Risk of venous thromboembolism occurrence among adults with selected autoimmune diseases: a study among a U.S. cohort of commercial insurance enrollees
Yusuf HR , Hooper WC , Grosse SD , Parker CS , Boulet SL , Ortel TL . Thromb Res 2015 135 (1) 50-7 OBJECTIVE: This study assessed the risk of venous thromboembolism (VTE) among privately insured adults in the U.S. with one or more of the following autoimmune diseases: autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), rheumatoid arthritis (RA), and systemic lupus erythematosus (SLE). MATERIALS AND METHODS: Using the Truven Health MarketScan(R) Databases, patients 18-64 years of age with a diagnosis of AIHA, ITP, RA, or SLE in 2007 and a sex and age-group matched comparison group of enrollees were followed up through 2010 to identify VTE events. Survival curve and Cox proportional hazards analyses were conducted to assess differences between groups. RESULTS: Among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases, the risk of at least one VTE event was 19.74, 7.72, 4.90, 9.89, and 13.35 per 1,000 person-years, respectively; among the comparison group, the risk was 1.91 per 1,000 person-years. The adjusted hazard ratios (aHRs) for VTE among patients with AIHA, ITP, RA, or SLE, or >1 of these diseases (when compared with the comparison group) tended to decline over follow-up time; at 1year, the aHRs were 6.30 (95% confidence interval [CI]: 4.44-8.94), 2.95 (95% CI: 2.18-4.00), 2.13 (95% CI: 1.89-2.40), 4.68 (95% CI: 4.10-5.33), and 5.11 (95% CI: 4.26-6.14), respectively. CONCLUSION: Having AIHA, ITP, RA, or SLE, or >1 of these diseases was associated with an increased likelihood of a VTE event. More research is necessary to develop better understanding of VTE occurrence among people with autoimmune diseases. |
Trends in diabetes incidence among 7 million insured adults, 2006-2011: the SUPREME-DM project
Nichols GA , Schroeder EB , Karter AJ , Gregg EW , Desai J , Lawrence JM , O'Connor PJ , Xu S , Newton KM , Raebel MA , Pathak RD , Waitzfelder B , Segal J , Lafata JE , Butler MG , Kirchner HL , Thomas A , Steiner JF . Am J Epidemiol 2015 181 (1) 32-9 An observational cohort analysis was conducted within the Surveillance, Prevention, and Management of Diabetes Mellitus (SUPREME-DM) DataLink, a consortium of 11 integrated health-care delivery systems with electronic health records in 10 US states. Among nearly 7 million adults aged 20 years or older, we estimated annual diabetes incidence per 1,000 persons overall and by age, sex, race/ethnicity, and body mass index. We identified 289,050 incident cases of diabetes. Age- and sex-adjusted population incidence was stable between 2006 and 2010, ranging from 10.3 per 1,000 adults (95% confidence interval (CI): 9.8, 10.7) to 11.3 per 1,000 adults (95% CI: 11.0, 11.7). Adjusted incidence was significantly higher in 2011 (11.5, 95% CI: 10.9, 12.0) than in the 2 years with the lowest incidence. A similar pattern was observed in most prespecified subgroups, but only the differences for persons who were not white were significant. In 2006, 56% of incident cases had a glycated hemoglobin (hemoglobin A1c) test as one of the pair of events identifying diabetes. By 2011, that number was 74%. In conclusion, overall diabetes incidence in this population did not significantly increase between 2006 and 2010, but increases in hemoglobin A1c testing may have contributed to rising diabetes incidence among nonwhites in 2011. |
Update on prevalence of periodontitis in adults in the United States: NHANES 2009-2012
Eke PI , Dye BA , Wei L , Slade GD , Thornton-Evans GO , Borgnakke WS , Taylor GW , Page RC , Beck JD , Genco RJ . J Periodontol 2015 86 (5) 1-18 This report describes prevalence, severity, and extent of periodontitis in the US adult population using combined data from the 2009-2010 and 2011-2012 cycles of the National Health and Nutrition Examination Survey (NHANES). METHODS: Estimates were derived for dentate adults 30 years and older from the civilian non-institutionalized population. Periodontitis was defined by combinations of clinical attachment loss (CAL) and periodontal probing depth (PPD) from six sites per tooth on all teeth, except third molars, using standard surveillance case definitions. For the first time in NHANES history, sufficient numbers of Non-Hispanic Asians were sampled in 2011-2012 to provide reliable estimates of their periodontitis prevalence. RESULTS: In 2009-2012, 46% of US adults representing 64.7 million people had periodontitis, with 8.9% having severe periodontitis. Overall, 3.8% of all periodontal sites (10.6% of all teeth) had PPD≥4 mm and 19.3% of sites (37.4% teeth) had CAL≥3 mm. Periodontitis prevalence was positively associated with increasing age and was higher among males. Periodontitis prevalence was highest in Hispanics (63.5%) and Non-Hispanic blacks (59.1%), followed by Non-Hispanic Asian Americans (50.0%), and lowest in Non-Hispanic whites (40.8%). Prevalence varied two-fold between the lowest and highest levels of socioeconomic status, whether defined by poverty or education. CONCLUSION(S): This study confirms a high prevalence of periodontitis in US adults aged 30 years and older, with almost half affected. The prevalence was greater in Non-Hispanic Asians than Non-Hispanic whites, although lower than other minorities. The distribution provides valuable information for population-based action to prevent or manage periodontitis in US adults. |
Exploring better links between clinics and communities to improve population health
Briss PA . Prev Chronic Dis 2015 12 E03 In this issue of Preventing Chronic Disease, Kristal et al (1) report on analyses of several standardized questions about health behaviors related to sugar-sweetened beverage consumption and other aspects of diet and physical activity in a Bronx population served by several federally qualified health centers. These analyses are part of a larger project that links clinical and community approaches to measuring and improving diet and physical activity behaviors. Other components of the larger project included electronic health record (EHR)–based referrals to community diabetes prevention resources and enhanced community access to more healthful foods. The larger project illustrates several innovative approaches that health care and community organizations might use for advancing population health through improved delivery of high-quality health care and better links between clinical and community resources. | The study by Kristal et al highlights the importance of measuring and acting on health-risk behaviors in both clinical and community settings. In the United States, just 4 modifiable risk behaviors (tobacco use, poor nutrition, physical inactivity, and unhealthy alcohol use) account for about 40% of mortality (2). In their study, Kristal et al programmed questions for assessing selected risk behaviors into the EHR. These questions, derived from the state-based Behavioral Risk Factor Surveillance System, also are used in the New York City Community Health Survey. The use of similar questions at several population levels (ie, clinic, community, and state) increases the ability of health care and community health providers and decision makers to use comparable data on risk factors and health outcomes in populations in different settings and at local, state, and national levels for diverse purposes — detecting problems, monitoring trends, targeting and triggering interventions, and comparing the results achieved in various health care and community contexts. |
Health-related quality of life and asthma among United States adolescents
Cui W , Zack MM , Zahran HS . J Pediatr 2015 166 (2) 358-64 OBJECTIVE: To examine the direction and the magnitude of associations between asthma and health-related quality of life (HRQoL) in a population-based sample of US adolescents. STUDY DESIGN: We obtained data from the 2001-2010 cross-sectional National Health and Nutrition Examination Survey. We used multinomial logistic regression and negative binomial regression to estimate corresponding percentages, prevalence ratios (PRs), and predicted days of 4 domains of HRQoL by 3 asthma status categories: never having asthma, having asthma without symptoms, and having asthma with symptoms. RESULTS: Compared with those who never had asthma, adolescents with asthma with symptoms of dry cough or wheezing reported significantly worse self-rated health (13.58% [95% CI, 10.32%-17.67%] vs 7.54% [95% CI, 6.50%-8.72%] for fair or poor health), significantly impaired physical health (PR = 1.34, P = .004; adjusted physically unhealthy days, 2.7 days vs 2 days), and impaired mental health (PR = 1.26, P = .025). Among adolescents having asthma with symptoms, those who currently smoked reported 1 more physically unhealthy day and 2.4 more mentally unhealthy days than those who did not smoke and did not have asthma. Those reporting limited physical functioning reported 2 more physically unhealthy days and 1.5 more mentally unhealthy days than those who did not report limited functioning. CONCLUSION: Adolescents with asthma and symptoms reported worse HRQoL compared with those with asthma not reporting symptoms and those without asthma. Those who smoked or reported limited physical functioning reported worse physical and mental HRQoL. Reducing symptoms, quitting smoking, and improving physical functioning may improve HRQoL among adolescents with asthma. |
High dietary acid load predicts ESRD among adults with CKD
Banerjee T , Crews DC , Wesson DE , Tilea AM , Saran R , Rios-Burrows N , Williams DE , Powe NR . J Am Soc Nephrol 2015 26 (7) 1693-700 Small clinical trials have shown that a reduction in dietary acid load (DAL) improves kidney injury and slows kidney function decline; however, the relationship between DAL and risk of ESRD in a population-based cohort with CKD remains unexamined. We examined the association between DAL, quantified by net acid excretion (NAEes), and progression to ESRD in a nationally representative sample of adults in the United States. Among 1486 adults with CKD age≥20 years enrolled in the National Health and Nutrition Examination Survey III, DAL was determined by 24-h dietary recall questionnaire. The development of ESRD was ascertained over a median 14.2 years of follow-up through linkage with the Medicare ESRD Registry. We used the Fine-Gray competing risks method to estimate the association of high, medium, and low DAL with ESRD after adjusting for demographics, nutritional factors, clinical factors, and kidney function/damage markers and accounting for intervening mortality events. In total, 311 (20.9%) participants developed ESRD. Higher levels of DAL were associated with increased risk of ESRD; relative hazards (95% confidence interval) were 3.04 (1.58 to 5.86) for the highest tertile and 1.81 (0.89 to 3.68) for the middle tertile compared with the lowest tertile in the fully adjusted model. The risk of ESRD associated with DAL tertiles increased as eGFR decreased (P trend=0.001). Among participants with albuminuria, high DAL was strongly associated with ESRD risk (P trend=0.03). In conclusion, high DAL in persons with CKD is independently associated with increased risk of ESRD in a nationally representative population. |
Hypertension-related congestive heart failure in West Africa: a framework for global blood pressure control
