Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000-2015.

BACKGROUND: The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. METHODS: The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. RESULTS: We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. DISCUSSION: We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.

Inequity in the face of success: understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries.

BACKGROUND: Between 2000-2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. METHODS: To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000-2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies. RESULTS: The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda - decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh - from 10 to 32% across geography - and in Ethiopia - from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia. CONCLUSION: Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.

Lessons from Peru to reduce under-5 mortality: understanding program implementation and context.

BACKGROUND: Health policymakers aiming to reduce under-5 mortality (U5M) often lack data regarding how successful interventions in other countries were implemented. The Exemplars in U5M Study identified countries that achieved significant reductions in amenable U5M. This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs). METHODS: This research utilized a hybrid implementation research framework and a mixed-methods approach to understand the factors associated with EBI implementation and the successful reduction of U5M between 2000-2015. A desk review of existing literature on EBIs and U5M in Peru was completed, and in-depth interviews were performed with key Peruvian informants to understand the implementation strategies employed and the contextual factors that facilitated or were barriers to success. For the purposes of this analysis, three EBIs were selected and evaluated: antenatal care visits (ANC), facility-based deliveries, and infant vaccination. RESULTS: Between 2000-2015, the percent of mothers attending at least four antenatal care visits rose from 69% to 96.9%, and the percent of facility-based deliveries increased from 56 to 91%. Three doses of the tetanus/diphtheria/pertussis vaccine, widely acknowledged as a key global health indicator, reached 90% by 2015. Key informants noted that economic growth, financial reforms, strong national commitment to reduce poverty in Peru, and national prioritization of maternal and child health, were important contextual factors that contributed to the successful reduction of U5M. They noted key strategies that helped achieve success during the implementation of EBIs, including utilization of data for decision-making, adaptation driven by cultural sensitivity to address gaps in coverage, and a focus on equity and anti-poverty initiatives with the participation of government, civil society, and political parties to assure continuity of policies. CONCLUSION: Several EBIs contributed to the successful reduction of U5M in Peru between 2000-2015. Strategies such as the focus on equity throughout the study period contributed to an increase in coverage of EBIs like ANC visits, facility-based deliveries and infant vaccination which worked to reduce U5M. Understanding how Peru successfully implemented programs that reduced preventable infant and child deaths could be useful to replicating this substantial public health success in other low- and middle-income countries.

Informal payments in health facilities in Peru in 2018: Analysis of a cross-sectional survey.

BACKGROUND: The Latin American region demonstrates the lowest levels of trust in health systems globally. Institutional corruption is a major factor in eroding trust. Corruption in health services, including extracting bribes and informal payments from patients, directly harms health outcomes and weakens services intended as public goods. In this study, we aim to characterize the frequency and distribution of informal payments within public health services in Peru. METHODS: We conducted a secondary analysis of a nationally representative cross-sectional survey, the 2018 National Household Survey of Living Conditions and Poverty, and identified all individuals reporting health insurance from the Ministry of Health (SIS-MINSA) or Social Security (ESSALUD). We defined self-reported informal payments in 2 ways: 1) being asked to pay a bribe at a health establishment in the past year (direct method), and 2) creating an overall indicator for non-zero cost of care for services that should be free (indirect method). We used descriptive statistics to quantify informal payments and bivariate analysis to identify sociodemographic characteristics of those most frequently reporting such payments. FINDINGS: 132,355 people were surveyed, including 69,839 (52.8%) with coverage from SIS-MINSA and 30,461 (23.03%) from ESSALUD. Less than 1% of participants directly reported informal payments, either at SIS-MINSA services (0.22%); or at ESSALUD (0.42%). Indirect reporting was more prevalent, including up to 10% of surgery patients and 17% of those hospitalized in SIS-MINSA facilities. Wealthier patients (19%) were more likely to report such payments. INTERPRETATION: While direct reporting of bribery was uncommon, we found moderate prevalence of informal payments in public health services in Peru using an indirect assessment method. Indirect reporting may exceed direct reporting due to difficulty in distinguishing appropriate and inappropriate payments, fear of reporting health care workers' behavior, or social tolerance of informal payments. Informal payments were more common among those with greater financial capital, indicating they may obtain enhanced services. Further research on patients' perception and reporting of informal payments is a key step towards accurate measurement and evidence-based intervention.

Inequalities in health system coverage and quality: a cross-sectional survey of four Latin American countries.

