A pilot project harnessing surveillance systems to support clinicians providing clinical care for people diagnosed with hepatitis C in Victoria, Australia, September 2021 to 31 March 2022.

BackgroundActive follow-up of chronic hepatitis C notifications to promote linkage to care is a promising strategy to support elimination.AimThis pilot study in Victoria, Australia, explored if the Department of Health could follow-up on hepatitis C cases through their diagnosing clinicians, to assess and support linkage to care and complete data missing from the notification.MethodsFor notifications received between 1 September 2021 and 31 March 2022 of unspecified hepatitis C cases (i.e. acquired > 24 months ago or of unknown duration), contact with diagnosing clinicians was attempted. Data were collected on risk exposures, clinical and demographic characteristics and follow-up care (i.e. HCV RNA test; referral or ascertainment of previous negative testing or treatment history). Reasons for unsuccessful doctor contact and gaps in care provision were investigated. Advice to clinicians on care and resources for clinical support were given on demand.ResultsOf 513 cases where information was sought, this was able to be obtained for 356 (69.4%). Reasons for unsuccessful contact included incomplete contact details or difficulties getting in touch across three attempts, particularly for hospital diagnoses. Among the 356 cases, 307 (86.2%) had received follow-up care. Patient-management resources were requested by 100 of 286 contacted diagnosing clinicians.ConclusionsMost doctors successfully contacted had provided follow-up care. Missing contact information and the time taken to reach clinicians significantly impeded the feasibility of the intervention. Enhancing system automation, such as integration of laboratory results, could improve completeness of notifications and support further linkage to care where needed.

Feticide Before Termination of Pregnancy in Singleton Pregnancy - Trends in England and Wales 2012-2020, a Cross-sectional Study.

Feticide is the practice of inducing fetal demise before the termination of pregnancy. In England and Wales, it is recommended for terminations of pregnancy beyond 21+6 weeks of gestation. This project analyses the trends in feticide in singleton pregnancy in England and Wales between 2012 and 2020. This project was a retrospective study that analysed data extracted from the Health and Social Act 4 (HSA4) forms submitted to the Department of Health and Social Care (DHSC). The data extracted by the DHSC included the prevalence of feticide, methods of feticide and termination, statutory grounds, gestation, service provider, maternal age, ethnicity and obstetric history. In addition, data analysis was carried out to identify trends. Between 2012 and 2020, there were 9310 feticides in England and Wales, undertaken in 0.5% of all abortions. The prevalence of feticide fluctuated; however, there was an overall decrease from 1084 cases in 2012 to 1000 cases in 2020. Intracardiac injection of potassium chloride was the most frequent method of achieving feticide (67.2%). Just over half (55.8%) of feticides took place under Ground E of the Abortion Act 1967, with the main indication being congenital malformations of the nervous system. Two-fifths (40.2%) of feticides took place at 23 weeks, 22.8% at 22 weeks and 13.5% between 20 and 21 weeks. The remainder occurred at later gestations: 17.5% at 24-29 weeks and 5.9% beyond 29 weeks. During our study period, it was more common for feticides to be carried out as part of a medical termination than a surgical termination and 60.3% occurred in NHS hospitals. Women undergoing feticide were mostly aged 30-34 years (38.3%) and of White ethnicity (78.6%). Feticide is an essential component of comprehensive abortion care for women undergoing late second and third-trimester abortions. This study provides insight into how feticide is carried out in England and Wales and demonstrates the effect of the COVID-19 pandemic on reducing feticide prevalence. Future research should analyse in more detail the use of the different methods of feticide.

Fraud, Access, and the Future of Telemedicine.

On July 20, 2022, the Department of Health and Human Services, Office of Inspector General (HHS-OIG), issued a Special Fraud Alert warning healthcare providers of increased fraudulent activity surrounding telemedicine companies. The Alert marks a further escalation of a multi-year effort by the Department of Justice (DOJ) and the HHS-OIG to crack down on multi-billion dollar fraud cases involving telehealth companies. It is the objective of this Commentary to place the HHS-OIG Special Fraud Alert in the context of enforcement efforts by the DOJ and HHS to stem the recent growth in telehealth fraud resulting from the COVID-19 pandemic. Taken together, it is apparent this is a critical moment in the evolution of telehealth and it is crucial to strike a proper balance between effective regulation and enforcement on the one hand, and access to care on the other.

