Risk factors of hypertension among adults aged 35-64 years living in an urban slum Nairobi, Kenya
Olack B , Wabwire-Mangen F , Smeeth L , Montgomery JM , Kiwanuka N , Breiman RF . BMC Public Health 2015 15 (1) 1251 BACKGROUND: Hypertension is an emerging public health problem in Sub Saharan Africa (SSA) and urbanization is considered to favor its emergence. Given a paucity of information on hypertension and associated risk factors among urban slum dwellers in SSA, we aimed to characterize the distribution of risk factors for hypertension and investigate their association with hypertension in an urban slum in Kenya. METHODS: We conducted a community based cross-sectional survey among adults 35 years and older living in Kibera slum Nairobi, Kenya. Trained interviewers collected data on socio demographic characteristics and self reported health behaviours using modified World Health Organization stepwise surveillance questionnaire for chronic disease risk factors. Anthropometric and blood pressure measurements were performed following standard procedures. Multiple logistic regression was used for analysis and odds ratios with 95 % confidence intervals were calculated to identify risk factors associated with hypertension. RESULT: A total of 1528 adults were surveyed with a mean age of 46.7 years. The age-standardized prevalence of hypertension was 29.4 % (95 % CI 27.0-31.7). Among the 418 participants classified as hypertensive, over one third (39.0 %) were unaware they had hypertension. Prevalence of current smoking and alcohol consumption was 8.5 and 13.1 % respectively. Over one quarter 26.2 % participants were classified as overweight (Body Mass Index [BMI] ≥25 to ≤29.9 kg/m(2)), and 17 % classified as obese (BMI ≥30 kg/m(2)). Overweight, obesity, current smoking, some level of education, highest wealth index, moderate physical activity, older age and being widowed were each independently associated with hypertension. When fit in a multivariable logistic regression model, being a widow [AOR = 1.7; (95 % CI, 1.1-2.6)], belonging to the highest wealth index [AOR = 1.6; (95 % CI, 1.1-2.5)], obesity [AOR = 1.8; 95 % CI, 1.1-3.1)] and moderate physical activity [AOR = 1.9; (95 % CI, 1.2-3.0)], all remained significantly associated with hypertension. CONCLUSION: Hypertension in the slum is a public health problem affecting at least one in three adults aged 35-64 years. Age, marital status, wealth index, physical inactivity and body mass index are important risk factors associated with hypertension. Prevention measures targeting the modifiable risk factors associated with hypertension are warranted to curb hypertension and its progressive effects. |
Multimorbidity patterns in the United States: implications for research and clinical practice
Goodman RA , Ling SM , Briss PA , Parrish RG , Salive ME , Finke BS . J Gerontol A Biol Sci Med Sci 2015 71 (2) 215-20 The increasing prevalence of persons with multimorbidity in many countries has sparked strong growth in research on the epidemiology of multimorbidity, in part to help improve approaches to preventing and managing chronic conditions ( 1–6 ). In this issue of the Journal , Garin and colleagues have made a major contribution to this field of research by examining nationally representative data from studies of noninstitutionalized, predominantly older adults in nine countries that represent the socioeconomic spectrum, and by using a common set of 12 chronic conditions to characterize epidemiologic patterns of multimorbidity among older adults in those countries ( 7 ). | Particularly noteworthy are their results for the relation between multimorbidity and sociodemographic factors (age, sex, education, marital status, wealth, and place of residence), as well as the most prevalent comorbid conditions (hypertension, arthritis, and cataract). In addition, their analysis identified selected multimorbidity combinations for each country and across countries, the most common of which are “cardio-respiratory” and “metabolic” patterns. |
Patterns of chronic conditions and their associations with behaviors and quality of life, 2010
Barile JP , Mitchell SA , Thompson WW , Zack MM , Reeve BB , Cella D , Smith AW . Prev Chronic Dis 2015 12 E222 INTRODUCTION: Co-occurring chronic health conditions elevate the risk of poor health outcomes such as death and disability, are associated with poor quality of life, and magnify the complexities of self-management, care coordination, and treatment planning. This study assessed patterns of both singular and multiple chronic conditions, behavioral risk factors, and quality of life in a population-based sample. METHODS: In a national survey, adults (n = 4,184) answered questions about the presence of 27 chronic conditions. We used latent class analysis to identify patterns of chronic conditions and to explore associations of latent class membership with sociodemographic characteristics, behavioral risk factors, and health. RESULTS: Latent class analyses indicated 4 morbidity profiles: a healthy class (class 1), a class with predominantly physical health conditions (class 2), a class with predominantly mental health conditions (class 3), and a class with both physical and mental health conditions (class 4). Class 4 respondents reported significantly worse physical health and well-being and more days of activity limitation than those in the other latent classes. Class 4 respondents were also more likely to be obese and sedentary, and those with predominantly mental health conditions were most likely to be current smokers. CONCLUSIONS: Subgroups with distinct patterns of chronic conditions can provide direction for screening and surveillance, guideline development, and the delivery of complex care services. |
Exploring potential reasons for the temporal trend in dialysis-requiring AKI in the United States
Hsu RK , McCulloch CE , Heung M , Saran R , Shahinian VB , Pavkov ME , Burrows NR , Powe NR , Hsu CY . Clin J Am Soc Nephrol 2015 11 (1) 14-20 BACKGROUND AND OBJECTIVES: The population incidence of dialysis-requiring AKI has risen substantially in the last decade in the United States, and factors associated with this temporal trend are not well known. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective cohort study using data from the Nationwide Inpatient Sample, a United States nationally representative database of hospitalizations from 2007 to 2009. We used validated International Classification of Diseases, Ninth Revision codes to identify hospitalizations with dialysis-requiring AKI and then, selected the diagnostic and procedure codes most highly associated with dialysis-requiring AKI in 2009. We applied multivariable logistic regression adjusting for demographics and used a backward selection technique to identify a set of diagnoses or a set of procedures that may be a driver for this changing risk in dialysis-requiring AKI. RESULTS: From 2007 to 2009, the population incidence of dialysis-requiring AKI increased by 11% per year (95% confidence interval, 1.07 to 1.16; P<0.001). Using backward selection, we found that the temporal trend in the six diagnoses, septicemia, hypertension, respiratory failure, coagulation/hemorrhagic disorders, shock, and liver disease, sufficiently and fully accounted for the temporal trend in dialysis-requiring AKI. In contrast, temporal trends in 15 procedures most commonly associated with dialysis-requiring AKI did not account for the increasing dialysis-requiring AKI trend. CONCLUSIONS: The increasing risk of dialysis-requiring AKI among hospitalized patients in the United States was highly associated with the changing burden of six acute and chronic conditions but not with surgeries and procedures. |
Invasive cancer incidence and survival - United States, 2012
Henley SJ , Singh SD , King J , Wilson RJ , O'Neil ME , Ryerson AB . MMWR Morb Mortal Wkly Rep 2015 64 (49) 1353-8 Many factors contribute to changes in cancer incidence, including changes in risk exposures or changes in the use of cancer screening tests (1). To monitor changes in cancer incidence and assess progress toward achieving Healthy People 2020 objectives,* CDC analyzed data from U.S. Cancer Statistics (USCS) for 2012, the most recent data available. USCS includes high quality incidence data from CDC's National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, survival data from NPCR, and mortality data from the National Vital Statistics System (2). In 2012, a total of 1,529,078 invasive cancers were reported to cancer registries in the United States (excluding Nevada), for an annual incidence rate of 440 cases per 100,000 persons. Cancer incidence rates were higher among males (483) than females (412), highest among blacks (446), and ranged by state, from 371 to 515 per 100,000 persons (355 in Puerto Rico). The proportion of persons with cancer who survived ≥5 years after diagnosis was 66%. The proportion was the same for males and females (66%) but lower among blacks (60%) compared with whites (66%). These cancer incidence, survival, and mortality surveillance data are continually tracked and used by states to effectively plan health care allocation and support services. |
Acute kidney injury recovery pattern and subsequent risk of CKD: an analysis of Veterans Health Administration data
Heung M , Steffick DE , Zivin K , Gillespie BW , Banerjee T , Hsu CY , Powe NR , Pavkov ME , Williams DE , Saran R , Shahinian VB . Am J Kidney Dis 2015 67 (5) 742-52 BACKGROUND: Studies suggest an association between acute kidney injury (AKI) and long-term risk for chronic kidney disease (CKD), even following apparent renal recovery. Whether the pattern of renal recovery predicts kidney risk following AKI is unknown. STUDY DESIGN: Retrospective cohort. SETTING & PARTICIPANTS: Patients in the Veterans Health Administration in 2011 hospitalized (>24 hours) with at least 2 inpatient serum creatinine measurements, baseline estimated glomerular filtration rate > 60mL/min/1.73m2, and no diagnosis of end-stage renal disease or non-dialysis-dependent CKD: 17,049 (16.3%) with and 87,715 without AKI. PREDICTOR: Pattern of recovery to creatinine level within 0.3mg/dL of baseline after AKI: within 2 days (fast), in 3 to 10 days (intermediate), and no recovery by 10 days (slow or unknown). OUTCOME: CKD stage 3 or higher, defined as 2 outpatient estimated glomerular filtration rates < 60mL/min/1.73m2 at least 90 days apart or CKD diagnosis, dialysis therapy, or transplantation. MEASUREMENTS: Risk for CKD was modeled using modified Poisson regression and time to death-censored CKD was modeled using Cox proportional hazards regression, both stratified by AKI stage. RESULTS: Most patients' AKI episodes were stage 1 (91%) and 71% recovered within 2 days. At 1 year, 18.2% had developed CKD (AKI, 31.8%; non-AKI, 15.5%; P<0.001). In stage 1, the adjusted relative risk ratios for CKD stage 3 or higher were 1.43 (95% CI, 1.39-1.48), 2.00 (95% CI, 1.88-2.12), and 2.65 (95% CI, 2.51-2.80) for fast, intermediate, and slow/unknown recovery. A similar pattern was observed in subgroup analyses incorporating albuminuria and sensitivity analysis of death-censored time to CKD. LIMITATIONS: Variable timing of follow-up and mostly male veteran cohort may limit generalizability. CONCLUSIONS: Patients who develop AKI during a hospitalization are at substantial risk for the development of CKD by 1 year following hospitalization and timing of AKI recovery is a strong predictor, even for the mildest forms of AKI. |
The association between psychological distress and self-reported sleep duration in a population-based sample of women and men
Cunningham TJ , Wheaton AG , Giles WH . Sleep Disord 2015 2015 172064 Mental health and sleep are intricately linked. This study characterized associations of psychological distress with short (≤6 hours) and long (≥9 hours) sleep duration among adults aged ≥18 years. 2013 Behavioral Risk Factor Surveillance System data (n = 36,859) from Colorado, Minnesota, Nevada, Tennessee, and Washington included the Kessler 6 (K6) scale, which has been psychometrically validated for measuring severe psychological distress (SPD); three specifications were evaluated. Overall, 4.0% of adults reported SPD, 33.9% reported short sleep, and 7.8% reported long sleep. After adjustment, adults with SPD had 1.58 (95% CI: 1.45, 1.72) and 1.39 (95% CI: 1.08, 1.79) times higher probability of reporting short and long sleep duration, respectively. Using an ordinal measure showed a dose-response association with prevalence ratios of 1.00, 1.16, 1.38, 1.67, and 2.11 for short sleep duration. Each additional point added to the K6 scale was associated with 1.08 (95% CI: 1.07, 1.10) and 1.02 (95% CI: 1.00, 1.03) times higher probability of reporting short and long sleep duration, respectively. Some results were statistically different by gender. Any psychological distress, not only SPD, was associated with a higher probability of short sleep duration but not long sleep duration. These findings highlight the need for interventions. |
Associations of relative handgrip strength and cardiovascular disease biomarkers in U.S. adults, 2011-2012
Lawman HG , Troiano RP , Perna FM , Wang CY , Fryar CD , Ogden CL . Am J Prev Med 2015 50 (6) 677-683 INTRODUCTION: Although decline in muscle mass and quality and resulting declines in muscle strength are associated with aging, more research is needed in general populations to assess the utility of handgrip strength as an indicator of muscle strength and cardiovascular disease risk. METHODS: Data from 4,221 participants aged ≥20 years in the 2011-2012 cycle of National Health and Nutrition Examination Survey were analyzed during 2014-2015. Standing isometric relative handgrip strength (calculated as maximal absolute handgrip strength from both hands divided by BMI) was used to predict cardiovascular biomarkers, including blood pressure (measured systolic and diastolic blood pressure); serum lipids (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides); and plasma insulin and glucose. RESULTS: Results from regression analyses showed that higher relative grip strength was significantly associated with lower systolic blood pressure, triglycerides, and plasma insulin and glucose, and higher high-density lipoprotein cholesterol in male and female participants (p<0.05 for all). Secondary descriptive analyses found that absolute handgrip strength increased significantly with increasing weight status, but relative handgrip strength decreased significantly with increasing weight status. CONCLUSIONS: Results suggest that increased relative handgrip strength may be associated with a better profile of cardiovascular health biomarkers among U.S. adults. Relative grip strength, which both adjusts for the confounding of mass and assesses concomitant health risks of increased body size and low muscle strength, may be a useful public health measure of muscle strength. |
Changes in fasting lipids during puberty
Eissa MA , Mihalopoulos NL , Holubkov R , Dai S , Labarthe DR . J Pediatr 2015 170 199-205 OBJECTIVE: To describe longitudinal changes in plasma lipid levels and pubertal stage in youths from age 8-18 years, in Project HeartBeat! STUDY DESIGN: Fasting blood samples and pubertal stage, using physical assessment of secondary sex characteristics, were obtained every 4 months for up to 4 years in a mixed longitudinal study of 633 children (49.1% female, 20.1% black), initially aged 8, 11, and 14 years. Total cholesterol, low density lipoprotein-cholesterol, high density lipoprotein-cholesterol, triglycerides (TG), and nonhigh density lipoprotein-cholesterol measurements were obtained. Data were collected from 1991-1995. RESULTS: Pubertal stage correlations with age varied among all race-sex groups (range, r = 0.61-0.70), and a given pubertal stage could represent a range of 5 years or more of chronological age. Throughout puberty, levels of total cholesterol, low density lipoprotein-cholesterol, and nonhigh density lipoprotein-cholesterol decreased, TG in males increased, and high density lipoprotein-cholesterol and TG in females showed no changes. Within a given pubertal stage, plasma lipid levels tended to differ by race, sex, or both. CONCLUSIONS: Lipid levels change markedly by pubertal stage, and patterns differ by sex and race. Chronological age ranges widely within a given pubertal stage and is an insensitive indicator of pubertal stage and the related changes in lipid levels. Pubertal development should be considered when determining screening criteria to identify youths with adverse blood lipid levels. |
Changing trends in asthma prevalence among children
Akinbami LJ , Simon AE , Rossen LM . Pediatrics 2015 137 (1) 1-7 BACKGROUND: Childhood asthma prevalence doubled from 1980 to 1995 and then increased more slowly from 2001 to 2010. During this second period, racial disparities increased. More recent trends remain to be described. METHODS: We analyzed current asthma prevalence using 2001-2013 National Health Interview Survey data for children ages 0 to 17 years. Logistic regression with quadratic terms was used to test for nonlinear patterns in trends. Differences between demographic subgroups were further assessed with multivariate models controlling for gender, age, poverty status, race/ethnicity, urbanicity, and geographic region. RESULTS: Overall, childhood asthma prevalence increased from 2001 to 2009 followed by a plateau then a decline in 2013. From 2001 to 2013, multivariate logistic regression showed no change in prevalence among non-Hispanic white and Puerto Rican children and those in the Northeast and West; increasing prevalence among 10- to 17-year-olds, poor children, and those living in the South; increasing then plateauing prevalence among 5- to 9-year-olds, near-poor children, and non-Hispanic black children; and increasing then decreasing prevalence among 0- to 4-year-olds, nonpoor, and Mexican children and those in the Midwest. Non-Hispanic black-white disparities stopped increasing, and Puerto Rican children remained with the highest prevalence. CONCLUSIONS: Current asthma prevalence ceased to increase among children in recent years and the non-Hispanic black-white disparity stopped increasing due mainly to plateauing prevalence among non-Hispanic black children. |
Role of Epithelial-Mesenchyme Transition in Chlamydia Pathogenesis.
