Accelerating Typhoid Conjugate Vaccine Introduction: What Can Be Learned From Prior New Vaccine Introduction Initiatives?

The health consequences of typhoid, including increasing prevalence of drug-resistant strains, can stress healthcare systems. While vaccination is one of the most successful and cost-effective health interventions, vaccine introduction can take years and require considerable effort. The Typhoid Vaccine Acceleration Consortium (TyVAC) employs an integrated, proactive approach to accelerate the introduction of a new typhoid conjugate vaccine to reduce the burden of typhoid in countries eligible for support from Gavi, the Vaccine Alliance. TyVAC and its partners are executing a plan, informed by prior successful vaccine introductions, and tailored to the nuances of typhoid disease and the typhoid conjugate vaccine. The iterative process detailed herein summarizes the strategy and experience gained from the first 2 years of the project.

Alcohol in emerging adulthood: 7-year study of problem and dependent drinkers.

OBJECTIVE: This study examined the level, changes and predictors of alcohol consumption and binge drinking over a 7-year period among young adults (18-25 years) who met the criteria for problem drinking. METHOD: Interviews with 270 18 to 25 years old problem and dependent drinkers from representative public and private substance use treatment programs and the general population were conducted after 1, 3, 5, and 7 years. Measures included demographic characteristics, severity measures, and both formal and informal influences on drinking. RESULTS: Overall alcohol consumption declined over time but leveled off around 24 years of age. Being male, not attending AA over time, as well as more baseline dependence symptoms and greater ASI alcohol and legal severity were associated with greater consumption and binge drinking. In addition, greater levels of binge drinking were associated with less education, earlier age of first use, and a larger social network of heavy drinkers. In conclusion, more attention should be paid to heavy drinking among young adults and to the factors that influence their drinking patterns.

Nonmedical use of prescription drugs among a longitudinal sample of dependent and problem drinkers.

BACKGROUND: Increasing trends in the nonmedical use of prescription drugs (NMPD) have been documented, yet little is known about the demographic, severity, and social network influences related to NMPD among treated and untreated problem and dependent drinkers. METHODS: To determine NMPD over four post-baseline interviews, the current study uses a 7-year longitudinal sample of 1598 dependent and problem drinkers, many also using illegal drugs, who were identified through a probability survey in the general population and consecutive intakes in public and private chemical dependency treatment programs in a California county. A panel model incorporating variables from the four post-baseline interviews was used, with baseline variables added for control. RESULTS: The use of illegal drugs (OR=2.18, CI 1.28-3.70), including marijuana (OR=2.66, CI 1.74-4.08), and the nonmedical use of prescription drugs prior to the baseline interview (OR=2.53, CI 1.48-4.33) were related to NMPD over the study period. Larger heavy alcohol and drug using social networks were also related to NMPD (OR=1.03, CI 1.01-1.05). CONCLUSIONS: When examining a sample of dependent and problem drinkers, many of the results obtained were similar to results in the literature predicting drug, and even alcohol, use more generally. In this sample, illegal drug use, and marijuana use were important predictors of NMPD. Thus, the nonmedical use of prescription drugs may not be the first problem noticed by health and psychiatric providers.

Addiction treatment history, medical services utilization, and cost: a longitudinal analysis of problem drinkers.

Few studies have examined the long-term patterns of health services utilization and cost for alcohol use disorders. This paper used data from baseline, 3-year, and 5-year follow-up interviews to compare utilization and cost of medical care services for problem drinkers who received chemical dependence treatment and those who did not. The analysis examined overnight hospital stays, emergency room visits, and medical office visits. The unadjusted analysis indicates that in the year immediately preceding each follow-up period, a significantly higher percentage of the chemical dependency treatment group stayed overnight at a hospital or used ER services. In terms of medical office visits, a significantly lower percentage of the treatment sample had office visits at the 5-year follow-up, but otherwise no significant differences existed. Most of the significant differences between the two groups vanished when we controlled for covariates. Researchers, policy makers, and clinicians could benefit from such information to develop alternative delivery models, formulate research initiatives, and determine areas for potential intervention and improvement.

Reasons for drinking less and their relationship to sustained remission from problem drinking.

