Changes in prevalence of chronic obstructive pulmonary disease and asthma in the US population and associated risk factors
Halldin CN , Doney BC , Hnizdo E . Chron Respir Dis 2014 12 (1) 47-60 Chronic lower airway diseases, including chronic obstructive pulmonary disease (COPD) and asthma, are currently the third leading cause of death in the United States. We aimed to evaluate changes in prevalence of and risk factors for COPD and asthma among the US adult population. We evaluated changes in prevalence of self-reported doctor-diagnosed COPD (i.e. chronic bronchitis and emphysema) and asthma and self-reported respiratory symptoms comparing data from the 1988-1994 and 2007-2010 National Health and Nutrition Examination Surveys. To investigate changes in the severity of each outcome over the two periods, we calculated changes in the proportions of spirometry-based airflow obstruction for each outcome. Prevalence of doctor-diagnosed chronic bronchitis and emphysema decreased significantly mainly among males, while asthma increased only among females. The self-reported disease and the respiratory symptoms were associated with increased prevalence of airflow obstruction for both periods. However, the prevalence of airflow obstruction decreased significantly in the second period among those with shortness of breath and doctor-diagnosed respiratory conditions (chronic bronchitis, emphysema, and asthma). COPD outcomes and asthma were associated with lower education, smoking, underweight and obesity, and occupational dusts and fumes exposure. Chronic lower airway diseases continue to be major public health problems. However, decreased prevalence of doctor-diagnosed chronic bronchitis and emphysema (in males) and decreased prevalence of airflow obstruction in those with respiratory symptoms and doctor-diagnosed respiratory diseases may indicate a declining trend and decrease in disease severity between the two periods. Continued focus on prevention of these diseases through public health interventions is prudent. |
Considering trends in sodium, trans fat, and saturated fat as key metrics of cardiometobolic risk reduction
Posner SF , Bowman BA , Collins JL . Prev Chronic Dis 2014 11 E230 The 2 articles by Urban and colleagues published this week in Preventing Chronic Disease report 15-year trends in sodium, trans fat, and saturated fat, 3 food components associated with increased risk for cardiovascular disease and obesity, in frequently ordered meal items (French fries, cheeseburgers, grilled chicken sandwiches, and regular cola) from leading US national fast food chain restaurants (1,2). These longitudinal findings track these 3 food components in foods that are frequently consumed by Americans. In recent surveys, almost half of Americans report eating fast food at least weekly (http://www.gallup.com/poll/163868/fast-food-major-part-diet.aspx), and similarly, nearly half report drinking soda daily (http://www.gallup.com/poll/156116/Nearly-Half-Americans-Drink-Soda-Daily.aspx). The findings by Urban et al confirm a substantial reduction in the content of trans fat and saturated fat in French fries but not in cheeseburgers or chicken sandwiches. Changes were inconsistent in sodium, saturated fat, and calories among food products, with the exception of sodas, where there was an increase in portion size. The authors conclude that, unlike the reduction observed in artificial trans fat in French fries, the content of sodium, saturated fat, and calories in the selected foods did not change much. Taken together, these findings indicate that little improvement has been made in the quality or energy density of popular fast food products and suggest the need for interventions to improve population health. | It is important to consider these findings in the larger context as public health researchers, practitioners, and policy makers develop and implement interventions to reduce intake of excessive calories, saturated fat, and artificial trans fat. Cheeseburgers, French fries, and a soda represent a quintessential part of American culture. Banter about them was central to the Saturday Night Live skit made famous by the late John Belushi. Similarly, songs made popular by performers such as Jimmy Buffett, Charlie Pride, the Gang of Four, and the Village People are all about having a cheeseburger, French fries, and a soda. These staples of the American diet are unlikely to disappear. However, central to American food choices is an unacceptably high prevalence of diet-related risk factors that compromise the health of Americans and contribute to the high costs of chronic disease. During the period examined by Urban and colleagues, the late 1990s through 2013, the US prevalence of chronic disease risk factors such as overweight, obesity, and hypertension have remained high, cardiovascular disease remains the leading cause of death, and prevalence of prediabetes and diabetes continues to increase (3). The continued popularity of fast food restaurants and continued high prevalence of diet-related risk factors remind public health researchers, practitioners, and policy makers that there is much that needs to be done. |
Clinical characteristics and genotypes of rotavirus in adults.
Anderson EJ , Shippee DB , Tate JE , Larkin B , Bregger MD , Katz BZ , Noskin GA , Sederdahl BK , Shane AL , Parashar UD , Yogev R . J Infect 2014 70 (6) 683-7 Immunity from a prior rotavirus infection is incomplete with infections occurring throughout life.1, 2, 3 Data suggest that rotavirus is responsible for 3–18% of adult diarrhea, particularly during the winter–spring.2, 3 We used data from our multi-year retrospective study2, 3, 4 of adults with community-acquired diarrhea from whom rotavirus was identified to describe the clinical characteristics, rotavirus genotypes, and predictors of adverse clinical outcomes. | The methods for this Institutional Review Board approved study have been published.2, 3, 4 Briefly, stool specimens from adults (≥18 years) submitted to Northwestern Memorial Hospital (Chicago, Illinois) for bacterial stool culture (BSC) were collected February–May from 2006 to 2011. Hospital-acquired diarrhea and duplicate specimens were excluded.2, 3, 4 Residual BSCs were analyzed for rotavirus by Rotaclone® and genotyped.2, 3, 4 Demographic information, medical co-morbidities, and outcomes were abstracted. Immunocompromised individuals were defined as previously outlined.2, 3 |
Oseltamivir-resistant influenza A(H1N1)pdm09 viruses, United States, 2013-14.
Okomo-Adhiambo M , Fry AM , Su S , Nguyen HT , Elal AA , Negron E , Hand J , Garten RJ , Barnes J , Xiyan X , Villanueva JM , Gubareva LV . Emerg Infect Dis 2015 21 (1) 136-41 We report characteristics of oseltamivir-resistant influenza A(H1N1)pdm09 viruses and patients infected with these viruses in the United States. During 2013-14, fifty-nine (1.2%) of 4,968 analyzed US influenza A(H1N1)pdm09 viruses had the H275Y oseltamivir resistance-conferring neuraminidase substitution. Our results emphasize the need for local surveillance for neuraminidase inhibitor susceptibility among circulating influenza viruses. |
Genetic analysis and characterization of wild poliovirus type 1 during sustained transmission in a population with >95% vaccine coverage, Israel 2013.
Shulman LM , Martin J , Sofer D , Burns CC , Manor Y , Hindiyeh M , Gavrilin E , Wilton T , Moran-Gilad J , Gamzo R , Mendelson E , Grotto I . Clin Infect Dis 2014 60 (7) 1057-64 BACKGROUND: Israel has >95% polio vaccine coverage with the last nine birth cohorts immunized exclusively with IPV. Using acute flaccid paralysis (AFP) and routine, monthly countrywide environmental surveillance, no wild poliovirus circulation was detected between 1989 and Feb 2013, after which wild type 1 polioviruses (WPV1-SOAS) have persistently circulated in southern Israel and intermittently in other areas without any paralytic cases as determined by intensified surveillance of environmental and human samples. AIM: To characterize antigenic and neurovirulence properties of WPV1-SOAS silently circulating in a highly vaccinated population. METHODS: WPV1-SOAS capsid genes from environmental and stool surveillance isolates were sequenced, their neurovirulence was determined using Tg21-PVR-transgenic mice and their antigenicity was characterized by in vitro neutralization using human sera, epitope-specific monoclonal murine anti-OPV antibodies, and sera from IPV immunized rats and mice. RESULTS: WPV1 amino acid sequences in neutralizing epitopes varied from Sabin 1 and Mahoney, with little variation among WPV1 isolates. Neutralization by MoAbs against three of four OPV epitopes was lost. Three-fold lower GMTs (Z=-4.018; P<0.001; Wilcoxon Signed Ranks Test) against WPV1 than against Mahoney in human serum correlated with 4 to 6-fold lower neutralization titers in serum from IPV immunized rats and mice. WPV1-SOAS isolates were neurovirulent (50% i.m. paralytic dose in Tg21-PVR-mice: log107.0). IPV immunized mice were protected against WPV1-induced paralysis. CONCLUSIONS: Phenotypic and antigenic profile changes of WPV1-SOAS may have contributed to the intense silent transmission, while the reduced neurovirulence to the absence of paralytic cases in the background of high population immunity. |
Serotype 10A in case patients with invasive pneumococcal disease: a pilot study of PCR-based serotyping in New Jersey
Pitts SI , Apostolou A , DasGupta S , Delgado N , Kirn TJ , Montana B , Tan C , McHugh LA . Public Health Rep 2015 130 (1) 54-9 In 2008, the New Jersey Department of Health (NJDOH) identified a 21.1% increase in reported invasive pneumococcal disease (IPD). In 2009, NJDOH piloted nucleic acid-based serotyping to characterize serotypes causing IPD. From April through September, NJDOH received specimens from 149 of 302 (49%) case patients meeting our case definition. An uncommon serotype, 10A, accounted for 25.2% of IPD overall and was identified in 12 counties, but it was associated with one county (rate ratio = 5.4, 95% confidence interval [CI] 2.1, 11.8). NJDOH subsequently conducted a case-control study to assess the presentation of and clinical risk factors for 10A IPD. Case patients with 10A IPD were more likely to have had immunosuppression, asthma, and multiple chronic medical conditions than control subjects had (odds ratio [OR] = 2.6, 95% CI 1.1, 6.3; OR=4.7, 95% CI 1.7, 13.2; and OR=2.3, 95% CI 1.0, 5.2, respectively). State-based pneumococcal serotype testing identified an uncommon serotype in New Jersey. Continued pneumococcal serotype surveillance might help the NJDOH identify and respond to future serotype-specific increases. |
Targeting the use of pooled HIV RNA screening to reduce cost in health department STD clinics: New York City, 2009-2011
