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A Comparison of Markov and Mechanistic Models for Soil-Transmitted Helminth Prevalence Projections in the Context of Survey Design.
Get PDFGlobally, there are over 1 billion people infected with soil-transmitted helminths (STHs), mostly living in marginalized settings with inadequate sanitation in sub-Saharan Africa and Southeast Asia. The World Health Organization recommends an integrated approach to STH morbidity control through improved access to sanitation and hygiene education and the delivery of preventive chemotherapy (PC) to school-age children delivered through schools. Progress of STH control programs is currently estimated using a baseline (pre-PC) school-based prevalence survey and then monitored using periodical school-based prevalence surveys, known as Impact Assessment Surveys (IAS). We investigated whether integrating geostatistical methods with a Markov model or a mechanistic transmission model for projecting prevalence forward in time from baseline can improve IAS design strategies. To do this, we applied these 2 methods to prevalence data collected in Kenya, before evaluating and comparing their performance in accurately informing optimal survey design for a range of IAS sampling designs. We found that, although both approaches performed well, the mechanistic method more accurately projected prevalence over time and provided more accurate information for guiding survey design. Both methods performed less well in areas with persistent STH hotspots where prevalence did not decrease despite multiple rounds of PC. Our findings show that these methods can be useful tools for more efficient and accurate targeting of PC. The general framework built in this paper can also be used for projecting prevalence and informing survey design for other neglected tropical diseases
Health Catch-UP!: a realist evaluation of an innovative multi-disease screening and vaccination tool in UK primary care for at-risk migrant patients.
Get PDFBACKGROUND: Migrants to the UK face disproportionate risk of infections, non-communicable diseases, and under-immunisation compounded by healthcare access barriers. Current UK migrant screening strategies are unstandardised with poor implementation and low uptake. Health Catch-UP! is a collaboratively produced digital clinical decision support system that applies current guidelines (UKHSA and NICE) to provide primary care professionals with individualised multi-disease screening (7 infectious diseases/blood-borne viruses, 3 chronic parasitic infections, 3 non-communicable disease or risk factors) and catch-up vaccination prompts for migrant patients. METHODS: We carried out a mixed-methods process evaluation of Health Catch-UP! in two urban primary healthcare practices to integrate Health Catch-UP! into the electronic health record system of primary care, using the Medical Research Council framework for complex intervention evaluation. We collected quantitative data (demographics, patients screened, disease detection and catch-up vaccination rates) and qualitative participant interviews to explore acceptability and feasibility. RESULTS: Ninety-nine migrants were assessed by Health Catch-UP! across two sites (S1, S2). 96.0% (n = 97) had complete demographics coding with Asia 31.3% (n = 31) and Africa 25.2% (n = 25), the most common continents of birth (S1 n = 92 [48.9% female (n = 44); mean age 60.6 years (SD 14.26)]; and S2 n = 7 [85.7% male (n = 6); mean age 39.4 years (SD16.97)]. 61.6% (n = 61) of participants were eligible for screening for at least one condition and uptake of screening was high 86.9% (n = 53). Twelve new conditions were identified (12.1% of study population) including hepatitis C (n = 1), hypercholesteraemia (n = 6), pre-diabetes (n = 4), and diabetes (n = 1). Health Catch-UP! identified that 100% (n = 99) of patients had no immunisations recorded; however, subsequent catch-up vaccination uptake was poor (2.0%, n = 1). Qualitative data supported acceptability and feasibility of Health Catch-UP! from staff and patient perspectives, and recommended Health Catch-UP! integration into routine care (e.g. NHS health checks) with an implementation package including staff and patient support materials, standardised care pathways (screening and catch-up vaccination, laboratory, and management), and financial incentivisation. CONCLUSIONS: Clinical Decision Support Systems like Health Catch-UP! can improve disease detection and implementation of screening guidance for migrant patients but require robust testing, resourcing, and an effective implementation package to support both patients and staff
A new method for estimating recent adult mortality from summary sibling histories.
