Driving delivery and uptake of catch-up vaccination among adolescent and adult migrants in UK general practice: a mixed methods pilot study.

BACKGROUND: Migrants in the UK and Europe face vulnerability to vaccine-preventable diseases (VPDs) due to missed childhood vaccines and doses and marginalisation from health systems. Ensuring migrants receive catch-up vaccinations, including MMR, Td/IPV, MenACWY, and HPV, is essential to align them with UK and European vaccination schedules and ultimately reduce morbidity and mortality. However, recent evidence highlights poor awareness and implementation of catch-up vaccination guidelines by UK primary care staff, requiring novel approaches to strengthen the primary care pathway. METHODS: The 'Vacc on Track' study (May 2021-September 2022) aimed to measure under-vaccination rates among migrants in UK primary care and establish new referral pathways for catch-up vaccination. Participants included migrants aged 16 or older, born outside of Western Europe, North America, Australia, or New Zealand, in two London boroughs. Quantitative data on vaccination history, referral, uptake, and sociodemographic factors were collected, with practice nurses prompted to deliver catch-up vaccinations following UK guidelines. Focus group discussions and in-depth interviews with staff and migrants explored views on delivering catch-up vaccination, including barriers, facilitators, and opportunities. Data were analysed using STATA12 and NVivo 12. RESULTS: Results from 57 migrants presenting to study sites from 18 countries (mean age 41 [SD 7.2] years; 62% female; mean 11.3 [SD 9.1] years in UK) over a minimum of 6 months of follow-up revealed significant catch-up vaccination needs, particularly for MMR (49 [86%] required catch-up vaccination) and Td/IPV (50 [88%]). Fifty-three (93%) participants were referred for any catch-up vaccination, but completion of courses was low (6 [12%] for Td/IPV and 33 [64%] for MMR), suggesting individual and systemic barriers. Qualitative in-depth interviews (n = 39) with adult migrants highlighted the lack of systems currently in place in the UK to offer catch-up vaccination to migrants on arrival and the need for health-care provider skills and knowledge of catch-up vaccination to be improved. Focus group discussions and interviews with practice staff (n = 32) identified limited appointment/follow-up time, staff knowledge gaps, inadequate engagement routes, and low incentivisation as challenges that will need to be addressed. However, they underscored the potential of staff champions, trust-building mechanisms, and community-based approaches to strengthen catch-up vaccination uptake among migrants. CONCLUSIONS: Given the significant catch-up vaccination needs of migrants in our sample, and the current barriers to driving uptake identified, our findings suggest it will be important to explore this public health issue further, potentially through a larger study or trial. Strengthening existing pathways, staff capacity and knowledge in primary care, alongside implementing new strategies centred on cultural competence and building trust with migrant communities will be important focus areas.

Understanding the views of adult migrants around catch-up vaccination for missed routine immunisations to define strategies to improve coverage: A UK in-depth interview study.

