Equity throughout the life course and the evolving role of the Pan American Health Organization

The objective of this article is to summarize the evolution of the regional commitments of the Pan American Health Organization (PAHO) on health promotion and strategies to improve the health and well-being of women, children, adolescents, and older persons. PAHO regional strategies approved by Member States in the last 20 years are used as the main source of information. The article presents the challenges of making health promotion a public health strategy widely applied in the Region of the Americas and the efforts to renew Member States' collective actions. The article also describes current PAHO efforts to include the positive aspects of health (i.e., well-being, optimal development, and functional ability) and the life course approach as opportunities to advance equity. The article reflects on immunization as a public good and the urgency to address the current challenges as a core element of the regional efforts to transform health systems after more than two years of the COVID-19 pandemic.

Comparison of static and dynamic models of maternal immunization to prevent infant pertussis in Brazil

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Dynamic transmission models of infectious disease capture the herd immunity effects of vaccination.

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We compared dynamic and static models of maternal acellular pertussis (aP) immunization built with Brazilian data.

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At infant vaccine coverage < 90–95%, both models estimate that maternal immunization is cost-effective.

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Only the dynamic model shows that maternal immunization is not cost-effective at infant coverage > 90–95%.

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The background effect of routine infant vaccination is critical to the cost-effectiveness of maternal aP immunization.

Background

This paper compares cost-effectiveness results from two models of maternal immunization to prevent pertussis in infants in Brazil, one static, one dynamic, to explore when static models are adequate for public health decisions and when the extra effort required by dynamic models is worthwhile.

Methods

We defined two scenarios to explore key differences between static and dynamic models, herd immunity and time horizon. Scenario 1 evaluates the incremental cost/DALY of maternal acellular pertussis (aP) immunization as routine infant vaccination coverage ranges from low/moderate up to, and above, the threshold at which herd immunity begins to eliminate pertussis. Scenario 2 compares cost-effectiveness estimates over the models’ different time horizons. Maternal vaccine prices of $9.55/dose (base case) and $1/dose were evaluated.

Results

The dynamic model shows that maternal immunization could be cost-saving as well as life-saving at low levels of infant vaccination coverage. When infant coverage reaches the threshold range (90–95%), it is expensive: the dynamic model estimates that maternal immunization costs $2 million/DALY at infant coverage > 95% and maternal vaccine price of $9.55/dose; at $1/dose, cost/DALY is $200,000. By contrast, the static model estimates costs/DALY only modestly higher at high than at low infant coverage. When the models’ estimates over their different time horizons are compared at infant coverage < 90–95%, their projections fall in the same range.

Conclusions

Static models may serve to explore an intervention’s cost-effectiveness against infectious disease: the direction and principal drivers of change were the same in both models. When, however, an intervention too small to have significant herd immunity effects itself, such as maternal aP immunization, takes place against a background of vaccination in the rest of the population, a dynamic model is crucial to accurate estimates of cost-effectiveness. This finding is particularly important in the context of widely varying routine infant vaccination rates globally.

Clinical Trial registry

Clinical Trial registry name and registration number: Not applicable.

OP0317 ACCURACY OF THE OMERACT DEFINITIONS FOR IDENTIFICATION OF CALCIUM PYROPHOSPHATE CRYSTALS WITH ULTRASOUND: FINAL RESULTS OF THE OMERACT US IN CPPD SUB-TASK FORCE STUDY

Background:

The OMERACT Ultrasound (US) in calcium pyrophosphate deposition disease (CPPD) sub-task force has been working on the use of US in CPPD since 2014 first creating definitions for CPPD identification and then assessing the reliability[1].

Objectives:

Objective of this study is to assess the diagnostic accuracy (truth) of US in CPPD.

