How do field epidemiologists learn? A protocol for a qualitative inquiry into learning in field epidemiology training programmes

INTRODUCTION

COVID-19 underscored the importance of field epidemiology training programmes (FETPs) as countries struggled with overwhelming demands. Experts are calling for more field epidemiologists with better training. Since 1951, FETPs have been building public health capacities across the globe, yet explorations of learning in these programmes are lacking. This qualitative study will (1) describe approaches to training field epidemiologists in FETP; (2) describe strategies for learning field epidemiology among FETP trainees and (3) explain the principles and practices aligning training approaches with learning strategies in FETP.

METHODS AND ANALYSIS

The research design, implementation and interpretation are collaborative efforts with FETP trainers. Data collection will include interviews with FETP trainers and trainees and participant observations of FETP training and learning events in four FETP in the Western Pacific Region. Data analysis will occur in three phases: (1) we will use the constant comparison method of Charmaz's grounded theory during open coding to identify and prioritise categories and properties in the data; (2) during focused coding, we will use constant comparison and Polkinghorne's analysis of narratives, comparing stories of prioritised categories, to fill out properties of those categories and (3) we will use Polkinghorne's narrative analysis to construct narratives that reflect domains of interest, identifying correspondence among Carr and Kemmis's practices, understandings and situations to explain principles and processes of learning in FETP.

ETHICS AND DISSEMINATION

We have obtained the required ethics approvals to conduct this research at The Australian National University (2021/771) and Taiwan's Ministry of Health and Welfare (112206). Data will not be available publicly, but anonymised findings will be shared with FETP for collaborative interpretation. Ultimately, findings and interpretations will appear in peer-reviewed journals and conferences.

Shiga Toxin‒Producing Escherichia coli Diagnoses from Health Practitioners, Queensland, Australia

In Queensland, Australia, 31 of 96 Shiga toxin‒producing Escherichia coli cases during 2020-2022 were reported by a specialty pathology laboratory servicing alternative health practitioners. Those new cases were more likely to be asymptomatic or paucisymptomatic, prompting a review of the standard public health response.

Assessing the impact of chickenpox and shingles vaccination using intermittent enhanced surveillance in Queensland, Australia

INTRODUCTION

Chickenpox and shingles are vaccine preventable diseases caused by varicella-zoster virus (VZV). Chickenpox is more common in children before adolescence and shingles among ≥50 years of age. With this study we aimed to determine changes in VZV epidemiology following chickenpox and shingles vaccine introduction in Queensland.

METHODS

This case series study used notified cases of VZV infection in Queensland from January 2010 to December 2021. In Queensland, VZV notifications are received as mostly clinically unspecified cases from pathology laboratories. Intermittent enhanced surveillance was conducted using clinician follow up to determine chickenpox and shingles clinical presentation, and we then analysed these by age-group, time period, and within vaccine eligible cohorts.

RESULTS

Of the 87,759 VZV notifications received, 70 % (n = 61,298) were notified as unspecified, followed by 23 % shingles (n = 19,927), and 7 % chickenpox (n = 6,534). Over the study period, the percent change in total notifications adjusted by age and sex was estimated to be an increase of 5.7 % (95 % CI 4.9-6.4) each year. The chickenpox notifications fell sharply at 18 months of age (eligible for chickenpox vaccine) with the rate being 57 % and 36 % lower among those aged 18-23 months compared to <12 and 12-17 months of age, respectively. Assuming all cases aged 60 years and older were shingles, notification rates of shingles decreased by 12-22 % among 70-79 years old (eligible for shingles vaccination) over the years 2017-2021 after vaccine introduction in 2016.

CONCLUSION

The VZV notification rate has increased over time in Queensland. Impact of chickenpox and shingles vaccines funded under National Immunisation Program is seen with a decline in notification rates among age-specific cohorts eligible to receive the vaccines under the program. Introduction of a second childhood dose chickenpox vaccine and more effective recombinant shingles vaccine may further improve the impact of the vaccination program.

After action review of the COVID-19 surveillance system in Quang Ninh Province, Vietnam, in 2020

Surveillance is the backbone of any response to an infectious disease outbreak, and comprehensive evaluation of surveillance systems is crucial. However, structured evaluations of surveillance systems during the COVID-19 pandemic are scarce. We conducted an after action review (AAR) of the performance of the COVID-19 surveillance system in Quang Ninh Province, Vietnam, during 2020 using the COVID-19-specific AAR methodology developed by the World Health Organization in combination with guidance from the US Centers for Disease Control and Prevention (CDC). We conducted a stakeholder survey, document reviews, and key informant interviews with staff from Quang Ninh CDC's COVID-19 surveillance system. The COVID-19 surveillance system was based on the pre-existing surveillance system in the province. The system's strengths were early preparation for emergency response, strong governance and central coordination, and multidisciplinary collaboration. Stakeholders agreed that the system proved useful and adaptive to the fast-evolving COVID-19 situation but was weakened by overly complex systems, redundant administrative processes, unclear communication channels, and lack of resources. Overall, the surveillance systems in Quang Ninh province proved effective in containing COVID-19 and adaptive in a fast-changing epidemiological context. Several recommendations were made based on identified areas of concern that are of relevance for COVID-19 surveillance systems in Vietnam and similar settings.

A five-year analysis of latent tuberculosis infection in Queensland, 2016-2020

Background Australia is aiming to reach tuberculosis pre-elimination targets by 2035. As a low-incidence setting, control efforts will increasingly rely on the management of latent tuberculosis infection (LTBI). We undertook this descriptive analysis to assess the recent trends of LTBI testing in Queensland. Methods Our objective was to describe the features of LTBI testing in Queensland, and to estimate the range of possible annual notifications were it to be made a notifiable condition. We collated both state-wide and region-specific data on tuberculin skin testing (TST) and interferon gamma release assays (IGRA) conducted in Queensland during the five-year period 1 January 2016 - 31 December 2020. We used reports on Medicare-funded TST and IGRA testing in Queensland, as well as tuberculosis notification data, to understand the representativeness of our data and to derive state-wide estimates. Results We analysed 3,899 public TST, 5,463 private TST, 37,802 public pathology IGRA, and 31,656 private pathology IGRA results. The median age of people tested was 31 years; 57% of those tested were female. From our data sources, an annual average of 1,067 positive IGRA and 354 positive TST results occurred in Queensland. Building on this minimum value, we estimate possible latent tuberculosis notifications in Queensland could range from 2,901 to 6,995 per annum. Private laboratory TSTs are estimated to contribute the lowest number of potential notifications (range: 170-340), followed by private laboratory IGRA testing (range: 354-922), public laboratory IGRA testing (range: 706-1,138), and public setting TSTs (range: 1,671-4,595). Conclusion If LTBI were to be made notifiable, these estimates would place it among the ten most notified conditions in Queensland. This has implications for potential surveillance methods and goals, and their associated system and resource requirements.

Short-term outcome and complications following cutaneous reconstruction using cranial superficial epigastric axial pattern flaps in dogs: six cases (2008-2022)

OBJECTIVES

To investigate short-term outcome and complications following the use of the cranial superficial epigastric axial pattern flap to reconstruct cutaneous defects in dogs.

MATERIALS AND METHODS

Medical records from dogs undergoing reconstructive surgery between 2008 and 2022 by means of cranial superficial epigastric axial pattern flap were reviewed. Data on signalment, reason for reconstruction, defect size, flap healing, post-operative complications and need for revision surgery were collected.

RESULTS

Six dogs were included in the study. Indications for reconstruction included neoplasia (4/6), skin necrosis due to vehicular trauma (1/6) and dog bite (1/6). Postoperative complications occurred in 50% of the patients and included seroma (1/6), bruising (2/6) and necrosis of the distal portion of the flap (2/6), with two dogs developing concurrent complications. One dog required open wound management and additional surgery. Overall outcome was scored excellent in three, good in two, and fair in one dog.

CLINICAL SIGNIFICANCE

Despite the relatively high complication rate, most of the complications were deemed minor and could be managed conservatively. Eventually, all wounds healed completely and only one flap required revision surgery.

Effect of COVID-19 pandemic restrictions on chlamydia and gonorrhoea notifications and testing in Queensland, Australia: an interrupted time series analysis

OBJECTIVE

To investigate trends in testing and notifications of chlamydia and gonorrhoea during the COVID-19 pandemic in Queensland, Australia.