Get PDFBACKGROUND: In low- and middle-income countries with limited death registration statistics, adult mortality rates are commonly estimated through sibling survival histories (SSH). In full SSH, respondents are asked about either the age, or the age and time of death, of each of their siblings in turn. Full SSH allow direct mortality estimation but can be time-consuming to collect. In this study, we introduce a new indirect estimation method using summary SSH, requiring only a limited set of questions to produce recent mortality estimates. METHODS: We developed a set of 192 microsimulations representing a wide range of fertility and mortality patterns, and reconstructed summary SSH within these simulations as if they had been collected from adults aged 15-49. For each age group of respondents, we calculated coefficients that convert the proportion of adult siblings who died in the previous 5 years into age-specific mortality rates. We then evaluated the performance of this new method with real data, using 154 Demographic and Health Surveys. RESULTS: The new indirect method provides mortality rates that are consistent with direct estimates from full SSH. Across all DHS, the mean absolute percentage error in the risk of dying in adulthood (ages 15-49) is 6% for both men and women. In all but one survey, 95% confidence intervals around the direct and indirect estimates overlap. As with direct estimates of adult mortality from SSH, the indirect estimates remain, however, lower than those of the Population Division of the United Nations. CONCLUSIONS: Summary questions on sibling survival can be included in censuses and rapid turn-around surveys for the measurement of recent adult mortality
EpiFusion: Joint inference of the effective reproduction number by integrating phylodynamic and epidemiological modelling with particle filtering.
Get PDFAccurately estimating the effective reproduction number (Rt) of a circulating pathogen is a fundamental challenge in the study of infectious disease. The fields of epidemiology and pathogen phylodynamics both share this goal, but to date, methodologies and data employed by each remain largely distinct. Here we present EpiFusion: a joint approach that can be used to harness the complementary strengths of each field to improve estimation of outbreak dynamics for large and poorly sampled epidemics, such as arboviral or respiratory virus outbreaks, and validate it for retrospective analysis. We propose a model of Rt that estimates outbreak trajectories conditional upon both phylodynamic (time-scaled trees estimated from genetic sequences) and epidemiological (case incidence) data. We simulate stochastic outbreak trajectories that are weighted according to epidemiological and phylodynamic observation models and fit using particle Markov Chain Monte Carlo. To assess performance, we test EpiFusion on simulated outbreaks in which transmission and/or surveillance rapidly changes and find that using EpiFusion to combine epidemiological and phylodynamic data maintains accuracy and increases certainty in trajectory and Rt estimates, compared to when each data type is used alone. We benchmark EpiFusion's performance against existing methods to estimate Rt and demonstrate advances in speed and accuracy. Importantly, our approach scales efficiently with dataset size. Finally, we apply our model to estimate Rt during the 2014 Ebola outbreak in Sierra Leone. EpiFusion is designed to accommodate future extensions that will improve its utility, such as explicitly modelling population structure, accommodations for phylogenetic uncertainty, and the ability to weight the contributions of genomic or case incidence to the inference
Characterisation of the SARS-CoV-2 pandemic in healthcare workers within the United Kingdom: Risk factors for infection during four successive waves.
