Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and pharmacological and psychosocial management
Bushby K , Finkel R , Birnkrant DJ , Case LE , Clemens PR , Cripe L , Kaul A , Kinnett K , McDonald C , Pandya S , Poysky J , Shapiro F , Tomezsko J , Constantin C , DMD Care Considerations Working Group . Lancet Neurol 2010 9 (1) 77-93 Duchenne muscular dystrophy (DMD) is a severe, progressive disease that affects 1 in 3600-6000 live male births. Although guidelines are available for various aspects of DMD, comprehensive clinical care recommendations do not exist. The US Centers for Disease Control and Prevention selected 84 clinicians to develop care recommendations using the RAND Corporation-University of California Los Angeles Appropriateness Method. The DMD Care Considerations Working Group evaluated assessments and interventions used in the management of diagnostics, gastroenterology and nutrition, rehabilitation, and neuromuscular, psychosocial, cardiovascular, respiratory, orthopaedic, and surgical aspects of DMD. These recommendations, presented in two parts, are intended for the wide range of practitioners who care for individuals with DMD. They provide a framework for recognising the multisystem primary manifestations and secondary complications of DMD and for providing coordinated multidisciplinary care. In part 1 of this review, we describe the methods used to generate the recommendations, and the overall perspective on care, pharmacological treatment, and psychosocial management. |
Physicians' participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study
Heisler M , Tierney E , Ackermann RT , Tseng C , Narayan KM , Crosson J , Waitzfelder B , Safford MM , Duru K , Herman WH , Kim C . Chronic Illn 2009 5 (3) 165-76 OBJECTIVES: In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. METHODS: 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n=4198) in 10 US health plans across the country and their physicians (n=1217). We characterized physicians' diabetes care PDM preferences and practices as 'no patient involvement,' 'physician-dominant,' 'shared,' or 'patient-dominant' and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients'satisfaction with physician communication; and (3) whether patients' A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. RESULTS: Most physicians preferred 'shared' PDM (58%) rather than 'no patient involvement' (9%), 'physician-dominant' (28%) or 'patient dominant' PDM (5%). However, most reported practicing 'physician-dominant' PDM (43%) with most of their patients, rather than 'no patient involvement' (13%), 'shared' (37%) or 'patient-dominant' PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred 'shared' PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred 'patient-dominant' treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred 'no patient involvement' in treatment decision-making. There were no differences in patients' satisfaction with their doctor's communication or control of A1c, SBP or LDL depending on their physicians' PDM preferences. Physicians' self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses. CONCLUSIONS: Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes. |
US outbreak investigations highlight the need for safe injection practices and basic infection control
Perz JF , Thompson ND , Schaefer MK , Patel PR . Clin Liver Dis 2010 14 (1) 137-51 Current understanding of viral hepatitis transmission in United States health care settings indicates progress over the past several decades with respect to the risks from transfusions or blood products. Likewise, risks to health care providers from sharps injuries and other blood and body fluid exposures have been reduced as a consequence of widespread hepatitis B vaccination and the adoption of safer work practices. Increasing recognition of outbreaks involving patient-to-patient spread of hepatitis B and hepatitis C virus infections, however, has uncovered a disturbing trend. This article highlights the importance of basic infection control and the need for increased awareness of safe injection practices. |
Molecular epidemiology of health care-associated transmission of hepatitis B and C viruses
Holmberg SD . Clin Liver Dis 2010 14 (1) 37-48 The term "molecular epidemiology" has been ascribed to a host of different activities that involve gene-sequence analysis. Some examples of molecular epidemiology include modeling exercises of phylogenetic trees to reconstruct epidemics; studies of the evolution of hepatitis C virus (HCV); rates of nucleotide substitution in the hepatitis B virus (HBV) surface (S) gene; variations in the core promoter/pre-core/core region of HBV genotype C from different sources; analysis of HBV surface antigen mutations; molecular clock analyses of the short-term evolution of HCV; and analyses of clades and surface antigen polymorphisms of HBV. However, for most epidemiologists molecular epidemiology of viral hepatitis usually refers to studies of gene-sequence homology in HBV or HCV recovered from people in the community or an institution that allows better characterization and assignment of related clusters of infection. |
Effects of oseltamivir treatment on duration of clinical illness and viral shedding and household transmission of influenza virus
Ng S , Cowling BJ , Fang VJ , Chan KH , Ip DK , Cheng CK , Uyeki TM , Houck PM , Malik Peiris JS , Leung GM . Clin Infect Dis 2010 50 (5) 707-14 BACKGROUND: Large clinical trials have demonstrated the therapeutic efficacy of oseltamivir against influenza. We assessed the indirect effectiveness of oseltamivir in reducing secondary household transmission in an incident cohort of influenza index patients and their household members. METHODS: We recruited index outpatients whose rapid test results were positive for influenza from February through September 2007 and January through September 2008. Household contacts were followed up for 7-10 days during 3-4 home visits to monitor symptoms. Nose and throat swabs were collected and tested for influenza by reverse-transcription polymerase chain reaction or viral culture. RESULTS: We followed up 384 index patients and their household contacts. Index patients who took oseltamivir within 24 h of symptom onset halved the time to symptom alleviation (adjusted acceleration factor, 0.56; 95% confidence interval [CI], 0.42-0.76). Oseltamivir treatment was not associated with statistically significant reduction in the duration of viral shedding. Household contacts of index patients who had taken oseltamivir within 24 h of onset had a nonstatistically significant lower risk of developing laboratory-confirmed infection (adjusted odds ratio, 0.54; 95% CI, 0.11-2.57) and a marginally statistically significant lower risk of clinical illness (adjusted odds ratio, 0.52; 95% CI, 0.25-1.08) compared with contacts of index patients who did not take oseltamivir. CONCLUSIONS: Oseltamivir treatment is effective in reducing the duration of symptoms, but evidence of household reduction in transmission of influenza virus was inconclusive. |
Influenza testing and antiviral prescribing practices among emergency department clinicians in 9 states during the 2006 to 2007 influenza season
Mueller MR , Smith PJ , Baumbach JP , Palumbo JP , Meek JI , Gershman K , Vandermeer M , Thomas AR , Long CE , Belflower R , Spina NL , Martin KG , Lynfield R , Openo KP , Kirley PD , Pasutti LE , Barnes BG , Schaffner W , Kamimoto L . Ann Emerg Med 2010 55 (1) 32-9 STUDY OBJECTIVE: Influenza causes significant widespread illness each year. Emergency department (ED) clinicians are often first-line providers to evaluate and make treatment decisions for patients presenting with influenza. We sought to better understand ED clinician testing and treatment practices in the Emerging Infections Program Network, a federal, state, and academic collaboration that conducts active surveillance for influenza-associated hospitalizations. METHODS: During 2007, a survey was administered to ED clinicians who worked in Emerging Infections Program catchment area hospitals' EDs. The survey encompassed the role of the clinician, years since completing clinical training, hospital type, influenza testing practices, and use of antiviral medications during the 2006 to 2007 influenza season. We examined factors associated with influenza testing and antiviral use. RESULTS: A total of 1,055 ED clinicians from 123 hospitals responded to the survey. A majority of respondents (85.3%; n=887) reported they had tested their patients for influenza during the 2006 to 2007 influenza season (Emerging Infections Program site range: 59.3 to 100%; P<.0001). When asked about antiviral medications, 55.7% (n=576) of respondents stated they had prescribed antiviral medications to some of their patients in 2006 to 2007 (Emerging Infections Program site range 32.9% to 80.3%; P<.0001). A positive association between influenza testing and prescribing antiviral medications was observed. Additionally, the type of hospital, location in which an ED clinician worked, and the number of years since medical training were associated with prescribing antiviral influenza medications. CONCLUSION: There is much heterogeneity in clinician-initiated influenza testing and treatment practices. Additional exploration of the role of hospital testing and treatment policies, clinicians' perception of influenza disease, and methods for educating clinicians about new recommendations is needed to better understand ED clinician testing and treatment decisions, especially in an environment of rapidly changing influenza clinical guidelines. Until influenza testing and treatment guidelines are better promulgated, clinicians may continue to test and treat influenza with inconsistency. |
Intermittent prophylaxis with oral Truvada protects macaques from rectal SHIV infection
Garcia-Lerma JG , Cong ME , Mitchell J , Youngpairoj AS , Zheng Q , Masciotra S , Martin A , Kuklenyik Z , Holder A , Lipscomb J , Pau CP , Barr JR , Hanson DL , Otten R , Paxton L , Folks TM , Heneine W . Sci Transl Med 2010 2 (14) 14ra4 HIV continues to spread globally, mainly through sexual contact. Despite advances in treatment and care, preventing transmission with vaccines or microbicides has proven difficult. A promising strategy to avoid transmission is prophylactic treatment with antiretroviral drugs before exposure to HIV. Clinical trials evaluating the efficacy of daily treatment with the reverse transcriptase inhibitors tenofovir disoproxil fumarate (TDF) or Truvada (TDF plus emtricitabine) are under way. We hypothesized that intermittent prophylactic treatment with long-acting antiviral drugs would be as effective as daily dosing in blocking the earliest stages of viral replication and preventing mucosal transmission. We tested this hypothesis by intermittently giving prophylactic Truvada to macaque monkeys and then exposing them rectally to simian-human immunodeficiency virus (SHIV) once a week for 14 weeks. A simple regimen with an oral dose of Truvada given 1, 3, or 7 days before exposure followed by a second dose 2 hours after exposure was as protective as daily drug administration, possibly because of the long intracellular persistence of the drugs. In addition, a two-dose regimen initiated 2 hours before or after virus exposure was effective, and full protection was obtained by doubling the Truvada concentration in both doses. We saw no protection if the first dose was delayed until 24 hours after exposure, underscoring the importance of blocking initial replication in the mucosa. Our results show that intermittent prophylactic treatment with an antiviral drug can be highly effective in preventing SHIV infection, with a wide window of protection. They strengthen the possibility of developing feasible, cost-effective strategies to prevent HIV transmission in humans. |
Antiretroviral prophylaxis to prevent perinatal HIV transmission in St. Petersburg, Russia: too little, too late
Hillis SD , Kuklina E , Akatova N , Kissin DM , Vinogradova EN , Rakhmanova AG , Stepanova E , Jamieson DJ , Robinson J , Vitek C , Miller WC . J Acquir Immune Defic Syndr 2010 54 (3) 304-10 BACKGROUND: We evaluated the influence of type and timing of prophylaxis on perinatal HIV transmission in St. Petersburg, Russia. METHODS: We linked surveillance data for 1498 HIV-infected mothers delivering from 2004 to 2007 with polymerase chain reaction data for 1159 infants to determine predictors of transmission. RESULTS: The overall perinatal transmission rate was 6.3% [73 of 1159, 95% confidence interval (CI) 4.9% to 7.7%]. Among the 12.8% (n = 149) of mother-infant pairs receiving full course (antenatal, intrapartum, postnatal) dual/triple antiretroviral prophylaxis, the transmission rate was 2.7%. Among the 1010 receiving less complete regimens (full course zidovudine, single-dose nevirapine, or incomplete), transmission ranged from 4.1% to 12.2%. Among the 28.9% (330) of mothers initiating antiretroviral drugs ≤20 weeks gestation, perinatal transmission was 1.8%, compared with 4.0%, 8.6%, and 11.3% for those initiating antiretrovirals at 21-28 weeks, 29-42 weeks, or during labor and delivery, respectively (P for trend <0.0001). Compared with those initiating antepartum prophylaxis ≤20 weeks, those initiating antepartum prophylaxis ≥29 weeks (or not at all) had increased transmission odds (adjusted odds ratio: 4.9, 95% CI: 1.8 to 12.9; odds ratio: 5.1, 95% CI: 2.0 to 13.1, respectively). CONCLUSIONS: In St. Petersburg, the potential for further reductions in perinatal transmission is evident, given low transmission among women receiving early combination prophylaxis. |
