Reported breast symptoms in the National Breast and Cervical Cancer Early Detection Program
Ryerson AB , Miller J , Eheman CR . Cancer Causes Control 2015 26 (5) 733-40 PURPOSE: The frequency and types of breast symptoms reported by women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) have never been characterized. This study aims to establish the frequency of reported symptoms and the diagnostic outcomes associated with reported symptoms. METHODS: We examined the frequency of symptoms reported prior to mammography using medical record abstraction data from women in the NBCCEDP. We also calculated adjusted odds ratios (aOR) of having an abnormal mammogram, an abnormal clinical breast examination, or a final diagnosis of breast cancer by symptoms, compared to asymptomatic women. RESULTS: In our sample of women, 10.3 % reported at least one symptom. Women with symptoms were younger and more likely to be non-Hispanic white. Among those reporting symptoms, breast lump (31.7 %) and pain or tenderness (49.3 %) was most common. A relatively low proportion of women with symptoms were diagnosed with in situ (0.9 %) or invasive breast cancer (4.3 %). However, a self-reported breast lump [aOR 13.7; 95 % confidence interval (CI) 7.8-24.1], inflammation or changes to the skin/nipple (aOR 27.8; 95 % CI 8.7-88.8), and other or unspecified symptoms (aOR 3.4; 95 % CI 2.1-7.5) were associated with an increased risk of invasive breast cancer. CONCLUSIONS: Although the prevalence of breast cancer among women reporting symptoms is relatively low, knowing which symptoms carry the highest breast cancer risk is important to assist in appropriate diagnostic workup. |
Tuberculosis and diabetes mellitus in the Republic of Kiribati: a case-control study
Viney K , Cavanaugh J , Kienene T , Harley D , Kelly PM , Sleigh A , O'Connor J , Mase S . Trop Med Int Health 2015 20 (5) 650-657 OBJECTIVES: To better inform local management of TB-diabetes collaborative activities, we aimed to determine the prevalence of diabetes among persons with and without TB and to determine the association between TB and diabetes in Kiribati, a Pacific Island nation. METHODS: We compared consecutively enrolled TB cases to a group of randomly selected community controls without evidence of TB. Diabetes was diagnosed by HbA1c, and clinical and demographic data were collected. A tuberculin skin test was administered to controls. The chi-square test was used to assess significance in differences between cases and controls. We also calculated an odds ratio, with 95% confidence intervals, for the odds of diabetes among cases relative to controls. Unweighted multivariate logistic regression was performed to adjust for the effects of age and sex. RESULTS: A total of 275 TB cases and 499 controls were enrolled. The diabetes prevalence in cases (101, 37%) was significantly greater than in controls (94, 19%) (adjusted odds ratio: 2.8; 95% CI 2.0-4.1). Fifty-five percent (108) of all diabetic diagnoses were new; this proportion was higher among controls (64.8%) than cases (46.5%). Five patients with TB were screened to detect one patient with diabetes. CONCLUSIONS: There is a strong association between TB and diabetes in Kiribati and bidirectional screening should be conducted in this setting. |
Use of the Persuasive Health Message framework in the development of a community-based mammography promotion campaign
Hall IJ , Johnson-Turbes A . Cancer Causes Control 2015 26 (5) 775-84 PURPOSE: We describe how the Persuasive Health Message (PHM) framework was used to guide the formative evaluation informing development of messages and materials used in a community-based multi-media campaign intended to motivate low-income African American women to obtain low- or no-cost mammograms through the CDC's National Breast and Cervical Cancer Early Detection Program. METHODS: Seventy-eight African American women were recruited for eight focus groups that discussed breast cancer screening. The moderator guide was developed in accordance with the PHM framework and solicited information on perceived threat and efficacy, cues, salient beliefs and referents, and barriers to self-efficacy. RESULTS: We created persuasive messages to emphasize that African American women are susceptible to the threat of breast cancer, but that their personal action in obtaining regular mammograms may lead to early detection, subsequent treatment, and reduced cancer mortality. The messages addressed concerns of self-efficacy by emphasizing that uninsured women can also obtain high-quality low- or no-cost mammograms. In an attempt to combat the sentiment that breast cancer is a death sentence, the messages indicated that breast cancer can be successfully treated, especially when detected early. CONCLUSIONS: The PHM framework consists of three steps: (1) determine information about threat and efficacy; (2) develop an audience profile; and (3) construct a persuasive message. It offered our team easy-to-follow, flexible steps to create a persuasive and effective campaign promoting awareness and use of mammogram screening among low-income African American women. |
Multivitamin-mineral use is associated with reduced risk of cardiovascular disease mortality among women in the United States
Bailey RL , Fakhouri TH , Park Y , Dwyer JT , Thomas PR , Gahche JJ , Miller PE , Dodd KW , Sempos CT , Murray DM . J Nutr 2015 145 (3) 572-8 BACKGROUND: Multivitamin-mineral (MVM) products are the most commonly used supplements in the United States, followed by multivitamin (MV) products. Two randomized clinical trials (RCTs) did not show an effect of MVMs or MVs on cardiovascular disease (CVD) mortality; however, no clinical trial data are available for women with MVM supplement use and CVD mortality. OBJECTIVE: The objective of this research was to examine the association between MVM and MV use and CVD-specific mortality among US adults without CVD. METHODS: A nationally representative sample of adults from the restricted data NHANES III (1988-1994; n = 8678; age ≥40 y) were matched with mortality data reported by the National Death Index through 2011 to examine associations between MVM and MV use and CVD mortality by using Cox proportional hazards models, adjusting for multiple potential confounders. RESULTS: We observed no significant association between CVD mortality and users of MVMs or MVs compared with nonusers; however, when users were classified by the reported length of time products were used, a significant association was found with MVM use of >3 y compared with nonusers (HR: 0.65; 95% CI: 0.49, 0.85). This finding was largely driven by the significant association among women (HR: 0.56; 95% CI: 0.37, 0.85) but not men (HR: 0.79; 95% CI: 0.44, 1.42). No significant association was observed for MV products and CVD mortality in fully adjusted models. CONCLUSIONS: In this nationally representative data set with detailed information on supplement use and CVD mortality data approximately 20 y later, we found an association between MVM use of >3 y and reduced CVD mortality risk for women when models controlled for age, race, education, body mass index, alcohol, aspirin use, serum lipids, blood pressure, and blood glucose/glycated hemoglobin. Our results are consistent with the 1 available RCT in men, indicating no relation with MVM use and CVD mortality. |
A public health approach to global management of hypertension
Angell SY , De Cock KM , Frieden TR . Lancet 2015 385 (9970) 825-7 Non-communicable diseases are responsible for two-thirds of deaths worldwide, with 80% occurring in low-income and middle-income countries (LMICs).1 Cardiovascular disease causes more deaths than any other non-communicable disease, and hypertension is the leading remediable risk factor for cardiovascular disease.2 Hypertension kills an estimated 9·4 million people annually worldwide—about as many as all infectious diseases combined.3 | Hypertension is probably the easiest chronic non-communicable disease to treat, since blood pressure measurement for diagnosis and monitoring is simple, drug regimens can be once daily and inexpensive, and treatments exist that do not need laboratory monitoring. However, hypertension is adequately controlled in only about 13% of people with the disorder worldwide.4 | Although there is some scepticism about the ability of LMICs to implement programmes to treat chronic disorders, antiretroviral treatment for HIV, which is substantially more complex and expensive than treatment for hypertension, has been successfully scaled up to reach at least 37% of HIV-infected people who are eligible for treatment. Most of these patients live in LMICs.5 This experience suggests that rapid expansion of treatment and control of hypertension in LMICs should be achievable. |
The effectiveness of targeting never or rarely screened women in a national cervical cancer screening program for underserved women
Benard VB , Royalty J , Saraiya M , Rockwell T , Helsel W . Cancer Causes Control 2015 26 (5) 713-9 PURPOSE: To evaluate the effectiveness of a policy supporting early detection and prevention of cervical cancer among low-income and uninsured women by comparing women who reported never or rarely being screened (last screen >5 years) to those who reported screening in the past ≤5 years. METHODS: We analyzed data from 1,485,251 women who received their first Pap test in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) from July 2002 through June 2012. Of these, 461,893 women (31 %) reported being never or rarely screened and 1,023,358 (69 %) reported being screened in the past 5 years. Demographic (age, race/ethnicity, residence, and region) and clinic (cytologic and histologic results) characteristics were examined for the two groups. RESULTS: Women who were aged ≥50 years, Asian and Pacific Islander, American Indian or Alaska Native, multiracial, living in non-metro areas, or living in the South or a territory were more likely to report being never or rarely screened. The percentage of abnormal Pap tests and the rate of precancer and cancer (combined) was higher in the never or rarely screened group compared with the screened group (abnormal percentage: 2.9 vs 2.6 %, p value < 0.01; rate of precancer and cancer: 6.9 vs 3.7 per 1,000 women, p value < 0.01). CONCLUSIONS: The priority of reaching never or rarely screened women should continue since those women who entered the NBCCEDP not adequately screened had a greater prevalence of high-grade histological lesions and invasive cervical cancers at later stages than women screened more recently. |
An evaluation of cancer survivorship activities across national comprehensive cancer control programs
Underwood JM , Lakhani N , Rohan E , Moore A , Stewart SL . J Cancer Surviv 2015 9 (3) 554-9 INTRODUCTION: Centers for Disease Control and Prevention's (CDC) National Comprehensive Cancer Control Program (NCCCP) funds states, the District of Columbia, tribal organizations, territories, and jurisdictions across the USA develop and implement jurisdiction-specific comprehensive cancer control (CCC) plans. The objective of this study was to analyze NCCCP action plan data for incorporation and appropriateness of cancer survivorship-specific goals and objectives. METHODS: In August 2013, NCCCP action plans maintained within CDC's Chronic Disease Management Information System (CDMIS) from years 2010 to 2013 were reviewed to assess the inclusion of cancer survivorship objectives. We used the CDMIS search engine to identify "survivorship" within each plan and calculated the proportion of programs that incorporate cancer survivorship-related content during the study period and in each individual year. Cancer survivorship objectives were then categorized by compatibility with nationally accepted, recommended strategies from the report A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies (NAP). RESULTS: From 2010 to 2013, 94 % (n = 65) of NCCCP action plans contained survivorship content in at least 1 year during the time period and 38 % (n = 26) of all NCCCP action plans addressed cancer survivorship every year during the study period. Nearly 64 % (n = 44) of NCCCP action plans included cancer survivorship objectives recommended in NAP. CONCLUSION: Nearly all NCCCP action plans addressed cancer survivorship from 2010 to 2013, and most programs implemented recommended cancer survivorship efforts during the time period. IMPLICATIONS FOR CANCER SURVIVORS: NCCCP grantees can improve cancer survivorship support by incorporating recommended efforts within each year of their plans. |
Health behaviors and quality of life among colorectal cancer survivors
Rohan EA , Townsend JS , Fairley TL , Stewart SL . J Natl Compr Canc Netw 2015 13 (3) 297-302 PURPOSE: To examine, at the population level, health behaviors, comorbidities, and health-related quality of life among colorectal cancer (CRC) survivors compared with other cancer survivors and persons without cancer. METHODS: We used data from the 2009 and 2010 Behavioral Risk Factor Surveillance System cancer survivor modules. We calculated descriptive statistics, conducted chi-square tests for comparisons, and used multivariable logistic regression analysis to compare CRC survivors with other cancer survivors and persons without cancer. RESULTS: Of the 52,788 cancer survivors included in this analysis, 4001 reported being CRC survivors. When compared with other cancer survivors, CRC survivors reported higher percentages of obesity and lack of physical activity; however, they had lower levels of current smoking. Adjusted results show that CRC survivors were significantly more likely to report lack of physical activity, fair/poor health, and other chronic health conditions compared with persons without a cancer diagnosis. Conversely, CRC survivors reported lower levels of current smoking than persons without cancer. CONCLUSIONS: CRC survivors have a higher proportion of heath conditions and behaviors that may significantly increase their risks for recurrence or development of a second cancer. Targeted interventions to address these health issues should be considered. |
Improving heart healthy lifestyles among participants in a Salud para su Corazon promotores model: the Mexican pilot study, 2009-2012
Balcazar H , Fernandez-Gaxiola AC , Perez-Lizaur AB , Peyron RA , Ayala C . Prev Chronic Dis 2015 12 E34 INTRODUCTION: In Mexico, cardiovascular disease and its risk factors are growing problems and major public health concerns. The objective of this study was to implement cardiovascular health promotion and disease prevention activities of the Salud para su Corazon model in a high-risk, impoverished, urban community in Mexico City. METHODS: We used a pretest-posttest (baseline to 12-week follow-up) design without a control group. Material from Salud para su Corazon was validated and delivered by promotores (community health workers) to community members from 6 geographic areas. Two validated, self-administered questionnaires that assessed participants' knowledge and behaviors relating to heart health were administered. We used t tests and chi(2) tests to evaluate pretest and posttest differences, by age group (≤60 and >60 years), for participants' 3 heart-healthy habits, 3 types of physical activity, performance skills, and anthropometric and clinical measurements. RESULTS: A total of 452 (82%) adult participants completed the program. Heart-healthy habits from pretest to posttest varied by age group. "Taking action" to modify lifestyle behaviors increased among adults aged 60 or younger from 31.5% to 63.0% (P < .001) and among adults older than 60 from 30.0% to 45.0% (P < .001). Positive responses for cholesterol and fat consumption reduction were seen among participants 60 or younger (P = .03). Among those older than 60, salt reduction and weight control increased (P = .008). Mean blood glucose concentration among adults older than 60 decreased postintervention (P = .03). CONCLUSION: Significant improvements in some heart-healthy habits were seen among adult participants. The model has potential to improve heart-healthy habits and facilitate behavioral change among high-risk adults. |
Improving understanding, promoting social inclusion, and fostering empowerment related to epilepsy: Epilepsy Foundation public awareness campaigns - 2001 through 2013
Price P , Kobau R , Buelow J , Austin J , Lowenberg K . Epilepsy Behav 2015 44 239-44 It is a significant public health concern that epilepsy, the fourth most common neurological disorder in the United States, is generally poorly understood by both the public and those living with the condition. Lack of understanding may magnify the challenges faced by those with epilepsy, including limiting treatment opportunities, effective management of symptoms, and full participation in daily life activities. Insufficient awareness of epilepsy and appropriate seizure first aid among the public and professionals can result in insufficient treatment, inappropriate seizure response, physical restraint, social exclusion, or other negative consequences. To address the need for increased public education and awareness about epilepsy, the national Epilepsy Foundation, supported by the Centers for Disease Control and Prevention, has conducted yearly multifaceted public education and awareness campaigns designed to reach the broad population and targeted segments of the population including youth, young adults, racial/ethnic groups (i.e., African-, Hispanic-, and Asian-Americans), and people with epilepsy and their caregivers. Campaign channels have included traditional media, social media, and community opinion leaders and celebrity spokespersons. The key activities of these campaigns, conducted from 2001 to 2013, are summarized in this report. |
Increased confusion and memory loss in households, 2011 Behavioral Risk Factor Surveillance System
Deokar AJ , Bouldin ED , Edwards VJ , Anderson LA . Prev Chronic Dis 2015 12 E29 Using data from the 2011 Behavioral Risk Factor Surveillance System (BRFSS), we examined households in 13 states (N = 81,012) in which the respondent or another adult household member experienced increased confusion or memory loss (ICML) in the preceding 12 months. A total of 12.6% of households reported at least 1 adult who experienced ICML, and in 5.4% of households all adults experienced ICML. Based on these results, an estimated 4 million households in these 13 states have a member with ICML, potentially affecting more than 10 million people. This study can inform public health communication campaigns aimed at increasing awareness of the signs and symptoms of cognitive decline and augment community planning efforts so that the needs of households in which 1 or more adults has cognitive decline are considered. |
Inflammatory markers and mortality among US adults with obstructive lung function
Ford ES , Cunningham TJ , Mannino DM . Respirology 2015 20 (4) 587-93 BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease is characterized by an inflammatory state of uncertain significance. The objective of this study was to examine the association between elevated inflammatory marker count (white blood cell count, C-reactive protein and fibrinogen) on all-cause mortality in a national sample of US adults with obstructive lung function (OLF). METHODS: Data for 1144 adults aged 40-79 years in the National Health and Nutrition Examination Survey III Linked Mortality Study were analysed. Participants entered the study from 1988 to 1994, and mortality surveillance was conducted through 2006. White blood cell count and fibrinogen were dichotomized at their medians, and C-reactive protein was divided into >3 and ≤3 g/L. The number of elevated inflammatory markers was summed to create a score of 0-3. RESULTS: The age-adjusted distribution of the number of elevated inflammatory markers differed significantly among participants with normal lung function, mild OLF, and moderate or worse OLF. Of the three dichotomized markers, only fibrinogen was significantly associated with mortality among adults with any OLF (maximally adjusted hazard ratio 1.49; 95% confidence interval (CI): 1.17-1.91). The maximally adjusted hazard ratios for having 1, 2 or 3 elevated markers were 1.17 (95% CI: 0.71-1.94), 1.44 (95% CI: 0.89-2.32) and 2.08 (95% CI: 1.29-3.37), respectively (P = 0.003). CONCLUSIONS: An index of elevated inflammatory markers predicted all-cause mortality among adults with OLF. |
Invasive cancer incidence and survival - United States, 2011
Henley SJ , Singh SD , King J , Wilson R , O'Neil ME , Ryerson AB . MMWR Morb Mortal Wkly Rep 2015 64 (9) 237-42 Because of improvements in early detection and treatment of cancer, the proportion of persons with cancer who survive ≥5 years after diagnosis has increased. To assess progress toward achieving Healthy People 2020 objectives,* CDC analyzed data from U.S. Cancer Statistics (USCS) for 2011, the most recent data available. USCS includes incidence and survival data from CDC's National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program and mortality data from the National Vital Statistics System. In 2011, a total of 1,532,066 invasive cancers were reported to cancer registries in the United States (excluding Nevada), for an annual incidence rate of 451 cases per 100,000 persons. Cancer incidence rates were higher among males (508) than females (410), highest among black persons (458), and ranged by state, from 374 to 509 per 100,000 persons (339 in Puerto Rico). The proportion of persons with cancer who survived ≥5 years after diagnosis was 65% and was similar among males (65%) and females (65%) but lower among black persons (60%) compared with white persons (65%). Surveillance of cancer incidence and survival are essential for identifying population groups with high cancer incidence rates and low cancer survival rates as well as for estimating the number of cancer survivors, which was 13.7 million in 2012. These data are being used by states to effectively develop comprehensive cancer control programs, including supporting the needs of cancer survivors. |
The African American Women and Mass Media (AAMM) campaign in Georgia: quantifying community response to a CDC pilot campaign
Hall IJ , Johnson-Turbes A , Berkowitz Z , Zavahir Y . Cancer Causes Control 2015 26 (5) 787-94 PURPOSE: To evaluate whether a culturally appropriate campaign using "Black radio" and print media increased awareness and utilization of local mammography screening services provided by the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program among African American women. METHODS: The evaluation used a quasi-experimental design involving data collection during and after campaign implementation in two intervention sites in GA (Savannah with radio and print media and Macon with radio only) and one comparison site (Columbus, GA). We used descriptive statistics to compare mammography uptake for African American women during the initial months of the campaign (8/08-1/09) with the latter months (2/09-8/09) and a post-campaign (9/09-12/09) period in each of the study sites. Comparisons of monthly mammogram uptake between cities were performed with multinomial logistic regression. We assumed a p value <0.05 to be significant. RESULTS: We observed an increase of 46 and 20 % in Savannah and Macon, respectively, from the initial period of the campaign to the later period. However, the increase did not persist in the post-campaign period. Analysis comparing monthly mammogram uptake in Savannah and Macon with Columbus showed a significant increase in uptake from the first to the second period in Savannah only (OR 1.269, 95 % CI (1.005-1.602), p = 0.0449). CONCLUSIONS: Dissemination of health promotion messages via a culturally appropriate, multicomponent campaign using Black radio and print media was effective in increasing mammogram uptake in Savannah among low-income, African American women. Additional research is needed to quantify the relative contribution of campaign radio, print media, and community components to sustain increased mammography uptake. |
Are the recent secular increases in the waist circumference of adults independent of changes in BMI?
Freedman DS , Ford ES . Am J Clin Nutr 2015 101 (3) 425-31 BACKGROUND: Several studies showed that the waist circumference of US adults has increased over the past 25 y. However, because of the high correlation between waist circumference and body mass index (BMI; in kg/m(2)) (r approximately 0.9), it is uncertain if these trends in waist circumference exceed those expected on the basis of BMI changes over this time period. OBJECTIVE: We assessed whether the recent trend in waist circumference was independent of changes in BMI, age, and race-ethnicity. DESIGN: We analyzed data from the 1999-2000 through 2011-2012 cycles of the NHANES. RESULTS: The mean waist circumference increased by approximately 2 cm (in men) and approximately 4 cm (in women) in adults in the United States over this 12-y period. In men, this increase was very close to what would be expected because of the 0.7 increase in mean BMI over this period. However, in women, most of the secular increase in waist circumference appeared to be independent of changes in BMI (mean: 0.6), age, and race-ethnicity over the 12-y period. We estimated that, independent of changes in these covariates, the mean waist circumference increased by 0.2 cm in men and 2.4 cm in women from 1999-2000 through 2011-2012; only the latter estimate was statistically significant. CONCLUSIONS: Our results indicate that, in women but not men, the recent secular trend in waist circumference is greater than what would be expected on the basis of changes in BMI. Possible reasons for this secular increase, along with sex differences, are uncertain. |
Breast and cervical cancers diagnosed and stage at diagnosis among women served through the National Breast and Cervical Cancer Early Detection Program
Miller JW , Royalty J , Henley J , White A , Richardson LC . Cancer Causes Control 2015 26 (5) 741-7 PURPOSE: To assess cancers diagnosed and the stage of cancer at the time of diagnosis among low-income, under-insured, or uninsured women who received services through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using the NBCCEDP database, we examined the number and percent of women diagnosed during 2009-2011 with in situ breast cancer, invasive breast cancer, and invasive cervical cancer by demographic and clinical characteristics, including age, race and ethnicity, test indication (screening or diagnostic), symptoms (for breast cancer), and screening history (for cervical cancer). We examined these characteristics by stage at diagnosis, a new variable included in the database obtained by linking with state-based central cancer registries. RESULTS: There were 11,569 women diagnosed with invasive breast cancer, 1,988 with in situ breast cancer, and 583 with invasive cervical cancer through the NBCCEDP. Women who reported breast symptoms or who had diagnostic mammography were more likely to be diagnosed with breast cancer, and at a later stage, than those who did not have symptoms or who had screening mammography. Women who had been rarely or never screened for cervical cancer were more likely to be diagnosed with cervical cancer, and at a later stage, than women who received regular screenings. CONCLUSIONS: Women served through the NBCCEDP who have not had prior screening or who have symptoms were more often diagnosed with late-stage disease. |
Colorectal cancer screening in US seniors ages 76-84 years
Klabunde CN , Shapiro JA , Kobrin S , Nadel MR , Zapka JM . J Community Health 2015 40 (4) 769-79 The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7 % (95 % CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9 % (95 % CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2 % indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed. |
A comparative analysis of breast cancer stage between women enrolled in the National Breast and Cervical Cancer Early Detection Program and women not participating in the program
Wu M , Austin H , Eheman CR , Myles Z , Miller J , Royalty J , Ryerson AB . Cancer Causes Control 2015 26 (5) 751-8 PURPOSE: To determine the proportional distribution of early- and late-stage breast cancers diagnosed in years 2004-2009 among women enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and to compare this distribution to that of geographically comparable non-enrolled women diagnosed with breast cancer. METHODS: Using data from the National Program of Cancer Registries, we compared the demographic characteristics and cancer stage distribution of women enrollees and non-enrollees by use of conditional logistic regression using the odds ratio as a measure of association. RESULTS: NBCCEDP enrollees were slightly younger and more likely to identify as African-American, API and AIAN than were non-enrollees. The proportion of late-stage breast cancer (regional and distant) decreased slightly over the study period. NBCCEDP enrollees generally were diagnosed at a later stage of breast cancer than were those not enrolled in the NBCCEDP. CONCLUSIONS: The NBCCEDP has been effective in achieving its goal of enrolling racial and ethnic populations; however, enrollees had a poorer stage distribution of breast cancer than did non-enrollees underscoring the need to expand breast cancer control efforts among low-income, underserved populations. |
Demographic and health status differences among people aged 45 or older with and without functional difficulties related to increased confusion or memory loss, 2011 Behavioral Risk Factor Surveillance System
Anderson LA , Deokar A , Edwards VJ , Bouldin ED , Greenlund KJ . Prev Chronic Dis 2015 12 E30 We examined the demographic and health characteristics of people aged 45 years or older in 21 states with self-reported increased confusion or memory loss (ICML) (n = 10,583) by whether or not they also reported functional difficulties related to ICML. We used data from the 2011 Behavioral Risk Factor Surveillance System optional module on impact of cognitive impairment. After adjusting for demographic differences, we found that respondents with ICML and functional difficulties were significantly more likely than those with ICML and no functional difficulties to report frequent poor physical health, frequent poor mental health, limited activity due to poor physical or mental health, and a need for more help. Further understanding of the implications for long-term services and supports is needed. |
Epidemiological and etiological characteristics of hand, foot, and mouth disease in Henan, China, 2008-2013.
