NEWS UPDATES

30 March 2017

From World TB Day on Friday, 24th March 2017, Mishal Khan was live on Financial Times. The topic was "How can we end the tuberculosis epidemic?" Please view the full interview here.

Also there is an article on CNN on "What happens when health care is scarce and TB rates are high" which includes Mishal's and national teams' work in 2015 in Cambodia. Please visit the website here.

Health Policy and Planning special collection of articles on TB for World Tuberculosis Day 2017 which includes;  

Evidence to inform resource allocation for tuberculosis control in Myanmar: a systematic review based on the SYSRA framework. Mishal S Khan, Sara U Schwanke Khilji, Saw Saw, Richard J Coker.

Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia. Mishal S Khan, Solomon Salve, John DH Porter

Please visit the website here.

14 March 2017

Paper entitled "Who acquires infection from whom and how? Disentangling multi-host and multi-mode transmission dynamics in the ‘elimination’ era" has been published in The Royal Society Publishing.

Joanne P. Webster, Anna Borlase, James W. Rudge authored the paper entitled "Who acquires infection from whom and how? Disentangling multi-host and multi-mode transmission dynamics in the ‘elimination’ era" which has been published in The Royal Society Publishing. DOI:10.1098/rstb.2016.0091.

Abstract

Multi-host infectious agents challenge our abilities to understand, predict and manage disease dynamics. Within this, many infectious agents are also able to use, simultaneously or sequentially, multiple modes of transmission. Furthermore, the relative importance of different host species and modes can itself be dynamic, with potential for switches and shifts in host range and/or transmission mode in response to changing selective pressures, such as those imposed by disease control interventions. The epidemiology of such multi-host, multi-mode infectious agents thereby can involve a multi-faceted community of definitive and intermediate/secondary hosts or vectors, often together with infectious stages in the environment, all of which may represent potential targets, as well as specific challenges, particularly where disease elimination is proposed. Here, we explore, focusing on examples from both human and animal pathogen systems, why and how we should aim to disentangle and quantify the relative importance of multi-host multi-mode infectious agent transmission dynamics under contrasting conditions, and ultimately, how this can be used to help achieve efficient and effective disease control.

The paper is available online here.

2 February 2017

Paper entitled "Guidelines, law, and governance: disconnects in the global control of airline-associated infectious diseases"  has been published in PubMed.

Grout A, Howard N, Coker R, Speakman EM  authored the paper entitled "Guidelines, law, and governance: disconnects in the global control of airline-associated infectious diseases" which has been published in PubMed. DOI: 10.1016/S1473-3099(16)30476-5.

Abstract

International air travel is increasingly affecting the epidemiology of infectious diseases. A particular public health, economic, and political concern is the role of air travel in bringing infectious passengers or vectors to previously non-endemic areas. Yet, little research has been done to investigate either the infection risks associated with air travel or the empirical evidence for the effectiveness of infection control measures on aircraft and at borders. We briefly review the interface between international and national legislation, policy, and guidelines in the context of existing infection risks and possible scenarios. We have found that public health guidance and legislation, which airlines are required to follow, are often contradictory and confusing. Infection control measures for air travel need to be underpinned by coherent and enforceable national and international legislation that is based on solid epidemiological evidence. We recommend further research investment into more effective on-board vector control, health screening, and risk communications strategies, and the development of enforceable and harmonised international legislation.

The paper is available online here

16 December 2016

Paper entitled "Evaluating the impact of healthcare provider training to improve tuberculosis management: A systematic review of methods and outcome indicators used" has been published in the International Journal of Infectious Diseases.

Shishi Wu, Imara Roychowdhury and Mishal Khan authored the paper entitled "Evaluating the impact of healthcare provider training to improve tuberculosis management: A systematic review of methods and outcome indicators used" which has been published in the International Journal of Infectious Diseases. DOI: 10.1016/j.ijid.2016.11.421

Abstract

Background

Developing human resources capacity is vital for tuberculosis (TB) control in low and middle-income countries. Although investments in TB healthcare provider (HCP) training programs have increased, it is unclear whether these are robustly evaluated. The objective of this systematic review is to synthesize the methods and outcome indicators used to assess TB HCP training programs.

Methods

We conducted a systematic scoping review of publications reporting on evaluations of training programs for HCPs–including doctors, nurses, paramedics and lay health workers - in three electronic databases, Google Scholar and five websites of non-profit organizations. We extracted data on the study location, population trained, outcomes assessed and evaluation approach.

Results

After screening 499 unique publications, 21 were eligible for inclusion in the analysis. The majority of evaluations were conducted in Africa. The most common evaluation method was review of patient records (8, 38%) and post-training interview with trainees (7, 33%). In terms of outcomes, more than half of the studies (12, 57%) evaluated knowledge acquisition of trainees with only six (29%) assessing on-the-job behavior change.

Conclusions

Even though more funds have been invested in HCP training, publications from robust evaluations assessing impact on quality of care and behavior change are limited.

The paper is available online here. 

Paper entitled "Less research on tuberculosis than HIV and malaria when research agendas are poorly coordinated: a systematic review of research outputs from Cambodia" has been published in the International Journal of Infectious Diseases.

Mishal Khan, Richard James, Neisha Sundaram, Shishi Wu, Mao Tang Eang, Saphonn Vonthanak and Richard Coker authored the paper entitled "Less research on tuberculosis than HIV and malaria when research agendas are poorly coordinated: a systematic review of research outputs from Cambodia" which has been published in the International Journal of Infectious Diseases. DOI: http://dx.doi.org/10.1016/j.ijid.2016.11.417

Highlights

•Our scoping review analysing trends research into HIV, malaria and TB in Cambodia revealed that there is much less evidence to inform policy decisions from TB research than from HIV or malaria.

•Considering that TB causes more deaths in Cambodia than HIV and malaria, our findings suggests that an increase in TB research may be needed.

•To ensure that future research addresses critical information gaps for policy decisions, a coherent research strategy could be developed by a national committee supported by the donor and research community.

Abstract

Objective

Coordination of health interventions and research is often weak during periods of political transition and unprecedented aid inflows, which Cambodia has recently experienced. Although HIV, tuberculosis (TB) and malaria have been a focus of international funding, TB has received much less. This study compares the number and methodology of studies conducted on TB, malaria and HIV in Cambodia, identifying evidence gaps and future research needs.

Methods

We searched three electronic databases and additional grey literature for studies on HIV, TB and malaria published between January 2000 and October 2015. Information about the diseases focus and methodology was extracted from included studies.

Results

We screened 2581 unique studies, including 712 in the analysis. Our results demonstrated that despite increasing numbers of publications, there were fewer studies on TB (16%), than HIV (43%) and malaria (41%). Observational epidemiological studies outnumbered other methodologies (44%) in all three diseases.

Conclusions

Despite substantial investments, important research areas appear to have been neglected in Cambodia; specifically, studies on TB, and studies involving economic, qualitative, interventional and genomics methods. The inter-disease disparity in published research in Cambodia identified, considered alongside disease burden, suggests that an increase in TB research may be needed to inform control strategies.

The paper is available online here. 

7 December 2016

A blog "The US election results and the fragility of global HIV control initiatives", written by Richard Coker and Mishal Khan has gotten picked up by Int’l Health & Development Daily.

The recent election of Donald Trump has cast a dark cloud of uncertainty over the United States’ role in international development, and for HIV/AIDS, has thrown the future of global control efforts into question.

Mitchell Warren from the AIDS Vaccine Advocacy Coalition has warned that this single event “could imperil [the] progress” made in the past two decades towards a rights-based response to the global HIV epidemic. Drew Gibson, a writer and social worker, had a more emotional response: “Do not listen when someone tells you it will all be OK. It will not. For people living with HIV and those that advocate alongside them, a Trump White House coupled with a Republican-controlled Congress is nothing less than a waking nightmare.”

The precarious situation we find ourselves in with respect to future efforts to tackle HIV/AIDS following the US election is a clear example of the massive and rapid influence of politicians and politics on disease control and global health security. In contrast, the incremental gains in scientific knowledge, and evidence of the benefits of effective interventions, can seem miniscule, slow, and our efforts depressingly futile when caught up in such a political maelstrom.

The fact that a government under Donald Trump could impact HIV/AIDS control so profoundly all over the world also highlights the dependency of low and middle income countries on US funding. America is the biggest foreign aid donor in the world (by total contributions, though not per capita or as fraction of GNP), representing almost a quarter of development assistance from major governments in 2014. Washington’s decisions on the amount of funding for health, through which institutions funds flow, and the strings attached for recipients, therefore have far-reaching effects on HIV/AIDS and other national disease control strategies.

With regards to the amount of funding and where it will go, many believe that Trump has so far sent mixed messages. He has said, albeit vaguely, that he broadly supports the idea of development aid and that he will commit to doubling the number of people receiving HIV/AIDS treatment worldwide through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). But he has also suggested that it is time to slash aid in favour of spending on priorities at home. There is a clear protectionist message here: foreign assistance will be provided where there is a clear benefit to the US. For example, Trump has stated that he would continue to deliver foreign aid to countries that he believes could turn into security risks, such as Pakistan.

On the strategic direction that funding will take, initial decisions on candidates for leadership positions to not bode well, at least for domestic policy, and likely reflect what is be the approach for international engagement. For example, Trump has recently announced that he would nominate one of the Congress’s main critics of Obamacare – Tom Price – to lead the Department of Health and Human Services. Price’s track record includes voting against abortion rights and anti-domestic violence laws. He would join vice president Mike Pence, who has previously suggested that federal money used to fund HIV/AIDS research should instead be diverted to programs that try and cure homosexuality by providing “assistance to those seeking to change their sexual behaviour.”

