Welcome to the fifth edition of the NIHR Global Health Research Unit on Global Surgery newsletter in which we showcase the Unit’s work in Health Economics, and celebrate the launch of CHEETAH. Please read on to find out about the great progress being made across all of the Unit’s activities.

Please continue to send us any items that you would like to be included in future editions of the newsletter. We look forward to hearing from you.


Health Economics is the study of how we make health and healthcare choices with finite resources. With constraints on finances, workforce capacity, and infrastructure, it is important to allocate these limited resources in a manner to promote their efficient use and to make sure that we get the maximum benefit. The NIHR Global Health Research Unit on Global Surgery (GSU) has embedded health economics across its project portfolio to support decision making in limited-resource settings. The Unit has two dedicated health economists (Mark Monahan & Mwayi Kachapila) to help drive the research forward.

The ongoing health economics activities within the Unit include systematic reviews, economic modelling, cost studies, and economic evaluations alongside GSU trials.

Surgical Site Infection (SSI)
SSI is a key outcome measure in the Unit’s FALCON, CHEETAH, and PENGUIN trials. To understand the current cost literature of SSI and the methodological challenges in estimating the financial burden of SSI, we did a systematic review of the costs of SSI in low- and middle- income countries1.

We were also interested in the potential scale of the financial burden of SSI across income settings. A cost of illness study, using the GlobalSurg datasets to populate the model, will quantify the cost burden of SSI in appendectomy patients.

Primary data collection on the costs associated with SSI is currently being collected as part of a dedicated FALCON substudy. The Key resource use In Wound Infection (KIWI) substudy is collecting data across three continents amongst adult FALCON patients.

One of the Unit’s health economists (Mark Monahan) is doing a staff PhD on the economics of SSI in low- and middle- income countries. The PhD will look at both the costs and quality of life information of the SSI to help support decision making in these settings.

Pneumonia is an important co-primary outcome of the PENGUIN study. Before the main trial commences, early economic modelling is underway to assess the preliminary cost-effectiveness of the trial interventions. Findings from the model will provide intuition of the main cost drivers and prioritize data collection efforts of important uncertain variables for the planned trial-based economic evaluation of PENGUIN.

The lack of the surgical workforce is a major challenge in rural settings in Ghana. Task-shifting may provide a sustainable means of addressing unmet surgical need. The TIGER trial will assess task shifting between surgeons and non-surgeon physicians in inguinal hernia repair. Quantifying the costs and benefits of increasing access to surgery will be a significant aim of the health economics analysis.

1.  Monahan M, Jowett S, Pinkney T, et al. Surgical site infection and costs in low-and middle-income countries: A systematic review of the economic burden. Plos one. 2020;15(6):e0232960.


FALCON is rapidly approaching the end of recruitment!

As at 18th August 2020 5594 patients have been recruited, therefore approximately 206 patients are needed to complete the trial. This takes into account over-recruitment in the clean-contaminated arm, which increased the total sample size required to 5800.

The DMC reviewed the data inputted to date last week and recommended that recruitment to the contaminated/dirty arm continue to target (2700).

Heartfelt thanks to the Hub and Spoke teams for responding to our call to enter data urgently; we are very grateful for all your efforts and would be delighted if you could continue to prioritise FALCON data entry in the coming months; this will help us to prepare for publication towards the end of this year, and will free up capacity to enter CHEETAH data in real-time as and when you receive the green light.


We are delighted to report the CHEETAH sprint has begun and the race is on!

Two of our Hub countries are now open and recruiting – India and Rwanda paving the way, with 13 sites between them now with that coveted `Green Light`, and almost 200 patients recruited so far. Amazing work from our Hub teams, congratulations!  We still need another 12,600 patients…so plenty of time for everyone to come on board, you are all welcome .

Now let’s talk TRAINING!!  Can we encourage those of you still to complete the online CHEETAH training modules (https://is.gd/CheetahOnlineTraining) to do so ASAP. Remember you don’t have to do all modules in one sitting and you can re-visit sections as many times as you wish. Remember to self-certify at the end of the training to indicate which modules you have completed and click ‘Submit’.  For those of you still requiring SIV training, please give the CHEETAH trials team some potential dates you are working towards and let’s get this in the diary!

Sadly, we are unable to make any on-site visits as you know,  but now we are all experts in the virtual world of ZOOM, we are sure we can make this work.

NEWSFLASH! – we have also created some very cool posters that can be used as a quick reminder about the trial for each of your CHEETAH theatres – please let the trials team know if you would like a supply of these and we will be happy to get them out to you!


