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bioRxiv2018

The impact of 10-valent Pneumococcal Conjugate Vaccine on the incidence of radiologically-confirmed pneumonia and clinically-defined pneumonia in Kenyan children.

BackgroundPneumococcal conjugate vaccines (PCV) are highly protective against invasive pneumococcal disease caused by vaccine serotypes but the burden of pneumococcal disease in developing countries is dominated by pneumonia, most of which is non-bacteraemic. We examined the impact of PCV on pneumonia incidence.\n\nMethodsWe linked prospective hospital surveillance for clinically-defined WHO severe or very-severe pneumonia at Kilifi County Hospital from 2002-2015 to population surveillance at Kilifi Health and Demographic Surveillance System, comprising 45,000 children aged <5 years. Chest radiographs were read according to a WHO standard. A 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PCV10) was introduced in Kenya in January 2011. In Kilifi, there was a catch-up campaign for children aged <5 years. We estimated the impact of PCV10 on pneumonia incidence through interrupted time series analysis accounting for seasonal and temporal trends.\n\nFindingsThe incidence of admission with clinically-defined pneumonia in 2002/3 was 21{middle dot}7/1000/year in children aged 2-59 months. This declined progressively over 13 years. By the end of March 2011, 61{middle dot}1% of children aged 2-11 months received [≥]2 doses and 62{middle dot}3% of children aged 12-59 months received [≥]1 dose of PCV10. Adjusted incidence rate ratios for admissions with radiologically-confirmed pneumonia, clinically-defined pneumonia, and diarrhoea (control condition), associated with PCV10 introduction, were 0{middle dot}52 (95% CI 0{middle dot}32-0{middle dot}86), 0{middle dot}73 (95% CI 0{middle dot}54-0{middle dot}97) and 0{middle dot}63, (95% CI 0{middle dot}31-1{middle dot}26), respectively. The annual incidence of clinically-defined pneumonia in December 2010 was 12{middle dot}2/1000; this was reduced by 3{middle dot}3/1000 with PCV10 introduction.\n\nInterpretationOver 13 years, hospitalisations for clinically-defined pneumonia declined progressively at Kilifi County Hospital but fell abruptly by 27% in association with PCV10 introduction. The incidence of radiologically-confirmed pneumonia fell by 48%. The burden of childhood pneumonia in Kilifi, Kenya, has been reduced substantially by PCV10.\n\nFundingGavi, Wellcome Trust

epidemiology↗

bioRxiv2018

A web-based, branching logic questionnaire for the automated classification of migraine

ObjectiveTo identify migraineurs and headache-free individuals with an online questionnaire and automated analysis algorithm.\n\nMethodsWe created a branching-logic, web-based questionnaire--the Penn Online Evaluation of Migraine (POEM)--to obtain standardized headache history from a previously studied cohort. Responses were analyzed with an automated algorithm to assign subjects to one of several categories based on ICHD-3 (beta) criteria. Following a pre-registered protocol, this result was compared to prior diagnostic classification by a neurologist following a direct interview.\n\nResultsOf 118 subjects contacted, 90 (76%) completed the questionnaire; of these 31 were headache-free, 29 migraine without aura (MwoA), and 30 migraine with aura (MwA). Mean age was 41 {+/-} 6 years and 76% were female. There were no significant demographic differences between groups. The median time to complete the questionnaire was 2.5 minutes. Sensitivity of the POEM tool was 42%, 59%, and 70%, and specificity was 100%, 84%, and 94% for headache-free, MwoA, and MwA, respectively. Sensitivity and specificity of the POEM tool for migraine overall (with or without aura), was 83% and 90%, respectively.\n\nConclusionsThe POEM web-based questionnaire, and associated analysis routines, identifies headache-free and migraine subjects with good specificity. It may be useful for classifying subjects for large-scale research studies.\n\nTrial Registration: https://osf.io/sq9ef

epidemiology↗

bioRxiv2018

Impact of 10-valent pneumococcal conjugate vaccine on invasive pneumococcal disease and nasopharyngeal carriage in Kenya

