ABSTRACT
Purpose of Study Sickle cell disease (SCD) disproportionately affects the Tharu population of Nepal, a marginalized indigenous group concentrated in the Dang district. SCD is a structural hemoglobinopathy resulting in abnormal red blood cells with a tendency to occlude microvasculature. Since 2015, University of British Columbia medical students and a local community partner, Creating Possibilities, have improved access to SCD screening and diagnosis for the Tharu population. However, interviews conducted in 2016- 2017 found that SCD-afflicted community members encounter a number of challenges to obtain treatment once diagnosed. The purpose of this study was to develop a questionnaire on barriers to accessing SCD care in this community. Methods Used The Barriers to Accessing SCD Care Questionnaire was developed from items in existing scales, deductive and inductive item generation, and feedback from expert local partners. Reviewing literature on barriers to accessing healthcare in the Western region of Nepal informed region-specific questionnaire items, while literature on accessing SCD treatment in resource-limited settings informed SCD-specific questionnaire items. We also reviewed the literature on barriers to treatment for various stigmatized chronic health conditions in low-resource settings. Summary of Results Qualitative interviews with SCD-afflicted Tharu individuals in 2016-2017 identified inadequate local medical resources, transportation, financial strain, and limited awareness as barriers to care. Based on the literature review, we organized all survey items under the themes transportation, medical infrastructure, finances, community attitudes, and personal attitudes. The questionnaire includes closed-ended questions using a Likert scale, as well as open-ended interview prompts. It was made in collaboration with local community members to ensure it is culturally appropriate, needs-specific, and easily understandable. The questionnaire received ethics board approval, and interviews will begin once local health authorities lift COVID-19 restrictions. Conclusions Results from the Barriers to Accessing SCD Care questionnaire will guide future community-based interventions.
ABSTRACT
Purpose of Study In 2015 the University of British Columbia partnered with Creating Possibilities (CP), a charitable organization located in Dang, Nepal. Each year, a team of medical students is sent to assist CP in the long term management of sickle cell disease (SCD) in rural Western Nepal. Due to COVID-19 limitations, we were unable to travel to Nepal this year for the field component of our project. Instead, we took this opportunity to reflect on the project as a whole and create a project status report, outlining the past five years of work. The purpose of this report included: summarizing overall project progress, identifying future project directions, and improving communication amongst project stakeholders. Methods Used To create the project status report, our team reviewed all project documents since 2015. We also conducted virtual interviews with previous team leads to clarify questions and fill in gaps. Project progress was assessed by comparing activities completed to date to the project's initial three main objectives. Summary of Results The first objective of characterizing the prevalence of SCD among the Tharu population is currently ongoing. Since 2015, we have conducted large-scale screening of the Tharu population, with 4483 individuals having been screened by our team. Thus far, a hemoglobin S prevalence of 9.3% has been estimated. Our second objective of identifying barriers to SCD management is also ongoing. Since 2016, yearly focus groups and needs assessments have been conducted with community members and health workers. Common themes of barriers included accessibility, financial limitations, and education. Finally, our third objective of implementing sustainable solutions for long term detection and management of SCD still needs to be addressed. Conclusions Screening and needs assessments will continue as we progress toward addressing our first two objectives. Following consultation with experts and a literature review, we have identified a pilot newborn screening program for SCD as the first step in addressing our third objective.
ABSTRACT
Background: A coronavirus disease 2019 (COVID-19) community outbreak was declared October 5-December 3, 2020, in the Restigouche region of New Brunswick, Canada. This article describes the epidemiological characteristics of the outbreak and assesses factors associated with its transmission in rural communities, informing public health measures and programming. Methods: A provincial line list was developed from case and contact interviews. Descriptive epidemiological methods were used to characterize the outbreak. Incidence rates among contacts, and by gender for the regional population were estimated. Results: There were 83 laboratory-confirmed cases of COVID-19 identified during the observation period. The case ages ranged from 10-89 years of age (median age group was 40-59 years of age) and 51.2% of the cases were male. Symptom onset dates ranged from September 27-October 27, 2020, with 83% of cases being symptomatic. A cluster of early cases at a social event led to multiple workplace outbreaks, though the majority of cases were linked to household transmission. Complex and overlapping social networks resulted in multiple exposure events and that obscured transmission pathways. The incidence rate among men was higher than women, men were significantly more likely to have transmission exposure at their workplace than women, and men were the most common index cases within a household. No transmission in school settings among children was documented despite multiple exposures. Conclusion: This investigation highlighted the gendered nature and complexity of a COVID-19 outbreak in a rural Canadian community. Targeted action at workplaces and strategic messaging towards men are likely required to increase awareness and adherence to public health measures to reduce transmission in these settings.
