Scientific evidence suggests that low-carbohydrate high-fat (LCHF) diets may be effective for managing non-communicable diseases (NCDs). Eat Better South Africa (EBSA) is an organization that runs LCHF nutrition education programs for women from low-income communities. Three focus group discussions (FGDs) were held with 18 women who had taken part in an EBSA program between 2015 and 2017, to explore their perceptions and to identify the facilitators and barriers they faced in implementing and sustaining dietary changes. Thematic analysis of the focus groups was conducted using NVivo 12 software. Women reported that they decided to enroll in the program because they suffered from NCDs. Most women said that the EBSA diet made them feel less hungry, more energetic and they felt that their health had improved. Most women spoke of socioeconomic challenges which made it difficult for them to follow EBSA’s recommendations, such as employment status, safety issues in the community, and lack of support from relatives and doctors. Hence, women felt they needed more support from EBSA after the program. The social determinants that affected these women’s ability to change their health behavior are also NCD risk factors, and these should be assessed to improve the program for other communities. Diet-related non-communicable diseases (NCDs) pose a huge burden in terms of financial cost, morbidity, and mortality ,2,3. In There is a general perception that the foods included in an LCHF diet are expensive and that most of the people who decide to follow this lifestyle in South Africa are reasonably affluent . This isThere are several nutrition education programs that operate in low socioeconomic settings in South Africa in an attempt to reduce the burden of NCDs ,35,36. EAs far as we are aware, no study has investigated the perceptions and experiences of participants taking part in an LCHF dietary intervention in South African communities where socioeconomic challenges such as poverty, unemployment and crime are prevalent. With an absence of evidence-based information, organizations that provide LCHF education in these communities, lack proper insight to evaluate and improve future programs. The current qualitative study therefore examines the perceptions and experiences of women who had taken part in an EBSA program, and by inference, had attempted to follow an LCHF diet. The purpose was to understand whether an LCHF diet was accessible and affordable to members of these communities, and to identify ways to improve the acceptance, compliance, and sustainability of future EBSA programs. This was a cross sectional qualitative study that used focus group discussions in women who had previously taken part in an EBSA intervention. Ethical approval (HREC REF 391/2018) was granted by the Faculty of Health Science Human Research Ethics Committee of the University of Cape Town and written informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki.This study included women from Ocean View who had taken part in an EBSA intervention in June 2015 (O15) and women from Atlantis who had taken part in an EBSA intervention in June 2016 (A16) or June 2017 (A17). Both communities are in the Western Cape Province of South Africa and originated during the Group Areas Act under the Apartheid government . Ocean VThe coach and ambassador from previous EBSA programs helped to recruit eligible participants for this study, using either the EBSA WhatsApp group, by telephone or at one of EBSA’s follow up meetings. Purposive criterion sampling  was usedFocus group discussions (FGDs) were conducted between September and October of 2018. The FGDs included 5 to 7 women and lasted, on average, 1 h and 50 min. In accordance with recommendations in the literature, our relatively homogeneous sample was large enough to identify 90% of the common themes ,42. The The focus groups discussions were audio recorded, translated, and transcribed from the original language (mostly Afrikaans) into English. Using NVivo 12, thematic analysis ,44,45 wa2. A total of 18 women completed the study by taking part in one of three FGDs. All participants reported that they had mixed-race ancestry. Mean age was 51.7 ± 11.9 years and mean body mass index (BMI) was 30.1 ± 6.7 kg/mSix themes were developed from the analysis: (i) motivations to enroll in the EBSA program; (ii) perceptions of the EBSA program structure; (iii) experiences with the recommended diet; (iv) EBSA’s influences on participants’ lives; (v) challenges during and after the EBSA program; and (vi) suggestions to improve the EBA program. Improving health was the major driver to participate in the EBSA program. Most of the women said they had pre-existing metabolic conditions, and many mentioned that they wanted to lose weight. Women acknowledged concerns around their health problems and anxiety that their unhealthy eating habits would lead to their premature death. Overall, the participants voiced a great desire to change their lives and become healthier.“I was very fat and a diabetic. I had high blood pressure and cholesterol. (A16)” “I cannot die before the time by not eating right. (O15)” “I decided that I am also going to join because I want to make a change in my life. (A17)”This was further emphasized by the participants´ references to family health history as their reason to take part in the program, as some had relatives who were dying or had died from metabolic conditions.“We have a family history of diabetes. I was told that I needed monitoring. (…) I decided to start Banting (A17).”Participants from A17 mentioned that they were encouraged by other women from the community who had participated in EBSA programs the year before. Participants from O15 and A16 said that they joined EBSA because it was offered to their wellness group for free. Some women said that they were influenced by groups on social media that promoted an LCHF lifestyle. Participants were particularly motivated by people’s pictures from before and after going on the “Banting” diet. “One of my friends joined (the EBSA program), she experienced an improvement in her health and weight, and that is the reason why I joined. (A17)”Women said that being part of a cohesive group of women was one aspect that they valued most from the program. In fact, it was mentioned that motivation dropped if the others were not attending the education sessions. In terms of EBSA’s team support, women from the A17 program reported being very happy with their coach and her continued support through the WhatsApp group, suggesting she was key to their experience.“Just to know that there are other people with you [in the EBSA program]. If you are on your own you could easy quit, but if you are with other people you feel more motivated. (O15)” “One thing that put me off was the [lack of] attendance of the people. (A17)”“The coach is very hands on with the WhatsApp group. Therefore, if we have any questions, we can go to the WhatsApp group and ask her directly. (A17)” Generally, participants spoke favorably of the educators. However, participants from A17 complained that the educator did not speak Afrikaans, and they found this was not inclusive enough for the mostly Afrikaans speaking community. The delivery of the educational sessions was perceived as very informative and helpful by some women; however, there was one complaint about some of the education material being too academic. In addition, some women felt uncomfortable about the lack of privacy when undergoing body measurements and the competitive nature of the weigh-ins which were intended to motivate weight loss during the program.“The educator could not speak Afrikaans fluently. (…) Many of the people in my area have had a huge problem with English. (A17)”“I found it [the EBSA program] to be very informative and I learned things that I never knew about sugar.” (A17)“They (the EBSA sessions) are academically long with many graphics. (A17)”“I do not like being in a group where we have to compete and the one looks to see how the other one looks. (A17)” Different views were expressed about whether the total number and frequency of the sessions was appropriate: some women mentioned that they were happy with the six sessions; some would have liked more sessions, while others would have preferred a larger gap between the sessions as they found the six sessions in a row were too much of a commitment“We had the six meetings, which means it was six Saturdays consecutively and I feel that there should have been a gap. (A17)”According to almost all of the women, the meal plans provided during the programs, were easy to follow and very helpful. One woman mentioned that this diet reminded her about how her ancestors used to eat. In general, women said that the diet made them feel more energetic, satiated for longer and that they could eat without feeling guilty. “What makes more sense for me regarding the program is how our ancestors ate and how my grandmother prepared food. (…). Everything was full cream. There weren’t low fat products and skimmed milk. (A16)”“I felt energetic and I did not feel sleepy. My thoughts were sharper. I was more alive. (A16)” “It [the LCHF diet] keeps you full for longer. (O15)” “You can now eat without feeling guilty. (A16)” Foods that many participants reported eating included eggs, cream, coconut oil, non-starchy vegetables, and chicken. Eggs in particular were highly regarded by most participants as an important and versatile food. Participants expressed an appreciation that eating certain fats like butter and animal fat was permitted more freely with the EBSA diet and said that this improved the taste of their food. Adding coconut oil or butter to coffee (Bulletproof coffee) as a meal substitute was reported quite often.“I think eggs are the most versatile out the whole diet. (O15)”“It is so nice to buy a piece of fat and put it over the vegetables. (A17)”“About a teaspoon of coconut oil, a dash of cream, a dash of milk. (…) That is the bulletproof coffee. (O15)”Participants were specifically asked about foods that EBSA had recommended that they disliked. Most participants were not dissatisfied with any of the foods except the taste of a coconut and seed-based flour product which was promoted as a substitute for grain-based flour. “The porridge [low-carbohydrate version] I do not really like, it does not have a great taste [laughing], it puts you completely off, huh. (A17”)Participants admitted that it was quite difficult to give up certain foods that were excluded from the EBSA diet, particularly processed foods such as chips, chocolate, and sugar sweetened beverages. “I love chocolate… [laughing] Yes, that was actually difficult for me to get rid of. (O15)”Many participants said that they could afford to follow the EBSA diet during the program and that it was not too expensive for them. There were some participants that said that they struggled to afford the recommended foods after the program, particularly those that were unemployed or were retrenched. Another unexpected factor that some women experienced around food was that certain food items that would ordinarily be available in local shops, were difficult to get hold of. Some participants felt that these items would sell out quickly due to the increased demand by EBSA participants, who were following the same meal plans. In terms of grain substitutes, women stated that the coach played an intermediary role by supplying ‘Banting’ products promoted by EBSA, which were not usually available in their communities.