Breast cancer screening attitudes, beliefs, and behaviors of Zuni Pueblo women: identifying cornerstones for building effective mammogram screening intervention programs

PURPOSE

Breast cancer is the leading form of cancer and has the second highest mortality rate of cancers for American Indian/Alaska Native (AI/AN) women. Early screening is critical. This study examines the breast cancer-related knowledge, beliefs, and behaviors of Zuni women in the Southwest United States (U.S.).

METHODS

In 2020 and 2021, a survey was administered to better understand cancer screening patterns in Zuni Pueblo; 110 women from 50 to 75 years of age were recruited to respond to the breast cancer screening portion. Inclusion criteria included self-identifying as AI, a member of the Zuni tribe, or married to a Zuni tribal member, and meeting the age and gender requirements. Descriptive statistics and bivariate analyses were conducted examining the associations between measures of breast cancer knowledge, beliefs, and behaviors and breast cancer screening status (never, ever/non-compliant, and ever/compliant).

RESULTS

Of survey participants, 47.3% have had a breast cancer screening and are up-to-date, 39.1% have had a screening in the past but are not up-to-date, and 13.6% have never been screened. Age was the only statistically significant socioeconomic predictor of breast cancer screening; the median (interquartile range) ages of each group are 62 (54, 68) ever/compliant, 56 (54, 68) ever/non-compliant, and 53 (51, 55) never (p-value < 0.001). Significant differences by health status and access to medical care include having a regular health care provider and going to see a provider for routine check-ups. The survey also shows differences in knowledge about breast cancer risk factors, beliefs, and behaviors. Women across all three screening statuses reported that they would get screened if encouraged by a health care provider.

CONCLUSION

While survey respondents report a relatively high rate of ever having had a breast cancer screening, less than half are compliant with screening guidelines, which shows there is an opportunity to improve breast cancer screening rates. With culturally tailored interventions, providers have the potential to improve breast cancer screening for Zuni women.

Preferences for CPSTF-Recommended Intervention Approaches for Increasing Cancer Screening Among Screen-Eligible Adults in Zuni Pueblo, USA

We identified preferences toward Community Preventive Services Task Force (CPSTF)-recommended intervention approaches among screen-eligible Zuni Pueblo members in New Mexico, USA and assessed if there were significant differences in those preferences, with the goal of informing the selection of intervention approaches for use in the Zuni Pueblo. We utilize data from a population-based survey (n = 280) focused on 15 CPSTF-recommended intervention approaches designed to improve screening for cervical, breast, and/or colorectal cancer screening. Model-adjusted results suggest some intervention approaches garnered significantly higher support than others. We offer six, data-driven recommendations for consideration by public health practitioners as they endeavor to improve cancer prevention in the Zuni Pueblo. This study provides a replicable model for other public health practitioners and health services researchers to incorporate community preferences in community-level intervention approach selection.

Cervical Cancer Knowledge and Screening Patterns in Zuni Pueblo Women in the Southwest United States

American Indian women experience cervical cancer disparities, including later-stage diagnosis and a higher cervical cancer mortality rate. These disparities are interconnected and linked to cervical cancer screening disparities. Cervical cancer when identified early is highly treatable. Individual- and health system-level factors often contribute to gaps in cervical cancer screening. To better understand the source of these inequities experienced by American Indian women, specifically Zuni women, this paper examines how knowledge about cervical cancer and related risk factors is linked to cervical cancer screening for Zuni women using primary data gathered by the Zuni Health Initiative in 2020 and 2021. We find that of the women who completed the survey (n = 171), women with greater cervical cancer knowledge are statistically significantly more likely to have received cervical cancer screening. Closer examination of knowledge on the specific risk factors for cervical cancer provides evidence upon which to develop a cervical cancer education intervention.

The relationship between mental health and public attention to the Brett Kavanaugh hearings and confirmation

RATIONALE

Researchers have rarely considered how public attention surrounding political events influences mental health. Specifically, in a politically polarized nation like the United States, it is possible that these events have a public mental health effect.

OBJECTIVE

This study examines the mental health effects associated with the 2018 U.S. Senate hearing and confirmation of Supreme Court Justice Brett Kavanaugh using public survey data.

METHODS

We use the interview date included in CDC data from the 2014-2018 Behavioral Risk Factor Surveillance System (BRFSS) to identify the effects of increased public attention on the Kavanaugh hearings and confirmation on the mental health of individuals who identify as female. We employ a triple difference model to control for possible confounding effects and target causality.

RESULTS

We find meaningful increases in both the number of "not good" mental health days reported and the probability of reporting any "not good" mental health days. On average, females reported 0.24 more poor mental health days during the one-month period surrounding the Kavanaugh confirmation and hearings than women did in the same 1-month period in 2014. This change represents a nearly 10% increase in mental health burden. The results are robust to the inclusion of a range of covariates as well as alternate specifications. In addition, we derive estimates of the societal costs associated with the increased mental health burden linked to Brett Kavanaugh's confirmation.

CONCLUSION

This study demonstrates that the Kavanaugh confirmation and hearings were associated with a notable rise in mental health challenges, especially among women. These results extend beyond personal experience and illustrate the societal costs linked to the resulting increased mental health burden. Further research on similar events is warranted.

Colorectal Cancer Screening Among Adults in Zuni Pueblo: Factors Associated with FOBT and Colonoscopy Utilization

Although strategies to mitigate barriers to colorectal cancer (CRC) screening have proven successful in some parts of the US, few of these strategies have been studied in rural, American Indian communities that may exhibit unique culturally driven attitudes toward and knowledge of colorectal cancer and experience increased barriers to healthcare access. In this study, we describe the results of a survey among CRC screen-eligible members of Zuni Pueblo (N = 218) on an array of questions regarding CRC screening behaviors, knowledge, satisfaction with and access to healthcare services, social support for CRC screening, perceptions toward FOBT, and preference for evidence-based interventions or strategies for improving CRC screening rates. Results from the multivariable model suggest age, having a regular healthcare provider, and harboring fewer negative perceptions toward FOBT are key drivers of ever completing CRC screening. Respondents reported strong support for Community Guide-recommended interventions and strategies for increasing CRC screening for nearly all proposed interventions. Results confirm the need for multilevel, multicomponent interventions, with a particular focus on improving Zuni Pueblo community members' access to a regular source of care, improving knowledge of CRC risk factor, and addressing negative perceptions toward CRC screening. These results provide critical, community-specific insight into better understanding the drivers of low guideline-adherent screening rates and inform local healthcare providers and community leaders of context-specific strategies to improve CRC screening in Zuni Pueblo.

