Neisseria gonorrhoeae antimicrobial susceptibility trends in Bangkok, Thailand, 2015-21: Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP).

Objectives: Rising antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global public health concern. Many ceftriaxone-resistant cases have been linked to Asia. In the WHO/CDC global Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP), we conducted AMR surveillance at two clinical sites in Bangkok, Thailand, 2015-21. Methods: Urethral discharge samples, from males with urethral discharge and/or dysuria, were Gram-stained and cultured. ETEST was performed to determine AMR. EGASP MIC alert values, CLSI and EUCAST breakpoints were used. Results: In 2015-21, gonococcal isolates were cultured from 1928 cases; most (64.1%) were males reporting having sex with females. The sensitivity and specificity of Gram-stained microscopy compared with culture for detection of gonococci were 97.5% and 96.6%, respectively. From 2015 to 2021, the azithromycin MIC90 increased from 0.125 to 1 mg/L, and the MIC90 of ceftriaxone and cefixime increased from 0.008 and ≤0.016 mg/L to 0.032 and 0.064 mg/L, respectively. Eight EGASP MIC alert values (in seven isolates) were identified. Five alert values were for cefixime (all resistant according to EUCAST breakpoints) and three for azithromycin (all resistant according to EUCAST breakpoints). The average annual resistance to ciprofloxacin during 2015-21 was 92%. Conclusions: A continuous high susceptibility to ceftriaxone, Thailand's first-line gonorrhoea treatment, was found. However, the increasing MICs of ceftriaxone, cefixime and azithromycin are a substantial threat, especially considering these are the last remaining options for the treatment of gonorrhoea. To monitor AMR, continuous and quality-assured gonococcal AMR surveillance such as the Thai WHO/CDC EGASP, ideally including WGS, is imperative globally.

High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study.

Background: Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex. Methods: The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence. Findings: From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001). Interpretation: Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings. Funding: U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.

HIV and syphilis prevalence among transgender women and men who have sex with men, Silom Community Clinic, Bangkok, Thailand, 2017-2019.

We assessed HIV and syphilis infection among MSM and TGW attending Silom Community Clinic from 2017 to 2019. Walk-in and referral clients completed a registration application including a question on gender identity. We compared the prevalence of HIV, syphilis, and HIV and syphilis coinfection among TGW and MSM. In a total of 1050 clients, 276 (26.3%) were TGW and 774 (74.7%) were MSM. Among TGW clients, HIV prevalence was 29.8%, syphilis prevalence was 38.4%, and coinfection prevalence was 18.5%. Comparing prevalence among TGW to MSM, the adjusted prevalence ratio (aPR) for HIV was 1.8 (95% CI:1.4-2.3), for syphilis was 1.2 (95% CI:1.0-1.4), and for HIV and syphilis coinfection was 2.1 (95% CI:1.4-2.9). The prevalence of syphilis was higher than HIV among TGW, with a PR of 1.3 (95% CI:1.1-1.6), and among MSM, with a PR of 1.4 (95% CI:1.2-1.7). TGW age 15-21 years had an HIV prevalence of 16.9% and syphilis prevalence of 30.8%. After adjusting for age, referral, and sexual behaviors, TGW remain significantly associated with HIV and syphilis prevalence. There is a substantial burden of HIV and HIV/syphilis co-infection among TGW. HIV/STI prevention are needed for TGW, including linkage to HIV care.

Complete Genome Sequence of Neisseria gonorrhoeae Multilocus Sequence Type ST7363 Isolated from Thailand.

A Neisseria gonorrhoeae multilocus sequence type (MLST) ST7363 strain was isolated from a patient at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, in 2010 and completely sequenced. This strain is susceptible to ceftriaxone and cefixime. A complete circular chromosome and circular plasmids were assembled from combined Oxford Nanopore Technologies (ONT) and Illumina sequencing.

Hepatitis B surface antigen seroprevalence among children in the Philippines, 2018.

