Illness Diaries Research Articles

Farm animal exposure, respiratory illnesses, and nasal cell gene expression

BackgroundFarm exposures in early life reduce the risks for childhood allergic diseases and asthma. There is less information about how farm exposures relate to respiratory illnesses and mucosal immune development. ObjectiveWe hypothesized that children raised in farm environments have a lower incidence of respiratory illnesses over the first two years of life than non-farm children. We also analyzed whether farm exposures or respiratory illnesses were related to patterns of nasal cell gene expression. MethodsThe Wisconsin Infant Study Cohort included farm (n=156) and non-farm (n=155) families with children followed to age 2 years. Parents reported prenatal farm and other environmental exposures. Illness frequency and severity were assessed using illness diaries and periodic surveys. Nasopharyngeal cell gene expression in a subset of 64 children at age two years was compared to farm exposure and respiratory illness history. ResultsFarm vs. non-farm children had nominally lower rates of respiratory illnesses (rate ratio 0.82 [0.69,0.97]) with a stepwise reduction in illness rates in children exposed to 0, 1, or ≥2 animal species, but these trends were non-significant in a multivariable model. Farm exposures and preceding respiratory illnesses were positively related to nasal cell gene signatures for mononuclear cells and innate and antimicrobial responses. ConclusionsMaternal and infant exposure to farms and farm animals was associated with nonsignificant trends for reduced respiratory illnesses. Nasal cell gene expression in a subset of children suggests that farm exposures and respiratory illnesses in early life are associated with distinct patterns of mucosal immune expression.

Secondary attack rates from asymptomatic and symptomatic influenza virus shedders in hospitals: Results from the TransFLUas influenza transmission study.

Nosocomial transmission of influenza is a major concern for infection control. We aimed to dissect transmission dynamics of influenza, including asymptomatic transmission events, in acute care. Prospective surveillance study during 2 influenza seasons. Tertiary-care hospital. Volunteer sample of inpatients on medical wards and healthcare workers (HCWs). Participants provided daily illness diaries and nasal swabs for influenza A and B detection and whole-genome sequencing for phylogenetic analyses. Contacts between study participants were tracked. Secondary influenza attack rates were calculated based on spatial and temporal proximity and phylogenetic evidence for transmission. In total, 152 HCWs and 542 inpatients were included; 16 HCWs (10.5%) and 19 inpatients (3.5%) tested positive for influenza on 109 study days. Study participants had symptoms of disease on most of the days they tested positive for influenza (83.1% and 91.9% for HCWs and inpatients, respectively). Also, 11(15.5%) of 71 influenza-positive swabs among HCWs and 3 (7.9%) of 38 influenza-positive swabs among inpatients were collected on days without symptoms; 2 (12.5%) of 16 HCWs and 2 (10.5%) of 19 inpatients remained fully asymptomatic. The secondary attack rate was low: we recorded 1 transmission event over 159 contact days (0.6%) that originated from a symptomatic case. No transmission event occurred in 61 monitored days of contacts with asymptomatic influenza-positive individuals. Influenza in acute care is common, and individuals regularly shed influenza virus without harboring symptoms. Nevertheless, both symptomatic and asymptomatic transmission events proved rare. We suggest that healthcare-associated influenza prevention strategies that are based on preseason vaccination and barrier precautions for symptomatic individuals seem to be effective.

Sources of viral respiratory infections in Canadian acute care hospital healthcare personnel