Health Literacy, Health Numeracy, and Cancer Screening Patterns in the Zuni Pueblo: Insights from and Limitations of "Standard" Questions

American Indians experience disparities in cancer screening, stage at disease diagnoses, and 5-year cancer survival. This study investigates how health literacy and health numeracy may be linked to cancer screening behaviors of Zuni Pueblo members using a survey exploring screening behaviors related to breast, cervical, and colorectal cancers. As part of a larger community-based cancer prevention and control project, Zuni Health Initiative staff conducted surveys from October 2020 through April 2021 of 281 participants (men ages 50-75 and women ages 21-75) from the Zuni Pueblo. Bivariate and multivariable analyses investigated associations between health literacy/numeracy measures and cancer screening behaviors. Bivariate analyses showed some associations between distinct measures of health literacy/numeracy and colorectal cancer (CRC) screening, including both colonoscopy (health literacy) and fecal occult blood testing (FOBT) (health numeracy), as well as cervical cancer screening (health literacy). There were no statistically significant associations between health literacy/numeracy measures and mammogram screening for breast cancer. In multivariable analyses, there were no consistent patterns between health literacy/numeracy and screening for any cancer. There are some individual findings worth noting, such as statistically significant findings for health numeracy and FOBT (those reporting lower health numeracy were less likely to report FOBT). An important finding of this study is that questions used to assess health literacy/numeracy did not identify associations aligned with previous research. We reflect on the ways the "standard" questions may not be sufficiently tailored to the Zuni experience and may contribute to health equity barriers.

Social determinants of the Latinx diabetes health disparity: A Oaxaca-Blinder decomposition analysis

Latinx people living in the U.S. report a disproportionately high prevalence of diabetes. This project builds on the existing social determinants of diabetes literature by examining factors associated with a greater likelihood of diabetes and investigates factors correlated with the Latinx/non-Latinx disparity. This project studies the adult sample (18 and older) from the 2010–2018 IPUMS Health: National Health Interview Survey (NHIS) data. Logistic regression analyses are used to examine the patterns between reporting Latinx identity and reporting diabetes with additional subgroup analyses of the Latinx and non-Latinx groups. Then, Oaxaca-Blinder decomposition is used to examine the patterns explaining the difference in self-reported diabetes between the Latinx and non-Latinx population for the whole sample and by age group.

The logistic regression analyses show that after adjusting for age and other key social determinants of health, Latinx individuals are approximately 64.5% (OR 1.645, [95% CI, 1.536–1.760]) more likely to report being diagnosed with diabetes than non-Latinx individuals. Individual characteristics of age, race, and smoking behaviors are identified as suppressors of the gap, and conversely, characteristics of income, education, and BMI all contribute to the Latinx diabetes disparity gap. The Oaxaca-Blinder decomposition results show that the measured social determinants of health characteristics explain a meaningful amount of the Latinx diabetes gap. Importantly, differences in education and income (which are more immediately actionable policy areas) make larger contributions to the gap than BMI or other health behaviors.

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The Latinx diabetes disparity should always presented after adjusting for age.

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In the age-adjusted model, Latinx adults are 64.5% more likely to report diabetes.

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Oaxaca-Blinder decomposition analysis shows how factors such as income, education, and BMI drive the diabetes disparity.

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Income and education are identified as modifiable factors to be prioritized in policy interventions aimed at reducing the diabetes disparity.

Delivered from the Temptation of Smoking: An Examination of Religion and Health Behaviors of New US Immigrants

This study aims to contribute to the literature on smoking, religion, and health, by analyzing the associations between smoking and health of a sample of US immigrants, who represent many religions, ethnicities, and cultural backgrounds. Immigrants to the USA have better health outcomes than their native-born peers. This paper asserts that the pattern of smoking, influenced by immigrants' religion and religiosity, is key to understanding this phenomenon. This study investigates the relationship between religion and health of new legal immigrants to the USA by analyzing the New Immigrant Survey. The findings suggest that there is a protective relationship between immigrant religion and smoking patterns, both in likelihood of having ever smoked and in quitting smoking.

Protecting children's health in a calorie-surplus context: Household structure and child growth in the United States

Studies from the social and health sciences have tended to view the household as the locus of access to and distribution of care, resources, monitoring and modeling for children's wellbeing. Obesity may present a special case for the study of investments in children, being a component of health for which more of certain inputs may not lead to better outcomes. We expanded on common measures of household structure in the child health literature by considering co-residence and relatedness of parents, grandparents, other relatives, and other children. Data were from a longitudinal sample of 6,700 children participating in the Early Childhood Longitudinal Study Kindergarten Class of 1998-99 (ECLS-K), the largest U.S. national dataset with measures of child anthropometrics and household structure at seven time-points over nine years. We used lagged survey-adjusted regressions to estimate associations between household structure and subsequent changes in children's weight between ages 5 and 14 years in terms of BMI gain and incident obesity. Adjusting for household structure more thoroughly, children living in households with two parents rather than one parent did not experience advantages in terms of less excess weight gain or lower incidence of obesity during elementary and middle school. Children living with a grandmother gained more weight than children not living with a grandmother. Living with siblings and with non-related adults was associated with less weight gain. These findings corroborate a scenario in which, for health problems associated with caloric surplus, classic household factors have more complex associations with child wellbeing.