Multicenter, hospital-based surveillance of rotavirus disease and strains among Indian children aged <5 years
Kang G , Arora R , Chitambar SD , Deshpande J , Gupte MD , Kulkarni M , Naik TN , Mukherji D , Venkatasubramaniam S , Gentsch JR , Glass RI , Parashar UD , Indian Rotavirus Strain Surveillance Network . J Infect Dis 2009 200 Suppl 1 S147-53 BACKGROUND: Current, nationally representative data on rotavirus disease burden and rotavirus strains in India are needed to understand the potential health benefits of rotavirus vaccination. METHODS: The Indian Rotavirus Strain Surveillance Network was established with 4 laboratories and 10 hospitals in 7 different regions of India. At each hospital, children aged <5 years who presented with acute gastroenteritis and required hospitalization with rehydration for at least 6 h were enrolled. A fecal specimen was obtained and was tested for rotavirus with use of a commercial enzyme immunoassay, and strains were characterized using reverse-transcription polymerase chain reaction. RESULTS: From December 2005 through November 2007, rotavirus was found in approximately 39% of 4243 enrolled patients. Rotavirus was markedly seasonal in northern temperate locations but was less seasonal in southern locations with a tropical climate. Rotavirus detection rates were greatest among children aged 6-23 months, and 13.3% of rotavirus infections involved children aged <6 months. The most common types of strains were G2P[4] (25.7% of strains), G1P[8] (22.1%), and G9P[8] (8.5%); G12 strains were seen in combination with types P[4], P[6], and P[8] and together comprised 6.5% of strains. CONCLUSIONS: These data highlight the need for development and implementation of effective prophylactic measures, such as vaccines, to prevent the large burden of rotavirus disease among Indian children. |
Population-based incidence of intussusception and a case-control study to examine the association of intussusception with natural rotavirus infection among Indian children
Bahl R , Saxena M , Bhandari N , Taneja S , Mathur M , Parashar UD , Gentsch J , Shieh WJ , Zaki SR , Glass R , Bhan MK , Delhi Intussusception Study Hospital Group . J Infect Dis 2009 200 Suppl 1 S277-81 BACKGROUND: A rotavirus vaccine previously licensed in the United States was withdrawn because it caused intussusception. Data on background intussusception rates in developing countries are required to plan pre- and postlicensure safety studies for new rotavirus vaccines. Also, it is unclear whether natural rotavirus infection is associated with intussusception. METHODS: Passive surveillance for intussusception in a large, well-defined, poor, urban population in Delhi, India, was conducted in 2 phases. Intussusception was confirmed by ultrasonography or surgery. Fecal samples obtained from patients with intussusception at study hospitals (irrespective of their residence in study areas) and healthy control subjects were tested for rotavirus with use of enzyme immunoassay. If available, resected intestinal tissue samples were tested for rotavirus with use of immunohistochemistical analysis and reverse-transcription polymerase chain reaction. RESULTS: The incidence of intussusception requiring hospitalization was 17.7 cases per 100,000 infant-years of follow-up (95% confidence interval, 5.9-41.4 cases per 100,000 infant-years). Detection rates of rotavirus in stool samples did not differ significantly between case patients and control subjects (4 of 42 case patients vs 6 of 92 control subjects), and no evidence of rotavirus was detected in any of the 22 patients with intussusception for whom intestinal tissue samples were available. CONCLUSIONS: The incidence of intussusception among Indian infants appears to be lower than that reported in other middle- and high-income countries. Natural rotavirus infection does not appear to be a major cause of intussusception in Indian infants. |
A retrospective evaluation of hospitalizations for acute gastroenteritis at 2 sentinel hospitals in central Japan to estimate the health burden of rotavirus
Kamiya H , Nakano T , Inoue M , Abd TT , Patel M , Orenstein WA , Parashar UD . J Infect Dis 2009 200 Suppl 1 S140-6 BACKGROUND: Two rotavirus vaccines have recently been licensed for use in >80 countries worldwide but not in Japan. To assess the value of introducing rotavirus vaccination in Japan, data on the burden of rotavirus disease are needed. METHODS: To describe the epidemiology of severe rotavirus disease among Japanese children aged <5 years, we examined retrospective demographic, clinical, and laboratory data from the period 2003-2007 for children hospitalized with acute gastroenteritis (AGE) at 2 sentinel hospitals in Japan. RESULTS: At each of the 2 hospitals, 17%-21% of all pediatric hospitalizations were for AGE. Three-fourths of all AGE-related admissions occurred during the winter (December-May). Rotavirus testing was performed for approximately three-fourths of patients admitted with AGE in the winter, of which 55% at one hospital and 59% at the other tested positive. By extrapolating the test results to those patients with AGE admitted in the winter who were not tested, we estimated that 39%-44% of year-round and 52%-57% of winter hospitalizations were attributable to rotavirus. The annual incidence of hospitalization for rotavirus AGE in the 2 cities served by the hospitals was estimated to be 3.8 and 4.9 per 1000 person-years. CONCLUSIONS: The burden of severe rotavirus disease among Japanese children is substantial and warrants consideration of vaccination as a prevention strategy. |
Rotavirus burden among children in the newly independent states of the former Union of Soviet Socialist Republics: literature review and first-year results from the rotavirus surveillance network
Mirzayeva R , Cortese MM , Mosina L , Biellik R , Lobanov A , Chernyshova L , Lashkarashvili M , Turkov S , Iturriza-Gomara M , Gray J , Parashar UD , Steele D , Emiroglu N , Rotavirus Surveillance Network . J Infect Dis 2009 200 Suppl 1 S203-14 BACKGROUND: Data on rotavirus burden among children in the 15 newly independent states of the former Union of Soviet Socialist Republics, particularly contemporary data from poorer countries, are not widely available. These data are desired by policy makers to assess the value of rotavirus vaccination, especially since the GAVI Alliance approved financial support for the region's eligible countries. The Rotavirus Surveillance Network was established to provide these data. METHODS: We reviewed the region's literature on rotavirus burden. We established an active surveillance network for rotavirus and analyzed data from 2007 from 4 sentinel hospitals in 3 countries (Georgia, Tajikistan, and Ukraine) that were collected using standardized enrollment and stool sample testing methods. RESULTS: Specimens for rotavirus testing were collected before 1997 in most studies, and the majority of studies were from 1 country, the Russian Federation. Overall, the studies indicated that approximately 33% of hospitalizations for gastroenteritis among children were attributable to rotavirus. The Rotavirus Surveillance Network documented that 1425 (42%) of 3374 hospitalizations for acute gastroenteritis among children aged <5 years were attributable to rotavirus (site median, 40%). Seasonal peaks (autumn through spring) were observed. Genotype data on 323 samples showed that G1P[8] was the most common type (32%), followed by G9P[8] (20%), G2P[4] (18%), and G4P[8] (18%). Infections due to G10 and G12 and mixed infections were also detected. CONCLUSIONS: The burden of rotavirus disease in the newly independent states is substantial. Vaccines should be considered for disease prevention. |
Rotavirus vaccination: cost-effectiveness and impact on child mortality in developing countries
Atherly D , Dreibelbis R , Parashar UD , Levin C , Wecker J , Rheingans RD . J Infect Dis 2009 200 Suppl 1 S28-38 BACKGROUND: Rotavirus is the leading cause of severe gastroenteritis in children <5 years of age and is responsible for >500,000 deaths annually; approximately 85% of this burden is in low-income countries eligible for financial support from the GAVI Alliance. We projected the uptake, health impact, and cost-effectiveness of introducing rotavirus vaccination in GAVI-eligible countries to help policy makers in prioritizing resources to gain the greatest health improvements for their constituencies. METHODS: A demand forecast model was used to predict adoption of rotavirus vaccine in the poorest countries in the world. We then modeled health outcomes and direct costs of a hypothetical birth cohort in the target population for scenarios with and without a rotavirus vaccine with use of data on health outcomes of rotavirus infection, vaccine effectiveness, and immunization rates. RESULTS: Vaccination would prevent 2.4 million rotavirus deaths and >82 million disability-adjusted life-years (DALYs) in 64 of the 72 GAVI-eligible countries introducing vaccine from 2007 through 2025. The cost per DALY averted decreases over time, from a high of US$450 per DALY averted in the first year to a sustained low of $30 per DALY during 2017-2025, with a cumulative figure of $43 per DALY averted during 2008-2025. By applying the baseline scenario with an initial vaccine price of $7 per dose for a 2-dose vaccine, with a gradual decrease beginning in 2012 and stabilizing at $1.25 per dose by 2017, vaccination was very cost-effective in all GAVI-eligible countries with use of each country's gross domestic product per DALY averted as a threshold. CONCLUSIONS: Introduction of rotavirus vaccines into the world's poorest countries is very cost-effective and is projected to substantially reduce childhood mortality. |
Rotavirus vaccines for infants in developing countries in Africa and Asia: considerations from a World Health Organization-sponsored consultation
Steele AD , Patel M , Parashar UD , Victor JC , Aguado T , Neuzil KM . J Infect Dis 2009 200 Suppl 1 S63-9 The World Health Organization (WHO) and its international partners have prioritized the development of rotavirus vaccines for the past 3 decades. In November 2005, the WHO's Strategic Advisory Group of Experts first reviewed the clinical efficacy data from 2 new live attenuated oral rotavirus vaccines, which demonstrated excellent protective efficacy against severe rotavirus disease in regions where they were evaluated. Despite these successes, the WHO has urged the clinical evaluation of these vaccines in populations of Africa and Asia, where most of the deaths due to rotavirus occur, and has emphasized the need for ongoing postlicensure safety monitoring in countries introducing vaccines. Clinical studies in Africa and Asia will soon provide data on the efficacy of both new vaccines in these populations. A WHO international consultative meeting convened to evaluate how to use these imminent data for the future use of rotavirus vaccines in developing countries. In brief, it was agreed that (1) even vaccines with lesser efficacy in developing countries, compared with industrialized countries, would still lead to substantial public health benefits and would be cost-effective in saving lives in Africa and Asia; (2) criteria, such as the WHO mortality strata and local epidemiology of rotavirus infection, would be appropriate measures for extrapolating the clinical data to other regions and countries; and (3) research toward understanding the programmatic limitations of rotavirus vaccine use may help develop strategies to improve vaccine uptake and overall impact. |
Sentinel hospital surveillance for rotavirus in Latin American and Caribbean countries