The premise of health as a human right in Latin America has been challenged by health system fragmentation, quality gaps, a growing burden of chronic disease, sociopolitical upheaval, and the COVID-19 pandemic. We characterised inequities in health system quality in Colombia, Mexico, Peru, and Uruguay. We did a cross-sectional telephone survey with up to 1250 adults in each country. We created binary outcomes in coverage, user experience, system competence, and confidence in the system and calculated the slope index of inequality by income and education. Although access to care was high, only a third of respondents reported having a high-quality source of care and 25% of those with mental health needs had those needs met. Two-thirds of adults were able to access relevant preventive care and 42% of older adults were screened for cardiovascular disease. Telehealth access, communication and autonomy in most recent visit, reasonable waiting times, and receiving preventive health checks showed inequalities favouring people with a high income. In Uruguay, inequality between government and social security services explained a substantial proportion of disparities in preventive health access. In other study countries, inequalities were also substantial within government and social security subsectors. Essential health system functions are unequal in these four Latin American countries.

Rethinking how development assistance for health can catalyse progress on primary health care.

Global campaigns to control HIV, tuberculosis, malaria, and vaccine-preventable illnesses showed that large-scale impact can be achieved by using additional international financing to support selected, evidence-based, high-impact investment areas and to catalyse domestic resource mobilisation. Building on this paradigm, we make the case for targeting additional international funding for selected high-impact investments in primary health care. We have identified and costed a set of concrete, evidence-based investments that donors could support, which would be expected to have major impacts at an affordable cost. These investments are in: (1) individuals and communities empowered to engage in health decision making, (2) a new model of people-centred primary care, and (3) next generation community health workers. These three areas would be supported by strengthening two cross-cutting elements of national systems. The first is the digital tools and data that support facility, district, and national managers to improve processes, quality of care, and accountability across primary health care. The second is the educational, training, and supervisory systems needed to improve the quality of care. We estimate that with an additional international investment of between US$1·87 billion in a low-investment scenario and $3·85 billion in a high-investment scenario annually over the next 3 years, the international community could support the scale-up of this evidence-based package of investments in the 59 low-income and middle-income countries that are eligible for external financing from the World Bank Group's International Development Association.

A systematic review of population and patient perspectives and experiences as measured in Latin American and Caribbean surveys.

High-quality health systems must provide accessible, people-centred care to both improve health and maintain population trust in health services. Furthermore, accurate measurement of population perspectives is vital to hold health systems accountable and to inform improvement efforts. To describe the current state of such measures in Latin America and the Caribbean (LAC), we conducted a systematic review of facility and population-based assessments that included patient-reported experience and satisfaction measures. Five databases were searched for publications on quantitative surveys assessing healthcare quality in Spanish- or Portuguese-speaking LAC countries, focusing on the domains of processes of care and quality impacts. We included articles published since 2011 with a national sampling frame or inclusion of multiple subnational regions. We tabulated and described these articles, identifying, classifying and summarizing the items used to assess healthcare quality into the domains mentioned earlier. Of the 5584 publications reviewed, 58 articles met our inclusion criteria. Most studies were cross-sectional (95%), assessed all levels of healthcare (57%) and were secondary analyses of existing surveys (86%). The articles yielded 33 unique surveys spanning 12 LAC countries; only eight of them are regularly administered surveys. The most common quality domains assessed were satisfaction (in 33 out of 58 articles, 57%), evidence-based/effective care (34%), waiting times (33%), clear communication (33%) and ease of use (31%). Items and reported ratings varied widely among instruments used, time points and geographical settings. Assessment of patient-reported quality measures through population- and facility-based surveys is present but heterogeneous in LAC countries. Satisfaction was measured frequently, although its use in accountability or informing quality improvement is limited. Measurement of healthcare quality in LAC needs to be more systematic, regular, comprehensive and to be led collaboratively by researchers, governments and policymakers to enable comparison of results across countries and to effectively inform policy implementation.

Assessment of regional body composition, physical function and sarcopenia among peruvian women aging with HIV: A cross-sectional study.

