Remote monitoring of inhaled bronchodilator use and weekly feedback about asthma management: an open-group, short-term pilot study of the impact on asthma control
Van Sickle D , Magzamen S , Truelove S , Morrison T . PLoS One 2013 8 (2) e55335 OBJECTIVE: Adequate symptom control is a problem for many people with asthma. We asked whether weekly email reports on monitored use of inhaled, short-acting bronchodilators might improve scores on composite asthma-control measures. METHODS: Through an investigational electronic medication sensor attached to each participant's inhaler, we monitored 4 months' use of inhaled, short-acting bronchodilators. Participants completed surveys, including the Asthma Control Test (ACT), to assess asthma control at entry and monthly thereafter. After the first month, participants received weekly email reports for 3 months. The reports summarized inhaled bronchodilator use during the preceding week and provided suggestions derived from National Asthma Education and Prevention Program (NAEPP) guidelines. Paired t-tests and random-effects mixed models were implemented to assess changes in primary asthma endpoints. RESULTS: Thirty individuals participated in the 4-month study; 29 provided complete asthma control information. Mean age was 36.8 years (range: 19-74 years); 52% of respondents were female. Mean ACT scores were 17.6 (Standard Deviation [SD] = 3.35) at entry and 18.4 (SD = 3.60) at completion of the first month. No significant difference appeared between ACT values at entry and completion of the first month (p = 0.66); however, after participants began receiving email reports and online information about their inhaler use, mean ACT scores increased 1.40 points (95% CI: 0.61, 2.18) for each subsequent study month. Significant decreases occurred in 2-week histories of daytime symptoms (beta = -1.35, 95% CI: -2.65, -0.04) and nighttime symptoms (beta = -0.84, 95% CI: -1.25, -0.44); no significant change in activity limitation (beta = -0.21, 95% CI: -0.69, 0.26) was observed. Participants reported increased awareness and understanding of asthma patterns, level of control, bronchodilator use (timing, location) and triggers, and improved preventive practices. CONCLUSIONS: Weekly email reports and access to online charts summarizing remote monitoring of inhaled bronchodilator frequency and location were associated with improved asthma control and a decline in day-to-day asthma symptoms. |
Sickle cell disease--the American saga
Siddiqi AE , Jordan LB , Parker CS . Ethn Dis 2013 23 (2) 245-8 The transformation of sickle cell disease (SCD) from obscurity in Africa to visibility in America over the past 100 years is intertwined with politics and race relations unique to America.1 Parallel to the development of a conventional scientific understanding of the disease and the evolution of disease control strategies, SCD also developed socio-politically. Initially thought to be a disease exclusively affecting a minority group, it was brought on the political agenda through concerted efforts made primarily by the community that identified closely with the people who suffered from it. The socio-political development that propelled investments in research into the disease’s origins, treatment, and models of care resulted in considerable improvements in life expectancy of people with SCD over the past nine decades.2 | In this article, we explore the timeline of scientific attention to SCD and the published literature, available from various online sources including the National Library of Medicine’s PubMed. In our online search, we used the key words and phrases: sickle cell disease history; history of sickle cell disease in United States; and prevalence of sickle cell disease. References found in retrieved articles and books provided additional sources of information aligned with our search. |
Preventing type 2 diabetes in communities across the U.S.: the National Diabetes Prevention Program
Albright AL , Gregg EW . Am J Prev Med 2013 44 S346-51 There are as many as 79 million people in the U.S. with prediabetes, and their risk of developing type 2 diabetes is four to 12 times higher than it is for people with normal glucose tolerance. Although advances in diabetes treatment are still needed, there is a critical need to implement effective strategies to stem the current and projected growth in new cases of type 2 diabetes. RCTs and translation studies have demonstrated that type 2 diabetes can be prevented or delayed in those at high risk, through a structured lifestyle intervention that can be delivered cost effectively. In order to bring this compelling lifestyle intervention to communities across America, Congress authorized the CDC to establish and lead the National Diabetes Prevention Program. Several aspects of the etiology of type 2 diabetes suggest that strategies addressing both those at high risk and the general population are necessary to make a major impact on the diabetes epidemic. |
World Health Organization regional assessments of the risks of poliovirus outbreaks
Lowther SA , Roesel S , O'Connor P , Landaverde M , Oblapenko G , Deshevoi S , Ajay G , Buff A , Safwat H , Salla M , Tangermann R , Khetsuriani N , Martin R , Wassilak S . Risk Anal 2013 33 (4) 664-79 While global polio eradication requires tremendous efforts in countries where wild polioviruses (WPVs) circulate, numerous outbreaks have occurred following WPV importation into previously polio-free countries. Countries that have interrupted endemic WPV transmission should continue to conduct routine risk assessments and implement mitigation activities to maintain their polio-free status as long as wild poliovirus circulates anywhere in the world. This article reviews the methods used by World Health Organization (WHO) regional offices to qualitatively assess risk of WPV outbreaks following an importation. We describe the strengths and weaknesses of various risk assessment approaches, and opportunities to harmonize approaches. These qualitative assessments broadly categorize risk as high, medium, or low using available national information related to susceptibility, the ability to rapidly detect WPV, and other population or program factors that influence transmission, which the regions characterize using polio vaccination coverage, surveillance data, and other indicators (e.g., sanitation), respectively. Data quality and adequacy represent a challenge in all regions. WHO regions differ with respect to the methods, processes, cut-off values, and weighting used, which limits comparisons of risk assessment results among regions. Ongoing evaluation of indicators within regions and further harmonization of methods between regions are needed to effectively plan risk mitigation activities in a setting of finite resources for funding and continued WPV circulation. |
Lifting the lid on toilet plume aerosol: a literature review with suggestions for future research
Johnson DL , Mead KR , Lynch RA , Hirst DV . Am J Infect Control 2013 41 (3) 254-8 BACKGROUND: The potential risks associated with "toilet plume" aerosols produced by flush toilets is a subject of continuing study. This review examines the evidence regarding toilet plume bioaerosol generation and infectious disease transmission. METHODS: The peer-reviewed scientific literature was searched to identify articles related to aerosol production during toilet flushing, as well as epidemiologic studies examining the potential role of toilets in infectious disease outbreaks. RESULTS: The studies demonstrate that potentially infectious aerosols may be produced in substantial quantities during flushing. Aerosolization can continue through multiple flushes to expose subsequent toilet users. Some of the aerosols desiccate to become droplet nuclei and remain adrift in the air currents. However, no studies have yet clearly demonstrated or refuted toilet plume-related disease transmission, and the significance of the risk remains largely uncharacterized. CONCLUSION: Research suggests that toilet plume could play a contributory role in the transmission of infectious diseases. Additional research in multiple areas is warranted to assess the risks posed by toilet plume, especially within health care facilities. |
Ocular tropism of respiratory viruses
Belser JA , Rota PA , Tumpey TM . Microbiol Mol Biol Rev 2013 77 (1) 144-56 SUMMARY: Respiratory viruses (including adenovirus, influenza virus, respiratory syncytial virus, coronavirus, and rhinovirus) cause a broad spectrum of disease in humans, ranging from mild influenza-like symptoms to acute respiratory failure. While species D adenoviruses and subtype H7 influenza viruses are known to possess an ocular tropism, documented human ocular disease has been reported following infection with all principal respiratory viruses. In this review, we describe the anatomical proximity and cellular receptor distribution between ocular and respiratory tissues. All major respiratory viruses and their association with human ocular disease are discussed. Research utilizing in vitro and in vivo models to study the ability of respiratory viruses to use the eye as a portal of entry as well as a primary site of virus replication is highlighted. Identification of shared receptor-binding preferences, host responses, and laboratory modeling protocols among these viruses provides a needed bridge between clinical and laboratory studies of virus tropism. |
Pre-symptomatic transmission of pandemic influenza H1N1 2009: investigation of a family cluster, Brazil
Freitas FT , Cabral AP , Barros EN , Burigo MJ , Prochnow RD , Silva LA , Widdowson MA , Sobel J . Epidemiol Infect 2013 141 (4) 763-6 SUMMARY: We investigated the first cluster of pandemic influenza H1N1 2009 reported in Brazil in May 2009. The index case-patient had travelled from the USA and had contact with 11 relatives before she presented with symptoms. We conducted face-to-face or telephone interviews with the index case-patient and all suspect cases. We found evidence of pre-symptomatic transmission of the virus to four of her contacts. This finding has public health implications because it indicates that viral transmission in communities may not be prevented solely by isolating symptomatic case-patients. |
Estimation of the national disease burden of influenza-associated severe acute respiratory illness in Kenya and Guatemala: a novel methodology