de Oliveira LH , Danovaro-Holliday MC , Andrus JK , de Fillipis AM , Gentsch J , Matus CR , Widdowson MA , Rotavirus Surveillance Network . J Infect Dis 2009 200 Suppl 1 S131-9 The burden of rotavirus disease in the Latin American region has been poorly understood despite the promise of effective vaccines. We describe here the implementation and results of a rotavirus surveillance network in the Latin American and Caribbean region. From 2005 through 2007, stool specimens and epidemiologic information were gathered from children <5 years of age who were hospitalized for acute diarrhea (3 looser-than-normal stools within <24 h) lasting <14 days with use of a standardized generic protocol. Stool samples were tested for rotavirus, and a proportion of detected strains were typed. The proportion of samples positive for rotavirus was applied to World Health Organization diarrhea-related mortality estimates to calculate rotavirus-associated mortality. In 2007, the network comprised 54 sites in 11 countries. During 2006-2007, specimens were collected from 19,817 children; 8141 of these specimens were positive for rotavirus. The median percentage of positive specimens in the country was 31.5% (range, 24%-47%). The risk of death from rotavirus diarrhea by age 5 years was 1 of 2874. Strong rotavirus winter seasonality was apparent, even in tropical Central America. Globally common strains (P[8] G1, P[8] G9, and P[4] G2) accounted for >75% of strains, although unusual strains, including G12, were detected at low levels. As rotavirus vaccines continue to be introduced in Latin America, maintenance of surveillance will provide robust pre-introduction data and a platform for estimating vaccine effectiveness and other measures of impact. |
Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America
Deeks SG , Gange SJ , Kitahata MM , Saag MS , Justice AC , Hogg RS , Eron JJ , Brooks JT , Rourke SB , Gill MJ , Bosch RJ , Benson CA , Collier AC , Martin JN , Klein MB , Jacobson LP , Rodriguez B , Sterling TR , Kirk GD , Napravnik S , Rachlis AR , Calzavara LM , Horberg MA , Silverberg MJ , Gebo KA , Kushel MB , Goedert JJ , McKaig RG , Moore RD . Clin Infect Dis 2009 49 (10) 1582-90 BACKGROUND: Although combination antiretroviral therapy continues to evolve, with potentially more effective options emerging each year, the ability of therapy to prevent multiple regimen failure and mortality in clinical practice remains poorly defined. METHODS: Sixteen cohorts representing over 60 sites contributed data on all individuals who initiated combination antiretroviral therapy. We identified those individuals who experienced virologic failure (defined as a human immunodeficiency virus [HIV] RNA level >1000 copies/mL), received modified therapy, and subsequently had a second episode of virologic failure. Multivariate Cox regression was used to assess factors associated with time to second regimen failure and the time to death after the onset of second regimen failure. RESULTS: Of the 42,790 individuals who received therapy, 7159 experienced a second virologic failure. The risk of second virologic failure decreased from 1996 (56 cases per 100 person-years) through 2005 (16 cases per 100 person-years; [Formula: see text]). The cumulative mortality after onset of second virologic failure was 26% at 5 years and decreased over time. A history of AIDS, a lower CD4(+) T cell count, and a higher plasma HIV RNA level were each independently associated with mortality. Similar trends were observed when analysis was limited to the subset of previously treatment-naive patients. CONCLUSIONS: Although the rates of multiple regimen failure have decreased dramatically over the past decade, mortality rates for those who have experienced failure of at least 2 regimens have remained high. Plasma HIV RNA levels, CD4(+) T cell counts at time of treatment failure, and a history of AIDS remain independent risk factors for death, which emphasizes that these factors remain important targets for those in need of more-aggressive therapeutic interventions. |
Trends in the epidemiology of human G1P[8] rotaviruses: a Hungarian study
Banyai K , Gentsch JR , Martella V , Bogdan A , Havasi V , Kisfali P , Szabo A , Mihaly I , Molnar P , Melegh B , Szucs G . J Infect Dis 2009 200 Suppl 1 S222-7 Epidemiological trends of the globally most common rotavirus genotype, G1P[8], were investigated in Hungary during a 16-year period by sequencing and phylogenetic analysis of the surface antigens. Antigen shift among epidemiologically major G1P[8] strains was observed in 6 seasons, as indicated by changes in the sublineages of the G1 VP7 and the P[8] VP4 genes. The temporal clustering of some rotavirus VP4 and VP7 gene sublineages and the periodic emergence and/or resurgence of previously unrecognized rotavirus sublineages in the study population suggest a dynamic nature for these common strains. Recently established international strain surveillance networks may help to identify and track the spread of epidemiologically important rotavirus strains across countries and continents. |
Uptake of rotavirus vaccine and national trends of acute gastroenteritis among children in Nicaragua
Orozco M , Vasquez J , Pedreira C , De Oliveira LH , Amador JJ , Malespin O , Andrus J , Tate J , Parashar U , Patel M . J Infect Dis 2009 200 Suppl 1 S125-30 BACKGROUND: In October 2006, a new rotavirus vaccine was introduced in Nicaragua and was available free to all age-eligible children. We assessed vaccine uptake and trends in acute gastroenteritis (AGE) to assess vaccine impact. METHODS: We analyzed national data from the period 2001-2007 on the total number of AGE episodes and on RotaTeq vaccine dose administration during 2006-2007. RESULTS: After the introduction of RotaTeq, 1-dose vaccine coverage rates rapidly increased to 80% among age-eligible children. During the 2007 rotavirus season, when combined 2- and 3-dose vaccine coverage among children aged 0-11 months was approximately 26%, the total number of AGE episodes among children aged 0-11 months decreased by 23%, compared with a decrease of 6% among unvaccinated children aged 12-59 months. Furthermore, a 12% decrease in the number of all-cause hospitalizations for AGE was noted among children aged 0-11 months, whereas a approximately 5% increase was observed among children aged 12-59 months. CONCLUSIONS: The high rate of vaccination among age-eligible children soon after vaccine introduction in Nicaragua indicates an efficient immunization program. However, in the age group at risk of rotavirus disease, vaccine coverage during the 2007 rotavirus season had yet to reach a level sufficient for making firm conclusions about vaccine impact. Epidemiologic studies to evaluate vaccine effectiveness and ongoing surveillance as vaccine uptake increases will allow a better assessment of vaccine impact. |
Assessment of postlicensure safety of rotavirus vaccines, with emphasis on intussusception
Bines JE , Patel M , Parashar U . J Infect Dis 2009 200 Suppl 1 S282-90 The global implementation of rotavirus vaccines will result in a major step toward limiting the disease burden of rotavirus infection. However, as history has shown with the experience of Rotashield (Wyeth Lederle Vaccines), the introduction of a new vaccine should occur in parallel with a postmarketing surveillance strategy to detect any unexpected or rare adverse events. Two new rotavirus vaccines (Rotarix [GSK Biologicals] and RotaTeq [Merck]) have been found to be safe and effective in large clinical trials involving >60,000 infants in the Americas and Europe. However, given that intussusception is an extremely rare event, some risk could be detected as the vaccine is administered to a larger number of infants. In response to a recommendation of the World Health Organization Global Advisory Committee for Vaccine Safety, a standardized approach to the postmarketing surveillance of rotavirus vaccine safety has been developed. We review the principal safety issues requiring further evaluation in postlicensure use of rotavirus vaccines. For intussusception, we also discuss challenges and approaches to monitoring. |
The burden of hospitalizations and clinic visits for rotavirus disease in children aged <5 years in the Philippines
Carlos CC , Inobaya MT , Bresee JS , Lagrada ML , Olorosa AM , Kirkwood CD , Widdowson MA . J Infect Dis 2009 200 Suppl 1 S174-81 BACKGROUND: Recent data on the burden of hospitalization and clinic visits for rotavirus gastroenteritis are needed to support the decision to introduce rotavirus vaccine in the Philippines. METHODS: From 2005 through 2006, children aged <5 years with acute diarrhea who attended 1 of 7 clinics and/or hospitals in Muntinlupa City, the Philippines, were enrolled. Clinical and demographic data were collected, and a stool specimen was obtained for rotavirus testing and typing for G and P antigens. The incidences of different clinical outcomes of rotavirus gastroenteritis were determined for 3 townships under surveillance and were extrapolated to the Philippines with use of national data sets. RESULTS: The prevalence of rotavirus was 31% (171/560) among children hospitalized with diarrhea, 30% (155/520) among those who presented to the emergency department, and 15% (56/385) among those who presented to a clinic. The annual estimated incidence (per 100,000 children aged <5 years) of rotavirus gastroenteritis in outpatient, emergency department, and inpatient settings was 755, 451, and 279, respectively. Of 274 strains, 50 (18%) were nontypeable. Of the 128 strains that underwent G and P typing, 98% belong to the globally common strains G3P[P], G2P[4], and G1P[8]. CONCLUSIONS: The burden of rotavirus gastroenteritis in the Philippines is high and is predominantly caused by strains against which current vaccines have shown good efficacy, suggesting that routine immunization will have a large impact on rotavirus disease burden. |
Burden of severe rotavirus diarrhea in Indonesia
Soenarto Y , Aman AT , Bakri A , Waluya H , Firmansyah A , Kadim M , Martiza I , Prasetyo D , Mulyani NS , Widowati T , Soetjiningsih , Karyana IP , Sukardi W , Bresee J , Widdowson MA . J Infect Dis 2009 200 Suppl 1 S188-94 Globally, rotavirus is the leading cause of diarrhea-related hospitalizations and deaths among young children, but the burden of rotavirus disease in Indonesia is poorly documented. From January through December 2006, we conducted prospective surveillance (inpatient and outpatient) among children aged <5 years at 6 hospitals in 6 provinces of Indonesia, using standardized methodology. Of 2240 enrolled children hospitalized for diarrhea, 1345 (60%) were rotavirus positive. Of 176 children enrolled in outpatient clinics in 3 hospitals, 73 (41%) were rotavirus positive. Among children hospitalized for diarrhea, dehydration was more common among those who tested positive for rotavirus than among those who did not (91% vs 82%; P < .05), as was vomiting (86% vs 67%; P < .05). Children aged 6-23 months experienced 72% of all rotavirus episodes. Rotavirus prevalence increased slightly in the cool, dry season. The most commonly detected genotypes were G9 (30%) and P[6] (56%). G1P[6] and G9P[6] accounted for 34% and 21% of strains, respectively. A high proportion of genotype P[6] was detected, in combination with the common G types G1 and G9. Available rotavirus vaccines would likely be efficacious against the most common circulating strains, but continued monitoring of uncommon genotypes is needed. |
Considerations for introduction of a rotavirus vaccine in Oman: rotavirus disease and economic burden
Al Awaidy SA , Bawikar S , Al Busaidy S , Baqiani S , Al Abedani I , Varghese R , Abdoan HS , Al Abdoon H , Bhatnagar S , Al Hasini KS , Mohan P , Shah S , Elamir E , Klena J , Ahmed SF , Teleb N , Parashar U , Patel MM . J Infect Dis 2009 200 Suppl 1 S248-53 Rotavirus is the most common cause of fatal childhood diarrhea worldwide. We provide the first estimates of the health care and economic burden of severe rotavirus disease in Oman. We conducted active, hospital-based surveillance of rotavirus disease at 11 regional public hospitals in Oman, using the guidelines suggested by the generic World Health Organization protocol. From July 2006 through June 2008, all children aged <5 years who were hospitalized for acute gastroenteritis were enrolled in the surveillance program, and their stool samples were tested for rotavirus using a commercially available enzyme immunoassay (ID EIA Rotavirus Test; Dako Diagnostics). Rotavirus was detected in samples from 1712 (49%) of 3470 children. These children were hospitalized for a median of 3 days for severe diarrhea. A marked seasonal peak was evident with a majority of the cases occurring from December through May. Of the rotavirus cases, 69% occurred in children aged 6-17 months. We identified a diverse strain pattern in Oman, with G2 (37%), G1 (38%), and G9 (11%) accounting for most of typeable strains. By our burden estimates, the Omani government spends an estimated US$791,817 and US$1.8 million annually to treat rotavirus-associated diarrhea in the outpatient and hospital settings, respectively. A rotavirus vaccination program might substantially reduce the burden of severe diarrhea among children in Oman. |
Cost-benefit analysis of a rotavirus immunization program in the Arab Republic of Egypt
