Emergency department utilization by Californians with sickle cell disease, 2005-2014.
Paulukonis ST , Feuchtbaum LB , Coates TD , Neumayr LD , Treadwell MJ , Vichinsky EP , Hulihan MM . Pediatr Blood Cancer 2016 64 (6) BACKGROUND: Clinical care for children and adults living with sickle cell disease (SCD) is often provided in the emergency department (ED). Population-based surveillance data can be used to describe the ED utilization patterns of this patient population. PROCEDURE: A cohort of pediatric and adult California patients with SCD was identified from multiple data sources, and 10 years (2005-2014) of their treat-and-release ED utilization data were analyzed. RESULTS: Among a cohort of 4,636 patients with SCD, 4,100 (88%) had one or more treat-and-release ED visits. There were 2.1 mean annual visits per person for the cohort (median 0.7; range 0-185). In a single year (2005), 53% had 0 treat-and-release ED visits, 35% had 1-3 visits, 9% had 4-10 visits, and 3% had 11 or more visits; this highest utilization group accounted for 45% of all patients' ED visits. ED utilization in this cohort was highest among young adults and also higher among older adults than pediatric patients. CONCLUSION: The majority of identified patients in each of the 10 years did not go to the ED, but nearly all had one or more such visits over the full span of time. This study highlights the power and utility of a multisource longitudinal data collection effort for SCD. Further study of the segment of the population with highest ED utilization may highlight areas where changes in healthcare and health policy could improve and extend the lives of patients with SCD. |
Trends in published meta-analyses in cancer research, 2008-2013.
Qadir XV , Clyne M , Lam TK , Khoury MJ , Schully SD . Cancer Causes Control 2016 28 (1) 5-12 In order to capture trends in the contribution of epidemiology to cancer research, we describe an online meta-analysis database resource for cancer clinical and population research and illustrate trends and descriptive detail of cancer meta-analyses from 2008 through 2013. A total of 4,686 cancer meta-analyses met our inclusion criteria. During this 6-year period, a fivefold increase was observed in the yearly number of meta-analyses. Fifty-six percent of meta-analyses concerned observational studies, mostly of cancer risk, more than half of which were genetic studies. The major cancer sites were breast, colorectal, and digestive. This online database for Cancer Genomics and Epidemiology Navigator will be continuously updated to allow investigators to quickly navigate the meta-analyses emerging from cancer epidemiology studies and cancer clinical trials. |
No one dies of old age anymore: A coordinated approach to comorbidities and the rheumatic diseases
Theis KA , Brady TJ , Helmick CG . Arthritis Care Res (Hoboken) 2017 69 (1) 1-4 Any idiot can face a crisis; it's the day-to-day living that wears you out, so said Anton Chekhov, himself a practicing physician, as well as a prolific author. For a growing number of people, day-to-day living means managing long-term conditions that co-exist and often exacerbate other ailments, resulting in multiple morbidities, multiple chronic conditions, or comorbidities. Whatever they are labeled, co-existing, co-occurring, etc., “the simultaneous presence of two (or more) chronic diseases or conditions in a person,” is a substantial medical and public health challenge. This special theme issue in Arthritis Care & Research spotlights this under-recognized and under-addressed problem, which has significant impact on people, medicine, and public health. | Comorbidities are a common problem in the US and internationally, and arthritis and other rheumatic diseases are among the most common comorbidities. Failure to recognize and address comorbidities leads to, at best, diminished quality-of-life, and, at worst, increased mortality. Our editorial addresses comorbidities first from the exceptional perspective of rheumatic diseases, and then from a more general perspective, which is influenced by the high prevalence and impact of rheumatic disease. We use the term “comorbidities” and its derivatives throughout, with the exception of some specific quotes, to mirror the language of the original call for submissions that Arthritis Care & Research published on the theme of Comorbidities and the Rheumatic Diseases. |
Shifting demographics among research project grant awardees at the National Heart, Lung, and Blood Institute (NHLBI)
Charette MF , Oh YS , Maric-Bilkan C , Scott LL , Wu CC , Eblen M , Pearson K , Tolunay HE , Galis ZS . PLoS One 2016 11 (12) e0168511 The present study was initiated because of concerns expressed by NHLBI-funded mid-career investigators regarding perceived difficulties in the renewal of their grant awards. This led us to ask: "Are mid-career investigators experiencing disproportionate difficulties in the advancement of their professional careers?" Our portfolio analysis indicates that there has been a significant and evolving shift in the demographics of research project grant (RPG) awardees at NHLBI. In 1998, mid-career (ages 41-55) investigators constituted approximately 60% of all investigators with the remaining 40% being equally divided between early-stage (ages 24-40) investigators and established (ages 56 to 70 and older) investigators. However, since 1998, the proportion of established RPG awardees has been increasing in a slowly progressive and strikingly linear fashion. At the same time the proportion of early-stage awardees fell precipitously until 2006 and then stabilized. During the same period, the proportion of mid-career awardees, which had been relatively stable through 2006, began to fall significantly. In examining potential causes of these demographic shifts we have identified certain inherent properties within the RPG award system that appear to promote an increasingly more established awardee population and a persistent decrease in the proportion of mid-career investigators. A collateral result of these demographic shifts, when combined with level or declining funding, is a significant reduction in the number of RPG awards received by NHLBI mid-career investigators and a corresponding decrease in the number of independent research laboratories. |
Using multi-year national survey cohorts for period estimates: an application of weighted discrete Poisson regression for assessing annual national mortality in US adults with and without diabetes, 2000-2006
Cheng YJ , Gregg EW , Rolka DB , Thompson TJ . Popul Health Metr 2016 14 (1) 48 BACKGROUND: Monitoring national mortality among persons with a disease is important to guide and evaluate progress in disease control and prevention. However, a method to estimate nationally representative annual mortality among persons with and without diabetes in the United States does not currently exist. The aim of this study is to demonstrate use of weighted discrete Poisson regression on national survey mortality follow-up data to estimate annual mortality rates among adults with diabetes. METHODS: To estimate mortality among US adults with diabetes, we applied a weighted discrete time-to-event Poisson regression approach with post-stratification adjustment to national survey data. Adult participants aged 18 or older with and without diabetes in the National Health Interview Survey 1997-2004 were followed up through 2006 for mortality status. We estimated mortality among all US adults, and by self-reported diabetes status at baseline. The time-varying covariates used were age and calendar year. Mortality among all US adults was validated using direct estimates from the National Vital Statistics System (NVSS). RESULTS: Using our approach, annual all-cause mortality among all US adults ranged from 8.8 deaths per 1,000 person-years (95% confidence interval [CI]: 8.0, 9.6) in year 2000 to 7.9 (95% CI: 7.6, 8.3) in year 2006. By comparison, the NVSS estimates ranged from 8.6 to 7.9 (correlation = 0.94). All-cause mortality among persons with diabetes decreased from 35.7 (95% CI: 28.4, 42.9) in 2000 to 31.8 (95% CI: 28.5, 35.1) in 2006. After adjusting for age, sex, and race/ethnicity, persons with diabetes had 2.1 (95% CI: 2.01, 2.26) times the risk of death of those without diabetes. CONCLUSION: Period-specific national mortality can be estimated for people with and without a chronic condition using national surveys with mortality follow-up and a discrete time-to-event Poisson regression approach with post-stratification adjustment. |
Years of life and productivity lost from potentially avoidable colorectal cancer deaths in US counties with lower educational attainment (2008-2012)
Weir HK , Li C , Henley SJ , Joseph D . Cancer Epidemiol Biomarkers Prev 2016 26 (5) 736-742 BACKGROUND: Educational-attainment (EA) is inversely associated with colorectal cancer (CRC) risk. CRC Screening can save lives if precancerous polyps or early cancers are found and successfully treated. This study aims to estimate the potential productivity loss (PPL) and associated avoidable CRC deaths among screen eligible adults residing in lower EA counties in the United States. METHODS: Mortality and population data were used to examine CRC deaths (2008-2012) among adults aged 50 to 74 years in lower EA counties, and to estimate the expected number of deaths using the mortality experience from high EA counties. Excess deaths (observed-expected) were used to estimate potential years life lost and the human capital method was used to estimate PPL in 2012 US dollars. RESULTS: County level CRC death rates were inversely associated with county level EA. Of the 100,857 CRC deaths in lower EA counties, we estimated that more than 21,000 (1in 5) was potentially avoidable and resulted in nearly $2 billion annual productivity loss. CONCLUSIONS: County level EA disparities contribute to a large number of potentially avoidable CRC deaths. Increased prevention and improved screening potentially could decrease deaths, and help reduce the associated economic burden in lower EA communities. Increased screening could further reduce deaths in all EA groups. IMPACT: These results estimate the large economic impact of potentially avoidable CRC deaths in economically disadvantaged communities, as measured by lower educational-attainment. |
Labeling cancer risk factors as lifestyle limits prevention activities across the life span
White MC , Peipins LA , Holman DM . Pediatrics 2016 138 S95-s97 Pediatricians have a long tradition as advocates for disease prevention and social welfare. Many pediatricians, however, may not appreciate the connection between the early life of children and the prevention of cancer later in life. Most cancers are diagnosed in adulthood and messages about cancer prevention have emphasized “lifestyle” as the focus of prevention efforts. The words we use can frame the discussion and direct our focus. Although a person’s lifestyle or way of life can reflect larger social and ecological factors as well as individual behaviors, contemporary use of the term lifestyle tends to steer us away from contextual factors and instead toward an individual-focused approach. Lifestyle medicine, for example, focuses on adult behaviors, such as smoking, diet, physical activity, and alcohol use. 2 A consideration of the factors in early life that influence cancer risk highlights some of the inherent limitations of using the term lifestyle when describing modifiable risk factors and opportunities for prevention. |
Leading causes of cancer mortality - Caribbean Region, 2003-2013
Razzaghi H , Quesnel-Crooks S , Sherman R , Joseph R , Kohler B , Andall-Brereton G , Ivey MA , Edwards BK , Mery L , Gawryszewski V , Saraiya M . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1395-1400 Cancer is one of the leading causes of deaths worldwide; in 2012, an estimated 65% of all cancer deaths occurred in the less developed regions of the world. In the Caribbean region, cancer is the second leading cause of mortality, with an estimated 87,430 cancer-related deaths reported in 2012. The Pan American Health Organization defines the Caribbean region as a group of 27 countries that vary in size, geography, resources, and surveillance systems. CDC calculated site- and sex-specific proportions of cancer deaths and age-standardized mortality rates (ASMR) for 21 English- and Dutch-speaking Caribbean countries, the United States, and two U.S. territories (Puerto Rico and the U.S. Virgin Islands [USVI]), using the most recent 5 years of mortality data available from each jurisdiction during 2003-2013. The selection of years varied by availability of the data from the countries and territories in 2015. ASMR for all cancers combined ranged from 46.1 to 139.3 per 100,000. Among males, prostate cancers were the leading cause of cancer deaths, followed by lung cancers; the percentage of cancer deaths attributable to prostate cancer ranged from 18.4% in Suriname to 47.4% in Dominica, and the percentage of cancer deaths attributable to lung cancer ranged from 5.6% in Barbados to 24.4% in Bermuda. Among females, breast cancer was the most common cause of cancer deaths, ranging from 14.0% of cancer deaths in Belize to 29.7% in the Cayman Islands, followed by cervical cancer. Several of the leading causes of cancer deaths in the Caribbean can be reduced through primary and secondary preventions, including prevention of exposure to risk factors, screening, early detection, and timely and effective treatment. |
Mammography rates after the 2009 revision to the United States Preventive Services Task Force breast cancer screening recommendation
Qin X , Tangka FK , Guy GP Jr , Howard DH . Cancer Causes Control 2016 28 (1) 41-48 BACKGROUND: In 2009, the United States Preventive Services Task Force (USPSTF) recommended against routine mammography screening for women aged 40-49 years. This revised recommendation was widely criticized and has sparked off intense debate. The objectives of this study are to examine the impact of the revised recommendation on the proportion of women receiving mammograms and how the effect varied by age. METHODS: We identified women who had continuous health insurance coverage and who did not have breast cancer between 2008 and 2011 in the Truven Health MarketScan Commercial Claims Databases using mammogram procedure codes. Using women aged 50-59 years as a control group, we used a differences-in-differences approach to estimate the impact of the revised recommendation on the proportion of women ages 40-49 years who received at least one mammogram. We also compared the age-specific changes in the proportion of women ages 35-59 years who were screened before and after the release of the revised recommendation. RESULTS: The proportion of women screened among the 40-49 and 50-59 age groups were 58.5 and 62.5%, respectively, between 2008 and 2009, and 56.9 and 62.0%, respectively, between 2010 and 2011. After 2009, the proportion of women screened declined by 1.2 percentage point among women aged 40-49 years (P < 0.01). The proportion of women screened decreased for all ages, and decreases were larger among women closer to the 40-year threshold. CONCLUSIONS: The 2009 USPSTF breast cancer recommendation was followed by a small reduction in the proportion of insured women aged 40-49 years who were screened. Reductions were larger among women at the younger end of the age range, who presumably had less prior experience with mammography than women nearing 50. |
Opportunities during early life for cancer prevention: highlights from a series of virtual meetings with experts
Holman DM , Buchanan ND . Pediatrics 2016 138 S3-s14 Compelling evidence suggests that early life exposures can affect lifetime cancer risk. In 2014, the Centers for Disease Control and Prevention's (CDC's) Cancer Prevention Across the Lifespan Workgroup hosted a series of virtual meetings with select experts to discuss the state of the evidence linking factors during the prenatal period and early childhood to subsequent risk of both pediatric and adult cancers. In this article, we present the results from a qualitative analysis of the meeting transcripts and summarize themes that emerged from our discussions with meeting participants. Themes included the state of the evidence linking early life factors to cancer risk, research gaps and challenges, the level of evidence needed to support taking public health action, and the challenges of communicating complex, and sometimes conflicting, scientific findings to the public. Opportunities for collaboration among public health agencies and other stakeholders were identified during these discussions. Potential next steps for the CDC and its partners included advancing and building upon epidemiology and surveillance work, developing and using evidence from multiple sources to inform decision-making, disseminating and communicating research findings in a clear and effective way, and expanding collaborations with grantees and other partners. As the science on early life factors and cancer risk continues to evolve, there are opportunities for collaboration to translate science into actionable public health practice. |
Education and employment participation in young adulthood. What role does arthritis play?
Jetha A , Theis KA , Boring MA , Barbour KE . Arthritis Care Res (Hoboken) 2016 69 (10) 1582-1589 OBJECTIVES: To examine the association between arthritis diagnosis and educational and employment participation among young adults, and to determine whether findings differ by self-rated health and age. METHODS: Data from the National Health Interview Survey, years 2009 to 2015, were combined and analyzed. Our sample was restricted to those aged 18-29 years either diagnosed with arthritis (n = 1,393) or not (n = 40,537). Prevalence and correlates of employment and educational participation were compared by arthritis status. Demographic characteristics, social role participation restrictions, health factors, and health system use variables were included as covariates. Models were stratified for age (18-23 versus 24-29) and self-rated health. Weighted proportions, univariate, and multivariate associations were calculated to examine the association between arthritis and educational and employment participation. RESULTS: Arthritis respondents were more likely to be female, married, report more social participation restrictions, fair/poor health, and functional limitations than those without arthritis. In multivariate models, arthritis was significantly associated with lower education (PR = 0.75; 95%CI 0.57-0.98) and higher employment participation (PR = 1.07; 95%CI 1.03-1.13). Additional stratified analyses indicated that the association between arthritis diagnosis and greater employment participation was uncovered for those aged 18-23 years and reporting higher self-rated health. CONCLUSION: Young adults with arthritis may be transitioning into employment at an earlier age than their non-arthritis peers. To inform the design of interventions that promote employment participation, there is a need for future research to better understand the educational and employment experiences of young adults with arthritis. This article is protected by copyright. All rights reserved. |
Effect of lifestyle interventions on glucose regulation among adults without impaired glucose tolerance or diabetes: A systematic review and meta-analysis
Zhang X , Imperatore G , Thomas W , Cheng YJ , Lobelo F , Norris K , Devlin HM , Ali MK , Gruss S , Bardenheier B , Cho P , Garcia de Quevedo I , Mudaliar U , Saaddine J , Geiss LS , Gregg EW . Diabetes Res Clin Pract 2016 123 149-164 This study systematically assessed the effectiveness of lifestyle interventions on glycemic indicators among adults (18years) without IGT or diabetes. Randomized controlled trials using physical activity (PA), diet (D), or their combined strategies (PA+D) with follow-up 12months were systematically searched from multiple electronic-databases between inception and May 4, 2016. Outcome measures included fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), fasting insulin (FI), homeostasis model assessment-estimated insulin resistance (HOMA-IR), and bodyweight. Included studies were divided into low-range (FPG <5.5mmol/L or HbA1c <5.5%) and high-range (FPG 5.5mmol/L or HbA1c 5.5%) groups according to baseline glycemic levels. Seventy-nine studies met inclusion criteria. Random-effect models demonstrated that compared with usual care, lifestyle interventions achieved significant reductions in FPG (-0.14mmol/L [95%CI, -0.19, -0.10]), HbA1c (-0.06% [-0.09, -0.03]), FI (%change: -15.18% [-20.01, -10.35]), HOMA-IR (%change: -22.82% [-29.14, -16.51]), and bodyweight (%change: -3.99% [-4.69, -3.29]). The same effect sizes in FPG reduction (0.07) appeared among both low-range and high-range groups. Similar effects were observed among all groups regardless of lengths of follow-up. D and PA+D interventions had larger effects on glucose reduction than PA alone. Lifestyle interventions significantly improved FPG, HbA1c, FI, HOMA-IR, and bodyweight among adults without IGT or diabetes, and might reduce progression of hyperglycemia to type 2 diabetes mellitus. |
Foreword: Cancer prevention can start early and last a lifetime
White MC , Holman DM , Massetti GM . Pediatrics 2016 138 S1-s2 As the nation’s health protection agency, the Centers for Disease Control and Prevention (CDC) works to protect the health and safety of all Americans. The CDC is perhaps best known for its efforts to prevent and control infectious diseases. It also strives to reduce the burden of chronic diseases, which have emerged as the leading causes of premature disability and death in the United States.1 In fact, cancer is the leading cause of death among persons aged <80 years, 2 and each year, >1.5 million people are told they have cancer.3 Although the complex process of carcinogenesis is not fully understood, research suggests that it may be possible to prevent, delay, or reverse the development of many cancers by influencing various biologic systems and environmental factors that operate over a person’s lifetime.4,5 To prevent chronic diseases such as cancer, the CDC supports cross-cutting strategies that include epidemiology and surveillance, policy and environmental approaches, health care interventions, and linkages between communities and clinical services.1 | Within the CDC, the Division of Cancer Prevention and Control works with national cancer organizations, state health agencies, and other key groups to develop, implement, and promote effective strategies for preventing and controlling cancer.6 The Cancer Prevention Across the Lifespan workgroup of the Division of Cancer Prevention and Control seeks to answer the following fundamental question: what more could the CDC do in collaboration with its various partners to reduce the incidence of cancer in the United States? Our approach is to review the scientific literature and engage scientific experts both within and outside of the CDC to explore new opportunities for primary prevention of cancer at different stages of life.7 Early life, defined roughly as the prenatal period through early childhood, is increasingly being recognized as a critical period for cancer development and cancer prevention efforts.8,9 |
Induction of cancer-associated fibroblast-like cells by carbon nanotubes dictates its tumorigenicity
Luanpitpong S , Wang L , Castranova V , Dinu CZ , Issaragrisil S , Chen YC , Rojanasakul Y . Sci Rep 2016 6 39558 Tumor microenvironment has been recognized as a key determinant of tumor formation and metastasis, but how tumor microenvironment is affected by nanomaterials is essentially unknown. Here, we investigated whether carbon nanotubes (CNTs), a widely used nanomaterial with known carcinogenic potential, can affect cancer-associated fibroblasts (CAFs), which are a key component of tumor microenvironment that provides necessary support for tumor growth. We show for the first time that single-walled CNT and to a lesser extent multi-walled and its COOH-functionalized form induced CAF-like cells, which are non-tumorigenic in animals, but promote tumor growth of human lung carcinoma and CNT-transformed lung epithelial cells. The mechanism by which CNT-induced CAF-like cells promote tumor growth involved the acquisition of cancer stem cells (CSCs) in cancer population. Gene knockdown experiments showed that an expression of podoplanin on CAF-like cells is essential for their effects, indicating the functional role of CAF-like cells and podoplanin in CNT tumorigenic process. Our findings unveil a novel mechanism of CNT-induced carcinogenesis through the induction of CAF-like cells that support CSCs and drive tumor formation. Our results also suggest the potential utility of podoplanin as a mechanism-based biomarker for rapid screening of carcinogenicity of CNTs and related nanomaterials for their safer design. |
Influences and practices in colorectal cancer screening among health care providers serving Northern Plains American Indians, 2011-2012
Nadeau M , Walaszek A , Perdue DG , Rhodes KL , Haverkamp D , Forster J . Prev Chronic Dis 2016 13 E167 INTRODUCTION: The epidemiology of colorectal cancer, including incidence, mortality, age of onset, stage of diagnosis, and screening, varies regionally among American Indians. The objective of the Improving Northern Plains American Indian Colorectal Cancer Screening study was to improve understanding of colorectal cancer screening among health care providers serving Northern Plains American Indians. METHODS: Data were collected, in person, from a sample of 145 health care providers at 27 health clinics across the Northern Plains from May 2011 through September 2012. Participants completed a 32-question, self-administered assessment designed to assess provider practices, screening perceptions, and knowledge. RESULTS: The proportion of providers who ordered or performed at least 1 colorectal cancer screening test for an asymptomatic, average-risk patient in the previous month was 95.9% (139 of 145). Of these 139 providers, 97.1% ordered colonoscopies, 12.9% ordered flexible sigmoidoscopies, 73.4% ordered 3-card, guaiac-based, fecal occult blood tests, and 21.6% ordered fecal immunochemical tests. Nearly two-thirds (64.7%) reported performing in-office guaiac-based fecal occult blood tests using digital rectal examination specimens. Providers who reported receiving a formal update on colorectal cancer screening during the previous 24 months were more likely to screen using digital rectal exam specimens than providers who had received a formal update on colorectal cancer screening more than 24 months prior (73.9% vs 56.9%, respectively, chi2 = 4.29, P = .04). CONCLUSION: Despite recommendations cautioning against the use of digital rectal examination specimens for colorectal cancer screening, the practice is common among providers serving Northern Plains American Indian populations. Accurate up-to-date, ongoing education for patients, the community, and health care providers is needed. |
Knowledge, attitudes, and beliefs related to hypertension and hyperlipidemia self-management among African-American men living in the southeastern United States
Long E , Ponder M , Bernard S . Patient Educ Couns 2016 100 (5) 1000-1006 OBJECTIVE: Perceptions of illness affect cardiovascular disease (CVD) self-management. This study explores knowledge, attitudes, and beliefs regarding hypertension and hyperlipidemia management among 34 of African-American men with hypertension and/or hyperlipidemia, age 40-65, living in the Southeastern United States. METHODS: In-person focus groups were conducted using semi-structured interview questions informed by the Health Belief Model (HBM). RESULTS: Participants had a high level of knowledge about hypertension self-management, but less about cholesterol self-management. Perceived severity of both conditions was acknowledged, though participants perceived hypertension as more severe. Barriers to self-management included medication side effects and unhealthy dietary patterns. Facilitators included social support, positive healthcare experiences, and the value placed on family. Cultural implications highlighted the importance of food in daily life and social settings. Participants expressed how notions of masculinity affected self-management-noting the impact of feelings of vulnerability and perceived lack of control stemming from diagnosis and treatment expectations. CONCLUSIONS: The findings highlight gaps in knowledge of hyperlipidemia versus hypertension, and the impact of cultural context and perceptions on engagement in self-management behaviors. PRACTICE IMPLICATIONS: Public health practitioners and healthcare providers serving African-American men should address cultural factors and notions of masculinity which can hinder effective disease management among this population. |
Access to cancer care and general medical care services among cancer survivors in the United States: An analysis of 2011 Medical Expenditure Panel Survey data
De Moor JS , Virgo KS , Li C , Chawla N , Han X , Blanch-Hartigan D , Ekwueme DU , McNeel TS , Rodriguez JL , Yabroff KR . Public Health Rep 2016 131 (6) 783-790 Objectives: Cancer survivors require appropriate health care to manage their unique health needs. This study describes access to cancer care among cancer survivors in the United States and compares access to general medical care between cancer survivors and people who have no history of cancer. Methods: We assessed access to general medical care using the core 2011 Medical Expenditure Panel Survey (MEPS). We assessed access to cancer care using the MEPS Experiences With Cancer Survey. We used multivariable logistic regression to compare access to general medical care among 2 groups of cancer survivors (those who reported having access to all necessary cancer care [n = 1088] and those who did not [n = 70]) with self-reported access to general medical care among people who had no history of cancer (n = 22 434). Results: Of the 1158 cancer survivors, 70 (6.0%) reported that they did not receive all necessary cancer care. Adjusted analyses found that cancer survivors who reported not receiving all necessary cancer care were also less likely to report receiving general medical care (78.0%) than cancer survivors who reported having access to necessary cancer care (87.1%) and people who had no history of cancer (87.8%). Conclusions: This study provides nationally representative data on the proportion of cancer survivors who have access to necessary cancer care and yields insight into factors that impede survivors’ access to both cancer care and general medical care. This study is a reference for future work on access to care. |
CDC Grand Rounds: Chronic fatigue syndrome - advancing research and clinical education
Unger ER , Lin JS , Brimmer DJ , Lapp CW , Komaroff AL , Nath A , Laird S , Iskander J . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1434-1438 Chronic fatigue syndrome (CFS) is a complex and serious illness that is often misunderstood. Experts have noted that the terminology "chronic fatigue syndrome" can trivialize this illness and stigmatize persons who experience its symptoms. The name was coined by a group of clinicians convened by CDC in the late 1980s to develop a research case definition for the illness, which, at the time, was called chronic Epstein-Barr virus syndrome. The name CFS was suggested because of the characteristic persistent fatigue experienced by all those affected and the evidence that acute or reactivated Epstein-Barr virus infection was not associated with many cases. However, the fatigue in this illness is striking and quite distinct from the common fatigue everyone experiences. A variety of other names have been used, including myalgic encephalomyelitis (ME), ME/CFS, chronic fatigue immune dysfunction, and most recently, systemic exertion intolerance disease. The lack of agreement about nomenclature need not be an impediment for advancing critically needed research and education. The term ME/CFS will be used in this article. |
Chronic conditions and barriers to care: exploring the health of migrant and seasonal farmworkers in Indiana
Sandoval-Rosario M , Hunter TM , Durnham A , Holt A , Pontones P , Perry G . Int J Hum Rights Healthc 2016 9 (4) 229-234 Purpose: Migrant and seasonal farmworkers (MSFWs) have many health challenges due to the nature of their work, low wages, living conditions, mobility, and lack of health insurance. The purpose of this paper is to assess the availability of health services, barriers to accessing health care, and the prevalence of chronic conditions among MSFWs in Indiana. Design/methodology/approach: A site-based convenience sample of MSFWs aged 14 years and older completed a cross-sectional survey. A total of 97 participants who currently or previously identified as farmworkers completed the questionnaire. Findings: Almost one-third of the respondents reported no access to a health care provider. Of those, 43 percent reported that cost prevented them from seeking care. Of those who reported chronic conditions (n=22), over 50 percent did not have access to a health care provider. These findings highlight the need to further investigate the magnitude of the problem and begin exploring ways to improve affordable health care access among MSFWs in Northeastern Indiana. Originality/value: The results from this study highlight the need for the development and implementation of community health education programs that target MSFWs in Indiana. The findings, although not generalized, offer important insights into health care challenges and barriers to access in Indiana. The authors recommend that assistance programs should be implemented for providing affordable health care services for Hispanic MSFWs. |
Ebola virus persistence in breast milk after no reported illness: a likely source of virus transmission from mother to child.
Sissoko D , Keita M , Diallo B , Aliabadi N , Fitter DL , Dahl BA , Bore JA , Koundouno FR , Singethan K , Meisel S , Enkirch T , Mazzarelli A , Amburgey V , Faye O , Sall AA , Magassouba N , Carroll MW , Anglaret X , Malvy D , Formenty P , Aylward RB , Keita S , Djingarey MH , Loman NJ , Gunther S , Duraffour S . Clin Infect Dis 2016 64 (4) 513-516 A nine-month-old infant died from Ebola virus (EBOV) disease with unknown epidemiological link. While her parents did not report previous illness, laboratory investigations revealed persisting EBOV RNA in the mother's breast milk and the father's seminal fluid. Genomic analysis strongly suggests EBOV transmission to the child through breastfeeding. |
Subtypes and risk behaviors among incident HIV cases in the Bangkok Men Who Have Sex with Men Cohort Study, Thailand, 2006-2015.
Lam CR , Holtz TH , Leelawiwat W , Mock P , Chonwattana W , Wimonsate W , Varangrat A , Thienkrua W , Rose C , Chitwarakorn A , Curlin ME . AIDS Res Hum Retroviruses 2016 33 (10) 1004-1012 INTRODUCTION: HIV-1 incidence and prevalence remain high among men who have sex with men (MSM), and transgender women (TGW), in Thailand. To examine the link between epidemiologic factors and HIV-1 subtype transmission among Thai MSM, we compared covariates of infection with HIV CRF01-AE and other HIV strains among participants in the Bangkok MSM Cohort Study (BMCS). MATERIALS AND METHODS: The BMCS was an observational cohort study of Thai MSM and TGW with up to 60 months of follow-up at 4-monthly intervals. Participants underwent HIV/STI testing, and provided behavioral data at each visit. Infecting viral strain was characterized by gene sequencing and/or multi-region hybridization assay. We correlated behavioral/clinical variables with infecting strain using Cox proportional hazards. RESULTS: Among a total of 1372 HIV seronegative enrolled participants with 4192 person-years of follow-up, we identified 215 seroconverters between April 2006 and December 2014, with 177 infected with CRF01_AE and 38 with non-CRF01_AE subtype. Age 18-21 years (AHR 2.2, 95% CI: 1.4-3.5), age 22-29 (1.6, 1.1-2.3), living alone (AHR 1.5, 1.1-2.1), drug use (AHR 2.2, 1.4-3.5), intermittent condom use (1.7, 1.3-2.3), any receptive anal intercourse (AHR 1.7, 1.2-2.4), group sex (1.5, 1.1-2.2), anti-HSV-1 (1.5, 1.1-2.1) and T. pallidum antibody positivity (2.5, 1.4-4.4) were associated with CRF01_AE infection. Age 18-21 years (5.1, 1.6-16.5), age 22-29 (3.6, 1.3-10.4), drug use (3.1, 1.3-7.5), group sex (2.4, 1.1-5.0), and hepatitis B virus surface antigen (3.6, 1.3-10.2) were associated with non-CRF01_AE infection. DISCUSSION: We observed several significant biological and behavioral correlates of infection with CRF01_AE and other HIV strains among Thai MSM. Divergence in correlates by strain may indicate differences HIV transmission epidemiology between CRF01_AE and other strains. These differences could reflect founder effects, transmission within networks distinguished by specific risk factors, and possibly biological differences between HIV strains. |
HIV-1 Infection and Transmission Networks of Younger People in Chicago, Illinois, 2005-2011.