Borges CM , Pathela P , Pirillo R , Blank S . Public Health Rep 2015 130 (1) 81-6 OBJECTIVE: Staff at public New York City sexually transmitted disease (STD) clinics screen patients for acute HIV infection (AHI) using pooled nucleic acid amplification tests. AHI screening is expensive but important for populations at high risk of acquiring HIV. We analyzed if targeting AHI screening in STD clinics could reduce program costs while maintaining AHI case detection. METHODS: From January 2009 through May 2010, we screened all patients with negative rapid HIV tests for AHI. Using risk information on cases detected during this universal screening period, we developed criteria for targeted AHI screening and compared case yields and testing costs during 12 months of universal screening (June 2009 through May 2010) vs. 12 months of targeted screening (June 2010 through May 2011). RESULTS: During the defined period of universal screening, we identified 40 AHI cases, and during targeted screening, we identified 35 AHI cases. Because of targeting efforts, the number needed to test to find one AHI case dropped from 1,631 to 254. With targeted screening, it cost an average of $4,535 per case detected and 39.3 cases were detected per 10,000 specimens; using universal screening, $29,088 was spent per case detected and 6.1 cases were detected per 10,000 specimens processed. CONCLUSION: Targeted screening identified similar numbers of AHI cases as when screening all clinic patients seeking HIV testing, but at one-seventh the cost. |
Notes from the field: aseptic meningitis outbreak associated with echovirus 30 among high school football players - Los Angeles County, California, 2014
Croker C , Civen R , Keough K , Ngo V , Marutani A , Schwartz B . MMWR Morb Mortal Wkly Rep 2015 63 (51) 1228 On August 4, 2014, the Acute Communicable Disease Control Program of the Los Angeles County Department of Public Health received a report of three aseptic meningitis cases among football players at a county high school. An investigation was conducted to determine the extent of the outbreak, identify potential exposures, and recommend control measures. An outbreak-associated aseptic meningitis case was defined as an illness of any team or family member with onset during July 28-August 11 with 1) cerebrospinal fluid pleocytosis and negative bacterial culture or 2) an emergency department visit with headache, fever, and stiff neck. Ten cases were identified; nine in males, and one in a female; patient ages ranged from 13 to 17 years. All the patients sought care at an emergency department, and five were hospitalized, resulting in 12 total hospital days. All 10 patients have recovered. Eight patients were football players, and two were siblings of football players. The most affected subgroup was the junior varsity football team, with seven cases out of 57 players (attack rate = 12.3%); the relative risk for aseptic meningitis was higher among players who were linemen than among those who were not linemen (relative risk = 5.4 [p = 0.03]). Of the 10 patients, eight tested positive by polymerase chain reaction for enterovirus, and two were not tested. Echovirus testing was performed at the California Viral and Rickettsial Disease Laboratory. Of the eight specimens testing positive for enterovirus, seven tested positive for echovirus 30, and one specimen could not be typed because of insufficient quantity. |
Perceptions of the risk for Ebola and health facility use among health workers and pregnant and lactating women - Kenema District, Sierra Leone, September 2014
Dynes MM , Miller L , Sam T , Vandi MA , Tomczyk B . MMWR Morb Mortal Wkly Rep 2015 63 (51) 1226-7 With an estimated maternal mortality ratio of 1,100 per 100,000 live births and a neonatal mortality rate of 49 per 1,000 live births, Sierra Leone has the highest maternal mortality ratio and the fourth highest neonatal mortality rate in the world, accounting for 2,400 maternal and 11,200 newborn deaths annually. By straining the fragile health care infrastructure, the Ebola virus disease (Ebola) epidemic might put pregnant women and their newborns at even greater risk for adverse outcomes. |
Community-acquired invasive GAS disease among Native Americans, Arizona, USA, winter 2013
Harris AM , Yazzie D , Antone-Nez R , Dine-Chacon G , Kinlacheeny JB , Foley D , Yasmin S , Adams L , Livar E , Terranella A , Yeager L , Komatsu K , Van Beneden C , Langley G . Emerg Infect Dis 2015 21 (1) 177-9 Group A streptococci (GAS) can cause severe invasive diseases, such as necrotizing fasciitis, streptococcal toxic shock syndrome, and sepsis. In 2012, ≈11,000 cases of invasive GAS (iGAS) disease and 1,100 associated deaths occurred in the United States (1,2). The risk for iGAS infection is 10 times higher among Native Americans than among the general population (3). Other predisposing factors for iGAS infection include skin wounds and underlying diseases, such as diabetes (1,3,4). Household risk factors include exposure to children with pharyngitis and crowding (4). Most iGAS infections occur sporadically within the community. Postpartum and postsurgical clusters arising from a common nosocomial source occur but are rare (5). | During the winter of 2012–13, a 3-fold increase in necrotizing fasciitis was observed at an Arizona hospital (hospital X) that predominantly treats Native Americans. Tribal leadership initiated a collaborative investigation with state and federal officials to characterize the outbreak and implement appropriate control measures. |
Contribution of influenza to acute exacerbations of chronic obstructive pulmonary disease in Kashmir, India, 2010-2012
Koul PA , Khan UH , Asad R , Yousuf R , Broor S , Lal RB , Dawood FS . Influenza Other Respir Viruses 2015 9 (1) 40-2 We estimate the contribution of influenza to hospitalizations for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in Kashmir, India. Prospective surveillance for influenza among patients hospitalized with AECOPD was conducted at a tertiary care hospital. Patients had clinical data collected and nasal/throat swabs tested for influenza viruses. Outcomes among patients with and without influenza were compared with logistic regression adjusting for age and underlying conditions. During October 2010-September 2012, 498 patients hospitalized with AECOPD were enrolled, of whom 40 (8%) had received influenza vaccine. Forty (8%) had influenza; influenza virus detection peaked in winter (January-March). Patients with influenza were more likely to die during hospitalization (adjusted OR 3.4, CI 1.0-11.4) than those without. |
Treatment outcomes of patients with tuberculosis in New York City
Bhavnani D , Lancki N , Winter I , Macaraig M . J Public Health Manag Pract 2014 21 (6) E11-8 CONTEXT: Treatment completion for tuberculosis (TB) is one of the essential components of TB prevention and control. Delays in treatment completion and incomplete treatment can result in increased transmission, development of drug resistance, and increased morbidity and mortality. Understanding the reasons for poor treatment outcomes may help improve TB control efforts. OBJECTIVE: To identify those at highest risk and determine the reasons for poor treatment outcomes among TB cases (January 2009-June 2010). DESIGN: Retrospective analysis. SETTING/PARTICIPANTS: New York City TB patients eligible to complete treatment within 12 months. MAIN OUTCOME MEASURES: Poisson regression models were used to identify risk factors associated with delayed completion and incomplete treatment compared with completion within 12 months of initiating treatment (timely completion). Reasons for delayed completion and incomplete treatment were summarized. RESULTS: Of 1008 cases eligible to complete treatment within 12 months, 921 (91%) had timely completion, 48 (5%) had delayed completion, and 39 (4%) had incomplete treatment. Cases with delayed completion and incomplete treatment were more likely to have extrapulmonary TB (adjusted risk ratio = 3.31; 95% confidence interval, 1.79-6.14; and adjusted risk ratio = 3.34; 95% confidence interval, 1.73-6.44, respectively). Primary reasons for delayed completion were a physician's decision to extend treatment (35%) and interrupted treatment (31%), whereas those for incomplete treatment included lost to care (38%), moved (28%), and refusal to continue treatment (26%). CONCLUSION: Overall, treatment completion in New York City was high. Patients with delayed completion and incomplete treatment had extrapulmonary disease in common. However, specific reasons suggest that delayed completion may be clinically motivated whereas incomplete treatment may result from social conditions. |
Enhancing the benefits of antiretroviral therapy in Vietnam: towards ending AIDS
Kato M , Long NH , Duong BD , Nhan do T , Nguyen TT , Hai NH , Giang le M , Hoa do M , Van NT , Suthar AB , Fontaine C , Nadol P , Lo YR , McConnell MS . Curr HIV/AIDS Rep 2014 11 (4) 487-95 Vietnam has a concentrated HIV epidemic, with the highest HIV prevalence being observed among people who inject drugs (PWID). Based on its experience scaling-up robust HIV interventions, Vietnam aims to further strengthen its response by harnessing the preventive benefits of antiretroviral therapy (ART). Mathematical modelling suggests that prioritizing key populations for earlier access to ART, combined with other prevention interventions, may have significant impact on the epidemic, cost-effectively reducing new HIV infections and deaths. Pilot studies are being conducted to assess feasibility and acceptability of expansion of HIV testing and counselling (HTC) and early ART among key populations and to demonstrate innovative service delivery models to address challenges in uptake of services across the care cascade. Earlier access of key populations to combination prevention interventions, combined with sustained political commitment and supportive environment for key populations, are essential for maximum impact of ART on the HIV epidemic in Vietnam. |
Human papillomavirus prevalence in invasive laryngeal cancer in the United States
Hernandez BY , Goodman MT , Lynch CF , Cozen W , Unger ER , Steinau M , Thompson T , Saber MS , Altekruse SF , Lyu C , Saraiya M . PLoS One 2014 9 (12) e115931 PURPOSE: Human papillomavirus (HPV) is a major risk factor for specific cancers of the head and neck, particularly malignancies of the tonsil and base of the tongue. However, the role of HPV in the development of laryngeal cancer has not been definitively established. We conducted a population-based, cancer registry study to evaluate and characterize the genotype-specific prevalence of HPV in invasive laryngeal cancer cases diagnosed in the U.S. METHODS: The presence of genotype-specific HPV DNA was evaluated using the Linear Array HPV Genotyping Test and the INNO-LiPA HPV Genotyping Assay in formalin-fixed paraffin embedded tissue from 148 invasive laryngeal cancer cases diagnosed in 1993-2004 within the catchment area of three U.S. SEER cancer registries. RESULTS: HPV DNA was detected in 31 of 148 (21%) invasive laryngeal cancers. Thirteen different genotypes were detected. Overall, HPV 16 and HPV 33 were the most commonly detected types. HPV was detected in 33% (9/27) of women compared with 18% (22/121) of men (p = 0.08). After adjustment for age and year of diagnosis, female patients were more likely to have HPV-positive laryngeal tumors compared to males (adjusted OR 2.84, 95% CI 1.07-7.51). Viral genotype differences were also observed between the sexes. While HPV 16 and 18 constituted half of HPV-positive cases occurring in men, among women, only 1 was HPV 16 positive and none were positive for HPV 18. Overall 5-year survival did not vary by HPV status. CONCLUSIONS: HPV may be involved in the development of a subset of laryngeal cancers and its role may be more predominant in women compared to men. |