Background10-valent pneumococcal conjugate vaccine (PCV10), delivered at 6, 10 and 14 weeks of age, was introduced in Kenya in January 2011, accompanied by a catch-up campaign in Kilifi County for children <5 years. Coverage with [≥]2 PCV10 doses in children 2-11 months was 80% in 2011 and 84% in 2016; coverage with [≥]1 dose in children 12-59 months was 66% and 87%, respectively.\n\nMethodsClinical and microbiological surveillance for invasive pneumococcal disease (IPD) among admissions of all ages at Kilifi County Hospital was linked to the Kilifi Health and Demographic Surveillance System from 1999-2016. We calculated the incidence rate ratio (IRR) comparing the pre-vaccine and post-vaccine eras, adjusted for confounding, and reported percent reduction in IPD as 1-IRR. Annual cross-sectional surveys of nasopharyngeal carriage were conducted from 2009-2016.\n\nFindingsSurveillance identified 667 IPD cases in 3,211,403 person-years of observation. IPD incidence in children <5 years fell sharply in 2011 following PCV10 introduction, and remained low (PCV10-type IPD: 60{middle dot}8 vs 3{middle dot}2/100,000 [92% reduction; 95%CI: 78, 97]; overall IPD: 81{middle dot}6 vs 15{middle dot}3/100,000 [68% reduction; 95%CI: 40, 83]; 1999-2010 vs 2012-2016). PCV10-type IPD also declined significantly in unvaccinated age groups (<2 months, 5-14 years, [≥]15 years), with estimated reductions of 100%, 74%, and 81%, respectively. There was no significant change in the incidence of non-PCV10 type IPD. In children aged <5 years, PCV10-type carriage declined by 74% and non-PCV10-type carriage increased by 71%.\n\nInterpretationIntroduction of PCV10 in Kenya resulted in a substantial reduction in PCV10-type IPD in children and adults without significant replacement disease. These findings suggest that routine infant PCV10 immunization programmes with catch-up campaigns will provide substantial direct and indirect protection in low-income settings in tropical Africa.

epidemiology↗

bioRxiv2018

Estimating energy expenditure from wrist and thigh accelerometry in free-living adults: a doubly labelled water study

BackgroundMany large studies have implemented wrist or thigh accelerometry to capture physical activity, but the accuracy of these measurements to infer Activity Energy Expenditure (AEE) and consequently Total Energy Expenditure (TEE) has not been demonstrated. The purpose of this study was to assess the validity of acceleration intensity at wrist and thigh sites as estimates of AEE and TEE under free-living conditions using a gold-standard criterion.\n\nMethodsMeasurements for 193 UK adults (105 men, 88 women, aged 40-66 years, BMI 20.4-36.6 kg{middle dot}m-2) were collected with triaxial accelerometers worn on the dominant wrist, non-dominant wrist and thigh in free-living conditions for 9-14 days. In a subsample (50 men, 50 women) TEE was simultaneously assessed with doubly labelled water (DLW). AEE was estimated from non-dominant wrist using an established estimation model, and novel models were derived for dominant wrist and thigh in the non-DLW subsample. Agreement with both AEE and TEE from DLW was evaluated by mean bias, Root Mean Squared Error (RMSE) and Pearson correlation.\n\nResultsMean TEE and AEE derived from DLW was 11.6 (2.3) MJ{middle dot}day-1 and 49.8 (16.3) kJ{middle dot}day-1{middle dot}kg-1. Dominant and non-dominant wrist acceleration were highly correlated in free-living (r=0.93), but less so with thigh (r=0.73 and 0.66, respectively). Estimates of AEE were 48.6 (11.8) kJ{middle dot}day-1{middle dot}kg-1 from dominant wrist, 48.6 (12.3) from non-dominant wrist, and 46.0 (10.1) from thigh; these agreed strongly with AEE (RMSE ~12.2 kJ{middle dot}day-1{middle dot}kg-1, r ~0.71) with small mean biases at the population level (~6%). Only the thigh estimate bias was statistically significantly different from the criterion. When combining these AEE estimates with estimated REE, agreement was stronger with the criterion (RMSE ~1.0 MJ{middle dot}day-1, r ~0.90). Conclusions: In UK adults, acceleration measured at either wrist or thigh can be used to estimate population levels of AEE and TEE in free-living conditions with high precision.

epidemiology↗

bioRxiv2018

Identification of salivary and plasma biomarkers for obesity in children by non-targeted metabolomic analysis

