ABSTRACT
BackgroundIn 2018 NICE and NHS England approved one year of weekly subcutaneous tocilizumab for use in relapsing or refractory GCA [1, 2]. During the COVID pandemic NHS England allowed extended use of tocilizumab in selected high risk patients [3]. This extension ended in March 2022. This has created a cohort of patients who are now no longer treated with tocilizumab and may be at risk of GCA flare. Currently, NHS England does not allow retreatment with tocilizumab.ObjectivesThis service evaluation used an intention-to-treat approach to retrospectively evaluate patients, who were ratified to receive tocilizumab for GCA according to the NICE guidance. We aimed to describe this cohort of patients for whom the use of tocilizumab had been approved, and their outcomes in terms of complications and disease control.Methods49 patients were ratified to receive tocilizumab between May 2019 and April 2022 by a specialist multidisciplinary team at a single tertiary rheumatology center. Their response was assessed in terms of relapse rates, steroid usage and complications as described below.Results80% of the 49 cohort of patients consisted of females (Table 1). 55% of patients were diagnosed with GCA on combination of clinical history, laboratory and temporal artery duplex findings. 94% (46/49) had at least a week's course of tocilizumab. Around half (51%) had relapsing disease. 6% had first dose as intravenous due to critical ischaemia. 27% (13/49) of patients developed complications whilst on treatment. Six developed cytopenia, 3 acquired infections and 4 stopped due to other reasons. As per guidelines, tocilizumab was stopped after 12 months in 25 patients (51%). 16% stopped treatment early due to complications. 18% had incomplete information. 10% had ongoing treatment. One patient died several months after finishing tocilizumab. 47% had methotrexate as DMARD therapy added prior to tocilizumab commencement (Figure 1). Out of 25 patients who completeted treatment, 24% (6/25) relapsed. 83% of these relapses were diagnosed on recurrence of symptoms and high inflammatory markers. In addition, 3 patients, who had tocilizumab suspended relapsed. 2/3 of these patients had treatment suspended due to infection. 5/9 relapse patients did not have preceding DMARD therapy. 22% (2/9) of relapse patients had PET-CT due to involvement of extra-cranial disease. 56% (5/9) relapsed following a median follow-up of 11 months. Of relapsed patients, seven were treated with increased dose of prednisolone and two patients received 6 months extension of tocilizumab with adequate tolerance and efficacy.ConclusionOur data shows good tolerability of tocilizumab and a 24% flare rate amongst patients who completed treatment. This is less than the 50% rate seen in GiACTA and other cohorts, where the majority of which occurred within 6 months of stopping treatment [4]. DMARD treatment may reduce relapse rate, but this will require further study. The data describing the efficacy of treatment beyond one year is limited [3]. However, with no established guidance for treating patients following tocilizumab, extension of treatment is a plausible option.References[1]Tocilizumab for treating giant cell arteritis, NICE Technology Appraisal Guidance, 18 April 2018. https://www.nice.org.uk/guidance/ta518/resources/tocilizumab-for-treating-giant-cell-arteritis-pdf-82606786726597[2]Stone J, Tuckwell K, Dimonaco S et al.Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017;377:317-328.[3]Regola F, Cerudelli E,Bosio G. Long-term treatment with tocilizumab in giant cell arteritis: efficacy and safety in a monocentric cohort of patients Rheumatology Adv Pract 2020;0:1–9.[4]Conway R, Putman MS, Mackie SL. Benchmarking tocilizumab use for giant cell arteritis. Rheumatol Adv Pract. 2022;6(2):rkac037.Figure 1.Table 1.GenderAge at time of diagnosisIndication for stopping treatmentMaleFemale50-5960-6970-7980-89Completed treatmentComplicationsOngoing treatmentIncomplete information18313162010251058Acknowledgements:NIL.Disclosure of InterestsNone Declared.