The World Health Organization Western Pacific Region (WPR) set a hepatitis B virus (HBV) control target to achieve HBV surface antigen (HBsAg) prevalence of <1% among children aged 5 years by 2017. The estimated HBsAg prevalence in the Philippines among adults was 16.7% during the pre-vaccine era. We estimated the HBsAg seroprevalence among children aged 5-7 years to measure the impact of vaccination. We conducted a household serosurvey, using a three-stage cluster survey methodology (provinces, clusters, and households). We estimated HBsAg prevalence using a rapid, point-of-care HBsAg test and calculated vaccination coverage by reviewing vaccination records or by caregiver recall. A questionnaire was administered to assess demographic variables for the child and family. We assessed the association between chronic HBV infection, vaccination coverage, and demographic variables, accounting for the complex survey design. Of the 2178 children tested, HBsAg was detected in 15 children [0.8%, 95% confidence interval (CI): 0.4, 1.7]. Only two of the HBsAg-positive children had been fully vaccinated against HBV. Based on documented vaccination or caregiver recall for the survey population, hepatitis B vaccine birth dose (HepB-BD) coverage was 53%, and the third dose hepatitis B vaccination (HepB3) coverage was 73 percent. Among the 1362 children with documented HepB-BD, timely HepB-BD coverage (given within 24 h of birth) was 43%; children born outside a health facility were less likely to receive a timely HepB-BD than those born in a health facility (adjusted odds ratio 0.10, 95% CI: 0.04, 0.23). HBsAg prevalence among children in the Philippines has decreased compared to the prevalence among adults in the pre-vaccination era. Strategies to further reduce HBsAg prevalence include ensuring that all children, whether born in health facilities or at home, receive a timely HepB-BD, and increasing HepB-BD and HepB3 coverage to reach the WPR goals of ≥95% coverage.

Recent declines in HIV infections at Silom Community Clinic Bangkok, Thailand corresponding to HIV prevention scale up: An open cohort assessment 2005-2018.

OBJECTIVES: We assessed HIV-1 infection among men who have sex with men (MSM) attending Silom Community Clinic (SCC) in Bangkok, Thailand from 2005 to 2018. Since 2014, Thailand increased implementation of HIV prevention strategies including pre-exposure prophylaxis and Treatment as Prevention. METHODS: MSM attending SCC were tested for HIV using rapid tests. We assessed trends in HIV prevalence, incidence and compared incidence before and after 2014. RESULTS: From 2005 to 2018, 14,034 clients attended SCC for HIV testing. The HIV prevalence increased from 19.2% in 2005-2006 to 34-0% in 2010, remained stable until 2016 and decreased to 17.2% in 2018 (p<0.0001). The HIV incidence was 4.1 per 100 person-years (PY), with an inverted U-shape trend and a peak in 2009 (p<0.0001). Incidence among young MSM aged 13-21 years remained high at 10.0 per 100 PY. Among those aged 22-29 years, lower incidence was found from Q 3 2016, with a relative risk reduction of 46.2% (p<0.001); and a similar reduction among those aged ≥30 years from Q4 2014, corresponding to scale up of HIV prevention strategies. CONCLUSION: We found a decline in HIV infection among Thai MSM. However, incidence remained high among young MSM.

Seroprevalence of chronic hepatitis B virus infection and immunity to measles, rubella, tetanus and diphtheria among schoolchildren aged 6-7 years old in the Solomon Islands, 2016.

The Western Pacific Region (WPR) established a goal to decrease chronic hepatitis B virus (HBV) infection among children to <1% and to achieve ≥95% hepatitis B vaccine birth dose (HepB-BD) and ≥95% three-dose (HepB3) coverage by 2017. In 2016, we conducted a national serosurvey in the Solomon Islands among 6-7-year-old school children to assess progress towards the control goal and immunity to measles, rubella, tetanus and diphtheria. Eighty schools were selected systematically proportional to their 6-7-year-old population; all 6-7-year-olds were enrolled. We collected basic demographic information and vaccination history. Children were tested for HBV surface antigen (HBsAg) using a rapid test, and for immunity to measles, rubella, tetanus, and diphtheria using a multiplex bead assay. In total, 1,249 out of 1,492 children (84%) were enrolled, among whom 1,169 (94%) underwent HBsAg testing and 1,156 (93%) provided dried blood spots. Almost 80% (n = 982) of enrolled children had vaccination cards, among whom 59% (n = 584) received a timely HepB-BD (within 24 hours of birth), 95% (n = 932) received HepB3, and >90% received vaccines for diphtheria, tetanus, and measles (rubella vaccine was not available at the time). HBsAg prevalence was 3.1% (95% confidence interval (CI): 2.0%-4.9%), with 55% of identified cases from one province. Among 982 children with vaccination cards, HBsAg prevalence was higher among children who had not received a timely HepB-BD and at least two HepB doses compared to those who had (4% vs. 2%). Of 1,156 tested children, immunoprotection estimates were 99% (95% CI: 98%-99%) for measles, 99% (95% CI: 97%-100%) for rubella, 85% (95% CI: 83%-87%) for tetanus, and 51% (95% CI: 47%-55%) for diphtheria. Improving timely HepB-BD coverage and maintaining high HepB3 coverage could help Solomon Islands reach the regional HBV control goal. Low immunity to tetanus and diphtheria suggests the need to introduce booster doses to ensure long-term protection.

