Maureen Cunningham

The Center for Human Development in Guatemala: An Innovative Model for Global Population Health

Edwin J. Asturias, MD, Gretchen Heinrichs, MD, DTMH, Gretchen Domek, MD, MPhil, John Brett, PhD, Elizabeth Shick, DDS, MPH, Maureen Cunningham, MD, MPH, Sheana Bull, PhD, Marco Celada, MD, Lee S. Newman, MD, MA, Liliana Tenney, MPH, Lyndsay Krisher, MPH, Claudia Luna-Asturias, MSW, Kelly McConnell, MD, Stephen Berman, MD* Center for Global Health, Colorado School of Public Health Partners with Children’s Hospital Colorado, 13199 E. Montview Boulevard, Campus Box A090, Aurora, CO 80045, USA; Department of Pediatrics, University of Colorado School of Medicine, 13123 E. 16th Avenue, Campus Box B065, Aurora, CO 80045, USA; Department of Obstetrics and Gynecology, University of Colorado School of Medicine, 13001 E. 17th Place, Campus Box C290, Aurora, CO 80045, USA; Department of Anthropology, College of Liberal Arts and Sciences, University of Colorado-Denver, PO Box 173364, Campus Box 103, Denver, CO 80217, USA; School of Dental Medicine, University of Colorado Anschutz Medical Campus, 13065 E. 17th Avenue, Campus Box F833, Aurora, CO 80045, USA; Center for Health, Work & Environment, Colorado School of Public Health, 13001 E. 17th Place, Campus Box B186, Aurora, CO 80045, USA

A comparison of H1N1 influenza among pediatric inpatients in the pandemic and post pandemic era.

BACKGROUND The novel influenza A H1N1 (A[H1N1]pdm09) strain emerged in 2009, contributing to significant morbidity and mortality. It is not known whether illness associated with A(H1N1) pdm09 in the post-pandemic era exhibits a similar disease profile. OBJECTIVE The objectives of this study were to compare the burden of disease of A(H1N1) pdm09 influenza from the 2009 pandemic year to the post-pandemic years (2010-2014), and to explore potential reasons for any differences. STUDY DESIGN We conducted a retrospective cohort study of inpatients admitted to Childrens Hospital Colorado with a positive respiratory specimen for influenza from May-December, 2009 and December, 2010-April, 2014. Univariate and multivariate analyses were conducted to compare the demographics and clinical characteristics of patients with H1N1 during the two periods. RESULTS There were 388 inpatients with influenza A(H1N1) pdm09 in 2009, and 117 during the post-pandemic years. Ninety-four percent of all H1N1 during the post-pandemic era was observed during the 2013-2014 influenza season. Patients with A(H1N1) pdm09 during the post-pandemic year were less likely to have an underlying medical condition (P<0.01). Patients admitted to the ICU during the post-pandemic year had a lower median age (5 vs 8 years, P=0.01) and a lower proportion of patients were intubated, had mental status changes, and ARDS compared with the pandemic years, (P<0.01 for all), with decreased mortality (P=0.02). CONCLUSION Patients with influenza A(H1N1) pdm09 during the post-pandemic years appeared to have less severe disease than patients with A(H1N1) pdm09 during the pandemic year. The reasons for this difference are likely multifactorial.

Infant, Maternal, and Hospital Factors' Role in Loss to Follow-up After Failed Newborn Hearing Screening

OBJECTIVE Completion of newborn hearing screening (NBHS) is recommended by 1 month old. Delays and loss to follow-up and documentation (LTF/LTD) after failed NBHS are common. Committees of experts have established hospital guidelines to reduce LTF/LTD. We aimed to identify maternal and infant factors associated with LTF/LTD and determine if adherence to hospital guidelines is associated with timely completion of follow-up screening. METHODS We conducted a retrospective study of all infants born in Colorado hospitals who failed the newborn admission hearing screening from 2007 to 2012 and a cross-sectional survey of NBHS coordinators at Colorado birthing hospitals. Neonatal intensive care unit infants were excluded. Outcomes included documented completion of the follow-up NBHS and completion by 1 month. Data sources comprised the electronic birth record, infant hearing integrated data system, and NBHS coordinator survey. Data were analyzed by logistic regression. RESULTS A total of 13,904 newborns did not pass the newborn admission hearing screening from 2007 to 2012, and 11,422 (82%) had documentation of a completed follow-up screening. A total of 10,558 (76%) completed follow-up screening by 1 month. All 53 NBHS coordinators completed the survey. Maternal age, education, smoking, and birth country; and payer, race, birth order, and population density were associated with completion of follow-up hearing screening. Maternal education, payer, population density, birth weight, and cleft lip were associated with completion by 1 month of age. Only birth in a facility that charges a rescreening fee was associated with completion of follow-up screening. CONCLUSIONS Low-income, rural, and minority infants are at risk for LTF. Further studies are needed to determine if adherence to guidelines can overcome barriers to follow-up.

