Infectious Disease Epidemiology in the Asia-Pacific Region

My Master of Philosophy in Applied Epidemiology (MAE) placement at the National Centre for Immunisation Research and Surveillance (NCIRS) focused on various vaccine preventable diseases from a state, national and international lens. In response to a rise in invasive meningococcal serogroup W disease in Australia, I performed a comprehensive epidemiological review of the disease. My findings informed the decision of the Australian Technical Advisory Group on Immunisation to support the addition of the quadrivalent meningococcal vaccine onto the National Immunisation Program, providing immunity for meningococcal serogroups A, C, W and Y in infants and young adults. A small outbreak of varicella among children in an outside of school hours care facility provided the opportunity to conduct an outbreak investigation and a vaccine effectiveness study. Although underpowered, this study demonstrated the occurrence of breakthrough varicella despite high one-dose coverage among primary school-aged children, and evidence for consideration of a two-dose nationally funded program. I performed another vaccine effectiveness study following a state-wide outbreak of rotavirus in New South Wales in 2017. This was accompanied by an epidemiological analysis of rotavirus notifications and a genetic profile analysis of hospitalised rotavirus cases. The rotavirus outbreak occurred despite high vaccine effectiveness and vaccine coverage. The findings indicated that rotavirus is increasing among the older population who do not have vaccine-induced immunity. I conducted the first evaluation of the Paediatric Active Enhanced Disease Surveillance (PAEDS) system. PAEDS is an NCIRS-led initiative and actively finds hospitalised cases of serious childhood conditions and adverse events following immunisation. I evaluated this system using a mixed methods study design involving data analysis and stakeholder questionnaires. This evaluation provided practical recommendations for the progression and continuation of PAEDS in a time where the future of PAEDS is unknown. As part of the international response to the diphtheria outbreak among refugees in Bangladesh, I assisted the response of the World Health Organization in Cox's Bazar. As an epidemiologist, I analysed communicable disease alerts and trends in the refugee camps as well as investigated disease reports and conducted risk assessments. I gained further international experience by assisting in an applied field epidemiology research study: 'Surveillance and Monitoring to Eliminate Lymphatic Filariasis and Scabies from Samoa'. I conducted field visits to dozens of households in remote villages of Samoa to collect mosquitoes for testing the prevalence of lymphatic filariasis antibodies and antigens. The works within this thesis fulfil the requirements of the MAE. This thesis reports analyses of the epidemiology of invasive meningococcal disease in Australia, vaccine effectiveness of varicella among highly vaccinated children in Brisbane, epidemiology and vaccine effectiveness of rotavirus in New South Wales, evaluation of a surveillance system of serious childhood conditions in Australia, as well as describes the response to a humanitarian emergency in Bangladesh and assistance in a field research study in Samoa. These projects contribute to the work of NCIRS in informing the National Immunisation Program and vaccine policy and practice, as well as to the evidence base of vaccine preventable diseases and international epidemiological research

Paediatric Obesity Research in Early Childhood and the Primary Care Setting: The TARGet Kids! Research Network

Primary paediatric health care is the foundation for preventative child health. In light of the recent obesity epidemic, paediatricians find themselves at the frontline of identification and management of childhood obesity. However, it is well recognized that evidence based approaches to obesity prevention and subsequent translation of this evidence into practice are critically needed. This paper explores the role of primary care in obesity prevention and introduces a novel application and development of a primary care research network in Canada—TARGet Kids!—to develop and translate an evidence-base on effective screening and prevention of childhood obesity

Field epidemiology in action: an Australian perspective of epidemic response to the Rohingya health emergencies in Cox’s Bazar, Bangladesh

Approximately one million Rohingya persons who fled waves of violence in Myanmar at different times, the latest being 25 August 2017, now live in two coastal districts in Bangladesh; Cox’s Bazar and Bandarban (1). In makeshift shelters made from bamboo and tarpaulin in camps sprawling through rough terrains, the Rohingya live in conditions of overcrowding, poor sanitation, high malnutrition and, on arrival, extremely low vaccination coverage (1-3).BK, JEM and MXT were supported by Australian Government Research Training Program (RTP) Scholarships

Implementation of N-1 process intensification in bioprocess development and production

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JACK trial protocol: a phase III multicentre cluster randomised controlled trial of a school-based relationship and sexuality education intervention focusing on young male perspectives.

INTRODUCTION: Teenage pregnancy remains a worldwide health concern which is an outcome of, and contributor to, health inequalities. The need for gender-aware interventions with a focus on males in addressing teenage pregnancy has been highlighted as a global health need by WHO and identified in systematic reviews of (relationship and sexuality education (RSE)). This study aims to test the effectiveness of an interactive film-based RSE intervention, which draws explicit attention to the role of males in preventing an unintended pregnancy by reducing unprotected heterosexual teenage sex among males and females under age 16 years. METHODS AND ANALYSIS: A phase III cluster randomised trial with embedded process and economic evaluations. If I Were Jack encompasses a culturally sensitive interactive film, classroom materials, a teacher-trainer session and parent animations and will be delivered to replace some of the usual RSE for the target age group in schools in the intervention group. Schools in the control group will not receive the intervention and will continue with usual RSE. Participants will not be blinded to allocation. Schools are the unit of randomisation stratified per country and socioeconomic status. We aim to recruit 66 UK schools (24 in Northern Ireland; 14 in each of England, Scotland and Wales), including approximately 7900 pupils. A questionnaire will be administered at baseline and at 12-14 months postintervention. The primary outcome is reported unprotected sex, a surrogate measure associated with unintended teenage pregnancy. Secondary outcomes include knowledge, attitudes, skills and intentions relating to avoiding teenage pregnancy in addition to frequency of engagement in sexual intercourse, contraception use and diagnosis of sexually transmitted infections. ETHICS AND DISSEMINATION: Ethical approval was obtained from Queen's University Belfast. Results will be published in peer-reviewed journals and disseminated to stakeholders. Funding is from the National Institute for Health Research. TRIAL REGISTRATION NUMBER: ISRCTN99459996

Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation

Objectives: To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. Setting: Two UK cystic fibrosis (CF) units. Participants: Fourteen adult PWCF; three professionals delivering adherence support (‘interventionists’); five multi-disciplinary CF team members. Interventions: Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). Primary and secondary measures: Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. Results: Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%–92%, respectively, indicating that interventionists needed to focus more on intervention ‘active ingredients’ during sessions. Conclusions: The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. Trial registration number: ISRCTN13076797; Results

Por Granada: Revista de Estudiantes, Vol. 2, Spring 2012

The magazine Por Granada publishes the students’ final project of the course Spain in Context taught by Prof. Lamas at Fordham in Granada. Rather than the academic research paper, the preferred format is the well-informed article of investigative journalism. Topics are chosen in consultation with Prof. Lamas and Begoña Calatrava, and must involve a demanding first-hand fieldwork in Granada. A number of interviews with locals are required to have the project approved. Students are requested to find their own sources and to create an adequate network of contacts to fully understand the chosen subject matter. All articles are the result of a thoughtful teamwork of their authors and have been originally written in Spanish.https://fordham.bepress.com/modlang_studentpubs/1003/thumbnail.jp

The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote aboriginal Australian health care setting

Background: Australian Aboriginal and Torres Strait Islander peoples (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the outcome of a study that aimed to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. Methods: A randomised controlled trial of Aboriginal researcher delivered tailored smoking cessation counselling during face-to-face visits, aiming for weekly for the first four weeks, monthly to six months and two monthly to12 months. The control (“usual care”) group received routine care relating to smoking cessation at their local primary health care service. Data collection occurred at enrolment, six and 12 months. The primary outcome was self-reported smoking cessation with urinary cotinine confirmation at final follow-up (median 13 (interquartile range 12–15) months after enrolment).Results: Participants in the intervention (n = 55) and usual care (n = 108) groups were similar in baseline characteristics, except the intervention group was slightly older. At final follow-up the smoking cessation rate for participants assigned to the intervention group (n = 6; 11%), while not statistically significant, was double that of usual care (n = 5; 5%; p = 0.131). A meta-analysis of these findings and a similarly underpowered but comparable study of pregnant Indigenous Australian women showed that Indigenous Australian participants assigned to the intervention groups were 2.4 times (95% CI, 1.01-5.5) as likely to quit as participants assigned to usual care. Conclusions: Culturally appropriate, multi-dimensional Indigenous quit smoking programs can be successfully implemented in remote primary health care. Intensive one-on-one interventions with substantial involvement from Aboriginal and Torres Strait Islander workers are likely to be effective in these settings. Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303)

Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study

Background: There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs)investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program. Methods: Qualitative study using data collected from multiple documentary sources related to the BOABS Study. As the project neared completion the research team participated in four workshops to review and conduct thematic analyses of these documents. Results: Challenges we encountered during the relatively complex BOABS Study included recruiting sufficient number of participants; managing the project in two distant locations and ensuring high quality work across both sites; providing appropriate training and support to Aboriginal researchers; significant staff absences, staff shortages and high workforce turnover; determining where and how the project fitted in the clinics and consequent siloing of the Aboriginal researchers relating to the requirements of RCTs; resistance to change, and maintaining organisational commitment and priority for the project.The results of this study also demonstrated the importance of local Aboriginal ownership, commitment, participation and control. This included knowledge of local communities, the flexibility to adapt interventions to local settings and circumstances, and taking sufficient time to allow this to occur. Conclusions: The keys to the success of the BOABS Study were local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety. There were difficulties associated with the BOABS Study being an RCT, and many of these are shared with stand-alone programs. Interventions targeted at particular health problems are best integrated with usual primary health care. Research to investigate complex interventions in Indigenous health should not be limited to randomised clinical trials and funding needs to reflect the additional, but necessary, cost of providing for local control of planning and implementation

Arizona\u27s Vulnerable Populations

Arizona’s vulnerable populations are struggling on a daily basis but usually do so in silence, undetected by traditional radar and rankings, often unaware themselves of their high risk for being pushed or pulled into a full crisis. Ineligible for financial assistance under strict eligibility guidelines, they don’t qualify as poor because vulnerable populations are not yet in full crisis. To be clear, this report is not about the “poor,” at least not in the limited sense of the word. It is about our underemployed wage earners, our single-parent households, our deployed or returning military members, our under-educated and unskilled workforce, our debt-ridden neighbors, our uninsured friends, our family members with no savings for an emergency, much less retirement