Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010
Flegal KM , Carroll MD , Kit BK , Ogden CL . JAMA 2012 307 (5) 491-7 CONTEXT: Between 1980 and 1999, the prevalence of adult obesity (body mass index [BMI] ≥30) increased in the United States and the distribution of BMI changed. More recent data suggested a slowing or leveling off of these trends. OBJECTIVE: To estimate the prevalence of adult obesity from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) and compare adult obesity and the distribution of BMI with data from 1999-2008. DESIGN, SETTING, AND PARTICIPANTS: NHANES includes measured heights and weights for 5926 adult men and women from a nationally representative sample of the civilian noninstitutionalized US population in 2009-2010 and for 22,847 men and women in 1999-2008. MAIN OUTCOME MEASURES: The prevalence of obesity and mean BMI. RESULTS: In 2009-2010 the age-adjusted mean BMI was 28.7 (95% CI, 28.3-29.1) for men and also 28.7 (95% CI, 28.4-29.0) for women. Median BMI was 27.8 (interquartile range [IQR], 24.7-31.7) for men and 27.3 (IQR, 23.3-32.7) for women. The age-adjusted prevalence of obesity was 35.5% (95% CI, 31.9%-39.2%) among adult men and 35.8% (95% CI, 34.0%-37.7%) among adult women. Over the 12-year period from 1999 through 2010, obesity showed no significant increase among women overall (age- and race-adjusted annual change in odds ratio [AOR], 1.01; 95% CI, 1.00-1.03; P=.07), but increases were statistically significant for non-Hispanic black women (P = .04) and Mexican American women (P=.046). For men, there was a significant linear trend (AOR, 1.04; 95% CI, 1.02-1.06; P<.001) over the 12-year period. For both men and women, the most recent 2 years (2009-2010) did not differ significantly (P=.08 for men and P=.24 for women) from the previous 6 years (2003-2008). Trends in BMI were similar to obesity trends. CONCLUSION: In 2009-2010, the prevalence of obesity was 35.5% among adult men and 35.8% among adult women, with no significant change compared with 2003-2008. |
Actions to control high blood pressure among hypertensive adults in Texas counties along the Mexico border: Texas BRFSS, 2007
Ayala C , Fang J , Escobedo L , Pan S , Balcazar HG , Wang G , Merritt R . Public Health Rep 2012 127 (2) 173-85 OBJECTIVES: We examined the prevalence of actions taken to control blood pressure as measured by taking antihypertensive medication or making lifestyle modifications among hypertensive adults residing along the Texas/Mexico border. METHODS: We used self-reported data from the 2007 Texas Behavioral Risk Factor Surveillance System, with oversampling of border counties. We calculated the age-standardized prevalence of actions taken to control hypertension by selected characteristics. RESULTS: In analyses that combined ethnicity with predominant language spoken, those least likely to take any action to control their blood pressure-either by taking an antihypertensive medication or by making any of four lifestyle modifications-were Spanish-speaking Hispanic people (83.2% +/- 2.7% standard error [SE]), with English-speaking non-Hispanic people (88.9% +/- 0.8% SE) having the highest prevalence of taking action to control blood pressure. When analyzed by type of medical category, uninsured Hispanic people (63.8% +/- 4.8% SE) had the lowest prevalence of taking action to control their blood pressure compared with uninsured non-Hispanic people (75.4% +/- 4.7% SE). Nonborder Texas residents with hypertension were more likely to take antihypertensive medications (78.4% +/- 1.0% SE) than border county residents with hypertension (70.7% +/- 2.0% SE). CONCLUSIONS: Public health efforts must be undertaken to improve the control of hypertension among residents of Texas counties along the Mexico border, particularly for uninsured Hispanic people. |
Participant satisfaction with group and individual components of Adolescent Impact: a secondary prevention intervention for HIV-positive youth
LaGrange RD , Abramowitz S , Koenig LJ , Barnes W , Conner L , Moschel D . AIDS Care 2012 24 (1) 119-28 Adolescent Impact, a developmentally targeted behavioral intervention aimed at decreasing risk behaviors and promoting health care adherence, was delivered to 83 HIV-infected youth, aged 13-21 years, receiving care in five urban HIV centers. Participants completed a patient satisfaction survey following the 12 part intervention consisting of seven groups and five individual sessions. A feedback questionnaire was also completed during each group session to gain more insight on participant experiences. Several indicators suggested high levels of satisfaction. First, overall attendance was relatively high. Second, participants rated their subjective experience and group content favorably. No differences in satisfaction ratings emerged between perinatally infected adolescents and those who acquired HIV through risk behaviors. However, differences emerged regarding perceived intervention utility and content-specific preferences. Findings suggest that Adolescent Impact participants were satisfied with the intervention and that a heterogeneous group of HIV-infected youth could be advantageously integrated into the same secondary prevention program. |
The Program Science initiative: improving the planning, implementation and evaluation of HIV/STI prevention programmes
Aral SO , Blanchard JF . Sex Transm Infect 2012 88 (3) 157-9 In this article, the authors describe the Program Science initiative in detail, discuss some of its recent accomplishments and explore its significance and timeliness in light of the HIV prevention challenges. The authors also describe the Programme Science series being launched and present a preview of future articles. |
Estimating age-specific influenza-related hospitalization rates during the pandemic (H1N1) 2009 in Davidson Co, TN
Jules A , Grijalva CG , Zhu Y , Talbot KH , Williams JV , Dupont WD , Edwards KM , Schaffner W , Shay DK , Griffin MR . Influenza Other Respir Viruses 2012 6 (3) e63-71 BACKGROUND: In April 2009, a pandemic caused by a novel influenza strain, the A(H1N1)pdm09 virus, started. Few age-specific estimates of hospitalizations associated with the first year of circulation of the pandemic virus are available. OBJECTIVES: To estimate age-specific hospitalization rates associated with laboratory-confirmed A(H1N1)pdm09 virus in Davidson County, TN, from May 2009 to March 2010. PATIENTS/METHODS: Two separate strategies were applied: capture-recapture and surveillance-sampling methods. For the capture-recapture estimates, we linked data collected via two independent prospective population-based surveillance systems: The Influenza Vaccine Effectiveness Network (Flu-VE) tested consenting county patients hospitalized with respiratory symptoms at selected hospitals using real-time reverse transcriptase polymerase chain reaction (rRT-PCR); the Emerging Infections Program identified county patients with positive influenza tests in all area hospitals. For the surveillance-sampling estimates, we applied the age-specific proportions of influenza-positive patients (from Flu-VE) to the number of acute respiratory illness hospitalizations obtained from the Tennessee Hospital Discharge Data system. RESULTS: With capture-recapture, we estimated 0.89 (95% CI, 0.72-1.49), 0.62 (0.42-1.11), 1.78 (0.99-3.63), and 0.76 (0.50-1.76) hospitalizations per 1000 residents aged <5, 5-17, 18-49, and ≥50 years, respectively. Surveillance-sampling estimated rates were 0.78 (0.46-1.22), 0.32 (0.14-0.69), 0.99 (0.64-1.52), and 1.43 (0.80-2.48) hospitalizations per 1000 residents aged <5, 5-17, 18-49, and ≥50 years, respectively. In all age-groups combined, we estimated approximately 1 influenza-related hospitalization per 1000 residents. CONCLUSIONS: Two independent methods provided consistent results on the burden of pandemic virus in Davidson County and suggested that the overall incidence of A(H1N1)pdm09-associated hospitalization was 1 per 1000 county residents. |
Female genital tract shedding of CXCR4-tropic HIV-1 is associated with a majority population of CXCR4-tropic HIV-1 in blood and declining CD4+ cell counts
Haaland R , Sullivan S , Evans-Strickfaden T , Lennox J , Hart C . AIDS Res Hum Retroviruses 2012 28 (11) 1524-32 This study compared HIV-1 genotypes shed over time (≤ 3.5 years) in the vaginal secretions (VS) and blood plasma (BP) of 15 chronically infected women. Analysis of predicted coreceptor tropism (CCR5 = R5, CXCR4 = X4) for quasispecies shedding revealed three patterns: (1) viral quasispecies shed in both VS and BP were restricted to R5-tropism at all time points, (2) quasispecies shed in VS were restricted to R5-tropism at all time points but X4 quasispecies were identified in the BP at one or more time points, (3) quasispecies shed in matched VS and BP both contained X4-tropic viruses. Overall, the frequency of X4 quasispecies circulation in VS was 2-fold less than in BP and detection of X4 virus in VS was more likely to occur when X4 quasispecies comprised more than 50% of BP viruses (p = 0.01) and when declines in blood CD4+ lymphocyte levels were the greatest (p = 0.038). Additionally, the mean number of predicted N-glycosylation sites between matched VS and BP samples were strongly correlated (r = 0.86, p < 0.0001) with glycosylation densities in the following order (VS R5 = BP R5 > BP X4 > VS X4). The X4 glyscosylation densities may result from compartmentalization pressures in the female genital tract or the delayed appearance of these viruses in VS. Our results suggest that the presence of X4 virus in VS is associated with a threshold population of X4 quasispecies in BP which are increasing during the HIV-induced failure of the human immune system. |
Antivirals for treatment of influenza: a systematic review and meta-analysis of observational studies
Hsu J , Santesso N , Mustafa R , Brozek J , Chen YL , Hopkins JP , Cheung A , Hovhannisyan G , Ivanova L , Flottorp SA , Saeterdal I , Wong AD , Tian J , Uyeki TM , Akl EA , Alonso-Coello P , Smaill F , Schunemann HJ . Ann Intern Med 2012 156 (7) 512-24 BACKGROUND: Systematic reviews of randomized, controlled trials in patients with influenza suggest a lack of evidence about the effects of antiviral therapy on several patient-important influenza outcomes. PURPOSE: To systematically review observational studies for benefits and harms of oseltamivir, zanamivir, amantadine, or rimantadine in the treatment of influenza. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL, SIGLE, the Chinese Biomedical Literature Database, Panteleimon, and LILACS up to November 2010; contact with pharmaceutical companies; and reference lists. STUDY SELECTION: Observational studies in any language that compared single antiviral therapy with no therapy or other antiviral therapy, or that had no comparator, for influenza or influenza-like illness. DATA EXTRACTION: Two independent investigators extracted data. Confidence in the estimates of the obtained effects (quality of evidence) was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation approach. DATA SYNTHESIS: 74 studies fulfilled the inclusion criteria. Meta-analyses of the few studies providing effects with adjustment for confounders suggest that in high-risk populations, oral oseltamivir may reduce mortality (odds ratio, 0.23 [95% CI, 0.13 to 0.43]; low-quality evidence), hospitalization (odds ratio, 0.75 [CI, 0.66 to 0.89]; low-quality evidence), and duration of symptoms (33 hours [CI, 21 to 45 hours]; very low-quality evidence) compared with no treatment. Earlier treatment with oseltamivir was generally associated with better outcomes. Inhaled zanamivir may lead to shorter symptom duration (23 hours [CI, 17 to 28 hours]; moderate-quality evidence) and fewer hospitalizations (odds ratio, 0.66 [CI, 0.37 to 1.18]) but more complications than no treatment. Direct comparison of oral oseltamivir and inhaled zanamivir suggests no important differences in key outcomes. Data from 1 study suggests that oral amantadine may reduce mortality and pneumonia associated with influenza A. No included study evaluated rimantadine. LIMITATIONS: Mortality was assessed in high-risk patients and generalizability is limited. The overall body of evidence is limited by risk for confounding and selection, reporting, and publication bias. CONCLUSION: Therapy with oral oseltamivir and inhaled zanamivir may provide a net benefit over no treatment of influenza. However, as with the randomized trials, the confidence in the estimates of the effects for decision making is low to very low. PRIMARY FUNDING SOURCES: World Health Organization and McMaster University. |
A distinct lineage of influenza A virus from bats.