Management of chronic conditions and optimization of overall health has become a primary global health concern in the care of people living with HIV in the era of highly active antiretroviral therapy (ART), particularly in lower-and-middle income countries where infrastructure for chronic disease management may be fragmented. Alterations in body composition can reflect important changes in musculoskeletal health, particularly among populations at risk for developing fat and muscle redistribution syndromes, such as women with HIV on ART. Given the lack of data on this topic in Latin America and the Caribbean, we designed an exploratory study to measure these outcomes in a population of women aging with HIV in Peru. We conducted a cross-sectional study among Peruvian women with and without HIV aged ≥40 years. Dual X-ray absorptiometry was used to measure trunk and limb lean mass (LM) and fat mass (FM). Physical performance was assessed with the Short Physical Performance Battery (SPPB) and physical strength with a dynamometer. Sarcopenia was assessed based upon EWGSOP criteria. We used linear regression to model associations between body composition, sarcopenia and physical performance scores. 104 women with HIV and 212 women without HIV were enrolled (mean age 52.4±8.2 vs. 56.4±8.8 years, p≤0.001). Among women with HIV, mean years since diagnosis was 11.8±6 and all were on ART. Mean SPPB score was 9.9 vs 10.8 (p<0.001) between both groups. Sarcopenia spectrum was found in 25.9% and 23.1%, respectively. In the multivariable regression analysis, trunk FM and older age were negatively correlated with physical performance among women with HIV. Severe sarcopenia was found among a greater proportion of those with HIV (3.8% vs. 0.9%, p = 0.84), however this finding was not statistically significant. Women with HIV had significantly lower SPPB scores compared to women without HIV, and trunk FM and upper limb LM were independent predictors for the SPPB and Grip Strength tests, respectively. Larger, prospective studies are needed in Latin America & the Caribbean to identify individuals at high risk for sarcopenia and declines in physical function, and to inform prevention guidelines.

Clinical Value of Serial Quantitative Analysis of Cytomegalovirus DNA in Blood and Saliva Over the First 24 Months of Life in Congenital Infection: The French Cymepedia Cohort.

OBJECTIVE: To evaluate cytomegalovirus (CMV) viral load dynamics in blood and saliva during the first 2 years of life in symptomatic and asymptomatic infected infants and to identify whether these kinetics could have practical clinical implications. STUDY DESIGN: The Cymepedia cohort prospectively included 256 congenitally infected neonates followed for 2 years. Whole blood and saliva were collected at inclusion and months 4 and 12, and saliva at months 18 and 24. Real-time CMV polymerase chain reaction (PCR) was performed, results expressed as log10 IU/mL in blood and in copies per milliliter in saliva. RESULTS: Viral load in saliva progressively decreased from 7.5 log10 at birth to 3.3 log10 at month 24. CMV PCR in saliva was positive in 100% and 96% of infants at 6 and 12 months, respectively. In the first month of life, neonatal saliva viral load of less than 5 log10 was related to a late CMV transplacental passage. Detection in blood was positive in 92% of neonates (147/159) in the first month of life. No viral load threshold values in blood or saliva could be associated with a high risk of sequelae. Neonatal blood viral load of less than 3 log10 IU/mL had a 100% negative predictive value for long-term sequelae. CONCLUSIONS: Viral loads in blood and saliva by CMV PCR testing in congenital infection fall over the first 24 months. In this study of infants affected mainly after primary maternal infection during pregnancy, all salivary samples were positive in the first 6 months of life and sequelae were not seen in infants with neonatal blood viral load of less than 3 log10 IU/mL.

Cost of community-based human papillomavirus self-sampling in Peru: A micro-costing study.

Background: Cost data of human papillomavirus (HPV) self-sampling programs from low-and-middle-income countries is limited. We estimated the total and unit costs associated with the Hope Project, a community-based HPV self-sampling social entrepreneurship in Peru. Methods: We conducted a micro-costing analysis from the program perspective to determine the unit costs of (1) recruitment/training of community women (Hope Ladies); (2) Hope Ladies distributing HPV self-sampling kits in their communities and the laboratory testing; and (3) Hope Ladies linking screened women with follow-up care. A procedural manual was used to identify the program's activities. A structured questionnaire and in-depth interviews were conducted with administrators to estimate the resource/time associated with activities. We obtained unit costs for each input previously identified from budgets and expenditure reports. Findings: From November 2018 to March 2020, the program recruited and trained 62 Hope Ladies who distributed 4,882 HPV self-sampling kits in their communities. Of the screened women, 586 (12%) tested HPV positive. The annual cost per Hope Lady recruited/trained was $147·51 (2018 USD). The cost per HPV self-sampling kit distributed/tested was $45·39, the cost per woman followed up with results was $55·64, and the cost per HPV-positive woman identified was $378·14. Personnel and laboratory costs represented 56·1% and 24·7% of the total programmatic cost, respectively. Interpretation: Our findings indicate that implementation of a community-based HPV self-sampling has competitive prices, which increases its likelihood to be feasible in Peru. Further economic evaluation is needed to quantify the incremental benefits of HPV self-sampling compared to more established options such as Pap tests. Funding: Thomas Francis Jr. Fellowship provided funding for data collection. The Hope Project was funded by grants from Grand Challenges Canada (TTS-1812-21131), Uniting for Health Innovation, Global Initiative Against HPV and Cervical Cancer, University of Manitoba, and the John E. Fogarty International Center (5D43TW009375-05).

