{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T07:28:18Z","timestamp":1774682898011,"version":"3.50.1"},"reference-count":52,"publisher":"BMJ","issue":"6","license":[{"start":{"date-parts":[[2021,6,9]],"date-time":"2021-06-09T00:00:00Z","timestamp":1623196800000},"content-version":"unspecified","delay-in-days":8,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill & Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1115490"],"award-info":[{"award-number":["OPP1115490"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["106698\/Z\/14\/Z"],"award-info":[{"award-number":["106698\/Z\/14\/Z"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2021,5,21]]},"published-print":{"date-parts":[[2021,6]]},"abstract":"<jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Empiric data on indirect (herd) effects of pneumococcal conjugate vaccines (PCVs) in settings with low or heterogeneous PCV coverage are limited. The indirect effects of PCV, which benefits both vaccinated and non-vaccinated individuals, are mediated by reductions in vaccine-type (VT) carriage (a prerequisite for disease). The aim of this study among hospitalised children in Lao People\u2019s Democratic Republic (Lao PDR) is to determine the effectiveness of a 13-valent PCV (PCV13) against VT pneumococcal nasopharyngeal carriage (direct effects) and the association between village-level PCV13 coverage and VT carriage (indirect effects).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Pneumococcal nasopharyngeal carriage surveillance commenced in December 2013, shortly after PCV13 introduction (October 2013). We recruited and swabbed children aged 2\u201359 months admitted to hospital with acute respiratory infection. Pneumococci were detected using <jats:italic>lytA<\/jats:italic> quantitative real-time PCR and serotyped using microarray. PCV13 status and village-level PCV13 coverage were determined using written immunisation records. Associations between both PCV13 status and village-level PCV13 coverage and VT carriage were calculated using generalised estimating equations, controlling for potential confounders.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>We enrolled 1423 participants and determined PCV13 coverage for 368 villages (269 863 children aged under 5\u2009years). By 2017, median village-level vaccine coverage reached 37.5%, however, the IQR indicated wide variation among villages (24.1\u201356.4). Both receipt of PCV13 and the level of PCV13 coverage were independently associated with a reduced odds of VT carriage: adjusted PCV13 effectiveness was 38.1% (95% CI 4.1% to 60.0%; p=0.032); and for each per cent increase in PCV13 coverage, the estimated odds of VT carriage decreased by 1.1% (95% CI 0.0% to 2.2%; p=0.056). After adjustment, VT carriage decreased from 20.0% to 12.8% as PCV13 coverage increased from zero to 60% among under 5.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Despite marked heterogeneity in PCV13 coverage, we found evidence of indirect effects in Lao PDR. Individual vaccination with PCV13 was effective against VT carriage.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjgh-2021-005187","type":"journal-article","created":{"date-parts":[[2021,6,9]],"date-time":"2021-06-09T12:02:15Z","timestamp":1623240135000},"page":"e005187","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":17,"title":["Indirect effects of 13-valent pneumococcal conjugate vaccine on pneumococcal carriage in children hospitalised with acute respiratory infection despite heterogeneous vaccine coverage: an observational study in Lao People\u2019s Democratic Republic"],"prefix":"10.1136","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8536-2048","authenticated-orcid":false,"given":"Jocelyn","family":"Chan","sequence":"first","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jana Y R","family":"Lai","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cattram D","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keoudomphone","family":"Vilivong","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Microbiology Laboratory, Mahosot Hospital, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMHWRU), Vientiane, Vientiane, Lao People's Democratic Republic"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eileen M","family":"Dunne","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Audrey","family":"Dubot-P\u00e9r\u00e8s","sequence":"additional","affiliation":[{"name":"Microbiology Laboratory, Mahosot Hospital, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMHWRU), Vientiane, Vientiane, Lao People's Democratic Republic"},{"name":"Unit\u00e9 des Virus \u00c9mergents, UVE: Aix-Marseille Univ - IRD 190 - Inserm 1207 - IHU M\u00e9diterran\u00e9e Infection, Marseille, France"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kimberley","family":"Fox","sequence":"additional","affiliation":[{"name":"Regional