Methods:

Consecutive patients waiting to undergo knee replacement surgery due to osteoarthritis were enrolled in 12 centres from 6 countries. Each patient underwent US examination of the knee, focusing on the menisci and the hyaline cartilage, the day prior to surgery, scoring each site for presence/absence of CPP as defined previously[1]. After surgery, the menisci and the condyles were retrieved and examined microscopically. Six samples were collected, both from the surface and from the internal part of menisci and cartilage trying to cover a large part of it. All slides were observed under transmitted light microscopy and by compensated polarised microscopy. A dichotomous score was given for the presence/absence of CPP. US and microscopic analysis were performed by different operators, blind to each other’s findings. Sensitivity and specificity of US were calculated using microscopic findings as the gold standard.

Results:

101 patients have been enrolled in the study. 33 patients have been excluded due to loss of anatomical pieces at surgery. The mean age of the remaining 68 pts was 71yo (±8), 44 women, 34 were affected by CPPD according to microscopy. Overall and per site diagnostic US accuracy results are presented in table 1

Diagnostic accuracySensitivitySpecificityPositive Predictive valueNegative Predictive valueGlobal0.750.910.590.690.87Medial meniscus0.820.870.770.770.87Lateral meniscus0.750.830.680.680.83Medial cartilage0.860.790.920.880.85Lateral cartilage0.820.710.880.770.84Medial side (combined cartilage and meniscus)0.820.880.760.790.87Lateral side (combined cartilage and meniscus)0.780.880.690.730.86

Conclusion:

Our results demonstrate that US is an accurate exam for identification of CPPD. The best combination of sensitivity and specificity is achieved by examining the medial aspect of the knee.

References:

[1]Filippou G, Scirè CA, Adinolfi A,et al.Identification of calcium pyrophosphate deposition disease (CPPD) by ultrasound: reliability of the OMERACT definitions in an extended set of joints—an international multiobserver study by the OMERACT Calcium Pyrophosphate Deposition Disease Ultrasound Subtask Force.Ann Rheum Dis2018;:annrheumdis-2017-212542. doi:10.1136/annrheumdis-2017-212542

Disclosure of Interests:

Georgios Filippou: None declared, Anna Scanu: None declared, Antonella Adinolfi: None declared, Carmela Toscano: None declared, Dario Gambera: None declared, Raquel Largo: None declared, Esperanza Naredo: None declared, Emilio Calvo: None declared, Gabriel Herrero-Beaumont: None declared, Pascal Zufferey: None declared, Christel Madelaine-Bonjour: None declared, Daryl MacCarter: None declared, Stanley Makman: None declared, Zachary Weber: None declared, Fabiana Figus: None declared, Ingrid Möller: None declared, Marwin Gutierrez: None declared, Carlos Pineda: None declared, Denise Clavijo Cornejo: None declared, Héctor García: None declared, Victor Ilizaliturri: None declared, Jaime Mendoza Torres: None declared, Raul Pichardo: None declared, Luis Carlos Rodriguez Delgado: None declared, Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work., Edoardo Cipolletta: None declared, Teodora Serban: None declared, Catalin Cirstoiu: None declared, Florentin Ananu Vreju: None declared, Dun Grecu: None declared, Gael Mouterde: None declared, Marcello Govoni: None declared, Leonardo Punzi: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Carlo Alberto Scirè: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi

Assessing preschoolers interactive behaviour: A validation study of the "Coding System for Mother-Child Interaction"

BACKGROUND

The preschool years are a period of great developmental achievements, which impact critically on a child's interactive skills. Having valid and reliable measures to assess interactive behaviour at this stage is therefore crucial. The aim of this study was to describe the adaptation and validation of the child coding of the Coding System for Mother-Child Interactions and discuss its applications and implications in future research and practice.

METHODS

Two hundred twenty Portuguese preschoolers and their mothers were videotaped during a structured task. Child and mother interactive behaviours were coded based on the task. Maternal reports on the child's temperament and emotional and behaviour problems were also collected, along with family psychosocial information.

