Comparative effectiveness research in cancer: what has been funded and what knowledge gaps remain?
Glasgow RE , Doria-Rose VP , Khoury MJ , Elzarrad M , Brown ML , Stange KC . J Natl Cancer Inst 2013 105 (11) 766-73 A recent explosion of interest in comparative effectiveness research (CER) has been accompanied by diverse attempts to define CER and specify CER research methods. We explore how CER is relevant across the cancer control continuum, including prevention, screening, diagnosis, treatment, and survivorship. We review cancer CER research funded by the National Cancer Institute by analyzing project characteristics along the dimensions of cancer type, stage of the cancer continuum, position on the T0 to T4 translational continuum, and the size and representativeness of both the settings and populations studied. We also provide an assessment of cost and resources considerations in CER. One hundred three relevant projects on CER were funded by the National Cancer Institute’s Division of Cancer Control and Population Science between 2009 and 2011. Prevention studies were most frequent (38.8%), and survivorship grants were least frequent (13.5%). Many projects included economic (35.0%) or simulation modeling (10.7%) approaches as well as multilevel behavioral (53.4%) and/or organizational change (54.4%) interventions. Most studies used convenience sampling (54.3%) and studied two or less settings (50.0%). Cancer CER is active and diverse but could be enhanced by a greater focus on knowledge integration, context, relevance to stakeholders, transparency, and population impact. | Processes for generating and evaluating evidence in cancer and other areas of health care are often slow, costly, or too unrepresentative to provide useful evidence to decision makers (1). Given cancer burden, increasing concerns about cancer treatment costs, and projections about the anticipated number of cancer survivors, there is a clear need for cancer comparative effectiveness research (CER) (2). Recently, CER has been recommended as a practical approach to determining what works in health care (3). As defined by the Institute of Medicine, CER is “the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care” (3). |
Strategic priorities to increase use of clinical preventive services among older US adults
Slonim A , Benson W , Anderson LA , Jones E . Prev Chronic Dis 2013 10 E52 The objective of this project was to obtain professionals' perceptions of system-level strategies with potential to increase use of clinical preventive services (CPS) among adults aged 50 years or older through community settings. Public health, aging services, and medical professionals participated in guided discussions and a modified Delphi process. Priority strategies, determined on the basis of a 70% or higher a priori agreement level, included enhancing community capacity; promoting the design of health information technologies to exchange data between clinical and community settings; promoting care coordination; broadening scope of practice; providing incentives to employers; and eliminating cost-sharing. Findings provide insights about preferences for system-level strategies that align with national and state initiatives to increase CPS use. |
Mesothelioma incidence in 50 states and the District of Columbia, United States, 2003-2008
Henley SJ , Larson TC , Wu M , Antao VC , Lewis M , Pinheiro GA , Eheman C . Int J Occup Environ Health 2013 19 (1) 1-10 BACKGROUND: The decline in asbestos use in the United States may impact mesothelioma incidence. OBJECTIVE: This report provides national and state-specific estimates of mesothelioma incidence in the United States using cancer surveillance data for the entire US population. METHODS: Data from the National Program for Cancer Registries and the Surveillance, Epidemiology, and End Results program were used to calculate incidence rates and annual percent change. RESULTS: During 2003-2008, an average of 1.05 mesothelioma cases per 100,000 persons were diagnosed annually in the United States; the number of cases diagnosed each year remained level, whereas rates decreased among men and were stable among women. CONCLUSION: US population-based cancer registry data can be used to determine the burden of mesothelioma and track its decline. Even 30 years after peak asbestos use in the United States, 3200 mesothelioma cases are diagnosed annually, showing that the US population is still at risk. |
Is there evidence of the new variant Chlamydia trachomatis in the United States?
Won H , Ramachandran P , Steece R , Van Der Pol B , Moncada J , Schachter J , Gaydos C . Sex Transm Dis 2013 40 (5) 352-3 A specific real-time polymerase chain reaction followed by melt curve analysis was developed for the detection of the Swedish variant (nvCT) strain of Chlamydia trachomatis (CT). Surveillance was performed on 476 CT-positive clinical specimens obtained from 15 laboratories around the United States using nucleic acid amplification test assays, which would not miss the nvCT. All were negative for nvCT; thus, there is no evidence of the nvCT in the United States. |
Virus-specific differences in rates of disease during the 2010 dengue epidemic in Puerto Rico
Sharp TM , Hunsperger E , Santiago GA , Munoz-Jordan JL , Santiago LM , Rivera A , Rodriguez-Acosta RL , Gonzalez Feliciano L , Margolis HS , Tomashek KM . PLoS Negl Trop Dis 2013 7 (4) e2159 BACKGROUND: Dengue is a potentially fatal acute febrile illness (AFI) caused by four mosquito-transmitted dengue viruses (DENV-1-4) that are endemic in Puerto Rico. In January 2010, the number of suspected dengue cases reported to the passive dengue surveillance system exceeded the epidemic threshold and an epidemic was declared soon after. METHODOLOGY/PRINCIPAL FINDINGS: To characterize the epidemic, surveillance and laboratory diagnostic data were compiled. A suspected case was a dengue-like AFI in a person reported by a health care provider with or without a specimen submitted for diagnostic testing. Laboratory-positive cases had: (i) DENV nucleic acid detected by reverse transcriptase-polymerase chain reaction (RT-PCR) in an acute serum specimen; (ii) anti-DENV IgM antibody detected by ELISA in any serum specimen; or (iii) DENV antigen or nucleic acid detected in an autopsy-tissue specimen. In 2010, a total of 26,766 suspected dengue cases (7.2 per 1,000 residents) were identified, of which 46.6% were laboratory-positive. Of 7,426 RT-PCR-positive specimens, DENV-1 (69.0%) and DENV-4 (23.6%) were detected more frequently than DENV-2 (7.3%) and DENV-3 (<0.1%). Nearly half (47.1%) of all laboratory-positive cases were adults, 49.7% had dengue with warning signs, 11.1% had severe dengue, and 40 died. Approximately 21% of cases were primary DENV infections, and 1-4 year olds were the only age group for which primary infection was more common than secondary. Individuals infected with DENV-1 were 4.2 (95% confidence interval [CI]: 1.7-9.8) and 4.0 (95% CI: 2.4-6.5) times more likely to have primary infection than those infected with DENV-2 or -4, respectively. CONCLUSIONS/SIGNIFICANCE: This epidemic was long in duration and yielded the highest incidence of reported dengue cases and deaths since surveillance began in Puerto Rico in the late 1960's. This epidemic re-emphasizes the need for more effective primary prevention interventions to reduce the morbidity and mortality of dengue. |
Missed opportunities for preventing congenital syphilis infection
Introcaso CE , Bradley H , Gruber D , Markowitz LE . Sex Transm Dis 2013 40 (5) 431 Louisiana has experienced high and increasing rates of congenital syphilis (CS) since 2005.1 Using data from Louisiana’s Office of Public Health Sexually Transmitted Disease/HIV Program’s electronic investigation and reporting system, we reviewed data for all patients with CS born from January 1, 2010 to October 6, 2011. Similar to other recent US reports, we found women with documented prenatal care who did not receive recommended testing or treatment for syphilis.2 | Fifty-five women gave birth to 57 infants identified as CS cases by the Louisiana Sexually Transmitted Disease/HIV Program; cases can be identified based on a mother’s history of untreated syphilis or findings in the infant.1 This corresponds to 51.9 cases per 100,000 births.3 Thirty-six women (65%) had documented prenatal care before 30 weeks of gestation. Of those 36, 4 (11%) had documented adequate treatment for syphilis before pregnancy, and 19 (53%) had adequate maternal treatment during pregnancy. Among those 23, 3 women had infants with abnormal evaluations. The remaining 20 women had infants who were classified as CS cases due to maternal serology or reasons that are unclear. Five (14%) of the 36 received penicillin-based treatment less than 30 days before delivery, and 8 (22%) had no treatment documented. No woman received non–penicillin-based treatment. Of the 8 women with no treatment documented, 1 had a positive syphilis test result 5 months before delivery, and 6 had their first positive test result at delivery or within 1 month of delivery, without documentation of prior negative test results. Only 1 untreated woman who tested positive at delivery had a documented negative syphilis test result at her first prenatal visit. The 5 women who received late treatment, together with the 7 women with no treatment who were tested late in pregnancy, represent 12 missed opportunities to prevent CS in Louisiana in less than 2 years. |
Prolonged university outbreak of meningococcal disease associated with a serogroup B strain rarely seen in the US
