Trends of insulin use among US adults with type 2 diabetes: the Behavioral Risk Factor Surveillance System, 1995-2007
Li C , Ford ES , Zhao G , Tsai J , Balluz LS , Giles WH . J Diabetes Complications 2012 26 (1) 17-22 OBJECTIVE: People with type 2 diabetes may need insulin therapy to compensate for their underlying pathogenic abnormalities and to improve glycemic control. We examined trends of insulin use among US adults aged ≥40 years with type 2 diabetes. METHODS: We analyzed data from the Behavioral Risk Factor Surveillance System collected annually during 1995-2007. Insulin use was assessed by self-report. Log-linear regression analyses with a robust error variance estimator were performed to estimate the prevalence, prevalence ratios, and their 95% confidence intervals. RESULTS: The overall crude and age-standardized proportion of insulin use decreased from 35% and 36% in 1995 to 23% and 22% in 2007, respectively. After adjustments for age, sex, race/ethnicity, education attainment, body mass index, and diabetes duration, the overall prevalence decreased from 33% to 22% (P<.0001 for linear trend). The decreasing rates were similar across sex (P=.23 for interaction between sex and survey year) and race/ethnicity (P=.35 for interaction between race/ethnicity and survey year). CONCLUSION: The proportion of insulin use decreased from 1995 to 2007 among US adults aged ≥40 years. Continuing efforts may be needed to properly identify those who may need to initiate and maintain insulin therapy among patients with type 2 diabetes as medically indicated. |
Prevalence of malignancies among U.S. male patients with haemophilia: a review of the Haemophilia Surveillance System
Dunn AL , Austin H , Soucie JM . Haemophilia 2012 18 (4) 532-9 SUMMARY: The prevalence of malignancies in US male patients with haemophilia, with or without concomitant viral infections, remains unknown. To estimate the prevalence of malignancy in US male patients with haemophilia. We investigated the prevalence of malignancies among male patients with haemophilia using data from a six-state haemophilia surveillance project. Case patients with malignancies were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes abstracted from hospital records and death certificates during the surveillance period. Cancer prevalence rates were calculated for each year during the surveillance and compared with age- and race-specific prevalence rates among the U.S. male population obtained from the Surveillance, Epidemiology and End Results (SEER) Program. A total of 7 cases of leukaemia, 23 cases of lymphoma and 56 classifiable solid malignancies were identified among 3510 case patients during a total of 15 330 annual data abstraction collections. The rates of leukaemia, lymphoma and liver cancer among case patients were significantly higher than the rates among U.S. males as judged by prevalence ratios of 3.1 [95% confidence interval (CI) = 1.4-7.0] and 2.9 (95% CI = 1.8-4.6), respectively. In contrast, the prevalence ratio of prostate cancer was lower than expected at 0.49 (95% CI = 0.31-0.77). Overall the prevalence of most cancers among case patients was similar to that of the U.S. male population. However, patients with haemophilia who have unexplained symptoms should be evaluated for malignancy. |
Primary health care providers' attitudes and counseling behaviors related to dietary sodium reduction
Fang J , Cogswell ME , Keenan NL , Merritt RK . Arch Intern Med 2012 172 (1) 76-8 High sodium intake is associated with increased blood pressure.1 Average sodium intake among US adults far exceeds recommendations.2 Primary care physicians and nurse practitioners are the first line of medical care and can influence opinions and behaviors of their patients.3,4 Although some information exists about perceived advice from health professionals related to sodium reduction,5 little is known about health care providers’ own perceptions about sodium intake and patient counseling behaviors about reducing sodium intake. We used data from DocStyles, aWeb-based survey of health care providers. Participants included health care providers who practiced in the United States; worked in an individual, group, or hospital setting; and had practiced medicine for a minimum of 3 years. In 2010, family/general practitioners (FGPs), internists, and nurse practitioners were asked questions on sodium. Response rates were 45.2% for FGPs and internists combined and 52.6% for nurse practitioners. | The sodium intake component of this survey consisted of 6 questions assessing health care providers’ opinions and perceived counseling behaviors related to reducing dietary sodium intake. The survey also included questions about health care provider characteristics, including sociodemographic (age, sex, and race/ethnicity), medical practice (type of practitioner, practice setting, years of practice, whether they practice at a teaching hospital, and the financial situation of the majority of their patients), and health-related behavior (self- reported height and weight; the number of days per week they eat at least 5 cups of fruit or vegetables; smoke cigarettes, cigars, or pipes; and exercise or keep their heart rate up for at least 30 min/d). |
Asthma incidence among children and adults: findings from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey-United States, 2006-2008
Winer RA , Qin X , Harrington T , Moorman J , Zahran H . J Asthma 2012 49 (1) 16-22 BACKGROUND: Asthma, a chronic respiratory condition affecting 8.2% of the US population (2009), causes significant societal and economic burden, resulting in missed school/work days, activity limitations, and increased healthcare utilization. Annual asthma prevalence estimates are available from national surveys, but these surveys have not routinely collected asthma incidence data that are important for identifying risk factors and trends in rates of disease onset. The Asthma Call-back Survey (ACBS), implemented in 2006, provides detailed asthma data that supplement Behavioral Risk Factor Surveillance System (BRFSS) data. We analyzed BRFSS and ACBS data to estimate annual asthma incidence and to determine whether these rates differed by age group, sex, and race/ethnicity. METHODS: BRFSS and ACBS data from the participating states during 2006-2008 (24 states and District of Columbia [DC] in 2006; 34 states and DC in 2007 and 2008) were analyzed to calculate 12-month incidence rates. Incident cases of asthma were defined as people diagnosed with asthma by a healthcare provider within 12 months prior to survey participation. RESULTS: Estimated asthma incidence among at-risk adults was 3.8/1000, whereas that among at-risk children was 12.5/1000. Incidence among children aged 0-4 years was 23.4/1000, more than five times greater than that among youth aged 12-17 years (4.4/1000). Adult females had 1.8 times greater asthma incidence than adult males (4.9/1000 vs. 2.8/1000, respectively). Incidence among non-Hispanic (NH) White adults was 3.9/1000, among NH non-White adults was 3.2/1000, and among Hispanic adults was 4.0/1000. CONCLUSIONS: This is the first successful application of the BRFSS-ACBS during 2006-2008 to estimate asthma incidence rates from participating states and DC. As with known patterns in asthma prevalence, we found that asthma incidence was higher in children than adults, higher in younger children than older children and adolescents, and higher in adult females than adult males. However, we were unable to identify statistically significant differences in asthma incidence among most race/ethnic groups. As additional data on asthma incidence become available from the ACBS, these rates, coupled with ACBS data on symptoms, asthma self-management practices, and healthcare utilization, may help asthma control programs identify risk factors for disease development and target asthma prevention and control measures to populations most affected. |
Craniectomy for malignant cerebral infarction: prevalence and outcomes in US hospitals
Walcott BP , Kuklina EV , Nahed BV , George MG , Kahle KT , Simard JM , Asaad WF , Coumans JV . PLoS One 2011 6 (12) e29193 OBJECT: Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database. METHODS: Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications. RESULTS: After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999-2000 to 14.46 in 2007-2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18-59 year old group was found to be 24%(p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered. CONCLUSIONS: Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure. |
Trends in clinical diagnoses of Rocky Mountain spotted fever among American Indians, 2001-2008
Folkema AM , Holman RC , McQuiston JH , Cheek JE . Am J Trop Med Hyg 2012 86 (1) 152-8 American Indians are at greater risk for Rocky Mountain spotted fever (RMSF) than the general U.S. population. The epidemiology of RMSF among American Indians was examined by using Indian Health Service inpatient and outpatient records with an RMSF International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis. For 2001-2008, 958 American Indian patients with clinical diagnoses of RMSF were reported. The average annual RMSF incidence was 94.6 per 1,000,000 persons, with a significant increasing incidence trend from 24.2 in 2001 to 139.4 in 2008 (P = 0.006). Most (89%) RMSF hospital visits occurred in the Southern Plains and Southwest regions, where the average annual incidence rates were 277.2 and 49.4, respectively. Only the Southwest region had a significant increasing incidence trend (P = 0.005), likely linked to the emergence of brown dog ticks as an RMSF vector in eastern Arizona. It is important to continue monitoring RMSF infection to inform public health interventions that target RMSF reduction in high-risk populations. |
Tuberculin skin test conversions in hospital housekeepers
Jereb JA , Privett TD , Pearson ML . Int J Tuberc Lung Dis 2012 16 (2) 279 In a recent edition of the Journal, Sherman and colleagues reported that compared to other groups of | health care workers, hospital housekeepers had the | highest rate of tuberculin skin test conversion during routine surveillance at a tertiary care hospital.1 | We found the same while investigating a nosocomial | multidrug-resistant tuberculosis outbreak at an urban community hospital in the early 1990s.2 Our | point-estimate of the period-adjusted conversion rate | for the housekeepers was 9.4 times the rate for hospital personnel who did not work in patient care areas, | such as clerical staff in medical records. We referenced two earlier reports of occupational skin test | surveillance with fi ndings similar to ours.3,4 |
Management of severe dengue
Gregory CJ , Tomashek KM . Pediatr Crit Care Med 2012 13 (1) 125 To determine the effect of inflammation and disease severity on midazolam pharmacokinetics (as surrogate marker of cytochrome 3A activity) and pharmacodynamics in critically ill children. | Design: | Analysis of prospectively collected pharmacokinetic and pharmacodynamic data from a midazolam study in critically ill children. | Setting: | Pediatric intensive care unit of a university hospital. | Patients: | Twenty-one critically ill children who needed midazolam for sedation. | Interventions: | None. | Measurements and Main Results: | We determined the relationship between inflammation (using C-reactive protein and leukocyte count as surrogate markers) and disease severity (Pediatric Logistic Organ Dysfunction and Pediatric Risk of Mortality scores) vs. the pharmacokinetics (clearance) and pharmacodynamics (COMFORT score, dose requirement) of midazolam. We found a significant negative correlation between disease severity and midazolam clearance corrected for body weight (r = −0.49, p = .02). Midazolam clearance was significantly lower in children with multiple organ failure (defined as Pediatric Logistic Organ Dysfunction ≥10, n = 11) compared with children without multiple organ failure (Pediatric Logistic Organ Dysfunction <10, n = 10) (median 0.14 [interquartile range, 0.11–0.23] vs. 0.28 [interquartile range, 0.14–0.43]) L/kg/h, p = .035). No other significant correlations were found. | Conclusions: | Results from this pilot study suggest that increased disease severity is associated with reduced midazolam clearance in critically ill children, most likely as a result of reduced cytochrome 3A activity. In contrast, reduced midazolam clearance does not seem to result in decreased midazolam dose requirements. |
Prevalence of anti-dengue immunoglobulin G antibodies among American Red Cross blood donors in Puerto Rico, 2006
Mohammed H , Tomashek KM , Stramer SL , Hunsperger E . Transfusion 2012 52 (8) 1652-6 BACKGROUND: Dengue is endemic in Puerto Rico and causes periodic outbreaks involving thousands of persons. Seroprevalence studies among blood donors can provide useful data on the immune status of the adult population. The objective of this study was to determine the prevalence of anti-dengue immunoglobulin (Ig)G antibodies in a random sample of blood donors to the American Red Cross (ARC) in Puerto Rico. STUDY DESIGN AND METHODS: Three-hundred randomly selected blood donations collected by the ARC from February 1 to March 31, 2006, were tested using an anti-dengue IgG enzyme-linked immunosorbent assay. One-third of the positive specimens were randomly selected and tested by a microneutralization test (MNT) to determine the serotypes of previous dengue infections. RESULTS: Most (84%) blood donors were male, and the mean age was 44.6 years (range, 18-80 years). The prevalence (95% confidence interval) of anti-dengue IgG antibodies was 92% (89%-95%). Of the 92 specimens tested by the MNT, reactivity to all four dengue serotypes was observed and 96% were secondary infections. The predominant serotype with the highest neutralization titers, as identified by at least a fourfold higher titer compared to any other serotype tested, was identified in 32 specimens; the most common predominant serotypes identified by the MNT were DENV-3 and DENV-2 (63%). Recent infection with DENV-1 was detected but, in 2005, routine surveillance did not detect any cases of this serotype. CONCLUSION: Supplementary serologic testing of donated blood can potentially provide information on the silent circulation or introduction of dengue serotypes. |
Efficacy of HIV/STI behavioral interventions for heterosexual African American men in the United States: a meta-analysis