Patel P , DiPette DJ . J Clin Hypertens (Greenwich) 2015 17 (4) 260-2 Despite significant advances in patient and healthcare provider education, nonpharmacologic recommendations, and the availability of safe and effective pharmacologic agents, hypertension and target organ damage secondary to the hypertensive process (ie, coronary artery disease, congestive heart failure, renal failure, and stroke) remains a major public health issue and significant cause of morbidity and mortality. While hypertension continues to be a concern in high‐income countries, such as the United States, the prevalence of hypertension is markedly increasing in low‐ and middle‐income countries.1 Thus, hypertension, as a leading cardiovascular disease risk factor, is a global concern affecting approximately 1 billion persons worldwide.2 To address the increasing importance of hypertension globally and in low‐ and middle‐income countries specifically, Ogah and colleagues report in this issue of the Journal an important and timely prospective observational study of the presentation and outcome of hypertensive heart failure in Nigerian Africans. The data were accrued from the Abeokuta Heart Failure Registry from the south Western Region of Nigeria. | The study is from a single, tertiary care medical center located in an urban city of approximately 1 million people, and the patients were studied for a 2‐year period between early 2009 to the end of 2010. During this period, a total of 452 patients were admitted to the medical center with a diagnosis of heart failure (9% of all admissions), of which 355 patients had heart failure secondary to hypertensive heart disease. Of these, 320 patients had complete data available and were included in the study. The diagnosis of heart failure was made and blood pressures were determined by standard criteria that included M‐mode and Doppler echocardiography (all read by a single observer) and by mercury sphygmomanometry, respectively. Data from the acute hospitalization were obtained and the patients were followed at periodic intervals for 180 days. Of the 320 patients studied, the mean age was 59 years and there were a greater number of men compared with women (58% vs 42%, respectively). A majority of the patients were married (73%), achieved a primary education (64%), were employed (95%), and lived within the urban catchment area (73%). Interestingly, 85% of the participants had de novo hypertensive heart failure while the remaining 15% had a history of hypertensive heart failure. Approximately, 12% had diabetes mellitus. It is interesting, as the authors point out, that the prevalence of comorbidities in the cohort was lower than reported in North America or Europe, while the severity of cardiovascular disease was markedly higher. Corroborative evidence was recently reported from the Prospective Urban and Rural Epidemiological Study (PURE), which demonstrated that among 17 low‐, middle‐, and high‐income countries, countries with low‐income status had the lowest risk burden yet substantially higher rates of cardiovascular morbidity and mortality compared with high‐income countries.3 |
Impact of inhibitors on hemophilia A mortality in the United States
Walsh CE , Soucie JM , Miller CH . Am J Hematol 2015 90 (5) 400-5 The previously published mortality studies are limited in hemophilia populations but suggest that there is no increased risk of mortality in factor VIII inhibitor patients. This retrospective study analyzed surveillance data collected on 7,386 males with severe hemophilia A over a 13-year period to assess the association between a current inhibitor and death. During the study period, 432 participants died, among whom 48 were patients with an inhibitor. Clinical characteristics most strongly associated with death were increased number of reported bleeds, signs of liver disease, infection with either HIV or HCV, and the presence of inhibitor. Patients who underwent successful tolerization were not considered inhibitor patients in our analysis. In a multivariable analysis, the odds of death were 70% higher among patients with a current inhibitor compared to those without an inhibitor (P < 0.01). Deaths among patients with inhibitors were much more likely to be attributed to bleeding complications than those among patients without an inhibitor (42 vs. 12%, P < 0.0001). We conclude that males with severe hemophilia A and a current inhibitor are at increased risk of death. |
Incidence and prevalence of Parkinson's disease among Navajo people living in the Navajo nation
Gordon PH , Mehal JM , Holman RC , Bartholomew ML , Cheek JE , Rowland AS . Mov Disord 2015 30 (5) 714-20 Parkinson's disease (PD) is largely unstudied among American Indians. Unique populations might harbor clues to elusive causes. We describe the incidence and prevalence of PD among Navajo people residing in the Navajo Nation, home to the largest American Indian tribe in the United States. We analyzed 2001-2011 inpatient and outpatient visit data for Navajo people obtained from the Indian Health Service, which provides health care to American Indian people living on the Navajo Reservation. Cases were defined by at least two inpatient or outpatient visits with the diagnosis of PD. Crude and age-adjusted incidence and prevalence rates were calculated overall as well as by age, sex, region of residence, and time period. Five hundred twenty-four Navajo people with median age-at-onset of 74.0 years were diagnosed with PD during the study period, yielding an average annual crude incidence rate of 22.5/100,000. Age-specific incidence was 232.0 for patients 65 years of age or older and 302.0 for 80 years of age or older. Age-adjusted incidence was 35.9 overall (238.1 for ≥65 years), was higher in men than in women (47.5 vs. 27.7; P < 0.001), varied by region (P = 0.03), and was similar between time periods (2002-2004 vs. 2009-2011). The age-adjusted point prevalence rate was 261.0. The rate of PD among Navajo People appears to be as high as or higher than rates reported in many other populations. Rates increased to the highest age group, consistent with population-based studies. Further investigation is warranted to examine risk factors for PD in this remote population. (c) 2015 International Parkinson and Movement Disorder Society. |
The association between objectively measured sedentary behavior and red blood cell distribution width in a national sample of US adults
Loprinzi PD , Ford ES . Am J Epidemiol 2015 181 (5) 357-9 Red blood cell distribution width (RDW), an indicator of anisocytosis, is a novel biomarker of cardiovascular disease (CVD) and all-cause mortality (1). Although findings are inconclusive, the pathophysiology linking RDW with morbidity/mortality may pertain to inflammation and/or disordered iron homeostasis (2). Consequently, identification of modifiable behaviors for prevention of unequal RDW, particularly in the general population, is needed. | Emerging research demonstrates that sedentary behavior (SB), even independently of physical activity, is predictive of CVD and premature mortality (3). Although results have been inconclusive, potential mechanisms for explaining this relationship include SB-induced inflammation and modulation of metabolic risk (4). Consequently, it is plausible to suggest that SB may be related to CVD and mortality via SB-induced anisocytosis. However, to our knowledge, no study has yet examined the association between SB and RDW. Identification of such an association may help to delineate a potential mechanism through which SB may influence CVD. Therefore, we decided to evaluate this possible association. |
Craniosynostosis and risk factors related to thyroid dysfunction
Carmichael S , Ma C , Rasmussen S , Cunningham M , Browne M , Dosiou C , Lammer E , Shaw G . Am J Med Genet A 2015 167A (4) 701-7 Thyroid disease is a common problem among women of reproductive age but often goes undiagnosed. Maternal thyroid disease has been associated with increased risk of craniosynostosis. We hypothesized that known risk factors for thyroid disease would be associated with risk of craniosynostosis among women not diagnosed with thyroid disease. Analyses included mothers of 1,067 cases and 8,494 population-based controls who were interviewed for the National Birth Defects Prevention Study. We used multivariable logistic regression to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CI). After excluding women with diagnosed thyroid disease, younger maternal age (AOR 0.7, 95% CI 0.6-0.9, for <25 years versus 25-29), black or other race-ethnicity (AOR 0.3, 95% CI 0.2-0.4 and AOR 0.6, 95% CI 0.4-0.8, respectively, relative to non-Hispanic whites), fertility medications or procedures (AOR 1.5, 95% CI 1.2-2.0), and alcohol consumption (AOR 0.8, 95% CI 0.7-0.9) were associated with risk of craniosynostosis, based on confidence intervals that excluded 1.0. These associations with craniosynostosis are consistent with the direction of their association with thyroid dysfunction (i.e., younger age, black race-ethnicity and alcohol consumption are associated with reduced risk and fertility problems are associated with increased risk of thyroid disease). This study thus provides support for the hypothesis that risk factors associated with thyroid dysfunction are also associated with risk of craniosynostosis. Improved understanding of the potential association between maternal thyroid function and craniosynostosis among offspring is important given that craniosynostosis carries significant morbidity and that thyroid disease is under-diagnosed and potentially modifiable. |
Tuberculosis incidence after 36 months' isoniazid prophylaxis in HIV-infected adults in Botswana: a posttrial observational analysis
Samandari T , Agizew TB , Nyirenda S , Tedla Z , Sibanda T , Mosimaneotsile B , Motsamai OI , Shang N , Rose CE , Shepherd J . AIDS 2015 29 (3) 351-9 OBJECTIVE: Thirty-six months of isoniazid preventive therapy (36IPT) was superior to 6 months of IPT (6IPT) in preventing tuberculosis (TB) among HIV-infected adults in Botswana. We assessed the posttrial durability of this benefit. DESIGN: A 36-month double-blind placebo controlled trial (1 : 1 randomization) with recruitment between November 2004 and July 2006 and observation until June 2011. METHODS: One thousand, nine hundred and ninety-five participants were followed in eight public health clinics. Twenty-four percent had a tuberculin skin test ≥5 mm (TST-positive). A minimum CD4 lymphocyte count was not required for enrolment. Antiretroviral therapy (ART) was provided in accordance with Botswana guidelines; 72% of participants retained by June 2011 had initiated ART. Multivariable analysis using Cox regression analysis included treatment arm, TST status, ART as a time-dependent variable and CD4 cell count at baseline and updated at 36 months. RESULTS: In the posttrial period, 2.13 and 2.14 per 100 person-years accumulated, whereas 0.93 and 1.13% TB incidence rates were observed in the 36IPT and 6IPT arms, respectively (P = 0.52). The crude hazard ratio of TB during the trial and posttrial was 0.57 [95% confidence intervals (CI) 0.33, 0.99] and 0.82 (95% CI 0.46, 1.49), and when restricted to TST-positive participants was 0.26 (95% CI 0.08, 0.80) and 0.40 (95% CI 0.15, 1.08), respectively. Multivariable analysis showed that ART use was associated with reduced death (adjusted hazard ratio 0.36, 95% CI 0.17-0.75) but not TB (0.92, 95% CI 0.55-1.53) in the posttrial period. CONCLUSION: The benefit of 36IPT for TB prevention declined posttrial in this cohort. Adjunctive measures are warranted to prevent TB among HIV-infected persons receiving long-term ART in TB-endemic settings. |
Polio eradicators use integrated analytical models to make better decisions
Thompson KM , Duintjer Tebbens RJ , Pallansch MA , Wassilak SGF , Cochi SL . Interfaces (Providence) 2015 45 (1) 5-25 Achieving global polio eradication requires that global stakeholders coordinate and cooperate to invest human and financial resources in interventions that prevent virus transmission. Reaching this goal depends on effective tools and interventions, and their optimal use. Poliovirus transmission occurs in a complex global system with rapidly evolving viruses that readily cross international borders. The U.S. Centers for Disease Control and Prevention, one of four spearheading partners of the Global Polio Eradication Initiative (GPEI), initiated a collaboration with Kid Risk, Inc. to develop and apply integrated analytical models to answer high-stakes policy questions related to managing the risks of polioviruses with consideration of human health and economic outcomes. Over the last decade, the collaboration innovatively combined numerous operations research and management science tools, including simulation, decision and risk analysis, system dynamics, and optimization to help policy makers understand and quantify the implications of their choices. These integrated modeling efforts helped motivate faster responses to polio outbreaks, leading to a global resolution and significantly reduced response time and outbreak sizes. Insights from the models also underpinned a 192-country resolution to coordinate global cessation of the use of one of the two vaccines after wild poliovirus eradication (i.e., allowing continued use of the other vaccine as desired). Finally, the model results helped us to make the economic case for a continued commitment to polio eradication by quantifying the value of prevention and showing the health and economic outcomes associated with the alternatives. The work helped to raise the billions of dollars needed to support polio eradication. The investments will prevent devastating cases of polio and realize an estimated $40-$50 billion in net benefits by the countries covered by the GPEI, while protecting the significantly larger net benefits enjoyed by the countries that stopped wild poliovirus transmission without support of the GPEI. |