Morgan E , Oster AM , Townsell S , Peace D , Benbow N , Schneider JA . Public Health Rep 2017 132 (1) 48-55 OBJECTIVE: Analysis of HIV nucleotide sequences can be used to identify people with highly similar HIV strains and understand transmission patterns. The objective of this study was to identify groups of people highly connected by HIV transmission and the extent to which transmission occurred within and between geographic areas in Chicago, Illinois. METHODS: We analyzed genetic sequences in the HIV-1 pol region in samples collected from people participating in the VARHS program in Chicago during 2005-2011. We determined pairwise genetic distance, inferred potential transmission events between HIV-infected people whose sequences were ≤1.5% genetically distant, and identified clusters of connected people. We used multivariable analysis to determine demographic characteristics and risk attributes associated with degree of connectivity. RESULTS: Of 1154 sequences, 177 (15.3%) were tied to at least 1 other sequence. We determined that younger people, men, non-Hispanic black people, and men who have sex with men were more highly connected than other HIV-infected people. We also identified a high degree of geographic heterogeneity-48 of 67 clusters (71.6%) contained people from >1 Chicago region (north, south, or west sides). CONCLUSION: Our results indicate a need to address HIV transmission through the networks of younger non-Hispanic black men who have sex with men. The high level of geographic heterogeneity observed suggests that HIV prevention programs should be targeted toward networks of younger people rather than geographic areas of high incidence. This study could also guide prevention efforts in other diverse metropolitan regions with characteristics similar to those of Chicago. |
High treatment success rates among HIV-infected multidrug-resistant tuberculosis patients after expansion of antiretroviral therapy in Botswana, 2006-2013
Shin SS , Modongo C , Boyd R , Caiphus C , Kuate L , Kgwaadira B , Zetola NM . J Acquir Immune Defic Syndr 2017 74 (1) 65-71 BACKGROUND: Few studies have examined multidrug-resistant (MDR) tuberculosis (TB) treatment outcomes among HIV-infected persons after widespread expansion of antiretroviral therapy (ART). We describe MDR-TB treatment outcomes among HIV-infected and HIV-uninfected patients in Botswana after ART expansion. METHODS: We retrospectively reviewed data from patients who started MDR-TB therapy in Botswana during 2006-2013. Multivariable regression models were used to compare treatment outcomes between HIV-infected and HIV-uninfected patients. RESULTS: We included 588 MDR-TB patients in the analysis, of whom, 47 (8.0%) and 9 (1.5%) were diagnosed with pre-extensively drug-resistant (XDR)-TB and XDR-TB, respectively. Of the 408 (69.4%) HIV-infected patients, 352 (86.0%) were on ART or started ART during treatment, and median baseline CD4 T-cell count was 234 cells/mm. Treatment success rates were 79.4% and 73.0% among HIV-uninfected and HIV-infected patients, respectively (P = 0.121). HIV-infected patients with CD4 T-cell count <100 cells/mm were more likely to die during treatment compared with HIV-uninfected patients (adjusted risk ratio = 1.890; 95% CI: 1.098 to 3.254). CONCLUSIONS: High rates of treatment success were achieved with programmatic management of MDR-TB and HIV in Botswana after widespread expansion of ART. However, a 2-fold increase in mortality was observed among HIV-infected persons with baseline CD4 <100 cells/mm compared with HIV-uninfected persons. |
Infectious disease hospitalizations among American Indian/Alaska Native and non-American Indian/Alaska Native persons in Alaska, 2010-2011
Gounder PP , Holman RC , Seeman SM , Rarig AJ , McEwen M , Steiner CA , Bartholomew ML , Hennessy TW . Public Health Rep 2017 132 (1) 65-75 OBJECTIVE: Reports about infectious disease (ID) hospitalization rates among American Indian/Alaska Native (AI/AN) persons have been constrained by data limited to the tribal health care system and by comparisons with the general US population. We used a merged state database to determine ID hospitalization rates in Alaska. METHODS: We combined 2010 and 2011 hospital discharge data from the Indian Health Service and the Alaska State Inpatient Database. We used the merged data set to calculate average annual age-adjusted and age-specific ID hospitalization rates for AI/AN and non-AI/AN persons in Alaska. We stratified the ID hospitalization rates by sex, age, and ID diagnosis. RESULTS: ID diagnoses accounted for 19% (6501 of 34 160) of AI/AN hospitalizations, compared with 12% (7397 of 62 059) of non-AI/AN hospitalizations. The average annual age-adjusted hospitalization rate was >3 times higher for AI/AN persons (2697 per 100 000 population) than for non-AI/AN persons (730 per 100 000 population; rate ratio = 3.7, P < .001). Lower respiratory tract infection (LRTI), which occurred in 38% (2486 of 6501) of AI/AN persons, was the most common reason for ID hospitalization. AI/AN persons were significantly more likely than non-AI/AN persons to be hospitalized for LRTI (rate ratio = 5.2, P < .001). CONCLUSIONS: A substantial disparity in ID hospitalization rates exists between AI/AN and non-AI/AN persons, and the most common reason for ID hospitalization among AI/AN persons was LRTI. Public health programs and policies that address the risk factors for LRTI are likely to benefit AI/AN persons. |
Sulfonamide-based inhibitors of aminoglycoside acetyltransferase Eis abolish resistance to kanamycin in Mycobacterium tuberculosis
Garzan A , Willby MJ , Green KD , Gajadeera CS , Hou C , Tsodikov OV , Posey JE , Garneau-Tsodikova S . J Med Chem 2016 59 (23) 10619-10628 A two-drug combination therapy where one drug targets an offending cell and the other targets a resistance mechanism to the first drug is a time-tested, yet underexploited approach to combat or prevent drug resistance. By high-throughput screening, we identified a sulfonamide scaffold that served as a pharmacophore to generate inhibitors of Mycobacterium tuberculosis acetyltransferase Eis, whose upregulation causes resistance to the aminoglycoside (AG) antibiotic kanamycin A (KAN) in Mycobacterium tuberculosis. Rational systematic derivatization of this scaffold to maximize Eis inhibition and abolish the Eis-mediated KAN resistance of M. tuberculosis yielded several highly potent agents. A crystal structure of Eis in complex with one of the most potent inhibitors revealed that the inhibitor bound Eis in the AG-binding pocket held by a conformationally malleable region of Eis (residues 28-37) bearing key hydrophobic residues. These Eis inhibitors are promising leads for preclinical development of innovative AG combination therapies against resistant TB. |
Update: Influenza activity - United States, October 2-December 17, 2016
Shang M , Blanton L , Kniss K , Mustaquim D , Alabi N , Barnes S , Budd A , Davlin SL , Kramer N , Garg S , Cummings CN , Flannery B , Fry AM , Grohskopf LA , Olsen SJ , Bresee J , Sessions W , Garten R , Xu X , Elal AI , Gubareva L , Barnes J , Wentworth DE , Burns E , Katz J , Jernigan D , Brammer L . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1439-1444 This report summarizes U.S. influenza activity during October 2-December 17, 2016. Influenza activity in the United States remained low in October and has been slowly increasing since November. Influenza A viruses were identified most frequently, with influenza A (H3N2) viruses predominating. Most influenza viruses characterized during this period were genetically or antigenically similar to the reference viruses representing vaccine components recommended for production in the 2016-17 Northern Hemisphere influenza vaccines. |
Uptake of HIV preexposure prophylaxis among commercially insured persons - United States, 2010-2014
Wu H , Mendoza MC , Huang YA , Hayes T , Smith DK , Hoover KW . Clin Infect Dis 2016 64 (2) 144-149 BACKGROUND: Daily, oral use of tenofovir disoproxil fumarate and emtricitabine (TDF-FTC) for preexposure prophylaxis (PrEP) is an effective strategy to prevent acquisition of human immunodeficiency virus (HIV) infection. It is important to monitor PrEP uptake at the national level to increase our understanding of trends in its utilization, but national HIV surveillance data do not include PrEP uptake. Our objective was to develop feasible methods to estimate PrEP uptake and to estimate uptake each year among commercially insured persons during 2010-2014. METHODS: We conducted a retrospective analysis of the 2010-2014 MarketScan database, a national sample of persons with commercial health insurance in the United States. We developed an algorithm to identify persons aged ≥16 years who were prescribed TDF-FTC for PrEP each year. We generated nationally representative estimates of prevalence of persons prescribed PrEP. RESULTS: We found a significantly increasing trend in the proportion of persons prescribed TDF-FTC for PrEP during the study period, with 417 users in 2010 and 9375 in 2014 (P < .001); 97% of PrEP users were male and 98% lived in metropolitan areas in 2014. During the study period, the numbers of women prescribed PrEP were low. CONCLUSIONS: Our analytic method provides the only feasible means to monitor PrEP uptake in the United States. Although a marked increasing trend in uptake was observed for men, the number of women who used PrEP remained very low during the study period. Interventions are needed to increase PrEP use by women at substantial risk of acquiring HIV infection. |
Use of oral cholera vaccine and knowledge, attitudes, and practices regarding safe water, sanitation and hygiene in a long-standing refugee camp, Thailand, 2012-2014
Scobie HM , Phares CR , Wannemuehler KA , Nyangoma E , Taylor EM , Fulton A , Wongjindanon N , Aung NR , Travers P , Date K . PLoS Negl Trop Dis 2016 10 (12) e0005210 Oral cholera vaccines (OCVs) are relatively new public health interventions, and limited data exist on the potential impact of OCV use on traditional cholera prevention and control measures-safe water, sanitation and hygiene (WaSH). To assess OCV acceptability and knowledge, attitudes, and practices (KAPs) regarding cholera and WaSH, we conducted cross-sectional surveys, 1 month before (baseline) and 3 and 12 months after (first and second follow-up) a preemptive OCV campaign in Maela, a long-standing refugee camp on the Thailand-Burma border. We randomly selected households for the surveys, and administered questionnaires to female heads of households. In total, 271 (77%), 187 (81%), and 199 (85%) households were included in the baseline, first and second follow-up surveys, respectively. Anticipated OCV acceptability was 97% at baseline, and 91% and 85% of household members were reported to have received 1 and 2 OCV doses at first follow-up. Compared with baseline, statistically significant differences (95% Wald confidence interval not overlapping zero) were noted at first and second follow-up among the proportions of respondents who correctly identified two or more means of cholera prevention (62% versus 78% and 80%), reported boiling or treating drinking water (19% versus 44% and 69%), and washing hands with soap (66% versus 77% and 85%); a significant difference was also observed in the proportion of households with soap available at handwashing areas (84% versus 90% and 95%), consistent with reported behaviors. No significant difference was noted in the proportion of households testing positive for Escherichia coli in stored household drinking water at second follow-up (39% versus 49% and 34%). Overall, we observed some positive, and no negative changes in cholera- and WaSH-related KAPs after an OCV campaign in Maela refugee camp. OCV campaigns may provide opportunities to reinforce beneficial WaSH-related KAPs for comprehensive cholera prevention and control. |
Viral shedding and transmission potential of asymptomatic and pauci-symptomatic influenza virus infections in the community
Ip DK , Lau LL , Leung NH , Fang VJ , Chan KH , Chu DK , Leung GM , Peiris JS , Uyeki TM , Cowling BJ . Clin Infect Dis 2016 64 (6) 736-742 BACKGROUND: Influenza virus infections are associated with a wide spectrum of disease. However, few studies have investigated in detail the epidemiology and virology of asymptomatic and mild illness with influenza virus infections. METHODS: In a community-based study in Hong Kong from 2008 to 2014, we followed up initially healthy individuals who were household contacts of symptomatic persons with laboratory-confirmed influenza, to identify secondary infections. Information from daily symptom diaries was used to classify infections as symptomatic (with at least two signs/symptoms of: fever ≥37.8 degrees C, headache, myalgia, cough, sore throat, runny nose and sputum), pauci-symptomatic (with one symptom only), or asymptomatic (reporting none of these symptoms). We compared the patterns of influenza viral shedding between these groups. RESULTS: We identified 235 virologically-confirmed secondary cases of influenza virus infection in the household setting, including 31 (13%) pauci-symptomatic and 25 (11%) asymptomatic cases. The duration of viral RNA shedding was shorter and declined more rapidly in pauci-symptomatic and asymptomatic cases compared with symptomatic cases. The mean levels of influenza viral RNA shedding in asymptomatic and pauci-symptomatic cases were approximately 1 to 2 log10 copies lower than in symptomatic cases. CONCLUSIONS: The presence of influenza viral shedding in influenza patients with very few or no symptoms reflects their potential for transmitting the virus to close contacts. These findings suggest that further research is needed to investigate the contribution of persons with asymptomatic or clinically mild influenza virus infections to influenza virus transmission in household, institutional, and community settings. |
The where and how for reaching transgender women and men who have sex with men with HIV prevention services in Guatemala
Miller WM , Miller WC , Barrington C , Weir SS , Chen SY , Emch ME , Pettifor AE , Paz-Bailey G . AIDS Behav 2016 21 (12) 3279-3286 This study aims to describe the transgender women and men who have sex with men (MSM) missed through venue-based sampling and illustrate how data on venues can be used to prioritize service delivery. Respondent-driven sampling (RDS) and time-location sampling (TLS) were used concurrently in 2010 for behavioral surveillance among MSM and transgender women in Guatemala City. RDS recruits who did not frequent venues (n = 106) were compared to TLS recruits (n = 609). TLS participants recruited at different types of venues were compared. RDS recruits who did not frequent venues were less educated, less likely to identify as gay, more likely to have concurrent partners and female sexual partners. Participants recruited at NGOs, saunas, hotels, streets and parks had more partners, were more likely to receive money for sex or have concurrent partners. Prevention programs for MSM and transgender women should characterize social venues and people that frequent them and improve service coverage through venues and social networks. |
Meningococcal disease in patients with human immunodeficiency virus infection: A review of cases reported through active surveillance in the United States, 2000-2008
Harris CM , Wu HM , Li J , Hall HI , Lee A , Zell E , Harrison LH , Petit S , Farley MM , Lynfield R , Miller L , Nichols M , Reingold A , Schaffner W , Thomas A , MacNeil JR , Clark TA , Cohn AC . Open Forum Infect Dis 2016 3 (4) ofw226 BACKGROUND: Although human immunodeficiency virus (HIV) infection is an established risk factor for several bacterial infections, the association between HIV infection and meningococcal disease remains unclear. METHODS: Expanded chart reviews were completed on persons with meningococcal disease and HIV infection reported from 2000 through 2008 from 9 US sites participating in an active population-based surveillance system for meningococcal disease. The incidence of meningococcal disease among patients meeting Centers for Disease Control and Prevention acquired immune deficiency syndrome (AIDS) surveillance criteria was estimated using data from the National HIV Surveillance System for the participating sites. RESULTS: Thirty-three cases of meningococcal disease in individuals with HIV infection were reported from participating sites, representing 2.0% of all reported meningococcal disease cases. Most (75.8%) persons with HIV infection were adult males aged 25 to 64 years old. Among all meningococcal disease cases aged 25 to 64 years old, case fatality ratios were similar among HIV-infected and HIV-uninfected persons (13.3% vs 10.6%; P = .6). The cumulative, mean incidence of meningococcal disease among patients aged 25 to 64 years old with HIV infection ever classified as AIDS was 3.5 cases per 100000 person years (95% confidence interval [CI], 2.1-5.6), compared with 0.3 cases per 100000 person years (95% CI, 0.3-0.3) for persons of the same age group not reported to have AIDS (relative risk = 12.9; 95% CI, 7.9-20.9). CONCLUSIONS: Individuals with HIV infection meeting the AIDS surveillance case definition have a higher incidence of meningococcal disease compared with the general adult population. |
Monitoring of persons with risk for exposure to Ebola virus - United States, November 3, 2014-December 27, 2015
Kabore HJ , Desamu-Thorpe R , Jean-Charles L , Toews KA , Avchen RN . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1401-1404 During November 3, 2014-December 27, 2015, CDC implemented guidance on movement and monitoring of persons in the United States with potential exposure to Ebola virus (Ebola) (1). Monitoring was concluded in December 2015. After CDC modified the guidance for monitoring travelers from Guinea (the last country for which monitoring of travelers was recommended) in late December 2015, jurisdictional reports were no longer collected by CDC. This report documents the number of persons monitored as part of the effort to isolate, test, and, if necessary, treat symptomatic travelers and other persons in the United States who had risk for exposure to Ebola during the period the guidance was in effect. Sixty jurisdictions, including all 50 states, two local jurisdictions, and eight territories and freely associated states, reported a total of 29,789 persons monitored, with >99% completing 21-day monitoring with no loss to follow-up exceeding 48 hours. No confirmed cases of imported Ebola were reported once monitoring was initiated. This landmark public health response demonstrates the robust infrastructure and sustained monitoring capacity of local, state, and territorial health authorities in the United States as a part of a response to an international public health emergency. |
More on treatment outcomes in multidrug-resistant tuberculosis
Brust JC , Shah NS , Gandhi NR . N Engl J Med 2016 375 (26) 2610 In 2013, the WHO relaxed the definition of cure in MDR-TB treatment,1 requiring only three negative cultures following the intensive phase instead of five.2 Despite this, Günther et al. question the need for even 3 cultures to define successful treatment outcomes.3 Although sending mycobacterial cultures can be onerous and expensive, it pales in comparison to the actual costs of MDR-TB treatment (range: US$10,000–200,000 versus culture: US$1.63–62.01).4,5 The authors note that 11% of their participants who had culture-converted by 6 months later relapsed. This rate might have been higher or detected sooner, had cultures been sent more regularly, as recently demonstrated in 5410 MDR-TB patients from 10 countries.5 Late detection of treatment failure increases the risk of amplified resistance and further transmission. | We believe that increasing lab capacity—especially in high-TB prevalence countries—would be more effective in detecting drug-resistant TB cases and managing treatment response. Rapid alternatives to culture, such as Gene Xpert®, should also be evaluated, but until such studies are done, we believe that monitoring of therapy for MDR-TB should be more, not less stringent. |
MTN-017: A rectal phase 2 extended safety and acceptability study of tenofovir reduced-glycerin 1% gel
Cranston RD , Lama JR , Richardson BA , Carballo-Dieguez A , Kunjara Na Ayudhya RP , Liu K , Patterson KB , Leu CS , Galaska B , Jacobson CE , Parikh UM , Marzinke MA , Hendrix CW , Johnson S , Piper JM , Grossman C , Ho KS , Lucas J , Pickett J , Bekker LG , Chariyalertsak S , Chitwarakorn A , Gonzales P , Holtz TH , Liu AY , Mayer KH , Zorrilla C , Schwartz JL , Rooney J , McGowan I . Clin Infect Dis 2016 64 (5) 614-620 BACKGROUND: HIV disproportionately affects men who have sex with men (MSM) and transgender women (TGW). Safe and acceptable topical HIV prevention methods that target the rectum are needed. METHODS: MTN-017 was a Phase 2, three-period, randomized sequence, open-label, expanded safety and acceptability crossover study comparing rectally applied reduced-glycerin (RG) 1% tenofovir (TFV) and oral emtricitabine/TFV disoproxil fumarate (FTC/TDF). In each 8-week study period participants were randomized to RG-TFV rectal gel daily; or RG-TFV rectal gel before and after receptive anal intercourse (RAI) (or at least twice weekly in the event of no RAI); or daily oral FTC/TDF. RESULTS: MSM and TGW (n=195) were enrolled from 8 sites in the United States, Thailand, Peru, and South Africa with mean age of 31.1 years (range 18-64). There were no differences in Grade 2 or higher adverse event rates in participants using daily gel (Incidence Rate Ratio (IRR): 1.09, p=0.59) or RAI gel (IRR: 0.90, p=0.51) compared to FTC/TDF. High adherence (≥80% of prescribed doses as assessed by unused product return and SMS reports) was less likely in the daily gel regimen (Odds Ratio (OR): 0.35, p<0.001) and participants reported less likelihood of future daily gel use for HIV protection compared to FTC/TDF (OR: 0.38, p<0.001). CONCLUSIONS: Rectal application of RG TFV gel was safe in MSM and TGW. Adherence and product use likelihood were similar for the intermittent gel and daily oral FTC/TDF regimens, but lower for the daily gel regimen. |
National influenza surveillance in the Philippines from 2006 to 2012: Seasonality and circulating strains
Lucero MG , Inobaya MT , Nillos LT , Tan AG , Arguelles VL , Dureza CJ , Mercado ES , Bautista AN , Tallo VL , Barrientos AV , Rodriguez T , Olveda RM . BMC Infect Dis 2016 16 (1) 762 BACKGROUND: The results of routine influenza surveillance in 13 regions in the Philippines from 2006 to 2012 are presented, describing the annual seasonal epidemics of confirmed influenza virus infection, seasonal and alert thresholds, epidemic curve, and circulating influenza strains. METHODS: Retrospective analysis of Philippine influenza surveillance data from 2006 to 2012 was conducted to determine seasonality with the use of weekly influenza positivity rates and calculating epidemic curves and seasonal and alert thresholds using the World Health Organization (WHO) global epidemiological surveillance standards for influenza. RESULTS: Increased weekly influenza positive rates were observed from June to November, coinciding with the rainy season and school opening. Two or more peaks of influenza activity were observed with different dominant influenza types associated with each peak. A-H1N1, A-H3N2, and two types of B viruses circulated during the influenza season in varying proportions every year. Increased influenza activity for 2012 occurred 8 weeks late in week 29, rather than the expected week of rise of cases in week 21 as depicted in the established average epidemic curve and seasonal threshold. The intensity was severe going above the alert threshold but of short duration. Southern Hemisphere vaccine strains matched circulating influenza virus for more surveillance years than Northern Hemisphere vaccine strains. CONCLUSIONS: Influenza seasonality in the Philippines is from June to November. The ideal time to administer Southern Hemisphere influenza vaccine should be from April to May. With two lineages of influenza B circulating annually, quadrivalent vaccine might have more impact on influenza control than trivalent vaccine. Establishment of thresholds and average epidemic curve provide a tool for policy-makers to assess the intensity or severity of the current influenza epidemic even early in its course, to help plan more precisely resources necessary to control the outbreak. Influenza surveillance activities should be continued in the Philippines and funding for such activities should already be incorporated into the Philippine health budget. |
Notes from the Field: New Delhi metallo-beta-lactamase-producing carbapenem-resistant Enterobacteriaceae identified in patients without known health care risk factors - Colorado, 2014-2016
Janelle SJ , Kallen A , de Man T , Limbago B , Walters M , Halpin A , Xavier K , Knutsen J , Badolato E , Bamberg WM . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1414-1415 Carbapenem-resistant Enterobacteriaceae (CRE) are considered an urgent threat in the United States because they are associated with high morbidity and mortality, limited treatment options, and potential for rapid spread among patients (1). Carbapenemases, enzymes that confer resistance to the carbapenem class of antibiotics, are believed to contribute to increasing transmission and regional spread of CRE because the genes encoding these enzymes can reside on mobile plasmids and can be transferred among bacterial species. Klebsiella pneumoniae carbapenemase (KPC) is the most common carbapenemase seen in the United States, but isolates with the New Delhi metallo-β-lactamase (NDM) are emerging. Known risk factors for carbapenemase-producing CRE, including NDM, include health care exposures such as hospitalization outside the United States, recent overnight admissions to short-stay and long-term acute care hospitals, residence in long-term care facilities, surgical procedures, and having indwelling devices. Community-associated CRE lack these health care exposures and are rare in the United States (2). During 2014–2016, NDM-producing CRE were isolated from patients in Colorado without known health care risk factors. | The Colorado Department of Public Health and Environment (CDPHE) has conducted statewide laboratory-based surveillance of CRE since November 2012. CRE isolates that are resistant to two or more carbapenems are tested for the KPC and NDM genes by polymerase-chain reaction at the CDPHE laboratory. As of April 2016, Colorado had reported the second highest number of NDM-producing CRE in the United States (3). NDM was first detected in Colorado in 2012 in eight patients during a hospital outbreak (4). Ten additional patients with NDM-producing CRE were identified in Colorado during 2014–2016. Among these 10 patients, the mean age was 64 years (range = 20–85 years); isolates from nine patients were from urine, and in one patient, from bile. Five patients had traveled internationally in the 2 months before specimen collection (two of whom had known hospitalizations during international travel) (Figure). In six patients, the isolate was detected from cultures collected in outpatient settings and lacked the known CRE risk factors of overnight stays in health care settings, dialysis, or surgery in the preceding 12 months, and had no invasive devices in the preceding 2 days (i.e., the isolates were community-associated). |
Notes from the field: Outbreak of Escherichia coli O157 infections associated with goat dairy farm visits - Connecticut, 2016
Laughlin M , Gambino-Shirley K , Gacek P , Phan Q , Stevenson L , Mercante A , Mullins J , Burnworth L , Blackstock A , Razeq JH , Cartter M , Nichols M . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1453-1454 On March 24, 2016, the Connecticut Department of Public Health (DPH) identified a cluster of seven culture-confirmed Shiga toxin–producing Escherichia coli (STEC) infections in patients ranging in age from 2 to 25 years. All seven patients reported bloody diarrhea; four were evaluated in an emergency department, three were hospitalized, and two developed hemolytic uremic syndrome (HUS). Six of the seven patients reported visiting the same goat dairy farm in southeastern Connecticut during the week preceding illness onset. An investigation was initiated by DPH, the Connecticut Department of Agriculture, CDC, and the local health district to determine the magnitude of the outbreak, identify risk factors and potential sources of infection, and develop recommendations to prevent further illnesses. A total of 50 confirmed cases of E. coli infection were associated with the outbreak, including 47 with an epidemiologic link to the goat farm. | PulseNet, the national molecular subtyping laboratory network for foodborne disease surveillance, and pulsed-field gel electrophoresis (PFGE) were used to identify the outbreak strains as STEC O157. A confirmed case was defined as 1) laboratory-confirmed E. coli O157 infection with the PFGE-identified outbreak strain or 2) physician-diagnosed HUS during March–April 2016 in a person with an epidemiologic link to the goat farm. Ill farm visitors were encouraged to contact DPH through a public statement released on March 28, 2016, and were interviewed about their visit. Environmental samples were collected at the farm and cultured, and the resulting bacterial isolates were compared with patient isolates using PFGE and whole genome sequencing. Genetic relatedness of isolates was determined by high-quality single nucleotide polymorphism analysis. The 2013 Compendium of Measures to Prevent Disease Associated with Animals in Public Settings was used to evaluate practices at the farm (1). |
Performance of clinical screening algorithms for tuberculosis intensified case finding among people living with HIV in western Kenya
Modi S , Cavanaugh JS , Shiraishi RW , Alexander HL , McCarthy KD , Burmen B , Muttai H , Heilig CM , Nakashima AK , Cain KP . PLoS One 2016 11 (12) e0167685 OBJECTIVE: To assess the performance of symptom-based screening for tuberculosis (TB), alone and with chest radiography among people living with HIV (PLHIV), including pregnant women, in Western Kenya. DESIGN: Prospective cohort study. METHODS: PLHIV from 15 randomly-selected HIV clinics were screened with three clinical algorithms [World Health Organization (WHO), Ministry of Health (MOH), and "Improving Diagnosis of TB in HIV-infected persons" (ID-TB/HIV) study], underwent chest radiography (unless pregnant), and provided two or more sputum specimens for smear microscopy, liquid culture, and Xpert MTB/RIF. Performance of clinical screening was compared to laboratory results, controlling for the complex design of the survey. RESULTS: Overall, 738 (85.6%) of 862 PLHIV enrolled were included in the analysis. Estimated TB prevalence was 11.2% (95% CI, 9.9-12.7). Sensitivity of the three screening algorithms was similar [WHO, 74.1% (95% CI, 64.1-82.2); MOH, 77.5% (95% CI, 68.6-84.5); and ID-TB/HIV, 72.5% (95% CI, 60.9-81.7)]. Sensitivity of the WHO algorithm was significantly lower among HIV-infected pregnant women [28.2% (95% CI, 14.9-46.7)] compared to non-pregnant women [78.3% (95% CI, 67.3-86.4)] and men [77.2% (95% CI, 68.3-84.2)]. Chest radiography increased WHO algorithm sensitivity and negative predictive value to 90.9% (95% CI, 86.4-93.9) and 96.1% (95% CI, 94.4-97.3), respectively, among asymptomatic men and non-pregnant women. CONCLUSIONS: Clinical screening missed approximately 25% of laboratory-confirmed TB cases among all PLHIV and more than 70% among HIV-infected pregnant women. National HIV programs should evaluate the feasibility of laboratory-based screening for TB, such as a single Xpert MTB/RIF test for all PLHIV, especially pregnant women, at enrollment in HIV services. |
Preliminary population size estimation of men who have sex with men in Kazakhstan: Implications for HIV testing and surveillance
Wu E , Terlikbayeva A , Hunt T , Primbetova S , Lee YG , Berry M . LGBT Health 2016 4 (2) 164-167 PURPOSE: The purpose of this study is to estimate the population size of men who have sex with men (MSM) in Kazakhstan and their HIV testing history. METHODS: We conducted structured interviews with MSM in four geographically disparate cities-N = 400 (n = 100/city)-to implement four population estimation methods and ascertain HIV testing history. RESULTS: Approximately 3.2% of men-corresponding to approximately 154,000 individuals-in Kazakhstan aged 18-59 are MSM. The 49.9% of the sample who reported taking an HIV test far exceeds the <1% reported as MSM in surveillance data. CONCLUSION: HIV testing surveillance in Kazakhstan has underestimated the number of MSM. This underscores the need to redress social and structural barriers to HIV testing and disclosure of sexual behavior experienced by MSM in Kazakhstan. Recommendations include promoting cultural sensitivity among testing staff through quality assurance and regular training, and increasing protection and public awareness through antidiscrimination policy development. |
Field evaluation of dried blood spots for HIV-1 viral load monitoring in adults and children receiving antiretroviral treatment in Kenya: Implications for scale-up in resource-limited settings
Schmitz ME , Agolory S , Junghae M , Broyles LN , Kimeu M , Ombayo J , Umuro M , Mukui I , Alwenya K , Baraza M , Ndiege K , Mwalili S , Rivadeneira E , Ng'ang'a L , Yang C , Zeh C . J Acquir Immune Defic Syndr 2016 74 (4) 399-406 BACKGROUND: WHO recommends viral load (VL) as the preferred method for diagnosing antiretroviral therapy (ART) failure; however, operational challenges have hampered the implementation of VL monitoring in most resource-limited settings. This study evaluated the accuracy of dried blood spot (DBS) VL testing under field conditions as a practical alternative to plasma in determining virologic failure (VF). METHODS: From May to December 2013, paired plasma and DBS specimens were collected from 416 adults and 377 children on ART ≥6 months at 12 clinics in Kenya. DBS were prepared from venous blood (V-DBS) using disposable transfer pipettes, and from finger-prick capillary blood using microcapillary tube (M-DBS) and directly spotting (D-DBS). All samples were tested on Abbott m2000 platform; V-DBS was also tested on Roche-CAP/CTM Version 2.0 platform. VF results were compared at three DBS thresholds (≥1000, ≥3000 and ≥5000 copies/ml) and a constant plasma threshold of ≥1000 copies/ml. RESULTS: On Abbott platform, at ≥1000 copies/ml threshold, sensitivities, specificities, and Kappa values for VF determination were ≥88.1%, ≥93.1% and ≥0.82 respectively for all DBS methods and it had the lowest percentage of downward misclassification compared to higher thresholds. V-DBS performance on CAP/CTM had significantly poorer specificity at all thresholds (1000-33.0%, 3000-60.9%, 5000-77.0%). No significant differences were found between adults and children. CONCLUSION: VL results from V-DBS, M-DBS and D-DBS were comparable to plasma for determining VF using the Abbott platform but not with CAP/CTM. A 1000 copies/ml threshold was optimal and should be considered for VF determination using DBS in adults and children. |
First occurrence of diabetes, chronic kidney disease, and hypertension among North American HIV-infected adults, 2000-2013
Wong C , Gange SJ , Buchacz K , Moore RD , Justice AC , Horberg MA , Gill MJ , Koethe JR , Rebeiro PF , Silverberg MJ , Palella FJ , Patel P , Kitahata MM , Crane HM , Abraham AG , Samji H , Napravnik S , Ahmed T , Thorne JE , Bosch RJ , Mayor AM , Althoff KN . Clin Infect Dis 2016 64 (4) 459-467 BACKGROUND: There remains concern regarding the occurrence of non-communicable diseases (NCDs) among individuals aging with HIV but few studies have described whether disparities between demographic subgroups are present among individuals on antiretroviral therapy (ART) with access to care. METHODS: We assessed the first documented occurrence of type 2 diabetes mellitus (DM), chronic kidney disease (CKD), and treated hypertension (HTN) by age, sex, and race within the North American AIDS Cohort Collaboration on Research and Design. HIV-infected adults (≥18 years) who initiated ART were observed for first NCD occurrence between 1 January 2000 - 31 December 2013. Cumulative incidences as of age 70 were estimated accounting for the competing risk of death; Poisson regression was used to compare rates of NCD occurrence by demographic subgroup. RESULTS: We included >50,000 persons with >250,000 person-years (PY) of follow-up. Median follow-up was 4.7 years (interquartile range (IQR): 2.4-8.1). Rates of first occurrence (per 100 PY) were: 1.2 for DM, 0.6 for CKD, and 2.6 for HTN. Relative to non-black women, the cumulative incidences were increased in black women (68% vs. 51% for HTN, 52% vs. 41% for DM, and 38% vs. 35% for CKD; all p<0.001); this disparity was also found among men (73% vs. 60% for HTN, 44% vs. 34% for DM, and 30% vs. 25% for CKD; all p<0.001). CONCLUSIONS: Racial disparities in the occurrence of DM, CKD, and HTN emphasize the need for prevention and treatment options for these HIV populations receiving care in North America. |
Heterogeneous shedding of influenza by human subjects and its implications for epidemiology and control
Canini L , Woolhouse ME , Maines TR , Carrat F . Sci Rep 2016 6 38749 Heterogeneity of infectiousness is an important feature of the spread of many infections, with implications for disease dynamics and control, but its relevance to human influenza virus is still unclear. For a transmission event to occur, an infected individual needs to release infectious particles via respiratory symptoms. Key factors to take into account are virus dynamics, particle release in relation to respiratory symptoms, the amount of virus shed and, importantly, how these vary between infected individuals. A quantitative understanding of the process of influenza transmission is relevant to designing effective mitigation measures. Here we develop an influenza infection dynamics model fitted to virological, systemic and respiratory symptoms to investigate how within-host dynamics relates to infectiousness. We show that influenza virus shedding is highly heterogeneous between subjects. From analysis of data on experimental infections, we find that a small proportion (<20%) of influenza infected individuals are responsible for the production of 95% of infectious particles. Our work supports targeting mitigation measures at most infectious subjects to efficiently reduce transmission. The effectiveness of public health interventions targeted at highly infectious individuals would depend on accurate identification of these subjects and on how quickly control measures can be applied. |
Incidence of medically attended influenza among residents of Shai-Osudoku and Ningo-Prampram Districts, Ghana, May 2013 - April 2015
Ntiri MP , Duque J , McMorrow ML , Frimpong JA , Parbie P , Badji E , Nzussouo NT , Benson EM , Adjabeng M , Dueger E , Widdowson MA , Dawood FS , Koram K , Ampofo W . BMC Infect Dis 2016 16 (1) 757 BACKGROUND: Influenza vaccination is recommended by the World Health Organization for high risk groups, yet few data exist on influenza disease burden in West Africa. METHODS: We estimated medically attended influenza-associated illness rates among residents of Shai-Osudoku and Ningo Pram-Pram Districts (SONPD), Ghana. From May 2013 to April 2015, we conducted prospective surveillance for severe acute respiratory illness (SARI) and influenza-like illness (ILI) in 17 health facilities. In 2015, we conducted a retrospective assessment at an additional 18 health facilities to capture all SONPD SARI and ILI patients during the study period. We applied positivity rates to those not tested to estimate total influenza cases. RESULTS: Of 612 SARI patients tested, 58 (9%) were positive for influenza. The estimated incidence of influenza-associated SARI was 30 per 100,000 persons (95% CI: 13-84). Children aged 0 to 4 years had the highest influenza-associated SARI incidence (135 per 100,000 persons, 95% CI: 120-152) and adults aged 25 to 44 years had the lowest (3 per 100,000 persons, 95% CI: 1-7) (p < 0.01). Of 2,322 ILI patients tested, 407 (18%) were positive for influenza. The estimated incidence of influenza-associated ILI was 844 per 100,000 persons (95% CI: 501-1,099). The highest incidence of influenza-associated ILI was also among children aged 0 to 4 years (3,448 per 100,000 persons, 95% CI: 3,727 - 3,898). The predominant circulating subtype during May to December 2013 and January to April 2015 was influenza A(H3N2) virus, and during 2014 influenza B virus was the predominant circulating type. CONCLUSIONS: Influenza accounted for 9% and 18% of medically attended SARI and ILI, respectively. Rates were substantive among young children and suggest the potential value of exploring the benefits of influenza vaccination in Ghana, particularly in this age group. |
Increased antiviral treatment among hospitalized children and adults with laboratory-confirmed influenza, 2010-2015
Appiah GD , Chaves SS , Kirley PD , Miller L , Meek J , Anderson E , Oni O , Ryan P , Eckel S , Lynfield R , Bargsten M , Zansky SM , Bennett N , Lung K , McDonald-Hamm C , Thomas A , Brady D , Lindegren ML , Schaffner W , Hill M , Garg S , Fry AM , Campbell AP . Clin Infect Dis 2016 64 (3) 364-367 Using population-based surveillance data, we analyzed antiviral treatment among hospitalized patients with laboratory-confirmed influenza. Treatment increased after the influenza A(H1N1) 2009 pandemic from 72% in 2010-2011 to 89% in 2014-2015 (P < .001). Overall, treatment was higher in adults (86%) than in children (72%); only 56% of cases received antivirals on the day of admission. |