Clinical Characteristics of Patients Hospitalized with Coronavirus Disease, Thailand.

Among 11 patients in Thailand infected with severe acute respiratory syndrome coronavirus 2, we detected viral RNA in upper respiratory specimens a median of 14 days after illness onset and 9 days after fever resolution. We identified viral co-infections and an asymptomatic person with detectable virus RNA in serial tests. We describe implications for surveillance.

Evaluation of the efficiency of dried blood spot-based measurement of hepatitis B and hepatitis C virus seromarkers.

Although hepatitis B (HBV) and C (HCV) virus infections are still global health issues, measuring sero-markers by standard venipuncture is challenging in areas limited with the adequate human resources and basic infrastructure. This study aimed to inform the usefulness of dried blood spot (DBS) sampling technique for epidemiological study of HBV and HCV in the resources limited areas. We compared specimen recovery rate expressed as analytical sensitivity ratio of HBsAg, HBcAb and anti-HCV between serum specimens and DBS samples (HemaSpot vs Whatman903). Sensitivity ratio was calculated as the ratio of the measured value from DBS to the measured value from serum. Then both the qualitative and quantitative comparisons of HBsAg detection by DBS were done using Cambodian samples. HBsAg, HBcAb and anti-HCV sensitivity ratios for the highest sample dilution (8-fold) were 31.2:1, 38.9:1 and 32.0:1 for Whatman903 card and 17.6:1, 23.5:1 and 26.3:1 for HemaSpot respectively. Detection efficacy of HemaSpot (80%) was not inferior to Whatman903 (60%) after 1 month storage, and no significant difference in any hepatitis virus sero-markers was observed in HemaSpot-spotted patient samples stored for 2 weeks at -25 °C and 29 °C. All reference HemaSpot -spotted 400 HBsAg sero-negative samples showed negative. Sensitivity and specificity of HBsAg in HemaSpot were 92.3% and 100%. The recovery expressed as analytical sensitivity ratio of HBsAg, HBcAb and anti-HCV of HemaSpot specimen were not inferior to Whatman903. Therefore, DBS with its usefulness proved as an acceptable tool for large epidemiological study of HBV and HCV in resources limited remote area.

An approach for preparing and responding to adverse events following immunization reported after hepatitis B vaccine birth dose administration.

The success of immunization programs in lowering the incidence of vaccine preventable diseases (VPDs) has led to increased public attention on potential health risks associated with vaccines. As a result, a scientifically rigorous response to investigating reported adverse events following immunization (AEFI) and effective risk communications strategies are critical to ensure public confidence in immunization. Globally, an estimated 257 million people have chronic hepatitis B virus (HBV) infection, which causes more than 686,000 premature deaths from liver cancer and cirrhosis. Hepatitis B vaccination is the most effective way to prevent mother-to-child transmission of HBV infection, especially when a timely birth dose is given within 24 h of birth. However, an infant's risk of dying is highest in the neonatal period, and thus, administering HepB-BD within 24 h of birth overlaps with the most fragile period in an infant's life. A working group formed in July 2016 following the publication of the case reports of the effects on vaccination coverage of media reports of infant deaths after HepB-BD administration in China and Vietnam. The goal of the working group was to create a framework and describe best practices for preparing for and responding to AEFI reported after HepB-BD administration, using existing resources. The framework includes six steps, including three preparation steps and three response steps. This document is written for national and regional immunization program staff. Prior to using the framework for preparation and response to AEFIs reported after HepB-BD administration, staff members should be familiar with how AEFI are detected, reported, and investigated in the country. The document might also be of interest to national regulatory staff members who monitor vaccine safety within the country.

Hepatitis B surface antigen seroprevalence among pre- and post-vaccine cohorts in Cambodia, 2017.

