Toward standardizing and reporting colorectal cancer screening indicators on an international level: the International Colorectal Cancer Screening Network
Benson VS , Atkin WS , Green J , Nadel MR , Patnick J , Smith RA , Villain P . Int J Cancer 2012 130 (12) 2961-2973 The International Colorectal Cancer Screening Network was established in 2003 to promote best practice in the delivery of organized colorectal cancer screening programs. To facilitate evaluation of such programs, we defined a set of universally applicable colorectal cancer screening measures and indicators. To test the feasibility of data collection, we requested data on these variables and basic program characteristics from 26 organized full programs and 9 pilot programs in 24 countries. The size of the target population for each program varied considerably from a few thousand to 36 million. The majority of programs used fecal occult blood tests for primary screening, with more using guaiac than immunochemical tests. There was wide variation in the ability of screening programs to report the requested measures and in the values reported. In general, pilot programs were more likely to provide screening measure values than were full programs. As expected, detection rates for polyps and neoplasia were substantially higher in programs screening with endoscopy than in those using fecal occult blood tests. It is hoped that the screening measures and indicators, once revised in the light of this survey, will be adopted and used by existing programs and those in the early planning stages, allowing international comparison with the goal of improved colorectal cancer screening quality. |
New roles for public health in cancer screening
Plescia M , Richardson LC , Joseph D . CA Cancer J Clin 2012 62 (4) 217-9 Screening tests for the early detection of breast, cervical, and colorectal cancer are prioritized clinical preventive services that can reduce the burden of cancer in the United States.1 While significant progress has been made in this area, screening rates for breast and cervical cancers have not improved in almost a decade and rates for colorectal cancer are unacceptably low. Lack of insurance has traditionally been the main factor preventing adults from obtaining cancer screening.2 Components of the Patient Protection and Affordable Care Act will help address this through Medicaid expansion, subsidized state insurance exchanges, and the elimination of cost sharing. | However, access to health insurance and medical care are not the only factors that limit participation in cancer screening. Many people who currently have health insurance and regular access to medical care are not being screened. Based on 2010 National Health Interview Survey data, among adults aged 50 to 75 years with a regular source of medical care, only 62% were up to date with screening for colorectal cancer and only 75% of women in this age range had received a mammogram within the preceding 2 years.3 Analyses of national Medicare data revealed that, despite coverage of cancer screening services, only 66% of eligible women had undergone a mammogram within the past 2 years4 and only 47% of adults had insurance claims documenting adequate screening for colorectal cancer.5 To realize the full potential of anticipated improvements in access to care, public health must provide leadership to ensure that cancer screening is proactive, organized, and equitable. |
Obesity and severe obesity forecasts through 2030
Finkelstein EA , Khavjou OA , Thompson H , Trogdon JG , Pan L , Sherry B , Dietz W . Am J Prev Med 2012 42 (6) 563-70 BACKGROUND: Previous efforts to forecast future trends in obesity applied linear forecasts assuming that the rise in obesity would continue unabated. However, evidence suggests that obesity prevalence may be leveling off. PURPOSE: This study presents estimates of adult obesity and severe obesity prevalence through 2030 based on nonlinear regression models. The forecasted results are then used to simulate the savings that could be achieved through modestly successful obesity prevention efforts. METHODS: The study was conducted in 2009-2010 and used data from the 1990 through 2008 Behavioral Risk Factor Surveillance System (BRFSS). The analysis sample included nonpregnant adults aged ≥18 years. The individual-level BRFSS variables were supplemented with state-level variables from the U.S. Bureau of Labor Statistics, the American Chamber of Commerce Research Association, and the Census of Retail Trade. Future obesity and severe obesity prevalence were estimated through regression modeling by projecting trends in explanatory variables expected to influence obesity prevalence. RESULTS: Linear time trend forecasts suggest that by 2030, 51% of the population will be obese. The model estimates a much lower obesity prevalence of 42% and severe obesity prevalence of 11%. If obesity were to remain at 2010 levels, the combined savings in medical expenditures over the next 2 decades would be $549.5 billion. CONCLUSIONS: The study estimates a 33% increase in obesity prevalence and a 130% increase in severe obesity prevalence over the next 2 decades. If these forecasts prove accurate, this will further hinder efforts for healthcare cost containment. |
Kawasaki syndrome and factors associated with coronary artery abnormalities, California
Callinan LS , Tabnak F , Holman RC , Maddox RA , Kim JJ , Schonberger LB , Vugia DJ , Belay ED . Pediatr Infect Dis J 2012 31 (9) 894-8 BACKGROUND: Kawasaki syndrome (KS) occurs in children less than 18 years of age and is the leading cause of acquired heart disease among children in the United States. Understanding the epidemiology of KS and factors associated with coronary artery abnormalities (CAA) may lead to timely diagnosis and treatment of KS and could limit CAA. METHODS: Epidemiologic characteristics, including risk factors for the development of CAA, among KS and incomplete KS patients less than 18 years of age with onset during 2000-2009 reported by the California Department of Public Health to the Centers for Disease Control and Prevention's national KS surveillance system were analyzed. RESULTS: A total of 2056 KS and incomplete KS patients less than 18 years of age were reported for 2000-2009. The median age of patients was 2 years; 60% of patients were male. Of 1818 patients with race information reported, 56% were white and 28% were Asian/Pacific Islander. Ninety-eight percent of patients received intravenous immunoglobulin (IVIG). Of 1843 patients with information on cardiac complications, 89 (5%) had coronary artery aneurysms and 341 (19%) had CAA. Characteristics associated with the occurrence of CAA in KS patients were male sex, Asian/Pacific Islander race, age less than 1 year or 9-17 years, and receiving IVIG treatment on or after the fifth day of illness. CONCLUSIONS: This study suggests that IVIG treatment before the fifth day of illness may reduce CAA among KS patients. Timely diagnosis and treatment of KS continue to be important in reducing the occurrence of cardiac complications. |
Absence of evidence for bornavirus infection in schizophrenia, bipolar disorder and major depressive disorder
Hornig M , Briese T , Licinio J , Khabbaz RF , Altshuler LL , Potkin SG , Schwemmle M , Siemetzki U , Mintz J , Honkavuori K , Kraemer HC , Egan MF , Whybrow PC , Bunney WE , Lipkin WI . Mol Psychiatry 2012 17 (5) 486-93 In 1983, reports of antibodies in subjects with major depressive disorder (MDD) to an as-yet uncharacterized infectious agent associated with meningoencephalitis in horses and sheep led to molecular cloning of the genome of a novel, negative-stranded neurotropic virus, Borna disease virus (BDV). This advance has enabled the development of new diagnostic assays, including in situ hybridization, PCR and serology based on recombinant proteins. Since these assays were first implemented in 1990, more than 80 studies have reported an association between BDV and a wide range of human illnesses that include MDD, bipolar disorder (BD), schizophrenia (SZ), anxiety disorder, chronic fatigue syndrome, multiple sclerosis, amyotrophic lateral sclerosis, dementia and glioblastoma multiforme. However, to date there has been no blinded case-control study of the epidemiology of BDV infection. Here, in a United States-based, multi-center, yoked case-control study with standardized methods for clinical assessment and blinded serological and molecular analysis, we report the absence of association of psychiatric illness with antibodies to BDV or with BDV nucleic acids in serially collected serum and white blood cell samples from 396 subjects, a study population comprised of 198 matched pairs of patients and healthy controls (52 SZ/control pairs, 66 BD/control pairs and 80 MDD/control pairs). Our results argue strongly against a role for BDV in the pathogenesis of these psychiatric disorders. |