ABSTRACT
Background. Risk factors for MIS-C, a rare but serious hyperinflammatory syndrome associated with SARS-CoV-2 infection, remain unclear. We evaluated household, clinical, and environmental risk factors potentially associated with MIS-C. Methods. This investigation included MIS-C cases hospitalized in 14 US pediatric hospitals in 2021. Outpatient controls were frequency-matched to case-patients by age group and site and had a positive SARS-CoV-2 viral test within 3 months of the admission of their matched MIS-C case (Figure 1). We conducted telephone surveys with caregivers and evaluated potential risk factors using mixed effects multivariable logistic regression, including site as a random effect. We queried regarding exposures within the month before hospitalization for MIS-C cases or the month after a positive COVID-19 test for controls. Enrollment scheme for MIS-C case-patients and SARS-CoV-2-positive outpatient controls. MIS-C case-patients were identified through hospital electronic medical records, while two outpatient controls per case were identified through registries of outpatient SARS-CoV-2 testing logs at facilities affiliated with that medical center. Caregivers of outpatient controls were interviewed at least four weeks after their positive test to ensure they did not develop MIS-C after their infection. Results. We compared 275 MIS-C case-patients with 494 outpatient SARS-CoV-2-positive controls. Race, ethnicity and social vulnerability indices were similar. MIS-C was more likely among persons who resided in households with >1 resident per room (aOR=1.6, 95% CI: 1.1-2.2), attended a large (>=10 people) event with little to no mask-wearing (aOR=2.2, 95% CI: 1.4-3.5), used public transportation (aOR=1.6, 95% CI: 1.2-2.1), attended school >2 days per week with little to no mask wearing (aOR=2.1, 95% CI: 1.0-4.4), or had a household member test positive for COVID-19 (aOR=2.1, 95% CI: 1.3-3.3). MIS-C was less likely among children with comorbidities (aOR=0.5, 95% CI: 0.3-0.9) and in those who had >1 positive SARS-CoV-2 test at least 1 month apart (aOR=0.4, 95% CI: 0.2-0.6). MIS-C was not associated with a medical history of recurrent infections or family history of underlying rheumatologic disease. Conclusion. Household crowding, limited masking at large indoor events or schools and use of public transportation were associated with increased likelihood of developing MIS-C after SARS-CoV-2 infection. In contrast, decreased likelihood of MIS-C was associated with having >1 SARS-CoV-2 positive test separated by at least a month. Our data suggest that additional studies are needed to determine if viral load, and/or recurrent infections in the month prior to MIS-C contribute to MIS-C risk. Medical and family history were not associated with MIS-C in our analysis.
ABSTRACT
Introduction: Anti-CD20 treated MS patients may have higher risk of severe SARS-CoV-2. Early reports indicate they mount attenuated antibody responses to SARS-CoV-2 vaccines, raising significant concerns about their protection, and the merit of aCD20 infusion delay to enable more robust vaccine responses. Little is known about cellular responses (particularly spike-antigen-specific T-cell responses) to these vaccines in B cell-depleted state. Aims: To characterize the magnitude and kinetics of both antibody-and cell-based responses to SARS-CoV-2 mRNA vaccines in aCD20 treated MS patients, compared to healthy controls (HC). Methods: Both humoral IgG responses to Spike (S) protein and its receptor-binding-domain (RBD), as well as Spike-reactive B cells (flow cytometry) and S-protein-specific CD4+ and CD8+ T-cell responses (activation-induced marker/AIM assays), were serially assessed in 21 MS patients on aCD20 therapy and 10 HC, pre-and post-SARS-CoV-2 mRNA vaccination (pre-vaccine-T1;10 days post primary-T2, pre-booster-T3;10-day post-booster-T4 and 30 days post-booster-T5). Results: Antibodies to both S-protein and RBD were induced in 100% of HC by T4 and, with some lag (by T5), in 89% and 50% of MS patients, respectively. Mean Spike-IgG concentrations for HC and MS patients at T5 were 165.3± 201.9 units/mL (u/ml) and 22.3± 58.2 u/mL respectively (p=0.0004);and 97± 136 u/ mL(HC) and 10.2± 29 u/mL (MS) (p<0.0001) for RBD-IgG. All 6 patients vaccinated longer than 20 weeks after the last aCD20 treatment exhibited partial B-cell reconstitution, and all had measurable spike-specific memory B-cells at T5. All MS patients and HC mounted CD4+ and CD8+ T-cell responses to vaccine. Expansion of activated (Ki67+CD38+) CD4+ T-cells was robust in HC and somewhat attenuated in MS patients (p= 0.03), while expansion of activated (Ki67+CD38+) CD8+ T cells was robust in both cohorts. In AIM assays, spike-antigen-specific responses of CD4+ T-cells of patients were similarly mildly attenuated compared to HC, while those of CD8+ T cells were similarly robust for both patients and HC. Conclusion: In spite of attenuated humoral SARS-CoV-2 mRNA vaccine responses, aCD20 treated patients mount robust CD8+ and mildly attenuated CD4+ T-cell responses. Longer time from last aCD20 infusion may enable more robust humoral and cell-based responses. It will be important to study how cell-based responses relate to protection, complications and risk of infecting others.
ABSTRACT
The coronavirus (COVID-19) pandemic has challenged the dental health profession in an unprecedented manner. Suspension of elective dental care across the United States during the initial phase of the pandemic was necessary to prevent viral transmission. The emergency dental care that was provided had to be tailored to minimize the generation of aerosols. With the suspension of elective care, over time, the proportion of dental emergencies was anticipated to rise. Dentists who care for children have continued to provide emergency dental treatment to this vulnerable population. Treatment decisions for pediatric dental emergencies had to be tailored to principles of public health that best mitigated risk of viral transmission. Decisions needed to balance the benefits of chosen treatment modality for the individual child with the risk of viral transmission to dental professionals and their staff, patients, and community. The paucity of reliable research for dentists to aid in clinical decision making may have left careproviders feeling ethically and morally insecure in shifting from a patient-centered to a community-centered paradigm. We present analysis of four pediatric emergency case scenarios that are representative of those likely to present to a private practice, academic setting, or emergency department during the COVID-19 pandemic. This analysis aims to empower dentists who care for children to implement the American Dental Association's Principles of Ethics and Code of Professional Conduct within the context of a global health crisis.