Chemical compounds in the saliva most likely to be associated with obesity are identified in a metabolomic analysis of paired whole saliva and plasma samples from 68 children (10-year old) who have also been evaluated for their gingival redness.\n\nResultsThrough metabolomic analysis119 compounds were found only in saliva, 210 only in plasma and 126 in both. The most common plasma metabolites were lipids. The most common saliva metabolites were peptides. Amino acids and their metabolites were common in both samples.\n\nSurrogate indicators were identified by computing correlations between saliva and plasma. 29 of the 126 found in both saliva and plasma had significant positive correlation and only 4 of those (urate, creatinine, pipecolate and hydroxyproline) were associated with obesity as potential surrogate biomarkers. The uremic toxin N1-Methyl-2-pyridone-5-carboxamide (2PY) was also elevated in the saliva of obese children. 21 biochemicals were elevated in both obesity and gingivitis suggesting that some biochemical pathways for gingivitis and obesity are shared.\n\nOf the metabolites found only in saliva, 35 were associated with obesity (p<0.01). The most significant was phosphate. Saliva had 53 dipeptides, seven of which were associated with obesity. Two volatile amines (putrescine and cadaverine) and their amino acid precursors (ornithine and lysine) were also associated with obesity.\n\nOf the metabolites found only in plasma, 64 were associated with obesity (p<0.01). Significant increases in branched-chain and aromatic amino acids, significant reductions in serotonin, serine, and glycine and increased androgen metabolism are changes observed in 10-year old obese children that have also been reported with adult patients having type II diabetes.\n\nConclusionsSalivary urate may be a valuable measure of metabolic disease particularly in association with fructose consumption. Elevated salivary creatinine levels and presence of 2PY suggests a possible association of obesity with developing kidney disease in obese children. Though not a surrogate variable, salivary phosphate, (AUROC= 0.8) could also be an important indicator of obesity. Cadaverine, putrescine and dipeptides are also likely oral bacterial products that could help define the metabolic pathways responsible for obesity. The results of this study indicate that salivary metabolites can be important indicators of developing metabolic disease in children and provide a biochemical signature in the pathways that lead to obesity.

epidemiology↗

bioRxiv2018

The respiratory microbiome and susceptibility to influenza virus infection

Influenza is a major cause of morbidity and mortality worldwide. However, vaccine effectiveness has been low to moderate in recent years and vaccine coverage remains low, especially in low- and middle-income countries. Supplementary methods of prevention should be explored to reduce the high burden of influenza.\n\nA potential target is the respiratory tract microbiome, complex microbial communities which envelop the respiratory epithelium and play an important role in shaping host immunity. Using a household transmission study, we examined whether the nose/throat microbiota was associated with influenza susceptibility among participants exposed to influenza virus in the household. Further, we characterized changes in the nose/throat microbiota to explore whether community stability was influenced by influenza virus infection.\n\nUsing a generalized linear mixed effects model, we found a bacterial community type associated with decreased susceptibility to influenza. The community type was rare and transitory among young children but a prevalent and stable community type among adults. Using boosting and linear mixed effects models, we found associations between the nose/throat microbiota and influenza also existed at the taxa level, specifically with the relative abundance of Alloprevotella, Prevotella, and Bacteroides oligotypes.\n\nWe found high rates of change in the bacterial community among both secondary cases and household contacts who were not infected during follow up. Preliminary results suggest short-term changes in the bacterial community structure may differ between the two groups, but further work is needed to validate our observations.\n\nLastly, age was strongly associated with susceptibility to influenza and the nose/throat bacterial community structure. Although additional studies are needed to determine causality, our results suggest the nose/throat microbiome may be a potential target for reducing the burden of influenza.\n\nAuthor summaryMicrobiome research has transformed our understanding of microbes and human health. Resident bacteria can protect the host from pathogens by shaping immunological responses. These new insights suggest the microbiome could be a target for preventing influenza virus infection, a major cause of illness and death worldwide. In this study, we explored the relationship between the nose/throat microbiota and influenza virus in Nicaraguan households.\n\nHousehold members were enrolled immediately after one member was diagnosed with influenza virus infection. This study design allowed us to identify associations between the microbiota and influenza susceptibility. We also explored whether influenza virus infection altered the bacterial community structure and found short-term changes were common among both secondary cases and household members who remained influenza negative during follow up. Lastly, we found age played major roles in both influenza susceptibility and in short-terms changes in the microbiota. Although much work is needed to determine causal relationships, our findings suggest strategies that appropriately modify the microbiome might be useful in preventing influenza virus infections.

epidemiology↗

bioRxiv2018

Association between activities outside work and presenteeism among Korean wage workers : using nationwide survey