Igietseme JU , Omosun Y , Stuchlik O , Reed MS , Partin J , He Q , Joseph K , Ellerson D , Bollweg B , George Z , Eko FO , Bandea C , Liu H , Yang G , Shieh WJ , Pohl J , Karem K , Black CM . PLoS One 2015 10 (12) e0145198 Chlamydia trachomatis genital infection in women causes serious adverse reproductive complications, and is a strong co-factor for human papilloma virus (HPV)-associated cervical epithelial carcinoma. We tested the hypothesis that Chlamydia induces epithelial-mesenchyme transition (EMT) involving T cell-derived TNF-alpha signaling, caspase activation, cleavage inactivation of dicer and dysregulation of micro-RNA (miRNA) in the reproductive epithelium; the pathologic process of EMT causes fibrosis and fertility-related epithelial dysfunction, and also provides the co-factor function for HPV-related cervical epithelial carcinoma. Using a combination of microarrays, immunohistochemistry and proteomics, we showed that chlamydia altered the expression of crucial miRNAs that control EMT, fibrosis and tumorigenesis; specifically, miR-15a, miR-29b, miR-382 and MiR-429 that maintain epithelial integrity were down-regulated, while miR-9, mi-R-19a, miR-22 and miR-205 that promote EMT, fibrosis and tumorigenesis were up-regulated. Chlamydia induced EMT in vitro and in vivo, marked by the suppression of normal epithelial cell markers especially E-cadherin but up-regulation of mesenchymal markers of pathological EMT, including T-cadherin, MMP9, and fibronectin. Also, Chlamydia upregulated pro-EMT regulators, including the zinc finger E-box binding homeobox protein, ZEB1, Snail1/2, and thrombospondin1 (Thbs1), but down-regulated anti-EMT and fertility promoting proteins (i.e., the major gap junction protein connexin 43 (Cx43), Mets1, Add1Scarb1 and MARCKSL1). T cell-derived TNF-alpha signaling was required for chlamydial-induced infertility and caspase inhibitors prevented both infertility and EMT. Thus, chlamydial-induced T cell-derived TNF-alpha activated caspases that inactivated dicer, causing alteration in the expression of reproductive epithelial miRNAs and induction of EMT. EMT causes epithelial malfunction, fibrosis, infertility, and the enhancement of tumorigenesis of HPV oncogene-transformed epithelial cells. These findings provide a novel understanding of the molecular pathogenesis of chlamydia-associated diseases, which may guide a rational prevention strategy. |
Racial discrimination and HIV-related risk behaviors in southeast Louisiana
Kaplan KC , Hormes JM , Wallace M , Rountree M , Theall KP . Am J Health Behav 2016 40 (1) 132-43 OBJECTIVES: We examined the relationship between cumulative experiences of racial discrimination and HIV-related risk taking, and whether these relationships are mediated through alcohol use among African Americans in semi-rural southeast Louisiana. METHODS: Participants (N = 214) reported on experiences of discrimination, HIV sexual risk-taking, history of sexually transmitted infection (STI), and health behaviors including alcohol use in the previous 90 days. Experiences of discrimination (scaled both by frequency of occurrence and situational counts) as a predictor of a sexual risk composite score as well as a history of STI was assessed using multivariate linear and logistic regression, respectively, including tests for mediation by alcohol use. RESULTS: Discrimination was common in this cohort, with respondents confirming their experience on average 7 of the 9 potential situations and on more than 34 separate occasions. After adjustment, discrimination was significantly associated with increasing sexual risk-taking and lifetime history of STI when measured either by frequency of occurrence or number of situations, although there was no evidence that these relationships were mediated through alcohol use. CONCLUSIONS: Cumulative experiences of discrimination may play a significant role in sexual risk behavior and consequently increase vulnerability to HIV and other STIs. |
Tuberculosis contact investigations - United States, 2003-2012
Young KH , Ehman M , Reves R , Maddox BL , Khan A , Chorba TL , Jereb J . MMWR Morb Mortal Wkly Rep 2016 64 1369-74 Mycobacterium tuberculosis is transmitted through the air from an infectious patient (index patient) to other persons (contacts) who share space. Exposure to M. tuberculosis can result in tuberculosis (TB) disease or latent TB infection (LTBI), which has no clinical symptoms or radiologic evidence of disease. The cycle of transmission can be ended by isolating and treating patients with TB disease, examining contacts, and treating LTBI to prevent progression to TB disease. CDC systematically collects aggregate data on contact investigations from the 50 states, the District of Columbia (DC), and Puerto Rico. Data from 2003-2012 were analyzed for trends in yields from contact investigations, in terms of numbers of contacts elicited and examined and the estimated number of TB cases averted through treatment of LTBI among contacts in 2012. During 2003-2012, the number of TB cases decreased, while the number of contacts listed per index patient with contacts elicited increased. In 2012, U.S. public health authorities reported 9,945 cases of TB disease (1) and 105,100 contacts. Among these contacts, 84,998 (80.9%) were examined; TB was diagnosed in 532 (0.6%) and LTBI in 15,411 (18.1%). Among contacts with LTBI, 10,137 (65.8%) started treatment, and 6,689 (43.4% of all contacts with LTBI) completed treatment. By investigating contacts in 2012, an estimated 128 TB cases (34% of all potential cases) over the initial 5 years were averted, but an additional 248 cases (66%) might have been averted if all potentially contagious TB patients had contacts elicited, all contacts were examined, and all infected contacts completed treatment. Enhancing contact investigation activities, particularly by ensuring completion of treatment by contacts recently infected with M. tuberculosis, is essential to achieve the goal of TB elimination. |
Tuberculosis screening outcomes for newly diagnosed persons living with HIV, Nyanza Province, Kenya, 2009
Burmen B , Modi S , Cavanaugh JS , Muttai H , McCarthy KD , Alexander H , Cain K . Int J Tuberc Lung Dis 2016 20 (1) 79-84 SETTING: Fifteen human immunodeficiency virus (HIV) clinics in Nyanza Region, Western Kenya. OBJECTIVE: To describe routine tuberculosis (TB) screening and diagnostic practices among newly enrolled people living with HIV (PLHIV) prior to the implementation of World Health Organization recommended TB intensified case finding. DESIGN: Retrospective chart abstraction of PLHIV aged 7 years who were newly enrolled in HIV care in July and August 2009, and who had not received antiretroviral treatment in the preceding 2 years or been diagnosed with TB in the previous year. Factors associated with evidence of TB diagnostic evaluation among symptomatic PLHIV were assessed. RESULTS: Of 1020 patients included in the analysis, 995 (98%) were screened for TB at enrolment and 613 (62%) reported TB symptoms. Ninety-six (16%) patients with symptoms had evidence of referral for TB diagnostic evaluation, including patients at large clinics, those with advanced HIV disease and those reporting multiple TB symptoms. Among the 43 (45%) with documented evaluation results, 26 (60%) were diagnosed with TB. CONCLUSION: Although most PLHIV were screened for TB, very few underwent an evaluation, and the proportion diagnosed with TB was very low. Efforts to improve TB screening should focus on standardizing the intensified case finding algorithm and linkage to, and adequate infrastructure for, TB diagnostic evaluation. |
The utility of population-based surveys to describe the continuum of HIV services for key and general populations
Hladik W , Benech I , Bateganya M , Hakim AJ . Int J STD AIDS 2016 27 (1) 5-12 Monitoring the cascade or continuum of HIV services - ranging from outreach services to anti-retroviral treatment - has become increasingly important as the focus in prevention moves toward biomedical interventions, in particular, 'Treatment as Prevention.' The HIV continuum typically utilises clinic-based care and treatment monitoring data and helps identify gaps and inform programme improvements. This paper discusses the merits of a population-based survey-informed continuum of services. Surveys provide individual-level, population-based data by sampling persons both in and outside the continuum, which facilitate the estimation of population fractions, such as the proportion of people living with HIV in care, as well as the examination of determinants for being in or outside the continuum. Survey-informed cascades of services may especially benefit key populations at increased risk for HIV infection for who social marginalisation, criminalisation, and stigma result in barriers to access and retention in services, a low social visibility, mobility, and outreach-based services can compromise clinic-based monitoring. Adding CD4+ T-cell count and viral load measurements to such surveys may provide population-level information on viral load suppression, stage of disease, treatment needs, and population-level transmission potential. While routine clinic-based reporting will remain the mainstay of monitoring, a survey-informed service cascade can address some of its limitations and offer additional insights. |
Notes from the field: Group A streptococcal pharyngitis misdiagnoses at a rural urgent-care clinic - Wyoming, March 2015
Harrist A , Van Houten C , Shulman ST , Van Beneden C , Murphy T . MMWR Morb Mortal Wkly Rep 2016 64 1383-5 Group A Streptococcus (GAS) is the most common bacterial cause of pharyngitis, implicated in 20%-30% of pediatric and 5%-15% of adult health care visits for sore throat. Along with the sudden onset of throat pain, GAS pharyngitis symptoms include fever, headache, and bilateral tender cervical lymphadenopathy. Accurate diagnosis and management of GAS pharyngitis is critical for limiting antibiotic overuse and preventing rheumatic fever, but distinguishing between GAS and viral pharyngitis clinically is challenging. Guidelines for diagnosis and management of GAS pharyngitis have been published by the Infectious Diseases Society of America (IDSA). IDSA recommends that patients with sore throat be tested for GAS to distinguish between GAS and viral pharyngitis; however, IDSA emphasizes the use of selective testing based on clinical symptoms and signs to avoid identifying GAS carriers rather than acute GAS infections. Therefore, testing for GAS usually is not recommended for the following: patients with sore throat and accompanying symptoms (e.g., cough, rhinorrhea) that strongly suggest a viral etiology; children aged <3 years, because acute rheumatic fever is extremely rare in this age group; and asymptomatic household contacts of patients with GAS pharyngitis. IDSA recommends penicillin or amoxicillin as the treatment of choice based on effectiveness and narrow spectrum of activity. To date, penicillin-resistant GAS has never been documented. |
Elevated mortality after successful tuberculosis treatment
van den Hof S , Borgdorff MW . Int J Tuberc Lung Dis 2016 20 (1) 2 There is limited published information on mortality rates after successful completion of tuberculosis treatment. While tuberculosis treatment outcomes are routinely recorded, monitoring patients after completion of treatment is not recommended in WHO guidelines, except for one year post-treatment monitoring of drug-resistant TB patients to identify recurrent TB (1,2). | In this issue Shuldiner et al. assessed post-treatment mortality through linkage of the national TB registry and civil registry in a cohort of 3250 successfully treated Israeli TB patients who had started treatment in the period 2000–2010 (3). These successfully treated patients had a 3.7 (95% CI 3.4–4.1) times higher risk of death than the general Israeli population. The standardized mortality ratio was highest in the age group 25–44 years and somewhat higher among men (4.2) than women (3.2). | Shuldiner et al. suggest that increased mortality after successful tuberculosis treatment may be due to pulmonary impairment caused by tuberculosis and/or to shared risk factors, such as smoking, for tuberculosis and conditions such as lung cancer. Tuberculosis is more likely to occur in patients with underlying conditions such as cancer and diabetes, in patients with specific risk factors such as smoking and HIV infection, as well as in those with more general socio-economic determinants, owing to living and working conditions with a higher risk of exposure to Mycobacterium tuberculosis and less access to high-quality health care (4), all of which are also independently associated with increased mortality rates. Thus, it is possible that the increased mortality rates post-tuberculosis treatment would reflect the risks associated with these other risk factors and underlying conditions rather than lung damage after tuberculosis. |
Factors associated with recurrent tuberculosis more than 12 months after treatment completion
Kim L , Moonan PK , Heilig CM , Woodruff RS , Kammerer JS , Haddad MB . Int J Tuberc Lung Dis 2016 20 (1) 49-56 SETTING: Even among persons who have completed a course of treatment for their first tuberculosis (TB) episode, patients with a history of TB are at higher risk for having TB. OBJECTIVE: To describe factors from the initial TB episode associated with recurrent TB among patients who completed treatment and remained free of TB for at least 12 months. DESIGN: During 1993-2006, US TB cases stratified by birth origin were examined. Cox proportional hazards regression was used to assess the association of factors during the initial episode with recurrence at least 12 months after treatment completion. RESULTS: Among 632 US-born patients, TB recurrence was associated with age 25-44 years (adjusted hazard ratio [aHR] 1.77, 99% confidence interval [CI] 1.02-3.09, attributable fraction [AF] 1-34%), substance use (aHR 1.57, 99%CI 1.23-2.02, AF 8-22%), and treatment supervised by health departments (aHR 1.42, 99%CI 1.03-1.97, AF 2-28%). Among 211 foreign-born patients, recurrence was associated with human immunodeficiency virus infection (aHR 2.24, 99%CI 1.27-3.98, AF 2-9%) and smear-positive TB (aHR 1.56, 99%CI 1.06-2.30, AF 3-33%). CONCLUSION: Factors associated with recurrence differed by origin of birth, and might be useful for anticipating greater risk for recurrent TB among certain patients with a history of TB. |
ART adherence as a key component of prevention with persons living with HIV in Mozambique
Dawson-Rose C , Gutin SA , Cummings B , Jaiantilal P , Johnson K , Mbofana F . J Assoc Nurses AIDS Care 2016 27 (1) 44-56 Medication adherence is an effective approach to prevent HIV transmission. In Mozambique, a country with a generalized epidemic, the government has adopted Positive Prevention (PP) training for clinicians as part of its national strategy. Our study, conducted after trainings in five clinics, examined the understanding of trained health care staff and their patients about the importance of adherence to antiretroviral therapy (ART), a key element of PP. Interviews with trained clinicians (n = 31) and patients (n = 57) were conducted and analyzed. Clinicians and patients demonstrated an understanding that ART adherence could decrease HIV transmission. However, participants also highlighted the difficulties of adherence when patients had limited access to food. At the same time that treatment as prevention awareness was increasing, poverty and widespread food insecurity were barriers to taking medications. In Mozambique, the full benefits of treatment as prevention may not be realized without adequate access to food. |
Risk factors for respiratory syncytial virus associated with acute lower respiratory infection in children under five years: Systematic review and meta-analysis
Shi T , Balsells E , Wastnedge E , Singleton R , Rasmussen ZA , Zar HJ , Rath BA , Madhi SA , Campbell S , Vaccari LC , Bulkow LR , Thomas ED , Barnett W , Hoppe C , Campbell H , Nair H . J Glob Health 2015 5 (2) 020416 BACKGROUND: Respiratory syncytial virus (RSV) is the most common pathogen identified in young children with acute lower respiratory infection (ALRI) as well as an important cause of hospital admission. The high incidence of RSV infection and its potential severe outcome make it important to identify and prioritise children who are at higher risk of developing RSV-associated ALRI. We aimed to identify risk factors for RSV-associated ALRI in young children. METHODS: We carried out a systematic literature review across 4 databases and obtained unpublished studies from RSV Global Epidemiology Network (RSV GEN) collaborators. Quality of all eligible studies was assessed according to modified GRADE criteria. We conducted meta-analyses to estimate odds ratios with 95% confidence intervals (CI) for individual risk factors. RESULTS: We identified 20 studies (3 were unpublished data) with "good quality" that investigated 18 risk factors for RSV-associated ALRI in children younger than five years old. Among them, 8 risk factors were significantly associated with RSV-associated ALRI. The meta-estimates of their odds ratio (ORs) with corresponding 95% confidence intervals (CI) are prematurity 1.96 (95% CI 1.44-2.67), low birth weight 1.91 (95% CI 1.45-2.53), being male 1.23 (95% CI 1.13-1.33), having siblings 1.60 (95% CI 1.32-1.95), maternal smoking 1.36 (95% CI 1.24-1.50), history of atopy 1.47 (95% CI 1.16-1.87), no breastfeeding 2.24 (95% CI 1.56-3.20) and crowding 1.94 (95% CI 1.29-2.93). Although there were insufficient studies available to generate a meta-estimate for HIV, all articles (irrespective of quality scores) reported significant associations between HIV and RSV-associated ALRI. CONCLUSIONS: This study presents a comprehensive report of the strength of association between various socio-demographic risk factors and RSV-associated ALRI in young children. Some of these amenable risk factors are similar to those that have been identified for (all cause) ALRI and thus, in addition to the future impact of novel RSV vaccines, national action against ALRI risk factors as part of national control programmes can be expected to reduce burden of disease from RSV. Further research which identifies, accesses and analyses additional unpublished RSV data sets could further improve the precision of these estimates. |
Serological measures of trachoma transmission intensity
Martin DL , Wiegand R , Goodhew B , Lammie P , Black CM , West S , Gaydos CA , Dize L , Mkocha H , Kasubi M , Gambhir M . Sci Rep 2015 5 18532 Ocular infection with Chlamydia trachomatis can lead to trachoma, a leading infectious cause of blindness. Trachoma is targeted for elimination by 2020. Clinical grading for ocular disease is currently used for evaluating trachoma elimination programs, but serological surveillance can be a sensitive measure of disease transmission and provide a more objective testing strategy than clinical grading. We calculated the basic reproduction number from serological data in settings with high, medium, and low disease transmission based on clinical disease. The data showed a striking relationship between age seroprevalence and clinical data, demonstrating the proof-of-principle that age seroprevalence predicts transmission rates and therefore could be used as an indicator of decreased transmission of ocular trachoma. |
Soap is not enough: handwashing practices and knowledge in refugee camps, Maban County, South Sudan
Phillips RM , Vujcic J , Boscoe A , Handzel T , Aninyasi M , Cookson ST , Blanton C , SBlum L , Ram PK . Confl Health 2015 9 39 BACKGROUND: Refugees are at high risk for communicable diseases due to overcrowding and poor water, sanitation, and hygiene conditions. Handwashing with soap removes pathogens from hands and reduces disease risk. A hepatitis E outbreak in the refugee camps of Maban County, South Sudan in 2012 prompted increased hygiene promotion and improved provision of soap, handwashing stations, and latrines. We conducted a study 1 year after the outbreak to assess the knowledge, attitudes, and practices of the refugees in Maban County. METHODS: We conducted a cross sectional survey of female heads of households in three refugee camps in Maban County. We performed structured observations on a subset of households to directly observe their handwashing practices at times of possible pathogen transmission. RESULTS: Of the 600 households interviewed, nearly all had soap available and 91 % reported water was available "always" or "sometimes". Exposure to handwashing promotion was reported by 85 % of the respondents. Rinsing hands with water alone was more commonly observed than handwashing with soap at critical handwashing times including "before eating" (80 % rinsing vs. 7 % washing with soap) and "before preparing/cooking food" (72.3 % vs 23 %). After toilet use, 46 % were observed to wash hands with soap and an additional 38 % rinsed with water alone. CONCLUSIONS: Despite intensive messaging regarding handwashing with soap and access to soap and water, rinsing hands with water alone rather than washing hands with soap remains more common among the refugees in Maban County. This practice puts them at continued risk for communicable disease transmission. Qualitative research into local beliefs and more effective messaging may help future programs tailor handwashing interventions. |
Ten-year trends of syphilis in sero-surveillance of pregnant women in Rwanda and correlates of syphilis-HIV co-infection
Mutagoma M , Balisanga H , Remera E , Gupta N , Malamba SS , Riedel DJ , Nsanzimana S . Int J STD AIDS 2015 28 (1) 45-53 Syphilis can be transmitted by pregnant women to their children and is a public health problem in Africa. A cross-sectional survey was conducted in 24 antenatal clinics from 2002 to 2003 and increased to 30 sites from 2005 to 2011. Participants were tested for syphilis and HIV. Multi-variate logistic regression was performed to identify risks associated with syphilis and its co-infection with HIV. Results showed that syphilis decreased from 3.8% in 2002 to 2.0% in 2011. Syphilis in the HIV-infected participants increased from 6.0% in 2002 to 10.8% in 2011, but decreased from 3.7% to 1.7% in the HIV-negative participants. In 2011, syphilis in urban participants was 2.7% and 1.4% in rural ones. HIV-infected participants screened positive for syphilis more frequently in both rural (aOR = 3.64 [95% CI: 1.56%-8.51%]) and urban areas (aOR = 7.26 [95% CI: 5.04%-10.46%]). Older participants (25-49 years) residing in urban areas (aOR = 0.43[95% CI: 0.32%-0.58%]) and women with secondary or high education (aOR = 0.35[95% CI: 0.20%-0.62%]) were less likely to screen positive for syphilis. HIV-syphilis co-infection was more likely in women residing in urban areas (aOR = 8.32[95% CI: 3.54%-19.56%]), but less likely in women with secondary/high education (aOR = 0.11[95% CI: 0.01%-0.77%]). In conclusion, syphilis increased in HIV-positive pregnant women, but decreased in HIV-negative women. Positive HIV status and young age were associated risks for syphilis. HIV-syphilis co-infection was associated with a lower level of education and urban residence. |
Timing of influenza epidemics and vaccines in the American tropics, 2002-2008, 2011-2014
Durand LO , Cheng PY , Palekar R , Clara W , Jara J , Cerpa M , El Omeiri N , Ropero AM , Ramirez JB , Araya JL , Acosta B , Bruno A , Calderon de Lozano C , Signor LD , Matute ML , Jackson-Betty S , Mung KS , Diaz-Quinonez JA , Lopez-Martinez I , Balmaseda A , Arevalo BM , Vazquez C , Gutierrez V , Garten R , Widdowson MA , Azziz-Baumgartner E . Influenza Other Respir Viruses 2015 10 (3) 170-5 BACKGROUND: Influenza-associated illness results in increased morbidity and mortality in the Americas. These effects can be mitigated with an appropriately chosen and timed influenza vaccination campaign. To provide guidance in choosing the most suitable vaccine formulation and timing of administration, it is necessary to understand the timing of influenza seasonal epidemics. OBJECTIVES: Our main objective was to determine if influenza occurs in seasonal patterns in the American tropics, and when these patterns occurred. METHODS: Publicly available, monthly seasonal influenza data from the Pan American Health Organization and WHO, from countries in the American tropics were obtained during 2002-2008 and 2011-2014 (excluding unseasonal pandemic activity during 2009-2010). For each country, we calculated the monthly proportion of samples that tested positive for influenza. We applied the monthly proportion data to a logistic regression model for each country. RESULTS: We analyzed 2002-2008 and 2011-2014 influenza surveillance data from the American tropics and identified 13 (81%) of 16 countries with influenza epidemics that, on average, started during May and lasted 4 months. CONCLUSIONS: The majority of countries in the American tropics have seasonal epidemics that start in May. Officials in these countries should consider the impact of vaccinating persons during April with the Southern Hemisphere formulation. |
Tuberculosis knowledge, awareness, and stigma among African-Americans in three southeastern counties in the USA: A qualitative study of community perspectives
