A case study of a community-organized wastewater surveillance in a small community: correlating weekly reported COVID-19 cases with SARS-CoV-2 RNA concentrations during fall 2020 to summer 2021 in Yarmouth, ME.

Wastewater surveillance offers a rapid evaluation of SARS-CoV-2 transmission in a community. We describe how a community group, the Yarmouth Wastewater Testing Team (YWTT), in Yarmouth, Maine, (population 8,990) utilized an asset-based community design framework to organize and manage a program to monitor SARS-CoV-2 RNA concentrations. From September 22, 2020 through June 8, 2021, the YWTT disseminated weekly reports of the wastewater results and reported COVID-19 cases within the Yarmouth postal code. After high and increasing SARS-CoV-2 RNA concentrations, the YWTT issued two community advisories to encourage extra care to reduce exposure. Correlations between SARS-CoV-2 RNA concentrations and COVID-19 cases were stronger the week after sampling, and the average of the COVID-19 cases during the week of sampling and the following week, indicating that surveillance provided advance notice of cases. A 10% increase in SARS-CoV-2 RNA concentrations was associated with a 13.29% increase in the average number of weekly reported cases of COVID-19 during the week of sampling and the following week (R2 = 0.42; p < 0.001). Adjusting for viral recovery (December 21, 2020 through June 8, 2021), improved R2 from 0.60 to 0.68. Wastewater surveillance was an effective tool for the YWTT to quickly respond to viral transmission.

Effect of Vitamin D and Calcium Supplementation on Cancer Incidence in Older Women: A Randomized Clinical Trial.

Importance: Evidence suggests that low vitamin D status may increase the risk of cancer. Objective: To determine if dietary supplementation with vitamin D3 and calcium reduces the risk of cancer among older women. Design, Setting, and Participants: A 4-year, double-blind, placebo-controlled, population-based randomized clinical trial in 31 rural counties (June 24, 2009, to August 26, 2015-the final date of follow-up). A total of 2303 healthy postmenopausal women 55 years or older were randomized, 1156 to the treatment group and 1147 to the placebo group. Duration of treatment was 4 years. Interventions: The treatment group (vitamin D3 + calcium group) received 2000 IU/d of vitamin D3 and 1500 mg/d of calcium; the placebo group received identical placebos. Main Outcomes and Measures: The primary outcome was the incidence of all-type cancer (excluding nonmelanoma skin cancers), which was evaluated using Kaplan-Meier survival analysis and proportional hazards modeling. Results: Among 2303 randomized women (mean age, 65.2 years [SD, 7.0]; mean baseline serum 25-hydroxyvitamin D level, 32.8 ng/mL [SD, 10.5]), 2064 (90%) completed the study. At year 1, serum 25-hydroxyvitamin D levels were 43.9 ng/mL in the vitamin D3 + calcium group and 31.6 ng/mL in the placebo group. A new diagnosis of cancer was confirmed in 109 participants, 45 (3.89%) in the vitamin D3 + calcium group and 64 (5.58%) in the placebo group (difference, 1.69% [95% CI, -0.06% to 3.46%]; P = .06). Kaplan-Meier incidence over 4 years was 0.042 (95% CI, 0.032 to 0.056) in the vitamin D3 + calcium group and 0.060 (95% CI, 0.048 to 0.076) in the placebo group; P = .06. In unadjusted Cox proportional hazards regression, the hazard ratio was 0.70 (95% CI, 0.47 to 1.02). Adverse events potentially related to the study included renal calculi (16 participants in the vitamin D3 + calcium group and 10 in the placebo group), and elevated serum calcium levels (6 in the vitamin D3 + calcium group and 2 in the placebo group). Conclusions and Relevance: Among healthy postmenopausal older women with a mean baseline serum 25-hydroxyvitamin D level of 32.8 ng/mL, supplementation with vitamin D3 and calcium compared with placebo did not result in a significantly lower risk of all-type cancer at 4 years. Further research is necessary to assess the possible role of vitamin D in cancer prevention. Trial Registration: clinicaltrials.gov Identifier: NCT01052051.

Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison: Professional and Service User Perspectives.

Ex-armed forces personnel represent a potentially vulnerable group within the prison population. To provide support to this group, we need to understand their needs and help-seeking behavior. A focus group with professionals and semi-structured interviews with service users explored perspectives of the treatment barriers faced by this group and their support needs. Data were analyzed using constant comparison methods, and four primary themes were identified. The findings suggest ex-armed forces personnel consider prison an opportunity to access support but find it difficult to ask for help. Staff having an awareness of military issues was thought to encourage help-seeking, but the variability of provision across prison establishments was considered a barrier. Resettlement was a prominent concern, and access to support when preparing for, and after, release was felt by all participants to be important. Implications for the provision of support in prison are discussed along with recommendations for practice.

Soldier, civilian, criminal: identifying pathways to offending of ex-armed forces personnel in prison.

Little is known about why some ex-armed forces personnel become involved in the criminal justice system, however, they represent the largest known occupational group in prison. In-depth interviews were employed to explore possible pathways to offending. Twenty ex-armed forces personnel in prison were recruited from five prisons in England. Data were analysed using a combination of thematic analysis and constant comparison methods rooted in grounded theory. Four predominant themes were identified: experiences of trauma and adversity; belonging; impulsivity and creating a soldier. Participants had experienced a number of traumatic incidents and adversity in their lives, encompassing pre, during and post-service but felt a sense of belonging in the armed forces. Participants demonstrated impulsivity in a number of areas with links to both their service in the armed forces and offending behaviour. The creation of the identity of 'soldier' was perceived to impact participants' lives in a number of ways, including their offending, alcohol use and coping with trauma. The interplay of these themes and their potential impact on participants' pathways to offending are discussed.

Obtaining and communicating information about genetics and genomics.

This is the eighth article in a series looking at how nurses can develop competence in genetics and genomics health care. The article explores the many ways in which nurses can acquire up to date and accurate genetic and genomic information, with the intention of improving their knowledge base. It enables nurses to discover the best ways of giving specific and complex information to patients and colleagues effectively and using straightforward language.

Exposure to a Vitamin D Best Practices Toolkit, Model, and E-Tools Increases Knowledge, Confidence, and the Translation of Research to Public Health and Practice.

Preventable vitamin D deficiency (VDD) is a global health concern. The prevention, early detection, and treatment of vitamin D deficiency aligning with serum 25-hydroxyvitamin D concentration recommendations of 40-60 ng/mL (100-150 nmol/L), provided by an international panel of 48 vitamin D researchers, would result in significant health benefits and cost savings to individuals and society. However, research shows that healthcare professionals lack knowledge and confidence in best practices with respect to vitamin D. A vitamin D toolkit was developed that included a model for decision-making support, e-tools, and accompanying resources and was implemented using an online, asynchronous learning management system. This pre-test, post-test, and follow-up survey study design aimed to increase nurses' and dietitians' levels of knowledge and confidence regarding vitamin D, aid in their translation of evidence into spheres of practice and influence, and help them identify translation barriers. The completion of the toolkit increased the participants' (n = 119) knowledge from 31% to 65% (p < 0.001) and their confidence from 2.0 to 3.3 (p < 0.001) on a scale of 1-5. Respondents reported using the model (100%) as a framework to successfully guide the translation of vitamin D knowledge into their sphere of influence or practice (94%) and identifying translation barriers. The toolkit should be included in interdisciplinary continuing education, research/quality improvement initiatives, healthcare policy, and institutions of higher learning to increase the movement of research into practice.

Suicide bereavement in the UK: Descriptive findings from a national survey.

