Surveillance instructions and knowledge among African American colorectal cancer survivors
Pisu M , Holt CL , Brown-Galvan A , Fairley T , Smith JL , White A , Hall IJ , Oster RA , Martin MY . J Oncol Pract 2014 10 (2) e45-50 INTRODUCTION: African Americans are less likely than other racial/ethnic groups to receive appropriate surveillance, an important component of care to achieve better long-term outcomes and well-being after colorectal cancer (CRC) treatment. This study explored survivors' understanding of surveillance instructions and purpose. PATIENTS AND METHODS: Interviews with 60 African American CRC survivors were recorded and transcribed. Compliance with surveillance guidelines was defined by disease stage and self-reported tests. Four coders (blind to compliance status) independently reviewed transcripts. Frequency of themes was reported by compliance status. RESULTS: Survivors (4 to 6 years postdiagnosis; women, 57%; age ≥ 65 years, 60%; rural location, 57%; early-stage disease, 62%) were 48% noncompliant. Most survivors reported receiving surveillance instructions from providers (compliant, 80%; noncompliant, 76%). There was variation in recommended frequency of procedures (eg, every 3 or 12 months) and in importance of surveillance stressed by physicians. Most survivors understood the need for follow-up (compliant, 87%; noncompliant, 79%). Lack of knowledge of/interest in surveillance was more common among noncompliant individuals (compliant, 32%; noncompliant, 52%). CONCLUSION: Patients' limited understanding about the importance of CRC surveillance and procedures may negatively affect compliance with recommendations in African American CRC survivors. Clear and enhanced communications about post-treatment recommendations in this population are warranted. |
Health and economic impact of breast cancer mortality in young women, 1970-2008
Ekwueme DU , Guy GP Jr , Rim SH , White A , Hall IJ , Fairley TL , Dean HD . Am J Prev Med 2014 46 (1) 71-9 BACKGROUND: Breast cancer is the second-leading cause of cancer-related deaths among women aged <50 years. Studies on the effects of breast cancer mortality among young women are limited. PURPOSE: To assess trends in breast cancer mortality rates among women aged 20-49 years, estimate years of potential life lost (YPLL), and the value of productivity losses due to premature mortality. METHODS: Age-adjusted rates and rate ratios (RRs) were calculated using 1970-2008 U.S. mortality data. Breast cancer mortality rates over time were assessed using Joinpoint regression modeling. YPLL was calculated using number of cancer deaths and the remaining life expectancy at the age of death. Value of productivity losses was estimated using the number of deaths and the present value of future lifetime earnings. RESULTS: From 1970 to 2008, the age-adjusted breast cancer mortality rate among young women was 12.02/100,000. Rates were higher in the Northeast (RR=1.03, 95% CI, 1.02-1.04). The annual decline in breast cancer mortality rates among blacks was smaller (-0.68%) compared with whites (-2.02%). The total number of deaths associated with breast cancer was 225,866, which accounted for an estimated 7.98 million YPLL. The estimated total productivity loss in 2008 was $5.49 billion and individual lifetime lost earnings were $1.10 million. CONCLUSIONS: Considering the effect of breast cancer on women of working age and the disproportionate impact on black women, more age-appropriate interventions with multiple strategies are needed to help reduce these substantial health and economic burdens, improve survival, and in turn reduce productivity costs associated with premature death. |
Relationship between persistent pain and 5-year mortality: a population-based prospective cohort study
Shega JW , Andrew M , Kotwal A , Lau DT , Herr K , Ersek M , Weiner DK , Chin MH , Dale W . J Am Geriatr Soc 2013 61 (12) 2135-41 OBJECTIVES: To assess the association between self-reported noncancer pain and 5-year mortality. DESIGN: Cohort. SETTING: Community-dwelling older adults. PARTICIPANTS: Canadian Study of Health and Aging 1996 wave. MEASUREMENTS: Registrar of Vital Statistics-established 5-year mortality. Noncancer pain was assessed using the 5-point verbal descriptor scale, dichotomized into no or very mild versus moderate, severe, or very severe pain. Frailty was the accumulation of health deficits. Cognitive status (Modified Mini-Mental State Examination) and depressed mood (five-item mental health screening questionnaire) were also assessed. Multivariable logistic regression and Cox proportional hazards were used to analyze the relationship between pain and 5-year mortality. RESULTS: Of 5,703 participants, 4,694 (82.3%) had complete data for analysis; 1,663 of these (35.4%) reported moderate, severe, or very severe pain, and 1,343 (28.6%) had died at 5-year follow-up. Four hundred ninety-six of those who died (29.8%) reported moderate, severe, or very severe pain and 847 (27.9%) no or very mild pain. Multivariate logistic analysis found that individuals with moderate, severe, or very severe pain had lower odds of 5-year mortality than those with no or very mild pain (odds ratio = 0.78, 95% confidence interval (CI) = 0.66-0.92; P < .001). The risk of death was lower in persons reporting moderate or greater pain than in those with no or very mild pain (HR = 0.85, 95% CI = 0.75-0.96; P = .01). An interaction between pain and sex explained this effect. Men with pain were not significantly more likely than men without pain to die (HR = 1.00, 95% CI = 0.84-1.19; P = .99), whereas women without pain (HR = 0.54, 95% CI = 0.47-0.63; P < 0.01) and women with pain (HR = 0.40; CI = 0.33-0.47; P < .01) had less risk of death than men without and with pain, respectively. CONCLUSION: Older women with pain were less likely to die within 5 years than older women without pain, men in pain, or men without pain. |
Self-monitoring as a mediator of weight loss in the SMART randomized clinical trial
Turk MW , Elci OU , Wang J , Sereika SM , Ewing LJ , Acharya SD , Glanz K , Burke LE . Int J Behav Med 2013 20 (4) 556-61 BACKGROUND: Integral components of behavioral weight-loss treatment include self-monitoring of diet and physical activity along with feedback to participants regarding their behaviors. While providing feedback has been associated with weight loss, no studies have examined the impact of feedback frequency on weight loss or the mediating role of self-monitoring adherence in this relationship. PURPOSE: This study examined the effect of participant feedback frequency on weight loss and determined if this effect was mediated by adherence to self-monitoring in a behavioral weight-loss trial conducted in the USA. METHOD: Participants (N = 210) were randomly assigned to one of three self-monitoring methods with either no-daily feedback messages or daily feedback messages: (1) paper diary (PD), no-daily feedback; (2) personal digital assistant (PDA), no-daily feedback; and (3) PDA, daily tailored feedback messages (PDA + FB). The Sobel test via bootstrapping examined the direct effect of feedback frequency on weight loss and the indirect effect through self-monitoring adherence. RESULTS: Receiving daily feedback messages significantly increased participants' self-monitoring adherence. A significant effect of feedback frequency on weight loss was noted; however, after adjusting for self-monitoring adherence, the effect of feedback frequency on weight loss was no longer significant. Feedback frequency had a significant indirect effect on weight loss through self-monitoring adherence. CONCLUSION: Self-monitoring adherence mediated the effect of feedback frequency on weight loss. Increasing the frequency with which participants receive feedback could enhance self-monitoring adherence, a critical component of behavioral weight-loss treatment. |
Trends in adult current asthma prevalence and contributing risk factors in the United States by state: 2000-2009
Zhang X , Morrison-Carpenter T , Holt JB , Callahan DB . BMC Public Health 2013 13 1156 BACKGROUND: Current asthma prevalence among adults in the United States has reached historically high levels. Although national-level estimates indicate that asthma prevalence among adults increased by 33% from 2000 to 2009, state-specific temporal trends of current asthma prevalence and their contributing risk factors have not been explored. METHODS: We used 2000-2009 Behavioral Risk Factor Surveillance System data from all 50 states and the District of Columbia (D.C.) to estimate state-specific current asthma prevalence by 2-year periods (2000-2001, 2002-2003, 2004-2005, 2006-2007, 2008-2009). We fitted a series of four logistic-regression models for each state to evaluate whether there was a statistically significant linear change in the current asthma prevalence over time, accounting for sociodemographic factors, smoking status, and weight status (using body mass index as the indicator). RESULTS: During 2000-2009, current asthma prevalence increased in all 50 states and D.C., with significant increases in 46/50 (92%) states and D.C. After accounting for weight status in the model series with sociodemographic factors, and smoking status, 10 states (AR, AZ, IA, IL, KS, ME, MT, UT, WV, and WY) that had previously shown a significant increase did not show a significant increase in current asthma prevalence. CONCLUSIONS: There was a significant increasing trend in state-specific current asthma prevalence among adults from 2000 to 2009 in most states in the United States. Obesity prevalence appears to contribute to increased current asthma prevalence in some states. |
Peripheral neuropathy in adolescents and young adults with type 1 and type 2 diabetes from the SEARCH for Diabetes in Youth follow-up cohort: a pilot study
Jaiswal M , Lauer A , Martin CL , Bell RA , Divers J , Dabelea D , Pettitt DJ , Saydah S , Pihoker C , Standiford DA , Rodriguez BL , Pop-Busui R , Feldman EL . Diabetes Care 2013 36 (12) 3903-8 OBJECTIVE: To estimate the prevalence of and risk factors for diabetic peripheral neuropathy (DPN) in a pilot study among youth participating in the SEARCH for Diabetes in Youth study. RESEARCH DESIGN AND METHODS: DPN was assessed using the Michigan Neuropathy Screening Instrument (MNSI) (examination for foot abnormalities, distal vibration perception, and ankle reflexes). An MNSI exam (MNSIE) score >2 is diagnostic for DPN. RESULTS: The MNSIE was completed in 399 subjects, including 329 youth with type 1 diabetes (mean age 15.7 +/- 4.3 years, duration 6.2 +/- 0.9 years) and 70 with type 2 diabetes (mean age 21.6 +/- 4.1 years, duration 7.6 +/- 1.8 years). Glycated hemoglobin (A1C) was similar in both groups (8.8 +/- 1.8% for type 1 vs. 8.5 +/- 2.9% for type 2). The prevalence of DPN was significantly higher in youth with type 2 compared with those with type 1 diabetes (25.7 vs. 8.2%; P < 0.0001). In unadjusted analyses, diabetes type, older age, longer duration of diabetes, increased waist circumference, elevated blood pressure, lower HDL cholesterol, and presence of microalbuminuria (urinary albumin-to-creatinine ratio >30 mg/g) were associated with DPN. The association between diabetes type and DPN remained significant after adjustment for age and sex (odds ratio 2.29 [95% CI 1.05-5.02], P = 0.03). CONCLUSIONS: DPN prevalence among youth with type 2 diabetes approached rates reported in adult populations with diabetes. Our findings suggest not only that youth with diabetes are at risk for DPN but also that many already show measurable signs of DPN. |
Profile of adults with type 2 diabetes and uptake of clinical care best practices: results from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component
Baillot A , Pelletier C , Dunbar P , Geiss L , Johnson JA , Leiter LA , Langlois MF . Diabetes Res Clin Pract 2013 103 (1) 11-9 AIMS: This study aimed to (1) describe the profile of adults with type 2 diabetes (T2D) in Canada and (2) assess the uptake of clinical care best practices, as defined by the Canadian Diabetes Association (CDA) Clinical Practice Guidelines (CPGs). METHODS: We used data from the 2011 Survey on Living with Chronic Diseases in Canada - Diabetes component. Participants were aged 20 years and older, living in the 10 Canadian provinces, with self-reported T2D. Descriptive analyses present the prevalence of complications and comorbidities, as well as the level of clinical monitoring and self-monitoring/lifestyle management recommendations participants received. RESULTS: We included 2335 participants with T2D, a mean age of 62.9 years, and high prevalence of complications/comorbidities and prescription medication use. Most participants reported being monitored as recommended for eye disease (73.9%), weight (81.0%), blood pressure (89.0%) and blood cholesterol levels (94.3%), but only 65.5% reported having at least two HbA1c tests during the last year and 46.5% reported an annual foot examination by a health professional. About two-thirds of the participants reported having received recommendations on weight management (59.9%) and physical activity (64.7%) from a health professional in the previous year; only 47.8% of the participants reported having received diet counseling to improve diabetes control. CONCLUSION: Although the uptake of CDA CPGs for clinical and self-monitoring was high, with the majority of the participants reporting meeting most indicators, it was lower for HbA1c measurement and foot examination. Uptake of lifestyle management recommendations provided by health professionals was also significantly lower. |
Association between birthplace and current asthma: the role of environment and acculturation
Iqbal S , Oraka E , Chew GL , Flanders WD . Am J Public Health 2013 104 Suppl 1 S175-82 OBJECTIVES: We evaluated associations between current asthma and birthplace among major racial/ethnic groups in the United States. METHODS: We used multivariate logistic regression methods to analyze data on 102 524 children and adolescents and 255 156 adults in the National Health Interview Survey (2001-2009). RESULTS: We found significantly higher prevalence (P < .05) of current asthma among children and adolescents (9.3% vs 5.1%) and adults (7.6% vs 4.7%) born in the 50 states and Washington, DC (US-born), than among those born elsewhere. These differences were among all age groups of non-Hispanic Whites, non-Hispanic Blacks, and Hispanics (excluding Puerto Ricans) and among Chinese adults. Non-US-born adults with 10 or more years of residency in the United States had higher odds of current asthma (odds ratio = 1.55; 95% confidence interval = 1.25, 1.93) than did those who arrived more recently. Findings suggested a similar trend among non-US-born children. CONCLUSIONS: Current asthma status was positively associated with being born in the United States and with duration of residency in the United States. Among other contributing factors, changes in environment and acculturation may explain some of the differences in asthma prevalence. (Am J Public Health. Published online ahead of print December 19, 2013: e1-e8. doi:10.2105/AJPH.2013.301509). |
Elimination of endemic measles, rubella, and congenital rubella syndrome from the Western hemisphere: the US experience.
Papania MJ , Wallace GS , Rota PA , Icenogle JP , Fiebelkorn AP , Armstrong GL , Reef SE , Redd SB , Abernathy ES , Barskey AE , Hao L , McLean HQ , Rota JS , Bellini WJ , Seward JF . JAMA Pediatr 2013 168 (2) 148-55 IMPORTANCE: To verify the elimination of endemic measles, rubella, and congenital rubella syndrome (CRS) from the Western hemisphere, the Pan American Health Organization requested each member country to compile a national elimination report. The United States documented the elimination of endemic measles in 2000 and of endemic rubella and CRS in 2004. In December 2011, the Centers for Disease Control and Prevention convened an external expert panel to review the evidence and determine whether elimination of endemic measles, rubella, and CRS had been sustained. OBJECTIVE: To review the evidence for sustained elimination of endemic measles, rubella, and CRS from the United States through 2011. DESIGN, SETTING, AND PARTICIPANTS: Review of data for measles from 2001 to 2011 and for rubella and CRS from 2004 to 2011 covering the US resident population and international visitors, including disease epidemiology, importation status of cases, molecular epidemiology, adequacy of surveillance, and population immunity as estimated by national vaccination coverage and serologic surveys. MAIN OUTCOMES AND MEASURES: Annual numbers of measles, rubella, and CRS cases, by importation status, outbreak size, and distribution; proportions of US population seropositive for measles and rubella; and measles-mumps-rubella vaccination coverage levels. RESULTS: Since 2001, US reported measles incidence has remained below 1 case per 1 000 000 population. Since 2004, rubella incidence has been below 1 case per 10 000 000 population, and CRS incidence has been below 1 case per 5 000 000 births. Eighty-eight percent of measles cases and 54% of rubella cases were internationally imported or epidemiologically or virologically linked to importation. The few cases not linked to importation were insufficient to represent endemic transmission. Molecular epidemiology indicated no endemic genotypes. The US surveillance system is adequate to detect endemic measles or rubella. Seroprevalence and vaccination coverage data indicate high levels of population immunity to measles and rubella. CONCLUSIONS AND RELEVANCE: The external expert panel concluded that the elimination of endemic measles, rubella, and CRS from the United States was sustained through 2011. However, international importation continues, and health care providers should suspect measles or rubella in patients with febrile rash illness, especially when associated with international travel or international visitors, and should report suspected cases to the local health department. |
Geotemporal analysis of Neisseria meningitidis clones in the United States: 2000-2005.
Wiringa AE , Shutt KA , Marsh JW , Cohn AC , Messonnier NE , Zansky SM , Petit S , Farley MM , Gershman K , Lynfield R , Reingold A , Schaffner W , Thompson J , Brown ST , Lee BY , Harrison LH . PLoS One 2013 8 (12) e82048 BACKGROUND: The detection of meningococcal outbreaks relies on serogrouping and epidemiologic definitions. Advances in molecular epidemiology have improved the ability to distinguish unique Neisseria meningitidis strains, enabling the classification of isolates into clones. Around 98% of meningococcal cases in the United States are believed to be sporadic. METHODS: Meningococcal isolates from 9 Active Bacterial Core surveillance sites throughout the United States from 2000 through 2005 were classified according to serogroup, multilocus sequence typing, and outer membrane protein (porA, porB, and fetA) genotyping. Clones were defined as isolates that were indistinguishable according to this characterization. Case data were aggregated to the census tract level and all non-singleton clones were assessed for non-random spatial and temporal clustering using retrospective space-time analyses with a discrete Poisson probability model. RESULTS: Among 1,062 geocoded cases with available isolates, 438 unique clones were identified, 78 of which had ≥2 isolates. 702 cases were attributable to non-singleton clones, accounting for 66.0% of all geocoded cases. 32 statistically significant clusters comprised of 107 cases (10.1% of all geocoded cases) were identified. Clusters had the following attributes: included 2 to 11 cases; 1 day to 33 months duration; radius of 0 to 61.7 km; and attack rate of 0.7 to 57.8 cases per 100,000 population. Serogroups represented among the clusters were: B (n = 12 clusters, 45 cases), C (n = 11 clusters, 27 cases), and Y (n = 9 clusters, 35 cases); 20 clusters (62.5%) were caused by serogroups represented in meningococcal vaccines that are commercially available in the United States. CONCLUSIONS: Around 10% of meningococcal disease cases in the U.S. could be assigned to a geotemporal cluster. Molecular characterization of isolates, combined with geotemporal analysis, is a useful tool for understanding the spread of virulent meningococcal clones and patterns of transmission in populations. |
Detection and characterization of Mycoplasma pneumoniae during an outbreak of respiratory illness at a university.
Waller JL , Diaz MH , Petrone B , Benitez AJ , Wolff BJ , Edison L , Tobin-D'Angelo M , Moore A , Martyn A , Dishman H , Drenzek CL , Turner K , Hicks LA , Winchell JM . J Clin Microbiol 2013 52 (3) 849-53 An outbreak at a university in Georgia was identified after eighty-three cases of probable pneumonia were reported among students. Respiratory specimens were obtained from 21 students for an outbreak investigation. The TaqMan Array Card (TAC), a qPCR-based multi-pathogen detection technology, was used to initially identify M. pneumoniae as the causative agent in this outbreak. TAC demonstrated 100% diagnostic specificity and sensitivity when compared to the multiplex qPCR assay for this agent. All M. pneumoniae specimens (n=12) and isolates (n=10) were found to be susceptible to macrolide antibiotics through genetic analysis. Strain diversity of M. pneumoniae associated with this outbreak setting was identified using a variety of molecular typing procedures, resulting in two P1 genotypes (types 1 (60%) and 2 (40%)) and seven different Multi-Locus Variable-Number Tandem-Repeat analysis (MLVA) profiles. Continued molecular typing of this organism, particularly during outbreaks, may enhance the current understanding of the epidemiology of M. pneumoniae and may ultimately lead to a more effective public health response. |
Trends in receipt of sexually transmitted disease services among women 15 to 44 years old in the United States, 2002 to 2006-2010
Haderxhanaj LT , Gift TL , Loosier PS , Cramer RC , Leichliter JS . Sex Transm Dis 2014 41 (1) 67-73 BACKGROUND: To describe recent trends in the receipt of sexually transmitted disease (STD) services among women (age, 15-44 years) from 2002 to 2006-2010 using the National Survey of Family Growth. METHODS: We analyzed trends in demographics, health insurance, and visit-related variables of women reporting receipt of STD services (counseling, testing, or treatment) in the past 12 months. We also analyzed trends in the source of STD services and the payment method used. RESULTS: Receipt of STD services reported by women in the past 12 months increased from 2002 (12.6%) to 2006-2010 (16.0%; P < 0.001). Receipt of services did not increase among adolescents (P = 0.592). Among women receiving STD services from a private doctor/HMO, the percentage with private insurance decreased over time (74.6%-66.8%), whereas the percentage with Medicaid increased (12.8%-19.7%; P = 0.020). For women receiving STD services at a public clinic or nonprimary care facility, there were no statistically significant differences by demographics, except that fewer adolescents but more young adults reported using a public clinic over time (P = 0.038). Among women who reported using Medicaid as payment, receipt of STD services at a public clinic significantly decreased (36.8%-25.4%; P = 0.019). For women who paid for STD services with private insurance, the only significant difference was an increase in having a copay over time (61.3%-70.1%; P = 0.012). CONCLUSIONS: Despite a significant increase in receipt of STD services over time, many women at risk for STDs did not receive services including adolescents. In addition, we identified important shifts in payment methods during this time frame. |
Trends in reported syphilis and gonorrhea among HIV-infected people in Arizona: implications for prevention and control
Skinner JM , Distefano J , Warrington J , Bailey SR , Winscott M , Taylor MM . Public Health Rep 2014 129 85-94 OBJECTIVE: HIV and sexually transmitted disease (STD) surveillance patterns in Arizona suggested the need for integrated data analyses to identify trends. METHODS: We compiled all HIV/AIDS cases diagnosed from 1998 to 2008 that were reported in Arizona and syphilis or gonorrhea cases diagnosed from 1998 to 2008 in Arizona. We used deterministic matching to identify individuals who were diagnosed with HIV and one or more STDs, and calculated time intervals between diagnoses. RESULTS: Of 23,940 people with HIV/AIDS reported from 1998 to 2008, 1,899 (2.6%) had at least one syphilis or gonorrhea diagnosis from 1998 to 2008. Approximately 85% of these cases reported male-to-male sexual contact. Among males with syphilis, HIV coinfection increased from 0.5% in 1998 to 29.1% in 2008. Among males with gonorrhea, HIV coinfection increased from 2.0% in 1998 to 3.1% in 2008. Among HIV cases diagnosed from 2004 to 2008 and reported with at least one syphilis or gonorrhea diagnosis, the majority of syphilis cases (76.1%) were diagnosed at or after HIV diagnosis, whereas a majority of gonorrhea cases (54.9%) were diagnosed prior to HIV diagnosis. CONCLUSION: Use of the deterministic matching method identified increases in STD infections among HIV-infected people. The routine performance of this cross-matching method may be a useful tool in identifying these high-risk individuals so that targeted partner services and appropriate care referrals may be used in a timely fashion. |
A tuberculosis outbreak fueled by cross-border travel and illicit substances: Nevada and Arizona
Mitruka K , Blake H , Ricks P , Miramontes R , Bamrah S , Chee C , Hickstein L . Public Health Rep 2014 129 (1) 78-85 OBJECTIVES: From May 2006 to August 2008, the Southern Nevada Health District identified eight tuberculosis (TB) cases in six adults and two children in a Hispanic community. We conducted an outbreak investigation to determine the extent of TB transmission and prevent additional cases. METHODS: We investigated TB cases in Nevada and Arizona with the outbreak genotype or cases with suspected epidemiologic links to this cluster but without genotyping data. We reviewed medical records and interviewed patients and contacts. Subsequently, genotype surveillance was conducted for approximately four years to monitor additional outbreak-related cases. RESULTS: Eight outbreak cases were identified among six adults and two children. All patients were Hispanic and five were U.S.-born. The index patient was diagnosed while detained in Immigration and Customs Enforcement custody but deported before treatment completion. He was lost to follow-up for two years, during which time he served as the source for six secondary TB cases, including his own child. Along with the index patient, five patients reportedly engaged in the sale or use of methamphetamine. Follow-up surveillance in the two states identified eight additional cases with the outbreak genotype; three had epidemiologic links to the index case. CONCLUSIONS: We found that incomplete TB treatment led to extensive TB transmission. We recommend thorough discharge planning and active measures to ensure continuity of care and TB treatment completion for people in custody at higher risk for loss to follow-up, which likely includes those engaged in the sale or use of illicit substances. |
High burden of rotavirus gastroenteritis in young children in rural western Kenya, 2010-2011
Khagayi S , Burton DC , Onkoba R , Ochieng B , Ismail A , Mutonga D , Muthoni J , Feikin DR , Breiman RF , Mwenda JM , Odhiambo F , Laserson KF . Pediatr Infect Dis J 2014 33 Suppl 1 S34-40 BACKGROUND: Diarrhea is a leading cause of hospitalization and death in children <5 years of age. OBJECTIVES: To facilitate evaluation of the impact of rotavirus vaccine introduction in western Kenya, we estimated baseline rates of rotavirus-associated hospitalization and mortality among children <5 years of age. METHODS: From January 2010 to December 2011, we collected demographic, clinical and laboratory data for children <5 years of age seeking care at the district hospital and 2 outpatient facilities within a Health and Demographic Surveillance System (HDSS). Children with acute gastroenteritis (AGE), defined as ≥3 loose stools and/or ≥1 episode of unexplained vomiting followed by loose stool within a 24-hour period, were asked to provide a stool sample for rotavirus ELISA testing. Rates of rotavirus-associated hospitalization and mortality were estimated using time of residence in the HDSS to calculate person-years of observation. To estimate the rotavirus-associated mortality rate, we applied the percentage positive for rotavirus among AGE hospitalizations to verbal autopsy estimates of diarrhea deaths in the HDSS. RESULTS: There were 4991 hospitalizations of children <5 years of age; 1134 (23%) were for AGE and stool specimens were obtained from 790 (70%). Rotavirus was detected in 211 (27%) specimens. Among 4951 <5 outpatient sick visits, 608 (12%) were for AGE; 320 (51%) provided specimens and 62 (20%) were positive for rotavirus. Rotavirus AGE accounted for 501 <5 hospitalizations per 100,000 person-years of observation. Rotavirus-associated <5 mortality was 136 deaths per 100,000 person-years of observation. CONCLUSIONS: Continued surveillance of rotavirus AGE will provide timely data on the population-level impact of rotavirus vaccine following its likely introduction in 2014. |
Respiratory syncytial virus circulation in seven countries with global disease detection regional centers
Haynes AK , Manangan AP , Iwane MK , Sturm-Ramirez K , Homaira N , Brooks WA , Luby S , Rahman M , Klena JD , Zhang Y , Yu H , Zhan F , Dueger E , Mansour AM , Azazzy N , McCracken JP , Bryan JP , Lopez MR , Burton DC , Bigogo G , Breiman RF , Feikin DR , Njenga K , Montgomery J , Cohen AL , Moyes J , Pretorius M , Cohen C , Venter M , Chittaganpitch M , Thamthitiwat S , Sawatwong P , Baggett HC , Luber G , Gerber SI . J Infect Dis 2013 208 Suppl 3 S246-54 BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of lower respiratory tract infections in young children globally, with the highest burden in low- and middle-income countries where the association between RSV activity and climate remains unclear. METHODS: Monthly laboratory-confirmed RSV cases and associations with climate data were assessed for respiratory surveillance sites in tropical and subtropical areas (Bangladesh, China, Egypt, Guatemala, Kenya, South Africa, and Thailand) during 2004-2012. Average monthly minimum and maximum temperatures, relative humidity, and precipitation were calculated using daily local weather data from the US National Climatic Data Center. RESULTS: RSV circulated with 1-2 epidemic periods each year in site areas. RSV seasonal timing and duration were generally consistent within country from year to year. Associations between RSV and weather varied across years and geographic locations. RSV usually peaked in climates with high annual precipitation (Bangladesh, Guatemala, and Thailand) during wet months, whereas RSV peaked during cooler months in moderately hot (China) and arid (Egypt) regions. In South Africa, RSV peaked in autumn, whereas no associations with seasonal weather trends were observed in Kenya. CONCLUSIONS: Further understanding of RSV seasonality in developing countries and various climate regions will be important to better understand the epidemiology of RSV and for timing the use of future RSV vaccines and immunoprophylaxis in low- and middle-income countries. |
Respiratory syncytial virus infection in Guatemala, 2007-2012
McCracken JP , Prill MM , Arvelo W , Lindblade KA , Lopez MR , Estevez A , Muller ML , Munoz F , Bernart C , Cortez M , Moir JC , Ortiz J , Paredes A , Iwane MK . J Infect Dis 2013 208 Suppl 3 S197-206 BACKGROUND: Respiratory syncytial virus (RSV) is a major cause of acute respiratory illness (ARI). Little is known about RSV disease among older children and adults in Central America. METHODS: Prospective surveillance for ARI among hospital patients and clinic patients was conducted in Guatemala during 2007-2012. Nasopharyngeal and oropharyngeal swab specimens were tested for RSV, using real-time reverse-transcription polymerase chain reaction. RESULTS: Of 6287 hospitalizations and 2565 clinic visits for ARI, 24% and 12%, respectively, yielded RSV-positive test results. The incidence of RSV-positive hospitalization for ARI was 5.8 cases/10 000 persons per year and was highest among infants aged <6 months (208 cases/10 000 persons per year); among adults, the greatest incidence was observed among those aged ≥65 years (2.9 cases/10 000 persons per year). The incidence of RSV-positive clinic visitation for ARI was 32 cases/10 000 persons per year and was highest among infants aged 6-23 months (186 cases/10 000 persons per year). Among RSV-positive hospital patients with ARI, underlying cardiovascular disease was associated with death, moribund discharge, intensive care unit admission, or mechanical ventilation (odds ratio, 4.1; 95% confidence interval, 1.9-8.8). The case-fatality proportion among RSV-positive hospital patients with ARI was higher for those aged ≥5 years than for those aged <5 years (13% vs 3%; P < .001). CONCLUSIONS: The incidences of RSV-associated hospitalization and clinic visitation for ARI were highest among young children, but a substantial burden of ARI due to RSV was observed among older children and adults. |
Trends in antimicrobial resistance in Neisseria gonorrhoeae in the USA: the Gonococcal Isolate Surveillance Project (GISP), January 2006-June 2012
Kirkcaldy RD , Kidd S , Weinstock HS , Papp JR , Bolan GA . Sex Transm Infect 2013 89 Suppl 4 iv5-iv10 BACKGROUND: Neisseria gonorrhoeae has progressively developed resistance to sulfonamides, penicillin, tetracycline and fluoroquinolones, and gonococcal susceptibility to cephalosporins has been declining worldwide. METHODS: We described trends in gonococcal antimicrobial susceptibility in the USA from January 2006 through June 2012. Susceptibility data for cefixime, ceftriaxone, azithromycin, penicillin, tetracycline and ciprofloxacin were obtained from the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance system that monitors antimicrobial susceptibility in urethral gonococcal isolates collected from symptomatic men at 25-30 sexually transmitted disease clinics throughout the USA. RESULTS: The percentage of isolates with elevated cefixime minimum inhibitory concentrations (MICs) (≥0.25 microg/mL) increased from 0.1% in 2006 to 1.4% in 2010-2011 and was 1.1% in the first 6 months of 2012. The percentage with elevated ceftriaxone MICs (≥0.125 microg/mL) increased from 0.1% in 2006 to 0.3%-0.4% during 2009 through the first 6 months of 2012. There were no temporal trends in the prevalence of elevated azithromycin MICs (≥2 microg/mL) (0.2%-0.5%). The prevalence of resistance remained high for penicillin (11.2%-13.2%), tetracycline (16.7%-22.8%) and ciprofloxacin (9.6%-14.8%). CONCLUSIONS: The proportion of gonococcal isolates with elevated cephalosporin MICs increased from 2006 to 2010, but plateaued during 2011 and the first 6 months of 2012. Resistance to previously recommended antimicrobials has persisted. As the number of antimicrobials available for gonorrhoea treatment dwindles, surveillance systems such as GISP will be critical to detect emerging resistance trends and guide treatment decisions. |
Viruses associated with acute respiratory infections and influenza-like illness among outpatients from the Influenza Incidence Surveillance Project, 2010-2011
Fowlkes A , Giorgi A , Erdman D , Temte J , Goodin K , Di Lonardo S , Sun Y , Martin K , Feist M , Linz R , Boulton R , Bancroft E , McHugh L , Lojo J , Filbert K , Finelli L . J Infect Dis 2013 209 (11) 1715-25 BACKGROUND: The Influenza Incidence Surveillance Project (IISP) monitored outpatient acute respiratory infection (ARI) and influenza like illness (ILI) to determine the incidence and contribution of associated viral etiologies. METHODS: From August 2010 through July 2011, 57 outpatient healthcare providers with enumerated patient populations in 12 US sites reported weekly the number of ILI and ARI (> 2 respiratory symptoms not meeting ILI criteria) visits and collected respiratory specimens on a subset for viral testing. Incidence was estimated using number of patients in the practice as the denominator, and virus-specific incidence was extrapolated from the proportion of patients testing positive. RESULTS: The age-adjusted annual incidence of outpatient visits for ARI and ILI combined was 95/1,000 population, with a viral etiology identified in 58% of specimens. Most frequently detected were rhinoviruses/enteroviruses (RV/EV) and influenza (21% each), resulting in an extrapolated incidence of 20 and 19/1,000 population, respectively. The influenza incidence was highest among patients aged 2 to 17 years, while other viruses had varied patterns among age groups. CONCLUSIONS: The IISP provides a unique opportunity to estimate outpatient respiratory illness burden by etiology. Influenza and RV/EV infections represent a substantial burden of respiratory disease in the US outpatient setting, particularly among children. |
Outbreak of variant influenza A(H3N2) virus in the United States
Jhung MA , Epperson S , Biggerstaff M , Allen D , Balish A , Barnes N , Beaudoin A , Berman L , Bidol S , Blanton L , Blythe D , Brammer L , D'Mello T , Danila R , Davis W , de Fijter S , Diorio M , Durand LO , Emery S , Fowler B , Garten R , Grant Y , Greenbaum A , Gubareva L , Havers F , Haupt T , House J , Ibrahim S , Jiang V , Jain S , Jernigan D , Kazmierczak J , Klimov A , Lindstrom S , Longenberger A , Lucas P , Lynfield R , McMorrow M , Moll M , Morin C , Ostroff S , Page SL , Park SY , Peters S , Quinn C , Reed C , Richards S , Scheftel J , Simwale O , Shu B , Soyemi K , Stauffer J , Steffens C , Su S , Torso L , Uyeki TM , Vetter S , Villanueva J , Wong KK , Shaw M , Bresee JS , Cox N , Finelli L . Clin Infect Dis 2013 57 (12) 1703-12 BACKGROUND: Variant influenza virus infections are rare but may have pandemic potential if person-to-person transmission is efficient. We describe the epidemiology of a multistate outbreak of an influenza A(H3N2) variant virus (H3N2v) first identified in 2011. METHODS: We identified laboratory-confirmed cases of H3N2v and used a standard case report form to characterize illness and exposures. We considered illness to result from person-to-person H3N2v transmission if swine contact was not identified within 4 days prior to illness onset. RESULTS: From 9 July to 7 September 2012, we identified 306 cases of H3N2v in 10 states. The median age of all patients was 7 years. Commonly reported signs and symptoms included fever (98%), cough (85%), and fatigue (83%). Sixteen patients (5.2%) were hospitalized, and 1 fatal case was identified. The majority of those infected reported agricultural fair attendance (93%) and/or contact with swine (95%) prior to illness. We identified 15 cases of possible person-to-person transmission of H3N2v. Viruses recovered from patients were 93%-100% identical and similar to viruses recovered from previous cases of H3N2v. All H3N2v viruses examined were susceptible to oseltamivir and zanamivir and resistant to adamantane antiviral medications. CONCLUSIONS: In a large outbreak of variant influenza, the majority of infected persons reported exposures, suggesting that swine contact at an agricultural fair was a risk for H3N2v infection. We identified limited person-to-person H3N2v virus transmission, but found no evidence of efficient or sustained person-to-person transmission. Fair managers and attendees should be aware of the risk of swine-to-human transmission of influenza viruses in these settings. |
Population-level associations between antiretroviral therapy scale-up and all-cause mortality in South Africa
Larson E , Bendavid E , Tuoane-Nkhasi M , Mbengashe T , Goldman T , Wilson M , Klausner JD . Int J STD AIDS 2013 25 (9) 636-42 Our aim was to describe the association between increasing access to antiretroviral therapy and all-cause mortality in South Africa from 2005 to 2009. We undertook a longitudinal, population-level study, using antiretroviral monitoring data reported by PEPFAR implementing partners and province-level and national all-cause mortality records from Statistics South Africa (provider of official South African government statistics) to analyse the association between antiretroviral treatment and mortality. Using mixed effects models with a random intercept for province, we estimated the contemporaneous and lagging association between antiretroviral treatment and all-cause mortality in South Africa. We also conducted subgroup analyses and estimated the number of deaths averted. For each 100 HIV-infected individuals on antiretroviral therapy reported by PEPFAR implementing partners in South African treatment programs, there was an associated 2.9 fewer deaths that year (95% CI: 1.5, 4.2) and 6.3 fewer deaths the following year (95% CI: 4.6, 8.0). The associated decrease in mortality the year after treatment reporting was seen in both adults and children, and men and women. Treatment provided from 2005 to 2008 was associated with 28,305 deaths averted from 2006 to 2009. The scale-up of antiretroviral treatment in South Africa was associated with a significant reduction in national all-cause mortality. |
Prevalence of cervical and oral human papillomavirus infections among US women
Steinau M , Hariri S , Gillison ML , Broutian TR , Dunne EF , Tong ZY , Markowitz LE , Unger ER . J Infect Dis 2013 209 (11) 1739-43 Data from the U.S. National Health and Nutrition Survey (NHANES) 2009-2010, indicated human papillomavirus (HPV) prevalence of 42.7% in the cervix and 3.8% in the oral cavity among adult females. Prevalence of oral HPV was 5-fold higher among women with cervical HPV than among those without (7.0% vs. 1.4%, prevalence ratio=4.9, 95% CI: 2.7-8.7. Among the 3% of women with HPV at both sites, complete type concordance was detected in 6.6% and partial agreement in 37.7%. These data suggest that HPV infections at these two sites are not independent, although type-specific concordance is low. |
Epidemiology of respiratory syncytial virus infection in rural and urban Kenya
Bigogo GM , Breiman RF , Feikin DR , Audi AO , Aura B , Cosmas L , Njenga MK , Fields BS , Omballa V , Njuguna H , Ochieng PM , Mogeni DO , Aol GO , Olack B , Katz MA , Montgomery JM , Burton DC . J Infect Dis 2013 208 Suppl 3 S207-16 BACKGROUND: Information on the epidemiology of respiratory syncytial virus (RSV) infection in Africa is limited for crowded urban areas and for rural areas where the prevalence of malaria is high. METHODS: At referral facilities in rural western Kenya and a Nairobi slum, we collected nasopharyngeal/oropharyngeal (NP/OP) swab specimens from patients with influenza-like illness (ILI) or severe acute respiratory illness (SARI) and from asymptomatic controls. Polymerase chain reaction assays were used for detection of viral pathogens. We calculated age-specific ratios of the odds of RSV detection among patients versus the odds among controls. Incidence was expressed as the number of episodes per 1000 person-years of observation. RESULTS: Between March 2007 and February 2011, RSV was detected in 501 of 4012 NP/OP swab specimens (12.5%) from children and adults in the rural site and in 321 of 2744 NP/OP swab specimens (11.7%) from those in the urban site. Among children aged <5 years, RSV was detected more commonly among rural children with SARI (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2-3.3), urban children with SARI (OR, 8.5; 95% CI, 3.1-23.6), and urban children with ILI (OR, 3.4; 95% CI, 1.2-9.6), compared with controls. The incidence of RSV disease was highest among infants with SARI aged <1 year (86.9 and 62.8 episodes per 1000 person-years of observation in rural and urban sites, respectively). CONCLUSIONS: An effective RSV vaccine would likely substantially reduce the burden of respiratory illness among children in rural and urban areas in Africa. |
Epidemiology of respiratory syncytial virus-associated acute lower respiratory tract infection hospitalizations among HIV-infected and HIV-uninfected South African children, 2010-2011
Moyes J , Cohen C , Pretorius M , Groome M , von Gottberg A , Wolter N , Walaza S , Haffejee S , Chhagan M , Naby F , Cohen AL , Tempia S , Kahn K , Dawood H , Venter M , Madhi SA . J Infect Dis 2013 208 Suppl 3 S217-26 BACKGROUND: There are limited data on respiratory syncytial virus (RSV) infection among children in settings with a high prevalence of human immunodeficiency virus (HIV). We studied the epidemiology of RSV-associated acute lower respiratory tract infection (ALRTI) hospitalizations among HIV-infected and HIV-uninfected children in South Africa. METHODS: Children aged <5 years admitted to sentinel surveillance hospitals with physician-diagnosed neonatal sepsis or ALRTI were enrolled. Nasopharyngeal aspirates were tested by multiplex real-time polymerase chain reaction assays for RSV and other viruses. Associations between possible risk factors and severe outcomes for RSV infection among HIV-infected and uninfected children were examined. The relative risk of hospitalization in HIV-infected and HIV-uninfected children was calculated in 1 site with population denominators. RESULTS: Of 4489 participants, 4293 (96%) were tested for RSV, of whom 1157 (27%) tested positive. With adjustment for age, HIV-infected children had a 3-5-fold increased risk of hospitalization with RSV-associated ALRTI (2010 relative risk, 5.6; [95% confidence interval (CI), 4.5-6.4]; 2011 relative risk, 3.1 [95% CI, 2.6-3.6]). On multivariable analysis, HIV-infected children with RSV-associated ALRTI had higher odds of death (adjusted odds ratio. 31.1; 95% CI, 5.4-179.8) and hospitalization for >5 days (adjusted odds ratio, 4.0; 95% CI, 1.5-10.6) than HIV-uninfected children. CONCLUSION: HIV-infected children have a higher risk of hospitalization with RSV-associated ALRTI and a poorer outcome than HIV-uninfected children. These children should be targeted for interventions aimed at preventing severe RSV disease. |
