Communication breakdown in Italy’s vaccination governance

Background

In 2017, Italy rebooted its mandatory vaccination regime, following a series of unfavourable court decisions placing vaccination in disrepute. Vaccination rates had steadily declined for half a decade, culminating in a measles epidemic. Existing studies demonstrate the role of vaccine hesitancy, but none have explored the role of government in the years prior to the new mandate. This study analyses the drivers of failures to address sliding vaccine confidence in Italy.

Methods

We engaged in qualitative analysis of primary sources, Italian and international scholarship, and semi-structured interviews with key informants. These were analysed using the coding software NVivo 12. We developed an empirically and theoretically informed schema to make sense of governance failures in knowledge and action.

Results

The resort to mandates in 2017 was triggered by a series of unfortunate events, further thwarted by governance capacity gaps. During 2012-2017, Italy's vaccination governance included no online campaigns to address concerns. Public health officials lacked crucial knowledge regarding the population, including strategies to address hesitancy. They were preoccupied with other significant changes to Italy's vaccination governance, notably the vaccination schedule. Limited financial resources from the political class constrained officials' capacity in a context of austerity. A credibility gap ensued, which officials sought to plug by constructing Italians as in need of firm instruction by mandatory vaccination.

Conclusions

When voluntary vaccination failed in Italy, the new mandates improved coverage rates. However, the vaccine confidence work explored in this study should not be neglected. The future governance of vaccine confidence requires that effective communications to address vaccine confidence be implemented Italy and other jurisdictions facing vaccine hesitancy and refusal problems.

Key messages

We analyse the Italian government’s response to the crisis of vaccine confidence prior to the introduction of mandates, in order to provide lessons for other governments. We identify and explain the gaps in governance capacity that prevented the addressing of sliding coverage rates.

A Whole-Organisation Approach to Increasing Bowel Screening Participation Rates

Background and context: Australia has one of the highest rates of bowel cancer in the world, yet if detected early more than 90% of cases can be successfully treated. The Australian government's National Bowel Cancer Screening Program (NBCSP) send a free at-home iFOBT to all eligible people aged 50-74. Current uptake of the program is low (∼40%). Increasing bowel screening is a key focus of Cancer Council Victoria's (CCV) strategic plan (2017-2021). Aim: CCV aims to increase NBCSP participation rates in the state of Victoria, Australia to 50% by 2021. Strategy/Tactics: In 2017, CCV implemented its first ever television-led bowel screening campaign. A whole-organization approach was adopted to develop, implement and evaluate the campaign. Program/Policy process: A whole-organization approach included working with CCVs behavioral researchers to understand barriers and motivating factors to screen, collaboration with the epidemiology center to identify evidence to target campaign delivery, stakeholder liaison with clinicians engaged with the organization, engagement with the organization's support services to respond to calls as a result of the campaign, working with the fundraising team to develop strategies to engage supporters, and leveraging our flagship Daffodil Day initiative with a focus on bowel cancer. Outcomes: Adopting a whole-organization approach enabled all facets of the organization to be involved in a common goal. This resulted in shared ownership of campaign deliverables, greater engagement of staff across the organization in bowel screening and the identification of innovative strategies that wouldn't have been possible had this approach not been adopted. Importantly, CCV’s campaign led to greater numbers of eligible people participating in bowel screening. What was learned: The identification of bowel screening as a CCV priority was critical for enabling cross-organizational collaboration. Taking a whole-organization approach resulted in the identification of existing programs and services to leverage the campaign, strengthening its reach and overall impact.

Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial

Imagery can improve functional outcomes post-anterior cruciate ligament repair (ACLR). Research is needed to investigate potential mechanisms for this effect. The aim of this study was to (a) evaluate the effectiveness of an imagery intervention to improve functional outcomes post-ACLR, and (b) explore potential mechanisms. A randomized-controlled pilot trial was conducted. Participants were randomized to guided imagery and standard rehabilitation or standard rehabilitation alone (control). The primary outcome was knee strength 6-month post-operatively. Secondary outcomes were knee laxity at 6-months, and change in psychological (self-efficacy) and neurohormonal (adrenaline, noradrenaline, dopamine) variables. Participants (n=21; 62% male) were 34.86 (SD 8.84) years. Following the intervention, no statistical differences between groups for knee strength extension at 180°/s (t=-0.43, P=0.67), or at 60°/s (t=-0.72, P=0.48) were found. A statistically significant effect was found for knee laxity, F=4.67, P<0.05, mean difference of -3.02 (95% CI -4.44 to -1.60), favoring the intervention. No differences were found for self-efficacy; however, an overall effect was found for noradrenaline, F(1, 19) 19.65, P<0.001, η(2) =0.52, and dopamine, F(1, 19) 6.23, P=0.02, η(2) =0.29, favoring the intervention. This imagery intervention improved knee laxity and healing-related neurobiological factors.

In Vitro Efficacy and Pharmacodynamic Indices for Antibiotics against Coagulase-Negative Staphylococcus Endophthalmitis Isolates

PURPOSE

To compare pharmacodynamic indices and minimal inhibitory concentrations for vancomycin, gatifloxacin, moxifloxacin, linezolid, and combined quinupristin and dalfopristin for historic and current human coagulase-negative staphylococcus (CoNS) endophthalmitis isolates.

DESIGN

Experimental study.

PARTICIPANTS

Fifty-nine CoNS endophthalmitis isolates retrieved from patients at the Bascom Palmer Eye Institute from 1993 through 2006.

METHODS

Coagulase-negative staphylococcal endophthalmitis isolates were recovered from the microbiology specimen bank, rehydrated, and processed for susceptibility testing using standard microbiological protocols. E tests were used to determine and compare mean inhibitory concentration for 50% of isolates (MIC50) and mean inhibitory concentration for 90% of isolates (MIC90) values. Peak concentration (C(max)) was defined as the maximum attainable aqueous concentration using topical or oral therapy, or both. The MIC50 and MIC90 values for each antibiotic are the minimum concentrations that inhibit 50% and 90% of CoNS endophthalmitis isolates, respectively. Significance was determined by the McNemar test. Pharmacodynamic indices (C(max)/MIC) were calculated using determined MIC values and published intraocular drug concentrations for topical and oral dosing. The pharmacodynamic index was defined as the achievable aqueous humor concentration of an antibiotic divided by the concentration of the antibiotic required to inhibit a specified percentage of microbiologic isolates.

MAIN OUTCOME MEASURES

Pharmacodynamic indices for new and conventional antibiotics.

RESULTS

General in vitro susceptibility patterns in descending order were vancomycin (100%), linezolid (100%), quinupristin and dalfopristin (98%), moxifloxacin (48%), and gatifloxacin (47%). The corresponding MIC50 and MIC90 values were vancomycin, 2 microg/ml and 3 microg/ml, respectively; linezolid, 1 microg/ml and 4 microg/ml; quinupristin and dalfopristin, 0.25 microg/ml and 0.5 microg/ml; moxifloxacin, 0.75 microg/ml and > or =32 microg/ml; and gatifloxacin, 2 microg/ml and > or =32 microg/ml. Pharmacokinetic indices (C(max)/MIC90) for topical dosing were all <1. There was a significant difference in the percent of isolates susceptible to combined quinupristin and dalfopristin, vancomycin, and linezolid compared with moxifloxacin and gatifloxacin. There was no statistical significance in CoNS susceptibility between the tested fluoroquinolones.

CONCLUSIONS

Vancomycin, linezolid, and combined quinupristin and dalfopristin were more effective in vitro than fluoroquinolones against CoNS in the current study. Reported aqueous concentrations of the antibiotics used in this study failed to provide adequate coverage for 90% of the CoNS endophthalmitis isolates.