Tong S , Li Y , Rivailler P , Conrardy C , Castillo DA , Chen LM , Recuenco S , Ellison JA , Davis CT , York IA , Turmelle AS , Moran D , Rogers S , Shi M , Tao Y , Weil MR , Tang K , Rowe LA , Sammons S , Xu X , Frace M , Lindblade KA , Cox NJ , Anderson LJ , Rupprecht CE , Donis RO . Proc Natl Acad Sci U S A 2012 109 (11) 4269-74 Influenza A virus reservoirs in animals have provided novel genetic elements leading to the emergence of global pandemics in humans. Most influenza A viruses circulate in waterfowl, but those that infect mammalian hosts are thought to pose the greatest risk for zoonotic spread to humans and the generation of pandemic or panzootic viruses. We have identified an influenza A virus from little yellow-shouldered bats captured at two locations in Guatemala. It is significantly divergent from known influenza A viruses. The HA of the bat virus was estimated to have diverged at roughly the same time as the known subtypes of HA and was designated as H17. The neuraminidase (NA) gene is highly divergent from all known influenza NAs, and the internal genes from the bat virus diverged from those of known influenza A viruses before the estimated divergence of the known influenza A internal gene lineages. Attempts to propagate this virus in cell cultures and chicken embryos were unsuccessful, suggesting distinct requirements compared with known influenza viruses. Despite its divergence from known influenza A viruses, the bat virus is compatible for genetic exchange with human influenza viruses in human cells, suggesting the potential capability for reassortment and contributions to new pandemic or panzootic influenza A viruses. |
Saliva, salivary gland, and hemolymph collection from Ixodes scapularis ticks
Patton TG , Dietrich G , Brandt K , Dolan MC , Piesman J , Gilmore RD Jr . J Vis Exp 2012 (60) Ticks are found worldwide and afflict humans with many tick-borne illnesses. Ticks are vectors for pathogens that cause Lyme disease and tick-borne relapsing fever (Borrelia spp.), Rocky Mountain Spotted fever (Rickettsia rickettsii), ehrlichiosis (Ehrlichia chaffeensis and E. equi), anaplasmosis (Anaplasma phagocytophilum), encephalitis (tick-borne encephalitis virus), babesiosis (Babesia spp.), Colorado tick fever (Coltivirus), and tularemia (Francisella tularensis) (1-8). To be properly transmitted into the host these infectious agents differentially regulate gene expression, interact with tick proteins, and migrate through the tick (3,9-13). For example, the Lyme disease agent, Borrelia burgdorferi, adapts through differential gene expression to the feast and famine stages of the tick's enzootic cycle (14,15). Furthermore, as an Ixodes tick consumes a bloodmeal Borrelia replicate and migrate from the midgut into the hemocoel, where they travel to the salivary glands and are transmitted into the host with the expelled saliva (9,16-19). As a tick feeds the host typically responds with a strong hemostatic and innate immune response (11,13,20-22). Despite these host responses, I. scapularis can feed for several days because tick saliva contains proteins that are immunomodulatory, lytic agents, anticoagulants, and fibrinolysins to aid the tick feeding (3,11,20,21,23). The immunomodulatory activities possessed by tick saliva or salivary gland extract (SGE) facilitate transmission, proliferation, and dissemination of numerous tick-borne pathogens (3,20,24-27). To further understand how tick-borne infectious agents cause disease it is essential to dissect actively feeding ticks and collect tick saliva. This video protocol demonstrates dissection techniques for the collection of hemolymph and the removal of salivary glands from actively feeding I. scapularis nymphs after 48 and 72 hours post mouse placement. We also demonstrate saliva collection from an adult female I. scapularis tick. |
Reduction in cadmium exposure in the United States population, 1988-2008: the contribution of declining smoking rates
Tellez-Plaza M , Navas-Acien A , Caldwell KL , Menke A , Muntner P , Guallar E . Environ Health Perspect 2012 120 (2) 204-9 BACKGROUUND: Public health policies such as tobacco control, air pollution reduction, and hazardous waste remediation may have reduced cadmium exposure among U.S. adults. However, trends in urine cadmium, a marker of cumulative cadmium exposure, have not been evaluated. OBJECTIVES: We estimated the trends in urine cadmium concentrations in U.S. adults using data from the National Health and Nutrition Examination Surveys (NHANES) from 1988 to 2008. We also evaluated the impact of changes in the distribution of available cadmium determinants (age, sex, race, education, body mass index, smoking, and occupation) at the population level to explain cadmium trends. METHODS: The study population included 19,759 adults ≥ 20 years of age with measures of urine cadmium and cadmium determinants. RESULTS: Age-adjusted geometric means of urine cadmium concentrations were 0.36, 0.35, 0.27, 0.27, 0.28, 0.25, and 0.26 microg/g creatinine in 1988-1991, 1991-1994, 1999-2000, 2001-2002, 2003-2004, 2005-2006, and 2007-2008, respectively. The age, sex, and race/ethnicity-adjusted percent reduction in urine cadmium geometric means comparing 1999-2002 and 2003-2008 with 1988-1994 were 27.8% (95% confidence interval: 22.3%, 32.9%) and 34.3% (29.9%, 38.4%), respectively (p-trend < 0.001), with reductions in all participant subgroups investigated. In never smokers, reductions in serum cotinine accounted for 15.6% of the observed reduction. In ever smokers, changes in smoking cessation, and cumulative and recent dose accounted for 17.1% of the observed reduction. CONCLUSIONS: Urine cadmium concentrations decreased markedly between 1988 and 2008. Declining smoking rates and changes in exposure to tobacco smoke may have played an important role in the decline of urine cadmium concentrations, benefiting both smokers and nonsmokers. Cadmium has been associated to several health outcomes in NHANES 1999-2008. Consequently, despite the observed decline, further reduction in cadmium exposure is needed. |
Predicting US- and state-level cancer counts for the current calendar year: Part II: evaluation of spatiotemporal projection methods for incidence
Zhu L , Pickle LW , Ghosh K , Naishadham D , Portier K , Chen HS , Kim HJ , Zou Z , Cucinelli J , Kohler B , Edwards BK , King J , Feuer EJ , Jemal A . Cancer 2012 118 (4) 1100-9 BACKGROUND: The current study was undertaken to evaluate the spatiotemporal projection models applied by the American Cancer Society to predict the number of new cancer cases. METHODS: Adaptations of a model that has been used since 2007 were evaluated. Modeling is conducted in 3 steps. In step I, ecologic predictors of spatiotemporal variation are used to estimate age-specific incidence counts for every county in the country, providing an estimate even in those areas that are missing data for specific years. Step II adjusts the step I estimates for reporting delays. In step III, the delay-adjusted predictions are projected 4 years ahead to the current calendar year. Adaptations of the original model include updating covariates and evaluating alternative projection methods. Residual analysis and evaluation of 5 temporal projection methods were conducted. RESULTS: The differences between the spatiotemporal model-estimated case counts and the observed case counts for 2007 were < 1%. After delays in reporting of cases were considered, the difference was 2.5% for women and 3.3% for men. Residual analysis indicated no significant pattern that suggested the need for additional covariates. The vector autoregressive model was identified as the best temporal projection method. CONCLUSIONS: The current spatiotemporal prediction model is adequate to provide reasonable estimates of case counts. To project the estimated case counts ahead 4 years, the vector autoregressive model is recommended to be the best temporal projection method for producing estimates closest to the observed case counts. (Cancer 2012;. (c) 2012 American Cancer Society.) |
Foodborne outbreaks of shigellosis in the USA, 1998-2008
Nygren BL , Schilling KA , Blanton EM , Silk BJ , Cole DJ , Mintz ED . Epidemiol Infect 2012 141 (2) 1-9 SUMMARY: We examined reported outbreaks of foodborne shigellosis in the USA from 1998 to 2008 and summarized demographic and epidemiological characteristics of 120 confirmed outbreaks resulting in 6208 illnesses. Most reported foodborne shigellosis outbreaks (n=70, 58%) and outbreak-associated illnesses (n=3383, 54%) were restaurant-associated. The largest outbreaks were associated with commercially prepared foods distributed in multiple states and foods prepared in institutional settings. Foods commonly consumed raw were implicated in 29 (24%) outbreaks and infected food handlers in 28 (23%) outbreaks. Most outbreaks (n=86, 72%) were caused by Shigella sonnei. Targeted efforts to reduce contamination during food handling at multiple points in the food processing and distribution system, including food preparation in restaurants and institutional settings, could prevent many foodborne disease outbreaks and outbreak-related illnesses including those due to Shigella. |
Atypical Listeria monocytogenes serotype 4b strains harboring a lineage II-specific gene cassette.