HIV/AIDS outbreak investigation in Jalalpur Jattan (JPJ), Gujrat, Pakistan
Ansari JA , Salman M , Safdar RM , Ikram N , Mahmood T , Zaheer HA , Walke H , Asghar RJ . J Epidemiol Glob Health 2013 3 (4) 261-8 BACKGROUND: In June-July 2008 a non-governmental organization (NGO) in Jalalpur Jattan (JPJ), Gujrat, Pakistan arranged two voluntary HIV screening camps after numerous HIV-infected persons reported to their treatment center in Lahore; 88 (35.8%) of 246 persons screened in those camps were positive by rapid test. Intense media coverage made the residents of JPJ hostile to further inquiries. The Pakistan Field Epidemiology Training and Laboratory Training Program (FELTP) was requested by the Provincial AIDS Control Program to carry out an epidemiological investigation. METHODS: HIV-positive persons or family members of patients who died of AIDS and consented to be interviewed during the period 15 December 2008 to 2 January 2009 were investigated. Enhanced contact tracing was done to identify additional cases. A structured questionnaire was used to collect data regarding clinical history, risk factors, and HIV knowledge and practices. The national HIV/STI Referral Laboratory collected blood samples for HIV serology and molecular studies independently following pre- and post-counseling. RESULTS: A total of 53 HIV-infected persons were investigated. Out of these, 47 (88.7%) were alive at the time of investigation and 27 (50.9%) of the cases were female with 6 children aged 10years or less. Median age was 35years (mean 34.7, range 3-70). Most frequent symptoms were unexplained fever 42 (79.2%), diarrhea 34 (64.15%) and skin infections 27 (50.9%); 13 (24.5%) had co-infection with tuberculosis (TB) and 10 (18.9%) with hepatitis (B or C). Use of injections 51 (96.2%), dental procedures 21 (40%) and barber shop visits among males 18 (72%) were common risk factors. Extramarital sex was reported by 4 (9.4%). Only 19 (35.8%) were aware that HIV can be sexually transmitted and 18 (34%) were aware of HIV transmission by blood transfusion. Phylogenetic analysis revealed HIV infection in this group was HIV-1 Subtype A, transmitted over a decade, and the situation is endemic rather than an outbreak. CONCLUSION: The investigation indicates high rates of HIV infection in JPJ. Unlike other studies from Pakistan, a high proportion of cases in females and children less than 10years of age were observed. Socio-cultural norms and stigmatization limited in-depth investigation of sexual and behavioral practices and history of drug abuse. A shift of HIV infection from high-risk groups to the general population was seen and requires vigilant surveillance besides targeted health education, clinical management, lab facilities for diagnosis and monitoring, and voluntary counseling and testing services to limit disease spread. |
Incidence and clinical features of respiratory syncytial virus infections in a population-based surveillance site in the Nile Delta region
Rowlinson E , Dueger E , Taylor T , Mansour A , Van Beneden C , Abukela M , Zhang X , Refaey S , Bastawy H , Kandeel A . J Infect Dis 2013 208 Suppl 3 S189-96 BACKGROUND: Most reports about respiratory syncytial virus (RSV) in developing countries rely on sentinel surveillance, from which population incidence is difficult to infer. We used the proportion of RSV infections from population-based surveillance with data from a healthcare utilization survey to produce estimates of RSV incidence in Damanhour district, Egypt. METHODS: We conducted population-based surveillance in 3 hospitals (2009-2012) and 3 outpatient clinics (2011-2012) in Damanhour district. Nasopharyngeal and oropharyngeal specimens from hospitalized patients with acute respiratory illness and outpatients with influenza-like illness were tested by real-time reverse transcriptase polymerase chain reaction for RSV. We also conducted a healthcare utilization survey in 2011-2012 to determine the proportion of individuals who sought care for respiratory illness. RESULTS: Among 5342 hospitalized patients and 771 outpatients, 12% and 5% tested positive for RSV, respectively. The incidence of RSV-associated hospitalization and outpatient visits was estimated at 24 and 608 (per 100 000 person-years), respectively. Children aged <1 year experienced the highest incidence of RSV-associated hospitalizations (1745/100 000 person-years). CONCLUSIONS: This study demonstrates the utility of combining a healthcare utilization survey and population-based surveillance data to estimate disease incidence. Estimating incidence and outcomes of RSV disease is critical to establish the burden of RSV in Egypt. |
Incidence of symptomatic A(H1N1)pdm09 influenza during the pandemic and post-pandemic periods in a rural Indian community
Fowler KB , Gupta V , Sullender W , Broor S , Widdowson MA , Lal RB , Krishnan A . Int J Infect Dis 2013 17 (12) e1182-5 BACKGROUND: Data on influenza illness rates with population denominators are needed to quantify overall morbidity and to prioritize public health intervention strategies. METHODS: The rates of influenza A(H1N1)pdm09 infection during pandemic phases were determined in a longitudinal community cohort study as part of an influenza vaccine study in a rural community of North India. RESULTS: During the 711 731 person-weeks of surveillance, a total of 1410/7571 (19%) febrile acute respiratory illness cases were positive for influenza. Of these, 749 (53%) were influenza A(H1N1)pdm09, 643 (46%) influenza B, and 18 (1%) influenza A (H3N2). The overall incidence rate of influenza-associated febrile acute respiratory illness was 128/1000 person-years. The incidence rates of influenza A(H1N1)pdm09 were high during both the pandemic phase (179/1000 person-years; November 2009 to January 2010) and post-pandemic phase (156/1000 person-years; August to October 2010), with children <18 years of age being at the greatest risk of influenza infection in the community. CONCLUSIONS: These findings provide important information for planning clinical and public health intervention strategies to mitigate the impact of influenza epidemics. |
Antiviral susceptibility of highly pathogenic avian influenza A(H5N1) viruses isolated from poultry, Vietnam, 2009-2011
Nguyen HT , Nguyen T , Mishin VP , Sleeman K , Balish A , Jones J , Creanga A , Marjuki H , Uyeki TM , Nguyen DH , Nguyen DT , Do HT , Klimov AI , Davis CT , Gubareva LV . Emerg Infect Dis 2013 19 (12) 1963-71 We assessed drug susceptibilities of 125 avian influenza A(H5N1) viruses isolated from poultry in Vietnam during 2009-2011. Of 25 clade 1.1 viruses, all possessed a marker of resistance to M2 blockers amantadine and rimantadine; 24 were inhibited by neuraminidase inhibitors. One clade 1.1 virus contained the R430W neuraminidase gene and reduced inhibition by oseltamivir, zanamivir, and laninamivir 12-, 73-, and 29-fold, respectively. Three of 30 clade 2.3.4 viruses contained a I223T mutation and showed 7-fold reduced inhibition by oseltamivir. One of 70 clade 2.3.2.1 viruses had the H275Y marker of oseltamivir resistance and exhibited highly reduced inhibition by oseltamivir and peramivir; antiviral agents DAS181 and favipiravir inhibited H275Y mutant virus replication in MDCK-SIAT1 cells. Replicative fitness of the H275Y mutant virus was comparable to that of wildtype virus. These findings highlight the role of drug susceptibility monitoring of H5N1 subtype viruses circulating among birds to inform antiviral stockpiling decisions for pandemic preparedness. |
Association between Mycobacterium tuberculosis complex phylogenetic lineage and acquired drug resistance
Yuen CM , Kurbatova EV , Click ES , Cavanaugh JS , Cegielski JP . PLoS One 2013 8 (12) e83006 BACKGROUND: Development of resistance to antituberculosis drugs during treatment (i.e., acquired resistance) can lead to emergence of resistant strains and consequent poor clinical outcomes. However, it is unknown whether Mycobacterium tuberculosis complex species and lineage affects the likelihood of acquired resistance. METHODS: We analyzed data from the U.S. National Tuberculosis Surveillance System and National Tuberculosis Genotyping Service for tuberculosis cases during 2004-2011 with assigned species and lineage and both initial and final drug susceptibility test results. We determined univariate associations between species and lineage of Mycobacterium tuberculosis complex bacteria and acquired resistance to isoniazid, rifamycins, fluoroquinolones, and second-line injectables. We used Poisson regression with backward elimination to generate multivariable models for acquired resistance to isoniazid and rifamycins. RESULTS: M. bovis was independently associated with acquired resistance to isoniazid (adjusted prevalence ratio = 8.46, 95% CI 2.96-24.14) adjusting for HIV status, and with acquired resistance to rifamycins (adjusted prevalence ratio = 4.53, 95% CI 1.29-15.90) adjusting for homelessness, HIV status, initial resistance to isoniazid, site of disease, and administration of therapy. East Asian lineage was associated with acquired resistance to fluoroquinolones (prevalence ratio = 6.10, 95% CI 1.56-23.83). CONCLUSIONS: We found an association between mycobacterial species and lineage and acquired drug resistance using U.S. surveillance data. Prospective clinical studies are needed to determine the clinical significance of these findings, including whether rapid genotyping of isolates at the outset of treatment may benefit patient management. |
CD4+ cell count, viral load, and drug resistance patterns among heterosexual breakthrough HIV infections in a study of oral preexposure prophylaxis
Chirwa LI , Johnson JA , Niska RW , Segolodi TM , Henderson FL , Rose CE , Li JF , Thigpen MC , Matlhaba O , Paxton LA , Brooks JT . AIDS 2013 28 (2) 223-6 We examined CD4 cell count and plasma viral load patterns among Botswana TDF/FTC Oral HIV Prophylaxis Trial (TDF2 study) participants who seroconverted, comparing participants assigned to receive tenofovir/emtricitabine with participants assigned to receive placebo. We also evaluated for antiretroviral drug resistance among the breakthrough HIV infections. Among nine seroconverters assigned to tenofovir/emtricitabine and 24 to placebo, there were no significant differences in their CD4 cell count or viral load profiles over time. Of the four participants who seroconverted on-study while receiving tenofovir/emtricitabine, none became infected as a result of drug-resistant HIV; moreover, no resistance mutations emerged following seroconversion. |
CDC Pregnancy Flu Line: monitoring severe illness among pregnant women with influenza
Ailes EC , Newsome K , Williams JL , McIntyre AF , Jamieson DJ , Finelli L , Honein MA . Matern Child Health J 2013 18 (7) 1578-82 The Centers for Disease Control and Prevention implemented the Pregnancy Flu Line (PFL) during the influenza A(H1N1)pdm09 (pH1N1) pandemic and continued operation through the 2010-2011 influenza season to collect reports of intensive care unit (ICU) admissions and deaths among pregnant women with influenza. The system documented the severe impact of influenza on pregnant women during both seasons with 181 ICU/survivals and 37 deaths reported during the 2009 fall pandemic wave and 69 ICU/survivals and ten deaths reported in the subsequent influenza season (2010-2011). A health department survey suggests PFL participants perceived public health benefits and minimum time burdens. |
Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada
Samji H , Cescon A , Hogg RS , Modur SP , Althoff KN , Buchacz K , Burchell AN , Cohen M , Gebo KA , Gill MJ , Justice A , Kirk G , Klein MB , Korthuis PT , Martin J , Napravnik S , Rourke SB , Sterling TR , Silverberg MJ , Deeks S , Jacobson LP , Bosch RJ , Kitahata MM , Goedert JJ , Moore R , Gange SJ . PLoS One 2013 8 (12) e81355 BACKGROUND: Combination antiretroviral therapy (ART) has significantly increased survival among HIV-positive adults in the United States (U.S.) and Canada, but gains in life expectancy for this region have not been well characterized. We aim to estimate temporal changes in life expectancy among HIV-positive adults on ART from 2000-2007 in the U.S. and Canada. METHODS: Participants were from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD), aged ≥20 years and on ART. Mortality rates were calculated using participants' person-time from January 1, 2000 or ART initiation until death, loss to follow-up, or administrative censoring December 31, 2007. Life expectancy at age 20, defined as the average number of additional years that a person of a specific age will live, provided the current age-specific mortality rates remain constant, was estimated using abridged life tables. RESULTS: The crude mortality rate was 19.8/1,000 person-years, among 22,937 individuals contributing 82,022 person-years and 1,622 deaths. Life expectancy increased from 36.1 [standard error (SE) 0.5] to 51.4 [SE 0.5] years from 2000-2002 to 2006-2007. Men and women had comparable life expectancies in all periods except the last (2006-2007). Life expectancy was lower for individuals with a history of injection drug use, non-whites, and in patients with baseline CD4 counts <350 cells/mm(3). CONCLUSIONS: A 20-year-old HIV-positive adult on ART in the U.S. or Canada is expected to live into their early 70 s, a life expectancy approaching that of the general population. Differences by sex, race, HIV transmission risk group, and CD4 count remain. |
Diagnosis, management, and prevention of rotavirus gastroenteritis in children
Parashar UD , Nelson EA , Kang G . BMJ 2013 347 f7204 Rotavirus is the leading cause of severe childhood gastroenteritis. Each year, rotavirus is responsible for about 25 million clinic visits, two million hospital admissions, and 180 000–450 000 deaths in children under 5 years of age globally.1–3 Although rotavirus infection is prevalent worldwide, most deaths from this infection occur in developing countries (fig 1). Gastroenteritis caused by rotavirus cannot be clinically distinguished from that caused by other enteric pathogens; diagnosis requires testing of fecal specimens with commercially available assays. However, rotavirus is not routinely tested for in patients with gastroenteritis because the results do not alter clinical management, which relies mainly on appropriate rehydration therapy. Orally administered live attenuated vaccines that mimic natural infection offer the best protection against rotavirus. Two licensed rotavirus vaccines have been available since 2006 and have been implemented in many countries. We review approaches to diagnosis, management, and prevention of rotavirus gastroenteritis. |
Survey of New Mexico school health professionals regarding preparedness to support sexual minority students
Mahdi I , Jevertson J , Schrader R , Nelson A , Ramos MM . J Sch Health 2014 84 (1) 18-24 BACKGROUND: For schools to be safe and supportive for students, school health professionals should be aware of the particular challenges lesbian, gay, bisexual, transgender, or questioning (LGBTQ) students face, especially the risk for discrimination, violent victimization, and depression in the school setting. We assessed school health professionals' preparedness to address needs of LGBTQ students. METHODS: We conducted a secondary analysis of data collected during a New Mexico school health conference. This analysis focused on the preparedness of 183 school nurses, counselors, and social workers to address needs of LGBTQ students. Data were analyzed by using chi-square tests, other non-parametric tests, and logistic regression. RESULTS: Social workers (84.6%) and counselors (81.5%) were more likely than school nurses (55.8%) to report moderate or high knowledge of LGBTQ youth health risks, including suicide and depression (p < .001). Approximately half of school counselors and social workers reported no or low knowledge of LGBTQ community-based organizations or knowledge of counselors experienced with LGBTQ concerns. CONCLUSION: School health professionals in New Mexico do not appear prepared to address needs of LGBTQ students. Schools should consider integrating specific content about LGBTQ health risks and health disparities in trainings regarding bullying, violence, cultural competency, and suicide prevention. |
A novel integration effort to reduce the risk for alcohol-exposed pregnancy among women attending urban STD clinics
Hutton HE , Chander G , Green PP , Hutsell CA , Weingarten K , Peterson KL . Public Health Rep 2014 129 56-62 Alcohol-exposed pregnancy (AEP) is a significant public health problem in the United States. Sexually transmitted disease (STD) clinics serve female clients with a high prevalence of heavy alcohol consumption coupled with ineffective contraceptive use. Project CHOICES (Changing High-Risk AlcOhol Use and Increasing Contraception Effectiveness) is an evidence-based, brief intervention to lower risk of AEP by targeting alcohol and contraceptive behaviors through motivational interviewing and individualized feedback. We describe our experience integrating and implementing CHOICES in STD clinics. This endeavor aligns with CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's program collaboration and service integration strategic priority to strengthen collaborative work across disease areas and integrate services provided by related programs at the client level. |
Health care utilization and access to human immunodeficiency virus (HIV) testing and care and treatment services in a rural area with high HIV prevalence, Nyanza Province, Kenya, 2007
Ackers ML , Hightower A , Obor D , Ofware P , Ngere L , Kubaje A , Laserson KF . Am J Trop Med Hyg 2013 90 (2) 224-33 We present health and demographic surveillance system data to assess associations with healthcare use and human immunodeficiency virus (HIV) service receipt in a high HIV prevalence area of western Kenya. Eighty-six percent of 15,302 residents indicated a facility/clinician for routine medical services; 60% reported active (within the past year) attendance. Only 34% reported a previous HIV test, and self-reported HIV prevalence was 6%. Active attendees lived only slightly closer to their reported service site (2.8 versus 3.1 km; P < 0.001) compared with inactive attendees. Multivariate analysis showed that younger respondents (< 30 years of age) and active and inactive attendees were more likely to report an HIV test compared with non-attendees; men were less likely to report HIV testing. Despite traveling farther for HIV services (median distance = 4.4 km), 77% of those disclosing HIV infection reported HIV care enrollment. Men and younger respondents were less likely to enroll in HIV care. Socioeconomic status was not associated with HIV service use. Distance did not appear to be the major barrier to service receipt. The health and demographic surveillance system data identified patterns of service use that are useful for future program planning. |
Increased hand washing reduces influenza virus surface contamination in Bangkok households, 2009-2010
Levy JW , Suntarattiwong P , Simmerman JM , Jarman RG , Johnson K , Olsen SJ , Chotpitayasunondh T . Influenza Other Respir Viruses 2014 8 (1) 13-6 Within a hand-washing clinical trial, we evaluated factors associated with fomite contamination in households with an influenza-infected child. Influenza virus RNA contamination was higher in households with low absolute humidity and in control households, suggesting that hand washing reduces surface contamination. |
Recreational vehicle water tanks as a possible source for Legionella infections
Litwin CM , Asebiomo B , Wilson K , Hafez M , Stevens V , Fliermans CB , Fields BS , Fisher JF . Case Rep Infect Dis 2013 2013 286347 We investigated recreational vehicle (RV) water reservoirs in response to a case of pneumonia in which Legionella pneumophila was cultured both from the patient and a RV reservoir in which he travelled. Water samples processed and cultured at the CDC according to standard protocol were positive for Legionella spp. in 4/17 (24%) faucets, 1/11 (9%) water tanks from 4/20 (20%) RVs from three different campsites. Legionella spp. that were isolated included L. pneumophila (serogroups 1 and 6), L. anisa, L. feeleii, and L. quateriensis. Environmental controls from the potable water of the three campsites were culture-negative. A survey of maintenance practices by the RV users at the campsites revealed that chlorine disinfection of the water tanks was rarely performed. To prevent the possibility of Legionella infections, RV owners should implement regular chlorine disinfection of their water tanks and follow the recommended maintenance guidelines according to their owner's manuals. |
The role of landscape composition and configuration on Pteropus giganteus roosting ecology and Nipah virus spillover risk in Bangladesh
Hahn MB , Gurley ES , Epstein JH , Islam MS , Patz JA , Daszak P , Luby SP . Am J Trop Med Hyg 2013 90 (2) 247-55 Nipah virus has caused recurring outbreaks in central and northwest Bangladesh (the "Nipah Belt"). Little is known about roosting behavior of the fruit bat reservoir, Pteropus giganteus, or factors driving spillover. We compared human population density and ecological characteristics of case villages and control villages (no reported outbreaks) to understand their role in P. giganteus roosting ecology and Nipah virus spillover risk. Nipah Belt villages have a higher human population density (P < 0.0001), and forests that are more fragmented than elsewhere in Bangladesh (0.50 versus 0.32 patches/km2, P < 0.0001). The number of roosts in a village correlates with forest fragmentation (r = 0.22, P = 0.03). Villages with a roost containing Polyalthia longifolia or Bombax ceiba trees were more likely case villages (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 1.3-90.6). This study suggests that, in addition to human population density, composition and structure of the landscape shared by P. giganteus and humans may influence the geographic distribution of Nipah virus spillovers. |
Urban leptospirosis in Africa: a cross-sectional survey of leptospira infection in rodents in the Kibera urban settlement, Nairobi, Kenya
Halliday JE , Knobel DL , Allan KJ , de CBronsvoort BM , Handel I , Agwanda B , Cutler SJ , Olack B , Ahmed A , Hartskeerl RA , Njenga MK , Cleaveland S , Breiman RF . Am J Trop Med Hyg 2013 89 (6) 1095-102 Leptospirosis is a widespread but under-reported cause of morbidity and mortality. Global re-emergence of leptospirosis has been associated with the growth of informal urban settlements in which rodents are thought to be important reservoir hosts. Understanding the multi-host epidemiology of leptospirosis is essential to control and prevent disease. A cross-sectional survey of rodents in the Kibera settlement in Nairobi, Kenya was conducted in September-October 2008 to demonstrate the presence of pathogenic leptospires. A real-time quantitative polymerase chain reaction showed that 41 (18.3%) of 224 rodents carried pathogenic leptospires in their kidneys, and sequence data identified Leptospira interrogans and L. kirschneri in this population. Rodents of the genus Mus (37 of 185) were significantly more likely to be positive than those of the genus Rattus (4 of 39; odds ratio = 15.03). Questionnaire data showed frequent contact between humans and rodents in Kibera. This study emphasizes the need to quantify the public health impacts of this neglected disease at this and other urban sites in Africa. |
Phenotypic variation among Culex pipiens complex (Diptera: Culicidae) populations from the Sacramento Valley, California: horizontal and vertical transmission of West Nile virus, diapause potential, autogeny, and host selection
Nelms BM , Kothera L , Thiemann T , Macedo PA , Savage HM , Reisen WK . Am J Trop Med Hyg 2013 89 (6) 1168-78 The vector competence and bionomics of Culex pipiens form pipiens L. and Cx. pipiens f. molestus Forskal were evaluated for populations from the Sacramento Valley. Both f. pipiens and f. molestus females became infected, produced disseminated infections, and were able to transmit West Nile virus. Form molestus females also transmitted West Nile virus vertically to egg rafts and F1 progeny, whereas f. pipiens females only transmitted to egg rafts. Culex pipiens complex from urban Sacramento blood-fed on seven different avian species and two mammalian species. Structure analysis of blood-fed mosquitoes identified K = 4 genetic clusters: f. molestus, f. pipiens, a group of genetically similar hybrids (Cluster X), and admixed individuals. When females were exposed as larvae to midwinter conditions in bioenvironmental chambers, 85% (N = 79) of aboveground Cx. pipiens complex females and 100% (N = 34) of underground f. molestus females did not enter reproductive diapause. |
Eco-geographical differentiation among Colombian populations of the Chagas disease vector Triatoma dimidiata (Hemiptera: Reduviidae)
Gomez-Palacio A , Triana O , Jaramillo ON , Dotson EM , Marcet PL . Infect Genet Evol 2013 20 352-61 Triatoma dimidiata is currently the main vector of Chagas disease in Mexico, most Central American countries and several zones of Ecuador and Colombia. Although this species has been the subject of several recent phylogeographic studies, the relationship among different populations within the species remains unclear. To elucidate the population genetic structure of T. dimidiata in Colombia, we analyzed individuals from distinct geographical locations using the cytochrome c oxidase subunit 1 gene and 7 microsatellite loci. A clear genetic differentiation was observed among specimens from three Colombian eco-geographical regions: Inter Andean Valleys, Caribbean Plains and Sierra Nevada de Santa Marta mountain (SNSM). Additionally, evidence of genetic subdivision was found within the Caribbean Plains region as well as moderate gene flow between the populations from the Caribbean Plains and SNSM regions. The genetic differentiation found among Colombian populations correlates, albeit weakly, with an isolation-by-distance model (IBD). The genetic heterogeneity among Colombian populations correlates with the eco-epidemiological and morphological traits observed in this species across regions within the country. Such genetic and epidemiological diversity should be taken into consideration for the development of vector control strategies and entomological surveillance. |
Epizootiological survey of small mammals as Leptospira spp. reservoirs in Eastern Croatia
Majetic ZS , Galloway R , Sabljic ER , Milas Z , Mojcec V , Habus J , Margaletic J , Pernar R , Turk N . Acta Trop 2013 131 111-6 In this survey we investigated a population of small mammals in Eastern Croatia in order to determine Leptospira carriage rates and identify circulating serovars. Out of 67 trapped animals, 20 (29.9%) isolates were obtained. Identification of isolates using microscopic agglutination test, pulsed field gel electrophoresis and multi locus sequence typing revealed that 10 (50.0%) isolates belong to serogroup Pomona, serovar Mozdok, 6 (30.0%) isolates to serogroup Australis, serovar Jalna, 2 (10.0%) isolates to serogroup Sejroe, serovar Saxkoebing, and 1 (5.0%) isolate to serogroup Grippotyphosa, serovar Grippotyphosa. One isolate from serogroup Bataviae was unable to be identified to the serovar level. Amplification of a 331-bp region of the locus LA0322 using real-time polymerase chain reaction determined that 12 (60.0%) isolates belong to L. kirschneri, 6 (30.0%) isolates to L. interrogans, and 2 (10.0%) isolates to L. borgpetersenii. Leptospira carriage rate was high (29.9%), which corresponds to a high incidence of human and domestic animal leptospirosis in Eastern Croatia. Furthermore, 90.0% of the isolates belong to serogroups Pomona, Australis and Sejroe which are also the most prevalent serogroups in humans in this area. These findings suggest that small mammals might be an important source of Leptospira spp. infection in Eastern Croatia. |
Preparing for safety monitoring after rotavirus vaccine implementation: a retrospective review of intussusception cases among children at a large teaching hospital in Rwanda, 2009-2012
Ngendahayo E , Bonane A , Ntakiyiruta G , Munyanshongore A , Muganga N , Bikoroti J , Mwenda JM , Tate JE , Ngabo F . Pediatr Infect Dis J 2014 33 Suppl 1 S99-S103 BACKGROUND: In some settings, rotavirus vaccines have been associated with a small risk of intussusception. This study describes the demographics, clinical characteristics and outcomes of children with intussusception in Rwanda before vaccine introduction in May 2012. METHODS: We retrospectively reviewed data on pediatric patients treated for intussusception at University Teaching Hospital of Kigali from January 2009 to June 2012. Hospital registries were reviewed to identify intussusception cases. Archived patient files were abstracted to collect data on demographics, clinical presentation, surgery and outcome. RESULTS: During the study period, 70 children ≤19 years of age were treated for intussusception and patient files were retrieved for 60 (86%) cases. Over half of patients (58%) were <1 year of age and 90% were transferred from a district hospital. Only 30% of patients presented within 3 days of symptom onset and 35% experienced a delay of ≥6 hours between surgical review and surgery. Surgical complications were experienced by 35% of children. Over 1 quarter (28%) of children died. Compared with children who survived, children who died were significantly more likely to have experienced complications (21% vs. 71%; P < 0.001) and to be female (28% vs. 65%; P = 0.009). DISCUSSION: Mortality due to intussusception was high among Rwanda children. Delays in presentation and treatment were common. Assessing trends in the number of cases to monitor for vaccine-associated intussusception will be difficult. Additional work is needed to further understand risk factors for mortality, to calculate incidence rates and to monitor the safety of the rotavirus vaccination program. |
Streptococcus pneumoniae non-susceptibility and outpatient antimicrobial prescribing rates at the Alaska Native Medical Center
Stevens RW , Wenger J , Bulkow L , Bruce MG . Int J Circumpolar Health 2013 72 22297 BACKGROUND: American Indian/Alaska Native (AI/AN) people suffer substantially higher rates of invasive pneumococcal disease (IPD) than the general US population. We evaluated antimicrobial prescribing data and their association with non-susceptibility in Streptococcus pneumoniae causing IPD in AI/AN people between 1992 and 2009. METHODS: Antimicrobial use data were gathered from the electronic patient management system and included all prescriptions dispensed to Alaska Native patients aged 5 years and older from outpatient pharmacies at the Alaska Native Medical Center (ANMC). Antimicrobial susceptibility data were gathered from pneumococcal isolates causing IPD among Anchorage Service Unit AI/AN residents aged 5 years and older. Data were restricted to serotypes not contained in the pneumococcal vaccine (PCV7). RESULTS: Over the study period, overall antimicrobial prescribing increased 59% (285/1,000 persons/year in 1992 to 454/1,000 persons per year in 2009, p<0.001). Trimethoprim/sulfamethoxazole prescribing increased (43/1,000 persons/year in 1992 to 108/1,000 persons/year in 2009, p<0.001) and non-susceptibility to trimethoprim/sulfamethoxazole in AI/AN patients ≥5 years of age increased in non-PCV7 serotypes (0-12%, p<0.05). Similarly, prescribing rates increased for macrolide antibiotics (46/1,000 persons/year in 1992 to 84/1,000 persons/year in 2009, p<0.05). We observed no statistically significant change over time in erythromycin non-susceptibility among non-PCV7 serotypes in AI/AN patients aged 5 years or greater (0-7%, p=0.087). CONCLUSION: Antimicrobial prescribing patterns of some antibiotics in the AI/AN population corresponded to increased antimicrobial resistance in clinical isolates. This study highlights the on-going threat of antimicrobial resistance, the critical importance of judicious prescribing of antibiotics and the potential utility of prescribing data for addressing this issue. |
Vaccines and pregnancy: past, present, and future
Rasmussen SA , Watson AK , Kennedy ED , Broder KR , Jamieson DJ . Semin Fetal Neonatal Med 2013 19 (3) 161-9 Vaccination during pregnancy with certain vaccines can prevent morbidity and mortality in pregnant women and their infants. However, previous recommendations often focused on the potential risks of vaccines to the fetus when used during pregnancy. In recent years, additional data have become available on the absence of increased risks for adverse events associated with vaccines when administered during pregnancy and on their benefits to mothers and infants. Currently two vaccines - (i) inactivated influenza, and (ii) tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) - are recommended for use by all pregnant women by the United States Advisory Committee on Immunization Practices. Here we review the history of vaccination during pregnancy, the current status of recommendations for vaccination during pregnancy in the USA, and the potential for future advances in this area, including key barriers that must be overcome to accommodate these advances. |
Brominated flame retardants in breast milk and behavioural and cognitive development at 36 months
Adgent MA , Hoffman K , Goldman BD , Sjodin A , Daniels JL . Paediatr Perinat Epidemiol 2014 28 (1) 48-57 BACKGROUND: Polybrominated diphenyl ethers (PBDEs) are persistent flame retardants found in the environment, in household dust, and in humans. Breast feeding is a prominent route of exposure in infancy. PBDEs adversely affect neurodevelopment in animals. Here, we estimate associations between PBDEs in breast milk and behaviour and cognitive skills in children at 36 months of age. METHODS: We prospectively studied 304 mothers and their children. We measured PBDEs in breast milk collected at 3 months postpartum. At 36 months, we measured child behaviour with the parent-rated Behavioral Assessment System for Children 2 (n = 192), and cognitive skills with the Mullen Scales of Early Learning (n = 184). We analysed data with robust regression. RESULTS: We detected BDE-28, -47, -99, -100, and -153 in >70% of milk samples. For each congener, the highest quartile of breast milk PBDE concentration, vs. the lowest, was associated with more anxious behaviour, after confounder adjustment. Select congeners were associated with increased withdrawal (BDE-28) and improved activity of daily living skills (BDE-153). Cognitive skills tended to be positively associated with PBDEs, especially language and fine motor skills. However, most estimates were imprecise. CONCLUSIONS: Here, lactational PBDE exposure was modestly and imprecisely associated with anxiety and withdrawal, but was also associated with improved adaptive and cognitive skills. Positive factors associated with breast feeding may have mitigated some of the hypothesised adverse neurodevelopmental outcomes associated with PBDEs. Further research is needed to inform our understanding of PBDE neurotoxicity and how sources of exposure might confound neurodevelopmental studies. |
Serum concentrations of polychlorinated biphenyls (PCBs) in participants of the Anniston Community Health Survey
Pavuk M , Olson JR , Sjodin A , Wolff P , Turner WE , Shelton C , Dutton ND , Bartell S . Sci Total Environ 2013 473-474c 286-297 Serum concentrations of 35 ortho-substituted polychlorinated biphenyl congeners (PCBs) were measured in 765 adults from Anniston, Alabama, where PCBs were manufactured between 1929 and 1971. As part of the Anniston Community Health Survey (ACHS), demographic data, questionnaire information, and blood samples were collected from participants in 2005-2007. Forty-six percent of study participants were African-American, 70% were female, and the median age was 56 years. The median concentration of the sum of 35 PCB congeners (SigmaPCBs) was 528ng/g lipid, with a 90th percentile of 2600ng/g lipid, minimum of 17.0ng/g lipid, and maximum of 27,337ng/g lipid. The least square geometric mean SigmaPCBs was more than 2.5 times higher for African-American participants than for White participants (866ng/g lipid vs. 331ng/g lipid); this difference did not change materially after adjustment for age, sex, body mass index (BMI) and current smoking. In spite of large differences in absolute PCB levels, relative contributions of individual congeners to SigmaPCBs were quite similar between race groups. Nevertheless, while percent contributions to SigmaPCBs for most of the most abundant penta- to heptachlorobiphenyls were higher among African-Americans, the percentages were higher in Whites for the lower-chlorinated PCBs 28 and 74 and for octa- to decachlorinated PCBs. No major differences were observed in geometric mean SigmaPCBs between women and men when adjusted for age, race, BMI and current smoking (516ng/g lipid vs. 526ng/g lipid). Principal component analysis revealed groups of co-varying congeners that appear to be determined by chlorine substitution patterns. These congener groupings were similar between ACHS participants and the National Health and Nutrition Examination Survey (NHANES) 2003-04 sample of the general United States population, despite ACHS participants having serum concentrations of SigmaPCBs two to three times higher than those in comparable age and race groups from NHANES. |
Serum concentrations of TCDD and other dioxin-like compounds in US Air Force veterans of Operation Ranch Hand
Pavuk M , Patterson DG Jr , Turner WE . Chemosphere 2013 102 18-23 We measured serum concentrations of seven dibenzo-p-dioxin congeners (PCDDs), ten dibenzofurans (PCDFs), four non-ortho polychlorinated biphenyls (noPCBs) and six mono-ortho polychlorinated biphenyls (moPCBs) in 1950 veterans of the Vietnam War. The veterans were participants in the Air Force Health Study (AFHS) who attended the final medical examination in 2002. Blood samples were collected from 777 Ranch Hands involved in the aerial spraying of herbicides in Vietnam and a comparison group of 1173 veterans ("Comparisons") who served in Southeast Asia during the same time period. Results for moPCBs were based on a random subsample of 800 veterans. The median 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) concentrations in 2002 were 5.0pgg-1 lipid in Ranch Hands and 2.2pgg-1 lipid in Comparisons. No substantial differences were found in measured concentrations of other PCDDs, PCDFs, and noPCBs. Similarly, no substantial differences were found for moPCBs in the subsample. The median total dioxin toxic equivalent (TEQ) in Ranch Hands was 18.7pgg-1 lipid for PCDDs, 3.4pgg-1 lipid for PCDFs, and 3.2pgg-1 lipid for noPCBs. Median TEQs in Comparisons were 14.4pgg-1 lipid for PCDDs, 3.5pgg-1 lipid for PCDFs, and 3.3pgg-1 lipid for noPCBs. These TEQs, with the exception of PCDD TEQ in Ranch Hands (primarily due to elevated TCDD), were similar to or lower than those reported for similar age and gender groups in the 2001-2002 National Health and Nutrition Examination Survey (NHANES). These findings support the assumption that the Ranch Hand veterans were not more highly exposed to dioxin-like compounds other than TCDD than were Comparison veterans or the general US population. |
Urinary polycyclic aromatic hydrocarbons and childhood obesity: NHANES (2001-2006)
Scinicariello F , Buser MC . Environ Health Perspect 2013 122 (3) 299-303 BACKGROUND: Polycyclic aromatic hydrocarbons (PAHs) are known carcinogens and suspected endocrine disruptors. Prenatal exposure to PAHs has been associated with obesity in early childhood. OBJECTIVE: We examined the association of urinary PAH metabolites with adiposity outcomes (BMI z-score, waist circumference, and rate of obesity) in children and adolescents. METHODS: We performed whole-sample analyses of 3,189 individuals 6-19 years of age who participated in the 2001-2006 National Health and Nutrition Examination Survey. We performed multivariate linear and logistic regression to analyze the association of BMI z-score, waist circumference (WC) and obesity with concentrations of single urinary PAH compounds and the sum of PAHs. Furthermore, the analyses were stratified by developmental stage [i.e., children (6-11) and adolescents (12-19)]. RESULTS: BMI z-score, WC, and obesity were positively associated with the molecular mass sum of the PAHs and the total sum of naphthalene metabolites. Most associations increased monotonically with increasing quartiles of exposure among children 6-11 years of age, whereas dose-response trends were less consistent for adolescents (12-19 years of age). Neither total PAHs nor total naphthalene metabolites were associated with overweight in either age group, and there was little evidence of associations between the outcomes and individual PAHs. CONCLUSIONS: Total urinary PAH metabolites and naphthalene metabolites were associated with higher body mass index, waist circumference, and obesity in children ages 6-11, with positive but less consistent associations among adolescents. |
Environmental assessment and exposure control of dust mites: a practice parameter
Portnoy J , Miller JD , Williams PB , Chew GL , Miller JD , Zaitoun F , Phipatanakul W , Kennedy K , Barnes C , Grimes C , Larenas-Linnemann D , Sublett J , Bernstein D , Blessing-Moore J , Khan D , Lang D , Nicklas R , Oppenheimer J , Randolph C , Schuller D , Spector S , Tilles SA , Wallace D . Ann Allergy Asthma Immunol 2013 111 (6) 465-507 Dust mites are 8-legged arthropods that live in the house dust of homes located in regions where they are prevalent. They have been recognized as the major source of allergens in house dust since 1967. The most common species found in homes in temperate regions of the United States are Dermatophagoides farinae and Dermatophagoides pteronyssinus. In addition, others, such as Blomia tropicalis, can be found in homes in tropical and subtropical regions. | Dust mites feed on organic materials, including skin scales, fungi, yeasts, and bacteria. Because they are composed of approximately 75% water by weight, they maintain their water balance through uptake of water vapor when RH is at least approximately 65%. They are susceptible to water loss when humidity decreases below 65% and have decreased survival and reproduction with an RH below 50%. | Mites produce and excrete numerous allergens into the environment, including cysteine proteases such as Der p 1 and Der f 1, serine proteases including Der p 3, 6 and 9, and proteases that can activate protease-activated receptor-2, which are proinflammatory in humans through a non–IgE-dependent mechanism. Mites also produce glycosidases and carbohydrate-binding proteins and muscle, cytoskeleton, and calcium-binding proteins. There is cross-reactivity among various mite species and between mites and other related families, such as crustaceans and cockroaches. |
Flame retardant exposure among collegiate United States gymnasts
Carignan CC , Heiger-Bernays W , McClean MD , Roberts SC , Stapleton HM , Sjodin A , Webster TF . Environ Sci Technol 2013 47 (23) 13848-56 Gymnastics training facilities contain large volumes of polyurethane foam, a material that often contains additive flame retardants such as PentaBDE. While investigations of human exposure to flame retardants have focused on the general population, potentially higher than background exposures may occur in gymnasts and certain occupational groups. Our objectives were to compare PentaBDE body burden among gymnasts to the general United States population and characterize flame retardants levels in gym equipment, air, and dust. We recruited 11 collegiate female gymnasts (ages 18-22) from one gym in the eastern United States. The geometric mean (GM) concentration of BDE-153 in gymnast sera (32.5 ng/g lipid) was 4-6.5 times higher than in the general United States population groups. Median concentrations of PentaBDE, TBB, and TBPH in paired handwipe samples were 2-3 times higher after practice compared to before, indicating the gymnasts contacted these flame retardants during practice. GM concentrations of PentaBDE, TBB, and TBPH were 1-3 orders of magnitude higher in gym air and dust than in residences. Our findings suggest that these collegiate gymnasts experienced higher exposures to PentaBDE flame retardants compared to the general United States population and that gymnasts may also have increased exposure to other additive flame retardants used in polyurethane foam such as TBB and TBPH. |
DDT/DDE and breast cancer: a meta-analysis
Ingber SZ , Buser MC , Pohl HR , Abadin HG , Murray HE , Scinicariello F . Regul Toxicol Pharmacol 2013 67 (3) 421-33 The biological basis for investigating dichlorodiphenyltrichloroethane (DDT) exposure and breast cancer risk stems from in vitro and animal studies indicating that DDT has estrogenic properties. The objective of this study was to update a meta-analysis from 2004 which found no association between dichlorodiphenyldichloroethylene (DDE) and breast cancer. We searched PubMed and Web of Science for studies published through June 2012 assessing DDT/DDE exposure and breast cancer. Summary Odds Ratios (ORs) with 95% confidence intervals (CIs) were calculated for the prevalence of breast cancer in the highest versus the lowest exposed groups for DDT and DDE. Difference of means of exposure for cases versus controls was analyzed for DDT and DDE. From the 500 studies screened, 46 were included in the meta-analysis. Slightly elevated, but not statistically significant summary ORs were found for DDE (1.05; 95% CI: 0.93-1.18) and DDT (1.02; 95% CI: 0.92-1.13). Lipid adjusted difference of means analysis found a significantly higher DDE concentration in cases versus controls (11.30ng/g lipid; p=0.01). No other difference of means analysis found significant relationships. The existing information does not support the hypothesis that exposure to DDT/DDE increases the risk of breast cancer in humans. |
Monoclonal B-cell lymphocytosis in healthy blood donors: an unexpectedly common finding.
