Prevalence of asymptomatic malaria and bed net ownership and use in Bhutan, 2013: a country earmarked for malaria elimination

BACKGROUND With dwindling malaria cases in Bhutan in recent years, the government of Bhutan has made plans for malaria elimination by 2016. This study aimed to determine coverage, use and ownership of LLINs, as well as the prevalence of asymptomatic malaria at a single time-point, in four sub-districts of Bhutan. METHODS A cross-sectional study was carried out in August 2013. Structured questionnaires were administered to a single respondent in each household (HH) in four sub-districts. Four members from 25 HH, randomly selected from each sub-district, were tested using rapid diagnostic tests (RDT) for asymptomatic Plasmodium falciparum and Plasmodium vivax infection. Multivariable logistic regression models were used to identify factors associated with LLIN use and maintenance. RESULTS All blood samples from 380 participants tested negative for Plasmodium infections. A total of 1,223 HH (92.5% of total HH) were surveyed for LLIN coverage and use. Coverage of LLINs was 99.0% (1,203/1,223 HH). Factors associated with decreased odds of sleeping under a LLIN included: washing LLINs nine months compared to washing LLINs every six months; HH in the least poor compared to the most poor socio-economic quintile; a HH income of Nu 5,001-10,000 (US$1 = Nu 59.55), and Nu >10,000, compared to HH with income of <Nu 1,500; HH located one to three hours walking distance to a health centre compared to being located closer to a health centre; a reported lack of knowledge as to what to do in event of LLINs being torn; and keeping LLINs in a box compared to keeping them hanging in the place of use. Factors associated with use of LLINs for purposes other than the intended use included: income group Nu 1,501-3,000 and HH located one to three hours walking distance from a health centre. CONCLUSIONS There was high coverage of LLINs in the study area with regular use of LLINs throughout the year. LLIN use for purposes other than malaria prevention was low. With high coverage and regular use of LLINs, and a zero prevalence of malaria infection found in historically high-risk communities during the peak malaria season, it appears Bhutan is on course to achieve malaria elimination.We acknowledge Queensland Infectious Disease Unit for providing funds to carry out this study

Leader Identity, Expertise Development and Influence - Exploring Principal Leadership in NSW Public Schools

Leader Identity, Expertise Development and Influence — Exploring Principal Leadership in NSW Public Schools investigates the increasingly complex role of school leadership by exploring the multifaceted development of six school principals throughout their career from novice to expert leaders. The use of leadership vignettes, interviews, leadership self-assessments and 360-degree profiles provides qualitative and quantitative research data on the professional experiences of the participant principals. The study explores the relationship between leader identity, expertise development, and influence in driving leadership and school effectiveness. Integrative approaches to leader development over a lifespan (Day, Harrison, & Halpin, 2009), an emerging model of leadership theory, provides the theoretical construct through which to map and analyse the journey of leader identity formation, expertise development, and adult learning. Underpinned by constructive adult development theories, it proposes an innovative approach for career-span leadership and expertise development. The research findings suggest new approaches for developing NSW principal preparation programs and educational leadership frameworks. It is intended that this research study will help to inform future leadership research and resources to support principal preparation, wellbeing, and succession planning initiatives in Australia and beyond

Unraveling the “paradox of the active user”: Determinants of individuals’ innovation with it-based work routines

As individuals become more experienced with information technologies (ITs), they become limited by well-learnedbehavioral routines for using an IT, which act to inhibit innovation. This “paradox of the active user” can prove problematicfor organizations, which derive benefits when organizational ITs are used to their fullest potential. Thus, to advance researchon individual differences and post-adoption use behaviors, this research-in-progress develops a research model examining therelationships among habit, IT mindfulness, and embeddedness of an IT-based routine on individuals’ innovation with IT.Identifying factors that foster or inhibit individuals’ attempts to innovate with ITs can provide actionable guidelines fordesigning managerial interventions to manage and maintain desired levels of user-initiated innovation in the post-adoptivecontext