ABSTRACT
Background/Aims The immune response to SARS-CoV-2 is known to be reduced in the immunocompromised. However, extent to which immunity is affected by immunosuppression in specific disease cohorts remains poorly characterised. Furthermore, implications of the ongoing vaccination booster programme require further study. Individuals with lupus nephritis (LN) require prolonged high-dose immunosuppression in order to maintain disease control, rendering them important to study in this context. We evaluated SARS-CoV-2 nucleocapsid and spike antibody response in this cohort during the Spring/Summer 2022 booster vaccine campaign. Nucleocapsid antibody indicates previous infection whilst spike antibody indicates previous infection and/or vaccination response. Titre of spike antibody to prevent infection is not known, but presence of antibodies is likely to protect against severe disease. Methods SARS-CoV-2 spike and nucleocapsid antibody were measured in adult patients with LN attending a tertiary centre rheumatology clinic. Data was collected retrospectively on disease, immunosuppression, vaccine status and history of natural exposure. Results 35 cases of LN were investigated, of which LN III, IV and V were predominant biopsy diagnoses. Regarding immunosuppressants, the Eurolupus Cyclophosphamide protocol had been used in the majority of patients to achieve initial control, with 3/35 patients still receiving pulsed courses at data collection. 18/35 were on Mycophenolate Mofetil;a further 13/35 had previously received this. 31/35 took at least 5mg Prednisolone daily;25/35 took Hydroxychloroquine;7/35 took Azathioprine;7/35 had previously been on Methotrexate, 3/35 took Tacrolimus;1/35 took Ciclosporin. Regarding B-cell depleting monoclonal antibody therapy, 13/35 had received Rituximab and 8/35 were receiving Belimumab. Antibody levels were measured between 4 weeks and 13 months after last dose of vaccination;mean duration was 6 months. 11/35 had confirmed COVID-19 infection;a further 8/35 reported a possible history. Of the 35, 32 (91%) had mounted detectable SARS-CoV-2 spike antibody above the bottom 10% of assay detection, indicating some immunity to vaccination or natural exposure. 20 (57%) had detectable nucleocapsid antibody, suggesting natural infection with antibody response. Only 2 (6%) had not mounted any antibody response. Of note, neither were fully vaccinated: one had 1 vaccination with blood test 8 months subsequent;one had 2 vaccinations with blood test 7 months subsequent. The latter was also notably on haemodialysis. All who received 3+ vaccinations had detectable spike antibody responses, as well as 75% of those who had received 2 vaccinations. Conclusion Our study is the first analysis, to our knowledge, of SARS-CoV-2 antibody response in a LN cohort. Whilst neutralising capacity and level of antibody providing protection remains under research, these findings provide at least some reassurance that individuals with LN on immunosuppression are capable of mounting an immune response against SARS-CoV-2. Further work is required to establish extent and duration of protection with serial vaccinations in this cohort.
ABSTRACT
Background: The COVID-19 pandemic continues to pose challenges for healthcare systems across the world. Many patients infected with the virus, whether mild or severe, have nutritional complications ranging from poor appetite to the need for nutrition support. Limited research has shown that nutritional status plays a significant role in disease outcomes for COVID-19 patients. Although the American Society for Parenteral and Enteral Nutrition set guidelines for the nutritional management of COVID-19 patients, to date there are few major studies investigating the association between nutritional risk and outcomes in these patients. Thus, the purpose of this study is to assess the association between nutritional status and outcomes in hospitalized patients with COVID-19 and to identify the most common feeding practices among these patients. Method(s): A descriptive research design was used. Researchers reviewed the medical records of a random sample of 300 adult patients diagnosed with COVID-19 admitted to an academic metropolitan healthcare system between March 2020 to March 2021. Nutritional status was obtained from the admission screening and assessment documentation by a clinical dietitian (RD). Patients were then stratified based on admission nutritional status as malnourished or not. Differences in hospital length of stay (LOS), ICU LOS, ventilator dependence (in hours), and mortality were compared between groups using Mann-Whitney U, independent t-test, and chi-square tests. Result(s): Malnourished patients had a longer median (IQR) length of stay compared to non-malnourished patients (8 days (3,16) vs 4 days (3,8), p = 0.001). More patients who were malnourished expired (10/43, 23.3%) compared to patients who were not malnourished (17/ 257, 6.6%) (p = 0.002). No significant differences were observed in ICU length of stay or hours on a ventilator between groups. Most patients in the study were fed orally (87.3%), while 12.7% were fed enterally, and none of the patients were fed through use of parenteral nutrition. Conclusion(s): Results suggest that malnourished patients with COVID-19 experienced several worse outcomes compared to patients with COVID-19 who were not malnourished during hospitalization. Other known factors that influence outcomes of patients with COVID-19 were not considered in this descriptive study. Subsequent analysis to account for race, obesity, and other comorbidities is needed.
