Comparing a range of potassium-enriched low sodium salt substitutes to common salt: Results of taste and visual tests in South African adults.

BACKGROUND AND AIMS: Potassium-enriched low sodium salt substitutes (LSSS), which replace a proportion of sodium chloride (NaCl) with potassium chloride (KCl), have been shown to reduce blood pressure and offer a potential solution to address the high burden of hypertension in South Africa. However, it is unknown which proportions of KCl in LSSS are acceptable. We compared the taste and visual acceptability of various LSSS in South African adults. METHODS AND RESULTS: Fifty-six adults underwent double-blind taste and visual tests of four LSSS (35%KCl/65%NaCl; 50%KCl/50%NaCl; 66%KCl/34%NaCl; 100%KCl) in comparison to 100%NaCl (common salt). Participants scored each product by taste ranking, taste perception and likeliness to use. Participants then visually inspected the five products and attempted to identify which was which. Almost half (45 %) of participants ranked the taste of 50%KCl/50 %NaCl as fantastic or really good. Furthermore, 62 % of participants liked and would be happy to use the 50 %KCl/50 %NaCl or felt this tasted like common salt. Only 12 % rated the 100%KCl highly for taste, and over half reported being unlikely to use this. Most participants (57.3 % and 36.4 %) were able to visually identify 100%NaCl and 100%KCl, while identification of other blends was generally poor. Responses were similar for 35%KCl/65%NaCl and 66%KCl/34%NaCl throughout. CONCLUSION: Our findings suggest that the taste of the 50%KCl salt substitute would be well tolerated by South African adults, most of which could not visually differentiate between this salt substitute and common salt.

Examining the referral of patients with elevated blood pressure to health resources in an under-resourced community in South Africa.

BACKGROUND: Low-and-middle income countries face a disproportionate burden of non-communicable diseases (NCDs) that threaten to overwhelm under-resourced health systems. Community health workers (CHWs) can promote NCD prevention, reach patients, and connect them to local community health resources; however, little has been done to examine how referrals to these resources are utilized by community members. The purpose of this study is to examine the use of referrals to community-based health resources and investigate the factors influencing patient utilization of referrals connecting them to appropriate health resources for elevated blood pressure (BP). METHODS: CHWs conducted home visits, which included BP screening and brief counseling, with community members in Soweto, South Africa. Participants with elevated (systolic BP: 121-139/ diastolic BP: 81-89 mmHg) or high (≥ 140/90 mmHg) BP were referred to either a local, community-based physical activity (PA) program managed by a non-governmental organization or local health clinics. The number of participants that received and utilized their referrals was tracked. Follow-up interviews were conducted with individuals given a referral who: (1) went to the PA program, (2) did not go to the PA program, (3) went to a clinic, and (4) did not go to a clinic. Interviews were transcribed and analyzed to identify common themes and differences between groups regarding their decisions to utilize the referrals. RESULTS: CHWs visited 1056 homes, with 1001 community members consenting to the screening; 29.2% (n = 292) of adults were classified as having optimal BP (≤120/80 mmHg), 35.8% (n = 359) had elevated BP, and 35.0% (n = 350) had high BP. One hundred and seventy-three participants accepted a referral to the PA program with 46 (26.6%) enrolling. Five themes emerged from the interviews: (1) prior knowledge and thoughts on BP, (2) psychosocial factors associated with BP control, (3) perception about receiving the referral, (4) contextual factors influencing referral utilization, and (5) perceived benefits of utilizing the referral. CONCLUSION: CHWs can successfully increase community members' access to health resources by providing appropriate referrals. However, greater attention needs to address community members' barriers and hesitancy to utilize health resources.