Mandal S , Wu HM , Macneil JR , Machesky K , Garcia J , Plikaytis BD , Quinn K , King L , Schmink SE , Wang X , Mayer LW , Clark TA , Gaskell JR , Messonnier NE , Diorio M , Cohn AC . Clin Infect Dis 2013 57 (3) 344-8 BACKGROUND: College students living in residential halls are at increased risk of meningococcal disease. Unlike for serogroups prevented by quadrivalent meningococcal vaccines, public health response to outbreaks of serogroup B meningococcal disease is limited by lack of a US licensed vaccine. METHODS: In March 2010 we investigated a prolonged outbreak of serogroup B disease associated with a university. In addition to case ascertainment, molecular typing of isolates was performed to characterize the outbreak. We conducted a matched case-control study to examine risk factors for serogroup B disease. Five controls per case, matched by college year, were randomly selected. Participants completed a risk factor questionnaire. Data were analyzed using conditional logistic regression. RESULTS: Between January 2008 and November 2010, we identified 13 meningococcal disease cases (seven confirmed, four probable, and two suspected) among university students (ten) or university-linked persons (three). One student died. Ten cases were determined to be serogroup B. Isolates from six confirmed cases had an indistinguishable pulse-field gel electrophoresis pattern and belonged to sequence type ST-269, clonal complex 269. Factors significantly associated with disease were Greek Society membership (matched odds ratio [mOR] 15.0; p=0.03), >1 kissing partner (mOR 13.7; p=0.03) and attending bars (mOR 8.1; p=0.04). CONCLUSIONS: The outbreak was associated with a novel serogroup B strain (CC269) and risk factors indicative of increased social mixing. Control measures were appropriate but limited by lack of vaccine. Understanding serogroup B transmission in college and other settings will help inform use of serogroup B vaccines currently under consideration for licensure. |
Global concerns regarding novel influenza A (H7N9) virus infections
Uyeki TM , Cox NJ . N Engl J Med 2013 368 (20) 1862-4 Severe disease in humans caused by a novel influenza A virus that is distinct from circulating human influenza A viruses is a seminal event. It might herald sporadic human infections from an animal source - e.g., highly pathogenic avian influenza (HPAI) A (H5N1) virus; or it might signal the start of an influenza pandemic - e.g., influenza A(H1N1)pdm09 virus. Therefore, the discovery of novel influenza A (H7N9) virus infections in three critically ill patients reported in the Journal by Gao and colleagues is of major public health significance. Chinese scientists are to be congratulated for the apparent speed with which . . . |
The hidden epidemic of hepatitis C virus infection in the United States: occult transmission and burden of disease
Ward JW . Top Antivir Med 2013 21 (1) 15-19 Society faces an immense burden of hepatitis C virus (HCV) infection-related morbidity and mortality. Transmission of HCV is ongoing, and the incidence of HCV infection has been increasing in recent years. New therapies for treating HCV infection hold considerable promise for increasing cure rates and thus reducing HCV transmission. However, many persons with HCV infection in the United States are unaware of their infection status. The Centers for Disease Control and Prevention (CDC) recently expanded its HCV testing recommendations to include 1-time HCV testing for individuals born between 1945 and 1965, a population with a 3% prevalence of infection. Linkage to care and treatment for those identified with infection through testing would have a profound impact in reducing HCV disease burden. Coordinated efforts by public health agencies, clinical care providers, laboratories, and payers are necessary to improve primary and secondary prevention of HCV disease. This article summarizes a presentation by John W. Ward, MD, at the IAS-USA live continuing medical education program held in Atlanta, Georgia, in October 2012. |
International travelers as sentinels for sustained influenza transmission during the 2009 influenza A(H1N1)pdm09 pandemic
Davis XM , Hay KA , Plier DA , Chaves SS , Lim PL , Caumes E , Castelli F , Kozarsky PE , Cetron MS , Freedman DO . J Travel Med 2013 20 (3) 177-84 BACKGROUND: International travelers were at risk of acquiring influenza A(H1N1)pdm09 (H1N1pdm09) virus infection during travel and importing the virus to their home or other countries. METHODS: Characteristics of travelers reported to the GeoSentinel Surveillance Network who carried H1N1pdm09 influenza virus across international borders into a receiving country from April 1, 2009, through October 24, 2009, are described. The relationship between the detection of H1N1pdm09 in travelers and the level of H1N1pdm09 transmission in the exposure country as defined by pandemic intervals was examined using analysis of variance (anova). RESULTS: Among the 203 (189 confirmed; 14 probable) H1N1pdm09 case-travelers identified, 56% were male; a majority, 60%, traveled for tourism; and 20% traveled for business. Paralleling age profiles in population-based studies only 13% of H1N1pdm09 case-travelers were older than 45 years. H1N1pdm09 case-travelers sought pre-travel medical advice less often (8%) than travelers with non-H1N1pdm09 unspecified respiratory illnesses (24%), and less often than travelers with nonrespiratory illnesses (43%; p < 0.0001). The number of days from first official H1N1pdm09 case reported by a country to WHO and the first GeoSentinel site report of a H1N1pdm09-exported case in a traveler originated from that country was inversely associated with each country's assigned pandemic interval, or local level of transmission intensity. CONCLUSION: Detection of travel-related cases appeared to be a reliable indicator of sustained influenza transmission within the exposure country and may aid planning for targeted surveillance, interventions, and quarantine protocols. |
Systematics and ecology of the brown dog tick, Rhipicephalus sanguineus
Gray J , Dantas-Torres F , Estrada-Pena A , Levin M . Ticks Tick Borne Dis 2013 4 (3) 171-80 Rhipicephalus sanguineus, the brown dog tick, kennel tick, or pan-tropical dog tick, is probably the most widespread ixodid tick, colonising both human and canine dwellings. It is of great significance in both human and veterinary medicine as a vector of several important pathogens and can also cause clinical illness in heavy infestations of dogs. However, there are still significant taxonomic uncertainties, and it is probable that some records of this tick refer to other species. Most past reviews have been broad-ranging or have focused on the pathogens that R. sanguineus transmits, and relatively few have considered its biology in detail or the issues around its true identity. The present review has paid most attention to the taxonomy of R. sanguineus and to the ecological factors that influence tick survival and distribution, particularly in a climate change context. It is evident that more research is required on the systematics of the R. sanguineus species complex, in order to elucidate the epidemiology and prevention of the diseases that it transmits, and to provide the relevant biological data required for development of predictive models of future tick distribution in a climate change scenario. |
Effects of low-temperature flea maintenance on the transmission of Yersinia pestis by Oropsylla montana
Williams SK , Schotthoeffer AM , Montenieri JA , Holmes JL , Vetter SM , Gage KL , Bearden SW . Vector Borne Zoonotic Dis 2013 13 (7) 468-78 Yersinia pestis, the causative agent of plague, is primarily a rodent-associated, flea-borne zoonosis maintained in sylvatic foci throughout western North America. Transmission to humans is mediated most commonly by the flea vector Oropsylla montana and occurs predominantly in the southwestern United States. With few exceptions, previous studies showed O. montana to be an inefficient vector at transmitting Y. pestis at ambient temperatures, particularly when such fleas were fed on susceptible hosts more than a few days after ingesting an infectious blood meal. We examined whether holding fleas at subambient temperatures affected the transmissibility of Y. pestis by this vector. An infectious blood meal containing a virulent Y. pestis strain (CO96-3188) was given to colony-reared O. montana fleas. Potentially infected fleas were maintained at different temperatures (6 degrees C, 10 degrees C, 15 degrees C, or 23 degrees C). Transmission efficiencies were tested by allowing up to 15 infectious fleas to feed on each of 7 naive CD-1 mice on days 1-4, 7, 10, 14, 17, and 21 postinfection (p.i.). Mice were monitored for signs of infection for 21 days after exposure to infectious fleas. Fleas held at 6 degrees C, 10 degrees C, and 15 degrees C were able to effectively transmit at every time point p.i. The percentage of transmission to naive mice by fleas maintained at low temperatures (46.0% at 6 degrees C, 71.4% at 10 degrees C, 66.7% at 15 degrees C) was higher than for fleas maintained at 23 degrees C (25.4%) and indicates that O. montana fleas efficiently transmit Y. pestis at low temperatures. Moreover, pooled percent per flea transmission efficiencies for flea cohorts maintained at temperatures of 10 degrees C and 15 degrees C (8.67% and 7.87%, respectively) showed a statistically significant difference in the pooled percent per flea transmission efficiency from fleas maintained at 23 degrees C (1.94%). This is the first comprehensive study to demonstrate efficient transmission of Y. pestis by O. montana fleas maintained at temperatures as low as 6 degrees C. Our findings further contribute to the understanding of plague ecology in temperate climates by providing support for the hypothesis that Y. pestis is able to overwinter within the flea gut and potentially cause infection during the following transmission season. The findings also might hold implications for explaining the focality of plague in tropical regions. |
Evaluation of imidacloprid-treated traps as an attract and kill system for filth flies during contingency operations
Dunford JC , Hoel DF , Hertz JC , England DB , Dunford KR , Stoops CA , Szumlas DE , Hogsette JA . US Army Med Dep J 2013 73-9 Two field trials were conducted to evaluate if filth fly trap efficacy was increased by augmentation with an insecticide application to the trap's exterior. Four Fly Terminator Pro traps (Farnam Companies, Inc, Phoenix, AZ) baited with Terminator Fly Attractant (in water) were suspended on polyvinyl chloride pipe framing at a municipal waste transfer site in Clay County, Florida. The outer surfaces of 2 traps were treated with Maxforce Fly Spot Bait (Bayer Environmental Science, Research Triangle Park, NC) (10% imidacloprid) to compare kill rates between treated and untreated traps. Kill consisted of total flies collected from inside traps and from mesh nets suspended beneath all traps, both treated and untreated. Each of 2 treated and untreated traps was rotated through 4 trap sites every 24 hrs. In order to evaluate operational utility and conservation of supplies during remote contingency operations, fly attractant remained in traps for the duration of the first trial but was changed daily during the second trial (following manufacturer's recommendations). In addition, (1/2) strength Terminator Fly Attractant was used during the first trial and traps were set at full strength during the second trial. Flies collected within the traps and in mesh netting were counted and identified. Three species, Musca domestica (L.), Chrysomya megacephala (F.), and Lucilia cuprina (Wiedemann), comprised the majority of samples in both trials. The net samples recovered more flies when the outer surface was treated with imidacloprid, however, treated traps collected fewer flies inside the trap than did untreated traps for both trials. No significant statistical advantage was found in treating Fly Terminator Pro trap exteriors with Maxforce Fly Spot Bait. However, reducing manufacturer's recommended strength of Terminator Fly Attractant showed similar results to traps set at full strength. Treating the outer surfaces may improve kill of fly species that do not enter the trap. Terminator Fly Attractant was also found to be more effective if traps were not changed daily and left to hold dead flies for longer periods. |