Socio-demographic differences in opinions about 2009 pandemic influenza A (H1N1) and seasonal influenza vaccination and disease among adults during the 2009-2010 influenza season
Santibanez TA , Singleton JA , Santibanez SS , Wortley P , Bell BP . Influenza Other Respir Viruses 2012 7 (3) 383-92 BACKGROUND: In April 2009, a novel influenza A virus emerged in the United States. By the end of July, influenza A (H1N1) 2009 monovalent (2009 H1N1) vaccine had been developed, licensed, and recommended by the Advisory Committee on Immunization Practices. Initial target groups for vaccination were identified and the first vaccine was publicly available in early October 2009. OBJECTIVE: This study examines socio-demographic differences in opinions about 2009 pandemic influenza A (H1N1) (pH1N1) and seasonal influenza disease and vaccines and the association with receipt of influenza vaccinations during the 2009-2010 influenza season. Changes in opinions over the course of the pH1N1 pandemic were also examined. METHODS: Data from the 2009 National H1N1 Flu Survey (NHFS) were analyzed. The NHFS was a CDC-sponsored telephone survey initiated in response to the 2009 pH1N1 pandemic to obtain weekly within-season estimates of vaccination coverage, opinions, and other information. RESULTS: Opinions about influenza vaccine and disease varied significantly by race/ethnicity, income, and education level. In multivariable logistic regression analysis, adjusted 2009 H1N1 vaccination coverage was most strongly associated with opinions about the effectiveness of the vaccine and personal risk of disease, varying from 7 to 11% among adults who believed the vaccine to have low effectiveness and themselves at low risk of influenza, to 50-53% among those who thought vaccine effectiveness to be high and themselves at high risk of influenza. CONCLUSION: Improving communication about personal risk and the effectiveness of influenza vaccines may improve vaccination coverage. The findings of difference in opinions could be used to target communication. |
Supporting the massive scale-up of antiretroviral therapy: the evolution of PEPFAR-supported treatment facilities in South Africa, 2005-2009
Larson E , O'Bra H , Brown J , Mbengashe T , Klausner JD . BMC Public Health 2012 12 173 BACKGROUND: South Africa has an estimated 1.5 million persons in need of antiretroviral therapy (ART). In 2004, the South African government began collaborating with the United States President's Emergency Plan for AIDS Relief (PEPFAR) to increase access to ART. We determined how PEPFAR treatment support changed from 2005-2009. METHODS: In order to describe the change in number and type of PEPFAR-supported ART facilities, we analyzed routinely collected program-monitoring data from 2005-2009. The collected data included the number, type and province of facilities as well as the number of patients receiving ART at each facility. RESULTS: The number of PEPFAR-supported facilities providing ART increased from 184 facilities in 2005 to 1,469 facilities in 2009. From 2005-2009 the number of PEPFAR-supported government facilities increased 10.1 fold from 54 to 546 while the number of PEPFAR-supported NGO facilities (including general practitioner and NGO facilities) increased 6.2 fold from 114 to 708. In 2009 the total number of persons treated at PEPFAR-supported NGO facilities was 43,577 versus 501,089 persons at PEPFAR-supported government facilities. Overall, the median number of patients receiving ART per site increased from 81 in 2005 to 136 in 2009. CONCLUSIONS: To mitigate the gap between those needing and those receiving ART, more facilities were supported. The proportion of government facilities supported and the median number of persons treated at these facilities increased. This shift could potentially be sustainable as government sites reach more individuals and receive government funding. These results demonstrate that PEPFAR was able to support a massive scale-up of ART services in a short period of time. |
Understanding influenza virus resistance to antiviral agents; early warning signs for wider community circulation
Fry AM , Gubareva LV . J Infect Dis 2012 206 (2) 145-7 Influenza viruses circulating among humans vary genetically from season to season and even within a season in different regions of the world. Thus, global surveillance for influenza viruses is critical to monitor for antigenic changes in circulating influenza viruses and to inform annual vaccine strain selection. In addition, surveillance is critical to monitor for virus susceptibility to antiviral drugs. Resistance to the adamantane class of drugs (amantadine and rimantadine), caused by substitutions at key amino acid residues in the M2 protein, has been widespread among influenza A viruses [1]. Adamantanes are not effective against currently circulating A(H3N2) viruses and 2009 pandemic influenza A(H1N1) (H1N1pdm09) viruses because of the S31N change in the M2 protein [2, 3]. Resistance to both approved neuraminidase (NA) inhibitors, oseltamivir and zanamivir, has been occasionally reported for all influenza virus A subtypes and influenza B viruses affecting humans [4]; however, widespread global circulation of influenza viruses resistant to an NA inhibitor (NAI) has occurred only once since the initiation of surveillance for NAI resistance in 1999 [5]. |
Virological response and HIV drug resistance 12 months after antiretroviral therapy initiation at 2 clinics in Nigeria
Ugbena R , Aberle-Grasse J , Diallo K , Bassey O , Jelpe T , Rottinghaus E , Azeez A , Akpan R , Muhammad M , Shanmugam V , Singh S , Yang C . Clin Infect Dis 2012 54 Suppl 4 S375-80 This report describes a pilot study, conducted in Nigeria, of the World Health Organization protocol for monitoring human immunodeficiency virus (HIV) drug resistance (HIVDR) and associated program factors among patients receiving first-line antiretroviral therapy (ART). In 2008, 283 HIV-infected patients starting ART were consecutively enrolled at 2 ART clinics in Abuja. Twelve months after ART initiation, 62% were alive and on first-line ART, 3% had died, 1% had transferred out of the program, and 34% were lost to follow-up. Among patients on first-line ART at 12 months, 90% had viral suppression. However, in view of the high loss to follow-up rate (34%), strategies for patient retention and tracking are critical to minimize possible HIVDR and optimize treatment outcomes. |
Moving toward TB elimination: implementation of statewide targeted tuberculin testing in Tennessee
Cain KP , Garman KN , Laserson KF , Ferrousier-Davis OP , Miranda AG , Wells CD , Haley CA . Am J Respir Crit Care Med 2012 186 (3) 273-9 RATIONALE: From 1993-2010, annual U.S. tuberculosis (TB) rates declined by 58%. However, this decline has slowed and disproportionately occurred among U.S.-born (78%) vs. foreign-born persons (47%). Addressing the high burden of latent TB infection (LTBI) must be prioritized. OBJECTIVES: Only Tennessee has implemented a state-wide program for finding and treating people with LTBI. The program was designed to address high state-wide TB rates and growing burden among the foreign-born. We sought to assess the feasibility and yield of Tennessee's program. METHODS: Analyzing data from the 4.8-year period from program inception in March 2002 through December 2006, we quantified patients screened using a TB risk assessment tool, tuberculin skin tests (TST) placed and read, TST results, and patients initiating and completing LTBI treatment. We then estimated the number needed to screen to find and treat one person with LTBI and to prevent one case of TB. MEASUREMENTS AND MAIN RESULTS: Of 168,517 persons screened, 102,709 had a TST placed and read. Among 9,090 (9%) with a positive TST result, 53% initiated treatment, 54% of whom completed treatment. An estimated 195 TB cases were prevented over the 4.8 years analyzed, and program performance measures improved annually. The number of TSTs placed to prevent one TB case ranged from 150 for foreign-born persons to 9,834 for persons without TB risk. CONCLUSIONS: Targeted tuberculin testing and LTBI treatment is feasible and likely to reduce TB rates over time. Yield and cost-effectiveness are maximized by prioritizing foreign-born persons, a large population with high TB risk. |
Noroviruses: the perfect human pathogens?