Huang X , Wei H , Wu S , Du Y , Liu L , Su J , Xu Y , Wang H , Li X , Wang Y , Liu G , Chen W , Klena JD , Xu B . Sci Rep 2015 5 8904 Hand, foot, and mouth disease (HFMD) is a common childhood illness caused by enteroviruses. HFMD outbreaks and reported cases have sharply increased in China since 2008. Epidemiological and clinical data of HFMD cases reported in Henan Province were collected from 2008 to 2013. Clinical specimens were obtained from a subset of these cases. Descriptive epidemiological methods were used to analyze the time, region and population distribution. The VP1 gene from EV71 and CA16 isolates was amplified, and the sequences were analyzed. 400,264 cases of HFMD were reported in this study, including 22,309 severe and 141 fatal cases. Incidence peaked between April and May. Laboratory confirmation was obtained for 27,692 (6.9%) cases; EV71, CA16, and other enteroviruses accounted for 59.5%, 14.1%, 26.4%, respectively. Phylogenetic analysis revealed that EV71 belonged to the C4a evolution branch of C4 sub-genotype and CA16 belonged to subtype B1a or B1b. The occurrence of HFMD in Henan was closely related to season, age and region distribution. Children under five were the most affected population. The major pathogens causing HFMD and their genotypes have not notably changed in Henan. The data strongly support the importance of EV71 vaccination in a high population density area such as Henan, China. |
Regional spread of Ebola virus, West Africa, 2014
Rainisch G , Shankar M , Wellman M , Merlin T , Meltzer MI . Emerg Infect Dis 2015 21 (3) 444-7 To explain the spread of the 2014 Ebola epidemic in West Africa, and thus help with response planning, we analyzed publicly available data. We found that the risk for infection in an area can be predicted by case counts, population data, and distances between affected and nonaffected areas. |
The role of HIV in the household introduction and transmission of influenza in an urban slum, Nairobi, Kenya, 2008-2011
Judd MC , Emukule GO , Njuguna H , McMorrow ML , Arunga GO , Katz MA , Montgomery JM , Wong JM , Breiman RF , Mott JA . J Infect Dis 2015 212 (5) 740-4 BACKGROUND: Little is known about how HIV infection affects influenza transmission within homes in sub-Saharan Africa. METHODS: We used respiratory illness surveillance and HIV testing data gathered in Kibera, an urban slum in Nairobi, Kenya to examine the impact of HIV status on (i) introducing influenza to the home and (ii) transmission to household contacts. RESULTS: While HIV status did not affect the likelihood of being an influenza index case, household contacts of HIV-infected influenza index cases had twice the risk of developing secondary ILI than contacts of HIV-negative index cases. CONCLUSIONS: HIV-infected influenza index cases may facilitate transmission of influenza within the home. |
Serotypes, seasonal trends, and antibiotic resistance of non-typhoidal Salmonella from human patients in Guangdong Province, China, 2009-2012
Liang Z , Ke B , Deng X , Liang J , Ran L , Lu L , He D , Huang Q , Ke C , Li Z , Yu H , Klena JD , Wu S . BMC Infect Dis 2015 15 53 BACKGROUND: Non-typhoidal Salmonella is a common cause of infectious diarrhea in humans. Antimicrobial-resistant Salmonella has become a global concern. METHODS: Using laboratory-based surveillance system for from September 2009 to December 2012 in Guangdong Province of China. The clinical information and samples of diarrhea patients were collected, according to the surveillance case definition. The lab tests were followed by standardized protocols, including sample isolation, isolates confirmation, serotyping, and antimicrobial susceptibility testing (AST). RESULTS: A total of 1,826 isolates were identified from 40,572 patients in 28 hospitals in 11 prefectures. The isolates ratio was highest in autumn (38.8%, 708/1826) and lowest in winter (6.4%, 117/1826). Children aged < 5 years were the group most affected by in Guangdong Province accounting for 73% (1,329/1,826), of whom the infants (< 1 year) were 81.5% (1084/1329) especially. A total of 108 serotypes were identified among the isolates. S. Typhimurium represented the most common serotype followed by serotype 4,5,12:i:-. CONCLUSIONS: Additional data and more refined methods can improve future surveillance. The invasive Salmonella isolates should also be included to the antibiotic resistance surveillance for clinical care or public health. |
Sputum culture conversion as a prognostic marker for end-of-treatment outcome in patients with multidrug-resistant tuberculosis: a secondary analysis of data from two observational cohort studies
Kurbatova EV , Cegielski JP , Lienhardt C , Akksilp R , Bayona J , Becerra MC , Caoili J , Contreras C , Dalton T , Danilovits M , Demikhova OV , Ershova J , Gammino VM , Gelmanova I , Heilig CM , Jou R , Kazennyy B , Keshavjee S , Kim HJ , Kliiman K , Kvasnovsky C , Leimane V , Mitnick CD , Quelapio I , Riekstina V , Smith SE , Tupasi T , van der Walt M , Vasilyeva IA , Via LE , Viiklepp P , Volchenkov G , Walker AT , Wolfgang M , Yagui M , Zignol M . Lancet Respir Med 2015 3 (3) 201-9 BACKGROUND: Sputum culture conversion is often used as an early microbiological endpoint in phase 2 clinical trials of tuberculosis treatment on the basis of its assumed predictive value for end-of-treatment outcome, particularly in patients with drug-susceptible tuberculosis. We aimed to assess the validity of sputum culture conversion on solid media at varying timepoints, and the time to conversion, as prognostic markers for end-of-treatment outcome in patients with multidrug-resistant (MDR) tuberculosis. METHODS: We analysed data from two large cohort studies of patients with MDR tuberculosis. We defined sputum culture conversion as two or more consecutive negative cultures from sputum samples obtained at least 30 days apart. To estimate the association of 2 month and 6 month conversion with successful treatment outcome, we calculated odds ratios (ORs) and 95% CIs with random-effects multivariable logistic regression. We calculated predictive values with bivariate random-effects generalised linear mixed modelling. FINDINGS: We assessed data for 1712 patients who had treatment success, treatment failure, or who died. Among patients with treatment success, median time to sputum culture conversion was significantly shorter than in those who had poor outcomes (2 months [IQR 1-3] vs 7 months [3 to ≥24]; log-rank p<0.0001). Furthermore, conversion status at 6 months (adjusted OR 14.07 [95% CI 10.05-19.71]) was significantly associated with treatment success compared with failure or death. Sputum culture conversion status at 2 months was significantly associated with treatment success only in patients who were HIV negative (adjusted OR 4.12 [95% CI 2.25-7.54]) or who had unknown HIV infection (3.59 [1.96-6.58]), but not in those who were HIV positive (0.38 [0.12-1.18]). Thus, the overall association of sputum culture conversion with a successful outcome was substantially greater at 6 months than at 2 months. 2 month conversion had low sensitivity (27.3% [95% confidence limit 16.6-41.4]) and high specificity (89.8% [82.3-94.4]) for prediction of treatment success. Conversely, 6 month sputum culture conversion status had high sensitivity (91.8% [85.9-95.4]), but moderate specificity (57.8% [42.5-71.6]). The maximum combined sensitivity and specificity for sputum culture conversion was reached between month 6 and month 10 of treatment. INTERPRETATION: Time to sputum culture conversion, conversion status at 6 months, and conversion status at 2 months in patients without known HIV infection can be considered as proxy markers of end-of-treatment outcome in patients with MDR tuberculosis, although the overall association with treatment success is substantially stronger for 6 month than for 2 month conversion status. Investigators should consider these results regarding the validity of sputum culture conversion at various timepoints as an early predictor of treatment efficacy when designing phase 2 studies before investing substantial resources in large, long-term, phase 3 trials of new treatments for MDR tuberculosis. FUNDING: US Agency for International Development, US Centers for Disease Control and Prevention, Division of Intramural Research of the US National Institute of Allergy and Infectious Diseases, Korea Centers for Disease Control and Prevention. |
Systems for rapidly detecting and treating persons with ebola virus disease - United States
Koonin LM , Jamieson DJ , Jernigan JA , Van Beneden CA , Kosmos C , Harvey MC , Pietz H , Bertolli J , Perz JF , Whitney CG , Halpin AS , Daley WR , Pesik N , Margolis GS , Tumpey A , Tappero J , Damon I . MMWR Morb Mortal Wkly Rep 2015 64 (8) 222-5 The U.S. Department of Health and Human Services (HHS), CDC, other U.S. government agencies, the World Health Organization (WHO), and international partners are taking multiple steps to respond to the current Ebola virus disease (Ebola) outbreak in West Africa to reduce its toll there and to reduce the chances of international spread. At the same time, CDC and HHS are working to ensure that persons who have a risk factor for exposure to Ebola and who develop symptoms while in the United States are rapidly identified and isolated, and safely receive treatment. HHS and CDC have actively worked with state and local public health authorities and other partners to accelerate health care preparedness to care for persons under investigation (PUI) for Ebola or with confirmed Ebola. This report describes some of these efforts and their impact. |
Update: influenza activity - United States, September 28, 2014-February 21, 2015
D'Mello T , Brammer L , Blanton L , Kniss K , Smith S , Mustaquim D , Steffens C , Dhara R , Cohen J , Chaves SS , Finelli L , Bresee J , Wallis T , Xu X , Abd Elal AI , Gubareva L , Wentworth D , Villanueva J , Katz J , Jernigan D . MMWR Morb Mortal Wkly Rep 2015 64 (8) 206-12 Influenza activity in the United States began to increase in mid-November, remained elevated through February 21, 2015, and is expected to continue for several more weeks. To date, influenza A (H3N2) viruses have predominated overall. As has been observed in previous seasons during which influenza A (H3N2) viruses predominated, adults aged ≥65 years have been most severely affected. The cumulative laboratory-confirmed influenza-associated hospitalization rate among adults aged ≥65 years is the highest recorded since this type of surveillance began in 2005. This age group also accounts for the majority of deaths attributed to pneumonia and influenza. The majority of circulating influenza A (H3N2) viruses are different from the influenza A (H3N2) component of the 2014-15 Northern Hemisphere seasonal vaccines, and the predominance of these antigenically and genetically drifted viruses has resulted in reduced vaccine effectiveness. This report summarizes U.S. influenza activity* since September 28, 2014, and updates the previous summary. |
Use of influenza antiviral medications among outpatients at high risk for influenza-associated complications during the 2013-14 influenza season
Havers FP , Flannery B , Clippard JR , Gaglani M , Zimmerman RK , Jackson LA , Petrie JG , McLean HQ , Nowalk MP , Jackson ML , Monto AS , Belongia EA , Eng HF , Lamerato L , Campbell AP , Fry AM . Clin Infect Dis 2015 60 (11) 1677-80 During the 2013-14 influenza season, we analyzed data from 6,004 outpatients aged ≥6 months with acute respiratory illness (ARI). Among the 2,786 ARI patients at higher risk for influenza complications, 835 (30%) presented to care ≤2 days from symptom onset; among those, 126 (15%) were prescribed an antiviral medication. |
Using HIV surveillance registry data to re-link persons to care: the RSVP Project in San Francisco
Buchacz K , Chen MJ , Parisi MK , Yoshida-Cervantes M , Antunez E , Delgado V , Moss NJ , Scheer S . PLoS One 2015 10 (3) e0118923 BACKGROUND: Persons with unsuppressed HIV viral load (VL) who disengage from care may experience poor clinical outcomes and potentially transmit HIV. We assessed the feasibility and yield of using the San Francisco Department of Public Health (SFDPH) enhanced HIV surveillance system (eHARS) to identify and re-engage such persons in care. METHODS: Using SFDPH eHARS data as of 4/20/2012 (index date), we selected HIV-infected adults who were alive, had no reported VL or CD4 cell count results in the past nine months (proxy for "out-of-care") and a VL >200 copies/mL drawn nine to 15 months earlier. We prioritized cases residing locally for investigation, and used information from eHARS and medical and public health databases to contact them for interview and referral to the SFDPH linkage services (LINCS). Twelve months later, we matched-back to eHARS data to assess how HIV laboratory reporting delays affected original eligibility, and if persons had any HIV laboratory results performed and reported within 12 months after index date ('new labs'). RESULTS: Among 434 eligible persons, 282 were prioritized for investigation, of whom 75 (27%) were interviewed, 79 (28%) could not be located, and 48 (17%) were located out of the area. Among the interviewed, 54 (72%) persons accepted referral to LINCS. Upon match-back to eHARS data, 324 (75%) in total were confirmed as eligible, including 221 (78%) of the investigated; most had new labs. CONCLUSIONS: Among the investigated persons presumed out-of-care, we interviewed and offered LINCS referral to about one-quarter, demonstrating the feasibility but limited yield of our project. Matching to updated surveillance data revealed that a substantial minority did not disengage from care and that most re-engaged in HIV care. Verifying persons' HIV care status with medical providers and improving timeliness of transfer and cross-jurisdictional sharing of HIV laboratory data may aid future efforts. |
West African female sex workers in Mali: reduction in HIV prevalence and differences in risk profiles of sex workers of differing nationalities of origin
Trout CH , Dembele O , Diakite D , Bougoudogo F , Doumbia B , Mathieu J , Haidara A , Sangare A , Traore S , Burtner J , Cabral H , Messersmith LJ . J Acquir Immune Defic Syndr 2015 68 Suppl 2 S221-31 BACKGROUND: Female sex workers (FSW) in Mali are highly vulnerable to HIV. Their prevalence in 2009 was 9 times higher (24.2%) than that among pregnant women (2.7%). METHODS: Four Integrated HIV/sexually transmitted infection (STI) Surveillance and Behavioral Surveys among FSW in Mali (2000, 2003, 2006, and 2009) tracked demographic characteristics, behavior, and HIV and STI prevalence. Logistic regression using generalized estimating equations to control for the cluster effect identified factors associated with HIV-positive serostatus adjusting for potential confounding. RESULTS: Of 2430 FSW, 40.8% were Nigerian, 36.8% were Malian, and 22.4% were from other neighboring countries. Between 2003 and 2009, HIV prevalence dropped from 44.14% to 28.49% (P < 0.0001) among Malians, from 21.33% to 12.71% (P = 0.0082) among Nigerians, and from 43.42% to 33.67% (P = 0.0442) among "others." Between 2000 and 2009, condom availability increased (89.18%-99.3%; P < 0.0001) as did HIV testing (40%-75%; P < 0.0001). Consistent condom use with clients improved for Malians (72.3%-81.5%; P = 0.0092), but not among Nigerians (92.7%-90.94%; P = 0.8240) and "others" (88.9%-88.48%; P = 0.8452). Consistent condom use with boyfriends was low and improved only for Nigerians (9.8%-28.4%; P = 0.0003). Factors associated with HIV prevalence in the multivariate model were older age, study year (2003 and 2006), nationality, lack of education, mobility, STI symptoms, gonorrhea prevalence, and younger age at first sex. CONCLUSIONS: This study documents progress in the fight against HIV among FSW in Mali. The different vulnerabilities to HIV found for different nationality FSW should be considered in programming and future research. |
Low viral suppression and high HIV diagnosis rate among men who have sex with men with syphilis - Baltimore, Maryland
Cooley LA , Pearl ML , Flynn C , Ross C , Hart-Cooper G , Elmore K , Blythe D , Morgan J , Oster AM . Sex Transm Dis 2015 42 (4) 226-31 BACKGROUND: The burden of syphilis and HIV among gay, bisexual, and other men who have sex with men (MSM) in Baltimore, Maryland, is substantial. Syphilis and HIV surveillance data were analyzed to characterize MSM with syphilis, including those with repeat infection and HIV coinfection, to strengthen prevention efforts. METHODS: MSM 15 years or older from Baltimore City or County diagnosed as having early syphilis in 2010 to 2011 were included. Those previously treated for syphilis in 2007 to 2011 were considered to have repeat syphilis infection. HIV surveillance data were used to identify HIV coinfection and assess viral suppression. For MSM not diagnosed as having HIV at or before their syphilis diagnosis, annual HIV diagnosis rates were estimated, using Baltimore City data. RESULTS: Of 460 MSM with early syphilis in 2010 or 2011, 92 (20%) had repeat infection; 55% of MSM with a single diagnosis and 86% with repeat infection were HIV coinfected. Among MSM diagnosed as having HIV, viral suppression was low (25%, or 46% of those with a viral load reported). Among Baltimore City MSM without a prior HIV diagnosis, estimated annual HIV diagnosis rates were high (5% for those with 1 syphilis diagnosis, 23% for those with repeat infection). CONCLUSIONS: Baltimore-area MSM with syphilis, particularly those with repeat infection, represent a unique population for whom coinfection with HIV is high. Increasing frequency of syphilis and HIV testing among Baltimore area MSM with a syphilis diagnosis and prioritizing HIV-infected MSM with syphilis in efforts to achieve viral suppression may improve outcomes locally for both infections. |
Epidemiology of human Mycobacterium bovis disease, California, USA, 2003-2011
Gallivan M , Shah N , Flood J . Emerg Infect Dis 2015 21 (3) 435-43 We conducted a retrospective review of California tuberculosis (TB) registry and genotyping data to evaluate trends, analyze epidemiologic differences between adult and child case-patients with Mycobacterium bovis disease, and identify risk factors for M. bovis disease. The percentage of TB cases attributable to M. bovis increased from 3.4% (80/2,384) in 2003 to 5.4% (98/1,808) in 2011 (p = 0.002). All (6/6) child case-patients with M. bovis disease during 2010-2011 had >1 parent/guardian who was born in Mexico, compared with 38% (22/58) of child case-patients with M. tuberculosis disease (p = 0.005). Multivariate analysis of TB case-patients showed Hispanic ethnicity, extrapulmonary disease, diabetes, and immunosuppressive conditions, excluding HIV co-infection, were independently associated with M. bovis disease. Prevention efforts should focus on Hispanic binational families and adults with immunosuppressive conditions. Collection of additional risk factors in the national TB surveillance system and expansion of whole-genome sequencing should be considered. |
Estimating influenza disease burden from population-based surveillance data in the United States
Reed C , Chaves SS , Daily Kirley P , Emerson R , Aragon D , Hancock EB , Butler L , Baumbach J , Hollick G , Bennett NM , Laidler MR , Thomas A , Meltzer MI , Finelli L . PLoS One 2015 10 (3) e0118369 Annual estimates of the influenza disease burden provide information to evaluate programs and allocate resources. We used a multiplier method with routine population-based surveillance data on influenza hospitalization in the United States to correct for under-reporting and estimate the burden of influenza for seasons after the 2009 pandemic. Five sites of the Influenza Hospitalization Surveillance Network (FluSurv-NET) collected data on the frequency and sensitivity of influenza testing during two seasons to estimate under-detection. Population-based rates of influenza-associated hospitalization and Intensive Care Unit admission from 2010-2013 were extrapolated to the U.S. population from FluSurv-NET and corrected for under-detection. Influenza deaths were calculated using a ratio of deaths to hospitalizations. We estimated that influenza-related hospitalizations were under-detected during 2010-11 by a factor of 2.1 (95%CI 1.7-2.9) for age < 18 years, 3.1 (2.4-4.5) for ages 18-64 years, and 5.2 (95%CI 3.8-8.3) for age 65+. Results were similar in 2011-12. Extrapolated estimates for 3 seasons from 2010-2013 included: 114,192-624,435 hospitalizations, 18,491-95,390 ICU admissions, and 4,915-27,174 deaths per year; 54-70% of hospitalizations and 71-85% of deaths occurred among adults aged 65+. Influenza causes a substantial disease burden in the U.S. that varies by age and season. Periodic estimation of multipliers across multiple sites and age groups improves our understanding of influenza detection in sentinel surveillance systems. Adjusting surveillance data using a multiplier method is a relatively simple means to estimate the impact of influenza and the subsequent value of interventions to prevent influenza. |
Evaluation of screening and treatment of cryptococcal antigenaemia among HIV-infected persons in Soweto, South Africa
Govender N , Roy M , Mendes J , Zulu T , Chiller T , Karstaedt A . HIV Med 2015 16 (8) 468-76 OBJECTIVES: We retrospectively evaluated clinic-based screening to determine the prevalence of cryptococcal antigenaemia and management and outcome of patients with antigenaemia. METHODS: Cryptococcal antigen (CrAg) screening of HIV-infected adults who attended the HIV clinic at Chris Hani Baragwanath Hospital was conducted over 19 months. Data collected from CrAg-positive patients included CD4 T-lymphocyte count at screening, prior or subsequent cryptococcal meningitis (CM), antifungal and antiretroviral treatment and outcome after at least 8 months. RESULTS: Of 1460 patients with no prior CM, 30 (2.1%) had a positive CrAg test. The prevalence of antigenaemia among patients with a CD4 count < 100 cells/mul and no prior CM was 2.8% (20 of 708). Of 29 evaluable CrAg-positive patients with no prior CM, 14 (48%) did not return for post-screening follow-up. Of these 14, five developed CM and one (7%) was known to be alive at follow-up. Of 15 patients who returned for follow-up, two already had evidence of nonmeningeal cryptococcosis. Overall, 11 received fluconazole, one did not and fluconazole treatment was unknown for three. Among these 15, one developed CM and 10 (67%) were known to be alive at follow-up. Overall, 18 (62%) of 29 CrAg-positive patients died or were lost to follow-up. Seven (0.5%) of 1430 CrAg-negative patients developed CM a median of 83 days post-screening (range 34 to 219 days). CONCLUSIONS: Loss to follow-up is the major operational issue relevant to scale-up of screen-and-treat. Patient outcomes may be improved by rapid access to CrAg results and focus on linkage to and retention in HIV care. |
Female and male differences in AIDS diagnosis rates among people who inject drugs in large U.S. metro areas from 1993 to 2007
West BS , Pouget ER , Tempalski B , Cooper HL , Hall HI , Hu X , Friedman SR . Ann Epidemiol 2015 25 (4) 218-25 PURPOSE: We estimated female and male incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess whether declines in IARs varied by sex after combination antiretroviral therapy (cART) dissemination. METHODS: We compared IARs and 95% confidence intervals for female and male PWID in 95 of the most populous MSAs. To stabilize estimates, we aggregated data across three-year periods, selecting a period immediately preceding cART (1993-1995) and the most recent after the introduction of cART for which data were available (2005-2007). We assessed disparities by comparing IAR 95% confidence intervals for overlap, female-to-male risk ratios, and disparity change scores. RESULTS: IARs declined an average of 58% for female PWID and 67% for male PWID between the pre-cART and cART periods. Among female PWID, IARs were significantly lower in the later period relative to the pre-cART period in 48% of MSAs. Among male PWID, IARs were significantly lower over time in 86% of MSAs. CONCLUSIONS: IARs among female PWID in large U.S. MSAs have declined more slowly than among male PWID. This suggests a need for increased targeting of prevention and treatment programs and for research on MSA level conditions that may drive differences in declining AIDS rates among female and male PWID. |
Global update on the susceptibility of human influenza viruses to neuraminidase inhibitors, 2013-2014
Takashita E , Meijer A , Lackenby A , Gubareva L , Rebelo-de-Andrade H , Besselaar T , Fry A , Gregory V , Leang SK , Huang W , Lo J , Pereyaslov D , Siqueira MM , Wang D , Mak GC , Zhang W , Daniels RS , Hurt AC , Tashiro M . Antiviral Res 2015 117 27-38 Four World Health Organization (WHO) Collaborating Centres for Reference and Research on Influenza and one WHO Collaborating Centre for the Surveillance, Epidemiology and Control of Influenza (WHO CCs) tested 10,641 viruses collected by WHO-recognized National Influenza Centres between May 2013 and May 2014 to determine 50% inhibitory concentration (IC50) data for neuraminidase inhibitors (NAIs) oseltamivir, zanamivir, peramivir and laninamivir. In addition, neuraminidase (NA) sequence data, available from the WHO CCs and from sequence databases (n=3206), were screened for amino acid substitutions associated with reduced NAI susceptibility. Ninety-five per cent of the viruses tested by the WHO CCs were from three WHO regions: Western Pacific, the Americas and Europe. Approximately 2% (n=172) showed highly reduced inhibition (HRI) against at least one of the four NAIs, commonly oseltamivir, while 0.3% (n=32) showed reduced inhibition (RI). Those showing HRI were A(H1N1)pdm09 with NA H275Y (n=169), A(H3N2) with NA E119V (n=1), B/Victoria-lineage with NA E117G (n=1) and B/Yamagata-lineage with NA H273Y (n=1); amino acid position numbering is A subtype and B type specific. Although approximately 98% of circulating viruses tested during the 2013-2014 period were sensitive to all four NAIs, a large community cluster of A(H1N1)pdm09 viruses with the NA H275Y substitution from patients with no previous exposure to antivirals was detected in Hokkaido, Japan. Significant numbers of A(H1N1)pdm09 NA H275Y viruses were also detected in China and the United States: phylogenetic analyses showed that the Chinese viruses were similar to those from Japan, while the United States viruses clustered separately from those of the Hokkaido outbreak, indicative of multiple resistance-emergence events. Consequently, global surveillance of influenza antiviral susceptibility should be continued from a public health perspective. |
Health communications and community mobilization during an Ebola response: partnerships with community and faith-based organizations
Santibanez S , Siegel V , O'Sullivan M , Lacson R , Jorstad C . Public Health Rep 2015 130 (2) 128-33 The 2014 Ebola outbreak is the largest Ebola outbreak in history, affecting multiple countries in West Africa.1 Although the risk of a widespread outbreak in the United States is very low, the unfamiliar nature of the disease contributes to uncertainty and mistrust. The Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO) are working to educate and prepare communities throughout the United States for the possibility of an Ebola case in their locality. Federal, state, and local authorities; businesses; schools; charitable foundations; and community and faith-based organizations (CFBOs) all have important roles in Ebola preparedness and response. In 2008, CDC and ASTHO developed a 10-step approach for health communications with CFBOs during public health emergencies.2 In this commentary, we describe how a modification of this 10-step approach can be used by state and local health departments to plan for health communications and community mobilization during an Ebola response. |
HIV testing in re-education through labour camps in Guangxi Autonomous Region, China (a cross-sectional survey)
Yap L , Reekie J , Liu W , Chen Y , Wu Z , Li J , Zhang L , Wand H , Donovan B , Butler T . Sex Transm Infect 2015 91 (6) 401-6 OBJECTIVE: HIV testing is mandatory in re-education-through-labour camps (laojiaosuo) in China yet no studies have reported on the process. METHODS: The survey response rate was 100% although 29 detainees were excluded because they were under 18 years of age. A cross-sectional face-to-face survey was conducted in three labour camps in Guangxi, located in the south-western region of China. RESULTS: Of the 755 detainees surveyed, 725 (96%) reported having a blood test in the labour camps of whom 493 (68%) thought this included an HIV test. 61 detainees self-reported they were HIV infected, their status confirmed by medical records, if available. Of these, 53 (87%) recalled receiving post-test HIV education, and 15 (25%) were currently receiving HIV antiretroviral therapy. Pretest education on HIV was provided to 233/725 (32%) detainees. The study further reports on detainees' reactions and feelings towards non-disclosure and disclosure of their HIV test results in the labour camps. CONCLUSIONS: Mandatory testing is almost universal in the labour camps although a proportion of detainees were unaware that this included an HIV test. HIV test results should be disclosed to all labour camp detainees to reduce their distress of not knowing and prevent misconceptions about their HIV status. Labour camps provide another opportunity to implement universal treatment ('Test and Treat') to prevent the spread of HIV. |
Identifying psychosocial and social correlates of sexually transmitted diseases among black female teenagers
Kraft JM , Whiteman MK , Carter MW , Snead MC , DiClemente RJ , Murray CC , Hatfield-Timajchy K , Kottke M . Sex Transm Dis 2015 42 (4) 192-7 BACKGROUND: Black teenagers have relatively high rates of sexually transmitted diseases (STDs), and recent research suggests the role of contextual factors, as well as risk behaviors. We explore the role of 4 categories of risk and protective factors on having a biologically confirmed STD among black, female teenagers. METHODS: Black teenage girls (14-19 years old) accessing services at a publicly funded family planning clinic provided a urine specimen for STD testing and completed an audio computer-assisted self-interview that assessed the following: risk behaviors, relationship characteristics, social factors, and psychosocial factors. We examined bivariate associations between each risk and protective factor and having gonorrhea and/or chlamydia, as well as multivariate logistic regression among 339 black female teenagers. RESULTS: More than one-fourth (26.5%) of participants had either gonorrhea and/or chlamydia. In multivariate analyses, having initiated sex before age 15 (adjusted odds ratio [aOR], 1.87) and having concurrent sex partners in the past 6 months (aOR, 1.55) were positively associated with having an STD. Living with her father (aOR, 0.44), believing that an STD is the worst thing that could happen (aOR, 0.50), and believing she would feel dirty and embarrassed about an STD (aOR, 0.44) were negatively associated with having an STD. CONCLUSIONS: Social factors and attitudes toward STDs and select risk behaviors were associated with the risk for STDs, suggesting the need for interventions that address more distal factors. Future studies should investigate how such factors influence safer sexual behaviors and the risk for STDs among black female teenagers. |
Identifying the most sensitive and specific sign and symptom combinations for cholera: results from an analysis of laboratory-based surveillance data from Haiti, 2012-2013
Lucien MA , Schaad N , Steenland MW , Mintz ED , Emmanuel R , Freeman N , Boncy J , Adrien P , Joseph GA , Katz MA . Am J Trop Med Hyg 2015 92 (4) 758-764 Since October 2010, over 700,000 cholera cases have been reported in Haiti. We used data from laboratory-based surveillance for diarrhea in Haiti to evaluate the sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of the cholera case definitions recommended by the World Health Organization (WHO). From April 2012 to May 2013, we tested 1,878 samples from hospitalized patients with acute watery diarrhea; 1,178 (62.7%) yielded Vibrio cholerae O1. The sensitivity and specificity of the WHO case definition for cholera in an epidemic setting were 91.3% and 43.1%, respectively, and the PPV and NPV were 72.8% and 74.8%, respectively. The WHO case definition for cholera in an area where cholera is not known to be present had lower sensitivity (63.1%) and NPV (55.1%) but higher specificity (74.2%) and PPV (80.0%). When laboratory diagnostic testing is not immediately available, clinicians can evaluate signs and symptoms to more accurately identify cholera patients. |