BACKGROUND: Those bereaved by suicide are a high-risk group of adverse health outcomes and suicidal behavior, yet little is known about the experiences and support needs of these individuals in the UK. METHODS: We conducted a national cross-sectional study using an online survey and analyzed the experiences of 7158 participants who had been bereaved or affected by suicide. RESULTS: Suicide had a major impact on 77% of participants, including those who had lost a friend and those exposed to suicide at a professional level. Mental and physical health problems linked to the suicide were reported in half. Adverse social outcomes and engaging in high-risk behaviors following the suicide were common. Over a third reported suicidal ideation and 8% had attempted suicide as a direct result of the suicide loss. Most had not accessed support services, with the majority viewing provision of local suicide bereavement support as inadequate. CONCLUSIONS: Our results highlight the need for a multi-disciplinary approach in postvention and the provision of proactive outreach to support those bereaved by suicide. Postvention efforts need to acknowledge the death of a friend by suicide as a significant loss.

International Consensus Statement on the diagnosis, multidisciplinary management and lifelong care of individuals with achondroplasia.

Achondroplasia, the most common skeletal dysplasia, is characterized by a variety of medical, functional and psychosocial challenges across the lifespan. The condition is caused by a common, recurring, gain-of-function mutation in FGFR3, the gene that encodes fibroblast growth factor receptor 3. This mutation leads to impaired endochondral ossification of the human skeleton. The clinical and radiographic hallmarks of achondroplasia make accurate diagnosis possible in most patients. However, marked variability exists in the clinical care pathways and protocols practised by clinicians who manage children and adults with this condition. A group of 55 international experts from 16 countries and 5 continents have developed consensus statements and recommendations that aim to capture the key challenges and optimal management of achondroplasia across each major life stage and sub-specialty area, using a modified Delphi process. The primary purpose of this first International Consensus Statement is to facilitate the improvement and standardization of care for children and adults with achondroplasia worldwide in order to optimize their clinical outcomes and quality of life.

Ethnic Minority Groups' Experiences of Suicide Bereavement: A Qualitative Exploratory Study.

It is estimated that between 36,000 and 360,000 people are affected by suicide every year in the UK, and a proportion may develop depression and post-traumatic stress disorder, or engage in high-risk behaviours. Recent systematic analyses have revealed a clear gap in research on suicide bereavement in minority ethnic groups. This study aimed to understand the experiences and support needs of individuals from ethnic minority backgrounds bereaved by suicide and was the first in the UK to investigate this matter. The study was a secondary analysis of data. Participants were 7158 people residing in the UK who completed an online survey about their experiences of suicide. Free-text qualitative responses of 227 participants who did not identify as White British were analysed using thematic analysis. Four themes were identified: maladaptive coping strategies, emotional processes following suicide, lack of support from agencies, and the importance of mental health awareness. Ethnic minority groups reported a lack of support despite attempts to engage with services, noted the prevalence of stigma within ethnic minority groups, and expressed a need to tackle this. These preliminary results suggest that ethnic minority individuals require visible and accessible services that can successfully engage with and support them.

Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths.

The world is in the grip of the COVID-19 pandemic. Public health measures that can reduce the risk of infection and death in addition to quarantines are desperately needed. This article reviews the roles of vitamin D in reducing the risk of respiratory tract infections, knowledge about the epidemiology of influenza and COVID-19, and how vitamin D supplementation might be a useful measure to reduce risk. Through several mechanisms, vitamin D can reduce risk of infections. Those mechanisms include inducing cathelicidins and defensins that can lower viral replication rates and reducing concentrations of pro-inflammatory cytokines that produce the inflammation that injures the lining of the lungs, leading to pneumonia, as well as increasing concentrations of anti-inflammatory cytokines. Several observational studies and clinical trials reported that vitamin D supplementation reduced the risk of influenza, whereas others did not. Evidence supporting the role of vitamin D in reducing risk of COVID-19 includes that the outbreak occurred in winter, a time when 25-hydroxyvitamin D (25(OH)D) concentrations are lowest; that the number of cases in the Southern Hemisphere near the end of summer are low; that vitamin D deficiency has been found to contribute to acute respiratory distress syndrome; and that case-fatality rates increase with age and with chronic disease comorbidity, both of which are associated with lower 25(OH)D concentration. To reduce the risk of infection, it is recommended that people at risk of influenza and/or COVID-19 consider taking 10,000 IU/d of vitamin D3 for a few weeks to rapidly raise 25(OH)D concentrations, followed by 5000 IU/d. The goal should be to raise 25(OH)D concentrations above 40-60 ng/mL (100-150 nmol/L). For treatment of people who become infected with COVID-19, higher vitamin D3 doses might be useful. Randomized controlled trials and large population studies should be conducted to evaluate these recommendations.