Bearing in mind that until 2010 federal immigration law prohibited people with HIV from visiting or immigrating to America, current unsettling political changes may put people living with HIV/AIDS – and broader global health security – at risk both domestic and internationally.

Please visit the blog here.

8 July 2016

Paper entitled "Economic interventions to improve population health: a scoping study of systematic reviews" has been published in BMC Public Health.

Mishal S. Khan, Bernie Y. Guan, Jananie Audimulam, Francisco Cervero Liceras, Richard J. Coker and Joanne Yoong authored the paper entitled "Economic interventions to improve population health: a scoping study of systematic reviews" which has been published in BMC Public Health. DOI: 10.1186/s12889-016-3119-5.

Abstract

Background

Recognizing the close relationship between poverty and health, national program managers, policy-makers and donors are increasingly including economic interventions as part of their core strategies to improve population health. However, there is often confusion among stakeholders about the definitions and operational differences between distinct types of economic interventions and financial instruments, which can lead to important differences in interpretation and expectations.

Methods

We conducted a scoping study to define and clarify concepts underlying key economic interventions - price interventions (taxes and subsidies), income transfer programs, incentive programs, livelihood support programs and health-related financial services – and map the evidence currently available from systematic reviews.

Results

We identified 195 systematic reviews on economic interventions published between 2005 and July 2015. Overall, there was an increase in the number of reviews published after 2010. The majority of reviews focused on price interventions, income transfer programs and incentive programs, with much less evidence available from systematic reviews on livelihood support programs and health-related financial services. We also identified a lack of evidence on: health outcomes in low income countries; unintended or perverse outcomes; implementation challenges; scalability and cost-effectiveness of economic interventions.

Conclusions

We conclude that while more research is clearly needed to assess suitability and effectiveness of economic interventions in different contexts, before interventions are tested and further systematic reviews conducted, a consistent and accurate understanding of the fundamental differences in terminology and approaches is essential among researchers, public health policy makers and program planners.

The paper is available online here. 

28 June 2016

Paper entitled "Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis" has been published in The Lancet.

Mishal S Khan, Anna Osei-Kofi, Abbas Omar, Hilary Kirkbride, Prof Anthony Kessel, Aula Abbara, Prof David Heymann, Prof Alimuddin Zumla, Dr Osman Dar authored the paper entitled "Pathogens, prejudice, and politics: the role of the global health community in the European refugee crisis" which has been published in The Lancet. DOI: http://dx.doi.org/10.1016/S1473-3099(16)30134-7.

Summary

Involuntary migration is a crucially important global challenge from an economic, social, and public health perspective. The number of displaced people reached an unprecedented level in 2015, at a total of 60 million worldwide, with more than 1 million crossing into Europe in the past year alone. Migrants and refugees are often perceived to carry a higher load of infectious diseases, despite no systematic association. We propose three important contributions that the global health community can make to help address infectious disease risks and global health inequalities worldwide, with a particular focus on the refugee crisis in Europe. First, policy decisions should be based on a sound evidence base regarding health risks and burdens to health systems, rather than prejudice or unfounded fears. Second, for incoming refugees, we must focus on building inclusive, cost-effective health services to promote collective health security. Finally, alongside protracted conflicts, widening of health and socioeconomic inequalities between high-income and lower-income countries should be acknowledged as major drivers for the global refugee crisis, and fully considered in planning long-term solutions.

The paper is available online here

28 June 2016

Paper entitled "Evidence to inform resource allocation for tuberculosis control in Myanmar: a systematic review based on the SYSRA framework" has been published in Health Policy Plan.

Mishal S Khan, Sara U Schwanke Khilji, Saw Saw and Richard J Coker authored the paper entitled "Evidence to inform resource allocation for tuberculosis control in Myanmar: a systematic review based on the SYSRA framework" which has been published in Health Policy Plan.(2016) doi: 10.1093/heapol/czw077 First published online: June 21, 2016.

Abstract

Myanmar represents an extreme example of the difficulties in optimally allocating resources for maximum public health benefit, on the basis of limited information. At the recent Myanmar Health Forum ‘Investing in Health’ much of the discussion revolved around what to invest in, how health systems could be strengthened, and what research and capacity building areas the international donor community should prioritise for support. Funding for infectious disease control, particularly HIV and tuberculosis, is being channelled to the country at an unprecedented rate, but very little research has been conducted in recent years, and existing information has not yet been synthesised. This paper presents findings of the first systematic literature review on tuberculosis control and the health system in Myanmar, with the aim of informing the development of optimal research priorities and strategies. Medline and grey literature were searched for relevant papers. Inclusion criteria and analyses were structured to capture data on the Myanmar health system, healthcare delivery, financing, tuberculosis control indicators and information systems. A total of 77 papers were included in the analysis. The results indicate that there has been a large increase in the number of peer-reviewed articles published on tuberculosis in Myanmar over the past decade, although the absolute number of studies remains small. We identified several areas in which evidence to inform policy and resource allocation decisions is lacking, including research focused on rural and/or vulnerable populations, analyses of risk factors for TB and drug resistance that can inform prevention strategies and economic analyses for optimising resource allocation. The gaps in research to inform policy identified through this study may be relevant to other low resource settings with extremely limited research capacity.

The paper is available online here

11 May 2016

Paper entitled "The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review" has been published in BMC Infectious Diseases.

Rebecca C. Harris, Louis Grandjean, Laura J. Martin, Alexander J. P. Miller, Joseph-Egre N. Nkang, Victoria Allen, Mishal S. Khan, Katherine Fielding and David A. J. Moore authored the paper entitled "The effect of early versus late treatment initiation after diagnosis on the outcomes of patients treated for multidrug-resistant tuberculosis: a systematic review" which has been published in BMC Infectious Diseases BMC series – open, inclusive and trusted201616:193, DOI: 10.1186/s12879-016-1524-0.

Abstract

Background

Globally it is estimated that 480 000 people developed multidrug-resistant tuberculosis (MDR-TB) in 2014 and 190 000 people died from the disease. Successful treatment outcomes are achieved in only 50 % of patients with MDR-TB, compared to 86 % for drug susceptible disease. It is widely held that delay in time to initiation of treatment for MDR-TB is an important predictor of treatment outcome. The objective of this review was to assess the existing evidence on the outcomes of multidrug- and extensively drug-resistant tuberculosis patients treated early (≤4 weeks) versus late (>4 weeks) after diagnosis of drug resistance.

Methods

Eight sources providing access to 17 globally representative electronic health care databases, indexes, sources of evidence-based reviews and grey literature were searched using terms incorporating time to treatment and MDR-TB. Two-stage sifting in duplicate was employed to assess studies against pre-specified inclusion and exclusion criteria. Only those articles reporting WHO-defined treatment outcomes were considered for inclusion. Articles reporting on fewer than 10 patients, published before 1990, or without a comparison of outcomes in patient groups experiencing different delays to treatment initiation were excluded.

Results

The initial search yielded 1978 references, of which 1475 unique references remained after removal of duplicates and 28 articles published pre-1990. After title and abstract sifting, 64 papers underwent full text review. None of these articles fulfilled the criteria for inclusion in the review.

Conclusions

Whilst there is an inherent logic in the theory that treatment delay will lead to poorer treatment outcomes, no published evidence was identified in this systematic review to support this hypothesis. Reports of programmatic changes leading to reductions in treatment delay exist in the literature, but attribution of differences in outcomes specifically to treatment delay is confounded by other contemporaneous changes. Further primary research on this question is not considered a high priority use of limited resources, though where data are available, improved reporting of outcomes by time to treatment should be encouraged.

The paper is available online here. 

3 March 2016

Paper entitled "Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey" has been published in BMC Infectious Diseases.

MS. Khan, TM. Khine, C. Hutchison, RJ. Coker, KM. Hane, AL. Innes and S. Aung authored the paper entitled "Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey" which has been published in BMC Infectious Diseases, BMC series – open, inclusive and trusted 2016 16:110, DOI: 10.1186/s12879-016-1429-y.

Abstract

Background

Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.

Methods

From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.

Results

Overall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.

Conclusions

Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

The paper is available online here. 

24 February 2016 

A letter entitled "Implementing health policy and systems research in Myanmar" has been published in The Lancet. 

Mishal Khan, Joanne Yoong, Zaw Myo Tun, Richard Coker authored the letter entitled "Implementing health policy and systems research in Myanmar", which has been published in The Lancet, Volume 387, No. 10020, p749–750, 20 February 2016 DOI: http://dx.doi.org/10.1016/S0140-6736(16)00329-9.

Summary

We agree with Karen Eggleston and colleagues' (Nov 21, p 2053)1 assertion that one of the greatest challenges facing Myanmar is the optimum allocation of scarce resources, and add that evidence to inform this is needed urgently. We started working to generate such evidence shortly after the move to a nominally civilian government in 2011 opened the country up to more international collaborations. Here, we summarise the insights gained while doing one of the first multidisciplinary research programmes on the health system and tuberculosis control in Myanmar, which included two literature reviews, a mixed-methods situational assessment, a case-control study of risk factors for emergence of drug resistance, a qualitative study of barriers to accessing health services, and an economic analysis of patient costs.

The letter is available online here.

