Abstracts provide a forum through which authors can share their insights and outcomes of advanced managed care practice through publication in AMCP's Journal of Managed Care Specialty Pharmacy (JMCP). Of the abstracts accepted for publication, most are presented as posters, so interested AMCP meeting attendees can review the findings and query authors. The main poster presentation is Thursday, April 9, 2015; posters are also displayed on Friday, April 10, 2015. The AMCP 2015 Annual Meeting Expo in San Diego, California, is expected to attract more than 3,500 managed care pharmacists and other health care professionals who manage and evaluate drug therapies, develop and manage networks, and work with medical managers and information specialists to improve the care of all individuals enrolled in managed care programs.


Pteropus bats. Vaccine uptake for horses is low despite the high case fatality rate of HeVD in both horses and people. We reviewed evidence-based communication interventions to promote and improve HeV vaccine uptake for horses by horse owners and conducted a preliminary evaluation of potential drivers for HeV vaccine uptake using the Behavioural and Social Drivers of Vaccination (BeSD) framework developed by the World Health Organization. Six records were eligible for review following a comprehensive search and review strategy of peer-reviewed literature, but evidence-based communication interventions to promote and improve HeV vaccine uptake for horses were lacking. An evaluation of potential drivers for HeV vaccine uptake using the BeSD framework indicated that horse owners’ perceptions, beliefs, social processes, and practical issues are similar to those experienced by parents making decisions about childhood vaccines, although the overall motivation to vaccinate is lower amongst horse owners. Some aspects of HeV vaccine uptake are not accounted for in the BeSD framework . Overall, problems associated with HeV vaccine uptake appear well-documented. We, therefore, propose to move from a problems-focused to a solutions-focused approach to reduce the risk of HeV for humans and horses. Following our findings, we suggest that the BeSD framework could be modified and used to develop and evaluate communication interventions to promote and improve HeV vaccine uptake by horse owners, which could have a global application to promote vaccine uptake for other zoonotic diseases in animals, such as rabies.Hendra virus disease (HeVD) is an emerging zoonosis in Australia, resulting from the transmission of Hendra virus (HeV) to horses from  Henipavirus, family Paramyxoviridae) is an emerging zoonotic virus that has been detected in Australia’s four mainland species of Pteropus bats [P. alecto [Hendra virus  in horses has expanded southward since its initial detection in Hendra, Queensland. Cases have recently been reported as far south as Scone ,6 and Weth Wales ,10.Therapeutics for the treatment of HeVD are not available; however, a vaccine for horses and post-exposure prophylaxis for humans have been developed ,2. HorseThinking and Feeling, relating to cognitive and emotional responses to vaccine-preventable diseases and vaccines, including disease risk perception and vaccine confidence; (2) Social Processes, defined as the social experiences related to vaccines, including gender equity, social norms about vaccination, and receiving health worker recommendations to be vaccinated; (3) Motivation, influenced by the former two domains and including vaccination intention, willingness, and hesitancy; and (4) Practical Issues, which are people’s experiences when trying to get vaccinated, including access barriers such as availability, affordability, ease of access, quality of service, and respect from health workers [The recent development of the Behavioural and Social Drivers of Vaccination (BeSD) framework has demonstrated value in understanding and promoting vaccine uptake by caregivers in the context of vaccine-preventable childhood diseases ,16. In t workers . Regardl workers . Given tThe objective of this review was to identify peer-reviewed information about evidence-based communication interventions that have been used to promote HeV vaccine uptake by horse owners. We hypothesised that there are few interventions; therefore, a secondary objective was to appraise information in the reviewed records against the domains of the BeSD framework as a preliminary assessment of the types of information available about factors that drive or hinder HeV vaccine uptake. This review and assessment will inform research and development of a program to promote HeV vaccination.The primary objective of the current study was to determine if there are evidence-based communication interventions to promote HeV vaccine uptake for horses. The secondary objective was to determine if the drivers of HeV vaccine uptake align with the domains of the behavioural and social drivers of vaccine uptake in the BeSD framework as a preliminary step to developing a framework for promoting HeV vaccine uptake.To achieve the primary objective, we conducted a comprehensive review using methods for critically appraised topics ,20 to idThe population of interest for the uptake of the HeV vaccine was people living in Australia who owned horses that could be at risk of HeVD. The term “communication intervention” was defined as any medium used to deliver information and ideas between parties to aid the discussion of topics of common interest, as well as inform, guide, and motivate a new or existing behaviour ,22,23. CSearches were conducted in July 2022 using the terms “Hendra*” and “Vaccin*” and “Communicat*” or “Behavio* change” and “Horse owner*” and “Australia*” in BIOSIS Previews Via Web of Science, Scopus, and Medline via Ovid .Duplicates were removed, then records were screened for eligibility for Objective 1 (communication interventions to promote HeV vaccine uptake) based on the title and abstract (Level 1), then on the full record (Level 2). Records eligible for data extraction (Level 3) that identified communication interventions to promote HeV vaccine uptake were peer-reviewed and in English. Planned data extraction included the targeted population, type of communication intervention, including the method of dissemination or use, and pre- or post-use evaluation.If records were not eligible for Level 3 data extraction for the primary objective but contained information about drivers of HeV vaccine uptake (secondary objective), data were extracted from each record and reported in a summary table including the population included in the study with their location and size, equine sectors represented, study design with objectives and factors studied, and main findings in the context of HeV vaccine uptake and the BeSD domains. The main findings were assessed for consistent and divergent (extraneous) themes according to the domains of the behavioural and social drivers of vaccine uptake in the BeSD framework  and described below . ExtraneThirty-three records were identified in the database searches, and six duplicate records were removed. Following a review of the title and abstract (Level 1), six records were eligible for review at Level 2. These records contained information from five studies (two records described different aspects of the same study) conducted from 2017 to 2021. The studies included a total of 239 participants .No records described evidence-based communication interventions to promote HeV vaccination uptake for horses  in the current review. However, it is clear that there are groups of horse owners with little motivation to vaccinate their horses against HeVD, and overall, motivation appears lower than that of parents for childhood vaccines because there is currently > 95% versus ~12% uptake for childhood vaccines and the HeV vaccine, respectively [The BeSD ectively ,37. Geneectively , but theectively . Where tLyssavirus, family Rhabdoviridae) is caused by a fatal zoonotic neurotropic virus that is transmitted to horses by direct contact (bites) from infected bats, racoons, foxes, and skunks [The lack of vaccine uptake for HeV in Australia is paralleled in the United States (US), where there is similarly poor rabies vaccine uptake for horses. Rabies  project . The SKAwhy behind the low uptake of HeVD risk mitigation behaviour by horse owners now needs to be understood in greater detail using mixed social research methods, including other influencing factors, such as the use of alternative mitigation strategies and zoonotic transmission risk, and how these preventive behaviours differ between horse owner types  [Despite the health impact of Hendra virus disease (HeVD) on horses and people, there are no evidence-based communication interventions to promote Hendra virus (HeV) vaccine uptake for horses in Australia. Using the World Health Organization’s Behavioural and Social Drivers of Vaccination (BeSD) framework for childhood vaccine uptake, we highlighted both similarities and differences in the perceptions, feelings, motivations, social processes, and practical issues that horse owners and parents face in the context of HeV and childhood vaccine decision-making, respectively. This provides some insight into horse owners’ HeVD preventive behaviour and alludes to the circumstances in which they might consider HeV vaccination. This current understanding of the ssional) ,25,26. Assional) , thus re


Bisphenol A (BPA) is a plasticizer that is widely used in the manufacturing of polycarbonate plastics (PC) and epoxy resins for use in a broad range of consumer products, including materials in contact with food and beverages, as well as medical devices, toys and dental sealants. BPA has been characterized as an endocrine disruptor chemical (EDC) that is able to interact with and activate endocrine receptors that alter hormonal homeostasis. Indeed, BPA has been reported to interact with estrogen receptors (ERα and ERβ), androgen receptors (ARs), thyroid hormone receptors (TRα and TRβ), glucocorticoid receptors (GRs), non-canonic estrogen-related receptor gamma (ERRγ) and G-protein-coupled receptor 30 (GPR30) by affecting the reproductive, metabolic and immune systems, along with neurodevelopmental processes. BPA regulates gene expression by activating intracellular transduction pathways via the cell surface and nuclear receptors, and also affects the antioxidant system (ROS accumulation) and impairs mitochondrial function. Human exposure to BPA occurs following BPA migration from the above-mentioned product containers and devices to the environment, including food; this type of migration represents the main route of exposure. For several years, the European Food Safety Authority (EFSA) has evaluated and updated the information on the effects of BPA on human health, including reduced fertility, an increased risk of cancer and the development of metabolic and cardiovascular diseases. Recently, the EFSA has established a new Tolerable Daily Intake value based on the observed immunological effects of exposure to BPA, and has identified the immune system as that most sensitive to BPA exposure. To reduce these health risks, the use and production of BPA have been restricted. However, BPA has been replaced by several bisphenol analogs, such as bisphenol S (BPS) and bisphenol F (BPF); their toxicological effects are comparable to those of BPA, and they have recently been detected in the environment, in food and even in humans. Owing to the rapidly expanding uses of bisphenol analogs, increasing attention has been paid to their toxicity and environmental effects.The purpose of this Special Issue, entitled “Molecular Mechanisms of Bisphenol A Toxicity and Effects of Environmental Levels on Health”, is to present studies on the molecular mechanism not only of Bisphenol A, but also of its analogues, including BPS, BPF and bisphenol AF (BPAF).Qian, L. et al.  observedIn addition to the toxic effects of BPA and its analogues on growth and reproduction, Liu, R et al.  present Oxidative stress induction was observed in an in vitro study on erythrocytes, where BPA and three intermediate products of its degradation, namely phenol, hydroquinone and 4-isopropylphenol, increased the reactive oxygen and nitrogen species (RONS) levels and reduced glutathione (GSH) levels [The valuable contributions included in the present update shed light on several mechanisms of action of BPA, as well as its analogues and degradation products; however, further studies are needed on the mechanisms of toxicity and effects exerted by bisphenol analogs that take into account combined exposure.