Lee S , Ward TJ , Graves LM , Wolf LA , Sperry K , Siletzky RM , Kathariou S . Appl Environ Microbiol 2012 78 (3) 660-7 Listeria monocytogenes is the etiological agent of listeriosis, a severe food-borne illness. The population of L. monocytogenes is divided into four lineages (I to IV), and serotype 4b in lineage I has been involved in numerous outbreaks. Several serotype 4b epidemic-associated clonal groups (ECI, -II, and -Ia) have been identified. In this study, we characterized a panel of strains of serotype 4b that produced atypical results with a serotype-specific multiplex PCR and possessed the lmo0734 to lmo0739 gene cassette that had been thought to be specific to lineage II. The cassette was harbored in a genomically syntenic locus in these isolates and in lineage II strains. Three distinct clonal groups (groups 1 to 3) were identified among these isolates based on single-nucleotide polymorphism-based multilocus genotyping (MLGT) and DNA hybridization data. Groups 1 and 2 had MLGT haplotypes previously encountered among clinical isolates and were composed of clinical isolates from multiple states in the United States. In contrast, group 3 consisted of clinical and environmental isolates solely from North Carolina and exhibited a novel haplotype. In addition, all group 3 isolates had DNA that was resistant to MboI, suggesting methylation of adenines at GATC sites. Sequence analysis of the lmo0734 to lmo0739 gene cassette from two strains (group 1 and group 3) revealed that the genes were highly conserved (>99% identity). The data suggest relatively recent horizontal gene transfer from lineage II L. monocytogenes into L. monocytogenes serotype 4b and subsequent dissemination among at least three distinct clonal groups of L. monocytogenes serotype 4b, one of which exhibits restrictions in regional distribution. |
Global TravEpiNet: A national consortium of clinics providing care to international travelers--analysis of demographic characteristics, travel destinations, and pretravel healthcare of high-risk US international travelers, 2009-2011
LaRocque RC , Rao SR , Lee J , Ansdell V , Yates JA , Schwartz BS , Knouse M , Cahill J , Hagmann S , Vinetz J , Connor BA , Goad JA , Oladele A , Alvarez S , Stauffer W , Walker P , Kozarsky P , Franco-Paredes C , Dismukes R , Rosen J , Hynes NA , Jacquerioz F , McLellan S , Hale D , Sofarelli T , Schoenfeld D , Marano N , Brunette G , Jentes ES , Yanni E , Sotir MJ , Ryan ET , Global TravEpiNet Consortium . Clin Infect Dis 2012 54 (4) 455-462 BACKGROUND: International travel poses a risk of destination-specific illness and may contribute to the global spread of infectious diseases. Despite this, little is known about the health characteristics and pretravel healthcare of US international travelers, particularly those at higher risk of travel-associated illness. METHODS: We formed a national consortium (Global TravEpiNet) of 18 US clinics registered to administer yellow fever vaccination. We collected data regarding demographic and health characteristics, destinations, purpose of travel, and pretravel healthcare from 13235 international travelers who sought pretravel consultation at these sites from January 2009 through January 2011. RESULTS: The destinations and itineraries of Global TravEpiNet travelers differed from those of the overall population of US international travelers. The majority of Global TravEpiNet travelers were visiting low- or lower-middle-income countries, and Africa was the most frequently visited region. Seventy-five percent of travelers were visiting malaria-endemic countries, and 38% were visiting countries endemic for yellow fever. Fifty-nine percent of travelers reported ≥1 medical condition. Atovaquone/proguanil was the most commonly prescribed antimalarial drug, and most travelers received an antibiotic for self-treatment of travelers' diarrhea. Hepatitis A and typhoid were the most frequently administered vaccines. CONCLUSIONS: Data from Global TravEpiNet provide insight into the characteristics and pretravel healthcare of US international travelers who are at increased risk of travel-associated illness due to itinerary, purpose of travel, or existing medical conditions. Improved understanding of this epidemiologically significant population may help target risk-reduction strategies and interventions to limit the spread of infections related to global travel. |
A randomized trial of a behavioral intervention for black MSM: the DiSH study
Koblin BA , Bonner S , Powell B , Metralexis P , Egan JE , Patterson J , Xu G , Hoover DR , Goodman K , Chin J , Tieu HV , Spikes P . AIDS 2012 26 (4) 483-8 OBJECTIVE: To test a new behavioral intervention for black MSM in reducing sexual risk and increasing social support and intentions to use condoms. DESIGN: A single-site, unblinded randomized trial in New York City with 3-month follow-up. METHODS: Participants (n=283) reporting at least two sexual partners and unprotected anal intercourse with a man in the past 3 months were enrolled and randomized to a social-cognitive theory-based intervention or control comparison. Men in the intervention group participated in five 2-h group sessions focused on creating a group environment with sexual risk-reduction information and exercises woven into joint meal preparation and sharing activities, while exploring self-efficacy perceptions and outcome expectancies. Intervention (n=142) and control (n=141) groups received standard HIV counseling and testing at baseline. RESULTS: No significant differences were found between study arms at 3 months in number of male partners, number of unprotected anal intercourse partners, proportion reporting unprotected sex, number of acts protected by condoms, self-efficacy, condom attitudes, condom intentions, social isolation and psychological distress. In both arms combined, declines from baseline to 3 months were observed in sexual risk behaviors, social isolation and psychological distress, whereas self-efficacy, condom attitudes and condom intentions improved. CONCLUSION: As the HIV epidemic continues to have a dramatic impact on black MSM in the USA, the urgency to design innovative interventions continues. |
Regular use of a home blood pressure monitor by hypertensive adults - HealthStyles, 2005 and 2008
Ayala C , Tong X , Keenan NL . J Clin Hypertens (Greenwich) 2012 14 (3) 172-7 The authors analyzed HealthStyles surveys 2005 and 2008 combined to assess the prevalence of regular home blood pressure monitor (HBPM) use among hypertensive adults. All data were self-reported. The authors calculated odds ratios (ORs) of regular HBPM use and relative percent change (RPC) in the use of HBPM between the 2 survey years. There were 3739 (32.6%) hypertensives in the 2 survey years combined. Based on the self-reported data, the proportion of hypertensives who regularly used an HBPM was 43.2%. Male sex, age, race/ethnicity, household income, and education were all associated with differences in the prevalence of regular HBPM use. Patients 65 years and older (OR, 2.38; 95% confidence interval [CI], 1.49-3.81) were significantly more likely to be regular HBPM users than those 18 to 34 years. Non-Hispanic blacks were significantly less likely (OR, 0.69; 95% CI, 0.55-0.86) to be regular HBPM users than non-Hispanic whites. From 2005 to 2008, the RPC in regular HBPM use was 14.2% (from 40.1% to 45.8%); the largest RPCs were for the 3 youngest age groups, men, non-Hispanic blacks, and those with a household income of $40,000 to 59,900. Because HBPM has been demonstrated to aid in hypertension control, health care professionals should promote its use especially among hypertensives who are younger, non-Hispanic blacks, Hispanics, or with a lower income. |
The association of depression, risky sexual behaviours and herpes simplex virus type 2 in adults in NHANES, 2005-2008
Pratt LA , Xu F , McQuillan GM , Robitz R . Sex Transm Infect 2012 88 (1) 40-4 OBJECTIVES: Depression has been linked to risky sexual behaviours in adolescents, but there is little research among adults. The goal of this analysis was to examine the associations between current depression and self-reported risky sexual behaviours in a nationally representative sample of US adults aged 20-59 years. The authors also examined the association between depression and infection with herpes simplex virus type 2 (HSV-2), a biological marker of risky sexual behaviours. METHODS: The authors used data from the 2005-2008 National Health and Nutrition Examination Surveys. Current depression was measured by the Patient Health Questionnaire-9. Antibodies to HSV-2 were tested using the enzymatic immunodot assay. The authors used logistic regression to examine the associations controlling for socio-demographic variables. RESULTS: Among 5273 adults aged 20-59 years, 7% had depression, 36% reported 10 or more lifetime sex partners, 15% had two or more past-year sex partners and 13% had first sex before 15 years of age. Persons with each of the risky sexual behaviours were more likely to have depression than those without. In stratified analyses, risky sexual behaviours were associated with depression in women but not in men. Among 3940 adults aged 20-49 years, 19% had HSV-2 infection. Persons with HSV-2 infection were more likely to have depression (OR 2.1, 95% CI 1.5 to 2.9). CONCLUSIONS: Risky sexual behaviour is related to current depression in adult women. Healthcare providers should be aware of this association and its potential implications in order to deliver better care for patients with depression or sexually transmitted infections. |
Associations between adverse childhood experiences, psychological distress, and adult alcohol problems