Royce RA , Colson PW , Woodsong C , Swinson-Evans T , Walton W , Maiuri A , DeLuca N . J Racial Ethn Health Disparities 2015 4 (1) 47-58 To inform strategies to address the tuberculosis (TB) excess among US-born African-Americans, we sought to understand the TB experience in the most highly affected southeastern communities. We conducted semi-structured interviews and focus groups in three communities with a TB excess-urban (Georgia and Tennessee) and rural (North Carolina). Participants from five groups provided diverse perspectives-African-Americans: patients with TB disease or latent TB infection (LTBI), or at high risk of contracting TB; and local community leaders and TB program staff. Few differences emerged between sites. Many participants demonstrated low levels of knowledge and awareness and held many misconceptions about TB. Patients expressed a preference for verbal communication of medical information. Patients reported fear of stigmatization and shunning, but few experienced discrimination. Patient trust for TB program staff was high, though community leaders often assumed the opposite. The findings will help guide interventions to improve knowledge and awareness regarding TB, including specific attention to the role of public and private health care providers in dispelling persistent misinformation about TB. The insight from these communities will help build the scientific foundation required to effectively eliminate health inequities. |
Virological response and antiretroviral drug resistance emerging during antiretroviral therapy at three treatment centers in Uganda
Kaleebu P , Kirungi W , Watera C , Asio J , Lyagoba F , Lutalo T , Kapaata AA , Nanyonga F , Parry CM , Magambo B , Nazziwa J , Nannyonjo M , Hughes P , Hladik W , Ruberantwari A , Namuwenge N , Musinguzi J , Downing R , Katongole-Mbidde E . PLoS One 2015 10 (12) e0145536 BACKGROUND: With the scale-up of antiretroviral therapy (ART), monitoring programme performance is needed to maximize ART efficacy and limit HIV drug resistance (HIVDR). METHODS: We implemented a WHO HIVDR prospective survey protocol at three treatment centers between 2012 and 2013. Data were abstracted from patient records at ART start (T1) and after 12 months (T2). Genotyping was performed in the HIV pol region at the two time points. RESULTS: Of the 425 patients enrolled, at T2, 20 (4.7%) had died, 66 (15.5%) were lost to follow-up, 313 (73.6%) were still on first-line, 8 (1.9%) had switched to second-line, 17 (4.0%) had transferred out and 1 (0.2%) had stopped treatment. At T2, 272 out of 321 on first and second line (84.7%) suppressed below 1000 copies/ml and the HIV DR prevention rate was 70.1%, just within the WHO threshold of ≥70%. The proportion of participants with potential HIVDR was 20.9%, which is higher than the 18.8% based on pooled analyses from African studies. Of the 35 patients with mutations at T2, 80% had M184V/I, 65.7% Y181C, and 48.6% (54.8% excluding those not on Tenofovir) had K65R mutations. 22.9% had Thymidine Analogue Mutations (TAMs). Factors significantly associated with HIVDR prevention at T2 were: baseline viral load (VL) <100,000 copies/ml [Adjusted odds ratio (AOR) 3.13, 95% confidence interval (CI): 1.36-7.19] and facility. Independent baseline predictors for HIVDR mutations at T2 were: CD4 count <250 cells/mul (AOR 2.80, 95% CI: 1.08-7.29) and viral load ≥100,000 copies/ml (AOR 2.48, 95% CI: 1.00-6.14). CONCLUSION: Strengthening defaulter tracing, intensified follow-up for patients with low CD4 counts and/or high VL at ART initiation together with early treatment initiation above 250 CD4 cells/ul and adequate patient counselling would improve ART efficacy and HIVDR prevention. The high rate of K65R and TAMs could compromise second line regimens including NRTIs. |
Legionellosis outbreak associated with a hotel fountain
Smith SS , Ritger K , Samala U , Black SR , Okodua M , Miller L , Kozak-Muiznieks NA , Hicks LA , Steinheimer C , Ewaidah S , Presser L , Siston AM . Open Forum Infect Dis 2015 2 (4) ofv164 BACKGROUND: In August 2012, the Chicago Department of Public Health (CDPH) was notified of acute respiratory illness, including 1 fatality, among a group of meeting attendees who stayed at a Chicago hotel during July 30-August 3, 2012. Suspecting Legionnaires' disease (LD), CDPH advised the hotel to close their swimming pool, spa, and decorative lobby fountain and began an investigation. METHODS: Case finding included notification of individuals potentially exposed during July 16-August 15, 2012. Individuals were interviewed using a standardized questionnaire. An environmental assessment was performed. RESULTS: One hundred fourteen cases were identified: 11 confirmed LD, 29 suspect LD, and 74 Pontiac fever cases. Illness onsets occurred July 21-August 22, 2012. Median age was 48 years (range, 22-82 years), 64% were male, 59% sought medical care (15 hospitalizations), and 3 died. Relative risks for hotel exposures revealed that persons who spent time near the decorative fountain or bar, both located in the lobby were respectively 2.13 (95%, 1.64-2.77) and 1.25 (95% CI, 1.09-1.44) times more likely to become ill than those who did not. Legionella pneumophila serogroup 1 was isolated from samples collected from the fountain, spa, and women's locker room fixtures. Legionella pneumophila serogroup 1 environmental isolates and a clinical isolate had matching sequence-based types. Hotel maintenance records lacked a record of regular cleaning and disinfection of the fountain. CONCLUSIONS: Environmental testing identified Legionella in the hotel's potable water system. Epidemiologic and laboratory data indicated the decorative fountain as the source. Poor fountain maintenance likely created favorable conditions for Legionella overgrowth. |
Preventive malaria treatment for contacts of patients with Ebola virus disease in the context of the west Africa 2014-15 Ebola virus disease response: an economic analysis
Carias C , Greening B Jr , Campbell CG , Meltzer MI , Hamel MJ . Lancet Infect Dis 2015 16 (4) 449-58 BACKGROUND: After the detection of an Ebola virus disease outbreak in west Africa in 2014, one of the elements of the response was to contact trace and isolate patients in specialised Ebola treatment units (ETUs) at onset of fever. We aimed to assess the economic feasibility of administering preventive malaria treatment to all contacts of patients with Ebola virus disease, to prevent the onset of febrile malaria and subsequent admission to ETUs. METHODS: We used a decision tree model to analyse the costs of preventive malaria treatment (artemisinin-based combination treatment [ACT]) for all contacts of patients with Ebola virus disease (in terms of administration and averted ETU-stay costs) and benefits (in terms of averted ETU admissions) in west Africa, from a health-care provider perspective. The period of analyses was 1 year, which is roughly similar to the duration of the 2014-15 west Africa Ebola outbreak response. We calculated the intervention's cost per ETU admission averted (average cost-effectiveness ratio) by season (wet and dry), country (Liberia, Sierra Leone, and Guinea), and age of contact (<5 years, 5-14 years, and ≥15 years). We did sensitivity analyses to assess how results varied with malaria parasite prevalence (in children aged 2-10 years), daily cost of ETU stay (for Liberian malaria incidence levels), and compliance and effectiveness of preventive malaria treatment. FINDINGS: Administration of ACTs to contacts of patients with Ebola virus disease was cost saving for contacts of all ages in Liberia, Sierra Leone, and Guinea, in both seasons, from a health-care provider perspective. In the wet season, preventive malaria treatment was estimated to reduce the probability of a contact being admitted to an ETU by a maximum of 36% (in Guinea, for contacts aged <5 years), and a minimum of 10% (in Guinea and Sierra Leone, for those aged ≥15 years). Assuming 85% compliance and taking into account the African population pyramid, the intervention is expected to be cost saving in contacts of all age groups in areas with malaria parasite prevalence in children aged 2-10 years as low as 10%. In Liberia during the wet season, malaria preventive treatment was cost saving even when average daily bed-stay costs were as low as US$5 for children younger than 5 years, $9 for those aged 5-14 years, and $22 for those aged 15 years or older. INTERPRETATION: Administration of preventive malaria treatment to contacts of patients with Ebola virus disease should be considered by public health officials when addressing Ebola virus disease outbreaks in countries and seasons where malaria reaches high levels of transmission. FUNDING: Centers for Disease Control and Prevention. |
Evaluating patterns in retention, continuation, gaps, and re-engagement in HIV care in a Medicaid-insured population, 2006-2012, United States
Byrd KK , Furtado M , Bush T , Gardner L . AIDS Care 2015 27 (11) 1387-95 We used the US-based MarketScan((R)) Medicaid Multi-state Databases to determine the un-weighted proportion of publically insured persons with HIV that were retained, continued, and re-engaged in care. Persons were followed for up to 84 months. Cox proportional hazards models were conducted to determine factors associated with gaps in care. Of the 6463 HIV cases identified in 2006, 61% were retained during the first 24 months, and 53% continued in care through 78 months. Between 8% and 30% experienced a gap in care, and 59% of persons who experienced a gap in care later re-engaged in care. Persons with one or more Charlson co-morbidities (HR 0.72, 95% CI 0.64-0.81), ages 40-59 (0.79, 0.71-0.88), mental illness diagnosis (0.79, 0.72-0.87), hepatitis C co-infection (0.83, 0.75-0.93), and female sex (0.86, 0.78-0.94) were less likely to experience a gap in care. Between 27% and 38% of those not retained in care continued to receive HIV-related laboratory services. This Medicaid claims database combines features of both clinic visits-based and surveillance lab-based surrogate measures to give a more complete picture of engagement in care than single-facility-based studies. |
HIV-1 evolution in breakthrough infections in a human trial of oral pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate
Ruone S , Paxton L , McLaurin T , Taylor A , Hanson D , Heneine W , Brooks JT , Garcia-Lerma JG . J Acquir Immune Defic Syndr 2015 72 (2) 129-32 We describe HIV-1 evolutionary dynamics in the four participants from the TDF2-PrEP trial who became HIV-1-infected while prescribed FTC/TDF. At seroconversion, virus diversity in the 2 participants with detectable drug was only 0.05% (95% CI=0.04-0.06) and 0.07% (0.06-0.08) compared to 2.25% (1.95-2.6) and 0.42% (0.36-0.49) in those with no detectable drug, and 0.07%-0.69% in placebo recipients (p>0.5). At 10 months, diversity in adherent participants was only 0.37% (0.31-0.41) and 0.86% (0.82-0.90) compared to 0.5%-1.7% among participants that did not take FTC/TDF (p>0.5). Although limited by the small number of infections that reduced the power to detect differences, we found that sequences from seroconverters with detectable drug were more homogeneous than those from placebo or non-adherent seroconverters. |
Immunolocalization and distribution of rubella antigen in fatal congenital rubella syndrome
Lazar M , Perelygina L , Martines R , Greer P , Paddock CD , Peltecu G , Lupulescu E , Icenogle J , Zaki SR . EBioMedicine 2015 3 86-92 BACKGROUND: An estimated 100,000 cases of congenital rubella syndrome (CRS) occur worldwide each year. The reported mortality rate for infants with CRS is up to 33%. The cellular mechanisms responsible for the multiple congenital defects in CRS are presently unknown. Here we identify cell types positive for rubella virus (RV) in CRS infants. METHODS: Cells and organs involved in RV replication were identified in paraffin-embedded autopsy tissues from three fatal case-patients by histopathologic examination and immunohistochemical (IHC) staining using a rabbit polyclonal RV antibody. Normal rabbit antisera and RV antisera preabsorbed with highly purified RV served as negative controls. RESULTS: RV antigen was found in interstitial fibroblasts in the heart, adventitial fibroblasts of large blood vessels, alveolar macrophages, progenitor cells of the outer granular layer of the brain, and in capillary endothelium and basal plate in the placenta. The antibody specificity was verified by IHC staining of multiple tissue sections from other infectious disease cases. RV infection of each cell type is consistent with abnormalities which have been identified in patients with CRS, in the heart, large blood vessels, and brain. Antigen distribution was consistent with inflammatory response to vascular injury and systemic spread of RV. CONCLUSIONS: The identification of RV positive cell types in CRS is important to better understand the pathology and pathogenesis of CRS. |
The impact of obesity and diabetes on the risk of disease and death due to invasive group A streptococcus infections in adults
Langley G , Hao Y , Pondo T , Miller L , Petit S , Thomas A , Lindegren ML , Farley MM , Dumyati G , Como-Sabetti K , Harrison LH , Baumbach J , Watt J , Van Beneden C . Clin Infect Dis 2015 62 (7) 845-52 BACKGROUND: Invasive group A Streptococcus (iGAS) infections cause significant morbidity and mortality worldwide. We analyzed whether obesity and diabetes were associated with iGAS infections and worse outcomes among an adult US population. METHODS: We determined the incidence of iGAS infections using 2010-2012 cases in adults aged ≥18 years from Active Bacterial Core surveillance (ABCs), a population-based surveillance system, as the numerator. For the denominator, we used ABCs catchment area population estimates from the 2011-2012 Behavioral Risk Factor Surveillance System (BRFSS) survey. The relative risk (RR) of iGAS was determined by obesity and diabetes status after adjusting for age group, gender, race and other underlying conditions through binomial logistic regression. Multivariable logistic regression was used to determine whether obesity or diabetes was associated with increased odds of death due to iGAS compared to normal weight and non-diabetic patients, respectively. RESULTS: Between 2010 and 2012, 2927 iGAS cases were identified. Diabetes was associated with an increased risk of iGAS in all racial groups (adjusted (a)RR ranged from 2.71-5.08). Grade 3 obesity (body mass index [BMI] ≥40) was associated with an increased risk of iGAS for whites (aRR=3.47; 95% confidence interval [CI] =3.00-4.01). Grades 1-2 (BMI= 30.0-<40.0) and grade 3 obesity were associated with an increased odds of death (OR=1.55, [95% CI=1.05, 2.29] and OR=1.62 [95% CI=1.01, 2.61], respectively) when compared to normal weight patients. CONCLUSIONS: These results may help target vaccines against GAS that are currently under development. Efforts to develop enhanced treatment regimens for iGAS may improve prognoses for obese patients. |
Acute flaccid myelitis of unknown etiology in California, 2012-2015
Van Haren K , Ayscue P , Waubant E , Clayton A , Sheriff H , Yagi S , Glenn-Finer R , Padilla T , Strober JB , Aldrovandi G , Wadford DA , Chiu CY , Xia D , Harriman K , Watt JP , Glaser CA . JAMA 2015 314 (24) 2663-2671 IMPORTANCE: There has been limited surveillance for acute flaccid paralysis in North America since the regional eradication of poliovirus. In 2012, the California Department of Public Health received several reports of acute flaccid paralysis cases of unknown etiology. OBJECTIVE: To quantify disease incidence and identify potential etiologies of acute flaccid paralysis cases with evidence of spinal motor neuron injury. DESIGN, SETTING, AND PARTICIPANTS: Case series of acute flaccid paralysis in patients with radiological or neurophysiological findings suggestive of spinal motor neuron involvement reported to the California Department of Public Health with symptom onset between June 2012 and July 2015. Patients meeting diagnostic criteria for other acute flaccid paralysis etiologies were excluded. Cerebrospinal fluid, serum samples, nasopharyngeal swab specimens, and stool specimens were submitted to the state laboratory for infectious agent testing. MAIN OUTCOMES AND MEASURES: Case incidence and infectious agent association. RESULTS: Fifty-nine cases were identified. Median age was 9 years (interquartile range [IQR], 4-14 years; 50 of the cases were younger than 21 years). Symptoms that preceded or were concurrent included respiratory or gastrointestinal illness (n = 54), fever (n = 47), and limb myalgia (n = 41). Fifty-six patients had T2 hyperintensity of spinal gray matter on magnetic resonance imaging and 43 patients had cerebrospinal fluid pleocytosis. During the course of the initial hospitalization, 42 patients received intravenous steroids; 43, intravenous immunoglobulin; and 13, plasma exchange; or a combination of these treatments. Among 45 patients with follow-up data, 38 had persistent weakness at a median follow-up of 9 months (IQR, 3-12 months). Two patients, both immunocompromised adults, died within 60 days of symptom onset. Enteroviruses were the most frequently detected pathogen in either nasopharynx swab specimens, stool specimens, serum samples (15 of 45 patients tested). No pathogens were isolated from the cerebrospinal fluid. The incidence of reported cases was significantly higher during a national enterovirus D68 outbreak occurring from August 2014 through January 2015 (0.16 cases per 100000 person-years) compared with other monitoring periods (0.028 cases per 100000 person-years; P <.001). CONCLUSIONS AND RELEVANCE: In this series of patients identified in California from June 2012 through July 2015, clinical manifestations indicated a rare but distinct syndrome of acute flaccid paralysis with evidence of spinal motor neuron involvement. The etiology remains undetermined, most patients were children and young adults, and motor weakness was prolonged. |
Assessment of oral fluid HIV test performance in an HIV pre-exposure prophylaxis trial in Bangkok, Thailand
Suntharasamai P , Martin M , Choopanya K , Vanichseni S , Sangkum U , Tararut P , Leelawiwat W , Anekvorapong R , Mock PA , Cherdtrakulkiat T , Leethochawalit M , Chiamwongpaet S , Gvetadze RJ , McNicholl JM , Paxton LA , Kittimunkong S , Curlin ME . PLoS One 2015 10 (12) e0145859 BACKGROUND: Rapid easy-to-use HIV tests offer opportunities to increase HIV testing among populations at risk of infection. We used the OraQuick Rapid HIV-1/2 antibody test (OraQuick) in the Bangkok Tenofovir Study, an HIV pre-exposure prophylaxis trial among people who inject drugs. METHODS: The Bangkok Tenofovir Study was a randomized, double-blind, placebo-controlled trial. We tested participants' oral fluid for HIV using OraQuick monthly and blood using a nucleic-acid amplification test (NAAT) every 3 months. We used Kaplan-Meier methods to estimate the duration from a positive HIV NAAT until the mid-point between the last non-reactive and first reactive oral fluid test and proportional hazards to examine factors associated with the time until the test was reactive. RESULTS: We screened 3678 people for HIV using OraQuick. Among 447 with reactive results, 436 (97.5%) were confirmed HIV-infected, 10 (2.2%) HIV-uninfected, and one (0.2%) had indeterminate results. Two participants with non-reactive OraQuick results were, in fact, HIV-infected at screening yielding 99.5% sensitivity, 99.7% specificity, a 97.8% positive predictive value, and a 99.9% negative predictive value. Participants receiving tenofovir took longer to develop a reactive OraQuick (191.8 days) than participants receiving placebo (16.8 days) (p = 0.02) and participants infected with HIV CRF01_AE developed a reactive OraQuick earlier than participants infected with other subtypes (p = 0.04). DISCUSSION: The oral fluid HIV test performed well at screening, suggesting it can be used when rapid results and non-invasive tools are preferred. However, participants receiving tenofovir took longer to develop a reactive oral fluid test result than those receiving placebo. Thus, among people using pre-exposure prophylaxis, a blood-based HIV test may be an appropriate choice. TRIAL REGISTRATION: ClinicalTrials.gov NCT00119106. |
Association between regimen composition and treatment response in patients with multidrug-resistant tuberculosis: A prospective cohort study
Yuen CM , Kurbatova EV , Tupasi T , Caoili JC , Van Der Walt M , Kvasnovsky C , Yagui M , Bayona J , Contreras C , Leimane V , Ershova J , Via LE , Kim H , Akksilp S , Kazennyy BY , Volchenkov GV , Jou R , Kliiman K , Demikhova OV , Vasilyeva IA , Dalton T , Cegielski JP . PLoS Med 2015 12 (12) e1001932 BACKGROUND: For treating multidrug-resistant tuberculosis (MDR TB), the World Health Organization (WHO) recommends a regimen of at least four second-line drugs that are likely to be effective as well as pyrazinamide. WHO guidelines indicate only marginal benefit for regimens based directly on drug susceptibility testing (DST) results. Recent evidence from isolated cohorts suggests that regimens containing more drugs may be beneficial, and that DST results are predictive of regimen effectiveness. The objective of our study was to gain insight into how regimen design affects treatment response by analyzing the association between time to sputum culture conversion and both the number of potentially effective drugs included in a regimen and the DST results of the drugs in the regimen. METHODS AND FINDINGS: We analyzed data from the Preserving Effective Tuberculosis Treatment Study (PETTS), a prospective observational study of 1,659 adults treated for MDR TB during 2005-2010 in nine countries: Estonia, Latvia, Peru, Philippines, Russian Federation, South Africa, South Korea, Thailand, and Taiwan. For all patients, monthly sputum samples were collected, and DST was performed on baseline isolates at the US Centers for Disease Control and Prevention. We included 1,137 patients in our analysis based on their having known baseline DST results for at least fluoroquinolones and second-line injectable drugs, and not having extensively drug-resistant TB. These patients were followed for a median of 20 mo (interquartile range 16-23 mo) after MDR TB treatment initiation. The primary outcome of interest was initial sputum culture conversion. We used Cox proportional hazards regression, stratifying by country to control for setting-associated confounders, and adjusting for the number of drugs to which patients' baseline isolates were resistant, baseline resistance pattern, previous treatment history, sputum smear result, and extent of disease on chest radiograph. In multivariable analysis, receiving an average of at least six potentially effective drugs (defined as drugs without a DST result indicating resistance) per day was associated with a 36% greater likelihood of sputum culture conversion than receiving an average of at least five but fewer than six potentially effective drugs per day (adjusted hazard ratio [aHR] 1.36, 95% CI 1.09-1.69). Inclusion of pyrazinamide (aHR 2.00, 95% CI 1.65-2.41) or more drugs to which baseline DST indicated susceptibility (aHR 1.65, 95% CI 1.48-1.84, per drug) in regimens was associated with greater increases in the likelihood of sputum culture conversion than including more drugs to which baseline DST indicated resistance (aHR 1.33, 95% CI 1.18-1.51, per drug). Including in the regimen more drugs for which DST was not performed was beneficial only if a minimum of three effective drugs was present in the regimen (aHR 1.39, 95% CI 1.09-1.76, per drug when three effective drugs present in regimen). The main limitation of this analysis is that it is based on observational data, not a randomized trial, and drug regimens varied across sites. However, PETTS was a uniquely large and rigorous observational study in terms of both the number of patients enrolled and the standardization of laboratory testing. Other limitations include the assumption of equivalent efficacy across drugs in a category, incomplete data on adherence, and the fact that the analysis considers only initial sputum culture conversion, not reversion or long-term relapse. CONCLUSIONS: MDR TB regimens including more potentially effective drugs than the minimum of five currently recommended by WHO may encourage improved response to treatment in patients with MDR TB. Rapid access to high-quality DST results could facilitate the design of more effective individualized regimens. Randomized controlled trials are necessary to confirm whether individualized regimens with more than five drugs can indeed achieve better cure rates than current recommended regimens. |
A chest radiograph scoring system in patients with severe acute respiratory infection: a validation study
Taylor E , Haven K , Reed P , Bissielo A , Harvey D , McArthur C , Bringans C , Freundlich S , Ingram RJ , Perry D , Wilson F , Milne D , Modahl L , Huang QS , Gross D , Widdowson MA , Grant CC . BMC Med Imaging 2015 15 (1) 61 BACKGROUND: The term severe acute respiratory infection (SARI) encompasses a heterogeneous group of respiratory illnesses. Grading the severity of SARI is currently reliant on indirect disease severity measures such as respiratory and heart rate, and the need for oxygen or intensive care. With the lungs being the primary organ system involved in SARI, chest radiographs (CXRs) are potentially useful for describing disease severity. Our objective was to develop and validate a SARI CXR severity scoring system. METHODS: We completed validation within an active SARI surveillance project, with SARI defined using the World Health Organization case definition of an acute respiratory infection with a history of fever, or measured fever of ≥ 38 degrees C; and cough; and with onset within the last 10 days; and requiring hospital admission. We randomly selected 250 SARI cases. Admission CXR findings were categorized as: 1 = normal; 2 = patchy atelectasis and/or hyperinflation and/or bronchial wall thickening; 3 = focal consolidation; 4 = multifocal consolidation; and 5 = diffuse alveolar changes. Initially, four radiologists scored CXRs independently. Subsequently, a pediatrician, physician, two residents, two medical students, and a research nurse independently scored CXR reports. Inter-observer reliability was determined using a weighted Kappa (kappa) for comparisons between radiologists; radiologists and clinicians; and clinicians. Agreement was defined as moderate (kappa > 0.4-0.6), good (kappa > 0.6-0.8) and very good (kappa > 0.8-1.0). RESULTS: Agreement between the two pediatric radiologists was very good (kappa = 0.83, 95 % CI 0.65-1.00) and between the two adult radiologists was good (kappa = 0.75, 95 % CI 0.57-0. 93). Agreement of the clinicians with the radiologists was moderate-to-good (pediatrician:kappa = 0.65; pediatric resident:kappa = 0.69; physician:kappa = 0.68; resident:kappa = 0.67; research nurse:kappa = 0.49, medical students: kappa = 0.53 and kappa = 0.56). Agreement between clinicians was good-to-very good (pediatrician vs. physician:kappa = 0.85; vs. pediatric resident:kappa = 0.81; vs. medicine resident:kappa = 0.76; vs. research nurse:kappa = 0.75; vs. medical students:kappa = 0.63 and 0.66). Following review of discrepant CXR report scores by clinician pairs, kappa values for radiologist-clinician agreement ranged from 0.59 to 0.70 and for clinician-clinician agreement from 0.97 to 0.99. CONCLUSIONS: This five-point CXR scoring tool, suitable for use in poorly- and well-resourced settings and by clinicians of varying experience levels, reliably describes SARI severity. The resulting numerical data enables epidemiological comparisons of SARI severity between different countries and settings. |