Surveillance during an era of rapidly changing poliovirus epidemiology in India: the role of one vs. two stool specimens in poliovirus detection, 2000-2010
Cardemil CV , Rathee M , Gary H , Wannemuehler K , Anand A , Mach O , Bahl S , Wassilak S , Chu SY , Khera A , Jafari HS , Pallansch MA . Epidemiol Infect 2013 142 (1) 1-9 SUMMARY: Since 2004, efforts to improve poliovirus detection have significantly increased the volume of specimen testing from acute flaccid paralysis (AFP) patients in India. One option to decrease collection and testing burden would be collecting only a single stool specimen instead of two. We investigated stool specimen sensitivity for poliovirus detection in India to estimate the contribution of the second specimen. We reviewed poliovirus isolation data for 303984 children aged <15 years with AFP during 2000-2010. Using maximum-likelihood estimation, we determined specimen sensitivity of each stool specimen, combined sensitivity of both specimens, and sensitivity added by the second specimen. Of 5184 AFP patients with poliovirus isolates, 382 (7.4%) were identified only by the second specimen. Sensitivity was 91.4% for the first specimen and 84.5% for the second specimen; the second specimen added 7.3% sensitivity, giving a combined sensitivity of 98.7%. Combined sensitivity declined, and added sensitivity increased, as the time from paralysis onset to stool collection increased (P = 0.032). The sensitivity added by the second specimen is important to detect the last chains of poliovirus transmission and to achieve certification of polio eradication. For sensitive surveillance, two stool specimens should continue to be collected from each AFP patient in India. |
Forecasting invasive pneumococcal disease trends after the introduction of 13-valent pneumococcal conjugate vaccine in the United States, 2010-2020
Link-Gelles R , Taylor T , Moore MR . Vaccine 2013 31 (22) 2572-7 INTRODUCTION: Pneumococcal vaccines are highly effective at preventing invasive pneumococcal disease (IPD), a leading cause of global morbidity. Because pneumococcal vaccines can be expensive, it is useful to estimate what impact might be expected from their introduction. Our objective was to develop a statistical model that could predict rates of IPD following introduction of 13-valent pneumococcal conjugate vaccine (PCV13) in the U.S. METHODS: We used active surveillance data to design and validate a Poisson model forecasting the reductions in IPD observed after U.S. introduction of 7-valent pneumococcal conjugate vaccine (PCV7) in 2000. We used this model to forecast rates of IPD from 2010 to 2020 in the presence of PCV13. Because increases in non-PCV7-type IPD were evident following PCV7 introduction, we evaluated varying levels of increase in non-PCV13-type IPD ("serotype replacement") by sensitivity analyses. RESULTS: A total of 43,507 cases of IPD were identified during 1998-2009; cases from this period were used to develop the model, which accurately predicted indirect effects of PCV7 in adults, as well as serotype replacement. Assuming that PCV13 provides similar protection against PCV13 serotypes as PCV7 did against PCV7 serotypes, the base-case model predicted approximately 168,000 cases of IPD prevented from 2011 to 2020. When serotype replacement was varied in sensitivity analyses from 0 to levels comparable to that seen with serotype 19A (the most common replacement serotype since PCV7 was introduced), the model predicted 167,000-170,000 cases prevented. The base-case model predicted rates of IPD in children under five years of age decreasing from 21.9 to 9.3 cases per 100,000 population. CONCLUSIONS: This model provides a "benchmark" for assessing progress in the prevention of IPD in the years after PCV13 introduction. The amount of serotype replacement is unlikely to greatly affect the overall number of cases prevented by PCV13. |
Correlates of self-reported pelvic inflammatory disease treatment in sexually experienced reproductive-aged women in the United States, 1995 and 2006-2010
Leichliter JS , Chandra A , Aral SO . Sex Transm Dis 2013 40 (5) 413-8 BACKGROUND: Few studies have examined recent temporal trends in self-reported receipt of pelvic inflammatory disease (PID) treatment. We assessed trends in receipt of PID treatment and associated correlates using national survey data. METHODS: We used data from the National Survey of Family Growth, a multistage national probability survey of 15- to 44-year-old women. We examined trends in self-reported receipt of PID treatment from 1995, 2002, to 2006-2010. In addition, we examined correlates of PID treatment in 1995 and 2006-2010 in bivariate and adjusted analyses. RESULTS: From 1995 to 2002, receipt of PID treatment significantly declined from 8.6% to 5.7% (P < 0.0001); however, there was no difference from 2002 to 2006-2010 (5.0%, P = 0.16). In bivariate analyses, racial differences in PID treatment declined across time; in 2006-2010, there was no significant difference between racial/ethnic groups (P = 0.22). Also in bivariate analyses, similar to 1995, in 2006 to 2010, some of the highest reports of receipt of PID treatment were women who were 35 to 44 years old (5.6%), had an income less than 150% of poverty level (7.5%), had less than high school education (6.7%), douched (7.7%), had intercourse before age 15 years (10.3%), and had 10 or more lifetime partners (8.0%). In adjusted analyses, differing from 1995, women at less than 150% of the poverty level were more likely (adjusted odds ratio [AOR], 2.60; 95% confidence interval [CI], 1.79-3.76) than women at 300% or more of the poverty level to have received PID treatment in 2006-2010. CONCLUSIONS: Receipt of PID treatment declined from 1995 to 2006-2010, with the burden affecting women of lower socioeconomic status. |
Foodborne disease outbreaks caused by Bacillus cereus, Clostridium perfringens, and Staphylococcus aureus, United States, 1998-2008
Bennett SD , Walsh KA , Gould LH . Clin Infect Dis 2013 57 (3) 425-33 From 1998-2008, 1,229 foodborne outbreaks caused by B. cereus, C. perfringens, S. aureus were reported in the United States; 39% were reported with a confirmed etiology. Vomiting was commonly reported in B. cereus (median: 75% of cases) and S. aureus outbreaks (median: 87%), but rarely in C. perfringens outbreaks (median: 9%). Meat or poultry dishes were commonly implicated in C. perfringens (63%) and S. aureus (55%) outbreaks, while rice dishes were commonly implicated in B. cereus outbreaks (50%). Errors in food processing and preparation were commonly reported (93%), regardless of etiology; contamination by a food worker was only common in S. aureus outbreaks (55%). Public health interventions should focus on these commonly reported errors to reduce the occurrence of outbreaks caused by B. cereus, C. perfringens, and S. aureus in the United States. |
Correlates of health attitudes among homosexual and bisexual men
Gust DA , Shinde S , Pals SL , Hardnett F , Chen RT , Sanchez T . J Epidemiol Glob Health 2013 3 (1) 31-39 There is increased emphasis on physician attention to the overall health and wellness of homosexual and bisexual men, though little is known about the health-related attitudes of these groups. This study determined factors associated with the health attitudes of homosexual and bisexual men and identified preferred sources of health information. For this study, the 2008 ConsumerStyles panel survey was used to create three health attitude scales and to determine factors associated with each scale. The three scales were labeled: (1) health motivation; (2) relationship with health care provider; and (3) self-perception of health literacy. In addition to other factors, higher scores for health motivation and relationship with health care provider were associated with black compared with white men. In contrast, lower scores for self-perception of health literacy were associated with black compared with white men. For information on an unfamiliar health condition, most homosexual and bisexual men chose the Internet. Black homosexual and bisexual men reported being motivated to be healthy and working well with their health care provider to manage their health. However, their perception of their own health motivation was low compared with the white men. Attempts to improve health literacy through Internet sites may be helpful in improving health attitudes and reducing negative health outcomes. (2013 Ministry of Health, Saudi Arabia.) |
Fatal adenovirus encephalomyeloradiculitis in an umbilical cord stem cell transplant recipient
Awosika OO , Lyons JL , Ciarlini P , Phillips RE , Alfson ED , Johnson EL , Koo S , Marty F , Drew C , Zaki S , Folkerth RD , Klein JP . Neurology 2013 80 (18) 1715-7 Adenovirus infections frequently complicate allogeneic stem cell transplants but nervous system involvement, usually presenting as encephalitis, is atypical. Progression from encephalitis to myeloradiculitis has not been described previously.(1) We present a unique case of fatal adenoviral encephalomyeloradiculitis with imaging and pathologic correlates. |
A survey of US travelers to Asia to assess compliance with recommendations for the use of Japanese encephalitis vaccine