8 January 2016

Paper entitled "Factors associated with the uptake of seasonal influenza vaccination in adults: a systematic review" has been published in Journal of Public Health.

May P. S. Yeung, Frank L.Y. Lam, and Richard Coker authored the paper entitled "Factors associated with the uptake of seasonal influenza vaccination in adults: a systematic review", which has been published in Journal of Public Health, doi: 10.1093/pubmed/fdv194.
Abstract
Background Studies on different populations have shown that a variety of factors influence attitudes and decision in the general population on vaccine uptake. This study explores factors associated with the uptake of influenza vaccination among adults.
Methods A systematic literature review was performed on literature searched in databases EMBASE, MEDLINE, Cochrane Library and Electronic Theses Online Service up until November 2013. A critical appraisal framework was designed to assess the methodological quality of the studies.
Results Twenty-three articles met the inclusion criteria and were selected for outcome analysis and 21 were quantitative observational studies. Advancement in age (OR 1.06–23.7) and having chronic diseases (OR 1.38–13.7) were strongly indicative of vaccine uptake. Perceptions on vaccine efficacy (OR 2.7–10.55) and vaccine safety and adverse events (OR 10.5) were more influential than the level of knowledge on influenza and its vaccination. Advice from doctors/health professionals/family and/or close friends and free vaccination were also key factors in association with uptake of vaccination.
Conclusions This review highlighted the finding that perception on vaccine efficacy, perception on vaccine safety and adverse events, advice from doctors/health professionals/family/close friends and free vaccination are changeable factors that are strongly associated with influenza vaccination in adults aged 18–64.
The paper is available online here.

18 August 2015 

Chevening-OSF-LSHTM Scholarships

These scholarships are open to MSc applicants from Azerbaijan, Belarus, Cambodia, Democratic Republic of Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Laos, Libya, Republic of Congo, South Sudan, Sudan, Syria, Turkmenistan, and Uzbekistan.

The deadline for these scholarships is 15 SEPTEMBER 2015.

Chevening offers

General Scheme (Main Award) Chevening Scholarships, and

Chevening Partnership Scholarships.

Chevening provides information about Partnership Scholarships, including the difference between Partnership Scholarships and general scheme (Main Award) Chevening Scholarships, under the Partners section of the Chevening website.

This advert provides information about Chevening Partnership Scholarships with the School, which are referred to as ‘Partnership Scholarships’, ‘Chevening-OSF-LSHTM Partnership Scholarships’, and ‘Partnership Awards’. 


Chevening-OSF-LSHTM Partnership Scholarships

The London School of Hygiene & Tropical Medicine (LSHTM) is a Chevening partner. This year Open Society Foundations (OSF) is co-sponsoring a number of these Chevening Partnership Scholarships for applicants who wish to study at the London School of Hygiene & Tropical Medicine.

We are offering up to 10 co-funded Partnership Scholarships for 2016-17. These particular scholarships are being offered in addition to the general scheme (Main Award) Chevening Scholarships. The top ten successful candidates will be offered a Partnership Scholarship and all other successful candidates will receive a Chevening Scholarship through the main award programme.

Award details

Chevening-OSF-LSHTM Partnership Scholarships will provide the same allowance and stipend package as a standard general scheme Chevening Award. A full Chevening Scholarship normally comprises:

Payment of tuition fees (country fee caps do not apply)

Economy travel to and from your country of residence 

Allowance to cover living expenses

Other allowances

Please visit the school website for more details here.

23 April 2015 

Paper entitled "Mortality Attributable to Seasonal Influenza A and B Infections in Thailand, 2005–2009: A Longitudinal Study" has been published in Oxford Journals.

Ben S. Cooper, Surachai Kotirum, Wantanee Kulpeng, Naiyana Praditsitthikorn, Malinee Chittaganpitch, Direk Limmathurotsakul, Nicholas P. J. Day, Richard Coker, Yot Teerawattananon and Aronrag Meeyai authored the paper entitled "Mortality Attributable to Seasonal Influenza A and B Infections in Thailand, 2005–2009: A Longitudinal Study", which has been published in  Oxford Journals, Am. J. Epidemiol. (2015)doi: 10.1093/aje/kwu360.

Abstract

Influenza epidemiology differs substantially in tropical and temperate zones, but estimates of seasonal influenza mortality in developing countries in the tropics are lacking. We aimed to quantify mortality due to seasonal influenza in Thailand, a tropical middle-income country. Time series of polymerase chain reaction–confirmed influenza infections between 2005 and 2009 were constructed from a sentinel surveillance network. These were combined with influenza-like illness data to derive measures of influenza activity and relationships to mortality by using a Bayesian regression framework. We estimated 6.1 (95% credible interval: 0.5, 12.4) annual deaths per 100,000 population attributable to influenza A and B, predominantly in those aged ≥60 years, with the largest contribution from influenza A(H1N1) in 3 out of 4 years. For A(H3N2), the relationship between influenza activity and mortality varied over time. Influenza was associated with increases in deaths classified as resulting from respiratory disease (posterior probability of positive association, 99.8%), cancer (98.6%), renal disease (98.0%), and liver disease (99.2%). No association with circulatory disease mortality was found. Seasonal influenza infections are associated with substantial mortality in Thailand, but evidence for the strong relationship between influenza activity and circulatory disease mortality reported in temperate countries is lacking.

The paper is available online here.  

25 February 2015

Paper entitled "Pilgrims and MERS-CoV: what’s the risk?" has been published in Emerging Themes in Epidemiology.

Tarek Soliman, Alex R Cook and Richard J Coker authored the paper entitled "Pilgrims and MERS-CoV: what’s the risk?", which has been published in Emerging Themes in Epidemiology, 2015, 12:3 doi:10.1186/s12982-015-0025-8

Abstract

The risk of Middle East Respiratory Syndrome Coronavirus spreading globally is worrying, given the annual mass gathering of the Hajj and the year-long influx of pilgrims undertaking the Umrah. Based on the incidence in Saudi Arabia since June 2012, the most likely scenario given recent pilgrim numbers is estimated to be one case per Hajj, and three Umrah pilgrims per year, but which could plausibly reach seven and ten pilgrims respectively. In addition to the 2015 Hajj, national surveillance systems should be on the alert for the low but long-lasting risk of infected pilgrims returning from the Umrah throughout the year.

The paper is available online here.  

20 February 2015

Paper entitled "Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study" has been published in The Lancet.

Dr Ligia Kiss, PhDcorrespondenceemail, Nicola S Pocock, MSc, Varaporn Naisanguansri, Soksreymom Suos, MA, Brett Dickson, BA, Doan Thuy, MA, Jobst Koehler, Kittiphan Sirisup, Nisakorn Pongrungsee, Van Anh Nguyen, MA, Rosilyne Borland, MA, Poonam Dhavan, MPH, Cathy Zimmerman, PhD authored the paper entitled "Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study", which has been published in The Lancet, Volume 3, No. 3, e154–e161, March 2015 DOI: http://dx.doi.org/10.1016/S2214-109X(15)70016-1

Summary

Background

Trafficking is a crime of global proportions involving extreme forms of exploitation and abuse. Yet little research has been done of the health risks and morbidity patterns for men, women, and children trafficked for various forms of forced labour.

Methods

We carried out face-to-face interviews with a consecutive sample of individuals entering 15 post-trafficking services in Cambodia, Thailand, and Vietnam. We asked participants about living and working conditions, experience of violence, and health outcomes. We measured symptoms of anxiety and depression with the Hopkins Symptoms Checklist and post-traumatic stress disorder with the Harvard Trauma Questionnaire, and used adjusted logistic regression models to estimate the effect of trafficking on these mental health outcomes, controlling for age, sector of exploitation, and time in trafficking.

Findings

We interviewed 1102 people, of whom 1015 reached work destinations. Participants worked in various sectors including sex work (329 [32%]), fishing (275 [27%]), and factories (136 [13%]). 481 (48%) of 1015 experienced physical violence, sexual violence, or both, with 198 (35%) of 566 women and girls reporting sexual violence. 478 (47%) of 1015 participants were threatened and 198 (20%) were locked in a room. 685 (70%) of 985 who had data available worked 7 days per week and 296 (30%) of 989 worked at least 11 hours per day. 222 (22%) of 983 had a serious injury at work. 61·2% (95% CI 58·2–64·2) of participants reported symptom of depression, 42·8% (39·8–45·9) reported symptoms of anxiety, and 38·9% (36·0–42·0) reported symptoms of post-traumatic stress disorder. 5·2% (4·0–6·8) had attempted suicide in the past month. Participants who experienced extremely excessive overtime at work, restricted freedom, bad living conditions, threats, or severe violence were more likely to report symptoms of depression, anxiety, and post-traumatic stress disorder.

The paper is available online here. 

16 February 2015

Paper entitled "Introducing One Health to the Ethical Debate About Zoonotic Diseases in Southeast Asia" has been published in Bioethics.

Benjamin Capps, Michele Marie Bailey, David Bickford, Richard Coker, Zohar Lederman, Andrew Lover, Tamra Lysaght and Paul Tambyah authored the paper entitled "Introducing One Health to the Ethical Debate About Zoonotic Diseases in Southeast Asia", which has been published in Bioethics, DOI: 10.1111/bioe.12145. Article first published online: 10 FEB 2015

Abstract

Pandemic plans recommend phases of response to an emergent infectious disease (EID) outbreak, and are primarily aimed at preventing and mitigating human-to-human transmission. These plans carry presumptive weight and are increasingly being operationalized at the national, regional and international level with the support of the World Health Organization (WHO). The conventional focus of pandemic preparedness for EIDs of zoonotic origin has been on public health and human welfare. However, this focus on human populations has resulted in strategically important disciplinary silos. As the risks of zoonotic diseases have implications that reach across many domains outside traditional public health, including anthropological, environmental, and veterinary fora, a more inclusive ecological perspective is paramount for an effective response to future outbreaks.