METHODS

Statewide disease notification and testing data between 1 January 2015 and 31 December 2021 were modelled using interrupted time series. A segmented regression model estimated the pre-pandemic trend and observed effect of the COVID-19 pandemic response on weekly chlamydia notifications, monthly gonorrhoea notifications and monthly testing figures. The intervention time point was 29 March 2020, when key COVID-19 public health restrictions were introduced.

RESULTS

There were 158 064 chlamydia and 33 404 gonorrhoea notifications and 2 107 057 combined chlamydia and gonorrhoea tests across the 72-month study period. All three studied outcomes were increasing prior to the COVID-19 pandemic. Immediate declines were observed for all studied outcomes. Directly after COVID-19 restrictions were introduced, declines were observed for all chlamydia notifications (mean decrease 48.4 notifications/week, 95% CI -77.1 to -19.6), gonorrhoea notifications among males (mean decrease 39.1 notifications/month, 95% CI -73.9 to -4.3) and combined testing (mean decrease 4262 tests/month, 95% CI -6646 to -1877). The immediate decline was more pronounced among males for both conditions. By the end of the study period, only monthly gonorrhoea notifications showed a continuing decline (mean decrease 3.3 notifications/month, p<0.001).

CONCLUSION

There is a difference between the immediate and sustained impact of the COVID-19 pandemic on reported chlamydia and gonorrhoea notifications and testing in Queensland, Australia. This prompts considerations for disease surveillance and management in future pandemics. Possible explanations for our findings are an interruption or change to healthcare services during the pandemic, reduced or changed sexual practices or changed disease transmission patterns due to international travel restrictions. As pandemic priorities shift, STIs remain an important public health priority to be addressed.

External validation of the Health Care Homes hospital admission risk stratification tool in the Aboriginal Australian population of the Northern Territory

Objective This study aimed to externally validate the Commonwealth's Health Care Homes (HCH) algorithm for Aboriginal Australians living in the Northern Territory (NT). Methods A retrospective cohort study design using linked primary health care (PHC) and hospital data was used to analyse the performance of the HCH algorithm in predicting the risk of hospitalisation for the NT study population. The study population consisted of Aboriginal Australians residing in the NT who have visited a PHC clinic at one of the 54 NT Government clinics at least once between 1 January 2013 and 31 December 2017. Predictors of hospitalisation included demographics, patient observations, medications, diagnoses, pathology results and previous hospitalisation. Results There were a total of 3256 (28.5%) emergency attendances or preventable hospitalisations during the study period. The HCH algorithm had an area under the receiver operating characteristic curve (AUC) of 0.58 for the NT remote Aboriginal population, compared with 0.66 in the Victorian cohort. A refitted model including 'previous hospitalisation' had an AUC of 0.72, demonstrating better discrimination than the HCH algorithm. Calibration was also improved in the refitted model, with an intercept of 0.00 and a slope of 1.00, compared with an intercept of 1.29 and a slope of 0.55 in the HCH algorithm. Conclusion The HCH algorithm performed poorly on the NT cohort compared with the Victorian cohort, due to differences in population demographics and burden of disease. A population-specific hospitalisation risk algorithm is required for the NT.

After action review of the COVID-19 surveillance system in Quang Ninh Province, Vietnam, in 2020

Surveillance is the backbone of any response to an infectious disease outbreak, and comprehensive evaluation of surveillance systems is crucial. However, structured evaluations of surveillance systems during the COVID-19 pandemic are scarce. We conducted a after action review (AAR) of the performance of the COVID-19 surveillance system in Quang Ninh Province, Vietnam, during 2020 using the COVID-19-specific AAR methodology developed by the World Health Organization in combination with guidance from the US Centers for Disease Control and Prevention (CDC). We conducted a stakeholder survey, document reviews, and key informant interviews with staff from Quang Ninh CDC's COVID-19 surveillance system. The COVID-19 surveillance system was based on the pre-existing surveillance system in the province. The system's strengths were early preparation for emergency response, strong governance and central coordination, and multidisciplinary collaboration. Stakeholders agreed that the system proved useful and adaptive to the fast-evolving COVID-19 situation but was weakened by overly complex systems, redundant administrative processes, unclear communication channels, and lack of resources. Overall, the surveillance systems in Quang Ninh province proved effective in containing COVID-19 and adaptive in a fast-changing epidemiological context. Several recommendations were made based on identified areas of concern that are of relevance for COVID-19 surveillance systems in Vietnam and similar settings.

Usefulness of linked data for infectious disease events: a systematic review

Surveillance is a key public health function to enable early detection of infectious disease events and inform public health action. Data linkage may improve the depth of data for response to infectious disease events. This study aimed to describe the uses of linked data for infectious disease events. A systematic review was conducted using Pubmed, CINAHL and Web of Science. Studies were included if they used data linkage for an acute infectious disease event (e.g. outbreak of disease). We summarised the event, study aims and designs; data sets; linkage methods; outcomes reported; and benefits and limitations. Fifty-four studies were included. Uses of linkage for infectious disease events included assessment of severity of disease and risk factors; improved case finding and contact tracing; and vaccine uptake, safety and effectiveness. The ability to conduct larger scale population level studies was identified as a benefit, in particular for rarer exposures, risk factors or outcomes. Limitations included timeliness, data quality and inability to collect additional variables. This review demonstrated multiple uses of data linkage for infectious disease events. As infectious disease events occur without warning, there is a need to establish pre-approved protocols and the infrastructure for data-linkage to enhance information available during an event.

Common Features of Selection Processes of Health System Performance Indicators in Primary Healthcare: A Systematic Review

BACKGROUND

Health system performance indicators are widely used to assess primary healthcare (PHC) performance. Despite the numerous tools and some convergence on indicator criteria, there is not a clear understanding of the common features of indicator selection processes. We aimed to review the literature to identify papers that document indicator selection processes for health system performance indicators in PHC.

METHODS

We searched the online databases Scopus, Medline, and CINAHL, as well as the grey literature, without time restrictions, initially on July 31, 2019 followed by an update November 13, 2020. Empirical studies or reports were included if they described the selection of health system performance indicators or frameworks, that included PHC indicators. A combination of the process focussed research question and qualitative analysis meant a quality appraisal tool or assessment of bias could not meaningfully be applied to assess individual studies. We undertook an inductive analysis based on potential indicator selection processes criteria, drawn from health system performance indicator appraisal tools reported in the literature.

RESULTS

We identified 16 503 records of which 28 were included in the review. Most studies used a descriptive case study design. We found no consistent variations between indicator selection processes of health systems of high income and low- or lower-middle income countries. Identified common features of selection processes for indicators in PHC include literature review or adaption of an existing framework as an initial step; a consensus building process with stakeholders; structuring indicators into categories; and indicator criteria focusing on validity and feasibility. The evidence around field testing with utility and consideration of reporting burden was less clear.

CONCLUSION

Our findings highlight several characteristics of health system indicator selection processes. These features provide the groundwork to better understand how to value indicator selection processes in PHC.

Undetected serovars: leptospirosis cases in the Cairns region during the 2021 wet season

Background Leptospirosis infection can lead to serious renal and cardiopulmonary complications and can be fatal. Following heavy rainfall and localised flooding in early 2021, Tropical Public Health Services in Cairns were alerted to an increase in leptospirosis cases in the region, with notifications almost three times higher than usual by mid-February. An epidemiological investigation was undertaken. Methods Leptospirosis notification data were obtained from the Queensland Notifiable Conditions System. Confirmed and probable cases residing in the Cairns region, with an onset date between 1 January and 31 May 2021, were included in the investigation. Case demographics, pathology results, symptoms, hospital stay information and presumed exposure sources were obtained from Queensland Health records; local rainfall data was obtained from the Australian Bureau of Meteorology. Case characteristics and rainfall were compared to the prior ten-year period and the distribution of cases by week of onset, address, exposure source and infecting serovar analysed. Results A total of 43 leptospirosis cases were notified between January and May 2021, the highest number recorded for the region since 2011. Presumed exposure sources were available for 40 cases (93.0%), with 33 cases (82.5%) exposed occupationally, including 25 cases working on banana farms. Infecting Leptospira serovars were identified for five cases (11.6%), with four infected with serovar Australis and one with serovar Zanoni. Limited information about the specific exposure sites for each case and a low serovar detection rate hampered the ability to confirm the presence or absence of a leptospirosis outbreak. While heavy rainfall is likely to have contributed to the spike in cases, no factors were identified as clearly associated with the increase. Conclusions A number of pathways are proposed to improve the collection of exposure site data and the identification of infecting serovars, in order to strengthen local leptospirosis surveillance and the ability to detect outbreaks in the Cairns region.