BACKGROUND: The World Health Organization's (WHO) Immunization Agenda 2030 emphasises ensuring equitable access to vaccination across the life course. This includes placing an emphasis on migrant populations who may have missed key childhood vaccines, doses, and boosters due to disrupted healthcare systems and the migration process, or differing vaccination schedules in home countries. Guidelines exist in the UK for offering catch-up vaccinations to adolscent and adult migrants with incomplete or uncertain vaccination status (including MMR, Td-IPV, MenACWY, HPV), but emerging evidence suggests awareness and implementation in primary care is poor. It is unclear whether patient-level barriers to uptake of catch-up vaccinations also exist. We explored experiences and views around catch-up vaccination among adult migrants from a range of backgrounds, to define strategies for improving catch-up vaccination policy and practice. METHODS: In-depth semi-structured interviews were carried out in two phases with adult migrant populations (refugees, asylum seekers, undocumented migrants, those with no recourse to public funds) on views and experiences around vaccination, involving a team of peer researchers from specific migrant communities trained through the study. In Phase 1, we conducted remote interviews with migrants resident in the UK for < 10 years, from diverse backgrounds. In Phase 2, we engaged specifically Congolese and Angolan migrants as part of a community-based participatory study. Topic guides were developed iteratively and piloted. Participants were recruited using purposive, opportunistic and snowball sampling methods. Interviews were conducted in English (interpreters offered), Lingala or French and were audio-recorded, transcribed and analysed using a thematic framework approach in NVivo 12. RESULTS: 71 participants (39 in Phase 1, 32 in Phase 2) were interviewed (Mean age 43.6 [SD:12.4] years, 69% female, mean 9.5 [SD:7] years in the UK). Aside from COVID-19 vaccines, most participants reported never having been offered vaccinations or asked about their vaccination history since arriving in the UK as adults. Few participants mentioned being offered specific catch-up vaccines (e.g. MMR/Td-IPV) when attending a healthcare facility on arrival in the UK. Vaccines such as flu vaccines, pregnancy-related or pre-travel vaccination were more commonly mentioned. In general, participants were not aware of adult catch-up vaccination but regarded it positively when it was explained. A few participants expressed concerns about side-effects, risks/inconveniences associated with access (e.g. links to immigration authorities, travel costs), preference for natural remedies, and hesitancy to engage in further vaccination campaigns due to the intensity of COVID-19 vaccination campaigns. Trust was a major factor in vaccination decisions, with distinctions noted within and between groups; some held a healthcare professional's recommendation in high regard, while others were less trusting towards the healthcare system because of negative experiences of the NHS and past experiences of discrimination, injustice and marginalisation by wider authorities. CONCLUSIONS: The major barrier to adult catch-up vaccination for missed routine immunisations and doses in migrant communities in the UK is the limited opportunities, recommendations or tailored vaccination information presented to migrants by health services. This could be improved with financial incentives for provision of catch-up vaccination in UK primary care, alongside training of healthcare professionals to support catch-up immunisation and raise awareness of existing guidelines. It will also be essential to address root causes of mistrust around vaccination, where it exists among migrants, by working closely with communities to understand their needs and meaningfully involving migrant populations in co-producing tailored information campaigns and culturally relevant interventions to improve coverage.

The immune status of migrant populations in Europe and implications for vaccine-preventable disease control: a systematic review and meta-analysis.

BACKGROUND: Ensuring vaccination coverage reaches established herd immunity thresholds (HIT) is the cornerstone of any vaccination programme. Diverse migrant populations in European countries have been associated with cases of vaccine-preventable diseases (VPD) and outbreaks, yet it is not clear to what extent they are an under-immunised group. METHODS: We did a systematic review and meta-analysis to synthesise peer-reviewed published primary research reporting data on the immune status of migrants in EU/EEA countries, the UK and Switzerland, calculating their pooled immunity coverage for measles, mumps, rubella, and diphtheria using random-effects models. We searched on Web of Science, Embase, Global Health and MEDLINE (January 1st 2000 to June 10th 2022), with no language restrictions. The protocol is registered with PROSPERO (CRD42018103666). FINDINGS: Of 1103 abstracts screened, 62 met eligibility criteria, of which 39 were included in the meta-analysis. The meta-analysis included 75 089 migrants, predominantly from outside Europe. Pooled immunity coverage among migrant populations was well below the recommended HIT for diphtheria (n = 7, 57.4% [95% CI: 43.1-71.7%] I2 = 99% vs HIT 83-86%), measles (n = 21, 83.7% [95% CI: 79.2-88.2] I2 = 99% vs HIT 93-95%), and mumps (n = 8, 67.1% [95% CI: 50.6-83.6] I2 = 99% vs HIT 88-93%), and midway for rubella (n = 29, 85.6% [95% CI: 83.1-88.1%] I2 = 99% vs HIT 83-94%), with high heterogeneity across studies. INTERPRETATION: Migrants in Europe are an under-immunised group for a range of important VPDs, with this study reinforcing the importance of engaging children, adolescents, and adults in 'catch-up' vaccination initiatives on arrival for vaccines, doses, and boosters they may have missed in their home countries. Co-designing strategies to strengthen catch-up vaccination across the life-course in under-immunised groups is an important next step if we are to meet European and global targets for VPD elimination and control and ensure vaccine equity.

Multi-infection screening for migrant patients in UK primary care: Challenges and opportunities.