“It wasn’t a problem [the diet]. I could make anything, and I did not spend a lot of money because it was natural stuff. Vegetables, eggs and chicken. (O15)”“I wanted to carry on [Banting], but then I was retrenched. There was no money to carry on. (O15)” “Sometimes the shop does not have butter or double cream yogurt because everybody wants to be on Banting. (A16)”“The coach provides Banting food [products labelled as……“Banting”], people can order from her. (A17)”Overall, it appears as though the EBSA program had a positive impact on participants’ lives as they said it provided many health benefits. Some participants stated that they became more active and started to exercise as a direct result of the program. Women reported that they felt healthier and they were no longer using some medication (e.g. antihypertensives).“The more I go, the more educated I am going to become and the more [weight] I am going to lose. (O15)”“When I started with the program I didn’t really like to exercise. When the Banting program started, SC motivated me to walk the first 10km. From then on, I do every walk that there is. (O15)”“I no longer needed my high blood pressure pills. (A17)”According to some of them, one factor which made the biggest impact was the nutritional knowledge they gained from the program. Understanding the harmful consequences of sugar and refined carbohydrate consumption was something they said they will never forget. In addition, women mentioned that there were other people who would benefit from having this knowledge and were encouraging them to join new programs or to try the diet.“When you go shopping, you will always be checking the ingredients (…). Subconsciously you know what you are allowed to and what you are not. You would always have that in the back of your mind (…). So, there is always that filter. (O15)” “When you look at people that is terribly overweight, or people eat things that they are not supposed to, then you intervene immediately. (A17)”When asked about some of the challenges they faced with regard to participating in the EBSA program, the most notable one was the lack of support from people they interacted with. Many participants complained that they were not supported by the medical practitioners they saw, because they did not agree with the EBSA recommended diet. Additionally, participants felt a lack of support from friends, relatives, and work colleagues during the early stages of the program. However, some participants reported that they received more support from their doctors and peers when they saw their health improvements. “When I went to see my physician (…) I told her I am Banting. She said I must not do this because it is a lot of fat and I must stop it immediately. When I went to her again after three months, I sat there all quiet and I did not say to her I am still on Banting. However, she said to me whatever you are doing just go ahead. (A17)” “I absolutely got no support. Not from my husband, not my mother, from nobody in the beginning. (…) When they saw what the program did to me and how I was (…) they began to support me. (A17)”A major challenge experienced by participants from O15 was the gang violence in the area. Women mentioned that lack of safety prevented them from being more active and made them feel stressed and anxious. Some women who lost a lot of weight during the program complained of an unexpected expense because they had to buy new clothes. “I think that the disadvantages were my clothes, it did take a lot of money. My clothes immediately were bigger. (A17)”Poor weather conditions appeared to be a challenge for some women to engage in activities and be motivated.“It was winter [during the EBSA program] and it rained. Believe me the weather does play a role. (A16)”When asked about ways in which the EBSA program could be improved or optimized, women made many suggestions. A major one was that the follow up sessions required a more structured schedule because attending these was seen as an important facilitator to adhering to the recommended diet. Also, participants mentioned that they did not know what to do once they reached their weight goals, so they proposed that EBSA should monitor them and provide weight maintenance plans. Some women even suggested that EBSA should run more than one program within the same year in the same community. “For instance, there are no fixed dates; (for the follow up sessions); (…) However, if we could come together and put fixed dates, then we know I need to make time to attend because support is very important. (A17)”“We want to maintain (weight). (…) They need to provide a session on maintenance. (A17)”“It the (EBSA program) should be twice a year [laughing]. (…) With a gap in between. (…) And during that big gap you start the monitoring. (A16)”Women felt that EBSA’s message would be better spread to the wider community if EBSA would make use of the local newspaper or radio station. Moreover, they mentioned that providing before and after pictures of participants who took part in the program would be a good motivator for women interested in the EBSA program. Participants also suggested that EBSA should run similar educational programs within the school environments or hospitals as they felt they would benefit from the nutritional knowledge.“We have a radio station, (…) we can get somebody to talk about healthy eating. (A17)” “The children are young, and they are supposed to learn the right way of eating. This could have a ripple effect and all these chronic diseases. (…) If we can do some awareness about it especially among children, it will also help. (A17)”“You will see all the people sitting there at the day hospital. They, young and old, are diabetics, they are obese and have high blood pressure. I have been taught the do’s and don’ts in terms of eating. (…) However, this is something new and this needs to be introduced to the broader community. (A17)”This study explored the experiences of a sample of women who had participated in an EBSA education program that promoted an LCHF diet as a sustainable lifestyle to prevent and treat metabolic health conditions. These participants were from two under-resourced South African communities where residents have limited access to education, employment, and health care . AlcoholA major finding was that the EBSA program and its recommended diet was well understood and well received by these participants. It is important to note however that the recruitment of participants in this study would likely have favored those that had an overall positive experience with the EBSA program. Any participants who were very dissatisfied with EBSA or an LCHF diet would probably have been more difficult to reach and less likely to enroll in the study. It is also unclear whether participants were actually following an LCHF diet or whether their body composition and health had in fact improved. Nevertheless, the very positive attitude of these participants toward an LCHF diet is encouraging. An interesting finding was that participants favorably related an LCHF diet to the way that their ancestors ate. This was also reported in a study with Māori participants , suggestFamily support is believed to be of aid in adherence to a range of dietary and health interventions ,56,57,58A qualitative study conducted in New Zealand reported that financial constraints prevented participants from adhering to an LCHF diet for an extended period of time . While tThe major finding from this study was that the EBSA program and its recommended LCHF diet was generally well understood and well received by these participants. Additionally, participants believed that their dietary changes had led to health improvements. This study highlighted some aspects of the program that participants felt were important to its success, for example the cohesive support group, as well as some challenges that need to be addressed, such as more structured follow up support. Information from this study, together with a site-specific community assessment was used to improve the design and delivery of a subsequent EBSA program. This program will be evaluated longitudinally using both qualitative and quantitative assessments to address some of the limitations of the current study.


There are currently five antigenically distinct HA proteins expressed by co-circulating influenza B viruses: B/YAM, B/VIC V1A (no deletion), B/VIC V1A-2DEL (2 aa deletion) and two antigenically distinguishable groups of B/VIC V1A-3DEL (3 aa deletion). The prevalence of these viruses differs across geographical regions, making it critical to have a sensitive, rapid diagnostic assay that detects and distinguishes these influenza B variant viruses during surveillance.During the 2016/17 influenza season, influenza B/VIC lineage variant viruses emerged with two  assay for detection and discrimination of influenza B/VIC lineage variant viruses.We designed a diagnostic assay with one pair of conserved primers and three probes specific to each genetic group. We used propagated influenza B/VIC variant viruses and clinical specimens to assess assay performance.This rRT-PCR assay detects and distinguishes the influenza B/VIC V1A, B/VIC V1A-2DEL, and B/VIC V1A-3DEL variant viruses, with no cross-reactivity. This assay can be run as a multiplex reaction, allowing for increased testing efficiency and reduced cost.Coupling this assay with the Centers for Disease Control and Prevention’s Human Influenza Virus Real-Time RT-PCR Diagnostic Panel Influenza B Lineage Genotyping Kit results in rapid detection and characterisation of circulating influenza B viruses. Detailed surveillance information on these distinct influenza B variant viruses will provide insight into their prevalence and geographical distribution and could aid in vaccine recommendations. Two B/VIC lineage variants with a deletion of 3 aa (V1A-3DEL) at aa positions 162–164  emerged shortly after via parallel evolution. The V1A-3DEL viruses have since been detected in Asia, Africa, Europe and America [Influenza B viruses co-circulate with influenza A strains during the annual influenza season, contributing to overall mortality and morbidity of influenza epidemics. In the 1980s, influenza B viruses evolved into two genetically and antigenically distinct lineages represented by B/Victoria/2/1987 (VIC) and B/Yamagata/16/1988 (YAM) that co-circulate in human hosts during influenza seasons worldwide . During The most effective method for prevention and control of influenza infection is vaccination ,4,9. LicHere we describe a real-time RT-PCR (rRT-PCR)-based assay for detection and discrimination of influenza B/VIC lineage deletion variants (Vic deletion assay). This assay is currently the only available method, to our knowledge, that can distinguish these B/VIC genetic groups, outside of a pyrosequencing technique and a conventional RT-PCR method, both recently published ,12. 