Increased rates of respiratory and diarrheal illnesses in HIV-negative people living with HIV-infected individuals in a densely populated urban slum
Wong JM , Cosmas L , Nyachieo D , Williamson JM , Olack B , Okoth G , Njuguna H , Feikin DR , Burke H , Montgomery JM , Breiman RF . J Infect Dis 2015 212 (5) 745-53 BACKGROUND: Prolonged pathogen shedding and increased duration of illness associated with infections in immunosuppressed individuals put close HIV-negative contacts of HIV-infected people at increased risk of exposure to infectious pathogens. METHODS: We calculated incidence and longitudinal prevalence (number of days per year) of influenza-like illness (ILI), diarrhea, and non-specific febrile illness during 2008 from a population-based surveillance program in the urban slum of Kibera (Kenya) consisting of 1830 HIV-negative household contacts of HIV-infected individuals and 13 677 individuals living in exclusively HIV-negative households. RESULTS: For individuals ≥5 years old, incidence was significantly increased for ILI (IRR, 1.47; P < .05) and diarrhea (IRR, 1.41; P < .05) in HIV-negative household contacts of HIV-infected individuals compared to exclusively HIV-negative households. The risk of illness among HIV-negative people was directly proportional to the number of HIV-infected people living in the home for ILI (IRR, 1.39; P < .05) and diarrhea (IRR, 1.36; P < .01). We found no increased rates of illness in children <5 years old who lived with HIV-infected individuals. CONCLUSIONS: Living with HIV-infected individuals is associated with modestly increased rates of respiratory and diarrheal infections in HIV-negative individuals >5 years old. Targeted interventions are needed, including ensuring that HIV-infected people are receiving appropriate care and treatment. |
Influenza virus infection is associated with increased risk of death amongst patients hospitalized with confirmed pulmonary tuberculosis in South Africa, 2010-2011
Walaza S , Tempia S , Dawood H , Variava E , Moyes J , Cohen AL , Wolter N , Groome M , von Mollendorf C , Kahn K , Pretorius M , Venter M , Madhi SA , Cohen C . BMC Infect Dis 2015 15 (1) 26 BACKGROUND: Data on the association between influenza and tuberculosis are limited. We describe the characteristics of patients with laboratory-confirmed tuberculosis, laboratory-confirmed influenza and tuberculosis-influenza co-infection. METHODS: Patients hospitalized with severe respiratory illness (acute and chronic) were enrolled prospectively in four provinces in South Africa. Naso/oropharyngeal specimens were tested for influenza virus by real time reverse transcriptase polymerase chain reaction. Tuberculosis testing was conducted as part of clinical management. RESULTS: From June 2010 through December 2011, 8032 patients were enrolled and influenza testing was conducted on 7863 (98%). Influenza virus was detected in 765 (10%) patients. Among 2959 patients with tuberculosis and influenza results, 2227 (75%) were negative for both pathogens, 423 (14%) were positive for tuberculosis alone, 275 (9%) were positive for influenza alone and 34 (1%) had influenza and tuberculosis co-infection. On multivariable analysis amongst individuals with symptoms for ≥ 7 days, tuberculosis influenza co-infection was associated with increased risk of death, (adjusted relative risk ratio (aRRR) (6.1, 95% confidence interval (CI) 1.6-23.4), as compared to tuberculosis only infection. This association was not observed in individuals with symptoms for <7 days (aRRR.0.8, 95% CI 0.1-7.0). CONCLUSION: Tuberculosis and influenza co-infection compared to tuberculosis single infection was associated with increased risk of death in individuals with symptoms ≥ 7 days. The potential public health impact of influenza vaccination among persons with laboratory-confirmed tuberculosis should be explored. |
Kericho CLinic-Based ART Diagnostic Evaluation (CLADE): design, accrual, and baseline characteristics of a randomized controlled trial conducted in predominately rural, district-level, HIV clinics of Kenya
Sawe FK , Obiero E , Yegon P , Langat RC , Aoko A , Tarus J , Kiptoo I , Langat RK , Maswai J , Bii M , Khamadi S , Shikuku KP , Close N , Sinei S , Shaffer DN . PLoS One 2015 10 (2) e0116299 BACKGROUND: Prospective clinical trial data regarding routine HIV-1 viral load (VL) monitoring of antiretroviral therapy (ART) in non-research clinics of Sub-Saharan Africa are needed for policy makers. METHODS: CLinic-based ART Diagnostic Evaluation (CLADE) is a randomized, controlled trial (RCT) evaluating feasibility, superiority, and cost-effectiveness of routine VL vs. standard of care (clinical and immunological) monitoring in adults initiating dual nucleoside reverse transcriptase inhibitor (NRTI)+non-NRTI ART. Participants were randomized (1:1) at 7 predominately rural, non-research, district-level clinics of western Kenya. Descriptive statistics present accrual patterns and baseline cohort characteristics. RESULTS: Over 15 months, 820 adults enrolled at 7 sites with 86-152 enrolled per site. Monthly site enrollment ranged from 2-92 participants. Full (100%) informed consent compliance was independently documented. Half (49.9%) had HIV diagnosed through voluntary counseling and testing. Study arms were similar: mostly females (57.6%) aged 37.6 (SD = 9.0) years with low CD4 (166 [SD = 106]) cells/m3). Notable proportions had WHO Stage III or IV disease (28.7%), BMI <18.5 kg/m2 (23.1%), and a history of tuberculosis (5.6%) or were receiving tuberculosis treatment (8.2%) at ART initiation. In the routine VL arm, 407/409 (99.5%) received baseline VL (234,577 SD = 151,055 copies/ml). All participants received lamivudine; 49.8% started zidovudine followed by 38.4% stavudine and 11.8% tenofovir; and, 64.4% received nevirapine as nNRTI (35.6% efavirenz). CONCLUSIONS: A RCT can be enrolled successfully in rural, non-research, resource limited, district-level clinics in western Kenya. Many adults presenting for ART have advanced HIV/AIDS, emphasizing the importance of universal HIV testing and linkage-to-care campaigns. TRIAL REGISTRATION: ClinicalTrials.gov NCT01791556. |
Antiretroviral treatment is associated with iron deficiency in HIV-infected Malawian women that is mitigated with supplementation, but is not associated with infant iron deficiency during 24 weeks of exclusive breastfeeding
Widen EM , Bentley ME , Chasela CS , Kayira D , Flax VL , Kourtis AP , Ellington SR , Kacheche Z , Tegha G , Jamieson DJ , van der Horst CM , Allen LH , Shahab-Ferdows S , Adair LS . J Acquir Immune Defic Syndr 2015 69 (3) 319-28 OBJECTIVE: In resource-limited settings without safe alternatives to breastfeeding, the WHO recommends exclusive breastfeeding and antiretroviral (ARV) prophylaxis. Given the high prevalence of anemia among HIV-infected women, mothers and their infants (via fetal iron accretion) may be at risk of iron deficiency. We assessed the effects of maternal micronutrient-fortified lipid-based nutrient supplements (LNS) and maternal ARV treatment or infant ARV prophylaxis on maternal and infant iron status during exclusive breastfeeding from birth to 24 weeks. METHODS: The Breastfeeding, Antiretrovirals, and Nutrition Study was a randomized controlled trial conducted in Lilongwe, Malawi from 2004-2010. HIV-infected mothers (CD4>200 cells/ul) and their infants were randomly assigned to 28-week interventions: maternal-LNS/maternal-ARV (n=424), maternal-LNS/infant-ARV (n=426), maternal-LNS (n=334), maternal-ARV (n=425), infant-ARV (n=426), or control (n=334). Longitudinal models tested intervention effects on hemoglobin (Hb). In a subsample (n=537) with multiple iron indicators, intervention effects on Hb, transferrin receptors (TfR) and ferritin were tested with linear and Poisson regression. RESULTS: In longitudinal models, LNS effects on maternal and infant Hb were minimal. In subsample mothers, maternal ARVs were associated with tissue iron depletion (TfR>8.3 mg/L) (Risk ratio (RR): 3.1, p<0.01), but not in ARV-treated mothers receiving LNS (p=0.17). LNS without ARVs, was not associated with iron deficiency or anemia (p>0.1). In subsample infants, interventions were not associated with impaired iron status (all p-values>0.1). CONCLUSIONS: Maternal ARV treatment with protease inhibitors is associated with maternal tissue iron depletion; but LNS mitigates adverse effects. ARVs do not appear to influence infant iron status; however, extended use needs to be evaluated. |
Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project
Flagg EW , Weinstock HS , Frazier EL , Valverde EE , Heffelfinger JD , Skarbinski J . Sex Transm Dis 2015 42 (4) 171-9 BACKGROUND: Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010. DESIGN: The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling. METHODS: Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction. RESULTS: Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection. CONCLUSIONS: Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing. |
Barriers to health care in rural Mozambique: a rapid ethnographic assessment of planned mobile health clinics for ART
Schwitters A , Lederer P , Zilversmit L , Gudo PS , Ramiro I , Cumba L , Mahagaja E , Jobarteh K . Glob Health Sci Pract 2015 3 (1) 109-16 BACKGROUND: In Mozambique, 1.6 million people are living with HIV, and over 60% of the population lives in rural areas lacking access to health services. Mobile health clinics, implemented in 2013 in 2 provinces, are beginning to offer antiretroviral therapy (ART) and basic primary care services. Prior to introduction of the mobile health clinics in the communities, we performed a rapid ethnographic assessment to understand barriers to accessing HIV care and treatment services and acceptability and potential use of the mobile health clinics as an alternative means of service delivery. METHODS: We conducted assessments in Gaza province in January 2013 and in Zambezia Province in April-May 2013 in districts where mobile health clinic implementation was planned. Community leaders served as key informants, and chain-referral sampling was used to recruit participants. Interviews were conducted with community leaders, health care providers, traditional healers, national health system patients, and traditional healer patients. Interviewees were asked about barriers to health services and about mobile health clinic acceptance. RESULTS: In-depth interviews were conducted with 117 participants (Gaza province, n = 57; Zambezia Province, n = 60). Barriers to accessing health services included transportation and distance-related issues (reliability, cost, and travel time). Participants reported concurrent use of traditional and national health systems. The decision to use a particular health system depended on illness type, service distance, and lack of confidence in the national health system. Overall, participants were receptive to using mobile health clinics for their health care and ability to increase access to ART. Hesitations concerning mobile health clinics included potentially long wait times due to high patient loads. Participants emphasized the importance of regular and published visit schedules and inclusion of community members in planning mobile health clinic services. CONCLUSION: Mobile health clinics can address many barriers to uptake of HIV services, particularly related to transportation issues. Involvement of community leaders, providers, traditional healers, and patients, as well as regularly scheduled mobile clinic visits, are critical to successful service delivery implementation in rural areas. |
Burden of Clostridium difficile infection in the United States
Lessa FC , Mu Y , Bamberg WM , Beldavs ZG , Dumyati GK , Dunn JR , Farley MM , Holzbauer SM , Meek JI , Phipps EC , Wilson LE , Winston LG , Cohen JA , Limbago BM , Fridkin SK , Gerding DN , McDonald LC . N Engl J Med 2015 372 (9) 825-34 BACKGROUND: The magnitude and scope of Clostridium difficile infection in the United States continue to evolve. METHODS: In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥ 1 year of age). Cases were classified as community-associated or health care-associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection. RESULTS: A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care-associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care-associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001). CONCLUSIONS: C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. (Funded by the Centers for Disease Control and Prevention.). |
Characteristics of tuberculosis cases that started outbreaks in the United States, 2002-2011
Haddad MB , Mitruka K , Oeltmann JE , Johns EB , Navin TR . Emerg Infect Dis 2015 21 (3) 508-10 A review of 26 tuberculosis outbreaks in the United States (2002-2011) showed that initial source case-patients had long infectious periods (median 10 months) and were characterized by substance abuse, incarceration, and homelessness. Improved timeliness of diagnosis and thorough contact investigations for such cases may reduce the risk for outbreaks. |
Cotrimoxazole prophylaxis and antiretroviral therapy: an observational cohort study in China
Cheng W , Wu Y , Wen Y , Ma Y , Zhao D , Dou Z , Zhang W , Bulterys M , Zhang F . Bull World Health Organ 2015 93 (3) 152-160 OBJECTIVE: To assess if cotrimoxazole prophylaxis administered early during antiretroviral therapy (ART) reduces mortality in Chinese adults who are infected with human immunodeficiency virus (HIV). METHODS: We did a retrospective observational cohort study using data from the Chinese national free antiretroviral database. Patients older than 14 years who started ART between 1 January 2010 and 31 December 2012 and had baseline CD4+ T-lymphocyte (CD4+ cell) count less than 200 cells/μL were followed until death, loss to follow-up or 31 December 2013. Hazard ratios (HRs) for several variables were calculated using multivariate analyses. FINDINGS: The analysis involved 23 816 HIV-infected patients, 2706 of whom died during the follow-up. Mortality in patients who did and did not start cotrimoxazole during the first 6 months of ART was 5.3 and 7.0 per 100 person–years, respectively. Cotrimoxazole was associated with a 37% reduction in mortality (hazard ratio, HR: 0.63; 95% confidence interval, CI: 0.56–0.70). Cotrimoxazole in addition to ART reduced mortality significantly over follow-up lasting 6 months (HR: 0.65; 95% CI: 0.59–0.73), 12 months (HR: 0.58; 95% CI: 0.49–0.70), 18 months (HR: 0.49; 95% CI: 0.38–0.63) and 24 months (HR: 0.66; 95% CI: 0.48–0.90). The mortality reduction was evident in patients with baseline CD4+ cell counts less than 50 cells/μL (HR: 0.60; 95% CI: 0.54–0.67), 50–99 cells/μL (HR: 0.66; 95% CI: 0.56–0.78) and 100–199 cells/μL (HR: 0.78; 95% CI: 0.62–0.98). CONCLUSION: Cotrimoxazole prophylaxis started early during ART reduced mortality and should be offered to HIV-infected patients in low- and middle-income countries. |
Comparison of Tick Feeding Success and Vector Competence for Borrelia burgdorferi Among Immature Ixodes scapularis (Ixodida: Ixodidae) of Both Southern and Northern Clades.
Goddard J , Embers M , Hojgaard A , Piesman J . J Med Entomol 2015 52 (1) 81-85 Northern and southern Ixodes scapularis Say populations differ greatly in density, host utilization, and especially questing behavior of the immatures. Haplotypes of I. scapularis in North America can be divided into two major clades-the All American Clade (haplotypes A through J) and the Southern Clade (M through O). This genetic variation may affect feeding success and vector competence. This study compared feeding success of larval I. scapularis measured by time-to-drop-off and subsequent transmissibility success of Borrelia burgdorferi to mice using ticks from Mississippi, Connecticut (both F haplotype), and Louisiana (haplotype O). Northern ticks (CT) fed to repletion much faster than MS and LA ticks: overall, 73.6% of CT ticks had dropped off mice at Day 3 compared to only 1.7% and 6.6% of ticks dropped off for MS and LA ticks at that same time point. As for vector competence, 4 of the 4 mice in each case (MS or CT) that had been fed on by infected nymphs tested positive for B. burgdorferi. In a second experiment, 5 of the 6 mice tested positive for B. burgdorferi after exposure to infected LA ticks as compared with 3 of the 4 mice exposed to infected CT ticks. These data demonstrate that there is no difference in northern and southern populations of I. scapularis in their ability to transmit B. burgdorferi, but the ability of the northern populations to feed rapidly on rodents exceeds that of southern populations. |
Considerations for the use of human participants in vector biology research: a tool for investigators and regulators
Achee NL , Youngblood L , Bangs MJ , Lavery JV , James S . Vector Borne Zoonotic Dis 2015 15 (2) 89-102 A thorough search of the existing literature has revealed that there are currently no published recommendations or guidelines for the interpretation of US regulations on the use of human participants in vector biology research (VBR). An informal survey of vector biologists has indicated that issues related to human participation in vector research have been largely debated by academic, national, and local Institutional Review Boards (IRBs) in the countries where the research is being conducted, and that interpretations and subsequent requirements made by these IRBs have varied widely. This document is intended to provide investigators and corresponding scientific and ethical review committee members an introduction to VBR methods involving human participation and the legal and ethical framework in which such studies are conducted with a focus on US Federal Regulations. It is also intended to provide a common perspective for guiding researchers, IRB members, and other interested parties (i.e., public health officials conducting routine entomological surveillance) in the interpretation of human subjects regulations pertaining to VBR. |
Characterization of silver nanoparticles in selected consumer products and its relevance for predicting children's potential exposures
Tulve NS , Stefaniak AB , Vance ME , Rogers K , Mwilu S , LeBouf RF , Schwegler-Berry D , Willis R , Thomas TA , Marr LC . Int J Hyg Environ Health 2015 218 (3) 345-57 Due to their antifungal, antibacterial, antiviral, and antimicrobial properties, silver nanoparticles (AgNPs) are used in consumer products intended for use by children or in the home. Children may be especially affected by the normal use of consumer products because of their physiological functions, developmental stage, and activities and behaviors. Despite much research to date, children's potential exposures to AgNPs are not well characterized. Our objectives were to characterize selected consumer products containing AgNPs and to use the data to estimate a child's potential non-dietary ingestion exposure. We identified and cataloged 165 consumer products claiming to contain AgNPs that may be used by or near children or found in the home. Nineteen products (textile, liquid, plastic) were selected for further analysis. We developed a tiered analytical approach to determine silver content, form (particulate or ionic), size, morphology, agglomeration state, and composition. Silver was detected in all products except one sippy cup body. Among products in a given category, silver mass contributions were highly variable and not always uniformly distributed within products, highlighting the need to sample multiple areas of a product. Electron microscopy confirmed the presence of AgNPs. Using this data, a child's potential non-dietary ingestion exposure to AgNPs when drinking milk formula from a sippy cup is 1.53mug Ag/kg. Additional research is needed to understand the number and types of consumer products containing silver and the concentrations of silver in these products in order to more accurately predict children's potential aggregate and cumulative exposures to AgNPs. |
Trends in insomnia and excessive daytime sleepiness among US adults from 2002 to 2012
Ford ES , Cunningham TJ , Giles WH , Croft JB . Sleep Med 2015 16 (3) 372-8 OBJECTIVE: Insomnia is a prevalent disorder in the United States and elsewhere. It has been associated with a range of somatic and psychiatric conditions, and adversely affects quality of life, productivity at work, and school performance. The objective of this study was to examine the trend in self-reported insomnia and excessive daytime sleepiness among US adults. METHODS: We used data of participants aged ≥18 years from the National Health Interview Survey for the years 2002 (30,970 participants), 2007 (23,344 participants), and 2012 (34,509 participants). RESULTS: The unadjusted prevalence of insomnia or trouble sleeping increased from 17.5% (representing 37.5 million adults) in 2002 to 19.2% (representing 46.2 million adults) in 2012 (relative increase: +8.0%) (P trend <0.001). The age-adjusted prevalence increased from 17.4% to 18.8%. Significant increases were present among participants aged 18-24, 25-34, 55-64, and 65-74 years, men, women, whites, Hispanics, participants with diabetes, and participants with joint pain. Large relative increases occurred among participants aged 18-24 years (+30.9%) and participants with diabetes (+27.0%). The age-adjusted percentage of participants who reported regularly having excessive daytime sleepiness increased from 9.8% to 12.7% (P trend <0.001). Significant increases were present in most demographic groups. The largest relative increase was among participants aged 25-34 years (+49%). Increases were also found among participants with hypertension, chronic obstructive pulmonary disease, asthma, and joint pain. CONCLUSIONS: Given the deleterious effects of insomnia on health and performance, the increasing prevalence of insomnia and excessive daytime sleepiness among US adults is a potentially troubling development. |
Deconstructing the differences: a comparison of GBD 2010 and CHERG inverted question marks approach to estimating the mortality burden of diarrhea, pneumonia, and their etiologies
Kovacs SD , Mullholland K , Bosch J , Campbell H , Forouzanfar MH , Khalil I , Lim S , Liu L , Maley SN , Mathers CD , Matheson A , Mokdad AH , OBrien K , Parashar U , Schaafsma TT , Steele D , Hawes SE , Grove JT . BMC Infect Dis 2015 15 (1) 16 BACKGROUND: Pneumonia and diarrhea are leading causes of death for children under five (U5). It is challenging to estimate the total number of deaths and cause-specific mortality fractions. Two major efforts, one led by the Institute for Health Metrics and Evaluation (IHME) and the other led by the World Health Organization (WHO)/Child Health Epidemiology Reference Group (CHERG) created estimates for the burden of disease due to these two syndromes, yet their estimates differed greatly for 2010. METHODS: This paper discusses three main drivers of the differences: data sources, data processing, and covariates used for modelling. The paper discusses differences in the model assumptions for etiology-specific estimates and presents recommendations for improving future models. RESULTS: IHME inverted question marks Global Burden of Disease (GBD) 2010 study estimated 6.8 million U5 deaths compared to 7.6 million U5 deaths from CHERG. The proportional differences between the pneumonia and diarrhea burden estimates from the two groups are much larger; GBD 2010 estimated 0.847 million and CHERG estimated 1.396 million due to pneumonia. Compared to CHERG, GBD 2010 used broader inclusion criteria for verbal autopsy and vital registration data. GBD 2010 and CHERG used different data processing procedures and therefore attributed the causes of neonatal death differently. The major difference in pneumonia etiologies modeling approach was the inclusion of observational study data; GBD 2010 included observational studies. CHERG relied on vaccine efficacy studies. DISCUSSION: Greater transparency in modeling methods and more timely access to data sources are needed. In October 2013, the Bill & Melinda Gates Foundation (BMGF) hosted an expert meeting to examine possible approaches for better estimation. The group recommended examining the impact of data by systematically excluding sources in their models. GBD 2.0 will use a counterfactual approach for estimating mortality from pathogens due to specific etiologies to overcome bias of the methods used in GBD 2010 going forward. |
Identification and characterization of multidrug-resistant Salmonella enterica serotype Albert isolates in the United States.
Folster JP , Campbell D , Grass J , Brown AC , Bicknese A , Tolar B , Joseph LA , Plumblee JR , Walker C , Fedorka-Cray PJ , Whichard JM . Antimicrob Agents Chemother 2015 59 (5) 2774-9 Salmonella enterica is one of the most common causes of bacterial foodborne illness in the United States. Although most Salmonella infections are self-limiting, antimicrobial treatment is critical for invasive salmonellosis. Primary antimicrobial treatment options include fluoroquinolones or extended-spectrum cephalosporins and antimicrobial resistance to these drugs may complicate treatment. At present, Salmonella enterica is composed of more than 2,600 unique serotypes, which vary greatly in geographic prevalence, ecological niche, and ability to cause human disease and it is important to understand and mitigate the source of human infection, particularly when antimicrobial resistance is found. In this study, we identified and characterized 19 Salmonella enterica serotype Albert isolates from food animals, retail meat, and humans collected in the United States during 2005-2013. All 5 isolates from non-human sources were obtained from turkeys or ground turkey and epidemiologic data suggest poultry consumption or live poultry exposure as the probable source of infection. Salmonella ser. Albert also appears to be geographically localized to the Midwestern states of the U.S. All 19 isolates displayed multidrug resistance (MDR), including decreased susceptibility to fluoroquinolones and resistance to extended-spectrum cephalosporins. Turkeys are a likely source of multidrug resistant Salmonella Albert, and circulation of resistance plasmids, as opposed to expansion of a single resistant strain, is playing a role. More work is needed to understand why these resistance plasmids spread and how their presence and the serotype they reside in contribute to human disease. |
Innate susceptibility to norovirus infections influenced by FUT2 genotype in a United States pediatric population.
Currier RL , Payne DC , Staat MA , Selvarangan R , Shirley SH , Halasa N , Boom JA , Englund JA , Szilagyi PG , Harrison CJ , Klein EJ , Weinberg GA , Wikswo ME , Parashar U , Vinje J , Morrow AL . Clin Infect Dis 2015 60 (11) 1631-8 BACKGROUND: Norovirus is a leading cause of acute gastroenteritis (AGE). Noroviruses bind to gut histo-blood group antigens (HBGAs), but only 70-80% of individuals have a functional copy of the FUT2 ("secretor") gene required for gut HBGA expression; these individuals are known as "secretors." Susceptibility to some noroviruses depends on FUT2 secretor status, but the population impact of this association is not established. METHODS: From 12/2011 to 11/2012, active AGE surveillance was performed at six geographically diverse US pediatric sites. Cases under five years were recruited from emergency departments and inpatient units; age-matched healthy controls were recruited at well-child visits. Salivary DNA was collected to determine secretor status and genetic ancestry. Stool was tested for norovirus by realtime RT-PCR. Norovirus genotype was then determined by sequencing. RESULTS: Norovirus was detected in 302 (21%) of 1465 AGE cases and 52 (6%) of 826 healthy controls. Norovirus AGE cases were 2.8-fold more likely than norovirus-negative controls to be secretors (p<0.001) in a logistic regression model adjusted for ancestry, age, site, and health insurance. Secretors comprised all 155 cases and 21 asymptomatic infections with the most prevalent norovirus, GII.4. Control children of Meso-American ancestry were more likely than children of European or African ancestry to be secretors (96% versus 74%, p<0.001). CONCLUSIONS: FUT2 status is associated with norovirus infection and varies by ancestry. GII.4 norovirus exclusively infected secretors. These findings are important to norovirus vaccine trials and design of agents that may block norovirus-HBGA binding. |
Draft Genome Sequence of a New Delhi Metallo-ß-Lactamase-5 (NDM-5)-Producing Multidrug-Resistant Escherichia coli Isolate.
de Man TJ , Perry KA , Avillan JJ , Rasheed JK , Limbago BM . Genome Announc 2015 3 (2) A multidrug-resistant Escherichia coli isolate from an abdominal lesion displayed resistance to all beta-lactams tested, including carbapenems, in addition to macrolides, fluoroquinolones, and tetracycline. Sequence analyses demonstrated the presence of blaNDM-5 in addition to at least 13 genes and 6 efflux pumps associated with antibiotic resistance. |
Molecular characterization of Echinococcus granulosus sensu lato from farm animals in Egypt.
Amer S , Helal IB , Kamau E , Feng Y , Xiao L . PLoS One 2015 10 (3) e0118509 Little is known on the diversity and public health significance of Echinococcus species in livestock in Egypt. In this study, 37 individual hydatid cysts were collected from dromedary camels (n=28), sheep (n=7) and buffalos (n=2). DNA was extracted from protoscoleces/germinal layer of individual cysts and amplified by PCR targeting nuclear (actin II) and mitochondrial (COX1 and NAD1) genes. Direct sequencing of amplicons indicated the presence of Echinococcus canadenesis (G6 genotype) in 26 of 28 camel cysts, 3 of 7 sheep cysts and the 2 buffalo derived cysts. In contrast, Echinococcus granulosus sensu stricto (G1 genotype) was detected in one cyst from a camel and 4 of 7 cysts from sheep, whereas Echinococcus ortleppi (G5 genotype) was detected in one cyst from a camel. This is the first identification of E. ortleppi in Egypt. |
Subtyping novel zoonotic pathogen Cryptosporidium chipmunk genotype I.
Guo Y , Cebelinski E , Matusevich C , Alderisio KA , Lebbad M , McEvoy J , Roellig DM , Yang C , Feng Y , Xiao L . J Clin Microbiol 2015 53 (5) 1648-54 Cryptosporidium chipmunk genotype I is an emerging zoonotic pathogen in humans. The lack of subtyping tools makes it impossible to determine the role of zoonotic transmission in epidemiology. To identify potential subtyping markers, we sequenced the genome of a human chipmunk genotype I isolate. Altogether, 9,509,783 bp of assembled sequences in 853 contigs were obtained, with an N50 of 117,886 bp and over 200-fold coverage. Based on the whole genome sequence data, two genetic markers encoding the 60-kDa glycoprotein (gp60) and a mucin protein (ortholog of cgd1_470) were selected for the development of a subtyping tool. The tool was used in characterizing chipmunk genotype I in 25 human specimens from four US states and Sweden, one specimen each from an eastern grey squirrel, a chipmunk and a deer mouse, and 4 water samples from New York. At the gp60 locus, although different subtypes were seen among animals, water and humans, the 15 subtypes identified differed mostly in the number of trinucleotide repeats (TCA, TCG or TCT) in the serine repeat region, with only two single nucleotide polymorphisms in the non-repeat region. Some geographic differences were found in subtype distribution of chipmunk genotype I from humans. In contrast, only two subtypes were found at the mucin locus, which differed from each other in the number of a 30-bp minisatellite repeat. Thus, Cryptosporidium chipmunk genotype I from humans and wildlife are genetically similar and zoonotic transmission could play a potential role in human infections. |
Genomic diversity of mumps virus and global distribution of the 12 genotypes.