Background: Migrants in Europe face a disproportionate burden of undiagnosed infection, including tuberculosis, blood-borne viruses, and parasitic infections and many belong to an under-immunised group. The European Centre for Disease Control (ECDC) has called for innovative strategies to deliver integrated multi-disease screening to migrants within primary care, yet this is poorly implemented in the UK. We did an in-depth qualitative study to understand current practice, barriers and solutions to infectious disease screening in primary care, and to seek feedback on a collaboratively developed digitalised integrated clinical decision-making tool called Health Catch UP!, which supports multi-infection screening for migrant patients. Methods: Two-phase qualitative study of UK primary healthcare professionals, in-depth semi-structured telephone-interviews were conducted. In Phase A, we conducted interviews with clinical staff (general practitioners (GPs), nurses, health-care-assistants (HCAs)); these informed data collection and analysis for phase B (administrative staff). Data were analysed iteratively, using thematic analysis. Results: In phase A, 48 clinicians were recruited (25 GPs, 15 nurses, seven HCAs, one pharmacist) and 16 administrative staff (11 Practice-Managers, five receptionists) in phase B. Respondents were positive about primary care's ability to effectively deliver infectious disease screening. However, we found current infectious disease screening lacks a standardised approach and many practices have no system for screening meaning migrant patients are not always receiving evidence-based care (i.e., NICE/ECDC/UKHSA screening guidelines). Barriers to screening were reported at patient, staff, and system-levels. Respondents reported poor implementation of existing screening initiatives (e.g., regional latent TB screening) citing overly complex pathways that required extensive administrative/clinical time and lacked financial/expert support. Solutions included patient/staff infectious disease champions, targeted training and specialist support, simplified care pathways for screening and management of positive results, and financial incentivisation. Participants responded positively to Health Catch-UP!, stating it would systematically integrate data and support clinical decision-making, increase knowledge, reduce missed screening opportunities, and normalisation of primary care-based infectious disease screening for migrants. Conclusions: Our results suggest that implementation of infectious disease screening in migrant populations is not comprehensively done in UK primary care. Primary health care professionals support the concept of innovative digital tools like Health Catch-UP! and that they could significantly improve disease detection and effective implementation of screening guidance but that they require robust testing and resourcing.

Patterns of Opioid Prescriptions in the Veterans Health Administration for Patients With Chronic Low-Back Pain After the Onset of the COVID-19 Pandemic: A Retrospective Cohort Analysis.

The COVID-19 pandemic led to severe disruptions in health care and a relaxation of rules surrounding opioid prescribing-changes which led to concerns about increased reliance on opioids for chronic pain and a resurgence of opioid-related harms. Although some studies found that opioid prescriptions increased in the first 6 months of the pandemic, we know little about the longer-term effects of the pandemic on opioid prescriptions. Further, despite the prevalence of pain in veterans, we know little about patterns of opioid prescriptions in the Veterans Health Administration (VA) associated with the pandemic. Using a retrospective cohort of VA patients with chronic low-back pain, we examined the proportion of patients with an opioid prescription and mean morphine milligram equivalents over a 3-year period-1 year prior to and 2 years after the pandemic's onset. Analyses revealed that both measures fell during the entire observation period. The largest decrease in the odds of filling an opioid prescription occurred in the first quarter of the pandemic, but this downward trend continued throughout the observation period, albeit at a slower pace. Clinically meaningful differences in opioid prescriptions and dose over time did not emerge based on patient race or rurality; however, differences emerged between female and male veterans, with decreases in opioid prescriptions slowing more markedly for women after the pandemic onset. These findings suggest that the pandemic was not associated with short- or long-term increases in opioid prescriptions or doses in the VA. PERSPECTIVE: This article examines opioid prescribing over a 3-year period-1 year prior to and 2 years after the onset of the COVID-19 pandemic-for VA patients with chronic low-back pain. Results indicate that, despite disruptions to health care, opioid prescriptions and doses decreased over the entire observation period.

Co-designing a theory-informed, multicomponent intervention to increase vaccine uptake with Congolese migrants: A qualitative, community-based participatory research study (LISOLO MALAMU).