Improving interactive health literacy skills of older adults: Lessons learned from formative organizational research with community partners
Parmer J , Furtado D , Rubin DL , Freimuth V , Kaley T , Okundaye M . Prog Community Health Partnersh 2015 9 (4) 531-6 BACKGROUND: Meals on Wheels (MOW) organizations are ideal community partners for delivering social support relating to health information exchange for vulnerable and home-bound older adults. OBJECTIVES: This article illustrates how formative organizational evaluation can be used to adapt health literacy interventions delivered by community partners. METHODS: Key informant interviews and ethnographic observations were conducted as part of a formative organizational evaluation of potential community partners. LESSONS LEARNED: The observed brevity of volunteer-client interaction led program planners to incorporate substantial emphasis on communicating with older adults into the health literacy coach training curriculum. Ethnographic observations made clear that program materials had to be portable and fit it in with the mobile nature of MOW delivery. CONCLUSIONS: Formative organizational research can greatly increase the chance of successful implementation of public health interventions when those interventions will be implemented in partnerships with community-based organizations in diverse settings and with varying practices. |
Adolescents' self-reported recall of anticipatory guidance provided during well-visits at nine medical clinics in San Diego, California, 2009-2011
Peddecord KM , Wang W , Wang L , Ralston K , Ly E , Friedman L , Curtis CR , Sawyer MH . J Adolesc Health 2015 58 (3) 267-75 PURPOSE: Anticipatory guidance (AG) is recommended for adolescent well care. AG recall is important in the event sequence that might lead to behavioral change, reduced health risk, and improved health. We assessed factors influencing adolescents' self-reported recall of specific AG topics. METHODS: Through convenience sampling of nine clinics in San Diego, California, 872 adolescents (429 aged 11-13 years; 443 aged 14-17 years) who had received well visits completed standardized surveys between 2009 and 2011. Adolescents were asked to report recall of either 17 or 23 age-appropriate AG topics that were analyzed in five categories (health maintenance; social/emotional, safety/violence; smoking/substance abuse, and puberty/sexual health); a summary score for all categories was developed. Summary scores' associations with demographic variables, visit characteristics (including having time without parents present [private time]), clinic procedures, and lead physician attitudes were assessed. RESULTS: AG recall was independently associated with adolescents having private time with clinicians, completing previsit questionnaires, reporting the well visit was helpful, and the well visit lasting at least 10 minutes. Higher summary recall scores were observed among adolescents who received care in clinics providing AG at both sick and well visits and having policies encouraging private time. Clinic electronic medical record use for AG prompts was associated with recall of fewer topics. CONCLUSIONS: To increase adolescents' AG recall and potentially foster behavior change, our results suggest medical providers should adopt procedures advocated by professional societies, including assuring adolescents receive private time during visits, increasing visit time during well visits, using patient-completed questionnaires, and providing AG during all visits. |
Temporal and spatial variability of entomological risk indices for West Nile virus infection in northern Colorado: 2006-2013
Fauver JR , Pecher L , Schurich JA , Bolling BG , Calhoon M , Grubaugh ND , Burkhalter KL , Eisen L , Andre BG , Nasci RS , LeBailly A , Ebel GD , Moore CG . J Med Entomol 2015 53 (2) 425-34 West Nile virus (WNV) is enzootic in northern Colorado. Annual surveillance activities in Fort Collins, CO, include collecting female Culex mosquitoes and testing them for the presence of WNV RNA in order to calculate 1) Culex female abundance, 2) WNV infection rate, and 3) the vector index (VI). These entomological risk indices inform public policy regarding the need for emergency adulticiding. Currently, these are calculated on a city-wide basis. In this study, we present descriptive data from historical surveillance records spanning 2006-2013 to discern seasonal and yearly patterns of entomological risk for WNV infection. Also, we retrospectively test the hypothesis that entomological risk is correlated with human transmission risk and is heterogeneous within the City of Fort Collins. Four logistically relevant zones within the city were established and used to test this hypothesis. Zones in the eastern portion of the city consistently had significantly higher Culex abundance and VI compared with zones in the west, leading to higher entomological risk indicators for human WNV infection in the east. Moreover, the relative risk of a reported human case of WNV infection was significantly higher in the eastern zones of the city. Our results suggest that a more spatially targeted WNV management program may better mitigate human risk for WNV infection in Fort Collins, and possibly other cities where transmission is enzootic, while at the same time reducing pesticide use. |
Linkages of weather and climate with Ixodes scapularis and Ixodes pacificus (Acari: Ixodidae), enzootic transmission of Borrelia burgdorferi, and Lyme disease in North America
Eisen RJ , Eisen L , Ogden NH , Beard CB . J Med Entomol 2015 53 (2) 250-61 Lyme disease has increased both in incidence and geographic extent in the United States and Canada over the past two decades. One of the underlying causes is changes during the same time period in the distribution and abundance of the primary vectors: Ixodes scapularis Say and Ixodes pacificus Cooley and Kohls in eastern and western North America, respectively. Aside from short periods of time when they are feeding on hosts, these ticks exist in the environment where temperature and relative humidity directly affect their development, survival, and host-seeking behavior. Other important factors that strongly influence tick abundance as well as the proportion of ticks infected with the Lyme disease spirochete, Borrelia burgdorferi, include the abundance of hosts for the ticks and the capacity of tick hosts to serve as B. burgdorferi reservoirs. Here, we explore the linkages between climate variation and: 1) duration of the seasonal period and the timing of peak activity; 2) geographic tick distributions and local abundance; 3) enzootic B. burgdorferi transmission cycles; and 4) Lyme disease cases. We conclude that meteorological variables are most influential in determining host-seeking phenology and development, but, while remaining important cofactors, additional variables become critical when exploring geographic distribution and local abundance of ticks, enzootic transmission of B. burgdorferi, and Lyme disease case occurrence. Finally, we review climate change-driven projections for future impact on vector ticks and Lyme disease and discuss knowledge gaps and research needs. |
Determination of insecticidal effect (LC50 and LC90) of organic fatty acids mixture (C8910+Silicone) against Aedes aegypti and Aedes albopictus (Diptera: Culicidae)
Dunford JC , Falconer A , Leite LN , Wirtz RA , Brogdon WG . J Med Entomol 2015 53 (3) 699-702 Emerging and re-emerging vector-borne diseases such as chikungunya and dengue and associated Aedes vectors are expanding their historical ranges; thus, there is a need for the development of novel insecticides for use in vector control programs. The mosquito toxicity of a novel insecticide and repellent consisting of medium-chain carbon fatty acids (C8910) was examined. Determination of LC50 and LC90 was made against colony-reared Aedes aegypti (L.) and Aedes albopictus (Skuse) using probit analysis on mortality data generated by Centers for Disease Control and Prevention bottle bioassays. Six different concentrations of C8910 + silicone oil yielded an LC50 of 160.3 microg a.i/bottle (147.6-182.7) and LC90 of 282.8 (233.2-394.2) in Ae. aegypti; five concentrations yielded an LC50 of 125.4 (116.1-137.6) and LC90 of 192.5 (165.0-278.9) in Ae. albopictus. Further development of C8910 and similar compounds could provide vector control specialists novel insecticides for controlling insect disease vectors. |
Indications and types of antibiotic agents used in 6 acute care hospitals, 2009-2010: A pragmatic retrospective observational study
Kelesidis T , Braykov N , Uslan DZ , Morgan DJ , Gandra S , Johannsson B , Schweizer ML , Weisenberg SA , Young H , Cantey J , Perencevich E , Septimus E , Srinivasan A , Laxminarayan R . Infect Control Hosp Epidemiol 2016 37 (1) 70-9 BACKGROUND: To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE: To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING: Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS: Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS: On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS: Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. |
A Systems Biology Approach Reveals Converging Molecular Mechanisms that Link Different POPs to Common Metabolic Diseases.
Ruiz P , Perlina A , Mumtaz M , Fowler BA . Environ Health Perspect 2015 124 (7) 1034-41 BACKGROUND: A number of epidemiological studies have identified statistical associations between persistent organic pollutants (POPs) and metabolic diseases, but testable hypotheses regarding underlying molecular mechanisms to explain these linkages have not been published. OBJECTIVES: To assess the underlying mechanisms of POPs that have been associated with metabolic diseases, 3 well-known POPs (2,3,7,8-Tetrachlorodibenzodioxin (TCDD), 2,2',4,4',5,5'-Hexachlorobiphenyl (PCB 153), and p,p'-Dichlorodiphenyldichloroethylene (p,p'-DDE)) were studied. We used advanced database search tools to delineate testable hypotheses and guide laboratory-based research studies into underlying mechanisms by which this POPs mixture could produce or exacerbate metabolic diseases. METHODS: For these studies searches, a proprietary systems biology software MetaCoreTM/MetaDrugTM was used to conduct advanced search queries for the underlying interactions database, followed by directional network construction to identify common mechanisms for these POPs within 2 or less interaction steps downstream of their primary targets. These common downstream pathways belong to various cytokine and chemokine families with experimental well-documented causal associations with type 2 diabetes. CONCLUSIONS: Our systems biology approach allowed identification of converging pathways leading to activation of common targets downstream. To our knowledge, this is the first study to propose an integrated global set of step-by-step molecular mechanisms for a combination of 3 common POPs, using a systems biology approach, which may link POPs exposure to diseases. Experimental evaluation of the proposed pathways may lead to development of predictive biomarkers of POPs' effects, which could translate into disease prevention and more effective clinical treatment strategies. |
Polychlorinated Biphenyls and Leukocyte Telomere Length: An Analysis of NHANES 1999-2002.
Scinicariello F , Buser MC . EBioMedicine 2015 2 (12) 1974-9 Polychlorinated biphenyls (PCBs) induce the expression of the proto-oncogene c-myc which has a role in cellular growth and proliferation programs. The c-myc up-regulates the telomerase reverse transcriptase which adds the telomeres repeating sequences to the chromosomal ends to compensate for the progressive loss of telomeric sequence. We performed multivariate linear regression to analyze the association of PCBs, polychlorinated dibenzo-p-dioxins, and 1,2,3,4,6,7,8-heptachlorodibenzofuran with leukocyte telomere length (LTL) in the adult population (n = 2413) of the National Health and Nutrition Examination Survey 1999-2002. LTL was natural log-transformed and the results were re-transformed and presented as percent differences. Individuals in the 3rd and 4th quartiles of the sum of PCBs were associated with 8.33% (95% CI: 4.08-13.88) and 11.63% (95% CI: 6.18-17.35) longer LTLs, respectively, compared with the lowest quartile, with evidence of a dose-response relationship (p-trend. <. 0.01). The association of the sum PCBs with longer LTL was found in both sexes.Additionally, 1,2,3,4,6,7,8-heptachlorodibenzofuran and 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin were associated with longer LTL. The age independent association between longer LTL and environmental exposures to PCBs, 1,2,3,4,6,7,8-heptachlorodibenzofuran and 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin may support a role as tumor promoter of these compounds. Further studies to evaluate the effect of these compounds on LTL are needed to more fully understand the implications of our finding. |
Volatile organic compounds in blood as biomarkers of exposure to JP-8 jet fuel among US Air Force personnel
Maule AL , Proctor SP , Blount BC , Chambers DM , McClean MD . J Occup Environ Med 2016 58 (1) 24-9 OBJECTIVE: This study aimed to evaluate blood volatile organic compound (VOC) levels as biomarkers of occupational jet propulsion fuel 8 (JP-8) exposure while controlling for smoking. METHODS: Among 69 Air Force personnel, post-shift blood samples were analyzed for components of JP-8, including ethylbenzene, toluene, o-xylene, and m/p-xylene, and for the smoking biomarker, 2,5-dimethylfuran. JP-8 exposure was characterized based on self-report and measured work shift levels of total hydrocarbons in personal air. Multivariate regression was used to evaluate the relationship between JP-8 exposure and post-shift blood VOCs while controlling for potential confounding from smoking. RESULTS: Blood VOC concentrations were higher among US Air Force personnel who reported JP-8 exposure and work shift smoking. Breathing zone total hydrocarbons was a significant predictor of VOC blood levels, after controlling for smoking. CONCLUSIONS: These findings support the use of blood VOCs as a biomarker of occupational JP-8 exposure. |
Windows of sensitivity to toxic chemicals in the motor effects development
Ingber SZ , Pohl HR . Regul Toxicol Pharmacol 2015 74 93-104 Many chemicals currently used are known to elicit nervous system effects. In addition, approximately 2000 new chemicals introduced annually have not yet undergone neurotoxicity testing. This review concentrated on motor development effects associated with exposure to environmental neurotoxicants to help identify critical windows of exposure and begin to assess data needs based on a subset of chemicals thoroughly reviewed by the Agency for Toxic Substances and Disease Registry (ATSDR) in Toxicological Profiles and Addenda. Multiple windows of sensitivity were identified that differed based on the maturity level of the neurological system at the time of exposure, as well as dose and exposure duration. Similar but distinct windows were found for both motor activity (GD 8-17 [rats], GD 12-14 and PND 3-10 [mice]) and motor function performance (insufficient data for rats, GD 12-17 [mice]). Identifying specific windows of sensitivity in animal studies was hampered by study designs oriented towards detection of neurotoxicity that occurred at any time throughout the developmental process. In conclusion, while this investigation identified some critical exposure windows for motor development effects, it demonstrates a need for more acute duration exposure studies based on neurodevelopmental windows, particularly during the exposure periods identified in this review. |
Monitoring exposure to polycyclic aromatic hydrocarbons in an Australian population using pooled urine samples
Thai PK , Heffernan AL , Toms LL , Li Z , Calafat AM , Hobson P , Broomhall S , Mueller JF . Environ Int 2015 88 30-35 Integrated exposure to polycyclic aromatic hydrocarbons (PAHs) can be assessed through monitoring of urinary mono-hydroxylated PAHs (OH-PAHs). The aim of this study was to provide the first assessment of exposure to PAHs in a large sample of the population in Queensland, Australia including exposure to infant (0-4y ears). De-identified urine specimens, obtained from a pathology laboratory, were stratified by age and sex, and pooled (n=24 pools of 100) and OH-PAHs were measured by gas chromatography-isotope dilution-tandem mass spectrometry. Geometric mean (GM) concentrations ranged from 30ng/L (4-hydroxyphenanthrene) to 9221ng/L (1-naphthol). GM of 1-hydroxypyrene, the most commonly used PAH exposure biomarker, was 142ng/L. The concentrations of OH-PAHs found in this study are consistent with those in developed countries and lower than those in developing countries. We observed no association between sex and OH-PAH concentrations. However, we observed lower urinary concentrations of all OH-PAHs in samples from infants (0-4 years), children (5-14 years) and the elderly (>60 year old) compared with samples from other age groups (15-29, 30-44 and 45-59 years) which may be attributed to age-dependent behaviour-specific exposure sources. |
Notes from the field: acute mercury poisoning after home gold and silver smelting - Iowa, 2014
Koirala S , Leinenkugel K . MMWR Morb Mortal Wkly Rep 2015 64 (49) 1365-6 In March 2014, a man, aged 59 years, who lived alone and had been using different smelting techniques viewed on the Internet to recover gold and silver from computer components, was evaluated at a local emergency department for shortness of breath, tremors, anorexia, and generalized weakness. During the smelting processes, he had used hydrogen peroxide, nitric acid, muriatic acid, and sulfuric acid purchased from local stores or Internet retailers. For protection, he wore a military gas mask of unknown type. The mask was used with filter cartridges, but their effectiveness against chemical fumes was not known. |
Perfluoroalkyl substances and food allergies in adolescents
Buser MC , Scinicariello F . Environ Int 2015 88 74-79 Perfluoroalkyl and polyfluoroalkyl substances (PFASs) are a class of organic compounds that are persistent in the environment due to their stable carbon-fluorine backbone, which is not susceptible to degradation. Research suggests these chemicals may exert an immunotoxic effect. The aim of this study is to investigate the associations between four PFASs - perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), and perfluorohexane sulfonic acid (PFHxS) - with food sensitization and food allergies in adolescent participants (ages 12-19years) in the National Health and Nutrition Examination Survey (NHANES) 2005-2006 and 2007-2010, respectively. We performed multivariate logistic regression to analyze the association between individual PFASs with food sensitization (defined as having at least 1 food-specific IgE level≥0.35kU/L) in NHANES 2005-2006 and food allergies (self-reported) in NHANES 2007-2010. Serum PFOA, PFOS, and PFHxS were statistically significantly associated with higher odds to have self-reported food allergies in NHANES 2007-2010. When using IgE levels as a marker of food sensitization, we found that serum PFNA was inversely associated with food sensitization (NHANES 2005-2006). In conclusion, we found that serum levels of PFASs were associated with higher odds to have self-reported food allergies. Conversely, adolescents with higher serum PFNA were less likely to be sensitized to food allergens. These results, along with previous studies, warrant further investigation, such as well-designed longitudinal studies. |
Bacteria in a water-damaged building: associations of actinomycetes and nontuberculous mycobacteria with respiratory health in occupants
Park JH , Cox-Ganser JM , White SK , Laney AS , Caulfield SM , Turner WA , Sumner AD , Kreiss K . Indoor Air 2015 27 (1) 24-33 We examined microbial correlates of health outcomes in building occupants with a sarcoidosis cluster and excess asthma. We offered employees a questionnaire and pulmonary function testing and collected floor dust and liquid/sludge from drain tubing traps of heat pumps that were analyzed for various microbial agents. Forty-nine percent of participants reported any symptom reflecting possible granulomatous disease (shortness of breath on exertion, flu-like achiness, or fever and chills) weekly in the last 4 weeks. In multivariate regressions, thermophilic actinomycetes (median=529 CFU/m2 ) in dust were associated with FEV1 /FVC [coefficient=-2.8 per inter-quartile range change, p=0.02], percent predicted FEF25-75% (coefficient=-12.9, p=0.01), and any granulomatous disease-like symptom [odds ratio (OR)=3.1, 95% confidence interval (CI)=1.45-6.73]. Mycobacteria (median=658 CFU/m2 ) were positively associated with asthma symptoms (OR=1.5, 95% CI=0.97-2.43). Composite score (median=11.5) of total bacteria from heat pumps was negatively associated with asthma (0.8, 0.71-1.00) and positively associated with FEV1 /FVC (coefficient=0.44, p=0.095). Endotoxin (median score=12.0) was negatively associated with two or more granulomatous disease-like symptoms (OR=0.8, 95% CI=0.67-0.98) and asthma (0.8, 0.67-0.96). Fungi or (1-->3)-beta-D-glucan in dust or heat pump traps were not associated with any health outcomes. Thermophilic actinomycetes and nontuberculous mycobacteria may have played a role in the occupants' respiratory outcomes in this water-damaged building. |
Comments on Sabariego et al. Measuring disability: Comparing the impact of two data collection approaches on disability rates. Int. J. Environ. Res. Public Health, 2015, 12, 10329-10351
Madans JH , Mont D , Loeb M . Int J Environ Res Public Health 2015 13 (1) ijerph13010065 In the article, Measuring Disability: Comparing the Impact of Two Data Collection Approaches on Disability Rates, in Volume 12 of the Journal International Journal of Environmental Research and Public Health, Carla Sabariego et al. raise several issues regarding the use of the short set of questions developed by the Washington Group on Disability Statistics (WG) as compared with the approach to disability measurement proposed through the Model Disability Survey (MDS). We address these below. |
Salmonella enterica infections in the United States and assessment of coefficients of variation: a novel approach to identify epidemiologic characteristics of individual serotypes, 1996-2011
Boore AL , Hoekstra RM , Iwamoto M , Fields PI , Bishop RD , Swerdlow DL . PLoS One 2015 10 (12) e0145416 BACKGROUND: Despite control efforts, salmonellosis continues to cause an estimated 1.2 million infections in the United States (US) annually. We describe the incidence of salmonellosis in the US and introduce a novel approach to examine the epidemiologic similarities and differences of individual serotypes. METHODS: Cases of salmonellosis in humans reported to the laboratory-based National Salmonella Surveillance System during 1996-2011 from US states were included. Coefficients of variation were used to describe distribution of incidence rates of common Salmonella serotypes by geographic region, age group and sex of patient, and month of sample isolation. RESULTS: During 1996-2011, more than 600,000 Salmonella isolates from humans were reported, with an average annual incidence of 13.1 cases/100,000 persons. The annual reported rate of Salmonella infections did not decrease during the study period. The top five most commonly reported serotypes, Typhimurium, Enteritidis, Newport, Heidelberg, and Javiana, accounted for 62% of fully serotyped isolates. Coefficients of variation showed the most geographically concentrated serotypes were often clustered in Gulf Coast states and were also more frequently found to be increasing in incidence. Serotypes clustered in particular months, age groups, and sex were also identified and described. CONCLUSIONS: Although overall incidence rates of Salmonella did not change over time, trends and epidemiological factors differed remarkably by serotype. A better understanding of Salmonella, facilitated by this comprehensive description of overall trends and unique characteristics of individual serotypes, will assist in responding to this disease and in planning and implementing prevention activities. |
Genome Sequences of Oblitimonas alkaliphila gen. nov. sp. nov. (Proposed), a Novel Bacterium of the Pseudomonadaceae Family.
