Comprehensive profiling of social mixing patterns in resource poor countries: a mixed methods research protocol

Background

Low-and-middle-income countries (LMICs) bear a disproportionate burden of communicable diseases. Social interaction data inform infectious disease models and disease prevention strategies. The variations in demographics and contact patterns across ages, cultures, and locations significantly impact infectious disease dynamics and pathogen transmission. LMICs lack sufficient social interaction data for infectious disease modeling.

Methods

To address this gap, we will collect qualitative and quantitative data from eight study sites (encompassing both rural and urban settings) across Guatemala, India, Pakistan, and Mozambique. We will conduct focus group discussions and cognitive interviews to assess the feasibility and acceptability of our data collection tools at each site. Thematic and rapid analyses will help to identify key themes and categories through coding, guiding the design of quantitative data collection tools (enrollment survey, contact diaries, exit survey, and wearable proximity sensors) and the implementation of study procedures.We will create three age-specific contact matrices (physical, nonphysical, and both) at each study site using data from standardized contact diaries to characterize the patterns of social mixing. Regression analysis will be conducted to identify key drivers of contacts. We will comprehensively profile the frequency, duration, and intensity of infants' interactions with household members using high resolution data from the proximity sensors and calculating infants' proximity score (fraction of time spent by each household member in proximity with the infant, over the total infant contact time) for each household member.

Discussion

Our qualitative data yielded insights into the perceptions and acceptability of contact diaries and wearable proximity sensors for collecting social mixing data in LMICs. The quantitative data will allow a more accurate representation of human interactions that lead to the transmission of pathogens through close contact in LMICs. Our findings will provide more appropriate social mixing data for parameterizing mathematical models of LMIC populations. Our study tools could be adapted for other studies.

Changing social contact patterns among US workers during the COVID-19 pandemic: April 2020 to December 2021

Non-pharmaceutical interventions minimize social contacts, hence the spread of respiratory pathogens such as influenza and SARS-CoV-2. Globally, there is a paucity of social contact data from the workforce. In this study, we quantified two-day contact patterns among USA employees. Contacts were defined as face-to-face conversations, involving physical touch or proximity to another individual and were collected using electronic self-kept diaries. Data were collected over 4 rounds from 2020 to 2021 during the COVID-19 pandemic. Mean (standard deviation) contacts reported by 1456 participants were 2.5 (2.5), 8.2 (7.1), 9.2 (7.1) and 10.1 (9.5) across round 1 (April-June 2020), 2 (November 2020-January 2021), 3 (June-August 2021), and 4 (November-December 2021), respectively. Between round 1 and 2, we report a 3-fold increase in the mean number of contacts reported per participant with no major increases from round 2-4. We then modeled SARS-CoV-2 transmission at home, work, and community settings. The model revealed reduced relative transmission in all settings in round 1. Subsequently, transmission increased at home and in the community but remained exceptionally low in work settings. To accurately parameterize models of infection transmission and control, we need empirical social contact data that capture human mixing behavior across time.

Association between body mass index (BMI) and severity of coronary artery disease in young onset acute coronary syndrome (ACS)

Funding Acknowledgements

Type of funding sources: None.

Background

A high body mass index (BMI) is seems to be associated with an increased incidence of coronary artery disease. If the affected person is young, the consequences are more tragic. There are variable information on the relation of incidence and severity of coronary artery disease in high BMI populations. We have examined the association between BMI and severity of coronary artery disease in young onset Acute Coronary Syndrome (ACS).

Methods

In this prospective observational study a total number of 150 patients, aged ≤45 years presented with acute coronary syndrome were enrolled to analyze association between Body Mass Index (BMI) and severity of coronary artery disease.

Results

The mean BMI in male was 24.6±3.6 and the mean BMI in female was 25.4±3.3. Among the 150 patients, 2(1.3%) was underweight, 78(52%) was normal, 60(40%) was overweight & 10(6.7%) was obese. All underweighted patients were diagnosed as STEMI. Among the normal BMI patients, 18(23.1%) had UA, 12(15.4%) had NSTEMI & 48 (61.5%) had STEMI. Among the overweight patients, 23(38.3%) had UA, 9(15%) had NSTEMI & 28(46.7%) had STEMI. And among the obese patients, 4(40%) had UA, 1 (10%) had NSTEMI & 5(50%) had STEMI. Considering involving coronary artery, left main coronary artery involvement was 0(0%), 6 (7.7%), 5 (8.3%) & 0(0%) in underweight, normal, overweight & obese patients respectively. Left anterior descending coronary artery involvement was 2(100%), 54 (69%), 45 (75%) & 7 (70%) in underweight, normal, overweight & obese patients respectively. Left circumflex coronary artery involvement was 1(50%), 33 (42%), 25 (41.7%) & 1 (9%) in underweight, normal, overweight & obese patients respectively. And right coronary artery involvement was 1(50%), 35 (44.9%), 31 (51.7%) & 5 (50%) in underweight, normal, overweight & obese patients respectively. In underweight patients 1(50%) had SVD and 1 (50%) had TVD. In normal BMI patients 40 (51.3%) had SVD, 11(14.1%) had DVD and 19 (24.4%) had TVD. In overweight patients 27 (45%) had SVD, 15 (25%) had DVD and 13 (21.7%) had TVD. And in obese patients 5 (50%) had SVD, 3(30%) had DVD and 0 (0%) had TVD. In all BMI group SVD was more common.

Conclusion

There is no statistically significant differences in severity of coronary artery in respect to body mass index (BMI), in patients presented with acute coronary syndrome.