Independent prescribing in the UK: insights from the Department of Health Allied Health Professions Medicines Project team.

BACKGROUND: The UK medicines legislation was amended ten years ago (2013) to allow podiatrists and physiotherapists independent prescribing rights, the first of the allied health professions to do so. Non-medical prescribing formed one part of a broader policy agenda promoting role flexibility in response to the challenge of an ageing population and the need to maintain effective health provision in the face of a contracting workforce. AIM: The aim of this study was to outline the experiences of the Department of Health AHP medicines project board team in working towards independent prescribing for podiatry and physiotherapy, with a particular focus on the challenges encountered. METHODS: In depth, open-ended interviews were conducted with eight of the core members of the project team, drawn from those individuals who served throughout the duration of the project (2010-2013). Included were the former Department of Health Chief and Deputy Chief Allied Health Professions Officers; the Department of Health Engagement and Communications Officer; representatives of the Health and Care Professions Council; the Medicines and Healthcare products Regulatory Agency; the Council of Deans of Health; the Royal College of Podiatry and the Chartered Society of Physiotherapy (The team also included the representative of the Allied Health Professions Federation. However, as that representative is also a researcher in this study, he has recused himself from any role as a participant.). Data were transcribed and subject to a thematic analysis. RESULTS: A complex picture of the project emerged revealing a range of obstacles and challenges, including inter-professional role boundary tensions and negative prior assumptions about the two professions. Success hinged upon the adoption of a dual strategy involving submission of a robust case of need focused on patient benefit coupled with the careful management of professional expectations. Underpinning theory from the sociology of the professions offers a supportive explanatory framework for understanding the relationships between the various stakeholders involved. CONCLUSIONS: Ultimately, success depended upon aligning the project aims with healthcare policy through a clear focus on patient benefit. Balancing competing professional and policy demands through a continual emphasis on improved patient care laid the foundations for future projects by other allied health professions.

Big data- and artificial intelligence-based hot-spot analysis of COVID-19: Gauteng, South Africa, as a case study.

The coronavirus disease 2019 (COVID-19) has developed into a pandemic. Data-driven techniques can be used to inform and guide public health decision- and policy-makers. In generalizing the spread of a virus over a large area, such as a province, it must be assumed that the transmission occurs as a stochastic process. It is therefore very difficult for policy and decision makers to understand and visualize the location specific dynamics of the virus on a more granular level. A primary concern is exposing local virus hot-spots, in order to inform and implement non-pharmaceutical interventions. A hot-spot is defined as an area experiencing exponential growth relative to the generalised growth of the pandemic. This paper uses the first and second waves of the COVID-19 epidemic in Gauteng Province, South Africa, as a case study. The study aims provide a data-driven methodology and comprehensive case study to expose location specific virus dynamics within a given area. The methodology uses an unsupervised Gaussian Mixture model to cluster cases at a desired granularity. This is combined with an epidemiological analysis to quantify each cluster's severity, progression and whether it can be defined as a hot-spot.

SARS-CoV-2 concentration in wastewater consistently predicts trends in COVID-19 case counts by at least two days across multiple WWTP scales.

Wastewater surveillance of SARS-CoV-2 has proven instrumental in mitigating the spread of COVID-19 by providing an economical and equitable approach to disease surveillance. Here, we analyze the correlation of SARS-CoV-2 RNA in influents of seven wastewater plants (WWTPs) across the state of South Carolina with corresponding daily case counts to determine whether underlying characteristics of WWTPs and sewershed populations predict stronger correlations. The populations served by these WWTPs have varying social vulnerability and represent 24% of the South Carolina population. The study spanned 15 months from April 19, 2020, to July 1, 2021, which includes the administration of the first COVID-19 vaccines. SARS-CoV-2 RNA concentrations were measured by either reverse transcription quantitative PCR (RT-qPCR) or droplet digital PCR (RT-ddPCR). Although populations served and average flow rate varied across WWTPs, the strongest correlation was identified for six of the seven WWTPs when daily case counts were lagged two days after the measured SARS-CoV-2 RNA concentration in wastewater. The weakest correlation was found for WWTP 6, which had the lowest ratio of population served to average flow rate, indicating that the SARS-CoV-2 signal was too dilute for a robust correlation. Smoothing daily case counts by a 7-day moving average improved correlation strength between case counts and SARS-CoV-2 RNA concentration in wastewater while dampening the effect of lag-time optimization. Correlation strength between cases and SARS-CoV-2 RNA was compared for cases determined at the ZIP-code and sewershed levels. The strength of correlations using ZIP-code-level versus sewershed-level cases were not statistically different across WWTPs. Results indicate that wastewater surveillance, even without normalization to fecal indicators, is a strong predictor of clinical cases by at least two days, especially when SARS-CoV-2 RNA is measured using RT-ddPCR. Furthermore, the ratio of population served to flow rate may be a useful metric to assess whether a WWTP is suitable for a surveillance program.