Queensland typhoid cluster linked to twelve-year carriage of Salmonella Typhi

In September 2021, a household cluster of three typhoid cases was investigated by Queensland public health authorities. Through case interviews and molecular typing, the investigation revealed chronic carriage of Salmonella Typhi persisting at least 12 years in the index case. This case report summarises the investigation and highlights the complexity of chronic pathogen carriage in the control and management of typhoid disease. Our findings raise considerations for prevention and treatment guidelines in Australia and demonstrate the beneficial role of molecular typing for complex case investigations.

Emergency Department staff experiences of screening and response for intimate partner violence in a multi-site feasibility study: Acceptability, enablers and barriers

BACKGROUND

Intimate partner violence is a lead cause of ill health and premature death among Australian women. Abused women are likely to present to Emergency Departments. Routine screening provides opportunities to identify and respond to intimate partner violence.

METHODS

A six-month screening feasibility study was conducted in two rural and one urban NSW Emergency Departments. Surveys with participating nurses, medical officers and social workers, as well as focus groups with nurses and social workers were conducted at each site to understand their experience.

RESULTS

Survey respondents (n = 198) agreed it was appropriate (87%) and acceptable (91%) to screen for intimate partner violence in Emergency Departments. Overall 62% of respondents suggested screening had positive impacts on womens' care. Focus group discussions with 39 nurses and social workers identified enablers of screening as: ease of use of the screening tool; availability of social work response within one hour (as per the study protocol); and executive support. Barriers were: high patient volume; lack of integration with existing processes; lack of privacy and brevity of training.

CONCLUSIONS

Screening in Emergency Departments was strongly supported by health practitioners who responded to the survey. Work is needed to address competing demands, integration of screening processes, and staff training.

Development of the COVID-19 Real-Time Information System for Preparedness and Epidemic Response (CRISPER), Australia

Accurate and current information has been highlighted across the globe as a critical requirement for the COVID-19 pandemic response. To address this need, many interactive dashboards providing a range of different information about COVID-19 have been developed. A similar tool in Australia containing current information about COVID-19 could assist general practitioners and public health responders in their pandemic response efforts. The COVID-19 Real-time Information System for Preparedness and Epidemic Response (CRISPER) has been developed to provide accurate and spatially explicit real-time information for COVID-19 cases, deaths, testing and contact tracing locations in Australia. Developed based on feedback from key users and stakeholders, the system comprises three main components: (1) a data engine; (2) data visualization and interactive mapping tools; and (3) an automated alert system. This system provides integrated data from multiple sources in one platform which optimizes information sharing with public health responders, primary health care practitioners and the general public.

Differential privacy for public health data: An innovative tool to optimize information sharing while protecting data confidentiality

Coronavirus disease 2019 (COVID-19) has highlighted the need for the timely collection and sharing of public health data. It is important that data sharing is balanced with protecting confidentiality. Here we discuss an innovative mechanism to protect health data, called differential privacy. Differential privacy is a mathematically rigorous definition of privacy that aims to protect against all possible adversaries. In layperson's terms, statistical noise is applied to the data so that overall patterns can be described, but data on individuals are unlikely to be extracted. One of the first use cases for health data in Australia is the development of the COVID-19 Real-Time Information System for Preparedness and Epidemic Response (CRISPER), which provides proof of concept for the use of this technology in the health sector. If successful, this will benefit future sharing of public health data.

Differential privacy is an innovative technique that can be applied to data to protect confidentiality. This has been used primarily to protect private sector data, but has significant implications for public health. We describe the methods of differential privacy in terms understandable to a non-computer-science audience. To our knowledge, this is the first article describing differential privacy in language and context appropriate for a health audience. The case study described shows the feasibility of the use of differential privacy for public health surveillance data to optimize information sharing while protecting data confidentiality. This method allows for data to be released in more granular detail in terms of time, place, and person without compromising privacy and confidentiality. Future research needs to consider other use cases, including a range of surveillance systems and applications in other types of health data.

Outcome of superficial brachial axial pattern flaps used to close skin defects in dogs: 16 cases (1996-2019)

OBJECTIVES

To report the complication rate, type of complications and outcome of the superficial brachial axial pattern flap when used for closure of skin defects in dogs.

MATERIALS AND METHODS

Medical records of dogs treated with a superficial brachial axial pattern flap for closure of a skin defect were reviewed. Information regarding signalment, reason for axial pattern flap use, skin flap size, flap healing, postoperative complications and need for revision surgery was collected.

RESULTS

Sixteen dogs were included in the study. Indications for the superficial brachial axial pattern flap included closure following tumour removal (15/16, 94%) and management of a non-healing wound on the olecranon (1/16, 6%). Postoperative complications occurred in all dogs and included partial dehiscence (7/16, 44%), partial flap necrosis (6/16. 38%), seroma formation (5/16, 31%), flap oedema (3/16, 19%) and complete flap necrosis (2/16, 13%). Eight flaps (50%) healed without open wound management or additional surgery. Five dogs required open wound management without additional surgery, and three dogs (19%) required revision surgery.

CLINICAL SIGNIFICANCE

Use of the superficial brachial axial pattern flap was associated with a high rate of complications. Most complications were managed without additional surgery and all wounds eventually healed, in some cases after prolonged open wound management.

Clinical characterisation of hypertrophic cardiomyopathy caused by MYH7 gene variants in children

Background

Variants in the cardiac Beta Myosin Heavy chain 7 gene (MYH7) are a common cause of hypertrophic cardiomyopathy (HCM) in adults, but their role in paediatric-onset HCM has not been systematically characterised. This study aims to describe the presentation, clinical characteristics and outcomes of childhood HCM secondary to disease-causing MYH7 variants.

Methods

Retrospective, longitudinal, data from 70 individuals meeting diagnostic criteria for HCM under the age of 18 years with disease-causing MYH7 variants from a single specialist centre (1991–2019) were collected. A Major Adverse Cardiac Event was defined as sudden cardiac death (SCD), heart failure-related death, cardiac transplantation, haemodynamically-compromising sustained ventricular arrhythmia or appropriate implantable cardioverter defibrillator (ICD) therapy.

Results

Median age at diagnosis was 9.2 years (IQR 4.2–13.3 years); 47 patients (67.1%) were less than 12 years and 7 (10.0%) were under the age of 1 at diagnosis. Twenty-two patients (31.4%) were probands. MYH7 variants were missense (n=67) or truncating (n=1). Reason for presentation were: family screening (n=45, 64.3%); cardiac symptoms (n=12, 17.1%); incidental finding (n=11, 15.7%); and out of hospital cardiac arrest (n=2, 2.9%). At baseline, mean maximum left ventricular wall thickness (MLVWT) z-score was 9.6 (±5.8), 11 patients (15.7%) had resting left ventricular outflow tract obstruction (left ventricular outflow tract gradient ≥30mmHg). Baseline phenotype did not significantly differ between probands and non-probands (MLVWT Z score 11.9 (±4.5) vs 8.5 (±6.1), p-value 0.0675). Over a median follow up of 3.6 years (IQR 1.8–7.9 years), 10 patients (14.3%) underwent a left ventricular septal myectomy at a median age 6.4 years (IQR 3.4–12.1 years) and 27 (38.6%) had an implantable cardioverter defibrillator (ICD) for primary (n=24, 34.3%) or secondary (n=3, 4.3%) prevention. Three patients (4.3%) died (SCD, n=1; heart-failure related, n=1; non-cardiac, n=1) and 3 (4.3%) underwent cardiac transplantation. Ten patients (14.3%) experienced a MACE. Patients who experienced a MACE were more likely to be probands [n= 6 (60.0%) vs n=16 (26.7%); p=0.036] but did not differ in terms of baseline phenotype (p=0.134).