ABSTRACT
Background: Maternally derived antibodies are crucial for neonatal immunity. Understanding the binding and -cross neutralization capacity of maternal/ cord antibody responses to COVID-19 vaccination during pregnancy can inform neonatal immunity. Method(s): Here we characterized binding and neutralizing antibody profile at delivery in 24 pregnant individuals following two doses of Moderna mRNA-1273 or Pfizer BNT162b2 vaccination. We evaluated the transplacental antibody transfer by profiling maternal and umbilical cord blood. We analyzed for SARS-CoV-2 multivariant cross-neutralizing antibody levels for wildtype Wuhan, Delta, Omicron BA1, BA2, and BA4/BA5 variants by enzyme-linked immunosorbent assay Results: Our results reveal that current vaccination induced significantly higher (p=0.003) RBD-specific binding IgG titers in cord blood compared to maternal blood for both Wuhan and Omicron BA1 strain. Interestingly, binding IgG antibody levels for the Omicron BA1 strain were significantly lower (P< 0.0001) when compared to the Wuhan strain in both maternal and cord blood. In contrast to the binding, the Omicron BA1, BA2, BA4/5 specific neutralizing antibody levels were significantly lower (P< 0.0001) compared to the Wuhan and Delta variants. It is interesting to note that the BA4/5 neutralizing capacity was not at all detected in both maternal and cord blood. Conclusion(s): Our data suggest that the initial series of COVID-19 mRNA vaccines were immunogenic in pregnant women, and vaccine-elicited binding antibodies were detectable in cord blood at significantly higher levels for Wuhan and Delta variants but not for Omicron variants. Interestingly, the vaccination did not induce neutralizing antibodies for Omicron variants. These results provide novel insight into the impact of vaccination on maternal humoral immune response and transplacental antibody transfer for SARS-CoV-2 variants and support the need for boosters as new variants emerge.
ABSTRACT
INTRODUCTION: Substantial changes were made to the provision of pregnancy ultrasound services during the COVID-19 pandemic with the intention of minimising virus transmission and maintaining service continuity. Published literature describing the impact of the pandemic on obstetric sonographers is predominantly quantitative in nature, however statistics cannot fully convey sonographers' voices. This study aimed to gain a deeper understanding of the lived experiences of UK obstetric sonographers performing pregnancy ultrasound scans during the pandemic. METHODS: A UK-wide, online, anonymous cross-sectional survey on Qualtrics XM™ was open to responses between 9th March and 6th May 2021. Whilst this survey contained some quantitative elements, open questions were included to capture additional qualitative detail from respondents about their perceptions and experiences of scanning during the pandemic. Key themes were generated from free text responses using thematic analysis. RESULTS: Written responses were received from 111/138 sonographers participating in the survey. Five themes were generated, depicting the impact of the pandemic on obstetric sonographers: 1) continuity in a crisis; 2) decisions about me, without me; 3) battle scars - the lasting damage of COVID-19; 4) what people think I do vs. what I really do; and 5) the human touch. A cross-cutting theme was sonographers' feelings of disconnection from senior figures and expectant parents which created a sense of abandonment and distrust. CONCLUSION: Survey respondents' self-reported experiences of ineffective leadership and management, and perceived lack of understanding of the complexity of the sonographer role are potential contributory factors in the high levels of moral injury and occupational burnout reported within the workforce during the pandemic.
Subject(s)
COVID-19 , Pregnancy , Female , Humans , COVID-19/epidemiology , Pandemics , Cross-Sectional Studies , Ultrasonography , United KingdomABSTRACT
The publisher regrets that the declarations of competing interest were missing from the published article. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The publisher would like to apologise for any inconvenience caused. © 2022 The Authors
ABSTRACT
Background: Airway stenosis is a known complication of prolonged intubation in hospitalized patients. With the high rate of intubations in patients with COVID-19 pneumonia, laryngotracheal stenosis (LTS) is a complication of COVID-19 that drastically reduces quality of life for patients who may remain tracheostomy-dependent. Methods: Patient medical history, laryngoscopy, and CT imaging were obtained from medical records. Results: We report four cases of complicated LTS following intubation after COVID-19 pneumonia and explore the current literature in a narrative review. Four patients developed LTS following intubation from COVID-19 pneumonia. Three patients remain tracheostomy-dependent, and the fourth required a heroic operative schedule to avoid tracheostomy. Conclusion: Intubation for COVID-19 pneumonia can result in severe LTS, which may persist despite endoscopic intervention. © 2022 by the authors.