Fuller JA , Summers A , Katz MA , Lindblade KA , Njuguna H , Arvelo W , Khagayi S , Emukule G , Linares-Perez N , McCracken J , Nokes DJ , Ngama M , Kazungu S , Mott JA , Olsen SJ , Widdowson MA , Feikin DR . PLoS One 2013 8 (2) e56882 BACKGROUND: Knowing the national disease burden of severe influenza in low-income countries can inform policy decisions around influenza treatment and prevention. We present a novel methodology using locally generated data for estimating this burden. METHODS AND FINDINGS: This method begins with calculating the hospitalized severe acute respiratory illness (SARI) incidence for children <5 years old and persons >=5 years old from population-based surveillance in one province. This base rate of SARI is then adjusted for each province based on the prevalence of risk factors and healthcare-seeking behavior. The percentage of SARI with influenza virus detected is determined from provincial-level sentinel surveillance and applied to the adjusted provincial rates of hospitalized SARI. Healthcare-seeking data from healthcare utilization surveys is used to estimate non-hospitalized influenza-associated SARI. Rates of hospitalized and non-hospitalized influenza-associated SARI are applied to census data to calculate the national number of cases. The method was field-tested in Kenya, and validated in Guatemala, using data from August 2009-July 2011. In Kenya (2009 population 38.6 million persons), the annual number of hospitalized influenza-associated SARI cases ranged from 17,129-27,659 for children <5 years old (2.9-4.7 per 1,000 persons) and 6,882-7,836 for persons >=5 years old (0.21-0.24 per 1,000 persons), depending on year and base rate used. In Guatemala (2011 population 14.7 million persons), the annual number of hospitalized cases of influenza-associated pneumonia ranged from 1,065-2,259 (0.5-1.0 per 1,000 persons) among children <5 years old and 779-2,252 cases (0.1-0.2 per 1,000 persons) for persons >=5 years old, depending on year and base rate used. In both countries, the number of non-hospitalized influenza-associated cases was several-fold higher than the hospitalized cases. CONCLUSIONS: Influenza virus was associated with a substantial amount of severe disease in Kenya and Guatemala. This method can be performed in most low and lower-middle income countries. |
Influenza A(H1N1)pdm09 during air travel
Neatherlin J , Cramer EH , Dubray C , Marienau KJ , Russell M , Sun H , Whaley M , Hancock K , Duong KK , Kirking HL , Schembri C , Katz JM , Cohen NJ , Fishbein DB . Travel Med Infect Dis 2013 11 (2) 110-8 The global spread of the influenza A(H1N1)pdm09 virus (pH1N1) associated with travelers from North America during the onset of the 2009 pandemic demonstrates the central role of international air travel in virus migration. To characterize risk factors for pH1N1 transmission during air travel, we investigated travelers and airline employees from four North American flights carrying ill travelers with confirmed pH1N1 infection. Of 392 passengers and crew identified, information was available for 290 (74%) passengers were interviewed. Overall attack rates for acute respiratory infection and influenza-like illness 1-7 days after travel were 5.2% and 2.4% respectively. Of 43 individuals that provided sera, 4 (9.3%) tested positive for pH1N1 antibodies, including 3 with serologic evidence of asymptomatic infection. Investigation of novel influenza aboard aircraft may be instructive. However, beyond the initial outbreak phase, it may compete with community-based mitigation activities, and interpretation of findings will be difficult in the context of established community transmission. |
The association between serum biomarkers and disease outcome in influenza A(H1N1)pdm09 virus infection: results of two international observational cohort studies
Davey RT Jr , Lynfield R , Dwyer DE , Losso MH , Cozzi-Lepri A , Wentworth D , Lane HC , Dewar R , Rupert A , Metcalf JA , Pett SL , Uyeki TM , Bruguera JM , Angus B , Cummins N , Lundgren J , Neaton JD . PLoS One 2013 8 (2) e57121 BACKGROUND: Prospective studies establishing the temporal relationship between the degree of inflammation and human influenza disease progression are scarce. To assess predictors of disease progression among patients with influenza A(H1N1)pdm09 infection, 25 inflammatory biomarkers measured at enrollment were analyzed in two international observational cohort studies. METHODS: Among patients with RT-PCR-confirmed influenza A(H1N1)pdm09 virus infection, odds ratios (ORs) estimated by logistic regression were used to summarize the associations of biomarkers measured at enrollment with worsened disease outcome or death after 14 days of follow-up for those seeking outpatient care (FLU 002) or after 60 days for those hospitalized with influenza complications (FLU 003). Biomarkers that were significantly associated with progression in both studies (p<0.05) or only in one (p<0.002 after Bonferroni correction) were identified. RESULTS: In FLU 002 28/528 (5.3%) outpatients had influenza A(H1N1)pdm09 virus infection that progressed to a study endpoint of complications, hospitalization or death, whereas in FLU 003 28/170 (16.5%) inpatients enrolled from the general ward and 21/39 (53.8%) inpatients enrolled directly from the ICU experienced disease progression. Higher levels of 12 of the 25 markers were significantly associated with subsequent disease progression. Of these, 7 markers (IL-6, CD163, IL-10, LBP, IL-2, MCP-1, and IP-10), all with ORs for the 3 versus 1 tertile of 2.5 or greater, were significant (p<0.05) in both outpatients and inpatients. In contrast, five markers (sICAM-1, IL-8, TNF-alpha, D-dimer, and sVCAM-1), all with ORs for the 3 versus 1 tertile greater than 3.2, were significantly (p≤.002) associated with disease progression among hospitalized patients only. CONCLUSIONS: In patients presenting with varying severities of influenza A(H1N1)pdm09 virus infection, a baseline elevation in several biomarkers associated with inflammation, coagulation, or immune function strongly predicted a higher risk of disease progression. It is conceivable that interventions designed to abrogate these baseline elevations might affect disease outcome. |
Coccidioidomycosis acquired in Washington State
Marsden-Haug N , Goldoft M , Ralston C , Limaye AP , Chua J , Hill H , Jecha L , Thompson GR 3rd , Chiller T . Clin Infect Dis 2013 56 (6) 847-50 Clinical, laboratory, and epidemiologic evidence suggest that 3 individuals with acute coccidioidomycosis were exposed in Washington State, significantly beyond previously identified endemic areas. Given the patients' lack of recent travel, coccidioidomycosis was not suspected, leading to delays in diagnosis and appropriate therapy. Clinicians should be aware of this possibility and consider the diagnosis. |
Maternal exposure to particulate air pollution and term birth weight: a multi-country evaluation of effect and heterogeneity
Dadvand P , Parker J , Bell ML , Bonzini M , Brauer M , Darrow LA , Gehring U , Glinianaia SV , Gouveia N , Ha EH , Leem JH , van den Hooven EH , Jalaludin B , Jesdale BM , Lepeule J , Morello-Frosch R , Morgan GG , Pesatori AC , Pierik FH , Pless-Mulloli T , Rich DQ , Sathyanarayana S , Seo J , Slama R , Strickland M , Tamburic L , Wartenberg D , Nieuwenhuijsen MJ , Woodruff TJ . Environ Health Perspect 2013 121 (3) 267-373 BACKGROUND: A growing body of evidence has associated maternal exposure to air pollution with adverse effects on fetal growth; however, the existing literature is inconsistent. OBJECTIVES: We aimed to quantify the association between maternal exposure to particulate air pollution and term birth weight and low birth weight (LBW) across 14 centers from 9 countries, and to explore the influence of site characteristics and exposure assessment methods on between-center heterogeneity in this association. METHODS: Using a common analytical protocol, International Collaboration on Air Pollution and Pregnancy Outcomes (ICAPPO) centers generated effect estimates for term LBW and continuous birth weight associated with PM10 and PM2.5 (particulate matter ≤ 10 and 2.5 microm). We used meta-analysis to combine the estimates of effect across centers (~3 million births) and used meta-regression to evaluate the influence of center characteristics and exposure assessment methods on between-center heterogeneity in reported effect estimates. RESULTS: In random-effects meta-analyses, term LBW was positively associated with a 10-mcg/m3 increase in PM10 [odds ratio (OR) = 1.03; 95% CI: 1.01, 1.05] and PM2.5 (OR = 1.10; 95% CI: 1.03, 1.18) exposure during the entire pregnancy, adjusted for maternal socioeconomic status. A 10-mcg/m3 increase in PM10 exposure was also negatively associated with term birth weight as a continuous outcome in the fully adjusted random-effects meta-analyses (-8.9 g; 95% CI: -13.2, -4.6 g). Meta-regressions revealed that centers with higher median PM2.5 levels and PM2.5:PM10 ratios, and centers that used a temporal exposure assessment (compared with spatiotemporal), tended to report stronger associations. CONCLUSION: Maternal exposure to particulate pollution was associated with LBW at term across study populations. We detected three site characteristics and aspects of exposure assessment methodology that appeared to contribute to the variation in associations reported by centers. |
Potential sources of bisphenol A in the neonatal intensive care unit
Duty SM , Mendonca K , Hauser R , Calafat AM , Ye X , Meeker JD , Ackerman R , Cullinane J , Faller J , Ringer S . Pediatrics 2013 131 (3) 483-9 OBJECTIVES: To determine whether nutritional intake and medical devices are bisphenol A (BPA) exposure sources among premature infants in the NICU. METHODS: Mothers and their premature infants cared for in the NICU for the past 3 days were recruited for this exposure assessment study. Forty-three mothers contributed 1 nutrition sample (breast milk or formula) to characterize the infant's intake. Two urine samples (before and after feeding) were collected from each of 55 infants. Medical device use was categorized as "low" or "high" based on the number and invasiveness of devices used. BPA urinary concentrations used as a biomarker to estimate BPA exposure were measured by online solid-phase extraction, high performance liquid chromatography, isotope dilution, tandem mass spectrometry. Nonparametric equivalence tests, intraclass correlations, and hierarchical linear mixed-effects models were conducted. RESULTS: Breast milk and formula samples did not differ in total BPA concentration nor did infants' median urinary concentration of total BPA before or after feedings. However, the median urinary total BPA concentration among infants who required the use of 4 or more medical devices in the past 3 days was significantly higher (36.6 microg/L) than among infants who required the use of 0 to 3 devices (13.9 microg/L). The calculated BPA exposures are lower than the US Environmental Protection Agency reference dose, but considerably higher (16- to 32-fold) than among infants or children from the general population. CONCLUSIONS: The number of medical devices used in the past 3 days, but not nutritional intake, was positively associated with exposure to BPA. |
Economic and health impacts associated with a Salmonella typhimurium drinking water outbreak-Alamosa, CO, 2008
