births and a matrix of inter-municipal distances, we describe the evolution of (i) the share of pregnant women that traveled across municipalities and (ii) the average distance they traveled. Next, we assess which of the previous variables explains the changes in travel distance over time. Finally, we estimate the difference in the average travel distance by individual risk factors and use regression analysis to measure the association between this distance and municipal socioeconomic determinants from the Brazilian census.

RESULTS

We observe that, on average, (i) the share of women traveling for childbirth increased, reaching 31% in 2017, and (ii) distances got longer, approaching the 60-kilometer mark by 2017. The increase in distance is mainly due to more women traveling. Nevertheless, regional disparities persist, especially between the north/inland and coastal regions. Women with high-risk pregnancies or newborns with risks such as low birth weight tend to travel longer distances. However, those residing in higher-development municipalities tend to travel shorter distances.

CONCLUSION

Long distances remain an obstacle to accessing delivery facilities. This matter affects the most vulnerable disproportionately. Policymakers must consider the geographic accessibility of mothers when expanding birth-related services. Additionally, more research is required to understand the decision to travel and the distance effectively traveled as different accessibility facets.

Optimizing the survey design for assessing schistosomiasis at the sub-district for treatment decision making

BACKGROUND

Schistosomiasis control programs typically launch with district-level, school-based preventive chemotherapy (PC). Recent World Health Organization recommendations are to shift to community-wide treatment where schistosomiasis prevalence is >10%. Simultaneously there is a push to move to sub-district PC to prioritize communities in need of treatment and alleviate the pressure on global praziquantel need, but few countries have sub-district prevalence data and no guidelines on how to collect this information.

METHODS/PRINCIPAL FINDINGS

Data collected from 57,161 school-aged children (SAC) across six countries (Burkina Faso, Ghana, Mali, Senegal, Sierra Leone, and Togo) to generate spatially realistic gold standard datasets that were used to evaluate different numbers of schools per sub-district (1-10) and district (5-30), number of SAC sampled per school (10-50), on accuracy of prevalence estimates. Sampling fewer children in more schools maximized accuracy of prevalence at the sub-district and district level. Surveying three schools per sub-district or 15 schools per district gave precise prevalence estimates. Increasing the number of SAC beyond 30 per school led to negligible improvements in reliably detecting schistosomiasis. Failure to detect schistosomiasis occurred more frequently in low (1-10%) prevalence and larger districts/sub-districts.

CONCLUSION

This study provides guidelines for evaluating sub-district schistosomiasis in a range of transmission settings. Among two-stage cluster surveys for schistosomiasis, our simulations show surveying three schools per sub-district and 20-30 SAC per school optimized cost-efficiency and minimized risk of mistreatment. Population size and endemicity influenced survey estimates, with the probability of misclassification being greater as populations increased or prevalence decreased.

Task-sharing with community health workers to treat hypertension: a scoping review

Many studies have implemented and evaluated task-sharing interventions with community health workers (CHWs) to manage hypertension. To identify gaps in research, we conducted a scoping review. We searched original articles published in PubMed and EMBASE between 2010 and 2022 and found 122 articles meeting our inclusion criteria. Only seven articles were from low-income countries (LICs), most of which were qualitative studies or mixed methods studies. In the identified 122 articles, CHWs often performed health education (61.3%) and measured blood pressure (60.4%). Whereas CHWs carried out pharmacological treatment in only three studies. Participant homes (75.0%) were the most common setting for receiving interventions. Our study identified specific needs for future research, specifically, studies in LICs that are experimental in design and that collect relevant qualitative information, and studies in which CHWs do advanced task. In addition, publications of CHW studies should provide a more comprehensive list of intervention features.

Identifying optimal locations for the development of health facilities towards the attainment of universal health coverage using geospatial techniques in Kishapu district, Tanzania

Two hours of travel time specified by the World Health Organization (WHO) to access quality health services is among the most important criteria for the Universal Health Coverage. However, locations of health facilities (HF) in many developing countries fail to realise this target due to a lack of appropriate models considering the local environment. This work used the central-place theory to explore locations of HF in Kishapu and their accessibility status based on two means of transport in the AccessMod tool: walking only and the combination of walking-and-motor devices. The results of the walking scenario indicated that the travel times to the health centres and hospitals exceeded 2 h, and a direct relationship existed between the facility level and the travel time spent to access it. The combined transport (walking and motorized) showed that dispensaries are easily accessible (14.5 min) compared to health centres (42.8 min) and hospitals (67.3 min). To address the challenge, we have developed a model revealing optimal sites with quick access for HF construction and improvement using Multi-Criteria-Evaluation and Analytical-Hierarchy Process methods weighting five criteria including distance from settlements (44% weight), roads (26% weight), existing health facilities (16% weight), rivers (9% weight) and railway (5% weight). A test of the model with both means of transport shows that at all places proposed to be optimal allow patitents to travel in less than 2 h, indicating that the proposed model can effectively and efficiently solve the challenge of allocating HF in society.

A continental-wide decline of occupancy and diversity in five Neotropical carnivores

The Neotropics are a global biodiversity hotspot that has undergone dramatic land use changes over the last decades. However, a temporal perspective on the continental-wide distributions of species in this region is still missing. To unveil it, we model the entire area of occupancy of five Neotropical carnivore species at two time periods (2000-2013 and 2014-2021) using integrated species distribution models (ISDMs) in a Bayesian framework. The carnivores are the jaguarundi (Herpailurus yagouaroundi), margay (Leopardus wiedii), maned wolf (Chrysocyon brachyurus), tayra (Eira barbara), and giant otter (Pteronura brasiliensis). We mapped the temporal change, the areas where gains and losses accumulated for all species (hotspots of change) and calculated the temporal species turnover and change in spatial turnover. We show that (1) most carnivore species have declined their area of occupancy (i.e., range size) in the last two decades, (2) their diversity has decreased over time, mostly in the Chaco region, and (3) that hotspots of fast species composition turnover are in Chaco, the Caatinga region, and northwest of Mexico. We discuss how these newly identified hotspots of change overlap with regions of well-known and pronounced land use transformation. These estimated patterns of overall decline are alarming, more so given that four out of the five species had been classified as not threatened by IUCN. The official global threat status of these species may need to be re-evaluated. All this would be invisible if standard forecasts, local expert knowledge, or static threat criteria, such as range size, were used. We thus provide a new approach to evaluate past species range dynamics based on multiple lines of evidence, which can be employed over more species in the future, particularly in under-sampled regions.

Inequities in Access to Tricuspid Valve Treatments: The Impact of Procedure and Volume Requirements

Background

Opportunities to minimize inequities in accessing treatments for tricuspid regurgitation disease should be considered.

Objective

The objective of this study was to explore how access to new tricuspid regurgitation technologies change when heart centers are restricted by payer coverage requirements.

Methods

This case series study identified U.S. hospitals with a record of performing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and tricuspid and mitral valve procedures for the calendar year 2021. Population 65+ years of age and Area Deprivation Index (ADI), were identified by zip code. We created 10 scenarios based on low, medium, and high hospital volumes for combinations of transcatheter aortic valve replacement, transcatheter edge-to-edge repair, tricuspid and mitral valve procedures. Distance from a zip code to scenario eligible hospitals was determined; the closest hospital to a zip code was identified as the distance someone with tricuspid regurgitation would have to travel for care. Each scenario was modeled with the dependent variable as the distance to the nearest scenario eligible hospital by ADI, controlling for population size 65+ years of age.

Results

A total of 929 U.S. hospitals met our study inclusion. ADI was statistically significant in every scenario-when ADI goes up (more deprivation), distance to the nearest hospital increases. Patients in zip codes with low ADI travel an average of 15 to 52 miles, medium ADI 31 to 67 miles, and high ADI 47 to 95 miles.

Conclusions

Patients in higher socioeconomic deprivation areas travel longer distances to hospitals meeting procedure volume requirements. Policymakers and patient advocacy groups should consider this to ensure equitable access to potentially life-saving technologies.