Early HIV infections among men who have sex with men in five cities in the United States
Paz-Bailey G , Smith A , Masciotra S , Zhang W , Bingham T , Flynn C , German D , Al-Tayyib A , Magnus M , LaLota M , Rose CE , Owen SM . AIDS Behav 2015 19 (12) 2304-10 We tested blood samples from men who have sex with men (MSM) to detect early HIV infection. Early HIV included both acute (infected past 30 days) and recent (estimated recency past 240 days). Acute infections were defined as screen immunoassay (IA) negative/NAAT-positive or IA-positive/Multispot-negative/NAAT-positive. Recent infections were defined as avidity index cutoff <30 % on an avidity-based IA and, (1) not reporting antiretroviral therapy use or, (2) HIV RNA >150 copies/mL. Of 937 samples, 26 % (244) were HIV-infected and of these 5 % (12) were early. Of early infections, 2 were acute and 10 recent; most (8/12) were among black MSM. Early infection was associated with last partner of black race [adjusted relative risk (ARR) = 4.6, confidence intervals (CI) 1.2-17.3], receptive anal sex at last sex (ARR = 4.3, CI 1.2-15.0), and daily Internet use to meet partners/friends (ARR = 3.3, CI 1.1-9.7). Expanding prevention and treatment for black MSM will be necessary for reducing incidence in the United States. |
Findings from integrated behavioral and biologic survey among males who inject drugs (MWID) - Vietnam, 2009-2010: evidence of the need for an integrated response to HIV, hepatitis B virus, and hepatitis C virus
Nadol P , O'Connor S , Duong H , Le LV , Thang PH , Tram TH , Ha HT , McConnell MS , Partridge J , Kaldor J , Law M , Nguyen TA . PLoS One 2015 10 (2) e0118304 INTRODUCTION: Given the overlapping modes of transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV), understanding the burden and relationship of these infections is critical for an effective response. Representative data on these infections among males who inject drugs (MWID), the key high-risk population for HIV in Vietnam, are currently lacking. METHODS: Data and stored specimens from Vietnam's 2009-2010 Integrated Biologic and Behavioral Survey, a cross-sectional study among high-risk populations, were used for this analysis. Plasma samples were tested for HIV, HBV, and HCV using commercial assays. A questionnaire was administered to provide demographic, behavior, and service-uptake information. Provincial-level analyses were conducted to profile MWID enrollees and to provide estimates on the prevalence of HIV, HBV, and HCV infection. RESULTS: Among 3010 MWID sampled across 10 provinces, the median (range) HIV prevalence was 28.1% (1.0%-55.5%). Median prevalence for current HBV infection (HBsAg+) was 14.1% (11.7%-28.0%), for previous exposure to HBV (total anti-HBc+) was 71.4% (49.9%-83.1%), and for current or past HCV infection (HCV Ag/Ab+) was 53.8% (10.9%-80.8%). In adjusted analysis, HBsAg+ (aOR: 2.09, 1.01-4.34) and HCV Ag/Ab+ (aOR: 19.58, 13.07-29.33) status were significantly associated with HIV infection; the association with total anti-HBc+ approached significance (aOR: 1.29, 0.99-1.68). CONCLUSION: The prevalence and association between HIV, HBV, and HCV are high among MWID in Vietnam. These findings indicate the need for integrated policies and practice that for the surveillance, prevention, screening, and treatment of both HIV and viral hepatitis among MWID in Vietnam. |
Hepatitis A outbreak among adults with developmental disabilities in group homes - Michigan, 2013
Bohm SR , Berger KW , Hackert PB , Renas R , Brunette S , Parker N , Padro C , Hocking A , Hedemark M , Edwards R , Bush RL , Khudyakov Y , Nelson NP , Teshale EH . MMWR Morb Mortal Wkly Rep 2015 64 (6) 148-52 Hepatitis A virus (HAV) infections among persons with developmental disabilities living in institutions were common in the past, but with improvements in care and fewer persons institutionalized, the number of HAV infections has declined in these institutions. However, residents in institutions are still vulnerable if they have not been vaccinated. On April 24, 2013, a resident of a group home (GH) for adults with disabilities in southeast Michigan (GH-A) was diagnosed with hepatitis A and died 2 days later of fulminant liver failure. Four weeks later, a second GH-A resident was diagnosed with hepatitis A. None of the GH-A residents or staff had been vaccinated against hepatitis A. Over the next 3 months, six more cases of hepatitis A were diagnosed in residents in four other Michigan GHs. Three local health departments were involved in case investigation and management, including administration of postexposure prophylaxis (PEP). Serum specimens from seven cases were found to have an identical strain of HAV genotype 1A. This report describes the outbreak investigation, the challenges of timely delivery of PEP for hepatitis A, and the need for preexposure vaccination against hepatitis A for adults living or working in GHs for the disabled. |
Household-level risk factors for influenza among young children in Dhaka, Bangladesh: a case-control study
Doshi S , Silk BJ , Dutt D , Ahmed M , Cohen AL , Taylor TH , Brooks WA , Goswami D , Luby SP , Fry AM , Ram PK . Trop Med Int Health 2015 20 (6) 719-29 OBJECTIVES: To identify household-level factors associated with influenza among young children in a crowded community in Dhaka, Bangladesh. METHODS: We conducted a case-control study using existing active surveillance for respiratory illness. Cases were children aged 12-59 months with laboratory-confirmed influenza. Controls were children frequency-matched by age group with no respiratory illness in the prior six months. We interviewed caregivers and observed household handwashing behavior. Soap consumption was estimated by summing weight differences of three bars of soap sequentially left in each household. We measured concentrations of airborne particulate matter <2.5 mug in diameter (PM2.5 ) in a subset of households. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI). RESULTS: We enrolled 145 cases and 341 controls between March 2009 and April 2010. Case and control household members were observed to wash hands with similar frequency during a five-hour period (mean, 0.64 events vs. 0.63, p=0.87), and similar daily soap consumption per capita (mean 2.92 grams vs. 2.93, p=0.92). Case households were more likely than controls to have crowded (≥4 persons) sleeping areas (aOR=1.67, CI: 1.06-2.63) and cross-ventilated cooking spaces (aOR=1.75, CI: 1.16-2.63). Case and control households had similar median 24-hour geometric mean PM2.5 concentrations in the cooking (69.2 vs. 69.6 mcg/m3 , p=0.45) and sleeping (65.4 vs. 67.4 mcg/m3 , p=0.19) spaces. CONCLUSIONS: Handwashing with soap was practiced infrequently, and was not associated with pediatric influenza in this community. Interventions aimed at crowded households may reduce influenza incidence in young children. |
Increases in recent HIV testing among men who have sex with men coincide with the Centers for Disease Control and Prevention's Expanded Testing Initiative
Cooley LA , Wejnert C , Rose CE , Paz-Bailey G . Clin Infect Dis 2015 60 (3) 483-5 According to National HIV Behavioral Surveillance system data, human immunodeficiency virus (HIV) testing increased among gay, bisexual, and other men who have sex with men from 2008 to 2011 in cities funded by the Centers for Disease Control and Prevention's Expanded Testing Initiative, suggesting that focused HIV testing initiatives might have positive effects. |
Comparison of antimicrobial susceptibility of pharyngeal, rectal, and urethral Neisseria gonorrhoeae isolates among men who have sex with men
Kidd S , Zaidi A , Asbel L , Baldwin T , Gratzer B , Guerry S , Kerani RP , Pathela P , Pettus K , Soge OO , Stirland A , Weinstock HS . Antimicrob Agents Chemother 2015 59 (5) 2588-95 The United States' surveillance for Neisseria gonorrhoeae antimicrobial susceptibility is based exclusively on male urethral isolates. These data inform gonorrhea treatment guidelines, including recommendations for treatment of extra-genital infection, but data on the susceptibility of extra-genital isolates are limited. We compared the antimicrobial susceptibility of pharyngeal, rectal, and urethral gonococcal isolates collected from men who have sex with men (MSM) at five sentinel sites throughout the United States. Minimum inhibitory concentrations (MICs) were determined by the agar dilution method. Generalized linear models were used to compare (1) the proportions of isolates with elevated MICs and (2) geometric mean MICs by anatomic site adjusted for city. During December 2011-September 2013, a total of 205 pharyngeal, 261 rectal, and 976 urethral isolates were obtained. The proportion of isolates with elevated ceftriaxone MICs (≥0.125 mug/ml) did not differ by anatomic site (0.5% of pharyngeal, 1.5% of rectal, and 1.7% of urethral isolates; city-adjusted odds ratio [95% CI] 0.4 [0.0, 3.9] for pharyngeal vs. urethral isolates, 0.9 [0.2, 4.2] for rectal vs. urethral isolates). The city-adjusted geometric mean ceftriaxone MICs of pharyngeal (0.0153 mug/ml) and rectal (0.0157 mug/ml) isolates did not differ from that of urethral isolates (0.0150 mug/ml) (ratio of geometric mean MICs [95% CI] 1.02 [0.90, 117] and 1.05 [0.93, 1.19], respectively). Similar results were observed for other antimicrobials, including cefixime and azithromycin. These findings suggest that, at the population level, gonococcal antimicrobial susceptibility surveillance based on urethral isolates from MSM adequately represents the susceptibility of N. gonorrhoeae circulating among MSM. |
Daily rifapentine for treatment of pulmonary tuberculosis. A randomized, dose-ranging trial
Dorman SE , Savic RM , Goldberg S , Stout JE , Schluger N , Muzanyi G , Johnson JL , Nahid P , Hecker EJ , Heilig CM , Bozeman L , Feng PJ , Moro RN , MacKenzie W , Dooley KE , Nuermberger EL , Vernon A , Weiner M . Am J Respir Crit Care Med 2015 191 (3) 333-43 RATIONALE: Rifapentine has potent activity in mouse models of tuberculosis chemotherapy but its optimal dose and exposure in humans are unknown. OBJECTIVES: We conducted a randomized, partially blinded dose-ranging study to determine tolerability, safety, and antimicrobial activity of daily rifapentine for pulmonary tuberculosis treatment. METHODS: Adults with sputum smear-positive pulmonary tuberculosis were assigned rifapentine 10, 15, or 20 mg/kg or rifampin 10 mg/kg daily for 8 weeks (intensive phase), with isoniazid, pyrazinamide, and ethambutol. The primary tolerability end point was treatment discontinuation. The primary efficacy end point was negative sputum cultures at completion of intensive phase. MEASUREMENTS AND MAIN RESULTS: A total of 334 participants were enrolled. At completion of intensive phase, cultures on solid media were negative in 81.3% of participants in the rifampin group versus 92.5% (P = 0.097), 89.4% (P = 0.29), and 94.7% (P = 0.049) in the rifapentine 10, 15, and 20 mg/kg groups. Liquid cultures were negative in 56.3% (rifampin group) versus 74.6% (P = 0.042), 69.7% (P = 0.16), and 82.5% (P = 0.004), respectively. Compared with the rifampin group, the proportion negative at the end of intensive phase was higher among rifapentine recipients who had high rifapentine areas under the concentration-time curve. Percentages of participants discontinuing assigned treatment for reasons other than microbiologic ineligibility were similar across groups (rifampin, 8.2%; rifapentine 10, 15, or 20 mg/kg, 3.4, 2.5, and 7.4%, respectively). CONCLUSIONS: Daily rifapentine was well-tolerated and safe. High rifapentine exposures were associated with high levels of sputum sterilization at completion of intensive phase. Further studies are warranted to determine if regimens that deliver high rifapentine exposures can shorten treatment duration to less than 6 months. Clinical trial registered with www.clinicaltrials.gov (NCT 00694629). |
Defining risk for prescription opioid overdose: pharmacy shopping and overlapping prescriptions among long-term opioid users in Medicaid