Improved survival with co-trimoxazole prophylaxis among people living with HIV/AIDS who initiated antiretroviral treatment in Henan Province, China
Zhu Q , Wang L , Lin W , Bulterys M , Yang W , Sun D , Cui Z , Kaplan J , Kleinman N , Wei X , Chung J , Wang Z . Curr HIV Res 2014 12 (5) 359-65 OBJECTIVES: This study aims to evaluate the effect of co-trimoxazole (CTX) prophylaxis on mortality reduction among HIV-infected patients receiving antiretroviral therapy (ART) in Henan Province, China. DESIGN: We conducted a retrospective study. METHODS: All individuals aged 15 years and older who initiated ART between 2008 and 2010 in Henan Province with completed CTX prophylaxis treatment information were included. The effect of CTX prophylaxis was estimated using Kaplan-Meier survival analysis and multivariate Cox proportional hazard modeling for mortality at 3-months and 12- months after ART initiation. RESULTS: Overall mortality among patients receiving both ART and CTX was nearly double at 3-months after ART initiation compared with that at 12-months (12.4 per 100 PY vs 6.3 per 100 PY, p<0.01). After adjusting for gender, age, TB history, year of ART initiation and CD4 count at ART initiation, CTX was associated with a significant reduction in 12-month mortality (adjusted hazard ratio (AHR) = 0.65, 95% confidence interval (CI): 0.44 - 0.95; p = 0.027) compared with persons not receiving CTX. The protective effect was more pronounced in the first 3 months after ART initiation (AHR = 0.53, 95% CI: 0.32 - 0.89; p = 0.017). CONCLUSION: CTX prophylaxis together with ART reduced mortality of adult HIV patients during the first 12 months of ART in Henan Province, China. The effect was highest in the first 3 months of ART. CTX should be prescribed to all HIV-infected adults who initiate ART. |
Adapting and implementing a community program to improve retention in care among patients with HIV in southern Haiti: "Group of 6"
Naslund JA , Dionne-Odom J , Junior Destine C , Jogerst KM , Renold Senecharles R , Jean Louis M , Desir J , Neptune Ledan Y , Beausejour JR , Charles R , Werbel A , Talbot EA , Joseph P , Pape JW , Wright PF . AIDS Res Treat 2014 2014 137545 OBJECTIVE: In Mozambique, a patient-led Community ART Group model developed by Medecins Sans Frontieres improved retention in care and adherence to antiretroviral therapy (ART) among persons with HIV. We describe the adaptation and implementation of this model within the HIV clinic located in the largest public hospital in Haiti's Southern Department. METHODS: Our adapted model was named Group of 6. Hospital staff enabled stable patients with HIV receiving ART to form community groups with 4-6 members to facilitate monthly ART distribution, track progress and adherence, and provide support. Implementation outcomes included recruitment success, participant retention, group completion of monthly monitoring forms, and satisfaction surveys. RESULTS: Over one year, 80 patients from nine communities enrolled into 15 groups. Six participants left to receive HIV care elsewhere, two moved away, and one died of a non-HIV condition. Group members successfully completed monthly ART distribution and returned 85.6% of the monthly monitoring forms. Members reported that Group of 6 made their HIV management easier and hospital staff reported that it reduced their workload. CONCLUSIONS: We report successful adaptation and implementation of a validated community HIV-care model in Southern Haiti. Group of 6 can reduce barriers to ART adherence, and will be integrated as a routine care option. |
Antiviral treatment among pregnant women with chronic hepatitis B
Fan L , Owusu-Edusei K Jr , Schillie SF , Murphy TV . Infect Dis Obstet Gynecol 2014 2014 546165 OBJECTIVE: To describe the antiviral treatment patterns for chronic hepatitis B (CHB) among pregnant and nonpregnant women. METHODS: Using 2011 MarketScan claims, we calculated the rates of antiviral treatment among women (aged 10-50 years) with CHB. We described the pattern of antiviral treatment during pregnancy and ≥1 month after delivery. RESULTS: We identified 6274 women with CHB during 2011. Among these, 64 of 507 (12.6%) pregnant women and 1151 of 5767 (20.0%) nonpregnant women received antiviral treatment (P < 0.01). Pregnant women were most commonly prescribed tenofovir (73.4%) and lamivudine (21.9%); nonpregnant women were most commonly prescribed tenofovir (50.2%) and entecavir (41.3%) (P < 0.01). Among 48 treated pregnant women with an identifiable delivery date, 16 (33.3%) were prescribed an antiviral before pregnancy and continued treatment for at least one month after delivery; 14 (29.2%) started treatment during the third trimester and continued at least one month after delivery. CONCLUSION: Among this insured population, pregnant women with CHB received an antiviral significantly less often than nonpregnant women. The most common antiviral prescribed for pregnant women was tenofovir. These data provide a baseline for assessing changes in treatment patterns with anticipated increased use of antivirals to prevent breakthrough perinatal hepatitis B virus infection. |
Time spent with patients by physicians, nurse practitioners, and physician assistants in community health centers, 2006-2010
Morgan P , Everett CM , Hing E . Healthc (Amst) 2014 2 (4) 232-237 BACKGROUND: As health systems struggle to meet access, cost and quality goals in the setting of increased demand, nurse practitioners (NPs) and physician assistants (PAs) are expected to help meet the need for care. The amount of time spent with each patient can affect the clinical productivity, quality of care, and satisfaction of patients and clinicians. This paper compares time spent per patient in community health centers by whether the provider is a physician, NP, or PA. METHODS: This paper uses National Ambulatory Medical Care Survey (NAMCS) Community Health Center (CHC) data from 2006-2010. The NAMCS CHC strata is a national sample of CHCs, providers within CHCs, and patient visits to CHCs. Provider characteristics and variables related to time spent with patients across provider types were compared using t tests and chi square tests of association. Multivariate linear regression analysis was used to compare time spent with patients, controlling for patient and visit characteristics. RESULTS: There were no differences in the number of visits by provider type, but PAs saw patients for a slightly larger portion of the week (3.8 days) than did physicians (3.5 days, p<0.05) or NPs (3.4 days, p<0.05). There were no statistical differences in the mean time spent per patient in the crude and adjusted analyses. CONCLUSION: Time spent per patient in CHCs is similar for physicians, NPs and PAs. This information may be useful to planners concerned with health system capacity and cost efficiency, and has implications for patient and provider satisfaction. |
Endophthalmitis outbreak associated with repackaged bevacizumab
Edison LS , Dishman HO , Tobin-D'Angelo MJ , Allen CR , Guh AY , Drenzek CL . Emerg Infect Dis 2015 21 (1) 171-3 An outbreak of endophthalmitis associated with repackaged bevacizumab occurred during February–March 2013 in Georgia and Indiana, USA. Bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA, USA) is a vascular endothelial growth factor inhibitor that is approved by the US Food and Drug Administration as an antineoplastic agent but is commonly used off-label to treat retinal disorders, including age-related macular degeneration (1,2). Bevacizumab is manufactured in single-use, preservative-free, 4-mL vials; compounding pharmacies repackage bevacizumab into syringes for intraocular administration at smaller doses (e.g., 1.25 mg bevacizumab in 0.05-mL injection). Repackaged bevacizumab has been linked to endophthalmitis outbreaks worldwide in which compounding procedure deficiencies have led to microbial contamination and subsequent endophthalmitis (3–7). Endophthalmitis often results in vision loss, particularly if the infection is not identified early and treated aggressively (4–6). | During March 6–8, 2013, four patients with age-related macular degeneration received a diagnosis of acute endophthalmitis after receiving intravitreal bevacizumab injections on March 4, 2013, at a retinal specialty clinic (clinic A) in Georgia. All 4 patients were injected with bevacizumab from the same lot (lot Z), which was repackaged at a Georgia compounding pharmacy (pharmacy A) on February 13, 2013. The Georgia Department of Public Health (DPH) and the Georgia Drug and Narcotics Agency (GDNA) were notified of the outbreak by clinic A, and the outbreak was investigated to determine the extent and source of infections and to prevent additional cases. |
Temporal variability of polybrominated diphenyl ether (PBDE) serum concentrations over one year
Makey CM , McClean MD , Sjodin A , Weinberg J , Carignan CC , Webster TF . Environ Sci Technol 2014 48 (24) 14642-9 Polybrominated diphenyl ethers (PBDEs) are flame retardant chemicals used in consumer products. They are common contaminants in human serum and associated with adverse health effects. Our objectives were to characterize PBDE serum concentrations in a New England cohort and assess temporal variability of this exposure biomarker over a one-year period. We collected three repeated measurements at six-month intervals from 52 office workers from the greater Boston (MA, United States) area from 2010 to 2011. The intraclass correlation coefficient for BDEs 28, 47, 99, 100, and 153 ranged from 0.87 to 0.99, indicating that a single serum measurement can reliably estimate exposure over a one-year period. This was true for both lipid adjusted and nonlipid adjusted concentrations. The kappa statistics, quantifying the level of agreement of categorical exposure classification, based on medians, tertiles, or quartiles ranged from 0.67 to 0.90. Some congeners showed nonsignificant increases from sampling round 1 (winter) to round 2 (summer) and significant decreases from round 2 to round 3 (winter). This study highlights the high reliability of a single serum PBDE measurement for use in human epidemiologic studies. |
Challenges to implementing communicable disease surveillance in New York City evacuation shelters after Hurricane Sandy, November 2012
Ridpath AD , Bregman B , Jones L , Reddy V , Waechter H , Balter S . Public Health Rep 2015 130 (1) 48-53 Hurricane Sandy hit New York City (NYC) on October 29, 2012. Before and after the storm, 73 temporary evacuation shelters were established. The total census of these shelters peaked at approximately 6,800 individuals. Concern about the spread of communicable diseases in shelters prompted the NYC Department of Health and Mental Hygiene (DOHMH) to rapidly develop a surveillance system to report communicable diseases and emergency department transports from shelters. We describe the implementation of this system. Establishing effective surveillance in temporary shelters was challenging and required in-person visits by DOHMH staff to ensure reporting. After system establishment, surveillance data were used to identify some potential disease clusters. For the future, we recommend pre-event planning for disease surveillance. |
Occurrence and molecular characterization of Cryptosporidium spp. and Enterocytozoon bieneusi in dairy cattle, beef cattle and water buffaloes in China.