ABSTRACT
Indoor air quality in schools has become a major concern in recent years with factors such as pollution and the impact of Covid-19 highly significant. Here we look at how filtration is playing a key role in protecting the health of students. © 2023 The authors.
ABSTRACT
Pharmaceutical technology is playing a key role in the battle against Covid-19 with advances being made in the development of vaccines, research and hospital care. Here we look at some recent developments. © 2022 Elsevier Ltd. All rights reserved.
ABSTRACT
Hotels across the world have reopened following the Covid-19 pandemic but there is a new dawn with customers acutely aware of air quality within their rooms and beyond. Here we look at how manufacturers and the industry have risen to the challenge. © 2022 The authors.
ABSTRACT
This systematic review aimed to evaluate the evidence for the outcomes of telehealth occupational therapy service delivery versus traditional in-person service delivery for children during the peak of the COVID-19 pandemic. Using three academic databases, a search string including the following keywords, telehealth, occupational, and child, returned 825 articles. Five articles were selected for full-text review after screening and employing the inclusion/exclusion criteria. A quality appraisal was completed, leaving two articles in this systematic review. Researchers found that moderate evidence supports the use of telehealth to disseminate occupational therapy service delivery. Researchers also found substantial evidence that supports the use of telehealth in overall satisfaction with services compared to traditional in-person therapy services. This systematic review confirms that telehealth has improved access to occupational therapy services. Further research needs to be conducted on the efficacy of specific interventions in the telehealth setting. © 2023 Taylor & Francis.
ABSTRACT
The COVID-19 pandemic is having a significant impact on the provision of non-COVID-19 related clinical services. Early recommendations for head and neck reconstructive surgery were based on guidance from expert groups, advocating de-intensification of surgery. Since then, patient outcomes derived data has suggested that the continued practice of head and neck reconstructive surgery based upon pre-pandemic standard of care is safe if appropriate measures are in place for appropriate screening and segregation of care pathways for patients. In addition, adequate levels of personal protective equipment (PPE) are vital for both patients and the healthcare team. We present the current practice guidance within the UK National Health Service (NHS) for head and neck reconstructive surgery in the COVID-19 pandemic era in the following areas: COVID-19 testing/screening, care pathways for patients, the potential future role of immunisation against SARS-CoV-2, airway management, selection of the type of reconstruction, postoperative care and rehabilitation. The guidance produced reflect the evolving nature of the response of NHS to the COVID-19 pandemic, some of the suggested practice protocols could differ from local policies in various parts of the world however the principles which underlie these standards are the results of regular review of the needs of the patients and health service, balanced against the background of the ebb and flow of the prevalence of COVID-19 infection within the community and healthcare settings. © Frontiers of Oral and Maxillofacial Medicine. All rights reserved.
ABSTRACT
Background: Neutrophil serine proteases (NSPs) are involved in the pathogenesis of COVID19 and are increased in severe and fatal infection. We investigated whether treatment with Brensocatib, an inhibitor of dipeptidyl peptidase-1, an enzyme responsible for the activation of NSPs, would improve outcomes in hospitalized patients with COVID19. Method(s): In a randomized, double-blind, placebo-controlled trial, 406 hospitalized patients with COVID19 with at least one risk factor for severe disease were randomized 1:1 to once-daily Brensocatib 25mg (n=192) or placebo (n=214) for 28 days. Primary outcome was the 7-point World Health Organisation Clinical Status scale at day 29. Secondary outcomes included time to clinical improvement, national early warning score, new oxygen and ventilation use, neutrophil elastase activity in blood and mortality. Finding(s): Brensocatib treatment was associated with worse clinical status at day 29 (adjusted odds ratio 0 72, 95%CI 0 57-0 92) compared to placebo. The adjusted hazard ratio (aHR) for time to clinical improvement was 0 87 (95%CI 0 76-1 00) and time to hospital discharge was 0 98 (95%CI 0 84-1 13). During the 28-day follow-up period, 23 (11%) and 29 (15%) patients died in the placebo and Brensocatib treated groups respectively). Oxygen and new ventilation use were greater in the Brensocatib treated patients. Neutrophil elastase activity in blood was significantly reduced in the Brensocatib group from baseline to day 29. Prespecified subgroup analyses of the primary outcome supported the primary results.