Strine TW , Dube SR , Edwards VJ , Prehn AW , Rasmussen S , Wagenfeld M , Dhingra S , Croft JB . Am J Health Behav 2012 36 (3) 408-23 OBJECTIVE: To examine the mediating role of psychological distress on the relationship between adverse childhood experiences and adult alcohol problems by gender. METHODS: Linear and logistic regression analyses were conducted on 7279 Kaiser-Permanente members, aged >18 years. RESULTS: Psychological distress mediated significant proportions of alcohol problems associated with childhood emotional abuse and neglect, physical abuse and neglect, mental illness in the household, parental separation or divorce, sexual abuse, and household drug use among women and mental illness in the household, emotional neglect, physical abuse, household drug use, and sexual abuse among men. CONCLUSION: It may be important to identify early childhood trauma and adult psychological distress in programs that focus on reducing alcohol abuse. |
Correlates of bisexual behaviors among men who have sex with men in El Salvador
Kim EJ , Creswell J , Guardado ME , Shah N , Kim AA , Nieto AI , de Maria Hernandez-Ayala F , Monterroso E , Paz-Bailey G . AIDS Behav 2012 17 (4) 1279-87 Bisexual behaviors may increase transmission pathways of HIV and sexually transmitted infections (STIs) from a higher prevalence group to lower prevalence groups in El Salvador. In 2008, men who have sex with men (MSM) were recruited in San Salvador and San Miguel using respondent driven sampling. Participants were interviewed and tested for HIV and STIs. Sixteen seeds and 797 MSM participated; 34.9% in San Salvador and 58.8% in San Miguel reported bisexual behavior. Bisexual behavior was associated with drug use (adjusted odds ratio (AOR) = 2.57, 95% CI: 1.30-5.06) and insertive anal sex (AOR = 5.45, 95% CI: 3.01-9.87), and inversely associated with having a stable male partner (AOR = 0.47, 95% CI: 0.26-0.84) and disclosing MSM behavior to family (AOR = 0.41, 95% CI: 0.22-0.75). Bisexual behavior was associated with risk behaviors with male and female partners that may be associated with HIV and STI transmission. Bisexual men displayed a distinct identity calling for tailored interventions. |
Novel genetic variation identified at fixed loci in ORF62 of the Oka varicella vaccine and in a case of vaccine-associated herpes zoster.
Quinlivan ML , Jensen NJ , Radford KW , Schmid DS . J Clin Microbiol 2012 50 (5) 1533-8 The live attenuated Oka varicella vaccine (vOka), derived from clade 2 wild type (wt) virus, pOka, is used for routine childhood immunization in several countries including the United States (US), causing dramatic declines in varicella incidence. vOka can cause varicella, establish latency and reactivate to cause herpes zoster (HZ). Three loci in varicella-zoster virus (VZV) open reading frame (ORF) 62 (106262, 107252, 108111) are used to distinguish vOka from wt VZV. A 4(th) position (105705) is also fixed for the vOka allele in nearly all vaccine batches. These 4 positions and two vOka mutations (106710 & 107599) reportedly absent from Varivax were analyzed on Varivax-derived ORF62 TOPO TA clones. The wt allele was detected at positions 105705 and 107252 on 3% and 2% of clones, respectively, but was absent at positions 106262 and 108111. Position 106710 was fixed for the wt allele whereas the vOka allele was present on 18.4% of clones at position 107599. We also evaluated the 4 vOka markers in an isolate obtained from a case of vaccine HZ. The isolate carried the vOka allele at positions 105705, 106262 and 108111. However, at position 107252 the wt allele was present. Thus, all of the ORF62 vOka markers previously regarded as fixed occur as the wt allele in a small percentage of vOka strains. Characterization of all four vOka markers in ORF62 and the Clade 2 subtype marker in ORF38 is now necessary to confirm vOka adverse events. |
Febrile seizures after 2010-2011 influenza vaccine in young children, United States: a vaccine safety signal from the vaccine adverse event reporting system.
Leroy Z , Broder K , Menschik D , Shimabukuro T , Martin D . Vaccine 2012 30 (11) 2020-3 During the 2010-2011 influenza season, the Centers for Disease Control and Prevention and the Food and Drug Administration conducted enhanced vaccine safety monitoring for possible febrile seizures in all trivalent influenza vaccine (TIV) products in the United States using the Vaccine Adverse Event Reporting System (VAERS). We used Empirical Bayesian data mining techniques to assess disproportionate reporting after TIV and reviewed febrile seizure reports in children aged <5 years. On November 23, 2010, the combination of the coding term "febrile convulsion" and the Fluzone((R)) TIV product exceeded a predetermined threshold in the VAERS database. By December 10, we confirmed 43 reports of febrile seizure following TIV in children aged 6-23 months. Clinical features of most reports were consistent with typical uncomplicated febrile seizures, and all children recovered. Further epidemiologic assessment of a possible association between TIV and febrile seizures was undertaken in a separate, population-based vaccine safety monitoring system. |
Support for seasonal influenza vaccination requirements among US healthcare personnel
Maurer J , Harris KM , Black CL , Euler GL . Infect Control Hosp Epidemiol 2012 33 (3) 213-21 OBJECTIVE: To measure support for seasonal influenza vaccination requirements among US healthcare personnel (HCP) and its associations with attitudes regarding influenza and influenza vaccination and self-reported coverage by existing vaccination requirements. DESIGN: Between June 1 and June 30, 2010, we surveyed a sample of US HCP ([Formula: see text]) recruited using an existing probability-based online research panel of participants representing the US general population as a sampling frame. SETTING: General community. PARTICIPANTS: Eligible HCP who (1) reported having worked as medical doctors, health technologists, healthcare support staff, or other health practitioners or who (2) reported having worked in hospitals, ambulatory care facilities, long-term care facilities, or other health-related settings. METHODS: We analyzed support for seasonal influenza vaccination requirements for HCP using proportion estimation and multivariable probit models. RESULTS: A total of 57.4% (95% confidence interval, 53.3%-61.5%) of US HCP agreed that HCP should be required to be vaccinated for seasonal influenza. Support for mandatory vaccination was statistically significantly higher among HCP who were subject to employer-based influenza vaccination requirements, who considered influenza to be a serious disease, and who agreed that influenza vaccine was safe and effective. CONCLUSIONS: A majority of HCP support influenza vaccination requirements. Moreover, providing HCP with information about the safety of influenza vaccination and communicating that immunization of HCP is a patient safety issue may be important for generating staff support for influenza vaccination requirements. |
Persistence of hepatitis A vaccine induced seropositivity in infants and young children by maternal antibody status: 10-year follow-up
Sharapov UM , Bulkow LR , Negus SE , Spradling PR , Homan C , Drobeniuc J , Bruce M , Kamili S , Hu DJ , McMahon BJ . Hepatology 2012 56 (2) 516-22 Persistence of seropositivity conferred by hepatitis A vaccine administered to children under 2 years of age is unknown and passively transferred maternal antibodies to hepatitis A virus (maternal anti-HAV) may lower the infant's immune response to the vaccine. Infants and young children (N=197) were randomized into three groups to receive a two dose hepatitis A vaccine (HAVRIX, GlaxoSmithKline; 720 EL.U. in 0.5 ml): group 1 at 6 and 12 months, group 2 at 12 and 18 months, and group 3 at 15 and 21 months of age; within each group infants were randomized by maternal anti-HAV status. Anti-HAV levels were measured at 1 and 6 months, and at 3, 5, 7 and 10 years after second dose of hepatitis A vaccination. Children in all groups had evidence of seroprotection (>10 mIU/mL) at 1 month after dose 2. At 10 years, all children retained seroprotective anti-HAV levels except for only 7% and 11% of children in group 1 born to anti-HAV negative and anti-HAV positive mothers, respectively and 4% of group 3 children born to anti-HAV negative mothers. At 10 years, children born to anti-HAV-negative mothers in Group 3 had highest geometric mean concentration (GMC) (97 mIU/mL, 95% CI: 71-133) and children born to anti-HAV-positive mothers in Group 1 had lowest GMC (29 mIU/mL, 95% CI: 20, 4052). Anti-HAV levels through 10 years of age correlated with initial peak anti-HAV levels (tested at 1 month after second dose). CONCLUSION: The seropositivity induced by hepatitis A vaccine given to children < 2 years of age persists for at least 10 years regardless of presence of maternal anti-HAV. (HEPATOLOGY 2012.). |
Prenatal care providers and influenza prevention and treatment: lessons from the field
Mersereau PW , Layton CM , Smith LR , Kendrick JS , Mitchell EW , Amoozegar JB , Williams JL . Matern Child Health J 2012 16 (2) 479-85 To better understand the knowledge, attitudes, and behaviors of providers regarding influenza infection and vaccination in pregnancy, fourteen focus groups were conducted among 92 providers in Atlanta, GA; Dallas, TX; and Portland, OR in late 2009. NVivo 8.0 was used for analysis. Most providers had no experience with pregnant women severely affected by influenza. Many perceived the 2009 H1N1 pandemic to be limited and mild. Providers knew that pregnant women should receive the 2009 H1N1 vaccine and reported plans to vaccinate more patients than the previous season. Most knew CDC guidelines for antiviral treatment and prophylaxis, but some reported hesitancy with presumptive treatment. Although awareness of influenza's potential to cause severe illness in pregnant women was observed, providers' experience and comfort with influenza prevention and treatment was suboptimal. Sustained efforts to educate prenatal care providers about influenza in pregnancy through trusted channels are critical. |
Impact of integration of hygiene kit distribution with routine immunizations on infant vaccine coverage and water treatment and handwashing practices of Kenyan mothers
