Research needs, environmental concerns, and logistical considerations for incorporating livestock grazing into coastal upland habitat management

Along the Gulf of Mexico (GoM) coast, natural resource managers continually struggle with managing coastal uplands due to front-end costs, prolonged maintenance, and habitat-specific ecological needs. Prescribed fire, mechanical removal, and chemical treatments are common habitat management techniques used to remove invasive species, clear understory, and achieve other management goals. However, rapid development and changing climate exacerbate the difficulty in using these techniques. A potential alternative or complementary technique is using livestock for habitat management (i.e., targeted or controlled grazing). In other regions of the world, using livestock for conservation or restoration of managed lands has shown to be a less intrusive and more financially viable alternative. To better understand the research needs, logistical, and environmental concerns related to using livestock for habitat management in the coastal uplands of the GoM, we developed and distributed a survey to three groups of land users, including natural resource managers, researchers, and livestock producers in the region. Survey results show that over 96% of respondents are interested in using livestock for habitat management, but less than 10% of respondents were aware of any information that could be used to inform grazing practices for coastal upland habitat management along the Gulf of Mexico coast. There were differences among surveyed groups, but generally small-sized cattle breeds and goats were identified as the livestock with the most potential for environmental benefit and ease of containment. General concerns and areas for further investigation were implementation (e.g., which livestock type to use and grazing intensity), logistical considerations (e.g., fencing and rotational frequency), impacts of grazing on water quality, wildlife, vegetation, and livestock nutrition. Survey respondents overwhelmingly (at least 75% of each group) indicated that livestock grazing ideally would not be a standalone management practice and should be used in conjunction with other habitat management techniques such as prescribed burns, mechanical clearing, or chemical treatments. The results of the survey could be used to develop applied research projects and guidance documents that directly address informational needs related to using livestock for habitat management of coastal uplands along the Gulf of Mexico coast.

1039. Clinical and Economic Impact of COVID-19 and Serologic Protection among Farm Workers: Results from the Guatemala Agricultural Workers and Respiratory Illness Impact (AGRI) Study

Background

In the Guatemala AGricultural workers and Respiratory Impact (AGRI) study, we evaluated the clinical and socioeconomic burdens of respiratory disease in a cohort of Guatemalan banana farm workers.

Methods

All eligible workers were offered enrollment from June 15–December 30, 2020, and annually, then followed for influenza-like illnesses (ILI) through: 1) self-reporting to study nurses, 2) sentinel surveillance at health posts, and 3) absenteeism. Workers with ILI submitted nasopharyngeal swabs for influenza, RSV, and SARS-CoV-2 testing, then completed surveys at days 0, 7, and 28. Enrollment and acute-illness serum samples were tested for anti-SARS-CoV-2 nucleocapsid IgG (anti-N, Roche Elecsys^®), and neutralizing antibodies (NAb) were tested in a subset using a lentivirus-based pseudovirion assay.

Results

Through October 10, 2021, 1,833 workers were enrolled. The majority were male (84%), young (mean 31 years), and healthy (< 13% had comorbidity). Through October 10, 2021, 1,833 workers developed 169 ILIs (12.0/100 person-years) and 43 (25.4%) of these ILIs were laboratory-confirmed SARS-CoV-2 (3.1/100 person-years). Workers with SARS-CoV-2-positive ILI reported more anosmia (p< 0.01), dysgeusia (p< 0.01), difficulty concentrating (p=0.01), and irritability (p=0.01), and greater clinical and well-being severity scores (Flu-iiQ) than test-negative ILIs (Fig 1); they also had greater absenteeism (p< 0.01) and lost income (median US$127.1, p< 0.01). Among 1334 workers enrolled in 2020, 616 (46.2%) had anti-N IgG suggestive of prior SARS-CoV-2 infection. COVID-19 incidence density for IgG-seropositive workers was 0.4/100 Person – Years (P – Y), lower than those who were seronegative (2.3/100 P – Y) (Fig 2). At enrollment, anti-N IgG titers in serum correlated with neutralizing antibody titers (R²=0.26, p< 0.0001). Notably, in < 6 months from enrollment, most workers with follow-up NAb testing (65/77, 84%) exhibited a 95% decrease in neutralizing antibody titers.

Conclusion

Guatemalan farm workers suffered a significant burden of COVID-19, including more severe clinical and economic outcomes than other respiratory illnesses. Ongoing vaccination programs and longitudinal serology will provide additional insight into long-term immunity.

Disclosures

Daniel Olson, MD, Pfizer: Grant/Research Support|Roche: Grant/Research Support Diva M Calvimontes, MD, Pfizer: Grant/Research Support Molly Lamb, PhD, Pfizer: Grant/Research Support Edwards Kathryn, MD, Bionet: Advisor/Consultant|IBM: Advisor/Consultant|Merck: Data Monitoring Committee|Moderna: Data Monitoring Committee|Pfizer: Data Monitoring Committee|Roche: Data Monitoring Committee|Sanofi: Data Monitoring Committee|Seqirus: Data Monitoring Committee|X-4 Pharma: Data Monitoring Committee Edwin J. Asturias, MD, Curevac: DSMB Member|Fundacion para la Salud Integral de los Guatemaltecos: Board Member|Inovio: DSMB Member|Merck: Honoraria|Pfizer: Grant/Research Support.

314. Performance of Saliva Compared to Nasopharyngeal Swab in Detection of SARS-CoV-2 at a Field Site in Rural Guatemala Using the Roche Cobas® Liat® Point-of-Care Assay

Background

Saliva samples are less invasive but not considered the gold standard for detecting SARS-CoV-2, and they are not validated for the Roche Cobas® Liat® platform. We aimed to evaluate the performance of a saliva sample compared to nasopharyngeal (NP) swab in the detection of SARS-CoV-2 on the Roche Cobas® Liat® platform at a research site in rural Guatemala.

Methods

Adults in an existing cohort study with influenza-like illness (ILI) provided clinical data and underwent NP swab (Copan) collection by trained nurses. Swabs were immediately placed into universal transport media (UTM), stored at 2-8 °C for less than 30 minutes and then tested on the Cobas Liat platform for SARS-CoV-2. Consenting subjects who had not eaten or drank in the last 2 hours were asked to provide a 5-mL saliva sample directly into an RNAse free container. The saliva sample remained at 2-8 °C for 24 hours, then diluted 1:2 with 0.85% saline (to reduce viscosity) and run on the same assay. We used descriptive statistics to compare the performance of saliva to NP swabs.

Results

Of the 28 subjects screened (1/10/22 - 4/26/22), 23 (82%) were consented and enrolled. The majority of subjects were male (78.3%) with a mean age of 31 years (range: 18-59 years). Of the 23 subjects enrolled, 14 (30.4%) reported fever and cough, 16 (34.8%) reported cough only, 14 (30.4%) reported fever only, and 2 (4.3%) reported cough and nasal congestion. The median symptom duration was 3.0 days (IQR: 1.5-5 days). Of the 23 subjects, 5 (23.7%) tested positive for SARS-CoV-2 in both sample types (NP swab and saliva); 3 (13%) were discordant, including 1 (4.3%) saliva-positive only and 2 (8.7%) NP-positive only. Compared to NP swab, preliminary performance of saliva in detection of SARS-CoV-2 included a sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 71.4%, 93.7%, 87%, 83.3%, and 88.2%, respectively. The Fisher’s exact test p-value (0.003) shows concordance between both tests.

Conclusion

Our preliminary results show good precision between NP and saliva samples in detection of SARS-CoV-2 on the Roche Cobas® Liat® platform. Ongoing data collection will provide greater insight on the discordant results, but our findings support the continued use of saliva in the detection of SARS-CoV-2 in this population.

Disclosures

Molly Lamb, PhD, Pfizer: Grant/Research Support Edwin J. Asturias, MD, Curevac: DSMB Member|Fundacion para la Salud Integral de los Guatemaltecos: Board Member|Inovio: DSMB Member|Merck: Honoraria|Pfizer: Grant/Research Support Diva Calvimontes, n/a, Pfizer: Grant/Research Support Daniel Olson, MD, Fundacion para la Salud Integral de los Guatemaltecos: Board Member|Pfizer: Grant/Research Support|Roche: Grant/Research Support.