Ortega O , El-Sayed N , Sanders JW , Abd-Rabou Z , Antil L , Bresee J , Mansour A , Adib I , Nahkla I , Riddle MS . J Infect Dis 2009 200 Suppl 1 S92-8 BACKGROUND: The availability of rotavirus vaccines makes the implementation of a national immunization program an important decision requiring economic considerations. METHODS: A cost-benefit analysis of a national rotavirus immunization program in Egypt, from the perspective of the Ministry of Health and Population, and a cost-effectiveness analysis, from a societal perspective, were conducted. RESULTS: For a birth cohort of 1.9 million children, a vaccination program was estimated to prevent 1,140,496 episodes of diarrhea, 438,395 outpatient visits, and 47,508 hospitalizations and to save 2873 lives, resulting in direct Ministry of Health and Population medical savings of $2,481,792 (14,369,578 Egyptian pounds [LE]). On the basis of a $9.18 (53 LE) single-dose cost, rotavirus vaccine introduction would cost the Ministry of Health and Population $34,203,445.87 (198,037,951.56 LE) in health expenditures. This equates to an incremental cost of $30.22 (174.95 LE) per infection prevented. Vaccination would prevent the loss of 94,993 disability-adjusted life-years, resulting in an incremental cost-effectiveness ratio of $363 per disability-adjusted life-year. CONCLUSIONS: The introduction of rotavirus vaccine to the national immunization program was not found to be cost saving based strictly from the Ministry of Health and Population perspective; however, the potential benefits of long-term health and economic gains from reduced mortality and morbidity, decreased direct costs of care for families, and indirect societal costs should be considered in such decisions. |
Diagnostic testing for 2009 pandemic influenza A (H1N1) virus infection in hospitalized patients
Uyeki T . N Engl J Med 2009 361 (25) e114 Establishing a diagnosis of 2009 pandemic influenza A (H1N1) virus infection in hospitalized patients can be challenging, especially in patients presenting late in their clinical course. Although real-time reverse-transcriptase polymerase chain reaction (RT-PCR) is the most sensitive testing method to detect 2009 H1N1 virus in respiratory specimens,1 results are not accessible right away. Influenza antigen–detection tests produce quick results, but reported sensitivities of rapid influenza diagnostic tests (RIDTs) to detect 2009 H1N1 virus infection in upper respiratory specimens as compared with real-time RT-PCR range from 10 to 70%; therefore, false negative RIDT results are common2 and also occur with direct immunofluorescence assay (DFA).3 One study reported lower RIDT detection for 2009 H1N1 virus than for seasonal influenza viruses.4 | Anecdotal reports indicate that some hospitalized patients did not receive antiviral treatment at admission because of a negative result of RIDT or immunofluorescence testing of upper respiratory tract specimens, with later confirmation of 2009 H1N1 by real-time RT-PCR. Empirical antiviral treatment should be started as soon as possible for hospitalized patients with suspected 2009 H1N1 and not withheld, because a negative RIDT or DFA result does not exclude 2009 H1N1 virus infection. Nor should treatment be delayed until real-time RT-PCR results are available. |
Economic costs of rotavirus gastroenteritis and cost-effectiveness of vaccination in developing countries
Rheingans RD , Antil L , Dreibelbis R , Podewils LJ , Bresee JS , Parashar UD . J Infect Dis 2009 200 Suppl 1 S16-27 BACKGROUND: Rotavirus is the leading cause of severe gastroenteritis in children worldwide. We evaluated the economic burden of rotavirus and the cost-effectiveness of vaccination from the health care perspective. METHODS: Estimates were based on existing epidemiological data, cost estimates, vaccine coverage, and efficacy data, as well as hypothetical vaccine prices. Outcome measures included health care and societal costs of rotavirus and benefits and incremental cost-effectiveness ratio of vaccination. Sensitivity analyses evaluated the impact of estimate uncertainty. RESULTS: Treatment costs increased with income level, and health burden decreased; however, burden varied across regions. On the basis of current vaccination coverage and timing, rotavirus vaccination would annually prevent 228,000 deaths, 13.7 million hospital visits, and 8.7 million disability-adjusted life-years, saving $188 million in treatment costs and $243 million in societal costs. At $5 per dose, the incremental cost-effectiveness ratio in low-, lower-middle-, and upper-middle-income countries was $88, $291, and $329 per disability-adjusted life-year averted, respectively, and $3,015, $9,951 and $11,296 per life saved, respectively. Vaccination would prevent approximately 45% of deaths and approximately 58% of associated medical visits and costs. CONCLUSIONS: Vaccination is a cost-effective strategy to reduce the health and economic burden of rotavirus. The cost-effectiveness of vaccination depends mostly on vaccine price and reaching children at highest risk of mortality. |
Holiday spikes in pneumococcal disease among older adults
Walter ND , Taylor TH Jr , Dowell SF , Mathis S , Moore MR , Active Bacterial Core Surveillance System Team . N Engl J Med 2009 361 (26) 2584-5 Rates of invasive pneumococcal disease in the United States increase dramatically, or “spike,” during winter holidays.1 We analyzed population-based surveillance data to determine whether spikes may be caused by increased transmission from children to older adults. | Pneumococci spread through upper respiratory secretions, especially those of young children.2 Certain serotypes disproportionately colonize young children.3 The introduction of the pediatric heptavalent pneumococcal conjugate vaccine (PCV7; Prevnar, Wyeth) in 2000 led to a decrease in invasive pneumococcal disease among vaccinated children and reduced transmission to unvaccinated persons.2,4 |
Hospital-based surveillance of rotavirus and other viral agents of diarrhea in children and adults in Russia, 2005-2007
Podkolzin AT , Fenske EB , Abramycheva NY , Shipulin GA , Sagalova OI , Mazepa VN , Ivanova GN , Semena AV , Tagirova ZG , Alekseeva MN , Molochny VP , Parashar UD , Vinje J , Maleev VV , Glass RI , Pokrovsky VI . J Infect Dis 2009 200 Suppl 1 S228-33 During a 2-year period in 2005-2007, we conducted surveillance of group A rotaviruses and other enteric agents among patients hospitalized with acute gastroenteritis in 8 different cities of the Russian Federation. Fecal specimens were gathered from 3208 children (including 2848 children aged <5 years) and 1354 adults who were admitted to hospitals in Moscow, St. Petersburg, Chelyabinsk, Nizhnii Novgorod, Tyumen, Khabarovsk, Makhachkala, and Yakutsk. Polymerase chain reaction was performed to detect rotaviruses of groups A and C, noroviruses of genogroups I and II, astrovirus, sapovirus, and enteric adenoviruses (group F). Group A rotavirus was the most common viral pathogen detected among children aged <5 years (43.6%), followed by norovirus (12.5%), whereas norovirus was the pathogen most commonly detected in adults (11.9%). P and G genotypes were determined for 515 rotavirus specimens, and the most prevalent genotypes were G1P[8] (44.9%), G4P[8] (40.0%), G2P[4] (8.5%), and G3P[8] (6.6%). This study is the first multicenter study of rotaviruses in the Russian Federation and documents the important burden of disease caused by this pathogen, which soon may be preventable by vaccination. |
Community-based hepatitis B screening programs in the United States in 2008
Rein DB , Lesesne SB , Leese PJ , Weinbaum CM . J Viral Hepat 2010 17 (1) 28-33 The Centers for Disease Control and Prevention (CDC) recommends hepatitis B surface antigen (HBsAg) testing to identify hepatitis B virus (HBV) infection for foreign-born persons from areas with HBsAg prevalence of > or = 2%. Currently, most HBsAg screening in the United States is performed by independent community organizations. For these HBsAg screening programs, we collected information about the location, number of people screened, other services beyond screening provided, the population/ethnicity groups targeted for screening, and the prevalence of HBsAg among those screened. We identified programs offering screening by contacting programs known to us, from interviews with identified programs, and from structured Internet searches, and collected information using a simple e-mail survey with follow-up phone calls. We identified 55 possible community HBsAg screening programs, of which we successfully contacted 31 programs. In the past year, contacted programs screened an estimated 21 817 patients with an 8.1% average HBsAg prevalence. The majority of programs screened persons born in Asia and their children, and a small number of programs screened persons from Africa or Eastern Europe; very few programs screened U.S.-born persons at risk of HBV infection due to behavioural factors. We identified few or no programs in the American Southeast, the Midwest, and the Southwest outside of California and the Houston area. The HBsAg screening programs that we contacted were effective in identifying and screening patients at risk of HBV as evidenced by the high prevalence observed among those screened. However, their efforts alone are likely insufficient to meet the need for screening recommended by CDC. |
Male mating biology
Howell PI , Knols BG . Malar J 2009 8 Suppl 2 S8 Before sterile mass-reared mosquitoes are released in an attempt to control local populations, many facets of male mating biology need to be elucidated. Large knowledge gaps exist in how both sexes meet in space and time, the correlation of male size and mating success and in which arenas matings are successful. Previous failures in mosquito sterile insect technique (SIT) projects have been linked to poor knowledge of local mating behaviours or the selection of deleterious phenotypes during colonisation and long-term mass rearing. Careful selection of mating characteristics must be combined with intensive field trials to ensure phenotypic characters are not antagonistic to longevity, dispersal, or mating behaviours in released males. Success has been achieved, even when colonised vectors were less competitive, due in part to extensive field trials to ensure mating compatibility and effective dispersal. The study of male mating biology in other dipterans has improved the success of operational SIT programmes. Contributing factors include inter-sexual selection, pheromone based attraction, the ability to detect alterations in local mating behaviours, and the effects of long-term colonisation on mating competitiveness. Although great strides have been made in other SIT programmes, this knowledge may not be germane to anophelines, and this has led to a recent increase in research in this area. |
Colonisation and mass rearing: learning from others
Benedict MQ , Knols BG , Bossin HC , Howell PI , Mialhe E , Caceres C , Robinson AS . Malar J 2009 8 Suppl 2 S4 Mosquitoes, just as other insects produced for the sterile insect technique (SIT), are subjected to several unnatural processes including laboratory colonisation and large-scale factory production. After these processes, sterile male mosquitoes must perform the natural task of locating and mating with wild females. Therefore, the colonisation and production processes must preserve characters necessary for these functions. Fortunately, in contrast to natural selection which favours a suite of characteristics that improve overall fitness, colonisation and production practices for SIT strive to maximize only the few qualities that are necessary to effectively control populations. However, there is considerable uncertainty about some of the appropriate characteristics due to the lack of data. Development of biological products for other applications suggest that it is possible to identify and modify competitiveness characteristics in order to produce competitive mass produced sterile mosquitoes. This goal has been pursued--and sometimes achieved--by mosquito colonisation, production, and studies that have linked these characteristics to field performance. Parallels are drawn to studies in other insect SIT programmes and aquaculture which serve as vital technical reference points for mass-production of mosquitoes, most of whose development occurs--and characteristics of which are determined--in an aquatic environment. Poorly understood areas that require further study are numerous: diet, mass handling and genetic and physiological factors that influence mating competitiveness. Compromises in such traits due to demands to increase numbers or reduce costs, should be carefully considered in light of the desired field performance. |
Modification by ALAD of the association between blood lead and blood pressure in the U.S. population: results from the Third National Health and Nutrition Examination Survey.
