Even though influenza vaccinations were provided free to all healthcare workers in the United States, healthcare workers were not 100% compliant. The non-compliance with influenza vaccinations may expose their patients, their families, and the public at large to a high-risk source of influenza infection. This study's research questions included how registered nurses perceived influenza and influenza vaccination; registered nurses' self-reported incidents with influenza vaccination; and factors that contributed to registered nurses' non-compliance with influenza vaccination. Guided by the theory of reasoned action and the theory of planned behavior, the purpose of this qualitative study was to determine the factors that contributed to the non-compliance of registered nurses with receiving the influenza vaccination. Twenty participants from a healthcare facility in Florida were interviewed using an interview guide. Audio data was transcribed to text data; text data was coded and thematically analyzed by using ATLAS.ti software. Results revealed that 70% of registered nurses were afraid of influenza vaccination, while 80% of them saw influenza vaccination as ineffective; 90% of them had bad experiences or have seen colleagues/friends who have had bad experiences after influenza vaccination. In addition, 40% of registered nurses claimed that they already had good immunity, while 20% of them declined influenza vaccination because of personal choices. Research findings from this study may be utilized to bring positive social change to society at large. The findings may be utilized to enhance existing strategies or policies or even help formulate new policies and strategies that would address the concerns of HCWs, especially registered nurses.

Background Respiratory viruses are a leading cause of acute lower respiratory infections (ALRI) in young children. The role of seasonal influenza virus in childhood ALRI is generally underappreciated. This is because the global burden of disease due to ALRI attributable to seasonal influenza virus in children is unknown. This thesis aims to estimate the global and regional hospital admissions for seasonal influenzaassociated ALRI and the possible boundaries for influenza-associated ALRI mortality in children younger than five years. The WHO has developed guidelines for influenza surveillance using severe acute respiratory infections (SARI) sentinel surveillance network. However, data from sentinel surveillance are not routinely used in estimating disease burden in a population. This thesis also aims to provide tools for estimating influenza disease burden using data from SARI sentinel surveillance in developing country settings. Methods Incidence data for influenza-associated ALRI (from passive, hospital-based studies) were collected using a systematic review of studies published between January 1, 1995 and October 31, 2010. These data were supplemented by unpublished data from 15 population-based studies that were obtained by forming a consortium of researchers (Influenza Study Group) working in developing countries. The incidence meta-estimates were applied to global and regional population estimates for 2008 to calculate the estimated number of hospitalised influenza-associated ALRI cases that year. The possible bounds for influenza-associated mortality were estimated by combining incidence estimates with in-hospital case fatality ratios and identifying studies with population-based data for influenza seasonality and monthly ALRI mortality. The data to estimate the incidence of all-cause hospitalised ALRI were collected using a systematic literature review that was supplemented with unpublished data from 24 population-based studies that were obtained by collaborating with research sites in developing countries (Severe ALRI Working Group). The hospitalised ALRI incidence meta-estimates were applied to global and regional population estimates for 2008 to calculate the estimated number of all-cause hospitalised ALRI cases that year. Data on the proportion of hospitalised ALRI cases that were positive for influenza were collected using a systematic review of the studies published between January 1, 1995 and December 31, 2011. The meta-estimates of the proportion of hospitalised ALRI cases positive for influenza were applied to the estimated number of hospitalised ALRI cases in the year 2008 to estimate the number of hospitalised influenza-associated ALRI cases globally and for the six WHO regions using this alternative method. The tools for estimating influenza disease burden using surveillance data were developed after a literature review and a survey of 27 end-users (influenza epidemiologists) in 24 countries. Results Thirty nine studies (21 from developing and 18 from industrialised regions) satisfying the eligibility criteria, provided data on the incidence of influenza-associated hospitalised ALRI. The incidence is highest in infants in the first six months of life, both in developing as well as industrialised countries. It is estimated that the incidence of hospitalised influenza-associated ALRI in children under the age of five years was about 1.5 (95% CI 1.0 to 2.3) and 1.2 (95% CI 0.9 to 1.6) per 1000 children in developing and industrialised countries respectively. This translates to about 911,000 (95% CI 617,000 to 1.4 million) hospitalisations worldwide due to influenza-associated ALRI in children younger than five years in 2008, 93% of the cases occurring in developing countries (where 90% of the global under-5 population reside). An estimated 21,500 (based on 20 studies) to 115,000 deaths (based on only 1 study) in under-five children were attributable to influenza-associated ALRI in 2008. Incidence and mortality varied substantially from year to year in any one setting. Eighty five studies (61 from developing and 24 from industrialised) reported incidence of hospitalised ALRI in children aged 0 to 4 years. It is estimated that about 11.3 (95% CI 9.5 to 13.5) million episodes of ALRI resulting in hospitalisation occurred worldwide in children aged 0 to 4 years in 2008, 92% of these occurring in developing countries. Twenty three studies (19 from developing and 4 from industrialised) reported data on proportion of hospitalised ALRI cases testing positive for influenza using laboratory tests. The estimated proportion of influenza-positive hospitalised ALRI cases was about 5.0 (95% CI 3.6 to 7) percent and 8.4 (95% CI 4.2 to 16.7) percent in developing and industrialised countries respectively. This translates to about 772,000 (95% CI 343,000 to 1.8 million) cases of influenza-associated hospitalised ALRI in children younger than five years worldwide in the year 2008. A manual (targeted at developing countries) describing the methods to estimate the disease burden associated with seasonal influenza using the various surveillance data was developed after considering the results of the preliminary survey. An electronic tool (based on a spread sheet model) to help the end-users (epidemiologists at sentinel surveillance sites and Ministries of Health) to estimate the disease burden at local and national levels was developed as an adjunct to the manual. The manual along with the electronic tool were piloted at three different sites in two developing countries (India and Ghana) and feedback from the end-users was obtained to make the version more user-friendly. The final draft of the manual along with the tool has been submitted to the WHO for final clearance. The member states and the WHO Eastern Mediterranean Regional Office decided to adopt the manual and in the first instance estimate the influenza disease burden in 8 member states having the requisite data for undertaking disease burden estimation. Conclusions Influenza is a common pathogen identified in children with ALRI and results in a substantial burden on hospital inpatient services worldwide. There are significant gaps in published data from developing countries (especially the African and Eastern Mediterranean regions of the WHO). Sufficient data to precisely estimate the role of influenza in childhood mortality from ALRI are not presently available. Effective use of sentinel surveillance data for disease burden estimation would greatly improve the quality and precision of disease burden estimates (especially those resulting in hospitalisation). Improved disease burden estimates (particularly at the national level) would inform policy makers and national governments in formulating immunization policies for vaccinating high-risk groups, and planning annual requirements for vaccines and anti-viral drugs against seasonal influenza.