INTRODUCTION: Disparities in the uptake of routine and COVID-19 vaccinations have been observed in migrant populations, and attributed to issues of mistrust, access and low vaccine confidence. Participatory research approaches and behaviour change theory hold the potential for developing tailored vaccination interventions that address these complex barriers in partnership with communities and should be explored further. METHODS: This study used a theory-informed, community-based participatory research approach to co-design a culturally tailored behaviour change intervention aimed at increasing COVID-19 vaccine uptake among Congolese migrants in London, United Kingdom (2021-2022). It was designed and led by a community-academic partnership in response to unmet needs in the Congolese community as the COVID-19 pandemic started. Barriers and facilitators to COVID-19 vaccination, information and communication preferences, and intervention suggestions were explored through qualitative in-depth interviews with Congolese migrants, thematically analysed, and mapped to the theoretical domains framework (TDF) and the capability, opportunity, motivation, behaviour model to identify target behaviours and strategies to include in interventions. Interventions were co-designed and tailored in workshops involving Congolese migrants. RESULTS: Thirty-two Congolese adult migrants (24 (75%) women, mean 14.3 (SD: 7.5) years in the United Kingdom, mean age 52.6 (SD: 11.0) years) took part in in-depth interviews and 16 (same sample) took part in co-design workshops. Fourteen barriers and 10 facilitators to COVID-19 vaccination were identified; most barrier data related to four TDF domains (beliefs about consequences; emotion; social influences and environmental context and resources), and the behavioural diagnosis concluded interventions should target improving psychological capability, reflective and automatic motivations and social opportunities. Strategies included culturally tailored behaviour change techniques based on education, persuasion, modelling, enablement and environmental restructuring, which resulted in a co-designed intervention comprising community-led workshops, plays and posters. Findings and interventions were disseminated through a community celebration event. CONCLUSIONS: Our study demonstrates how behavioural theory can be applied to co-designing tailored interventions with underserved migrant communities through a participatory research paradigm to address a range of health issues and inequalities. Future research should build on this empowering approach, with the goal of developing more sensitive vaccination services and interventions which respond to migrant communities' unique cultural needs and realities. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement (PPI) were embedded in the participatory study design and approach, with community members co-producing all stages of the study and co-authoring this paper. An independent PPI board (St George's Migrant Health Research Group Patient and Public Involvement Advisory Board) comprising five adult migrants with lived experience of accessing healthcare in the United Kingdom were also consulted at significant points over the course of the study.

Defining drivers of under-immunization and vaccine hesitancy in refugee and migrant populations.

BACKGROUND/OBJECTIVE: Some refugee and migrant populations globally showed lower uptake of COVID-19 vaccines and are also considered to be an under-immunized group for routine vaccinations. These communities may experience a range of barriers to vaccination systems, yet there is a need to better explore drivers of under-immunization and vaccine hesitancy in these mobile groups. METHODS: We did a global rapid review to explore drivers of under-immunization and vaccine hesitancy to define strategies to strengthen both COVID-19 and routine vaccination uptake, searching MEDLINE, Embase, Global Health PsycINFO and grey literature. Qualitative data were analysed thematically to identify drivers of under-immunization and vaccine hesitancy, and then categorized using the 'Increasing Vaccination Model'. RESULTS: Sixty-three papers were included, reporting data on diverse population groups, including refugees, asylum seekers, labour migrants and undocumented migrants in 22 countries. Drivers of under-immunization and vaccine hesitancy pertaining to a wide range of vaccines were covered, including COVID-19 (n = 27), human papillomavirus (13), measles or Measles-mumps-rubella (MMR) (3), influenza (3), tetanus (1) and vaccination in general. We found a range of factors driving under-immunization and hesitancy in refugee and migrant groups, including unique awareness and access factors that need to be better considered in policy and service delivery. Acceptability of vaccination was often deeply rooted in social and historical context and influenced by personal risk perception. CONCLUSIONS: These findings hold direct relevance to current efforts to ensure high levels of global coverage for a range of vaccines and to ensure that marginalized refugee and migrant populations are included in the national vaccination plans of low-, middle- and high-income countries. We found a stark lack of research from low- and middle-income and humanitarian contexts on vaccination in mobile groups. This needs to be urgently rectified if we are to design and deliver effective programmes that ensure high coverage for COVID-19 and routine vaccinations.

Acidification-Induced Structure Evolution of Lipid Nanoparticles Correlates with Their In Vitro Gene Transfections.