Multidimensional Healthcare Access Barriers to Prostate-Specific Antigen Testing: A Nation-Wide Panel Study in the United States From 2006 to 2020

BACKGROUND

Rising metastatic prostate cancer incidence has renewed debate regarding benefits of prostate-specific antigen (PSA) screening. Identifying barriers to accessing screening for individuals at high risk of lethal prostate cancer may slow this rise. We examined associations of access barriers with receipt of PSA testing, stratified by sociodemographic factors.

METHODS

We pooled data from male respondents to Behavior Risk Factor Surveillance Systems (BRFSS) surveys from 2006 to 2020. Questions related to affordability (insurance, cost of visits) and accommodation (regular primary care provider (PCP), physician recommending a PSA test) were considered as individual-level barriers. For availability, we linked provider density from the 2012 Area Health Resource File and estimated driving times to closest health facility within Micropolitan and Metropolitan Statistical Area (MMSA) using Google Earth Engine. These measures were used to compute a spatial accessibility index. We fit survey-weighted, covariate-adjusted logistic regression models to estimate associations of barriers with receipt of PSA within the past 2 years and examined effect modification by sociodemographic factors.

RESULTS

There were 185,643 participants, of whom 73% were White, 11% were Black, 4% were Asian, and 11% were Hispanic. Physician recommendation was the strongest predictor of having a PSA test (aOR: 14.5, 95% CI: 13.6, 15.6). Not having a regular PCP (aOR: 0.29, 95% CI: 0.27, 0.31), insurance (aOR: 0.64, 95% CI: 0.58, 0.71), and prohibitive cost of care (aOR: 0.82, 95% CI: 0.75, 0.90) were associated with lower PSA testing. Access barriers were stronger predictors of PSA testing for Asian and White participants compared to other groups (Phet < 0.004 for insurance and regular PCP) and for those with college education compared to those without (Phet < 0.05 for insurance, perceived unaffordability).

DISCUSSION

Physician recommendation was the strongest predictor of receipt of PSA testing, regardless of sociodemographic grouping. Future studies should consider access barriers jointly and across sociodemographic strata.

National-scale 1-km maps of hospital travel time and hospital accessibility in China

Ensuring equitable access to health services is crucial for public welfare and social equity, and is a key objective of the United Nations' Sustainable Development Goals (SDGs). However, existing datasets often define hospital accessibility using travel time to hospitals in geographic dimension only, without considering the supply (hospital capacity) and demand (population distribution) dynamics. To overcome this limitation, we developed and validated a national-scale 1 km map of both hospital travel time and hospital accessibility in China. We used the Gaussian two-step floating catchment area (Ga2SFCA) model to calculate hospital accessibility, incorporating hospital capacity and service population. Various file types and statistical indicators are provided, making the dataset highly accessible for non-specialists. The dataset fills the gap in publicly available nationwide hospital accessibility data for China and can serve as a critical tool in optimizing resource allocation and developing targeted strategies to improve healthcare equity.

Urban and rural disparities in general hospital accessibility within a Chinese metropolis

Accessibility is one of the crucial criteria for measuring the ease of access to public services in a region. Given China's historical rural-urban dualism and rapid urbanization process, there exist significant disparities in public services within metropolises. This study selects Nanjing as a representative metropolis and employs the Gaussian two-step floating catchment area method and an improved potential model to calculate the accessibility of comprehensive hospitals. Spatial autocorrelation and urban-rural disparities are analyzed, confirming spatial variations in healthcare service equity. The results show that: ①The spatial variability of accessibility to comprehensive hospitals is significant. The Gaussian two-step floating catchment method overestimates overall accessibility, and for Nanjing, the improved potential model with β = 1.5 proves more suitable. ②Accessibility exhibits pronounced clustering characteristics. Healthcare conditions for residents in the northern part of Liuhe District, eastern part of Qixia District, western part of Pukou District, peripheral areas of Jiangning District, eastern part of Gaochun District, and residents in Lishui District need improvement. ③Comprehensive healthcare services are relatively lacking in nearly 60% of rural areas. Our research findings provide valuable insights for improving spatial justice in public infrastructure in metropolises of developing countries.

Strategic vaccine stockpiles for regional epidemics of emerging viruses: A geospatial modeling framework

Multinational epidemics of emerging infectious diseases are increasingly common, due to anthropogenic pressure on ecosystems and the growing connectivity of human populations. Early and efficient vaccination can contain outbreaks and prevent mass mortality, but optimal vaccine stockpiling strategies are dependent on pathogen characteristics, reservoir ecology, and epidemic dynamics. Here, we model major regional outbreaks of Nipah virus and Middle East respiratory syndrome, and use these to develop a generalized framework for estimating vaccine stockpile needs based on spillover geography, spatially-heterogeneous healthcare capacity and spatially-distributed human mobility networks. Because outbreak sizes were highly skewed, we found that most outbreaks were readily contained (median stockpile estimate for MERS-CoV: 2,089 doses; Nipah: 1,882 doses), but the maximum estimated stockpile need in a highly unlikely large outbreak scenario was 2-3 orders of magnitude higher (MERS-CoV: ∼87,000 doses; Nipah ∼ 1.1 million doses). Sensitivity analysis revealed that stockpile needs were more dependent on basic epidemiological parameters (i.e., death and recovery rate) and healthcare availability than any uncertainty related to vaccine efficacy or deployment strategy. Our results highlight the value of descriptive epidemiology for real-world modeling applications, and suggest that stockpile allocation should consider ecological, epidemiological, and social dimensions of risk.

The Right to Healthcare Must Include the Right to Ease of Physical Access: Exploring Geography-Health Nexus in GIDA Communities in the Philippines

Using the United Nations' 'leave no one behind' framework for the achievement of sustainable development goals, this article underscores the key role of geography as one of the core factors why certain people are left behind, deprived, and continue to experience inequality in terms of access to (quality) health care facilities and services. This article specifically examines the consequences of physical inaccessibility to health outcomes and health-seeking behavior in geographically isolated and disadvantaged areas (GIDAs) in the Philippines. This article illustrates that physical accessibility is an ignored aspect of the public health paradigm. For that reason, public health facilities, no matter how critical the facility is to a person's care, are not an immediate option for GIDA residents who seek medical aid. Responsive policy measures are vital to address this seemingly paradigmatic error. Subsidizing transportation costs and allocating funds for road improvements are called for, among other changes. The government must act on the people's right to ease of access as part of fulfilling fundamental health-related state obligations. But for the government to act, it will be crucial for claimants to health rights to proactively demand these changes. The latter is key for the fulfillment of the affected people's right to get easier access to meaningful health care.

The nexus between geographical distance and institutional delivery trends in Ethiopia: evidence from nationwide surveys

Background

Giving birth in a healthcare facility with the guidance of skilled healthcare providers allows access to necessary medical interventions. Ethiopia has implemented several strategies to enhance institutional delivery and decrease maternal mortality; however, the rate of institutional delivery remains low. This study examines the role of distance to healthcare institutions on institutional delivery in Ethiopia, and how this has changed over time.

Method

This study used data from two rounds of the Ethiopian Demographic and Health Survey (2011 and 2016), a spatial database detailing the locations of healthcare facilities, and Ethiopian road network data. The sample included 22,881 women who delivered within the 5 years preceding each survey and lived in 1,295 villages. Bivariate and multivariable logistic regression analyses were used to investigate how the distance to health facilities and other potential determinants influenced institutional delivery trends.

Results

The rate of institutional deliveries in Ethiopia has increased from 10% in 2011 to 26% in 2016. Likewise, the average transportation distance to health facilities has decreased from 22.4 km in 2011 to 20.2 km in 2016 at the national level. Furthermore, a one-kilometer increase in the distance to the nearest health facility was associated with a 1% decrease in the likelihood of delivering at a health facility in 2016 (odds ratio (OR) = 0.99, 95% CI [0.98-0.99], p < 0.05). Additionally, mothers who are more educated, have completed more antenatal care visits, live in wealthier households in more urban areas, and cohabit with more educated husbands are more likely to deliver at healthcare facilities. These variables showed consistent relevance in both survey rounds, suggesting that key determinants remained largely unchanged throughout the study period.