Ailes E , Budge P , Shankar M , Collier S , Brinton W , Cronquist A , Chen M , Thornton A , Beach MJ , Brunkard JM . PLoS One 2013 8 (3) e57439 In 2008, a large Salmonella outbreak caused by contamination of the municipal drinking water supply occurred in Alamosa, Colorado. The objectives of this assessment were to determine the full economic costs associated with the outbreak and the long-term health impacts on the community of Alamosa. We conducted a postal survey of City of Alamosa (2008 population: 8,746) households and businesses, and conducted in-depth interviews with local, state, and nongovernmental agencies, and City of Alamosa healthcare facilities and schools to assess the economic and long-term health impacts of the outbreak. Twenty-one percent of household survey respondents (n = 369/1,732) reported diarrheal illness during the outbreak. Of those, 29% (n = 108) reported experiencing potential long-term health consequences. Most households (n = 699/771, 91%) reported municipal water as their main drinking water source at home before the outbreak; afterwards, only 30% (n = 233) drank unfiltered municipal tap water. The outbreak's estimated total cost to residents and businesses of Alamosa using a Monte Carlo simulation model (10,000 iterations) was approximately $1.5 million dollars (range: $196,677-$6,002,879), and rose to $2.6 million dollars (range: $1,123,471-$7,792,973) with the inclusion of outbreak response costs to local, state and nongovernmental agencies and City of Alamosa healthcare facilities and schools. This investigation documents the significant economic and health impacts associated with waterborne disease outbreaks and highlights the potential for loss of trust in public water systems following such outbreaks. |
Routine data from prevention of mother-to-child transmission (PMTCT) HIV testing not yet ready for HIV surveillance in Mozambique: a retrospective analysis of matched test results
Young PW , Mahomed M , Horth RZ , Shiraishi RW , Jani IV . BMC Infect Dis 2013 13 96 BACKGROUND: Opt-out HIV testing is offered at 70% of antenatal care (ANC) clinics in Mozambique through the prevention of mother-to-child transmission (PMTCT) program. If routine data from this program were of sufficient quality, their heightened coverage and continuous availability could complement or even replace biannual sentinel serosurveys that currently serve as the primary HIV surveillance system in Mozambique. METHODS: We assessed the efficacy of routine HIV testing data from prevention of mother-to-child transmission programs for estimating the prevalence of HIV infection among pregnant women. The PMTCT program uses sequential point-of-care rapid tests conducted on site while ANC surveillance surveys use dried blood spots tested sequentially for HIV-1/2 antibodies at a central laboratory. We compared matched routine PMTCT and ANC surveillance test results collected during 2007 and 2009 ANC surveillance surveys from 36 sentinel sites. RESULTS: After excluding 659 women without PMTCT data, including 83 who refused rapid testing, test results from a total of 20,563 women were available. Pooling the data from both years indicated HIV prevalence from routine PMTCT testing was 14.4% versus 15.2% from surveillance testing (relative difference -5.1%; absolute difference -0.78%). Positive percent agreement (PPA) of PMTCT versus surveillance tests was 88.5% (95% Confidence Interval [CI]: 85.7-91.3%), with 19 sites having PPA below 90%; Negative percent agreement (NPA) was 98.9% (CI: 98.5-99.2%). No significant difference was found among three regions (North, Center and South), however both PPA and NPA were significantly higher in 2009 than 2007 (p < 0.05). CONCLUSIONS: We found low PPA of PMTCT test results compared to surveillance data which is indicative either of testing errors or data reporting problems. Nonetheless, PPA improved significantly from 2007 to 2009, a possible positive trend that should be investigated further. Although use of PMTCT test results would not dramatically change HIV prevalence estimates among pregnant women, the impact of site-level differences on surveillance models should be evaluated before these data are used to replace or complement ANC surveillance surveys. |
Fatal occupational injuries among U.S. law enforcement officers: a comparison of national surveillance systems
Tiesman HM , Swedler DI , Konda S , Pollack KM . Am J Ind Med 2013 56 (6) 693-700 BACKGROUND: This study describes and compares the three surveillance systems used to record occupational injury fatalities among U.S. law enforcement officers (LEOs). METHODS: The Census of Fatal Occupational Injuries (CFOI), National Law Enforcement Officer Memorial Fund database (NLEOMF), and Law Enforcement Officers Killed and Assaulted reports (LEOKA) were examined for LEO deaths between 2003 and 2009. Fatality rates per 100,000 workers were calculated and compared. RESULTS: Between 2003 and 2009, the NLEOMF reported 1,050 fatalities (rate of 16.4 per 100,000 workers), the CFOI reported 968 fatalities (15.1 per 100,000), and the LEOKA recorded 853 fatalities (13.3 per 100,000). The LEOKA under-counted the number of fatalities compared to the NLEOMF and CFOI. Discrepancies were found between the LEOKA, NLEOMF, and CFOI regarding age, race, and Hispanic origin. Similar patterns for cause of fatality were found; however, the NLEOMF recorded a higher number of "other" fatalities compared to the other two systems. CONCLUSIONS: This study fills a critical knowledge gap by providing an overview of the three surveillance systems used to enumerate LEO occupational deaths. Understanding the differences across the systems is critical when utilizing them for surveillance research. (Am. J. Ind. Med. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.) |
First use of multiple imputation with the National Tuberculosis Surveillance System
Vinnard C , Wileyto EP , Bisson GP , Winston CA . Epidemiol Res Int 2013 2013 (875234) AIMS: The purpose of this study was to compare methods for handling missing data in analysis of the National Tuberculosis Surveillance System of the Centers for Disease Control and Prevention. Because of the high rate of missing human immunodeficiency virus (HIV) infection status in this dataset, we used multiple imputation methods to minimize the bias that may result from less sophisticated methods. METHODS: We compared analysis based on multiple imputation methods with analysis based on deleting subjects with missing covariate data from regression analysis (case exclusion), and determined whether the use of increasing numbers of imputed datasets would lead to changes in the estimated association between isoniazid resistance and death. RESULTS: Following multiple imputation, the odds ratio for initial isoniazid resistance and death was 2.07 (95% CI 1.30, 3.29); with case exclusion, this odds ratio decreased to 1.53 (95% CI 0.83, 2.83). The use of more than 5 imputed datasets did not substantively change the results. CONCLUSIONS: Our experience with the National Tuberculosis Surveillance System dataset supports the use of multiple imputation methods in epidemiologic analysis, but also demonstrates that close attention should be paid to the potential impact of missing covariates at each step of the analysis. (2013 Christopher Vinnard et al.) |
Impact of data editing methods on estimates of smoking prevalence, Global Youth Tobacco Survey, 2007-2009
Lam E , Rolle I , Shin M , Lee KA . Prev Chronic Dis 2013 10 E38 Accuracy of self-reported data may be improved by data editing, a mechanism to produce accurate information by excluding inconsistent data based on a set number of predetermined decision rules. We compared data editing methods in the Global Youth Tobacco Survey (GYTS) with other editing approaches and evaluated the effects of these on smoking prevalence estimates. We evaluated 5 approaches for handling inconsistent responses to questions regarding cigarette use: GYTS, do-nothing, gatekeeper, global, and preponderance. Compared with GYTS data edits, the do-nothing and gatekeeper approaches produced similar estimates, whereas the global approach resulted in lower estimates and the preponderance approach, higher estimates. Implications for researchers using GYTS include recognition of the survey's data editing methods and documentation in their study methods to ensure cross-study comparability. |
Implications of risk stratification for diabetes prevention: the case of hemoglobin a1c
Gregg EW , Geiss L , Zhang P , Zhuo X , Williamson DF , Albright AL . Am J Prev Med 2013 44 S375-80 Although glycated hemoglobin (HbA1c) has been widely recommended for the diagnosis of diabetes, considerable ambiguity remains about how HbA1c should be used to identify people with prediabetes or other high-risk states for preventive interventions. The current paper provides a synthesis of the epidemiologic basis and the health and economic implications of using various HbA1c-based risk-stratification approaches for diabetes prevention. HbA1c predicts diabetes and related outcomes across a wide range of HbA1c values. However, the authors estimate that, among U.S. adults, the top 15% of the nondiabetic HBA1c distribution (HbA1c of 5.7%-6.4%) accounts for 47% of diabetes cases over 5 years, and the top 30% (5.5%-6.4%) accounts for about 70% of cases. Although this clustering of eventual cases at the high end of the HbA1c risk distribution means that intervention resources will be more efficient when applied to the upper end of the distribution, no obvious threshold exists to prioritize people for preventive interventions. Thus, the choice of optimal thresholds is a tradeoff, wherein selecting a lower HbA1c cut-point will lead to a higher rate of eligibility and health benefits for more people, and a higher HbA1c cut-point will lead to fewer cases of diabetes prevented but greater "economic efficiency" in terms of diabetes cases prevented per intervention participant. Selection of optimal HbA1c thresholds also may change with the evolving science, as better evidence on the biologic effectiveness of lower-intensity interventions and effects of lifestyle interventions on additional outcomes could pave the way for a more comprehensive, tiered approach to risk stratification. |
Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia
Owusu-Edusei K Jr , Gift TL , Chesson HW , Kent CK . Am J Epidemiol 2013 177 (5) 463-73 Observational studies have found mixed results on the impact of jail-based chlamydia screen-and-treat programs on community prevalence. In the absence of controlled trials or prospectively designed studies, dynamic mathematical models that incorporate movements in and out of jail and sexual contacts (including disease transmission) can provide useful information. We explored the impact of jail-based chlamydia screening on a hypothetical community's prevalence with a deterministic compartmental model focusing on heterosexual transmission. Parameter values were obtained from the published literature. Two analyses were conducted. One used national values (large community); the other used values reported among African Americans-the population with the highest incarceration rates and chlamydia burden (small community). A comprehensive sensitivity analysis was carried out. For the large-community analysis, chlamydia prevalence decreased by 13% (from 2.3% to 2.0%), and based on the ranges of parameter values (including screening coverage of 10%-100% and a postscreening treatment rate of 50%-100%) used in the sensitivity analysis, this decrease ranged from 0.1% to 58%. For the small-community analysis, chlamydia prevalence decreased by 54% (from 4.6% to 2.1%). Jail-based chlamydia screen-and-treat programs have the potential to reduce chlamydia prevalence in communities with high incarceration rates. However, the magnitude of this potential decrease is subject to considerable uncertainty. |
CrcZ and CrcX regulate carbon source utilization in Pseudomonas syringae pathovar tomato strain DC3000.