May Measurement Month 2021: an analysis of blood pressure screening results from South Africa.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. In Sub-Saharan Africa, hypertension prevalence is higher and cardiovascular events occur at a younger age than in Europe or America. May Measurement Month (MMM) is a global campaign initiated by the International Society of Hypertension (ISH) aimed at raising awareness of high BP. In South Africa, the MMM campaign in 2017, 2018, and 2019 revealed that approximately one-third of adults had hypertension, only half of hypertensives were receiving antihypertensive therapy, and only a third of those with hypertension had controlled BP. These data highlight the need for continued BP screening and awareness campaigns in South Africa. From May to November 2021, a cross-sectional survey of volunteers aged ≥18 years was performed. Blood pressure measurements, definition of hypertension, and statistical analyses followed the MMM protocol. The screening sites targeted the general population mainly on university campuses and pharmacies in preference to hospitals and clinics, aiming to raise awareness and allow access to screening in those less likely to be aware of their BP status. Of the 2294 individuals (age 37.3 ± 16.9 years) screened, 30.8% had hypertension. Of those with hypertension, only 48.6% were aware and 43.5% were receiving treatment for hypertension. A large proportion (50.4%) of individuals receiving antihypertensive medication had uncontrolled BP (≥140/90 mmHg). In conclusion, the high prevalence of hypertension, despite the young adult age, and the high proportions of individuals unaware of their hypertension and with uncontrolled BP underscore the necessity for hypertension awareness campaigns and more rigorous management of hypertension.

Validation of a short food group questionnaire to determine intakes from healthy and unhealthy food groups in 5-9-year-old South African children.

BACKGROUND: Reliable dietary data for children are necessary to investigate associations with health outcomes. The present study aimed to develop and validate a questionnaire to determine the frequency of intakes of specific healthy and unhealthy food groups in young children. METHODS: Participants were 5-9-year-old South African children (n = 920) from 10 urban schools. Their parents completed a demographic questionnaire and the food intake questionnaire with food pictures. Based on the literature, four healthy food groups (fruits, vegetables, milk, meat/fish/poultry/eggs) and six unhealthy food groups (hot and cold sugar-sweetened beverages, candy, salty snacks, cakes and fast foods) were included, with five different frequency responses. Six experienced nutritionists assessed the face validity and content validity. After pilot testing, construct validity and homogeneity were determined in the participants. Convergent validity was determined using urinary sodium and potassium concentrations as biological intake markers. RESULTS: Nutritionists confirmed face and content validity. Caregivers confirmed understanding of the questionnaire. Three factors explained 50.2% of the variance, with most unhealthy food groups as factor 1, fruits and vegetables as factor 2, and animal source protein and milk groups clustered with sugar-sweetened beverages as factor 3. The frequency of milk group, fruits and vegetables intake correlated negatively, whereas the frequency of salty snacks and fast foods intakes correlated positively with the urinary sodium:potassium ratio. CONCLUSIONS: The healthy and unhealthy food group questionnaire has advantages of low respondent burden, as well as acceptable content and convergent validity in South African children. The questionnaire may be used to investigate associations between food intakes and health outcomes.

Cardiovascular health metrics in low and middle-income countries: A scoping review.

BACKGROUND: In 2010 the American Heart Association defined the concept of ideal cardiovascular health to renew the focus on primordial prevention for cardiovascular disease. Evidence primarily from high-income countries suggests ideal CVH prevalence is low and decreases with age, with vulnerable populations differentially affected. We aimed to identify and characterize the evidence relevant to CVH metrics in low- and middle-income countries (LMICs). METHODS: We followed the Joanna Briggs Institute guideline for the conduct of this scoping review. We searched MEDLINE, Embase, LILACS and study registers from inception to 14 March 2022. We included cross-sectional and cohort studies in populations representing a geographically-defined unit (urban or rural) in LMICs, and with data on CVH metrics i.e. all health or clinical factors (cholesterol, blood pressure, glycemia and body mass index) and at least one health behavior (smoking, diet or physical activity). We report findings following the PRISMA-Scr extension for scoping reviews. RESULTS: We included 251 studies; 85% were cross-sectional. Most studies (70.9%) came from just ten countries. Only 6.8% included children younger than 12 years old. Only 34.7% reported seven metrics; 25.1%, six. Health behaviors were mostly self-reported; 45.0% of studies assessed diet, 58.6% physical activity, and 90.0% smoking status. CONCLUSIONS: We identified a substantial and heterogeneous body of research presenting CVH metrics in LMICs. Few studies assessed all components of CVH, especially in children and in low-income settings. This review will facilitate the design of future studies to bridge the evidence gap. This scoping review protocol was previously registered on OSF: https://osf.io/sajnh.