Yang Z , Wilsey B , Bohm M , Soulsby M , Roy K , Ritley D , Jones C , Melnikow J . J Pain 2015 16 (5) 445-53 Use of multiple pharmacies concurrently (pharmacy shopping) and overlapping prescriptions may be indicators for potential misuse or abuse of prescription opioid medications. To evaluate strategies for identifying patients at high risk, we first compared different definitions of pharmacy shopping and then added the indicator of overlapping opioid prescriptions. We identified a cohort of 90,010 Medicaid enrollees who used ≥3 opioid prescriptions for ≥90 days during 2008-10 from a multi-state Medicaid claims database. We compared the diagnostic odds ratios (DORs) for opioid overdose events of nine pharmacy shopping definitions. Within a 90-day interval, a threshold of four pharmacies had the highest DOR and was used to define pharmacy shopping. The overdose rate was higher in the subgroup with overlapping prescriptions (18.5 per 1,000 person years [PYs]) than in the subgroup with pharmacy shopping as the sole indicator (10.7 per 1,000 PYs). Among the subgroup with both conditions, the overdose rate was 26.3 per 1,000 PYs, compared with 4.3 per 1,000 PYs for those with neither condition. Overlapping opioid prescriptions and pharmacy shopping measures had adjusted hazard ratios of 3.0 and 1.8, respectively, for opioid overdose. Using these measures will improve accurate identification of patients at highest risk of opioid overdose, the first step in implementing targeted prevention policies. PERSPECTIVE: Long-term prescription opioid use may lead to adverse events, including overdose. Pharmacy shopping and overlapping opioid prescriptions are both associated with adverse outcomes. This study demonstrates that using both indicators will better identify those at high risk of overdose. |
Vinyl flooring in the home is associated with children's airborne butylbenzyl phthalate and urinary metabolite concentrations
Just AC , Miller RL , Perzanowski MS , Rundle AG , Chen Q , Jung KH , Hoepner L , Camann DE , Calafat AM , Perera FP , Whyatt RM . J Expo Sci Environ Epidemiol 2015 25 (6) 574-9 Prior studies have shown that vinyl flooring as well as the vinyl-softening plasticizers butylbenzyl phthalate (BBzP) and di(2-ethylhexyl) phthalate (DEHP) are associated with asthma and airway inflammation. Although DEHP exposure is primarily dietary, whether home vinyl flooring contributes to indoor air and urinary metabolite concentrations for these two phthalates is unclear. Exposures to BBzP and DEHP were examined in a prospective birth cohort of New York City children (n=239) using: (i) visual observation of potential phthalate containing flooring, (ii) a 2-week home indoor air sample, and (iii) concurrent urinary metabolites in a subset (n=193). The category "vinyl or linoleum" flooring was observed in 135 (56%) of monitored rooms; these rooms had statistically significantly higher indoor air geometric mean concentrations of BBzP (23.9 ng/m3) than rooms with wood or carpet flooring (10.6 ng/m3). Children from homes with "vinyl or linoleum" flooring also had significantly higher urinary BBzP metabolite concentrations than other children. Indoor air BBzP and urinary metabolite concentrations were correlated positively (Spearman's rho 0.40). By contrast, indoor air DEHP was not associated with flooring type nor with its urinary metabolite concentrations. Vinyl flooring in the home may be an important source of children's exposure to BBzP via indoor air. |
Notes from the field: use of unvalidated urine mycotoxin tests for the clinical diagnosis of illness - United States, 2014
Kawamoto M , Page E . MMWR Morb Mortal Wkly Rep 2015 64 (6) 157-8 In February 2014, CDC's National Institute for Occupational Safety and Health received a request for a health hazard evaluation from a union representative in an office building. A female employee reported the onset of symptoms involving multiple organ systems upon returning to work after a prolonged absence. The employee searched the Internet for descriptions of symptoms matching hers, found a laboratory offering "toxic mold testing" direct to consumers, and submitted a urine sample, despite the absence of musty odors and signs of fungal growth in her office. The laboratory reported "positive" concentrations of two mycotoxins: ochratoxin at 2.8 parts per billion (ppb) and tricothecenes at 0.4 ppb. The laboratory cutoff for "positive" was ≥2.0 ppb for ochratoxin and ≥0.2 ppb for tricothecenes. The interpretation accompanying the laboratory report said the results "revealed that you have an unusual level of that mycotoxin(s) present in your body." |
Hypothermia-related deaths - Wisconsin, 2014, and United States, 2003-2013
Meiman J , Anderson H , Tomasallo C . MMWR Morb Mortal Wkly Rep 2015 64 (6) 141-3 Hypothermia is defined as a core body temperature of <95 degrees F (<35 degrees C) and is caused by environmental exposure, drug intoxication, or metabolic or nervous system dysfunction. Exposure to cold is a leading cause of weather-related mortality and is responsible for approximately twice the number of deaths annually as exposure to heat in the United States. To understand the risk factors for hypothermia-related death and improve prevention efforts, during January 1-April 30, 2014, a period of record low temperatures, the Wisconsin Division of Public Health began active surveillance for hypothermia. Suspected hypothermia-related deaths were reported by coroners or medical examiners and identified in death records. Hypothermia was confirmed as the cause of death by review of death investigation narratives. This report describes three selected cases of hypothermia-related deaths in Wisconsin and summarizes characteristics of all cases that occurred in the state during the period of active surveillance. A summary of hypothermia-related deaths for the United States during 2003-2013 also is presented for comparison and to assess national mortality trends. Hypothermia continues to be an important cause of weather-related death. Key risk factors include drug intoxication, mental illness, and social isolation. State and local health agencies might need to focus outreach on vulnerable populations and target interventions for groups at highest risk for death. |
The perils of straying from protocol: sampling bias and interviewer effects
Ngongo CJ , Frick KD , Hightower AW , Mathingau FA , Burke H , Breiman RF . PLoS One 2015 10 (2) e0118025 Fidelity to research protocol is critical. In a contingent valuation study in an informal urban settlement in Nairobi, Kenya, participants responded differently to the three trained interviewers. Interviewer effects were present during the survey pilot, then magnified at the start of the main survey after a seemingly slight adaptation of the survey sampling protocol allowed interviewers to speak with the "closest neighbor" in the event that no one was home at a selected household. This slight degree of interviewer choice led to inferred sampling bias. Multinomial logistic regression and post-estimation tests revealed that the three interviewers' samples differed significantly from one another according to six demographic characteristics. The two female interviewers were 2.8 and 7.7 times less likely to talk with respondents of low socio-economic status than the male interviewer. Systematic error renders it impossible to determine which of the survey responses might be "correct." This experience demonstrates why researchers must take care to strictly follow sampling protocols, consistently train interviewers, and monitor responses by interview to ensure similarity between interviewers' groups and produce unbiased estimates of the parameters of interest. |
Notes from the field: fatal gastrointestinal mucormycosis in a premature infant associated with a contaminated dietary supplement - Connecticut, 2014
Vallabhaneni S , Walker TA , Lockhart SR , Ng D , Chiller T , Melchreit R , Brandt ME , Smith RM . MMWR Morb Mortal Wkly Rep 2015 64 (6) 155-6 In October 2014, a hospital in Connecticut notified CDC and the Connecticut Department of Public Health of a fatal case of gastrointestinal mucormycosis in a preterm infant. The infant, born at 29 weeks' gestation and weighing 1,400 grams (about 3 pounds), had developed signs and symptoms initially consistent with necrotizing enterocolitis approximately 1 week after birth. Exploratory laparotomy revealed complete ischemia of the gastrointestinal tract from the esophagus to the rectum; a portion of necrotic cecum was sent for microscopic examination. Following surgery, the infant developed multiple areas of vascular occlusion, including a large clot in the aorta, findings not usually associated with necrotizing enterocolitis. The infant died soon after. Histopathology results from the resected cecum revealed an angioinvasive fungal infection consistent with mucormycosis. Gastrointestinal mucormycosis is an extremely rare fungal infection caused by mold in the order Mucorales. It occurs predominantly in low birth weight infants, patients with diarrhea and malnutrition, and those receiving peritoneal dialysis; mortality is 85%. Local investigation revealed that the infant had received a dietary supplement, ABC Dophilus Powder, for 7 days, beginning on day 1 of life. |
Outbreak of Salmonella Newport infections linked to cucumbers - United States, 2014
Angelo KM , Chu A , Anand M , Nguyen TA , Bottichio L , Wise M , Williams I , Seelman S , Bell R , Fatica M , Lance S , Baldwin D , Shannon K , Lee H , Trees E , Strain E , Gieraltowski L . MMWR Morb Mortal Wkly Rep 2015 64 (6) 144-7 In August 2014, PulseNet, the national molecular subtyping network for foodborne disease surveillance, detected a multistate cluster of Salmonella enterica serotype Newport infections with an indistinguishable pulse-field gel electrophoresis (PFGE) pattern (XbaI PFGE pattern JJPX01.0061). Outbreaks of illnesses associated with this PFGE pattern have previously been linked to consumption of tomatoes harvested from Virginia's Eastern Shore in the Delmarva region and have not been linked to cucumbers or other produce items. To identify the contaminated food and find the source of the contamination, CDC, state and local health and agriculture departments and laboratories, and the Food and Drug Administration (FDA) conducted epidemiologic, traceback, and laboratory investigations. A total of 275 patients in 29 states and the District of Columbia were identified, with illness onsets occurring during May 20-September 30, 2014. Whole genome sequencing (WGS), a highly discriminating subtyping method, was used to further characterize PFGE pattern JJPX01.0061 isolates. Epidemiologic, microbiologic, and product traceback evidence suggests that cucumbers were a source of Salmonella Newport infections in this outbreak. The epidemiologic link to a novel outbreak vehicle suggests an environmental reservoir for Salmonella in the Delmarva region that should be identified and mitigated to prevent future outbreaks. |
Whole blood gene expression profiles distinguish clinical phenotypes of venous thromboembolism.
Lewis DA , Suchindran S , Beckman MG , Hooper WC , Grant AM , Heit JA , Manco-Johnson M , Moll S , Philipp CS , Kenney K , De Staercke C , Pyle ME , Chi JT , Ortel TL . Thromb Res 2015 135 (4) 659-65 INTRODUCTION: Recurrent venous thromboembolism (VTE) occurs infrequently following a provoked event but occurs in up to 30% of individuals following an initial unprovoked event. There is limited understanding of the biological mechanisms that predispose patients to recurrent VTE. OBJECTIVES: To identify whole blood gene expression profiles that distinguished patients with clinically distinct patterns of VTE. PATIENTS/METHODS: We studied 107 patients with VTE separated into 3 groups: (1) 'low-risk' patients had one or more provoked VTE; (2) 'moderate-risk' patients had a single unprovoked VTE; (3) 'high-risk' patients had ≥2 unprovoked VTE. Each patient group was also compared to twenty-five individuals with no personal history of VTE. Total RNA from whole blood was isolated and hybridized to Illumina HT-12V4 Beadchips to assay whole genome expression. RESULTS: Using class prediction analysis, we distinguished high-risk patients from low-risk patients and healthy controls with good receiver operating curve characteristics (AUC=0.81 and 0.84, respectively). We also distinguished moderate-risk individuals and low-risk individuals from healthy controls with AUC's of 0.69 and 0.80, respectively. Using differential expression analysis, we identified several genes previously implicated in thrombotic disorders by genetic analyses, including SELP, KLKB1, ANXA5, and CD46. Protein levels for several of the identified genes were not significantly different between the different groups. CONCLUSION: Gene expression profiles are capable of distinguishing patients with different clinical presentations of VTE, and genes relevant to VTE risk are frequently differentially expressed in these comparisons. |
Reporting incidental findings in genomic scale clinical sequencing--a clinical laboratory perspective: a report of the Association for Molecular Pathology.