To identify and analyse ongoing nutrition-related surveillance programmes led and/or funded by national authorities in countries in South-East Asian and Western Pacific Regions.We systematically searched for publications in PubMed® and Scopus, manually searched the grey literature and consulted with national health and nutrition officials, with no restrictions on publication type or language. We included low- and middle-income countries in the World Health Organization South-East Asia Region, and the Association of Southeast Asian Nations and China. We analysed the included programmes by adapting the United States Centers for Disease Control and Prevention’s public health surveillance evaluation framework.We identified 82 surveillance programmes in 18 countries that repeatedly collect, analyse and disseminate data on nutrition and/or related indicators. Seventeen countries implemented a national periodic survey that exclusively collects nutrition-outcome indicators, often alongside internationally linked survey programmes. Coverage of different subpopulations and monitoring frequency vary substantially across countries. We found limited integration of food environment and wider food system indicators in these programmes, and no programmes specifically monitor nutrition-sensitive data across the food system. There is also limited nutrition-related surveillance of people living in urban deprived areas. Most surveillance programmes are digitized, use measures to ensure high data quality and report evidence of flexibility; however, many are inconsistently implemented and rely on external agencies’ financial support.Efforts to improve the time efficiency, scope and stability of national nutrition surveillance, and integration with other sectoral data, should be encouraged and supported to allow systemic monitoring and evaluation of malnutrition interventions in these countries. The goal is to synergistically address shared factors of multiple malnutrition forms, often termed as double- or triple-duty interventions, across various societal subsystems to ensure maximum and sustainable impact.–Previous research shows the scope of commonly used nutrition surveillance methods in low- and middle-income countries.As part of the Systemic Actions to Reduce Malnutrition In All Its Forms in South-east Asian Countries and China  project, we conducted a systematic scoping review with the aim of identifying and analysing ongoing, nutrition-related national surveillance programmes for Member States in the World Health Organization (WHO) South-East Asia and Western Pacific Regions, and of the Association of Southeast Asian Nations (ASEAN).–Our systematic scoping review is based on the six-stage published framework.We searched for relevant studies, reports and documents on currently ongoing nutrition surveillance programmes. We searched two online databases, PubMed® and Scopus, for relevant publications using a combination of key search terms: monitor*, survey*, surveillance, weight, nutrition*, diet*, food*, eating and health*. We searched the databases from January 2014 to 29 January 2022 for most countries, and for some countries from inception to 29 January 2022, and updated this search to 26 June 2023. More details are available in the online repository.For our manual search, we conducted both forward and backward reference searches of the identified articles in the database search to locate additional relevant publications.We complemented our desk-based literature search with consultation meetings and email communications with senior nutrition officials at health ministries in study countries from February until September 2022. These officials have been responsible for the design, deployment or implementation of national nutrition  surveillance programmes, and/or are familiar with existing or the development of nutrition surveillance programmes in their countries.We continuously refined and expanded our literature search and evaluation criteria in response to earlier search and consultation results, where desk-based research  and expert consultation informed each other iteratively.,Here we define a nutrition surveillance, or monitoring, programme as repeated collection, analysis, interpretation and dissemination of primary data on the anthropometric and biochemical nutrition outcomes (exclusively or embedded) and behavioural or food system indicators that influence anthropometric or biochemical nutrition outcomes.We covered ongoing nutrition surveillance programmes in 18 low- and middle-income countries, 11 WHO South-East Asia Region Member States and seven WHO Western Pacific Region Member States. Ten of these 18 countries are ASEAN Member States . We inclOur selection of programmes and relevant publications was defined by the eligibility criteria as specified under the inclusion and exclusion criteria presented in Box 1We included a programme when it is ongoing, led and funded by a country’s governmental body and repeatedly collects, analyses, interprets and disseminates primary data on anthropometric, biochemical, behavioural and/or food system indicators relating to nutrition. Examples include large-scale, repeated surveys, and data from repeatedly used sentinel sites and educational/childcare settings. Primary data refers to data that are collected for surveillance purposes.Related publications were included when these covered methodological information on one, or multiple ongoing nationally representative nutrition  surveillance data collection programme(s).We included nutrition (-related) surveillance programmes that are ongoing, or with minimally one recently completed data collection round, that are conducted on a continuous and/or periodic basis.We included programmes that had implemented at least one data collection round, and are predicted to see future rounds.Programmes and related publications that we included had to collect primary data on anthropometric and/or nutrition-related indicators, and be operating in at least one of the Member States of WHO South-East Asia Region, the Association of Southeast Asian Nations and/or China. The programme could cover any age and demographic group.We included all types of literature (or study designs) that provide information relevant to the design, methods, findings, and impact on or information for, at least one surveillance programme, such as government reports and conference papers.Publications could be written in any language.Organizational or researcher-led collections and analyses of nutrition and related data which do not form part of a larger surveillance programme were not included.Publications that focus on secondary use of data from nutrition surveillance programmes when official documentation on methodological and operational information is available.Nutrition and health surveillance programmes that were discontinued before 2022.Programmes and related publications that do not collect primary data on anthropometric and/or nutrition indicators. Programmes and related publications that do not include relevant information or data on surveillance programmes in the following countries: China, any Member States of the WHO South-East Asia Region, and/or the Association of Southeast Asian Nations. Programmes implemented in high-income countries were excluded.WHO: World Health Organization.We imported the results from the academic database search into Endnote X9 . Two researchers independently screened titles and abstracts using the specified eligibility criteria in the open-access web-based systematic reviewing application Rayyan . We resolved disagreements following abstract screening through discussions to build consensus. To ensure a low number of false negatives, we screened a preliminary test set of 50–100 records.We extracted data for each surveillance programme via a purposively developed form on the basis of components and operation characteristics that are listed in the updated United States Centers for Disease Control and Prevention (CDC) guidelines for public health surveillance programmes. The 2001 CDC updated guidelines are commonly applied, and intended to be universally applicable for describing and evaluating a large variety of different public health surveillance programmes.,The data extraction form included the authors, publication date, publication title, type of primary surveillance, main objectives (which we categorized based on previous work),To provide a comprehensive description of surveillance at a national and programme level , we analBox 2We reported on programme-level validated measures and quality assurance methods that were used to ensure data quality. We also report data completeness as an indicator of data quality.We based our analysis of flexibility on whether the programme reports any evidence of accommodated changes to the programme methods and operation between data collection rounds with the purpose of incorporating relevant indicators and adapting to population’s nutritional needs.We analysed national and programme-level representativeness through identification of geographical locations, subpopulation groups, and accurate reporting of nutrition-related events. The latter refers to the notion whether the collected data can be disaggregated by sociodemographic variables important to nutrition.The timeliness and simplicity of surveillance programmes refers to both national and individual programme structure, and ease of operation. Based on available information, we analysed whether the identified programme digitized their data collection, processing and dissemination during its most recent round. We also describe whether there are any overlapping years of indicator selection, any reported barriers to timely and simple implementation, and the central body and partnerships being responsible for surveillance programmes at country level.We analysed stability by considering any mentioned issues during the collection, management and provision of data, and the consistency of data collection (were there any gaps between data collection?), and type of funding.a Our selection was guided by the adapted US Centers of Disease Control and Prevention guidelines,,,–,–,,,,––,–,–,,–,–,–,–,–,–,–,––,,,–,,,,,,,,,,,We identified 54 945 unique papers through our academic database search; 26 of these met the inclusion criteria and we used them to derive programme information.,,,Most identified programmes had a methodological report which was publicly available on the respective government or international agency website. Several reports were not available in English,We provided an overview of the descriptive analysis of the included programmes and a summary of the main findings in Box 3Seventeen countries have implemented national programmes that exclusively collect data on individual nutrition and diet-outcome indicators.No countries monitor indicators on all forms of malnutrition, or on food environment and wider food systems.The majority of countries have digitized data collection, implemented comprehensive measures to promote data quality, and scaled-up or increased monitoring scope in comparison to its preceding round.Most programmes report higher than 80% response rates.All countries, if information is available, implement rigorous training and supervision practices prior to and during data collection.All countries have one or more programmes that adopted programmatic changes between data collection rounds.All countries have one or more programmes that included new indicators and subpopulation groups.Seven countries monitor