Ma J , Li P , Zhao X , Xu H , Wu W , Wang Y , Guo Y , Wang L , Feng Y , Xiao L . Vet Parasitol 2014 207 220-7 Cryptosporidium spp. and Enterocytozoon bieneusi are important protists in a wide range of vertebrate hosts, causing diarrheal diseases. Cattle are considered potential reservoirs of Cryptosporidium infection in humans, although their role in the transmission of E. bieneusi is not clear. In the present work, 793 fecal specimens from dairy cattle, native beef cattle, and water buffaloes on 11 farms in China were examined for the presence of Cryptosporidium spp. and E. bieneusi using nested PCR targeting the small subunit (SSU) rRNA gene of Cryptosporidium spp. and the internal transcribed spacer (ITS) of E. bieneusi. For Cryptosporidium, 144/446 (32.3%) dairy cattle, 44/166 (26.5%) beef cattle, and 43/181 (23.8%) water buffaloes were PCR-positive. Sequence analysis was successful for 213 of the 231 Cryptosporidium-positive isolates; among them 94 had Cryptosporidium andersoni, 61 had Cryptosporidium bovis, 54 had Cryptosporidium ryanae, 2 had a Cryptosporidium suis-like genotype, and 2 had mixed infections of C. bovis and C. ryanae. In dairy and beef cattle, C. andersoni and C. bovis were the most common species, whereas C. ryanae was the dominant species in water buffaloes. The latter species produced SSU rRNA sequences different between cattle and water buffaloes. For E. bieneusi, the infection rate of E. bieneusi in dairy cattle, beef cattle and water buffaloes was 4.9%, 5.4% and 2.2%, respectively. All 35 E. bieneusi-positive specimens were successfully sequenced, revealing the presence of four genotypes: three Group 2 genotypes previously reported in cattle as well as humans (I, J and BEB4) and one Group 1 genotype recently reported in yaks (CHN11). Genotypes I and J were the most common genotypes in dairy and beef cattle, while genotype CHN11 was the only genotype seen in water buffaloes. Thus, the distribution of Cryptosporidium spp. and E. bieneusi in water buffaloes might be different from in dairy and beef cattle in China. These findings indicate that some of the Cryptosporidium species and all four E. bieneusi genotypes identified in bovine animals in the study areas may have zoonotic potential. |
Increased outbreaks associated with nonpasteurized milk, United States, 2007-2012
Mungai EA , Behravesh CB , Gould LH . Emerg Infect Dis 2015 21 (1) 119-22 The number of US outbreaks caused by nonpasteurized milk increased from 30 during 2007-2009 to 51 during 2010-2012. Most outbreaks were caused by Campylobacter spp. (77%) and by nonpasteurized milk purchased from states in which nonpasteurized milk sale was legal (81%). Regulations to prevent distribution of nonpasteurized milk should be enforced. |
Phylodynamic analysis of clinical and environmental Vibrio cholerae isolates from Haiti reveals diversification driven by positive selection.
Azarian T , Ali A , Johnson JA , Mohr D , Prosperi M , Veras NM , Jubair M , Strickland SL , Rashid MH , Alam MT , Weppelmann TA , Katz LS , Tarr CL , Colwell RR , Morris JG Jr , Salemi M . mBio 2014 5 (6) Phylodynamic analysis of genome-wide single-nucleotide polymorphism (SNP) data is a powerful tool to investigate underlying evolutionary processes of bacterial epidemics. The method was applied to investigate a collection of 65 clinical and environmental isolates of Vibrio cholerae from Haiti collected between 2010 and 2012. Characterization of isolates recovered from environmental samples identified a total of four toxigenic V. cholerae O1 isolates, four non-O1/O139 isolates, and a novel nontoxigenic V. cholerae O1 isolate with the classical tcpA gene. Phylogenies of strains were inferred from genome-wide SNPs using coalescent-based demographic models within a Bayesian framework. A close phylogenetic relationship between clinical and environmental toxigenic V. cholerae O1 strains was observed. As cholera spread throughout Haiti between October 2010 and August 2012, the population size initially increased and then fluctuated over time. Selection analysis along internal branches of the phylogeny showed a steady accumulation of synonymous substitutions and a progressive increase of nonsynonymous substitutions over time, suggesting diversification likely was driven by positive selection. Short-term accumulation of nonsynonymous substitutions driven by selection may have significant implications for virulence, transmission dynamics, and even vaccine efficacy. IMPORTANCE: Cholera, a dehydrating diarrheal disease caused by toxigenic strains of the bacterium Vibrio cholerae, emerged in 2010 in Haiti, a country where there were no available records on cholera over the past 100 years. While devastating in terms of morbidity and mortality, the outbreak provided a unique opportunity to study the evolutionary dynamics of V. cholerae and its environmental presence. The present study expands on previous work and provides an in-depth phylodynamic analysis inferred from genome-wide single nucleotide polymorphisms of clinical and environmental strains from dispersed geographic settings in Haiti over a 2-year period. Our results indicate that even during such a short time scale, V. cholerae in Haiti has undergone evolution and diversification driven by positive selection, which may have implications for understanding the global clinical and epidemiological patterns of the disease. Furthermore, the continued presence of the epidemic strain in Haitian aquatic environments has implications for transmission. |
Health risk behaviors by length of time in the United States among high school students in five sites
Jones SE , Pezzi C , Rodriguez-Lainz A , Whittle L . J Immigr Minor Health 2014 18 (1) 150-60 One in five public school students is from an immigrant-headed household. We used Youth Risk Behavior Survey data from one state and four large urban school districts to examine whether length of time living in the US was associated with health risk behaviors. Logistic regression models, using weighted data, controlled for sex, race/ethnicity, and grade. Compared to US natives, not having always lived in the US was correlated with lower risk for some behaviors (e.g., current marijuana use and alcohol use) among high school students, but higher risk for other behaviors (e.g., attempted suicide, physical inactivity). Many findings were inconsistent across the study sites. Interventions that specifically target recently-arrived school-aged youth to prevent behaviors that put health and safety at risk, may result in the best outcomes for immigrant youth. Care should be taken to understand the specific health risks present in different immigrant communities. |
Circulating vaccine-derived polioviruses in the extreme north region of Cameroon
Endegue-Zanga MC , Sadeuh-Mba SA , Iber J , Burns C , Nimpa-Mengouo M , Demanou M , Vernet G , Etoa FX , Njouom R . J Clin Virol 2015 62 80-3 BACKGROUND: The World Health Organization (WHO) poliovirus eradication program includes careful surveillance of acute-flaccid paralysis (AFP) and mass and routine immunization with oral polio vaccine (OPV). In populations with low vaccine coverage, the live-attenuated Sabin strains, OPV types 1, 2 and 3, can evolve into virulent vaccine-derived polioviruses (VDPVs) and circulate in the community. Until recently, circulating VDPVs (cVDPVs) had not been reported in Cameroon despite the fact that VDPV2 outbreaks have occurred in nearby countries. OBJECTIVES: This study aimed to characterize virus isolates from four AFP patients infected with cVDPV2 in the Extreme North region of Cameroon in 2013. STUDY DESIGN: The complete VP1 region of the four VDPV strains was sequenced and the relationships with cVDPVs from neighboring countries were investigated. RESULTS: All four patients were infected by cVDPV2 strains showing 1.2-2.0% nucleotide difference compared to the reference Sabin 2 VP1 sequence. Phylogenetic analysis indicated that the VDPV strains were genetically linked to cVDPV2 lineages of the recent Chad cVDPV2 outbreak. CONCLUSIONS: The circulation of pathogenic VDPVs suggests that there are localized immunization gaps in some districts like Makary, Mada and Kolofata in Cameroon. To avoid poliomyelitis outbreaks in Cameroon, especially in the districts close to neighboring countries with ongoing cVDPV outbreaks, high polio vaccine coverage is essential. |
Relative insignificance of virus inactivation during aluminum electrocoagulation of saline waters
Tanneru CT , Narayanan J , Hill VR , Chellam S . Environ Sci Technol 2014 48 (24) 14590-8 Combined removal and inactivation of the MS2 bacteriophage from model saline (0-100 mM NaCl) waters by electrochemical treatment using a sacrificial aluminum anode was evaluated. Both chemical and electrodissolution contributed to coagulant dosing since measured aluminum concentrations were statistically higher than purely electrochemical predictions using Faraday's law. Electrocoagulation generated only small amounts of free chlorine in situ but effectively destabilized viruses and incorporated them into Al(OH)3(s) flocs during electrolysis. Low chlorine concentrations combined with virus shielding and aggregation within flocs resulted in very slow disinfection rates necessitating extended flocculation/contact times to achieve significant log-inactivation. Therefore, the dominant virus control mechanism during aluminum electrocoagulation of saline waters is "physical" removal by uptake onto flocs rather than "chemical" inactivation by chlorine. Attenuated total reflectance-Fourier transform infrared spectroscopy provided evidence for oxidative transformations of capsid proteins including formation of oxyacids, aldehydes, and ketones. Electrocoagulation significantly altered protein secondary structures decreasing peak areas associated with turns, bends, alpha-helices, beta-structures, and random coils for inactivated viruses compared with the MS2 stock. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) measurements showed rapid initial RNA damage following a similar trend as plaque assay measurements of infectious viruses. However, ssRNA cleavage measured by qRT-PCR underestimated inactivation over longer durations. Although aluminum electrocoagulation of saline waters disorders virus capsids and damages RNA, inactivation occurs at a sufficiently low rate so as to only play a secondary role to floc-encapsulation during residence times typical of electrochemical treatment. |
SLIPTA e-tool improves laboratory audit process in Vietnam and Cambodia
Nguyen TT , McKinney B , Pierson A , Luong KN , Hoang QT , Meharwal S , Carvalho HM , Nguyen CQ , Nguyen KT , Bond KB . Afr J Lab Med 2014 3 (2) 219 BACKGROUND: The Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist is used worldwide to drive quality improvement in laboratories in developing countries and to assess the effectiveness of interventions such as the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. However, the paperbased format of the checklist makes administration cumbersome and limits timely analysis and communication of results. Development of e-Tool: In early 2012, the SLMTA team in Vietnam developed an electronic SLIPTA checklist tool. The e-Tool was pilot tested in Vietnam in mid-2012 and revised. It was used during SLMTA implementation in Vietnam and Cambodia in 2012 and 2013 and further revised based on auditors' feedback about usability. OUTCOMES: The SLIPTA e-Tool enabled rapid turn-around of audit results, reduced workload and language barriers and facilitated analysis of national results. Benefits of the e-Tool will be magnified with in-country scale-up of laboratory quality improvement efforts and potential expansion to other countries. |
