Evaluating the Efficacy of Training Programs for Community Health Workers in Rural Uganda

Background: The Ministry of Health and Omnimed, a non-profit U.S.-based organization that works with international communities to provide basic health education, have partnered to provide health training to community health workers (henceforth referred to as village health workers or VHWs) in rural villages in Uganda. The training is provided via an intensive five-day long session that introduces a wide variety of themes in basic health education taught by experts in the respective fields. The participants are selected by the local government based on their age, reliability, level of education and availability. On the first day, the participants are given a pre-test that evaluates their level of knowledge about the subjects that will be taught during the training session, and are given the same questions as a post-test on the last day of training. This is done to evaluate how much information the participants learned about basic health during the training. The participants are followed after this training by quarterly meetings, focus groups and further, more specific, training sessions. We analyzed data from the pre- and post-tests to evaluate the amount of information learned through the training sessions and we also evaluated feedback from the focus groups to determine how trainees thought the program was affecting their community and to analyze the challenges facing the VHWs. Objectives: The objective of this project was two-fold: 1) to evaluate the amount of information about basic health retained by VHWs who participated in a week-long training session; and 2) to follow-up with VHWs to see what changes they noticed in their communities and determine what challenges they face in disseminating health information in their villages. Methods: The study sample consisted of 110 participants who were asked to complete the pre- and post-tests. The pre- and post-training test consisted of 49 multiple choice questions, written in Luganda, with a total possible score of 105. The pre-test was distributed to the participants on the first day of the training session. Participants were administered post-tests on the last day of the training session. The questions and the delivery of the exams were the same at both points in time. The grading of the tests was as follows: each correct answer received one point, incorrect answers received no points, and questions with more than one answer received no points. We compared the percentage of correct answers of the pre- and post-tests to determine any changes in knowledge as a result of the training session. A total of 99 trainees were recruited to participate in focus groups. Focus groups were conducted three and six months after the original training session and involved five to ten VHWs per session. Questionnaires were distributed to the groups and questions were read aloud with discussion about each topic. We asked the VHWs: 1) Have you noticed healthy changes in your community?; 2) What changes have you noticed; 3) How does the community view a VHW?; and 4) What support could you use as a VHW? Results: The VHWs selected from the communities were aged 25-40, were more likely to be female than male, and generally had a non-health related occupation. One hundred and two participants completed both the pre- and post-tests. The average difference between test scores at the two points in time was an improvement of 20.25 points, or 19.3%. The range of differences between the scores was -5 to +61. Given that the VHWs were not previously educated about basic health, this was viewed a marginal improvement. However, the data from the focus groups indicates that the VHWs were enacting changes in their community. The participants in the focus group were also aged 25-40 and 43 were males and 56 were females. The focus groups demonstrated that 86% of the VHWs noticed positive changes in the community; including the creation of latrines (34%), more drying racks (16%), more hand-washing (11%), increased usage of boiled water (9%) and the newfound creation and usage of “tippy-taps” (8%). When asked if the community viewed the VHWs as a positive asset, 81% answered yes. Lastly, when queried as to what support VHWs could use to facilitate their work, the majority answered some type of transport (51%); while other popular answers were gumboots and raingear, more training, cell phones or a stipend to compensate them for their work. Conclusion: The increased mean score of the post-tests indicates that the VHWs did learn basic health information during the training session. However, the improvement in score was not as notable as one would expect given the intense nature of the trainings and the baseline level of knowledge being somewhat low. The data from the focus groups, however, indicated that VHWs are creating positive change in their communities. This could mean that the simple act of appointing one person to educate their community imbues in them a responsibility to spread the knowledge that they do possess; however basic it may be. It also could indicate that the VHWs learned more at the training sessions than the test scores reveal. This could be due to a multitude of factors, including difficulty with reading, the advanced nature of the test questions, difficulty with multiple choice questions, or difficulty applying knowledge to the test, especially considering that most of the VHWs were adults many years out of school. In light of this information, one could consider a different method of evaluation, and more focus on the follow-up to assess what the VHWs are actually able to do in their communities. Moving forward, it would be ideal to evaluate the villages themselves via a system of door-to-door surveys that ask the villagers about changes they have or have not made and if they have seen any improvement in their health. This information will provide further evidence as to whether VHWs are an ideal model in the field of health education