1186 IMPROVED PERFORMANCE AGAINST SSNAP PARAMETERS FOR THROMBOLYSED STROKE PATIENTS FOLLOWING CHANGES IN PRACTICE

Background

The CQC inspection of the Royal Lancaster Infirmary (RLI) in May 2021 rated the performance of the stroke department unsatisfactory, leading to a number of changes. A retrospective audit was performed to determine the impact of these changes for thrombolysed stroke patients.

Aim

This retrospective audit assessed the performance of the stroke department at the RLI against the parameters set by the ‘Sentinel Stroke National Audit Program’ (SSNAP), comparing 6-month periods before and after the CQC inspection in May 2021.

Method

Using electronic medical records and SSNAP data, we reviewed every thrombolysed stroke patient at the RLI between November 2020 until April 2021 and from May 2021 until November 2021, assessing 10 parameters and comparing the results with SSNAP targets. Since May 2021, changes to practice introduced included opening a new, larger stroke unit located directly opposite the Emergency Department, ring-fencing stroke beds, doubling the number of stroke specialists and stroke consultants reviewing all suspected stroke patients face-to-face within working hours.

Results

46 patients were thrombolysed with 42 confirmed as having had ischaemic strokes on subsequent MRI imaging. All patients were discussed with a stroke consultant before thrombolysis. Mean time from arrival to CT improved from 51 to 34.5 minutes, admission to stroke unit from 7hr53 to 4hr36 and to thrombolysis from 2hr18 to 1hr22. The number of thrombolysis complications decreased from 5 to 2. Since the changes, the SSNAP grade for stroke unit admission improved from C to A and specialist assessments from E to B.

Conclusion

The changes implemented following the May 2021 CQC inspection have had a positive impact on the care of thrombolysed stroke patients and overall SSNAP grades at RLI. Improvements are still required and the next steps include improving the efficiency of thrombolysis times and further improving SSNAP grades.

Key ethical considerations to guide the adjudication of a single-dose HPV vaccine schedule

There is a high burden of human papillomavirus (HPV) associated cancers in low- and middle-income countries (LMICs). Reducing the recommended dosing schedule from two doses to one makes the vaccine schedule logistically simpler and lowers the cost. This could make the distribution of the current vaccine supply more equitable and lead to the protection of more people. However, the clinical trials studying the efficacy of a single-dose schedule have not yet delivered final results. Against this background, the question is whether a single-dose HPV vaccine recommendation is appropriate now, and if so, what are the ethical considerations of such a recommendation? We developed three ethical recommendations: (1) adopt a holistic view of evidence to justify policy decisions; (2) prioritize the reduction in global disparities in decision-making at all levels; and (3) be transparent in the reporting of how key stakeholder interests have shaped the collection and interpretation of the evidence, and ultimate decisions. The complex discussion regarding the HPV single-dose vaccine schedule highlights the need for in-depth engagement globally to improve our understanding of country-specific contexts, and how those contexts influence decisions regarding the HPV vaccine single-dose recommendation.

Changing social contact patterns among US workers during the COVID-19 pandemic: April 2020 to December 2021

Non-pharmaceutical interventions minimize social contacts, hence the spread of SARS-CoV-2. We quantified two-day contact patterns among USA employees from 2020-2021 during the COVID-19 pandemic. Contacts were defined as face-to-face conversations, involving physical touch or proximity to another individual and were collected using electronic diaries. Mean (standard deviation) contacts reported by 1,456 participants were 2.5 (2.5), 8.2 (7.1), 9.2 (7.1) and 10.1 (9.5) across round 1 (April-June 2020), 2 (November 2020-January 2021), 3 (June-August 2021), and 4 (November-December 2021), respectively. Between round 1 and 2, we report a 3-fold increase in the mean number of contacts reported per participant with no major increases from round 2-4. We modeled SARS-CoV-2 transmission at home, work, and community. The model revealed reduced relative transmission in all settings in round 1. Subsequently, transmission increased at home and in the community but remained very low in work settings. Contact data are important to parameterize models of infection transmission and control.

Teaser

Changes in social contact patterns shape disease dynamics at workplaces in the USA.

MomsTalkShots, tailored educational app, improves vaccine attitudes: a randomized controlled trial

BACKGROUND

Many pregnant women and parents have concerns about vaccines. This analysis examined the impact of MomsTalkShots, an individually tailored educational application, on vaccine attitudes of pregnant women and mothers.

METHODS

MomsTalkShots was the patient-level component of a multi-level intervention to improve maternal and infant vaccine uptake that also included provider- and practice-level interventions. The impact of these interventions was studied using a two-by-two factorial design, randomizing at both the patient- and the practice-level. Study staff recruited pregnant women from a diverse set of prenatal care practices in Colorado and Georgia between June 2017 and July 2018. All participants (n = 2087) received a baseline survey of maternal and infant vaccine intentions and attitudes, and two follow-up surveys at least 1 month and 1 year after their infant's birth, respectively. Half of participants (n = 1041) were randomly assigned to receive educational videos through MomsTalkShots, algorithmically tailored to their vaccine intentions, attitudes, and demographics. Since the practice/provider intervention did not appear impactful, this analysis focused on MomsTalkShots regardless of the practice/provider intervention.

RESULTS

By 1 month post-birth, MomsTalkShots increased perceived risk of maternal influenza disease (61% among MomsTalkShots recipients vs 55% among controls; Odds Ratio: 1.61, 95% Confidence Interval: 1.23-2.09), confidence in influenza vaccine efficacy (73% vs 63%; OR: 1.97, 95%CI: 1.47-2.65), and perceived vaccine knowledge (55% vs 48%; OR: 1.39, 95%CI: 1.13-1.72). Among those intending not to vaccinate at baseline, MomsTalkShots increased perceived risk of maternal influenza disease (38% vs 32%; OR: 2.07, 95%CI: 1.15-3.71) and confidence in influenza vaccine efficacy (44% vs 28%; OR: 2.62, 95%CI: 1.46-4.69). By 1 year post-birth, MomsTalkShots increased perceived vaccine knowledge (62% vs 50%; OR: 1.74, 95%CI: 1.36-2.24) and trust in vaccine information from obstetricians and pediatricians (64% vs 55%; OR: 1.53, 95%CI: 1.17-2.00). Among those uncertain about vaccinating at baseline, MomsTalkShots increased perceived vaccine knowledge (47% vs 12%; OR: 6.89, 95%CI: 1.52-31.25) and reduced infant vaccine safety concerns (71% vs 91%; OR: 0.24, 95%CI: 0.06-0.98).