Conclusion

MYH7 variants can cause infantile and childhood-onset disease, which is associated with significant early cardiac morbidity and mortality. Adverse outcomes were more common in those presenting as probands.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medical Research Council, Great Ormond Street Hospital charity.

Clinical features and natural history of RASopathy-associated hypertrophic cardiomyopathy in children

Background

The RASopathies are a group of genetic disorders caused by germline mutations in genes encoding components of the RAS/MAPK signalling pathway and frequently associated with hypertrophic cardiomyopathy (HCM). The clinical features and outcomes of RASopathy-related HCM are incompletely understood and most published studies are limited by relatively small numbers and incomplete clinical characterisation.

Purpose

To describe the clinical features outcomes in a large, single-centre cohort of patients with RASopathy-associated HCM diagnosed &lt;18 years.

Methods

Data from 105 patients [68 (64.8%) males] diagnosed in childhood with RASopathy-associated HCM at a single specialist centre between 1985 and 2020 were retrospectively analysed.

Results

The RASopathy diagnosis was Noonan syndrome in 69 patients (65.7%); NSML in 10 (9.5%); CFC in 6 (5.7%); Costello in 5 (4.8%) and 15 patients (14.2%) had another Noonan-like variant. 72 patients (68.6%) had a pathogenic/likely pathogenic variant in a RAS-MAPK gene, most commonly PTPN11 [n=25 (34.7%)], followed by RAF 1 [n=13 (18.1%)]. 100 patients (95.2%) were probands, 9 (8.6%) had family history of cardiomyopathy and 2 (1.9%) family history of sudden cardiac death (SCD). 52 (49.5%) had concomitant congenital heart defects (CHD) [ASD 13 (25%), VSD 6 (11.5%), PDA 1 (1.9%), &gt;1 CHD 32 (61.5%)]. 29 (27.6%) had symptoms at baseline assessment and 56 (53.3%) were on cardiac medication. The distribution of left ventricular hypertrophy (LVH) was concentric in 47 (44.7%); 32 (30.5%) had asymmetric septal hypertrophy (ASH), and undocumented in 25 patients (23.8%). 45 patients (42.9%) had biventricular hypertrophy (BVH). Resting left ventricular outflow tract obstruction (LVOTO) was present in 39 (37.1%) with haemodynamically significant LVOTO (≥50mmHg) in 23 (21.9%). Resting right ventricular outflow tract obstruction (RVOTO) was present in 21 (20%). Over a median follow up time of 6 years, 19 patients (18.1%) died [1 (5.3%) SCD; 2 (10.5%) due to Heart Failure-related death; 1 (5.3%) due to another CVS cause; 5 (26.3%) due to a non-CVS cause and for 10 (52.6%) cause of death was unknown]. Incidence rate of death was calculated at 2.7 deaths per 100 person-years. Surgical septal myectomy was performed in 9 patients (8.6%) and 3 (2.9%) underwent cardiac transplantation. 14 patients (13.3%) suffered arrhythmic events [atrial tachycardia 6 (42.9%), Non-Sustained Ventricular Tachycardia 4 (3.8%), and Ventricular Tachycardia/Ventricular Fibrillation 4 (3.8%)].

Conclusion

To our knowledge, this is the largest cohort of RASopathy-associated HCM. The findings show a heterogeneous clinical presentation with a high prevalence of morbidity and mortality. Further work is needed to determine predictors of outcome in this population.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Onassis Foundation

Clinical characteristics and natural history of pre-adolescent non-syndromic hypertrophic cardiomyopathy

Background

The clinical presentation and natural history of pre-adolescent sarcomeric hypertrophic cardiomyopathy (HCM) has not been systematically characterised. The aim of this study was to describe the clinical characteristics and outcomes of a large, international, multicentre cohort of children diagnosed with non-syndromic HCM below the age of 12.

Methods

Data from the International Paediatric Hypertrophic Cardiomyopathy Consortium on 639 children meeting diagnostic criteria for HCM below 12 years of age (pre-adolescent) were collected and compared with 568 diagnosed aged 12–16 years. Patients with syndromic and metabolic HCM were excluded.

Results

Of 639 (male n=417, 65.3%) children with pre-adolescent HCM, 339 (53.1%) had a family history of HCM and 57 (8.9%) a family history of sudden cardiac death (SCD). At the time of baseline assessment; 132 (20.7%) had heart failure symptoms and 39 (6.1%) reported unexplained syncope. Median maximal left ventricular wall thickness on echocardiogram was 13.6mm (IQR 10–19) with a corresponding median z-score of 8.7 (5.3–14.4). 145 (22.7%) had left ventricular outflow tract obstruction (LVOTO) (maximal LVOT gradient≥30mmHg) and 35 (5.5%) had severe LVOTO (gradient≥90mmHg). Over a median follow up 5.6 years (IQR 2.3–10), 10.5% underwent a myectomy and 23.2% implantable cardiac defibrillator (ICD) implantation for primary (81.8%) or secondary (14.2%) prevention. 42 (6.7%) patients died [SCD 4.9%, heart failure death 0.8%, other 1%] and 21 (3.3%) underwent cardiac transplantation. 69 (10.8%) patients had an arrhythmic event (SCD n=31, resuscitated cardiac arrest n=17, appropriate ICD therapy n=14, sustained VT with haemodynamic compromise n=7). Compared to those presenting after 12 years, those under 12 were less likely to have a family history of SCD (8.9% vs 13%, p:0.047) or report unexplained syncope (6.1% vs 12.3%, p&lt;0.00). The degree of hypertrophy did not differ but a higher proportion of pre-adolescent patients had LVOTO (22.7% vs 14.4%, p&lt;0.00). A higher proportion of pre-adolescent underwent a myectomy (10.5% vs 7.2%, p:0.045) but a lower proportion received a primary prevention ICD (18.9% vs 30.1%, p:0.041). The overall proportion of patients reaching the mortality or arrhythmic end-points did not differ, but SCD and resuscitated cardiac arrest events were more frequent in pre-adolescent patients (4.9% vs 3.9% and 2.7 vs 1.6% respectively).

Conclusion

Pre-adolescent HCM is associated with a high symptom burden and variable cardiac phenotype, comparable to those presenting later in childhood. Despite baseline similarities and equal overall survival, younger patients were less likely to receive a primary prevention ICD despite being more likely to experience a SCD or resuscitated cardiac arrest. This study suggests that younger patients should not be considered a distinct entity for risk stratification and that similar management strategies to older HCM patients should be employed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BHF (British Heart Foudnation) MRC (Medical Research Council)

External validation of the HCM Risk-Kids model for predicting sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). The newly developed HCM Risk-Kids model provides clinicians with individualised estimates of risk. The aim of this study was to externally validate the model in a large independent, multi-centre patient cohort.

Methods

A retrospective, longitudinal cohort of patients diagnosed with HCM aged 1–16 years independent of the HCM-Risk-Kids development and internal validation cohort was studied. Data on HCM Risk-Kids predictor variables (unexplained syncope, non-sustained ventricular tachycardia, maximal left ventricular wall-thickness, left atrial diameter and left ventricular outflow tract gradient) were collected from the time of baseline clinical evaluation. The performance of the HCM Risk-Kids model in predicting risk at 5 years was assessed.

Results

The cohort consisted of 421 patients with a median age at baseline evaluation of 12.3 years (IQR 7.3, 14.4). Over a median total follow up 3.48 years (IQR 1.83, 6.62, range 1 month – 20.7 years). Fourteen patients (3.3%) died and 10 (2.4%) underwent cardiac transplantation. Twenty-three patients (5.4%) met the SCD end-point within 5-years, with an overall incidence rate of 2.03 per 100 patient years (95% CI 1.48–2.78). Model validation showed a Harrell's C-index of 0.745 (95% CI 0.52–0.97) and Uno's C-index 0.714 (95% 0.58–0.85) with a calibration slope of 1.15 (95% 0.51–1.80). Figure 1a describes the agreement between predicted and observed 5-year cumulative proportion of SCD or equivalent events for each tertile of predicted risk in one imputed data set. One hundred and twenty-five (29.7%) patients had a predicted 5-year risk of ≥6%. SCD events occurred in 6 patients (2.0%) with a predicted risk &lt;6% and 17 (13.6%) with a predicted risk ≥6. A 5-year predicted risk threshold of ≥6% identified 17 (73.9%) SCD-events with a corresponding C-statistic of 0.702 (95% CI 0.60–0.81) (Figure 1b).