ABSTRACT
Methods: This retrospective study included adults with COVID-19 (ICD-10: U07.1) and pneumonia (ICD-10 subcodes within J11.x - J16.x, J18.x) May 2020-December 2021 in the Premier Healthcare Database, analyzing severity, treatment patterns and clinical outcomes. Result(s): Between May 2020 and December 2021: N=338,930 patients in 856 hospitals 79% of patients received any dexamethasone(DEX);>50% received any remdesivir(RDV) Combination therapy use increased: DEX+RDV only from <1% of patients to 29%;DEX+RDV with baricitinib or tocilizumab from <1% to 19% RDV initiation in the first 2 days of hospitalization increased 41% to 88% Overall all-cause mortality increased 19% to 24% with large differences between severity subgroups: in December 2021, 20%, 32%, 46% and 60%, respectively, in no supplementary oxygen(NSOc), low-flow(LFO), highflow/non-invasive(HFO/NIV) and invasive mechanical ventilation/ECMO(IMV/ECMO) Overall median hospital LOS and ICU LOS remained between 6-10 days, with notable variation by severity subgroup and over time Overall ICU use was 35%-38%, with large differences by severity subgroups: in December 2021, 28%, 47%, 67% and 94%, respectively, in NSOc, LFO, HFO/NIV and IMV/EC Conclusion(s): COVID-19 can result in severe outcomes;understanding treatment and severity trends can improve prognosis.
ABSTRACT
Experiential learning opportunities (Kolb, 1984;Simons et al., 2012), such as internships, provide valuable real-world learning experiences for undergraduate students. Internships are especially important for students majoring or specialising in writing, who can gain valuable workplace experience and build portfolio pieces from working for a company or organisation. The COVID-19 pandemic and resulting social distancing measures forced internship experiences to shift to remote and hybrid opportunities. In this article, four faculty from three universities in the United States detail the ways that they pivoted their undergraduate writing internship programs to adapt to public health requirements and changing student needs between 2020–2022. We provide information on creating remote and hybrid internship opportunities and courses, building internship program infrastructure, integrating technology and project management tools into student internship experiences, securing funding for otherwise unpaid internships, and supporting students during their internship programmes. The article concludes with future directions in writing student internships and other pre-professional experiences, as well as additional resources for internship coordinators. Practitioner Notes 1. Respond to student exigences, needs, and material realities with flexibility and empathy. 2. Prepare to promote student interns on campus and in your local community with physical promotional materials and brief elevator pitches at meetings, social gatherings, and university-sponsored events. 3. Empower student interns through peer-review and peer support networks 4. Work with a combination of project management tools (Basecamp, Google Suite tools, Slack, and Zoom), and strategies to centralise communication between instructors, students, and community/campus partners. 5. Work with a combination of project management tools (Basecamp, Google Suite tools, Slack, and Zoom) and strategies to centralise communication between instructors, students, and community/campus partners. © 2023, University of Wollongong. All rights reserved.
ABSTRACT
While supply chain disruptions are a drastic example of changes businesses must react to, being flexible and reactive will prove beneficial for companies. While being able to react to such disruptions is important, it is even more vital for supply chains to be proactive in a Covid-19 reality. Companies need to be adapting to changes in how customer relationships are maintained within digital supply chain (DSC) platforms. With more and more people working remotely, companies must still ensure their customer relationships are being maintained. This is one example of a supply chain challenge that this paper looks to unfold. By highlight the importance of digital platforms in e-procurement, increased technology and transparency are vital to successful companies, either B2C, B2B. Companies who are willing to learn and adapt become more competitive. The paper briefly dives into SAP Ariba and Jaggaer, and their role in aiding e-procurement and CRM. Copyright © 2023 Inderscience Enterprises Ltd.