BACKGROUND: Hepatitis B virus (HBV) infection is highly endemic in most low income countries including Cambodia. This nationwide serosurvey was conducted to assess the impact of hepatitis B vaccination and to determine whether Cambodia met the WHO regional 2017 target of hepatitis B surface antigen (HBsAg) seroprevalence less than 1% in five-year-old children. METHODS: A cross-sectional multi-stage cluster survey was conducted among children born during 2010-2012 and their mothers in Cambodia. HBsAg prevalence was estimated by rapid point-of-care testing, and demographic data, including vaccination history, was collected. Vaccine coverage in children and the prevalence of HBsAg among children and mothers was calculated taking into account the complex survey design. Factors associated with children's failure to receive timely (within 24 h) vaccination were analysed by multivariate logistic analysis. FINDINGS: A total of 2,520 children 5-7 years old and 2,028 mothers were recruited. In total, 78.4% of children received hepatitis B vaccination birth-dose (HepB-BD); of these, 58.7% were administered ≤ 24 h. Birth at home or "other" location were independent risk factors for children's failure to receive timely HepB-BD. Overall HBsAg seroprevalence was 4.39% (95%CI: 3.53%-5.45%) among mothers and 0.56% (95%CI: 0.32%-0.98%) among children. The prevalence among children without hepatitis B vaccination was 4.62% (95%CI: 1.31%-14.97%). Among children with a HBsAg-positive mother, prevalence was 10.11% (95%CI: 5.41%-18.11%). INTERPRETATION: Having achieved the 2017 target of less than 1% HBsAg prevalence among 5 years old children, Cambodia can now focus on eliminating mother-to-child transmission of HBV. Moreover, the high HBsAg prevalence among mothers suggests that routine screening with proper linkage to care and treatment is needed. Strengthening measures to improve vaccination coverage further and eliminate mother-to-child transmission by coordinated programming with other services offering additional HBV interventions will help move towards the global goal of hepatitis B elimination by 2030. FUNDING: As per sources of funding.

Hepatitis B vaccination coverage among health care workers in China.

OBJECTIVES: Nation-wide hepatitis B vaccination coverage among healthcare workers (HCWs) is not well researched in China. This study aims to investigate the self-reported hepatitis B vaccination status among HCWs in China. METHODS: We conducted a cross-sectional survey of health_care workers' vaccination statuses in 120 hospitals in China by collecting demographic and vaccination data. Univariate and multivariate logistic regression analysis were used to assess factors associated with hepatitis B vaccination coverage. RESULTS: Eighty-six percent (2,666/3,104) of respondents reported having received at least one dose of the hepatitis B vaccination and 60% (1,853/3,104) reported having completed ≥3 doses of the hepatitis B vaccination. Factors associated with completing ≥3 doses of the hepatitis B vaccination included workplaces offering free hepatitis B vaccination with vaccination management, age, medical occupation, hospital level, acceptable hepatitis B knowledge and having received training on hepatitis B. HCWs in workplaces offering a free hepatitis B vaccine with vaccination management were 1.4 times more likely (OR = 1.4, 95% CI: 1.1-1.8) to complete their hepatitis B vaccination compared to HCWs in workplaces that did not offer a free hepatitis B vaccine. Either the possession of acceptable hepatitis B knowledge or an age of 30-39 years increased the odds of complete hepatitis B vaccination by 1.3-fold (95% CIs: 1.1-1.5 and 1.1-1.7, respectively) over their referent category. The receipt of training on hepatitis B was also associated with a higher percentage of completing the hepatitis B vaccination (OR = 1.5, 95% CI: 1.2-1.8). The main self-reported reason for incomplete hepatitis B vaccination was "forgot to complete follow-up doses" among 43% (234/547) of respondents. Among those who never received any hepatitis B vaccination, only 30% (131/438) intended to be vaccinated. Obtaining immunity from work (40%) and hospitals that did not provide hepatitis B vaccination activities (40%) were the top reasons mentioned for refusing hepatitis B vaccination. CONCLUSIONS: The complete hepatitis B vaccination rate among HCWs in China is low, and the desire of HCWs for vaccination is indifferent; therefore, education campaigns are needed. In addition, a free national hepatitis B vaccination policy for HCWs that includes vaccination management should be prioritized to improve hepatitis B coverage among HCWs who are at-risk for HBV infection.

Progress Toward Hepatitis B Control and Elimination of Mother-to-Child Transmission of Hepatitis B Virus - Western Pacific Region, 2005-2017.