RESULTS

Interrater agreement was confirmed. The use of child Cooperation, Enthusiasm, and Negativity as subscales was supported by their correlations across tasks. Moreover, these subscales were correlated with each other, which supports the use of a global child interactive behaviour score. Convergent validity with a measure of emotional and behavioural problems (Child Behaviour Checklist 1 ½-5) was established, as well as divergent validity with a measure of temperament (Children's Behaviour Questionnaire-Short Form). Regarding associations with family variables, child interactive behaviour was only associated with maternal behaviour.

CONCLUSIONS

Findings suggest that this coding system is a valid and reliable measure for assessing child interactive behaviour in preschool age children. It therefore represents an important alternative to this area of research and practice, with reduced costs and with more flexible training requirements. Attention should be given in future research to expanding this work to clinical populations and different age groups.

Molecular and epidemiologic study of Clostridium difficile reveals unusual heterogeneity in clinical strains circulating in different regions in Portugal

Clostridium difficile infection (CDI) represents a great healthcare burden in developed countries. The emergence of the epidemic PCR ribotype (RT) 027 and its acquired fluoroquinolones resistance have accentuated the need for an active surveillance of CDI. Here we report the first countrywide study of CDI in Portugal with the characterization of 498 C. difficile clinical isolates from 20 hospitals in four regions in Portugal regarding RT, virulence factors and antimicrobial susceptibility. We identified 96 RTs with marked variations between and within regions, as only six RTs appeared in all four regions. RT027 was the most frequent RT overall (18.5%) and among healthcare facility-associated isolates (19.6%), while RT014 was the most common among community-associated isolates (12%). The north showed a high RT diversity among isolates and a low moxifloxacin (MXF) resistance rate (11.9%), being the only region in which RT027 was not predominant. In contrast, the isolates from the centre presented the highest RT027 frequency, and 53.4% were resistant to MXF. Overall, MXF resistance (33.2%) was associated (p <0.001) with the presence of binary toxin genes and mutations in tcdC regardless of the RT. Both traits appeared in almost 30% of the strains. RT027 showed a reduced susceptibility to metronidazole (p <0.01), and RT126 had higher minimum inhibitory concentrations to vancomycin (p = 0.03) compared to other RTs. The present study highlights an unusual heterogeneity of RTs in Portugal, with a high frequency of hypervirulent RTs and the emergence of virulence factors in non-027 RTs, emphasizing the need for a surveillance system for CDI in Portugal.

Orbital and spin photon angular momentum transfer in liquid crystals

All-optical angular control of the molecular alignment in liquid-crystal films is demonstrated using a laser beam having an elliptically shaped intensity profile. The material birefringence is unimportant, as proven by the fact that good alignment is obtained with unpolarized light. This raises the possibility of achieving optical angular control of transparent isotropic bodies. A general theoretical approach, based on light and matter angular momentum conservation, shows that the optical alignment is due to the internal compensation between the transfer of the orbital and the spin part of angular momentum of the incident photons to the material.

Topical delivery of caffeine from some commercial formulations

Permeation of caffeine through human skin and artificial membranes (mounted in modified Franz type diffusion cells) was evaluated, either from saturated solutions or from commercially available topical formulations (all containing 3% caffeine). Data interpretation of the caffeine diffusion through human skin does not implicate transfer through pores despite caffeine being a relatively polar molecule. No correlation was found between transfer though the synthetic membranes (cellulose acetate impregnated with isopropyl myristate and silicone rubber soaked in isopropyl myristate) and that observed through skin. The synthetic membranes can be used for assessing product performance in quality assurance but will give little indication of its performance in vivo. The study investigated the percutaneous permeation of caffeine through human skin in order to obtain a mechanistic interpretation of its route of permeation. Synthetic membranes were also examined to determine if they could be used as models for human skin. Different commercial formulations investigated to determine the significance of enhancement strategies.

