Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-30 (of 34 Records) |
Query Trace: Bhatt A [original query] |
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Polio, public health memories and temporal dissonance of re-emerging infectious diseases in the global north
Kasstan-Dabush B , Flores SA , Easton D , Bhatt A , Saliba V , Chantler T . Soc Sci Med 2024 357 117196 Social science research on polio has been centred in the global south, where countries that remain endemic or vulnerable to outbreaks are located. However, closely-related strains of poliovirus were detected in the sewage systems of several New York State counties and London boroughs in 2022. These detections constituted the first encounters with polio in the United States and United Kingdom for a generation - for both public health agencies and publics alike. This paper takes the transnational spread of poliovirus in 2022 as an opportunity to critique how public health memories of twentieth-century polio epidemics were mobilised to encourage vaccine uptake among groups considered vulnerable to transmission, notably Orthodox Jewish families. The study integrates data collected in London and New York as part of academic engagement with health protection responses to the spread of polio. Methods in both settings involved ethnographic research, and a total of 59 in-depth semi-structured interviews with public health professionals, healthcare providers, and Orthodox Jewish community partners and residents. Analysis of results demonstrate that narratives of epidemiological progress were deployed in public health responses in London and New York, often through references to sugar cubes, iron lungs, and timelines that narrate the impact of routine childhood immunisations. While memories of polio were deployed in both settings to provoke an urgency to vaccinate, vulnerable publics instead considered the more recent legacy of the COVID-19 pandemic when deciding whether to trust recommendations and responses. Critical attention to memory places analysis on the divergences between institutional (public health agencies) and peopled (publics) responses to disease events. Responses to re-emerging infectious disease outbreaks engender a temporal dissonance when historical narratives are evoked in ways that contrast with the contemporary dilemmas of people and parents. |
An overview of the COVID-19 pediatric vaccine program - The U.S. experience vaccinating children ages 6 months through 17 years
Chatham-Stephens K , Carter RJ , Duggar C , Woodworth KR , Carnes CA , Bhatt A , Ottis C , Voegeli C , Stokley S , Vogt T . Vaccine 2024 COVID-19 vaccination decreases risk for COVID-19 illness and severe disease in children, including multisystem inflammatory syndrome (MIS-C) and death. On December 13, 2020, CDC recommended COVID-19 vaccination for persons ages ≥16 years, with expansion on May 12, 2021, to adolescents ages 12-15 years; to children ages 5-11 years on November 2, 2021; and to children ages 6 months-4 years on June 18, 2022. Following each age-specific recommendation, the U.S. government collaborated with state and local governments, vaccine manufacturers, and numerous other public and private entities, to ensure rapid, broad, and equitable COVID-19 vaccine distribution to strategic locations across the country to maximize access. However, vaccination coverage among children has been lower than among adults and lower among younger children than adolescents. As of May 10, 2023, COVID-19 primary series vaccination coverage was 61.8% among U.S. children ages 12-17 years, 32.9% among those ages 5-11 years, and 5.5% among those ages 6 months-4 years. This manuscript describes the planning and implementation of the U.S. COVID-19 pediatric vaccine program, including successes (e.g., the availability of pharmacy vaccination to extend access beyond more traditional pediatric vaccine providers) and challenges (e.g., multi-dose vaccine vials instead of single-dose vials, leading to concerns about wastage) to provide a historical record of the program and to help inform planning and implementation of future routine or pandemic-related pediatric vaccination campaigns. |
2022 Polio outbreak, Rockland County, NY: Cost evaluation of strategies to prevent future outbreaks of vaccine-preventable diseases
Pike J , Lueken J , Zajac J , Tippins A , Doss S , De Coteau A , Punjabi C , Souto M , Bhatt A . Vaccine 2024 In 1994, the World Health Organization Region of the Americas was declared polio-free. In July 2022, a confirmed case of paralytic polio in an unvaccinated adult resident of Rockland County, New York was reported by the New York State Department of Health (NYSDOH) and Rockland County Department of Health (RCDOH). While only one case was identified, a single case of paralytic polio represents a public health emergency in the United States. The patient's county of residence was identified to have low vaccination coverage indicating that the community was at risk for additional cases. Disease outbreaks are resource-intensive and incur high costs to the patient, local health departments, and to society. These costs are potentially avoidable for vaccine-preventable diseases and thus, highlight the urgency to not only interrupt transmission but to prevent future vaccine-preventable disease outbreaks by improving vaccination coverage. Following case confirmation, an investigation and response was initiated by NYSDOH, along with local health departments and the Centers for Disease Control and Prevention (CDC). After the initial investigation and response, collaborative efforts to mitigate risk and strengthen routine immunization continued, which included provider outreach and immunization record assessments of Head Start and licensed childcare facilities (primarily those with missing or incomplete required vaccination coverage reports from the previous year) in Rockland County. We estimated the costs of (1) provider outreach and (2) childcare and pre-kindergarten immunization record assessments of select licensed childcare and Head Start facilities in Rockland County. The total labor cost incurred for these activities was $138,514 with a total of 2,555 h incurred. Often there are unique opportunities in the midst of an outbreak for public health to implement activities to proactively address low vaccination and strengthen vaccination coverage and possibly prevent future outbreaks. Understanding the cost of these activities might help inform future outbreak planning. |
Racial and ethnic differences in hypertension-related telehealth and in-person outpatient visits before and during the COVID-19 pandemic among Medicaid Beneficiaries