CONCLUSIONS

MomsTalkShots improved pregnant women's and mothers' knowledge and perceptions of maternal and infant vaccines and the diseases they prevent, and offers a scalable tool to address vaccine hesitancy.

TRIAL REGISTRATION

Registered at Clinicaltrials.gov on 13/09/2016 (registration number: NCT02898688).

Healthcare professionals' perceptions and recommendations regarding adolescent vaccinations in Georgia and Tennessee during the COVID-19 pandemic: A qualitative research

INTRODUCTION

Despite its benefits, HPV vaccine uptake has been historically lower than other recommended adolescent vaccines in the United States (US). While hesitancy and misinformation have threatened vaccinations for many years, the adverse impacts from COVID-19 pandemic on preventive services have been far-reaching.

OBJECTIVES

To explore the perceptions and experiences of adolescent healthcare providers regarding routine vaccination services during the COVID-19 pandemic.

METHODOLOGY

Between December 2020 and May 2021, in-depth qualitative interviews were conducted via Zoom video conferencing among a purposively selected, diverse group of adolescent healthcare providers (n = 16) within 5 healthcare practices in the US southeastern states of Georgia and Tennessee. Audio recordings were transcribed verbatim and analyzed using a rapid qualitative analysis framework. Our analysis was guided by the grounded theory and inductive approach.

RESULTS

Participants reported that patient-provider communications; effective use of presumptive languaging; provider's continuing education/training; periodic reminders/recall messages; provider's personal conviction on vaccine safety/efficacy; early initiation of HPV vaccination series at 9 years; community partnerships with community health navigators/vaccine champions/vaccine advocates; use of standardized forms/prewritten scripts/standard operating protocols for patient-provider interactions; and vaccine promotion through social media, brochures/posters/pamphlets as well as outreaches to schools and churches served as facilitators to adolescent HPV vaccine uptake. Preventive adolescent services were adversely impacted by the COVID-19 pandemic at all practices. Participants highlighted an initial decrease in patients due to the pandemic, while some practices avoided the distribution of vaccine informational materials due to sanitary concerns.

CONCLUSION

As part of a larger study, we provided contextual information to refine an intervention package currently being developed to improve adolescent preventive care provision in healthcare practices. Our results could inform the implementation of comprehensive intervention strategies that improve HPV vaccination rates. Additionally, lessons learned (e.g. optimizing patient- provider interactions) could be adopted to expand COVID-19 vaccine acceptance on a sizable scale.

Social contact patterns among employees in 3 U.S. companies during early phases of the COVID-19 pandemic, April to June 2020

We measured contact patterns using online diaries for 304 employees of 3 U.S. companies working remotely. The median number of daily contacts was 2 (IQR 1-4); majority were conversation (55 %), occurred at home (64 %) and lasted >4 h (38 %). These data are crucial for modeling outbreak control among the workforces.

Clinical Presentation, Management and In-Hospital Outcome of COVID-19 among Non-Healthcare Personnel and Healthcare Personnel in a Tertiary Cardiac Care Hospital

The huge numbers of non-healthcare personnel (non-HCP) who get infected by corona virus disease 2019 (COVID-19) not only paralyze health care systems but also put health care personnel (HCP) at potential risk globally. Objective of the study was to compare the Healthcare personnel (HCP) and non-HCP COVID-19 cases. This prospective observational study was carried out in National Heart Foundation Hospital and Research Institute of Bangladesh from March 08, 2020 to July 20, 2020. During this study period all admitted non-HCP who subsequently was diagnosed as COVID-19 positive by rRT-PCR and HCP of this hospital, who experienced fever or respiratory symptoms or came in close contact with COVID-19 patients at home or their workplace and become COVID-19 positive, were included. Out of 320 infected patients, 181(56.6%) patients were non-HCP and 139(43.4%) were HCP. Non-HCP were older than HCP (Mean age: 52.95±13.82 years vs. 34.08±11.11 years; p=0.001). Non-HCP were predominantly male and HCP were predominantly female (73.5% vs. 41% & 26.5% vs. 59%; p=0.001). Non-HCP had more risk factors and co-morbidities than HCP (p=0.001). Typical symptoms of COVID-19 such as fever and cough were prevalent in HCP. More aggressive treatment was required for non-HCP. Non-HCP had more severe disease and higher case fatality rate (9.4% vs. 0.7%; p=0.001) than HCP. Disease severity (OR 0.03, 95% CI 0.01-0.15) and DM (OR 0.09, 95% CI 0.01-0.94) were the independent predictor of mortality. Non-HCP was older in age, predominantly male and had more co-morbidities than HCP. Typical symptoms of COVID-19 were prevalent in HCP. Non-HCP had more severe disease and higher case fatality rate than HCP.