Shim YK , Rachel JM , Ghia P , Boren J , Abbasi F , Dagklis A , Venable G , Kang J , Degheidy H , Plapp FV , Vogt RF , Menitove JE , Marti GE . Blood 2013 123 (9) 1319-26 Circulating monoclonal B cells may be detected in healthy adults, a condition called monoclonal B-cell lymphocytosis (MBL). MBL has also been identified in donated blood, but no systematic study of blood donors has been reported. Using sensitive and specific laboratory methods, we detected MBL in 149 (7.1%; 95% CI, 6.0%-8.3%) of 2098 unique donors ages 45 years or older in a Midwestern U.S. regional blood center between 2010 and 2011. Most of the 149 donors had low-count MBL, including 99 CLL-like (66.4%), 22 atypical (14.8%), and 19 CD5- (12.8%) immunophenotypes. However, five donors (3.4%) had B-cell clonal counts above 500 cells/microl, including three with 1693-2887 cells/microl; the clone accounted for nearly all their circulating B-cells. Four donors (2.7%) had two distinct MBL clones. Of 51 MBL samples in which IGHV-D-J genotypes could be determined, 71% and 29% used IGHV3- and IGHV4-family genes, respectively. Sequencing revealed 82% with somatic hypermutation, while 18% had greater than 98% germ-line identity, including five with entirely germ-line sequences. In conclusion, MBL prevalence is much higher in blood donors than previously reported and, although uncommon, the presence of high-count MBL warrants further investigations to define the biological fate of the transfused cells in recipients. |
Use of population-based surveillance to determine the incidence of rotavirus gastroenteritis in an urban slum and a rural setting in Kenya
Breiman RF , Cosmas L , Audi A , Mwiti W , Njuguna H , Bigogo GM , Olack B , Ochieng JB , Wamola N , Montgomery JM , Williamson J , Parashar UD , Burton DC , Tate JE , Feikin DR . Pediatr Infect Dis J 2014 33 Suppl 1 S54-61 BACKGROUND: Rotavirus gastroenteritis is a major cause of mortality among children <2 years of age. Disease burden data are important for introducing and sustaining new rotavirus vaccines in immunization programs. METHODS: We analyzed population-based infectious disease surveillance data from 2007 to 2010 from Kenyan sites in rural and urban slum areas. Stool specimens were collected from patients of all ages presenting to study clinics with diarrheal disease and tested for rotavirus by enzyme immunoassay. Incidence rates were adjusted using data on healthcare utilization (from biweekly home visits) and proportion of stools collected at study clinics from patients meeting case definitions. RESULTS: Rotavirus was detected in 285 (9.0%) of 3174 stools tested, including 122 (11.9%) from children <5 years of age and 162 (7.6%) from participants ≥5 years of age. Adjusted incidence rates for infants were 13,419 and 12,135 per 100,000 person-years of observation in rural and urban areas, respectively. Adjusted incidence rates were high in adults across age ranges. The rates suggest that annually, among children <5 years of age, there are >54,500 cases of rotavirus-associated gastroenteritis in rural Nyanza Province and >16,750 cases in Nairobi urban slums. CONCLUSIONS: Community-based surveillance in urban and rural Kenya suggests that rotavirus plays an important role as a cause of acute gastroenteritis in adults, as well as in children. In addition to substantially preventing illness and complications from diarrheal disease in children, rotavirus infant immunization has the potential of indirectly preventing diarrheal disease in older children and adults, assuming children are the predominant sources of transmission. |
Preparing for the scale-up of rotavirus vaccine introduction in Africa: establishing surveillance platforms to monitor disease nurden and vaccine impact
Mwenda JM , Tate JE , Steele AD , Parashar UD . Pediatr Infect Dis J 2014 33 Suppl 1 S1-5 Countries in Africa have begun introducing rotavirus vaccines in their national immunization programs, and wide-scale rollout across the continent is expected during the next few years. In preparation for vaccine introduction, many countries initiated surveillance for rotavirus and other studies to document disease burden, to describe the epidemiology and to monitor circulating rotavirus strains in Africa. In addition, 2 countries sought to systematically investigate cases of intussusception, a rare adverse event that has been associated with rotavirus vaccines in some settings. The ongoing surveillance provided data that will serve as a baseline against which the impact of rotavirus vaccines in Africa can be assessed. |
Facebook-augmented partner notification in a cluster of syphilis cases in Milwaukee
Hunter P , Oyervides O , Grande KM , Prater D , Vann V , Reitl I , Biedrzycki PA . Public Health Rep 2014 129 43-49 Public health professionals face many challenges in infectious disease cluster case identification and partner notification (PN), especially in populations using social media as a primary communication venue. We present a method using Facebook and social network diagram illustration to identify, link, and notify individuals in a cluster of syphilis cases in young black men who have sex with men (MSM). Use of Facebook was crucial in identifying two of 55 individuals with syphilis, and the cooperation of socially connected individuals with traditional PN methods yielded a high number of contacts per case. Integration of PN services for HIV and sexually transmitted diseases, as well as collaboration between the city and state information systems, assisted in the cluster investigation. Given that rates of syphilis and HIV infection are increasing significantly in young African American MSM, the use of social media can provide an additional avenue to facilitate case identification and notification. |
Active surveillance for carbapenem-resistant Enterobacteriaceae using stool specimens submitted for testing for Clostridium difficile
Banach DB , Francois J , Blash S , Patel G , Jenkins SG , Labombardi V , Kreiswirth BN , Srinivasan A , Calfee DP . Infect Control Hosp Epidemiol 2014 35 (1) 82-4 Active surveillance to identify asymptomatic carriers of carbapenem-resistant Enterobacteriaceae (CRE) is a recommended strategy for CRE control in healthcare facilities. Active surveillance using stool specimens tested for Clostridium difficile is a relatively low-cost strategy to detect CRE carriers. Further evaluation of this and other risk factor-based active surveillance strategies is warranted. |
Burden of encephalitis-associated hospitalizations in the United States, 1998-2010
Vora NM , Holman RC , Mehal JM , Steiner CA , Blanton J , Sejvar J . Neurology 2014 82 (5) 443-51 OBJECTIVE: To estimate the burden of encephalitis-associated hospitalizations in the United States for 1998-2010. METHODS: Using the Nationwide Inpatient Sample, a nationally representative database of hospitalizations, estimated numbers and rates of encephalitis-associated hospitalizations for 1998-2010 were calculated. Etiology and outcome of encephalitis-associated hospitalizations were examined, as well as accompanying diagnoses listed along with encephalitis on the discharge records. Total hospital charges (in 2010 US dollars) were assessed. RESULTS: An estimated 263,352 (standard error: 3,017) encephalitis-associated hospitalizations occurred in the United States during 1998-2010, which corresponds to an average of 20,258 (standard error: 232) encephalitis-associated hospitalizations per year. A fatal outcome occurred in 5.8% (95% confidence interval [CI]: 5.6%-6.0%) of all encephalitis-associated hospitalizations and in 10.1% (95% CI: 9.2%-11.2%) and 17.1% (95% CI: 14.6%-20.0%) of encephalitis-associated hospitalizations in which a code for HIV or a tissue or organ transplant was listed, respectively. The proportion of encephalitis-associated hospitalizations in which an etiology for encephalitis was specified was 50.3% (95% CI: 49.6%-51.0%) and that for which the etiology was unspecified was 49.7% (95% CI: 49.0%-50.4%). Total charges for encephalitis-associated hospitalizations in 2010 were an estimated $2.0 billion. CONCLUSIONS: Encephalitis remains a major public health concern in the United States. Among the large number of encephalitis-associated hospitalizations for which an etiology is not reported may be novel infectious and noninfectious forms of encephalitis. Associated conditions such as HIV or transplantation increase the risk of a fatal outcome from an encephalitis-associated hospitalization and should be monitored. |
Comparing active and passive varicella surveillance in Philadelphia, 2005-2010: recommendations for the transition to nationwide passive varicella disease surveillance
Viner K , Perella D , Lopez A , Bialek S , Nguyen M , Spells N , Watson B . Public Health Rep 2014 129 (1) 47-54 OBJECTIVE: The Philadelphia Department of Public Health (PDPH) conducts active surveillance for varicella in West Philadelphia. For its approximately 300 active surveillance sites, PDPH mandates biweekly reports of varicella (including zero cases) and performs intensive case investigations. Elsewhere in Philadelphia, surveillance sites passively report varicella cases, and abbreviated investigations are conducted. We used active varicella surveillance program data to inform the transition to nationwide passive varicella surveillance. METHODS: We compared classification of reported cases, varicella disease incidence, and reporting completeness for active and passive surveillance areas for 2005-2010. We assessed reporting completeness using capture-recapture analysis of 2- to 18-year-old cases reported by schools/daycare centers and health-care providers. RESULTS: From 2005 to 2010, PDPH received 3,280 passive and 969 active surveillance varicella case reports. Most passive surveillance reports were classified as probable cases (18% confirmed, 56% probable, and 26% excluded), whereas nearly all of the active surveillance reports were either confirmed or excluded (36% confirmed, 11% probable, and 53% excluded). Overall incidence rates calculated using confirmed/probable cases were similar in the active and passive surveillance areas. Detection of laboratory-confirmed, breakthrough, and moderate-to-severe cases was equivalent for both surveillance areas. CONCLUSIONS: Although active surveillance for varicella results in better classified cases, passive surveillance provides comparable data for monitoring disease trends in breakthrough and moderate-to-severe varicella. To further improve passive surveillance in the two-dose-varicella vaccine era, jurisdictions should consider conducting periodic enhanced surveillance, encouraging laboratory testing, and collecting additional varicella-specific variables for passive surveillance. |
Completion of advance directives among U.S. consumers
Rao JK , Anderson LA , Lin FC , Laux JP . Am J Prev Med 2014 46 (1) 65-70 BACKGROUND: Current, ongoing national surveys do not include questions about end-of-life (EOL) issues. In particular, population-based data are lacking regarding the factors associated with advance directive completion. PURPOSE: To characterize U.S. adults who did and did not have an advance directive and examine factors associated with their completion, such as the presence of a chronic condition and regular source of health care. METHODS: Data were analyzed in 2013 from adults aged 18 years and older who participated in the 2009 or 2010 HealthStyles Survey, a mail panel survey designed to be representative of the U.S. population. Likelihood ratio tests were used to examine the associations between advance directive completion and demographic and socioeconomic variables (education, income, employment status); presence of a chronic condition; regular source of health care; and self-reported EOL concerns or discussions. Multiple logistic regression analyses identified independent predictors related to advance directive completion. RESULTS: Of the 7946 respondents, 26.3% had an advance directive. The most frequently reported reason for not having one was lack of awareness. Advance directive completion was associated with older age, more education, and higher income and was less frequent among non-white respondents. Respondents with advance directives also were more likely to report having a chronic disease and a regular source of care. Advance directives were less frequent among those who reported not knowing if they had an EOL concern. CONCLUSIONS: These data indicate racial and educational disparities in advance directive completion and highlight the need for education about their role in facilitating EOL decisions. |
Data harmonization process for creating the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Atlas
Elmore K , Nelson R , Gant Z , Jeffries C , Broeker L , Mirabito M , Roberts H . Public Health Rep 2014 129 63-69 In 2009, the CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) initiated the online, interactive NCHHSTP Atlas. The goal of the Atlas is to strengthen the capacity to monitor the diseases overseen by NCHHSTP and to illustrate demographic, spatial, and temporal variation in disease patterns. The Atlas includes HIV, AIDS, viral hepatitis, sexually transmitted disease, and tuberculosis surveillance data, and aims to provide a single point of access to meet the analytical and data dissemination needs of NCHHSTP. To accomplish this goal, an NCHHSTP-wide Data Harmonization Workgroup reviewed surveillance data collected by each division to harmonize the data across diseases, allowing one to query data and generate comparable maps and tables via the same user interface. Although we were not able to harmonize all data elements, data standardization is necessary and work continues toward that goal. |
Surveillance for respiratory infections in low- and middle-income countries: experience from the Centers for Disease Control and Prevention's Global Disease Detection International Emerging Infections Program
Breiman RF , Van Beneden CA , Farnon EC . J Infect Dis 2013 208 Suppl 3 S167-72 In 2001 with its first International Emerging Infections Program (IEIP) established in Bangkok, Thailand, the Centers for Disease Control and Prevention (CDC) began building capacity in strategically located countries for infectious disease surveillance, diagnostics, epidemic detection and response, and collection of epidemiologic data to drive policy on prevention and control of priority infectious diseases. The vision of establishing programs that focus on emerging infectious disease detection and response evolved into what are now called Global Disease Detection (GDD) Regional Centers. The GDD program was established in 2004 to provide support for the CDC's international programs and was expanded to include the IEIP and other programs as part of the GDD Regional Centers when CDC's Center for Global Health was established in 2010 [1]. The GDD Program builds global capacity to identify and respond to emerging diseases, and to conduct applied public health research on disease prevention and control [2]. The GDD Centers include 6 programs that support their host countries in building capacity to comply with the Revised International Health Regulations (IHR 2005). The 3 core programs are the International Emerging Infections Program, the cornerstone of the GDD Centers that serves as a platform to study emerging diseases and their prevention and control; the Field Epidemiology Training Program, which trains scientists in applied epidemiology and public health laboratory science; and the Influenza Program, which supports detection and response for seasonal and pandemic influenza. The remaining 3 GDD programs include the One Health Program, integrating animal and human health investigations of zoonotic diseases; the Strengthening Laboratory Capacity Program; and the Risk Communication and Emergency Response Program, supporting health communication and helping countries establish infrastructure for Emergency Operations Centers and systems. Some GDD Centers additionally have a Refugee Health Program that works closely with IEIP and other GDD programs. |
Unraveling R0: considerations for public health applications
Ridenhour B , Kowalik JM , Shay DK . Am J Public Health 2013 104 (2) e32-41 We assessed public health use of R0, the basic reproduction number, which estimates the speed at which a disease is capable of spreading in a population. These estimates are of great public health interest, as evidenced during the 2009 influenza A (H1N1) virus pandemic. We reviewed methods commonly used to estimate R0, examined their practical utility, and assessed how estimates of this epidemiological parameter can inform mitigation strategy decisions. In isolation, R0 is a suboptimal gauge of infectious disease dynamics across populations; other disease parameters may provide more useful information. Nonetheless, estimation of R0 for a particular population is useful for understanding transmission in the study population. Considered in the context of other epidemiologically important parameters, the value of R0 may lie in better understanding an outbreak and in preparing a public health response. |
Blood lead level association with lower body weight in NHANES 1999-2006
Scinicariello F , Buser MC , Mevissen M , Portier CJ . Toxicol Appl Pharmacol 2013 273 (3) 516-23 BACKGROUND: Lead exposure is associated with low birth-weight. The objective of this study is to determine whether lead exposure is associated with lower body weight in children, adolescents and adults. METHODS: We analyzed data from NHANES 1999-2006 for participants aged ≥3 using multiple logistic and multivariate linear regression. Using age- and sex-standardized BMI Z-scores, overweight and obese children (ages 3-19) were classified by BMI ≥85th and ≥95th percentiles, respectively. The adult population (age ≥20) was classified as overweight and obese with BMI measures of 25-29.9 and ≥30, respectively. Blood lead level (BLL) was categorized by weighted quartiles. RESULTS: Multivariate linear regressions revealed a lower BMI Z-score in children and adolescents when the highest lead quartile was compared to the lowest lead quartile (beta (SE)=-0.33 (0.07), p<0.001), and a decreased BMI in adults (beta (SE)=-2.58 (0.25), p<0.001). Multiple logistic analyses in children and adolescents found a negative association between BLL and the percentage of obese and overweight with BLL in the highest quartile compared to the lowest quartile (OR=0.42, 95% CI: 0.30-0.59; and OR=0.67, 95% CI: 0.52-0.88, respectively). Adults in the highest lead quartile were less likely to be obese (OR=0.42, 95% CI: 0.35-0.50) compared to those in the lowest lead quartile. Further analyses with blood lead as restricted cubic splines, confirmed the dose-relationship between blood lead and body weight outcomes. CONCLUSIONS: BLLs are associated with lower body mass index and obesity in children, adolescents and adults. |
Detection of human enteroviruses and parechoviruses as part of the national enterovirus surveillance in the Netherlands, 1996-2011
van der Sanden SM , Koopmans MP , van der Avoort HG . Eur J Clin Microbiol Infect Dis 2013 32 (12) 1525-31 Laboratories of the Dutch Working Group on Clinical Virology have routinely performed enterovirus diagnostics in the Netherlands since the early 1960s, with country-wide coverage. Enterovirus-positive samples are typed for clinical and epidemiological purposes, as well as to document the absence of poliovirus circulation. Human parechoviruses 1 and 2, initially recognized as enteroviruses, and since 2006 also the higher numbered human parechovirus types, have been detected as part of this surveillance. The purpose of this report is to describe the national enterovirus surveillance data from stool specimens collected in the Netherlands between 1996 and 2011 by all the participating laboratories. Since 2007, the average annual percentage of human enterovirus- and parechovirus-positive specimens increased from 6.5 to 10.8 % and from 0.3 to 2.5 % of the total numbers of specimens tested, respectively, following a gradual implementation of molecular diagnostics directly on clinical samples. Increased detection rates were observed for human enterovirus species A coxsackieviruses (from 0.1 to 0.5 %). Human enteroviruses of species B, C, and D were detected at average rates of 4.7, 0.04, and 0.005 %, respectively. The introduction of molecular diagnostics also resulted in an increase in the number of untyped enterovirus-positive specimens for which the presence of poliovirus was not excluded (from 1.3 to 3.1 % since 2007). To increase knowledge on human entero- and parechovirus epidemiology and type-specific pathogenesis, as well as to warrant the quality of the poliovirus surveillance in the Netherlands, it is of importance to continue the typing of enterovirus- and parechovirus-positive samples. |
Ciguatera and scombroid fish poisoning in the United States
Pennotti R , Scallan E , Backer L , Thomas J , Angulo FJ . Foodborne Pathog Dis 2013 10 (12) 1059-66 BACKGROUND: Ciguatera and scombroid fish poisonings are common causes of fish-related foodborne illness in the United States; however, existing surveillance systems underestimate the overall human health impact. OBJECTIVES: This study aimed to describe existing data on ciguatera and scombroid fish poisonings from outbreak and poison control center reports and to estimate the overall number of ciguatera and scombroid fish-poisoning illnesses, hospitalizations, and deaths in the United States. METHODS: We analyzed outbreak data from the Foodborne Disease Outbreak Surveillance Systems (FDOSS) from 2000 to 2007 and poison control center call data from the National Poison Data System (NPDS) from 2005 to 2009 for reports of ciguatera and scombroid fish poisonings. Using a statistical model with many inputs, we adjusted the outbreak data for undercounting due to underreporting and underdiagnosis to generate estimates. Underreporting and underdiagnosis multipliers were derived from the poison control call data and the published literature. RESULTS: Annually, an average of 15 ciguatera and 28 scombroid fish-poisoning outbreaks, involving a total of 60 and 108 ill persons, respectively, were reported to FDOSS (2000-2007). NPDS reported an average of 173 exposure calls for ciguatoxin and 200 exposure calls for scombroid fish poisoning annually (2005-2009). After adjusting for undercounting, we estimated 15,910 (90% credible interval [CrI] 4140-37,408) ciguatera fish-poisoning illnesses annually, resulting in 343 (90% CrI 69-851) hospitalizations and three deaths (90% CrI 1-7). We estimated 35,142 (90% CrI: 10,496-78,128) scombroid fish-poisoning illnesses, resulting in 162 (90% CrI 0-558) hospitalizations and 0 deaths. CONCLUSIONS: Ciguatera and scombroid fish poisonings affect more Americans than reported in surveillance systems. Although additional data can improve these assessments, the estimated number of illnesses caused by seafood intoxication illuminates this public health problem. Efforts, including education, can reduce ciguatera and scombroid fish poisonings. |
Rotavirus G and P types circulating in the eastern region of Kenya: predominance of G9 and emergence of G12 genotypes.
Kiulia NM , Nyaga MM , Seheri ML , Wolfaardt M , van Zyl WB , Esona MD , Irimu G , Inoti M , Gatinu BW , Njenga PK , Taylor MB , Nyachieo A . Pediatr Infect Dis J 2014 33 Suppl 1 S85-8 BACKGROUND: The World Health Organization has recommended that rotavirus (RV) vaccines be included in all national immunization programs as part of a strategy to control RV-associated diarrheal diseases. Hospital-based surveillance of RV infection is therefore crucial in monitoring the impact pre- and post-vaccine introduction and also to document changes in genotype distribution. This study sought to determine the RV genotypes circulating in the eastern region of Kenya before introduction of the RV vaccine. METHODS: During September 2009 to August 2011, 500 stool samples were collected from children <5 years of age admitted for acute diarrhea in hospitals in the eastern region of Kenya and analyzed for the presence of group A RV using an enzyme immunoassay. G and P genotypes were determined using hemi-nested reverse transcriptase polymerase chain reaction. RESULTS: One hundred and eighty nine out of 500 (38%) samples analyzed were positive for rotavirus. The following G types were detected: G9 (50.9%), G1 (26.8%), G8 (12.1%), G12 (3.1%), G2 (0.6%), mixed G (1.3%) and 5.1% were G nontypeable. P types detected included: P[8] (63.7%), P[4] (12.1%), P[6] (4.5%), mixed P (7.6%) and 12.1% were P nontypeable. The most dominant strain was G9P[8] (35%), followed by G1P[8] (26.8%), G8P[4] (9.6%), G12P[6] (2.5%), G9P[6] (1.9%), G9P[4] (1.3%), G8P[8] (1.3%), and G2P[4] (0.6%). CONCLUSIONS: The present study demonstrates the recurring changing genotypes of RV circulating in Kenya, with genotypes G9, G1 and G8 being the dominant strains circulating in the eastern region of Kenya between 2009 and 2011. Additionally, G12 genotype was detected for the first time in Kenya. |
Mutation analysis of a cohort of US patients with hemophilia B.
Li T , Miller CH , Driggers J , Payne AB , Ellingsen D , Hooper WC . Am J Hematol 2013 89 (4) 375-9 Hemophilia B (HB) is a disorder resulting from genetic mutations in the Factor 9 gene (F9). Genotyping of HB patients is important for genetic counseling and patient management. Here we report a study of mutations identified in a large sample of HB patients in the US. Patients were enrolled through an inhibitor surveillance study at 17 hemophilia treatment centers (HTCs). A total of 87 unique mutations were identified from 225 of the 226 patients, including deletions, insertions, and point mutations. Point mutations were distributed throughout the F9 gene and were found in 86% of the patients. Of these mutations, 24 were recurrent in the population, and 3 of them (c.316G>A, c.1025C>T and c.1328T>A) accounted for 84 patients (37.1%). Haplotype analysis revealed that the high recurrence arose from a founder effect. The severity of HB was found to correlate with the type of mutation. Inhibitors developed only in severe cases with large deletions and nonsense mutations. None of the mild or moderate patients developed inhibitors. Our results provide a resource describing F9 mutations in US HB patients and confirm previous findings that patients bearing large deletions and nonsense mutations are at high risk of developing inhibitors. |
Full-length genome characterization and genetic relatedness analysis of hepatitis A virus outbreak strains associated with acute liver failure among children.
Vaughan G , Forbi JC , Xia GL , Fonseca-Ford M , Vazquez R , Khudyakov YE , Montiel S , Waterman S , Alpuche C , Goncalves Rossi LM , Luna N . J Med Virol 2014 86 (2) 202-8 Clinical infection by hepatitis A virus (HAV) is generally self-limited but in some cases can progress to liver failure. Here, an HAV outbreak investigation among children with acute liver failure in a highly endemic country is presented. In addition, a sensitive method for HAV whole genome amplification and sequencing suitable for analysis of clinical samples is described. In this setting, two fatal cases attributed to acute liver failure and two asymptomatic cases living in the same household were identified. In a second household, one HAV case was observed with jaundice which resolved spontaneously. Partial molecular characterization showed that both households were infected by HAV subtype IA; however, the infecting strains in the two households were different. The HAV outbreak strains recovered from all cases grouped together within cluster IA1, which contains closely related HAV strains from the United States commonly associated with international travelers. Full-genome HAV sequences obtained from the household with the acute liver failure cases were related (genetic distances ranging from 0.01% to 0.04%), indicating a common-source infection. Interestingly, the strain recovered from the asymptomatic household contact was nearly identical to the strain causing acute liver failure. The whole genome sequence from the case in the second household was distinctly different from the strains associated with acute liver failure. Thus, infection with almost identical HAV strains resulted in drastically different clinical outcomes. |
Replacement and positive evolution of subtype A and B respiratory syncytial virus g-protein genotypes from 1997-2012 in South Africa
Pretorius MA , van Niekerk S , Tempia S , Moyes J , Cohen C , Madhi SA , Venter M . J Infect Dis 2013 208 Suppl 3 S227-37 BACKGROUND: Of the respiratory syncytial virus (RSV) genotypes previously described in South Africa during 1997-2002, only GA2 and GA5 persisted until 2006, with BA having replaced all previous RSV-B genotypes. This poses the question whether RSV-A is more stable than RSV-B and whether positive selection drives evolution of genotypes. METHODS: RSV-positive specimens were randomly selected during 2009-2012, subtyped, sequenced, and compared to RSV recovered from specimens obtained during 1997-2001 and 2006-2009. Bayesian phylogenetic analysis was performed on the G-protein. RESULTS: Phylogenetic analysis indicated that RSV-A genotype GA2 dissolved to form SAA2 (unique to South Africa), NA1 and NA2 (identified in Japan), and ON1 (identified in Canada and having a 72-bp insertion) and that GA5 drifted from 1999-2012 to form 3 subgenotypes (GA5 I-III). RSV-B genotypes all had the 60-bp insertion typical of BA genotypes but clustered into subgenotypes BA8-10. Positive selection was identified in the G-protein of both subtypes, but RSV-A's rate of evolution was slower than that of RSV-B, with the most recent common ancestors dating from 1945 and 1951, respectively. Seven new positively selected sites were identified in South African strains, 2 for RSV-A and 5 for RSV-B. CONCLUSION: Positive selection drove both RSV-A and -B genotypes to evolve, resulting in replacement of all genotypes over the 15-year study period in South Africa. |
DNA-DNA hybridization study of strains of Chryseobacterium, Elizabethkingia and Empedobacter and of other usually indole-producing non-fermenters of CDC groups IIc, IIe, IIh and IIi, mostly from human clinical sources, and proposals of Chryseobacterium bernardetii sp. nov., Chryseobacterium carnis sp. nov., Chryseobacterium lactis sp. nov., Chryseobacterium nakagawai sp. nov. and Chryseobacterium taklimakanense comb. nov
Holmes B , Steigerwalt AG , Nicholson AC . Int J Syst Evol Microbiol 2013 63 4639-62 The taxonomic classification of 182 phenotypically similar isolates was evaluated using DNA-DNA hybridization and 16S rRNA gene sequence analysis. These bacterial isolates were mainly derived from clinical sources; all were Gram-negative non-fermenters and most were indole-producing. Phenotypically, they resembled species from the genera Chryseobacterium, Elizabethkingia or Empedobacter or belonged to CDC groups IIc, IIe, IIh and IIi. Based on these analyses, four novel species are described: Chryseobacterium bernardetii sp. nov. (type strain NCTC 13530(T) = CCUG 60564(T) = CDC G229(T)), Chryseobacterium carnis sp. nov. (type strain NCTC 13525(T) = CCUG 60559(T) = CDC G81(T)), Chryseobacterium lactis sp. nov. (type strain NCTC 11390(T) = CCUG 60566(T) = CDC KC1864(T)) and Chryseobacterium nakagawai sp. nov. (type strain NCTC 13529(T) = CCUG 60563(T) = CDC G41(T)). The new combination Chryseobacterium taklimakanense comb. nov. (type strain NCTC 13490(T) = X-65(T) = CCTCC AB 208154(T) = NRRL B-51322(T)) is also proposed to accommodate the reclassified Planobacterium taklimakanense. |
Substance use and sexual risk behaviors among American Indian and Alaska Native high school students
de Ravello L , Everett Jones S , Tulloch S , Taylor M , Doshi S . J Sch Health 2014 84 (1) 25-32 BACKGROUND: We describe the prevalence of behaviors that put American Indian and Alaska Native (AI/AN) high school students at risk for teen pregnancy and sexually transmitted infections (STIs) and the relationships among race/ethnicity and these behaviors. METHODS: We analyzed merged 2007 and 2009 data from the national Youth Risk Behavior Survey, a biennial, self-administered, school-based survey of US students in grades 9-12 (N = 27,912). Prevalence estimates and logistic regression, controlling for sex and grade, were used to examine the associations between race/ethnicity, and substance use, and sexual risk behaviors. RESULTS: Of the 26 variables studied, the adjusted odds ratios (AOR) were higher among AI/AN than White students for 18 variables (ranging from 1.4 to 2.3), higher among AI/AN than Black students for 13 variables (ranging from 1.4 to 4.2), and higher among AI/AN than Hispanic students for 5 variables (ranging from 1.4 to 1.5). Odds were lower among AI/AN than Black students for many of the sexual risk-related behaviors. CONCLUSIONS: The data suggest it is necessary to develop targeted, adolescent-specific interventions aimed at reducing behaviors that put AI/AN high school students at risk for teen pregnancy, STI/HIV, and other health conditions. |
Men at risk; a qualitative study on HIV risk, gender identity and violence among men who have sex with men who report high risk behavior in Kampala, Uganda
King R , Barker J , Nakayiwa S , Katuntu D , Lubwama G , Bagenda D , Lane T , Opio A , Hladik W . PLoS One 2013 8 (12) e82937 In Uganda, men who have sex with men (MSM) are at high risk for HIV. Between May 2008 and February 2009 in Kampala, Uganda, we used respondent driven sampling (RDS) to recruit 295 MSM≥18 years who reported having had sex with another man in the preceding three months. The parent study conducted HIV and STI testing and collected demographic and HIV-related behavioral data through audio computer-assisted self-administered interviews. We conducted a nested qualitative sub-study with 16 men purposively sampled from among the survey participants based on responses to behavioral variables indicating higher risk for HIV infection. Sub-study participants were interviewed face-to-face. Domains of inquiry included sexual orientation, gender identity, condom use, stigma, discrimination, violence and health seeking behavior. Emergent themes included a description of sexual orientation/gender identity categories. All groups of men described conflicting feelings related to their sexual orientation and contextual issues that do not accept same-sex identities or behaviors and non-normative gender presentation. The emerging domains for facilitating condom use included: lack of trust in partner and fear of HIV infection. We discuss themes in the context of social and policy issues surrounding homosexuality and HIV prevention in Uganda that directly affect men's lives, risk and health-promoting behaviors. |
Overview of the CDC Cervical Cancer (Cx3) Study: an educational intervention of HPV testing for cervical cancer screening
Benard VB , Saraiya M , Greek A , Hawkins NA , Roland KB , Manninen D , Ekwueme DU , Miller JW , Unger ER . J Womens Health (Larchmt) 2013 23 (3) 197-203 BACKGROUND: The recommended screening interval when using the Papanicolaou (Pap) and human papillomavirus (HPV) test (co-testing) is 5 years. However because providers are reluctant to extend the screening interval, we launched a study to identify barriers to appropriate use of the co-test and to implement an educational intervention to promote evidence-based screening practices. This article provides an overview of the study including the multi-component intervention and participant demographics. METHODS: The study was conducted in 15 clinics associated with 6 Federally Qualified Health Centers (FQHCs) in Illinois. Each clinic received HPV tests to administer with routine Pap tests among enrolled patients (n=2,246) and was assigned to a study arm: intervention arm (n=7) received a multi-component educational intervention (small media, academic detailing, and website) for providers and printed educational materials for patients, and control arm (n=8) received printed copies of general guidelines. Clinic coordinators (n=15), providers (n=98), and patients (n=984) completed baseline surveys to assess screening practices. RESULTS: Providers reported an average age of 41.3 years and were predominately female, non-Hispanic, and white. Patients reported an average age of 45.0 years and nearly two-thirds were Hispanic or black. Of the 2,246 patients, 89% had a normal co-test. Lessons learned from the study included the importance of buy-in at a high level in the organization, a champion provider, and a clinical coordinator devoted to the study. CONCLUSION: Materials from this study can be adapted to educate providers and patients on appropriate use of the co-test and encourage extended screening intervals as a safe and effective practice. |
How many "get screened" messages does it take? evidence from colorectal cancer screening promotion in the United States, 2012
Cooper CP , Gelb CA , Hawkins NA . Prev Med 2013 60 27-32 OBJECTIVE: Colorectal cancer screening has been widely promoted in the United States. We investigated the association between reported exposure to screening information during the past year and screening participation and knowledge. METHOD: Data from the 2012 HealthStyles Fall survey of U.S. adults were examined using adjusted logistic regression to examine the frequency of exposure to screening information as a predictor of screening participation and knowledge; analyses were limited to participants aged ≥50 years with no history of colorectal cancer or polyps (N=1,714). RESULTS: Nearly half of participants (44.9%) reported exposure to colorectal cancer screening information during the previous year. The most common sources of screening information were news reports, advertisements, and health care providers. Screening participation and knowledge consistently increased with the reported frequency of exposure to screening information, and these associations generally persisted when demographic variables were controlled. Compared with unexposed participants, significant gains in screening participation were associated with exposure to screening information 2-3 times (Adj. OR= 1.84, p=0.001), 4-9 times (Adj. OR= 2.00, p=0.001), and ≥10 times (Adj. OR= 3.03, p<0.001) in the adjusted model. CONCLUSIONS: Increasing public exposure to screening promotion messages may augment screening participation and knowledge. |
Three cases of donor-derived pulmonary tuberculosis in lung transplant recipients and review of 12 previously reported cases: opportunities for early diagnosis and prevention
Mortensen E , Hellinger W , Keller C , Cowan LS , Shaw T , Hwang S , Pegues D , Ahmedov S , Salfinger M , Bower WA . Transpl Infect Dis 2014 16 (1) 67-75 INTRODUCTION: Solid organ transplant recipients have a higher frequency of tuberculosis (TB) than the general population, with mortality rates of approximately 30%. Although donor-derived TB is reported to account for <5% of TB in solid organ transplants, the source of Mycobacterium tuberculosis infection is infrequently determined. METHODS: We report 3 new cases of pulmonary TB in lung transplant recipients attributed to donor infection, and review the 12 previously reported cases to assess whether cases could have been prevented and whether any cases that might occur in the future could be detected and investigated more quickly. Specifically, we evaluate whether opportunities existed to determine TB risk on the basis of routine donor history, to expedite diagnosis through routine mycobacterial smears and cultures of respiratory specimens early post transplant, and to utilize molecular tools to investigate infection sources epidemiologically. FINDINGS: On review, donor TB risk was present among 7 cases. Routine smears and cultures diagnosed 4 asymptomatic cases. Genotyping was used to support epidemiologic findings in 6 cases. CONCLUSION: Validated screening protocols, including microbiological testing and newer technologies (e.g., interferon-gamma release assays) to identify unrecognized M. tuberculosis infection in deceased donors, are warranted. |
Diarrheal illness among US residents providing medical services in Haiti during the cholera epidemic, 2010 to 2011
Schilling KA , Cartwright EJ , Stamper J , Locke M , Esposito DH , Balaban V , Mintz E . J Travel Med 2014 21 (1) 55-7 Although nosocomial transmission of cholera is rare, two US healthcare workers (HCW) became ill with cholera after providing medical services during the Haiti cholera epidemic. To assess the incidence of diarrheal illness and explore preventive health behaviors practiced by US residents who provided medical services in Haiti, we conducted a cross-sectional, anonymous, web-based survey. We e-mailed 896 participants from 50 US-based, health-focused non-governmental organizations (NGOs), of whom 381 (43%) completed the survey. Fifty-six percent of respondents (n = 215) reported providing some care for patients with cholera. Diarrhea was reported by 31 (8%) respondents. One person was diagnosed with cholera by serologic testing. NGOs responding to international emergencies should ensure ample access to basic hygiene supplies and should promote their use to reduce the incidence of diarrheal illness among HCW working overseas. |
Report of the 13th vancomycin-resistant Staphylococcus aureus from the United States
Limbago BM , Kallen AJ , Zhu W , Eggers P , McDougal LK , Albrecht VS . J Clin Microbiol 2013 52 (3) 998-1002 Vancomycin-resistant Staphylococcus aureus (VRSA), important multidrug-resistant organisms of public health concern, have been infrequently identified in the United States since 2002. All previous VRSA belonged to clonal complex 5, a lineage associated primarily with healthcare. This report describes the most recent (13th) U.S. VRSA; the first in a community strain. |
Microbial biofilms on needleless connectors for central venous catheters: a comparison of standard and silver-coated devices collected from patients in an acute care hospital
Perez E , Williams M , Jacob JT , Reyes MD , Chernetsky Tejedor S , Steinberg JP , Rowe L , Ganakammal SR , Changayil S , Weil MR , Donlan RM . J Clin Microbiol 2013 52 (3) 823-31 Microorganisms may colonize needleless connectors (NCs) on intravascular catheters, forming biofilms and predisposing patients to catheter- associated infection (CAI). Standard and silver-coated NCs were collected from catheterized intensive care unit patients to characterize biofilm formation using culture-dependent and culture-independent methods and to investigate association between NC usage and biofilm characteristics. Viable microorganisms were detected by plate count (PC) from 46% of standard and 59% of silver-coated NCs (p=0.11). There were no significant associations (p>0.05, chi-squared test) between catheter type, side of catheter placement, number of catheter lumens, site of catheter placement, or NC duration, and positive NC. There was an association (p=0.04, chi-squared test) between infusion type and positive standard NCs. Viable microorganisms exhibiting intracellular esterase activity were detected on >90% of both NC types (p=0.751), suggesting that a large percentage of organisms were not culturable using the conditions provided in this study. Amplification of the 16S ribosomal RNA gene from selected NCs provided a substantially larger number of operational taxonomic units per NC than PC (26-43 vs 1-4), suggesting that culture-dependent methods may substantially underestimate microbial diversity on NCs. NC bacterial communities were clustered by patient and venous access type and may reflect the composition of the patient's local microbiome but may also contain organisms from the healthcare environment. NCs provide a portal of entry for a wide diversity of opportunistic pathogens to colonize the catheter lumen, forming a biofilm and increasing the potential for CAI, highlighting the importance of catheter maintenance practices to reduce microbial contamination. |
Molecular characterization of Staphylococcus aureus and influenza virus coinfections in patients with fatal pneumonia
Denison AM , Deleon-Carnes M , Blau DM , Shattuck EC , McDougal LK , Rasheed JK , Limbago BM , Zaki SR , Paddock CD . J Clin Microbiol 2013 51 (12) 4223-5 Molecular techniques were used to characterize genetic features of Staphylococcus aureus in 66 fatal cases of pneumonia caused by S. aureus and influenza A or B viruses. Nucleic acids were extracted from formalin-fixed, paraffin-embedded tissues. The majority of cases revealed genetic markers for Panton-Valentine leukocidin, mecA, and spa type t008. |
Executive summary: developing a new, national approach to surveillance for ventilator-associated events
Magill SS , Klompas M , Balk R , Burns SM , Deutschman CS , Diekema D , Fridkin S , Greene L , Guh A , Gutterman D , Hammer B , Henderson D , Hess DR , Hill NS , Horan T , Kollef M , Levy M , Septimus E , Vanantwerpen C , Wright D , Lipsett P . Ann Am Thorac Soc 2013 10 (6) S220-3 In September 2011, the CDC convened a Ventilator-Associated Pneumonia (VAP) Surveillance Definition Working Group to organize a formal process for leaders and experts of key stakeholder organizations to discuss the challenges of VAP surveillance definitions and to propose new approaches to VAP surveillance in adult patients (Table 1). The charges to the Working Group were to: | Critically review a draft, streamlined VAP surveillance definition developed for use in adult patients; Suggest modifications to enhance the reliability and credibility of the surveillance definition within the critical care and infection prevention communities; Propose a final adult surveillance definition algorithm, to be implemented in the CDC’s National Healthcare Safety Network (NHSN), taking into consideration the potential future use of the definition algorithm in public reporting, interfacility comparisons, and pay-for-reporting and pay-for-performance programs. |
Clonally related Burkholderia contaminans among ventilated patients without cystic fibrosis
Peterson AE , Chitnis AS , Xiang N , Scaletta JM , Geist R , Schwartz J , Dement J , Lawlor E , Lipuma JJ , O'Connell H , Noble-Wang J , Kallen AJ , Hunt DC . Am J Infect Control 2013 41 (12) 1298-300 We investigated a cluster of 10 Burkholderia cepacia complex-positive cultures among ventilated patients and those with a tracheostomy in an acute care hospital. Isolates from 5 patients had outbreak-strain-related Burkholderia contaminans. Isolates of B. cepacia complex unrelated to the outbreak strain were cultured from a sink drain. The investigation identified practices that might have led to contamination of patient respiratory care supplies with tap water, which might have contributed to the cluster. |
Seasonal influenza vaccination at school: a randomized controlled trial
Humiston SG , Schaffer SJ , Szilagyi PG , Long CE , Chappel TR , Blumkin AK , Szydlowski J , Kolasa MS . Am J Prev Med 2014 46 (1) 1-9 BACKGROUND: Influenza vaccination coverage for U.S. school-aged children is below the 80% national goal. Primary care practices may not have the capacity to vaccinate all children during influenza vaccination season. No real-world models of school-located seasonal influenza (SLV-I) programs have been tested. PURPOSE: Determine the feasibility, sustainability, and impact of an SLV-I program providing influenza vaccination to elementary school children during the school day. DESIGN: In this pragmatic randomized controlled trial of SLV-I during two vaccination seasons, schools were randomly assigned to SLV-I versus standard of care. Seasonal influenza vaccine receipt, as recorded in the state immunization information system (IIS), was measured. SETTING/PARTICIPANTS: Intervention and control schools were located in a single western New York county. Participation (intervention or control) included the sole urban school district and suburban districts (five in Year 1, four in Year 2). INTERVENTION: After gathering parental consent and insurance information, live attenuated and inactivated seasonal influenza vaccines were offered in elementary schools during the school day. MAIN OUTCOME MEASURES: Data on receipt of ≥1 seasonal influenza vaccination in Year 1 (2009-2010) and Year 2 (2010-2011) were collected on all student grades K through 5 at intervention and control schools from the IIS in the Spring of 2010 and 2011, respectively. Additionally, coverage achieved through SLV-I was compared to coverage of children vaccinated elsewhere. Preliminary data analysis for Year 1 occurred in Spring 2010; final quantitative analysis for both years was completed in late Fall 2012. RESULTS: Results are shown for 2009-2010 and 2010-2011, respectively: Children enrolled in suburban SLV-I versus control schools had vaccination coverage of 47% vs 36%, and 52% vs 36% (p<0.0001 both years). In urban areas, coverage was 36% vs 26%, and 31% vs 25% (p<0.001 both years). On multilevel logistic analysis with three nested levels (student, school, school district) during both vaccination seasons, children were more likely to be vaccinated in SLV-I versus control schools; ORs were 1.6 (95% CI=1.4, 1.9; p<0.001) and 1.5 (95% CI=1.3, 1.8; p<0.001). CONCLUSIONS: Delivering influenza vaccine during school is a promising approach to improving pediatric influenza vaccination coverage. TRIAL REGISTRY: ClinicalTrials.govNCT01224301. |
Systematic review of the effect of pneumococcal conjugate vaccine dosing schedules on immunogenicity
Deloria Knoll M , Park DE , Johnson TS , Chandir S , Nonyane BA , Conklin L , Fleming-Dutra KE , Loo JD , Goldblatt D , Whitney CG , O'Brien KL . Pediatr Infect Dis J 2014 33 Suppl 2 S119-29 BACKGROUND: Despite the breadth of studies demonstrating benefits of pneumococcal conjugate vaccine (PCV), uncertainty remains regarding the optimal PCV dosing schedule in infants. METHODS: We conducted a systematic literature review of PCV immunogenicity published from 1994 to 2010 (supplemented post hoc with studies from 2011). Studies included for analysis evaluated ≥2 doses of 7-valent or higher product (excluding Aventis-Pasteur PCV11) administered to nonhigh-risk infants ≤6 months of age. Impact of PCV schedule on geometric mean antibody concentration (GMC) and proportion of subjects over 0.35 mcg/mL were assessed at various time points; the GMC 1 month postdose 3 (for various dosing regimens) for serotypes 1, 5, 6B, 14, 19F and 23F was assessed in detail using random effects linear regression, adjusted for product, acellular diphtheria-tetanus-pertussis/whole-cell diphtheria- tetanus-pertussis coadministration, laboratory method, age at first dose and geographic region. RESULTS: From 61 studies, we evaluated 13 two-dose (2+0) and 65 three-dose primary schedules (3+0) without a booster dose, 11 "2+1" (2 primary plus booster) and 42 "3+1" schedules. The GMC after the primary series was higher following 3-dose schedules compared with 2-dose schedules for all serotypes except for serotype 1. Pre- and postbooster GMCs were generally similar regardless of whether 2 or 3 primary doses were given. GMCs were significantly higher for all serotypes when dose 3 was administered in the second year (2+1) compared with ≤6 months of age (3+0). CONCLUSIONS: While giving the third dose in the second year of life produces a higher antibody response than when given as part of the primary series in the first 6 months, the lower GMC between the 2-dose primary series and booster may result in less disease protection for infants in that interval than those who completed the 3-dose primary series. Theoretical advantages of higher antibodies induced by giving the third dose in the second year of life, such as increased protection against serotype 1 disease, longer duration of protection or more rapid induction of herd effects, need to be evaluated in practice. |