50/mL) or 50% egg-infectious dose (EID50 /mL), respectively [Influenza viruses tested in this study were grown to high titre in either Madin–Darby canine kidney (MDCK) cells or embryonated chicken eggs (ECE) . Infectiectively . InfluenInfluenza B virus lineages were confirmed using antigenic characterisation by HI assay on MDCK-propagated virus isolates and genetic sequence analysis. The antigenic characteristics of virus isolates were determined by HI tests using post-infection ferret sera raised against representative human influenza B viruses. The HI test was performed as described previously .Viral RNA was extracted from 100 µL of supernatant or allantoic fluid and eluted into 100 µL of RNA elution buffer using a MagNA Pure Compact RNA isolation kit on a MagNA Pure Compact instrument (Roche Applied Science) .Oligonucleotide primers and probes for the Vic deletion assay were designed based on available nucleotide sequence data from the GenBank database of the National Center for Biotechnology Information (NCBI) and the Global Initiative on Sharing All Influenza Data (GISAID).plus dual-labelled hydrolysis probes (BHQplus) that were labelled at the 5'-end with the reporter molecule 6-carboxyfluorescein (FAM) or Hex and CAL Fluor Red 610 and with BHQ1 (FAM or Hex) or BHQ2 (CAL Fluor Red 610) at the 3’-end. The Vic 3_Del probe was labelled at the 5'-end with the reporter molecule 6-carboxyfluorescein (FAM) and BHQ1 at the 3’-end, and included a triplet of locked nucleic acids (LNA) [The Vic deletion assay includes a single set of conserved amplification primers and three deletion-specific dual-labelled hydrolysis probes, including VIC 2_Del, Vic 3_Del and Vic No_Del probes. The three probes, targeted to the deletion region of the HA gene of influenza B viruses, were designed to specifically detect and differentiate V1A-2DEL, V1A-3DEL and the V1A genetic group (no-deletion) viruses (B/VIC No_Del), respectively . The Vicds (LNA) ,18 that We further evaluated primer and probe sequence specificity by sequence analysis of 51,759 gene segments available in the NCBI or GISAID databases. Primers were designed to have annealing temperatures of ca 60 °C and probes were designed to have annealing temperatures of ca 68 °C using PrimerExpress 3.0 software . Primers were synthesised by the Biotechnology Core Facility at the CDC.Taq activation at 95 °C for 2 min and 45 cycles of 95 °C for 15 s and 55 °C for 30 s. All analytical performance data were collected on an ABI 7500 Fast Dx Real-time PCR instrument. Increases in fluorescent signal were registered during the annealing step of the reaction. All data were analysed with the sequence detector software (SDS) v1.4.1 (Life Technologies).Reaction conditions for rRT-PCR were based upon the US Food and Drug Administration (FDA)-approved CDC Human Influenza Virus Real-Time RT-PCR Diagnostic Panel (Flu rRT-PCR Dx Panel) ,19,20. PIn order to demonstrate rRT-PCR performance of the VIC deletion assay, five B/VIC lineage viruses and two B/YAM lineage viruses from recent circulating genetic groups, including the WHO-recommended influenza B vaccine viruses B/Colorado/6/2017 (V1A-2DEL), B/Brisbane/60/2008 (V1A) and B/Phuket/3073/2013 (B/Yam) were selected for assay evaluation . AnalytiThe analytical sensitivity and specificity of the Vic deletion assay were evaluated by comparison with the performance of the universal influenza B assay (InfB) from the CDC Flu rRT-PCR Dx Panel. The InfB assay is designed for detection of the nonstructural (NS) gene in all influenza B viruses by targeting highly conserved regions of the NS gene. A quantified synthetic RNA material  containing sequences from the NS gene region derived from B/Colorado/06/2017 (EPI 969380) was tested in triplicate to determine the minimum RNA copy number detectable by the InfB assay.We further assessed the analytical specificity using these five B/VIC lineage deletion viruses and two B/YAM lineage viruses, 24 seasonal influenza A and two avian influenza A viruses.To demonstrate the performance of the Vic deletion assay against clinical specimens, we tested 167 clinical specimens, including 67 B/VIC-positive and 30 B/YAM-positive to demonstrate the assay’s clinical sensitivity, as well as 30 seasonal influenza A-positive samples and 30 influenza-negative samples as determined by the CDC rRT-PCR Flu Panel to demonstrate the assay’s clinical specificity.The specimens evaluated were collected in the course of public health surveillance and human subjects’ approval was not required for this project.Influenza B viruses from the V1A, V1A-2DEL, V1A-3DEL and Yam lineages were antigenically characterised in HI tests using post-infection ferret sera raised against representative human influenza B viruses. The HI assays demonstrated that both the V1A-2DEL and the V1A-3DEL variant influenza B viruses were antigenically distinct from each other and from the no-deletion B/VIC virus (V1A), as the viruses from each of the genetic groups were not well inhibited by antiserum raised against the other genetic groups (reductions in HI titres of 4–32-fold compared with the homologous HI titres) .The Vic deletion assay was developed using the ABI 7500 Fast Dx Real-time PCR system for the qualitative detection and characterisation of B/VIC virus RNA in respiratory specimens from patients presenting with influenza-like illness (ILI).We designed three influenza B/VIC genetic group-specific probes to target the deletion region of aa position 162–164 (corresponding to nt position 529–537) of the HA gene in influenza B viruses . The seqAnalytical performance studies, evaluated by testing 10-fold serial dilutions of RNA extracted from recently circulating influenza B viruses, demonstrated that the sensitivity of the VIC 2_Del, VIC 3_Del and VIC No_Del assays was comparable to the InfB assay of the CDC Flu rRT-PCR Dx Panel.Supplementary Table S2. Three quantified B/VIC viruses B/Maryland/15/2016 (V1A-2DEL), B/Hong Kong/269/2017 (V1A-3DEL) and B/Florida/103/2016 (V1A) were used to determine the limit of detection of the Vic 2_Del, Vic 3_Del and Vic No_Del assays, respectively. The results demonstrated that the sensitivity of Vic 2_Del and Vic No_Del assays were comparable to InfB assay, with < 3 cycle thresholds (Ct) difference between the InfB assay and the positive target of the Vic deletion assay. The Vic 3_Del assay was slightly less sensitive than the InfB assay, as the Ct value of Vic 3_Del probe was 3 Ct above the InfB target in two dilutions of B/Hong Kong/269/2017 . This correlates to 10−2.5~ −0.8 ID50 per reaction (5.0 µL/reaction). To understand how many copies of RNA per reaction the deletion assay will detect, we first used Armored RNA Quant CDC-9-containing sequences from the NS gene region derived from B/Colorado/06/2017 to evaluate the InfB assay. We then matched rRT-PCR results of the serial dilution of virus titres to RNA copies based on comparable Ct values in the InfB assay. Given this comparison, we estimate that the Vic 2_Del and Vic No_Del probes will detect five RNA copies per reaction and the Vic 3_Del probe will detect ca 50 RNA copies per reaction. Therefore, the sensitivity of the Vic deletion assay was ca 5–50 RNA copies per reaction (Supplementary Table S2).The limits of detection of Vic 2_Del, Vic 3_Del and Vic No_Del assays were 10reaction . Two addSupplementary Table S2).We also developed a triplex rRT-PCR assay with one pair of conserved primers with FAM-labelled Vic 3_Del probe, Hex-labelled Vic 2_Del probe and CAL Fluor Red 610-labelled Vic No_Del probe. This triplex rRT-PCR Vic deletion assay showed the same level of sensitivity and specificity as the singleplex assays in detecting and discriminating the B/VIC deletion variant viruses .In order to demonstrate the absence of cross-reactivity with influenza A viruses subtypes, we performed exclusivity testing by examining 12 isolates each of contemporary seasonal influenza A(H3N2) and A(H1N1)pdm09 viruses as well as the benchmark highly pathogenic avian influenza (HPAI) A(H5N1) strain, A/Vietnam/1203/2004, and Asian lineage avian influenza A(H7N9) virus, A/Anhui/01/2013. All influenza A viruses were negative in all three assays  and, the rRT-PCR results were confirmed by sequencing . All 30 The Vic deletion assay presented here is intended for the qualitative detection of the influenza B/VIC lineage HA gene deletion variant viruses using rRT-PCR technology. The analytical and clinical performance of the Vic deletion assay in either the singleplex or triplex configuration demonstrates that the assay is highly efficient, sensitive and comparable to the gold standard CDC rRT-PCR Flu Panel InfB assay . We haveThe key genetic distinction between V1A, V1A-2DEL, and V1A-3DEL viruses is within the same nucleic acid region, presenting a challenge for rRT-PCR probe design. We used two chemical modifications in probe design, LNA and BHQplus chemistry, which allowed for greater stability and specificity. Including LNA in real-time PCR probes improves detection of mismatches significantly ,17. The Sequence alignments using HA gene sequences from 2010 to 2019 demonstrated the conserved primers to be stable with no conserved genetic changes observed (data not shown). Although the areas chosen for the conserved amplification primers and the deletion type-specific probes are currently stable, genetic changes following rapid virus evolution and the variable nature of RNA viruses may require periodic updates of the Vic deletion assay primer and probe sequences.The number and percentage of circulating V1A-2DEL and V1A-3DEL viruses has increased significantly since initial identification , making Given its sensitivity and specificity, the rapidity of results, the fact that the Vic deletion assay can be run on equipment that is readily available in most diagnostic laboratories and the fact that the assay can be multiplexed for testing efficiency and cost-savings, this is a suitable assay for influenza surveillance. Combining the CDC Vic deletion assay with the CDC Flu rRT-PCR Dx Panel Influenza B Lineage Genotyping Kit will allow for rapid identification of the distinct influenza B viral genetic groups B/YAM, B/VIC V1A, V1A-2DEL and V1A-3DEL . This wi


Opportunities to provide clinical immersion experiences to bioengineering undergraduate students have expanded over the last several years. These programs allow students to observe the clinical environment in order to better understand workflow processes, the context in which medical equipment is used, and identify unmet needs firsthand. While each program focuses on identifying unmet needs, these experiences vary in content and implementation. Here we discuss features of clinical immersion programs, share details of our program after six years, and present data regarding post-graduation employment of our participants. Students who participated in the University of Illinois at Chicago Clinical Immersion Program are not more likely to pursue careers in industry as compared to non-participants, nor do they demonstrate an ability to find a job more quickly than non-participants. However, participants who did enter into industry self-reported that the program was impactful to both their career interests and ability to find their first employment position. The Engineer of 2020: Visions of Engineering in the New CenturyEducating the Engineer of 2020: Adapting Engineering Education to the New Century.37Much effort has been focused on ensuring that engineering education reflects contemporary technology development and innovation. In the early 1990s, K-12 education shifted to emphasize the philosophy of “learning by doing”, giving rise to the pedagogical approach of contextual learning.For bioengineering students, contextual learning can be used to teach the design of medical devices, which requires an understanding of the device, performance requirements, and use in its native environment. Historically, there has been limited, if any, exposure to the clinical environment in the undergraduate bioengineering curricula, and the design of devices and medical equipment has primarily focused on technical functionality. Yet the ability for bioengineers to observe how users in the clinical or hospital environment interact with medical devices enables the informed design of these devices. When bioengineering students work in collaboration with end users and other stakeholders , they’re empowered to