Henny KD , Crepaz N , Lyles CM , Marshall KJ , Aupont LW , Jacobs ED , Liau A , Rama S , Kay LS , Willis LA , Charania MR . AIDS Behav 2012 16 (5) 1092-114 This meta-analysis estimates the overall efficacy of HIV prevention interventions to reduce HIV sexual risk behaviors and sexually transmitted infections (STIs) among heterosexual African American men. A comprehensive search of the literature published during 1988-2008 yielded 44 relevant studies. Interventions significantly reduced HIV sexual risk behaviors and STIs. The stratified analysis for HIV sexual risk behaviors indicated that interventions were efficacious for studies specifically targeting African American men and men with incarceration history. In addition, interventions that had provision/referral of medical services, male facilitators, shorter follow-up periods, or emphasized the importance of protecting family and significant others were associated with reductions in HIV sexual risk behaviors. Meta-regression analyses indicated that the most robust intervention component is the provision/referral of medical services. Findings indicate that HIV interventions for heterosexual African American men might be more efficacious if they incorporated a range of health care services rather than HIV/STI-related services alone. |
Global perspectives for prevention of infectious diseases associated with mass gatherings
Abubakar I , Gautret P , Brunette GW , Blumberg L , Johnson D , Poumerol G , Memish ZA , Barbeschi M , Khan AS . Lancet Infect Dis 2012 12 (1) 66-74 We assess risks of communicable diseases that are associated with mass gatherings (MGs), outline approaches to risk assessment and mitigation, and draw attention to some key challenges encountered by organisers and participants. Crowding and lack of sanitation at MGs can lead to the emergence of infectious diseases, and rapid population movement can spread them across the world. Many infections pose huge challenges to planners of MGs; however, these events also provide an opportunity to engage in public health action that will benefit host communities and the countries from which participants originate. |
Hospital-based prevalence of malaria and dengue in febrile patients in Bangladesh
Faruque LI , Zaman RU , Alamgir AS , Gurley ES , Haque R , Rahman M , Luby SP . Am J Trop Med Hyg 2012 86 (1) 58-64 We conducted a nationwide study at six tertiary hospitals from December 2008 through November 2009 to investigate etiologies of febrile illnesses in Bangladesh. Febrile patients meeting a clinical case definition were enrolled from inpatient and outpatient medicine and pediatric units. We assessed 720 febrile patients over 12 months; 69 (9.6%) were positive for IgM antibodies against dengue virus by enzyme-linked immunosorbent assay, and four malaria patients (0.56%) were confirmed with immuno-chromatography and microscopic slide tests. We identified dengue cases throughout the year from rural (49%) and urban areas (51%). We followed-up 55 accessible dengue-infected patients two months after their initial enrollment: 45 (82%) patients had fully recovered, 9 (16%) reported ongoing jaundice, fever and/or joint pain, and one died. Dengue infection is widespread across Bangladesh, but malaria is sufficiently uncommon that it should not be assumed as the cause of fever without laboratory confirmation. |
Hyperparathyroidism and complications associated with vitamin D deficiency in HIV-infected adults in New York City, NY
Kwan CK , Eckhardt B , Baghdadi J , Aberg JA . AIDS Res Hum Retroviruses 2012 28 (9) 1025-32 BACKGROUND: Although recent studies report a high prevalence of vitamin D deficiency in HIV-infected adults similar to that in the general population, metabolic complications of vitamin D deficiency may be worsened with HIV infection and remain insufficiently characterized. We conducted a retrospective cross-sectional cohort study to determine prevalence and correlates of vitamin D deficiency and hyperparathyroidism among HIV-infected patients attending an urban clinic. METHODS: Vitamin D deficiency was defined as 25(OH)-vitamin D <20 ng/ml and insufficiency as 20 to <30 ng/ml, and hyperparathyroidism as parathyroid-hormone >65 pg/mL. We used Chi2 test to compare proportions and logistic regression to assess for associations. RESULTS: Among 463 HIV-infected patients, prevalence of vitamin D deficiency was 59%. Prevalence of hyperparathyroidism was 30% among patients with vitamin D deficiency, 23% among those with insufficiency, and 12% among those with sufficient vitamin D levels. Vitamin D deficiency was associated with increased odds of hyperparathyroidism. Severe vitamin D deficiency was associated with elevated alkaline phosphatase, a marker for increased bone turnover. Although efavirenz use was associated with vitamin D deficiency, and protease-inhibitor use with decreased odds of vitamin D deficiency, there was no statistical difference in rates of hyperparathyroidism stratified by combination antiretroviral therapy (cART) use. CONCLUSIONS: Given the increased risk of osteopenia with HIV infection and cART use, vitamin D supplementation for all HIV-infected patients on cART should be prescribed in accordance to the 2011 Endocrine Society guidelines. In HIV-infected patients with severe vitamin D deficiency or hyperparathyroidism, screening for osteomalacia and osteopenia may be warranted. |
A cluster of dengue cases in American missionaries returning from Haiti, 2010
Sharp TM , Pillai P , Hunsperger E , Santiago GA , Anderson T , Vap T , Collinson J , Buss BF , Safranek TJ , Sotir MJ , Jentes ES , Munoz-Jordan JL , Arguello DF . Am J Trop Med Hyg 2012 86 (1) 16-22 Dengue is an acute febrile illness caused by four mosquito-borne dengue viruses (DENV-1 to -4) that are endemic throughout the tropics. After returning from a 1-week missionary trip to Haiti in October of 2010, 5 of 28 (18%) travelers were hospitalized for dengue-like illness. All travelers were invited to submit serum specimens and complete questionnaires on pre-travel preparations, mosquito avoidance practices, and activities during travel. DENV infection was confirmed in seven (25%) travelers, including all travelers that were hospitalized. Viral sequencing revealed closest homology to a 2007 DENV-1 isolate from the Dominican Republic. Although most (88%) travelers had a pre-travel healthcare visit, only one-quarter knew that dengue is a risk in Haiti, and one-quarter regularly used insect repellent. This report confirms recent DENV transmission in Haiti. Travelers to DENV-endemic areas should receive dengue education during pre-travel health consultations, follow mosquito avoidance recommendations, and seek medical care for febrile illness during or after travel. |
Development of the Respiratory Index of Severity in Children (RISC) score among young children with respiratory infections in South Africa
Reed C , Madhi SA , Klugman KP , Kuwanda L , Ortiz JR , Finelli L , Fry AM . PLoS One 2012 7 (1) e27793 OBJECTIVE: Pneumonia is a leading cause of death in children worldwide. A simple clinical score predicting the probability of death in a young child with lower respiratory tract infection (LRTI) could aid clinicians in case management and provide a standardized severity measure during epidemiologic studies. METHODS: We analyzed 4,148 LRTI hospitalizations in children <24 months enrolled in a pneumococcal conjugate vaccine trial in South Africa from 1998-2001, to develop the Respiratory Index of Severity in Children (RISC). Using clinical data at admission, a multivariable logistic regression model for mortality was developed and statistically evaluated using bootstrap resampling techniques. Points were assigned to risk factors based on their coefficients in the multivariable model. A child's RISC score is the sum of points for each risk factor present. Separate models were developed for HIV-infected and non-infected children. RESULTS: Significant risk factors for HIV-infected and non-infected children included low oxygen saturation, chest indrawing, wheezing, and refusal to feed. The models also included age and HIV clinical classification (for HIV-infected children) or weight-for-age (for non-infected children). RISC scores ranged up to 7 points for HIV-infected or 6 points for non-infected children and correlated with probability of death (0-47%, HIV-infected; 0-14%, non-infected). Final models showed good discrimination (area under the ROC curve) and calibration (goodness-of-fit). CONCLUSION: The RISC score incorporates a simple set of risk factors that accurately discriminate between young children based on their risk of death from LRTI, and may provide an objective means to quantify severity based on the risk of mortality. |
Meeting report: mode(s) of action of asbestos and related mineral fibers
Gwinn MR , Devoney D , Jarabek AM , Sonawane B , Wheeler J , Weissman DN , Masten S , Thompson C . Environ Health Perspect 2011 119 (12) 1806-10 BACKGROUND: Although asbestos in general is well known to cause a range of neoplastic and non-neoplastic human health effects, not all asbestos fiber types have the same disease-causing potential, and the mode of action (MOA) of specific types of asbestos and related fibers for various health outcomes are not well understood.OBJECTIVES: A workshop was held to discuss the state of the science of the MOA for asbestos-related disease. The objective was to review the range of asbestos-induced health effects (including those at sites remote to the respiratory tract). We sought to identify existing knowledge gaps and define what research is needed to address these gaps and advance asbestos research.DISCUSSION: Discussions centered on areas of uncertainty in the field, including the ways asbestos is defined and characterized, the role of different fiber characteristics (e.g., length and mineralogy) in disease, and the impact of low-dose exposures on human health. Studying the dosimetry and mode of action of multiple fiber types would enhance our understanding of asbestos-related disease. To better elucidate the MOA of specific asbestos fibers, the risk assessor requires data as to specific characteristics of asbestos in determining fiber toxicity (e.g., surface area, mineral type), which may inform efforts to assess and control exposures and prevent adverse human health outcomes for the diverse range of fiber types. Specific research aims were defined for these topics and for overarching issues to be addressed, including the use of standardized terminology, test materials, and better experimental models to aid in data extrapolation to humans.CONCLUSION: To resolve these and other issues, participants agreed that diverse scientific disciplines must coordinate to better understand the MOA leading to the various asbestos-related disease end points. |
The Sudden Unexpected Infant Death Case Registry: a method to improve surveillance
Shapiro-Mendoza CK , Camperlengo LT , Kim SY , Covington T . Pediatrics 2012 129 (2) e486-93 This article describes a multistate population-based surveillance system for monitoring sudden unexpected infant deaths (SUIDs) known as the SUID Case Registry pilot program. The pilot program represents collaboration between the Centers for Disease Control and Prevention and the National Center for Child Death Review (NCCDR), which is funded by the Health Resources and Services Administration. The SUID Case Registry builds on existing child death review system activities and protocols. The objectives of the SUID Case Registry are to collect accurate and consistent population-based data about the circumstances and events associated with SUID cases, to improve the completeness and quality of SUID case investigations, and to use a decision-making algorithm with standardized definitions to categorize SUID cases. States who participate in the pilot program commit to review all SUID cases in their state by using their multidisciplinary state and local child death review teams. These teams request and review data from death scene investigators, medical examiners and coroners, law enforcement, social services, pediatric and obstetric providers, and public health per usual, but as part of the pilot program, supplement their SUID case reviews by discussing additional medical, environmental, and behavioral factors, and entering this data using the NCCDR Web-based Case Reporting System. This new surveillance system aims to improve knowledge of factors surrounding SUID events and improve investigation practices. The surveillance system will allow researchers and program planners to create prevention strategies and interventions, ultimately reducing SUIDs and injury-related infant deaths. |
Modelling tuberculosis trends in the USA
Hill AN , Becerra JE , Castro KG . Epidemiol Infect 2012 140 (10) 1-11 SUMMARY: We present a mathematical transmission model of tuberculosis in the USA. The model is calibrated to recent trends of declining incidence in the US-born and foreign-born populations and is used in assessing relative impacts of treatment of latently infected individuals on elimination time, where elimination is defined as annual incidence <1 case/million. Provided current control efforts are maintained, elimination in the US-born population can be achieved before the end of this century. However, elimination in the foreign-born population is unlikely in this timeframe even with higher rates of targeted testing and treatment of residents of and immigrants to the USA with latent tuberculosis infection. Cutting transmission of disease as an interim step would shorten the time to elimination in the US-born population but foreign-born rates would remain above the elimination target. |
Hepatitis A epidemiology goes global
Holmberg SD . Clin Infect Dis 2012 54 (6) 782-3 It may not be appreciated that a hepatitis A virus (HAV) outbreak investigation in several states in Australia, as described in this issue of Clinical Infectious Diseases [1], was viewed with intense interest on the other side of the world. In fact, it is considered a harbinger of hepatitis A investigations to come. This seemingly straightforward investigation—with molecular epidemiologic techniques now almost standard in any outbreak examination—may nonetheless be considered a landmark. The world is “flatter” and food and food products produced in one country (along with the pathogens they may carry) can be exported almost anywhere. We observed this in the United States when HAV infections in several states were acquired from green onions imported from northern Mexico [2, 3]. Although somewhat downplayed in the Donnan et al [1] article, molecular epidemiology from their investigation showed that samples from affected persons in both the Netherlands and Australia had sequence identity, and standard “shoe-leather” epidemiology showed large odds ratios for persons in both countries who had consumed semidried tomatoes from Turkey. These semidried tomatoes are different from the sun-dried tomatoes common in US supermarkets and are often used by restaurants and in commercial food production to make pizza, sauces, and similar items. The Australian investigation showed that, indeed, those who ate not only semidried tomatoes but also those who ate tomato-based foods in restaurants were at substantially greater risk of HAV infection. | In this country, there has been an abiding concern that imported food items potentially contaminated with hepatitis A can and do enter this country frequently. With funding from the Center for Disease Control and Prevention (CDC) Food Safety Initiative, several state and city health departments interview and collect serum from persons with acute hepatitis A. The specimens are then processed at CDC’s Division of Viral Hepatitis Laboratory, where recent marked improvements in sequencing of the HAV genome (and other types of viral hepatitis genomes) have made such work easier and faster than ever. CDC now holds a “library” of partial and complete gene sequences of the HAV genome, which include >3000 domestic specimens and >2000 specimens from other countries (although some are duplicate sequences from outbreak investigations). As new specimens are sent to CDC, they are sequenced and compared with extant sequences held in the library to gain insight into origins and transmission patterns. |