Conclusion

The impact of distance from health facilities on institutional delivery in Ethiopia remains evident, although its influence is relatively modest. The other factors, including education, antenatal care, socioeconomic status, urban residence, and partner education, remained consistent between the two surveys. These determinants have consistently influenced institutional delivery, highlighting the importance of a comprehensive approach that addresses both access to and socioeconomic factors to improve maternal and infant health across the country.

Is Access to Optimal Concussion Care for Pediatric Athletes Limited by Geography?

OBJECTIVE

To evaluate access to optimal concussion care based on a pediatric patients' geography; the hypothesis is that differential access across the Unites States exists.

DESIGN

Employed a novel strategy using internet searches to find local care, mimicking what families might do in different parts of the country.

SETTING

Virtual internet searches.

PARTICIPANTS

Not applicable.

INDEPENDENT VARIABLE

Various metropolitan and rural geographic regions within each state in the United States.

MAIN OUTCOME MEASURES

Evaluate access (defined as distance to clinic and ability to see pediatric patients) and optimal care (defined as self-referral process and presence of multidisciplinary care).

RESULTS

Search strategy yielded 490 results. Overall ∼60% were within 50 miles of searched locations with significant differences in access based on rural versus metropolitan areas ( P < 0.0001); in rural areas, only ∼22% of results were within 50 miles. Only about one-third of the results (n = 157) saw pediatric patient with no differences between regions. There was significant regional and geographic variation for optimal care regarding both self-referral processes and access to multidisciplinary care. A diverse group of specialists was represented in search results for concussion care.

CONCLUSIONS

Nationwide, there is an overall lack of access to multidisciplinary concussion care for pediatric patients. Additionally, those in rural communities face more limitations related to access to facilities with increased distances from closest clinic sites.

Cross-provincial inpatient mobility patterns and their determinants in China

BACKGROUND

The incongruity between the regional supply and demand of healthcare services is a persistent challenge both globally and in China. Patient mobility plays a pivotal role in addressing this issue. This study aims to delineate the cross-provincial inpatient mobility network (CIMN) in China and identify the underlying factors influencing this CIMN.

METHODS

We established China's CIMN by applying a spatial transfer matrix, utilizing the flow information from 5,994,624 cross-provincial inpatients in 2019, and identified the primary demand and supply provinces for healthcare services. Subsequently, we employed GeoDetector to analyze the impact of 10 influencing factors-including medical resources, medical quality, and medical expenses-on the spatial patterns of CIMN.

FINDINGS

Beijing, Shanghai, Zhejiang, and Jiangsu provinces are the preferred medical destinations for cross-provincial inpatients, while Anhui, Henan, Hebei, and Jiangsu provinces are the main sources for cross-provincial inpatients. Patient flow between provinces decreases with distance. The spatial distribution of medical resources, medical quality, and medical expenses account for 87%, 73%, and 56% of the formation of CIMN, respectively. Additionally, interactions between these factors enhance explanatory power, suggesting that considering their interactions can more effectively optimize medical resources and services.

CONCLUSIONS

The analysis of CIMN reveals the supply and demand patterns of healthcare services, providing insights into the inequality characteristics of healthcare access. Furthermore, understanding the driving factors and their interactions offers essential evidence for optimizing healthcare services.

Effects of climate change and human activities on vector-borne diseases

Vector-borne diseases are transmitted by haematophagous arthropods (for example, mosquitoes, ticks and sandflies) to humans and wild and domestic animals, with the largest burden on global public health disproportionately affecting people in tropical and subtropical areas. Because vectors are ectothermic, climate and weather alterations (for example, temperature, rainfall and humidity) can affect their reproduction, survival, geographic distribution and, consequently, ability to transmit pathogens. However, the effects of climate change on vector-borne diseases can be multifaceted and complex, sometimes with ambiguous consequences. In this Review, we discuss the potential effects of climate change, weather and other anthropogenic factors, including land use, human mobility and behaviour, as possible contributors to the redistribution of vectors and spread of vector-borne diseases worldwide.

Travel time to cataract surgical services in Kenya, Malawi and Rwanda: demonstrating a standardised indicator of physical access to cataract surgery

BACKGROUND

Travel time can be used to assess health services accessibility by reflecting the proximity of services to the people they serve. We aimed to demonstrate an indicator of physical access to cataract surgery and identify subnational locations where people were more at risk of not accessing cataract surgery.

METHODS

We used an open-access inventory of public health facilities plus key informants in Kenya, Malawi and Rwanda to compile a geocoded inventory of cataract facilities. For each country, gridded estimates of the population aged ≥ 50 years and a travel-time friction surface were combined and a least-cost-path algorithm applied to estimate the shortest travel time between each grid and the nearest cataract facility. We categorised continuous travel time by 1-, 2- and 3 h thresholds and calculated the proportion of the population in each category.

RESULTS

At the national level, the proportion of the population aged ≥ 50 years within 2 h travel time to permanent cataract surgical services was 97.2% in Rwanda (n = 10 facilities), 93.5% in Kenya (n = 74 facilities) and 92.0% in Malawi (n = 6 facilities); this reduced to 77.5%, 84.1% and 52.4% within 1 h, respectively. The least densely populated subnational regions had the poorest access to cataract facilities in Malawi (0.0%) and Kenya (1.9%).

CONCLUSION

We demonstrated an indicator of access that reflects the distribution of the population at risk of age-related cataract and identifies regions that could benefit from more accessible services. This indicator provides additional demand-side context for eye health planning and supports WHO's goal of advancing integrated people-centred eye care.

Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data

BACKGROUND

Progress on skilled birth attendance (SBA) has been very uneven across low-income and middle-income countries (LMICs). There is scant empirical evidence on the role of fundamental development processes in explaining differences in SBA outcomes across world regions over time in these settings. We therefore aimed to estimate how these processes have contributed to observed changes in SBA across Latin America and the Caribbean, South Asia, Southeast Asia, and sub-Saharan Africa.

METHODS

We pooled all available Demographic and Health Survey (DHS) rounds that contained detailed birth attendance information. The compiled data covers about 1·1 million births (1·1 million female individuals) from 103 DHS rounds in 37 countries. We estimated the determinants of SBA using multivariable regression techniques and Oaxaca-Blinder decompositions for different world regions and time periods (1990s, 2000s, and 2010s).

FINDINGS

We show that progress in SBA is associated with improvements in terms of household-level wealth, mothers' education, urbanisation, contraceptive knowledge, and proxies of female empowerment. Furthermore, we show that changes in the underlying relationship between SBA and specific development indicators (wealth, education, and rural residence status) have further contributed to the observed rise in SBA across LMICs. Our findings further suggest that certain determinants of improvements in SBA are region-specific (eg, importance of rural residence status in sub-Saharan Africa), whereas some of the studied processes (eg, poverty, maternal education, and urbanisation) have become less predictive for the uptake of SBA over time.

INTERPRETATION

Although substantial progress has been made in increasing SBA rates over the past three decades across LMICs, further efforts for continued progress are still needed to achieve international targets on SBA as part of the Sustainable Development Goals, the Every Newborn Action Plan, and the Ending Preventable Maternal Mortality initiative. According to our findings, these efforts can include general policies (eg, female empowerment) and region-specific policies (eg, poverty reduction programmes in Southeast Asia).

FUNDING

Bernhard Nocht Institute for Tropical Medicine.

TRANSLATIONS

For the French and Indonesian translations of the abstract see Supplementary Materials section.

Extreme Temperatures and Stroke Mortality: Evidence From a Multi-Country Analysis

BACKGROUND

Extreme temperatures contribute significantly to global mortality. While previous studies on temperature and stroke-specific outcomes presented conflicting results, these studies were predominantly limited to single-city or single-country analyses. Their findings are difficult to synthesize due to variations in methodologies and exposure definitions.

METHODS

Within the Multi-Country Multi-City Network, we built a new mortality database for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we conducted a multinational case-crossover study on the relationship between extreme temperatures and stroke. In the first stage, we fitted a conditional quasi-Poisson regression for daily mortality counts with distributed lag nonlinear models for temperature exposure separately for each city. In the second stage, the cumulative risk from each city was pooled using mixed-effect meta-analyses, accounting for clustering of cities with similar features. We compared temperature-stroke associations across country-level gross domestic product per capita. We computed excess deaths in each city that are attributable to the 2.5% hottest and coldest of days based on each city's temperature distribution.