Development and assessment of an indirect vision training programme for operatory dentistry: Effects on working posture.

OBJECTIVES: Students experience difficulty working with indirect vision and often adopt inadequate working postures because of it. This study created and then assessed the effects of an indirect vision preclinical training programme on dental students' working posture. METHODS: The study enrolled students in the third year of the 5-year undergraduate programme in dentistry in the School of Dentistry of São Paulo State University (UNESP), Araraquara (N = 54). The programme consisted of four training sessions in which students performed different types of activities in which only a mirror was used to see the procedure they were performing. To evaluate posture, students were asked to perform class III cavity preparations (distal-palatal and mesial-palatal preparations) on upper central and lateral incisors in a dental mannequin (tooth numbers 11, 12, 21 and 22) both before and after the indirect vision training programme. Photographs were taken of the students' working postures. The photographs were assessed by a duly trained researcher using the Compliance Assessment of Dental Ergonomic Posture Requirements. A descriptive statistical analysis was performed, and the assumptions of normality were verified. Student's paired t test was also performed. The significance level adopted was 5%. RESULTS: A significant difference was found between the percentages of correct ergonomic postures adopted before and after the training programme (p = 0.039). CONCLUSIONS: The preclinical training programme for indirect vision was found to have a positive effect on the working postures of the students evaluated herein.

The feminization of medicine in Latin America: 'More-the-merrier' will not beget gender equity or strengthen health systems.

This viewpoint addresses the lack of gender diversity in medical leadership in Latin America and the gap in evidence on gender dimensions of the health workforce. While Latin America has experienced a dramatic change in the gender demographic of the medical field, the health sector employment pipeline is rife with entrenched and systemic gender inequities that continue to perpetuate a devaluation of women; ultimately resulting in an under-representation of women in medical leadership. Using data available in the public domain, we describe and critique the trajectory of women in medicine and characterize the magnitude of gender inequity in health system leadership over time and across the region, drawing on historical data from Mexico as an illustrative case. We propose recommendations that stand to disrupt the status quo to more appropriately value women and their representation at the highest levels of decision making for health. We call for adequate measurement of equity in medical leadership as a matter of national, regional, and global priority and propose the establishment of a regional observatory to monitor and evaluate meaningful progress towards gender parity in the health sector as well as in medical leadership.

The Annual costs of treating genital warts in the Public Healthcare Sector in Peru.

OBJECTIVES: To estimate the cost of six different techniques used to treat Genital Warts and the annual average cost of treating a typical GW patient in Peru. To estimate the annual economic burden diagnosing and treating GW in the Peruvian public healthcare system. METHODS: We developed a prevalence-based, cost-of-illness study from the provider's perspective, the healthcare facilities under the purview of Peruvian Ministry of Health. We used an activity-based costing approach. We conducted primary data collection in three regions in Peru and supplemented it with governmental data. Uncertainty of the costing estimates was assessed via Monte Carlo simulations. We estimated the average cost and associated confidence intervals for six treatment options - three topical and three surgical - and the overall cost per patient. RESULTS: The average treatment cost per patient was 59.9USD (95 %CI 45.5, 77.6). Given a population of 18.4 million adults between 18 and 60 years of age and a GW prevalence of 2.28 %, the annual cost of treating GW was 25.1 million USD (uncertainty interval 16.9, 36.6). CONCLUSIONS: This study provides the first quantification of the economic burden of treating genital warts in Peru and one of the few in Latin America. The costing data did not include other healthcare providers or out-of-pocket expenditures, and hence we present a conservative estimate of the COI of GW in Peru. Our findings bring attention to the financial burden of treating GW, a vaccine-preventable disease.

Building and Sustaining Effective Partnerships for Training the Next Generation of Global Health Leaders.