Systematic review of the effect of pneumococcal conjugate vaccine dosing schedules on prevention of pneumonia
Loo JD , Conklin L , Fleming-Dutra KE , Deloria Knoll M , Park DE , Kirk J , Goldblatt D , O'Brien KL , Whitney CG . Pediatr Infect Dis J 2014 33 Suppl 2 S140-51 BACKGROUND: Pneumonia is the leading cause of morbidity and mortality among children <5 years of age globally. Pneumococcal conjugate vaccines (PCVs) are known to provide protection against vaccine serotype pneumococcal pneumonia; uncertainty exists regarding the optimum PCV dosing schedule. METHODS: We conducted a systematic review of studies published from 1994 to 2010 (supplemented post hoc with studies from 2011) documenting the effect of PCV dosing schedules on clinical and radiologically confirmed pneumonia, pneumococcal pneumonia and empyema among children of ages targeted to receive vaccine. Data on 2- and 3-dose schedules were included. Percent change of pneumonia incidence rates from baseline to most recent year post-PCV introduction was calculated. RESULTS: We identified 42 primary citations that evaluated PCV schedules and pneumonia. Thirty-seven (88%) were from North America, Europe or Australia; 37 (88%) evaluated PCV7 and 1 (2%) PCV10. Two studies (both observational) compared multiple schedules within the study. We found evidence of reduced clinical and radiologically confirmed pneumonia incidence for all schedules, including 2+1 (1 nonrandomized trial, 5 observational studies), 3+0 (5 randomized trials, 2 observational studies) and 3+1 (5 clinical trials, 24 observational studies) schedules. The magnitude of disease impact did not differ among schedules. Evidence for impact on pneumococcal pneumonia and empyema varied. CONCLUSIONS: All schedules (2+1, 3+0 and 3+1) reduced clinical and radiologically confirmed pneumonia. Quantifying differences in pneumonia disease impact between schedules was difficult due to heterogeneity among studies in design, case definition and population. These findings support World Health Organization recommendations for 3-dose schedules administered as either 3+0 or 2+1 regimens. Pneumonia impact data are still needed on expanded serotype PCV products, developing country settings and the role for a booster dose. |
Systematic review of the effect of pneumococcal conjugate vaccine dosing schedules on vaccine-type invasive pneumococcal disease among young children
Conklin L , Loo JD , Kirk J , Fleming-Dutra KE , Deloria Knoll M , Park DE , Goldblatt D , O'Brien KL , Whitney CG . Pediatr Infect Dis J 2014 33 Suppl 2 S109-18 BACKGROUND: Pneumococcal conjugate vaccines (PCV) are being implemented globally using a variety of different schedules. The optimal schedule to maximize protection of vaccinated children against vaccine-type invasive pneumococcal disease (VT-IPD) is not known. METHODS: To assess the relative benefit of various PCV dosing schedules, we conducted a systematic review of studies published in English from 1994 to 2010 (supplemented post hoc with studies from 2011) on PCV effectiveness against VT-IPD among children targeted to receive vaccine. Data on 2-dose and 3-dose primary series, both with and without a booster ("2+0," "2+1," "3+0" and "3+1"), were included. For observational studies using surveillance data or case counts, we calculated percentage reduction in VT-IPD before and after PCV introduction. RESULTS: Of 4 randomized controlled trials and 31 observational studies reporting VT-IPD among young children, none evaluated a 2+0 complete series, 7 (19%) evaluated 2+1, 4 (11%) 3+0 and 27 (75%) 3+1. Most (86%) studies were from North America or Europe. Only 1 study (observational) directly compared 2 schedules (3+0 vs. 3+1); results supported the use of a booster dose. In clinical trials, vaccine efficacy ranged from 65% to 71% with 3+0 and 83% to 94% with 3+1. Surveillance data and case counts demonstrate reductions in VT-IPD of up to 100% with 2+1 (6 studies) or 3+1 (17 studies) schedules and up to 90% with 3+0 (2 studies). Reductions were observed as early as 1 year after PCV introduction. CONCLUSIONS: These data support the use of 2+1, 3+0 and 3+1 schedules, although most data of PCV impact on VT-IPD among young children are from high-income countries using 3+1. Differences between schedules for impact on VT-IPD are difficult to discern based on available data. |
Systematic review of the effect of pneumococcal conjugate vaccine dosing schedules on vaccine-type nasopharyngeal carriage
Fleming-Dutra KE , Conklin L , Loo JD , Knoll MD , Park DE , Kirk J , Goldblatt D , Whitney CG , O'Brien KL . Pediatr Infect Dis J 2014 33 Suppl 2 S152-60 BACKGROUND: Pneumococcal conjugate vaccines (PCV) reduce nasopharyngeal carriage of vaccine type (VT) pneumococci, an important driver of vaccine programs' overall benefits. The dosing schedule that best reduces carriage is unclear. METHODS: We performed a systematic review of English language publications from 1994 to 2010 (supplemented post hoc with studies from 2011) reporting PCV effects on VT carriage to assess variability in effect by dosing schedule. RESULTS: We identified 32 relevant studies (36 citations) from 12,980 citations reviewed. Twenty-one (66%) evaluated PCV7; none used PCV10 or PCV13. Five studies evaluated 2 primary doses and 13 three primary doses. After the first year of life, 14 evaluated 3-dose primary series with PCV booster (3+1), seven 3 doses plus 23-valent polysaccharide booster "3+1PPV23," five "3+0," four "2+1," three "2+1PPV23" and two "2+0." Four studies directly compared schedules. From these, 3 primary doses reduced VT carriage more than 2 doses at 1-7 months following the series (1 study significant; 2 borderline). In a study, the 2+1 schedule reduced VT carriage more than 2+0 at 18, but not at 24 months of age. One study of a 23-valent pneumococcal polysaccharide vaccine booster showed no effect. All 16 clinical trials with unvaccinated controls and 11 observational studies with before-after designs showed reduction in VT carriage. CONCLUSIONS: The available literature demonstrates VT-carriage reduction for 2+0, 2+1, 3+0 and 3+1 PCV schedules, but not for 23-valent pneumococcal polysaccharide vaccine booster. Comparisons between schedules show that 3 primary doses and a 2+1 schedule may reduce carriage more than 2 primary doses and a 2+0 schedule, respectively. |
Systematic review of the indirect effect of pneumococcal conjugate vaccine dosing schedules on pneumococcal disease and colonization
Loo JD , Conklin L , Fleming-Dutra KE , Knoll MD , Park DE , Kirk J , Goldblatt D , O'Brien KL , Whitney CG . Pediatr Infect Dis J 2014 33 Suppl 2 S161-71 BACKGROUND: To aid decision making for pneumococcal conjugate vaccine (PCV) use in infant national immunization programs, we summarized the indirect effects of PCV on clinical outcomes among nontargeted age groups. METHODS: We systematically reviewed the English literature on infant PCV dosing schedules published from 1994 to 2010 (with ad hoc addition of 2011 articles) for outcomes on children >5 years of age and adults including vaccine-type nasopharyngeal carriage (VT-NP), vaccine-type invasive pneumococcal disease (VT-IPD) and syndromic pneumonia. RESULTS: Of 12,980 citations reviewed, we identified 21 VT-IPD, 6 VT-NP and 9 pneumonia studies. Of these 36, 21 (58%) included 3 primary doses plus PCV or pneumococcal polysaccharide vaccine (PPV23) booster schedule (3+1 or 3+PPV23), 5 (14%) 3+0, 9 (25%) 2+1 and 1 (3%) 2+0. Most (95%) were PCV7 studies. Among observational VT-IPD studies, all schedules (2+1, 3+0 and 3+1) demonstrated reductions in incidence among young adult groups. Among syndromic pneumonia observational studies (2+1, 3+0 and 3+1), only 3+1 schedules showed significant indirect impact. Of 2 VT-NP controlled trials (3+0 and 3+1) and 3 VT-NP observational studies (2+1, 3+1 and 3+PPV23), 3+1 and 3+PPV23 schedules showed significant indirect effect. The 1 study to directly compare between schedules was a VT-NP study (2+0 vs. 2+1), which found no indirect effect on older siblings and parents of vaccinated children with either schedule. CONCLUSIONS: Indirect benefit of a 3+1 infant PCV dosing schedule has been demonstrated for VT-IPD, VT-NP and syndromic pneumonia; 2+1 and 3+0 schedules have demonstrated indirect effect only for VT-IPD. The choice of optimal infant PCV schedule is limited by data paucity on indirect effects, especially a lack of head-to-head studies and studies of PCV10 and PCV13. |
Would young women attending sexually transmitted disease clinics benefit from human papillomavirus vaccination? An assessment of human papillomavirus DNA and seropositivity from human papillomavirus sentinel surveillance, 2003-2005
Dunne EF , Flagg EW , Unger ER , Hsu K , Ghanen K , Kerndt P , Shlay JC , Koutsky LA , Datta DS , Panicker G , Zaidi A , Weinstock H , Markowitz LE . Sex Transm Dis 2014 41 (1) 46-9 BACKGROUND: There are limited data on the proportion who have been exposed to vaccine-type human papillomavirus (HPV) among women attending sexually transmitted disease (STD) clinics; this information could inform the potential benefits of HPV vaccination for women attending this venue. METHODS: Human papillomavirus surveillance was conducted in STD clinics in Baltimore, MD; Boston, MA; Denver, CO; Los Angeles, CA; and Seattle, WA, among women receiving cervical cancer screening from January 2003 to December 2005. The women had specimens collected for cervical cytology HPV testing by L1 consensus polymerase chain reaction testing and serologic assessment for HPV 6, 11, 16, and 18 using the competitive Luminex immunoassay. Results from 880 women with adequate specimens were included. Women were HPV naive if they were both HPV DNA negative and seronegative for a specific HPV type. RESULTS: One hundred seventy women (19.3%) had HPV 16, 18, 6, or 11 DNA, and 418 (47.5%) were HPV 16, 18, 6, or 11 seropositive. Four hundred ten (46.6%) women were naive to all 4 types, 570 (64.8%) were naive to both HPV 16 and 18, and 545 (61.9%) were naive to both HPV 6 and 11. Almost all (99.3%) women were naive to at least 1 vaccine HPV type. CONCLUSIONS: Almost half of young women age eligible for HPV vaccine and attending STD clinics were naive to all 4 HPV types, and more than half were naive to both HPV 16 and 18. This assessment suggests that most young women attending this venue might benefit from HPV vaccination. |
The differential impact of coadministered vaccines, geographic region, vaccine product and other covariates on pneumococcal conjugate vaccine immunogenicity
Park DE , Johnson TS , Nonyane BA , Chandir S , Conklin L , Fleming-Dutra KE , Loo JD , Goldblatt D , Whitney CG , O'Brien KL , Deloria Knoll M . Pediatr Infect Dis J 2014 33 Suppl 2 S130-9 BACKGROUND: Antipneumococcal capsular polysaccharide antibody concentrations are used as predictors of vaccine efficacy against vaccine serotype (ST) pneumococcal disease among infants. While pneumococcal conjugate vaccines (PCV) are recommended globally, factors associated with optimal PCV immune response are not well described. We aimed to systematically assess local setting factors, beyond dosing schedule, which may affect PCV antibody levels. METHODS: We conducted a literature review of PCV immunogenicity, abstracting data from published reports, unpublished sources, and conference abstracts from 1994 to 2010 (and ad hoc 2011 reports). Studies included in this analysis evaluated ≥ 2 primary doses of PCV before 6 months of age in non-high-risk populations, used 7-valent or higher PCV products (excluding Aventis-Pasteur and Merck products) and provided information on geometric mean concentration (GMC) for STs 1, 5, 6B, 14, 19F or 23F. Using random effects meta-regression, we assessed the impact of geographic region, coadministered vaccines and PCV product on postprimary GMC, adjusting for dosing schedule and ELISA laboratory method. RESULTS: Of 12,980 citations reviewed, we identified 103 vaccine study arms for this analysis. Children in studies from Asia, Africa and Latin America had significantly higher GMC responses compared with those in studies from Europe and North America. Coadministration with acellular pertussis DTP compared with whole-cell DTP had no effect on PCV immunogenicity except for ST14, where GMCs were higher when coadministered with acellular pertussis DTP. Vaccine product, number of PCV doses, dosing interval, age at first dose and ELISA laboratory method also affected the GMC. CONCLUSIONS: PCV immunogenicity is associated with geographic region and vaccine product; however, the associations and magnitude varied by ST. Consideration of these factors is essential when comparing PCV immunogenicity results between groups and should be included in the evidence base when selecting optimal PCV vaccine schedules in specific settings. |
Reports to the Vaccine Adverse Event Reporting System after hepatitis A and hepatitis AB vaccines in pregnant women
Moro PL , Museru OI , Niu M , Lewis P , Broder K . Am J Obstet Gynecol 2013 210 (6) 561 e1-6 OBJECTIVE: To characterize adverse events (AEs) after Hepatitis A vaccines (Hep A) and Hepatitis A and Hepatitis B combination vaccine (Hep AB) in pregnant women reported to the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system. STUDY DESIGN: We searched VAERS for AEs reports in pregnant women who received Hep A or Hep AB from 01/01/1996-04/05/2013. Clinicians reviewed all reports and available medical records. RESULTS: VAERS received 139 reports of AEs in pregnant women; 7 (5.0%) were serious; No maternal or infant deaths were identified. Sixty-five (46.8%) did not describe an AE. For those women whose gestational age was available, most were vaccinated during the first trimester, 50/60 (83.3%) for Hep A and 18/21 (85.7%) for Hep AB. The most common pregnancy-specific outcomes following Hep A or Hep AB vaccinations were spontaneous abortion in 15 (10.8%) reports, elective termination in 10 (7.2%), and pre-term delivery in 7 (5.0%) reports. The most common non-pregnancy specific outcome was urinary tract infection and nausea vomiting with 3 (2.2%) reports each. One case of amelia of the lower extremities was reported in an infant following maternal Hep A immunization. CONCLUSIONS: This review of VAERS reports did not identify any concerning pattern of AEs in pregnant women or their infants following maternal HepA or HepAB immunizations during pregnancy. |
Serum antibody response to matrix protein 2 following natural infection with 2009 pandemic influenza A(H1N1) virus in humans
Zhong W , Reed C , Blair PJ , Katz JM , Hancock K . J Infect Dis 2013 209 (7) 986-94 Natural infection-induced humoral immunity to M2 protein of influenza A viruses in humans is not fully understood at present. Existing evidence suggests that anti-M2 antibody responses following influenza A virus infection are weak and/or transient. We show that seroprevalence of anti-M2 antibodies increased with age in 317 sera from healthy individuals in the U.S. in 2007-08. Infection with 2009 pandemic H1N1 influenza A virus [A(H1N1)pdm09] elicited a recall serum antibody response to M2 protein of the A(H1N1)pdm09 virus in 47% of the affected 118 individuals tested. Anti-M2 antibody responses were more robust among individuals with preexisting antibodies to M2 protein. Moreover, the antibodies induced as a result of infection with A(H1N1)pdm09 virus were cross-reactive with M2 protein of seasonal influenza A viruses. These results emphasize the need to further investigate the possible roles of anti-M2 antibodies in human influenza A virus infection. |
Pre-exposure rabies vaccination among US international travelers: findings from the Global TravEpiNet Consortium
Dolan SB , Jentes ES , Sotir MJ , Han P , Blanton JD , Rao SR , Larocque RC , Ryan ET , The Global Travepinet Consortium . Vector Borne Zoonotic Dis 2013 14 (2) 160-7 BACKGROUND: People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010. MATERIAL AND METHODS: We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation. RESULTS: Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations >6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination. CONCLUSIONS: Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations. |
Progress and challenges in RSV prophylaxis and vaccine development
Haynes LM . J Infect Dis 2013 208 Suppl 3 S177-83 Respiratory syncytial virus (RSV) is a respiratory tract pathogen that causes significant morbidity and mortality in children aged <5 years (most disease occurs at age <1 year) and is a major public health burden worldwide. More than 90% of children are infected at least once with RSV before the age of 2 years [1–3]. RSV accounts for approximately 70% of hospitalizations due to bronchiolitis [1, 4]. In the United States alone, the estimated healthcare costs associated with RSV hospitalizations exceed $950 million, making it a significant economic burden [5]. Further, the RSV burden is disproportionately greater in children aged <5 years living in developing countries [3]. RSV infection does not confer long-term protection, as reinfections occur throughout life, which poses a significant disease risk in individuals with cardiopulmonary disease, immunocompromised patients, and the elderly [7]. In the elderly, complications of RSV infection often result from exacerbation of underlying pulmonary and cardiac disease. [7]. | A member of the Paramyxoviridae family, Pneumovirus genus, RSV exists as an enveloped virus containing a negative-sense, single-stranded RNA genome. The genome encodes for the following 11 proteins: nonstructural proteins (NS1, NS2, and M2-2), the viral nucleocapsid protein (N), phosphoprotein (P), matrix (M), RNA-dependent RNA polymerase (L), M2-1, and 3 surface glycoproteins (G [attachment], F [fusion], and SH [small hydrophobic]). There are 2 RSV major groups, A and B, and multiple genotypes within each group. The protective immune response to RSV infection is primarily directed against the 2 major surface viral glycoproteins, F and G. The F glycoprotein seems most important for induction of protective immunity and is associated with a high serum neutralizing antibody response as well as activation of CD14 and Toll-like receptor-4 (TLR-4) [8]. RSV F protein undergoes structural rearrangement during the fusion process. Antigenic sites on the postfusion form of the protein have been associated with a range of neutralizing activity. However, recent evidence suggests that most of the F protein–specific neutralizing antibodies in human sera are directed against the prefusion form of the RSV F protein. Thus, the antigenic nature of the RSV F protein may have important implications for prophylaxis and vaccine development [9]. The RSV G protein has been implicated in the pathogenesis of disease after primary infection and formalin-inactivated (FI-RSV)–enhanced disease [6]. The highest degree of antigenic diversity in RSV is found in the RSV G protein. This diversity may play an important role in viral pathogenesis by facilitating immune evasion. The ability of this protein to evade or inhibit the host immune response may complicate vaccine development. RSV binds to several surface ligands, including cellular glycosaminoglycans, CX3CR1 [10], ICAM-I [11], Annexin-II [12], and nucleolin [13]. |
Effect of age on the risk of fever and seizures following immunization with measles-containing vaccines in children
Rowhani-Rahbar A , Fireman B , Lewis E , Nordin J , Naleway A , Jacobsen SJ , Jackson LA , Tse A , Belongia EA , Hambidge SJ , Weintraub E , Baxter R , Klein NP . JAMA Pediatr 2013 167 (12) 1111-7 IMPORTANCE: The first dose of live attenuated measles-containing vaccines is associated with an increased risk of febrile seizures 7 to 10 days following immunization among 12- to 23-month-old children. The combination measles, mumps, rubella, and varicella vaccine is associated with a 2-fold increased risk of febrile seizures 7 to 10 days following immunization compared with the separately administered measles, mumps, and rubella and varicella vaccines. It is unknown whether the magnitude of these increased risks depends on age at immunization. OBJECTIVE: To examine the potential modifying effect of age on the risk of fever and seizures following immunization with measles-containing vaccines. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study at 8 Vaccine Safety Datalink sites of a total of 840 348 children 12 to 23 months of age who had received a measles-containing vaccine from 2001 through 2011. EXPOSURES: Any measles-containing vaccines and measles-containing vaccines by type. MAIN OUTCOMES AND MEASURES: Fever and seizure events occurring during a 42-day postimmunization observation period. RESULTS: In the analysis of any measles-containing vaccines, the increased risk of seizures during the 7- to 10-day risk interval, using the remainder of the observation period as the control interval, was significantly greater among older children (relative risk, 6.5; 95% CI, 5.3-8.1; attributable risk, 9.5 excess cases per 10 000 doses; 95% CI, 7.6-11.5) than among younger children (relative risk, 3.4; 95% CI, 3.0-3.9; attributable risk = 4.0 excess cases per 10 000 doses; 95% CI, 3.4-4.6). The relative risk of postimmunization fever was significantly greater among older children than among younger children; however, its attributable risk was not. In the analysis of vaccine type, measles, mumps, rubella, and varicella vaccine was associated with a 1.4-fold increase in the risk of fever and 2-fold increase in the risk of seizures compared with measles, mumps, and rubella vaccine administered with or without varicella vaccine in both younger and older children. CONCLUSIONS AND RELEVANCE: Measles-containing vaccines are associated with a lower increased risk of seizures when administered at 12 to 15 months of age. Findings of this study that focused on safety outcomes highlight the importance of timely immunization of children with the first dose of measles-containing vaccines. |
Effect of reduced dose schedules and intramuscular injection of anthrax vaccine adsorbed on immunological response and safety profile: a randomized trial
Wright JG , Plikaytis BD , Rose CE , Parker SD , Babcock J , Keitel W , El Sahly H , Poland GA , Jacobson RM , Keyserling HL , Semenova VA , Li H , Schiffer J , Dababneh H , Martin SK , Martin SW , Marano N , Messonnier NE , Quinn CP . Vaccine 2013 32 (8) 1019-28 OBJECTIVE: We evaluated an alternative administration route, reduced schedule priming series, and increased intervals between booster doses for anthrax vaccine adsorbed (AVA). AVA's originally licensed schedule was 6 subcutaneous (SQ) priming injections administered at months (m) 0, 0.5, 1, 6, 12 and 18 with annual boosters; a simpler schedule is desired. METHODS: Through a multicenter randomized, double blind, non-inferiority Phase IV human clinical trial, the originally licensed schedule was compared to four alternative and two placebo schedules. 8-SQ group participants received 6 SQ injections with m30 and m42 "annual" boosters; participants in the 8-IM group received intramuscular (IM) injections according to the same schedule. Reduced schedule groups (7-IM, 5-IM, 4-IM) received IM injections at m0, m1, m6; at least one of the m0.5, m12, m18, m30 vaccine doses were replaced with saline. All reduced schedule groups received a m42 booster. Post-injection blood draws were taken two to four weeks following injection. Non-inferiority of the alternative schedules was compared to the 8-SQ group at m2, m7, and m43. Reactogenicity outcomes were proportions of injection site and systemic adverse events (AEs). RESULTS: The 8-IM group's m2 response was non-inferior to the 8-SQ group for the three primary endpoints of anti-protective antigen IgG geometric mean concentration (GMC), geometric mean titer, and proportion of responders with a 4-fold rise in titer. At m7 anti-PA IgG GMCs for the three reduced dosage groups were non-inferior to the 8-SQ group GMCs. At m43, 8-IM, 5-IM, and 4-IM group GMCs were superior to the 8-SQ group. Solicited injection site AEs occurred at lower proportions in the IM group compared to SQ. Route of administration did not influence the occurrence of systemic AEs. A 3 dose IM priming schedule with doses administered at m0, m1, and m6 elicited long term immunological responses and robust immunological memory that was efficiently stimulated by a single booster vaccination at 42 months. CONCLUSIONS: A priming series of 3 intramuscular doses administered at m0, m1, and m6 with a triennial booster was non-inferior to more complex schedules for achieving antibody response. |
The evolution and diversity of a low complexity vaccine candidate, merozoite surface protein 9 (MSP-9), in Plasmodium vivax and closely related species
Chenet SM , Pacheco MA , Bacon DJ , Collins WE , Barnwell JW , Escalante AA . Infect Genet Evol 2013 20 239-48 The merozoite surface protein-9 (MSP-9) has been considered a target for an anti-malarial vaccine since it is one of many proteins involved in the erythrocyte invasion, a critical step in the parasite life cycle. Orthologs encoding this antigen have been found in all known species of Plasmodium parasitic to primates. In order to characterize and investigate the extent and maintenance of MSP-9 genetic diversity, we analyzed DNA sequences of the following malaria parasite species: Plasmodium falciparum, Plasmodium reichenowi, Plasmodium chabaudi, Plasmodium yoelii, Plasmodium berghei, Plasmodium coatneyi, Plasmodium gonderi, Plasmodium knowlesi, Plasmodium inui, Plasmodium simiovale, Plasmodium fieldi, Plasmodium cynomolgi and Plasmodium vivax and evaluated the signature of natural selection in all MSP-9 orthologs. Our findings suggest that the gene encoding MSP-9 is under purifying selection in P. vivax and closely related species. We further explored how selection affected different regions of MSP-9 by comparing the polymorphisms in P. vivax and P. falciparum, and found contrasting patterns between these two species that suggest differences in functional constraints. This observation implies that the MSP-9 orthologs in human parasites may interact differently with the host immune response. Thus, studies carried out in one species cannot be directly translated into the other. |
Examination of links between herpes zoster incidence and childhood varicella vaccination
Hales CM , Harpaz R , Joesoef MR , Bialek SR . Ann Intern Med 2013 159 (11) 739-45 BACKGROUND: Introduction of a universal varicella vaccine program for U.S. children in 1996 sparked concern that less-frequent exposure to varicella would decrease external boosting of immunity to varicella zoster virus and thereby increase incidence of herpes zoster (HZ). OBJECTIVE: To determine whether the varicella vaccination program has influenced trends in HZ incidence in the U.S. population older than 65 years. DESIGN: Retrospective study of Medicare claims. SETTING: Medicare, 1992 through 2010. PARTICIPANTS: 2 848 765 beneficiaries older than 65 years. MEASUREMENTS: Annual HZ incidence from 1992 through 2010; rate ratios (RRs) for HZ incidence by age, sex, and race or ethnicity; and state-level varicella vaccination coverage. RESULTS: 281 317 incident cases of HZ occurred. Age- and sex-standardized HZ incidence increased 39% from 10.0 per 1000 person-years in 1992 to 13.9 per 1000 person-years in 2010 with no evidence of a statistically significant change in the rate of increase after introduction of the varicella vaccination program. Before introduction of this program, HZ incidence was higher in women (RR, 1.21 [95% CI, 1.19 to 1.24]) than men and was lower in black persons (RR, 0.51 [CI, 0.48 to 0.53]) and Hispanic persons (RR, 0.76 [CI, 0.72 to 0.81]) than white persons. In a model adjusted for sex, age, and calendar year from 1997 to 2010, HZ incidence did not vary by state varicella vaccination coverage (RR, 0.9998 [CI, 0.9993 to 1.0003]). LIMITATION: Uncertain level and consistency of health-seeking behavior and access and uncertain accuracy of disease coding. CONCLUSION: Age-specific HZ incidence increased in the U.S. population older than 65 years even before implementation of the childhood varicella vaccination program. Introduction and widespread use of the vaccine did not seem to affect this increase. This information is reassuring for countries considering universal varicella vaccination. |
Hepatitis B vaccine immunogenicity among adults vaccinated during an outbreak response in an assisted living facility-Virginia, 2010
Bender TJ , Sharapov U , Utah O , Xing J , Hu D , Rybczynska J , Drobeniuc J , Kamili S , Spradling PR , Moorman AC . Vaccine 2013 32 (7) 852-6 BACKGROUND: Failure to adhere to infection control guidelines, especially during assisted monitoring of blood glucose, has caused multiple hepatitis B outbreaks in assisted living facilities (ALFs). In conjunction with the response to such an outbreak at an ALF ("Facility X") where most residents had neuropsychiatric disorders, we evaluated seroprotection rates conferred by hepatitis B vaccine and assessed the influence of demographic factors on vaccine response. METHODS: Residents were screened for hepatitis B and C infection, and those susceptible were vaccinated against hepatitis A and hepatitis B with one dose of TWINRIX (GSK) given at 0, 1, and 7 months. Blood samples were collected 1-2 months after receipt of the third vaccine dose to test for antibody to hepatitis B surface antigen (anti-HBs). RESULTS: Of the 27 residents who had post-vaccination blood specimens collected, 22 (81%) achieved anti-HBs concentrations ≥10mIU/mL. Neither age nor neuropsychiatric comorbidity was significant determinants of seroprotection. Geometric mean concentration was lower among residents aged 60-74 years (74.3mIU/mL) than among residents aged 46-59 years (105.3mIU/mL) but highest among residents aged ≥75 years (122.5mIU/mL). The effect of diabetes on vaccination response could not be examined because 16/17 (94%) diabetic residents had HBV infection by the time of investigation. CONCLUSIONS: Adult vaccine recipients of all ages, even those over 60 years of age, demonstrated a robust capacity for achieving hepatitis B seroprotection in response to the combined hepatitis A/hepatitis B vaccine. The role for vaccination in interrupting HBV transmission during an outbreak remains unclear, but concerns about age-related response to hepatitis B vaccine may be insufficient to justify foregoing vaccination of susceptible residents of ALFs. |
Highly divergent type 2 and 3 vaccine-derived polioviruses isolated from sewage in Tallinn, Estonia
Al-Hello H , Jorba J , Blomqvist S , Raud R , Kew O , Roivainen M . J Virol 2013 87 (23) 13076-80 Highly divergent vaccine-derived polioviruses (VDPVs) have been isolated from sewage in Tallinn, Estonia, since 2002. Sequence analysis of VDPVs of serotypes 2 and 3 showed that they shared common noncapsid region recombination sites, indicating origination from a single trivalent oral polio vaccine dose, estimated to have been given between 1986 and 1998. The sewage isolates closely resemble VDPVs chronically excreted by persons with common variable immunodeficiency, but no chronic excretors have yet been identified in Estonia. |
Immediate hypersensitivity reactions following monovalent 2009 pandemic influenza A (H1N1) vaccines: Reports to VAERS
Halsey NA , Griffioen M , Dreskin SC , Dekker CL , Wood R , Sharma D , Jones JF , Larussa PS , Garner J , Berger M , Proveaux T , Vellozzi C . Vaccine 2013 31 (51) 6107-12 BACKGROUND: Hypersensitivity disorders following vaccinations are a cause for concern. OBJECTIVE: To determine the type and rate by age, gender, and vaccine received for reported hypersensitivity reactions following monovalent 2009 pandemic influenza A (H1N1) vaccines. DESIGN: A systematic review of reports to the Vaccine Adverse Event Reporting System (VAERS) following monovalent 2009 pandemic influenza A (H1N1) vaccines. SETTING/PATIENTS: US Civilian reports following vaccine received from October 1, 2009 through May 31, 2010. MEASUREMENTS: Age, gender, vaccines received, diagnoses, clinical signs, and treatment were reviewed by nurses and physicians with expertise in vaccine adverse events. A panel of experts, including seven allergists reviewed complex illnesses and those with conflicting evidence for classification of the event. RESULTS: Of 1984 reports, 1286 were consistent with immediate hypersensitivity disorders and 698 were attributed to anxiety reactions, syncope, or other illnesses. The female-to-male ratio was ≥4:1 for persons 20-to-59 years of age, but approximately equal for children under 10. One hundred eleven reports met Brighton Collaboration criteria for anaphylaxis; only one-half received epinephrine for initial therapy. The overall rate of reported hypersensitivity reactions was 10.7 per million vaccine doses distributed, with a 2-fold higher rate for live vaccine. LIMITATIONS: Underreporting, especially of mild events, would result in an underestimate of the true rate of immediate hypersensitivity reactions. Selective reporting of events in adult females could have resulted in higher rates than reported for males. CONCLUSIONS: Adult females may be at higher risk of hypersensitivity reactions after influenza vaccination than men. Although the risk of hypersensitivity reactions following 2009 pandemic influenza A (H1N1) vaccines was low, all clinics administering vaccines should be familiar with treatment guidelines for these adverse events, including the use of intramuscular epinephrine early in the course of serious hypersensitivity reactions. |
Impact of immunosuppression on recall immune responses to influenza vaccination in stable renal transplant recipients
Cowan M , Chon WJ , Desai A , Andrews S , Bai Y , Veguilla V , Katz JM , Josephson MA , Wilson PC , Sciammas R , Chong AS . Transplantation 2013 97 (8) 846-53 BACKGROUND: The recommendation by the American Society of Transplantation for annual trivalent inactivated influenza vaccination greater than 3 to 6 months post-kidney transplantation provides a unique opportunity to test the in vivo impact of immunosuppression on recall T- and B-cell responses to influenza vaccination. METHODS: This study took advantage of recent breakthroughs in the single-cell quantification of human peripheral blood B-cell responses to prospectively evaluate both B- and T-cell responses to the seasonal (2010 and 2011) influenza vaccine in 23 stable renal transplant recipients and 22 healthy controls. RESULTS AND CONCLUSION: The results demonstrate that the early B-cell response to influenza vaccination, quantified by the frequency of influenza-specific antibody-secreting cells (ASC) in peripheral blood, was significantly reduced in stable transplant recipients compared to healthy controls. The magnitude of the seroresponse and the rate of seroconversion were also blunted. The influenza-specific interferon-gamma (IFNgamma) T-cell response was significantly reduced in transplant recipients; however, there was no correlation between the magnitude of the influenza-specific IgG ASC and IFNgamma responses. The induction of memory T- and B-cell responses to influenza vaccination supports the recommendation to vaccinate while the blunted responses demonstrate the efficacy of immunosuppression in controlling memory responses individual transplant recipients. |
Impact of prior seasonal H3N2 influenza vaccination or infection on protection and transmission of emerging variants of influenza A(H3N2)v virus in ferrets
Houser KV , Pearce MB , Katz JM , Tumpey TM . J Virol 2013 87 (24) 13480-9 Influenza H3N2 A viruses continue to circulate in swine and occasionally infect humans, resulting in outbreaks of variant influenza H3N2 [A(H3N2)v] virus. It has been previously demonstrated in ferrets that A(H3N2)v viruses transmit as efficiently as seasonal influenza viruses, raising concern over the pandemic potential of these viruses. However, A(H3N2)v viruses have not acquired the ability to transmit efficiently among humans, which may be due in part to existing cross-reactive immunity to A(H3N2)v viruses. Although current seasonal H3N2 and A(H3N2)v viruses are antigenically distinct from one another, historical H3N2 viruses have some antigenic similarity to A(H3N2)v viruses and previous exposure to these viruses may provide a measure of immune protection sufficient to dampen A(H3N2)v virus transmission. Here, we evaluated whether prior seasonal H3N2 influenza virus vaccination or infection affects virus replication and transmission of A(H3N2)v virus in the ferret animal model. We found that the seasonal trivalent inactivated influenza virus vaccine (TIV) or a monovalent vaccine prepared from an antigenically related 1992 seasonal influenza H3N2 (A/Beijing/32/1992) virus failed to substantially reduce A(H3N2)v (A/Indiana/08/2011) virus shedding and subsequent transmission to naive hosts. Conversely, ferrets primed by seasonal H3N2 virus infection displayed reduced A(H3N2)v virus shedding following challenge, which blunted transmission to naive ferrets. A higher level of specific IgG and IgA antibody titers detected among infected versus vaccinated ferrets was associated with the degree of protection offered by seasonal H3N2 virus infection. The data demonstrate in ferrets that the efficiency of A(H3N2)v transmission is disrupted by preexisting immunity induced by seasonal H3N2 virus infection. |
Adult immunization policies in advanced economies: vaccination recommendations, financing, and vaccination coverage
Wu LA , Kanitz E , Crumly J , D'Ancona F , Strikas RA . Int J Public Health 2013 58 (6) 865-74 OBJECTIVES: While many countries have robust child immunization programs and high child vaccination coverage, vaccination of adults has received less attention. The objective of this study was to describe the adult vaccination policies in developed countries. METHODS: From 2010 to 2011, we conducted a survey of 33 advanced economies as defined by the International Monetary Fund. The survey asked about national recommendations for adults for 16 vaccines or vaccine components, funding mechanisms for recommended adult vaccines, and the availability of adult vaccination coverage estimates. RESULTS: Thirty-one of 33 (93.9 %) advanced economies responded to the survey. Twelve of 31 (38.7 %) reported having a comprehensive adult immunization schedule. The total number of vaccines or vaccine components recommended for adults ranged from one to 15 with a median of 10. Seasonal influenza (n = 30), tetanus (n = 28), pneumococcal polysaccharide (n = 27), and hepatitis B (n = 27) were the most frequently recommended vaccines or components. CONCLUSIONS: Approximately two-thirds of survey respondents do not have a comprehensive adult vaccine schedule, and most do not measure vaccination coverage. We found that a funding mechanism is available for most recommended adult vaccines. |
Determinants and coverage of vaccination in children in Western Kenya from a 2003 cross-sectional survey
Calhoun LM , van Eijk AM , Lindblade KA , Odhiambo FO , Wilson ML , Winterbauer E , Slutsker L , Hamel MJ . Am J Trop Med Hyg 2013 90 (2) 234-41 This study assesses full and timely vaccination coverage and factors associated with full vaccination in children ages 12-23 months in Gem, Nyanza Province, Kenya in 2003. A simple random sample of 1,769 households was selected, and guardians were invited to bring children under 5 years of age to participate in a survey. Full vaccination coverage was 31.1% among 244 children. Only 2.2% received all vaccinations in the target month for each vaccination. In multivariate logistic regression, children of mothers of higher parity (odds ratio [OR] = 0.27, 95% confidence interval [95% CI] = 0.13-0.65, P ≤ 0.01), children of mothers with lower maternal education (OR = 0.35, 95% CI = 0.13-0.97, P ≤ 0.05), or children in households with the spouse absent versus present (OR = 0.40, 95% CI = 0.17-0.91, P ≤ 0.05) were less likely to be fully vaccinated. These data serve as a baseline from which changes in vaccination coverage will be measured as interventions to improve vaccination timeliness are introduced. |
We can have it all: improved surveillance outcomes and decreased personnel costs associated with electronic reportable disease surveillance, North Carolina, 2010
Samoff E , Dibiase L , Fangman MT , Fleischauer AT , Waller AE , MacDonald PD . Am J Public Health 2013 103 (12) 2292-7 OBJECTIVES: We assessed the timeliness, accuracy, and cost of a new electronic disease surveillance system at the local health department level. We describe practices associated with lower cost and better surveillance timeliness and accuracy. METHODS: Interviews conducted May through August 2010 with local health department (LHD) staff at a simple random sample of 30 of 100 North Carolina counties provided information on surveillance practices and costs; we used surveillance system data to calculate timeliness and accuracy. We identified LHDs with best timeliness and accuracy and used these categories to compare surveillance practices and costs. RESULTS: Local health departments in the top tertiles for surveillance timeliness and accuracy had a lower cost per case reported than LHDs with lower timeliness and accuracy ($71 and $124 per case reported, respectively; P = .03). Best surveillance practices fell into 2 domains: efficient use of the electronic surveillance system and use of surveillance data for local evaluation and program management. CONCLUSIONS: Timely and accurate surveillance can be achieved in the setting of restricted funding experienced by many LHDs. Adopting best surveillance practices may improve both efficiency and public health outcomes. |
Traumatic brain injury among older adults at level I and II trauma centers
Dams-O'Connor K , Cuthbert JP , Whyte J , Corrigan JD , Faul M , Harrison-Felix C . J Neurotrauma 2013 30 (24) 2001-13 Individuals 65 years of age and over have the highest rates of traumatic brain injury (TBI)-related hospitalizations and deaths, and older adults (defined variably across studies) have particularly poor outcomes after TBI. The factors predicting these outcomes remain poorly understood, and age-specific care guidelines for TBI do not exist. This study provides an overview of TBI in older adults using data from the National Trauma Data Bank (NTDB) gathered between 2007 and 2010, evaluates age group-specific trends in rates of TBI over time using U.S. Census data, and examines whether routinely collected information is able to predict hospital discharge status among older adults with TBI in the NTDB. Results showed a 20-25% increase in trauma center admissions for TBI among the oldest age groups (those >=75 years), relative to the general population, between 2007 and 2010. Older adults (>=65 years) with TBI tended to be white females who have incurred an injury from a fall resulting in a "severe" Abbreviated Injury Scale (AIS) score of the head. Older adults had more in-hospital procedures, such as neuroimaging and neurosurgery, tended to experience longer hospital stays, and were more likely to require continued medical care than younger adults. Older age, injury severity, and hypotension increased the odds of in-hospital death. The public health burden of TBI among older adults will likely increase as the Baby Boom generation ages. Improved primary and secondary prevention of TBI in this cohort is needed. |
Trends in prevalence, knowledge, attitudes, and practices of helmet use in Cambodia: results from a two year study
Bachani AM , Branching C , Ear C , Roehler DR , Parker EM , Tum S , Ballesteros MF , Hyder AA . Injury 2013 44 Suppl 4 S31-7 INTRODUCTION: Road traffic injuries (RTIs) are a major cause of both morbidity and mortality globally. Relative to countries with similar economic patterns both within and outside of South-East Asia, Cambodia's road traffic fatality rate is high, with motorcyclists accounting for more than half of all fatalities as a result of head injuries. Despite the initiation of national motorcycle helmet legislation for Cambodian drivers in 2009, helmet use among both drivers and passengers remains low. METHODS: This study adopted a two-pronged approach to assess the current status of and knowledge, attitudes, and practices (KAPs) towards helmet use among drivers and passengers in five provinces in Cambodia. The objective was to better understand helmet use over a two year period since the introduction of the 2009 legislation. Researchers conducted both (1) direct observation of daytime and nighttime helmet use (January 2011-January 2013) and (2) roadside KAP interviews with motorcyclists (November 2010-November 2012). RESULTS: The observed helmet rate across all study sites was 33% during nighttime and 48% during daytime, with proportions up to ten times higher among drivers compared with passengers. Self-reported helmet use was higher than observed use. Within the past 30 days, 60% of respondents reported that they "always" wore a helmet when they were drivers while only 24% reported they "always" wore a helmet as a passenger. Reported barriers for use among drivers included: "driving route", "forgetfulness", and "inconvenience/discomfort." CONCLUSION: Despite awareness of the protective value of helmets, motorcycle helmet use rates remain low in Cambodia. Many misconceptions remain in Cambodia regarding helmet use, including that they are unnecessary for short distance or at low speeds. These serve as an important barrier to helmet use, which, if dispelled and coupled with visible and regular enforcement, may significantly reduce the number of motorcycle-related injuries and fatalities. |
Implementing an evidence-based fall prevention program in an outpatient clinical setting
Li F , Harmer P , Stock R , Fitzgerald K , Stevens J , Gladieux M , Chou LS , Carp K , Voit J . J Am Geriatr Soc 2013 61 (12) 2142-9 OBJECTIVES: To investigate the dissemination potential of a Tai Ji Quan-based program, previously shown to be efficacious for reducing risk of falls in older adults, through outpatient clinical settings. DESIGN: A single-group pre/post design in which participants attended a twice-weekly Tai Ji Quan training program for 24 weeks. SETTING: Communities in Lane County, Oregon. PARTICIPANTS: Independently living individuals (N = 379) aged 65 and older. MEASUREMENTS: Using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, the primary outcome was the proportion of participating healthcare providers who made referrals. Secondary outcomes were the proportion of referred individuals agreeing to participate and enrolling in the program, and measures of program implementation, maintenance, and effectiveness (on measures of falls, balance, gait, physical performance, and balance efficacy). RESULTS: Of the 252 providers invited to participate, 157 made referrals (62% adoption rate). Of 564 individuals referred, 379 (67% reach) enrolled in the program, which was successfully implemented in senior and community centers with good fidelity, 283 completed the program (75% retention), and 212 of these attended 75% or more of the 48 sessions. Participants reported a reduction in falls, with an incidence rate of 0.13 falls per person-month, and showed significant improvement from baseline in all outcome measures. A 3-month postintervention follow-up indicated encouraging levels of program maintenance among providers, participants, and community centers. CONCLUSION: Healthcare providers successfully implemented a protocol to refer individuals at risk of falling to a Tai Ji Quan-based program. The evidence-based program appears readily scalable and exportable, with potential for substantial clinical and public health effect. |
Identification of vaccine-derived polioviruses using dual-stage real-time RT-PCR.
Kilpatrick DR , Ching K , Iber J , Chen Q , Yang SJ , De L , Williams AJ , Mandelbaum M , Sun H , Oberste MS , Kew OM . J Virol Methods 2013 197 25-8 Vaccine-derived polioviruses (VDPVs) are associated with polio outbreaks and prolonged infections in individuals with primary immunodeficiencies. VDPV-specific PCR assays for each of the three Sabin oral poliovirus vaccine (OPV) strains were developed, targeting sequences within the VP1 capsid region that are selected for during replication of OPV in the human intestine. Over 2,400 Sabin-related isolates and identified 755 VDPVs were screened. Sensitivity of all assays was 100%, while specificity was 100% for serotypes 1 and 3, and 76% for serotype 2. The assays permit rapid, sensitive identification of OPV-related viruses and flag programmatically important isolates for further characterization by genomic sequencing. |
Application of real time RT-PCR for the genetic homogeneity and stability tests of the seed candidates for live attenuated influenza vaccine production.
Shcherbik S , Sergent SB , Davis WG , Shu B , Barnes J , Kiseleva I , Larionova N , Klimov A , Bousse T . J Virol Methods 2014 195 18-25 Development and improvement of quality control tests for live attenuated vaccines are a high priority because of safety concerns. Live attenuated influenza vaccine (LAIV) viruses are 6:2 reassortants containing the hemagglutinin (HA) and neuraminidase (NA) gene segments from circulating influenza viruses to induce protective immune responses, and the six internal gene segments from a cold-adapted Master Donor Virus (MDV). LAIV candidate viruses for the 2012-2013 seasons, A/Victoria/361/2011-CDC-LV1 (LV1) and B/Texas/06/2011-CDC-LV2B (LV2B), were created by classical reassortment of A/Victoria/361/2011 and MDV-A A/Leningrad/134/17/57 (H2N2) or B/Texas/06/2011 and MDV-B B/USSR/60/69. In an attempt to provide better identity and stability testing for quality control of LV1 and LV2B, sensitive real-time RT-PCR assays (rRT-PCR) were developed to detect the presence of undesired gene segments (HA and NA from MDV and the six internal genes from the seasonal influenza viruses). The sensitivity of rRT-PCR assays designed for each gene segment ranged from 0.08 to 0.8EID50 (50% of Egg Infectious Dose) per reaction for the detection of undesired genes in LV1 and from 0.1 to 1EID50 per reaction for the detection of undesired genes in LV2B. No undesired genes were detected either before or after five passages of LV1 or LV2B in eggs. The complete genome sequencing of LV1 and LV2B confirmed the results of rRT-PCR, demonstrating the utility of the new rRT-PCR assays to provide the evidence for the homogeneity of the prepared vaccine candidate. |
Allele-specific qRT-PCR demonstrates superior detection of single nucleotide polymorphisms as genetic markers for West Nile virus compared to Luminex® and quantitative sequencing.