Jin L , Orvell C , Myers R , Rota PA , Nakayama T , Forcic D , Hiebert J , Brown KE . Rev Med Virol 2015 25 (2) 85-101 The WHO recently proposed an updated nomenclature for mumps virus (MuV). WHO currently recognizes 12 genotypes of MuV, assigned letters from A to N (excluding E and M), which are based on the nucleotide sequences of small hydrophobic (SH) and haemagglutinin-neuraminidase (HN) genes. A total of 66 MuV genomes are available in GenBank, representing eight of the 12 genotypes. To complete this dataset, whole genomes of seven isolates representing six genotypes (D, H, I, J, K and L) and one unclassified strain were sequenced. SH and HN genes of other representative strains were also sequenced. The degree of genetic divergence, predicted amino acid substitutions in the HN and fusion (F) proteins and geographic distributions of MuV strains were analysed based on the updated dataset. Nucleotide heterogeneity between genotypes reached 20% within the SH gene, with a maximum of 9% within the HN gene. The geographic and chronologic distributions of the 12 genotypes were summarised. This review contributes to our understanding of strain diversity for wild type MuV, and the results support the current WHO nomenclature. |
Opportunities for translational epidemiology: the important role of observational studies to advance precision oncology.
Marrone M , Schilsky RL , Liu G , Khoury MJ , Freedman AN . Cancer Epidemiol Biomarkers Prev 2015 24 (3) 484-9 Within current oncology practice, several genomic applications are being used to inform treatment decisions with molecularly targeted therapies in breast, lung, colorectal, melanoma, and other cancers. This commentary introduces a conceptual framework connecting the full spectrum of biomedical research disciplines, including fundamental laboratory research, clinical trials, and observational studies in the translation of genomic applications into clinical practice. The conceptual framework illustrates the contribution that well-designed observational epidemiologic studies provide to the successful translation of these applications, and characterizes the role observational epidemiology plays in driving the dynamic and iterative bench-to-bedside, and bedside-to-bench translation continuum. We also discuss how the principles of this conceptual model, emphasizing integration of multidisciplinary research, can be applied to the evolving paradigm in "precision oncology" focusing on multiplex tumor sequencing, and we identify opportunities for observational studies to contribute to the successful and efficient translation of this paradigm. |
Salmonella serotype determination utilizing high-throughput genome sequencing data.
Zhang S , Yin Y , Jones MB , Zhang Z , Deatherage Kaiser BL , Dinsmore BA , Fitzgerald C , Fields PI , Deng X . J Clin Microbiol 2015 53 (5) 1685-92 Serotyping forms the basis of national and international surveillance networks for Salmonella, one of the most prevalent foodborne pathogens worldwide (1-3). Public health microbiology is currently being transformed by whole genome sequencing (WGS) which opens the door to serotype determination using WGS data. SeqSero (www.denglab.info/SeqSero) is a novel web-based tool for determining Salmonella serotypes using high-throughput genome sequencing data. SeqSero is based on curated databases of Salmonella serotype determinants (rfb gene cluster, fliC and fljB alleles) and is predicted to determine serotype rapidly and accurately for nearly the full spectrum of Salmonella serotypes (more than 2,300 serotypes), from both raw sequencing reads and genome assemblies. The performance of SeqSero was evaluated by testing: 1) raw reads from genomes of 308 Salmonella isolates of known serotype; 2) raw reads from genomes of 3,306 Salmonella isolates sequenced and made publicly available by GenomeTrakr, a U.S. national monitoring network operated by the Food and Drug Administration; and 3) 354 other publicly available draft or complete Salmonella genomes. We also demonstrated Salmonella serotype determination from raw sequencing reads of fecal metagenomes from mice orally infected with this pathogen. SeqSero can help to maintain the well-established utility of Salmonella serotyping when integrated into a platform of WGS-based pathogen subtyping and characterization. |
Novel mutations on the ace-1 gene of the malaria vector Anopheles albimanus provide evidence for balancing selection in an area of high insecticide resistance in Peru.
Liebman KA , Pinto J , Valle J , Palomino M , Vizcaino L , Brogdon W , Lenhart A . Malar J 2015 14 74 BACKGROUND: Resistance to multiple classes of insecticides has been detected in the malaria vector Anopheles albimanus in northwest Peru. Acetylcholinesterase (AChE) insensitivity has previously been associated with resistance to organophosphate (OP) and carbamate (CA) insecticides in arthropods. A single point mutation on the ace-1 gene (G119S) associated with resistance to OPs and CAs has been described previously in four anopheline species, but not in field-collected An. albimanus. The present study aimed to characterize the role of ace-1 in conferring resistance to both OPs and CAs in the An. albimanus population in Tumbes, Peru. METHODS: The frequency and intensity of resistance to OPs and CAs was quantified through bioassays of female An. albimanus collected between 2012 and 2014, and the presence of insensitive AChE was confirmed using biochemical assays. A portion of the ace-1 gene flanking codon 119 was amplified and sequenced from individuals used in the bioassays and biochemical assays, as well as from historical samples collected in 2008. Statistical analyses were conducted to determine: (1) associations between genotype and AChE insensitivity; and, (2) associations between genotype and resistance phenotype. RESULTS: After confirming high levels of resistance to fenitrothion, malathion, and bendiocarb through bioassays, two novel polymorphisms were identified at the first and second loci of codon 119, with all individuals from the 2012-2014 collections being heterozygous at the first base (G/T) and either heterozygous (G/C) or homozygous mutants (C/C) at the second base. Based on sequence data from historical samples, these mutations arose prior to 2008, but became fixed in the population between 2008 and 2012. Homozygotes at the second locus had significantly higher levels of AChE insensitivity than heterozygotes (p <0.05). Individuals phenotypically susceptible to OPs and CAs were more likely to be heterozygous at the second locus (p <0.01). Cloning identified four individuals each containing three distinct genotypes, suggesting that a duplication of the ace-1 gene may have occurred. CONCLUSIONS: The occurrence of heterozygotes at two loci and the presence of three genotypes in four individuals suggest that balancing selection could be maintaining OP and CA resistance in this population, while minimizing associated fitness costs. |
Notes from the field: adverse events associated with administration of simulation intravenous fluids to patients - United States, 2014
Robyn MP , Hunter JC , Burns A , Newman AP , White J , Clement EJ , Lutterloh E , Quinn M , Edens C , Epstein L , Seiber K , Nguyen D , Kallen A , Blog D . MMWR Morb Mortal Wkly Rep 2015 64 (8) 226-7 On December 23, 2014, the New York State Department of Health (NYSDOH) was notified of adverse health events in two patients who had been inadvertently administered nonsterile, simulation 0.9% sodium chloride intravenous (IV) fluids at an urgent care facility. Simulation saline is a nonsterile product not meant for human or animal use; it is intended for use by medical trainees practicing IV administration of saline on mannequins or other training devices. Both patients experienced a febrile illness during product administration and were hospitalized; one patient developed sepsis and disseminated intravascular coagulation. Neither patient died. Staff members at the clinic reported having ordered the product through their normal medical supply distributor and not recognizing during administration that it was not intended for human use. |
The importance of clinical surveillance in detecting Legionnaires' disease outbreaks: a large outbreak in a hospital with a Legionella disinfection system, Pennsylvania, 2011-2012
Demirjian A , Lucas CE , Garrison LE , Kozak-Muiznieks NA , States S , Brown EW , Wortham JM , Beaudoin A , Casey ML , Marriott C , Ludwig AM , Sonel AF , Muder RR , Hicks LA . Clin Infect Dis 2015 60 (11) 1596-602 BACKGROUND: Healthcare-associated Legionnaires' disease (LD) is a preventable pneumonia with a 30% case-fatality rate. The Centers for Disease Control and Prevention guidelines recommend a high index of suspicion for the diagnosis of healthcare-associated LD. We characterized an outbreak and evaluated contributing factors in a hospital using copper-silver ionization for prevention of Legionella growth in water. METHODS: Through medical chart review at a large, urban tertiary care hospital in November 2012, we identified patients diagnosed with LD during 2011-2012. Laboratory-confirmed cases were categorized as definite, probable, and not healthcare-associated based on time spent in the hospital during the incubation period. We performed an environmental assessment of the hospital, including collection of samples for Legionella culture. Clinical and environmental isolates were compared by genotyping. Copper and silver ion concentrations were measured in 11 water samples. RESULTS: We identified five definite and 17 probable healthcare-associated LD cases; six case-patients died. Of 25 locations (mostly potable water) where environmental samples were obtained for Legionella-specific culture, all but two showed Legionella growth; eleven isolates were identical to three clinical isolates by sequence-based typing. Mean copper and silver concentrations were at or above the manufacturer's recommended target for Legionella control. Despite this, all samples where copper and silver concentrations were tested showed Legionella growth. CONCLUSIONS: This outbreak was linked to the hospital's potable water system and highlights the importance of maintaining a high index of suspicion for healthcare-associated LD, even in the setting of a long-term disinfection program. |
Infection prevention and control in the podiatric medical setting: challenges to providing consistently safe care
Wise ME , Bancroft E , Clement EJ , Hathaway S , High P , Kim M , Lutterloh E , Perz JF , Sehulster LM , Tyson C , White-Comstock MB , Montana B . J Am Podiatr Med Assoc 2015 Unsafe practices are an underestimated contributor to the disease burden of bloodborne viruses. Outbreaks associated with failures in basic infection prevention have been identified in nonhospital settings with increased frequency in the United States during the past 15 years, representing an alarming trend and indicating that the challenge of providing consistently safe care is not always met. As has been the case with most medical specialties, there have been public health investigations by state and local health departments, and the Centers for Disease Control and Prevention have identified some instances of unsafe practices that have placed podiatric medical patients at risk for viral, bacterial, and fungal infections. All health-care providers, including podiatric physicians, must make infection prevention a priority in any setting in which care is delivered. |
Bisphenol A exposure and behavioral problems among inner city children at 7-9 years of age
Roen EL , Wang Y , Calafat AM , Wang S , Margolis A , Herbstman J , Hoepner LA , Rauh V , Perera FP . Environ Res 2015 142 739-45 BACKGROUND: Bisphenol A (BPA) is a ubiquitous endocrine disrupting compound. Several experimental and epidemiological studies suggest that gestational BPA exposure can lead to neurodevelopmental and behavioral problems in early-life, but results have been inconsistent. We previously reported that prenatal BPA exposure may affect child behavior and differently among boys and girls at ages 3-5 years. OBJECTIVES: We investigated the association of prenatal and early childhood BPA exposure with behavioral outcomes in 7-9 year old minority children and hypothesized that we would observe the same sex-specific pattern observed at earlier ages. METHODS: African-American and Dominican women enrolled in an inner-city prospective cohort study and their children were followed from mother's pregnancy through children's age 7-9 years. Women during the third trimester of pregnancy and children at ages 3 and 5 years provided spot urine samples. BPA exposure was categorized by tertiles of BPA urinary concentrations. The Child Behavioral Checklist (CBCL) was administered at ages 7 and 9 to assess multiple child behavior domains. Associations between behavior and prenatal (maternal) BPA concentrations and behavior and postnatal (child) BPA concentration were assessed via Poisson regression in models stratified by sex. These models accounted for potential confounders including prenatal or postnatal urinary BPA concentrations, child age at CBCL assessment, ethnicity, gestational age, maternal intelligence, maternal education and demoralization, quality of child's home environment, prenatal environmental tobacco smoke exposure, and prenatal mono-n-butyl phthalate concentration. RESULTS: The direction of the associations differed between boys and girls. Among boys (n=115), high prenatal BPA concentration (upper tertile vs. lower two tertiles) was associated with increased internalizing (beta=0.41, p<0.0001) and externalizing composite scores (beta=0.40, p<0.0001) and with their corresponding individual syndrome scales. There was a general decrease in scores among girls that was significant for the internalizing composite score (beta=-0.17, p=0.04) (n=135). After accounting for possible selection bias, the results remained consistent for boys. Conversely, high postnatal BPA concentration was associated with increased behaviors on both the internalizing composite (beta=0.30, p=0.0002) and externalizing composite scores (beta=0.33, p<0.0001) and individual subscores in girls but fewer symptoms in boys. These results remained significant in girls after accounting for selection bias. CONCLUSION: These results suggest BPA exposure may affect childhood behavioral outcomes in a sex-specific manner and differently depending on timing of exposure. |
Burden of norovirus in healthcare facilities and strategies for outbreak control
Kambhampati A , Koopmans M , Lopman BA . J Hosp Infect 2015 89 (4) 296-301 Norovirus is the most frequently occurring cause of community-acquired acute gastroenteritis in people of all ages. It is also one of the most frequent causes of outbreaks in healthcare settings, affecting both long-term care facilities and acute care hospitals. Whereas norovirus gastroenteritis is typically mild and resolves without medical attention, healthcare-associated infections often affect vulnerable populations, resulting in severe infections and disruption of healthcare services. Globally, most norovirus outbreaks in hospitals and residential care institutions are associated with genogroup II type 4 (GII.4) strains. Recent data demonstrate that excess mortality occurs during outbreak periods in healthcare facilities. Nosocomial outbreaks can result in large economic and societal costs. Current control measures for norovirus are largely based on general infection control principles, and treatment is mainly supportive and non-specific. While neither vaccines nor antiviral agents are currently available, both are being developed with encouraging results. |
Emergency postexposure vaccination with vesicular stomatitis virus-vectored Ebola vaccine after needlestick.
Lai L , Davey R , Beck A , Xu Y , Suffredini AF , Palmore T , Kabbani S , Rogers S , Kobinger G , Alimonti J , Link CJ Jr , Rubinson L , Stroher U , Wolcott M , Dorman W , Uyeki TM , Feldmann H , Lane HC , Mulligan MJ . JAMA 2015 313 (12) 1249-55 IMPORTANCE: Safe and effective vaccines and drugs are needed for the prevention and treatment of Ebola virus disease, including following a potentially high-risk exposure such as a needlestick. OBJECTIVE: To assess response to postexposure vaccination in a health care worker who was exposed to the Ebola virus. DESIGN AND SETTING: Case report of a physician who experienced a needlestick while working in an Ebola treatment unit in Sierra Leone on September 26, 2014. Medical evacuation to the United States was rapidly initiated. Given the concern about potentially lethal Ebola virus disease, the patient was offered, and provided his consent for, postexposure vaccination with an experimental vaccine available through an emergency Investigational New Drug application. He was vaccinated on September 28, 2014. INTERVENTIONS: The vaccine used was VSVDeltaG-ZEBOV, a replicating, attenuated, recombinant vesicular stomatitis virus (serotype Indiana) whose surface glycoprotein gene was replaced by the Zaire Ebola virus glycoprotein gene. This vaccine has entered a clinical trial for the prevention of Ebola in West Africa. RESULTS: The vaccine was administered 43 hours after the needlestick occurred. Fever and moderate to severe symptoms developed 12 hours after vaccination and diminished over 3 to 4 days. The real-time reverse transcription polymerase chain reaction results were transiently positive for vesicular stomatitis virus nucleoprotein gene and Ebola virus glycoprotein gene (both included in the vaccine) but consistently negative for Ebola virus nucleoprotein gene (not in the vaccine). Early postvaccination cytokine secretion and T lymphocyte and plasmablast activation were detected. Subsequently, Ebola virus glycoprotein-specific antibodies and T cells became detectable, but antibodies against Ebola viral matrix protein 40 (not in the vaccine) were not detected. CONCLUSIONS AND RELEVANCE: It is unknown if VSVDeltaG-ZEBOV is safe or effective for postexposure vaccination in humans who have experienced a high-risk occupational exposure to the Ebola virus, such as a needlestick. In this patient, postexposure vaccination with VSVDeltaG-ZEBOV induced a self-limited febrile syndrome that was associated with transient detection of the recombinant vesicular stomatitis vaccine virus in blood. Strong innate and Ebola-specific adaptive immune responses were detected after vaccination. The clinical syndrome and laboratory evidence were consistent with vaccination response, and no evidence of Ebola virus infection was detected. |
Relationship between Guillain-Barre syndrome, influenza-related hospitalizations, and influenza vaccine coverage
Iqbal S , Li R , Gargiulo P , Vellozzi C . Vaccine 2015 33 (17) 2045-9 Some studies reported an increased risk of Guillain-Barre syndrome (GBS) within six weeks of influenza vaccination. It has also been suggested that this finding could have been confounded by influenza illnesses. We explored the complex relationship between influenza illness, influenza vaccination, and GBS, from an ecologic perspective using nationally representative data. We also studied seasonal patterns for GBS hospitalizations. Monthly hospitalization data (2000-2009) for GBS, and pneumonia and influenza (P&I) in the Nationwide Inpatient Sample were included. Seasonal influenza vaccination coverage for 2004-2005 through the 2008-2009 influenza seasons (August-May) was estimated from the National Health Interview Survey data. GBS seasonality was determined using Poisson regression. GBS and P&I temporal clusters were identified using scan statistics. The association between P&I and GBS hospitalizations in the same month (concurrent) or in the following month (lagged) were determined using negative binomial regression. Vaccine coverage increased over the years (from 19.7% during 2004-2005 to 35.5% during 2008-2009 season) but GBS hospitalization did not follow a similar pattern. Overall, a significant correlation between monthly P&I and GBS hospitalizations was observed (Spearman's correlation coefficient=0.7016, p<0.0001). A significant (p=0.001) cluster of P&I hospitalizations during December 2004-March 2005 overlapped a significant (p=0.001) cluster of GBS hospitalization during January 2005-February 2005. After accounting for effects of monthly vaccine coverage and age, P&I hospitalization was significantly associated (p<0.0001) with GBS hospitalization in the concurrent month but not with GBS hospitalization in the following month. Monthly vaccine coverage was not associated with GBS hospitalization in adjusted models (both concurrent and lagged). GBS hospitalizations demonstrated a seasonal pattern with winter months having higher rates compared to the month of June. P&I hospitalization rates were significantly correlated with hospitalization rates for GBS. Vaccine coverage did not significantly affect the rates of GBS hospitalization at the population level. |
Rotavirus-specific IgG antibodies from mothers' serum may inhibit infant immune responses to the pentavalent rotavirus vaccine
Becker-Dreps S , Vilchez S , Velasquez D , Moon SS , Hudgens MG , Zambrana LE , Jiang B . Pediatr Infect Dis J 2015 34 (1) 115-6 Rotavirus vaccines have lower effectiveness in low and middle income countries (LMICs). One possible explanation is vaccine inhibition by rotavirus-specific antibodies present in mothers’ sera or breast milk. IgG antibodies in maternal sera are transferred through the placenta and may inhibit vaccine-elicited immune responses, as recently reported for the 116E rotavirus vaccine (1). Also, breast milk IgA and neutralizing antibodies (NA) may directly inhibit the oral vaccine upon administration (2,3). Breast milk from LMIC mothers has higher levels of rotavirus-specific antibodies as compared to mothers from high income countries (3,4), indicating a greater potential for inhibition. We examined the association between rotavirus-specific antibodies in maternal sera and breast milk and immunogenicity to the first dose of the pentavalent rotavirus vaccine (RV5, Rotateq®) in respective infants. | Mother-infant pairs were recruited in León, Nicaragua in 2012. Eligibility criteria included: normal birthweight, gestational age > 35 weeks, currently breastfeeding > four times daily, and mother and infant without known immune disorder or blood transfusion. We measured rotavirus-specific antibodies in maternal and infant serum at the time of RV5 immunization, and in infant serum four weeks following the first dose (post-dose 1) by EIA (2,4). Breast milk samples of mothers collected at the time of immunization were assayed for rotavirus-specific IgA and NA (2). For IgA and IgG assays, we started dilutions at 1:10, while for breast milk NA assays, we started dilutions at 1:2. Pre-immunization seropositivity was defined as pre-immunization rotavirus-specific IgA titers > 40 (5). Seroconversion was defined as > four-fold increase in rotavirus-specific IgA titers in the infant between the pre-immunization and post-dose 1 serum samples. Spearman’s rank correlation coefficients were estimated to examine associations between rotavirus-specific IgG antibodies in maternal serum and infant pre-immunization serum. Wilcoxon rank sum tests were used to compare antibody titers between groups. |
Physician response to parental requests to spread out the recommended vaccine schedule
Kempe A , O'Leary ST , Kennedy A , Crane LA , Allison MA , Beaty BL , Hurley LP , Brtnikova M , Jimenez-Zambrano A , Stokley S . Pediatrics 2015 135 (4) 666-77 OBJECTIVES: To assess among US physicians (1) frequency of requests to spread out recommended vaccination schedule for children <2 years, (2) attitudes regarding such requests, and (3) strategies used and perceived effectiveness in response to such requests. METHODS: An e-mail and mail survey of a nationally representative sample of pediatricians and family physicians from June 2012 through October 2012. RESULTS: The response rate was 66% (534 of 815). In a typical month, 93% reported some parents of children <2 years requested to spread out vaccines; 21% reported ≥10% of parents made this request. Most respondents thought these parents were putting their children at risk for disease (87%) and that it was more painful for children (84%), but if they agreed to requests, it would build trust with families (82%); further, they believed that if they did not agree, families might leave their practice (80%). Forty percent reported this issue had decreased their job satisfaction. Most agreed to spread out vaccines when requested, either often/always (37%) or sometimes (37%); 2% would often/always, 4% would sometimes, and 12% would rarely dismiss families from their practice if they wanted to spread out the primary series. Physicians reported using a variety of strategies in response to requests but did not think they were effective. CONCLUSIONS: Virtually all providers encounter requests to spread out vaccines in a typical month and, despite concerns, most are agreeing to do so. Providers are using many strategies in response but think few are effective. Evidence-based interventions to increase timely immunization are needed to guide primary care and public health practice. |
Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis
Drolet M , Benard E , Boily MC , Ali H , Baandrup L , Bauer H , Beddows S , Brisson J , Brotherton JM , Cummings T , Donovan B , Fairley CK , Flagg EW , Johnson AM , Kahn JA , Kavanagh K , Kjaer SK , Kliewer EV , Lemieux-Mellouki P , Markowitz L , Mboup A , Mesher D , Niccolai L , Oliphant J , Pollock KG , Soldan K , Sonnenberg P , Tabrizi SN , Tanton C , Brisson M . Lancet Infect Dis 2015 15 (5) 565-80 BACKGROUND: Human papillomavirus (HPV) vaccination programmes were first implemented in several countries worldwide in 2007. We did a systematic review and meta-analysis to assess the population-level consequences and herd effects after female HPV vaccination programmes, to verify whether or not the high efficacy reported in randomised controlled clinical trials are materialising in real-world situations. METHODS: We searched the Medline and Embase databases (between Jan 1, 2007 and Feb 28, 2014) and conference abstracts for time-trend studies that analysed changes, between the pre-vaccination and post-vaccination periods, in the incidence or prevalence of at least one HPV-related endpoint: HPV infection, anogenital warts, and high-grade cervical lesions. We used random-effects models to derive pooled relative risk (RR) estimates. We stratified all analyses by age and sex. We did subgroup analyses by comparing studies according to vaccine type, vaccination coverage, and years since implementation of the vaccination programme. We assessed heterogeneity across studies using I2 and chi2 statistics and we did trends analysis to examine the dose-response association between HPV vaccination coverage and each study effect measure. FINDINGS: We identified 20 eligible studies, which were all undertaken in nine high-income countries and represent more than 140 million person-years of follow-up. In countries with female vaccination coverage of at least 50%, HPV type 16 and 18 infections decreased significantly between the pre-vaccination and post-vaccination periods by 68% (RR 0.32, 95% CI 0.19-0.52) and anogenital warts decreased significantly by 61% (0.39, 0.22-0.71) in girls 13-19 years of age. Significant reductions were also recorded in HPV types 31, 33, and 45 in this age group of girls (RR 0.72, 95% CI 0.54-0.96), which suggests cross-protection. Additionally, significant reductions in anogenital warts were also reported in boys younger than 20 years of age (0.66 [95% CI 0.47-0.91]) and in women 20-39 years of age (0.68 [95% CI 0.51-0.89]), which suggests herd effects. In countries with female vaccination coverage lower than 50%, significant reductions in HPV types 16 and 18 infection (RR 0.50, 95% CI 0.34-0.74]) and in anogenital warts (0.86 [95% CI 0.79-0.94]) occurred in girls younger than 20 years of age, with no indication of cross-protection or herd effects. INTERPRETATION: Our results are promising for the long-term population-level effects of HPV vaccination programmes. However, continued monitoring is essential to identify any signals of potential waning efficacy or type-replacement. FUNDING: The Canadian Institutes of Health Research. |
Effect of provider prompts on adolescent immunization rates: a randomized trial
Szilagyi PG , Serwint JR , Humiston SG , Rand CM , Schaffer S , Vincelli P , Dhepyasuwan N , Blumkin A , Albertin C , Curtis CR . Acad Pediatr 2015 15 (2) 149-57 OBJECTIVE: Adolescent immunization rates are suboptimal. Experts recommend provider prompts at health care visits to improve rates. We assessed the impact of either electronic health record (EHR) or nurse- or staff-initiated provider prompts on adolescent immunization rates. METHODS: We conducted a randomized controlled trial, allocating practices in 1 of 2 practice-based research networks (PBRN) to provider prompts or standard-of-care control. Ten primary care practices participated, 5 intervention and 5 controls, each matched in pairs on urban, suburban, or rural location and practice type (pediatric or family medicine), from a PBRN in Greater Rochester, New York (GR-PBRN); and 12 practices, 6 intervention, 6 controls, similarly matched, from a national pediatric continuity clinic PBRN (CORNET). The study period was 1 year per practice, ranging from June 2011 to January 2013. Study participants were adolescents 11 to 17 years attending these 22 practices; random sample of chart reviews per practice for baseline and postintervention year to assess immunization rates (n = 7,040 total chart reviews for adolescents with >1 visit in a period). The intervention was an EHR prompt (4 GR-PBRN and 5 CORNET practice pairs) (alert) that appeared on providers' computer screens at all office visits, indicating the specific immunizations that adolescents were recommended to receive. Staff prompts (1 GR-PBRN pair and 1 CORNET pair) in the form of a reminder sheet was placed on the provider's desk in the exam room indicating the vaccines due. We compared immunization rates, stratified by PBRN, for routine vaccines (meningococcus, pertussis, human papillomavirus, influenza) at study beginning and end. RESULTS: Intervention and control practices within each PBRN were similar at baseline for demographics and immunization rates. Immunization rates at the study end for adolescents who were behind on immunizations at study initiation were not significantly different for intervention versus control practices for any vaccine or combination of vaccines. Results were similar for each PBRN and also when only EHR-based prompts was assessed. For example, at study end, 3-dose human papillomavirus vaccination rates for GR-PBRN intervention versus control practices were 51% versus 53% (adjusted odds ratio 0.96; 95% confidence interval 0.64-1.34); CORNET intervention versus control rates were 50% versus 42% (adjusted odds ratio 1.06; 95% confidence interval 0.68-1.88). CONCLUSIONS AND RELEVANCE: In both a local and national setting, provider prompts failed to improve adolescent immunization rates. More rigorous practice-based changes are needed. |
Hepatitis B vaccination among adolescents 13-17 years, United States, 2006-2012
