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Robert Meade and colleagues highlight the need for research and solutions aimed at reducing heat at both work and home to protect the most vulnerable workers

Background Frontline clinics - primary care clinics that predominantly serve low-income and socially disadvantaged communities - are facing increasing impacts from climate-related extreme events. This study evaluated staff perspectives at frontline clinics on the health risks of climate change, the impacts of extreme events on their clinics and patients, and their motivators to improve climate resiliency. Methods A national, cross-sectional survey was conducted of staff working at frontline clinics including administrators, case workers, and providers across the United States. Survey questions assessed clinic and respondent attributes, knowledge of health risks of climate change, preferences for climate change educational and operational resources, and clinic and patient climate impacts and resilience. The survey was distributed electronically to a convenience sample of primary care clinics and to the National Association of Community Health Centers (NACHC) and National Association of Free and Charitable Clinics (NAFC) listservs. Data was collected from September to November of 2021. Respondents were current staff who consented to the survey. Responses were collected via Qualtrics, and the statistical analysis was completed using Stata. Results A total of 430 surveys were completed representing clinics in 43 states. Most (82.0%) respondents reported human activities were causing climate change. Over half (52.8%) of respondents reported an operational disruption to their clinic from extreme events in the past 3 years, and another 54.4% had plans in place to address risks from extreme events. The most useful resources identified to improve operational resilience were checklists and planning guidance. Over half (52.0%) of respondents reported they were motivated to use these resources to improve clinic preparedness. Most (84.4%) providers and case workers reported that climate change impacted patient health, however only 36.2% discussed health risks with patients, with barriers including more pressing topics and time available. Another 55.7% of respondents reported they were motivated to learn ways to help patients prepare for extreme events. Conclusions Climate-related extreme events were reported to impact patient health and disrupt frontline clinic operations. Overcoming gaps in knowledge about climate change impacts on health and providing climate educational resources can engender motivation to improve clinic and patient resilience to climate change.

The effect of improvements in surveillance and reporting on an increased incidence of Lyme borreliosis is not yet known; however, it is likely that at least some of the increase in reported numbers of cases is associated with improved diagnostics, education, and surveillance.9,10 CLIMATE SENSITIVITY OF THE VECTOR TICK AND SPIROCHETE Ixodes scapularis ticks are very susceptible to their abiotic environment and climate, as they spend most of their life cycle in the environment rather than in the host and are cold-blooded organisms.12 This likely contributes to the seasonality of Lyme disease, most cases of which occur in late spring and summer. More studies are needed to fully understand the tick-spirochete interactions in a changing climate.14 CHANGE TO ANIMAL HOSTS White-tailed deer, which are the main animal host for the adult tick species that carries Lyme disease, have expanded their range throughout Canada as a result of climatic changes and variation in the way land is used.9 Within Europe, increasing populations of deer are driving an increase in tick numbers.16 Additionally, in the United States, land use changes have resulted in the removal of chaparral vegetation in areas such as California. Additionally, reforestation and strategies aimed at increasing the quality of woodlands and forests to encourage recreation may also encourage an increase in tick populations, and exposure of humans to the animal hosts and vector.17 As city borders come closer to wilderness and urban areas expand, there is also a potential for increase in host exposure.3,18 Urban regreening may also lead to an increase in urban tick populations and resultant exposures within cities themselves.17 CLIMATE-RESILIENT SOLUTIONS TO THE SPREAD OF VECTOR-BORNE DISEASE Combating climate change through both mitigation and adaptation can reduce the climate-related impacts on health. If northern latitudes, where the vectors are currently expanding, are no longer suitable for the vectors themselves, incidence may decrease. [...]multiple adaptive measures can be taken to respond to the climate change–influenced increasing incidence and range of vector-borne disease.

With the ultimate goal of developing an accident and emergency (A&E) department HIV testing program in Belize City, Belize, we sought input from key stakeholders on program components and potential facilitators and barriers to HIV testing in emergency care. We conducted semistructured interviews among 4 key stakeholder groups at Karl Heusner Memorial Hospital Authority (KHMHA) in Belize City: (1) 20 A&E patients, (2) 5 A&E physicians, (3) 5 A&E nurses, and (4) 5 KHMHA administrators. We performed a qualitative content analysis of the interview transcripts and isolated important themes. Major themes included: (1) Patient selection: patients preferred to test all A&E patients. All other stakeholder groups preferred testing specific patient groups. (2) Training: Specific training should be completed for staff. (3) Confidentiality: integral for testing. (4) Facilitators and barriers: facilitators included respectful relationships, privacy, resources, coordination, and education. Barriers included stigmatization, patient willingness, inadequate resources, privacy, and testing biases.

Domestic cooking with biomass fuels exposes women and children to pollutants that impair health. The objective of the study was to investigate the extent of household air pollution from biomass fuels and the effectiveness of stove intervention to improve indoor air quality, exposure-related health problems, and lung function. We conducted a community-based pilot study in three rural communities in southwest Nigeria. Indoor levels of particulate matter (PM 2.5 ) and carbon monoxide (CO) were measured, and exposure-related health complaints were assessed in 59 households that used firewood exclusively for cooking. Fifty-nine mother–child pairs from these households were evaluated pre-intervention and 1 year after distribution and monitored use of low-emission stoves. Mean age (± SD; years) of mothers and children were 43.0 ± 11.7 and 13.0 ± 2.5, respectively. Median indoor PM 2.5 level was 1414.4 μg/m 3 [interquartile range (IQR) 831.2–3437.0] pre-intervention and was significantly reduced to 130.3 μg/m 3 (IQR 49.6–277.1; p  < 0.0001) post-intervention. Similarly, the median CO level was reduced from 170.3 ppm (IQR 116.3–236.2) to 14.0 ppm (IQR 7.0–21.0; p  < 0.0001). There were also significant reductions in frequency of respiratory symptoms (dry cough, chest tightness, difficult breathing, and runny nose) in mothers and children. Over 25 % of mothers and children had moderate airway obstruction on spirometry pre-intervention that did not improve 1 year after intervention period. Cooking with firewood causes household air pollution and compromised lung health. Introduction of low-emission stoves was effective at improving indoor air quality and reducing exposure-related symptoms.

To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting. This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status. Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9–12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1–19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6–4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4–6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified. The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.

Background Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting. Methods/design The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction. Discussion Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma. Trial registration ClinicalTrials.gov ( NCT02698228 ), registered on 16 February 2016.