Rwanda: Transforming Eye Care

 The charity ‘Vision for a Nation’ has transformed eye care in Rwanda and now the Government of Rwanda has assumed responsibility for the management and financing of primary eye care services as from January 2018.

“In just five years we have built a sustainable nationwide eye care service that is accessible to all 11.8 million Rwandans.

In the first truly nationwide programme of its kind, we have worked with the Government of Rwanda to:

  • Establish local eye care services across Rwanda
  • Develop an eye health course for the rapid training of general nurses
  • Train general nurses for deployment at all of the nation’s 502 health centres
  • Build a nationwide supply chain for eye medication and glasses from Asia to all of the health centres
  • Mobilise the public to access the new service at their local health centre
  • Extend the service to each of the nation’s 15,000 local villages”

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Superbugs: Low-income countries must not be left behind

Dr Marc Sprenger
WHO Director, Antimicrobial Resistance Secretariat

Commentary

“While the world has woken up to the threat of antimicrobial resistance and is starting to respond, many low-income countries are struggling to find capacity and need greater support. That is the headline finding of a groundbreaking global survey of how well countries think they are doing in fighting antimicrobial resistance, conducted by the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and the World Organisation for Animal Health (OIE).

Dr Marc Sprenger, WHO Director, Antimicrobial Resistance Secretariat

Bacteria are rapidly developing resistance to antibiotics. Viruses, fungi and parasites are doing the same. This is because we have been overusing and misusing medicines for decades. It’s called antimicrobial resistance, and it is a major global threat.

This silent tsunami, in which we are losing our ability to protect against infections such as pneumonia, tuberculosis and malaria, has been neglected for far too long. For years, microbiologists have been warning—with increasing volume—that indiscriminate use of antibiotics and similar drugs in humans and animals is increasingly rendering them ineffective.

Now, antimicrobial resistance has finally come to the forefront in health and political circles, leading to the development in 2015 of a Global Action Plan, endorsed by Ministers of Health and Agriculture at the governing bodies of WHO, FAO and OIE, and Heads of State at a high-level meeting of the UN General Assembly last September. Since then, countries have been developing national action plans to put the globally-agreed policy changes into practice.

Our survey of country progress offers some good news. More than 90% of people in the world (6.5 billion) live in a country that has developed, or is developing, a national action plan on antimicrobial resistance. Some of the key areas in which countries report that they are doing well are: training doctors, nurses, and other health workers on how to reduce the spread of antimicrobial resistance; improving the prevention and control of infections; and strengthening systems to detect the extent of the problem. These are incredible achievements. National plans are multisectoral—which means that leaders in human health, animal health, and the environment, who often talk about joined-up approaches, are actually putting it into action.

When you drill down into the numbers, a slightly less rosy picture emerges. High-income countries that already have stronger health and agricultural systems are much better prepared to deal with antimicrobial resistance—more than 80% of these countries have a plan in place, or are developing one. By contrast, about 30% of low-income countries either have or are developing a plan. This is not surprising. Many low-income countries lack the expertise or capacity to develop a national plan, or they are overwhelmed by dealing with fragile health systems or outbreaks of infectious diseases.

Yet low-income countries are the ones that need to be the best prepared since they are likely to bear the brunt of resistance: infectious diseases are much more common, and their health systems are much weaker and less able to adapt as first-line antibiotics (which tend to be cheaper) become less effective. The burden of harder-to-treat infectious diseases and the impact of treatment failure in human lives and relative economic cost will be much higher than in richer countries.

The lack of preparedness in low-income countries should concern us all, no matter how rich a country we live in. Antibiotic resistance will not just affect the ability to treat diseases such as malaria or tuberculosis, which many might think occur in the poorest parts of the world. Resistant bacteria will challenge our ability to treat women in childbirth, people undergoing surgery, or those on cancer chemotherapy. And, in a globalized world, microbes don’t respect national borders. They spread with ease.”

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World population projected to reach 9.8 billion in 2050, and 11.2 billion in 2100

The current world population of 7.6 billion is expected to reach 8.6 billion in 2030, 9.8 billion in 2050 and 11.2 billion in 2100, according to a new United Nations report being launched today. With roughly 83 million people being added to the world’s population every year, the upward trend in population size is expected to continue, even assuming that fertility levels will continue to decline.

The World Population Prospects: The 2017 Revision, published by the UN Department of Economic and Social Affairs, provides a comprehensive review of global demographic trends and prospects for the future. The information is essential to guide policies aimed at achieving the new Sustainable Development Goals.