The rational design of lipid nanoparticles (LNPs) for enhanced gene delivery remains challenging because of incomplete knowledge of their formulation-structure relationship that impacts their intracellular behavior and consequent function. Small-angle neutron scattering has been used in this work to investigate the structure of LNPs encapsulating plasmid DNA upon their acidification (from pH 7.4 to 4.0), as would be encountered during endocytosis. The results revealed the acidification-induced structure evolution (AISE) of the LNPs on different dimension scales, involving protonation of the ionizable lipid, volume expansion and redistribution of aqueous and lipid components. A similarity analysis using an LNP's structural feature space showed a strong positive correlation between function (measured by intracellular luciferase expression) and the extent of AISE, which was further enhanced by the fraction of unsaturated helper lipid. Our findings reveal molecular and nanoscale changes occurring during AISE that underpin the LNPs' formulation-nanostructure-function relationship, aiding the rational design of application-directed gene delivery vehicles.

Use of social media platforms by migrant and ethnic minority populations during the COVID-19 pandemic: a systematic review.

OBJECTIVE: Migrants and ethnic minority groups have been disproportionately impacted by COVID-19 and have lower levels of vaccine uptake in some contexts. We aimed to determine the extent and nature of social media use in migrant and ethnic minority communities for COVID-19 information, and implications for preventative health measures including vaccination intent and uptake. DESIGN: A systematic review of published and grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched databases including Embase, Web of Science, PubMed NIH, CINAHL, facilitated through the WHO Global Research on COVID-19 database from 31 December 2019 to 9 June 2021. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Research reporting the use of social media by migrants and/or ethnic minority groups in relation to COVID-19. DATA EXTRACTION: We extracted data on key outcomes, study design, country, population under study and sample size. RESULTS: 1849 unique records were screened, and 21 data sources were included, including populations in the UK, USA, China, Jordan, Qatar and Turkey. We found evidence of consistent use of a range of social media platforms for COVID-19 information in some migrant and ethnic minority populations (including WeChat, Facebook, WhatsApp, Instagram, Twitter, YouTube), which may stem from difficulty in accessing COVID-19 information in their native languages or from trusted sources. Some evidence suggested circulating misinformation and social media use may be associated with lower participation in preventative health measures, including vaccine intent and uptake, findings which are likely relevant to multiple population groups. CONCLUSIONS: Social media platforms are an important source of information about COVID-19 for some migrant and ethnic minority populations. Urgent actions and further research are now needed to better understand effective approaches to tackling circulating misinformation, and to seize on opportunities to better use social media platforms to support public health communication and improve vaccine uptake. REGISTRATION: This study has been registered with PROSPERO (CRD42021259190).

Impacts of chain and head lengths of nonionic alkyl ethoxylate surfactants on cytotoxicity to human corneal and skin cells in agri-spraying processes.

HYPOTHESIS: Nonionic surfactants are widely used as co-formulants in agrochemical sprays. During spraying, they may come into direct contact with humans and animals, causing irritation in different tissues. However, how the molecular structures of these surfactants affect their toxicity towards human eye and skin at the cellular level has not been well characterised. EXPERIMENT: In this study, the cytotoxicities of two sets of nonionic surfactants (alkyl ethoxylate, CnEm) against human corneal and skin cell lines were examined, with one set composed of varied surfactant head length but fixed tail length (C12E4-23) and the other set oppositely composed (C10-16E6). The cell viability and morphology against different nonionic surfactants for varied exposure times were studied, followed by characterisation of their membrane-lytic ability. FINDING: Nonionic surfactants with intermediate amphiphilicity killed cells rapidly due to their strong membrane-lytic power. Those with weak or strong hydrophobicity exhibited low cytotoxicity but had different modes of action depending on their hydrophobicity. Hydrophobic surfactants were found to adsorb on to cell membranes with no observed structural damage for 2 hr. Hydrophilic surfactants were also found to adsorb on to cell membranes but did cause mild structural changes. While the changes were not sufficient to elicit large cytoplasmic leakage over short periods of time, membrane associations did cause cell shrinkage which eventually resulted in cell death over longer exposure periods. These results revealed that the specific amphiphilic nature of nonionic surfactants played a crucial role in determining their cytotoxicity. This work provided a useful basis for the assessment of amphiphilicity of the nonionic surfactants used in agrochemical sprays by balancing their efficiency, toxicity and environmental impact.

Recovery-oriented inpatient mental health care and readmission.

