Toward a more cogent approach to the challenges of multimorbidity
Goodman RA , Parekh AK , Koh HK . Ann Fam Med 2012 10 (2) 100-1 This issue of the Annals, as well as the previous one, confronts the enormous public health challenges of multimorbidity. More than 1 in 4 Americans has multiple (2 or more) chronic conditions, including physical and behavioral health problems, accounting for an estimated two-thirds of total US health care spending.1 An individual’s risks for a variety of adverse health outcomes (eg, poor functional status, unnecessary hospitalizations, and adverse drug events) rise as the number of multiple chronic conditions increases.2 | The Centers for Medicare and Medicaid Services (CMS) has just released even more detailed information with respect to its Medicare fee-for-service populations,3 exposing the exceptional complexity and sheer burden that multiple chronic conditions pose for patients, health facilities, payers, and clinicians. In its recently released chart book Chronic Conditions Among Medicare Beneficiaries,3 CMS describes detailed demographics and prevalence measures of multiple medical conditions in this population and the dramatic impact on service utilization and spending. Examples of key findings are that two-thirds (20.7 million beneficiaries) had at least 2 or more chronic conditions; about 50% of beneficiaries with stroke or heart failure had 5 or more additional chronic conditions; beneficiaries with 6 or more chronic conditions accounted for about one-half of Medicare spending on hospitalizations; more than one-quarter of beneficiaries with 6 or more chronic conditions had a hospital readmission within 30 days; and the 12% of beneficiaries with 6 or more chronic conditions accounted for 43% of Medicare spending. For health systems that have traditionally focused on research and treatment of single conditions, these tremendous challenges have forced many to escalate efforts to identify and implement solutions. |
The potential impact of the National Osteoporosis Foundation guidance on treatment eligibility in the USA: an update in NHANES 2005-2008
Dawson-Hughes B , Looker AC , Tosteson AN , Johansson H , Kanis JA , Melton LJ 3rd . Osteoporos Int 2012 23 (3) 811-20 This analysis of National Health and Nutrition Examination Survey (NHANES) 2005-2008 data describes the prevalence of risk factors for osteoporosis and the proportions of men and postmenopausal women age 50 years and older who are candidates for treatment to lower fracture risk, according to the new Fracture Risk Assessment Tool (FRAX)-based National Osteoporosis Foundation Clinician's Guide. INTRODUCTION: It is important to update estimates of the proportions of the older US population considered eligible for pharmacologic treatment for osteoporosis for purposes of understanding the health care burden of this disease. METHODS: This is a cross-sectional study of the NHANES 2005-2008 data in 3,608 men and women aged 50 years and older. Variables in the analysis included race/ethnicity, age, lumbar spine and femoral neck bone mineral density, risk factor profiles, and FRAX 10-year fracture probabilities. RESULTS: The prevalence of osteoporosis of the femoral neck ranged from 6.0% in non-Hispanic black to 12.6% in Mexican American women. Spinal osteoporosis was more prevalent among Mexican American women (24.4%) than among either non-Hispanic blacks (5.3%) or non-Hispanic whites (10.9%). Treatment eligibility was similar in Mexican American and non-Hispanic white women (32.0% and 32.8%) and higher than it was in non-Hispanic black women (11.0%). Treatment eligibility among men was 21.1% in non-Hispanic whites, 12.6% in Mexican Americans, and 3.0% in non-Hispanic blacks. CONCLUSIONS: Nineteen percent of older men and 30% of older women in the USA are at sufficient risk for fracture to warrant consideration for pharmacotherapy. |
Annals meeting reports: Diabetes and oral disease: implications for health professionals
Albert DA , Ward A , Allweiss P , Graves DT , Knowler WC , Kunzel C , Leibel RL , Novak KF , Oates TW , Papapanou PN , Schmidt AM , Taylor GW , Lamster IB , Lalla E . Ann N Y Acad Sci 2012 1255 1-15 Diabetes and Oral Disease: Implications for Health Professionals was a one-day conference convened by the Columbia University College of Dental Medicine, the Columbia University College of Physicians and Surgeons, and the New York Academy of Sciences on May 4, 2011 in New York City. The program included an examination of the bidirectional relationship between oral disease and diabetes and the interprofessional working relationships for the care of people who have diabetes. The overall goal of the conference was to promote discussion among the healthcare professions who treat people with diabetes, encourage improved communication and collaboration among them, and, ultimately, improve patient management of the oral and overall effects of diabetes. Attracting over 150 members of the medical and dental professions from eight different countries, the conference included speakers from academia and government and was divided into four sessions. This report summarizes the scientific presentations of the event. |
Concordance of programmatic and laboratory-based multidrug-resistant tuberculosis treatment outcomes in Peru
Alexy ER , Podewils LJ , Mitnick CD , Becerra MC , Laserson KF , Bonilla C . Int J Tuberc Lung Dis 2012 16 (3) 364-369 BACKGROUND: Confirmation of cure for multidrugresistant tuberculosis (MDR-TB) patients requires laboratory tests for Mycobacterium tuberculosis growth on culture media. Outcome decisions dictate patient management, and inaccuracies place patients at an increased risk of morbidity and mortality, and may contribute to continued transmission of MDR-TB. OBJECTIVE: To examine concordance between programmatic and laboratory-based MDR-TB treatment outcomes. METHODS: The study population included 1658 MDRTB patients in Peru treated between 1996 and 2002 with both program and laboratory-based outcomes. Laboratory-based outcomes were assigned according to international standards requiring at least five consecutive negative cultures in the last 12 months of treatment to confirm cure. RESULTS: Compared to the global culture-defined standard classification, only 1.1% of treatment successes, but 54.3% of failures, were misclassified programmatically. Overall, 10.4% of patients identified by a clinician as having a successful treatment outcome still had cultures positive for MDR-TB. CONCLUSION: Most patients with successful treatment outcomes by strict culture definitions were also classified by clinicians as having successful outcomes. However, many culture-confirmed failures were missed. In light of delays and incomplete access to culture in MDR-TB programs, efforts should be made to improve the accuracy of programmatically determined treatment outcomes. (2012 The Union.) |
Rifampicin-resistant Mycobacterium tuberculosis: susceptibility to isoniazid and other anti-tuberculosis drugs
Kurbatova EV , Cavanaugh JS , Shah NS , Wright A , Kim H , Metchock B , Van Deun A , Barrera L , Boulahbal F , Richter E , Martin-Casabona N , Arias F , Zemanova I , Drobniewski F , Santos Silva A , Coulter C , Lumb R , Cegielski JP . Int J Tuberc Lung Dis 2012 16 (3) 355-357 Based on data from 14 Supranational Tuberculosis (TB) Reference Laboratories worldwide, the proportion of rifampicin (RMP) resistant isolates that were isoniazid (INH) susceptible by phenotypic drug susceptibility testing varied widely (0.5-11.6%). RMP-resistant isolates that were INH-susceptible had significantly lower rates of resistance to other first- and second-line anti-tuberculosis drugs (except rifabutin) compared to multidrug-resistant isolates. RMP resistance is not a lways a good proxy for a presumptive diagnosis of multidrug-resistant TB, which has implications for use of molecular assays that identify only RMP resistanceassociated DNA mutations. (2012 The Union.) |
Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance
Magiorakos AP , Srinivasan A , Carey RB , Carmeli Y , Falagas ME , Giske CG , Harbarth S , Hindler JF , Kahlmeter G , Olsson-Liljequist B , Paterson DL , Rice LB , Stelling J , Struelens MJ , Vatopoulos A , Weber JT , Monnet DL . Clin Microbiol Infect 2012 18 (3) 268-281 Many different definitions for multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) bacteria are being used in the medical literature to characterize the different patterns of resistance found in healthcare-associated, antimicrobial-resistant bacteria. A group of international experts came together through a joint initiative by the European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC), to create a standardized international terminology with which to describe acquired resistance profiles in Staphylococcus aureus, Enterococcus spp., Enterobacteriaceae (other than Salmonella and Shigella), Pseudomonas aeruginosa and Acinetobacter spp., all bacteria often responsible for healthcare-associated infections and prone to multidrug resistance. Epidemiologically significant antimicrobial categories were constructed for each bacterium. Lists of antimicrobial categories proposed for antimicrobial susceptibility testing were created using documents and breakpoints from the Clinical Laboratory Standards Institute (CLSI), the European Committee on Antimicrobial Susceptibility Testing (EUCAST) and the United States Food and Drug Administration (FDA). MDR was defined as acquired non-susceptibility to at least one agent in three or more antimicrobial categories, XDR was defined as non-susceptibility to at least one agent in all but two or fewer antimicrobial categories (i.e. bacterial isolates remain susceptible to only one or two categories) and PDR was defined as non-susceptibility to all agents in all antimicrobial categories. To ensure correct application of these definitions, bacterial isolates should be tested against all or nearly all of the antimicrobial agents within the antimicrobial categories and selective reporting and suppression of results should be avoided. |
Neisseria gonorrhoeae with high-level resistance to azithromycin: case report of the first isolate identified in the United States
Katz AR , Komeya AY , Soge OO , Kiaha MI , Lee MV , Wasserman GM , Maningas EV , Whelen AC , Kirkcaldy RD , Shapiro SJ , Bolan GA , Holmes KK . Clin Infect Dis 2012 54 (6) 841-3 We report on the first Neisseria gonorrhoeae isolate in the United States identified with high-level resistance to azithromycin. This report discusses the epidemiologic case investigation, the molecular studies of resistance-associated mutations and N. gonorrhoeae multiantigen sequence typing, and challenges posed by emerging gonococcal antimicrobial resistance. |