Duffy MR , Reed C , Edelson PJ , Blumensaadt S , Crocker K , Griggs A , Biggerstaff BJ , Delorey MJ , Hayes EB , Fischer M . J Travel Med 2013 20 (3) 165-70 BACKGROUND: Japanese encephalitis (JE) vaccine is recommended for travelers to Asia whose itineraries increase their risk of exposure to JE virus. The numbers of travelers with such itineraries and the proportion of those who receive JE vaccine are unknown. We performed a survey to estimate the proportion of US travelers to Asia who receive JE vaccine according to the Advisory Committee on Immunization Practices (ACIP) recommendations. METHODS: We surveyed US residents ≥18 years old departing on 38 flights to Asia selected through a stratified random sample of all direct flights to JE-endemic countries from three US airports. We asked participants about planned itineraries and activities, sources of travel health information, JE vaccination status, and potential barriers to vaccination. Participants planning to spend ≥30 days in Asia or at least half of their time in rural areas were defined as "higher JE risk" travelers for whom vaccination should have been considered. RESULTS: Of 2,341 eligible travelers contacted, 1,691(72%) completed the survey. Among these 1,691 participants, 415 (25%) described itineraries for which JE vaccination should have been considered. Of these 415 higher JE risk travelers, only 47 (11%) reported receiving ≥1 dose of JE vaccine. Of the 164 unvaccinated higher JE risk travelers who visited a health care provider before their trip, 113 (69%) indicated that they had never heard of JE vaccine or their health care provider had not offered or recommended JE vaccine. CONCLUSIONS: A quarter of surveyed US travelers to Asia reported planned itineraries for which JE vaccination should have been considered. However, few of these at-risk travelers received JE vaccine. |
A systematic review of anti-rotavirus serum IgA antibody titer as a potential correlate of rotavirus vaccine efficacy
Patel M , Glass R , Jiang B , Santosham M , Lopman B , Parashar U . J Infect Dis 2013 208 (2) 284-94 BACKGROUND: Identifying an immunological correlate of protection for rotavirus vaccines [Rotarix (RV1) and RotaTeq (RV5)] would substantially facilitate testing of interventions for improving efficacy in developing countries and evaluating additional candidate rotavirus vaccines. METHODS: We accessed PubMed and ClinicalTrials.gov to identify immunogenicity and efficacy trials for RV1 and RV5 to correlate anti-rotavirus serum IgA antibody titers versus efficacy in regions stratified by all-cause under-5 mortality rates (u5MR). We established a cutoff point for IgA GMT that predicted lower efficacy and calculated pooled vaccine efficacy among countries with high versus low IgA titers. FINDINGS: We observed an inverse correlation between u5MR and IgA GMT for RV1 (r(2)=0.72; P<0.001 and RV5 (r(2)=0.66; P<0.001) and between efficacy and IgA GMT for both vaccines (r(2)=0.56; P=0.005). Post-immunization anti-rotavirus IgA GMTs less than 90 were associated with decline in vaccine efficacy. Efficacy during first 2 years of life was significantly lower among countries with IgA GMT <90 (44%; 95% CI: 30-55) compared to countries with GMT >90 (85%; 95%CI: 82-88). INTERPRETATION: We observed a significant correlation between IgA titers and rotavirus vaccine efficacy and hypothesize that a critical level of IgA antibody titer is associated with a sufficient level of sustained protection after rotavirus vaccination. |
Vitamin D is not associated with serologic response to influenza vaccine in adults over 50 years old
Sundaram ME , Talbot HK , Zhu Y , Griffin MR , Spencer S , Shay DK , Coleman LA . Vaccine 2013 31 (16) 2057-61 Vitamin D deficiency has been implicated in risk of respiratory illness. We determined whether serum vitamin D levels are related to influenza vaccine response measured by hemagglutination antibody inhibition (HAI) titer in adults aged ≥50 years old. The study was a prospective cohort study conducted over two influenza seasons (fall 2008-spring 2009 and fall 2009-spring 2010) in Marshfield, WI and Nashville, TN including 1103 community-dwelling adult volunteers ≥50 years of age. Pre-vaccination levels of serum vitamin D and HAI titer levels pre- and 21-28 days post-influenza vaccination were measured. Seroprotection was defined as HAI ≥40; seroconversion was defined as ≥4-fold rise in HAI titers from pre- to post-vaccination. More than 25% of participants were vitamin D deficient (<25ng/mL). Vitamin D measured as a continuous variable was not related to pre- or post-vaccination seroprotection or seroconversion for any vaccine strain in any year. Vitamin D deficiency was associated with a greater frequency of post-vaccination seroprotection for seasonal H1N1 in the first year of the study, but was not related to seroprotection or seroconversion for any other strain in either year. No consistent association was found between vitamin D levels or vitamin D deficiency and serologic response to influenza vaccination in older adults. Cell-mediated immune parameters should also be explored in order to further investigate possible relationships between micronutrient status and influenza vaccine response. |
Enterovirus 71 encephalitis: A new vaccine on the horizon?
Pallansch MA , Oberste MS . Lancet 2013 381 (9871) 976-977 ince its discovery in 1969, enterovirus 71 (EV71) has been associated with outbreaks of severe neurological disease and mild hand, foot, and mouth disease.1 The virus circulates worldwide and caused several outbreaks of poliomyelitis-like paralysis and brainstem encephalitis in eastern Europe during the 1970s, with few associated outbreaks of hand, foot, and mouth disease. Yet in Europe and North America, EV71 is a common cause (as are several other enteroviruses) of hand, foot, and mouth disease—a common illness of young children—although few cases are regarded as serious in these regions. | In 1997, EV71 was implicated in the deaths of 34 children due to neurogenic cardiopulmonary failure during a hand, foot, and mouth disease outbreak in Sarawak, Malaysia.1, 2 Since then, hundreds of deaths have been attributed to EV71 infection during large disease outbreaks throughout the Asia-Pacific region, including in Taiwan, Malaysia, China, Vietnam, and Cambodia.3 In 2009, China reported more than 1·1 million hand, foot, and mouth disease cases, more than 13 000 of which were classed as severe, and 353 deaths were reported. During this period, EV71 was also circulating in Europe, North America, and Africa, but led to few severe cases and deaths. |
Differential profiles and inhibitory effect on rotavirus vaccines of non-antibody components in breast milk from mothers in developing and developed countries
Moon SS , Tate JE , Ray P , Dennehy PH , Archary D , Coutsoudis A , Bland R , Newell ML , Glass RI , Parashar U , Jiang B . Pediatr Infect Dis J 2013 32 (8) 863-70 BACKGROUND: Live oral rotavirus vaccines have been less immunogenic and efficacious for children of developing countries than for those in middle income and industrialized countries and the basis for these differences is not fully understood. Recently, we demonstrated that breastmilk from mothers in India had significantly higher IgA and neutralizing activity against rotavirus that could reduce the effective titer of rotavirus vaccines reaching the gut when compared to that from mothers in the US. We extended our study to understand the specific contribution of those non-antibody components in breastmilk to the neutralizing activity against rotavirus vaccine we observed. METHODS: Breastmilk samples were collected from mothers of breast-feeding infants aged between 4 to 29 weeks (i.e., vaccine eligible age) in India (N=40), South Africa (N=50) and the United States (N=51). We examined breastmilk for lactoferrin, lactadherin, rotavirus-specific IgA, and neutralizing activity against three rotavirus vaccine strains: Rotarix; RotaTeq G1; and 116E using enzyme immunoassays; a plaque reduction assay; or a microneutralization assay. FINDINGS: We observed higher levels of lactoferrin, lactadherin, IgA, and neutralizing activity in breastmilk specimens from Indian and South African women than those from American women. We demonstrated positive associations between levels of lactoferrin or IgA and neutralizing activity in Indian and South African specimens, but not in American specimens. We demonstrated that the inhibitory effect of lactoferrin was dose- or species-dependent, as evidenced by greater reduction in titer of Rotarix and 116E by human lactoferrin. Lactadherin also exhibited inhibitory activity to rotavirus vaccines but appeared to be less effective. INTERPRETATION: The lower immunogenicity and efficacy of rotavirus vaccines in developing countries could be explained, in part, by synergistic inhibitory effect of high levels of antibody and non-antibody components in breastmilk consumed by infants at the time of immunization. Therefore, there is a need for alternative rotavirus vaccine strategies in breastfeeding populations. |
Serological diagnosis of North American paragonimiasis by Western blot using Paragonimus kellicotti adult worm antigen
Fischer PU , Curtis KC , Folk SM , Wilkins PP , Marcos LA , Weil GJ . Am J Trop Med Hyg 2013 88 (6) 1035-40 We studied the value of an IgG Western blot (WB) with Paragonimus kellicotti (Pk) antigen for diagnosis of North American paragonimiasis. The test was evaluated with sera from patients with Pk and Paragonimus westermani infections, with control sera from patients with other helminth infections, and sera from healthy Americans. All 11 proven Pk infection sera and two samples from suspected cases that were negative by P. westermani WB at Centers for Disease Control and Prevention (CDC) contained antibodies to antigens at 34 kDa and at 21/23 kDa. Seven of 7 P. westermani sera contained antibodies to the 34 kDa antigen, but only 2 recognized the 21/23 kDa doublet. No control samples were reactive with these antigens. Antibody reactivity declined after praziquantel treatment. Thus, the P. kellicotti WB appears to be superior to P. westermani WB for diagnosing Pk infections, and it may be useful for assessing responses to treatment. |
Neuraminidase inhibitor susceptibility testing of influenza type B viruses in China during 2010 and 2011 identifies viruses with reduced susceptibility to oseltamivir and zanamivir