What Do We Rate When We Rate Our Health? Decomposing Age-related Contributions to Self-rated Health

Self-ratings of health (SRH) indicate current health-related quality of life and independently predict mortality. Studies show the SRH of older adults appears less influenced by physical health than the SRH of younger adults. But if physical health accounts less for the SRH of older adults, what factors take its place? To understand the relative contributions of social, emotional, and physical states to SRH by age, we analyzed data from the National Health Interview Survey 2006 to 2011 ( N = 153,341). In age-stratified regressions, physical health and functional limitations declined as correlates of SRH for older age strata, while social factors, such as gender and race, increased in importance. Oaxaca-Blinder decomposition showed that if younger respondents had similar health conditions, they would rate their health more poorly than current cohorts of older adults do. The declining influence of physical health on SRH in old age appears to be due in part to displacement by social factors.

Establishing the feasibility of assessing the mental health of children displaced by the Syrian conflict

BACKGROUND

In the humanitarian crisis context of conflict zones, collecting data is essential for identifying and addressing the mental health needs of refugee children to avoid mass suffering. This study tested the feasibility of recruiting refugees caring for children and using established and brief parent-report questionnaires in a challenging context to collect mental health data on refugee children displaced by Syria's conflict.

METHODS

Caregivers of 4-10-year olds attending primary schools run by non-governmental organisation (NGO) Generation Freedom in and near refugee camps on the Syrian-Turkish border were invited to complete the Pediatric Emotional Distress Scale (PEDS) and Strengths and Difficulties Questionnaire (SDQ).

RESULTS

It was possible to reach 144 adult refugees caring for children with research participation information and use informed consent procedures. A total of 106 caregivers completed the questionnaires yielding a good return rate (74%). Eighty-two (77.4%) caregivers had complete data on the PEDS and 61 (57.5%) on the SDQ. Almost half (49%) of the children met the clinical cut-off for being anxious/withdrawn and 62% for being fearful rated using the PEDS and 45% for SDQ rated emotional symptoms. More than a third had clinical levels of behavioural problems on both scales.

CONCLUSIONS

It proved feasible to collect child mental health data in challenging conditions in the context of the Syrian crisis with support from a local NGO providing humanitarian assistance. The PEDS performed better than the SDQ in this context. High levels of emotional distress and behavioural problems in children reiterate the urgent need for evidence-based psychosocial support.

Dynamic chemical equilibrium in a polar desert pond: a sensitive index of meteorological cycles

The dramatic variation in the composition of a brine pond in Antarctica is a seasonal phenomenon. The phase relations of salts in solution are such that hydrologic conditions and temperature determine composition during the austral summer. Temperature is the primary determinant of composition during the winter.

Physically active families - de-bunking the myth? A qualitative study of family participation in physical activity

BACKGROUND

The benefits of physical activity for reducing obesity and related chronic diseases are well known. The need for more family-based interventions to increase physical activity is frequently cited in the literature; however, little is known about if and how families are physically active together, and what factors might influence family-based participation in regular physical activity. This study examined the types of activities (physical and sedentary) engaged in as a family and explored parents' perceptions of the importance, frequency, nature and barriers to family physical activity.

METHODS

Semi-structured telephone interviews were conducted with 30 parents (26 female, four male) of 10- to 11-year-old schoolchildren who attended either low, middle or high socio-economic status schools in Bristol, UK. Interviews were transcribed verbatim, anonymized and analysed using conventional content analysis.

RESULTS

The majority of parents rated family engagement in physical activity as important, and identified benefits such as increased parent-child communication, spending time together, enjoyment, enhanced mental health, weight control and physical fitness. Despite these benefits most parents reported their families did little or no physical activity together as a family unit during the week, and any activities performed together were usually sedentary in nature. They reported increased family physical activity on the weekends but rarely including the full family unit simultaneously. Parents in two-parent households commonly paired off with one or more children because of complexities of schedules. Commonly reported barriers were busy lifestyles, diverse ages and interests of children and adults, bad weather, and lack of access to facilities, transportation and money to support activities.

CONCLUSIONS

Family-based interventions might be more effective if they are designed to accommodate the complex demands and needs of two-parent and single-parent families and provide affordable, diverse activities appealing to a wide range of interests.

Evaluation of a diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b vaccine given concurrently with meningococcal group C conjugate vaccine at 2, 3 and 4 months of age

BACKGROUND AND OBJECTIVE

In view of the possible introduction of diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b (DTaP-IPV-Hib, eg Pediacel) vaccine in the UK, a study of the immunogenicity of Pediacel when given with one of two different meningococcal group C conjugate (MCC) vaccines at 2, 3 and 4 months of age was conducted.

METHODS

Randomised controlled study in 241 infants.

RESULTS

Post vaccination, the proportion of infants with anti-polyribosylribitol phosphate (PRP) levels > or =0.15 microg/ml was 93.2% (95% confidence interval (CI) 86.6 to 96.7) in the Pediacel group compared with 100% (95% CI 96.4 to 100) in the diphtheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DTwP-Hib) group. The anti-PRP response was lower in infants receiving either Pediacel or DTwP-Hib when these vaccines were given concomitantly with meningococcal group C conjugate with diphtheria-derived protein CRM(197) as conjugate protein (MCC-CRM) compared with meningococcal group C conjugate with tetanus toxoid as conjugate protein (MCC-TT). For group C meningococcus, the proportion of infants with serum bactericidal antibody (SBA) titre > or =1:8 in the Pediacel group was 99.0% compared with 100% in the DTwP-Hib group. The MCC SBA geometric mean titre (GMT) was lower in those receiving Pediacel with MCC-TT than in those receiving DTwP-Hib with MCC-TT, although all titres were well above the protective threshold. The MCC SBA GMT was similar in those receiving Pediacel and DTwP-Hib and MCC-CRM. Responses to all other vaccine components were equivalent in the two groups.

CONCLUSIONS

Pediacel is immunogenic when given at 2, 3 and 4 months of age. Coadministration of MCC vaccine can influence the Hib response, and the MCC response to a tetanus conjugate can be influenced by the nature of the coadministered DTP-Hib vaccine.