The Effects of Substance Use and Depressive Symptoms on High-Risk Sexual Behaviors in Sexually Active Vermont Adolescents

Background: There is a high prevalence of substance use, depressive symptoms, and high-risk sexual behaviors (HRSB) among adolescents, but the relationships between these variables is less clear. Objective: To identify associations between these behaviors and outcomes, this study aims to address how depressive symptoms paired with substance use impacts HRSB in adolescents. Methods: Adolescent self-reported depressive and suicidal symptoms, substance use, and HRSB were obtained from the 2015 Vermont Youth Risk Behavior Survey (YRBS) (n= 17,041). The associations between exposures (substance use and depressive symptoms) with HRSB were studied. Variables were calculated using prevalence ratios with 95% confidence intervals (CI) and logistic regression to determine adjusted odds ratios (OR). Results: Adolescents who attempted suicide more than once were \u3e5 times more likely to engage in 4+ HRSB (OR=5.19, P\u3c.001). Low-level drug users were 1.76 times more likely to engage in 4+ HRSB (p=\u3c0.05) and high-level users 6.69 times more likely (p\u3c.001). Reporting sexual intercourse with same sex partners was significantly associated with HRSB, while reported sexual orientation was not. Conclusions: There are associations between both self-reported depressive symptoms and substance use with high-risk sexual behavior in adolescents

Incidence and All-Cause Mortality Rates in Neonates Infected With Carbapenem Resistant Organisms

INTRODUCTION: Multidrug-resistant, Gram-negative infections, particularly due to carbapenem resistant organisms (CRO), have increased globally. Few studies have reported on the burden of CRO in neonates from low-middle income countries (LMIC). This study aimed to determine the incidence and mortality rates of culture-confirmed Gram-negative infections, with a special focus on CRO in a neonatal unit from a LMIC. MATERIALS AND METHODS: Positive bacterial cultures from sterile sites of infants admitted in the neonatal unit from the 1st January 2018 to 31st December 2019, were reviewed retrospectively. Type of organism, susceptibility and outcomes were recorded. Data on Gram-negative isolates, including the CRO, were extracted. Rates and outcomes were analysed. RESULTS: There were 2219 neonates with organisms isolated from sterile sites (blood and cerebrospinal fluid), accounting for 30% of all admissions, giving a neonatal sepsis incidence of 17.9/1000 patient-days. There was a total of 1746 positive isolates (excluding coagulase negative Staphyloccocus). Of these, 1706 (98%) were isolated from blood, and 40 (2%) from cerebrospinal fluid. Overall, 1188 (68%) were Gram-negative, 371 (21%) Gram-positive and 187 (10.7%) fungal isolates. The common Gram-negatives were Acinetobacter baumannii (526/1188;44%) and Klebsiella pneumoniae (469/1188;40%). Carbapenem resistance was observed in 359 (68%) of the Acinetobacter baumannii (CRAB) and in 103 (18%) of the Enterobacterales (CRE) isolates, with 98% of CRE being Klebsiella pneumoniae (CR-Klebs). Twenty-four (41%) of Pseudomonas species were carbapenem resistant. Overall, carbapenem resistance was seen in 42% of all Gram-negative organisms. The rate of CRAB and CRE were 2.9 and 0.8/1000 patient-days respectively. The overall, all-cause in-hospital mortality rate in infants with Gram-negative isolates was 22%, with higher mortality rate in those infected with CRO compared to non-CRO (34% vs 13%; OR 3.44; 95% CI 2.58–4.60; p < 0.001). The mortality rate in infants with CRE was higher than those with CRAB (48% vs 33%; OR 1.85; 95% CI 1.18–2.89; p = 0.007). CONCLUSION: We observed a high incidence of positive cultures from sterile sites. The common organisms isolated were Gram-negatives, and among these carbapenem resistance was high and was associated with high mortality. Mortality was higher in infants with CRE compared to those with CRAB