Increased STD testing among sexually active persons receiving medical care for HIV infection in the United States, 2009 - 2013
Mattson CL , Bradley H , Beer L , Johnson C , Pearson WS , Shouse RL . Clin Infect Dis 2016 64 (5) 629-634 BACKGROUND: Current guidelines recommend that all sexually active HIV-infected persons be tested at least annually for syphilis, chlamydia, and gonorrhea. We examined temporal trends in syphilis, chlamydia, and gonorrhea testing among sexually active HIV-infected adults receiving medical care in the United States during 2009-2013. METHODS: Using medical record data from the Medical Monitoring Project, a population-based HIV surveillance system, we assessed the proportion of adults in HIV medical care who were tested for syphilis, chlamydia, and gonorrhea in the past 12 months by year and stratified by sex and sexual behavior, age, and race/ethnicity. RESULTS: During 2009-2013, the proportion of sexually active HIV-infected adults in medical care who were tested in the past year for all three examined STDs increased from 20% to 36% (PTREND < 0.01). Overall testing for syphilis increased from 55% to 65% (PTREND < 0.01), and significant increases were noted for the following subgroups: MSM (58% to 69%), non-Hispanic whites (48% to 64%), and all age groups with the exception of 18-29 year olds. Overall testing for chlamydia and gonorrhea increased from 22% to 42% (PTREND < 0.01) and significant increases were noted for most sub-groups. CONCLUSIONS: STD testing significantly increased among sexually active HIV-infected adults receiving medical care; however, the majority of persons were not tested for all three STDs in 2013. While increased testing indicates progress, testing remained far below recommended guidelines. Our findings suggest enhanced efforts may be warranted to screen all sexually active HIV-infected adults for syphilis, chlamydia, and gonorrhea. |
Barriers to universal prescribing of antiretroviral therapy by HIV care providers in the United States, 2013-2014
Weiser J , Brooks JT , Skarbinski J , West BT , Duke CC , Gremel GW , Beer L . J Acquir Immune Defic Syndr 2016 74 (5) 479-487 INTRODUCTION: HIV treatment guidelines recommend initiating ART regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed antiretroviral therapy (ART). We examined reasons for this gap in the care continuum. METHODS: During 2013-2014, we surveyed a probability sample of HIV care providers, of whom 1,234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason. RESULTS: Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤ 20 vs. >200 patients (adjusted prevalence ratios [aPR] 0.69, 95% confidence interval [CI] 0.47-1.02, P=.03), practiced at non-Ryan White HIV/AIDS Program (RWHAP)-funded facilities (aPR 0.85, 95% CI 0.74-0.98, P=.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI 0.65-0.98, P=.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1-10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases; 31.1% reported adherence concerns due to mental health disorders or substance abuse and 21.4% reported adherence concerns due to social problems, e.g., homelessness, as factors in >50% of cases when deferring ART. CONCLUSIONS: An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications or barriers to treatment. Low-volume providers and those at non-RWHAP-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns. |
CDC-funded HIV testing, HIV positivity, and linkage to HIV medical care in non-health care settings among young men who have sex with men (YMSM) in the United States
Seth P , Walker T , Figueroa A . AIDS Care 2016 29 (7) 1-5 In the United States, HIV infection disproportionately affects young gay, bisexual, and other men who have sex with men, aged 13-24 years (collectively referred to as YMSM), specifically black YMSM. Knowledge of HIV status is the first step for timely and essential prevention and treatment services. Because YMSM are disproportionately affected by HIV, the number of CDC-funded HIV testing events, overall and newly diagnosed HIV positivity, and linkage to HIV medical care among YMSM in non-health care settings were examined from 61 health department jurisdictions. Differences by age and race/ethnicity were analyzed. Additionally, trends in number of HIV testing events and newly diagnosed HIV positivity were examined from 2011 to 2015. In 2015, 42,184 testing events were conducted among YMSM in non-health care settings; this represents only 6% of tests in non-health care settings. Overall and newly diagnosed HIV positivity was 2.8% and 2.1%, respectively, with black/African-American YMSM being disproportionately affected (5.6% for overall; 4% for newly diagnosed); 71% of YMSM were linked within 90 days. The newly diagnosed HIV positivity among YMSM decreased from 2.8% in 2011 to 2.4% in 2015, and the number of newly diagnosed YMSM also decreased. Further targeted testing efforts among YMSM are needed to identify undiagnosed YMSM, specifically black YMSM. |
Comprehensive HIV prevention for transgender persons
Neumann MS , Finlayson TJ , Pitts NL , Keatley J . Am J Public Health 2016 107 (2) e1-e6 Transgender persons are at high risk for HIV infection, but prevention efforts specifically targeting these people have been minimal. Part of the challenge of HIV prevention for transgender populations is that numerous individual, interpersonal, social, and structural factors contribute to their risk. By combining HIV prevention services with complementary medical, legal, and psychosocial services, transgender persons' HIV risk behaviors, risk determinants, and overall health can be affected simultaneously. For maximum health impact, comprehensive HIV prevention for transgender persons warrants efforts targeted to various impact levels-socioeconomic factors, decision-making contexts, long-lasting protections, clinical interventions, and counseling and education. We present current HIV prevention efforts that reach transgender persons and present others for future consideration. |
Developing a motion comic for HIV/STD prevention for young people ages 15-24, part 1: Listening to your target audience
Willis LA , Kachur R , Castellanos TJ , Spikes P , Gaul ZJ , Gamayo AC , Durham M , Jones S , Nichols K , Han Barthelemy S , LaPlace L , Staatz C , Hogben M , Robinson S , Brooks JT , Sutton MY . Health Commun 2016 33 (2) 1-10 Young people (15-24 years) in the United States are disproportionately affected by infection with human immunodeficiency virus (HIV) and sexually transmitted diseases (STD). Shortfalls in HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI) likely contribute to this discrepancy. In this report we describe our experience developing a novel means of health communication combining entertainment-education theory and recent technological advances to create a HIV/STD-focused "motion comic." We also report the audience satisfaction and acceptance of the intervention. We used the Health Belief Model (HBM), entertainment-education (EE) principles, and the Sabido Method (SM) and conducted three rounds of focus groups to develop a 38-minute HIV/STD focused motion comic for young people between the ages 15 and 24 years. Participants indicated that motion comics were an acceptable method of delivering HIV/STD prevention messages. They also expressed satisfaction with motion comics plot, story settings, the tone of humor, and drama. Our results suggest that motion comics are a viable new method of delivering health communication messages about HIV/STD and other public health issues, and warrant further development and broader evaluation. |
Developing a motion comic for HIV/STD prevention for young people ages 15-24, part 2: Evaluation of a pilot intervention
Willis LA , Kachur R , Castellanos TJ , Nichols K , Mendoza MC , Gaul ZJ , Spikes P , Gamayo AC , Durham MD , LaPlace L , Straw J , Staatz C , Buge H , Hogben M , Robinson S , Brooks J , Sutton MY . Health Commun 2016 33 (3) 1-9 In the United States, young people (ages 15-24 years) are disproportionately affected by human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), due at least in part to inadequate or incorrect HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI). Comic book narratives are a proven method of HIV/STD prevention communication to strengthen KABI for HIV/STD prevention. Motion comics, a new type of comic media, are an engaging and low-cost means of narrative storytelling. The objective of this study was to quantitatively evaluate the effectiveness of a pilot six-episode HIV/STD-focused motion comic series to improve HIV/STD-related KABI among young people. We assessed change in HIV/STD knowledge, HIV stigma, condom attitudes, HIV/STD testing attitudes, and behavioral intentions among 138 participants in 15 focus groups immediately before and after viewing the motion comic series. We used paired t-tests and indicators of overall improvement to assess differences between surveys. We found a significant decrease in HIV stigma (p < .001) and increases in both HIV knowledge (p = .002) and behavioral intentions to engage in safe sex (p < .001). In summary, this motion comic intervention improved HIV/STD-related KABI of young adult viewers by reducing HIV stigma and increasing behavioral intentions to engage in safer sex. Our results demonstrate the promise of this novel intervention and support its use to deliver health messages to young people. |
Discovery and optimization of two Eis inhibitor families as kanamycin adjuvants against drug-resistant M. tuberculosis
Garzan A , Willby MJ , Green KD , Tsodikov OV , Posey JE , Garneau-Tsodikova S . ACS Med Chem Lett 2016 7 (12) 1219-1221 Drug-resistant tuberculosis (TB) is a global threat and innovative approaches such as using adjuvants of anti-TB therapeutics are required to combat it. High-throughput screening yielded two lead scaffolds of inhibitors of Mycobacterium tuberculosis (Mtb) acetyltransferase Eis, whose upregulation causes resistance to the anti-TB drug kanamycin (KAN). Chemical optimization on these scaffolds resulted in potent Eis inhibitors. One compound restored the activity of KAN in a KAN-resistant Mtb strain. Model structures of Eis-inhibitor complexes explain the structure-activity relationship. |
Disparities in tuberculosis treatment completion by incarceration status, U.S., 1999-2011
Mitruka K , Volkmann T , Pratt RH , Kammerer JS . Am J Prev Med 2016 52 (4) 483-490 INTRODUCTION: Treatment completion is the cornerstone of tuberculosis (TB) control strategy globally. Although the majority of reported TB cases in the U.S. have documented treatment completion, individuals diagnosed while incarcerated are less likely to have documentation of whether or not they completed treatment. This study assessed trends and correlates of no documented treatment completion among individuals incarcerated at diagnosis. METHODS: U.S. National TB Surveillance System (1999-2011) data on cases eligible for treatment completion were analyzed during 2014-2015. Treatment outcomes and trends in no documented completion were assessed by incarceration status. Multivariable logistic regression identified correlates of no documented completion among people incarcerated at diagnosis. RESULTS: A lower proportion of individuals incarcerated at diagnosis had documented TB treatment completion than non-incarcerated individuals (75.6% vs 93.7%), and a higher proportion were lost to follow-up (10.7% vs 2.2%) or moved (9.4% vs 2.3%) during treatment (p<0.001). The 1999-2011 trend in no documented completion significantly increased among those incarcerated at diagnosis and declined among non-incarcerated individuals. Being foreign born was the strongest correlate of no documented completion among people incarcerated at diagnosis (AOR=2.86, 95% CI= 2.35, 3.49). Social risk factors for TB (e.g., homelessness, substance abuse), although common among incarcerated individuals, did not emerge as correlates of no documented completion. CONCLUSIONS: People diagnosed with TB disease at U.S. correctional facilities, especially the foreign born, require enhanced strategies for documenting TB treatment completion. Strengthened collaboration between correctional and public health agencies could improve continuity of care among released inmates. |
Stable transmission of Borrelia burgdorferi sensu stricto on the Outer Banks of North Carolina
Levine JF , Apperson CS , Levin M , Kelly TR , Kakumanu ML , Ponnusamy L , Sutton H , Salger SA , Caldwell JM , Szempruch AJ . Zoonoses Public Health 2016 64 (5) 337-354 The spirochaete (Borrelia burgdorferi) associated with Lyme disease was detected in questing ticks and rodents during a period of 18 years, 1991-2009, at five locations on the Outer Banks of North Carolina. The black-legged tick (Ixodes scapularis) was collected at varied intervals between 1991 and 2009 and examined for B. burgdorferi. The white-footed mouse (Peromyscus leucopus), house mouse (Mus musculus) marsh rice rat (Oryzomys palustris), marsh rabbit (Sylvilagus palustris), eastern cottontail (Sylvilagus floridanus) and six-lined racerunner (Cnemidophorus sexlineatus) were live-trapped, and their tissues cultured to isolate spirochaetes. Borrelia burgdorferi isolates were obtained from questing adult I. scapularis and engorged I. scapularis removed from P. leucopus, O. palustris and S. floridanus. The prevalence of B. burgdorferi infection was variable at different times and sites ranging from 7 to 14% of examined questing I. scapularis. Mitochondrial (16S) rRNA gene phylogenetic analysis from 65 adult I. scapularis identified 12 haplotypes in two major clades. Nine haplotypes were associated with northern/Midwestern I. scapularis populations and three with southern I. scapularis populations. Sixteen isolates obtained from tick hosts in 2005 were confirmed to be B. burgdorferi by amplifying and sequencing of 16S rRNA and 5S-23S intergenic spacer fragments. The sequences had 98-99% identity to B. burgdorferi sensu stricto strains B31, JD1 and M11p. Taken together, these studies indicate that B. burgdorferi sensu stricto is endemic in questing I. scapularis and mammalian tick hosts on the Outer Banks of North Carolina. |
Prevalence and diversity of tick-borne pathogens in nymphal Ixodes scapularis (Acari: Ixodidae) in eastern National Parks
Johnson TL , Graham CB , Boegler KA , Cherry CC , Maes SE , Pilgard MA , Hojgaard A , Buttke DE , Eisen RJ . J Med Entomol 2016 54 (3) 742-751 Tick-borne pathogens transmitted by Ixodes scapularis Say (Acari: Ixodidae), also known as the deer tick or blacklegged tick, are increasing in incidence and geographic distribution in the United States. We examined the risk of tick-borne disease exposure in 9 national parks across six Northeastern and Mid-Atlantic States and the District of Columbia in 2014 and 2015. To assess the recreational risk to park visitors, we sampled for ticks along frequently used trails and calculated the density of I. scapularis nymphs (DON) and the density of infected nymphs (DIN). We determined the nymphal infection prevalence of I. scapularis with a suite of tick-borne pathogens including Borrelia burgdorferi, Borrelia miyamotoi, Anaplasma phagocytophilum, and Babesia microti Ixodes scapularis nymphs were found in all national park units; DON ranged from 0.40 to 13.73 nymphs per 100 m2 Borrelia burgdorferi, the causative agent of Lyme disease, was found at all sites where I. scapularis was documented; DIN with B. burgdorferi ranged from 0.06 to 5.71 nymphs per 100 m2 Borrelia miyamotoi and A. phagocytophilum were documented at 60% and 70% of the parks, respectively, while Ba. microti occurred at just 20% of the parks. Ixodes scapularis is well established across much of the Northeastern and Mid-Atlantic States, and our results are generally consistent with previous studies conducted near the areas we sampled. Newly established I. scapularis populations were documented in two locations: Washington, D.C. (Rock Creek Park) and Greene County, Virginia (Shenandoah National Park). This research demonstrates the potential risk of tick-borne pathogen exposure in national parks and can be used to educate park visitors about the importance of preventative actions to minimize tick exposure. |
An epidemiological study of avian influenza A (H5) virus in nomadic ducks and their raising practices in northeastern Bangladesh, 2011-2012
Sarkar S , Khan SU , Mikolon A , Rahman MZ , Abedin J , Zeidner N , Sturm-Ramirez K , Luby SP . Influenza Other Respir Viruses 2016 11 (3) 275-282 BACKGROUND: In Bangladesh nomadic duck flocks are groups of domestic ducks reared for egg production that are moved to access feeding sites beyond their owners' village boundaries and are housed overnight in portable enclosures in scavenging areas. The objectives of this study were to measure the prevalence of influenza A virus RNA and H5-specific antibodies in nomadic ducks and to characterize nomadic duck raising practices in northeastern Bangladesh. METHODS: We tested duck egg yolk specimens by competitive ELISA to detect antibodies against avian influenza A (H5) and environmental fecal samples by real time reverse transcription polymerase chain reaction (rRT-PCR) to detect influenza A virus RNA and H5 subtype. RESULTS: The median age of the ducks was 24 months (range: 8-36 months) and the median flock size was 300 ducks (range: 105-1,100). Of 1,860 egg yolk samples, 556 (30%, 95% confidence interval (CI): 28-32) were positive for antibodies against H5 and 58 flocks (94%) had at least one egg with H5 specific antibodies. Of 496 fecal samples, 121 (24%, 95% CI: 22-29) had detectable influenza A RNA. Thirty-three flocks (53%) had at least one fecal sample positive for influenza A RNA. CONCLUSIONS: Nomadic ducks in Bangladesh are commonly infected with avian influenza A (H5) virus and may serve as a bridging host for transmission of avian influenza A (H5) virus or other avian influenza A viruses subtypes between wild waterfowl, backyard poultry, and humans in Bangladesh. |
Evaluation of doxycycline-laden oral bait and topical fipronil delivered in a single bait box to control Ixodes scapularis (Acari: Ixodidae) and reduce Borrelia burgdorferi and Anaplasma phagocytophilum infection in small mammal reservoirs and host-seeking ticks
Dolan MC , Schulze TL , Jordan RA , Schulze CJ , Ullmann AJ , Hojgaard A , Williams MA , Piesman J . J Med Entomol 2016 54 (2) 403-410 A field trial was conducted on residential properties in a Lyme disease endemic area of New Jersey to determine the efficacy of Maxforce Tick Management System (TMS) bait boxes modified with doxycycline hyclate-laden bait to reduce the acarological risk of Lyme disease and the utility of galvanized steel shrouds to protect the bait boxes from squirrel depredation and ability to routinely service these devices. The strategy began with a 9-wk deployment against larvae followed by a 17-wk deployment against nymphs and larvae the second year. Passive application of fipronil reduced nymphal and larval tick burdens on small mammals by 76 and 77%, respectively, and nymphal tick abundance by 81% on treated properties. In addition, the percentage of infected small mammals recovered from intervention areas following treatment was reduced by 96% for Borrelia burgdorferi and 93% for Anaplasma phagocytophilum Infection prevalence in host-seeking nymphal ticks for both B. burgdorferi and A. phagocytophilum were reduced by 93 and 61%, respectively. Results indicate that Maxforce TMS bait boxes fitted with doxycycline-impregnated bait is an effective means of reducing ticks and infection prevalence for B. burgdorferi and A. phagocytophilum in both rodent reservoirs and questing Ixodes scapularis Say ticks. The protective shroud allows the device to be routinely serviced and protect against squirrel depredation. |
Evaluation of Gulf Coast ticks (Acari: Ixodidae) for Ehrlichia and Anaplasma species
Allerdice ME , Hecht JA , Karpathy SE , Paddock CD . J Med Entomol 2016 54 (2) 481-484 Amblyomma maculatum Koch (the Gulf Coast tick) is an aggressive, human-biting ixodid tick distributed throughout much of the southeastern United States and is the primary vector for Rickettsia parkeri, an emerging human pathogen. Amblyomma maculatum has diverse host preferences that include white-tailed deer, a known reservoir for Ehrlichia and Anaplasma species, including the human pathogens E. ewingii and E. chaffeensis To examine more closely the potential role of A. maculatum in the maintenance of various pathogenic Ehrlichia and Anaplasma species, we screened DNA samples from 493 questing adult A. maculatum collected from six U.S. states using broad-range Anaplasmataceae and Ehrlichia genus-specific PCR assays. Of the samples tested, four (0.8%) were positive for DNA of Ehrlichia ewingii, one (0.2%) was positive for Anaplasma platys, and one (0.2%) was positive for a previously unreported Ehrlichia species closely related to Ehrlichia muris and an uncultivated Ehrlichia species from Haemaphysalis longicornis ticks in Japan. No ticks contained DNA of Ehrlichia chaffeensis, Ehrlichia canis, the Panola Mountain Ehrlichia, or Anaplasma phagocytophilum This is the first identification of E. ewingii, A. platys, and the novel Ehrlichia in questing Gulf Coast ticks; nonetheless the low prevalence of these agents suggests that A. maculatum is not likely an important vector of these zoonotic pathogens. |
Impact of autocidal gravid ovitraps on Chikungunya virus incidence in Aedes aegypti (Diptera: Culicidae) in Areas with and without traps
Barrera R , Acevedo V , Felix GE , Hemme RR , Vazquez J , Munoz JL , Amador M . J Med Entomol 2016 54 (2) 387-395 Puerto Rico detected the first confirmed case of chikungunya virus (CHIKV) in May 2014 and the virus rapidly spread throughout the island. The invasion of CHIKV allowed us to observe Aedes aegypti (L.) densities, infection rates, and impact of vector control in urban areas using CDC autocidal gravid ovitraps (AGO traps) for mosquito control over several years. Because local mosquitoes can only get the virus from infectious residents, detecting the presence of virus in mosquitoes functions as a proxy for the presence of virus in people. We monitored the incidence of CHIKV in gravid females of Ae. aegypti in four neighborhoods-two with three AGO traps per home in most homes and two nearby neighborhoods without AGO mosquito control traps. Monitoring of mosquito density took place weekly using sentinel AGO traps from June to December 2014. In all, 1,334 pools of female Ae. aegypti (23,329 individuals) were processed by real-time reverse transcription PCR to identify CHIKV and DENV RNA. Density of Ae. aegypti females was 10.5 times lower (91%) in the two areas with AGO control traps during the study. Ten times (90.9%) more CHIKV-positive pools were identified in the nonintervention areas (50/55 pools) than in intervention areas (5/55). We found a significant linear relationship between the number of positive pools and both density of Ae. aegypti and vector index (average number of expected infected mosquitoes per trap per week). Temporal and spatial patterns of positive CHIKV pools suggested limited virus circulation in areas with AGO traps. |
Insecticidal activity of thymoquinone and related compounds against Culex quinquefasciatus (Diptera: Culicidae)
Scott ML , Adams MF , Karchesy JJ , McAllister JC . J Med Entomol 2016 54 (3) 785-787 Insecticides based on botanical sources have taken on increased attention due to differing modes of action from current insecticides in use and the view that they may be environmentally friendly. Thymoquinone, a component in the essential oil of incense cedar heartwood, has been shown to have insecticidal action against adult mosquitoes. This study evaluated relative toxicities of thymoquinone, selected derivatives of thymoquinone, hydroquinone, and arbutin to determine if any had similar or better activity. The intrinsic toxicities of hydroquinone and thymohydroquinone were not significantly different from thymoquinone, while libocedrol and arbutin were significantly less toxic. |
Isolation and characterization of a novel Rickettsia species (Rickettsia asembonensis sp. nov.) obtained from cat fleas (Ctenocephalides felis)
Maina AN , Luce-Fedrow A , Omulo S , Hang J , Chan TC , Ade F , Jima DD , Ogola E , Ge H , Breiman RF , Njenga MK , Richards AL . Int J Syst Evol Microbiol 2016 66 (11) 4512-4517 A novel rickettsial agent, 'Candidatus Rickettsia asembonensis' strain NMRCiiT, was isolated from cat fleas, Ctenocephalides felis, from Kenya. Genotypic characterization of the new isolate based on sequence analysis of five rickettsial genes, rrs, gltA, ompA, ompB and sca4, indicated that this isolate clustered with Rickettsia felis URRWXCal2. The degree of nucleotide similarity demonstrated that isolate NMRCiiT belongs within the genus Rickettsia and fulfils the criteria for classification as a representative of a novel species. The name Rickettsia asembonensis sp. nov. is proposed, with NMRCiiT (=DSM 100172T=CDC CRIRC RAS001T=ATCC VR-1827T) as the type strain. |
Integrating health into buildings of the future
Heidari L , Younger M , Chandler G , Gooch J , Schramm P . J Sol Energy Eng 2017 139 (1) 010802 The health and wellbeing of building occupants should be a key priority in the design, building, and operation of new and existing buildings. Buildings can be designed, renovated, and constructed to promote healthy environments and behaviors and mitigate adverse health outcomes. This paper highlights health in terms of the relationship between occupants and buildings, as well as the relationship of buildings to the community. In the context of larger systems, smart buildings and green infrastructure strategies serve to support public health goals. At the level of the individual building, interventions that promote health can also enhance indoor environmental quality (IEQ) and provide opportunities for physical activity. Navigating the various programs that use metrics to measure a building's health impacts reveals that there are multiple co-benefits of a "healthy building," including those related to the economy, environment, society, transportation, planning, and energy efficiency. |
Urinary concentrations of the antibacterial agent triclocarban in United States residents: 2013-2014 National Health and Nutrition Examination Survey
Ye X , Wong LY , Dwivedi P , Zhou X , Jia T , Calafat AM . Environ Sci Technol 2016 50 (24) 13548-13554 Triclocarban is widely used as an antibacterial agent in personal care products, and the potential for human exposure exists. We present here the first nationally representative assessment of exposure to triclocarban among Americans ≥6 years of age who participated in the 2013-2014 National Health and Nutrition Examination Survey. We detected triclocarban at concentrations above 0.1 mug/L in 36.9% of 2686 urine samples examined. Triclocarban was detected more frequently in adolescents and adults than in children, and in non-Hispanic black compared to other ethnic groups. In univariate analysis, log-creatinine, sex, age, race, and body surface area (BSA) were significantly associated with the likelihood of having triclocarban concentrations above the 95th percentile. In multiple regression models, persons with BSA at or above the median (≥1.86 m2) were 2.43 times more likely than others, and non-Hispanic black and non-Hispanic white were 3.71 times and 2.23 times more likely than "all Hispanic," respectively, to have urinary concentrations above the 95th percentile. We found no correlations between urinary concentrations of triclocarban and triclosan, another commonly used antibacterial agent. Observed differences among demographic groups examined may reflect differences in physiological factors (i.e., BSA) as well as use of personal care products containing triclocarban. |
Modeling emissions from CAFO poultry farms in Poland and evaluating potential risk to surrounding populations
Pohl HR , Citra M , Abadin HA , Szadkowska-Stanczyk I , Kozajda A , Ingerman L , Nguyen A , Murray HE . Regul Toxicol Pharmacol 2016 84 18-25 The world-wide use of concentrated animal feeding operations (CAFOs) for livestock production demands the need to evaluate the potential impact to public health. We estimated the exposure of various airborne pollutants for populations residing in close proximity to 10 poultry CAFOs located in Central Poland. Ammonia (NH3), carbon dioxide (CO2), carbon monoxide (CO), hydrogen sulfide (H2S), methane (CH4), nitrogen dioxide (NO2), nitrous oxide (N2O), sulfur dioxide (SO2), and organic dust were the pollutants of interest for this study. Because no monitoring data were available, we used the steady-state Gaussian dispersion model AERMOD to estimate pollutant concentrations for the exposed population in order to calculate the hazard index (HI) for a combined mixture of chemicals. Our results indicate that while the levels of certain pollutants are expected to exceed background levels commonly found in the environment they did not result in calculated hazard indexes which exceeded unity suggesting low potential for adverse health effects for the surrounding community for the mixture of chemicals. The study was conducted through a cooperation between the Agency for Toxic Substances and Disease Registry (ATSDR) in the USA and the Nofer Institute of Occupational Medicine (NIOM) in Poland. |
Physiologically based pharmacokinetic toolkit to evaluate environmental exposures: applications of the dioxin model to study real life exposures
Emond C , Ruiz P , Mumtaz M . Toxicol Appl Pharmacol 2016 315 70-79 Chlorinated dibenzo-p-dioxins (CDDs) are a series of mono- to octa-chlorinated homologous chemicals commonly referred to as polychlorinated dioxins. One of the most potent, well-known, and persistent member of this family is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). As part of translational research to make computerized models accessible to health risk assessors, we present a Berkeley Madonna recoded version of the human physiologically based pharmacokinetic (PBPK) model used by the U.S. Environmental Protection Agency (EPA) in the recent dioxin assessment. This model incorporates CYP1A2 induction, which is an important metabolic vector that drives dioxin distribution in the human body, and it uses a variable elimination half-life that is body burden dependent. To evaluate the model accuracy, the recoded model predictions were compared with those of the original published model. The simulations performed with the recoded model matched well with those of the original model. The recoded model was then applied to available data sets of real life exposure studies. The recoded model can describe acute and chronic exposures and can be useful for interpreting human biomonitoring data as part of an overall dioxin and/or dioxin-like compounds risk assessment. |
House dust endotoxin levels are associated with adult asthma in a U.S. farming population
Carnes MU , Hoppin JA , Metwali N , Wyss AB , Hankinson JL , O'Connell EL , Richards M , Long S , Beane Freeman LE , Sandler DP , Henneberger PK , Barker-Cummings C , Umbach DM , Thorne PS , London SJ . Ann Am Thorac Soc 2016 14 (3) 324-331 RATIONALE: Endotoxin initiates a pro-inflammatory response from the innate immune system. Studies in children suggest endotoxin exposure from house dust may be an important risk factor for asthma, but few studies have been conducted in adult populations. OBJECTIVES: To investigate the association of house dust endotoxin levels with asthma and related phenotypes (wheeze, atopy, and pulmonary function) in a large U.S. farming population. METHODS: Dust was collected from the bedrooms (n=2,485) of participants enrolled in a case-control study of current asthma (927 cases) nested within the Agricultural Health Study. Dust endotoxin was measured by Limulus amebocyte lysate assay. Outcomes were measured by questionnaire, spirometry, and blood draw. We evaluated associations using linear and logistic regression. MEASUREMENTS AND MAIN RESULTS: Endotoxin was significantly associated with current asthma (Odds Ratio (OR)=1.30, 95% confidence interval (CI)=1.14-1.47), and this relationship was modified by early life farm exposure (born on a farm: OR=1.18, 95% CI=1.02-1.37; not born on a farm: OR=1.67, 95% CI=1.26-2.20, Interaction p-value=0.05). Significant positive associations were seen with both atopic and nonatopic asthma. Endotoxin was not related to either atopy or wheeze. Higher endotoxin was related to lower FEV1/FVC in asthma cases only (Interaction p=0.01). For asthma, there was suggestive evidence of a gene by environment interaction for the CD14 variant, rs2569190 (Interaction p=0.16), but not for the TLR4 variants, rs4986790 or rs4986791. CONCLUSIONS: House dust endotoxin was associated with current atopic and nonatopic asthma in a U.S. farming population. The degree of the association with asthma depended on early life farm exposures. Furthermore, endotoxin was associated with lower pulmonary function in asthmatics. |
Association of school district policies for radon testing and radon-resistant new construction practices with indoor radon zones
Foster S , Everett Jones S . Int J Environ Res Public Health 2016 13 (12) Radon is a naturally occurring, colorless, odorless, and tasteless radioactive gas. Without testing, its presence is unknown. Using nationally representative data from the 2012 School Health Policies and Practices Study, we examined whether the prevalence of school district policies for radon testing and for radon-resistant new construction practices varied by district location in relation to the U.S. Environmental Protection Agency Map of Radon Zones. Among school districts located in counties with high predicted average indoor radon, 42.4% had policies for radon testing and 37.5% had policies for radon-resistant new construction practices. These findings suggest a critical need for improved awareness among policy makers regarding potential radon exposure for both students and school staff. |
Public health surveillance systems: Recent advances in their use and evaluation
Groseclose SL , Buckeridge DL . Annu Rev Public Health 2016 38 57-79 Surveillance is critical for improving population health. Public health surveillance systems generate information that drives action, and the data must be of sufficient quality and with a resolution and timeliness that matches objectives. In the context of scientific advances in public health surveillance, changing health care and public health environments, and rapidly evolving technologies, the aim of this article is to review public health surveillance systems. We consider their current use to increase the efficiency and effectiveness of the public health system, the role of system stakeholders, the analysis and interpretation of surveillance data, approaches to system monitoring and evaluation, and opportunities for future advances in terms of increased scientific rigor, outcomes-focused research, and health informatics. Expected final online publication date for the Annual Review of Public Health Volume 38 is March 20, 2017. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates. |
Health care provider knowledge and attitudes regarding reporting diseases and events to public health authorities in Tennessee
Fill MA , Murphree R , Pettit AC . J Public Health Manag Pract 2016 23 (6) 581-588 CONTEXT: In the United States, state laws require health care providers to report specific diseases and events to public health authorities, a fundamental facet of disease surveillance. However, reporting by providers is often inconsistent, infrequent, and delayed. OBJECTIVE: To examine knowledge, attitudes, and practices regarding provider disease reporting and to understand current barriers to provider disease reporting. DESIGN: A cross-sectional study was conducted via an anonymous, standardized electronic survey. SETTING: The survey was conducted at Vanderbilt University Medical Center, a large, tertiary academic medical center in Nashville, Tennessee. PARTICIPANTS: Health care providers in 4 specialties (internal medicine, pediatrics, obstetrics-gynecology, and emergency medicine). MAIN OUTCOME MEASURE(S): Knowledge of and attitudes regarding provider reporting of diseases to public health authorities in Tennessee. RESULTS: The majority of providers acknowledged they cared for patients with reportable diseases (362/435, 83.2%) and believed that it was their responsibility to report to public health authorities (429/436, 98.4%); however, less than half had ever reported a case (206/436, 47.2%). The median percent correct on the knowledge assessment of Tennessee reportable diseases and conditions was 81.3% (interquartile range = 68.8-87.5). Providers cited a lack of knowledge of which diseases are reportable (186/429, 43.3%) and the logistics of reporting (153/429, 35.7%) as the primary barriers for compliance. CONCLUSION: Most providers acknowledged they cared for patients with reportable diseases and believed they had an obligation to report to public health authorities. However, a lack of knowledge about reporting was frequently described as a limitation to report effectively. Many knowledge deficits were significantly greater among residents than other providers. IMPLICATIONS FOR POLICY & PRACTICE: The policy and practice implications of these findings include a demonstrated need for education of providers about disease reporting as well as development of more convenient reporting mechanisms. Fundamental knowledge of reportable disease requirements and procedures is critical for participation in the broader public health system. |
Outbreak of Salmonella Oslo Infections Linked to Persian Cucumbers - United States, 2016.
Bottichio L , Medus C , Sorenson A , Donovan D , Sharma R , Dowell N , Williams I , Wellman A , Jackson A , Tolar B , Griswold T , Basler C . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1430-1433 In April 2016, PulseNet, the national molecular subtyping network for foodborne disease surveillance, detected a multistate cluster of Salmonella enterica serotype Oslo infections with an indistinguishable pulsed-field gel electrophoresis (PFGE) pattern (XbaI PFGE pattern OSLX01.0090).* This PFGE pattern was new in the database; no previous infections or outbreaks have been identified. CDC, state and local health and agriculture departments and laboratories, and the Food and Drug Administration (FDA) conducted epidemiologic, traceback, and laboratory investigations to identify the source of this outbreak. A total of 14 patients in eight states were identified, with illness onsets occurring during March 21-April 9, 2016. Whole genome sequencing, a highly discriminating subtyping method, was used to further characterize PFGE pattern OSLX01.0090 isolates. Epidemiologic evidence indicates Persian cucumbers as the source of Salmonella Oslo infections in this outbreak. This is the fourth identified multistate outbreak of salmonellosis associated with cucumbers since 2013. Further research is needed to understand the mechanism and factors that contribute to contamination of cucumbers during growth, harvesting, and processing to prevent future outbreaks. |
Multistate outbreak of Escherichia coli O157:H7 infections associated with consumption of fresh spinach: United States, 2006
Sharapov UM , Wendel AM , Davis JP , Keene WE , Farrar J , Sodha S , Hyytia-Trees E , Leeper M , Gerner-Smidt P , Griffin PM , Braden C . J Food Prot 2016 79 (12) 2024-2030 During September to October, 2006, state and local health departments and the Centers for Disease Control and Prevention investigated a large, multistate outbreak of Escherichia coli O157:H7 infections. Case patients were interviewed regarding specific foods consumed and other possible exposures. E. coli O157:H7 strains isolated from human and food specimens were subtyped using pulsed-field gel electrophoresis and multiple-locus variable-number tandem repeat analyses (MLVA). Two hundred twenty-five cases (191 confirmed and 34 probable) were identified in 27 states; 116 (56%) case patients were hospitalized, 39 (19%) developed hemolytic uremic syndrome, and 5 (2%) died. Among 176 case patients from whom E. coli O157:H7 with the outbreak genotype (MLVA outbreak strain) was isolated and who provided details regarding spinach exposure, 161 (91%) reported fresh spinach consumption during the 10 days before illness began. Among 116 patients who provided spinach brand information, 106 (91%) consumed bagged brand A. E. coli O157:H7 strains were isolated from 13 bags of brand A spinach collected from patients' homes; isolates from 12 bags had the same MLVA pattern. Comprehensive epidemiologic and laboratory investigations associated this large multistate outbreak of E. coli O157:H7 infections with consumption of fresh bagged spinach. MLVA, as a supplement to pulsed-field gel electrophoresis genotyping of case patient isolates, was important to discern outbreak-related cases. This outbreak resulted in enhanced federal and industry guidance to improve the safety of leafy green vegetables and launched an independent collaborative approach to produce safety research in 2007. |
Genetic Diversity of Currently Circulating Rubella Viruses: A Need to Define More Precise Viral Groups.