anthropometry indicators among all age groups.Nine countries collect data on most micronutrient biomarkers.Five countries monitor individual dietary intake periodically among all age groups.While there are variations in terms of representativeness across countries, elderly people were commonly not represented in the monitoring of anthropometry and dietary data.Limited surveillance in urban deprived areas.All countries collect data which can be disaggregated by important nutrition-related population characteristics. Most programmes that collect nutrition and nutrition-related indicators were coordinated and implemented by countries’ health ministries.Most countries’ local surveillance programmes collected data on nutrition-outcome and/or diet-outcome indicators with consistent time intervals between rounds.Nine countries have an internally funded national surveillance programme that exclusively collects nutrition-outcome data.We identified 82 nationally representative government-led and -funded surveillance programmes that repeatedly collect primary data on nutrition and/or diet outcome indicators. Some of the programmes implemented a first round within the last decade and may conduct, or have planned, future rounds. The programmes were either local or internationally linked. On a national level, health ministries (or an embedded research institute) coordinated and implemented most programmes that collect nutrition and nutrition-related indicators. The ministries use the collected data to inform the development and evaluation of national policies and nutrition programmes. To a lesser extent, programmes are designed to collect data that governments can leverage for informed decision-making and to monitor national objectives.,,,,,–,,,,,,,,,,,,,,,,,,,,,Of the 18 countries, eight exclusively collect data on individual nutrition and diet-outcome indicators through an established national nutrition surveillance programme, on a continuous basis, .,,,,,,The type of collected data, used methods and monitoring frequency differed substantially across programmes and countries. We found that all countries periodically collect weight and height data, and most countries take waist and hip circumferences . China, https://www.who.int/publications/journals/bulletin/). The Thai government implemented a surveillance programme that annually collects information on median urinary iodine among pregnant women, in households and antenatal care clinics.All countries periodically measure anaemia with varying monitoring frequency . Nine countries  also collect data on most other micronutrient deficiencies . Several individual programmes in Brunei Darussalam, India, Maldives and Sri Lanka had lower-than targeted response rates due to respondents’ poor access to field sites or refusal of biochemical measurements.Coverage of population groups for nutrition-outcome indicators differs to a large extent. Except Brunei Darussalam, all countries cover anthropometric information on nutrition status among children younger than 5 years, and all countries include women of reproductive age for anthropometry at varying time intervals.Bangladesh, China, India, Indonesia, Malaysia, Philippines and Thailand have national surveillance that covers measurement of anthropometric nutrition status among all age groups . Common All countries collect nutrition and diet outcome data that can be disaggregated by key sociodemographic factors, including socioeconomic status. Six countries rely on the Global School-Based Student Health Surveys for young adolescent (10–14 years of age) weight and height (self-reported) which cannot be disaggregated by socioeconomic status. Aside from one programme in Bangladesh and two in India, urban deprived areas or informal settlements, and mobile populations  are generally not represented within national nutrition surveillance.,,,,––,–All countries have programmes that are digitized, mainly through the incorporation of computer-assisted personal interviews  in their most recent surveillance rounds. While there is limited annual overlap between identified programmes for collected nutrition data within countries, data for infant and young child feeding were overlapping in the Philippines and Viet Nam; ,,–,,,,,,,–,,,,Included programmes in most countries did not report to have experienced any preparation or operation issues in their latest round. Reported issues mainly related to financial costs (two programmes), logistical challenges (two programmes), and few trained data collection personnel (one programme). Most countries’ continuous and periodic programmes collected data with consistent time intervals between rounds and with limited interruptions. Bangladesh, China, India, Indonesia, Malaysia, Philippines, Sri Lanka, Thailand and Viet Nam have exclusive nutrition-focused programmes that were fully funded by their respective national governments.Through our analysis of publicly available literature and consultations with national nutrition and health officials, we identified and described ongoing national and internationally linked nutrition surveillance programmes for 18 countries. Our review shows large variations between countries in terms of scope, and frequency of monitoring. Many countries implement one or multiple nutrition- and diet-focused periodical surveillance programmes with wide intervals. Few countries collect continuous comprehensive information on individual diet and micronutrient biomarkers. The latter finding is consistent with a recent review on the availability and use of micronutrient data in low- and middle-income countries worldwide.While the identified nutrition surveillance programmes generally allow for disaggregation of important nutrition-related sociodemographic variables, most surveys do not accurately represent populations in vulnerable settings with prevalent malnutrition issues. Many low- and middle-income countries have a substantial proportion of their population living in such settings,While included countries have reliable individual surveillance programmes, national nutrition surveillance is at risk of being unsustainable since many programmes are reliant on external funding. Most national health officials expressed the need for stable funding mechanisms. Past experiences in establishing and expanding nutrition surveillance programmes suggest that collaborating with a wider range of partners with similar interests, priorities and information, under the guidance of a governmental body, fosters a more sustainable nutrition surveillance.Not unique to south-east Asia, most other countries implement internationally linked multicountry survey platforms, for example, Demographic and Health Surveys, Multiple Indicator Cluster Surveys and the WHO STEPwise approach.,We found limited monitoring of food environment and broader food system indicators within nutrition surveillance programmes led by national health authorities. Similarly, non-health governmental bodies also inadequately monitor these indicators to directly back the national nutrition agenda. Ideally, countries’ local health and/or nutrition agencies should possess the expertise and capacity to transform broader environment data into comprehensible nutrition-sensitive indicators and metrics. This information should then be used to devise, monitor and enhance nutrition interventions and policies.By incorporating three different literature search strategies, including an academic database search, grey literature search, and consultations with senior officials of national health authorities where possible, we ensured that we produce a comprehensive review. In addition, including 14 national health and nutrition officials knowledgeable about the surveillance programmes in their respective countries as co-authors further reinforces the credibility of our review findings. Another strength of the study is the use of CDC’s integrative and adaptive framework to obtain a more comprehensive picture of the current state of nutrition surveillance in south-east Asia.,Our review also has limitations. We mainly focused on nationally representative, government-led and -funded programmes. In every country, nutrition-related data originate from diverse sources, varying in form and format, including commercial databases like Euromonitor, as well as research organizations. Future research should explore other sources to get a more comprehensive picture of the countries’ national nutrition information systems.Box 4Innovative, cost-effective techniques are needed for timely monitoring of nutrition and dietary outcomes that national authorities can use to accurately track population nutrition, and assess the impact of nutritional interventions.To improve representativeness in surveillance programmes, innovative sampling methods are needed to include the most vulnerable populations. Integration of intersectoral, nutrition-sensitive data and adapting or adopting well- established food system monitoring instruments


Interventions to tackle the social determinants of health can improve outcomes during pregnancy and early childhood, leading to better health across the life course. Variation in content, timing and implementation of policies across the 4 UK nations allows for evaluation. We conducted a policy-mapping review (1981–2021) to identify relevant UK early years policies across the social determinants of health framework, and determine suitable candidates for evaluation using administrative data.We used open keyword and category searches of UK and devolved Government websites, and hand searched policy reviews. Policies were rated and included using five criteria: (1) Potential for policy to affect maternal and child health outcomes; (2) Implementation variation across the UK; (3) Population reach and expected effect size; (4) Ability to identify exposed/eligible group in administrative data; (5) Potential to affect health inequalities. An expert consensus workshop determined a final shortlist.336 policies and 306 strategy documents were identified. Policies were mainly excluded due to criteria 2–4, leaving 88. The consensus workshop identified three policy areas as suitable candidates for natural experiment evaluation using administrative data: pregnancy grants, early years education and childcare, and Universal Credit.Our comprehensive policy review identifies valuable opportunities to evaluate sociostructural impacts on mother and child outcomes. However, many potentially impactful policies were excluded. This may lead to the inverse evidence law, where there is least evidence for policies believed to be most effective. This could be ameliorated by better access to administrative data, staged implementation of future policies or alternative evaluation methods. In the UK, a plethora of policies and strategies target child and maternal health, with a demonstrable political will to invest in the early years.The social determinants of health framework identifies ‘upstream’ or sociostructural factors such as childcare, schools, housing, welfare, transport, health and social care, and the workplace as important elements affecting child health and health inequalities.Political devolution in the UK has led to policy divergence. This offers an opportunity to conduct natural experiment evaluations that determine the impact of upstream policies on child health and health inequalities.This comprehensive review of UK early years policies across the social determinants of health domain contributes to tackling the inverse evidence law in maternal and