'We're the First Port of Call' - Perspectives of Ambulance Staff on Responding to Deaths by Suicide: A Qualitative Study.

INTRODUCTION: Exposure to suicide is a known risk factor for suicide. Ambulance staff are exposed to work-related stressors including attending suicides, which may elevate their risk for mental health problems/suicide. Little is known about ambulance staff's perspectives on how they experience these events and whether they feel equipped to respond to bereaved families at the scene of death. This study explores the perspectives of ambulance staff about responding to deaths by suicide. MATERIALS AND METHODS: A convenience sample of ambulance staff recruited from one ambulance service in England. In-depth, qualitative, semi-structured face-to-face interviews conducted with nine ambulance staff (six male, three female) to explore experiences of responding to suicide. Data analyzed using thematic analysis. RESULTS: Participants reported the experience of job-related strain including exposure to the suicide/suicidal ideation of colleagues; they described suppressing their distress despite significant emotional impact. All participants had been personally bereaved by suicide and responding to suicide was a common part of their job. They were often the first professionals at the scene, and undertook varied and often conflicting roles: negotiating with patients in crisis; informing individuals of the death of a loved one; preserving the body/potential crime scene; dealing with the intense emotional reactions of bereaved individuals. Participants reported long-term, salient memories of these events; however, there was a reported lack of acknowledgment in the workplace that suicides may be traumatic and no guidance for staff on how to cope. Opportunities to debrief were reportedly rare, and there was reluctance to access work-based liaison services. Training in how to respond to individuals bereaved by suicide was also lacking. DISCUSSION: The study is the first to reveal the complex challenges faced by ambulance staff in responding to suicide without adequate training and support. It demonstrates the potential impact that responding to suicide can have personally and professionally on staff, and emphasizes the need for employers to support staff wellbeing in better ways. Training and postvention support could enable better coping among staff, more effective support for bereaved individuals and reduce the risk of death by suicide both in those bereaved by suicide and in ambulance staff.

Experiences of support from primary care and perceived needs of parents bereaved by suicide: a qualitative study.

BACKGROUND: People bereaved by suicide are a vulnerable group, also at risk of dying by suicide. The importance of postvention support (intervention after suicide) has recently been highlighted; however, little is known about the support needs of parents bereaved by suicide in the UK, and the role played by general practice. AIM: To explore the perspectives, experiences, and support needs of parents bereaved by suicide. DESIGN AND SETTING: This was a qualitative study, with semi-structured interviews conducted between 2012 and 2014 in the north of England and the Midlands, with parents bereaved by their son or daughter's suicide. METHOD: Interviews explored parents' experiences of suicide bereavement following the death of their son or daughter, with a focus on their experiences of support from primary care. Interviews were analysed thematically using constant comparison. RESULTS: Twenty-three interviews were conducted. Three themes were identified from the data: the importance of not feeling alone; perceived barriers to accessing support; and the need for signposting for additional support. Some parents reported having experienced good support from their general practice; others described a number of barriers to accessing help, including triage processes. Primary care was considered to be an important avenue of support but GPs were often perceived as uncertain how to respond. The need for information, signposting to avenues of support, and the helpfulness of group support were also highlighted. CONCLUSION: Parents believed it was important that people working in general practice have an awareness of suicide bereavement and understanding of their needs, including knowledge of where to direct people for further support.

Evaluation of the Impact of the PABBS Suicide Bereavement Training on Clinicians' Knowledge and Skills.