Conclusions

This study reports the first external validation of the HCM Risk-Kids model in a large and geographically diverse patient population. A 5-year predicted risk of ≥6% identified over 70% of events, confirming that HCM Risk-Kids provides a method for individualised risk predictions and shared decision making in children with HCM. Incorporation of the model into routine clinical care will enable independent prospective model validation and assessment of the effect of its use in clinical practice.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): British Heart FoundationMedical Research Council Observed vs predicted risk by tertilesObserved vs predicted by threshold

Superficial temporal axial pattern flap for facial reconstruction of skin defects in dogs and cats

OBJECTIVES

Report the use, complications and outcome of the superficial temporal axial pattern flap (STA) when used for closure of skin defects localised to the maxillofacial region in dogs and cats.

MATERIALS AND METHODS

Multi-centre retrospective cohort study. Medical records of dogs and cats treated with a STA flap for closure of skin defects were reviewed. Information regarding signalment, reason for axial pattern flap use, flap size, flap healing, postoperative complications including need for surgical revision and overall outcome were collected.

RESULTS

Nineteen patients were included: nine dogs and 10 cats. Indications for the STA flap included closure of defects following excision of tumours (18/19, 94.7%) and fungal granuloma resection (1/19, 5.2%). 100% flap survival occurred in 17 of 19 flaps (89.4%). Postoperative complications occurred in eight of 19 flaps (42.1%). A major complication of full thickness partial necrosis of the flap occurred in one of 19 cases (5.2%), where the flap length exceeded recommended guidelines. Minor complications related to the flap were seen in four of 19 cases (21%). This included partial thickness flap necrosis, flap oedema and wound discharge. Complications related to the location of surgery (5/19, 26.3%) included mild ectropion, mild exposure of the eye, reduced ability to blink and subcutaneous emphysema.

CLINICAL SIGNIFICANCE

The STA flap is a good option for closure of a skin defect localised to the maxillofacial region. STA flaps were associated with a high percentage of survival and a low incidence of major complications.

POS1268 COVID-19 VACCINE HESITANCY AMONG RHEUMATOLOGY PATIENTS RECEIVING INFLUENZA VACCINE

Background:

Adults with rheumatic diseases are a COVID-19 vulnerable population with potential increased risk for severe infection. COVID-19 vaccines are a key strategy to ending the pandemic. Unfortunately, fears about vaccines, some of which are propagated by misinformation, are common and may prevent or inappropriately delay vaccination. Refusal or uncertainty to get a vaccine despite its availability is known as vaccine hesitancy.

Objectives:

This study aims at defining causes of COVID-19 vaccine hesitancy among rheumatology patients.

Methods:

Between November and December 2020, a cross-sectional survey was completed by rheumatology patients presenting to a large Canadian tertiary-care center for influenza immunization. COVID-19 risk factors, previous COVID-19 infection, the likelihood of getting a future COVID-19 vaccine (scale 0-10), and contextual, individual, and vaccine-specific potential determinants of vaccine hesitancy were assessed. Patients were classified into 5 groups based on how likely they were to get a future COVID-19 vaccine (0= not likely at all; 2.5= unlikely; 5= intermediate; 7.5= likely; 10= highly likely). A machine learning approach (XgBoost) was used to fit univariate models for a multi-class correlation.

Results:

157 rheumatology patients completed the survey. Most were females (n=112, 71%) with a mean age of 54.6 (standard deviation 17.9). The majority (73%) had tertiary-education, and 46% were employed at the time of the survey. The most common rheumatology diagnoses were rheumatoid arthritis (n=90, 58%), systemic lupus erythematosus/vasculitis (n=41, 26%) and spondyloarthropathies (n=39, 25%). Most patients were on immunosuppressors (n=93, 59%). Only half (n=85, 54%) were highly likely to accept a future COVID vaccine, 17% (n=26) likely, 19% (n=30) intermediate, 6% (n=10) unlikely, and 4% (n=6) not likely at all. One hundred thirty-five patients (86%) previously received the flu vaccine, whereas 6% (n=10) previously rejected it. Only three patients were previously diagnosed with COVID-19 (2%) one of whom was hospitalized. Eighty-seven patients (56%) considered that the COVID-19 vaccine should be mandatory, and 101 (65%) that they should receive it. Most respondents were somewhat concerned about receiving a future COVID-19 vaccine (n=116, 76%) despite that 65% believed that vaccines benefits outweighed their risks. Almost all, (n=145, 96%) believed that governmental decisions about vaccines are in the best interest of the population, while less than half (n=70, 45%) were confident that pharmaceutical companies would provide safe and effective vaccines. One hundred participants (65%) denied feeling social pressure to get the vaccine, and 55% (n=81) were willing to pay for the vaccine. Feeling social pressure about getting a COVID-19 vaccine, having severe concerns about receiving a future COVID-19 vaccine, distrust in pharmaceutical companies, lower education, and doubts of whether vaccines benefits outweigh their risks, were negatively associated with COVID vaccine acceptance.

Conclusion:

Forty six percent of rheumatology patients being immunized against influenza showed at least some hesitancy towards COVID-19 vaccination. Multiple contextual, individual, and vaccine-related factors may contribute. Targeted educational strategies, including producing and communicating data on vaccine safety, may help promote vaccine uptake in this potentially vulnerable population.

Disclosure of Interests:

None declared

Effectiveness of quadrivalent influenza vaccination in the first year of a funded childhood program in Queensland, Australia, 2018

BACKGROUND

Following high influenza activity in 2017, the state of Queensland, Australia, funded a quadrivalent inactivated influenza vaccination program for children aged 6 months to <5 years in 2018. We calculated influenza vaccine effectiveness (VE) among children eligible for this program.

METHODS

A matched case-control study was conducted. Cases were identified using Queensland 2018 influenza notification data among children age-eligible for funded vaccination. Controls were drawn from Australian Immunisation Register records of Queensland resident children age-eligible for funded influenza vaccine. Up to 10 controls per case were matched for location and birthdate. First dose vaccination was valid if received ≥14 days prior to specimen collection; a second dose was valid if received ≥28 days after first dose receipt. VE was calculated for vaccine doses and adherence to national recommendations for two doses in the first season (schedule completeness) and adjusted (VE_adj) for sex and First Nations status.

RESULTS

There were 1,125 cases and 10,645 matched controls analysed. Overall VE_adj against laboratory-confirmed influenza was 51% (95% confidence interval (CI) 41-60). VE_adj was 60% (95% CI 46-70) for children who received two doses in 2018, and 60% (95% CI 48-69) for children vaccinated appropriately according to schedule completeness. VE increased with age.

CONCLUSIONS

Moderate vaccine effectiveness was observed for children eligible for the funded program in Queensland in 2018, adding to the sparse evidence for influenza vaccine use in Australian children. Adhering to the national first season two dose schedule for influenza vaccine receipt in children ensures maximum protection.

Co-expression patterns of chimeric antigen receptor (CAR)-T cell target antigens in primary and recurrent ovarian cancer

OBJECTIVE

Chimeric antigen receptor (CAR)-T cell strategies ideally target a surface antigen that is exclusively and uniformly expressed by tumors; however, no such antigen is known for high-grade serous ovarian carcinoma (HGSC). A potential solution involves combinatorial antigen targeting with AND or OR logic-gating. Therefore, we investigated co-expression of CA125, Mesothelin (MSLN) and Folate Receptor alpha (FOLRA) on individual tumor cells in HGSC.

METHODS

RNA expression of CA125, MSLN, and FOLR1 was assessed using TCGA (HGSC) and GTEx (healthy tissues) databases. Antigen expression profiles and CD3+, CD8+ and CD20+ tumor-infiltrating lymphocyte (TIL) patterns were assessed in primary and recurrent HGSC by multiplex immunofluorescence and immunohistochemistry.