Lauer AC , Nicholson AC , Humrighouse BW , Emery B , Drobish A , Juieng P , Loparev V , McQuiston JR . Genome Announc 2015 3 (6) Results obtained through 16S rRNA gene sequencing and phenotypic testing of eight related, but unidentified, isolates located in a historical collection at the Centers for Disease Control and Prevention suggested that these isolates belong to a novel genera of bacteria. The genomes of the bacteria, to be named Oblitimonas alkaphilia gen. nov. sp. nov., were sequenced using Illumina technology. Closed genomes were produced for all eight isolates. |
Complete Genome Sequences of Two Shiga Toxin-Producing Escherichia coli Strains from Serotypes O119:H4 and O165:H25.
Lindsey RL , Knipe K , Rowe L , Garcia-Toledo L , Loparev V , Juieng P , Trees E , Strockbine N , Stripling D , Gerner-Smidt P . Genome Announc 2015 3 (6) Shiga toxin-producing Escherichia coli (STEC) is an important foodborne pathogen. Here, we report complete whole-genome sequences for two STEC strains of serotypes O119:H4 and O165:H25 isolated from clinical cases in the United States. |
Next-Generation Sequencing Reveals Frequent Opportunities for Exposure to Hepatitis C Virus in Ghana.
Forbi JC , Layden JE , Phillips RO , Mora N , Xia GL , Campo DS , Purdy MA , Dimitrova ZE , Owusu DO , Punkova LT , Skums P , Owusu-Ofori S , Sarfo FS , Vaughan G , Roh H , Opare-Sem OK , Cooper RS , Khudyakov YE . PLoS One 2015 10 (12) e0145530 Globally, hepatitis C Virus (HCV) infection is responsible for a large proportion of persons with liver disease, including cancer. The infection is highly prevalent in sub-Saharan Africa. West Africa was identified as a geographic origin of two HCV genotypes. However, little is known about the genetic composition of HCV populations in many countries of the region. Using conventional and next-generation sequencing (NGS), we identified and genetically characterized 65 HCV strains circulating among HCV-positive blood donors in Kumasi, Ghana. Phylogenetic analysis using consensus sequences derived from 3 genomic regions of the HCV genome, 5'-untranslated region, hypervariable region 1 (HVR1) and NS5B gene, consistently classified the HCV variants (n = 65) into genotypes 1 (HCV-1, 15%) and genotype 2 (HCV-2, 85%). The Ghanaian and West African HCV-2 NS5B sequences were found completely intermixed in the phylogenetic tree, indicating a substantial genetic heterogeneity of HCV-2 in Ghana. Analysis of HVR1 sequences from intra-host HCV variants obtained by NGS showed that three donors were infected with >1 HCV strain, including infections with 2 genotypes. Two other donors share an HCV strain, indicating HCV transmission between them. The HCV-2 strain sampled from one donor was replaced with another HCV-2 strain after only 2 months of observation, indicating rapid strain switching. Bayesian analysis estimated that the HCV-2 strains in Ghana were expanding since the 16th century. The blood donors in Kumasi, Ghana, are infected with a very heterogeneous HCV population of HCV-1 and HCV-2, with HCV-2 being prevalent. The detection of three cases of co- or super-infections and transmission linkage between 2 cases suggests frequent opportunities for HCV exposure among the blood donors and is consistent with the reported high HCV prevalence. The conditions for effective HCV-2 transmission existed for ~ 3-4 centuries, indicating a long epidemic history of HCV-2 in Ghana. |
Identification and Characterization of Microsatellite Markers Derived from the Whole Genome Analysis of Taenia solium.
Pajuelo MJ , Eguiluz M , Dahlstrom E , Requena D , Guzman F , Ramirez M , Sheen P , Frace M , Sammons S , Cama V , Anzick S , Bruno D , Mahanty S , Wilkins P , Nash T , Gonzalez A , Garcia HH , Gilman RH , Porcella S , Zimic M . PLoS Negl Trop Dis 2015 9 (12) e0004316 BACKGROUND: Infections with Taenia solium are the most common cause of adult acquired seizures worldwide, and are the leading cause of epilepsy in developing countries. A better understanding of the genetic diversity of T. solium will improve parasite diagnostics and transmission pathways in endemic areas thereby facilitating the design of future control measures and interventions. Microsatellite markers are useful genome features, which enable strain typing and identification in complex pathogen genomes. Here we describe microsatellite identification and characterization in T. solium, providing information that will assist in global efforts to control this important pathogen. METHODS: For genome sequencing, T. solium cysts and proglottids were collected from Huancayo and Puno in Peru, respectively. Using next generation sequencing (NGS) and de novo assembly, we assembled two draft genomes and one hybrid genome. Microsatellite sequences were identified and 36 of them were selected for further analysis. Twenty T. solium isolates were collected from Tumbes in the northern region, and twenty from Puno in the southern region of Peru. The size-polymorphism of the selected microsatellites was determined with multi-capillary electrophoresis. We analyzed the association between microsatellite polymorphism and the geographic origin of the samples. RESULTS: The predicted size of the hybrid (proglottid genome combined with cyst genome) T. solium genome was 111 MB with a GC content of 42.54%. A total of 7,979 contigs (>1,000 nt) were obtained. We identified 9,129 microsatellites in the Puno-proglottid genome and 9,936 in the Huancayo-cyst genome, with 5 or more repeats, ranging from mono- to hexa-nucleotide. Seven microsatellites were polymorphic and 29 were monomorphic within the analyzed isolates. T. solium tapeworms were classified into two genetic groups that correlated with the North/South geographic origin of the parasites. CONCLUSIONS/SIGNIFICANCE: The availability of draft genomes for T. solium represents a significant step towards the understanding the biology of the parasite. We report here a set of T. solium polymorphic microsatellite markers that appear promising for genetic epidemiology studies. |
HIV-1 Drug Resistance Mutations: Potential Applications for Point-of-Care Genotypic Resistance Testing.
Rhee SY , Jordan MR , Raizes E , Chua A , Parkin N , Kantor R , Van Zyl GU , Mukui I , Hosseinipour MC , Frenkel LM , Ndembi N , Hamers RL , Rinke de Wit TF , Wallis CL , Gupta RK , Fokam J , Zeh C , Schapiro JM , Carmona S , Katzenstein D , Tang M , Aghokeng AF , De Oliveira T , Wensing AM , Gallant JE , Wainberg MA , Richman DD , Fitzgibbon JE , Schito M , Bertagnolio S , Yang C , Shafer RW . PLoS One 2015 10 (12) e0145772 The increasing prevalence of acquired and transmitted HIV-1 drug resistance is an obstacle to successful antiretroviral therapy (ART) in the low- and middle-income countries (LMICs) hardest hit by the HIV-1 pandemic. Genotypic drug resistance testing could facilitate the choice of initial ART in areas with rising transmitted drug resistance (TDR) and enable care-providers to determine which individuals with virological failure (VF) on a first- or second-line ART regimen require a change in treatment. An inexpensive near point-of-care (POC) genotypic resistance test would be useful in settings where the resources, capacity, and infrastructure to perform standard genotypic drug resistance testing are limited. Such a test would be particularly useful in conjunction with the POC HIV-1 viral load tests that are currently being introduced in LMICs. A POC genotypic resistance test is likely to involve the use of allele-specific point mutation assays for detecting drug-resistance mutations (DRMs). This study proposes that two major nucleoside reverse transcriptase inhibitor (NRTI)-associated DRMs (M184V and K65R) and four major NNRTI-associated DRMs (K103N, Y181C, G190A, and V106M) would be the most useful for POC genotypic resistance testing in LMIC settings. One or more of these six DRMs was present in 61.2% of analyzed virus sequences from ART-naive individuals with intermediate or high-level TDR and 98.8% of analyzed virus sequences from individuals on a first-line NRTI/NNRTI-containing regimen with intermediate or high-level acquired drug resistance. The detection of one or more of these DRMs in an ART-naive individual or in a individual with VF on a first-line NRTI/NNRTI-containing regimen may be considered an indication for a protease inhibitor (PI)-containing regimen or closer virological monitoring based on cost-effectiveness or country policy. |
Showing Value in Newborn Screening: Challenges in Quantifying the Effectiveness and Cost-Effectiveness of Early Detection of Phenylketonuria and Cystic Fibrosis.
Grosse SD . Healthcare (Basel) 2015 3 (4) 1133-1157 Decision makers sometimes request information on the cost savings, cost-effectiveness, or cost-benefit of public health programs. In practice, quantifying the health and economic benefits of population-level screening programs such as newborn screening (NBS) is challenging. It requires that one specify the frequencies of health outcomes and events, such as hospitalizations, for a cohort of children with a given condition under two different scenarios-with or without NBS. Such analyses also assume that everything else, including treatments, is the same between groups. Lack of comparable data for representative screened and unscreened cohorts that are exposed to the same treatments following diagnosis can result in either under- or over-statement of differences. Accordingly, the benefits of early detection may be understated or overstated. This paper illustrates these common problems through a review of past economic evaluations of screening for two historically significant conditions, phenylketonuria and cystic fibrosis. In both examples qualitative judgments about the value of prompt identification and early treatment to an affected child were more influential than specific numerical estimates of lives or costs saved. |
Annual medical expenditure and productivity loss among colorectal, female breast, and prostate cancer survivors in the United States
Zheng Z , Yabroff KR , Guy GP Jr , Han X , Li C , Banegas MP , Ekwueme DU , Jemal A . J Natl Cancer Inst 2016 108 (5) BACKGROUND: There are limited nationally representative estimates of the annual economic burden among survivors of the three most prevalent cancers (colorectal, female breast, and prostate) in both nonelderly and elderly populations in the United States. METHODS: The 2008 to 2012 Medical Expenditure Panel Survey data were used to identify colorectal (n = 540), female breast (n = 1568), and prostate (n = 1170) cancer survivors and individuals without a cancer history (n = 109 423). Excess economic burden attributable to cancer included per-person excess annual medical expenditures and productivity losses (employment disability, missed work days, and days stayed in bed). All analyses were stratified by cancer site and age (nonelderly: 18-64 years vs elderly: ≥65 years). Multivariable analyses controlled for age, sex, race/ethnicity, marital status, education, number of comorbidities, and geographic region. All statistical tests were two-sided. RESULTS: Compared with individuals without a cancer history, cancer survivors experienced annual excess medical expenditures (for the nonelderly population, colorectal: $8647, 95% confidence interval [CI] = $4932 to $13 974, P < .001; breast: $5119, 95% CI = $3439 to $7158, P < .001; prostate: $3586, 95% CI = $1792 to $6076, P < .001; for the elderly population, colorectal: $4913, 95% CI = $2768 to $7470, P < .001; breast: $2288, 95% CI = $814 to $3995, P = .002; prostate: $3524, 95% CI = $1539 to $5909, P < .001). Nonelderly colorectal and breast cancer survivors experienced statistically significant annual excess employment disability (13.6%, P < .001, and 4.8%, P = .001) and productivity loss at work (7.2 days, P < .001, and 3.3 days, P = .002) and at home (4.5 days, P < .001, and 3.3 days, P = .003). In contrast, elderly survivors of all three cancer sites had comparable productivity losses as those without a cancer history. CONCLUSIONS: Colorectal, breast, and prostate cancer survivors experienced statistically significantly higher economic burden compared with individuals without a cancer history; however, excess economic burden varies by cancer site and age. Targeted efforts will be important in reducing the economic burden of colorectal, breast, and prostate cancer. |
Lack of health insurance among adults aged 18 to 64 years: Findings from the 2013 Behavioral Risk Factor Surveillance System
Okoro CA , Zhao G , Dhingra SS , Xu F . Prev Chronic Dis 2015 12 E231 INTRODUCTION: The objective of this study was to estimate the prevalence of lack of health insurance among adults aged 18 to 64 years for each state and the United States and to describe populations without insurance. METHODS: We used 2013 Behavioral Risk Factor Surveillance System data to categorize states into 3 groups on the basis of the prevalence of lack of health insurance in each state compared with the national average (21.5%; 95% confidence interval, 21.1%-21.8%): high-insured states (states with an estimated prevalence of lack of health insurance below the national average), average-insured states (states with an estimated prevalence of lack of health insurance equivalent to the national average), and low-insured states (states with an estimated prevalence of lack of health insurance higher than the national average). We used bivariate analyses to compare the sociodemographic characteristics of these 3 groups after age adjustment to the 2000 US standard population. We examined the distribution of Medicaid expansion among the 3 groups. RESULTS: Compared with the national age-adjusted prevalence of lack of health insurance, 24 states had lower rates of uninsured residents, 12 states had equivalent rates of uninsured, and 15 states had higher rates of uninsured. Compared with adults in the high-insured and average-insured state groups, adults in the low-insured state group were more likely to be non-Hispanic black or Hispanic, to have less than a high school education, to be previously married (divorced, widowed, or separated), and to have an annual household income at or below $35,000. Seventy-one percent of high-insured states were expanding Medicaid eligibility compared with 67% of average-insured states and 40% of low-insured states. CONCLUSION: Large variations exist among states in the estimated prevalence of health insurance. Many uninsured Americans reside in states that have opted out of Medicaid expansion. |
Hospitalization charges for children with birth defects in Texas, 2001 to 2010
Moffitt KB , Case AP , Farag NH , Canfield MA . Birth Defects Res A Clin Mol Teratol 2015 106 (3) 155-63 BACKGROUND: State-specific information about hospitalizations of children with birth defects can improve understanding of changes in occurrence, treatment practices, and health care financing policies. This study analyzed aggregated data on hospital charges and length of stay for a large, diverse population. METHODS: We extracted hospitalization data for children diagnosed with birth defects from the Texas Hospital Inpatient Discharge Public Use Data File (2001-2010). Analyses compared total charges and length of stay for children with and without a diagnosis code of any birth defect among 45 standard categories. We also examined trends for total charges by expected payer type. RESULTS: In Texas, 431,296 hospital stays were reported for children with birth defects, with total charges of $24.8 billion. Mean hospital stay for children with birth defects was more than twice that of those without, whereas mean of hospital total charges was approximately six times greater. Pyloric stenosis accounted for the largest number of hospitalizations, followed by certain cardiac defects. Pediatric hospitalizations for birth defects increased 273.7%, compared with a 214.7% increase overall. The percentage of charges with Medicaid as expected payer (2004-2010) ranged from 56.5 to 62.0%. CONCLUSION: Charges associated with these conditions are far greater than those associated with pediatric hospitalizations for other causes, whether in the newborn period or beyond. However, these charges vary depending on specific diagnoses, expected payer source, and year of treatment. |
The cost of cancer registry operations: Impact of volume on cost per case for core and enhanced registry activities
Subramanian S , Tangka FK , Beebe MC , Trebino D , Weir HK , Babcock F . Eval Program Plann 2015 55 1-8 BACKGROUND: Cancer registration data is vital for creating evidence-based policies and interventions. Quantifying the resources needed for cancer registration activities and identifying potential efficiencies are critically important to ensure sustainability of cancer registry operations. METHODS: Using a previously validated web-based cost assessment tool, we collected activity-based cost data and report findings using 3 years of data from 40 National Program of Cancer Registry grantees. We stratified registries by volume: low-volume included fewer than 10,000 cases, medium-volume included 10,000-50,000 cases, and high-volume included >50,000 cases. RESULTS: Low-volume cancer registries incurred an average of $93.11 to report a case (without in-kind contributions) compared with $27.70 incurred by high-volume registries. Across all registries, the highest cost per case was incurred for data collection and abstraction ($8.33), management ($6.86), and administration ($4.99). Low- and medium-volume registries have higher costs than high-volume registries for all key activities. CONCLUSIONS: Some cost differences by volume can be explained by the large fixed costs required for administering and performing registration activities, but other reasons may include the quality of the data initially submitted to the registries from reporting sources such as hospitals and pathology laboratories. Automation or efficiency improvements in data collection can potentially reduce overall costs. |
Notes from the Field: Hepatitis C Outbreak in a Dialysis Clinic - Tennessee, 2014.