[A case of retroperitoneal fibrosis with spontaneous regression]

Retroperitoneal fibrosis has an unknown pathogenesis. Medical treatment should be preferred to surgery. However, surgical treatment is required when an ureteral involvement is present. A case of retroperitoneal fibrosis with spontaneous regression is reported. Current knowledge on pathogenesis, diagnosis and preferred treatment is outlined.

[Multicenter study of isolated micro-organisms resistant to antimicrobials in 10 Portuguese hospitals in 1994]

In 1994, Microbiology Laboratories of ten Portuguese hospitals analysed isolated microorganisms found in blood and urine samples and studied antimicrobial susceptibilities of the most frequent bacterial pathogens. From 63780 blood samples, the most frequent were Staphylococcus spp. and from 69189 urine samples significant numbers of Escherichia coli, Enterococcus spp., Pseudomonas aeruginosa and Candida spp. were isolated. Escherichia coli strains (c.7000) revealed a low percentage of resistance to antibiotics with the exceptions of ampicillin (48%) and co-trimoxazol (25%). Klebsiella pneumoniae isolates (c.2000) revealed important resistance to ampicillin (98%), cephalotin (31%), co-trimoxazol (38%) and gentamicin (28%), while values for 3rd generation cephalosporins varied among hospitals, with several strains showing phenotype of extended-spectrum beta-lactamase. A great variation in resistance values of P. aeruginosa (c.4000) was found in relation to the antibiotics as well as to the hospitals. Resistance to methicillin in S. aureus (c.6000) was high, reaching an average of 47%, and it was even higher with S. epidermidis (c.3000) and S. haemolyticus (c.650). Only vancomycin was always active against these strains. In E. faecalis (c.2500) resistance was of 2% to ampicillin, 35% to gentamicin, 45% to streptomycin and 1% to vancomycin. E. faecium isolates (c.300) showed the most worrying results with 70% resistance to ampicillin, 42% to gentamicin, 59% to streptomycin and 9% (30 strains isolated in 5 hospitals) to vancomycin. Vancomycin resistant strains were also resistant to all other antibiotics.

[Carotid thromboendarterectomy: personal experience and review of the literature]

Carotid endoarterectomy (CEA) is known to prevent cerebrovascular accidents. Between February 1987 and December 1993 we performed 97 CEA on 82 patients (62 male and 20 female, median age 66 +/- 7.6 years) 95.1% reported previous hemispheric neurological accidents; 4.9% were asymptomatic. Operative indications for asymptomatic patients were high degree stenosis (> 70%) of the internal carotid artery and ulcerated plaques with a moderate degree (50%) of stenosis. Major events (transient ischemic attack and stroke) were recorded in 73.2% cases. Preoperative investigations consisted of Duplex scan, arteriography, and cerebral CT scan or NMR. Operative mortality was 2.06% (2 cases) and perioperative stroke was 5.1% (5 cases). The sensibility, sensitivity and accuracy of Duplex scan to detect ulcerated plaques was 88.7%, 85.2% and 87.5% respectively. At a median follow-up of 33 months (range 6-81 months) 74 (92.5%) patients are free of strokes whereas 1 patient died for stroke. In our series the annual incidence of stroke was 0.5%. Our results suggest that Duplex scan is a reliable exam to investigate the carotid axis and CEA is a safe operation that prevents future cerebrovascular accidents.

[Salivary IgA in a group of children with recurrent respiratory infections]

Salivary IgA were examined in a group of children with recurring respiratory infections (RRI) in order to complete research into the immunological profile of such children. IgA assays were performed in 21 children suffering from RRI both in the remission period (Summer) and during infections (Winter). No children revealed any real disorder in basic salivary IgA. Salivary IgA levels were however about ten times higher in the Winter (the infection period). In a control group of 15 healthy children in the same age range, IgA levels were also high in the winter but still lower than those found in the RRI group. It is therefore concluded that children with RRI do not, as has often been suggested, present any basic disorder in salivary IgA, but that the response of secretory IgA is far more sensitive to infection than the system as a whole.