RESULTS

We collected data for a total of 3 443 969 ischemic strokes and 2 454 267 hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000 ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1 (95% empirical CI, 8.6-9.4) and 2.2 (95% empirical CI, 1.9-2.4) excess deaths, respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot days contributed 11.2 (95% empirical CI, 10.9-11.4) and 0.7 (95% empirical CI, 0.5-0.8) excess deaths, respectively. We found that countries with low gross domestic product per capita were at higher risk of heat-related hemorrhagic stroke mortality than countries with high gross domestic product per capita (P=0.02).

CONCLUSIONS

Both extreme cold and hot temperatures are associated with an increased risk of dying from ischemic and hemorrhagic strokes. As climate change continues to exacerbate these extreme temperatures, interventional strategies are needed to mitigate impacts on stroke mortality, particularly in low-income countries.

Fine-scale maps of malaria incidence to inform risk stratification in Laos

BACKGROUND

Malaria risk maps are crucial for controlling and eliminating malaria by identifying areas of varying transmission risk. In the Greater Mekong Subregion, these maps guide interventions and resource allocation. This article focuses on analysing changes in malaria transmission and developing fine-scale risk maps using five years of routine surveillance data in Laos (2017-2021). The study employed data from 1160 geolocated health facilities in Laos, along with high-resolution environmental data.

METHODS

A Bayesian geostatistical framework incorporating population data and treatment-seeking propensity was developed. The models incorporated static and dynamic factors and accounted for spatial heterogeneity.

RESULTS

Results showed a significant decline in malaria cases in Laos over the five-year period and a shift in transmission patterns. While the north became malaria-free, the south experienced ongoing transmission with sporadic outbreaks.

CONCLUSION

The risk maps provided insights into changing transmission patterns and supported risk stratification. These risk maps are valuable tools for malaria control in Laos, aiding resource allocation, identifying intervention gaps, and raising public awareness. The study enhances understanding of malaria transmission dynamics and facilitates evidence-based decision-making for targeted interventions in high-risk areas.

Zero-Dose Childhood Vaccination Status in Rural Democratic Republic of Congo: Quantifying the Relative Impact of Geographic Accessibility and Attitudes toward Vaccination

Despite efforts to increase childhood vaccination coverage in the Democratic Republic of the Congo (DRC), approximately 20% of infants have not started their routine immunization schedule (zero-dose). The present study aims to evaluate the relative influence of geospatial access to health facilities and caregiver perceptions of vaccines on the vaccination status of children in rural DRC. Pooled data from two consecutive nationwide immunization surveys conducted in 2022 and 2023 were used. Geographic accessibility was assessed based on travel time from households to their nearest health facility using the AccessMod 5 model. Caregiver attitudes to vaccination were assessed using the survey question "How good do you think vaccines are for your child?" We used logistic regression to assess the relationship between geographic accessibility, caregiver attitudes toward vaccination, and their child's vaccination status. Geographic accessibility to health facilities was high in rural DRC, with 88% of the population living within an hour's walk to a health facility. Responding that vaccines are "Bad, Very Bad, or Don't Know" relative to "Very Good" for children was associated with a many-fold increased odds of a zero-dose status (ORs 69.3 [95%CI: 63.4-75.8]) compared to the odds for those living 60+ min from a health facility, relative to <5 min (1.3 [95%CI: 1.1-1.4]). Similar proportions of the population fell into these two at-risk categories. We did not find evidence of an interaction between caregiver attitude toward vaccination and travel time to care. While geographic access to health facilities is crucial, caregiver demand appears to be a more important driver in improving vaccination rates in rural DRC.

Temporal and spatial dynamics of Plasmodium falciparum clonal lineages in Guyana

Plasmodium parasites, the causal agents of malaria, are eukaryotic organisms that obligately undergo sexual recombination within mosquitoes. In low transmission settings, parasites recombine with themselves, and the clonal lineage is propagated rather than broken up by outcrossing. We investigated whether stochastic/neutral factors drive the persistence and abundance of Plasmodium falciparum clonal lineages in Guyana, a country with relatively low malaria transmission, but the only setting in the Americas in which an important artemisinin resistance mutation (pfk13 C580Y) has been observed. We performed whole genome sequencing on 1,727 Plasmodium falciparum samples collected from infected patients across a five-year period (2016-2021). We characterized the relatedness between each pair of monoclonal infections (n = 1,409) through estimation of identity-by-descent (IBD) and also typed each sample for known or candidate drug resistance mutations. A total of 160 multi-isolate clones (mean IBD ≥ 0.90) were circulating in Guyana during the study period, comprising 13 highly related clusters (mean IBD ≥ 0.40). In the five-year study period, we observed a decrease in frequency of a mutation associated with artemisinin partner drug (piperaquine) resistance (pfcrt C350R) and limited co-occurence of pfcrt C350R with duplications of plasmepsin 2/3, an epistatic interaction associated with piperaquine resistance. We additionally observed 61 nonsynonymous substitutions that increased markedly in frequency over the study period as well as a novel pfk13 mutation (G718S). However, P. falciparum clonal dynamics in Guyana appear to be largely driven by stochastic factors, in contrast to other geographic regions, given that clones carrying drug resistance polymorphisms do not demonstrate enhanced persistence or higher abundance than clones carrying polymorphisms of comparable frequency that are unrelated to resistance. The use of multiple artemisinin combination therapies in Guyana may have contributed to the disappearance of the pfk13 C580Y mutation.

The medical competence of health care providers in sub-Saharan Africa: Evidence from 16 127 providers across 11 countries

Despite a consensus that quality of care is critically deficient in low-income countries, few nationally representative studies provide comparable measures of quality of care across countries. To address this gap, we used nationally representative data from in-person administrations of clinical vignettes to measure the competence of 16 127 health care providers across 11 sub-Saharan African countries. Rather than large variations across countries, we found that 81% of the variation in competence is within countries and the characteristics of health care providers do not explain most of this variation. Professional qualifications-including cadre and education-are only weakly associated with competence: across our sample, one-third of nurses are more competent than the average doctor in the same country and one-quarter of doctors are less competent than the average nurse. Finally, while younger cohorts do tend to be more competent, perhaps reflecting improvements in medical education, it would take 25 decades of turnover to improve care by 10 percentage points, on average, if we were to rely on such improvements alone. These patterns necessitate a fundamentally different approach to health care human resource management, calling into question typical staffing policies based on qualifications and seniority rather than directly measured quality.

Effectiveness of Using AI-Driven Hotspot Mapping for Active Case Finding of Tuberculosis in Southwestern Nigeria

Background: Nigeria is among the top five countries that have the highest gap between people reported as diagnosed and estimated to have developed tuberculosis (TB). To bridge this gap, there is a need for innovative approaches to identify geographical areas at high risk of TB transmission and targeted active case finding (ACF) interventions. Leveraging community-level data together with granular sociodemographic contextual information can unmask local hotspots that could be otherwise missed. This work evaluated whether this approach helps to reach communities with higher numbers of undiagnosed TB. Methodology: A retrospective analysis of the data generated from an ACF intervention program in four southwestern states in Nigeria was conducted. Wards (the smallest administrative level in Nigeria) were further subdivided into smaller population clusters. ACF sites and their respective TB screening outputs were mapped to these population clusters. This data were then combined with open-source high-resolution contextual data to train a Bayesian inference model. The model predicted TB positivity rates on the community level (population cluster level), and these were visualised on a customised geoportal for use by the local teams to identify communities at high risk of TB transmission and plan ACF interventions. The TB positivity yield (proportion) observed at model-predicted hotspots was compared with the yield obtained at other sites identified based on aggregated notification data. Results: The yield in population clusters that were predicted to have high TB positivity rates by the model was at least 1.75 times higher (p-value < 0.001) than the yield in other locations in all four states. Conclusions: The community-level Bayesian predictive model has the potential to guide ACF implementers to high-TB-positivity areas for finding undiagnosed TB in the communities, thus improving the efficiency of interventions.