A qualitative inquiry into the patient-related barriers to linkage and retention in HIV care within the community setting.

Background: People with the Human Immunodeficiency Virus (PWH) experience barriers to care within the community that impedes their progress from when they discover that they are HIV positive to becoming virally suppressed. For individuals with HIV to achieve sustained viral suppression, they must be linked to care to start receiving anti-retroviral therapy and remain retained in care for continuous treatment. However, HIV surveillance data shows that many PWH are not linked to care and become lost to continuous follow-up care. Although pharmacists, PWH, and social workers interact with one another and are aware of their roles in HIV care, their perspectives on barriers to linkage and retention in care have not been investigated collectively. Objectives: Explore the perspectives of PWH, pharmacists, and social workers on barriers to linkage and retention of HIV care within the community setting. Methods: Convenience sampling was used to recruit 15 stakeholders (five PWH, five community pharmacists, and five social workers) who participated in 1-h, semi-structured interviews based on three domains of the Patient-centered Medical Home Model including (1) experiences (individual and system-level barriers to care experienced by PWH), (2) activities (social workers and pharmacists initiatives that impact adherence to care)and (3) interventions (critical issues pharmacists can address in the community to engage PWH in their HIV care). We conducted a directed content analysis based on deductive coding. To establish rigor, we focused on Lincoln and Guba's criteria of rigorous qualitative methodology: credibility, dependability, confirmability, and transferability. Similarities and divergences of themes were discussed during data analysis and agreement was reached before interpretation. Results: Emergent themes uncovered barriers to linkage and retention in HIV care as HIV-related stigma, having mental health illnesses including a history of substance abuse and social determinants of health such as homelessness, food insecurity, and insurance issues. Conclusion: The perspectives of pharmacists, social workers, and PWH can provide insight into barriers that should be identified and addressed in people living with HIV to enhance their linkage and retention in care.

