Belize has one of the highest cervical cancer burdens among Latin American and Caribbean countries, despite the implementation of national policies to increase access to prevention and treatment services. This study evaluates the policies, infrastructure, and workforce of the cervical cancer management system in Belize to inform capacity building efforts.In 2018, health facility assessments were conducted across all six districts of Belize at the national pathology facility and 12 public facilities identified as critical to cervical cancer control. Human and infrastructure resource availability and existing policies related to cervical cancer screening and treatment services were assessed through a structured instrument.The public cervical cancer screening workforce in Belize consists of 75 primary care nurses and physicians—one per 1,076 screening-eligible women, with 44% conducting rural outreach. All districts have at least one screening facility, but 50% perform screening services only once per week. Colposcopy and loop electrical excision procedures are available in three and four districts, respectively; radical hysterectomy and chemotherapy are available in two districts; and radiation therapy is unavailable. Of essential pathology equipment, 38.5% were present and functional, 23% were present but nonfunctional, and 38.5% were unavailable. Additionally, 35% of supplies were unavailable at the time of assessment, and 75% were unavailable at least once in the 12 months before assessment.Public-sector cervical cancer management services differ among districts of Belize, with tertiary service availability concentrated in the largest district. Screening, outreach, and pathology are limited mostly by resource availability. This study characterizes the current capacity of services in Belize and pinpoints health system components for future investment and capacity-building efforts. Cervical cancer diagnostic and treatment resources are concentrated in the largest districts of Belize, creating geographic barriers to accessing critical interventions.RelevanceBeyond characterizing the cervical cancer management system in Belize, this study provides a framework for evaluating  cervical cancer services in other low- and middle-income countries to support World Health Organization's targets for  accelerating the elimination of cervical cancer.3 In response, Nicaragua, Mexico, Argentina, El Salvador, Guatemala, and Honduras each began the implementation of national HPV vaccination and HPV-based or visual inspection with acetic acid (VIA)-based screening programs by 2017 as recommended by the WHO.8 Belize, a culturally and ecologically diverse LAC country of just under 400,000 citizens on the eastern coast of Central America, experiences some of the highest cervical cancer incidence and mortality rates among its peers. The 2018 estimates of cervical cancer incidence and mortality from the International Agency for Research on Cancer: Global Cancer Observatory found Belize to have age-standardized incidence and mortality rates of 28.0 and 16.2 cases per 100,000 population, respectively—far greater than those in other LAC countries  and North America .10The high cervical cancer incidence and mortality rates in Latin American and Caribbean (LAC) countries exemplify the global inequity of cervical cancer and its association with poverty.Recent policies implemented by the Ministry of Health (MOH) in Belize have aimed to increase the availability of HPV vaccination, cervical cancer screening services, and treatment options. Belize has been capitalizing on the opportunity to reduce cervical cancer incidence and mortality through implementations that have been performed and validated in other resource-constrained LAC nations. However, a detailed understanding of the Belizean health system must be considered before implementing newly targeted, fiscally sound, national health programs to maximize efficacy, value, and sustainability. The purpose of this cross-sectional study is to provide a baseline assessment of resource availability in Belize and explore areas of potential investment.This cross-sectional needs assessment was conducted in Belize in June 2018. Across all six districts of Belize, all public regional health facilities, the national health facility, the single national pathology facility, and any public health facilities that offered screening with VIA were included. VIA-based screening was used as an inclusion criterion for public health facilities because it serves as the current national cervical cancer screening approach. MOH officials who implemented the VIA program in Belize were consulted to ensure that all facilities offering VIA screening were included in the analysis. This study was approved by the Institutional Review Board at the Rutgers New Jersey Medical School and by the Director of Health Services at the MOH in Belize.The lead investigator (S.S.N.) underwent training with a MOH official (N.L.B.) and senior clinical investigator (M.H.E.) before beginning the study and performing the environmental scan of cervical cancer prevention in Belize. Cervical cancer prevention and treatment infrastructure and resources availability were assessed by conducting health facility assessments (HFAs) and one pathology facility assessment at the single national pathology facility in Belize. The Epidemiology Unit of the MOH and the Statistical Institute of Belize provided population-level demographic data for each district.12 Because Belize's official language is English, all questionnaires were conducted in English. Data fields within HFAs are described in Table HFAs were performed using questionnaires constructed from international guidelines and subsequent incorporation of indicators from relevant literature in similar environments of care.The capacity of the single national pathology facility in Belize was evaluated by taking stock of commonly used materials , documenting supply shortages in the previous year, and documenting the functional status of all necessary equipment .All HFA and pathology facility assessment data were collected using a secure Research Electronic Data Capture database and deidentified to maintain the privacy of each institution.Population-level data from the MOH and the Statistical Institute of Belize were compiled by district  and geographic region . Facility assessment data were then categorized by district and region to estimate capacity for each area.First, the screening and outreach workforces were estimated by totaling the number of nurses and general practitioners offering screening at each facility and those participating in regular outreach to rural health care centers or outposts. Regular outreach was defined as at least once per month. These data were tabulated for each district and normalized by the national population of women ages 25-70 years (screening-eligible women) in 2018.The availability of services including cervical cytology and VIA was subsequently described by categorically recording the frequency with which the facilities offered these services: 1 day per week, 2-4 days per week, every day in a given week, or sporadically. The geographic distribution of offered preventative and treatment services were estimated by assessing the number of health facilities in each district that offered the following: cervical cytology, VIA with cryotherapy (single-visit approach), loop electrosurgical excision procedure, colposcopy, biopsy, pathology in house, simple hysterectomy, radical hysterectomy, chemotherapy, and radiation therapy.Pathology equipment and supply availability was determined by direct investigation into essential equipment's presence on site, after which facility personnel responded to a binary question assessing equipment functionality. For each piece of essential equipment, the equipment was marked as present and functional, present but nonfunctional, or not present. The availability of 20 essential supplies for comprehensive cervical cancer screening including cytology and histology was determined by direct inquiry of supplies on site. Supplies were marked as either available or unavailable. Facility personnel also reported whether each item had been unavailable at any point during the 12 months before the study (June 2017-June 2018).A total of 13 facilities were assessed, including three regional health care centers, the national referral hospital, the national pathology facility, and eight community health centers that met the inclusion criteria of participating in cervical cancer prevention with VIA. Characteristics of the visited facilities are summarized in Table In 2018, the cervical cancer screening workforce in Belize consisted of 75 nurses and physicians, with a density of approximately one health care provider for every 1,076 screening-eligible women. The workforce dedicated to outreach to rural facilities and communities consisted of 33 nurses and physicians, with a density of one health care provider for every 1,291 screening-eligible women living in rural communities. Stann Creek district had highest screening and outreach workforce density , Orange Walk district had the lowest screening workforce density , and Toledo had the lowest outreach workforce density  of essential equipment was present and functional at the time of assessment; 38.5% (n = 5) of equipment was not present and 23% (n = 3) was present but nonfunctional Fig A. ThirtyThis study is the first to comprehensively describe the capacity of cervical cancer prevention and treatment infrastructure in the Belizean public health care system by providing estimates of human resources, screening capacity, service availability, and pathology infrastructure. These findings create a snapshot of the current state of cervical cancer management in Belize and can be used to set attainable goals for increasing cervical cancer prevention efforts, generate hypotheses for the reasons of cervical cancer burden, and develop a framework for capacity building in other nations.13 Potential solutions to the limited ability of the cervical cancer screening workforce to engage the rural population include employing community health workers to bolster the screening workforce. Some countries across Africa, Asia, and South and Central America have employed community health workers without formal training as health care providers to conduct cervical cancer screening.14 HPV self-sampling is another innovative screening approach that can be implemented in rural areas to further improve screening access without relying on a larger screening workforce. Self-sampling also enables increased compliance among women who would not otherwise present for screening and has the additional advantage of being conducted in the privacy of one's home.15 A study of women in rural Newfoundland found that cervical cancer screening rates increased significantly by 15.2% in those who were able to self-collect samples when compared with a control intervention .16 Similar observations were made in rural Cameroon, supporting the efficacy of self-collect samples in low- and middle-income countries as well.17The cervical cancer screening workforce in Belize relies primarily on nurses and general practitioners to perform the majority of cervical cytology and VIA procedures. Although a benchmark for screening workforce density has yet to be described, the present estimate of the Belizean screening workforce would require that each professional screens 359 women per year to achieve 100% screening