Health systems performance in sub-Saharan Africa: governance,outcome and equity

Background  

The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance.     

Outbreak of meningococcal infection amongst soldiers deployed in operations

Background: Meningococcal infection may lead to life threatening meningitis and fulminant meningococcal sepsis. Sporadic cases of meningococcal infection have been reported in soldiers but no outbreak in soldiers has been reported earlier from India. This outbreak in soldiers serving in counter insurgency role under field setting was effectively controlled without compromising their operational commitment.     

Individual risk assessment and information technology to optimise screening frequency for diabetic retinopathy

Aims/hypothesis

The aim of this study was to reduce the frequency of diabetic eye-screening visits, while maintaining safety, by using information technology and individualised risk assessment to determine screening intervals.

Methods

A mathematical algorithm was created based on epidemiological data on risk factors for diabetic retinopathy. Through a website, www.risk.is, the algorithm receives clinical data, including type and duration of diabetes, HbA_1c or mean blood glucose, blood pressure and the presence and grade of retinopathy. These data are used to calculate risk for sight-threatening retinopathy for each individual??s worse eye over time. A risk margin is defined and the algorithm recommends the screening interval for each patient with standardised risk of developing sight-threatening retinopathy (STR) within the screening interval. We set the risk margin so that the same number of patients develop STR within the screening interval with either fixed annual screening or our individualised screening system. The database for diabetic retinopathy at the Department of Ophthalmology, Aarhus University Hospital, Denmark, was used to empirically test the efficacy of the algorithm. Clinical data exist for 5,199 patients for 20?years and this allows testing of the algorithm in a prospective manner.

Results

In the Danish diabetes database, the algorithm recommends screening intervals ranging from 6 to 60?months with a mean of 29?months. This is 59% fewer visits than with fixed annual screening. This amounts to 41 annual visits per 100 patients.

Conclusion

Information technology based on epidemiological data may facilitate individualised determination of screening intervals for diabetic eye disease. Empirical testing suggests that this approach may be less expensive than conventional annual screening, while not compromising safety. The algorithm determines individual risk and the screening interval is individually determined based on each person??s risk profile. The algorithm has potential to save on healthcare resources and patients?? working hours by reducing the number of screening visits for an ever increasing number of diabetic patients in the world.     

Adjuvants LT-K63 and CpG enhance the activation of dendritic cells in neonatal mice

Dendritic cells (DC) play a major role in the priming of T cells and initiating specific immune responses. We assessed the effects of the adjuvants LT-K63 and CpG on neonatal DC in vivo and in vitro . Cytokine levels (IL-10, IL-12p70 and IL-12p40/IL-23p40) were measured and the expression of the activation markers CD86, CD40 and MHCII on CD11c⁺ DC was analysed by using FACS. The proportion of MHCII^high CD11c⁺ DC was higher in neonatal mice immunized with a pneumococcal conjugate (PncTT) and LT-K63 or CpG compared with that when PncTT was alone. In vitro stimulation with LT-K63 enhanced the expression of CD86 more on CD11c⁺ DC from spleens of mice immunized as neonates than those immunized as adults, whereas in vitro stimulation with CpG enhanced the expression of CD86 and CD40 on CD11c⁺ DC similarly in both age groups. CpG stimulation in vitro enhanced IL-10 and IL-12(p70) production in mice immunized as neonates with PncTT and either adjuvant, but not PncTT alone. The adjuvants LT-K63 and CpG enhance the activation of CD11c⁺ DC in mice immunized as neonates and can thereby overcome one of the limiting factors in the initiation of the immune response to conjugate vaccines in early life. The fact that neonatal DC are more susceptible to stimulation with either adjuvant, LT-K63 or CpG, could imply that neonatal CD11c⁺ DC are more easily activated than adult CD11c⁺ DC, and/or be a consequence of the predominance of different DC subsets in neonatal and adult mice.