Midwives are crucial human resources for health to achieve universal health care

@#Midwives are primarily considered as professionals with expertise in assisting women before, during, and after childbirth. Thus, the competencies for midwifery as defined by the International Confederation of Midwives revolve principally around assessment and provision of care to women and the fetus/newborn/infant during the pre-pregnancy and antenatal periods, labor and birth, postnatal/postpartum periods.1 The availability of skilled midwives in communities has allowed women, especially those who belong to lower income groups, to access professional services around childbirth, as reflected in responses from the National Demographic and Household Survey.2 For instance, while 50% of all women surveyed received antenatal care from a midwife, it is notable that 70% of those who belonged to the lowest wealth quintile were seen by a midwife during the antenatal period. Furthermore, midwives assisted 30% of deliveries reported by respondents, while roughly a little over a third of deliveries for each of the three lowest quintiles were attended by a midwife. Furthermore, in the Philippine setting, midwives are recognized as the first professional point of contact for most members of a community, especially in rural and remote places, as midwives are the ones deployed to manage Barangay Health Stations. Elaborating the scope of the practice of midwifery in relation to the provision of “primary health care services in the community” as stipulated in Republic Act No. 73923, the Board of Midwifery of the Professional Regulation Commission, in a primer for the profession, stated that midwives are expected to, among others, (a) implement government health programs in accordance with policies and guidelines of the Department of Health; (b) supervise barangay health workers; and (c) manage a Barangay Health Station.4 Stated differently, midwives, given the scope of work that they do and the areas where they are deployed, serve as the face and touchpoint of the health sector in our communities. They are the embodiment of the different health policies and programs enacted at the national and local levels through which Filipinos experience, individually and collectively, the drive for better health (or lack thereof ) advanced by different agencies, personalities, and stakeholders. However, as pointed out by Felipe-Dimog et al.5 in this issue of Acta Medica Philippina, midwives, especially those working in the public health sector, may take on roles beyond that contemplated by law. For instance, in the course of my professional practice during which I was deployed briefly in a rural health unit, and worked with an urban health department, I have encountered midwives who were tasked to work as program coordinators (or assistant coordinators), sanitation inspectors, field epidemiologists, and supply managers, among others, because of scarcity in the overall staff complement of health departments. Given their close ties with their areas of assignments, midwives are also expected to be community coordinators, if not organizers. The extent to which midwives are assigned these additional tasks depend on their professional relationship with their immediate supervisor; the level of trust and confidence reposed on them by their superiors; in some instances, their attendance to specific training workshops; as well as the availability of more qualified personnel (or lack thereof ) in the locality. Yet despite all these – placement in remote, if not hardship posts; additional assignments beyond their job description – midwives receive salaries that may not be commensurate after consideration of the job context. Staff midwife positions (i.e., Midwife I to III) in government institutions are remunerated at Salary Grades 9 to 13 (i.e., approximate gross pay of PHP 21,000 to PHP 31,000, based on the fourth tranche of the Salary Standardization Law, but may be lower depending on the income classification of the local government unit6). Additional compensation and benefits under special laws may not always be provided as this will depend on the paying capacity of the employing agency. Furthermore, midwives – especially those who completed the two-year program under the previous policy – also must contend with issues concerning their professional status. I have personally encountered community members who do not consider midwives as professionals in the same league as nurses or physicians, or who view midwives as “assistants” or “subordinates” of nurses and physicians, forgetting that a certain degree of independent practice is allowed each professional licensed by the Republic of the Philippines. Midwives play a crucial role in caring for Filipinos not only around childbirth – this is their primary professional duty – but throughout the lifespan – especially for midwives working in local health departments. Stakeholders must not forget to give due recognition to the value and worth contributed by midwives in shaping the health and well-being of each generation of Filipinos.

Informal dementia care: The carer's lived experience at the divides between policy and practice.

Support for informal dementia care at a local community level is not working for most carers today. Carers looking after a person with dementia have long lamented the absence of an empowered named support and an effectively actioned care plan. Drawing on literary writing and social research, we argue in this article that these challenges have existed since dementia emerged as a major condition in the West during the 1980s. Based on this historical context, we ask: Why has this issue persisted over the last four decades? How have healthcare politics and policy initiatives responded to these requests? And what can we learn from this for the current, COVID-19 exacerbated crisis of care? This article focuses on the English context, to discuss these ongoing challenges in the light of a series of policy papers, and to ask what is hampering the implementation of such policy initiatives. In England, local authorities are responsible for dementia support. This article focuses on the situation in a county in the Midlands where one of us (AB) has been lobbying local government for over a decade. The discussion contextualises the lived experience of dementia care within the situation exacerbated by the COVID-19 pandemic, ensuing politics of crises and persistent emphasis on cure over care. We find that the absence on two points centrally challenges care: a joined-up approach between health and social care and adequate information on available care support services, accessible through an empowered named contact. To enhance the lived experience of dementia care, consistent provision of individual named support and professional care support, as and when required, should become essential to local implementation of the care policy.

Factors associated with human papillomavirus and meningococcal vaccination among adolescents living in rural and urban areas.

Background: Studies have shown that adolescent vaccination rates with human papillomavirus (HPV) and quadrivalent meningococcal conjugate (MenACWY) vaccines are lower in rural areas of the U.S. than in urban areas. We sought to determine factors associated with vaccine acceptance in these two settings. Methods: We conducted a cross-sectional survey of 536 parents or guardians of teens age 13 through 15 years in select rural and urban counties of Minnesota and Wisconsin. We collected information on demographic variables, receipt of adolescent vaccines, and attitudes toward HPV vaccine in particular. Multivariable logistic regression models were used to assess associations between covariates and outcomes of interest (HPV vaccine receipt and MenACWY receipt). Results: Of the 536 respondents, 267 (50%) resided in a rural county. Most respondents were female (78%) and non-Hispanic White (88%). About half (52%) of teens of the surveyed parents received the three vaccines recommended specifically for adolescents: 90% received tetanus-diphtheria-acellular pertussis (Tdap), 84% received MenACWY, and 60% received one or more doses of HPV vaccine. Rural and urban parents surveyed differed on several covariates relating to teen's health services, parent's demographics, and household characteristics. Parent's perception of the importance that their healthcare providers placed on vaccination with HPV and MenACWY were independently associated with receipt of each of those vaccines (odds ratio [OR] 6.37, 95% confidence interval [CI] 2.90-13.96 and OR 2.15, 95% CI 1.07-4.31, respectively). Parents of vaccinated teens were less likely to report concerns about potential harm from the HPV vaccine or having heard stories about health problems caused by the HPV vaccine. Conclusion: Teen receipt of HPV vaccine and MenACWY appears to be influenced by parents' perception of vaccine importance, provider recommendations, and concerns regarding potential harm from the HPV vaccine. Continued education of providers and parents of the importance of adolescent vaccinations is warranted.