Hall AJ . J Infect Dis 2012 205 (11) 1622-4 Noroviruses are perhaps the perfect human pathogens. These viruses possess essentially all of the attributes of an ideal infectious agent: highly contagious, rapidly and prolifically shed, constantly evolving, evoking limited immunity, and only moderately virulent, allowing most of those infected to fully recover, thereby maintaining a large susceptible pool of hosts. These characteristics have enabled noroviruses to become the leading cause of endemic diarrheal disease across all age groups [1], the leading cause of foodborne disease [2], and the cause of half of all gastroenteritis outbreaks worldwide [3]. In the United States alone, noroviruses are responsible for an estimated 21 million cases of acute gastroenteritis annually, including >70 000 hospitalizations and nearly 800 deaths [2, 4, 5]. In developing countries, where the greatest burden of diarrheal disease occurs, noroviruses have been estimated to cause up to 200 000 deaths each year in children <5 years of age [6]. Although recognition of this immense disease burden is relatively recent, it is unclear whether it has long been present and failed to be recognized because of lack of sensitive diagnostics or if, in fact, noroviruses represent a truly emergent public health issue [7]. Regardless, attempts to address the overwhelming burden of norovirus disease first require an understanding of the complexity and efficiency with which these viruses spread. |
Haemophilus haemolyticus causing clinical disease
Anderson R , Wang X , Briere EC , Katz LS , Cohn AC , Clark TA , Messonnier NE , Mayer LW . J Clin Microbiol 2012 50 (7) 2462-5 We report seven cases of Haemophilus haemolyticus invasive disease detected in the United States, which were previously misidentified as non-typeable Haemophilus influenzae (Hi). All cases had different symptoms and presentations. Our study suggests that a testing scheme that includes reliable PCR assays and standard microbiological methods should be used in order to improve H. haemolyticus identification. |
HIV drug resistance early warning indicators in cohorts of individuals starting antiretroviral therapy between 2004 and 2009: World Health Organization global report from 50 countries
Bennett DE , Jordan MR , Bertagnolio S , Hong SY , Ravasi G , McMahon JH , Saadani A , Kelley KF . Clin Infect Dis 2012 54 Suppl 4 S280-9 The World Health Organization developed a set of human immunodeficiency virus drug resistance (HIVDR) early warning indicators (EWIs) to assess antiretroviral therapy clinic and program factors associated with HIVDR. EWIs are monitored by abstracting data routinely recorded in clinical records, and the results enable clinics and program managers to identify problems that should be addressed to minimize preventable emergence of HIVDR in clinic populations. As of June 2011, 50 countries monitored EWIs, covering 131,686 patients initiating antiretroviral treatment between 2004 and 2009 at 2107 clinics. HIVDR prevention is associated with patient care (appropriate prescribing and patient monitoring), patient behavior (adherence), and clinic/program management efforts to reduce treatment interruptions (follow up, retention on first-line ART, procurement and supply management of antiretroviral drugs). EWIs measure these factors and the results have been used to optimize patient and population treatment outcomes. |
HIV-1 and breastfeeding in the United States
Little KM , Hu DJ , Dominguez KL . Adv Exp Med Biol 2012 743 261-70 While breastfeeding remains a significant source of mother-to-child HIV transmission (MTCT) globally, it is the recommended infant feeding option for HIV-infected women in resource-limited settings. However, HIV-infected women in the USA-where breast milk alternatives are acceptable, feasible, affordable, sustainable, and safe-have been counseled to avoid all breastfeeding since 1985. A number of studies have found that despite such recommendations against breastfeeding by HIV-infected women, a very small proportion of HIV-infected women in the USA continue to breastfeed their infants for various reasons. Many of these women received late or no prenatal care, inadequate antiretroviral (ARV) prophylaxis, or were not diagnosed with HIV until at or after labor and delivery. While breastfeeding has never been a major source of perinatal HIV infections in the USA, studies have identified the practice as a risk factor for MTCT in the USA. Complete avoidance remains the only sure way to prevent late postnatal HIV transmission through breastfeeding. (2012 Springer Science+Business Media New York.) |
HIV-1 virological response and prevalence of HIV-1 drug resistance among patients receiving antiretroviral therapy, Shandong, China
Zhang J , Kang D , Lin B , Sun X , Fu J , Bi Z , Nkengasong JN , Yang C . AIDS Res Hum Retroviruses 2012 28 (12) 1658-65 Shandong province has been providing antiretroviral therapy (ART) to eligible HIV/AIDS patients since 2003 using first-line regimens. We conducted a cross-sectional study to assess virological response and resistance development from ART-patients. Between 2006 and 2008, blood was collected from 143 ART-patients. Viral load (VL) was determined with a detection limit of 50 copies/ml; those with detectable VL were genotyped with dried plasma spots using a broadly sensitive genotyping assay. Resistance mutations were identified using the Stanford HIV drug resistance database. Of the 143 patients, 72% (95% confidence interval (CI): 65.9-78.2) suppressed their VL to <50 copies/ml. Genotyping analysis of the remaining 40 patients revealed that 21 (53%, CI: 37.0-68.0) harbored ≥ 1 mutations. The most common mutations were thymidine-analog mutations (22.5%) and M184V (10%) to nucleoside reverse transcriptase inhibitor (NRTI), and V106I/A /M (17.5%), Y181C (15%) and H221Y (12.5%) to Non-NRTI (NNRTI); 13 patients had mutations to both NRTI and NNRTI. Patients with VL >1,000 copies/ml appear to harbor more mutations than those with VL between 50 and 1000 (62.1% vs 27.3%, p>0.05). Resistance mutations were intensified among 10 patients for whom two sequential specimens were obtained and accumulation of resistance mutations predicted compromised treatment outcomes and future drug selections. This study provides a snapshot of virological response and resistance profile for patients on first-line regimens, indicating patient monitoring is a critical component in preventing the accumulations of resistance mutations among patients failing their regimens and thus maintain the effectiveness of the first-line regimens. |
HIV-HBV coinfection--a global challenge
Kourtis AP , Bulterys M , Hu DJ , Jamieson DJ . N Engl J Med 2012 366 (19) 1749-52 Human immunodeficiency virus type 1 (HIV-1) and hepatitis B virus (HBV) exact a high toll worldwide. Both can lead to chronic disease, cancer, and death, and neither can be eradicated with the use of current therapies. Antiviral drug resistance often develops after patients have received treatment for some time and is usually followed by the loss of clinical benefit. Coinfection with the two viruses exacerbates the negative effects. | Worldwide, HBV is the leading cause of chronic liver disease and a leading cause of death, accounting for up to half of all cases of cirrhosis and hepatocellular carcinoma.1 An estimated 400 million people are infected with HBV,1 with the majority of cases occurring in regions of Asia and Africa where the virus is endemic. There, up to 70% of adults show serologic evidence of current or prior infection, and 8 to 15% have chronic HBV infection.1 | These staggering infection rates largely reflect a failure of maternal and child health programs. The majority of HBV infections in settings where the virus is highly endemic occur through perinatal transmission (predominant in East and Southeast Asia) or in young children, transmitted through close household contact or through medical or traditional scarification procedures (predominant in Africa).1 Perinatal HBV infection is associated with a 90% risk of chronic hepatitis B, as compared with a risk of less than 5% among adults with intact immunity.1 The risk of perinatal transmission is lower in Africa than in Asia, a disparity that could be due to a lower prevalence of hepatitis Be antigen (HBeAg) and other differences in the pathogenic characteristics of circulating HBV genotypes.1 |
B lymphocyte-derived humoral immune defenses in breast milk transmission of the HIV-1
Belec L , Kourtis AP . Adv Exp Med Biol 2012 743 139-60 The UNAIDS estimated that more than 370,000 (230,000-510,000) children were infected by human immunodeficiency virus (HIV) type 1 through mother-to-child transmission (MTCT) worldwide in 2009, with the majority (>90%) occurring in sub-Saharan Africa (a drop of 24% from 5 years earlier). The majority of MTCT occurs during pregnancy and birth. In addition, postnatal transmission of HIV from HIV-infected mother to her child through prolonged breastfeeding is well recognized, and may account for one-third to half of new infant HIV infections worldwide. While studies of maternal or infant antiretroviral prophylaxis during the period of breastfeeding have shown substantial potential for reduction of infant HIV infections, postnatal virus transmissions may continue to occur even in the setting of optimal antiretroviral prophylaxis. Therefore, development of immunologic strategies to reduce HIV transmission via breast milk remains important to improving survival of infants born to HIV-infected mothers in the developing world. (2012 Springer Science+Business Media New York.) |
Breastfeeding and transmission of HIV-1: epidemiology and global magnitude
Fowler MG , Kourtis AP , Aizire J , Onyango-Makumbi C , Bulterys M . Adv Exp Med Biol 2012 743 3-25 Over the past two decades, major strides have been made in HIV-1 research and prevention. Among these advances, some of the most remarkable and sustained achievements have been in reducing the risk of transmission of HIV-1 from mothers to their infants. In resource-rich settings such as the USA and Europe, mother-to-child transmission (MTCT) of HIV-1 has successfully been reduced to less than 1-2% with the goal of virtual elimination of new cases. This success in prevention of mother-to-child transmission (PMTCT) of HIV-1 has been achieved by widespread implementation of effective PMTCT antiretroviral therapy (ART) regimens, and obstetrical interventions as well as avoidance of breastfeeding through the use of infant formula. (2012 Springer Science+Business Media New York.) |
Cellular immunity in breast milk: implications for postnatal transmission of HIV-1 to the infant
Sabbaj S , Ibegbu CC , Kourtis AP . Adv Exp Med Biol 2012 743 161-9 Breastfeeding accounts for up to 40% of all infant human immunodeficiency virus (HIV) type 1 infections in resource-limited settings, where prolonged breastfeeding is the only available and safe infant feeding option. However, most breastfed infants remain uninfected even after prolonged exposure to breast milk. The factors in breast milk that protect the majority of breastfed infants of HIV-infected mothers from infection remain largely undetermined. Breast milk contains a multitude of immune parameters, including immunoglobulins, antimicrobial substances, pro-and anti-inflammatory cytokines, and leukocytes. Moreover, breast milk not only provides passive protection, but also can directly modulate the immunological development of the infant. Cell-mediated immunity in breast milk has not been as extensively studied as humoral immunity, described in Chap. 10. There is, however, increasing interest in the role that lymphocytes, macrophages, and other immune cell types play, both in innate and in adaptive breast milk immunity. (2012 Springer Science+Business Media New York.) |
Distinct clinical and epidemiological features of tuberculosis in New York City caused by the RD(Rio)Mycobacterium tuberculosis sublineage
Weisenberg SA , Gibson AL , Huard RC , Kurepina N , Bang H , Lazzarini LC , Chiu Y , Li J , Ahuja S , Driscoll J , Kreiswirth BN , Ho JL . Infect Genet Evol 2012 12 (4) 664-70 BACKGROUND: Genetic tracking of Mycobacterium tuberculosis is a cornerstone of tuberculosis (TB) control programs. The RD(Rio)M. tuberculosis sublineage was previously associated with TB in Brazil. We investigated 3847 M. tuberculosis isolates and registry data from New York City (NYC) (2001-2005) to: (1) affirm the position of RD(Rio) strains within the M. tuberculosis phylogenetic structure, (2) determine its prevalence, and (3) define transmission, demographic, and clinical characteristics associated with RD(Rio) TB. METHODS: Isolates classified as RD(Rio) or non-RD(Rio)M. tuberculosis by multiplex PCR were further classified as clustered (2 isolates) or unique based primarily upon IS6110-RFLP patterns and lineage-specific cluster proportions were calculated. The secondary case rate of RD(Rio) was compared with other prevalent M. tuberculosis lineages. Genotype data were merged with the data from the NYC TB Registry to assess demographic and clinical characteristics. RESULTS: RD(Rio) strains were found to: (1) be restricted to the Latin American-Mediterranean family, (2) cause approximately 8% of TB cases in NYC, and (3) be associated with heightened transmission as shown by: (i) a higher cluster proportion compared to other prevalent lineages, (ii) a higher secondary case rate, and (iii) cases in children. Furthermore, RD(Rio) strains were significantly associated with US-born Black or Hispanic race, birth in Latin American and Caribbean countries, and isoniazid resistance. CONCLUSIONS: The RD(Rio) genotype is a single M. tuberculosis strain population that is emerging in NYC. The findings suggest that expanded RD(Rio) case and exposure identification could be of benefit due to its association with heightened transmission. |
Infection and transmission of Rift Valley fever viruses lacking the NSs and/or NSm genes in mosquitoes: potential role for NSm in mosquito infection.