Office for the Western Pacific, World Health Organization (WHO), Manila, Philippines"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason","family":"Hinds","sequence":"additional","affiliation":[{"name":"Institute for Infection and Immunity, St George\u2019s University of London, London, UK"},{"name":"BUGS Bioscience London Bioscience Innovation Centre, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kerryn A","family":"Moore","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Monica L","family":"Nation","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Casey L","family":"Pell","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anonh","family":"Xeuatvongsa","sequence":"additional","affiliation":[{"name":"National Immunization Programme, Ministry of Health, Vientiane, Lao People's Democratic Republic"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manivanh","family":"Vongsouvath","sequence":"additional","affiliation":[{"name":"Mahosot Hospital, Vientiane, Lao People's Democratic Republic"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paul N","family":"Newton","sequence":"additional","affiliation":[{"name":"Microbiology Laboratory, Mahosot Hospital, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMHWRU), Vientiane, Vientiane, Lao People's Democratic Republic"},{"name":"Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kim","family":"Mulholland","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, London, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Catherine","family":"Satzke","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Department of Microbiology and Immunology, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David A B","family":"Dance","sequence":"additional","affiliation":[{"name":"Microbiology Laboratory, Mahosot Hospital, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit (LOMHWRU), Vientiane, Vientiane, Lao People's Democratic Republic"},{"name":"Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fiona M","family":"Russell","sequence":"additional","affiliation":[{"name":"Infection and Immunity, Murdoch Childrens Research Institute (MCRI), Parkville, Victoria, Australia"},{"name":"Centre for International Child Health, Department of Paediatrics, The University of Melbourne, The Royal Children's Hospital, Parkville, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,6,9]]},"reference":[{"key":"2025073014585385000_6.6.e005187.1","doi-asserted-by":"crossref","first-page":"e744","DOI":"10.1016\/S2214-109X(18)30247-X","article-title":"Burden of Streptococcus pneumoniae and Haemophilus influenzae type B disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000-15","volume":"6","author":"Wahl","year":"2018","journal-title":"Lancet Glob Health"},{"key":"2025073014585385000_6.6.e005187.2","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0000000000000083"},{"key":"2025073014585385000_6.6.e005187.3","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0000000000000084"},{"key":"2025073014585385000_6.6.e005187.4","doi-asserted-by":"crossref","first-page":"e51","DOI":"10.1016\/S2214-109X(16)30306-0","article-title":"Indirect effects of childhood pneumococcal conjugate vaccination on invasive pneumococcal disease: a systematic review and meta-analysis","volume":"5","author":"Shiri","year":"2017","journal-title":"Lancet Glob Health"},{"key":"2025073014585385000_6.6.e005187.5","doi-asserted-by":"publisher","DOI":"10.1586\/erv.12.53"},{"key":"2025073014585385000_6.6.e005187.6","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0172414","article-title":"Impact of vaccine herd-protection effects in cost-effectiveness analyses of childhood vaccinations. A quantitative comparative analysis","volume":"12","author":"Holubar","year":"2017","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.7","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2017-019795","article-title":"Evaluation of different infant vaccination schedules incorporating pneumococcal vaccination (the Vietnam pneumococcal project): protocol of a randomised controlled trial","volume":"8","author":"Temple","year":"2018","journal-title":"BMJ Open"},{"key":"2025073014585385000_6.6.e005187.8","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001839","article-title":"The potential for reducing the number of pneumococcal conjugate vaccine doses while sustaining herd immunity in high-income countries","volume":"12","author":"Flasche","year":"2015","journal-title":"PLoS Med"},{"key":"2025073014585385000_6.6.e005187.9","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2018-021512"},{"key":"2025073014585385000_6.6.e005187.10","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2019.08.073"},{"key":"2025073014585385000_6.6.e005187.11","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0000000000000279"},{"key":"2025073014585385000_6.6.e005187.12","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0000000000001207"},{"key":"2025073014585385000_6.6.e005187.13","doi-asserted-by":"publisher","DOI":"10.1093\/oxfordjournals.epirev.a017990"},{"key":"2025073014585385000_6.6.e005187.14","unstructured":"AM K MA , von S L , et al . Effectiveness of an oral cholera vaccine in Zanzibar: findings from a mass vaccination campaign and observational cohort study. The Lancet Infectious diseases 2012;12."