Worwa G , Andrade CC , Thiemann TC , Park B , Maharaj PD , Anishchenko M , Brault AC , Reisen WK . J Virol Methods 2014 195 76-85 To enable in vivo and in vitro competitive fitness comparisons among West Nile viruses (WNV), three reference viruses were marked genetically by site-directed mutagenesis with five synonymous nucleotide substitutions in the envelope gene region of the genome. Phenotypic neutrality of the mutants was assessed experimentally by competitive replication in cell culture and genetic stability of the substituted nucleotides was confirmed by direct sequencing. Luminex((R)) technology, quantitative sequencing and quantitative RT-PCR (qRT-PCR) were compared in regard to specificity, sensitivity and accuracy for quantitation of wildtype and genetically marked viruses in mixed samples based on RNA obtained from samples of known viral titers. Although Luminex((R)) technology and quantitative sequencing provided semi-quantitative or qualitative measurements, a sequence-specific primer extension approach using a specific reverse primer set in singleplex qRT-PCR demonstrated the best quantitation and specificity in the detection of RNA from wildtype and mutant viruses. |
Molecular signatures of antibody responses derived from a systems biology study of five human vaccines.
Li S , Rouphael N , Duraisingham S , Romero-Steiner S , Presnell S , Davis C , Schmidt DS , Johnson SE , Milton A , Rajam G , Kasturi S , Carlone GM , Quinn C , Chaussabel D , Palucka AK , Mulligan MJ , Ahmed R , Stephens DS , Nakaya HI , Pulendran B . Nat Immunol 2013 15 (2) 195-204 Many vaccines induce protective immunity via antibodies. Systems biology approaches have been used to determine signatures that can be used to predict vaccine-induced immunity in humans, but whether there is a 'universal signature' that can be used to predict antibody responses to any vaccine is unknown. Here we did systems analyses of immune responses to the polysaccharide and conjugate vaccines against meningococcus in healthy adults, in the broader context of published studies of vaccines against yellow fever virus and influenza virus. To achieve this, we did a large-scale network integration of publicly available human blood transcriptomes and systems-scale databases in specific biological contexts and deduced a set of transcription modules in blood. Those modules revealed distinct transcriptional signatures of antibody responses to different classes of vaccines, which provided key insights into primary viral, protein recall and anti-polysaccharide responses. Our results elucidate the early transcriptional programs that orchestrate vaccine immunity in humans and demonstrate the power of integrative network modeling. |
Highly-sensitive allele-specific PCR testing identifies a greater prevalence of transmitted HIV drug resistance in Japan.
Nishizawa M , Hattori J , Shiino T , Matano T , Heneine W , Johnson JA , Sugiura W . PLoS One 2013 8 (12) e83150 BACKGROUND: The transmission of drug-resistant HIV in newly identified infected populations has become an underlying epidemic which can be better assessed with sensitive resistance testing. Since minority drug resistant variants cannot be detected by bulk sequencing, methods with improved sensitivity are required. Thus, the goal of this study was to evaluate if transmitted drug resistance mutations at minority levels in Japanese patients could be identified using highly sensitive allele-specific PCR (AS-PCR). MATERIALS AND METHODS: Samples were taken from newly diagnosed HIV/AIDS cases at the National Nagoya Hospital from January 2008 to December 2009. All samples were bulk sequenced for HIV protease and reverse transcriptase. To detect minority populations with drug resistance, we used AS-PCR with mutation-specific primers designed for seven reverse transcriptase inhibitor resistance mutations, M41L, K65R, K70R, K103N, Y181C, M184V, and T215F/Y, and for three protease inhibitor resistance mutations, M46I/L and L90M. RESULTS: We studied 149 newly identified HIV cases. Bulk sequencing detected 8 cases with NRTI resistance mutations (one with A62V, one D67E, one T215D, one T215E, two with T215L and two T215S) and 15 with PI resistance mutations (one with N88D and 14 with M46I). Results obtained by AS-PCR and bulk sequencing demonstrated good concordance but the AS-PCR enabled the detection of seven additional drug-resistant cases (one M41L, two with K65R, two with K70R, and one M184V) in the RT region. Additionally, AS-PCR assays identified 15 additional cases with M46I, five with M46L and four cases with L90M in the protease region. CONCLUSIONS: Using AS-PCR substantially increased the detection of transmitted drug resistance in this population from 15.4% to 26.8%, further supporting the benefit of sensitive testing among drug-naive populations. Since the clinical impact of minority drug-resistant populations is not fully comprehended for all mutations, follow-up studies are needed to understand their significance for treatment. |
Real-time RT-PCR assays to differentiate wild-type group A rotavirus strains from Rotarix(®) and RotaTeq(®) vaccine strains in stool samples.
Gautam R , Esona MD , Mijatovic-Rustempasic S , Ian Tam K , Gentsch JR , Bowen MD . Hum Vaccin Immunother 2013 10 (3) 767-77 Group A rotaviruses (RVA) are the leading cause of severe diarrhea in young children worldwide. Two live-attenuated RVA vaccines, Rotarix(R) and RotaTeq(R) are recommended by World Health Organization (WHO) for routine immunization of all infants. Rotarix(R) and RotaTeq(R) vaccines have substantially reduced RVA associated mortality but occasionally have been associated with acute gastroenteritis (AGE) cases identified in vaccinees and their contacts. High-throughput assays are needed to monitor the prevalence of vaccine strains in AGE cases and emergence of new vaccine-derived strains following RVA vaccine introduction. In this study, we have developed quantitative real-time RT-PCR (qRT-PCR) assays for detection of Rotarix(R) and RotaTeq(R) vaccine components in stool samples. Real-time RT-PCR assays were designed for vaccine specific targets in the genomes of Rotarix(R) (NSP2, VP4) and RotaTeq(R) (VP6, VP3-WC3, VP3-human) and validated on sequence confirmed stool samples containing vaccine strains, wild-type RVA strains, and RVA-negative stools. For quantification, standard curves were generated using dsRNA transcripts derived from RVA gene segments. Rotarix(R) NSP2 and VP4 qRT-PCR assays exhibited 92-100% sensitivity, 99-100% specificity, 94-105% efficiency, and a limit of detection of 2-3 copies per reaction. RotaTeq(R) VP6, VP3-WC3, and VP3-human qRT-PCR assays displayed 100% sensitivity, 94-100% specificity, 91-102% efficiency and limits of detection of 1 copy, 2 copies, and 140 copies, respectively. These assays permit rapid identification of Rotarix(R) and RotaTeq(R) vaccine components in stool samples from clinical and surveillance studies and will be helpful in determining the frequency of vaccine strain-associated AGE. |
Evaluation of supplemental testing with the Multispot HIV-1/HIV-2 Rapid Test and APTIMA HIV-1 RNA Qualitative Assay to resolve specimens with indeterminate or negative HIV-1 Western blots.
Linley L , Ethridge SF , Oraka E , Owen SM , Wesolowski LG , Wroblewski K , Landgraf KM , Parker MM , Brinson M , Branson BM . J Clin Virol 2013 58 Suppl 1 e108-12 BACKGROUND: The use of Western blot (WB) as a supplemental test after reactive sensitive initial assays can lead to inconclusive or misclassified HIV test results, delaying diagnosis. OBJECTIVE: To determine the proportion of specimens reactive by immunoassay (IA) but indeterminate or negative by WB that could be resolved by alternative supplemental tests recommended under a new HIV diagnostic testing algorithm. STUDY DESIGN: Remnant HIV diagnostic specimens that were reactive on 3rd generation HIV-1/2 IA and either negative or indeterminate by HIV-1 WB from 11 health departments were tested with the Bio-Rad Multispot HIV-1/HIV-2 Rapid Test (Multispot) and the Gen-Probe APTIMA HIV-1 RNA Qualitative Assay (APTIMA). RESULTS: According to the new testing algorithm, 512 (89.8%) specimens were HIV-negative, 55 (9.6%) were HIV-1 positive (including 19 [3.3%] that were acute HIV-1 and 9 [1.6%] that were positive for HIV-1 by Multispot but APTIMA-negative), 2 (0.4%) were HIV-2 positive, and 1 (0.2%) was HIV-positive, type undifferentiated. 47 (21.4%) of the 220 WB-indeterminate and 8 (2.3%) of the 350 WB-negative specimens were HIV-1 positive. CONCLUSION: Applying the new HIV diagnostic algorithm retrospectively to WB-negative and indeterminate specimens, the HIV infection status could be established for nearly all of the specimens. IA-reactive HIV-infected persons with WB-negative results had been previously misclassified as uninfected, and HIV diagnosis was delayed for those with WB-indeterminate specimens. These findings underscore the limitations of the WB to confirm HIV infection after reactive results from contemporary 3rd or 4th generation IAs that can detect HIV antibodies several weeks sooner than the WB. |
A murine monoclonal antibody with broad specificity for occupationally relevant diisocyanates
Lemons AR , Siegel PD , Mhike M , Law BF , Hettick JM , Bledsoe TA , Nayak AP , Beezhold DH , Green BJ . J Occup Environ Hyg 2014 11 (2) 101-10 Diisocyanates (dNCOs) used in industrial applications are well known low molecular weight allergens. Occupational exposure is associated with adverse health outcomes including allergic sensitization and occupational asthma. In this study, we report the production and initial characterization of a dNCO-hapten specific murine IgM monoclonal antibody (mAb). Female BALB/c mice were immunized intraperitoneally with 25 mug of 4,4'-methylene diphenyl diisocyanate (MDI)-keyhole limpet hemocyanin. Following six biweekly booster immunizations, splenocytes were recovered and fused to Sp2/0-Ag14 murine myeloma cell line for hybridoma production. Hybridomas were then screened in a solid-phase indirect enzyme-linked immunosorbent assay (ELISA) against 40:1 4,4'-MDI- human serum albumin (HSA). mAb reactivity to dNCO-HSA conjugates and dNCO-HSA spiked human serum were characterized using a sandwich ELISA. One hybridoma produced a multimeric IgM mAb (15D4) that reacted with 4,4'-MDI-HSA. Sandwich ELISA analysis demonstrated comparable reactivity with other occupationally relevant dNCO-HSA adducts, including 2,4-toluene diisocyanate (TDI)-HSA, 2,6-TDI-HSA, and 1,6-hexamethylene diisocyanate (HDI)-HSA, but not other electrophilic chemical HSA conjugates. The limit of quantification (LOQ) of 4,4'-MDI-HSA, 2,4-TDI-HSA, 2,6-TDI-HSA, and 1,6-HDI-HSA sandwich ELISAs were 567.2, 172.7, 184.2, and 403.5 ng/mL (8.67, 2.60, 2.77, and 6.07 pmol/mL), respectively. In contrast, experiments using dNCO-supplemented human sera showed an increase in the detectable limit of the assay. A mAb has been produced that has potential utility for detecting mixed diisocyanate exposures in occupational environments. The mAb may have additional utility in the standardization of specific IgE detection immunoassays as well as chromatographic-mass spectrometric methods to enrich dNCO adducted HSA in the plasma of occupationally exposed workers. |
Evaluation of sampling methods for Bacillus spore-contaminated HVAC filters
Calfee MW , Rose LJ , Tufts J , Morse S , Clayton M , Touati A , Griffin-Gatchalian N , Slone C , McSweeney N . J Microbiol Methods 2014 96 1-5 The objective of this study was to compare an extraction-based sampling method to two vacuum-based sampling methods (vacuum sock and 37mm cassette filter) with regards to their ability to recover Bacillus atrophaeus spores (surrogate for Bacillus anthracis) from pleated heating, ventilation, and air conditioning (HVAC) filters that are typically found in commercial and residential buildings. Electrostatic and mechanical HVAC filters were tested, both without and after loading with dust to 50% of their total holding capacity. The results were analyzed by one-way ANOVA across material types, presence or absence of dust, and sampling device. The extraction method gave higher relative recoveries than the two vacuum methods evaluated (p≤0.001). On average, recoveries obtained by the vacuum methods were about 30% of those achieved by the extraction method. Relative recoveries between the two vacuum methods were not significantly different (p>0.05). Although extraction methods yielded higher recoveries than vacuum methods, either HVAC filter sampling approach may provide a rapid and inexpensive mechanism for understanding the extent of contamination following a wide-area biological release incident. |
Evaluation of swabs and transport media for the recovery of Yersinia pestis
Gilbert SE , Rose LJ , Howard M , Bradley MD , Shah S , Silvestri E , Schaefer FW 3rd , Noble-Wang J . J Microbiol Methods 2014 96 35-41 The Government Accountability Office report investigating the surface sampling methods used during the 2001 mail contamination with Bacillus anthracis brought to light certain knowledge gaps that existed regarding environmental sampling with biothreat agents. Should a contamination event occur that involves non-spore forming biological select agents, such as Yersinia pestis, surface sample collection and processing protocols specific for these organisms will be needed. Two Y. pestis strains (virulent and avirulent), four swab types (polyester, macrofoam, rayon, and cotton), two pre-moistening solutions, six transport media, three temperatures, two levels of organic load, and four processing methods (vortexing, sonicating, combined sonicating and vortexing, no agitation) were evaluated to determine the conditions that would yield the highest percent of cultivable Y. pestis cells after storage. The optimum pre-moistening agent/transport media combination varied with the Y. pestis strain and swab type. Directly inoculated macrofoam swabs released the highest percent of cells into solution (93.9% recovered by culture) and rayon swabs were considered the second best swab option (77.0% recovered by culture). Storage at 4 degrees C was found to be optimum for all storage times and transport media. In a worst case scenario, where the Y. pestis strain is not known and sample processing and analyses could not occur until 72h after sampling, macrofoam swabs pre-moistened with PBS supplemented with 0.05% Triton X-100 (PBSTX), stored at 4 degrees C in neutralizing buffer (NB) as a transport medium (PBSTX/NB) or pre-moistened with NB and stored in PBSTX as a transport medium (NB/PBSTX), then vortexed 3min in the transport medium, performed significantly better than all other conditions for macrofoam swabs, regardless of strain tested (mean 12 - 72h recovery of 85.9-105.1%, p<0.001). In the same scenario, two combinations of pre-moistening medium/transport medium were found to be optimal for rayon swabs stored at 4 degrees C (p<0.001), then sonicated 3min in the transport medium; PBSTX/PBSTX and NB/PBSTX (mean 12-72h recovery of 83.7-110.1%). |
Impact of body mass index on the detection of radiographic localized pleural thickening
Larson TC , Franzblau A , Lewin M , Goodman AB , Antao VC . Acad Radiol 2014 21 (1) 3-10 RATIONALE AND OBJECTIVES: Subpleural fat can be difficult to distinguish from localized pleural thickening (LPT), a marker of asbestos exposure, on chest radiographs. The aims of this study were to examine the influence of body mass index (BMI) on the performance of radiograph readers when classifying LPT and to model the risk of false test results with varying BMI. MATERIALS AND METHODS: Subjects (n = 200) were patients being screened or treated for asbestos-related health outcomes. A film chest radiograph, a digital chest radiograph, and a high-resolution computed tomography (HRCT) chest scan were collected from each subject. All radiographs were independently read by seven B readers and scored using the International Labour Office system. HRCT scans, read by three experienced thoracic radiologists, served as the gold standard for the presence of LPT. We calculated measures of radiograph reader performance, including sensitivity and specificity, for each image modality. We also used logistic regression to estimate the probability of a false-positive and a false-negative result while controlling for covariates. RESULTS: The proportion of false-positive readings correlated with BMI. While controlling for covariates, regression modeling showed the probability of a false-positive result increased with increasing BMI category, younger age, not having pleural calcification, and among subjects not reporting occupational or household contact asbestos exposure. CONCLUSIONS: Clinicians should be cautious when evaluating radiographs of younger obese persons for the presence of asbestos-related pleural plaque, particularly in populations having an anticipated low or background prevalence of LPT. |
Challenges with new rapid influenza diagnostic tests
Olsen SJ , Kittikraisak W , Fernandez S , Suntarattiwong P , Chotpitayasunondh T . Pediatr Infect Dis J 2014 33 (1) 117-8 Rapid influenza diagnostic tests (RIDTs) are often used at point-of-care due to their ease of use and rapidly available results. Most tests are lateral flow immunoassays that detect chromatographic changes if an influenza antigen is present in the respiratory specimen. These tests have high specificity (therefore, a positive is almost certainly a true positive) but low sensitivity (therefore, will often miss true cases).1,2 A newer immunofluorescence assay, Sofia A+B FIA (Quidel, San Diego, CA), demonstrated increased sensitivity but maintained high specificity.3 However, on December 3, 2012, Quidel issued a voluntary recall of certain lots of Sofia A+B because of false positive results.4 | In August 2011, we began a prospective cohort study of children aged ≤36 months at Queen Sirikit National Institute of Child Health, the largest pediatric referral hospital in Thailand. Children (equal numbers of high risk and healthy) are followed for 2 years and parents contacted weekly to inquire about whether their child had acute respiratory illness. Ill children came to the hospital and had a combined nasal and throat swab collected and tested for influenza viruses by realtime reverse transcription polymerase chain reaction (rRT-PCR).5 In addition, a separate nasal swab was taken and tested using 1 of 2 RIDTs made by Quidel (QuickVue A+B during August 2011 to January 20, 2013; Sofia A+B during January 21, 2013 to May 2013). | Of the 1152 specimens tested with QuickVue A+B, 59 (5.1%) were positive by rRT-PCR. Compared with rRT-PCR, Quick-Vue A+B had a sensitivity of 55.9% (33/59; 95% confidence interval (CI): 42.4–68.8%) and a specificity of 99.4% (1086/1093; 95% CI: 98.7–99.7%). Seven (0.6%) were false positive on QuickVue A+B. Of the 370 specimens tested with Sofia A+B, 12 (3.2%) were positive by rRT-PCR. Compared with rRT-PCR, Sofia had a sensitivity of 100% (12/12; 95% CI: 73.5–100.0%) and a specificity of 61.2% (219/358; 95% CI: 55.9–66.3%). One-hundred thirty nine (38.8%) were false positive on Sofia. Of the 139 false positives, 123 (88.5%) were influenza B and 16 were influenza A. There was no difference in the time between illness onset and specimen collection date between true and false positives (median days = 2; P = 0.96), nor was there a difference between the prevalence of influenza during the 2 periods (5.1% vs. 3.2%, P = 0.1). Two lots of the Sofia assay were used and both had poor specificity (data not shown). |
Comparison of a commercial dengue IgM capture ELISA with dengue antigen focus reduction microneutralization test and the Centers for Disease Control Dengue IgM Capture-ELISA
Welch RJ , Chang GJ , Litwin CM . J Virol Methods 2014 195 247-9 Dengue (DENV) infection is caused by an arbovirus that is a member of the family Flaviviridae, genus Flavivirus. The diagnosis of acute dengue infection using clinical signs and symptoms can be difficult since the manifestations cannot be readily differentiated from other infections. Therefore the diagnosis of acute dengue infection depends upon laboratory assays. Dengue virus ELISAs have been designed for the detection of IgM and IgG antibodies in addition to nonstructural 1 (NS1) antigens. The InBios IgM Dengue ELISA was compared to the Antigen Focus Reduction Microneutralization Test (FRmuNT90) and Centers for Disease Control Dengue IgM Capture-ELISA (CDC MAC-ELISA). The calculated sensitivity, specificity and agreement of the InBios ELISA compared to FRmuNT90 and CDC MAC-ELISA was 88.7% (C.I. 81.4-93.7), 93.1% (C.I. 89.1-95.8) and 91.5% (C.I. 86.3-95.0), respectively. In summary the InBios IgM Dengue ELISA sensitivity and specificity is comparable to other commercially available IgM Capture-ELISAs. |
Randomization modeling to ascertain clustering patterns of human papillomavirus types detected in cervicovaginal samples in the United States
Querec TD , Gurbaxani BM , Unger ER . PLoS One 2013 8 (12) e82761 Detection of multiple human papillomavirus (HPV) types in the genital tract is common. Associations among HPV types may impact HPV vaccination modeling and type replacement. The objectives were to determine the distribution of concurrent HPV type infections in cervicovaginal samples and examine type-specific associations. We analyzed HPV genotyping results from 32,245 cervicovaginal specimens collected from women aged 11 to 83 years in the United States from 2001 through 2011. Statistical power was enhanced by combining 6 separate studies. Expected concurrent infection frequencies from a series of permutation models, each with increasing fidelity to the real data, were compared with the observed data. Statistics were computed based on the distributional properties of the randomized data. Concurrent detection occurred more than expected with 0 or ≥3 HPV types and less than expected with 1 and 2 types. Some women bear a disproportionate burden of the HPV type prevalence. Type associations were observed that exceeded multiple hypothesis corrected significance. Multiple HPV types were detected more frequently than expected by chance and associations among particular HPV types were detected. However vaccine-targeted types were not specifically affected, supporting the expectation that current bivalent/quadrivalent HPV vaccination will not result in type replacement with other high-risk types. |
Relative accuracy of serum, whole blood, and oral fluid HIV tests among Seattle men who have sex with men
Stekler JD , O'Neal JD , Lane A , Swanson F , Maenza J , Stevens CE , Coombs RW , Dragavon JA , Swenson PD , Golden MR , Branson BM . J Clin Virol 2013 58 Suppl 1 e119-22 BACKGROUND: Point-of-care (POC) rapid HIV tests have sensitivity during the "window period" comparable only to earliest generation EIAs. To date, it is unclear whether any POC test performs significantly better than others. OBJECTIVE: Compare abilities of POC tests to detect early infection in real time. STUDY DESIGN: Men who have sex with men (MSM) were recruited into a prospective, cross-sectional study at two HIV testing sites and a research clinic. Procedures compared four POC tests: one performed on oral fluids and three on fingerstick whole blood specimens. Specimens from participants with negative POC results were tested by EIA and pooled nucleic acid amplification testing (NAAT). McNemar's exact tests compared numbers of HIV-infected participants detected. RESULTS: Between February 2010 and May 2013, 104 men tested HIV-positive during 2479 visits. Eighty-two participants had concordant reactive POC results, 3 participants had concordant non-reactive POC tests but reactive EIAs, and 8 participants had acute infection. Of 12 participants with discordant POC results, OraQuick ADVANCE Rapid HIV-1/2 Antibody Test performed on oral fluids identified fewer infections than OraQuick performed on fingerstick (p=.005), Uni-Gold Recombigen HIV test (p=.01), and determine HIV-1/2 Ag/Ab combo (p=.005). CONCLUSIONS: These data confirm that oral fluid POC testing detects fewer infections than other methods and is best reserved for circumstances precluding fingerstick or venipuncture. Regardless of specimen type, POC tests failed to identify many HIV-infected MSM in Seattle. In populations with high HIV incidence, the currently approved POC antibody tests are inadequate unless supplemented with p24 antigen tests or NAAT. |
Tuberculosis screening by tuberculosis skin test or QuantiFERON(R)-TB Gold In-Tube Assay among an immigrant population with a high prevalence of tuberculosis and BCG vaccination
Painter JA , Graviss EA , Hai HH , Nhung DT , Nga TT , Ha NP , Wall K , Loan le TH , Parker M , Manangan L , O'Brien R , Maloney SA , Hoekstra RM , Reves R . PLoS One 2013 8 (12) e82727 RATIONALE: Each year 1 million persons acquire permanent U.S. residency visas after tuberculosis (TB) screening. Most applicants undergo a 2-stage screening with tuberculin skin test (TST) followed by CXR only if TST-positive at > 5 mm. Due to cross reaction with bacillus Calmette-Guerin (BCG), TST may yield false positive results in BCG-vaccinated persons. Interferon gamma release assays exclude antigens found in BCG. In Vietnam, like most high TB-prevalence countries, there is universal BCG vaccination at birth. OBJECTIVES: 1. Compare the sensitivity of QuantiFERON (R)-TB Gold In-Tube Assay (QFT) and TST for culture-positive pulmonary TB. 2. Compare the age-specific and overall prevalence of positive TST and QFT among applicants with normal and abnormal CXR. METHODS: We obtained TST and QFT results on 996 applicants with abnormal CXR, of whom 132 had TB, and 479 with normal CXR. RESULTS: The sensitivity for tuberculosis was 86.4% for QFT; 89.4%, 81.1%, and 52.3% for TST at 5, 10, and 15 mm. The estimated prevalence of positive results at age 15-19 years was 22% and 42% for QFT and TST at 10 mm, respectively. The prevalence increased thereafter by 0.7% year of age for TST and 2.1% for QFT, the latter being more consistent with the increase in TB among applicants. CONCLUSIONS: During 2-stage screening, QFT is as sensitive as TST in detecting TB with fewer requiring CXR and being diagnosed with LTBI. These data support the use of QFT over TST in this population. |
Utility of (1-3)-beta-D-glucan testing for diagnostics and monitoring response to treatment during the multistate outbreak of fungal meningitis and other infections
Litvintseva AP , Lindsley MD , Gade L , Smith R , Chiller T , Lyons JL , Thakur KT , Zhang SX , Grgurich DE , Kerkering TM , Brandt ME , Park BJ . Clin Infect Dis 2013 58 (5) 622-30 BACKGROUND: The 2012 outbreak of fungal meningitis associated with contaminated methylprednisolone produced by a compounding pharmacy has resulted in over 750 infections. An important question facing patients and clinicians is the duration of antifungal therapy. We evaluated (1-3)-beta-D-glucan (BDG) as a marker for monitoring response to treatment. METHODS: We determined sensitivity and specificity of BDG testing using the Fungitell assay, by testing 41 cerebrospinal fluid (CSF) specimens from confirmed cases of fungal meningitis and 66 negative control CSFs. We also assessed whether BDG levels correlate with clinical status by using incident samples from 108 case-patients with meningitis and 20 patients with serially collected CSF. RESULTS: A cut-off value of 138 pg/mL provided 100% sensitivity and 98% specificity for diagnosis of fungal meningitis in this outbreak. Patients with serially collected CSF were divided into two groups: those in whom BDG levels declined with treatment and those in whom BDG remained elevated. While most patients with a decline in CSF BDG had clinical improvement, all three patents with continually elevated BDG had poor clinical outcomes (stroke, meningitis relapse, or development of new disease). CONCLUSIONS: Our data suggest that BDG using CSF is a highly sensitive test for diagnosis of fungal meningitis in this outbreak. Analysis of BDG levels in serially collected CSF demonstrated that BDG may correlate with clinical response. Routine measurement of BDG in CSF may provide useful adjunctive data for the clinical management of outbreak-associated meningitis patients. |
Viruses detected among sporadic cases of parotitis, United States, 2009-2011
Barskey AE , Juieng P , Whitaker BL , Erdman DD , Oberste MS , Chern SW , Schmid DS , Radford KW , McNall RJ , Rota PA , Hickman CJ , Bellini WJ , Wallace GS . J Infect Dis 2013 208 (12) 1979-86 BACKGROUND: Sporadic cases of parotitis are generally assumed to be mumps, which often requires a resource-intensive public health response. This project surveyed the frequency of viruses detected among such cases. METHODS: During 2009-2011, 8 jurisdictions throughout the United States investigated sporadic cases of parotitis. Epidemiologic information, serum, and buccal and oropharyngeal swabs were collected. Polymerase chain reaction methods were used to detect a panel of viruses. Anti-mumps virus immunoglobulin M (IgM) antibodies were detected using a variety of methods. RESULTS: Of 101 specimens, 38 were positive for a single virus: Epstein-Barr virus (23), human herpesvirus (HHV)-6B (10), human parainfluenza virus (HPIV)-2 (3), HPIV-3 (1), and human bocavirus (1). Mumps virus, enteroviruses (including human parechovirus), HHV-6A, HPIV-1, and adenoviruses were not detected. Early specimen collection did not improve viral detection rate. Mumps IgM was detected in 17% of available specimens. Patients in whom a virus was detected were younger, but no difference was seen by sex or vaccination profile. No seasonal patterns were identified. CONCLUSIONS: Considering the timing of specimen collection, serology results, patient vaccination status, and time of year may be helpful in assessing the likelihood that a sporadic case of parotitis without laboratory confirmation is mumps. |
The Multispot rapid HIV-1/HIV-2 differentiation assay is comparable with the Western blot and an immunofluorescence assay at confirming HIV infection in a prospective study in three regions of the United States
Pandori MW , Westheimer E , Gay C , Moss N , Fu J , Hightow-Weidman LB , Craw J , Hall L , Giancotti FR , Mak ML , Madayag C , Tsoi B , Louie B , Patel P , Owen SM , Peters PJ . J Clin Virol 2013 58 Suppl 1 e92-6 BACKGROUND: A new HIV diagnostic algorithm has been proposed which replaces the use of the HIV-1 Western blot and HIV-1 immunofluorescence assays (IFA) as the supplemental test with an HIV-1/HIV-2 antibody differentiation assay. OBJECTIVES: To compare an FDA-approved HIV-1/HIV-2 antibody differentiation test (Multispot) as a confirmatory test with the HIV-1 Western blot and IFA. STUDY DESIGN: Participants were screened with an HIV-1/HIV-2 combination Antigen/Antibody (Ag/Ab) screening assay. Specimens with repeatedly reactive results were tested with Multispot and either Western blot or IFA. Specimens with discordant screening and confirmatory results were resolved with HIV-1 RNA testing. RESULTS: Individuals (37,876) were screened for HIV infection and 654 (1.7%) had a repeatedly reactive Ag/Ab assay result. On Multispot, 554 (84.7%) were HIV-1 reactive, 0 (0%) were HIV-2 reactive, 1 (0.2%) was reactive for both HIV-1 and HIV-2 (undifferentiated), 9 (1.4%) were HIV-1 indeterminate, and 90 (13.8%) were non-reactive. HIV-1 RNA was detected in 47/90 Multispot non-reactive (52.2%) specimens. Among specimens confirmed to have HIV infection (true positives), Multispot and Western blot detected HIV-1 antibody in a similar proportion of cases (93.7% vs. 94.4% respectively) while Multispot and IFA also detected HIV-1 antibody in a similar proportion of cases (84.5% vs. 83.4% respectively). CONCLUSIONS: In this study, Multispot confirmed HIV infections at a similar proportion to Western blot and IFA. Multispot, Western blot, and IFA, however, did not confirm all of the reactive Ag/Ab assay results and underscores the importance of HIV NAT testing to resolve discordant screening and confirmatory results. |
Mycobacterium tuberculosis specific CD8(+) T cells rapidly decline with antituberculosis treatment
Nyendak MR , Park B , Null MD , Baseke J , Swarbrick G , Mayanja-Kizza H , Nsereko M , Johnson DF , Gitta P , Okwera A , Goldberg S , Bozeman L , Johnson JL , Boom WH , Lewinsohn DA , Lewinsohn DM . PLoS One 2013 8 (12) e81564 RATIONALE: Biomarkers associated with response to therapy in tuberculosis could have broad clinical utility. We postulated that the frequency of Mycobacterium tuberculosis (Mtb) specific CD8(+) T cells, by virtue of detecting intracellular infection, could be a surrogate marker of response to therapy and would decrease during effective antituberculosis treatment. OBJECTIVES: We sought to determine the relationship of Mtb specific CD4(+) T cells and CD8(+) T cells with duration of antituberculosis treatment. MATERIALS AND METHODS: We performed a prospective cohort study, enrolling between June 2008 and August 2010, of HIV-uninfected Ugandan adults (n = 50) with acid-fast bacillus smear-positive, culture confirmed pulmonary TB at the onset of antituberculosis treatment and the Mtb specific CD4(+) and CD8(+) T cell responses to ESAT-6 and CFP-10 were measured by IFN-gamma ELISPOT at enrollment, week 8 and 24. RESULTS: There was a significant difference in the Mtb specific CD8(+) T response, but not the CD4(+) T cell response, over 24 weeks of antituberculosis treatment (p<0.0001), with an early difference observed at 8 weeks of therapy (p = 0.023). At 24 weeks, the estimated Mtb specific CD8(+) T cell response decreased by 58%. In contrast, there was no significant difference in the Mtb specific CD4(+) T cell during the treatment. The Mtb specific CD4(+) T cell response, but not the CD8(+) response, was negatively impacted by the body mass index. CONCLUSIONS: Our data provide evidence that the Mtb specific CD8(+) T cell response declines with antituberculosis treatment and could be a surrogate marker of response to therapy. Additional research is needed to determine if the Mtb specific CD8(+) T cell response can detect early treatment failure, relapse, or to predict disease progression. |
Planned variation in preanalytical conditions to evaluate biospecimen stability in the National Children's Study (NCS)
Mechanic L , Mendez A , Merrill L , Rogers J , Layton M , Todd D , Varanasi A , O'Brien B , Meyer Iii WA , Zhang M , Schleicher RL , Moye J . Clin Chem Lab Med 2013 51 (12) 2287-94 BACKGROUND: Preanalytical conditions encountered during collection, processing, and storage of biospecimens may influence laboratory results. The National Children's Study (NCS) is a planned prospective cohort study of 100,000 families to examine the influence of a wide variety of exposures on child health. In developing biospecimen collection, processing, and storage procedures for the NCS, we identified several analytes of different biochemical categories for which it was unclear to what extent deviations from NCS procedures could influence measurement results. METHODS: A pilot study was performed to examine effects of preanalytic sample handling conditions (delays in centrifugation, freezing delays, delays in separation from cells, additive delay, and tube type) on concentrations of eight different analytes. A total of 2825 measurements were made to assess 15 unique combinations of analyte and handling conditions in blood collected from 151 women of childbearing age (≥20 individuals per handling condition). RESULTS: The majority of analytes were stable under the conditions evaluated. However, levels of plasma interleukin-6 and serum insulin were decreased in response to sample centrifugation delays of up to 5.5 h post-collection (p<0.0001). In addition, delays in freezing centrifuged plasma samples (comparing 24, 48 and 72 h to immediate freezing) resulted in increased levels of adrenocorticotropic hormone (p=0.0014). CONCLUSION: Determining stability of proposed analytes in response to preanalytical conditions and handling helps to ensure high-quality specimens for study now and in the future. The results inform development of procedures, plans for measurement of analytes, and interpretation of laboratory results. |
Pulmonary cerium dioxide nanoparticle exposure differentially impairs coronary and mesenteric arteriolar reactivity
Minarchick VC , Stapleton PA , Porter DW , Wolfarth MG , Ciftyurek E , Barger M , Sabolsky EM , Nurkiewicz TR . Cardiovasc Toxicol 2013 13 (4) 323-37 Cerium dioxide nanoparticles (CeO2 NPs) are an engineered nanomaterial (ENM) that possesses unique catalytic, oxidative, and reductive properties. Currently, CeO2 NPs are being used as a fuel catalyst but these properties are also utilized in the development of potential drug treatments for radiation and stroke protection. These uses of CeO2 NPs present a risk for human exposure; however, to date, no studies have investigated the effects of CeO2 NPs on the microcirculation following pulmonary exposure. Previous studies in our laboratory with other nanomaterials have shown impairments in normal microvascular function after pulmonary exposures. Therefore, we predicted that CeO2 NP exposure would cause microvascular dysfunction that is dependent on the tissue bed and dose. Twenty-four-hour post-exposure to CeO2 NPs (0-400 mug), mesenteric, and coronary arterioles was isolated and microvascular function was assessed. Our results provided evidence that pulmonary CeO2 NP exposure impairs endothelium-dependent and endothelium-independent arteriolar dilation in a dose-dependent manner. The CeO2 NP exposure dose which causes a 50 % impairment in arteriolar function (EC50) was calculated and ranged from 15 to 100 mug depending on the chemical agonist and microvascular bed. Microvascular assessments with acetylcholine revealed a 33-75 % reduction in function following exposure. Additionally, there was a greater sensitivity to CeO2 NP exposure in the mesenteric microvasculature due to the 40 % decrease in the calculated EC50 compared to the coronary microvasculature EC50. CeO2 NP exposure increased mean arterial pressure in some groups. Taken together, these observed microvascular changes may likely have detrimental effects on local blood flow regulation and contribute to cardiovascular dysfunction associated with particle exposure. |
Pyridoxylamine reactivity kinetics as an amine based nucleophile for screening electrophilic dermal sensitizers
Chipinda I , Mbiya W , Adigun RA , Morakinyo MK , Law BF , Simoyi RH , Siegel PD . Toxicology 2013 315C 102-109 Chemical allergens bind directly, or after metabolic or abiotic activation, to endogenous proteins to become allergenic. Assessment of this initial binding has been suggested as a target for development of assays to screen chemicals for their allergenic potential. Recently we reported a nitrobenzenethiol (NBT) based method for screening thiol reactive skin sensitizers, however, amine selective sensitizers are not detected by this assay. In the present study we describe an amine (pyridoxylamine (PDA)) based kinetic assay to complement the NBT assay for identification of amine-selective and non-selective skin sensitizers. UV-Vis spectrophotometry and fluorescence were used to measure PDA reactivity for 57 chemicals including anhydrides, aldehydes, and quinones where reaction rates ranged from 116 to 6.2x10-6M-1s-1 for extreme to weak sensitizers, respectively. No reactivity towards PDA was observed with the thiol-selective sensitizers, non-sensitizers and prohaptens. The PDA rate constants correlated significantly with their respective murine local lymph node assay (LLNA) threshold EC3 values (R2=0.76). The use of PDA serves as a simple, inexpensive amine based method that shows promise as a preliminary screening tool for electrophilic, amine-selective skin sensitizers. |
Estimates of mumps seroprevalence may be influenced by antibody specificity and serologic method
Latner DR , McGrew M , Williams NJ , Sowers SB , Bellini WJ , Hickman CJ . Clin Vaccine Immunol 2013 21 (3) 286-97 Neutralizing antibodies are assumed to be essential for protection against mumps virus infection, but their measurement is labor and time intensive. For this reason ELISA assays are typically used to measure mumps specific IgG. However, since there is poor correlation between mumps neutralization titers and ELISA assays that measure the presence of mumps specific IgG, ELISA assays that better correlate with neutralization are needed. To address this issue, we measured mumps antibody by plaque reduction neutralization, by a commercial ELISA (whole-virus antigen), and by ELISAs specific for the mumps nucleoprotein and hemagglutinin. The results indicate that differences in the antibody response to the individual mumps proteins could partially explain the lack of correlation among various serologic tests. Furthermore, the data indicate that some seropositive individuals have low levels of neutralizing antibody. If neutralizing antibody is important for protection, this suggests that previous estimates of immunity based on whole-virus ELISA may be overstated. |
Evaluation of pigtail macaques as a model for the effects of copper intrauterine devices on HIV infection
Engel RM , Morris M , Henning T , Ritter JM , Jones TL , Dietz S , Ayers J , Vishwanathan SA , Jenkins L , Zaki S , Wildemeersch D , Garber D , Powell N , Michael Hendry R , McNicholl J , Kersh EN . J Med Primatol 2013 43 (5) 349-59 BACKGROUND: Long-acting, hormonal contraception may increase HIV risk. Copper intrauterine devices (IUDs) could serve as non-hormonal alternatives. We pilot a pigtail macaque model for evaluating HIV susceptibility factors during copper IUD use. METHODS: Frameless and flexible GyneFix(R) copper IUDs were surgically implanted into three SHIVSF 162p3 -positive macaques via hysterotomy and monitored for up to 4 months. Four macaques served as non-IUD controls. RESULTS: All animals retained the devices without complications. No consistent change in vaginal viral RNA or inflammatory cytokines was seen. Two animals had altered menstrual cycles and experienced marked thinning of vaginal epithelium after IUD insertion. Histological examination of uterine tissue at necropsy revealed endometrial ulceration and lymphocytic inflammation with glandular loss at sites of direct IUD contact. CONCLUSIONS: Although the need for insertion surgery could limit its usefulness, this model will allow studies on copper IUDs and SHIV shedding, disease progression, and HIV susceptibility factors. |
Evaluation of the CDC proposed laboratory HIV testing algorithm among men who have sex with men (MSM) from five US metropolitan statistical areas using specimens collected in 2011
Masciotra S , Smith AJ , Youngpairoj AS , Sprinkle P , Miles I , Sionean C , Paz-Bailey G , Johnson JA , Owen SM . J Clin Virol 2013 58 Suppl 1 e8-e12 BACKGROUND: Until recently most testing algorithms in the United States (US) utilized Western blot (WB) as the supplemental test. CDC has proposed an algorithm for HIV diagnosis which includes an initial screen with a Combo Antigen/Antibody 4th generation-immunoassay (IA), followed by an HIV-1/2 discriminatory IA of initially reactive-IA specimens. Discordant results in the proposed algorithm are resolved by nucleic acid-amplification testing (NAAT). OBJECTIVES: Evaluate the results obtained with the CDC proposed laboratory-based algorithm using specimens from men who have sex with men (MSM) obtained in five metropolitan statistical areas (MSAs). STUDY DESIGN: Specimens from 992 MSM from five MSAs participating in the CDC's National HIV Behavioral Surveillance System in 2011 were tested at local facilities and CDC. The five MSAs utilized algorithms of various screening assays and specimen types, and WB as the supplemental test. At the CDC, serum/plasma specimens were screened with 4th generation-IA and the Multispot HIV-1/HIV-2 discriminatory assay was used as the supplemental test. NAAT was used to resolve discordant results and to further identify acute HIV infections from all screened-non-reactive missed by the proposed algorithm. Performance of the proposed algorithm was compared to site-specific WB-based algorithms. RESULTS: The proposed algorithm detected 254 infections. The WB-based algorithms detected 19 fewer infections; 4 by oral fluid (OF) rapid testing and 15 by WB supplemental testing (12 OF and 3 blood). One acute infection was identified by NAAT from all screened-non-reactive specimens. CONCLUSIONS: The proposed algorithm identified more infections than the WB-based algorithms in a high-risk MSM population. OF testing was associated with most of the discordant results between algorithms. HIV testing with the proposed algorithm can increase diagnosis of infected individuals, including early infections. |
Immunologic predictors of coronary artery calcium progression in a contemporary HIV cohort
Baker JV , Hullsiek KH , Singh A , Wilson E , Henry K , Lichtenstein K , Onen N , Kojic E , Patel P , Brooks JT , Hodis HN , Budoff M , Sereti I . AIDS 2013 28 (6) 831-40 BACKGROUND: Identifying immunologic mechanisms that contribute to premature cardiovascular disease (CVD) among HIV-positive patients will inform prevention strategies. METHODS: Coronary artery calcium (CAC) progression was studied in an HIV cohort. Immunophenotypes were measured on baseline cryopreserved peripheral blood mononuclear cells using multicolor flow cytometry. Logistic regression identified predictors of CAC progression after adjusting for traditional and HIV-related risk factors. RESULTS: Baseline characteristics for the analysis cohort (n = 436) were median age 42 years, median CD4 cell count 481 cells/mul, and 78% receiving antiretroviral therapy. Higher frequencies of CD16 monocytes were associated with greater likelihood of CAC progression, after adjusting for traditional and HIV risk factors [odds ratio per doubling was 1.66 for CD14/CD16 (P = 0.02), 1.36 for CD14/CD16 (P = 0.06), and 1.69 for CD14/CD16 (P = 0.01)]. Associations for CD16 monocytes persisted when restricted to participants with viral suppression. We found no significant associations for CAC progression with other cellular phenotypes, including T-cell activation and senescence markers. CONCLUSION: Circulating CD16 monocytes, potentially reflecting a more pro-atherogenic subpopulation, independently predicted greater CAC progression among HIV-infected persons at low risk for AIDS. In contrast to T-cell abnormalities classically associated with AIDS-related disease progression, these data highlight the potential role of monocyte activation in HIV-related CVD risk. |
Aspergillus collagen-like genes (acl): identification, sequence polymorphism, and assessment for PCR-based pathogen detection
Tuntevski K , Durney BC , Snyder AK , Lasala PR , Nayak AP , Green BJ , Beezhold DH , Rio RV , Holland LA , Lukomski S . Appl Environ Microbiol 2013 79 (24) 7882-95 The genus Aspergillus is a burden to public health due to its ubiquitous presence in the environment, its production of allergens, and wide demographic susceptibility among cystic fibrosis, asthmatic, and immunosuppressed patients. Current methods of detection of Aspergillus colonization and infection rely on lengthy morphological characterization or nonstandardized serological assays that are restricted to identifying a fungal etiology. Collagen-like genes have been shown to exhibit species-specific conservation across the noncollagenous regions as well as strain-specific polymorphism in the collagen-like regions. Here we assess the conserved region of the Aspergillus collagen-like (acl) genes and explore the application of PCR amplicon size-based discrimination among the five most common etiologic species of the Aspergillus genus, including Aspergillus fumigatus, A. flavus, A. nidulans, A. niger, and A. terreus. Genetic polymorphism and phylogenetic analysis of the aclF1 gene were additionally examined among the available strains. Furthermore, the applicability of the PCR-based assay to identification of these five species in cultures derived from sputum and bronchoalveolar fluid from 19 clinical samples was explored. Application of capillary electrophoresis on nanogels was additionally demonstrated to improve the discrimination between Aspergillus species. Overall, this study demonstrated that Aspergillus acl genes could be used as PCR targets to discriminate between clinically relevant Aspergillus species. Future studies aim to utilize the detection of Aspergillus acl genes in PCR and microfluidic applications to determine the sensitivity and specificity for the identification of Aspergillus colonization and invasive aspergillosis in immunocompromised subjects. |
Comparative evaluation of vacuum-based surface sampling methods for collection of Bacillus spores
Calfee MW , Rose LJ , Morse S , Mattorano D , Clayton M , Touati A , Griffin-Gatchalian N , Slone C , McSweeney N . J Microbiol Methods 2013 95 (3) 389-96 In this study, four commonly-used sampling devices (vacuum socks, 37mm 0.8mum mixed cellulose ester (MCE) filter cassettes, 37mm 0.3mum polytetrafluoroethylene (PTFE) filter cassettes, and 3M forensic filters) were comparatively evaluated for their ability to recover surface-associated spores. Aerosolized spores (~10(5)CFUcm(-2)) of a Bacillus anthracis surrogate were allowed to settle onto three material types (concrete, carpet, and upholstery). Ten replicate samples were collected using each vacuum method, from each material type. Stainless steel surfaces, inoculated simultaneously with test materials, were sampled with pre-moistened wipes. Wipe recoveries were utilized to normalize vacuum-based recoveries across trials. Recovery (CFUcm(-2)) and relative recovery (vacuum recovery/wipe recovery) were determined for each method and material type. Recoveries and relative recoveries ranged from 3.8x10(3) to 7.4x10(4)CFUcm(-2) and 0.035 to 1.242, respectively. ANOVA results indicated that the 37mm MCE method exhibited higher relative recoveries than the other methods when used for sampling concrete or upholstery. While the vacuum sock resulted in the highest relative recoveries on carpet, no statistically significant difference was detected. The results of this study may be used to guide selection of sampling approaches following biological contamination incidents. |
Comparison of HIV oral fluid and plasma antibody results during early infection in a longitudinal Nigerian cohort
Luo W , Masciotra S , Delaney KP , Charurat M , Croxton T , Constantine N , Blattner W , Wesolowski L , Owen SM . J Clin Virol 2013 58 Suppl 1 e113-8 BACKGROUND: Oral fluid (OF) testing is a less-invasive alternative to blood-based testing for HIV. The performance of HIV OF tests has not been extensively evaluated in serially collected paired specimens from seroconverters. OBJECTIVE: To compare paired OF and plasma test performance in a cohort of HIV-1 seroconverters from Nigeria. STUDY DESIGN: Paired plasma and OF specimens from 14 seroconverters collected during 24 months of longitudinal follow up were included in the study. Plasma and OF were tested using Avioq HIV-1 Microelisa System, and first reactivity in plasma and OF specimens was compared. OF specimens reactive by Avioq were subsequently tested by OraSure HIV-1 Western blot. Genetic Systems HIV-1 Western blot was also performed on the corresponding plasma of the first 2 Avioq-OF positive time-points. RESULTS: Of the 14 seroconverters, 5 (35.7%) had concordant results between plasma and OF for all time points tested, whereas 9 (64.3%) showed reactivity on plasma before OF specimens early in infection. The median delay between plasma and OF reactivity was 29 days (range: 0 day-20 months) (p<0.0039); the median overall delay for OF compared to RNA testing was 69.5 days. Delayed antibody response with OF was observed in both males and females regardless of viral load or HIV subtypes. CONCLUSIONS: Results demonstrate decreased sensitivity of OF testing compared to blood-based testing with specimens obtained early after HIV infection. Programs that utilize OF testing in populations with increased risk of incident HIV infection should understand these limitations of OF testing. |
Decrease in formalin-inactivated respiratory syncytial virus (FI-RSV) enhanced disease with RSV G glycoprotein peptide immunization in BALB/c mice
Rey GU , Miao C , Caidi H , Trivedi SU , Harcourt JL , Tripp RA , Anderson LJ , Haynes LM . PLoS One 2013 8 (12) e83075 Respiratory syncytial virus (RSV) is a high priority target for vaccine development. One concern in RSV vaccine development is that a non-live virus vaccine would predispose for enhanced disease similar to that seen with the formalin inactivated RSV (FI-RSV) vaccine. Since a mAb specific to RSV G protein can reduce pulmonary inflammation and eosinophilia seen after RSV infection of FI-RSV vaccinated mice, we hypothesized that RSV G peptides that induce antibodies with similar reactivity may limit enhanced disease after subunit or other non-live RSV vaccines. In support of this hypothesis, we show that FI-RSV vaccinated mice administered RSV G peptide vaccines had a significant reduction in enhanced disease after RSV challenge. These data support the importance of RSV G during infection to RSV disease pathogenesis and suggest that use of appropriately designed G peptide vaccines to reduce the risk of enhanced disease with non-live RSV vaccines merits further study. |
Development of a Luminex-based multiplex assay for detection of mutations conferring resistance to echinocandins in Candida glabrata
Pham CD , Bolden CB , Kuykendall RJ , Lockhart SR . J Clin Microbiol 2013 52 (3) 790-5 Echinocandins are the recommended treatment for invasive candidiasis due to Candida glabrata. Resistance to echinocandins is known to be caused by non-synonymous mutations in the hotspot-1 (HS1) regions of the FKS1 and FKS2 genes which encode a subunit of the beta-1,3-glucan synthase, the target of the echinocandins. Here, we describe the development of a microsphere-based assay using Luminex MagPix technology to identify mutations in the FKS1 and FKS2 HS1 domains which confer in vitro echinocandin resistance in C. glabrata isolates. The assay is rapid and can be performed with high throughput. The assay was validated using 102 isolates that had FKS1-HS1 and FKS2-HS1 domains previously characterized by DNA sequencing. The assay was 100% concordant with DNA sequencing results. The assay was then used for high throughput screening of 1032 C. glabrata surveillance isolates. Sixteen new isolates with mutations were identified, as well as a mutation new to our collection, del659F. This assay provides a rapid and cost-effective way to screen C. glabrata isolates for echinocandin resistance. |
Diagnostic performance of rectal swab versus bulk stool specimens for the detection of rotavirus and norovirus: Implications for outbreak investigations
Arvelo W , Hall AJ , Estevez A , Lopez B , Gregoricus N , Vinje J , Gentsch JR , Parashar U , Lindblade KA . J Clin Virol 2013 58 (4) 678-82 BACKGROUND: In January of 2008, during the peak of the rotavirus season in Guatemala, a gastroenteritis outbreak with high mortality among infants was reported in Guatemala. Despite extensive efforts, the investigation was limited by the lack of bulk stool specimens collected, particularly from the more severely dehydrated or deceased children. OBJECTIVES: We evaluated the diagnostic performance of rectal swab specimens compared with bulk stool for the detection of rotavirus and norovirus. STUDY DESIGN: Patients with diarrhea (≥3 loose stools in 24h) were enrolled through an ongoing surveillance system in Guatemala. From January through March 2009, we attempted to enroll 100 patients <5 years old captured by the diarrhea surveillance, and collected paired bulk stool and rectal swabs specimens from them. Specimens were tested for norovirus using real-time reverse transcription-polymerase chain reaction and for rotavirus via enzyme immunoassay. RESULTS: We enrolled 102 patients with paired specimens; 91% of 100 paired specimens tested for rotavirus yielded concordant results positive for rotavirus with a negativity rate of 83%. Among 100 paired specimens tested for norovirus, 86% were concordant norovirus detection and the negativity rate was 85%. The diagnostic performance for rotavirus and norovirus detection did not differ significantly between the two specimen types. CONCLUSIONS: Testing of properly collected fecal specimens using rectal swabs may be a viable alternative to bulk stool for detection of rotavirus and norovirus, particularly during outbreaks where collection of bulk stool may be difficult. |
Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011
Visser SN , Danielson ML , Bitsko RH , Holbrook JR , Kogan MD , Ghandour RM , Perou R , Blumberg SJ . J Am Acad Child Adolesc Psychiatry 2014 53 (1) 34-46 e2 OBJECTIVE: Data from the 2003 and 2007 National Survey of Children's Health (NSCH) reflect the increasing prevalence of parent-reported attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment by health care providers. This report updates these prevalence estimates for 2011 and describes temporal trends. METHOD: Weighted analyses were conducted with 2011 NSCH data to estimate prevalence of parent-reported ADHD diagnosis, current ADHD, current medication treatment, ADHD severity, and mean age of diagnosis for U.S. children/adolescents aged 4 to 17 years and among demographic subgroups. A history of ADHD diagnosis (2003-2011), as well as current ADHD and medication treatment prevalence (2007-2011), were compared using prevalence ratios and 95% confidence intervals. RESULTS: In 2011, 11% of children/adolescents aged 4 to 17 years had ever received an ADHD diagnosis (6.4 million children). Among those with a history of ADHD diagnosis, 83% were reported as currently having ADHD (8.8%); 69% of children with current ADHD were taking medication for ADHD (6.1%, 3.5 million children). A parent-reported history of ADHD increased by 42% from 2003 to 2011. Prevalence of a history of ADHD, current ADHD, medicated ADHD, and moderate/severe ADHD increased significantly from 2007 estimates. Prevalence of medicated ADHD increased by 28% from 2007 to 2011. CONCLUSIONS: Approximately 2 million more U.S. children/adolescents aged 4 to 17 years had been diagnosed with ADHD in 2011, compared to 2003. More than two-thirds of those with current ADHD were taking medication for treatment in 2011. This suggests an increasing burden of ADHD on the U.S. health care system. Efforts to further understand ADHD diagnostic and treatment patterns are warranted. |
Maternal mortality and morbidity in the United States: where are we now?