Muleta D , Kainer MA , Moore-Moravian L , Wiese A , Ward J , McMaster S , Nguyen D , Forbi JC , Mixson-Hayden T , Collier M . MMWR Morb Mortal Wkly Rep 2016 64 1386-7 Outbreaks of hepatitis C virus (HCV) infections can occur among hemodialysis patients when recommended infection control practices are not followed (1). On January 30, 2014, a dialysis clinic in Tennessee identified acute HCV in a patient (patient A) during routine screening and reported it to the Tennessee Department of Health. Patient A had enrolled in the dialysis clinic in March 2010 and had annually tested negative for HCV (including a last HCV test on December 19, 2012), until testing positive for HCV antibodies (anti-HCV) on December 18, 2013 (confirmed by a positive HCV nucleic acid amplification test). Patient A reported no behavioral risk factors, but did have multiple health care exposures. |
The risk of nosocomial transmission of Rift Valley Fever
Al-Hamdan NA , Panackal AA , Al Bassam TH , Alrabea A , Al Hazmi M , Al Mazroa Y , Al Jefri M , Khan AS , Ksiazek TG . PLoS Negl Trop Dis 2015 9 (12) e0004314 In 2000, we investigated the Rift Valley fever (RVF) outbreak on the Arabian Peninsula-the first outside Africa-and the risk of nosocomial transmission. In a cross-sectional design, during the peak of the epidemic at its epicenter, we found four (0.6%) of 703 healthcare workers (HCWs) IgM seropositive but all with only community-associated exposures. Standard precautions are sufficient for HCWs exposed to known RVF patients, in contrast to other viral hemorrhagic fevers (VHF) such as Ebola virus disease (EVD) in which the route of transmission differs. Suspected VHF in which the etiology is uncertain should be initially managed with the most cautious infection control measures. |
Cardiothoracic surgical site phaeohyphomycosis caused by Bipolaris mould, multiple US states, 2008-2013: a clinical description
Vallabhaneni S , Purfield AE , Benedict K , Luvsansharav U , Lockhart SR , Pham CD , Pascoe N , Heseltine G , Chung W , Hall E , Brust KB , Wheeler CF , Halpin AL , Park BJ . Med Mycol 2015 54 (3) 318-21 Bipolaris mould surgical site infections (SSIs) are exceedingly rare. We describe 21 cases of Bipolaris SSIs in pediatric and adult cardiothoracic surgery patients at ten hospitals in Texas, Arkansas, and Florida during 2008-2013. Median case-patient age was 55 years (range: 3 days-82 years), and 19 (90%) were male. Ten (48%) had coronary artery bypass or valve surgery, and seven (33%) had heart transplantation. Fifteen (71%) had more than one cardiothoracic procedure (median: 3, range: 1-11). Thirteen (62%) case-patients (all 5 pediatric patients, and 8 (50%) of 16 adult patients) had delayed sternal closure (chest closed >1 day [median = 8 days; range: 2-22] following the initial cardiothoracic procedure). Thirteen (62%) had mediastinitis. Median time from initial surgery to positive Bipolaris culture was 20 days (range: 6-497). Sixteen (76%) case-patients died. |
Renaissance of an "old" vaccine
Sutter RW , Kew OM . Lancet Infect Dis 2015 16 (3) 268-70 When the inactivated poliovirus vaccine (IPV) developed by Salk and Youngner was licensed in 1955,1 it raised hopes that this feat would herald the end of poliomyelitis. The vaccine's widespread use led to substantial declines in the incidence of poliomyelitis, but after a small resurgence of cases in the late 1950s, the public health community shifted to the oral poliovirus vaccine (OPV) developed by Sabin,2 and until now, only two countries worldwide (Iceland and Sweden) never introduced OPV. | In the 1970s, van Wezel developed a more potent version of IPV, referred to as enhanced-potency IPV.3 This formulation became the standard in the 1980s, and continues to be produced by the four Salk-IPV manufacturers—ie, GlaxoSmithKline (Belgium), Sanofi-Pasteur (France and Canada), Statens Serum Institute (Denmark), and Bilthoven Biologicals (Netherlands). | After the resolution by the World Health Assembly in 1988 to eradicate polio globally, massive use of OPV both in routine vaccination and in campaigns has brought the world close to eradication (only Afghanistan and Pakistan are polio-endemic). To eliminate or minimise vaccine-associated paralytic poliomyelitis,4 and to capitalise on the progress towards eradication, high-income countries recently considered IPV with renewed interest. Most high-income countries currently use IPV schedules. The last of which, Japan, licensed a diphtheria toxoid, tetanus toxoid, and acellular pertussis vaccine combined with Sabin-IPV (DTaP–Sabin-IPV) in 2013.5 |
Notes from the field: Injection safety and vaccine administration errors at an employee influenza vaccination clinic - New Jersey, 2015
Taylor L , Greeley R , Dinitz-Sklar J , Mazur N , Swanson J , Wolicki J , Perz J , Tan C , Montana B . MMWR Morb Mortal Wkly Rep 2015 64 (49) 1363-4 On September 30, 2015, the New Jersey Department of Health (NJDOH) was notified by an out-of-state health services company that an experienced nurse had reused syringes for multiple persons earlier that day. This occurred at an employee influenza vaccination clinic on the premises of a New Jersey business that had contracted with the health services company to provide influenza vaccinations to its employees. The employees were to receive vaccine from manufacturer-prefilled, single-dose syringes. However, the nurse contracted by the health services company brought three multiple-dose vials of vaccine that were intended for another event. The nurse reported using two syringes she found among her supplies to administer vaccine to 67 employees of the New Jersey business. She reported wiping the syringes with alcohol and using a new needle for each of the 67 persons. One of the vaccine recipients witnessed and questioned the syringe reuse, and brought it to the attention of managers at the business who, in turn, reported the practice to the health services company contracted to provide the influenza vaccinations. |
Preexisting chronic health conditions and health insurance status associated with vaccine receipt among adolescents
Seib K , Underwood NL , Gargano LM , Sales JM , Morfaw C , Weiss P , Murray D , Vogt TM , DiClemente RJ , Hughes JM . J Adolesc Health 2015 58 (2) 148-53 PURPOSE: Four vaccines are routinely recommended for adolescents: tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); meningococcal-conjugate (MCV4); and a yearly seasonal influenza vaccine. Vaccination promotion and outreach approaches may need to be tailored to certain populations, such as those with chronic health conditions or without health insurance. METHODS: In a controlled trial among middle and high school students in Georgia, 11 schools were randomized to one of three arms: no intervention, parent education brochure, or parent education brochure plus a student curriculum on the four recommended vaccines. Parents in all arms were surveyed regarding their adolescent's vaccine receipt, chronic health conditions, and health insurance status. RESULTS: Of the 686 parents, most (91%) reported their adolescent had received at least one of the four vaccines: Tdap (82%), MCV4 (59%), current influenza vaccine (53%) and HPV (48%). Twenty-three percent of parents reported that their adolescent had asthma. Most parents reported that their adolescent's insurance was Medicaid (60%) or private insurance (34%), and 6% reported no insurance. More adolescents with a chronic health condition received any adolescent vaccine than adolescents without a chronic health condition (p < .0001). Among those with no insurance, fewer had received any adolescent vaccine than those with Medicaid or private insurance (p < .0001). CONCLUSIONS: The federal Vaccines for Children program offers recommended vaccines free to eligible children (including those without health insurance). Our findings suggest that parents may not be aware of this program or eligibility for it, thus revealing a need for education or other fixes. |
Prior infection with influenza virus but not vaccination leaves a long-term immunological imprint that intensifies the protective efficacy of antigenically drifted vaccine strains
Kim JH , Liepkalns J , Reber AJ , Lu X , Music N , Jacob J , Sambhara S . Vaccine 2015 34 (4) 495-502 The role of pre-existing immunity for influenza vaccine responses is of great importance for public health, and thus has been studied in various contexts, yet the impact of differential priming on vaccine responses in the midst of antigenic drift remains to be elucidated. To address this with antigenically related viruses, mice were first primed by either infection or immunization with A/Puerto Rico/8/34 (PR8) virus, then immunized with whole-inactivated A/Fort Monmouth/1/47 (FM1) virus. The ensuing vaccine responses and the protective efficacy of FM1 were superior in PR8 infection-primed mice compared to PR8 immunization-primed or unprimed mice. Increased FM1-specific Ab responses of PR8 infection-primed mice also broadened cross-reactivity against contemporary as well as antigenically more drifted strains. Further, prior infection heightened the protective efficacy of antigenically distant strains, such as A/Brisbane/59/2006 infection followed by immunization with split pandemic H1N1 vaccine (A/California/07/2009). Therefore, influenza infection is a significant priming event that intensifies future vaccine responses against drift strains. |
Hepatitis B vaccination uptake and correlates of serologic response among HIV-infected and uninfected men who have sex with men (MSM) in Bangkok, Thailand
Chonwattana W , Raengsakulrach B , Holtz TH , Wasinrapee P , Tongtoyai J , Chaikummao S , Pattanasin S , McNicholl JM , van Griensven F , Curlin ME . Vaccine 2015 34 (17) 2044-50 BACKGROUND: Vaccination against hepatitis B virus (HBV) is recommended for all HBV-susceptible men who have sex with men (MSM). There is limited information on correlates of immunity to HBV vaccination in this group. We present serologic response rates to hepatitis B vaccine and identify factors associated with impaired response among HIV-uninfected and HIV-infected Thai MSM. METHODOLOGY: HBV-susceptible volunteers were offered hepatitis B vaccination at months zero, one, and six. We measured baseline (pre-vaccination) total serum IgG and IgG subclasses (all participants), baseline CD4 count, and plasma HIV-1 viral load (PVL) (HIV+ participants). HBV serologies were retested at 12 months. Serologic responses were compared between all groups in men receiving three vaccine doses. RESULTS: 511/651 HIV-negative and 64/84 HIV-positive participants completed the three-dose series. Response rates in HIV-uninfected and -infected participants were 90.1% vs. 50.0% (p<0.0001). Median pre-vaccination IgG was higher among non-responders than responders overall (1238.9.0 vs. 1057.0mg/dL, p=0.003) and among HIV-infected participants (1534.0 vs. 1244.5mg/dL, p=0.005), but not significantly among HIV-uninfected participants (1105.5 vs. 1054.3mg/dL, p=0.96). Pre-vaccination IgG1 and IgG3 levels were higher among HIV-positive than HIV-negative participants (median 866.0 vs. 520.3, and 105.8 vs. 83.1mg/dL, respectively, p<0.0001). Among HIV-infected participants, median CD4 count in non-responders was 378 cells/muL vs. 431 cells/muL in responders (p=0.20). Median PVL in non-responders was 64,800 copies/mL vs. 15500 copies/mL in responders (p=0.04). Participants with pre-vaccination plasma IgG >1550mg/dL and PVL >10,000 copies/mL were almost always non-responsive (p<0.01). CONCLUSIONS: HIV infection was associated with poor vaccine responses. High plasma viral load, elevated pre-vaccination total serum IgG and elevated pre-vaccination IgG1 are associated with poorer response to vaccination among HIV-infected MSM. In this group, the combination of high PVL and pre-vaccination total IgG is highly predictive of vaccine failure. |
Immunogenicity and safety of a novel monovalent high-dose inactivated poliovirus type 2 vaccine in infants: a comparative, observer-blind, randomised, controlled trial
Saez-Llorens X , Clemens R , Leroux-Roels G , Jimeno J , Clemens SA , Weldon WC , Oberste MS , Molina N , Bandyopadhyay AS . Lancet Infect Dis 2015 16 (3) 321-30 BACKGROUND: Following the proposed worldwide switch from trivalent oral poliovirus vaccine (tOPV) to bivalent types 1 and 3 OPV (bOPV) in 2016, inactivated poliovirus vaccine (IPV) will be the only source of protection against poliovirus type 2. With most countries opting for one dose of IPV in routine immunisation schedules during this transition because of cost and manufacturing constraints, optimisation of protection against all poliovirus types will be a priority of the global eradication programme. We assessed the immunogenicity and safety of a novel monovalent high-dose inactivated poliovirus type 2 vaccine (mIPV2HD) in infants. METHODS: This observer-blind, comparative, randomised controlled trial was done in a single centre in Panama. We enrolled healthy infants who had not received any previous vaccination against poliovirus. Infants were randomly assigned (1:1) by computer-generated randomisation sequence to receive a single dose of either mIPV2HD or standard trivalent IPV given concurrently with a third dose of bOPV at 14 weeks of age. At 18 weeks, all infants were challenged with one dose of monovalent type 2 OPV (mOPV2). Primary endpoints were seroconversion and median antibody titres to type 2 poliovirus 4 weeks after vaccination with mIPV2HD or IPV; and safety (as determined by the proportion and nature of serious adverse events and important medical events for 8 weeks after vaccination). The primary immunogenicity analyses included all participants for whom a post-vaccination blood sample was available. All randomised participants were included in the safety analyses. This trial is registered with ClinicalTrials.gov, number NCT02111135. FINDINGS: Between April 14 and May 9, 2014, 233 children were enrolled and randomly assigned to receive mIPV2HD (117 infants) or IPV (116 infants). 4 weeks after vaccination with mIPV2HD or IPV, seroconversion to poliovirus type 2 was recorded in 107 (93.0%, 95% CI 86.8-96.9) of 115 infants in the mIPV2HD group compared with 86 (74.8%, 65.8-82.4) of 115 infants in the IPV group (difference between groups 18.3%, 95% CI 5.0-31.1; p<0.0001), and median antibody titres against poliovirus type 2 were 181 (95% CI 72.0-362.0) in the mIPV2HD group and 36 (18.0-113.8) in the IPV group (difference between groups 98.8, 95% CI 60.7-136.9; p<0.0001). Serious adverse events were reported for six (5%) of 117 infants in the mIPV2HD group and seven (6%) of 116 infants in the IPV group during the 8-week period after vaccination; none were related to vaccination. No important medical events were reported. INTERPRETATION: Our findings lend support to the use of mIPV2HD as an option for stockpiling for outbreak response or primary protection in selected areas at risk for emergence of poliovirus type 2 during the next phase of the polio eradication plan. FUNDING: Bill & Melinda Gates Foundation. |
Influenza vaccine effectiveness for hospital and community patients using control groups with and without non-influenza respiratory viruses detected, Auckland, New Zealand 2014
Pierse N , Kelly H , Thompson MG , Bissielo A , Radke S , Huang QS , Baker MG , Turner N . Vaccine 2015 34 (4) 503-509 BACKGROUND: We aimed to estimate the protection afforded by inactivated influenza vaccine, in both community and hospital settings, in a well characterised urban population in Auckland during 2014. METHODS: We used two different comparison groups, all patients who tested negative for influenza and only those patients who tested negative for influenza and had a non-influenza respiratory virus detected, to calculate the vaccine effectiveness in a test negative study design. Estimates were made separately for general practice outpatient consultations and hospitalised patients, stratified by age group and by influenza type and subtype. Vaccine status was confirmed by electronic record for general practice patients and all respiratory viruses were detected by real time polymerase chain reaction. RESULTS: 1039 hospitalised and 1154 general practice outpatient consultations met all the study inclusion criteria and had a respiratory sample tested for influenza and other respiratory viruses. Compared to general practice patients, hospitalised patients were more likely to be very young or very old, to be Maori or Pacific Islander, to have a low income and to suffer from chronic disease. Vaccine effectiveness (VE) adjusted for age and other participant characteristics using all influenza negative controls was 42% (95% CI: 16 to 60%) for hospitalised and 56% (95% CI: 35 to 70%) for general practice patients. The vaccine appeared to be most effective against the influenza A(H1N1)pdm09 strain with an adjusted VE of 62% (95% CI:38 to 77%) for hospitalised and 59% (95% CI:36 to 74%) for general practice patients, using influenza virus negative controls. Similar results found when patients testing positive for a non-influenza respiratory virus were used as the control group. CONCLUSION: This study contributes to validation of the test negative design and confirms that inactivated influenza vaccines continue to provide modest but significant protection against laboratory-confirmed influenza. |
Comparability of neuraminidase inhibition antibody titers measured by enzyme-linked lectin assay (ELLA) for the analysis of influenza vaccine immunogenicity
Eichelberger MC , Couzens L , Gao Y , Levine M , Katz J , Wagner R , Thompson CI , Hoschler K , Laurie K , Bai T , Engelhardt OG , Wood J . Vaccine 2015 34 (4) 458-465 Neuraminidase-inhibition (NI) antibody titers can be used to evaluate the immunogenicity of inactivated influenza vaccines and have provided evidence of serologic cross-reactivity between seasonal and pandemic H1N1 viruses. The traditional thiobarbituric acid assay is impractical for large serologic analyses, and therefore many laboratories use an enzyme-linked lectin assay (ELLA) to determine serum NI antibody titers. The comparability of ELLA NI antibody titers when measured in different laboratories was unknown. Here we report a study conducted through the Consortium for the Standardisation of Influenza SeroEpidemiology (CONSISE) to evaluate the variability of the ELLA. NI antibody titers of a set of 12 samples were measured against both N1 and N2 neuraminidase antigens in 3 independent assays by each of 23 laboratories. For a sample repeated in the same assay, ≥96% of N1 and N2 assays had less than a 4-fold difference in titer. Comparison of the titers measured in assays conducted on 3 different days in the same laboratory showed that a four-fold difference in titer was uncommon. Titers of the same sera measured in different laboratories spanned 3 to 6 two-fold dilutions (i.e., 8-64 fold difference in titer), with an average percent geometric coefficient of variation (%GCV) of 112 and 82% against N1 and N2 antigens, respectively. The difference in titer as indicated by fold range and %GCV was improved by normalizing the NI titers to a standard that was included in each assay. This study identified background signal and the amount of antigen in the assay as critical factors that influence titer, providing important information toward development of a consensus ELLA protocol. |
Current status and uptake of influenza vaccination over time among senior adults in the United States
Lu PJ , O'Halloran A , Ding H , Greby SM , Williams WW . Hum Vaccin Immunother 2015 11 (12) 2849-51 Influenza is a major cause of morbidity and mortality among older adults in the United States, who may also have chronic medical conditions that place them at high risk for complications from influenza. The U.S. Public Health Service recommended influenza vaccination of adults ≥65 y and chronically ill persons since 1961 and beginning with the 2010-11 influenza season, the Advisory Committee on Immunization Practices (ACIP) has expanded its recommendation to vaccinate all persons 6 months of age and older. Medicare coverage for influenza vaccination began in 1993. However, despite the presence of a safe and effective vaccine, long-standing recommendations on vaccination, and federal financial support for vaccination, vaccination levels among adults ≥65 y are not optimal. Studies have shown that influenza vaccination coverage among U.S. adults ≥ 65 y steadily increased from 30.1% in 1989 to 64.2% in 1997, but plateaued near 65% from 1998 to 2013. Increasing influenza vaccination coverage among older adults in the United States will require more cooperation among health-care providers, professional organizations, vaccine manufacturers, and public health departments to raise public awareness about the benefits of influenza vaccination and to ensure continued administration of vaccinations throughout the influenza season. |
Suicidal ideation and mental health of Bhutanese refugees in the United States
Aoe T , Shetty S , Sivilli T , Blanton C , Ellis H , Geltman PL , Cochran J , Taylor E , Lankau EW , Lopes Cardozo B . J Immigr Minor Health 2015 18 (4) 828-835 Refugee agencies noticed a high number of suicides among Bhutanese refugees resettled in the United States between 2009 and 2012. We aimed to estimate prevalence of mental health conditions and identify factors associated with suicidal ideation among Bhutanese refugees. We conducted a stratified random cross-sectional survey and collected information on demographics, mental health conditions, suicidal ideation, and post-migration difficulties. Bivariate logistic regressions were performed to identify factors associated with suicidal ideation. Prevalence of mental health conditions were: depression (21 %), symptoms of anxiety (19 %), post-traumatic stress disorder (4.5 %), and suicidal ideation (3 %), significant risk factors for suicidal ideation included: not being a provider of the family; perceiving low social support; and having symptoms of anxiety and depression. These findings suggest that Bhutanese refugees in the United States may have a higher burden of mental illness relative to the US population and may benefit from mental health screening and treatment. Refugee communities and service providers may benefit from additional suicide awareness training to identify those at highest risk. |
The National Violent Death Reporting System: overview and future directions
Blair JM , Fowler KA , Jack SP , Crosby AE . Inj Prev 2015 22 Suppl 1 i6-11 OBJECTIVE: To describe the National Violent Death Reporting System (NVDRS). This is a surveillance system for monitoring the occurrence of homicides, suicides, unintentional firearm deaths, deaths of undetermined intent, and deaths from legal intervention (excluding legal executions) in the US. DESIGN: This report provides information about the history, scope, data variables, processes, utility, limitations, and future directions of the NVDRS. RESULTS: The NVDRS currently operates in 32 states, with the goal of future expansion to all 50 states, the District of Columbia, and US territories. The system uses existing primary data sources (death certificates, coroner/medical examiner reports, and law enforcement reports), and links them together to provide a comprehensive picture of the circumstances surrounding violent deaths. CONCLUSIONS: This report provides an overview of the NVDRS including a description of the system, discussion of its expanded capability, the use of new technologies as the system has evolved, how the data are being used for violence prevention efforts, and future directions. |
In search of teen dating violence typologies