Shifts in country population rankings
The new projections include some notable findings at the country level. China (with 1.4 billion inhabitants) and India (1.3 billion inhabitants) remain the two most populous countries, comprising 19 and 18% of the total global population. In roughly seven years, or around 2024, the population of India is expected to surpass that of China.

Among the ten largest countries worldwide, Nigeria is growing the most rapidly. Consequently, the population of Nigeria, currently the world’s 7th largest, is projected to surpass that of the United States and become the third largest country in the world shortly before 2050.

Most of the global increase is attributable to a small number of countries
From 2017 to 2050, it is expected that half of the world’s population growth will be concentrated in just nine countries: India, Nigeria, the Democratic Republic of the Congo, Pakistan, Ethiopia, the United Republic of Tanzania, the United States of America, Uganda and Indonesia (ordered by their expected contribution to total growth).

The group of 47 least developed countries (LDCs) continues to have a relatively high level of fertility, which stood at 4.3 births per woman in 2010-2015. As a result, the population of these countries has been growing rapidly, at around 2.4 % per year. Although this rate of increase is expected to slow significantly over the coming decades, the combined population of the LDCs, roughly one billion in 2017, is projected to increase by 33 % between 2017 and 2030, and to reach 1.9 billion persons in 2050.

Similarly, Africa continues to experience high rates of population growth. Between 2017 and 2050, the populations of 26 African countries are projected to expand to at least double their current size.

The concentration of global population growth in the poorest countries presents a considerable challenge to governments in implementing the 2030 Agenda for Sustainable Development, which seeks to end poverty and hunger, expand and update health and education systems, achieve gender equality and women’s empowerment, reduce inequality and ensure that no one is left behind.

Slower world population growth due to lower fertility rates
In recent years, fertility has declined in nearly all regions of the world. Even in Africa, where fertility levels are the highest of any region, total fertility has fallen from 5.1 births per woman in 2000-2005 to 4.7 in 2010-2015.

Europe has been an exception to this trend in recent years, with total fertility increasing from 1.4 births per woman in 2000-2005 to 1.6 in 2010-2015.

More and more countries now have fertility rates below the level required for the replacement of successive generations (roughly 2.1 births per woman), and some have been in this situation for several decades. During 2010-2015, fertility was below the replacement level in 83 countries comprising 46 % of the world’s population. The ten most populous countries in this group are China, the United States of America, Brazil, the Russian Federation, Japan, Viet Nam, Germany, the Islamic Republic of Iran, Thailand, and the United Kingdom (in order of population size).

Lower fertility leads also to ageing populations
The report highlights that a reduction in the fertility level results not only in a slower pace of population growth but also in an older population.

Compared to 2017, the number of persons aged 60 or above is expected to more than double by 2050 and to more than triple by 2100, rising from 962 million globally in 2017 to 2.1 billion in 2050 and 3.1 billion in 2100.

In Europe, 25% of the population is already aged 60 years or over. That proportion is projected to reach 35% in 2050 and to remain around that level in the second half of the century. Populations in other regions are also projected to age significantly over the next several decades and continuing through 2100. Africa, for example, which has the youngest age distribution of any region, is projected to experience a rapid ageing of its population. Although the African population will remain relatively young for several more decades, the percentage of its population aged 60 or over is expected to rise from 5% in 2017 to around 9% in 2050, and then to nearly 20% by the end of the century.

Globally, the number of persons aged 80 or over is projected to triple by 2050, from 137 million in 2017 to 425 million in 2050. By 2100 it is expected to increase to 909 million, nearly seven times its value in 2017.

Population ageing is projected to have a profound effect on societies, underscoring the fiscal and political pressures that the health care, old-age pension and social protection systems of many countries are likely to face in the coming decades.

Higher life expectancy worldwide
Substantial improvements in life expectancy have occurred in recent years. Globally, life expectancy at birth has risen from 65 years for men and 69 years for women in 2000-2005 to 69 years for men and 73 years for women in 2010-2015. Nevertheless, large disparities across countries remain.

Although all regions shared in the recent rise of life expectancy, the greatest gains were for Africa, where life expectancy rose by 6.6 years between 2000-2005 and 2010-2015 after rising by less than 2 years over the previous decade.

The gap in life expectancy at birth between the least developed countries and other developing countries narrowed from 11 years in 2000-2005 to 8 years in 2010-2015. Although differences in life expectancy across regions and income groups are projected to persist in future years, such differences are expected to diminish significantly by 2045-2050.

The increased level and reduced variability in life expectancy have been due to many factors, including a lower under-five mortality rate, which fell by more than 30 % in 89 countries between 2000-2005 and 2010-2015. Other factors include continuing reductions in fatalities due to HIV/AIDS and progress in combating other infectious as well as non-communicable diseases.