Creanga AA , Berg CJ , Ko JY , Farr SL , Tong VT , Bruce FC , Callaghan WM . J Womens Health (Larchmt) 2014 23 (1) 3-9 This article provides a brief overview of the work conducted by the Division of Reproductive Health at the Centers for Disease Control and Prevention on severe maternal morbidity and mortality in the United States. The article presents the latest data and trends in maternal mortality and severe maternal morbidity, as well as on maternal substance abuse and mental health disorders during pregnancy, two relatively recent topics of interest in the Division, and includes future directions of work in all these areas. |
Prevalence of cerebral palsy, co-occurring autism spectrum disorders, and motor functioning - Autism and Developmental Disabilities Monitoring Network, USA, 2008
Christensen D , Van Naarden Braun K , Doernberg NS , Maenner MJ , Arneson CL , Durkin MS , Benedict RE , Kirby RS , Wingate MS , Fitzgerald R , Yeargin-Allsopp M . Dev Med Child Neurol 2014 56 (1) 59-65 AIM: The aim of this study was to report the prevalence and characteristics of children with cerebral palsy (CP). METHOD: Children with CP (n=451) were ascertained by the Autism and Developmental Disabilities Monitoring (ADDM) Network, a population-based, record-review surveillance system monitoring CP in four areas of the USA. Prevalence was calculated as the number of children with CP among all 8-year-old children residing in these areas in 2008. Motor function was categorized by Gross Motor Function Classification System level and walking ability. Co-occurring autism spectrum disorders (ASD) and epilepsy were ascertained using ADDM Network surveillance methodology. RESULTS: The period prevalence of CP for 2008 was 3.1 per 1000 8-year-old children (95% confidence interval 2.8-3.4). Approximately 58% of children walked independently. Co-occurring ASD frequency was 6.9% and was higher (18.4%) among children with non-spastic CP, particularly hypotonic CP. Co-occurring epilepsy frequency was 41% overall, did not differ by ASD status or CP subtype, and was highest (67%) among children with limited or no walking ability. INTERPRETATION: The prevalence of CP in childhood from US surveillance data has remained relatively constant, in the range of 3.1 to 3.6 per 1000, since 1996. The higher frequency of ASD in non-spastic than in spastic subtypes of CP calls for closer examination. |
Excess screen time in US children: association with family rules and alternative activities
Gingold JA , Simon AE , Schoendorf KC . Clin Pediatr (Phila) 2014 53 (1) 41-50 We describe the association of screen time in excess of American Academy of Pediatrics recommendations (≤2 h/d) with family television-use policies and regular nonscreen activities among US school-aged children. Data from the 2007 National Survey of Children's Health were used. The sum of minutes spent on television, videos, video games, and recreational computer use was calculated for children 6 to 17 years old. Bivariate and multivariate logistic regression models were used to calculate relative odds of exceeding American Academy of Pediatrics guidelines and of heavy screen use (>4 h/d) for varying family media-use policies and frequency of alternative activities (physical activity and family meals). In all, 49% of school-aged children had screen time >2 h/d and 16% had screen time >4 h/d. Lower frequency of family meals, presence of TV in the bedroom, absence of rules about TV viewing, and less physical activity were associated with both >2 and >4 hours per day of screen time. |
Financial and nonfinancial burden among families of CSHCN: changes between 2001 and 2009-2010
Ghandour RM , Hirai AH , Blumberg SJ , Strickland BB , Kogan MD . Acad Pediatr 2014 14 (1) 92-100 OBJECTIVE: We use the latest data to explore multiple dimensions of financial burden among children with special health care needs (CSHCN) and their families in 2009-2010 and changes since 2001. METHODS: Five burden indicators were assessed using the 2001 and 2009-2010 National Surveys of CSHCN: past-year health-related out-of-pocket expenses of ≥$1,000 or ≥3% of household income; perceived financial problems; changes in family employment; and >10 hours of weekly care provision/coordination. Unadjusted and adjusted prevalence estimates were used to assess burden in 2009-2010 and calculate absolute and relative measures of change since 2001. Prevalence rate ratios for each burden type in 2009-2010 compared to 2001 were estimated by logistic regression. RESULTS: Nearly half of CSHCN and their families experienced some form of burden in 2009-2010. The percentage of CSHCN living in families that paid ≥$1,000 or ≥3% of household income out of pocket for health care rose 120% and 35%, respectively, between 2001 and 2009-2010, while the prevalence of caregiving and employment burdens declined. Relative to 2001, in 2009-2010, CSHCN who were privately insured or least affected by their conditions were 1.7 times as likely to live in families that paid ≥3% of household income out of pocket, while publicly insured children were 20% less likely to do so and those most severely affected were 12% more likely to do so. CONCLUSIONS: Over the past decade, increases in financial burden and declines in employment and caregiving burdens were observed for CSHCN families. Public insurance expansions may have buffered increases in financial burden, yet disparities persist. |
National trends in primary cesarean delivery, labor attempts, and labor success, 1990-2010
Simon AE , Uddin SG . Am J Obstet Gynecol 2013 209 (6) 554 e1-8 OBJECTIVE: The national primary cesarean delivery rate increased until 2004, but after 2004, this rate cannot be tracked using Vital Statistics data. Additionally, it is unknown whether changes in the primary cesarean delivery rate reflect changes in the rate of labor attempts, labor success, or both. Here, using hospital discharge data, we examined national trends in primary cesarean deliveries, labor attempts, and labor success among women without prior cesarean delivery between 1990 and 2010. STUDY DESIGN: This analysis of serial cross-sectional data from the National Hospital Discharge Survey used Joinpoint regression to assess trends over time and logistic regression with marginal effects to identify rates of change over time and adjust for demographic and clinical factors. RESULTS: The primary cesarean delivery rate declined 0.2 percentage points per year (95% confidence interval [CI], 0.1-0.3) between 1990 and 1999, increased 1.0 percentage point per year (95% CI, 0.8-1.2) between 1999 and 2004, and increased 0.3 percentage points (95% CI, 0.1-0.6) per year from 2004 until 2010. Between 1998 and 2005, the rate of labor attempts declined 0.4 percentage points (95% CI, 0.3-0.5) per year. No changes in the labor attempt rate occurred between 2005 and 2010. Labor success rates increased 0.2 percentage points (95% CI, 0.1-0.3) per year between 1990 and 1998 but then declined 0.5 (95% CI, 0.5-0.8) percentage points per year from 1998 to 2010. Adjusted results were similar. CONCLUSION: The primary cesarean delivery rate continued to increase after 2004. Increases in the primary cesarean delivery rate after 2005 were driven by declines in labor success rates. |
The effect of cotrimoxazole prophylactic treatment on malaria, birth outcomes, and postpartum CD4 count in HIV-infected women
Dow A , Kayira D , Hudgens MG , Van Rie A , King CC , Ellington S , Chome N , Kourtis A , Turner AN , Kacheche Z , Jamieson DJ , Chasela C , van der Horst C . Infect Dis Obstet Gynecol 2013 2013 340702 BACKGROUND: Limited data exist on cotrimoxazole prophylactic treatment (CPT) in pregnant women, including protection against malaria versus standard intermittent preventive therapy with sulfadoxine-pyrimethamine (IPTp). METHODS: Using observational data we examined the effect of CPT in HIV-infected pregnant women on malaria during pregnancy, low birth weight and preterm birth using proportional hazards, logistic, and log binomial regression, respectively. We used linear regression to assess effect of CPT on CD4 count. RESULTS: Data from 468 CPT-exposed and 768 CPT-unexposed women were analyzed. CPT was associated with protection against malaria versus IPTp (hazard ratio: 0.35, 95% Confidence Interval (CI): 0.20, 0.60). After adjustment for time period this effect was not statistically significant (adjusted hazard ratio: 0.66, 95% CI: 0.28, 1.52). Among women receiving and not receiving CPT, rates of low birth weight (7.1% versus 7.6%) and preterm birth (23.5% versus 23.6%) were similar. CPT was associated with lower CD4 counts 24 weeks postpartum in women receiving (-77.6 cells/ mu L, 95% CI: -125.2, -30.1) and not receiving antiretrovirals (-33.7 cells/ mu L, 95% CI: -58.6, -8.8). CONCLUSIONS: Compared to IPTp, CPT provided comparable protection against malaria in HIV-infected pregnant women and against preterm birth or low birth weight. Possible implications of CPT-associated lower CD4 postpartum warrant further examination. |
Health care needs of children with Tourette syndrome
Bitsko RH , Danielson M , King M , Visser SN , Scahill L , Perou R . J Child Neurol 2013 28 (12) 1626-36 To document the impact of Tourette syndrome on the health care needs of children and access to health care among youth with Tourette syndrome, parent-reported data from the 2007-2008 National Survey of Children's Health were analyzed. Children with Tourette syndrome had more co-occurring mental disorders than children with asthma or children without Tourette syndrome or asthma and had health care needs that were equal to or greater than children with asthma (no Tourette syndrome) or children with neither asthma nor Tourette syndrome. Health care needs were greatest among children with Tourette syndrome and co-occurring mental disorders, and these children were least likely to receive effective care coordination. Addressing co-occurring conditions may improve the health and well-being of children with Tourette syndrome. Strategies such as integration of behavioral health and primary care may be needed to improve care coordination. |
Hospitalizations and deaths caused by diarrhea in children five years old and younger at four hospitals in Haiti, 2010-2012
Derby KS , Lucien MA , Leshem E , Steenland MW , Juin S , Gerard AJ , Katz MA . Am J Trop Med Hyg 2013 90 (2) 291-3 Worldwide, diarrhea is a major contributor to morbidity and mortality in children; however, there are few data on the burden of diarrheal disease in Haiti. We conducted a retrospective review of hospital discharge registries from 2010 to 2012 in the pediatric wards of four Haitian hospitals and recorded the number of all-cause hospitalizations and deaths as well as diarrheal hospitalizations and deaths by age (≤ 2 and 3-5 years) and epidemiological week. Diarrhea was associated with 3,582 (33.7%) of 10,621 hospitalizations and 62 (11.5%) of 540 in-hospital deaths in children ≤ 5 years old. Of these children, 88.5% and 96.8%, respectively, were among children ≤ 2 years old. The highest proportions of diarrhea-associated hospitalizations occurred from January to April. At four Haitian hospitals over a 3-year period, during which time a major epidemic of cholera occurred, diarrheal disease in children ≤ 5 years was a major contributor to pediatric hospitalizations and mortality. |
Body mass index and birth defects: Texas, 2005-2008
Marengo L , Farag NH , Canfield M . Matern Child Health J 2013 17 (10) 1898-907 Texas ranks 12th nationally in the proportion of adult residents who are obese; approximately 67 % of Texans are overweight or obese. Studies indicate that obesity is related to an increased risk for birth defects; however, small sample sizes have limited the scope of birth defects investigated, and only four levels of body mass index (BMI) are typically explored. Using six BMI levels, we evaluated the association between maternal BMI and birth defects in a population-based registry covering ~1.6 million births. Texas birth defect cases were linked to 2005-2008 vital records. Maternal BMI was calculated using self-reported prepregnancy weight and height from the vital record and categorized as follows: underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), class I obese (BMI 30-34.9), class II obese (BMI 35-39.9) and class III obese (BMI ≥40). Prevalence ratios for specific birth defects for maternal BMI categories were estimated by using normal weight as the referent, adjusted for maternal age and race/ethnicity, and stratified by maternal diabetes status. Risk for certain birth defects increased with increasing BMI (i.e., atrial and ventricular septal defects, pulmonary valve atresia, patent ductus arteriosus, and clubfoot). Risk for birth defects was substantially increased among some obese mothers (BMI ≥30) (e.g., spina bifida, tetralogy of Fallot, cleft lip with or without cleft palate, hypospadias, and epispadias). Conversely, mothers with higher BMI had a lower risk for having an infant or fetus with gastroschisis (aPR = 0.35; 95 % CI = 0.12, 0.80). Given the increased risk for birth defects associated with obesity, preconception counseling should emphasize the importance of maintaining normal weight. |
Reducing sodium across the board: a pilot program in Schenectady County independent restaurants
Schuldt J , Levings JL , Kahn-Marshall J , Hunt G , Mugavero K , Gunn JP . J Public Health Manag Pract 2014 20 S31-7 Excess sodium intake can lead to increased blood pressure. Restaurant foods contribute nearly a quarter of the sodium consumed in the American diet. The objective of the pilot project was to develop and implement in collaboration with independent restaurants a tool, the Restaurant Assessment Tool and Evaluation (RATE), to assess efforts to reduce sodium in independent restaurants and measure changes over time in food preparation categories, including menu, cooking techniques, and products. Twelve independent restaurants in Schenectady County, New York, voluntarily participated. From initial assessment to a 6-month follow-up assessment using the RATE, 11 restaurants showed improvement in the cooking category, 9 showed improvement in the menu category, and 7 showed improvement in the product category. Menu analysis conducted by the Schenectady County Health Department staff suggested that reported sodium-reduction strategies might have affected approximately 25% of the restaurant menu items. The findings from this project suggest that a facilitated assessment, such as the RATE, can provide a useful platform for independent restaurant owners and public health practitioners to discuss and encourage sodium reduction. The RATE also provides opportunities to build and strengthen relationships between public health care practitioners and independent restaurant owners, which may help sustain the positive changes made. |
Sodium reduction: an important public health strategy for heart health
Mugavero KL , Gunn JP , Dunet DO , Bowman BA . J Public Health Manag Pract 2014 20 S1-5 High intake of dietary sodium is associated with elevated blood pressure, which increases the risk of heart disease and stroke.1 Heart disease and stroke are the first and fourth leading causes of death in the United States2; from a public health perspective, this makes control of hypertension an important issue. | To address this, the Million Hearts initiative (led by the US Department of Health and Human Services), Dietary Guidelines for Americans, Healthy People 2020, and guidelines from numerous health organizations recommend reducing the amount of sodium consumed in the diet.3 Most sodium consumed by Americans comes from processed and restaurant foods. Because these sources make up a large part of the American diet and because consumers have little control over the level of sodium in these foods, it is often difficult for consumers to reduce their sodium intake.4 Many of the ingredients and food products served in schools, work sites, and group meal sites such as senior citizen centers contain high levels of sodium. Even when food purchasers and food service staff try to offer healthier food options, lower-sodium ingredients and products may not be easily available and accessible. |
Sodium-reduction strategies for meals prepared for older adults
Losby JL , Patel D , Schuldt J , Hunt GS , Stracuzzi JC , Johnston Y . J Public Health Manag Pract 2014 20 S23-30 This article describes lessons learned from implementing sodium-reduction strategies in programs that provide meals to older adults in 2 New York counties, with one county replicating the approaches of the other. The implemented sodium-reduction strategies were product substitutions, recipe modifications, and cooking from scratch. Both counties were able to achieve modest sodium reductions in prepared meals. Lessons learned to implement sodium reduction strategies include the following: (1) identifying partners with shared experience and common goals; (2) engaging experts; (3) understanding the complexity of the meals system for older adults; (4) conducting sodium nutrient analysis; (5) making gradual and voluntary reductions to sodium content; and (6) working toward sustainable sodium reduction. |
Use of environmental change strategies to facilitate sodium reduction: a case study in a rural California school district
Taylor S , Tibbett T , Patel D , Bishop E . J Public Health Manag Pract 2014 20 S38-42 CONTEXT: Excess sodium consumption increases the risk for hypertension, which is a leading risk factor for cardiovascular disease. For children and teenagers, school meals are a significant source of sodium consumption. OBJECTIVE: To describe the environmental change strategies that were implemented to reduce sodium in the school meals of a rural California school district. DESIGN: Descriptions of the environmental strategies, with an emphasis on staff training and infrastructure improvements. SETTING: School district of approximately two thousand 9th- to 12th-grade students in rural, northern California. PARTICIPANTS: School administration and food service staff at the 5 high schools in Anderson Union High School District. INTERVENTION: Shasta County Public Health partnered with Anderson Union High School District to (1) facilitate changes to meal preparation practices, (2) improve cafeteria infrastructure, and (3) provide training and technical assistance to improve procurement strategies. RESULTS: Environmental strategies to reduce sodium in school meals were implemented in 2011. Anderson Union High School District has continued to successfully implement scratch cooking and improve procurement strategies to reduce sodium in school meals. CONCLUSION: Using an approach that includes environmental change strategies can lead to sodium reduction in a school setting. |
Insurance coverage of medical foods for treatment of inherited metabolic disorders
Berry SA , Kenney MK , Harris KB , Singh RH , Cameron CA , Kraszewski JN , Levy-Fisch J , Shuger JF , Greene CL , Lloyd-Puryear MA , Boyle CA . Genet Med 2013 15 (12) 978-82 PURPOSE: Treatment of inherited metabolic disorders is accomplished by use of specialized diets employing medical foods and medically necessary supplements. Families seeking insurance coverage for these products express concern that coverage is often limited; the extent of this challenge is not well defined. METHODS: To learn about limitations in insurance coverage, parents of 305 children with inherited metabolic disorders completed a paper survey providing information about their use of medical foods, modified low-protein foods, prescribed dietary supplements, and medical feeding equipment and supplies for treatment of their child's disorder as well as details about payment sources for these products. RESULTS: Although nearly all children with inherited metabolic disorders had medical coverage of some type, families paid "out of pocket" for all types of products. Uncovered spending was reported for 11% of families purchasing medical foods, 26% purchasing supplements, 33% of those needing medical feeding supplies, and 59% of families requiring modified low-protein foods. Forty-two percent of families using modified low-protein foods and 21% of families using medical foods reported additional treatment-related expenses of $100 or more per month for these products. CONCLUSION: Costs of medical foods used to treat inherited metabolic disorders are not completely covered by insurance or other resources. |
Safety activities in small businesses
Sinclair Raymond C , Cunningham Thomas R . Saf Sci 2014 64 32-38 BACKGROUND: Workplace injuries occur at higher rates in smaller firms than in larger firms, and the number of workplace safety activities appear to be inversely associated with those rates. Predictors of safety activities are rarely studied. METHODS: This study uses data from a national random survey of firms (n= 722) with less than 250 employees conducted in 2002. RESULTS: We found that, regardless of firm size or industry, safety activities were more common in 2002 than they were in a similar 1983 study. Having had an OSHA inspection in the last five years and firm size were stronger predictors of safety activities than industry hazardousness and manager's perceptions of hazardousness. All four variables were significant predictors ( range .19 to .28; R2= 27). CONCLUSIONS: Further progress in the prevention of injuries in small firms will require attention to factors likely subsumed within the firm size variable, especially the relative lack of slack resources that might be devoted to safety activities. 2013. |
Application of a translational research model to assess the progress of occupational safety research in the international commercial fishing industry
Lucas DL , Kincl LD , Bovbjerg VE , Lincoln JM . Saf Sci 2014 64 71-81 Translating basic science research into population-level health benefits is a challenge in all areas of public health, including occupational safety in the fishing industry. Translational research is a process for developing evidence-based interventions and implementing them in practice. The purpose of this study was to organize the literature on occupational safety in the fishing industry within the T0-T4 phases of translational research to identify areas of strength and consensus, as well as gaps for future translational research to address. A comprehensive search of the English language literature on the topic of occupational safety in the fishing industry was completed. Scientific investigations of safety problems in the fishing industry first appeared in the literature during the 1950s. The bulk of research has focused on descriptive epidemiology in the T0 phase of translational research. A positive trend in recent studies is the growing emphasis on translational research (i.e. the T1-T4 phases). These types of studies aim to move research-to-practice by investigating potential solutions to safety problems and by developing, implementing and evaluating interventions. Recommendations for future translational research include using consistent methods of injury classification and risk analysis, developing interventions targeted at specific problems in the highest-risk fisheries, and addressing the barriers and facilitators to widespread implementation of interventions. Workplace safety in the fishing industry will improve if future research concentrates on identifying and testing promising safety measures that are effective, practical and scalable. Translational research is the key to making progress toward the prevention of work-related injuries in the fishing industry. 2013. |
Case studies: evaluation of cut-resistant sleeves and possible fiberglass fiber shedding at a steel mill
Ceballos DM , Tapp LC , Wiegand DM . J Occup Environ Hyg 2014 11 (2) D28-33 The National Institute for Occupational Safety and Health (NIOSH) received a health hazard evaluation (HHE) request from employees and union representatives at a steel mill. They were concerned with skin and upper respiratory irritation, and safety and hygiene issues regarding the required use of cut-resistant protective sleeves. The manufacturer of the cut-resistant sleeves reported that the sleeves were made of a blended weave of para-aramid (Kevlar), cellulose, and E-glass fibers. New sleeves were shown to emit very few fibers into the air under controlled use conditions.(1) However, employees were concerned that the sleeves could shed respirable fiberglass fibers, that this shedding could increase after repeated launderings, and that this exposure could cause skin irritation, respiratory irritation, or chronic respiratory disease. | During our evaluation, we met with union representatives and company health and safety managers, toured the facility, and confidentially interviewed employees. We collected surface samples using either Stick-to-it lift tape (SKC Inc., Eighty Four, Pa.) or vacuuming with a polycarbonate filter from work surfaces, workers’ skin, and workers’ clothing, including the surface of new and laundered protective sleeves. We also collected bulk samples of new and laundered protective sleeves and other potential sources of fibers at the steel mill (i.e., insulation materials). These samples were analyzed by stereomicroscope and polarized light microscopy for identification of fiberglass, Kevlar, and cellulose fibers, as well as for fiber morphology and size. This case study focuses on the industrial hygiene sampling component of our evaluation. Information regarding the medical interviews, and safety and hygiene issues related to the use of the sleeves can be found in the NIOSH HHE report. (2) |
Characterization of exposures to workers covered under the U.S. Energy Employees Compensation Act
Neton JW . Health Phys 2014 106 (2) 249-58 Since the mid-1940s, hundreds of thousands of workers have been engaged in nuclear weapons-related activities for the U.S. Department of Energy (DOE) and its predecessor agencies. In 2000, Congress promulgated the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), which provides monetary compensation and medical benefits to certain energy employees who have developed cancer. Under Part B of EEOICPA, the National Institute for Occupational Safety and Health (NIOSH) is required to estimate radiation doses for those workers who have filed a claim, or whose survivors have filed a claim, under Part B of the Act. To date, over 39,000 dose reconstructions have been completed for workers from more than 200 facilities. These reconstructions have included assessment of both internal and external exposure at all major DOE facilities, as well as at a large number of private companies [known as Atomic Weapons Employer (AWE) facilities in the Act] that engaged in contract work for the DOE and its predecessor agencies. To complete these dose reconstructions, NIOSH has captured and reviewed thousands of historical documents related to site operations and worker/workplace monitoring practices at these facilities. Using the data collected and reviewed pursuant to NIOSH's role under EEOICPA, this presentation will characterize historical internal and external exposures received by workers at DOE and AWE facilities. To the extent possible, use will be made of facility specific coworker models to highlight changes in exposure patterns over time. In addition, the effects that these exposures have on compensation rates for workers are discussed.Introduction of Characterization of Exposures to Workers (Video 1:59, http://links.lww.com/HP/A3). |
Determining sample size and a passing criterion for respirator fit-test panels
Landsittel D , Zhuang Z , Newcomb W , Berry Ann R . J Occup Environ Hyg 2014 11 (2) 77-84 Few studies have proposed methods for sample size determination and specification of passing criterion (e.g., number needed to pass from a given size panel) for respirator fit-tests. One approach is to account for between- and within- subject variability, and thus take full advantage of the multiple donning measurements within subject, using a random effects model. The corresponding sample size calculation, however, may be difficult to implement in practice, as it depends on the model-specific and test panel-specific variance estimates, and thus does not yield a single sample size or specific cutoff for number needed to pass. A simple binomial approach is therefore proposed to simultaneously determine both the required sample size and the optimal cutoff for the number of subjects needed to achieve a passing result. The method essentially conducts a global search of the type I and type II errors under different null and alternative hypotheses, across the range of possible sample sizes, to find the lowest sample size which yields at least one cutoff satisfying, or approximately satisfying all pre-determined limits for the different error rates. Benchmark testing of 98 respirators (conducted by the National Institute for Occupational Safety and Health) is used to illustrate the binomial approach and show how sample size estimates from the random effects model can vary substantially depending on estimated variance components. For the binomial approach, probability calculations show that a sample size of 35 to 40 yields acceptable error rates under different null and alternative hypotheses. For the random effects model, the required sample sizes are generally smaller, but can vary substantially based on the estimate variance components. Overall, despite some limitations, the binomial approach represents a highly practical approach with reasonable statistical properties. |
Retrospective cohort study of a microelectronics and business machine facility
Silver SR , Pinkerton LE , Fleming DA , Jones JH , Allee S , Luo L , Bertke SJ . Am J Ind Med 2013 57 (4) 412-24 OBJECTIVES: We examined health outcomes among 34,494 workers employed at a microelectronics and business machine facility 1969-2001. METHODS: Standardized mortality ratio (SMR) and standardized incidence ratios were used to evaluate health outcomes in the cohort and Cox regression modeling to evaluate relations between scores for occupational exposures and outcomes of a priori interest. RESULTS: Just over 17% of the cohort (5,966 people) had died through 2009. All cause, all cancer, and many cause-specific SMRs showed statistically significant deficits. In hourly males, SMRs were significantly elevated for non-Hodgkin's lymphoma and rectal cancer. Salaried males had excess testicular cancer incidence. Pleural cancer and mesothelioma excesses were observed in workers hired before 1969, but no available records substantiate use of asbestos in manufacturing processes. A positive, statistically significant relation was observed between exposure scores for tetrachloroethylene and nervous system diseases. CONCLUSIONS: Few significant exposure-outcome relations were observed, but risks from occupational exposures cannot be ruled out due to data limitations and the relative youth of the cohort. |
Physiological evaluation of air-fed ensembles
Turner NL , Powell JB , Sinkule EJ , Novak DA . Ann Occup Hyg 2013 58 (2) 241-50 The goal of this study was to evaluate the respiratory and metabolic stresses of air-fed ensembles used by workers in the nuclear, chemical, and pharmaceutical industries during rest, low-, and moderate-intensity treadmill exercise. Fourteen men and six women wore two different air-fed ensembles (AFE-1 and AFE-2) and one two-piece supplied-air respirator (SA) at rest (REST) and while walking for 6min at oxygen consumption (V.O2) rates of 1.0 (LOW) and 2.0 l min-1 (MOD). Inhaled CO2 (FICO2), inhaled O2 (FIO2), pressure, and temperature were measured continuously breath-by-breath. For both LOW and MOD, FICO2 was significantly lower (P < 0.03) and FIO2 was significantly greater (P < 0.008) for SA compared with AFE-1 and AFE-2 in women, while in men, similar trends were observed. Significantly lower FICO2 (P < 0.009) and significantly greater FIO2 (P < 0.04) were consistently observed in AFE-1 compared with AFE-2 in men during LOW and MOD. For both men and women, average FICO2 exceeded 2.0% in AFE-2 during MOD. During LOW and MOD, average FIO2 in AFE-1 and AFE-2 dropped <19.5% in men and women. For men and women, average inhalation pressures (PIave) were significantly greater in both air-fed ensembles than SA (P < 0.001) during REST, LOW, and MOD. Inhaled gas temperature was significantly lower in SA than in either air-fed ensemble (P < 0.001). When the air supply was shut off during walking, the time taken for minimum FICO2 to reach 2.0% was <38 s for all three ensembles in both men and women, an observation that has implications for the design of emergency escape protocols for air-fed ensemble wearers. Results show that inhaled gas concentrations may reach physiologically stressful levels in air-fed ensembles during moderate-intensity treadmill walking. |
The effects of impact vibration on peripheral blood vessels and nerves
Krajnak KM , Waugh S , Johnson C , Miller GR , Xu X , Warren C , Dong RG . Ind Health 2013 51 (6) 572-80 Research regarding the risk of developing hand-arm vibration syndrome after exposure to impact vibration has produced conflicting results. This study used an established animal model of vibration-induced dysfunction to determine how exposure to impact vibration affects peripheral blood vessels and nerves. The tails of male rats were exposed to a single bout of impact vibration (15 min exposure, at a dominant frequency of 30 Hz and an unweighted acceleration of approximately 345 m/s(2)) generated by a riveting hammer. Responsiveness of the ventral tail artery to adrenoreceptor-mediated vasoconstriction and acetylcholine-mediated re-dilation was measured ex vivo. Ventral tail nerves and nerve endings in the skin were assessed using morphological and immunohistochemical techniques. Impact vibration did not alter vascular responsiveness to any factors or affect trunk nerves. However, 4 days following exposure there was an increase in protein-gene product (PGP) 9.5 staining around hair follicles. A single exposure to impact vibration, with the exposure characteristics described above, affects peripheral nerves but not blood vessels. |
Impact of low filter resistances on subjective and physiological responses to filtering facepiece respirators
Roberge RJ , Kim JH , Powell JB , Shaffer RE , Ylitalo CM , Sebastian JM . PLoS One 2013 8 (12) e84901 Ten subjects underwent treadmill exercise at 5.6 km/h over one hour while wearing each of three identical appearing, cup-shaped, prototype filtering facepiece respirators that differed only in their filter resistances (3 mm, 6 mm, and 9 mm H2O pressure drop). There were no statistically significant differences between filtering facepiece respirators with respect to impact on physiological parameters (i.e., heart rate, respiratory rate, oxygen saturation, transcutaneous carbon dioxide levels, tympanic membrane temperature), pulmonary function variables (i.e., tidal volume, respiratory rate, volume of carbon dioxide production, oxygen consumption, or ventilation), and subjective ratings (i.e., exertion, thermal comfort, inspiratory effort, expiratory effort and overall breathing comfort). The nominal filter resistances of the prototype filtering facepiece respirators correspond to airflow resistances ranging from 2.1 - 6.6 mm H2O/L/s which are less than, or minimally equivalent to, previously reported values for the normal threshold for detection of inspiratory breathing resistance (6 - 7.6 mm H2O/L/sec). Therefore, filtering facepiece respirators with filter resistances at, or below, this level may not impact the wearer differently physiologically or subjectively from those with filter resistances only slightly above this threshold at low-moderate work rates over one hour. |
Job control, psychological demand, and farmworker health: evidence from the National Agricultural Workers Survey
Grzywacz JG , Alterman T , Gabbard S , Shen R , Nakamoto J , Carroll DJ , Muntaner C . J Occup Environ Med 2013 56 (1) 66-71 OBJECTIVE: Improve understanding of the potential occupational health impact of how agricultural jobs are organized. Exposure to low job control, high psychological demands, and high job strain were hypothesized to have greater risk for poor self-rated physical health and elevated depressive symptoms. METHODS: Cross-sectional data (N = 3691) obtained using the Work Organization and Psychosocial Factors module of the US National Agricultural Workers Survey fielded in 2009-2010. RESULTS: More than one fifth (22.4%) of farmworkers reported fair/poor health, and 8.7% reported elevated depressive symptoms. High psychological demand was associated with increased risk of fair/poor health (odds ratio, 1.73; 95% confidence interval, 1.4 to 2.2) and elevated depressive symptoms (odds ratio, 2.6; 95% confidence interval, 1.9 to 3.8). CONCLUSIONS: The organization of work in field agriculture may pose risks for poor occupational health outcomes among a vulnerable worker population. |
Asthma in health care workers: 2008 and 2010 behavioral risk factor surveillance system asthma call-back survey
White GE , Mazurek JM , Moorman JE . J Occup Environ Med 2013 55 (12) 1463-8 OBJECTIVE: To estimate the prevalence of current asthma and the proportion of asthma that is work-related among health care and non-health care workers. METHODS: We used 2008 and 2010 Behavioral Risk Factor Surveillance System High Risk/Health Care Worker Module and Asthma Call-Back Survey data collected in 35 states and the District of Columbia to estimate prevalence ratios (PRs). RESULTS: Significantly more health care workers/volunteers than non-health care workers/volunteers with current asthma had asthma attacks (PR = 1.23; 95% confidence interval = 1.03 to 1.46) and asthma symptoms within the past year (PR = 1.07; 95% confidence interval = 1.00 to 1.14). There was no significant difference in the proportion of health care and non-health care workers/volunteers diagnosed with current asthma or work-related asthma. CONCLUSIONS: The results of this study are consistent with previous research showing that health care workers with asthma have higher proportions of asthma attacks than non-health care workers. |
Bladder cancer incidence among workers exposed to o-toluidine, aniline and nitrobenzene at a rubber chemical manufacturing plant
Carreon T , Hein MJ , Hanley KW , Viet SM , Ruder AM . Occup Environ Med 2013 71 (3) 175-82 BACKGROUND: An earlier investigation found increased bladder cancer incidence among workers at a rubber chemical manufacturing plant that used o-toluidine, aniline and nitrobenzene. The cohort was expanded to include additional workers (n=1875) and updated through 2007 to assess bladder cancer with improved exposure characterisation. METHODS: Work histories were updated and exposure categories and ranks were developed for o-toluidine, aniline and nitrobenzene combined. Incident cancers were identified by linkage to six state cancer registries. Residency in time-dependent cancer registry catchment areas was determined. SIR and standardised rate ratios for bladder cancer were calculated by exposure category and cumulative rank quartiles for different lag periods. Cox regression was used to model bladder cancer incidence with estimated cumulative rank, adjusting for confounders. Indirect methods were used to control for smoking. RESULTS: Excess bladder cancer was observed compared to the New York State population (SIR=2.87, 95% CI 2.02 to 3.96), with higher elevations among workers definitely exposed (moderate/high) (SIR=3.90, 95% CI 2.57 to 5.68), and in the highest cumulative rank quartile (SIR=6.13, 95% CI 2.80 to 11.6, 10-year lag). Bladder cancer rates increased significantly with estimated cumulative rank (10-year lag). Smoking only accounted for an estimated 8% elevation in bladder cancer incidence. CONCLUSIONS: Bladder cancer incidence remains elevated in this cohort and significantly associated with estimated cumulative exposure. Results are consistent with earlier findings in this and other cohorts. Despite other concurrent chemical exposures, we consider o-toluidine most likely responsible for the bladder cancer incidence elevation and recommend a re-examination of occupational exposure limits. |
Respiratory disease mortality among US coal miners; results after 37 years of follow-up
Graber JM , Stayner LT , Cohen RA , Conroy LM , Attfield MD . Occup Environ Med 2014 71 (1) 30-9 OBJECTIVES: To evaluate respiratory related mortality among underground coal miners after 37 years of follow-up. METHODS: Underlying cause of death for 9033 underground coal miners from 31 US mines enrolled between 1969 and 1971 was evaluated with life table analysis. Cox proportional hazards models were fitted to evaluate the exposure-response relationships between cumulative exposure to coal mine dust and respirable silica and mortality from pneumoconiosis, chronic obstructive pulmonary disease (COPD) and lung cancer. RESULTS: Excess mortality was observed for pneumoconiosis (SMR=79.70, 95% CI 72.1 to 87.67), COPD (SMR=1.11, 95% CI 0.99 to 1.24) and lung cancer (SMR=1.08; 95% CI 1.00 to 1.18). Coal mine dust exposure increased risk for mortality from pneumoconiosis and COPD. Mortality from COPD was significantly elevated among ever smokers and former smokers (HR=1.84, 95% CI 1.05 to 3.22; HRK=1.52, 95% CI 0.98 to 2.34, respectively) but not current smokers (HR=0.99, 95% CI 0.76 to 1.28). Respirable silica was positively associated with mortality from pneumoconiosis (HR=1.33, 95% CI 0.94 to 1.33) and COPD (HR=1.04, 95% CI 0.96 to 1.52) in models controlling for coal mine dust. We saw a significant relationship between coal mine dust exposure and lung cancer mortality (HR=1.70; 95% CI 1.02 to 2.83) but not with respirable silica (HR=1.05; 95% CI 0.90 to 1.23). In the most recent follow-up period (2000-2007) both exposures were positively associated with lung cancer mortality, coal mine dust significantly so. CONCLUSIONS: Our findings support previous studies showing that exposure to coal mine dust and respirable silica leads to increased mortality from malignant and non-malignant respiratory diseases even in the absence of smoking. |
Reactivation of Chagas disease in a bone marrow transplant patient: case report and review of screening and management
Guiang KM , Cantey P , Montgomery SP , Ailawadhi S , Qvarnstrom Y , Price T , Blodget E . Transpl Infect Dis 2013 15 (6) E264-7 We report a patient with an autologous stem cell transplant and history of residence in a Chagas disease (CD) endemic area who developed Chagas reactivation after induction for transplantation. We recommend that patients at risk for CD be screened before transplantation, and patients found to have chronic infection be monitored for reactivation post transplant. |
School-based mass distributions of mebendazole to control soil-transmitted helminthiasis in the Munshiganj and Lakshmipur districts of Bangladesh: an evaluation of the treatment monitoring process and knowledge, attitudes, and practices of the population
Hafiz I , Berhan M , Keller A , Haq R , Chesnaye N , Koporc K , Rahman M , Rahman S , Mathieu E . Acta Trop 2013 141 385-90 Bangladesh's national deworming program targets school-age children (SAC) through bi-annual school-based distributions of mebendazole. Qualitative and quantitative methods were applied to identify challenges related to treatment monitoring within the Munshiganj and Lakshmipur Districts of Bangladesh. Key stakeholder interviews identified several obstacles for successful treatment monitoring within these districts; ambiguity in defining the target population, variances in the methods used for compiling and reporting treatment data, and a general lack of financial and human resources. A treatment coverage cluster survey revealed that bi-annual primary school-based distributions proved to be an effective strategy in reaching school-attending SAC, with rates between 63.0%-73.3%, however, the WHO target of regular treatment of at least 75% of SAC has yet to be reached. Particularly low coverage was seen amongst non-school attending children (11.4%-14.3%), most likely due to the lack of national policy to effectively target this vulnerable group. Survey findings on water and sanitation coverage were impressive, with the majority of households and schools having access to latrines (98.6%-99.3%) and safe drinking water (98.2%-100%). The challenge now for the Bangladeshi control program is to achieve the WHO target of regular treatment of at least 75% of SAC at risk, irrespective of school-enrollment status. |
Soil-transmitted helminth infection and nutritional status among urban slum children in Kenya
