SummaryBackgroundSurgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world.MethodsThis international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231.FindingsBetween Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p<0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p<0·001).InterpretationCountries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.FundingDFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant,...

BackgroundSugar sweetened beverages (SSBs) are the primary source of dietary added sugars in children, with high consumption commonly observed in more deprived areas where obesity prevalence is also highest. Associations between SSB consumption and obesity in children have been widely reported. In March 2016, a two-tier soft drinks industry levy (SDIL) on drinks manufacturers to encourage reformulation of SSBs in the UK was announced, and then implemented in April 2018. We examined trajectories in the prevalence of obesity at ages 4-5 years and 10-11 years, 19 months after the implementation of SDIL, overall and by sex and deprivation.Methods and FindingsData were from the National Child Measurement Programme and included annual repeat cross-sectional measurement of over one million children aged 4-5 and 10-11 years in state-maintained primary schools. Interrupted time series analysis of monthly obesity prevalence data from September 2013 to November 2019 was used to estimate absolute and relative changes in obesity prevalence compared to a counterfactual (adjusted for temporal variations in obesity prevalence) estimated from the trend prior to SDIL announcement. Differences between observed and counterfactual estimates were examined in November 2019 by age (4-5 or 10-11 years) and additionally by sex and deprivation quintile. In 10-11 year old children there was an overall absolute reduction in obesity prevalence (defined as >95th centile on the UK90 growth charts) of 0.8% (95%CI: 0.3, 1.3). In 10-11 year old girls the reduction was 1.6% (95%CI: 1.1, 2.1), with greatest reductions in the two most deprived quintiles (e.g. there was an absolute reduction of 2.4% (95%CI: 1.6, 3.2) in prevalence of obesity in the most deprived quintile). In 10-11 year old boys, there was no change in obesity prevalence, except in the least deprived quintile where there was a 1.6% (95%CI: 0.7,2.5) absolute increase. In 4-5 year old children, relative to the counterfactual, there were overall increases in obesity prevalence in both genders (combined) and all deprivation quintiles except the most deprived where there was no change.ConclusionsOur results suggest the SDIL was associated with decreased prevalence of obesity in 10-11 year old girls, with the greatest effects in those living in the most deprived areas. Additional strategies beyond SSB taxation will be needed to reduce obesity prevalence overall, and particularly in older boys and younger children.Trial registrationISRCTN18042742

Background The UK Soft Drinks Industry Levy (SDIL) was announced in March 2016, became law in April 2017, and was implemented in April 2018. Empirical analyses of commercial responses have not been undertaken to establish the scale, direction or nuance of industry media messaging around fiscal policies. We aimed to develop a detailed understanding of industry reactions to the SDIL in publicly available media, including whether and how these changed from announcement to implementation. Methods We searched Factiva to identify articles related to sugar, soft-drinks, and the SDIL, between 16th March 2016–5th April 2018. Articles included were UK publications written in English and reporting a quotation from an industry actor in response to the SDIL. We used a longitudinal thematic analysis of public statements by the soft-drinks industry that covered their reactions in relation to key policy milestones. Results Two hundred and ninety-eight articles were included. After the announcement in March 2016, there was strong opposition to the SDIL. After the public consultation, evolving opposition narratives were seen. After the SDIL became law, reactions reflected a shift to adapting to the SDIL. Following the publication of the final regulations, statements sought to emphasise industry opportunities and ensure the perceived profitability of the soft drinks sector. The most significant change in message (from opposition to adapting to the SDIL) occurred when the SDIL was implemented (6th April 2018). Conclusion Reactions to the SDIL changed over time. Industry modified its media responses from a position of strong opposition to one that appeared to focus on adaptation and maximising perceived profitability after the SDIL became law. This shift suggests that the forces that shape industry media responses to fiscal policies do not remain constant but evolve in response to policy characteristics and the stage of the policy process to maximise beneficial framing.

Background The UK soft drinks industry levy (SDIL) was announced in March 2016 and implemented in April 2018, encouraging manufacturers to reduce the sugar content of soft drinks. This is the first study to investigate changes in individual-level consumption of free sugars in relation to the SDIL. Methods We used controlled interrupted time series (2011-2019) to explore changes in consumption of free sugars in the whole diet and from soft drinks alone, 11 months post-SDIL implementation in a nationally representative sample of adults (>18y; n=7,999) and children (1.5-19y; n=7656) drawn from the UK National Diet and Nutrition Survey. Estimates were based on differences between observed data and a counterfactual scenario of no SDIL announcement/implementation. Models included protein consumption (control) and accounted for autocorrelation. Results Accounting for trends prior to the SDIL announcement there were absolute reductions in daily consumption of free sugars from the whole diet in children and adults of 4.8g(95%CI: 0.6g to 9.1g) and 10.9g(95%CI: 7.8g to 13.9g), respectively. Comparable reductions in free sugar consumption from drinks alone were 3.0g(95%CI: 0.1g to 5.8g) and 5.5g(95%CI: 2.7g to 8.3g). The percentage of total dietary energy from free sugars declined over the study period but was not significantly different to the counterfactual. Conclusion The SDIL led to significant reductions in dietary free sugar consumption in children and adults. Energy from free sugar as a percentage of total energy did not change relative to the counterfactual which could be due to simultaneous reductions in total energy intake associated with reductions in dietary free sugar.