coverage, a target which is not feasible in the current work conditions. Furthermore, a minority of the outreach workforce serves the rural regions where more than half of Belizeans reside.18 Data from screening programs in Malawi and Honduras suggest that delays in screening and subsequent treatment result in a significant loss to follow-up rate.20Although workforce density is a critical factor that affects timely access to care when needed, the frequency with which a particular service is offered provides additional context to the question of access. In Belize, 50% of the facilities that offer cervical cytology or VIA screening services do so only once per week. Approximately 42% of clinics offer cervical cytology daily, whereas only 25% of the clinics offered VIA and cryotherapy daily. Increasing screening coverage in Belize could be accomplished by increasing the proportion of facilities offering VIA daily. Without building new facilities or hiring more personnel, shifting priorities of health care workers toward offering screening more consistently could improve access. Prioritizing increasing the frequency of VIA screening could also address potential loss to follow-up and lack of access to early-stage treatment. VIA been shown to be more cost effective and easier to adopt than cervical cytology, and VIA results are available immediately, eliminating the risk of loss to follow-up by enabling same-day screening and treatment.21 By 2018, Belize had 12 VIA programs in the public sector alone, with plans to scale up VIA availability to a total of 15 public and private centers by 2020, according to the Cancer Prevention and Control Strategic Plan.21 Although all of the six districts in Belize offer standard cervical cytology and VIA, the present analysis of treatment options has highlighted a decrease in geographically equitable availability as services become more advanced .nced Fig . The mos25 Since reliability of pathology resource availability in Belize is low and cytology accuracy is variable, there may be a stronger impetus for investing in decentralized screening such as VIA or other techniques that do not rely on pathology infrastructure, such as HPV-based strategies.28 Furthermore, the WHO has advocated for HPV-based testing or VIA in countries where cervical cytology programs are not sustainable.29Supporting the advancements made in screening and treatment services, the foundation of effective cervical cancer control and national cancer management is sustainable pathology infrastructure to process HPV samples, as well as cytology and histology services. In Belize, where the national pathology facility processes most cytology and tissue samples in the country, delays or challenges in the pathology program could drastically affect the entirety of the cervical cancer prevention and management system. In Figure The main limitation of this investigation was the lack of sampling of rural health care centers. The health care centers sampled were primarily urban health care centers, as well as regional hospitals and the national referral hospital Table . AlthougIn conclusion, over the past decade, Belize has implemented a number of cervical cancer prevention and treatment programs throughout all regions to address increasing burden of disease. This study elucidated that the extent of benefits from these programs is limited by workforce constraints at the local level and pathology infrastructure at the national level. Workforce growth and training and implementation of decentralized screening services may improve cervical cancer management and support sustainable services delivery at local clinics, regional treatment centers, and the national pathology facility. Belize has a more-than-adequate foundation of health care services that can be built upon through future developments. Future research incorporating a qualitative assessment of health care workers and administrators will allow for better contextualization of findings to ensure that future implementations of Belize bring us closer to a cervical cancer–free future.


This study aims to synthesize existing literature concerning eating difficulties among older adults with dementia in long-term care facilities. A scoping review, using the framework proposed by Arksey & O'Malley (2005) and improved and supplemented by Levac et al. (2010), was conducted. Literature was searched from five bibliographic databases—Research Information Sharing Service (RISS), Korean studies Information Service System (KISS), National Digital Science Library (NDSJ), Korean Medical Database (KMBASE), DataBase Periodical Information Academic(DBPia), Google Scholar, and gray literature. Literature selection and characteristics were approved by two independent reviewers, using pre-tested forms to determine final inclusion. Eventually, 111 articles from 2012–2020 were identified, and the 11 articles were used for the final analysis. We found that primarily utilized Eating behavior scale (EBS) and Edinburgh feeding evaluation in dementia scale (EdFED) had utilized as measurement tools for evaluating eating behavior. The most common factors related to eating behavior of older adults with dementia included cognitive and physical functions in the individual domain, the caregiver's attitude toward eating in the inter-individual domain, and types of meal in the environmental domain. Therefore, it is essential to develop measurement tools that reflect the eating behavior of older adults with dementia, a comprehensive understanding of the eating behavior of old adults with dementia, and create effective interventions that can be implemented in the specificity of long-term care facilities in Korea. The results of this analysis are intended to be used as basis to develop a meal support programs for older adults with dementia.


International agreements commit nations to control or eradicate invasive alien species. The scale of this challenge exceeds available resources and so it is essential to prioritise the management of invasive alien species. Species prioritisation for management may consider the likelihood and scale of impact (risk assessment) and the feasibility, costs and effectiveness of management (risk management). Risk assessment processes are widely used, risk management less so. To assess the cost effectiveness of prioritisation, we considered 26 high-risk species considered for eradication from Great Britain (GB) with pre-existing risk assessment and risk management outputs. We used these to consider the relative reduction in risk per unit cost when managing prioritised species based on different criteria. We showed that the cost effectiveness of prioritisation within our sample using risk assessment scores alone performed no better than a random ranking of the species. In contrast, prioritisation including management feasibility produced nearly two orders of magnitude improvement compared to random ranking. We concluded that basing management actions on priorities based solely on risk assessment without considering management feasibility risks the inefficient use of limited resources. In this study, the cost effectiveness of species prioritisation action was greatly increased by the inclusion of a risk management assessment. International agreements commit nations to control or eradicate invasive alien species. The scale of this challenge exceeds available resources and so it is essential to prioritise the management of invasive alien species. Species prioritisation for management typically involves a hierarchy of processes that consider the likelihood and scale of impact (risk assessment) and the feasibility, costs and effectiveness of management (risk management). Risk assessment processes are widely used, risk management less so, but are a crucial component of resource decision making. To assess the cost-effectiveness of prioritisation, we considered 26 high-risk species considered for eradication from Great Britain (GB) with pre-existing risk assessment and risk management outputs. We extracted scores to reflect the overall risk to GB posed by the species, together with the estimated cost and the overall feasibility of eradication. We used these to consider the relative reduction in risk per unit cost when managing prioritised species based on different criteria. We showed that the cost-effectiveness of prioritisation within our sample using risk assessment scores alone, performed no better than a random ranking of the species. In contrast, prioritisation including management feasibility produced nearly two orders of magnitude improvement compared to random. We conclude that basing management actions on priorities based solely on risk assessment without considering management feasibility risks the inefficient use of limited resources. In this study, the cost-effectiveness of species prioritisation for action was greatly increased by the inclusion of risk management assessment.  Managing the increasing risks and impacts of invasive alien species (IAS) is one of the great societal challenges of the 21st century ,4,5. A nInternational and national legislation on IAS and their supporting processes are still evolving , while tA range of existing processes is available to support prioritisation based on different criteria. These may be used in isolation or in a sequential manner, and their use varies between different countries. A risk assessment (RA) is a systematic approach to assess the scale and likelihood of arrival, establishment, spread and impact of alien species to identify those that are likely to become invasive ,20,21,22A further set of methods considers the feasibility and costs of management. These are often applied subsequent to the initial identification of high-risk species through RA. We collectively refer to these approaches as risk management (RM), although other terms, such as risk treatment, are also used. They provide the process by which the cost–benefit  or feasiEffective prioritisation of species and management options are essential if the limited funds available to reduce the impacts of IAS are to be effectively targeted. Given the variety of approaches applied in different countries, there is a need to better understand the cost effectiveness of different approaches to the prioritisation of species and their management, together with the effects of including different criteria on the outcome. Here, we consider the cost effectiveness of different approaches to prioritisation for rapid eradication based on a sample of high-risk species already identified as having high potential impacts in Great Britain. We compare the cost effectiveness of prioritisation based on the use of RA, RM and both methods in combination, using scores from independently undertaken RA and RM assessments already published in the literature. We use a simple cost effectiveness measure of cumulative risk reduction per unit cost to compare different approaches to prioritisation and attempt to quantify the benefits of incorporating both RA and RM considerations in decision making and risk communication through a wider process of risk analysis. Alopochen aegyptiacus (Egyptian goose), Cabomba caroliniana (a fanwort), Dreissena bugensis (quagga mussel), Egeria densa (large-flowered waterweed), Hemigrapsus sanguineus (Asian shore crab), Hydropotes inermis (Chinese water deer), Ichthyosaura alpestris , Lacerta bilineata (green lizard), Lysichiton americanus (American skunk-cabbage), Orconectes limosus (spiney-cheek crayfish), Orconectes