Reidy DE , Ball B , Houry D , Holland KM , Valle LA , Kearns MC , Marshall KJ , Rosenbluth B . J Adolesc Health 2015 58 (2) 202-7 PURPOSE: The goal of the present research was to identify distinct latent classes of adolescents that commit teen dating violence (TDV) and assess differences on demographic, behavioral, and attitudinal correlates. METHODS: Boys and girls (N = 1,149; Mage = 14.3; Grades 6-12) with a history of violence exposure completed surveys assessing six indices of TDV in the preceding 3 months. Indices of TDV included controlling behaviors, psychological TDV, physical TDV, sexual TDV, fear/intimidation, and injury. In addition, adolescents provided demographic and dating history information and completed surveys assessing attitudes condoning violence, relationship skills and knowledge, and reactive/proactive aggression. RESULTS: Latent class analysis indicated a three-class solution wherein the largest class of students was nonviolent on all indices ("nonaggressors") and the smallest class of students demonstrated high probability of nearly all indices of TDV ("multiform aggressors"). In addition, a third class of "emotional aggressors" existed for which there was a high probability of controlling and psychological TDV but low likelihood of any other form of TDV. Multiform aggressors were differentiated from emotional and nonaggressors on the use of self-defense in dating relationships, attitudes condoning violence, and proactive aggression. Emotional aggressors were distinguished from nonaggressors on nearly all measured covariates. CONCLUSIONS: Evidence indicates that different subgroups of adolescents engaging in TDV exist. In particular, a small group of youth engaging in multiple forms of TDV can be distinguished from a larger group of youth that commit acts of TDV restricted to emotional aggression (i.e., controlling and psychological) and most youth that do not engage in TDV. |
Injury surveillance as a distributed system of systems
McClure RJ , Mack K . Inj Prev 2015 22 Suppl 1 i1-2 The contemporary definition of surveillance is | The ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated with timely dissemination of these data to those who need to know. The final link the surveillance chain is the application of these data to prevention and control.1 | In 2008, Professor Pless wrote an excellent criticism of modern injury surveillance in a commentary in this Journal; Surveillance alone is not the answer.2 The main point of the commentary was in his observation that, | I question whether there is any evidence that a surveillance system—even one that operates perfectly—actually contributes to prevention. …. Surveillance is sterile and pointless if it is not somehow tied to preventive interventions. | There are three ways for injury surveillance to fail the ‘Pless test’. The first way to fail is by not getting the right information into the right hands in a time and matter that allows data to be used for prevention programmes. The second way to fail is to spend ones resources looking for data, when data is not what is needed to solve the problem. Not recognising this distinction in circumstances where the second case holds true, can create accelerated efforts to collect “more and better” data in a vain attempt to improve injury outcomes, when the resources should be better applied elsewhere. The third way to fail the test as originally stated is an inevitable consequence of the wording of the challenge. An injury surveillance system could clear the first two hurdles yet still fail if data translation and implementation are outcomes for which the surveillance system is being held accountable. |
The CDC Injury Center's response to the growing public health problem of falls among older adults
Houry D , Florence C , Baldwin G , Stevens J , McClure R . Am J Lifestyle Med 2015 20 (10) 74-7 BACKGROUND: Older adult falls are a significant cause of morbidity and mortality in the United States. This leading cause of injury in adults aged 65 and older results in $35 billion in direct medical costs. OBJECTIVE: To project the number of older adult falls by 2030 and the associated lifetime medical cost. A secondary objective is to review what clinicians can do to incorporate falls screening and prevention into their practice for community-dwelling older adults. METHODS: Using the CDC's Web-based Injury Statistics Query and Reporting System and the US Census Bureau data, the number of older adults in 2030, fatal falls, and medical costs associated with fall injuries was projected. In addition, evidence-based interventions that can be integrated into clinical practice were reviewed. RESULTS: The number of older adult fatal falls is projected to reach 100,000 per year by 2030 with an associated cost of $100 billion. By integrating screening for falls risk into clinical practice, reviewing and modifying medications, and recommending Vitamin D supplementation, physicians can reduce future falls by nearly 25%. CONCLUSION: Falls in older adults will continue to rise substantially and become a significant cost to our health care system if we do not begin to focus on prevention in the clinical setting. |
Curriculum development around parenting strategies to prevent and respond to child sexual abuse in Sub-Saharan Africa: A program collaboration between Families Matter! and Global Dialogues
Miller KS , Winskell K , Pruitt KL , Saul J . J Child Sex Abus 2015 24 (8) 839-52 Despite widespread recognition of child sexual abuse as a serious problem in sub-Saharan Africa, few far-reaching programmatic interventions addressing child sexual abuse in this setting are currently available, and those interventions that do exist tend to focus on response rather than prevention. The Families Matter! Program is an evidence-based intervention for parents and caregivers of 9- to 12-year-olds in sub-Saharan African countries which promotes positive parenting practices and effective parent-child communication about sex-related issues. This article describes the enhancement of a new Families Matter! Program session on child sexual abuse, drawing on authentic narratives contributed by young people to the Global Dialogues from Africa youth scriptwriting competitions. Experiences are shared with a view to informing the development of interventions addressing child sexual abuse in sub-Saharan Africa. |
Supplementation of H1N1pdm09 split vaccine with heterologous tandem repeat M2e5x virus-like particles confers improved cross-protection in ferrets
Music N , Reber AJ , Kim MC , York IA , Kang SM . Vaccine 2015 34 (4) 466-473 Current influenza vaccines induce strain-specific immunity to the highly variable hemagglutinin (HA) protein. It is therefore a high priority to develop vaccines that induce broadly cross-protective immunity to different strains of influenza. Since influenza A M2 proteins are highly conserved among different strains, five tandem repeats of the extracellular peptide of M2 in a membrane-anchored form on virus-like particles (VLPs) have been suggested to be a promising candidate for universal influenza vaccine. In this study, ferrets were intramuscularly immunized with 2009 H1N1 split HA vaccine ("Split") alone, influenza split vaccine supplemented with M2e5x VLP ("Split+M2e5x"), M2e5x VLP alone ("M2e5x"), or mock immunized. Vaccine efficacy was measured serologically and by protection against a serologically distinct viral challenge. Ferrets immunized with Split+M2e5x induced HA strain specific and conserved M2e immunity. Supplementation of M2e5x VLP to split vaccination significantly increased the immunogenicity of split vaccine compared to split alone. The Split+M2e5x ferret group showed evidence of cross-reactive protection, including faster recovery from weight loss, and reduced inflammation, as inferred from changes in peripheral leukocyte subsets, compared to mock-immunized animals. In addition, ferrets immunized with Split+M2e5x shed lower viral nasal-wash titers than the other groups. Ferrets immunized with M2e5x alone also show some protective effects, while those immunized with split vaccine alone induced no protective effects compared to mock-immunized ferrets. These studies suggest that supplementation of split vaccine with M2e5x-VLP may provide broader and improved cross-protection than split vaccine alone. |
Two Listeria monocytogenes pseudo-outbreaks caused by contaminated laboratory culture media
Matanock A , Katz LS , Jackson KA , Kucerova Z , Conrad AR , Glover WA , Nguyen V , Mohr MC , Marsden-Haug N , Thompson D , Dunn JR , Stroika S , Melius B , Tarr C , Dietrich SE , Kao AS , Kornstein L , Li Z , Maroufi A , Marder EP , Meyer R , Perez-Osorio AC , Reddy V , Reporter R , Carleton H , Tweeten S , Waechter H , Yee LM , Wise ME , Davis K , Jackson B . J Clin Microbiol 2015 54 (3) 768-70 Listeriosis is a serious foodborne infection that disproportionately affects elderly adults, pregnant women, newborns, and immunocompromised individuals. Diagnosis is made by culturing Listeria monocytogenes from sterile body fluids or products of conception. This report describes investigations of two listeriosis pseudo-outbreaks caused by contaminated laboratory media made from sheep blood. |
Automated pressure map segmentation for quantifying phalangeal kinetics during cylindrical gripping
Sinsel EW , Gloekler DS , Wimer BM , Warren CM , Wu JZ , Buczek FL . Med Eng Phys 2015 38 (2) 72-9 Inverse dynamics models used to investigate musculoskeletal disorders associated with handle gripping require accurate phalangeal kinetics. Cylindrical handles wrapped with pressure film grids have been used in studies of gripping kinetics. We present a method fusing six degree-of-freedom hand kinematics and a kinematic calibration of a cylinder-wrapped pressure film. Phalanges are modeled as conic frusta and projected onto the pressure grid, automatically segmenting the pressure map into regions of interest (ROIs). To demonstrate the method, segmented pressure maps are presented from two subjects with substantially different hand length and body mass, gripping cylinders 50 and 70 mm in diameter. For each ROI, surface-normal force vectors were summed to create a reaction force vector and center of pressure location. Phalangeal force magnitudes for a data sample were similar to that reported in previous studies. To evaluate our method, a surrogate was designed for each handle such that when modeled as a phalanx it would generate a ROI around the cells under its supports; the classification F-score was above 0.95 for both handles. Both the human subject results and the surrogate evaluation suggest that the approach can be used to automatically segment the pressure map for quantifying phalangeal kinetics of the fingers during cylindrical gripping. |
Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period
Leffert LR , Clancy CR , Bateman BT , Cox M , Schulte PJ , Smith EE , Fonarow GC , Kuklina EV , George MG , Schwamm LH . Am J Obstet Gynecol 2015 214 (6) 723.e1-723.e11 BACKGROUND: Stroke is a rare but devastating event during pregnancy, occurring in 34/100,000 deliveries, and obstetricians are often the first providers to be contacted by symptomatic patients. At least half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women as pregnancy has been an exclusion criteria for all reperfusion trials. Until recently, pregnancy and obstetrical delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator (tPA) in Federal Drug Administration labeling. OBJECTIVE: The primary study objective was to compare the characteristics and outcomes of pregnant or postpartum versus non-pregnant women with ischemic stroke who received acute reperfusion therapy. STUDY DESIGN: Pregnant or postpartum (<6 weeks; N=338) and non-pregnant (N=24,303) women aged 18-44 with ischemic stroke from 1,991 hospitals participating in the American Heart Association's Get With the Guidelines-Stroke (GWTG) Registry from 2008 to 2013 were identified by medical history or ICD-9 codes. Acute stroke reperfusion therapy was defined as intravenous (IV) tPA, catheter-based thrombolysis or thrombectomy, or any combination thereof. A sensitivity analysis was done on patients receiving IV tPA monotherapy, only. Chi-square tests were used for categorical variables and Wilcoxon Rank-Sum for continuous variables. Conditional logistic regression was used to assess the association of pregnancy with short-term outcomes. RESULTS: Baseline characteristics of the pregnant or postpartum versus non-pregnant women with ischemic stroke revealed a younger group who, despite greater stroke severity, were less likely to have a history of hypertension or arrive via emergency medical services. There were similar rates of acute stroke reperfusion therapy in the pregnant or postpartum versus non-pregnant women (11.8% vs. 10.5%, p=0.42). Pregnant or postpartum women were less likely to receive IV tPA monotherapy (4.4% vs. 7.9%; p=0.03), primarily due to "pregnancy" and "recent surgery". There was a trend toward increased symptomatic intracranial hemorrhage in the pregnant or postpartum tPA-treated patients yet no cases of major systemic bleeding or in-hospital death, and similar rates of discharge to home. Data on the timing of pregnancy, available in 145/338 cases, showed 44.8% of pregnancy-related strokes were antepartum, 2.8% during delivery and 52.4% postpartum. CONCLUSIONS: Using data from The GWTG-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to non-pregnant women, despite lower rates of IV tPA use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients most likely to safely benefit from reperfusion therapy. |
Hospitalizations attributable to respiratory infections among children with neurologic disorders
Havers F , Fry AM , Chen J , Christensen D , Moore C , Peacock G , Finelli L , Reed C . J Pediatr 2015 170 135-41 e1-5 OBJECTIVES: To characterize respiratory infection hospitalizations in children with neurologic disorders and to compare them with those of the general pediatric population. STUDY DESIGN: We analyzed claims data from commercial insurance and Medicaid enrollees <19 years of age from July 2006 to June 2011 who had ≥1 visit with an International Classification of Diseases, Ninth Revision, diagnosis code for a neurologic disorder. We identified hospitalizations with primary diagnosis codes indicating a respiratory infection and compared hospitalization rates with random samples of children from the commercial and Medicaid databases (comparison groups). RESULTS: Among 33 651 923 children, 255 046 (0.76%) had ≥1 neurologic condition. Among children with neurologic conditions, 8249 of 68 717 hospitalizations (12%) were attributed to a respiratory infection (rate: 21/1000 person-years), although rates varied by disorder. Children with neurologic disorders had greater rates than children in comparison groups (relative rate: Commercial Claims 7.4 [95% CI 7.1-7.7]; Medicaid 5.0 [95% CI 4.8-5.2]). Children <2 years were most likely to be hospitalized, although those 10-18 years were 14.5 (95% CI 13.3-16.7) times more likely to be hospitalized than age-matched comparison groups. Co-occurring deafness, blindness, and scoliosis were associated with increased respiratory hospitalization rates. CONCLUSIONS: Children with neurologic disorders are at 5- to 7-fold greater risk for hospitalization from respiratory infections compared with all children, although rates vary widely by disorder type, age, and comorbidities. Children with specific neurologic disorders and those who had co-occurring conditions have the highest rates. |
Chorioamnionitis and culture-confirmed, early-onset neonatal infections
Wortham JM , Hansen NI , Schrag SJ , Hale E , Van Meurs K , Sanchez PJ , Cantey JB , Faix R , Poindexter B , Goldberg R , Bizzarro M , Frantz I , Das A , Benitz WE , Shane AL , Higgins R , Stoll BJ . Pediatrics 2015 137 (1) BACKGROUND: Current guidelines for prevention of neonatal group B streptococcal disease recommend diagnostic evaluations and empirical antibiotic therapy for well-appearing, chorioamnionitis-exposed newborns. Some clinicians question these recommendations, citing the decline in early-onset group B streptococcal disease rates since widespread intrapartum antibiotic prophylaxis implementation and potential antibiotic risks. We aimed to determine whether chorioamnionitis-exposed newborns with culture-confirmed, early-onset infections can be asymptomatic at birth. METHODS: Multicenter, prospective surveillance for early-onset neonatal infections was conducted during 2006-2009. Early-onset infection was defined as isolation of a pathogen from blood or cerebrospinal fluid collected ≤72 hours after birth. Maternal chorioamnionitis was defined by clinical diagnosis in the medical record or by histologic diagnosis by placental pathology. Hospital records of newborns with early-onset infections born to mothers with chorioamnionitis were reviewed retrospectively to determine symptom onset. RESULTS: Early-onset infections were diagnosed in 389 of 396 586 live births, including 232 (60%) chorioamnionitis-exposed newborns. Records for 229 were reviewed; 29 (13%) had no documented symptoms within 6 hours of birth, including 21 (9%) who remained asymptomatic at 72 hours. Intrapartum antibiotic prophylaxis exposure did not differ significantly between asymptomatic and symptomatic infants (76% vs 69%; P = .52). Assuming complete guideline implementation, we estimated that 60 to 1400 newborns would receive diagnostic evaluations and antibiotics for each infected asymptomatic newborn, depending on chorioamnionitis prevalence. CONCLUSIONS: Some infants born to mothers with chorioamnionitis may have no signs of sepsis at birth despite having culture-confirmed infections. Implementation of current clinical guidelines may result in early diagnosis, but large numbers of uninfected asymptomatic infants would be treated. |
Data linkage between the National Birth Defects Prevention Study and the Occupational Information Network (O*NET) to assess workplace physical activity, sedentary behaviors, and emotional stressors during pregnancy
Lee LJ , Symanski E , Lupo PJ , Tinker SC , Razzaghi H , Pompeii LA , Hoyt AT , Canfield MA , Chan W . Am J Ind Med 2015 59 (2) 137-49 BACKGROUND: Knowledge of the prevalence of work-related physical activities, sedentary behaviors, and emotional stressors among pregnant women is limited, and the extent to which these exposures vary by maternal characteristics remains unclear. METHODS: Data on mothers of 6,817 infants without major birth defects, with estimated delivery during 1997 through 2009 who worked during pregnancy were obtained from the National Birth Defects Prevention Study. Information on multiple domains of occupational exposures was gathered by linking mother's primary job to the Occupational Information Network Version 9.0. RESULTS: The most frequent estimated physical activity associated with jobs during pregnancy was standing. Of 6,337 mothers, 31.0% reported jobs associated with standing for ≥75% of their time. There was significant variability in estimated occupational exposures by maternal age, race/ethnicity, and educational level. CONCLUSIONS: Our findings augment existing literature on occupational physical activities, sedentary behaviors, emotional stressors, and occupational health disparities during pregnancy. |
Demographic differences among a national sample of US youth with behavioral disorders
Visser SN , Deubler EL , Bitsko RH , Holbrook JR , Danielson ML . Clin Pediatr (Phila) 2015 55 (14) 1358-1362 This study’s objective was to compare the demographic patterns in the diagnosed prevalence of attention-deficit/ hyperactivity disorder (ADHD) to oppositional defiant disorder and conduct disorder (ODD/CD) in a national sample, with consideration for children with both disorders. Prior to 2013, these frequently co-occurring disorders have been nosologically grouped together in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as behavioral disorders with childhood onset.1,2 However in the 2013 DSM-5, ADHD was grouped with neurodevelopmental disorders, and ODD and CD were grouped with disruptive disorders.3 Investigating the epidemiology of ADHD and ODD/CD has the potential to inform efforts to diagnose, treat, and manage these disorders. This information is particularly relevant for pediatricians, who are the single largest group of diagnosing physicians, diagnosing approximately 39% of children with ADHD.4 |
Analysis of alternatives for using cable bolts as primary support at two low-seam coal mines
Esterhuizen GS , Tulu IB . Int J Min Sci Technol 2015 26 (1) 23-30 Cable bolts are sometimes used in low-seam coal mines to provide support in difficult ground conditions. This paper describes cable bolting solutions at two low-seam coal mines in similar ground conditions. Both mines used support systems incorporating cable bolts as part of the primary support system. Two original cable bolt based support systems as well as two modified systems are evaluated to estimate their ability to prevent large roof falls. One of the support systems incorporated passive cable bolts, while the other used pre-tensioned cable bolts. The results and experience at the mines showed that the modified systems provided improved stability over the original support systems. The presence of the cable bolts is the most important contribution to stability against large roof falls, rather than the details of the support pattern. It was also found that a heavy steel channel can improve the safety of the system because of the 'sling' action it provides. Additionally, the analysis showed that fully-grouted rebar bolts load much earlier than the cable bolts, and pre-tensioning of the cable bolts can result in a more uniform distribution of loading in the roof. |
A different perspective: NIOSH researchers learn from CM operator responses to proximity detection systems
Haas E , Ducarme J . Coal Age 2015 120 (10) 34-35 Given the consistent increase in the number of proximity detection systems (PDSs) being used in underground coal mines, it si critical to understand ways that PDS technology influences mineworkers' assessmnet of their environment and subsequent behaviors. Regardless of the particular PDS model, it is importaant to document these general respones to the technology and any changes in workers' ability to perceive, understand and make safe decisions on the job. |
Predictors of micronutrient powder intake adherence in a pilot programme in Nepal
Mirkovic KR , Perrine CG , Subedi GR , Mebrahtu S , Dahal P , Staatz C , Jefferds ME . Public Health Nutr 2015 19 (10) 1-9 OBJECTIVE: Poor adherence to recommended intake protocols is common and a top challenge for micronutrient powder (MNP) programmes globally. Identifying modifiable predictors of intake adherence could inform the design and implementation of MNP projects. DESIGN: We assessed high MNP intake adherence among children who had received MNP ≥2 months ago and consumed ≥1 sachet (n 771). High MNP intake adherence was defined as maternal report of child intake ≥45 sachets. We used logistic regression to assess demographic, intervention components and perception-of-use factors associated with high MNP intake. SETTING: Four districts of Nepal piloting an integrated infant and young child feeding and MNP project. SUBJECTS: Children aged 6-23 months were eligible to receive sixty MNP sachets every 6 months with suggested intake of one sachet daily for 60 d. Cross-sectional surveys representative of children aged 6-23 months were conducted. RESULTS: Receiving a reminder card was associated with increased odds for high intake (OR=2.18, 95 % CI 1.14, 4.18); exposure to other programme components was not associated with high intake. Mothers perceiving ≥1 positive effects in their child after MNP use was also associated with high intake (OR=6.55, 95 % CI 4.29, 10.01). Perceiving negative affects was not associated; however, the child not liking the food with MNP was associated with lower odds of high intake (OR=0.12, 95 % CI 0.08, 0.20). CONCLUSIONS: Behaviour change intervention strategies tailored to address these modifiable predictors could potentially increase MNP intake adherence. |
Research in brief: Motor vehicle safety for law enforcement officers - still a priority
Tiesman HM , Heick R . Police Chief 2015 82 (4) 22-23 The IACP Research Advisory Committee is proud to offer the monthly Research in Brief column. This column features evidence-based research summaries that highlight actionable recommendations for Police Chief magazine readers to consider within their own agencies. The goal of the column is to feature research that is innovative, credible, and relevant to a diverse law enforcement audience. |
Independent Emergence of the Plasmodium Falciparum Kelch Propeller Domain Mutant Allele C580Y in Guyana.
