1
|
Lewis M, Nash S, Lee AJ. Cost and Affordability of Habitual and Recommended Diets in Welfare-Dependent Households in Australia. Nutrients 2024; 16:659. [PMID: 38474788 PMCID: PMC10935407 DOI: 10.3390/nu16050659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
It is crucial to ensure healthy diets are affordable in low socioeconomic groups, such as welfare-dependent households, who experience higher rates of diet-related disease than others. This study assessed the cost of habitual (unhealthy) and recommended (healthy) diets in six welfare-dependent and six other, comparable Australian households, using either popular branded products or the cheapest available alternatives. It also assessed diet affordability in welfare-dependent households, before and after modest increases in government welfare payments introduced in early September 2023. Results confirmed that recommended diets were less expensive than habitual diets in all households unless the cheapest available products were included. This strategy reduced habitual diet costs by 35-37% and recommended diet costs by 30-32%. The lower cost differential could aid perceptions that healthy foods are more expensive than unhealthy foods. In April 2023, 23-37% of the income of welfare-dependent households with children was required to purchase recommended diets; this reduced only to 20-35% in September 2023. Hence, the increases in welfare payments were insufficient to meaningfully improve the affordability of healthy diets in the most vulnerable Australians. In the current cost-of-living crisis, there is an urgent need for more welfare support to help purchase healthy diets. Monitoring of diet cost and affordability is also required.
Collapse
Affiliation(s)
- Meron Lewis
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston, QLD 4006, Australia; (S.N.); (A.J.L.)
| | | | | |
Collapse
|
2
|
Uddin MG, Nash S, Rahman A, Dabrowski T, Olbert AI. Data-driven modelling for assessing trophic status in marine ecosystems using machine learning approaches. Environ Res 2024; 242:117755. [PMID: 38008200 DOI: 10.1016/j.envres.2023.117755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/05/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
Assessing eutrophication in coastal and transitional waters is of utmost importance, yet existing Trophic Status Index (TSI) models face challenges like multicollinearity, data redundancy, inappropriate aggregation methods, and complex classification schemes. To tackle these issues, we developed a novel tool that harnesses machine learning (ML) and artificial intelligence (AI), enhancing the reliability and accuracy of trophic status assessments. Our research introduces an improved data-driven methodology specifically tailored for transitional and coastal (TrC) waters, with a focus on Cork Harbour, Ireland, as a case study. Our innovative approach, named the Assessment Trophic Status Index (ATSI) model, comprises three main components: the selection of pertinent water quality indicators, the computation of ATSI scores, and the implementation of a new classification scheme. To optimize input data and minimize redundancy, we employed ML techniques, including advanced deep learning methods. Specifically, we developed a CHL prediction model utilizing ten algorithms, among which XGBoost demonstrated exceptional performance, showcasing minimal errors during both training (RMSE = 0.0, MSE = 0.0, MAE = 0.01) and testing (RMSE = 0.0, MSE = 0.0, MAE = 0.01) phases. Utilizing a novel linear rescaling interpolation function, we calculated ATSI scores and evaluated the model's sensitivity and efficiency across diverse application domains, employing metrics such as R2, the Nash-Sutcliffe efficiency (NSE), and the model efficiency factor (MEF). The results consistently revealed heightened sensitivity and efficiency across all application domains. Additionally, we introduced a brand new classification scheme for ranking the trophic status of transitional and coastal waters. To assess spatial sensitivity, we applied the ATSI model to four distinct waterbodies in Ireland, comparing trophic assessment outcomes with the Assessment of Trophic Status of Estuaries and Bays in Ireland (ATSEBI) System. Remarkably, significant disparities between the ATSI and ATSEBI System were evident in all domains, except for Mulroy Bay. Overall, our research significantly enhances the accuracy of trophic status assessments in marine ecosystems. The ATSI model, combined with cutting-edge ML techniques and our new classification scheme, represents a promising avenue for evaluating and monitoring trophic conditions in TrC waters. The study also demonstrated the effectiveness of ATSI in assessing trophic status across various waterbodies, including lakes, rivers, and more. These findings make substantial contributions to the field of marine ecosystem management and conservation.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland.
| | - Stephen Nash
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | | | - Agnieszka I Olbert
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland
| |
Collapse
|
3
|
Lee SE, Amin N, Mannent LP, Bachert C, Gross G, Cho SH, Praestgaard A, Siddiqui S, Nash S, Kamat S, Khan AH, Jacob Nara JA. The relationship of sinus opacification, olfaction and dupilumab efficacy in patients with CRSwNP. Rhinology 2023; 61:531-540. [PMID: 37453138 DOI: 10.4193/rhin22.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Loss of sense of smell is one of the most burdensome symptoms of chronic rhinosinusitis with nasal polyps (CRSwNP) but its relationship to sinus disease on imaging is unclear. Dupilumab improves sense of smell and radiographic severity of sinus disease in patients with CRSwNP. We investigated the relationship of sinus opacification severity and loci to olfactory impairment and dupilumab efficacy in patients with CRSwNP from the SINUS-24/SINUS-52 (NCT02912468/NCT02898454) studies. METHODS Sinus opacification was evaluated using the Lund-Mackay computed tomography (LMK-CT) score and sense of smell using patient-reported loss of smell (LoS) score, University of Pennsylvania Smell Identification Test (UPSIT) score and the 22-item Sino-Nasal Outcome Test (SNOT-22) smell/taste item. RESULTS At baseline, 95% of patients (688/724) had impaired sense of smell and opacification was extensive across all sinuses. Greater olfactory impairment was associated with greater opacification, especially in the ethmoid, sphenoid and frontal sinuses. At Week 24, reductions in LMK-CT total score and ethmoid and sphenoid sinus scores with dupilumab were weakly correlated with improvements in sense of smell assessed by LoS, UPSIT and SNOT-22 smell/taste item. More dupilumab than placebo patients achieved clinically meaningful improvement in LMK-CT total score at Week 24 and Week 52. CONCLUSION Radiographic disease severity on imaging was associated with smell outcomes in this cohort. Opacification of the ethmoid, sphenoid and frontal sinuses was associated with severe smell loss. These data suggest that dupilumab effects on smell may be partly mediated through reduced sinus inflammation.
Collapse
Affiliation(s)
- S E Lee
- Division of Otolaryngology - Head and Neck Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - N Amin
- Clinical Sciences Global Development, Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - L P Mannent
- Global Clinical Development, Sanofi, Chilly-Mazarin, France
| | - C Bachert
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Münster, Münster, Germany, and International Airway Research Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China, and Upper Airways Research Laboratory and Department of Otorhinolaryngology, Ghent University, Ghent, Belgium
| | - G Gross
- Department of Internal Medicine, University of Texas Southwestern Medical School, Dallas, TX, USA
| | - S H Cho
- Division of Allergy-Immunology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - A Praestgaard
- Department of Biostatistics, Sanofi, Cambridge, MA, USA
| | - S Siddiqui
- Medical Affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - S Nash
- Medical Affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - S Kamat
- Medical Affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - A H Khan
- Global Medical Affairs, Sanofi, Chilly-Mazarin, France
| | | |
Collapse
|
4
|
Hogan CA, Miller S, Piantadosi A, Gaston DC, Simner PJ, Nash S, Babady NE. Which trial do we need? Plasma metagenomic next-generation sequencing to diagnose infections in patients with haematological malignancies and febrile neutropenia: proposal for a randomized-controlled trial. Clin Microbiol Infect 2023; 29:1474-1479. [PMID: 37244468 DOI: 10.1016/j.cmi.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Catherine A Hogan
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada; Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steve Miller
- Delve Bio, San Francisco, CA, USA; Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Anne Piantadosi
- Emory University Department of Medicine, Division of Infectious Diseases, Atlanta, GA, USA; Emory University Department of Pathology and Laboratory Medicine, Atlanta, GA, USA
| | - David C Gaston
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Patricia J Simner
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen Nash
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Solna, Sweden
| | - N Esther Babady
- Department of Pathology and Laboratory Medicine, Clinical Microbiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
5
|
Uddin MG, Jackson A, Nash S, Rahman A, Olbert AI. Comparison between the WFD approaches and newly developed water quality model for monitoring transitional and coastal water quality in Northern Ireland. Sci Total Environ 2023; 901:165960. [PMID: 37541496 DOI: 10.1016/j.scitotenv.2023.165960] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/04/2023] [Accepted: 07/30/2023] [Indexed: 08/06/2023]
Abstract
This study aims to evaluate existing approaches for monitoring and assessing water quality in waterbodies in the North of Ireland using newly developed methodologies. The results reveal significant differences between the new technique and the existing "one-out, all-out" approach in rating water quality. The new approach found the water quality status to be "good," "fair," and "marginal," whereas the existing "one-out, all-out" technique classified water quality as "good," and "moderate," respectively. The new technique outperformed existing approaches in rating the water quality of different waterbody types, with high R2 = 1, NSE = 0.99, and MEF = 0 values. Furthermore, the final assessment of water quality using the new methodologies had the lowest uncertainty (<1 %), whereas the efficiency measures (NSE and MEF) indicate that the new approaches are bias-free to assess water quality at any geographic scale. The results of this study reveal that the newly proposed methodologies are effective in assessing the water quality states of transitional and coastal waterbodies in the North of Ireland. The study also highlighted the limitations of existing approaches and the importance of updating water resource management systems for better protection of these waterbodies. The findings have significant implications for water resource management and planning in the North of Ireland and other similar regions.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland.
| | - Aoife Jackson
- College of Science and Engineering, Natural Sciences, University of Galway, Ireland
| | - Stephen Nash
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Agnieszka I Olbert
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland
| |
Collapse
|
6
|
Uddin MG, Diganta MTM, Sajib AM, Rahman A, Nash S, Dabrowski T, Ahmadian R, Hartnett M, Olbert AI. Assessing the impact of COVID-19 lockdown on surface water quality in Ireland using advanced Irish water quality index (IEWQI) model. Environ Pollut 2023; 336:122456. [PMID: 37673321 DOI: 10.1016/j.envpol.2023.122456] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/23/2023] [Accepted: 08/23/2023] [Indexed: 09/08/2023]
Abstract
The COVID-19 pandemic has significantly impacted various aspects of life, including environmental conditions. Surface water quality (WQ) is one area affected by lockdowns imposed to control the virus's spread. Numerous recent studies have revealed the considerable impact of COVID-19 lockdowns on surface WQ. In response, this research aimed to assess the impact of COVID-19 lockdowns on surface water quality in Ireland using an advanced WQ model. To achieve this goal, six years of water quality monitoring data from 2017 to 2022 were collected for nine water quality indicators in Cork Harbour, Ireland, before, during, and after the lockdowns. These indicators include pH, water temperature (TEMP), salinity (SAL), biological oxygen demand (BOD5), dissolved oxygen (DOX), transparency (TRAN), and three nutrient enrichment indicators-dissolved inorganic nitrogen (DIN), molybdate reactive phosphorus (MRP), and total oxidized nitrogen (TON). The results showed that the lockdown had a significant impact on various WQ indicators, particularly pH, TEMP, TON, and BOD5. Over the study period, most indicators were within the permissible limit except for MRP, with the exception of during COVID-19. During the pandemic, TON and DIN decreased, while water transparency significantly improved. In contrast, after COVID-19, WQ at 7% of monitoring sites significantly deteriorated. Overall, WQ in Cork Harbour was categorized as "good," "fair," and "marginal" classes over the study period. Compared to temporal variation, WQ improved at 17% of monitoring sites during the lockdown period in Cork Harbour. However, no significant trend in WQ was observed. Furthermore, the study analyzed the advanced model's performance in assessing the impact of COVID-19 on WQ. The results indicate that the advanced WQ model could be an effective tool for monitoring and evaluating lockdowns' impact on surface water quality. The model can provide valuable information for decision-making and planning to protect aquatic ecosystems.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland.
| | - Mir Talas Mahammad Diganta
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland
| | - Abdul Majed Sajib
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Stephen Nash
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | | | - Reza Ahmadian
- School of Engineering, Cardiff University, The Parade, Cardiff, CF24 3AQ, UK
| | - Michael Hartnett
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland
| | - Agnieszka I Olbert
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco-HydroInformatics Research Group (EHIRG), Civil Engineering, University of Galway, Ireland
| |
Collapse
|
7
|
Uddin MG, Rahman A, Nash S, Diganta MTM, Sajib AM, Moniruzzaman M, Olbert AI. Marine waters assessment using improved water quality model incorporating machine learning approaches. J Environ Manage 2023; 344:118368. [PMID: 37364491 DOI: 10.1016/j.jenvman.2023.118368] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 05/06/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Abstract
In marine ecosystems, both living and non-living organisms depend on "good" water quality. It depends on a number of factors, and one of the most important is the quality of the water. The water quality index (WQI) model is widely used to assess water quality, but existing models have uncertainty issues. To address this, the authors introduced two new WQI models: the weight based weighted quadratic mean (WQM) and unweighted based root mean squared (RMS) models. These models were used to assess water quality in the Bay of Bengal, using seven water quality indicators including salinity (SAL), temperature (TEMP), pH, transparency (TRAN), dissolved oxygen (DOX), total oxidized nitrogen (TON), and molybdate reactive phosphorus (MRP). Both models ranked water quality between "good" and "fair" categories, with no significant difference between the weighted and unweighted models' results. The models showed considerable variation in the computed WQI scores, ranging from 68 to 88 with an average of 75 for WQM and 70 to 76 with an average of 72 for RMS. The models did not have any issues with sub-index or aggregation functions, and both had a high level of sensitivity (R2 = 1) in terms of the spatio-temporal resolution of waterbodies. The study demonstrated that both WQI approaches effectively assessed marine waters, reducing uncertainty and improving the accuracy of the WQI score.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland.