virilis (virile crayfish), Podarcis muralis , Procambarus acutus (white river crayfish), Procambarus clarkia (red swamp crayfish) and Sarracenia purpurea (purple pitcher plant). The 11 species considered likely to establish in the near future were: Corbicula fluminalis (Asian clam), Corvus splendens (house crow), Gracilaria vermiculophylla (a seaweed), Homarus americanus (American lobster), Mnemiopsis leidyi (American comb jelly), Nyctereutes procyonoides (raccoon dog), Procyon lotor (raccoon), Rapana venosa (rapa whelk), Tamias sibiricus (Siberian chipmunk), Threskiornis aethiopicus (sacred ibis) and Vespa velutina (Asian hornet). Together these 26 species comprise 5 plants, 11 invertebrates and 10 vertebrates from marine (5), freshwater (9) and terrestrial (12) environments. RA and RM scores were available for all 26 species from previous studies, the methods and results of which are publicly available [We assessed a total of 26 species considered likely to establish in GB in the near future or that were already established, but with limited distributions. The 15 established species were see : Alopochvailable ,30,36.RA scores for each species included an overall risk score, as well as four component scores representing the separate risks of entry, establishment, spread and species impact from published risk assessments . Each coRM scores for each species included a score for the overall feasibility of eradication, and seven component scores for effectiveness, practicality, management cost, management impact, acceptability, likelihood of reinvasion and window of opportunity . Each coWe estimated the cost of eradicating each species as the mid-point of the RM component ‘cost’ . The potential benefit of eradication was considered to be the impact removed by eradicating each species and was calculated by multiplying the RA components ‘spread’ (1–5) and ‘impact’ (1–5), resulting in a total potential impact removed score of 1–25. Spread and impact were combined because taken together they assess both the extent and severity of potential impact.RA = overall risk, from 3 (high risk) to 1 (low risk);RM = overall feasibility of eradication, from 5 (very high) to 1 (very low); and,RA + RM = sum of numeric scores for overall risk and overall feasibility of eradication, from 8 (highest) to 2 (lowest). Note that this method is the equivalent of the matrix approach used in previous presentations of this data .Overall, RA and RM scores were used to order species using three different prioritisation methods: Ties within both the RA and RM methods were ordered by the geometric mean of the individual component scores . Ties within the RA + RM method were ordered by the highest sum of the geometric mean of RA and RM component scores. The relative cost–benefit of these three prioritisation methods was examined by comparing the cumulative cost of eradicating species in prioritised sequence to the cumulative benefit of removing their potential impact. Comparison was made using the area under the curve (AUC) statistic , where ap-value under the null hypothesis was (0.005–0.032), RA + RM; AUC = 0.724, p-value 95% CI (0.005–0.032)). The RA prioritisation gave an AUC less than the mean of the random rankings )  for the –0.994)) .The cost of eradicating the top ten ranked species identified by the different approaches to prioritisation varied by nearly two orders of magnitude, with priorities identified by RM and RA + RM providing a significantly greater reduction in risk per unit cost than the use of RA alone .Our analysis shows including the evaluation of risk management in IAS prioritisation yields greater risk reduction per unit cost. Prioritising species present in Great Britain with limited distributions or those likely to establish in the near future by risk assessment alone favoured species that were more costly to eradicate. While preventative methods might also be considered to limit the arrival of IAS, rapid eradication was a valid management option for such species, so we consider this to be a realistic assessment of the species prioritisation choices required at this stage of the invasion process in GB.There was little correspondence between the lists produced by RA alone or RM/RA + RM, with only one species in the top ten RA ranking featured in the RM or RA + RM lists, while the RM and RA + RM ranks contained nine shared species in the first ten. The RA approach in isolation prioritised three species that were considered very costly to eradicate and where the overall feasibility of management was scored low or very low. The cost of eradicating the top ten species prioritised through the use of RM or RA + RM was two orders of magnitude lower than if it were based on RA alone, and the cost effectiveness of the prioritisation of management based on RA alone offered no improvement over selecting species in a random order. This study used existing data from previous studies ,30,36. TThis example is based on the prioritisation for the rapid eradication of species with a limited distribution. We expect that the relative value of RA and RM varies depending on the stage of the invasion process, and the processes are often used in a hierarchical sequence. RA is particularly useful for horizon scanning to identify species that may become invasive and to inform management to prevent their entry or establishment. When considering rapid removal, eradication and long-term management  to deal The use of systematic methods to guide IAS legislation and action has clear benefits. RA is a key element of this, but if used to prioritise species for management in isolation it can lead to a mismatch between the species being prioritised and the most cost-effective approaches to management. Few published lists of priority IAS consider management feasibility, and lists such as the EU Species of Union Concern are based on RA, although the inclusion of a species on these lists places management responsibilities on the EU member states. Here, we show that the inclusion of RM as part of a broader risk analysis process for the prioritisation of IAS significantly improved cost effectiveness compared to the use of RA alone. We believe that RA and RM should be used together to guide the species priorities, in particular when considering eradication and on-going management action ,39. ThisThe efficient prioritisation of invasive alien species for management is important if limited resources are to be deployed effectively to reduce their impacts. We showed that using only risk assessment scores to evaluate the cost effectiveness of prioritisation within our sample performed no better than a random ranking of the species. In contrast, prioritisation including management feasibility produced nearly two orders of magnitude improvement in cost effectiveness compared to a random ranking. We conclude that basing management actions on priorities based solely on risk assessment without considering management feasibility risks the inefficient use of limited resources.


Immunization is among the most cost-effective public health interventions available and is estimated to have averted at least 37 million deaths between 2000 and 2019. Since the establishment of the Expanded Programme on Immunization in 1974, global vaccination coverage increased and the coverage gap between rich and poor countries decreased. Creation of Gavi, the Vaccine Alliance, in 2000 allowed the poorest countries in the world to benefit from new, life-saving vaccines and expand the breadth of protection against an increasing number of vaccine-preventable diseases. Despite this progress, inequities in access to and uptake of vaccines persist. Opportunities to realize the full potential of vaccines are within reach but require focused, tailored and committed action by Governments and immunization stakeholders. The Immunization Agenda 2030 provides a framework for action during the next decade to attain a world where everyone, everywhere, at every age fully benefits from vaccines for good health and well-being. Immunization is one of the most cost-effective public health preventive measures in countries of all income levels . Six vacThe global scaleup of immunization programs began with the establishment of EPI in 1974 by the World Health Assembly (WHA) . The adoInitial progress was slow and by 1980, coverage with 3 doses of diphtheria-tetanus-pertussis (DTP)-containing vaccines (DTP3) globally was around 20% with a wide disparity in coverage between high- and low-income countries; DTP3 coverage in the poorest countries was 5% . In respThe achievements of the EPI, along with the eradication of smallpox in 1980, laid the ground for launching aspirational vaccine-preventable disease goals over the next 20 years, including the eradication of poliomyelitis, elimination of maternal and neonatal tetanus, and elimination of measles and rubella in all WHO regions. Surveillance to document progress towards eradication and elimination goals led to the initiation and strengthening of communicable disease surveillance, especially in low- and middle-income countries (LMICs), which has served to detect and respond to epidemics of both vaccine-preventable and other communicable diseases for the past 40 years.Haemophilus influenzae type b [Hib], Japanese encephalitis, Neisseria meningitidis serogroup A, measles, Streptococcus pneumoniae, rotavirus, rubella, and yellow fever) in 98 LMICs relative to no vaccination [Immunization has contributed to Millennium Development Goal 4 to reduce childhood mortality. All-cause mortality in children younger than 5 years decreased by 47% between the year 2000 (9.7 million deaths) and 2019 (5.2 million deaths) . It is ecination . In a recination , represeIn the 1990s, immunization coverage stagnated and the slow introduction into lower-income countries of new life-saving vaccines, which were developed and implemented in many high-income countries (HICs), created serious inequities in protection from infectious disease threats to infant and child survival. In response, the Children’s Vaccine Initiative (CVI), an alliance of United Nations agencies, private foundations, and industry, was launched in 1990 with a vision that all children would be immunized and set 3 goals of vaccine supply, new vaccine development, and improved vaccine delivery . HoweverUntil 2020, Gavi approached country eligibility for support through the specification of economic status; those with per capita gross national income (GNI) below an established threshold over the preceding 3 years (according to the World Bank data published each July) can seek support for the introduction of new or underused vaccines, as well as for health systems strengthening funds for vaccine delivery infrastructure. Eligibility was set at an amount of US$1500 in 2011 and is updated annually to account for inflation . CountriThe Global Vaccine Action Plan (GVAP) was a global strategy developed in response to a call in 2010 for a Decade of Vaccines . GVAP waGVAP demonstrated that coordination and alignment of immunization partners are critical for attaining the aspirations of the decade. Even with these elements, attaining all goals remained elusive and only the target for introduction of new vaccines was met  . NeverthThrough the global polio eradication efforts, cases of paralytic poliomyelitis decreased from 350 000 in 1988 to 140 in 2020, after touching a historic low of 22 cases in 2017 [Energized by the certification of the eradication of type 2 wild poliovirus