SummaryBackgroundViral respiratory illnesses are common causes of outbreaks and can be fatal to some patients.AimTo investigate the association between laboratory-confirmed viral respiratory infections and potential sources of exposure during the previous 7 days.MethodsIn this nested case–control analysis, healthcare personnel from nine Canadian hospitals who developed acute respiratory illnesses during the winters of 2010/11–2013/14 submitted swabs that were tested for viral pathogens. Associated illness diaries and the weekly diaries of non-ill participants provided information on contact with people displaying symptoms of acute respiratory illness in the previous week. Conditional logistic regression assessed the association between cases, who were matched by study week and site with controls with no respiratory symptoms.FindingsThere were 814 laboratory-confirmed viral respiratory illnesses. The adjusted odds ratio (aOR) of a viral illness was higher for healthcare personnel reporting exposures to ill household members [7.0, 95% confidence interval (CI) 5.4–9.1], co-workers (3.4, 95% CI 2.4–4.7) or other social contacts (5.1, 95% CI 3.6–7.1). Exposures to patients with respiratory illness were not associated with infection (aOR 0.9, 95% CI 0.7–1.2); however, healthcare personnel with direct patient contact did have higher odds (aOR 1.3, 95% CI 1.1–1.6). The aORs for exposure and for direct patient contact were similar for illnesses caused by influenza.ConclusionCommunity and co-worker contacts are important sources of viral respiratory illness in healthcare personnel, while exposure to patients with recognized respiratory infections is not associated. The comparatively low risk associated with direct patient contact may reflect transmission related to asymptomatic patients or unrecognized infections.

Which healthcare workers work with acute respiratory illness? Evidence from Canadian acute-care hospitals during 4 influenza seasons: 2010-2011 to 2013-2014.

Healthcare workers (HCWs) are at risk of acquiring and transmitting respiratory viruses while working in healthcare settings. To investigate the incidence of and factors associated with HCWs working during an acute respiratory illness (ARI). HCWs from 9 Canadian hospitals were prospectively enrolled in active surveillance for ARI during the 2010-2011 to 2013-2014 influenza seasons. Daily illness diaries during ARI episodes collected information on symptoms and work attendance. At least 1 ARI episode was reported by 50.4% of participants each study season. Overall, 94.6% of ill individuals reported working at least 1 day while symptomatic, resulting in an estimated 1.9 days of working while symptomatic and 0.5 days of absence during an ARI per participant season. In multivariable analysis, the adjusted relative risk of working while symptomatic was higher for physicians and lower for nurses relative to other HCWs. Participants were more likely to work if symptoms were less severe and on the illness onset date compared to subsequent days. The most cited reason for working while symptomatic was that symptoms were mild and the HCW felt well enough to work (67%). Participants were more likely to state that they could not afford to stay home if they did not have paid sick leave and were younger. HCWs worked during most episodes of ARI, most often because their symptoms were mild. Further data are needed to understand how best to balance the costs and risks of absenteeism versus those associated with working while ill.

The TransFLUas influenza transmission study in acute healthcare - recruitment rates and protocol adherence in healthcare workers and inpatients

BackgroundDetailed knowledge about viral respiratory disease transmission dynamics within healthcare institutions is essential for effective infection control policy and practice. In the quest to study viral transmission pathways, we aimed to investigate recruitment rates and adherence of healthcare workers (HCWs) and hospital inpatients with a study protocol that involves prospective surveillance based on daily mid-turbinate nasal swabs and illness diaries.MethodsSingle center prospective surveillance of patients and HCWs in three different hospital departments of a tertiary care center during an entire influenza season in Switzerland. Inpatients and acute care HCWs were asked to provide mid-turbinate nasal swabs and illness diaries on a daily basis. Study protocol adherence and recruitment rates were the primary outcomes of interest.ResultsA total 251 participants (59 (23.5%) health care workers and 192 (76.5%) inpatients) were recruited from three different hospital wards. Recruitment rates differed between HCWs (62.1% of eligible HCWs) and inpatients (32.5%; P < 0.001), but not within HCWs (P = 0.185) or inpatients (P = 0.301) of the three departments. The total number of study-days was 7874; 2321 (29.5%) for inpatients and 5553 (70.5%) for HCWs. HCWs were followed for a median of 96 days (range, 71–96 days) and inpatients for 8 days (range, 3–77 days). HCWs provided swabs on 73% (range, 0–100%) of study days, and diaries on 77% (range 0–100%). Inpatients provided swabs and diaries for 83% (range, 0–100%) of days in hospital. In HCWs, increasing age, working in internal medicine and longer duration of total study participation were positively associated with the proportion of swabs and diaries collected. Adherence to the study protocol was significantly lower in physicians as compared to nurses for both swabs (P = 0.042) and diaries (P = 0.033). In inpatients, no association between demographic factors and adherence was detected.Conclusions Prospective surveillance of respiratory viral disease was feasible in a cohort of inpatients and HCWs over an entire influenza season, both in terms of recruitment rates and adherence to a study protocol that included daily specimen collection and illness diaries.Trial registrationclinicaltrials.govNCT02478905. Date of registration June 23, 2015.