Crabtree MB , Kent Crockett RJ , Bird BH , Nichol ST , Erickson BR , Biggerstaff BJ , Horiuchi K , Miller BR . PLoS Negl Trop Dis 2012 6 (5) e1639 BACKGROUND: Rift Valley fever virus is an arthropod-borne human and animal pathogen responsible for large outbreaks of acute and febrile illness throughout Africa and the Arabian Peninsula. Reverse genetics technology has been used to develop deletion mutants of the virus that lack the NSs and/or NSm virulence genes and have been shown to be stable, immunogenic and protective against Rift Valley fever virus infection in animals. We assessed the potential for these deletion mutant viruses to infect and be transmitted by Aedes mosquitoes, which are the principal vectors for maintenance of the virus in nature and emergence of virus initiating disease outbreaks, and by Culex mosquitoes which are important amplification vectors. METHODOLOGY AND PRINCIPAL FINDINGS: Aedes aegypti and Culex quinquefasciatus mosquitoes were fed bloodmeals containing the deletion mutant viruses. Two weeks post-exposure mosquitoes were assayed for infection, dissemination, and transmission. In Ae. aegypti, infection and transmission rates of the NSs deletion virus were similar to wild type virus while dissemination rates were significantly reduced. Infection and dissemination rates for the NSm deletion virus were lower compared to wild type. Virus lacking both NSs and NSm failed to infect Ae. aegypti. In Cx. quinquefasciatus, infection rates for viruses lacking NSm or both NSs and NSm were lower than for wild type virus. CONCLUSIONS/SIGNIFICANCE: In both species, deletion of NSm or both NSs and NSm reduced the infection and transmission potential of the virus. Deletion of both NSs and NSm resulted in the highest level of attenuation of virus replication. Deletion of NSm alone was sufficient to nearly abolish infection in Aedes aegypti mosquitoes, indicating an important role for this protein. The double deleted viruses represent an ideal vaccine profile in terms of environmental containment due to lack of ability to efficiently infect and be transmitted by mosquitoes. |
Safety and pharmacokinetics of escalating daily doses of the antituberculosis drug rifapentine in healthy volunteers
Dooley KE , Bliven-Sizemore EE , Weiner M , Lu Y , Nuermberger EL , Hubbard WC , Fuchs EJ , Melia MT , Burman WJ , Dorman SE . Clin Pharmacol Ther 2012 91 (5) 881-8 Rifapentine (RPT) is an antituberculosis drug that may shorten treatment duration when substituted for rifampin (RIF). The maximal tolerated daily dose of RPT and its potential for cytochrome 3A4 induction and autoinduction at clinically relevant doses are unknown. In this phase I, dose-escalation study among healthy volunteers, daily doses as high as a prespecified maximum of 20 mg/kg/day were well tolerated. Steady-state RPT concentrations increased with dose from 5 to 15 mg/kg, but area under the plasma concentration-time curve (AUC(0-24)) and maximum concentration (C(max)) were similar in the 15- and 20-mg/kg cohorts. Although RPT pharmacokinetics (PK) appeared to be time-dependent, accumulation occurred with daily dosing. The mean AUC(0-12) of oral midazolam (MDZ), a cytochrome 3A (CYP3A) probe drug, was reduced by 93% with the coadministration of RPT and by 74% with the coadministration of RIF (P < 0.01). Changes in the oral clearance of MDZ did not vary by RPT dose. In conclusion, RPT was tolerated at doses as high as 20 mg/kg/day, its PK were less than dose-proportional, and its CYP3A induction was robust. |
Molecular epidemiological investigation to determine the source of a fatal case of serotype 22F pneumococcal meningitis.
Lamaro-Cardoso J , de Lemos AP , Carvalho Mda G , Pimenta FC , Roundtree A , Motta L , Vieira MA , Sgambatti S , Thorn LK , Pessoa-Junior V , Minamisava R , Harrison LH , Beall BW , Brandileone MC , Andrade AL . J Med Microbiol 2012 61 686-92 A child's death due to pneumococcal meningitis after contracting the disease in an after-school programme prompted an investigation to assess nasopharyngeal (NP) carriage among her contacts. The serotype of the meningitis case isolate was determined, together with the serotypes of the NP specimens of contacts, comprising the case patient's brother, the case patient's after-school programme contacts and the brother's day-care centre (DCC) contacts. NP swabs from 155 children and 69 adults were obtained. Real-time PCR and conventional multiplex PCR (CM-PCR) assays were used to detect pneumococcal carriage and determine serotypes. Broth-enriched culture of NP specimens followed by pneumococcal isolation and Quellung-based serotyping were also performed. DNA extracts prepared from cerebrospinal fluid of the index case and from the NP strain isolated from the brother and from one attendee of the brother's DCC were subjected to genotyping. Pneumococcal carriage assessed by real-time PCR and culture was 49.6 and 36.6 %, respectively (P<0.05). Twenty-three serotypes were detected using CM-PCR, with serotypes 6A/6B, 14, 19F, 6C/6D, 22F/22A, 23F and 11A/11D being the most frequent. All eight serotype 22F/22A NP specimens recovered were from children attending the brother's DCC. The meningitis case isolate and the NP carriage isolate from the patient's brother were both serotype 22F and shared the same new multilocus sequence type (ST6403) with the attendee of the brother's DCC. CM-PCR proved to be useful for assessing carriage serotype distribution in a setting of high-risk pneumococcal transmission. The causal serotype appeared to be linked to the brother of the case patient and attendees of his DCC. |
A systematic review of rotavirus strain diversity in India, Bangladesh, and Pakistan
Miles MG , Lewis KD , Kang G , Parashar UD , Steele AD . Vaccine 2012 30 Suppl 1 A131-9 Of the estimated half-million deaths from rotavirus globally each year, approximately one-third (N=160,000 deaths) occur in the Indian subcontinent (defined as India, Bangladesh, and Pakistan). Two commercial vaccines are available for use and recommended by WHO, although the prohibitive vaccine price has limited their introduction into routine childhood immunization programs. New rotavirus vaccines are in late clinical development, including two advanced candidates in India. As significant shifts in rotavirus strain diversity have occurred in the past three decades and questions remain regarding whether strain replacement may occur following introduction of rotavirus vaccines, it is important to understand the temporal and regional strain diversity profile before vaccine introduction. We reviewed 33 peer-reviewed manuscripts from the Indian subcontinent and found that the most common G-types (G1-4) and P-types (P[4] and P[8]) globally accounted for three-fourths of all strains in the subcontinent. However, strains varied by region, and temporal analysis showed the decline of G3 and G4 in recent years and the emergence of G9 and G12. Our findings underscore the large diversity of rotavirus strains in the Indian subcontinent and highlight the need to conduct surveillance on a regional scale to better understand strain diversity before and after rotavirus vaccine introduction. |
Public health surveillance and data collection: general principles and impact on hemophilia care
Soucie JM . Hematology 2012 17 Suppl 1 144-6 Public health surveillance is the ongoing collection, analysis, and dissemination of health related data to provide information that can be used to monitor and improve the health of populations. Such surveillance systems can be established in many settings to study a variety of populations and conditions. The most effective systems are designed around specific, well-defined objectives, collect data in a standardized fashion, analyze the data frequently, and disseminate the results to those who need to know the information. Surveillance has been used to determine the occurrence rates of hemophilia and to characterize the population affected by this rare but potentially serious congenital disorder. Data from surveillance systems have been used to identify risk factors for complications that, once identified, have been modified through public health interventions. The effectiveness of these interventions can be assessed by continued surveillance, thereby assuring improvement in care of people affected by hemophilia around the world. |
Evaluation of integrated registers for tuberculosis and HIV surveillance in children, Ethiopia, 2007-2009
Click ES , Feleke B , Pevzner E , Fantu R , Gadisa T , Assefa D , Melaku Z , Cain K , Menzies H . Int J Tuberc Lung Dis 2012 16 (5) 625-7 In 2008, Ethiopia implemented tuberculosis (TB) treatment registers that included columns for recording human immunodeficiency virus (HIV) test results (integrated registers) to replace the previous system of separate TB and HIV registers (pre-integration registers). We compared the proportion of children with documented HIV rapid test results at eight hospitals before and after adopting the integrated registers. HIV status was more consistently documented in the integrated registers; however, HIV status for infants aged <18 months could not be assessed, as the registers did not capture results from polymerase chain reaction-based testing. Recording procedures should be revised to document age-appropriate HIV diagnostic results and ensure referral for appropriate care. |
Knowledge integration at the center of genomic medicine.