Quality of in-hospital care for adults with acute bacterial meningitis: a national retrospective survey

BACKGROUND

Most adults with bacterial meningitis and meningococcal septicaemia present to junior doctors who have limited experience of these conditions. In contrast to paediatric practice, data from industrialized countries with regard to current hospital management practice are lacking.

AIM

To examine whether current practice meets recommended standards in hospital management of community-acquired bacterial meningitis and meningococcal septicaemia among adults.

DESIGN

National audit of medical records.

METHODS

We conducted a survey of all patients with acute bacterial meningitis and meningococcal septicaemia admitted to 18 randomly selected acute hospitals in England and Wales between 1 January 2000 and 31 December 2001. All stages of care, including pre-hospital management, initial hospital assessment, record keeping, and ongoing hospital and public health management, were assessed.

RESULTS

We identified 212 cases of bacterial meningitis and meningococcal septicaemia; 190 cases remained in the final analysis. Clinical record keeping did not meet acceptable standards in 33% of cases. Parenteral antibiotics were given within 1 h of hospital arrival in 56% of cases, increasing to 79% among those with an initial differential diagnosis that included bacterial meningitis or meningococcal septicaemia. A full severity of illness assessment was made in 27%. The quality of clinical practice varied widely between hospitals. This was most pronounced in the timeliness of consultant review (p < 0.0005).

DISCUSSION

The quality of adult clinical practice for bacterial meningitis and meningococcal septicaemia needs improvement. This study provides a tool for developing targeted interventions to improve quality of care and outcome among adults with life-threatening infections, both in the UK and in other countries.

How should general practitioners investigate suspected urinary tract infection? Variations in laboratory-confirmed bacteriuria in South West England

We analysed by age and sex the inter-laboratory variation in submission rates and positivity rates of urine samples from primary care that were submitted to seven microbiology laboratories within the South West of England. There was an almost twofold difference between the lowest and highest submission and positivity rates across all sex and age groups. This could not be accounted for by differences in population, age mix or numbers of nursing home beds. Increased submission in children will increase diagnosis of urinary tract infection (UTI). In contrast, over-investigation in other age groups increases laboratory and primary care costs and, in the asymptomatic elderly, may lead to unnecessary antibiotic treatment. Continued education is needed in primary care to improve the management of urinary symptoms. Laboratory-based studies of UTI are likely to underestimate the true incidence of this infection substantially. Standardised protocols for urine specimen submission are essential for practices and laboratories participating in surveillance of UTI and antibiotic resistance. In our discussion we offer seven recommendations for improving UTI investigation in general practice.

Yellow fever vaccine: a successful vaccination of an immunocompromised patient

We report on the successful vaccination of a patient, 21/2 yr after bone marrow transplantation for myeloma. He was not severely immunosupressed and responded to the yellow fever vaccine (17D, a live attenuated vaccine) without any adverse affects.

Prevalence of urinary catheterization in UK nursing homes

A postal questionnaire survey was undertaken in registered nursing homes in three different health districts in England: Gloucestershire, North Staffordshire and Leeds. Nursing homes may be registered as general nursing or mental health homes. If homes also have provision for residential beds these are defined as dual registered homes. Overall, 9% (438/4900) of residents, with an equal male:female split, had urinary catheters. There was no significant difference in the overall urinary catheterization rate in the three districts (P=0.9). There was a wide range of urinary catheterization prevalence between homes, with some homes of all three categories having no catheterized residents and several with a prevalence of over 40%. The wide range of prevalence may be due to differences in residents' underlying medical conditions or to differences in attitudes towards urinary catheterization by nursing home staff. Almost all homes (114/124, 92%) stated they had an infection control policy, but 31% (38/124) did not have a written policy on urinary catheter care. In view of the potential for morbidity, infection control policies should include a section on the care of urinary catheters and this should form part of the continuing training of nursing home staff.

Genetic analysis of capsular status of meningococcal carrier isolates

The meningococcal capsule is the primary virulence factor with systemic isolates requiring full expression of the capsule but with capability to down-regulate the capsule in order to invade. The meningococcal capsular operon is composed of a number of genes that are involved in capsular synthesis and transport. Differences in capsular synthesis genes may allow discrimination between meningococcal serogroups whereas absence of genes for either synthesis or transport imply that the meningococcus is unencapsulated. Although mechanisms such as slipped-strand mispairing and acquisition of insertion sequences have been demonstrated to be involved in regulation of capsular expression, few studies have addressed the mechanisms of capsular expression in carrier isolates. Following a community-based intervention programme for an outbreak of meningococcal disease, we collected meningococcal carrier isolates from the intervention area and control areas. We undertook genetic analysis of the capsular operon and the mechanisms of capsular regulation, together with an investigation of the potential of capsular genes to identify the genogroup of non-serogroupable isolates. Use of the siaD gene allowed the discrimination of 30/89 (34%) non-serogroupable isolates into B, C, W135 and Y with a siaA gene PCR permitting the characterization of a further 6 isolates whose capsules contained sialic acid. Slipped-strand mispairing was evident in only 4 of 13 genogroupable B isolates and the insertion sequence IS1301 was found in 2 of 36 siaA-positive isolates. Of 51 non-genogroupable isolates 25 (49%) were shown to be ctrA negative. There was a higher percentage of ctrA-positive isolates (P<0.001) amongst meningococcal strains obtained from those sampled in non-intervention schools than those sampled at intervention schools. The ctrA-negative isolates warrant further investigation of their genotypic organization since such avirulent strains may be important in conferring natural protection against invasive disease. We found that after mass antibiotic prophylaxis, recolonization occurs preferentially with non-pathogenic meningococcal strains. This as implications for assessment of the benefits of mass antibiotic and vaccination programmes for outbreak control. Previously expressed concerns of increased risk due to removal of protective ora may have been overstated.

How do microbiology consultants undertake their jobs? A survey of consultant time and tasks in South West England

AIMS

To measure the total consultant medical microbiologist (CMM) weekly workload, to identify time spent on different activities, and to differentiate those tasks that were viewed by a consensus of consultants as core activities from those that could be accorded a lower priority.