The fate of Lyngbya majuscula toxins in three potential consumers

Blooms of Lyngbya majuscula have been reported with increasing frequency and severity in the last decade in Moreton Bay, Australia. A number of grazers have been observed feeding upon this toxic cyanobacterium. Differences in sequestration of toxic compounds from L. majuscula were investigated in two anaspideans, Stylocheilus striatus, Bursatella leachii, and the cephalaspidean Diniatys dentifer. Species fed a monospecific diet of L. majuscula had different toxin distribution in their tissues and excretions. A high concentration of lyngbyatoxin-a was observed in the body of S. striatus (3.94 mg/kg⁻¹) compared to bodily secretions (ink 0.12 mg/kg⁻¹; fecal matter 0.56 mg/kg⁻¹; eggs 0.05 mg/kg⁻¹). In contrast, B. leachii secreted greaterconcentrations of lyngbyatoxin-a (ink 5.41 mg/kg⁻¹; fecal matter 6.71 mg/kg⁻¹) than that stored in the body (2.24 mg/kg⁻¹). The major internal repository of lyngbyatoxin-a and debromoaplysiatoxin was the digestive gland for both S. striatus (6.31 ± 0.31 mg/kg⁻¹) and B. leachii (156.39 ± 46.92 mg/kg⁻¹). D. dentifer showed high variability in the distribution of sequestered compounds. Lyngbyatoxin-a was detected in the digestive gland (3.56 ± 3.56 mg/kg⁻¹) but not in the head and foot, while debromoaplysiatoxin was detected in the head and foot (133.73 ± 129.82 mg/kg⁻¹) but not in the digestive gland. The concentrations of sequestered secondary metabolites in these animals did not correspond to the concentrations found in L. majuscula used as food for these experiments, suggesting it may have been from previous dietary exposure. Trophic transfer of debromoaplysiatoxin from L.majuscula into S. striatus is well established; however, a lack of knowledge exists for other grazers. The high levels of secondary metabolites observed in both the anaspidean and the cephalapsidean species suggest that these toxins may bioaccumulate through marine food chains.\u

Plankton Community Changes and Nutrient Dynamics Associated with Blooms of the Pelagic Cyanobacterium <i>Trichodesmium</i> in the Gulf of Mexico and the Great Barrier Reef

Blooms of the harmful dinoflagellate Karenia brevis on the West Florida Shelf (WFS), Gulf of Mexico, are hypothesized to initiate in association with the colonial cyanobacterium Trichodesmium spp. and benefit from dissolved organic nitrogen (DON) release derived from N2-fixation by the cyanobacteria. Previous studies have detected DON release using direct experimental measurements, but there have been few studies that have followed nutrient release by in situ blooms of Trichodesmium and the associated plankton community. It was determined that long-term Trichodesmium spp. and Karenia brevis abundances on the WFS were related, following a 2-month lag. A separate Eulerian study of a Trichodesmium erythraeum bloom event was conducted over 9 days on the Great Barrier Reef. Concentrations of T. erythraeum increased over the course of the study, with coincident increases in dinoflagellate abundance and decreases in diatom abundance. Inside the bloom, concentrations of NH4+, PO43−, and DON increased significantly. The copepod grazer Macrosetella gracilis also increased in abundance as T. erythraeum numbers increased, contributing to nutrient release. Copepod grazing rates were measured, and N release rates estimated. Together, these studies show that Trichodesmium blooms have consequences for dinoflagellate abundance at both seasonal and ephemeral scales via direct and indirect N release

Abstract P1-01-03: The Impact of Comorbid HIV infection on Neoadjuvant and Adjuvant Chemotherapy Relative Dose Intensity in South African Breast Cancer Patients

Abstract Introduction In the South African Breast Cancer and HIV Outcomes (SABCHO) study, early-stage breast cancer patients living with HIV, compared to their HIV-negative counterparts, demonstrated higher overall mortality and lower rates of pathologic complete response if treated with neoadjuvant chemotherapy. We aimed to determine if comorbid HIV also impacted receipt of timely and complete neoadjuvant and adjuvant chemotherapy. Methods We retrospectively identified Black, stage I-III SABCHO participants diagnosed with breast cancer from June 2015 to July 2019 and who received at least 2 doses of neoadjuvant or adjuvant chemotherapy at either Charlotte Maxeke Johannesburg Academic Hospital (Gauteng) or Grey’s Hospital (KwaZulu-Natal). Data on the originally prescribed chemotherapy regimen and the dose and timing of all received chemotherapy was extracted from patients’ medical records, as well as values from all complete blood counts and metabolic panels performed during treatment. Relative dose intensity (RDI) was calculated for each agent in the prescribed regimen with the mean RDI of all agents representing the RDI of the full regimen. We assessed for associations between full regimen RDI and HIV status using a multivariable linear regression model that included demographic and clinical covariates also shown to impact RDI. We also compared rates of myelosuppression, alkaline phosphatase elevation, and creatinine elevation using linear regression. Using previously collected survival data, we compared overall mortality based on overall RDI above or below 0.85. Results We analyzed data from 325 eligible subjects, 166 of whom were living with HIV. No differences based on HIV status were appreciated in the prescribed chemotherapy regimens. For women without HIV median RDI was 0.87 (interquartile range (IQR) 0.77-0.94) and, in those living with HIV, it was 0.89 (IQR 0.77-0.95). HIV status showed no significant association with RDI on multivariable analysis, and the only patient characteristics associated with RDI were estrogen/progesterone receptor (ER/PR) and HER2 status. Patients living with HIV experienced more CTCAE v5.0 grade 3+ anemia and leukopenia than those without HIV (anemia: 10.8% vs 1.9%, p=0.001; leukopenia: 8.4% vs 1.9%, p=0.008) and were more likely to receive at least one dose of filgrastim (24.7% vs 10.7%, p=0.001). Receipt of RDI greater or less than 0.85 did not predict overall mortality in the full cohort or HIV status subgroups. A trend towards improved survival with RDI greater than 0.85 was seen among the 69 participants with ER/PR negative disease (hazard ratio: 0.60, 95% confidence interval: 0.30-1.21, p = 0.15). Conclusions Neoadjuvant and adjuvant chemotherapy RDI did not differ by HIV status among women in the SABCHO study, although women living with HIV experienced more myelotoxicity during treatment. Efforts to reduce chemotherapy dose reduction and delays should target all South African breast cancer patients. Citation Format: Daniel S. O’Neil, Oluwatosin A Ayeni, Hayley A. Farrow Woolridge, Wenlong Carl Chen, Georgia Demetriou, Ines Buccimazza, Sharon Cacala, Maureen Joffe, Michael Antoni, Gilberto Lopes, Yoanna Pumpalova, Witness Mapanga, Judith S. Jacobson, Katherine D. Crew, Alfred I. Neugut, Paul Ruff, Herbert Cubasch. The Impact of Comorbid HIV infection on Neoadjuvant and Adjuvant Chemotherapy Relative Dose Intensity in South African Breast Cancer Patients [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-01-03