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Stephen Nash
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | - Mir Talas Mahammad Diganta
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland
| | - Abdul Majed Sajib
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland
| | - Md Moniruzzaman
- The Department of Geography and Environment, Jagannath University, Dhaka, Bangladesh
| | - Agnieszka I Olbert
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland; Eco HydroInformatics Research Group (EHIRG), School of Engineering, College of Science and Engineering, University of Galway, Ireland
| |
Collapse
|
8
|
Henriques A, Nash S, Barofsky D, Bollen G, Lapierre A, Schwarz S, Sumithrarachchi C, Zhao Q, Villari ACC. Quantification and purification of isotopic contamination at the ReAccelerator of the Facility for Rare Isotope Beams. Rev Sci Instrum 2023; 94:103306. [PMID: 37815423 DOI: 10.1063/5.0165850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023]
Abstract
At the ReAccelerator within the Facility for Rare Isotope Beams, a combination of an interchangeable aluminum foil and a silicon detector was developed to quantify isobaric contamination in rare isotope beams. The device is simple to operate and is now used routinely. In this article, we describe the system and show an application of the device to determine the level of contamination of an Si-32 rare isotope beam by stable S-32. In addition, we describe how the new diagnostic device helped confirm an enhancement of the beam purity prior to beam delivery to experiments.
Collapse
Affiliation(s)
- A Henriques
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - S Nash
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - D Barofsky
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - G Bollen
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - A Lapierre
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - S Schwarz
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - C Sumithrarachchi
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - Q Zhao
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| | - A C C Villari
- Facility for Rare Isotope Beams, Michigan State University, East Lansing, Michigan 48824, USA
| |
Collapse
|
9
|
Thompson JA, Leurent B, Nash S, Moulton LH, Hayes RJ. Cluster randomized controlled trial analysis at the cluster level: The clan command. Stata J 2023; 23:754-773. [PMID: 37850046 PMCID: PMC7615216 DOI: 10.1177/1536867x231196294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
In this article, we introduce a new command, clan, that conducts a cluster-level analysis of cluster randomized trials. The command simplifies adjusting for individual- and cluster-level covariates and can also account for a stratified design. It can be used to analyze a continuous, binary, or rate outcome.
Collapse
Affiliation(s)
- Jennifer A. Thompson
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, U.K
| | - Baptiste Leurent
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, U.K.; Department of Statistical Science University College London London, U.K
| | - Stephen Nash
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine London, U.K
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Richard J. Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine London, U.K
| |
Collapse
|
10
|
Holloway P, Gibson M, Nash S, Holloway T, Cardwell J, Al Omari B, Abu‐Basha E, Mangtani P, Guitian J. A cross-sectional study of Q fever in Camels: Risk factors for infection, the role of small ruminants and public health implications for desert-dwelling pastoral communities. Zoonoses Public Health 2023; 70:238-247. [PMID: 36601879 PMCID: PMC10952281 DOI: 10.1111/zph.13019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 01/06/2023]
Abstract
Q fever represents an important 'neglected zoonosis', with high prevalences recorded across the Middle East region. Among rural desert-dwelling communities in the region, camel milk is largely consumed raw, due to perceptions of dromedaries as a uniquely clean livestock species mentioned in the Qur'an and Islamic hadith, while milk from other livestock species is usually boiled. As a result, camels present a unique public health threat among such communities from milk-borne pathogens, including Coxiella burnetii. In view of this, a cross-sectional study was conducted among dromedary herds in southern Jordan between September 2017 and October 2018, including 404 camels from 121 randomly selected herds. In addition, 510 household members associated with these herds were interviewed regarding potential high-risk practices for zoonotic transmission. Weight adjusted camel population seroprevalence for C. burnetii was 49.6% (95% CI: 44.7-54.5), with evidence of maternally derived immunity in calves ≤6 months old. Adjusted herd-level prevalence was 76.0% (95% CI 72.7-80.2). It was estimated 30.4% (144/477) of individuals consumed raw milk from infected herds monthly or more. Following multivariable logistic regression analysis, seropositive status in camels was found to be associated with increasing age, high herd tick burdens, keeping the herd together throughout the year including when calving, and owning larger (>50) sheep and goat flocks, with goats presenting a higher risk than sheep. Racing camel status was found to be protective. Socioculturally appropriate interventions aimed at raising awareness of potential risks associated with drinking raw camel milk, alongside appropriate livestock management interventions, should be considered.
Collapse
Affiliation(s)
| | | | - Stephen Nash
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Bilal Al Omari
- Jordan University of Science and TechnologyAr‐RamthaJordan
| | - Ehab Abu‐Basha
- Jordan University of Science and TechnologyAr‐RamthaJordan
| | | | | |
Collapse
|
11
|
Uddin MG, Nash S, Rahman A, Olbert AI. A sophisticated model for rating water quality. Sci Total Environ 2023; 868:161614. [PMID: 36669667 DOI: 10.1016/j.scitotenv.2023.161614] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 06/17/2023]
Abstract
Here, we present the Irish Water Quality Index (IEWQI) model for assessing transitional and coastal water quality in an effort to improve the method and develop a tool that can be used by environmental regulators to abate water pollution in Ireland. The developed model has been associated with the adoption of water quality standards formulated for coastal and transitional waterbodies according to the water framework directive legislation by the environmental regulator of Irish water. The model consists of five identical components, including (i) indicator selection technique is to select the crucial water quality indicator; (ii) sub-index (SI) function for rescaling various water quality indicators' information into a uniform scale; (iii) indicators' weight method for estimating the weight values based on the relative significance of real-time information on water quality; (iii) aggregation function for computing the water quality index (WQI) score; and (v) score interpretation scheme for assessing the state of water quality. The IEWQI model was developed based on Cork Harbour, Ireland. The developed IEWQI model was applied to four coastal waterbodies in Ireland, for assessing water quality using 2021 water quality data for the summer and winter seasons in order to evaluate model sensitivity in terms of spatio-temporal resolution of various waterbodies. The model efficiency and uncertainty were also analysed in this research. In terms of different spatio-temporal magnitudes of various domains, the model shows higher sensitivity in four application domains during the summer and winter. In addition, the results of uncertainty reveal that the IEWQI model architecture may be effective for reducing model uncertainty in order to avoid model eclipsing and ambiguity problems. The findings of this study reveal that the IEWQI model could be an efficient and reliable technique for the assessment of transitional and coastal water quality more accurately in any geospatial domain.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland.
| | - Stephen Nash
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Agnieszka I Olbert
- School of Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| |
Collapse
|
12
|
Lewis M, Herron LM, Chatfield MD, Tan RC, Dale A, Nash S, Lee AJ. Healthy Food Prices Increased More Than the Prices of Unhealthy Options during the COVID-19 Pandemic and Concurrent Challenges to the Food System. Int J Environ Res Public Health 2023; 20:3146. [PMID: 36833837 PMCID: PMC9967271 DOI: 10.3390/ijerph20043146] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 06/09/2023]
Abstract
Food prices have escalated due to impacts of the COVID-19 pandemic on global food systems, and other regional shocks and stressors including climate change and war. Few studies have applied a health lens to identify the most affected foods. This study aimed to assess costs and affordability of habitual (unhealthy) diets and recommended (healthy, equitable and more sustainable) diets and their components in Greater Brisbane, Queensland, Australia from 2019 to 2022 using the Healthy Diets Australian Standardised Affordability and Pricing protocol. Affordability was determined for reference households at three levels of income: median, minimum wage, and welfare-dependent. The recommended diet cost increased 17.9%; mostly in the last year when the prices of healthy foods, such as fruit, vegetables and legumes, healthy fats/oils, grains, and meats/alternatives, increased by 12.8%. In contrast, the cost of the unhealthy foods and drinks in the habitual diet 'only' increased 9.0% from 2019 to 2022, and 7.0% from 2021 to 2022. An exception was the cost of unhealthy take-away foods which increased by 14.7% over 2019-2022. With government COVID-19-related payments, for the first time recommended diets were affordable for all and food security and diets improved in 2020. However, the special payments were withdrawn in 2021, and recommended diets became 11.5% less affordable. Permanently increasing welfare support and providing an adequate minimum wage, while keeping basic, healthy foods GST-free and increasing GST to 20% on unhealthy foods, would improve food security and diet-related health inequities. Development of a Consumer Price Index specifically for healthy food would help highlight health risks during economic downturns.
Collapse
Affiliation(s)
- Meron Lewis
- School of Public Health, Faculty of Medicine, The University of Queensland, Herston 4006, Australia
| | | | | | | | | | | | | |
Collapse
|
13
|
Uddin MG, Nash S, Rahman A, Olbert AI. A novel approach for estimating and predicting uncertainty in water quality index model using machine learning approaches. Water Res 2023; 229:119422. [PMID: 36459893 DOI: 10.1016/j.watres.2022.119422] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/20/2022] [Accepted: 11/23/2022] [Indexed: 06/17/2023]
Abstract
With the significant increase in WQI applications worldwide and lack of specific application guidelines, accuracy and reliability of WQI models is a major issue. It has been reported that WQI models produce significant uncertainties during the various stages of their application including: (i) water quality indicator selection, (ii) sub-index (SI) calculation, (iii) water quality indicator weighting and (iv) aggregation of sub-indices to calculate the overall index. This research provides a robust statistically sound methodology for assessment of WQI model uncertainties. Eight WQI models are considered. The Monte Carlo simulation (MCS) technique was applied to estimate model uncertainty, while the Gaussian Process Regression (GPR) algorithm was utilised to predict uncertainties in the WQI models at each sampling site. The sub-index functions were found to contribute to considerable uncertainty and hence affect the model reliability - they contributed 12.86% and 10.27% of uncertainty for summer and winter applications, respectively. Therefore, the selection of sub-index function needs to be made with care. A low uncertainty of less than 1% was produced by the water quality indicator selection and weighting processes. Significant statistical differences were found between various aggregation functions. The weighted quadratic mean (WQM) function was found to provide a plausible assessment of water quality of coastal waters at reduced uncertainty levels. The findings of this study also suggest that the unweighted root means squared (RMS) aggregation function could be potentially also used for assessment of coastal water quality. Findings from this research could inform a range of stakeholders including decision-makers, researchers, and agencies responsible for water quality monitoring, assessment and management.