Newly identified HIV infections in correctional facilities, United States, 2007
VanHandel M , Beltrami JF , Macgowan RJ , Borkowf CB , Margolis AD . Am J Public Health 2012 102 Suppl 2 S201-4 We used Centers for Disease Control and Prevention HIV Counseling and Testing System data from 2007 to determine the percentage and characteristics of persons newly identified as HIV-positive in US correctional facilities. The newly identified HIV positivity was 0.7%, and 30% of detainees newly identified with HIV were categorized as having low-risk heterosexual contact or no acknowledged risk. Correctional facilities should provide detainees with routine opt-out HIV testing, unless the prevalence of previously undiagnosed HIV infection has been documented to be less than 0.1%. (Am J Public Health. Published online ahead of print March 8, 2012: e1-e4. doi:10.2105/AJPH.2011.300614). |
High prevalence of Mycoplasma genitalium among female sex workers in Honduras: implications for the spread of HIV and other sexually transmitted infections
Johnston LG , Paz-Bailey G , Morales-Miranda S , Morgan M , Alvarez B , Hickman L , Monterroso E . Int J STD AIDS 2012 23 (1) 5-11 This study describes HIV, sexually transmitted infections (STI) and risk factors associated with Mycoplasma genitalium among female sex workers (FSWs) in four cities in Honduras. In 2006, 795 FSWs from Tegucigalpa, San Pedro Sula, La Ceiba and Comayagua were recruited using respondent-driven sampling (RDS) and tested for HIV prevalence and STI. HIV prevalence ranged from no infections in Comayagua to 5.4% in Tegucigalpa. With the exception of Comayagua, more than 20% of FSWs were infected with M. genitalium. M. genitalium in the aggregated cities was associated with HIV positivity, being aged ≤30 years old, drinking alcohol more than once weekly and always using condoms with regular clients in the past month. In comparison with a 2001 surveillance study we found lower rates of HIV infection. Interventions for HIV control and prevention among FSWs, including promotion of condom use, are needed in Honduras. |
Discordance among commercially available diagnostics for latent tuberculosis infection
Mancuso JD , Mazurek GH , Tribble D , Olsen C , Aronson NE , Geiter L , Goodwin D , Keep LW . Am J Respir Crit Care Med 2012 185 (4) 427-34 RATIONALE: There is uncertainty regarding how to interpret discordance between tests for latent tuberculosis infection. OBJECTIVES: The objective of this study was to assess discordance between commercially available tests for latent tuberculosis in a low-prevalence population, including the impact of nontuberculous mycobacteria. METHODS: This was a cross-sectional comparison study among 2,017 military recruits at Fort Jackson, South Carolina, from April to June 2009. Several tests were performed simultaneously with a risk factor questionnaire, including (1) QuantiFERON-TB Gold In-Tube test, (2) T-SPOT.TB test, (3) tuberculin skin test, and (4) Battey skin test using purified protein derivative from the Battey bacillus. MEASUREMENTS AND MAIN RESULTS: In this low-prevalence population, the specificities of the three commercially available diagnostic tests were not significantly different. Of the 88 subjects with a positive test, only 10 (11.4%) were positive to all three tests; 20 (22.7%) were positive to at least two tests. Bacille Calmette-Guerin vaccination, tuberculosis prevalence in country of birth, and Battey skin test reaction size were associated with tuberculin skin test-positive, IFN-gamma release assay-negative test discordance. Increasing agreement between the three tests was associated with epidemiologic criteria indicating risk of infection and with quantitative test results. CONCLUSIONS: For most positive results the three tests identified different people, suggesting that in low-prevalence populations most discordant results are caused by false-positives. False-positive tuberculin skin test reactions associated with reactivity to nontuberculous mycobacteria and bacille Calmette-Guerin vaccination may account for a proportion of test discordance observed. |
The United States Trypanosoma cruzi Infection Study: evidence for vector-borne transmission of the parasite that causes Chagas disease among United States blood donors
Cantey PT , Stramer SL , Townsend RL , Kamel H , Ofafa K , Todd CW , Currier M , Hand S , Varnado W , Dotson E , Hall C , Jett PL , Montgomery SP . Transfusion 2012 52 (9) 1922-30 BACKGROUND: Screening US blood donors for Trypanosoma cruzi infection is identifying autochthonous, chronic infections. Two donors in Mississippi were identified through screening and investigated as probable domestically acquired vector-borne infections, and the US T. cruzi Infection Study was conducted to evaluate the burden of and describe putative risk factors for vector-borne infection in the United States. STUDY DESIGN AND METHODS: Blood donors who tested enzyme-linked immunosorbent assay repeat reactive and positive by radioimmunoprecipitation assay, and whose mode of infection could not be identified, were evaluated with a questionnaire to identify possible sources of infection and by additional serologic and hemoculture testing for T. cruzi infection. RESULTS: Of 54 eligible donors, 37 (69%) enrolled in the study. Fifteen (41%) enrollees had four or more positive serologic tests and were considered positive for T. cruzi infection; one was hemoculture positive. Of the 15, three (20%) donors had visited a rural area of an endemic country, although none had stayed for 2 or more weeks. All had lived in a state with documented T. cruzi vector(s) or infected mammalian reservoir(s), 13 (87%) reported outdoor leisure or work activities, and 11 (73%) reported seeing wild reservoir animals on their property. CONCLUSION: This report adds 16 cases, including one from the Mississippi investigation, of chronic T. cruzi infection presumably acquired via vector-borne transmission in the United States to the previously reported seven cases. The estimated prevalence of autochthonous infections based on this study is 1 in 354,000 donors. Determining US foci of vector-borne transmission is needed to better assess risk for infection. |
Climate predictors of the spatial distribution of human plague cases in the West Nile region of Uganda
MacMillan K , Monaghan AJ , Apangu T , Griffith KS , Mead PS , Acayo S , Acidri R , Moore SM , Mpanga JT , Enscore RE , Gage KL , Eisen RJ . Am J Trop Med Hyg 2012 86 (3) 514-23 East Africa has been identified as a region where vector-borne and zoonotic diseases are most likely to emerge or re-emerge and where morbidity and mortality from these diseases is significant. Understanding when and where humans are most likely to be exposed to vector-borne and zoonotic disease agents in this region can aid in targeting limited prevention and control resources. Often, spatial and temporal distributions of vectors and vector-borne disease agents are predictable based on climatic variables. However, because of coarse meteorological observation networks, appropriately scaled and accurate climate data are often lacking for Africa. Here, we use a recently developed 10-year gridded meteorological dataset from the Advanced Weather Research and Forecasting Model to identify climatic variables predictive of the spatial distribution of human plague cases in the West Nile region of Uganda. Our logistic regression model revealed that within high elevation sites (above 1,300 m), plague risk was positively associated with rainfall during the months of February, October, and November and negatively associated with rainfall during the month of June. These findings suggest that areas that receive increased but not continuous rainfall provide ecologically conducive conditions for Yersinia pestis transmission in this region. This study serves as a foundation for similar modeling efforts of other vector-borne and zoonotic disease in regions with sparse observational meteorologic networks. |
Maternal prenatal urinary phthalate metabolite concentrations and child mental, psychomotor, and behavioral development at 3 years of age
Whyatt RM , Liu X , Rauh VA , Calafat AM , Just AC , Hoepner L , Diaz D , Quinn J , Adibi J , Perera FP , Factor-Litvak P . Environ Health Perspect 2012 120 (2) 290-5 BACKGROUND: Research suggests that prenatal phthalate exposures affect child executive function and behavior. OBJECTIVE: We evaluated associations between phthalate metabolite concentrations in maternal prenatal urine and mental, motor, and behavioral development in children at 3 years of age. METHODS: Mono-n-butyl phthalate (MnBP), monobenzyl phthalate (MBzP), monoisobutyl phthalate (MiBP), and four di-2-ethylhexyl phthalate metabolites were measured in a spot urine sample collected from 319 women during the third trimester. When children were 3 years of age, the Mental Development Index (MDI) and Psychomotor Development Index (PDI) were measured using the Bayley Scales of Infant Development II, and behavior problems were assessed by maternal report on the Child Behavior Checklist. RESULTS: Child PDI scores decreased with increasing loge MnBP [estimated adjusted beta-coefficient = -2.81; 95% confidence interval (CI): -4.63, -1.0] and loge MiBP (beta = -2.28; 95% CI: -3.90, -0.67); odds of motor delay increased significantly [per loge MnBP: estimated adjusted odds ratio (OR) = 1.64; 95% CI: 1.10, 2.44; per loge MiBP: adjusted OR =1.82; 95% CI: 1.24, 2.66]. In girls, MDI scores decreased with increasing loge MnBP (beta = -2.67; 95% CI: -4.70, -0.65); the child sex difference in odds of mental delay was significant (p = 0.037). The ORs for clinically withdrawn behavior were 2.23 (95% CI: 1.27, 3.92) and 1.57 (95% CI: 1.07, 2.31) per loge unit increase in MnBP and MBzP, respectively; for clinically internalizing behaviors, the OR was 1.43 (95% CI: 1.01, 1.90) per loge unit increase in MBzP. Significant child sex differences were seen in associations between MnBP and MBzP and behaviors in internalizing domains (p < 0.05). CONCLUSION: Certain prenatal phthalate exposures may decrease child mental and motor development and increase internalizing behaviors. |
Irritancy and allergic responses induced by exposure to the indoor air chemical 4-oxopentanal