The SLMTA programme: transforming the laboratory landscape in developing countries
Yao K , Maruta T , Luman ET , Nkengasong JN . Afr J Lab Med 2014 3 (2) 194 BACKGROUND: Efficient and reliable laboratory services are essential to effective and well-functioning health systems. Laboratory managers play a critical role in ensuring the quality and timeliness of these services. However, few laboratory management programmes focus on the competencies required for the daily operations of a laboratory in resource-limited settings. This report provides a detailed description of an innovative laboratory management training tool called Strengthening Laboratory Management Toward Accreditation (SLMTA) and highlights some challenges, achievements and lessons learned during the first five years of implementation (2009-2013) in developing countries. PROGRAMME: SLMTA is a competency-based programme that uses a series of short courses and work-based learning projects to effect immediate and measurable laboratory improvement, while empowering laboratory managers to implement practical quality management systems to ensure better patient care. A SLMTA training programme spans from 12 to 18 months; after each workshop, participants implement improvement projects supported by regular supervisory visits or on-site mentoring. In order to assess strengths, weaknesses and progress made by the laboratory, audits are conducted using the World Health Organization's Regional Office for Africa (WHO AFRO) Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist, which is based on International Organization for Standardization (ISO) 15189 requirements. These internal audits are conducted at the beginning and end of the SLMTA training programme. CONCLUSION: Within five years, SLMTA had been implemented in 617 laboratories in 47 countries, transforming the laboratory landscape in developing countries. To our knowledge, SLMTA is the first programme that makes an explicit connection between the performance of specific management behaviours and routines and ISO 15189 requirements. Because of this close relationship, SLMTA is uniquely positioned to help laboratories seek accreditation to ISO 15189. |
Using standard and institutional mentorship models to implement SLMTA in Kenya
Makokha EP , Mwalili S , Basiye FL , Zeh C , Emonyi WI , Langat R , Luman ET , Mwangi J . Afr J Lab Med 2014 3 (2) 220 BACKGROUND: Kenya is home to several high-performing internationally-accredited research laboratories, whilst most public sector laboratories have historically lacked functioning quality management systems. In 2010, Kenya enrolled an initial eight regional and four national laboratories into the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. To address the challenge of a lack of mentors for the regional laboratories, three were paired, or 'twinned', with nearby accredited research laboratories to provide institutional mentorship, whilst the other five received standard mentorship. Objectives: This study examines results from the eight regional laboratories in the initial SLMTA group, with a focus on mentorship models. METHODS: Three SLMTA workshops were interspersed with three-month periods of improvement project implementation and mentorship. Progress was evaluated at baseline, mid-term, and exit using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) audit checklist and scores were converted into a zero- to five-star scale. RESULTS: At baseline, the mean score for the eight laboratories was 32%; all laboratories were below the one-star level. At mid-term, all laboratories had measured improvements. However, the three twinned laboratories had increased an average of 32 percentage points and reached one to three stars; whilst the five non-twinned laboratories increased an average of 10 percentage points and remained at zero stars. At exit, twinned laboratories had increased an average 12 additional percentage points (44 total), reaching two to four stars; non-twinned laboratories increased an average of 28 additional percentage points (38 total), reaching one to three stars. CONCLUSION: The partnership used by the twinning model holds promise for future collaborations between ministries of health and state-of-the-art research laboratories in their regions for laboratory quality improvement. Where they exist, such laboratories may be valuable resources to be used judiciously so as to accelerate sustainable quality improvement initiated through SLMTA. |
Weighing the costs: implementing the SLMTA programme in Zimbabwe using internal versus external facilitators
Shumba E , Nzombe P , Mbinda A , Simbi R , Mangwanya D , Kilmarx PH , Luman ET , Zimuto SN . Afr J Lab Med 2014 3 (2) 248 BACKGROUND: In 2010, the Zimbabwe Ministry of Health and Child Welfare (MoHCW) adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme as a tool for laboratory quality systems strengthening. OBJECTIVES: To evaluate the financial costs of SLMTA implementation using two models (external facilitators; and internal local or MoHCW facilitators) from the perspective of the implementing partner and to estimate resources needed to scale up the programme nationally in all 10 provinces. METHODS: The average expenditure per laboratory was calculated based on accounting records; calculations included implementing partner expenses but excluded in-kind contributions and salaries of local facilitators and trainees. We also estimated theoretical financial costs, keeping all contextual variables constant across the two models. Resource needs for future national expansion were estimated based on a two-phase implementation plan, in which 12 laboratories in each of five provinces would implement SLMTA per phase; for the internal facilitator model, 20 facilitators would be trained at the beginning of each phase. RESULTS: The average expenditure to implement SLMTA in 11 laboratories using external facilitators was approximately US$5800 per laboratory; expenditure in 19 laboratories using internal facilitators was approximately $6000 per laboratory. The theoretical financial cost of implementing a 12-laboratory SLMTA cohort keeping all contextual variables constant would be approximately $58 000 using external facilitators; or $15 000 using internal facilitators, plus $86 000 to train 20 facilitators. The financial cost for subsequent SLMTA cohorts using the previously-trained internal facilitators would be approximately $15 000, yielding a breakeven point of 2 cohorts, at $116 000 for either model. Estimated resources required for national implementation in 120 laboratories would therefore be $580 000 using external facilitators ($58 000 per province) and $322 000 using internal facilitators ($86 000 for facilitator training in each of two phases plus $15 000 for SLMTA implementation in each province). CONCLUSION: Investing in training of internal facilitators will result in substantial savings over the scale-up of the programme. Our study provides information to assist policy makers to develop strategic plans for investing in laboratory strengthening. |
Working toward a sustainable laboratory quality improvement programme through country ownership: Mozambique's SLMTA story
Masamha J , Skaggs B , Pinto I , Mandlaze AP , Simbine C , Chongo P , de Sousa L , Kidane S , Yao K , Luman ET , Samogudo E . Afr J Lab Med 2014 3 (2) 253 BACKGROUND: Launched in 2009, the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme has emerged as an innovative approach for the improvement of laboratory quality. In order to ensure sustainability, Mozambique embedded the SLMTA programme within the existing Ministry of Health (MOH) laboratory structure. OBJECTIVE: This article outlines the steps followed to establish a national framework for quality improvement and embedding the SLMTA programme within existing MOH laboratory systems. METHODS: The MOH adopted SLMTA as the national laboratory quality improvement strategy, hired a dedicated coordinator and established a national laboratory quality technical working group comprising mostly personnel from key MOH departments. The working group developed an implementation framework for advocacy, training, mentorship, supervision and audits. Emphasis was placed on building local capacity for programme activities. After receiving training, a team of 25 implementers (18 from the MOH and seven from partner organisations) conducted baseline audits (using the Stepwise Laboratory Quality Improvement Process Towards Accreditation [SLIPTA] checklist), workshops and site visits in six reference and two central hospital laboratories. Exit audits were conducted in six of the eight laboratories and their results are presented. RESULTS: The six laboratories demonstrated substantial improvement in audit scores; median scores increased from 35% at baseline to 57% at exit. It has been recommended that the National Tuberculosis Reference Laboratory apply for international accreditation. CONCLUSION: Successful implementation of SLMTA requires partnership between programme implementers, whilst effectiveness and long-term viability depend on country leadership, ownership and commitment. Integration of SLMTA into the existing MOH laboratory system will ensure durability beyond initial investments. The Mozambican model holds great promise that country leadership, ownership and institutionalisation can set the stage for programme success and sustainability. |
Maximising mentorship: variations in laboratory mentorship models implemented in Zimbabwe
Nzombe P , Luman ET , Shumba E , Mangwanya D , Simbi R , Kilmarx PH , Zimuto SN . Afr J Lab Med 2014 3 (2) 241 BACKGROUND: Laboratory mentorship has proven to be an effective tool in building capacity and assisting laboratories in establishing quality management systems. The Zimbabwean Ministry of Health and Child Welfare implemented four mentorship models in 19 laboratories in conjunction with the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. Objectives: This study outlines how the different models were implemented, cost involved per model and results achieved. METHODS: Eleven of the laboratories had been trained previously in SLMTA (Cohort I). They were assigned to one of three mentorship models based on programmatic considerations: Laboratory Manager Mentorship (Model 1, four laboratories); One Week per Month Mentorship (Model 2, four laboratories); and Cyclical Embedded Mentorship (Model 3, three laboratories). The remaining eight laboratories (Cohort II) were enrolled in Cyclical Embedded Mentorship incorporated with SLMTA training (Model 4). Progress was evaluated using a standardised audit checklist. RESULTS: At SLMTA baseline, Model 1-3 laboratories had a median score of 30%. After SLMTA, at mentorship baseline, they had a median score of 54%. At the post-mentorship audit they reached a median score of 75%. Each of the three mentorship models for Cohort I had similar median improvements from pre- to post-mentorship (17 percentage points for Model 1, 23 for Model 2 and 25 for Model 3; p > 0.10 for each comparison). The eight Model 4 laboratories had a median baseline score of 24%; after mentorship, their median score increased to 63%. Median improvements from pre-SLMTA to post-mentorship were similar for all four models. CONCLUSION: Several mentorship models can be considered by countries depending on the available resources for their accreditation implementation plan. |
Progressing beyond SLMTA: are internal audits and corrective action the key drivers of quality improvement?