Associations among depression, perceived self-efficacy, and immune function and health in preadolescent children

Experimental animal studies and adult research consistently show that stress exposure and/or psychological symptoms are associated with poorer health and immune functioning. The application to children is not yet clear, however, and we lack developmental models for studies in this area. The objective of this paper was to test the hypothesis that self-reported self-efficacy and depression, two markers of psychological well-being in children, would predict immunity and rate of illnesses. The data are based on a prospective study of 141 healthy, normally developing children aged 7-13 years who were recruited from an ambulatory pediatric setting. Children completed self-efficacy and depression measures and had blood obtained for IL-6 plasma levels and natural killer cell functional assays on three occasions, 6 months apart. Parents maintained weekly child illness diaries over 1 year using a thermometer to record fever. Parent psychiatric symptoms and income were used as covariates. Results indicated that, across the three occasions of measurement collected over the 1-year period, higher perceived self-efficacy was significantly associated with lower plasma interleukin 6 concentrations. There was no overall main effect of depressive symptoms on immune measures; however, for older girls, higher depression was associated with elevated natural killer cell cytotoxicity and an increased rate of total illnesses and febrile illnesses. The findings provide some of the first evidence that psychological processes are associated with immunity and health in a normally developing sample of preadolescents. Furthermore, the pattern of results suggests a modified model of a link between psychological well-being and immunological processes in children. These results build on and expand research on the notion of allostatic load and develop a groundwork for developmental studies in this area.

From awareness to involvement? A qualitative study of respiratory patients' awareness of health service change.

BACKGROUND Despite the policy rhetoric, patient involvement in health service decisions remains limited. Highlighted barriers include a concern that most patients are unable to see beyond personal aspects of their care in order to contribute meaningfully to health service development, and a perception that professionals do not welcome patient involvement. OBJECTIVES We aimed to explore respiratory patients' awareness of changes in local health service provision and provide insight into health professionals' attitudes to engaging patients. METHODS Nested within an ethnographic study of health service reconfiguration, we recruited 31 patients with a range of respiratory diseases from four case study areas in England and Wales. Data from telephone interviews, illness diaries and focus groups with patients, and interviews with health professionals and managers were transcribed and analysed using the Framework approach. RESULTS Participants were not only aware of trends in health service provision (e.g. emergence of new professional roles, shift from secondary to primary care) but interpreted changes in the light of local and national events. Despite this awareness, none of the patients was formally involved in service development, though some contributed to local voluntary groups. Professionals generally welcomed the need for patients' views to be heard. DISCUSSION AND CONCLUSIONS Our data give grounds for optimism. Patients are aware of and interested in a broad range of health-related issues. Professionals' motivation to involve patients in service development may be underestimated. Although practical obstacles remain, our findings should encourage the ongoing search for effective models of promoting patient engagement in health-care services.

From support to boundary: A qualitative study of the border between self-care and professional care

Objective While healthcare systems globally are promoting self-care, patients’ perceptions of the policy shift remain relatively unexplored. Our qualitative study explored how organisation of care shaped patients’ perceptions and experiences of self-care in dealing with their respiratory illnesses. Methods We recruited 31 people, representing a range of ages and respiratory conditions and generated data using illness diaries, telephone interviews and focus group discussions. Data were transcribed, analysed and triangulated using the framework approach. Results Patients were aware of the increasing focus on self-care, but felt that the term was incongruous as it described what they were already doing. While many respondents appreciated increased clinical responsibility some felt ‘abandoned’ by professionals. To be active partners in care, they needed flexible access to trusted healthcare professionals who respected patients’ knowledge about their condition and preferences for management. Conclusion The shift to self-care needs to be underpinned by a whole system change. Professionals need communication skills to engage with patients as partners in care, working within systems that offer flexible access to supportive care. Practice implications Systems of care for people with long-term conditions need to ensure flexible access between self-care and professional support. Simplification of systems, clear sign-posting and co-ordination of individual patient care by a key trusted professional are essential.