How do we best engage young people in decision-making about their health? A scoping review of deliberative priority setting methods.

INTRODUCTION: International organisations have called to increase young people's involvement in healthcare and health policy development. We currently lack effective methods for facilitating meaningful engagement by young people in health-related decision-making. The purpose of this scoping review is to identify deliberative priority setting methods and explore the effectiveness of these in engaging young people in healthcare and health policy decision-making. METHODS: Seven databases were searched systematically, using MeSH and free text terms, for articles published in English before July 2021 that described the use of deliberative priority setting methods for health decision-making with young people. All titles, abstracts and full-text papers were screened by a team of six independent reviewers between them. Data extraction followed the Centre for Reviews and Dissemination guidelines. The results are presented as a narrative synthesis, structured around four components for evaluating deliberative processes: 1) representation and inclusion of diverse participants, 2) the way the process is run including levels and timing of participant engagement, 3) the quality of the information provided to participants and 4) resulting outcomes and decisions. FINDINGS: The search yielded 9 reviews and 21 studies. The more engaging deliberative priority setting tools involved young people-led committees, mixed methods for identifying and prioritising issues and digital data collection and communication tools. Long-term and frequent contact with young people to build trust underpinned the success of some of the tools, as did offering incentives for taking part and skills development using creative methods. The review also suggests that successful priority setting processes with young people involve consideration of power dynamics, since young people's decisions are likely to be made together with family members, health professionals and academics. DISCUSSION: Young people's engagement in decision-making about their health is best achieved through investing time in building strong relationships and ensuring young people are appropriately rewarded for their time and contribution. If young people are to be instrumental in improving their health and architects of their own futures, decision-making processes need to respect young people's autonomy and agency. Our review suggests that methods of power-sharing with young people do exist but that they have yet to be adopted by organisations and global institutions setting global health policy.

Food insecurity and coping strategies and their association with anxiety and depression: a nationally representative South African survey.

OBJECTIVE: To investigate food insecurity and related coping strategies among South African households and their associations with anxiety and depression. DESIGN: Cross-sectional study. Food insecurity and coping strategies were assessed using a modified Community Childhood Hunger Identification Project and the Coping Strategies Index questionnaires. The Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 were used to assess anxiety and depression risk. Ordered logistic regressions were used to test associations of food insecurity and related coping strategies with anxiety and depression. SETTING: South Africa during COVID-19, October 2021. PARTICIPANTS: Nationally representative sample of 3402 adults, weighted to 39,640,674 South African households. RESULTS: About 20·4 % of South African households were food insecure, with the most affected being from the lowest socio-economic groups. Shifting from 'food secure' to 'at risk' or from 'at risk' to 'food insecure' group was associated with 1·7 times greater odds of being in a higher category of anxiety or depression (P < 0·001). All coping strategies were used to some extent in South African households, with 46·0 % relying on less preferred and less expensive foods and 20·9 % sending a household member to beg for food. These coping strategies were mostly used by food-insecure households. Although the odds of moving to a higher category of anxiety and depression were observed among all coping strategies (all P < 0·001), begging for food was associated with the highest odds (OR = 2·3). CONCLUSIONS: Food insecurity remains a major health threat in South Africa. Public measures to address mental health should consider reductions in food insecurity as part of their strategy.

Using the COM-B model and Behaviour Change Wheel to develop a theory and evidence-based intervention for women with gestational diabetes (IINDIAGO).