Anderson SE , Franko J , Jackson LG , Wells JR , Ham JE , Meade BJ . Toxicol Sci 2012 127 (2) 371-81 Over the last two decades, there has been an increasing awareness regarding the potential impact of indoor air pollution on human health. People working in an indoor environment often experience symptoms such as eye, nose and throat irritation. Investigations into these complaints have ascribed the effects, in part, to compounds emitted from building materials, cleaning/consumer products, and indoor chemistry. One suspect indoor air contaminant that has been identified is the dicarbonyl 4-oxopentanal (4-OPA). 4-OPA is generated through the ozonolysis of squalene and several high volume production compounds that are commonly found indoors. Following preliminary workplace sampling that identified the presence of 4-OPA, these studies examined the inflamatory and allergic responses to 4-OPA following both dermal and pulmonary exposure using a murine model. 4-OPA was tested in a combined local lymph node assay (LLNA) and identified to be an irritant and sensitizer. A Th1-mediated hypersensitivity response was supported by a positive response in the mouse ear swelling test (MEST). Pulmonary exposure to 4-OPA caused a significant elevation in nonspecific airway hyperreactivity, increased numbers of lung associated lymphocytes and neutrophils and increased interferon-gamma production by lung associated lymph nodes. These results suggest that both dermal and pulmonary exposure to 4-OPA may elicit irritant and allergic responses and may help to explain some of the adverse health effects associated with poor indoor air quality. |
What are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? Results from western Kenya, January 2007-July 2010
Murray EL , Khagayi S , Ope M , Bigogo G , Ochola R , Muthoka P , Njenga K , Odhiambo F , Burton D , Laserson KF , Breiman RF , Feikin DR , Katz MA . Epidemiol Infect 2012 141 (1) 1-11 SUMMARY: Influenza causes severe illness and deaths, and global surveillance systems use different clinical case definitions to identify patients for diagnostic testing. We used data collected during January 2007-July 2010 at hospital-based influenza surveillance sites in western Kenya to calculate sensitivity, specificity, positive predictive value, and negative predictive value for eight clinical sign/symptom combinations in hospitalized patients with acute respiratory illnesses, including severe acute respiratory illness (SARI) (persons aged 2-59 months: cough or difficulty breathing with an elevated respiratory rate or a danger sign; persons aged 5 years: temperature 38 degrees C, difficulty breathing, and cough or sore throat) and influenza-like illness (ILI) (all ages: temperature 38 degrees C and cough or sore throat). Overall, 4800 persons aged 2 months were tested for influenza; 416 (9%) had laboratory-confirmed influenza infections. The symptom combination of cough with fever (subjective or measured 38 degrees C) had high sensitivity [87.0%, 95% confidence interval (CI) 83.3-88.9], and ILI had high specificity (70.0%, 95% CI 68.6-71.3). The case definition combining cough and any fever is a simple, sensitive case definition for influenza in hospitalized persons of all age groups, whereas the ILI case definition is the most specific. The SARI case definition did not maximize sensitivity or specificity. |
Asthma outcomes: healthcare utilization and costs
Akinbami LJ , Sullivan SD , Campbell JD , Grundmeier RW , Hartert TV , Lee TA , Smith RA . J Allergy Clin Immunol 2012 129 S49-64 BACKGROUND: Measures of healthcare utilization and indirect impact of asthma morbidity are used to assess clinical interventions and estimate cost. OBJECTIVE: National Institutes of Health institutes and other federal agencies convened an expert group to propose standardized measurement, collection, analysis, and reporting of healthcare utilization and cost outcomes in future asthma studies. METHODS: We used comprehensive literature reviews and expert opinion to compile a list of asthma healthcare utilization outcomes that we classified as core (required in future studies), supplemental (used according to study aims and standardized), and emerging (requiring validation and standardization). We also have identified methodology to assign cost to these outcomes. This work was discussed at an National Institutes of Health-organized workshop in March 2010 and finalized in September 2011. RESULTS: We identified 3 ways to promote comparability across clinical trials for measures of healthcare utilization, resource use, and cost: (1) specify the study perspective (patient, clinician, payer, and society); (2) standardize the measurement period (ideally 12 months); and (3) use standard units to measure healthcare utilization and other asthma-related events. CONCLUSIONS: Large clinical trials and observational studies should collect and report detailed information on healthcare utilization, intervention resources, and indirect impact of asthma, so that costs can be calculated and cost-effectiveness analyses can be conducted across several studies. Additional research is needed to develop standard, validated survey instruments for collection of provider-reported and participant-reported data regarding asthma-related health care. |
Pneumococcal genome sequencing tracks a vaccine escape variant formed through a multi-fragment recombination event.
Golubchik T , Brueggemann AB , Street T , Gertz RE Jr , Spencer CC , Ho T , Giannoulatou E , Link-Gelles R , Harding RM , Beall B , Peto TE , Moore MR , Donnelly P , Crook DW , Bowden R . Nat Genet 2012 44 (3) 352-5 Streptococcus pneumoniae ('pneumococcus') causes an estimated 14.5 million cases of serious disease and 826,000 deaths annually in children under 5 years of age. The highly effective introduction of the PCV7 pneumococcal vaccine in 2000 in the United States provided an unprecedented opportunity to investigate the response of an important pathogen to widespread, vaccine-induced selective pressure. Here, we use array-based sequencing of 62 isolates from a US national monitoring program to study five independent instances of vaccine escape recombination, showing the simultaneous transfer of multiple and often large (up to at least 44 kb) DNA fragments. We show that one such new strain quickly became established, spreading from east to west across the United States. These observations clarify the roles of recombination and selection in the population genomics of pneumococcus and provide proof of principle of the considerable value of combining genomic and epidemiological information in the surveillance and enhanced understanding of infectious diseases. |
Travel and tropical medicine practice among infectious disease practitioners
Streit JA , Marano C , Beekmann SE , Polgreen PM , Moore TA , Brunette GW , Kozarsky PE . J Travel Med 2012 19 (2) 92-5 BACKGROUND: Infectious disease specialists who evaluate international travelers before or after their trips need skills to prevent, recognize, and treat an increasingly broad range of infectious diseases. Wide variation exists in training and percentage effort among providers of this care. In parallel, there may be variations in approach to pre-travel consultation and the types of travel-related illness encountered. Aggregate information from travel-medicine providers may reveal practice patterns and novel trends in infectious illness acquired through travel. METHODS: The 1,265 members of the Infectious Disease Society of America's Emerging Infections Network were queried by electronic survey about their training in travel medicine, resources used, pre-travel consultations, and evaluation of ill-returning travelers. The survey also captured information on whether any of 10 particular conditions had been diagnosed among ill-returning travelers, and if these diagnoses were perceived to be changing in frequency. RESULTS: A majority of respondents (69%) provided both pre-travel counseling and post-travel evaluations, with significant variation in the numbers of such consultations. A majority of all respondents (61%) reported inadequate training in travel medicine during their fellowship years. However, a majority of recent graduates (55%) reported adequate preparation. Diagnoses of malaria, traveler's diarrhea, and typhoid fever were reported by the most respondents (84, 71, and 53%, respectively). CONCLUSIONS: The percent effort dedicated to pre-travel evaluation and care of the ill-returning traveler vary widely among infectious disease specialists, although a majority participate in these activities. On the basis of respondents' self-assessment, recent fellowship training is reported to equip graduates with better skills in these areas than more remote training. Ongoing monitoring of epidemiologic trends of travel-related illness is warranted. |
The CDC's Center for Global Health
Frieden TR , De Cock KM . Lancet 2012 379 (9820) 986-8 The strategy of the recently established Center for Global Health (CGH) at the US Centers for Disease Control and Prevention (CDC) is to enhance the public health capacity of global partners, increase global health security, and maximise the health impact of specific programmes and interventions through a focus on scientific rigour, scalability, and sustainability. We welcome the opportunity to describe the work of CGH1 and are committed to continuing to increase our impact. | CGH builds on CDC's 60-year history of evidence-based global health programmes. Previously, CDC had five large and many small programmes engaged in global health work; CGH was formed 2 years ago to draw together the large and coordinate the small programmes to enable more effective collaboration within CDC and with host country, bilateral, and multilateral partners.2 |
Deaths in international travelers arriving in the United States, July 1, 2005 to June 30, 2008