in 2015, the Global Polio Eradication Initiative called for the withdrawal of oral polio vaccines starting with the type 2 component of oral polio vaccine (OPV2). This was achieved through a globally synchronized initiative referred to as the “Switch,” in which 156 countries and territories still using oral polio vaccine simultaneously switched from the use of trivalent OPV  to bivalent OPV , in a 2-week time-period, thus removing OPV type 2 from routine use. The global Switch was an unprecedented endeavor and successful milestone for the program, and was accompanied by the introduction of at least 1 dose of inactivated polio vaccine (IPV) in the 126 countries that had an OPV-only schedule. However, since 2016, several challenges have confronted the polio program, including global IPV shortages that contributed to lower than desired coverage in countries where the vaccine was introduced, and months of delay in IPV introduction in many countries. Additionally, the emergence of circulating type 2 vaccine-derived poliovirus (cVDPV2) cases occurred quickly after the Switch, requiring expansive and repeated deployment of monovalent OPV2 from the global stockpile for outbreak response, which has reseeded type 2 poliovirus (vaccine derived) in communities with type 2 immunity gaps, creating a vicious cycle spreading and escalating cVDPVs over the past 2 years. In 2020, there were over 1087 AFP cases due to cVDPVs reported from 24 countries . It is hPrior to the introduction of measles vaccine in 1963, measles caused an estimated 2.6 million deaths annually . This feThe maternal and neonatal tetanus initiative, launched in 1999, targeted 59 endemic countries aiming to reduce neonatal tetanus incidence to < 1/1000 live births in every district of each country . By 2019DTP3 coverage is used as a marker of overall immunization program performance because DTP is universally recommended and coverage with 3 doses of DTP permits standardized monitoring over time and across countries. The massive equity gap between the rich and poor countries in 1980 has been markedly reduced; however, since 2000, DTP3 global coverage has remained stagnant between 84% and 86% . In 2019Since 2000, the number of vaccines included in childhood immunization schedules has increased dramatically. The historic time lag in the introduction of new vaccines between rich and poor countries has been shortened. Consequently, while DTP3 coverage has remained flat since 2000, the breadth of protection, reflecting the number of antigens and their coverage, has increased substantially . FurtherMany factors contributed to the achievements in immunization over the past decades. Improvements in delivery infrastructure; vaccine-preventable disease surveillance and the requisite regional and global lab networks; ever growing community engagement and advocacy on the value of vaccines; more sophisticated information and social media platforms; electronic data collection, management, and use; vaccine research and development capacity; expansion and coordination of vaccine regulatory and safety monitoring systems; increasingly data-driven policy decision making at the country level; and global partnership all underpin this progress. Here we highlight a few factors that are less scientifically driven, yet essential to fully realize the promise of vaccines.National government commitment to prioritizing immunization programs is widely recognized as one of the most impactful success factors without which other efforts falter. Many LMICs have substantially enhanced their commitments to immunization. In 2011, national health ministers in the WHO South-East Asia region expressed their commitment through the Delhi Call for Action to intensify the drive toward achieving high routine immunization coverage throughout the region . SimilarEnsuring an adequate supply of safe and effective vaccines remains a global priority in a world with unprecedented changes in the vaccine industry and market . LMIC maPredictable financing and innovative procurement mechanisms managed through UNICEF, Gavi, and the Pan American Health Organization Revolving Fund have further contributed to successful tiered pricing mechanisms and substantially reduced pricing for newer vaccines. The weighted average price of the pentavalent vaccine  for Gavi countries declined from US$2.98 in 2010 to US$0.79 in 2019 . The VacSupply chain and logistics systems that strive to ensure the uninterrupted availability of high-quality and potent vaccines up to the point of administration are the delivery backbone to a well-functioning immunization system, as referred to in WHO’s Immunization Practice Advisory Committee 2014 call to action . The regWhile strong service delivery systems are essential for achieving high and equitable vaccination coverage, these systems need to be accompanied by appropriate policies and strategies that promote the equitable and timely delivery of vaccination. The WHO Global Routine Immunization Strategies and Practices (GRISP) lays out in a comprehensive manner 9 transformative investments that enable resilient programs . GRISP pWhile there has been measurable progress in the current decade, several challenges have impeded progress. Additional efforts, leveraging available opportunities, are needed to realize the new global vision and impact goals of the IA2030 and achieve the 2030 Sustainable Development Goals .Achieving and sustaining high and equitable vaccination coverage is fundamental to securing the greatest impact possible with existing and new vaccines. Despite progress in several countries that have had longstanding low vaccination coverage, many have difficulties in equitably reaching and sustaining the 90% target. Several issues merit consideration. In 2019, 20 million children were un- or underimmunized with DTP3, and 14 million of these did not even receive the first dose of DTP, referred to as “zero dose” children . These cExisting legislation, policies, and guidelines may inadvertently create or exacerbate inequities. Policies that limit services to individuals registered with civil authorities in a country or region can create barriers for refugee, mobile, or migrant populations, excluding them from access to public health services, including immunization. Gender strongly influences achieving immunization program goals in many settings. A myriad of social and policy structures, such as the ability of women to seek immunization services without having to be accompanied, the gender of immunization workers going door to door, or services that also meet the health needs of women coming for their child’s immunization services are all examples. Examining existing laws and policies through an equity lens will reveal opportunities to address inequities through enactment of new legislation, revision of legal frameworks, and establishment of new policies .The positive correlation between health care worker density and immunization coverage is well documented . NeverthThe addition of new, more expensive vaccines to EPI has led to increases in the cost of a full vaccination course for a child since 1974; in the last decade alone, the average global immunization expenditures per live birth has increased by 50% . Access While government health budgets will remain the primary sources of immunization financing, new financing mechanisms need to be explored if LMICs are to sustain their immunization programs. As part of their efforts towards achieving universal health coverage, several new mechanisms are being used or considered for the costs of delivering an essential package of health services. An immunization financing resource guide provides options for raising additional resources to support immunization programs and the use of social insurance to partly finance immunization programs .The uptake of new vaccines in MICs that are not eligible for Gavi support has been slower than in Gavi-eligible countries . In factA major obstacle to closing current immunization gaps has been the lack of timely and high-quality data to inform decision making, operational planning, performance management of immunization staff, and service delivery. This information is essential at all levels of the health system for the effective delivery of immunization services. The absence of such data has consequences including missed opportunities to identify under- or unimmunized persons, inadequate defaulter tracking, and burdensome data collection processes that divert health provider time and attention away from the provision of high-quality service delivery. WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) highlighted these issues and recommended specific actions to improve the quality and use of data .Inaccuracies in vaccination coverage estimates result from imprecise estimates of the target population size (the denominator) and errors in the recording of immunization doses administered (the numerator). In many LMICs, estimates of the target population size are from national census data, which are often very outdated. Despite the well-documented benefits of civil registration and vital statistic systems (CRVS), countries have been slow to adopt these systems. WHO guidelines and tools are available to conduct comprehensive assessment of CRVS and to strengthen them . SeveralAn increasing number of LMICs are leveraging the availability of new information and communication technologies to update their immunization data management systems that would improve the recording, timely transmission, and use of data to monitor their programs. Electronic immunization registries (EIRs) are computerized, confidential, population-based systems that contain individual-level information on vaccine doses administered , 60. An Many other LMICs are using the District Health Information Software 2 (DHIS2), an open source, web-based health management information system platform, to collect and manage health and immunization data . DHIS2 hSurveillance is required to measure disease burden, quantify the impact of immunization programs in reducing vaccine-preventable diseases, and identify changes in disease epidemiology that may require modifications of vaccination schedules and/or adaptation of program strategies. Disease surveillance data are also key for informing policy decisions and supporting sustained financing for the immunization program. The surveillance systems in many LMICs remain fragmented into disease-specific surveillance initiatives largely dependent on external resources. A shift to country-owned, comprehensive disease surveillance is needed to address the fragmentation, improve efficiencies, and ultimately lead to sustainable surveillance as is laid out in WHO’s new global strategy for comprehensive vaccine-preventable disease surveillance .Funding for disease surveillance activities has leaned heavily on the Global Polio Eradication Initiative for many years and is expected to wind down over this decade. Alternate funding, including more country-level commitment to surveillance, will be needed. An investment case for surveillance in the African region indicates that if current vaccine-preventable disease surveillance and laboratory networks are enhanced, there would be an estimated 45-fold return on investment by 2030 .Safety monitoring and surveillance for adverse events following immunization are key components of a strong immunization program. The WHO Global Vaccine Safety Blueprint aims to optimize the safety of vaccines through effective use of