Lu PJ , Yankey D , Jeyarajah J , O'Halloran A , Elam-Evans L , Greby SM , Singleton JA , Murphy TV . Vaccine 2015 33 (15) 1855-64 BACKGROUND: Hepatitis B (HepB) vaccination is the most effective measure to prevent HBV infection. Routine HepB vaccination was recommended for infants in 1991 and catch-up vaccination has been recommended for adolescents since in 1995. The purpose of this study is to assess HepB vaccination among adolescents 13-17 years. METHODS: The 2006-2012 NIS-Teen were analyzed. Vaccination trends and coverage by birth cohort among adolescents were evaluated. Multivariable logistic regression and predictive marginal models are used to identify factors independently associated with HepB vaccination. RESULTS: HepB vaccination coverage increased from 81.3% in 2006 to 92.8% in 2012. Coverage varied by birth cohort and 79-83% received vaccination before 2 years of age for those who were born during 1995 and 1999. Among those who had not received vaccination by 11 years of age, for the 1993-1995 birth cohorts, 9-15% were vaccinated during ages 11-12 years, and 27-37% had been vaccinated through age 16 years. Coverage among adolescents 13-17 years in 2012 ranged by state from 84.4% in West Virginia to 98.7% in Florida (median 93.3%). Characteristics independently associated with a higher likelihood of HepB vaccination included living more than 5 times above poverty level, living in Northeastern or Southern region of the United States, and having a mixed facility as their vaccination provider. Those with a hospital listed as their vaccination provider and those who did not have a well-child visit at age 11-12 years were independently associated with a lower likelihood of HepB vaccination. CONCLUSIONS: Efforts focused on groups with lower coverage may reduce disparities in coverage and prevent hepatitis B infection. Parents and providers should routinely review adolescent immunizations. Routine reminder/recall, expanded access in health care settings, and standing order programs should be incorporated into routine clinical care of adolescents. |
Antibody responses among adolescent females receiving the quadrivalent HPV vaccine series corresponding to standard or non-standard dosing intervals
Russell K , Dunne EF , Kemper AR , Dolor RJ , Unger ER , Panicker G , Markowitz LE , Walter EB . Vaccine 2015 33 (16) 1953-8 Quadrivalent human papillomavirus vaccine (HPV4) is recommended as a 3-dose series administered at 0, 1-2, and 6 months. However, this dosing schedule is often not followed leading to longer dosing intervals. We conducted a prospective study to assess antibody titers to HPV4 when dose 2 and/or dose 3 were administered on schedule or delayed. Healthy females (N=331) aged 9-18 years were enrolled at the time of receipt of HPV4 dose 2 or 3. Participants were classified as belonging to one of four groups depending upon timing of receipt of HPV4: both doses on time; only dose 2 delayed later than 90 days; only dose 3 delayed later than 180 days; or both doses 2 and 3 delayed. Pre- and post-dose 3 blood samples were assayed for HPV antibody titers (types 6, 11, 16, and 18). Post-dose 3 geometric mean titers (GMTs) for all HPV types were not significantly lower for any of the delayed dosing groups when compared to the on time group. When compared to the on time group, the post dose 3 GMTs in the delayed dose 3 group were significantly higher (p<0.05) for HPV types 6, 11, and 16. Our findings suggest that delays of dose 2 or 3 do not interfere with immune responses after completion of the 3-dose series. These results support current recommendations to not administer additional doses of HPV4 vaccine if dose 2, dose 3, or both doses have been administered late. |
Appraising the evidence for public health policy components using the quality and impact of component evidence assessment
Barbero C , Gilchrist S , Schooley MW , Chriqui JF , Luke DA , Eyler AA . Glob Heart 2015 10 (1) 3-11 An essential strategy expected to reduce the global burden of chronic and cardiovascular disease is evidence-based policy. However, it is often unknown what specific components should constitute an evidence-based policy intervention. We have developed an expedient method to appraise and compare the strengths of the evidence bases suggesting that individual components of a policy intervention will contribute to the positive public health impact of that intervention. Using a new definition of "best available evidence," the Quality and Impact of Component (QuIC) Evidence Assessment analyzes dimensions of evidence quality and evidence of public health impact to categorize multiple policy component evidence bases along a continuum of "emerging," "promising impact," "promising quality," and "best." QuIC was recently applied to components from 2 policy interventions to prevent and improve the outcomes of cardiovascular disease: public-access defibrillation and community health workers. Results illustrate QuIC's utility in international policy practice and research. |
Sexual violence victimization and associations with health in a community sample of Hispanic women
Basile KC , Smith SG , Walters ML , Fowler DN , Hawk K , Hamburger ME . J Ethn Cult Divers Soc Work 2015 24 (1) 1-17 This study sought to add to the limited information currently available on circumstances of sexual violence victimization and associated negative health experiences among Hispanic women. Data come from a community sample of mostly Mexican women in an urban southwestern city. Household interviews were completed with a sample of 142 women during 3 months in 2010. Findings indicate that 31.2% of women reported rape victimization and 22.7% reported being sexually coerced in their lifetime. Victims of rape and/or sexual coercion were significantly more likely to report symptoms of depression and post-traumatic stress disorder (PTSD) during their lifetime. Among victims whose first unwanted sexual experience resulted in rape and/or sexual coercion, perpetrators were almost always someone known to the victims, and were mostly family members or intimate partners, depending on the victim’s age. About one-fifth of victims were injured and 17.1% needed medical services. These findings suggest the need for more attention to the physical and mental health needs of sexually victimized Hispanic women. |
Suicidal thoughts and behaviors in children and adolescents with chronic tic disorders
Storch EA , Hanks CE , Mink JW , McGuire JF , Adams HR , Augustine EF , Vierhile A , Thatcher A , Bitsko R , Lewin AB , Murphy TK . Depress Anxiety 2015 32 (10) 744-53 OBJECTIVE: Despite evidence of elevated risk factors for suicidal thoughts and behavior in youth with Tourette syndrome and chronic tic disorders (CTD), few studies have actually examined that relationship. This study documented the frequency and clinical correlates of suicidal thoughts and behaviors in a sample of children and adolescents with CTD (N = 196, range 6-18 years old). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control. METHOD: Youth and parents completed a battery of measures that assessed co-occurring psychiatric diagnoses, child emotional and behavioral symptoms, and impairment due to tics or co-occurring conditions. RESULTS: A structured diagnostic interview identified that 19 youths with CTD (9.7%) experienced suicidal thoughts and/or behaviors, which was elevated compared to 3 youths (3%) who experienced these thoughts in a community control sample (N = 100, range 6-18 years old, P = .03). For youth with CTD, suicidal thoughts and behaviors were frequently endorsed in the context of anger and frustration. The Child Behavior Checklist (CBCL) anxious/depressed, withdrawn, social problems, thought problems, and aggressive behavior subscales, as well as the total internalizing problems scale, were associated with the presence of suicidal thoughts and/or behaviors. Suicidal thoughts and/or behaviors were significantly associated with tic symptom severity; tic-related impairment; and obsessive-compulsive, depressive, anxiety, and attention-deficit/hyperactivity disorders' symptom severity. CBCL anxiety/depression scores mediated the relationship between tic severity and suicidal thoughts and behaviors. CONCLUSIONS: Findings suggest that about 1 in 10 youth with CTD experience suicidal thoughts and/or behaviors, which are associated with a more complex clinical presentation and often occur in the presence of anger and frustration. |
Suicide trends among persons aged 10-24 years - United States, 1994-2012
Sullivan EM , Annest JL , Simon TR , Luo F , Dahlberg LL . MMWR Morb Mortal Wkly Rep 2015 64 (8) 201-5 Suicide is the second leading cause of death among persons aged 10-24 years in the United States and accounted for 5,178 deaths in this age group in 2012. Firearm, suffocation (including hanging), and poisoning (including drug overdose) are the three most common mechanisms of suicide in the United States. Previous reports have noted that trends in suicide rates vary by mechanism and by age group in the United States, with increasing rates of suffocation suicides among young persons. To test whether this increase is continuing and to determine whether it varies by demographic subgroups among persons aged 10-24 years, CDC analyzed National Vital Statistics System mortality data for the period 1994-2012. Trends in suicide rates were examined by sex, age group, race/ethnicity, region of residence, and mechanism of suicide. Results of the analysis indicated that, during 1994-2012, suicide rates by suffocation increased, on average, by 6.7% and 2.2% annually for females and males, respectively. Increases in suffocation suicide rates occurred across demographic and geographic subgroups during this period. Clinicians, hotline staff and others who work with young persons need to be aware of current trends in suffocation suicides in this group so that they can accurately assess risk and educate families. Media coverage of suicide incidents and clusters should follow established guidelines to avoid exacerbating risk for "suicide contagion" among vulnerable young persons.* Suicide contagion is a process by which exposure to the suicide or suicidal behavior of one or more persons influences others who are already vulnerable and thinking about suicide to attempt or die by suicide. Early prevention strategies are needed to reduce the likelihood of young persons developing suicidal thoughts and behavior. |
Teen dating violence (physical and sexual) among US high school students: findings from the 2013 National Youth Risk Behavior Survey
Vagi KJ , O'Malley Olsen E , Basile KC , Vivolo-Kantor AM . JAMA Pediatr 2015 169 (5) 474-82 IMPORTANCE: National estimates of teen dating violence (TDV) reveal high rates of victimization among high school populations. The Centers for Disease Control and Prevention's national Youth Risk Behavior Survey has provided often-cited estimates of physical TDV since 1999. In 2013, revisions were made to the physical TDV question to capture more serious forms of physical TDV and to screen out students who did not date. An additional question was added to assess sexual TDV. OBJECTIVES: To describe the content of new physical and sexual TDV victimization questions first administered in the 2013 national Youth Risk Behavior Survey, to share data on the prevalence and frequency of TDV (including the first-ever published overall "both physical and sexual TDV" and "any TDV" national estimates using these new questions), and to assess associations of TDV experience with health-risk behaviors. DESIGN, SETTING, AND PARTICIPANTS: Secondary data analysis of a cross-sectional survey of 9900 students who dated, from a nationally representative sample of US high school students, using the 2013 national Youth Risk Behavior Survey. MAIN OUTCOMES AND MEASURES: Two survey questions separately assessed physical and sexual TDV; this analysis combined them to create a 4-level TDV measure and a 2-level TDV measure. The 4-level TDV measure includes "physical TDV only," "sexual TDV only," "both physical and sexual TDV," and "none." The 2-level TDV measure includes "any TDV" (either or both physical and sexual TDV) and "none." Sex-stratified bivariate and multivariable analyses assessed associations between TDV and health-risk behaviors. Results: In 2013, among students who dated, 20.9% of female students (95% CI, 19.0%-23.0%) and 10.4% of male students (95% CI, 9.0%-11.7%) experienced some form of TDV during the 12 months before the survey. Female students had a higher prevalence than male students of physical TDV only, sexual TDV only, both physical and sexual TDV, and any TDV. All health-risk behaviors were most prevalent among students who experienced both forms of TDV and were least prevalent among students who experienced none (all P < .001). CONCLUSIONS AND RELEVANCE: The 2013 TDV questions allowed for new prevalence estimates of TDV to be established that represent a more complete measure of TDV and are useful in determining associations with health-risk behaviors among youth exposed to these different forms of TDV. |
The burden of child maltreatment in the East Asia and Pacific region
Fang X , Fry DA , Brown DS , Mercy JA , Dunne MP , Butchart AR , Corso PS , Maynzyuk K , Dzhygyr Y , Chen Y , McCoy A , Swales DM . Child Abuse Negl 2015 42 146-62 This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region's per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region's GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally. |
Evaluating the occurrence of Escherichia albertii in chicken carcass rinses by PCR, Vitek analysis, and sequencing of the rpoB gene.
Lindsey RL , Fedorka-Cray PJ , Abley M , Turpin JB , Meinersmann RJ . Appl Environ Microbiol 2015 81 (5) 1727-34 Escherichia albertii is a recently described species that has been associated with gastroenteritis in humans and with healthy and ill birds. Most recently, it has been identified as the causative agent in a food-borne outbreak in Japan. The distribution and clinical importance of E. albertii are not well studied because its importance is unclear. Culture methods for clinical isolation frequently miss E. albertii or incorrectly identify it as Shigella spp., Escherichia coli, or Hafnia alvei. This study was designed to determine if E. albertii could be recovered from chicken carcass rinses collected at slaughter during a 1-year period from November 2009 until October 2010. Colonies were isolated from chicken carcass rinses and tested by PCR for the presence or absence of clpX, lysP, mdh, intimin (eae), Shiga toxins 1 and 2 (stx1, stx2, and stx2f), heat-stable enterotoxin A (staA), and cytolethal distending toxins 1 and 2 (cdtB) genes. Sixty-five isolates were analyzed by sequencing a section of the rpoB gene. Analysis of the rpoB gene sequences revealed 14 fixed differences between E. albertii and other, closely related organisms. The fixed differences found in the rpoB gene could aid in future discrimination of E. albertii from closely related bacteria. |
DNA sequencing for confirmation of rifampin resistance detected by Cepheid Xpert MTB/RIF assay.
McAlister AJ , Driscoll J , Metchock B . J Clin Microbiol 2015 53 (5) 1752-3 DNA sequencing of rpoB and culture-based drug susceptibility results were evaluated for samples referred for confirmation of rifampin resistance detected by Cepheid Xpert(R) MTB/RIF. Silent mutations and mutations associated with low-level resistance were found in the study population. These data support CDC recommendations to confirm Xpert rifampin resistance results. |
Development of a metabolic biosignature for detection of early lyme disease.
Molins CR , Ashton LV , Wormser GP , Hess AM , Delorey MJ , Mahapatra S , Schriefer ME , Belisle JT . Clin Infect Dis 2015 60 (12) 1767-75 BACKGROUND: Early Lyme disease patients often present to the clinic prior to developing a detectable antibody response to Borrelia burgdorferi, the etiologic agent. Thus, existing two-tier serology-based assays yield low sensitivities (29-40%) for early infection. The lack of an accurate laboratory test for early Lyme disease contributes to misconceptions about diagnosis and treatment, and underscores the need for new diagnostic approaches. METHODS: Retrospective serum samples from patients with early Lyme disease, other diseases, and healthy controls were analyzed for small molecule metabolites by liquid chromatography-mass spectrometry (LC-MS). A metabolomics data workflow was applied to select a biosignature for classifying early Lyme disease and non-Lyme disease patients. A statistical model of the biosignature was trained using the patients' LC-MS data, and subsequently applied as an experimental diagnostic tool with LC-MS data from additional patient sera. The accuracy of this method was compared with standard two-tier serology. RESULTS: Metabolic biosignature development selected 95 molecular features that distinguished early Lyme disease patients from healthy controls. Statistical modeling reduced the biosignature to 44 molecular features, and correctly classified early Lyme disease patients and healthy controls with a sensitivity of 88% (84-95%), and a specificity of 95% (90-100%). Importantly, the metabolic biosignature correctly classified 77-95% of the of serology negative Lyme disease patients. CONCLUSION: The data provide proof-of-concept that metabolic profiling for early Lyme disease can achieve significantly greater (p<0.0001) diagnostic sensitivity than current two-tier serology, while retaining high specificity. |
Serologic cross-reactions between nucleocapsid proteins of human respiratory syncytial virus and human metapneumovirus
Zhang Y , Pohl J , Brooks WA , Erdman DD . J Clin Microbiol 2015 53 (5) 1609-15 Human respiratory syncytial virus (hRSV) and human metapneumovirus (hMPV) share virologic and epidemiologic features and cause clinically similar respiratory illness in predominantly young children. In a previous study of acute febrile respiratory illness in Bangladesh, we tested paired serum specimens from of 852 children presenting fever and cough for diagnostic antibody rises to hRSV and hMPV by enzyme immunoassay (EIA). Unexpectedly, of 93 serum pairs that showed a ≥4-fold antibody rise to hRSV, 24 (25.8%) showed a concurrent rise to hMPV; of 91 pairs showing a rise to hMPV, 13 (14.3%) showed a concurrent rise to hRSV. We speculated that common antigens shared by these viruses could explain this finding. Since the nucleocapsid (N) proteins of these viruses show the greatest sequence homology, we tested hyperimmune antisera prepared to each virus against baculovirus expressed recombinant N (recN) proteins for potential cross-reactivity. The antisera were reciprocally reactive with both proteins. To localize common antigenic regions, we first expressed the carboxy domain of the hMPV N protein that was the most highly conserved region within the hRSV N protein. Although reciprocally reactive with antisera by Western blot, this truncated protein did not react with hMPV IgG positive human sera by EIA. Using 5 synthetic peptides that spanned the amino-terminal portion of the hMPV N protein, we identified a single peptide that was cross-reactive with human sera positive for either virus. Antiserum prepared to this peptide was reactive with recN proteins of both viruses, indicating that a common immunoreactive site exists in this region. |
MDSC and TGF-beta are required for facilitation of tumor growth in the lungs of mice exposed to carbon nanotubes
Shvedova AA , Kisin ER , Yanamala N , Tkach AV , Gutkin DW , Star A , Shurin GV , Kagan VE , Shurin MR . Cancer Res 2015 75 (8) 1615-23 During last decades, changes have been observed in the frequency of different histological subtypes of lung cancer - one of the most common causes of morbidity and mortality - with a declining proportion of squamous cell carcinomas and an increasing proportion of adenocarcinomas, particularly in developed countries. This suggests the emergence of new etiological factors and mechanisms including those defining the lung microenvironment promoting tumor growth. Assuming that the lung is the main portal of entry for broadly used nanomaterials and their established pro-inflammatory propensities, we hypothesized that nanomaterials may contribute to changes facilitating tumor growth. Here we report that an acute exposure to single-walled carbon nanotubes (SWCNT) induces recruitment and accumulation of lung-associated myeloid-derived suppressor cells (MDSC) and MDSC-derived production of TGF-beta resulting in up-regulated tumor burden in the lung. The production of TGF-beta by MDSC requires their interaction with both SWCNT and tumor cells. We conclude that pulmonary exposure to SWCNT favors the formation of a niche that supports ingrowth of lung carcinoma in vivo via activation of TGF-beta production by SWCNT-attracted and pre-sensitized MDSC. |
Neuraminidase mutations conferring resistance to oseltamivir in influenza A(H7N9) viruses
Marjuki H , Mishin VP , Chesnokov AP , De La Cruz JA , Davis CT , Villanueva JM , Fry AM , Gubareva LV . J Virol 2015 89 (10) 5419-26 Human infections by avian influenza A(H7N9) virus entail substantial morbidity and mortality. Treatment of infected patients with the neuraminidase (NA) inhibitor oseltamivir was associated with emergence of viruses carrying NA substitutions. In the NA inhibition (NI) assay, R292K conferred highly reduced inhibition by oseltamivir, while E119V and I222K each caused reduced inhibition. To facilitate establishment of laboratory correlates of clinically relevant resistance, experiments were conducted in ferrets infected with virus carrying wild-type or variant NA genes recovered from the A/Taiwan/1/2013 isolate. Oseltamivir treatment (5 or 25 mg/kg/dose) was given 4 hours post-infection followed by twice daily treatment for 5 days. Treatment of ferrets infected with wild-type virus resulted in a modest dose-dependent reduction (0.7-1.5 log10TCID50) in nasal wash viral titers and inflammation response. Conversely, treatment failed to significantly inhibit the replication of R292K or E119V viruses. A small reduction of viral titers was detected on day 5 in ferrets infected with the I222K virus. Propensity for oseltamivir resistance emergence was assessed in oseltamivir-treated animals infected with wild-type virus; emergence of R292K virus was detected in 3 of 6 ferrets within 5-7 days post-infection. Collectively, we demonstrate that R292K, E119V and I222K reduced the inhibitory activity of oseltamivir not only in the NI assay, but also in infected ferrets, judged particularly by viral loads in nasal washes, and may signal the need for alternative therapeutics. Thus, these clinical outcomes measured in the ferret model may correlate with clinically relevant oseltamivir resistance in humans. IMPORTANCE: This report provides more evidence for using the ferret model to assess susceptibility of influenza A(H7N9) viruses to oseltamivir, the most prescribed anti-influenza drug. The information gained can be used to assist in the establishment of laboratory correlates of human disease and drug therapy. The rapid emergence of viruses with R292K in treated ferrets correlates well with the multiple reports on this NA variant in treated human patients. Our findings highlight the importance for discovery and characterization of new antiviral drugs with different mechanism of action and the use of combination treatment strategies against emerging viruses with pandemic potential such as avian H7N9 virus, particularly against those carrying drug resistance markers. |
Performance of rapid influenza diagnostic tests (QuickVue) for influenza A and B infection in India
Koul PA , Mir H , Bhat MA , Khan UH , Khan MM , Chadha MS , Lal RB . Indian J Med Microbiol 2015 33 Suppl S26-31 BACKGROUND: Rapid point-of-care (POC) tests provide an economical alternative for rapid diagnosis and treatment of influenza, especially in public health emergency situations. OBJECTIVES: To test the performance of a rapid influenza diagnostic test, QuickVue (Quidel) as a POC test against a real-time polymerase chain reaction (RT-PCR) assay for detection of influenza A and B in a developing country setting. STUDY DESIGN: In a prospective observational design, 600 patients with influenza-like illness (ILI) or with severe acute respiratory illness (SARI) who were referred to the Influenza Clinic of a tertiary care hospital in Srinagar, India from September 2012 to April 2013, were enrolled for diagnostic testing for influenza using QuickVue or RT-PCR. All influenza A-positive patients by RT-PCR were further subtyped using primers and probes for A/H1pdm09 and A/H3. RESULTS: Of the 600 patients, 186 tested positive for influenza A or B by RT-PCR (90 A/H1N1pdm09, 7 A/H3 and 89 influenza B), whereas only 43 tested positive for influenza (influenza A = 22 and influenza B = 21) by QuickVue. Thus, the sensitivity of the QuickVue was only 23% (95% confidence interval, CI: 17.3-29.8) and specificity was 100% (95% CI: 99.1-100) with a positive predictive value (PPV) of 100% (95% CI 91.8-100) and a negative predictive value (NPV) of 74.3% (95% CI: 70.5-77.9) as compared to RT-PCR. CONCLUSIONS: The high specificity of QuickVue suggest that this POC test can be a useful tool for patient management or triaging during a public health crisis but a low sensitivity suggests that a negative test result need to be further tested using RT-PCR. |
Effect of interferents on the performance of direct-reading organic vapor monitors
LeBouf RF , Coffey CC . J Air Waste Manag Assoc 2015 65 (3) 261 Direct-reading organic vapor monitors are often used to measure volatile organic compound concentrations in complex chemical gas mixtures. However, there is a paucity of data on the impact of multiple gases on monitor performance, even though it is known that monitor sensitivity may vary by chemical. This study investigated the effects of interferents on the performance of the MIRAN SapphIRe Portable Ambient Air Analyzer (SAP) and Century Portable Toxic Vapor Analyzer (TVA-1000) when sampling a specific agent of interest (cyclohexane). The TVA-1000 contained a dual detector: a photoionization detector (PID) and a flame ionization detector (FID). Three devices of each monitor were challenged with different combinations of cyclohexane and potential interferent vapors (hexane, methyl ethyl ketone, trichloroethylene, and toluene) at 21°C and 90% relative humidity (RH), an extreme environmental condition. Five replicates at four target concentrations were tested: 30, 150, 300, and 475 ppm. Multiple proportions of cyclohexane to interferent enabled the determination of the interferent effect on monitor performance. The monitor concentrations were compared to reference concentrations measured using NIOSH Method 1500. Three scenarios were investigated: no response factor, cyclohexane response factor, and weighted-mixed response factor applied. False negatives occurred more frequently for PID (21.1%), followed by FID (4.8%) and SAP (0.2%). Measurements from all monitors generally had a positive bias compared to the reference measurements. Some monitor measurements exceeded twice the reference concentrations: PID (36.8%), SAP (19.8%), and FID (6.3%). Evaluation of the 95% confidence intervals indicated that performance of all monitors varied by concentration. In addition, the performance of the PID and SAP varied by presence of an interfering compound, especially toluene and hexane for the PID and trichloroethylene for the SAP. Variability and bias associated with all these monitors preclude supplanting traditional sorbent-based tube methods for measuring volatile organic compounds (VOCs), especially for compliance monitoring. Industrial hygienists need to use care when using any of the three monitor detection types to measure the concentration of unknown chemical mixtures. Monitor performance is affected by the presence of interferents. Application of manufacturer recommended response factors may not adequately scale measurements to minimize monitor bias when compared to standard reference methods. Users should calibrate their monitors to a known reference method prior to use, if possible. Each of the monitors has its own limitations, which should be considered to ensure quality measurements are reported. |
Evaluation of the dark-medium objective lens in counting asbestos fibers by phase-contrast microscopy
Lee EG , Nelson JH , Kashon ML , Harper M . Ann Occup Hyg 2015 59 (5) 616-28 A Japanese round-robin study revealed that analysts who used a dark-medium (DM) objective lens reported higher fiber counts from American Industrial Hygiene Association (AIHA) Proficiency Analytical Testing (PAT) chrysotile samples than those using a standard objective lens, but the cause of this difference was not investigated at that time. The purpose of this study is to determine any major source of this difference by performing two sets of round-robin studies. For the first round-robin study, 15 AIHA PAT samples (five each of chrysotile and amosite generated by water-suspended method, and five chrysotile generated by aerosolization method) were prepared with relocatable cover slips and examined by nine laboratories. A second round-robin study was then performed with six chrysotile field sample slides by six out of nine laboratories who participated in the first round-robin study. In addition, two phase-shift test slides to check analysts' visibility and an eight-form diatom test plate to compare resolution between the two objectives were examined. For the AIHA PAT chrysotile reference slides, use of the DM objective resulted in consistently higher fiber counts (1.45 times for all data) than the standard objective (P-value < 0.05), regardless of the filter generation (water-suspension or aerosol) method. For the AIHA PAT amosite reference and chrysotile field sample slides, the fiber counts between the two objectives were not significantly different. No statistically significant differences were observed in the visibility of blocks of the test slides between the two objectives. Also, the DM and standard objectives showed no pattern of differences in viewing the fine lines and/or dots of each species images on the eight-form diatom test plate. Among various potential factors that might affect the analysts' performance of fiber counts, this study supports the greater contrast caused by the different phase plate absorptions as the main cause of high counts for the AIHA PAT chrysotile slides using the DM objective. The comparison of fiber count ratios (DM/standard) between the AIHA PAT chrysotile samples and chrysotile field samples indicates that there is a fraction of fibers in the PAT samples approaching the theoretical limit of visibility of the phase-contrast microscope with 3-degree phase-shift. These fibers become more clearly visible through the greater contrast from the phase plate absorption of the DM objective. However, as such fibers are not present in field samples, no difference in counts between the two objectives was observed in this study. The DM objective, therefore, could be allowed for routine fiber counting as it will maintain continuity with risk assessments based on earlier phase-contrast microscopy fiber counts from field samples. Published standard methods would need to be modified to allow a higher aperture specification for the objective. |
Field assessment of dried Plasmodium falciparum samples for malaria rapid diagnostic test quality control and proficiency testing in Ethiopia
Tamiru A , Boulanger L , Chang MA , Malone JL , Aidoo M . Malar J 2015 14 (1) 11 BACKGROUND: Rapid diagnostic tests (RDTs) are now widely used for laboratory confirmation of suspected malaria cases to comply with the World Health Organization recommendation for universal testing before treatment. However, many malaria programmes lack quality control (QC) processes to assess RDT use under field conditions. Prior research showed the feasibility of using the dried tube specimen (DTS) method for preserving Plasmodium falciparum parasites for use as QC samples for RDTs. This study focused on the use of DTS for RDT QC and proficiency testing under field conditions. METHODS: DTS were prepared using cultured P. falciparum at densities of 500 and 1,000 parasites/ inverted question markL; 50 inverted question markL aliquots of these along with parasite negative human blood controls (0 parasites/ inverted question markL) were air-dried in specimen tubes and reactivity verified after rehydration. The DTS were used in a field study in the Oromia Region of Ethiopia. Replicate DTS samples containing 0, 500 and 1,000 parasites/ inverted question markL were stored at 4 degrees C at a reference laboratory and at ambient temperatures at two nearby health facilities. At weeks 0, 4, 8, 12, 16, 20, and 24, the DTS were rehydrated and tested on RDTs stored under manufacturer-recommended temperatures at the RL and on RDTs stored under site-specific conditions at the two health facilities. Reactivity of DTS stored at 4 degrees C at the reference laboratory on RDTs stored at the reference laboratory was considered the gold standard for assessing DTS stability. A proficiency-testing panel consisting of one negative and three positive samples, monitored with a checklist was administered at weeks 12 and 24. RESULTS: At all the seven time points, DTS stored at both the reference laboratory and health facility were reactive on RDTs stored under the recommended temperature and under field conditions, and the DTS without malaria parasites were negative. At the reference laboratory and one health facility, a 500 parasites/ inverted question markL DTS from the proficiency panel was falsely reported as negative at week 24 due to errors in interpreting faint test lines. CONCLUSIONS: The DTS method can be used under field conditions to supplement other RDT QC methods and health worker proficiency in Ethiopia and possibly other malaria-endemic countries. |