Hepatitis B vaccine (HepB), which has been available since 1982, provides lifelong protection against hepatitis B virus (HBV) infection and the associated 20%-30% increased lifetime risk for developing cirrhosis or hepatocellular carcinoma among >95% of vaccine recipients (1). Before HepB introduction into national childhood immunization schedules, the estimated hepatitis B surface antigen (HBsAg) prevalence in the World Health Organization (WHO) Western Pacific Region (WPR)* was >8% in 1990 (2). In 2005, the WPR was the first WHO region to establish a hepatitis B control goal, with an initial target of reducing HBsAg prevalence to <2% among children aged 5 years by 2012. In 2013, the WPR set more stringent control targets to achieve by 2017, including reducing HBsAg prevalence to <1% in children aged 5 years and increasing national coverage with both timely HepB birth dose (HepB-BD) (defined as administration within 24 hours of birth) and the third HepB dose (HepB3) to ≥95% (3). All WPR countries/areas endorsed the Regional Action Plan for Viral Hepatitis in the Western Pacific Region 2016-2020 in 2015 (4) and the Regional Framework for the Triple Elimination of Mother-to-Child Transmission of human immunodeficiency virus (HIV), Hepatitis B and Syphilis in Asia and the Pacific 2018-2030 (triple elimination framework) in 2017 (5). These regional targets and strategies are aligned with program targets established by the WHO Global Health Sector Strategy on Viral Hepatitis 2016-2021 that aim to reduce HBsAg prevalence among children aged 5 years to ≤1% by 2020 and to ≤0.1% by 2030 (6). This report describes progress made to achieve hepatitis B control in the WPR and the steps taken to eliminate mother-to-child transmission (MTCT) of HBV during 2005-2017. During this period, regional timely HepB-BD and HepB3 coverage increased from 63% to 85% and from 76% to 93%, respectively. As of December 2017, 15 (42%) countries/areas achieved ≥95% timely HepB-BD coverage; 18 (50%) reached ≥95% HepB3 coverage; and 19 (53%) countries/areas as well as the region as a whole were verified to have achieved the regional and global target of <1% HBsAg prevalence among children aged 5 years. Continued implementation of proven vaccination strategies will be needed to make further progress toward WPR hepatitis B control targets. In addition to high HepB-BD and HepB3 coverage, enhanced implementation of complementary hepatitis B prevention services through the triple elimination framework, including routine HBsAg testing of pregnant women, timely administration of hepatitis B immunoglobulin to exposed newborns, and antiviral treatment of mothers with high viral loads, will be needed to achieve the global hepatitis B elimination target by 2030.

Integrated approach for triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis is highly effective and cost-effective: an economic evaluation.

BACKGROUND: The Regional Framework for Triple Elimination of Mother-to-Child Transmission (EMTCT) of HIV, Hepatitis B (HBV) and Syphilis in Asia and the Pacific 2018-30 was endorsed by the Regional Committee of WHO Western Pacific in October 2017, proposing an integrated and coordinated approach to achieve elimination in an efficient, coordinated and sustainable manner. This study aims to assess the population impacts and cost-effectiveness of this integrated approach in the Cambodian context. METHODS: Based on existing frameworks for the EMTCT for each individual infection, an integrated framework that combines infection prevention procedures with routine antenatal care was constructed. Using decision tree analyses, population impacts, cost-effectiveness and the potential reduction in required resources of the integrated approach as a result of resource pooling and improvements in service coverage and coordination, were evaluated. The tool was assessed using simulated epidemiological data from Cambodia. RESULTS: The current prevention programme for 370,000 Cambodian pregnant women was estimated at USD$2.3 ($2.0-$2.5) million per year, including the duration of pregnancy and up to 18 months after delivery. A model estimate of current MTCT rates in Cambodia was 6.6% (6.2-7.1%) for HIV, 14.1% (13.1-15.2%) for HBV and 9.4% (9.0-9.8%) for syphilis. Integrating HIV and syphilis prevention into the existing antenatal care framework will reduce the total time required to provide this integrated care by 19% for health care workers and by 32% for pregnant women, resulting in a net saving of $380,000 per year for the EMTCT programme. This integrated approach reduces HIV and HBV MTCT to 6.1% (5.7-6.5%) and 13.0% (12.1-14.0%), respectively, and substantially reduces syphilis MCTC to 4.6% (4.3-5.0%). Further introduction of either antiviral treatment for pregnant women with high viral load of HBV, or hepatitis B immunoglobulin (HBIG) to exposed newborns, will increase the total cost of EMTCT to $4.4 ($3.6-$5.2) million and $3.3 ($2.7-$4.0) million per year, respectively, but substantially reduce HBV MTCT to 3.5% (3.2-3.8%) and 5.0% (4.6-5.5%), respectively. Combining both antiviral and HBIG treatments will further reduce HBV MTCT to 3.4% (3.1-3.7%) at an increased total cost of EMTCT of $4.5 ($3.7-$5.4) million per year. All these HBV intervention scenarios are highly cost-effective ($64-$114 per disability-adjusted life years averted) when the life benefits of these prevention measures are considered. CONCLUSIONS: The integrated approach, using antenatal, perinatal and postnatal care as a platform in Cambodia for triple EMTCT of HIV, HBV and syphilis, is highly cost-effective and efficient.