Scinicariello F , Yesupriya A , Chang MH , Fowler BA . Environ Health Perspect 2010 118 (2) 259-64 BACKGROUND: Environmental lead exposure has been found to be associated with an increased risk of hypertension. Individuals vary greatly in susceptibility to lead toxicity, and genetic susceptibility has often been cited as the probable cause for such variation. OBJECTIVE: The main objective is to determine the role of the aminolevulinic acid dehydratase (ALAD) gene, which encodes the main carrier protein of lead in blood, in the association between lead exposure and blood pressure (BP) and hypertension in the U.S. population. METHODS: We analyzed data from individuals ≥ 17 years of age who participated in the Third National Health and Nutrition Examination Survey for whom DNA was available (n = 6,016). Multivariable logistic and linear regressions stratified by race/ethnicity were used to examine whether hypertension and BP were associated with ALAD and blood lead levels (BLL).Results: BLL was associated with systolic BP in non-Hispanic whites and with hypertension and systolic and diastolic BP in non-Hispanic blacks. BLL was not associated with BP outcomes in Mexican Americans. Non-Hispanic white ALAD2 carriers in the highest BLL quartile (3.852.9 microg/dL) had a significantly higher adjusted prevalence odds ratio for hypertension compared with ALAD1 homozygous individuals. We also found a significant interaction between lead concentration and the ALAD2 allele in non-Hispanic whites and non-Hispanic blacks in relation to systolic BP. CONCLUSIONS: BLL may be an important risk factor for hypertension and increased systolic and diastolic BP. These associations may be modified by ALAD genotype. EDITOR'S SUMMARY: Elevated blood pressure (BP) has been consistently associated with high blood lead levels (BLL ≥ 40 microg/dL), but not lower BLL. Scinicariello et al. (p. 259) hypothesized that associations might be modified by a common variant allele of the aminolevulinic acid dehydratase (ALAD) gene, which encodes the primary carrier protein for lead in blood. The authors analyzed data from 6,016 participants ≥ 17 years of age in the Third National Health and Nutrition Examination Survey to estimate associations and joint effects of BLL and the variant ALAD2 allele (any ALAD2 allele vs. two copies of the common ALAD1 allele) with the prevalence of hypertension (use of antihypertensive medication, systolic BP ≥ 140 mmHg, or diastolic BP ≥ 90 mmHg), systolic BP, and diastolic BP. The authors report that a doubling of the BLL (e.g., from 1 to 2 microg/dL or 2 to 4 microg/dL) was positively associated with systolic BP among non-Hispanic whites, with a stronger association among ALAD2 carriers than noncarriers (2.46 vs. 0.72 mmHg increase in BP, respectively; p = 0.04). However, among non-Hispanic blacks BLL was inversely associated with BP among ALAD2 carriers (4.04 mmHg decrease in systolic BP compared with a 1.76 mmHg increase among ALAD1 homozygotes; p = 0.02.) The authors conclude that results suggest effects of low BLL on BP that may be modified by ALAD genotype. |
Serum dioxin concentrations and time to pregnancy
Eskenazi B , Warner M , Marks AR , Samuels S , Needham L , Brambilla P , Mocarelli P . Epidemiology 2010 21 (2) 224-31 BACKGROUND: Pollution may play a role in population trends of declining semen quality and regional differences in time to pregnancy (TTP) in industrialized societies. Dioxins including 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) have been suspected. In 1976, an explosion near Seveso, Italy resulted in the highest TCDD exposure known in residential populations. Twenty years later, we conducted a retrospective cohort study, the Seveso Women's Health Study. METHODS: Of 981 participants, 472 women attempted pregnancy after the explosion, and 278 delivered a livebirth not associated with contraceptive failure. Individual serum TCDD levels were measured from samples collected soon after the explosion and extrapolated to the conception attempt. We examined the relation of TCDD levels to time to pregnancy (parameterized as the monthly probability of conception within the first 12 months of trying) and to infertility (defined as conception after at least 12 months of trying). We modeled fecundability with discrete-time Cox proportional hazards regression, and we modeled fertility with logistic regression. We tested the sensitivity of the conclusions to differing definitions of eligibility and outcome. RESULTS: Median TCDD level was 50 parts per trillion, median time to pregnancy was 2 months, and 17% reported taking 12 or more months to conceive. For every 10-fold increase in serum TCDD, we observed a 25% increase in time to pregnancy (adjusted-fecundability odds ratio = 0.75 [95% confidence interval (CI) = 0.60-0.95]) and about a doubling in odds of infertility (adjusted odds ratio = 1.9 [95% CI = 1.1-3.2]). Results were similar for extrapolated TCDD and sensitivity analyses. CONCLUSIONS: We found dose-related increases in TTP and infertility associated with individual serum TCDD levels in the women from Seveso, Italy. These findings may have implications for fertility in industrialized areas. |
Exposure of the U.S. population to acrylamide in the National Health and Nutrition Examination Survey 2003-2004
Vesper HW , Caudill SP , Osterloh JD , Meyers T , Scott D , Myers GL . Environ Health Perspect 2010 118 (2) 278-83 BACKGROUND: The lifelong exposure of the population to acrylamide has raised concerns about the possible health effects of the chemical. Data on the extent of exposure to acrylamide and its primary metabolite, glycidamide, are needed to aid in the assessment of potential health effects. OBJECTIVES: The aim of this study was to assess human exposure to acrylamide and glycidamide in the general U.S. population through the measurement of hemoglobin adducts of acrylamide (HbAA) and glycidamide (HbGA). METHODS: HbAA and HbGA were measured in 7,166 subjects from the National Health and Nutrition Examination Survey. Stratified HbAA and HbGA data were reported by sex, age groups, race/ethnicity (Mexican American, non-Hispanic black, non-Hispanic white), and smoking status based on serum cotinine levels. Covariate-adjusted geometric means for each demographic group were calculated using multiple regression analysis. RESULTS: HbAA and HbGA levels ranged from 3 to 910 and from 4 to 756 pmol/g hemoglobin, respectively, with smokers having the highest levels overall. Tobacco smoke exposure in nonsmokers had a small but significant effect on HbAA and HbGA levels. Adjusted geometric mean levels for children 311 years of age were higher than for adults ≥ 60 years of age [mean (95% confidence interval): HbAA, 54.5 (49.151.5) and HbGA, 73.9 (71.376.6) vs. HbAA, 46.2 (44.348.2) and HbGA, 41.8 (38.745.2)]. Levels were highest in Mexican Americans [HbAA: 54.8 (51.957.8), HbGA: 57.9 (53.762.5)], whereas non-Hispanic blacks had the lowest HbGA levels [43.5 (41.145.9)]. CONCLUSIONS: U.S. population levels of acrylamide and glycidamide adducts are described. The high variability among individuals but modest differences between population subgroups suggest that sex, age, and race/ethnicity do not strongly affect acrylamide exposure. Adduct concentration data can be used to estimate relative exposure and to validate intake estimates. EDITOR'S SUMMARY: Human exposure to acrylamide, a neurotoxin and suspected human carcinogen, occurs via dietary sources, tobacco smoke, and occupational production or use. Carcinogenic effects are attributed to DNA adducts formed with the phase I metabolite glycidamide, and body burdens and risks may be partly determined by factors that influence acrylamide metabolism, including genetic variants and factors that induce metabolism gene expression (e.g., medications and alcohol). Vesper et al. (p. 278) measured hemoglobin adducts of acrylamide (HbAA) and glycidamide (HbGA) in blood samples from 7,166 participants in the National Health and Nutrition Examination Survey, and estimated HbGA:HbAA ratios to assess variation in metabolic conversion. The authors report that smokers had the highest adjusted geometric mean levels of HbAA and HbGA and that adduct levels in nonsmokers were associated with tobacco smoke exposure (based on serum cotinine levels). In addition, adduct levels and HbGA:HbAA ratios were higher in children 311 years of age than in adults ≥ 60 years of age, and in Mexican Americans compared with other participants. The authors note that differences among population subgroups were modest relative to differences among individuals within subgroups, and suggest that factors other than sex, age, and race/ethnicity may be primarily responsible for variation in acrylamide exposure and metabolism. |
The association between childhood asthma prevalence and monitored air pollutants in metropolitan areas, United States, 2001-2004
Akinbami LJ , Lynch CD , Parker JD , Woodruff TJ . Environ Res 2010 110 (3) 294-301 BACKGROUND: Air pollution exposure has been linked to adverse respiratory health outcomes among children, primarily in studies of acute exposures that are often in limited geographic areas. We sought to assess the association between chronic outdoor air pollution exposure, as measured by 12-month averages by county, and asthma among children in metropolitan areas across the nation. METHODS: Eligible children included those aged 3-17 years residing in US metropolitan areas who were sampled in the 2001-2004 National Health Interview Survey (N=34,073). 12-month average air pollutant levels for sulfur dioxide, nitrogen dioxide, ozone and particulate matter were compiled by county for 2000-2004. Eligible children were linked to pollutant levels for the previous 12 months for their county of residence. Adjusted odds ratios of having current asthma or an asthma attack in the past 12 months were estimated in single pollutant logistic regression models. RESULTS: Children in counties with ozone and, to a less consistent degree, particulate matter levels in the highest quartile were more likely to have current asthma and/or a recent asthma attack than children residing in counties with the lowest pollution levels; the adjusted odds for current asthma for the highest quartile of estimated ozone exposure was 1.56 (95% confidence interval [CI]: 1.15, 2.10) and for recent asthma attack 1.38 (95% CI: 0.99, 1.91). No associations were found with sulfur dioxide or nitrogen dioxide levels. CONCLUSION: Although the current US standard for ozone is based on short-term exposure, this cross-sectional study suggests that chronic (12-month) exposure to ozone and particles is related to asthma outcomes among children in metropolitan areas throughout the US. |
Mapping, monitoring, and surveillance of neglected tropical diseases: towards a policy framework
Baker MC , Mathieu E , Fleming FM , Deming M , King JD , Garba A , Koroma JB , Bockarie M , Kabore A , Sankara DP , Molyneux DH . Lancet 2010 375 (9710) 231-8 As national programmes respond to the new opportunities presented for scaling up preventive chemotherapy programmes for the coadministration of drugs to target lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma, possible synergies between existing disease-specific policies and protocols need to be examined. In this report we compare present policies for mapping, monitoring, and surveillance for these diseases, drawing attention to both the challenges and opportunities for integration. Although full integration of all elements of mapping, monitoring, and surveillance strategies might not be feasible for the diseases targeted through the preventive chemotherapy approach, there are opportunities for integration, and we present examples of integrated strategies. Finally, if advantage is to be taken of scaled up interventions to address neglected tropical diseases, efforts to develop rapid, inexpensive, and easy-to-use methods, whether disease-specific or integrated, should be increased. We present a framework for development of an integrated monitoring and evaluation system that combines both integrated and disease-specific strategies. |
Near real-time surveillance for influenza vaccine safety: proof-of-concept in the Vaccine Safety Datalink Project
Greene SK , Kulldorff M , Lewis EM , Li R , Yin R , Weintraub ES , Fireman BH , Lieu TA , Nordin JD , Glanz JM , Baxter R , Jacobsen SJ , Broder KR , Lee GM . Am J Epidemiol 2010 171 (2) 177-88 The emergence of pandemic H1N1 influenza in 2009 has prompted public health responses, including production and licensure of new influenza A (H1N1) 2009 monovalent vaccines. Safety monitoring is a critical component of vaccination programs. As proof-of-concept, the authors mimicked near real-time prospective surveillance for prespecified neurologic and allergic adverse events among enrollees in 8 medical care organizations (the Vaccine Safety Datalink Project) who received seasonal trivalent inactivated influenza vaccine during the 2005/06-2007/08 influenza seasons. In self-controlled case series analysis, the risk of adverse events in a prespecified exposure period following vaccination was compared with the risk in 1 control period for the same individual either before or after vaccination. In difference-in-difference analysis, the relative risk in exposed versus control periods each season was compared with the relative risk in previous seasons since 2000/01. The authors used Poisson-based analysis to compare the risk of Guillain-Barre syndrome following vaccination in each season with that in previous seasons. Maximized sequential probability ratio tests were used to adjust for repeated analyses on weekly data. With administration of 1,195,552 doses to children under age 18 years and 4,773,956 doses to adults, no elevated risk of adverse events was identified. Near real-time surveillance for selected adverse events can be implemented prospectively to rapidly assess seasonal and pandemic influenza vaccine safety. |
Outcomes of interest in evidence-based evaluations of genetic tests.