Hegde M , Bale S , Bayrak-Toydemir P , Gibson J , Bone Jeng LJ , Joseph L , Laser J , Lubin IM , Miller CE , Ross LF , Rothberg PG , Tanner AK , Vitazka P , Mao R . J Mol Diagn 2015 17 (2) 107-17 Advances in sequencing technologies have facilitated concurrent testing for many disorders, and the results generated may provide information about a patient's health that is unrelated to the clinical indication, commonly referred to as incidental findings. This is a paradigm shift from traditional genetic testing in which testing and reporting are tailored to a patient's specific clinical condition. Clinical laboratories and physicians are wrestling with this increased complexity in genomic testing and reporting of the incidental findings to patients. An enormous amount of discussion has taken place since the release of a set of recommendations from the American College of Medical Genetics and Genomics. This discussion has largely focused on the content of the incidental findings, but the laboratory perspective and patient autonomy have been overlooked. This report by the Association of Molecular Pathology workgroup discusses the pros and cons of next-generation sequencing technology, potential benefits, and harms for reporting of incidental findings, including the effect on both the laboratory and the patient, and compares those with other areas of medicine. The importance of genetic counseling to preserve patient autonomy is also reviewed. The discussion and recommendations presented by the workgroup underline the need for continued research and discussion among all stakeholders to improve our understanding of the effect of different policies on patients, providers, and laboratories. |
Post-licensure surveillance of quadrivalent live attenuated influenza vaccine United States, Vaccine Adverse Event Reporting System (VAERS), July 2013-June 2014.
Haber P , Moro PL , Cano M , Lewis P , Stewart B , Shimabukuro TT . Vaccine 2015 33 (16) 1987-92 BACKGROUND: Quadrivalent live attenuated influenza vaccine (LAIV4) was approved in 2012 for healthy persons aged 2-49 years. Beginning with the 2013-2014 influenza season, LAIV4 replaced trivalent live attenuated influenza vaccine (LAIV3). METHODS: We analyzed LAIV4 reports to VAERS, a national spontaneous reporting system. LAIV4 reports in 2013-2014 were compared to LAIV3 reports from the previous three influenza seasons. Medical records were reviewed for non-manufacturer serious reports (i.e., death, hospitalization, prolonged hospitalization, life-threatening illness, permanent disability) and reports of selected conditions of interest. We conducted Empirical Bayesian data mining to identify disproportional reporting for LAIV4. RESULTS: In 2013-2014, 12.7 million doses of LAIV4 were distributed and VAERS received 779 reports in individuals aged 2-49 years; 95% were non-serious. Expired drug administered (42%), fever (13%) and cough (8%) were most commonly reported in children aged 2-17 years when LAIV4 was administered alone, while headache (18%), expired drug administered (15%) and exposure during pregnancy (12%) were most common in adults aged 18-49 years. We identified one death report in a child who died from complications of cerebellar vascular tumors. Among non-death serious reports, neurologic conditions were common in children and adults. In children, seizures (3) and Guillain-Barre syndrome (2) were the most common serious neurologic outcomes. We identified three serious reports of asthma/wheezing following LAIV4 in children. Data mining detected disproportional reporting for vaccine administration errors and for influenza illness in children. CONCLUSIONS: Our analysis of VAERS reports for LAIV4 did not identify any concerning patterns. The data mining finding for reports of influenza illness is consistent with low LAIV4 vaccine effectiveness observed for influenza A disease in children in 2013-2014. Reports of LAIV4 administration to persons in whom the vaccine is not recommended (e.g., pregnant women) indicate the need for education, training and screening regarding indications. |
Reduction in HPV 16/18-associated high grade cervical lesions following HPV vaccine introduction in the United States - 2008-2012
Hariri S , Bennett NM , Niccolai LM , Schafer S , Park IU , Bloch KC , Unger ER , Whitney E , Julian P , Scahill MW , Abdullah N , Levine D , Johnson ML , Steinau M , Markowitz LE . Vaccine 2015 33 (13) 1608-13 BACKGROUND: Prevention of pre-invasive cervical lesions is an important benefit of HPV vaccines, but demonstrating impact on these lesions is impeded by changes in cervical cancer screening. Monitoring vaccine-types associated with lesions can help distinguish vaccine impact from screening effects. We examined trends in prevalence of HPV 16/18 types detected in cervical intraepithelial neoplasia 2, 3, and adenocarcinoma in situ (CIN2+) among women diagnosed with CIN2+ from 2008 to 2012 by vaccination status. We estimated vaccine effectiveness against HPV 16/18-attributable CIN2+ among women who received ≥1 dose by increasing time intervals between date of first vaccination and the screening test that led to detection of CIN2+ lesion. METHODS: Data are from a population-based sentinel surveillance system to monitor HPV vaccine impact on type-specific CIN2+ among adult female residents of five catchment areas in California, Connecticut, New York, Oregon, and Tennessee. Vaccination and cervical cancer screening information was retrieved. Archived diagnostic specimens were obtained from reporting laboratories for HPV DNA typing. RESULTS: From 2008 to 2012, prevalence of HPV 16/18 in CIN2+ lesions statistically significantly decreased from 53.6% to 28.4% among women who received at least one dose (Ptrend<.001) but not among unvaccinated women (57.1% vs 52.5%; Ptrend=.08) or women with unknown vaccination status (55.0% vs 50.5%; Ptrend=.71). Estimated vaccine effectiveness for prevention of HPV 16/18-attributable CIN2+ was 21% (95% CI: 1-37), 49% (95% CI: 28-64), and 72% (95% CI: 45-86) in women who initiated vaccination 25-36 months, 37-48 months, and >48 months prior to the screening test that led to CIN2+ diagnosis. CONCLUSIONS: Population-based data from the United States indicate significant reductions in CIN2+ lesions attributable to types targeted by the vaccines and increasing HPV vaccine effectiveness with increasing interval between first vaccination and earliest detection of cervical disease. |
HPV "coverage"
Schuchat A . N Engl J Med 2015 372 (8) 775-6 This issue of the journal presents a milestone in expanding coverage against cancers associated with human papillomavirus (HPV). Joura and coauthors’ report of a randomized controlled trial of 9-valent vs. quadrivalent HPV vaccine in over 14,000 young women found vaccine efficacy of nearly 97% against high-grade cervical/vulvar/vaginal disease related to types 31, 33, 45, 52, and 581. The intent-to-treat analysis found no benefit of 9-valent vs. quadrivalent vaccine, presumably because so many of the 16–26 year old study subjects had already been infected with the five additional HPV-types by the study’s onset. The rationale for vaccination at 11–12 years is to provide protection before HPV acquisition. | What HPV researchers talk about when they talk about “coverage” is the distribution of HPV-types in cancers. Earlier formulations targeted the most common oncogenic types, 16 and 18, responsible for about 70% of cervical cancers. The 9-valent vaccine’s additional types are expected to target up to 15–20% more cervical cancers and 5–20% more of other HPV-related cancers2,3. While HPV-related cancer coverage can now expand, other types of coverage present ongoing challenges. |
Inactivated human rotavirus vaccine induces heterotypic antibody response: correction and development of IgG avidity assay
Velasquez DE , Wang Y , Jiang B . Hum Vaccin Immunother 2015 11 (2) 531-3 To improve lower efficacy among infants in low income countries and the safety (e.g., rare but severe intussusception) of live oral rotavirus vaccines, we have developed CDC-9 strain with G1P[8] specificity as a candidate inactivated rotavirus vaccine (IRV). This IRV of three doses elicits high titers of IgG, neutralizing activity to homotypic and heterotypic human strains and IgG avidity in guinea pigs, thus is a promising alternative to enhance global immunization against rotavirus in children. |
Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older: United States, 2015
Kim DK , Bridges CB , Harriman KH . Ann Intern Med 2015 162 (3) 214-23 In October 2014, the Advisory Committee on Immunization Practices (ACIP) approved the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2015. This schedule provides a summary of ACIP recommendations for the use of vaccines routinely recommended for adults aged 19 years or older in two figures, footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults. Changes in the 2015 adult immunization schedule from the 2014 schedule included the August 2014 recommendation for routine administration of the 13-valent pneumococcal conjugate vaccine (PCV13) in series with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for all adults aged 65 years or older, the August 2014 revision on contraindications and precautions for the live attenuated influenza vaccine (LAIV), and the October 2014 approval by the Food and Drug Administration to expand the approved age for use of recombinant influenza vaccine (RIV). These revisions were also reviewed and approved by the American College of Physicians, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Nurse-Midwives. |
Clinical guidance for smallpox vaccine use in a postevent vaccination program
Petersen BW , Damon IK , Pertowski CA , Meaney-Delman D , Guarnizo JT , Beigi RH , Edwards KM , Fisher MC , Frey SE , Lynfield R , Willoughby RE . MMWR Recomm Rep 2015 64 1-26 This report outlines recommendations for the clinical use of the three smallpox vaccines stored in the U.S. Strategic National Stockpile for persons who are exposed to smallpox virus or at high risk for smallpox infection during a postevent vaccination program following an intentional or accidental release of the virus. No absolute contraindications exist for smallpox vaccination in a postevent setting. However, several relative contraindications exist among persons with certain medical conditions. CDC recommendations for smallpox vaccine use were developed in consideration of the risk for smallpox infection, risk for an adverse event following vaccination, and benefit from vaccination. Smallpox vaccines are made from live vaccinia viruses that protect against smallpox disease. They do not contain variola virus, the causative agent of smallpox. The three smallpox vaccines stockpiled are ACAM2000, Aventis Pasteur Smallpox Vaccine (APSV), and Imvamune. Surveillance and containment activities including vaccination with replication-competent smallpox vaccine (i.e., vaccine viruses capable of replicating in mammalian cells such as ACAM2000 and APSV) will be the primary response strategy for achieving epidemic control. Persons exposed to smallpox virus are at high risk for developing and transmitting smallpox and should be vaccinated with a replication-competent smallpox vaccine unless severely immunodeficient. Because of a high likelihood of a poor immune response and an increased risk for adverse events, smallpox vaccination should be avoided in persons with severe immunodeficiency who are not expected to benefit from vaccine, including bone marrow transplant recipients within 4 months of transplantation, persons infected with HIV with CD4 cell counts <50 cells/mm3, and persons with severe combined immunodeficiency, complete DiGeorge syndrome, and other severely immunocompromised states requiring isolation. If antivirals are not immediately available, it is reasonable to consider the use of Imvamune in the setting of a smallpox virus exposure in persons with severe immunodeficiency. Persons without a known smallpox virus exposure might still be at high risk for developing smallpox infection depending on the magnitude of the outbreak and the effectiveness of the public health response. Such persons will be defined by public health authorities and should be screened for relative contraindications to smallpox vaccination. Relative contraindications include atopic dermatitis (eczema), HIV infection (CD4 cell counts of 50-199 cells/mm3), other immunocompromised states, and vaccine or vaccine-component allergies. Persons with relative contraindications should be vaccinated with Imvamune when available and authorized for use by the Food and Drug Administration. These recommendations will be updated as new data on smallpox vaccines become available and further clinical guidance for other medical countermeasures including antivirals is developed. |
Comparison of impact and cost-effectiveness of rotavirus supplementary and routine immunization in a complex humanitarian emergency, Somali case study
Gargano LM , Tate JE , Parashar UD , Omer SB , Cookson ST . Confl Health 2015 9 5 BACKGROUND: A humanitarian emergency involves a complete breakdown of authority that often disrupts routine health care delivery, including immunization. Diarrheal diseases are a principal cause of morbidity and mortality among children during humanitarian emergencies. The objective of this study was to assess if vaccination against rotavirus, the most common cause of severe diarrhea among children, either as an addition to routine immunization program (RI) or supplemental immunization activity (SIA) would be cost-effective during a humanitarian emergency to decrease diarrhea morbidity and mortality, using Somalia as a case study. METHODS: An impact and cost-effectiveness analysis was performed comparing no vaccine; two-dose rotavirus SIA and two-dose of RI for the 424,592 births in the 2012 Somali cohort. The main summary measure was the incremental cost per disability-adjusted life-year (DALY) averted. Univariate sensitivity analysis examined the extent to which the uncertainty in the variables affected estimates. RESULTS: If introduced in Somalia, a full-series rotavirus RI and SIA would save 908 and 359 lives, respectively, and save US$63,793 and US$25,246 in direct medical costs, respectively. The cost of a RI strategy would be US$309,458. Because of the high operational costs, a SIA strategy would cost US$715,713. US$5.30 per DALY would be averted for RI and US$37.62 per DALY averted for SIA. Variables that most substantially influenced the cost-effectiveness for both RI and SIA were vaccine program costs, mortality rate, and vaccine effectiveness against death. CONCLUSIONS: Based on our model, rotavirus vaccination appears to be a cost-effective intervention as either RI or SIA, as defined by the World Health Organization as one to three times the per capita Gross Domestic Product (Somalia $112 in 2011). RI would have greater health impact and is more cost effective than SIA, assuming feasibility of reaching the target population. However, given the lack of infrastructure, whether RI is realistic in this setting remains unanswered, and alternative approaches like SIA should be further examined. |