CEI activity is rapidly picking up pace within the Unit’s pump-priming studies, most recently in the Abdominal TB study in India and the Burns study in South Africa.

In addition, the CEI survey set up with the NIHR was distributed amongst participating global health researchers to capture the impact of the COVID-19 pandemic on CEI activity in LMICs, highlighting barriers and solutions, and mapping best practice during the global pandemic. A focus group on this topic was also conducted with NIHR-funded global health researchers based in LMICs. The qualitative data from 31 survey participants and the outcomes of the focus group have been analysed and a report is being written to be shared with the NIHR CEI working group and steering committee. Findings will be shared widely in form of a publication, on social media platforms and potentially via webinars – highlighting this as an excellent example for shared learning


The final two awards for the NIHR GSU fellowship scheme for students in hub countries to take an online post-graduate degree were awarded to candidates in Rwanda who will begin the MSc Surgical Sciences at the University of Edinburgh in September 2020.

In July this year, fully funded by the NIHR GSU under this scheme graduated! Unfortunately, COVID19 prevented the usual celebration ceremony this year, but graduands were invited to defer until next year or to graduate in the online ceremony.

Congratulations to Dickson Bandoh, Frank Gyamfi, Emmanual Owusu (Ghana Hub), Jackson Nshimyiyera (Rwanda Hub), Juan Gouws and Gareth Chilton (South Africa Hub) on completing the Surgical Sciences programme!

Here are some of our other scholars!

Final work on the main GS3 analysis and manuscript has now re-started after a pause due to Covid19. The manuscript will be shared mid-August with the GS3 National Leads and submission for peer review will take place towards the end of the month. 

CRANE trial Cluster RAndomised trial of a Nutritional intErvention to improve outcomes after cancer surgery in low and middle income countries

A meta-analysis of pre-operative oral nutrition as part of the CRANE study is now complete. Qualitative analysis of interviews conducted during the Annual Prioritisation meeting in Ghana in 2019 is ongoing to establish a nutritional screening tool and sustainable nutritional intervention for patients undergoing cancer surgery in LMICs.

Analysis of data in the GS3 dataset demonstrates severe malnutrition occurs in >50% LMIC patients and is an independent predictor of 30-day mortality.

An observational data collection study to establish the feasibility of a nutritional intervention is now beginning. This part of the study aims to:

  1.  Determine the impact of preoperative oral nutritional supplements on short-term outcomes in patients undergoing cancer surgery.
  2. Identify and validate nutritional screening tool for patients in LMICs undergoing surgery for cancer.
  3. Establish the feasibility of a cluster randomised trial of a sustainable nutritional intervention for patients in LMICs undergoing sugery for cancer.

 The recruitment target for the study is 200 patients in India, Ghana, The Philippines and Zambia. Ethics approval for the study is now in place in India and close to completion in Ghana. Remote site initiation visits will begin soon, starting in India.

New GlobalSurg-CovidSurg Study!

The GlobalSurg and CovidSurg collaboratives are coming together for a new study in Autumn 2020.
 The aims of GlobalSurg-CovidSurg Week are:
  • To assess key global surgical indicators, including postoperative mortality.
  • To determine the optimal timing of surgery following SARS-CoV-2 infection. All patients are eligible to be included regardless of their SARS-CoV-2 status, so all hospitals can get involved even if they have not had any SARS-CoV-2 patients.
Key points about GlobalSurg-CovidSurg Week:
  • Prospective, observational cohort study, with no changes to patient management.
  • All hospitals can participate
  • All surgical specialties can participate
  • Data collection will be in 7-day blocks in October 2020.
  • All collaborators will be included as PubMed citable co-authors on resulting publications.
Please encourage all hospitals in your spoke networks to register for the study following the steps below
  1. Please register your interest on our online form.
  2. Access the study documents online at globalsurg.org/surgweek.

CovidSurg continues to go from strength to strength. Numerous publications are imminent from the CovidSurg Cohort and Cancer studies and recent publications have received extensive attention worldwide for example COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. 2020 Jul 4;396(10243):27-38:
  • Citations 84; cited in WHO guidance; Altmetric score 2,843 (#748 overall amongst 15.6 million outputs); media coverage included BBC; The Daily Telegraph; CBC; CNN Español; Medscape; New York Times; Süddeutsche Zeitung; Times of India; The Hindu.



We would love to hear from you for the next edition of the newsletter.
Please send any updates that you would like included to Tammy Dufty by 1st September.

Please feel free to forward this newsletter to others that you think might be interested.



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