Khoury MJ , Gwinn M , Dotson WD , Schully SD . Genet Med 2012 14 (7) 643-7 Three articles in this issue of Genetics in Medicine describe examples of "knowledge integration," involving methods for generating and synthesizing rapidly emerging information on health-related genomic technologies and engaging stakeholders around the evidence. Knowledge integration, the central process in translating genomic research, involves three closely related, iterative components: knowledge management, knowledge synthesis, and knowledge translation. Knowledge management is the ongoing process of obtaining, organizing, and displaying evolving evidence. For example, horizon scanning and "infoveillance" use emerging technologies to scan databases, registries, publications, and cyberspace for information on genomic applications. Knowledge synthesis is the process of conducting systematic reviews using a priori rules of evidence. For example, methods including meta-analysis, decision analysis, and modeling can be used to combine information from basic, clinical, and population research. Knowledge translation refers to stakeholder engagement and brokering to influence policy, guidelines and recommendations, as well as the research agenda to close knowledge gaps. The ultrarapid production of information requires adequate public and private resources for knowledge integration to support the evidence-based development of genomic medicine. (Genet Med advance online publication 3 May 2012.) |
Modifiable risk factors for West Nile virus infection during an outbreak--Arizona, 2010
Gibney KB , Colborn J , Baty S , Bunko Patterson AM , Sylvester T , Briggs G , Stewart T , Levy C , Komatsu K , Macmillan K , Delorey MJ , Mutebi JP , Fischer M , Staples JE . Am J Trop Med Hyg 2012 86 (5) 895-901 West Nile virus (WNV) is the leading cause of mosquito-borne disease in the United States; however, risk factors for infection are poorly defined. We performed a case-control study to identify modifiable risk factors for WNV infection. Case-patients (N = 49) had laboratory evidence of recent WNV infection, whereas control-subjects (N = 74) had negative WNV serology. We interviewed participants, surveyed households, and assessed environmental data. WNV infection was associated with living in or near Water District X within Gilbert Township (adjusted odds ratio [aOR] 5.2; 95% confidence interval [95% CI] = 1.5-18.1), having water-holding containers in their yard (aOR 5.0; 95% CI = 1.5-17.3), and not working or attending school outside the home (aOR 2.4; 95% CI = 1.1-5.5). During this outbreak, WNV infection was likely primarily acquired peri-domestically with increased risk associated with potential mosquito larval habitats around the home and neighborhood. |
Healthy lifestyle behaviors and all-cause mortality among adults in the United States
Ford ES , Bergmann MM , Boeing H , Li C , Capewell S . Prev Med 2012 55 (1) 23-7 OBJECTIVE: To examine the links between three fundamental healthy lifestyle behaviors (not smoking, healthy diet, and adequate physical activity) and all-cause mortality in a national sample of adults in the United States. METHOD: We used data from 8375 U.S. participants aged ≥20 years of the National Health and Nutrition Examination Survey 1999-2003 who were followed through 2006. RESULTS: During a mean follow-up of 5.7 years, 745 deaths occurred. Compared with their counterparts, the risk for all-cause mortality was reduced by 56% (95% confidence interval [CI]: 35%-69%) among adults who were nonsmokers, 51% (95% CI: 39%, 60%) among adults who were physically active, and 23% (95% CI: 0%, 40%) among adults who consumed a healthy diet. Compared with participants who had no healthy behaviors, the risk decreased progressively as the number of healthy behaviors increased. Adjusted hazard ratios and 95% confidence interval were 0.60 (0.39, 0.92), 0.47 (0.32, 0.68), and 0.18 (0.11, 0.28) for 1, 2, and 3 healthy behaviors, respectively. CONCLUSION: Adults who do not smoke, consume a healthy diet, and engage in sufficient physical activity can substantially reduce their risk for early death. |
Homophobia is associated with sexual behavior that increases risk of acquiring and transmitting HIV infection among black men who have sex with men
Jeffries WL4th , Marks G , Lauby J , Murrill CS , Millett GA . AIDS Behav 2012 17 (4) 1442-53 We investigated whether the experience of homophobic events increases the odds of engaging in unprotected anal intercourse (UAI) among black men who have sex with men (MSM) and whether social integration level buffered the association. Participants (N = 1,154) reported homophobic events experienced in the past 12 months. Social integration measures included social support, closeness with family members and friends, attachment to the black gay community, openness about sexuality within religious communities, and MSM social network size. Logistic regression analyses indicated that experiencing homophobia was associated with (1) UAI among men not previously diagnosed with HIV and (2) sexual HIV transmission risk behavior among men who knew they were HIV-infected. None of the social integration measures buffered these associations. Homophobia may promote acquisition and transmission of HIV infection among black MSM. Interventions are needed to reduce homophobia experienced by black MSM. |
Water treatment and handwashing behaviors among non-pregnant friends and relatives of participants in an antenatal hygiene promotion program in Malawi
Russo ET , Sheth A , Menon M , Wannemuehler K , Weinger M , Kudzala AC , Tauzie B , Masuku HD , Msowoya TE , Quick R . Am J Trop Med Hyg 2012 86 (5) 860-5 Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases. To integrate hygiene improvement with antenatal care, free hygiene kits (water storage containers, water treatment solution, soap) and educational messages were distributed to pregnant women at antenatal clinics in Malawi. We assessed water treatment and hygiene practices of 275 non-pregnant friends and relatives of the hygiene kit recipients at baseline and follow-up nine months later to measure program impact on non-participants in the same communities. At follow-up, friends and relatives who did not receive kits or education were more likely than at baseline to purchase and use water treatment solution (25% versus 1%; P < 0.0001) and demonstrate correct handwashing practices (60% versus 18%; P < 0.0001). This antenatal clinic-based program resulted in improved water treatment and hygiene behaviors among non-pregnant friends and relatives living in the same communities as hygiene kit recipients, suggesting that program benefits extended beyond direct beneficiaries. |
Effects of the Gama Cuulu radio serial drama on HIV-related behavior change in Zambia
Kraft JM , Hill Z , Membe I , Zhang Y , Meassick EO , Monsour M , Maumbi M , Ndubani P , Manengu JM , Mwinga A . J Health Commun 2012 17 (8) 929-45 The Gama Cuulu radio serial drama is written and produced in Zambia's Southern Province. It promotes behavior change and service use to prevent HIV transmission. The authors evaluated the effects of Gama Cuulu on intermediate outcomes (e.g., perceived norms), as well as number of sexual partners, condom use, and HIV testing in the past year among adults between 18 and 49 years of age. The authors used a pretest/posttest assessment with a comparison group design, with Southern Province as the intervention area and Western Province as the comparison area. Approximately 1,500 in-person interviews were conducted in both provinces in 2006 (pretest), 2007, and 2008. Regression models included terms for province, time, and the interaction of the two. Outcomes improved in both provinces (e.g., by 2008, 37.6% of participants in Southern Province and 28.3% participants in Western Province tested for HIV in the past year). Pretest-to-posttest changes in condom use (from 20.2% to 29.4% in Southern Province) and 5 intermediate outcomes were significantly different in the 2 provinces. However, changes in condom use were not associated with listening to Gama Cuulu and changes in other outcomes were similar in both provinces. Weak intervention effects might be attributable to implementation challenges or the saturation of HIV programs in Zambia. |
Rotavirus vaccines for children in developing countries: understanding the science, maximizing the impact, and sustaining the effort