Rivailler P , Abernathy E , Icenogle J . J Gen Virol 2016 98 (3) 396-404 Recent studies have shown that the currently circulating rubella viruses are mostly members of two genotypes, 1E and 2B. Also, genetically distinct viruses of genotype 1G have been found in East and West Africa. This study used a Mantel test to objectively include both genetic diversity and geographic location in the definition of lineages, and identified statistically justified lineages (n=13) and sub-lineages (n=9) of viruses within genotypes 1G, 1E and 2B. Genotype 2B viruses were widely distributed, while viruses of genotype 1E as well as 1G and 1J were much more geographically restricted. This analysis showed that more precise groupings for rubella viruses are possible, which should improve the ability to track rubella viruses worldwide. A year by year analysis revealed gaps in surveillance that need to be resolved in order to support the surveillance needed for enhanced control and elimination goals for rubella. |
Complete Genome Sequences of Enterococcus rotai LMG 26678T and Enterococcus silesiacus LMG 23085T.
Lauer AC , Humrighouse BW , Loparev V , Shewmaker PL , Whitney AM , McQuiston JR , McLaughlin RW . Genome Announc 2016 4 (6) The inclusion of molecular methods in the characterization of the novel species Enterococcus horridus necessitated the sequencing and assembly of the genomes of the closely related Enterococcus rotai and Enterococcus silesiacus Sequencing using Illumina technology in combination with optical mapping led to the generation of closed genomes for both isolates. |
Universal Human Papillomavirus Typing Assay: Whole Genome Sequencing Following Target Enrichment.
Li T , Unger ER , Batra D , Sheth M , Steinau M , Jasinski J , Jones J , Rajeeven MS . J Clin Microbiol 2016 55 (3) 811-823 We designed a universal HPV typing assay based on target enrichment and whole genome sequencing (eWGS). The RNA bait included 23,941 probes targeting 191 HPV types and 12 targeting beta-globin as control. We used Agilent SureSelect XT2 protocol for library preparation, Illumina HiSeq 2500 for sequencing and CLC genomics workbench for sequence analysis. Mapping stringency for type assignment was determined based on 8 (6 HPV-positive and 2 HPV negative) control samples. Using the optimal mapping conditions, types were assigned to 24 blinded samples. eWGS results were 100% concordant with Linear Array (LA) genotyping results for 9 plasmid samples and fully or partially concordant for 9 of the 15 cervical-vaginal samples, with 95.83% overall-type specific concordance for LA genotyping. eWGS identified 7 HPV types not included in the LA genotyping. Since this method does not involve degenerate primers targeting HPV genomic regions, PCR bias in genotype detection is minimized. With further refinements aimed at reducing cost and increasing throughput, this first application of eWGS for universal HPV typing could be a useful method to elucidate HPV epidemiology. |
Analysis of complete genomes of the rubella virus genotypes 1E and 2B which circulated in China, 2000-2013.
Zhu Z , Chen MH , Abernathy E , Icenogle J , Zhou S , Wang C , Zhao C , Wang Y , Chen H , Si Y , Xu W . Sci Rep 2016 6 39025 Rubella viruses of genotypes 1E and 2B are currently the most frequently detected wild-type viruses in the world. Genotype 1E viruses from China have been genetically distinct from genotype 1E viruses found elsewhere, while genotype 2B viruses found in China are not distinguishable from genotype 2B viruses from other areas. Genetic clusters of viruses of both genotypes were defined previously using sequences of the 739-nt genotyping window. Here we report phylogenic analysis using whole genomic sequences from seven genotype 1E and three genotype 2B viruses which were isolated in China between 2000 and 2013 and confirm the subgrouping of current circulating genotypes 1E and 2B viruses. In addition, the whole genomic characterization of Chinese rubella viruses was clarified. The results indicated that the Chinese rubella viruses were highly conserved at the genomic level, and no predicted amino acid variations were found at positions where functional domains of the proteins were identified. Therefore, it gives us the idea that the rubella control and elimination goal should be achieved if vaccine immunization coverage continues maintaining at the high level. |
Genome Sequences of Multidrug-Resistant, Colistin-Susceptible and -Resistant Klebsiella pneumoniae Clinical Isolates from Pakistan.
Crawford MA , Timme R , Lomonaco S , Lascols C , Fisher DJ , Sharma SK , Strain E , Allard MW , Brown EW , McFarland MA , Croley T , Hammack TS , Weigel LM , Anderson K , Hodge DR , Pillai SP , Morse SA , Khan E , Hughes MA . Genome Announc 2016 4 (6) The emergence and spread of colistin resistance among multidrug-resistant (MDR) Klebsiella pneumoniae represent a critical threat to global health. Here, we report the complete genome sequences of 10 MDR, colistin-susceptible and -resistant K. pneumoniae clinical isolates obtained in Pakistan between 2010 and 2013. |
Whole Genome Sequence and Comparative Genomics of the Novel Lyme Borreliosis Causing Pathogen, Borrelia mayonii.
Kingry LC , Batra D , Replogle A , Rowe LA , Pritt BS , Petersen JM . PLoS One 2016 11 (12) e0168994 Borrelia mayonii, a Borrelia burgdorferi sensu lato (Bbsl) genospecies, was recently identified as a cause of Lyme borreliosis (LB) among patients from the upper midwestern United States. By microscopy and PCR, spirochete/genome loads in infected patients were estimated at 105 to 106 per milliliter of blood. Here, we present the full chromosome and plasmid sequences of two B. mayonii isolates, MN14-1420 and MN14-1539, cultured from blood of two of these patients. Whole genome sequencing and assembly was conducted using PacBio long read sequencing (Pacific Biosciences RSII instrument) followed by hierarchical genome-assembly process (HGAP). The B. mayonii genome is ~1.31 Mbp in size (26.9% average GC content) and is comprised of a linear chromosome, 8 linear and 7 circular plasmids. Consistent with its taxonomic designation as a new Bbsl genospecies, the B. mayonii linear chromosome shares only 93.83% average nucleotide identity with other genospecies. Both B. mayonii genomes contain plasmids similar to B. burgdorferi sensu stricto lp54, lp36, lp28-3, lp28-4, lp25, lp17, lp5, 5 cp32s, cp26, and cp9. The vls locus present on lp28-10 of B. mayonii MN14-1420 is remarkably long, being comprised of 24 silent vls cassettes. Genetic differences between the two B. mayonii genomes are limited and include 15 single nucleotide variations as well as 7 fewer silent vls cassettes and a lack of the lp5 plasmid in MN14-1539. Notably, 68 homologs to proteins present in B. burgdorferi sensu stricto appear to be lacking from the B. mayonii genomes. These include the complement inhibitor, CspZ (BB_H06), the fibronectin binding protein, BB_K32, as well as multiple lipoproteins and proteins of unknown function. This study shows the utility of long read sequencing for full genome assembly of Bbsl genomes, identifies putative genome regions of B. mayonii that may be linked to clinical manifestation or tissue tropism, and provides a valuable resource for pathogenicity, diagnostic and vaccine studies. |
Complete Genome Sequences of Four Bordetella pertussis Vaccine Reference Strains from Serum Institute of India.
Weigand MR , Peng Y , Loparev V , Johnson T , Juieng P , Gairola S , Kumar R , Shaligram U , Gowrishankar R , Moura H , Rees J , Schieltz DM , Williamson Y , Woolfitt A , Barr J , Tondella ML , Williams MM . Genome Announc 2016 4 (6) Serum Institute of India is among the world's largest vaccine producers. Here, we report the complete genome sequences for four Bordetella pertussis strains used by Serum Institute of India in the production of whole-cell pertussis vaccines. |
Familial Creutzfeldt-Jakob Disease Cluster Among an African American Family.
Johnson MG , Bradley KK , Coffman RL , Belay ED . J Public Health Manag Pract 2016 23 (6) 614-617 Familial Creutzfeldt-Jakob disease (fCJD) results from inheritance of mutations in the prion protein gene. Confirming fCJD diagnosis is essential for informing persons of their potential hereditary risk and for genetic counseling to support personal decisions for genetic testing and family planning. We describe a case of fCJD that was linked to a large cluster of African Americans with fCJD identified through a public health investigation, including 8 confirmed cases and 13 suspected cases involving 7 generations in 1 family. Genetic counseling is an important component of fCJD management for families coping with genetic prion diseases. |
A Phylogeny-Based Global Nomenclature System and Automated Annotation Tool for H1 Hemagglutinin Genes from Swine Influenza A Viruses.
Anderson TK , Macken CA , Lewis NS , Scheuermann RH , Van Reeth K , Brown IH , Swenson SL , Simon G , Saito T , Berhane Y , Ciacci-Zanella J , Pereda A , Davis CT , Donis RO , Webby RJ , Vincent AL . mSphere 2016 1 (6) The H1 subtype of influenza A viruses (IAVs) has been circulating in swine since the 1918 human influenza pandemic. Over time, and aided by further introductions from nonswine hosts, swine H1 viruses have diversified into three genetic lineages. Due to limited global data, these H1 lineages were named based on colloquial context, leading to a proliferation of inconsistent regional naming conventions. In this study, we propose rigorous phylogenetic criteria to establish a globally consistent nomenclature of swine H1 virus hemagglutinin (HA) evolution. These criteria applied to a data set of 7,070 H1 HA sequences led to 28 distinct clades as the basis for the nomenclature. We developed and implemented a web-accessible annotation tool that can assign these biologically informative categories to new sequence data. The annotation tool assigned the combined data set of 7,070 H1 sequences to the correct clade more than 99% of the time. Our analyses indicated that 87% of the swine H1 viruses from 2010 to the present had HAs that belonged to 7 contemporary cocirculating clades. Our nomenclature and web-accessible classification tool provide an accurate method for researchers, diagnosticians, and health officials to assign clade designations to HA sequences. The tool can be updated readily to track evolving nomenclature as new clades emerge, ensuring continued relevance. A common global nomenclature facilitates comparisons of IAVs infecting humans and pigs, within and between regions, and can provide insight into the diversity of swine H1 influenza virus and its impact on vaccine strain selection, diagnostic reagents, and test performance, thereby simplifying communication of such data. IMPORTANCE A fundamental goal in the biological sciences is the definition of groups of organisms based on evolutionary history and the naming of those groups. For influenza A viruses (IAVs) in swine, understanding the hemagglutinin (HA) genetic lineage of a circulating strain aids in vaccine antigen selection and allows for inferences about vaccine efficacy. Previous reporting of H1 virus HA in swine relied on colloquial names, frequently with incriminating and stigmatizing geographic toponyms, making comparisons between studies challenging. To overcome this, we developed an adaptable nomenclature using measurable criteria for historical and contemporary evolutionary patterns of H1 global swine IAVs. We also developed a web-accessible tool that classifies viruses according to this nomenclature. This classification system will aid agricultural production and pandemic preparedness through the identification of important changes in swine IAVs and provides terminology enabling discussion of swine IAVs in a common context among animal and human health initiatives. |
Transforming evidence generation to support health and health care decisions
Califf RM , Robb MA , Bindman AB , Briggs JP , Collins FS , Conway PH , Coster TS , Cunningham FE , De Lew N , DeSalvo KB , Dymek C , Dzau VJ , Fleurence RL , Frank RG , Gaziano JM , Kaufmann P , Lauer M , Marks PW , McGinnis JM , Richards C , Selby JV , Shulkin DJ , Shuren J , Slavitt AM , Smith SR , Washington BV , White PJ , Woodcock J , Woodson J , Sherman RE . N Engl J Med 2016 375 (24) 2395-2400 Making better choices about health and health care requires the best possible evidence. Unfortunately, many of the decisions made today in our health care system are not supported by high-quality evidence1-4 derived from randomized, controlled trials or well-designed observational studies. But as rich, diverse sources of digital data become widely available for research and as analytical tools continue to grow in power and sophistication, the research and health care communities now have the opportunity to quickly and efficiently generate the scientific evidence needed to support improved decision making about health and health care. | The pursuit of high-quality, data-driven evidence in no way detracts from the importance of expert opinion and qualitative information as a complementary source of knowledge to inform policy decisions or population and individual choices; in fact, it enhances it. However, we believe there is an opportunity to use qualitative methods to supplement high-quality quantitative data with a more focused approach. |
p16(INK4A) expression in invasive laryngeal cancer
Hernandez BY , Rahman M , Lynch CF , Cozen W , Unger ER , Steinau M , Thompson T , Saber MS , Altekruse SF , Goodman MT , Powers A , Lyu C , Saraiya M . Papillomavirus Res 2016 2 52-55 We examined p16 expression in tumors from a population-based sample of laryngeal cancer cases diagnosed in the U.S. Samples had been previously genotyped for HPV DNA. Overall, p16 expression was observed in laryngeal tissue from 8 of 101 (7.9%) cases. p16 expression was observed in 2 of 16 (12.5%) cases previously determined to be HPV DNA positive. The two cases dually positive for p16 and HPV DNA were non-keratinizing SCC and papillary SCC tumors that were positive for genotypes 18 and 35/89, respectively. Positivity for p16 and/or HPV DNA was not associated with 5-year survival (log-rank p value=0.55). Our findings support a limited role of HPV in laryngeal carcinogenesis. p16 is not a reliable surrogate for HPV status in laryngeal cancers and is not a predictor of laryngeal cancer survival. |
Primary care physicians' perspective on financial issues and adult immunization in the Era of the Affordable Care Act
Hurley LP , Lindley MC , Allison MA , Crane LA , Brtnikova M , Beaty BL , Snow M , Bridges CB , Kempe A . Vaccine 2016 35 (4) 647-654 BACKGROUND: Financial barriers to adult vaccination are poorly understood. Our objectives were to assess among general internists (GIM) and family physicians (FP) shortly after Affordable Care Act (ACA) implementation: (1) proportion of adult patients deferring or refusing vaccines because of cost and frequency of physicians not recommending vaccines for financial reasons; (2) satisfaction with reimbursement for vaccine purchase and administration by payer type; (3) knowledge of Medicare coverage of vaccines; and (4) awareness of vaccine-specific provisions of the ACA. METHODS: We administered an Internet and mail survey from June to October 2013 to national networks of 438 GIMs and 401 FPs. RESULTS: Response rates were 72% (317/438) for GIM and 59% (236/401) for FP. Among physicians who routinely recommended vaccines, up to 24% of GIM and 30% of FP reported adult patients defer or refuse certain vaccines for financial reasons most of the time. Physicians reported not recommending vaccines because they thought the patient's insurance would not cover it (35%) or the patient could be vaccinated more affordably elsewhere (38%). Among physicians who saw patients with this insurance, dissatisfaction ('very dissatisfied') was highest for payments received from Medicaid (16% vaccine purchase, 14% vaccine administration) and Medicare Part B (11% vaccine purchase, 11% vaccine administration). Depending on the vaccine, 36-71% reported not knowing how Medicare covered the vaccine. Thirty-seven percent were 'not at all aware' and 19% were 'a little aware' of vaccine-specific provisions of the ACA. CONCLUSIONS: Patients are refusing and physicians are not recommending adult vaccinations for financial reasons. Increased knowledge of private and public insurance coverage for adult vaccinations might position physicians to be more likely to recommend vaccines and better enable them to refer patients to other vaccine providers when a particular vaccine or vaccines are not offered in the practice. |
Geographic variations in incremental costs of heart disease among Medicare beneficiaries, by type of service, 2012
Wakim R , Ritchey M , Hockenberry J , Casper M . Prev Chronic Dis 2016 13 E180 Using 2012 data on fee-for-service Medicare claims, we documented regional and county variation in incremental standardized costs of heart disease (ie, comparing costs between beneficiaries with heart disease and beneficiaries without heart disease) by type of service (eg, inpatient, outpatient, post-acute care). Absolute incremental total costs varied by region. Although the largest absolute incremental total costs of heart disease were concentrated in southern and Appalachian counties, geographic patterns of costs varied by type of service. These data can be used to inform development of policies and payment models that address the observed geographic disparities. |
Insurance status among adults with hypertension - the impact of underinsurance
Fang J , Zhao G , Wang G , Ayala C , Loustalot F . J Am Heart Assoc 2016 5 (12) BACKGROUND: Hypertension is a major risk factor for heart disease and stroke. Health insurance coverage affects hypertension treatment and control, but limited information is available for US adults with hypertension who are classified as underinsured. METHODS AND RESULTS: Using Behavioral Risk Factor Surveillance System 2013 data, we identified adults with self-reported hypertension. On the basis of self-reported health insurance status and health care-related financial burdens, participants were categorized as uninsured, underinsured, or adequately insured. Proxies for health care received included whether they reported taking antihypertensive medications and whether they visited a doctor for a routine checkup in the past year. We assessed the association between health insurance status and health care received, adjusting for selected sociodemographic characteristics. Among 123 257 participants from 38 states and District of Columbia with self-reported hypertension, 12% were uninsured, 26% were underinsured, and 62% were adequately insured. In adjusted models using adequately insured participants as referent, both uninsured (adjusted odds ratio, 0.39; 95% CI, 0.35-0.43) and underinsured (0.83, 0.76-0.89) participants were less likely to report using antihypertensive medication than those of adequately insured participants. Similarly, adjusted odds ratio of visiting a doctor for routine checkup in the past year were 0.25 (0.23-0.28) for those who were uninsured and 0.78 (0.72-0.84) for those who were underinsured compared to those with adequate insurance. CONCLUSIONS: Uninsured and underinsured participants with hypertension were less likely to report receiving care compared to those with adequate insurance coverage. Disparities in health care coverage may necessitate targeted interventions, even among people with health insurance. |
Annual economic burden of productivity losses among adult survivors of childhood cancers
Guy GP Jr , Berkowitz Z , Ekwueme DU , Rim SH , Yabroff KR . Pediatrics 2016 138 S15-s21 BACKGROUND AND OBJECTIVES: Although adult survivors of childhood cancers have poorer health and greater health limitations than other adults, substantial gaps remain in understanding the economic consequences of surviving childhood cancer. Therefore, we estimated the economic burden of productivity losses among adult survivors of childhood cancers. METHODS: We examined health status, functional limitations, and productivity loss among adult survivors of childhood cancers (n = 239) diagnosed at ≤14 years of age compared with adults without a history of cancer (n = 304 265) by using the 2004-2014 National Health Interview Survey. We estimated economic burden using the productivity loss from health-related unemployment, missed work days, missed household productivity, and multivariable regression models controlling for age, sex, race/ethnicity, education, comorbidities, and survey year. RESULTS: Childhood cancer survivorship is associated with a substantial economic burden. Adult survivors of childhood cancers are more likely to be in poorer health, need assistance with personal care and routine needs, have work limitations, be unable to work because of health, miss more days of work, and have greater household productivity loss compared with adults without a history of cancer (all P < .05). The annual productivity loss for adult survivors of childhood cancer is $8169 per person compared with $3083 per person for individuals without a history of cancer. CONCLUSIONS: These findings underscore the importance of efforts to reduce the health and economic burden among adult survivors of childhood cancer. In addition, this study highlights the potential productivity losses that could be avoided during adulthood from the prevention of childhood cancer in the United States. |
Cost of informal care for patients with cardiovascular disease or diabetes: current evidence and research challenges
Joo H , Zhang P , Wang G . Qual Life Res 2016 26 (6) 1379-1386 PURPOSE: Patients with cardiovascular disease (CVD) or diabetes often require informal care. The burden of informal care, however, was not fully integrated into economic evaluation. We conducted a literature review to summarize the current evidence on economic burden associated with informal care imposed by CVD or diabetes. METHODS: We searched EconLit, EMBASE, and PubMed for publications in English during the period of 1995-2015. Keywords for the search were informal care cost, costs of informal care, informal care, and economic burden. We excluded studies that (1) did not estimate monetary values, (2) examined methods or factors affecting informal care, or (3) did not address CVD or diabetes. RESULTS: Our search identified 141 potential abstracts, and 10 of the articles met our criteria. Although little research has been conducted, studies used different methods without much consensus, estimates suffered from recall bias, and study samples were small, the costs of informal care have been found high. In 2014 US dollars, estimated additional annual costs of informal care per patient ranged from $1563 to $7532 for stroke, $860 for heart failure, and $1162 to $5082 for diabetes. The total cost of informal care ranged from $5560 to $143,033 for stoke, $12,270 to $20,319 for heart failure, and $1192 to $1321 for diabetes. CONCLUSIONS: The costs of informal care are substantial, and excluding them from economic evaluation would underestimate economic benefits of interventions for the prevention of CVD and diabetes. |
Cost-effectiveness of monovalent rotavirus vaccination of infants in Malawi: A postintroduction analysis using individual patient-level costing data
Bar-Zeev N , Tate JE , Pecenka C , Chikafa J , Mvula H , Wachepa R , Mwansambo C , Mhango T , Chirwa G , Crampin AC , Parashar UD , Costello A , Heyderman RS , French N , Atherly D , Cunliffe NA . Clin Infect Dis 2016 62 Suppl 2 S220-8 BACKGROUND: Rotavirus vaccination reduces childhood hospitalization in Africa, but cost-effectiveness has not been determined using real-world effectiveness and costing data. We sought to determine monovalent rotavirus vaccine cost-effectiveness in Malawi, one of Africa's poorest countries and the first Gavi-eligible country to report disease reduction following introduction in 2012. METHODS: This was a prospective cohort study of children with acute gastroenteritis at a rural primary health center, a rural first referral-level hospital and an urban regional referral hospital in Malawi. For each participant we itemized household costs of illness and direct medical expenditures incurred. We also collected Ministry of Health vaccine implementation costs. Using a standard tool (TRIVAC), we derived cost-effectiveness. RESULTS: Between 1 January 2013 and 21 November 2014, we recruited 530 children aged <5 years with gastroenteritis. Costs did not differ by rotavirus test result, but were significantly higher for admitted children and those with increased severity on Vesikari scale. Adding rotavirus vaccine to the national schedule costs Malawi $0.42 per dose in system costs. Vaccine copayment is an additional $0.20. Over 20 years, the vaccine program will avert 1 026 000 cases of rotavirus gastroenteritis, 78 000 inpatient admissions, 4300 deaths, and 136 000 disability-adjusted-life-years (DALYs). For this year's birth cohort, it will avert 54 000 cases of rotavirus and 281 deaths in children aged <5 years. The program will cost $10.5 million and save $8.0 million in averted healthcare costs. Societal cost per DALY averted was $10, and the cost per rotavirus case averted was $1. CONCLUSIONS: Gastroenteritis causes substantial economic burden to Malawi. The rotavirus vaccine program is highly cost-effective. Together with the demonstrated impact of rotavirus vaccine in reducing population hospitalization burden, its cost-effectiveness makes a strong argument for widespread utilization in other low-income, high-burden settings. |
Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP)
Tangka FK , Subramanian S , Hoover S , Royalty J , Joseph K , DeGroff A , Joseph D , Chattopadhyay S . Eval Program Plann 2016 62 67-72 The Colorectal Cancer Control Program (CRCCP) provided funding to 29 grantees to increase colorectal cancer screening. We describe the screening promotion costs of CRCCP grantees to evaluate the extent to which the program model resulted in the use of funding to support interventions recommended by the Guide to Community Preventive Services (Community Guide). We analyzed expenditures for screening promotion for the first three years of the CRCCP to assess cost per promotion strategy, and estimated the cost per person screened at the state level based on various projected increases in screening rates. All grantees engaged in small media activities and more than 90% used either client reminders, provider assessment and feedback, or patient navigation. Based on all expenditures, projected cost per eligible person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively. CRCCP grantees expended the majority of their funding on Community Guide recommended screening promotion strategies but about a third was spent on other interventions. Based on this finding, future CRC programs should be provided with targeted education and information on evidence-based strategies, rather than broad based recommendations, to ensure that program funds are expended mainly on evidence-based interventions. |
Notes from the Field: Investigation of Elizabethkingia anophelis Cluster - Illinois, 2014-2016.
Navon L , Clegg WJ , Morgan J , Austin C , McQuiston JR , Blaney DD , Walters MS , Moulton-Meissner H , Nicholson A . MMWR Morb Mortal Wkly Rep 2016 65 (48) 1380-1381 Elizabethkingia spp., formerly known as Flavobacterium and Chryseobacterium, are multidrug-resistant, Gram negative bacilli found in the environment that can cause health care–associated outbreaks (1). Elizabethkingia meningoseptica was first identified by Elizabeth King in 1959 as a cause of meningitis outbreaks among hospitalized newborns (2). Elizabethkingia anophelis (EKA) was first identified in 2011 from the midgut of a mosquito (3); a recent series of cases from Hong Kong indicate that EKA health care–associated infections cause significant morbidity and have a high case-fatality rate (23.5%) (4). | In February 2016, the Wisconsin Department of Health Services notified the Illinois Department of Public Health (IDPH) and other neighboring health departments of an ongoing outbreak of EKA among Wisconsin residents. To determine if Illinois had related cases, IDPH sent memos on February 10 and March 29, 2016 to Illinois health care providers, infection preventionists and laboratories, requesting all available isolates of Elizabethkingia spp. dating back 2 years, to January 1, 2014. Twelve isolates from 11 patients were sent to CDC for testing; specimen collection dates ranged from June 23, 2014 to March 31, 2016. | On April 14, 2016, CDC informed IDPH that all submitted isolates were identified as EKA and that a genetic cluster (11 isolates from 10 patients) distinct from the Wisconsin outbreak strain had been identified, based on pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS). The eleven isolates were an average of 39.6 single nucleotide polymorphisms (SNPs) apart by WGS, with a range of 9–60 SNPs in the core of the genomic sequence shared across the isolates (80% of the genome). This SNP range corresponded to PFGE patterns with zero (indistinguishable) to three (closely related) band pattern differences. By comparison, some historic EKA isolates tested by CDC have differed by approximately 1,000 SNPs, with the more distantly related EKA strains differing by tens of thousands of SNPs. Phylogenetic analysis followed by bootstrapping statistical analysis provided strong support that these Illinois isolates clustered together and were genetically distinct from other EKA isolates submitted to CDC. |
A cluster of group A streptococcal infections in a skilled nursing facility-the potential role of healthcare worker presenteeism
Kobayashi M , Lyman MM , Francois Watkins LK , Toews KA , Bullard L , Radcliffe RA , Beall B , Langley G , Beneden CV , Stone ND . J Am Geriatr Soc 2016 64 (12) e279-e284 Objectives: To determine the extent of a group A streptococcus (GAS) cluster (2 residents with invasive GAS (invasive case-patients), 2 carriers) caused by a single strain (T antigen type 2 and M protein gene subtype 2.0 (T2, emm 2.0)), evaluate factors contributing to transmission, and provide recommendations for disease control. Design: Cross-sectional analysis and retrospective review. Setting: Skilled nursing facility (SNF). Participants: SNF residents and staff. Measurements: The initial cluster was identified through laboratory notification and screening of SNF residents with wounds. Laboratory and SNF administrative records were subsequently reviewed to identify additional residents with GAS, oropharyngeal and wound (if present) swabs were collected from SNF staff and residents to examine GAS colonization, staff were surveyed to assess infection control practices and risk factors for GAS colonization, epidemiologic links between case-patients and persons colonized with GAS were determined, and facility infection control practices were assessed. Results: No additional invasive case-patients were identified. Oropharyngeal swabs obtained from all 167 SNF residents were negative; one wound swab grew GAS that was the same as the outbreak strain (T2, emm 2.0). The outbreak strain was not identified in any of the 162 staff members. One of six staff members diagnosed with GAS pharyngitis worked while ill and had direct contact with invasive case-patients within a few weeks before their onset of symptoms. Additional minor breaches in infection control were noted. Conclusion: Sick healthcare workers may have introduced GAS into the SNF, with propagation by infection control lapses. "Presenteeism," or working while ill, may introduce and transmit GAS to vulnerable in SNF populations. Identification of an invasive GAS case-patient should trigger a prompt response by facilities to prevent further transmission and workplace culture, and policies should be in place to discourage presenteeism in healthcare settings. |
PD-1 inhibitor gastroenterocolitis: case series and appraisal of 'immunomodulatory gastroenterocolitis'
Gonzalez RS , Salaria SN , Bohannon CD , Huber AR , Feely MM , Shi C . Histopathology 2016 70 (4) 558-567 AIMS: PD-1 inhibitors facilitate immune response against certain tumour types, including melanoma. These drugs have led to prolonged survival but can also result in autoimmune-type side effects, including gastrointestinal inflammation. The histopathological effects of this medication class have not been well studied. METHODS AND RESULTS: We identified 37 gastrointestinal tract biopsies from 20 patients taking a PD-1 or PD-L1 inhibitor and evaluated clinicopathological findings. Diarrhoea was the most common symptom, and endoscopic findings ranged from mild erythema to erosion/ulceration. Common histological findings included lamina propria expansion, villous blunting (if applicable), intra-epithelial neutrophils and increased crypt/gland apoptosis, although intra-epithelial lymphocytes were rarely prominent. A few cases showed crypt rupture with resultant histiocytic/granulomatous response. Most patients responded to drug cessation and/or steroids, but follow-up endoscopies were not performed. CONCLUSIONS: PD-1/PD-L1 inhibitors can cause gastritis, enteritis and colitis, similar to other immunomodulatory antibodies (such as CTLA-4 inhibitors and PI3Kdelta inhibitors), but the histological findings vary somewhat among drug classes. Clinical history, lack of prominent intra-epithelial lymphocytes and crypt rupture may help to distinguish PD-1 inhibitor gastroenterocolitis from mimics, which include other medication effect, inflammatory bowel disease, graft-versus-host disease, cytomegalovirus infection and autoimmune enteropathy. |
Shedding of porcine circovirus type 1 DNA and rotavirus RNA by infants vaccinated with Rotarix®.