The DURATIONS randomised trial design: estimation targets, analysis methods and operating characteristics

Background. Designing trials to reduce treatment duration is important in several therapeutic areas, including TB and antibiotics. We recently proposed a new randomised trial design to overcome some of the limitations of standard two-arm non-inferiority trials. This DURATIONS design involves randomising patients to a number of duration arms, and modelling the so-called duration-response curve. This article investigates the operating characteristics (type-1 and type-2 errors) of different statistical methods of drawing inference from the estimated curve. Methods. Our first estimation target is the shortest duration non-inferior to the control (maximum) duration within a specific risk difference margin. We compare different methods of estimating this quantity, including using model confidence bands, the delta method and bootstrap. We then explore the generalisability of results to estimation targets which focus on absolute event rates, risk ratio and gradient of the curve. Results. We show through simulations that, in most scenarios and for most of the estimation targets, using the bootstrap to estimate variability around the target duration leads to good results for DURATIONS design-appropriate quantities analogous to power and type-1 error. Using model confidence bands is not recommended, while the delta method leads to inflated type-1 error in some scenarios, particularly when the optimal duration is very close to one of the randomised durations. Conclusions. Using the bootstrap to estimate the optimal duration in a DURATIONS design has good operating characteristics in a wide range of scenarios, and can be used with confidence by researchers wishing to design a DURATIONS trial to reduce treatment duration. Uncertainty around several different targets can be estimated with this bootstrap approach.Comment: 4 figures, 1 table + additional materia

Impact of Nutrition Intervention on Mental Health Outcomes in Adults: Preliminary Evidence from a Systematic Review and Meta-Analysis

Background and objectives: Mental health disorders are the leading cause of ill health and disability in adults, with depression and anxiety being the most prevalent. Emerging evidence indicates roles for specific nutrients—particularly, omega-3 fatty acids, vitamin D, folate, and the metabolically related B vitamins (B12, B6 and riboflavin)—in protecting against depression and anxiety, but the evidence is conflicting. The aim was to conduct a systematic review and meta-analysis investigating the effect of intervention with nutritional factors on mental health outcomes in adults. Methods: Searches were conducted using the following electronic bibliographic databases: MEDLINE, EMBASE and PsycINFO. Inclusion criteria were randomised controlled trials (RCTs) or controlled dietary interventions, participants aged ≥18 years, study duration ≥12 weeks and depression or anxiety outcome measures. The risk of bias and quality of the evidence were assessed using the Cochrane Risk of Bias 2 tool and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework, respectively. Results: A total of 83 studies met the inclusion criteria, of which 73 were included in the meta-analysis. Regarding the role of specific nutrients in depression, RCTs with B vitamins (standardised mean difference, SMD, −1.91 95% CI −3.69, −0.13) and zinc (SMD −0.59 95% CI −0.86, −0.30) indicated significant benefits in reducing depression. Although no overall effect of vitamin D intervention in reducing depression for studies was found, subgroup analysis showed a beneficial effect of 12-week duration (SMD −0.29 95% CI −0.57, −0.01), while no significant effect of omega-3 fatty acid intervention was observed (SMD −0.47 95% CI −0.98, 0.04). RCTs with vitamin D indicated beneficial effects in reducing anxiety (SMD −0.69 95% CI −1.27, −0.11). No significant effect of omega-3 fatty acids on anxiety was shown, while there were insufficient RCTs with B vitamins and zinc in relation to anxiety. Discussion: This preliminary analysis demonstrated a potential role for B vitamins, vitamin D and zinc, but no benefit of intervention with omega-3 fatty acids, on depression. Vitamin D may play a role in reducing anxiety, whereas omega-3 does not. Confirmation of these preliminary findings is required from new RCTs with relevant nutrients