Neuzil KM , Parashar UD , Steele AD . Vaccine 2012 30 Suppl 1 A1-2 The past 5 years have been a period of extraordinary achievement in the rotavirus field. Countries throughout the world licensed, recommended, and introduced rotavirus vaccines, and the impact on childhood disease in early-adopter countries in the Americas, Europe, and Australia has been dramatic [1]. Since the introduction of rotavirus vaccines in Mexico in 2007, for example, the number of children younger than 5 years of age who die as a result of diarrheal illness each year is half the number as compared to before vaccine introduction. In absolute terms, this effect translates into over 2500 lives saved through rotavirus vaccination in Mexico alone over a three-year period [2]. In the United States, where death from diarrheal disease is rare, routine rotavirus vaccination prevents an estimated 40,000 to 60,000 hospitalizations each year [3]. | For developing countries in Africa and Asia, where the preponderance of rotavirus-related deaths occur, the lack of an evidence base for the efficacy of oral rotavirus vaccines delayed policy decisions on their use. Fortunately, the past 5 years has yielded progress in these countries as well: the large randomized, controlled efficacy trials of currently licensed rotavirus vaccines were completed; the World Health Organization (WHO) recommended global use of the vaccine; and, in 2011, the first GAVI-eligible country in Africa—Sudan—introduced the vaccine [4], [5], [6], [7]. In September 2011, the GAVI Alliance approved rotavirus vaccine funding for 16 new countries, including 12 in Africa. The goal of this special supplement of Vaccine is to bring together a wealth of information on rotavirus and rotavirus vaccines in low-resource countries in order to accelerate vaccine introduction in the remaining countries and guide future research and vaccine development efforts. |
Secondary efficacy endpoints of the pentavalent rotavirus vaccine against gastroenteritis in sub-Saharan Africa
Tapia MD , Armah G , Breiman RF , Dallas MJ , Lewis KD , Sow SO , Rivers SB , Levine MM , Laserson KF , Feikin DR , Victor JC , Ciarlet M , Neuzil KM , Steele AD . Vaccine 2012 30 Suppl 1 A79-85 The efficacy of the pentavalent rotavirus vaccine (PRV), RotaTeq((R)), was evaluated in a double-blind, placebo-controlled, multicenter Phase III clinical trial conducted (April 2007-March 2009) in 3 low-income countries in Africa: Ghana, Kenya, and Mali. In total, 5468 infants were randomized 1:1 to receive 3 doses of PRV/placebo at approximately 6, 10, and 14 weeks of age; concomitant administration with routine EPI vaccines, including OPV, was allowed. HIV-infected infants were not excluded. The primary endpoint, vaccine efficacy (VE) against severe-rotavirus gastroenteritis (RVGE), as measured by Vesikari scoring system (VSS, score ≥11), from ≥14 days following Dose 3 through a follow-up period of nearly 2 years in the combined 3 African countries, and secondary endpoints by total follow-up period have been previously reported. In this study, we report post hoc subgroup analyses on secondary endpoints of public health importance. VE against RVGE of any severity was 49.2% (95%CI: 29.9, 63.5) through the first year of life and 30.5% (95%CI: 16.7, 42.2) through the complete follow-up period. VE against severe-gastroenteritis of any etiology was 21.5% (95%CI: <0, 38.4) through the first year of life and 10.6% (95%CI: <0, 24.9) through the complete follow-up period. Through the complete follow-up period, VE against severe-RVGE caused by (i) vaccine-contained G and P types (G1-G4, P1A[8]), (ii) non-vaccine G types (G8, G9, G10), and (iii) non-vaccine P types (P1B[4], P2A[6]) was 34.0% (95%CI:11.2, 51.2), 81.8% (95%CI:16.5, 98.0) and 40.7% (95%CI:8.4, 62.1), respectively. There was a trend towards higher VE with higher disease severity, although in some cases the numbers were small. In African countries with high under-5 mortality rates, PRV significantly reduced RVGE through nearly 2 years of follow-up; more modest reductions were observed against gastroenteritis of any etiology. PRV provides protection against severe-RVGE caused by diverse rotavirus genotypes, including those not contained in the vaccine. |
Systematic review of regional and temporal trends in global rotavirus strain diversity in the pre rotavirus vaccine era: insights for understanding the impact of rotavirus vaccination programs
Banyai K , Laszlo B , Duque J , Steele AD , Nelson EA , Gentsch JR , Parashar UD . Vaccine 2012 30 Suppl 1 A122-30 Recently, two rotavirus vaccines have been recommended for routine immunization of infants worldwide. These vaccines proved efficacious during clinical trials and field use in both developing and developed countries, and appear to provide good protection against a range of rotavirus genotypes, including some that are not included in the vaccines. However, since conclusive data that the vaccines will protect against a wide variety of rotavirus strains are still lacking and since vaccines may exert some selection pressure, a detailed picture of global strain prevalence from the pre-rotavirus vaccine era is important to evaluate any potential changes in circulating strains observed after widespread introduction of rotavirus vaccines. Thus, we systematically reviewed rotavirus genotyping studies spanning a 12-year period from 1996 to 2007. In total, approximately 110,000 strains were genotyped from 100 reporting countries. Five genotypes (G1-G4, and G9) accounted for 88% of all strains, although extensive geographic and temporal differences were observed. For example, the prevalence of G1 strains declined from 2000 onward, while G3 strains re-emerged, and G9 and G12 strains emerged during the same period. When crude strain prevalence data were weighted by region based on the region's contribution to global rotavirus mortality, the importance of genotypes G1 and G9 strains that were more prevalent in regions with low mortality was reduced and conversely the importance of G8 strains that were more prevalent in African settings with greater contribution to global rotavirus mortality was increased. This study provides the most comprehensive, up-to-date information on rotavirus strain surveillance in the pre-rotavirus vaccine era and will provide useful background to examine the impact of rotavirus vaccine introduction on future strain prevalence. |
Viscerotropic disease: case definition and guidelines for collection, analysis, and presentation of immunization safety data
Gershman MD , Staples JE , Bentsi-Enchill AD , Breugelmans JG , Brito GS , Bastoscamacho LA , Cottin P , Domingo C , Durbin A , Gascon J , Guenaneche F , Hayes EB , Jelenik Z , Khromava A , Martins RD , Wilson MM , Massy N , Nasidi A , Niedrig M , Sherwat A , Tsai T , Vilella A , Wilson ME , Kohl KS . Vaccine 2012 30 (33) 5038-58 Viscerotropic disease (VTD) is defined as acute multiple organ system dysfunction that occurs following vaccination. The severity of VTD ranges from relatively mild multisystem disease to severe multiple organ system failure and death. The term VTD was first used shortly after the initial published reports in 2001 of febrile multiple organ system failure following yellow fever (YF) vaccination [1–7]. To date, VTD has been reported only in association with YF vaccine and has been thus referred to as YF vaccine-associated viscerotropic disease (YEL-AVD). | YF vaccine is manufactured from the live attenuated 17D virus substrain. It is considered relatively safe and effective in preventing YF disease, which results from YF virus transmission through the bite of an infected mosquito [8]. YF virus circulates in sub-Saharan Africa and tropical South America, where it causes endemic and intermittently epidemic disease. Most YF disease in these areas is attributable to jungle (sylvatic) or savanna (intermediate) transmission cycles, which occur predominantly in sparsely populated forested areas and rural villages, respectively [8]. To protect vulnerable populations, endemic countries target YF vaccination efforts towards their residents, who reside in both rural and urban settings with varying resources. |
Workshop on intussusception in African countries - meeting report
Steele AD , Patel M , Cunliffe NA , Bresee JS , Borgstein E , Parashar UD . Vaccine 2012 30 Suppl 1 A185-9 Rotavirus causes approximately 450,000 deaths annually among children less than 5 years of age worldwide, almost half of which occur in Africa. After the recent completion of successful trials of 2 new rotavirus vaccines, the World Health Organization has recommended these vaccines for all children worldwide. Because a previous rotavirus vaccine, Rotashield((R)), was associated with intussusception, a form of intestinal obstruction among infants, the current rotavirus vaccines were tested in large clinical trials and found to be safe. However, due to the past Rotashield((R)) experience, post licensure monitoring of intussusception is considered to be crucial after the introduction of future oral rotavirus vaccines. Thus, in planning for future introductions of rotavirus vaccine in Africa, a workshop of experts working on intussusception was convened by the World Health Organization in May 2004 in association with the Pan-African Association of Paediatric Surgeons (PAPSA) in Malawi. In brief, delegates from ten countries presented data from retrospective record reviews of intussusception events from 1993 to 2003 at selected hospitals in their respective countries. This review showed that age of intussusception onset during infancy varies markedly with peak prevalence between 4 and 6 months of life. Diagnostic modality (e.g., contrast enema, ultrasound) was employed in <20% of the events; nearly 70% of the intussusception events were diagnosed at the time of surgery. Overall, case-fatality was high, approximately 13%, in these African countries. The findings of this meeting highlight the challenges in implementing surveillance for intussusception after rotavirus vaccine introduction in Africa. The deliberations identified some concrete steps necessary to establish active surveillance at sentinel sites in African countries. This is becoming more urgent now that many countries are expressing interest in introducing rotavirus vaccines. |