Wang D , Sleeman K , Huang W , Nguyen HT , Levine M , Cheng Y , Li X , Tan M , Xing X , Xu X , Klimov AI , Gubareva LV , Shu Y . Antiviral Res 2013 97 (3) 240-4 Influenza type B viruses are responsible for substantial morbidity and mortality in humans. Antiviral drugs are an important supplement to vaccination for reducing the public health impact of influenza virus infections. Influenza B viruses are not sensitive to M2 inhibitors which limit the current therapeutic options to two neuraminidase inhibitors (NAIs), oseltamivir and zanamivir, which are licensed in many countries. Drug resistance is a public health concern which has necessitated monitoring of influenza virus drug susceptibilities through active global surveillance. Here, we report the results of drug susceptibility surveillance of influenza type B viruses (n=680) collected in mainland China during two calendar years, 2010 and 2011, assessed using functional neuraminidase (NA) inhibition (NI) assays. Four influenza B viruses exhibited reduced susceptibilities to oseltamivir, but not zanamivir, and shared the amino acid substitution I221T (ATC-->ACC), at this conserved residue in the NA active site (I222T in N2 numbering). Additionally, a single virus with reduced susceptibility to both oseltamivir and zanamivir was identified and contained an amino acid substitution D197N (GAC-->AAC) at another conserved residue in the NA active site (D198N in N2 numbering). This report underlies the importance of continued influenza antiviral susceptibility surveillance globally, even in countries where the use of NAIs has been low or non-existing. |
Non-invasive serum fibrosis markers for screening and staging chronic hepatitis C virus (HCV) patients in a large U.S. cohort
Holmberg SD , Lu M , Rupp LB , Lamerato LE , Moorman AC , Vijayadeva VX , Boscarino JA , Henkle EW , Gordon SC . Clin Infect Dis 2013 57 (2) 240-6 BACKGROUND: Liver biopsy remains critical for staging liver disease in hepatitis C virus (HCV)-infected persons, but is a bottleneck to evaluation, follow-up and treatment of HCV. Our analysis sought to validate 'APRI' (aspartate aminotransferase [AST]-to-platelet ratio index) and 'FIB-4,' an index from serum fibrosis markers (alanine aminotransferase [ALT], AST, and platelets plus patient age) to stage liver disease. METHODS: Biopsy results from HCV patients in the Chronic Hepatitis Cohort Study ('CHeCS') were mapped to a F0-F4 equivalent scale; APRI and FIB-4 scores at the time of biopsy were then mapped to the same scale. RESULTS: We identified 2,372 liver biopsies from HCV-infected patients with contemporaneous laboratory values for imputing APRI and FIB-4. Fibrosis stage distributions by the equivalent biopsy scale were: 267 (11%) F0; 555 (23%) F1; 648 (27%) F2; 394 (17%) F3; and 508 (21%) F4. Mean APRI and FIB-4 values significantly increased with successive fibrosis levels (p<0.05). The areas under the curves using receiver operating characteristic curves (AUROC) analysis distinguishing severe (F3-F4) from mild-to-moderate fibrosis (F0-F2) were: 0.80 (0.78, 0.82) for APRI; and 0.83 (0.81, 0.85) for FIB-4. There was a significant difference between the AUROCs of FIB-4 and APRI (p<0.001); 88% of persons who had a FIB-4 score>2.0 were at stage F2 or higher. CONCLUSION: In a large observational cohort, FIB-4 was good at differentiating five stages of chronic HCV infection. It can be useful: in screening patients who need biopsy and therapy; for monitoring less advanced disease patients; and for longitudinal studies. |
Identifying and classifying bloodstream infections among hemodialysis patients
Kallen AJ . Semin Dial 2013 26 (4) 407-15 Bloodstream infections (BSIs) are a prominent clinical problem in patients undergoing hemodialysis. These infections appear to be more common among patients who have a central line as their dialysis access and can be associated with substantial morbidity and mortality. Accurately diagnosing BSIs clearly influences patient management, but is also an important part of an infection prevention program; particularly as facility BSI rates are becoming a recognized quality measure for which dialysis facilities might be held accountable. Blood cultures remain the gold standard for diagnosing BSIs and a number of practices can affect the sensitivity and specificity of this important laboratory test. Optimizing the collection of blood cultures can assist providers with interpretation of positive blood cultures and can help minimize the impact of false-positive and false-negative cultures. This review will describe differences between BSI definitions, examine the use of blood cultures to identify these infections including the use of recommended best practices to maximize culture yield, and highlight characteristics that can assist in the clinical interpretation of positive blood cultures. |
Is bleach-sedimented smear microscopy an alternative to direct microscopy under programme conditions in India?
Vishnu PH , Bhat P , Bansal A , Satyanarayana S , Alavadi U , Ohri BS , Rao Shrinivas MS , Desikan P , Jaju J , Rao VG , Moonan PK . Public Health Action 2013 3 (1) 23-25 This cross-sectional multi-centric study compared the yield of and potential benefit for detecting smear-positive pulmonary tuberculosis (PTB) by bleach sedimentation (2% sodium-hypochlorite) versus direct microscopy under programme conditions in India. Among 3168 PTB suspects, 684 (21.6%) were detected by bleach sedimentation vs. 625 (19.7%) by direct microscopy, with a proportional overall agreement of 96% ( = 0.88). While 594 patients were smear-positive with both methods, 31 patients detected by direct microscopy were missed and an additional 90 patients were detected by bleach sedimentation. Overall, bleach sedimentation increased the yield of smear-positive TB detection; however; it also increased the time to results. (2013 The Union.) |
Activation and cell death in human dendritic cells infected with Nipah virus
Gupta M , Lo MK , Spiropoulou CF . Virology 2013 441 (1) 49-56 Nipah virus (NiV) is a highly pathogenic paramyxovirus that causes pulmonary disease and encephalitis in humans with 40-70% fatality. Interactions between NiV and the human immune system remain poorly understood. Here, we demonstrate the effects of NiV infection on DC and T cell function. Using an in vitro system, we found that NiV infects and replicates at low levels in DCs and induces the expression of TNF-alpha, IL-1alpha, IL-1beta, IL-8, and IP-10. NiV infection activates DCs, and upregulates the expression of CD40, CD80, and CD86. Also have reduced levels of bcl2 and high levels of active caspase 3, suggesting the induction of apoptosis. DCs infected by NiV are unable to efficiently prime CD4 and CD8 T cells, but instead induce apoptosis in T cells. Interestingly, DCs treated with inactivated NiV also show signs of apoptosis. These findings indicate that NiV infected DCs could play an important role in NiV pathogenesis. |
Apoptosis induced by tungsten carbide-cobalt nanoparticles in JB6 cells involves ROS generation through both extrinsic and intrinsic apoptosis pathways
Zhao J , Bowman L , Magaye R , Leonard SS , Castranova V , Ding M . Int J Oncol 2013 42 (4) 1349-59 In this study, apoptosis and related signaling induced by WC-Co nanoparticles were investigated in JB6 cells and rat lung macrophages. Electron spin resonance (ESR) and fluorescent staining indicated that both WC-Co nanoparticles and fine particles stimulated reactive oxygen species (ROS) generation. Catalase exhibited an inhibitory effect on WC-Co nanoparticle-induced ROS as well as mitochondrial membrane permeability damage. Further study indicated that WC-Co nanoparticles elicited higher cytotoxicity and apoptotic induction than fine particles. Western blot analysis showed activation of proapoptotic factors including Fas, Fas-associated protein with death domain (FADD), caspase 3, 8 and 9, BID and BAX. In addition, both cytochrome c and apoptosis-inducing factor (AIF) were upregulated and released from mitochondria to the cytoplasm. Our findings demonstrate that, on a mass basis, WC-Co nanoparticles exhibit higher cytotoxicity and apoptotic induction than fine particles. Apoptosis induced by WC-Co nanoparticles and fine particles involves both extrinsic and intrinsic apoptosis pathways. |
Race-ethnicity is a strong correlate of circulating fat-soluble nutrient concentrations in a representative sample of the U.S. population
Schleicher RL , Sternberg MR , Pfeiffer CM . J Nutr 2013 143 (6) 966S-76S Sociodemographic and lifestyle factors exert important influences on nutritional status; however, information on their association with biomarkers of fat-soluble nutrients is limited, particularly in a representative sample of adults. Serum or plasma concentrations of vitamin A, vitamin E, carotenes, xanthophylls, 25-hydroxyvitamin D [25(OH)D], SFAs, MUFAs, PUFAs, and total fatty acids (tFAs) were measured in adults (aged ≥20 y) during all or part of NHANES 2003-2006. Simple and multiple linear regression models were used to assess 5 sociodemographic variables (age, sex, race-ethnicity, education, and income) and 5 lifestyle behaviors (smoking, alcohol consumption, BMI, physical activity, and supplement use) and their relation to biomarker concentrations. Adjustment for total serum cholesterol and lipid-altering drug use was added to the full regression model. Adjustment for latitude and season was added to the full model for 25(OH)D. Based on simple linear regression, race-ethnicity, BMI, and supplement use were significantly related to all fat-soluble biomarkers. Sociodemographic variables as a group explained 5-17% of biomarker variability, whereas together, sociodemographic and lifestyle variables explained 22-23% [25(OH)D, vitamin E, xanthophylls], 17% (vitamin A), 15% (MUFAs), 10-11% (SFAs, carotenes, tFAs), and 6% (PUFAs) of biomarker variability. Although lipid adjustment explained additional variability for all biomarkers except for 25(OH)D, it appeared to be largely independent of sociodemographic and lifestyle variables. After adjusting for sociodemographic, lifestyle, and lipid-related variables, major differences in biomarkers were associated with race-ethnicity (from -44 to 57%), smoking (up to -25%), supplement use (up to 21%), and BMI (up to -15%). Latitude and season attenuated some race-ethnicity differences. Of the sociodemographic and lifestyle variables examined, with or without lipid adjustment, most fat-soluble nutrient biomarkers were significantly associated with race-ethnicity. |
Race-ethnicity is related to biomarkers of iron and iodine status after adjusting for sociodemographic and lifestyle variables in NHANES 2003-2006