Collapse
Affiliation(s)
- Md Galal Uddin
- Civil Engineering, School of Engineering, College of Science and Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland.
| | - Stephen Nash
- Civil Engineering, School of Engineering, College of Science and Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Agnieszka I Olbert
- Civil Engineering, School of Engineering, College of Science and Engineering, University of Galway, Ireland; Ryan Institute, University of Galway, Ireland; MaREI Research Centre, University of Galway, Ireland
| |
Collapse
|
14
|
Bachert C, Khan A, Lee S, Peters A, Nash S, Radwan A, Jacob-Nara J. DUPILUMAB IMPROVES CHRONIC RHINOSINUSITIS WITH NASAL POLYPS DISEASE OUTCOMES IRRESPECTIVE OF TYPE 2 SIGNATURE DEFINITION. Ann Allergy Asthma Immunol 2022. [DOI: 10.1016/j.anai.2022.08.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
15
|
Soler Z, Lane A, Patel Z, Mattos J, Xia C, Khan A, Nash S. ASSOCIATION BETWEEN SMELL LOSS, DISEASE BURDEN, AND DUPILUMAB EFFICACY IN CHRONIC RHINOSINUSITIS WITH NASAL POLYPS. Ann Allergy Asthma Immunol 2022. [DOI: 10.1016/j.anai.2022.08.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
16
|
Uddin MG, Nash S, Mahammad Diganta MT, Rahman A, Olbert AI. Robust machine learning algorithms for predicting coastal water quality index. J Environ Manage 2022; 321:115923. [PMID: 35988401 DOI: 10.1016/j.jenvman.2022.115923] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/06/2022] [Accepted: 07/30/2022] [Indexed: 06/15/2023]
Abstract
Coastal water quality assessment is an essential task to keep "good water quality" status for living organisms in coastal ecosystems. The Water quality index (WQI) is a widely used tool to assess water quality but this technique has received much criticism due to the model's reliability and inconsistence. The present study used a recently developed improved WQI model for calculating coastal WQIs in Cork Harbour. The aim of the research is to determine the most reliable and robust machine learning (ML) algorithm(s) to anticipate WQIs at each monitoring point instead of repeatedly employing SI and weight values in order to reduce model uncertainty. In this study, we compared eight commonly used algorithms, including Random Forest (RF), Decision Tree (DT), K-Nearest Neighbors (KNN), Extreme Gradient Boosting (XGB), Extra Tree (ExT), Support Vector Machine (SVM), Linear Regression (LR), and Gaussian Naïve Bayes (GNB). For the purposes of developing the prediction models, the dataset was divided into two groups: training (70%) and testing (30%), whereas the models were validated using the 10-fold cross-validation method. In order to evaluate the models' performance, the RMSE, MSE, MAE, R2, and PREI metrics were used in this study. The tree-based DT (RMSE = 0.0, MSE = 0.0, MAE = 0.0, R2 = 1.0 and PERI = 0.0) and the ExT (RMSE = 0.0, MSE = 0.0, MAE = 0.0, R2 = 1.0 and PERI = 0.0) and ensemble tree-based XGB (RMSE = 0.0, MSE = 0.0, MAE = 0.0, R2 = 1.0 and PERI = +0.16 to -0.17) and RF (RMSE = 2.0, MSE = 3.80, MAE = 1.10, R2 = 0.98, PERI = +3.52 to -25.38) models outperformed other models. The results of model performance and PREI indicate that the DT, ExT, and GXB models could be effective, robust and significantly reduce model uncertainty in predicting WQIs. The findings of this study are also useful for reducing model uncertainty and optimizing the WQM-WQI model architecture for predicting WQI values.
Collapse
Affiliation(s)
- Md Galal Uddin
- School of Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland.
| | - Stephen Nash
- School of Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland
| | - Mir Talas Mahammad Diganta
- School of Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Agnieszka I Olbert
- School of Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland
| |
Collapse
|
17
|
Uddin MG, Nash S, Rahman A, Olbert AI. A comprehensive method for improvement of water quality index (WQI) models for coastal water quality assessment. Water Res 2022; 219:118532. [PMID: 35533623 DOI: 10.1016/j.watres.2022.118532] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 06/14/2023]
Abstract
Here, we present an improved water quality index (WQI) model for assessment of coastal water quality using Cork Harbour, Ireland, as the case study. The model involves the usual four WQI components - selection of water quality indicators for inclusion, sub-indexing of indicator values, sub-index weighting and sub-index aggregation - with improvements to make the approach more objective and data-driven and less susceptible to eclipsing and ambiguity errors. The model uses the machine learning algorithm, XGBoost, to rank and select water quality indicators for inclusion based on relative importance to overall water quality status. Of the ten indicators for which data were available, transparency, dissolved inorganic nitrogen, ammoniacal nitrogen, BOD5, chlorophyll, temperature and orthophosphate were selected for summer, while total organic nitrogen, dissolved inorganic nitrogen, pH, transparency and dissolved oxygen were selected for winter. Linear interpolation functions developed using national recommended guideline values for coastal water quality are used for sub-indexing of water quality indicators and the XGBoost rankings are used in combination with the rank order centroid weighting method to determine sub-index weight values. Eight sub-index aggregation functions were tested - five from existing WQI models and three proposed by the authors. The computed indices were compared with those obtained using a multiple linear regression (MLR) approach and R2 and RMSE used as indicators of aggregation function performance. The weighted quadratic mean function (R2 = 0.91, RMSE = 4.4 for summer; R2 = 0.97, RMSE = 3.1 for winter) and the unweighted arithmetic mean function (R2 = 0.92, RMSE = 3.2 for summer; R2 = 0.97, RMSE = 3.2 for winter) proposed by the authors were identified as the best functions and showed reduced eclipsing and ambiguity problems compared to the others.
Collapse
Affiliation(s)
- Md Galal Uddin
- Civil Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland.
| | - Stephen Nash
- Civil Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, Australia; The Gulbali Institute of Agriculture, Water and Environment, Charles Sturt University, Wagga Wagga, Australia
| | - Agnieszka I Olbert
- Civil Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland; Ryan Institute, National University of Ireland Galway, Ireland; MaREI Research Centre, National University of Ireland Galway, Ireland
| |
Collapse
|
18
|
Boubli JP, Janiak MC, Porter LM, de la Torre S, Cortés-Ortiz L, Da Silva MNF, Rylands AB, Nash S, Bertuol F, Byrne H, Silva FE, Rohe F, de Vries D, Beck RMD, Ruiz-Gartzia I, Kuderna LFK, Marques-Bonet T, Hrbek T, Farias IP, Van Heteren AH, Roos C. Ancient DNA of the pygmy marmoset type specimen Cebuella pygmaea (Spix, 1823) resolves a taxonomic conundrum. Zool Res 2021; 42:761-771. [PMID: 34643070 PMCID: PMC8645880 DOI: 10.24272/j.issn.2095-8137.2021.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The pygmy marmoset, the smallest of the anthropoid primates, has a broad distribution in Western Amazonia. Recent studies using molecular and morphological data have identified two distinct species separated by the Napo and Solimões-Amazonas rivers. However, reconciling this new biological evidence with current taxonomy, i.e., two subspecies, Cebuella pygmaea pygmaea (Spix, 1823) and Cebuella pygmaea niveiventris (Lönnberg, 1940), was problematic given the uncertainty as to whether Spix’s pygmy marmoset (Cebuella pygmaea pygmaea) was collected north or south of the Napo and Solimões-Amazonas rivers, making it unclear to which of the two newly revealed species the name pygmaea would apply. Here, we present the first molecular data from Spix’s type specimen of Cebuella pygmaea, as well as novel mitochondrial genomes from modern pygmy marmosets sampled near the type locality (Tabatinga) on both sides of the river. With these data, we can confirm the correct names of the two species identified, i.e., C. pygmaea for animals north of the Napo and Solimões-Amazonas rivers and C. niveiventris for animals south of these two rivers. Phylogenetic analyses of the novel genetic data placed into the context of cytochrome b gene sequences from across the range of pygmy marmosets further led us to re-evaluate the geographical distribution for the two Cebuella species. We dated the split of these two species to 2.54 million years ago. We discuss additional, more recent, subdivisions within each lineage, as well as potential contact zones between the two species in the headwaters of these rivers.
Collapse
Affiliation(s)
- Jean P Boubli
- School of Science, Engineering & Environment, University of Salford, Salford M5 4WT, UK.,Instituto Nacional de Pesquisas da Amazônia, Manaus, Amazonas 69060-001, Brazil. E-mail:
| | - Mareike C Janiak
- School of Science, Engineering & Environment, University of Salford, Salford M5 4WT, UK
| | - Leila M Porter
- Department of Anthropology, Northern Illinois University, DeKalb, IL 60115-2828, USA
| | - Stella de la Torre
- College of Biological and Environmental Sciences, Universidad San Francisco de Quito, Quito 170901, Ecuador
| | - Liliana Cortés-Ortiz
- Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Maria N F Da Silva
- Instituto Nacional de Pesquisas da Amazônia, Manaus, Amazonas 69060-001, Brazil
| | | | - Stephen Nash
- Global Wildlife Conservation, Austin, TX 78767, USA
| | - Fabrício Bertuol
- Laboratório de Evolução e Genética Animal, Universidade Federal do Amazonas, Manaus, Amazonas 69080-900, Brazil
| | - Hazel Byrne
- Department of Anthropology, University of Utah, Salt Lake City, UT 84112, USA
| | - Felipe E Silva
- Research Group on Primate Biology and Conservation, Mamirauá Institute for Sustainable Development, Tefé, Amazonas 69553-225, Brazil
| | - Fabio Rohe
- Instituto Nacional de Pesquisas da Amazônia, Manaus, Amazonas 69060-001, Brazil
| | - Dorien de Vries
- School of Science, Engineering & Environment, University of Salford, Salford M5 4WT, UK
| | - Robin M D Beck
- School of Science, Engineering & Environment, University of Salford, Salford M5 4WT, UK
| | - Irune Ruiz-Gartzia
- Experimental and Health Sciences Department (DCEXS), Institut de Biologia Evolutiva, Universitat Pompeu Fabra-CSIC, Barcelona 08002, Spain
| | - Lukas F K Kuderna
- Experimental and Health Sciences Department (DCEXS), Institut de Biologia Evolutiva, Universitat Pompeu Fabra-CSIC, Barcelona 08002, Spain
| | - Tomas Marques-Bonet
- Experimental and Health Sciences Department (DCEXS), Institut de Biologia Evolutiva, Universitat Pompeu Fabra-CSIC, Barcelona 08002, Spain
| | - Tomas Hrbek
- Laboratório de Evolução e Genética Animal, Universidade Federal do Amazonas, Manaus, Amazonas 69080-900, Brazil.,Department of Biology, Trinity University, San Antonio, TX 78212, USA
| | - Izeni P Farias
- Laboratório de Evolução e Genética Animal, Universidade Federal do Amazonas, Manaus, Amazonas 69080-900, Brazil
| | - Anneke H Van Heteren
- Bavarian State Collection of Zoology, Zoologische Staatssammlung München, Staatliche Naturkundliche Sammlungen Bayerns, Munich 81247, Germany.,GeoBio-Center, Ludwig-Maximilians-Universität München, Munich 80333, Germany.,Department Biologie II, Ludwig-Maximilians-Universität München, Munich 82152, Germany
| | - Christian Roos
- Gene Bank of Primates and Primate Genetics Laboratory, German Primate Center, Leibniz Institute for Primate Research, Göttingen 37077, Germany
| |
Collapse
|
19
|
Nash S, Morgan KE, Frost C, Mulick A. Power and sample-size calculations for trials that compare slopes over time: Introducing the slopepower command. Stata J 2021; 21:575-601. [PMID: 37476648 PMCID: PMC7614632 DOI: 10.1177/1536867x211045512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Trials of interventions that aim to slow disease progression may analyze a continuous outcome by comparing its change over time-its slope-between the treated and the untreated group using a linear mixed model. To perform a sample-size calculation for such a trial, one must have estimates of the parameters that govern the between- and within-subject variability in the outcome, which are often unknown. The algebra needed for the sample-size calculation can also be complex for such trial designs. We have written a new user-friendly command, slopepower, that performs sample-size or power calculations for trials that compare slope outcomes. The package is based on linear mixed-model methodology, described for this setting by Frost, Kenward, and Fox (2008, Statistics in Medicine 27: 3717-3731). In the first stage of this approach, slopepower obtains estimates of mean slopes together with variances and covariances from a linear mixed model fit to previously collected user-supplied data. In the second stage, these estimates are combined with user input about the target effectiveness of the treatment and design of the future trial to give an estimate of either a sample size or a statistical power. In this article, we present the slopepower command, briefly explain the methodology behind it, and demonstrate how it can be used to help plan a trial and compare the sample sizes needed for different trial designs.