Briere EC , Ryman TK , Cartwright E , Russo ET , Wannemuehler KA , Nygren BL , Kola S , Sadumah I , Ochieng C , Watkins ML , Quick R . J Infect Dis 2012 205 Suppl 1 S56-64 Integration of immunizations with hygiene interventions may improve use of both interventions. We interviewed 1361 intervention and 1139 comparison caregivers about hygiene practices and vaccination history, distributed water treatment and hygiene kits to caregivers during infant vaccination sessions in intervention clinics for 12 months, and conducted a followup survey of 2361 intervention and 1033 comparison caregivers. We observed significant increases in reported household water treatment (30% vs 44%, P < .0001) and correct handwashing technique (25% vs 51%, P < .0001) in intervention households and no changes in comparison households. Immunization coverage improved in both intervention and comparison infants (57% vs 66%, P = .04; 37% vs 53%, P < .0001, respectively). Hygiene kit distribution during routine immunizations positively impacted household water treatment and hygiene without a negative impact on vaccination coverage. Further study is needed to assess hygiene incentives, implement alternative water quality indicators, and evaluate the impact of this intervention in other settings. |
Integration of routine vaccination and hygiene interventions: a comparison of 2 strategies in Kenya
Ryman TK , Briere EC , Cartwright E , Schlanger K , Wannemuehler KA , Russo ET , Kola S , Sadumah I , Nygren BL , Ochieng C , Quick R , Watkins ML . J Infect Dis 2012 205 Suppl 1 S65-76 BACKGROUND: Hygiene interventions reduce child mortality from diarrhea. Vaccination visits provide a platform for delivery of other health services but may overburden nurses. We compared 2 strategies to integrate hygiene interventions with vaccinations in Kenya's Homa Bay district, 1 using community workers to support nurses and 1 using nurses. METHODS: Homa Bay was divided into 2 geographical areas, each with 9 clinics. Each area was randomly assigned to either the nurse or community-assisted strategy. At infant vaccination visits hygiene kits were distributed by the nurse or community member. Surveys pre- and post-intervention, measured hygiene indicators and vaccination coverage. Interviews and focus groups assessed acceptability. RESULTS: Between April 2009 and March 2010, 39,158 hygiene kits were distributed. Both nurse and community-assisted strategies were well-accepted. Hygiene indicators improved similarly in nurse and community sites. However, residual chlorine in water changed in neither group. Vaccination coverage increased in urban areas. In rural areas coverage either remained unchanged or increased with 1 exception (13% third dose poliovirus vaccine decrease). CONCLUSIONS: Distribution of hygiene products and education during vaccination visits was found to be feasible using both delivery strategies. Additional studies should consider assessing the use of community members to support integrated service delivery. |
Adherence to expanded influenza immunization recommendations among primary care providers
O'Leary ST , Crane LA , Wortley P , Daley MF , Hurley LP , Dong F , Stokley S , Babbel CI , Seewald L , Gahm C , Dickinson LM , Kempe A . J Pediatr 2012 160 (3) 480-486 e1 OBJECTIVE: To assess practices regarding the expanded Advisory Committee on Immunization Practices (ACIP) recommendations for influenza vaccination in children among US pediatricians and family medicine physicians (FMs) and strategies to promote vaccination. STUDY DESIGN: We administered a survey between July and October 2009 to 416 pediatricians and 424 FMs from nationally representative networks. RESULTS: The response rate was 75% (79% pediatricians, 70% FMs). FMs were less likely than pediatricians to report adherence to ACIP recommendations (35% vs 65%; adjusted risk ratio [RR], 0.60; 95% CI, 0.50-0.72). Most physicians (89% pediatricians and 89% FMs) reported using posters or pamphlets to encourage influenza vaccination, and 57% pediatricians and 41% FMs reported offering after hours dedicated influenza vaccination clinics. Only 23% pediatricians and 14% FMs reported providing written, telephone, or e-mail reminders to all children. Having dedicated influenza vaccination clinics after hours or weekends was associated with routine vaccination of all children (adjusted RR, 1.33; 95% CI, 1.15-1.57). CONCLUSION: In the first year of the expanded ACIP recommendations to immunize all eligible children against influenza, two-thirds of pediatricians and one-half of FMs reported adherence, although less than one-quarter were actively engaging in reminder/recall efforts. Practices that adhered to the ACIP recommendations were more likely to put a substantial effort into promoting vaccination opportunities. |
Bridging the gap between data and public health needs. In the heat of a signal: responding to a vaccine safety signal for febrile seizures after 2010-11 influenza vaccine in young children, United States
Broder KR , Martin DB , Vellozzi C . Vaccine 2012 30 (11) 2032-4 In the middle of the 2010–11 influenza season, public health | officials at the Centers for Disease Control and Prevention (CDC) | and the Food and Drug Administration (FDA) faced a dilemma. | For the first time since data have been collected in the United | States, a signal for an increased risk of febrile seizures after the | current season’s trivalent inactivated influenza vaccine (TIV) was | detected in young children in the two main US vaccine safety | surveillance systems: the Vaccine Adverse Event Reporting System (VAERS) (for the Fluzone® product) [1] and the Vaccine Safety | Datalink (VSD) [2]. VAERS data suggested the febrile seizure cases | were mostly in children younger than age 2 years [1], while the | VSD signal was in the 6–59 month age group [2]. As more data | became available in the VSD, we learned that the increased risk | might be primarily occurring in young children who had received | TIVconcomitantly with 13-valent pneumococcal conjugate vaccine | (PCV13) [2]. In the midst of the scientific uncertainty surrounding this safety signal, CDC and FDA strove to provide the public | with timely, accurate risk data. Influenza vaccine has substantial | benefits in young children [3]. We did not want to create confusion by presenting preliminary risk data that might, unnecessarily | limit uptake of influenza vaccine in the pediatric population. We | wanted the public to know that this signal had been identified and | that physicians and other scientists were assessing whether there | was truly an increased risk. CDC and FDA were also considering | any potential impact on vaccine recommendations or the product labeling. Findings from the VAERS and VSD studies on febrile | seizures after 2010–11 TIV are described elsewhere in this issue | of the journal [1,2]. Here, we present a glimpse into the vaccine | safety signal response process and highlight decisions CDC and | FDA faced during the “heat of the signal” as events were rapidly | unfolding |
Building on success--potential to improve coverage of multiple health interventions through integrated delivery with routine childhood vaccination
Anand A , Luman ET , O'Connor PM . J Infect Dis 2012 205 Suppl 1 S28-39 BACKGROUND: Integrating delivery of nonvaccine interventions with childhood vaccinations has been suggested as a mechanism to accelerate progress toward Millennium Development Goals. METHODS: Demographic health surveys from 28 sub-Saharan African countries were analyzed to determine potential coverage with 5 nonvaccine interventions that could be delivered to children, mothers, and families during routine infant vaccinations. Potential coverage levels were calculated among households with children aged 12-23 months, based on existing coverage of interventions and vaccinations. FINDINGS: Most (>60%) children in families that had not received nonvaccine interventions had been vaccinated. If nonvaccine interventions could be delivered with vaccinations, the median percentage of households owning a bed net could increase from 46% to 92% and those with improved or treated sources of water from 55% to 91%. The median percentage of children who had received vitamin A supplementation could increase from 66% to 90%. Mothers who have been tested for human immunodeficiency virus could increase from 16% to 86%. CONCLUSIONS: In Africa, vaccination programs could provide a platform to substantially increase coverage of nonvaccine interventions. Studies are needed to investigate programmatic approaches to optimize the selection, adoption, and long-term utilization of these interventions and to assess the impact on vaccination and other intervention coverage. |
Building on success: should other health services be integrated into the immunization platform?
Luman ET , Dietz V , Andrus JK , Binkin N . J Infect Dis 2012 205 Suppl 1 NP This supplement was sponsored by the Global Immunization Division, U.S. Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC, WHO, or UNICEF. |
Is spinal cord injury a new emerging risk factor for stroke?
Kuklina EV , Kryscio RJ . Neurology 2012 78 (14) 1034-5 Progress in the treatment of spinal cord injury (SCI) has increased patient survival drastically over the last 50 years.(1) An estimated 232,000 to 316,000 persons in the United States live with SCI.(2) Fortunately, mortality in the first 2 years after injury has declined 40% over the last 3 decades(3); in contrast, mortality after the first 2 years postinjury remains static. Hence, prolonging life and enhancing quality of life for persons with SCI becomes a priority. Currently, cardiovascular disease (CVD) is second only to pulmonary conditions as the chief cause of mortality in patients with SCI.(2). |
Development of a novel genus-specific real-time PCR assay for detection and differentiation of Bartonella species and genotypes.