The paper is available online here.

2 February 2015

Paper entitled "Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia", has been published in Health Policy and Planning.

Mishal S Khan, Solomon Salve and John DH Porter authored the paper entitled "Engaging for-profit providers in TB control: lessons learnt from initiatives in South Asia", which has been published in Health Policy and Planning on 20 January 2015, doi: 10.1093/heapol/czu137

Abstract

There has been a huge expansion in the private health-care sector over the past two decades, particularly in South Asia, resulting in over 80% of patients seeking care from private health providers. Despite concerns about the quality and equity of private sector service provision, most government public health bodies recognize that the private sector reaches individuals that public institutions cannot cater to, thereby being important in moving closer to universal health coverage. Numerous initiatives have been launched and are being planned to involve private practitioners in effectively diagnosing, reporting and managing infectious diseases such as tuberculosis. However, there is a notable dearth of papers discussing which elements of private sector engagement strategies are more or less successful and the ethical issues that arise when engagement strategies are operationalized. This article brings together the authors’ experiences of working on projects to engage private allopathic health providers in Pakistan, Bangladesh and India for improved tuberculosis control. Motivations of and strategies required to engage private allopathic heath providers, specifically doctors, diagnostic laboratories and pharmacies, and some of the ethical issues that arise when designing programmes for engagement are discussed.

The paper is available online here.

5 January 2015

Paper entitled "Good Quality Locally Procured Drugs Can Be as Effective as Internationally Quality Assured Drugs in Treating Multi-Drug Resistant Tuberculosis" has been publichsed in Plos One.

Ejaz Qadeer , Razia Fatima , Katherine Fielding , Fahad Qazi , David Moore , Mishal S. Khan authored the paper entitled "Good Quality Locally Procured Drugs Can Be as Effective as Internationally Quality Assured Drugs in Treating Multi-Drug Resistant Tuberculosis", which has been published in Plos One, Published: April 29, 2015DOI: 10.1371/journal.pone.0126099

Abstract

Background

Owing toGiven the high costs of drugs to treat multi-drug resistant tuberculosis (MDR-TB), the Green Light Committee (GLC) initiative enables TB programs to procure quality-assured drugs at reduced prices. Despite price reductions, internationally quality assured (IQA) drugs can be more expensive than locally procured drugs. There is little evidence to inform decision-makers about whether IQA drugs are more effective than local drugs. This is the first study to compare outcomes between MDR-TB patients treated using IQA, and locally procured drugs in the same hospitals during the same time period.

The paper is available online here. 

16 December 2014

Congratulations to Richard Coker who has received a confirmed letter from the Faculty of Public Health, Mahidol University, for his Adjunct Professor position.

17 November 2014

Paper entitled "How can Southeast Asia increase its preparedness for an Ebola outbreak?", has been published in the East Asia Forum.

Mishal Khan, Andrew Lover and Richard Coker authored the paper entitled "How can Southeast Asia increase its preparedness for an Ebola outbreak?", which has been published in the East Asia Forum on 15 November 2014

Southeast Asia is no stranger to epidemics and is a hotspot for emerging disease threats. There have been serious economic and health-sector impacts from zoonoses including Nipah virus infections, SARS and highly pathogenic avian influenza (commonly known as bird flu). While these events catalysed some change in infectious disease policies within the region, many countries’ interest has since waned. Many governments, faced with numerous other pressing health priorities, have classified the threat of other emergencies as remote.

But the recent emergence of Ebola Virus Disease (EVD) in West Africa has laid bare fragilities within international health responses on a global scale, even in countries — such as the US and Spain — where it was previously unthinkable that secondary transmission could occur within health facilities.

A new framework is necessary to assess the risk of an EVD outbreak occurring within a country if a case crosses its borders, and to act as a guide on how to increase country-level preparedness. The framework, which builds on a rapid assessment toolkit for communicable diseases, is designed to highlight that the effectiveness of a country’s response to an outbreak is dependent on a combination of broad (horizontal) factors related to the political environment, health system and local population, as well as on targeted disease-specific (vertical) measures to prevent the disease from spreading.

The paper is available online here.

17 November 2014

WHO's response "Tuberculosis control: hard questions" on the paper "How to hinder tuberculosis control: five easy steps. (published in The Lancet on 24 July 2014,doi:10.1016/S0140-6736(14)61175-2)", has been published in The Lancet, Volume 384, Issue 9956, Page 1744, 15 November 2014, doi:10.1016/S0140-6736(14)62065-1

Although in their Comment in The Lancet Mishal Khan and Richard Coker (Aug 23, p 646) raise real and well known challenges in the global tuberculosis response, they fail to propose any solutions and downplay efforts and achievements by many stakeholders to address these complex issues. We have some questions:
How much can the statement that countries are “incentivised to obscure programmatic challenges” be generalised? Are the definite tuberculosis burden declines in countries such as China and Cambodia, reported from prevalence surveys somehow unconnected to the expansion of tuberculosis control efforts over the past few years?
What should replace performance-based funding to prevent the so-called perverse incentive by international donors? Financing needs to somehow be linked to performance measured through targets and indicators. How could accountability be otherwise demonstrated?
Can there really be any trade-offs between the “urgency to treat” versus “long-term health systems strengthening goals” as is proposed? We need both, as outlined in the WHO post-2015 Global Strategy endorsed by the World Health Assembly. Would it be ethical to delay introduction of new tools until health systems are working to perfection? How would this affect urgently needed development of new diagnostics, drugs, and vaccines, or operational research to guide their introduction?
Is there a counter-proposal to the essential, WHO-recommended health systems to deliver treatment to patients with multidrug-resistant tuberculosis? Can we ethically watch patients with multidrug-resistant tuberculosis die while waiting for improved health systems? Is duty of care different for tuberculosis than for cancer or HIV? Would anyone privileged enough to live in an affluent country decline treatment if they contracted multidrug-resistant tuberculosis? Should we not learn from HIV control how creativity and mass action can overcome formidable programmatic barriers associated with complicated, costly interventions?
The latest WHO Global Tuberculosis Report (and special supplement) stresses that prevention and proper first-line treatment are the first step in the control of multidrug-resistant tuberculosis. Is the growing evidence showing that scale-up of multidrug-resistant tuberculosis services and improved treatment are achievable under programmatic condition—even in high-burden countries—not convincing enough to let us proceed with both prevention and treatment?
We believe that the public health crisis of drug-resistant tuberculosis needs urgent, concerted actions, although we may not yet have all the answers.
All authors are staff members of WHO. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of WHO. We declare no competing interests.
The WHO response is available online here.

Tuberculosis control: hard questions — Authors' reply, has been published in The Lancet, Volume 384, Issue 9956, Page 1745, 15 November 2014, doi:10.1016/S0140-6736(14)62066-3

We thank Karin Weyer and colleagues for their interest in our Comment. We would like to address the following two conceptual disagreements.
First, in reference to the role of academic discourse, we happily accept the criticism that our Comment does not propose simple solutions to all issues raised. The purpose of our Comment, in keeping with the role of academic discourse, was to stimulate debate about questions that do not yet have clear answers. Although we do not downplay the efforts of any stakeholder, we question the need to promote simple solutions that WHO seems to expect to work in all settings. For example, we do not suggest that performance-based funding be replaced. We highlight issues that can arise when programme managers are responsible for providing data that might affect their job security.
Weyer and colleagues imply that we suggest that the reported decrease in tuberculosis notifications from China is “unconnected to the expansion of tuberculosis control efforts”. We simply highlight that correlation does not necessarily mean causation. We acknowledge that attribution is challenging, but causal pathways are important to elicit. Instead of proposing simple solutions or methods, we are arguing for a more profound understanding of how disease-specific programmes sit within health systems and, more widely, acknowledging contextual complexity.
Second, in attempting to address the ethically and politically challenging notion of how resources are best allocated, Weyer and colleagues question whether it is ethical to “watch patients with multidrug-resistant tuberculosis die while waiting for improved health systems” (a solution they ascribe to us). Yes, to passively wait for improvements in health systems is unethical; resources should be actively channeled towards improvement. This debate is timely and somehow ironic in light of the unfolding Ebola epidemic in west Africa and the recent WHO statement that scarcity of health workers is the single greatest impediment to the humanitarian response. We do not suggest that all interventions for tuberculosis should be deferred until health systems are “working to perfection”, but we do question how interventions will be implemented effectively if the interactions between tuberculosis programmes and the health system are largely ignored. The new diagnostics, drugs, and vaccines that Weyer and colleagues state are urgently needed cannot be delivered to patients in need without health systems that function effectively, efficiently, and equitably.
Calls for action are often heard but seldom given substance. Our Comment was a cry for a more nuanced understanding of local context and fewer communiqués in which norms and simplistic recommendations are formulated.
We declare no competing interests
Authors' reply is available online here.