IntroductionPresenteeism is a significant global health issue nowadays and can influence to producitivity loss. So, there were many studies to analyse relationship between workplace factor and presenteeism. But a few studies have considered non-occupational factor. The purpose of this study was to examine the association between presenteeism and activities outside work, such as, volunteering, self-development, leisure/sports, gardening & house repair activity, in Korean wage workers.\n\nMethodsThis study analysed the 4th Korean Working Condition Survey(KWCS) and overall 19,294 wage workers participated. To find the relationship between presenteeism and activities outside work, multivariate logistic regression analysis was used after adjusting for general and occupational characteristics.\n\nResultsAmong self-development, leisure/sports and gardening & house repair activities significantly increased the odds ratio of presenteeism (Odds ratio[OR] =1.33, 95% confidence interval[CI]: 1.23-1.43, OR = 1.40, 95% CI: 1.29-1.51 and OR = 1.09, 95% CI: 1.01-1.18, respectively).\n\nConclusionsSome of activities outside work were related to presenteeism in Korean wage workers. Although many of previous studies addressed positive effect of those activities for health, this study showed negative effect of activities oudside work for health. And we should consider Korean organizational culture for this reason and need more structural studies to find out specific factors.

epidemiology↗

bioRxiv2018

Repeated Measures Regression In Laboratory, Clincal And Enviromental Research - Different Between/Within Subject Slopes And Common Misconceptions

When using repeated measures linear regression models to make causal inference in laboratory, clinical and environmental research, it is often assumed that the Within Subject association of differences (or changes) in predictor value across replicates is the same as the Between Subject association of differences in those predictor values. But this is often false, for example with body weight as the predictor and blood cholesterol the outcome i) a 10 pound weight increase in the same adult more greatly a higher increase in cholesterol in that adult than does ii) one adult weighing 10 pounds more than a second reflect increased cholesterol levels in the first adult as the weigh difference in i) more closely tracks higher body fat while that in ii) is also influenced by heavier adults being taller. Hence to make causal inferences, different Within and Between subject slopes should be separately modeled. A related misconception commonly made using generalized estimation equations (GEE) and mixed models (MM) on repeated measures (i.e. for fitting Cross Sectional Regression) is that the working correlation structure used only influences variance of model parameter estimates. But only independence working correlation guarantees the modeled parameters have any interpretability. We illustrate this with an example where changing working correlation from independence to equicorrelation qualitatively biases parameters of GEE models and show this happens because Between and Within Subject slopes for the predictor variables differ. We then describe several common mechanisms that cause Within and Between Subject slopes to differ as; change effects, lag/reverse lag and spillover causality, shared within subject measurement bias or confounding, and predictor variable measurement error. The misconceptions noted here should be better publicized in laboratory, clinical and environmental research. Repeated measures analyses should compare Within and Between subject slopes of predictors and when they differ, investigate the reasons this has happened.\n\nHIGHLIGHTSWhen using repeated measures with time varying predictors variables in laboratory, clinical and environmental research: O_LICross sectional regressions with any working correlation structure other than independence often give non-meaningful results\nC_LIO_LIBetween/Within subject decomposition of slopes should be undertaken when making causal inferences\nC_LIO_LIInvestigators should investigate the reasons Between and Within Subject slopes differ if this occurs\nC_LI

epidemiology↗

bioRxiv2018

Composition and consistence of the bacterial microbiome in upper, middle and lower esophagus before and after Lugol’s iodine staining

Esophageal bacteria, as the integral composition of human ecosystem, have been reported to be associated with esophageal lesions. However, few studies focus on microbial compositions in different esophageal segments, especially after Lugols iodine staining (LIS) in the endoscopic examination for the screening of esophageal cancer. To investigate the composition of the bacterial microbiome in upper, middle and lower esophagus and if LIS would affect the detection of bacteria, 141 fasting samples including the upper, middle and lower esophagus from 27 participants were collected by brushing the mucosal surface of the esophagus before (Eso) and after (Lug) LIS. Bacterial V3-V4 region of 16S rRNA gene was amplified and sequenced by Illuminas sequencing platform and analyzed using LEfSe system to identify specific microbiota. The top six abundant bacterial phyla taxa among three locations from both Eso and Lug groups were Proteobacteria, Firmicutes, Bacteroidetes, Actinobacteria, Fusobacteria and TM7. In terms of genera, the bacterium in three locations from two groups was all characterized by a highest relative abundance of Streptococcus. Bacteria diversity and the relative abundance between Eso and Lug were comparable (P > 0.05). Bacteria diversity was consistent in different esophageal locations for an individual, but it was significantly distinguishing in different subjects (P < 0.05). In Conclusion, the bacterial microbiome in healthy esophagus are highly diverse and consistent even among three physiological stenosis at all clades. Lugols iodine staining would not change local microenvironment in term of microbial composition. These finding provide an essential baseline for future studies investigating local and systemic bacterial microbiome and esophageal diseases.

epidemiology↗

bioRxiv2018

Vertical transmission of Zika virus from orally infected Aedes aegypti produces infectious adult progeny.