Collapse
Affiliation(s)
- Stephen Nash
- Department of Infectious Disease Epidemiology
London School of Hygiene and Tropical Medicine
London, UK
| | - Katy E. Morgan
- Department of Medical Statistics London School
of Hygiene and Tropical Medicine London, UK
| | - Chris Frost
- Department of Medical Statistics London School
of Hygiene and Tropical Medicine London, UK
| | - Amy Mulick
- Department of Non-communicable Disease
Epidemiology London School of Hygiene and Tropical
Medicine London, UK
| |
Collapse
|
20
|
Holloway P, Gibson M, van Doremalen N, Nash S, Holloway T, Letko M, Cardwell JM, Al Omari B, Al-Majali A, Abu-Basha E, Mangtani P, Munster VJ, Guitian J. Risk Factors for Middle East Respiratory Syndrome Coronavirus Infection among Camel Populations, Southern Jordan, 2014-2018. Emerg Infect Dis 2021; 27:2301-2311. [PMID: 34423762 PMCID: PMC8386791 DOI: 10.3201/eid2709.203508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
After the first detection of Middle East respiratory syndrome coronavirus (MERS-CoV) in camels in Jordan in 2013, we conducted 2 consecutive surveys in 2014–2015 and 2017–2018 investigating risk factors for MERS-CoV infection among camel populations in southern Jordan. Multivariate analysis to control for confounding demonstrated that borrowing of camels, particularly males, for breeding purposes was associated with increased MERS-CoV seroprevalence among receiving herds, suggesting a potential route of viral transmission between herds. Increasing age, herd size, and use of water troughs within herds were also associated with increased seroprevalence. Closed herd management practices were found to be protective. Future vaccination strategies among camel populations in Jordan could potentially prioritize breeding males, which are likely to be shared between herds. In addition, targeted management interventions with the potential to reduce transmission between herds should be considered; voluntary closed herd schemes offer a possible route to achieving disease-free herds.
Collapse
|
21
|
Muhumuza R, Ssemata AS, Kakande A, Ahmed N, Atujuna M, Nomvuyo M, Bekker LG, Dietrich JJ, Tshabalala G, Hornschuh S, Maluadzi M, Chibanda-Stranix L, Nematadzira T, Weiss HA, Nash S, Fox J, Seeley J. Exploring Perceived Barriers and Facilitators of PrEP Uptake among Young People in Uganda, Zimbabwe, and South Africa. Arch Sex Behav 2021; 50:1729-1742. [PMID: 33954824 PMCID: PMC8213546 DOI: 10.1007/s10508-020-01880-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 05/09/2023]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy. Few studies have explored adolescents and young people's perspectives toward PrEP. We conducted 24 group discussions and 60 in-depth interviews with males and females aged 13-24 years in Uganda, Zimbabwe, and South Africa between September 2018 and February 2019. We used the framework approach to generate themes and key concepts for analysis following the social ecological model. Young people expressed a willingness to use PrEP and identified potential barriers and facilitators of PrEP uptake. Barriers included factors at individual (fear of HIV, fear of side effects, and PrEP characteristics), interpersonal (parental influence, absence of a sexual partner), community (peer influence, social stigma), institutional (long waiting times at clinics, attitudes of health workers), and structural (cost of PrEP and mode of administration, accessibility concerns) levels. Facilitators included factors at individual (high HIV risk perception and preventing HIV/desire to remain HIV negative), interpersonal (peer influence, social support and care for PrEP uptake), community (adequate PrEP information and sensitization, evidence of PrEP efficacy and safety), institutional (convenient and responsive services, provision of appropriate and sufficiently resourced services), and structural (access and availability of PrEP, cost of PrEP) levels. The findings indicated that PrEP is an acceptable HIV prevention method. PrEP uptake is linked to personal and environmental factors that need to be considered for successful PrEP roll-out. Multi-level interventions needed to promote PrEP uptake should consider the social and structural drivers and focus on ways that can inspire PrEP uptake and limit the barriers.
Collapse
Affiliation(s)
- Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Andrew Sentoogo Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Ayoub Kakande
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda
| | - Nadia Ahmed
- Desmond Tutu HIV Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Millicent Atujuna
- Desmond Tutu HIV Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mangxilana Nomvuyo
- Desmond Tutu HIV Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Foundation, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Janan Janine Dietrich
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Bellville, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stefanie Hornschuh
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mamakiri Maluadzi
- Perinatal HIV Research Unit, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Helen Anne Weiss
- MRC International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen Nash
- MRC International Statistics & Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Fox
- Department of Infectious Diseases, King's College London, London, UK
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, P.O. Box 49, Entebbe, Uganda.
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| |
Collapse
|
22
|
Singh U, Castle J, Greenhalgh S, Hussain U, Descamps T, Nash S, Wilson M, Hunt R, Kirwan CC. O44: WOUND HEALING INFLAMMATORY MARKERS PREDICT PROGNOSIS AND SURVIVAL IN EARLY BREAST CANCER. Br J Surg 2021. [DOI: 10.1093/bjs/znab117.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Cancer is likened to a non-healing wound. There is limited evidence on the expression of wound healing tissue inflammatory markers, CD68(pan-macrophage marker), HO-1(tumour cell marker) and FAP(cancer-associated fibroblast marker) in human breast cancer.
Method
In 201 invasive breast cancer and 58 DCIS patients, CD68+TAM expression, tumour HO-1 and fibroblast FAP expression, quantified by immunohistochemistry(dichotomised: high/present vs low/absent), was correlated with tumour factors (grade, proliferation(Ki67), ER, HER2); demographic factors, behavioural factors (smoking, alcohol) and survival status(DFS, OS)
Result
High CD68+macrophage expression was increased in invasive breast cancer, compared to DCIS, and normal tissue distant from the tumour(59%,41%and 6% respectively; p<0.001).In invasive cancer,CD68+TAM expression increased with increasing tumour grade(Grade 1:42%, Grade 2:58%, Grade 3:72%; p=0.006), high Ki67(71%vs.47%; p=0.004), ER negativity(79.4%vs.55.4%; p=0.01) and HER2(HER2 positive 81.8% vs. HER2 negative 56.3%; p=0.03). CD68+TAM expression was higher in high compared to low/intermediate grade DCIS(44% % vs. 31% p=0.52). CD68+TAM expression was increased in patients who self-reported alcohol intake(non-drinker 43% vs. drinker 62%; p=0.01). HO-1 was associated with shorter DFS(HR:3.22,p=0.027) and OS(HR:2.86,p=0.029).FAP fibroblast expression correlated with longer DFS (HR:0.296,p=0.029) and OS (HR:0.271,p=0.008).
Conclusion
Tumour inflammation as assessed by CD68+TAM expression shows utility in identifying aggressive breast cancer sub-types. The association reported between CD68+TAM density and alcohol intake suggests a possible mechanism for alcohol as a risk factor for breast cancer. The prognostic value of HO-1 and FAP expression demonstrated here suggests a functional role of these wound healing markers in breast cancer. HO-1:Heme-oxygenase-1; FAP:Fibroblast activation protein; TAM:Tumour associated macrophage; DCIS: Ductal carcinoma in situ
Take-home message
Wound healing pathways of inflammation may be implicated in early breast cancer development
Collapse
Affiliation(s)
- U Singh
- Division of Cancer Sciences, The University of Manchester
| | - J Castle
- Division of Cancer Sciences, The University of Manchester
| | | | - U Hussain
- Manchester University NHS Foundation Trust
| | | | - S Nash
- Manchester University NHS Foundation Trust
| | - M Wilson
- Manchester University NHS Foundation Trust
| | - R Hunt
- Manchester University NHS Foundation Trust
| | - CC Kirwan
- Division of Cancer Sciences, The University of Manchester
- Manchester University NHS Foundation Trust
| |
Collapse
|
23
|
Singh U, Castle J, Shaker H, Greenhalgh S, Hussain U, Descamps T, Nash S, Wilson M, Hunt R, Kirwan C. PO-75 The relationship between the coagulation and inflammatory phases of wound healing in early breast cancer. Thromb Res 2021. [DOI: 10.1016/s0049-3848(21)00248-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
24
|
Gon G, Ali SM, Aunger R, Campbell OM, de Barra M, de Bruin M, Juma M, Nash S, Tajo A, Westbrook J, Woodd S, Graham WJ. A Practical Guide to Using Time-and-Motion Methods to Monitor Compliance With Hand Hygiene Guidelines: Experience From Tanzanian Labor Wards. Glob Health Sci Pract 2020; 8:827-837. [PMID: 33361245 PMCID: PMC7784080 DOI: 10.9745/ghsp-d-20-00221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/19/2020] [Indexed: 12/05/2022]
Abstract
Understanding hand hygiene behaviors is critical in hospitals. We developed the HANDS at birth tool—and provide information on its design and implementation–to capture the complex patterns of health care workers’ hand hygiene including hand rubbing/washing, glove use, and recontamination. Background: Good-quality evidence on hand hygiene compliance among birth attendants in low-resource labor wards is limited. The World Health Organization Hand Hygiene Observation Form is widely used for directly observing behaviors, but it does not support capturing complex patterns of behavior. We developed the HANDS at Birth tool for direct observational studies of complex patterns of hand rubbing/washing, glove use, recontamination, and their determinants among birth attendants. Understanding these behaviors is particularly critical in wards with variable patient volumes or unpredictable patient complications, such as emergency departments, operating wards, or triage and isolation wards during epidemics. Here we provide detailed information on the design and implementation of the HANDS at Birth tool, with a particular focus on low-resource settings. We developed the HANDS at Birth tool from available guidelines, unstructured observation, and iterative refinement based on consultation with collaborators and pilot results. We designed the tool with WOMBAT software, which supports collecting multidimensional time-and-motion data. Our analysis of the tool’s performance centered on interobserver agreement and convergent validity and the implications of the data structure for data analysis. The HANDS at Birth tool encompasses various hand actions and context-relevant information. Hand actions include procedures relevant during labor and delivery; hand hygiene or glove actions; and other types of touch. During field implementation, we used the tool for continuous observation of the birth attendant. Interobserver agreement was good (kappa range: 0.7–0.9), and the tool showed convergent validity. Using the HANDS at Birth tool is a feasible way to obtain useful information about compliance with hand hygiene procedures. The tool could be used after simple training and allows for collection of reliable information about the complex pattern of hygiene behaviors. Future studies should explore using this tool to observe behavior in labor wards in other settings and in other types of wards.
Collapse
Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Said M Ali
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | - Robert Aunger
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Oona M Campbell
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, United Kingdom
| | - Marijn de Bruin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mohammed Juma
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amour Tajo
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | | | - Susannah Woodd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wendy J Graham
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| |
Collapse
|
25
|
Gon G, de Barra M, Dansero L, Nash S, Campbell OMR. Birth attendants' hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review. BMC Health Serv Res 2020; 20:1116. [PMID: 33267879 PMCID: PMC7713338 DOI: 10.1186/s12913-020-05925-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 11/15/2020] [Indexed: 12/13/2022] Open
Abstract
Background With an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers’ hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs. Methods We conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities. Results We obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1–38%). Three studies described two multi-component interventions, both were shown to be feasible. Conclusions Hand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.
Collapse
Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, UK
| | | | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| |
Collapse
|
26
|
Nash S, Dietrich J, Ssemata AS, Herrera C, O'Hagan K, Else L, Chiodi F, Kelly C, Shattock R, Chirenje M, Lebina L, Khoo S, Bekker LG, Weiss HA, Gray C, Stranix-Chibanda L, Kaleebu P, Seeley J, Martinson N, Fox J. Combined HIV Adolescent Prevention Study (CHAPS): comparison of HIV pre-exposure prophylaxis regimens for adolescents in sub-Saharan Africa-study protocol for a mixed-methods study including a randomised controlled trial. Trials 2020; 21:900. [PMID: 33121503 PMCID: PMC7596950 DOI: 10.1186/s13063-020-04760-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV remains a major public health issue, especially in Eastern and Southern Africa. Pre-exposure prophylaxis is highly effective when adhered to, but its effectiveness is limited by cost, user acceptability and uptake. The cost of a non-inferiority phase III trial is likely to be prohibitive, and thus, it is essential to select the best possible drug, dose and schedule in advance. The aim of this study, the Combined HIV Adolescent PrEP and Prevention Study (CHAPS), is to investigate the drug, dose and schedule of pre-exposure prophylaxis (PrEP) required for the protection against HIV and the acceptability of PrEP amongst young people in sub-Saharan Africa, and hence to inform the choice of intervention for future phase III PrEP studies and to improve strategies for PrEP implementation. METHODS We propose a mixed-methods study amongst young people aged 13-24 years. The first component consists of qualitative research to identify the barriers and motivators towards the uptake of PrEP amongst young people in South Africa, Uganda and Zimbabwe. The second component is a randomised clinical trial (ClinicalTrials.gov NCT03986970, June 2019) using a novel ex vivo HIV challenge method to investigate the optimal PrEP treatment (FTC-TDF vs FTC-TAF), dose and schedule. We will recruit 144 amongst HIV-negative uncircumcised men aged 13-24 years from voluntary male medical circumcision clinics in two sites (South Africa and Uganda) and randomise them into one of nine arms. One group will receive no PrEP prior to surgery; the other arms will receive either FTC-TDF or FTC-TAF, over 1 or 2 days, and with the final dose given either 6 or 20 h prior to surgery. We will conduct an ex vivo HIV challenge on their resected foreskin tissue. DISCUSSION This study will provide both qualitative and quantitative results to help decide the optimum drug, dose and schedule for a future phase III trial of PrEP. The study will also provide crucial information on successful strategies for providing PrEP to young people in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT03986970 . Registered on 14 June 2019.