Affordability, availability and acceptability barriers to health care for the chronically ill: Longitudinal case studies from South Africa

BackgroundThere is an increasing burden of chronic illness in low and middle income countries, driven by TB/HIV, as well as non-communicable diseases. Few health systems are organized to meet the needs of chronically ill patients, and patients' perspectives on the difficulties of accessing care need to be better understood, particularly in poor resourced settings, to achieve this end. This paper describes the experience of poor households attempting to access chronic care in a rural area of South Africa.MethodsA household survey (n = 1446 individuals) was combined with qualitative longitudinal research that followed 30 case study households over 10 months. Illness narratives and diaries provided descriptive textual data of household interactions with the health system.ResultsIn the survey 74% of reported health problems were 'chronic', 48% of which had no treatment action taken in the previous month. Amongst the case study households, of the 34 cases of chronic illness, only 21 (62%) cases had an allopathic diagnosis and only 12 (35%) were receiving regular treatment. Livelihoods exhausted from previous illness and death, low income, and limited social networks, prevented consultation with monthly expenditure for repeated consultations as high as 60% of income. Interrupted drug supplies, insufficient clinical services at the clinic level necessitating referral, and a lack of ambulances further hampered access to care. Poor provider-patient interaction led to inadequate understanding of illness, inappropriate treatment action, 'healer shopping', and at times a break down in cooperation, with the patient 'giving up' on the public health system. However, productive patient-provider interactions not only facilitated appropriate treatment action but enabled patients to justify their need for financial assistance to family and neighbours, and so access care. In addition, patients and their families with understanding of a disease became a community resource drawn on to assist others.ConclusionIn strengthening the public sector it is important not only to improve drug supply chains, ambulance services, referral systems and clinical capacity at public clinics, and to address the financial constraints faced by the socially disadvantaged, but also to think through how providers can engage with patients in a way that strengthens the therapeutic alliance.

The associations between psychosocial stress and the frequency of illness, and innate and adaptive immune function in children

Objective Family processes have a substantial impact on children’s social and emotional well-being, but little is known about the effects of family stress on children’s physical health. To begin to identify potential links between family stress and health in children, we examined associations between specific aspects of family psychosocial stress and the frequency of illnesses in children, measures of innate and adaptive immune function, and human herpesvirus 6 (HHV-6) reactivation. Study design Prospective study of 169 ambulatory school-age children and parents. Parents completed multiple assessments of stress at 7 sequential six-month visits and maintained weekly illness diaries for their children over three years using a thermometer to record fever. Children had blood obtained for HHV-6 and immune function studies at each visit including natural killer (NK) cell function and the percentage of CD4 and CD8 cells associated with immune control of cytomegalovirus (CMV). Results Parental psychiatric symptoms were associated with a higher frequency of illnesses: for each 1 U increase in symptom score children had an increased 1-year rate of total illnesses of 40% (rate ratio, 1.40; 95% CI, 1.06–1.85) and febrile illnesses of 77% (rate ratio, 1.77, 95% CI, 1.00–3.13). Parental psychiatric symptom scores were also associated with enhanced NK cell function (estimate, 0.15; 95% CI, 0.05–0.26) and increased percentages of CD8+CD28-CD57+ cells in the blood of CMV seropositive children (estimate, 2.57; 95% CI, 0.36–4.79). HHV-6 reactivation was not detected. Conclusions There is an association between specific psychosocial stress exposure and rates of illness and immune function in normally developing children.