Filiatrault MJ , Stodghill PV , Wilson J , Butcher BG , Chen H , Myers CR , Cartinhour SW . RNA Biol 2013 10 (2) 245-55 Small non-coding RNAs (ncRNAs) are important components of many regulatory pathways in bacteria and play key roles in regulating factors important for virulence. Carbon catabolite repression control is modulated by small RNAs (crcZ or crcZ and crcY) in Pseudomonas aeruginosa and Pseudomonas putida. In this study, we demonstrate that expression of crcZ and crcX (formerly designated psr1 and psr2, respectively) is dependent upon RpoN together with the two-component system CbrAB, and is influenced by the carbon source present in the medium in the model plant pathogen Pseudomonas syringae pv tomato DC3000. The distribution of the members of the Crc ncRNA family was also determined by screening available genomic sequences of the Pseudomonads. Interestingly, variable numbers of the Crc family members exist in Pseudomonas genomes. The ncRNAs are comprised of three main subfamilies, named CrcZ, CrcX and CrcY. Most importantly the CrcX subfamily appears to be unique to all P. syringae strains sequenced to date. |
Use of whole genome sequencing to determine the microevolution of Mycobacterium tuberculosis during an outbreak.
Kato-Maeda M , Ho C , Passarelli B , Banaei N , Grinsdale J , Flores L , Anderson J , Murray M , Rose G , Kawamura LM , Pourmand N , Tariq MA , Gagneux S , Hopewell PC . PLoS One 2013 8 (3) e58235 RATIONALE: Current tools available to study the molecular epidemiology of tuberculosis do not provide information about the directionality and sequence of transmission for tuberculosis cases occurring over a short period of time, such as during an outbreak. Recently, whole genome sequencing has been used to study molecular epidemiology of over short time periods. OBJECTIVE: To describe the microevolution of during an outbreak caused by one drug-susceptible strain. METHOD AND MEASUREMENTS: We included 9 patients with tuberculosis diagnosed during a period of 22 months, from a population-based study of the molecular epidemiology in San Francisco. Whole genome sequencing was performed using Illumina's sequencing by synthesis technology. A custom program written in Python was used to determine single nucleotide polymorphisms which were confirmed by PCR product Sanger sequencing. MAIN RESULTS: We obtained an average of 95.7% (94.1-96.9%) coverage for each isolate and an average fold read depth of 73 (1 to 250). We found 7 single nucleotide polymorphisms among the 9 isolates. The single nucleotide polymorphisms data confirmed all except one known epidemiological link. The outbreak strain resulted in 5 bacterial variants originating from the index case A1 with 0-2 mutations per transmission event that resulted in a secondary case. CONCLUSIONS: Whole genome sequencing analysis from a recent outbreak of tuberculosis enabled us to identify microevolutionary events observable during transmission, to determine 0-2 single nucleotide polymorphisms per transmission event that resulted in a secondary case, and to identify new epidemiologic links in the chain of transmission. |
Impact of medical and behavioural factors on influenza-like illness, healthcare-seeking, and antiviral treatment during the 2009 H1N1 pandemic: USA, 2009-2010
Biggerstaff M , Jhung MA , Reed C , Garg S , Balluz L , Fry AM , Finelli L . Epidemiol Infect 2013 142 (1) 1-12 SUMMARY: We analysed a cross-sectional telephone survey of U.S. adults to assess the impact of selected characteristics on healthcare-seeking behaviours and treatment practices of people with influenza-like illness (ILI) from September 2009 to March 2010. Of 216 431 respondents, 8.1% reported ILI. After adjusting for selected characteristics, respondents aged 18-64 years with the following factors were more likely to report ILI: a diagnosis of asthma [adjusted odds ratio (aOR) 1.88, 95% CI 1.67-2.13] or heart disease (aOR 1.41, 95% CI 1.17-1.70), being disabled (aOR 1.75, 95% CI 1.57-1.96), and reporting financial barriers to healthcare access (aOR 1.63, 95% CI 1.45-1.82). Similar associations were seen in respondents aged 65 years. Forty percent of respondents with ILI sought healthcare, and 14% who sought healthcare reported receiving influenza antiviral treatment. Treatment was not more frequent in patients with high-risk conditions, except those aged 18-64 years with heart disease (aOR 1.90, 95% CI 1.03-3.51). Of patients at high risk for influenza complications, self-reported ILI was greater but receipt of antiviral treatment was not, despite guidelines recommending their use in this population. |
Hepatitis A vaccination coverage among adults 18-49 years traveling to a country of high or intermediate endemicity, United States
Lu PJ , Byrd KK , Murphy TV . Vaccine 2013 31 (19) 2348-57 BACKGROUND: Since 1996, hepatitis A vaccine (HepA) has been recommended for adults at increased risk for infection including travelers to high or intermediate hepatitis A endemic countries. In 2009, travel outside the United States and Canada was the most common exposure nationally reported for persons with hepatitis A virus (HAV) infection. OBJECTIVE: To assess HepA vaccination coverage among adults 18-49 years traveling to a country of high or intermediate endemicity in the United States. METHODS: We analyzed data from the 2010 National Health Interview Survey (NHIS), to determine self-reported HepA vaccination coverage (=1 dose) and series completion (=2 dose) among persons 18-49 years who traveled, since 1995, to a country of high or intermediate HAV endemicity. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with HepA vaccine receipt. RESULTS: In 2010, approximately 36.6% of adults 18-49 years reported traveling to high or intermediate hepatitis A endemic countries; among this group unadjusted HepA vaccination coverage was 26.6% compared to 12.7% among non-travelers (P-values<0.001) and series completion were 16.9% and 7.6%, respectively (P-values<0.001). On multivariable analysis among all respondents, travel status was an independent predictor of HepA coverage and series completion (both P-values<0.001). Among travelers, HepA coverage and series completion (=2 doses) were higher for travelers 18-25 years (prevalence ratios 2.3, 2.8, respectively, P-values<0.001) and for travelers 26-39 years (prevalence ratios 1.5, 1.5, respectively, P-value<0.001, P-value=0.002, respectively) compared to travelers 40-49 years. Other characteristics independently associated with a higher likelihood of HepA receipt among travelers included Asian race/ethnicity, male sex, never having been married, having a high school or higher education, living in the western United States, having greater number of physician contacts or receipt of influenza vaccination in the previous year. HepB vaccination was excluded from the model because of the significant correlation between receipt of HepA vaccination and HepB vaccination could distort the model. CONCLUSIONS: Although travel to a country of high or intermediate hepatitis A endemicity was associated with higher likelihood of HepA vaccination in 2010 among adults 18-49 years, self-reported HepA vaccination coverage was low among adult travelers to these areas. Healthcare providers should ask their patients' upcoming travel plans and recommend and offer travel related vaccinations to their patients. |
Increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines is not associated with risk of autism
DeStefano F , Price CS , Weintraub ES . J Pediatr 2013 163 (2) 561-7 OBJECTIVE: To evaluate the association between autism and the level of immunologic stimulation received from vaccines administered during the first 2 years of life. STUDY DESIGN: We analyzed data from a case-control study conducted in 3 managed care organizations (MCOs) of 256 children with autism spectrum disorder (ASD) and 752 control children matched on birth year, sex, and MCO. In addition to the broader category of ASD, we also evaluated autistic disorder and ASD with regression. ASD diagnoses were validated through standardized in-person evaluations. Exposure to total antibody-stimulating proteins and polysaccharides from vaccines was determined by summing the antigen content of each vaccine received, as obtained from immunization registries and medical records. Potential confounding factors were ascertained from parent interviews and medical charts. Conditional logistic regression was used to assess associations between ASD outcomes and exposure to antigens in selected time periods. RESULTS: The aOR (95% CI) of ASD associated with each 25-unit increase in total antigen exposure was 0.999 (0.994-1.003) for cumulative exposure to age 3 months, 0.999 (0.997-1.001) for cumulative exposure to age 7 months, and 0.999 (0.998-1.001) for cumulative exposure to age 2 years. Similarly, no increased risk was found for autistic disorder or ASD with regression. CONCLUSION: In this study of MCO members, increasing exposure to antibody-stimulating proteins and polysaccharides | in vaccines during the first 2 years of life was not related to the risk of developing an ASD. (J Pediatr2013). |
The mediating effect of hostility toward women on the relationship between childhood emotional abuse and sexual violence perpetration
Vivolo-Kantor AM , DeGue S , DiLillo D , Cuadra LE . Violence Vict 2013 28 (1) 178-91 Some evidence suggests that childhood emotional abuse (CEA) may serve as a risk factor for sexual violence (SV) perpetration; however, little is known about the mechanisms by which CEA may influence SV. This study examined the relationship between CEA and SV by assessing the mediating role of hostility toward women (HTW) in a sample of adjudicated adult males (N = 360). Approximately 1 in 5 participants was classified as sexually violent based on self-reported behavior and/or criminal records. Results indicted that CEA significantly predicted HTW and SV, and HTW significantly predicted SV. As hypothesized, the relationship between CEA and SV was no longer significant after controlling for HTW, supporting the role of HTW as a mediator between CEA and SV. Efforts that aim to prevent CEA or that address early aggressive attitudes or behavior toward women may have a positive impact on preventing or reducing SV. |
Descriptive factors of abusive head trauma in young children-United States, 2000-2009