OBJECTIVE: This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. METHOD: The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data. FINDINGS: Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of GLP-1 receptor agonists on cardiovascular outcomes in patients with type 2 diabetes and chronic kidney disease: A systematic review and meta-analysis.

AIM: To evaluate the cardiovascular outcomes of glucagon-like peptide-1 receptor agonists (GLP1-RA) in patients with type 2 diabetes (T2DM) and chronic kidney disease (CKD). MATERIALS AND METHODS: We searched PubMed, Ovid MEDLINE, CINAHL, and Web of Science databases for randomized controlled trials reporting event rates for a composite cardiovascular outcome of cardiovascular death, myocardial infarction, and stroke in patients with T2DM and CKD receiving GLP1-RA or placebo. Studies were restricted to those reporting specific event rates for patients with CKD separately from the overall population. We conducted a meta-analysis using a random-effects model. This meta-analysis was registered on PROSPERO (CRD42022320157). RESULTS: A total of four studies comprising 7130 patients was included in our analysis. Four different GLP1-RA were assessed in a population with CKD defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 . Treatment with GLP1-RA was not associated with a significant reduction in the composite cardiovascular end point of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke (odds ratio (OR) 0.80; 95% confidence interval (CI), 0.59-1.07; p = 0.13) among patients with T2DM and CKD. Individual components of the composite cardiovascular end point were assessed in two trials and did not show evidence of an effect of GLP1-RA in reducing cardiovascular end points. CONCLUSIONS: Pooled analysis of clinical trials reporting separate cardiovascular events rates in patients with T2DM and CKD did not find GLP1-RA to be associated with a reduction in composite cardiovascular event rates. Select GLP1-RA may offer cardiovascular event reduction in patients with T2DM and CKD, but this does not appear to be a class effect. Use of GLP1-RA with demonstrated cardiovascular benefits should be preferred in patients with CKD and T2DM to further reduce cardiovascular risk.

"We don't routinely check vaccination background in adults": a national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care.

OBJECTIVES: Explore primary care professionals' views around barriers/facilitators to catch-up vaccination in adult migrants (foreign-born; over 18 years of age) with incomplete/uncertain vaccination status and for routine vaccines to inform development of interventions to improve vaccine uptake and coverage. DESIGN: Qualitative interview study with purposive sampling and thematic analysis. SETTING: UK primary care. PARTICIPANTS: 64 primary care professionals (PCPs): 48 clinical-staff including general practitioners, practice nurses and healthcare assistants; 16 administrative-staff including practice managers and receptionists (mean age 45 years; 84.4% women; a range of ethnicities). RESULTS: Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters and not be aligned with the UK's vaccine schedule, from both personal and service-delivery levels, with themes including: lack of training and knowledge of guidance among staff; unclear or incomplete vaccine records; and lack of incentivisation (including financial) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. Where delivery models existed, they were diverse and fragmented, but included a combination of opportunistic and proactive programmes. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal, with specific nationality groups reported as more hesitant about specific vaccines, including measles, mumps and rubella (MMR). CONCLUSIONS: WHO's new Immunization Agenda 2030 calls for greater focus to be placed on delivering vaccination across the life course, targeting underimmunised groups for catch-up vaccination at any age, and UK primary care services therefore have a key role. Vaccine uptake in adult migrants could be improved through implementing new financial incentives or inclusion of adult migrant vaccination targets in Quality Outcomes Framework, strengthening care pathways and training and working directly with local community-groups to improve understanding around the benefits of vaccination at all ages.

Implementation and staff understanding of shared decision-making in the context of recovery-oriented care across US Veterans Health Administration (VHA) inpatient mental healthcare units: a mixed-methods evaluation.