Characteristics and spectrum of disease among ill returned travelers from pre- and post-earthquake Haiti: the GeoSentinel experience
Esposito DH , Han PV , Kozarsky PE , Walker PF , Gkrania-Klotsas E , Barnett ED , Libman M , McCarthy AE , Field V , Connor BA , Schwartz E , Macdonald S , Sotir MJ . Am J Trop Med Hyg 2012 86 (1) 23-28 To describe patient characteristics and disease spectrum among foreign visitors to Haiti before and after the 2010 earthquake, we used GeoSentinel Global Surveillance Network data and compared 1 year post-earthquake versus 3 years pre-earthquake. Post-earthquake travelers were younger, predominantly from the United States, more frequently international assistance workers, and more often medically counseled before their trip than pre-earthquake travelers. Work-related stress and upper respiratory tract infections were more frequent post-earthquake; acute diarrhea, dengue, and Plasmodium falciparum malaria were important contributors of morbidity both pre- and post-earthquake. These data highlight the importance of providing destination- and disaster-specific pre-travel counseling and post-travel evaluation and medical management to persons traveling to or returning from a disaster location, and evaluations should include attention to the psychological wellbeing of these travelers. For travel to Haiti, focus should be on mosquito-borne illnesses (dengue and P. falciparum malaria) and travelers' diarrhea. |
The Rwanda Field Epidemiology and Laboratory Training Program: training skilled disease detectives
Ntahobakurira I , Antara S , Galgalo TB , Kakoma JB , Karema C , Nyatanyi T , Theogene R , Mukabayire O , Lowrance D , Raghunathan P , Ayebazibwe N , Mukanga D , Nsubuga P , Binagwaho A . Pan Afr Med J 2011 10 7 Rwanda still suffers from communicable diseases which frequently lead to epidemics. In addition to other health workforce needs, Rwanda also lacks a public health workforce that can operate multi-disease surveillance and response systems at the national and sub-national levels. In 2009 and 2010 the Rwanda Ministry of Health and its partners from the Government of Rwanda (GOR) as well as the United States (US) Centers for Disease Control and Prevention, the African Field Epidemiology Network, and other partners embarked on a series of activities to develop a public health workforce that would be trained to operate disease surveillance and response systems at the national and district levels. The Rwanda Field Epidemiology and Laboratory Training Program (RFELTP) is a 2-year public health leadership development training program that provides applied epidemiology and public health laboratory training while the trainees provide public health service to the Ministry of Health. RFELTP is hosted at the National University of Rwanda School of Public Health for the didactic training. RFELTP is funded by GOR, the US Presidents Emergency Plan for AIDS Relief and the World Bank; it is managed by a multi-sectoral steering committee headed by the Minister of Health. The first RFELTP cohort has 15 residents who were recruited from key health programs in GOR. Over the first year of implementation, these 15 residents have conducted a variety of field investigations and responded to several outbreaks. RFELTP has also trained 145 frontline health workers through its two-week applied short courses. In the future, RFELTP plans to develop a veterinary track to address public health issues at the animal-human interface. |
The Tanzania Field Epidemiology and Laboratory Training Program: building and transforming the public health workforce
Mmbuji P , Mukanga D , Mghamba J , Ahly M , Mosha F , Azima S , Senga S , Moshiro C , Semali I , Rolle I , Wiktor S , McQueen S , McElroy P , Nsubuga P . Pan Afr Med J 2011 10 9 The Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) was established in 2008 as a partnership among the Ministry of | Health and Social Welfare (MOHSW), Muhimbili University of Health and Allied Sciences, National Institute for Medical Research, and local and | international partners. TFELTP was established to strengthen the capacity of MOHSW to conduct public health surveillance and response, manage national disease control and prevention programs, and to enhance public health laboratory support for surveillance, diagnosis, treatment and disease monitoring. TFELTP is a 2-year full-time training program with approximately 25% time spent in class, and 75% in the field. TFELTP offers two tracks leading to an MSc degree in either Applied Epidemiology or, Epidemiology and Laboratory Management. Since 2008, the program has enrolled a total of 33 trainees (23 males, 10 females). Of these, 11 were enrolled in 2008 and 100% graduated in 2010. All 11 graduates of cohort 1 are currently employed in public health positions within the country. Demand for the program as measured by the number of applicants has grown from 28 in 2008 to 56 in 2011. While training the public health leaders of the country, TFELTP has also provided essential service to the country in responding to high-profile disease outbreaks, and evaluating and improving its public health surveillance systems and diseases control programs. TFELTP was involved in the country assessment of the revised International Health Regulations (IHR) core capabilities, development of the Tanzania IHR plan, and incorporation of IHR into the revised Tanzania Integrated Disease Surveillance and Response (IDSR) guidelines. TFELTP is training a competent core group of public health leaders for Tanzania, as well as providing much needed service to the MOHSW in the areas of routine surveillance, outbreak detection and response, and disease program management. However, the immediate challenges that the program must address include development of a full range of in-country teaching capacity for the program, as well as a career path for graduates. |
Vaccine-preventable diseases, immunizations, and the Epidemic Intelligence Service
Hinman AR , Orenstein WA , Schuchat A . Am J Epidemiol 2011 174 S16-22 During 1946-2005, vaccine-preventable diseases were the topic of approximately 20% of all epidemic-assistance investigations by the Centers for Disease Control and Prevention. Both in the United States and abroad, current and former Epidemic Intelligence Service officers have played a critical role in describing the epidemiology of vaccine-preventable diseases, contributing to development of immunization policies, participating in the implementation of immunization programs, and establishing effective means for assessing adverse events following immunization. As newer vaccines are developed and introduced, they will continue to play similar roles and most likely will be involved increasingly in investigations of the factors that affect people's willingness to accept vaccination for themselves or their children. |
The West Africa Field Epidemiology and Laboratory Training Program, a strategy to improve disease surveillance and epidemic control in West Africa
Mutabaruka E , Sawadogo M , Tarnagda Z , Ouedraogo L , Sangare L , Ousmane B , Ndjakani Y , Namusisi O , Mukanga D , Evering-Watley M , Hounton S , Nsubuga P . Pan Afr Med J 2011 10 10 The West Africa Field Epidemiology and Laboratory Training Program (WA-FELTP) which was established in September 2007, is an inter-country, competency-based, in-service and post -graduate training program in applied epidemiology and public health that builds the capacity to strengthen the surveillance and response system as well as epidemic control in the French-speaking countries where they are implemented. The overall purpose is to provide epidemiological and public health laboratory services to the public health systems at national, provincial, district and local levels. The program includes four countries: Burkina Faso, Mali, Niger, and Togo with an overarching goal to progressively cover all French speaking countries in West Africa through a phased-in approach. WA-FELTP’s 2- year Master’s program was launched in 2010 with 12 residents, three from each country, and consists of medical and veterinary doctors, pharmacists, and laboratory scientists. The training comprises 25% didactic sessions and 75% practical in-the-field mentored training. During the practical training, residents provide service to their respective ministries of health and ministries of animal resources by contributing to outbreak investigations and activities that help to improve national surveillance systems at national, regional, district and local levels. The pressing challenges that the program must address consist of the lack of funds to support the second cohort of trainees, though trainee selection was completed, inadequate funds to support staff compensation, and shortage of funds to support trainees’ participation in critical activities in field epidemiology practice, and a need to develop a 5-year plan for sustainability. |
Maternal and child health epidemic-assistance investigations, 1946-2005
Rochat RW , Heath CW Jr , Chu SY , Marchbanks PA . Am J Epidemiol 2011 174 S80-8 In this article, the authors focus on epidemic-assistance investigations that dealt with maternal and child health problems, including unintended and adolescent pregnancy and family planning; international reproductive health surveys among refugees; pregnancy outcomes, including abortion, maternal mortality, infant mortality, and birth defects; leukemia; and Reye syndrome. During 1946-2005, a total of 1,969 investigations had sufficient data to classify them as possibly related to maternal and child health and were characterized by distinctive periods. Those related to family planning, pregnancy intention, and reproductive health among refugees began in the early 1970s and continued through 2005. Abortion-related investigations occurred during 1971-1982. Investigations of non-abortion-related maternal morbidity and mortality began in 1979 and included 2 international epidemic-assistance investigations. Investigations of clusters of disease among infants began in the 1960s, with a special focus on Reye syndrome during 1964-1984. Investigations of childhood cancer and birth defects began in the late 1950s. The Centers for Disease Control and Prevention has used the epidemic-assistance investigations mechanism to respond to a wide range of health concerns of women and children. The investigations of abortion-related health problems might have had the best-documented impact on public policy and public health. |
Overview of the impact of epidemic-assistance investigations of foodborne and other enteric disease outbreaks, 1946-2005
Wright AP , Gould LH , Mahon B , Sotir MJ , Tauxe RV . Am J Epidemiol 2011 174 S23-35 Epidemic-assistance investigations (Epi-Aids) in response to outbreaks of foodborne and other enteric pathogens have identified novel pathogens, clinical syndromes, and sequelae; described new reservoirs and vehicles of transmission; evaluated existing prevention strategies; and identified deficiencies in the food safety systems on local, national, and international levels. Since the first Epi-Aid was issued in 1946, approximately 23% (1,023 of 4,484 for which investigations were initiated) of all Epi-Aids have been related to foodborne or other enteric diseases. Epi-Aid results have yielded valuable insights into the epidemiology of these pathogens and have molded prevention strategies for detecting, responding to, and preventing future outbreaks. New challenges, brought about in part by centralization and globalization of the food supply, will continue to emerge. The need for Epi-Aids of such outbreaks undoubtedly will persist as an integral part of future public health response efforts, prevention strategies, and training programs. |
Environmental- and injury-related epidemic-assistance investigations, 1946-2005
Falk H , Briss P . Am J Epidemiol 2011 174 S65-79 This paper summarizes environmental investigations (n = 458) conducted during the first 60 years of the epidemic-assistance investigation program at the Centers for Disease Control and Prevention. These investigations were grouped into 10 categories: toxic chemicals (n = 102), indoor air quality and outdoor air toxics (n = 21), new or rare epidemic diseases and unexplained syndromes (n = 29), natural disasters (n = 81), terrorism and unintentional human-made disasters (n = 9), substance use and abuse (n = 13), environmental aspects of infectious disease (n = 132), those affecting neonates and infants (n = 11), violence and injuries (n = 51), and miscellaneous (n = 9). Among the most important or prominent were studies of lead and arsenic toxicity at smelters, mercury in paint and beauty creams, dioxin in waste oil in Missouri, polychlorinated biphenyls and multiple other toxic chemicals, global pesticide poisoning outbreaks, hepatic angiosarcoma among vinyl chloride workers, toxic oil syndrome in Spain, eosinophilia-myalgia syndrome from contaminated L-tryptophan, diethylene glycol poisoning in Haiti, aflatoxicosis in Kenya, Gulf War illness among veterans, impact and needs assessments during natural disasters (e.g., Hurricane Katrina (2005) and the Mount St. Helens volcano eruptions (1980)), risk factors for heat-related mortality, domestic and international terrorist attacks, Parkinsonism related to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in California, and unintentional injury- and violence-related events. |
Epidemic assistance by the Centers for Disease Control and Prevention: role of the Epidemic Intelligence Service, 1946-2005