Maina RN , Mengo DM , Mohamud AD , Ochieng SM , Milgo SK , Sexton CJ , Moyo S , Luman ET . Afr J Lab Med 2014 3 (2) 222 BACKGROUND: Kenya has implemented the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme to facilitate quality improvement in medical laboratories and to support national accreditation goals. Continuous quality improvement after SLMTA completion is needed to ensure sustainability and continue progress toward accreditation. METHODS: Audits were conducted by qualified, independent auditors to assess the performance of five enrolled laboratories using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. End-of-programme (exit) and one year post-programme (surveillance) audits were compared for overall score, star level (from zero to five, based on scores) and scores for each of the 12 Quality System Essential (QSE) areas that make up the SLIPTA checklist. RESULTS: All laboratories improved from exit to surveillance audit (median improvement 38 percentage points, range 5-45 percentage points). Two laboratories improved from zero to one star, two improved from zero to three stars and one laboratory improved from three to four stars. The lowest median QSE scores at exit were: internal audit; corrective action; and occurrence management and process improvement (< 20%). Each of the 12 QSEs improved substantially at surveillance audit, with the greatest improvement in client management and customer service, internal audit and information management (> 50 percentage points). The two laboratories with the greatest overall improvement focused heavily on the internal audit and corrective action QSEs. CONCLUSION: Whilst all laboratories improved from exit to surveillance audit, those that focused on the internal audit and corrective action QSEs improved substantially more than those that did not; internal audits and corrective actions may have acted as catalysts, leading to improvements in other QSEs. Systematic identification of core areas and best practices to address them is a critical step toward strengthening public medical laboratories. |
Evidence from 617 laboratories in 47 countries for SLMTA-driven improvement in quality management systems
Yao K , Luman ET . Afr J Lab Med 2014 3 (2) 262 BACKGROUND: The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme is a large-scale effort to improve the quality of laboratories in resource-limited countries. Objectives: This study sought to evaluate the first four years (2010-2013) of SLMTA implementation. METHODS: Country-level data were submitted by SLMTA programme leads and compiled globally. Performance was measured before (baseline) and after (exit) SLMTA implementation using an audit checklist which results in a percentage score and a rating of zero to five stars. Some laboratories continued to monitor performance in post-exit surveillance audits. We evaluated score improvements using two-tailed t-tests for equal variances and estimated the number of tests performed by SLMTA laboratories based on star level. RESULTS: SLMTA was implemented in 617 laboratories in 47 countries in Africa, the Caribbean, Latin America and Southeast Asia. At the baseline audit, the laboratories scored an average of 39% on the checklist and 84% of them were rated below one star. As of December 2013, 302 laboratories had completed the SLMTA programme; mean checklist scores increased from 39% at baseline to 64% at exit (p < 0.001) over an average 16-month programme duration. Ninety-two laboratories conducted a surveillance audit at a median of 11 months after their exit audit; 62% further increased their performance. Six SLMTA laboratories have achieved accreditation status. In total, the 617 SLMTA laboratories conduct an estimated 111 million tests annually. Only 16% of these tests were conducted by laboratories with at least one star at baseline, which increased to 68% of tests after SLMTA training. Thus, approximately 23 million tests are conducted annually by laboratories previously at zero stars that now have one to five stars; this number is projected to increase to 58 million when currently-enrolled laboratories complete the programme. CONCLUSION: SLMTA has transformed the laboratory landscape in resource-limited countries worldwide and has the potential to make a substantial and sustainable impact on the quality of laboratory testing and patient care. |
Field trial evaluation of the performances of point-of-care tests for screening G6PD deficiency in Cambodia
Roca-Feltrer A , Khim N , Kim S , Chy S , Canier L , Kerleguer A , Tor P , Chuor CM , Kheng S , Siv S , Kachur PS , Taylor WR , Hwang J , Menard D . PLoS One 2014 9 (12) e116143 BACKGROUND: User-friendly, accurate, point-of-care rapid tests to detect glucose-6-phosphate dehydrogenase deficiency (G6PDd) are urgently needed at peripheral level to safely recommend primaquine for malaria elimination. METHODS: The CareStart G6PD RDT (AccessBio, New Jersey, USA), a novel rapid diagnostic test and the most commonly used test, the fluorescent spot test (FST) were assessed against the quantitatively measured G6PD enzyme activity for detecting G6PDd. Subjects were healthy males and non-pregnant females aged 18 years or older residing in six villages in Pailin Province, western Cambodia. FINDINGS: Of the 938 subjects recruited, 74 (7.9%) were severe and moderately severe G6PD deficient (enzyme activity <30%), mostly in male population; population median G6PD activity was 12.0 UI/g Hb. The performances of the CareStart G6PD RDT and the FST, according to different cut-off values used to define G6PDd were very similar. For the detection of severe and moderately severe G6PDd (enzyme activity <30%, <3.6 UI/g Hb) in males and females, sensitivity and negative (normal status) predictive value were 100% for both point-of-care tools. When the G6PDd cut-off value increased (from <40% to <60%), the sensitivity for both PoCs decreased: 93.3% to 71.7% (CareStart G6PD RDT, p = 10-6) and 95.5% to 73.2% (FST, p = 10-6) while the specificity for both PoCs remained similar: 97.4% to 98.3% (CareStart G6PD RDT, p = 0.23) and 98.7% to 99.6% (FST, p = 0.06). The cut-off values for classifying individuals as normal were 4.0 UI/g Hb and 4.3 UI/g Hb for the CareStart G6PD RDT and the FST, respectively. CONCLUSIONS: The CareStart G6PD RDT reliably detected moderate and severe G6PD deficient individuals (enzyme activity <30%), suggesting that this novel point-of-care is a promising tool for tailoring appropriate primaquine treatment for malaria elimination by excluding individuals with severe G6PDd for primaquine treatment. |
The impact of SLMTA in improving laboratory quality systems in the Caribbean region
Guevara G , Gordon F , Irving Y , Whyms I , Parris K , Beckles S , Maruta T , Ndlovu N , Albalak R , Alemnji G . Afr J Lab Med 2014 3 (2) 199 BACKGROUND: Past efforts to improve laboratory quality systems and to achieve accreditation for better patient care in the Caribbean Region have been slow. OBJECTIVE: To describe the impact of the Strengthening of Laboratory Management Toward Accreditation (SLMTA) training programme and mentorship amongst five clinical laboratories in the Caribbean after 18 months. METHOD: Five national reference laboratories from four countries participated in the SLMTA programme that incorporated classroom teaching and implementation of improvement projects. Mentors were assigned to the laboratories to guide trainees on their improvement projects and to assist in the development of Quality Management Systems (QMS). Audits were conducted at baseline, six months, exit (at 12 months) and post-SLMTA (at 18 months) using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist to measure changes in implementation of the QMS during the period. At the end of each audit, a comprehensive implementation plan was developed in order to address gaps. RESULTS: Baseline audit scores ranged from 19% to 52%, corresponding to 0 stars on the SLIPTA five-star scale. After 18 months, one laboratory reached four stars, two reached three stars and two reached two stars. There was a corresponding decrease in nonconformities and development of over 100 management and technical standard operating procedures in each of the five laboratories. CONCLUSION: The tremendous improvement in these five Caribbean laboratories shows that SLMTA coupled with mentorship is an effective, user-friendly, flexible and customisable approach to the implementation of laboratory QMS. It is recommended that other laboratories in the region consider using the SLMTA training programme as they engage in quality systems improvement and preparation for accreditation. |
Accelerating the spread of laboratory quality improvement efforts in Botswana
Mokobela KO , Moatshe MT , Modukanele M . Afr J Lab Med 2014 3 (2) 207 BACKGROUND: In 2002, the Ministry of Health (MoH) of Botswana began its journey toward laboratory accreditation in an effort to enhance the quality of laboratory services. After a difficult start, the MoH recognised the need for a more practical and sustainable method for change that could be implemented nationally; they therefore adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. OBJECTIVE: This study describes the process and lessons learned in implementing SLMTA and the role of supplemental training and mentoring so as to achieve Botswana's national laboratory quality improvement goal. Methods: Eight laboratories were enrolled into the SLMTA programme in 2010, which included a series of workshops and improvement projects conducted over nine months. Four of these laboratories received supplementary training and focused mentorship from the Botswana Bureau of Standards (BOBS). Laboratory performance was measured at baseline and exit using the World Health Organization Regional Office for Africa's Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. One laboratory did not receive an exit audit and was thus excluded from the analysis. RESULTS: An 18 percentage-point improvement was observed when comparing the median baseline score (53%) to the median exit score (71%) for the seven laboratories. Laboratories that received additional training and mentorship from BOBS improved 21 percentage points, whilst non-BOBS-mentored laboratories improved eight percentage points. Hospital management buy-in and strong laboratory staff camaraderie were found to be essential for the positive changes observed. CONCLUSION: SLMTA facilitated improvements in laboratory quality management systems, yielding immediate and measurable results. This study suggests that pairing the SLMTA programme with additional training and mentorship activities may lead to further increases in laboratory performance; and that SLMTA is a practical approach to extending quality improvement to MOH laboratories. |
Attaining ISO 15189 accreditation through SLMTA: a journey by Kenya's National HIV Reference Laboratory
Gachuki T , Sewe R , Mwangi J , Turgeon D , Garcia M , Luman ET , Umuro M . Afr J Lab Med 2014 3 (2) 216 BACKGROUND: The National HIV Reference Laboratory (NHRL) serves as Kenya's referral HIV laboratory, offering specialised testing and external quality assessment, as well as operating the national HIV serology proficiency scheme. In 2010, the Kenya Ministry of Health established a goal for NHRL to achieve international accreditation. OBJECTIVES: This study chronicles the journey that NHRL took in pursuit of accreditation, along with the challenges and lessons learned. METHODS: NHRL participated in the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme from 2010-2011. Improvement projects were undertaken to address gaps in the 12 quality system essentials through development of work plans, team formation, training and mentorship of personnel. Audits were conducted and the scores used to track progress along a five-star grading scale. Standard quality indicators (turnaround time, specimen rejection rates and service interruptions) were measured. Costs of improvement projects and accreditation were estimated based on expenditures. RESULTS: NHRL scored 45% (zero stars) at baseline in March 2010 and 95% (five stars) after programme completion in October 2011; in 2013 it became the first public health laboratory in Kenya to attain ISO 15189 accreditation. From 2010-2013, turn-around times decreased by 50% - 95%, specimen rejections decreased by 93% and service interruptions dropped from 15 to zero days. Laboratory expenditures associated with achieving accreditation were approximately US $36 500. CONCLUSION: International accreditation is achievable through SLMTA, even for a laboratory with limited initial quality management systems. Key success factors were dedication to a shared goal, leadership commitment, team formation and effective mentorship. Countries wishing to achieve accreditation must ensure adequate funding and support. |