Lawson CJ , Dykewicz CA , Molinari NA , Lipman H , Alvarado-Ramy F . J Travel Med 2012 19 (2) 96-103 BACKGROUND:The Centers for Disease Control and Prevention's (CDC) Quarantine Activity Reporting System (QARS), which documents reports of morbidity and mortality among travelers, was analyzed to describe the epidemiology of deaths during international travel. METHODS: We analyzed travel-related deaths reported to CDC from July 1, 2005 to June 30, 2008, in which international travelers died (1) on a U.S.-bound conveyance, or (2) within 72 hours after arriving in the United States, or (3) at any time after arriving in the United States from an illness possibly acquired during international travel. We analyzed age, sex, mode of travel (eg, by air, sea, land), date, and cause of death, and estimated rates using generalized linear models. RESULTS: We identified 213 deaths. The median age of deceased travelers was 66 years (range 1-95); 65% were male. Most deaths (62%) were associated with sea travel; of these, 111 (85%) occurred in cruise ship passengers and 20 (15%) among cargo and cruise ship crew members. Of 81 air travel-associated deaths, 77 occurred in passengers, 3 among air ambulance patients, and 1 in a stowaway. One death was associated with land travel. Deaths were categorized as cardiovascular (70%), infectious disease (12%), cancer (6%), unintentional injury (4%), intentional injury (1%), and other (7%). Of 145 cardiovascular deaths with reported ages, 62% were in persons 65 years of age and older. Nineteen (73%) of 26 persons who died from infectious diseases had chronic medical conditions. There was significant seasonal variation (lowest in July-September) in cardiovascular mortality in cruise ship passengers. CONCLUSIONS: Cardiovascular conditions were the major cause of death for both sexes. Travelers should seek pre-travel medical consultation, including guidance on preventing cardiovascular events, infections, and injuries. Persons with chronic medical conditions and the elderly should promptly seek medical care if they become ill during travel. |
A county-level examination of the relationship between HIV and social determinants of health: 40 states, 2006-2008
Gant Z , Lomotey M , Hall HI , Hu X , Guo X , Song R . Open AIDS J 2012 6 1-7 BACKGROUND: Social determinants of health (SDH) are the social and physical factors that can influence unhealthy or risky behavior. Social determinants of health can affect the chances of acquiring an infectious disease - such as HIV - through behavioral influences and limited preventative and healthcare access. We analyzed the relationship between social determinants of health and HIV diagnosis rates to better understand the disparity in rates between different populations in the United States. METHODS: Using National HIV Surveillance data and American Community Survey data at the county level, we examined the relationships between social determinants of health variables (e.g., proportion of whites, income inequality) and HIV diagnosis rates (averaged for 2006-2008) among adults and adolescents from 40 states with mature name-based HIV surveillance. RESULTS: Analysis of data from 1,560 counties showed a significant, positive correlation between HIV diagnosis rates and income inequality (Pearson correlation coefficient rho = 0.40) and proportion unmarried - ages >15 (rho = 0.52). There was a significant, negative correlation between proportion of whites and rates (rho = -0.67). Correlations were low between racespecific social determinants of health indicators and rates. CONCLUSIONS/IMPLICATIONS: Overall, HIV diagnosis rates increased as income inequality and the proportion unmarried increased, and rates decreased as proportion of whites increased. The data reflect the higher HIV prevalence among non-whites. Although statistical correlations were moderate, identifying and understanding these social determinants of health variables can help target prevention efforts to aid in reducing HIV diagnosis rates. Future analyses need to determine whether the higher proportion of singles reflects higher populations of gay and bisexual men. |
Antimicrobial stewardship 2012: science driving practice
Srinivasan A , Fishman N . Infect Control Hosp Epidemiol 2012 33 (4) 319-21 This edition of Infection Control and Hospital Epidemiology | (ICHE) is dedicated to articles on antimicrobial stewardship. | Though such articles appear regularly in the pages of ICHE, | this is the first time that an entire issue has been devoted to | the topic. By design, this issue comes at a time of tremendous | growth in the importance of antimicrobial stewardship. The | combination of rising rates of antimicrobial resistance, a rapidly dwindling effective antimicrobial armamentarium, and | increasing financial pressures for hospitals has spurred new | interest in the one intervention that has been proven to address all these problems simultaneously. | A number of organizations have recognized the importance of implementing stewardship interventions and programs in hospitals, with major efforts being spearheaded by | the Centers for Disease Control and Prevention (CDC) and | the Society for Healthcare Epidemiology of America (SHEA). | The creation of SHEA's Antimicrobial Stewardship Taskforce | and the launch of CDC's "Get Smart for Healthcare" campaign (http://www.cdc.gov/getsmart/healfhcare) marked the | start of a new era of a nationally coordinated effort to promote inpatient antibiotic stewardship in the United States. | The growing importance and profile of antibiotic stewardship are reflected in the inclusion of several antibiotic | quality measures in the new "inpatient infection control | worksheet" currently being piloted by the Center for Medicare | and Medicaid Services (available at https://www.cms.gov/ | Surveycertificationgeninfo/downloads/SCLetter 12_01 .pdf). | The measures are not all encompassing, nor will they independently improve antibiotic use in hospitals. However, it is | hoped that they will both raise awareness of the importance | of improving antibiotic use in hospitals and help lay a foundation for accomplishing that goal. |
Recurrent Guillain-Barre syndrome following vaccination
Baxter R , Lewis N , Bakshi N , Vellozzi C , Klein NP . Clin Infect Dis 2012 54 (6) 800-804 BACKGROUND: Guillain-Barre syndrome (GBS) is an acute polyradiculopathy, thought to be autoimmune, which has been reported following vaccinations. The Advisory Committee on Immunization Practices recommends not administering influenza vaccine to individuals who have had a history of GBS within 6 weeks of a prior influenza vaccination if they are not at high risk of severe complications from influenza illness. METHODS: We identified GBS cases from the Kaiser Permanente Northern California databases from 1995 into 2006 using hospital discharge codes; each medical record was neurologist-reviewed and only GBS-confirmed cases were included for follow-up. We followed confirmed cases through 2008 for vaccinations and recurrent GBS. RESULTS: We identified 550 cases of GBS over 33 million person-years. Following their GBS diagnoses, 989 vaccines were given to 279 of these individuals, including 405 trivalent inactivated influenza vaccines (TIV) administered to 107 individuals with a prior diagnosis of GBS. Among the 550 total cases of GBS, 18 initially had onset within 6 weeks of TIV; of these, 2 were revaccinated with TIV without a recurrence of GBS. Only 6 individuals of 550 (1.1%) had a second (recurrent) diagnosis of GBS. Among these 6 individuals, none had any vaccine exposure at all in the 2 months prior to the second onset of GBS. CONCLUSIONS: In our population of over 3 million members, during an 11-year period, risk of GBS recurrence was low. There were no cases of recurrent GBS after influenza vaccination and none within 6 weeks after any vaccine. |
The risk of Guillain-Barre syndrome associated with influenza A (H1N1) 2009 monovalent vaccine and 2009-2010 seasonal influenza vaccines: results from self-controlled analyses
Tokars JI , Lewis P , Destefano F , Wise M , Viray M , Morgan O , Gargiullo P , Vellozzi C . Pharmacoepidemiol Drug Saf 2012 21 (5) 546-52 PURPOSE: The Centers for Disease Control and Prevention Emerging Infections Program implemented active, population-based surveillance for Guillain-Barre syndrome (GBS) following H1N1 vaccines in 10 states/metropolitan areas. We report additional analyses of these data using self-controlled methods, which avoid potential confounding from person-level factors and co-morbidities. METHODS: Surveillance officers identified GBS cases with symptom onset during October 2009-April 2010 and ascertained receipt of H1N1 vaccines. We calculated self-controlled relative risks by comparing the number of cases with onset during a risk interval 1-42 days after vaccination with cases with onset during fixed (days 43-84) or variable (days 43-end of study period) control intervals. We calculated attributable risks by applying statistically significant relative risks to an independent estimate of GBS incidence. RESULTS: Fifty-nine GBS cases received H1N1 vaccine with or without seasonal vaccine. The relative risk was 2.1 (95%CI 1.2, 3.5) by the variable-window and 3.0 (95%CI 1.4, 6.4) by the fixed-window analyses. The corresponding attributable risks per million doses administered were 1.5 (95%CI 0.3, 3.4) and 2.8 (95%CI 0.6, 7.4). CONCLUSIONS: These attributable risks are similar to those of some previous formulations of seasonal influenza vaccine (about one to two cases per million doses administered), suggesting a low risk of GBS following the H1N1 vaccine that is not clearly higher than that of seasonal influenza vaccines. (Published 2012. This article is a US Government work and is in the public domain in the USA.) |
Lack of interference by zoster vaccine with the immune response to yellow fever vaccine
Stier DM , Weber IB , Staples JE . J Travel Med 2012 19 (2) 122-3 Concerns exist about the serologic response to yellow fever (YF) vaccine when given within 28 days of another live virus vaccine. We report the case of a healthy adult who received 17D YF vaccine 21 days following administration of another live viral vaccine, and developed a protective level of immunity against YF virus. |
Elicitation of anti-1918 influenza virus immunity early in life prevents morbidity and lower levels of lung infection by 2009 pandemic H1N1 influenza virus in aged mice
Giles BM , Bissel SJ , Craigo JK , Dealmeida DR , Wiley CA , Tumpey TM , Ross TM . J Virol 2012 86 (3) 1500-13 The Spanish influenza virus pandemic of 1918 was responsible for 40 million to 50 million deaths and is antigenically similar to the swine lineage 2009 pandemic influenza virus. Emergence of the 2009 pandemic from swine into humans has raised the possibility that low levels of cross-protective immunity to past shared epitopes could confer protection. In this study, influenza viruslike particles (VLPs) were engineered to express the hemagglutinin (HA) and genes from the 1918 influenza virus to evaluate the duration of cross-protection to the H1N1 pandemic strain by vaccinating young mice (8 to 12 weeks) and then allowing the animals to age to 20 months. This immunity was long lasting, with homologous receptor-blocking antibodies detected throughout the lifespan of vaccinated mice. Furthermore, the 1918 VLPs fully protected aged mice from 2009 pandemic H1N1 virus challenge 16 months after vaccination. Histopathological assessment showed that aged vaccinated mice had significant protection from alveolar infection but less protection of the bronchial tissue than adult vaccinated mice. Additionally, passive transfer of immune serum from aged vaccinated mice resulted in protection from death but not morbidity. This is the first report describing the lifelong duration of cross-reactive immune responses elicited by a 1918 VLP vaccine in a murine model. Importantly, these lifelong immune responses did not result in decreased total viral replication but did prevent infection of the lower respiratory tract. These findings show that immunity acquired early in life can restrict the anatomical location of influenza viral replication, rather than preventing infection, in the aged. |