Why the tobacco industry fears point of sale display bans

Banning the display of tobacco products represents a major step in tobacco control and will help to reduce tobacco sales.

Smoking and gambling: a trance inducing ritual

"Smoking is a powerful re-inforcement for the trance-inducing rituals associated with gambling."

The feasibility of a porcine model of acute coronary occlusion and reperfusion using off-pump coronary artery bypass grafting

We developed an open-chest porcine model of acute coronary occlusion and surgical reperfusion, and attempted to prevent intra-operative ischaemic ventricular fibrillation (VF) by a Retrograde Intracoronary Glyceryl trinitrate (RIG) infusion into the occluded vessel. Five Yorkshire pigs (weight 50 +/- 1.1 kg), randomized into 3 groups, underwent median sternotomy under general anaesthesia. One pig (Group 1, control) underwent sternotomy and pericardiotomy only. Four pigs underwent acute left anterior descending (LAD) coronary occlusion. Two pigs were not reperfused (Group 2). Two pigs underwent surgical reperfusion (Group 3) via left internal mammary artery (LIMA) grafting to the LAD using the Off-Pump Coronary Artery Bypass (OPCAB) technique. Ischaemic injury was assessed using 7-lead electrocardiography (ECG) and transthoracic/epimyocardial echocardiography (ECHO). Group 1: transient intraoperative hypotension and VF occurred. Successful resuscitation and 10-week survival (until sacrifice) with normal left ventricular (LV) function was achieved. Group 2: there were ECG and ECHO evidence of acute LV ischaemic dysfunction in both pigs. The surviving pig had persistent anterior hypokinesis at 8 1/2 months. The other died intra-operatively following progressive ischaemic LV dysfunction despite resuscitative attempts. Group 3: the surviving pig had normal LV function at 8 months. Initial anterior LV akinesis normalized within 7 days. The other developed post-occlusion haemodynamic instability and died intra-operatively despite reperfusion. In this porcine model, acute LAD artery occlusion modified by the novel RIG infusion technique, followed by surgical reperfusion (OPCAB) is feasible. This model would facilitate further development of OPCAB surgical expertise and understanding of the pathophysiology of ischaemia-reperfusion injury.

Medicinal plants used for dogs in Trinidad and Tobago

This paper documents ethnoveterinary medicines used to treat dogs in Trinidad and Tobago. In 1995, a 4-stage process was used to conduct the research and document the ethnoveterinary practices. Twenty-eight ethnoveterinary respondents were identified using the school-essay method, which is a modified rapid rural appraisal (RRA) technique. Semi-structured interviews were held with these respondents as well as with 30 veterinarians, 27 extension officers and 19 animal-health assistants and/or agricultural officers, and the seven key respondents that they identified. The final step involved hosting four participatory workshops with 55 of the respondents interviewed to discuss the ethnoveterinary data generated from the interviews and to determine dosages for some of the plants mentioned. Supplementary interviews were conducted in 1997 and 1998. Seeds of Carica papaya, and leaves of Cassia alata, Azadirachta indica, Gossypium spp., Cajanus cajan and Chenopodium ambrosiodes are used as anthelmintics. The anthelmintics Gossypium spp. and Chenopodium ambrosiodes are the most frequently used species. Crescentia cujete pulp, Musa spp. stem exudate, the inside of the pods of Bixa orellana, leaves of Cordia curassavica and Eclipta alba plant tops are used for skin diseases. Musa spp. stem exudate, seeds of Manilkara zapota, Pouteria sapota and Mammea americana and leaves of Cordia curassavica, Scoparia dulcis and Nicotiana tabacum are used to control ectoparasites. Dogs are groomed with the leaves of Cordia curassavica, Bambusa vulgaris and Scoparia dulcis. Psidium guajava buds and leaves and the bark of Anacardium occidentale are used for diarrhoea. Owners attempt to achieve milk let-down with a decoction of the leaves of Stachytarpheta jamaicensis. The plant uses parallel those practised in human folk medicine in other Caribbean countries and in other tropical countries.