Building local human resources to implement SLMTA with limited donor funding: the Ghana experience
Nkrumah B , van der Puije B , Bekoe V , Adukpo R , Kotey NA , Yao K , Fonjungo PN , Luman ET , Duh S , Njukeng PA , Addo NA , Khan FN , Woodfill CJI . Afr J Lab Med 2014 3 (2) 214 BACKGROUND: In 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources. OBJECTIVES: To demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources. METHOD: Local partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental training on internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM). RESULTS: The local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors' salaries, SLMTA training and improvement project support. CONCLUSION: Building in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such models promote country ownership, capacity building and the use of local human resources for the expansion of SLMTA. |
Decentralised facility-based training as an alternative model for SLMTA implementation: the Cameroon experience
Ndasi J , Dimite L , Mbome V , Awasom C , Ngale E , Akuro S , Leonard E , Bolu O , Asong T , Njukeng P , Shang J . Afr J Lab Med 2014 3 (2) 231 BACKGROUND: The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme is designed to build institutional capacity to help strengthen the tiered laboratory system. Most countries implement the SLMTA three-workshop series using a centralised model, whereby participants from several laboratories travel to one location to be trained together. OBJECTIVES: We assessed the effectiveness and cost of conducting SLMTA training in a decentralised manner as compared to centralised training. Methods: SLMTA was implemented in five pilot laboratories in Cameroon between October 2010 and October 2012 by means of a series of workshops, laboratory improvement projects and on-site mentorship. The first workshop was conducted in the traditional centralised approach. The second and third workshops were decentralised, delivered on-site at each of the five enrolled laboratories. Progress was monitored by repeated audits using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. RESULTS: Audit scores for all laboratories improved steadily through the course of the programme. Median improvement was 11 percentage points after the first (centralised) training and an additional 24 percentage points after the second (decentralised) training. The estimated per-laboratory cost of the two training models was approximately the same at US$21 000. However, in the decentralised model approximately five times as many staff members were trained, although it also required five times the amount of trainer time. CONCLUSION: Decentralised SLMTA training was effective in improving laboratory quality and should be considered as an alternative to centralised training. |
2014 updates to the NIOSH hazardous drug list
Connor TH , MacKenzie BA . Pharm Purch Prod 2015 11 (11) 90,92,96 Due to concerns about exposure of health care workers to hazardous drugs, The National Institute for Occupational Safety and Health (NIOSH) convened a Hazardous Drug Working Group in 2000 in Washington, DC. The primary output of the group, which disbanded in 2007, was the 2004 publication of the NIOSH Alert: Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings. This alert included a definition of hazardous drugs that was modified from a definition proposed by the American Society of Hospital Pharmacists (currently the American Society of Health-System Pharmacists). The 2004 alert included a sample, non-all-inclusive list of 136 drugs that should be handled as hazardous. It comprised lists being used at that time by four institutions: The National Institutes of Health, Johns Hopkins University, University of Michigan, and Northside Hospital in Atlanta. It also included a list generated by the Pharmaceutical Research and Manufacturers of America (PhRMA). At the time the 2004 Alert was published, NIOSH acknowledged that it would update the hazardous drug list as needed. After deciding on an approach and a mechanism to perform these updates, NIOSH reviewed all new drugs approved by the FDA and all new warnings on existing drugs from 2004 to 2007, to determine whether they qualified as hazardous under the NIOSH definition. This resulted in the official update that was published in 2010, which contained 31 additions to the original list. The list was updated a second time in 2012 with 33 additions and 15 removals. The Latest Update: The process of updating the hazardous drug list includes a number of steps and takes about two years to complete; therefore, the list is about two to three years out of date when it is published. Currently, the expert review panel is made up of at least 10 members representing pharmacy and nursing organizations (ASHP, Hematology/Oncology Pharmacy Association, Oncology Nursing Society, American Nurses Association), government (Food and Drug Administration, Department of Veterans Affairs, Occupational Safety and Health Administration), industry (Biological Industry Organization, drug manufacturers), and academia. |
Application of an informatics-based decision-making framework and process to the assessment of radiation safety in nanotechnology
Hoover MD , Myers DS , Cash LJ , Guilmette RA , Kreyling WG , Oberdorster G , Smith R , Cassata JR , Boecker BB , Grissom MP . Health Phys 2015 108 (2) 179-94 The National Council on Radiation Protection and Measurements (NCRP) established NCRP Scientific Committee 2-6 to develop a report on the current state of knowledge and guidance for radiation safety programs involved with nanotechnology. Nanotechnology is the understanding and control of matter at the nanoscale, at dimensions between approximately 1 and 100 nm, where unique phenomena enable novel applications. While the full report is in preparation, this paper presents and applies an informatics-based decision-making framework and process through which the radiation protection community can anticipate that nano-enabled applications, processes, nanomaterials, and nanoparticles are likely to become present or are already present in radiation-related activities; recognize specific situations where environmental and worker safety, health, well-being, and productivity may be affected by nano-related activities; evaluate how radiation protection practices may need to be altered to improve protection; control information, interpretations, assumptions, and conclusions to implement scientifically sound decisions and actions; and confirm that desired protection outcomes have been achieved. This generally applicable framework and supporting process can be continuously applied to achieve health and safety at the convergence of nanotechnology and radiation-related activities. |
Modifying welding process parameters can reduce the neurotoxic potential of manganese-containing welding fumes
Sriram K , Lin GX , Jefferson AM , Stone S , Afshari A , Keane MJ , McKinney W , Jackson M , Chen BT , Schwegler-Berry D , Cumpston A , Cumpston JL , Roberts JR , Frazer DG , Antonini JM . Toxicology 2014 328 168-78 Welding fumes (WF) are a complex mixture of toxic metals and gases, inhalation of which can lead to adverse health effects among welders. The presence of manganese (Mn) in welding electrodes is cause for concern about the potential development of Parkinson's disease (PD)-like neurological disorder. Consequently, from an occupational safety perspective, there is a critical need to prevent adverse exposures to WF. As the fume generation rate and physicochemical characteristics of welding aerosols are influenced by welding process parameters like voltage, current or shielding gas, we sought to determine if changing such parameters can alter the fume profile and consequently its neurotoxic potential. Specifically, we evaluated the influence of voltage on fume composition and neurotoxic outcome. Rats were exposed by whole-body inhalation (40mg/m3; 3h/dayx5 d/weekx2 weeks) to fumes generated by gas-metal arc welding using stainless steel electrodes (GMA-SS) at standard/regular voltage (25V; RVSS) or high voltage (30V; HVSS). Fumes generated under these conditions exhibited similar particulate morphology, appearing as chain-like aggregates; however, HVSS fumes comprised of a larger fraction of ultrafine particulates that are generally considered to be more toxic than their fine counterparts. Paradoxically, exposure to HVSS fumes did not elicit dopaminergic neurotoxicity, as monitored by the expression of dopaminergic and PD-related markers. We show that the lack of neurotoxicity is due to reduced solubility of Mn in HVSS fumes. Our findings show promise for process control procedures in developing prevention strategies for Mn-related neurotoxicity during welding; however, it warrants additional investigations to determine if such modifications can be suitably adapted at the workplace to avert or reduce adverse neurological risks. |
Reply to Italiano et al
Esposito DH , Rosenthal BM , Slesak G , Tappe D , Fayer R , Bottieau E , Brown C , Grobusch MP , Malvy D , von Sonnenburg F , Sotir MJ , Steiner F , Zanger P , Kozarsky PE . Clin Infect Dis 2014 60 (7) 1135-6 We appreciate Italiano et al’s [1] interest in our article [2] and agree that our case definition, described in our methods as “intentionally specific,” may have excluded some travelers infected with Sarcocystis nesbitti. Nevertheless, we believe that published data from outbreak investigations in Malaysia offer ample evidence that peripheral eosinophilia and myositis are important distinguishing components of human acute muscular sarcocystosis (AMS) [2–8]. It is expected that some patients would not have these findings at any given point in their illness; indeed, our Figure 4 shows subthreshold laboratory values during the late phase of disease [2], a finding corroborated elsewhere [3–6]. We concur that some ill patients will not develop detectable eosinophilia or myositis at all. As in all infectious diseases, variations in the clinical manifestations, laboratory testing results, and the courses of illness should be expected. Such variation may stem from host factors, the infectious load, or the infecting Sarcocystis species [9] or even strain. In this light, performing serial clinical and laboratory investigations seems warranted when evaluating and managing patients with suspected AMS. |
Plasmodium vivax trophozoite-stage proteomes
