Global challenges and opportunities for tackling antimicrobial resistance

This post was written by Sophie Allcock andoriginally posted on the Global Health, Epidemiology and Genomics blog – view more at: http://gheg-journal.co.uk/blog/

Antimicrobial resistance (AMR) is a global public health concern. In 2014, an estimated 700,000 deaths were attributed to AMR globally and it is predicted that by 2050 this number could reach 10 million.[1] Antibiotics have been the cornerstone of many medical interventions, for example surgical interventions, transplants and the treatment of common bacterial infections, for decades. Without effective antibiotics, many medical practices that we now consider to be routine will be jeopardised.

Although there is much global attention to AMR, there is a need to better understand the burden, distribution and determinants of AMR at the population level. Antimicrobial use, appropriate or inappropriate, is a driver of AMR yet there is a lack of specific advice as to which interventions are likely to have the greatest impact on reducing the emergence and spread of AMR in both hospital and community settings.

In our paper “Antimicrobial resistance in human populations: challenges and opportunities”, we argue for the integration of a range of epidemiological approaches, which could help to improve our understanding of the population level factors that may influence the development and spread of AMR. This is important for informing interventions to reducing excess use of antimicrobials, whilst also ensuring that those in need of these treatments have access to them.

One such approach is to use routine clinical data and electronic health records (EHRs) in combination with pathogen surveillance, using techniques such as whole-genome sequencing. This could help to improve our understanding of drug resistance, how it emerges and how it spreads. EHRs could also provide an insight into prescribing practices in general practices and hospitals, and how this could be related to the emergence of drug-resistant infections. Using prospective (or longitudinal) study designs, researchers could explore the real-time development of resistant strains in a given population as well as the factors that may drive resistance.

Other preventative strategies to reduce the burden of AMR include basic hygiene and sanitation practices, waste management and safe food preparation. However, in some low- and middle-income countries (LMICs), conducting these basic practices can be challenging due to human resource constrains and weaker civil and health infrastructures. Furthermore, it is often the case in these countries that more people suffer due to a lack of access to drugs than drug resistance itself.

The suggested research initiatives may help to better understand the burden, distribution and determinants of AMR. These approaches should be combined with improved preventative measures, including vaccinations and good hygiene and sanitation practices to reduce the need for therapy in the first instance, and strategies to reduce excess use of antimicrobials to slow the development of resistance. Furthermore, although AMR is a global problem, we need to consider that the issue differs by county and setting, therefore so must the approach taken to tackle AMR.

Reference:
1. O’Niell J., Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, in The review on antimicrobial resistance. 2016, HM Government and the Wellcome Trust: London.

The paper “Antimicrobial resistance in human populations: challenges and opportunities” by S. Allcock, E. H. Young, M. Holmes, D. Gurdasani, G. Dougan, M. S. Sandhu, L. Solomon and M. E. Török has been published Open Access in Global Health, Epidemiology and Genomics and is available here.

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A formula for concern: The boom of milk-based formula sales

PHN Editorial Highlight: ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?
Blog by Phillip Baker

To ensure children get the best start in life the World Health Organization recommends that infants are exclusively breastfed to six months of age with ongoing breastfeeding for up to two years of age and beyond. Yet worldwide the prevalence of infants exclusively breast fed to six months hovers at around 37% and has improved only marginally in recent decades.

In contrast, the study of 80 countries demonstrates that global milk-based formula sales are booming. In the five-years between 2008 and 2013 world total milk formula sales grew by 40.8% from 5.5 to 7.8kg per infant/child, a figure projected to increase to 10.8kg by 2018.

This global sales boom applies not only to infant formula (for consumption by infants aged 0-6 months) but also to follow-up (7-12 months) and toddler (13-36 months) formulas, which can displace ongoing breastfeeding if marketed and consumed inappropriately.

We describe this as indicative of a global ‘infant and young child feeding transition’ i.e. a shift from lower to higher formula diets at the population level. Although the idea of such a transition is not new, the rate and scale of change described in the study is potentially unprecedented.