The Effects of Distance, Time, and Nonspatial Factors on Hemodialysis Access in Qatar

Background A long distance and time spent traveling to a hemodialysis (HD) center and other factors, such as comorbidities, can significantly impact HD patient compliance, satisfaction, and cost. Uncertainty about HD-dependent patients' geographical location may lead to inappropriate distribution of HD centers. The present study investigates travel time, distance, and nonspatial factors affecting HD center accessibility within a 30-km radius in the State of Qatar. Materials and methods The study included all HD-dependent patients residing in Qatar between March 1, 2020, and December 31, 2021. There were 921 patients dialyzed in six HD centers across Qatar. Our methodology incorporated descriptive and analytical cross-sectional designs to accurately identify the shortest routes and quickest travel times. We used two applications (Maptive {Vancouver, WA: BatchGeo LLC} and Google Maps {Mountain View, CA: Google LLC}) and marked a driving distance of 30 km as the main assessment scale and measurement standard, allowing optimum spatial accessibility determination. Results On average, patients traveled approximately 19±4.2 km, requiring almost 17.6±3.4 minutes to reach the assigned HD center three times per week. Based on geographic-spatial accessibility analysis, patients living in Umm Salal drove 31.4±3.5 km in 32.4±4.7 minutes, Al Daayen patients drove 30.2 km in 25.3 minutes, and others even drove more than 70 km to access HD sessions. Approximately 37.8% of Qatar's municipalities had no HD centers within their boundaries, but nearly 47% of HD-dependent patients lived in those municipalities. Additionally, some municipalities had HD centers; however, their general population density was less than 100 inhabitants/km2, and they had relatively few patients requiring regular HD. We noted a statistically significant correlation between the patients' residences and the locations of HD centers, whether they were located within or outside municipalities. Also, nonspatial factors may have affected the likelihood of reaching a hemodialysis center within a 30-km distance, including two or more comorbid conditions, having HD for at least five years, living in a municipality with more than 1,000 inhabitants/km2, being female, and attending dialysis centers that are more than 30 km away. Conclusion Although the available HD centers were sufficient for the present number of patients requiring HD, HD center locations did not match the patients' distribution, leading to difficulties for some patients. Understanding the impact of this geographic mismatch, population density, and other spatial factors helps significantly improve patient care and satisfaction at minimal cost. Furthermore, considering all these factors is crucial when planning new centers to achieve higher satisfaction and compliance as well as better health care.

Eligibility of cardiac arrest patients for extracorporeal cardiopulmonary resuscitation and their clinical characteristics: a retrospective two-centre study

BACKGROUND AND IMPORTANCE

Sudden cardiac arrest has a high incidence and often leads to death. A treatment option that might improve the outcomes in refractory cardiac arrest is Extracorporeal Cardiopulmonary Resuscitation (ECPR).

OBJECTIVES

This study investigates the number of in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients eligible to ECPR and identifies clinical characteristics that may help to identify which patients benefit the most from ECPR.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective two-centre study was conducted in Rotterdam, the Netherlands. All IHCA and OHCA patients between 1 January 2017 and 1 January 2020 were screened for eligibility to ECPR. The primary outcome was the percentage of patients eligible to ECPR and patients treated with ECPR. The secondary outcome was the comparison of the clinical characteristics and outcomes of patients eligible to ECPR treated with conventional Cardiopulmonary Resuscitation (CCPR) vs. those of patients treated with ECPR.

MAIN RESULTS

Out of 1246 included patients, 412 were IHCA patients and 834 were OHCA patients. Of the IHCA patients, 41 (10.0%) were eligible to ECPR, of whom 20 (48.8%) patients were actually treated with ECPR. Of the OHCA patients, 83 (9.6%) were eligible to ECPR, of whom 23 (27.7%) were actually treated with ECPR. In the group IHCA patients eligible to ECPR, no statistically significant difference in survival was found between patients treated with CCPR and patients treated with ECPR (hospital survival 19.0% vs. 15.0% respectively, 4.0% survival difference 95% confidence interval -21.3 to 28.7%). In the group OHCA patients eligible to ECPR, no statistically significant difference in-hospital survival was found between patients treated with CCPR and patients treated with ECPR (13.3% vs. 21.7% respectively, 8.4% survival difference 95% confidence interval -30.3 to 10.2%).

CONCLUSION

This retrospective study shows that around 10% of cardiac arrest patients are eligible to ECPR. Less than half of these patients eligible to ECPR were actually treated with ECPR in both IHCA and OHCA.

Assessing the accuracy of health facility typology in representing the availability of health services: a case study in Mali

INTRODUCTION

Using health facility types as a measure of service availability is a common approach in international standards for health system policy and planning. However, this proxy may not accurately reflect the actual availability of specific health services.

OBJECTIVE

This study aims to evaluate the reliability of health facility typology as an indicator of specific health service availability and explore whether certain facility types consistently provide particular services.

DESIGN

We analysed a comprehensive dataset containing information from 1725 health facilities in Mali. To uncover and visualise patterns within the dataset, we used two analytical techniques: Multiple Correspondence Analysis and Between-Class Analysis. These analyses allowed us to quantitatively measure the influence of health facility types on the variation in health service provisioning. Additionally, we developed and calculated a Consistency Index, which assesses the consistency of a health facility type in providing specific health services. By examining various health facilities and services, we sought to determine the accuracy of facility types as indicators of service availability.

SETTING

The study focused on the health system in Mali as a case study.

RESULTS

Our findings indicate that using health facility types as a proxy for service availability in Mali is not an accurate representation. We observed that most of the variation in service provision does not stem from differences between facility types but rather within facility types. This suggests that relying solely on health facility typology may lead to an incomplete understanding of health service availability.

CONCLUSIONS

These results have significant implications for health policy and planning. The reliance on health facility types as indicators for health system policy and planning should be reconsidered. A more nuanced and evidence-based understanding of health service availability is crucial for effective health policy and planning, as well as for the assessment and monitoring of health systems.

Examining geospatial and temporal distribution of invasive non-typhoidal Salmonella disease occurrence in sub-Saharan Africa: a systematic review and modelling study

BACKGROUND

Invasive non-typhoidal Salmonella (iNTS) disease is a significant health concern in sub-Saharan Africa. While our knowledge of a larger-scale variation is growing, understanding of the subnational variation in iNTS disease occurrence is lacking, yet crucial for targeted intervention.

METHOD

We performed a systematic review of reported occurrences of iNTS disease in sub-Saharan Africa, consulting literature from PubMed, Embase and Web of Science published since 2000. Eligibility for inclusion was not limited by study type but required that studies reported original data on human iNTS diseases based on the culture of a normally sterile site, specifying subnational locations and the year, and were available as full-text articles. We excluded studies that diagnosed iNTS disease based on clinical indications, cultures from non-sterile sites or serological testing. We estimated the probability of occurrence of iNTS disease for sub-Saharan Africa on 20 km × 20 km grids by exploring the association with geospatial covariates such as malaria, HIV, childhood growth failure, access to improved water, and sanitation using a boosted regression tree.

RESULTS

We identified 130 unique references reporting human iNTS disease in 21 countries published from 2000 through 2020. The estimated probability of iNTS occurrence grids showed significant spatial heterogeneity at all levels (20 km × 20 km grids, subnational, country and subregional levels) and temporal heterogeneity by year. For 2020, the probability of occurrence was higher in Middle Africa (0.34, 95% CI: 0.25 to 0.46), followed by Western Africa (0.33, 95% CI: 0.23 to 0.44), Eastern Africa (0.24, 95% CI: 0.17 to 0.33) and Southern Africa (0.08, 95% CI: 0.03 to 0.11). Temporal heterogeneity indicated that the probability of occurrence increased between 2000 and 2020 in countries such as the Republic of the Congo (0.05 to 0.59) and Democratic Republic of the Congo (0.10 to 0.48) whereas it decreased in countries such as Uganda (0.65 to 0.23) or Zimbabwe (0.61 to 0.37).