Vision screening as part of the school health policy in South Africa from the perspective of school health nurses.

BACKGROUND:  Vision screenings of school-going children are essential in the early detection of visual anomalies common in different age categories, which may negatively affect their academic ability and social development. Hence, their inclusion in school health policies is imperative. The aim of this study was to assess the implementation of vision screening protocols in the current Integrated School Health Screening policy of South Africa from the perspective of school health personnel. AIM:  The study sought to explore the perceptions, experiences and attitudes of the school health nurses on vision screenings included as part of the school health screenings in Gauteng province (South Africa). SETTING:  This study was located across three public healthcare facilities across Gauteng at primary healthcare levels. METHODS:  Three teams of 13 school health personnel from three primary healthcare facilities in the district of Ekurhuleni were invited to participate in the study. Focus group interviews were conducted for generating information on collective opinions and the rationale behind their views. RESULTS:  Results of the collected qualitative data revealed challenges related to training, vision screening tests, referral criteria and follow-ups or referral pathways. In addition, further challenges reported were related to communication, time, space and consent forms not signed by the parents. CONCLUSION:  Improved cohesion and communication between all role players will enable reasonable and professional provision of validated vision screening services that have the best chance of early detection of children with vision anomalies to negate possible adverse effects on their scholarly performance.

Moderate-to-vigorous intensity physical activity among adolescents in the USA during the COVID-19 pandemic.

This study aimed to evaluate adolescents' moderate-to-vigorous intensity physical activity (MVPA) during the COVID-19 pandemic with regards to sociodemographic characteristics and determine mental health and resiliency factors associated with MVPA among a diverse national sample of adolescents ages 10-14 years. Data were collected during the pandemic in May 2020 from the Adolescent Brain Cognitive Development Study (ABCD, N = 5,153), a national prospective cohort study in the U.S. MVPA was quantified as the product of reported duration and frequency (hours per week), which was further summarized as the proportion meeting age-appropriate 2018 Physical Activity Guidelines for Americans. A similar estimate was generated using MVPA data collected prior to the pandemic. Mental health and resiliency measures were collected during the pandemic. Regression models examined associations between mental health or resiliency measures and MVPA during the pandemic. Median MVPA was 2 h per week (IQR 0, 6). Overall, the percentage of the cohort meeting MVPA guidelines decreased from 16.1% (pre-pandemic) to 8.9% (during the pandemic). Racial/ethnic minority adolescents and adolescents from lower socioeconomic backgrounds were significantly less likely to meet MVPA guidelines during the pandemic. Poorer mental health, COVID-related worry, and stress were associated with lower MVPA, while more social support and coping behaviors were associated with higher MVPA during the pandemic. In this large, national sample of adolescents, the proportion of those meeting MVPA Guidelines was lower during the COVID-19 pandemic, with significant disparities by race/ethnicity and socioeconomic status. Interventions to promote social support and coping behaviors may improve MVPA levels among adolescents during the pandemic.

Reduced COVID-19 hospitalizations among New York City residents following age-based SARS-CoV-2 vaccine eligibility: Evidence from a regression discontinuity design.