Suchdev PS , Davis SM , Bartoces M , Ruth LJ , Worrell CM , Kanyi H , Odero K , Wiegand RE , Njenga SM , Montgomery JM , Fox LM . Am J Trop Med Hyg 2013 90 (2) 299-305 To evaluate the nutritional impact of soil-transmitted helminth (STH) infection, we conducted a cross-sectional survey of 205 pre-school- (PSC) and 487 school-aged children (SAC) randomly selected from the surveillance registry of the Centers for Disease Control and Prevention of the Kibera slum in Kenya. Hemoglobin, iron deficiency (ID), vitamin A deficiency (VAD), inflammation, malaria, anthropometry, and STH ova were measured. Poisson regression models evaluated associations between STH and malnutrition outcomes and controlled for confounders. Approximately 40% of PSC and SAC had STH infection, primarily Ascaris and Trichuris; 2.9% of PSC and 1.1% of SAC had high-intensity infection. Malnutrition prevalence among PSC and SAC was anemia (38.3% and 14.0%, respectively), ID (23.0% and 5.0%, respectively), VAD (16.9% and 4.5%, respectively), and stunting (29.7% and 16.9%, respectively). In multivariate analysis, STH in PSC was associated with VAD (PR = 2.2, 95% confidence interval = 1.1-4.6) and ID (PR = 3.3, 95% confidence interval = 1.6-6.6) but not anemia or stunting. No associations were significant in SAC. Integrated deworming and micronutrient supplementation strategies should be evaluated in this population. |
Mass drug administration for malaria
Poirot E , Skarbinski J , Sinclair D , Kachur SP , Slutsker L , Hwang J . Cochrane Database Syst Rev 2013 12 (12) CD008846 BACKGROUND: Mass drug administration (MDA), defined as the empiric administration of a therapeutic antimalarial regimen to an entire population at the same time, has been a historic component of many malaria control and elimination programmes, but is not currently recommended. With renewed interest in MDA and its role in malaria elimination, this review aims to summarize the findings from existing research studies and program experiences of MDA strategies for reducing malaria burden and transmission. OBJECTIVES: To assess the impact of antimalarial MDA on population asexual parasitaemia prevalence, parasitaemia incidence, gametocytaemia prevalence, anaemia prevalence, mortality and MDA-associated adverse events. SEARCH METHODS: We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE+, EMBASE, to February 2013. We also searched CABS Abstracts, LILACS, reference lists, and recent conference proceedings. SELECTION CRITERIA: Cluster-randomized trials and non-randomized controlled studies comparing therapeutic MDA versus placebo or no MDA, and uncontrolled before-and-after studies comparing post-MDA to baseline data were selected. Studies administering intermittent preventive treatment (IPT) to sub-populations (for example, pregnant women, children or infants) were excluded. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed studies for inclusion, extracted data and assessed risk of bias. Studies were stratified by study design and then subgrouped by endemicity, by co-administration of 8-aminoquinoline plus schizonticide drugs and by plasmodium species. The quality of evidence was assessed using the GRADE approach. MAIN RESULTS: Two cluster-randomized trials, eight non-randomized controlled studies and 22 uncontrolled before-and-after studies are included in this review. Twenty-two studies (29 comparisons) compared MDA to placebo or no intervention of which two comparisons were conducted in areas of low endemicity (≤5%), 12 in areas of moderate endemicity (6-39%) and 15 in areas of high endemicity (≥ 40%). Ten studies evaluated MDA plus other vector control measures. The studies used a wide variety of MDA regimens incorporating different drugs, dosages, timings and numbers of MDA rounds. Many of the studies are now more than 30 years old. Areas of low endemicity (≤5%)Within the first month post-MDA, a single uncontrolled before-and-after study conducted in 1955 on a small Taiwanese island reported a much lower prevalence of parasitaemia following a single course of chloroquine compared to baseline (1 study, very low quality evidence). This lower parasite prevalence was still present after more than 12 months (one study, very low quality evidence). In addition, one cluster-randomized trial evaluating MDA in a low endemic setting reported zero episodes of parasitaemia at baseline, and throughout five months of follow-up in both the control and intervention arms (one study, very low quality evidence). Areas of moderate endemicity (6-39%)Within the first month post-MDA, the prevalence of parasitaemia was much lower in three non-randomized controlled studies from Kenya and India in the 1950s (RR 0.03, 95% CI 0.01 to 0.08, three studies, moderate quality evidence), and in three uncontrolled before-and-after studies conducted between 1954 and 1961 (RR 0.29, 95% CI 0.17 to 0.48, three studies,low quality evidence).The longest follow-up in these settings was four to six months. At this time point, the prevalence of parasitaemia remained substantially lower than controls in the two non-randomized controlled studies (RR 0.18, 95% CI 0.10 to 0.33, two studies, low quality evidence). In contrast, the two uncontrolled before-and-after studies found mixed results: one found no difference and one found a substantially higher prevalence compared to baseline (not pooled, two studies, very low quality evidence). Areas of high endemicity (≥40%)Within the first month post-MDA, the single cluster-randomized trial from the Gambia in 1999 found no significant difference in parasite prevalence (one study, low quality evidence). However, prevalence was much lower during the MDA programmes in three non-randomized controlled studies conducted in the 1960s and 1970s (RR 0.17, 95% CI 0.11 to 0.27, three studies, moderate quality evidence), and within one month of MDA in four uncontrolled before-and-after studies (RR 0.37, 95% CI 0.28 to 0.49, four studies,low quality evidence).Four trials reported changes in prevalence beyond three months. In the Gambia, the single cluster-randomized trial found no difference at five months (one trial, moderate quality evidence). The three uncontrolled before-and-after studies had mixed findings with large studies from Palestine and Cambodia showing sustained reductions at four months and 12 months, respectively, and a small study from Malaysia showing no difference after four to six months of follow-up (three studies,low quality evidence). 8-aminoquinolinesWe found no studies directly comparing MDA regimens that included 8-aminoquinolines with regimens that did not. In a crude subgroup analysis with a limited number of studies, we were unable to detect any evidence of additional benefit of primaquine in moderate- and high-transmission settings. Plasmodium speciesIn studies that reported species-specific outcomes, the same interventions resulted in a larger impact on Plasmodium falciparum compared to P. vivax. AUTHORS' CONCLUSIONS: MDA appears to reduce substantially the initial risk of malaria parasitaemia. However, few studies showed sustained impact beyond six months post-MDA, and those that did were conducted on small islands or in highland settings.To assess whether there is an impact of MDA on malaria transmission in the longer term requires more quasi experimental studies with the intention of elimination, especially in low- and moderate-transmission settings. These studies need to address any long-term outcomes, any potential barriers for community uptake, and contribution to the development of drug resistance. |
Fulminant and fatal encephalitis caused by Acanthamoeba in a kidney transplant recipient: case report and literature review
Satlin MJ , Graham JK , Visvesvara GS , Mena H , Marks KM , Saal SD , Soave R . Transpl Infect Dis 2013 15 (6) 619-26 Acanthamoeba is the most common cause of granulomatous amebic encephalitis, a typically fatal condition that is classically described as indolent and slowly progressive. We report a case of Acanthamoeba encephalitis in a kidney transplant recipient that progressed to death within 3 days of symptom onset and was diagnosed at autopsy. We also review clinical characteristics, treatments, and outcomes of all published cases of Acanthamoeba encephalitis in solid organ transplant (SOT) recipients. Ten cases were identified, and the infection was fatal in 9 of these cases. In 6 patients, Acanthamoeba presented in a fulminant manner and death occurred within 2 weeks after the onset of neurologic symptoms. These acute presentations are likely related to immunodeficiencies associated with solid organ transplantation that result in an inability to control Acanthamoeba proliferation. Skin lesions may predate neurologic involvement and provide an opportunity for early diagnosis and treatment. Acanthamoeba is an under-recognized cause of encephalitis in SOT recipients and often presents in a fulminant manner in this population. Increased awareness of this disease and its clinical manifestations is essential to attain an early diagnosis and provide the best chance of cure. |
Heart transplantation for Chagas cardiomyopathy in the United States
Kransdorf EP , Czer LS , Luthringer DJ , Patel JK , Montgomery SP , Velleca A , Mirocha J , Zakowski PC , Zabner R , Gaultier CR , Qvarnstrom Y , Benedict T , Steurer F , Bosserman E , Paddock CD , Rafiei M , Kobashigawa JA . Am J Transplant 2013 13 (12) 3262-8 Since an initial case in 2006, we noted multiple patients undergoing heart transplantation (HTx) for Chagas cardiomyopathy (CC) at our transplant program. The clinical characteristics, laboratory results and outcomes of patients with CC undergoing HTx in the United States have not been reported previously. In 2010, we implemented a systematic screening and management program for patients undergoing HTx for CC. Before HTx, all patients with idiopathic dilated cardiomyopathy who were born in a Chagas disease endemic country were screened for Trypanosoma cruzi (TC) infection with serology. After HTx, monitoring for TC reactivation was performed using clinical visits, echocardiography, endomyocardial biopsy and serial whole blood polymerase chain reaction (PCR) testing. Between June 2006 and January 2012, 11 patients underwent HTx for CC. One patient was empirically treated due to the presence of TC amastigotes in explanted cardiac tissue. Two patients experienced allograft dysfunction due to TC reactivation and three patients experienced subclinical reactivation (positive PCR results), which were treated. Chagas disease is a common cause of dilated cardiomyopathy in patients from endemic countries undergoing HTx at a transplant program in the United States. Reactivation is common after transplantation and can cause adverse outcomes. |
Assessment of quality of life as a tool for measuring morbidity due to Schistosoma mansoni infection and the impact of treatment
Won KY , Abudho B , Blackstock A , Montgomery SP , Kennedy ED , Person B , Mwinzi PN , Ochola EA , Foo KT , Hightower AW , Karanja DM , Secor WE . Am J Trop Med Hyg 2013 90 (2) 322-8 Recently, health measurements have broadened to include the assessment of quality of life (QOL). This study was conducted to assess whether the short form of the World Health Organization (WHO) QOL questionnaire (WHOQOL-BREF) was an effective tool for measuring morbidity due to Schistosoma mansoni infection and whether it could detect an impact of treatment with praziquantel. A total of 724 adults 18-85 years of age were enrolled. At baseline, S. mansoni prevalence was 73.2% by stool examination and 75.4% by circulating cathodic antigen, and there was no association between infection status and WHOQOL-BREF scores. Six months after treatment, S. mansoni prevalence was lower and the proportion of persons with higher WHOQOL-BREF scores significantly increased among persons who were infected at baseline. However, a similar increase was observed in persons infected at baseline. In areas of high prevalence, the WHOQOL-BREF may not be able to detect the benefits of schistosomiasis control programs. |
Clinical characteristics of Acanthamoeba keratitis infections in 28 states, 2008 to 2011
Ross J , Roy SL , Mathers WD , Ritterband DC , Yoder JS , Ayers T , Shah RD , Samper ME , Shih CY , Schmitz A , Brown AC . Cornea 2013 33 (2) 161-8 PURPOSE: The aim was to describe a geographically and clinically diverse sample of cases of Acanthamoeba keratitis (AK) and establish the risk factors for poor outcomes among patients with this disease. METHODS: We conducted a retrospective, population-based case series of 116 patients with AK identified through a national surveillance network. Data were collected via a medical record review by diagnosing ophthalmologists and by phone interviews with patients. Exact logistic regression modeling was used to determine risk factors for poor visual outcomes. RESULTS: Among patients with data available on contact lens use, it was found that 93.3% wore contact lenses. The median time from symptom onset to care seeking was 2 days, whereas the median time from symptom onset to diagnosis was 27 days. Keratoplasty was performed in 27 of 81 patients with available outcome data and was more likely in patients >40 years old [odds ratio (OR) 5.25, 95% confidence interval (CI) 1.49-21.92]. When adjusted for age, the risk factors for keratoplasty included the presence of a ring infiltrate (OR 40.00, 95% CI 3.58-447.0) or any sign of stromal invasion (OR 10.48, 95% CI 2.56-55.09). One-third of patients with available data on best-corrected visual acuity had a best-corrected visual acuity <20/200, with the presence of a ring infiltrate as the only significant predictor of this outcome when adjusted for age (aOR 3.45, 95% CI 1.01-12.31). CONCLUSIONS: AK remains challenging to diagnose. Consequently, patients with advanced disease are more likely to have poor outcomes, particularly if they are older. The increasing awareness of AK among general eye care providers may shorten referral times and potentially improve outcomes. |
Cutaneous emergence of Eustrongylides in two persons from South Sudan
Eberhard ML , Ruiz-Tiben E . Am J Trop Med Hyg 2013 90 (2) 315-7 Two large, living worms were collected as they emerged from the lower limb of each of two persons in South Sudan. The worms were observed by staff of the South Sudan Guinea Worm Eradication Program during surveillance activities in communities at-risk for cases of Guinea worm disease (dracunculiasis). The worms measured 7 and 8 cm in length and were identified as fourth-stage larvae of Eustrongylides. This is the first report of such worms emerging from the skin; all five previous reports of human infection involved surgical removal of worms from the peritoneal cavity. |
Physical activity patterns among U.S. adults with and without serious psychological distress
Okoro CA , Stoodt G , Rohrer JE , Strine TW , Li C , Balluz LS . Public Health Rep 2014 129 (1) 30-8 OBJECTIVE: A physically active lifestyle is recommended for overall health-both physical and mental. Serious psychological distress (SPD) is associated with adverse health behaviors. We compared patterns of physical activity (PA) among adults with and without SPD using current public health guidelines for PA and examined whether adults with SPD were physically active at recommended levels. METHODS: We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to assess SPD using the Kessler 6 (K6) scale of nonspecific psychological distress and PA categories based on the 2008 U.S. Department of Health and Human Services guidelines. Complete data were available for 78,886 adults in 16 states that used an optional BRFSS mental illness and stigma module containing the K6 scale. We performed multiple logistic regression analyses to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: The unadjusted prevalence of SPD was 3.9% (95% CI 3.6, 4.2), and the age-adjusted prevalence of SPD was 3.8% (95% CI 3.5, 4.1). After adjusting for age, sex, race/ethnicity, education, employment, body mass index, smoking status, and heavy drinking, adults with SPD were significantly less likely to be physically active at recommended levels than adults without SPD. PRs were attenuated but remained significant after further adjustment for limitations to PA. CONCLUSION: Adults with SPD are less likely to meet current PA recommendations than adults without SPD, highlighting the need for targeted interventions. |
System factors to explain 2009 pandemic H1N1 state vaccination rates for children and high-risk adults in US emergency response to pandemic
Davila-Payan C , Swann J , Wortley PM . Vaccine 2014 32 (2) 246-51 INTRODUCTION: During the 2009-2010 H1N1 pandemic, children and high-risk adults had priority for vaccination. Vaccine in short supply was allocated to states pro-rata by population, but vaccination rates as of January 2010 varied among states from 21.3% to 84.7% for children and 10.4% to 47.2% for high-risk adults. States had different campaign processes and decisions. OBJECTIVE: To determine program and system factors associated with higher state pandemic vaccination coverage for children and high-risk adults during an emergency response with short supply of vaccine. METHODS: Regression analysis of factors predicting state-specific H1N1 vaccination coverage in children and high-risk adults, including state campaign information, demographics, preventive or health-seeking behavior, preparedness funding, providers, state characteristics, and surveillance data. RESULTS: Our modeling explained variation in state-specific vaccination coverage with an adjusted R-squared of 0.82 for children and 0.78 for high-risk adults. We found that coverage of children was positively associated with programs focusing on school clinics and with a larger proportion of doses administered in public sites; negatively with the proportion of children in the population, and the proportion not visiting a doctor because of cost. The coverage for high-risk adults was positively associated with shipments of vaccine to "general access" locations, including pharmacy and retail, with the percentage of women with a Pap smear within the past 3 years and with past seasonal influenza vaccination. It was negatively associated with the expansion of vaccination to the general public by December 4, 2009. For children and high-risk adults, coverage was positively associated with the maximum number of ship-to-sites and negatively associated with the proportion of medically underserved population. CONCLUSION: Findings suggest that distribution and system decisions such as vaccination venues and providers targeted can positively impact vaccination rates for children and high-risk adults. Additionally, existing health infrastructure, health-seeking behaviors, and access affected coverage. |
Program collaboration and service integration activities among HIV programs in 59 U.S. health departments
Fitz Harris LF , Toledo L , Dunbar E , Aquino GA , Nesheim SR . Public Health Rep 2014 129 33-42 OBJECTIVES: We identified the level and type of program collaboration and service integration (PCSI) among HIV prevention programs in 59 CDC-funded health department jurisdictions. METHODS: Annual progress reports (APRs) completed by all 59 health departments funded by CDC for HIV prevention activities were reviewed for collaborative and integrated activities reported by HIV programs for calendar year 2009. We identified associations between PCSI activities and funding, AIDS diagnosis rate, and organizational integration. RESULTS: HIV programs collaborated with other health department programs through data-related activities, provider training, and providing funding for sexually transmitted disease (STD) activities in 24 (41%), 31 (53%), and 16 (27%) jurisdictions, respectively. Of the 59 jurisdictions, 57 (97%) reported integrated HIV and STD testing at the same venue, 39 (66%) reported integrated HIV and tuberculosis testing, and 26 (44%) reported integrated HIV and viral hepatitis testing. Forty-five (76%) jurisdictions reported providing integrated education/outreach activities for HIV and at least one other disease. Twenty-six (44%) jurisdictions reported integrated partner services among HIV and STD programs. Overall, the level of PCSI activities was not associated with HIV funding, AIDS diagnoses, or organizational integration. CONCLUSIONS: HIV programs in health departments collaborate primarily with STD programs. Key PCSI activities include integrated testing, integrated education/outreach, and training. Future assessments are needed to evaluate PCSI activities and to identify the level of collaboration and integration among prevention programs. |
Program collaboration and service integration in the prevention and control of HIV infection, viral hepatitis, STDs, and tuberculosis in the U.S.: lessons learned from the field
Fenton KA , Aquino GA , Dean HD . Public Health Rep 2014 129 1-4 his supplemental issue of Public Health Reports (PHR) presents a selection of innovative approaches, studies, and lessons learned from efforts to implement program collaboration and service integration (PCSI) in the prevention and control of human immunodeficiency virus (HIV) infection, viral hepatitis, sexually transmitted diseases (STDs), and tuberculosis (TB) in the United States. Promotion of a comprehensive approach for these diseases is an important cross-cutting goal for the Centers for Disease Control and Prevention's (CDC's) National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).1 | NCHHSTP's PCSI efforts are intended to strengthen collaborative work across disease areas and to integrate services that are provided by related programs at the client level. The catalyst for this systems change stems from the enhanced understanding of how these diseases synergistically relate with one another.2 With the rise of infectious disease syndemics (e.g., HIV and TB3) and the resultant increase in burden of disease,4 guidance has been produced to help state and local health departments better integrate service delivery.2,5–7 PCSI aims to organize and blend interrelated prevention strategies in an effort to provide more comprehensive delivery of services.2 |
Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010-2012
Cummings PL , Kuo T , Gase LN , Mugavero K . J Public Health Manag Pract 2014 20 S16-22 Since sodium is ubiquitous in the food supply, recent approaches to sodium reduction have focused on increasing the availability of lower-sodium products through system-level and environmental changes. This article reviews integrated efforts by the Los Angeles County Sodium Reduction Initiative to implement these strategies at food venues in the County of Los Angeles government. The review used mixed methods, including a scan of the literature, key informant interviews, and lessons learned during 2010-2012 to assess program progress. Leveraging technical expertise and shared resources, the initiative strategically incorporated sodium reduction strategies into the overall work plan of a multipartnership food procurement program in Los Angeles County. To date, 3 County departments have incorporated new or updated nutrition requirements that included sodium limits and other strategies. The strategic coupling of sodium reduction to food procurement and general health promotion allowed for simultaneous advancement and acceleration of the County's sodium reduction agenda. |
Advances in public health accreditation readiness and quality improvement: evaluation findings from the National Public Health Improvement Initiative
McLees AW , Thomas CW , Nawaz S , Young AC , Rider N , Davis M . J Public Health Manag Pract 2014 20 (1) 29-35 INTRODUCTION: Continuous quality improvement is a central tenet of the Public Health Accreditation Board's (PHAB) national voluntary public health accreditation program. Similarly, the Centers for Disease Control and Prevention launched the National Public Health Improvement Initiative (NPHII) in 2010 with the goal of advancing accreditation readiness, performance management, and quality improvement (QI). OBJECTIVE: Evaluate the extent to which NPHII awardees have achieved program goals. DESIGN: NPHII awardees responded to an annual assessment and program monitoring data requests. Analysis included simple descriptive statistics. SETTING: Seventy-four state, tribal, local, and territorial public health agencies receiving NPHII funds. PARTICIPANTS: NPHII performance improvement managers or principal investigators. MAIN OUTCOME MEASURE(S): Development of accreditation prerequisites, completion of an organizational self-assessment against the PHAB Standards and Measures, Version 1.0, establishment of a performance management system, and implementation of QI initiatives to increase efficiency and effectiveness. RESULTS: Of the 73 responding NPHII awardees, 42.5% had a current health assessment, 26% had a current health improvement plan, and 48% had a current strategic plan in place at the end of the second program year. Approximately 26% of awardees had completed an organizational PHAB self-assessment, 72% had established at least 1 of the 4 components of a performance management system, and 90% had conducted QI activities focused on increasing efficiencies and/or effectiveness. CONCLUSIONS: NPHII appears to be supporting awardees' initial achievement of program outcomes. As NPHII enters its third year, there will be additional opportunities to advance the work of NPHII, compile and disseminate results, and inform a vision of high-quality public health necessary to improve the health of the population. |
Chlamydia and gonorrhea diagnosis, treatment, personnel cost savings, and service delivery improvements after the implementation of express sexually transmitted disease testing in Maricopa County, Arizona
Rukh S , Khurana R , Mickey T , Anderson L , Velasquez C , Taylor M . Sex Transm Dis 2014 41 (1) 74-8 BACKGROUND: The demand for low-cost sexually transmitted disease (STD) services in Maricopa County (Phoenix area) is high. Improved methods for STD/HIV testing are needed to increase the number of patients receiving testing. OBJECTIVES: The present study sought to evaluate an STD/HIV express testing (ET) option for patients identified as being at lower risk for infection. METHODS: Clients reporting current STD symptoms, contact to an infected partner, or health department referral were identified via questionnaire and routed to a traditional provider visit (PV); those not reporting these situations were routed to ET (laboratory-only). Demographics, treatment completion, and treatment intervals were compared among patients diagnosed as having chlamydia and gonorrhea through ET and PV encounters in September 2008 to July 2011. Personnel costs were compared for each of the 2 visit types. The number of clinic turn-aways for the 2-month time interval before the start of the program was compared with the 2-month interval at the end of the evaluation. RESULTS: Of the 36,946 clients seen at Maricopa County Department of Public Health, 7466 (20.2%) were patients seen through express visits. Overall chlamydia and gonorrhea positivity was lower among ET patients (527/7466; 7.1%) as compared with those tested through PVs (6323/29,480; 21.4%). Treatment completion rates were comparable but were higher among patients seen through PVs (99%) as compared with ET (94%). A savings of $2936 per 1000 patients seen was achieved when 20% of clients were routed through ET. Clinic turn-aways decreased significantly, from 159 clients during the 2 months before implementation of ET to 6 patients during the last 2 months of evaluation (96% reduction). CONCLUSIONS: This ET system included an effective patient routing process that provided an efficient way to increase access to STD testing among persons at lower risk, at a reduced cost per patient, while maintaining high treatment coverage. |
Preventing hepatitis B though universal vaccination: reduction of inequalities through the GAVI China project
Cui F , Liang X , Gong X , Chen Y , Wang F , Zheng H , Wu Z , Miao N , Hadler SC , Hutin YJ , Luo H , Yang W . Vaccine 2013 31 Suppl 9 J29-35 OBJECTIVE: In order to measure hepatitis B coverage and progress in equality with respect to protection against hepatitis B in poverty-affected areas funded by the Global Alliance on Vaccine and Immunization project funded in poverty-affected counties. METHODS: We reviewed routinely reported coverage data and conducted a national stratified, validation, cross-sectional survey in October 2010, according to WHO recommended sampling method. First, we stratified China into three regions (Eastern, Central and Western) based on economic criteria. Second, in each region, we selected eight counties with a probability proportional to population size. Third, in each selected county, we selected (a) 10 townships at random among the list of townships of the county. RESULTS: We visited 244 townships as part of the final evaluation (71 in the East, 86 in the Center and 87 in the West). Overall, in these 244 townships, surveyed TBD coverage increased from 60% in 2002 to 91% in 2009 and surveyed three dose of hepatitis B vaccine coverage increased from 71% in 2002 to 93% in 2009. Overall, in the GAVI supported areas, the HepB3/DTP3 ratio increased from 57% in 2002 to 94% in 2009. CONCLUSION: Pro-poor GAVI approach was an effective way to reduce inequity among children through provision of free vaccination. When vaccine and AD syringes were provided for free, they closed the gap between Eastern and Western regions and between the rich and the poor. |
Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania
Wallace A , Kimambo S , Dafrossa L , Rusibamayila N , Rwebembera A , Songoro J , Arthur G , Luman E , Finkbeiner T , Goodson JL . J Acquir Immune Defic Syndr 2013 66 (1) e8-e14 BACKGROUND: In 2009, a project was implemented in 8 primary health clinics throughout Tanzania to explore the feasibility of integrating pediatric HIV prevention services with routine infant immunization visits. METHODS: We conducted interviews with 66 conveniently sampled mothers of infants who had received integrated HIV and immunization services and 16 providers who delivered the integrated services to qualitatively identify benefits and challenges of the intervention midway through project implementation. FINDINGS: Mothers' perceived benefits of the integrated services included time savings, opportunity to learn their child's HIV status and receive HIV treatment if necessary. Providers' perceived benefits included reaching mothers who usually would not come for only HIV testing. Mothers and providers reported similar challenges, including mothers' fear of HIV testing, poor spousal support, perceived mandatory HIV testing, poor patient flow affecting confidentiality of service delivery, heavier provider workloads, and community stigma against HIV-infected persons; the latter a more frequent theme in rural compared to urban locations. INTERPRETATION: Future scale-up should ensure privacy of these integrated services received at clinics and community outreach to address stigma and perceived mandatory testing. Increasing human resources for health to address higher workloads and longer waiting times for proper patient flow is necessary in the long term. |
Effect of the first federally funded US antismoking national media campaign
McAfee T , Davis KC , Alexander RL Jr , Pechacek TF , Bunnell R . Lancet 2013 382 (9909) 2003-11 BACKGROUND: Every year, smoking kills more than 5 million people globally, including 440,000 people in the USA, where the long-term decline in smoking prevalence has slowed. The US Centers for Disease Control and Prevention (CDC) delivered a national, 3-month antismoking campaign called Tips From Former Smokers (Tips) that started in March, 2012, in which hard-hitting, emotionally evocative television advertising was featured, depicting smoking-related suffering in real people. We aimed to assess the effects of the Tips campaign. METHODS: We undertook baseline and follow-up surveys of nationally representative cohorts of adult smokers and non-smokers. The national effect of the Tips campaign was estimated by applying rates of change in the cohort before and after the campaign to US census data. FINDINGS: 3051 smokers and 2220 non-smokers completed baseline and follow-up assessments. 2395 (78%) smokers and 1632 (74%) non-smokers recalled seeing at least one Tips advertisement on television during the 3-month campaign. Quit attempts among smokers rose from 31.1% (95% CI 30.3-31.9) at baseline to 34.8% (34.0-35.7) at follow-up, a 12% relative increase. The prevalence of abstinence at follow-up among smokers who made a quit attempt was 13.4% (95% CI 9.7-17.2). Nationally, an estimated 1.64 million additional smokers made a quit attempt, and 220,000 (95% CI 159,000-282,000) remained abstinent at follow-up. Recommendations by non-smokers to quit grew from 2.6% at baseline to 5.1% at follow-up, and the prevalence of people talking with friends and family about the dangers of smoking rose from 31.9% (95% CI 31.3-32.5) to 35.2% (34.6-35.9), resulting in an estimated 4.7 million additional non-smokers recommending cessation services and more than 6 million talking about the dangers of smoking. INTERPRETATION: The high-exposure Tips media campaign was effective at increasing population-level quit attempts. The growth in smokers who quit and became sustained quitters could have added from a third to almost half a million quality-adjusted life-years to the US population. Expanded implementation of similar campaigns globally could accelerate progress on the WHO Framework Convention on Tobacco Control and reduce smoking prevalence globally. FUNDING: CDC, US Department of Health and Human Services. |
Evaluation of immunization injection safety in China, 2010: achievements, future sustainability
Wu Z , Cui F , Chen Y , Miao N , Gong X , Luo H , Wang F , Zheng H , Kane M , Hadler SC , Hutin YJ , Liang X , Yang W . Vaccine 2013 31 Suppl 9 J43-8 OBJECTIVE: The study objectives were to evaluate injection practices in China in the post GAVI project era and provide guidance for policy makers to update national standards for injection practices and further improve vaccination services. METHODS: We conducted a national stratified, cross-sectional survey in October 2010, according to WHO recommended sampling methods. First, we stratified China into three regions (Eastern, Central and Western) based on economic criteria. Second, in each region, we selected eight counties with a probability proportional to population size. Third, in each selected county, we selected (a) 10 townships at random among the list of townships of the county and (b) the one county level hospital. RESULTS: With respect to the risk to the patient, we never observed open injection equipment lying around or needles left in the septum of multi-dose vials. We never observed sterilizable injection devices syringes in any of the facilities. The proportion of facilities using sharps containers was highest in the East (85%), intermediate in the West (79%) and lowest in the Central region (56%). In 2009, auto-disable syringes and safety boxes were used in 78% and 79% facilities in GAVI supported areas of the Western region, respectively. Only one facility presented evidence of attempts to re-sterilize disposable injection equipment in the Eastern region. CONCLUSIONS: Use of AD syringe and sharps containers increased in vaccination services in China, especially in GAVI supported areas, leading to sustainable progress in terms of elimination of reuse of injection devices. However, risk to patients still existed, including persisting use of standard disposable syringes and attempts to re-use disposable devices. |
Evaluation of policies and practices to prevent mother to child transmission of hepatitis B virus in China: results from China GAVI project final evaluation
Cui F , Luo H , Wang F , Zheng H , Gong X , Chen Y , Wu Z , Miao N , Kane M , Hennessey K , Hadler SC , Hutin YJ , Liang X , Yang W . Vaccine 2013 31 Suppl 9 J36-42 BACKGROUND: Mother to Child Transmission (MTCT) has remained a leading cause of HBV infection in China, accounting for 40% of total infections. Providing hepatitis B vaccine (HepB) to all infants within 24h of birth (Timely Birth Dose, TBD), and subsequent completion of at least 3 vaccine doses is key to preventing perinatal HBV infection. In 2002, with the financial support of the Global Alliance on Vaccine and Immunization (GAVI) targeted to Western region and 223 poverty-affected counties in Central region, hepatitis B vaccine was provided for free. In 2010, we evaluated the China GAVI project in terms of its activities to prevent perinatal infections. OBJECTIVE: The objectives of the evaluation were to (1) measure achievements in the China GAVI project in terms of TBD coverage, and (2) describe practices for HBsAg screening of pregnant women and HBIG use outside the GAVI China project. METHODS: We used the methods recommended by WHO to select a cluster sample of health care facilities for the purpose of an injection safety assessment. We stratified China into three regions based on economic criteria, and selected eight counties with a probability proportional to population size in each region. In each selected county, we selected (a) 10 townships at random among the list of townships of the county and (b) the one county level hospital. In each hospital, we abstracted 2002 through 2009 records to collect information regarding birth cohorts, hospitals deliveries, vaccine management, hepatitis B vaccination delivery, HBsAg screening practices and results, and HBIG administration. In addition, in all hospitals, we abstracted records regarding the delivery of TBD. RESULTS: We visited 244 facilities in the three regions, including 24 county hospitals and 220 township hospitals. We reviewed 837,409 birth summary records, 699,249 for infants born at county or township hospitals. Hospital delivery rates increased from 58% in 2002 to 93% in 2009. Surveyed TBD coverage increased from 60% in 2002 to 91% in 2009 (+31%). Surveyed TBD coverage among children born in hospitals increased from 73% in 2002 to 98% in 2009. Between 2002 and 2009, the proportion of pregnant women screened for HBsAg increased from 64% in 2002 to 85% in 2009. In 2009, the proportion of infants born to women screened and found to be HBsAg positive who did not receive any immunization within 24h after birth ranged from 0% to 0.7% across regions. CONCLUSIONS: Increased availability of hepatitis B vaccine, along with efforts to improve hospital deliveries, increased TBD coverage in China. This decreased perinatal HBV transmission and will reduce disease burden in the future. Screening for HBsAg to guide HBIG administration has begun, but with heterogeneous immuno-prophylaxis practices and a poor system for follow up. |
The impact of hepatitis B vaccine in China and in the China GAVI Project
Hadler SC , Fuqiang C , Averhoff F , Taylor T , Fuzhen W , Li L , Xiaofeng L , Weizhong Y . Vaccine 2013 31 Suppl 9 J66-72 The China GAVI Project (CGP) was initiated in 2002 to provide hepatitis B (HB) vaccine to infants born in the less developed areas of China including the Western provinces and poverty counties of Middle provinces, to prevent the consequences of hepatitis B virus infection. By 2009, the project areas had raised coverage of 3 doses of HB vaccine and timely birth doses to almost 90% among infants, comparable to those in wealthier Eastern provinces, and reduced HBV prevalence to <1% among children in these areas. We estimated the impact in disease prevented by HB vaccine in China between 1992, when the vaccine was routinely recommended, and 2009, and in CGP areas for the years 2003-2009, when the CGP was active. A published model was used to estimate the burden of chronic and acute HBV infection and death prevented due to HB vaccination in China and the CGP areas using data from national serosurveys in China in 1992 and 2006, and HB vaccine coverage from surveys in 2004, 2006 and 2010. We used sigmoid modeling to estimate vaccine coverage nationally, regionally, and CGP areas. We also estimated the incremental impact of the CGP on HB vaccine coverage in those underserved areas. Our findings suggest that between 1992 and 2009, HB vaccination in China has prevented 24million chronic HBV infections and 4.3million future deaths due to cirrhosis, hepatocellular carcinoma and acute hepatitis. During the CGP between 2003 and 2009, an estimated 3.8million chronic HBV infections and 680,000 deaths were prevented in CGP areas. We found that the CGP funding increased HB vaccine coverage in project areas by 4-15% for HB3 and 4-27% for timely birth dose beyond the coverage expected without the CGP. The CGP represents a highly successful public health collaboration between the national government and international partners. |
Impact of proficiency testing program for laboratories conducting early infant diagnosis of HIV-1 in low to middle-income countries
Garcia A , Subbarao S , Zhang G , Parsons L , Nkengasong J , Ou CY , Ellenberger D . J Clin Microbiol 2013 52 (3) 773-80 A voluntary, cost-free external quality assessment (EQA) program established by the U.S. Centers for Disease Control and Prevention (CDC) was implemented to primarily monitor the performance of laboratories conducting HIV Early Infant Diagnosis (EID) from dried blood spots (DBS) in low to middle-income countries since 2006. Ten blinded DBS proficiency test (PT) specimens and 100 known HIV-positive and negative DBS specimens (to be used as internal controls) were shipped tri-annually to participating laboratories with reports for the PT specimens due within 30 days. The participant's results and summary of the performance of all participating laboratories and each diagnostic method were provided after each test cycle. Enrollment in the CDC PT program expanded progressively from 17 laboratories from 11 countries in 2006 to include 136 laboratories from 41 countries at the end of 2012. Despite external pressures to test and treat more children while expanding EID programs, mean PT test scores significantly improved over time as demonstrated by the upward trend from mid-2006 to end of 2012 (P = 0.001) and increase in the percentage of laboratories scoring 100% (P =0.003). The mean test scores plateaued over the past 10 testing cycles, ranging between 98.2 and 99.7% and discordant test results still occur, but at a rate no higher than 2.6%. Analysis of these test results suggests a positive impact of proficiency testing on the testing performance of the participating laboratories and a continuous training program and proficiency testing participation may translate into laboratories improving their testing accuracy. |
Key outcomes and addressing remaining challenges - perspectives from a final evaluation of the China GAVI project
Yang W , Liang X , Cui F , Li L , Hadler SC , Hutin YJ , Kane M , Wang Y . Vaccine 2013 31 Suppl 9 J73-8 During the China GAVI project, implemented between 2002 and 2010, more than 25 million children received hepatitis B vaccine with the support of project, and the vaccine proved to be safe and effective. With careful consideration for project savings, China and GAVI continually adjusted the budget, additionally allowing the project to spend operational funds to support demonstration projects to improve timely birth dose (TBD), conduct training of EPI staff, and to monitor the project impact. Results from the final evaluation indicated the achievement of key outcomes. As a result of government co-investment, human resources at county level engaged in hepatitis B vaccination increased from 29 per county on average in 2002 to 66 in 2009. All project counties funded by the GAVI project use auto-disable syringes for hepatitis B vaccination and other vaccines. Surveyed hepatitis B vaccine coverage increased from 71% in 2002 to 93% in 2009 among infants. The HBsAg prevalence declined from 9.67% in 1992 to 0.96% in 2006 among children under 5 years of age. However, several important issues remain: (1) China still accounts for the largest annual number of perinatal HBV infections (estimated 84,121) in the WHO WPR region; (2) China still lacks a clear national policy for safe injection of vaccines; (3) vaccination of high risk adults and protection of health care workers are still not implemented; (4) hepatitis B surveillance needs to be refined to more accurately monitor acute hepatitis B; and (5) a program for treatment of persons with chronic HBV infection is needed. Recommendations for future hepatitis B control include: using the lessons learned from the China GAVI project for future introductions of new vaccines; addressing unmet needs with a second generation hepatitis B program to reach every infant, including screening mothers, and providing HBIG for infants born to HBsAg positive mothers; expanding vaccination to high risk adults; addressing remaining unsafe injection issues; and improving monitoring of acute hepatitis B. This paper describes findings and discusses perspectives from a final project evaluation, a national stratified validated cross-sectional survey done in October 2010. |
Criteria for fairly allocating scarce health-care resources to genetic tests: which matter most?