CONCLUSION

The iNTS disease occurrence varied greatly across sub-Saharan Africa, with certain regions being disproportionately affected. Exploring regions at high risk for iNTS disease, despite the limitations in our data, may inform focused resource allocation. This targeted approach may enhance efforts to combat iNTS disease in more affected areas.

Associations between school-based fluoride mouth-rinse program, medical-dental expense subsidy policy, and children's oral health in Japan: an ecological study

BACKGROUND

Dental caries are a common non-communicable disease among children. As a public health measure at the prefectural level, school-based fluoride mouth-rinse (S-FMR) program, medical/dental expense subsidy policies, and other factors may reduce the incidence of dental caries and tooth loss. Prefectures focusing on promoting oral health policies may promote both, but the interaction effect of implementing both subsidy policies and S-FMR at the prefectural level on caries prevention has not yet been examined.

METHODS

We conducted an ecological study using two-wave panel data, prefecture-level aggregated data in Japan for 2016 and 2018. Coefficient and 95% confidence intervals (CI) were calculated for the dependent variables for oral health using mixed-effects linear regression analysis adjusted for possible confounders. Two dependent variables were used; the standardized claim ratio (SCR) of deciduous tooth extraction and 12-year-olds' decayed, missing, or filled permanent teeth (DMFT). Four independent variables were S-FMR, the SCR of dental sealants, prefectural income per person, and subsidy policy in three models: co-payment until children enter elementary school (n = 23), no co-payment until children enter elementary school (n = 7), and co-payment continuing beyond elementary school (n = 17). The effects of six interaction terms, each representing a unique pairing from the four independent variables, were individually calculated.

RESULTS

S-FMR was negatively associated with the SCR of deciduous tooth extractions and DMFT (coefficient = -0.11, 95% CI -0.20; -0.01 and coefficient = -0.003, 95% CI -0.005; -0.001, respectively). No co-payment until children enter elementary school was positively associated with the SCR of deciduous tooth extraction compared to co-payment until children enter elementary school(coefficient = 11.42, 95% CI 3.29; 19.55). SCR of dental sealants was positively associated with the SCR of deciduous tooth extractions (coefficient = 0.12, 95% CI 0.06; 0.19) but negatively associated with DMFT (coefficient = -0.001, 95% CI -0.003; -0.0001). Per capita prefectural income was positively associated with the SCR of deciduous tooth extractions(coefficient = 0.01, 95% CI 0.001; 0.02). No interaction was found between S-FMR and the subsidy policy at both outcomes.

CONCLUSION

High S-FMR utilization and no co-payment until children enter elementary school were associated with fewer deciduous tooth extractions. Also, S-FMR and dental sealant were associated with decreased DMFT.

Capacity and establishment rules govern the number of nonnative species in communities of ground-dwelling invertebrates

Nonnative species are a key agent of global change. However, nonnative invertebrates remain understudied at the community scales where they are most likely to drive local extirpations. We use the North American NEON pitfall trapping network to document the number of nonnative species from 51 invertebrate communities, testing four classes of drivers. We sequenced samples using the eDNA from the sample's storage ethanol. We used AICc informed regression to evaluate how native species richness, productivity, habitat, temperature, and human population density and vehicular traffic account for continent-wide variation in the number of nonnative species in a local community. The percentage of nonnatives varied 3-fold among habitat types and over 10-fold (0%-14%) overall. We found evidence for two types of constraints on nonnative diversity. Consistent with Capacity rules (i.e., how the number of niches and individuals reflect the number of species an ecosystem can support) nonnatives increased with existing native species richness and ecosystem productivity. Consistent with Establishment Rules (i.e., how the dispersal rate of nonnative propagules and the number of open sites limits nonnative species richness) nonnatives increased with automobile traffic-a measure of human-generated propagule pressure-and were twice as common in pastures than native grasslands. After accounting for drivers associated with a community's ability to support native species (native species richness and productivity), nonnatives are more common in communities that are regularly seasonally disturbed (pastures and, potentially deciduous forests) and those experiencing more vehicular traffic. These baseline values across the US North America will allow NEON's monitoring mission to document how anthropogenic change-from disturbance to propagule transport, from temperature to trends in local extinction-further shape biotic homogenization.

The impact of transportation mode, socioeconomic deprivation and rurality on travel times to radiotherapy and surgical services for patients with prostate cancer: A national population-based evaluation

BACKGROUND

The distances that patients have to travel can influence their access to cancer treatment. We investigated the determinants of travel time, separately for journeys by car and public transport, to centres providing radical surgery or radiotherapy for prostate cancer.

METHODS

Using national cancer registry records linked to administrative hospital data, we identified patients who had radical surgery or radiotherapy for prostate cancer between January 2017 and December 2018 in the English National Health Service. Estimated travel times from the patients' residential area to the nearest specialist surgical or radiotherapy centre were estimated for journeys by car and by public transport.

RESULTS

We included 13,186 men who had surgery and 26,581 who had radiotherapy. Estimated travel times by public transport (74.4 mins for surgery and 69.4 mins for radiotherapy) were more than twice as long as by car (33.4 mins and 29.1mins, respectively). Patients living in more socially deprived neighbourhoods in rural areas had the longest travel times to the nearest cancer treatment centres by car (62.0 mins for surgery and 52.1 mins for radiotherapy). Conversely patients living in more affluent neighbourhoods in urban conurbations had the shortest (18.7 mins for surgery and 17.9 mins for radiotherapy).

CONCLUSION

Travel times to cancer centres vary widely according to mode of transport, socioeconomic deprivation, and rurality. Policies changing the geographical configuration of cancer services should consider the impact on the expected travel times both by car and by public transport to avoid enhancing existing inequalities in access to treatment and patient outcomes.

Determinants of intention to conceal tuberculosis status among family members: an analysis of seven Sub-Saharan African countries

BACKGROUND

Tuberculosis (TB) remains a significant public health burden in Sub-Saharan Africa (SSA), accounting for about 25% of global TB cases. In several communities, TB diagnosis, treatment, and control have become a critical challenge, largely due to the intention to conceal TB status among family members. It is therefore crucial to understand the factors associated with the intentions to conceal TB status among family members in SSA.

METHODS

This quantitative study utilised data from the most recent Demographic and Health Surveys (DHS). The objective was to examine the factors associated with the intention to conceal the TB status of family members. The sample consisted of 58,849 individuals aged 10 years or older from seven SSA countries. Binary logistic regression was employed to assess the associations between TB status concealment and various socio-demographic and economic variables.

RESULTS

The overall prevalence of TB status concealment intentions for the seven countries was 28.0% (95% CI: 27.6-28.4). Malawi and Eswatini accounted for the highest (47.3%) and lowest (3.0%) prevalence of TB concealment intentions respectively. TB status concealment intentions decreased with increasing age (p < 0.001). Living in rural areas was associated with lower odds of intending to conceal the TB of family members compared to living in urban areas (aOR = 0.92; p = 0.008). Higher education levels were associated with lower odds of TB status concealment intentions (aOR = 0.50; p < 0.001) compared to lower education levels. As participants wealth index increased, the odds of TB status concealment intentions decreased (aOR = 0.83; p < 0.001). Country of residence also showed significant associations with individuals in Ghana (aOR = 4.51; p < 0.001), Lesotho (aOR = 2.08; p < 0.001), Malawi (aOR = 4.10; p < 0.001), Namibia (aOR = 4.40; p < 0.001), and Sao-Tome and Principe (aOR = 5.56; p < 0.001) showing higher odds of TB status concealment intentions compared to Eswatini.

CONCLUSIONS

The findings conclude that several social determinants of health, including age, urbanicity, education, and wealth contribute to TB status concealment intentions for family members. Considering these factors is important for designing targeted interventions to improve TB control in the sample. In light of the unavailability of cultural variables in the dataset, future research can leverage qualitative approaches to conduct a more comprehensive exploration of the cultural factors linked to TB status concealment intentions in the population.