BACKGROUND: In clinical trials, several SARS-CoV-2 vaccines were shown to reduce risk of severe COVID-19 illness. Local, population-level, real-world evidence of vaccine effectiveness is accumulating. We assessed vaccine effectiveness for community-dwelling New York City (NYC) residents using a quasi-experimental, regression discontinuity design, leveraging a period (January 12-March 9, 2021) when ≥ 65-year-olds were vaccine-eligible but younger persons, excluding essential workers, were not. METHODS: We constructed segmented, negative binomial regression models of age-specific COVID-19 hospitalization rates among 45-84-year-old NYC residents during a post-vaccination program implementation period (February 21-April 17, 2021), with a discontinuity at age 65 years. The relationship between age and hospitalization rates in an unvaccinated population was incorporated using a pre-implementation period (December 20, 2020-February 13, 2021). We calculated the rate ratio (RR) and 95% confidence interval (CI) for the interaction between implementation period (pre or post) and age-based eligibility (45-64 or 65-84 years). Analyses were stratified by race/ethnicity and borough of residence. Similar analyses were conducted for COVID-19 deaths. RESULTS: Hospitalization rates among 65-84-year-olds decreased from pre- to post-implementation periods (RR 0.85, 95% CI: 0.74-0.97), controlling for trends among 45-64-year-olds. Accordingly, an estimated 721 (95% CI: 126-1,241) hospitalizations were averted. Residents just above the eligibility threshold (65-66-year-olds) had lower hospitalization rates than those below (63-64-year-olds). Racial/ethnic groups and boroughs with higher vaccine coverage generally experienced greater reductions in RR point estimates. Uncertainty was greater for the decrease in COVID-19 death rates (RR 0.85, 95% CI: 0.66-1.10). CONCLUSION: The vaccination program in NYC reduced COVID-19 hospitalizations among the initially age-eligible ≥ 65-year-old population by approximately 15% in the first eight weeks. The real-world evidence of vaccine effectiveness makes it more imperative to improve vaccine access and uptake to reduce inequities in COVID-19 outcomes.

Q fever prevention in Australia: general practitioner and stakeholder perspectives on preparedness and the potential of a One Health approach.

OBJECTIVE: To examine stakeholder perspectives on the factors of an effective approach to reduce Q fever risk including disease prevention, and the perceived potential benefits of a One Health framework. METHODS: Semi-structured interviews were conducted with general practitioners (GPs), veterinarians, government authorities, researchers, and representatives from the farming industry. Transcripts were thematically analysed. RESULTS: Six major themes were identified as key factors underpinning an effective approach to Q fever: understanding Q fever burden; effective surveillance; the role of general practitioners and other stakeholders; barriers and enablers of vaccination; an integrated approach; and increased Q fever awareness. Most participants perceived GPs to play a central role in disease detection, notification, treatment and prevention through health promotion and vaccination, despite GPs acknowledging limited awareness of Q fever. Participants suggested leadership is required from the Department of Health (DoH) to foster inter-sectoral communication and collaboration. CONCLUSIONS: A One Health approach holds opportunities for zoonosis prevention. We recommend that medical curricula and professional development be enhanced, zoonosis working group networks strengthened, government-industry partnerships established, and relevant stakeholders included within an integrated program. IMPLICATIONS FOR PUBLIC HEALTH: Updating medical curricula, GP professional development programs and inter-sectoral collaboration led by health departments may reduce Q fever burden.

Temporal trends in the epidemiology of inflammatory bowel diseases in the public healthcare system in Brazil: A large population-based study.

Background: Population-based data on epidemiology of Inflammatory Bowel Diseases (IBD) in Brazil are scarce. This study aims to define temporal trends of incidence and prevalence rates of Crohn's disease (CD) and ulcerative colitis (UC) in Brazil. Methods: All IBD patients from the public healthcare national system were included from January 2012 to December 2020. Average Annual Percent Change (AAPC) and 95% confidence intervals (CI) were calculated using log-linear regression for incidence and binomial regression for prevalence. Moran's I autocorrelation index was used to analyse clustering of cities by level of prevalence. Findings: A total of 212,026 IBD patients were included. Incidence of IBD rose from 9.4 in 2012 to 9.6 per 100,000 in 2020 (AAPC=0.8%; 95% CI -0.37, 1.99); for UC, incidence increased from 5.7 to 6.9 per 100,000 (AAPC=3.0%; 95% CI 1.51, 4.58) and for CD incidence decreased from 3.7 to 2.7 per 100,000 (AAPC=-3.2%; 95% CI -4.45, -2.02). Prevalence of IBD increased from 30.0 in 2012 to 100.1 per 100,000 in 2020 (AAPC=14.8%; CI 14.78-14.95); for UC, from 15.7 to 56.5 per 100,000 (AAPC=16.0%; CI 15.94, 16.17); for CD from 12.6 to 33.7 per 100,000 (AAPC=12.1% CI 11.95, 12.02). A south-north gradient was observed in 2020 prevalence rates of IBD [I=0.40 (p<0.0001)], CD [I=0.22 (p<0.0001)] and UC [I=0.42 (p<0.0001)]. Interpretation: Incidence of CD is decreasing whereas of UC is increasing, leading to stabilization in the incidence of IBD from 2012 to 2020 in Brazil. Prevalence of IBD has been climbing with 0.1% of Brazilians living with IBD in 2020. Funding: None.