Considerations of antiviral treatment to interrupt mother-to-child transmission of hepatitis B virus in China.

Background: Treating high-risk women with antivirals in their third trimester is a promising intervention to further reduce perinatal transmission in neonates born to hepatitis B surface antigen positive [HBsAg(+)] mothers. Methods: We estimated the number of perinatal infections based on coverage and effectiveness of hepatitis B immunization. We compared cost-effectiveness of different approaches to identify high-risk women for antiviral treatment, by region and urban/rural residence. Results: Of the 16.59 million live births in 2015, 1.04 million infants (6.3%) were born to HBsAg(+) mothers and 268 201 infants (1.6%) to HBsAg(+) and HBeAg(+) dual-positive mothers. Despite immunoprophylaxis, 51 478 perinatal hepatitis B virus (HBV) transmissions were estimated to have occurred from HBsAg and HBeAg dual-positive mothers in 2015. Using HBeAg or HBV viral load testing to identify high-risk pregnant women and to treat them with Tenofovir, the incremental cost ranged from US$68.2 million to US$90.3 million. Assuming HBV viral load testing is available and used to guide treatment and all women with HBV viral loads >200 000 IU/ml are treated, 25 912 infections would be averted at a projected cost of US$3500 per infection averted. Conclusions: Identifying high-risk pregnant women and providing them with antiviral treatment is feasible and cost-effective to interrupt perinatal HBV transmissions. Policy options should be urgently explored in order for China to reach the HBV elimination goal of 0.1% prevalence among children by 2030.

Countries' interest in a hepatitis B vaccine licensed for the controlled temperature chain; survey results from African and Western Pacific regions.

Chronic hepatitis B infection can be prevented by hepatitis B vaccine birth dose (hepB-BD) given within 24 h after birth, followed by two hepatitis B vaccinations within the first year of life. Yet nearly half of World Health Organization (WHO) Member States do not provide a hepB-BD. Barriers are primarily attributed to vaccine storage and transportation, as well as high rates of home births. Delivering the vaccine outside the cold chain could potentially increase coverage. To do this, WHO recommends vaccines be licensed for use in a "controlled temperature chain" (CTC), which requires a given product to tolerate temperature excursions up to at least 40 °C for a minimum of three days. To date, no hepB vaccine is labelled for CTC. To inform dialogue with manufacturers, WHO conducted a survey among countries in the African and Western Pacific Regions (AFR and WPR) to assess demand for a hepatitis B product licensed for use in a CTC. Twenty-five (44%) countries responded, with 8 of 11 (73%) from the WPR and 17 of 46 (37%) from the AFR. Of these responding countries, 5 in AFR and all 8 in WPR have introduced universal hepB-BD. Seventy-two percent indicated that CTC would facilitate the provision of hepB-BD. While no overall difference in responses was detected between countries either providing or not providing hepB-BD, countries that already introduced hepB-BD but had low hepB-BD coverage were particularly interested in CTC. Irrespective of hepB-BD policy, responding countries suggested that a CTC-licenced product would be beneficial, though the price of such a vaccine would influence procurement decisions. This survey was beneficial to inform the CTC agenda. However, countries' lack of experience with HepB-BD as well as with CTC and the fact that countries were commenting on a product that is not yet on the market should be acknowledged.

Improving hepatitis B birth dose coverage through village health volunteer training and pregnant women education.