Lee JS , Bhatt A , Pollack LM , Jackson SL , Omeaku N , Lowe Beasley K , Wilson C , Luo F , Roy K . Telemed J E Health 2024 Background: Little is known about the trends and costs of hypertension management through telehealth among individuals enrolled in Medicaid. Methods: Using MarketScan(®) Medicaid database, we examined outpatient visits among people with hypertension aged 18-64 years. We presented the numbers of hypertension-related telehealth and in-person outpatient visits per 100 individuals and the proportion of hypertension-related telehealth outpatient visits to total outpatient visits by month, overall, and by race and ethnicity. For the cost analysis, we presented total and patient out-of-pocket (OOP) costs per visit for telehealth and in-person visits in 2021. Results: Of the 229,562 individuals, 114,445 (49.9%) were non-Hispanic White, 80,692 (35.2%) were non-Hispanic Black, 3,924 (1.71%) were Hispanic. From February to April 2020, the number of hypertension-related telehealth outpatient visits per 100 persons increased from 0.01 to 6.13, the number of hypertension-related in-person visits decreased from 61.88 to 52.63, and the proportion of hypertension-related telehealth outpatient visits increased from 0.01% to 10.44%. During that same time, the proportion increased from 0.02% to 13.9% for non-Hispanic White adults, from 0.00% to 7.58% for non-Hispanic Black adults, and from 0.12% to 19.82% for Hispanic adults. The average total and patient OOP costs per visit in 2021 were $83.82 (95% confidence interval [CI], 82.66-85.05) and $0.55 (95% CI, 0.42-0.68) for telehealth and $264.48 (95% CI, 258.87-269.51) and $0.72 (95% CI, 0.65-0.79) for in-person visits, respectively. Conclusions: Hypertension management via telehealth increased among Medicaid recipients regardless of race and ethnicity, during the COVID-19 pandemic. These findings may inform telehealth policymakers and health care practitioners. |
Impact of SARS-CoV-2 infection on the association between laboratory tests and severe outcomes among hospitalized children
Xie J , Kuppermann N , Florin TA , Tancredi DJ , Funk AL , Kim K , Salvadori MI , Yock-Corrales A , Shah NP , Breslin KA , Chaudhari PP , Bergmann KR , Ahmad FA , Nebhrajani JR , Mintegi S , Gangoiti I , Plint AC , Avva UR , Gardiner MA , Malley R , Finkelstein Y , Dalziel SR , Bhatt M , Kannikeswaran N , Caperell K , Campos C , Sabhaney VJ , Chong SL , Lunoe MM , Rogers AJ , Becker SM , Borland ML , Sartori LF , Pavlicich V , Rino PB , Morrison AK , Neuman MI , Poonai N , Simon NE , Kam AJ , Kwok MY , Morris CR , Palumbo L , Ambroggio L , Navanandan N , Eckerle M , Klassen TP , Payne DC , Cherry JC , Waseem M , Dixon AC , Ferre IB , Freedman SB . Open Forum Infect Dis 2023 10 (10) ofad485 BACKGROUND: To assist clinicians with identifying children at risk of severe outcomes, we assessed the association between laboratory findings and severe outcomes among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children and determined if SARS-CoV-2 test result status modified the associations. METHODS: We conducted a cross-sectional analysis of participants tested for SARS-CoV-2 infection in 41 pediatric emergency departments in 10 countries. Participants were hospitalized, had laboratory testing performed, and completed 14-day follow-up. The primary objective was to assess the associations between laboratory findings and severe outcomes. The secondary objective was to determine if the SARS-CoV-2 test result modified the associations. RESULTS: We included 1817 participants; 522 (28.7%) SARS-CoV-2 test-positive and 1295 (71.3%) test-negative. Seventy-five (14.4%) test-positive and 174 (13.4%) test-negative children experienced severe outcomes. In regression analysis, we found that among SARS-CoV-2-positive children, procalcitonin ≥0.5 ng/mL (adjusted odds ratio [aOR], 9.14; 95% CI, 2.90-28.80), ferritin >500 ng/mL (aOR, 7.95; 95% CI, 1.89-33.44), D-dimer ≥1500 ng/mL (aOR, 4.57; 95% CI, 1.12-18.68), serum glucose ≥120 mg/dL (aOR, 2.01; 95% CI, 1.06-3.81), lymphocyte count <1.0 × 10(9)/L (aOR, 3.21; 95% CI, 1.34-7.69), and platelet count <150 × 10(9)/L (aOR, 2.82; 95% CI, 1.31-6.07) were associated with severe outcomes. Evaluation of the interaction term revealed that a positive SARS-CoV-2 result increased the associations with severe outcomes for elevated procalcitonin, C-reactive protein (CRP), D-dimer, and for reduced lymphocyte and platelet counts. CONCLUSIONS: Specific laboratory parameters are associated with severe outcomes in SARS-CoV-2-infected children, and elevated serum procalcitonin, CRP, and D-dimer and low absolute lymphocyte and platelet counts were more strongly associated with severe outcomes in children testing positive compared with those testing negative. |
Rural and urban differences in hypertension management through telehealth before and during the COVID-19 pandemic among commercially insured patients
Lee JS , Bhatt A , Jackson SL , Pollack LM , Omeaku N , Lowe K , Wilson C , Luo F , Roy K . Am J Hypertens 2023 BACKGROUND: The COVID-19 pandemic prompted a rapid increase in telehealth use. However, limited evidence exists on how rural and urban residents used telehealth and in-person outpatient services to manage hypertension during the pandemic. METHODS: This longitudinal study analyzed 701,410 US adults (18-64 years) in the MarketScan Commercial Claims Database, who were continuously enrolled from January 2017 through March 2022. We documented monthly numbers of hypertension-related telehealth and in-person outpatient visits (per 100 individuals), and the proportion of telehealth visits among all hypertension-related outpatient visits, from January 2019 through March 2022. We used Welch's 2-tail t-test to differentiate monthly estimates by rural-urban status and month-to-month changes. RESULTS: From February through April 2020, the monthly number of hypertension-related telehealth visits per 100 individuals increased from 0.01 to 6.05 (P<0.001) for urban residents and from 0.01 to 4.56 (P<0.001) for rural residents. Hypertension-related in-person visits decreased from 20.12 to 8.30 (P<0.001) for urban residents and from 20.48 to 10.15 (P<0.001) for rural residents. The proportion of hypertension-related telehealth visits increased from 0.04% to 42.15% (P<0.001) for urban residents and from 0.06% to 30.98% (P<0.001) for rural residents. From March 2020 to March 2022, the monthly average of the proportions of hypertension-related telehealth visits was higher for urban residents than for rural residents (10.19% vs. 6.96%; P<0.001). CONCLUSIONS: Data show that rural residents were less likely to use telehealth for hypertension management. Understanding trends in hypertension-related telehealth utilization can highlight disparities in the sustained use of telehealth to advance accessible health care. |
Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study
De Schacht C , Nhacule E , Belo C , Young PW , Bhatt N , Júnior F , Pimentel De Gusmão E , Muquingue H , Muteerwa A , Bila D , Ouenzar MA , Madede T , Cumbane R , Amorim G , Viegas E . BMJ Open 2023 13 (6) e068988 INTRODUCTION: As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The 'COVid and hIV' (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic's impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines. METHODS AND ANALYSIS: A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures. ETHICS AND DISSEMINATION: Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums. TRIAL REGISTRATION NUMBER: NCT05022407. |
Economics of team-based care for blood pressure control: Updated Community Guide Systematic Review