Niederkrotenthaler T , Xu L , Parks SE , Sugerman DE . Child Abuse Negl 2013 37 (7) 446-55 OBJECTIVE: Abusive head trauma (AHT) is a leading cause of severe injury in maltreated children in the United States. There is little research from nationally representative datasets available to characterize young children who had AHT compared to non-abusive head trauma (NAHT). METHODS: Using the recent CDC AHT case definition, we performed a retrospective analysis of 2000, 2003, 2006 and 2009 hospitalization data using the Kids' Inpatient Database (KID) from the Healthcare Cost and Utilization Project. Logistic regression was used to compare AHT to NAHT patients <2 years of age. Socio-demographic data and indicators of socioeconomic status (i.e., insurance status and household income), presence of chronic conditions, injury severity (i.e., length of hospital stay and vital status), hospital specialization (i.e., hospital type), hospital region, and season of admission were used as independent variables. RESULTS: A weighted sample of 7,603 AHT and 25,339 NAHT patients was identified. National rates for AHT were 39.8 per 100,000 population for children <1 year and 6.8 per 100,000 population for children 1 year old. Compared to NAHT, children with AHT were more often <1 year of age (adjusted odds ratio [aOR]=2.66; 95% confidence interval [CI]: 2.35-3.01), male (aOR=1.10; 95% CI: 1.01-1.20), enrolled in Medicaid (aOR=2.78; 95% CI: 2.49-3.11), hospitalized longer (aOR=8.26; 95% CI: 7.24-9.43), died during hospitalization (aOR=5.12; 95% CI: 4.01-6.53), and seen at children's hospitals (aOR=1.97; 95% CI: 1.63-2.38) and hospitals outside the Northeast [aOR=2.65 (95% CI: 2.10-3.33) for the Midwest, 1.90 (95% CI: 1.52-2.38) for the South and 1.93 (95% CI: 1.45-2.57) for the West, respectively]. CONCLUSIONS: The results confirm that injuries from AHT are more severe and more often lethal than other head injuries. Socioeconomically disadvantaged families with children <1 year are an important focus for primary prevention. The associations of AHT, compared to NAHT with hospital type and hospital region warrant further investigation. Referral or reporting patterns, or true differences in the incidence may contribute to the identified associations. |
Rift Valley fever virus clearance and protection from neurologic disease are dependent on CD4+ T cell and virus-specific antibody responses
Dodd KA , McElroy AK , Jones ME , Nichol ST , Spiropoulou CF . J Virol 2013 87 (11) 6161-71 Rift Valley fever virus (RVFV) causes outbreaks of severe disease in people and livestock throughout Africa and the Arabian Peninsula. Human RVFV infections generally manifest as a self-limiting febrile illness, but in some individuals, the disease can progress to a fatal encephalitis or hemorrhagic syndrome. Little is known about the host characteristics that predispose development of more severe disease. Early in infection, interferon-mediated antiviral responses are critical for controlling RVFV replication, but the roles of downstream adaptive immune responses in determining clinical outcome have not been examined. Here, using a C57BL/6 mouse disease model, we evaluated the roles of B cells and T cells in RVFV pathogenesis. Given the profound inhibition of the innate response by the viral NSs protein and rapid course of wild-type infection, we utilized an attenuated RVFV lacking NSs to examine host responses following primary infection. Experiments utilizing B cell deficient mice or targeted T cell depletions of wild-type mice demonstrated that B cells and CD4+ T cells, but not CD8+ T cells, were critical for mediating viral clearance, even in the presence of a functional innate response. One-third of CD4-depleted mice developed severe neurologic disease following infection, in contrast to virus-infected mock-depleted mice that showed no clinical signs. CD4+ T cells were required for robust IgG and neutralizing antibody responses that correlated with RVFV clearance from peripheral tissues. Further, CD4-depleted mice demonstrated significantly stronger pro-inflammatory responses relative to controls, suggesting CD4+ T cells regulate immune responses to RVFV infection. Together, these results indicate CD4+ T cells are critical determinants of RVFV pathogenesis and play an important role in preventing onset of neurologic disease. |
Scenarios and methods that induce protruding or released CNTs after degradation of nanocomposite materials
Hirth S , Cena L , Cox G , Tomovic Z , Peters T , Wohlleben W . J Nanopart Res 2013 15 (4) 1-15 Nanocomposite materials may be considered as a low-risk application of nanotechnology, if the nanofillers remain embedded throughout the life-cycle of the products in which they are embedded. We hypothesize that release of free CNTs occurs by a combination of mechanical stress and chemical degradation of the polymer matrix. We experimentally address limiting cases: Mechanically released fragments may show tubular protrusions on their surface. Here we identify these protrusions unambiguously as naked CNTs by chemically resolved microscopy and a suitable preparation protocol. By size-selective quantification of fragments we establish as a lower limit that at least 95% of the CNTs remain embedded. Contrary to classical fiber composite approaches, we link this phenomenon to matrix materials with only a few percent elongation at break, predicting which materials should still cover their CNT nanofillers after machining. Protruding networks of CNTs remain after photochemical degradation of the matrix, and we show that it takes the worst case combinations of weathering plus high-shear wear to release free CNTs in the order of mg/m2/year. Synergy of chemical degradation and mechanical energy input is identified as the priority scenario of CNT release, but its lab simulation by combined methods is still far from real-world validation. (Graphical Abstract: [Figure not available: see fulltext.]) 2013 The Author(s). |
Genotypic characterization of Egypt enterotoxigenic Escherichia coli isolates expressing coli surface antigen 6
El-Gendy AM , Mansour A , Shaheen HI , Monteville MR , Armstrong AW , El-Sayed N , Young SY , Klena JD . J Infect Dev Ctries 2013 7 (2) 90-100 INTRODUCTION: One approach to control enterotoxigenic Escherichia coli (ETEC) infections has been to develop vaccines focused on inducing protective immunity against surface expressed antigenic factors. One such factor is coli surface antigen 6 (CS6); ETEC isolates expressing CS6 may also simultaneously co-express surface antigens CS4 or CS5. However, there is little information regarding the inter-relationships of isolates expressing the CS6 antigen alone or in combination with CS4 or CS5. METHODOLOGY: A total of 62 CS6-associated ETEC isolates were evaluated for their antimicrobial susceptibility, mechanisms of resistance, toxin genes, colonization factor expression, and XbaI-pulsed-field gel electrophoretic profiles. RESULTS: We observed 46 XbaI profiles; 31 were exclusive to ETEC expressing CS6 alone and 15 among the ETEC co-expressing CS4 or CS5. Nearly half (47%) of these isolates were resistant to ampicillin, a third (37%) of the isolates were resistant to trimethoprim-sulfamethoxazole, and 24% of the isolates were tetracycline-resistant. A blaTEM gene was detected in 24 (83%) ampicillin-resistant isolates. Trimethoprim-sulfamethoxazole-resistant isolates (n = 23) carried either sulI (n = 1, 4%), sulII (n = 8, 35%) or both genes (n = 10, 43%); 4 had no detectable sul gene. CONCLUSIONS: Our results show a lack of clonality among Egypt CS6 E. coli isolates and supports the use and the further research on vaccines targeting this cell surface antigen. |
Host-rabies virus protein-protein interactions as druggable antiviral targets
Lingappa UF , Wu X , Macieik A , Yu SF , Atuegbu A , Corpuz M , Francis J , Nichols C , Calayag A , Shi H , Ellison JA , Harrell EK , Asundi V , Lingappa JR , Prasad MD , Lipkin WI , Dey D , Hurt CR , Lingappa VR , Hansen WJ , Rupprecht CE . Proc Natl Acad Sci U S A 2013 110 (10) E861-8 We present an unconventional approach to antiviral drug discovery, which is used to identify potent small molecules against rabies virus. First, we conceptualized viral capsid assembly as occurring via a host-catalyzed biochemical pathway, in contrast to the classical view of capsid formation by self-assembly. This suggested opportunities for antiviral intervention by targeting previously unappreciated catalytic host proteins, which were pursued. Second, we hypothesized these host proteins to be components of heterogeneous, labile, and dynamic multi-subunit assembly machines, not easily isolated by specific target protein-focused methods. This suggested the need to identify active compounds before knowing the precise protein target. A cell-free translation-based small molecule screen was established to recreate the hypothesized interactions involving newly synthesized capsid proteins as host assembly machine substrates. Hits from the screen were validated by efficacy against infectious rabies virus in mammalian cell culture. Used as affinity ligands, advanced analogs were shown to bind a set of proteins that effectively reconstituted drug sensitivity in the cell-free screen and included a small but discrete subfraction of cellular ATP-binding cassette family E1 (ABCE1), a host protein previously found essential for HIV capsid formation. Taken together, these studies advance an alternate view of capsid formation (as a host-catalyzed biochemical pathway), a different paradigm for drug discovery (whole pathway screening without knowledge of the target), and suggest the existence of labile assembly machines that can be rendered accessible as next-generation drug targets by the means described. |
Introducing new diagnostics into STI control programmes: the importance of programme science
Peeling RW , Mabey D , Ballard RC . Sex Transm Infect 2013 89 (2) 115-9 Many innovative diagnostic technologies will become commercially available over the next 5-10 years. These tests can potentially transform the diagnosis of sexually transmitted infections but their introduction into control programmes can be hampered by health system constraints, and political, cultural, socioeconomic and behavioural factors. We used the introduction of syphilis rapid tests to illustrate the importance of programme science to address the gap between accruing evidence of acceptable test performance and the complexity of programme design, implementation and evaluation of test deployment to address public health needs and improve patient-important outcomes. |
Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta-analysis