child health research (where the least evidence is available for settings where need is greatest).The review identifies three policy priority areas in child and maternal health for future research: welfare grants in pregnancy and early childhood, early years education and childcare, and Universal Credit and welfare policies.Many child policies were found not to be suitable for natural experimental evaluation, which could lead to the inverse evidence law.There is a need for better access to administrative data  and staged implementation of future policies (affording greater cross-country variation).This study offers a framework to distil and prioritise candidate policies for natural experiment methods using administrative data.Every Child MattersGetting it Right for Every ChildChildren and Young People’s StrategyFirst 1000 days of life,The Best Start for Life: A Vision for the 1001 Critical DaysGiving every child the best start in life is a key policy goal for a healthy society. Government strategies and policies identify childhood and pregnancy as crucial stages for policy intervention. Commitment to children’s rights and well-being is evident across the historical strategies of the four UK nations: The social determinants of children’s health are key to improving health outcomes. The social determinants of health (SDoH) framework identifies the inter-relationship between parents, communities and the wider macro level context.All four UK nations are politically and financially committed to early years interventions. Yet a divergence in philosophical stance combined with devolved decision making has led to deviation in policies and priorities.To contribute towards tackling the inverse evidence law in maternal and child health, we conducted a comprehensive review of the UK policy landscape to identify candidate early years policies for possible future evaluation. We endeavoured to identify all government  policies that potentially affect maternal and child health across the SDoH framework; and determine suitable candidates for evaluation using administrative data. There is great possibility for natural experimental evaluations based on policy variation in content, timing and implementation across the four UK nations, including but not limited to those enabled by political devolution.During Spring/Summer 2020, we mapped the policy landscape in the four UK nations to identify national variations that potentially impact on child and maternal health outcomes. Both national and devolved policy owners were identified. This included the UK policy landscape  as well as the devolved administrations in Scotland, Wales and Northern Ireland. The policy topic areas were aligned with the SDoH framework: welfare, employment, health, housing, education and the environment. This was supplemented with a search of the four Public Health Agencies in 2021.Two search methods were adopted for each national government website: (1) Open keyword search: ‘child’, ‘child health’, ‘child and maternal health’ and (2) Category search: categories selected based on the SDoH (listed above) with all subcategories inspected. Key department websites relevant to the SDoH were included, for example, Departments of Health, Housing, Education, Environment and Social Security across all UK nations. The category search of department websites covered policies, development plans, frameworks and legislation. The Public Health Agencies in the UK nations were similarly searched using category and open keyword searches.When using the open keyword search, sites typically reported numerical results. Some sites, for example, Scottish Government and NI Direct, were searched manually due to multiple links being listed on each separate web page. In these instances, cases are reported as the total number of web pages searched. Each website was manually searched until saturation point was reached, that is, no new policies were identified. The search strategy was iterative with the identification of policies in one nation prompting an equivalent search in the other UK nations.The search strategy was supplemented with hand searching of existing policy horizon scanning documents and multiple reports published by the British Academy Childhood Policy Programme. Additionally, existing public health policy reviews and evaluations of interventions were examined to identify any other relevant policies.The life course periods in the early years can be divided into pregnancy, infancy and preschool. Any policy that could impact on maternal or child health during these early years periods was included. Early years policies were identified from the 1940s until 2021. Due to data availability, we excluded all policies before 1981 and limited the search of earlier decades. To direct the search strategy, inclusion and exclusion criteria were further defined see . Data we10.1136/archdischild-2022-325219.supp1Supplementary dataThe Maternal and Child Health Network (MatCHNet) is a multidisciplinary community of public health researchers, methodologists, policy makers and service providers. The network aims to harness cross-country administrative data to evaluate national policy impacts on maternal, infant and child health, and health inequalities across the four UK nations. MatCHNet is one of four networks funded by the UK Prevention Research Partnership. During several workshops, MatCHNet’s expert group determined essential criteria to form the basis for subsequent filtering. The aim was to identify (include) whole national policies that could potentially be evaluated using administrative data. We discussed necessary elements to conduct policy evaluations and derived five essential criteria: (1) Potential for policy to affect maternal and child health outcomes; (2) Implementation variation across the UK; (3) Population reach and expected effect size; (4) Ability to identify exposed/eligible group in administrative data ; and (5) Potential to affect health inequalities. The group determined the key filtering criteria were 2–4, with criteria 1 and 5 used to prioritise policies for analysis after the initial filtering.All policies were reviewed and assigned essential criteria by ES, and subsequently reviewed by AP, JG and RG. Policies were defined as being included or excluded as potential candidates for future evaluation. The filtering focused on essential criteria 2 (whole nation policies that vary across the UK) as well as criteria 3 and 4 (proportion of population to benefit/effect size and identifying the exposed/eligible group in administrative data). This process was based on judgement and consensus was agreed for each policy by at least two of the above reviewers. The input of an additional reviewer was sought where a decision could not be made.The policy prioritisation exercise was based on discussions at three stakeholder consultations (held during 2021), an online prioritisation poll (51 responses) and a final consensus workshop. The stakeholder group consisted of representatives from central and local government, public health agencies, service providers, and third sector organisations from across the four UK nations. Online poll respondents were 39% academics, 35% National Health Service, with representation from government departments (4%), the voluntary sector (12%) and service provision (2%). At the final consensus workshop, our expert group identified a shortlist of policies for potential future evaluation, which included consideration of the remaining criteria 1  and 5 . The expert group also considered previous and ongoing policy evaluations to ascertain knowledge gaps and policy areas requiring further investigation.The search strategy identified 17 892 records from open keyword searches and 18 297 from the category search . After cAfter filtering (criteria 2–4), 88 policies were found to vary across the four UK nations (across the six domains). During the filtering process, 65 records were removed. These were either duplicates across the domains  or met the exclusion criteria on closer inspection. Examining the filtering decisions across the social determinants domains indicates heterogeneity in terms of suitability for future analysis see . Some 64The 16 shortlisted candidate policies  were in The three policy areas are broadly similar across countries but differ in timing of implementation and exposed populations, offering opportunities for evaluation of effectiveness see . For exaFrom our extensive searching, we narrowed 336 policies and 306 strategy documents to 88 policies across the SDoH domains. Most included policies were in the welfare domain and other prominent domains were education, environment and health. After consultation and consensus workshops, we identified three policy areas as suitable candidates for natural experimental evaluation using administrative data: pregnancy and early childhood grants (welfare), early years childcare (education) and Universal Credit (welfare).A closer inspection of the excluded policies illustrates key challenges for policy evaluation using administrative data. First, many policies are focused on local and community interventions, which leads to local variances in service provision.Childcare Grant ; Lone Parents’Childcare Grant (Scotland)). While these grants may have a significant effect on individual families and the respective groups may be identifiable from birth registrations and education data, the small populations are challenging for data analysis. Likewise, homelessness prevention policies are problematic to evaluate since homeless people are difficult to identify from administrative data or not included in some data sources.Second, the small proportion of the population exposed to policies leads to challenges in conducting data analysis; for example, welfare policies supporting full-time students or single parents with childcare costs In the absence of a definitive guide, we conducted a comprehensive overview of policies around child and maternal health in the UK. The search strategy, nonetheless, does have limitations. While the filtering process was based on expert judgement, there is limited evidence for some of the policy effects. The uniformity of search across the websites was hampered by platform heterogeneity, requiring adaptability and iterative hand searching. The dynamic nature of the platforms also creates challenges to replicating the search strategy.Searching policy sites in this manner potentially omits past policy developments, with websites focused on current policies. Additional reports and policy reviews are necessary to supplement historical details. Reliance on policy titles can potentially exclude relevant interventions, for example, the Northern Ireland Extended Schools ProgrammePolitical devolution and a relatively homogeneous health and services policy environment in the UK presents a unique opportunity for child and maternal health researchers. A wide-ranging search of the UK policy landscape identified valuable opportunities to evaluate upstream, sociostructural impacts on mother and child outcomes. Three key policy priority areas in child and maternal health were identified for future evaluation.However, this process highlighted many potentially impactful policies that did not meet the criteria for natural experimental evaluation, which could lead to the inverse evidence law. This could be ameliorated by better access to administrative data , staged implementation of future policies (affording greater cross-country variation) or alternative evaluation methods .