Collapse
Affiliation(s)
- S Nash
- London School of Hygiene and Tropical Medicine, London, UK
| | - J Dietrich
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - A S Ssemata
- MRC/UVRI Uganda Research Unit On Aids, Entebbe, Uganda
| | | | - K O'Hagan
- University of Cape Town, Cape Town, South Africa
| | - L Else
- University of Liverpool, Liverpool, UK
| | - F Chiodi
- Karolinska Institutet, Solna, Sweden
| | - C Kelly
- King's College London, London, UK
| | | | - M Chirenje
- University of Zimbabwe, Harare, Zimbabwe
| | - L Lebina
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - S Khoo
- University of Liverpool, Liverpool, UK
| | - L-G Bekker
- Desmond Tutu HIV Foundation, Cape Town, South Africa
| | - H A Weiss
- London School of Hygiene and Tropical Medicine, London, UK
| | - C Gray
- University of Cape Town, Cape Town, South Africa
| | | | - P Kaleebu
- MRC/UVRI Uganda Research Unit On Aids, Entebbe, Uganda
| | - J Seeley
- London School of Hygiene, London, UK
| | - N Martinson
- University of the Witwatersrand Perinatal HIV Research Unit, Johannesburg, South Africa
| | - J Fox
- King's College London, London, UK.
| | | |
Collapse
|
27
|
Kirwan PD, Hibbert M, Kall M, Nambiar K, Ross M, Croxford S, Nash S, Webb L, Wolton A, Delpech VC. HIV prevalence and HIV clinical outcomes of transgender and gender-diverse people in England. HIV Med 2020; 22:131-139. [PMID: 33103840 DOI: 10.1111/hiv.12987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/07/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We provide the first estimate of HIV prevalence among trans and gender-diverse people living in England and compare outcomes of people living with HIV according to gender identity. METHODS We analysed a comprehensive national HIV cohort and a nationally representative self-reported survey of people accessing HIV care in England (Positive Voices). Gender identity was recorded using a two-step question co-designed with community members and civil society. Responses were validated by clinic follow-up and/or self-report. Population estimates were obtained from national government offices. RESULTS In 2017, HIV prevalence among trans and gender-diverse people was estimated at 0.46-4.78 per 1000, compared with 1.7 (95% credible interval: 1.6-1.7) in the general population. Of 94 885 people living with diagnosed HIV in England, 178 (0.19%) identified as trans or gender-diverse. Compared with cisgender people, trans and gender-diverse people were more likely to be London residents (57% vs. 43%), younger (median age 42 vs. 46 years), of white ethnicity (61% vs. 52%), under psychiatric care (11% vs. 4%), to report problems with self-care (37% vs. 13%), and to have been refused or delayed healthcare (23% vs. 11%). Antiretroviral uptake and viral suppression were high in both groups. CONCLUSIONS HIV prevalence among trans and gender-diverse people living in England is relatively low compared with international estimates. Furthermore, no inequalities were observed with regard to HIV care. Nevertheless, trans and gender-diverse people with HIV report poorer mental health and higher levels of discrimination compared with cisgender people.
Collapse
Affiliation(s)
- P D Kirwan
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK.,Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - M Hibbert
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - M Kall
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - K Nambiar
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - S Croxford
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - S Nash
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| | - L Webb
- LGBT Foundation, Manchester, UK
| | - A Wolton
- Chelsea and Westminster Hospital NHS Trust, London, UK
| | - V C Delpech
- Blood Safety, Hepatitis, Sexually Transmitted Infections and HIV Division, Public Health England, London, UK
| |
Collapse
|
28
|
Abaasa A, Nash S, Mayanja Y, Price MA, Fast PE, Kaleebu P, Todd J. Comparison of HIV Risk Behaviors Between Clinical Trials and Observational Cohorts in Uganda. AIDS Behav 2020; 24:2872-2884. [PMID: 32277309 PMCID: PMC7467908 DOI: 10.1007/s10461-020-02838-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many key populations have high-risk behaviors for HIV infection making them suitable for HIV vaccine efficacy trials. However, these behaviors may change when participants enroll into a trial. We used HIV simulated vaccine efficacy trials (SiVETs) nested within observational cohorts of fisherfolks and female sex workers in Uganda to evaluate this difference. We screened observational cohort participants for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (n = 953) continued participation in the observational cohorts. We determined risk behaviors at baseline and at 1 year, assigned a numeric score to each behavior and defined composite score as the sum of reported behaviors. We compared changes in scores over 12 months. Both observational cohorts and SiVETs saw a significant decrease in score but greatest in the SiVETs. Investigators recruiting for trials from these populations should consider the likely effect of reduction in risk behaviors on incident HIV infection and trial statistical power.
Collapse
|
29
|
Edwards A, Siedner MJ, Nash S, Neuman M, Danaviah S, Smit T, Gareta D, Kowal P, Seeley J. HIV serostatus, inflammatory biomarkers and the frailty phenotype among older people in rural KwaZulu-Natal, South Africa. Afr J AIDS Res 2020; 19:177-185. [PMID: 32892699 DOI: 10.2989/16085906.2020.1790398] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective: We compared the prevalence of frailty by HIV serostatus and related biomarkers to the modified frailty phenotype among older individuals in a rural population in South Africa. Methods: Questionnaire data were from a cohort of people living with HIV (PWH) on antiretroviral therapy (ART) and HIV-uninfected people aged 50 years and older sampled from the Africa Health Research Institute Demographic Health and Surveillance area in northern KwaZulu-Natal. The prevalence of frailty was compared using five categories: (1) physical activity; (2) mobility; (3) fatigue; (4) gait speed; and (5) grip strength, and assessed for demographic, clinical, and inflammatory correlates of frailty. Results: Among 614 individuals in the study, 384 (62.5%) were women. The median age at study enrolment was 64 years [Interquartile range (IQR) (58.6-72.0)]. 292 (47.6%) were PWH. 499 (81%) were classified as either pre-frail or frail. 43 (7%) were frail and HIV positive, 185 (30%) were pre-frail and HIV positive, 57 were frail and HIV negative and 214 (35%) were pre-frail and HIV negative. Frailty was similar for HIV negative and PWH (17.7% vs 14.7%, p = 0.72). Women were more likely to be frail (18.3% vs 13.04%, p = 0.16). The prevalence of frailty increased with age for both HIV groups. In the multivariable analysis, the odds of being frail were higher in those aged 70 years and above than those aged between 50 and 59 years (p < 0.001). Females were less likely to be pre-frail than males (p < 0.001). There was no association between any of the inflammatory biomarkers and frailty and pre-frailty. Conclusion: In this population, the prevalence of frailty is similar for PWH and people without HIV, but higher for women than men. These data suggest that the odds of developing frailty is similar for PWH over the age of 50 years, who survive into older age, as for people without HIV.
Collapse
Affiliation(s)
- Anita Edwards
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Harvard Medical School, Boston, USA
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Neuman
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Paul Kowal
- World Health Organization, Division of Data, Analytics and Delivery for Impact, Geneva, Switzerland
| | - Janet Seeley
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
30
|
Mugisha Okello J, Nash S, Kowal P, Naidoo N, Chatterji S, Boerma T, Seeley J. Survival of people aged 50 years and older by HIV and HIV treatment status: findings from three waves of the SAGE-Wellbeing of Older People Study (SAGE-WOPS) in Uganda. AIDS Res Ther 2020; 17:17. [PMID: 32410634 PMCID: PMC7226937 DOI: 10.1186/s12981-020-00276-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 05/05/2020] [Indexed: 12/28/2022] Open
Abstract
Background Data on the survival status of older adults on antiretroviral treatment (ART) are scarce in sub-Saharan Africa. The objective of this study was to determine the survival status of people aged 50 years and older who were HIV-negative, HIV-positive not on ART, and HIV-positive on ART. Methods We used three waves of data from the World Health Organisation Study on Global Ageing and adult health- Well Being of Older People Study cohort in Uganda, conducted in 2009, 2012–2013 and 2015–2016. The cohort included HIV-negative and HIV-positive persons aged 50 years and older recruited from multiple rural and peri-urban sites in Uganda. Data were collected using interviewer-administered questionnaire. Time-dependent ART data were collected from medical records using a data-abstraction form. This study was conducted before the universal test and treat policy came into effect. We fitted Cox survival models to estimate hazard ratios to compare the risk of death between groups, adjusted for age, sex, marital status and hypertension. Results Of 623 participants, 517 (82.9%) of respondents had follow-up data and were included in this analysis. We observed 1571 person-years of follow-up from 274 people who were HIV-negative, and 1252 from 243 who were HIV-positive. The estimated mortality adjusted hazard ratio (aHR) was 1.89 (95% CI 1.0–3.4; p = 0.04) among people living with HIV compared to HIV-negative people. The aHR for mortality among people receiving ART compared with HIV-negative people was 1.75 (95% CI 0.9–3.5). People who were HIV-positive and not receiving ART had the greatest risk of death (aHR = 2.09, 95% CI 1.0–4.4 compared with HIV negative participants). The aHR for HIV-positive people not receiving ART, compared to those who were on treatment, was 1.19 (95% CI 0.6–2.5). Conclusion Older adults living with HIV on ART had a risk of mortality that was nearly twice as high as HIV-negative adults. Further analyses of longitudinal data should be done to understand factors that affect the survival of older adults on ART.
Collapse
|
31
|
Stockdale L, Nash S, Farmer R, Raynes J, Mallikaarjun S, Newton R, Fletcher HA. Cytomegalovirus Antibody Responses Associated With Increased Risk of Tuberculosis Disease in Ugandan Adults. J Infect Dis 2020; 221:1127-1134. [PMID: 31689350 DOI: 10.1093/infdis/jiz581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent evidence highlights human cytomegalovirus (HCMV) and immune activation as risk factors for tuberculosis disease. It is not known whether other herpesviruses are also implicated, nor whether a dose-response relationship exists between tuberculosis risk and herpes coinfection. METHODS This nested case-control study used stored serum samples from 25 persons with tuberculosis up to 10 years before tuberculosis diagnosis and between 3 and 6 matched controls without tuberculosis from a rural Ugandan cohort. Samples were investigated for Epstein-Barr virus, herpes simplex virus, and HCMV-specific immunoglobulin G (IgG), serum markers of inflammation, and mycobacterial antibody levels. RESULTS Humoral response to HCMV, but not Epstein-Barr or herpes simplex virus, was associated with increased risk of active tuberculosis disease up to 10 years before diagnosis. Individuals with medium HCMV IgG were 2.8 times more likely to have tuberculosis (P = .055), and those with high HCMV IgG 3.4 times more likely to have tuberculosis (P = .007). Mycobacterial antibody levels were not associated with differences in odds of tuberculosis disease. Interferon-induced protein 10 was independently associated with increased odds of tuberculosis (odds ratio, 4.2; P = .009). CONCLUSIONS These data provide evidence of a dose response between magnitude of HCMV IgG with risk of tuberculosis disease. An inflammatory environment, characterized by serum interferon-induced protein 10 and interleukin 1α, is independently associated with increased risk of tuberculosis disease.
Collapse
Affiliation(s)
- Lisa Stockdale
- London School of Hygiene & Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Stephen Nash
- London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Ruth Farmer
- London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - John Raynes
- London School of Hygiene & Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
| | | | - Robert Newton
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- University of York, Department of Health Sciences, York, United Kingdom
- International Agency for Research on Cancer, Lyon, France
| | - Helen A Fletcher
- London School of Hygiene & Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| |
Collapse
|
32
|
Gon G, Virgo S, de Barra M, Ali SM, Campbell OM, Graham WJ, Nash S, Woodd SL, de Bruin M. Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards. Int J Environ Res Public Health 2020; 17:ijerph17041438. [PMID: 32102276 PMCID: PMC7068290 DOI: 10.3390/ijerph17041438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/16/2022]
Abstract
Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58–5.14), a higher workload (OR:29.4; CI:12.9–67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02–3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98–1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5–8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.