Thacker SB , Stroup DF , Sencer DJ . Am J Epidemiol 2011 174 S4-15 Since 1946, the Centers for Disease Control and Prevention has responded to urgent requests from US states, federal agencies, and international organizations through epidemic-assistance investigations (Epi-Aids). The authors describe the first 60 years of Epi-Aids, breadth of problems addressed, evolution of methodologies, scope of activities, and impact of investigations on population health. They reviewed Epi-Aid reports and EIS Bulletins, contacted current and former Epidemic Intelligence Service staff, and systematically searched the PubMed and Web of Science databases. They abstracted information on dates, location, staff involved, health problems, methods, and impacts of investigations according to a preplanned protocol. They assessed the methods presented as well as the quality of reports. During 1946-2005, a total of 4,484 investigations of health events were initiated by 2,815 Epidemic Intelligence Service officers. In the early years, the majority were in response to infectious agents, although environmental problems emerged. Investigations in subsequent years focused on occupational conditions, birth defects, reproductive health, tobacco use, cancer, violence, legal debate, and terrorism. These Epi-Aids heralded expansion of the agency's mission and presented new methods in statistics and epidemiology. Recommendations from Epi-Aids led to policy implementation, evaluation, or modification. Epi-Aids provide the Centers for Disease Control and Prevention with the agility to respond rapidly to public health crises. |
Epidemic assistance from the Centers for Disease Control and Prevention involving American Indians and Alaska Natives, 1946-2005
Cheek JE , Hennessy TW , Redd JT , Cobb N , Bryan RT . Am J Epidemiol 2011 174 S89-96 The authors describe 169 Centers for Disease Control and Prevention epidemic-assistance investigations involving American Indians and Alaska Natives that occurred during 1946-2005. The unique relation between the US federal government and American Indian and Alaska Native tribes is described in the context of transfer in the 1950s of responsibility for Indian health to the US Public Health Service, which at the time included the Communicable Disease Center, the Centers for Disease Control and Prevention's precursor. The vast majority of epidemic-assistance investigations were for infectious disease outbreaks (86%), with a relatively limited number, since 1980 only, involving environmental exposures and chronic disease. Although outbreaks investigated were often widespread geographically, the majority were limited in scope, typically involving fewer than 100 patients. Epidemic-assistance investigations for hepatitis A, gastrointestinal and foodborne infectious diseases, vaccine-preventable diseases, zoonotic and vectorborne diseases, acute respiratory tract infections, environmental exposures, and chronic diseases are described chronologically in more detail. |
Epidemic Intelligence Service investigations of respiratory illness, 1946-2005
Hadler SC , Castro KG , Dowdle W , Hicks L , Noble G , Ridzon R . Am J Epidemiol 2011 174 S36-46 Infectious respiratory pathogens were the suspected cause of 480 outbreaks investigated by the Centers for Disease Control and Prevention's Epidemic Intelligence Service officers during 1946-2005. All epidemic-assistance investigation reports and associated articles from scientific journals were reviewed. Investigations identified 25 different infectious respiratory pathogens including, most frequently, tuberculosis, influenza, and legionellosis. Other bacterial-, viral-, and fungal-related pathogens also were identified. Epidemic-assistance investigations were notable for first identifying Legionnaires disease and Pontiac fever, hantavirus pulmonary syndrome, and new strains of human and avian influenza, as well as emerging challenges (e.g., multidrug-resistant tuberculosis and pneumococcus). The investigations provided clinical insights into such diseases as pulmonary anthrax and identified high risks of serious respiratory illnesses for persons infected with human immunodeficiency virus, other immunocompromised persons, and persons with diabetes. They identified settings placing persons at high risk of acquiring disease, including nursing homes, prisons, homeless shelters, and hospitals. Travel also placed persons at risk. Key environmental factors related to spread of diseases and occupational risks for brucellosis and psittacosis were identified. The outbreak investigations constitute a wealth of prevention experience and provide the basis for recommendations to mitigate outbreaks and reduce future risks. |
Fifty-five years of international epidemic-assistance investigations conducted by CDC's disease detectives
Rolle IV , Pearson ML , Nsubuga P . Am J Epidemiol 2011 174 S97-112 For more than 60 years, the Centers for Disease Control and Prevention (CDC) has used its scientific expertise to help people throughout the world live healthier, safer, longer lives through science-based health action. In 1951, CDC officially established the Epidemic Intelligence Service to help build public health capacity. During 1950-2005, CDC's Epidemic Intelligence Service officers conducted 462 international epidemiologic field investigations in 131 foreign countries and 7 territories. Investigations have included responding to emerging infectious and noninfectious disease outbreaks, assisting in disaster response, and evaluating core components of public health programs worldwide. Approximately 81% of investigations were responses to infectious disease outbreaks, but the proportion of investigations related to chronic and other noninfectious conditions increased 7-fold (6%-45%). These investigations have contributed to detecting and characterizing new pathogens (e.g., severe acute respiratory syndrome-associated coronavirus) and conditions, provided insights regarding factors that cause or contribute to disease acquisition (e.g., Ebola hemorrhagic fever), led to development of new diagnostics and surveillance technologies, and provided information upon which global health policies and regulations can be based. CDC's disease detectives will undoubtedly continue to play a critical role in global health and in responding to emerging global disease threats. |
The genesis and evolution of the African Field Epidemiology Network
Mukanga D , Tshimanga M , Wurapa F , Binka F , Serwada D , Bazeyo W , Pariyo G , Wabwire-Mangen F , Gitta S , Chungong S , Trostle M , Nsubuga P . Pan Afr Med J 2011 10 2 In an effort to contain the frequently devastating epidemics in sub-Saharan Africa, the World Health Organization (WHO) Regional Office for Africa launched the Integrated Disease Surveillance and Response (IDSR) strategy in an effort to strengthen surveillance and response. However, 36 sub-Saharan African countries have been described as experiencing a human resource crisis by the WHO. Given this human resource situation, the challenge remains for these countries to achieve, among others, the health-related Millennium Development Goals (MDGs). This paper describes the process through which the African Field Epidemiology Network (AFENET) was developed, as well as how AFENET has contributed to addressing the public health workforce crisis, and the development of human resource capacity to implement | IDSR in Africa. AFENET was established between 2005 and 2006 as a network of Field Epidemiology Training Programs (FETPs) and Field Epidemiology and Laboratory Training Programs (FELTPs) in Africa. This resulted from an expressed need to develop a network that would advocate for the unique needs of African FETPs and FELTPs, provide service to its membership, and through which programs could develop joint projects to address the public health needs of their countries. A total of eight new programs have been developed in sub-Saharan Africa since 2006. Programs established after 2006 represent over 70% of current FETP and FELTP enrolment in Africa. In addition to growth in membership and programs, AFENET has recorded significant growth in external partnerships. Beginning with USAID, CDC and WHO in | 2004-2006, a total of at least 26 partners have been added by 2011. Drawing from lessons learnt, AFENET is now a resource that can be relied upon to expand public health capacity in Africa in an efficient and practical manner. National, regional and global health actors can leverage it to meet health-related targets at all levels. The AFENET story is one that continues to be driven by a clearly recognized need within Africa to develop a network that would serve public health systems development, looking beyond the founders, and using the existing capacity of the founders and partners to help other countries build capacity for IDSR and the International Health Regulations (IHR, 2005). |
The African Field Epidemiology Network - networking for effective field epidemiology capacity building and service delivery
Sheba GN , Mukanga D , Babirye R , Dahlke M , Tshimanga M , Nsubuga P . Pan Afr Med J 2011 10 3 Networks are a catalyst for promoting common goals and objectives of their membership. Public Health networks in Africa are crucial, because of the severe resource limitations that nations face in dealing with priority public health problems. For a long time, networks have existed on the continent and globally, but many of these are disease-specific with a narrow scope. The African Field Epidemiology Network (AFENET) is a public health network established in 2005 as a non-profit networking alliance of Field Epidemiology and Laboratory Training Programs (FELTPs) and Field Epidemiology Training Programs (FETPs) in Africa. AFENET is dedicated to helping ministries of health in Africa build strong, effective and sustainable programs and capacity to improve public health systems by partnering with global public health experts. The Network’s goal is to strengthen field epidemiology and public health laboratory capacity to contribute effectively to addressing epidemics and other major public health problems in Africa. AFENET currently networks 12 FELTPs and FETPs in sub-Saharan Africa with operations in 20 countries. AFENET has a unique tripartite working relationship with government technocrats from human health and animal sectors, academicians from partner universities, and development partners, presenting the Network with a distinct vantage point. Through the Network, African nations are making strides in strengthening their health systems. Members are able to: leverage resources to support field epidemiology and public health laboratory training and service delivery notably in the area of outbreak investigation and response as well as disease surveillance; by-pass government bureaucracies that often hinder and frustrate development partners; and consolidate efforts of different partners channelled through the FELTPs by networking graduates through alumni associations and calling on them to offer technical support in various public health capacities as the need arises. AFENET presents a bridging platform between governments and the private sector, allowing for continuity of health interventions at the national and regional level while offering free exit and entry for existing and new partners respectively. AFENET has established itself as a versatile networking model that is highly responsive to members’ needs. Based on the successes recorded in AFENET’s first 5 years, we envision that the Network’s membership will continue to expand as new training programs are established. The lessons learned will be useful in initiating new programs and building sustainability frameworks for FETPs and FELTPs in Africa. AFENET will continue to play a role in coordinating, advocacy, and building capacity for epidemic disease preparedness and response. |
Afterword
Frieden TR . Am J Epidemiol 2011 174 S113-4 In 1949, Alexander Langmuir became the first chief epidemiologist at the Communicable Disease Center (CDC) in Atlanta, Georgia. Among his many contributions to the agency and to public health, 2 of the most important--the Epidemic Intelligence Service (EIS) and his particular brand of epidemic-assistance investigation (the Epi-Aid)--are highlighted in this supplement to the American Journal of Epidemiology. What makes these and many other of Langmuir's innovations so remarkable is their continued relevance to the health challenges we face in this new century. CDC (now the Centers for Disease Control and Prevention) is recognized globally for its quality science, not only in epidemiology and laboratory practice but also in the behavioral and social sciences, statistics, and economics. Support to state and local health departments has been instrumental to CDC's success during its first 60 years, and the articles describing Epi-Aids in this supplement capture this partnership elegantly. They also reflect the evolution of CDC from an agency focused almost entirely on communicable diseases to one engaged in a broad array of global public health challenges. |
Central African Field Epidemiology and Laboratory Training Program: building and strengthening regional workforce capacity in public health
Andze GO , Namsenmo N , Illunga BK , Kazambu D , Delissaint D , Kuaban C , Mbopi-Kéou F , Gabsa W , Mulumba L , Bangamingo J , Ngulefac J , Dahlke M , Mukanga D , Nsubuga P . Pan Afr Med J 2011 10 4 The Central African Field Epidemiology and Laboratory Training Program (CAFELTP) is a 2-year public health leadership capacity building training program. It was established in October 2010 to enhance capacity for applied epidemiology and public health laboratory services in three countries: Cameroon, Central African Republic, and the Democratic Republic of Congo. The aim of the program is to develop a trained public health workforce to assure that acute public health events are detected, investigated, and responded to quickly and effectively. The program consists of 25% didactic and 75% practical training (field based activities). Although the program is still in its infancy, the residents have already responded to six outbreak investigations in the region, evaluated 18 public health surveillance systems and public health programs, and completed 18 management projects. Through these various activities, information is shared to understand similarities and differences in the region leading to new and innovative approaches in public health. The program provides opportunities for regional and international networking in field epidemiology and laboratory activities, and is particularly beneficial for countries that may not have the immediate resources to host an individual country program. Several of the trainees from the first cohort already hold leadership positions within the ministries of health and national laboratories, and will return to their assignments better equipped to face the public health challenges in the region. They bring with them knowledge, practical training, and experiences gained through the program to shape the future of the public health landscape in their countries. |
Single nucleotide polymorphism in the promoter region of the CD209 gene is associated with human predisposition to severe forms of tick-borne encephalitis.