AIMS: To compare representative general population and treated samples on their reasons for drinking less and whether particular reasons were related to sustained remission from problem drinking for either group. PARTICIPANTS AND DESIGN: A total of 659 problem drinking adults in a Northern California county identified through a probability survey in the general population (n = 239) and a survey of consecutive admissions to public and private alcohol and drug programs (n = 420), who reported drinking less at the one-year follow-up and provided reasons for reducing their drinking, were assessed 1-, 3-, and 5-years post-baseline regarding their problem drinking status. MEASUREMENTS: Logistic regression models were used to predict sustained remission from problem drinking. RESULTS: While the treated sample endorsed a majority of reasons in significantly higher proportions than the general population sample, the same three reasons were significant for both groups in predicting sustained remission from problem drinking: hitting rock bottom, experiencing a traumatic event and undergoing a spiritual awakening. Interventions by medical personnel and family members were either non-significant predictors or significantly negatively related to sustained improvement for both general population and treated problem drinkers. CONCLUSIONS: General population and treatment samples have similar reasons for cutting down as they relate to sustained remission from problem drinking.

Alcohol consumption, risk of injury, and high-cost medical care.

This study examined the effect of alcohol use on the probabilities of injury, inpatient hospital stay, and emergency department visit. Data were obtained from a sample of adults (N = 1219) recruited from a Northern California county. Alcohol use measures included number of drinks, heavy drinking days, and an indicator variable for problem drinking. Models were estimated for men and women separately while controlling for confounders. Results indicate that most alcohol use measures were not significantly related to injury probability or medical care utilization. Among the exceptions, problem drinking was a significant positive predictor of any emergency department visit for both sexes. When drinkers during the past year were divided into light, moderate, and heavy drinking groups and compared to lifetime abstainers, all male drinkers had a higher probability of injury, and light and moderate female drinkers had a lower probability of an emergency department visit.

How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals.

AIMS: To compare representative treatment and untreated samples of alcohol-dependent individuals in rates of abstinence and non-problematic use at 1-year follow-up. PARTICIPANTS AND DESIGN: A total of 482 alcohol-dependent adults in a northern California county identified through a probability survey of problem drinkers in the general population (n = 111) or a survey of consecutive admissions to public and private substance abuse programs (n = 371) were interviewed in person at baseline and by telephone at 1 year. MEASUREMENTS: Logistic regression models were used to predict 30-day abstinence and 12-month non-problematic alcohol use. RESULTS: At follow-up, alcohol-dependent individuals in the treatment sample had higher abstinence rates and non-problematic use outcomes than those in the untreated general population sample. In logistic regression models of the merged samples, being in the treatment sample was related strongly and positively to abstinence and non-problematic use. Having more drug users and heavy drinkers in one's social network, higher psychiatric comorbidity, and more social consequences were inversely related to abstinence and non-problematic use in the treatment sample. The number of drug users and heavy drinkers in one's social network was also inversely related to abstinence in both the treatment and untreated general population samples. Results predicting non-problematic use were similar. CONCLUSIONS: These results are consistent with other studies that examine treatment effectiveness in the absence of a controlled trial. Although natural recovery also occurs, alcohol-dependent individuals benefit from treatment. Co-occurring psychiatric problems continue to be major barriers to treatment effectiveness. An emphasis on changing social networks to be conducive to recovery could heighten both clinical effectiveness and prevention efforts within communities.

Dependent and problem drinking over 5 years: a latent class growth analysis.

Understanding the long-term course of problematic drinking is a fundamental concern for health services research in the alcohol field. The stability of, or change in, the course of drinking--especially heavy drinking--has both theoretical and applied relevance to alcohol research. We explore the application of latent class growth modeling to 5 years of survey data collected from dependent and problem drinkers--some not in treatment at baseline--in an attempt to uncover prototypical longitudinal drinking patterns. Results indicated that five profiles of drinkers can be used to represent their longitudinal course of alcohol consumption: early quitters (N = 88), light/non-drinkers (N = 76), gradual improvers (N = 129), moderate drinkers (N = 229), and heavy drinkers (N = 572). Significant baseline factors included ASI drug severity, dependence symptoms, and marital status. Attendance at AA meetings, the size of one's heavy drinking and drug using social network, past treatment, receiving suggestions about one's drinking, and contacts with the medical system were significant influences. The size of heavy drinking and drug using social networks was noticeably larger for the heavy drinkers. Findings also support the usefulness of a semi-parametric latent group-based approach as a tool for analyzing alcohol-related behaviors.

The role of community services and informal support on five-year drinking trajectories of alcohol dependent and problem drinkers.