The role of health information technology in care coordination in the United States
Hsiao CJ , King J , Hing E , Simon AE . Med Care 2015 53 (2) 184-90 OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all. |
Developing a smartphone interface for the Florida environmental public health tracking web portal
Jordan M , DuClos C , Folsom J , Thomas R . J Public Health Manag Pract 2015 21 Suppl 2 S50-4 As smartphone and tablet devices continue to proliferate, it is becoming increasingly important to tailor information delivery to the mobile device. The Florida Environmental Public Health Tracking Program recognized that the mobile device user needs Web content formatted to smaller screen sizes, simplified data displays, and reduced textual information. The Florida Environmental Public Health Tracking Program developed a smartphone-friendly version of the state Web portal for easier access by mobile device users. The resulting smartphone-friendly portal combines calculated data measures such as inpatient hospitalizations and emergency department visits and presents them grouped by county, along with temporal trend graphs. An abbreviated version of the public health messaging provided on the traditional Web portal is also provided, along with social media connections. As a result of these efforts, the percentage of Web site visitors using an iPhone tripled in just 1 year. |
Assessing the sources of Asian versus non-Asian disparities in delinquency
Feldmeyer B , Cui W . J Ethn Crim Justice 2015 13 (1) 30-58 Research on race/ethnicity and crime has often overlooked the patterns and predictors of Asian American offending, particularly compared to those of other racial/ethnic groups. The current study addresses this gap in the research using data from the National Longitudinal Study of Adolescent Health to assess the degree to which social factors drawn from criminological theories are able to account for Asian versus non-Asian (White, Black, Latino, and Native American) levels of delinquency. This analysis also extends prior work by exploring the sources of these disparities in delinquency using (a) multiple offense types (violent, property, and drug offending), (b) multiple theoretical approaches (social bond, anomie/strain, and social learning perspectives), and (c) measures that capture the frequency and intensity of serious delinquency for a nationally representative sample of youth. Findings indicate that Asian American youth report lower levels of violence and drug use than other racial/ethnic groups, which are explained by a combination of protective factors, including lower levels of strain, strong bonds to school, and less exposure to delinquent peers. |
Leveraging biospecimen resources for discovery or validation of markers for early cancer detection.
Schully SD , Carrick DM , Mechanic LE , Srivastava S , Anderson GL , Baron JA , Berg CD , Cullen J , Diamandis EP , Doria-Rose VP , Goddard KA , Hankinson SE , Kushi LH , Larson EB , McShane LM , Schilsky RL , Shak S , Skates SJ , Urban N , Kramer BS , Khoury MJ , Ransohoff DF . J Natl Cancer Inst 2015 107 (4) Validation of early detection cancer biomarkers has proven to be disappointing when initial promising claims have often not been reproducible in diagnostic samples or did not extend to prediagnostic samples. The previously reported lack of rigorous internal validity (systematic differences between compared groups) and external validity (lack of generalizability beyond compared groups) may be effectively addressed by utilizing blood specimens and data collected within well-conducted cohort studies. Cohort studies with prediagnostic specimens (eg, blood specimens collected prior to development of clinical symptoms) and clinical data have recently been used to assess the validity of some early detection biomarkers. With this background, the Division of Cancer Control and Population Sciences (DCCPS) and the Division of Cancer Prevention (DCP) of the National Cancer Institute (NCI) held a joint workshop in August 2013. The goal was to advance early detection cancer research by considering how the infrastructure of cohort studies that already exist or are being developed might be leveraged to include appropriate blood specimens, including prediagnostic specimens, ideally collected at periodic intervals, along with clinical data about symptom status and cancer diagnosis. Three overarching recommendations emerged from the discussions: 1) facilitate sharing of existing specimens and data, 2) encourage collaboration among scientists developing biomarkers and those conducting observational cohort studies or managing healthcare systems with cohorts followed over time, and 3) conduct pilot projects that identify and address key logistic and feasibility issues regarding how appropriate specimens and clinical data might be collected at reasonable effort and cost within existing or future cohorts. |
Development and validation of an internationally-standardized, high-resolution capillary gel-based electrophoresis PCR-ribotyping protocol for Clostridium difficile.
Fawley WN , Knetsch CW , MacCannell DR , Harmanus C , Du T , Mulvey MR , Paulick A , Anderson L , Kuijper EJ , Wilcox MH . PLoS One 2015 10 (2) e0118150 PCR-ribotyping has been adopted in many laboratories as the method of choice for C. difficile typing and surveillance. However, issues with the conventional agarose gel-based technique, including inter-laboratory variation and interpretation of banding patterns have impeded progress. The method has recently been adapted to incorporate high-resolution capillary gel-based electrophoresis (CE-ribotyping), so improving discrimination, accuracy and reproducibility. However, reports to date have all represented single-centre studies and inter-laboratory variability has not been formally measured or assessed. Here, we achieved in a multi-centre setting a high level of reproducibility, accuracy and portability associated with a consensus CE-ribotyping protocol. Local databases were built at four participating laboratories using a distributed set of 70 known PCR-ribotypes. A panel of 50 isolates and 60 electronic profiles (blinded and randomized) were distributed to each testing centre for PCR-ribotype identification based on local databases generated using the standard set of 70 PCR-ribotypes, and the performance of the consensus protocol assessed. A maximum standard deviation of only +/-3.8bp was recorded in individual fragment sizes, and PCR-ribotypes from 98.2% of anonymised strains were successfully discriminated across four ribotyping centres spanning Europe and North America (98.8% after analysing discrepancies). Consensus CE-ribotyping increases comparability of typing data between centres and thereby facilitates the rapid and accurate transfer of standardized typing data to support future national and international C. difficile surveillance programs. |
Using mutual information to capture major concerns of postural control in a tossing activity
Gazula H , Chang CC , Lu ML , Hsiang SM . J Biomech 2015 48 (6) 1105-11 Human body motion for load-tossing activity was partitioned into three phases using four critical events based on the load position viz. lift-off, closest to body, peak and release. For each phase, three objective functions values, viz. mobilization, stabilization and muscular torque utilization, used to control the motion patterns, were then calculated. We hypothesize that the relationships between different objective functions can be extracted using information theory. The kinematic data obtained with 36 treatment combinations (2 tossing distances, 2 tossing heights, 3 weights, and 3 target clearances) was used to estimate the mutual information between each pair of objective functions and construct Chow-Liu trees. Results from this research indicate that there was no dominant concern in the first two phases of the activity; however, torque utilization and mobilization were found to be important factors in the third phase of the load tossing activity. |
The notch signaling regulates CD105 expression, osteogenic differentiation and immunomodulation of human umbilical cord mesenchymal stem cells
Na T , Liu J , Zhang K , Ding M , Yuan BZ . PLoS One 2015 10 (2) e0118168 Mesenchymal stem cells (MSCs) are a group of multipotent cells with key properties of multi-lineage differentiation, expressing a set of relatively specific surface markers and unique immunomodulatory functions. IDO1, a catabolic enzyme of tryptophan, represents a critical molecule mediating immunomodulatory functions of MSCs. However, the signaling pathways involved in regulating these key properties still remain elusive. To investigate the involvement of Notch signaling as well as other potential signaling pathway(s) in regulating these critical properties of MSCs, we treated human umbilical cord-derived mesenchymal stem cells (hUC-MSCs) with gamma-secreatase inhibitor I (GSI-I), which inhibits both Notch signaling and ubiquitin-proteasome activities. It was shown that the GSI-I treatment resulted in apoptosis, reduced expression of surface markers CD73, CD90 and CD105, reduced osteogenic differentiation, and reduction of the hUC-MSCs-mediated suppression of Th1 lymphocyte proliferation and the IFN-gamma-induced IDO1 expression. Through distinguishing the effects of GSI-I between Notch inhibition and proteasome inhibition, it was further observed that, whereas both Notch inhibition and proteasome inhibition were attributable to the reduced CD105 expression and osteogenic differentiation, but not to the induced apoptosis. However, Notch inhibition, but not proteasome inhibition, only contributed to the significant effect of GSI-I on Th1 proliferation probably through reducing IDO1 promoter activity. In conclusion, the Notch signaling may represent a very important cell signaling capable of regulating multiple critical properties, especially the immunomodulatory functions of MSCs. |
Identification of di-2-ethylhexyl terephthalate (DEHTP) metabolites using human liver microsomes for biomonitoring applications
Silva MJ , Samandar E , Calafat AM , Ye X . Toxicol In Vitro 2015 29 (4) 716-21 Di-2-ethylhexyl terephthalate (DEHTP), a structural isomer of the plasticizer di-2-ethylhexyl phthalate (DEHP), is used in food packaging and medical devices, among other applications, and is a potential replacement for DEHP and other ortho-phthalate plasticizers. Identifying sensitive and specific biomarkers of DEHTP is necessary to assess humans' background exposure to DEHTP. Using mass spectrometry, we investigated the metabolism of DEHTP by human liver microsomes to identify in vitro DEHTP metabolites. We unequivocally identified terephthalic acid (TPA) and mono-2-ethylhydroxyhexyl terephthalate (MEHHTP), using authentic standards, and tentatively identified mono-2-ethylhexyl terephthalate (MEHTP) and two other oxidative metabolites of DEHTP: mono-2-ethyloxohexyl terephthalate (MEOHTP), and mono-2-ethyl-5-carboxypentyl terephthalate (MECPTP) from their mass spectrometry fragmentation patterns. We also evaluated the formation of in vitro metabolites of DEHP. DEHTP and DEHP produced similar metabolites, but their metabolite profiles differed considerably. DEHTP metabolized to form TPA, a metabolite of several terephthalates, as the major in vitro metabolite, followed by MEHTP, MEHHTP, MEOHTP and MECPTP. MEHTP, MEHHTP, MEOHTP and MECPTP, which are specific metabolites of DEHTP, may be suitable biomarkers for assessing exposure to DEHTP. Nonetheless, data on the urinary excretion fraction and temporal stability of these metabolites, among other considerations, are needed to demonstrate their utility as exposure biomarkers. |
Advances in mechanisms and signaling pathways of carbon nanotube toxicity
Dong J , Ma Q . Nanotoxicology 2015 9 (5) 1-19 Carbon nanotubes (CNT) have been developed into new materials with a variety of industrial and commercial applications. In contrast, the physicochemical properties of CNT at the nanoscale render them the potency to generate toxic effects. Indeed, the potential health impacts of CNT have drawn a great deal of attention in recent years, owing to their identified toxicological and pathological consequences including cytotoxicity, inflammation, fibrosis, genotoxicity, tumorigenesis, and immunotoxicity. Understanding the mechanisms by which CNT induce toxicity and pathology is thus urgently needed for accurate risk assessment of CNT exposure in humans, and for safe and responsible development and commercialization of nanotechnology. Here, we summarize and discuss recent advances in this area with a focus on the molecular interactions between CNT and mammalian systems, and the signaling pathways important for the development of CNT toxicity such as the NF-kappaB, NLRP3 inflammasome, TGF-beta1, MAPK, and p53 signaling cascades. With the current mechanistic evidence summarized in this review, we expect to provide new insights into CNT toxicology at the molecular level and offer new clues to the prevention of health effects resulting from CNT exposure. Moreover, we disclose questions and issues that remain in this rapidly advancing field of nanotoxicology, which would facilitate ascertaining future research directions. |
Airborne fiber size characterization in exposure estimation: evaluation of a modified transmission electron microcopy protocol for asbestos and potential use for carbon nanotubes and nanofibers