Inching toward a serogroup B meningococcal vaccine for infants
Cohn AC , Messonnier NE . JAMA 2012 307 (6) 614-5 In the past decade, the introduction of meningococcal conjugate vaccines has led to substantial reductions in meningococcal disease. Monovalent serogroup C vaccines have virtually eliminated serogroup C disease from the United Kingdom and other countries, and serogroup A, C, W, and Y vaccines have reduced disease among adolescents in the United States.1,2 In 2010 and 2011, Burkina Faso, Mali, Niger, and part of Nigeria introduced serogroup A conjugate vaccine, which may eliminate epidemic meningitis from the meningitis belt of Africa. These accomplishments have been dampened by the lack of effective serogroup B meningococcal vaccines. Serogroup B meningococcal disease causes substantial morbidity and mortality globally, especially in young infants.3-5 Serogroup B disease can be devastating; 5% to 10% of children with the disease do not survive and another 10% to 20% experience long-term sequelae such as hearing loss, limb loss, and neurologic deficits.5 Disease burden is lower in the United States than in other countries; incidence of serogroup B disease is 0.16 per 100 000 population but 3.08 per 100 000 population among infants younger than 12 months.4 In contrast, incidence of serogroup B disease in several countries in Europe, including the United Kingdom, is about 10-fold that in the United States.3 | Serogroup B polysaccharide has not been a successful vaccine target because it is similar to human neural cell glycopeptide and therefore poorly immunogenic in humans. For a serogroup B vaccine to have a substantial effect on disease burden, it will need to be immunogenic and safe in young infants, protect against a high proportion of serogroup B strains, and provide long-term protection. |
Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine
Smith KJ , Wateska AR , Nowalk MP , Raymund M , Nuorti JP , Zimmerman RK . JAMA 2012 307 (8) 804-12 CONTEXT: The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. OBJECTIVE: To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. DESIGN, SETTING, AND PARTICIPANTS: A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. MAIN OUTCOME MEASURES: Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28,900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45,100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496,000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. CONCLUSION: Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution. |
N95 filtering facepiece respirator deadspace temperature and humidity
Roberge RJ , Kim JH , Benson S . J Occup Environ Hyg 2012 9 (3) 166-71 The objective of this study was to determine the levels of heat and humidity that develop within the deadspace of N95 filtering facepiece respirators (N95 FFR). Seventeen subjects wore two models each of N95 FFR and N95 FFR with an exhalation valve (N95 FFR/EV) while exercising on a treadmill at a low-moderate work rate for 1 and 2 hr in a temperate ambient environment. FFR deadspace temperature and relative humidity were monitored by a wireless sensor housed within the FFR. Each FFR was weighed pre- and post-testing to determine moisture retention. After 1 hr, FFR deadspace temperature and humidity were markedly elevated above ambient levels, and the FFR deadspace mean apparent heat index was 54 degrees C. N95 FFR/EV use resulted in significantly lower deadspace temperatures than N95 FFR (p = 0.01), but FFR deadspace humidity levels were not significantly different (p = 0.32). Compared with the first hour of use, no significant increase in FFR deadspace heat and humidity occurred over the second hour. FFR mean moisture retention was < 0.3 grams over 2 hr. N95 FFR/EV offer a significant advantage in deadspace heat dissipation over N95 FFR at a low-moderate work rate over 1 hr of continuous use but offered no additional benefit in humidity amelioration. Moisture retention in N95 FFR and N95 FFR/EV is minimal after 2 hr of use. [Supplementary materials are available for this article. Go to the publisher's online edition of Journal of Occupational and Environmental Hygiene for the following free supplemental resource: a file containing N95 filtering facepiece respirator deadspace mean RH and temperature recordings for 17 subjects treadmill exercising at 5.6 Km/H over 1 hour.]. |
Quantification of the spatial distribution of rectally applied surrogates for microbicide and semen in colon with SPECT and magnetic resonance imaging
Cao YJ , Caffo BS , Fuchs EJ , Lee LA , Du Y , Li L , Bakshi RP , Macura K , Khan WA , Wahl RL , Grohskopf LA , Hendrix CW . Br J Clin Pharmacol 2012 74 (6) 1013-22 AIMS: We sought to quantitatively describe the distribution of rectally administered gels and seminal fluid surrogates using novel concentration-distance parameters that could be repeated over time. These methods are needed to rationally develop rectal microbicides to target and prevent HIV infection. METHODS: Eight subjects were dosed rectally with radiolabeled and gadolinium-labeled gels to simulate microbicide gel and seminal fluid. Rectal doses were given with and without simulated receptive anal intercourse. Twenty-four hour distribution was assessed with indirect single photon emission computed tomography (SPECT)/computed tomography (CT) and magnetic resonance (MR) imaging, and direct assessment via sigmoidoscopic brushes. Concentration-distance curves were generated using an algorithm for fitting SPECT data in 3-dimensions. Three novel concentration-distance parameters were defined to quantitatively describe the distribution of radiolabels: maximal distance (D(max) ), distance at maximal concentration (D(Cmax) ), mean residence distance (D(ave) ). RESULTS: The SPECT/CT distribution of microbicide and semen surrogates was similar. Between 1 hour and 24 hours post-dose, the surrogates migrated retrograde in all three parameters (relative to coccygeal level; geometric mean [95% confidence interval]): maximal distance (D(max) ), 10 cm (8.6-12) to 18 cm (13-26); distance at maximal concentration (D(Cmax) ), 3.8 cm (2.7-5.3) to 4.2 cm (2.8-6.3); mean residence distance (D(ave) ), 4.3 cm (3.5-5.1) to7.6 cm (5.3-11). Sigmoidoscopy and MRI correlated only roughly with SPECT/CT. CONCLUSIONS: Rectal microbicide surrogates migrated retrograde during the 24 hours following dosing. Spatial kinetic parameters estimated using three dimensional curve fitting of distribution data should prove useful for evaluating rectal formulations of drugs for HIV prevention and other indications. (2012 (c) The Authors. British Journal of Clinical Pharmacology (c) 2012 The British Pharmacological Society.) |
Inclusion of a CRF01_AE HIV envelope protein boost with a DNA/MVA prime-boost vaccine: impact on humoral and cellular immunogenicity and viral load reduction after SHIV-E challenge
Cox JH , Ferrari MG , Earl P , Lane JR , Jagodzinski LL , Polonis VR , Kuta EG , Boyer JD , Ratto-Kim S , Eller LA , Pham DT , Hart L , Montefiori D , Ferrari G , Parrish S , Weiner DB , Moss B , Kim JH , Birx D , Vancott TC . Vaccine 2012 30 (10) 1830-40 The current study assessed the immunogenicity and protective efficacy of various prime-boost vaccine regimens in rhesus macaques using combinations of recombinant DNA (rDNA), recombinant MVA (rMVA), and subunit gp140 protein. The rDNA and rMVA vectors were constructed to express Env from HIV-1 subtype CRF01_AE and Gag-Pol from CRF01_AE or SIVmac 239. One of the rMVAs, MVA/CMDR, has been recently tested in humans. Immunizations were administered at months 0 and 1 (prime) and months 3 and 6 (boost). After priming, HIV env-specific serum IgG was detected in monkeys receiving gp140 alone or rMVA but not in those receiving rDNA. Titers were enhanced in these groups after boosting either with gp140 alone or with rMVA plus gp140. The groups that received the rDNA prime developed env-specific IgG after boosting with rMVA with or without gp140. HIV Env-specific serum IgG binding antibodies were elicited more frequently and of higher titer, and breadth of neutralizing antibodies was increased with the inclusion of the subunit Env boost. T cell responses were measured by tetramer binding to Gag p11c in Mamu-A*01 macaques, and by IFN-gamma ELISPOT assay to SIV-Gag. T cell responses were induced after vaccination with the highest responses seen in macaques immunized with rDNA and rMVA. Macaques were challenged intravenously with a novel SHIV-E virus (SIVmac239 Gag-Pol with an HIV-1 subtype E-Env CAR402). Post challenge with SHIV-E, antibody titers were boosted in all groups and peaked at 4 weeks. Robust T cell responses were seen in all groups post challenge and in macaques immunized with rDNA and rMVA a clear boosting of responses was seen. A greater than two-log drop in RNA copies/ml at peak viremia and earlier set point was achieved in macaques primed with rDNA, and boosted with rMVA/SHIV-AE plus gp140. Post challenge viremia in macaques immunized with other regimens was not significantly different to that of controls. These results demonstrate that a gp140 subunit and inclusion of SIV Gag-Pol may be critical for control of SHIV post challenge. |
Adaptation of a duck influenza A virus in quail