pharmacovigilance principles and methods and assist low and LMICs to have at least minimal capacity for vaccine safety activities .It is naive to assume that if health services are made accessible to communities, that health-seeking behavior will follow . AnalysiMICs account for 60% of global deaths in children younger than 5 years, and a similar or greater share of vaccine-preventable deaths and unvaccinated children . The iniThe COVID-19 pandemic has demonstrated that immunization systems need to have the resilience to rapidly recover from acute shocks, such as during prolonged disease outbreaks and other causes of disruption. Lessons need to be documented from the Global Polio Eradication Initiative and case studies developed from exemplar countries who have overcome the challenges posed by conflict, civil unrest, and other humanitarian emergencies to cultivate best practices on sustaining immunization services during periods of severe disruption. In addition, countries need to improve their preparedness for and capacity to rapidly detect and respond to outbreaks of vaccine-preventable diseases to mitigate the risks of a prolonged epidemic. Conversely, data from outbreaks should be used to identify root causes behind immunity gaps, to address both vaccine supply- and demand-side shortcomings.The COVID-19 pandemic has revealed the vulnerability of the immunization program, an essential health service. In the first quarter of 2020, sharp declines in immunization coverage, ranging from 10% to 50% relative to 2019, occurred as severe social and physical distancing policies were implemented in many countries around the world . During An unprecedented worldwide effort began in January 2020 to develop safe and effective COVID-19 vaccines to help end the COVID-19 pandemic that has impacted the lives and livelihoods of people worldwide. Following interim phase 3 clinical trial results and authorization for emergency use, COVID-19 vaccines began rollout in December 2020. This is an unprecedented landmark in immunization and shows how this pandemic has created a paradigm shift in the process, speed and scale vaccines are being developed, deployed, and financed. The goal of facilitating fair and equitable access to COVID-19 vaccines has motivated the establishment of the COVAX Global Vaccine Facility as the vaccine pillar of the Access to COVID Tools Accelerator. The Facility, co-led by WHO, Gavi, and the Coalition for Epidemic Preparedness Innovations in partnership with UNICEF and others, aims to assure speed, scale, and equitable access to COVID-19 vaccines with demonstrated efficacy and safety .The WHO target product profile for COVID-19 vaccines provides a benchmark of the minimum characteristics needed for the assessment of candidates . There aNew technologies and innovative strategies have the potential to increase the reach and impact of immunization programs. While research has led to the development of new life-saving vaccines, research to develop new or improved products better suited to local needs, implementation research on how to optimize immunization among underserved populations, and to develop, evaluate, and scale up innovations for immunization service delivery could amplify the impact of available products as well as those in the pipeline. One example of targeting innovations to local needs is The Vaccine Innovation Prioritization Strategy, which undertook a formal process, including engaging in-country stakeholders, to prioritize 3 vaccine product innovations (among 24) with the greatest potential to achieve equity, improve immunization systems, and focus investment; these 3 innovations are microarray patches, heat-stable controlled temperature chain liquid formulations, and barcoding on primary containers . HoweverImmunization beyond the infant schedule has not yet reached the scale of implementation it merits. The reasons to build strong immunization services throughout the life course are many . First, In August 2020, all WHO member states endorsed the Immunization Agenda 2030: A Global Strategy to Leave No One Behind (IA2030) . IA2030 IA2030 focuses on tailored implementation and adaptive approaches to country contexts and is built to be flexible to new challenges throughout the decade. The main shift from GVAP is a move away from disease-specific ways of operating and place immunization as an integral part of strong people-centered primary health care service. The agenda places countries at the center, supported by accountable partners including those outside the health sector. Other shifts include the importance of data-driven program and policy improvements, and the importance placed on targeted ways of addressing inequities and gender-related barriers. Measles being the most contagious vaccine-preventable disease, is recognized as a pathfinder for IA2030, signaling when and where immunization services need to be improved. To operationalize IA2030, regional IA2030 plans are being developed and countries are integrating the strategies into national immunization strategies aligned with the public health plans in each country. The monitoring and accountability framework is being developed through a wide country consultation process and will be presented to the World Health Assembly in May 2021. The IA2030 offers a valuable platform for sustaining global commitment and promoting greater accountability for improved health and well-being.


High Alt Med Biol. 22:335–341, 2021.—Mitigating the spread of COVID-19, an airborne infection, can lead to delays in the prehospital response and impair the performance of search and rescue (SAR) services in mountainous and remote areas. We provide an overview of the developing epidemiological situation related to the COVID-19 pandemic in mountainous areas and review current protocols to determine their suitability for mountain rescue teams. We also discuss using novel technologies to reduce the adverse effects caused by COVID-19 mitigation strategies such as delays caused by donning personal protective equipment (PPE) and reduced rescuer performance due to impaired movement and ventilation. COVID-19 has spread even in mountainous and remote locations. Dedicated protocols for the use of PPE appropriate for SAR rescuers exerting physical effort in remote areas and using technologies such as drones, telemedicine, and localization and contact tracing applications could contribute to an effective and timely emergency response in mountainous and remote settings.van Veelen, Michiel J., Anna Voegele, Simon Rauch, Marc Kaufmann, Hermann Brugger, and Giacomo Strapazzon. COVID-19 pandemic in mountainous areas: impact, mitigation strategies, and new technologies in search and rescue operations.  Currently, only the National Alpine and Speleological Rescue Corps of Italy has published a protocol specifically for the SAR setting , as shown in A key decision point in protocols is whether members of SAR teams should continuously wear PPE during mountain and remote SAR operations . WearingNew PPE protocols against airborne infectious diseases should be compatible with technical equipment and specific environments such as snow and water in an avalanche, canyoning, or cave rescue . The number of members involved in patient transport and care should be minimized  phone signal is not needed to send out an alert, and speed location as coordinates is tracked in real-time and transmitted directly to the SAR services, optimizing human and logistical resources. Furthermore, the use of anonymized COVID-19 contact tracing applications installed on smartphones facilitates contact tracing after a mission by identifying the chain of contact of patients or providers tested positive for COVID-19. These applications utilize continuous Bluetooth signal emission and detection, which flags close contact with a positive COVID case, leading to an alert prompting the exposed person to get tested Zastrow, . This idEducation and training in new protocols utilizing PPE and novel technologies are crucial and provide essential guidance on further management. The main issues of working with PPE in acute care are safe and timely donning practices, likely requiring a buddy to prevent self-contamination, and safeguarding effective, closed-loop communication while wearing PPE (Lim et al., Epidemiological data support the fact that COVID-19 occurs in mountainous areas. Current trends point toward rising numbers of visitors in these areas worldwide especially after lockdown periods, increasing the chances of transmission in case of a rescue. There is currently a scarcity of published protocols describing the use of PPE suitable for SAR rescuers to protect themselves from COVID-19. Therefore, we advocate for establishing concrete recommendations by an international body such as the International Commission for Mountain Emergency Medicine ICAR MedCom, in which input from experts worldwide, as well as from nonpublished protocols, can be incorporated. As the pandemic and its mitigation strategies evolve rapidly, guidelines will need to be updated regularly. The use of technologies such as drones, telemedicine, and mobile applications could contribute to an effective and timely emergency response in mountainous settings while limiting the risk of viral transmission. Compliance will depend on providers' successful education. Focused research is needed on the feasibility and outcome of implementing mitigation strategies and the use of novel technologies in the field to make recommendations for future uses.


Dear Editor,Inhalational exposure to toxic chemicals present in humidifier disinfectant (HD), such as polyhexamethylene guanidine (PHMG), was identified as a cause of the serious lung injury,COL1A2  in the present study was notable. Further comparison of gene expressions between human and rat lung tissues  have been previously reported to be associated with lung diseases such as idiopathic pulmonary fibrosis (IPF). In the ingenuity pathway analysis (IPA), significant networks, canonical pathway, and disease/bio‐function were predicted in human lung tissues with HDLI and rat lung tissues exposed to PHMG  with interaction enrichment of differentially expressed proteins (DEPs) based on protein expression analysis  using previously reported IPF transcriptome data Table  comparedLimitations of the present study are the relatively small number of samples, due to the scarcity of HDLI patients and the low availability of human lung tissues, and insufficient evaluation of the functions of the identified candidates. Although disease severity, stage, and progression during tissue acquisition might affect gene expression, we were unable to account for this factor in the present work. However, to minimize this, we analyzed lung samples during the acute phase, and replicated human expression changes in the rat model following exposure to PHMG. In addition, we integrated multispecies multi‐omics  approaches, and performed interactome network analysis, to avoid issues with its low coverage in analyzed data. In summary, this study identified several DEGs and further validated DEPs in HDLI, along with differences in mechanisms between children and adults and human–rat commonality, hoping that these results may provide new insight into the HDLI pathogenesis and chemical‐induced lung injury and fibrosis.The authors declare that there is no conflict of interest.SUPPORTING INFORMATIONClick here for additional data file.SUPPORTING INFORMATIONClick here for additional data file.