Pfeiffer CM , Sternberg MR , Caldwell KL , Pan Y . J Nutr 2013 143 (6) 977S-85S The NHANES 2003-2006 has assessed iron and iodine status, 2 trace element nutrients of continued public health interest, in the U.S. population. We investigated associations of sociodemographic (age, sex, race-ethnicity, education, income) and lifestyle (smoking, alcohol consumption, BMI, physical activity, dietary supplement use) variables with the iron status indicators serum ferritin, soluble transferrin receptor (sTfR), and body iron in women aged 20-49 y (n = 2539, 2513, and 2509, respectively) and with urine iodine, a biomarker of iodine intake, in adults aged ≥20 y (n = 3066). Significant correlations between the study variables and biomarkers were weak (|r| ≤ 0.24). Urine creatinine (uCr) was moderately significantly correlated with urine iodine (r = 0.52). The individual variables explained ≤5% of the variability in biomarker concentrations in bivariate analysis. In multiple regression models, sociodemographic and lifestyle variables together explained 4-13% of the variability in iron indicators and 41% of the variability in urine iodine (uCr in the model). The adjusted estimated body iron was approximately 1 unit (mg/kg) lower in non-Hispanic black vs. non-Hispanic white women and approximately 1 unit higher in women who smoked vs. those who did not and in women consuming 1 vs. 0 alcoholic drinks/d. The adjusted estimated urine iodine concentration (uCr in the model) was 34% lower in non-Hispanic blacks vs. non-Hispanic whites, 22% higher in supplement users vs. nonusers, and 11% higher with every 10-y increase in age. In summary, after adjusting for sociodemographic and lifestyle variables (and uCr in the iodine model), race-ethnicity retained a strong association with sTfR, body iron, and urine iodine; smoking and alcohol consumption with iron biomarkers; and supplement use and age with urine iodine. |
Regression modeling plan for 29 biochemical indicators of diet and nutrition measured in NHANES 2003-2006
Sternberg MR , Schleicher RL , Pfeiffer CM . J Nutr 2013 143 (6) 948S-56S The collection of articles in this supplement issue provides insight into the association of various covariates with concentrations of biochemical indicators of diet and nutrition (biomarkers), beyond age, race, and sex, using linear regression. We studied 10 specific sociodemographic and lifestyle covariates in combination with 29 biomarkers from NHANES 2003-2006 for persons aged ≥20 y. The covariates were organized into 2 sets or "chunks": sociodemographic (age, sex, race-ethnicity, education, and income) and lifestyle (dietary supplement use, smoking, alcohol consumption, BMI, and physical activity) and fit in hierarchical fashion by using each category or set of related variables to determine how covariates, jointly, are related to biomarker concentrations. In contrast to many regression modeling applications, all variables were retained in a full regression model regardless of significance to preserve the interpretation of the statistical properties of beta coefficients, P values, and CIs and to keep the interpretation consistent across a set of biomarkers. The variables were preselected before data analysis, and the data analysis plan was designed at the outset to minimize the reporting of false-positive findings by limiting the amount of preliminary hypothesis testing. Although we generally found that demographic differences seen in biomarkers were over- or underestimated when ignoring other key covariates, the demographic differences generally remained significant after adjusting for sociodemographic and lifestyle variables. These articles are intended to provide a foundation to researchers to help them generate hypotheses for future studies or data analyses and/or develop predictive regression models using the wealth of NHANES data. |
Selected physiologic variables are weakly to moderately associated with 29 biomarkers of diet and nutrition, NHANES 2003-2006
Haynes BM , Pfeiffer CM , Sternberg MR , Schleicher RL . J Nutr 2013 143 (6) 1001S-10S The physiologic status of an individual may influence biomarkers of nutritional status. To help researchers with planning studies and interpreting data, we assessed the associations between common physiologic variables (fasting, inflammation, renal function, and pregnancy) and 29 biomarkers of diet and nutrition measured in blood or urine in a representative sample of the adult U.S. population (aged ≥20 y; pregnancy variable and iron indicators limited to women aged 20-49 y) participating in NHANES 2003-2006. We compared simple linear regression (model 1) with multiple linear regression [model 2, controlling for age, sex, race-ethnicity, smoking, supplement use, and the physiologic factors (and urine creatinine for urine biomarkers)] and report significant findings from model 2. Not being fasted was positively associated with most water-soluble vitamins (WSVs) and related metabolites (RMs). Some WSV, fat-soluble vitamin (FSV) and micronutrient (MN), and phytoestrogen concentrations were lower in the presence of inflammation (C-reactive protein ≥5 mg/L), whereas fatty acids and most iron indicators were higher. Most WSVs and RMs were higher when renal function was impaired [estimated glomerular filtration rate <60 mL/(min 1.73 m2)]. Most WSV, FSV and MN, and fatty acid concentrations were higher in pregnant compared with nonpregnant women, but vitamins A and B-12 and most iron indicators were lower. The estimated changes in biomarker concentrations with different physiologic status were mostly small to moderate (≤25%) and generally similar between models; renal function, however, showed several large differences for WSV and RM concentrations. This descriptive analysis of associations between physiologic variables and a large number of nutritional biomarkers showed that controlling for demographic variables, smoking, and supplement use generally did not change the interpretation of bivariate results. The analysis serves as a useful basis for more complex future research. |
Sociodemographic and lifestyle variables are compound- and class-specific correlates of urine phytoestrogen concentrations in the U.S. population
Rybak ME , Sternberg MR , Pfeiffer CM . J Nutr 2013 143 (6) 986S-94S Isoflavones and lignans are plant-derived dietary compounds generally believed to be beneficial to human health. We investigated the extent to which sociodemographic (age, sex, race-ethnicity, education, and income) and lifestyle variables (smoking, alcohol consumption, BMI, physical activity, and dietary supplement use) were correlates of spot urine concentration for daidzein, genistein, O-desmethylangolensin (DMA), equol, enterodiol, and enterolactone in the U.S. population aged ≥20 y (NHANES 2003-2006). We performed correlation analyses with continuous variables and calculated stratified unadjusted geometric means for each sociodemographic and lifestyle variable. We used bivariate significance testing and covariate adjustment by use of multiple regression models to identify influential variables and used beta coefficients to estimate relative effects. Urine creatinine was also included in our analyses because of its use in correcting for variable dilution in spot urine samples. We observed many significant (P < 0.05) associations with the sociodemographic and lifestyle variables that withstood covariate adjustment. Smoking was a significant correlate of urine DMA and enterolactone, with concentrations at least 25% lower in smokers vs. nonsmokers. Consumers of 1 daily alcoholic drink vs. none were estimated to have 18-21% lower urine equol and DMA concentrations. A 25% increase in BMI was associated with a 21% lower urine enterolactone concentration, and increasing physical activity was associated with a >6% higher urine enterolactone concentration. Dietary supplement use was not significantly associated with any of the urine phytoestrogens. Overall, we found that relationships between sociodemographic and lifestyle variables and urine phytoestrogen concentration were highly compound and class specific. |
Among 10 sociodemographic and lifestyle variables, smoking is strongly associated with biomarkers of acrylamide exposure in a representative sample of the U.S. population
Vesper HW , Sternberg MR , Frame T , Pfeiffer CM . J Nutr 2013 143 (6) 995S-1000S Hemoglobin adducts of acrylamide (HbAA) and glycidamide (HbGA) have been measured as biomarkers of acrylamide exposure and metabolism in a nationally representative sample of the U.S. population in the NHANES 2003-2004. We assessed the association of sociodemographic (age, sex, race-ethnicity, education, and income) and lifestyle (smoking, alcohol consumption, BMI, physical activity, and dietary supplement use) variables with these biomarkers in U.S. adults (aged ≥20 y). We used bivariate and multiple regression models and assessed the magnitude of an estimated change in biomarker concentration with change in a covariable for 2 biomarkers of acrylamide exposure. Smoking was strongly and significantly correlated with HbAA and HbGA concentrations (rs = 0.51 and 0.42, respectively), with biomarker concentrations being 126 and 101% higher in smokers compared with nonsmokers after adjusting for sociodemographic and lifestyle covariates. Age was moderately and significantly correlated with both biomarkers (rs = -0.21 and -0.22, respectively). BMI (rs = -0.11) and alcohol consumption (rs = 0.13) were weakly yet significantly correlated with HbAA concentrations only. The estimated percentage change in biomarker concentration was ≤20% for all variables other than smoking after adjusting for sociodemographic and lifestyle covariates. Using multiple regression models, the sociodemographic variables explained 9 and 7% whereas the sociodemographic and lifestyle variables together explained 46 and 25% of the variability in HbAA and HbGA, respectively, showing the importance of considering and adequately controlling for these variables in future studies. Our findings will be useful in the design and analysis of future studies that assess and evaluate exposure to acrylamide and its metabolism to glycidamide. |
Behaviors and attitudes associated with low drinking water intake among US adults, Food Attitudes and Behaviors Survey, 2007