Growth has been especially rapid in several industrialising countries in Asia: China, Indonesia, Malaysia, Vietnam and Thailand. As home to the world’s second largest infant/child population (~41 million aged 0-36 months in 2013) the most significant absolute change has been in China. Other highly-populated countries undergoing significant growth include South Africa, Iran, Turkey, Brazil and Peru.

These results are troubling because formula-fed children experience poorer health and developmental outcomes than breastfed children including an increased risk of death, pneumonia, diarrhoea, obesity and type-2 diabetes, ear infections and asthma. Formula feeding also harms mothers due to the forgone protective effects of breastfeeding against breast and ovarian cancer.

Infant and young child feeding is typically portrayed as an individual behaviour, as a matter of free parental choice. The study offers a counter-view – the observed results are likely to reflect transformations in wider social, economic and social systems that structure infant and young child feeding choices at the population level.

In this view, the global infant and young child feeding transition is driven largely by the expansion of transnational formula companies and more intensive formula marketing, the shift of labour and production out of the home (especially in Asia’s vast manufacturing centres where millions of women have become employed, often with no or limited maternity protections), and the failure of regulations and policies designed to promote, protect and support breastfeeding in these new contexts.

These findings are important for several reasons. The results raise serious concern that the rapid changes observed are not being captured in a timely manner by existing international nutrition monitoring systems.

Existing regulations intended to protect the health of children and mothers and to prevent unethical formula marketing are not working effectively. Renewed efforts towards the implementation, monitoring and enforcement of the International Code of Marketing of Breast-Milk Substitutes, including stronger accountability mechanisms for governments and industry are urgently needed.

Stronger maternity protections that enable breastfeeding (e.g. adequate maternity leave, paid lactation breaks, flexible working hours, and nursing facilities) are also urgently needed for millions of working mothers, especially in Africa and Asia.

This can only come about through greater political priority and strengthened governance mechanisms for infant and young child nutrition.

The paper, ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?’ is published in the journalPublic Health Nutrition and is freely available until 12th June 2016.
Authors: Phillip Baker, Julie Smith, Libby Salmon, Sharon Friel, George Kent, Alessandro Iellamo, JP Dadhich, Mary J Renfrew.
Funding: This analysis was unfunded. However, the lead author was employed through an Australian Research Council Discovery Project (number 130101478).

Source: A formula for concern: The boom of milk-based formula sales – Cambridge Journals Blog

Addressing the gender gap in global health leadership – via Global Health, Epidemiology and Genomics

IMG_9460 (003)

This post was written by Pascale Allotey andoriginally posted on the Global Health, Epidemiology and Genomics blog – read more at: http://cambridge.org/gheg-journal

In recognition of International Women’s Day 2016, GHEG is inviting submissions for a themed collection on Women in Global Health.

A core mission of global health is to achieve health equity for all people worldwide. Women, particularly in resource-limited settings, experience a disproportionate burden of disease and mortality due to inequities in access to basic health care, nutrition and education.(1) The imbalance in the health burden between genders is therefore a key focus, addressed by both the Millennium Development Goals and more recently, the Sustainable Development Goals.

However, despite this key goal to address gender inequities within the field of global health, women still occupy less than a quarter of global health leadership roles.(1) Ilona Kickbusch’s recent #WGH100 Twitter campaign to identify women leaders working at the forefront of global health, arose from a frustration with the lack of visibility of women in critical public spaces in the field.(2) Like other industries, the reasons for this imbalance include lack of opportunities, family commitments and lack of confidence. Whilst many institutions have attempted to address these issues, tackling the gender gap in leadership still requires a more proactive strategy.