OBJECTIVE: The purpose of this study was to examine how informal support and community services impact the course of alcohol disorders by examining the trajectories of alcohol consumption over 5 years in dependent and problem drinkers. METHOD: Alcohol dependent adults (n = 600) and problem drinkers (n = 992) were identified through probability surveys in the general population and in public and private treatment programs throughout a California county. Participants were interviewed at baseline and again 1, 3 and 5 years later. Models controlling for demographic characteristics, problem severity, community services and recovery-oriented social networks were estimated, using a multi-level, mixed model to predict alcohol consumption over time. RESULTS: A significant trend of reduced drinking over time was observed for both dependent and problem drinkers. Recovery-oriented social networks and AA participation predicted decreased consumption for both groups. Contacts with medical, mental health, welfare and legal systems were predictive of reduced consumption for problem drinkers. In the dependent group, only contacts with mental health agencies marginally predicted decreased consumption. CONCLUSIONS: Findings point to the importance of developing mechanisms for better identifying problem drinkers in the course of contacts with health and social service systems and for facilitating use of self-help groups and positive changes in social networks. Development of recovery-oriented social networks should be emphasized to extend the benefits of treatment for dependent individuals.

Who goes to alcohol and drug treatment? Understanding utilization within the context of insurance.

OBJECTIVE: This study assesses the differential roles of demographic characteristics, problem severity, motivational factors and insurance in entrance into alcohol and drug treatment. METHOD: A probability sample of adult problem and dependent drinkers from a Northem California county (N = 672) and consecutive adult intakes from the county's public (n = 298) and private (n = 628) alcohol and drug treatment programs. Interviewers conducted telephone screening for individuals meeting problem-drinking criteria in the general population; in-person interviews were conducted for those who screened positive, and also for individuals entering treatment. RESULTS: Insurance did not play an independent role in treatment entry. In logistic regression analysis, using a model from the medical utilization literature, black ethnicity (odds ratio [OR] = 2.98, p < .001); older age (OR = 4.67, p < .001); less education (OR = 1.81, p < .01); legal (OR = 7.46, p < .001) and work (OR = 3.57,p <.001) pressures; higher psychiatric (OR = 4.03,p <.001) and drug (OR = 3.04,p <.001) severity; and social consequences (OR = 1.35, p < .01) predicted treatment entry. Interventions from legal sources (OR = 6.22, p < .01) were related to entering treatment for the uninsured; legal (OR = 7.02, p < .001), workplace (OR = 6.01, p < .001) and family (OR = 1.62, p < .05) pressures were related for the insured. CONCLUSIONS: Social consequences, rather than severity of dependence, in both insured and uninsured problem drinkers are important predictors of treatment entry when traditional utilization measures are controlled. Public programs play a crucial part in the alcohol and drug treatment system, and their viability is important as health policy changes.

Does marital status predict long-term drinking? Five-year observations of dependent and problem drinkers.

OBJECTIVE: Married individuals have lower rates of problem drinking, but little is known about this relationship in the context of other factors. This longitudinal analysis examines marital status with other individual predisposing, problem severity and social predisposing characteristics to understand its strength in predicting alcohol consumption over 5 years. METHOD: A probability sample of dependent (n = 600) and problem (n = 992) drinkers was recruited through consecutive adult intakes from a Northern California county's alcohol and drug treatment programs and through a general population survey. Annual volume of drinks consumed over a 5-year period-measured at baseline, and at 1, 3 and 5 years later-was estimated in four nested models using maximum likelihood estimation via PROC MIXED. RESULTS: In simpler models that examined only marital status, married individuals drank significantly less than those never married (p < .01 for problem drinkers and p < .05 for dependent drinkers); however, when our models added individual predisposing, problem severity and social predisposing characteristics, marital status was no longer significant in predicting a trajectory of decreased drinking. For problem drinkers, the following characteristics were more important than marital status in predicting alcohol consumption over the 5 years: individual predisposing characteristics (age, p < .001; income, p < .001; education, p < .001; and age of initiation of regular alcohol use, p < .001), problem severity (number of alcohol dependence symptoms, p < .001; number of alcohol-related social consequences, p < .001; and higher drug severity, p < .05) and social predisposing characteristics (family member with an alcohol problem, p < .05; the size of heavy alcohol- and drug-using social network, p < .05; and chemical dependency treatment in the prior year, p < .001). For those who were alcohol dependent, income (p < .05), number of alcohol dependence symptoms (p < .001), higher drug severity (p < .05) and a heavy alcohol- and drug-using social network (p < .05 ) were more important than marital status in predicting consumption. CONCLUSIONS: In longitudinal models, individual predisposing, problem severity and social predisposing characteristics are more important than marital status in predicting alcohol consumption.

A prospective study of the factors influencing entry to alcohol and drug treatment.