Barkhash AV , Perelygin AA , Babenko VN , Brinton MA , Voevoda MI . Antiviral Res 2012 93 (1) 64-8 Tick-borne encephalitis virus (TBEV) is a neurotropic, positive-sense RNA virus of the genus Flavivirus (family Flaviviridae) which can cause a variety of clinical manifestations in humans. Previously the severity and outcome of dengue fever and hepatitis C (diseases caused by viruses from the family Flaviviridae) were associated with the rs4804803 single nucleotide polymorphism (SNP) located in the promoter region of the human CD209 gene. This gene encodes dendritic cell-specific ICAM3-grabbing nonintegrin (DC-SIGN), a C-type lectin pathogen-recognition receptor expressed on the surface of dendritic cells and some types of macrophages. In the current study, a possible association between two SNPs in the promoter region of the CD209 gene (rs4804803 and rs2287886) and predisposition to severe forms of TBEV-induced disease was investigated. The genotypic, allelic and haplotypic frequencies of these SNPs were analyzed in 136 non-immunized Russian patients with different clinical manifestations of tick-borne encephalitis (TBE) and in a control group. An increase in the frequency of the rs2287886 SNP AA homozygotes and the A allele was detected among patients with severe central nervous system disease compared with the group of patients with meningitis (P=0.003 and 0.019), or a combined group of patients with mild forms (fever and meningitis) (P=0.003 and 0.026), or the control group (P=0.007 and 0.035). Thus, our results suggest that the CD209 gene promoter region rs2287886 SNP is associated with predisposition to severe forms of TBE in the Russian population. |
Prevalence estimates of health risk behaviors of immigrant Latino men who have sex with men
Rhodes SD , McCoy TP , Hergenrather KC , Vissman AT , Wolfson M , Alonzo J , Bloom FR , Alegria-Ortega J , Eng E . J Rural Health 2012 28 (1) 73-83 PURPOSE: Little is known about the health status of rural immigrant Latino men who have sex with men (MSM). These MSM comprise a subpopulation that tends to remain "hidden" from both researchers and practitioners. This study was designed to estimate the prevalence of tobacco, alcohol, and drug use, and sexual risk behaviors of Latino MSM living in rural North Carolina. METHODS: A community-based participatory research (CBPR) partnership used respondent-driven sampling (RDS) to identify, recruit, and enroll Latino MSM to participate in an interviewer-administered behavioral assessment. RDS-weighted prevalence of risk behaviors was estimated using the RDS Analysis Tool. Data collection occurred in 2008. RESULTS: A total of 190 Latino MSM was reached; the average age was 25.5 years and nearly 80% reported being from Mexico. Prevalence estimates of smoking everyday and past 30-day heavy episodic drinking were 6.5% and 35.0%, respectively. Prevalence estimates of past 12-month marijuana and cocaine use were 56.0% and 27.1%, respectively. Past 3-month prevalence estimates of sex with at least one woman, multiple male partners, and inconsistent condom use were 21.2%, 88.9%, and 54.1%, respectively. CONCLUSIONS: Respondents had low rates of tobacco use and club drug use, and high rates of sexual risk behaviors. Although this study represents an initial step in documenting the health risk behaviors of immigrant Latino MSM who are part of a new trend in Latino immigration to the southeastern United States, a need exists for further research, including longitudinal studies to understand the trajectory of risk behavior among immigrant Latino MSM. |
Need for oversight and standardization of HIV screening for living organ donors
Al-Samarrai T , Gounder P , Bernard MA , Shepard CW . Am J Transplant 2012 12 (3) 789-90 In their analysis of undetected human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections among potential organ donors, Ellingson et al. conclude that nucleic acid testing (NAT), in addition to enzyme immunoassays (EIA) as is currently required by Organ Procurement and Transplantation Network (OPTN) policy (1) would significantly reduce undetected HCV infection, but due to limitations of the data, are equivocal regarding a similar addition of NAT screening for HIV. However, their data are derived from deceased potential donors only and the risk estimates may require separate modeling for living donors. Although the OPTN has oversight of living and deceased organ donors, there are few policies specifically for living donation, and none that specify the type and timing of HIV screening prior to transplant (2). | Our recent investigation of HIV transmission attributable to living donor kidney transplantation demonstrated the need for more effective pretransplant screening of living donors and risk behavior counseling (3). The donor screened HIV negative by EIA 79 days pretransplant and acquired HIV after screening but prior to transplantation; repeat screening was not performed prior to transplantation. With increasing numbers of living donors, establishment of best practices specifically for living organ donation is long overdue. OPTN policies should be revised to clearly distinguish deceased donors, necessitating immediate pretransplant screening, from living donors who may acquire HIV and other infections after screening. |
Vaccination coverage in Haiti: results from the 2009 national survey
Rainey JJ , Lacapere F , Danovaro-Holliday MC , Mung K , Magloire R , Kananda G , Cadet JR , Lee CE , Chamouillet H , Luman E . Vaccine 2012 30 (9) 1746-51 INTRODUCTION: Since 1977, vaccinations to protect against tuberculosis, diphtheria, tetanus, pertussis, polio, and measles (and rubella since 2009) have been offered to children in Haiti through the routine immunization program. From April to July 2009, a national vaccination coverage survey was conducted to assess the success of the routine vaccination program at reaching children in Haiti. METHODS: A multi-stage cluster survey was conducted using a modified WHO methodology for household sampling. A standardized questionnaire was administered to collect vaccination histories, demographic information, and reasons for under-vaccination of children aged 12-23 months. A child who received the eight recommended routine vaccinations was considered fully vaccinated. The routine vaccination schedule was used to define valid doses and estimate the percent of children vaccinated on time. RESULTS: Among 1345 children surveyed, 40.4% (95% CI: 36.6-44.2) of the 840 children with vaccination cards had received all eight recommended vaccinations. Coverage was highest for the Bacille Calmette-Guerin vaccine (87.3%), the first doses of the diphtheria-tetanus-pertussis vaccine (92.0%) and oral poliovirus vaccine (93.4%) and lowest for measles vaccine (46.9%). Assuming similar coverage for the 505 children without cards, overall coverage with the complete vaccination series among all children was 31.9%. Timely vaccination rates were lower. Reasons for under-vaccination included not having enough time to reach the vaccination location (24.8%), having a child who was ill (13.8%), and not knowing when, or forgetting, to go for vaccination (12.8%). CONCLUSIONS AND RECOMMENDATIONS: Coverage for early-infant vaccines was high; however, most children did not complete their full vaccination series, and many children received vaccinations later than recommended. Efforts to improve the vaccination program should include increasing the frequency of outreach services, training for vaccination staff to minimize missed opportunities, and better communicating the timing of vaccinations to encourage caregivers to bring their children for vaccinations at the recommended age. Efforts to promote the benefits of vaccination and card retention are also needed. |
Public health impact of including two lineages of influenza B in a quadrivalent seasonal influenza vaccine
Reed C , Meltzer MI , Finelli L , Fiore A . Vaccine 2012 30 (11) 1993-8 The annual trivalent influenza vaccine (TIV) includes viruses representing three influenza strains - one A/H1N1, one A/H3N2, and one B, although two antigenically distinct lineages of influenza B (Victoria and Yamagata) co-circulate annually in the United States. Predicting which lineage of influenza B will predominate during a season is challenging, and cross-protection by immunization against the other lineage is expected to be low. One proposed alternative is to produce a quadrivalent influenza vaccine (QIV) including an influenza B virus from each of the two circulating lineages. We estimated the additional public health benefit of QIV compared with TIV by calculating the expected impact on influenza-related health outcomes (illness, hospitalization, and death) over ten influenza seasons (1999/2000-2008/2009). We included data on the annual incidence of influenza-associated outcomes, virologic circulation, vaccine coverage, and vaccine effectiveness. We also considered annual vaccine production capacity, since available resources would have produced four vaccine viruses instead of three, potentially resulting in fewer doses of QIV. Use of QIV could have reduced annual cases (range: 2200-970,000), hospitalizations (range: 14-8200), and deaths (range: 1-485) in the US. During earlier seasons, adjusting production capacity for a fourth virus in QIV could have resulted in reduced overall influenza vaccine availability and net increases in influenza-associated outcomes. However, in recent seasons, the expected supply of QIV is likely to exceed the doses of vaccine actually administered. The potential net impact of QIV on influenza-associated outcomes is expected to vary between seasons, depending on annual variability in the incidence of influenza caused by the two influenza B lineages, vaccine coverage, and effectiveness. The additional protection provided by including a second lineage of influenza B could result in a modest reduction in influenza-associated outcomes. |
Health-related quality of life in the anthrax vaccination program for workers in the laboratory response network
Stewart B , Zhang Y , Rose Jr CE , Tokars JI , Martin SW , Franzke LH , McNeil MM . Vaccine 2012 30 (10) 1841-6 BACKGROUND: In 2002 CDC initiated the Anthrax Vaccination Program (AVP) to provide voluntary pre-exposure vaccination with Anthrax Vaccine Adsorbed (AVA) for persons at high risk of exposure to Bacillus anthracis spores. There has been concern that AVA could be associated with long term impairment of mental and/or physical health. OBJECTIVES: To ascertain whether physical and mental functional status, as measured by the SF-36v2 health survey (Medical Outcomes Trust, Boston, MA), of AVA recipients and controls changed differently over time. METHODS: We enrolled 437 exposed (received AVA) and 139 control subjects. The exposed group received AVA under then-current Advisory Committee on Immunization Practices (ACIP) recommendations. SF-36v2 surveys were completed at 0, 12, and 30 months. SF-36v2 physical and mental scores both range from 0 to 100 with an estimated national average of 50 points. RESULTS: For physical scores, the average change from baseline was -0.53 for exposed vs. -0.67 for controls at 12 months (p=0.80) and -1.09 for exposed vs. -1.97 for controls at 30 months (p=0.23). For mental scores, the average change from baseline was -1.50 for exposed vs. -1.64 for controls at 12 months (p=0.86) and -2.11 for exposed vs. -0.24 for controls at 30 months (p=0.06). In multivariable analysis, the difference in mental score change between exposed vs. controls at 30 months was less pronounced (p=0.37) but other findings were similar to univariate analyses. CONCLUSIONS: These results do not favor an association between receipt of AVA and an altered health related quality of life over a 30-month period. |
Impact of vaccination against Haemophilus influenzae type b with and without a booster dose on meningitis in four South American countries
Garcia S , Lagos R , Munoz A , Picon T , Rosa R , Alfonso A , Abriata G , Gentile A , Romanin V , Regueira M , Chiavetta L , Agudelo CI , Castaneda E , De la Hoz F , Higuera AB , Arce P , Cohen AL , Verani J , Zuber P , Gabastou JM , Pastor D , Flannery B , Andrus J . Vaccine 2012 30 (2) 486-92 To inform World Health Organization recommendations regarding use of Haemophilus influenzae type b (Hib) vaccines in national immunization programs, a multi-country evaluation of trends in Hib meningitis incidence and prevalence of nasopharyngeal Hib carriage was conducted in four South American countries using either a primary, three-dose immunization schedule without a booster dose or with a booster dose in the second year of life. Surveillance data suggest that high coverage of Hib conjugate vaccine sustained low incidence of Hib meningitis and low prevalence of Hib carriage whether or not a booster dose was used. |
Invasive disease due to Haemophilus influenzae serotype b ten years after routine vaccination, South Africa, 2003-2009