Dement JM , Kuempel ED , Zumwalde RD , Ristich AM , Fernback JE , Smith RJ . Am J Ind Med 2015 58 (5) 494-508 BACKGROUND: Airborne fiber size has been shown to be an important factor relative to adverse lung effects of asbestos and suggested in animal studies of carbon nanotubes and nanofibers (CNT/CNF). MATERIALS AND METHODS: The International Standards Organization (ISO) transmission electron microscopy (TEM) method for asbestos was modified to increase the statistical precision of fiber size determinations, improve efficiency, and reduce analysis costs. Comparisons of the fiber size distributions and exposure indices by laboratory and counting method were performed. RESULTS: No significant differences in size distributions by the ISO and modified ISO methods were observed. Small but statistically-significant inter-lab differences in the proportion of fibers in some size bins were found, but these differences had little impact on the summary exposure indices. The modified ISO method produced slightly more precise estimates of the long fiber fraction (>15 mum). CONCLUSIONS: The modified ISO method may be useful for estimating size-specific structure exposures, including CNT/CNF, for risk assessment research. |
Detection of botulinum toxins A, B, E, and F in foods by Endopep-MS
Kalb SR , Krilich JC , Dykes JK , Luquez C , Maslanka SE , Barr JR . J Agric Food Chem 2015 63 (4) 1133-1141 Botulism is caused by exposure to botulinum neurotoxins (BoNTs). BoNTs are proteins secreted by some species of clostridia; these neurotoxins are known to interfere with nerve impulse transmission, thus causing paralysis. Botulism may be contracted through consumption of food either naturally or intentionally contaminated with BoNT. The human lethal dose of BoNT is not known but is estimated to be between 0.1 and 70 mug; thus, it is important to be able to detect small amounts of this toxin in foods to ensure food safety and to identify the source of an outbreak. Our laboratory previously reported on the development of Endopep-MS, a mass-spectrometric-based endopeptidase method for the detection and differentiation of BoNT. This method can detect BoNT at levels below the historic standard mouse bioassay in clinical samples such as serum, stool, and culture supernatants. We have now expanded this assay to detect BoNT in over 50 foods including representative products that were involved in actual botulism investigations. The foods tested by the Endopep-MS included those with various acidities, viscosities, and fat levels. Dairy and culturally diverse products were also included. This work demonstrates that the Endopep-MS method can be used to detect BoNT/A, /B, /E, and /F in foods at levels spiked below that of the limit of detection of the mouse bioassay. Furthermore, we successfully applied this method to investigate several foods associated with botulism outbreaks. |
Development of urine standard reference materials for metabolites of organic chemicals including polycyclic aromatic hydrocarbons, phthalates, phenols, parabens, and volatile organic compounds
Schantz MM , Benner BA Jr , Heckert NA , Sander LC , Sharpless KE , Vander Pol SS , Vasquez Y , Villegas M , Wise SA , Alwis KU , Blount BC , Calafat AM , Li Z , Silva MJ , Ye X , Gaudreau E , Patterson DG Jr , Sjodin A . Anal Bioanal Chem 2015 407 (11) 2945-54 Two new Standard Reference Materials (SRMs), SRM 3672 Organic Contaminants in Smokers' Urine (Frozen) and SRM 3673 Organic Contaminants in Non-Smokers' Urine (Frozen), have been developed in support of studies for assessment of human exposure to select organic environmental contaminants. Collaborations among three organizations resulted in certified values for 11 hydroxylated polycyclic aromatic hydrocarbons (OH-PAHs) and reference values for 11 phthalate metabolites, 8 environmental phenols and parabens, and 24 volatile organic compound (VOC) metabolites. Reference values are also available for creatinine and the free forms of caffeine, theobromine, ibuprofen, nicotine, cotinine, and 3-hydroxycotinine. These are the first urine Certified Reference Materials characterized for metabolites of organic environmental contaminants. Noteworthy, the mass fractions of the environmental organic contaminants in the two SRMs are within the ranges reported in population survey studies such as the National Health and Nutrition Examination Survey (NHANES) and the Canadian Health Measures Survey (CHMS). These SRMs will be useful as quality control samples for ensuring compatibility of results among population survey studies and will fill a void to assess the accuracy of analytical methods used in studies monitoring human exposure to these organic environmental contaminants. |
Maternal cigarette smoking and congenital heart defects
Correa A , Levis DM , Tinker SC , Cragan JD . J Pediatr 2015 166 (4) 801-4 Congenital heart defects (CHDs) are of public health concern because they affect approximately 1% of newborns,1-3 are a leading cause of infant mortality,4 and often result in increased use and costs of health services among affected children, adolescents, and adults.5 In recent decades, epidemiologic research has made notable progress in the identification of modifiable risk factors for some CHDs (eg, congenital rubella infection, use of certain medications, and pregestational diabetes).6 For most CHDs, however, the causes remain unknown. In this issue of The Journal, Sullivan et al7 describe results of a population-based study in which they assessed the possible association of maternal periconceptional cigarette smoking and the occurrence of CHDs among live births by linking self-reports of cigarette smoking on birth certificates with records of children with CHD (ie, cases) identified from birth certificates and a statewide hospital discharge registry. The authors examined 19 specific CHD phenotypes and observed associations between maternal cigarette smoking during the first trimester of pregnancy and 3 phenotypes: pulmonary valve anomalies, pulmonary artery anomalies, and isolated secundum type of atrial septal defects. They also observed a suggestion of a doseresponse relationship between maternal cigarette smoking and the risk of CHDs examined as a group. These findings are of interest because they highlight: (1) methodologic issues common to studies of associations of maternal cigarette smoking, a prevalent and modifiable exposure, with specific CHD phenotypes in the offspring; (2) challenges in interpreting the nature of observed associations between maternal cigarette smoking and CHDs; and (3) opportunities for prevention and smoking cessation efforts among women of childbearing age. |
Prevalence of Duchenne and Becker muscular dystrophies in the United States
Romitti PA , Zhu Y , Puzhankara S , James KA , Nabukera SK , Zamba GK , Ciafaloni E , Cunniff C , Druschel CM , Mathews KD , Matthews DJ , Meaney FJ , Andrews JG , Conway KM , Fox DJ , Street N , Adams MM , Bolen J . Pediatrics 2015 135 (3) 513-21 OBJECTIVE: To estimate prevalence of childhood-onset Duchenne and Becker muscular dystrophies (DBMD) in 6 sites in the United States by race/ethnicity and phenotype (Duchenne muscular dystrophy [DMD] or Becker muscular dystrophy [BMD]). METHODS: In 2002, the Centers for Disease Control and Prevention established the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) to conduct longitudinal, population-based surveillance and research of DBMD in the United States. Six sites conducted active, multiple-source case finding and record abstraction to identify MD STARnet cases born January 1982 to December 2011. We used cross-sectional analyses to estimate prevalence of DBMD per 10 000 boys, ages 5 to 9 years, for 4 quinquennia (1991-1995, 1996-2000, 2001-2005, and 2006-2010) and prevalence per 10 000 male individuals, ages 5 to 24 years, in 2010. Prevalence was also estimated by race/ethnicity and phenotype. RESULTS: Overall, 649 cases resided in an MD STARnet site during ≥1 quinquennia. Prevalence estimates per 10 000 boys, ages 5 to 9 years, were 1.93, 2.05, 2.04, and 1.51, respectively, for 1991-1995, 1996-2000, 2001-2005, and 2006-2010. Prevalence tended to be higher for Hispanic individuals than non-Hispanic white or black individuals, and higher for DMD than BMD. In 2010, prevalence of DBMD was 1.38 per 10 000 male individuals, ages 5 to 24 years. CONCLUSIONS: We present population-based prevalence estimates for DBMD in 6 US sites. Prevalence differed by race/ethnicity, suggesting potential cultural and socioeconomic influences in the diagnosis of DBMD. Prevalence also was higher for DMD than BMD. Continued longitudinal surveillance will permit us to examine racial/ethnic and socioeconomic differences in treatment and outcomes for MD STARnet cases. |
Association between HIV programs and quality of maternal health inputs and processes in Kenya
Kruk ME , Jakubowski A , Rabkin M , Kimanga DO , Kundu F , Lim T , Lumumba V , Oluoch T , Robinson KA , El-Sadr W . Am J Public Health 2015 105 Suppl 2 e1-e4 We assessed whether quality of maternal and newborn health services is influenced by presence of HIV programs at Kenyan health facilities using data from a national facility survey. Facilities that provided services to prevent mother-to-child HIV transmission had better prenatal and postnatal care inputs, such as infrastructure and supplies, and those providing antiretroviral therapy had better quality of prenatal and postnatal care processes. HIV-related programs may have benefits for quality of care for related services in the health system. |
Childhood Obesity Research Demonstration (CORD): the cross-site overview and opportunities for interventions addressing obesity community-wide
Foltz JL , Belay B , Dooyema CA , Williams N , Blanck HM . Child Obes 2015 11 (1) 4-10 BACKGROUND: This is the first of a set of articles in this issue on the Childhood Obesity Research Demonstration (CORD) project and provides an overview of the multisite approach and community-wide interventions. Innovative multisetting, multilevel approaches that integrate primary healthcare and public health interventions to improve outcomes for children with obesity need to be evaluated. The CORD project aims to improve BMI and obesity-related behaviors among underserved 2- to 12-year-old children by utilizing these approaches. METHODS: The CORD consortium, structure, model terminology and key components, and common measures were solidified in year 1 of the CORD project. Demonstration sites applied the CORD model across communities in years 2 and 3. Evaluation plans for year 4 include site-specific analyses as well as cross-site impact, process, and sustainability evaluations. RESULTS: The CORD approach resulted in commonalities and differences in participant, intervention, comparison, and outcome elements across sites. Products are to include analytic results as well as cost assessment, lessons learned, tools, and materials. DISCUSSION: Foreseen opportunities and challenges arise from the similarities and unique aspects across sites. Communities adapted interventions to fit their local context and build on strengths, but, in turn, this flexibility makes cross-site evaluation challenging. CONCLUSION: The CORD project represents an evidence-based approach that integrates primary care and public health strategies and evaluates multisetting multilevel interventions, thus adding to the limited research in this field. CORD products will be disseminated to a variety of stakeholders to aid the understanding, prevention, and management of childhood obesity. |
The Childhood Obesity Research Demonstration project: linking public health initiatives and primary care interventions community-wide to prevent and reduce childhood obesity
Blanck HM , Collins JL . Child Obes 2015 11 (1) 1-3 Childhood obesity is a serious national health problem with 17% of American youth living with obesity.1 In 2010, the Patient Protection and Affordable Care Act (ACA) appropriated $25 million for a 4-year community-based study to determine whether an integrated model of primary care and public health services can improve underserved children's risk factors for obesity. In response, the CDC established the Childhood Obesity Research Demonstration (CORD) to meet the requirements of the ACA and address the call by expert groups for comprehensive, multilevel, multisetting approaches to prevent and reduce childhood obesity.2 This commentary introduces the nine articles in this issue that describe the research collaboration funded by the CDC. | Obesity-related health behaviors, such as nutrition and physical activity, are shaped by multiple sources of influence and environments, including the home, early care and education, school, healthcare, and other community settings. Therefore, a host of setting stakeholders who influence these settings, including government, education, the private setting, nonprofit organizations, and families, have a role to play in creating healthier communities. CORD will add to the limited research available on comprehensive, community-wide models for childhood obesity prevention. A recent comparative effectiveness review of the peer-reviewed childhood obesity prevention literature in developed countries found there is a need for more studies that include results from interventions occurring in multiple settings.3 The systematic review found a very limited number of articles with multiple settings and only one community-based, multiple-setting, early childhood obesity prevention study that measured weight and had at least 1 year of follow-up.4 In school-aged youth in the United States, Shape Up Somerville has been novel in its results of reducing BMI over 2 years through a community-based participatory research approach that met the community's interests and strengths and interventions that could be included into existing “platforms” (schools, afterschool, and community).5 |
Trends in worker hearing loss by industry sector, 1981-2010
Masterson EA , Deddens JA , Themann CL , Bertke S , Calvert GM . Am J Ind Med 2015 58 (4) 392-401 BACKGROUND: The purpose of this study was to estimate the incidence and prevalence of hearing loss for noise-exposed U.S. workers by industry sector and 5-year time period, covering 30 years. METHODS: Audiograms for 1.8 million workers from 1981-2010 were examined. Incidence and prevalence were estimated by industry sector and time period. The adjusted risk of incident hearing loss within each time period and industry sector as compared with a reference time period was also estimated. RESULTS: The adjusted risk for incident hearing loss decreased over time when all industry sectors were combined. However, the risk remained high for workers in Healthcare and Social Assistance, and the prevalence was consistently high for Mining and Construction workers. CONCLUSIONS: While progress has been made in reducing the risk of incident hearing loss within most industry sectors, additional efforts are needed within Mining, Construction and Healthcare and Social Assistance. |
Prevalence of pfhrp2 and pfhrp3 gene deletions in Puerto Lempira, Honduras.