Diaz MH , Bai Y , Malania L , Winchell JM , Kosoy MY . J Clin Microbiol 2012 50 (5) 1645-9 The genus Bartonella includes numerous species with varied host association, including several that infect humans. Development of a molecular diagnostic method capable of detecting the diverse repertoire of Bartonella species while maintaining genus specificity has been a challenge. We developed a novel real-time PCR assay targeting a 301 bp region of the ssrA gene of Bartonella and demonstrated specific amplification in over 30 Bartonella species, subspecies, and strains. Subsequent analysis of ssrA sequences was sufficient to discriminate Bartonella species and provided phylogenetic data consistent with that of gltA, a commonly used gene for differentiating Bartonella genotypes. Using this assay we identified Bartonella DNA in 29% and 47% of blood specimens from elk in Wyoming and cattle in the Republic of Georgia, respectively. Sequence analysis of a subset of genotypes from elk specimens revealed a cluster most closely related to B. capreoli, and genotypes from cattle were identified as B. bovis, both Bartonella species commonly found in wild and domestic ruminants. Considering the widespread geographic distribution and infectivity potential to a variety of hosts, this assay may be an effective diagnostic method for identification of Bartonella infections in humans and have utility in Bartonella surveillance studies. |
A real-time PCR assay for HPV52 detection and viral load quantification.
Onyekwuluje JM , Steinau M , Swan DC , Unger ER . Clin Lab 2012 58 61-6 BACKGROUND: Human papillomavirus (HPV) 52 is one of the most frequent high risk HPV types found in cervical and anal infections. Reliable and well characterized methods for HPV 52 detection are therefore of great importance. Unfortunately one of the most widely used commercially available HPV typing assays, the Roche Linear Array (LA), detects type 52 only through its XR probe which cross-reacts with types 33, 35 and 58 and fails to give unambiguous detection of HPV 52. METHODS: To address this problem a real-time TaqMan PCR assay for HPV 52 targeting the E6/E7 region was developed and validated, which can be applied as robust duplex assay simultaneously detecting beta-globin as genomic control and reference or as highly sensitive single target detection assay. RESULTS: Optimized primer and probe concentrations produced linear PCR amplifications over seven logs of targets (10(1) - 10(7)). The detection limit for HPV 52 was reproducibly at 10 copies per reaction for the duplex assay format and 5 copies for the single-plex format. The assay was very type-specific and no amplification signal was observed with 10(7) copies of the related HPV33, 35, and 58 DNA. Of 89 samples that tested unambiguously positive for HPV 52 in the LA, 75 were confirmed in the duplex format and 88 in the single-plex format. An additional 100 samples negative for HPV 52 in LA were all negative in both HPV 52 real-time PCR assay formats. CONCLUSIONS: These results indicate 92.6% and 99.5% accuracy relative to LA for the duplex and single-plex formats, respectively. In ongoing testing of 18,484 from various studies, 10.8% required the HPV52 TaqMan assay to unequivocally determine the status. Including the HPV 52 duplex assay provides the ability to monitor variations in the cell yield in various methods of sample collection and processing. This additional information is useful in QC monitoring of epidemiologic studies. |
Systemic immune cell response in rats after pulmonary exposure to manganese-containing particles collected from welding aerosols
Antonini JM , Zeidler-Erdely PC , Young SH , Roberts JR , Erdely A . J Immunotoxicol 2012 9 (2) 184-92 Welding fume inhalation affects the immune system of exposed workers. Manganese (Mn) in welding fume may induce immunosuppressive effects. The goal was to determine if Mn in welding fume alters immunity by reducing the number of circulating total leukocytes and specific leukocyte sub-populations. Sprague-Dawley rats were treated by intratracheal instillation (ITI) with either a single dose (2.00 mg/rat) or repeated doses (0.125 or 2.00 mg/rat for 7 weeks) with welding fumes that contained different levels of Mn. Additional rats were treated by ITI once a week for 7 weeks with the two doses of manganese chloride (MnCl(2)). Bronchoalveolar lavage was performed to assess lung inflammation. Also, whole blood was recovered, and the number of circulating total leukocytes, as well as specific lymphocyte subsets, was determined by flow cytometry. The welding fume highest in Mn content significantly increased lung inflammation, injury, and production of inflammatory cytokines and chemokines compared to all other treatment groups. In addition, the same group expressed significant decreases in the number of circulating CD4(+) and CD8(+) T-lymphocytes after a single exposure, and significant reductions in the number of circulating total lymphocytes, primarily CD4(+) and CD8(+) T-lymphocytes, after repeated exposures (compared to control values). Repeated MnCl(2) exposure led to a trend of a reduction (but not statistically significant) in circulating total lymphocytes, attributable to the changes in the CD4(+) T-lymphocyte population levels. The welding fume with the lower concentration of Mn had no significant effect on the numbers of blood lymphocytes and lymphocyte subsets compared to control values. Evidence from this study indicates that pulmonary exposure to certain welding fumes cause decrements in systemic immune cell populations, specifically circulating T-lymphocytes, and these alterations in immune cell number are not dependent exclusively on Mn, but likely a combination of other metals present in welding fume. |
A message from the laboratory community to the National Cholesterol Education Program Adult Treatment Panel IV
Vesper HW , Wilson PW , Rifai N . Clin Chem 2012 58 (3) 523-7 The National Cholesterol Education Program (NCEP)5. Adult Treatment Panel IV (ATP IV) is poised to release its guidelines on the detection, evaluation, and treatment of high blood cholesterol in adults for comments by the scientific and medical communities. We briefly summarize the current status of lipid and lipoprotein testing in the US. | Since its inception in 1985, the NCEP has recognized the value of accurate and precise lipid and lipoprotein testing for the effective implementation of its mission to lower morbidity and mortality from coronary heart disease in the US by reducing the percentage of Americans with high blood cholesterol. The NCEP Laboratory Standardization Panel and the Working Group on Lipoprotein Measurement were established to assess the status of lipid and lipoprotein testing, develop means to improve these measurements, and create analytical performance goals to meet clinical needs. This program provided a comprehensive approach to the measurement of total cholesterol, triglycerides, HDL cholesterol (HDL-C) and LDL cholesterol (LDL-C). The recommendations developed by this panel and working group were based on data and information generated by the CDC Lipid Standardization Program. The latter program also helped in implementing the NCEP recommendations by providing for standardization of lipid measurements performed for patient care and ensuring accurate measurements in research studies (1, 2). The resulting improvements in the accuracy and precision of these laboratory measurements allowed the effective implementation of NCEP guidelines and enabled the monitoring of its success (3, 4). |
Defective calcium inactivation causes long QT in obese insulin-resistant rat
Lin YC , Huang J , Kan H , Castranova V , Frisbee JC , Yu HG . Am J Physiol Heart Circ Physiol 2012 302 (4) H1013-22 The majority of diabetic patients who are overweight or obese die of heart disease. We suspect that the obesity-induced insulin resistance may lead to abnormal cardiac electrophysiology. We tested this hypothesis by studying an obese insulin-resistant rat model, the obese Zucker rat (OZR). Compared with the age-matched control, lean Zucker rat (LZR), OZR of 16-17 wk old exhibited an increase in QTc interval, action potential duration, and cell capacitance. Furthermore, the L-type calcium current (I(CaL)) in OZR exhibited defective inactivation and lost the complete inactivation back to the closed state, leading to increased Ca(2+) influx. The current density of I(CaL) was reduced in OZR, whereas the threshold activation and the current-voltage relationship of I(CaL) were not significantly altered. L-type Ba(2+) current (I(BaL)) in OZR also exhibited defective inactivation, and steady-state inactivation was not significantly altered. However, the current-voltage relationship and activation threshold of I(BaL) in OZR exhibited a depolarized shift compared with LZR. The total and membrane protein expression levels of Cav1.2 [pore-forming subunit of L-type calcium channels (LTCC)], but not the insulin receptors, were decreased in OZR. The insulin receptor was found to be associated with the Cav1.2, which was weakened in OZR. The total protein expression of calmodulin was reduced, but that of Cavbeta2 subunit was not altered in OZR. Together, these results suggested that the 16- to 17-wk-old OZR has 1) developed cardiac hypertrophy, 2) exhibited altered electrophysiology manifested by the prolonged QTc interval, 3) increased duration of action potential in isolated ventricular myocytes, 4) defective inactivation of I(CaL) and I(BaL), 5) weakened the association of LTCC with the insulin receptor, and 6) decreased protein expression of Cav1.2 and calmodulin. These results also provided mechanistic insights into a remodeled cardiac electrophysiology under the condition of insulin resistance, enhancing our understanding of long QT associated with obese type 2 diabetic patients. |
Development and certification of a standard reference material for vitamin D metabolites in human serum
Phinney KW , Bedner M , Tai SS , Vamathevan VV , Sander LC , Sharpless KE , Wise SA , Yen JH , Schleicher RL , Chaudhary-Webb M , Pfeiffer CM , Betz JM , Coates PM , Picciano MF . Anal Chem 2012 84 (2) 956-62 The National Institute of Standards and Technology (NIST), in collaboration with the National Institutes of Health's Office of Dietary Supplements (NIH-ODS), has developed a Standard Reference Material (SRM) for the determination of 25-hydroxyvitamin D [25(OH)D] in serum. SRM 972 Vitamin D in Human Serum consists of four serum pools with different levels of vitamin D metabolites and has certified and reference values for 25(OH)D(2), 25(OH)D(3), and 3-epi-25(OH)D(3). Value assignment of this SRM was accomplished using a combination of three isotope-dilution mass spectrometry approaches, with measurements performed at NIST and at the Centers for Disease Control and Prevention (CDC). Chromatographic resolution of the 3-epimer of 25(OH)D(3) proved to be essential for accurate determination of the metabolites. |