Gomez GB , Kamb ML , Newman LM , Mark J , Broutet N , Hawkes SJ . Bull World Health Organ 2013 91 (3) 217-26 OBJECTIVE: To perform a systematic review and meta-analysis of reported estimates of adverse pregnancy outcomes among untreated women with syphilis and women without syphilis. METHODS: PubMed, EMBASE and Cochrane Libraries were searched for literature assessing adverse pregnancy outcomes among untreated women with seroreactivity for infection and non-seroreactive women. Adverse pregnancy outcomes were fetal loss or stillbirth, neonatal death, prematurity or low birth weight, clinical evidence of syphilis and infant death. Random-effects meta-analyses were used to calculate pooled estimates of adverse pregnancy outcomes and, where appropriate, heterogeneity was explored in group-specific analyses. FINDINGS: Of the 3258 citations identified, only six, all case-control studies, were included in the analysis. Pooled estimates showed that among untreated pregnant women with syphilis, fetal loss and stillbirth were 21% more frequent, neonatal deaths were 9.3% more frequent and prematurity or low birth weight were 5.8% more frequent than among women without syphilis. Of the infants of mothers with untreated syphilis, 15% had clinical evidence of congenital syphilis. The single study that estimated infant death showed a 10% higher frequency among infants of mothers with syphilis. Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (66.5% [95% confidence interval, CI: 58.0-74.1]; = 91.8%; < 0.001) and women without syphilis (14.3% [95% CI: 11.8-17.2]; = 95.9%; < 0.001). CONCLUSION: Untreated maternal syphilis is associated with adverse pregnancy outcomes. These findings can inform policy decisions on resource allocation for the detection of syphilis and its timely treatment in pregnant women. |
US prevalence and trends in tobacco smoke exposure among children and adolescents with asthma
Kit BK , Simon AE , Brody DJ , Akinbami LJ . Pediatrics 2013 131 (3) 407-14 OBJECTIVE: To examine exposure to tobacco smoke products (TSPs), environmental tobacco smoke (ETS), and in-home smoke among youth with asthma in the United States. METHODS: Nationally representative, cross-sectional data from 2250 youth aged 4 to 19 years with current asthma in the 1988-1994, 1999-2004, and 2005-2010 National Health and Nutrition Examination Survey (NHANES) were analyzed. Outcomes were use of TSPs (serum cotinine level >10 ng/mL or self-reported recent use of cigarettes, cigars, or pipes) and, among non-TSP users, ETS exposure (serum cotinine ≥0.05 ng/mL) and in-home smoke exposure (reported). Multiple logistic regression analyses assessed the associations between the outcomes and age, gender, race/ethnicity, and family income. RESULTS: Among adolescents (aged 12-19 years) with asthma in 2005-2010, 17.3% reported TSP use. Among youth (aged 4-19 years) with asthma who did not use TSPs, 53.2% were exposed to ETS and 17.6% had in-home smoke exposure. Among low-income youth, 70.1% and 28.1% had exposure to ETS and in-home smoke, respectively. After controlling for sociodemographic factors, higher prevalence of exposure to ETS and in-home smoke persisted among low-income youth. Between 1988-1994 and 2005-2010, there was a decline in ETS and in-home smoke exposure (both P < .001). CONCLUSIONS: ETS exposure among youth with asthma declined between 1988-1994 and 2005-2010, but a majority remained exposed in 2005-2010, with higher exposure among low-income youth. More than 1 in 6 youth with asthma in 2005-2010 were exposed to in-home smoke and a similar portion of adolescents used TSPs. |
The natural history of spina bifida in children pilot project: research protocol
Alriksson-Schmidt AI , Thibadeau JK , Swanson ME , Marcus D , Carris KL , Siffel C , Ward E . JMIR Res Protoc 2013 2 (1) e2 BACKGROUND: Population-based empirical information to inform health care professionals working with children with spina bifida currently is lacking. Spina bifida is a highly complex condition that not only affects mobility but many additional aspects of life. We have developed a pilot project that focuses on a broad range of domains: surgeries, development and learning, nutrition and physical growth, mobility and functioning, general health, and family demographics. Specifically, we will: (1) explore the feasibility of identifying and recruiting participants using different recruitment sources, (2) test a multidisciplinary module to collect the data, (3) determine the utility of different methods of retrieving the data, and (4) summarize descriptive information on living with spina bifida. OBJECTIVE: The overall objective of the project was to provide information for a future multistate prospective study on the natural history of spina bifida. METHODS: Families with a child 3 to 6 years of age with a diagnosis of spina bifida were eligible for enrollment. Eligible families were identified through a US population-based tracking system for birth defects and from a local spina bifida clinic. RESULTS: This is an ongoing project with first results expected in 2013. CONCLUSIONS: This project, and the planned multistate follow-up project, will provide information both to health care professionals experienced in providing care to patients with spina bifida, and to those who have yet to work with this population. The long-term purpose of this project is to increase the knowledge about growing up with spina bifida and to guide health care practices by prospectively studying a cohort of children born with this condition. (JMIR Res Protoc 2013; 2(1): e2) doi:10.2196/resprot.2209 |
Pregnancy outcomes in HIV-infected women receiving long-term isoniazid prophylaxis for tuberculosis and antiretroviral therapy
Taylor AW , Mosimaneotsile B , Mathebula U , Mathoma A , Moathlodi R , Theebetsile I , Samandari T . Infect Dis Obstet Gynecol 2013 2013 195637 OBJECTIVE: While 6- to 12-month courses of isoniazid for tuberculosis prevention are considered safe in pregnant women, the effects of longer-term isoniazid prophylaxis or isoniazid in combination with antiretroviral therapy (ART) are not established in human-immunodeficiency-virus-(HIV-) infected women who experience pregnancy during the course of therapy. DESIGN: Nested study of pregnancy outcomes among HIV-infected women participating in a placebo-controlled, TB-prevention trial using 36 months daily isoniazid. Pregnancy outcomes were collected by interview and record review. RESULTS: Among 196 pregnant women, 103 (52.6%) were exposed to isoniazid during pregnancy; all were exposed to antiretroviral drugs. Prior to pregnancy they had received a median of 341 days (range 1-1095) of isoniazid. We observed no isoniazid-associated hepatitis or other severe isoniazid-associated adverse events in the 103 women. Pregnancy outcomes were 132 term live births, 42 premature births, 11 stillbirths, 8 low birth weight, 6 spontaneous abortions, 4 neonatal deaths, and 1 congenital abnormality. In a multivariable model, neither isoniazid nor ART exposure during pregnancy was significantly associated with adverse pregnancy outcome (adjusted odds ratios 0.6, 95% CI: 0.3-1.1 and 1.8, 95% CI 0.9-3.6, resp.). CONCLUSIONS Long-term isoniazid prophylaxis was not associated with adverse pregnancy outcomes, such as preterm delivery, even in the context of ART exposure. |
Prevalence and reasons for introducing infants early to solid foods: variations by milk feeding type
Clayton HB , Li R , Perrine CG , Scanlon KS . Pediatrics 2013 131 (4) e1108-14 OBJECTIVE: To examine the prevalence of, and mothers' self-reported reasons for, introducing solid foods to infants earlier than recommended (aged <4 months) and the variation in reasons for early introduction by milk feeding type. METHODS: The study included 1334 mothers who participated in the national longitudinal Infant Feeding Practices Study II (2005-2007). Monthly 7-day food-frequency questions throughout infancy were used to determine infant age at solid food introduction and to classify infant's milk feeding at introduction as breast milk only, formula only, or mixed. Reasons for introducing solid foods at age <4 months were assessed through maternal responses to a list of 12 potential reasons. Analyses included descriptive statistics and multivariable logistic regression. RESULTS: Overall, 40.4% of mothers introduced solid foods before age 4 months. Prevalence varied by milk feeding type (24.3%, 52.7%, and 50.2% for breastfed, formula-fed, and mixed-fed infants, respectively). The most commonly cited reasons for early introduction of solid food were as follows: "My baby was old enough," "My baby seemed hungry," "I wanted to feed my baby something in addition to breast milk or formula," "My baby wanted the food I ate," "A doctor or other health care professional said my baby should begin eating solid food," and "It would help my baby sleep longer at night." Four of these reasons varied by milk feeding type. CONCLUSIONS: Our findings highlight the high prevalence of early introduction of solids and provide details on why mothers introduced solid foods early. |
Effects of a large-scale micronutrient powder and young child feeding education program on the micronutrient status of children 6-24 months of age in the Kyrgyz Republic
Serdula MK , Lundeen E , Nichols EK , Imanalieva C , Minbaev M , Mamyrbaeva T , Timmer A , Aburto NJ . Eur J Clin Nutr 2013 67 (7) 703-7 BACKGROUND/OBJECTIVES: To combat iron and other micronutrient deficiencies, the Ministry of Health of the Kyrgyz Republic launched a regional Infant and Young Child Nutrition (IYCN) program in 2009, which included promotion of home fortification with micronutrient powder (MNP) containing iron (12.5 mg elemental iron), vitamin A (300 mcg) and other micronutrients. Every 2 months children aged 6-24 months were provided 30 sachets to be taken on a flexible schedule. The objective was to assess biochemical indicators of iron and vitamin A status among children aged 6-24 months at the baseline and follow-up surveys. SUBJECTS/METHODS: Cross-sectional representative cluster surveys were conducted in 2008 (n=571 children) and 2010 (n=541). Data collected included measurement of hemoglobin, serum ferritin, soluble transferrin receptor (sTfR), retinol-binding protein, C-reactive protein (CRP) and alpha1-glycoprotein acid (AGP). RESULTS: Among all children, declines were observed in the prevalence of: anemia, 50.6% versus 43.8% (P=0.05); total iron deficiency (either low ferritin or high sTfR), 77.3% versus 63.7% (P<0.01); and iron deficiency anemia, 45.5% versus 33.4% (P<0.01). Among children without inflammation as measured by CRP and AGP, similar declines were observed, but only declines in total iron deficiency and iron deficiency anemia reached statistical significance. Among all children and those without inflammation, the prevalence of vitamin A deficiency remained the same. CONCLUSIONS: One year after the introduction of home fortification with MNP, within a larger IYCN program, the prevalence of anemia, iron deficiency and iron deficiency anemia declined, but vitamin A deficiency remained unchanged. (European Journal of Clinical Nutrition advance online publication, 27 March 2013; doi:10.1038/ejcn.2013.67.) |