Collapse
Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
- Correspondence:
| | - Sandra Virgo
- University of Kent, Higher Education Access Tracker, Catenrbury CT2 7NZ, UK;
| | - Mícheál de Barra
- Department of Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK;
| | - Said M. Ali
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar 9820, Tanzania;
| | - Oona M. Campbell
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Wendy J. Graham
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Susannah L. Woodd
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Marijn de Bruin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB24 3FX, UK;
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, 6525 GA Nijmegen, The Netherlands
| |
Collapse
|
33
|
Abaasa A, Todd J, Nash S, Mayanja Y, Kaleebu P, Fast PE, Price M. Comparison of retention in observational cohorts and nested simulated HIV vaccine efficacy trials in the key populations in Uganda. BMC Med Res Methodol 2020; 20:32. [PMID: 32050900 PMCID: PMC7014936 DOI: 10.1186/s12874-020-00920-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 02/06/2020] [Indexed: 12/03/2022] Open
Abstract
Background Outcomes in observational studies may not best estimate those expected in the HIV vaccine efficacy trials. We compared retention in Simulated HIV Vaccine Efficacy Trials (SiVETs) and observational cohorts drawn from two key populations in Uganda. Methods Two SiVETs were nested within two observational cohorts, one in Fisherfolk (FF) and another one in Female Sex Workers (FSW). Adult participants in each observational cohort were screened for enrolment into SiVETs. Those screened-out or not screened continued participation in the observational (non-SiVET) cohorts. SiVET participants were administered a licensed hepatitis B vaccine in a schedule that mimicked an actual HIV vaccine efficacy trial. Both cohorts were followed for 12 months and retention was assessed through dropout, defined as lost to follow up, being uncontactable, refusal to continue or missing the last study clinic visit. Dropout rates were compared using Poisson models giving rate ratios and 95% confidence intervals (95%CI). Results Out of 1525 participants (565 FF and 960 FSW), 572 (38%) were enrolled into SiVETs (282-FF and 290-FSW), and 953 (62%) remained in the non-SiVET cohorts. Overall, 326 (101 SiVET, 225 non-SiVET) dropped out in 1260 Person Years of Observation (PYO), a dropout rate of 25.9 /100 PYO (95%CI: 23.2–28.8); fewer dropped out in the SiVET cohorts (18.4, 95% CI: 15.1–22.4) than in the non-SiVET cohorts (31.6, 95% CI: 27.8–36.1), rate ratio (RR) =0.58, 95% CI: 0.46–0.73. In all cohorts, the dropout was more marked in FSW than in FF population. Duration lived in community was associated with dropout in both SiVETs and religion in both non-SiVET cohorts. Conclusion The rate of dropout was lower in SiVET compared to non-SiVET cohort. Though the difference in dropout between SiVET and non-SiVET was generally similar, the actual dropout rates were higher in the FSW population. Conduct of SiVETs in these key populations could mean that designing HIV Vaccine Efficacy Trials will benefit from lower dropout rate shown in SiVET than non-SiVET observational cohort.
Collapse
Affiliation(s)
- Andrew Abaasa
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda. .,London School of Hygiene and Tropical Medicine, London, UK.
| | - Jim Todd
- London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London, UK
| | - Yunia Mayanja
- MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Patricia E Fast
- International AIDS Vaccine Initiative, New York, USA.,Pediatric Infectious Diseases, School of Medicine, Stanford University, Palo Alto, California, USA
| | - Matt Price
- International AIDS Vaccine Initiative, New York, USA.,Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, USA
| |
Collapse
|
34
|
Nalwoga A, Cose S, Nash S, Miley W, Asiki G, Kusemererwa S, Yarchoan R, Labo N, Whitby D, Newton R. Relationship Between Anemia, Malaria Coinfection, and Kaposi Sarcoma-Associated Herpesvirus Seropositivity in a Population-Based Study in Rural Uganda. J Infect Dis 2019; 218:1061-1065. [PMID: 29741631 DOI: 10.1093/infdis/jiy274] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/07/2018] [Indexed: 02/07/2023] Open
Abstract
We examined anemia and malaria as risk factors for Kaposi sarcoma-associated herpesvirus (KSHV) seropositivity and antibody levels in a long-standing rural Ugandan cohort, in which KSHV is prevalent. Samples from 4134 children, aged 1-17 years, with a sex ratio of 1:1, and 3149 adults aged 18-103 years, 41% of whom were males, were analyzed. Among children, malaria infection was associated with higher KSHV prevalence (61% vs 41% prevalence among malaria infected and uninfected, respectively); malaria was not assessed in adults. Additionally, lower hemoglobin level was associated with an increased prevalence of KSHV seropositivity, both in children and in adults.
Collapse
Affiliation(s)
- Angela Nalwoga
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, United Kingdom
| | - Stephen Cose
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,London School of Hygiene and Tropical Medicine, United Kingdom
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, United Kingdom
| | - Wendell Miley
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, MD
| | - Gershim Asiki
- African Population and Health Research Centre, Nairobi, Kenya
| | - Sylvia Kusemererwa
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Nazzarena Labo
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, MD
| | - Denise Whitby
- Viral Oncology Section, AIDS and Cancer Virus Program, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, MD
| | - Robert Newton
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda.,University of York, United Kingdom
| |
Collapse
|
35
|
Stockdale L, Nalwoga A, Nash S, Elias S, Asiki G, Kusemererwa S, Gilchrist JJ, Newton R, MacLennan CA. Cross-sectional study of IgG antibody levels to invasive nontyphoidal Salmonella LPS O-antigen with age in Uganda. Gates Open Res 2019; 3:1501. [PMID: 31410397 PMCID: PMC6640003 DOI: 10.12688/gatesopenres.13034.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 11/20/2022] Open
Abstract
Invasive nontyphoidal
Salmonella (iNTS) disease is a major cause of deaths among children and HIV-infected individuals in sub-Saharan Africa. Acquisition of IgG to iNTS lipopolysaccharide (LPS) O-antigen in Malawi in early childhood corresponds with a fall in cases of iNTS disease suggesting that vaccines able to induce such antibodies could confer protection. To better understand the acquisition of IgG to iNTS in other African settings, we performed a cross-sectional seroepidemiological study using sera from 1090 Ugandan individuals aged from infancy to old age. Sera were analysed for IgG to LPS O-antigen of
S. Typhimurium and
S. Enteritidis using an in-house ELISA. Below 18 months of age, most children lacked IgG to both serovars. Thereafter, specific IgG levels increased with age, peaking in adulthood, and did not wane noticeably in old age. There was no clear difference in antibody levels between the sexes and the few HIV-infected individuals in the study did not have obviously different levels from uninfected subjects. While IgG to iNTS is acquired at a younger age in Malawian compared with Ugandan children, it is not clear whether this is due to differences in the populations themselves, their exposure to iNTS, or variations between assays used. In conclusion, there is a need to develop a harmonised method and standards for measuring antibodies to iNTS across studies and to investigate acquisition of such antibodies with age across different sites in sub-Saharan Africa.
Collapse
Affiliation(s)
- Lisa Stockdale
- Department of Paediatrics, University of Oxford, Oxford, OX3 7LE, UK
| | - Angela Nalwoga
- MRC/UVRI and LSHTM Uganda Research Institute, Entebbe, Uganda.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Stephen Nash
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Sean Elias
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7DQ, UK
| | - Gershim Asiki
- MRC/UVRI and LSHTM Uganda Research Institute, Entebbe, Uganda
| | | | - James J Gilchrist
- Department of Paediatrics, University of Oxford, Oxford, OX3 7LE, UK
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Institute, Entebbe, Uganda.,Clinical Epidemiology, University of York, York, UK
| | - Calman A MacLennan
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7DQ, UK
| |
Collapse
|
36
|
Nash S. Frontline Lessons from Vietnam's Battle to Save Biodiversity. Bioscience 2019. [DOI: 10.1093/biosci/biz033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
37
|
Sanya RE, Nkurunungi G, Hoek Spaans R, Nampijja M, O’Hara G, Kizindo R, Oduru G, Kabuubi Nakawungu P, Niwagaba E, Abayo E, Kabagenyi J, Zziwa C, Tumusiime J, Nakazibwe E, Kaweesa J, Muwonge Kakooza F, Akello M, Lubyayi L, Verweij J, Nash S, van Ree R, Mpairwe H, Tukahebwa E, Webb EL, Elliott AM. The Impact of Intensive Versus Standard Anthelminthic Treatment on Allergy-related Outcomes, Helminth Infection Intensity, and Helminth-related Morbidity in Lake Victoria Fishing Communities, Uganda: Results From the LaVIISWA Cluster-randomized Trial. Clin Infect Dis 2019; 68:1665-1674. [PMID: 30202872 PMCID: PMC6495012 DOI: 10.1093/cid/ciy761] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/03/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The prevalence of allergy-related diseases is increasing in low-income countries. Parasitic helminths, common in these settings, may be protective. We hypothesized that intensive, community-wide, anthelminthic mass drug administration (MDA) would increase allergy-related diseases, while reducing helminth-related morbidity. METHODS In an open, cluster-randomized trial (ISRCTN47196031), we randomized 26 high-schistosomiasis-transmission fishing villages in Lake Victoria, Uganda, in a 1:1 ratio to receive community-wide intensive (quarterly single-dose praziquantel plus albendazole daily for 3 days) or standard (annual praziquantel plus 6 monthly single-dose albendazole) MDA. Primary outcomes were recent wheezing, skin prick test positivity (SPT), and allergen-specific immunoglobulin E (asIgE) after 3 years of intervention. Secondary outcomes included helminths, haemoglobin, and hepatosplenomegaly. RESULTS The outcome survey comprised 3350 individuals. Intensive MDA had no effect on wheezing (risk ratio [RR] 1.11, 95% confidence interval [CI] 0.64-1.93), SPT (RR 1.10, 95% CI 0.85-1.42), or asIgE (RR 0.96, 95% CI 0.82-1.12). Intensive MDA reduced Schistosoma mansoni infection intensity: the prevalence from Kato Katz examinations of single stool samples from each patient was 23% versus 39% (RR 0.70, 95% CI 0.55-0.88), but the urine circulating cathodic antigen test remained positive in 85% participants in both trial arms. Hookworm prevalence was 8% versus 11% (RR 0.55, 95% CI 0.31-1.00). There were no differences in anemia or hepatospenomegaly between trial arms. CONCLUSIONS Despite reductions in S. mansoni intensity and hookworm prevalence, intensive MDA had no effect on atopy, allergy-related diseases, or helminth-related pathology. This could be due to sustained low-intensity infections; thus, a causal link between helminths and allergy outcomes cannot be discounted. Intensive community-based MDA has a limited impact in high-schistosomiasis-transmission fishing communities, in the absence of other interventions. CLINICAL TRIALS REGISTRATION ISRCTN47196031.
Collapse
Affiliation(s)
- Richard E Sanya
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gyaviira Nkurunungi
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Remy Hoek Spaans
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Margaret Nampijja
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Geraldine O’Hara
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Robert Kizindo
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Gloria Oduru
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Prossy Kabuubi Nakawungu
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Emmanuel Niwagaba
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Elson Abayo
- Entebbe Hospital, Wakiso District Local Government, Uganda
| | - Joyce Kabagenyi
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Christopher Zziwa
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | | | | | - James Kaweesa
- Vector Control Division, Ministry of Health, Kampala, Uganda
| | | | - Mirriam Akello
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Lawrence Lubyayi
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | - Jaco Verweij
- Laboratory for Medical Microbiology and Immunology, St Elisabeth Hospital, Tilburg, The Netherlands
| | - Stephen Nash
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Ronald van Ree
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Harriet Mpairwe
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
| | | | - Emily L Webb
- Medical Research Council Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Alison M Elliott
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, United Kingdom
| |
Collapse
|
38
|
Kuteesa MO, Weiss HA, Abaasa A, Nash S, Nsubuga RN, Newton R, Seeley J, Kamali A. Feasibility of conducting HIV combination prevention interventions in fishing communities in Uganda: A pilot cluster randomised trial. PLoS One 2019; 14:e0210719. [PMID: 30917121 PMCID: PMC6436767 DOI: 10.1371/journal.pone.0210719] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 01/01/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We assessed feasibility of an HIV-combination-prevention trial among fishing communities in Uganda. DESIGN Cluster randomised trial in four fishing communities on Lake Victoria, Uganda. Two intervention communities received a combination-prevention-package (behaviour change communication, condom promotion, HIV testing, voluntary male medical circumcision and referral for anti-retroviral therapy if HIV-positive). All four communities received routine government HIV care services. METHODS Using household census data we randomly selected a cohort of consenting residents aged ≥18 years. A baseline sero-survey in July 2014 was followed by two repeat surveys in March and December 2015. We measured uptake of HIV prevention methods, loss-to-follow-up and HIV incidence, accounting for multistage survey design. RESULTS A total of 862 participants were enrolled and followed for 15 months. Participation was 62% and 74% in the control and intervention arms respectively; Overall loss to follow up (LTFU) was 21.6% and was similar by arm. Self-reported abstinence/faithfulness increased between baseline and endline in both arms from 53% to 73% in the control arm, and 55% to 67% in the intervention arm. Reported condom use throughout the study period was 36% in the intervention arm vs 28% in the control arm; number of male participants reporting circumsicion in both arms from 58% to 79% in the intervention arm, and 39% to 46% in the control arm. Independent baseline predictors of loss-to-follow-up were: being HIV positive, residence in the community for <1 year, younger age, living in an urban area, and being away from the area for >1 month/year. CONCLUSIONS Recruitment and retention of participants in longitudinal trials in highly mobile HIV fishing communities is challenging. Future research should investigate modes for locating and retaining participants, and delivery of HIV-combination prevention.