METHODS

A self administered questionnaire completed by consultant medical microbiologists in the Public Health Laboratory Service South West Group.

RESULTS

Reported hours worked by respondents ranged from 41 to 65 hours each week, excluding on call activities. Eleven of 20 respondents reported working in excess of 48 hours each week. There was no correlation between hours worked and laboratory workload as measured by numbers of specimens. Clinical liaison, result authorisation, infection control, and management activities took up most time. Working practices varied widely between individuals, partly reflecting their differing roles in the laboratory. A consensus was reached regarding the relative importance and priority of many regular CMM activities.

CONCLUSIONS

Consultant microbiologists can identify, with consensus, both high and lower priority activities in their daily practice. If such clinical priorities can be more widely agreed across the profession, this would provide a rational approach to workload control.

Workload and stress in consultant medical microbiologists and virologists: a questionnaire survey

AIMS

To document demography, changing workload patterns, job satisfaction, morale, and prevalence of stress and psychological morbidity among UK consultant medical microbiologists and virologists.

METHOD

A questionnaire survey of all identified UK practising consultant medical microbiologists and virologists (n= 464).

RESULTS

Among 367 respondents (79%), there were 33 virologists and at least 89 single handed consultants. Over half the respondents (58%) were working a 1 : 1 or 1 : 2 on call rota during the week and a similar proportion (51%) at weekends. Of all consultants (including those working part time), 56% were working more than 48 hours weekly. Working more than 48 hours weekly, and being on call 1 : 1 or 1 : 2 at weekends, were both independently associated with increased psychological morbidity. Those on call 1 : 1 or 1 : 2 at weekends were also more likely to have low or very low morale. Female consultants were more likely to have higher stress scores. More than half of the respondents (208 of 363; 57%) were making active financial provision to retire early, and 198 of 363 (55%) did not intend to work beyond the age of 60.

CONCLUSIONS

The long hours worked by many consultant microbiologists and virologists are in breach of the European Working Time Directive and are associated with a higher degree of psychological morbidity. For most consultants, the frequency of on call commitments is demanding and job satisfaction and morale have deteriorated. Urgent action is needed, particularly to support those working more than 48 hours each week and those on call at weekends 1 : 1 or 1 : 2. However, a major expansion of the consultant establishment cannot be achieved rapidly, and will be slowed further if early retirements become more frequent.

IgG antibody subclass responses determined by immunoblot in infants' sera following vaccination with a meningococcal recombinant hexavalent PorA OMV vaccine

The introduction of meningococcal serogroup C conjugate vaccines into the UK immunisation schedule has led to the decline of serogroup C disease in those vaccinated but there is no imminent vaccine solution for serogroup B disease. The PorA outer membrane protein (OMP) is a potential serogroup B vaccine candidate and an outer membrane vesicle (OMV) vaccine containing six different PorA OMPs (each representing a different serosubtype) has been evaluated in phase II trials with encouraging results. Little is known about the IgG subclass response to the various antigens contained within this vaccine. These responses are important due to the different half-lives and complement fixing abilities of these antibodies. In this study, immunoblotting was undertaken with infants' sera following either three or four doses of vaccine, and OMVs from six isogenic meningococcal strains differing only in their PorA serosubtype. Following either three or four doses of the vaccine, IgG(3) and IgG(1) subclass antibodies were induced to all six of the isogenic strains, although sera collected after four doses of vaccine showed stronger antibody levels. IgG(3) was found in more sera than IgG(1). For both sets of sera, the two isogenic strains expressing P1.5,2 and P1.5(c),10 induced stronger IgG subclass antibody responses than the other four meningococcal strains. The recombinant hexavalent PorA OMV vaccine stimulates both IgG(1) and IgG(3) subclass antibodies, the subclasses that are most effective in activating the complement system.

Evaluation of De-O-acetylated meningococcal C polysaccharide-tetanus toxoid conjugate vaccine in infancy: reactogenicity, immunogenicity, immunologic priming, and bactericidal activity against O-acetylated and De-O-acetylated serogroup C strains

The polysaccharide capsule of serogroup C Neisseria meningitidis (MenC) has been integral to vaccine development. Licensed MenC vaccines contain the O-acetylated (OAc+) form of polysaccharide. Some MenC strains have de-O-acetylated (OAc-) polysaccharide, which may affect antibody specificity and functional activity when used in a vaccine. We evaluated an OAc-MenC conjugate-tetanus toxoid conjugate (MCC-TT) vaccine given concomitantly with whole-cell diphtheria-tetanus-pertussis, Haemophilus influenzae type b, and oral polio immunization in 83 infants at 2, 3, and 4 months of age. Serum bactericidal activities (SBA) against OAc+ and OAc- MenC strains and OAc+ and OAc- polysaccharide-specific immunoglobulin G (IgG) levels were evaluated. MCC-TT vaccine was well tolerated. All infants produced SBA titers of > or = 8 after a single dose at 2 months of age. The SBA geometric mean titer for OAc+ strain C11 increased from 2.7 (95% confidence interval [CI] 2.2 to 3.2) to 320 (95% CI, 237 to 432), 773 (95% CI, 609 to 982), and 1,063 (95% CI, 856 to 1319) after one, two, and three doses of MCC-TT, respectively. OAc- IgG levels were twice as high as OAc+ IgG levels after the primary series of MCC-TT vaccine, and the SBA was significantly higher against the OAc- MenC strain. Antibody responses to booster vaccination with either OAc+ MenC polysaccharide vaccine (MACP) or a fourth dose of MCC-TT at 14 months of age provided evidence of immunologic memory. The acetylation status of the booster vaccine influenced the specificity of the response, with significantly higher OAc- IgG levels and SBA after MCC-TT vaccine compared to MACP vaccine but similar OAc+ antibody levels. MCC-TT vaccine is highly immunogenic and primes for immunologic memory against OAc+ and OAc- MenC strains in infancy.