Efficient linking of birth certificate and newborn screening databases for laboratory investigation of congenital cytomegalovirus infection and preterm birth: Florida, 2008
DePasquale JM , Freeman K , Amin MM , Park S , Rivers S , Hopkins R , Cannon MJ , Dy B , Dollard SC . Matern Child Health J 2012 16 (2) 486-94 The objectives of this study are (1) to design an accurate method for linking newborn screening (NBS) and state birth certificate databases to create a de-identified study database; (2) To assess maternal cytomegalovirus (CMV) seroprevalence by measuring CMV IgG in newborn dried blood spots; (3) To assess congenital CMV infection among newborns and possible association with preterm birth. NBS and birth databases were linked and patient records were de-identified. A stratified random sample of records based on gestational age was selected and used to retrieve blood spots from the state NBS laboratory. Serum containing maternal antibodies was eluted from blood spots and tested for the presence of CMV IgG. DNA was extracted from blood spots and tested for the presence of CMV DNA. Analyses were performed with bivariable and multivariable logistic regression models. Linkage rates and specimen collection exceeded 98% of the total possible yielding a final database with 3,101 newborn blood spots. CMV seroprevalence was 91% among Black mothers, 83% among Hispanic mothers, 59% among White mothers, and decreased with increasing amounts of education. The prevalence of CMV infection in newborns was 0.45% and did not vary significantly by gestational age. Successful methods for database linkage, newborn blood spots collection, and de-identification of records can serve as a model for future congenital exposure surveillance projects. Maternal CMV seroprevalence was strongly associated with race/ethnicity and educational level. Congenital CMV infection rates were lower than those reported by other studies and lacked statistical power to examine associations with preterm birth. |
Improving adolescent health through interventions targeted to parents and other caregivers: a recommendation
Community Preventive Services Task Force . Am J Prev Med 2012 42 (3) 327-8 SUMMARY: The Community Preventive Services Task Force recommends person-to-person interventions intended to modify adolescents' risk and protective behaviors by improving their caregivers' parenting skills, on the basis of sufficient evidence of effectiveness in reducing adolescent risk behaviors. These interventions, conducted face-to-face or by telephone, occur outside of clinical settings. |
Characteristics of suicides among US Army active duty personnel in 17 US states from 2005 to 2007
Logan J , Skopp NA , Karch D , Reger MA , Gahm GA . Am J Public Health 2012 102 S40-S44 Suicides are increasing among active duty US Army soldiers. To help focus prevention strategies, we characterized 56 US Army suicides that occurred from 2005 to 2007 in 17 US states using 2 large-scale surveillance systems. We found that intimate partner problems and military-related stress, particularly job stress, were common among decedents. Many decedents were also identified as having suicidal ideation, a sad or depressed mood, or a recent crisis before death. Focusing efforts to prevent these forms of stress might reduce suicides among soldiers. |
An analysis of reservoir conditions and responses in longwall panel overburden during mining and its effect on gob gas well performance
Schatzel SJ , Karacan CÖ , Dougherty H , Goodman GVR . Eng Geol 2012 127 65-74 NIOSH conducted a cooperative research study to provide direct measurements of changing reservoir conditions in longwall panel overburden. The field measurements documented changes in permeabilities, methane concentrations, fluid pressures, and the effects of adjacent gob gas ventholes (GGVs) on NIOSH boreholes drilled in the study panel. Three different stratigraphic horizons were monitored by the NIOSH boreholes. Results indicated that the gob gas venthole fracture network formed 24 to 46m (80 to 150 ft) ahead of the mining face. Overburden permeabilities within the same overburden test zones were ~1md prior to undermining, increasing to hundreds or thousands of md during undermining. Permeabilities measured seven months after undermining showed additional increases. The relationship between changing reservoir conditions, longwall face position, and surface movement is discussed. Recommendations are made to optimize GGV performance by evaluating changes in subsidence produced by mining, resulting in rock stresses that substantially influence induced fracture permeability. Mechanisms to account for the observed changes in reservoir conditions are reported. |
Consumption of added sugar among U.S. children and adolescents, 2005-2000
Ervin RB , Kit BK , Carroll MD , Ogden CL . NCHS Data Brief 2012 (87) 1-8 The consumption of added sugars, which are sweeteners added to processed and prepared foods, has been associated with measures of cardiovascular disease risk among adolescents, including adverse cholesterol concentrations. Although the percent of daily calories derived from added sugars declined between 1999-2000 and 2007-2008, consumption of added sugars remains high in the diets of Americans. The 2010 Dietary Guidelines recommend limiting total intake of discretionary calories, which include added sugars and solid fats, to 5%-15% of daily caloric intake, yet many Americans continue to exceed these recommendations. This data brief presents results for added sugar consumption among U.S. children and adolescents for 2005-2008. |
Shift work and the incidence of injury among police officers
Violanti JM , Fekedulegn D , Andrew ME , Charles LE , Hartley TA , Vila B , Burchfiel CM . Am J Ind Med 2012 55 (3) 217-27 BACKGROUND: Police officers may be injury prone due to fatigue, erratic work hours, and insufficient sleep. This study explored injury incidence among police officers across shifts. METHODS: Day-to-day shift data from computerized payroll records (1994-2010) were available from a mid-sized urban police department (n=430). Sleep duration, shift activity level, returning to work after days off, and injury incidence over time were also examined. RESULTS: Age-adjusted incidence rate ratio (IRR) for injury on the midnight shift was 72% larger than the day shift (IRR=1.72; 95% CI=1.26-2.36) and 66% larger than the afternoon shift (IRR=1.66; 95% CI=1.23-2.25). Injury incidence for the first day back on the midnight shift was 69% larger than day shift (IRR=1.69; 95% CI=1.23-2.32) and 54% larger than the afternoon shift (IRR=1.54; 95% CI=1.36-1.76). High activity level combined with midnight shift work put officers at increased injury risk (IRR=2.31; P=0.0003). Probability of remaining free of injury was significantly higher for day shift than midnight shift (P< 0.0001). CONCLUSIONS: Higher injury risk was associated with night shift work in police officers. Night shift combined with high work activity was strongly associated with injury risk. There was a significantly higher probability of not being injured on day compared to midnight or afternoon shifts. (Am. J. Ind. Med. 55:217-227, 2012. (c) 2011 Wiley Periodicals, Inc.) |
Musculoskeletal symptoms and associated risk factors in a large sample of Chinese workers in Henan province of China
Yu S , Lu ML , Gu G , Zhou W , He L , Wang S . Am J Ind Med 2012 55 (3) 281-93 OBJECTIVE: To investigate the one-year prevalence of musculoskeletal symptoms and associated risk factors in a large sample of Chinese workers in various industrial settings. METHODS: A total of 5,338 (3,632 males and 1,706 females) workers from 13 companies participated in this study. Musculoskeletal symptoms in different body regions in the previous year and their risk factors were assessed by a self-reported questionnaire. Logistic regression analyses were performed to estimate the individual, work-related physical and psychosocial risk factors for the musculoskeletal symptoms. RESULTS: The most commonly affected body regions among the workers were lower back (59.7%), neck (48.6%), shoulders (38.8%), and wrists (33.5%). Female workers had greater prevalence of musculoskeletal symptoms in the neck, shoulders, and wrists than male workers. Results of multivariate analyses indicated that individual, work-related physical and psychosocial factors were associated with the musculoskeletal symptoms. CONCLUSION: The results suggest that interventions aimed at reducing musculoskeletal symptoms in the Chinese working population should take into account multiple risk areas including individual, physical job characteristics and work-related psychosocial factors. (Am. J. Ind. Med. 55:281-293, 2012. (c) 2011 Wiley Periodicals, Inc.) |
Occupational noise exposure assessment using O*NET and its application to a study of hearing loss in the US general population
Choi YH , Hu H , Tak S , Mukherjee B , Park SK . Occup Environ Med 2012 69 (3) 176-83 OBJECTIVES: Although occupational noise is a well known risk factor for hearing loss, little epidemiological evidence has been reported on its association with hearing loss in the general population, in part, because of the difficulty in exposure assessment. This study introduced a quantitative occupational noise exposure assessment tool using the Occupational Information Network (O*NET) database and evaluated its applicability for epidemiological research using data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. METHODS: The O*NET noise exposure data were assessed by questionnaires across numerous occupations, asking the frequency of exposure to sounds and noise levels that are distracting and uncomfortable (with five possible responses from 'never' to 'every day'). Means of the O*NET noise scores were computed to correspond to NHANES occupational categories and assigned to 3828 adults aged 20-69 years, who participated in the 1999-2004 NHANES. Pure-tone averages (PTA) of hearing thresholds at 0.5, 1, 2 and 4 kHz were computed, and hearing loss was defined as a PTA >25 dB in either ear. Linear and logistic regression models with either continuous or quintiles of the O*NET noise scores were fitted on log-transformed PTA and binary hearing loss, respectively. RESULTS: Noise scores ranged from 1.80 to 4.37 with mean+/-SE of 3.06+/-0.02. After controlling for potential confounders, the highest (vs lowest) noise score quintile had a 22.5% (95% CI 11.0% to 35.2%) increase in PTA, and there was a linear dose-dependent trend across the quintiles of noise scores (p trend<0.0001). The adjusted OR for hearing loss comparing the highest with the lowest noise score quintiles was 2.1 (95% CI 1.2 to 3.6). CONCLUSION: This study suggests that the O*NET noise score is a useful tool for examining occupational noise-induced health effects in the general population in the absence of actual occupational noise exposure assessment data. |