RESULTS

At the transcriptional level, each antigen was overexpressed in >90% of cases; however, MSLN and FOLR1 showed substantial expression in healthy tissues. At the protein level, CA125 was expressed by the highest proportion of cases and tumor cells per case, followed by MSLN and FOLRA. The most promising pairwise combination was CA125 and/or MSLN (OR gate), with 51.9% of cases containing ≥90% of tumor cells expressing one or both antigens. In contrast, only 5.8% of cases contained ≥90% of tumor cells co-expressing CA125 and MSLN (AND gate). Antigen expression patterns showed modest correlations with TIL. Recurrent tumors retained expression of all three antigens and showed increased TIL densities.

CONCLUSIONS

An OR-gated CAR-T cell strategy against CA125 and MSLN would target the majority of tumor cells in most cases. Antigen expression and T-cell infiltration patterns are favorable for this strategy in primary and recurrent disease.

Penetrance of hypertrophic cardiomyopathy and outcome in sarcomeric mutation carriers

Background

Predictive genetic screening of the first degree relatives of patients with hypertrophic cardiomyopathy (HCM) caused by sarcomere protein (SP) gene mutations is current standard of care, but there are few data on long-term outcomes in mutation carriers without HCM.

Purpose

To establish the role of sex and genotype in HCM penetrance as well as the rate of major adverse clinical events in SP mutation carriers and following the diagnosis of HCM.

Methods

Retrospective analysis of consecutive adult and paediatric SP mutation carriers identified during family screening and who did not fulfill diagnostic criteria for HCM at first evaluation.

Results

321 individuals from 170 families [median age first evaluation 15.2 years (IQR 7.3–32.6); 153 (47.7%) males] were evaluated. Causal SP genes were: MYBPC3 (n=133 (41.4%)), MYH7 (n=77 (24.0%)), TNNI3 (n=51 (15.9%)), TNNT2 (n=40 (12.5%)), TPM1 (n=9 (2.8%)), MYL2 (n=6 (1.9%)), and ACTC1 (n=1 (0.3%)); 4 (1.3%) carried multiple mutations.

After a median follow up of 7.4 years (IQR 2.5–12.7), 89 (27.7%) patients developed HCM. Disease penetrance at the age of 50 years was 47% (95% CI 38%-56%). One hundred and fifty three (47.7%) individuals underwent cardiac magnetic resonance (CMR) imaging; among those diagnosed with HCM, 22/89 (24.7%) fulfilled criteria on CMR but not echocardiography.

In a multivariable model adjusted for genotype, follow up duration and evaluation with CMR, independent predictors of HCM development were male sex (HR 3.11; CI 1.82–5.32) and abnormal ECG (HR 7.87; CI 4.43–13.97). Patients with MYH7 and multiple mutations were more likely to develop HCM than those with MYBPC3 mutations (HR 2.03; CI 1.04–3.96 and HR 10.13; CI 1.40–72.92, respectively). Disease penetrance was lowest in carriers of TNNI3 mutations (HR 0.13; CI 0.03–0.48).

There were no major adverse events in individuals without HCM. Following the diagnosis of HCM, the combined rate of all-cause death, appropriate defibrillator shock or resuscitated cardiac arrest was 1.1%/year [median follow up 4.0 years (IQR 2.1–8.9)].

Conclusions

Approximately 50% of SP mutation carriers develop HCM by the age of 50 and become prone to disease complications during long-term follow-up. Sex, MYH7 mutations and the presence of an abnormal ECG are associated with a higher risk of disease development. CMR should be employed systematically in long-term screening.

HCM penetrance by sex

Funding Acknowledgement

Type of funding source: None

Clinical outcomes and programming strategies of implantable cardioverter defibrillator (ICD) devices during childhood in hypertrophic cardiomyopathy: a UK national cohort study

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). ICDs have been shown to be effective at terminating malignant ventricular arrhythmias but at the expense of a high incidence of complications. The optimal device and programming strategies to reduce complications in this patient group are unknown.

Purpose

To describe the programming strategies and clinical outcomes of ICD implantation in childhood HCM.

Methods

Anonymised, non-invasive clinical data were collected from a retrospective, longitudinal multi-centre cohort of children (&lt;16 years) with HCM (n=687) and an ICD in-situ from the United Kingdom.

Results

96 patients (61 male (64%), 6 non-sarcomeric (6%)) underwent ICD implantation at a median age 14yr (IQR 11–16, range 3–16) and weight 52.3 kg (IQR 34.8–63.1). Indication for ICD was primary prevention in 72 (75%). 82 (85%) had an endovascular system, 3 (3%) epicardial and 11 (12%) subcutaneous system. 61 patients (74%) were receiving one or more cardioactive medications at implantation [B blockers n=66, 70%, disopyramide n=14, 15%, amiodarone n=7, 7%, calcium channel blocker n=7, 9%, other n=5, 6%]. Programming practices varied: all had VF therapies activated (median 220bpm, IQR 212–230); 70 (73%) had a VT zone programmed (median rate 187 bpm, SD 20.9), of which 26 (27%) had therapies activated. 50 patients (61%) had antitachycardia pacing (ATP) activated. Over a median follow up of 53.6 months (IQR 27.3,108.4), 4 patients (4.2%) died following arrhythmic events despite a functioning device. 25 patients had 53 appropriate therapies (ICD shock n=47, ATP n=8), incidence rate 5.22 (95% CI 3.5–7.8). On univariable analysis, secondary prevention indication for ICD implantation was the only predictor of therapy [16 (64%) vs 8 (11.3%), p value &lt;0.001]. 8 (8.3%) patients had 9 inappropriate therapies (ICD shock n=4, ATP n=5), incidence rate 1.37 (95% CI 0.65–2.8), caused by T wave oversensing (n=2), lead migration (n=1), supraventricular tachycardia (n=1). Device complications were seen in 30 patients (31%), including lead complications (n=16) and infection (n=10). No clinical characteristics predicted time to inappropriate therapy or lead complication.

Conclusions

In a contemporary cohort of children with HCM, the incidence of inappropriate therapies is lower than previously reported, yet complication rates remain higher than reported in adult patients. No clinical, device or programming strategies were associated with inappropriate therapies or lead complications.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation

The relationship between left ventricular outflow tract gradient and sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

The most common mode of death in childhood hypertrophic cardiomyopathy (HCM) is sudden cardiac death (SCD). Left ventricular outflow tract obstruction (LVOTO) is an established risk factor for SCD in adults with the disease. In contrast, the prognostic implications of LVOTO in childhood disease is unclear, with recent studies suggesting that it may have an inverse relationship with the risk of SCD.

Purpose

The aim of this study was to explore the role of LVOTO and the risk of SCD in childhood HCM.

Methods

A multi-centre, retrospective, longitudinal cohort of 871 children (diagnosed with HCM &lt;16 years of age) was used to explore the relationship between SCD and LVOTO (LVOT gradient ≥30mmHg).

Results

189 patients (23%) had LVOTO, which was mild (30–50mmHg), moderate (50–100mmHg) or severe (&gt;100mmHg) in 58 (6.7%), 98 (11.3%) and 33 (3.8%), respectively. The risk of SCD showed an inverse relation to LVOT gradient severity compared to those with no obstruction: mild HR 1.75 (95% CI 0.89–3.44), moderate HR 1.04 (95% 0.55–1.98), and severe HR 0.7 (0.36–1.35) [figure].On univariable analysis [table] LVOTO was associated with heart failure symptoms (NYHA&gt;1) [p &lt;0.001], maximal wall thickness (MWT) [p &lt;0.001], left atrial (LA) diameter [p &lt;0.001], and future myectomy occurring during follow up [p &lt;0.001]. The inverse relationship observed was not altered by the presence or absence of other traditional risk factors.

Conclusions

LVOTO appears to have a complex relationship with the risk of SCD in childhood HCM, with multiple contributing factors. The pathophysiological mechanisms behind this observation need further exploration, which may be limited by low patient numbers

Cummulative incidence of SCD by LVOTO

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation

Factors That Influence Data Use to Improve Health Service Delivery in Low- and Middle-Income Countries

BACKGROUND

Health service delivery indicators are designed to reveal how well health services meet a community's needs. Effective use of the data can enable targeted improvements in health service delivery. We conducted a systematic review to identify the factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income settings.

METHODS

We reviewed empirical studies published in 2005 or later that provided evidence on the use of health service delivery data at the primary care level in low- and middle-income countries. We searched Scopus, Medline, the Cochrane Library, and citations of included studies. We also searched the gray literature, using a separate strategy. We extracted information on study design, setting, study population, study objective, key findings, and any identified lessons learned.