Get PDFBACKGROUND: Healthcare workers were at a high risk of infection early in the SARS-CoV-2 pandemic. It is uncertain to what extent occupational, household and community factors contributed, and how this changed over time. We aimed to characterise the risk factors for infection over four successive waves of the pandemic in a large, UK healthcare worker cohort (SIREN). METHODS: Participants underwent fortnightly SARS-CoV-2 PCR testing and symptom/exposure questionnaire. Attack rates and adjusted OR of infection were calculated according to participant characteristics and exposures for each wave between 1st October 2020 and 30th August 2022. FINDINGS: 19,427 participants were included in the second wave, 20,260 in the third, 11,937 in the fourth, and 6503 in the fifth. The attack rates of infection were 9.1% (alpha), 6.6% (delta), 36.6% (omicron BA.1/2) and 15.9% (omicron BA.4/5), respectively. Occupational risk factors were only apparent in the second wave, during which significant social distancing measures were in place. These were identified as working as a healthcare assistant, nurse or bedside therapist, and working on an inpatient ward. Occupational exposure requiring personal protective equipment was also a risk. In subsequent waves, without social restrictions, occupational characteristics were not risk factors. Instead, living with others compared to living alone was a risk, particularly children. During the third wave (winter 2021-2022), having a colleague with COVID-19 was identified as a risk for the first time. INTERPRETATION: Our findings highlight clinical areas and occupational groups in which there may be scope to prevent healthcare-associated infections, particularly during winter pressures. Prospective studies targeting these are essential to establish which interventions are most effective. This study also underscores the importance of community circulation and exposures when considering healthcare workforce protection
Indirect effects of the COVID-19 pandemic: A cause-of-death analysis of life expectancy changes in 24 countries, 2015 to 2022.
Get PDFWorldwide, mortality was strongly affected by the COVID-19 pandemic, both directly through COVID-19 deaths and indirectly through changes in other causes of death. Here, we examine the impact of the pandemic on COVID-19 and non-COVID-19 mortality in 24 countries: Australia, Austria, Brazil, Bulgaria, Canada, Chile, Croatia, Czechia, Denmark, England and Wales, Hungary, Japan, Latvia, Lithuania, The Netherlands, Northern Ireland, Poland, Russia, Scotland, South Korea, Spain, Sweden, Switzerland, and the United States. Using demographic decomposition methods, we compare age- and cause-specific contributions to changes in female and male life expectancy at birth in 2019-2020, 2020-2021, and 2021-2022 with those before the COVID-19 pandemic (2015-2019). We observe large life expectancy losses due to COVID-19 in most countries, usually followed by partial recoveries. Life expectancy losses due to cardiovascular disease (CVD) mortality were widespread during the pandemic, including in countries with substantial (Russia, Central and Eastern Europe, and the Baltic countries) and more modest (United States) improvements in CVD mortality before the pandemic. Many Anglo-Saxon countries, including Canada, Scotland, and the United States, continued their prepandemic trajectories of rising drug-related mortality. Most countries saw small changes in suicide mortality during the pandemic, while alcohol mortality increased and cancer mortality continued to decline. Patterns for other causes were more variable. By 2022, life expectancy had still not returned to prepandemic levels in several countries. Our results suggest important indirect effects of the pandemic on non-COVID-19 mortality through the consequences of COVID-19 infection, nonpharmaceutical interventions, and underreporting of COVID-19-related deaths
Co-located Heroin Assisted Treatment within primary care: A preliminary analysis of the implications for healthcare access, cost, and treatment delivery in the UK.
Get PDFBACKGROUND: The UK is experiencing its highest rate of drug related deaths in 25 years. Poor and inconsistent access to healthcare negatively impacts health outcomes for people who use drugs. Innovation in models of care which promote access and availability of physical treatment is fundamental. Heroin Assisted Treatment (HAT) is a treatment modality targeted at the most marginalised people who use drugs, at high risk of mortality and morbidity. The first service-provider initiated HAT service in the UK ran between October 2019 and November 2022 in Middlesbrough, England. The service was co-located within a specialist primary care facility offering acute healthcare treatment alongside injectable diamorphine. METHODS: Analysis of anonymised health records for healthcare costs (not including drug treatment) took place using descriptive statistics prior and during engagement with HAT, at both three (n=15) and six (n=12) months. Primary outcome measures were incidents of wound care, skin and soft tissue infections (SSTIs), overdose (OD) events, unplanned overnight stays in hospital, treatment engagement (general and within hospital care settings) and ambulance incidents. Secondary outcome measures were costs associated with these events. RESULTS: A shift in healthcare access for participants during HAT engagement was observed. HAT service attendance appeared to support health promoting preventative care, and reduce reactive reliance on emergency healthcare systems. At three and six months, engagement for preventative wound care and treatment for SSTIs increased at the practice. Unplanned emergency healthcare interactions for ODs, overnight hospital stays, serious SSTIs, and ambulance incidents reduced, and there was an increase in treatment engagement (i.e. a reduction in appointments which were not engaged with). There was a decrease in treatment engagement in hospital settings. Changes in healthcare utilisation during HAT translated to a reduction in healthcare costs of 58% within six months compared to the same timeframe from the period directly prior to commencing HAT. CONCLUSION: This exploratory study highlights the potential for innovative harm reduction interventions such as HAT, co-located with primary care services, to improve healthcare access and engagement for a high-risk population. Increased uptake of primary healthcare services translated to reductions in emergency healthcare use and associated costs. Although costs of HAT provision are substantial, the notable cost-savings in health care should be an important consideration in service implementation planning
Quality of information and social norms in Spanish-speaking TikTok videos as levers of commercial practices: The case of semaglutide.