Yamada S , Shinya K , Takada A , Ito T , Suzuki T , Suzuki Y , Le QM , Ebina M , Kasai N , Kida H , Horimoto T , Rivailler P , Chen LM , Donis RO , Kawaoka Y . J Virol 2012 86 (3) 1411-20 Quail are thought to serve as intermediate hosts of influenza A viruses between aquatic birds and terrestrial birds, such as chickens, due to their high susceptibility to aquatic-bird viruses, which then adapt to replicate efficiently in their new hosts. However, does replication of aquatic-bird influenza viruses in quail similarly result in their efficient replication in humans? Using sialic acid-galactose linkage-specific lectins, we found both avian (sialic acid-alpha2-3-galactose [Siaalpha2-3Gal] linkages on sialyloligosaccharides)--and human (Siaalpha2-6Gal)-type receptors on the tracheal cells of quail, consistent with previous reports. We also passaged a duck H3N2 virus in quail 19 times. Sequence analysis revealed that eight mutations accumulated in hemagglutinin (HA) during these passages. Interestingly, many of the altered HA amino acids found in the adapted virus are present in human seasonal viruses, but not in duck viruses. We also found that stepwise stalk deletion of neuraminidase occurred during passages, resulting in reduced neuraminidase function. Despite some hemagglutinin mutations near the receptor binding pocket, appreciable changes in receptor specificity were not detected. However, reverse-genetics-generated viruses that possessed the hemagglutinin and neuraminidase of the quail-passaged virus replicated significantly better than the virus possessing the parent HA and neuraminidase in normal human bronchial epithelial cells, whereas no significant difference in replication between the two viruses was observed in duck cells. Further, the quail-passaged but not the original duck virus replicated in human bronchial epithelial cells. These data indicate that quail can serve as intermediate hosts for aquatic-bird influenza viruses to be transmitted to humans. |
Antibody inhibition of a viral type 1 interferon decoy receptor cures a viral disease by restoring interferon signaling in the liver
Xu RH , Rubio D , Roscoe F , Krouse TE , Truckenmiller ME , Norbury CC , Hudson PN , Damon IK , Alcami A , Sigal LJ . PLoS Pathog 2012 8 (1) e1002475 Type 1 interferons (T1-IFNs) play a major role in antiviral defense, but when or how they protect during infections that spread through the lympho-hematogenous route is not known. Orthopoxviruses, including those that produce smallpox and mousepox, spread lympho-hematogenously. They also encode a decoy receptor for T1-IFN, the T1-IFN binding protein (T1-IFNbp), which is essential for virulence. We demonstrate that during mousepox, T1-IFNs protect the liver locally rather than systemically, and that the T1-IFNbp attaches to uninfected cells surrounding infected foci in the liver and the spleen to impair their ability to receive T1-IFN signaling, thus facilitating virus spread. Remarkably, this process can be reversed and mousepox cured late in infection by treating with antibodies that block the biological function of the T1-IFNbp. Thus, our findings provide insights on how T1-IFNs function and are evaded during a viral infection in vivo, and unveil a novel mechanism for antibody-mediated antiviral therapy. |
Risk factors for diarrhea-associated infant mortality in the United States, 2005-2007
Mehal JM , Esposito DH , Holman RC , Tate JE , Sinden LL , Parashar UD . Pediatr Infect Dis J 2012 31 (7) 717-21 BACKGROUND: Diarrhea-associated deaths among US children increased from the mid-1980s through 2006, particularly among infants. Understanding risk factors for diarrhea-associated death could improve prevention strategies. METHODS: Records of singleton infants with diarrhea listed anywhere on the death certificate were selected from the US Linked Birth/Infant Death data for 2005-2007; characteristics of these infants were compared with those of infants who survived their first year. RESULTS: During 2005-2007, 1087 diarrhea-associated infant deaths were reported; 86% occurred among low birthweight (LBW, <2500 grams) infants. Compared with normal birthweight (NBW, ≥2500 grams) infants, LBW infants had a greater mortality rate (RR: 91.9, 95% CI: 77.4-109.0) and younger median age at death (7 versus 15 weeks, p<0.0001). The most common co-diagnoses for diarrhea-associated death among LBW and NBW infants were sepsis (26%) and volume depletion (20%), respectively. Among LBW infants, 97% of diarrhea-associated deaths occurred in inpatient settings, whereas 27% of NBW infant deaths occurred in outpatient settings and 5.3% in the decedent's home. Male sex, black race, unmarried status, and low 5-minute Apgar score (<7) increased mortality odds among LBW infants while, among NBW infants, low 5-minute Apgar score, black race, young maternal age (<25 years) and high birth order (third or more) increased mortality odds. CONCLUSIONS: Efforts to reduce diarrhea-associated morality should focus on understanding and improving management of diarrhea in vulnerable LBW infants. For prevention of diarrhea-associated deaths in NBW infants, educating mothers who fit the high risk profile regarding home hydration therapy and timely access to medical treatment is important. |
Parental age and autism spectrum disorders
Parner ET , Baron-Cohen S , Lauritsen MB , Jorgensen M , Schieve LA , Yeargin-Allsopp M , Obel C . Ann Epidemiol 2012 22 (3) 143-50 PURPOSE: We sought to study the possible association between parental age and autism spectrum disorder (ASD) by using both a cohort design and a sibling design. METHODS: Our cohort included all singleton births in Denmark from January 1, 1980, through December 31, 2003, a total of 1,311,736 children. Cases of ASDs were obtained from the Danish National Psychiatric Register using International Classification of Diseases (ICD)-8 and ICD-10. RESULTS: A total of 9556 children were diagnosed with an ASD. Both maternal and paternal age were associated with a greater risk of ASD in the offspring (hazard ratios ranging from 1.21 (1.10-1.34) to 1.65 (1.09-2.48) depending on combinations of parental age categories; <35, 35-39, and 40+ years). For mothers younger than 35 years, the risk of ASD increased with increasing father's age group. For fathers younger than 35 years, the risk of ASD increased with increasing maternal age. CONCLUSIONS: We found an association between parental age and ASD in the cohort study, but the combined underlying mechanisms through which paternal and maternal age impact ASD risk do not seem to act synergistically. The results of the sibling analysis suggest that the association between parental age and ASD found in the cohort study cannot be accounted for by common genetic and environmental factors. |
Folic acid use and nonsyndromic orofacial clefts in China: a prospective cohort study
Li S , Chao A , Li Z , Moore CA , Liu Y , Zhu J , Erickson JD , Hao L , Berry RJ . Epidemiology 2012 23 (3) 423-32 BACKGROUND: Questions remain about the effectiveness, dose, and timing of folic acid in preventing orofacial clefts. Case-control studies report conflicting results. There have been no cohort studies of orofacial clefts and the use of folic acid without other vitamins. METHODS: In a prospective cohort of 240,244 women enrolled between 1993 and 1995 in 1 northern and 2 southern provinces in China, we examined the risk of nonsyndromic cleft lip with or without cleft palate (CL/P) and cleft palate alone (CP) in relation to maternal use of 400 mcg of folic acid without other vitamins. RESULTS: Daily use of 400 mcg of folic acid without other vitamins, started before the last menstrual period (LMP), was associated with reduced risk of CL/P with adjusted rate ratio (aRR) of 0.69 (95% confidence interval = 0.55-0.87). The greatest reduction in risk was observed in the north among daily users who began taking folic acid pills before LMP (aRR = 0.21 [0.10-0.44]); in the south there was marginal reduction in risk (aRR = 0.81 [0.63-1.05]). No evidence of reduced CL/P risk was observed among women who started folic acid pills on or after their LMP. No persuasive evidence for reduction in CP risk was seen with folic acid pill use at any time. CONCLUSION: Daily maternal consumption of 400 mcg of folic acid without other vitamins, started before mother's LMP, was associated with a reduced risk of CL/P in babies born in a high-prevalence region of China. |
High prevalence of hypertension and placental insufficiency, but no in utero HIV transmission, among women on HAART with stillbirths in Botswana
Shapiro RL , Souda S , Parekh N , Binda K , Kayembe M , Lockman S , Svab P , Babitseng O , Powis K , Jimbo W , Creek T , Makhema J , Essex M , Roberts DJ . PLoS One 2012 7 (2) e31580 BACKGROUND: Increased stillbirth rates occur among HIV-infected women, but no studies have evaluated the pathological basis for this increase, or whether highly active antiretroviral therapy (HAART) influences the etiology of stillbirths. It is also unknown whether HIV infection of the fetus is associated with stillbirth. METHODS: HIV-infected women and a comparator group of HIV-uninfected women who delivered stillbirths were enrolled at the largest referral hospital in Botswana between January and November 2010. Obstetrical records, including antiretroviral use in pregnancy, were extracted at enrollment. Verbal autopsies; maternal HIV, CD4 and HIV RNA testing; stillbirth HIV PCR testing; and placental pathology (blinded to HIV and treatment status) were performed. RESULTS: Ninety-nine stillbirths were evaluated, including 62 from HIV-infected women (34% on HAART from conception, 8% on HAART started in pregnancy, 23% on zidovudine started in pregnancy, and 35% on no antiretrovirals) and 37 from a comparator group of HIV-uninfected women. Only 2 (3.7%) of 53 tested stillbirths from HIV-infected women were HIV PCR positive, and both were born to women not receiving HAART. Placental insufficiency associated with hypertension accounted for most stillbirths. Placental findings consistent with chronic hypertension were common among HIV-infected women who received HAART and among HIV-uninfected women (65% vs. 54%, p = 0.37), but less common among HIV-infected women not receiving HAART (28%, p = 0.003 vs. women on HAART). CONCLUSIONS: In utero HIV infection was rarely associated with stillbirths, and did not occur among women receiving HAART. Hypertension and placental insufficiency were associated with most stillbirths in this tertiary care setting. |
Self-reported academic grades and other correlates of sugar-sweetened soda intake among US adolescents