Microbiology and laboratory diagnosis

In 1887, Anton Weichselbaum, a Viennese doctor, was the first to report the isolation of meningococci from patients with meningitis (1). Shortly after, came the first description of lumbar puncture in living patients (2), leading to the isolation of meningococci from acute cases of meningitis. Three years later, Kiefer grew meningococci from the nasopharynx of cases of meningococcal disease, and from their contacts (3), a finding of immense significance in advancing understanding of the epidemiology and pathogenesis of the disease. Early serological typing systems demonstrated that there were important differences between meningococci in terms of their virulence (4).

Ability of 3 different meningococcal C conjugate vaccines to induce immunologic memory after a single dose in UK toddlers

To test for immunologic memory after a single dose of meningococcal C conjugate (MCC) vaccine in toddlers, 226 children 12-18 months old were randomized to receive 1 of 3 MCC vaccines, with a C polysaccharide booster 6 months later. The protein conjugate was diphtheria mutant toxoid in 2 vaccines (MCC-CRM(197)) and was tetanus toxoid in the third (MCC-TT). One month after the MCC vaccines, 91%-100% of children had serum bactericidal antibody (SBA) titers > or =8, and 89%-100% had a > or =4-fold increase. Geometric mean titer (GMT) increased from <4 to 215 (95% confidence interval [CI], 166-279). MCC-TT induced higher SBA GMTs (P<.001) and higher proportions with SBA > or =8 (P=.02) than did the MCC-CRM(197) vaccines. By 6 months, GMTs had decreased to 55.1 (95% CI, 40-76), but IgG antibody avidity increased (P<.001). Induction of immunologic memory was confirmed by a GMT of 1977 (range, 1535-2547) after the polysaccharide booster and a further increase in avidity. This evidence justified the use of a single dose in a catch-up immunization program for children 1-18 years old.

Improved methods of detection of meningococcal DNA from oropharyngeal swabs from cases and contacts of meningococcal disease

In the UK the increasing use of pre-admission parenteral antibiotic therapy in meningococcal disease has lessened the value of routine cultures as a tool to confirm diagnosis, and laboratory confirmation of invasive meningococcal infection is achieved increasingly by non-culture, nucleic acid amplification methods. The purpose of this study was to evaluate a DNA extraction and meningococcal-specific DNA amplification methodology for detection of meningococci from oropharyngeal swabs. One hundred and six swabs from suspected or confirmed cases of meningococcal disease, and 94 swabs from contacts of meningococcal disease cases were examined. Of laboratory-confirmed cases, 38/65 (58.5%) yielded a positive oropharyngeal swab PCR result and 5/24 (20.8%) swabs from suspected but laboratory-unconfirmed cases were PCR positive. No significant differences in PCR positivity rates were found between the types of swab transport systems utilized, but transport time to the testing laboratory was found to affect PCR positivity (P < 0.05). Application of meningococcus-specific PCR to oropharyngeal swabs, in addition to routine culture of swabs, can provide valuable epidemiological information as well as case confirmation for contact management. PCR amplification of meningococcal PCR from oropharyngeal swabs will also increase the ascertainment in swabbing surveys carried out as part of meningococcal disease outbreak investigation and management.

Immunogenicity and reactogenicity of a pneumococcal conjugate vaccine administered combined with a haemophilus influenzae type B conjugate vaccine in United Kingdom infants

BACKGROUND

Streptococcus pneumoniae is a major disease burden in young children and the incidence of antibiotic-resistant pneumococcal strains is increasing. Multivalent pneumococcal saccharide-protein conjugate vaccines have recently been developed.

OBJECTIVES

To assess the immunogenicity and reactogenicity of a 7-valent pneumococcal conjugate vaccine (7VPnC) administered as a separate injection or as a combined injection with Haemophilus influenzae type b vaccine (HbOC) at 2, 3 and 4 months of age.

METHODS

Randomized controlled trial of 368 healthy UK infants receiving routine vaccines only (control group), routine vaccines and 7VPnC as a separate injection (separate group), or routine vaccines and 7VPnC combined with HbOC (combined group) at 2, 3 and 4 months. The control group received 7VPnC at 5, 6 and 7 months. All groups received pneumococcal polysaccharide vaccine at 13 to 16 months. Anticapsular IgG antibodies to 7VPnC serotypes were measured at 2, 5, 13 and 14 months and safety data collected.

RESULTS

IgG antibody concentrations at 5 months were higher in the two treatment groups compared with the controls for all 7VPnC serotypes (P < 0.001) and higher in the separate group than the combined group for five 7VPnC serotypes (P < 0.05). For both treatment groups antibody concentrations were higher at 14 months (range, 6.6 to 25.3 microg/ml) than at 5 months (range, 0.6 to 2.5 microg/ml) for all 7VPnC serotypes (P < 0.001).

CONCLUSION

7VPnC was well-tolerated, safe and immunogenic when administered as a separate or as a combined 7VPnC/HbOC injection. Although antibody responses were lower in the infants who received the combination compared with those who received 7VPnC as a separate injection, marked anamnestic responses to polysaccharide challenge were observed, suggesting that both groups were immunologically primed.

Invasive Haemophilus influenzae disease in adults

We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascertained from reference laboratory records and notifications from five NHS regions over the 5 years from 1 October 1990, a period encompassing the introduction of routine Hib childhood immunization (October 1992). A total of 446 cases were identified, a rate of 0.73 infections per 10(5) adults per annum. Though numbers of Hib infections in adults fell after the introduction of Hib vaccines for children (P = 0.035), and there was no increase in infections caused by other capsulated Hi serotypes, total numbers of invasive Hi infections increased due to a large rise in infections caused by non-capsulated Hi (ncHi) strains (P = 0.0067). There was an unexpectedly low rate of infections in those aged 75 years or more (P < 0.0001). The commonest clinical presentations were pneumonia with bacteraemia (227/350, 65%) and bacteraemia alone (62/350, 18%) and the highest rates of disease were in the 65-74 years age group (P < 0.0001). Clinical presentation was not influenced by the capsulation status of the invading Hi strain. 103/350 cases (29%) died within 1 month, and 207/350 (59%) within 6 months of their Hi infection. Case fatality rates were high in all age groups. Pre-existing diseases were noted in 220/350 cases and were associated with a higher case fatality rate (82% vs. 21%, P < 0.0001). After the introduction of Hib immunization in children, invasive Hib infections in unimmunized adults also declined, but the overall rate of invasive Hi disease in adults increased, with most infections now caused by non-capsulated strains. Physicians and microbiologists should be aware of the changing epidemiology, the high associated mortality and high risk of underlying disease. Invasive haemophilus infections in adults should be investigated and treated aggressively.

