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Maternal and neonatal tetanus is still a substantial but preventable cause of mortality in many developing countries. Case fatality from these diseases remains high and treatment is limited by scarcity of resources and effective drug treatments. The Maternal and Neonatal Tetanus Elimination Initiative, launched by WHO and its partners, has made substantial progress in eliminating maternal and neonatal tetanus. Sustained emphasis on improvement of vaccination coverage, birth hygiene, and surveillance, with specific approaches in high-risk areas, has meant that the incidence of the disease continues to fall. Despite this progress, an estimated 58 000 neonates and an unknown number of mothers die every year from tetanus. As of June, 2014, 24 countries are still to eliminate the disease. Maintenance of elimination needs ongoing vaccination programmes and improved public health infrastructure.

Data concerning intensive care unit (ICU)-acquired bacterial colonization and infections are scarce from low and middle-income countries (LMICs). ICU patients in these settings are at high risk of becoming colonized and infected with antimicrobial-resistant organisms (AROs). We conducted a prospective observational study at the Ho Chi Minh City Hospital for Tropical Diseases, Vietnam from November 2014 to January 2016 to assess the ICU-acquired colonization and infections, focusing on the five major pathogens in our setting: Staphylococcus aureus (S. aureus), Escherichia coli (E. coli), Klebsiella spp., Pseudomonas spp. and Acinetobacter spp., among adult patients with more than 48 hours of ICU stay. We found that 61.3% (223/364) of ICU patients became colonized with AROs: 44.2% (161/364) with rectal ESBL-producing E. coli and Klebsiella spp.; 30.8% (40/130) with endotracheal carbapenemase-producing Acinetobacter spp.; and 14.3% (52/364) with nasal methicillin-resistant S. aureus. The incidence rate of ICU patients becoming colonized with AROs was 9.8 (223/2,276) per 100 patient days. Significant risk factor for AROs colonization was the Charlson Comorbidity Index score. The proportion of ICU patients with HAIs was 23.4% (85/364), and the incidence rate of ICU patients contracting HAIs was 2.3 (85/3,701) per 100 patient days. The vascular catheterization (central venous, arterial and hemofiltration catheter) was significantly associated with hospital-acquired bloodstream infection. Of the 77 patients who developed ICU-acquired infections with one of the five specified bacteria, 44 (57.1%) had prior colonization with the same organism. Vietnamese ICU patients have a high colonization rate with AROs and a high risk of subsequent infections. Future research should focus on monitoring colonization and the development of preventive measures that may halt spread of AROs in ICU settings.

In 2022, we established a residual sample serosurveillance program in Ho Chi Minh City, Vietnam. During September 2022-April 2024, we found low measles antibody seroprevalence in children in the city's western region, where a measles outbreak began in May 2024. Serosurveillance could be a useful tool for outbreak prediction and prevention.

Background Despite the successful implementation of the Expanded Programme on Immunization (EPI) for the past three decades, Vietnam has recently witnessed outbreaks of vaccine-preventable diseases, indicating a potential gap in immunisation uptake across population groups. Daklak province is a rural highland area, home to 46 ethnic groups with complicated socio-economic backgrounds. The province reported sporadic outbreaks of vaccine-preventable diseases and low vaccine uptake in some remote low-socioeconomic groups despite a high record of provincial coverage. Within this context, we aim to explore the perspectives and experiences of ethnic minority communities related to EPI vaccination and how socio-economic and contextual factors influence such views and practices in Daklak province. Methods We used qualitative data collected between 2018 and 2022 from in-depth interviews, focus group discussions, and participant observation with different stakeholders of the EPI programme. The study took place in nine districts across 25 communes of the province with different socio-economic characteristics and vaccination patterns. We invited mothers who were the primary caregivers taking children to vaccination and healthcare workers who were directly involved in vaccination delivery in the local areas. We incorporated the SAGE’s public health framework of the vaccine hesitancy matrix and the anthropological concept of structural vulnerability to discern the structural roots of vaccine attitudes and behaviours of the community. Results Overall, the research shows that views and behaviours related to children’s vaccination are complicatedly influenced by multi-ecological factors. In particular, we found a critical influence of socioeconomic conditions and social networks on the community’s vaccine acceptance and uptake. The community’s interaction with the health system and the government through local healthcare workers was also critical in fostering community trust towards vaccines and the EPI programme. In addition, we revealed that the issues with non-compliance to the EPI in the lowest-uptake communities were structurally related to their economic vulnerabilities and social marginalisation. Conclusions These findings implicate the need for tailoring public health and socioeconomic interventions to enhance vaccination opportunities in the marginalised groups.