Introduction: Partnerships are essential to creating effective global health leadership training programs. Global pandemics, including the HIV/AIDS pandemic, and more recently the COVID-19 pandemic, have tested the impact and stability of healthcare systems. Partnerships must be fostered to prepare the next generation of leaders to collaborate effectively and improve health globally. Objectives: We provide key matrices that predict success of partnerships in building global health leadership capacity. We highlight opportunities and challenges to building effective partnerships and provide recommendations to promote development of equitable and mutually beneficial partnerships. Findings: Critical elements for effective partnership when building global health leadership capacity include shared strategic vision, transparency and excellent communication, as well as intentional monitoring and evaluation of the partnership, not just the project or program. There must be recognition that partnerships can be unpredictable and unequal, especially if the end is not defined early on. Threats to equitable and effective partnerships include funding and co-funding disparities between partners from high-income and low-income countries, inequalities, unshared vision and priorities, skewed decision-making levels, and limited flexibility to minimize inequalities and make changes. Further, imbalances in power, privilege, position, income levels, and institutional resources create opportunities for exploitation of partners, particularly those in low-income countries, which widens the disparities and limits success and sustainability of partnerships. These challenges to effective partnering create the need for objective documentation of disparities at all stages, with key milestones to assess success and the environment to sustain the partnerships and their respective goals. Conclusions: Developing effective and sustainable partnerships requires a commitment to equality from the start by all partners and an understanding that there will be challenges that could derail otherwise well-intended partnerships. Guidelines and training on evaluation of partnerships exist and should be used, including generic indicators of equity, mutual benefit, and the added value of partnering. Key Takeaways: Effective partnerships in building global health leadership capacity require shared strategic vision and intentional monitoring and evaluation of goalsInequalities in partnerships may arise from disparities in infrastructure, managerial expertise, administrative and leadership capacity, as well as limited mutual benefit and mutual respectTo promote equitable and effective partnerships, it is critical to highlight and monitor key measures for success of partnerships at the beginning of each partnership and regularly through the lifetime of the partnership.We recommend that partnerships should have legal and financial laws through executed memoranda of understanding, to promote accountability and facilitate objective monitoring and evaluation of the partnership itself.More research is needed to understand better the contextual predictors of the broader influence and sustainability of partnership networks in global health leadership training.

Third-trimester repeat HIV testing: it is time we make it universal.

Since the 1990s, perinatal transmission of HIV has decreased substantially, largely as a result of improved detection secondary to routine HIV screening in pregnancy and the use of antiretroviral therapy. However, despite reductions in HIV transmission, elimination of perinatal transmission, defined as an incidence of perinatal HIV infection of <1 per 100,000 live births and a transmission rate of <1%, remains elusive. An estimated 80% of perinatal transmissions occur after 36 weeks' gestation, which highlights the importance of diagnosis and treatment of maternal HIV infection before the highest-risk period for perinatal transmission. With timely identification of seroconversion, intrapartum and neonatal interventions can lower the risk of perinatal transmission from 25% to 10%, substantially reducing perinatal transmission events. The American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention recommend that routine HIV testing be performed in all pregnancies, as early in the prenatal course as possible. Third-trimester repeat testing is only recommended for individuals known to be at high risk of acquiring HIV (ie, those who are incarcerated; who reside in jurisdictions with elevated HIV incidence; who are receiving care in facilities that have an HIV incidence in pregnant women > 1 per 1000 per year; or have signs or symptoms of acute HIV). However, among reproductive-age women, heterosexual intercourse is the most common mode of HIV transmission, and the risk of HIV seroconversion is greater during pregnancy than outside of pregnancy. Furthermore, state statutes for HIV testing in pregnancy are largely lacking. In this clinical opinion, we reviewed the evidence in support of universal third-trimester repeat HIV testing in pregnancy using a successful state-mandated testing program in Illinois. In addition, we provided clinical recommendations to further reduce missed perinatal transmission cases by implementing universal third-trimester repeat testing, obtaining hospital buy-in, monitoring testing adherence, bridging communications across multidisciplinary teams, and engaging clinicians in advocacy work.

Cognition and daily activities in a general population sample aged +55.

Objective: We tested the association of individual cognitive domains measured with the Mini-Mental State Examination (MMSE) and disability. Method: Cross-sectional study in a population-based cohort aged ≥55 years (n = 4,803). Sample was divided into two groups: individuals with cognition within the normal range (CNR) (n = 4,057) and those with cognitive impairment (CI) (n = 746). Main outcome measures: The MMSE, the Katz Index (Basic Activities of Daily Living, bADL), the Lawton and Brody Scale (Instrumental Activities of Daily Living, iADL), and the Geriatric Mental State (GMS-AGECAT). Results: MMSE-orientation was associated with disability in bADL, iADL and a decrease in social participation, regardless of cognitive status. MMSE-attention was associated with disability in iADL, but only in CNR. MMSE-language was associated with disability in bADL, iADL and with reduced social participation, but only in CI. Conclusions: The associations observed between disability and orientation may have clinical and public health implications.