Antenatal care providers' attitudes and beliefs towards maternal vaccination in Kenya

Background: Maternal immunization is known to be one of the best strategies to protect both mothers and their infants from infectious diseases. Studies have shown that healthcare providers play a critical role in implementation of maternal immunization. However, little is known about providers' attitudes and beliefs towards vaccination that can influence their vaccine recommendations, specifically in low to middle income countries (LMIC). Methods: A self-administrated knowledge, attitude and behavior (KAB) survey was provided to 150 antenatal care providers across four different regions (Nairobi, Mombasa, Marsabit, and Siaya counties) of Kenya. The research staff visited the 150 clinics and hospitals and distributed a quantitative KAB survey. Results: Nearly all of the antenatal care providers (99%) recommended tetanus maternal vaccination. Similarly, 99% of the providers agreed that they would agree to provide additional vaccinations for pregnant women and reported that they always advise their patients to get vaccinated. Between 80 and 90% of the providers reported that religious beliefs, ethnicity, cultural background and political leaders do not affect their attitude or beliefs towards recommending vaccines. Conclusions: Considering the positive responses of healthcare providers towards vaccine acceptance and recommendation, these results highlight an opportunity to work in partnership with these providers to improve coverage of maternal vaccination and to introduce additional vaccines (such as influenza). In order to achieve this, logistical barriers that have affected the coverage of the currently recommended vaccines, should be addressed as part of this partnership.

Racial/Ethnic Disparities in Maternal Vaccine Knowledge, Attitudes, and Intentions

OBJECTIVES

Although disparities in maternal vaccine acceptance among racial/ethnic groups are well documented, the reasons for these disparities are unclear. The objective of this study was to describe differences in pregnant women's knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines by race/ethnicity.

METHODS

We collected survey data from 1862 pregnant women from diverse prenatal care practices in Georgia and Colorado from June 2017 through July 2018. We performed multiple logistic regressions to determine differences in intentions, knowledge, attitudes, beliefs, and trust by race/ethnicity and calculated odds ratios (ORs) and 95% CIs.

RESULTS

Compared with White women, Black and Hispanic women were less confident in vaccine safety and efficacy and less likely to perceive risk of acquiring vaccine-preventable diseases, report provaccine social norms, indicate having enough vaccine knowledge, and trust vaccine information from health care providers and public health authorities. Black women were the least confident in the safety of the maternal influenza vaccine (OR = 0.37; 95% CI, 0.27-0.49); maternal tetanus, diphtheria, and acellular pertussis vaccine (OR = 0.37; 95% CI, 0.27-0.52); and infant vaccines overall (OR = 0.40; 95% CI, 0.28-0.58), and were least likely to intend to receive both maternal vaccines (OR = 0.35; 95% CI, 0.27-0.47) or all infant vaccines on time (OR = 0.45; 95% CI, 0.34-0.61) as compared with White women.

CONCLUSIONS

Understanding differences in behavioral constructs integral to vaccine decision making among women of different races/ethnicities can lead to tailored interventions to improve vaccine acceptance.

Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru

BACKGROUND

Maternal immunization has the potential to reduce both maternal and infant morbidity and mortality by protecting women from complications during pregnancy as well as conferring protection for babies who are too young to be vaccinated. Limited evidence is available about the drivers of maternal immunization in middle-income countries such as Peru. Vaccines against tetanus, diphtheria and influenza are recommended beginning in the second trimester in Peru; however, vaccination coverage has remained low in Peru compared to other countries in the region. As additional vaccines are recommended for administration in pregnancy, a better understanding of the perceptions and attitudes of pregnant women that influence vaccination are needed to design communication materials.

METHODS

We conducted an exploratory qualitative study to understand the individual level factors influencing pregnant women's vaccine uptake. We interviewed pregnant women about their knowledge, perceptions and experiences with vaccination during pregnancy. Community health workers recruited women in a peri urban area of Peru in April 2018.

RESULTS

Twelve women were interviewed, the majority of which had received vaccination during the current pregnancy. The most common reasons for vaccination were to protect the baby and because vaccines are effective. Concerns included vaccine safety during pregnancy and adverse effects on the unborn baby. Some women mentioned that because vaccines are given later in pregnancy, the unborn baby is stronger, so vaccines will not harm them. Women highlighted that the main reason for not being vaccinated was lack of information. They also noted that they were the decision-maker in whether or not they were vaccinated. Most women said that they trusted healthcare providers and that trust was linked to providing information through open communication.

CONCLUSIONS

Overall, participants were supportive of maternal vaccination. They believed that vaccines were effective in protecting both their unborn baby and themselves. The main reason given for non-vaccination was lack of knowledge about vaccination in pregnancy. The strong desire expressed by study participants to get more information presents an opportunity for immunization programs to develop interventions that facilitate better information dissemination to pregnant women to increase vaccination uptake.

PERCEPTION OF HOARDING BEHAVIOR AMONG GENERAL POPULATION OF RAWALPINDI AND ISLAMABAD CITIES OF PAKISTAN: AN EXPLORATORY QUALITATIVE INQUIRY

Background: Hoarding is a complex phenomenon that has received extensive attention in recent years. Most studies have been conducted in Western culture with few from other regions of world, which advocates need to explore the phenomenon in different cultural contexts. Objective of this study was to ascertain the perception of hoarding behavior among general population of Rawalpindi and Islamabad cities of Pakistan.Materials Methods: This exploratory qualitative study with grounded theory design was conducted in National Institute of Psychology, Quaid-i-Azam University, Islamabad, Pakistan from September 2015-May 2016. Sample of 46 subjects from different socio-cultural backgrounds was selected from otherwise healthy adult (20-60 years) population of Rawalpindi Islamabad cities of Pakistan by purposive sampling. A qualitative research methodology was employed to develop theoretical understanding of phenomenon. Focus group discussions with six groups were conducted to assess existence and phenomenology of hoarding behavior in present cultural framework. Data was analyzed using grounded theory method.Results: Findings of this study support current literature concerning the role of emotional attachments, associated positive and negative affect, certain personality characteristics and early experiences in development and maintenance of hoarding behavior. This study also confirms that material possessions are source of security by providing sense of identity to owner, and are considered symbols of status in society. Finally, it involves the account of socio-cultural aspects like status transformation, with resulting sense of competition, gender role, impact of material deprivation, and religious construction of phenomenon that emerged as more of culture specific elements in indigenous settings of Pakistan.Conclusion: This study addresses factors that underpin major themes in relation to form and prevalence of hoarding behavior in cultural context of Pakistan and discusses the findings in reference to the similarities and differences with extant literature.