Much is known about factors related to entering alcohol and drug treatment, but most research comprises cross-sectional "snapshots" in time. It is not known whether the reasons for entering treatment endure when problem drinkers are studied over time. This study contracts characteristics predicting treatment entry in a cross-sectional analysis at baseline with a longitudinal perspective at 1- and 3-year follow-up interviews. Sociodemographic characteristics were less important in the longitudinal analysis. In contrast to the social consequences important at the baseline interview, physiologic symptoms of alcohol dependence and interventions by medical professionals were prominent at later interview points. The findings have implications for interventions by health professionals, both for the development of early interventions targeting individuals to treatment and for a continuing care service model.

Gender differences in the relationship of community services and informal support to seven-year drinking trajectories of alcohol-dependent and problem drinkers.

OBJECTIVE: The purpose of this study was to examine how community service contacts and informal support are related to the course of drinking for dependent and problem-drinking persons in a population-based sample of women versus men over 7 years. METHOD: Alcohol-dependent (n = 600) and problem-drinking (n = 992) men and women were identified through probability surveys in the general population and treatment programs throughout a California county. Participants were interviewed at baseline and again 1, 3, 5, and 7 years later. Models predicting the differential impact of community services and informal influences on men and women's alcohol consumption over time were estimated using a multilevel mixed model, while controlling for demographic characteristics and problem severity. RESULTS: Dependent and problem-drinking men consumed more than women, yet a trend of reduced drinking over time was found for both men and women. Alcoholics Anonymous attendance was related to decreased consumption for men and women regardless of severity; contact with the mental health system was similarly related to decreased consumption for both genders. For problem-drinking women, welfare contacts were related to decreased consumption. A family intervention was the only informal influence that had differential effects on dependent and problem-drinking men and women's alcohol consumption. CONCLUSIONS: Findings point to the continued benefits of facilitating social support and mental health visits for both dependent and problem-drinking men and women. Developing means to identify and intervene in the range of community service settings, particularly in the mental health and legal system, continues to be important. Innovative interventions for families to encourage engagement in chemical dependency treatment are also warranted.

Course of recovery from alcoholism.

This article represents the proceedings of a symposium at the 2005 Research Society on Alcoholism meeting in Santa Barbara, California, organized and chaired by Kamilla L. Venner. This symposium integrated current empirical research on the course of recovery from alcoholism from multiple perspectives, an aim that is consistent with NIAAA's new focus on the process of recovery. The presentations and presenters were as follows: (1) The Role of Community Services and Informal Support on 7-Year Drinking Outcomes in Treated and Untreated Drinkers, by Helen Matzger; (2) The Sequence of Recovery Events in a Native American Sample, by Kamilla L. Venner; (3) Transformational Change in Recovery, by Alyssa A. Forcehimes; (4) Social Settings and Substance Use: Contextual Factors in Recovery, by Rudolf H. Moos; and (5) A Broader View of Change in Drinking Behavior, by discussant Mark L. Willenbring. A theme connecting the presentations was that treatment is but one discrete aspect to recovery and that sustained recovery is often influenced by an individual interaction with others within a social context. Collectively, presentations underscored the need to think more broadly about factors contributing to the remission of alcohol dependence.

Missed opportunities in addressing drinking behavior in medical and mental health services.

BACKGROUND: Epidemiological and clinical literature point to the importance of screening for alcohol problems in medical and psychiatric settings. However, little is known about which problem drinkers seek help from those services or about the characteristics of those who have their drinking addressed. METHODS: We interviewed a probability sample of adult dependent and problem drinkers in the general population (n = 672) and consecutive admissions to chemical dependency programs in a northern California county (n = 926). We reinterviewed them 1 year later and measured medical and mental health visits and whether their drinking was addressed during the visit. RESULTS: Almost two-thirds of problem drinkers had a medical visit, and approximately one-third had a mental health visit, yet drinking was not often discussed, especially during medical visits. Many of those more likely to have a visit were not more likely to have their drinking addressed. Women and individuals older than 40 years had more medical and mental health visits [odds ratio (OR), 1.71; p < 0.001 and OR, 1.55; p < 0.001, respectively, for women; OR, 1.57; p < 0.05 and OR, 1.64; p < 0.05, respectively, for age >/=40 years], but were not more likely to have their drinking addressed in either setting, and women were less likely than men to have their drinking addressed in mental health settings (OR, 0.62; p < 0.05). Those with higher alcohol severity and those who had attended chemical dependency treatment during the previous year were more likely to have their drinking addressed in each setting. Insurance status predicted medical, but not mental health, visits and was not related to having drinking addressed in either setting. CONCLUSIONS: Drinking behavior was not routinely addressed by medical and mental health practitioners for dependent and problem-drinking men and women who presented in public and private medical and mental health settings.