Persistent disparities in SARS-CoV-2 test percent positivity by neighborhood in New York City, March 1-July 25, 2020.

PURPOSE: To examine neighborhood-level disparities in SARS-CoV-2 molecular test percent positivity in New York City (NYC) by demographics and socioeconomic status over time to better understand COVID-19 inequities. METHODS: Across 177 neighborhoods, we calculated the Spearman correlation of neighborhood characteristics with SARS-CoV-2 molecular test percent positivity during March 1-July 25, 2020 by five periods defined by trend in case counts: increasing, declining, and three plateau periods to account for differential testing capacity and reopening status. RESULTS: Percent positivity was positively correlated with neighborhood racial and ethnic characteristics and socioeconomic status, including the proportion of the population who were Latino and Black non-Latino, uninsured, Medicaid enrollees, transportation workers, or had low educational attainment. Correlations were generally consistent over time despite increasing testing rates. Neighborhoods with high proportions of these correlates had median percent positivity values of 62.6%, 28.7%, 6.4%, 2.8%, and 2.2% in the five periods, respectively, compared with 40.6%, 11.7%, 1.7%, 0.9%, and 1.0% in neighborhoods with low proportions of these correlates. CONCLUSIONS: Disparities in SARS-CoV-2 molecular test percent positivity persisted in disadvantaged neighborhoods during multiple phases of the first few months of the COVID-19 epidemic in NYC. Mitigation of the COVID-19 burden is still urgently needed in disproportionately affected communities.

US deceased kidney transplantation: Estimated GFR, donor age and KDPI association with graft survival.

BACKGROUND: Despite a significant shortage of kidneys for transplantation in the US, kidneys from older deceased donors are infrequently transplanted. This is primarily over concern of graft quality and transplant durability. METHODS: The US national transplant database (2000-2018) was assessed for deceased donor kidney transplant patient and graft survival, graft durability and stratified by donor age (<65 years>), Kidney Donor Profile Index (KDPI) and estimated glomerual filtration rate (GFR) one year post-transplantation (eGFR-1) were calculated. FINDINGS: Recipients of kidneys transplanted from deceased donors >65 years had a lower eGFR-1, (median 39 ml/min) than recipients of younger donor kidneys (median 54 ml/min). However, death-censored graft survival, stratified by eGFR-1, demonstrated similar survival, irrespective of donor age or KDPI. The durability of kidney survival decreases as the achieved eGFR-1 declines. KDPI has a poor association with eGFR-1 and lesser for graft durability. While recipients of kidneys > 65 years had a higher one year mortality than younger kidney recipients, recipients of kidneys > 65 years and an eGFR-1 <30 ml/min, had a lower survival than an untransplanted waitlist cohort (p<0.001). INTERPRETATION: The durability of kidney graft survival after transplantation was associated with the amount of kidney function gained through the transplant (eGFR-1) and the rate of graft loss (return to dialysis) was not significantly associated with donor age. 24.9% of recipients of older donor kidneys failed to achieve sufficient eGFR-1 providing a transplant survival benefit. While there is significant benefit from transplanting older kidneys, better decision-making tools are required to avoid transplanting kidneys that provide insufficient renal function. FUNDING: None.

Are venous thromboembolism risk assessment tools reliable in the stratification of microvascular risk following lower extremity reconstruction?