Latent Class Analysis of Maternal Vaccine Attitudes and Beliefs

Background. Maternal vaccine coverage is suboptimal, and a substantial proportion of parents have concerns about vaccines. Most parents seek out vaccine information during and immediately after their first pregnancy. No study to our knowledge has analyzed survey data to identify homogeneous groups of pregnant women based on their vaccine attitudes and beliefs. Aims. To identify homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs to facilitate audience segmentation and targeting of tailored educational interventions. Method. Between June 2017 and July 2018, we surveyed 2,196 pregnant women recruited from geographically and sociodemographically diverse prenatal care practices in Georgia and Colorado. We then performed a latent class analysis to identify homogeneity among groups of pregnant women. Results. Our latent class analysis produced three groups of pregnant women: vaccine supporters (36% of women), vaccine acceptors (41%), and vaccine skeptics (23%). Discussion. The major difference between the supporters and the acceptors were whether they mostly “strongly agreed” or just “agreed” to Likert-type scale survey items assessing their vaccine attitudes and beliefs. The skeptics most frequently chose “disagree” or “don’t know” for items assessing attitudinal constructs such as confidence in vaccine safety and efficacy and disease susceptibility. However, even skeptics often chose “agree” for items assessing constructs such as disease severity and self-efficacy. Conclusions. This article provides useful insight into the homogeneity among groups of pregnant women based on their vaccine attitudes and beliefs. This knowledge should help facilitate audience segmentation and targeting of tailored educational interventions among this population.

Patient Decision Making Related to Maternal and Childhood Vaccines: Exploring the Role of Trust in Providers Through a Relational Theory of Power Approach

Immunization is one of the most effective ways to prevent infectious diseases. However, vaccination rates are suboptimal in the United States. Obstetric providers are critical in influencing vaccine decision making among pregnant women, as trust between a patient and provider may facilitate willingness to accept vaccination. Little is known about how power between a patient and provider affects vaccine acceptance. This study explored pregnant women's trust in obstetric providers within the context of vaccines. Using concepts from the relational theory of power, we conducted 40 in-depth interviews with a purposive sample of pregnant women from four Ob-Gyn practices each in Georgia and Colorado. Results suggest that to enhance trust, providers could gain distributive power by conveying empathy. Designated power through medical experience was associated with both trust and distrust, as some women trusted their providers because of their authority and medical credentials, while others viewed authority and experience as reasons to distrust their provider. To increase acceptance, providers should acknowledge the underlying power dynamics within these interpersonal relationships and strengthen rapport with patients through empathy and dialogue.

Factors associated with referring close contacts to an app with individually-tailored vaccine information

BACKGROUND

Infants too young to be fully vaccinated are vulnerable to potentially deadly influenza and pertussis infections. The cocooning strategy limits this risk by vaccinating those likely to interact with the infant and mother during this vulnerable time, such as close friends and family members. Distribution of accurate and accessible vaccine information through existing social networks could be an important tool in increasing vaccine confidence and coverage.

METHODS

We surveyed 1095 pregnant women from diverse prenatal care practices in Georgia and Colorado. These women were surveyed through a mobile app to assess vaccine intentions, attitudes, beliefs, norms, and levels of trust, and then presented brief individually-tailored educational videos about maternal and infant vaccines and the cocooning strategy. They were then given the opportunity to refer up to six contacts to enroll in the app and receive similar vaccine education.

RESULTS

Twenty-eight percent of these women referred at least one contact, with an average of 2.67 contacts per referring woman. Most referrals (93%) were partners, parents, siblings, relatives, or close friends. Attitudinal constructs significantly associated with increased likelihood of referring contacts included: intention to receive maternal influenza vaccine, perceived safety of maternal Tdap vaccine, perceived efficacy of maternal influenza vaccine, perceived susceptibility to and severity of influenza during pregnancy, and trust in vaccine information from the Centers for Disease Control and Prevention (CDC) and academic institutions. Uncertainty about infant vaccine intentions was associated with decreased likelihood of referring contacts.

CONCLUSIONS

Pregnant women who valued vaccination and trusted vaccine information from academic institutions were more likely to refer an educational app about vaccines than those who did not. Further research is needed to determine the potential impact of this strategy on vaccine coverage when implemented on a large scale.

TRIAL REGISTRATION

The survey informing this article was part of a randomized controlled trial funded by the National Institutes of Health [clinicaltrials.gov registration number NCT02898688].

Characterizing the vaccine knowledge, attitudes, beliefs, and intentions of pregnant women in Georgia and Colorado

Vaccine coverage for maternal vaccines is suboptimal; only about half of pregnant women received influenza and Tdap vaccines in 2018. We explored knowledge, attitudes, beliefs, intentions, and trust regarding maternal and infant vaccines among pregnant women. Between June 2017 and July 2018, we surveyed 2196 pregnant women recruited from geographically and socio-demographically diverse prenatal care practices in Georgia and Colorado (56% response rate). Fifty-six percent of pregnant women intended to receive both influenza and Tdap vaccines during pregnancy and 68% intended to vaccinate their baby with all recommended vaccines on time. Attitudinal constructs associated with intention to vaccinate include confidence in vaccine safety (ORs: 16–38) and efficacy (ORs: 4–19), perceived risk of vaccine-preventable diseases (ORs: 2–6), social norms (ORs: 4–10), and trust in sources of vaccine information. Women pregnant with their first child were less likely than women who had prior children to intend to vaccinate themselves and their children, more likely to be unsure about their intentions to receive both maternal and infant vaccines, and less likely to report feeling they had enough knowledge or information about vaccines and vaccine safety (p < .01). This demonstrates an opportunity for vaccine education to increase vaccine confidence and informed decision-making, especially among first-time pregnant women.