Restricted availability of maintenance staff and replacement parts, means that equipment is often non-functioning or cannot be used to its full potential.2 10 Additionally, the paucity of appropriately trained staff and limited infection control measures can result in more frequent complications, which may worsen outcomes and further increase costs.11 12 Costing studies conducted in high-income countries have reported average costs of ICU care between US$1700 and 4500 per day (adjusted to 2014 prices).13 14 The delivery of critical care is less expensive in LMICs largely because of much lower labour costs; for example, a study based in an Indian hospital estimated the average daily cost of ICU care was US$109 (2014 prices).15 Although this amount may appear low, the average annual healthcare expenditure per capita across LMICs is only around 5% that of high-income countries.16 Furthermore, in LMICs, critical care costs are often not fully covered by the health/insurance systems and patients’ and their families can incur high out-of-pocket expenses.17–19 Currently costs severely restrict access to ICU care in LMICs, particularly for the socioeconomically disadvantaged and uninsured, and there is an urgent need to develop an alternative affordable critical care model for LMICs.20 What can be done? The emergence of new technologies, means there are huge opportunities to expand capacity and improve the care of critically ill patients in LMICs.10 21 22 A substantial proportion of critical care costs in LMICs are to cover staffing and fixed asset equipment costs as opposed to actual medications and laboratory tests.15 Methods impacting these may be a way of reducing costs, allowing expansion of capacity as well as improving the care quality. In high-income settings, AI algorithms have been shown to improve the management of sepsis and lower mortality.24 25 The ability of AI systems to continuously learn and adapt means that computer-assisted clinical decision-support systems can be tailored to the needs of a specific context or setting. [...]algorithms could be created to help in the management of diseases such as malaria, dengue and tetanus, which are uncommon in high-income ICU settings but are significant problems in LMICs. [...]the development of training and capacity building programmes is particularly important—not only for ICU physicians but also for nurses and other clinical personnel.2 It is vital that these training programmes, as well as covering specific ICU clinical skills also include basic management and organisational aspects of critical care.2 Successful initiatives such as Train-the-Trainer and peer-to-peer programmes have been shown to be successful in LMICs and could be further expanded.29 30 Conclusion Improving the quality and availability of critical care is essential for reducing the burden of preventable deaths in LMICs.

Currently a rarity in high-income countries, tetanus is a diagnosis not to miss. Deaths from tetanus fell by almost 90% between 1990 and 2019, largely reflecting the success of WHO's Maternal and Neonatal Tetanus Elimination campaign. However, deaths among children and adults have plateaued, and tetanus remains an important vaccine-preventable cause of morbidity and mortality, notably in southern Asia, southeast Asia, and sub-Saharan Africa. Tetanus results from infections with spore-forming Clostridium tetani bacteria, usually acquired via contaminated wounds and burns. C tetani releases a potent neurotoxin, causing muscle spasms, rigidity, and dysautonomia. Important complications include laryngeal spasm and resultant airway obstruction and respiratory arrest, nosocomial infections, and sequelae of prolonged immobility. Tetanus is usually diagnosed on the basis of clinical signs and symptoms, but microbiological tests can serve as useful adjuncts. Treatment is multifaceted, requiring source control, antibiotic therapy, and antitoxin administration. With prolonged, quality intensive care, many patients survive with good functional outcome. However, due to challenges in leveraging routinely-collected health-care data and performing high-quality trials in resource-constrained settings, several key questions remain unanswered and optimal treatment strategies are contested. In this Review, we provide a state-of-the-art summary of global tetanus epidemiology, its clinical features and differential diagnosis, principles of management, and prognosis.