This year’s theme for International Women’s day is Planet 50-50 by 2030: step it up for gender equality. The goal, spearheaded by UN Women, is to achieve gender equality in the next 15 years – by increasing investment in gender equality, striving for parity for women at all levels of decision-making, eliminating discriminatory legislation, and addressing social norms that perpetuate discrimination against women.(3)

The campaign for equality in leadership is important for reasons other than proportional representation. Research in several settings has shown that women in leadership positions are more likely than their male counterparts to invest in infrastructure and programmes that address women’s concerns.(1) Similarly, policies of women in leadership tend to be more responsive to the needs of women and children and recognise women’s responsibility for decision-making when it comes to the health of their families.(1, 2)

In an attempt to address and explore the issues surrounding gender and leadership in global health, GHEG will be publishing a themed collection on Women in Global Health. We invite submissions that explore, among other things, the current landscape, the potential reasons behind the current gender imbalance in global health roles, suggestions for practice and policy that can catalyse change, and descriptions of effective formal partnerships and campaigns on Women in Global Health. The deadline for this call is the 31st May 2016. To find out more visit: http://journals.cambridge.org/gheg/womenglobalhealth-cfp

 
References
1. Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(8):1103-7.
2. Devi S. Twitter campaign highlights top women in global health. Lancet (London, England). 2015;385(9965):318.
3. Press release: World leaders agree: We must close the gender gap [press release]. 2015.

Announcing the publication of the first papers in GHEG

GHG blog image - cover
We are delighted to announce the publication of the first papers in Global Health, Epidemiology and Genomics. As GHEG is fully Open Access, these papers, and all papers published in the future, are freely accessible online. Here we provide a brief summary of our first three publications.

 A forum for global population health, technological advances and implementation science
 Manjinder Sandhu

A welcome editorial by our Editor in Chief, marking the launch of Global Health, Epidemiology and Genomics. Dr Sandhu highlights the strengths of the broad interdisciplinary scope of the journal and its international editorial board and invites the global health community to engage and contribute to the journal so that it becomes a valuable, practical and informative resource.
Read the full article here

 

favicon Study Profile: The Durban Diabetes Study (DDS): a platform for chronic disease research
 Thomas Hird et al.

A study profile of The Durban Diabetes Study (DDS), an on-going population-based cross-sectional survey of an urban black population in Durban, South Africa. The DDS was established to investigate a broad range of lifestyle, medical and genetic factors and their association with diabetes. It provides a rich platform for investigating the distribution, interrelation and aetiology of other chronic diseases and their risk factors, which can be utilised for other research studies.
Read the full article here

 

Favicon long Capitalizing on Natural Experiments in Low- to Middle- Income Countries to Explore Epigenetic Contributions to Disease Risk in Migrant Populations
 J. Jaime Miranda et al.

 

A commentary on the value of epigenetics as a tool for understanding differential disease risk in migrant populations. The authors highlight the merit of exploring migrant chronic disease risk in low- to middle-income countries, particularly in the context of rural-to-urban migration, with increasing urbanisation in this setting.
Read the full article here
More articles will be published in the coming weeks, and you can be notified when new articles are published by signing up to content alerts here. Here’s a preview of what’s coming soon:

  • H3Africa Multi-Centre Study of the Prevalence and Environmental and Genetic Determinants of Type 2 Diabetes in Sub-Saharan Africa: Study Protocol
    Kenneth Ekoru et al.
  • Regulatory Developments in the Conduct of Clinical Trials in India
    Dhvani Mehta and Ranjit Roy Chaudhury

GHEG accepts original research articles, brief reports, structured reviews and commentaries as well as protocols, research resources and analysis. We are waiving the Article Processing Charge for all articles submitted to GHEG before the end of 2016. We invite contributions from a range of disciplines:
Epidemiology, Clinical trials, Genetics, Observational studies, Qualitative studies, Anthropological studies, Social science, Community intervention, Health systems, Health services, Population genetics, Population history.
For further information on the journal and how to submit please visit our website. Or if you wish to submit your manuscript directly please visit: http://mc.manuscriptcentral.com/gheg.

Rising risk of obesity among China’s ‘left behind children’

Boys in Rural ChinaThe December Nutrition Society paper of the month, is from Public Health Nutrition and is entitled, ‘A multi-level analysis of the relationship between parental migration and left-behind children’s macronutrient intakes in rural China.’