Goodman AB , Blanck HM , Sherry B , Park S , Nebeling L , Yaroch AL . Prev Chronic Dis 2013 10 E51 INTRODUCTION: Water is vital for life, and plain water is a calorie-free option for hydration. Increasing consumption of drinking water is a strategy to reduce energy intake and lose or maintain weight; however, information on the characteristics of consumers who drink water is limited. Our objective was to describe the characteristics of people who have a low intake of drinking water and to determine associations between their behaviors and attitudes and their intake of water. METHODS: We analyzed data from a nationally representative sample of 3,397 US adults who participated in the National Cancer Institute's 2007 Food Attitudes and Behaviors Survey. Multivariable logistic regression was used to identify sociodemographic characteristics and health-related behaviors and attitudes associated with self-reported drinking water intake of less than 4 cups per day. RESULTS: Overall, 7% of adults reported no daily consumption of drinking water, 36% reported drinking 1 to 3 cups, 35% reported drinking 4 to 7 cups, and 22% reported drinking 8 cups or more. The likelihood of drinking less than 4 cups of water daily was significantly higher among participants aged 55 years or older than among those aged 18 to 34 (adjusted odds ratio [AOR], 1.3), among residents of the Northeast than among residents of the South (AOR, 1.4), among participants who consumed 1 cup or less of fruits or vegetables per day than among those who consumed 4.5 cups or more (AOR, 3.0), among participants who did not exercise than among those who exercised 150 minutes or more per week (AOR, 1.7), and among participants who were neither trying to gain nor lose weight than among those trying to lose weight (AOR, 1.3). CONCLUSION: Low drinking water intake was associated with age, region of residence, and several unhealthful behaviors and attitudes. Understanding characteristics associated with low drinking water intake may help to identify populations that could benefit from interventions to help adults drink more water. |
The CDC's second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population is a valuable tool for researchers and policy makers
Pfeiffer CM , Sternberg MR , Schleicher RL , Haynes BM , Rybak ME , Pirkle JL . J Nutr 2013 143 (6) 938S-47S The CDC's National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population (Nutrition Report) is a serial publication that provides ongoing assessment of the population's nutritional status. The Nutrition Report presents data on blood and urine biomarker concentrations (selected water- and fat-soluble vitamins and nutrients, trace elements, dietary bioactive compounds) from a representative sample of the population participating in the NHANES. The Second Nutrition Report (released in 2012) contains reference information (means and percentiles) for 58 biomarkers measured during all or part of 2003-2006, stratified by age, sex, and race-ethnicity. Where available, we presented cutoff-based prevalence data during 2003-2006 and data on changes in biomarker concentrations or prevalence since 1999. Blood vitamin concentrations were generally higher in older (≥60 y) than in younger (20-39 y) adults and lower in Mexican Americans and non-Hispanic blacks than in non-Hispanic whites. Nearly 80% of Americans (aged ≥6 y) were not at risk of deficiencies in any of the 7 vitamins studied (vitamins A, B-6, B-12, C, D, and E and folate). Deficiency rates varied by age, sex, and race-ethnicity. Approximately 90% of women (aged 12-49 y) were not at risk of iron deficiency, but only 68% were not at risk of deficiencies in iron and all 7 vitamins. Young women (20-39 y) had median urine iodine concentrations bordering on insufficiency. First-time data are presented on plasma concentrations of 24 saturated and mono- and polyunsaturated fatty acids. Tabulation and graphical presentation of NHANES data in the Second Nutrition Report benefits those organizations involved in developing and evaluating nutrition policy. |
Finger tendon travel associated with sequential trigger nail gun use
Lowe B , Albers J , Hudock S , Krieg E . IIE Trans Occup 2013 1 (2) 109-118 OCCUPATIONAL APPLICATIONS: This article reports a method for assessing finger tendon motion associated with the use of a sequential actuation trigger pneumatic nail gun. The two-stage actuation process of the sequential actuation trigger reduces risk of nail puncture injury from unintended nail discharge (relative to the higher risk of the contact actuation trigger). However, widespread adoption of the sequential actuation trigger nail gun throughout the construction industry has been hindered by beliefs about productivity and musculoskeletal concerns about the repetitive trigger actuation and finger motion for each nail fired. Though existing guidelines for finger tendon travel exposure are not well established, predictions derived with the present method combined with productivity standards suggest insufficient evidence to contradict the safety-based recommendation to adopt the sequential actuation trigger trigger. BACKGROUND: Pneumatic nail guns used in wood framing are equipped with one of two triggering mechanisms. Sequential actuation triggers have been shown to be a safer alternative to contact actuation triggers because they reduce traumatic injury risk. However, the sequential actuation trigger must be depressed for each individual nail fired as opposed to the contact actuation trigger, which allows the trigger to be held depressed as nails are fired repeatedly by bumping the safety tip against the workpiece. As such, concerns have been raised about risks for cumulative trauma injury, and reduced productivity, due to repetitive finger motion with the sequential actuation trigger. PURPOSE: This study developed a method to predict cumulative finger flexor tendon travel associated with the sequential actuation trigger nail gun from finger joint kinematics measured in the trigger actuation and productivity standards for wood-frame construction tasks. METHODS: Finger motions were measured from six users wearing an instrumented electrogoniometer glove in a simulation of two common framing tasks: wall building and flat nailing of material. Flexor tendon travel was calculated from the ensemble average kinematics for an individual nail fired. RESULTS: Finger flexor tendon travel was attributable mostly to proximal interphalangeal and distal interphalangeal joint motion. Tendon travel per nail fired appeared to be slightly greater for a wall-building task than a flat nailing task. The present study data, in combination with construction industry productivity standards, suggest that a high-production workday would be associated with less than 60 m/day cumulative tendon travel per worker (based on 1700 trigger presses/day). CONCLUSION AND APPLICATIONS: These results suggest that exposure to finger tendon travel from sequential actuation trigger nail gun use may be below levels that have been previously associated with high musculoskeletal disorder risk. |
Challenge of N95 filtering facepiece respirators with viable H1N1 influenza aerosols
Harnish DA , Heimbuch BK , Husband M , Lumley AE , Kinney K , Shaffer RE , Wander JD . Infect Control Hosp Epidemiol 2013 34 (5) 494-499 OBJECTIVE: Specification of appropriate personal protective equipment for respiratory protection against influenza is somewhat controversial. In a clinical environment, N95 filtering facepiece respirators (FFRs) are often recommended for respiratory protection against infectious aerosols. This study evaluates the ability of N95 FFRs to capture viable H1N1 influenza aerosols. METHODS: Five N95 FFR models were challenged with aerosolized viable H1N1 influenza and inert polystyrene latex particles at continuous flow rates of 85 and 170 liters per minute. Virus was assayed using Madin-Darby canine kidney cells to determine the median tissue culture infective dose (TCID50). Aerosols were generated using a Collison nebulizer containing H1N1 influenza virus at [Formula: see text] TCID50/mL. To determine filtration efficiency, viable sampling was performed upstream and downstream of the FFR. RESULTS: N95 FFRs filtered 0.8 micrometer particles of both H1N1 influenza and inert origins with more than 95% efficiency. With the exception of 1 model, no statistically significant difference in filtration performance was observed between influenza and inert particles of similar size. Although statistically significant differences were observed for 2 models when comparing the 2 flow rates, the differences have no significance to protection. CONCLUSIONS: This study empirically demonstrates that a National Institute for Occupational Safety and Health-approved N95 FFR captures viable H1N1 influenza aerosols as well as or better than its N95 rating, suggesting that a properly fitted FFR reduces inhalation exposure to airborne influenza virus. This study also provides evidence that filtration efficiency is based primarily on particle size rather than the nature of the particle's origin. |
Chemical exposure and hearing loss
Campo P , Morata TC , Hong O . Dis Mon 2013 59 (4) 119-138 Workers are commonly exposed to multiple factors and substances that are hazardous to health. For instance, in 2005. approximately 30% of the European workers reported being exposed to noise during at least a quarter of the time spent in their work environment, 11 % reported inhaling vapors such as solvents and thinners: 19% reported exposure to smoke, fumes, powder or dust; and 14% reported handling chemical substances. Although occupational noise exposure has long been recognized in the United States and in Europe as the most deleterious factor to hearing the impact of chemical-induced hearing loss on workers should not be underestimated. A cursory survey of the literature for the last three decades reveals that concern about the effects of chemicals on hearing has grown steadily. The proliferation of work-related substances and medicinal drugs (mostly antitumor drugs and aminoglycosides) has been accompanied by an equivalent increase in the number of scientific publications on the hearing risks encountered by chemical-exposed persons. Cause for concern is even greater when the synergistic risks of co-exposures are considered. For example, physiological factors may increase the severity of a chemical's effect on hearing. Today, robust evidence also confirms that the effects of ototoxic substances on ear function can be aggravated by noise, which remains a well-recognized cause of hearing impairment. In an expert forecast supervised by the European Agency for Safety and Health at Work' (EU-OSHA, 2009), "combined exposure to noise and