Jacob V , Reynolds JA , Chattopadhyay SK , Nowak K , Hopkins DP , Fulmer E , Bhatt AN , Therrien NL , Cuellar AE , Kottke TE , Clymer JM , Rask KJ . Am J Prev Med 2023 65 (4) 735-754 INTRODUCTION: This paper examined the recent evidence from economic evaluations of team-based care for controlling high blood pressure. METHODS: The search covered studies published from January 2011 through January 2021 and was limited to those based in the United States (U.S.) and other high-income countries. This yielded 35 studies, 23 based in the U.S. and 12 in other high-income countries. Analyses were conducted during May 2021 through February 2023. All monetary values reported are in 2020 U.S. dollars. RESULTS: The median intervention cost per patient per year was $438 for U.S. studies and $299 for all studies. The median change in healthcare cost per patient per year following the intervention was -$140 for both U.S. studies and for all studies. The median net cost per patient per year was $439 for U.S. studies and $133 for all studies. Median cost per quality adjusted life year gained was $12,897 for U.S. studies and $15,202 for all studies, which are below a conservative benchmark of $50,000 for cost-effectiveness. DISCUSSION: Intervention cost and net cost were higher in the U.S. compared to other high- income countries. Healthcare cost averted did not exceed intervention cost in most studies. The evidence shows team-based care for blood pressure control is cost-effective, re-affirming the favorable cost-effectiveness conclusion reached in the 2015 systematic review. |
Project ECHO interprofessional telementoring: Using a novel case-based approach for building the U.S Public Health Service clinical response in pain and substance use disorder
Katzman JG , Bhatt S , Krishnasamy V , Mells LCJE , Rubel S , Tomedi L , Jacobsohn VC , Groves CRJ , Neubert CP . J Interprof Educ Pract 2022 29 Background: The opioid overdose crisis is a US public health emergency that caused over an estimated 93,000 deaths in 2020. To build the clinical capacity of the Commissioned Corps of the US Public Health Service (USPHS), the US Centers for Disease Control and Prevention and Prevention (CDC) collaborated with Project ECHO in pain and substance use disorder (SUD). Purpose: The purpose of this article is to describe the evaluation results of an interprofessional telementoring program using novel clinical vignettes. Method: Interprofessional Project ECHO Pain faculty and the CDC recruited a diverse group of 163 USPHS clinical officers to join one (of two) 16-week, hour-long ECHO Opioid and Pain (OP) telementoring sessions. The structured curriculum included chronic pain, substance use, harm reduction and mental health-related didactics, as well as novel clinical vignettes. Discussion: During this OP telementoring training, novel clinical vignettes were used successfully to train USPHS officers in an interprofessional “all-teach, all-learn” team-based, interdisciplinary learning environment. Over 30% (n = 48) of the USPHS officers attended at least 9 of the 16 sessions. Cohort surveys demonstrated that participants (n = 26) self-reported significantly increased knowledge regarding chronic pain, SUD, and mental health issues when compared to baseline. Focus group participants (n = 41) noted increased self-efficacy in clinical skills and compassion regarding patient care. Conclusion: This interprofessional ECHO training using novel clinical vignettes demonstrates the potential to increase clinical response capacity in pain management and SUD treatment by improving both knowledge and self-efficacy among participants. © 2022 |
Post-COVID-19 Conditions Among Children 90 Days After SARS-CoV-2 Infection.
Funk AL , Kuppermann N , Florin TA , Tancredi DJ , Xie J , Kim K , Finkelstein Y , Neuman MI , Salvadori MI , Yock-Corrales A , Breslin KA , Ambroggio L , Chaudhari PP , Bergmann KR , Gardiner MA , Nebhrajani JR , Campos C , Ahmad FA , Sartori LF , Navanandan N , Kannikeswaran N , Caperell K , Morris CR , Mintegi S , Gangoiti I , Sabhaney VJ , Plint AC , Klassen TP , Avva UR , Shah NP , Dixon AC , Lunoe MM , Becker SM , Rogers AJ , Pavlicich V , Dalziel SR , Payne DC , Malley R , Borland ML , Morrison AK , Bhatt M , Rino PB , Beneyto Ferre I , Eckerle M , Kam AJ , Chong SL , Palumbo L , Kwok MY , Cherry JC , Poonai N , Wassem M , Simon NJ , Freedman SB . JAMA Netw Open 2022 5 (7) e2223253 IMPORTANCE: Little is known about the risk factors for, and the risk of, developing post-COVID-19 conditions (PCCs) among children. OBJECTIVES: To estimate the proportion of SARS-CoV-2-positive children with PCCs 90 days after a positive test result, to compare this proportion with SARS-CoV-2-negative children, and to assess factors associated with PCCs. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study, conducted in 36 emergency departments (EDs) in 8 countries between March 7, 2020, and January 20, 2021, included 1884 SARS-CoV-2-positive children who completed 90-day follow-up; 1686 of these children were frequency matched by hospitalization status, country, and recruitment date with 1701 SARS-CoV-2-negative controls. EXPOSURE: SARS-CoV-2 detected via nucleic acid testing. MAIN OUTCOMES AND MEASURES: Post-COVID-19 conditions, defined as any persistent, new, or recurrent health problems reported in the 90-day follow-up survey. RESULTS: Of 8642 enrolled children, 2368 (27.4%) were SARS-CoV-2 positive, among whom 2365 (99.9%) had index ED visit disposition data available; among the 1884 children (79.7%) who completed follow-up, the median age was 3 years (IQR, 0-10 years) and 994 (52.8%) were boys. A total of 110 SARS-CoV-2-positive children (5.8%; 95% CI, 4.8%-7.0%) reported PCCs, including 44 of 447 children (9.8%; 95% CI, 7.4%-13.0%) hospitalized during the acute illness and 66 of 1437 children (4.6%; 95% CI, 3.6%-5.8%) not hospitalized during the acute illness (difference, 5.3%; 95% CI, 2.5%-8.5%). Among SARS-CoV-2-positive children, the most common symptom was fatigue or weakness (21 [1.1%]). Characteristics associated with reporting at least 1 PCC at 90 days included being hospitalized 48 hours or more compared with no hospitalization (adjusted odds ratio [aOR], 2.67 [95% CI, 1.63-4.38]); having 4 or more symptoms reported at the index ED visit compared with 1 to 3 symptoms (4-6 symptoms: aOR, 2.35 [95% CI, 1.28-4.31]; ≥7 symptoms: aOR, 4.59 [95% CI, 2.50-8.44]); and being 14 years of age or older compared with younger than 1 year (aOR, 2.67 [95% CI, 1.43-4.99]). SARS-CoV-2-positive children were more likely to report PCCs at 90 days compared with those who tested negative, both among those who were not hospitalized (55 of 1295 [4.2%; 95% CI, 3.2%-5.5%] vs 35 of 1321 [2.7%; 95% CI, 1.9%-3.7%]; difference, 1.6% [95% CI, 0.2%-3.0%]) and those who were hospitalized (40 of 391 [10.2%; 95% CI, 7.4%-13.7%] vs 19 of 380 [5.0%; 95% CI, 3.0%-7.7%]; difference, 5.2% [95% CI, 1.5%-9.1%]). In addition, SARS-CoV-2 positivity was associated with reporting PCCs 90 days after the index ED visit (aOR, 1.63 [95% CI, 1.14-2.35]), specifically systemic health problems (eg, fatigue, weakness, fever; aOR, 2.44 [95% CI, 1.19-5.00]). CONCLUSIONS AND RELEVANCE: In this cohort study, SARS-CoV-2 infection was associated with reporting PCCs at 90 days in children. Guidance and follow-up are particularly necessary for hospitalized children who have numerous acute symptoms and are older. |
Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study.