Mijatovic-Rustempasic S , Immergluck LC , Parker TC , Laghaie E , Mohammed A , McFadden T , Parashar UD , Bowen MD , Cortese MM . Hum Vaccin Immunother 2016 13 (4) 0 Thirty-three infants aged approximately 2 months had serial stool samples collected after receipt of Rotarix(R) vaccine dose 1, and assessed for shedding of porcine circovirus type 1 DNA and Rotavirus group A RNA by molecular methods. We did not find strong evidence that porcine circovirus type 1 replication occurred. Porcine circovirus type 1 genome with the same sequence as that in Rotarix(R) was detected in a few infants as late as day ≥13; while this timing could suggest there may have been replication and not just transient passage through the gastrointestinal tract, the lack of increase in copy numbers in any infant supports transient passage and there are inherent limitations to the results. We found that 21% of infants did not shed Rotarix(R) RVA RNA beyond the day 3 sample, which may suggest lack of vaccine virus replication. Of the infants in whom Rotarix RVA RNA shedding continued, peak copy numbers were reached on days 3-5 for approximately 40%, and after day 5 in approximately 60%, and shedding can be prolonged (≥45 days). |
Pneumonia prevention: Cost-effectiveness analyses of two vaccines among refugee children aged under two years, Haemophilus influenzae type b-containing and pneumococcal conjugate vaccines, during a humanitarian emergency, Yida camp, South Sudan
Gargano LM , Hajjeh R , Cookson ST . Vaccine 2017 35 (3) 435-442 By September 2013, war between Sudan and South Sudan resulted in >70,000 Sudanese refugees and high pneumonia incidence among the 20,000 refugees in Yida camp, South Sudan. Using Medecins Sans Frontieres (MSF)-provided data and modifying our decision-tree models, we estimated if administering Haemophilus influenzae type b (Hib)-containing (pentavalent vaccine, also with diphtheria pertussis and tetanus [DPT] and hepatitis B) and pneumococcal conjugate (PCV) vaccines were cost-effective against hospitalized pneumonia. Among children < 2 years old, compared with no vaccination, one- and two-doses of combined Hib-containing and PCV would avert an estimated 118 and 125 pneumonia cases, and 8.5 and 9.1 deaths, respectively. The cost per Disability-Adjusted-Life-Year averted for administering combined one- and two-doses was US$125 and US$209, respectively. MSF demonstrated that it was possible to administer these vaccines during an emergency and our analysis found it was highly cost-effective, even with just one-dose of either vaccine. Despite unknown etiology, there is strong field and now economic rationale for administering Hib and PCV during at least one humanitarian emergency. |
Fifty years of global immunization at CDC, 1966-2015
Mast EE , Cochi SL , Kew OM , Cairns KL , Bloland PB , Martin R . Public Health Rep 2017 132 (1) 18-26 On November 23, 1965, President Lyndon Johnson announced plans for a 5-year smallpox eradication and measles control program in West Africa that enabled the Centers for Disease Control and Prevention (CDC) to establish a Smallpox Eradication Program in January 1966. Since then, CDC’s global immunization endeavors have encompassed global smallpox eradication, the establishment and growth of the Expanded Program on Immunization (EPI) to strengthen national immunization programs, global efforts to eradicate polio and eliminate measles and rubella, and vaccine introduction into national immunization schedules beyond the original 6 EPI vaccines. CDC has provided scientific leadership, evidence-based guidance, and programmatic strategies to build public health infrastructure around the world, needed to achieve and measure the impact of these global immunization initiatives. This article marks the 50th anniversary of CDC’s global immunization leadership, highlights key historical events, and provides an overview of CDC’s future directions. | Before 1955, smallpox and diphtheria-tetanus-pertussis vaccines were the only routinely recommended childhood vaccines in the United States. The roots of global immunization at CDC began after clinical trials for the Salk inactivated polio vaccine (IPV) in 1954. After investigators announced on April 12, 1955, that Salk IPV was safe and effective, large-scale vaccination campaigns were implemented across the United States, and IPV was set to join diphtheria-tetanus-pertussis and smallpox vaccines in the childhood vaccination schedule. However, improperly prepared IPV by Cutter Pharmaceuticals used for the vaccination campaigns led to 200 cases of paralysis and 10 deaths.1 |
Routine vaccination coverage in northern Nigeria: results from 40 district-level cluster surveys, 2014-2015
Gunnala R , Ogbuanu IU , Adegoke OJ , Scobie HM , Uba BV , Wannemuehler KA , Ruiz A , Elmousaad H , Ohuabunwo CJ , Mustafa M , Nguku P , Waziri NE , Vertefeuille JF . PLoS One 2016 11 (12) e0167835 BACKGROUND: Despite recent success towards controlling poliovirus transmission, Nigeria has struggled to achieve uniformly high routine vaccination coverage. A lack of reliable vaccination coverage data at the operational level makes it challenging to target program improvement. To reliably estimate vaccination coverage, we conducted district-level vaccine coverage surveys using a pre-existing infrastructure of polio technical staff in northern Nigeria. METHODS: Household-level cluster surveys were conducted in 40 polio high risk districts of Nigeria during 2014-2015. Global positioning system technology and intensive supervision by a pool of qualified technical staff were used to ensure high survey quality. Vaccination status of children aged 12-23 months was documented based on vaccination card or caretaker's recall. District-level coverage estimates were calculated using survey methods. RESULTS: Data from 7,815 children across 40 districts were analyzed. District-level coverage with the third dose of diphtheria-pertussis-tetanus vaccine (DPT3) ranged widely from 1-63%, with all districts having DPT3 coverage below the target of 80%. Median coverage across all districts for each of eight vaccine doses (1 Bacille Calmette-Guerin dose, 3 DPT doses, 3 oral poliovirus vaccine doses, and 1 measles vaccine dose) was <50%. DPT3 coverage by survey was substantially lower (range: 28%-139%) than the 2013 administrative coverage reported among children aged <12 months. Common reported reasons for non-vaccination included lack of knowledge about vaccines and vaccination services (50%) and factors related to access to routine immunization services (15%). CONCLUSIONS: Survey results highlighted vaccine coverage gaps that were systematically underestimated by administrative reporting across 40 polio high risk districts in northern Nigeria. Given the limitations of administrative coverage data, our approach to conducting quality district-level coverage surveys and providing data to assess and remediate issues contributing to poor vaccination coverage could serve as an example in countries with sub-optimal vaccination coverage, similar to Nigeria. |
Surveillance of adverse events after seasonal influenza vaccination in pregnant women and their infants in the Vaccine Adverse Event Reporting System, July 2010-May 2016
Moro P , Baumblatt J , Lewis P , Cragan J , Tepper N , Cano M . Drug Saf 2016 40 (2) 145-152 INTRODUCTION: Routine immunization of pregnant women with seasonal inactivated influenza vaccines (IIVs) is recommended in all trimesters of pregnancy. A review of the Vaccine Adverse Event Reporting System (VAERS) during 1990-2009 did not find any unexpected patterns of pregnancy complications or fetal outcomes after administration of IIV or live attenuated influenza vaccines (LAIVs). During the 2009-2010 pandemic influenza A (H1N1) vaccination campaign, a study noted that the number of VAERS reports from pregnant women who received the H1N1 2009 inactivated monovalent vaccine (n = 288) increased compared with 1990-2009 seasonal IIV pregnancy reports (n = 148). OBJECTIVES: The objective of this study was to assess the safety of seasonal influenza vaccines in pregnant women and their infants whose reports were submitted to VAERS during 2010-2016. METHODS: We searched VAERS for US reports of adverse events (AEs) in pregnant women who received IIV or LAIV from 1 July 2010 through 6 May 2016. Clinicians reviewed reports and available medical records and assigned a primary clinical category for each report. Reports were coded as serious based on the Code of Federal Regulations. RESULTS: We identified 671 reports after seasonal influenza vaccines administered to pregnant women: 544 after IIV and 127 after LAIV. Serious events occurred among 61 (11.2%) reports following IIV and one (0.8%) report following LAIV. No deaths were reported. Among reports with trimester information (n = 296), IIV was administered during the first trimester in 116 (39.2%). Among IIV reports, the most frequent pregnancy-specific AE was spontaneous abortion in 62 (11.4%) reports, followed by stillbirth in ten (1.8%) and preterm delivery in six (1.1%). The most common non-pregnancy-specific AEs were injection-site reactions (55 [10.1%]). Neonatal or infant outcomes were reported in 22 (4.0%) reports, seven of which had major birth defects of different types and no neonatal deaths. CONCLUSION: As in 2009-2010, no new or unexpected patterns in maternal or fetal outcomes were observed during 2010-2016. |
Trends in childhood pneumococcal vaccine coverage in Shanghai, China, 2005-2011: a retrospective cohort study
Boulton ML , Ravi NS , Sun X , Huang Z , Wagner AL . BMC Public Health 2016 16 109 BACKGROUND: In China, the pneumococcal conjugate vaccine (PCV7) and the pneumococcal polysaccharide vaccine (PPSV23) are not offered under the government's Expanded Program on Immunization and are instead administered for a fee. PCV7 is more effective and covers more serotypes associated with invasive disease in children, but is also more expensive, than PPSV23. Because of their expense, there is concern that these vaccines, especially PCV7, have low uptake particularly among non-locals, migrants from outside of Shanghai. This paper characterizes the differential coverage of PCV7 and PPSV23 between locals and non-locals in Shanghai, and illustrates coverage trends over time. METHODS: In this retrospective cohort study, children born between 2005 and 2011 were sampled from the Shanghai Immunization Program Information System. Bivariate and multivariable analyses examined the relationships between demographic characteristics, residency status (non-locals vs locals), and vaccination coverage. RESULTS: PPSV23 coverage (29.8 %) among children over 2 years of age was higher than PCV7 coverage (10.1 %) for locals and non-locals. Uptake of PCV7 increased substantially after children were 2 years of age. Overall, non-local populations had higher PPSV23 coverage (OR: 1.34; 98 % CI: 1.22, 1.46) but lower PCV7 coverage (OR: 0.617, 98 % CI: 0.547, 0.695) than locals. CONCLUSIONS: There is a need for increasing overall pneumococcal coverage in Shanghai children, particularly with the more effective PCV7 vaccine. Morbidity and mortality due to invasive pneumococcal disease for children <1 year of age are unlikely to be mitigated if the current age-related vaccination patterns are not improved. |
Use of a 2-dose schedule for human papillomavirus vaccination - updated recommendations of the Advisory Committee on Immunization Practices
Meites E , Kempe A , Markowitz LE . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1405-1408 Vaccination against human papillomavirus (HPV) is recommended to prevent HPV infections and HPV-associated diseases, including cancers. Routine vaccination at age 11 or 12 years has been recommended by the Advisory Committee on Immunization Practices (ACIP) since 2006 for females and since 2011 for males (1,2). This report provides recommendations and guidance regarding use of HPV vaccines and updates ACIP HPV vaccination recommendations previously published in 2014 and 2015 (1,2). This report includes new recommendations for use of a 2-dose schedule for girls and boys who initiate the vaccination series at ages 9 through 14 years. Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons. |
WHO consultation on group B Streptococcus vaccine development: Report from a meeting held on 27-28 April 2016
Kobayashi M , Schrag SJ , Alderson MR , Madhi SA , Baker CJ , Sobanjo-Ter Meulen A , Kaslow DC , Smith PG , Moorthy VS , Vekemans J . Vaccine 2016 37 (50) 7307-7314 Globally, group B Streptococcus (GBS) remains a leading cause of sepsis and meningitis in infants in the first 90days of life. Intrapartum antibiotic prophylaxis (IAP) for women at increased risk of transmitting GBS to their newborns has been effective in reducing part, but not all, of the GBS disease burden in many high income countries (HICs). In low- and middle-income countries (LMICs), IAP use is low. Immunization of pregnant women with a GBS vaccine represents an alternative strategy to protecting newborns and young infants, through transplacental antibody transfer and potentially by reducing new vaginal colonization. This vaccination strategy was first suggested in the 1970s and several potential GBS vaccines have completed phase I/II clinical trials. During the 2015 WHO Product Development for Vaccines Advisory Committee meeting, GBS was identified as a high priority for the development of a vaccine for maternal immunization because of the major public health burden posed by GBS in LMICs, and the high technical feasibility for successful development. Following this meeting, the first WHO technical consultation on GBS vaccines was held on the 27th and 28th of April 2016, to consider development pathways for such vaccines, focused on their potential role in reducing newborn and young infant deaths and possibly stillbirths in LMICs. Discussion topics included: (1) pathophysiology of disease; (2) current gaps in the knowledge of global disease burden and serotype distribution; (3) vaccine candidates under development; (4) design considerations for phase III trials; and (5) pathways to licensure, policy recommendations and use. Efforts to address gaps identified in each of these areas are needed to establish the public health need for, the development and deployment of, efficacious GBS vaccines. In particular, more work is required to understand the global disease burden of GBS-associated stillbirths, and to develop quality-assured standardized antibody assays to identify correlates of protection. |
Parental-reported full influenza vaccination coverage of children in the u.S
Zhai Y , Santibanez TA , Kahn KE , Srivastav A . Am J Prev Med 2016 52 (4) e103-e113 INTRODUCTION: Depending upon influenza vaccination history, children aged 6 months-8 years need one or two doses of influenza vaccine to be considered fully vaccinated. The objectives of this study were to quantify the percentage of children aged 6 months-8 years who were fully vaccinated against influenza based on parental report, overall, by state, and by sociodemographic characteristics, and to examine sociodemographic characteristics associated with being fully vaccinated. METHODS: Data from the National Immunization Survey-Flu for the 2012-2013 and 2013-2014 influenza seasons were analyzed in 2015 using the Kaplan-Meier method to produce vaccination coverage estimates. Wald chi-square tests were used to test for bivariate associations, and Cox proportional hazards models were used to test for demographic characteristics independently associated with the child being fully vaccinated. RESULTS: The percentages of children aged 6 months-8 years who were fully vaccinated during the 2012-2013 and 2013-2014 influenza seasons were 41.0% and 45.2%, respectively. Full vaccination varied widely by state and was more likely for children requiring only one dose. Based on the statistical models, children likely to be fully vaccinated were older, non-black, had a mother with an education >12 years, or lived in a high-income household. CONCLUSIONS: Most children in the U.S. are not fully vaccinated against influenza. Reminder systems and interventions that reduce or remove barriers to children receiving their second doses of influenza vaccine may improve full influenza vaccination coverage among all children. |
Population impact and effectiveness of monovalent rotavirus vaccination in urban Malawian children 3 years after vaccine introduction: ecological and case-control analyses
Bar-Zeev N , Jere KC , Bennett A , Pollock L , Tate JE , Nakagomi O , Iturriza-Gomara M , Costello A , Mwansambo C , Parashar UD , Heyderman RS , French N , Cunliffe NA . Clin Infect Dis 2016 62 Suppl 2 S213-9 BACKGROUND: Rotavirus vaccines have been introduced in many low-income African countries including Malawi in 2012. Despite early evidence of vaccine impact, determining persistence of protection beyond infancy, the utility of the vaccine against specific rotavirus genotypes, and effectiveness in vulnerable subgroups is important. METHODS: We compared rotavirus prevalence in diarrheal stool and hospitalization incidence before and following rotavirus vaccine introduction in Malawi. Using case-control analysis, we derived vaccine effectiveness (VE) in the second year of life and for human immunodeficiency virus (HIV)-exposed and stunted children. RESULTS: Rotavirus prevalence declined concurrent with increasing vaccine coverage, and in 2015 was 24% compared with prevaccine mean baseline in 1997-2011 of 32%. Since vaccine introduction, population rotavirus hospitalization incidence declined in infants by 54.2% (95% confidence interval [CI], 32.8-68.8), but did not fall in older children. Comparing 241 rotavirus cases with 692 test-negative controls, VE was 70.6% (95% CI, 33.6%-87.0%) and 31.7% (95% CI, -140.6% to 80.6%) in the first and second year of life, respectively, whereas mean age of rotavirus cases increased from 9.3 to 11.8 months. Despite higher VE against G1P[8] than against other genotypes, no resurgence of nonvaccine genotypes has occurred. VE did not differ significantly by nutritional status (78.1% [95% CI, 5.6%-94.9%] in 257 well-nourished and 27.8% [95% CI, -99.5% to 73.9%] in 205 stunted children;P= .12), or by HIV exposure (60.5% [95% CI, 13.3%-82.0%] in 745 HIV-unexposed and 42.2% [95% CI, -106.9% to 83.8%] in 174 exposed children;P= .91). CONCLUSIONS: Rotavirus vaccination in Malawi has resulted in reductions in disease burden in infants <12 months, but not in older children. Despite differences in genotype-specific VE, no genotype has emerged to suggest vaccine escape. VE was not demonstrably affected by HIV exposure or stunting. |
Congenital anomalies: Case definition and guidelines for data collection, analysis, and presentation of immunization safety data
DeSilva M , Munoz FM , McMillan M , Kawai AT , Marshall H , Macartney KK , Joshi J , Oneko M , Rose AE , Dolk H , Trotta F , Spiegel H , Tomczyk S , Shrestha A , Kochhar S , Kharbanda EO . Vaccine 2016 34 (49) 6015-6026 Need for developing case definitions and guidelines for data collection, analysis, and presentation for congenital anomalies as an adverse event following immunization | Congenital anomalies, also commonly referred to as birth defects, congenital disorders, congenital malformations, or congenital abnormalities, are conditions of prenatal origin that are present at birth, potentially impacting an infant's health, development and/or survival. We will use the term congenital anomalies in this report. Congenital anomalies encompass a wide array of structural and functional abnormalities that can occur in isolation (i.e., single defect) or as a group of defects (i.e., multiple defects). Multiple defects may occur as part of well-described associations, such as the non-random co-occurrence of Vertebral anomalies, Anal atresia, Cardiac defects, Tracheoesophageal fistula, and/or Esophageal atresia, Renal and Radial anomalies, and Limb defects (VACTERL) [1]. | Congenital anomalies vary substantially in severity. Some congenital anomalies are associated with spontaneous abortion, stillbirth, or death in the early postnatal period. Global deaths due to congenital anomalies decreased from 750.6 thousand in 1990 to 632.1 thousand in 2013, with respective age-standardized death rates of 11.0 and 8.7 per 100,000 [2]. Subtypes of fatal congenital anomalies (with estimated number of global deaths in 2013 in thousands) are congenital heart anomalies (323.4), neural tube defects (68.9), Down's syndrome (36.4), and chromosomal unbalanced rearrangements (17.3) [2]. Other congenital anomalies may have little impact on survival. Anomalies which affect an infant's life expectancy, health status, physical or social functioning may be described as “major” anomalies. In contrast, “minor” anomalies are those with little or no impact on health or short-term or long-term function [3]. We have chosen to focus on major anomalies for this case definition due to their impact on public health and pre-existing structure for surveillance and reporting by large national and international organizations. |
Displaced populations due to humanitarian emergencies and its impact on global eradication and elimination of vaccine-preventable diseases
Lam E , Diaz M , Maina AG , Brennan M . Confl Health 2016 10 27 Populations affected by humanitarian emergencies may require unique strategies to ensure access to life-saving vaccines and attain sufficiently high population immunity to interrupt virus circulation. Vaccination strategies among displaced populations should not be an afterthought and must be part of the vaccine-preventable disease eradication and elimination initiatives from the start. |
The promise of electronic case reporting
MacKenzie WR , Davidson AJ , Wiesenthal A , Engel JP , Turner K , Conn L , Becker SJ , Moffatt S , Groseclose SL , Jellison J , Stinn J , Garrett NY , Helmus L , Harmon B , Richards CL , Lumpkin JR , Iademarco MF . Public Health Rep 2016 131 (6) 742-746 Public health surveillance is focused on the detection of acute, chronic, and emerging threats to the health of the population to direct disease control and prevention efforts.1 Public health surveillance relies on health care providers to report to public health agencies conditions or outbreaks that may impact the broader population. This case reporting is mandated through laws and regulations at the state and local levels. Notification of cases to the Centers for Disease Control and Prevention (CDC) is facilitated by agreements between states and the federal government.2 Historically, case reporting has been based on paper reports or Internet-based entry of reports to state health department systems, but these reports are often slow or incomplete and place a substantial burden of work on health care providers and public health agencies.3 The future of surveillance is electronic case reporting (eCR), by which cases of reportable conditions are automatically generated from electronic health record (EHR) systems and transmitted to public health agencies for review and action. | eCR holds promise for enhancing the quality and effectiveness of public health surveillance.4 Greater use of eCR could result in (1) more complete and accurate case data in near real time for public health action; (2) earlier detection of cases, permitting earlier intervention and lowered transmission of disease; (3) improved detection of outbreaks to allow earlier investigation and, potentially, earlier identification of risk factors for the spread of disease; and (4) creation of a new infrastructure to support rapid reporting of newly recognized and emerging conditions. In this commentary, we review the promise of eCR and present our vision for a nationally interoperable eCR system that allows for timely reporting to public health and information sharing among jurisdictions. |
Talking with young children about concussions: an exploratory study
Kroshus E , Gillard D , Haarbauer-Krupa J , Goldman RE , Bickham DS . Child Care Health Dev 2016 43 (5) 758-767 BACKGROUND: Concussion education for children early in their participation in organized sport may help shape lasting attitudes about concussion safety. However, existing programming and research focus on older ages. METHODS: Qualitative interviews about concussions were conducted with twenty children between the ages of six and eight. Structural, descriptive and pattern coding were used to organize the transcribed interviews and identify emergent themes. RESULTS: Eighteen of the participants indicated that they had heard of the word concussion, with 12 describing the injury as related to the brain or head. The most frequently described mechanisms of injury were impacts to the head or falls, and symptoms tended to be somatic, such as generalized pain. The most frequently endorsed strategy to avoid sustaining a concussion was to 'follow the rules.' Multiple participants referenced parents as an informal source of information about concussions. CONCLUSIONS: While most participants demonstrated some awareness about concussions, there were clear knowledge gaps that can be addressed with developmentally appropriate concussion education programming. Consistent with their developmental stage, interventions targeted at children in this age range may be most successful if they use basic logic, concrete ideas, provide rules to be followed and engage parents in dissemination. |
The potential role of science, technology, engineering, and math programs in reducing teen dating violence and intimate partner violence
D'Inverno AS , Kearns MC , Reidy DE . J Womens Health (Larchmt) 2016 25 (12) 1199-1203 Science, technology, engineering, and math (STEM) are growing fields that provide job stability, financial security, and health prosperity for professionals in these fields. Unfortunately, females are underrepresented in STEM, which is potentially both a consequence and precipitant of gender inequity in the United States. In addition to the financial and health benefits, increasing the number of girls and women in STEM fields may also indirectly prevent and/or reduce teen dating violence and intimate partner violence by: (1) increasing women's financial independence, thereby reducing dependence on potentially abusive partners; (2) decreasing household poverty and financial stress, which may lead to reductions in relationship discord; and (3) increasing attitudes and beliefs about women as equals, thereby increasing gender equity. In this commentary, we discuss the potential role of primary and secondary school STEM programs in reducing violence against women. We review the literature on existing evaluations of STEM programs for educational outcomes, discuss the limitations of these evaluations, and offer suggestions for future research. |
The association between adverse childhood experiences and risk of cancer in adulthood: a systematic review of the literature
Holman DM , Ports KA , Buchanan ND , Hawkins NA , Merrick MT , Metzler M , Trivers KF . Pediatrics 2016 138 S81-s91 CONTEXT: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. OBJECTIVE: This systematic review summarizes the literature on associations between ACEs and risk of cancer in adulthood. DATA SOURCES: We searched PubMed to identify relevant publications published on or before May 31, 2015. STUDY SELECTION: We included original research quantifying the association between ACEs and adult cancer incidence. Case reports and reviews were excluded. DATA ABSTRACTION: Two reviewers independently abstracted and summarized key information (eg, ACE type, cancer type, risk estimates) from included studies and resolved all discrepancies. RESULTS: Twelve studies were included in the review. In studies in which ACE summary scores were calculated, significant associations were observed between the scores and an increased risk of cancer in adulthood. Of the different types of ACEs examined, physical and psychological abuse victimization were associated with risk of any cancer in 3 and 2 studies, respectively. Two studies also reported significant associations with regard to sexual abuse victimization (1 for cervical cancer and 1 for any cancer). However, 2 other studies reported no significant associations between childhood sexual or physical abuse and incidence of cervical or breast cancer. LIMITATIONS: Because of heterogeneity across studies, we were unable to compute a summary effect estimate. CONCLUSIONS: These findings suggest that childhood adversity in various forms may increase a person's cancer risk. Further research is needed to understand the mechanisms driving this relationship and to identify opportunities to prevent and mitigate the deleterious effects of early adversity on long-term health. |
Serro 2 Virus Highlights the Fundamental Genomic and Biological Features of a Natural Vaccinia Virus Infecting Humans.
Trindade GS , Emerson GL , Sammons S , Frace M , Govil D , Fernandes Mota BE , Abrahao JS , de Assis FL , Olsen-Rasmussen M , Goldsmith CS , Li Y , Carroll D , Guimaraes da Fonseca F , Kroon E , Damon IK . Viruses 2016 8 (12) Vaccinia virus (VACV) has been implicated in infections of dairy cattle and humans, and outbreaks have substantially impacted local economies and public health in Brazil. During a 2005 outbreak, a VACV strain designated Serro 2 virus (S2V) was collected from a 30-year old male milker. Our aim was to phenotypically and genetically characterize this VACV Brazilian isolate. S2V produced small round plaques without associated comets when grown in BSC40 cells. Furthermore, S2V was less virulent than the prototype strain VACV-Western Reserve (WR) in a murine model of intradermal infection, producing a tiny lesion with virtually no surrounding inflammation. The genome of S2V was sequenced by primer walking. The coding region spans 184,572 bp and contains 211 predicted genes. Mutations in envelope genes specifically associated with small plaque phenotypes were not found in S2V; however, other alterations in amino acid sequences within these genes were identified. In addition, some immunomodulatory genes were truncated in S2V. Phylogenetic analysis using immune regulatory-related genes, besides the hemagglutinin gene, segregated the Brazilian viruses into two clusters, grouping the S2V into Brazilian VACV group 1. S2V is the first naturally-circulating human-associated VACV, with a low passage history, to be extensively genetically and phenotypically characterized. |
Laboratory Investigation of <i>Salmonella enterica</i> serovar Poona Outbreak in California: Comparison of Pulsed-Field Gel Electrophoresis (PFGE) and Whole Genome Sequencing (WGS) Results.
Kozyreva VK , Crandall J , Sabol A , Poe A , Zhang P , Concepcion-Acevedo J , Schroeder MN , Wagner D , Higa J , Trees E , Chaturvedi V . PLoS Curr 2016 8 INTRODUCTION: Recently, Salmonella enterica serovar Poona caused a multistate outbreak, with 245 out of 907 cases occurring in California. We report a comparison of pulsed-field gel electrophoresis (PFGE) results with whole genome sequencing (WGS) for genotyping of Salmonella Poona isolates. METHODS: CA Salmonella Poona isolates, collected from July to August 2015, were genotyped by PFGE using XbaI restriction enzyme. WGS was done using Nextera XT library kit with 2x300 bp or 2x250 bp sequencing chemistry on the Illumina MiSeq Sequencer. Reads were mapped to the de novo assembled serovar Poona draft genome (48 contigs, N50= 223,917) from the outbreak using CLCbio GW 8.0.2. The phylogenetic tree was generated based on hqSNPs calling. Genomes were annotated with CGE and PHAST online tools. In silico MLST was performed using the CGE online tool. RESULTS: Human (14) and cucumber (2) Salmonella Poona isolates exhibited 3 possibly related PFGE patterns (JL6X01.0018 [predominant], JL6X01.0375, JL6X01.0778). All isolates that were related by PFGE also clustered together according to the WGS. One isolate with a divergent PFGE pattern (JL6X01.0776) served as an outlier in the phylogenetic analysis and substantially differed from the outbreak clade by WGS. All outbreak isolates were assigned to MLST sequence type 447. The majority of the outbreak-related isolates possessed the same set of Salmonella Pathogenicity Islands with few variations. One outbreak isolate was sequenced and analyzed independently by CDC and CDPH laboratories; there was 0 SNP difference in results. Additional two isolates were sequenced by CDC and the raw data was processed through CDPH and CDC analysis pipelines. Both data analysis pipelines also generated concordant results. Discussion: PFGE and WGS results for the recent CA Salmonella enterica serovar Poona outbreak provided concordant assignment of the isolates to the outbreak cluster. WGS allowed more robust determination of genetic relatedness, provided information regarding MLST-type, pathogenicity genes, and bacteriophage content. WGS data obtained independently at two laboratories showed complete agreement. |
Integrating advanced molecular technologies into public health.
Gwinn M , MacCannell DR , Khabbaz RF . J Clin Microbiol 2016 55 (3) 703-714 Advances in laboratory and information technologies are transforming public health microbiology. High-throughput genome sequencing and bioinformatics are enhancing our ability to investigate and control outbreaks, detect emerging infectious diseases, develop vaccines, and combat antimicrobial resistance-all with increased accuracy, timeliness, and efficiency. The Advanced Molecular Detection (AMD) initiative has allowed the Centers for Disease Control and Prevention (CDC) to provide leadership and coordination in integrating new technologies into routine practice throughout the US public health laboratory system. Collaboration and partnerships are the key to navigating this transition and to leveraging the next generation of methods and tools most effectively for public health. |
Evaluation of the GeneXpert for Human Monkeypox Diagnosis.
Li D , Wilkins K , McCollum AM , Osadebe L , Kabamba J , Nguete B , Likafi T , Balilo MP , Lushima RS , Malekani J , Damon IK , Vickery MC , Pukuta E , Nkawa F , Karhemere S , Tamfum JM , Okitolonda EW , Li Y , Reynolds MG . Am J Trop Med Hyg 2016 96 (2) 405-410 Monkeypox virus (MPXV), a zoonotic orthopoxvirus (OPX), is endemic in the Democratic Republic of Congo (DRC). Currently, diagnostic assays for human monkeypox (MPX) focus on real-time quantitative polymerase chain reaction (qPCR) assays, which are typically performed in sophisticated laboratory settings. Herein, we evaluate the accuracy and utility of a multiplex MPXV assay using the GeneXpert platform, a portable rapid diagnostic device that may serve as a point-of-care test to diagnose infections in endemic areas. The multiplex MPX/OPX assay includes a MPX-specific qPCR test, OPX-generic qPCR test, and an internal control qPCR test. In total, 164 diagnostic specimens (50 crusts and 114 vesicular swabs) were collected from suspected MPX cases in Tshuapa District, DRC, under national surveillance guidelines. The specimens were tested with the GeneXpert MPX/OPX assay and an OPX qPCR assay at the Institut National de Recherche Biomedicale (INRB) in Kinshasa. Aliquots of each specimen were tested in parallel with a q-specific MPX qPCR assay at the Centers for Disease Control and Prevention. The results of the MPX qPCR were used as the gold standard for all analyses. The GeneXpert MPX/OPX assay performed at INRB had a sensitivity of 98.8% and specificity of 100%. The GeneXpert assay performed well with both crust and vesicle samples. The GeneXpert MPX/OPX test incorporates a simple methodology that performs well in both laboratory and field conditions, suggesting its viability as a diagnostic platform that may expand and expedite current MPX detection capabilities. |
Burkholderia humptydooensis sp. nov., a New Species Related to Burkholderia thailandensis and the Fifth Member of the Burkholderia pseudomallei Complex.
Tuanyok A , Mayo M , Scholz H , Hall CM , Allender CJ , Kaestli M , Ginther J , Spring-Pearson S , Bollig MC , Stone JK , Settles EW , Busch JD , Sidak-Loftis L , Sahl JW , Thomas A , Kreutzer L , Georgi E , Gee JE , Bowen RA , Ladner JT , Lovett S , Koroleva G , Palacios G , Wagner DM , Currie BJ , Keim P . Appl Environ Microbiol 2016 83 (5) During routine screening for endemic Burkholderia pseudomallei from water wells in northern Australia, Gram-staining-negative bacteria (strains MSMB43T, MSMB121, and MSMB122) with a similar morphology and biochemical pattern to B. pseudomallei and B. thailandensis were co-isolated with B. pseudomallei on Ashdown's selective agar. To determine the exact taxonomic position of these strains and to distinguish them from B. pseudomallei and B. thailandensis, they were subjected to a series of phenotypic and molecular analyses. Biochemical and fatty acid methyl esters analysis was unable to distinguish B. humptydooensis sp. nov. from closely related species. In MALDI-TOF analysis, all isolates grouped together in a cluster separate from other Burkholderia spp. 16S rRNA and recA sequence analysis demonstrated phylogenetic placement for B. humptydooensis sp. nov. in a novel clade within the B. pseudomallei group. MLST analysis of the three isolates in comparison with MLST data from 3,340 B. pseudomallei strains and related taxa revealed a new sequence type (ST318). Genome to genome distance calculations and average nucleotide identity of all isolates to both B. thailandensis and B. pseudomallei, based on whole genome sequences, also confirmed B. humptydooensis sp. nov. as a novel Burkholderia species within the pseudomallei complex. Molecular analyses clearly demonstrate that strains MSMB43T, MSMB121, and MSMB122 belong to a novel Burkholderia species for which the name Burkholderia humptydooensis sp. nov. is proposed with the type strain MSMB43T (=BAA-2767; LMG 29471, CP013380-CP013382). IMPORTANCE: Burkholderia pseudomallei is a soil dwelling bacteria and the causative agent of melioidosis. The genus Burkholderia consists of a diverse group of species with the closest relatives of B. pseudomallei referred to as the B. pseudomallei complex. A proposed novel species, B. humptydooensis sp. nov, was isolated from a bore water sample from the Northern Territory in Australia. B. humptydooensis sp. nov., is phylogenetically distinct from B. pseudomallei and other members of the pseudomallei complex making it the fifth member of this important group of bacteria. |
Secretomes of Mycoplasma hyopneumoniae and Mycoplasma flocculare reveal differences associated to pathogenesis.
Paes JA , Lorenzatto KR , de Moraes SN , Moura H , Barr JR , Ferreira HB . J Proteomics 2016 154 69-77 Mycoplasma hyopneumoniae and Mycoplasma flocculare cohabit the porcine respiratory tract. However, M. hyopneumoniae causes the porcine enzootic pneumonia, while M. flocculare is a commensal bacterium. Comparative analyses demonstrated high similarity between these species, which includes the sharing of all predicted virulence factors. Nevertheless, studies related to soluble secretomes of mycoplasmas were little known, although they are important for bacterial-host interactions. The aim of this study was to perform a comparative analysis between the soluble secreted proteins repertoires of the pathogenic Mycoplasma hyopneumoniae and its closely related commensal Mycoplasma flocculare. For that, bacteria were cultured in medium with reduced serum concentration and secreted proteins were identified by a LC-MS/MS proteomics approach. Altogether, 62 and 26 proteins were identified as secreted by M. hyopneumoniae and M. flocculare, respectively, being just seven proteins shared between these bacteria. In M. hyopneumoniae secretome, 15 proteins described as virulence factors were found; while four putative virulence factors were identified in M. flocculare secretome. For the first time, clear differences related to virulence were found between these species, helping to elucidate the pathogenic nature of M. hyopneumoniae to swine hosts. BIOLOGICAL SIGNIFICANCE: For the first time, the secretomes of two porcine respiratory mycoplasmas, namely the pathogenic M. hyopneumoniae and the commensal M. flocculare were compared. The presented results revealed previously unknown differences between these two genetically related species, some of which are associated to the M. hyopneumoniae ability to cause porcine enzootic pneumonia. |
Simultaneous Emergence of Multidrug-Resistant Candida auris on 3 Continents Confirmed by Whole-Genome Sequencing and Epidemiological Analyses.