identify unmet needs and opportunities for innovation. Thus, clinical immersion programs help develop students’ ability to communicate across discipline boundaries and understand why designs must meet multiple realistic constraints.21Do It By Design stresses the value of obtaining first-hand feedback from physicians, nurses and lay-users in the earliest stages of product conception and design.3Human Factors Engineering – Design of Medical Devices, issued in 2009, focuses on the incorporation of user considerations, including user feedback for iterative design refinements, environmental considerations, anthropometry, and user needs. Literature has also shown that primary ethnographic research, including both observations of and interviews with users in their natural environment, is critical to the successful design of medical devices.In fact, the FDA has increasingly emphasized the importance of identifying user needs and understanding user-device interaction to avoid safety issues, product recalls, and patient harm.To improve undergraduate bioengineering students’ ability to identify and validate true clinical needs and develop solutions according to a user-centered design process, clinical immersion programs have been offered over the last ten years at institutions across the country. Table 39Broad guidance from Biodesign and federal funding has helped expand the number of clinical immersion programs offered to bioengineering students. While a needs-based approach is common, content and implementation varies.In this report, we evaluate the impact of the Clinical Immersion Program at the University of Illinois at Chicago on participant career intentions and post-graduate outcomes. We tested the hypothesis that participation in a clinical immersion program would affect post-graduation outcomes compared to non-participants. To the best of our knowledge, this is the first publication to report on post-graduation outcomes of students who participated in a clinical immersion program.The University of Illinois at Chicago (UIC) is a large, public, Research I institution situated in the urban center of the city and is recognized as being among the top 5% most ethnically diverse colleges and universities in the country.The Clinical Immersion Program (CIP) at UIC was designed to enhance bioengineering student preparedness for industry positions through exposure to clinical-based needs identification as a method to enhance the design of medical devices. This program provides direct exposure to the clinical environment and methodical approaches to observe, interview, identify, and prioritize user needs for effective and efficient engineering design. Over the course of the program, a wide variety of clinical departments have participated in CIP, as listed in Table CIP was first offered in 2014 as a 6-week, summer-based internship taught by faculty from bioengineering and design. Nine rising senior bioengineering students were selected from a pool of applicants and placed in two, 3-week long clinical rotations. Each week began with a half day of guided instruction in a workshop setting focused on user-centered design, ethnographic research, and opportunities for teams to analyze and synthesize their clinical observations. Students spent the remainder of the week (Tuesday through Friday) in their clinical rotations (at least 30 h/week) under the direction of a physician mentor. Program emphasis was placed on generating meaningful needs statements based on the team observations. Ultimately, teams generated two needs statements, one per clinical rotation. Recognizing the “deep dive” engineering students take into the clinical environments, participants were asked to keep a blog to encourage reflection on their experiences.18In 2015, the program was expanded to 12 undergraduate bioengineering students as well as additional clinical departments.35In 2017, the program was modified to allow interdisciplinary teams to spend the full 6-week duration of the program in a single clinical department.This research was approved by an Institutional Review Board at the University of Illinois at Chicago. To assess the effect of CIP on student outcomes, two mixed methods surveys were administered. The first survey (graduation survey) was administered to graduating undergraduate students each spring semester from 2015 to 2018, corresponding to CIP participants from 2014 to 2017. This survey was designed to provide information on students’ experience at UIC and to identify post-graduate career intent. GPA was obtained from college records for comparative analysis. The second survey (follow-up survey) was administered in the spring of 2019 to all undergraduates graduates from 2015 to 2018. This survey was designed to identify student outcomes and related quantifiable metrics. Both surveys were administered using Qualtrics.t test. Differences in the proportion of students who had advanced placement (AP) college credits or participated in undergraduate research or internship was determined by Fisher’s exact test.Differences in graduating GPA were determined by unpaired From the graduation survey, the effect of CIP on students’ post-graduation intent  was determined by Fisher’s exact test. The administered survey originally included four options for post-graduation intent . However, the CIP participant cohort was limited in number and stratification into additional groups was precluded. Therefore, post-graduate intent was binarized.t test. Differences in the proportion of students whose industry jobs related to engineering was determined by Fisher’s exact test. CIP participants who entered industry were also asked if the program was part of their interview (yes or no), how CIP had impacted their ability to find said position , and how CIP impacted their career interests . Both 5-point Likert scales extended from strongly negative to strongly positive. Statistical analyses were performed using SPSS  and significance was accepted at p ≤ 0.05.From the follow-up survey, the effect of CIP on graduates’ placement , was determined by Fisher’s exact test. Similar to the graduation survey, these outcomes were binarized from four original options. For the graduates who entered industry, the effect of CIP on time required to finding employment was determined by unpaired Between 2015 and 2018, 214 undergraduate students graduated from the Richard and Loan Hill Department of Bioengineering from UIC. Of these graduates, 178 (83.1%) completed the graduation survey and 76 (35.5%) completed the follow-up. Between these two surveys, 67 (31.3%) respondents qualified for paired analysis, including 18 who had participated in CIP between 2014 and 2017.p = 0.011). However, CIP participants were not more likely to have AP credits or to have an undergraduate research or internship experience prior to graduating (p ≥ 0.116).Comparisons between respondents stratified by survey type and participation in CIP are presented in Table p ≥ 0.1865). Here, ‘other’ career paths include graduate and professional school. From the follow-up survey, two respondents (from non-CIP) did not select between “industry” or “graduate or professional school” as an outcome, and an additional two selected both. The two graduates who selected both industry and schooling were categorized as having gone to industry since that preceded further schooling.At the time of graduation, 72% of CIP participants intended to enter industry, compared to 67% of non-participants. Immediately after graduation, 72% of the CIP participants entered into industry , as opposed to 57% of the non-participants. However, CIP participants were not more likely to either intend on or actually enter into industry than non-participants (p = 0.411). Nor were CIP participants more likely to find a position related to engineering than non-participants (p = 0.2348). However, a majority of the CIP participants in industry (9/13) indicated that the program was part of their job interview. Moreover, all CIP participants indicated that the program had between a positive and strongly positive impact on both getting their position after graduation (3.46 ± 0.78) and their career interests (3.61 ± 0.50).Of the respondents that entered industry immediately after graduation, there was no significant difference in the amount of time to finding that position between the two groups , HR clearance  as well as scheduling within specific clinics. Further, it is imperative to communicate clear expectations for participating clinical faculty, particularly since this experience differs greatly from a typical clinical shadowing experience. Careful attention must be given to select program applicants, considering professionalism, maturity and self-initiative. Finally, the development of a process that leverages the strengths of one’s institution is critical for a successful program. There is also advantage in ongoing refinement to ensure that the program continues to meet the needs of students.There were limitations to the current study. First, the limited number of survey respondents, particularly in the CIP participant cohort, makes statistical significance more difficult to demonstrate. Statistical significance in our measured outcome metrics may exist but could not be demonstrated in the current study. Second, the outcome data presented in this study represents the immediate post-graduate effects of CIP. Longer retrospective studies may elucidate other potential differences between cohorts. Third, student outcomes and career placement are the result of complicated and numerous influences. It can be potentially misleading to attribute outcomes to the influence of a single program. However, responses from CIP participants indicate a positive impact of the program regarding their career interests and placement. Fourth, the program has steadily changed since its inception, which can alter our ability to determine an effect of the program on student outcomes. However, the central theme of the Clinical Immersion Program has been and continues to be exposure to the clinical environment and stakeholders in order to better understand their needs. This continued focus provides a consistent experience for participants across all program years.The Clinical Immersion Program at the University of Illinois at Chicago was designed to enhance bioengineering student preparedness for industry positions by providing direct exposure to the clinical environment and teach methodical approaches to observe, interview, identify, and prioritize user needs for efficient and effective engineering design. Since the program’s inception, it has grown dynamically to accommodate extended exposure in a single clinical department, interdisciplinary teaming, and early concept development. Here we assessed the effects of CIP on student outcomes. To the best of our knowledge, this is the first report to evaluate the impact of a clinical immersion program on student career paths. There was no effect of CIP on the likelihood of students to intend on or enter into industry, as compared to graduate, medical or other professional training, but the participants who did enter into industry indicated the program was impactful to both their career interests and ability to find an industry position. Future work could involve robust evaluation of senior design projects to compare projects stemming from the Clinical Immersion Program and improved post-graduation surveys controlling for multiple variables with increased sample sizes. In addition, it would be beneficial to obtain employer feedback about our graduates to determine any difference between groups.