Office "Phone First" Systems Reduce Emergency Department/Urgent Care Utilization by Medicaid-Enrolled Children

BACKGROUND

Emergency department and urgent care (ED/UC) visits for common conditions can be more expensive with less continuity than office care provided by primary care physicians.

METHODS

We used quality-improvement methods to enhance telephone triage for pediatric patients by adding additional "Phone First" services including: 1) enhanced office-hours telephone triage and advice with available same-day appointments, 2) follow-up calls to parents of children self-referred to an ED/UC, and 3) parent education to telephone the office for advice prior to seeking acute care. We hypothesized that enhanced office services would reduce ED/UC utilization and cost. We compared changes in ED/UC encounter rates between intervention and regional practices for 4 years (2014-2017) using general linear models, and evaluated balancing measures (after-hour phone calls, acute care phone calls, acute care visits, well child visits) for Medicaid-enrolled and commercially-insured children.

RESULTS

The study practices dramatically increased office-hours acute care phone triage and advice which correlated with 23.8% to 80.5% (P < 0.001) reductions in ED/UC rates for Medicaid-enrolled children. Office acute care visits decreased modestly. ED/UC visits did not decrease for children in the comparison region. In phone surveys, 94% of parents indicated satisfaction with the ED/UC follow-up call. The decrease in ED/UC visits resulted in an estimated annual cost of care savings for Medicaid-enrolled children in 2017 of $12.61 per member per month which projected to $169 million cost of care savings in Colorado and $6.8 billion in the United States.

CONCLUSION

"Phone First" services in pediatric practices during office-hours reduced ED/UC encounters and cost of care for Medicaid-enrolled children.

Reassessing the Value of CSF Protein and Glucose Measurement in Pediatric Infectious Meningitis

OBJECTIVES

Infectious meningitis (IM) in US children is increasingly rare and new rapid multiplex PCR-based testing is increasingly available. We evaluated the added value of cerebrospinal fluid (CSF) protein and glucose tests to predict IM when compared with information provided by CSF white blood cell count (WBC) and multiplex polymerase chain reaction (PCR).

METHODS

We retrospectively reviewed CSF results from October 2015 to August 2017 in patients 0 to 18 years at a US children's hospital. Noninfectious evaluations were excluded. Test characteristics were calculated for CSF WBC, protein, and glucose in isolation and in parallel for prediction of microbiologically confirmed IM. Chart review was performed to identify consideration of protein and glucose in medical decision-making (MDM).

RESULTS

We identified 735 patients including 446 <2 months; 45 (6.1%) had microbiologically-confirmed IM, including 23 (5.2%) age <2 months. Multiplex PCR and/or CSF WBC identified all IM patients. When added to CSF WBC, measurement of glucose made no contribution to sensitivity, specificity, positive predictive value (PPV) or negative predictive value (NPV), and protein had no impact on sensitivity and decreased the specificity, PPV, and NPV compared with CSF WBC alone. Abnormal protein was documented in MDM in 6 (0.8%) patients, all of whom had elevated WBC counts also cited. Glucose was not mentioned in MDM.

CONCLUSIONS

Multiplex PCR testing and WBC may be sufficient to predict meningitis in children in low incidence settings. Protein and glucose did not contribute significant additional information. More intentional use of protein and glucose testing in patients with suspected IM may achieve higher value care.

Malaria Is Associated With Kaposi Sarcoma-Associated Herpesvirus Seroconversion in a Cohort of Western Kenyan Children

BACKGROUND

We aimed to determine whether Plasmodium falciparum infection affects age of Kaposi sarcoma-associated herpesvirus (KSHV) seroconversion in Kenyan children.

METHODS

Kenyan children (n = 144) enrolled at age 1 month, from 2 sites with different levels of malaria transmission (stable/high vs unstable/low) were followed to age 24 months. Plasma was tested for KSHV antibodies using enzyme-linked immunosorbent assay (ELISA; K8.1 and LANA) and a multiplex bead-based assay (K8.1, K10.5, ORF38, ORF50, and LANA) and whole blood tested for P. falciparum DNA using quantitative PCR. Cox proportional hazards models were used to assess associations between P. falciparum DNA detection, malaria annualized rate (P. falciparum detections/person-years), and enrollment site (malaria-high vs malaria-low) with time to KSHV seroconversion.

RESULTS

KSHV seroprevalence was 63% by age 2 years when assessed by multiplex assay. Children with P. falciparum were at increased hazards of earlier KSHV seroconversion and, among children with malaria, the hazard of becoming KSHV seropositive increased significantly with increasing malaria annualized rate. Children from the malaria-high transmission region had no significant difference in hazards of KSHV seroconversion at 12 months but were more likely to become KSHV seropositive by age 24 months.

DISCUSSION

Malaria exposure increases the risk for KSHV seroconversion early in life.

757. Association between cumulative febrile, respiratory and diarrheal illness in the first year of life and neurodevelopmental and growth outcomes among a cohort of children in rural Guatemala

Background

Recurrent infections are associated with neurodevelopmental (ND) delay in infants, but the primary drivers are poorly understood. Leveraging an infant cohort from rural Guatemala designed to evaluate the effects of post-natal Zika virus on ND (DMID 16-0057), we evaluated the association between cumulative illness and ND delay and stunting.

Methods

Infants enrolled at 0-3 months of age underwent weekly at-home surveillance for caregiver-reported syndromic illness, including cough, fever and vomiting/diarrhea for a 12-month period. Anthropometric assessments and ND testing by Guatemalan psychologists using the Mullen Scales of Early Learning (MSEL) were perforrmed at 12-15 months of age. Multivariable generalized linear regression models were used to test associations between syndromic illness in infancy, 12-15-month MSEL Early Learning Composite (ELC) Score, and stunting (height-for-age &lt; -2 SD) at 12-15 months.

Results

The cohort (n=425) had a mean enrollment age of 1.3 months; 202 (48%) were female, 387 (91%) self-reported a literate mother, and 301 (71%) were breastfeeding at study completion. Infants had reported illness for a median of 16 weeks during the surveillance period; cough was reported most frequently (median=11 weeks, range=0-37 weeks). Lower maternal education (p=0.007) and literacy (p=0.002) as well as infant age (p=0.007) and male gender (p=0.004) were associated with MSEL ELC Score &lt;85 (-1 SD). After adjusting for gender, breastfeeding, age, and maternal literacy, the cumulative number of weeks with reported cough (p=0.0009), fever (p=0.0001), or any syndromic illness (p=0.0007) were associated with decreased 12-month MSEL ECL Score; there was no association with diarrhea/vomiting (p=0.36). There was no association between caregiver-reported syndromic illnesses (any type) and stunting at final study visit.

Conclusion

In a cohort of Guatemalan infants, cumulative fever and cough episodes were significantly associated with lower MSEL ELC Score, whereas there was no association with diarrhea/vomiting. In this low-resource community, these findings highlight the potential negative ND consequences of febrile illness and persistent cough in the first year of life. NIAID Contract HHSN272201300015I Task Order HHSN27200013 (Co-PIs: FMM and EJA).

Disclosures

Molly Lamb, PhD, BioFire (Grant/Research Support) Evan J. Anderson, MD, Sanofi Pasteur (Scientific Research Study Investigator)

684. The impact of rapid molecular respiratory testing on provider and parental decision making for children with respiratory illness evaluated in an ED setting

Background

Rapid respiratory testing (RRT) can decrease ancillary testing, length of stay and antibiotic use for hospitalized children. Less is known regarding the impact of RRT in the emergency department (ED).

Our objectives were to determine if RRT impacts ED provider clinical decision making, family acceptance, and subsequent healthcare visitation for children with influenza-like illness (ILI).

Methods

Randomized controlled trial of children 1 month-18 years of age presenting to a tertiary care pediatric ED with ILI. All children received a nasopharyngeal swab and RRT and were randomized to the intervention group (RRT result given to clinicians/families) or control group (results not available unless obtained clinically). Outcomes included provider decision-making (anti-infective prescribing, ED diagnostic testing, disposition), family acceptance of RRT (willingness to undergo future testing) and repeat healthcare visits (clinic or ED). Providers in the intervention group were surveyed after RRT results were available, and families in both arms were contacted 1 and 10 days later.