Baseline microcephaly prevalence in rural Guatemala: implications for neonatal screening for congenital Zika virus infection

Abstract Background Microcephaly is the result of disturbance in early brain development and has various causes. Zika was identified in Central America in early 2015. Establishing baseline microcephaly rates in areas affected by Zika is important for the assessment of the burden and contribution of Zika to microcephaly in low-resource settings. Methods We undertook a retrospective review of records from a community wellness programme in rural Guatemala where trained community health workers obtained data on weight, length, and head circumference for infants aged 0 to 13 days, enrolled in the programme between August 1, 2014, and March 31, 2016. We estimated gestational age using a Z-score of zero for length on the modified Fenton growth curve. Z-scores for head circumference and weight, adjusted for gestational age and sex, were then calculated. We used univariate logistic regression to test associations between microcephaly and low weight (Z ≤−1), small size for gestational age (weight below 10th percentile for gestational age), and sex. We analysed head circumference Z-scores and microcephaly for changes over time using birth month as well as multiple time-breaks (we compared infants born before versus after April 30, 2015; October 31, 2015; and January 31, 2016) with Student t-tests, and logistic and linear regression. Findings We included 296 infants: mean head circumference Z-score was −0·68 (95% CI −0·78 to −0·58). 20 infants (6·8%) had a head circumference Z-score ≤–2 and were considered to have microcephaly, giving a microcephaly prevalence of 676 per 10 000 livebirths. One infant (0·3%) had a head circumference Z-score ≤–3. Weight ≤–1 SD (OR 4·59 (1·69–12·41, p=0·003) and small for gestational age (6·65, 1·88–23·55, p=0·003) were associated with microcephaly. Sex was not significantly associated with microcephaly. Birth month and time-breaks were not associated with microcephaly nor with head circumference Z score. Interpretation Baseline neonatal microcephaly present in this rural Guatemalan community before and during Guatemalas early Zika epidemic is more than 100 and 300 times higher than baseline rates reported before the Zika virus epidemic in Puerto Rico and Brazil, respectively. Increased microcephaly rate associated with Zika epidemics in other countries was not detectable in our study population, probably because data were collected early in the Zika epidemic. High baseline microcephaly rates have important implications for neonatal screening programmes to identify infants congenitally infected with Zika in low-income countries. Funding The Center for Global Health at the University of Colorado and the Jose Fernando Bolanos Menendez Foundation provided funding for the wellness programme.

Missed Opportunities for Influenza Vaccination Among Hospitalized Children With Influenza at a Tertiary Care Facility

OBJECTIVES To identify the extent and characteristics of missed opportunities for influenza vaccination among children hospitalized with influenza at a tertiary childrens hospital. METHODS We conducted a retrospective cohort study of hospitalized patients with polymerase chain reaction-confirmed influenza admitted to Childrens Hospital Colorado from 2010 to 2014. We reviewed medical records for vaccination status and previous visits. The primary outcome was the proportion of underimmunized patients hospitalized with influenza with at least 1 missed opportunity visit (visit before influenza diagnosis in which an eligible patient did not receive the influenza vaccine). The relationship between sociodemographic characteristics and the primary outcome were examined using χ(2) tests and nonparametric tests, and variables with P < .2 were entered into a multivariate logistic regression model. RESULTS Among 322 patients hospitalized with influenza, 199 (61%) were undervaccinated; 83 of 199 (42%) had at least 1 missed opportunity for influenza vaccination. Multivariate analysis demonstrated that high-risk status (adjusted odds ratio 6.9, 95% confidence interval 3.8-12.4) was associated with increased odds of having a missed opportunity visit. Most missed opportunity visits were to subspecialty clinics (42%), and most visits (71%) occurred from September to November. CONCLUSIONS More than 40% of hospitalizations for influenza in children are associated with at least 1 missed opportunity visit at a tertiary center. Our findings highlight the potential role of tertiary care institutions in increasing influenza vaccination rates among children.

