R. MacIntyre

Research: The challenges of clinical trials in the exclusion zone: The case of the frail elderly

Frail older people have been systematically excluded from randomised controlled trials (RCT). We aim to recruit older, frail hospitalised patients in an RCT and evaluate the frailty index (FI) as a measure to describe the types of people included in the study. We recruited 315 hospitalised patients aged 65 years; age ranged from 60 to 102 years. Baseline assessment scores ranged as follow: Mini‐Mental Status Examination from 7 to 30, Barthel index from 5 to 100 and FI from 2 to 24. Total deaths were 20 (6%). We demonstrated that it is feasible to recruit frail older people into RCTs. The FI does not show any ‘floor’ or ‘ceiling’ effects. We can measure frailty in an RCT cohort, and we believe that clinical trials should include more frail older people and that the use of an FI can facilitate such trials and generate reliable data to guide future medical practice in a rapidly ageing society.

Burden of severe rotavirus disease in Australia

Aim:  To analyse the epidemiology of coded rotavirus hospitalisations in Australia from 1993 to 2002, with a view to understanding the pre‐vaccination burden of severe disease in Australia. This study also seeks to determine the burden of rotavirus‐related mortality.

Do corticosteroids reduce the mortality of influenza A (H1N1) infection? A meta-analysis

IntroductionCorticosteroids are used empirically in influenza A (H1N1) treatment despite lack of clear evidence for effective treatment. This study aims to assess the efficacy of corticosteroids treatment for H1N1 infection.MethodsSystematic review and meta-analysis were used to estimate the efficacy of corticosteroids for the prevention of mortality in H1N1 infection. Databases searched included MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Clinical Trials and so on, and bibliographies of retrieved articles, from April 2009 to October 2014. We included both cohort studies and case-control studies reported in English or Chinese that compared treatment effects between corticosteroids and non-corticosteroids therapy in inpatients with H1N1 virus infection. Cohort studies employed mortality as outcome, and case-control studies employed deaths as cases and survivors as controls; both were assessed in this meta-analysis.ResultsIn total twenty-three eligible studies were included. Both cohort studies (nine studies, n = 1,405) and case-control studies (14 studies, n = 4,700) showed a similar trend toward increased mortality (cohort studies relative risk was 1.85 with 95% confidence interval (CI) 1.46 to 2.33; case-control studies odds ratio was 4.22 with 95% CI 3.10 to 5.76). The results from both subgroup analyses and sensitive analyses were consistent with each other, showing that steroid treatment is associated with mortality. However, considering the fact that corticosteroids were tend to be used in sickest case-patients and heterogeneity was observed between studies, we cannot make a solid conclusion.ConclusionsAvailable evidence did not support the use of corticosteroids as standard care for patients with severe influenza. We conclude that further research is required.

Predictors of Pneumococcal Vaccination Uptake in Hospitalized Patients Aged 65 Years and Over Shortly Following the Commencement of a Publicly Funded National Pneumococcal Vaccination Program in Australia

In January 2005, Australia became the first country to introduce a publicly funded pneumococcal vaccination program for persons 65 years and older which is free at point of service, although the vaccine cost had previously been partially subsidised. Hospitalisation in this age group is an important indicator of risk of invasive pneumococcal disease but vaccine uptake has been suboptimal. To determine vaccination rates and predictors of vaccination in the elderly hospitalised patients before and after January 2005. We validated vaccination status against general practitioner (GP) records for patients aged ≥65 years admitted to a large teaching hospital in Sydney between 16th of May 2005 and the 20th of February 2006 and examined predictors of vaccinationCommencement of the new program resulted in a significant increase in vaccination uptake from 39% of inpatients prior to the free program to 73% in the same cohort of inpatients post January 2005. We found that patient recall of vaccination status was not reliable. Self-report of pneumococcal vaccination had a sensitivity of 0.53 and a specificity of 0.55, highlighting that validation of vaccination status is required. Age over 80 years and dementia significantly predicted under-vaccination. This highlights the importance of integrating free vaccine supply and delivery in primary care to achieve high vaccination coverage. However, demented patients and the very elderly remain under-vaccinated, despite being admitted to hospital for active management of acute conditions.

mHealth for the control of TB/HIV in developing countries

mHealth (healthcare using mobile communication technologies) is being strengthened as a new tool to tackle the global crisis in inadequate workforce and patient monitoring, especially in resource-limited settings. High numbers of people living with TB/HIV fail treatment and develop resistance because they cannot maintain a high degree of adherence to their medication regimens. This paper illustrates how a simple and inexpensive SMS-based mHealth application can be used to facilitate the TB/HIV treatment.

Differences in the attitude and knowledge of hospital health care workers regarding older patient vaccinations.

Streptococcus pneumoniae infections are lethal for certain high-risk groups including adults aged 65 years and over. Despite long-standing recommendations for their routine use among elderly persons and other high-risk groups, these vaccines continue to be underused, especially in the very frail elderly. The implementation of organized vaccination programs are important facilitators of vaccine delivery. However, pneumococcal vaccination has not been well embraced by hospital health care workers. For a vaccination program to be able to succeed multiple components should be incorporated such as standing orders, special clinics, and provider feedback. This survey aims to compare attitudes and knowledge of hospital-based doctors and nurses Results: The nurses are less enthusiastic about vaccination and consider the diseases less serious. This has implications particularly for hospital-based strategies for improving vaccination uptake, where gaining the support of nursing staff will be crucial. Discussion: Vaccine delivery efforts must make dramatic improvements if the pneumococcal vaccination goals for elderly persons and other high-risk adults are to be met. Material and Methods: Self administered survey of hospital nurses and doctors utilizing all wards in a large, tertiary referral adult hospital in Sydney, Australia.