25 July 2014
Paper entitled "How to hinder tuberculosis control: five easy steps", has been published in The Lancet
Mishal S Khan and Richard J Coker authored the paper entitled "How to hinder tuberculosis control: five easy steps", which has been published in The Lancet on 24 July 2014,doi:10.1016/S0140-6736(14)61175-2
Summary
The control of tuberculosis remains an area of interest and concern. Some recent Lancet papers bring positive news, albeit with important questions left unanswered. Wang and colleagues' longitudinal study 1 concluded that tuberculosis prevalence in China was reduced by shifting to the recommended approach based on directly observed treatment, short course (DOTS) for tuberculosis diagnosis and treatment, but did not consider that economic progress might have also been a driver. 
The paper is available online here.

To read the full article please click here.

1 May 2014

The London School of Hygiene and Tropical Medicine is pleased to be offering four Handa Scholarships to Cambodian students accepted onto the 2014-15 MSc in Public Health via Distance Learning. This is a great opportunity to study for a UK Master’s degree while living and working in Cambodia.

Details for the scholarship are on the LSHTM website: http://www.lshtm.ac.uk/study/funding/handa_scholarships.html

There are a few eligibility requirements:

Eligibility

* Applicants must hold an offer of admission to the MSc in Public Health by Distance Learning course commencing in 2014-15. To apply for the course please follow the instructions on the University of London course website, here.
* Applicants must be nationals of Cambodia, and must be resident within Cambodia for the duration of their studies.
* Applicants must meet the following English Language Requirements: 7.0 overall for IELTS, with at least 7.0 for written English and at least 6.0 for the other skills (applicants who do not quite meet this criteria may still be considered).

* Any potential students that the Master's via Distance Learning can be undertaken between 2-5 years.

Application deadline: 31 July 2014

30 April 2014

Short Course - Vaccinology for Clinical and Public Health Practice

Jointly Organised by London School of Hygiene & Tropical Medicine & Saw Swee Hock School of Public Health

This course is designed to provide an understanding of the concepts used in the evaluation of vaccines, Participants will learn epidemiological and immunological principles relevant to public health evaluation of vaccines, conduct and interpretation of vaccine trials, post-marketing surveillance, and more advanced topics involved in decision-making and vaccine introduction, including herd immunity, the application of mathematical models to predict vaccine impact, and economic evaluation of vaccines. Participants will have the opportunity to apply these concepts in problem-solving exercises and through an expert panel discussion covering emerging issues related to vaccination.

This course is relevant to public health and medical professionals in private , public and non-profit sectors, policy-makers in the health sector, and field researchers with a strong interest in vaccine efficacy, safety and impact.

For more information on the course, please see the course brochure here.

For registration, please register online here.

Closing date for Registration: 1 October 2014

For more information, please visit: http://www.sph.nus.edu.sg/index.php/education/short-courses

 

9 April 2014

Paper entitled "Re-assessing the relationship between sporozoite dose and incubation period in Plasmodium vivax malaria: a systematic re-analysis", has been published in Parasitology

Andrew A. Lover and Richard J. Coker authored the paper entitled "Re-assessing the relationship between sporozoite dose and incubation period in Plasmodium vivax malaria: a systematic re-analysis", which has been published in Parasitology, volume 141, issue 06, pp. 859-868.

Summary

Infections with the malaria parasite Plasmodium vivax are noteworthy for potentially very long incubation periods (6-9 months), which present a major barrier to disease elemination. Increased sporozoite challenge has been reported to be associated with both shorter incubation and pre-patent periods in a range of human challenge studies. However, this evidence base has scant empirical foundation, as these historical analyses were limited by available analytic methods, and provides no quantitative estimates of effect size. Following a comprehensive literature search, we re-analysed all identified studies using survival and/or logistic models plus contingency tables. We have found very weak evidence for dose-dependence at entomologically plausible inocula levels. These results strongly suggest that sporozoite dosage is not an important driver of long-latency. Evidence presented suggests that parasite strain and vector species have quantitatively greater impacts, and the potential existence of a dose threshold for human dose-response to sporozoites. Greater consideration of the complex interplay between these aspects of vectors and parasites are important for human challenge experiments, vaccine trials, and epidemiology towards global malaria elimination.

The paper is available online here.

6 March 2014

Prof Richard Coker talks about pandemics for the series Old War, New Methods

Richard Coker spoke with the Straits Times about how a pandemic could be used as a future weapon of terrorism, for the series Old War, New Methods.

While terrorists use violence to create shock, awe and fear, the fear factor that is triggered when a pandemic sweeps the world can become larger than the disease itself, Prof Coker explains. "A terrorist mastermind's aim is to create social disruptions and he can do this by playing on man's fear of the disease."

To read the full article please click here.

 31 January 2014

Report entitled "Regional Mechanisms of Communicable Disease Control in Asia and Europe”, has been published by ASIA-EUROPE Foundation

Extracts from this report have previously been published in two articles under the following two titles: 
“Communicable diseases and governance: A tale of two regions”, by Marco Liverani, Piya Hanvoravongchai and Richard J. Coker (Global Public Health, 7(6), 574-87) and "Protecting Europe from diseases", by Marco Liverani and Richard J. Coker (Journal of Health Politics, Policy, and Law, 37(6), 915-934).

The full report is available online here.

10 October 2013 

Paper entitled "Distribution of selected healthcare resources for influenza pandemic response in Cambodia", has been published in International Journal for Equity in Health

Sara U Schwanke KhiljiJames W Rudge, Tom Drake, Irwin Chavez, Khieu Borin, Sok Touch and Richard Coker authored the paper entitled "Distribution of selected healthcare resources for influenza pandemic response in Cambodia", which has been published in International Journal for Equity in Health 2013, 12:82 doi:10.1186/1475-9276-12-82

Abstract 

Introduction

Human influenza infection poses a serious public health threat in Cambodia, a country at risk for the emergence and spread of novel influenza viruses with pandemic potential. Prior pandemics demonstrated the adverse impact of influenza on poor communities in developing countries. Investigation of healthcare resource distribution can inform decisions regarding resource mobilization and investment for pandemic mitigation.

Methods

A health facility survey performed across Cambodia obtained data on availability of healthcare resources important for pandemic influenza response. Focusing on five key resources considered most necessary for treating severe influenza (inpatient beds, doctors, nurses, oseltamivir, and ventilators), resource distributions were analyzed at the Operational District (OD) and Province levels, refining data analysis from earlier studies. Resources were stratified by respondent type (hospital vs. District Health Office [DHO]). A summary index of distribution inequality was calculated using the Gini coefficient. Indices for local spatial autocorrelation were measured at the OD level using geographical information system (GIS) analysis. Finally, a potential link between socioeconomic status and resource distribution was explored by mapping resource densities against poverty rates.

Results

Gini coefficient calculation revealed variable inequality in distribution of the five key resources at the Province an OD levels. A greater percentage of the population resides in areas of relative under-supply (28.5%) than over-supply (21.3%). Areas with more resources per capita showed significant clustering in central Cambodia while areas with fewer resources clustered in the northern and western provinces. Hospital-based inpatient beds, doctors, and nurses were most heavily concentrated in areas of the country with the lowest poverty rates; however, beds and nurses in Non-Hospital Medical Facilities (NHMF) showed increasing concentrations at higher levels of poverty.

Conclusions

There is considerable heterogeneity in healthcare resource distribution across Cambodia. Distribution mapping at the local level can inform policy decisions on where to stockpile resources in advance of and for reallocation in the event of a pandemic. These findings will be useful in determining future health resource investment, both for pandemic preparedness and for general health system strengthening, and provide a foundation for future analyses of equity in health services provision for pandemic mitigation planning in Cambodia.

The paper is available online here. 

23 September 2013 

Meeting : Collaborative meeting in Myanmar

HE Union Minister for Health Prof Pe Thet Khin, Deputy Minister for Health Dr.Than Aung, Director General, Department of Medical Science Dr. Than Zaw Myint, Deputy Director General (Medical Care), Department of Health Dr. Than Win, Rector, University of Public Health Prof. Nay Soe Maung and Head of CDPRG Prof. Richard Coker had a meeting in Nay Pyi Taw, Myanmar to discuss for future collaborations.  

17 September 2013 

CAP-TB launches new online Knowledge Gateway

CAP-TB has launched a new website that will serve as an information hub, library, and news center for the work of partners and other TB experts. If you work in global health, TB, or manage public health efforts in Asia, the site will be consistently useful to you.

Control and Prevention of Tuberculosis (CAP-TB) is a five-year project funded by the U.S. Agency for International Development (USAID) to help to reduce the incidence and mortality related to Multi-Drug Resistant TB (MDR-TB.) The project supports activities in partnership with the National TB Programs (NTPs) and local organizations in Myanmar, China, and Thailand. 

The project, which runs from October 2011-October 2016, aims to reduce MDR-TB-related incidence and mortality in these three target countries.

Professor Richard Coker, a noted researcher from the London School of Hygiene and Tropical Medicine. As partners of the CAP-TB team, Professor Coker and his team will use macro-economic modeling to analyze different funding allocations and their impact on TB control. These analyses will help to ensure that project and national/provincial TB program efforts are directed toward maximul effect.

CAP-TB's Chief of Party, Dr.Anh Innes

Visit the site at: www.cap-tb.org.  

7 August 2013 

Editorial on "Human to human transmission of H7N9" has been published in BMJ

Dr.James Rudge and Prof.Richard Coker authored an editorial in the BMJ on evidence that the new bird flu visus, H7N9, has passed between humans. They conclude that, while the study "might not suggest that H7N9 is any closer to delivering the next pandemic, it does provide a timely reminder of the need to remain extremely vigilant". BMJ 2013;347 doi: http://dx.doi.org/10.1136/bmj.f4730 

Please see the editorial here

The original research article in BMJ by Qi and colleagues can be found here.