RESULTS

Twelve studies met the inclusion criteria. This small number of studies suggests there is insufficient evidence to draw reliable conclusions. However, a content analysis identified the following potentially influential factors, which we classified into 3 categories: governance (leadership, participatory monitoring, regular review of data); production of information (presentation of findings, data quality, qualitative data); and health information system resources (electronic health management information systems, organizational structure, training). Contextual factors and performance-based financing were also each found to have a role; however, discussing these as mediating factors may not be practical in terms of promoting data use.

CONCLUSION

Scant evidence exists regarding factors that influence the use of health service delivery indicators to improve delivery of primary health care services in low- and middle-income countries. However, the existing evidence highlights some factors that may have a role in improving data use. Further research may benefit from comparing data use factors across different types of program indicators or using our classification as a framework for field experiments.

The impact of perceived heat stress symptoms on work-related tasks and social factors: A cross-sectional survey of Australia's Monsoonal North

Heat poses a significant occupational hazard for labour-intensive workers in hot and humid environments. Therefore, this study measured the prevalence of heat-stress symptoms and impact of heat exposure on labour-intensive industries within the Monsoonal North region of Australia. A cohort of 179 workers completed a questionnaire evaluating environmental exposure, chronic (recurring) and/or severe (synonymous with heat stroke) symptoms of heat stress, and impact within work and home settings. Workers reported both chronic (79%) and severe (47%) heat stress symptoms, with increased likelihood of chronic symptoms when exposed to heat sources (OR 1.5-1.8, p = 0.002-0.023) and decreased likelihood of both chronic and severe symptoms when exposed to air-conditioning (Chronic: OR 0.5, p = <0.001, Severe: OR 0.7, p = 0.019). Negative impacts of heat exposure were reported for both work and home environments (30-60% respectively), highlighting the need for mitigation strategies to reduce occupational heat stress in the Monsoonal North.

Do dehydroepiandrosterone, progesterone, and testosterone influence women's depression and anxiety levels? Evidence from hair-based hormonal measures of 2105 rural Indian women

Depressive and anxiety disorders substantially contribute to the global burden of disease, particularly in poor countries. Higher prevalence rates for both disorders among women indicate sex hormones may be integrated in the pathophysiology of these disorders. The Kshetriya Gramin Financial Services study surveyed a random sample of 4160 households across 876 villages in rural Tamil Nadu, India. An interviewer-administered questionnaire was conducted to quantify depressive (K6-D) and anxiety (K6-A) symptoms. Alongside, hair samples for sex hormone profiling were collected from a subsample of 2105 women aged 18-85 years. Importantly, 5.9%, 14.8%, and 46.3% of samples contained non-detectable hormone levels for dehydroepiandrosterone, progesterone, and testosterone, respectively. Our primary analysis imputes values for the non-detectable sample and we check robustness of results when non-detectable values are dropped. In this cohort of women from rural India, higher depressive symptomatology is associated with lower levels of dehydroepiandrosterone and higher depressive and anxiety symptoms are associated with higher levels of testosterone. Progesterone shows no clear association with either depressive or anxiety symptoms. These results support a potential protective effect of higher endogenous dehydroepiandrosterone levels. An important caveat on the potential negative effect of hair testosterone levels on women's mental health is that the testosterone analysis is sensitive to how non-detectable values are treated.

227A novel risk prediction model for sudden cardiac death in childhood hypertrophic cardiomyopathy (HCM Risk-Kids)

Background

Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM) but there is no validated algorithm to identify those at highest risk. This study sought to develop and validate a SCD risk prediction model that provides individualized risk estimates.

Methods

A prognostic model was derived from an international, retrospective, multi-center longitudinal cohort study of 1024 consecutively evaluated patients aged ≤16 years. The model was developed using pre-selected predictor variables [unexplained syncope, maximal left ventricular (LV) wall thickness (MWT), left atrial diameter (LAD), LV outflow tract (LVOT) gradient and non-sustained ventricular tachycardia (NSVT)] identified from the literature and internally validated using bootstrapping.

Results

Over a median follow up of 5.3 years (IQR 2.6, 8.2, total patient years 5984), 89 (8.7%) patients died suddenly or had an equivalent event [annual event rate 1.49 (95% CI 1.15–1.92)]. The pediatric model was developed using pre-selected variables to predict the risk of SCD. The model's ability to predict risk at 5 years was validated; C-statistic was 0.69 (95% CI 0.66–0.72) and the calibration slope was 0.98 (95% CI 0.58–1.38). For every 10 ICDs implanted in patients with ≥6% 5-year SCD risk, potentially 1 patient will be saved from SCD at 5 years.

Conclusions

This new validated risk stratification model for SCD in childhood HCM provides accurate individualized estimates of risk at 5 years using readily obtained clinical risk factors.

Acknowledgement/Funding

British Heart Foundation

P3443Myotonic dystrophy type 1 in childhood: benign from a cardiac perspective?

Introduction/Purpose

Patients with myotonic dystrophy (DM1) have an increased risk of cardiac conduction disease and ventricular tachycardia associated with sudden cardiac death. Whilst this is well-established in adults, there is little published data on cardiac abnormalities in paediatric patients. To our knowledge this is the largest described cohort of children with DM1. The aim of this study is to better understand the prevalence and type of cardiac abnormalities in paediatric patients with DM1.

Methods

We retrospectively studied consecutive patients referred to our paediatric quaternary institution between 31 December 2000 and 31 January 2019. The electronic patient record was reviewed for the presence of cardiac manifestations, including clinical assessment in clinic, echocardiogram, 12 lead ECG and 24-hour ECG.

Results

60 children were identified with a diagnosis of DM1, 56 (93%) with the congenital form of the disease. The median age at diagnosis was 2.4 (IQR 1.2–24, n=52) months. 51 (85%) were under regular formal cardiac follow up. Cardiac symptoms (syncope, palpitations or chest pain) were present in 6 (10%). 12 lead ECGs were available in 50 (83%) and there was at least one echocardiogram performed in 57 (95%). There were 3 deaths (5%), 2 sudden and unexplained (aged 11 and 6.5 years old). 1 child (2%) underwent pacemaker implantation due to the presence of syncope and evidence of progressive conduction disease (Mobitz II AV block).

During the period of follow-up, 37 (62%) patients had evidence of conduction disease on 12 lead ECG or Holter: 1st degree or higher AV block (35%, n=21), trifascicular block (6.7%, n=4), intraventricular conduction delay (32%, n=19), prolonged QTc (15%, n=9) and junctional rhythm (5% n=3). In addition to abnormalities of conduction, 27 (45%) patients had axis deviation and 12 (20%) abnormal repolarisation.

Abnormalities were present in 8 (14%) of those with an echocardiogram. 2 (3.5%) had hypertrophic cardiomyopathy. Other abnormalities included bicuspid aortic valve, aortic root dilatation, dyskinetic septal motion, pericardial effusion, mitral valve thickening and perimembranous VSD.

24 (40%) patients had a signal averaged ECG of which 14 (58%) were positive in 1 or more vector. 3 (5%) patients had an exercise test with no arrhythmia or progression of conduction abnormalities. 1 patient had an invasive EP study showing a prolonged HV interval but no inducible ventricular tachycardia.

Conclusions

There appears to be a high incidence of cardiac involvement in children with DM1. Adverse events (death and pacemaker implantation) are represented in our cohort. More studies are required in order to establish how we might better identify those at risk of progression of conduction disease and ventricular arrhythmia. Regular and lifelong cardiac follow up is advisable but risk stratification and device implantation remains challenging.

Lessons for health program monitoring and evaluation in a low resource setting

Numerous guidelines outline best practices for health program monitoring and evaluation (M&E). However, health programs are often implemented in less than ideal circumstances where these best practices may not be resourced or feasible. This article describes how M&E has been conducted for a health service delivery improvement program in remote Papua New Guinea and outlines lessons learned. The lessons learned were to integrate M&E into every aspect of the program, strengthen existing health information data, link primary data collection with existing program activities, conduct regular monitoring and feedback for early identification of implementation issues, involve the program team in evaluation, and communicate M&E data through multiple mediums to stakeholders. These lessons could be applied to other health programs implemented in low resource settings.