von Gottberg A , Cohen C , Whitelaw A , Chhagan M , Flannery B , Cohen AL , de Gouveia L , Plessis MD , Madhi SA , Klugman KP . Vaccine 2012 30 (3) 565-571 INTRODUCTION: South Africa started routine infant immunization against Haemophilus influenzae serotype b (Hib) disease in 1999 with an accelerated three-dose schedule of Hib conjugate vaccine (HibCV) without a booster dose. Following initial declines in Hib disease, national surveillance has identified increasing numbers of Hib disease episodes in fully vaccinated children. MATERIALS AND METHODS: We reviewed national laboratory-based surveillance data from 2003 through 2009 for invasive Hib disease episodes among children <5 years, including HIV status and vaccination histories. We defined HibCV failures as invasive Hib disease in children at least four months of age who had received all recommended doses of HibCV. RESULTS: Despite high HibCV vaccination coverage, detection rates of Hib disease in children <5 years increased from 0.7 per 100,000 population in 2003 to 1.3/100,000 in 2009 (p<0.001). Among 263 episodes of invasive Hib disease among children with known vaccination status, 135 (51%) were classified as vaccine failures. Of vaccine failures, 55% occurred among case patients ≥18 months old. HIV status was documented for 90 children with vaccine failure; 53% were not HIV infected. DISCUSSION AND CONCLUSIONS: Vaccine failures, which occurred in both HIV-infected and -uninfected children, comprised half of the rise in invasive Hib disease detected in South African children 10 years after national introduction of Hib vaccine. These findings suggest that HibCV recommendations may require revision. In November 2010, children in South Africa began receiving a booster dose of HibCV as part of a pentavalent vaccine. |
Comparison of DNA extraction methodologies used for assessing fungal diversity via ITS sequencing.
Rittenour WR , Park JH , Cox-Ganser JM , Beezhold DH , Green BJ . J Environ Monit 2012 14 (3) 766-74 Traditional methods of assessing fungal exposure have been confounded by a number of limiting variables. The recent utilization of molecular methods such as internal transcribed spacer (ITS) sequencing of ribosomal RNA genes has provided improved insight into the diversity of fungal bioaerosols in indoor, outdoor and occupational environments. However, ITS analyses may also be confounded by a number of methodological limitations. In this study, we have optimized this technology for use in occupational or environmental studies. Three commonly used DNA extraction methodologies (UltraClean Soil kit, High Pure PCR Template kit, and EluQuik/DNeasy kit) were compared in terms of sensitivity and susceptibility to PCR inhibitors in dust for three common fungal bioaerosols, Aspergillus versicolor, Rhizopus microsporus and Wallemia sebi. Environmental dust samples were then studied using each extraction methodology and results were compared to viable culture data. The extraction methods differed in terms of their ability to efficiently extract DNA from particular species of fungi (e.g. Aspergillus versicolor). In addition, the ability to remove PCR inhibitors from dust samples was most effective using the soil DNA extraction kit. The species composition varied greatly between ITS clone libraries generated with the different DNA extraction kits. However, compared to viable culture data, ITS clone libraries included additional fungal species that are incapable of growth on solid culture medium. Collectively, our data indicated that DNA extraction methodologies used in ITS sequencing studies of occupational or environmental dust samples can greatly influence the fungal species that are detected. |
Reproducibility of serology assays for pandemic influenza H1N1: collaborative study to evaluate a candidate WHO International Standard
Wood JM , Major D , Heath A , Newman RW , Hoschler K , Stephenson I , Clark T , Katz JM , Zambon MC . Vaccine 2012 30 (2) 210-7 Haemagglutination-inhibition (HI) and virus neutralisation (VN) assays are used to evaluate immunogenicity of pandemic H1N1 vaccines; however these bioassays are poorly standardised leading to inter-laboratory variation. A candidate International Standard (IS) for antibody to H1N1pdm virus (09/194) was prepared from pooled sera of subjects who had either recovered from H1N1pdm infection or who had been immunised with an adjuvanted subunit vaccine prepared from reassortant virus NYMC X-179A (derived from A/California/7/2009 virus). Ten laboratories from seven countries tested the candidate IS, 09/194 and a panel of human sera by HI and VN using the A/California/7/2009 virus (six laboratories) and/or the reassortant virus NYMC X-179A (ten laboratories). As expected, the inter-laboratory variability for HI and VN assay results was high. For results of antibody tests to NYMC X-179A, the % geometric coefficient of variation (%GCV) for 09/194 between laboratories was 83% for HI and 192% for VN. For tests of all sera, the median %GCV ranged from 95 to 345% for HI (80-fold variation) and 204 to 383% for VN (109-fold variation), but for the titres relative to 09/194 the median %GCV was much reduced (HI 34-231%; VN 44-214%). For tests of antibody to the A/California/7/2009 wild type virus there were similar reductions in %GCV when 09/194 was used. These results suggest that 09/194 will be of use to standardise assays of antibody to A/California/7/2009 vaccine and 09/194 has now been established by WHO as an IS for antibody to A/California/7/2009 with an assigned potency of 1300 IU per ml. |
International collaborative proficiency study of Human Papillomavirus type 16 serology
Eklund C , Unger ER , Nardelli-Haefliger D , Zhou T , Dillner J . Vaccine 2012 30 (2) 294-9 We performed an international proficiency study of Human Papillomavirus (HPV) type 16 serology. A common methodology for serology based on virus-like particle (VLP) ELISA was used by 10 laboratories in 6 continents. The laboratories used the same VLP reference reagent, which was selected as the most stable, sensitive and specific VLP preparation out of VLPs donated from 5 different sources. A blinded proficiency panel consisting of 52 serum samples from women with PCR-verified HPV 16-infection, 11 control serum samples from virginal women and the WHO HPV 16 International Standard (IS) serum were distributed. The mean plus 3 standard deviations of the negative control serum samples was the most generally useful "cut-off" criterion for distinguishing positive and negative samples. Using sensitivity of at least 50% and a specificity of 100% as proficiency criteria, 6/10 laboratories were proficient. In conclusion, an international Standard Operating Procedure for HPV serology, an international reporting system in International Units (IU) and a common "cut-off" criterion have been evaluated in an international HPV serology proficiency study. |
Public health laboratory systems development in East Africa through training in laboratory management and field epidemiology
Mosha F , Oundo J , Mukanga D , Njenga K , Nsubuga P . Pan Afr Med J 2011 10 14 Laboratories are integral to the delivery of quality health care and for public health functions; however laboratory systems and services are often neglected in resource-poor settings such as the East African region. In order to sustainably strengthen national laboratory systems in resourcepoor countries, there is a need to train laboratory personnel to work in clinical as well as public health laboratories. In 2004,Kenya, Uganda, Tanzania, and South Sudan began training public health laboratory workers jointly with field epidemiologists in the Kenya Field Epidemiology and Laboratory Training Program (FELTP), and later through the Tanzania FELTP, as a strategy to strengthen public health laboratories. These programs train laboratory epidemiologists through a two-year public health leadership development course, and also offer various types of short course training for frontline staff. The FELTP laboratory graduates in Kenya, Tanzania, Uganda, and South Sudan are working in their respective countries to strengthen public health laboratory systems while the short course participants provide a pool of frontline implementers with the capacity to support the lower tiers of health systems, as well as serve as surge capacity for the regions and the national level. Through training competent public health laboratory workers, the East African ministries of health, in collaboration with other regional partners and stakeholders are now engaged in developing and implementing a holistic approach that will guarantee an overall strengthening of the health system by using welltrained public health laboratory leaders to drive the process. Strengthening public health laboratory medicine in East Africa is critical to improve health-care systems. The experience with the FELTP model in East Africa is a step in the right direction towards ensuring a stronger role for the laboratory in public health. |
Apaf-1 deficiency confers resistance to ultraviolet-induced apoptosis in mouse embryonic fibroblasts by disrupting reactive oxygen species amplification production and mitochondrial pathway
Feng R , Han J , Ziegler J , Yang M , Castranova V . Free Radic Biol Med 2011 52 (5) 889-97 Apoptosis requires tightly regulated cell death pathways. The signaling pathways that trigger a cell to undergo apoptosis after UV radiation are cell type specific and are currently being defined. Here, we have used pharmacological and genetic tools to demonstrate the decisive part of the mitochondrial pathway in UVC-induced apoptosis in mouse embryo fibroblasts (MEFs). UVC-induced apoptosis proceeded independent of the activation of death receptor components. In contrast, soon after UV radiation, MAPK activation and generation of reactive oxygen species (ROS) increased, followed by a decline in mitochondrial membrane potential (MMP) and cytochrome c release, as well as activation of caspase-9 and -3 and the upregulation of p47-phox. Deficiency of apaf-1, a critical member of the apoptosome, dramatically abolished all the UV-induced signal deterioration and cell death. In parallel, UVC-induced apoptosis was largely attenuated by either DN-caspase-9 or Bcl-X(L) overexpression. Pretreatment of cells with N-acetylcysteine or catalase but not Tempol decreased UVC-induced MAPK activation and apoptosis. Inhibition of JNK and caspase attenuated p47-phox upregulation. Altogether, we have for the first time demonstrated the critical role of Apaf-1 in the regulation of MAPK, ROS, and MMP in UVC-radiated MEFs and propose that the amplification feedback loop among mitochondrial signal molecules culminates in the demise of the cell. |
Electronic fetal heart rate monitoring and its relationship to neonatal and infant mortality in the United States
Klebanoff MA , Branum AM , Schoendorf KC , Lynch CD . Am J Obstet Gynecol 2012 206 (1) e18-9 The Journal recently published an article suggesting a causal association between electronic fetal monitoring (EFM) and decreased infant mortality.1 We have strong reservations regarding the ability of that paper to offer guidance regarding the effectiveness of EFM because it is inappropriate to use vital statistics data to make the leap from statistical association to causation. | Several years ago, two of us contributed to a set of American Journal of Obstetrics and Gynecology commentaries discussing the reasonable use of secondary vital statistics data.2, 3 Those commentaries raised important issues and limitations that should be considered, acknowledged, and addressed. |
Enhancing early identification and coordination of intervention services for young children with autism spectrum disorders: report from the Act Early Regional Summit Project
Peacock G , Lin SC . Disabil Health J 2012 5 (1) 55-9 BACKGROUND: Increasing prevalence of autism spectrum disorders (ASD) and the merits of early intervention support the importance of early identification and detection. The Act Early Initiative attempts to address the states' capacity to support this process of early identification and early intervention. OBJECTIVE: The Centers for Disease Control and Prevention (CDC) Health Resources and Services Administration (HRSA) collaborated with the Association of University Centers on Disabilities (AUCD) to develop strategies that will address state capacity for responding to the increasing demand for earlier identification, earlier diagnoses, and coordination of service systems for children with ASDs and other developmental disabilities (DD). METHODS: Act Early regional summits were held to engage stakeholders from the early detection and intervention community including parents, state agencies, provider groups, autism and related disability organizations, and academia. The stakeholders then used the Logic Model to facilitate the teams' planning process. The Logic Model enables teams to understand the strengths and gaps within their state resources and plan specific activities to achieve concrete outcomes. RESULTS: States identified opportunities and challenges in early identification of children with delay. One of the particular challenges identified were low income, rural and non-English speaking populations encountering more challenges than others in accessing diagnosis and early intervention services. CONCLUSIONS: The Summits are a unique model that demonstrates the importance of developing comprehensive state plans to advance the collaboration and coordination of early detection and intervention service systems for children with ASDs and related DDs from all racial, ethnic, geographical, and socioeconomic backgrounds. |
Association between parental nativity and autism spectrum disorder among US-born non-Hispanic white and Hispanic children, 2007 National Survey of Children's Health