Large movements of refugees and other migrants
There continue to be large movements of migrants between regions, often from low- and middle-income countries toward high-income countries. The volume of the net inflow of migrants to high-income countries in 2010-2015 (3.2 million per year) represented a decline from a peak attained in 2005-2010 (4.5 million per year). Although international migration at or around current levels will be insufficient to compensate fully for the expected loss of population tied to low levels of fertility, especially in the European region, the movement of people between countries can help attenuate some of the adverse consequences of population ageing.

The report observes that the Syrian refugee crisis has had a major impact on levels and patterns of international migration in recent years, affecting several countries. The estimated net outflow from the Syrian Arab Republic was 4.2 million persons in 2010-2015. Most of these refugees went to Syria’s neighbouring countries, contributing to a substantial increase in the net inflow of migrants especially to Turkey, Lebanon and Jordan.

10 facts on the state of global health

WHO…

Collecting and comparing health data from across the globe is a way to describe health problems, identify trends and help decision-makers set priorities.

Studies describe the state of global health by measuring the burden of disease – the loss of health from all causes of illness and deaths worldwide. They detail the leading causes of deaths worldwide and in every region, and provide information on more than 130 diseases and injuries across the world.

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Diarrhoea kills half a million children globally

“Globally, in 2015, we estimate that diarrhoea was a leading cause of death among all ages (1·31 million deaths, 95% uncertainty interval [95% UI] 1·23 million to 1·39 million), as well as a leading cause of DALYs because of its disproportionate impact on young children (71·59 million DALYs, 66·44 million to 77·21 million). Diarrhoea was a common cause of death among children under 5 years old (499 000 deaths, 95% UI 447 000–558 000). The number of deaths due to diarrhoea decreased by an estimated 20·8% (95% UI 15·4–26·1) from 2005 to 2015. Rotavirus was the leading cause of diarrhoea deaths (199 000, 95% UI 165 000–241 000), followed by Shigella spp (164 300, 85 000–278 700) and Salmonella spp (90 300, 95% UI 34 100–183 100). Among children under 5 years old, the three aetiologies responsible for the most deaths were rotavirus, Cryptosporidium spp, and Shigella spp. Improvements in safe water and sanitation have decreased diarrhoeal DALYs by 13·4%, and reductions in childhood undernutrition have decreased diarrhoeal DALYs by 10·0% between 2005 and 2015.” Study published in the Lancet

 

 

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Precision global health: beyond prevention and control

“As we step into 2017 and look back at the past year, Zika undoubtedly stands out. 2016 saw the rise and fall of the epidemic in the Americas and worldwide spread of cases, until WHO declared on Nov 18 that the virus and associated consequences no longer constituted a Public Health Emergency of International Concern, but represented a “significant enduring public health challenge requiring intense action”. As such, Zika joined other “enduring public health challenges” to which “intense action” has been directed for a long time, particularly other communicable and vector-borne diseases, on the list of health priorities. With Zika we are almost in uncharted territory: the heterogeneity in the natural history of the disease and transmission pathways still blur the picture of what is likely to be a long-term global health issue. Yet with some other diseases, a wealth of knowledge and seemingly defined course of action have not enabled us to close the chapter.

Much has been achieved on malaria, for example, but progress is fragile and we are still scrambling in areas where the burden persists despite decades of interventions. One major concern is resistance to pyrethroids used in long-lasting insecticidal nets (LLIN), a cornerstone of malaria control. During the 65th American Society for Tropical Medicine and Hygiene (ASTMH) meeting in Atlanta in November, WHO released the results of a study that shows that LLINs provide protection against malaria even in areas with resistance. However, in this issue of The Lancet Global Health, Laura Steinhardt and colleagues report contrasting results of a case control study in Haiti that raises doubts on the usefulness of nets in a low transmission setting, hinting that their mass distribution is not a panacea everywhere. In fact, a session at ASTMH explored key knowledge gaps in malaria interventions and raised thought-provoking questions on what is needed to finally get rid of the disease, given issues of resistance, uncertainties about newer strategies such as seasonal malaria chemoprevention or intermittent preventive treatment for pregnant women, and potential impact of the RTS,S vaccine. As highlighted during the session, there is no silver bullet, and success may only be found by putting multiple axes of pressure on the vector through combinations of interventions. The trick is figuring out what combination works in what setting, and that seems to be the next big question around malaria elimination: how do we develop decision tools to tailor interventions to a set of biological and social determinants—in other words, how do we move on to a more customised approach, through what could be called “precision global health”?