Some 61 million rural children left behind by parents moving to China’s booming urban centres are at risk from increased fat and reduced protein in their diets.

The study of 975 children from 140 rural villages in nine provinces carefully analysed nutritional intake and showed a particular risk to boys who were left behind in the care of grandparents or a mother who sought work away from home.

There are sound financial reasons why so many people move from rural to urban areas in China, but the benefits that more money brings to a family can often be at the expense of child nutrition. The Chinese government needs to recognise this growing problem among rural communities and this research provides some evidence to target health policies on encouraging a balanced diet.

The study finds that ‘left behind’ boys in particular consumed more fat and less protein than those from complete families, which potentially leaves them at increased risk of obesity and stunted growth. This has important policy implications in a specific cultural-context where son preferences are powerful.

Although the results of the study don’t provide reasons for this change in diet, we speculate that mothers moving away from home generally earn less, and that these lower earnings act in combination with grandparents’ poorer dietary knowledge or willingness to spend more on food.

Another factor at work could be that prices of protein-based foods such as eggs and meat have increased faster than many households’ incomes – meaning that even though money is being sent home from one or both parents, nutrition doesn’t always improve.

The process of parental migration is complex and the reasons for problems in boys’ nutrition are not straightforward, however we can see that both parents and grandparents in rural areas need to be educated about good diet.

Because raising children can fall on all members of the family, good care-giving practice needs to become more widespread.

The paper, ‘A multi-level analysis of the relationship between parental migration and left-behind children’s macronutrient intakes in rural China,’ was published in the journal, Public Health Nutrition and is available to read in full at http://journals.cambridge.org/ns/dec15

Authors Nan Zhang, Laia Bécares and Tarani Chandola

Funding- Economic and Social Research Council (ESRC) Postgraduate Scholarship

Cambridge launch new open access journal – Global Health, Epidemiology and Genomics

GHG blog image - cover

Cambridge unveils new Open Access journal – Global Health, Epidemiology and Genomics (GHEG)

Cambridge University Press is delighted to announce a major new open access journal, Global Health, Epidemiology and Genomics (GHEG), dedicated to publishing and disseminating research that addresses and increases understanding of global and population health issues through the application of population science, genomics and applied technologies.

Global Health, Epidemiology and Genomics is the Press’s second Open Access journal in the field of global health, joining Global Mental Health which launched in 2014. Spanning both non-communicable and communicable diseases, GHEG will specifically integrate epidemiology, genomics and related technological advances in the global health context. Topics relevant to GHEG will include studies, methods and resources relating to global population health, disease aetiology, variation in disease susceptibility, drug resistance and surveillance, health care and health care systems, pharmacogenomics and stratified medicine, as well as the challenges of implementing new developments into clinical practice and the community, globally. In addition to more traditional Original Research and Review Articles, GHEG will support submission of Resources and Analyses that provide a framework for integrating and facilitating genomics and global health studies.

The Editor-in-Chief of GHEG is Dr Manjinder Sandhu, head of the Global Health Group based at the University of Cambridge and the Wellcome Trust Sanger Institute. The international Editorial team includes recognised leaders in global health, epidemiology and genomics from around the world who have taken a lead in shifting attention and action to global health and populations, as well as a wider Editorial Board that will reflect and emphasize the broad scope of the field.

Dr Sandhu said, “I am committed to making GHEG an innovative, engaging and practical resource for the global health research community through which we can publish new scientific research, exchange ideas within and across our related disciplines and share resources to facilitate efforts to increase our understanding of human health and shape effective disease management worldwide.”

Professor Alex Brown, Deputy Director of the South Australia Health & Medical Research Institute (SAHMRI) and one of the journal’s Associate Editors commented, “I am delighted to be involved with GHEG, an exciting venture which recognises the relevance and importance of the work being undertaken in the field of global health, epidemiology and genomics and the widespread benefits to be gained by applying technological advances and innovations to research into population health including within disadvantaged population groups. By facilitating discussion and encouraging the sharing of resources GHEG looks to actively support contributions in these areas.”