Results

There were 920 ED visits from 908 enrolled children; 629 (68%) families from both arms and 443 (96%) providers from the intervention arm completed surveys. Most providers (33%) were ED trained and < 5 years post-training (37%). Clinical decisions were changed in 17% of visits based on RRT results, most commonly by ED trained physicians, advanced practice providers, and those < 5 years post-training (Table). The most common decision changes were antiviral use and avoidance of diagnostic tests (Figure). Families were more willing to undergo future RRT if they were in the intervention group, or if RRT results were available in 20 minutes. In the control arm, 22 families (7%) stated they would not have sought additional medical visits if RRT results were available. In the intervention group, 20 families (6.7%) reported that the RRT influenced how their child received care, and 14 families (17%) sought additional care due to RRT results.

Figure. Provider Clinical Decision Making Based on Results of Rapid Respiratory Testing, n = 443

Characteristics of providers and patients by provider decision type

Conclusion

RRT impacts clinical decision making for 1 in 5 ED visits, specifically antiviral prescribing and reduced diagnostic testing. Most families were in favor of RRT, which impacts additional health care visits after the ED encounter.

Disclosures

Suchitra Rao, MD, BioFire (Grant/Research Support) Molly Lamb, PhD, BioFire (Grant/Research Support) Rakesh Mistry, MD, MSCE, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

1407. Cytomegalovirus (CMV) infection in the first year of life in a cohort of infants in rural Guatemala

Background

Little is known about the epidemiology of Cytomegalovirus (CMV) infection in low resource countries. We evaluated the frequency and effects of post-natal CMV infection in infants from a prospective cohort study designed to assess the effects of post-natal Zika on neurodevelopment (ND) in rural Guatemala.

Infants with CMV infection (blue bars) were older compared CMV-negative (red bars) infants.

Methods

Infants were evaluated for CMV infection by PCR using urine samples collected at 0-3 months of age. ND testing was conducted by local psychologists using a culturally adapted Mullen Scales of Early Learning (MSEL). We explored associations between CMV infection and microcephaly, neurological, visual and hearing deficits, malnutrition and ND outcomes at 1 year of age.

Results

The infant cohort (N = 469) had a mean age at enrollment of 1.5 (SD 0.75) months; 47% were female and 71% were breastfeeding at 1 year. A total of 103 (22%) were CMV positive and the majority of these (97%) were > 4 weeks of age at testing. Infants > 4 weeks of age were more likely to be CMV positive (P < 0.0001) (Figure). Gender was not correlated with CMV positivity. Among children with head circumference (HC) measurements, microcephaly (HC < 2 SD) was present in 9/87 (10.3%) CMV positive and 35/338 (10.4%) CMV negative infants at 0-3 months of age (p =0.99). Among 438 infants who underwent screening for hearing deficits and a complete ophthalmologic evaluation, none of the CMV positive children had abnormal vision or hearing. Abnormal neurological exams in the first year of life occurred in 50/100 (50%) CMV positive and 166/365 (45.5%) CMV negative infants (p =0.56). There was no association between CMV infection at 0-3 months and MSEL overall or subdomain scores at 1 year (overall Relative risk (RR) 1.02, 95% CI 0.99-1.05, p=0.16). Malnutrition at 0-3 months (RR: 1.53, 95% CI 0.89-2.66, p = 0.13) and 1 year (RR: 1.10, 95% CI 0.77-1.58, p=0.59) was not associated with CMV infection at 0-3 months.

Conclusion

In a cohort of Guatemalan infants, postnatal CMV infection was common (22%) and more likely to occur after the neonatal period. There was no correlation between CMV infection and microcephaly at 0-3 months or at 1 year of age, nor with abnormal nutritional, neurologic, ophthalmologic, hearing or ND deficits at 1 year of age. This is the first epidemiologic report on CMV infection in early life in rural Guatemala.

Disclosures

Molly Lamb, PhD, BioFire (Grant/Research Support)

150. the RAPID trial: randomized Controlled Trial assessing point-of-care influenza and Other Respiratory Virus diagnostics in the Pediatric ED Setting

Background

Respiratory illnesses represent one of the commonest reasons for pediatric visits to the ED, and over 50% of these children are prescribed antibiotics despite a viral etiology in most cases. Our objectives were to determine whether rapid respiratory pathogen (RRP) testing decreases antibiotic and health care utilization among children evaluated in the ED with a respiratory illness.

Methods

We conducted a randomized controlled trial among children 1 mo-18 yrs of age attending an ED with influenza like illness (ILI). All children received a nasopharyngeal swab for RRP testing, and were randomized to the intervention group (result given to providers and parents) or control group (result not given, routine clinical care). Families were interviewed on enrollment, 1 and 10 days later. The primary outcome was antibiotic use. Secondary outcomes included antiviral use, hospitalization and recurrent medical visits. Intention to treat (ITT) (assigned group) and pragmatic (provider knows test results) analyses were conducted using SAS v 9.4. Pragmatic analyses were adjusted using multivariable Poisson regression.

Results

Among 920 visits (890 children) with ILI, 795 (85%) were RRP positive. Sociodemographic characteristics between groups were similar; 37% of children in the intervention group were discharged before results were available and 12% of children in the control group underwent clinical testing. The median age was 2.1 yrs (IQR 0.88–5.6); 35% had high-risk comorbidities. In the ITT intervention group, children were more likely to receive antibiotics (RR 1.3, 95% CI 1.0–1.7) (Table 1). In adjusted pragmatic analyses, children with known results were more likely to receive antivirals (RR 2.6 95% CI 1.5–4.3) and be hospitalized (RR 2.0, 95% CI 1.5–2.7); antibiotic use was not significant (Table 2). Children testing negative for a virus were more likely to receive antibiotics than those with a virus (35% vs 23%, p = 0.01).

Table 1. Clinical Outcomes by Study Arm, Intention to Treat Analyses

Table 2. Clinical Outcomes by Study Arm, Pragmatic Analyses

Conclusion

Knowledge of testing led to a paradoxical increase in antibiotic prescribing, as well as an increase in appropriate antiviral prescribing, ED length of stay and hospitalization. Further studies are needed to assess whether RRP testing with faster turn around times or coupled with stewardship interventions may impact outcomes.

Disclosures

Suchitra Rao, MD, BioFire (Grant/Research Support) Molly Lamb, PhD, BioFire (Grant/Research Support) Rakesh Mistry, MD, MSCE, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

Changes in sedentary behaviour in European Union adults between 2002 and 2017

BACKGROUND

Sedentary behaviour (SB) has been identified as an important mortality risk factor. Health organizations have recognised SB as a public health challenge with major health, social, and economic consequences. Researchers have alerted the need to develop specific strategies, to monitor, prevent, and reduce SB. However, there is no systematic analysis of the SB changes in European Union adults. We aimed to examine SB changes between 2002 and 2017 in the European Union (EU) adult population.

METHODS

SB prevalence (>4h30mins of sitting time/day) of 96,004 adults as a whole sample and country-by-country was analysed in 2002, 2005, 2013, and 2017 of the Sport and Physical Activity EU Special Eurobarometers' data. The SB question of a modified version of the International Physical Activity Questionnaire was considered. SB prevalence between countries and within years was analysed with a χ2 test, and SB between genders was analysed with the Z-Score test for two population proportions.

RESULTS

An association between the SB prevalence and the years was found (p <  0.001), with increases for the whole sample (2002: 49.3%, 48.5-50.0 95% confidence interval (CI); 2017: 54.5%, 53.9-55.0 95% CI) and men (2002: 51.2%, 50.0-52.4 95% CI; 2017: 55.8%, 55.0-56.7 95% CI) and women (2002: 47.6%, 46.6-48.7 95% CI; 2017: 53.4%, 52.6-54.1 95% CI) separately. The adjusted standardised residuals showed an increase in the observed prevalence versus the expected during 2013 and 2017 for the whole sample and women and during 2017 for men. For all years, differences were observed in the SB prevalence between countries for the whole sample, and men and women separately (p <  0.001). Besides, the SB prevalence was always higher in men versus women in the overall EU sample (p <  0.001).