Dr.James Rudge also comments on the findings at BBC News Online here. 

BMJ podcast about H7N9 by Dr.James Rudge can be found here.

31 July 2013 

Short Course - Vaccinology for Clinical and Public Health Practice

Jointly Organised by London School of Hygiene & Tropical Medicine & Saw Swee Hock School of Public Health

This course is designed to provide an understanding of the concepts used in the evaluation of vaccines, Participants will learn epidemiological and immunological principles relevant to public health evaluation of vaccines, conduct and interpretation of vaccine trials, post-marketing surveillance, and more advanced topics involved in decision-making and vaccine introduction, including herd immunity, the application of mathematical models to predict vaccine impact, and economic evaluation of vaccines. Participants will have the opportunity to apply these concepts in problem-solving exercises and through an expert panel discussion covering emerging issues related to vaccination.

This course is relevant to public health and medical professionals in both private and public sectors, and field researchers with a strong interest in vaccine efficacy, safety and impact. Participants will be expected to have a basic understanding of research methods relevant to public health. The course is intensive and a good command of the English language is essential. Basic knowledge of Microsoft Office Word and Excel is also essential.

For more information on the course, please see the course brochure here.

For registration, please register online here.

Closing date for Registration: 30 September 2013

For more information, please visit: http://www.sph.nus.edu.sg/index.php/education/short-courses 

14 June 2013 

Paper entitled "Health system strengthening in Myanmar during political reforms: perspectives from international agencies", has been published in Health Policy and Planning

Isabelle Risso-Gill, Martin McKee, Richard Coker, Peter Piot and Helena Legido-Quigley authored the paper entitled "Health system strengthening in Myanmar during political reforms: perspectives from international agencies", which has been published in Health Policy and Planning 2013 ; 1-9 doi:10.1093/heapol/czt037

Abstract

Myanmar has undergone a remarkable political transformation in the last 2 years, with its leadership voluntarily transitioning from an isolated military regime to a quasi-civilian government intent on re-engaging with the international community. Decades of underinvestment have left the country underdeveloped with a fragile health system and poor health outcomes., International aid agencies have found engagement with the Myanmar government difficult but this is changing rapidly and it is opportune to consider how Myanmar can engage with the global health system strengthening (HSS) agenda. Nineteen semi-structured, face-to-face interviews were conducted with representatives from international agencies working in Myanmar to capture their perspectives on HSS following political reform. They explored their perceptions of HSS and the opportunities for implementation. Participants reported challenges in engaging with government, reflecting the disharmony between actors, economic sanctions and barriers to service delivery due to health system weaknesses and bureaucracy. Weaknesses included human resources, data and medical products/infrastructure and logistical challenges. Agencies had mixed views of health system finance and governance, identifying problems and also some positive aspects. There is little consensus on how HSS should be approached in Myanmar, but much interest in collaborating to achieve it. Despite myriad challenges and concerns, participants were generally positive about the recent political changes, and remain optimistic as they engage in HSS activities with the government. 

The paper is available online here.

12 June 2013 

Paper entitled "Human influenza A H5N1 in Indonesia: health care service-associated delays in treatment initiation", has been published in BMC Public Health

Wiku Adisasmito, Dewi Nur Aisyah, Tjandra Yoga Aditama, Rita Kusriastuti, Trihono, Agus Suwandono, Ondri Dwi Sampurno, Prasenohadi, Nurshanty A Sapada, MJN Mamahit, Anna Swenson, Nancy A Dreyer and Richard Coker authored the paper entitled "Human influenza A H5N1 in Indonesia", which has been published in BMC Public Health 2013,13:571 doi:10.1186/1471-2458-13-571 

Abstract 

Background

Indonesia has had more recorded human cases of influenza A H5N1 than any other country, with one of the world's highest case fatality rates. Understanding barriers to treatment may help ensure life-saving influenza-specific treatment is provided early enough to meaningfully improve clinical outcomes.

Methods

Data for this observational study of humans infected with influenza A H5N1 were obtained primarily from Ministry of Health, Provincial and District Health Office clinical records. Data included time from symptom onset to presentation for medical care, source of medical care provided, influenza virology, time to initiation of influenza-specific treatment with antiviral drugs, and survival.

Results

Data on 124 human cases of virologically confirmed avian influenza were collected between September 2005 and December 2010, representing 73% of all reported Indonesia cases. The median time from health service presentation to antiviral drug initiation was 7.0 days. Time to viral testing was highly correlated with starting antiviral treatment (p < 0.0001). We found substantial variability in the time to viral testing (p = 0.04) by type of medical care provider. Antivirals were started promptly after diagnosis (median 0 days).

Conclusions

Delays in the delivery of appropriate care to human cases of avian influenza H5N1 in Indonesia appear related to delays in diagnosis rather than presentation to health care settings. Either cases are not suspected of being H5N1 cases until nearly one week after presenting for medical care, or viral testing and/or antiviral treatment is not available where patients are presenting for care. Health system delays have increased since 2007. 

The paper is available online here.   

10 June 2013 

Paper entitled "Human H5N1 influenza infections in Cambodia 2005--2011: case series and cost-of-illness", has been published in BMC Public Health

Karen Humphries-Waa, Tom Drake, Anthony Huszar, Marco Liverani, Khien Borin, Sok Touch, Teng Srey and Richard Coker authored the paper entitled "Human H5N1 influenza infections in Cambodia 2005--2011: case series and cost-of-illness", which has been published in BMC Public Health 2013, 13:549 doi:10.1186/1471-2458-13-549

Background

Southeast Asia has been identified as a potential epicentre of emerging diseases with pandemic capacity, including highly pathogenic influenza, Cambodia in particular has the potential for high rates of avoidable deaths from pandemic influenza due to large gaps in health system resources. This study seeks to better understand the course and cost-of-illness for cases of highly pathogenic avian influenza in Cambodia.

The paper is available online here. 

29 May 2013 

Paper entitled "Pandemic influenza preparedness planning : lessons from Cambodia", has been published in the WHO South-East Asia Journal of Public Health

Anthony C. Huszar, Tom Drake, Teng Srey, Sok Touch and Richard Coker authored the paper entitled "Pandemic influenza preparedness planning : lessons from Cambodia", which has been published in the WHO South-East Asia Journal of Public Health ISSN 2224-3151 Volume 1, Issue 4, October-December 2012, P.369-373

Introduction

Experts have estimated that a pandemic influenza outbreak could cost more than million lives worldwide. When considered in combination with recent research demonstrating human-to-human transmission potential of the highly pathogenic strain of avian influenza A(H5N1), this highlights the growing need for public health officials to review their pandemic influenza preparedness strategy. This is especially true for South-East Asia which is predicted to be the likely epicentre of future pandemics. 

Following the 2009 H1N1 swine flu pandemic, many governments drew upon guidance from the World Health Organization (WHO) pandemic influenza preparedness framework to revise their national pandemic influenza plans. Cambodia was no different and the government updated its National Comprehensive Avian and Human Influenza Plan by producing three further pandemic influenza strategies.

The paper can be downloaded here. (Page 369-373)  

25 April 2013

Paper entitled "Quantifying Effect of Geographic Location on Epidemiology of Plasmodium vivax Malaria", has been published in the Emerging Infectious Disease Journal

Andrew A. Lover and Richard Coker authored the paper entitled "Quantifying Effect of Geographic Location on Epidemiology of Plasmodium vivax Malaria", which has been published in the Emerging Infectious Disease Journal ISSN: 1080-6059. Volume 19, Number 7 - July 2013

Abstract 

Recent autochthonous transmission of Plasmodium vivax malaria in previously malaria-free temperate regions has generated renewed interest in the epidemiology of this disease. Accurate estimates of the incubation period and time to relapse are required for effective malaria surveillance; however, this information is currently lacking. By using historical data from experimental human infections with diverse P. vivax strains, survival analysis models were used to obtain quantitative estimates of the incubation period and time to first relapse for P. vivax malaria in broad geographic regions. Results show that Eurasian strains from temperate regions have longer incubation periods, and Western Hemisphere strains from tropical and temperate regions have longer times to relapse compared with Eastern Hemisphere strains. The diversity in these estimates of key epidemiologic parameters for P. vivax supports the need for elucidating local epidemiology to inform clinical follow-up and to build an evidence base toward global elimination of malaria.

The paper is available online here. 

 9 April 2013 

Paper entitled “Priority setting in global health: Towards a minimum DALY value", has been published in Health Economics

Tom Drake authored the paper entitled "Priority setting in global health: Towards a minimum DALY value", which has been published in Health Economicsdoi: 10.1002/hec.2925

SUMMARY

Rational and analytic healthcare decision making employed by many national healthcare-funding bodies could also be expected from global health donors. Cost effectiveness analysis of healthcare investment options presents the effectiveness of a particular action in proportion to the resources required, and cost effectiveness thresholds, while somewhat arbitrary, define the level at which the investment can be considered value for money. Currently, cost effectiveness thresholds reflect the national budget context or willingness-to-pay, which is problematic when making cross-country comparisons. Defining a global minimum monetary value for the disability adjusted life year (DALY) would in effect set a global baseline cost effectiveness threshold. A global minimum DALY value would reflect a universal minimum value on human health, irrespective of a national provider's willingness or ability to pay. A minimum DALY value and associated threshold has both limitations and flaws but is justified on similar grounds to the Millennium Development Goals or the absolute poverty threshold and has the potential to radically improve transparency and efficiency of priority setting in global health.