Background: Health-care professionals do not routinely receive training on how best to support parents bereaved by suicide. Evidence-based training - Postvention Assisting Those Bereaved by Suicide (PABBS) - was designed to address this gap. Aims: The study aimed (a) to pilot PABBS training and evaluate its perceived effectiveness (impact on self-reported knowledge, skills and confidence) in managing suicide bereavement; and (b) to explore training acceptability. Method: A pre- and postevaluation design was used. Professionals attended intensive, structured 1-day PABBS training comprising: didactic/interactive teaching; practice-orientated activities supported with real-life materials and a manual/workbook. Evaluation forms completed immediately before and after training analyzed: (a) self-reported changes in knowledge, skills, and confidence (perceived effectiveness of training); and (b) the acceptability of training. Results: In total, 62 professionals completed training. Perceived knowledge, skills, and confidence improved after training as did self-reported understanding, motivation to learn more, and intention to change practice. Training was highly rated, particularly the evidence-based, real-life materials, with some suggestions for improvement. Limitations: Self-selected sample and reliance on self-report measures are the study's limitations. Conclusion: PABBS training may help address gaps in professionals' capacity to support parents bereaved by suicide. The evidence-based content was highly acceptable and appeared to be a key ingredient in effecting self-reported changes in attitudes/intentions.

The private partners of public health: public-private alliances for public good.

OBJECTIVE: We sought to convey lessons learned by the Centers for Disease Control and Prevention's (CDC's) Prevention Research Centers (PRCs) about the value and challenges of private-sector alliances resulting in innovative health promotion strategies. Several PRCs based in a variety of workplace and community settings contributed. METHODS: We conducted interviews with principal investigators, a literature review, and a review of case studies of private-sector alliances in a microbusiness model, a macrobusiness model, and as multiparty partnerships supporting public health research, implementation, and human resource services. RESULTS: Private-sector alliances provide many advantages, particularly access to specialized skills generally beyond the expertise of public health entities. These skills include manufacturing, distribution, marketing, business planning, and development. Alliances also allow ready access to employee populations. Public health entities can offer private-sector partners funding opportunities through special grants, data gathering and analysis skills, and enhanced project credibility and trust. Challenges to successful partnerships include time and resource availability and negotiating the cultural divide between public health and the private sector. Critical to success are knowledge of organizational culture, values, mission, currency, and methods of operation; an understanding of and ability to articulate the benefits of the alliance for each partner; and the ability and time to respond to unexpected changes and opportunities. CONCLUSION: Private-public health alliances are challenging, and developing them takes time and resources, but aspects of these alliances can capitalize on partners' strengths, counteract weaknesses, and build collaborations that produce better outcomes than otherwise possible. Private partners may be necessary for program initiation or success. CDC guidelines and support materials may help nurture these alliances.

25-Hydroxyvitamin D variability within-person due to diurnal rhythm and illness: a case report.

BACKGROUND: Vitamin D nutrition research requires accurate measures of circulating 25-hydroxyvitamin D. Our objectives were to test whether a diurnal fluctuation in blood-spot concentrations of 25-hydroxyvitamin D can be demonstrated statistically in a single individual, and whether such fluctuation is affected by the pre-dose versus post-dose timing of the blood draw. CASE PRESENTATION: The participant in this case study was a generally healthy Caucasian woman in her 40s who has taken 5000 IU vitamin D3 supplement at midday for over 1 year. Each blood sample was drawn individually from a finger prick onto filter paper at morning, midday, or night, on 4 days (three groups of five individual blood samples per collection day). On days 1 and 2, the midday samples were collected approximately 1 hour after the supplement was taken; on days 3 and 4, the midday samples were collected within an hour prior to supplementation (the classical, daily "trough" value for a drug). There was a significant daily pattern of variation in 25-hydroxyvitamin D concentrations (analysis of variance p ≤ 0.02 for 3 of the 4 days): peak midday mean 25-hydroxyvitamin D was approximately 20% higher than in the morning, and approximately 13% higher than in the evening. Trough sampling produced no significant difference in 25-hydroxyvitamin D compared to sampling an hour after the dose. An incidental finding was that acute illness during the study was related to acutely lower 25-hydroxyvitamin D at every sampling time in the day (p < 0.00001). CONCLUSIONS: There was a consistent diurnal variation in 25-hydroxyvitamin D, with the peak at midday. There was no difference between trough versus post-dose blood draws. Acute illness may acutely lower serum 25-hydroxyvitamin D levels. Because within-person, within-day variability in 25-hydroxyvitamin D is approximately 20%, sampling time introduces systematic error in vitamin D nutritional assessment that is bigger than random analytical error or choice of assay method.