Multiple efforts have been taken across the world to bridge gaps in evidence and provide recommendations for dementia care and caregiver support during the COVID-19 pandemic. We aimed to review the available literature on measures used to alleviate the negative impacts of the pandemic on dementia care.We searched three databases: PubMed, CINAHL and PsycINFO to identify studies that described strategies that were recommended or taken to provide care and support to persons with dementia and their caregivers during the COVID-19 pandemic.We included a total of 37 papers, originating from high, middle and low-income countries. We also included 6 papers exploring safety of COVID-19 vaccinations. Infection prevention recommendations predominantly involved providing consistent reminders to persons with dementia to engage in infection prevention measures and included measures to restrict wandering in long-term care settings to reduce spread of infection. Medical care included tele and video consultations to maintain and monitor clinical stability. Guidance for continuing rehabilitation activities for persons with dementia through remotely conducted cognitive stimulating activities, physical exercises and environmental modifications were further highlighted by multiple studies/articles. In addition, strategies to support caregivers were also advised and included teleconsultations and psycho-educational programs.The COVID-19 pandemic has exposed gaps in health and social care systems across the world, but has also revealed the enduring dedication of clinicians, expert groups and dementia support organizations to modify and adapt existing dementia care services to meet the needs of persons with dementia and their caregivers during periods of emergency. T1.2Due to increase in COVID-19 cases, there was closure of non-essential services which included diagnostic and follow-up services, pharmacologic and non-pharmacologic management  of dementia patients 1.3Multiple studies have examined the impact of confinement measures associated with the COVID-19 pandemic on persons with dementia and their caregivers. Worsening or new onset of neuropsychiatric symptoms 1.4Significant disruptions to daily routines due to the pandemic led to numerous challenges in caring for persons with dementia and reduced supports available to caregivers, which in turn contributed to caregiver burnout and stress. Altieri and Santangelo In response to the challenges encountered by persons with dementia and their caregivers during the COVID-19 pandemic, in the initial phase of the pandemic, several expert groups developed recommendations to guide care of persons with dementia and ensure their well-being and safety. Given the wide range of care strategies that were developed, there is a need to review different approaches and consolidate the various efforts made to mitigate the negative consequences of the pandemic. This effort will aid in developing strong evidence-based guidelines that can inform dementia care practice during the ongoing COVID-19 pandemic.In this paper, our objective was to review available studies and methods that aimed to alleviate the wide range of negative impacts of COVID-19 pandemic on persons with dementia and their caregivers.2We reviewed literature regarding the provision of dementia care during the COVID-19 pandemic across the world, with specific focus towards measures or recommendations for dementia care and support for caregivers.2.1We included studies that described measures that were taken or could be taken to provide daily care, medical care or general support to persons with dementia or cognitive impairment and their caregivers. The inclusion criteria included: 1) Articles by experts and expert groups that described strategies or recommendations to provide dementia care during the COVID-19 pandemic; 2) Primary research studies, special articles, perspective articles, reports, commentaries, recommendations and guidelines; and 3) Articles and studies that are peer-reviewed.We excluded articles that were not in English, reviews, papers not specific to persons with dementia or cognitive impairment, those which focused only on the impact of confinement on persons with dementia and their caregivers and any grey literature.2.2th, 2021. We searched three main databases: PubMed, CINAHL and PsycINFO. A search strategy was initially developed for PubMed and later translated for CINAHL and PsycINFO using the database specific search syntax. In order to identify key subjects and search terms we identified search terms used in other reviews .2.3A template was formulated to extract data and included information on author, publication country, type of article, sample size, setting, daily care, medical care, social care and support for caregivers. Two authors [JR and AP] completed this data extraction.3For the search conducted on vaccinations, we identified a total of 81 records: 64 records from PubMed, 7 from PsychINFO and 10 from CINAHL. After removal of duplicates, 73 records were screened using their title and abstract, with 63/73 excluded after screening. We then assessed 10 full-text articles, with 5 articles ,59,60,61On reviewing these studies, several forms of interventions were identified to support persons with dementia and their families. Studies were grouped into four main themes that emerged: infection prevention, medical care, functional rehabilitation and care for persons with dementia, and caregiver support. These main themes were further divided into different sub-themes, which are summarized in 3.1Review of literature revealed several recommended measures to reduce risks of infection and maintain continuity of medical care. A crucial need for caregivers to provide continuous reminders to persons with dementia to maintain hygiene standards and reduce risks of infection through hand washing, wearing masks and social distancing were highlighted in the majority of studies ,53. UsinIn long-term care settings, additional measures needed to be taken to reduce risks of infection such as training for caregivers to implement a strong infection prevention management plan 3.2Strategies were also developed to diminish disruptions in medical care provision. Telemedicine during the COVID-19 pandemic became the primary and effective way to deliver medical care to vulnerable persons with dementia without exposing them to infection risks ,42,52,55In addition, a few studies have examined the effectiveness and impact of vaccinations on persons with dementia. A study conducted across five long-term care facilities in Spain found that the Pfizer (mRNA) vaccine was safe in older adults [the sample included those with mild to severe dementia] and that it provided immunogenicity irrespective of old age, fragility, and co-morbidities A brief overview of the recommendations that can be followed to support medical care for persons with dementia are provided in 3.3Review of articles revealed that rehabilitation and care for persons with dementia was provided in the following major areas: multidisciplinary care, cognitive stimulation, reducing behavioral and psychological symptoms, help for activities of daily living (ADLs), environmental modifications, physical exercise, overcoming social isolation, general wellbeing and safety, and advanced care. The recommendations for functional rehabilitation and care for persons with dementia is summarized in Dementia care is multidisciplinary in nature and during the pandemic, consultations with psychologists, occupational therapists and speech pathologists was supported through use of technology ,50,55. TCognitive stimulation therapy for dementia includes a range of activities that can be individualized and be applied under home conditions To compensate for the interruption of face-to face interactions, online cognitive stimulating and socially engaging activities were implemented across many groups supporting persons with dementia. Leisure interests such as playing music and movies on tablets, and internet-based games ,34; smarVarious interventions were found helpful for management of behavioural and psychological symptoms in persons with dementia, and included environmental modifications, physical exercise and psychological treatment ,65,66. EMany care-settings worldwide recommended environmental modifications especially during the pandemic such as posting signs in rooms for orientation Regular physical activity and a healthy lifestyle has been found to delay the progression of dementia, improve cognitive functioning, reduce frailty, and lower the risk of depression and other behavioral and psychological symptoms Preserving and improving the activities of daily living (ADLs) is a foremost patient related outcome, and this was also emphasised during the COVID-19 pandemic. Some of the interventions implemented to maintain ADLs were the use of electronic reminders ,36, enviTo prevent persons with dementia from being socially isolated, various experts provided guidelines developed through practice and research to enhance social interaction among nursing home residents and family. Window visits to family members, i.e., setting up large windows where persons with dementia and family members interact with each other were offered by residential care homes Several collaborative approaches were initiated to support dementia care in the community such as partnerships with governmental initiatives for community dementia care and support via telephonic, video and social media platforms The general wellbeing and safety during COVID-19 pandemic was addressed through tele-assessments [video and phone consultations] for quality of life, physical and mental wellbeing and by providing relaxation and meditative exercises using electronic media ,38. AddiAdditionally, to support terminal illness of persons with dementia during the pandemic, the usage of electronic and audiovisual programs were advised for end-of-life planning, dealing with bereavement, and information sharing between nursing homes and families and to provide a useful avenue of support ,31,51,533.4A number of recommendations have been provided to reduce caregiver stress and support caregivers during the COVID-19 pandemic. Reaching out to caregivers through various mobile and web-based platforms such as text messaging, chat forums or video recordings can aid in ensuring that specific needs of caregivers are brought to the attention of health professionals ,23,50. PBesides addressing the medical and psychosocial needs of caregivers, the crucial need for other essential services such as food and medication was also recognised. Deliveries can be provided by local markets and pharmacies ,35. Fore4A detailed review of literature of dementia care during the COVID-19 pandemic revealed that a wide range of helpful measures were developed towards support of persons with dementia and their caregivers. The main areas of care included measures to prevent infection specific to persons with dementia, medical care, functional rehabilitation and support for persons with dementia and caregiver supportAs the COVID-19 pandemic spread quickly across the world from when the first cases were reported in China in December 2019, persons with dementia have been amongst the most vulnerable groups affected. This has raised concerns for dementia care as early as March 2020 While most published studies were in the form of guidelines and recommendations, there were several of primary research studies that were conducted Infection prevention guidelines and recommendations, medical care, functional rehabilitation, multidisciplinary care for persons with dementia amidst the COVID-19 pandemic was the focus of most intervention guidelines and research studies ,45,53,55Technology provides new opportunities for assessment, management, and follow-up care for persons with dementia to maintain functional independence and safety and to improve quality and access to care ,67. TeleWhile COVID-19 pandemic has accelerated the use of telemedicine and telerehabilitation for consultations and management of persons with dementia, there are some concerns that are encountered while using such modern technology: (i) the quality of internet connection in certain geographical locations and socio-economic groups may not be good In conclusion, while the COVID-19 pandemic has exposed the vulnerabilities of persons with dementia and their caregivers, it has also revealed the resilience and commitment of the dementia community to reframe existing services and provide care during periods of emergency. The multidisciplinary requirement of dementia care was recreated through a variety of services that encompassed medical, non-pharmacological and psychosocial care strategies. The ongoing pandemic emphasises the need to continue these efforts and build evidence for their effectiveness, and ensure their implementation across global communities.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