Fatty acid, amino acid, mineral and antioxidant contents of acha (Digitaria exilis) grown on the Jos Plateau, Nigeria
Glew RH , Laabes EP , Presley JM , Schulze J , Andrews R , Wang YC , Chang YC , Chuang LT . Int J Nutr Metab 2013 5 (1) 1-8 Digitaria exilis (Kippist) Stapf (also known as acha, hungry rice) has been cultivated for millennia in the dry savannahs of West Africa, but much remains to be learned about its nutritional properties. Acha was collected in four villages in Northern Nigeria and analyzed for fatty acids, minerals, amino acids and antioxidant content. Fatty acids accounted for 1.91% of the dry weight, with 47.4% linoleic acid and 30.5% oleic acid. The content of the essential minerals, copper, magnesium, molybdenum, zinc and calcium averaged 4.88, 1060, 0.23, 23.0 and 172 mcg/g, respectively. The protein content was 6.53% and the essential amino acid pattern, except for lysine, compared favorably to a World Health Organization (WHO) reference protein. The total polyphenolic content of methanolic extracts of acha matched that of common cereals (for example, maize, rice, wheat) and the extracts contained substantial amounts of free-radical scavenging substances. Thus, acha is a source of many nutrients critical to human health. |
Are your coal miners prepared to self-escape?
Peters RH , Kosmoski D . Coal Age 2013 118 (1) 26-28 What is self-escape competence? Webster’s dictionary defines competence as "having sufficient knowledge, judgment, skills, or strength for a particular duty." Ennis (2008) defines competence as "the capability of applying or using knowledge, skills, abilities, behaviors, and personal characteristics to successfully perform critical work tasks, specific functions, or operate in a given role or position. Personal characteristics may be mental/intellectual/cognitive, social/emotional/attitudinal, and physical/psychomotor attributes necessary to perform the job." We refer to the knowledge, skills and abilities miners need to have in order to evacuate from their mine quickly and safely as self-escape competencies. It is very important that every coal miner is capable of independently getting out of the mine in an emergency. |
Evaluation of a rapid colorimetric field test to assess the effective life of long-lasting insecticide-treated mosquito nets in the Lao PDR
Green MD , Mayxay M , Beach R , Pongvongsa T , Phompida S , Hongvanthong B , Vanisaveth V , Newton PN , Vizcaino L , Swamidoss I . Malar J 2013 12 (1) 57 BACKGROUND: Malaria morbidity and mortality have been significantly reduced through the proper use of insecticide-treated mosquito nets, but the extra protection afforded by the insecticide diminishes over time. The insecticide depletion rates vary according to location where wash frequency and wear are influenced by cultural habits as well as the availability of water. Monitoring of available insecticides on the net surface is essential for determining the effective life of the net. Therefore, a rapid and inexpensive colorimetric field test for cyanopyrethroids (Cyanopyrethroid Field Test or CFT) was used to measure surface levels of deltamethrin on insecticide-coated polyester nets (PowerNetsTM) in rural Lao PDR over a two-year period. METHODS: Net surface levels of deltamethrin were measured by wiping the net with filter paper and measuring the adsorbed deltamethrin using the CFT. A relationship between surface levels of deltamethrin and whole net levels was established by comparing results of the CFT with whole levels assayed by high-performance liquid chromatography (HPLC). An effective deltamethrin surface concentration (EC80) was determined by comparing mosquito mortality (WHO Cone Test) with CFT and HPLC results. Five positions (roof to bottom) on each of 23 matched nets were assayed for deltamethrin surface levels at 6, 12, and 24 months. Mosquito mortality assays (WHO Cone Tests) were performed on a subset of eleven 24-month old nets and compared with the proportion of failed nets as predicted by the CFT. RESULTS: At six months, the nets retained about 80% of the baseline (new net) levels of deltamethrin with no significant differences between net positions. At 12 months, ~15-40%, and at 24 months <10% of deltamethrin was retained on the nets, with significant differences appearing between positions. Results from the CFT show that 93% of the nets failed (deltamethrin surface levels ≤ EC80) at 24 months. This value is in agreement with 91% failure as determined by the WHO Cone Test on a subset of 11 nets. The CFT results show that 50% of the nets from Laos failed at 12 months of normal use. CONCLUSION: The CFT is a useful and accurate indicator of net efficacy and may be substituted for mosquito bioassays. |
Research as a part of public health emergency response
Lurie N , Manolio T , Patterson AP , Collins F , Frieden T . N Engl J Med 2013 368 (13) 1251-1255 The authors review lessons learned from several recent public health emergencies and argue that we must conduct research during emergencies to improve our capacity to prevent illness and injury. They propose policies to facilitate timely research. |
Teaching population health: a competency map approach to education
Kaprielian VS , Silberberg M , McDonald MA , Koo D , Hull SK , Murphy G , Tran AN , Sheline BL , Halstater B , Martinez-Bianchi V , Weigle NJ , de Oliveira JS , Sangvai D , Copeland J , Tilson HH , Scutchfield FD , Michener JL . Acad Med 2013 88 (5) 626-37 A 2012 Institute of Medicine report is the latest in the growing number of calls to incorporate a population health approach in health professionals' training. Over the last decade, Duke University, particularly its Department of Community and Family Medicine, has been heavily involved with community partners in Durham, North Carolina, to improve the local community's health. On the basis of these initiatives, a group of interprofessional faculty began tackling the need to fill the curriculum gap to train future health professionals in public health practice, community engagement, critical thinking, and team skills to improve population health effectively in Durham and elsewhere. The Department of Community and Family Medicine has spent years in care delivery redesign and curriculum experimentation, design, and evaluation to distinguish the skills trainees and faculty need for population health improvement and to integrate them into educational programs. These clinical and educational experiences have led to a set of competencies that form an organizational framework for curricular planning and training. This framework delineates which learning objectives are appropriate and necessary for each learning level, from novice through expert, across multiple disciplines and domains. The resulting competency map has guided Duke's efforts to develop, implement, and assess training in population health for learners and faculty. In this article, the authors describe the competency map development process as well as examples of its application and evaluation at Duke and limitations to its use with the hope that other institutions will apply it in different settings. |
Learning about after action reporting from the 2009 H1N1 pandemic: a workshop summary
Stoto MA , Nelson C , Higdon MA , Kraemer J , Singleton CM . J Public Health Manag Pract 2013 19 (5) 420-7 OBJECTIVE: To analyze key variations in the after action report/improvement plan (AAR/IP) process used by state and local health departments following the 2009 H1N1 pandemic and identify ideas for improving that process. DESIGN: Workshop participants discussed their AAR findings and the methods used to prepare their reports and implications for improving the AAR/IP process in future events. PARTICIPANTS: Workshop participants included state and local health department personnel who had submitted AAR/IPs to the Centers for Disease Control and Prevention (CDC) for review. MEASURES: Workshop participants were asked to consider the question: On the basis of what you heard in this workshop, what would you do differently if you could redo your 2009 H1N1 AAR/IP? RESULTS: Workshop discussions revealed wide differences in the participants' understanding of the intended uses and users of the AAR/IPs, their scope, timing, and format, and the use of external consultants in their preparation, and on the strengths and weaknesses of various approaches. The AAR/IPs also varied in the extent to which they sought to identify root causes and the methods they used to do so. CONCLUSIONS: The AAR/IPs can be useful for both accountability and quality improvement, but these objectives require different foci and methodological approaches. Notably, the AAR/IPs can also be used as an opportunity to hold health departments accountable for conducting root cause analyses and making the improvements that follow from them. Federal agencies requiring the AAR/IPs should clarify the purpose and issues of scope and timing; develop training materials and exemplary cases of effective AAR/IPs, particularly of root cause analysis applied to public health emergency preparedness, professional guidelines, and standards for consultants; and consider developing a peer model for preparing AAR/IPs. |
Nursing and midwifery regulation and HIV scale-up: establishing a baseline in east, central and southern Africa