OBJECTIVES: To examine the understanding and practice of shared decision-making (SDM) within the context of recovery-oriented care across Veterans Health Administration (VHA) inpatient mental healthcare units. DESIGN: VHA inpatient mental health units were scored on the Recovery-Oriented Acute Inpatient Scale (RAIN). Scores on the RAIN item for medication SDM were used to rank each site from lowest to highest. The top 7 and bottom 8 sites (n=15) were selected for additional analyses using a mixed-methods approach, involving qualitative interviews, observation notes and quantitative data. SETTING: 34 VHA inpatient mental health units located in every geographical region of the USA. PARTICIPANTS: 55 treatment team members. RESULTS: Our results identified an overarching theme of 'power-sharing' that describes participants' conceptualisation and practice of medication decision-making. Three levels of power sharing emerged from both interview and observational data: (1) No power sharing: patients are excluded from treatment decisions; (2) Limited power sharing: patients are informed of treatment decisions but have limited influence on the decision-making process; and (3) Shared-power: patients and providers work collaboratively and contribute to medication decisions. Comparing interview to observational data, only observational data indicating those themes differentiate top from bottom scoring sites on the RAIN SDM item scores. All but one top scoring sites indicated shared power medication decision processes, whereas bottom sites reflected mostly no power sharing. Additionally, our findings highlight three key factors that facilitate the implementation of SDM: inclusion of veteran in treatment teams, patient education and respect for patient autonomy. CONCLUSIONS: Implementation of SDM appears feasible in acute inpatient mental health units. Although most participants were well informed about SDM, that knowledge did not always translate into practice, which supports the need for ongoing implementation support for SDM. Additional contextual factors underscore the value of patients' self-determination as a guiding principle for SDM, highlighting the role of a supporting, empowering and autonomy-generating environment.

Hepatosteatosis and Atherosclerotic Plaque at Coronary CT Angiography.

Purpose: To assess the association between nonalcoholic fatty liver disease (NAFLD) and quantitative atherosclerotic plaque at CT. Materials and Methods: In this post hoc analysis of the prospective Scottish Computed Tomography of the HEART trial (November 2010 to September 2014), hepatosteatosis and coronary artery calcium score were measured at noncontrast CT. Presence of stenoses, visually assessed high-risk plaque, and quantitative plaque burden were assessed at coronary CT angiography. Multivariable models were constructed to assess the impact of hepatosteatosis and cardiovascular risk factors on coronary artery disease. Results: Images from 1726 participants (mean age, 58 years ± 9 [SD]; 974 men) were included. Participants with hepatosteatosis (155 of 1726, 9%) had a higher body mass index, more hypertension and diabetes mellitus, and higher cardiovascular risk scores (P < .001 for all) compared with those without hepatosteatosis. They had increased coronary artery calcium scores (median, 43 Agatston units [AU] [interquartile range, 0-273] vs 19 AU [0-225], P = .046), more nonobstructive disease (48% vs 37%, P = .02), and higher low-attenuation plaque burden (5.11% [0-7.16] vs 4.07% [0-6.84], P = .04). However, these associations were not independent of cardiovascular risk factors. Over a median of 4.7 years, there was no evidence of a difference in myocardial infarction between those with and without hepatosteatosis (1.9% vs 2.4%, P = .92). Conclusion: Hepatosteatosis at CT was associated with an increased prevalence of coronary artery disease at CT, but this was not independent of the presence of cardiovascular risk factors.Keywords: CT, Cardiac, Nonalcoholic Fatty Liver Disease, Coronary Artery Disease, Hepatosteatosis, Plaque QuantificationClinical trial registration no. NCT01149590 Supplemental material is available for this article. © RSNA, 2022See also commentary by Abohashem and Blankstein in this issue.

Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review.

Understanding why some migrants in Europe are at risk of underimmunisation and show lower vaccination uptake for routine and COVID-19 vaccines is critical if we are to address vaccination inequities and meet the goals of WHO's new Immunisation Agenda 2030. We did a systematic review (PROSPERO: CRD42020219214) exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of undervaccination among migrants in the EU and European Economic Area, the UK, and Switzerland. We searched MEDLINE, CINAHL, and PsycINFO from 2000 to 2021 for primary research, with no restrictions on language. 5259 data sources were screened, with 67 studies included from 16 countries, representing 366 529 migrants. We identified multiple access barriers-including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals-for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines. Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of undervaccination in migrants (p<0·05), including African origin, recent migration, and being a refugee or asylum seeker. We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants' barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake. These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

Isolation and Characterization of a ssDNA Aptamer against Major Soluble Antigen of Renibacterium salmoninarum.