Vertical transmission, or pathogen transfer from mother to offspring, can facilitate persistence of emerging arboviruses, such as Zika virus (ZIKV), in mosquito populations. Understanding vertical transmission and the different environmental and temporal conditions that affect it is important to assess whether new outbreaks could occur without reintroduction of the virus. To determine the rate of vertical transmission for ZIKV, Aedes aegypti females were fed on ZIKV infected blood, maintained under three temperature conditions (27{degrees}C, 30{degrees}C, and 33{degrees}C), and allowed to oviposit three times. Progeny were tested for virus presence at 3, 7, and 14 days after adult emergence. The overall vertical transmission rate was 6.5% (3.9 - 9.9). Vertical transmission was observed across all maternal temperature conditions and was detected in adult progeny as young as 3 days and as late as 14 days post-emergence. In total, 3.4% (1.6 - 6.2) of adult progeny produced saliva with detectable ZIKV, indicating their capacity to transmit ZIKV to humans. To our knowledge, this is the first evidence that vertical transmission occurs from orally-infected female Aedes aegypti to their adult progeny at a range of temperatures, and proof that Zika virus can persist in the saliva of those progeny throughout their lifetimes. These results suggest that the virus may be maintained in Ae. aegypti populations without a vertebrate host, allowing for human infections to occur without consistent re-introductions of ZIKV.\n\nAuthor SummaryIn 2015, Zika virus spread to over 50 countries. However, it is not known whether the virus persisted in the outbreak areas or became locally extinct. One way mosquito-borne viruses, like Zika, could become established is by transferring directly between mosquito generations rather than circulating between mosquitoes and humans. This is known as vertical transmission, and happens when the virus infects the developing eggs of infected maternal mosquitoes. As with other mosquito-borne diseases, like dengue, in order to infect humans the virus must be present in the saliva of infected mosquito progeny during blood feeding. We found vertical transmission occurred throughout the infected mothers reproductive lifetime and across a range of temperature conditions. Vertically infected progeny had Zika virus in their saliva as early as three days after adult emergence, implying that they could infect a person even during their first bloodmeal. Importantly, this work indicates that Zika virus could establish itself in the mosquito population even when human to mosquito transmission is not actively occurring.

epidemiology↗

bioRxiv2018

A comparative study of machine learning algorithms in predicting severe complication after bariatric surgery

Accurate models to predict severe postoperative complications could be of value in the preoperative assessment of potential candidates for bariatric surgery. Traditional statistical methods have so far failed to produce high accuracy. To find a useful algorithm to predict the risk for severe complication after bariatric surgery, we trained and compared 29 supervised machine learning (ML) algorithms using information from 37,811 patients operated with a bariatric surgical procedure between 2010 and 2014 in Sweden. The algorithms were then tested on 6,250 patients operated in 2015. Most ML algorithms showed high accuracy (>90%) and specificity (>0.9) in both the training and test data. However, none achieved an acceptable sensitivity in the test data. ML methods may improve accuracy of prediction but we did not yet identify one with a high enough sensitivity that can be used in clinical praxis in bariatric surgery. Further investigation on deeper neural network algorithms is needed.