Unwin HJT , Hillis S , Cluver L , Flaxman S , Goldman PS , Butchart A , Bachman G , Rawlings L , Donnelly CA , Ratmann O , Green P , Nelson CA , Blenkinsop A , Bhatt S , Desmond C , Villaveces A , Sherr L . Lancet Child Adolesc Health 2022 6 (4) 249-259 BACKGROUND: In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood). METHODS: We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates. FINDINGS: The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7-90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3-76·7) of children were paternal orphans, whereas 23·5% (23·3-23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood. INTERPRETATION: Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally. FUNDING: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London. |
Outcomes of SARS-CoV-2-Positive Youths Tested in Emergency Departments: The Global PERN-COVID-19 Study.
Funk AL , Florin TA , Kuppermann N , Tancredi DJ , Xie J , Kim K , Neuman MI , Ambroggio L , Plint AC , Mintegi S , Klassen TP , Salvadori MI , Malley R , Payne DC , Simon NJ , Yock-Corrales A , Nebhrajani JR , Chaudhari PP , Breslin KA , Finkelstein Y , Campos C , Bergmann KR , Bhatt M , Ahmad FA , Gardiner MA , Avva UR , Shah NP , Sartori LF , Sabhaney VJ , Caperell K , Navanandan N , Borland ML , Morris CR , Gangoiti I , Pavlicich V , Kannikeswaran N , Lunoe MM , Rino PB , Kam AJ , Cherry JC , Rogers AJ , Chong SL , Palumbo L , Angelats CM , Morrison AK , Kwok MY , Becker SM , Dixon AC , Poonai N , Eckerle M , Wassem M , Dalziel SR , Freedman SB . JAMA Netw Open 2022 5 (1) e2142322 IMPORTANCE: Severe outcomes among youths with SARS-CoV-2 infections are poorly characterized. OBJECTIVE: To estimate the proportion of children with severe outcomes within 14 days of testing positive for SARS-CoV-2 in an emergency department (ED). DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study with 14-day follow-up enrolled participants between March 2020 and June 2021. Participants were youths aged younger than 18 years who were tested for SARS-CoV-2 infection at one of 41 EDs across 10 countries including Argentina, Australia, Canada, Costa Rica, Italy, New Zealand, Paraguay, Singapore, Spain, and the United States. Statistical analysis was performed from September to October 2021. EXPOSURES: Acute SARS-CoV-2 infection was determined by nucleic acid (eg, polymerase chain reaction) testing. MAIN OUTCOMES AND MEASURES: Severe outcomes, a composite measure defined as intensive interventions during hospitalization (eg, inotropic support, positive pressure ventilation), diagnoses indicating severe organ impairment, or death. RESULTS: Among 3222 enrolled youths who tested positive for SARS-CoV-2 infection, 3221 (>99.9%) had index visit outcome data available, 2007 (62.3%) were from the United States, 1694 (52.6%) were male, and 484 (15.0%) had a self-reported chronic illness; the median (IQR) age was 3 (0-10) years. After 14 days of follow-up, 735 children (22.8% [95% CI, 21.4%-24.3%]) were hospitalized, 107 (3.3% [95% CI, 2.7%-4.0%]) had severe outcomes, and 4 children (0.12% [95% CI, 0.03%-0.32%]) died. Characteristics associated with severe outcomes included being aged 5 to 18 years (age 5 to <10 years vs <1 year: odds ratio [OR], 1.60 [95% CI, 1.09-2.34]; age 10 to <18 years vs <1 year: OR, 2.39 [95% CI 1.38-4.14]), having a self-reported chronic illness (OR, 2.34 [95% CI, 1.59-3.44]), prior episode of pneumonia (OR, 3.15 [95% CI, 1.83-5.42]), symptoms starting 4 to 7 days prior to seeking ED care (vs starting 0-3 days before seeking care: OR, 2.22 [95% CI, 1.29-3.82]), and country (eg, Canada vs US: OR, 0.11 [95% CI, 0.05-0.23]; Costa Rica vs US: OR, 1.76 [95% CI, 1.05-2.96]; Spain vs US: OR, 0.51 [95% CI, 0.27-0.98]). Among a subgroup of 2510 participants discharged home from the ED after initial testing and who had complete follow-up, 50 (2.0%; 95% CI, 1.5%-2.6%) were eventually hospitalized and 12 (0.5%; 95% CI, 0.3%-0.8%) had severe outcomes. Compared with hospitalized SARS-CoV-2-negative youths, the risk of severe outcomes was higher among hospitalized SARS-CoV-2-positive youths (risk difference, 3.9%; 95% CI, 1.1%-6.9%). CONCLUSIONS AND RELEVANCE: In this study, approximately 3% of SARS-CoV-2-positive youths tested in EDs experienced severe outcomes within 2 weeks of their ED visit. Among children discharged home from the ED, the risk was much lower. Risk factors such as age, underlying chronic illness, and symptom duration may be useful to consider when making clinical care decisions. |
Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study.
Hillis SD , Unwin HJT , Chen Y , Cluver L , Sherr L , Goldman PS , Ratmann O , Donnelly CA , Bhatt S , Villaveces A , Butchart A , Bachman G , Rawlings L , Green P , Nelson CA3rd , Flaxman S . Lancet 2021 398 (10298) 391-402 BACKGROUND: The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation. METHODS: We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60-84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection-fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers. FINDINGS: Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000-1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000-1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15-50 years. Between two and five times more children had deceased fathers than deceased mothers. INTERPRETATION: Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children. FUNDING: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London. |
COVID-19 Vaccination Coverage Among Adults - United States, December 14, 2020-May 22, 2021.