Improving antibiotic use in low-income countries: an overview of evidence on determinants

The inappropriate use of antibiotics has often been identified as a problem in effective health care delivery. High levels of antibiotics use, often clinically unnecessary, have led to a steady increase in drug resistance. Low-income countries, home to the majority of the world's population, are believed to have an important role in this phenomena. Effective intervention in these practices is often constrained by the paucity of information on determinants of antibiotic use. This review provides information from studies on the factors that influence the use of antibiotics by health providers, dispensers and community members in low-income countries. A proper understanding of these factors should be seen as a precondition for the development of more effective policies and programmes to address inappropriate antibiotic use. The review encompasses physicians’ practices, the role of drug dispensers, and the influences on patterns of drug use across community members. Although a set of papers with useful research data was identified, probably the most important finding of the review was the scarcity of research. If interventions into antibiotic use are to be effective, future research must explore in more depth the socio-cultural rationality of antibiotic usage. The most productive approach would be to combine quantitative studies of the patterns of antibiotic use with the rich variety of qualitative methods like case simulations, focus group discussions, in-depth interviews, informal interviews, or illness diaries to explore determinants. Research programmes alone are unlikely to improve antibiotic use. Priority programme activities would include a carefully designed mix of activities by governments, health delivery systems, health training institutions, professional societies, pharmaceutical companies, consumer organisations, and international organisations. Strategies that lean too heavily on professional education are unlikely to result in large-scale or long-lasting improvement.

Families' Medical Self-Care Management in a Primary Health Care Area in Sweden

Medical self-care (MSC) is the range of activities undertaken to promote or restore health when dealing with a medical problem (MP). The aim of the study was to map out families' MPs and how these were managed in terms of reactive and restorative MSC. In a primary health care area in Sweden, 93 consecutive families were interviewed by telephone eight times during a four-month period. The instruments used were structured questions and illness diaries about MPs, which were analysed using descriptive statistics. In total, 621 MPs were reported and the most common complaints were ear-nose-throat problems. The mean number of MPs and mean duration of days for children were 1.9 and 13, for mothers 1.7 and 15, and for fathers 0.9 and 7.0, respectively. In five percent of all MP cases the families tried to manage their MPs by reading medical books and pharmacy brochures. In one-fifth of the MPs the families tried non-medical treatments comprising both external and internal application. The hospital's department of...

Approaching the locked dialogues of the body: Communicating symptoms through illness diaries

Objective - To describe and analyse communication following the use of an illness diary method in consultations with patients suffering from longstanding illness without clinical findings. Design - Action research in own practice with qualitative formative evaluation of material provided by the use of the diary method. Analysis followed a procedure modified from phenomenologically-based methodology. Setting - The practice of the main author. Subjects - 36 consultations with 16 patients where the illness diary method was applied. Result - Communication following illness diary utilisation could be summarised as: 1) illness diaries as medical documentation, 2) making access to the insight of the patient, 3) exploring internal dialogues and locked voices, and 4) adding meaning to a spoken message through writing (creative distance). By changing the frames of conversation through illness diary utilisation towards one or more of these four levels of communication, the patient may become a more equal consultation partner. Conclusion - Illness diaries can provide clinically relevant information and may emphasise the patient's input and significance in medical dialogues on longstanding symptoms without clinical findings.

Targeting symptoms for self-care health education: a multivariate analysis of physician contacts.

The purpose of this study was to identify common acute symptoms that were significantly related to the decision to seek medical care. Data were from the Seattle Virus Watch, a 4-year study of 149 young families designed to monitor viral infection, regardless of medical care contact. Illness diaries were maintained by the families and checked for accuracy every 2 weeks during home visits by study personnel. Age sex, family unit, medical contact, duration and presence or absence of 80 symptoms in 17 categories were recorded for each illness. In 11,583 person-months of observation, 3,929 illness records were compiled. Using physician contact as the dependent variable and the illness information as independent variables, a series of discriminant analyses were performed on a 50% random sample of illnesses. Success of each analysis was tested on the remainder of the illnesses. Fever and ear symptoms were significant predictors in all age groups and cough was significant in four of five age groups. These symptoms are suggested as logical choices for health education programs in self-care of acute illnesses.