Inactivated polio vaccination using a microneedle patch is immunogenic in the rhesus macaque
Edens C , Dybdahl-Sissoko NC , Weldon WC , Oberste MS , Prausnitz MR . Vaccine 2015 33 (37) 4683-90 The phased replacement of oral polio vaccine (OPV) with inactivated polio vaccine (IPV) is expected to significantly complicate mass vaccination campaigns, which are an important component of the global polio eradication endgame strategy. To simplify mass vaccination with IPV, we developed microneedle patches that are easy to administer, have a small package size, generate no sharps waste and are inexpensive to manufacture. When administered to rhesus macaques, neutralizing antibody titers were equivalent among monkeys vaccinated using microneedle patches and conventional intramuscular injection for IPV types 1 and 2. Serologic response to IPV type 3 vaccination was weaker after microneedle patch vaccination compared to intramuscular injection; however, we suspect the administered type 3 dose was lower due to a flawed pre-production IPV type 3 analytical method. IPV vaccination using microneedle patches was well tolerated by the monkeys. We conclude that IPV vaccination using a microneedle patch is immunogenic in rhesus macaques and may offer a simpler method of IPV vaccination of people to facilitate polio eradication. |
Acute inflammatory responses of nanoparticles in an intra-tracheal instillation rat model
Armstead AL , Minarchick VC , Porter DW , Nurkiewicz TR , Li B . PLoS One 2015 10 (3) e0118778 Exposure to hard metal tungsten carbide cobalt (WC-Co) "dusts" in enclosed industrial environments is known to contribute to the development of hard metal lung disease and an increased risk for lung cancer. Currently, the influence of local and systemic inflammation on disease progression following WC-Co exposure remains unclear. To better understand the relationship between WC-Co nanoparticle (NP) exposure and its resultant effects, the acute local pulmonary and systemic inflammatory responses caused by WC-Co NPs were explored using an intra-tracheal instillation (IT) model and compared to those of CeO2 (another occupational hazard) NP exposure. Sprague-Dawley rats were given an IT dose (0-500 mug per rat) of WC-Co or CeO2 NPs. Following 24-hr exposure, broncho-alveolar lavage fluid and whole blood were collected and analyzed. A consistent lack of acute local pulmonary inflammation was observed in terms of the broncho-alveolar lavage fluid parameters examined (i.e. LDH, albumin, and macrophage activation) in animals exposed to WC-Co NP; however, significant acute pulmonary inflammation was observed in the CeO2 NP group. The lack of acute inflammation following WC-Co NP exposure contrasts with earlier in vivo reports regarding WC-Co toxicity in rats, illuminating the critical role of NP dose and exposure time and bringing into question the potential role of impurities in particle samples. Further, we demonstrated that WC-Co NP exposure does not induce acute systemic effects since no significant increase in circulating inflammatory cytokines were observed. Taken together, the results of this in vivo study illustrate the distinct differences in acute local pulmonary and systemic inflammatory responses to NPs composed of WC-Co and CeO2; therefore, it is important that the outcomes of pulmonary exposure to one type of NPs may not be implicitly extrapolated to other types of NPs. |
Bacterial enteric infections detected by culture-independent diagnostic tests - FoodNet, United States, 2012-2014
Iwamoto M , Huang JY , Cronquist AB , Medus C , Hurd S , Zansky S , Dunn J , Woron AM , Oosmanally N , Griffin PM , Besser J , Henao OL . MMWR Morb Mortal Wkly Rep 2015 64 (9) 252-7 The increased availability and rapid adoption of culture-independent diagnostic tests (CIDTs) is moving clinical detection of bacterial enteric infections away from culture-based methods. These new tests do not yield isolates that are currently needed for further tests to distinguish among strains or subtypes of Salmonella, Campylobacter, Shiga toxin-producing Escherichia coli, and other organisms. Public health surveillance relies on this detailed characterization of isolates to monitor trends and rapidly detect outbreaks; consequently, the increased use of CIDTs makes prevention and control of these infections more difficult. During 2012-2013, the Foodborne Diseases Active Surveillance Network (FoodNet*) identified a total of 38,666 culture-confirmed cases and positive CIDT reports of Campylobacter, Salmonella, Shigella, Shiga toxin-producing E. coli, Vibrio, and Yersinia. Among the 5,614 positive CIDT reports, 2,595 (46%) were not confirmed by culture. In addition, a 2014 survey of clinical laboratories serving the FoodNet surveillance area indicated that use of CIDTs by the laboratories varied by pathogen; only CIDT methods were used most often for detection of Campylobacter (10%) and STEC (19%). Maintaining surveillance of bacterial enteric infections in this period of transition will require enhanced surveillance methods and strategies for obtaining bacterial isolates. |
Corticosterone primes the neuroinflammatory response to DFP in mice: potential animal model of Gulf War illness
O'Callaghan JP , Kelly KA , Locker AR , Miller DB , Lasley SM . J Neurochem 2015 133 (5) 708-21 Gulf War Illness (GWI) is a multi-symptom disorder with features characteristic of persistent sickness behavior. Among conditions encountered in the GW theater were physiological stressors (e.g., heat/cold/physical activity/sleep deprivation), prophylactic treatment with the reversible AChE inhibitor, pyridostigmine bromide (PB), the insect repellent, DEET, and potentially the nerve agent, sarin. Prior exposure to the anti-inflammatory glucocorticoid, CORT, at levels associated with high physiological stress, can paradoxically prime the CNS to produce a robust proinflammatory response to neurotoxicants and systemic inflammation; such neuroinflammatory effects can be associated with sickness behavior. Here, we examined whether CORT primed the CNS to mount neuroinflammatory responses to GW exposures as a potential model of GWI. Male C57BL/6 mice were treated with chronic (14d) PB/DEET, subchronic (7-14d) CORT, and acute exposure (day 15) to diisopropyl fluorophosphate (DFP), a sarin surrogate and irreversible AChE inhibitor. DFP alone caused marked brain-wide neuroinflammation assessed by qPCR of TNF-alpha, IL6, CCL2, IL-1beta, LIF and OSM. Pretreatment with high physiological levels of CORT greatly augmented (up to 300-fold) the neuroinflammatory responses to DFP. Anti-inflammatory pretreatment with minocycline suppressed many proinflammatory responses to CORT+DFP. Our findings are suggestive of a possible critical, yet unrecognized interaction between the stressor/environment of the GW theater and agent exposure(s) unique to this war. Such exposures may in fact prime the CNS to amplify future neuroinflammatory responses to pathogens, injury or toxicity. Such occurrences could potentially result in the prolonged episodes of sickness behavior observed in GWI. |
Determination of toxic metals in little cigar tobacco with 'triple quad' ICP-MS
Pappas RS , Martone N , Gonzalez-Jimenez N , Fresquez MR , Watson CH . J Anal Toxicol 2015 39 (5) 347-52 Smoking remains the leading cause of preventable death in the USA. Much of the focus on harmful and potentially harmful constituents (HPHCs) in tobacco products has been on cigarettes. Little cigars gained popularity over the last decade until tobacco taxes made cigarettes more expensive in the USA. Many little cigar brands are similar in size with cigarettes and may be smoked in a similar manner. Scant data are available on HPHC concentrations in little cigars, therefore we developed and applied a new analytical method to determine concentrations of 10 toxic metals in little cigar tobacco. The method utilizes 'triple quadrupole' ICP-MS. By optimizing octapole bias, energy discrimination and cell gas flow settings, we were able to accurately quantify a range of elements including those for which the cell gas reactions were endothermic. All standard modes (Single Quad No Gas, MS-MS NH3/He and MS-MS O2) were utilized for the quantitation of 10 toxic metals in little cigar tobacco, including uranium, which was added as an analyte in the new method. Because of the elimination of interfering ions at 'shifted analyte masses', detection limits were lower compared with a previous method. Tobacco selenium concentrations were below the limit of detection in the previous method, but the new technology made it possible to report all selenium concentrations. |
Stressful life events experienced by women in the year before their infants' births - United States, 2000-2010
Burns ER , Farr SL , Howards PP . MMWR Morb Mortal Wkly Rep 2015 64 (9) 247-51 Epidemiologic studies suggest that prenatal stress is associated with preterm birth, low birth weight, and peripartum anxiety and depressive symptoms. The most recent population-based study, assessing trends in stress experienced in the year before an infant's birth, used 1990-1995 data from 11 states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). That study found that 64% of women surveyed reported experiencing at least one stressful life event (SLE), although the prevalence declined slightly over the study period. PRAMS data for 2000-2010 were used to examine more recent trends and to determine if the prevalence of SLEs has continued to decrease in the past decade. Additionally, 2010 data were used to determine the extent that maternal demographics and state of residence are associated with SLEs. This report describes the results of those analyses, which found that most women in the sample reported experiencing ≥1 SLEs in the year before their infant's birth, although the prevalence of experiencing SLEs decreased during 2000-2010. In 2010, based on data from 27 states, 70.2% of women reported ≥1 SLEs. The mean number of SLEs was 1.81, ranging from 1.41 in New York City to 2.26 in Oklahoma. SLEs were most frequently financial. Prevalence of SLEs varied by PRAMS reporting site and maternal demographics. Younger, less educated, unmarried, and Medicaid-covered women had the highest prevalence of SLEs. Public health practitioners and clinicians can use the information on trends and risk factors for SLEs to determine the likelihood that pregnant women might benefit from screening for stressors during pregnancy. |
Trends in parent-reported emotional and behavioral problems among children using special education services
Pastor PN , Reuben CA . Psychiatr Serv 2015 66 (6) 656-9 OBJECTIVE: This report describes trends in health conditions reported by parents as the limitations leading to special education services for their children. METHODS: Data are reported for children ages 6-17 (N=182,998) surveyed in households in the 2001-2012 National Health Interview Survey. RESULTS: Between 2001 and 2012, the overall percentage of U.S. children ages 6-17 who were receiving special education services increased from 7.2% to 8.7%. Between 2001 and 2012, the leading causes of activity limitations among children receiving special education services included emotional or behavioral problems, which increased from 36% to 43%; speech problems, which increased from 16% to 22%; and learning disability, which decreased from 41% to 27%. There were no significant trends in any of the other conditions considered as possible sources of activity limitations. CONCLUSIONS: Emotional and behavioral problems have become the most frequently reported source of activity limitations among children receiving special education services. |
Urinary phthalate metabolite concentrations and blood glucose levels during pregnancy
Robledo CA , Peck JD , Stoner J , Calafat AM , Carabin H , Cowan L , Goodman JR . Int J Hyg Environ Health 2015 218 (3) 324-30 PURPOSE: To examine associations between phthalate metabolite urinary concentrations during early pregnancy and blood glucose levels obtained at the time of screening for gestational diabetes mellitus (GDM). METHODS: Upon initiation of prenatal care, women with a mean gestational age of 12.8 weeks were recruited for a study of environmental chemical exposures (n=110) and provided a spot urinary specimen. Blood glucose concentrations (mg/dl) were obtained from the electronic medical record for those patients who did not experience a pregnancy loss and did not transfer care to another facility prior to glucose screening (n=72). Urinary concentrations of nine phthalate metabolites and creatinine were measured at the US Centers for Disease Control and Prevention. Associations between tertiles of phthalate metabolites concentrations and blood glucose levels were estimated using linear regression. RESULTS: Compared to pregnant women in the lowest concentration tertile, women with the highest urinary concentrations (≥3rd tertile) of mono-iso-butyl phthalate (tertile: ≥15.3mug/l, beta=-18.3, 95% CI: -35.4, -1.2) and monobenzyl phthalate (tertile: ≥30.3mug/l, beta=-17.3, 95% CI: -34.1, -0.4) had lower blood glucose levels at the time of GDM screening after adjustment for urinary creatinine and demographic covariates. CONCLUSION: Because maternal glucose levels increase during pregnancy to provide adequate nutrition for fetal growth and development, these findings may have implications for fetal health. However, given the limitations of our study, findings should be interpreted cautiously. |
Urinary phthalate metabolites in relation to maternal serum thyroid and sex hormone levels during pregnancy: a longitudinal analysis
Johns LE , Ferguson KK , Soldin OP , Cantonwine DE , Rivera-Gonzalez LO , Del Toro LV , Calafat AM , Ye X , Alshawabkeh AN , Cordero JF , Meeker JD . Reprod Biol Endocrinol 2015 13 4 BACKGROUND: Increasing scientific evidence suggests that exposure to phthalates during pregnancy may be associated with an elevated risk of adverse reproductive outcomes such as preterm birth. Maternal endocrine disruption across pregnancy may be one pathway mediating some of these relationships. We investigated whether urinary phthalate metabolites were associated with maternal serum thyroid (free thyroxine [FT4], free triiodothyronine [FT3], and thyroid-stimulating hormone [TSH]), and sex (estradiol, progesterone, and sex hormone-binding globulin [SHBG]) hormone levels at multiple time points during pregnancy. METHODS: Preliminary data (n = 106) were obtained from an ongoing prospective birth cohort in Northern Puerto Rico. We collected urine and serum sample at the first and third study visits that occurred at 18 +/- 2 and 26 +/- 2 weeks of gestation, respectively. To explore the longitudinal relationships between urinary phthalate metabolites and serum thyroid and sex hormone concentrations, we used linear mixed models (LMMs) adjusted for prepregnancy body mass index (BMI) and maternal age. An interaction term was added to each LMM to test whether the effect of urinary phthalate metabolites on serum thyroid and sex hormone levels varied by study visit. In cross-sectional analyses, we stratified BMI- and age-adjusted linear regression models by study visit. RESULTS: In adjusted LMMs, we observed significant inverse associations between mono-3-carboxypropyl phthalate (MCPP) and FT3 and between mono-ethyl phthalate (MEP) and progesterone. In cross-sectional analyses by study visit, we detected stronger and statistically significant inverse associations at the third study visit between FT3 and MCPP as well as mono-carboxyisooctyl phthalate (MCOP); also at the third study visit, significant inverse associations were observed between FT4 and metabolites of di-(2-ethylhexyl) phthalate (DEHP). The inverse association between MEP and progesterone was consistent across study visits. CONCLUSIONS: In this group of pregnant women, urinary phthalate metabolites may be associated with altered maternal serum thyroid and sex hormone levels, and the magnitude of these effects may depend on the timing of exposure during gestation. |
Methods for surveillance of fetal alcohol syndrome: the Fetal Alcohol Syndrome Surveillance Network II (FASSNetII) - Arizona, Colorado, New York, 2009 - 2014
O'Leary LA , Ortiz L , Montgomery A , Fox DJ , Cunniff C , Ruttenber M , Breen A , Pettygrove S , Klumb D , Druschel C , Frias JL , Robinson LK , Bertrand J , Ferrara K , Kelly M , Gilboa SM , Meaney FJ . Birth Defects Res A Clin Mol Teratol 2015 103 (3) 196-202 Surveillance of fetal alcohol syndrome (FAS) is important for monitoring the effects of prenatal alcohol exposure and describing the public health burden of this preventable disorder. Building on the infrastructure of the Fetal Alcohol Syndrome Surveillance Network (FASSNet, 1997-2002), in 2009 the Centers for Disease Control and Prevention awarded 5-year cooperative agreements to three states, Arizona, Colorado, and New York, to conduct population-based surveillance of FAS. The Fetal Alcohol Syndrome Surveillance Network II (FASSNetII, 2009-2014) developed a surveillance case definition based on three clinical criteria: characteristic facial features, central nervous system abnormalities, and growth deficiency. FASSNetII modified the FASSNet methods in three important ways: (1) estimation of a period prevalence rather than birth prevalence; (2) surveillance of FAS among school-age children (ages 7-9 years) to better document the central nervous system abnormalities that are not apparent at birth or during infancy; and (3) implementation of an expert clinical review of abstracted data for probable and confirmed cases classified through a computerized algorithm. FASSNetII abstracted data from multiple sources including birth records, medical records from child development centers or other specialty clinics, and administrative databases such as hospital discharge and Medicaid. One challenge of FASSNetII was its limited access to non-medical records. The FAS prevalence that could be estimated was that of the population identified through an encounter with the healthcare system. Clinical and public health programs that identify children affected by FAS provide critical information for targeting preventive, medical and educational services in this vulnerable population. |
Oral and intramuscular treatment options for early postpartum endometritis in low-resource settings: a systematic review
Meaney-Delman D , Bartlett LA , Gravett MG , Jamieson DJ . Obstet Gynecol 2015 125 (4) 789-800 OBJECTIVE: To suggest options for oral and intramuscular antibiotic treatment of early postpartum endometritis in low-resource community settings where intravenous antibiotics are unavailable. DATA SOURCES: Studies were identified through MEDLINE from inception through December 2014. Search terms included [("anti-bacterial agents [MeSH]" or "anti-infective agents [MeSH]") and ("endometritis [MeSH]" or "puerperal infection [MeSH]")]. A second search using the terms [("endometritis or endomyometritis or puerperal infection) and (antibiotics or antimicrobials or anti-bacterial agents or anti-infective agents)"] was also used. Additionally, all references from selected articles were reviewed, a hand-search of a subject matter expert library was conducted, and a search of ClinicalTrials.gov was performed. METHODS OF STUDY SELECTION: We conducted a systematic review of the literature in two phases. Phase I provides a summary of clinical cure data from prospective studies of oral and intramuscular antimicrobial regimens as well as summarizes evidence from trials of intravenous antimicrobials. Phase II is a quantitative analysis of pathogens from intrauterine postpartum endometritis samples. Based on these results, and with consideration of existing recommendations for antibiotic use during breastfeeding, we suggest oral and intramuscular antimicrobial options for the treatment of early postpartum endometritis after vaginal delivery in low-resource settings. TABULATION, INTEGRATION, AND RESULTS: Reports involving oral or intramuscular antimicrobial treatment of postpartum endometritis are rare and of generally poor quality. Antimicrobial trials of postpartum endometritis treatment and intrauterine microbiology studies suggest five antimicrobial regimens may be effective: oral clindamycin plus intramuscular gentamicin, oral amoxicillin-clavulanate, intramuscular cefotetan, intramuscular meropenem or imipenem-cilastatin, and oral amoxicillin in combination with oral metronidazole. CONCLUSION: This review provides suggestions for oral, intramuscular, and combined antimicrobial regimens that may warrant additional study. Experimental trials should consider clinical effectiveness, safety and side effects profiles, and feasibility of community-based treatment. |
Perinatal disparities between American Indians and Alaska Natives and other US populations: comparative changes in fetal and first day mortality, 1995-2008
Wingate MS , Barfield WD , Smith RA , Petrini J . Matern Child Health J 2015 19 (8) 1802-12 To compare fetal and first day outcomes of American Indian and Alaskan Natives (AIAN) with non-AIAN populations. Singleton deliveries to AIAN and non-AIAN populations were selected from live birth-infant death cohort and fetal deaths files from 1995-1998 and 2005-2008. We examined changes over time in maternal characteristics of deliveries and disparities and changes in risks of fetal, first day (<24 h), and cause-specific deaths. We calculated descriptive statistics, odds ratios and confidence intervals, and ratio of odds ratios (RORs) to indicate changes in disparities. Along with black mothers, AIANs exhibited the highest proportion of risk factors including the highest proportion of diabetes in both time periods (4.6 and 6.5 %). Over time, late fetal death for AIANs decreased 17 % (aOR = 0.83, 95 % CI 0.72-0.97), but we noted a 47 % increased risk over time for Hispanics (aOR = 1.47, 95 % CI 1.40-1.55). Our data indicated no change over time among AIANs for first day death. For AIANs compared to whites, increased risks and disparities persisted for mortality due to congenital anomalies (ROR = 1.28, 95 % CI 1.03-1.60). For blacks compared to AIANs, the increased risks of fetal death (2005-2008: aOR = 0.60, 95 % CI 0.53-0.68) persisted. For Hispanics, lower risks compared to AIANs persisted, but protective effect declined over time. Disparities between AIAN and other groups persist, but there is variability by race/ethnicity in improvement of perinatal outcomes over time. Variability in access to care and pregnancy management should be considered in relation to health equity for fetal and early infant deaths. |
Prevalence and characteristics associated with gestational weight gain adequacy
Deputy NP , Sharma AJ , Kim SY , Hinkle SN . Obstet Gynecol 2015 125 (4) 773-781 OBJECTIVE: To estimate the prevalence of gestational weight gain adequacy according to the 2009 Institute of Medicine recommendations and examine demographic, behavioral, psychosocial, and medical characteristics associated with inadequate and excessive gain stratified by prepregnancy body mass index (BMI) category. METHODS: We used cross-sectional, population-based data on women delivering full-term (37 weeks of gestation or greater), singleton neonates in 28 states who participated in the 2010 or 2011 Pregnancy Risk Assessment Monitoring System. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for inadequate and excessive compared with adequate gain, stratified by prepregnancy BMI. RESULTS: Overall, 20.9%, 32.0%, and 47.2% of women gained inadequate, adequate, and excessive gestational weight, respectively. Prepregnancy BMI was strongly associated with weight gain outside recommendations. Compared with normal-weight women (prevalence 51.8%), underweight women (4.2%) had decreased odds of excessive gain (adjusted OR 0.50, CI 0.40-0.61), whereas overweight and obese class I, II, and III (23.6%, 11.7%, 5.4%, and 3.5%, respectively) women had increased odds of excessive gain (adjusted OR range 2.07, CI 1.63-2.62 to adjusted OR 2.99, CI 2.63-3.40). Underweight and obese class II and III women had increased odds of inadequate gain (adjusted OR 1.25, CI 1.01-1.55 to 1.86, CI 1.45-2.36). Most characteristics associated with weight gain adequacy were demographic such as racial or ethnic minority status and education and varied by prepregnancy BMI. Notably, one behavioral characteristic-smoking cessation-was associated with excessive gain among normal-weight and obese women. CONCLUSION: Most women gained weight outside recommendations. Understanding characteristics associated with inadequate or excessive weight gain may identify potentially at-risk women and inform much-needed interventions. LEVEL OF EVIDENCE: III. |
Etiology of diarrhea among children under the age five in China: results from a five-year surveillance
Yu J , Jing H , Lai S , Xu W , Li M , Wu J , Liu W , Yuan Z , Chen Y , Zhao S , Wang X , Zhao Z , Ran L , Wu S , Klena JD , Feng L , Li F , Ye X , Qiu Y , Wang X , Yu H , Li Z , Yang W . J Infect 2015 71 (1) 19-27 OBJECTIVES: Diarrhea is a leading cause of morbidity and mortality for children, although sparse data is available on the etiology of diarrhea in China. This study was conducted to determine main causes that underlie childhood diarrhea and related diseases. METHOD: Surveillance data for diarrhea was collected from 213 participating hospitals between 2009 and 2013. These stool specimens, from children aged 0-59 months, were then analyzed for a panel of etiological agents consisting of 5 viruses, 8 bacteria and 3 protozoa. The proportion of children who tested positive for each pathogen was calculated and seasonal patterns for major organisms were determined. RESULTS: Pathogens were identified in 44.6% of the 32,189 samples from children with diarrhea. The most commonly detected pathogens were rotavirus (29.7% of cases), norovirus (11.8%), Diarrheagenic Escherichia coli (DEC; 5.0%), adenovirus (4.8%), non-typhoidal Salmonella (NTS; 4.3%), and Shigella spp. (3.6%). A strong seasonal pattern was observed for these organisms, including rotavirus (winter), norovirus (autumn), and DEC, NTS, and Shigella (summer). CONCLUSION: A wide range of enteropathogens were detected in this five-year surveillance study; rotavirus and norovirus were most common among children under the age five. These findings should serve as robust evidence for public health entities when planning and developing national intervention programs in China. |
Etiology of pediatric fever in Western Kenya: a case-control study of falciparum malaria, respiratory viruses, and streptococcal pharyngitis
O'Meara WP , Mott JA , Laktabai J , Wamburu K , Fields B , Armstrong J , Taylor SM , MacIntyre C , Sen R , Menya D , Pan W , Nicholson BP , Woods CW , Holland TL . Am J Trop Med Hyg 2015 92 (5) 1030-7 In Kenya, > 10 million episodes of acute febrile illness are treated annually among children under 5 years. Most are clinically managed as malaria without parasitological confirmation. There is an unmet need to describe pathogen-specific etiologies of fever. We enrolled 370 febrile children and 184 healthy controls. We report demographic and clinical characteristics of patients with Plasmodium falciparum, group A streptococcal (GAS) pharyngitis, and respiratory viruses (influenza A and B, respiratory syncytial virus [RSV], parainfluenza [PIV] types 1-3, adenovirus, human metapneumovirus [hMPV]), as well as those with undifferentiated fever. Of febrile children, 79.7% were treated for malaria. However, P. falciparum was detected infrequently in both cases and controls (14/268 [5.2%] versus 3/133 [2.3%], P = 0.165), whereas 41% (117/282) febrile children had a respiratory viral infection, compared with 24.8% (29/117) controls (P = 0.002). Only 9/515(1.7%) children had streptococcal infection. Of febrile children, 22/269 (8.2%) were infected with > 1 pathogen, and 102/275(37.1%) had fevers of unknown etiology. Respiratory viruses were common in both groups, but only influenza or parainfluenza was more likely to be associated with symptomatic disease (attributable fraction [AF] 67.5% and 59%, respectively). Malaria was overdiagnosed and overtreated. Few children presented to the hospital with GAS pharyngitis. An enhanced understanding of carriage of common pathogens, improved diagnostic capacity, and better-informed clinical algorithms for febrile illness are needed. |
Factors associated with high hospital resource use in a population-based study of children with orofacial clefts
Razzaghi H , Dawson A , Grosse SD , Allori AC , Kirby RS , Olney RS , Correia J , Cassell CH . Birth Defects Res A Clin Mol Teratol 2015 103 (2) 127-43 BACKGROUND: Little is known about population-based maternal, child, and system characteristics associated with high hospital resource use for children with orofacial clefts (OFC) in the US. METHODS: This was a statewide, population-based, retrospective observational study of children with OFC born between 1998 and 2006, identified by the Florida Birth Defects Registry whose records were linked with longitudinal hospital discharge records. We stratified the descriptive results by cleft type [cleft lip with cleft palate, cleft lip, and cleft palate] and by isolated versus nonisolated OFC (accompanied by other coded major birth defects). We used Poisson regression to analyze associations between selected characteristics and high hospital resource use (≥90(th) percentile of estimated hospitalized days and inpatient costs) for birth, postbirth, and total hospitalizations initiated before age 2 years. RESULTS: Our analysis included 2,129 children with OFC. Infants who were born low birth weight (<2500 grams) were significantly more likely to have high birth hospitalization costs for CLP (adjusted prevalence ratio: 1.6 [95% confidence interval: 1.0-2.7]), CL (adjusted prevalence ratio: 3.0 [95% confidence interval: 1.1-8.1]), and CP (adjusted prevalence ratio: 2.3 [95% confidence interval: 1.3-4.0]). Presence of multiple birth defects was significantly associated with a three- to eleven-fold and a three- to nine-fold increase in the prevalence of high costs and number of hospitalized days, respectively; at birth, postbirth before age 2 years and overall hospitalizations. CONCLUSION: Children with cleft palate had the greatest hospital resources use. Additionally, the presence of multiple birth defects contributed to greater inpatient days and costs for children with OFC. |
Infant and maternal characteristics in neonatal abstinence syndrome - selected hospitals in Florida, 2010-2011
Lind JN , Petersen EE , Lederer PA , Phillips-Bell GS , Perrine CG , Li R , Hudak M , Correia JA , Creanga AA , Sappenfield WM , Curran J , Blackmore C , Watkins SM , Anjohrin S . MMWR Morb Mortal Wkly Rep 2015 64 (8) 213-6 Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy. |
The association between maternal parity and birth defects