Serum sialic acid in young type-1 diabetic patients

It is well established that serum total sialic acid (TSA) is elevated in patients with type-2 diabetes mellitus (NIDDM) compared to non-diabetics. However, it is not clear whether serum TSA is also elevated in type-1 diabetic patients (IDDM). Twenty-one type-1 patients were studied along with age and sex matched normal non-diabetic subjects (ten males and 11 females). Their ages were 24.8+/-3.4 years (20-30) and 23.5+/-3.9 years (18-30) respectively. The duration of diabetes mellitus was 12.6+/-6.7 years (1-24) with a HBA1c of 9.0+/-2.2% (6.0-14.9). There was no significant difference in serum TSA of the type-1 diabetic patients 689+/-107 mg/l versus 670+/-119 mg/l in the normal subjects. Nor was there a significant correlation between serum TSA with patient age (r = -0.31), urine albumin/creatinine ratio (ACR) (r = 0.25), HBA1c (r = 0.36), plasma random glucose (r = -0.04) or diabetes duration (r = -0.09) in the diabetic patients. However, there was a significant correlation between serum TSA and mean daily insulin dose (r = 0.51, P<0.02) and also serum cholesterol and triglyceride (r = 0.58, P<0.01 and r = 0.49, P<0.04, respectively) in the type-1 diabetic patients. In summary, we conclude that serum TSA is not elevated in young type-1 diabetic patients compared with normal age and sex matched control subjects. However, the relationship between serum TSA and serum lipids and also mean daily insulin dose merits further research.

A secondary school outbreak of mumps following the childhood immunization programme in England and Wales

Since the introduction of routine measles, mumps and rubella immunization for children in England and Wales in 1988, the incidence of mumps has declined steadily. We describe an outbreak of mumps in 1996 attacking 34 of a cohort of 98 schoolchildren born in 1982 and 1983. This is the largest outbreak in the UK since the introduction of the vaccine into the childhood immunization schedule. Salivary IgM assay was used as a simple, minimally invasive test to confirm the diagnosis. The occurrence of the outbreak demonstrates that British children who were just too old to receive mumps immunization in 1988 continue to be at risk of this disease as a result of diminished natural exposure. Further cases and outbreaks in this cohort are to be expected. Cohorts born before 1982 appear to be at less risk, presumably because of naturally acquired infection before the introduction of immunization.

Mathematical modelling of infection and disease due to Neisseria meningitidis and Neisseria lactamica

BACKGROUND

Invasive meningococcal disease, due to Neisseria meningitidis, is an important cause of morbidity and mortality in young children and adolescents. Nasopharyngeal carriage of meningococci (MC), is most prevalent in young adults whereas carriage of Neisseria lactamica (LC), a related non-pathogenic organism, is most prevalent in young children. The objective of this study was to use modelling techniques to test hypotheses on the processes that govern the incidence of meningococcal disease (MD).

METHODS

Deterministic compartmental models were fitted to age structured data sets of MC, LC and MD.

RESULTS

The model most consistent with the available data sets is one where LC inhibits MC, an inhibition that lasts for a mean of 4.7 years. The hypothesis that LC also acts as a natural immunogen against MD was consistent with this model. The second peak of MD observed among adolescents could be due to the peak in the acquisition of MC in this age group.

CONCLUSIONS

The role of LC as a natural immunogen against asymptomatic and symptomatic meningococcal infection was consistent with available field data. If the introduction of novel meningococcal vaccines into a population changes the prevalence of MC or LC, this could have a substantial impact on the effectiveness of immunization programmes. This paper demonstrates the potential utility of modelling to estimate these effects.

Design and baseline characteristics for the aminoguanidine Clinical Trial in Overt Type 2 Diabetic Nephropathy (ACTION II)

Advanced glycosylation endproduct (AGE) formation has been implicated in the development and progression of nephropathy in type 2 diabetes mellitus. In diabetic animals, aminoguanidine inhibits AGE-mediated cross-linking of proteins in vascular and renal tissue and slows the progression of renal disease. ACTION II is a randomized, double-blind, placebo-controlled trial comparing two dose levels of aminoguanidine with placebo on the progression of nephropathy in 599 type 2 diabetic patients with renal disease from 84 centers in the United States and Canada. The primary endpoint is time to doubling of serum creatinine concentration. Secondary endpoints include the effect of aminoguanidine on time to all-cause mortality, end-stage renal disease (ESRD), cardiovascular morbidity and mortality, rate of change in indices of renal function (iothalamate, Cockcroft and Gault [C&G] calculated creatinine and measured creatinine clearances), proteinuria, retinopathy, circulating and urinary AGE levels, and estimation of the relationship between plasma aminoguanidine concentrations and primary and secondary efficacy endpoints and adverse events. Progression of macrovascular disease was monitored and fundus photography performed. Type 2 diabetic patients aged 30 to 70 years were eligible for the trial if their blood pressure was < or =180 mm Hg systolic and < or =120 mm Hg diastolic, serum creatinine concentration > or =1.0 mg/dL (in women) or > or =1.2 mg/dL (in men), C&G clearance > or =40 mL/min, and proteinuria > or =500 mg/d with diabetic retinopathy or diabetic nephropathy on renal biopsy. Recruitment began in July 1995 and terminated in December 1996. The trial randomized a total of 599 subjects. At baseline, the mean (standard deviation [SD]) age was 58 (7.7) years, diabetes duration 16.5 (7.5) years, body mass index 32 kg/m2 (10-90% range 2642), arterial blood pressure 105 (12) mm Hg, C-peptide concentration 2.55 (1.71) ng/mL, serum glucose concentration 201 (89) mg/dL, hemoglobin A1c 8.7% (1.6), serum creatinine concentration 1.6 (0.5) mg/dL, iothalamate clearance 52 (25) mL/min/1.73 m2, proteinuria 4.1 (4.2) g/d, triglycerides 259 (214) mg/dL, and LDL cholesterol 144 (40) mg/dL. Patients are 72% male, 68% white, 16% black, and 16% Asian American and Native American. At baseline, 76% were receiving concomitant angiotensin-converting enzyme (ACE) inhibitors and 43% lipid-lowering agents. Follow-up in ACTION II was scheduled to continue through December 1998, so that follow-up was to be 2 years after the date of randomization of the final enrolled patient. The trial in fact ended in March 1998. This trial will contribute to our understanding of the natural history of type 2 diabetes mellitus-associated nephropathy and determine whether aminoguanidine will slow the progression of established diabetic renal disease.