published_or_final_version / abstract / toc / Paediatrics and Adolescent Medicine / Master / Master of Philosophy

published_or_final_version / abstract / Microbiology / Master / Master of Philosophy

published_or_final_version / abstract / Microbiology / Master / Master of Philosophy

published_or_final_version / Microbiology / Doctoral / Doctor of Philosophy

published_or_final_version / Chemistry / Doctoral / Doctor of Philosophy

The consistent seasonal signal that characterizes annual influenza epidemics has long suggested a causal link between the physical environment and the transmission of influenza. Yet, despite considerable interest--dating as far back as Hippocrates--the environmental factors that facilitate the seasonal spread of influenza remain unclear. Historically, significant study of influenza seasonality was based almost exclusively on temperate regions,.due to a lack of high-quality influenza data in low-latitudes. In turn, although numerous hypotheses have been forwarded to explain the seasonal nature of influenza in temperate regions, few acknowledge the seasonal patterns in lower latitudes.This dissertation examines the scientific evidence for the seasonal mechanisms that potentially explain the complex seasonal patterns of influenza disease activity across the latitudinal gradient extending from temperate to tropical regions. I identified seasonal climatic variables that are potentially responsible for influenza seasonality from observational, experimental, ecological and anecdotal studies. I then used a global database of influenza seasonality to assess the consistency of relationships between influenza seasonality and the seasonality of relevant climatic variables. I determined that no single climatic variable is consistently correlated with seasonal influenza activity across temperate, subtropical and tropical regions.However, I did find a significant U-shaped relationship between specific humidity and influenza epidemics globally with epidemics becoming increasingly likely as specific humidity increases or decreases from approximately 12 g/kg. Further, I examined the temporal and spatial variation of influenza activity and specific humidity during the 2009 A/H1N1 pandemic across Mexico, which spans temperate, subtropical and tropical regions. I show that specific humidity may have modified the progression of three distinct waves of infection during the pandemic. These patterns are in agreement with the U-shaped relationship between specific humidity and seasonal influenza epidemics observed at a global scale. In all, this is the first time that relationships between climate and influenza (both seasonal and pandemic) activity have been successfully synthesized into a single parsimonious model across temperate, subtropical and tropical regions.

This dissertation develops technology for microfluidic point-of-care (POC) immunoassay devices, divided into three papers, and explores the use of a quartz crystal microbalance for real time monitoring of blood coagulation in a fourth paper. The concept of POC testing has been well established around the world. With testing conveniently brought to the vicinity of the patient or testing site, results can be obtained in a much shorter time. There has been a global push in recent years to develop POC molecular diagnostics devices for resource-limited regions where well equipped centralized laboratories are not readily accessible. POC testing has applications in medical/veterinary diagnostics, environmental monitoring, as well as defense related testing. In the first paper, we demonstrated the use of latex immunoagglutination assays within a microfluidic chip to be an effective and sensitive method for detecting the bovine viral diarrhea virus. In the second paper the feasibility and general ease of integrating liquid core optical components onto a microfluidic lab-on-a-chip type device, for point-of-care AI diagnosis is demonstrated. In the third paper particle agglutination assays, utilizing light scattering measurements at a fixed angle from incident light delivery, for pathogen detection are explored in both Rayleigh and Mie scatter regimes through scatter intensity simulations and compared to experimental results. In the fourth paper a quartz crystal microbalance was used for real-time monitoring of fibrinogen cross-linking on three model biomaterial surfaces.

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