Lockhart SR , Etienne KA , Vallabhaneni S , Farooqi J , Chowdhary A , Govender NP , Colombo AL , Calvo B , Cuomo CA , Desjardins CA , Berkow EL , Castanheira M , Magobo RE , Jabeen K , Asghar RJ , Meis JF , Jackson B , Chiller T , Litvintseva AP . Clin Infect Dis 2016 64 (2) 134-140 BACKGROUND: Candida auris, a multidrug-resistant yeast that causes invasive infections, was first described in 2009 in Japan and has since been reported from several countries. METHODS: To understand the global emergence and epidemiology of C. auris, we obtained isolates from 54 patients with C. auris infection from Pakistan, India, South Africa, and Venezuela during 2012-2015 and the type specimen from Japan. Patient information was available for 41 of the isolates. We conducted antifungal susceptibility testing and whole-genome sequencing (WGS). RESULTS: Available clinical information revealed that 41% of patients had diabetes mellitus, 51% had undergone recent surgery, 73% had a central venous catheter, and 41% were receiving systemic antifungal therapy when C. auris was isolated. The median time from admission to infection was 19 days (interquartile range, 9-36 days), 61% of patients had bloodstream infection, and 59% died. Using stringent break points, 93% of isolates were resistant to fluconazole, 35% to amphotericin B, and 7% to echinocandins; 41% were resistant to 2 antifungal classes and 4% were resistant to 3 classes. WGS demonstrated that isolates were grouped into unique clades by geographic region. Clades were separated by thousands of single-nucleotide polymorphisms, but within each clade isolates were clonal. Different mutations in ERG11 were associated with azole resistance in each geographic clade. CONCLUSIONS: C. auris is an emerging healthcare-associated pathogen associated with high mortality. Treatment options are limited, due to antifungal resistance. WGS analysis suggests nearly simultaneous, and recent, independent emergence of different clonal populations on 3 continents. Risk factors and transmission mechanisms need to be elucidated to guide control measures. |
Trends in testing for Mycobacterium tuberculosis complex from US Public Health Laboratories, 2009-2013
Tyrrell F , Stafford C , Yakrus M , Youngblood M , Hill A , Johnston S . Public Health Rep 2017 132 (1) 56-64 OBJECTIVE: We investigated data from US public health laboratories funded through the Centers for Disease Control and Prevention's Tuberculosis Elimination and Laboratory Cooperative Agreement to document trends and challenges in meeting national objectives in tuberculosis (TB) laboratory diagnoses. METHODS: We examined data on workload and turnaround time from public health laboratories' progress reports during 2009-2013. We reviewed methodologies, laboratory roles, and progress toward rapid detection of Mycobacterium tuberculosis complex through nucleic acid amplification (NAA) testing. We compared selected data with TB surveillance reports to estimate public health laboratories' contribution to national diagnostic services. RESULTS: During the study period, culture and drug susceptibility tests decreased, but NAA testing increased. Public health laboratories achieved turnaround time benchmarks for drug susceptibility tests at lower levels than for acid-fast bacilli smear and identification from culture. NAA positivity in laboratories among surveillance-reported culture-positive TB cases increased from 26.6% (2355 of 8876) in 2009 to 40.0% (2948 of 7358) in 2013. Public health laboratories provided an estimated 50.9% (4285 of 8413 in 2010) to 57.2% (4210 of 7358 in 2013) of culture testing and 88.3% (6822 of 7727 in 2011) to 94.4% (6845 of 7250 in 2012) of drug susceptibility tests for all US TB cases. CONCLUSIONS: Public health laboratories contribute substantially to TB diagnoses in the United States. Although testing volumes mostly decreased, the increase in NAA testing indicates continued progress in rapid M tuberculosis complex detection. |
Hollow carbon spheres trigger inflammasome-dependent IL-1beta secretion in macrophages
Andon FT , Mukherjee SP , Gessner I , Wortmann L , Xiao L , Hultenby K , Shvedova AA , Mathur S , Fadeel B . Carbon N Y 2017 113 243-251 It is disputed whether inflammasome activation leading to secretion of pro-inflammatory interleukin (IL)-1beta in macrophages transpires independently of cell death or whether the two processes are linked. Here, we synthesized hollow carbon spheres (HCS) and investigated their effects on primary human monocyte-derived macrophages (HMDM); short (500 nm) non-functionalized single-walled carbon nanotubes (SWCNT) were included for comparison. HCS (250 nm) were readily taken up by HMDM and induced ROS production, but did not trigger a loss of cell viability. However, a dose- and time-dependent release of IL-1beta was detected in lipopolysaccharide (LPS)-primed macrophages upon exposure to HCS, while SWCNT-induced secretion of IL-1β was less pronounced. HCS-triggered IL-1beta secretion was cathepsin B- and caspase-1-dependent, and was accompanied by a reduction in intracellular K+. Furthermore, cytokine secretion was reduced following treatment with the antioxidant, N-acetylcysteine, and cytochalasin D, an inhibitor of actin polymerization. HCS also triggered IL-1beta release in LPS-primed THP.1 cells, but not in THP.1 cells with silencing of ASC, NLRP3, or caspase-1 expression, providing evidence that IL-1beta was elicited through NLRP3 inflammasome activation. These studies shed light on the effects of HCS on primary macrophages, and show that spherical carbon-based nanoparticles are potent inflammasome activators. |
Characterization of an aerosol microconcentrator for analysis using microscale optical spectroscopies
Zheng L , Kulkarni P , Zavvos K , Liang H , Birch ME , Dionysiou DD . J Aerosol Sci 2017 104 66-78 Efficient microconcentration of aerosols to a substrate is essential for effectively coupling the collected particles to microscale optical spectroscopies such as laser-induced or spark microplasma, or micro-Raman or infrared spectroscopies. In this study, we present detailed characterization of a corona-based aerosol microconcentration technique developed previously (Diwakar & Kulkarni, 2012). The method involves two coaxial electrodes separated by a few millimeters, one held at a high electrical potential and the other grounded. The particles are collected on the collection (i.e., ground) electrode from a coaxial aerosol flow in a one-step charge-and-collect scheme using corona discharge and electrical precipitation between the two electrodes. Performance of the corona microconcentration method was determined experimentally by measuring collection efficiency, wall losses, and particle deposition density. An intrinsic spectroscopic sensitivity was experimentally determined for the aerosol microconcentrator. Using this sensitivity, we show that corona-based microconcentration is much superior to alternative methods, including filtration, focused impaction using aerodynamic lens, and spot collection using condensational growth. The method offers unique advantages for compact, hand-held aerosol analytical instrumentation. |
Rapid and sensitive point-of-care detection of Orthopoxviruses by ABICAP immunofiltration
Stern D , Olson VA , Smith SK , Pietraszczyk M , Miller L , Miethe P , Dorner BG , Nitsche A . Virol J 2016 13 (1) 207 BACKGROUND: The rapid and reliable detection of infectious agents is one of the most challenging tasks in scenarios lacking well-equipped laboratory infrastructure, like diagnostics in rural areas of developing countries. Commercially available point-of-care diagnostic tests for emerging and rare diseases are particularly scarce. RESULTS: In this work we present a point-of-care test for the detection of Orthopoxviruses (OPV). The OPV ABICAP assay detects down to 1 x 104 plaque forming units/mL of OPV particles within 45 min. It can be applied to clinical material like skin crusts and detects all zoonotic OPV infecting humans, including Vaccinia, Cowpox, Monkeypox, and most importantly Variola virus. CONCLUSIONS: Given the high sensitivity and the ease of handling, the novel assay could be highly useful for on-site diagnostics of suspected Monkeypox virus infections in areas lacking proper laboratory infrastructure as well as rapid on-site testing of suspected bioterrorism samples. |
Role of H7 hemagglutinin in murine infectivity of influenza viruses following ocular inoculation
Belser JA , Sun X , Creager HM , Johnson A , Ridenour C , Chen LM , Tumpey TM , Maines TR . Virology 2016 502 13-19 H7 subtype influenza viruses have demonstrated an ocular tropism in humans, causing conjunctivitis and not respiratory symptoms in many infected individuals. However, the molecular determinants which confer ocular tropism are still poorly understood. Here, we used a murine model of ocular inoculation to demonstrate that H7 influenza viruses are more likely to cause infection following ocular exposure than are non-H7 subtype viruses. We included investigation regarding the potential role of several properties of influenza viruses with murine infectivity following ocular inoculation, including virus lineage, pathogenicity, and HA cleavage site composition. Furthermore, we examined the potential contribution of internal proteins to murine ocular infectivity. These studies establish a link between H7 subtype viruses and the risk of heightened infectivity in a mammalian species following ocular exposure, and support the development of non-traditional inoculation methods and models to best understand the human risk posed by influenza viruses of all subtypes. |
Surveillance at private laboratories identifies small outbreaks of hepatitis E in urban Bangladesh
Sazzad HM , Labrique AB , Teo CG , Luby SP , Gurley ES . Am J Trop Med Hyg 2016 96 (2) 395-399 Although large outbreaks of hepatitis E are regularly identified in south Asia, the majority of south Asian countries lack surveillance systems for this disease, which has hindered burden of disease estimates and prioritization of resources for prevention. Our study aimed to identify small hepatitis E outbreaks through a sentinel private laboratory in Dhaka, Bangladesh. We identified patients with detectable IgM antibody against hepatitis E virus. We defined a small outbreak as at least two laboratory-confirmed cases or ≥ 2 acute jaundice cases from the sentinel cases' family, neighborhood, or workplace. From November 2008 to November 2009, we identified 29 small outbreaks of hepatitis E from one private laboratory. The median number of cases in each outbreak was three. Cases were identified every month. Eighteen outbreaks occurred among families or neighbors, and 11 in the workplace. Among 103 cases identified as part of outbreaks, 31 (30%) sought care for diagnosis. In Bangladesh, collaboration between government public health surveillance and private laboratories can strengthen capacity for outbreak detection and improve estimates of disease burden. |
Thrombospondin-1 mediates multi-walled carbon nanotube induced impairment of arteriolar dilation
Mandler WK , Nurkiewicz TR , Porter DW , Olfert IM . Nanotoxicology 2016 11 (1) 1-31 Pulmonary exposure to multi-walled carbon nanotubes (MWCNT) has been shown to disrupt endothelium-dependent arteriolar dilation in the peripheral microcirculation. The molecular mechanisms behind these arteriolar disruptions have yet to be fully elucidated. The secreted matricellular matrix protein thrombospondin-1 (TSP-1) is capable of moderating arteriolar vasodilation by inhibiting soluble guanylate cyclase activity. We hypothesized that TSP-1 may be a link between nanomaterial exposure and observed peripheral microvascular dysfunction. To test this hypothesis, wild-type C57B6J (WT) and TSP-1 knockout (KO) mice were exposed via lung aspiration to 50 microg MWCNT or a sham dispersion medium control. Following exposure (24hrs), arteriolar characteristics and reactivity were measured in the gluteus maximus muscle using intravital microscopy (IVM) coupled with microiontophoretic delivery of acetylcholine (ACh) or sodium nitroprusside (SNP). In WT mice exposed to MWCNT, skeletal muscle TSP-1 protein increased > 5-fold compared to sham exposed, and exhibited a 39% and 47% decrease in endothelium-dependent and independent vasodilation, respectively. In contrast, TSP-1 protein was not increased following MWCNT exposure in KO mice and exhibited no loss in dilatory capacity. Microvascular leukocyte leukocyte-endothelium interactions were measured by leukocyte adhesion and rolling activity in assessing third order venules. The WT+MWCNT group demonstrated 223% higher leukocyte rolling compared to WT+SHAM controls. TSP-1 KO animals exposed to MWCNT showed no differences from WT+SHAM control. These data provide evidence that TSP-1 is likely a central mediator of the systemic microvascular dysfunction that follows pulmonary MWCNT exposure. |
Long-term sentinel surveillance for enterotoxigenic Escherichia coli and non-0157 shiga toxin-producing E. coli in Minnesota
Medus C , Besser JM , Juni BA , Koziol B , Lappi V , Smith KE , Hedberg CW . Open Forum Infect Dis 2016 3 (1) ofw003 Background. Enterotoxigenic Escherichia coli (ETEC) and non-O157 Shiga toxin-producing E. coli (STEC) are not detected by conventional culture methods. The prevalence of ETEC infections in the United States is unknown, and recognized cases are primarily associated with foreign travel. Gaps remain in our understanding of STEC epidemiology. Methods. Two sentinel surveillance sites were enrolled: an urban health maintenance organization laboratory (Laboratory A) and a rural hospital laboratory (Laboratory B). Residual sorbitol MacConkey (SMAC) plates from stool cultures performed at Laboratory A (1996-2006) and Laboratory B (2000-2008) were collected. Colony sweeps from SMAC plates were tested for genes encoding STEC toxins stx1 and stx2 (1996-2008) and ETEC heat-labile and heat-stable toxins eltB, estA 1, 2 and 3 (2000-2008) by polymerase chain reaction (PCR)-based assays. Results. In Laboratory A, a bacterial pathogen was identified in 7.0% of 21 970 specimens. During 1996-2006, Campylobacter was the most common bacterial pathogen (2.7% of cultures), followed by Salmonella (1.2%), Shigella (1.0%), and STEC (0.9%). Among STEC (n = 196), O157 was the most common serogroup (31%). During 2000-2006, ETEC (1.9%) was the second most common bacterial pathogen after Campylobacter (2.6%). In Laboratory B, of 19 293 specimens tested, a bacterial pathogen was identified for 5.5%, including Campylobacter (2.1%), STEC (1.3%), Salmonella (1.0%), and ETEC (0.8%). Among STEC (n = 253), O157 was the leading serogroup (35%). Among ETEC cases, 61% traveled internationally. Conclusions. Enterotoxigenic E. coli and STEC infections were as common as most other enteric bacterial pathogens, and ETEC may be detected more frequently by culture-independent multiplex PCR diagnostic methods. A high proportion of ETEC cases were domestically acquired. |
Performance of Celera RUO integrase resistance assay across multiple HIV-1 subtypes
Wallis CL , Viana RV , Saravanan S , de Jesus CS , Zeh C , Halvas EK , Mellors JW . J Virol Methods 2016 241 41-45 BACKGROUND: HIV-1 sequence variation is a major obstacle to developing molecular based assays for multiple subtypes. This study sought to independently assess performance characteristics of the ViroSeq HIV-1 Integrase RUO Genotyping Kit (Celera, US) for samples of multiple different HIV-1 subtypes. METHODS: 264 samples were tested in the validation, 106 from integrase inhibitor naive patients' sent for routine HIV-1 drug resistance testing after failing a 1st- or 2nd-line regimen, and 158 samples from an external virology quality assurance program (VQA). For the latter, 53 unique VQA samples were tested in two to five different laboratories to assess assay reproducibility. For all assays, viral RNA was extracted using the ViroSeq extraction module, reverse transcribed, and amplified in a one-step reaction. Four sequencing primers were used to span codons 1-288 of integrase. The Rega subtyping tool was used for subtype assignment. Integrase polymorphisms and mutations were determined as differences from the HXB2 sequence and by the Stanford database, respectively. Sequences obtained from the different laboratories were aligned and sequence homology determined. RESULTS: HIV-1 RNA in the 264 samples ranged from 3.15 to 6.74logcopies/ml. Successful amplification was obtained for 97% of samples (n=256). The 8 samples that failed to amplify were subtype D (n=3), subtype C (n=1), CRF01_AE (n=1), subtype A1 (n=2), and an unassigned subtype (n=1). Of the 256 that successfully amplified samples, 203 (79%) were successfully sequenced with bidirectional coverage. Of the 53 unsuccessful samples, 13 (5%) failed sequencing and 40 (16%) did not have full bidirectional sequence, as a result of failure of sequencing primers: Primer A (n=1); Primer B (n=18); Primer C (n=1); Primer D (n=7) or short sequences (n=16). For the 135 VQA samples (30 unique samples) that were assayed by different laboratories, homology of the sequences obtained ranged from 92.1% to 100%. However, Laboratory 2 detected more mixtures (74%) compared to the other four laboratories, whereas Laboratory 1 detected the least number of mixtures (35%), likely due to differences between the labs in the methods of sequence analysis. Mutations associated with integrase resistance were observed in seven of the 106 (7%) clinical samples [one sample: Q148K; E138K; G140A; two samples: T97A and four samples: L74I]. Of the four samples with L74I, 3 were subtype G. CONCLUSION: Of the total 264 samples tested, 243 (92%) of samples were able to be amplified and sequenced to generate an integrase genotype. Sequencing results were similar between the testing laboratories with the exception of mixture detection. Mutations associated with integrase inhibitor resistance were observed in only 7% of integrase inhibitor naive samples, and some of these mutations are likely to be due to subtype-specific polymorphisms rather than selection by an integrase inhibitor. |
25-hydroxycholesterol inhibition of Lassa virus infection through aberrant GP1 glycosylation
Shrivastava-Ranjan P , Bergeron E , Chakrabarti AK , Albarino CG , Flint M , Nichol ST , Spiropoulou CF . mBio 2016 7 (6) Lassa virus (LASV) infection is a major public health concern due to high fatality rates and limited effective treatment. The interferon-stimulated gene cholesterol 25-hydroxylase (CH25H) encodes an enzyme that catalyzes the production of 25-hydroxycholesterol (25HC). 25HC is involved in regulating cholesterol biosynthesis and has recently been identified as a potent antiviral targeting enveloped virus entry. Here, we show a previously unrecognized role of CH25H in inhibiting LASV glycoprotein glycosylation and the production of infectious virus. Overexpression of CH25H or treatment with 25HC decreased LASV G1 glycoprotein N-glycan maturation and reduced the production of infectious LASV. Depletion of endogenous CH25H using small interfering RNA (siRNA) enhanced the levels of fully glycosylated G1 and increased infectious LASV production. Finally, LASV particles produced from 25HC-treated cells were found to be less infectious, to incorporate aberrantly glycosylated GP1 species, and to be defective in binding alpha-dystroglycan, an attachment and entry receptor. Our findings identify a novel role for CH25H in controlling LASV propagation and indicate that manipulation of the expression of CH25H or the administration of 25HC may be a useful anti-LASV therapy. IMPORTANCE: Lassa fever is an acute viral hemorrhagic fever in humans caused by Lassa virus (LASV). No vaccine for LASV is currently available. Treatment is limited to the administration of ribavirin, which is only effective when given early in the course of illness. Cholesterol 25-hydroxylase (CH25H) is a recently identified interferon-stimulated gene (ISG); it encodes an enzyme that catalyzes the production of 25-hydroxycholesterol (25HC), which inhibits several viruses. Here, we identify a novel antiviral mechanism of 25HC that is dependent on inhibiting the glycosylation of Lassa virus (LASV) glycoprotein and reducing the infectivity of LASV as a means of suppressing viral replication. Since N-linked glycosylation is a critical feature of other enveloped-virus glycoproteins, 25HC may be a broad inhibitor of virus infectivity. |
Antibacterial and antiviral effectiveness of two household water treatment devices that use monobrominated hydantoinylated polystyrene
Enger KS , Leak ES , Aw TG , Coulliette AD , Rose JB . J Water Health 2016 14 (6) 950-960 Many different household water treatment (HWT) methods have been researched and promoted to mitigate the serious burden of diarrheal disease in developing countries. However, HWT methods using bromine have not been extensively evaluated. Two gravity-fed HWT devices (AquaSure and Waterbird) were used to test the antimicrobial effectiveness of HaloPure(R) Br beads (monobrominated hydantoinylated polystyrene) that deliver bromine. As water flows over the beads, reactive bromine species are eluted, which inactivate microorganisms. To assess log10 reduction values (LRVs) for Vibrio cholerae, Salmonella enterica Typhimurium, bacteriophage MS2, human adenovirus 2 (HAdV2), and murine norovirus (MN), these organisms were added to potable water and sewage-contaminated water. These organisms were quantified before and after water treatment by the HWT devices. On average, 6 LRVs against Vibrio were attained, as well as 5 LRVs against Salmonella, 4 LRVs against MS2, 5 LRVs against HAdV2, and 3 LRVs against MN. Disinfection was similar regardless of whether sewage was present. Polymer beads delivering bromine to drinking water are a potentially effective and useful component of HWT methods in developing countries. |
Differential activation of RAW 264.7 macrophages by size-segregated crystalline silica
Mischler SE , Cauda EG , Di Giuseppe M , McWilliams LJ , St Croix C , Sun M , Franks J , Ortiz LA . J Occup Med Toxicol 2016 11 57 BACKGROUND: Occupational exposure to crystalline silica is a well-established occupational hazard. Once in the lung, crystalline silica particles can result in the activation of alveolar macrophages (AM), potentially leading to silicosis, a fibrotic lung disease. Because the activation of alveolar macrophages is the beginning step in a complicated inflammatory cascade, it is necessary to define the particle characteristics resulting in this activation. The aim of this research was to determine the effect of the size of crystalline silica particles on the activation of macrophages. METHODS: RAW 264.7 macrophages were exposed to four different sizes of crystalline silica and their activation was measured using electron microscopy, reactive oxygen species (ROS) generation by mitochondria, and cytokine expression. RESULTS: These data identified differences in particle uptake and formation of subcellular organelles based on particle size. In addition, these data show that the smallest particles, with a geometric mean of 0.3 mum, significantly increase the generation of mitochondrial ROS and the expression of cytokines when compared to larger crystalline silica particles, with a geometric mean of 4.1 mum. CONCLUSION: In summary, this study presents novel data showing that crystalline silica particles with a geometric mean of 0.3 mum enhance the activation of AM when compared to larger silica particles usually represented in in vitro and in vivo research. |
Development of a Machine Learning Algorithm for the Surveillance of Autism Spectrum Disorder.
Maenner MJ , Yeargin-Allsopp M , Van Naarden Braun K , Christensen DL , Schieve LA . PLoS One 2016 11 (12) e0168224 The Autism and Developmental Disabilities Monitoring (ADDM) Network conducts population-based surveillance of autism spectrum disorder (ASD) among 8-year old children in multiple US sites. To classify ASD, trained clinicians review developmental evaluations collected from multiple health and education sources to determine whether the child meets the ASD surveillance case criteria. The number of evaluations collected has dramatically increased since the year 2000, challenging the resources and timeliness of the surveillance system. We developed and evaluated a machine learning approach to classify case status in ADDM using words and phrases contained in children's developmental evaluations. We trained a random forest classifier using data from the 2008 Georgia ADDM site which included 1,162 children with 5,396 evaluations (601 children met ADDM ASD criteria using standard ADDM methods). The classifier used the words and phrases from the evaluations to predict ASD case status. We evaluated its performance on the 2010 Georgia ADDM surveillance data (1,450 children with 9,811 evaluations; 754 children met ADDM ASD criteria). We also estimated ASD prevalence using predictions from the classification algorithm. Overall, the machine learning approach predicted ASD case statuses that were 86.5% concordant with the clinician-determined case statuses (84.0% sensitivity, 89.4% predictive value positive). The area under the resulting receiver-operating characteristic curve was 0.932. Algorithm-derived ASD "prevalence" was 1.46% compared to the published (clinician-determined) estimate of 1.55%. Using only the text contained in developmental evaluations, a machine learning algorithm was able to discriminate between children that do and do not meet ASD surveillance criteria at one surveillance site. |
Recent increases in the U.S. Maternal mortality rate: Disentangling trends from measurement issues
Creanga AA , Callaghan WM . Obstet Gynecol 2017 129 (1) 206-207 MacDorman et al1 aim to quantify the contribution of a pregnancy checkbox added to the 2003 U.S. standard death certificate to the estimated increase in U.S. maternal mortality during 2000–2014. Given its variable adoption by states, both in terms of format and timing, the authors skillfully employ innovative methods to estimate maternal mortality and are to be congratulated. | As the authors recognize, the analysis relies on the cause-of-death information recorded on death certificates and a statistical definition of maternal deaths—all records of women who died during or within 42 days of pregnancy who receive an International Classification of Diseases (version 10) O chapter code (except O96 and O97) are considered maternal deaths. Of note, using the Centers for Disease Control and Prevention's WONDER mortality data,2 the proportion of females aged 15–54 years with the nonspecific O chapter-coded underlying cause of death O26.8 (other specified pregnancy-related conditions) or O99.8 (other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) increased from less than 10% to more than 40% during 2000–2014 as more states used the pregnancy checkbox (Fig. 1). At first glance, this suggests an increase in maternal deaths that parallels documented increases in chronic medical conditions in pregnant women in the United States.3 However, the incorrect marking of the pregnancy checkbox vis-à-vis pregnant status or timing of death can influence the assignment of cause-of-death International Classification of Diseases codes, especially regarding these nonspecific O codes. |
Risk Factors Associated With Bordetella pertussis Among Infants ≤4 Months of Age in the Pre-Tdap Era: United States, 2002-2005
Curtis CR , Baughman AL , DeBolt C , Goodykoontz S , Kenyon C , Watson B , Cassiday PK , Miller C , Pawloski LC , Tondella MC , Bisgard KM . Pediatr Infect Dis J 2016 36 (8) 726-735 BACKGROUND: In the United States, infants have the highest reported pertussis incidence and death rates. Improved understanding of infant risk factors is needed to optimize prevention strategies. METHODS: We prospectively enrolled infants ≤4 months of age with incident-confirmed pertussis from 4 sites during 2002-2005 (preceding pertussis-antigen-containing vaccination recommendations for adolescents/adults); each case-patient was age- and site-matched with 2 control subjects. Caregivers completed structured interviews. Infants and their contacts ≥11 years of age were offered serologic testing for IgG; being seropositive was defined as ≥94 anti-pertussis toxin IgG enzyme-linked immunosorbent assay units/mL. RESULTS: Enrolled subjects (115 case-patients; 230 control subjects) had 4,396 contacts during incubation periods; 83 (72%) case-patients had ≥1 contact with prolonged (≥5 days) new cough in primary or secondary households. In multivariable analysis, the odds for pertussis were higher for infants with primary/secondary household contacts who had a prolonged new cough, compared with infants who did not. These contacts included mother (adjusted matched odds ratio [aMOR] 43.8; 95% confidence interval [CI], 6.45-298.0) and ≥1 nonmother contact (aMOR, 20.1; 95% CI, 6.48-62.7). Infants receiving breast milk with 0-1 formula feedings daily had decreased pertussis odds (aMOR, 0.27; 95% CI, 0.08-0.89), compared with those receiving more formula. Of 41 tested case-patients, 37 (90%) were seropositive. CONCLUSIONS: Pertussis in infants was associated with prolonged new cough (≥5 days) in infants' household contacts. Findings suggest breastfeeding protects against pertussis, and warrants recommendation with pertussis prevention strategies, which currently include pertussis vaccination of pregnant mothers and infants' close contacts. |
Trends in weight-for-length among infants in WIC From 2000 to 2014
Freedman DS , Sharma AJ , Hamner HC , Pan L , Panzera A , Smith RB , Blanck HM . Pediatrics 2016 139 (1) OBJECTIVES: To describe the prevalence and secular trends of high weight-for-length among infants (ages, 3-23 months) in the biennial US Department of Agriculture Women, Infants, and Children Program and Participants Characteristic (WIC-PC) Survey from 2000 through 2014 (n = 16 927 120). METHODS: Weight-for-length was considered to be "high" if it was ≥2 SDs above the sex- and age-specific median in the World Health Organization growth standards. Poisson regression was used to calculate adjusted prevalence ratios. RESULTS: The overall prevalence of high weight-for-length increased from 13.4% in 2000 to 14.5% in 2004, remained constant until 2010, and then decreased by >2 percentage points (to 12.3%) through 2014. The prevalence of high weight-for-length was associated with sex (higher among boys), race-ethnicity (highest among American Indians/Alaskan Natives), and with both age (positive) and family income (inverse). The secular trends, however, were fairly similar within categories of these variables. From 2010 to 2014, the prevalence of high weight-for-length decreased in 40 states and 3 (of 5) US territories, with the largest decreases seen in Puerto Rico (-9 percentage points) and Kentucky (-7 percentage points), and the largest increase (+2 percentage points) seen in West Virginia. CONCLUSIONS: Although the current results cannot be considered representative of infants in the populations, the prevalence of a high weight-for-length has decreased among infants in WIC-PC since 2010. These decreases were similar across categories of most characteristics, but there were substantial differences across jurisdictions, possibly reflecting differences in policy and local programs that target maternal and infant health. |
Hepatitis B surface antigen testing among pregnant women, United States 2014
Kolasa M , Tsai Y , Xu J , Fenlon N , Schillie S . Pediatr Infect Dis J 2016 36 (7) e175-e180 BACKGROUND: Post-exposure prophylaxis administered to infants shortly after birth prevents approximately 90% of cases of perinatal Hepatitis B Virus (HBV) transmission. The Advisory Committee on Immunization Practices (ACIP) recommends that all pregnant women be tested for hepatitis B surface antigen (HBsAg) at an early prenatal visit during each pregnancy to detect active infection with HBV. This study sought to determine the proportion and characteristics of pregnant women tested\not tested according to ACIP recommendations METHODS:: We analyzed MarketScan databases to assess prenatal HBsAg testing among women with commercial and Medicaid health care coverage according to demographic and clinical characteristics. Pregnant women age 15-44 years continuously enrolled in a health plan in the MarketScan database during 2013 and 2014 and with a live birth in 2014 were included. RESULTS: Among commercially-insured women, 239,955 (87.7%) received HBsAg testing and 59.6% were tested during their first trimester. Among Medicaid-enrolled women, 57,268 (83.6%) received HBsAg testing and 39.4% were tested during their first trimester. Among women with high risk pregnancies, HBsAg testing occurred in 87.3% of those with commercial insurance and 84.8% with Medicaid. Testing also varied by maternal age; among women with commercial insurance, testing was greatest among women age 26-44 years, and among women with Medicaid, testing was greatest among younger women (15-25 years). Testing was lowest among women residing in the Northeast (commercial insurance only). CONCLUSION: Prenatal HBsAg testing identifies HBV-infected pregnant women so their infants can receive timely immunoprophylaxis. Efforts to optimize HBsAg testing among all pregnant women are needed to further prevent perinatal HBV transmission. |
Differences in infant care practices and smoking among Hispanic mothers living in the United States
Provini LE , Corwin MJ , Geller NL , Heeren TC , Moon RY , Rybin DV , Shapiro-Mendoza CK , Colson ER . J Pediatr 2016 182 321-326 e1 OBJECTIVE: To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking. STUDY DESIGN: We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking. RESULTS: When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy. CONCLUSIONS: Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep. |
MINER Act technology; Past, present and the future
Snyder DP , Burr JF , Moore SM , Fernando R . Min Eng 2016 68 (12) 45-54 The Mine Improvement and New Emergency Response Act of 2006 (MINER Act Public Law 109-236) was passed by Congress in response to three major underground coal mine accidents in the United States that claimed the lives of 19 miners. The Act resulted in substantial changes in the underground coal industry relative to the use of technology for mine escape, rescue, disaster response and other areas where the lack of these technologies contributed to the fatalities caused by these tragedies. This year marks the 10th anniversary of the MINER Act, which makes it an opportune time to reflect on the events that led to its passage, the changes that have been made since then, and the work that remains to be done. |
Nutrition standards for food service guidelines for foods served or sold in municipal government buildings or worksites, United States, 2014
Onufrak SJ , Zaganjor H , Moore LV , Carlson S , Kimmons J , Galuska D . Prev Chronic Dis 2016 13 E172 INTRODUCTION: The Institute of Medicine and Centers for Disease Control and Prevention have recommended that government agencies use nutrition standards for foods and beverages sold and provided at their facilities. In this study, we examine written nutrition standards for foods sold or served in local government buildings or worksites among US municipalities. METHODS: We used data from a 2014 national survey of 1,945 municipal governments serving populations of 1,000 or more to assess the presence of written nutrition standards, the food groups or nutrients addressed by standards, and the populations served by facilities where standards are applied. The prevalence of standards was estimated by municipality population size, rural-urban status, census region, poverty prevalence, education level, and racial/ethnic composition. RESULTS: Overall, 3.2% of US municipalities reported nutrition standards with greater prevalence observed among large municipalities (12.8% of municipalities with ≥50,000 people vs 2.2% of municipalities with <2,500 people, P < .001). Prevalence differed by region, and standards were most common in the West (6.6%) and least common in the Midwest (2.0%, P = .003).The most common nutrition topics addressed in standards were offering low-calorie beverages, fruits and vegetables, and free drinking water. Most standards applied to facilities serving government employees (67%) or the general public (66%), with fewer serving institutionalized populations (23%). CONCLUSION: Few municipal governments reported having written nutrition standards for foods and beverages sold in their facilities in 2014. Implementing nutrition standards for foods sold or served by local governments is a strategy for increasing access to healthier foods and beverages among municipal employees and local residents. |
Parameters associated with design effect of child anthropometry indicators in small-scale field surveys
Hulland EN , Blanton CJ , Leidman EZ , Bilukha OO . Emerg Themes Epidemiol 2016 13 13 BACKGROUND: Cluster surveys provide rapid but representative estimates of key nutrition indicators in humanitarian crises. For these surveys, an accurate estimate of the design effect is critical to calculate a sample size that achieves adequate precision with the minimum number of sampling units. This paper describes the variability in design effect for three key nutrition indicators measured in small-scale surveys and models the association of design effect with parameters hypothesized to explain this variability. METHODS: 380 small-scale surveys from 28 countries conducted between 2006 and 2013 were analyzed. We calculated prevalence and design effect of wasting, underweight, and stunting for each survey as well as standard deviations of the underlying continuous Z-score distribution. Mean cluster size, survey location and year were recorded. To describe design effects, median and interquartile ranges were examined. Generalized linear regression models were run to identify potential predictors of design effect. RESULTS: Median design effect was under 2.00 for all three indicators; for wasting, the median was 1.35, the lowest among the indicators. Multivariable linear regression models suggest significant, positive associations of design effect and mean cluster size for all three indicators, and with prevalence of wasting and underweight, but not stunting. Standard deviation was positively associated with design effect for wasting but negatively associated for stunting. Survey region was significant in all three models. CONCLUSIONS: This study supports the current field survey guidance recommending the use of 1.5 as a benchmark for design effect of wasting, but suggests this value may not be large enough for surveys with a primary objective of measuring stunting or underweight. The strong relationship between design effect and region in the models underscores the continued need to consider country- and locality-specific estimates when designing surveys. These models also provide empirical evidence of a positive relationship between design effect and both mean cluster size and prevalence, and introduces standard deviation of the underlying continuous variable (Z-scores) as a previously unexplored factor significantly associated with design effect. The magnitude and directionality of this association differed by indicator, underscoring the need for further investigation into the relationship between standard deviation and design effect. |
Physician characteristics associated with sugar-sweetened beverage counseling practices
VanFrank BK , Park S , Foltz JL , McGuire LC , Harris DM . Am J Health Promot 2016 32 (6) 1365-1374 PURPOSE: Frequent sugar-sweetened beverage (SSB) consumption is associated with chronic disease. Although physician counseling can positively affect patient behavior, physicians' personal characteristics may influence counseling practices. We explored SSB-related topics physicians discuss when counseling overweight/obese patients and examined associations between physicians' SSB-related counseling practices and their personal and medical practice characteristics. DESIGN: Cross-sectional survey. SETTING: DocStyles survey, 2014. PARTICIPANTS: A total of 1510 practicing US physicians. MEASURES: Physician's SSB counseling on calories, added sugars, obesity/weight gain, health effects, consumption frequency, water substitution, and referral. ANALYSIS: Adjusted odds ratios (aORs) were calculated with multivariable logistic regression, adjusting for physician's personal and medical practice characteristics. RESULTS: Most physicians (98.5%) reported SSB-related counseling. The most reported topic was obesity/weight gain (81.4%); the least reported were added sugars (53.1%) and referral (35.0%). Physicians in adult-focused specialties had lower odds than pediatricians of counseling on several topics (aOR range: 0.26-0.64). Outpatient physicians had higher odds than inpatient physicians of counseling on consumption frequency and water substitution (aOR range: 1.60-2.01). Physicians consuming SSBs ≥1 time/day (15.7%) had lower odds than nonconsumers of counseling on most topics (aOR range: 0.58-0.68). CONCLUSION: Most physicians reported SSB-related counseling; obesity/weight gain was discussed most frequently. Counseling opportunities remain in other topic areas. Opportunities also exist to strengthen SSB counseling practices in adult-focused specialties, inpatient settings, and among physicians who consume SSBs daily. |
Differences in food and beverage marketing policies and practices in US school districts, by demographic characteristics of school districts, 2012
Merlo CL , Michael S , Brener ND , Coffield E , Kingsley BS , Zytnick D , Blanck H . Prev Chronic Dis 2016 13 E169 INTRODUCTION: Foods and beverages marketed in schools are typically of poor nutritional value. School districts may adopt policies and practices to restrict marketing of unhealthful foods and to promote healthful choices. Students' exposure to marketing practices differ by school demographics, but these differences have not yet been examined by district characteristics. METHODS: We analyzed data from the 2012 School Health Policies and Practices Study to examine how food and beverage marketing and promotion policies and practices varied by district characteristics such as metropolitan status, size, and percentage of non-Hispanic white students. RESULTS: Most practices varied significantly by district size: a higher percentage of large districts than small or medium-sized districts restricted marketing of unhealthful foods and promoted healthful options. Compared with districts whose student populations were majority (>50%) non-Hispanic white, a higher percentage of districts whose student populations were minority non-Hispanic white (≤50% non-Hispanic white) prohibited advertising of soft drinks in school buildings and on school grounds, made school meal menus available to students, and provided families with information on school nutrition programs. Compared with suburban and rural districts, a higher percentage of urban districts prohibited the sale of soft drinks on school grounds and used several practices to promote healthful options. CONCLUSION: Preliminary findings showing significant associations between district demographics and marketing policies and practices can be used to help states direct resources, training, and technical assistance to address food and beverage marketing and promotion to districts most in need of improvement. |
Metal exposures at three U.S. electronic scrap recycling facilities
Ceballos D , Beaucham C , Page E . J Occup Environ Hyg 2016 14 (6) 0 Many metals found in electronic scrap are known to cause serious health effects, including but not limited to cancer and respiratory, neurologic, renal, and reproductive damage. The National Institute for Occupational Safety and Health/Centers for Disease Control and Prevention performed three health hazard evaluations at electronic scrap recycling facilities in the U.S. to characterize employee exposure to metals and recommend control strategies to reduce these exposures. We performed air, surface, and biological monitoring for metals. We found one overexposure to lead and two overexposures to cadmium. We found metals on non-production surfaces, and the skin and clothing of workers before they left work in all of the facilities. We also found some elevated blood lead levels (above 10 micrograms per deciliter), however no employees at any facility had detectable mercury in their urine or exceeded 34% of the OELs for blood or urine cadmium. This manuscript focuses on sampling results for lead, cadmium, mercury, and indium. We provided recommendations for improving local exhaust ventilation, reducing the recirculation of potentially contaminated air, using respirators until exposures are controlled, and reducing the migration of contaminants from production to non-production areas. We also recommended ways for employees to prevent taking home metal dust by using work uniforms laundered on-site, storing personal and work items in separate lockers, and using washing facilities equipped with lead-removing cleaning products. |
Exposure control practices for administering nitrous oxide: a survey of dentists, dental hygienists and dental assistants
Boiano JM , Steege AL , Sweeney MH . J Occup Environ Hyg 2016 14 (6) 0 Engineering, administrative, and work practice controls have been recommended for many years to minimize exposure to nitrous oxide during dental procedures. To better understand the extent to which these exposure controls are used, the NIOSH Health and Safety Practices Survey of Healthcare Workers was conducted among members of professional practice organizations representing dentists, dental hygienists and dental assistants. The anonymous, modular, web-based survey was completed by 284 dental professionals in private practice who administered nitrous oxide to adult and/or pediatric patients in the seven days prior to the survey. Use of primary engineering controls [i.e., nasal scavenging mask and/or local exhaust ventilation (LEV) near the patient's mouth] was nearly universal, reported by 93% and 96% of respondents who administered to adult (A) and pediatric (P) patients, respectively. However, adherence to other recommended precautionary practices were lacking to varying degrees, and were essentially no different among those administering nitrous oxide to adult or pediatric patients. Examples of work practices which increase exposure risk, expressed as percent of respondents, included: not checking nitrous oxide equipment for leaks (41% A; 48% P); starting nitrous oxide gas flow before delivery mask or airway mask was applied to patient (13% A; 12% P); and not turning off nitrous oxide gas flow before turning off oxygen flow to the patient (8% A; 7% P). Absence of standard procedures to minimize worker exposure to nitrous oxide (13% of all respondents) and not being trained on safe handling and administration of nitrous oxide (3%) were examples of breaches of administrative controls which may also increase exposure risk. Successful management of nitrous oxide emissions should include properly fitted nasal scavenging masks, supplemental LEV (when nitrous oxide levels cannot be adequately controlled using nasal masks alone), adequate general ventilation, regular inspection of nitrous oxide delivery and scavenging equipment for leaks, availability of standard procedures to minimize exposure, periodic training, ambient air and exposure monitoring, and medical surveillance. |