CONCLUSIONS

SB prevalence increased between 2002 and 2017 for the EU as a whole and for both sexes separately. Additionally, differences in SB prevalence were observed for all years between EU countries in the whole sample and both sexes separately. Lastly, SB was consistently higher in men than women. These findings reveal a limited impact of current policies and interventions to tackle SB at the EU population level.

Interpregnancy Interval in a Rural Guatemalan Population: Results from a Quality Improvement Database

OBJECTIVE

This analysis describes the interpregnancy interval (time from livebirth to subsequent conception) in a convenience sample of women living in Southwest Guatemala and the association of antepartum characteristics and postpartum outcomes with a short interpregnancy interval (< 24 months).

METHODS

This is an observational study of a convenience sample of women enrolled in the Madres Sanas community antenatal/postnatal nursing program supported by the Center for Human Development in Southwest Trifinio, Guatemala, between October 1, 2018 and October 1, 2019. We observed the distribution of interpregnancy intervals among the population of women with a reported date of last live birth, and used bivariate comparisons to compare women with a short interpregnancy interval (< 24 months) to those with an optimal interval ([Formula: see text] 24 months) by antepartum, obstetric and delivery, and postpartum outcomes.

RESULTS

171 parous women enrolled in the Madres Sanas program between October 1, 2018 and October 1, 2019, and reported the date of their last live birth. One hundred-forty-one (82.5%) women delivered and 130 of those women (92.2%) were seen for their 40-day postpartum visit. The mean interval was 37.1 months with a 22.1-month standard deviation. The median interval was 33.7 months with an interquartile range of 19.6-49.5 months. Among these women, 113 (66.1%) the interpregnancy interval was at least 24 months. The only covariate of all sociodemographic, obstetric and antepartum, delivery, and postpartum characteristics that differed between women who achieved an interval ([Formula: see text] 24 months) compared to those that did not (< 24 months), was age (median 22.9, interquartile range (IQR) [19.1,27.0] vs median 24.8, IQR [21.6,27.9], respectively, p = 0.006). A regression model found that with each increasing year of age, the interpregnancy interval increases by 1.08 months, p = 0.025.

CONCLUSION

Among parous women, two-thirds of women space pregnancies at least 24 months. Older women were more likely to have a longer interval between live births.

Identification of Enteropathogens by Multiplex PCR among Rural and Urban Guatemalan Children with Acute Diarrhea

Multiplex polymerase chain reaction (PCR) platforms have enhanced understanding of intestinal pathogens in low- and middle-income countries (LMICs). However, few such studies have been performed in Latin America, where poverty, poor sanitation, and undernutrition persist. Multiplex PCR (BioFire, Salt Lake City, UT) was used to identify viral, bacterial, and parasitic pathogens in stool collected on day 1 and 31 from children aged 6 to 35 months with acute, non-bloody diarrhea in two locations (rural and urban) in Guatemala. We analyzed correlation between pathogens and clinical, demographic, and socioeconomic variables; described patterns of pathogen acquisition, persistence, and clearance over the 30-day period; and calculated population attributable fractions (PAFs) for diarrheal causation for individual pathogens. We analyzed 316 subjects (144 urban; 172 rural) enrolled between March 2015 and January 2016. Rural subjects had significantly more malnutrition, animal exposure, and unimproved water/sanitation infrastructure. The majority of subjects had multiple pathogens/sample (4.8 rural and 2.7 urban). Few meaningful correlates were identified between individual pathogens and clinical, demographic, or environmental variables. Escherichia coli pathotypes, Shigella, Campylobacter, and Giardia had high rates of persistence between initial and 30-day follow-up. Statistically significant adjusted PAFs were identified for Campylobacter (14.9%, 95% CI: 3.2-23.1), norovirus (10.2%, 95% CI: 0.4-17.1), sapovirus (7.6%, 95% CI: 2.3-10.9), and adenovirus 40/41 (5.6%, 95% CI: 0.3-8.7). These observations further characterize the diversity and complexity of enteric pathogens in children in LMICs. Patterns of chronic symptomatic and asymptomatic infection among Latin American children are similar to those observed in other LMIC regions. Findings have direct implications for practitioners treating individuals with acute infectious diarrhea and should inform regional public health strategies.

2319. Clinical Predictors of Influenza and Hospitalization of Children with Influenza in an Emergent Care Setting

Background

Objective measures utilizing early vital sign data show promise in predicting more severe outcomes among adults with influenza, but data are sparse in children. The objectives of this study were to determine the value of vital signs in predicting influenza infection or hospitalization due to influenza infection among children evaluated in an emergency department (ED) or urgent care (UC) setting in Colorado.

Methods

We evaluated vital signs obtained from a prospective cohort study of children aged 6 months to 8 years of age with influenza like illness evaluated at an ED/UC site in Aurora, CO from 2016–2018, and who underwent influenza testing by PCR. We collected the first set of vital signs, peak heart rate and temperature, and converted heart rate (HR) and respiratory rate (RR) to z-scores by age. HR z scores were further adjusted for temperature. Bivariable analyses for each vital sign as a predictor of influenza-related hospitalization and influenza infection as main outcomes were conducted. Predictors with P < 0.2 were entered into a multivariable logistic regression model to determine odds ratios (OR) and 95% CI; model performance was assessed using the Brier score and discriminative ability with the C statistic.

Results

Among 1478 children, 411 were positive for influenza, of which 28 were hospitalized. In multivariable analyses, among children with influenza infection, lower initial oxygen saturation (OR 0.87, 95% CI 0.78–0.98, P = 0.026) and higher adjusted respiratory rate (OR 2.09, 95% CI 1.21–3.61, P = 0.0085) were significant predictors of hospitalization (Figure 1). Among children with ILI, higher peak temperature (OR 1.46, 95% CI 1.30–1.63, P < 0.0001), lower adjusted peak heart rate (OR 0.79, 95% CI 0.69–0.90, P = 0.0005), higher initial oxygen saturation (OR 1.07, 95% CI 1.03–1.12 P = 0.002) and lower adjusted respiratory rate (OR 0.74, 95% CI 0.64–0.87, P = 0.0002) were significant predictors for having PCR-confirmed influenza. However, this model had poor calibration and discriminatory ability.

Conclusion

Higher respiratory rate adjusted for age and lower initial oxygen saturation were significant predictors of hospitalization among young children with PCR-confirmed influenza, but were not reliable discriminators of having influenza infection.

Disclosures

All authors: No reported disclosures.

846. Postnatally Acquired Zika Virus (ZIKV) Infection in Infants and Young Children in Guatemala: Serologic and Neurodevelopmental (ND) Evaluation

Background

Diagnosing ZIKV infection in children in dengue (DENV) endemic regions is challenging. The kinetics and effects of maternal Ab on infant infection responses remain unknown, as do the ND effects of ZIKV acquired in early life.

Methods

This is a population-based prospective cohort study in infant–mother pairs and children <5 years in a rural DENV endemic area of Guatemala evaluating the incidence and ND outcomes of postnatally cquired ZIKV infection. Subjects were followed 1 year for symptoms of flavivirus-like illness (FLI), serologic and virologic evidence of ZIKV or DENV infection and ND outcomes. ZIKV and DENV neutralizing antibodies (NAb) were measured at enrollment and longitudinally. Subjects were classified as ZIKV- or DENV-infected based on NAb. Specimens from acute illnesses were tested for viral RNA by rRT-PCR. ND was assessed at enrollment and longitudinally using an adapted Mullen Scales of Early Learning (MSEL).

Results

In total, 1,371 subjects (374 children 1–5 years, 500 infants, 497 mothers) were enrolled from June 2017 to July 2018. Among 1,335 evaluable subjects, 7.6% (101) had serologic evidence of recent ZIKV infection (NAb >500 or >100 and DENV-neg); 13.2% (176) were DENV-pos only; 44.8% (598) were ZIKV-neg (NAb15 −<100) or low (<500) ZIKV and DENV NAb, suggesting prior flavivirus infection or cross-reactivity (Figures 1 and 2). ZIKV infection alone was more prevalent in children 1–5 years, while infants’ serologic pattern was similar to that of their mothers. One child ZIKV seroconverted. In 391 FLI episodes (67 children 1–5 years and 215 infants with fever, rash, myalgia, and conjunctivitis; 109 mothers with fever, myalgia, and joint pain), acute DENV infections, but not ZIKV, were identified by rRT-PCR. MSEL scores were similar to US norms in infants <12 m (composite mean 94.8, SD 11.9), but lower in children 1–5 years in all domains (mean 75.1, SD 17.4, P < 0.0001) (Figure 3).