BACKGROUND: In South Africa, the prevalence of gestational diabetes (GDM) is growing, concomitant with the dramatically increasing prevalence of overweight/obesity among women. There is an urgent need to develop tailored interventions to support women with GDM to mitigate pregnancy risks and to prevent progression to type 2 diabetes post-partum. The IINDIAGO study aims to develop and evaluate an intervention for disadvantaged GDM women attending three large, public-sector hospitals for antenatal care in Cape Town and Soweto, SA. This paper offers a detailed description of the development of a theory-based behaviour change intervention, prior to its preliminary testing for feasibility and efficacy in the health system. METHODS: The Behaviour Change Wheel (BCW) and the COM-B model of behaviour change were used to guide the development of the IINDIAGO intervention. This framework provides a systematic, step-by-step process, starting with a behavioural analysis of the problem and making a diagnosis of what needs to change, and then linking this to intervention functions and behaviour change techniques to bring about the desired result. Findings from primary formative research with women with GDM and healthcare providers were a key source of information for this process. RESULTS: Key objectives of our planned intervention were 1) to address women's evident need for information and psychosocial support by positioning peer counsellors and a diabetes nurse in the GDM antenatal clinic, and 2) to offer accessible and convenient post-partum screening and counselling for sustained behaviour change among women with GDM by integrating follow-up into the routine immunisation programme at the Well Baby clinic. The peer counsellors and the diabetes nurse were trained in patient-centred, motivational counselling methods. CONCLUSIONS: This paper offers a rich description and analysis of designing a complex intervention tailored to the challenging contexts of urban South Africa. The BCW was a valuable tool to use in designing our intervention and tailoring its content and format to our target population and local setting. It provided a robust and transparent theoretical foundation on which to develop our intervention, assisted us in making the hypothesised pathways for behaviour change explicit and enabled us to describe the intervention in standardised, precisely defined terms. Using such tools can contribute to improving rigour in the design of behavioural change interventions. TRIAL REGISTRATION: First registered on 20/04/2018, Pan African Clinical Trials Registry (PACTR): PACTR201805003336174.

The Effects of COVID-19 Pandemic Lockdowns on Alcohol Consumption and Tobacco Smoking Behaviour in South Africa: A National Survey.

INTRODUCTION: During the first phase of the coronavirus (COVID-19) pandemic lockdowns in South Africa (SA), both alcohol and tobacco were considered non-essential goods and their sales were initially prohibited and further restricted to certain days and timeframes. This study investigates self-reported changes in alcohol consumption and tobacco smoking behaviour in the general population during the COVID-19 pandemic lockdowns in SA. METHODS: A cross-sectional national survey was conducted in October 2021 (before the Omicron wave 4 and while SA was in low-level lockdown) among 3,402 nationally representative respondents (weighted to 39,640,674) aged 18 years and older. Alcohol consumption and tobacco use were assessed from the beginning of the lockdown towards the end of March 2020 until October 2021 using the WHO-AUDIT and the US Centre for Disease Control (CDC) Global Adult Tobacco Survey questionnaires, respectively. RESULTS: Among those that drank alcohol (33.2%), 31.4% were classified as having a drinking problem that could be hazardous or harmful and 18.9% had severe alcohol use disorder during the COVID-19 lockdowns. Twenty-two per cent (22.0%) of those that reported alcohol consumption reported that the COVID-19 pandemic lockdowns changed their alcohol consumption habits, with 38.1% reporting a decreased intake or quitting altogether. Among the one in five respondents (19.2%) who had ever smoked, most reported smoking at the time of the survey (82.6%) with many classified as light smokers (87.8%; ≤10 cigarettes/day). Almost a third (27.2%) of those smoking reported that the COVID-19 pandemic lockdowns had changed their use of tobacco products or vaping, with 60.0% reporting a reduction/quitting tobacco use. Given that sales were restricted this indicates that people could still get hold of tobacco products. Heavy smoking was associated with older age (p = 0.02), those classified as wealthy (p < 0.001), those who started or increased tobacco smoking during the pandemic lockdowns (p = 0.01) and residential provinces (p = 0.04). CONCLUSION: Given restrictions on the sale of alcohol and tobacco in SA between 27 March and August 17, 2020, during the pandemic, respondents reported an overall decline in alcohol consumption and tobacco use which might suggest that the regulatory restrictive strategies on sales had some effect but may be inadequate, especially during times where individuals are likely to experience high-stress levels. These changes in alcohol consumption and tobacco use were different from what was reported in several European countries, possibly due to differences in the restrictions imposed in SA when compared to these European countries.

Cross-sectional associations between mental health indicators and social vulnerability, with physical activity, sedentary behaviour and sleep in urban African young women.