},{"key":"2025073014585385000_6.6.e005187.15","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0088139","article-title":"Methods to assess the impact of mass oral cholera vaccination campaigns under real field conditions","volume":"9","author":"Deen","year":"2014","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.16","unstructured":"UNICEF, World Health Organization, World Bank, UN-DESA Population Division . Levels and trends in child mortality report 2019 estimates: developed by the un Inter-agency group for child mortality estimation. World Health organization 2019."},{"key":"2025073014585385000_6.6.e005187.17","doi-asserted-by":"crossref","unstructured":"von Mollendorf C , Lim R , Choummanivong M . Evaluation strategies for measuring pneumococcal conjugate vaccine impact in low-resource settings. Expert Review of Vaccines 2020;Submitted.","DOI":"10.1080\/14760584.2021.1965474"},{"key":"2025073014585385000_6.6.e005187.18","unstructured":"World Health Organization . Global health Observatory data Repository. who. Available: https:\/\/apps.who.int\/gho\/data\/view.main.ghe3002015-CH9 [Accessed 19 Apr 2021]."},{"key":"2025073014585385000_6.6.e005187.19","doi-asserted-by":"crossref","unstructured":"Satzke C , Dunne EM , Choummanivong M . Pneumococcal carriage in vaccine-eligible children and unvaccinated infants in Lao PDR two years following the introduction of the 13-valent pneumococcal conjugate vaccine 2018.","DOI":"10.1016\/j.vaccine.2018.10.077"},{"key":"2025073014585385000_6.6.e005187.20","doi-asserted-by":"publisher","DOI":"10.1093\/aje\/kwy219"},{"key":"2025073014585385000_6.6.e005187.21","unstructured":"Lao Statistics Bureau . Results of population and housing census 2015 2016."},{"key":"2025073014585385000_6.6.e005187.22","unstructured":"Statistics Bureau L . Lao population and housing census 2015 provisional report Ministry of planning and investment 2015."},{"key":"2025073014585385000_6.6.e005187.23","doi-asserted-by":"crossref","unstructured":"Nguyen VH , Dubot-P\u00e9r\u00e8s A , Russell FM , et al . Acute respiratory infections in hospitalized children in Vientiane, Lao PDR - the importance of respiratory syncytial virus. Sci Rep 2017;7.doi:10.1038\/s41598-017-09006-6","DOI":"10.1038\/s41598-017-09006-6"},{"key":"2025073014585385000_6.6.e005187.24","doi-asserted-by":"publisher","DOI":"10.1093\/oxfordjournals.aje.a115884"},{"key":"2025073014585385000_6.6.e005187.25","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2013.08.062"},{"key":"2025073014585385000_6.6.e005187.26","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2011.07.042"},{"key":"2025073014585385000_6.6.e005187.27","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2105-12-88"},{"key":"2025073014585385000_6.6.e005187.28","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001903"},{"key":"2025073014585385000_6.6.e005187.29","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0199363","article-title":"Pneumococcal carriage and serotype distribution among children with and without pneumonia in Mozambique, 2014-2016","volume":"13","author":"Adebanjo","year":"2018","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.30","unstructured":"Open Source Geospatial Foundation Project . QGIS geographic information system. 2020."},{"key":"2025073014585385000_6.6.e005187.31","unstructured":"StataCorp . Stata statistical software: release 15 2019."},{"key":"2025073014585385000_6.6.e005187.32","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1177\/1536867X1801800202","article-title":"Baselinetable: a command for creating one- and two-way tables of summary statistics","volume":"18","author":"Donath","year":"2018","journal-title":"Stata J"},{"key":"2025073014585385000_6.6.e005187.33","doi-asserted-by":"publisher","DOI":"10.1016\/j.vaccine.2018.10.077"},{"key":"2025073014585385000_6.6.e005187.34","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/cix638"},{"key":"2025073014585385000_6.6.e005187.35","doi-asserted-by":"crossref","first-page":"100014","DOI":"10.1016\/j.lanwpc.2020.100014","article-title":"The effectiveness of the 13-valent pneumococcal conjugate vaccine against hypoxic pneumonia in children in Lao People\u2019s Democratic Republic: An observational hospital-based test-negative study","volume":"2","author":"Weaver","year":"2020","journal-title":"The Lancet Regional Health - Western Pacific"},{"key":"2025073014585385000_6.6.e005187.36","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0098128","article-title":"Direct