Middle school vaccination requirements and adolescent vaccination coverage
Bugenske E , Stokley S , Kennedy A , Dorell C . Pediatrics 2012 129 (6) 1056-63 OBJECTIVE: To determine if middle school vaccination requirements are associated with higher coverage for adolescent vaccines. METHODS: School entry requirements for receipt of vaccination for school entry or education of parents for 3 vaccines recommended for adolescents: tetanus/diphtheria-containing (Td) or tetanus/diphtheria/acellular pertussis (TdaP), meningococcal conjugate (MenACWY), and human papillomavirus (HPV) vaccines in place for the 2008-2009 school year were reviewed for the 50 states and the District of Columbia. Vaccination coverage levels for adolescents 13 to 17 years of age by state requirement status and change in coverage from 2008 to 2009 were assessed by using the 2008-2009 National Immunization Survey-Teen. RESULTS: For the 2008-2009 school year, 32 states had requirements for Td/TdaP (14 specifically requiring TdaP) and none required education; 3 states required MenACWY vaccine and 10 others required education; and 1 state required HPV vaccine and 5 required education. Compared with states with no requirements, vaccination requirements were associated with significantly higher coverage for MenACWY (71% vs 53%, P < .001) and Td/TdaP (80% vs 70%, P < .001) vaccines. No association was found between education-only requirements and coverage levels for MenACWY and HPV vaccines. States with new 2008-2009 vaccination requirements (n = 6, P = .04) and states with preexisting vaccination requirements (n = 26, P = .02) for Td/TdaP experienced a significant increase in TdaP coverage over states with no requirements. CONCLUSIONS: Middle school vaccination requirements are associated with higher coverage for Td/TdaP and MenACWY vaccines, whereas education-only requirements do not appear to increase coverage levels for MenACWY or HPV vaccines. The impact on coverage should continue to be monitored as more states adopt requirements. |
Neonatal vaccine-strain varicella zoster virus infection 22 days after maternal post-partum vaccination
Kluthe M , Herrera A , Blanca H , Leung J , Bialek SR , Schmid DS . Pediatr Infect Dis J 2012 31 (9) 977-9 A 25-day-old infant developed varicella 22 days after her mother received varicella vaccine postpartum. Infection with vaccine-strain varicella zoster virus was confirmed by genetic analysis. The mother had no post-vaccination rash nor did other contacts have rash or recent vaccination. Potential means of transmission to the infant are explored. |
Parental and societal values for the risks and benefits of childhood combination vaccines
Gidengil C , Lieu TA , Payne K , Rusinak D , Messonnier M , Prosser LA . Vaccine 2012 30 (23) 3445-52 BACKGROUND: New combination vaccines reduce the number of injections needed for immunization. However, possible drawbacks include higher prices, extra doses of vaccine antigens and increased minor adverse events. Our objective was to measure parental and societal values for attributes of childhood combination vaccines. METHODS: We conducted a discrete choice experiment using an online survey of adults administered by Knowledge Networks. Values were measured for attributes of combination vaccines for a hypothetical child aged 6 months: (1) number of injections, (2) extra dose of hepatitis B vaccine, (3) 20% higher chance of fever, (4) community-level immunization coverage of 2-year-olds of 90% or 80%, and (5) cost per visit. Logistic regression with generalized estimating equations was used to analyze the value of different attributes and generate a marginal willingness-to-pay for a change in attribute level. RESULTS: The response rate was 64% (N=558). Most respondents were parents (63%) and most respondents agreed that combination vaccines were safe (77%). Respondents were willing to pay $7.68 to avoid an injection (compared to $9.94 when looking at parents only). However, respondents were willing to pay $41.57 to avoid higher risk of fever after one set of immunizations (10% versus 30%) and $65.42 for higher immunization coverage rates. These results were very similar for parents only. There was no significant preference to avoid an extra dose of hepatitis B vaccine. CONCLUSIONS: Respondents were willing to pay larger amounts to avoid increased risk of minor adverse events and to increase community-level immunization coverage than to avoid injections. These values should be taken into account when determining the risks and benefits of combination vaccines. |
Projected health and economic impact of rotavirus vaccination in GAVI-eligible countries: 2011-2030
Atherly DE , Lewis KD , Tate J , Parashar UD , Rheingans RD . Vaccine 2012 30 Suppl 1 A7-A14 Rotavirus is the leading cause of diarrheal disease in children under 5 years of age. It is responsible for more than 450,000 deaths each year, with more than 90% of these deaths occurring in low-resource countries eligible for support by the GAVI Alliance. Significant efforts made by the Alliance and its partners are providing countries with the opportunity to introduce rotavirus vaccines into their national immunization programs, to help prevent childhood illness and death. We projected the cost-effectiveness and health impact of rotavirus vaccines in GAVI-eligible countries, to assist decision makers in prioritizing resources to achieve the greatest health benefits for their populations. A decision-analytic model was used to project the health outcomes and direct costs of a birth cohort in the target population, with and without a rotavirus vaccine. Current data on disease burden, vaccine efficacy, immunization rates, and costs were used in the model. Vaccination in GAVI-eligible countries would prevent 2.46 million childhood deaths and 83 million disability-adjusted life years (DALYs) from 2011 to 2030, with annual reductions of 180,000 childhood deaths at peak vaccine uptake. The cost per DALY averted is $42 for all GAVI countries combined, over the entire period. Rotavirus vaccination would be considered very cost-effective for the entire cohort of GAVI countries, and in each country individually, as cost-effectiveness ratios are less than the gross domestic product (GDP) per capita. Vaccination is most cost-effective and has the greatest impact in regions with high rotavirus mortality. Rotavirus vaccination in GAVI-eligible countries is very cost-effective and is projected to substantially reduce childhood mortality in this population. |
Effectiveness and cost of immunization recall at school-based health centers
Kempe A , Barrow J , Stokley S , Saville A , Glazner JE , Suh C , Federico S , Abrams L , Seewald L , Beaty B , Daley MF , Dickinson LM . Pediatrics 2012 129 (6) e1446-52 BACKGROUND AND OBJECTIVE: Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers (SBHCs). We assessed (1) immunization rates achieved with recall among sixth-grade girls (demonstration study); (2) effectiveness of recall among sixth-grade boys (randomized controlled trial [RCT]); and (3) cost of conducting recall in SBHCs. METHODS: During October 2008 through March 2009, in 4 Denver public SBHCs, we conducted (1) a demonstration study among 265 girls needing ≥1 recommended adolescent vaccine and (2) an RCT among 264 boys needing vaccines, with half randomized to recall and half receiving usual care. Immunization rates for recommended adolescent vaccines were assessed 6 months after recall. First dose costs were assessed by direct observation and examining invoices. RESULTS: At the end of the demonstration study, 77% of girls had received ≥1 vaccine and 45% had received all needed adolescent vaccines. Rates of receipt among those needing each of the vaccines were 68% (160/236) for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, 57% (142/248) for quadrivalent meningococcal conjugate vaccine, and 59% (149/253) for the first human papillomavirus vaccine. At the end of the RCT, 66% of recalled boys had received ≥1 vaccine and 59% had received all study vaccines, compared with 45% and 36%, respectively, of the control group (P < .001). Cost of conducting recall ranged from $1.12 to $6.87 per recalled child immunized. CONCLUSIONS: SBHC-based recall was effective in improving immunization rates for all adolescent vaccines, with effects sizes exceeding those achieved with younger children in practice settings. |