Protocol for spatial prediction of soil transmitted helminth prevalence in the Western Pacific region using a meta-analytical approach

BACKGROUND

Soil transmitted helminth (STH) infections are estimated to impact 24% of the world's population and are responsible for chronic and debilitating morbidity. Disadvantaged communities are among the worst affected and are further marginalized as infection prevalence fuels the poverty cycle. Ambitious targets have been set to eliminate STH infections, but accurate epidemiological data will be required to inform appropriate interventions. This paper details the protocol for an analysis that aims to produce spatial prediction mapping of STH prevalence in the Western Pacific Region (WPR).

METHODS

The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. The study design will combine the principles of systematic review, meta-analysis, and geospatial analysis. Systematic searches will be undertaken in PubMed, Scopus, ProQuest, Embase, and Web of Science for studies undertaken post 2000, to identify surveys that enable the prevalence of human STH infection within the WPR to be calculated. Covariate data for multivariable analysis will be obtained from publicly accessible sources. Survey data will be geolocated, and STH prevalence and covariates will be linked to produce a spatially referenced dataset for analysis. Bayesian model-based geostatistics will be used to generate spatially continuous estimates of STH prevalence mapped to a resolution of 1 km2. A separate geospatial model will be constructed for each STH species. Predictions of prevalence will be made for unsampled locations and maps will be overlaid for each STH species to obtain co-endemicity maps.

DISCUSSION

This protocol facilitates study replication and may be applied to other infectious diseases or alternate geographies. Results of the subsequent analysis will identify geographies with high STH prevalence's and can be used to inform resource allocation in combating this neglected tropical disease.

TRIAL REGISTRATION

Open Science Framework: osf.io/qmxcj.

Geographic pair matching in large-scale cluster randomized trials

Cluster randomized trials are often used to study large-scale public health interventions. In large trials, even small improvements in statistical efficiency can have profound impacts on the required sample size and cost. Location integrates many socio-demographic and environmental characteristics into a single, readily available feature. Here we show that pair matching by geographic location leads to substantial gains in statistical efficiency for 14 child health outcomes that span growth, development, and infectious disease through a re-analysis of two large-scale trials of nutritional and environmental interventions in Bangladesh and Kenya. Relative efficiencies from pair matching are ≥1.1 for all outcomes and regularly exceed 2.0, meaning an unmatched trial would need to enroll at least twice as many clusters to achieve the same level of precision as the geographically pair matched design. We also show that geographically pair matched designs enable estimation of fine-scale, spatially varying effect heterogeneity under minimal assumptions. Our results demonstrate broad, substantial benefits of geographic pair matching in large-scale, cluster randomized trials.

Mapping heterogeneity in family planning indicators in Burkina Faso, Kenya, and Nigeria, 2000-2020

BACKGROUND

Family planning is fundamental to women's reproductive health and is a basic human right. Global targets such as Sustainable Development Goal 3 (specifically, Target 3.7) have been established to promote universal access to sexual and reproductive healthcare services. Country-level estimates of contraceptive use and other family planning indicators are already available and are used for tracking progress towards these goals. However, there is likely heterogeneity in these indicators within countries, and more local estimates can provide crucial additional information about progress towards these goals in specific populations. In this analysis, we develop estimates of six family indicators at a local scale, and use these estimates to describe heterogeneity and spatial-temporal patterns in these indicators in Burkina Faso, Kenya, and Nigeria.

METHODS

We used a Bayesian geostatistical modelling framework to analyse geo-located data on contraceptive use and family planning from 61 household surveys in Burkina Faso, Kenya, and Nigeria in order to generate subnational estimates of prevalence and associated uncertainty for six indicators from 2000 to 2020: contraceptive prevalence rate (CPR), modern contraceptive prevalence rate (mCPR), traditional contraceptive prevalence rate (tCPR), unmet need for modern methods of contraception, met need for family planning with modern methods, and intention to use contraception. For each country and indicator, we generated estimates at an approximately 5 × 5-km resolution and at the first and second administrative levels (regions and provinces in Burkina Faso; counties and sub-counties in Kenya; and states and local government areas in Nigeria).

RESULTS

We found substantial variation among locations in Burkina Faso, Kenya, and Nigeria for each of the family planning indicators estimated. For example, estimated CPR in 2020 ranged from 13.2% (95% Uncertainty Interval, 8.0-20.0%) in Oudalan to 38.9% (30.1-48.6%) in Kadiogo among provinces in Burkina Faso; from 0.4% (0.0-1.9%) in Banissa to 76.3% (58.1-89.6%) in Makueni among sub-counties in Kenya; and from 0.9% (0.3-2.0%) in Yunusari to 31.8% (19.9-46.9%) in Somolu among local government areas in Nigeria. There were also considerable differences among locations in each country in the magnitude of change over time for any given indicator; however, in most cases, there was more consistency in the direction of that change: for example, CPR, mCPR, and met need for family planning with modern methods increased nationally in all three countries between 2000 and 2020, and similarly increased in all provinces of Burkina Faso, and in large majorities of sub-counties in Kenya and local government areas in Nigeria.

CONCLUSIONS

Despite substantial increases in contraceptive use, too many women still have an unmet need for modern methods of contraception. Moreover, country-level estimates of family planning indicators obscure important differences among locations within the same country. The modelling approach described here enables estimating family planning indicators at a subnational level and could be readily adapted to estimate subnational trends in family planning indicators in other countries. These estimates provide a tool for better understanding local needs and informing continued efforts to ensure universal access to sexual and reproductive healthcare services.

Temporal and spatial dynamics of Plasmodium falciparum clonal lineages in Guyana

Plasmodium parasites, the causal agents of malaria, are eukaryotic organisms that obligately undergo sexual recombination within mosquitoes. However, in low transmission settings where most mosquitoes become infected with only a single parasite clone, parasites recombine with themselves, and the clonal lineage is propagated rather than broken up by outcrossing. We investigated whether stochastic/neutral factors drive the persistence and abundance of Plasmodium falciparum clonal lineages in Guyana, a country with relatively low malaria transmission, but the only setting in the Americas in which an important artemisinin resistance mutation (pfk13 C580Y) has been observed. To investigate whether this clonality was potentially associated with the persistence and spatial spread of the mutation, we performed whole genome sequencing on 1,727 Plasmodium falciparum samples collected from infected patients across a five-year period (2016-2021). We characterized the relatedness between each pair of monoclonal infections (n=1,409) through estimation of identity by descent (IBD) and also typed each sample for known or candidate drug resistance mutations. A total of 160 clones (mean IBD ≥ 0.90) were circulating in Guyana during the study period, comprising 13 highly related clusters (mean IBD ≥ 0.40). In the five-year study period, we observed a decrease in frequency of a mutation associated with artemisinin partner drug (piperaquine) resistance (pfcrt C350R) and limited co-occurence of pfcrt C350R with duplications of plasmepsin 2/3, an epistatic interaction associated with piperaquine resistance. We additionally report polymorphisms exhibiting evidence of selection for drug resistance or other phenotypes and reported a novel pfk13 mutation (G718S) as well as 61 nonsynonymous substitutions that increased markedly in frequency. However, P. falciparum clonal dynamics in Guyana appear to be largely driven by stochastic factors, in contrast to other geographic regions. The use of multiple artemisinin combination therapies in Guyana may have contributed to the disappearance of the pfk13 C580Y mutation.

Mapping Access to Children's Hospitals in Texas

Vehicle access, travel time, and distance to hospitals and emergency rooms with sufficient patient beds are critical healthcare accessibility measures, especially for children who require specific pediatric services. In a large state like Texas with vast rural areas and limited public transit infrastructure, 75% of the children live over an hour from the closest facility that provides pediatric emergency services or specialty care. In view of this challenge, this study first sought to map the prevailing geographical accessibility to children's hospitals and, second, to model the hospital beds per capita for each hospital's service area within the state of Texas. The results showed disparities in accessing emergency pediatric care, especially in rural areas. However, despite major metro areas recording better geographical accessibility to pediatric healthcare, residents in these areas may experience limited hospital bed availability. The findings indicate an urgent need for more pediatric healthcare services in rural Texas. Given the increasing population growth in metro areas and their surroundings, there is also a need for the expansion of healthcare infrastructure in these areas.