Botkin JR , Teutsch SM , Kaye CI , Hayes M , Haddow JE , Bradley LA , Szegda K , Dotson WD , EGAPP Working Group . Genet Med 2010 12 (4) 228-35 Genetic tests are increasingly available for use in traditional clinical practice settings and through direct-to-consumer marketing. The need for evidence-based information and guidance on their appropriate use has never been more apparent. The independent Working Group of the Evaluation of Genomic Applications in Practice and Prevention Initiative commissions evidence-based reviews and develops recommendations to inform decision making surrounding the implementation of genetic tests and other applications of genomic technologies into clinical practice. A critical component of this analysis involves the identification and appropriate weighting of relevant health outcomes from genetic testing. Impacts of testing on morbidity and mortality are central considerations although research to document such outcomes can be challenging to conduct. In considering the broader impacts of genetic tests on the individual, familial and societal levels, psychosocial outcomes often take on increasing importance, and their systematic evaluation is a challenge for traditional methods of evidence-based review. Incorporating these types of outcomes in evidence-based processes is possible, however, and necessary to extract balanced and complete (or as complete as available data will allow) information on potential benefits and on potential harms. The framework used by the Evaluation of Genomic Applications in Practice and Prevention Working Group in considering, categorizing, and weighting health-related outcomes as applied to genomic technologies is presented here. |
Drug use, high-risk sex behaviors, and increased risk for recent HIV infection among men who have sex with men in Chicago and Los Angeles
Carey JW , Mejia R , Bingham T , Ciesielski C , Gelaude D , Herbst JH , Sinunu M , Sey E , Prachand N , Jenkins RA , Stall R . AIDS Behav 2009 13 (6) 1084-96 We examined how drugs, high-risk sexual behaviors, and socio-demographic variables are associated with recent HIV infection among men who have sex with men (MSM) in a case-control study. Interviewers collected risk factor data among 111 cases with recent HIV infection, and 333 HIV-negative controls from Chicago and Los Angeles. Compared with controls, cases had more unprotected anal intercourse (UAI) with both HIV-positive and HIV-negative partners. MSM with lower income or prior sexually transmitted infections (STI) were more likely to be recently HIV infected. Substances associated with UAI included amyl nitrate ("poppers"), methamphetamine, Viagra (or similar PDE-5 inhibitors), ketamine, and gamma hydroxybutyrate (GHB). Cases more frequently used Viagra, poppers, and methamphetamine during UAI compared with controls. In multivariate analysis, income, UAI with HIV-positive partners, Viagra, and poppers remained associated with recent HIV seroconversion. Better methods are needed to prevent HIV among MSM who engage in high-risk sex with concurrent drug use. |
The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV
Wolitski RJ , Pals SL , Kidder DP , Courtenay-Quirk C , Holtgrave DR . AIDS Behav 2009 13 (6) 1222-32 HIV-related stigma negatively affects the lives of persons living with HIV/AIDS (PLWHA). Homeless/unstably housed PLWHA experience myriad challenges and may be particularly vulnerable to the effects of HIV-related stigma. Homeless/unstably housed PLWHA from 3 U.S. cities (N = 637) completed computer-assisted interviews that measured demographics, self-assessed physical and mental health, medical utilization, adherence, HIV disclosure, and risk behaviors. Internal and perceived external HIV stigma were assessed and combined for a total stigma score. Higher levels of stigma were experienced by women, homeless participants, those with a high school education or less, and those more recently diagnosed with HIV. Stigma was strongly associated with poorer self-assessed physical and mental health, and perceived external stigma was associated with recent non-adherence to HIV treatment. Perceived external stigma was associated with decreased HIV disclosure to social network members, and internal stigma was associated with drug use and non-disclosure to sex partners. Interventions are needed to reduce HIV-related stigma and its effects on the health of homeless/unstably housed PLWHA. |
Intentional abstinence among homeless and unstably housed persons living with HIV/AIDS
Courtenay-Quirk C , Zhang J , Wolitski RJ . AIDS Behav 2009 13 (6) 1119-28 Some persons living with HIV/AIDS (PLWHA) engage in periods of sexual abstinence. Baseline data from a larger study of homeless/unstably housed PLWHA indicated that 20% (125/644) intentionally abstained from sex in the past 90 days. Reasons included: (1) 'not interested' (n = 78); (2) did not want to infect someone (n = 46); and (3) did not have a partner (n = 37). Abstinence was less likely among all who had a main partner. Among men who have sex with men (MSM), abstinence was less likely among those with a detectable viral load. It was more likely among heterosexual men who were experiencing current housing problems and who had at least a high school education. Among women, abstinence was less likely among African Americans and those whose social networks were more aware of their HIV status. Better understanding of motivations to abstain may improve how programs serving PLWHA address this issue. |
Health literacy and child health promotion: implications for research, clinical care, and public policy
Sanders LM , Shaw JS , Guez G , Baur C , Rudd R . Pediatrics 2009 124 Suppl 3 S306-14 The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers. |
Influenza immunization coverage among residents of long-term care facilities certified by CMS, 2005-2006: the newest MDS quality indicator
Bardenheier BH , Wortley P , Ahmed F , Hales C , Shefer A . J Am Med Dir Assoc 2010 11 (1) 59-69 BACKGROUND: In October 2005, the Centers for Medicare and Medicaid Services (CMS) required that long-term care (LTC) facilities certified by CMS offer each resident annual influenza vaccination. Subsequently, vaccination status was added to resident assessments collected beginning in the influenza season, 2005-2006. This is the first year immunization coverage can be reported based on a census of LTC residents. OBJECTIVES: Report influenza immunization coverage for LTC residents by state, resident, and facility characteristics. Identify uses of the data and areas in need of improvement. METHODS: Analysis of CMS' Minimum Data Set of 1,851,676 residents in nursing homes from October 1 through December 31 but who could have been discharged between January 1 and March 31 merged with data for 14,493 non-hospital-based facilities from the Online Survey and Certification Assessment Reporting System. RESULTS: Overall, 83% of residents were offered the vaccine and 72% had received the vaccine. Almost 10% refused to receive the vaccine, 14% were not offered the vaccine, 1% were ineligible, and 3% were missing vaccination status. Vaccination coverage varied significantly among states (range: 49% to 87%). Fewer African Americans and Hispanics than whites were offered the vaccine (79% and 79% versus 84%, respectively) and received it (65% and 66% versus 73%, respectively); more African Americans refused the vaccine (12%) than residents of other races and/or ethnicities. Residents of Medicaid-certified-only facilities had higher levels of vaccination than residents of other facilities (82% versus ≤73%). CONCLUSION: MDS immunization data can be used as surveillance to work with states to improve coverage. Further research to examine racial disparities in vaccination among LTC residents is needed. |
Acceptability of human papillomavirus vaccine for males: a review of the literature
Liddon N , Hood J , Wynn BA , Markowitz LE . J Adolesc Health 2010 46 (2) 113-23 The quadrivalent human papillomavirus virus vaccine was recently licensed for use in males in the United States. This study reviews available published literature on acceptability among parents, health care providers, and young males. Among 23 published articles, half were conducted in the United States. The majority (87%) used quantitative survey methodology, and 13% used more explorative qualitative techniques. Convenience samples were used in most cases (74%) and 26% relied on nationally representative samples. Acceptability of a human papillomavirus virus (HPV) vaccine that protects against cervical cancer and genital warts was high in studies conducted among male college students (74%-78%) but lower in a community sample of males (33%). Among mothers of sons, support of HPV vaccination varied widely from 12% to 100%, depending on the mother's ethnicity and type of vaccine, but was generally high for a vaccine that would protect against both genital warts and cervical cancer. Health providers' intention to recommend HPV vaccine to male patients varied by patient age but was high (82%-92%) for older adolescent patients. A preference to vaccinate females over males was reported in a majority of studies among parents and health care providers. Messages about cervical cancer prevention for female partners did not resonate among adult males or parents. Future acceptability studies might incorporate more recent data on HPV-related disease, HPV vaccines, and cost-effectiveness data to provide more current information on vaccine acceptability. |
Violent victimization and perpetration during adolescence: developmental stage dependent ecological models
Matjasko JL , Needham BL , Grunden LN , Farb AF . J Youth Adolesc 2010 39 (9) 1053-66 Using a variant of the ecological-transactional model and developmental theories of delinquency on a nationally representative sample of adolescents, the current study explored the ecological predictors of violent victimization, perpetration, and both for three different developmental stages during adolescence. We examined the relative influence of individual and family characteristics, peers, and neighborhood characteristics on the odds of experiencing violent victimization and perpetration over time with two waves of the National Longitudinal Study of Adolescent Health for those adolescents who reported no exposure to violence at Wave 1 (N = 8,267; 50% female; 59% Caucasian; 17% African-American; 14% Hispanic). We found that more proximal factors differentiated between different experiences with violence at Wave 2. Also, negative peers significantly differentiated between violent victimization and perpetration, and this influence was strongest in early adolescence. In exploratory analyses, we found that middle adolescents were particularly vulnerable to their disadvantaged neighborhoods for a high-risk group. This analysis is one of the few that considers multiple ecological contexts simultaneously and provides support for developmental differences within adolescence on the influence that peers and neighborhoods have in predicting violent victimization and perpetration. |
Does out-of-home placement mediate the relationship between child maltreatment and adult criminality?
DeGue S , Spatz Widom C . Child Maltreat 2009 14 (4) 344-55 Existing research on child welfare interventions as mediators of the criminal consequences of child maltreatment has focused on juvenile delinquency rather than adult criminality. This study uses a prospective sample of 772 maltreated youth to examine out-of-home placement as a mediator of adult criminality. Arrest data were collected from official records when the full sample was a mean age of 31.8, having ample opportunity for involvement with the criminal justice system. Overall, out-of-home placement showed a neutral or slightly positive effect on adult criminality compared to no placement, consistent with earlier findings. However, prior delinquency and placement instability were significant risk factors for adult criminality. Gender, not race, was identified as a significant moderator of the relationship between placement and adult criminality, with different patterns of response to placement for males and females. Thus, whether placement experiences influence adult criminal consequences of child maltreatment might depend on prior delinquency, placement stability, and gender. |
Reactive oxygen species-activated Akt/ASK1/p38 signaling pathway in nickel compound-induced apoptosis in BEAS 2B cells
Pan J , Chang Q , Wang X , Son Y , Zhang Z , Chen G , Luo J , Bi Y , Chen F , Shi X . Chem Res Toxicol 2010 23 (3) 568-77 Nickel compounds are carcinogenic to humans, possibly through induction of reactive oxygen species (ROS) that damage macromolecules including DNA and proteins. The aim of the present study is to elucidate the role of the ROS-mediated Akt/apoptosis-regulating signal kinase (ASK) 1/p38 pathway in nickel-induced apoptosis. Exposure of human bronchial epithelial cells (BEAS-2B) to nickel compounds induced the generation of ROS and activation of Akt that is associated with the activation of ASK1 and p38 mitogen-activated protein kinase. Immunoblotting suggested a down-regulation of several antiapoptotic proteins, including Bcl-2 and Bcl-xL in the nickel compound-treated cells. Indeed, a notable cell apoptosis following nickel compound treatment is evident as revealed by flow cytometry analysis. N-Acetyl-l-cysteine (NAC, a general antioxidant) and vitamin E or catalase (a specific H(2)O(2) inhibitor) all decreased nickel-induced ROS generation. Scavenging of nickel-induced ROS by NAC or catalase attenuated Akt, ASK1, and p38 MAPK activation and apoptosis, which implies involvement of ROS in the Akt/ASK1/p38 pathway. In addition, nickel-induced activation of p38 MAPK was attenuated by a small interference of RNA specific to ASK1 (siRNA ASK1), implying that p38 MAPK was downstream of ASK1, while ASK1 activation was not reversely regulated by the inhibition of p38 MAPK by SB203580, a widely used p38 MAPK inhibitor. Silencing Akt by siRNA reduced the activation of ASK1 and p38 MAPK and cell apoptosis, whereas without nickel stimulation, siRNA Akt had no effect on the activation of ASK1 and p38 MAPK. Thus, these results suggest that the ROS-dependent Akt-ASK1-p38 axis is important for nickel-induced apoptosis. |
Comparison of amino acids and acylcarnitines assay methods used in newborn screening assays by tandem mass spectrometry
De Jesus VR , Chace DH , Lim TH , Mei JV , Hannon WH . Clin Chim Acta 2010 411 684-9 BACKGROUND: The analysis of amino acids (AA) and acylcarnitines (AC) by tandem mass spectrometry (MS/MS) is performed in newborn screening laboratories worldwide. While butyl esterification assays are routine, it is possible to detect AAs and ACs as their native free acids (underivatized). The Centers for Disease Control and Prevention's Newborn Screening Quality Assurance Program provides dried-blood spot (DBS) quality control (QC) and proficiency testing (PT) programs for numerous MS/MS analytes. We describe empirical differences between derivatization and non-derivatization techniques for selected AAs and ACs. METHODS: DBS materials were prepared at levels near, above and below mean domestic laboratory cut-offs, and distributed to program participants for MS/MS analysis. Laboratories reported quantitative and qualitative results. QC DBS materials were assayed in-house following established protocols. RESULT: Minor differences (<15%) between quantitative values resulting from butyl esters and free acid techniques were observed for the majority of the analytes. Mass spectrometric response from underivatized dicarboxylic acid acylcarnitines was less intense than their butyl esters. CONCLUSIONS: The use of underivatized techniques may also result in the inability to differentiate isobaric acylcarnitines. Laboratories should establish their own protocols by focusing on the decisions that identify test results requiring additional follow-up testing versus those that do not. |