Schieve LA , Boulet SL , Blumberg SJ , Kogan MD , Yeargin-Allsopp M , Boyle CA , Visser SN , Rice C . Disabil Health J 2012 5 (1) 18-25 BACKGROUND: Limited studies suggest the prevalence of autism spectrum disorders (ASD) varies by whether maternal and child birth country are discordant. OBJECTIVE/HYPOTHESIS: We explored associations between ASD and maternal and paternal nativity in a sample of US-born non-Hispanic white (NHW, n = 37,265) and US-born Hispanic (n = 4,690) children in the 2007 National Survey of Children's Health (NSCH). METHODS: We assessed ASD prevalence within race-ethnicity and parental nativity subgroups. Prevalence ratios (aPR), comparing each group to NHW children with 2 US-born parents, were adjusted for child age, sex, and receipt of care in a medical home. Estimates were weighted to reflect US noninstitutionalized children. Standard errors were adjusted to account for the complex sample design. RESULTS: In NHW children with 2 US-born parents, ASD prevalence was 1.19%; estimates were similar for NHW children with a foreign-born mother or father. There was a striking heterogeneity between Hispanic children with 2 US-born versus 2 foreign-born parents (ASD prevalence 2.39% versus 0.31%, p = .05). Even after adjustment, PRs comparing ASD prevalence in Hispanic versus NHW children were vastly different for Hispanic subgroups, suggesting a substantially lower prevalence for Hispanic children with both parents foreign-born (aPR 0.2, 95% confidence interval 0.1-0.5) and a higher prevalence for Hispanic children with both parents US-born (aPR 2.0 [0.8-4.6]). CONCLUSIONS: Previous studies comparing ASD prevalence between NHW and Hispanic children based on a composite Hispanic grouping without consideration of parental nativity likely missed important differences between these racial-ethnic groups. Continuing efforts toward improving early identification in Hispanic children are needed. |
Attitudes toward newborn screening for cytomegalovirus infection
Din ES , Brown CJ , Grosse SD , Wang C , Bialek SR , Ross DS , Cannon MJ . Pediatrics 2011 128 (6) e1434-42 OBJECTIVE: Newborns are not routinely screened for cytomegalovirus (CMV), the leading infectious cause of developmental disability. Congenital CMV satisfies a number of criteria for inclusion in newborn screening, and screening potentially offers benefits. Screening could also introduce harms such as anxiety and unnecessary costs for the families of the substantial proportion of CMV-infected children who never develop CMV-related disabilities. Our objective was to assess attitudes toward newborn screening for CMV. METHODS: We analyzed responses to 5 statements about CMV and newborn screening from 3922 participants in the 2009 HealthStyles survey, a national mail survey designed to include a group similar to the US population with respect to gender, age, race/ethnicity, income, and household size. Two-step cluster analysis was performed to identify clusters of parental attitudes. RESULTS: The majority of respondents strongly or somewhat agreed that they would want to have their newborn tested for CMV even if it was not performed routinely (84%), they had to pay $20 (87%), or CMV-related problems never developed (84%). Nearly half (47%) of them "would worry that the CMV test would lead to unneeded doctor visits and expenses," and 32% "think CMV problems are too rare to worry about." Three clusters of parent respondents were identified on the basis of their attitudes toward CMV screening: "strongly in favor" (31%), "moderately in favor" (49%), and "weakly opposed" (20%). CONCLUSIONS: Among most parents, costs, worry, and anxiety associated with newborn screening for CMV would be acceptable. Although attitudes were generally favorable, a minority of the parents were weakly opposed to newborn screening for CMV. |
Outbreak of beriberi among African Union troops in Mogadishu, Somalia
Watson JT , El Bushra H , Lebo EJ , Bwire G , Kiyengo J , Emukule G , Omballa V , Tole J , Zuberi M , Breiman RF , Katz MA . PLoS One 2011 6 (12) e28345 CONTEXT AND OBJECTIVES: In July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies. DESIGN, SETTING, AND PARTICIPANTS: The illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness. RESULTS: From April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported. CONCLUSIONS: An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources. |
Lung cancer risk among construction workers in California, 1988-2007
Calvert GM , Luckhaupt S , Lee SJ , Cress R , Schumacher P , Shen R , Tak S , Deapen D . Am J Ind Med 2012 55 (5) 412-22 BACKGROUND: Although lung cancer risks can vary by race/ethnicity and by construction occupation, these risks have not been examined extensively. METHODS: This study analyzed 110,937 lung cancer cases identified from the California Cancer Registry between 1988 and 2007. Mean age at diagnosis, proportion diagnosed at an advanced stage, and proportion with 3-year survival were calculated for lung cancer cases employed in the construction industry. Case-control methodology was also used to assess the risk of lung cancer. Morbidity odds ratios (MORs) were estimated by conditional logistic regression. RESULTS: Construction workers were found to have a significantly elevated risk for all lung cancer combined (MOR = 1.57) and for each lung cancer histologic subtype examined. All construction occupations, except managers/engineers and supervisors, had a significantly elevated risk for all lung cancer combined. Roofers and welders had the highest risks for total lung cancer and for each of the histologic subtypes. Construction workers in each of the four race/ethnicity groups also had significantly increased lung cancer risks. Compared to non-construction workers, construction workers were diagnosed at an earlier age, at a more advanced stage, and had significantly lower 3-year survival, though differences were modest. CONCLUSION: These findings justify additional reductions in carcinogenic exposures in construction, and increased support for smoking cessation programs at construction sites. (Am. J. Ind. Med. (c) 2012 Wiley Periodicals, Inc.) |
Occupational health and safety surveillance and research using workers' compensation data
Utterback DF , Schnorr TM , Silverstein BA , Spieler EA , Leamon TB , Amick BC 3rd . J Occup Environ Med 2012 54 (2) 171-6 OBJECTIVE: Examine uses of US workers' compensation (WC) data for occupational safety and health purposes. METHODS: This article is a summary of the proceedings from an invitational workshop held in September 2009 to discuss the use of WC data for occupational safety and health prevention purposes. RESULTS: Workers' compensation data systems, although limited in many ways, contain information such as medical treatments, their costs and outcomes, and disability causes that are unavailable from national occupational surveillance sources. CONCLUSIONS: Despite their limitations, WC records are collected in a manner consistent with many occupational health and safety surveillance needs. Reports are available on the use of WC data for surveillance and research purposes such as estimating the frequency, magnitude, severity, and cost of compensated injuries. Inconsistencies in WC data can limit generalization of research results. |
Identification of diacetyl substitutes at a microwave popcorn production plant
Boylstein R . J Occup Environ Hyg 2012 9 (2) D33-4 Diacetyl (2,3-butanedione) is a volatile diketone commercially synthesized and used to make butter flavoring for food production. It also is a naturally occurring product of fermentation and is found in butter, wine, and coffee. Diacetyl was first recognized as a respiratory health hazard at a microwave popcorn production plant.( Citation1 – Citation3 ) The inhalation of butter flavorings containing diacetyl can cause severe shortness of breath and cough in workers exposed during microwave popcorn manufacturing. These symptoms may result from a rare, disabling lung disease called bronchiolitis obliterans, which has caused death or the need for lung transplant in some exposed microwave popcorn workers. Bronchiolitis obliterans has also been identified in flavoring and diacetyl manufacturing workers.( Citation4 , Citation5 ) Accordingly, flavor manufacturers have started to substitute other chemicals for diacetyl in butter flavorings, including chemically similar diketones. |
Association between cumulative fiber exposure and respiratory outcomes among Libby vermiculite workers
Larson TC , Antao VC , Bove FJ , Cusack C . J Occup Environ Med 2012 54 (1) 56-63 OBJECTIVE: To examine the association between cumulative fiber exposure and health outcomes in workers (n = 336) with Libby amphibole exposure. METHODS: Exposure-response relationships were explored by the use of logistic regression, with cumulative fiber exposure modeled in categories and as a continuous variable. RESULTS: The use of spline functions with lifetime cumulative fiber exposure as a continuous variable showed that the odds of localized pleural thickening were significantly elevated at less than 1 f/cc-y. Odds of parenchymal abnormalities, restrictive spirometry, and chronic bronchitis were also significantly elevated at 108, 166, and 24 f/cc-y, respectively. CONCLUSIONS: The odds of several pulmonary health outcomes are correlated with cumulative exposure to Libby amphibole. That relatively low-lifetime cumulative exposures are associated with localized pleural thickening has implications for the non-cancer-risk assessment for Libby amphibole. |
An evaluation of sound restoration hearing protection devices and audibility issues in mining
Azman AS , Hudak RL . Noise Control Eng J 2011 59 (6) 622-630 Despite advancements in engineering noise controls and the use of administrative controls, miners are still dependent on hearing protection devices for prevention of noise-induced hearing loss. However, miners often complain of reduced audibility or confusion about identifying spoken words when wearing conventional hearing protectors. This leads to an increased risk of miners being struck by moving equipment or errors in communication with co-workers. Miners will often remove their hearing protectors to overcome these obstacles. To address this problem, electronic technology exists that allows some amount of sound to pass through the hearing protector, therefore restoring some audibility of the passively attenuated sounds. This paper will present the results of testing completed on a selection of four sound restoration hearing protection devices, with the objective of determining if they provide improved speech intelligibility to workers near certain types of mining equipment. |
Analysis of a mechanism suspension to reduce noise from horizontal vibrating screens
Yantek DS , Lowe MJ . Noise Control Eng J 2011 59 (6) 568-580 A-weighted sound levels around vibrating screens in coal preparation plants often exceed 90 dB. The National Institute for Occupational Safety and Health (NIOSH) is developing noise controls to reduce noise generated by horizontal vibrating screens. Horizontal vibrating screen noise is dominated by sound radiated from the screen body. NIOSH researchers analyzed a mechanism suspension system that could reduce screen body-radiated noise. A finite element (FE) model of the entire screen was used to analyze the screen with the added mechanism suspension. The spring rates for the mechanism suspension were tuned to transmit vibration at the mechanism operating speed while attenuating vibration transmitted from the mechanisms to the screen body at frequencies above 100 Hz. The FE results were used to estimate the A-weighted sound power level radiated by the screen sides and feedbox for various mechanism suspension spring rates. The results indicate that a tuned mechanism suspension could reduce the A-weighted sound power level radiated by the screen body due to gear and bearing forces inside the mechanisms by 7 to 18 dB. |
Malaria survey in post-earthquake Haiti--2010
Townes D , Existe A , Boncy J , Magloire R , Vely JF , Amsalu R , Tavernier MD , Muigai J , Hoibak S , Albert M , McMorrow M , Slutsker L , Kachur SP , Chang M . Am J Trop Med Hyg 2012 86 (1) 29-31 Haiti's Ministry of Public Health and Population collaborated with global partners to enhance malaria surveillance in two disaster-affected areas within 3 months of the January 2010 earthquake. Data were collected between March 4 and April 9, 2010 by mobile medical teams. Malaria rapid diagnostic tests (RDTs) were used for case confirmation. A convenience sample of 1,629 consecutive suspected malaria patients was included. Of these patients, 1,564 (96%) patients had malaria RDTs performed, and 317 (20.3%) patients were positive. Of the 317 case-patients with a positive RDT, 278 (87.7%) received chloroquine, 8 (2.5%) received quinine, and 31 (9.8%) had no antimalarial treatment recorded. Our experience shows that mobile medical teams trained in the use of malaria RDTs had a high rate of testing suspected malaria cases and that the majority of patients with positive RDTs received appropriate antimalarial treatment. Malaria RDTs were useful in the post-disaster setting where logistical and technical constraints limited the use of microscopy. |
The increase of imported malaria acquired in Haiti among US travelers in 2010
Agarwal A , McMorrow M , Arguin PM . Am J Trop Med Hyg 2012 86 (1) 9-10 From 2004 to 2009, the number of malaria cases reported in Haiti increased nearly fivefold. The effect of the 2010 earthquake and its aftermath on malaria transmission in Haiti is not known. Imported malaria cases in the United States acquired in Haiti tripled from 2009 to 2010, likely reflecting both the increased number of travelers arriving from Haiti and the increased risk of acquiring malaria infection in Haiti. The demographics of travelers and the proportion of severe cases are similar to those statistics reported in previous years. Non-adherence to malaria chemoprophylaxis remains a nearly universal modifiable risk factor among these cases. |
Cryptosporidium tyzzeri and Cryptosporidium pestis: which name is valid?