Rogowski WH , Grosse SD , Schmidtke J , Marckmann G . Eur J Hum Genet 2014 22 (1) 25-31 The use of genetic tests is expanding rapidly. Given limited health-care budgets throughout Europe and few national coverage decisions specifically for genetic tests, decisions about allocating scarce resources to genetic tests are frequently ad hoc and left to lower-level decision makers. This study assesses substantive ethical and economic criteria to prioritize genetic services in a reasonable and fair manner. Principles for allocating health-care resources can be classified into four categories: need-based allocation; maximizing total benefits; treating people equally; and promoting and rewarding social usefulness. In the face of scarcity, the degree of an individual's need for medical intervention is an important criterion. Also, different economic concepts of efficiency are of relevance in the theory and practice of prioritizing genetic tests. Equity concerns are most likely to be relevant in terms of avoiding undesirable inequities, which may also set boundaries to the use of efficiency as a prioritization criterion. The aim of promoting and rewarding social usefulness is unlikely to be relevant to the question of what priority a genetic test should have in clinical practice. Further work is needed to select an appropriate set of criteria; operationalize them; and assign weights before some kind of standardized priority information can be added to information sources for genetic services. Besides the substantive criteria, formal considerations like those pointed out in the framework of accountability for reasonableness need to be considered in decision making. |
A study of incentives to support and promote public health accreditation
Thielen L , Leff M , Corso L , Monteiro E , Fisher JS , Pearsol J . J Public Health Manag Pract 2014 20 (1) 98-103 CONTEXT: Accreditation of public health agencies through the Public Health Accreditation Board is voluntary. Incentives that encourage agencies to apply for accreditation have been suggested as important factors in facilitating participation by state and local agencies. OBJECTIVE: The project describes both current and potential incentives that are available at the federal, state, and local levels. DESIGN: Thirty-nine key informants from local, state, tribal, federal, and academic settings were interviewed from March through May 2012. Through open-ended interviews, respondents were asked about incentives that were currently in use in their settings and incentives they thought would help encourage participation in Public Health Accreditation Board accreditation. RESULTS: Incentives currently in use by public health agencies based on interviews include (1) financial support, (2) legal mandates, (3) technical assistance, (4) peer support workgroups, and (5) state agencies serving as role models by seeking accreditation themselves. Key informants noted that state agencies are playing valuable and diverse roles in providing incentives for accreditation within their own states. Key informants also identified the Centers for Disease Control and Prevention and other players, such as private foundations, public health institutes, national and state associations, and academia as providing both technical and financial assistance to support accreditation efforts. CONCLUSIONS: State, tribal, local, and federal agencies, as well as related organizations can play an important role by providing incentives to move agencies toward accreditation. |
Transforming public health practice through accreditation (a user guide for the special accreditation issue)
Beitsch LM , Corso LC , Davis MV , Joly BM , Kronstadt J , Riley WJ . J Public Health Manag Pract 2014 20 (1) 2-3 In 2003, the Institute of Medicine recommended serious examination of health department accreditation as one strategy to improve public health agency performance.1 Three years later and just over 6 years ago, national voluntary public health accreditation was a promising idea with a blueprint for implementation, courtesy of the Exploring Accreditation Project, jointly funded by the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.2,3 The concept had the broad support of national public health practice organizations and drew from the experiences of states such as Michigan, Missouri, North Carolina, and Washington, which had developed their own state-driven accreditation or standards programs.4,5 Nonetheless, the road ahead has not always been a straight, unwavering line, with a guaranteed successful outcome. | In 2007, the Public Health Accreditation Board (PHAB) was formed as a fledgling organization under the auspices of a board of incorporators made up of the executives of the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of Local Boards of Health, and the National Association of County & City Health Officials, representing the larger practice community. The Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention co-supported PHAB's activities to lead the field-driven development and testing of the many critical elements of a national accreditation program. In September 2011, national voluntary public health accreditation launched to receptive audiences, even as health departments grappled with budget reductions and staffing shortages. Throughout the years of exploring and developing a national accreditation program, the nexus between accreditation and strengthening health department performance has remained a central tenet, essential to PHAB, to its earliest applicants and to the hundreds of health departments preparing to apply. |
Use of first-line treatment for Neisseria gonorrhoeae after treatment guideline changes
Anschuetz G , Asbel L , Salmon ME , Johnson CC . Sex Transm Dis 2014 41 (1) 64-6 After 2 notices with treatment recommendation changes for Neisseria gonorrhoeae, the Philadelphia Department of Public Health documented medical therapy for 92% (3279/3551) of cases; 3001 (92%) received a recommended therapy. Nonrecommended therapies were documented in 8% of cases. Providers diagnosing 2 or less N. gonorrhoeae cases were more likely to use nonrecommended therapy. |
Leveraging the revised National Public Health Performance Standards to meet today's ever-changing public health system landscape
Daub T , Doshi S , Elligers JJ , Pavletic D , Pyron T . J Public Health Manag Pract 2014 20 (1) 135-7 This article is a commentary on leveraging the revised National Public Health Performance Standards to meet today's ever-changing public health system landscape. | The role of health departments in delivering the 10 essential public health services (EPHS) is important to fulfilling public health's mission to ensure the conditions in which people can be healthy.1,2 This mission has never been one that can be achieved by health departments acting alone.1,2 However, recent public health program cuts and job losses have highlighted a need for increased collaboration between health departments and their system partners.3 The 2010 passage of the Patient Protection and Affordable Care Act also generated new opportunities for health departments to work with system partners to improve the public's health.4,5 | For the past decade, the National Public Health Performance Standards (NPHPS), versions 1 and 2, have offered tools to assess the performance of state and local public health systems (PHS) on the 10 EPHS.6,7 In 2013, these NPHPS were revised (version 3) to provide health departments and their system partners with an updated tool for assessing and improving performance within the context of existing organizational challenges and a constantly changing landscape of public health services. With the release of NPHPS version 3 and the 2011 launch of a national public health agency accreditation system by the Public Health Accreditation Board (PHAB), both agency and system performance improvement tools now exist. |
Optimizing the protection of research participants and personnel in HIV-related research where TB is prevalent: practical solutions for improving infection control
Farley JE , Landers TF , Godfrey C , Lipke V , Sugarman J . J Acquir Immune Defic Syndr 2014 65 Suppl 1 S19-23 Tuberculosis (TB) is a leading cause of death among persons with HIV globally. HIV-related research in TB endemic areas raises some unique and important ethical issues in infection control related to protecting both research participants and personnel. To address such concerns, this article provides practical guidance to help research teams develop strategies to prevent TB transmission in studies involving persons with HIV in TB endemic settings. |
Physician nonadherence with a hepatitis C screening program
Southern WN , Drainoni ML , Smith BD , Koppelman E , McKee MD , Christiansen CL , Gifford AL , Weinbaum CM , Litwin AH . Qual Manag Health Care 2014 23 (1) 1-9 BACKGROUND: Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention. SUBJECTS AND METHODS: Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured. RESULTS: A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence. |
Guiding the way to public health improvement: exploring the connections between the Community Guide's evidence-based interventions and health department accreditation standards
Mercer SL , Banks SM , Verma P , Fisher JS , Corso LC , Carlson V . J Public Health Manag Pract 2014 20 (1) 104-10 CONTEXT: Recent years have seen rising interest in initiatives that focus on public health improvement. This includes support for accreditation of public health departments-administered by the Public Health Accreditation Board (PHAB)-and increasing expectations that health departments should use evidence-based programs, services, and policies (interventions) such as those described in The Guide to Community Preventive Services (The Community Guide). OBJECTIVE: This project was initiated to explore the potential connections between Community Guide interventions and PHAB domains, standards, and measures. DESIGN: The project team focused on developing a Crosswalk tool to assist health departments in identifying evidence-based interventions from The Community Guide whose implementation could help document conformity with PHAB domains, standards, and measures. All Community Preventive Services Task Force-recommended interventions were reviewed to determine whether they reflect the intent and requirements of the PHAB standards and measures. MAIN OUTCOME MEASURES: Three types of connections were defined through which Community Guide interventions could be relevant to the required documentation for a PHAB measure. All instances of these connections were identified and included in the Crosswalk. RESULTS: The Crosswalk tool consists of 2 tables. The first table cross-references individual PHAB domains, standards, and measures with interventions from The Community Guide that could help provide documentation for accreditation. The second table can help accreditation preparation staff to engage with program staff. It is searchable by Community Guide topic, identifying the PHAB measures that relate to each Community Guide intervention within that topic. The type, location, and extent of connections between Community Guide interventions and PHAB domains, standards, and measures are presented and discussed. CONCLUSIONS: Tools such as the Crosswalk can be instrumental in advancing the use of evidence-based interventions in public health practice. |
Improving public health through state health improvement planning: a framework for action
Marshall D , Pyron T , Jimenez J , Coffman J , Pearsol J , Koester D . J Public Health Manag Pract 2014 20 (1) 23-8 BACKGROUND: State health improvement plans (SHIPs) identify priorities for making the greatest impacts on health promotion and disease prevention, specific to the needs of state populations. Both SHIPs and the state health assessments on which they are based are prerequisites for Public Health Accreditation Board national accreditation. OBJECTIVE: To identify and evaluate existing SHIPs to develop guidance to support health departments in the state health improvement planning process. DESIGN: In 2010, the Association of State and Territorial Health Officials (ASTHO) conducted a comprehensive search for existing SHIPs. A systematic evaluation of existing SHIPS was accomplished by means of primary source document review using a standardized data collection form. Using data derived from these SHIPs and guidance from a workgroup of practitioners, ASTHO developed the ASTHO SHIP Guidance and Resources (SHIP Guidance) Framework. RESULTS: The search yielded 25 states (49%) having a SHIP completed or in progress. Fifteen states (29%) had no SHIP but had a Healthy People plan, and 10 states (20%) had no SHIP or Healthy People plan. No information was available for 1 state. Findings were reviewed, evaluated, and incorporated into the SHIP Guidance. The SHIP Guidance provides a framework for the implementation, monitoring, and evaluation of a SHIP process using 12 key steps. CONCLUSIONS: As public health/health care integration and accreditation readiness activity grows, multisector engagement through a SHIP will continue to be a priority for state public health and improving health outcomes. The SHIP Guidance provides a systematic, flexible approach for states conducting or updating state health assessments and SHIPs. |
Institutionalizing public health department accreditation through CDC opportunities
Monroe J , Collins J , Ikeda R , Khabbaz R . J Public Health Manag Pract 2014 20 (1) 141-4 This commentary discusses institutionalizing public health department accreditation through CDC opportunities. To realize these opportunities, it requires the engagement of national, state, and local partners. | Everybody doing his best is not the answer. It is first necessary that people know what to do. | W. Edwards Deming | The Centers for Disease Control and Prevention (CDC) mission is to help create the expertise, information, and tools that people and communities need to protect their health—through health promotion; prevention of disease, injury, and disability; and preparedness to promptly address new health threats. It has a long-standing partnership with state, tribal, local, and territorial health departments to help accomplish and further the public health mission. States and localities have the legal responsibility for public health and serve on the front lines as the first to recognize and respond to health threats. The federal government, on the contrary, has resources, expertise, and the responsibility to assess the health of the nation and make recommendations for improvement.1 Given the diversity in size, structure, and activities in health departments, developing standards for governmental public health practice has been a long-standing challenge. Fortunately, the collaborative work necessary to establish accreditation through the Public Health Accreditation Board (PHAB) has forged a national consensus on standards for public health departments. |
Instrumental roles of governance in accreditation: responsibilities of public health governing entities
Wallace H , Tilson H , Carlson VP , Valasek T . J Public Health Manag Pract 2014 20 (1) 61-3 In the decades following the War of Independence, local boards of health were established in major colonial population centers to fight recurrent epidemics of infectious diseases.1 As public health practices evolved with improvements in science and medicine, local boards of health assumed a governance role ensuring a close connection between the health department and the community it served. Today, the legal authority for public health governance is most commonly fulfilled by boards of health but it may also be performed by commissions, councils, individuals, or other legally accountable bodies. Decisions made by these governing entities will drive the process toward accreditation for their public health departments. We will explore how those decisions are best informed. | With the leadership and support of the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation, the concept of accrediting public health departments has gained national support. Public health department accreditation is defined as “the development of a set of standards, a process to measure health department performance against those standards, and reward or recognition for those health departments who meet the standards.”2 The first national voluntary public health accreditation program for state, local, territorial, and tribal public health authorities/agencies was launched in September 2011 by the Public Health Accreditation Board (PHAB). The standards and measures against which these health departments are evaluated (the PHAB Standards and Measures, Version 1.0)3 are divided into 12 domains—one domain for each of the 10 essential public health services4 plus domains for public health department administration and public health governance. |
Advancing accreditation through the National Public Health Improvement Initiative
Thomas CW , Pietz H , Corso L , Erlwein B , Monroe J . J Public Health Manag Pract 2014 20 (1) 36-8 The commentary describes the role of the Centers for Disease Control and Prevention's National Public Health Improvement Initiative in advancing health department accreditation readiness activities. | For more than 2 decades, the Institute of Medicine has drawn national attention to the need for strengthening the public health infrastructure and related capabilities to protect and ensure the public's health.1,2 A strong and sustainable public health infrastructure is critical for public health departments to operate efficiently and effectively in delivering the 10 essential public health services necessary to meet the health needs of communities. | In its 2003 report, The Future of the Public's Health in the 21st Century, the Institute of Medicine called for strengthening public health performance and exploring health department accreditation as a way to ensure that public health services and programs are efficient and effective in addressing the public health challenges of today and tomorrow.3 Four years later and with support from the Centers for Disease Control and Prevention (CDC) and the Robert Wood Johnson Foundation, the Public Health Accreditation Board (PHAB) was established and work began to develop a national program to improve the quality of practice and performance within public health departments. Based on the 10 essential public health services, PHAB accreditation provides a means for a health department to identify performance improvement opportunities, enhance management, develop leadership, and strengthen community relationships; leading organizations to improved accountability, credibility, and better health outcomes. The program was successfully launched in fall 2011, and the first 11 PHAB-accredited public health departments were announced in March 2013, with many more health department applications in process.4 |
CDC/NACCHO Accreditation Support Initiative: advancing readiness for local and tribal health department accreditation
Monteiro E , Fisher JS , Daub T , Zamperetti MC . J Public Health Manag Pract 2014 20 (1) 14-9 CONTEXT: Health departments have various unique needs that must be addressed in preparing for national accreditation. These needs require time and resources, shortages that many health departments face. OBJECTIVE: The Accreditation Support Initiative's goal was to test the assumption that even small amounts of dedicated funding can help health departments make important progress in their readiness to apply for and achieve accreditation. DESIGN: Participating sites' scopes of work were unique to the needs of each site and based on the proposed activities outlined in their applications. Deliverables and various sources of data were collected from sites throughout the project period (December 2011-May 2012). SETTING/PARTICIPANTS: Awardees included 1 tribal and 12 local health departments, as well as 5 organizations supporting the readiness of local and tribal health departments. RESULTS: Sites dedicated their funding toward staff time, accreditation fees, completion of documentation, and other accreditation readiness needs and produced a number of deliverables and example documents. All sites indicated that they made accreditation readiness gains that would not have occurred without this funding. CONCLUSIONS: Preliminary evaluation data from the first year of the Accreditation Support Initiative indicate that flexible funding arrangements may be an effective way to increase health departments' accreditation readiness. |
Dosing schedules for pneumococcal conjugate vaccine: considerations for policy makers
Whitney CG , Goldblatt D , O'Brien KL . Pediatr Infect Dis J 2014 33 Suppl 2 S172-81 Since second generation pneumococcal conjugate vaccines (PCVs) targeting 10 and 13 serotypes became available in 2010, the number of national policy makers considering these vaccines has steadily increased. An important consideration for a national immunization program is the timing and number of doses-the schedule-that will best prevent disease in the population. Data on disease epidemiology and the efficacy or effectiveness of PCV schedules are typically considered when choosing a schedule. Practical concerns, such as the existing vaccine schedule, and vaccine program performance are also important. In low-income countries, pneumococcal disease and deaths typically peak well before the end of the first year of life, making a schedule that provides PCV doses early in life (eg, a 6-, 10- and 14-week schedule) potentially the best option. In other settings, a schedule including a booster dose may address disease that peaks in the second year of life or may be seen to enhance a schedule already in place. A large and growing body of evidence from immunogenicity studies, as well as clinical trials and observational studies of carriage, pneumonia and invasive disease, has been systematically reviewed; these data indicate that schedules of 3 or 4 doses all work well, and that the differences between these regimens are subtle, especially in a mature program in which coverage is high and indirect (herd) effects help enhance protection provided directly by a vaccine schedule. The recent World Health Organization policy statement on PCVs endorsed a schedule of 3 primary doses without a booster or, as a new alternative, 2 primary doses with a booster dose. While 1 schedule may be preferred in a particular setting based on local epidemiology or practical considerations, achieving high coverage with 3 doses is likely more important than the specific timing of doses. |
Review of Institute of Medicine and National Research Council recommendations for One Health Initiative
Rubin C , Myers T , Stokes W , Dunham B , Harris S , Lautner B , Annelli J . Emerg Infect Dis 2013 19 (12) 1913-7 Human health is inextricably linked to the health of animals and the viability of ecosystems; this is a concept commonly known as One Health. Over the last 2 decades, the Institute of Medicine (IOM) and the National Research Council (NRC) have published consensus reports and workshop summaries addressing a variety of threats to animal, human, and ecosystem health. We reviewed a selection of these publications and identified recommendations from NRC and IOM/NRC consensus reports and from opinions expressed in workshop summaries that are relevant to implementation of the One Health paradigm shift. We grouped these recommendations and opinions into thematic categories to determine if sufficient attention has been given to various aspects of One Health. We conclude that although One Health themes have been included throughout numerous IOM and NRC publications, identified gaps remain that may warrant targeted studies related to the One Health approach. |
National survey of training needs reported by public health professionals in chronic disease programs in state, territorial, and local governments
Wilcox LS , Majestic EA , Ayele M , Strasser S , Weaver SR . J Public Health Manag Pract 2013 20 (5) 481-9 CONTEXT: In 2009, the National Association of Chronic Disease Directors published desirable competencies for professionals in public health chronic disease programs. Assessing the training needs of these professionals is an important step toward providing appropriate training programs in chronic disease prevention and control competencies. OBJECTIVES: Conduct a survey of the chronic disease workforce in state and local health departments to identify professional training needs. DESIGN: We conducted a cross-sectional survey of state, territorial, and local public health professionals who work in chronic disease programs to identify their self-reported training needs, using the membership lists of 3 professional organizations that included practitioners in chronic disease public health programs. SETTING: The survey was national, used a convenience sample, and was conducted in 2011. PARTICIPANTS: The survey was developed using an algorithm to select anonymous participants from the membership lists of the National Association of Chronic Disease Directors, the Directors for Health Promotion and Education, and the National Association of County & City Health Officials. OUTCOME MEASURES: The survey included questions about professional background, chronic disease activities, confidence about skills, and needs for training. RESULTS: The survey had 567 responses (38% response ratio). The majority of the respondents were female, non-Hispanic white, and 40 years or older. Respondents were not confident of their skills in health economics (38%) and technology and data management (23%). The most requested training topics were assessing the effects of policies, laws, and regulations (70%) and health economics (66%). CONCLUSIONS: This survey included local, territorial, and state public health professionals who work in chronic disease programs. These reported training needs in quantitative measurement methods and policy-related topics suggest key subjects for future training and education curricula. |
Origins, design and implementation of the China GAVI project
Liang X , Cui F , Hadler S , Wang X , Luo H , Chen Y , Kane M , Shapiro C , Yang W , Wang Y . Vaccine 2013 31 Suppl 9 J8-J14 China received GAVI support for hepatitis B vaccination in 2001 because of high disease burden and strong government will to protect infants at risk. The China/GAVI project, implemented since 2002, was funded 50% by GAVI and 50% by the Government of China. The purpose of the project was to increase coverage of hepatitis B vaccine through a pro-poor approach targeting all counties of the 12 Western provinces and poverty counties of the 10 Central provinces, to accelerate integration of hepatitis B vaccine into routine immunization, and assure immunization injection safety. The mechanism of internal coordination among multiple government entities and international cooperation was established and comprehensive strategies were used to improve vaccine coverage and injection safety. After 8 years of implementation, 193,000 health care workers in 118,316 health care facilities participated in the project, mostly at the township hospitals level (55,051) and in community centres (104,547). Through the China GAVI project, the 85% HepB3 coverage goal was reached in 98% of GAVI China project counties, the 75% timely birth dose (TBD) coverage goal was reached in 80% of GAVI project counties, and AD syringes were introduced into 100% of GAVI-supported areas. Additionally, the GAVI project was instrumental in convincing the Chinese Government to sustainably introduce and fully fund HepB vaccine for all newborns in China. The impact of hepB vaccination on HBsAg prevalence was observed throughout China, as HBsAg prevalence (previously approximately 10%) is now less than 1% among children under 5 years of age. |
Elective medical and veterinary student rotations in applied epidemiology at the Centers for Disease Control and Prevention, 1975-2012
Cohen L , Coronado F , Folowoshele C , Massoudi M , Koo D . J Public Health Manag Pract 2013 20 (5) 534-41 CONTEXT: Health professionals who can bridge the gap between public health and clinical medicine are needed. The Centers for Disease Control and Prevention Epidemiology Elective Program (EEP) offers a rotation in public health for medical and veterinary students that provides an introduction to public health, preventive medicine, and the principles of applied epidemiology through real-world, hands-on experiential learning. OBJECTIVE: To describe EEP, including its role in the integration of medicine and public health, and career paths for those who subsequently have enrolled in the Epidemic Intelligence Service (EIS). DESIGN: A review of files of EEP students participating June 1975 to May 2012 and EIS files to determine which EEP participants subsequently enrolled in EIS and their current employment. RESULTS: During January 1975 to May 2012, a total of 1548 students participated in EEP. Six hundred thirty-eight (41.2%) EEP students participated in field-based epidemic-assistance investigations. Among 187 students completing an exit survey implemented during 2007, a total of 175 (93.6%) indicated an increased understanding or competence in applied epidemiology and public health, and 98 (52.4%) indicated that they would apply to EIS. Among the 165 (10.7%) who enrolled in and completed EIS by July 2012, 106 (64.2%) are currently employed in public health and 65 (39.4%) are board-certified in preventive medicine, board eligible, or currently enrolled in the Centers for Disease Control and Prevention Preventive Medicine Residency or Fellowship. CONCLUSIONS: The CDC Epidemiology Elective Program offers opportunities for medical and veterinary students to participate in real-world public health learning activities. The Epidemiology Elective Program provides increased understanding and competence in applied epidemiology, provides students with opportunities to learn about population health and health care problems and the tools to help them bridge the gap between clinical medicine and public health, and serves as a source for EIS and other public health-related training and careers. |
Findings from a hepatitis B birth dose assessment in health facilities in the Philippines: opportunities to engage the private sector
Patel MK , Capeding RZ , Ducusin JU , de Quiroz Castro M , Garcia LC , Hennessey K . Vaccine 2013 32 (39) 5140-4 BACKGROUND: Hepatitis B vaccination in the Philippines was introduced in 1992 to reduce the high burden of chronic hepatitis B virus (HBV) infection in the population; in 2007, a birth dose (HepB-BD) was introduced to decrease perinatal HBV transmission. Timely HepB-BD coverage, defined as doses given within 24h of birth, was 40% nationally in 2011. A first step in improving timely HepB-BD coverage is to ensure that all newborns born in health facilities are vaccinated. METHODS: In order to assess ways of improving the Philippines' HepB-BD program, we evaluated knowledge, attitudes, and practices surrounding HepB-BD administration in health facilities. Teams visited selected government clinics, government hospitals, and private hospitals in regions with low reported HepB-BD coverage and interviewed immunization and maternity staff. HepB-BD coverage was calculated in each facility for a 3-month period in 2011. RESULTS: Of the 142 health facilities visited, 12 (8%) did not provide HepB-BD; seven were private hospitals and five were government hospitals. Median timely HepB-BD coverage was 90% (IQR 80%-100%) among government clinics, 87% (IQR 50%-97%) among government hospitals, and 50% (IQR 0%-90%) among private hospitals (p=0.02). The private hospitals were least likely to receive supervision (53% vs. 6%-31%, p=0.0005) and to report vaccination data to the national Expanded Programme on Immunization (36% vs. 96%-100%, p<0.0001). CONCLUSIONS: Private sector hospitals in the Philippines, which deliver 18% of newborns, had the lowest timely HepB-BD coverage. Multiple avenues exist to engage the private sector in hepatitis B prevention including through existing laws, newborn health initiatives, hospital accreditation processes, and raising awareness of the government's free vaccine program. |
The inception, achievements, and implications of the China GAVI Alliance Project on Hepatitis B Immunization
Kane MA , Hadler SC , Lee L , Shapiro CN , Cui F , Wang X , Kumar R . Vaccine 2013 31 Suppl 9 J15-20 The China GAVI Hepatitis B Immunization Project was initiated in 2002 with the signing of a Memorandum of Understanding between GAVI and the Government of China. The Project was one of the three (China, India, and Indonesia) GAVI-initiated special projects done to support countries too large to receive full GAVI support for hepatitis B vaccine and safe injections. The Project in China was designed by the Chinese Government and partners to deliver free hepatitis B vaccine and safe injections to all newborns in the 12 Western Provinces and Poverty Counties in 10 Provinces of Central China (1301 Counties with approximately 5.6 million births per year), eliminating the gap in immunization coverage between wealthier and poorer regions of China. The project budget (USD 76 million) was equally shared by GAVI and the Chinese Government. Initially planned for 5 years, two no cost extensions extended the project to 2011. Although China produced hepatitis B vaccine, before the project the vaccine was sold to parents who were also charged a "user fee" for the syringe and vaccine administration. Basic Expanded Program on Immunization (EPI) vaccines such as BCG, DTP, Polio, and measles vaccines were provided free to parents, although they were charged a user fee. Vaccines were sold by China CDC Offices at provincial, prefecture, county level and township hospitals, and village doctors received a substantial portion of their income from the sale of hepatitis B and other vaccines. The result of charging for hepatitis B vaccine was that coverage was relatively high in Eastern and wealthier counties in Central China ( approximately 80-90%), but was much lower ( approximately 40%) in Western China and Poverty Counties where parents could not afford the vaccine. The Project was administered by the China MOH and China CDC EPI program, and two Project Co-managers, one from the Chinese Government and the other an international assignee, were chosen. The project had an oversight Operational Advisory Group composed of the Chinese Government, WHO, UNICEF, and GAVI. The initial targets of the project as delineated in the initial MOU for the Project areas (HepB3 coverage will reach 85% at the county level, >75% of newborns at the county level will receive the first dose of hepatitis B within 24h of birth, and all immunization injections will be with auto disable [AD] syringes) were substantially exceeded. The differential in vaccine coverage between wealthier and poorer parts of China was eliminated contributing to a great improvement in equity. With additional contributions of the Chinese Government the Project was accomplished substantially under budget allowing for additional catch up immunization of children under 15 years of age. More than 5 million health workers were trained in how to deliver hepatitis B vaccine, timely birth dose (TBD), and safe injections, and public awareness of hepatitis B and its prevention rose significantly. TBD coverage was expedited by concurrent efforts to have women deliver in township clinics and district hospitals instead of at home. The effective management of the Project, with a Project office sitting within the China EPI and an Operational Advisory Group for oversight, could serve as a model for other GAVI projects worldwide. Most importantly, the carrier rate in Chinese children less than 5 years of age has fallen to 1%, from a level of 10% before the inception of the Project. Liver cancer, one of the major cancer killers in China (250,000-300,000 annual estimated deaths), will dramatically decline as immunized cohorts of Chinese children age. While hepatitis C and non-alcoholic liver disease also exist in China and can lead to liver cancer and cirrhosis, the majority of liver disease in China is hepatitis B related and therefore preventable. The authors believe that China's success in preventing hepatitis B is one of the greatest public health achievements of the 21st century. Work remains to be done in several key areas. There are still pockets of home births in rural provinces where a TBD is difficult to deliver, and China is strengthening its policy of screening pregnant women for HBsAg and delivering HBIG plus vaccine to newborns of HBV carrier mothers. Approximately 10% of the adult population of China remain chronic carriers of hepatitis B virus and cannot be helped by the vaccine, so prevention of liver cancer and cirrhosis in those groups remains a future challenge for China. |
Characteristics of health impact assessments reported in Australia and New Zealand 2005-2009
Haigh F , Harris E , Chok HNG , Baum F , Harris-Roxas B , Kemp L , Spickett J , Keleher H , Morgan R , Harris M , Wendel AM , Dannenberg AL . Aust N Z J Public Health 2013 37 (6) 534-546 OBJECTIVE: To describe the use and reporting of Health Impact Assessment (HIA) in Australia and New Zealand between 2005 and 2009. METHODS: We identified 115 HIAs undertaken in Australia and New Zealand between 2005 and 2009. We reviewed 55 HIAs meeting the study's inclusion criteria to identify characteristics and appraise the quality of the reports. RESULTS: Of the 55 HIAs, 31 were undertaken in Australia and 24 in New Zealand. The HIAs were undertaken on plans (31), projects (12), programs (6) and policies (6). Compared to Australia, a higher proportion of New Zealand HIAs were on policies and plans and were rapid assessments done voluntarily to support decision-making. In both countries, most HIAs were on land use planning proposals. Overall, 65% of HIA reports were judged to be adequate. CONCLUSION: This study is the first attempt to empirically investigate the nature of the broad range of HIAs done in Australia and New Zealand and has highlighted the emergence of HIA as a growing area of public health practice. It identifies areas where current practice could be improved and provides a baseline against which future HIA developments can be assessed. IMPLICATIONS: There is evidence that HIA is becoming a part of public health practice in Australia and New Zealand across a wide range of policies, plans and projects. The assessment of quality of reports allows the development of practical suggestions on ways current practice may be improved. The growth of HIA will depend on ongoing organisation and workforce development in both countries. |
Impact of prostate cancer on sexual relationships: a longitudinal perspective on intimate partners' experiences
Ramsey SD , Zeliadt SB , Blough DK , Moinpour CM , Hall IJ , Smith JL , Ekwueme DU , Fedorenko CR , Fairweather ME , Koepl LM , Thompson IM , Keane TE , Penson DF . J Sex Med 2013 10 (12) 3135-43 INTRODUCTION: In this prospective study of localized prostate cancer patients and their partners, we analyzed how partner issues evolve over time, focusing on satisfaction with care, influence of cancer treatment, and its impact on relationship with patient, cancer worry, and personal activities. AIMS: Our study aims were twofold: (i) to determine whether the impact of treatment on patients and partners moderate over time and (ii) if receiving surgery (i.e., radical prostatectomy) influences partner issues more than other treatments. METHODS: Patients newly diagnosed with localized prostate cancer and their female partners were recruited from three states to complete surveys by mail at three time points over 12 months. MAIN OUTCOME MEASURES: The four primary outcomes assessed in the partner analysis included satisfaction with treatment, cancer worry, and the influence of cancer and its treatment on their relationship (both general relationship and sexual relationship). RESULTS: This analysis included 88 patient-partner pairs. At 6 months, partners reported that cancer had a negative impact on their sexual relationship (39%-somewhat negative and 12%-very negative). At 12 months, this proportion increased substantially (42%-somewhat negative and 29%-very negative). Partners were significantly more likely to report that their sexual relationship was worse when the patient reported having surgery (P = 0.0045, odds ratio = 9.8025, 95% confidence interval 2.076-46.296). A minority of partners reported significant negative impacts in other areas involving their personal activities (16% at 6 months and 25% at 12 months) or work life (6% at 6 months, which increased to 12% at 12 months). CONCLUSION: From partners' perspectives, prostate cancer therapy has negative impact on sexual relationships and appears to worsen over time. |
The association of bisphenol-A urinary concentrations with antral follicle counts and other measures of ovarian reserve in women undergoing infertility treatments
Souter I , Smith KW , Dimitriadis I , Ehrlich S , Williams PL , Calafat AM , Hauser R . Reprod Toxicol 2013 42 224-31 In this prospective cohort of women undergoing infertility treatments, we measured specific-gravity adjusted urinary BPA (SG-BPA) concentrations and used regression models to evaluate the association of BPA with antral follicle count (AFC), day-3 serum follicle stimulating hormone levels (FSH), and ovarian volume (OV). BPA, detected in >80% of women, had a geometric mean (+/-GSD) of 1.6+/-2.0, 1.7+/-2.1, and 1.5+/-1.8mug/L for the women contributing to the AFC (n=154), day-3 FSH (n=120), and OV (n=114) analyses, respectively. There was an average decrease in AFC of 12% (95% CI: -23%, -0.6%), 22% (95% CI: -31%, -11%), and 17% (95% CI: -27%, -6%), in the 2nd, 3rd, and 4th SG-BPA quartile compared to the 1st quartile, respectively (p-trend: <0.001). No association of SG-BPA with FSH or OV was observed. Among women from an infertility clinic, higher urinary BPA concentrations were associated with lower AFC, raising concern for possible accelerated follicle loss and reproductive aging. |
Social work and adverse childhood experiences research: implications for practice and health policy
Larkin H , Felitti VJ , Anda RF . Soc Work Public Health 2014 29 (1) 1-16 Medical research on "adverse childhood experiences" (ACEs) reveals a compelling relationship between the extent of childhood adversity, adult health risk behaviors, and principal causes of death in the United States. This article provides a selective review of the ACE Study and related social science research to describe how effective social work practice that prevents ACEs and mobilizes resilience and recovery from childhood adversity could support the achievement of national health policy goals. This article applies a biopsychosocial perspective, with an emphasis on mind-body coping processes to demonstrate that social work responses to adverse childhood experiences may contribute to improvement in overall health. Consistent with this framework, the article sets forth prevention and intervention response strategies with individuals, families, communities, and the larger society. Economic research on human capital development is reviewed that suggests significant cost savings may result from effective implementation of these strategies. |
Self-reported maternal cigarette smoke exposure during the periconceptional period and the risk for omphalocoele
Feldkamp ML , Srisukhumbowornchai S , Romitti PA , Olney RS , Richardson SD , Botto LD . Paediatr Perinat Epidemiol 2014 28 (1) 67-73 BACKGROUND: We investigated whether maternal exposure to cigarette smoke was associated with omphalocoele and whether periconceptional folic acid modified the association. METHODS: We analysed data from the National Birth Defects Prevention Study on omphalocoele case (n = 301) and control (n = 8135) mothers for infants born from 1997 through 2007. Mothers who reported active smoking or exposure to second-hand smoke during the periconceptional period (1 month before conception to 3 months after) were considered exposed. Those who reported use of folic acid supplements during the same period were considered supplement users. Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression adjusted for alcohol use, preconception body mass index, and race/ethnicity. RESULTS: One hundred fifteen (38.2%) case and 2592 (31.9%) control mothers reported exposure to cigarette smoke during the periconceptional period. Adjusted odds ratios [95% confidence intervals] were 1.19 [0.94, 1.53] for any smoke exposure, 0.87 [0.54, 1.40] for active smoking, 1.38 [1.00, 1.90] for second-hand smoke exposure, and 1.16 [0.80, 1.67] for both exposures combined. No dose-response relationship was observed. Folic acid-containing supplements did not reduce the risk for omphalocoele among women with active or second-hand smoke exposure. CONCLUSIONS: Self-reported active maternal smoking, with or without exposure to second-hand smoke, during the periconceptional period was not associated with omphalocoele. In contrast, there was a possible association with periconceptional exposure to second-hand smoke. |
Trends in exposure to pro-tobacco advertisements over the Internet, in newspapers/magazines, and at retail stores among U.S. middle and high school students, 2000-2012
Agaku IT , King BA , Dube SR . Prev Med 2014 58 45-52 BACKGROUND: Most tobacco use begins during youth. Thus, this study assessed the prevalence, trends, and correlates of pro-tobacco advertising among United States students in grades 6-12 during 2000-2012. METHODS: Data from the 2000-2012 National Youth Tobacco Survey were analyzed to assess self-reported exposure to pro-tobacco advertisements through three media: over the Internet, in newspapers/magazines, and at retail stores. Trends during 2000-2012 were assessed in a binary logistic regression model (P<0.05). RESULTS: Among all middle and high school students, the overall prevalence of exposure to Internet pro-tobacco advertisements increased from 22.3% to 43.0% during 2000-2012 (P<0.001 for linear trend). During the same period, declines were observed in the overall prevalence of exposure to pro-tobacco advertisements in newspapers/magazines (65.0% to 36.9%) and at retail stores (87.8% to 76.2%) (P<0.001 for all linear trends). CONCLUSION: Exposure to pro-tobacco advertisements over the Internet increased significantly during 2000-2012 among United States middle and high school students, while a decline in exposure to advertisements in newspapers or magazines, and at retail stores occurred during the same period. However, over two-thirds of students still reported retail store exposure to pro-tobacco advertisements in 2012. Enhanced and sustained efforts would be beneficial to reduce even more exposure to all forms of pro-tobacco advertisements among youths. |
Exploring the relationship between cigarette prices and smoking among adults: a cross-country study of low- and middle-income nations
Kostova D , Tesche J , Perucic AM , Yurekli A , Asma S . Nicotine Tob Res 2014 16 Suppl 1 S10-5 INTRODUCTION: Evidence on the relationship between cigarette prices and adult smoking in low- and middle-income countries (LMICs) is relatively limited. This study offers new descriptive evidence on this relationship using data from a set of 13 LMICs. METHODS: We use Global Adult Tobacco Survey (GATS) cross-country data from approximately 200,000 participants aged 15 and older. Estimates on the relationship between prices and adult smoking were obtained from logit models of smoking participation and ordinary least squares models of conditional cigarette demand. RESULTS: Higher prices were associated with lower demand across countries, in terms of both smoking prevalence and daily number of cigarettes smoked among smokers. Our estimates suggest that the total price elasticity of cigarette demand in LMICs is approximately -0.53. We find that higher socioeconomic status (SES), represented through wealth and education effects is associated with lower chance of smoking overall, but among existing smokers, it may be associated with a larger number of cigarettes smoked. CONCLUSIONS: After controlling for a set of individual demographic and country characteristics, cigarette prices retain a significant role in shaping cigarette demand across LMICs. Because higher SES is associated with a reduced chance of smoking overall but also with increased daily consumption among current smokers, optimal tobacco tax policies in LMICs may face an added need to accommodate to shifting SES structures within the populations of these countries. |
Characteristics of designated drivers and their passengers from the 2007 National Roadside Survey in the United States
Bergen G , Yao J , Shults RA , Romano E , Lacey JH . Traffic Inj Prev 2014 15 (3) 273-7 OBJECTIVE: The objectives of this study were to estimate the prevalence of designated driving in the United States, compare these results with those from the 1996 National Roadside Survey, and explore the demographic, drinking, and trip characteristics of both designated drivers and their passengers. METHODS: The data used were from the 2007 National Roadside Survey, which randomly stopped drivers, administered breath tests for alcohol, and administered a questionnaire to drivers and front seat passengers. RESULTS: Almost a third (30%) of nighttime drivers reported being designated drivers, with 84 percent of them having a blood alcohol concentration of zero. Drivers who were more likely to be designated drivers were those with a blood alcohol concentration that was over zero but still legal; who were under 35 years of age; who were African American, Hispanic, or Asian; and whose driving trip originated at a bar, tavern, or club. Over a third of passengers of designated drivers reported consuming an alcoholic drink the day of the survey compared to a fifth of passengers of nondesignated drivers. One fifth of passengers of designated drivers who reported drinking consumed 5 or more drinks that day. CONCLUSIONS: Designated driving is widely used in the United States, with the majority of designated drivers abstaining from drinking alcohol. However, because designated driving separates drinking from driving for passengers in a group traveling together, this may encourage passengers to binge drink, which is associated with many adverse health consequences in addition to those arising from alcohol-impaired driving. Designated driving programs and campaigns, although not proven to be effective when used alone, can complement proven effective interventions to help reduce excessive drinking and alcohol-impaired driving. |
Retention of participants in medication-assisted programs in low- and middle-income countries: an international systematic review
Feelemyer J , Des Jarlais D , Arasteh K , Abdul-Quader AS , Hagan H . Addiction 2013 109 (1) 20-32 BACKGROUND AND AIMS: Medication-assisted treatment (MAT) is a key component in overdose prevention, reducing illicit opiate use and risk of blood-borne virus infection. By retaining participants in MAT programs for longer periods of time, more noticeable and permanent changes in drug use, risk behavior and quality of life can be achieved. Many studies have documented retention in MAT programs in high-income countries, using a 50% average 12-month follow-up retention rate as a marker for a successful MAT program. This study contributes to a systematic understanding of how successful programs have been in retaining participants in low- and middle-income countries (LMIC) over time. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic literature search to identify MAT program studies that documented changes in retention over time for participants in buprenorphine and methadone programs in LMIC. Retention was measured for participants by length of follow-up, type of MAT and treatment dosage. RESULTS: There were 58 MAT program studies, with 27 047 participants eligible for inclusion in the review. Overall average retention after 12 months was 54.3% [95% confidence interval (CI) = 46.2, 63.7%]. Overall average retention was moderately good for both buprenorphine (48.3%, 95% CI = 22.1, 74.6%) and methadone (56.6%, 95% CI = 45.9%, 67.3%) after 12 months of treatment. Among programs using methadone there was no statistically significant difference in average retention by dosage level, and the 10 highest and lowest dosage programs obtained similar average retention levels after 12 months. CONCLUSION: Medication-assisted treatment programs in low- and middle-income countries achieve an average 50% retention rate after 12 months, with wide variation across programs but little difference between those using buprenorphine versus methadone. |
Trends in tobacco smoke exposure and blood lead levels among youths and adults in the United States: the National Health and Nutrition Examination Survey, 1999-2008
Richter PA , Bishop EE , Wang J , Kaufmann R . Prev Chronic Dis 2013 10 E213 INTRODUCTION: Tobacco smoke is a source of exposure to thousands of toxic chemicals including lead, a chemical of longstanding public health concern. We assessed trends in blood lead levels in youths and adults with cotinine-verified tobacco smoke exposure by using 10 years of data from the National Health and Nutrition Examination Survey. METHODS: Geometric mean levels of blood lead are presented for increasing levels of tobacco smoke exposure. Regression models for lead included age, race/ethnicity, poverty, survey year, sex, age of home, birth country, and, for adults, alcohol consumption. Lead levels were evaluated for smokers and nonsmokers on the basis of age of residence and occupation. RESULTS: Positive trend tests indicate that a linear relationship exists between smoke exposure and blood lead levels in youths and adults and that secondhand smoke exposure contributes to blood lead levels above the level caused by smoking. CONCLUSION: Youths with secondhand smoke exposure had blood lead levels suggestive of the potential for adverse cognitive outcomes. Despite remediation efforts in housing and the environment and declining smoking rates and secondhand smoke exposure in the United States, tobacco smoke continues to be a substantial source of exposure to lead in vulnerable populations and the population in general. |
Costs of raccoon rabies incidents in cattle herds in Hampshire County, West Virginia, and Guernsey County, Ohio
Chipman RB , Cozzens TW , Shwiff SA , Biswas R , Plumley J , O'Quin J , Algeo TP , Rupprecht CE , Slate D . J Am Vet Med Assoc 2013 243 (11) 1561-7 OBJECTIVE: To determine direct and indirect costs associated with raccoon rabies incidents involving cattle herds in Hampshire County, WV, in 2008 and Guernsey County, Ohio, in 2010. DESIGN: Ex post cost analysis. ANIMALS: 1 cattle herd in Hampshire County, WV, in 2008 and 1 cattle herd in Guernsey County, Ohio, in 2010. PROCEDURES: Data were collected for each incident through telephone and email interviews with 16 federal, state, and county agency personnel involved in the case investigations and coordinated responses for rabies in the cattle herds. To characterize the economic impact associated with rabies in the 2 cattle herds, cost analysis was conducted with 7 cost variables (salary and benefits for personnel involved in the response, human postexposure prophylaxis, indirect patient costs, rabies diagnostic testing, cattle carcass disposal, market value of euthanized cattle, and enhanced rabies surveillance). Estimates of direct costs were determined on the basis of agency records and other relevant data obtained from notes and reports made by agency staff at the time of the incident and from a review of the literature. RESULTS: Primary costs included the market value of euthanized cattle ($51,461 in West Virginia; $12,561 in Ohio), human postexposure prophylaxis ($17,959 in West Virginia; $11,297 in Ohio), and salary and benefits for personnel involved in the response ($19,792 in West Virginia; $14,496 in Ohio). CONCLUSIONS AND CLINICAL RELEVANCE:These results should provide a basis for better characterization of the economic impact of wildlife rabies in cattle in the United States. |
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