Access to comprehensive sexual and reproductive health (SRH) services remains a challenge worldwide. Describing community pharmacists’ SRH services in countries with different scopes of practice will aid in understanding how pharmacists view their roles and how to support them in providing needed services. A cross-sectional web-based survey was administered to pharmacists working in community pharmacies in Japan, Thailand, and Canada. The survey covered 7 SRH categories: pregnancy tests, ovulation tests, contraception, emergency contraception, sexually transmitted and blood-borne infections, maternal and perinatal health, and general sexual health. Descriptive statistics were used to analyze the data. A total of 922 eligible responses were included in the analysis . Most Thai and Canadian participants reported dispensing hormonal contraceptives  and emergency contraceptive pills . Most Japanese participants provided patient education on barrier contraceptives for men (56%) and information on the safety of medications in pregnancy (74%) and breastfeeding (76%). The majority of participants expressed interest in additional training and expanding their roles in SRH. Sharing international experiences can guide challenges faced by the evolution of pharmacists’ practice in SRH. Providing pharmacists support could help their readiness for this role. Access to comprehensive sexual and reproductive health (SRH) services remains a challenge worldwide. According to the World Health Organization (WHO), 4.3 billion people of reproductive age worldwide will not have access to at least one SRH intervention in their lifetime . More reThe evolution of pharmacy practice is an international phenomenon. Development, adoption, and integration of new roles and responsibilities by pharmacists have been the trend over the past few decades ,12,13. BSeveral factors prevent the translation of contemporary patient-oriented pharmacy practice models globally ,18. One Given the prominent role in communities as part of primary health care, describing community pharmacists’ SRH services in countries with a different scope of practice will aid in understanding how pharmacists view their roles, see themselves as SRH providers, and what support they need to provide SRH services. To our knowledge, there is limited information regarding pharmacists’ experiences as SRH providers in Canada ,22,23,24The general characteristics and differences among educational programs, pharmacy regulations, and scope of practice between Japan, Canada, and Thailand are highlighted in The number of years required to obtain a pharmacy degree is similar in these countries. In Japan, completing the extended Bachelor of Pharmacy (6 years) is mandatory to qualify for the national examination for entry to practice. Influenced by the US-Thai consortium, Thailand developed their first Doctor of Pharmacy (PharmD) program in 1999. Since 2014, a 6-year PharmD program has been compulsory for national licensure . PharmacThe scope of practice differs in each country. In Canada, Alberta is the province with the broadest scope of practice and was the first to implement prescribing authority for pharmacists in 2007 . LegislaPharmacy practice in Japan is principally focused on dispensing medications and providing patient counselling . HoweverIn the last decade, Thailand has expanded community pharmacists’ roles to meet the needs of the public. After more than 10 years since transitioning to a 6-year PharmD program , communiThis was a descriptive, cross-sectional international study using survey methods. Results were analyzed and reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies .An anonymous, web-based survey was distributed electronically in Japan, Thailand, and Canada (Alberta) using REDCap. REDCap is an electronic data capture tool hosted by the Women & Children’s Health Research Institute at the University of Alberta ,51. The The survey was conducted from June 2020 to June 2021, with each country distributing the survey at different times. The period to collect responses was 1 to 6 months; in Thailand and Japan, the survey was open for 6 months due to slower response. Details about the strategies used are provided in The development and content of the survey have been described previously ,53. The The survey covered 7 common SRH categories: pregnancy tests, ovulation tests, contraception , emergency contraception, sexually and blood-borne transmitted infections, maternal and perinatal health, and general sexual health, and included 6 sections: demographics, provision of SRH services, attitudes towards the provision of SRH services, confidence when educating patients on SRH topics, factors influencing the provision of SRH services, and additional training preferences . The surA 5-point Likert-type scale was used to assess attitudes towards  and factors influencing the provision of SRH services . The primary outcomes were the proportion of participants providing SRH services, the proportion of participants agreeing (or disagreeing) with a series of statements regarding pharmacists as SRH providers and the influence of factors in the provision of SRH services. Secondary outcomes were the proportion of participants interested in expanding their roles in SRH and additional training preferences, including SRH knowledge and competencies.Survey responses were anonymous. A neutral language was used when designing the survey questions to minimize response bias. Increasing the number of days the survey was open and sending invitation and reminder emails were strategies used to reduce non-response bias and improve response rates ,55,56.There was no sample size set a priori.For analysis, eligibility was defined as submitted survey responses. Partial and unsubmitted responses were not included. Descriptive statistics were used to analyze the variables. Analysis was performed using Microsoft® Excel v.16.70 (Microsoft Corporation 2018).This study received approval from the Josai International University Research Ethics Review Committee (10M200001), the Chulalongkorn University Research Ethics Review Committee (114.1/63), and the University of Alberta Health Research Ethics Board (Pro00095881).A total of 1,265 pharmacists attempted the survey , and 922 eligible responses from community pharmacists were included in the analysis . Participants were primarily female and between 20 and 40 years of age . RegardiAll categories of SRH services were, to some extent, provided in the three countries . HoweverOverall, participants’ attitudes in all three countries were positive toward pharmacists’ roles in SRH . Most paIn general, most participants from the three countries responded that all factors included in the survey influenced the provision of SRH services to some extent . In JapaMost respondents expressed interest in additional training in SRH services . More than half of the participants in Japan (54%) and about three-quarters of the participants in Thailand and Canada  were interested in expanding their roles in SRH.Participants’ preferences varied between countries. For Japanese participants interested in additional training, the top preferences were emergency contraception (77%) and hormonal contraceptives (63%), followed by pregnancy/postpartum/breastfeeding (59%). Additionally, the preferred areas for Thai participants were sexual dysfunction (68%), pregnancy/postpartum/breastfeeding (59%), and sexual health concerns of LGBTQ+ patients (55%). In Canada, approximately half of the participants or more preferred more training in the areas of STBBI treatment (64%), STBBI prevention (55%), and sexual health concerns of LGBTQ+ patients (50%) .In terms of SRH competencies, more than 60% reported interest in additional training related to the use of appropriate and straightforward language when counselling patients . This was the preferred choice for participants in Japan and Thailand, while for Canadian participants, their top selection was additional training on providing referrals (75%). Less than half of the participants reported interest in additional training related to confidentiality and privacy . A higher proportion of Japanese participants considered approaching individuals nonjudgmentally a relevant topic for training (55%) .This multi-country study examined SRH services provided by pharmacists from regions with different regulations around pharmacy practice and perspectives regarding SRH. Results showed that pharmacists were involved in providing SRH services and had a positive attitude towards pharmacists’ roles in SRH. Participants’ perceptions of factors influencing the provision of SRH were similar in the three countries, as well as the willingness to expand roles and receive additional SRH training. The findings from this study can be used to inform education and training needs as well as potential barriers to the adoption of SRH services offered by community pharmacists.Overall, a high percentage of Alberta pharmacists reported providing patient education across several SRH areas in addition to the provision of emergency contraception. This may be a reflection of changes in the scope of practice  and healWe found that community pharmacists from countries with different scopes of practice see themselves as SRH providers and consider offering advice on SRH topics an essential part of their roles. Still, they face similar challenges when providing SRH services. Regardless of differences in educational, economic, and healthcare system contexts, a set of competencies essential for patient care practice are similar in all regions ,61. ProvOne of the common findings was the willingness to receive more SRH training. However, the top preferences differed between countries, which can be influenced by the role participants associate with being an SRH provider. The focus of Japanese participants was emergency contraception, one of the main SRH discussion topics on the public agenda in Japan . It is nTo position pharmacists as SRH providers and increase access to SRH services, it is relevant that they see themselves as SRH providers. Recognizing that pharmacists’ process to identify as SRH providers is dynamic, complex, and influenced by many factors will help to find the best tools and strategies to support their identity formation. Sharing international experiences on the influence of the changes in the profession can help to face challenges brought by this process. Exploring what different countries do to support their pharmacy workforce to prepare them to be SRH providers can inform the development of training programs and implementation strategies customized to the practice environment. Expanding the offer of continuing education programs and creating pharmacist-specific guidelines and practice tools based on the context of each jurisdiction are some of the recommendations of this work.The strengths of this study include the description of community pharmacists’ perspectives regarding the provision of SRH services in Canada, Japan, and Thailand. This study is the first to characterize perceptions of SRH practice in several topics from pharmacists in countries with different scopes of practice. Despite these strengths, several limitations need to be considered. This study may not be generalized to other regions in the selected countries and nations. Due to our study design, the results are limited due to volunteer, acquiescence, social desirability, and non-response bias. The sample size was not calculated a priori, and the number of participants varied between countries. No current detailed pharmacy workforce statistics are available to consider the representativeness of the population we aimed to survey in Japan and Thailand. However, the representativeness of this sample of the Canadian (Alberta) pharmacists’ population has been described before . The surCommunity pharmacists in countries with different scopes of practice and pharmacy regulations reported providing services in several SRH areas. While the extent to which pharmacists self-report the provision of SRH services varied in each country, pharmacists were interested in expanding SRH services and additional SRH training. Addressing factors that influence the provision of SRH services and supporting pharmacists is essential for expanding access. Sharing international experiences can guide challenges faced with the evolution of practice in SRH. Introducing support strategies based on local needs and international experiences, such as creating continuing education opportunities and practice tools, could help support pharmacists in providing care for individuals seeking SRH services.