McNeese ML , Selwyn BJ , Duong H , Canfield M , Waller DK . Birth Defects Res A Clin Mol Teratol 2015 103 (2) 144-56 BACKGROUND: Previous studies observed that first birth is associated with an increased risk of some categories of birth defects. However, multiple statistical tests were conducted and it was unclear which of these associations would be replicated in a larger study. We used a large database to assess the association between maternal parity and 65 birth defects including birth defects that have not been previously studied. METHODS: Using data from the Texas Birth Defects Registry for years 1999-2009, the risk of a birth defect occurring in a first, third, or fourth or higher birth was compared to the risk of a birth defect occurring in a second birth. RESULTS: Women having their first birth had significantly increased odds of having an infant with 24 of 65 categories of birth defects when compared to women having their second birth. We also observed associations between first birth and an increased risk of five birth defects not previously reported (small penis, preaxial polydactyly, anomalies of the thoracic vertebrae, anomalies of the lumbar vertebrae, and sacroccygeal anomalies). Women having their third or fourth or higher birth had significantly increased odds of giving birth to infants with five of 65 birth defects when compared to second births. CONCLUSIONS: Our observations regarding the categories of birth defects that were associated with first births were highly consistent with observations from two previous studies. Research into biological, behavioral, and environmental factors that may increase the risk of specific birth defects among first births is needed to further explore these associations. |
Comparison of perinatal risk factors associated with autism spectrum disorder (ASD), intellectual disability (ID), and co-occurring ASD and ID
Schieve LA , Clayton HB , Durkin MS , Wingate MS , Drews-Botsch C . J Autism Dev Disord 2015 45 (8) 2361-72 While studies report associations between perinatal outcomes and both autism spectrum disorder (ASD) and intellectual disability (ID), there has been little study of ASD with versus without co-occurring ID. We compared perinatal risk factors among 7547 children in the 2006-2010 Autism and Developmental Disability Monitoring Network classified as having ASD + ID, ASD only, and ID only. Children in all three groups had higher rates of preterm birth (PTB), low birth weight, small-for-gestational-age, and low Apgar score than expected based on the US birth cohort adjusted for key socio-demographic factors. Associations with most factors, especially PTB, were stronger for children with ID only than children with ASD + ID or ASD only. Associations were similar for children with ASD + ID and ASD only. |
US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011
Hicks LA , Bartoces MG , Roberts RM , Suda KJ , Hunkler RJ , Taylor TH Jr , Schrag SJ . Clin Infect Dis 2015 60 (9) 1308-16 BACKGROUND: Appropriate antibiotic prescribing is an essential strategy to reduce the spread of antibiotic resistance. US prescribing practices have not been thoroughly characterized. We analyzed outpatient antibiotic prescribing data to identify where appropriate antibiotic prescribing interventions could have the most impact. METHODS: Oral antibiotic prescriptions dispensed during 2011 were extracted from the IMS Health Xponent database. The number of prescriptions and census denominators were used to calculate prescribing rates. Prescription totals were calculated for each provider specialty. Regression modeling was used to examine the association between socioeconomic and population health factors and prescribing rates. RESULTS: Healthcare providers prescribed 262.5 million courses of antibiotics in 2011(842 prescriptions per 1000 persons). Penicillins and macrolides were the most common antibiotic categories prescribed. The most commonly prescribed individual antibiotic agent was azithromycin. Family practitioners prescribed the most antibiotic courses (24%). The prescribing rate was higher in the South census region (931 prescriptions per 1000 persons) than in the West (647 prescriptions per 1000 persons; P < .001); this pattern was observed among all age groups, including children ≤2 and persons ≥65 years of age. Counties with a high proportion of obese persons, infants and children ≤2 years of age, prescribers per capita, and females were more likely to be high prescribing by multivariable analysis (adjusted odds ratio, >1.0). CONCLUSIONS: Efforts to characterize antibiotic prescribing practices should focus on the South census region and family practitioners. Further understanding of the factors leading to high prescribing among key target populations will inform appropriate prescribing interventions. |
Namibia's transition from whole blood-derived pooled platelets to single-donor apheresis platelet collections
Pitman JP , Basavaraju SV , Shiraishi RW , Wilkinson R , von Finckenstein B , Lowrance DW , Marfin AA , Postma M , Mataranyika M , Smit Sibinga CT . Transfusion 2015 55 (7) 1685-92 BACKGROUND: Few African countries separate blood donations into components; however, demand for platelets (PLTs) is increasing as regional capacity to treat causes of thrombocytopenia, including chemotherapy, increases. Namibia introduced single-donor apheresis PLT collections in 2007 to increase PLT availability while reducing exposure to multiple donors via pooling. This study describes the impact this transition had on PLT availability and safety in Namibia. STUDY DESIGN AND METHODS: Annual national blood collections and PLT units issued data were extracted from a database maintained by the Blood Transfusion Service of Namibia (NAMBTS). Production costs and unit prices were analyzed. RESULTS: In 2006, NAMBTS issued 771 single and pooled PLT doses from 3054 whole blood (WB) donations (drawn from 18,422 WB donations). In 2007, NAMBTS issued 486 single and pooled PLT doses from 1477 WB donations (drawn from 18,309 WB donations) and 131 single-donor PLT doses. By 2011, NAMBTS issued 837 single-donor PLT doses per year, 99.1% of all PLT units. Of 5761 WB donations from which PLTs were made in 2006 to 2011, a total of 20 (0.35%) were from donors with confirmed test results for human immunodeficiency virus or other transfusion-transmissible infections (TTIs). Of 2315 single-donor apheresis donations between 2007 and 2011, none of the 663 donors had a confirmed positive result for any pathogen. As apheresis replaced WB-derived PLTs, apheresis production costs dropped by a mean of 8.2% per year, while pooled PLT costs increased by an annual mean of 21.5%. Unit prices paid for apheresis- and WB-derived PLTs increased by 9 and 7.4% per year on average, respectively. CONCLUSION: Namibia's PLT transition shows that collections from repeat apheresis donors can reduce TTI risk and production costs. |
Sodium monitoring in commercially processed and restaurant foods
Ahuja JK , Pehrsson PR , Haytowitz DB , Wasswa-Kintu S , Nickle M , Showell B , Thomas R , Roseland J , Williams J , Khan M , Nguyen Q , Hoy K , Martin C , Rhodes D , Moshfegh A , Gillespie C , Gunn J , Merritt R , Cogswell M . Am J Clin Nutr 2015 101 (3) 622-31 BACKGROUND: Most sodium in the US diet comes from commercially processed and restaurant foods. Sodium reduction in these foods is key to several recent public health efforts. OBJECTIVE: The objective was to provide an overview of a program led by the USDA, in partnership with other government agencies, to monitor sodium contents in commercially processed and restaurant foods in the United States. We also present comparisons of nutrients generated under the program to older data. DESIGN: We track approximately 125 commercially processed and restaurant food items ("sentinel foods") annually using information from food manufacturers and periodically by nationwide sampling and laboratory analyses. In addition, we monitor >1100 other commercially processed and restaurant food items, termed "priority-2 foods" (P2Fs) biennially by using information from food manufacturers. These foods serve as indicators for assessing changes in the sodium content of commercially processed and restaurant foods in the United States. We sampled all sentinel foods nationwide and reviewed all P2Fs in 2010-2013 to determine baseline sodium concentrations. RESULTS: We updated sodium values for 73 sentinel foods and 551 P2Fs in the USDA's National Nutrient Database for Standard Reference (releases 23-26). Sodium values changed by at least 10% for 43 of the sentinel foods, which, for 31 foods, including commonly consumed foods such as bread, tomato catsup, and potato chips, the newer sodium values were lower. Changes in the concentrations of related nutrients (total and saturated fat, total sugar, potassium, or dietary fiber) that were recommended by the 2010 Dietary Guidelines for Americans for reduced or increased consumption accompanied sodium reduction. The results of sodium reduction efforts, based on resampling of the sentinel foods or re-review of P2Fs, will become available beginning in 2015. CONCLUSION: This monitoring program tracks sodium reduction efforts, improves food composition databases, and strengthens national nutrition monitoring. |
Top sources of dietary sodium from birth to age 24 mo, United States, 2003-2010
Maalouf J , Cogswell ME , Yuan K , Martin C , Gunn JP , Pehrsson P , Merritt R , Bowman B . Am J Clin Nutr 2015 101 (5) 1021-8 BACKGROUND: Sodium intake is high in US children. Data are limited on the dietary sources of sodium, especially from birth to age 24 mo. OBJECTIVE: We identified top sources of dietary sodium in US children from birth to age 24 mo. DESIGN: Data from the NHANES 2003-2010 were used to examine food sources of sodium (population proportions and mean intakes) in 778 participants aged 0-5.9 mo, 914 participants aged 6-11.9 mo, and 1219 participants aged 12-23.9 mo by sociodemographic characteristics. RESULTS: Overall, mean dietary sodium intake was low in 0-5.9-mo-old children, and the top contributors were formula (71.7%), human milk (22.9%), and commercial baby foods (2.2%). In infants aged 6-11.9 mo, the top 5 contributors were formula (26.7%), commercial baby foods (8.8%), soups (6.1%), pasta mixed dishes (4.0%), and human milk (3.9%). In children aged 12-23.9 mo, the top contributors were milk (12.2%), soups (5.4%), cheese (5.2%), pasta mixed dishes (5.1%), and frankfurters and sausages (4.6%). Despite significant variation in top food categories across racial/ethnic groups, commercial baby foods were a top food contributor in children aged 6-11.9 mo, and frankfurters and sausages were a top food contributor in children aged 12-23.9 mo. The top 5 food categories that contributed to sodium intake also differed by sex. Most of the sodium consumed (83-90%) came from store foods (e.g., from the supermarket). In children aged 12-23.9 mo, 9% of sodium consumed came from restaurant foods, and 4% of sodium came from childcare center foods. CONCLUSIONS: The vast majority of sodium consumed comes from foods other than infant formula or human milk after the age of 6 mo. Although the majority of sodium intake was from store foods, after age 12 mo, restaurant foods contribute significantly to intake. Reducing the sodium content in these settings would reduce sodium intake in the youngest consumers. |
Unmetabolized folic acid is detected in nearly all serum samples from US children, adolescents, and adults
Pfeiffer CM , Sternberg MR , Fazili Z , Yetley EA , Lacher DA , Bailey RL , Johnson CL . J Nutr 2015 145 (3) 520-31 BACKGROUND: Serum total folate consists mainly of 5-methyltetrahydrofolate (5-methylTHF). Unmetabolized folic acid (UMFA) may occur in persons consuming folic acid-fortified foods or supplements. OBJECTIVES: We describe serum 5-methylTHF and UMFA concentrations in the US population ≥1 y of age by demographic variables and fasting time, stratified by folic acid-containing dietary supplement use. We also evaluate factors associated with UMFA concentrations >1 nmol/L. METHODS: Serum samples from the cross-sectional NHANES 2007-2008 were measured for 5-methylTHF (n = 2734) and UMFA (n = 2707) by HPLC-tandem mass spectrometry. RESULTS: In supplement users compared with nonusers, we found significantly higher geometric mean concentrations of 5-methylTHF (48.4 and 30.7 nmol/L, respectively) and UMFA (1.54 and 0.794 nmol/L, respectively). UMFA concentrations were detectable (>0.3 nmol/L) in >95% of supplement users and nonusers, regardless of demographic or fasting characteristics; concentrations differed significantly by age and fasting time, but not by sex and race-ethnicity, both in supplement users and nonusers. The prevalence of UMFA concentrations >1 nmol/L was 33.2% overall and 21.0% in fasting (≥8 h) adults (≥20 y of age). Using multiple logistic regression analysis, UMFA concentrations >1 nmol/L were associated with being older, non-Hispanic black, nonfasting (<8 h), having smaller body surface area, higher total folic acid intake (diet and supplements), and higher red blood cell folate concentrations. In fasting adults, a decrease in the mean daily alcohol consumption was also associated with increased odds of UMFA concentrations >1 nmol/L. CONCLUSIONS: UMFA detection was nearly ubiquitous, and concentrations >1 nmol/L were largely but not entirely explained by fasting status and by total folic acid intake from diet and supplements. These new UMFA data in US persons ≥1 y of age provide much-needed information on this vitamer in a fortified population with relatively high use of dietary supplements. |
The Global Nutrition Report 2014: actions and accountability to accelerate the world's progress on nutrition
Haddad L , Achadi E , Ag Bendech M , Ahuja A , Bhatia K , Bhutta Z , Blossner M , Borghi E , Colecraft E , de Onis M , Eriksen K , Fanzo J , Flores-Ayala R , Fracassi P , Kimani-Murage E , Nago Koukoubou E , Krasevec J , Newby H , Nugent R , Oenema S , Martin-Prevel Y , Randel J , Requejo J , Shyam T , Udomkesmalee E , Reddy KS . J Nutr 2015 145 (4) 663-71 In 2013, the Nutrition for Growth Summit called for a Global Nutrition Report (GNR) to strengthen accountability in nutrition so that progress in reducing malnutrition could be accelerated. This article summarizes the results of the first GNR. By focusing on undernutrition and overweight, the GNR puts malnutrition in a new light. Nearly every country in the world is affected by malnutrition, and multiple malnutrition burdens are the "new normal." Unfortunately, the world is off track to meet the 2025 World Health Assembly (WHA) targets for nutrition. Many countries are, however, making good progress on WHA indicators, providing inspiration and guidance for others. Beyond the WHA goals, nutrition needs to be more strongly represented in the Sustainable Development Goal (SDG) framework. At present, it is only explicitly mentioned in 1 of 169 SDG targets despite the many contributions improved nutritional status will make to their attainment. To achieve improvements in nutrition status, it is vital to scale up nutrition programs. We identify bottlenecks in the scale-up of nutrition-specific and nutrition-sensitive approaches and highlight actions to accelerate coverage and reach. Holding stakeholders to account for delivery on nutrition actions requires a well-functioning accountability infrastructure, which is lacking in nutrition. New accountability mechanisms need piloting and evaluation, financial resource flows to nutrition need to be made explicit, nutrition spending targets should be established, and some key data gaps need to be filled. For example, many UN member states cannot report on their WHA progress and those that can often rely on data >5 y old. The world can accelerate malnutrition reduction substantially, but this will require stronger accountability mechanisms to hold all stakeholders to account. |
Iodized salt sales in the United States
Maalouf J , Barron J , Gunn JP , Yuan K , Perrine CG , Cogswell ME . Nutrients 2015 7 (3) 1691-5 Iodized salt has been an important source of dietary iodine, a trace element important for regulating human growth, development, and metabolic functions. This analysis identified iodized table salt sales as a percentage of retail salt sales using Nielsen ScanTrack. We identified 1117 salt products, including 701 salt blends and 416 other salt products, 57 of which were iodized. When weighted by sales volume in ounces or per item, 53% contained iodized salt. These findings may provide a baseline for future monitoring of sales of iodized salt. |
The association between food insecurity and obesity in children - the National Health and Nutrition Examination Survey
Kaur J , Lamb MM , Ogden CL . J Acad Nutr Diet 2015 115 (5) 751-758 BACKGROUND: Food insecurity can put children at greater risk of obesity because of altered food choices and nonuniform consumption patterns. OBJECTIVE: We examined the association between obesity and both child-level food insecurity and personal food insecurity in US children. DESIGN: Data from 9,701 participants in the National Health and Nutrition Examination Survey, 2001-2010, aged 2 to 11 years were analyzed. Child-level food insecurity was assessed with the US Department of Agriculture's Food Security Survey Module based on eight child-specific questions. Personal food insecurity was assessed with five additional questions. Obesity was defined, using physical measurements, as body mass index (calculated as kg/m2) greater than or equal to the age- and sex-specific 95th percentile of the Centers for Disease Control and Prevention growth charts. Logistic regressions adjusted for sex, race/ethnic group, poverty level, and survey year were conducted to describe associations between obesity and food insecurity. RESULTS: Obesity was significantly associated with personal food insecurity for children aged 6 to 11 years (odds ratio=1.81; 95% CI 1.33 to 2.48), but not in children aged 2 to 5 years (odds ratio=0.88; 95% CI 0.51 to 1.51). Child-level food insecurity was not associated with obesity among 2- to 5-year-olds or 6- to 11-year-olds. CONCLUSIONS: Personal food insecurity is associated with an increased risk of obesity only in children aged 6 to 11 years. Personal food-insecurity measures may give different results than aggregate food-insecurity measures in children. |
Dietary sodium reduction does not affect circulating glucose concentrations in fasting children or adults: findings from a systematic review and meta-analysis
Patel SM , Cobb P , Saydah S , Zhang X , de Jesus JM , Cogswell ME . J Nutr 2015 145 (3) 505-13 BACKGROUND: Although evidence shows that reduced sodium intake lowers blood pressure, some studies suggest that sodium reduction may adversely affect insulin resistance and glucose tolerance. OBJECTIVES: The objectives were to assess the effects of sodium reduction on glucose tolerance, evaluate strengths and weaknesses of the relevant scientific literature, and provide direction for future research. METHODS: We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, and Web of Science through August 2014. Both randomized and nonrandomized intervention trials were included in our meta-analyses. The effects of sodium reduction on glucose tolerance were evaluated in 37 articles, but because of a lack of comparable data, 8 trials were excluded from the meta-analyses. RESULTS: Participants were 10-79 y old, either primarily healthy or with hypertension. In meta-analyses of 20 randomized, crossover trials (n = 504 participants) and 9 nonrandomized crossover trials (n = 337), circulating glucose concentrations of fasting participants were not affected by reduction in sodium intake. In contrast, in meta-analyses of 19 of the 20 randomized, crossover trials (n = 494), fasting insulin concentrations were 9.53 pmol/L higher (95% CI: 5.04, 14.02 pmol/L higher) with sodium reduction. In 9 nonrandomized trials (n = 337), fasting insulin did not differ with reduced sodium intake. Results differed little when the analyses were restricted to studies with a low risk of bias and duration of ≥7 d. CONCLUSIONS: This meta-analysis revealed no evidence that, in trials with a short intervention and large reductions in sodium, circulating glucose concentrations differed between groups. Recommendations for future studies include extending intervention durations, ensuring comparability of groups at baseline through randomization, and assessing sodium intakes relevant to population sodium reduction. In addition, analyses on other metabolic variables were limited because of the number of trials reporting these outcomes and lack of consistency across measures, suggesting a need for comparable measures of glucose tolerance across studies. |
Revisiting Pneumatic Nail Gun Trigger Recommendations
Albers J , Lowe BD , Lipscomb H , Hudock SD , Dement J , Evanoff B , Fullen M , Gillen M , Kaskutas V , Nolan J , Patterson D , Platner J , Pompeii L , Schoenfisch A . Prof Saf 2015 60 (3) 30-33 Pneumatic framing nail gun use is ubiquitous throughout the modern homebuilding industry. This tool has a safety device at the end of the gun muzzle that must be depressed before the fastener can be discharged. Generally, these devices have two types of trigger systems that then define how the nail gun fires in response to a trigger press: 1. The sequential actuation trigger requires that each nail can only be discharged when the safety tip is first depressed and, while held depressed, the trigger is squeezed. 2. The contact actuation trigger allows the operator to first squeeze the trigger and, while holding the trigger squeezed, repeatedly bump the safety tip on the workpiece to shoot multiple nails. In the authors' view, however, an unintended consequence of the recommendations published in (Baggs, et al, 1999) and (2001) has been the creation of the appearance of competing risks with nail gun trigger systems. |
Unstable sitting in the workplace - are there physical activity benefits?
Lowe BD , Swanson NG , Hudock SD , Lotz WG . Am J Health Promot 2015 29 (4) 207-9 The increasingly popular practice of using a stability ball (exercise/fitness ball) as a sitting surface runs counter to conventional human factors/ergonomics guidelines for seated workspace design. Employees sitting on stability balls in an office environment present safety risks that might be justifiable if the practice has a definitive benefit to the promotion of health. However, the published studies and best evidence to date call into question even the theoretical basis for this practice and do not suggest significant health benefits. First, biomechanical studies do not confirm the intended trunk muscle activation. Second, energy expenditure studies show a small (if any) increase in metabolic demand that is unlikely to be effective in combating sedentary work risk factors. Until studies demonstrate more conclusive benefits, the practice of stability ball sitting should be viewed skeptically as a general workplace recommendation in the interest of health or wellness. |
Vital Signs: seat belt use among long-haul truck drivers - United States, 2010
Chen GX , Collins JW , Sieber WK , Pratt SG , Rodriguez-Acosta RL , Lincoln JE , Birdsey J , Hitchcock EM , Robinson CF . MMWR Morb Mortal Wkly Rep 2015 64 (8) 217-21 BACKGROUND: Motor vehicle crashes were the leading cause of occupational fatalities in the United States in 2012, accounting for 25% of deaths. Truck drivers accounted for 46% of these deaths. This study estimates the prevalence of seat belt use and identifies factors associated with nonuse of seat belts among long-haul truck drivers (LHTDs), a group of workers at high risk for fatalities resulting from truck crashes. METHODS: CDC analyzed data from its 2010 national survey of LHTD health and injury. A total of 1,265 drivers completed the survey interview. Logistic regression was used to examine the association between seat belt nonuse and risk factors. RESULTS: An estimated 86.1% of LHTDs reported often using a seat belt, 7.8% used it sometimes, and 6.0% never. Reporting never using a belt was associated with often driving ≥10 mph (16 kph) over the speed limit (adjusted odds ratio [AOR] = 2.9), working for a company with no written safety program (AOR = 2.8), receiving two or more tickets for moving violations in the preceding 12 months (AOR = 2.2), living in a state without a primary belt law (AOR = 2.1); and being female (AOR = 2.3). CONCLUSIONS: Approximately 14% of LHTDs are at increased risk for injury and death because they do not use a seat belt on every trip. Safety programs and other management interventions, engineering changes, and design changes might increase seat belt use among LHTDs. IMPLICATIONS FOR PUBLIC HEALTH: Primary state belt laws can help increase belt use among LHTDs. Manufacturers can use recently collected anthropometric data to design better-fitting and more comfortable seat belt systems. |
Volatile organic compounds off-gassing from firefighters' personal protective equipment ensembles after use
Fent KW , Evans DE , Booher D , Pleil JD , Stiegel MA , Horn GP , Dalton J . J Occup Environ Hyg 2015 12 (6) 404-14 Firefighters' personal protective equipment (PPE) ensembles will become contaminated with various compounds during firefighting. Some of these compounds will off-gas following a response, which could result in inhalation exposure. This study was conducted to determine the magnitude and composition of volatile organic compounds (VOCs) generated during controlled structure burns that subsequently off-gassed from the firefighters' PPE, and were systemically absorbed and exhaled in firefighters' breath. Three crews of five firefighters performed entry, suppression, and overhaul during a controlled burn. We used evacuated canisters to sample air inside the burn structure during active fire and overhaul. After each burn, we placed PPE from two firefighters inside clean enclosures and sampled the air using evacuated canisters over 15 min. Firefighters' exhaled breath was collected 1 hr before and 4-14 min after each burn. Using gas chromatography/mass spectrometry, the evacuated canister samples were analyzed for 64 VOCs and the exhaled breath samples were analyzed for benzene, toluene, ethylbenzene, xylene, and styrene (BTEXS). Fourteen of the same VOCs were detected off-gassing from PPE in 50% or more of the samples. Compared to background levels, we measured >5 fold increases in mean off-gas concentrations of styrene, benzene, 1,4-dichlorobenzene, acetone, and cyclohexane. Several of the compounds detected off-gassing from PPE were also measured at concentrations above background during active fire and overhaul, including benzene, propene, and styrene. The overhaul and off-gas air concentrations were well below applicable short-term occupational exposure limits. Compared to pre-burn levels, we measured >2 fold increases in mean breath concentrations of benzene, toluene, and styrene after the burns. Air concentrations of BTEXS measured off-gassing from firefighters' used PPE and in firefighters' post-burn exhaled breath were significantly correlated. The firefighters may have absorbed BTEXS through both the dermal route (during firefighting) and inhalation route (from off-gassing PPE after firefighting). Firefighters should be made aware of the potential for inhalation exposure when doffing and traveling in confined vehicles with contaminated PPE and take measures to minimize this exposure pathway. |
NIOSH Manual of Analytical Methods 5th edition and harmonization of occupational exposure monitoring
Ashley K . Gefahrst Reinhalt Luft 2015 75 7-16 The NIOSH Manual of Analytical Methods (NMAM) is a collection of methods for sampling and analysis of contaminants in workplace air (or surfaces) and in the blood and urine of workers who are occupationally exposed. NIOSH methods are used worldwide for occupational exposure assessment. They have been developed or adapted by NIOSH and/or its partners and have been evaluated according to established protocols and performance criteria. NMAM also includes chapters on quality assurance, sampling guidance, instrumentation, aerosol measurement, gas and vapor monitoring, portable monitoring devices, and so forth. Often NIOSH methods are developed in coordination with voluntary consensus standards organizations. Efforts to harmonize NIOSH methods with relevant consensus standards procedures are highlighted. NIOSH also has a formal Memorandum of Understanding (MOU) with the Institute for Occupational Safety and Health of the German Social Accident Insurance (lFA), whereby both are adopting selected methods. An overview of recent research and technology transfer activities relating to NMAM methods is provided. Included are newly approved methods and those under development, as well as needs for new methods and updates. Of particular interest are recent NIOSH recommendations on air samplers used for sampling and analysis of airborne particles. |
A pilot assessment of occupational health hazards in the U.S. electronic scrap recycling industry
Ceballos DM , Gong W , Page E . J Occup Environ Hyg 2015 12 (7) 482-8 The National Institute for Occupational Safety and Health (NIOSH) surveyed a randomly selected sample of electronic scrap (e-scrap) recycling facilities nationwide to characterize work processes, exposures, and controls. Despite multiple attempts to contact 278 facilities, only 47 responded (17% response rate). Surveyed facilities reported recycling a wide variety of electronics. The most common recycling processes were manual dismantling and sorting. Other processes included shredding, crushing, and automated separation. Many facilities reported that they had health and safety programs in place. However, some facilities reported the use of compressed air for cleaning, a practice that can lead to increased employee dust exposures, and some facilities allowed food and drinks in the production areas, a practice that can lead to ingestion of contaminants. Although our results may not be generalizable to all U.S. e-scrap recycling facilities, they are informative regarding health and safety programs in the industry. We concluded that e-scrap recycling has the potential for a wide variety of occupational exposures particularly because of the frequent use of manual processes. On-site evaluations of e-scrap recyclers are needed to determine if reported work processes, practices, and controls are effective and meet current standards and guidelines. Educating the e-scrap recycling industry about health and safety best practices, specifically related to safe handling of metal dust, would help protect employees. |
Extended follow-up of lung cancer and non-malignant respiratory disease mortality among California diatomaceous earth workers
Gallagher LG , Park RM , Checkoway H . Occup Environ Med 2015 72 (5) 360-5 OBJECTIVES: Millions of workers worldwide are employed in occupations involving potentiality hazardous exposure to crystalline silica. The diatomaceous earth industry can have particularly high exposures, but there is a lower likelihood of simultaneously occurring confounding exposures. We extended follow-up for diatomaceous earth industry workers previously studied for mortality. METHODS: The cohort included 2342 white men who were employed for at least 1 year at a diatomaceous earth plant in Lompoc, California beginning in 1942. Workers' vital status was updated using the National Death Index through 2011, an extension of 19 years from earlier studies. Detailed work history and quantitative air monitoring measurements estimated exposure intensity. Cox proportional hazards modelling estimated HRs and 95% CIs. SMRs were calculated. RESULTS: Elevated mortality was observed by quartile of cumulative crystalline silica exposure for lung cancer (HR=2.03, 95% CI 1.07 to 3.85, highest quartile, unlagged) and non-malignant respiratory disease (NMRD) (HR=3.59, 95% CI 1.94 to 6.67, highest quartile, unlagged), although trends were not statistically significant. Associations were attenuated when adjusted for smoking and asbestos exposure. Mortality from NMRD was significantly increased over the entire follow-up compared to the general population (SMR=1.37, 95% CI 1.17 to 1.60). An increase for lung cancer was confined to the earlier follow-up (SMR=1.29, 95% CI 1.01 to 1.61). CONCLUSIONS: The risk of lung cancer and NMRD mortality remained elevated, although generally non-significant, and exposure-response trends with cumulative crystalline silica persisted on extended follow-up of this cohort. The findings support a generally consistently observed aetiological relation between crystalline silica and lung cancer. |