There is a paucity of data regarding initial bacterial colonization on admission to Intensive Care Units (ICUs) in low and middle-income countries (LMICs). Patients admitted to ICUs in LMICs are at high-risk of subsequent infection with antimicrobial-resistant organisms (AROs). We conducted a prospective, observational study at the Hospital for Tropical Diseases in Ho Chi Minh City, Vietnam from November 2014 to January 2016 to assess the colonization and antimicrobial susceptibility of Staphylococcus aureus, Escherichia coli, Klebsiella spp., Pseudomonas spp. and Acinetobacter spp. among adult patients within 48 hours of ICU admission. We found the admission colonization prevalence (with at least one of the identified organisms) was 93.7% (785/838) and that of AROs was 63.1% (529/838). The colonization frequency with AROs among patients admitted from the community was comparable to those transferred from other hospitals (62.2% vs 63.8%). Staphylococcus aureus was the most commonly isolated bacteria from nasal swabs (13.1%, 110/838) and the methicillin-resistant Staphylococcus aureus nasal colonization prevalence was 8.6% (72/838). We isolated Escherichia coli from rectal swabs from almost all enrolled patients (88.3%, 740/838) and 52.1% (437/838) of patients were colonized by extended spectrum β-lactamase producing Escherichia coli. Notably, Klebsiella pneumoniae was the most frequently isolated bacteria from the tracheal swabs (11.8%, 18/153). Vietnamese ICU patients have a high rate of colonization with AROs and are thus at risk of subsequent infections with these organisms if good infection control practices are not in place.

Antimicrobial use is associated with emergence of antimicrobial resistance. We report hospital antimicrobial procurement, as a surrogate for consumption in humans, expenditure and prices in public hospitals in Vietnam, a lower middle-income country with a high burden of drug resistant infections. Data on antimicrobial procurement were obtained from tender-winning bids from provincial health authorities and public hospitals with detailed bids representing 28.7% (1.68 / 5.85 billion US $) of total hospital medication spend in Vietnam. Antimicrobials were classified using the Anatomical Therapeutic Chemical (ATC) Index and the 2019 WHO Access, Watch, Reserve (AWaRe) groups. Volume was measured in number of Defined Daily Doses (DDD). Antimicrobial prices were presented per DDD. Expenditure on systemic antibacterials and antifungals accounted for 28.6% (US $482.6 million/US $1.68 billion) of the total drug bids. 83% of antibacterials (572,698,014 DDDs) by volume (accounting for 45.5% of the antibacterials spend) were domestically supplied. Overall, the most procured antibacterials by DDD were second generation cephalosporins, combinations of penicillins and beta-lactamase inhibitors, and penicillins with extended spectrum. For parenteral antibacterials this was third generation cephalosporins. The average price for antibacterials was US $15.6, US $0.86, US $0.4 and US $11.7 per DDD for Reserve, Watch, Access and non-recommended/unclassified group antibacterials, respectively. Antimicrobials accounted for a substantial proportion of the funds spent for medication in public hospitals in Vietnam. The pattern of antibacterial consumption was similar to other countries. The high prices of Reserve group and non-recommended/unclassified antibacterials suggests a need for a combination of national pricing and antimicrobial stewardship policies to ensure appropriate accessibility.

Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.

The spread of machine learning models, coupled with by the growing adoption of electronic health records (EHRs), has opened the door for developing clinical decision support systems. However, despite the great promise of machine learning for healthcare in low-middle-income countries (LMICs), many data-specific limitations, such as the small size and irregular sampling, hinder the progress in such applications. Recently, deep generative models have been proposed to generate realistic-looking synthetic data, including EHRs, by learning the underlying data distribution without compromising patient privacy. In this study, we first use a deep generative model to generate synthetic data based on a small dataset (364 patients) from a LMIC setting. Next, we use synthetic data to build models that predict the onset of hospital-acquired infections based on minimal information collected at patient ICU admission. The performance of the diagnostic model trained on the synthetic data outperformed models trained on the original and oversampled data using techniques such as SMOTE. We also experiment with varying the size of the synthetic data and observe the impact on the performance and interpretability of the models. Our results show the promise of using deep generative models in enabling healthcare data owners to develop and validate models that serve their needs and applications, despite limitations in dataset size.