Escherichia coli (E. coli) was reported in nine studies. Risk factors for AMU include herd size, vaccine use, and start date of calving season. Conclusions: Overall, a small number of AMR studies were available for synthesis in primarily one population (cows) reporting E. coli AMR. Additional studies targeting reasons for AMU in calves, the impact of management procedures on AMU, potential environmental AMR sources, and AMR in respiratory pathogens and enteric organisms other than E. coli for pre-weaning calves are required to inform AMR risk mitigation strategies.Background: The magnitude and knowledge gaps regarding antimicrobial use (AMU) and antimicrobial resistance (AMR) have not been summarized for the North American cow–calf production sector, although estimates of AMU and AMR are essential to AMR risk analysis. The objectives of this scoping review were to map AMU and AMR in the beef cow–calf sector in Canada and the United States, summarize published AMU/AMR predictors, and identify research gaps. Methods: An electronic search was conducted of four bibliographic databases and Google Scholar, augmented by a hand-search of captured studies. Results: Twenty-three of three-hundred and forty-three publications screened advanced to data extraction. Of these, 10 were conducted in the USA and 13 in Canada. Thirteen studied AMR and twelve studied AMU, with two reporting both. Of twelve captured AMU studies, nine presented counts of herd AMU by antimicrobial class or specific antimicrobial. Antimicrobial resistance in  Limiting the emergence and spread of antimicrobial resistance (AMR) is critical to preserving the world’s ability to treat diseases in humans, animals, and plants, reduce food safety and security risks, protect the environment, and maintain progress toward the Sustainable Development Goals . The AMRThe use of antimicrobials in livestock production has been identified as one driver of AMR occurrence in both human and animal populations . AntimicThe international bodies governing food safety, at both pre-harvest ) and harvest level (Codex Alimentarius) of the farm-to-fork continuum, recommend risk analysis as the framework for the investigation of animal health and food safety problems to inform policy of member states ,4. EstimWhile antimicrobials are important to animal health and welfare in all livestock commodities including the beef industry, information is limited on AMU in the North American cow–calf industry. Antimicrobial use has been reported in pre-weaning calves for treatment of diseases such as calf diarrhea and respiratory disease, and in cows for diseases such as lameness associated with infection, although the proportion of individuals treated within a herd tends to be relatively low, in both the United States of America (USA) and Canada ,7. TheseIn both Canada and the U.S., federal authorities collaborate with national veterinary associations to support veterinarians and ultimately producers in antimicrobial stewardship, by monitoring data on resistance and antimicrobial use ,14. The The magnitude of AMU and AMR have not been specifically summarized for the relatively extensively managed North American cow–calf production sector, although differences in AMU and AMR between the cow–calf and more intensively managed feedlot sectors have been reported ,16. ThisScoping reviews are appropriate for assessing the extent of the knowledge in an emerging field, or to identify, map, report or discuss the characteristics/concepts in that field . In contA scoping review was deemed appropriate as the aim of this review was to describe the published research available to support risk-based policy-making for AMR and antimicrobial stewardship initiatives in the North American beef cow–calf sector. The objectives of this scoping review were to map AMU/AMR research conducted in the North American beef cow–calf sector, summarize published AMU/AMR literature, describe predictors for resistance development in the beef cow–calf sector, and identify research gaps pertaining to the development of AMR risk mitigation strategies. The review specifically targeted animals not identified as being sick to summarize AMR data from the baseline population and to avoid laboratory diagnostic samples from sick animals that had potentially been treated with antimicrobials multiple times.The electronic bibliographic search yielded 343 unique citations, including the additional citations captured in the follow-up search conducted in June 2023. First-level title and abstract screening excluded 294 publications, for reasons including only sampling out-of-scope populations  and sampling locations . Another 32 publications were excluded after full-text review, for reasons including sampling only clinically ill animals, sampling animals not identifiable as beef cow–calf sector, and not reporting primary research. The Google Scholar search additionally identified one relevant thesis , one jouOf the 23 relevant publications, 10 were conducted in the USA and 13 in Canada between 1999 and 2020. Thirteen described investigations of AMR, twelve studied AMU, and two studied both. The most frequently studied population was pre-weaned calves n = 17), followed by cows (n = 14) with breeding bulls the least frequently described population (n = 2). Two AMU studies investigating producer attitudes studied usage at the herd level and did not report usage stratified by class of cattle , followe. The numA map displaying the provinces and states from which samples originated, across the included studies, is presented in While several investigators have identified the value of studying individual animal data in verifying producer reporting of AMU ,41, onlyNine AMU studies described herd-level usage (Yes/No) for classes of antimicrobials  or specific antimicrobials , aggregated as counts of herds that reported use . The panThe objectives for AMU were reported in seven of 12 included studies, ranging from “Prevention, control, or treatment”  to “TreaTetracycline use was reported by most herds in the identified studies, ranging from 36%  to 88%  for injePopulation-averaged individual-level reasons for AMU were reported by U. S. ,24 and CWithin-herd AMU was reported as categorical summaries from herd records in two Canadian studies ,31 for ep < 0. 05) predictors included herd size, with larger herds more likely to report AMU; and classes of livestock, with greater odds of AMU reported in calves relative to cows for multiple antimicrobials investigated  included in all but two of these studies and other enteric bacteria  less frequently reported , and all E. coli studies used breakpoints endorsed by the Clinical and Laboratory Standards Institute (CLSI) or its predecessor, the National Committee for Clinical Laboratory Standards (NCCLS). Other breakpoints  were reported in three studies investigating Campylobacter spp. Only three studies reported Salmonella, and in one of the two studies, there was only one isolate.Broth microdilution was the most frequently used method of antimicrobial susceptibility testing  associated with AMR in one or more studies included herd attributes such as calf mortality  [Predictors significantly (ith AMR)  and calfith AMR) , with a ith AMR) . An incrith AMR) . One stuith AMR) . The magp < 0.05) significant. Ionophore feeding was reported to have a significant (p < 0.05) association with decreased odds of cefotaxime-resistant bacteria [E. coli resistance to ≥2 antimicrobials [Several herd-level management practices, such as regularly disinfecting water troughs, and quarantining new arrivals to the herd, were associated with significantly reduced odds of AMR . While mbacteria . Herds icrobials .Individual-level factors significantly associated with AMR included calf age, with calves greater than 10 days of age having increased odds of AMR relative to those less than three days old , and preE. coli bacteria was resistance to one or more antimicrobials, reported in five publications representing fifteen studies across various populations and hierarchical levels of aggregation. A summary of the most frequently reported quantitative AMR outcomes in enteric bacteria originating from North American beef cow–calf herds is presented in The most frequently reported AMR outcome in E. coli resistance in cows to one or more of the following antimicrobials: cephalosporins, tetracyclines, sulphonamides, or aminoglycosides. Resistance varied across antimicrobials, populations sampled, and level of aggregation. Resistance in E. coli, aggregated at the isolate level, was relatively low, with AMR occurring more frequently in samples originating from calves relative to cows  or diamino-pyrimidines  . FindingOverall, a relatively small number (n = 23) of relevant publicly available studies of AMU or AMR in North American beef cow–calf production were captured. These largely originated from several research or surveillance groups: the Western College of Veterinary Medicine (n = 10 studies), the United States Department of Agriculture ) (n = 3), Ontario Veterinary College (n = 2), and the College of Veterinary Medicine of the University of Tennessee (n = 2). However, this coverage emphasizes the major beef-producing regions of the U.S. and Western Canada ,7.The most recent sampling captured is from 2019–2020, reported in only one Canadian study . SignifiThe value of using multiple information sources to validate AMU data, especially including individual treatment records, has been previously reported ,42. HoweMost (n = 11) of the AMU studies in this review reported count-based AMU metrics only. This is especially noteworthy as one study that presented multiple usage metrics found comparative usage across groups varied based on the outcome metric selected . This obStudies reporting herd-level AMU alone do not fully capture herd exposure to AMU. Two studies capturing AMU choices for herds, as well as the proportion of individual animals treated within herds, reported a relatively small proportion of individuals being treated within herds reporting usage of a given antimicrobial ,31. PopuInvestigation and reporting of beef cow–calf sector AMU are contingent on producers securing this information in a retrievable form, preferably with individual animal records. One study included in this review  reportedInvestigation of whether antimicrobials are being used prudently  similarly would require knowing the true diagnosis, the producer’s diagnosis, what the veterinarian prescribed for treatment, and whether/how accurately this was administered by the beef producer. Confirmation of producer diagnoses by a veterinarian is not practical or even possible in many instances due to the distance of cattle from the nearest clinic, as well as limited opportunities for observation, restraint, and timely treatment in extensively managed animals. Telemedicine opportunities are increasing, but cell phone coverage is inconsistent in many areas used for grazing. These questions also necessitate accurate individual treatment records, as well as substantial time and resources to correlate records to other information sources including herd protocols, drug invoices, and garbage can audits. Studies assessing prudent use are rarely reported, even in more intensively managed and therefore less logistically demanding sectors such as dairy and swine production, and no such investigation of prudent use in the beef cow–calf sector was captured in our search. When executed, these studies can be informative: a survey of Danish dairy farms validating treatment records with other information sources reported that of 12,930 beta-lactam drug use records, 1669 were under the manufacturer’s recommended daily dose and 6814 were over . HoweverUnderstanding the herd manager’s process for making treatment decisions is fundamental to assessing the prudent use of antimicrobials in beef cow–calf operations. This intrinsically involves documenting the use of treatment protocols drafted by the attending veterinarian. One Tennessee study of producer attitudes towards antimicrobial use reported that of 147 cow–calf producers responding to this question, 15% (22/147 (respondents) had written treatment protocols for the treatment of sick animals . An earlWhile studies aiming to characterize antimicrobial exposure should ideally include both the level  and duration of exposure, this information was reported