Collapse
Affiliation(s)
- Monica O. Kuteesa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
- * E-mail:
| | - Helen A. Weiss
- London School of Hygiene and Tropical Medicine, London United Kingdom
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London United Kingdom
| | - Andrew Abaasa
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London United Kingdom
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London United Kingdom
| | | | - Rob Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe Uganda
- London School of Hygiene and Tropical Medicine, London United Kingdom
| | | |
Collapse
|
39
|
Abaasa A, Nash S, Mayanja Y, Price M, Fast PE, Kamali A, Kaleebu P, Todd J. Simulated vaccine efficacy trials to estimate HIV incidence for actual vaccine clinical trials in key populations in Uganda. Vaccine 2019; 37:2065-2072. [PMID: 30857933 DOI: 10.1016/j.vaccine.2019.02.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/25/2019] [Accepted: 02/27/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fisherfolks (FF) and female sex workers (FSW) in Uganda could be suitable key populations for HIV vaccine efficacy trials because of the high HIV incidence and good retention in observational cohorts. However, the observed HIV incidence may differ in participants who enroll into a trial. We used simulated vaccine efficacy trials (SiVET) nested within observational cohorts in these populations to evaluate this difference. METHODS SiVETs were nested in two observational cohorts (Jul 2012-Apr 2014 in FF and Aug 2014-Apr 2017 in FSW). From Jan 2012 all observational cohort participants (aged 18-49 years) presenting for quarterly visits were screened for enrolment into SiVETs, until 572 were enrolled. Those not enrolled (screened-out or not screened) in SiVET continued participation in the observational cohorts. In addition to procedures in the observational cohorts (HIV testing & risk assessment), SiVET participants were given a licensed Hepatitis B vaccine mimicking a schedule of a possible HIV vaccine, and followed-up for 12 months. FINDINGS In total, 3989 participants were enrolled into observational cohorts (1575 FF prior to Jul 2012 and 2414 FSW prior to Aug 2014). Of these 3622 (90.8%) returned at least once, 672 (44.1%) were screened and 572 enrolled in the SiVETs. HIV incidence pre SIVETs was 4.5/100 person years-at-risk (pyar), 95%CI (3.8-5.5). HIV incidence in SiVET was 3.5/100 pyar, (2.2-5.6) and higher in those not enrolled in the SiVET, 5.9/100 pyar, (4.3-8.1). This difference was greatest among FF. In the 12 months post-SIVET period (FF, May 2014-Apr 2015 and FSW, May 2017-Apr 2018), the HIV incidence was 3.7/100 pyar, (2.5-5.8). INTERPRETATION HIV incidence was lower in SiVET participants compared to non-SiVET. This difference was different for the two populations. Researchers designing HIV efficacy trials using observational cohort data need to consider the potential for lower than expected HIV incidence following screening and enrolment.
Collapse
Affiliation(s)
- Andrew Abaasa
- MRC/UVRI & LSTHM Uganda Research Unit, Entebbe, Uganda; London School of Hygiene and Tropical Medicine, London, UK.
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London, UK
| | - Yunia Mayanja
- MRC/UVRI & LSTHM Uganda Research Unit, Entebbe, Uganda
| | - Matt Price
- International AIDS Vaccine Initiative, New York, USA; University of California at San Francisco, Department of Epidemiology and Biostatistics, San Francisco, USA
| | - Patricia E Fast
- International AIDS Vaccine Initiative, New York, USA; Pediatric Infectious Diseases, School of Medicine, Stanford University, USA
| | | | | | - Jim Todd
- London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
40
|
Gon G, de Bruin M, de Barra M, Ali SM, Campbell OM, Graham WJ, Juma M, Nash S, Kilpatrick C, Penn-Kekana L, Virgo S, Woodd S. Hands washing, glove use, and avoiding recontamination before aseptic procedures at birth: A multicenter time-and-motion study conducted in Zanzibar. Am J Infect Control 2019; 47:149-156. [PMID: 30293743 PMCID: PMC6367567 DOI: 10.1016/j.ajic.2018.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Our primary objective was to assess hand hygiene (HH) compliance before aseptic procedures among birth attendants in the 10 highest-volume facilities in Zanzibar. We also examined the extent to which recontamination contributes to poor HH. Recording exact recontamination occurrences is not possible using the existing World Health Organization HH audit tool. METHODS In this time-and-motion study, 3 trained coders used WOMBATv2 software to record the hand actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence intervals (CIs) for individual behaviors (hand washing/rubbing, avoiding recontamination and glove use) and for behavioral sequences during labor and delivery were calculated. RESULTS We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance with hand rubbing/washing was 24.6% (95% CI, 21.6-27.8). Only 9.6% (95% CI, 7.6-11.9) of birth attendants also donned gloves and avoided recontamination. Half of the time when rubbing/washing or glove donning was performed, hands were recontaminated prior to the aseptic procedure. CONCLUSIONS In this study, HH compliance by birth attendants before aseptic procedures was poor. To our knowledge, this is the first study in a low- to middle-income country to show the large contribution to poor HH compliance from hand and glove recontamination before the procedure. Recontamination is an important driver of infection risk from poor HH. It should be understood for the purposes of improvement and therefore included in HH monitoring and interventions.
Collapse
Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom.
| | - Marijn de Bruin
- University of Aberdeen, Institute of Applied Health Sciences, Aberdeen, United Kingdom
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, United Kingdom
| | - Said M Ali
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar, Tanzania
| | - Oona M Campbell
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Wendy J Graham
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Mohammed Juma
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar, Tanzania
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Claire Kilpatrick
- Consultant, World Health Organization IPC Global Unit, Service Delivery and Safety Department, Geneva, Switzerland
| | - Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Sandra Virgo
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Susannah Woodd
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| |
Collapse
|
41
|
Stockdale L, Nash S, Nalwoga A, Gibson L, Painter H, Raynes J, Asiki G, Newton R, Fletcher H. HIV, HCMV and mycobacterial antibody levels: a cross-sectional study in a rural Ugandan cohort. Trop Med Int Health 2019; 24:247-257. [PMID: 30506614 PMCID: PMC6378403 DOI: 10.1111/tmi.13188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES A growing evidence base implicates human cytomegalovirus (HCMV) as a risk factor for TB disease. We investigated total IgG and mycobacteria-specific antibodies in a cross-sectional study nested within a rural Ugandan General Population Cohort (GPC), in relation to HIV infection and the magnitude of HCMV IgG response. METHODS Sera from 2189 individuals (including 27 sputum-positive TB cases) were analysed for antibodies against mycobacteria (Ag85A, PPD, LAM, ESAT6/CFP10) and HCMV, tetanus toxoid (TT) and total IgG. RESULTS Anti-mycobacterial antibodies increased with age until approximately 20 years, when they plateaued. Higher HCMV exposure (measured by IgG) was associated with lower levels of some anti-mycobacterial antibodies, but no increase in total IgG. HIV infection was associated with a decrease in all anti-mycobacterial antibodies measured and with an increase in total IgG. CONCLUSIONS The increase in anti-mycobacterial antibodies with age suggests increasing exposure to non-tuberculous mycobacteria (NTM), and to M.tb itself. HIV infection is associated with decreased levels of all mycobacterial antibodies studied here, and high levels of HCMV IgG are associated with decreased levels of some mycobacterial antibodies. These findings point towards the importance of humoral immune responses in HIV/TB co-infection and highlight a possible role of HCMV as a risk factor for TB disease.
Collapse
Affiliation(s)
- Lisa Stockdale
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Stephen Nash
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Angela Nalwoga
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Medical Research Council/Uganda Virus Research InstituteEntebbeUganda
| | - Lorna Gibson
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Hannah Painter
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - John Raynes
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Gershim Asiki
- African Population and Health Research CenterNairobiKenya
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Robert Newton
- Medical Research Council/Uganda Virus Research InstituteEntebbeUganda
- Department of Health SciencesUniversity of YorkYorkUK
- International Agency for Research on CancerLyonFrance
| | - Helen Fletcher
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| |
Collapse
|
42
|
Abstract
BACKGROUND Although patients value evidence-based therapeutic activities, little is known about nurses' perceptions.AimsTo investigate whether implementing an activities training programme would positively alter staff perceptions of the ward or be detrimental through the increased workload (trial registration: ISRCTN 06545047). METHOD We conducted a stepped wedge cluster randomised trial involving 16 wards with psychology-led nurse training as the intervention. The main outcome was a staff self-report measure of perceptions of the ward (VOTE) and secondary outcomes measuring potential deterioration were the Index of Work Satisfaction (IWS) and the Maslach Burnout Inventory (MBI). Data were analysed using mixed-effects regression models, with repeated assessments from staff over time. RESULTS There were 1075 valid outcome measurements from 539 nursing staff. VOTE scores did not change over time (standardised effect size 0.04, 95% CI -0.09 to 0.18, P = 0.54), neither did IWS or MBI scores (IWS, standardised effect size 0.02, 95% CI -0.11 to 0.16, P = 0.74; MBI standardised effect size -0.09, 95% CI -0.24 to 0.06, P = 0.24). There was a mean increase of 1.5 activities per ward (95% CI -0.4 to 3.4, P = 0.12) and on average 6.3 more patients attended groups (95% CI -4.1 to 16.6, P = 0.23) following training. Staff feedback on training was positive. CONCLUSIONS Our training programme did not change nurses' perceptions of the ward, job satisfaction or burnout. During the study period many service changes occurred, most having a negative impact through increased pressure on staffing, patient mix and management so it is perhaps unsurprising that we found no benefits or reduction in staff skill.Declaration of interestNone.