Contextual factors and health service performance from the perspective of the provincial health administrators in Papua New Guinea

INTRODUCTION

The Rural Primary Health Services Delivery Project aims to improve the quality and coverage of health services to rural populations in Papua New Guinea. There are limitations in measuring performance of such projects through analysis of health information system data alone due to data quality issues and a multitude of unmeasured factors that affect performance. A mixed methods study was undertaken to understand the contextual factors that affect health service performance.

METHODS

A performance assessment framework was developed including service delivery indicators derived from the National Health Information System. Prior to implementation, a baseline analysis of the indicators was undertaken. Subsequently, semi-structured interviews were conducted with health administrators, in which they were asked about factors they perceived to influence health facility performance. During the interviews, key informants were provided with health indicators for their province and asked to interpret the performance of facilities. Interviews were transcribed and inductive thematic analysis performed.

RESULTS

Performance indicators varied greatly within and between districts. Key informants cited a number of reasons for this variation. Health facilities accessible by road in urban areas, with competent and/or higher level staff and health services operated by churches or private companies, were cited as contributors to high performance. For high performing districts, key informants also discussed use of health information, planning and targeted strategies to improve performance. Inadequate numbers of staff, poorly skilled staff, funding delays and challenging geography were major contributors noted for poor performance.

CONCLUSION

Analysis of quantitative indicators needs to be performed at health facility level in order to understand district level performance. Interpretation of performance through key informant interviews provided useful insight into previously undocumented contextual factors affecting health delivery performance. The sequential explanatory mixed methods design could be applied to evaluations of other health service delivery programs in similar contexts.

A Partnership Model for Improving Service Delivery in Remote Papua New Guinea: A Mixed Methods Evaluation

Background: The Community Mine Continuation Agreement Middle (CMCA) and South Fly Health Program (the Health Program) is a partnership for improving health service delivery in remote Papua New Guinea (PNG). The Health Program is delivered by a private contractor working in partnership with existing health service providers to improve service delivery using existing government systems, where possible, and aligns with national policies, plans and strategies. A midline evaluation was conducted to determine changes in health service delivery since commencement of the Health Program.

Methods: A mixed methods evaluation was undertaken mid-way through implementation of the Health Program, including a pre/post analysis of health service delivery indicators, semi-structured interviews with health workers and assessment of health facility equipment and infrastructure.

Results: Improvements in many of the long-term expected outcomes of the Health Program were observed when compared to the pre-program period. The number of outpatient visits per person per year and number of outreach clinics per 1000 children under 5 years increased by 15% and 189% respectively (P<.001). Increases in vaccination coverage for infants aged <1 year were observed: 58 % for pentavalent 1st dose (P<.001) and 75% for 1st dose Sabin (P<.001), 30% for 3rd dose pentavalent (P<.001) and 26% for measles vaccination (P<.001). Family planning coverage remained at similar levels (increasing 5%, P=.095) and antenatal care coverage increased by 26% (P<.001). Supervised deliveries coverage declined by 32% (P<.001), a continuation of the pre-Program trend. The proportion of facilities with standard equipment items, transport and lighting increased. Health worker training, in particular obstetric training, was most commonly cited by health workers as leading to improved services.

Conclusion: Following implementation, substantial improvements in health service delivery indicators were observed in the Health Program area as compared with pre-program period and the stagnating or declining national performance. This model could be considered for similar contexts where existing health service providers require external assistance to provide basic health services to the community

The impact of subsidized low aromatic fuel (LAF) on petrol (gasoline) sniffing in remote Australian indigenous communities

Background

Since 2005, the Australian Government has subsidized the production and distribution of Low Aromatic Fuel (LAF) as a deterrent against petrol (gasoline) sniffing in remote Indigenous communities. LAF is used in place of unleaded petrol as a fuel for vehicles and other engines. This paper reports findings from an independent evaluation of the LAF rollout.

Methods

Forty one Indigenous communities were surveyed between 2010 and 2014, with each community being visited twice at a two yearly interval. Quantitative data on prevalence of petrol sniffing were collected, as well as qualitative data on the acceptability of LAF, evidence of substitution for inhaled petrol with other drugs, and programs such as recreational, training and employment opportunities. Prevalence rates of sniffing per 1000 population for each survey year and community were calculated by dividing the total number of sniffers by the population aged 5–39 years and multiplying by 1000.

Results

Between 2011–12 and 2013–14, the total estimated number of people sniffing petrol declined from 289 to 204, a fall of 29.4%. At both times, the median petrol sniffing prevalence rate was lower in communities with LAF than in communities without LAF. In 17 of the 41 communities, comparable data were available over a longer period, commencing in 2005–06. Fifteen of these communities stocked LAF over the entire period. In these communities, the median rate of petrol sniffing declined by 96%, from 141.6 per 1000 population in 2005–06 to 5.5 in 2013–14 (p < 0.05). LAF was widely accepted, although acceptance was often qualified by a belief that LAF harmed engines. Anecdotal reports suggest that the fall in petrol sniffing may have been offset by increased use of cannabis and other drugs, but the relationship is not one of simple cause-and-effect, with evidence that an increase in cannabis use in communities commenced before the LAF rollout began. Provision of services in communities has improved in recent years, but many programs continue to be inadequately resourced.

Conclusions

The rollout of LAF appears to have contributed to reducing petrol sniffing and associated harms in Australian Indigenous communities.

Open-label taste-testing study to evaluate the acceptability of both strawberry-flavored and orange-flavored amylmetacresol/2,4-dichlorobenzyl alcohol throat lozenges in healthy children

Background

Acute sore throat (pharyngitis) is one of the most common illnesses for which children are seen by primary care physicians. Most cases are caused by viruses and are benign and self-limiting. Clinically proven, over-the-counter throat lozenges provide rapid and effective relief of acute sore throat symptoms, and are increasingly important in self-management of this condition.

Objective

The purpose of this study (International Standard Randomized Controlled Trial Number: ISRCTN34958871) was to evaluate the acceptability of two licensed, commercially available sore throat lozenges containing amylmetacresol and 2,4-dichlorobenzyl (AMC/DCBA)—one strawberry flavored and the other orange flavored—in healthy children.

Study design

This was an open-label, single-dose, crossover, taste-testing study in children recruited via a clinical database and advertisements over a 3.5-week period.

Setting

Potentially eligible participants were invited to attend the taste-testing session at a clinic.

Participants

At the screening session, which took place either before or on the day of taste testing, details of relevant medical history, medication, and demographics were recorded. Of the 108 screened subjects, 102 were recruited. These were healthy male and female children aged 6–12 years.

Intervention

Each child cleansed their palate with water and water biscuits before tasting a strawberry-flavored lozenge (Strepsils^® strawberry sugar free, Reckitt Benckiser Healthcare Limited, Nottingham, UK; PL 00063/0395), which was sucked for 1 minute and then expelled. The orange-flavored lozenge (Strepsils^® orange with vitamin C, Reckitt Benckiser Healthcare Limited, Nottingham, UK; PL 016242152) was tasted at least 15 minutes later following further cleansing of the palate. The spontaneous reaction of the child on tasting each lozenge was observed and recorded. Subjects were asked to indicate their liking for each lozenge, using a 7-point hedonic facial scale, and were required to answer a series of questions relating to what they liked and disliked about the taste and the feel of the lozenge in the mouth and throat. The primary endpoint was the proportion of subjects with a hedonic facial score of >4. Secondary endpoints included the spontaneous reaction of the child on tasting the lozenge and responses to questions related to taste.

Results

The taste of the lozenge was scored >4 (i.e. ‘good’, ‘really good’, or ‘super good’) by 85.3 % of subjects for the strawberry flavor and 49.0 % for the orange flavor (p < 0.0001). The mean (standard deviation) score was 5.72 (1) for the strawberry-flavored lozenge and 4.35 (2) for the orange-flavored lozenge. The proportion of subjects willing to take the lozenge again was 94 % for the strawberry flavor and 56 % for the orange flavor.

Conclusions

Strawberry-flavored AMC/DCBA lozenges were liked by, and acceptable to, the majority of the children. AMC/DCBA orange-flavored lozenges were also liked by, and acceptable to, approximately half the children. Overall, both strawberry and orange would be suitable flavors for lozenges intended for children when they suffer from sore throat.