Diesel J , Sterrett N , Dasgupta S , Kriss JL , Barry V , Vanden Esschert K , Whiteman A , Cadwell BL , Weller D , Qualters JR , Harris L , Bhatt A , Williams C , Fox LM , Meaney Delman D , Black CL , Barbour KE . MMWR Morb Mortal Wkly Rep 2021 70 (25) 922-927 The U.S. COVID-19 vaccination program launched on December 14, 2020. The Advisory Committee on Immunization Practices recommended prioritizing COVID-19 vaccination for specific groups of the U.S. population who were at highest risk for COVID-19 hospitalization and death, including adults aged ≥75 years*; implementation varied by state, and eligibility was gradually expanded to persons aged ≥65 years beginning in January 2021. By April 19, 2021, eligibility was expanded to all adults aged ≥18 years nationwide.(†) To assess patterns of COVID-19 vaccination coverage among U.S. adults, CDC analyzed data submitted on vaccinations administered during December 14, 2020-May 22, 2021, by age, sex, and community-level characteristics. By May 22, 2021, 57.0% of persons aged ≥18 years had received ≥1 COVID-19 vaccine dose; coverage was highest among persons aged ≥65 years (80.0%) and lowest among persons aged 18-29 years (38.3%). During the week beginning February 7, 2021, vaccination initiation among adults aged ≥65 years peaked at 8.2%, whereas weekly initiation among other age groups peaked later and at lower levels. During April 19-May 22, 2021, the period following expanded eligibility to all adults, weekly initiation remained <4.0% and decreased for all age groups, including persons aged 18-29 years (3.6% to 1.9%) and 30-49 years (3.5% to 1.7%); based on the current rate of weekly initiation (as of May 22), younger persons will not reach the same levels of coverage as older persons by the end of August. Across all age groups, coverage (≥1 dose) was lower among men compared with women, except among adults aged ≥65 years, and lower among persons living in counties that were less urban, had higher social vulnerabilities, or had higher percentages of social determinants of poor health. Continued efforts to improve vaccination confidence and alleviate barriers to vaccination initiation, especially among adults aged 18-49 years, could improve vaccination coverage. |
HIV infection in Eastern and Southern Africa: Highest burden, largest challenges, greatest potential
Parker E , Judge MA , Macete E , Nhampossa T , Dorward J , Langa DC , de Schacht C , Couto A , Vaz P , Vitoria M , Molfino L , Idowu RT , Bhatt N , Naniche D , Le Souëf PN . South Afr J HIV Med 2021 22 (1) 1237 Background: The burden of HIV is especially concerning for Eastern and Southern Africa (ESA), as despite expansion of test-and-treat programmes, this region continues to experience significant challenges resulting from high rates of morbidity, mortality and new infections. Hard-won lessons from programmes on the ground in ESA should be shared. Objectives: This report summarises relevant evidence and regional experts’ recommendations regarding challenges specific to ESA. Method: This commentary includes an in-depth review of relevant literature, progress against global goals and consensus opinion from experts. Results: Recommendations include priorities for essential research (surveillance data collection, key and vulnerable population education and testing, in-country testing trials and evidence-based support services to improve retention in care) as well as research that can accelerate progress towards the prevention of new infections and achieving ambitious global goals in ESA. Conclusion: The elimination of HIV in ESA will require continued investment, commitment to evidence-based programmes and persistence. Local research is critical to ensuring that responses in ESA are targeted, efficient and evaluated. © 2021. The Authors. Licensee: AOSIS. |
Cardiopulmonary impact of particulate air pollution in high-risk populations: JACC State-of-the-Art Review
Newman JD , Bhatt DL , Rajagopalan S , Balmes JR , Brauer M , Breysse PN , Brown AGM , Carnethon MR , Cascio WE , Collman GW , Fine LJ , Hansel NN , Hernandez A , Hochman JS , Jerrett M , Joubert BR , Kaufman JD , Malik AO , Mensah GA , Newby DE , Peel JL , Siegel J , Siscovick D , Thompson BL , Zhang J , Brook RD . J Am Coll Cardiol 2020 76 (24) 2878-2894 Fine particulate air pollution <2.5 μm in diameter (PM(2.5)) is a major environmental threat to global public health. Multiple national and international medical and governmental organizations have recognized PM(2.5) as a risk factor for cardiopulmonary diseases. A growing body of evidence indicates that several personal-level approaches that reduce exposures to PM(2.5) can lead to improvements in health endpoints. Novel and forward-thinking strategies including randomized clinical trials are important to validate key aspects (e.g., feasibility, efficacy, health benefits, risks, burden, costs) of the various protective interventions, in particular among real-world susceptible and vulnerable populations. This paper summarizes the discussions and conclusions from an expert workshop, Reducing the Cardiopulmonary Impact of Particulate Matter Air Pollution in High Risk Populations, held on May 29 to 30, 2019, and convened by the National Institutes of Health, the U.S. Environmental Protection Agency, and the U.S. Centers for Disease Control and Prevention. |
Parental vaccine hesitancy and childhood influenza vaccination
Santibanez TA , Nguyen KH , Greby SM , Fisher A , Scanlon P , Bhatt A , Srivastav A , Singleton JA . Pediatrics 2020 146 (6) OBJECTIVES: To quantify the prevalence of parental vaccine hesitancy (VH) in the United States and examine the association of VH with sociodemographics and childhood influenza vaccination coverage. METHODS: A 6-question VH module was included in the 2018 and 2019 National Immunization Survey-Flu, a telephone survey of households with children age 6 months to 17 years. RESULTS: The percentage of children having a parent reporting they were "hesitant about childhood shots" was 25.8% in 2018 and 19.5% in 2019. The prevalence of concern about the number of vaccines a child gets at one time impacting the decision to get their child vaccinated was 22.8% in 2018 and 19.1% in 2019; the prevalence of concern about serious, long-term side effects impacting the parent's decision to get their child vaccinated was 27.3% in 2018 and 21.7% in 2019. Only small differences in VH by sociodemographic variables were found, except for an 11.9 percentage point higher prevalence of "hesitant about childhood shots" and 9.9 percentage point higher prevalence of concerns about serious, long-term side effects among parents of Black compared with white children. In both seasons studied, children of parents reporting they were "hesitant about childhood shots" had 26 percentage points lower influenza vaccination coverage compared with children of parents not reporting hesitancy. CONCLUSIONS: One in 5 children in the United States have a parent who is vaccine hesitant, and hesitancy is negatively associated with childhood influenza vaccination. Monitoring VH could help inform immunization programs as they develop and target methods to increase vaccine confidence and vaccination coverage. |
Characteristics of adults with congenital heart defects in the United States