High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening

A variety of microcephaly case definitions detect high background prevalence in rural Guatemala, which complicates congenital Zika screening efforts. In addition, gestational age is needed for most screening tools but is usually unknown in low-resource settings. Fenton growth curves, originally designed for use in preterm infants, offer a standardized approach to adjust for unknown gestational age and may improve screening efforts. A variety of microcephaly case definitions detect high background prevalence in rural Guatemala, which complicates congenital Zika screening efforts. In addition, gestational age is needed for most screening tools but is usually unknown in low-resource settings. Fenton growth curves, originally designed for use in preterm infants, offer a standardized approach to adjust for unknown gestational age and may improve screening efforts. Background: Congenital microcephaly is the result of a disturbance in early brain development and can have multiple etiologies. Establishing background prevalence of microcephaly in Zika virus (ZIKV)-affected areas is important for improving identification of ZIKV-affected newborns. However, to date, there is limited consistent guidance for the accurate identification of microcephaly in infants of unknown gestational age, a common concern in low- and middle-income countries. Methods: Occipital frontal head circumference (OFC) obtained from infants (0–13 days) of unknown gestational age at enrollment in a pregnancy registry in rural Guatemala from August 2014 to March 2016 were retrospectively reviewed. Trained community health nurses recorded anthropometry in an online database. In April 2015, ZIKV was identified in this population. Gestational age was approximated in 2 ways: presumed term and estimated using z-score of zero for height on modified Fenton growth curves. After which, z-scores for OFC and weight were obtained. Microcephaly and microcephaly background prevalence were estimated using 7 established microcephaly case definitions from national and international organizations and 3 proposed definitions using Fenton growth curves. Independent associations with microcephaly and OFC, including relationship with date of birth, were assessed with prevalence ratios and linear regression. Results: For 296 infants, the mean OFC was 33.1 cm (range, 29.5 to 37 cm) and the mean OFC z-score was −0.68. Depending on case definition, 13 to 125 infants were classified as having microcephaly (background prevalence 439 to 4,223 per 10,000 live births), and 1 to 9 infants were classified as having severe microcephaly (<−3 standard deviation [SD]) (34 to 304 per 10,000 live births). Five (1.7%) infants met all the microcephaly case definitions. Weight ≤−1 SD (prevalence rate [PR], 3.77; 95% confidence interval [CI]: 1.6 to 8.8; P=.002) and small for gestational age (PR, 4.68; 95% CI, 1.8 to 12.3; P=.002) were associated with microcephaly. Date of birth was not associated with OFC z-score or OFC after adjusting for gestational age and gender. Conclusions: Estimated background microcephaly is high in rural Guatemala compared with reported rates in Latin America prior to ZIKV epidemic, which has important implications for neonatal screening programs for congenital ZIKV infection. Fenton growth curves offer a standardized approach to the identification of microcephaly in infants of unknown gestational age.

Group based learning among caregivers: assessing mothers’ knowledge before and after an early childhood intervention in rural Guatemala

Background: The first three years of a child’s life are a critical period for brain growth and development. Caregiver interventions during this period that improve early childhood health and development have the potential to enhance a child’s physical, mental, and social well-being. Methods: This was a pretest/posttest quasi experimental program evaluation. Early childhood education materials were adapted to create two separate interventions consisting of 30-page interactive flipchart talks to educate mothers on health and development topics relevant to 0–6 and 6–12 month old children. Three community health workers performed the talks with groups of 5–8 mothers. Short learning assessments were given individually to each mother pre-intervention (pretest), immediately post-intervention (posttest 1), and two weeks post-intervention (posttest 2). Demographic surveys and focus group discussions were conducted with all participants. Results: Mothers (n = 77) had an average age of 33.6 years and had an average of 3.6 living children. Most of the mothers (71%) had received some primary education, but 23% had received no formal schooling. For the 0–6 months flipchart learning assessment (n = 38), the mean pretest score was 77% correct. The mean posttest 1 score improved to 87% (p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 90% (p = 0.01). For the 6–12 months flipchart learning assessment (n = 39), the mean pretest score was 78%. The mean posttest 1 score improved to 89% (p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 92% (p = 0.03). Conclusions: Mothers in an impoverished region of southwestern Guatemala significantly increased their knowledge about child health topics following a short interactive group talk. Mothers further increased their knowledge two weeks after the intervention, without specific re-exposure to the intervention materials, suggesting assimilation and informal reinforcement through group based learning with other mothers in their community.

11452009 H1N1 Compared to Post-pandemic H1N1 Influenza Among Pediatric Inpatients

Pediatric Inpatients Suchitra Rao, MB, BS; Joshua Williams, MD; Maureen Cunningham, MD; Donna Curtis, MD, MPH; Dayanand Bagdure, MD; Mary Glode, MD, FIDSA; Samuel R. Dominguez, MD, PhD; Pediatrics (Infectious Diseases), University of Colorado School of Medicine, Aurora, CO; Pediatrics, University of Colorado School of Medicine, Aurora, CO; Pediatric Infectious Disease, University of Colorado Denver School of Medicine, Aurora, CO; Pediatric Critical Care, University of Maryland, Baltimore, MD; Pediatric Infectious Diseases, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO; Department of Infectious Disease, Children’s Hospital Colorado/University of Colorado School of Medicine, Aurora, CO