Anderson DC , Lapp SA , Akinyi S , Meyer EV , Barnwell JW , Korir-Morrison C , Galinski MR . J Proteomics 2014 115 157-76 Plasmodium vivax is the causative infectious agent of 80-300 million annual cases of malaria. Many aspects of this parasite's biology remain unknown. To further elucidate the interaction of P. vivax with its Saimiri boliviensis host, we obtained detailed proteomes of infected red blood cells, representing the trophozoite-enriched stage of development. Data from two of three biological replicate proteomes, emphasized here, were analyzed using five search engines, which enhanced identifications and resulted in the most comprehensive P. vivax proteomes to date, with 1375 P. vivax and 3209 S. boliviensis identified proteins. Ribosome subunit proteins were noted for both P. vivax and S. boliviensis, consistent with P. vivax's known reticulocyte host-cell specificity. A majority of the host and pathogen proteins identified belong to specific functional categories, and several parasite gene families, while 33% of the P. vivax proteins have no reported function. Hemoglobin was significantly oxidized in both proteomes, and additional protein oxidation and nitration was detected in one of the two proteomes. Detailed analyses of these post-translational modifications are presented. The proteins identified here significantly expand the known P. vivax proteome and complexity of available host protein functionality underlying the host-parasite interactive biology, and reveal unsuspected oxidative modifications that may impact protein function. BIOLOGICAL SIGNIFICANCE: Plasmodium vivax malaria is a serious neglected disease, causing an estimated 80 to 300 million cases annually in 95 countries. Infection can result in significant morbidity and possible death. P. vivax, unlike the much better-studied Plasmodium falciparum species, cannot be grown in long-term culture, has a dormant form in the liver called the hypnozoite, has a reticulocyte host-cell preference in the blood, and creates caveolae vesicle complexes at the surface of the infected reticulocyte membranes. Studies of stage-specific P. vivax expressed proteomes have been limited in scope and focused mainly on pathogen proteins, thus limiting understanding of the biology of this pathogen and its host interactions. Here three P. vivax proteomes are reported from biological replicates based on purified trophozoite-infected reticulocytes from different Saimiri boliviensis infections (the main non-human primate experimental model for P. vivax biology and pathogenesis). An in-depth analysis of two of the proteomes using 2D LC/MS/MS and multiple search engines identified 1375 pathogen proteins and 3209 host proteins. Numerous functional categories of both host and pathogen proteins were identified, including several known P. vivax protein family members (e.g., PHIST, eTRAMP and VIR), and 33% of protein identifications were classified as hypothetical. Ribosome subunit proteins were noted for both P. vivax and S. boliviensis, consistent with this parasite species' known reticulocyte host-cell specificity. In two biological replicates analyzed for post-translational modifications, hemoglobin was extensively oxidized, and various other proteins were also oxidized or nitrated in one of the two replicates. The cause of such protein modification remains to be determined but could include oxidized heme and oxygen radicals released from the infected red blood cell's parasite-induced acidic digestive vacuoles. In any case, the data suggests the presence of distinct infection-specific conditions whereby both the pathogen and host infected red blood cell proteins may be subject to significant oxidative stress. |
Driving hospital transformation with SLMTA in a regional hospital in Cameroon
Eno LT , Asong T , Ngale E , Mangwa B , Ndasi J , Mouladje M , Lekunze R , Mbome V , Njukeng P , Shang J . Afr J Lab Med 2014 3 (2) 221 BACKGROUND: Inspired by the transformation of the Regional Hospital Buea laboratory through implementation of the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme, hospital management adapted the SLMTA toolkit to drive hospitalwide quality improvement. OBJECTIVE: This paper describes changes in the hospital following the quality improvement activities in hygiene and sanitation, the outpatient waiting area and the surgical and maternity wards. METHODS: In March 2011, hospital management established a quality improvement task force and created a hospital-wide quality improvement roadmap, following the SLMTA model. The roadmap comprised improvement projects, accountability plans, patient feedback forms and log books to track quality indicators including patient wait time, satisfaction level, infection rates, birth outcomes and hospital revenue. RESULTS: There was steady improvement in service delivery during the 11 months after the introduction of the quality improvement initiatives: patient wait time at the reception was reduced from three hours to less than 30 minutes and patient satisfaction increased from 15% to 60%. Treatment protocols were developed and documented for various units, infrastructure and workflow processes were improved and there was increased staff awareness of the importance of providing quality services. Maternal infection rates dropped from 3% to 0.5% and stillbirths from 5% to < 1%. The number of patients increased as a result of improved services, leading to a 25% increase in hospital revenue. CONCLUSION: The SLMTA programme was adapted successfully to meet the needs of the entire hospital. Such a programme has the potential to impact positively on hospital quality systems; consideration should be made for development of a formal SLMTA-like programme for hospital quality improvement. |
Relationship between social cognitive theory constructs and self-reported condom use: assessment of behaviour in a subgroup of the Safe in the City trial
Snead MC , O'Leary AM , Mandel MG , Kourtis AP , Wiener J , Jamieson DJ , Warner L , Malotte CK , Klausner JD , O'Donnell L , Rietmeijer CA , Margolis AD . BMJ Open 2014 4 (12) e006093 OBJECTIVES: Previous studies have found social cognitive theory (SCT)-framed interventions are successful for improving condom use and reducing sexually transmitted infections (STIs). We conducted a secondary analysis of behavioural data from the Safe in the City intervention trial (2003-2005) to investigate the influence of SCT constructs on study participants' self-reported use of condoms at last intercourse. METHODS: The main trial was conducted from 2003 to 2005 at three public US STI clinics. Patients (n=38 635) were either shown a 'safer sex' video in the waiting room, or received the standard waiting room experience, based on their visit date. A nested behavioural assessment was administered to a subsample of study participants following their index clinic visit and again at 3 months follow-up. We used multivariable modified Poisson regression models to examine the relationships among SCT constructs (sexual self-efficacy, self-control self-efficacy, self-efficacy with most recent partner, hedonistic outcome expectancies and partner expected outcomes) and self-reported condom use at last sex act at the 3-month follow-up study visit. RESULTS: Of 1252 participants included in analysis, 39% reported using a condom at last sex act. Male gender, homosexual orientation and single status were significant correlates of condom use. Both unadjusted and adjusted models indicate that sexual self-efficacy (adjusted relative risk (RRa)=1.50, 95% CI 1.23 to 1.84), self-control self-efficacy (RRa=1.67, 95% CI 1.37 to 2.04), self-efficacy with most recent partner (RRa=2.56, 95% CI 2.01 to 3.27), more favourable hedonistic outcome expectancies (RRa=1.83, 95% CI 1.54 to 2.17) and more favourable partner expected outcomes (RRa=9.74, 95% CI 3.21 to 29.57) were significantly associated with condom use at last sex act. CONCLUSIONS: Social cognitive skills, such as self-efficacy and partner expected outcomes, are an important aspect of condom use behaviour. TRIAL REGISTRATION NUMBER: clinicaltrials.gov (#NCT00137370). |
Parenthood and leaving home in young adulthood
Goldscheider FK , Hofferth SL , Curtin SC . Popul Res Policy Rev 2014 33 (6) 771-796 With increases in nonmarital fertility, the sequencing of transitions in early adulthood has become even more complex. Once the primary transition out of the parental home, marriage was first replaced by nonfamily living and cohabitation; more recently, many young adults have become parents before entering a coresidential union. Studies of leaving home, however, have not examined the role of early parenthood. Using the Young Adult Study of the 1979 National Longitudinal Survey of Youth (n = 4,674), we use logistic regression to analyze parenthood both as a correlate of leaving home and as a route from the home. We find that even in mid-adolescence, becoming a parent is linked with leaving home. Coming from a more affluent family is linked with leaving home via routes that do not involve children rather than those that do, and having a warm relationship with either a mother or a father retards leaving home, particularly to nonfamily living, but is not related to parental routes out of the home. |
Tobacco cessation among users of telephone and web-based interventions - four states, 2011-2012
Puckett M , Neri A , Thompson T , Underwood JM , Momin B , Kahende J , Zhang L , Stewart SL . MMWR Morb Mortal Wkly Rep 2015 63 (51) 1217-21 Smoking caused an average of 480,000 deaths per year in the United States from 2005 to 2009, and three in 10 cancer deaths in the United States are tobacco related. Tobacco cessation is a high public health priority, and all states offer some form of tobacco cessation service. Quitlines provide telephone-based counseling services and are an effective intervention for tobacco cessation. In addition to telephone services, 96% of all U.S. quitlines offer Web-based cessation services. Evidence is limited on the number of tobacco users who use more than one type of service, and studies report mixed results on whether combined telephone and Web-based counseling improves long-term cessation compared with telephone alone. CDC conducted a survey of users of telephone and Web-based cessation services in four states to determine the cessation success of users of these interventions. After adjusting for multiple variables, persons who used both telephone and Web-based services were more likely to report abstinence from smoking for 30 days at follow up (odds ratio = 1.3) compared with telephone-only users and with Web-only users (odds ratio = 1.5). These findings suggest that states might consider offering both types of cessation services to increase cessation success. |
Validation of selected items on the 2003 U.S. Standard Certificate of Live Birth: New York City and Vermont
Dietz P , Bombard J , Mulready-Ward C , Gauthier J , Sackoff J , Brozicevic P , Gambatese M , Nyland-Funke M , England L , Harrison L , Farr S . Public Health Rep 2015 130 (1) 60-70 OBJECTIVE: We assessed the validity of selected items on the 2003 revised U.S. Standard Certificate of Live Birth to understand the accuracy of new and existing items. METHODS: We calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of select variables reported on the birth certificate using the medical record as the gold standard for a representative sample of live births in New York City (n=603) and Vermont (n=664) in 2009. RESULTS: In both sites, sensitivity was excellent (>90%) for Medicaid coverage at delivery, any previous live births, and current method of delivery; sensitivity was moderate (70%-90%) for gestational diabetes; and sensitivity was poor (<70%) for premature rupture of the membranes and gestational hypertension. In both sites, PPV was excellent for Medicaid coverage, any previous live births, previous cesarean delivery, and current method of delivery, and poor for premature rupture of membranes. In both sites, almost all items had excellent (>90%) specificity and NPV. CONCLUSION: Further research is needed to determine how best to improve the quality of data on the birth certificate. Future revisions of the birth certificate may consider removing those items that have consistently proven difficult to report accurately. |
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