Get PDFSocial media can be a platform to spread misinformation and reinforce potentially harmful norms in the interest of commercial actors. There are norms related to obesity that commercial actors promote such as "obesity is an individual problem" and the "pharmaceuticalization of obesity". In this study, we assess the quality of information about semaglutide, and the descriptive norms related to its use as levers of commercial practices in social media. We carried out a content analysis of Spanish speaking TikTok videos published between January 2022 and November 2023. We used the DISCERN instrument to assess the quality of information and classified the social norms disseminated through the videos and the narrating voices. The overall quality of information was low, with a mean DISCERN score of 29.8 out of 75. Although healthcare professionals and professional communicators performed slightly better compared to other voices, critical aspects of good health communication were often lacking; 155 videos (71%) did not mention any risk related to the use of semaglutide and only 11.9% of videos mentioned one or more serious risks. In 85% of videos, obesity was depicted as an individual problem. About half of the videos normalized the use of semaglutide and 79% of videos promoted the pharmaceuticalization of obesity by mentioning losing weight as a benefit of using semaglutide but not mentioning the need to make lifestyle changes. The combination of poor-quality health information and the promotion of potentially harmful norms related to semaglutide use is a public health concern. Further research on the commercial determinants of health in the context of semaglutide use is needed, as well as actions to mitigate the risks of misinformation and harmful health-related norms
Effectiveness of 234 interventions to improve life satisfaction: A rapid systematic review.
Get PDFThis rapid review evaluates interventions aimed at improving life satisfaction and aids policymakers, researchers, and practitioners by identifying research strengths, gaps, and future directions for life satisfaction research. Intervention inclusion criteria were: use of a control group; delivered in high-income OECD country; randomised control trials or quasi-experimental studies; published between Jan 2011-Oct 2023; English language; uses a validated life satisfaction outcome measure. Of 9520 search results across five academic databases and grey literature sources, a total of 189 studies with 234 intervention arms met criteria for inclusion. The six themes (18 total subthemes) identified were: Emotion-based activities (intrapersonal and interpersonal, n = 154); Didactic emotional development (n = 30); Health promotion (n = 31); Social media (n = 4); Music (n = 3); and Multi-component interventions (n = 12). Meta-analyses were possible in six subthemes and examined overall standardised mean differences (SMD) in life satisfaction from pre-to post-intervention between the intervention and control group. The review primarily identified intrapersonal (related to self) emotional activities as generally associated with small improvements in life satisfaction: mindfulness (SMD: 0.28 (95% Confidence Interval: 0.13, 0.42)), gratitude (0.19 (0.11, 0.27)) and therapy (0.33 (0.12, 0.53)). Additionally, meta-analysis revealed a moderate effect of emotional skills development training (SMD 0.50 (0.12, 0.88)) and a small effect of exercise (SMD: 0.33 (0.04, 0.62)) on life satisfaction. Subthemes with mixed evidence (i.e., some interventions were effective while others were not) included: positivity and prosocial activities, emotional regulation and resilience training, health promotion education, 'other' intrapersonal emotion-based activities which could not otherwise be categorised, and multi-component interventions. The findings of this rapid review offer comprehensive insight into effective interventions for improving life satisfaction as well as areas for further research
Combined interventions for the testing and treatment of HIV and schistosomiasis among fishermen in Malawi: a three-arm, cluster-randomised trial.