Special considerations in breast cancer risk and survival

Experimental and clinical evidence suggests that breast neoplasia appears to be a hormone-dependent process that may also be influenced by dietary factors in many women. Conflicting reports on the relationship between exogenous hormones and the development, progression, and recurrence of breast cancer are critically examined in this report. The absolute breast cancer risk associated with either hormone replacement therapy or oral contraceptive use has not been clearly defined. Data from some large prospective studies have actually documented lower mortality rates for women taking hormone replacement compared with those for women who did not have hormone replacement therapy. In this regard, age, duration of use, and preexisting breast cancer risk factors must be taken into account. Although the results of two major prospective clinical trials addressing the role of timing of surgery within the menstrual cycle are forthcoming, the majority of studies have found no consistent association between timing of surgery and breast cancer survival. Recently reported prospective randomized data showing that selective-estrogen-receptor-modulators can act as effective chemoprevention agents in women at increased risk for breast cancer development are presented. Finally, information regarding the effect of dietary manipulation on breast cancer risk and survival is reviewed.

Preferred real-ear insertion gain on a commercial hearing aid at different speech and noise levels

In the present study, we measured preferred real-ear insertion gain (REIG) under different levels of speech and noise to assess whether current automatic gain control (AGC) and automatic signal processing (ASP) hearing aids are operating optimally. Preferred REIG for optimal speech clarity was determined under seven speech and noise conditions. In four conditions, speech (discourse passages) was varied from 55 dB SPL to 85 dB SPL in 10-dB steps at a fixed signal-to-noise ratio (S/N) of +5. In the remaining conditions, speech was fixed at 65 dB SPL while the noise level was varied in 5-dB steps to yield S/Ns from +10 to -5. The results showed that subjects selected less gain as speech or noise levels were increased. In general, less overall gain was selected as speech level was increased, and less overall gain, especially in the low-frequency region, was selected as the S/N ratio became progressively poorer. These results are discussed in relation to how hearing aids with adaptive frequency/gain responses should respond to varying input levels to achieve optimal clarity of speech.

Development of compliance chamber diaphragms with reduced permeability

The implantable ventricular assist systems currently undergoing clinical readiness testing shuttle the displaced gas between the non-blood side of the pumping diaphragm and an elastic chamber generally called a "compliance chamber" or variable volume device. The movement of the stored gas allows the pump to fill and empty without compression or expansion of the gas behind the pump diaphragm. The material used for the construction of compliance chambers should be fatigue resistant to withstand the 63 million flexes per year of the blood pump. The material should also be biocompatible and highly impervious to gases. Significant diffusion of gases from the compliance system necessitates external make-up gases to somehow be added to the internal system. Material selection is complicated by the fact that most fatigue-resistant elastomers also have high gas permeability. In order to solve this problem, bilayer compliance chambers have been developed using biocompatible and fatigue-resistant polyolefin rubber comolded with relatively impervious butyl rubber.

Leukotriene C4 and D4 formation by particulate enzymes

The homogenate of rat basophilic leukemia cells, when incubated with arachidonic acid, glutathione, and calcium, formed 3 isomers of 5,12-dihydroxyeicosatetraenoic acid and 2 isomers of 5,6-dihydroxyeicosatetraenoic acid, as well as leukotriene (LT) C4 and D4. The products were identified by high pressure liquid chromatography, ultraviolet spectral analysis, co-migration with standards, bioassay, and gas chromatography-mass spectrometry. The enzymes responsible for the formation of LTC4 and LTD4 from LTA4 were found in the 10,000 x g pellet and, therefore, appear to be particulate. The possibility that these enzymes are bound to the cell membrane suggest that the formation of these leukotrienes might be important in the basophil and mast cells release reaction.