A Randomized Study of Immune Plasma for the Treatment of Severe Influenza

Summary Background: Influenza causes significant morbidity and mortality despite currently available treatments. Anecdotal reports suggest plasma with high antibody titers towards influenza may be of benefit in the treatment of severe influenza. Methods: We conducted a randomized, open-label, multicenter phase 2 trial at 29 academic medical centers in the United States to assess the safety and efficacy of anti-influenza plasma with hemagglutination inhibition (HAI) antibody titers of ≥ 1:80 to the infecting strain. Hospitalized children and adults (including pregnant women) with severe influenza A or B (defined as hypoxia or tachypnea) were randomly assigned to receive either 2 units (or pediatric equivalent) of anti-influenza plasma plus standard care (P+S), versus standard care alone (S), and were followed for 28 days. The primary endpoint was time to normalization of patients’ respiratory status (respiratory rate of ≤ 20 for adults or age defined thresholds of 20–38 for children), and a room air saturation of oxygen ≥ 93%. ClinicalTrials.gov Identifier: NCT01052480 Findings: Between January 13, 2011 and March 2, 2015, 113 participants were screened, and 98 were randomized. Of the participants with confirmed influenza, 28 of 42 (67%) of P+S participants normalized their respiratory status by Day 28, as compared to 24 of 45 (53%) of S participants (p=0·069). The estimated hazard ratio comparing P+S to S was 1·71 (95% CI: 0·96 to 3·06). Six participants died, 1 (2%) and 5 (10%) from the P+S and S arms respectively (p=0·093). P+S participants had non-significant reductions in days in hospital (median 6 vs. 11 days, p=0·13) and days on mechanical ventilation (median 0 vs. 3 days, p=0·14), and significantly improved clinical status at Day 7 (p=0·020). Fewer P+S participants experienced SAEs compared to S recipients (20% vs. 38%, p= 0·041), the most frequent of which were acute respiratory distress syndrome (1 [2%] vs 2 [4%]) and stroke (1 [2%] vs 2 [4%]). Interpretation Results from this Phase II randomized trial of immune plasma for the treatment of severe influenza provides support for a possible benefit of immunotherapy across the primary and secondary endpoints. A Phase III randomized trial is now underway to further evaluate this intervention

Microbial production along the West Florida Shelf: Responses of bacteria and viruses to the presence and phase of Karenia brevis blooms

Bacterial abundance, production, protein and nucleic acid synthesis, growth, and viral abundance were measured in waters associated with three bloom stages of the “red tide” dinoflagellate Karenia brevis along the south West Florida Shelf (WFS). Measurements were taken: (1) when no bloom was present; (2) during the initiation stage of a bloom; and (3) during the maintenance stage of a bloom. Results indicate that the bacterial community was nutrient limited in the non-bloom period, with highest abundance and production rates occurring near and within estuaries. Abundance of virus like particles (VLPs) was higher within estuaries, but we hypothesize VLPs were not a high source of bacterial mortality, possibly due to high decay rates due to UV degradation or extracellular nucleases. High bacterial production, balanced protein to nucleic acid synthesis, and statistically similar bacteria abundances measured on consecutive days within the initiating bloom suggest a highly productive community with equally high mortality. VLP abundance declined during the first 48h within both bloom stages, suggesting that viral genomes were either within host cells (not evident in water column samples), or bacterial mortality was due to mixotrophic grazing by K. brevis. Using a conservative grazing rate of 1bacteriaK. brevis−1h−1, K. brevis grazing could account for >100% of bacterial mortality during an initiating bloom. Bacterial abundance and production were significantly decreased and protein to nucleic acid synthesis became unbalanced during the maintenance phase bloom. An increase in VLP abundance during the maintenance phase was most likely the cause of bacterial mortality as mixotrophic grazing could only account for ∼4% of the change in bacterial abundance. Together, these data suggest that the associated bacteria and viruses play a critical role in the formation and termination of K. brevis blooms