Guidelines for determining probability of causation under the Energy Employees Occupational Illness Compensation Program Act of 2000; revision of guidelines on non-radiogenic cancers. Final rule
Centers for Disease Control and Prevention , Hinnefeld S . Fed Regist 2012 77 (24) 5711-4 In a notice of proposed rulemaking published in the Federal Register on March 21, 2011, the Department of Health and Human Services (HHS) proposed to treat chronic lymphocytic leukemia (CLL) as a radiogenic cancer under the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA) (76 FR 15268). Under this final rule, CLL will be treated as being potentially caused by radiation and hence as potentially compensable under EEOICPA. HHS reverses its decision to exclude CLL from such treatment. |
The identification of a sensitizing component used in the manufacturing of an ink ribbon
Anderson SE , Tapp L , Durgam S , Meade BJ , Jackson LG , Cohen DE . J Immunotoxicol 2012 9 (2) 193-200 Skin diseases including dermatitis constitute approximately 30% of all occupational illnesses, with a high incidence in the printing industry. An outbreak of contact dermatitis among employees at an ink ribbon manufacturing plant was investigated by scientists from the National Institute for Occupational Safety and Health (NIOSH). Employees in the process areas of the plant were exposed to numerous chemicals and many had experienced skin rashes, especially after the introduction of a new ink ribbon product. To identify the causative agent(s) of the occupational dermatitis, the murine local lymph node assay (LLNA) was used to identify the potential of the chemicals used in the manufacture of the ink ribbon to induce allergic contact dermatitis. Follow-up patch testing with the suspected allergens was conducted on exposed employees. Polyvinyl butyral, a chemical component used in the manufacture of the ink ribbon in question and other products, tested positive in the LLNA, with an EC3 of 3.6%, which identifies it as a potential sensitizer; however, no employees tested positive to this chemical during skin patch testing. This finding has implications beyond those described in this report because of occupational exposure to polyvinyl butyral outside of the printing industry. |
A multicenter evaluation of diagnostic tools to define endpoints for programs to eliminate bancroftian filariasis
Gass K , Beau de Rochars MV , Boakye D , Bradley M , Fischer PU , Gyapong J , Itoh M , Ituaso-Conway N , Joseph H , Kyelem D , Laney SJ , Legrand AM , Liyanage TS , Melrose W , Mohammed K , Pilotte N , Ottesen EA , Plichart C , Ramaiah K , Rao RU , Talbot J , Weil GJ , Williams SA , Won KY , Lammie P . PLoS Negl Trop Dis 2012 6 (1) e1479 Successful mass drug administration (MDA) campaigns have brought several countries near the point of Lymphatic Filariasis (LF) elimination. A diagnostic tool is needed to determine when the prevalence levels have decreased to a point that MDA campaigns can be discontinued without the threat of recrudescence. A six-country study was conducted assessing the performance of seven diagnostic tests, including tests for microfilariae (blood smear, PCR), parasite antigen (ICT, Og4C3) and antifilarial antibody (Bm14, PanLF, Urine SXP). One community survey and one school survey were performed in each country. A total of 8,513 people from the six countries participated in the study, 6,443 through community surveys and 2,070 through school surveys. Specimens from these participants were used to conduct 49,585 diagnostic tests. Each test was seen to have both positive and negative attributes, but overall, the ICT test was found to be 76% sensitive at detecting microfilaremia and 93% specific at identifying individuals negative for both microfilariae and antifilarial antibody; the Og4C3 test was 87% sensitive and 95% specific. We conclude, however, that the ICT should be the primary tool recommended for decision-making about stopping MDAs. As a point-of-care diagnostic, the ICT is relatively inexpensive, requires no laboratory equipment, has satisfactory sensitivity and specificity and can be processed in 10 minutes-qualities consistent with programmatic use. Og4C3 provides a satisfactory laboratory-based diagnostic alternative. |
A field trial of alternative targeted screening strategies for Chagas disease in Arequipa, Peru
Hunter GC , Borrini-Mayori K , Ancca Juarez J , Castillo Neyra R , Verastegui MR , Malaga Chavez FS , Cornejo del Carpio JG , Cordova Benzaquen E , Naquira C , Gilman RH , Bern C , Levy MZ . PLoS Negl Trop Dis 2012 6 (1) e1468 BACKGROUND: Chagas disease is endemic in the rural areas of southern Peru and a growing urban problem in the regional capital of Arequipa, population approximately 860,000. It is unclear how to implement cost-effective screening programs across a large urban and periurban environment. METHODS: We compared four alternative screening strategies in 18 periurban communities, testing individuals in houses with 1) infected vectors; 2) high vector densities; 3) low vector densities; and 4) no vectors. Vector data were obtained from routine Ministry of Health insecticide application campaigns. We performed ring case detection (radius of 15 m) around seropositive individuals, and collected data on costs of implementation for each strategy. RESULTS: Infection was detected in 21 of 923 (2.28%) participants. Cases had lived more time on average in rural places than non-cases (7.20 years versus 3.31 years, respectively). Significant risk factors on univariate logistic regression for infection were age (OR 1.02; p=0.041), time lived in a rural location (OR 1.04; p=0.022), and time lived in an infested area (OR 1.04; p=0.008). No multivariate model with these variables fit the data better than a simple model including only the time lived in an area with triatomine bugs. There was no significant difference in prevalence across the screening strategies; however a self-assessment of disease risk may have biased participation, inflating prevalence among residents of houses where no infestation was detected. Testing houses with infected-vectors was least expensive. Ring case detection yielded four secondary cases in only one community, possibly due to vector-borne transmission in this community, apparently absent in the others. CONCLUSIONS: Targeted screening for urban Chagas disease is promising in areas with ongoing vector-borne transmission; however, these pockets of epidemic transmission remain difficult to detect a priori. The flexibility to adapt to the epidemiology that emerges during screening is key to an efficient case detection intervention. In heterogeneous urban environments, self-assessments of risk and simple residence history questionnaires may be useful to identify those at highest risk for Chagas disease to guide diagnostic efforts. |
The impact of neurocysticercosis in California: a review of hospitalized cases
Croker C , Redelings M , Reporter R , Sorvillo F , Mascola L , Wilkins P . PLoS Negl Trop Dis 2012 6 (1) e1480 To assess the burden of neurocysticercosis (NCC) in California we examined statewide hospital discharge data for 2009. There were 304 cases hospitalized with NCC identified (incidence=0.8 per 100,000). Cases were mostly Latino (84.9%), slightly more likely to be male than female (men 57.6%, women 42.4%) with an average age of 43.5 years. A majority of cases were hospitalized in Southern California (72.1%) and many were hospitalized in Los Angeles County (44.7%). Men were more likely than women to have severe disease including hydrocephalus (29.7% vs. 18.6%, p=0.027), resulting in longer hospitalizations (>4 days, 48.0% vs. 32.6%, p=0.007) that were more costly (charge>$40 thousand men=46.9% vs. woman=4.1%, p=0.026). Six deaths were recorded (2.0%). The total of NCC-related hospital charges exceeded $17 million; estimated hospital costs exceeded $5 million. Neurocysticercosis causes appreciable disease and exacts a considerable economic burden in California. |
Integrating climate change adaptation into public health practice: using adaptive management to increase adaptive capacity and build resilience
Hess JJ , McDowell JZ , Luber G . Environ Health Perspect 2012 120 (2) 171-9 BACKGROUND: Climate change is expected to have a range of health impacts, some of which are already apparent. Public health adaptation is imperative, but there has been little discussion of how to increase adaptive capacity and resilience in public health systems. OBJECTIVES: We explored possible explanations for the lack of work on adaptive capacity, outline climate-health challenges that may lie outside public health's coping range, and consider changes in practice that could increase public health's adaptive capacity. METHODS: We conducted a substantive, interdisciplinary literature review focused on climate change adaptation in public health, social learning, and management of socioeconomic systems exhibiting dynamic complexity. DISCUSSION: There are two competing views of how public health should engage climate change adaptation. Perspectives differ on whether climate change will primarily amplify existing hazards, requiring enhancement of existing public health functions, or present categorically distinct threats requiring innovative management strategies. In some contexts, distinctly climate-sensitive health threats may overwhelm public health's adaptive capacity. Addressing these threats will require increased emphasis on institutional learning, innovative management strategies, and new and improved tools. Adaptive management, an iterative framework that embraces uncertainty, uses modeling, and integrates learning, may be a useful approach. We illustrate its application to extreme heat in an urban setting. CONCLUSIONS: Increasing public health capacity will be necessary for certain climate-health threats. Focusing efforts to increase adaptive capacity in specific areas, promoting institutional learning, embracing adaptive management, and developing tools to facilitate these processes are important priorities and can improve the resilience of local public health systems to climate change. |
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