Gurvitz M , Dunn JE , Bhatt A , Book WM , Glidewell J , Hogue C , Lin AE , Lui G , McGarry C , Raskind-Hood C , Van Zutphen A , Zaidi A , Jenkins K , Riehle-Colarusso T . J Am Coll Cardiol 2020 76 (2) 175-182 BACKGROUND: In the United States, >1 million adults are living with congenital heart defects (CHDs), but gaps exist in understanding the health care needs of this growing population. OBJECTIVES: This study assessed the demographics, comorbidities, and health care use of adults ages 20 to 64 years with CHDs. METHODS: Adults with International Classification of Disease-9th Revision-Clinical Modification CHD-coded health care encounters between January 1, 2008 (January 1, 2009 for Massachusetts) and December 31, 2010 were identified from multiple data sources at 3 U.S. sites: Emory University (EU) in Atlanta, Georgia (5 counties), Massachusetts Department of Public Health (statewide), and New York State Department of Health (11 counties). Demographics, insurance type, comorbidities, and encounter data were collected. CHDs were categorized as severe or not severe, excluding cases with isolated atrial septal defect and/or patent foramen ovale. RESULTS: CHD severity and comorbidities varied across sites, with up to 20% of adults having severe CHD and >50% having ≥1 additional cardiovascular comorbidity. Most adults had ≥1 outpatient encounters (80% EU, 90% Massachusetts, and 53% New York). Insurance type differed across sites, with Massachusetts having a large proportion of Medicaid (75%) and EU and New York having large proportions of private insurance (44% EU, 67% New York). Estimated proportions of adults with CHD-coded health care encounters varied greatly by location, with 1.2 (EU), 10 (Massachusetts), and 0.6 (New York) per 1,000 adults based on 2010 census data. CONCLUSIONS: This was the first surveillance effort of adults with CHD-coded inpatient and outpatient health care encounters in 3 U.S. geographic locations using both administrative and clinical data sources. This information will provide a clearer understanding of health care use in this growing population. |
Leading Practices in Antimicrobial Stewardship: Conference Summary
Baker DW , Hyun D , Neuhauser MM , Bhatt J , Srinivasan A . Jt Comm J Qual Patient Saf 2019 45 (7) 517-523 The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS: The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS: The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION: The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs. |
Collaborative solutions to antibiotic stewardship in small community and critical access hospitals
Bhatt J , Smith B , Neuhauser MM , Srinivasan A , Moore P , Hyun DY . Acad Med 2019 94 (10) 1419-1421 The overuse and misuse of antibiotics affects patients in many ways, including by driving antibiotic resistance, a serious public health threat in the United States and around the world. To improve patient safety and address rising rates of resistance, an increasing number of health care facilities have created antibiotic stewardship programs (ASPs). ASPs have been successful in slowing the emergence of resistance and improving patient outcomes. However, there are serious geographic and resource barriers to ASP adoption in small community hospitals and critical access hospitals. Fortunately, many barriers can be overcome by using collaborative models to bring together key stakeholders, including large hospitals and health systems and academic medical centers; hospital associations; federal, state, and local public health organizations; and federal and state offices of rural health. These stakeholders are ideally positioned to assist with stewardship efforts in small community and critical access hospitals and, in doing so, can improve patient safety while stemming the spread of resistant bacteria. |
Increasing HPV vaccination rates through national provider partnerships
Mitchell K , Saraiya M , Bhatt A . J Womens Health (Larchmt) 2019 28 (6) 747-751 Human papillomavirus (HPV) vaccine is routinely recommended for adolescents at age 11 or 12 years for protection from cancers and other diseases caused by HPV infection. In 2012, only 53.8% of females and 20.8% of males aged 13-17 received one or more doses of HPV vaccine. Due to low vaccination uptake, the Centers for Disease Control and Prevention supported the efforts of several national partner organizations to help raise HPV vaccination rates. National partners include the Academic Pediatric Association, the American Academy of Pediatrics, the American Cancer Society, the National Area Health Education Centers Organization, and the National Association of County and City Health Officials. These national partners have focused on improving provider education on effective HPV vaccine recommendations, prioritizing HPV vaccination, forming strong partnerships, developing and disseminating HPV vaccination resources for members and the public, and quality improvement. |
Surveillance of congenital heart defects among adolescents at three U.S. sites
Lui GK , McGarry C , Bhatt A , Book W , Riehle-Colarusso TJ , Dunn JE , Glidewell J , Gurvitz M , Hoffman T , Hogue CJ , Hsu D , Obenhaus S , Raskind-Hood C , Rodriguez FH 3rd , Zaidi A , Van Zutphen AR . Am J Cardiol 2019 124 (1) 137-143 The prevalence, co-morbidities, and healthcare utilization in adolescents with congenital heart defects (CHDs) is not well understood. Adolescents (11 to 19 years old) with a healthcare encounter between January 1, 2008 (January 1, 2009 for MA) and December 31, 2010 with a CHD diagnosis code were identified from multiple administrative data sources compiled at 3 US sites: Emory University, Atlanta, Georgia (EU); Massachusetts Department of Public Health (MA); and New York State Department of Health (NY). The estimated prevalence for any CHD was 4.77 (EU), 17.29 (MA), and 4.22 (NY) and for severe CHDs was 1.34 (EU), 3.04 (MA), and 0.88 (NY) per 1,000 adolescents. Private or commercial insurance was the most common insurance type for EU and NY, and Medicaid for MA. Inpatient encounters were more frequent in severe CHDs. Cardiac co-morbidities included rhythm and conduction disorders at 20% (EU), 46% (MA), and 9% (NY) as well as heart failure at 3% (EU), 15% (MA), and 2% (NY). Leading noncardiac co-morbidities were respiratory/pulmonary (22% EU, 34% MA, 16% NY), infectious disease (17% EU, 22% MA, 20% NY), non-CHD birth defects (12% EU, 23% MA, 14% NY), gastrointestinal (10% EU, 28% MA, 13% NY), musculoskeletal (10% EU, 32% MA, 11% NY), and mental health (9% EU, 30% MA, 11% NY). In conclusion, this study used a novel approach of uniform CHD definition and variable selection across administrative data sources in 3 sites for the first population-based CHD surveillance of adolescents in the United States. High resource utilization and co-morbidities illustrate ongoing significant burden of disease in this vulnerable population. |
American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy
Witt DM , Nieuwlaat R , Clark NP , Ansell J , Holbrook A , Skov J , Shehab N , Mock J , Myers T , Dentali F , Crowther MA , Agarwal A , Bhatt M , Khatib R , Riva JJ , Zhang Y , Guyatt G . Blood Adv 2018 2 (22) 3257-3291 BACKGROUND: Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat venous thromboembolism (VTE). OBJECTIVE: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and other health care professionals in their decisions about the use of anticoagulants in the management of VTE. These guidelines assume the choice of anticoagulant has already been made. METHODS: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS: The panel agreed on 25 recommendations and 2 good practice statements to optimize management of patients receiving anticoagulants. CONCLUSIONS: Strong recommendations included using patient self-management of international normalized ratio (INR) with home point-of-care INR monitoring for vitamin K antagonist therapy and against using periprocedural low-molecular-weight heparin (LMWH) bridging therapy. Conditional recommendations included basing treatment dosing of LMWH on actual body weight, not using anti-factor Xa monitoring to guide LMWH dosing, using specialized anticoagulation management services, and resuming anticoagulation after episodes of life-threatening bleeding. |
Persistence of endothelial thrombomodulin in a patient with infectious purpura fulminans treated with protein C concentrate