INTRODUCTION: The incidence of flap failure is significantly higher in the lower extremity compared to free tissue transfer in the head, neck and breast. The most common cause of flap failure is venous thrombosis. The aim of this study was to assess the reliability of venous thromboembolism (VTE) risk assessment tools in this high-risk cohort and to assess the ability of such tools to identify patients at risk of developing microvascular venous thrombosis and venous thromboembolism following lower extremity free flap reconstruction. METHODS: A single centre retrospective cohort study was conducted between August 2012-August 2019. Adult patients who had undergone free tissue transfer following open lower extremity fractures were eligible for inclusion. All patients were retrospectively risk assessed using the Department of Health (DoH), Modified Caprini and Padua VTE risk assessment tools. RESULTS: Fifty-eight patients were included; all were at high risk of DVT according to the DoH (mean score ± SD, 3.7 ± 0.93), Caprini (10.2 ± 1.64) and Padua (5.4 ± 0.86) risk assessment tools. All patients received appropriate thromboprophylaxis; the incidence of symptomatic hospital acquired VTE was 3.5%. Micro-anastomotic venous thrombosis occurred in 4 patients resulting in one amputation. Partial flap necrosis occurred in 7 patients. There were no significant differences in scaled Caprini (median score, 10 vs 9, z = 1.289, p = 0.09), DoH (3 vs 3, z = 0.344, p = 0.36), and Padua (5 vs 5.5, z= -0.944, p = 0.17) scores between those with and without microvascular venous thrombosis. CONCLUSION: This data suggests that current VTE risk assessment tools do not predict risk of microvascular venous thrombosis following lower extremity reconstruction. Further prospective studies are required to optimise risk prediction models and thromboprophylaxis use in this cohort.

Narrowing but persisting gender pay gap among employees of the US Department of Health and Human Services during 2010-2018.

BACKGROUND: The gender pay gap in the United States (US) has narrowed over the last several decades, with the female/male earnings ratio in the US increased from about 60% before the 1980s to about 79% by 2014. However, the gender pay gap among the healthcare workforce persists. The objective of this study is to estimate the gender pay gap in the US federal governmental public health workforce during 2010-2018. METHODS: We used an administrative dataset including annual pay rates and job characteristics of employees of the US Department of Health and Human Services. Employees' gender was classified based on first names. Regression analyses were used to estimate the gender pay gap using the predicted gender. RESULTS: Female employees of the DHHS earned about 13% less than men in 2010, and 9.2% less in 2018. Occupation, pay plan, and location explained more than half of the gender pay gap. Controlling for job grade further reduces the gap. The unexplained portion of the gender pay gap in 2018 was between 1.0 and 3.5%. Female employees had a slight advantage in terms of pay increase over the study period. CONCLUSIONS: While the gender pay gap has narrowed within the last two decades, the pay gap between female and male employees in the federal governmental public health workforce persists and warrants continuing attention and research. Continued efforts should be implemented to reduce the gender pay gap among the health workforce.

A flow cytometric assay for HLA-DR expression on monocytes validated as a biomarker for enrollment in sepsis clinical trials.

PURPOSE: Decreased expression of HLA-DR on monocytes (mHLA-DR) is a reliable indicator of immunosuppression in patients with sepsis and is correlated with increased risk of secondary infection and mortality. A flow cytometry-based laboratory developed test for the measurement of mHLA-DR in whole blood was validated for clinical trial enrollment, which is considered medical decision-making, for patients with severe sepsis or septic shock. METHODS: The BD Quantibrite™ anti-HLA-DR/anti-monocyte reagent measures antibodies bound per cell of HLA-DR on CD14+ monocytes. The mHLA-DR assay was planned to support inclusion/exclusion of patients for a clinical trial and was validated according to New York State Department of Health (NYSDOH) requirements for a new non-malignant leukocyte immunophenotyping assay. RESULTS: Normal, healthy donor and sepsis patient samples were stable up to 72 h post-collection in Cyto-Chex BCT phlebotomy tubes. Pre-determined acceptance criteria were met for precision parameters (average %CV ≤ 20%) and global laboratory-to-laboratory comparisons (average %Δ ≤ 20%). The approaches taken to evaluate and report accuracy, analytical specificity and sensitivity, reportable range, reference interval, and the proposed multi-level quality control were accepted by NYSDOH. CONCLUSIONS: In this study, the validation strategy necessary when the intended use of assay results changes from exploratory to medical decision making (patient enrollment), which successfully resulted in regulatory approval, is described.