epidemiology↗

bioRxiv2018

Predicting HIV Incidence in the SEARCH Trial: A Mathematical Modelling Study

IntroductionSEARCH is one of four randomized-controlled trials (RCTs) investigating the strategy of community-based treatment-as-prevention (TasP) for the reduction of HIV incidence in sub-Saharan Africa. SEARCH takes place among 32 pair-matched rural communities in three regions of East Africa and exceeded the UNAIDS 90-90-90 targets for HIV testing, linkage to care, and viral suppression in the intervention arm. We used mathematical modeling to estimate expected 3-year cumulative HIV incidence in both arms of the trial, using different assumptions about two main sources of uncertainty: scale-up of antiretroviral therapy (ART) in the control arm, and the degree of mixing between SEARCH residents and non-residents.\n\nMethodsWe used the HIV modelling software EMOD-HIV to configure and calibrate a new model of the SEARCH communities. The 32 trial communities were clustered into six nodes (three for the control arm and three for the intervention arm) using k-means clustering based on community HIV prevalence, male circumcision rates, mobility, and geographic region. The model was parameterized using data on demographics, HIV prevalence, male circumcision rates, and viral suppression data collected at trial baseline in 2013, and calibrated to nodespecific and age-specific HIV prevalence, ART coverage, and population size. Using data on ART scale-up in subsequent follow-up years in the trial, we varied linkage to ART in the control arm and the degree of external mixing between SEARCH residents and non-residents.\n\nResultsIf no external mixing and no additional control arm ART linkage occurred, we estimate the trial would report a relative risk (RR) of 0.60 (95% CI 0.54-0.67, p<0.001), with all simulations showing a significant result. However, if SEARCH residents mixed equivalently with non-residents and ART linkage in the control arm also increased such that the control arm also exceeded the 73% viral suppression target, the RR is estimated to be 0.96 (95% CI 0.87-1.06, p=0.458) and 72% of simulations are non-significant. Given our \"best guess\" assumptions about external mixing and year 3 data on ART linkage in the control arm, the RR is estimated to be 0.90 (95% CI 0.81-1.00, p=0.05), with 49% non-significant simulations.\n\nConclusionThe SEARCH trial is predicted to show a 4-40% reduction in cumulative 3-year incidence, but between 18-72% of simulations were non-significant if either or both ART linkage in the control arm and external mixing are substantial. Despite achieving the 90-90-90 targets, our \"best guess\" is that the SEARCH trial has an equal probability of reporting a non-significant reduction in HIV incidence as it does a significant reduction.

epidemiology↗

bioRxiv2018

A malaria transmission model with seasonal mosquito life-history traits

In this paper we develop and analyse a malaria model with seasonality of mosquito life-history traits: periodic-mosquitoes per capita birth rate, -mosquitoes death rate, -probability of mosquito to human disease transmission, -probability of human to mosquito disease transmission and -mosquitoes biting rate. All these parameters are assumed to be time dependent leading to a nonautonomous differential equation systems. We provide a global analysis of the model depending on two thresholds parameters [Formula] and [Formula] (with [Formula]). When [Formula], then the disease-free stationary state is locally asymptotically stable. In the presence of the human disease-induced mortality, the global stability of the disease-free stationary state is guarantied when [Formula]. On the contrary, if [Formula], the disease persists in the host population in the long term and the model admits at least one positive periodic solution. Moreover, by a numerical simulation, we show that a subcritical (backward) bifurcation is possible at [Formula]. Finally, the simulation results are in accordance with the seasonal variation of the reported cases of a malaria-epidemic region in Mpumalanga province in South Africa.

epidemiology↗

bioRxiv2018

Assessment of Auditable Pharmaceutical Transactions at Public Hospitals in Gamo Gofa, Southern Ethiopia, a Comparative cross-sectional study, July 2017

BackgroundAvailability of essential medicines is necessary to maintain health of the community. In Ethiopia, availability of medicines was low (65%), with high expiry rate (8.24%), low patient knowledge on correct dosage (50.5%) and satisfaction on pharmacy services (74.5%). To avert these problems, the government had endorsed legislation on a system called \"Auditable Pharmaceutical Transactions and Services (APTS)\". However, the outcomes and challenges in implementation of this system were not assessed.\n\nObjectiveTo assess the implementation status of APTS and its challenges at public hospitals in Gamo Gofa Zone Southern Ethiopia, April 2017.\n\nMethodsFacility based Cross sectional study was conducted in two APTS implementing hospitals in Gamo Gofa zone. Semi structured Self-administered questionnaire was distributed to all pharmacy staffs in selected hospitals. APTS reports of 12 months (with different characteristics) were reviewed. Four hundred patients were interviewed by data collectors about patient knowledge and satisfaction using WHO questionnaire. The data were entered and analyzed using Statistical package for social science students/SPSS version 20. T-test and linear regression was used to evaluate significant differences between two hospitals with level of significance pre-set at p-value [≤]0.05.\n\nResultsAll dispensing units in primary hospital had six (75%) out of the eight essential equipment for dispensing practice. it was found that respondents in general hospital stated higher scores in general setting of outpatient pharmacy (4.58 Versus 4.25; P <0.001), but lower scores for availability and cost of medicines (4.24 vs 4.43; P<0.05) when compared with those in primary level hospital. There was no significant difference in instruction of medicine provided by dispenser (2.58 vs 2.59; P>0.05), dispenser client interaction (3.09 vs 4.08; P>0.05) and total satisfaction score (2.09 vs 2.02; P>0.05).\n\nConclusion and recommendationsIn our study Quality of Auditable Pharmaceutical Transactions and Service was low, especially regarding patient knowledge about medicines, unaffordability of medicines, less availability of prescribed drugs, poor transparency of pharmaceutical transactions, insufficient counseling practice and limited facilities for dispensing such as, key medicines, formularies and standard guidelines. We therefore recommend the following measures responsible bodies to improve these gaps y taking administrative actions and providing continued education and training for dispensers.