Comparison of West African and Congo Basin monkeypox viruses in BALB/c and C57BL/6 mice
Hutson CL , Abel JA , Carroll DS , Olson VA , Braden ZH , Hughes CM , Dillon M , Hopkins C , Karem KL , Damon IK , Osorio JE . PLoS One 2010 5 (1) e8912 Although monkeypox virus (MPXV) studies in wild rodents and non-human primates have generated important knowledge regarding MPXV pathogenesis and inferences about disease transmission, it might be easier to dissect the importance of virulence factors and correlates of protection to MPXV in an inbred mouse model. Herein, we compared the two clades of MPXV via two routes of infection in the BALB/c and C57BL/6 inbred mice strains. Our studies show that similar to previous animal studies, the Congo Basin strain of MPXV was more virulent than West African MPXV in both mouse strains as evidenced by clinical signs. Although animals did not develop lesions as seen in human MPX infections, localized signs were apparent with the foot pad route of inoculation, primarily in the form of edema at the site of inoculation; while the Congo Basin intranasal route of infection led to generalized symptoms, primarily weight loss. We have determined that future studies with MPXV and laboratory mice would be very beneficial in understanding the pathogenesis of MPXV, in particular if used in in vivo imaging studies. Although this mouse model may not suffice as a model of human MPX disease, with an appropriate inbred mouse model, we can unravel many unknown aspects of MPX pathogenesis, including virulence factors, disease progression in rodent hosts, and viral shedding from infected animals. In addition, such a model can be utilized to test antivirals and the next generation of orthopoxvirus vaccines for their ability to alter the course of disease. |
Changing trends in low birth weight rates among non-hispanic black infants in the United States, 1991-2004
Ferre C , Handler A , Hsia J , Barfield W , Collins JW Jr . Matern Child Health J 2010 15 (1) 29-41 We examined trends in low birth weight (LBW, <2,500 g) rates among US singleton non-Hispanic black infants between 1991 and 2004. We conducted Joinpoint regression analyses, using birth certificate data, to describe trends in LBW, moderately LBW (MLBW, 1,500-2,499 g), and very LBW (VLBW, <1,500 g) rates. We then conducted cross-sectional and binomial regression analyses to relate these trends to changes in maternal or obstetric factors. Non-Hispanic black LBW rates declined -7.35% between 1991 and 2001 and then increased +4.23% through 2004. The LBW trends were not uniform across birth weight subcategories. Among MLBW births, the 1991-2001 decease was -10.20%; the 2001-2004 increase was +5.61%. VLBW did not follow this pattern, increasing +3.84% between 1991 and 1999 and then remaining relatively stable through 2004. In adjusted models, the 1991-2001 MLBW rate decrease was associated with changes in first-trimester prenatal care, cigarette smoking, education levels, maternal foreign-born status, and pregnancy weight gain. The 2001-2004 MLBW rate increase was independent of changes in observed maternal demographic characteristics, prenatal care, and obstetric variables. Between 1991 and 2001, progress occurred in reducing MLBW rates among non-Hispanic black infants. This progress was not maintained between 2001 and 2004 nor did it occur for VLBW infants between 1991 and 2004. Observed population changes in maternal socio-demographic and health-related factors were associated with the 1991-2001 decrease, suggesting multiple risk factors need to be simultaneously addressed to reduce non-Hispanic black LBW rates. |
Maternal caffeine consumption and risk of neural tube defects
Schmidt RJ , Romitti PA , Burns TL , Browne ML , Druschel CM , Olney RS , National Birth Defects Prevention Study . Birth Defects Res A Clin Mol Teratol 2009 85 (11) 879-89 BACKGROUND: Animal studies demonstrate teratogenic effects of caffeine, whereas human studies are inconclusive. METHODS: Associations between maternal caffeine consumption and neural tube defects (NTDs) by type of NTD (anencephaly, spina bifida, or encephalocele) were examined using data from the National Birth Defects Prevention Study (NBDPS). Total average daily caffeine from coffee, tea, soda, and chocolate consumption during the year before pregnancy was estimated for 768 mothers of infants with NTDs and 4143 mothers of infants without birth defects who gave birth during 1997 through 2002. Periconceptional use of caffeine-containing medications was evaluated separately. Adjusted odds ratios (OR) and 95% confidence intervals (CI) associated with consumption of total caffeine and each caffeine source were estimated from logistic regression models. RESULTS: Positive associations were observed between spina bifida and total caffeine consumption (OR 1.4; 95% CI: 1.1-1.9) and each caffeine source except caffeinated tea, which showed a negative association with spina bifida (OR 0.7; 95% CI: 0.6-0.9). Associations with modestly increased risk of NTDs and encephalocele were also observed. The association between caffeine consumption and anencephaly differed by maternal race/ethnicity. No dose effects were found. CONCLUSIONS: Additional studies should confirm whether women who consume caffeine are at increased risk for pregnancies complicated by NTDs. |
Preface: Health issues in indigenous children: an evidence-based approach for the general pediatrician
Chang AB , Singleton R . Pediatr Clin North Am 2009 56 (6) xvii-xix Why does the subject of health issues in Indigenous children deserve a special issue? Is the management of common disease in Indigenous children different from that for non-Indigenous children? Why adopt an evidence-based approach? | Globally, the disparity in health between Indigenous and non-Indigenous people is striking. It is most marked and well documented in affluent countries: Aboriginal and Torres Strait Islanders in Australia; Māori in New Zealand; First Nation, Inuit, and Metis People in Canada; and American Indians and Alaska Natives in the United States (here forth, all of these groups are referred to as Indigenous).1 In these affluent countries, the disease patterns (frequency, age distribution, severity and/or contributors to disease) in Indigenous children are substantially different from those in non-Indigenous children. For example, trials of currently recommended antibiotic regimens for ear infections in Australian Indigenous children showed poorer resolution rates than trials published from studies in non-Indigenous children.2 Also while the basic management of such illnesses as asthma in Indigenous children is identical to that in non–Indigenous children (eg, optimal treatment with use of appropriate asthma medications and devices, asthma action plan, etc.), the delivery of health care and asthma programs require modification. Thus, this issue is dedicated to health in Indigenous children. |
Public health projects for preventing the recurrence of neural tube defects in the United States
Collins JS , Canfield MA , Pearson K , Kirby RS , Case AP , Mai CT , Major J , Mulinare J , National Birth Defects Prevention Network . Birth Defects Res A Clin Mol Teratol 2009 85 (11) 935-8 BACKGROUND: The recurrence risk for neural tube defects (NTDs) in subsequent pregnancies is approximately 3%, or 40 times the background risk. Prevention projects target these high-risk women to increase their folic acid consumption during the periconceptional period, a behavior which decreases their recurrence risk by at least 85%. This study surveyed birth defect surveillance programs to assess their NTD recurrence prevention activities and to identify components of intervention projects that might be implemented in states with limited resources. METHODS: In 2005, the National Birth Defects Prevention Network developed and distributed an online survey to primary state birth defects surveillance contacts for the purpose of gathering information on NTD recurrence prevention activities in the United States. RESULTS: Responses came from 37 contacts in 34 states and Puerto Rico. There were 13 active NTD recurrence prevention projects, four past projects, and three planned projects. Fifteen past and present projects recommended that women with a prior NTD-affected birth take 4.0 mg of folic acid daily, and four projects provided folic acid to the women. Reasons given for not having an NTD recurrence prevention project included staffing limitations (53%), lack of funds (47%), lack of priority (18%), and confidentiality/privacy concerns (6%). CONCLUSIONS: Only 15 states and Puerto Rico had or were planning NTD recurrence prevention projects. An NTD recurrence prevention project using minimal resources should consist of timely case ascertainment, educational materials, and mechanisms for disseminating these materials. |
Birth defects and preterm birth: overlapping outcomes with a shared strategy for research and prevention
Dolan SM , Callaghan WM , Rasmussen SA . Birth Defects Res A Clin Mol Teratol 2009 85 (11) 874-8 According to the most recent national statistics, the first and second leading causes of infant mortality in the United States in 2006 were 1) “congenital malformations, deformations, and chromosomal abnormalities” (birth defects) and 2) “disorders related to short gestation and low birth weight, not elsewhere classified” (preterm birth). These two causes accounted for 20.4 and 17.0% of all deaths in the first year of life in the United States, respectively (Heron et al.,2009). When a more inclusive classification of causes of death as “preterm-related” (i.e., where the cause of death was a direct consequence of preterm birth, and where 75% or more of the infants whose deaths were attributed to that cause were born preterm) was used, an even higher proportion of infant deaths (36.5% in 2006) were attributed to being born preterm (Callaghan et al.,2006; MacDorman et al.,2007). Thus, whether the traditional cause-of-death classification or the newer classification incorporating preterm-related deaths is used, these rankings demonstrate that, overall, birth defects and preterm birth are responsible for a significant proportion of deaths among infants in the United States and exact a huge toll on individuals, families, and society. | Separating causes of infant mortality into discrete categories of birth defects and preterm birth suggests that these outcomes are distinct entities, with unique etiologies and prevention strategies, and that different research approaches and public health plans should be developed to tackle these challenging adverse perinatal outcomes. However, further analysis demonstrates that there is much overlap between the outcomes of preterm birth and birth defects. We propose an integrated approach to the prevention of birth defects and preterm birth that recognizes them as overlapping outcomes that are amenable to a shared strategy for research and prevention. In this commentary we outline the evidence supporting this approach. |
Functional difficulties among school-aged children: United States, 2001-2007
Pastor PN , Reuben CA , Loeb M . Natl Health Stat Report 2009 (19) 1-23 OBJECTIVE: This report presents estimates of basic actions difficulty, which includes difficulties related to sensory, motor, cognitive, and emotional or behavioral functioning, in U.S. children aged 5-17 years based on questions from the National Health Interview Survey (NHIS). Selected estimates are shown for the educational and health care service use of children with and without basic actions difficulty. METHODS: Estimates of basic actions difficulty were derived from the Family Core and the Sample Child Core questionnaires of the 2001-2007 NHIS. Estimates were generated and compared using SUDAAN, a statistical package that adjusts for the complex sample design of NHIS. RESULTS: Approximately 18% of children aged 5-17 had basic actions difficulty in one or more of the following domains of functioning: sensory, movement, cognitive, or emotional or behavioral. The percentage of children with difficulty in specific domains varied: 3% had sensory difficulty, 2% movement difficulty, 9% cognitive difficulty, and 10% emotional or behavioral difficulty. From 2001 through 2007, the percentage of children aged 5-17 with basic actions difficulty remained stable at about 18%. Children with and without basic actions difficulty differed greatly in their use of both educational and health care services. One-third of children with basic actions difficulty used special education services compared with 2% of children without basic actions difficulty. A substantially higher percentage of children with basic actions difficulty used health care services, including mental health care, other types of therapy, and prescription medication, than children without basic actions difficulty. |
An indigenous plant food used by lactating mothers in West Africa: the nutrient composition of the leaves of Kigelia africana in Ghana
Glew RS , Amoako Atta B , Ankar Brewoo G , Presley JM , Chang YC , Chuang LT , Millson M , Smith BR , Glew RH . Ecol Food Nutr 2010 49 (1) 72-83 Although the leaves of Kigelia africana are used to make a palm-nut soup which is consumed mainly by lactating women in many parts of sub-Saharan Africa, little is known about the nutrient qualities of this underutilized and underappreciated plant food. Leaves of Kigelia africana, called osausage treeo in English and onufuteno in the Twi language of Ghana, were collected in Kumasi and analyzed for their content of nutritionally important fatty acids, amino acids, minerals, and trace elements. The dried leaves contained 1.62% fatty acids, of which -linolenic acid and linolenic acid accounted for 44% and 20%, respectively, of the total. Protein accounted for 12.6% of the dry weight and, except for lysine, its overall essential amino acid profile compared favorably to a World Health Organization protein standard for school children. Kigelia leaf contained considerable amounts of many essential elements, including calcium (7,620g/g), iron (161g/g), magnesium (2,310g/g), manganese (14.6g/g), zinc (39.9g/g), and chromium (0.83g/g); selenium, however, was not detected. These data indicate that Kigelia africana leaf compares favorably with many other commonly-consumed green leafy vegetables such as spinach and provides a rational basis for promoting the conservation and propagation of the plant and encouraging its wider use in the diets of populations in sub-Saharan Africa. |
Safety tips for roadway work zones
Mulhern B , Lentz TJ . Occup Health Saf 2010 79 (1) 18-20 June 3, 2008, turned into a nightmare for Chris and Janet Augeri. Instead of celebrating their son Rob's 31st birthday, they were making plans for his funeral. | Robert (Rob) Augeri of Londonderry, N.H., a husband and father of four children ranging in age from 1 to 12, was killed at 1:30 a.m. while working in a highway construction zone. Rob was painting lines in the roadway on Interstate 495 near Methuen, Mass., when a dump truck backed into him in the closed left travel lane. Neither the driver of the truck nor his passenger was injured. |
The national study to prevent blood exposure in paramedics: rates of exposure to blood