in only one included study . This stIf the AMU data are to be used for benchmarking, comprehensiveness of the data and representativeness of study target populations are crucial. Antimicrobial use is intertwined with herd health and influenced by a range of management practices such as calving heifers and cows together, or failure to sort cow–calf pairs out of the calving area . ReportiThe chronological time of sampling is a potential predictor of interest to industry and policy-makers. However, given the relatively small number of studies included in this review, the range of outcomes and other potential predictors  , expecteComparability is an important consideration across study populations, sub-populations , or herds. The population at risk can vary by population size and structure, average weight at treatment, as well as the risk period for being treated . Within E. coli AMR studies tended to test for a group of antimicrobials similar to the Canadian Integrated Program Antimicrobial Resistance Surveillance (CIPARS) panel [E. coli AMR studies used NARMS breakpoints. The 2008 USA NAHMS studies [Several differences were noted between Canadian and USA AMR studies. The Canadian S) panel , using C studies  represenEscherichia coli was the most frequently reported enteric bacterial target, possibly due to its value as an indicator organism with potential public health impact [E. coli precludes the effective assessment of the samples for resistance to many macrolides important in veterinary medicine due to intrinsic resistance [h impact . Selectisistance , leavingCows were sampled more frequently than calves, likely reflecting the relative ease of handling for both groups. The outcomes measured were reported at levels ranging from isolate to industry sector , and this contributed to a relatively small group of surveys per outcome which could be compared or potentially pooled for summary estimates.Mannheimia haemolytica (n = 2) and those studying enteric organisms (n = 10). The two studies of respiratory pathogens did not report risk factors occurring pre-weaning for AMR, given the studies’ focus on AMR trends throughout the production cycle. In combination with the relatively small number of herds sampled , research gaps remain in improving our understanding of AMR prevalence and risk factors for important pathogens. The finding of “unhealthy” calves having increased odds of AMR suggests the possible importance of some herd health and herd-level management procedures in mitigating AMU [The twelve captured studies of AMR fell into two broad groups: those studying respiratory pathogens such as ting AMU . A recenting AMU .Multiple potential sources of bias exist within and across the included studies, including selection bias at both the herd and individual levels of sampling. Recruitment of herds to observational studies requires owner consent, and this inherently introduces selection bias for owners having the interest and willingness to contribute time and resources to allow physical sample or data collection . IndividFor some time, technological advances have been suggested as potential opportunities to reduce AMU or mitigate AMR . Within Given the complexity of the dataset, with a myriad of potential herd- and individual-level predictors, and the identified data gaps, the studies captured in this review collectively provide incomplete evidence required by policy-makers to support benchmarking or to inform risk models in support of public health. For example, when reporting AMU by drug class, an accompanying listing of the specific drugs captured by the study survey would be helpful in supporting the assessment of the comparability of findings across studies. More detailed reporting of drugs captured by each survey would also support differentiating the use of “long-acting” vs. repeatedly dosed products, which is of interest pertaining to the logistics underlying drug choices, and also the potential for longer exposure to a lower level of the active drug. However, an issue in extensively managed operations is that short-acting drugs might only be used once due to difficulty in capturing the animal a second or third time—leading to incomplete treatment and increased risk of AMR. Single-dose drugs could logistically be preferable at times, especially in animals on pasture, in that single-use drugs could be more effective in clearing the original infection if used in the right animals at the right time.Producers and veterinarians additionally need to continue to improve documentation and tools to promote responsible management of AMU in the beef cow–calf sector, to inform the social license to operate, and to prevent potential treatment failure associated with AMR. This requires identification of the major purposes for AMU, and those diseases most frequently associated with the use of drug classes important in human medicine. In Canada, MIAs are categorized as Very High Importance, High Importance, or Medium Importance based on indications for usage in human medicine and available alternatives . In the E. coli as the microbial target of interest, additional studies of AMR with other enteric organisms as well as for respiratory pathogens in pre-weaning calves would be useful in prioritizing disease syndromes for AMU mitigation strategies. Pre-weaning calves are of particular interest to the industry as they represent the risk of AMR in calves entering the feedlot, potentially limiting options for treating bovine respiratory disease.Current findings across this dataset suggest a relatively small proportion of cattle receive antimicrobials in the cow–calf sector. There is, however, evidence to suggest areas for potential improvement. Beef calves in spring are the most likely group on-farm to receive treatment  includinE. coli isolates from cow–calf operations suggest the importance of further investigating other potential drivers of AMR such as the environmental burden of AMR in cow–calf production [One included study describes the isolation of AMR bacteria from the environment of cow–calf operations , as do ooduction .This scoping review had several potential limitations. We did not chart data specifically pertaining to risk of bias (ROB) per se given the current lack of widely endorsed guidelines for assessing individual observational studies for ROB or incorporating ROB in furthermore focused syntheses such as systematic review and meta-analysis of observational studies ,58. We dThis scoping review was conducted following a protocol informed by Joanna Briggs Institute (JBI) Evidence Synthesis  and the Given the aim of the review, the condition, context, and population (CoCoPop acronym) was used to characterize eligibility criteria . The criCondition: Antimicrobial use or antimicrobial resistance, or risk factors potentially associated with either of these, reported in any metric.Context: Environmental factors can have an impact on the frequency of occurrence of the conditions of interest [interest , and thePopulation: Studies with healthy/asymptomatic animals produced in beef cow–calf herds in Canada and the USA were eligible. Studies of all classes of livestock within the cow–calf sector  were eligible. For studies reporting data from cow–calf operations as well as other enterprises such as stockers, backgrounding or feedlots, or studies sampling operations which combined one or more of these enterprises with cow–calf production, sampling from the populations of interest was deemed relevant, and sampling originating from populations outside of scope  was not included in data extraction.Inclusion: Primary research investigating beef cow–calf populations in Canada and the USA, of any size, was eligible with no restrictions on year or language of publication. If the research included AMR outcomes, only data originating from sampling clinically healthy as opposed to ill animals were deemed relevant. Journal articles, government or industry publications, and theses were all deemed relevant.Exclusion: Studies conducted in countries other than Canada and the USA were excluded to restrict data to regionally relevant herd management practices, licensed antimicrobials, and regulations limiting access. Additionally, AMR studies were excluded if they only sampled clinically ill or symptomatic animals, or they did not report outcomes identifiable as originating from clinically healthy animals or collected as part of routine surveillance from privately owned herds. Calf rearing operations, in which dairy calves not destined for the breeding herd are fed to slaughter, were outside scope, even if reporting on calves of beef breeds. Studies investigating cattle in feedlots or only, or only sampling cattle raised within organic or antibiotic-free production systems, or herds purposively selected for known minimal antimicrobial use, were also deemed outside of scope.An initial search was conducted on 22 January 2022 in three electronic bibliographic databases: Web of Science, Scopus, and AGRICOLA, using a three-term search. One term described the populations of interest . The second term described the outcome of interest . The third term described location . Examples of the specific search strategies employed in each database are presented in the study protocol in A commercial spreadsheet program was used to manage the data . First-level relevance screening was performed independently by two reviewers on abstracts captured by the search. The first level screening form asked four questions: “Is the literature in the form of a journal article, thesis, or government report?”; “Does the research take place in Canada or the United States?”; “Does the study include data from cow-calf herds?”; and “Does the article contain information on AMU or AMR?”. Those citations deemed relevant using this form were promoted to second-level relevance screening, and the full paper was obtained.The objective of second-level relevance screening was a full-text review by two independent reviewers to confirm eligibility. Relevant publications contained information on AMU or AMR in the cow–calf sector of the beef industry, specifically the Canadian or American cow–calf industries. First- and second-level relevance screening conflicts were resolved through discussion and confirmation by the senior author.Third-level data extraction was performed by a single reviewer using a pre-tested data extraction form capturing major characteristics of each relevant study, such as year of sampling, populations studied, broad outcome(s) reported  and metrics used, as well as level of data aggregation . Copies of the three relevance screening forms used are available online in For purposes of this review, a study was defined as an investigation of AMU or AMR in a defined population, identifiable by beef cow–calf sub-populations . A publication (synonymous with “paper”) was defined as a publicly available description of one or more studies. The same study population could be sampled for different studies . Multiple studies could originate from the same overall study population, within one publication . For purposes of mapping the literature, all relevant publications were included in data extraction. If multiple publications sampled the same population for different studies and reported different outcomes, these were indicated with a superscript in tables.Descriptive statistics were computed in a commercial spreadsheet program .E. coli for pre-weaning calves are required to inform the development of AMR risk mitigation strategies. Studies specifically describing the decision-making processes of producers in AMU, which report AMU or AMR as an outcome of interest, are currently research gaps.The dataset captured focused predominately on one AMU metric (count), studied at one hierarchical level (herd), and one population (cows) was investigated for AMR, leaving several major information gaps in most of the published literature. A small number of risk factors significantly associated with AMU  and AMR (biosecurity procedures) were reported. Additional studies targeting major reasons for AMU in calves, the impact of management procedures on usage, potential environmental sources of AMR, and AMR in respiratory pathogens and enteric organisms in addition to This research is especially important given the importance of AMU in cattle relative to overall livestock use in Canada and the USA.