Katy Christomanou, Publishing Director for STM Journals at Cambridge University Press, added, “This launch affirms our long-term commitment in the global health field and reflects our strong investment in maintaining and extending our successful presence in this area. We are highly enthusiastic at the prospect of working alongside such an outstanding editorial team.”

Global Health, Epidemiology and Genomics will be hosted on Cambridge’s industry-leading platform, Cambridge Journals Online (CJO). The Journal will benefit from a range of the latest author services including article level usage metrics and Altmetric data. In addition, for articles submitted during 2015 and 2016, Cambridge University Press will waive all article processing charges.

For more information please visit the journal website: journals.cambridge.org/gheg

 

Pregnant women lack guidance on iodine intake levels


Pregnant women are not getting enough information about the need to include iodine in their diets, despite high awareness of general advice for pregnancy nutrition.

While 96% of pregnant women surveyed by researchers were aware of general nutritional recommendations for pregnant women, only 12% were aware of iodine-specific advice.

The study, published in the British Journal of Nutrition, estimated the median intake of iodine during pregnancy was 190 micrograms (ug) per day, with 74% consuming less than the World Health Organisation (WHO) recommended intake of 250ug daily.

Iodine is required for the production of thyroid hormones, which are crucial for fetal development with links between iodine deficiency and developmental impairments.

Dr Emilie Combet, who led the reserch at the University of Glasgow, said: “Women aren’t receiving the message about the importance of iodine in pregnancy, meaning they cannot make informed choices to ensure they get the amount they require.”

Iodine deficiency affects 1.9 billion people globally and is the most preventable cause of intellectual disability. The UK is ranked 8th in a list of iodine-deficient countries in the world.

The main sources of iodine-rich foods are seafood and dairy products, and in some countries iodine-fortified salt or bread. In the UK, the Reference Nutrient Intake (RNI) for adults is 140ug per day, with no proposed increment for pregnant and lactating women.

Unborn children and young infants are entirely reliant on their mother for iodine supply, making babies and pregnant or lactating mothers the most vulnerable groups of the population.

At present there is no recommendation for routine iodine supplementation in the UK unlike folic acid and Vitamin D, or routine testing in pregnancy that would reflect iodine levels, as there is with iron.

The study surveyed 1,026 women across the UK who were pregnant or mothers of children aged up to 36 months. Participants were asked about their awareness of nutritional guidelines and completed a food frequency questionnaire.

Knowledge of iodine-rich foods was low, with 56% unable to identify any iodine-rich food and the majority wrongfully believing dark green vegetables and table salt had high levels. Most, 84% were unaware that iodine from diet is important for the healthy development of the unborn baby, and only 11% had heard about iodine from a healthcare professional.

Dr Combet said: “Iodine is crucial during pregnancy and the first months of life, to ensure adequate brain development, but achieving over 200ug a day of iodine through diet requires regular consumption of iodine-rich foods such as milk and sea fish. Not everyone will have the knowledge, means or opportunity to achieve this.

“There is an ongoing debate as to whether there should be some form of fortification of food with iodine. Iodine-fortified salt is common in other countries, but using salt as the delivery method has raised concerns since it is perceived to clash with public health messaging around reducing salt intake to combat high blood pressure. However, other countries have demonstrated that both measures could be held simultaneously. We need to work toward a solution.

“The most important issue to come from this study, however, was the lack of awareness of the important role iodine plays in fetal development and how to consume adequate levels of this essential mineral. This is something that needs to be addressed. Our current Yorkhill Children Charity – funded project us developing tools and resources for health care professionals and women either pregnant or planning a pregnancy.”

This paper is freely available for 2 weeks

Related links

Dr Emilie Combet: researcher profile

Media enquiries: stuart.forsyth@glasgow.ac.uk / 0141 330 4831

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