ABSTRACT
Purpose: The aim of this paper is to assess the use of social media by Gen Z consumers and the ways they impact on and re-shape their fashion consumption journey. This generational approach uses the lens of uses and gratifications theory (UGT) to explore the customer fashion retail journey from the perspective of the Gen Z consumer. Design/methodology/approach: The research uses an exploratory approach in response to the relative lack of research in to GenZ consumers combined with a need to understand shopping journeys. Mixed methods were used with a first phase of interviews followed by a survey of 102 Gen Z students recruited online in the UK during the COVID-19 pandemic. Findings: The study found that GenZ users of social media for shopping sought gratification from experiences derived from social relationships, entertainment and information. The need for immediate gratification was found in new information and meeting new people to maintain social relationships, learn about products and inform the shopping journey. Further, the research supported the importance of visual images in the affective gratification of shopping needs. Resale sites on social media were favoured for their low prices, information about previously owned fashion items and the opportunity to exercise sustainable fashion choices. Originality/value: The research advances understanding of fashion shopping journeys through social media and online resale sites. It demonstrates that younger consumers, GenZ, shop through the gratification of experiences informed by their social networks and wider contacts. The linear stages of pre to post–purchase shopping are merged and looped as they exchange information about their shopping journey, from information gathering to post–purchase comments. The role of the brand to these knowledgeable consumers conducting their own resale trade is to facilitate access to and information about their products. © 2023, Emerald Publishing Limited.
ABSTRACT
Background: Patients with disabilities and those from diverse equity-deserving backgrounds have been disproportionately affected by the SARS COV-2 ("COVID-19") pandemic. Objective: To describe the significant needs and social determinants of health that affected a group of uninsured patients (from equity-deserving groups) with rehabilitation diagnoses during the early months of the COVID-19 pandemic. Design: Retrospective cohort study utilizing a telephone-based needs assessment from April to October, 2020. Setting: Free interdisciplinary rehabilitation clinic serving patients with physical disabilities from equity-deserving minority backgrounds. Participants: 51 uninsured, diverse patients with spinal cord injuries, brain injuries, amputations, strokes, and other diagnoses requiring interdisciplinary rehabilitation care. Methods: Using a non-structured approach, telephone-based needs assessments were collected monthly. Reported needs were summarized into themes and the frequencies of each theme were recorded. Results: From the total number of concerns, medical issues were reported with the highest frequency (46%), followed by equipment needs (30%) and mental health concerns (30%). Other frequently mentioned needs centered around themes of rent, employment, and supplies. Rent and employment were more frequently cited in earlier months, and equipment problems were more frequently cited in later months. A minority of patients reported they had no needs, some of whom had acquired insurance. Conclusions: Our objective was to describe the needs of a racially and ethnically diverse set of uninsured individuals with physical disabilities seen at a specialized interdisciplinary rehabilitation pro bono clinic during the early months of COVID-19. Medical issues, equipment needs, and mental health concerns were the top three needs. To optimally serve them, care providers must be aware of current and future needs for their underserved patients, especially if future lockdowns occur.
ABSTRACT
Coronavirus Disease 2019 (COVID-19) has been accompanied by numerous factors which have adversely affected Small Island Develop-ing States (SIDS). Despite several COVID-19 vaccination campaigns and the number of in-dividuals who have been afflicted by, or died from, contracting the virus, many Jamaicans have delayed their vaccination against CO-VID-19. This study investigates the factors that have shaped the attitudes of Jamaicans towards COVID-19 vaccines. Its findings are based on content analysis of Jamaican newspapers (N=200), including columns, editorials, and news stories published in the online editions of two of the country's lead-ing publications (The Jamaica Gleaner and the Jamaica Observer). The study finds that several factors shape the attitudes of Jamaicans towards COVID-19 vaccines. These include the potential side effects of COVID-19 vac-cines, personal choice, perception of the pan-demic, insufficient knowledge regarding the efficacy of the vaccines, religious beliefs, and distrust of the Jamaican government and health authorities. The study highlights that for SIDS, like Jamaica, which are characterised by fragile economies and ailing public health care systems, vaccine hesitancy is a potential barrier to overcoming some of the challenges linked to the current pandemic.The study points to the critical need to improve the COVID-19 vaccination uptake among Jamaicans. Understanding the speci-ficities concerning vaccine hesitancy will al-low the Jamaican government and healthcare providers to better organise public sensitisation campaigns to address the concerns of the un-vaccinated in Jamaica.