Conclusion

Serologic evidence of recent ZIKV infection, but no acute ZIKV, was documented in young children in Guatemala. Infant seroreactivity derives from prior maternal infection and DENV cross-reactivity. Observed substantial differences in ND scores between infants and children 1–5 years challenge the ability to isolate the potential effects of ZIKV infection in early life. NIAID Contract HHSN272201300015I Task Order HHSN27200013. FMM and EJA Co-PIs.

Disclosures

Flor M. Munoz, MD, Biocryst: Grant/Research Support; CDC: Research Grant; Moderna: Other Financial or Material Support, Safety Monitoring Board Member/Chair; NIH: Research Grant; Novavax: Research Grant; UP to Date: Author and Editor: Royalties, Other Financial or Material Support.

2731. Does Last Season’s Influenza Vaccination Affect Current Season’s Vaccine Effectiveness in Young Children?

Background

We evaluated influenza VE over two consecutive years vs. the current season against influenza illness during two H3N2-predominant seasons in children receiving care at emergency/urgent care (ED/UC) facilities in metropolitan Colorado.

Methods

We conducted a test-negative case–control analysis of 1478 children aged 6 months to 8 years enrolled at Children’s Hospital Colorado ED/UC with influenza like illness during the 2016–2017 and 2017–2018 influenza seasons. The primary outcome was PCR-confirmed influenza and vaccination status was confirmed using electronic medical record and parental interviews. Vaccination status was defined as completely vaccinated (all doses of influenza vaccine according to child’s age); partially or not vaccinated children were defined as unvaccinated. Multivariable logistic regression models adjusted for high-risk medical condition, age, race and insurance status were used to calculate odds ratios (OR) and 95% confidence intervals. Vaccine effectiveness was calculated as (1 − OR) × 100.

Results

Of the 1224 (82.8%) children enrolled in the study with known vaccination status for both seasons, 361 (29%) tested positive for influenza. Overall, VE against influenza was 49% (95% CI, 33–61%) after adjusting for other covariates in the model. VE did not differ significantly between those vaccinated in both seasons and those vaccinated in only the current season (VE 69%, 95% CI 41–115) (Table 1).

Conclusion

Our estimates of influenza VE for two predominantly H3N2-influenza seasons in Colorado are comparable to the CDC -VE for children 6 months to 8 years. VE against ED or UC-attended influenza illness in children did not vary significantly by prior seasons’ vaccination status.

Disclosures

All authors: No reported disclosures.

2801. Post-Natal Zika Virus Infection and Impact on Neurodevelopment Among a Cohort of Children in Rural Guatemala

Background

The impact of early post-natal Zika virus (ZIKV) infection on neurodevelopment (ND) is unknown. A prospective study of post-natal ZIKV infection in rural Guatemala (ZIKV study) enrolled a cohort of children ages 1–5 years, including children previously enrolled in a dengue virus (DENV) study during the 2015–2016 ZIKV epidemic. We evaluated ND outcomes by age and ZIKV infection status.

Methods

Subjects enrolled in the ZIKV study June 2017–April 2018 underwent ND testing using the Mullen Scales of Early Learning (MSEL) at baseline and 12 months later. ZIKV/DENV-1/2 FRNT50 was performed on enrollment and on banked serum samples from the 2015 to 2016 subset. ZIKV serostatus and MSEL scores were correlated using multiple linear mixed models, adjusted for age and gender when appropriate, to evaluate their association. Geolocation was used to explore clustering of ZIKV serostatus and MSEL score.

Results

We enrolled 183 children (43% female, mean age 3.2 years). Of these, 38 (21%) were classified as ZIKV-positive (+), 111 (61%) ZIKV-negative (-), 31 (17%) ZIKV-possible, and 3 (2%) ZIKV-indeterminate. ZIKV(+) cases and higher composite MSEL scores clustered in more densely populated areas (Figure 1). ZIKV(+) serostatus was associated with higher MSEL composite (increase in log score 0.09, P = 0.003) and subdomain scores: fine motor (0.13, P = 0.011), visual reception (0.15, P = 0.002), receptive language (0.09, P = 0.041), gross motor (0.14, P = 0.09), and expressive language (0.09, P = 0.058) (Figure 2). Of the 78 children (43%) with 2015–2016 samples, 46 (59%) remained ZIKV(−), 16 (21%) seroconverted from ZIKV(−) or possible/indeterminate to ZIKV(+), and 16 (21%) were indeterminate when enrolled in the ZIKV study. ZIKV seroconversion was associated with higher composite (0.13, P = 0.02) MSEL scores compared with ZIKV(−).

Conclusion

In this exploratory analysis, post-natal ZIKV infection was not associated with adverse ND outcomes in children age 1–5 years. Overall, ZIKV(+) status was associated with higher average ND scores than ZIKV(−), and scores decreased with age for most children, independent of ZIKV status. The correlation of ZIKV(+) status and higher MSEL scores may be confounded by geographic-related factors or other confounders. NIAID Contract HHSN272201300015I Task Order HHSN27200013 (Co-PIs: FMM & EJA).

Disclosures

Flor M. Munoz, M.D, Biocryst: Grant/Research Support; CDC: Research Grant; Moderna: Other Financial or Material Support, Safety Monitoring Board Member/Chair; NIH: Research Grant; Novavax: Research Grant; UP to Date: Author and Editor - Royalties, Other Financial or Material Support.

Edmonton Obesity Staging System for Pediatrics, quality of life and fitness in adolescents with obesity

BACKGROUND

Body mass index (BMI) is often used to diagnose obesity in childhood and adolescence but has limitations as an index of obesity-related morbidity. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) is a clinical staging system that uses weight-related comorbidities to determine health risk in paediatric populations. The purpose of this study was to investigate the associations of EOSS-P and BMI percentile with quality of life (QOL), cardiorespiratory fitness (CRF) and muscular strength in adolescents with obesity.

METHODS

Participants were enrolled at baseline in the Healthy Eating, Aerobic and Resistance Training in Youth trial (BMI = 34.6 ± 4.5 kg m-2, age = 15.6 ± 1.4 years, N = 299). QOL, CRF (peak oxygen uptake, VO2peak) and muscular strength were assessed by the Pediatric QOL Inventory (PedsQL), indirect calorimetry during a maximal treadmill test and eight-repetition maximum bench and leg press tests, respectively. Participants were staged from 0 to 3 (absent to severe health risk) according to EOSS-P. Associations were assessed using age-adjusted and sex-adjusted general linear models.

RESULTS

Quality of life decreased with increasing EOSS-P stages (p < 0.001). QOL was 75.7 ± 11.4 in stage 0/1, 69.1 ± 13.1 in stage 2 and 55.4 ± 13.0 in stage 3. BMI percentile was associated with VO2peak (β = -0.044 mlO2 kg-1 min-1 per unit increase in BMI percentile, p < 0.001), bench press (β = 0.832 kg per unit increase in BMI percentile, p = 0.029) and leg press (β = 3.992 kg, p = 0.003). There were no significant differences in treadmill time or VO2peak between EOSS-P stages (p > 0.05).

CONCLUSION

As EOSS-P stages increase, QOL decreases. BMI percentile was negatively associated with CRF and positively associated with muscular strength.

The global school-based student health survey as a tool to guide adolescent health interventions in rural Guatemala

Background

Adolescents from rural areas in low-middle income countries face increasing physical and mental health challenges that are not well characterized or addressed due to resource limitations. We used the Global School-based Student Health Survey (GSHS) to describe adolescent health behaviors, and to inform prioritization of health promotion efforts in a resource-limited, rural, agricultural region in Guatemala.