Collapse
Affiliation(s)
- Emese Csipke
- Doctor, Senior Research Fellow,Division of Psychiatry,University College London,UK
| | - Til Wykes
- Professor Dame,Institute of Psychiatry,Psychology and Neuroscience,King's College London,South London and Maudsley NHS Foundation Trust,UK
| | - Stephen Nash
- Statistician,London School of Hygiene and Tropical Medicine,UK
| | - Paul Williams
- Statistician,Institute of Psychiatry, Psychology and Neuroscience,Kings College London,UK
| | - Leo Koeser
- Research Assistant,Institute of Psychiatry, Psychology and Neuroscience,Kings College London,UK
| | - Paul McCrone
- Professor of Health Economics,Institute of Psychiatry,Psychology and Neuroscience,King's College London,UK
| | - Diana Rose
- Professor of User-Led Research,Institute of Psychiatry,Psychology and Neuroscience,King's College London,UK
| | - Tom Craig
- Professor of Social Psychiatry,Institute of Psychiatry,Psychology and Neuroscience,King's College London,UK
| |
Collapse
|
43
|
Wykes T, Csipke E, Rose D, Craig T, McCrone P, Williams P, Koeser L, Nash S. Patient involvement in improving the evidence base on mental health inpatient care: the PERCEIVE programme. Programme Grants Appl Res 2018. [DOI: 10.3310/pgfar06070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDespite the movement towards care in the community, 40% of the NHS budget on mental health care is still attributed to inpatient services. However, long before the Francis Report highlighted grave shortcomings in inpatient care, there were reports by service user groups on the poor quality of these services in mental health. The programme provides a particular focus on the inclusion of the patient’s perspective in the development and evaluation of evidence.ObjectivesTo understand how changes to inpatient care affect the perceptions of the ward by service users and staff by using stakeholder participatory methods.DesignThe programme consisted of four work packages (WPs). (1) Lasting Improvements for Acute Inpatient SEttings (LIAISE): using participatory methods we developed two new scales [Views On Therapeutic Environment (VOTE) for staff and Views On Inpatient CarE (VOICE) for service users]. (2) Client Services Receipt Inventory – Inpatient (CITRINE): working with nurses and service users we developed a health economic measure of the amount of contact service users have with staff. The self-report measure records interactions with staff as well as the number of therapeutic activities attended. (3) Delivering Opportunities for Recovery (DOORWAYS): a stepped-wedge randomised controlled trial to test if training ward nurses to deliver therapeutic group activities would improve the perception of the ward by service users and staff. A total of 16 wards were progressively randomised and we compared the VOICE, VOTE and CITRINE measures before and after the intervention. A total of 1108 service users and 539 staff participated in this trial. (4) Bringing Emergency TreatmenT to Early Resolution (BETTER PATHWAYS) was an observational study comparing two service systems. The first was a ‘triage’ system in which service users were admitted to the triage ward and then either transferred to their locality wards or discharged back into the community within 7 days. The second system was routine care. We collected data from 454 service users and 284 nurses on their perceptions of the wards.Main outcome measuresThe main outcomes for the DOORWAYS and BETTER project were service user and staff perceptions of the ward (VOICE and VOTE, respectively) and the health economic measure was CITRINE. All were developed in WPs 1 and 2.ResultsWe developed reliable and valid measures of (1) the perceptions of inpatient care from the perspectives of service users and nurses (VOICE and VOTE) and (2) costs of interactions that were valued by service users (CITRINE). In the DOORWAYS project, after adjusting for legal status, we found weak evidence for benefit (standardised effect of –0.18, 95% CI 0.38 improvement to 0.01 deterioration;p = 0.062). There was only a significant benefit for involuntary patients following the staff training (N582, standardised effect of –0.35, 95% CI –0.57 to –0.12;p = 0.002; interactionp-value 0.006). VOTE scores did not change over time (standardised effect size of 0.04, 95% CI –0.09 to 0.18;p = 0.54). We found no evidence of an improvement in cost-effectiveness (estimated effect of £33, 95% CI –£91 to £146;p = 0.602), but resource allocation did change towards patient-perceived meaningful contacts by an average of £12 (95% CI –£76 to £98;p = 0·774). There were no significant differences between the triage and routine models of admission in terms of better perceptions by service users (estimated effect 0.77-point improvement in VOICE score on the triage ward;p = 0.68) or nurses (estimated effect of 1.68-point deterioration in VOTE on the triage ward;p = 0.38) or in terms of the cost of the length of care provided (£391 higher on triage;p = 0.77).Strengths and limitationsWe have developed measures using methods involving both service users and staff from mental health services. The measures were developed specifically for acute inpatient services and, therefore, cannot be assumed to be useful for other services. For instance, extensions of the measures are under construction for use in mother and baby units. The strength of the BETTER PATHWAYS and DOORWAYS projects is the large-scale data collection. However, we were testing specific services based in inner city areas and stretching to inner urban areas. It may be that different effects would be found in more rural communities or in different types of inpatient care.Future workOur database will be used to develop an understanding of the mediating and moderating factors for improving care quality.Trial registrationCurrent Controlled Trials ISRCTN06545047.FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 7. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Til Wykes
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Emese Csipke
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Diana Rose
- Health Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Thomas Craig
- Health Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Health Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Paul Williams
- Health Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Leonardo Koeser
- Health Services and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Stephen Nash
- Department of Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| |
Collapse
|
44
|
Fatima P, Antora AH, Dewan F, Nash S, Sethi M. Impact of contraceptive counselling training among counsellors participating in the FIGO postpartum intrauterine device initiative in Bangladesh. Int J Gynaecol Obstet 2018; 143 Suppl 1:49-55. [DOI: 10.1002/ijgo.12605] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Parveen Fatima
- Obstetrical and Gynaecological Society of Bangladesh Dhaka Bangladesh
| | | | - Farhana Dewan
- Obstetrical and Gynaecological Society of Bangladesh Dhaka Bangladesh
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine London UK
| | - Maya Sethi
- International Federation of Gynecology and Obstetrics London UK
| |
Collapse
|
45
|
Nash S, Tittle V, Abaasa A, Sanya RE, Asiki G, Hansen CH, Grosskurth H, Kapiga S, Grundy C. The validity of an area-based method to estimate the size of hard-to-reach populations using satellite images: the example of fishing populations of Lake Victoria. Emerg Themes Epidemiol 2018; 15:11. [PMID: 30123310 PMCID: PMC6090724 DOI: 10.1186/s12982-018-0079-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 07/31/2018] [Indexed: 05/29/2023] Open
Abstract
Background Information on the size of populations is crucial for planning of service and resource allocation to communities in need of health interventions. In resource limited settings, reliable census data are often not available. Using publicly available Google Earth Pro and available local household survey data from fishing communities (FC) on Lake Victoria in Uganda, we compared two simple methods (using average population density) and one simple linear regression model to estimate populations of small rural FC in Uganda. We split the dataset into two sections; one to obtain parameters and one to test the validity of the models. Results Out of 66 FC, we were able to estimate populations for 47. There were 16 FC in the test set. The estimates for total population from all three methods were similar, with errors less than 2.2%. Estimates of individual FC populations were more widely discrepant. Conclusions In our rural Ugandan setting, it was possible to use a simple area based model to get reasonable estimates of total population. However, there were often large errors in estimates for individual villages.
Collapse
Affiliation(s)
- Stephen Nash
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK
| | - Victoria Tittle
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK
| | - Andrew Abaasa
- 2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | | | - Gershim Asiki
- 2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Christian Holm Hansen
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK.,2MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Heiner Grosskurth
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK.,3Mwanza Interventions Trials Unit (MITU/NIMR), Mwanza, Tanzania
| | - Saidi Kapiga
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK.,3Mwanza Interventions Trials Unit (MITU/NIMR), Mwanza, Tanzania
| | - Chris Grundy
- 1London School of Hygiene and Tropical Medicine, Room G13, Keppel Street, London, WC1E 7HT UK
| | | |
Collapse
|
46
|
Trotry C, Rode G, Nash S. Descriptive study of post-minor stroke cognitive defects (modified ranking scale ≤ 2), impact on quality of life and return to work. Ann Phys Rehabil Med 2018. [DOI: 10.1016/j.rehab.2018.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
47
|
Nash S. Converging Ills in America's Ecosystems. Bioscience 2018. [DOI: 10.1093/biosci/biy044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Stephen Nash
- Stephen Nash is a journalist and a contributor to the Feature section of BioScience. His book Virginia Climate Fever won the American Institute of Physics award for science writing in 2015. His latest book, Grand Canyon for Sale: Public Lands versus Private Interests in the Era of Climate Change, was published by the University of California Press in 2017
| |
Collapse
|
48
|
Brown AE, Nash S, Connor N, Kirwan PD, Ogaz D, Croxford S, Angelis DD, Delpech VC. Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK. HIV Med 2018; 19:505-512. [PMID: 29923668 DOI: 10.1111/hiv.12617] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Our objective was to present recent trends in the UK HIV epidemic (2007-2016) and the public health response. METHODS HIV diagnoses and clinical markers were extracted from the HIV and AIDS Reporting System; HIV testing data in sexual health services (SHS) were taken from GUMCAD STI Surveillance System. HIV data were modelled to estimate the incidence in men who have sex with men (MSM) and post-migration HIV acquisition in heterosexuals. Office for National Statistics (ONS) data enabled mortality rates to be calculated. RESULTS New HIV diagnoses have declined in heterosexuals as a result of decreasing numbers of migrants from high HIV prevalence countries entering the UK. Among MSM, the number of HIV diagnoses fell from 3570 in 2015 to 2810 in 2016 (and from 1554 to 1096 in London). Preceding the decline in HIV diagnoses, modelled estimates indicate that transmission began to fall in 2012, from 2800 [credible interval (CrI) 2300-3200] to 1700 (CrI 900-2700) in 2016. The crude mortality rate among people promptly diagnosed with HIV infection was comparable to that in the general population (1.22 vs. 1.39 per 1000 aged 15-59 years, respectively). The number of MSM tested for HIV at SHS increased annually; 28% of MSM who were tested in 2016 had been tested in the preceding year. In 2016, 76% of people started antiretroviral therapy within 90 days of diagnosis (33% in 2007). CONCLUSIONS The dual successes of the HIV transmission decline in MSM and reduced mortality are attributable to frequent HIV testing and prompt treatment (combination prevention). Progress towards the elimination of HIV transmission, AIDS and HIV-related deaths could be achieved if combination prevention, including pre-exposure prophylaxis, is replicated for all populations.
Collapse
Affiliation(s)
- A E Brown
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - S Nash
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - N Connor
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - P D Kirwan
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - D Ogaz
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - S Croxford
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | | | - V C Delpech
- HIV and STI Department, National Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| |
Collapse
|
49
|
Stockdale L, Nash S, Nalwoga A, Painter H, Asiki G, Fletcher H, Newton R. Human cytomegalovirus epidemiology and relationship to tuberculosis and cardiovascular disease risk factors in a rural Ugandan cohort. PLoS One 2018; 13:e0192086. [PMID: 29408860 PMCID: PMC5800673 DOI: 10.1371/journal.pone.0192086] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/16/2018] [Indexed: 12/11/2022] Open
Abstract
Human cytomegalovirus (HCMV) infection has been associated with increased mortality, specifically cardiovascular disease (CVD), in high-income countries (HICs). There is a paucity of data in low- and middle-income countries (LMICs) where HCMV seropositivity is higher. Serum samples from 2,174 Ugandan individuals were investigated for HCMV antibodies and data linked to demographic information, co-infections and a variety of CVD measurements. HCMV seropositivity was 83% by one year of age, increasing to 95% by five years. Female sex, HIV positivity and active pulmonary tuberculosis (TB) were associated with an increase in HCMV IgG levels in adjusted analyses. There was no evidence of any associations with risk factors for CVD after adjusting for age and sex. HCMV infection is ubiquitous in this rural Ugandan cohort from a young age. The association between TB disease and high HCMV IgG levels merits further research. Known CVD risk factors do not appear to be associated with higher HCMV antibody levels in this Ugandan cohort.
Collapse
Affiliation(s)
- Lisa Stockdale
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
| | - Angela Nalwoga
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Hannah Painter
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
| | - Gershim Asiki
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
| | - Helen Fletcher
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, United Kingdom
| | - Robert Newton
- Medical Research Council/Uganda Virus Research Institute, Entebbe, Uganda
- University of York, Department of Health Sciences, York, United Kingdom
- International Agency for Research on Cancer, Lyon, France
| |
Collapse
|
50
|
Wykes T, Csipke E, Williams P, Koeser L, Nash S, Rose D, Craig T, McCrone P. Improving patient experiences of mental health inpatient care: a randomised controlled trial. Psychol Med 2018; 48:488-497. [PMID: 28726599 PMCID: PMC5757411 DOI: 10.1017/s003329171700188x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 06/13/2017] [Accepted: 06/14/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients' views of ward care. METHOD Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013. RESULTS In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect -0·35, 95% CI -0·57 to -0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, -0.01, 95% CI -0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect -0.18 s.d., 95% CI -0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI -£76 to £98, p = 0.774). CONCLUSION Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.
Collapse
Affiliation(s)
- T. Wykes
- Institute of Psychiatry, Psychology and
Neuroscience, King's College London, London,
UK
- South London and Maudsley NHS Trust,
London, UK
| | - E. Csipke
- Division of Psychiatry,
University College London, London,
UK
| | - P. Williams
- Institute of Psychiatry, Psychology and
Neuroscience, Kings College London, London,
UK
| | - L. Koeser
- Institute of Psychiatry, Psychology and
Neuroscience, Kings College London, London,
UK
| | - S. Nash
- London School of Hygiene and Tropical
Medicine, Keppel Street, London,
UK
| | - D. Rose
- Service User Research Enterprise, Institute of
Psychiatry, Psychology and Neuroscience, King's College London,
London, UK
| | - T. Craig
- Health Services and Population Research
Department, Institute of Psychiatry, Psychology and Neuroscience, King's College
London, London, UK
| | - P. McCrone
- Health Economics, Health Services and Population
Research, Institute of Psychiatry, Psychology and Neuroscience, King's College
London, London, UK
| |
Collapse
|