Declining prevalence of hearing loss in US adults aged 20 to 69 years
Hoffman HJ , Dobie RA , Losonczy KG , Themann CL , Flamme GA . JAMA Otolaryngol Head Neck Surg 2016 143 (3) 274-285 Importance: As the US population ages, effective health care planning requires understanding the changes in prevalence of hearing loss. Objective: To determine if age- and sex-specific prevalence of adult hearing loss has changed during the past decade. Design, Setting, and Participants: We analyzed audiometric data from adults aged 20 to 69 years from the 2011-2012 cycle of the US National Health and Nutrition Examination Survey, a cross-sectional, nationally representative interview and examination survey of the civilian, noninstitutionalized population, and compared them with data from the 1999-2004 cycles. Logistic regression was used to examine unadjusted, age- and sex-adjusted, and multivariable-adjusted associations with demographic, noise exposure, and cardiovascular risk factors. Data analysis was performed from April 28 to June 3, 2016. Interventions: Audiometry and questionnaires. Main Outcomes and Measures: Speech-frequency hearing impairment (HI) defined by pure-tone average of thresholds at 4 frequencies (0.5, 1, 2, and 4 kHz) greater than 25 decibels hearing level (HL), and high-frequency HI defined by pure-tone average of thresholds at 3 frequencies (3, 4, and 6 kHz) greater than 25 decibels HL. Results: Based on 3831 participants with complete threshold measurements (1953 men and 1878 women; mean [SD] age, 43.6 [14.4] years), the 2011-2012 nationally weighted adult prevalence of unilateral and bilateral speech-frequency HI was 14.1% (27.7 million) compared with 15.9% (28.0 million) for the 1999-2004 cycles; after adjustment for age and sex, the difference was significant (odds ratio [OR], 0.70; 95% CI, 0.56-0.86). Men had nearly twice the prevalence of speech-frequency HI (18.6% [17.8 million]) as women (9.6% [9.7 million]). For individuals aged 60 to 69 years, speech-frequency HI prevalence was 39.3% (95% CI, 30.7%-48.7%). In adjusted multivariable analyses for bilateral speech-frequency HI, age was the major risk factor (60-69 years: OR, 39.5; 95% CI, 10.5-149.4); however, male sex (OR, 1.8; 95% CI, 1.1-3.0), non-Hispanic white (OR, 2.3; 95% CI, 1.3-3.9) and non-Hispanic Asian race/ethnicity (OR, 2.1; 95% CI, 1.1-4.2), lower educational level (less than high school: OR, 4.2; 95% CI, 2.1-8.5), and heavy use of firearms (≥1000 rounds fired: OR, 1.8; 95% CI, 1.1-3.0) were also significant risk factors. Additional associations for high-frequency HI were Mexican-American (OR, 2.0; 95% CI, 1.3-3.1) and other Hispanic race/ethnicity (OR, 2.4; 95% CI, 1.4-4.0) and the combination of loud and very loud noise exposure occupationally and outside of work (OR, 2.4; 95% CI, 1.4-4.2). Conclusions and Relevance: Adult hearing loss is common and associated with age, other demographic factors (sex, race/ethnicity, and educational level), and noise exposure. Age- and sex-specific prevalence of HI continues to decline. Despite the benefit of delayed onset of HI, hearing health care needs will increase as the US population grows and ages. |
Reducing float coal dust: Field evaluation of an inline auxiliary fan scrubber
Patts JR , Colinet JF , Janisko SJ , Barone TL , Patts LD . Min Eng 2016 68 (12) 63-68 Controlling float coal dust in underground coal mines before dispersal into the general airstream can reduce the risk of mine explosions while potentially achieving a more effective and efficient use of rock dust. A prototype flooded-bed scrubber was evaluated for float coal dust control in the return of a continuous miner section. The scrubber was installed inline between the face ventilation tubing and an exhausting auxiliary fan. Airborne and deposited dust mass measurements were collected over three days at set distances from the fan exhaust to assess changes in float coal dust levels in the return due to operation of the scrubber. Mass-based measurements were collected on a per-cut basis and normalized on the basis of per ton mined by the continuous miner. The results show that average float coal dust levels measured under baseline conditions were reduced by more than 90 percent when operating the scrubber. |
Resurgence of progressive massive fibrosis in coal miners - Eastern Kentucky, 2016
Blackley DJ , Crum JB , Halldin CN , Storey E , Laney AS . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1385-1389 Coal workers' pneumoconiosis, also known as "black lung disease," is an occupational lung disease caused by overexposure to respirable coal mine dust. Inhaled dust leads to inflammation and fibrosis in the lungs, and coal workers' pneumoconiosis can be a debilitating disease. The Federal Coal Mine Health and Safety Act of 1969 (Coal Act),* amended in 1977, established dust limits for U.S. coal mines and created the National Institute for Occupational Safety and Health (NIOSH)-administered Coal Workers' Health Surveillance Program with the goal of reducing the incidence of coal workers' pneumoconiosis and eliminating its most severe form, progressive massive fibrosis (PMF),dagger which can be lethal. The prevalence of PMF fell sharply after implementation of the Coal Act and reached historic lows in the 1990s, with 31 unique cases identified by the Coal Workers' Health Surveillance Program during 1990-1999. Since then, a resurgence of the disease has occurred, notably in central Appalachia (Figure 1) (1,2). This report describes a cluster of 60 cases of PMF identified in current and former coal miners at a single eastern Kentucky radiology practice during January 2015-August 2016. This cluster was not discovered through the national surveillance program. This ongoing outbreak highlights an urgent need for effective dust control in coal mines to prevent coal workers' pneumoconiosis, and for improved surveillance to promptly identify the early stages of the disease and stop its progression to PMF. |
Using respondent driven sampling to identify malaria risks and occupational networks among migrant workers in Ranong, Thailand
Wangroongsarb P , Hwang J , Thwing J , Karuchit S , Kumpetch S , Rand A , Drakeley C , MacArthur JR , Kachur SP , Satimai W , Meek S , Sintasath DM . PLoS One 2016 11 (12) e0168371 BACKGROUND: Ranong Province in southern Thailand is one of the primary entry points for migrants entering Thailand from Myanmar, and borders Kawthaung Township in Myanmar where artemisinin resistance in malaria parasites has been detected. Areas of high population movement could increase the risk of spread of artemisinin resistance in this region and beyond. METHODS: A respondent-driven sampling (RDS) methodology was used to compare migrant populations coming from Myanmar in urban (Site 1) vs. rural (Site 2) settings in Ranong, Thailand. The RDS methodology collected information on knowledge, attitudes, and practices for malaria, travel and occupational histories, as well as social network size and structure. Individuals enrolled were screened for malaria by microscopy, Real Time-PCR, and serology. RESULTS: A total of 619 participants were recruited in Ranong City and 623 participants in Kraburi, a rural sub-district. By PCR, a total of 14 (1.1%) samples were positive (2 P. falciparum in Site 1; 10 P. vivax, 1 Pf, and 1 P. malariae in Site 2). PCR analysis demonstrated an overall weighted prevalence of 0.5% (95% CI, 0-1.3%) in the urban site and 1.0% (95% CI, 0.5-1.7%) in the rural site for all parasite species. PCR positivity did not correlate with serological positivity; however, as expected there was a strong association between antibody prevalence and both age and exposure. Access to long-lasting insecticidal treated nets remains low despite relatively high reported traditional net use among these populations. CONCLUSIONS: The low malaria prevalence, relatively smaller networks among migrants in rural settings, and limited frequency of travel to and from other areas of malaria transmission in Myanmar, suggest that the risk for the spread of artemisinin resistance from this area may be limited in these networks currently but may have implications for regional malaria elimination efforts. |
Maternal Malaria and Malnutrition (M3) initiative, a pooled birth cohort of 13 pregnancy studies in Africa and the Western Pacific
Unger HW , Cates JE , Gutman J , Briand V , Fievet N , Valea I , Tinto H , d'Alessandro U , Landis SH , Adu-Afarwuah S , Dewey KG , Ter Kuile F , Dellicour S , Ouma P , Slutsker L , Terlouw DJ , Kariuki S , Ayisi J , Nahlen B , Desai M , Madanitsa M , Kalilani-Phiri L , Ashorn P , Maleta K , Mueller I , Stanisic D , Schmiegelow C , Lusingu J , Westreich D , van Eijk AM , Meshnick S , Rogerson S . BMJ Open 2016 6 (12) e012697 PURPOSE: The Maternal Malaria and Malnutrition (M3) initiative has pooled together 13 studies with the hope of improving understanding of malaria-nutrition interactions during pregnancy and to foster collaboration between nutritionists and malariologists. PARTICIPANTS: Data were pooled on 14 635 singleton, live birth pregnancies from women who had participated in 1 of 13 pregnancy studies. The 13 studies cover 8 countries in Africa and Papua New Guinea in the Western Pacific conducted from 1996 to 2015. FINDINGS TO DATE: Data are available at the time of antenatal enrolment of women into their respective parent study and at delivery. The data set comprises essential data such as malaria infection status, anthropometric assessments of maternal nutritional status, presence of anaemia and birth weight, as well as additional variables such gestational age at delivery for a subset of women. Participating studies are described in detail with regard to setting and primary outcome measures, and summarised data are available from each contributing cohort. FUTURE PLANS: This pooled birth cohort is the largest pregnancy data set to date to permit a more definite evaluation of the impact of plausible interactions between poor nutritional status and malaria infection in pregnant women on fetal growth and gestational length. Given the current comparative lack of large pregnancy cohorts in malaria-endemic settings, compilation of suitable pregnancy cohorts is likely to provide adequate statistical power to assess malaria-nutrition interactions, and could point towards settings where such interactions are most relevant. The M3 cohort may thus help to identify pregnant women at high risk of adverse outcomes who may benefit from tailored intensive antenatal care including nutritional supplements and alternative or intensified malaria prevention regimens, and the settings in which these interventions would be most effective. |
Intermittent preventive treatment with sulfadoxine-pyrimethamine: More than just an antimalarial?
Gutman J , Slutsker L . Am J Trop Med Hyg 2016 96 (1) 9-10 Malaria in pregnancy is associated with increased risk for both maternal and neonatal adverse outcomes, notably low birthweight and neonatal mortality.1 Since 2004, following studies that showed that intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) reduced the risk of these adverse events,2 the World Health Organization (WHO) recommended IPTp-SP for all areas in Africa with moderate-to-high malaria transmission.3 IPTp-SP is associated with significant reductions in low birthweight, with a protective efficacy of approximately 26% in an analysis of national survey data from 32 countries.4 This impact has been presumed to be a result of the antimalarial effects of SP. Because resistance to SP has increased, particularly in eastern and southern Africa, SP is no longer recommended for treatment of acute malaria illness, even in combination with artemisinins. Despite this, even in areas where the efficacy of SP to clear parasitemia has clearly decreased, IPTp-SP has continued to show benefit for preventing low birthweight.5 Moreover, no other antimalarials have yet been shown to be an ideal replacement for SP for IPTp. Studies evaluating potential alternative IPTp regimens have had mixed outcomes on birthweight,6,7 leading to the hypothesis that SP may exert some of its effect through antibacterial or anti-inflammatory actions.6 In Lusaka, Zambia, where malaria parasite prevalence is < 1%, Stoner and others show that among human immunodeficiency virus (HIV)-positive women, receipt of IPTp-SP was associated with a dose-dependent reduction in the risk of low birthweight, as well as an increase in gestational age, further suggesting a mechanism other than antimalarial activity as an explanation for a reduced risk of low birthweight among women receiving IPTp-SP during pregnancy (Stoner and others). |
'Beyond "test and treat" - malaria diagnosis for improved pediatric fever management in sub-Saharan Africa' by Emily White Johansson
Kachur SP . Glob Health Action 2016 9 34416 Since 2010, the World Health Organization has recommended universal malaria diagnostic testing to guide treatment of febrile illness as a fundamental component of malaria case management (1). Malaria control programs and their partners have been gradually expanding diagnostic testing, largely through point-of-care rapid diagnostic tests (RDTs). For the past 2 years, global purchases of malaria RDTs have equaled or slightly exceeded treatment doses of artemisinin-based combination therapies (ACT), and nearly half of globally reported malaria cases have been diagnostically confirmed (2). Emily White Johansson's doctoral thesis – summarized in this issue (3) – examined early experience expanding malaria diagnostic testing across sub-Saharan Africa and points to some key directions for additional scholarship and program implementation. | Johansson and her colleagues (4–7) interrogated nationwide malaria coverage surveys from more than a dozen countries, conducted original qualitative and quantitative research in Uganda, and unleashed powerful big data approaches on a comprehensive health service assessment data set from Malawi – all with the goal of expanding the previously limited understanding of malaria diagnostic practices just as malaria RDTs were being introduced for routine practice. Collectively, it is an analytical tour de force. The resulting publications demonstrate program-relevant observations. Access to malaria diagnostic testing was poor and wildly inequitable shortly following the universal diagnosis policy – particularly in peripheral health facilities. None of the nationwide surveys showed the promised reductions in ACT consumption at a population level, at least not at first. Moreover, countries varied greatly in terms of what impact malaria diagnostic testing had on fever management overall. While clinical guidelines for antibiotic use appeared straightforward, they still required considerable judgment on the part of health workers – who were frequently left feeling unsupported, especially when malaria test results were negative. Once malaria diagnostic testing had become established, however, a majority of health workers adapted to using the results to guide malaria-specific treatment. But antibiotic overtreatment was common, especially among children testing negative for malaria, and was influenced by the presence of other symptoms such as cough or difficult breathing. Arriving at each of these discrete findings, Dr. Johansson establishes an approach that she and others can revisit as new evidence and experience accumulate. |
Diagnosis and treatment of leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH)
Aronson N , Herwaldt BL , Libman M , Pearson R , Lopez-Velez R , Weina P , Carvalho EM , Ephros M , Jeronimo S , Magill A . Clin Infect Dis 2016 63 (12) e202-e264 It is important to realize that leishmaniasis guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The IDSA and ASTMH consider adherence to these guidelines to be voluntary, with the ultimate determinations regarding their application to be made by the physician in the light of each patient's individual circumstances. |
Understanding the demographic differences in neighborhood walking supports
Carlson SA , Watson KB , Paul P , Schmid TL , Fulton JE . J Phys Act Health 2016 14 (4) 1-28 BACKGROUND: Information about how presence and usefulness of neighborhood supports for walking differs by demographic characteristics can help guide community strategies to promote walking. METHODS: Reported presence and usefulness of neighborhood supports (shops, transit stops, sidewalks, parks, interesting things to look at, well-lit at night, low crime rate, and cars following speed limit) were examined in 3,973 U.S. adults who completed the 2014 SummerStyles survey. RESULTS: Percentage reporting neighborhood supports as present ranged from 25.3% (SE=0.8) for interesting things to 55.8% (SE=1.0) for low crime rate. Percentage who reported a support as useful ranged from 24.6% (SE=1.4) for transit stops to 79.0% (SE=1.1) for sidewalks among those with the support. This percentage ranged from 13.4% (SE=0.8) for transit stops to 52.8% (SE=1.1) for shops among those without the support. One or more demographic differences were observed for the presence of each support, and the presence of all supports differed by education and metro status. Demographic patterns were less clear when examining usefulness and patterns often differed by support type and presence. CONCLUSION: Presence and usefulness of neighborhood supports for walking can differ by type and demographic characteristics. Recognizing these difference can help communities plan and implement strategies to promote walking. |
Better health faster: The 5 essential public health law services
Burris S , Ashe M , Blanke D , Ibrahim J , Levin DE , Matthews G , Penn M , Katz M . Public Health Rep 2016 131 (6) 747-753 It is easy to identify health laws that have helped Americans live longer, healthier lives. Indeed, most of the greatest public health accomplishments of the last century depended on legal action. The coordination of research, policy development, public education, and advocacy in the tobacco control movement shows that success is attainable even in the face of powerful industry opposition.1 The development of automobile safety laws during the past 30 years shows how well-conducted, properly diffused research can instigate policy cascades and guide policy refinement over time.2 These examples of “interventional health law”3—using law as a tool of intervention—also illustrate that developing, enacting, evaluating, and spreading health laws is not just the work of lawyers. In these and many examples like them, health advocates, researchers, public health practitioners, and lawyers work in strategic partnership to improve population health through law and policy. | Consistent with the literature on the art and science of evidence translation,4,5 these efforts were built on effective practices, such as cultivating partnerships among diverse stakeholders. These partnerships promote (1) research that is targeted at the most strategically relevant questions; (2) the development of model laws based on the best available science; (3) sophisticated community education and advocacy campaigns to win, defend, and enforce effective policies; and (4) enforcement to ensure that improved public health outcomes are achieved and sustained.6–8 The starting point for this commentary is that public health law is not just the work of lawyers but must also be owned by the range of public health disciplines as a transdisciplinary activity.9 |
Healthcare provider attitudes of safety of intrauterine devices in the postpartum period
Rauh-Benoit LA , Tepper NK , Zapata LB , Whiteman MK , Curtis KM , Mandel MG , Marchbanks PA , Jamieson DJ . J Womens Health (Larchmt) 2016 26 (7) 768-773 OBJECTIVE: Immediate postpartum intrauterine devices (IUDs) have been underutilized in the United States despite their known safety. Understanding how providers' attitudes contribute to underutilization is important in improving access. Our objective was to examine healthcare providers' perceptions of the safety of immediate postpartum IUDs before publication of United States contraceptive guidelines. MATERIALS AND METHODS: We analyzed survey data collected from December 2009 to March 2010 from 635 office-based physicians and 1368 Title X clinic providers (overall response rate of 64.8%). Providers were asked how safe they thought copper and levonorgestrel (LNG) IUDs were in postpartum women (very safe, safe, unsafe, very unsafe, and unsure). Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) for characteristics associated with considering immediate and delayed postpartum IUDs to be safe. RESULTS: Less than 40% of respondents considered immediate or delayed IUD insertion to be safe. Providers with <1 day of family planning training had decreased odds of considering immediate postpartum IUD insertion to be safe compared with unsafe/unsure (aOR 0.18, 95% CI 0.04-0.84 for copper IUD and aOR 0.17, 95% CI 0.04-0.81 for LNG-IUD). Providers without training in postpartum or interval copper IUD insertion had decreased odds of considering immediate postpartum copper IUD insertion (aOR 0.40, 95% CI 0.16-0.79) and delayed postpartum insertion for both IUD types to be safe (aOR 0.34, 95% CI 0.18-0.66 for copper IUD and aOR 0.41, 95% CI 0.21-0.77 for LNG-IUD). CONCLUSIONS: Before United States contraceptive guidelines, a majority of providers perceived immediate postpartum IUDs to be unsafe. |
2GETHER - The Dual Protection Project: Design and rationale of a randomized controlled trial to increase dual protection strategy selection and adherence among African American adolescent females
Ewing AC , Kottke MJ , Kraft JM , Sales JM , Brown JL , Goedken P , Wiener J , Kourtis AP . Contemp Clin Trials 2016 54 1-7 BACKGROUND: African American adolescent females are at elevated risk for unintended pregnancy and sexually transmitted infections (STIs). Dual protection (DP) is defined as concurrent prevention of pregnancy and STIs. This can be achieved by abstinence, consistent condom use, or the dual methods of condoms plus an effective non-barrier contraceptive. Previous clinic-based interventions showed short-term effects on increasing dual method use, but evidence of sustained effects on dual method use and decreased incident pregnancies and STIs are lacking. METHODS/DESIGN: This manuscript describes the 2GETHER Project. 2GETHER is a randomized controlled trial of a multi-component intervention to increase dual protection use among sexually active African American females aged 14-19years not desiring pregnancy at a Title X clinic in Atlanta, GA. The intervention is clinic-based and includes a culturally tailored interactive multimedia component and counseling sessions, both to assist in selection of a DP method and to reinforce use of the DP method. The participants are randomized to the study intervention or the standard of care, and followed for 12months to evaluate how the intervention influences DP method selection and adherence, pregnancy and STI incidence, and participants' DP knowledge, intentions, and self-efficacy. DISCUSSION: The 2GETHER Project is a novel trial to reduce unintended pregnancies and STIs among African American adolescents. The intervention is unique in the comprehensive and complementary nature of its components and its individual tailoring of provider-patient interaction. If the trial interventions are shown to be effective, then it will be reasonable to assess their scalability and applicability in other populations. |
Conceptualizing and measuring safe, stable, nurturing relationships and environments in educational settings
Robinson LR , Leeb RT , Merrick MT , Forbes LW . J Child Fam Stud 2016 25 (5) 1488-1504 Most children and adolescents older than five years spend at least six hours of their day in school settings. Like parents, education professionals can promote health and protect youth from harm by providing safe, stable, nurturing relationships and environments. The Centers for Disease Control and Prevention (CDC) has developed a framework which posits that safe, stable, nurturing relationships and environments are Essentials for Childhood and are fundamental to promoting health and well-being; protecting youth from maltreatment and other violence and victimization; and ensuring optimal, healthy development. In this paper, the authors propose an approach to applying safe, stable, nurturing relationships and environments to the school ecology; review select survey measures to examine these constructs within educational settings; and suggest available indicators to measure safety, stability, and nurturance within the school context. |
A statistical framework to evaluate extreme weather definitions from a health perspective: A demonstration based on extreme heat events
Vaidyanathan A , Kegler SR , Saha SS , Mulholland JA . Bull Am Meteorol Soc 2016 97 (10) 1817-1830 A statistical framework for evaluating definitions of extreme weather phenomena can help weather agencies and health departments identify the definition(s) most applicable for alerts and other preparedness operations related to extreme weather episodes. |
Bayesian hierarchical structure for quantifying population variability to inform probabilistic health risk assessments
Shao K , Allen BC , Wheeler MW . Risk Anal 2016 37 (10) 1865-1878 Human variability is a very important factor considered in human health risk assessment for protecting sensitive populations from chemical exposure. Traditionally, to account for this variability, an interhuman uncertainty factor is applied to lower the exposure limit. However, using a fixed uncertainty factor rather than probabilistically accounting for human variability can hardly support probabilistic risk assessment advocated by a number of researchers; new methods are needed to probabilistically quantify human population variability. We propose a Bayesian hierarchical model to quantify variability among different populations. This approach jointly characterizes the distribution of risk at background exposure and the sensitivity of response to exposure, which are commonly represented by model parameters. We demonstrate, through both an application to real data and a simulation study, that using the proposed hierarchical structure adequately characterizes variability across different populations. |
CDC Grand Rounds: modeling and public health decision-making
Fischer LS , Santibanez S , Hatchett RJ , Jernigan DB , Meyers LA , Thorpe PG , Meltzer MI . MMWR Morb Mortal Wkly Rep 2016 65 (48) 1374-1377 Mathematical models incorporate various data sources and advanced computational techniques to portray real-world disease transmission and translate the basic science of infectious diseases into decision-support tools for public health. Unlike standard epidemiologic methods that rely on complete data, modeling is needed when there are gaps in data. By combining diverse data sources, models can fill gaps when critical decisions must be made using incomplete or limited information. They can be used to assess the effect and feasibility of different scenarios and provide insight into the emergence, spread, and control of disease. During the past decade, models have been used to predict the likelihood and magnitude of infectious disease outbreaks, inform emergency response activities in real time, and develop plans and preparedness strategies for future events, the latter of which proved invaluable during outbreaks such as severe acute respiratory syndrome and pandemic influenza. Ideally, modeling is a multistep process that involves communication between modelers and decision-makers, allowing them to gain a mutual understanding of the problem to be addressed, the type of estimates that can be reliably generated, and the limitations of the data. As models become more detailed and relevant to real-time threats, the importance of modeling in public health decision-making continues to grow. |
State Medicaid expansion tobacco cessation coverage and number of adult smokers enrolled in expansion coverage - United States, 2016
DiGiulio A , Haddix M , Jump Z , Babb S , Schecter A , Williams KS , Asman K , Armour BS . MMWR Morb Mortal Wkly Rep 2016 65 (48) 1364-1369 In 2015, 27.8% of adult Medicaid enrollees were current cigarette smokers, compared with 11.1% of adults with private health insurance, placing Medicaid enrollees at increased risk for smoking-related disease and death. In addition, smoking-related diseases are a major contributor to Medicaid costs, accounting for about 15% (>$39 billion) of annual Medicaid spending during 2006-2010. Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications are effective treatments for helping tobacco users quit. Insurance coverage for tobacco cessation treatments is associated with increased quit attempts, use of cessation treatments, and successful smoking cessation (3); this coverage has the potential to reduce Medicaid costs. However, barriers such as requiring copayments and prior authorization for treatment can impede access to cessation treatments (3,5). As of July 1, 2016, 32 states (including the District of Columbia) have expanded Medicaid eligibility through the Patient Protection and Affordable Care Act (ACA), which has increased access to health care services, including cessation treatments. CDC used data from the Centers for Medicare and Medicaid Services (CMS) Medicaid Budget and Expenditure System (MBES) and the Behavioral Risk Factor Surveillance System (BRFSS) to estimate the number of adult smokers enrolled in Medicaid expansion coverage. To assess cessation coverage among Medicaid expansion enrollees, the American Lung Association collected data on coverage of, and barriers to accessing, evidence-based cessation treatments. As of December 2015, approximately 2.3 million adult smokers were newly enrolled in Medicaid because of Medicaid expansion. As of July 1, 2016, all 32 states that have expanded Medicaid eligibility under ACA covered some cessation treatments for all Medicaid expansion enrollees, with nine states covering all nine cessation treatments for all Medicaid expansion enrollees. All 32 states imposed one or more barriers on at least one cessation treatment for at least some enrollees. Providing barrier-free access to cessation treatments and promoting their use can increase use of these treatments and reduce smoking and smoking-related disease, death, and health care costs among Medicaid enrollees. |
Tobacco-specific nitrosamines in the tobacco and mainstream smoke of U.S. Commercial cigarettes
Edwards SH , Rossiter LM , Taylor KM , Holman MR , Zhang L , Ding YS , Watson CH . Chem Res Toxicol 2016 30 (2) 540-551 Tobacco-specific nitrosamines (TSNAs) are N-nitroso-derivatives of pyridine-alkaloids (e.g., nicotine) present in tobacco and cigarette smoke. Two TSNAs, N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), are included on the Food and Drug Administration's list of harmful and potentially harmful constituents (HPHCs) in tobacco products and tobacco. The amounts of four TSNAs (NNK, NNN, N-nitrosoanabasine (NAB), and N'-nitrosoanatabine (NAT)) in the tobacco and mainstream smoke from 50 U.S. commercial cigarette brands were measured from November 15, 2011 to January 4, 2012 using a validated HPLC/MS/MS method. Smoke samples were generated using the International Organization of Standardization (ISO) and Canadian Intense (CI) machine-smoking regimens. NNN and NAT were the most abundant TSNAs in tobacco filler and smoke across all cigarette brands, whereas NNK and NAB were present in lesser amounts. The average ratios for each TSNA in mainstream smoke to filler content is 29% by the CI smoking regimen and 13% for the ISO machine-smoking regimen. The reliability of individual TSNAs to predict total TSNA amounts in the filler and smoke was examined. NNN, NAT, and NAB have a moderate to high correlation (R2 = 0.61-0.98, p < 0.0001), and all three TSNAs individually predict total TSNAs with minimal difference between measured and predicted total TSNA amounts (error < 7.4%). NNK has weaker correlation (R2 = 0.56-0.82; p < 0.0001) and is a less reliable predictor of total TSNA quantities. Tobacco weight and levels of TSNAs in filler influence TSNA levels in smoke from the CI machine-smoking regimen. In contrast, filter ventilation is a major determinant of levels of TSNAs in smoke by the ISO machine-smoking regimen. Comparative analysis demonstrates substantial variability in TSNA amounts in tobacco filler and mainstream smoke yields under ISO and CI machine-smoking regimens among U.S. commercial cigarette brands. |
US adults' perceptions of the harmful effects during pregnancy of using electronic vapor products versus smoking cigarettes, Styles Survey, 2015
Nguyen KH , Tong VT , Marynak KL , King BA . Prev Chronic Dis 2016 13 E175 INTRODUCTION: Research suggests aerosol from electronic vapor products (EVPs) has fewer harmful constituents than conventional cigarette smoke. Even so, EVPs and other nicotine-containing products are not safe to use during pregnancy. We examined perceptions among US adults regarding harm in using EVPs rather than smoking cigarettes during pregnancy. METHODS: Data came from the 2015 Styles Survey, an Internet panel survey of a sample of US adults aged 18 years or older (N = 4,127). Perceived harm was assessed by asking respondents whether using EVPs was less, equally, or more harmful for pregnant women than smoking cigarettes. Descriptive statistics were used to estimate perceived harm overall and by sociodemographic characteristics and tobacco-use status. Perceived harm was assessed among all adults, women of reproductive age (18-44 years, n = 820), and women of nonreproductive age (≥45 years, n = 1,398). RESULTS: Among all adults, 11.1% believed using EVPs during pregnancy was less harmful than smoking conventional cigarettes, 51.0% believed it was equally harmful, 11.6% believed it was more harmful, and 26.2% did not know. Prevalence of perception of less harm, by demographic category, was greatest among adults aged 18 to 24 years, men, non-Hispanic whites, adults with less than a high school diploma, current EVP users, and current cigarette smokers (P < .05). Prevalence of perception of less harm was greater among women of reproductive age (9.6%) than among those of nonreproductive age (7.9%) (P < .05). CONCLUSION: US adults have varying levels of perceptions about the harms of EVP use versus cigarette smoking during pregnancy. Efforts are warranted to prevent nicotine exposure during pregnancy and to educate adults on the dangers of using any form of tobacco during pregnancy, including EVPs. |
Nondaily smokers' characteristics and likelihood of prenatal cessation and postpartum relapse
Rockhill KM , Tong VT , England LJ , D'Angelo DV . Nicotine Tob Res 2016 19 (7) 810-816 INTRODUCTION: This study aimed to calculate the prevalence of pre-pregnancy nondaily smoking (<1 cigarette/day), risk factors, and report of prenatal provider smoking education; and assess the likelihood of prenatal cessation and postpartum relapse for nondaily smokers. METHODS: We analyzed data from 2009 to 2011 among women with live-born infants participating in the Pregnancy Risk Assessment Monitoring System. We compared characteristics of pre-pregnancy daily smokers (≥1 cigarette/day), nondaily smokers, and nonsmokers (chi-square adjusted p < .025). Between nondaily and daily smokers, we compared proportions of prenatal cessation, postpartum relapse (average 4 months postpartum), and reported provider education. Multivariable logistic regression calculated adjusted prevalence ratios (APR) for prenatal cessation among pre-pregnancy smokers (n = 27 360) and postpartum relapse among quitters (n = 13 577). RESULTS: Nondaily smokers (11% of smokers) were more similar to nonsmokers and differed from daily smokers on characteristics examined (p ≤ .001 for all). Fewer nondaily smokers reported provider education than daily smokers (71.1%, 86.3%; p < .001). A higher proportion of nondaily compared to daily smokers quit during pregnancy (89.7%, 49.0%; p < .001), and a lower proportion relapsed postpartum (22.2%, 48.6%; p < .001). After adjustment, nondaily compared to daily smokers were more likely to quit (APR: 1.65; 95% confidence interval [CI]: 1.58-1.71) and less likely to relapse postpartum (APR: 0.55; 95% CI: 0.48-0.62). CONCLUSIONS: Nondaily smokers were more likely to quit smoking during pregnancy, less likely to relapse postpartum, and less likely to report provider education than daily smokers. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond. IMPLICATION: Nondaily smoking (<1 cigarette/day) is increasing among US smokers and carries a significant risk of disease. However, smoking patterns surrounding pregnancy among nondaily smokers are unknown. Using 2009-2011 data from the Pregnancy Risk Assessment Monitoring System, we found pre-pregnancy nondaily smokers compared to daily smokers were 65% more likely to quit smoking during pregnancy and almost half as likely to relapse postpartum. Providers should educate all women, regardless of frequency of use, about the harms of tobacco during pregnancy, provide effective cessation interventions, and encourage women to be tobacco free postpartum and beyond. |
Excess mortality among people who report lifetime use of illegal drugs in the United States: A 20-year follow-up of a nationally representative survey
Walker ER , Pratt LA , Schoenborn CA , Druss BG . Drug Alcohol Depend 2016 171 31-38 OBJECTIVE: The purpose of this study was to determine the mortality risks, over 20 years of follow-up in a nationally representative sample, associated with illegal drug use and to describe risk factors for mortality. METHODS: We analyzed data from the 1991 National Health Interview Survey, which is a nationally representative household survey in the United States, linked to the National Death Index through 2011. This study included 20,498 adults, aged 18-44 years in 1991, with 1047 subsequent deaths. A composite variable of self-reported lifetime illegal drug use was created (hierarchical categories of heroin, cocaine, hallucinogens/inhalants, and marijuana use). RESULTS: Mortality risk was significantly elevated among individuals who reported lifetime use of heroin (HR=2.40, 95% CI: 1.65-3.48) and cocaine (HR=1.27, 95% CI: 1.04-1.55), but not for those who used hallucinogens/inhalants or marijuana, when adjusting for demographic characteristics. Baseline health risk factors (smoking, alcohol use, physical activity, and BMI) explained the greatest amount of this mortality risk. After adjusting for all baseline covariates, the association between heroin or cocaine use and mortality approached significance. In models adjusted for demographics, people who reported lifetime use of heroin or cocaine had an elevated mortality risk due to external causes (poisoning, suicide, homicide, and unintentional injury). People who had used heroin, cocaine, or hallucinogens/inhalants had an elevated mortality risk due to infectious diseases. CONCLUSIONS: Heroin and cocaine are associated with considerable excess mortality, particularly due to external causes and infectious diseases. This association can be explained mainly by health risk behaviors. |
Increases in drug and opioid-involved overdose deaths - United States, 2010-2015
Rudd RA , Seth P , David F , Scholl L . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1445-1452 The U.S. opioid epidemic is continuing, and drug overdose deaths nearly tripled during 1999-2014. Among 47,055 drug overdose deaths that occurred in 2014 in the United States, 28,647 (60.9%) involved an opioid. Illicit opioids are contributing to the increase in opioid overdose deaths. In an effort to target prevention strategies to address the rapidly changing epidemic, CDC examined overall drug overdose death rates during 2010-2015 and opioid overdose death rates during 2014-2015 by subcategories (natural/semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone). Rates were stratified by demographics, region, and by 28 states with high quality reporting on death certificates of specific drugs involved in overdose deaths. During 2015, drug overdoses accounted for 52,404 U.S. deaths, including 33,091 (63.1%) that involved an opioid. There has been progress in preventing methadone deaths, and death rates declined by 9.1%. However, rates of deaths involving other opioids, specifically heroin and synthetic opioids other than methadone (likely driven primarily by illicitly manufactured fentanyl), increased sharply overall and across many states. A multifaceted, collaborative public health and law enforcement approach is urgently needed. Response efforts include implementing the CDC Guideline for Prescribing Opioids for Chronic Pain (4), improving access to and use of prescription drug monitoring programs, enhancing naloxone distribution and other harm reduction approaches, increasing opioid use disorder treatment capacity, improving linkage into treatment, and supporting law enforcement strategies to reduce the illicit opioid supply. |
The break up: Evaluation of an anti-smoking educational campaign for lesbians, gays, and bisexuals in Los Angeles County
Plant A , Montoya JA , Tyree R , Aragon L , Weber M , Le Veque M , Anderson CM , Soler RE , Kent C . J Health Commun 2016 22 (1) 1-8 Lesbian, gay, and bisexual (LGB) adults in the United States have a higher prevalence of smoking than their heterosexual counterparts. In 2013, the Los Angeles County Department of Public Health launched a social marketing and outreach campaign called Break Up to reduce the prevalence of smoking in LGB communities. Break Up was evaluated using cross-sectional, street-intercept surveys before and near the end of campaign. Surveys measured demographics, campaign awareness, and self-reported smoking-related outcomes. Bivariate statistics and logistic regression models were used to identify whether campaign awareness was associated with smoking-related outcomes. Calls by LGB persons to a smokers' helpline were also measured. Among those interviewed at endline, 32.7% reported Break Up awareness. Awareness was associated with thinking of quitting smoking and ever taking steps to quit but not with smoking cessation (defined as not smoking in the past 30 days among those who had smoked in the past 6 months). There was a 0.7% increase in the percentage of weekly calls by LGB persons to the helpline in the year after the campaign. Break Up reached about a third of its intended audience. The campaign was associated with smoking cessation precursors and may have led to an increase in helpline utilization, but there is no evidence it affected quit attempts. This study adds to the limited literature on tobacco programs for LGB persons and, as far as we know, is one of the first to evaluate tobacco-free social marketing in this important yet understudied population. |
Characteristics of electronic cigarette use among middle and high school students - United States, 2015
Singh T , Kennedy S , Marynak K , Persoskie A , Melstrom P , King BA . MMWR Morb Mortal Wkly Rep 2016 65 (5051) 1425-1429 Electronic cigarettes (e-cigarettes) are now the most commonly used tobacco product among U.S. youths; in 2015, 5.3% of middle school students and 16.0% of high school students reported using e-cigarettes in the past 30 days. However, limited information exists on the e-cigarette product types and brands used and the substances used in these products by youths. CDC and the Food and Drug Administration (FDA) analyzed data from the 2015 National Youth Tobacco Survey (NYTS) to examine the characteristics of e-cigarette use among U.S. middle (grades 6-8) and high (grades 9-12) school students in 2015, including types of products used, brands of products used, and whether substances other than nicotine were used with the products. Among respondents reporting ever having used an e-cigarette, 14.5% used only disposable e-cigarettes, 53.4% used only rechargeable/refillable e-cigarettes, and 32.1% used both types. Two of the most commonly used e-cigarette brands were blu (26.4%, 1.65 million youths) and VUSE (12.2%, 760,000 youths); half of students (50.7%, 3.18 million) did not know the brand of e-cigarette they used. One third (32.5%) of those who reported ever using an e-cigarette also reported having used e-cigarettes for substances other than nicotine. Preventing youths from beginning use of any tobacco product, including e-cigarettes, is critical to tobacco use prevention and control strategies in the United States. Monitoring the characteristics of e-cigarette use among youths, including product types, brands, and ingredients, is important to inform strategies to prevent and reduce e-cigarette use among youths. |
Consumption of combustible and smokeless tobacco - United States, 2000-2015
Wang TW , Kenemer B , Tynan MA , Singh T , King B . MMWR Morb Mortal Wkly Rep 2016 65 (48) 1357-1363 Combustible and smokeless tobacco use causes adverse health outcomes, including cardiovascular disease and multiple types of cancer. Standard approaches for measuring tobacco use include self-reported surveys of use and consumption estimates based on tobacco excise tax data. To provide the most recently available tobacco consumption estimates in the United States, CDC used federal excise tax data to estimate total and per capita consumption during 2000-2015 for combustible tobacco (cigarettes, roll-your-own tobacco, pipe tobacco, small cigars, and large cigars) and smokeless tobacco (chewing tobacco and dry snuff). During this period, total combustible tobacco consumption decreased 33.5%, or 43.7% per capita. Although total cigarette consumption decreased 38.7%, cigarettes remained the most commonly used combustible tobacco product. Total noncigarette combustible tobacco (i.e., cigars, roll-your-own, and pipe tobacco) consumption increased 117.1%, or 83.8% per capita during 2000-2015. Total consumption of smokeless tobacco increased 23.1%, or 4.2% per capita. Notably, total cigarette consumption was 267.0 billion cigarettes in 2015 compared with 262.7 billion in 2014. These findings indicate that although cigarette smoking declined overall during 2000-2015, and each year from 2000 to 2014, the number of cigarettes consumed in 2015 was higher than in 2014, and the first time annual cigarette consumption was higher than the previous year since 1973. Moreover, the consumption of other combustible and smokeless tobacco products remains substantial. Implementation of proven tobacco prevention interventions is warranted to further reduce tobacco use in the United States. |
Shifting clade distribution, reassortment, and emergence of new subtypes of highly pathogenic avian influenza A(H5) viruses collected in Vietnamese poultry from 2012 to 2015.