Methods

In July 2015, a group of volunteers administered the GSHS to students from seven schools in four communities in the southwest Trifinio region of Guatemala. Prevalence and predictors of nutritional, mental, and sexual health behaviors were calculated from survey responses, and summarized in region- and school-level reports. Facilitated discussion of survey results with local leadership in January 2016 led to the identification of priorities for school-based health interventions.

Results

Five hundred fifty-four out of 620 (87%) students aged 12–18 years completed the survey. Prevalence of unhealthy dietary behaviors and body size was high: 61% reported high current soft drink intake, 18% were overweight, and 31% were moderate-severely stunted. In multivariable regression models, being food insecure was marginally associated with being underweight/stunted (OR = 1.95, 95%CI = 0.95–4.0). Boys were more likely than girls to report being sexually active (25% versus 6.4%, p < 0.001). Local school leadership identified food insecurity and sexual education as priority areas for intervention, and made plans for providing breakfast in schools, sexual education curriculum development and teacher training, and continued adolescent health reporting and evaluation.

Conclusions

The GSHS is a rapid, cost-efficient, useful tool for surveillance of adolescent health behaviors in vulnerable, resource-limited populations. Results of a locally-administered GSHS informed school-based interventions to decrease food insecurity, early sexual initiation, and teen pregnancy in a rural Guatemalan region.

1119. Risk Factors for Clostridium difficile Acquisition and Persistence among Guatemalan Children

Background

Little is known about the epidemiology and risk factors for Clostridium difficile infection (CDI) among children in low and middle-income countries (LMICs). We sought to characterize the clinical, demographic, and environmental factors associated with C.difficile acquisition and persistence over time, and assess the relationship between CDI and additional diarrheal pathogens among rural and urban Guatemalan children.

Methods

Children 6–35 months old with acute nonbloody diarrhea (&lt;72 hours) were enrolled in an acute diarrhea clinical trial between March 2015 and January 2016 at two sites (one rural and one urban) in Guatemala. Stool samples collected at baseline and 30 days later were analyzed by multiplex PCR (FilmArray™ GI-Panel, BioFire, USA) that identifies 22 viral, parasitic and bacterial diarrheal pathogens including C. difficile. Subjects were characterized by combination of baseline and 30-day C.difficile sample results: −/+ (new acquisition), +/− (clearance), and +/+ (persistence). Associations between these categorizations and demographic, epidemiologic, and co-infecting pathogenic organisms were assessed using multivariable generalized linear models.

Results

CDI was present in 26 of 298 subjects at baseline; 13 (50%) had persistence at 30 days and 13 (50%) cleared. New acquisition at day 30 occurred in 23 subjects. In multivariable analysis adjusted for age, recent hospitalization was marginally significantly associated with C. difficile presence in stool at baseline (prevalence ratio [PR] 2.65, P = 0.07). In subjects with either new C. difficile acquisition or persistence between baseline and day 30, residence in the rural site (PR 0.33, P = 0.003)) and presence of E. coli pathotypes: enteropathogenic (EPEC), enteroaggregative (EAEC), and enterotoxigenic (ETEC) (PR 0.43, P = 0.01)) were associated with reduced risk of CDI.

Conclusion

In an LMIC pediatric population, the presence of E. coli pathotypes appeared protective against C. difficile persistence/new acquisition. These findings add to our current understanding that CDI occurs in part as a result of competition within the intestinal microbiota, which may be independent of the potential pathogenicity of competing microbes. We hypothesize that this phenomenon could be suppressing the C. difficile burden among children in LMICs.

Disclosures

All authors: No reported disclosures.

986. Evaluation of Moderate-to-Severe Influenza Disease in Children 6 Months to 8 Years of Age in Colorado

Background

A clinical endpoint of moderate-to-severe (M/S) influenza has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. This definition has not been evaluated against clinically relevant outcomes like hospitalization, emergency room care, antimicrobial use, and child/parental absenteeism.

Methods

We conducted a prospective observational study of children aged 6 months–8 years with influenza at the Children’s Hospital Colorado Emergency Department (ED) and its affiliates during two influenza seasons (2016–2017 and 2017–2018). Children with influenza-like-illness (ILI) were enrolled and tested for influenza by polymerase chain reaction (PCR). Parents of influenza cases and matched influenza-negative controls were contacted 2 weeks later for follow-up. The primary outcome was hospitalization for M/S influenza vs. mild influenza. Secondary outcomes included recurrent ED visits, antimicrobial use, child/parental absenteeism. Interim analyses were conducted using SAS v9.4.

Results

Among the 1,480 enrolled children with ILI, 410 (28%) tested positive for influenza by PCR. The median age of influenza cases was 4.0 years (IQR 2.2–6.1), and 20% were considered high-risk for influenza complications. Of influenza cases, 284 (69%) met the definition for M/S influenza. Among M/S influenza subjects, 8.4% were hospitalized, compared with 1.6% with mild influenza (risk difference (RD) 6.9%; 95% CI: 3.0–10.8, P < 0.01). Subjects with M/S influenza were more likely to receive antibiotics (RD 12.0%, 95% CI: 3.4–20.6, P < 0.01) with a trend to higher antiviral use (RD 6.9%, 95% CI: −0.7–14.5, P = 0.09). There was no significant difference for recurrent ED visits nor child/parental absenteeism. After adjusting for comorbidities, age, and influenza strain, the relative risk (RR) of hospitalization or recurrent ED visits was higher among those with M/S influenza vs. mild influenza (RR 2.18, 95% CI: 1.02–4.64, P = 0.04).

Conclusion

Children with M/S influenza have a higher risk of hospitalization compared with mild disease. This proposed definition is a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children.

Disclosures

S. Rao, GSK: Investigator, Research grant. E. Yanni, GSK: Employee, Salary. R. Bekkat-Berkani, GSK: Employee, Salary. A. Schuind, GSK: Employee, Salary. B. Innis, GSK: Employee, Salary. R. Mistry, GSK: Investigator, Research support. E. J. Asturias, GSK: Investigator, Research grant and Research support.

Performance of a Mobile Phone App-Based Participatory Syndromic Surveillance System for Acute Febrile Illness and Acute Gastroenteritis in Rural Guatemala

BACKGROUND

With their increasing availability in resource-limited settings, mobile phones may provide an important tool for participatory syndromic surveillance, in which users provide symptom data directly into a centralized database.

OBJECTIVE

We studied the performance of a mobile phone app-based participatory syndromic surveillance system for collecting syndromic data (acute febrile illness and acute gastroenteritis) to detect dengue virus and norovirus on a cohort of children living in a low-resource and rural area of Guatemala.

METHODS

Randomized households were provided with a mobile phone and asked to submit weekly reports using a symptom diary app (Vigilant-e). Participants reporting acute febrile illness or acute gastroenteritis answered additional questions using a decision-tree algorithm and were subsequently visited at home by a study nurse who performed a second interview and collected samples for dengue virus if confirmed acute febrile illness and norovirus if acute gastroenteritis. We analyzed risk factors associated with decreased self-reporting of syndromic data using the Vigilant-e app and evaluated strategies to improve self-reporting. We also assessed agreement between self-report and nurse-collected data obtained during home visits.

RESULTS

From April 2015 to June 2016, 469 children in 207 households provided 471 person-years of observation. Mean weekly symptom reporting rate was 78% (range 58%-89%). Households with a poor (<70%) weekly reporting rate using the Vigilant-e app during the first 25 weeks of observation (n=57) had a greater number of children (mean 2.8, SD 1.5 vs mean 2.5, SD 1.3; risk ratio [RR] 1.2, 95% CI 1.1-1.4), were less likely to have used mobile phones for text messaging at study enrollment (61%, 35/57 vs 76.7%, 115/150; RR 0.6, 95% CI 0.4-0.9), and were less likely to access care at the local public clinic (35%, 20/57 vs 67.3%, 101/150; RR 0.4, 95% CI 0.2-0.6). Parents of female enrolled participants were more likely to have low response rate (57.1%, 84/147 vs 43.8%, 141/322; RR 1.4, 95% CI 1.1-1.9). Several external factors (cellular tower collapse, contentious elections) were associated with periods of decreased reporting. Poor response rate (<70%) was associated with lower case reporting of acute gastroenteritis, norovirus-associated acute gastroenteritis, acute febrile illness, and dengue virus-associated acute febrile illness (P<.001). Parent-reported syndromic data on the Vigilant-e app demonstrated agreement with nurse-collected data for fever (kappa=.57, P<.001), vomiting (kappa=.63, P<.001), and diarrhea (kappa=.61, P<.001), with decreased agreement as the time interval between parental report and nurse home visit increased (<1 day: kappa=.65-.70; ≥2 days: kappa=.08-.29).