Chenet SM , Akinyi Okoth S , Huber CS , Chandrabose J , Lucchi NW , Talundzic E , Krishnalall K , Ceron N , Musset L , Macedo de Oliveira A , Venkatesan M , Rahman R , Barnwell JW , Udhayakumar V . J Infect Dis 2015 213 (9) 1472-5 Suspected artemisinin resistance in Plasmodium falciparum can be explored by examining polymorphisms in the Kelch (PfK13) propeller domain. Sequencing of PfK13 and other gene resistance markers was performed on 98 samples from Guyana. Five of these samples carried the C580Y allele in the PfK13 propeller domain, with flanking microsatellite profiles different from those observed in Southeast Asia. These molecular data demonstrate independent emergence of the C580Y K13 mutant allele in Guyana, where resistance alleles to previously used drugs are fixed. Therefore, continued molecular surveillance and periodic assessment of therapeutic efficacy of ACT in Guyana and neighboring countries, is warranted. |
Use of the novel therapeutic agent miltefosine for the treatment of primary amebic meningoencephalitis: report of one fatal and one surviving case
Cope JR , Conrad DA , Cohen N , Cotilla M , Dasilva A , Jackson J , Visvesvara G . Clin Infect Dis 2015 62 (6) 774-6 Primary amebic meningoencephalitis (PAM) is a fulminant central nervous system infection caused by the thermophilic free-living ameba Naegleria fowleri. Few survivals have been documented and adequate treatment is lacking. We report two PAM cases, one fatal and one surviving, treated with the novel antiparasitic agent miltefosine. |
Missed opportunities to deliver intermittent preventive treatment for malaria to pregnant women 2003-2013: a systematic analysis of 58 household surveys in sub-Saharan Africa
Andrews KG , Lynch M , Eckert E , Gutman J . Malar J 2015 14 (1) 521 BACKGROUND: Despite the availability of effective preventive measures, including intermittent preventive treatment for malaria during pregnancy (IPTp), malaria continues to cause substantial disease burden among pregnant women in malaria-endemic areas. IPTp coverage remains low, despite high antenatal care (ANC) attendance. To highlight areas of potential improvement, trends in IPTp coverage were assessed over time, missed opportunities to deliver IPTp at ANC were quantified, and delivery of IPTp was compared to that of tetanus toxoid (TT). METHODS: Data from 58 Demographic and Health Surveys conducted between 2003 and 2013 in 31 sub-Saharan African countries, with relevant questions on IPTp, ANC and TT were used to assess ANC attendance, and IPTp and TT delivery. A missed opportunity for IPTp delivery is an ANC visit at which IPTp could have been delivered according to policy but was not. RESULTS: The proportion of pregnant women who received ≥2 doses of IPTp increased in surveyed countries from nearly zero before to a median of 29.6 % (IQR 20.1-42.5 %) seven or more years after IPTp policy adoption. ANC attendance was high (median 76.6 % reported ≥3 visits); however, even seven or more years post policy adoption, a median of 72.9 % (IQR 58.4-79.5 %) ANC visits were missed opportunities to deliver IPTp. Among primigravid women, a median of 61.5 % (IQR 50.9-72.9 %) received two doses of TT; delivery of recommended TT exceeded IPTp in all but one surveyed country. CONCLUSIONS: IPTp coverage measured by household surveys is unsatisfactorily low, even many years after policy adoption. The many missed opportunities to deliver IPTp suggest that deficiencies in delivery at ANC are a significant contributing factor to the low coverage levels. High levels of TT delivery indicate capacity to deliver preventive measures at ANC. Further research is required to determine the factors driving the discrepancies between IPTp and TT coverage, and how these may be addressed to improve IPTp coverage. |
Through a culturally competent lens: Why the program evaluation standards matter
Gill S , Kuwahara R , Wilce M . Health Promot Pract 2016 17 (1) 5-8 Program evaluation is an important tool for all health professionals as it enables us to learn what works, what does not, and how we can make improvements. In this article, we describe how both program staff and evaluators can use the program evaluation standards to ensure their work is culturally competent and stakeholder driven. When public health programs and their evaluations are responsive to culture and context, and they include meaningful-not token-stakeholder engagement, we produce better evaluations that are more likely to yield useful findings and lead to more effective programs. Effective programs are culturally competent programs that benefit communities in meaningful, respectful ways. |
Arriving at results efficiently: Using the enhanced evaluability assessment approach
Losby JL , Vaughan M , Davis R , Tucker-Brown A . Prev Chronic Dis 2015 12 E224 Evidence, particularly practice-based evidence, is needed to guide public health practice. With the goal of contributing to practice-based evidence, the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention combined and streamlined aspects of an evaluability assessment and an effectiveness evaluation to create the Enhanced Evaluability Assessment (EEA). This approach offers a viable and less costly alternative to evaluators and practitioners by quickly identifying and evaluating models with evidence of effectiveness that can be replicated and expanded. The EEA can be applied to a range of public health topics, not just cardiovascular health. This article provides a step-by-step description of the EEA. |
Unintended pregnancy risk and contraceptive use among women aged 45 to 50 years - Massachusetts, 2006, 2008, and 2010
Godfrey EM , Zapata LB , Cox CM , Curtis KM , Marchbanks PA . Am J Obstet Gynecol 2015 214 (6) 712 e1-8 BACKGROUND: Little is known about unintended pregnancy (UIP) risk and current contraceptive use among women aged 45 years and over in the United States (US). OBJECTIVES: To describe the prevalence of women aged 45-50 years at risk for UIP and their current contraceptive use and to compare these findings to those of women in younger age groups. STUDY DESIGN: We analyzed 2006, 2008 and 2010 Massachusetts Behavioral Risk Factor Surveillance System data, the only US state to routinely collect contraceptive data from women beyond age 44 years. Women aged 18-50 years (n=4,930) were considered at risk for UIP unless they reported current pregnancy, past hysterectomy, not being sexually active in the past year, having a same sex partner, or wanting to become pregnant. Among women considered at risk (n=3,605), we estimated the prevalence of current contraceptive use by age group. Among women considered at risk and aged 45-50 years (n=940), we examined characteristics associated with current method use. Analyses were conducted on weighted data using SUDAAN. RESULTS: Among women aged 45-50 years, 77.6% were at risk for UIP, which was similar to other age groups. As age increased, hormonal contraceptive use (shots, pills, patch, or ring) decreased, while permanent contraception (tubal ligation or vasectomy) increased as did non-use of contraception. Of women aged 45-50 years at risk for UIP, 66.9% reported using some contraceptive method; permanent contraception was the leading method reported by 44.0% and contraceptive non-use was reported by 16.8%. CONCLUSION: A substantial proportion of women aged 45-50 years were considered at risk for UIP. Permanent contraception was most commonly used by women in this age group. Compared with other age groups, more women aged 45-50 years were not using any contraception. Population-based surveillance efforts are needed to follow trends among this age group and better meet their family planning needs. Although expanding surveillance systems to include women through age 50 years requires additional resources, fertility trends showing increasingly delayed childbearing, uncertain end of fecundity, and potential adverse consequences of unplanned pregnancy in older age may justify these expenditures. |
Projecting the unmet need and costs for contraception services after the Affordable Care Act
August EM , Steinmetz E , Gavin L , Rivera MI , Pazol K , Moskosky S , Weik T , Ku L . Am J Public Health 2015 106 (2) e1-e8 OBJECTIVES: We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. METHODS: We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. RESULTS: The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states' current Medicaid expansion plans. CONCLUSIONS: The Affordable Care Act increases women's insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed. (Am J Public Health. Published online ahead of print December 21, 2015: e1-e8. doi:10.2105/AJPH.2015.302928). |
Assessing relationship and sexual satisfaction in adolescent relationships formed online and offline
Blunt-Vinti HD , Wheldon C , McFarlane M , Brogan N , Walsh-Buhi ER . J Adolesc Health 2016 58 (1) 11-6 PURPOSE: Using the Internet to meet new people is becoming more common; however, such behavior is often considered risky, particularly for adolescents. Nevertheless, adolescents are meeting people through online venues and some are forming romantic/sexual relationships. The purpose of this study was to examine the relationship and sexual satisfaction reported by teens in online- and offline-initiated relationships. METHODS: Data were collected from 273 13-19 year olds visiting a publicly funded clinic through 2010 and 2011. Questions included where respondents met the partner (online vs. offline), time between meeting and first sex, how well they knew the partner, and relationship and sexual (R&S) satisfaction. Analyses consisted of descriptive statistics, t tests, and path analysis, exploring R&S satisfaction in online- and offline-initiated relationships. RESULTS: R&S satisfaction scores were moderate for adolescents who reported meeting partners online and in person but were statistically higher in offline-initiated relationships. There was an inverse relationship between having an online partner and both relationship and sexual satisfaction. Additionally, knowing partners for a longer period of time and feeling more knowledgeable about partners before having sex were statistically significantly related to higher R&S satisfaction. CONCLUSIONS: Teens in this study reported more satisfying relationships with partners met offline compared with online. Results suggest that encouraging teens to wait longer and to get to know their partner(s) better before engaging in sex may improve satisfaction with, and quality of, those relationships. These findings provide an important contribution to sexual health promotion among young people, with whom technology use is ubiquitous. |
Increases in drug and opioid overdose deaths - United States, 2000-2014
Rudd RA , Aleshire N , Zibbell JE , Gladden RM . MMWR Morb Mortal Wkly Rep 2016 64 1378-82 The United States is experiencing an epidemic of drug overdose (poisoning) deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin). CDC analyzed recent multiple cause-of-death mortality data to examine current trends and characteristics of drug overdose deaths, including the types of opioids associated with drug overdose deaths. During 2014, a total of 47,055 drug overdose deaths occurred in the United States, representing a 1-year increase of 6.5%, from 13.8 per 100,000 persons in 2013 to 14.7 per 100,000 persons in 2014. The rate of drug overdose deaths increased significantly for both sexes, persons aged 25-44 years and ≥55 years, non-Hispanic whites and non-Hispanic blacks, and in the Northeastern, Midwestern, and Southern regions of the United States. Rates of opioid overdose deaths also increased significantly, from 7.9 per 100,000 in 2013 to 9.0 per 100,000 in 2014, a 14% increase. Historically, CDC has programmatically characterized all opioid pain reliever deaths (natural and semisynthetic opioids, methadone, and other synthetic opioids) as "prescription" opioid overdoses. Between 2013 and 2014, the age-adjusted rate of death involving methadone remained unchanged; however, the age-adjusted rate of death involving natural and semisynthetic opioid pain relievers, heroin, and synthetic opioids, other than methadone (e.g., fentanyl) increased 9%, 26%, and 80%, respectively. The sharp increase in deaths involving synthetic opioids, other than methadone, in 2014 coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl, a synthetic opioid; however, illicitly manufactured fentanyl cannot be distinguished from prescription fentanyl in death certificate data. These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence, and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl. |
Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012
Levy B , Paulozzi L , Mack KA , Jones CM . Am J Prev Med 2015 49 (3) 409-13 INTRODUCTION: Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time. METHODS: IMS Health's National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013. RESULTS: In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%). CONCLUSIONS: The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain. |
Urinary concentrations of PAH and VOC metabolites in marijuana users
Wei B , Alwis KU , Li Z , Wang L , Valentin-Blasini L , Sosnoff CS , Xia Y , Conway KP , Blount BC . Environ Int 2015 88 1-8 BACKGROUND: Marijuana is seeing increased therapeutic use, and is the world's third most-popular recreational drug following alcohol and tobacco. This widening use poses increased exposure to potentially toxic combustion by-products from marijuana smoke and the potential for public health concerns. OBJECTIVES: To compare urinary metabolites of polycyclic aromatic hydrocarbons (PAHs) and volatile organic compounds (VOCs) among self-reported recent marijuana users and nonusers, while accounting for tobacco smoke exposure. METHODS: Measurements of PAH and VOC metabolites in urine samples were combined with questionnaire data collected from participants in the National Health and Nutrition Examination Surveys (NHANES) from 2005 to 2012 in order to categorize participants (≥18years) into exclusive recent marijuana users and nonusers. Adjusted geometric means (GMs) of urinary concentrations were computed for these groups using multiple regression analyses to adjust for potential confounders. RESULTS: Adjusted GMs of many individual monohydroxy PAHs (OH-PAHs) were significantly higher in recent marijuana users than in nonusers (p<0.05). Urinary thiocyanate (p<0.001) and urinary concentrations of many VOC metabolites, including metabolites of acrylonitrile (p<0.001) and acrylamide (p<0.001), were significantly higher in recent marijuana users than in nonusers. CONCLUSIONS: We found elevated levels of biomarkers for potentially harmful chemicals among self-identified, recent marijuana users compared with nonusers. These findings suggest that further studies are needed to evaluate the potential health risks to humans from the exposure to these agents when smoking marijuana. |
National and state attitudes of US adults toward tobacco-free school grounds, 2009-2010
Kruger J , Patel R , Kegler MC , Brener ND , King BA . Prev Chronic Dis 2015 12 E229 INTRODUCTION: Schools are an important environment for addressing tobacco use among youth. Tobacco-free school policies can help reduce the social acceptability of tobacco use and prevent tobacco initiation among youth. This study assessed attitudes toward tobacco-free school grounds among US adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of adults aged 18 or older in the 50 US states and District of Columbia. Respondents were considered to have a favorable attitude toward tobacco-free school grounds if they reported tobacco use should be completely banned on school grounds, including fields and parking lots, and at all school events. Data were assessed using descriptive statistics and multivariable logistic regression, overall and by tobacco use status. Correlates were sex, age, race/ethnicity, education, marital status, income, sexual orientation, US region, and whether respondent lived with any children aged 17 years or younger. RESULTS: Nationally, 86.1% of adults had a favorable attitude toward tobacco-free school grounds, with larger percentages among nontobacco users (91.9%) than current users (76.1%). State prevalence ranged from 80.0% (Kentucky) to 90.9% (Washington). Overall odds of favorable attitudes were higher among nontobacco users (referent, current users), women (referent, men), and adults aged 25 or older (referent, aged 18-24); odds were lower among residents of the South (referent, West) and lesbian, gay, bisexual, or transgender adults (referent, heterosexual or straight). CONCLUSION: Nearly 9 in 10 US adults have a favorable attitude toward tobacco-free school grounds, but attitudes vary across states and subpopulations. Opportunities exist to educate the public about the benefits of tobacco-free school grounds, which might help reduce tobacco use among youth. |
Postpartum smoking relapse after quitting during pregnancy: Pregnancy Risk Assessment Monitoring System, 2000-2011
Rockhill KM , Tong VT , Farr SL , Robbins CL , D'Angelo DV , England LJ . J Womens Health (Larchmt) 2015 25 (5) 480-8 BACKGROUND: Relapsing to smoking postpartum jeopardizes a woman's health and her infant's health. Our study estimated the proportion and identified characteristics associated with postpartum relapse using a large population-based sample. MATERIALS AND METHODS: We analyzed Pregnancy Risk Assessment Monitoring System data among women with live births. Relapse was defined as smoking at survey completion among those who quit by the last 3 months of pregnancy. We assessed linear trends for relapse during 2000-2011 in 40 sites overall and individually using logistic regression. Adjusted prevalence ratios (aPRs) were calculated to assess characteristics associated with relapse during 2009-2011 (n = 13,076). RESULTS: During 2000-2011, the proportion of women who relapsed postpartum remained unchanged overall (p = 0.84) and by site (p ≥ 0.05 for each), ranging in 2011 from 30.8% to 52.2% (Wyoming-Arkansas). Characteristics associated with relapse compared with reference groups were prepregnancy daily smoking (aPR = 1.80; 95% confidence interval (CI): 1.59-2.04); age <20 years (aPR = 1.51; 1.24-1.84), 20-24 years (aPR = 1.39; 1.17-1.65), or 25-34 years (aPR = 1.26; 1.07-1.48); not initiating breastfeeding (aPR = 1.34; 1.24-1.44); not having a complete home smoking ban (aPR = 1.27; 1.14-1.42); being black non-Hispanic (aPR = 1.25; 1.14-1.38); being multiparous (aPR = 1.20; 1.11-1.28); experiencing 3-5 stressors during pregnancy (aPR = 1.12; 1.01-1.24); having an unintended pregnancy (aPR = 1.11; 1.03-1.19); and having 12 years of education (aPR = 1.09; 1.01-1.17). CONCLUSIONS: There was no change in the proportion of women relapsing postpartum during 2000-2011. In 2011, nearly half (42%) of women relapsed after quitting smoking during pregnancy. Disparities exist by site and by maternal characteristics. A comprehensive approach maximizing tobacco control efforts and developing effective clinical interventions delivered across sectors is necessary for long-term tobacco abstinence among women. |
Electronic nicotine delivery system use among U.S. adults, 2014
Caraballo RS , Jamal A , Nguyen KH , Kuiper NM , Arrazola RA . Am J Prev Med 2015 50 (2) 226-9 INTRODUCTION: Electronic nicotine delivery system (ENDS) use has increased rapidly in the U.S. in recent years. The availability and use of ENDS raise new issues for public health practice and tobacco regulation, as it is unknown whether patterns of ENDS use enhance, deter, or have no impact on combustible tobacco product use. This study assessed past-month, lifetime, and frequency of ENDS use among current, former, and never adult cigarette smokers. METHODS: Data were analyzed from the 2014 Styles, a national consumer-based probability-based web panel survey of U.S. adults aged ≥18 years (n=4,269) conducted during June and July. Lifetime ENDS users were defined as those who reported having used ENDS ≥1 day in their lifetime. Past-month ENDS users were defined as those who reported using ENDS in the past 30 days. RESULTS: In 2014, overall lifetime and past-month ENDS use was 14.1% and 4.8%, respectively. By smoking status, 49.5% of current, 14.7% of former, and 4.1% of never cigarette smokers had used ENDS in their lifetime, whereas 20.6% of current, 4.0% of former, and 0.8% of never smokers used ENDS in the past month. Among current and former cigarette smokers who ever used ENDS, 44.1% and 44.7% reported using ENDS >10 days in their lifetime, respectively. CONCLUSIONS: Because the effect ENDS use has on combustible tobacco products use is unknown, and lifetime and past-month ENDS use is more common among current than former or never smokers, continued surveillance of ENDS use among adults is critical to programs and policies. |
Increasing the dose of television advertising in a national antismoking media campaign: results from a randomised field trial
McAfee T , Davis KC , Shafer P , Patel D , Alexander R , Bunnell R . Tob Control 2015 26 (1) 19-28 BACKGROUND: While antismoking media campaigns have demonstrated effectiveness, less is known about the country-level effects of increased media dosing. The 2012 US Tips From Former Smokers (Tips) campaign generated approximately 1.6 million quit attempts overall; however, the specific dose-response from the campaign was only assessed by self-report. OBJECTIVE: Assess the impact of higher ad exposure during the 2013 Tips campaign on quit-related behaviours and intentions, campaign awareness, communication about campaign, and disease knowledge. METHODS: A 3-month national media buy was supplemented within 67 (of 190) randomly selected local media markets. Higher-dose markets received media buys 3 times that of standard-dose markets. We compared outcomes of interest using data collected via web-based surveys from nationally representative, address-based probability samples of 5733 cigarette smokers and 2843 non-smokers. RESULTS: In higher-dose markets, 87.2% of smokers and 83.9% of non-smokers recalled television campaign exposure versus 75.0% of smokers and 73.9% of non-smokers in standard-dose markets. Among smokers overall, the relative quit attempt rate was 11% higher in higher-dose markets (38.8% vs 34.9%; p<0.04). The higher-dose increase was larger in African-Americans (50.9% vs 31.8%; p<0.01). Smokers in higher-dose markets without a mental health condition, with a chronic health condition, or with only some college education made quit attempts at a higher rate than those in standard-dose markets. Non-smokers in higher-dose markets were more likely to talk with family or friends about smoking dangers (43.1% vs 35.7%; p<0.01) and had greater knowledge of smoking-related diseases. CONCLUSIONS: The US 2013 Tips antismoking media campaign compared standard and higher doses by randomisation of local media markets. Results demonstrate the effectiveness of a higher dose for engaging non-smokers and further increasing quit attempts among smokers, especially African-Americans. |
Contextual predictors of injection drug use among black adolescents and adults in US metropolitan areas, 1993-2007
Cooper HL , West B , Linton S , Hunter-Jones J , Zlotorzynska M , Stall R , Wolfe ME , Williams L , Hall HI , Cleland C , Tempalski B , Friedman SR . Am J Public Health 2015 106 (3) e1-e10 OBJECTIVES: We sought to determine whether contextual factors shape injection drug use among Black adolescents and adults. METHODS: For this longitudinal study of 95 US metropolitan statistical areas (MSAs), we drew annual MSA-specific estimates of the prevalence of injection drug use (IDU) among Black adolescents and adults in 1993 through 2007 from 3 surveillance databases. We used existing administrative data to measure MSA-level socioeconomic status; criminal justice activities; expenditures on social welfare, health, and policing; and histories of Black uprisings (1960-1969) and urban renewal funding (1949-1974). We regressed Black IDU prevalence on these predictors by using hierarchical linear models. RESULTS: Black IDU prevalence was lower in MSAs with declining Black high-school dropout rates, a history of Black uprisings, higher percentages of Black residents, and, in MSAs where 1992 White income was high, higher 1992 Black income. Incarceration rates were unrelated. CONCLUSIONS: Contextual factors shape patterns of drug use among Black individuals. Structural interventions, especially those that improve Black socioeconomic security and political strength, may help reduce IDU among Black adolescents and adults. |
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