Hepatitis B is highly endemic in the Republic of Kiribati, while the coverage of timely birth dose vaccination, the primary method shown to prevent mother-to-child transmission of hepatitis B virus, was only 66% in 2014. Children born at home are especially at high risk, as they have limited access to timely birth dose (i.e. within 24 h) vaccination. To improve birth dose coverage, a project to improve linkages between village health volunteers and health workers and educate pregnant women on hepatitis B vaccination was carried out in 16 communities with low birth dose coverage in Kiribati from November 2014 to May 2015. After project completion, the coverage of timely birth dose administration increased significantly both in the densely populated capital region of South Tarawa (from 89% to 95%, p=0.001) and the Outer Islands (from 57% to 83%, p<0.001). The coverage of timely birth dose administration among infants born at home increased significantly from 70% to 84% in South Tarawa (p=0.001) and from 49% to 75% in the Outer Islands (p<0.001). Timely birth dose was associated with being born in a hospital, being born during the study period and caregivers having developed an antenatal birth dose plan. The project demonstrates a successful model for improving hepatitis B vaccine birth dose coverage that could be adopted in other areas in Kiribati as well as other similar settings.

The flow and fate of digestive enzymes in the field cricket, Gryllus bimaculatus.

The flow of enzymes, the ratio of bound to unbound enzymes, and their inactivation in the cricket Gryllus bimaculatus was studied. The digestive enzymes are forced forward into the crop by caecal contraction and then they are mixed with freshly chewed food and saliva, forming a crop-chyme. This chyme is blended by crop peristalsis, and periodic opening of the preproventricular valve (PPV) allows posterior movement into the proventriculus and further into the midgut. The contraction of the crop is modulated by Grybi-AST and Grybi-SK peptides, which are partially secreted by the caecal endocrine cells. Most of the aminopeptidase and the four disaccharidases examined are membrane bound (62-80%); the remaining (20-38%) as well all trypsin, chymotrypsin, lipase, and amylase are secreted free into the caecal lumen. Cricket trypsin loses only 30% of its activity in 4 h and very little thereafter. The presence of digestive products in the lumen appears to retard further trypsin autolysis. Cricket trypsin digests 42% of the chymotrypsin, 37% of the lipase, and 45% of the amylase in the caecal fluids over 24 h in vitro no significant difference. Without Ca ion amylase was almost completely digested. About 50% of the membrane bound and free aminopeptidase was digested in the caecal lumen, and about 30-38% of the bound and free maltase. This loss of digestive enzyme activity is possible, because enzyme secretion rates are high, the unbound enzymes are effectively recycled, and the time of nutrient passage is short.

Veteran Status, Sociodemographic Characteristics, and Healthcare Factors Associated with Visiting a Mental Health Professional.

Using data from a nationally representative study of the community-dwelling U.S. population, we estimated the percentage of male veterans who visited a mental health professional in the past year, compared it to an estimate from non-veteran males, and examined factors associated with visiting a mental health professional. We found that 10.5% of male veterans visited a mental health professional in the past year, compared to only 5.6% of male non-veterans. In the regression models, veteran status, sociodemographic factors, and healthcare utilization were independently associated with visiting a mental health professional. These findings demonstrate the importance of using nationally representative data to assess the mental healthcare needs of veterans.

Integrating HIV, hepatitis B and syphilis screening and treatment through the Maternal, Newborn and Child Health platform to reach global elimination targets.

Every year, an estimated 180 000 babies in the Western Pacific Region are infected by hepatitis B, 13 000 by syphilis and 1400 by HIV through mother-to-child transmission. (1) These infections can be largely prevented by antenatal screening, treatment and timely vaccination for newborns. Despite challenges in controlling each disease, major achievements have been made. National immunization programmes have reduced the regional hepatitis B prevalence from over 8% in 1990 to 0.93% among children born in 2012. In addition, HIV testing and treatment have helped keep the regional prevalence of HIV infections at 0.1%. In contrast, the number of maternal syphilis cases is still high in the Western Pacific Region, with an estimated 45 million cases in 2012. Elimination of mother-to-child transmission of these infections cannot be achieved through vertically applied programming and require using and augmenting to the shared Maternal, Newborn and Child Health platform to coordinate, integrate and enable cost efficiencies for these elimination efforts. The Regional Framework for Triple Elimination of Mother-to-Child Transmission of HIV, Hepatitis B and Syphilis in Asia and the Pacific 2018-2030 offers such a coordinated approach towards achieving the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis and provides guidance for decision-makers, managers and health professionals working in programmes addressing maternal, newborn and child health, HIV, hepatitis, sexually transmitted infections and immunization.