Get PDFBACKGROUND: Undiagnosed HIV and schistosomiasis are highly prevalent among fishermen in the African Great Lakes region. We aimed to evaluate the efficacy of lakeside interventions integrating services for HIV and male genital schistosomiasis on the prevalence of schistosomiasis, uptake of antiretroviral therapy (ART) for HIV, and voluntary male medical circumcision (VMMC) among fishermen in Malawi. METHODS: We conducted a three-arm, cluster-randomised trial in 45 lakeshore fishing communities (clusters) in Mangochi, Malawi. Clusters were defined geographically by their home community as the place where fishermen leave their boats (ie, a landing site). Eligible participants were male fishermen (aged ≥18 years) who resided in a cluster. Clusters were randomly allocated (1:1:1) through computer-generated random numbers to either enhanced standard of care (SOC), which offered invitation with information leaflets to a beach clinic offering HIV testing and referral, and presumptive treatment for schistosomiasis with praziquantel; peer education (PE), in which a nominated fisherman was responsible for explaining the study leaflet to promote services to his boat crew; or peer distribution education (PDE), in which the peer educator explained the leaflet and distributed HIV self-test kits to his boat crew. The beach clinic team and fishermen were not masked to intervention allocation; however, investigators were masked until the final analysis. Coprimary composite outcomes were the proportion of participants who had at least one Schistosoma haematobium egg observed on light microscopy from 10 mL of urine filtrate and the proportion who had self-reported initiating ART or scheduling VMMC by day 28. Outcomes were analysed by intention to treat; multiple imputation for missing outcomes was done; random-effect binomial models adjusting for baseline imbalance and clustering were used to compute unadjusted and adjusted risk differences, risk ratios (RRs) and 95% CIs, and intracluster correlation coefficients for each outcome. This trial is registered with ISRCTN, ISRCTN14354324. FINDINGS: Between March 1, 2022, and Jan 29, 2023, 45 (65·2%) of 69 clusters assessed for eligibility were enrolled in the trial, with 15 clusters per arm. Of the 6036 fishermen screened at baseline, 5207 (86·3%) were eligible for participation: 1745 (87·6%) of 1991 in the enhanced SOC group, 1687 (81·9%) of 2061 in the PE group, and 1775 (89·5%) of 1984 in the PDE group. Compared with the prevalence of active schistosomiasis in the enhanced SOC group (292 [16·7%] of 1745), 241 (13·6%) of 1775 fishermen in the PDE group (adjusted RR 0·80 [95% CI 0·69-0·94]; p=0·0054) and 263 (15·6%) of 1687 fishermen in the PE group (0·92 [0·79-1·07]; p=0·28) had schistosomiasis at day 28. 230 (13·2%) in the enhanced SOC group, 281 (16·7%) in the PE group, and 215 (12·1%) in the PDE group initiated ART or were scheduled for VMMC. ART initiation or VMMC scheduling was not significantly increased with the PDE intervention (0·88 [0·74-1·05); p=0·15) and was marginally increased with the PE intervention (1·16 [0·99-1·37]; p=0·069) when compared with the enhanced SOC group. No serious adverse events were reported in this trial. INTERPRETATION: We found weak evidence for the use of peer education to increase uptake of ART and VMMC, but strong evidence for the added distribution of HIV self-test kits to promote high engagement with services and reduce the prevalence of active schistosomiasis, suggesting a high potential for scale-up in hard-to-reach communities across Malawi. FUNDING: Wellcome Trust and the UK National Institute for Health Research