Antenatal care providers' attitudes and beliefs towards maternal vaccination in Kenya

Background: Maternal immunization is known to be one of the best strategies to protect both mothers and their infants from infectious diseases. Studies have shown that healthcare providers play a critical role in implementation of maternal immunization. However, little is known about providers' attitudes and beliefs towards vaccination that can influence their vaccine recommendations, specifically in low to middle income countries (LMIC). Methods: A self-administrated knowledge, attitude and behavior (KAB) survey was provided to 150 antenatal care providers across four different regions (Nairobi, Mombasa, Marsabit, and Siaya counties) of Kenya. The research staff visited the 150 clinics and hospitals and distributed a quantitative KAB survey. Results: Nearly all of the antenatal care providers (99%) recommended tetanus maternal vaccination. Similarly, 99% of the providers agreed that they would agree to provide additional vaccinations for pregnant women and reported that they always advise their patients to get vaccinated. Between 80 and 90% of the providers reported that religious beliefs, ethnicity, cultural background and political leaders do not affect their attitude or beliefs towards recommending vaccines. Conclusions: Considering the positive responses of healthcare providers towards vaccine acceptance and recommendation, these results highlight an opportunity to work in partnership with these providers to improve coverage of maternal vaccination and to introduce additional vaccines (such as influenza). In order to achieve this, logistical barriers that have affected the coverage of the currently recommended vaccines, should be addressed as part of this partnership.

Intrahepatic Kinetics of lndium-111-Labelled Platelets

The intrahepatic kinetics of 111indium-labelled platelets have been studied using dynamic gamma camera scintigraphy immediately following injection. Platelets labelled in saline with mIn-oxine or 111In-acetylacetonate underwent rapidly reversible hepatic sequestration, indicating that they were “activated”. Platelets labelled in plasma with 111In-tropolonate, however, did not display this phenomenon. On the assumption that plasma-labelled platelets display a normal initial bio-distribution, mean intrahepatic platelet transit time, as a factor of the transit time of 99m-Tc labelled red cells, was 1.45 ± SE 0.12 (n = 6), implying the normal presence of a small intrahepatic platelet pool. Unlike the liver, transit through the spleen was not sensitive to the labelling medium; thus the mean intrasplenic transit time of plasma-labelled platelets was 9.3 ± SE 0.7 min (n = 10), and of saline-labelled platelets 9.5 ± SE 0.3 min (n = 8).

Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings

Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.

A randomized trial of maternal influenza immunization decision-making: A test of persuasive messaging models

OBJECTIVE

We sought to examine the effectiveness of persuasive communication interventions on influenza vaccination uptake among black/African American pregnant women in Atlanta, Georgia.

METHODS

We recruited black/African American pregnant women ages 18 to 50 y from Atlanta, GA to participate in a prospective, randomized controlled trial of influenza immunization messaging conducted from January to April 2013. Eligible participants were randomized to 3 study arms. We conducted follow-up questionnaires on influenza immunization at 30-days post-partum with all groups. Chi-square and t tests evaluated group differences, and outcome intention-to-treat assessment utilized log-binomial regression models.

RESULTS

Of the 106 enrolled, 95 women completed the study (90% retention), of which 31 were randomly assigned to affective messaging intervention ("Pregnant Pause" video), 30 to cognitive messaging intervention ("Vaccines for a Healthy Pregnancy" video), and 34 to a comparison condition (receipt of the Influenza Vaccine Information Statement). The three groups were balanced on baseline demographic characteristics and reported health behaviors. At baseline, most women (63%, n = 60) reported no receipt of seasonal influenza immunization during the previous 5 y. They expressed a low likelihood (2.1 ± 2.8 on 0-10 scale) of obtaining influenza immunization during their current pregnancy. At 30-days postpartum follow-up, influenza immunization was low among all participants (7-13%) demonstrating no effect after a single exposure to either affective messaging (RR = 1.10; 95% CI: 0.30-4.01) or cognitive messaging interventions (RR = 0.57; 95% CI: 0.11-2.88). Women cited various reasons for not obtaining maternal influenza immunizations. These included concern about vaccine harm (47%, n = 40), low perceived influenza infection risk (31%, n = 26), and a history of immunization nonreceipt (24%, n = 20).

CONCLUSION

The findings reflect the limitations associated with a single exposure to varying maternal influenza immunization message approaches on vaccine behavior. For this population, repeated influenza immunization exposures may be warranted with alterations in message format, content, and relevance for coverage improvement.

Prevalence of Vitamin D deficiency in Pakistan and implications for the future

BACKGROUND AND AIMS

vitamin D deficiency (25-hydroxyvitamin D) affects over one billion people worldwide. Vitamin D deficiency results in progression of osteoporosis as well as other conditions. Previous studies have shown high rates of vitamin D deficiency in Pakistan despite appreciable levels of sunshine. However, none have assessed vitamin D deficiency across all age groups, genders, incomes, and locations to guide future strategies.

METHODS

Questionnaire and blood sampling among 4830 randomly selected citizens.

RESULTS

High levels of deficiency among all age groups, genders, income levels, and locations. Amongst the selected citizens, 53.5% had vitamin D deficiency, 31.2% had insufficient vitamin D, and only 15.3% normal vitamin D.