Data are publicly available to identify geographic differences in health outcomes, including chronic obstructive pulmonary disease (COPD), and social vulnerability; however, examples of combining data across sources to understand disease burden in the context of community vulnerability are lacking.www.cdc.gov/PLACES) with social vulnerability measures from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index , including 4 themes , and the overall Social Vulnerability Index (SVI). We used the merged data set to create vulnerability profiles by COPD prevalence, explore joint geographic patterns, and calculate COPD population estimates by vulnerability levels.We merged county and census tract model-based estimates of COPD prevalence from PLACES  had high median vulnerability rankings (range: 0–1) for 2 themes: socioeconomic  and household composition and disability . Concordant high COPD prevalence and vulnerability for these themes were clustered along the Ohio and lower Mississippi rivers. The estimated number of adults with COPD residing in counties with high vulnerability was 2.5 million (tract: 4.7 million) for the socioeconomic theme and 2.3 million (tract: 5.0 million) for the household composition and disability theme .Data from 2 publicly available tools can be combined, analyzed, and visualized to jointly examine local COPD estimates and social vulnerability. These analyses can be replicated with other measures to expand the use of these cross-cutting tools for public health planning. Data are available to identify geographic differences in health outcomes and community-wide measures of social determinants of health. Examples of how to combine and use data across different sources are lacking.We demonstrated how prevalence estimates of chronic obstructive pulmonary disease from PLACES and social vulnerability measures from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index can be jointly examined. We provide examples of tables, figures, and maps that can be created from the combined data.These analyses can be replicated to examine different health measures or for more focused geographies to inform public health planning and expand the use of these cross-cutting tools.Social determinants of health (SDOH) are conditions in the environments where people are born, live, learn, work, and play that affect a wide range of health, function, and quality-of-life outcomes . IncorpoSocial vulnerability measures are factors related to community-level income, education, race or ethnicity, household composition, disability, housing, and transportation, as well as composite social vulnerability indexes (SVIs) . SVIs weJointly examining local health and social vulnerability data can improve understanding of the interplay of these issues in the community setting and can enhance community planning strategies addressing chronic conditions, such as COPD. For example, local, state, and federal planning agencies and partner organizations can use these data to determine distribution of COPD-related resources and programming that address issues related to the cost of treatment in communities where socioeconomic vulnerabilities are highest. By combining these 2 types of data, it may also be possible to identify local areas where high levels of COPD prevalence occur with high social vulnerability. Identifying these areas can help inform allocation of appropriate resources and promote engagement of cross-sector partners like education, transportation, and housing, with the shared goal of improving people's environments and their health.www.cdc.gov/PLACES) and social vulnerability measures from the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (CDC/ATSDR SVI)  can be jointly examined. We first observed the correlations between COPD prevalence and CDC/ATSDR SVI variables at 2 geographic levels, county and census tract. Two geographic levels were examined because practitioners may be interested in how results vary depending on geographic level. Next, we showed how to 1) use these data to create a social vulnerability profile for areas with low, moderate, and high COPD prevalence; 2) jointly explore geographic patterns in these estimates by using bivariate maps; and 3) generate estimates for the prevalence and number of adults with COPD living in counties and tracts with low, moderate, and high vulnerability. We illustrate how publicly available data can be used to implement these types of analyses, and we provide tabular and graphic summaries that can inform public health planning discussions. We present findings at the national level, but analyses can be limited to a more focused geography . We conclude with a discussion of key issues to consider when jointly examining these data.Our study demonstrates how COPD prevalence estimates from PLACES (www.cdc.gov/PLACES) provides annual model-based estimates for counties, incorporated and census-designated places, census tracts, and ZIP Code Tabulation Areas (ZCTAs) across the US for 29 chronic disease–related measures, including a measure of COPD prevalence , 2014https://www.atsdr.cdc.gov/placeandhealth/svi) uses ACS data to determine the social vulnerability of US counties and census tracts. ACS is a nationwide survey conducted by the US Census Bureau to produce sample-based estimates across multiple geographies . ,11. http–2018, and rankings were created based on percentiles of raw estimates . Percentiles for the components of each theme were summed and the totals were used to determine theme-specific percentile rankings. For overall SVI, the sums for each theme were totaled, and this sum was used to create rankings and determine overall percentile rankings. Maps at the county and tract level are provided for these rankings via the CDC/ATSDR SVI Interactive Map application (Raw estimates and percentile rankings from the 2018 CDC/ATSDR SVI (released in 2020) for each county and tract were downloaded from the website. For the individual components, raw estimates were based on the ACS 2014lication . When ext statistic to determine whether they were significantly different from zero; correlations were described as strong (>0.50), moderate (0.30–0.50), or weak (<0.30)  . Median  (<0.30) ; 2) crosr = 0.48 [county], 0.51 [tract]). Correlations were strong for the socioeconomic theme, and strong to moderate for all components within the theme. Correlations were strong for the household composition and disability theme although correlations differed across components. Correlations were negative and moderate at the county level and weak at the tract level for the minority status and language theme with correlations moderate to weak for both components within the theme. Correlations were weak for the housing type and transportation theme with variability across components.Correlations between COPD prevalence and individual components, themes, and the overall SVI were in similar ranges for county and tract estimates . The relMedian values for the components, themes, and the overall SVI were examined by COPD prevalence category . Median COPD county and tract median prevalence increased as vulnerability increased from low to high vulnerability for the socioeconomic, household composition and disability, and housing type and transportation (tract-level only) themes, and the overall SVI . ConversCounties and census tracts with the highest model-based COPD prevalence estimates (quartile 4) were clustered along the Ohio and lower Mississippi rivers . BivariaAlthough tools exist for understanding data related to geographic differences in health outcomes and social vulnerability, few examples show how to combine data across sources to improve their usefulness for public health planning. By using data from PLACES and the CDC/ATSDR SVI, we demonstrated how these 2 tools can be combined to examine local-level estimates of COPD burden in the context of local-level social vulnerability. Continued efforts are needed to explore the many opportunities to combine data across tools to best support national, state, and local public health planning efforts.By jointly examining community social vulnerability and health data, local planners and public health professionals can enhance their planning of strategies for addressing chronic conditions, including COPD. A previous study demonstrated the use of small area estimates to predict the number of adults with COPD living in the forecasted path of a hurricane . This deWe identified areas of concordance and discordance between high and low COPD prevalence and vulnerability. Identifying these types of clusters can help guide public health planning; however, other factors may contribute to the clustering. First, the PLACES statistical approach incorporates sex, age, race and ethnicity, education, and county-level poverty when generating estimates ,14. It iWe presented a case study at the national level to demonstrate how these 2 data sets can be combined to inform public health planning. However, efforts to replicate these analyses within more focused geographies  could help better inform state and local efforts in planning and implementing strategies for COPD prevention , early diagnosis, treatment , and management . Our overall findings were similar regardless of whether county or tract data were examined, with one exception: estimates of the total number of adults with COPD living in areas defined as having low, moderate, or high vulnerability differed when using county versus tract estimates. The reason for this is likely the wider range in county population  compared with the range in tract population . For example, counties with large populations could be highly influential when calculating aggregate population estimates. For generating aggregate population estimates, it may be best to use the smallest geographic unit for which the measures are available.https://livingatlas.arcgis.com). Several interactive tools also provide access to measures of health outcomes along with social and economic factors within a single application or include functions that allow users to stratify maps of health outcomes by ranges of SDOH measures or vice versa .These dSimilar analyses could be conducted to inform efforts that focus on other health outcomes , health risk behaviors , prevention practices , or health status  that are included as PLACES measures. As analyses plans are developed, it is important to consider existing knowledge related to the health measure and consider how to conceptualize a joint analysis to best inform the planning and decision-making process . In addiWe provided an example of using estimates from 2 validated CDC data sources for public health planning; however, our approach has several limitations. First, both tools rely on estimates based on samples of the population. All estimates have associated margins of error, and estimates can be affected by biases from the surveys themselves . We did not include measures of error in our analysis and did not provide CIs for aggregate estimates. Second, the PLACES approach has limitations, which are discussed elsewhere ,14, and We demonstrated how data from 2 publicly available tools can be combined, analyzed, and visualized to jointly examine local COPD estimates and social vulnerability. By understanding this approach and improving awareness of these tools, public health practitioners can enhance their use of these data to inform public health planning to better inform actions to improve health.


Dear Editor,1. The majority of cases in the current outbreak have occurred in men who have sex with men (MSM), and the lesions are most commonly found in the anogenital region. Some patients have also presented with oral and oropharyngeal lesions, which can progress to painful ulcers and tonsillar abscesses2. Furthermore, dysphagia has been shown in approximately 25% of monkeypox patients requiring hospital admission3.Monkeypox is a double-stranded DNA virus of the Poxviridae family that has spread globally since May 2022, posing a serious public health threat. The primary human-to-human transmission routes include respiratory droplets and close contact with skin lesions4, it is critical that speech and language therapists are prepared to identify swallowing difficulties early and provide appropriate treatment for each case, avoiding dysphagia-associated complications such as dehydration, malnutrition, aspiration pneumonia, and prolonged hospital stay. Patients with oropharyngeal lesions must be evaluated using specific anamnesis, validated questionnaires, and clinical swallowing examination. It is also necessary to inspect and manipulate oral structures, as well as evaluate pain and masticatory function. Furthermore, due to disease transmission pathways, speech and language therapists must care for monkeypox patients in accordance with biosafety best practices.Because dysphagia can be found in patients with the most severe forms of monkeypox5. Therefore, we recommend that patients with monkeypox and oropharyngeal involvement be evaluated by a multidisciplinary team, including (1) an oral diet assessment with multiple consistencies using disposable utensils; (2) cranial nerve evaluation; and (3) adoption of clinically appropriate compensatory strategies to determine the safest and most adequate nutritional route, considering medical history, current disease, and oropharyngeal performance.Videofluoroscopic swallowing study (VFSS) is recognized as the gold-standard technique to assess dysphagia and to determine the most appropriate treatment plan for patients with swallowing disturbances. However, flexible endoscopic evaluation of swallowing (FEES) can be used as an alternative method when VFSS was either not available or not applicable. FEES can easily and directly assess oropharyngeal secretion management and the efficacy of cleaning mechanisms such as coughing and throat clearingIn this letter, we highlight important considerations on the role of the speech and language therapist in the diagnosis and management of dysphagia in monkeypox patients. Studies on the functional consequences of the disease are needed to understand possible sequelae and specific needs of these patients.