effect of 10-valent conjugate pneumococcal vaccination on pneumococcal carriage in children Brazil","volume":"9","author":"Andrade","year":"2014","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.37","doi-asserted-by":"crossref","first-page":"e289","DOI":"10.1093\/cid\/ciz1164","article-title":"Dose-specific effectiveness of 7- and 13-valent pneumococcal conjugate vaccines against vaccine-serotype Streptococcus pneumoniae colonization in children","volume":"71","author":"Lewnard","year":"2020","journal-title":"Clinical Infectious Diseases"},{"key":"2025073014585385000_6.6.e005187.38","doi-asserted-by":"crossref","DOI":"10.1186\/s12916-019-1450-2","article-title":"Determinants of high residual post-PCV13 pneumococcal vaccine-type carriage in Blantyre, Malawi: a modelling study","volume":"17","author":"Louren\u00e7o","year":"2019","journal-title":"BMC Med"},{"key":"2025073014585385000_6.6.e005187.39","doi-asserted-by":"crossref","first-page":"858","DOI":"10.1097\/INF.0000000000000717","article-title":"The efficacy and duration of protection of pneumococcal conjugate vaccines against nasopharyngeal carriage: a meta-regression model","volume":"34","author":"Le Polain De Waroux","year":"2015","journal-title":"Pediatr Infect Dis J"},{"key":"2025073014585385000_6.6.e005187.40","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0195799","article-title":"Pneumococcal carriage in children and their household contacts six years after introduction of the 13-valent pneumococcal conjugate vaccine in England","volume":"13","author":"Southern","year":"2018","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.41","doi-asserted-by":"publisher","DOI":"10.1097\/INF.0b013e31824214ac"},{"key":"2025073014585385000_6.6.e005187.42","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0129649","article-title":"Seasonality of pneumococcal nasopharyngeal carriage in rural Gambia determined within the context of a cluster randomized pneumococcal vaccine trial","volume":"10","author":"Bojang","year":"2015","journal-title":"PLoS One"},{"key":"2025073014585385000_6.6.e005187.43","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/cit721"},{"key":"2025073014585385000_6.6.e005187.44","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1016\/S0140-6736(05)66550-6","article-title":"Herd immunity conferred by killed oral cholera vaccines in Bangladesh: a reanalysis","volume":"366","author":"Ali","year":"2005","journal-title":"The Lancet"},{"key":"2025073014585385000_6.6.e005187.45","doi-asserted-by":"crossref","first-page":"2666","DOI":"10.1016\/j.vaccine.2018.03.051","article-title":"Factors associated with routine immunization coverage of children under one year old in Lao People\u2019s Democratic Republic","volume":"36","author":"Phoummalaysith","year":"2018","journal-title":"Vaccine"},{"key":"2025073014585385000_6.6.e005187.46","doi-asserted-by":"crossref","first-page":"4103","DOI":"10.1016\/j.vaccine.2016.06.053","article-title":"Monitoring vaccination coverage: defining the role of surveys","volume":"34","author":"Cutts","year":"2016","journal-title":"Vaccine"},{"key":"2025073014585385000_6.6.e005187.47","unstructured":"World Health Organization . Limitations related to globally reported immunization subnational data 2020."},{"key":"2025073014585385000_6.6.e005187.48","unstructured":"Lao Statistics Bureau . Lao social indicator survey II 2017. Lao PDR, 2018. Available: https:\/\/www.unicef.org\/laos\/media\/306\/file\/LSIS2017ENG.pdf [Accessed 4 Feb 2021]."},{"key":"2025073014585385000_6.6.e005187.49","doi-asserted-by":"publisher","DOI":"10.1017\/S0950268804001980"},{"key":"2025073014585385000_6.6.e005187.50","doi-asserted-by":"publisher","DOI":"10.1128\/JCM.01551-07"},{"key":"2025073014585385000_6.6.e005187.51","doi-asserted-by":"crossref","first-page":"2367","DOI":"10.1016\/j.vaccine.2010.01.005","article-title":"Huge impact of assumptions on indirect effects on the cost-effectiveness of routine infant vaccination with 7-valent conjugate vaccine (Prevnar)","volume":"28","author":"Rozenbaum","year":"2010","journal-title":"Vaccine"},{"key":"2025073014585385000_6.6.e005187.52","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1002845"}],"container-title":["BMJ Global Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjgh-2021-005187","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T21:59:07Z","timestamp":1753912747000},"score":1,"resource":{"primary":{"URL":"https:\/\/gh.bmj.com\/lookup\/doi\/10.1136\/bmjgh-2021-005187"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6]]},"references-count":52,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6,9]]},"published-print":{"date-parts":[[2021,6]]}},"alternative-id":["10.1136\/bmjgh-2021-005187"],"URL":"https:\/\/doi.org\/10.1136\/bmjgh-2021-005187","relation":{},"ISSN":["2059-7908"],"issn-type":[{"value":"2059-7908","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6]]}}}