epidemiology↗

bioRxiv2018

Knowledge and self-care practice of leprosy patients at ALERT Hospital, Ethiopia

BackgroundLeprosy is a chronic infectious disease of public health importance and one of the leading causes of permanent physical disability. The integration of leprosy service to the general health system in Ethiopia made leprosy patients to be seen by non-leprosy specialists which could lead to misdiagnosis and delay in treatment. In addition to the multi-drug treatment, patient self - care practice is crucial for the successful treatment of the disease. This study was aimed to assess the knowledge and self-care practices of leprosy patients and associated factors at ALERT leprosy referral Hospital in Ethiopia.\n\nMethodA cross-sectional study was conducted ALERT leprosy referral Hospital, Addis Ababa, Ethiopia. A total of 424 leprosy patients were interviewed using pre-tested structured questionnaires. The questionnaires included core points such as socio-demographic characteristics, knowledge of leprosy and self-care practices. Blooms cut off point was used to describe the knowledge and self-care practice of the respondents and statistical significance was assessed at 95% confidence interval with 5% of level of significance.\n\nResultThe knowledge score of the respondents was poor for 276 (65.1%) and good for 148 (34.9%). The level of knowledge was significantly varied within age groups (P= 000), sex (P=000), marital status (p=0.003), educational status (p=000) and income (p-000). More than three-fourth (77.4%) of interviewed patients had poor self-care practice and only less than a quarter (22.6%) of patients had good self-care practice score (P=000). Age (p=0.002), Previous disability due to leprosy (P=000), Knowledge of leprosy (p=0.038) and income (P=0.028) significantly associated with poor self-care practice. On the other hand, educational status, sex, marital status and health education did not associated with leprosy self-care practice.\n\nConclusionAlthough, leprosy treatment, disability prevention and rehabilitation program run in the country under general public health care service for decades, poor leprosy self-care practice and poor leprosy knowledge had been confirmed in this study. Therefore, the leprosy service program should re-visit its strategy and mode of delivery to improve the leprosy knowledge and leprosy self-care practices of patients.\n\nAuthor summaryLeprosy is an infectious bacterial disease. It is a curable disease if treated early before disability occurs with the correct regimen. However, treatment cannot reverse disability once occurred. in addition to chemotherapeutic treatment, lack of social and psychological treatment may expose patients to disability as they may not adhere to treatment. To prevent disability it is vital to empower leprosy patients through promoting self-confidence, providing knowledge and self-care skills. In the present study, we investigated the knowledge and self-care practice of 424 leprosy patients at ALERT hospital through face-to face guided interview. It was found that majority of patients had poor knowledge about leprosy. Some factors such as sex, income status, age and educational status of the patient significantly affected the level of leprosy knowledge. Similarly, it was found that 77% of patients had poor self-care practice which significantly varied with income status, knowledge of leprosy, age and having previous disability. Therefore, it is very important to improve the leprosy knowledge and self-care skills of patients. This can be achieved through dealing with issues such as the physical, emotional, intellectual and social aspects of the patients in addition to the chemotherapeutic treatment.

epidemiology↗

bioRxiv2018

Introducing risk inequality metrics in tuberculosis policy development

Global stakeholders including the World Health Organization rely on predictive models for developing strategies and setting targets for tuberculosis care and control programs. Failure to account for variation in individual risk leads to substantial biases that impair data interpretation and policy decisions1,2. Anticipated impediments to estimating heterogeneity for each parameter are discouraging despite considerable technical progress in recent years. Here we identify acquisition of infection as the single process where heterogeneity most fundamentally impacts model outputs, due to cohort selection imposed by dynamic forces of infection. Individuals with higher risk of acquiring infection are predominantly affected by the pathogen, leaving the unaffected pool with those whose intrinsic risk is lower. This causes susceptibility pools to attain average risks which are lower under higher forces of infection. Interventions that modify the force of infection change the strength of selection, and therefore alter average risks in the pools which feed further incidence. Inability to account for these dynamics is what makes homogenous models unsuitable. We introduce concrete metrics to approximate risk inequality in tuberculosis, demonstrate their utility in mathematical models, and pack the information into a risk inequality coefficient which can be calculated and reported by national tuberculosis programs for use in policy development and modeling.