ototoxic substances" was rated as an emerging risk. Industrial ototoxic chemicals have predominantly been assessed through animal studies. which are supported by data from epidemiologic studies on human workers from various industries. Bergstrom and Nystrom (1986) published the seminal results of a 20-year longitudinal study performed with 319 Swedish employees from different industrial sectors. This study began in 1958 and involved testing workers' hearing regularly. Its findings showed that a large proportion (23%) of the employees working in a chemical division suffered from hearing impairment, despite their exposure to lower noise levels than other divisions. Based on this type of evidence, researchers have long hypothesized that industrial solvents pose an additive risk to hearing. Scientific findings in animals are generally considered qualitatively relevant to human health. provided no substantial difference in biological response (e.g. metabolism) exists between test animals and humans. Despite these findings. (urrent research is limited by the following: (1) a lack of detailed exposure histories; (2) the presence of confounding factors (ototoxic drugs, tobacco, alcohol consumption. aging. and exposures outside the workplace); (3) and the fact that chemical exposure scenarios used in experimental investigations are qualitatively different from real-world occupational settings. In this extensive, but not exhaustive, review of the literature, the authors hope to share the evidence indicating that noise is not the only source of work-related hearing damage and to draw greater attention to the matter of chemically induced hearing loss. The present publication intends to provide occupational physicians and other health professionals with a clear picture of what is known about how chemical substances may affect hearing ability in the general population, and more specifically. in workers. The article describes the following: (1) chemicals that can be noxious to the inner ear; (2) work areas where exposure to ototoxic substances are likely; (3) and the basic features of the physiological mechanisms leading to hearing impairment. This article also addresses the limitations of pure-tone air-conduction audiometry when assessing chemical-induced hearing loss and proposes a more complete approach to evaluate the auditory neurosensory hearing receptor and the neural pathways involved in the stapedial reflex. With the proposed battery of tests, physicians will be able to evaluate both ototoxicity and neurotoxicity. Throughout this manuscript. emphasis is placed on the need for stronger links between primary care and occupational physicians. This could help preserve patients' hearing status as a part of their overall health. |
Conceptual heuristic models of the interrelationships between obesity and the occupational environment
Pandalai SP , Schulte PA , Miller DB . Scand J Work Environ Health 2013 39 (3) 221-32 OBJECTIVE: Research and interventions targeting the relationship between work, its attendant occupational hazards, and obesity are evolving but merit further consideration in the public health arena. In this discussion paper, conceptual heuristic models are described examining the role of obesity as both a risk factor and health outcome in the occupational setting. METHODS: PubMed was searched using specific criteria from 2000 and onwards for evidence to support conceptual models in which obesity serves as a risk factor for occupational disease or an outcome of occupational exposures. Nine models are presented: four where obesity is a risk factor and five where it is an adverse effect. RESULTS: A broad range of work-related health effects are associated with obesity including musculoskeletal disorders, asthma, liver disease, and cardiovascular disease, among others. Obesity can be associated with occupational hazards such as shift work, sedentary work, job stress, and exposure to some chemicals. CONCLUSION: Identification of combinations of risk factors pertinent to obesity in the occupational environment will provide important guidance for research and prevention. |
Depression, social factors, and farmworker health care utilization
Georges A , Alterman T , Gabbard S , Grzywacz JG , Shen R , Nakamoto J , Carroll DJ , Muntaner C . J Rural Health 2013 29 Suppl 1 s7-16 PURPOSE: Farmworkers frequently live in rural areas and experience high rates of depressive symptoms. This study examines the association between elevated depressive symptoms and health care utilization among Latino farmworkers. METHODS: Data were obtained from 2,905 Latino farmworkers interviewed for the National Agricultural Workers Survey. Elevated depressive symptoms were measured using the Center for Epidemiologic Studies Depression short-form. A dichotomous health care utilization variable was constructed from self-reported use of health care services in the United States. A categorical measure of provider type was constructed for those reporting use of health care. RESULTS: Over 50% of farmworkers reported at least 1 health care visit in the United States during the past 2 years; most visits occurred in a private practice. The odds of reporting health care utilization in the United States were 45% higher among farmworkers with elevated depressive symptoms. Type of provider was not associated with depressive symptoms. Women were more likely to seek health care; education and family relationships were associated with health care utilization. CONCLUSIONS: Latino farmworkers who live and work in rural areas seek care from private practices or migrant/Community Health Clinics. Farmworkers with elevated depressive symptoms are more likely to access health care. Rural health care providers need to be prepared to recognize, screen, and treat mental health problems among Latino farmworkers. Outreach focused on protecting farmworker mental health may be useful in reducing health care utilization while improving farmworker quality of life. |
Coal mine dust lung diseases: new lessons from an old exposure
Petsonk EL , Rose C , Cohen R . Am J Respir Crit Care Med 2013 187 (11) 1178-85 Coal mining remains a sizable industry, with millions of working and retired coal miners worldwide. This article provides an update on recent advances in the understanding of respiratory health issues in coal miners and focuses on the spectrum of disease caused by inhalation of coal mine dust, termed coal mine dust lung disease (CMDLD). In addition to the historical interstitial lung diseases (coal worker's pneumoconiosis, silicosis, and mixed dust pneumoconiosis), coal miners are at risk for dust-related diffuse fibrosis (DDF) and chronic airway diseases including emphysema and chronic bronchitis. Recent recognition of rapidly progressive pneumoconiosis in younger miners, mainly in the eastern United States, has increased the sense of urgency and the need for vigilance in medical research, clinical diagnosis, and exposure prevention. Given the risk for disease progression even after exposure removal, along with few medical treatment options, there is an important role for chest physicians in the recognition and management of lung disease associated with work in coal mining. |
Annual deaths attributable to physical inactivity: Whither the missing 2 million?
Lee IM , Bauman AE , Blair SN , Heath GW , Kohl Iii HW , Pratt M , Hallal PC . Lancet 2013 381 (9871) 992-993 The Global Burden of Disease (GBD) | 2010 team (Dec 15, p 2224)1 | estimate | that 3·2 million deaths per year | are attributable to inactivity. Yet in | The Lancet’s Physical Activity Series | (LPAS), we estimated 5·3 million such | deaths.2 | Why the substantial diff erence? | There are two key methodological | diff erences between the studies. First, | LPAS used data from standardised | surveys to estimate the level of | inactivity in adults in 122 countries, | defi ning inactive people as those not | meeting current guidelines—ie, 150 min | of moderate-intensity physical activity | (about 600 metabolic equivalent [MET] | min) per week. All others were regarded | as active. GBD did not give details | on countries that provided inactivity | data, but defi ned four categories: 0, | 600–3999, 4000–7999, and ≥8000 | MET min per week. It is unclear how | these levels were constructed, since | ≥8000 MET min per week is equivalent | to about 38 h per week of brisk walking |
Government's role in protecting health and safety
Frieden TR . N Engl J Med 2013 368 (20) 1857-9 What is the appropriate role of governmental public health action? Law and public opinion recognize protection of health and safety as a core government function, but public health actions are sometimes characterized as inappropriately intrusive. Such criticism has a long history, but today we accept many public health measures that were once considered misguided, intrusive, or controversial. Public health initiatives include efforts to promote free and open information to facilitate informed decision making, protect individuals from being harmed by other individuals and groups, and facilitate societal action to promote and protect health (see Potential Public Health Actions of a Responsive . . . |
A historical note on the association between the legal status of expedited partner therapy and physician practice
Cramer R , Hogben M , Handsfield HH . Sex Transm Dis 2013 40 (5) 349-51 Potential legal liability for practicing expedited partner therapy is a common concern among providers, although it has been uncertain how these concerns translate into clinical practice. This study suggests that providers are more likely to practice expedited partner therapy in more favorable legal environments. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Disease Reservoirs and Vectors
- Epidemiology and Surveillance
- Food Safety
- Health Behavior and Risk
- Healthcare Associated Infections
- Immunity and Immunization
- Laboratory Sciences
- Nutritional Sciences
- Occupational Safety and Health
- Occupational Safety and Health - Mining
- Physical Activity
- Public Health Law
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CDC Science Clips is an online, continuously updated, searchable database of scientific literature published by CDC authors. Each article features an Altmetric Attention Score to track social and mainstream media mentions. If you are aware of a CDC-authored publication that does not appear in this database, please let us know.
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