Bendapudi PK , Robbins A , LeBoeuf N , Pozdnyakova O , Bhatt A , Duke F , Sells R , McQuiston J , Humrighouse B , Rouaisnel B , Colling M , Stephenson KE , Saavedra A , Losman JA . Blood Adv 2018 2 (21) 2917-2921 Purpura fulminans (PF) is a rare life-threatening complication of bacterial sepsis that is characterized by a highly thrombotic subtype of disseminated intravascular coagulation (DIC) and mortality of up to 80%.1 Patients with PF develop a severe deficiency in protein C (PC), a serine protease that is a key endogenous anticoagulant.2 PC is activated at the endothelial surface by thrombin in the presence of the cofactor thrombomodulin (TM). Activated PC (APC) is cytoprotective3 and inhibits thrombin generation by cleaving coagulation factors Va and VIIIa.4 Therefore, TM is a crucial regulatory “switch” governing negative feedback of coagulation. The initiating event in PF is hypothesized to be loss of TM from the endothelial surface in response to infection.5 As a result, conversion of PC to APC is impaired, and coagulation proceeds unchecked.3 Although therapy with PC concentrate has been proposed as a strategy to target the underlying pathophysiologic lesion in PF,6 the belief that endothelial TM loss is an early event in PF that renders infused PC ineffective has limited its widespread adoption.2,5 We report herein data on the kinetics of TM loss in a patient with PF that support the use of supplemental PC in upfront treatment of severe cases. |
Compromise of second-line antiretroviral therapy due to high rates of human immunodeficiency virus drug resistance in Mozambican treatment-experienced children with virologic failure
Vaz P , Buck WC , Bhatt N , Bila D , Auld A , Houston J , Cossa L , Alfredo C , Jobarteh K , Sabatier J , Macassa E , Sousa A , DeVos J , Jani I , Yang C . J Pediatric Infect Dis Soc 2018 9 (1) 6-13 Background: Virologic failure (VF) is highly prevalent in sub-Saharan African children on antiretroviral therapy (ART) and is often associated with human immunodeficiency virus drug resistance (DR). Most children still lack access to routine viral load (VL) monitoring for early identification of treatment failure, with implications for the efficacy of second-line ART. Methods: Children aged 1 to 14 years on ART for >/=12 months at 6 public facilities in Maputo, Mozambique were consecutively enrolled after informed consent. Chart review and caregiver interviews were conducted. VL testing was performed, and specimens with >/=1000 copies/mL were genotyped. Results: Of the 715 children included, the mean age was 103 months, 85.8% had no immunosuppression, 73.1% were taking stavudine/lamivudine/nevirapine, and 20.1% had a history prevention of mother-to-child transmission exposure. The mean time on ART was 60.0 months. VF was present in 259 patients (36.3%); 248 (95.8%) specimens were genotyped, and DR mutations were found in 238 (96.0%). Severe immunosuppression and nutritional decline were associated with DR. M184V and Y181C were the most common mutations. In the 238 patients with DR, standard second-line ART would have 0, 1, 2, and 3 effective antiretrovirals in 1 (0.4%), 74 (31.1%), 150 (63.0%), and 13 (5.5%) patients, respectively. Conclusion: This cohort had high rates of VF and DR with frequent compromise of second-line ART. There is urgent need to scale-up VL monitoring and heat-stable protease inhibitor formulations or integrase inhibitorsfor a more a durable first-line regimen that can feasibly be implemented in developing settings. |
Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort study
Kleinschmidt I , Bradley J , Knox TB , Mnzava AP , Kafy HT , Mbogo C , Ismail BA , Bigoga JD , Adechoubou A , Raghavendra K , Cook J , Malik EM , Nkuni ZJ , Macdonald M , Bayoh N , Ochomo E , Fondjo E , Awono-Ambene HP , Etang J , Akogbeto M , Bhatt RM , Chourasia MK , Swain DK , Kinyari T , Subramaniam K , Massougbodji A , Oke-Sopoh M , Ogouyemi-Hounto A , Kouambeng C , Abdin MS , West P , Elmardi K , Cornelie S , Corbel V , Valecha N , Mathenge E , Kamau L , Lines J , Donnelly MJ . Lancet Infect Dis 2018 18 (6) 640-649 BACKGROUND: Scale-up of insecticide-based interventions has averted more than 500 million malaria cases since 2000. Increasing insecticide resistance could herald a rebound in disease and mortality. We aimed to investigate whether insecticide resistance was associated with loss of effectiveness of long-lasting insecticidal nets and increased malaria disease burden. METHODS: This WHO-coordinated, prospective, observational cohort study was done at 279 clusters (villages or groups of villages in which phenotypic resistance was measurable) in Benin, Cameroon, India, Kenya, and Sudan. Pyrethroid long-lasting insecticidal nets were the principal form of malaria vector control in all study areas; in Sudan this approach was supplemented by indoor residual spraying. Cohorts of children from randomly selected households in each cluster were recruited and followed up by community health workers to measure incidence of clinical malaria and prevalence of infection. Mosquitoes were assessed for susceptibility to pyrethroids using the standard WHO bioassay test. Country-specific results were combined using meta-analysis. FINDINGS: Between June 2, 2012, and Nov 4, 2016, 40 000 children were enrolled and assessed for clinical incidence during 1.4 million follow-up visits. 80 000 mosquitoes were assessed for insecticide resistance. Long-lasting insecticidal net users had lower infection prevalence (adjusted odds ratio [OR] 0.63, 95% CI 0.51-0.78) and disease incidence (adjusted rate ratio [RR] 0.62, 0.41-0.94) than did non-users across a range of resistance levels. We found no evidence of an association between insecticide resistance and infection prevalence (adjusted OR 0.86, 0.70-1.06) or incidence (adjusted RR 0.89, 0.72-1.10). Users of nets, although significantly better protected than non-users, were nevertheless subject to high malaria infection risk (ranging from an average incidence in net users of 0.023, [95% CI 0.016-0.033] per person-year in India, to 0.80 [0.65-0.97] per person year in Kenya; and an average infection prevalence in net users of 0.8% [0.5-1.3] in India to an average infection prevalence of 50.8% [43.4-58.2] in Benin). INTERPRETATION: Irrespective of resistance, populations in malaria endemic areas should continue to use long-lasting insecticidal nets to reduce their risk of infection. As nets provide only partial protection, the development of additional vector control tools should be prioritised to reduce the unacceptably high malaria burden. FUNDING: Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development. |
Performance characteristics of finger-stick dried blood spots (DBS) on the determination of human immunodeficiency virus (HIV) treatment failure in a pediatric population in Mozambique
Chang J , de Sousa A , Sabatier J , Assane M , Zhang G , Bila D , Vaz P , Alfredo C , Cossa L , Bhatt N , Koumans EH , Yang C , Rivadeneira E , Jani I , Houston JC . PLoS One 2017 12 (7) e0181054 Quantitative plasma viral load (VL) at 1000 copies /mL was recommended as the threshold to confirm antiretroviral therapy (ART) failure by the World Health Organization (WHO). Because of ongoing challenges of using plasma for VL testing in resource-limited settings (RLS), especially for children, this study collected 717 DBS and paired plasma samples from children receiving ART ≥1 year in Mozambique and compared the performance of DBS using Abbott's VL test with a paired plasma sample using Roche's VL test. At a cut-off of 1000 copies/mL, sensitivity of DBS using Abbott DBS VL test was 79.9%, better than 71.0% and 63.9% at 3000 and 5000 copies/mL, respectively. Specificities were 97.6%, 98.8%, 99.3% at 1000, 3000, and 5000 copies/mL, respectively. The Kappa value at 1000 copies/mL, 0.80 (95% CI: 0.73, 0.87), was higher than 0.73 (95% CI: 0.66, 0.80) and 0.66 (95% CI: 0.59, 0.73) at 3000, 5000 copies/mL, respectively, also indicating better agreement. The mean difference between the DBS and plasma VL tests with 95% limits of agreement by Bland-Altman was 0.311 (-0.908, 1.530). Among 73 children with plasma VL between 1000 to 5000 copies/mL, the DBS results were undetectable in 53 at the 1000 copies/mL threshold. While one DBS sample in the Abbott DBS VL test may be an alternative method to confirm ART failure at 1000 copies/mL threshold when a plasma sample is not an option for treatment monitoring, because of sensitivity concerns between 1,000 and 5,000 copies/ml, two DBS samples may be preferred accompanied by careful patient monitoring and repeat testing. |