Nguyen DT , Jang Y , Nguyen TD , Jones J , Shepard SS , Yang H , Gerloff N , Fabrizio T , Nguyen LV , Inui K , Yang G , Creanga A , Wang L , Mai DT , Thor S , Stevens J , To TL , Wentworth DE , Nguyen T , Pham DV , Bryant JE , Davis CT . J Virol 2016 91 (5) Whole genome sequences of representative highly pathogenic avian influenza A(H5) viruses from Vietnam were generated, comprising samples from poultry outbreaks and active market surveillance collected from January 2012 to August 2015. Six hemagglutinin gene clades were characterized. Clade 1.1.2 was predominant in southern Mekong provinces throughout 2012 and 2013, but gradually disappeared and was not detected after April 2014. Clade 2.3.2.1c viruses spread rapidly during 2012 and were detected in the south and center of the country. A number of clade 1.1.2 and 2.3.2.1c inter-clade reassortant viruses were detected with different combinations of internal genes derived from 2.3.2.1a and 2.3.2.1b viruses indicating extensive co-circulation. Although reassortment generated genetic diversity at the genotype level, there was relatively little genetic drift within the individual gene segments suggesting genetic stasis over recent years. Antigenically, clade 1.1.2, 2.3.2.1a, 2.3.2.1b, 2.3.2.1c viruses remained related to earlier viruses and WHO recommended pre-pandemic vaccine strains representing these clades. Clade 7.2 viruses, although only detected in small numbers, were the exception as indicated by introduction of a genetically and antigenically diverse strain in 2013. Clade 2.3.4.4 viruses (H5N1 and H5N6) were likely introduced in April 2014 and appeared to gain dominance across northern and central regions. Antigenic analyses of clade 2.3.4.4 viruses compared to existing clade 2.3.4 candidate vaccine viruses (CVV) indicated the need for an updated vaccine virus. A/Sichuan/26221/2014 (H5N6), was developed and ferret antisera generated against this virus was demonstrated to inhibit some but not all clade 2.3.4.4 viruses suggesting consideration of alternative clade 2.3.4.4 CVVs. IMPORTANCE: Highly pathogenic avian influenza (HPAI) A(H5) viruses have circulated continuously in Vietnam since 2003 resulting in hundreds of poultry outbreaks and sporadic human infections. Despite significant reduction in the number of human infections in recent years, poultry outbreaks continue to occur and the virus continues to diversify. Vaccination of poultry has been used as a means to control spread and impact of the virus but due to the diversity and changing distribution of antigenically distinct viruses, the utility of vaccines in the face of mismatched circulating strains remains questionable. This study assesses the putative amino acid changes in viruses leading to antigenic variability, underscoring the complexity of vaccine selection for both veterinary and public health purposes. Given the overlapping geographic distribution of multiple, antigenically distinct clades of HPAI A(H5) viruses in Vietnam, the vaccine efficacy of bivalent poultry vaccine formulations should be tested in the future. |
Routine argyrophil techniques detect Rickettsia rickettsii in tissues of patients with fatal Rocky Mountain spotted fever
Paddock CD , Sanders JH , Denison AM , Muehlenbachs A , Zaki SR . J Histotechnol 2016 39 (4) 116-122 Rickettsia rickettsii, a bacterial tickborne pathogen that causes Rocky Mountain spotted fever (RMSF), stains poorly or not at all with conventional tissue Gram techniques, and contemporary visualization of the pathogen in formalin-fixed, paraffin-embedded tissues has relied almost entirely on immunohistochemical staining methods that are generally limited to specialized research laboratories or national reference centers. To our knowledge, previously described argyrophil-based histochemical techniques have not successfully detected rickettsiae in formalin-fixed, paraffin-embedded tissues. To investigate the ability of standard silver impregnation techniques to demonstrate the occurrence and distribution of R. rickettsii in tissues of patients with RMSF confirmed by molecular and immunohistochemical methods, three widely recognized and commercially available silver impregnation methods (Warthin–Starry, Steiner, and Dieterle’s) were applied to various tissues obtained at autopsy from 10 patients with fatal RMSF. R. rickettsii bacteria were demonstrated in one or more tissues of all patients, using each of the argyrophil-based methods, and appeared as small, dark brown-to-black lanceolate rods, often in pairs and occasionally surrounded by a faint halo. Rickettsiae were identified most consistently in small arteries and arterioles of liver, kidney, and leptomeninges, and were localized predominantly to the cytoplasm of endothelial cells and less often within the internal elastic lamella and smooth muscle of the media. This validation of argyrophilic techniques to detect R. rickettsii demonstrates the utility of inexpensive core histochemical methods in the diagnosis of infectious agents in pathology specimens and may have utility in certain resource-limited settings where RMSF is endemic. |
Spread of yellow fever virus outbreak in Angola and the Democratic Republic of the Congo 2015-16: a modelling study
Kraemer MU , Faria NR , Reiner RC Jr , Golding N , Nikolay B , Stasse S , Johansson MA , Salje H , Faye O , Wint GRW , Niedrig M , Shearer FM , Hill SC , Thompson RN , Bisanzio D , Taveira N , Nax HH , Pradelski BSR , Nsoesie EO , Murphy NR , Bogoch II , Khan K , Brownstein JS , Tatem AJ , de Oliveira T , Smith DL , Sall AA , Pybus OG , Hay SI , Cauchemez S . Lancet Infect Dis 2016 17 (3) 330-338 BACKGROUND: Since late 2015, an epidemic of yellow fever has caused more than 7334 suspected cases in Angola and the Democratic Republic of the Congo, including 393 deaths. We sought to understand the spatial spread of this outbreak to optimise the use of the limited available vaccine stock. METHODS: We jointly analysed datasets describing the epidemic of yellow fever, vector suitability, human demography, and mobility in central Africa to understand and predict the spread of yellow fever virus. We used a standard logistic model to infer the district-specific yellow fever virus infection risk during the course of the epidemic in the region. FINDINGS: The early spread of yellow fever virus was characterised by fast exponential growth (doubling time of 5-7 days) and fast spatial expansion (49 districts reported cases after only 3 months) from Luanda, the capital of Angola. Early invasion was positively correlated with high population density (Pearson's r 0.52, 95% CI 0.34-0.66). The further away locations were from Luanda, the later the date of invasion (Pearson's r 0.60, 95% CI 0.52-0.66). In a Cox model, we noted that districts with higher population densities also had higher risks of sustained transmission (the hazard ratio for cases ceasing was 0.74, 95% CI 0.13-0.92 per log-unit increase in the population size of a district). A model that captured human mobility and vector suitability successfully discriminated districts with high risk of invasion from others with a lower risk (area under the curve 0.94, 95% CI 0.92-0.97). If at the start of the epidemic, sufficient vaccines had been available to target 50 out of 313 districts in the area, our model would have correctly identified 27 (84%) of the 32 districts that were eventually affected. INTERPRETATION: Our findings show the contributions of ecological and demographic factors to the ongoing spread of the yellow fever outbreak and provide estimates of the areas that could be prioritised for vaccination, although other constraints such as vaccine supply and delivery need to be accounted for before such insights can be translated into policy. FUNDING: Wellcome Trust. |
Travel volume to the United States from countries and U.S. territories with local Zika virus transmission
Nelson B , Morrison S , Joseph H , Wojno A , Lash RR , Haber Y , Berro A , Cetron M , Grills A . PLoS Curr 2016 8 INTRODUCTION: Air, land, and sea transportation can facilitate rapid spread of infectious diseases. In May 2015 the Pan American Health Organization (PAHO) issued an alert regarding the first confirmed Zika virus infection in Brazil. As of March 8, 2016, the U.S. Centers for Disease Control and Prevention (CDC) had issued travel notices for 33 countries and 3 U.S. territories with local Zika virus transmission. METHODS: Using data from five separate datasets from 2014 and 2015, we estimated the annual number of passenger journeys by air and land border crossings to the United States from the 33 countries and 3 U.S. territories listed in the CDC's Zika travel notices as of March 8, 2016. We also estimated the annual number of passenger journeys originating in and returning to the United States (primarily on cruises) with visits to seaports in areas with local Zika virus transmission. Because of the adverse pregnancy and birth outcomes that have been associated with Zika virus disease, the number of passenger journeys completed by women of childbearing age and pregnant women was also estimated. RESULTS: An estimated 216.3 million passenger journeys by air, land, and sea are made annually to the United States from areas with local Zika virus transmission (as of March 8). The destination states with the largest numbers of arrivals were Texas (by land) and Florida (by air and sea). An estimated 51.7 million passenger journeys were made by women of childbearing age and an estimated 2.3 million were made by pregnant women. CONCLUSION: Travel volume analyses provide important information that can be used to effectively target public health interventions as well as direct public health resources and efforts at local, regional, and country-specific levels. |
Virus-like particles displaying H5, H7, H9 hemagglutinins and N1 neuraminidase elicit protective immunity to heterologous avian influenza viruses in chickens
Pushko P , Tretyakova I , Hidajat R , Zsak A , Chrzastek K , Tumpey TM , Kapczynski DR . Virology 2016 501 176-182 Avian influenza (AI) viruses circulating in wild birds pose a serious threat to public health. Human and veterinary vaccines against AI subtypes are needed. Here we prepared triple-subtype VLPs that co-localized H5, H7 and H9 antigens derived from H5N1, H7N3 and H9N2 viruses. VLPs also contained influenza N1 neuraminidase and retroviral gag protein. The H5/H7/H9/N1/gag VLPs were prepared using baculovirus expression. Biochemical, functional and antigenic characteristics were determined including hemagglutination and neuraminidase enzyme activities. VLPs were further evaluated in a chicken AI challenge model for safety, immunogenicity and protective efficacy against heterologous AI viruses including H5N2, H7N3 and H9N2 subtypes. All vaccinated birds survived challenges with H5N2 and H7N3 highly pathogenic AI (HPAI) viruses, while all controls died. Immune response was also detectable after challenge with low pathogenicity AI (LPAI) H9N2 virus suggesting that H5/H7/H9/N1/gag VLPs represent a promising approach for the development of broadly protective AI vaccine. |
Lyme borreliosis
Steere AC , Strle F , Wormser GP , Hu LT , Branda JA , Hovius JW , Li X , Mead PS . Nat Rev Dis Primers 2016 2 16090 Lyme borreliosis is a tick-borne disease that predominantly occurs in temperate regions of the northern hemisphere and is primarily caused by the bacterium Borrelia burgdorferi in North America and Borrelia afzelii or Borrelia garinii in Europe and Asia. Infection usually begins with an expanding skin lesion, known as erythema migrans (referred to as stage 1), which, if untreated, can be followed by early disseminated infection, particularly neurological abnormalities (stage 2), and by late infection, especially arthritis in North America or acrodermatitis chronica atrophicans in Europe (stage 3). However, the disease can present with any of these manifestations. During infection, the bacteria migrate through the host tissues, adhere to certain cells and can evade immune clearance. Yet, these organisms are eventually killed by both innate and adaptive immune responses and most inflammatory manifestations of the infection resolve. Except for patients with erythema migrans, Lyme borreliosis is diagnosed based on a characteristic clinical constellation of signs and symptoms with serological confirmation of infection. All manifestations of the infection can usually be treated with appropriate antibiotic regimens, but the disease can be followed by post-infectious sequelae in some patients. Prevention of Lyme borreliosis primarily involves the avoidance of tick bites by personal protective measures. |
Male-to-female sexual transmission of Zika virus-United States, January-April 2016
Russell K , Hills SL , Oster AM , Porse CC , Danyluk G , Cone M , Brooks R , Scotland S , Schiffman E , Fredette C , White JL , Ellingson K , Hubbard A , Cohn A , Fischer M , Mead P , Powers AM , Brooks JT . Clin Infect Dis 2016 64 (2) 211-213 We report on 9 cases of male-to-female sexual transmission of Zika virus in the United States occurring January-April 2016. This report summarizes new information about both timing of exposure and symptoms of sexually transmitted Zika virus disease, and results of semen testing for Zika virus from 2 male travelers. |
Monitoring and preventing congenital Zika syndrome
Honein MA , Jamieson DJ . N Engl J Med 2016 375 (24) 2393-2394 The devastating fetal and infant outcomes associated with thalidomide use and rubella infection during pregnancy were key factors in the establishment of population-based surveillance for birth defects in the United States and globally to better monitor and address the effect of teratogens.1,2 This year, the recognition that Zika virus (ZIKV) infection during pregnancy can cause microcephaly and serious brain abnormalities and growing evidence of its association with other birth defects has similar potential to transform our approach to global surveillance for, research on, and prevention of birth defects.3 ZIKV infection during pregnancy highlights the challenges of adequately monitoring and documenting adverse effects in fetuses and infants. For example, the excess microcephaly after a ZIKV disease outbreak in French Polynesia that has now been documented was identified only by retrospective assessment.4 To ensure consistency in both pregnancy registries and ongoing birth-defect surveillance, the Centers for Disease Control and Prevention (CDC) has established surveillance case definitions to monitor birth defects potentially related to ZIKV infection during pregnancy: brain abnormalities with or without microcephaly, neural tube defects and other early brain malformations, eye abnormalities, and other consequences of central nervous system dysfunction (www.cdc.gov/zika/geo/pregnancy-outcomes.html. opens in new tab). |
Notes from the Field: plague in domestic cats - Idaho, 2016
Kassem AM , Tengelsen L , Atkins B , Link K , Taylor M , Peterson E , Machado A , Carter K , Hutton S , Turner K , Hahn C . MMWR Morb Mortal Wkly Rep 2016 65 (48) 1378-1379 In May 2015, Yersinia pestis, the bacterium that causes plague, was identified in dead Piute ground squirrels (Urocitellus mollis) reported through the Idaho Department of Fish and Game’s wildlife mortality monitoring program; in June 2015, the Idaho Division of Public Health (DPH) sent an advisory to veterinarians in four southwestern Idaho counties requesting that they notify their local public health officials of suspected plague in animals.* Y. pestis was not confirmed in any pets during 2015. | During May 30–July 26, 2016, local veterinarians notified public health officials that five dogs and 12 cats were being evaluated for possible plague. Local veterinarians also performed necropsies, when applicable, to establish the diagnosis. Idaho’s Central District Health Department and Eastern Idaho Public Health coordinated with DPH on submission of specimens to the DPH Bureau of Laboratories for Y. pestis testing and interviewed veterinary staff and pet owners. Specimens from blood, spleen, liver, and lymph nodes were screened using real–time polymerase chain reaction and confirmed by culture and phage lysis testing. | Among evaluated animals, Y. pestis was isolated from six of 12 cats; five of the six were from areas in southwestern Idaho where dead ground squirrels with confirmed Y. pestis had been reported in May 2016, and one was from from eastern Idaho. Among these six cats, specimen collection occurred during May 31–July 12, 2016; cats ranged in age from 10 months to 14.5 years (median = 4 years), four (67%) were male, five (83%) resided both indoors and outdoors, and one resided outdoor only. All six cats were domestic shorthair breed and had been neutered or spayed. Fever and lymphadenopathy (n = 4, 67%) were the most commonly reported signs of illness. None of the cats had known pulmonary involvement. Three of the six cats were treated with appropriate antibiotics (1); of these, two survived and one was euthanatized. The three other cats had died or had been euthanatized. All six cats reportedly had contact with ground squirrels and other wild rodents or rabbits before becoming ill; one had flea control administered before illness onset. |
Preliminary report of microcephaly potentially associated with Zika virus infection during pregnancy - Colombia, January-November 2016
Cuevas EL , Tong VT , Rozo N , Valencia D , Pacheco O , Gilboa SM , Mercado M , Renquist CM , Gonzalez M , Ailes EC , Duarte C , Godoshian V , Sancken CL , Turca AM , Calles DL , Ayala M , Morgan P , Perez EN , Bonilla HQ , Gomez RC , Estupinan AC , Gunturiz ML , Meaney-Delman D , Jamieson DJ , Honein MA , Martinez ML . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1409-1413 In Colombia, approximately 105,000 suspected cases of Zika virus disease (diagnosed based on clinical symptoms, regardless of laboratory confirmation) were reported during August 9, 2015-November 12, 2016, including nearly 20,000 in pregnant women (1,2). Zika virus infection during pregnancy is a known cause of microcephaly and serious congenital brain abnormalities and has been associated with other birth defects related to central nervous system damage (3). Colombia's Instituto Nacional de Salud (INS) maintains national surveillance for birth defects, including microcephaly and other central nervous system defects. This report provides preliminary information on cases of congenital microcephaly identified in Colombia during epidemiologic weeks 5-45 (January 31-November 12) in 2016. During this period, 476 cases of microcephaly were reported, compared with 110 cases reported during the same period in 2015. The temporal association between reported Zika virus infections and the occurrence of microcephaly, with the peak number of reported microcephaly cases occurring approximately 24 weeks after the peak of the Zika virus disease outbreak, provides evidence suggesting that the period of highest risk is during the first trimester of pregnancy and early in the second trimester of pregnancy. Microcephaly prevalence increased more than fourfold overall during the study period, from 2.1 per 10,000 live births in 2015 to 9.6 in 2016. Ongoing population-based birth defects surveillance is essential for monitoring the impact of Zika virus infection during pregnancy on birth defects prevalence and measuring the success in preventing Zika virus infection and its consequences, including microcephaly. |
Assessing change in avian influenza A(H7N9) virus infections during the fourth epidemic - China, September 2015-August 2016
Xiang N , Li X , Ren R , Wang D , Zhou S , Greene CM , Song Y , Zhou L , Yang L , Davis CT , Zhang Y , Wang Y , Zhao J , Li X , Iuliano AD , Havers F , Olsen SJ , Uyeki TM , Azziz-Baumgartner E , Trock S , Liu B , Sui H , Huang X , Zhang Y , Ni D , Feng Z , Shu Y , Li Q . MMWR Morb Mortal Wkly Rep 2016 65 (49) 1390-1394 Since human infections with avian influenza A(H7N9) virus were first reported by the Chinese Center for Disease Control and Prevention (China CDC) in March 2013, mainland China has experienced four influenza A(H7N9) virus epidemics. Prior investigations demonstrated that age and sex distribution, clinical features, and exposure history of A(H7N9) virus human infections reported during the first three epidemics were similar. In this report, epidemiology and virology data from the most recent, fourth epidemic (September 2015-August 2016) were compared with those from the three earlier epidemics. Whereas age and sex distribution and exposure history in the fourth epidemic were similar to those in the first three epidemics, the fourth epidemic demonstrated a greater proportion of infected persons living in rural areas, a continued spread of the virus to new areas, and a longer epidemic period. The genetic markers of mammalian adaptation and antiviral resistance remained similar across each epidemic, and viruses from the fourth epidemic remained antigenically well matched to current candidate vaccine viruses. Although there is no evidence of increased human-to-human transmissibility of A(H7N9) viruses, the continued geographic spread, identification of novel reassortant viruses, and pandemic potential of the virus underscore the importance of rigorous A(H7N9) virus surveillance and continued risk assessment in China and neighboring countries. |
Birth defects among fetuses and infants of US women with evidence of possible Zika virus infection during pregnancy
Honein MA , Dawson AL , Petersen EE , Jones AM , Lee EH , Yazdy MM , Ahmad N , Macdonald J , Evert N , Bingham A , Ellington SR , Shapiro-Mendoza CK , Oduyebo T , Fine AD , Brown CM , Sommer JN , Gupta J , Cavicchia P , Slavinski S , White JL , Owen SM , Petersen LR , Boyle C , Meaney-Delman D , Jamieson DJ . JAMA 2016 317 (1) 59-68 Importance: Understanding the risk of birth defects associated with Zika virus infection during pregnancy may help guide communication, prevention, and planning efforts. In the absence of Zika virus, microcephaly occurs in approximately 7 per 10000 live births. Objective: To estimate the preliminary proportion of fetuses or infants with birth defects after maternal Zika virus infection by trimester of infection and maternal symptoms. Design, Setting, and Participants: Completed pregnancies with maternal, fetal, or infant laboratory evidence of possible recent Zika virus infection and outcomes reported in the continental United States and Hawaii from January 15 to September 22, 2016, in the US Zika Pregnancy Registry, a collaboration between the CDC and state and local health departments. Exposures: Laboratory evidence of possible recent Zika virus infection in a maternal, placental, fetal, or infant sample. Main Outcomes and Measures: Birth defects potentially Zika associated: brain abnormalities with or without microcephaly, neural tube defects and other early brain malformations, eye abnormalities, and other central nervous system consequences. Results: Among 442 completed pregnancies in women (median age, 28 years; range, 15-50 years) with laboratory evidence of possible recent Zika virus infection, birth defects potentially related to Zika virus were identified in 26 (6%; 95% CI, 4%-8%) fetuses or infants. There were 21 infants with birth defects among 395 live births and 5 fetuses with birth defects among 47 pregnancy losses. Birth defects were reported for 16 of 271 (6%; 95% CI, 4%-9%) pregnant asymptomatic women and 10 of 167 (6%; 95% CI, 3%-11%) symptomatic pregnant women. Of the 26 affected fetuses or infants, 4 had microcephaly and no reported neuroimaging, 14 had microcephaly and brain abnormalities, and 4 had brain abnormalities without microcephaly; reported brain abnormalities included intracranial calcifications, corpus callosum abnormalities, abnormal cortical formation, cerebral atrophy, ventriculomegaly, hydrocephaly, and cerebellar abnormalities. Infants with microcephaly (18/442) represent 4% of completed pregnancies. Birth defects were reported in 9 of 85 (11%; 95% CI, 6%-19%) completed pregnancies with maternal symptoms or exposure exclusively in the first trimester (or first trimester and periconceptional period), with no reports of birth defects among fetuses or infants with prenatal exposure to Zika virus infection only in the second or third trimesters. Conclusions and Relevance: Among pregnant women in the United States with completed pregnancies and laboratory evidence of possible recent Zika infection, 6% of fetuses or infants had evidence of Zika-associated birth defects, primarily brain abnormalities and microcephaly, whereas among women with first-trimester Zika infection, 11% of fetuses or infants had evidence of Zika-associated birth defects. These findings support the importance of screening pregnant women for Zika virus exposure. |
Borrelia mayonii sp. nov., a member of the Borrelia burgdorferi sensu lato complex, detected in patients and ticks in the upper midwestern United States
Pritt BS , Respicio-Kingry LB , Sloan LM , Schriefer ME , Replogle AJ , Bjork J , Liu G , Kingry LC , Mead PS , Neitzel DF , Schiffman E , Hoang Johnson DK , Davis JP , Paskewitz SM , Boxrud D , Deedon A , Lee X , Miller TK , Feist MA , Steward CR , Theel ES , Patel R , Irish CL , Petersen JM . Int J Syst Evol Microbiol 2016 66 (11) 4878-4880 Lyme borreliosis (LB) is a multisystem disease caused by spirochetes in the Borrelia burgdorferisensu lato (Bbsl) genospecies complex. We previously described a novel Bbsl genospecies (type strain MN14-1420T) that causes LB among patients with exposures to ticks in the upper midwestern USA. Patients infected with the novel Bbsl genospecies demonstrated higher levels of spirochetemia and somewhat differing clinical symptoms as compared with those infected with other Bbsl genospecies. The organism was detected from human specimens using PCR, microscopy, serology and culture. The taxonomic status was determined using an eight-housekeeping-gene (uvrA, rplB, recG, pyrG, pepX, clpX, clpA and nifS) multi-locus sequence analysis (MLSA) and comparison of 16S rRNA gene, flaB, rrf-rrl, ospC and oppA2 nucleotide sequences. Using a system threshold of 98.3 % similarity for delineation of Bbsl genospecies by MLSA, we demonstrated that the novel species is a member of the Bbsl genospecies complex, most closely related to B. burgdorferisensu stricto (94.7-94.9 % similarity). This same species was identified in Ixodes scapularis ticks collected in Minnesota and Wisconsin. This novel species, Borrelia mayonii sp. nov, is formally described here. The type strain, MN14-1420, is available through the Deutsche Sammlung von Mikroorganismen und Zelkulturen GmbH (DSM 102811) and the American Type Culture Collection (ATCC BAA-2743). |
Dengue and chikungunya virus infections among young febrile adults evaluated for acute HIV-1 infection in coastal Kenya
Ngoi CN , Price MA , Fields B , Bonventure J , Ochieng C , Mwashigadi G , Hassan AS , Thiong'o AN , Micheni M , Mugo P , Graham S , Sanders EJ . PLoS One 2016 11 (12) e0167508 BACKGROUND: Fever is common among patients seeking care in sub-Saharan Africa (sSA), but causes other than malaria are rarely diagnosed. We assessed dengue and chikungunya virus infections among young febrile adults evaluated for acute HIV infection (AHI) and malaria in coastal Kenya. METHODS: We tested plasma samples obtained in a cross-sectional study from febrile adult patients aged 18-35 years evaluated for AHI and malaria at urgent care seeking at seven health facilities in coastal Kenya in 2014-2015. Dengue virus (DENV) and chikungunya virus (CHIKV) were amplified using quantitative real-time reverse-transcription polymerase chain reaction. We conducted logistic regression analyses to determine independent predictors of dengue virus infection. RESULTS: 489 samples that were negative for both AHI and malaria were tested, of which 43 (8.8%, 95% confidence interval [CI]: 6.4-11.7) were positive for DENV infection. No participant was positive for CHIKV infection. DENV infections were associated with clinic visits in the rainy season (adjusted odds ratio (AOR) = 3.0, 95% CI: 1.3-6.5) and evaluation at a private health facility (AOR 5.2, 95% CI: 2.0-13.1) or research health facility (AOR = 25.6, 95% CI: 8.9-73.2) instead of a public health facility. CONCLUSION: A high prevalence of DENV infections was found in febrile young adult patients evaluated for AHI. Our data suggests that DENV, along with AHI and malaria, should be considered in the differential diagnosis of the adult patient seeking care for fever in coastal Kenya. |
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