Cross-sectional study of the combined associations of dietary and supplemental eicosapentaenoic acid + docosahexaenoic acid on Omega-3 Index.

Studies have linked an Omega-3 Index (O3I), which measures eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) in red blood cell membranes, of ≥8% with improved health. Previous studies found that the American Heart Association (AHA) recommendation of 1-2 seafood meals per week does not achieve an O3I ≥8% even with an EPA + DHA supplement; however, these studies did not assess the frequency or amount of supplemental intake. Among participants in a predominantly US and Canadian cohort with high nutrient supplement use, we hypothesized that those adhering to the AHA guidelines would not have an average O3I ≥8% but that those taking a daily supplement would. Fish consumption and EPA + DHA supplement use were reported by 1795 participants; 985 also completed a blood spot test for O3I. A majority (71%) consumed <2 servings per week of fatty fish, and 61% took an EPA + DHA supplement. The amount of EPA + DHA for 1 serving (based on the product label) significantly differed among the >400 supplement products (50-3570 mg). O3I was ≥8.0% in 19% of participants. Among non-supplement takers, 3% of those consuming 1 fish serving per week and 17% consuming ≥2 achieved an O3I ≥8.0%. Among those consuming ≥2 fish servings per week, only those also taking an average of 1100 mg/d of supplemental EPA + DHA had a median O3I ≥8.0%. Based on the relationship between supplemental EPA + DHA intake and O3I for non-fish eaters (R2 = 0.40, P < .0001), an average of ~1300 mg/d of EPA + DHA achieved an O3I of 8.0%. This study suggests that following the AHA guidelines does not produce an O3I ≥8% nor does taking 1 serving per day of most omega-3 supplements.

Health Services and Infrastructure Recovery of a Major Public Hospital in Liberia During the 2014-2016 Ebola Epidemic.

During the 2014-2016 Ebola outbreak, health services in Liberia collapsed. Health care facilities could not support effective infection prevention and control (IPC) practices to prevent Ebola virus disease (EVD) transmission necessitating their closure. This report describes the process by which health services and infrastructure were recovered in the public hospital in Monrovia, Liberia. The authors conducted an assessment of the existing capacity for health care provision, including qualitative interviews with community members, record reviews in Ebola treatment units, and phone calls to health facilities. Assessment information was used to determine necessary actions to re-establish services, including building and environmental renovations, acquiring IPC supplies, changing health care practices, hiring additional staff, developing and using an EVD screening tool, and implementing psychosocial supports. On-site monitoring was continued for 2 years to assess what changes were sustained. Described in the report are 2 cases that highlight the challenge of safely re-establishing services with only a symptom-based screening tool and no laboratory tests available on-site. Despite fears among the public, health workers, and the international community, the actions taken enabled basic health care services to be provided during EVD transmission and led to sustainable improvements. This experience suggests that providing routine medical needs helps limit the morbidity and mortality during times of disease outbreak. (Disaster Med Public Health Preparedness. 2018;13:767-773).

The mental health and substance misuse needs of male ex-armed forces personnel in prison.

Ex-armed forces personnel constitute the largest known occupational group in prison but there is little evidence regarding their mental health, or substance misuse, needs. A total of 105 participants were interviewed and measures assessing symptoms of common mental health (CMH) problems and substance misuse were completed along with a review of their health care records. Forty (38%) participants screened for current CMH problems (CCMH) and high levels of dual symptomology and alcohol misuse were assessed. Thirty-nine (37%) had a mental health diagnosis recorded, most commonly for post-traumatic stress disorder (PTSD), depression and personality disorder. Those who screened for a CCMH problem were more likely to have pre-service vulnerability to negative health outcomes and those with dual symptomology were more likely to have experienced deployment during their service. Findings suggest the mental health needs of this group are similar to the general prison population. Potentially higher prevalences of PTSD and alcohol misuse may direct service provision.