Bacterial kidney disease (BKD) is a major health problem of salmonids, affecting both wild and cultured salmon. The disease is caused by Renibacterium salmoninarum (Rs), a fastidious, slow-growing and strongly Gram-positive diplobacillus that produces chronic, systemic infection characterized by granulomatous lesions in the kidney and other organs, often resulting in death. Fast detection of the pathogen is important to limit the spread of the disease, particularly in hatcheries or aquaculture facilities. Aptamers are increasingly replacing conventional antibodies as platforms for the development of rapid diagnostic tools. In this work, we describe the first instance of isolating and characterizing a ssDNA aptamer that binds with high affinity to p57 or major soluble antigen (MSA), the principal antigen found on the cell wall surface of Rs. Specifically, in this study a construct of the full-length protein containing a DNA binding domain (MSA-R2c) was utilized as target. Aptamers were isolated from a pool of random sequences using GO-SELEX (graphene oxide-systematic evolution of ligands by exponential enrichment) protocol. The selection generated multiple aptamers with conserved motifs in the random region. One aptamer with high frequency of occurrence in different clones was characterized and found to display a strong binding affinity to MSA-R2c with a Kd of 3.0 ± 0.6 nM. The aptamer could be potentially utilized for the future development of a sensor for rapid and onsite detection of Rs in water or in infected salmonids, replacing time-consuming and costly lab analyses.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic review.

Migrant populations are one of several underimmunised groups in the EU or European Economic Area (EU/EEA), yet little is known about their involvement in outbreaks of vaccine-preventable diseases. This information is vital to develop targeted strategies to improve the health of diverse migrant communities. We did a systematic review (PROSPERO CRD42019157473; Jan 1, 2000, to May 22, 2020) adhering to PRISMA guidelines, to identify studies on vaccine-preventable disease outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, varicella, Neisseria meningitidis, and Haemophilus influenzae) involving migrants residing in the EU/EEA and Switzerland. We identified 45 studies, reporting on 47 distinct vaccine-preventable disease outbreaks across 13 countries. Most reported outbreaks involving migrants were of measles (n=24; 6496 cases), followed by varicella (n=11; 505 cases), hepatitis A (n=7; 1356 cases), rubella (n=3; 487 cases), and mumps (n=2; 293 cases). 19 (40%) outbreaks, predominantly varicella and measles, were reported in temporary refugee camps or shelters. Of 11 varicella outbreaks, nine (82%) were associated with adult migrants. Half of measles outbreaks (n=11) were associated with migrants from eastern European countries. In conclusion, migrants are involved in vaccine-preventable disease outbreaks in Europe, with adult and child refugees residing in shelters or temporary camps at particular risk, alongside specific nationality groups. Vulnerability varies by disease, setting, and demographics, highlighting the importance of tailoring catch-up vaccination interventions to specific groups in order to meet regional and global vaccination targets as recommended by the new Immunisation Agenda 2030 framework for action. A better understanding of vaccine access and intent in migrant groups and a greater focus on co-designing interventions is urgently needed, with direct implications for COVID-19 vaccine delivery.

A Mouse Model That Mimics AIDS-Related Cytomegalovirus Retinitis: Insights into Pathogenesis.

With the appearance of the worldwide AIDS pandemic four decades ago came a number of debilitating opportunistic infections in patients immunosuppressed by the pathogenic human retrovirus HIV. Among these was a severe sight-threatening retinal disease caused by human cytomegalovirus (HCMV) that remains today a significant cause of vision loss and blindness in untreated AIDS patients without access or sufficient response to combination antiretroviral therapy. Early investigations of AIDS-related HCMV retinitis quickly characterized its hallmark clinical features and unique histopathologic presentation but did not begin to identify the precise virologic and immunologic events that allow the onset and development of this retinal disease during HIV-induced immunosuppression. Toward this end, several mouse models of experimental cytomegalovirus retinitis have been developed to provide new insights into the pathophysiology of HCMV retinitis during AIDS. Herein, we provide a summary and comparison of these mouse models of AIDS-related HCMV retinitis with particular emphasis on one mouse model developed in our laboratory in which mice with a murine acquired immunodeficiency syndrome (MAIDS) of murine retrovirus origin develops a reproducible and well characterized retinitis following intraocular infection with murine cytomegalovirus (MCMV). The MAIDS model of MCMV retinitis has advanced the discovery of many clinically relevant virologic and immunologic mechanisms of virus-induced retinal tissue destruction that are discussed and summarized in this review. These findings may extend to the pathogenesis of AIDS-related HCMV retinitis and other AIDS-related opportunistic virus infections.