Influenza vaccine effectiveness against influenza-associated hospitalization in 2015/16 season, Beijing, China

BACKGROUND Vaccination is recommended to prevent influenza virus infection and associated complications. This study aimed to estimate the influenza vaccine effectiveness (VE) against hospitalization in the 2015/16 season in Beijing. METHODS Patients who were hospitalized in the 5 study hospitals between 1 Oct 2015 and 15 May 2016 were recruited. Influenza vaccination status was obtained for PCR-confirmed influenza patients and the selected controls who tested negative for the virus. Conditional logistic regression was used to estimate the influenza VE matching by calendar week, and adjusting for age, study sites, underlying medical conditions, smoking status, and hospital admissions over the past 12months. RESULTS The overall VE was -37.9% (95% CI: -103.3, 6.5) against laboratory-confirmed influenza-associated hospitalization. The 2015-16 seasonal vaccine was had -61.9% (95% CI: -211.9, 15.9), -5.4% (95% CI: -108.1, 46.6) and -45.2% (95% CI: -152.6, 16.5) effectiveness to prevent infection from A(H1N1)pdm09, A(H3N2) and influenza B, respectively. CONCLUSIONS Influenza vaccination did not show effective protection against hospitalization with influenza in 2015/16 season in Beijing.

Tool for E-Health Preparedness Assessment in the Context of an Influenza Pandemic

E-Health applications may mitigate the impact of a pandemic by facilitating disease surveillance and control activities, and improving performance of medical practices. The implementation of these applications requires proper planning and management. E-Health preparedness assessment represents an important step in change management, and including this step in its planning stage may increase the chances of its implementation success. This article presents a three-phase methodology that was developed and utilised in a collaborative project on E-Health preparedness assessment in the context of an influenza pandemic. Based on this project, a software tool set was newly developed to partially automate the assessment process.

Post-pandemic assessment of public knowledge, behavior, and skill on influenza prevention among the general population of Beijing, China

Summary Background The aim of this study was to assess the knowledge, behavioral, and skill responses toward influenza in the general population of Beijing after pandemic influenza A (H1N1) 2009. Methods A cross-sectional study was conducted in Beijing, China, in January 2011. A survey was conducted in which information was collected using a standardized questionnaire. A comprehensive evaluation index system of health literacy related to influenza was built to evaluate the level of health literacy regarding influenza prevention and control among residents in Beijing. Results Thirteen thousand and fifty-three valid questionnaires were received. The average score for the sum of knowledge, behavior, and skill was 14.12±3.22, and the mean scores for knowledge, behavior, and skill were 4.65±1.20, 7.25±1.94, and 2.21±1.31, respectively. The qualified proportions of these three sections were 23.7%, 11.9%, and 43.4%, respectively, and the total proportion with a qualified level was 6.7%. There were significant differences in health literacy level related to influenza among the different gender, age, educational level, occupational status, and location groups (p <0.05). There was a significant association between knowledge and behavior (r =0.084, p <0.001), and knowledge and skill (r =0.102, p <0.001). Conclusions The health literacy level remains low among the general population in Beijing and the extent of relativities in knowledge, behavior, and skill about influenza was found to be weak. Therefore, improvements are needed in terms of certain aspects, particularly for the elderly and the population of rural districts. Educational level, as a significant factor in reducing the spread of influenza, should be considered seriously when intervention strategies are implemented.

Knowledge and attitudes towards rotavirus diarrhea and the vaccine amongst healthcare providers in Yogyakarta Indonesia

BackgroundRotavirus has been identified as the most common pathogen associated with severe diarrhoea. Two effective vaccines against the pathogen have been licensed. However, many countries including Indonesia have yet to introduce the vaccine into their national immunisation programs. This study aimed to examine the attitudes of healthcare providers (HCPs) and other health stakeholders towards the pathogen and the vaccine.MethodsSemi-structured in-depth interviews were undertaken in two districts of Yogyakarta Province, Indonesia with nurses, midwives, primary care providers, pediatricians and other health stakeholders. Thematic analysis was undertaken.ResultsFourteen interviews were conducted between August and October 2013. We identified that while participants do not consider diarrhea to be an important problem in Indonesia, they do acknowledge that it can be serious if not properly treated. While the majority had some level of knowledge about rotavirus, not all participants knew that a vaccine was available. There were mixed feelings towards the need for the vaccine. Some felt that the vaccine is not ranked as a priority as it is not listed on the national program. However, others agreed there is a rationale for its use in Indonesia. The cost of the vaccine (when sold in the private sector) was perceived to be the primary barrier impacting on its use.ConclusionsThe high cost and the low priority given to this vaccine by the public health authorities are the biggest obstacles impacting on the acceptance of this vaccine in Indonesia. HCPs need to be reminded of the burden of disease associated with rotavirus. In addition, reminding providers about the costs associated with treating severe cases versus the costs associated with prevention may assist with improving the acceptance of HCPs towards the vaccine. Promotion campaigns need to target the range of HCPs involved in the provision of care to infants and pregnant women.