CONCLUSIONS

In a resource-limited area of rural Guatemala, a mobile phone app-based participatory syndromic surveillance system demonstrated a high reporting rate and good agreement between parental reported data and nurse-reported data during home visits. Several household-level and external factors were associated with decreased syndromic reporting. Poor reporting rate was associated with decreased syndromic and pathogen-specific case ascertainment.

Enteropathogen Identification by Multiplex PCR in Guatemalan Children with Acute, Non-bloody Diarrhea

Background

Diarrhea is a leading cause of morbidity and mortality in children in low and middle income countries (LMICs). Assessing diarrhea etiology in LMICs is of great importance in order to better develop both therapeutic and public health strategies, but is hampered by the complexity of potential diarrheal pathogens, and diverse methodology needed for pathogen identification

Methods

Subjects 6 to 35 months old with acute, moderate severity, non-bloody diarrhea were enrolled in a diarrheal treatment trial, conducted at one rural (N = 172) and two urban sites (N = 144) in Guatemala. Diarrheal pathogens were determined in stool by multiplex PCR (FilmArray GI® Biofire) which allows simultaneous identification of 23 bacterial, viral, parasitic pathogens. Descriptive statistics on demographics, pathogen load, and differences in pathogen occurrence by site were performed; differences were assessed with t-test and chi² test

Results

Nearly all (96.8%) subjects had pathogens identified, and most had multiple potential pathogens identified (mean pathogen count: 2.7 urban and 4.8 rural; P < 0.001 (Figure 1). Notable pathogen differences were observed between rural and urban populations. Bacteria (particularly E.coli pathotypes and Campylobacter) and protozoa (particularly giardia) were more common in the rural population (Figure2). Viral pathogens were either similar or more common (norovirus; P = 0.04) in the urban population; rotavirus was uncommon in both sites (10 rural and 12 urban cases). A similar pattern of pathogen evolution with patient age was noted in both settings, with a decrease in the relative number of viral and increase in parasitic pathogens (Figure 3). Important demographic and socioeconomic differences between rural and urban were noted: rural subjects had poorer nutritional status, underdeveloped water and sanitation facilities and more domestic animal exposure

Conclusion

Acute diarrheal episodes in Guatemalan children were associated with a complex spectrum of pathogens when determined by multiplex PCR, with distinct patterns in rural and urban populations. Future studies to precisely determine diarrheal etiologies in LMICs will need to incorporate controls to sort causative organisms from those colonizing the intestine.

Disclosures

All authors: No reported disclosures.

Perceived quality of life among caregivers of children with a childhood-onset dystrophinopathy: a double ABCX model of caregiver stressors and perceived resources

Background

Duchenne and Becker muscular dystrophies, collectively referred to as dystrophinopathies, are recessive X-linked disorders characterized by progressive muscle weakness and ultimately cardiac and respiratory failure. Immediate family members are often primary caregivers of individuals with a dystrophinopathy.

Methods

We explored the impact of this role by inviting primary caregivers (n = 209) of males diagnosed with childhood-onset dystrophinopathy who were identified by the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) to complete a mailed questionnaire measuring perceived social support and stress, spirituality, and family quality of life (FQoL). Bivariate and multivariate analyses examined associations between study variables using the Double ABCX model as an analytic framework.

Results

Higher stressor pile-up was associated with lower perceived social support (r = -0.29, p < .001), availability of supportive family (r = -0.30, p < .001) or non-family (r = -0.19, p < .01) relationships, and higher perceived stress (r = 0.33, p < .001); but not with spirituality (r = -0.14, p > 0.05). FQoL was positively associated with all support measures (correlations ranged from: 0.25 to 0.58, p-values 0.01–0.001) and negatively associated with perceived stress and control (r = -0.49, p < .001). The association between stressor pile-up and FQoL was completely mediated through global perceived social support, supportive family relationships, and perceived stress and control; supportive non-family relationships did not remain statistically significant after controlling for other mediators.

Conclusions

Findings suggest caregiver adaptation to a dystrophinopathy diagnosis can be optimized by increased perceived control, supporting family resources, and creation of a healthy family identity. Our findings will help identify areas for family intervention and guide clinicians in identifying resources that minimize stress and maximize family adaptation.

Impact of hypothermic preservation on tissue yield and viability in pig pancreata

INTRODUCTION

Chronic shortage of quality human cadaveric pancreata limits islet transplantation. Porcine islet xenotransplantation is being explored to increase the donor pool. For clinical-ready islets, centralized animal husbandry, Current Good Manufacturing Practice-regulated processing facilities, and organ transportation support are required. Amount of cold ischemia time (CIT) before isolation significantly affects transplantation. The goal of this study was to determine the maximum safe CIT of whole pancreata before islet isolation.

MATERIALS AND METHODS

Pancreata were rapidly removed from Yorkshire pigs (age, 14-22 days) and stored in modified University of Wisconsin solution or in EuroCollins solution at 4(°)C. Pancreata were processed with <1 hour CIT (control) or stored for 4 or 12 hours before isolation. Islet yield and percent purity and viability were determined after 7 days of in vitro tissue culture and maturation. Samples from nonprocessed pancreata were collected and snap-frozen in liquid nitrogen at 0, 3, 6, 9, 12, 15, and 24 hours of preservation, then analyzed for adenosine diphosphate/adenosine triphosphate ratio as a measure of tissue energetics.

RESULTS

Up to 12 hours in cold storage had no significant impact on overall islet yield after 7 days of in vitro culture compared with controls; islet yield at the end of the maturation process was 28,700 ± 500 islet equivalents per pancreas (mean ± SEM control yield, 30,300 ± 900 islet equivalents per pancreas); islet purity was 75 ± 5% compared with 74 ± 5% in controls. Islet viability was significantly reduced at 12 hours compared with controls (80 ± 6% vs 96 ± 5%; P < .05). The tissue adenosine diphosphate/adenosine triphosphate ratio was maintained within the first 6 hours (1.6 ± 0.1 to 1.8 ± 0.2; P = NS) but was markedly increased during the 24-hour study (3.3 ± 0.1 at 24 hours), indicating a progressive loss of adenosine triphosphate tissue stores.

CONCLUSIONS

Young pig pancreata can be hypothermically stored for up to 12 hours without affecting islet yield and purity; however, islet viability is reduced. These data highlight the need for uniform shipping parameters to standardize islet quality, ideally with CIT <6 hours.

Function and viability of human islets encapsulated in alginate sheets: in vitro and in vivo culture

Islet encapsulation offers an immune system barrier for islet transplantation, and encapsulation within an alginate sheetlike structure offers the ability to be retrievable after transplanted. This study aims to show that human islets encapsulated into islet sheets remain functional and viable after 8 weeks in culture or when transplanted into the subcutaneous space of rats. Human islets were isolated from cadaveric organs. Dissociation and purification were done using enzymatic digestion and a continuous Ficoll-UWD gradient. Purified human islets were encapsulated in alginate sheets. Human Islet sheets were either kept in culture, at 37°C and 5% CO(2), or transplanted subcutaneously into Lewis rats. After 1, 2, 4, and 8 weeks, the human islet sheets were retrieved from the rats and assessed. The viability of the sheets was measured using fluorescein diacetate (FDA)/propidium iodide (PI), and function was measured through glucose-stimulated insulin release, in which the sheets were incubated for an hour in low-glucose concentration (2.8 mmol/L) and then high (28 mmol/L), then high (28 mmol/L) plus 3-isobutyl-1-methylxanthine (50 μm). Human islet sheets remained both viable, above 70%, and functional, with a stimulation index (insulin secretion in high glucose divided by insulin secretion in low glucose) above 1.5, over 8 weeks of culture or subcutaneous transplantation. Islet transplantation continues to make advances in the treatment of type 1 diabetes. These preliminary results suggest that encapsulated islets sheets can survive and maintain islet viability and function in vivo, within the subcutaneous region.