The paper is available online here.

8 April 2013

Paper entitled “Trade years of life to make the whole world healthier”, has been published in New Scientist

Roman Carasco, Alex Cook and Richard Coker authored the paper entitled "Trade years of life to make the whole world healthier", which has been published in New Scientist, Magazine issue 2911

To solve the tragedy of child mortality we need to set up an international market in ill health

About 6 million children under 5 die from infectious diseases each year. Most of those deaths occur in low-income countries as a result of diseases that can be prevented cheaply, such as diarrhoea, malaria or measles.

This tragedy is a result of two fundamental problems in global health: money and support from richer countries are insufficient; and the available funds are often not used efficiently.

Why does this happen? One important cause is that global health is a public good, and like many other public goods it suffers from the tragedy of the commons. The benefits of contributing – reduced risk of new emerging diseases, for example – are shared by free riders as well as contributors. You don't have to pay into the system to reap the rewards.

At present, global health investment is voluntary and few countries make sizeable donations. Since the start of the global financial crisis, investment has stagnated.

Is there a way to improve the situation? We think so. Although the world does not have a lot of experience in managing global commons, there is an example we can learn from: carbon trading.

The paper is available online here.

 25 March 2013

Paper  entitled "Analysis of 2009 pandemic influenza A/H1N1 outcomes in 19 European countries: association with completeness of national strategic plans", has been published in BMJ Open

Aronrag Meeyai, Ben S Cooper and Richard Coker authored the paper entitled "Analysis of 2009 pandemic influenza A/H1N1 outcomes in 19 European countries: association with completeness of national strategic plans", which has been published in BMJ Open. 2013;3:e002253 doi:10.1136/bmjopen-2012-002253

Abstract

Objective: To describe changes in reported influenza activity associated with the 2009 H1N1 pandemic in European countries and determine whether there is a correlation between these changes and completeness of national strategic pandemic preparedness.

Design: A retrospective correlational study.

Setting: Countries were included if their national strategic plans had previously been analysed and if weekly influenza-like illness (ILI) data from sentinel networks between week 21, 2006 and week 20, 2010 were more than 50% complete.

Outcome measures: For each country we calculated three outcomes: the percentage change in ILI peak height during the pandemic relative to the prepandemic mean; the timing of the ILI peak and the percentage change in total cases relative to the prepandemic mean. Correlations between these outcomes and completeness of a country's national strategic pandemic preparedness plan were assessed using the Pearson product–moment correlation coefficient.

Results: Nineteen countries were included. The ILI peak occurred earlier than the mean seasonal peak in 17 countries. In 14 countries the pandemic peak was higher than the seasonal peak, though the difference was large only in Norway, the UK and Greece. Nine countries experienced more total ILI cases during the pandemic compared with the mean for prepandemic years. Five countries experienced two distinct pandemic peaks. There was no clear pattern of correlation between overall completeness of national strategic plans and pandemic influenza outcome measures and no evidence of association between these outcomes and components of pandemic plans that might plausibly affect influenza outcomes (public health interventions, vaccination, antiviral use, public communication). Amongst the 17 countries with a clear pandemic peak, only the correlation between planning for essential services and change in total ILI cases significantly differed from zero: correlation coefficient (95% CI) 0.50 (0.02, 0.79).

Conclusions: The diversity of pandemic influenza outcomes across Europe is not explained by the marked variation in the completeness of pandemic plans.

The paper is available online here.

22 March 2013

Meeting : Surges in demand for health services : Health system impacts and capacity to respond in Indonesia

A meeting to disseminate results from the Surge in Indonesia project was held in Jakarta, Indonesia on 14th March 2013. The project investigators are Prof Richard Coker, Prof Wiku Adisasmito and Dr James Rudge. The lead researcher is Dr.Samantha Watson. The briefing note from the meeting can be downloaded here. 

21 March 2013

Paper entitled "Health Systems' "Surge Capacity": State of the art and priorities for future research", has been published in the Milbank Quarterly

Samantha K. Watson, James W. Rudge and Richard Coker authored the paper entitled "Health Systems' "Surge Capacity": State of the art and priorities for future research", which has been published in the Milbank QuarterlyVolume 91, Issue 1 (pages 78-122) doi: 10.1111/milq.12003

Context: Over the past decade, a number of high-impact natural hazard events, together with the increased recognition of pandemic risks, have intensified interest in health systems' ability to prepare for, and cope with, "surges" (sudden large-scale escalations) in treatment needs. In this article, we identify key concepts and components associated with this emerging research theme. We consider the requirements for a standardized conceptual framework for future research capable of informing policy to reduce the morbidity and mortality impacts of such incidents. Here our objective is to appraise the consistency and utility of existing conceptualizations of health systems' surge capacity and their components, with a view to standardizing concepts and measurements to enable future research to generate a cumulative knowledge base for policy and practice.

Methods: A systematic review of the literature on concepts of health systems' surge capacity, with a narrative summary of key concepts relevant to public health.

Findings: The academic literature on surge capacity demonstrates considerable variation in its conceptualization, terms, definitions, and applications. This, together with an absence of detailed and comparable data, has hampered efforts to develop standardized conceptual models, measurements, and metrics. Some degree of consensus is evident for the components of surge capacity, but more work is needed to integrate them. The overwhelming concentration in the United States complicates the generalizability of existing approaches and findings.

Conclusions: The concept of surge capacity is a useful addition to the study of health systems' disaster and/or pandemic planning, mitigation, and response, and it has far-reaching policy implications. Even though research in this area has grown quickly, it has yet to fulfill its potential to generate knowledge to inform policy. Work is needed to generate robust conceptual and analytical frameworks, along with innovations in data collection and methodological approaches that enhance health systems' readiness for, and response to, unpredictable high-consequence surges in demand.

The paper is available online here.

4 March 2013

Meeting: Towards Cost-Effective Pandemic Influenza Mitigation in Cambodia

A meeting to disseminate results from the CamFlu project was held in Phnom Penh, Cambodia on 20th February 2013. The meeting was opened by H.E. Prof Eng Huot, Sectretary of State for Health in Cambodia.  The project investigators are Prof Richard Coker, Dr Sok Touch and Dr Khieu Borin. The lead researcher is Tom Drake. The briefing note from the meeting can be downloaded here.

22 February 2013

Paper  entitled "Who Should Pay for Global Health , and How Much?", has been published in PLOS Medicine

Luis R. Carrasco, Richard Coker and Alex R. Cook authored the paper entitled "Who Should Pay for Global Health, and How Much?", which has been published in PLOS Medicine 10(2): e1001392. doi:10.1371/journal.pmed.1001392

Summary Points

    • Mechanisms to establish the expected financial contribution from each country to achieve the health Millennium Development Goals (MDGs) could encourage scaling-up of contributions.

    • Mirroring global carbon permit markets to mitigate climate change, we propose a cap-and-trade system consisting of a global cost-effectiveness criterion and a disability-adjusted life year (DALY) global credit market.

    • Under this system, high-income and middle-income countries should contribute, respectively, 74% and 26% of the additional US$36–US$45 billion annually needed to attain the health MDGs. The change relative to current contributions would vary, with some countries needing to scale-up substantiall21pxy their expected annual contributions under the proposed market (e.g., US, US$7–US$10 billion; China, US$2–US$3 billion; Japan, US$2 billion; Germany, US$1.5–US$2 billion), while a few already meet or exceed their required contributions (i.e., Norway, the United Arab Emirates, Luxembourg, and the UK).

    • A DALY tradable credit market offers the potential to increase the efficiency of global health investments while promoting international obligations to the pursuit of an agreed global common good.

14 December 2012

Paper entitled "An analysis of health system resources in relation to pandemic response capacity in the Greater Mekong Subregion", has been published in the International Journal of Health Geographics

Prof Richard Coker, James Rudge and colleagues authored the paper "An analysis of health system resources in relation to pandemic response capacity in the Greater Mekong Subregion", resulting from the work of the AsiaFluCap project (http://www.cdprg.org/asiaflucap.php), which has been published in the International Journal of Health Geographics 2012, 11:53 doi:10.1186/1476-072X-11-53 

The paper is available online at http://www.ij-healthgeographics.com/content/11/1/53/abstract

Abstract

Background: There is increasing perception that countries cannot work in isolation to militate against the threat of pandemic influenza. In the Greater Mekong Subregion (GMS) of Asia, high socioeconomic diversity and fertile conditions for the emergence and spread of infectious diseases underscore the importance of transnational cooperation. Investigation of healthcare resource distribution and inequalities can help determine the need for, and inform decisions regarding, resource sharing and mobilisation.

Methods: We collected data on healthcare resources deemed important for responding to pandemic influenza through surveys of hospitals and district health offices across four countries of the GMS (Cambodia, Lao PDR, Thailand, Vietnam). Focusing on four key resource types  (oseltamivir, hospital beds, ventilators, and health workers), we mapped and analysed resource distributions at province level to identify relative shortages, mismatches, and clustering of resources. We analysed inequalities in resource distribution using the Gini coefficient and Theil index.