B-Vitamin Biomarkers in Relation to Immune Function in Older Adults: Preliminary Analysis from the TUDA Study

Background and objectives: Immune function typically declines with age, increasing susceptibility to disease. Many factors contribute to this decline, including nutritional status. Emerging evidence shows associations of folate and related B-vitamins (B12, B6, and riboflavin) with immune health, but these interactions are complex. The aim of this study was to investigate B-vitamin biomarkers in relation to immune function in ageing. We hypothesised that the higher status of certain B-vitamins will be associated with improved inflammatory markers. Methods: The data were analysed from the Trinity-Ulster-Department of Agriculture (TUDA) study, aimed at investigating health and lifestyle factors in relation to disease, in community-dwelling older adults recruited from the island of Ireland (2008–2012). Of the 5186 TUDA participants, 2724 fulfilled the inclusion criteria for the current investigation. We measured B-vitamin biomarkers, namely, red blood cell folate, serum B12, plasma pyridoxal-5-phosphate (PLP; B6), the erythrocyte glutathione reductase activation coefficient (EGRac; riboflavin), pro-inflammatory markers (interleukin IL-6, tumor necrosis factor-alpha [TNF-α], and c-reactive protein [CRP]), and the anti-inflammatory marker (IL-10). Results: Plasma PLP was negatively associated with CRP (β: −0.066; 95% CI: −0.005–0.000; p = 0.020), and plasma homocysteine was positively associated with CRP (β: 0.062; 95% CI: 0.003–0.066; p = 0.030) and TNF-α (β: 0.086; 95% CI: 0.023–0.124; p = 0.004). No other significant associations between B-vitamins and inflammatory markers were found. As regards general characteristics, the concentrations of IL-6 (p = 0.040) and CRP (p = 0.010) increased with age; CRP (p &lt; 0.001); TNF-α (p = 0.024) increased with BMI; higher IL-6 (p = 0.041) was associated with living alone; and higher CRP (p &lt; 0.001) was associated with smoking. Discussion: These preliminary findings suggest that improving vitamin B6 status and maintaining a healthy weight in older age may support a healthier immune system. Further investigation, particularly in the form of randomised controlled trials, is required to confirm the current findings and investigate the impact of B-vitamins on immune function

Malaria burden and costs of intensifi ed control in Bhutan, 2006–14: an observational study and situation analysis

Introduction The number of malaria cases has fallen in Bhutan in the past two decades, and the country has a goal of complete elimination of malaria by 2016. The aims of this study are to ascertain the trends and burden of malaria, the costs of intensifi ed control activities, the main donors of funding for the control activities, and the costs of diff erent preventive measures in the pre-elimination phase (2006–14) in Bhutan. Methods We undertook a descriptive analysis of malaria surveillance data from 2006 to 2014, using data from the Vector-borne Disease Control Programme (VDCP) run by the Department of Public Health of Bhutan’s Ministry of Health. Malaria morbidity and mortality in local Bhutanese people and foreign nationals were analysed. The cost of diff erent control and preventive measures were calculated, and the average numbers of long-lasting insecticidal nests per person were estimated. Findings A total of 5491 confi rmed malaria cases occurred in Bhutan between 2006 and 2014. By 2013, there was an average of one long-lasting insecticidal net for every 1·51 individuals. The cost of procuring long-lasting insecticidal nets accounted for more than 90% of the total cost of prevention measures. The Global Fund to Fight AIDS, Tuberculosis and Malaria was the main international donor, accounting for more than 80% of the total funds. Interpretation The malaria burden in Bhutan decreased signifi cantly during the study period with high coverage of long-lasting insecticidal nets. The foreseeable challenges that require national attention to maintain a malaria-free status after elimination are importation of malaria, especially from India; continued protection of the population in endemic districts through complete coverage with long-lasting insecticidal nets and indoor residual spraying; and exploration of local funding modalities post-elimination in the event of a reduction in international funding