The usefulness of immunohistochemistry to differentiate between nasal carcinoma and lymphoma in cats: 140 cases (1986-2000)

A retrospective evaluation of 232 feline nasal biopsies initially diagnosed as either carcinoma or lymphoma was performed by two pathologists. One or both pathologists disagreed with the original diagnosis in 15 cases (7%), 14 of which had original diagnoses of carcinoma. Out of the 232 cases, 140, including the disputed ones, were subjected to immunohistochemical staining with epithelial and lymphoid markers. Immunohistochemical staining of the 15 disputed cases showed that the original diagnoses were incorrect in 67% (10/15), unverified in 13% (2/15) and correct in 20% (3/15). Among the consensual diagnoses, immunohistochemistry revealed that 3% (4/125) of diagnoses were unverified because they did not stain for any of the markers evaluated. This report demonstrates the importance of immunohistochemistry in establishing a correct histologic diagnosis for nasal neoplasms in cats.

Patient (PT) participation and disaster (D) agency (AG) coordination for oncology (ONC) PT D preparedness (PREP): Analysis of the Great Southern California Shake Out (GSCSO) drill and implications for regional and national emergency (E) planning (P)

e17549

Background: PT E PREP is important (Katrina, Los Angeles fires 2007, 2008). MOASC developed the ONC PT E Network (OPEN) (www.open-central.com; Proc ASCO 2006 a6142, 2007 a17003 , and 2008 a6545). On Novermber 13, 2008, 28 organizations and sponsors (US and Cal govt and private) conducted the GSCSO drill with a Richter scale 7.8 earthquake. MOASC tested OPEN as part of GSCSO. Methods: In OPEN, PTs were given wallet cards with E information (diagnosis, stage, treatment, doses). As part of GSCSO, MOASC a) surveyed two practices in two counties to evaluate ONC PT motivation and PREP; and b) surveyed D AG to determine the triage program for ONC PTs who required CT. PTs in two offices pretended the ONC offices had been closed due to the D. They were asked to call the MOASC E line and advise an address to which they would evacuate where MOASC referred PTs to a participating physician for chemotherapy (CT). Results: 36 PTs participated. In office interviews, PTs had concerns about transportation to evacuation locations during the D, how they would find available phone lines during an E, and whether MOASC lines would be responsive in an E. Only 5 PTs (13.9%) contacted the MOASC E line within 24 hours. The 4 most available D AGs were unaware of how to triage ONC PTs requiring CT, and were unaware of MOASC and ASCO resources. They wanted to refer ONC PTs to E rooms which would be unresponsive to PT needs for CT. Conclusions: ONC PTs are not yet motivated for D PREP (concerns regarding current CT have higher priority). Responding AGs are not capable of correctly triaging ONC PTs for CT. Neither PTs nor doctors have a list of D AGs. State ONC societies, ASCO, and ACCC should create regional E phone response lines through state societies, regional E oncologist contacts, and a single national facilitating D response office, as well as coordinate regional and national D AGs so that PTs can be triaged to appropriate resources. National D AGs funded to coordinate responses should be the source of support for this process. Motivating ONC PTs for EP will require reimbursed practice participation.

No significant financial relationships to disclose.

Interviewing alleged victims with intellectual disabilities

BACKGROUND

When interviewing alleged victims of crime, it is important to obtain reports that are as accurate and complete as possible. This can be especially difficult when the alleged victims have intellectual disabilities (ID). This study explored how alleged victims with ID are interviewed by police officers in Sweden and how this may affect their ability to report information as accurately as possible.

METHODS

Twelve interviews with 11 alleged victims were selected from a larger sample. The complainants were interviewed when their chronological ages ranged from 6.1 to 22 years. A quantitative analysis examined the type of questions asked and the numbers of words and details they elicited in response.

RESULTS

Instead of open-ended questions, the interviewers relied heavily on focused questions, which are more likely to elicit inaccurate information. When given the opportunity, the witnesses were able to answer directive questions informatively.

CONCLUSIONS

Interviewers need special skills in order to interview alleged victims who have ID. In addition to using more open-ended questions, interviewers should speak in shorter sentences.

Implementation of the California Oncology Emergency Preparedness Plan (COEPP): Updated results of an ASCO-supported state oncology society (SOS) project for patient (PT) protection

17003

Background: Following the Katrina disaster MOASC began developing a plan to provide continuity of care to cancer PT in the event of a disaster. ASCO provided grant support to further develop the plan and begin implementation. COEPP included oncologist (ONC) and PT education and enrollment, developing a simple, portable, PT owned data storage system, ensuring drug availability, establishing offsite data storage, and implementing a communications system. This report updates the progress and problems encountered in this process. Methods: A committee was formed to develop the plan. ONC were educated through the MOASC website and meetings. A PT wallet card (WC) was developed as an initial method to store clinical data. Drug companies were contacted to provide support and emergency drugs. Communication avenues were identified. Attitudes of ONC were surveyed through interviews. Results: ONC readily agreed to join the COEPP. The PT WC have recently begun to be distributed. PT have been enthusiastic to participate. HIPPA compliant digital storage is being explored, but lack of standardization remains a problem. These efforts have required considerable time expenditures by committee members. Drug companies have expressed enthusiasm, and to date, one company has provided a sizable grant. Drug manufacturers and drug wholesalers have separate emergency plans for determining who is responsible for ensuring drug availability to PT and storing current distribution data. However, ONC membership in COEPP continues to increase, and WC have been widely accepted by PT indicating success of the initial part of the program. Educational materials and WC examples will be distributed at the poster. Conclusions: COEPP, while still early in development, is becoming a successful model of emergency preparedness to protect continuity of care for cancer PT. Adequate funding is required for network development, coordination, legal protections, eventual digitization of treatment records, coordination of drug availability, and ONC and PT educational materials. With grants, this model plan can be implemented in other regions by SOS.

No significant financial relationships to disclose.

Development of a model emergency oncology response system (EORS): The California oncology emergency master plan (COEMP)

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Background: Hurricane Katrina displaced patients (PT) and physicians (MD). Time & resources were needed to match displaced PT with oncology (ONC) practices (PRC) for ongoing care. Disruption of care can be life-threatening to ONC PT who need to adhere to schedules & monitoring. California (CA) is particular risk for natural disaster. In order to better support PT in a future emergency (E) MOASC & ANCO created a model EORS with pilot implementation of select elements. Methods: MOASC & ANCO prepared a multi-component COEMP. Joint calls & meetings yielded a draft EORS approved by both society boards. Initial & long-term funding is expected via granting mechanisms. Pilot implementation of specific elements began in 11/2005. Results: Goals of the COEMP are: Establish dedicated E ONC MD network; Create a voluntary ONC-specific PT medical record (MR) template & secure data repository; Create & test a functional E MD responder system for CA ONC MD; Develop liaison with relief providers (Homeland Security, FEMA, Red Cross); Strengthen existing role with Bio-Pharma (BP) for delivery of medicine (Rx) to displaced PT and PRC; Develop specific educational materials for the EORS (PT, MDs, Insurers, BP); Create & distribute an EORS “PT Wallet Card” with PT national digital record (NDR) and E responder contacts. To prioritize components of the COEMP, a needs assessment, reviewing past E experience, response, and current capacity, has been initiated. The specific active components of the EORS include: 1-E ONC MD support network: ONC MDs have been invited to volunteer via email and at regional meetings. 2-Secure PT MR repository: MDs and PT will coordinate relevant MR, insurance, and E contact data, in locations (home of PT, w/relatives, NDR). 3-E coordinator MDs & staff will respond to E calls from PT/MD via phone & email. 4-Open dialogue with BP for E access to Rx for displaced PT. 5-Educational & training for PRC and PT in printed & electronic form. Conclusions: COEMP provides an initial E model for ONC. It may be applicable for state societies or national ONC groups. At ASCO 2006, MDs will be invited to participate and expand COEMP capabilities. Although we hope COEMP/EORS need never be used, its development will enable ONC practices to be more prepared for loco-regional E.

No significant financial relationships to disclose.