Population coverage of artemisinin-based combination treatment in children younger than 5 years with fever and Plasmodium falciparum infection in Africa, 2003-2015: a modelling study using data from national surveys
Bennett A , Bisanzio D , Yukich JO , Mappin B , Fergus CA , Lynch M , Cibulskis RE , Bhatt S , Weiss DJ , Cameron E , Gething PW , Eisele TP . Lancet Glob Health 2017 5 (4) e418-e427 BACKGROUND: Artemisinin-based combination therapies (ACTs) are the most effective treatment for uncomplicated Plasmodium falciparum malaria infection. A commonly used indicator for monitoring and assessing progress in coverage of malaria treatment is the proportion of children younger than 5 years with reported fever in the previous 14 days who have received an ACT. We propose an improved indicator that incorporates parasite infection status (as assessed by a rapid diagnostic test [RDT]), which is available in recent household surveys. In this study we estimated the annual proportion of children younger than 5 years with fever and a positive RDT in Africa who received an ACT in 2003-15. METHODS: Our modelling study used cross-sectional data on treatment for fever and RDT status for children younger than 5 years compiled from all nationally available representative household surveys (the Malaria Indicator Surveys, Demographic and Health Surveys, and Multiple Indicator Cluster Surveys) across sub-Saharan Africa between 2003 and 2015. Estimates for the proportion of children younger than 5 years with a fever within the previous 14 days and P falciparum infection assessed by RDT who received an ACT were incorporated in a generalised additive mixed model, including data on ACT distributions, to estimate coverage across all countries and time periods. We did random effects meta-analyses to examine individual, household, and community effects associated with ACT coverage. FINDINGS: We obtained data on 201 704 children younger than 5 years from 103 surveys (22 MIS, 61 DHS, and 20 MICS) across 33 countries. RDT results were available for 40 of these surveys including 40 261 (20%) children, and we predicted RDT status for the remaining 161 443 (80%) children. Our results showed that ACT coverage in children younger than 5 years with a fever and P falciparum infection increased across sub-Saharan Africa in 2003-15, but even in 2015, only 19.7% (95% CI 15.6-24.8) of children younger than 5 years with a fever and P falciparum infection received an ACT. In meta-analyses, children younger than 5 years were more likely to receive an ACT for fever and P falciparum infection if they lived in an urban area (vs rural area; odds ratio [OR] 1.18, 95% CI 1.06-1.31), had household wealth above the national median (vs wealth below the median; OR 1.26, 1.16-1.39), had a caregiver with any education (vs no education; OR 1.31, 1.22-1.41), had a household insecticide-treated net (ITN; vs no ITN; OR 1.21, 1.13-1.29), were older than 2 years (vs ≤2 years; OR 1.09, 1.01-1.17), or lived in an area with a higher mean P falciparum prevalence in children aged 2-10 years (OR 1.12, 1.02-1.23). In the subgroup of children for whom treatment was sought, those who sought treatment in the public sector were more likely to receive an ACT (vs the private sector; OR 3.18, 2.67-3.78). INTERPRETATION: Despite progress during the 2003-15 malaria programme, ACT treatment for children with malaria remains unacceptably low. More work is needed at the country level to understand how health-care access, service delivery, and ACT supply might be improved to ensure appropriate treatment for all children with malaria. FUNDING: US President's Malaria Initiative and Medicines for Malaria Venture. |
Human papillomavirus vaccine as an anticancer vaccine: Collaborative efforts to promote human papillomavirus vaccine in the National Comprehensive Cancer Control Program
Townsend JS , Steele CB , Hayes N , Bhatt A , Moore AR . J Womens Health (Larchmt) 2017 26 (3) 200-206 Widespread use of the human papillomavirus (HPV) vaccine has the potential to reduce incidence from HPV-associated cancers. However, vaccine uptake among adolescents remains well below the Healthy People 2020 targets. The Centers for Disease Control and Prevention (CDC) National Comprehensive Cancer Control Program (NCCCP) awardees are well positioned to work with immunization programs to increase vaccine uptake. The CDC chronic disease management information system was queried for objectives and activities associated with HPV vaccine that were reported by NCCCP awardees from 2013 to 2016 as part of program reporting requirements. A content analysis was conducted on the query results to categorize interventions according to strategies outlined in The Guide to Community Preventive Services and the 2014 President's Cancer Panel report. Sixty-two percent of NCCCP awardees had planned or implemented at least one activity since 2013 to address low HPV vaccination coverage in their jurisdictions. Most NCCCP awardees (86%) reported community education activities, while 65% reported activities associated with provider education. Systems-based strategies such as client reminders or provider assessment and feedback were each reported by less than 25% of NCCCP awardees. Many NCCCP awardees report planning or implementing activities to address low HPV vaccination coverage, often in conjunction with state immunization programs. NCCCP awardees can play a role in increasing HPV vaccination coverage through their cancer prevention and control expertise and access to partners in the healthcare community. |
The World Health Organization measles programmatic risk assessment tool-pilot testing in India, 2014
Goel K , Naithani S , Bhatt D , Khera A , Sharapov UM , Kriss JL , Goodson JL , Laserson KF , Goel P , Kumar RM , Chauhan LS . Risk Anal 2016 37 (6) 1063-1071 Measles is a leading cause of child mortality, and reduction of child mortality is a key Millennium Development Goal. In 2014, the World Health Organization and the U.S. Centers for Disease Control and Prevention developed a measles programmatic risk assessment tool to support country measles elimination efforts. The tool was pilot tested in the State of Uttarakhand in August 2014 to assess its utility in India. The tool assessed measles risk for the 13 districts of Uttarakhand as a function of indicator scores in four categories: population immunity, surveillance quality, program delivery performance, and threat. The highest potential overall score was 100. Scores from each category were totaled to assign an overall risk score for each district. From this risk score, districts were categorized as low, medium, high, or very high risk. Of the 13 districts in Uttarakhand in 2014, the tool classified one district (Haridwar) as very high risk and three districts (Almora, Champawat, and Pauri Garhwal) as high risk. The measles risk in these four districts was largely due to low population immunity from high MCV1-MCV2 drop-out rates, low MCV1 and MCV2 coverage, and the lack of a supplementary immunization activity (SIA) within the past three years. This tool can be used to support measles elimination in India by identifying districts that might be at risk for measles outbreaks, and to guide risk mitigation efforts, including strengthening routine immunization services and implementing SIAs. |
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