For more than a decade, suicide rates in Australia have shown no improvement despite significant investment in reforms to support regionally driven initiatives. Further recommended reforms by the Productivity Commission call for Federal and State and Territory Government funding for mental health to be pooled and new Regional Commissioning Authorities established to take responsibility for efficient and effective allocation of ‘taxpayer money.’ This study explores the sufficiency of this recommendation in preventing ongoing policy resistance. A system dynamics model of pathways between psychological distress, the mental health care system, suicidal behaviour and their drivers was developed, tested, and validated for a large, geographically diverse region of New South Wales; the Hunter New England and Central Coast Primary Health Network (PHN). Multi-objective optimisation was used to explore potential discordance in the best-performing programs and initiatives (simulated from 2021 to 2031) across mental health outcomes between the two state-governed Local Health Districts (LHDs) and the federally governed PHN. Impacts on suicide deaths, mental health-related emergency department presentations, and service disengagement were explored. A combination of family psychoeducation, post-attempt aftercare, and safety planning, and social connectedness programs minimises the number of suicides across the PHN and in the Hunter New England LHD , and performs well in the Central Coast LHD , suggesting that aligned strategic decision making between the PHN and LHDs would deliver substantial impacts on suicide. Results also highlighted a marked trade-off between minimising suicide deaths versus minimising service disengagement. This is explained in part by the additional demand placed on services of intensive suicide prevention programs leading to increases in service disengagement as wait times for specialist community based mental health services and dissatisfaction with quality of care increases. Competing priorities between the PHN and LHDs (each seeking to optimise the different outcomes they are responsible for) can undermine the optimal impact of investments for suicide prevention. Systems modelling provides essential regional decision analysis infrastructure to facilitate coordinated federal and state investments for optimal impacts. This has occurred despite a national commitment to improving mental health outcomes, decades of investments, national mental health system reforms, and successive ‘strategic’ mental health and suicide prevention action plans premised on complementing state and territory government actions and promising to deliver timely, coordinated, quality mental health care6. A range of explanations for this policy resistance have been proffered including Australia’s federated arrangements with regards to financial and service-related responsibilities for mental health care that have challenged attempts at accountability7, and the complexity of the mental health service system that is fragmented, difficult to navigate, and lacking coordination9.For more than a decade, the rates of mental health-related emergency department (ED) presentations in Australia have been increasing across all age groups11. While a robust, outcomes-focussed monitoring infrastructure is certainly needed, alone it is unlikely to deliver impact; two additional challenges will need to be overcome. Firstly, investment decisions to improve mental health outcomes and prevent suicide cannot simply rely on data monitoring. Effective decision making to address complex problems requires an appropriate predictive planning framework  to leverage this data, forecast future trajectories of population mental health and suicide outcomes, and simulate the likely impacts of alternative options for investments in programs, services and initiatives; enabling investments that are strategic rather than dispersed9. Systems modelling is uniquely able to capture population and demographic dynamics and changes over time in social and economic drivers of psychological distress; it captures feedback loops that drive the vicious and virtuous cycles that exist in the real world; it captures the fluctuating interplay between service supply versus demand, and workforce dynamics; and it captures change over time in individual intervention effects and the potentially non-additive effects of intervention combinations13. These characteristics of complex systems bedevil traditional analytic approaches14. Secondly, different actors in the system can have different priorities and agendas based on their source of financing, community needs, system pressures, competing views of local stakeholders, and political considerations.Much has been written regarding the vital role of systematic and timely monitoring of mental health and suicide outcomes  as a key driver of accountability, improved system performance, and continuous system-wide quality improvement in mental health care and suicide prevention16. Five years on from these reforms, persistent system failures have been attributed to ‘a lack of clarity across the tiers of government about roles, responsibilities and funding, leading to persistent wasteful overlaps, yawning gaps in service provision, and limited accountability’17 for mental health outcomes. To address this issue, further reforms have been recommended that call for Australian Government and State and Territory Government funding for mental health to be pooled and new Regional Commissioning Authorities be established to take responsibility for allocating these pooled resources and improve ‘efficient and effective use of taxpayer money’17.As part of the most recent major reforms (2015), the Australian Government established 31 Primary Health Networks (PHNs) across the country to decentralise decision making and enable investments in programs, services and initiatives that better respond to local population needs, contexts and priorities18 and collective interaction with these models to quantify the trade-offs of alternative system strengthening strategies, offer promise in helping to achieve alignment of agendas for collaborative, coordinated, optimised, and sustained investments and actions.On the surface, the implementation of overarching regional governance structures, pooling of resources, and systematic and timely monitoring of mental health and suicide outcomes represent an obvious and ideal solution to the problem of waste, inefficiencies, gaps in service systems and increasing accountability for investments made across the mental health system . However, this solution is unlikely to negate the need for integrated systems modelling and monitoring infrastructure to support strategic investment decisions and overcome policy resistance. Nor will it necessarily ensure the buy-in of stakeholders working across the system required for successful implementation and integration of new programs, services, and initiatives. Participatory approaches to the development of systems modelsThis study aimed to answer three key questions; (1) what impact on suicide outcomes could be achieved for the region if the optimal combination of programs and initiatives were identified and implemented; (2) if the priorities of the PHN and two LHD were aligned , would independent decision making regarding the optimal combination of programs and initiatives for the PHN catchment as a whole or LHD sub-regions deliver similar impacts on suicide outcomes; (3) if the priorities of the PHN and two Local Health Districts (LHDs) were not aligned , would impact on suicide outcomes for the region be undermined. In addressing these questions, this study will inform optimal strategies for overcoming policy resistance and delivering significant reductions in suicide for the region and will inform whether the pooling of funds and/or the aligning of agendas across national- and state-governed agencies is important.19. Within the HNECC PHN region, a range of LGAs have significant levels of relative disadvantage20. In 2017–2018, the rate at which people aged 18 years and over experienced high or very high psychological distress was 13.5 per 100, higher than the NSW (12.4 per 100) and Australian (12.9 per 100) averages19. Over the period 2013–2017 there were a total of 764  deaths from suicide and self-inflicted injuries, which was higher than both NSW  and Australia  for the same time period19. These high rates of suicide in the region prompted the two LHDs  to come together with the HNECC PHN to explore how best to invest in coordinated actions to reduce suicidal behaviour and other key mental health indicators in the region. The functions and responsibilities of PHNs  and LHDs  in the Australian context is well described22.The Hunter New England and Central Coast (HNECC) PHN is the second largest PHN in New South Wales, covering 133,812 square kilometres, reaching from just north of Sydney, across the north west of NSW, to the Queensland border. It incorporates 23 Local Government Areas (LGAs) and is serviced by the Hunter New England Local Health District (HNE LHD) and Central Coast Local Health District (CC LHD). In 2018, estimated resident population for the HNECC PHN catchment was 1,269,7829 and included: (1) a population component, capturing changes over time in the size of the population resulting from births, migration, and mortality; (2) a psychological distress component that models flows of people to and from states of low or no psychological distress (Kessler 10 [K10] scores below 15), and moderate to very high psychological distress (K10 score 16–50); (3) a mental health services component that models the movement of psychologically distressed people through one of several possible service pathways across the primary to tertiary service continuum involving  general practitioners, psychiatrists and allied mental health professionals , psychiatric inpatient care, community mental health centres, and online services; and (4) a suicidal behaviour component that captures self-harm hospitalisations (used as a proxy for suicide attempts—see limitations) and suicide