CONCLUSION

High rates of vitamin D deficiency in Pakistan despite high levels of sunshine and previous Food Acts asking for food fortification with vitamin D. Public health strategies are needed to address high deficiency rates, including food fortification, i.e. nurture, alongside increasing exposure to sunlight, i.e. nature. This will involve all key stakeholder groups.

Factors Associated with Intention to Receive Influenza and Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Vaccines during Pregnancy: A Focus on Vaccine Hesitancy and Perceptions of Disease Severity and Vaccine Safety

BACKGROUND

Improving influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccine coverage among pregnant women is needed.

PURPOSE

To assess factors associated with intention to receive influenza and/or Tdap vaccinations during pregnancy with a focus on perceptions of influenza and pertussis disease severity and influenza vaccine safety.

METHODS

Participants were 325 pregnant women in Georgia recruited from December 2012 - April 2013 who had not yet received a 2012/2013 influenza vaccine or a Tdap vaccine while pregnant. Women completed a survey assessing influenza vaccination history, likelihood of receiving antenatal influenza and/or Tdap vaccines, and knowledge, attitudes and beliefs about influenza, pertussis, and their associated vaccines.

RESULTS

Seventy-three percent and 81% of women believed influenza and pertussis, respectively, would be serious during pregnancy while 87% and 92% believed influenza and pertussis, respectively, would be serious to their infants. Perception of pertussis severity for their infant was strongly associated with an intention to receive a Tdap vaccine before delivery (p=0.004). Despite perceptions of disease severity for themselves and their infants, only 34% and 44% intended to receive antenatal influenza and Tdap vaccines, respectively. Forty-six percent had low perceptions of safety regarding the influenza vaccine during pregnancy, and compared to women who perceived the influenza vaccine as safe, women who perceived the vaccine as unsafe were less likely to intend to receive antenatal influenza (48% vs. 20%; p < 0.001) or Tdap (53% vs. 33%; p < 0.001) vaccinations.

CONCLUSIONS

Results from this baseline survey suggest that while pregnant women who remain unvaccinated against influenza within the first three months of the putative influenza season may be aware of the risks influenza and pertussis pose to themselves and their infants, many remain reluctant to receive influenza and Tdap vaccines antenatally. To improve vaccine uptake in the obstetric setting, our findings support development of evidence-based vaccine promotion interventions which emphasize vaccine safety during pregnancy and mention disease severity in infancy.

Improving developmental screening among pediatricians in New Mexico: findings from the developmental screening initiative

BACKGROUND

Seven pediatric primary care practices participated in New Mexico's Developmental Screening Initiative in a year-long quality improvement project with the goal of implementing standardized developmental screening tools.

METHODS

The initiative utilized a learning collaborative approach and the Model for Improvement to promote best practice about developmental screening outlined by the American Academy of Pediatrics. Also, the project emphasized interagency collaboration to improve communication between medical providers and state and community agencies that provide services to children with developmental delays.

RESULTS

A total of 1139 medical records were reviewed by the 7 practices, at 5 intervals during the intervention. At baseline, there were dramatic differences among the practices, with some not engaged in screening at all. Overall, the use of standardized developmental screening increased from 27% at baseline to 92% at the end of the project.

SOCS3-mediated regulation of inflammatory cytokines in PTEN and p53 inactivated triple negative breast cancer model

Somatic mutations or deletions of TP53 and PTEN in ductal carcinoma in situ (DCIS) lesions have been implicated in progression to invasive ductal carcinomas. A recent molecular and mutational analysis of breast cancers revealed that inactivation of tumor suppressors, p53 and PTEN are strongly associated with triple negative breast cancer. In addition, these tumor suppressors play important roles in regulating self-renewal in normal and malignant stem cells. To investigate their role in breast carcinogenesis, we knocked down these genes in human mammary cells and in non-transformed MCF10A cells. p53 and PTEN knockdown synergized to activate pro-inflammatory IL6/Stat3/NF-κB signaling. This resulted in generation of highly metastatic EMT-like cancer stem cells (CSCs) resulting in tumors whose gene expression profile mimicked that found in basal/claudin-low molecular subtype within the triple negative breast tumors. Constitutive activation of this loop in transformed cells was dependent on proteolytic degradation of SOCS3 resulting in low levels of this protein in basal/claudin low cell lines and primary tumors. In non-transformed cells, transient activation of the IL6 inflammatory loop induced SOCS3 expression leading to pathway inactivation. In transformed cells, enforced expression of SOCS3 or interfering with IL6 pathway via IL6R blockade inhibited tumor growth and metastasis in mouse xenograft models. Furthermore, circulating tumor cells were significantly reduced in tumor bearing animals when treated with anti-IL6R antibodies. These studies uncover important connections between inflammation and carcinogenesis and suggest that blocking pro-inflammatory cytokines may be utilized as an attractive strategy to target triple negative breast tumors which currently lacks molecularly targeted therapies.

Autophagy triggered by magnolol derivative negatively regulates angiogenesis

Angiogenesis has a key role in the tumor progression and metastasis; targeting endothelial cell proliferation has emerged as a promising therapeutic strategy for the prevention of cancer. Previous studies have revealed a complex association between the process of angiogenesis and autophagy and its outcome on tumorigenesis. Autophagy, also known as type-II cell death, has been identified as an alternative way of cell killing in apoptotic-resistant cancer cells. However, its involvement in chemoresistance and tumor promotion is also well known. In this study, we used a derivate of natural product magnolol (Ery5), a potent autophagy inducer, to study the association between the autophagy and angiogenesis in both in vitro and in vivo model system. We found that the robust autophagy triggered by Ery5, inhibited angiogenesis and caused cell death independent of the apoptosis in human umbilical cord vein endothelial cells and PC-3 cells. Ery5 induced autophagy effectively inhibited cell proliferation, migration, invasion and tube formation. We further demonstrated that Ery5-mediated autophagy and subsequent inhibition of angiogenesis was reversed when autophagy was inhibited through 3-methyl adenine and knocking down of key autophagy proteins ATG7 and microtubule-associated protein light chain 3. While evaluating the negative regulation of autophagy on angiogenesis, it was interesting to find that angiogenic environment produced by the treatment of VEGF and CoCl2 remarkably downregulated the autophagy and autophagic cell death induced by Ery5. These studies, while disclosing the vital role of autophagy in the regulation of angiogenesis, also suggest that the potent modulators of autophagy can lead to the development of effective therapeutics in apoptosis-resistant cancer.