Park SY , Sherry B , Foti K , Blanck HM . J Acad Nutr Diet 2012 112 (1) 125-131 High consumption of sugar-sweetened drinks has been associated with obesity and other adverse health consequences. This cross-sectional study examined the association of demographic characteristics, weight status, self-reported academic grades, and behavioral factors with sugar-sweetened soda intake among a nationally representative sample of US high school students. Analysis was based on the 2009 national Youth Risk Behavior Survey and included 16,188 students in grades 9 through 12. The main outcome measure was daily sugar-sweetened soda intake (eg, drank a can, bottle, or glass of soda [excluding diet soda] at least one time per day during the 7 days before the survey). Nationally, 29.2% of students reported drinking sugar-sweetened soda at least one time per day. Logistic regression analyses showed factors significantly associated with sugar-sweetened soda intake at least one time per day included male sex (adjusted odds ratio [OR]=1.47), Hispanic ethnicity (vs whites; OR=0.81), earning mostly B, C, and D/F grades (vs mostly As; OR=1.26, 1.66, and 2.19, respectively), eating vegetables fewer than three times per day (OR=0.72), trying to lose weight (OR=0.72), sleeping 8 hours (OR=1.18), watching television >2 hours/day (OR=1.71), playing video or computer games or using a computer for other than school work >2 hours/day (OR=1.53), being physically active at least 60 minutes/day on 5 days during the 7 days before the survey (OR=1.19), and current cigarette use (OR=2.01). The significant associations with poor self-reported academic grades, inadequate sleep, sedentary behaviors, and cigarette smoking suggest research should examine why soda consumption is associated with these behaviors to inform the design of future nutrition interventions. |
Vitamin D status and determinants of deficiency among non-pregnant Jordanian women of reproductive age
Nichols EK , Khatib IM , Aburto NJ , Sullivan KM , Scanlon KS , Wirth JP , Serdula MK . Eur J Clin Nutr 2012 66 (6) 751-6 BACKGROUND/OBJECTIVES: Vitamin D deficiency, a risk factor for osteomalacia and osteoporosis, is a re-emerging health problem globally. While sunlight is an important vitamin D source, previous investigations among women whose culture encourages skin covering have been small, not nationally representative, or both. We investigated serum 25-hydroxyvitamin D (25(OH)D(3)) status and factors associated with deficiency in a nationally representative survey of 2013 Jordanian women of reproductive age in Spring 2010. SUBJECTS/METHODS: We measured 25(OH)D(3) concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with skin covering and other factors. RESULTS: Results showed 60.3% (95% CI: 57.1-63.4%) deficiency (<12 ng/ml) and 95.7% (95% CI: 94.4-96.8%) insufficiency (<20 ng/ml) among women. Prevalence of deficiency was 1.60 times higher for women who covered with a scarf/hijab (95% CI: 1.06-2.40, P=0.024) and 1.87 times higher for women who wore full cover, or a niqab (95% CI: 1.20-2.93, P=0.006), compared with the women who did not wear a scarf/hijab or niqab. Compared with rural women completing at least secondary education, prevalence of deficiency was 1.30 times higher for urban women of the same education level (95% CI: 1.08-1.57, P=0.006), 1.18 times higher for urban women completing less than secondary education (95% CI: 0.98-1.43, P=0.09), and 0.66 times lower for rural women completing less than secondary education (95% CI: 0.52-0.84, P=0.001). CONCLUSION: Vitamin D deficiency and insufficiency pose significant public health problems in Jordanian women. Prevalence of deficiency is significantly higher among urban women and among women who cover with a scarf/hijab or niqab. (European Journal of Clinical Nutrition advance online publication, 14 March 2012; doi:10.1038/ejcn.2012.25.) |
Low influenza vaccination rates among child care workers in the United States: assessing knowledge, attitudes, and behaviors
de Perio MA , Wiegand DM , Evans SM . J Community Health 2012 37 (2) 272-81 Influenza can spread quickly among children and caregivers in child day care settings. Vaccination is the most effective method to prevent influenza. We determined 2009 pandemic influenza A (H1N1) (pH1N1) and seasonal influenza vaccination rates during the 2009-2010 influenza season among child care center employees, assessed knowledge and attitudes regarding the vaccines, and determined factors associated with vaccine receipt. Using a cross-sectional study design, from January 30-March 1, 2010, we surveyed 384 (95%) of 403 employees at 32 licensed child centers in the United States about personal and work characteristics, vaccine receipt, and knowledge and attitudes regarding each vaccine. Forty-five (11%) and eighty five (22%) respondents reported receiving the pH1N1 and seasonal influenza vaccines, respectively. The most common reasons cited for not getting either vaccine were "I don't think I need the vaccine," "I don't think the vaccine will keep me from getting the flu," and "the vaccine is not safe." Factors independently associated with receipt of either vaccine included belief in its efficacy, having positive attitudes towards it, and feeling external pressure to get it. Child care center employees had low rates of pH1N1 and seasonal influenza vaccination largely due to misconceptions about the need for and efficacy of the vaccine. Public health messages should address misconceptions about vaccines, and employers should consider methods to maximize influenza vaccination of employees as part of a comprehensive influenza prevention program. |
Pesticide use and fatal injury among farmers in the Agricultural Health Study
Waggoner JK , Henneberger PK , Kullman GJ , Umbach DM , Kamel F , Beane Freeman LE , Alavanja MC , Sandler DP , Hoppin JA . Int Arch Occup Environ Health 2012 86 (2) 177-87 PURPOSE: To assess whether pesticide use practices were associated with injury mortality among 51,035 male farmers from NC and IA enrolled in the Agricultural Health Study. METHODS: We used Cox proportional hazards models adjusted for age and state to estimate fatal injury risk associated with self-reported use of 49 specific pesticides, personal protective equipment, specific types of farm machinery, and other farm factors collected 1-15 years preceding death. Cause-specific mortality was obtained through linkage to mortality registries. RESULTS: We observed 338 injury fatalities over 727,543 person-years of follow-up (1993-2008). Fatal injuries increased with days/year of pesticide application, with the highest risk among those with 60+ days of pesticide application annually [hazard ratio (HR) = 1.87; 95% confidence interval (CI) = 1.10, 3.18]. Chemical-resistant glove use was associated with decreased risk (HR = 0.73; 95% CI = 0.58, 0.93), but adjusting for glove use did not substantially change estimates for individual pesticides or pesticide use overall. Herbicides were associated with fatal injury, even after adjusting for operating farm equipment, which was independently associated with fatal injury. Ever use of five of 18 herbicides (2,4,5-T, paraquat, alachlor, metribuzin, and butylate) were associated with elevated risk. In addition, 2,4-D and cyanazine were associated with fatal injury in exposure-response analyses. There was no evidence of confounding of these results by other herbicides. CONCLUSION: The association between application of pesticides, particularly certain herbicides, and fatal injuries among farmers should be interpreted cautiously but deserves further evaluation, with particular focus on understanding timing of pesticide use and fatal injury. |
Post-hire asthma among insect-rearing workers
Suarthana E , Shen A , Henneberger PK , Kreiss K , Leppla NC , Bueller D , Lewis DM , Bledsoe TA , Janotka E , Petsonk EL . J Occup Environ Med 2012 54 (3) 310-317 OBJECTIVE: To evaluate the incidence of post-hire asthma (PHA) among insect-rearing workers, defined as asthma, the symptoms of which appeared after hire at the current workplace. METHODS: We surveyed the health of workers at three insect-rearing facilities and an associated office facility. We calculated the incidence and estimated hazard ratios for PHA. RESULTS: Post-hire asthma incidence in 157 insect-rearing workers was 16.2 per 1000 person-years compared with 9.2 per 1,000 person-years in 70 office workers. Workers with predominant exposure to Lepidoptera had an incidence of 26.9 per 1000 person-years and a hazard ratio of 5.5 (95% confidence interval: 1.6 to 23.9) adjusted for sex, race, and parental asthma. In contrast, the presence of specific immunoglobulin E to Lepidoptera antigens was not associated with PHA. CONCLUSION: Insect-rearing workers had a high incidence of PHA, primarily accounted for by workplace exposure to Lepidoptera. |
Potential determinants of coal workers' pneumoconiosis, advanced pneumoconiosis, and progressive massive fibrosis among underground coal miners in the United States, 2005-2009
Laney AS , Petsonk EL , Hale JM , Wolfe AL , Attfield MD . Am J Public Health 2012 102 Suppl 2 S279-83 OBJECTIVES: We better defined the distribution and determinants of coal workers' pneumoconiosis (CWP) among US underground coal miners. METHODS: We obtained chest radiographs from the mobile unit of an enhanced surveillance program begun in 2005 by the National Institute for Occupational Safety and Health for underground coal miners. B Readers classified them for presence of pneumoconiosis. RESULTS: Miners from 15 states participated (n = 6658). The prevalence of CWP was higher in 3 states (Kentucky, 9.0%; Virginia, 8.0%; West Virginia, 4.8%) than in 12 other states (age-adjusted risk ratio [RR] = 4.5; 95% confidence interval [CI] = 3.3, 6.1). Miners in these 3 states were younger and had less mining tenure, but advanced CWP (category ≥ 2/1; RR = 8.1; 95% CI = 3.9, 16.9) and progressive massive fibrosis (RR = 10.5; 95% CI = 3.8, 29.1) was more prevalent among them. Advanced CWP and progressive massive fibrosis were more prevalent among workers at mines with fewer than 155 miners, irrespective of mining region, than among workers at larger mines. CONCLUSIONS: Enhanced surveillance results confirmed the persistence of severe CWP among US coal miners and documented the health consequences of inadequate dust control for miners in parts of Appalachia and at smaller mines. (Am J Public Health. Published online ahead of print March 8, 2012: e1-e5. doi:10.2105/AJPH.2011.300427). |
Molecular characterization of Cryptosporidium in children in Oyo State, Nigeria: implications for infection sources
Ayinmode AB , Fagbemi BO , Xiao L . Parasitol Res 2012 110 (1) 479-81 A study was conducted to detect and identify Cryptosporidium spp. in 43 children from Oyo State, Nigeria. Using nested polymerase chain reaction, 11.6% of the children were identified as positive for Cryptosporidium spp. Restriction fragment length polymorphism analysis and DNA sequencing of the PCR products showed the presence of three subtype families of Cryptosporidium hominis (two isolates of Ia and one isolate of Ib) and Cryptosporidium parvum (two isolates of IIc), all anthroponotic in nature. This study identified a high diversity of Cryptosporidium subtypes and clearly suggested that anthroponotic rather than zoonotic transmission played a more important role in the epidemiology of Cryptosporidium in the studied area. |