Salivary antibodies following parenteral immunization of infants with a meningococcal serogroup A and C conjugated vaccine

Bacterial and viral salivary antibody testing is proving sensitive and specific, useful for epidemiological studies, and is simple and non-invasive. Salivary serogroup C polysaccharide-specific (SC PS-S) IgA and IgG were determined as a proportion of total salivary IgA and IgG in a group of UK infants who were recipients of a conjugated A/C meningococcal PS vaccine. Geometric mean concentrations (GMCs) of salivary SC PS-S IgG per mg of total IgG (microg/mg) were 0.1 pre-vaccination, rising to 8.2 post first, 16.1 post second and 29.3 post third dose of vaccine. For IgA, the corresponding GMCs in ng/mg were 0.1, 82.8, 69.6 and 91.2. Significant correlations (P < 0.0001) were found between serum Ig and salivary IgG SC PS-S antibody for pre-vaccine and 1 month post each dose of vaccine suggesting that SC PS-S IgG in saliva was largely derived from serum. Of the five infants whose sera were analysed for isotype-specific responses, only traces of IgM and IgA were measurable suggesting that the SC PS-S IgA was locally produced. These findings suggests that the widespread use of meningococcal conjugate vaccines is likely to reduce nasopharyngeal carriage and may thereby induce herd immunity in the vaccinated population.

Immunogenicity and reactogenicity in UK infants of a novel meningococcal vesicle vaccine containing multiple class 1 (PorA) outer membrane proteins

The development of effective vaccines against serogroup B meningococci is of great public health importance. We assessed a novel genetically engineered vaccine containing six meningococcal class 1 (PorA) outer membrane proteins representing 80% of prevalent strains in the UK. 103 infants were given the meningococcal vaccine at ages 2, 3 and 4 months with routine infant immunisations, with a fourth dose at 12-18 months. The vaccine was well tolerated. Three doses evoked good immune responses to two of six meningococcal strains expressing PorA proteins contained in the vaccine. Following a fourth dose, larger bactericidal responses to all six strains were observed, suggesting that the initial course had primed memory lymphocytes and revaccination stimulated a booster response. This hexavalent PorA meningococcal vaccine was safe and evoked encouraging immune responses in infants. Vaccines of this type warrant further development and evaluation.

Meningococcal serogroup C conjugate vaccine is immunogenic in infancy and primes for memory

The safety, immunogenicity, and immunologic priming of 2 dosages (2 microgram or 10 microgram) of a meningococcal C oligosaccharide-CRM197 conjugate vaccine was evaluated in 114 infants vaccinated at ages 2, 3, and 4 months. Antibody persistence and response to boosting with 10 microgram of meningococcal C polysaccharide were assessed. The meningococcal conjugate vaccine produced fewer local reactions than concurrent routine immunizations. Total serogroup C-specific immunoglobulin geometric mean concentration (GMC) increased from 0.3 microgram/mL before vaccination to 13.1 microgram/mL at age 5 months. Serum bactericidal antibody (SBA) geometric mean titers (GMTs) rose from <1:4 to 1:1057 at 5 months and fell by 14 months to 1:19. Following boosting, anti-C-specific immunoglobulin GMC rose to 15.9 microgram/mL and SBA GMT to 1:495. Antibody responses in the 10-microgram dose cohort were significantly higher at 5 months (P<.01) than in the 2-microgram dose cohort but were lower after polysaccharide boosting (P=.02). This meningococcal conjugate vaccine was well tolerated and immunogenic and induced immunologic memory in infants.

Acquisition and carriage of meningococci in marine commando recruits

Meningococcal acquisition is a prerequisite for invasive disease. Three hundred and eleven male marine commando recruits were studied throughout 29 weeks of basic training to identify factors influencing meningococcal carriage and acquisition including troop number, season, smoking, respiratory infection, antibiotic usage and nasopharyngeal bacterial interference flora. A high carriage rate on entry to training (118/311, 37.9%) and subsequent sustained high rates of meningococcal acquisition were found. Of the potential factors examined, only active and passive smoking were found to be associated significantly with meningococcal carriage on entry. The association between active smoking and meningococcal carriage was dose-dependent, with odds ratios (OR) of 2.2 (95% CIs 1.0-4.8) and 7.2 (95% CIs 2.3-22.9) for light and heavy smokers respectively. Passive smoking predisposed independently to carriage (OR 1.8, 95% CIs 1.1-3.0). Active and passive smoking combined to give an attributable risk for meningococcal carriage of 33%. In contrast, despite a high and sustained rate of meningococcal acquisition in the study population, none of the risk factors investigated, including active smoking, was associated significantly with meningococcal acquisition. No cases of meningococcal disease occurred during the 16-month study period. Therefore smoking may increase the duration of meningococcal carriage rather than the rate of acquisition, consistent with the increased risk of meningococcal disease from passive as opposed to active smoking. Public health measures that reduce the prevalence of smoking should reduce the risk of meningococcal disease.