epidemiology↗

bioRxiv2018

Instilling Good Knowledge, Attitude and Practices among the Indigenous People of Malaysia Concerning Dog Associated Zoonotic Infections

BackgroundThe Jahai, a subethnic of the indigenous people of peninsular Malaysia, have commonly used dogs for hunting but have started to move away from traditional hunter-gatherer lifestyle, leaving dogs which were commonly used for hunting to wander around the villages and to multiply in numbers.\n\nObjectiveThe objective of this study was to instil good knowledge, attitude and practices of the Jahai community concerning dog associated zoonotic infections using One Health concept.\n\nMethodsThis non-experimental pre and post-test intervention study was conducted among Jahai villagers aged 12 years and above living in a village located in the Belum forest in Malaysia. Interventions included health education and promotion using discussions, posters, slide presentations, comics and video clips with relevant content. In addition the children of the village were taught correct hand washing techniques and dog associated zoonotic infections.\n\nResultsIn general most aspects of knowledge, attitude and practice improved post intervention. The knowledge on risk of infections transmitted from pet dogs (X2=4.293, p= 0.038) and the practice of washing hands before eating (X2=14.984, p <0.001) improved significantly. The increase in the mean scores of the participants knowledge (t=-9.875, p=<0.001) and attitude (t= -4.100, p=<0.001) post intervention was statistically significant.\n\nConclusionThis study showed the effectiveness of a multidisciplinary team using One Health concept to successfully improve knowledge, attitude and practices related to dog associated infections. A sustained and committed health education and promotion interventions involving the community and school children in promoting heath should be custom made for indigenous communities, and sanitation and hygienic practices reinforced at every opportunity.\n\nAuthors SummaryThe indigenous people of peninsular Malaysia are a marginalized group; they are socio economically deprived and have low levels of education. One such group is the Jahai, who commonly used dogs for hunting, but have recently started to move away from traditional hunter-gatherer lifestyle, resulting in the dogs to multiply in numbers and roam as strays in the village. The community is now at risk of dog associated zoonotic infections. Studies have shown that health education and promotion can improve knowledge, attitude and practices of dog associated infections. However most of the studies were done among dog owners and in communities with fairly good education levels. A holistic approach using One Health concept was used to instil good knowledge, attitude and practices of the Jahai community concerning dog associated zoonotic infections. This non-experimental pre and post-test intervention study was conducted among Jahai villagers aged 12 years and above living in a village located in the Belum forest in Malaysia. The findings of this study showed the effectiveness of a multidisciplinary team using One Health concept to successfully improve knowledge, attitude and practices related to dog associated zoonotic infections.

epidemiology↗

bioRxiv2018

Tuberculosis in the military: Trends in notification and treatment outcomes within the Zimbabwe Defence Force, Dependants and Communities 2010-2015

BackgroundHistorically, tuberculosis (TB) has been responsible for significant disease burden among the military both during peace and conflict. A routine review of Zimbabwe Defence Force (ZDF) data showed 36% of reported deaths could be attributed to TB. We conducted a study to determine the TB trends and outcomes among patients managed in ZDF health facilities between 2010-2015.\n\nMethodsRetrospective cohort study of TB patients (military and dependents). Data were extracted from ZDF TB registers and analyzed for trends in notification and outcomes. Independent factors associated with unfavourable TB treatment outcomes were modeled using multivariable regression.\n\nResultsOf the total 1298 TB patients, 84% were males, median age 37 years and 92% from Army facilities. Ninety three percentage had pulmonary TB, 87% were new patients and 68% HIV co-infected (97% on antiretroviral therapy[ART]). Number of TB cases reduced two-fold between 2010-2015 (317 vs 115). Treatment outcomes remained relatively stable with overall treatment success of 81%, 9.9% deaths, 0.2% loss to follow up, 2.2% treatment failure, 6.6% not evaluated. Clients who were HIV-positive and not on ART were 3.81 times likely to have unfavourable outcome.\n\nConclusionThis is the first study of TB in an African defence force showed decreasing trends in notified TB cases. Though treatment success was comparable over time, it still fell below international targets. Being HIV-positive (even with ART) was associated with increased unfavourable outcomes. Continued monitoring, evaluation and increased support of the TB programme within this high risk population is recommended.

epidemiology↗