The Tailored Activity Program (TAP) is a proven program delivered primarily by occupational therapists addressing dementia-related clinical symptoms including caregiver well-being. Although used in 9 countries including the United States, scaling and widespread dissemination is challenging. We discuss key revisions to TAP to facilitate dissemination including matching assessments to those used in different practice settings, translation of materials into different languages, providing worksheets to help trainees adapt TAP to local contexts and a training/certification online experience using story board, an interactive media integrated onto the Blackboard learn management system, to provide on-demand training modules. The learning platform allows learners to engage with others, preview modules and share experiences. Revisions enable greater flexibility for program adaptation yet adherence to its core principles. With over 150 trainees, we use REAIM to evaluate effectiveness of modifications and to understand implications for its reach. Part of a symposium sponsored by the Behavioral Interventions for Older Adults Interest Group.


Vibrio cholerae were food preparation areas, near the patient’s bed and the latrine. Effectiveness varied between programs, with statistically significant reductions in V. cholerae concentrations 30 minutes after spraying in two programs. Surface contamination after 24 hours was variable between households and programs. Program challenges included difficulty locating households, transportation and funding limitations, and reaching households quickly after case presentation (disinfection occurred 2–6 days after reported cholera onset). Program advantages included the concurrent deployment of hygiene promotion activities. Further research is indicated on perception, recontamination, cost-effectiveness, viable but nonculturable V. cholerae, and epidemiological coverage. We recommend that, if spraying is implemented, spraying agents should: disinfect surfaces systematically until wet using 0.2/2.0% chlorine solution, including kitchen spaces, patients’ beds, and latrines; arrive at households quickly; and, concurrently deploy hygiene promotion activities.Household spraying is a commonly implemented, yet an under-researched, cholera response intervention where a response team sprays surfaces in cholera patients’ houses with chlorine. We conducted mixed-methods evaluations of three household spraying programs in the Democratic Republic of Congo and Haiti, including 18 key informant interviews, 14 household surveys and observations, and 418 surface samples collected before spraying, 30 minutes and 24 hours after spraying. The surfaces consistently most contaminated with  Cholera remains a global health concern, with an estimated 2.9 million cases and 95,000 deaths per year. Household spraying is an outbreak response activity where the houses of cholera patients are disinfected by spraying chlorine to interrupt cholera transmission within households. The effectiveness and appropriateness of this intervention have been questioned but it remains widely implemented. We conducted three mixed-methods evaluations of household spraying programs in the Democratic Republic of the Congo and in Haiti. By sampling surfaces before, 30 minutes and 24 hours after spraying, we were able to identify household surfaces that were consistently the most contaminated at baseline . We also found that spraying chlorine could inactivate bacteria on household surfaces but that effectiveness was inconsistent, likely due to differences in spraying protocols between programs such as the amount of chlorine applied onto surfaces. Through key informant interviews, structured observations and household surveys, we also gained insights into the advantages and challenges of each program. This work contributes to the scientific evidence base necessary to optimize cholera response strategies; the combination of microbiological and qualitative information allowed us to formulate concrete recommendations for outbreak response programs. Vibrio cholerae O1/O139 bacteria can cause profuse watery stool and vomiting and, if untreated, can result in severe dehydration and death within hours ). Across programs, spoons were used to dose chlorine and a wooden stick or spraying nozzle was used to mix solutions. No program had a written protocol available for chlorine solution preparation. In Program A, agents asked for “clean” water from a household member, measured the required volume using their graduated 12-L spraying equipment, and mixed the solution on site for immediate use. In Program B, agents prepared the HTH solution at the cholera treatment center (CTC) by estimating the required volume of tap water using a container of known capacity such as a 20-L bucket; the 0.2% solution was transported in the sprayer tank (5 L) and used within 24 hours, and the 2.0% solution was kept in a 2-L opaque jerrycan, transferred into the spraying equipment as needed, and kept for up to 5–7 days. In Program C, solutions were prepared at the NGO office with tap water measured in the graduated sprayer tank (5 L); solutions were stored and transported in the equipment for use within 24 hours.Measured chlorine concentration in Program A ranged from 0.10–0.29% and 1.03–2.30% for the targeted 0.2% and 2.0% solutions, respectively; 0.16–0.23% and 0.89–1.69% in Program B; and, 0.05–0.25% and 0.16–1.10% in Program C . Please Spraying agents in Program A sprayed surfaces in a systematic manner for disinfection, starting where the cholera case slept, proceeding through each room in the same direction, and spraying until surfaces were visibly wet. Spraying was completed in 5–10 minutes, using approximately 5–10 L of 0.2% chlorine solution per patient house; additional time was taken to spray five neighboring latrines using approximately 5 L of 2.0% solution in total.Spraying agents in programs B and C did not appear to target specific areas or follow a defined protocol for household spraying. In Program B, 2–5 minutes was spent at each patient’s house using an average of 4 L total of 0.2% chlorine solution to spray 21 houses (~0.2 L per house) and 0.5–2 L of 2.0% chlorine solution was used to spray the latrines (~0.02–0.1 L per latrine). In Program C, 2–5 L of 0.2% chlorine solution were sprayed in each patient’s house over approximately 5 minutes; the volume of 2.0% chlorine solution used was not recorded.Three concerns were raised during interviews: identification of target households, transportation, and rejection and security issues.During the six days the study team followed Program A spraying agents, three houses listed for disinfection could not be located. Three spraying agents from Program A (50%) stated they felt patients sometimes provide incorrect addresses due to fear of stigmatization. Additionally, the study team found household identification was particularly challenging in camp settings, due to population movements and high density. During the Program B evaluation, all houses were found by spraying teams, sometimes with the help of a patient’s relative. Three interviewees (43%) from Program B still reported locating houses was difficult and time-consuming, mentioning the lack of precise addresses as an issue. They suggested the use of cell phones as a means to contact their base for guidance on locating houses.Transportation, in particular, availability of motorcycles and fuel, was mentioned as a challenge in 5 (83%) and 3 (43%) interviews with spraying agents from Programs A and B, respectively. These concerns were linked to funding (or funding continuity) issues, explicitly mentioned by 4 interviewees (67%) in Program A and 2 interviewees (29%) in Program B.In Program C, logistics appeared to function smoothly for the 11 cholera response teams. Concerns raised by spraying agents during interviews included security in some neighborhoods and, in three instances (60%), refusal of household spraying. The latter was attributed to fear of stigmatization or lack of trust in response team motives.The number of household members ranged from 2–13, with a mean of 6, 8.5, and 5 in Programs A, B, and C, respectively . In ProgSurvey respondents estimated they were 1–3 and 0.2–1.5 hours away from the closest CTC in Programs A and B, respectively. In Program C, no respondent knew the closest CTC. No household deaths due to cholera were reported by study participants. Overall, 2–6 days had elapsed between reported cholera/diarrhea symptom onset and spraying team arrival. Having a clean house was the most common reason why survey respondents reported appreciating household spraying (71%), followed by feeling safe (21%). When asked about what they did not like, all respondents reported “everything was good” (Programs A and B) or they did not know (Program C). Please note that, due to programmatic response protocol, two of four patients in Program C were acute watery diarrhea cases and not suspected cholera cases.V. cholerae concentrations were consistently found around food preparation spaces/floors, latrine floors, and near the patients’ sleeping areas  households. Between 30 minutes and 24 hours after spraying, an increase in the number of surfaces contaminated with V. cholerae was seen in 10 out of 14 (71%) households  before spraying, compared to four and five surfaces 30 minutes and 24 hours after spraying, respectively. Statistically, there was decreased contamination 30 minutes (p<0.001) and 24 hours (p = 0.007) after spraying as compared to before spraying, and no statistical difference between 30 minutes and 24 hours (p = 0.064).In Program A, before spraying, 25 surfaces across 5 houses were positive for V. cholerae before spraying, compared to 25 surfaces (range 3–7) and 39 surfaces (range 5–9) 30 minutes and 24 hours after spraying, respectively (2) before spraying, compared to 10 and 13 surfaces 30 minutes and 24 hours