Boal WL , Leiss JK , Ratcliffe JM , Sousa S , Lyden JT , Li J , Jagger J . Int Arch Occup Environ Health 2010 83 (2) 191-9 OBJECTIVE: The purpose of this analysis is to present incidence rates of exposure to blood among paramedics in the United States by selected variables and to compare all percutaneous exposure rates among different types of healthcare workers. METHODS: A survey on blood exposure was mailed in 2002-2003 to a national sample of paramedics. Results for California paramedics were analyzed with the national sample and also separately. RESULTS: The incidence rate for needlestick/lancet injuries was 100/1,000 employee-years [95% confidence interval (CI), 40-159] among the national sample and 26/1,000 employee-years (95% CI, 15-38) for the California sample. The highest exposure rate was for non-intact skin, 230/1,000 employee-years (95% CI, 130-329). The rate for all exposures was 465/1,000 employee-years (95% CI, 293-637). California needlestick/lancet rates, but not national, were substantially lower than rates in earlier studies of paramedics. Rates for all percutaneous injuries among paramedics were similar to the mid to high range of rates reported for most hospital-based healthcare workers. CONCLUSIONS: Paramedics in the United States are experiencing percutaneous injury rates at least as high as, and possibly substantially higher than, most hospital-based healthcare workers, as well as substantially higher rates of exposure to blood on non-intact skin. |
Occupational exposure of health care personnel to hepatitis B and hepatitis C: prevention and surveillance strategies
Maccannell T , Laramie AK , Gomaa A , Perz JF . Clin Liver Dis 2010 14 (1) 23-36 Ensuring the safety of personnel working in health care environments can be challenging and requires a multifaceted approach to target reductions in occupational exposures to blood-borne pathogens, such as hepatitis B or hepatitis C. This article reviews the epidemiology of occupational exposures to hepatitis B and hepatitis C in health care personnel in hospital settings. The nature and likelihood of risk to health care personnel are evaluated along with estimates of seroconversion risk. The review focuses on prevention programs and available surveillance programs to aid in monitoring and reducing occupational exposures to blood-borne pathogens. |
An outbreak of neurological autoimmunity with polyradiculoneuropathy in workers exposed to aerosolised porcine neural tissue: a descriptive study
Lachance DH , Lennon VA , Pittock SJ , Tracy JA , Krecke KN , Amrami KK , Poeschla EM , Orenstein R , Scheithauer BW , Sejvar JJ , Holzbauer S , Devries AS , Dyck PJ . Lancet Neurol 2010 9 (1) 55-66 BACKGROUND: Between November, 2006, and May, 2008, a subacute neurological syndrome affected workers from two swine abattoirs in Minnesota and Indiana who had occupational exposure to aerosolised porcine brain. We aimed to describe the pathogenic and immunological characteristics of this illness. METHODS: All patients from two abattoirs who presented or were referred to the Mayo Clinic (Rochester, MN, USA) with neurological symptoms were included. We recorded details of exposure to aerosolised brain tissue and did comprehensive neurological, laboratory, neuroimaging, electrophysiological, pathological, and autoimmune serological assessments. Healthy controls were recruited from the community and from workers at the plant in Minnesota. FINDINGS: 24 patients were identified (21 from Minnesota, three from Indiana). The shortest duration from first exposure to symptom onset was 4 weeks. No infectious agent that could trigger disease was identified. All patients developed polyradiculoneuropathy, which was usually sensory predominant and painful. Two patients had initial CNS manifestations: transverse myelitis and meningoencephalitis. Nerve conduction studies localised abnormalities to the most proximal and distal nerve segments. Quantitative sensory and autonomic testing revealed involvement of large and small sensory fibres and sweat fibres. MRI showed prominent abnormalities of roots and ganglia. Nerve biopsies identified mild demyelination, axonal degeneration, and perivascular inflammation. Protein concentrations were high in the CSF of 18 (86%) of 21 patients. Sera from all patients and 29 (34%) of 85 unaffected workplace controls (but none of 178 community controls) had a distinctive neural-reactive IgG; 75% of patients' sera contained an IgG specific to myelin basic protein. Seropositivity correlated directly with exposure risk in patients and controls. 17 patients required immunomodulatory therapies, six improved spontaneously, and one was lost to follow-up after exposure stopped. INTERPRETATION: The neurological disorder described is autoimmune in origin and is related to occupational exposure to multiple aerosolised porcine brain tissue antigens. The pattern of nerve involvement suggests vulnerability of nerve roots and terminals where the blood-nerve barrier is most permeable. FUNDING: Mayo Clinic Foundation; Minnesota Department of Health; Centers for Disease Control and Prevention. |
Regional bumps: case studies from the 1958 bump symposium
Whyatt J , Varley F . Trans Soc Min Metall Explor Inc 2010 326 101-105 A variety of dynamic failure cases with regional impact were described at a bump symposium held in 1958. These types of events, while rare, are of particular interest because their ability to impact a large area has disaster potential. These cases can be grouped into two broad classes of events by mechanism. These are (1) a slip along steeply dipping faults and (2) the fracturing of strong strata above or below the coal seam. Both failure modes produce dynamic or "shock" loads on the perimeter (roof, rib and floor) of mine openings. Special consideration should be given to these failure modes in the planning of deep coal mines, since their occurrence is not within the professional experience of many contemporary workers. In addition, their potential is not evaluated by many of the analysis tools commonly used to evaluate hazards in coal mine plans. |
Enhanced fire escape training for mine workers using virtual reality simulation
Orr TJ , Mallet LG , Margolis KA . Min Eng 2009 61 (11) 41-44 Recent U.S. mine disasters identified a need for improved training of miners in escape from mine fires and explosions. Researchers at the National Institute for Occupational Safety and Health's (NIOSH) Spokane Research Laboratory (SRL) have designed fire-escape training software for use in a mine-safety training course. The software allows four trainees to work together in a virtual world via a computer network. Trainees responded favorably and showed a marked improvement in locating the proper evacuation routes on subsequent trials. In collaboration with the Pittsburgh Research Laboratory (PRL), a more elaborate fire evacuation scenario is being developed. Further study is needed to confirm that virtual training will translate to improved safety outcomes in the real world. |
Protecting and enhancing health: community engagement, collaborations, and incentives for prevention
Simoes EJ , Sumaya CV . J Prim Prev 2010 31 21-9 The US health care system and its reform has become a focal point of public debate, engaging many who traditionally have not participated in the dialogue around population health needs and resources. In this essay, we discuss aspects of a transformed health care system that addresses major health needs of Americans through health promotion, disease prevention, and personal health care (i.e., diagnosis and treatment). We bring attention to the role of communities and patients on the health issues with a focus on public (population) health practice, emphasizing collaboration among government health agencies at all levels and other health-related public and private organizations. | This discussion is necessary, relevant, and timely because it is occurring concurrently with the emerging national, state, and local discourse on health reform. Significant funding targeting health system changes are already unfolding with the American Recovery and Reinvestment Act (ARRA) of 2009. (Steinbrook 2009; Agency for Healthcare Research and Quality 2009; US Department of Health & Human Services 2009). |
A public health focus on infertility prevention, detection, and management
Macaluso M , Wright-Schnapp TJ , Chandra A , Johnson R , Satterwhite CL , Pulver A , Berman SM , Wang RY , Farr SL , Pollack LA . Fertil Steril 2010 93 (1) 16 e1-10 In 2002, 2 million American women of reproductive age were infertile. Infertility is also common among men. The Centers for Disease Control and Prevention (CDC) conducts surveillance and research on the causes of infertility, monitors the safety and efficacy of infertility treatment, and sponsors national prevention programs. A CDC-wide working group found that, despite this effort, considerable gaps and opportunities exist in surveillance, research, communication, and program and policy development. We intend to consult with other federal agencies, professional and consumer organizations, the scientific community, the health care community, industry, and other stakeholders, and participate in the development of a national public health plan for the prevention, detection, and management of infertility. |
Repeat pap testing and colposcopic biopsies in the underserved
Trivers KF , Benard VB , Eheman CR , Royalty JE , Ekwueme DU , Lawson HW . Obstet Gynecol 2009 114 (5) 1049-1056 To quantify repeat Pap testing and colposcopy biopsies among women in the National Breast and Cervical Cancer Early Detection Program between 2003 and 2006 (N=955,494). Rates of repeat Pap testing (two tests within 9 months) and colposcopic biopsies were estimated along with 95% confidence intervals (CIs). Odds ratios and 95% CIs for receipt of colposcopic biopsy compared with repeat Pap testing were estimated from multivariable logistic regression models. Finally, we estimated positive predictive values and 95% CIs of cervical intraepithelial neoplasia (CIN) 2 or worse (CIN 3, carcinoma in situ, invasive cancer) for two strategies: 1) repeat Pap testing followed by colposcopic biopsy and 2) colposcopic biopsy alone. There were 39,583 and 53,880 women with repeat Pap testing and colposcopic biopsy, respectively, from 2003 to 2006. Overall, age-standardized rates of repeat Pap testing and colposcopic biopsies were 37.2 per 1,000 women and 39.3 per 1,000 women, respectively. Younger women, Hispanic women, and African-American women were more likely to receive colposcopic biopsies compared with repeat Pap tests. Positive predictive values of colposcopic biopsy were highest after abnormal Pap test results (27% after a result of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion, 70% after a result of high-grade squamous intraepithelial lesion/ squamous cell cancer). Colposcopic biopsies are common among young women after being screened for cervical cancer and, except among those with the most severe Pap test results, may not be efficient in detecting serious disease. These results conflict with current recommendations for less aggressive follow-up for most young women. copyright 2009 by The American College of Obstetricians and Gynecologists. |
Stalled decline in fertility in Ecuador
Ishida K , Stupp P , Sotomayor JO . Int Perspect Sex Reprod Health 2009 35 (4) 203-6 Many developing countries have experienced rapid declines in fertility since the 1960s. Although some have already reached the replacement level of 2.1 lifetime births per woman, and others are expected to do so in the future, the decrease in fertility in other countries has slowed or even stalled.1 Ecuador clearly falls into the latter category. After remaining at approximately 7.0 lifetime births per woman between 1955 and 1969, its total fertility rate (TFR) steadily declined throughout the 1970s and 1980s, reaching 3.8 births in 1989; the average yearly decline over this period was 0.17 births per year. However, the decline slowed between 1989 and 2004 to an average of 0.03 births per year, and the country's TFR in 2004 was 3.3 births per woman. |
A motivational intervention can improve retention in PCIT for low-motivation child welfare clients
Chaffin M , Valle LA , Funderburk B , Gurwitch R , Silovsky J , Bard D , McCoy C , Kees M . Child Maltreat 2009 14 (4) 356-68 A motivational orientation intervention designed to improve parenting program retention was field tested versus standard orientation across two parenting programs, Parent-Child Interaction Therapy (PCIT) and a standard didactic parent training group. Both interventions were implemented within a frontline child welfare parenting center by center staff. Participants had an average of six prior child welfare referrals, primarily for neglect. A double-randomized design was used to test main and interaction effects. The motivational intervention improved retention only when combined with PCIT (cumulative survival = 85% vs. around 61% for the three other design cells). Benefits were robust across demographic characteristics and participation barriers but were concentrated among participants whose initial level of motivation was low to moderate. There were negative effects for participants with relatively high initial motivation. The findings suggest that using a motivational intervention combined with PCIT can improve retention when used selectively with relatively low to moderately motivated child welfare clients. |
Psychosocial characteristics and sexual behaviors of people in care for HIV infection: an examination of men who have sex with men, heterosexual men and women
Golin C , Marks G , Wright J , Gerkovich M , Tien HC , Patel SN , Gardner L , O'Daniels C , Wilson TE , Thrun M , Thompson M , Raffanti S , Quinlivan EB . AIDS Behav 2009 13 (6) 1129-42 Few studies have examined the psychosocial factors associated with sexual transmission behaviors among HIV-positive men who have sex with men (MSM), heterosexual men (MSW) and women. We enrolled 1,050 sexually active HIV-positive patients at seven HIV clinics in six US cities as part of a clinic-based behavioral intervention. We describe the sexual transmission behaviors and examine demographic, clinical, psychosocial, and clinic prevention variables associated with unprotected anal or vaginal intercourse (UAVI). Twenty-three percent of MSM, 12.3% of MSW and 27.8% of women engaged in UAVI with partners perceived to be HIV-negative or of unknown serostatus. Among MSM and MSW, having multiple partners and lower self-efficacy were associated with increased odds of UAVI. Self-rating one's health status as excellent/very good was a risk factor for UAVI among MSM. Among women, binge drinking and stressful life events were associated with UAVI. These findings identify variables that warrant attention in targeted interventions. |
Estimated pregnancy rates for the United States, 1990-2005: an update
Ventura SJ , Abma JC , Mosher WD , Henshaw SK . Natl Vital Stat Rep 2009 58 (4) 1-14 OBJECTIVES: This report presents detailed pregnancy rates for 1990-2005, updating a national series of rates extending since 1976. METHODS: Tabular data on pregnancy rates by age, race and Hispanic origin, and by marital status are presented and briefly described. RESULTS: in 2005, an estimated 6,408,000 pregnancies resulted in 4.14 million live births, 1.21 million induced abortions, and 1.06 million fetal losses. The 2005 pregnancy rate of 103.2 pregnancies per 1000 women aged 15-44 years is 11 percent below the 1990 peak of 115.8. The teenage pregnancy rate dropped 40 percent from 1990 to 2005, reaching an historic low of 70.6 per 1000 women aged 15-19 years. Rates fell much more for younger than for older teenagers. |
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