deaths. Figure A system dynamics model was developed using a participatory modelling approach  numbers of self-harm hospitalisations and suicide deaths, and self-harm hospitalisation and suicide rates per 100,000 population. The model also provided estimates of the prevalence of moderate to very high psychological distress and the total (cumulative) mental health-related ED presentations and psychiatric hospitalisations, and a range of measures of mental health service usage . All outputs were calculated every 0.4375 days  over a period of 28 years, starting from 1 January 2011, permitting comparisons of model outputs with historic data from 2011 to 2017 and forecasts of the impacts of intervention scenarios described below simulated over a 10-year period from 2021 to 2031.Parameter values that could not be derived directly from available data or published research were estimated via constrained optimisation, implemented in Stella Architect ver. 1.9.4, using historical time series data on the prevalence of psychological distress, self-harm hospitalisations and suicide rates, and mental health-related service usage . Powell’s method was employed to obtain the set of  parameter values minimising the sum of the mean absolute percent error calculated for each time series separately .In addition to the ability to scale up or down mental health services capacity captured in the core model structure, a range of mental health and suicide prevention programs and initiatives selected by the participating stakeholders were integrated into the model Table . These p23). Analyses in which five interventions were selected from the 12 interventions modelled yielded results similar to those for combinations of four interventions, indicating that our general conclusions are not dependent upon the choice of intervention set size  numbers of suicides, mental health-related ED presentations, and patients disengaging from services under all (495) possible combinations of four interventions selected from the 12 programs, services and initiatives modelled. Differences in projected numbers of suicides, ED presentations, and disengagements from services between the baseline scenario and each intervention scenario across the PHN and in the two LHDs were calculated for the period 2021–2031. We identified the best-performing  combinations of interventions for each outcome across the PHN and in each LHD , as well as all intervention combinations performing better than every other combination on at least one outcome; these latter combinations, corresponding to non-dominated or Pareto optimal solutions, may be considered as equally optimal alternatives where the goal is to simultaneously minimise suicide mortality, ED presentations, and disengagement from care . Differences in projected numbers of suicides, ED presentations, and patients disengaging from services between the baseline and intervention scenarios were calculated for each set of parameter values and summarised using simple descriptive statistics.This modelling study did not require ethics approval.Not applicable.Projected numbers of suicides, mental health-related ED presentations, and patients disengaging from services per year under the baseline  scenario are presented in Fig. Under the business-as-usual scenario, 1778 suicides, 155,901 mental health-related ED presentations, and 544,972 disengagements from services are projected for the PHN over the forecast period  or sub-regional (LHD) levels if agendas are aligned in prioritising suicide prevention. In contrast, competing priorities between the PHN and LHDs  can undermine optimal impacts of investments to prevent suicide deaths. Understanding such trade-offs and their implications for mental health outcomes and suicide prevention is not possible without the ability to forecast comparative impacts of alternative investment strategies. Therefore, in short, the Productivity Commission’s recently recommended pooling of national and state funding for mental health under new Regional Commissioning Authorities is neither necessary nor sufficient to prevent ongoing policy resistance.This study harnessed systems modelling and simulation to explore whether the recent Productivity Commission recommendations to pool resources under a unifying regional governance structure would be sufficient to prevent persistent policy resistance. Findings offer promise that policy resistance can be overcome with implementation of the optimal mix of programs and initiatives and indicate that reductions in suicide deaths in the order of 14.2–16% over 10 years are achievable across the region, however, the scale of this potential impact falls well short of the ambitious Premier’s Target to reduce the rate of suicide deaths in NSW by 20% by 202326. Securing the required leadership and sustained support for effective, coordinated implementation of best performing interventions identified by systems modelling requires representatives from across the regional mental health and social systems and broader community to come together to debate, weigh up the trade-offs, and prioritise the key mental health outcomes to be addressed. Regardless of whether proposed reforms are implemented in Australia, the participatory systems modelling approach will be essential for coordinating regional investments in mental health system strengthening and suicide prevention and reducing fragmentation. The participatory systems modelling approach would support the integrated decision analytic, monitoring and evaluation ecosystem needed to achieve the transparency and accountability required for more effective mental health outcomes both regionally and nationally.A unifying regional governance structure will not negate the need for advanced decision analytic capability provided by systems modelling and simulation to identify optimal combinations of programs and initiatives for suicide prevention, as well as consensus building processes to unite regional stakeholders behind an agreed agenda. Studies have highlighted the importance of political support from local authorities and acceptance of proposed interventions by the local community for successful implementation of public health programsFinally, the unintuitive finding of a marked trade-off between minimising suicide deaths versus minimising service disengagement  is explained in part by the additional demand placed on the regional mental health service systems of intensive suicide prevention programs. For example, post suicide attempt assertive aftercare is an active outreach and enhanced contact program designed to intensively support those presenting to services after a suicide attempt in order to prevent re-attempt. It is implemented through existing community-based mental healthcare (CMHC) services. In the context of restrictions in responsive expansion of regional workforces, new programs introduced consume existing service capacity. This in turn leads to increases in service disengagement as wait times for specialist community based mental health services and dissatisfaction with quality of care increases.There are several limitations that require consideration when interpreting the findings of this study. There is potential measurement bias in the range of secondary data used to parameterise the model including the population health surveys, Medicare claims data, and PHN and Local Health District (LHD) datasets. The model acknowledges these potential sources of measurement bias and a number of commonly used strategies were employed to address them, including the triangulation of multiple data sources, parameter estimation via constrained optimisation, and local verification to identify plausible estimates.In addition, there is potentially an under-enumeration of suicide cases used to calibrate the model, due to the misclassification of suicides to ICD codes relating to unintentional injury and events of ‘undetermined intent.’ Also, in the absence of a direct measure of suicide attempts, self-harm hospitalisations are used as a proxy in this study. Suicide attempts identified from hospital admissions data likely only capture those cases serious enough to warrant medical intervention, and instances of self-harm where the intent wasn’t clear may be not coded as suicide attempts. However, this under-enumeration is consistent across simulations of the baseline case and intervention scenarios and as such is unlikely to affect the forecast estimates of impact  of intervention strategies or the strategic insights derived from the model. Ongoing systematic monitoring and evaluation can determine the extent to which the model forecasts are corresponding with real-world outcomes over time, allowing refinement of model parameters to improve forecasting capabilities. Finally, as the impacts of simulated scenarios are subject to the population, demographic, behavioural, and service dynamics of the modelled region, they may not be generalisable to other regions.The suite of programs, services and initiatives used in this analysis by no means represents an exhaustive list of potentially effective strategies, nor are these optimisation results intended to provide ‘the answer.’ Rather, this work demonstrates how systems modelling can provide a quantitative framework for bringing together a body of evidence, data, and local knowledge in a way that answers questions that cannot be achieved through analysis of any single dataset or through real world experimentation. A further strength of the approach is the ability to bring together representatives from different parts of the mental health system, funded by different levels of government, and engage them in a process that helps them better understand the upstream and downstream implications of investments designed to strengthen a particular part of the system. Strategy dialogues supported by a robust, objective systems modelling platform promotes communication and relationship building between system actors that traditionally do not interact. This approach also promotes the aligning of agendas needed for collaborative and coordinated action. Systems models can be iteratively refined and informed by (and will in turn inform) data collected from relevant surveys, administrative data sets, and new research. Following initial model development, key indicators for ongoing monitoring are identified, often engaging different jurisdictions and diverse stakeholders (including lived experience groups) in the process of strengthening their regional decision support asset. This not only improves the predictive capabilities of systems models over time but has the potential to keep system actors invested in sustaining their engagement with the model as a long term, collective, regionally-based decision support asset, and as an objective, constructive platform for supporting ongoing cooperation.Decades of investments, statutory inquiries, mental health system reforms, and strategic action plans, have failed to reduce suicide rates in Australia. This study has demonstrated that competing priorities between PHNs and LHDs can undermine the optimal impact of investments for suicide prevention and that the Productivity Commission’s recently recommended pooling of national and state funding for mental health under new Regional Commissioning Authorities is neither necessary nor sufficient to prevent ongoing policy resistance. Systems modelling provides essential regional decision analysis infrastructure to facilitate optimally coordinated federal and state investments.Supplementary Information.