Fluoroquinolone and macrolide co-resistance in clinical isolates of Campylobacter species: a 15-year study in Karachi, Pakistan

Fluoroquinolone and macrolide antibiotics are generally considered as first-line drugs for the treatment of severe campylobacteriosis. This study was conducted to analyse the trend of erythromycin and ofloxacin resistance among Campylobacter spp. isolated from stool specimens over a period of 15 years (1992-2007) at The Aga Khan University clinical laboratory in Karachi, Pakistan. A total of 83 396 stool specimens were processed, with a 14% isolation rate for enteric pathogens. The isolation rate of Campylobacter spp. was low during 1992-93 (6%-13%), peaked in 1996 (46%), then ranged from 20% to 40%. We report a rising trend in ofloxacin resistance, re-emergence of erythromycin resistance and indications of co-resistance to both drugs in clinical isolates of Campylobacter spp.

Hyperemesis gravidarum and fetal gender: a retrospective study

This retrospective study of 9,980 women who delivered at the James Paget Hospital, Norfolk, UK, over 5 years, aimed to primarily determine whether the incidence of hyperemesis gravidarum (HG) is higher in the presence of a female fetus. The results showed that more women with HG had a female fetus compared with women without HG. Also found was that heavy ketonuria was more prevalent in women with a female fetus compared with women with a male fetus, and the mean number of admissions per woman was also higher in women with a female fetus compared with women with a male fetus. It can be concluded that women presenting with HG are more likely to have a female fetus and that women with HG and a female fetus tend to a higher level of ketonuria and an increased number of hospital admissions.

Measurement of natural radioactivity in sand samples collected along the bank of rivers Indus and Kabul in northern Pakistan

Radioactivity is a part of the natural environment. The presence of natural radioactivity in sand and other building materials results in internal and external exposure to the general public. Therefore, it is desirable to determine the concentration of naturally occurring radionuclides, namely (232)Th, (226)Ra and (40)K in sand, bricks and cement which are commonly used as building materials in Pakistan. In this context, sand samples were collected from 18 different locations covering an area of ∼1000 km(2) along the banks of river Indus (Ghazi to Jabba) and river Kabul (Nowshera to Kund) in the northern part of Pakistan, whereas bricks and cement samples were collected from local suppliers of the studied area. In order to measure the specific activities in these samples, a P-type coaxial high-purity germanium-based gamma-ray spectrometer was used. In sand samples, the average specific activities of (226)Ra, (232)Th, and (40)K were found to be 30.5±11.4, 53.2±19.5 and 531±49 Bq kg(-1), whereas in brick samples, specific activities of 30±14, 41±21 and 525±183 Bq kg(-1) were observed, respectively. In cement samples, measured specific activity values were 21±5, 14±3 and 231±30 Bq kg(-1), respectively. Radium equivalent activities were calculated and found to be 143.8±38.6, 124±49.8 and 56.69±7 Bq kg(-1) for sand, brick and cement samples, respectively. The annual mean effective dose for the studied sand samples was found to be 0.40 mSv. External and internal hazard indices were less than unity for all the studied samples. The present results have been compared with those reported in the literature.

Emotion recognition and duration of untreated first-episode psychosis among patients in Pakistan

OBJECTIVE

To investigate the impact of duration of untreated psychosis on emotion recognition in patients with first-episode psychosis.

METHODS

A sample of 60 patients with schizophrenia, schizoaffective and substance-induced psychoses were selected from psychiatric inpatients and outpatients of 3 hospitals in Lahore and 1 in Faisalabad, Pakistan. Patients were divided into short (n = 28) and long (n = 32) duration of untreated psychosis groups, according to whether they had had symptoms for < 80 or ≥ 80 weeks, respectively. Emotion recognition ability was assessed with the help of the Urdu version of a computerised experimental FEEL (Facially Expressed Emotion Labeling) test using 6 basic emotional expressions that appeared on a computer screen followed by possible responses.

RESULTS

Patients with prolonged durations of untreated psychosis showed poorer performance in recognition of facial expressions of emotion than those with short durations of untreated psychosis. This was apparent in general and especially for expressions of anger, surprise, and sadness. First-episode psychosis patients showed higher accuracy rates for recognising positive as opposed to negative emotions. The duration of untreated psychosis correlated positively with positive symptoms of psychosis. Symptom distribution differed across categories of psychosis, but there were similarities in patients with schizophrenia and schizoaffective disorders.

CONCLUSIONS

These findings support recourse to early detection and intervention strategies in psychosis and provide valuable information on how first-episode psychosis patients behave in complex emotional and social situations.

Review of drug treatment for female sexual dysfunction

Female sexual dysfunction (FSD) incorporates various sexual disorders including hypoactive sexual desire disorder, sexual arousal disorder, orgasmic and sexual pain disorders. Although many strategies have been formulated for the treatment of male sexual problems, FSD remains an area that warrants further research and trial studies to identify the most efficacious treatment options. Research has highlighted numerous pharmacological interventions that have been trialled and found to exhibit positive effects. These include hormonal therapies, prostaglandins, dopaminergic agonists, phosphodiesterase type-5 (PDE-5) inhibitors and melanocortin agonists.