McCarthy CF , Voss J , Verani AR , Vidot P , Salmon ME , Riley PL . J Int AIDS Soc 2013 16 (1) 18051 INTRODUCTION: Shifting HIV treatment tasks from physicians to nurses and midwives is essential to scaling-up HIV services in sub-Saharan Africa. Updating nursing and midwifery regulations to include task shifting and pre-service education reform can help facilitate reaching new HIV targets. Donor-supported initiatives to update nursing and midwifery regulations are increasing. However, there are gaps in our knowledge of current practice and education regulations and a lack of information to target and implement regulation strengthening efforts. We conducted a survey of national nursing and midwifery councils to describe current nursing and midwifery regulations in 13 African countries. METHODS: A 30-item survey was administered to a convenience sample of 13 national nursing and midwifery regulatory body leaders in attendance at the PEPFAR-supported African Health Profession Regulatory Collaborative meeting in Nairobi, Kenya on 28 February, 2011. The survey contained questions on task shifting and regulations such as registration, licensure, scope of practice, pre-service education accreditation, continuing professional development and use of international guidelines. Survey data were analyzed to present country-level, comparative and regional findings. RESULTS: Task shifting to nurses and midwives was reported in 11 of the 13 countries. Eight countries updated their scope of practice within the last five years; only one reported their regulations to reflect task shifting. Countries vary with regard to licensure, pre-service accreditation and continuing professional development regulations in place. There was no consistency in terms of what standards were used to design national practice and education regulations. DISCUSSION: Many opportunities exist to assist countries to modernise regulations to incorporate important advancements from task shifting and pre-service reform. Appropriate, revised regulations can help sustain successful health workforce strategies and contribute to further scale-up HIV services and other global health priorities. CONCLUSIONS: This study provides fundamental information from which to articulate goals and to measure the impact of regulation strengthening efforts. |
Screening low-income women of reproductive age for cardiovascular disease risk factors
Robbins CL , Keyserling TC , Pitts SB , Morrow J , Majette N , Sisneros JA , Ronay A , Farr SL , Urrutia RP , Dietz PM . J Womens Health (Larchmt) 2013 22 (4) 314-21 BACKGROUND: Identifying and treating chronic diseases, their precursors, and other cardiovascular disease (CVD) risk factors during family planning visits may improve long-term health and reproductive outcomes among low-income women. A cross-sectional study design was used to describe the prevalence of chronic diseases (hypertension, high cholesterol, and diabetes), their precursors (pre-hypertension, borderline high cholesterol, and pre-diabetes), and related CVD risk factors (such as obesity, smoking, and physical inactivity) among low-income women of reproductive age. METHODS: Prevalence of chronic diseases, their precursors, and related CVD risk factors were assessed for 462 out of 859 (53.8%) female family planning patients, ages 18-44 years, who attended a Title X clinic in eastern North Carolina during 2011 and 2012 and consented to participate. Data were obtained from clinical measurements, blood test results, and questionnaire. Differences in distribution of demographic and health care characteristics and CVD risk factors by presence of prehypertension and pre-diabetes were assessed by Pearson chi-square tests. RESULTS: The prevalence of hypertension was 12%, high cholesterol 16%, and diabetes 3%. Nearly two-thirds of women with hypertension were newly diagnosed (62%) as were 75% of women with diabetes. The prevalence of pre-hypertension was 35%, pre-diabetes 31%, obesity 41%, smoking 32%, and physical inactivity 42%. The majority of participants (87%) had one or more chronic disease or related cardiovascular disease risk factor. CONCLUSIONS: CVD screening during family planning visits can identify significant numbers of women at risk for poor pregnancy outcomes and future chronic disease and can provide prevention opportunities if effective interventions are available and acceptable to this population. |
Meeting the contraceptive needs of teens and young adults: youth-friendly and long-acting reversible contraceptive services in U.S. family planning facilities
Kavanaugh ML , Jerman J , Ethier K , Moskosky S . J Adolesc Health 2013 52 (3) 284-92 PURPOSE: Increased use of contraceptive services, including long-acting reversible contraceptives (LARCs), among sexually active teens and young adults could significantly reduce unintended pregnancy. Objectives were to describe youth-friendly contraceptive services (including LARC) available to teens and young adults at U.S. publicly funded family planning facilities. METHODS: Between April and September 2011, center directors at a nationally representative sample of 1,196 U.S. publicly funded family planning facilities were surveyed to assess accessibility and provision of contraceptive services for teens and young adults; 584 (52%) responded. RESULTS: Facilities were accessible to young clients in several ways, including not requiring scheduled appointments for method refills (67%) and having flexible hours (64%). Most facilities provided outreach and/or education to young people (70%), and 27% used social network media to do this. Most facilities took steps to ensure confidentiality for young clients. These youth-friendly practices were more common at Planned Parenthood, Title X, and reproductive health focused facilities than at other facilities. Long-acting reversible contraceptive methods were regularly discussed with younger clients at less than half the facilities. Youth-friendly sites had increased rates of LARC provision among younger clients. The most common challenges to providing contraceptive and LARC services to younger clients were the costs of LARC methods (60%), inconvenient clinic hours (51%), staff concerns about intrauterine device (IUD) use among teens (47%), and limited training on implant insertion (47%). CONCLUSIONS: Improving the ability of family planning facilities to provide youth-friendly contraceptive and LARC-specific methods to younger clients may increase the use of highly effective contraception in this population. |
Preconception care: the perfect opportunity for health care providers to advise lifestyle changes for hypertensive women
Bombard JM , Robbins CL , Dietz PM , Valderrama AL . Am J Health Promot 2013 27 S43-9 PURPOSE: To provide estimates for prevalence of health care provider advice offered to reproductive-aged women and to assess their association with behavior change. DESIGN: Cross-sectional study using the 2009 Behavioral Risk Factor Surveillance System. SETTING: Nineteen states/areas. SUBJECTS: Women aged 18 to 44 years with a self-reported history of hypertension or current antihypertensive medication use (n = 2063). MEASURES: Self-reported hypertension; sociodemographic and health care access indicators; and provider advice and corresponding self-reported behavior change to improve diet, limit salt intake, exercise, and reduce alcohol use. ANALYSIS: We estimated prevalence and prevalence ratios for receipt of provider advice and action to change habits. We calculated 95% confidence interval (CI) and used chi(2) tests to assess associations. RESULTS: Overall, 9.8% of reproductive-aged women had self-reported hypertension; most reported receiving advice to change eating habits (72.9%), reduce salt intake (74.6%), and exercise (82.1%), and most reported making these changes. Only 44.7% reported receiving advice to reduce alcohol intake. Women who received provider advice were more likely to report corresponding behavior change compared to those who did not (prevalence ratios ranged from 1.3 [95% CI, 1.2-1.5, p < .05] for exercise to 1.6 [95% CI, 1.4-1.8, p < .05] for reducing alcohol use. CONCLUSION: Health care providers should routinely advise hypertensive reproductive-aged women about lifestyle changes to reduce blood pressure and improve pregnancy outcomes. |
Effective strategies for promoting preconception health--from research to practice
Mitchell EW , Verbiest S . Am J Health Promot 2013 27 S1-3 The development and publication of this supplement of the American Journal of Health Promotion have provided an opportunity to connect with new partners in the field of preconception health education, assess the current state of the science on this topic, and note gaps in research that we hope readers will consider filling. As guest editors, we appreciate our colleagues who submitted articles for consideration, the guest reviewers for their time and willingness to serve, and the journal staff for their flexibility and support throughout the process. This supplement serves as a platform to elevate contributions made in the context of preconception health promotion since 2006 as well as to issue a call to action to expand the work being done in this important arena. | Six years ago, in partnership with over 35 national organizations and hundreds of partners, a select panel of experts on preconception health issued a series of 4 goals, 10 recommendations, and over 40 action steps focused on improving the health and well-being of women and men of childbearing age.1 The recommendations addressed a number of domains, including consumer education, clinical care, advocacy and policy, research, and public health and community interventions. A complete list of the recommendations and action steps is included in the online version of this article (http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5506a1.htm). Four national workgroups were created to move this agenda forward based on these different domains. To catalyze action in the context of consumer education and health promotion, the National Preconception Health Consumer Workgroup was formed. A main charge of the consumer workgroup continues to be to improve the knowledge, attitudes, and behaviors of men and women related to preconception health by using information that is relevant across various age groups, literacy levels, and cultural and ethnic groups.1 This journal issue on preconception health focuses mainly on women's preconception health and is one example of the consumer workgroup's efforts. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Environmental Health
- Epidemiology and Surveillance
- Genetics and Genomics
- Health Behavior and Risk
- Immunity and Immunization
- Injury and Violence
- Laboratory Sciences
- Maternal and Child Health
- Nutritional Sciences
- Occupational Safety and Health - Mining
- Parasitic Diseases
- Public Health Leadership and Management
- Reproductive Health
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