Socioeconomic, Demographic, and Environmental Factors May Inform Malaria Intervention Prioritization in Urban Nigeria

Urban population growth in Nigeria may exceed the availability of affordable housing and basic services, resulting in living conditions conducive to vector breeding and heterogeneous malaria transmission. Understanding the link between community-level factors and urban malaria transmission informs targeted interventions. We analyzed Demographic and Health Survey Program cluster-level data, alongside geospatial covariates, to describe variations in malaria prevalence in children under 5 years of age. Univariate and multivariable models explored the relationship between malaria test positivity rates at the cluster level and community-level factors. Generally, malaria test positivity rates in urban areas are low and declining. The factors that best predicted malaria test positivity rates within a multivariable model were post-primary education, wealth quintiles, population density, access to improved housing, child fever treatment-seeking, precipitation, and enhanced vegetation index. Malaria transmission in urban areas will likely be reduced by addressing socioeconomic and environmental factors that promote exposure to disease vectors. Enhanced regional surveillance systems in Nigeria can provide detailed data to further refine our understanding of these factors in relation to malaria transmission.

Updating estimates of Plasmodium knowlesi malaria risk in response to changing land use patterns across Southeast Asia

BACKGROUND

Plasmodium knowlesi is a zoonotic parasite that causes malaria in humans. The pathogen has a natural host reservoir in certain macaque species and is transmitted to humans via mosquitoes of the Anopheles Leucosphyrus Group. The risk of human P. knowlesi infection varies across Southeast Asia and is dependent upon environmental factors. Understanding this geographic variation in risk is important both for enabling appropriate diagnosis and treatment of the disease and for improving the planning and evaluation of malaria elimination. However, the data available on P. knowlesi occurrence are biased towards regions with greater surveillance and sampling effort. Predicting the spatial variation in risk of P. knowlesi malaria requires methods that can both incorporate environmental risk factors and account for spatial bias in detection.

METHODS & RESULTS

We extend and apply an environmental niche modelling framework as implemented by a previous mapping study of P. knowlesi transmission risk which included data up to 2015. We reviewed the literature from October 2015 through to March 2020 and identified 264 new records of P. knowlesi, with a total of 524 occurrences included in the current study following consolidation with the 2015 study. The modelling framework used in the 2015 study was extended, with changes including the addition of new covariates to capture the effect of deforestation and urbanisation on P. knowlesi transmission.

DISCUSSION

Our map of P. knowlesi relative transmission suitability estimates that the risk posed by the pathogen is highest in Malaysia and Indonesia, with localised areas of high risk also predicted in the Greater Mekong Subregion, The Philippines and Northeast India. These results highlight areas of priority for P. knowlesi surveillance and prospective sampling to address the challenge the disease poses to malaria elimination planning.

The impact of digital skills on health: Evidence from the China General Social Survey

Objective

The widespread penetration of the internet and digital technology have profoundly impacted the global economy and people's lives. Although the impact of digital skills on social development and personal lifestyles is well-documented, their influence on health and health inequalities remains underexplored. This study aims to analyze the impact of digital skills on health and health inequalities and to investigate the underlying mechanisms.

Methods

This study utilized cross-sectional data from the 2017 China General Social Survey (N = 2195). We employed the Ordered Probit (O-Probit) model and ordinary least squares regression to examine the impact of digital skills on health and explore the underlying mechanisms. Health inequalities across different groups were measured using the health concentration index.

Results

Enhancing digital skills enhances population health by boosting economic status, increasing social participation, and improving access to information. However, the impact varies by age and residence. Digital skills have a stronger effect on the health of young and middle-aged individuals, as well as urban residents, compared to older adults and rural populations. Furthermore, digital skills exacerbate health inequalities, benefiting high-income groups and widening the gap between income levels.

Conclusions

Widespread promotion and continuous improvement of digital skills are key to enhancing public health. We need to focus on the popularization of digital skills and the construction of digital infrastructure for low-income disadvantaged groups and rural areas, as well as use various means to reduce group and regional differences in the impact of digital skills on health conditions.

Geo-Demographic and Socioeconomic Determinants of Diagnosed Hypertension among Urban Dwellers in Ibadan, Nigeria: A Community-based Study

Background

The relationship between diagnosed high blood pressure (HBP) and proximity to health facilities and noise sources is poorly understood. We investigated the relationship between proximity to noise sources, sociodemographic and economic factors, and diagnosed HBP in Ibadan, Nigeria.

Methods

We investigated 13,531 adults from the African Rigorous Innovative Stroke Epidemiological Surveillance (ARISES) study in Ibadan. Using a Geographic Information System (GIS), the locations of healthcare facilities, pharmaceutical shops, bus stops, churches, and mosques were buffered at 100m intervals, and coordinates of persons diagnosed with HBP were overlaid on the buffered features. The number of persons with diagnosed HBP living at every 100m interval was estimated. Gender, occupation, marital status, educational status, type of housing, age, and income were used as predictor variables. Analysis was conducted using Spearman rank correlation and binary logistic regression at p<0.05.

Results

There was a significant inverse relationship between the number of persons diagnosed with HBP and distance from pharmaceutical shops (r=-0.818), churches (r=-0.818), mosques (r=-0.893) and major roads (r=-0.667). The odds of diagnosed HBP were higher among the unemployed (AOR=1.58, 95% CI: 1.11-2.24), currently married (AOR=1.45, CI: 1.11-1.89), and previously married (1.75, CI: 1.29-2.38). The odds of diagnosed HBP increased with educational level and age group.

Conclusion

Proximity to noise sources, being unemployed and educational level were associated with diagnosed HBP. Reduction in noise generation, transmission, and exposure could reduce the burden of hypertension in urban settings.

Applying a zero-corrected, gravity model estimator reduces bias due to heterogeneity in healthcare utilization in community-scale, passive surveillance datasets of endemic diseases

Data on population health are vital to evidence-based decision making but are rarely adequately localized or updated in continuous time. They also suffer from low ascertainment rates, particularly in rural areas where barriers to healthcare can cause infrequent touch points with the health system. Here, we demonstrate a novel statistical method to estimate the incidence of endemic diseases at the community level from passive surveillance data collected at primary health centers. The zero-corrected, gravity-model (ZERO-G) estimator explicitly models sampling intensity as a function of health facility characteristics and statistically accounts for extremely low rates of ascertainment. The result is a standardized, real-time estimate of disease incidence at a spatial resolution nearly ten times finer than typically reported by facility-based passive surveillance systems. We assessed the robustness of this method by applying it to a case study of field-collected malaria incidence rates from a rural health district in southeastern Madagascar. The ZERO-G estimator decreased geographic and financial bias in the dataset by over 90% and doubled the agreement rate between spatial patterns in malaria incidence and incidence estimates derived from prevalence surveys. The ZERO-G estimator is a promising method for adjusting passive surveillance data of common, endemic diseases, increasing the availability of continuously updated, high quality surveillance datasets at the community scale.

Disparities in treatment and survival in early-stage hepatocellular carcinoma in California

BACKGROUND AND OBJECTIVES

Curative intent therapy is the standard of care for early-stage hepatocellular carcinoma (HCC). However, these therapies are under-utilized, with several treatment and survival disparities. We sought to demonstrate whether the type of facility and distance from treatment center (with transplant capabilities) contributed to disparities in curative-intent treatment and survival for early-stage HCC in California.

METHODS

We performed a retrospective analysis of the California Cancer Registry for patients diagnosed with stage I or II primary HCC between 2005 and 2017. Primary and secondary outcomes were receipt of treatment and overall survival, respectively. Multivariable logistic regression and Multivariable Cox proportional hazards regression were used to evaluate associations.

RESULTS

Of 19 059 patients with early-stage HCC, only 36% (6778) received curative-intent treatment. Compared to Non-Hispanic White patients, Hispanic patients were less likely, and Asian/Pacific Islander patients were more likely to receive curative-intent treatment. Our results showed that rural residence, public insurance, lower neighborhood SES, and care at non-National Cancer Institute-designated cancer center were associated with not receiving treatment and decreased survival.

CONCLUSIONS

Although multiple factors influence receipt of treatment for early-HCC, our findings suggest that early intervention programs should target travel barriers and access to specialist care to help improve oncologic outcomes.