Xiao L , Ryan UM , Fayer R , Bowman DD , Zhang L . Exp Parasitol 2012 130 (3) 308-9 The dispute on the validity of Cryptosporidium pestis and Cryptosporidium tyzzeri origins from the uncertainty on the identity of Cryptosporidium parvum described by Tyzzer in 1912 and the interpretation of the Principal of Priority of the International Code of Zoological Nomenclature (ICZN). Using a rigid interpretation of the Principal of Priority, one researcher proposed to rename C. parvum as C. pestis and retain C. parvum for Cryptosporidium mouse genotype I on the basis that Tyzzer was probably describing mouse genotype I. However, the ICZN clearly states that the Principle of Priority is to be used to promote stability and is not intended to upset a long-accepted name. Because mice are known to be naturally infected with C. parvum, and the 1985 taxonomic re-description of C. parvum for bovine and human isolates is accepted by almost all Cryptosporidium researchers, the prevailing name C. parvum for the species infective to calves and humans must be retained to avoid confusion. The designation of C. tyzzeri for the mouse genotype I brings further clarity to the taxonomy of Cryptosporidium spp. in humans, cattle, and domestic mice. |
Epidemiological assessment of continuing transmission of lymphatic filariasis in Samoa
Joseph H , Maiava F , Naseri T , Silva U , Lammie P , Melrose W . Ann Trop Med Parasitol 2011 105 (8) 567-578 Ongoing transmission of lymphatic filariasis (LF) was assessed in five Samoan villages by measuring microfilaraemia (Mf), circulating filarial antigen (CFA) and antibody prevalence. Compared to the other villages, Fasitoo-Tai had a significantly higher Mf prevalence (3.2%), CFA prevalence (14.6%) and antibody prevalence in children (62.0%) (P<0.05). Puapua had a significantly lower CFA prevalence (2.5%), no detectable Mf-positive individuals and significantly low antibody prevalence in children (7.9%) (P,0.05). Siufaga, previously believed to be LF-free, recorded >1% CFA prevalence and a high antibody prevalence in children (46.6%). Overall, antibody prevalence in children appeared to reflect the transmission dynamics in the villages and, in Siufaga, identified an area of ongoing transmission. The Filariasis Cellabs Enzyme-Linked Immunosorbent Assay (CELISA), based on recombinant antigen Bm14, to detect antibodies, could potentially be a promising diagnostic tool for inclusion in future surveillance in the South Pacific. (W. S. Maney & Son Ltd 2011.) |
Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign
Sinkowitz-Cochran RL , Garcia-Williams A , Hackbarth AD , Zell B , Baker GR , McCannon CJ , Beltrami EM , Jernigan JA , McDonald LC , Goldmann DA . Infect Control Hosp Epidemiol 2012 33 (2) 135-43 BACKGROUND: Little is known about how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign differ among levels of healthcare staff. DESIGN: Evaluation of a mixed qualitative and quantitative methodology ("trilogic evaluation model"). SETTING: Six hospitals that joined the campaign before June 2006. PARTICIPANTS: Three strata of staff (executive leadership, midlevel, and frontline) at each hospital. RESULTS: Surveys were completed in 2008 by 135 hospital personnel (midlevel, 43.7%; frontline, 38.5%; executive, 17.8%) who also participated in 20 focus groups. Overall, 93% of participants were aware of the IHI campaign in their hospital and perceived that 58% (standard deviation, 22.7%) of improvements in quality at their hospital were a direct result of the campaign. There were significant differences between staff levels on the organizational culture (OC) items, with executive-level staff having higher scores than midlevel and frontline staff. All 20 focus groups perceived that the campaign interventions were sustainable and that data feedback, buy-in, hardwiring (into daily activities), and leadership support were essential to sustainability. CONCLUSIONS: The trilogic model demonstrated that the 3 levels of staff had markedly different perceptions regarding the IHI campaign and OC. A framework in which frontline, midlevel, and leadership staff are simultaneously assessed may be a useful tool for future evaluations of OC and quality initiatives such as the IHI campaign. |
Peripartum hysterectomy in the United States: nationwide 14 year experience
Bateman BT , Mhyre JM , Callaghan WM , Kuklina EV . Am J Obstet Gynecol 2012 206 (1) 63 e1-8 OBJECTIVE: The objective of the study was to examine the trends in the rate of peripartum hysterectomy and the contribution of changes in maternal characteristics to these trends. STUDY DESIGN: This was a cross-sectional study of peripartum hysterectomy identified from hospitalizations for delivery recorded in the 1994-2007 Nationwide Inpatient Sample. RESULTS: The overall rate of peripartum hysterectomy increased by 15% during the study period. The rate of hysterectomy for abnormal placentation increased by 1.2-fold; adjustment for previous cesarean delivery explained nearly all of this increase. The rate of hysterectomy for uterine atony following repeat cesarean delivery increased nearly 4-fold, following primary cesarean delivery approximately 2.5-fold, and following vaginal delivery about 1.5-fold. This fast growing trend in peripartum hysterectomy secondary to uterine atony was also largely explained by increasing rates of primary and repeat cesareans. CONCLUSION: Rates of peripartum hysterectomy increased substantially in the United States from 1994 to 2007; much of this increase was due to rising rates of cesarean delivery. |
Assisted reproductive technology program reporting
Kissin DM , Jamieson DJ , Barfield WD . JAMA 2011 306 (23) 2564; author reply 2564-5 Dr Adashi and Senator Wyden (D-OR) commented on the Centers for Disease Control and Prevention’s (CDC’s) National Assisted Reproductive Technology Surveillance System (NASS).1 The Society for Assisted Reproductive Technology started collecting assisted reproductive technology (ART) data from member-clinics in 1986; the CDC has been collecting detailed information on all ART procedures performed annually in the United States since 1995 and has been monitoring ART effectiveness and safety. | Several factors contribute to the high quality of surveillance data, including support of professional societies and consumer organizations, as well as annual data validation of a sample of ART programs. However, there are areas for improvement. Currently, ART programs submit their data to the CDC 1 year after the end of the reporting year to allow collection of complete information about births following successful ART procedures. Another year is needed for statistical analyses, preparation, and publication of the ART Success Rates Report.2 Thus, the report describing ART procedures performed in 2009 is published at the end of 2011. To improve the timeliness of publishing clinic-specific success rates, the CDC plans to release these rates in advance of the aggregate national data beginning in 2012. Outreach to the few nonreporting ART clinics, which tend to be smaller and may not belong to the relevant professional societies, could improve completeness of the NASS.2 The quality of reported data can be further improved by prospective reporting, ie, initial reporting of ART procedure (cycle start date and patient’s demographic information) within 4 days of procedure initiation, and complete reporting when the outcome of the procedure is known. All member-clinics of the Society for Assisted Reproductive Technology are now required to report prospectively.3 Extension of prospective reporting to non–member-clinics (approximately 15% of ART clinics) could further improve data quality and accountability. |
Deaths: preliminary data for 2010
Murphy SL , Xu JQ , Kochanek KD . Natl Vital Stat Rep 2012 60 (4) 1-69 OBJECTIVES: This report presents preliminary U.S. data on deaths, death rates, life expectancy, leading causes of death, and infant mortality for 2010 by selected characteristics such as age, sex, race, and Hispanic origin. METHODS: Data in this report are based on death records comprising more than 98 percent of the demographic and medical files for all deaths in the United States in 2010. The records are weighted to independent control counts for 2010. Comparisons are made with 2009 final data. RESULTS: The age-adjusted death rate decreased from 749.6 deaths per 100,000 population in 2009 to 746.2 deaths per 100,000 population in 2010. From 2009 to 2010, age-adjusted death rates decreased significantly for 7 of the 15 leading causes of death: Diseases of heart, Malignant neoplasms, Chronic lower respiratory diseases, Cerebrovascular diseases, Accidents (unintentional injuries), Influenza and pneumonia, and Septicemia. Assault (homicide) fell from among the top 15 leading causes of death in 2010, replaced by Pneumonitis due to solids and liquids as the 15th leading cause of death. The age-adjusted death rate increased for 5 leading causes of death: Alzheimer’s disease, Nephritis, nephrotic syndrome and nephrosis, Chronic liver disease and cirrhosis, Parkinson's disease, and Pneumonitis due to solids and liquids. Life expectancy increased by 0.1 year from 78.6 in 2009 to 78.7 in 2010. |
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