Mosquito infection studies with Aotus monkeys and humans infected with the Chesson strain of Plasmodiun vivax
Collins WE , Sullivan JS , Jeffery GM , Nace D , Williams T , Galland GG , Williams A , Barnwell JW . Am J Trop Med Hyg 2012 86 (3) 398-402 Oocyst counts were compared between mosquitoes that fed on humans versus mosquitoes that fed on Aotus monkeys, both of which were infected with the Chesson strain of Plasmodium vivax. Oocyst counts obtained from mosquitoes fed on humans were almost 10-fold higher in number. Mosquitoes were more likely to be infected and with a higher rate of infection when they fed on monkeys before the peak in the asexual parasite count. Mosquitoes that fed on humans were more likely to be more heavily infected when fed after the peak in the asexual count. Of several species of owl monkeys, Aotus vociferans was infected at a higher frequency. On the basis of oocyst counts, Anopheles dirus were the most susceptible and An. maculatus were the least susceptible of the mosquito species tested. |
Proteomic changes at 8 weeks after infection are associated with chronic liver pathology in experimental schistosomiasis
Manivannan B , Jordan TW , Secor WE , La Flamme AC . J Proteomics 2012 75 (6) 1838-48 Chronic Schistosoma mansoni infection can present as a moderate or severe disease, termed intestinal or hepatosplenic schistosomiasis, respectively. Similarly, either moderate splenomegaly or hypersplenomegaly syndrome develops in CBA/J mice by 20 weeks of infection and is similar to intestinal or hepatosplenic schistosomiasis respectively. Using this mouse model and two-dimensional differential in gel electrophoresis, the liver proteomic signatures of uninfected mice and mice infected for 6, 8, 12, or 20 weeks were compared, and significant protein spots identified using mass spectrometry. We found the greatest number of changes at 12 weeks suggesting that this period represents the peak time of change. Pathway analysis identified specific proteins and pathways that correlated to the pathological changes indicative of severe disease, and these pathways were involved as early as 8 weeks after infection. These findings provide insight into the development of severe liver pathology in schistosomiasis and may aid in developing biomarkers for hepatosplenic schistosomiasis. |
Fatal Naegleria fowleri infection acquired in Minnesota: possible expanded range of a deadly thermophilic organism
Kemble SK , Lynfield R , Devries AS , Drehner DM , Pomputius WF 3rd , Beach MJ , Visvesvara GS , da Silva AJ , Hill VR , Yoder JS , Xiao L , Smith KE , Danila R . Clin Infect Dis 2012 54 (6) 805-9 BACKGROUND: Primary amebic meningoencephalitis (PAM), caused by the free-living ameba Naegleria fowleri, has historically been associated with warm freshwater exposures at lower latitudes of the United States. In August 2010, a Minnesota resident, aged 7 years, died of rapidly progressive meningoencephalitis after local freshwater exposures, with no history of travel outside the state. PAM was suspected on the basis of amebae observed in cerebrospinal fluid. METHODS: Water and sediment samples were collected at locations where the patient swam during the 2 weeks preceding illness onset. Patient and environmental samples were tested for N. fowleri with use of culture and real-time polymerase chain reaction (PCR); isolates were genotyped. Historic local ambient temperature data were obtained. RESULTS: N. fowleri isolated from a specimen of the patient's brain and from water and sediment samples was confirmed using PCR as N. fowleri genotype 3. Surface water temperatures at the times of collection of the positive environmental samples ranged from 22.1 degrees C to 24.5 degrees C. August 2010 average air temperature near the exposure site was 25 degrees C, 3.6 degrees C above normal and the third warmest for August in the Minneapolis area since 1891. CONCLUSIONS: This first reported case of PAM acquired in Minnesota occurred 550 miles north of the previously reported northernmost case in the Americas. Clinicians should be aware that N. fowleri-associated PAM can occur in areas at much higher latitude than previously described. Local weather patterns and long-term climate change could impact the frequency of PAM. |
Post-project assessment of community-supported emergency transport systems for health care services in Tanzania
Ahluwalia IB , Robinson D , Vallely L , Myeya J , Ngitoria L , Kitambi V , Kabakama A . Int Electron J Health Educ 2012 15 1-15 We examined the continuation of community-organized and financed emergency transport systems implemented by the Community-Based Reproductive Health Project (CBRHP) from 1998 to 2000 in two rural districts in Tanzania. The CBRHP was a multipronged program, one component of which focused on affordable transport to health facilities from the villages. In 2006-2007, we assessed the existence and continuation of community-supported emergency transport systems. A total of 249 persons in 29 villages were surveyed, and qualitative data were collected to identify features of community-supported transport systems that have continued. Twelve villages reported having an emergency transport system for obstetrical/medical emergencies to a dispensary/district hospital. Six systems continue to be community supported and have been functioning since CBRHP activities ended in 2000. In these six villages, the modes of transport include tricycles with platforms, canoes, oxcarts, and stretchers. A total of 272 people have used the emergency transport system since its implementation; 47% were pregnant women experiencing obstetrical difficulties. In 2006, 35% (29/84) of users were women with obstetrical difficulties. The community-supported transport systems provide a critical service to villagers in rural areas who experience health emergencies that necessitate facility level care and while some communities continue to maintain support for these systems, other do not. Future research should focus on examining long-term sustainability of community level efforts aimed at increasing access to health care facilities and explore reasons for community level decisions to continue or discontinue activities over time, to fully understand the process of sustainability. |
The relationship of level of positive mental health with current mental disorders in predicting suicidal behavior and academic impairment in college students
Keyes CL , Eisenberg D , Perry GS , Dube SR , Kroenke K , Dhingra SS . J Am Coll Health 2012 60 (2) 126-33 OBJECTIVE: To investigate whether level of positive mental health complements mental illness in predicting students at risk for suicidal behavior and impaired academic performance. PARTICPANTS: A sample of 5,689 college students participated in the 2007 Healthy Minds Study and completed an Internet survey that included the Mental Health Continuum-Short Form and the Patient Health Questionnaire screening scales for depression and anxiety disorders, questions about suicide ideation, plans, and attempts, and academic impairment. RESULTS: Just under half (49.3%) of students were flourishing and did not screen positive for a mental disorder. Among students who did, and those who did not, screen for a mental disorder, suicidal behavior and impaired academic performance were lowest in those with flourishing, higher among those with moderate, and highest in those with languishing mental health. CONCLUSIONS: Positive mental health complements mental disorder screening in mental health surveillance and prediction of suicidal behavior and impairment of academic performance. |
A Bayesian analysis of the 2009 decline in tuberculosis morbidity in the United States
Chen MP , Shang N , Winston CA , Becerra JE . Stat Med 2012 31 (27) 3278-84 Although annual data are commonly used to model linear trends and changes in trends of disease incidence, monthly data could provide additional resolution for statistical inferences. Because monthly data may exhibit seasonal patterns, we need to consider seasonally adjusted models, which can be theoretically complex and computationally intensive. We propose a combination of methods to reduce the complexity of modeling seasonal data and to provide estimates for a change in trend when the timing and magnitude of the change are unknown. To assess potential changes in trend, we first used autoregressive integrated moving average (ARIMA) models to analyze the residuals and forecast errors, followed by multiple ARIMA intervention models to estimate the timing and magnitude of the change. Because the variable corresponding to time of change is not a statistical parameter, its confidence bounds cannot be estimated by intervention models. To model timing of change and its credible interval, we developed a Bayesian technique. We avoided the need for computationally intensive simulations by deriving a closed form for the posterior distribution of the time of change. Using a combination of ARIMA and Bayesian methods, we estimated the timing and magnitude of change in trend for tuberculosis cases in the United States. Copyright (c) 2012 John Wiley & Sons, Ltd. |
Invasion of canine erythrocytes by Bartonella vinsonii subsp. berkhoffii
Billeter SA , Breitschwerdt EB , Levy MG . Vet Microbiol 2012 156 213-6 Bartonella vinsonii subsp. berkhoffii is a recognized cause of endocarditis in dogs and human patients and has been associated with cardiac arrhythmias, myocarditis, granulomatous lymphadenitis, polyarthritis, and granulomatous rhinitis in dogs. Little is known regarding the mode of transmission or cellular localization of this bacteria following infection of a canine host. The aim of the current study was to determine whether erythrocytes may serve as a site of infection by B. vinsonii subsp. berkhoffii. In the study, we successfully demonstrate the invasion of canine erythrocytes by a B. vinsonii subsp. berkhoffii genotype III strain using an in vitro model system. Dog erythrocytes were incubated with B. vinsonii subsp. berkhoffii after which tubes were treated with gentamicin at 12, 24, and 48h post-inoculation. After gentamicin elimination of extracellular bacteria, there was a gradual increase in intra-erythrocytic bacteria, as assessed by colony forming units per ml, at each collection time point. The largest recovery of intracellular bacteria occurred at 48h post-infection. These results suggest that canine erythrocytes may serve in the maintenance of bacteremia due to B. vinsonii subsp. berkhoffii within an infected host. |
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