BACKGROUND: Relationships between mental health and multiple health behaviours have not been explored in young South African women experiencing social constraints. The aim of this study was to identify associations between mental health indicators and risk factors with physical activity, sedentary behaviour, and sleep, amongst young women living in Soweto, a predominantly low-income, urban South African setting. METHODS: For this cross-sectional study, baseline measurements for participants (n = 1719, 18.0-25.9 years old) recruited for the Healthy Life Trajectories Initiative were used including: physical activity, sedentary behaviour (sitting, screen and television time), sleep (duration and quality), depression and anxiety indicators, emotional health, adverse childhood experiences, alcohol-use risk; social vulnerability, self-efficacy, and social support. RESULTS: Multiple regression analyses showed that depression (ß = 0.161, p < 0.001), anxiety (ß = 0.126, p = 0.001), adverse childhood experiences (ß = 0.076, p = 0.014), and alcohol-use risk (ß = 0.089, p = 0.002) were associated with poor quality sleep. Alcohol-use risk was associated with more screen time (ß = 0.105, p < 0.001) and television time (ß = 0.075, p < 0.016). Social vulnerability was associated with lower sitting time (ß = - 0.187, p < 0001) and screen time (ß = - 0.014, p < 0.001). Higher self-efficacy was associated with more moderate- to vigorous-intensity physical activity (ß = 0.07, p = 0.036), better-quality sleep (ß = - 0.069, p = 0.020) and less television time (ß = - 0.079, p = 0.012). Having no family support was associated with more sitting time (ß = 0.075, p = 0.022). Binomial logistic regression analyses supported these findings regarding sleep quality, with anxiety and depression risk doubling the risk of poor-quality sleep (OR = 2.425, p < 0.001, OR = 2.036, p = 0.003 respectively). CONCLUSIONS: These findings contribute to our understanding of how mental health indicators and risk factors can be barriers to health behaviours of young women in Soweto, and that self-efficacy and social support can be protective for certain of these behaviours for these women. Our results highlight the uniqueness of this setting regarding associations between mental health and behaviours associated with non-communicable diseases risk.

Obesity, hypertension, and tobacco use associated with left ventricular remodeling and hypertrophy in South African women: Birth to Twenty Plus Cohort.

BACKGROUND: Left ventricular hypertrophy (LVH) is a marker of increased risk in developing future life-threatening cardiovascular disease (CVD), however, it is unclear how CVD risk factors, such as obesity, blood pressure (BP), and tobacco use, are associated with left ventricular (LV) remodeling and LVH in urban African populations. Therefore, we aimed to identify the prevalence of LVH as well as the health factors associated with LV remodeling and LVH, within black South African adult women and their pre-pubescent children. METHODS: Black female adults (n = 123; age: 29-68 years) and their children (n = 64; age: 4-10; 55% female) were recruited from the Birth to Twenty Plus Cohort in Soweto, South Africa. Tobacco and alcohol use, physical activity, presence of diabetes mellitus, heart disease, and medication were self-reported. Height, weight, and blood pressure were measured in triplicate to determine the prevalence of obesity and hypertension respectively. Echocardiography was used to assess LV mass at end-diastole, based on linear measurements, and indexed to body surface area to determine LVH. RESULTS: Hypertension and obesity prevalences were 35.8% and 59.3% for adults and 45.3% and 6.3% for children. Self-reported tobacco use in adults was 22.8%. LVH prevalence was 35.8% in adults (75% eccentric: 25% concentric), and 6.3% in children. Concentric remodeling was observed in 15.4% of adults, however, concentric remodeling was only found in one child. In adults, obesity [OR: 2.54 (1.07-6.02; p = 0.02)] and hypertension [3.39 (1.08-10.62; p = 0.04)] significantly increased the odds of LVH, specifically eccentric LVH, while concentric LVH was associated with self-reported tobacco use [OR: 4.58 (1.18-17.73; p = 0.03)]. Although no logistic regression was run within children, of the four children LVH, three had elevated blood pressure and the child with normal blood pressure was overweight. CONCLUSIONS: The association between obesity, hypertension, tobacco use, and LVH in adults, and the 6% prevalence of LVH in children, calls for stronger public health efforts to control risk factors and monitor children who are at risk.

Police referrals for domestic abuse before and during the first COVID-19 lockdown: An analysis of routine data from one specialist service in South Wales.