Correlates of hopelessness in the high suicide risk police occupation
Violanti JM , Andrew ME , Mnatsakanova A , Hartley TA , Fekedulegn D , Burchfiel CM . Police Pract Res 2015 17 (5) 408-419 Police officers are chronically exposed to work stress. We examined specific stressors that may be associated with hopelessness, a possible risk factor for suicide in this high suicide risk population. The study included 378 officers (276 men and 102 women) with complete data. Analysis of variance was used to estimate mean levels of hopelessness scores as associated with stress, adjusted for age, gender, and race/ethnicity. Posttraumatic symptoms were tested as a modifier of the association between stress and hopelessness. Increasing stress of administrative practices and lack of support were significantly associated with increasing hopelessness among officers (p < .006 – hopelessness range: 1.64–2.65; and p < .001 – hopelessness range 1.60–2.80, respectively). Posttraumatic stress disorder (PTSD) symptoms significantly modified the association between lack of organizational support and hopelessness (p < .010) with significant association only among individuals with higher PTSD symptoms (p < .001). Results suggest that hopelessness is associated with specific stressors in police work, and this is modified by posttraumatic symptomatology. |
Demographic trends of sick leave absenteeism among civil service employees at a federal agency from 2004 to 2012
Gajewski K , Burris D , Spears DR , Sullivan K , Oyinloye O , McNeil C , Meechan P , Warnock E , Trapp J , Decker KC , Chapman S . J Occup Environ Med 2015 57 (3) 277-83 OBJECTIVE: To investigate the associations between demographic variables and sick leave use. METHODS: We analyzed sick leave use among civil servants at a federal agency (FA) from 2004 to 2012 by demographic and FA-specific variables. We used a mixed methods approach and type III analysis to build a descriptive model of sick leave proportions and demographic variables. RESULTS: Sick absenteeism usage varied significantly (variation of greater than one sick day per year) by sex, Emergency Operations Center response tier, length of service at the FA, age, and general schedule pay grade level. Our final descriptive model contained age, sex, response tier and an interaction term between age and sex. CONCLUSIONS: Future studies should examine these associations on smaller time scales, perhaps breaking the data down by month or day of the week. |
Transplant patient with skin nodules
Kandukuri S , Morgan M , Zakowski P , Govinda V , Falk J , Roy S , Chaux G , Ghandehari S , Wu J . Am J Dermatopathol 2015 37 (3) 254-6 Answer: Acanthanmoeba spp. Hematoxylin and eosin (H/E)-stained tissue sections revealed edematous mucose with evidence of moderate acute and chronic inflammation and confluent areas of necrosis. Within the necrotic tissue were scattered double-walled wrinkled cystic structures and trophozoites were identified within a vessel wall, indicitave of angioinvasion. Gomori Methenamine silver (GMS) and periodic acid Schiff stains highlighted the cysts and trophozoites. |
Unprogrammed deworming in the Kibera slum, Nairobi: implications for control of soil-transmitted helminthiases
Harris JR , Worrell CM , Davis SM , Odero K , Mogeni OD , Deming MS , Mohammed A , Montgomery JM , Njenga SM , Fox LM , Addiss DG . PLoS Negl Trop Dis 2015 9 (3) e0003590 BACKGROUND: Programs for control of soil-transmitted helminth (STH) infections are increasingly evaluating national mass drug administration (MDA) interventions. However, "unprogrammed deworming" (receipt of deworming drugs outside of nationally-run STH control programs) occurs frequently. Failure to account for these activities may compromise evaluations of MDA effectiveness. METHODS: We used a cross-sectional study design to evaluate STH infection and unprogrammed deworming among infants (aged 6-11 months), preschool-aged children (PSAC, aged 1-4 years), and school-aged children (SAC, aged 5-14 years) in Kibera, Kenya, an informal settlement not currently receiving nationally-run MDA for STH. STH infection was assessed by triplicate Kato-Katz. We asked heads of households with randomly-selected children about past-year receipt and source(s) of deworming drugs. Local non-governmental organizations (NGOs) and school staff participating in school-based deworming were interviewed to collect information on drug coverage. RESULTS: Of 679 children (18 infants, 184 PSAC, and 477 SAC) evaluated, 377 (55%) reported receiving at least one unprogrammed deworming treatment during the past year. PSAC primarily received treatments from chemists (48.3%) or healthcare centers (37.7%); SAC most commonly received treatments at school (55.0%). Four NGOs reported past-year deworming activities at 47 of >150 schools attended by children in our study area. Past-year deworming was negatively associated with any-STH infection (34.8% vs 45.4%, p = 0.005). SAC whose most recent deworming medication was sourced from a chemist were more often infected with Trichuris (38.0%) than those who received their most recent treatment from a health center (17.3%) or school (23.1%) (p = 0.05). CONCLUSION: Unprogrammed deworming was received by more than half of children in our study area, from multiple sources. Both individual-level treatment and unprogrammed preventive chemotherapy may serve an important public health function, particularly in the absence of programmed deworming; however, they may also lead to an overestimation of programmed MDA effectiveness. A standardized, validated tool is needed to assess unprogrammed deworming. |
Morbidity associated with schistosomiasis before and after treatment in young children in Rusinga Island, Western Kenya
Davis SM , Wiegand RE , Mulama F , Kareko EI , Harris R , Ochola E , Samuels AM , Rawago F , Mwinzi PM , Fox LM , Odiere MR , Won KY . Am J Trop Med Hyg 2015 92 (5) 952-8 Schistosoma mansoni infection is a major cause of organomegaly and ultimately liver fibrosis in adults. Morbidity in pre-school-aged children is less defined, and they are currently not included in mass drug administration (MDA) programs for schistosomiasis control. We report results of a study of the association of schistosomiasis with organomegaly in a convenience sample of 201 children under 7 years old in Rusinga, Kenya on two cross-sectional visits, before and after praziquantel treatment. Data included stool examination and serology for schistosomiasis, the Niamey ultrasound protocol to stage hepatosplenic morbidity including organomegaly, and potential confounders including malaria. Unadjusted and adjusted Poisson regressions were performed. The baseline prevalence of schistosomiasis by antibody and/or stool was 80.3%. Schistomiasis was associated with hepatomegaly (adjusted prevalence ratio [aPR] = 1.4; 95% confidence interval [CI]: 1.0-2.1) and splenomegaly (aPR = 2.4; 95% CI: 1.4-4.2). The association with hepatomegaly persisted posttreatment (aPR = 1.4; 95% CI: 1.1-1.6). Schistosomiasis was associated with morbidity in this cohort. Efforts to include young children in mass treatment campaigns should intensify. |
Ocular involvement following an epidemic of Toxoplasma gondii infection in Santa Isabel do Ivai, Brazil
Silveira C , Muccioli C , Holland GN , Jones JL , Yu F , de Paulo A , Belfort R Jr . Am J Ophthalmol 2015 159 (6) 1013-1021 e3 PURPOSE: To investigate ocular involvement (prevalence, incidence, lesion characteristics) following post-natally acquired infection with an "atypical" genotype of Toxoplasma gondii during a well-characterized 2001 outbreak in Santa Isabel do Ivai, Brazil, attributed to a contaminated municipal reservoir. DESIGN: Prospective longitudinal cohort study. METHODS: We performed ophthalmic examinations on 290 of 454 individuals with serologic evidence of T. gondii infection during the epidemic (positive IgM antibody tests). Prevalence of ophthalmic findings (intraocular inflammatory reactions [including transient, isolated retinal whitening without clinically apparent retinal necrosis] and necrotizing retinochoroiditis) at initial examination (baseline) and incidence of new findings during 10.5 months of follow-up were calculated. Cumulative risks of ophthalmic events were determined (Kaplan-Meier technique). RESULTS: Ocular involvement was present in 33 (11.5%) of 288 IgM+ individuals at baseline, including 17 with focal retinal whitening only and 13 with necrotizing retinochoroiditis. Incidence of new ocular involvement was estimated to be 1.73 events per 100 person-months (PM); cumulative risk at 10.5 months was 30.1%. Incident necrotizing retinochoroiditis was more common among those with focal retinal whitening at baseline (6.7/100PM) than among those with no ocular involvement at baseline (1.11/100PM; hazard ratio 6.07 [1.94-19.01]; p<0.0001). CONCLUSIONS: Water-borne infection with an atypical genotype of T. gondii is associated with substantial risk of ocular involvement. Lesions may continue to develop during the first year after infection. The increased risk of late necrotizing retinochoroiditis associated with isolated focal retinal whitening at presentation suggests the early presence of parasites in the retina, despite initial lack of observable retinal necrosis. |
Ocular involvement following post-natally acquired Toxoplasma gondii infection in southern Brazil: a 28-year experience
Arantes TE , Silveira C , Holland GN , Muccioli C , Yu F , Jones JL , Goldhardt R , Lewis KG , Belfort R Jr . Am J Ophthalmol 2015 159 (6) 1002-1012 e2 PURPOSE: To determine the incidence of, and risk factors for, ocular involvement among people known to have post-natally acquired Toxoplasma gondii infection in a region of southern Brazil where there is a high prevalence of endemic disease. DESIGN: Retrospective longitudinal cohort study. METHODS: Records of 302 patients with serologic evidence of recent T. gondii infection (a positive anti-T.gondii IgM antibody test) from Erechim, Rio Grande do Sul state, Brazil (1974-2002) were analyzed. The incidence of ocular involvement was calculated in terms of person-years (PY) of follow-up. Risk factors for ocular involvement were analyzed using log-rank and Fisher exact tests. RESULTS: At initial ocular examination (baseline), 30 patients (9.9%) had intraocular inflammation only (anterior chamber cells and flare, vitreous inflammatory reactions, retinal whitening), without clinically apparent necrotizing retinochoroiditis. At baseline, men were more likely to have ocular involvement (p=0.043) and anti-parasitic treatment was associated with less ocular involvement (p=0.015). Follow-up examinations were performed on 255 patients (median follow-up, 13.7 months [range 0.4-261.9 months]). Among those without ocular involvement at baseline, the incidence of necrotizing retinochoroiditis was 6.4/100-PY. Patients >40 years of age at first IgM test had a greater risk of incident necrotizing retinochoroiditis (HR=4.47, 95% CI=1.67-11.93, p=0.003) than younger patients. The incidence of recurrent necrotizing retinochoroiditis was 10.5/100PY. CONCLUSION: Isolated intraocular inflammatory reactions can be an initial manifestation of T. gondii infection, with necrotizing retinochoroiditis occurring months or years later. Male sex and older age are risk factors for toxoplasmic retinochoroiditis. Anti-toxoplasmic treatment may protect against early ocular involvement. |
First imported Plasmodium ovale malaria in Central America: case report of a Guatemalan soldier and a call to improve its accurate diagnosis
Castellanos ME , Diaz S , Parsons E , Peruski LF , Enriquez F , Ramirez JL , Padilla N . Mil Med Res 2015 2 3 The Mesoamerican Ministers of Health have set 2020 as the target for malaria elimination to be achieved in the region. Imported malaria cases are a potential threat to countries attempting elimination or working to prevent resurgence. We report the first imported Plasmodium ovale infection with molecular confirmation in Central America, which occurred in a Guatemalan soldier that had been deployed in Africa. The obstacles for its diagnosis using the standard microscopy technique and the need to improve its detection are discussed. |
Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators
Carinci F , Van Gool K , Mainz J , Veillard J , Pichora EC , Januel JM , Arispe I , Kim SM , Klazinga NS . Int J Qual Health Care 2015 27 (2) 137-46 OBJECTIVE: To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work. DESIGN: A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development. SETTING: International group of countries participating to OECD projects. PARTICIPANTS: Members of the OECD HCQI expert group. RESULTS: A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions. CONCLUSIONS: The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies. |
Women's health: 30 years of progress in the U.S. Department of Health and Human Services
Woods CM , Applebaum B , Green Y , Kallgren DL , Kappeler E . Public Health Rep 2015 130 (2) 123-7 In 1983, the Assistant Secretary for Health at the U.S. Department of Health and Human Services (HHS) convened the first-ever U.S. Public Health Service Task Force on Women's Health Issues to identify important women's health issues and develop a blueprint for enmeshing those issues with the priorities of the U.S. Public Health Service (PHS). The landmark Report of the Public Health Service Task Force on Women's Health Issues,1 published in Public Health Reports in 1985, outlined recommendations to accomplish this goal. One recommendation supported the creation of a standing committee comprising HHS agency representatives who would report regularly to the PHS and HHS leadership. To fulfill this recommendation, HHS established the Coordinating Committee on Women's Health (CCWH) in 1984 to advise the Assistant Secretary for Health on activities to safeguard and improve the physical and mental health of women in the United States. This deliberate focus on women's health, which continues today, has led to substantial advances in the field.2 This commentary highlights the work done by HHS agencies and offices, through collaborations and partnerships, to address the categorized recommendations of the 30-year-old report: | Promote a safe and healthful physical and social environment | Provide services for the prevention and treatment of disease | Conduct research and evaluation | Recruit and train health-care personnel | Educate and inform the public and disseminate research information | Design guidance for legislative and regulatory measures |
Preparing master of public health graduates to work in local health departments
Hemans-Henry C , Blake J , Parton H , Koppaka R , Greene CM . J Public Health Manag Pract 2015 22 (2) 194-9 OBJECTIVE: To identify key competencies and skills that all master of public health (MPH) graduates should have to be prepared to work in a local health department. METHODS: In 2011-2012, the New York City Department of Health and Mental Hygiene administered electronic surveys to 2 categories of staff: current staff with an MPH as their highest degree, and current hiring managers. RESULTS: In all, 312 (77%) staff members with an MPH as their highest degree and 170 (57%) hiring managers responded to the survey. Of the respondents with an MPH as their highest degree, 85% stated that their MPH program prepared them for work at the New York City Health Department. Skills for which MPH graduates most often stated they were underprepared included facility in using SAS(R) statistical software, quantitative data analysis/statistics, personnel management/leadership, and data collection/database management/data cleaning. Among the skills hiring managers identified as required of MPH graduates, the following were most often cited as those for which newly hired MPH graduates were inadequately prepared: quantitative data analysis, researching/conducting literature reviews, scientific writing and publication, management skills, and working with contracts/requests for proposals. CONCLUSION: These findings suggest that MPH graduates could be better prepared to work in a local health department upon graduation. To be successful, new MPH graduate hires should possess fundamental skills and knowledge related to analysis, communication, management, and leadership. Local health departments and schools of public health must each contribute to the development of the current and future public health workforce through both formal learning opportunities and supplementary employment-based training to reinforce prior coursework and facilitate practical skill development. |
Establishing a field epidemiology elective for medical students in Kenya: a strategy for increasing public health awareness and workforce capacity
Arvelo W , Gura Z , Amwayi S , Wiersma P , Omolo J , Becknell S , Jones D , Ongore D , Dicker R . J Epidemiol Glob Health 2015 5 (1) 33-9 Medical students have limited exposure to field epidemiology, even though will assume public health roles after graduation. We established a 10-week elective in field epidemiology during medical school. Students attended one-week didactic sessions on epidemiology, and nine weeks in field placement sites. We administered pre- and post-tests to evaluate the training. We enrolled 34 students in 2011 and 2012. In 2011, we enrolled five of 24 applicants from a class of 280 medical students. In 2012, we enrolled 18 of 81 applicants from a class of 360 students; plus 11 who participated in the didactic sessions only. Among the 34 students who completed the didactic sessions, 74% were male, and their median age was 24 years (range: 22-26). The median pre-test score was 64% (range: 47-88%) and the median post-test score was 82% (range: 72-100%). Successful completion of the field projects was 100%. Six (30%) students were not aware of public health as a career option before this elective, 56% rated the field experience as outstanding, and 100% reported it increased their understanding of epidemiology. Implementing an elective in field epidemiology within the medical training is a highly acceptable strategy to increase awareness for public health among medical students. |
Gender role orientation is associated with health-related quality of life differently among African-American, Hispanic, and White youth
Scott SM , Wallander JL , Depaoli S , Elliott MN , Grunbaum JA , Tortolero SR , Cuccaro PM , Schuster MA . Qual Life Res 2015 24 (9) 2139-49 PURPOSE: This study examined the association between gender role orientation (GRO) and health-related quality of life (HRQOL) in youth, and how this relationship may differ between males and females as well as among African-American, White, and Hispanic individuals. GRO has been reported to influence serious health outcomes including cancer, heart disease, mental illness, and mortality rates. However, few studies have examined the link between GRO and health outcomes for children, even though gender identity is formed in childhood. METHODS: Data were examined from 4824 participants in the Healthy Passages project, a population-based survey of fifth-grade children in three US metropolitan areas. Children reported their own HRQOL using the PedsQL and degree of female, male, and androgynous GRO using the Children's Sex Role Inventory. RESULTS: Based on structural equations analysis, male GRO was positively associated with HRQOL for all racial/ethnic groups, regardless of sex, whereas female GRO was associated with better HRQOL for Hispanic and White females and poorer HRQOL for Hispanic males. Androgynous GRO was associated with better HRQOL among Hispanic and White females, but not males nor African-Americans of either sex. CONCLUSIONS: Racial/ethnic differences emerged for female and androgynous, but not male, GROs. Hispanic males are the only group for which GRO (female) was associated with poorer HRQOL. Future research should find ways to help youth overcome negative effects on health from gender beliefs and behavior patterns with sensitivity to racial/ethnic membership. |
A Bayesian method for analyzing combinations of continuous, ordinal, and nominal categorical data with missing values
Zhang X , Boscardin W , Belin TR , Wan X , He Y , Zhang K . J Multivar Anal 2015 135 43-58 From a Bayesian perspective, we propose a general method for analyzing a combination of continuous, ordinal (including binary), and categorical/nominal multivariate measures with missing values. We assume multivariate normal linear regression models for multivariate continuous measures, multivariate probit models for correlated ordinal measures, and multivariate multinomial probit models for multivariate categorical/nominal measures. Then we assume a multivariate normal linear model on the continuous vector comprised of continuous variables and those underlying normal variables for ordinal variables from multivariate probit models and for categorical variables from multinomial probit models. We develop a Markov chain Monte Carlo (MCMC) algorithm to estimate unknown parameters including regression parameters, cut-points for ordinal data from the multivariate probit models, and the covariance matrix encompassing both continuous variables and the underlying normal latent variables. Combining the continuous variables and the normal latent variables allows us to model combinations of continuous, ordinal, and categorical multivariate data simultaneously. The framework incorporates flexible priors for the covariance matrix, provides a foundation for inference about the underlying covariance structure, and imputes missing data where needed. The method is illustrated through simulated examples and two real data applications. |
Past year quit attempts and use of cessation resources among cigarette-only smokers and cigarette smokers who use other tobacco products
Schauer GL , Pederson LL , Malarcher AM . Nicotine Tob Res 2015 18 (1) 41-7 INTRODUCTION: It is unclear how use of other tobacco products impacts cigarette-smoking cessation. We assessed differences in past year cigarette smoking quit attempts and use of counseling and medication among current cigarette-only users, cigarette and cigar users, and cigarette and smokeless tobacco (SLT) users. METHODS: Data came from 24,448 current cigarette-only, 1,064 cigarette and cigar only, and 508 cigarette and SLT only users who responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey. Demographic, smoking, and cessation characteristics were computed by group. Bivariate and multivariable logistic regression models assessed the relationship of tobacco use group to making a past year quit attempt, and use of counseling or medication during the last quit attempt. RESULTS: Dual users of cigarettes and cigars or SLT had similar interest in quitting and prevalence of reported past year quit attempts compared to cigarette-only users. In unadjusted analyses, cigarette and SLT users had higher odds of trying to quit in the past year compared to cigarette-only users (OR=1.31, 95% CI: 1.05, 1.64); no differences were found for cigarette and cigar users. However, adjusting for demographic and cigarette smoking variables, both groups of dual users had similar odds as cigarette-only users for having made a past year cigarette smoking quit attempt, and to have used counseling or medication during the last quit attempt. CONCLUSION: Dual tobacco use was not associated with decreased attempts to quit smoking cigarettes; however, use of evidence-based treatment was sub-optimal among cigarette-only and dual users and should be increased. |
Effect of stressful life events on changes in smoking among the French: longitudinal findings from GAZEL
Tamers SL , Okechukwu C , Marino M , Gueguen A , Goldberg M , Zins M . Eur J Public Health 2015 25 (4) 711-5 BACKGROUND: Changes in life events may play a contributing role in changes in smoking behaviors. The objective was to examine the impact of stressful life events (SLEs) on smoking among French adults. METHODS: We examined smoking prevalence in 20 625 employees of the French GAZEL cohort for up to 5 years before and after a SLE during three time periods (years -1 vs. -5; years +1 vs. -1; years +5 vs. +1). Repeated measures analysis of time series data indexed to events were used, employing generalized estimating equations. RESULTS: For women, comparing 1 year after vs. 1 year before SLEs, decreased odds of smoking were found for employment promotion (OR: 0.80; 95% CI = 0.67-0.95), marriage (OR: 0.57; 95% CI = 0.48-0.68) and divorce (OR: 0.78; 95% CI = 0.68-0.90). Comparing 5 years after to 1 year after SLEs, women had decreased odds of smoking for important purchase (OR: 0.87; 95% CI = 0.79-0.96), children leaving home (OR: 0.83; 95% CI = 0.74-0.93), retirement (OR: 0.73; 95% CI = 0.64-0.83) and death of loved one (OR: 0.86; 95% CI = 0.79-0.93). For men, decreased odds of smoking were observed in all three time periods for all SLEs except when comparing 1 year before to 5 years before marriage (OR: 1.66; 95% CI = 1.09-2.52) and divorce (OR: 1.49; 95% CI = 1.25-1.77). CONCLUSION: Time surrounding SLEs during which individuals are susceptible to changing smoking behaviors may be an important consideration. |
A common source outbreak of severe delirium associated with exposure to the novel synthetic cannabinoid ADB-PINACA
Schwartz MD , Trecki J , Edison LA , Steck AR , Arnold JK , Gerona RR . J Emerg Med 2015 48 (5) 573-80 BACKGROUND: Since 2009, synthetic cannabinoid (SC) use has emerged as a growing public health threat in the United States (US). Several outbreaks of unexpected, severe toxicity linked to SC use have been reported since 2012. Reports of varied and significant morbidity after SC use are expected to increase because newer compounds enter the marketplace more frequently as manufacturers attempt to circumvent regulatory efforts. CASE REPORT: We report a cluster of 7 patients who experienced a spectrum of anxiety, delirium, psychosis, and aggressive behaviors after smoking the same SC-containing product at a party. An 8th patient with the same exposure source presented with delayed onset seizures. Biologic samples were analyzed for novel, newly identified SCs belonging to the FUBINACA family of compounds. A previously unknown SC, N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-pentyl-1H-indazole-3-carboxamide (ADB-PINACA) was identified in biologic samples from 7 of the individuals. ADB-PINACA was identified in the SC-containing product ("Crazy Clown") seized by law enforcement and identified as the product smoked by the 8 patients in the reported cluster. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The information compiled using this cluster of cases, and a similar reported outbreak of altered mental status in Colorado, implicating the same SC (ADB-PINACA) and brands of SC-containing products, aided the US Drug Enforcement Administration in its temporary scheduling of ADB-PINACA and three other SCs. In this outbreak, close cooperation between public health and law enforcement allowed for a rapid intervention, which halted the outbreak by interrupting the common source and accelerated regulatory efforts to prevent further morbidity and mortality. |
Reliability of reported maternal smoking: comparing the birth certificate to maternal worksheets and prenatal and hospital medical records, New York City and Vermont, 2009
Howland RE , Mulready-Ward C , Madsen AM , Sackoff J , Nyland-Funke M , Bombard JM , Tong VT . Matern Child Health J 2015 19 (9) 1916-24 Maternal smoking is captured on the 2003 US Standard Birth Certificate based on self-reported tobacco use before and during pregnancy collected on post-delivery maternal worksheets. Study objectives were to compare smoking reported on the birth certificate to maternal worksheets and prenatal and hospital medical records. The authors analyzed a sample of New York City (NYC) and Vermont women (n = 1,037) with a live birth from January to August 2009 whose responses to the Pregnancy Risk Assessment Monitoring System survey were linked with birth certificates and abstracted medical records and maternal worksheets. We calculated smoking prevalence and agreement (kappa) between sources overall and by maternal and hospital characteristics. Smoking before and during pregnancy was 13.7 and 10.4 % using birth certificates, 15.2 and 10.7 % using maternal worksheets, 18.1 and 14.1 % using medical records, and 20.5 and 15.0 % using either maternal worksheets or medical records. Birth certificates had "almost perfect" agreement with maternal worksheets for smoking before and during pregnancy (kappa = 0.92 and 0.89) and "substantial" agreement with medical records (kappa = 0.70 and 0.74), with variation by education, insurance, and parity. Smoking information on NYC and Vermont birth certificates closely agreed with maternal worksheets but was underestimated compared with medical records, with variation by select maternal characteristics. Opportunities exist to improve birth certificate smoking data, such as reducing the stigma of smoking, and improving the collection, transcription, and source of information. |
Comparing verbal autopsy cause of death findings as determined by physician coding and probabilistic modelling: a public health analysis of 54 000 deaths in Africa and Asia
Byass P , Herbst K , Fottrell E , Ali MM , Odhiambo F , Amek N , Hamel MJ , Laserson KF , Kahn K , Kabudula C , Mee P , Bird J , Jakob R , Sankoh O , Tollman SM . J Glob Health 2015 5 (1) 010402 BACKGROUND: Coverage of civil registration and vital statistics varies globally, with most deaths in Africa and Asia remaining either unregistered or registered without cause of death. One important constraint has been a lack of fit-for-purpose tools for registering deaths and assigning causes in situations where no doctor is involved. Verbal autopsy (interviewing care-givers and witnesses to deaths and interpreting their information into causes of death) is the only available solution. Automated interpretation of verbal autopsy data into cause of death information is essential for rapid, consistent and affordable processing. METHODS: Verbal autopsy archives covering 54 182 deaths from five African and Asian countries were sourced on the basis of their geographical, epidemiological and methodological diversity, with existing physician-coded causes of death attributed. These data were unified into the WHO 2012 verbal autopsy standard format, and processed using the InterVA-4 model. Cause-specific mortality fractions from InterVA-4 and physician codes were calculated for each of 60 WHO 2012 cause categories, by age group, sex and source. Results from the two approaches were assessed for concordance and ratios of fractions by cause category. As an alternative metric, the Wilcoxon matched-pairs signed ranks test with two one-sided tests for stochastic equivalence was used. FINDINGS: The overall concordance correlation coefficient between InterVA-4 and physician codes was 0.83 (95% CI 0.75 to 0.91) and this increased to 0.97 (95% CI 0.96 to 0.99) when HIV/AIDS and pulmonary TB deaths were combined into a single category. Over half (53%) of the cause category ratios between InterVA-4 and physician codes by source were not significantly different from unity at the 99% level, increasing to 62% by age group. Wilcoxon tests for stochastic equivalence also demonstrated equivalence. CONCLUSIONS: These findings show strong concordance between InterVA-4 and physician-coded findings over this large and diverse data set. Although these analyses cannot prove that either approach constitutes absolute truth, there was high public health equivalence between the findings. Given the urgent need for adequate cause of death data from settings where deaths currently pass unregistered, and since the WHO 2012 verbal autopsy standard and InterVA-4 tools represent relatively simple, cheap and available methods for determining cause of death on a large scale, they should be used as current tools of choice to fill gaps in cause of death data. |
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