Abdallah JF , Okoth SA , Fontecha GA , Torres RE , Banegas EI , Matute ML , Bucheli ST , Goldman IF , de Oliveira AM , Barnwell JW , Udhayakumar V . Malar J 2015 14 (1) 19 BACKGROUND: Recent studies have demonstrated the deletion of the histidine-rich protein 2 (PfHRP2) gene (pfhrp2) in field isolates of Plasmodium falciparum, which could result in false negative test results when PfHRP2-based rapid diagnostic tests (RDTs) are used for malaria diagnosis. Although primary diagnosis of malaria in Honduras is determined based on microscopy, RDTs may be useful in remote areas. In this study, it was investigated whether there are deletions of the pfhrp2, pfhrp3 and their respective flanking genes in 68 P. falciparum parasite isolates collected from the city of Puerto Lempira, Honduras. In addition, further investigation considered the possible correlation between parasite population structure and the distribution of these gene deletions by genotyping seven neutral microsatellites. METHODS: Sixty-eight samples used in this study, which were obtained from a previous chloroquine efficacy study, were utilized in the analysis. All samples were genotyped for pfhrp2, pfhrp3 and flanking genes by PCR. The samples were then genotyped for seven neutral microsatellites in order to determine the parasite population structure in Puerto Lempira at the time of sample collection. RESULTS: It was found that all samples were positive for pfhrp2 and its flanking genes on chromosome 8. However, only 50% of the samples were positive for pfhrp3 and its neighboring genes while the rest were either pfhrp3-negative only or had deleted a combination of pfhrp3 and its neighbouring genes on chromosome 13. Population structure analysis predicted that there are at least two distinct parasite population clusters in this sample population. It was also determined that a greater proportion of parasites with pfhrp3-(and flanking gene) deletions belonged to one cluster compared to the other. CONCLUSION: The findings indicate that the P. falciparum parasite population in the municipality of Puerto Lempira maintains the pfhrp2 gene and that PfHRP2-based RDTs could be considered for use in this region; however continued monitoring of parasite population will be useful to detect any parasites with deletions of pfhrp2. |
The value of the "system" in public health services and systems research
Thomas CW , Corso L , Monroe JA . Am J Public Health 2015 105 Suppl 2 e1-e3 Public health services and systems research (PHSSR) provides the evidence and scientific foundation for increasing understanding of the public health system, supporting health system improvements, and advancing the field of public health practice. A focus on the "system" in "public health systems and services research" remains as important as ever and is becoming more complex over time. |
Defining and assessing quality improvement outcomes: a framework for public health
McLees AW , Nawaz S , Thomas C , Young A . Am J Public Health 2015 105 Suppl 2 e1-e7 We describe an evidence-based framework to define and assess the impact of quality improvement (QI) in public health. Developed to address programmatic and research-identified needs for articulating the value of public health QI in aggregate, this framework proposes a standardized set of measures to monitor and improve the efficiency and effectiveness of public health programs and operations. We reviewed the scientific literature and analyzed QI initiatives implemented through the Centers for Disease Control and Prevention's National Public Health Improvement Initiative to inform the selection of 5 efficiency and 8 effectiveness measures. This framework provides a model for identifying the types of improvement outcomes targeted by public health QI efforts and a means to understand QI's impact on the practice of public health. |
Defining the functions of public health governance
Carlson V , Chilton MJ , Corso LC , Beitsch LM . Am J Public Health 2015 105 Suppl 2 e1-e8 We conducted a literature review in 2011 to determine if accepted governance functions continue to reflect the role of public health governing entities. Reviewing literature and other source documents, as well as consulting with practitioners, resulted in an iterative process that identified 6 functions of public health governance and established definitions for each of these: policy development; resource stewardship; continuous improvement; partner engagement; legal authority; and oversight of a health department. These functions provided context for the role of governing entities in public health practice and aligned well with existing public health accreditation standards. Public health systems research can build from this work in future explorations of the contributions of governance to health department performance. |
Changing sociodemographic factors and teen fertility: 1991-2009
Driscoll AK , Abma JC . Matern Child Health J 2015 19 (10) 2159-67 This study analyzed the roles of trends in sociodemographic factors known to be related to the risk of a teen birth. The goal was to analyze the roles of these trends in maternal education, family structure and mother's age at first birth in the likelihood of adolescents becoming teen mothers across multiple birth cohorts of women covering the years since 1991. Data are from the 1995, 2002, 2006-2010 and 2011-2013 National Surveys of Family Growth (NSFG). Consecutive birth cohorts of female respondents were constructed and retrospectively followed to estimate the risk of a teen birth for each cohort. Logistic regression models estimate the odds of a teen birth across cohorts and within strata of the predictors across cohorts. Maternal education rose across cohorts; the proportion who were non-Hispanic white declined. In general, the likelihood of an adolescent birth did not change within categories of the predictors that are considered at higher risk for a teen birth across birth cohorts. Specifically, there was no change in the odds of a teen birth among women whose mothers did not finish high school, those born to teen mothers and those not from two-parent families. The odds of a birth declined across cohorts for black women. The findings suggest that much of the decline in teen birth rates is due to declines in the proportion of teens in higher risk categories, rather than to declines within those categories. |
Impact of depression on quality-adjusted life expectancy (QALE) directly as well as indirectly through suicide
Jia H , Zack MM , Thompson WW , Crosby AE , Gottesman II . Soc Psychiatry Psychiatr Epidemiol 2015 50 (6) 939-49 PURPOSE: To estimate quality-adjusted life expectancy (QALE) loss among US adults due to depression and QALE losses associated with the increased risk of suicide attributable to depression. METHOD: We ascertained depressive symptoms using the eight-item Patient Health Questionnaire (PHQ-8) on the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System (BRFSS) surveys. We estimated health-related quality of life (HRQOL) scores from BRFSS data (n = 276,442) and constructed life tables from US Compressed Mortality Files to calculate QALE by depression status. QALE loss due to depression is the difference in QALE between depressed and non-depressed adults. QALE loss associated with suicide deaths is the difference between QALE from only those deaths that did not have suicide recorded on the death certificate and QALE from all deaths including those with a suicide recorded on the death certificate. RESULTS: At age 18, QALE was 28.0 more years for depressed adults and 56.8 more years for non-depressed adults, a 28.9-year QALE loss due to depression. For depressed adults, only 0.41 years of QALE loss resulted from deaths by suicide, and only 0.26 years of this loss could be attributed to depression. CONCLUSION: Depression symptoms lead to a significant burden of disease from both mortality and morbidity as assessed by QALE loss. The 28.9-year QALE loss at age 18 associated with depression markedly exceeds estimates reported elsewhere for stroke (12.4-year loss), heart disease (10.3-year loss), diabetes mellitus (11.1-year loss), hypertension (6.3-year loss), asthma (7.0-year loss), smoking (11.0-year loss), and physical inactivity (8.0-year loss). |
Binary regression with differentially misclassified response and exposure variables
Tang L , Lyles RH , King CC , Celentano DD , Lo Y . Stat Med 2015 34 (9) 1605-20 Misclassification is a long-standing statistical problem in epidemiology. In many real studies, either an exposure or a response variable or both may be misclassified. As such, potential threats to the validity of the analytic results (e.g., estimates of odds ratios) that stem from misclassification are widely discussed in the literature. Much of the discussion has been restricted to the nondifferential case, in which misclassification rates for a particular variable are assumed not to depend on other variables. However, complex differential misclassification patterns are common in practice, as we illustrate here using bacterial vaginosis and Trichomoniasis data from the HIV Epidemiology Research Study (HERS). Therefore, clear illustrations of valid and accessible methods that deal with complex misclassification are still in high demand. We formulate a maximum likelihood (ML) framework that allows flexible modeling of misclassification in both the response and a key binary exposure variable, while adjusting for other covariates via logistic regression. The approach emphasizes the use of internal validation data in order to evaluate the underlying misclassification mechanisms. Data-driven simulations show that the proposed ML analysis outperforms less flexible approaches that fail to appropriately account for complex misclassification patterns. The value and validity of the method are further demonstrated through a comprehensive analysis of the HERS example data. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
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- Environmental Health
- Epidemiology and Surveillance
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- Genetics and Genomics
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