BACKGROUND: COVID-19 lockdown measures may have led to more, and increasingly severe, domestic abuse. This study examines police referrals to a specialist domestic abuse service in Wales, UK before and during the first lockdown. METHODS: Routine data relating to 2292 police referrals for female adult victim-survivors from December 2019 until July 2020 were analysed and presented in the form of descriptive statistics to monitor changes in referral rates and the profile of those referrals. RESULTS: There was little increase in the overall volume of police referrals during lockdown, but the proportion assessed as high risk increased, and children became the primary source of third-party referrals, with a higher proportion of reports made by other third parties as restrictions eased. Police reports for cases of Child/Adolescent to Parent Violence (C/APV) occurred almost exclusively during lockdown. CONCLUSIONS: The increase in risk level despite less clear increase in volume may suggest unmet need, with victims less likely to seek help during lockdown other than for more severe instances. Increased reports by children suggest increased exposure of children to domestic abuse during school closure. Unmet need for women and children may have been made visible to services, and acquaintances, as measures began to ease.

A Phase 1, Open-Label Assessment of a Dengue Virus-1 Live Virus Human Challenge Strain.

BACKGROUND: Dengue human infection models (DHIM) have been used as a safe means to test the viability of prophylaxis and therapeutics. METHODS: A phase 1 study of 12 healthy adult volunteers using a challenge virus, DENV-1-LVHC strain 45AZ5, was performed. A dose escalating design was used to determine the safety and performance profile of the challenge virus. Subjects were evaluated extensively until 28 days and then out to 6 months. RESULTS: Twelve subjects received the challenge virus: 6 with 0.5 mL of 6.5 × 103 plaque-forming units (PFU)/mL (low-dose group) and 6 with 0.5 mL of 6.5 × 104 PFU/mL (mid-dose group). All except 1 in the low-dose group developed detectable viremia. For all subjects the mean incubation period was 5.9 days (range 5-9 days) and mean time of viremia was 6.8 days (range 3-9 days). Mean peak for all subjects was 1.6 × 107 genome equivalents (GE)/mL (range 4.6 × 103 to 5 × 107 GE/mL). There were no serious adverse events or long-term safety signals noted. CONCLUSIONS: We conclude that DENV-1-LVHC was well-tolerated, resulted in an uncomplicated dengue illness, and may be a suitable DHIM for therapeutic and prophylactic product testing. CLINICAL TRIALS REGISTRATION: NCT02372175.

Food insecurity, diet quality and body composition: data from the Healthy Life Trajectories Initiative (HeLTI) pilot survey in urban Soweto, South Africa.

OBJECTIVE: To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested. DESIGN: Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level < 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry. SETTING: The urban township of Soweto, Johannesburg, South Africa. PARTICIPANTS: Non-pregnant women aged 18-25 years (n 1534). RESULTS: Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = -0·35, 95 % CI -0·70, -0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models. CONCLUSIONS: Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.

Young women's perceptions of life in urban South Africa: Contextualising the preconception knowledge gap.

Raising awareness to support improved health and well-being of young women in sub-Saharan Africa is critical, particularly in the preconception period in order to achieve improved health for multiple generations. To inform messaging campaign on preconception health, we conducted eight focus group discussions (FGDs) with young women in Soweto to understand their perceptions and access to health messages. Preconception health was generally not a familiar topic for young women. Participants prioritised information seeking for other pressing challenges they faced such as poverty and unemployment. Within this context, mental health was viewed as important, while physical health only gained importance when illness was present or during pregnancy. Television, radio and community health workers were all viewed as useful communication channels for health messaging. Understanding the importance of preconception health of young adults to benefit from the triple dividend of better health now, better health for the future and for children is a critical knowledge gap for young women. Messages aimed to improve preconception physical and mental health could leverage significant health gains. Health messages should be contextualised within the experiences that young women face and should offer information to help young women cope with their challenges.

Effect of Antimalarial Drugs on the Immune Response to Intramuscular Rabies Vaccination Using a Postexposure Prophylaxis Regimen.