after spraying, respectively. Statistically, there was decreased contamination 30 minutes after spraying (p = 0.014), but not 24 hours after spraying (p = 0.804), as compared to before spraying, and a statistical difference was seen in bacterial counts between 30 minutes and 24 hours (p = 0.008). Specifically, between 30 minutes and 24 hours after spraying, observed contamination levels increased on 25 surfaces, including water containers (3), latrine floors (2), latrine walls (2), and patient’s bed (2). A decrease in contamination levels was noted on 6 surfaces, including inside walls (2).In Program B, 40 surfaces  were positive for ectively . OverallV. cholerae before spraying, compared to 11 surfaces (range 2–5) and 33 surfaces (range 2–7) 30 minutes and 24 hours after spraying, respectively (2) before spraying, compared to 5 and 10 surfaces 30 minutes and 24 hours after spraying, respectively. Statistically, no difference in bacterial counts was seen between sampling points before, 30 minutes, and 24 hours after spraying (p = 0.062).In Program C, 22 surfaces  were positive for ectively . OverallE. coli concentrations before spraying were detected on kitchen and latrine floors, and near the patients’ sleeping areas  households. Between 30 minutes and 24 hours after spraying, an increase in the number of surfaces contaminated with E. coli was also seen in 10 out of 14 (71%) households  and 18 surfaces (range 2–5), 30 minutes and 24 hours after spraying, respectively  were positive for ectively . StatistE. coli before spraying, compared to 23 surfaces (range 2–7) and 31 surfaces (range 5–7), 30 minutes and 24 hours after spraying, respectively  were positive for ectively . StatistE. coli before spraying, compared to 10 surfaces (range 2–3) and 12 surfaces (range 2–4) 30 minutes and 24 hours after spraying, respectively  were positive for ectively . StatistE. coli results  household spraying with chlorine can reduce bacterial contamination on household surfaces, however, effectiveness was not consistent across programs and recontamination within 24 hours was seen in the majority of households; 3) spraying programs provide opportunities for the concurrent deployment of hygiene promotion activities; and, 4) programs face challenges in locating houses as well as context-specific challenges.We conducted mixed-methods evaluations of three household spraying programs implemented in cholera response. Our results indicate that: 1) before disinfection, the highest concentrations of V. cholerae were found on surfaces in cholera patient houses. The locations identified in this study as the most contaminated  are consistent with known cholera transmission pathways [The first study objective was to determine where pathways ,41 and ppathways –44. We dV. cholerae and indicator bacteria on surfaces, and thus reduce cholera transmission risk. These results are in line with previous laboratory-based evaluations of chlorine spraying [V. cholerae and E. coli over 24 hours was only observed in Program A. In Program B, spraying resulted in a statistically significant reduction in V. cholerae and E. coli but surfaces that were highly contaminated before spraying remained highly contaminated and reductions were not sustained over 24 hours. In Program C, no statistically significant difference was seen before/after spraying. Differences in effectiveness can be attributed to different spraying procedures. In Program A, agents were observed to systematically apply a larger volume of relatively accurately dosed 0.2 and 2.0% chlorine solution, compared to Programs B and C, where ambitious coverage objectives (20–30 houses in addition to that of the case) may have led sprayers to spend less time–and chlorine solution–at each house. Based on these differences, and a recent laboratory study where spraying chlorine was observed to achieve incomplete surface coverage [In terms of effectiveness, this study is the first we know of to provide evidence suggesting that household spraying can inactivate culturable spraying . Howevercoverage , we hypoV. cholerae may be influenced by the presence/absence of infected individuals, which was not assessed in this evaluation. It is unclear from this evaluation whether spraying program characteristics or variable household cleaning habits are linked to recontamination with V. cholerae and indicator bacteria. Given that surfaces are typically soiled with organic matter, which inactivates chlorine [Sampling 24 hours after spraying indicated that recontamination could occur. Differences between households in observed recontamination with chlorine , and recchlorine , recontaThe following  progOur work had several limitations, including: 1) small sample size which restricts the generalizability of observations and ability to detect associations between contamination and household variables; 2) sampling of adjacent surfaces before, 30 minutes, and 24 hours after spraying, which may have had different initial bacterial concentrations, to assess effectiveness; 3) not integrating bacterial recovery rates from surfaces into sample concentration calculations due to uncertainty, which may lead to differential underestimates of concentration levels between surface materials; and, 4) potential biases in qualitative responses and/or behaviors from household respondents  and program staff (Hawthorne effect), neither of which impact our main results from microbiological surface sampling.V. cholerae identification and VBNC cells, and the preliminary nature of this research. Each is described further below.Three other study considerations are important to note: speed of deployment to carry out an evaluation in a humanitarian context, the question of In addition to results presented herein, we also deployed to Mozambique after Cyclone Idai, but arrived after spraying programs ended due to delays in securing approvals. This highlights a challenge of conducting research in some humanitarian contexts. Interviews conducted in Mozambique after the program ended support and expand upon our other results herein. Retrospective key informant interviews were conducted with three spraying program staff and five recipients of household spraying. In this program, a team of four visited patient households to carry out spraying , conduct a short survey, and test drinking water for chlorine residual. Both case and neighboring households received a hygiene kit and hygiene promotion messages, and latrines were sprayed. Spraying agents appreciated that transportation was provided. Households indicated this was their first interaction with a household spraying program, and the most commonly reported household appreciation for spraying was because it was effective against pests such as mosquitos, ants, and mice. Our experience in this and other evaluations highlights the importance of rapid research team deployment, although challenges in securing relevant approvals can delay evaluations.V. cholerae using viability-qPCR  to confpossible ,51. In p samples ,53. Our V. cholerae from representative household surfaces; and, 5) refine methods to test and analyze VBNC cells, and to determine the environmental and epidemiological relevance of VBNC V. cholerae on surfaces. If future evaluations with larger sample sizes establish that household spraying is acceptable, cost-effective, and can reliably inactivate V. cholerae on household surfaces, health impact evaluations could be considered.The third consideration is that this study was preliminary and not designed to answer questions of stigma, recontamination, cost-effectiveness, spraying efficacy, and epidemiological coverage. Thus, further research is needed to: 1) complete behavioral research to understand perceptions of household spraying; 2) in well-implemented programs, understand when and how recontamination occurs and if spraying should be repeated; 3) compare effectiveness, cost-effectiveness, and acceptability of household spraying and alternative interventions such as the distribution of household cleaning supplies to support decision-making; 4) complete further laboratory research with known recovery rates to assess chlorine efficacy–potentially including chlorine compounds other than HTH that might be used for spraying solutions, such as sodium dichlorosisocyanurate (NaDCC)–at inactivating Overall, our results suggest that household spraying may be effective at reducing the risk of cholera transmission via fomites. While many questions remain, if responders choose to implement household spraying, our results support the following recommendations: 1) spraying agents should be trained to disinfect households systematically, including kitchen spaces, patient’s sleeping area, and latrines; 2) 0.2% chlorine should be used on household surfaces and 2.0% chlorine in latrines, soiled surfaces and, if acceptable, kitchen spaces; 3) sufficient time and resources should be available for spraying agents to meet program coverage objectives in terms of number of houses to disinfect, while performing disinfection carefully and spraying surfaces until visibly wet; 4) spraying agents should arrive at households as quickly as possible, with the assistance of communication units or patient relatives; and, 5) hygiene promotion activities should be concurrently deployed with household spraying and agents trained accordingly.S1 File(XLSX)Click here for additional data file.S1 FigE. coli concentrations on selected surfaces before, 30 minutes and 24 hours after household spraying. (Bottom) Number of surfaces where E. coli were detected (>5 CFU/100 cm2), by program and household.(Top) (TIF)Click here for additional data file.S2 Fig2), by program and household.(Top) Total coliforms concentrations on selected surfaces before, 30 minutes and 24 hours after household spraying. (Bottom) Number of surfaces where total coliforms were detected (>5 CFU/100 cm(TIF)Click here for additional data file.