The idea of a “precision” approach to global health is not limited to malaria. Prevention strategies against soil-transmitted helminths (STH) for example have included water, sanitation, and hygiene interventions and mass drug administration, another imperfect and controversial intervention as highlighted in an Article by Vivian Welch and colleagues and two Comments in this issue. In their network meta-analysis, Welch and colleagues found little to no effect of mass deworming on children’s growth, cognition, and school attendance. Eliminating the last pockets of STH incidence and prevalence will therefore require another precision approach, maybe one that combines controlling the parasites with working on more distal determinants of infection such as poverty.

A tailored approach will also help in reaching broader global health targets. The decrease in child mortality during the Millennium Development Goals era has been real but insufficient, and unequal. In some areas progress could be accelerated with more refined targeting of causes of death. Knowing where to target interventions to reduce mortality, by analysing the variability in the distribution of health outcomes for different causes would optimise efforts to reduce child mortality. A study by Marshall Burke and colleagues published in the last issue provides such valuable input, by identifying subnational mortality hotspots across sub-Saharan Africa in which the mortality decline is not on target to reach the Sustainable Development Goals (SDG) by 2030, as well as potential drivers for the difference in mortality. Spatial analyses of this kind provide crucial granular information—in line with a precision approach to global health—that could contribute to the progress towards the SDGs.

So beyond the essential steps of event surveillance and case management, on which the prevention and control of diseases are based, if we are to truly advance health and eliminate diseases, a case can be made for a tailored approach and the advent of precision-style global health.” Lancet – Global Health – Jan 2017

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World Malaria Day 2017

About World Malaria Day

World Malaria Day is a chance to shine a spotlight on the global effort to control malaria. Each year on April 25, Roll Back Malaria (RBM) partner organizations unite around a common World Malaria Day theme.

It is an occasion to highlight the need for continued investment and sustained political commitment for malaria prevention and control.

2017 Theme

For World Malaria Day 2017 we have decided to build on the momentum from last year by keeping the theme:

End Malaria For Good

Malaria remains both a major cause and a consequence of global poverty and inequity: its burden is greatest in the least developed areas and among the poorest members of society. Many of those most vulnerable – especially young children and pregnant women – are still not able to access the life-saving prevention, diagnosis and treatment they so urgently need.

According to the World Malaria Report 2016, in 2015, there were 212 million new cases of malaria and 429,000 deaths. One child dies from malaria every two minutes.

We can be the generation that ends malaria – one of the oldest and deadliest diseases in human history.

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Fertility apps: The ‘next wave’ in solving global family planning crisis

Global family planning expert Leslie Heyer is one of many advocates who warns that the funding cuts will have devastating consequences for women and their families, especially in the developing world. When women don’t have the ability to plan their pregnancies, she said, they and their unborn babies suffer higher physical and mental health risks, higher risk of abuse, and lower education levels for themselves and for their children.

Heyer is the founder of Cycle Technologies, a provider of family-planning tools to women worldwide. Some of Cycle’s methods – like CycleBeads and Dot – provide forms of contraception requiring nothing more than a mobile phone.

Heyer said these digital options can be accessible, cost-effective alternatives to traditional contraceptive methods, which are often reliant on fragile supply systems and subjected to restrictions under policymakers.

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Heart Disease and Strokes top the 10 most common causes of death

Of the 56.4 million deaths worldwide in 2015, more than half (54%) were due to the top 10 causes. Ischaemic heart disease and stroke are the world’s biggest killers, accounting for a combined 15 million deaths in 2015. These diseases have remained the leading causes of death globally in the last 15 years.

Chronic obstructive pulmonary disease claimed 3.2 million lives in 2015, while lung cancer (along with trachea and bronchus cancers) caused 1.7 million deaths. Diabetes killed 1.6 million people in 2015, up from less than 1 million in 2000. Deaths due to dementias more than doubled between 2000 and 2015, making it the 7th leading cause of global deaths in 2015.

Lower respiratory infections remained the most deadly communicable disease, causing 3.2 million deaths worldwide in 2015. The death rate from diarrhoeal diseases almost halved between 2000 and 2015, but still caused 1.4 million deaths in 2015. Similarly, tuberculosis killed fewer people during the same period, but is still among the top 10 causes with a death toll of 1.4 million. HIV/AIDS is no longer among the world’s top 10 causes of death, having killed 1.1 million people in 2015 compared with 1.5 million in 2000.

Road injuries killed 1.3 million people in 2015, about three-quarters (76%) of whom were men and boys.

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