BACKGROUND: Chloroquine can impair the immune responses to intradermal rabies vaccination. Current guidelines recommend an extra intramuscular dose be given for postexposure prophylaxis in previously unvaccinated persons taking any antimalarial drug. METHODS: We conducted a randomized, open-label, single-site study in 103 previously unvaccinated healthy adults age ≥18 to ≤60 years old to evaluate the effects of chloroquine, atovaquone/proguanil (Malarone), and doxycycline on the antibody response to a purified chick embryo cell vaccine, given on a postexposure prophylaxis schedule. All treatment groups received antimalarials 14 days prior to and during vaccination. RESULTS: All subjects achieved accepted neutralizing antibody titers of ≥0.5 IU/mL following the second rabies vaccination dose and maintained this protection through the duration of the study. We observed a reduction in rabies antibody geometric mean titer in the chloroquine versus control groups 28 days after vaccination: 2.3 versus 6.87 IU/mL, respectively (P < .001, t test). A significant difference was not observed for those taking Malarone or doxycycline. CONCLUSIONS: We conclude that there is no reduction of rabies antibody response in subjects taking Malarone or doxycycline, but a significant reduction in those taking chloroquine; however, accepted antibody levels were achieved for all 3 antimalarials. CLINICAL TRIALS REGISTRATION: NCT02564471.

Serologic Response of 2 Versus 3 Doses and Intradermal Versus Intramuscular Administration of a Licensed Rabies Vaccine for Preexposure Prophylaxis.

BACKGROUND: The World Health Organization recommends intradermal (ID) administration of rabies vaccine for preexposure prophylaxis. METHODS: In a randomized trial in adults assigned to 1 of 6 treatment groups (ID vs intramuscular [IM], 2 vs 3 doses, and controls), rabies neutralizing antibody titers were measured to 1 year postvaccination. RESULTS: ID vaccination produced acceptable antibody levels in all subjects (2- and 3-dose groups). At day 365, acceptable levels were 40% for IM and 50% for ID 2-dose schedule, and 70% for IM and 60% for ID 3-dose schedule. CONCLUSIONS: ID rabies vaccination induces acceptable antibody titers at a fraction of the dose. CLINICAL TRIALS REGISTRATION: NCT02374814.

Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study.

BACKGROUND: Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. METHODS: A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. RESULTS: Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. CONCLUSIONS: Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.

NOVEL RADIOGRAPHIC TECHNIQUE FOR PREGNANCY DETECTION IN THE MANED WOLF (CHRYSOCYON BRACHYURUS) WITHOUT ANESTHESIA.

Maned wolves ( Chrysocyon brachyurus ) maintained in ex situ populations challenge veterinarians and managers with high neonatal mortality and parental incompetence. These challenges led to the development of a novel diagnostic approach for pregnancy detection using radiographic imaging without anesthesia or sedation. To do this, a specialized crate was constructed to easily contain a single maned wolf, allowing the capture of lateral projection radiographic images of the abdomen prior to and throughout a 66-day pregnancy (days 20, 34, 48, and 55 of 66). Radiographs taken at days 48 and 55 postbreeding showed evidence of neonatal skeleton mineralization, confirming pregnancy with two pups. The dam gave birth at day 66 to two pups. This technical report describes a novel approach without anesthesia for successful radiographic pregnancy detection and determination of litter size in the maned wolf, a midsize carnivore, using a specially constructed crate.

FATAL GASTRIC DILATION IN TWO ADULT BLACK-FOOTED FERRETS (MUSTELA NIGRIPES).

Acute gastric dilation resulting in death was identified in two adult black-footed ferrets (Mustela nigripes) housed at the Smithsonian Conservation Biology Institute in Front Royal, Virginia. Both individuals were adult males (3 and 5 yr) and previously clinically healthy prior to the event. The etiology of gastric dilation in both cases could not be definitively determined, and necropsy revealed severe cardiovascular compromise secondary to bloat. Limited literature is available regarding a syndrome of this type in adult black-footed ferrets. Differential diagnoses considered included gastric dilatation volvulus (GDV), severe gastric distention of unknown origin, and gastric outflow obstruction. Given the severity of this syndrome and the findings in these two cases, acute gastric dilation should be considered in black-footed ferrets presenting with acute abdominal distention, respiratory distress, and cardiovascular compromise.