Despite the advantages of having a child as a medical resident, the transition back to residency after parental leave can be challenging. This study is the first to investigate this issue using a nation-wide Canadian sample of both residents and program directors.N = 99 pairs), there was no difference in the total number of challenges reported, but program directors reported offering significantly more accommodations than female residents reported being offered, t(196) = 13.06, p < .001.A questionnaire was developed and made available online. Respondents included 437 female residents, 33 male residents, and 172 residency program directors. The mean length of parental leave was nine months for female residents and six weeks for male residents. Almost all female residents (97.5%) breastfed with an average duration of 12 months. The top challenges reported by residents were feeling guilty for being away from their family, long and unpredictable work hours, sleep deprivation, and finding time to study. When female residents and program directors were matched to both school and program (Our data indicate there is a need for better communication between resident parents and program directors, as well as clear program-specific parental leave policies, particularly for supporting breastfeeding mothers as they return to work. These residents reported receiving much less support during this period than they did while pregnant.14Within Canada, studies investigating the challenges of having children during residency have been limited to surveys of residents in either a specific residency program, such as Obstetrics and Gynecology,8,9,14,17 These appear to be exacerbated by the fact that many program directors report receiving no guidance or formal policies for how to support resident parents as they return from parental leave.11,18 For instance, most institutional or residency association parental leave policies only cover basic human rights issues related to pregnancy, the length of parental leave, and in some cases breastfeeding.11 A recent review of all Canadian residency program parental leave policies noted that support for resident parents varies considerably across institutions and residency programs and does not appear to be consistent, universal, or guaranteed.3 As a result, support for resident parents appears to be dependent on how parental leave is approached and handled by each program director, instead of on institutional policies.3,5 Several reports have outlined specific accommodations that could help support residents as they return from parental leave, such as the option to return to residency part-time, to remain involved in academic and/or clinical work during parental leave, the provision of on-site childcare, as well as the provision of time, privacy, and storage to help maintain breastfeeding.1,4,11,14 However, no study has formally examined whether Canadian resident parents are being offered any of these accommodations on a national scale.The most common challenges reported by female residents when returning to residency after taking parental leave included fatigue from sleep deprivation, challenges related to breastfeeding or pumping at work, childcare difficulties, and lack of support from partners and/or preceptors.Although it is important to develop parental leave policies that are unique to each specialty, a nationwide study from all specialties can provide important data that can be used by various stakeholders  to help create or improve institutional program-specific parental leave policies. Collecting these data, along with other pertinent data for prospective resident parents  can also serve to better inform and prepare future resident parents for the challenges that lie ahead. Gathering information from both residents and program directors is important to assess whether program directors are aware of the difficulties resident parents face and to provide more complete and accurate information about what accommodations are currently being offered to resident parents from multiple perspectives. Our study is unique in three respects. This is likely the first national study to examine common issues associated with parental leave by surveying both residents and program directors from all medical schools and residency programs in Canada. We also recruited a large sample of physician mothers who were either current residents or had completed a residency within the last 20 years. This range allowed us to examine whether the experiences of resident mothers have changed over time. Finally, this study is one of only a few studies to survey male resident parents, who also face challenges when returning to residency after the birth of their child that may often be overlooked.8 previously piloted and published surveys (permission to use these surveys was obtained by contacting the lead author). We reviewed the results of several other quantitative and qualitative studies9,10,12,14,16 and developed additional questions based on these results that included extra demographic information,10,16 challenges associated with returning to residency after parental leave,14,16 requested accomodations,16 program directors’ attitudes towards having a child during residency, and satisfaction regarding parental leave experiences that served as valuable exploratory data from a nationwide sample. We also included questions regarding a few topics that would be informative for prospective resident parents . Participants were given an opportunity to provide open-ended comments at the end of the survey. We applied thematic analysis in analysing and summarizing these open-ended comments. The questionnaire for male residents was identical to the one for female residents with the exception that it excluded questions about breastfeeding. All questionnaires were also available in French and were translated by a native French speaker (copies of French questionnaires are available upon request). Most questions elicited a yes (1) or no (0) response; however, some questions had a five-point Likert scale . The resident questionnaire was piloted with two individuals to ensure clarity of the survey questions and to estimate the time required to complete the survey. Since we derived our questions from previously published surveys and empirical literature, we assumed we had sufficient construct representation in our surveys. Other sources of validity evidence were not part of our study. See Supplemental data for copies of the questionnaires.For our study, we used quantitative surveys to collect a wide range of data from a large number of participants in a short time period. To develop our resident and program director surveys, we conducted a literature review using PubMed database using multiple search terms  that included articles published between Jan, 1, 1970 and November 1, 2018 with data from North America. Articles were screened by title and abstract for relevancy . We searched the references in pertinent research articles, meta-analyses, and commentaries for any studies not discovered in the PubMed search. We adapted the resident and program director surveys from Hutchinson et al.’s1), and 30.8% for current Program directors from programs in the CARMS R1 program list . A 30% response rate is typical for studies using online questionnaires that are able to directly contact the entire target population.7,8,9 The study was reviewed and approved by the Health Research Ethics Authority (HREA) at Memorial University of Newfoundland. Consent was implied when participants clicked ‘next page’ after reading the information page, and this was outlined in the information page description.From November 2018 to April 2019, surveys were available online using Qualtrics. Invitations to participate in the study were sent to program directors by either contacting their postgraduate medical education department to distribute a letter of invitation or emailing them directly. Current and past residents were recruited by contacting provincial residency associations to advertise in their newsletters, and advertising on targeted social medial platforms . Based on our data, we are able to estimate response rates for our study of approximately 13.6% for female residents who took parental leave in the last 10 years , 3.0% for male residents who took parental leave in the last 10 years , data from these participants is presented for descriptive purposes only. Finally, to control for multiple comparisons, a significant level of p < .01 was used for all analyses.Four female residents were excluded from the study because they had not yet finished their maternity leave. Eleven program directors reported having no experience with a resident taking parental leave; thus, only their demographic data were included in the study. Due to the small number of male residents in the study (https://www.carms.ca/program-descriptions/) with additional groupings for Medicine Subspecialties, Pediatric Subspecialties, and Enhanced Skills in Family Medicine.Participants included 437 female and 33 male past or current residents who took parental leave during a Canadian residency program, as well as 172 current Canadian residency program directors. Twenty female residents (4.6%), five male residents (15.2%), and 38 program directors (22.1%) completed the French version of the questionnaires. Demographic data for each group, including training setting and residency program are presented in N = 416; 95.2%) and male  residents, having a child during residency was planned. The top five reported reasons why female residents chose to have a child during residency were: i) advanced maternal age, ii) financial benefits, such as federal parental leave funding, provincial top-up funding and medical benefits, (iii) feeling ready to have a child, (iv) having the option to take a full year of parental leave, and v) because they felt it was easier to transition back to residency, due to the supervised learning environment, compared to taking parental leave after residency. For male residents, advanced parental age and being ready to have a child were the two main reasons reported for having a child during residency. When asked if they would recommend having a child during residency, the majority of female  and male  residents reported yes. Similarly, 148 (86.0%) program directors stated they would not discourage residents from having a child during residency, and many program directors commented that they felt residency was the best time to have children.For most female  and some male  residents reported informing their program director that they were having a child between 12-20 weeks of gestation, while only a small percentage  did so before 12 weeks of gestation. Similarly, 104 program directors (61.5%) reported they were typically informed about the intention to take parental leave between 12-20 weeks, while only 6.5% reported being informed before 12 weeks of gestation. One program director commented, “I wish residents would tell me earlier so that I can plan things such as getting their rural rotations out of the way before the baby is born and avoiding heavy rotations late in gestation.” The majority of female  and male  residents reported that their program director reacted either positively or very positively when they were informed about the pregnancy. Interestingly, there was a significant positive correlation between when female residents informed their program directors about their pregnancy and their perceived reaction from their program directors ; more positive reactions were associated with earlier disclosure.Most female (N = 288), the top five reasons reported for taking less time were: i) not wanting to significantly delay residency training, ii) rules regarding the timing of licensing exams to be able to write with their cohort, iii) financial concerns, iv) not wanting to lose clinical skills, and v) having a partner that took some parental leave. For male residents, not wanting to significantly delay residency training and having a partner that took parental leave were the two main reasons reported for not taking a longer paternity leave. Interestingly, only one third of female  and male  residents reported they would have liked to have taken a longer leave.The mean reported length of parental leave was approximately nine months for female residents and six weeks for male residents. For female residents who took less than 12 months of maternity leave (N = 223) of female residents and 66.6% (N = 22) of male residents rated their experience of returning to residency following parental leave as either positive or very positive. Similarly, 54.7% (N = 239) of female residents and 63.7% (N = 21) of male residents reported being either satisfied or very satisfied with how well their program provided accommodations and support when they returned to residency duties. Female residents who reported being more satisfied with their program’s level of accommodation and support were more likely to report that their program director reacted positively when informed about the pregnancy , and more likely to report fewer challenges , and a greater number of accommodations offered . The majority of program directors reported being either satisfied or very satisfied with how well their program provided accommodations for residents returning from maternity leave  and residents returning from paternity leave . Interestingly, program directors who reported having more female residents take parental leave in their program over the last 10 years reported offering more accommodations  and were more satisfied with the level of support and accommodation their program provided , than those who reported fewer female residents taking parental leave.Fifty-one percent  to help make it work in the first year back to work, as few community daycares accept children under the age of two. Childcare appeared to be particularly difficult for surgical residents who start work early, as well as residents whose partner is a physician or resident with their own long hours and call shifts to schedule. For female residents, 110 (25.2%) reported relying on their partner for childcare, 97 (22.2%) used a community daycare, 77 (17.6%) used a nanny, 55 (12.6%) relied on a grandparent, and 52 (11.9%) used a home daycare when returning to residency. The majority of male residents relied on their partner  or a community daycare . Several residents stated they wished their preceptors had more experience with or education about the challenges of having children during residency. In particular, one female resident expressed what seems to be a common frustration in wishing that preceptors were better at recognizing that taking a year off for maternity leave may cause some “mental fog,” and some difficulty recalling information learned prior to parental leave, which might make residents appear less “high functioning” when they immediately return to work. However, it appears that many program directors are already aware of this issue, as one program director stated, “Residents typically take a few weeks to get back in the groove of residency after a leave. Their performance generally remains the same or declines due to sleep deprivation, but some residents perform better because they get more organized.”A thematic analysis of the comments provided by residents and program directors allowed us to further explore these challenges in more detail. For instance, many residents commented that finding childcare was “r =-.340, p < .001). Sixty percent of female residents continued to breastfeed or pump after returning to residency duties and 73% of these residents took less than 12 months of leave. Only 15% of female residents reported being offered breaks or a private area to breastfeed or pump. Out