Results: Three quarters of the Cambodian population and two thirds of the Laotian population live in relatively underserved provinces (those with resource densities in the lowest quintile across the region) in relation to health workers, ventilators, and hospital beds. More than a quarter of the Thai population is relatively underserved for health workers and oseltamivir. Approximately one fifth of the Vietnamese population is underserved for beds and ventilators. All Cambodia provinces are underserved for at least one resource. In Lao PDR, 11 percent of the population is underserved by all four resource items. Of the four resources, ventilators and oseltamivir were most unequally distributed. Cambodia generally showed the higher inequalities in resource distribution compared to other countries. Decomposition of the Theil index suggests that inequalities result principally from differences within, rather than between, countries.

Conclusions: There is considerable heterogeneity in healthcare resource distribution within and across countries of the GMS. Most inequalities result from within countries. Given the inequalities, mismatches and clustering of resources observed here, resource sharing and mobilization in a pandemic scenario could be crucial for more effective and equitable use of the resources that are available in the GMS. 

4 December 2012

Paper entitled "Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?" has been published in the Bulletin of the World Health Organization

Tom Drake, Zaid Chalabi and Richard Coker authored the paper entitled "Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?", which has been published in the Bulletin of the WHO 2012;90:940-941. doi: 10.2471/BLT.12.109025. This paper was produced as part of the CamFlu project, an economic evaluation of pandemic influenza mitigation investment options for Cambodia, funded by Gesellschaft für Internationale Zusammenarbeit (GIZ).  

The paper is available online at http://www.who.int/bulletin/volumes/90/12/12-109025/en/index.html#

Paper entitled "Avian and pandemic human influenza policy in South-East Asia: the interface between economic and public health imperatives" has been published in the Health Policy and Planning Journal. 

Richard Coker, Head of Communicable Diseases Policy Research Group (CDPRG), LSHTM and colleagues have published the paper entitled "Avian and pandemic human influenza policy in South-East Asia: the interface between economic and public health imperatives" in the Health Policy and Planning Journal. (2012) 27 (5): 374-383 doi: 10.1093/heapol/czr056

Abstract

The aim of this study was to analyse the contemporary policies regarding avian and human pandemic influenza control in three South-East Asia countries: Thailand, Indonesia and Vietnam. An analysis of poultry vaccination policy was used to explore the broader policy of influenza A H5N1 control in the region. The policy of antiviral stockpiling with oseltamivir, a scarce regional resource, was used to explore human pandemic influenza preparedness policy. Several policy analysis theories were applied to analyse the debate on the use of vaccination for poultry and stockpiling of antiviral drugs in each country case study. We conducted a comparative analysis across emergent themes.

The study found that whilst Indonesia and Vietnam introduced poultry vaccination programmes, Thailand rejected this policy approach. By contrast, all three countries adopted similar strategic policies for antiviral stockpiling in preparation. In relation to highly pathogenic avian influenza, economic imperatives are of critical importance. Whilst Thailand's poultry industry is large and principally an export economy, Vietnam's and Indonesia's are for domestic consumption. The introduction of a poultry vaccination policy in Thailand would have threatened its potential to trade and had a major impact on its economy. Powerful domestic stakeholders in Vietnam and Indonesia, by contrast, were concerned less about international trade and more about maintaining a healthy domestic poultry population. Evidence on vaccination was drawn upon differently depending upon strategic economic positioning either to support or oppose the policy.

With influenza A H5N1 endemic in some countries of the region, these policy differences raise questions around regional coherence of policies and the pursuit of an agreed overarching goal, be that eradication or mitigation. Moreover, whilst economic imperatives have been critically important in guiding policy formulation in the agriculture sector, questions arise regarding whether agriculture sectoral policy is coherent with public health sectoral policy across the region.

Full text: http://heapol.oxfordjournals.org/content/27/5/374.full.pdf+html 

Paper entitled " Pandemic influenza H1N1 2009 in Thailand" is published in the WHO South-East Asia Journal of Public Health

Aronrag Meeyai and Richard Coker,et al. have published the paper on Pandemic influenza H1N1 2009 in Thailand in the WHO South-East Asia Journal of Public Health, Vol. 1 No. 1, January – March, 2012. 2012;1(1):59-68

Abstract

Background: Developing a quantitative understanding of pandemic influenza dynamics in SouthEast Asia is important for informing future pandemic planning. Hence, transmission dynamics of influenza A/H1N1 were determined across space and time in Thailand.

Methods: Dates of symptom onset were obtained for all daily laboratory-confirmed cases of influenza A/H1N1pdm in Thailand from 3 May 2009 to 26 December 2010 for four different geographic regions (Central, North, North-East, and South). These data were analysed using a probabilistic epidemic reconstruction, and estimates of the effective reproduction number, R(t), were derived by region and over time.

Results: Estimated R(t) values for the first wave peaked at 1.54 (95% CI: 1.42-1.71) in the Central region and 1.64 (95% CI: 1.38-1.92) in the North, whilst the corresponding values in the North-East and the South were 1.30 (95% CI: 1.17-1.46) and 1.39 (95% CI: 1.32-1.45) respectively. As the R(t) in the Central region fell below one, the value of R(t) in the rest of Thailand increased above one. R(t) was above one for 30 days continuously through the first wave in all regions of Thailand. During the second wave R(t) was only marginally above one in all regions except the South.

Conclusions: In Thailand, the value of R(t) varied by region in the two pandemic waves. Higher R(t) estimates were found in Central and Northern regions in the first wave. Knowledge of regional variation in transmission potential is needed for predicting the course of future pandemics and for analysing the potential impact of control measures

Full text please visit: http://www.searo.who.int/publications/journals/seajph/media/2012/seajph_v1n1/whoseajphv1i1p59.pdf

Job Opportunity : Overseas Lecturer in Health Systems Analysis

We are seeking an enthusiastic Lecturer to join our CDPRG group, Department of Global Health and Development, based in Thailand.  The primary role for this post will be to work with the team to develop a research programme in health systems in SE Asia; in addition the post holder will support two GIZ funded projects undertaking health systems analyses in Cambodia and Indonesia.

We are looking for an applicant, to start as soon as possible, with a background in health systems and policy analysis, health economics, or related discipline, with experience in primarily quantitative research. As the GIZ projects involve development and simulation of healthcare “surge” scenarios, experience with mathematical modelling and/or programming is also desirable (but not essential).

The successful applicant will be based in Bangkok for the duration of the post, but will need to be able to travel between research partners and other collaborators in other SE Asian countries.

Salary will be on the Lecturer scale (£38,140-£44,165 per annum inclusive plus displacement allowance if applicable). The post will be subject to the LSHTM overseas terms and conditions of service, including membership of the Universities Superannuation Scheme.  The post is full time for one year in the first instance. 

Applications should be made on-line via our website at http://jobs.lshtm.ac.uk.The reference for this post is RC09.  

Applications should also include a CV and the names of two referees, one of whom should be the most recent employer and may be approached immediately if shortlisted, should also be included with the on-line application.  Any queries regarding the application process may be addressed to jobs@lshtm.ac.uk

The London School of Hygiene & Tropical Medicine is committed to being an equal opportunities employer.

Paper entitled " H5N1 Avian Influenza in Children" has been published in Clinical Infectious Diseases

15 March 2012:

Co authored by Prof Richard Coker, the paper "H5N1 Avian Influenza in Children" has been published in Clinical Infectious Diseases journal doi:10.1093/cid/cis295 and is available online here.

Abstract

Background: Avian influenza continues to pose a threat to humans and maintains the potential for greater transmissibility. Understanding the clinical presentation and prognosis in children will help guide effective diagnosis and treatment. 

Methods: A global patient registry was created to enable systematic collection of clinical, exposure, treatment and outcomes data on confirmed cases of H5N1. Bivariate and multivariate statistical tools were used to describe clinical presentation and evaluate factors prognostic of survival. 

Results: Data were available from 13 countries on 193 cases <18 years who were confirmed as having been infected with H5N1; 35.2% of cases were from Egypt. The case fatality rate (CFR) for children was 48.7%, with Egypt having very low pediatric CFR. Overall, children aged ≤5 years had the lowest CFR and were brought to hospital more quickly and treated sooner than older children. Pediatric cases who presented for medical care with a complaint of rhinorrhea had a 76% reduction in the likelihood of death compared with those who presented without rhinorrhea, even after statistical adjustment for age, having been infected in Egypt, and oseltamivir treatment (P=0.02). Delayed initiation of treatment with oseltamivir increases the likelihood of death, with an overall 75% increase in the adjusted odds ratio for death for each day of delay.

Conclusions: The presence of rhinorrhea appears to indicate a better prognosis for children with H5N1, with most cases surviving regardless of age, country or treatment. For cases treated with oseltamivir, early initiation of treatment substantially enhances the chance of survival.

 January 2012

The CDPRG office was officially inaugurated on 25 January 2012. Located in Mahidol Univerisity's central Bangkok campus, the office provides a hub for research activities and collaborations across the region. Associate Professor Phitaya Charupoonphol, Dean of the Faculty of Public Health at Mahidol University, opened proceedings by extending a formal welcome to the group, with the official inauguration led by Professor Anne Mills, Vice Director of LSHTM & Professor of Health Economics and Policy. In her speech, Professor Mills emphasised the strategic importance of heightening the School's regional presence, and of developing institutional settings for international collaboration. Professor Richard Smith, Head of the Faculty of Public Health & Policy, and Professor Richard Coker, Head of CDPRG, joined Professor Mills in extending their thanks to the Group's hosts at Mahidol. The ceremony was followed by an afternoon of research dissemination activities to develop links and explore avenues for future regional collaboration.