of 191 female residents who reported they stopped breastfeeding earlier than they had planned, 112 (58.6%) stopped because of returning to residency duties, either because it was too difficult to pump at work or because their supply permanently dropped after lengthy call shifts. Many female residents felt that residency programs should have a specific policy about pumping at work that provides basic accommodations, such as dedicated time for pumping and a private pumping space that is convenient to access, given that discrimination due to breastfeeding is a Human Rights violation in several provinces.20-22 Many female residents also felt there was not enough education about the benefits of breastfeeding and challenges of pumping amongst preceptors. Support for breastfeeding/pumping appeared to be particularly important for residents in surgical specialties who were less likely to take a full year of maternity leave for fear of losing their procedural skills and being ineligible to write their exam with their cohort. For instance, one female surgical resident commented, “I took the entire year off partially so that I could facilitate breastfeeding. I would have considered returning to my residency earlier had I felt that pumping at work would have been a feasible option.”Breastfeeding and finding time to pump at work was a major concern for many female residents. In our sample, 97.5% of female residents breastfed and the average duration was 12 months. Duration of breastfeeding was positively correlated with the length of parental leave .Finally, we also identified several new challenges when reviewing the residents’ comments. For instance, many female residents commented that a lack of communication and poor support from their preceptor during the period of transition back to residency duties after parental leave was a challenge. These residents reported wishing they had received a monthly email while on leave or at least one face-to-face meeting when returning to residency to I think it's very important to have an understanding of the stress that parents face when they return to residency training after maternity or paternity leave. I wish there was more transparency or direction from our PGME office about options or accommodations that can be offered to these parents.While another program director commented,Accommodations are made in the form of the leave itself. I do not see a good reason to make more accommodations. It is a choice to have children so when residents are back at work, they should be back at work (to do otherwise is unfair to those who choose not to have children).I think the very first month after maternity leave is crucial as it’s a transition phase in terms of learning and juggling work-life balance.” Many female residents wished they were given protected study time during weekdays, especially during the year of their licensing exam, as it can be challenging to find time to study outside work hours with a young child at home. Some residents report using their vacation time to study, while others proposed either extending residency to allow for a dedicated study block, or allowing residents to attend academic/teaching sessions during their parental leave so that they can use this time slot for studying when they return from parental leave. Male residents uniquely requested longer paid leave, and reduced stigma.When residents were given the option to comment on other possible accommodations that might be helpful, many suggested having a re-acclimatization period in the first month of returning to residency, with refresher courses or a gradual increase in hours and call shifts. One resident stated, “N = 1.8%) female residents reported receiving a handbook with information for resident parents.Both female residents and program directors felt that it was important for universities to provide clear program-specific policies and guidance for parental leave. In particular, residents requested knowing which accommodations were available, such as whether part-time return or waivers of training might be possible. Waivers of training, which are typically a maximum of three months for RCPSC residents and one month for family medicine residents, were of particular interest to the male residents in our study, who did not want to significantly delay their training. Several residents noted they could have used practical advice on work-life balance, knowing what memberships can be suspended and re-started after parental leave , accrued vacation weeks while on leave, and information regarding the rules for being eligible to write their licensing exam or for taking a second parental leave during residency. Only eight (DF) are reported.Due to unequal sample sizes between the female resident and program director groups, direct comparisons between these two groups were done using t-tests after matching each program director to a female resident from the same school and same program . When data from more than one female resident or program director from a particular school and program were available, random sampling in SPSS was used to choose matched pairs. Levene's test was calculated to ensure homogeneity of variance for the t-tests. In cases where Levene's test was significant, , adjusted p-values are reported, while the original degrees of freedom (t(196) = 13.06, p < .001, Cohen’s d = 1.86  = 3.53, p = .001, Cohen’s d = 0.50).Finally, when female residents and program directors were compared using matched samples, program directors reported being significantly more satisfied with the accommodations and support provided by their program than female residents, r =-.180, p=.002, with more recent graduates being from family medicine. Thus, for each significant correlation, follow-up analyses were conducted separately for female residents in family medicine (N =121) and female residents in RCPSC specialty programs (N = 314). Female residents who started their residency program more recently reported receiving more positive reactions from their program directors when they were informed of the pregnancy than those who started residency less recently . Further analyses revealed this finding was significant for RCPSC residents , but not significant for family medicine residents. Residents who started more recently also reported having more challenges ; however, this finding was significant for RCPSC residents , but not for family medicine residents. Finally, residents who started more recently reported being offered more accommodations than their predecessors ; however, this finding was significant for family medicine residents , but not for RCPSC residents.In order to examine the change in female residents’ experiences over time, correlational analyses were conducted using the year residents started residency and other variables of interest. There was a significant correlation between residency year and residency program , to certain residents if they are asked on a case-by-case basis, as many residents in the present study stated they were unaware that they could ask for accommodations and did not speak to their program directors when challenges arose. Given than most resident parents, regardless of their residency program or institution, face the same types of challenges when they return to residency , it seems only fair that all resident parents should be offered the same accommodations. However, our findings, as illustrated in Our study used one of the largest and most heterogeneous samples of Canadian resident parents and program directors to gather important national data on the experiences of resident parents as they return to residency after parental leave. Our study is also one of the first to examine which accommodations are currently being offered to resident parents from both the resident and program director perspectives. Our findings indicate that program directors appear to be aware of the most common challenges resident parents face. They reported offering significantly more accommodations than female residents in the same residency program at the same institution report being offered. One possible explanation of these results could be that program directors might only offer these accommodations 4 program directors can encourage early disclosure by ensuring this information is kept confidential, offering support regardless of the pregnancy outcome, and informing residents that it is in their best interest to disclose as early as possible. Based on feedback received from residents in this study, we recommend that program directors meet face-to-face with residents planning to take a parental leave at least once, and continue to have regular communication in-person or over email when the resident returns after leave to provide additional support. These sessions could help program directors identify the most critical challenges and most necessary accommodations for their own specific program, which could aid in the development of better parental leave polices.Residents should be encouraged to inform their program director about their need for parental leave as soon as possible to allow for more flexibility in rotation scheduling and less disruption to the workload of their peers. Our data show that most program directors react positively when being informed about the need for parental leave, especially when they are informed earlier in the pregnancy. Given that some female residents may be hesitant to reveal their pregnancy until the risk of miscarriage is lower,Fortunately, our findings suggest that support for resident parents is improving, as female residents who started their residency more recently reported receiving a more positive reaction from their program director when informing them of their pregnancy, and for family medicine residents, being offered more accommodations. Interestingly, RCPSC residents who started their training more recently reported having more challenges than their predecessors. Perhaps this finding reflects a shift in culture and higher expectations of accommodations, with more resident mothers attempting to breastfeed and pump at work, as well as attempting to avoid burnout and improve their work-life balance.11,18 The lack of clear policies and guidelines for accommodating resident parents as they return to work results in substantial variability in the number of accommodations offered by program directors in the same residency program or at the same institution. This can be frustrating for both resident parents, and program directors. Not surprisingly, the most supportive program directors in our study were those who had the most experience dealing with residents taking parental leave or had a child themselves during residency, making them more aware of the challenges their residents face.Despite numerous articles highlighting the need for written program-specific parental leave policies, few residency programs appear to have one in place, especially for the transition period when residents return to duties following parental leave.Ideally, all residency programs would have their own written parental leave policy that: i) includes information about which accommodations might be possible for resident parents on a case-by-case basis , ii) adheres to federal law and the provincial resident union contract, iii) is inclusive for all types of parents , and iv) is accessible to all residents. Prospective residents may be particularly interested in this information as it could affect their decision about where to do their residency training.23,24 and resident associations16,25 Finally, our study identifies several topics, such as the benefits of breastfeeding, the challenges of pumping at work, and the cognitive fatigue in the first few weeks back at work, that could be topics for faculty development for preceptors and program directors.At a minimum, all residency programs should ensure they provide adequate support for breastfeeding mothers through the provision of adequate time and a private space for pumping breast milk, as this is a human rights requirement. Providing breastfeeding support for resident mothers may enable some residents to return to residency earlier or return part-time, which might be important for those who want to keep their clinical and procedural skills proficient. All residents, regardless of whether they plan to have a child or not, should be made aware of online resources for resident parents. For instance, comprehensive handbooks and checklists for residents planning to take parental leave during residency have recently been created and made available online by a few Canadian residency programscurrent program directors, whereas our sample of female residents included those who started residency between 1998 and 2018 (mean year of starting residency = 2011). If current program directors offer more accommodations to resident parents than their predecessors, this could explain the significant difference we found between program directors and female residents in the total number of accommodations offered. However, when we excluded matched resident-program director pairs where the female resident started residency earlier than 2013, there was still a significant group difference t(88) = 9.43, p < .001, where program directors reported offering more accommodations than female residents reported being offered.This study has several limitations. First, we were unable to collect data from all program directors or all residents who took parental leave in the last 20 years; thus, our recruitment of participants may suffer from selection bias. It is possible that residents with more negative experiences or program directors who are more supportive of resident parents may have been more interested in participating in our study. Similarly, because we relied on self-reports from residents who completed their training over the last 20 years, it is possible that not all residents’ experiences were recalled accurately or completely, leading to recall bias in our data. Given that we were unable to collect data from all program directors across Canada, unequal sample sizes across schools and programs limited our ability to make any direct comparisons across these demographic variables. Next, we did not collect data on the sex of the program directors, the number of years they had served as program director, or whether they had a child during their own residency training, which may have been interesting to examine in terms of the level of support they provide resident parents. Finally, when using resident-program director pairs matched by school and program, we were unable to match by year, which may have influenced our results. For instance, our participants included Our study demonstrates that there are still significant improvements to be made in supporting resident parents in Canada as they return from parental leave. On a positive note, our study shows that many program directors are aware of the challenges that resident parents face after taking parental leave and are willing to discuss possible accommodations on a case-by-case basis. Many residents offered possible solutions that could have reduced the challenges they experienced and improved their work-life balance during the transition back to residency training. While it may not be possible logistically to provide resident parents with all their requested accommodations, ensuring all resident parents have access to basic accommodations (e.g. breastfeeding support), regular contact and support from their program director, and a written, detailed, program-specific parental leave policy at the start of their training, could considerably enhance the experiences of both resident parents and program directors as they navigate through this challenging transition period.