Effectiveness and net cost of reminder/recall for adolescent immunizations
Suh CA , Saville A , Daley MF , Glazner JE , Barrow J , Stokley S , Dong F , Beaty B , Dickinson LM , Kempe A . Pediatrics 2012 129 (6) e1437-45 OBJECTIVE: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues. METHODS: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines. RESULTS: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses. CONCLUSIONS: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low. |
Immunogenicity of the pentavalent rotavirus vaccine in African infants
Armah GE , Breiman RF , Tapia MD , Dallas MJ , Neuzil KM , Binka FN , Sow SO , Ojwando J , Ciarlet M , Steele AD . Vaccine 2012 30 Suppl 1 A86-93 We recently completed a double-blind, placebo-controlled, multicenter Phase III clinical trial of the pentavalent rotavirus vaccine (PRV) in three African countries, Ghana, Kenya, and Mali, from April 2007 to March 2009. The immunogenicity of PRV in African infants is described. In total, 5468 infants were randomized 1:1 to receive 3 doses of PRV or placebo at approximately 6, 10, and 14 weeks of age. Breastfeeding and concomitant administration of EPI vaccines, including OPV, were allowed, and HIV-infected infants were not excluded. Immunogenicity of PRV was assessed by measuring serum anti-rotavirus IgA responses, as well as serum neutralization antibody (SNA) to the human rotavirus serotypes G1, G2, G3, G4 and P1A[8] in approximately 150 infants per country. Sera were collected pre-dose 1 (pD1) and approximately 14 days post-dose 3 (PD3) for immunological analysis. For the sero-response rates (≥3-fold rise from pD1 to PD3), the number of subjects evaluable included those with both pD1 and PD3 data available. PRV was immunogenic in African children and significantly reduced severe RVGE in African children through the first two years of life. The pooled anti-rotavirus IgA sero-response rate was 78.3%, with consistent rates in each of the African sites: 73.8% (Kenya), 78.9% (Ghana), and 82.5% (Mali); but generally lower than that reported in Europe and USA. PD3 GMTs (28.2 dilution-units) were 5-10 times lower than those assessed in subjects in clinical trials in developed countries. SNA responses to human rotavirus serotypes G1-G4 and P1A[8] ranged from 6.3% (G3) to 26.5% (G4). PD3 SNA GMTs to G1 and P1A[8] were 4-fold and 3-fold lower respectively, when compared to the corresponding GMTs in subjects who received PRV in similar studies conducted in developed countries. PRV was immunogenic in African infants, and the anti-rotavirus IgA sero-response rates were similar across all three African sites although lower than those observed in Europe and USA. While immune correlates of protection have not been established for rotavirus, the findings are consistent with lower efficacy rates demonstrated during this trial. Further investigation is needed to understand the reason for the lower immunogenicity observed. |
A dose-escalation safety and immunogenicity study of a new live attenuated human rotavirus vaccine (Rotavin-M1) in Vietnamese children
Anh DD , Van Trang N , Thiem VD , Anh NTH , Mao ND , Wang Y , Jiang B , Hien ND , Luan LT . Vaccine 2012 30 A114-A121 We tested a candidate live, oral, rotavirus vaccine (Rotavin-M1) derived from an attenuated G1P [8] strain (KH0118-2003) isolated from a child in Vietnam. The vaccine was tested first for safety in 29 healthy adults. When deemed safe, it was further tested for safety and immunogenicity in 160 infants (4 groups) aged 6-12 weeks in a dose and schedule ranging study. The vaccine was administered in low titer (10(6.0) FFU/dose) on a 2-dose schedule given 2 months apart (Group 2L) and on a 3-dose schedule given 1 month apart (Group 3L) and in high titer (10(6.3) FFU/dose) in 2 doses 2 months apart (Group 2H) and in 3 doses 1 month apart (Group 3H). For comparison, 40 children (group Rotarix) were given 2 doses of the lyophilized Rotarix vaccine (10(6.5) CCID(50)/dose) 1 month apart. All infants were followed for 30 days after each dose for clinical adverse events including diarrhea, vomiting, fever, abdominal pain, irritability and intussusception. Immunogenicity was assessed by IgA seroconversion and viral shedding was monitored for 7 days after administration of each dose. Two doses of Rotavin-M1 (10(6.3) FFU/dose) were well tolerated in adults. Among infants (average 8 weeks of age at enrollment), administration of Rotavin-M1 was safe and did not lead to an increased rate of fever, diarrhea, vomiting or irritability compared to Rotarix, indicating that the candidate vaccine virus had been fully attenuated by serial passages. No elevation of levels of serum transaminase, blood urea, or blood cell counts were observed. The highest rotavirus IgA seroconversion rate (73%, 95%CI (58-88%)) was achieved in group 2H (2 doses - 10(6.3) FFU/dose, 2 months apart). The 2 dose schedules performed slightly better than the 3 dose schedules and the higher titer doses performed slightly better than the lower titer doses. These rates of seroconversion were similar to that of the Rotarix group (58%, 95%CI (42-73%)). However more infants who received Rotarix (65%) shed virus in their stool after the first dose than those who received Rotavin-M1 (44-48%) (p<0.05) and the percent shedding decreased after subsequent doses of either vaccine. Rotavin-M1 vaccine is safe and immunogenic in Vietnamese infants. A trial in progress will assess the safety, immunogenicity and efficacy of Rotavin-M1 (2 doses at 10(6.3) FFU/dose) in a larger number of infants. The trial registration numbers are NCT01375907 and NCT01377571. (2011 Elsevier Ltd.) |
Prevalence of traumatic brain injury among prisoners in South Carolina
Ferguson PL , Pickelsimer EE , Corrigan JD , Bogner JA , Wald M . J Head Trauma Rehabil 2012 27 (3) E11-20 OBJECTIVE: To determine lifetime prevalence of traumatic brain injury (TBI) in a statewide sample of prisoners. DESIGN: Retrospective and cross-sectional cohort study. PARTICIPANTS: Stratified random sample of prisoners scheduled to be released by release type for each gender (275 men and 267 women with completed sentences and 19 men and 15 women granted parole) and a random sample of prisoners by gender with lifetime or death sentences (26 men and 34 women). PRIMARY MEASURE: Weighted prevalence of TBI. In-person interviews ascertained history of TBI using a customized version of the Ohio State University TBI Identification Method. RESULTS: Sixty-five percent of male releases and nonreleases, and 72% and 73% of female releases and nonreleases, reported at least 1 TBI with an alteration of consciousness. Forty-two percent of male releases and 50% of nonreleases, and 50% of female releases and 33% of nonreleases, reported at least 1 TBI with loss of consciousness. Thirty-five percent of male releases and 42% of nonreleases, and 55% of female releases and 58% of nonreleases, reported ongoing symptoms from TBI. CONCLUSIONS: A substantial proportion of prisoners reported having experienced a TBI during their lifetime. The ongoing TBI symptoms reported by prisoners may impact their success on release. |
Helmet use among motorcyclists in Cambodia: a survey of use, knowledge, attitudes, and practices
Bachani AM , Tran NT , Sann S , Ballesteros MF , Gnim C , Ou A , Sem P , Nie X , Hyder AA . Traffic Inj Prev 2012 13 Suppl 1 31-6 OBJECTIVE: Road traffic injuries (RTIs) are a leading cause of disability and fatality globally. Motorcycle-related injuries, mainly head injuries, and related deaths and disabilities are a significant contributor to the burden of disease in low- and middle-income countries (LMICs). Helmets have been proven to be an effective way to reduce the risk of head injury. As motorcycle use continually increases in Cambodia, head injuries and related deaths and disabilities are expected to rise. This article aims to assess the current status of helmet use in Cambodia, as well as the knowledge, attitudes, and practices among motorcyclists, in order to assist with better planning and implementation of injury prevention strategies. METHODS: Two separate methodologies were employed for this study. Helmet observations were conducted in Phnom Penh, Kandal, Kampong Speu, Siem Reap, and Kampong Cham to assess the current status of helmet use during the day and at night. Roadside knowledge, attitudes, and practice (KAP) interviews were also conducted in Phnom Penh, Kandal, and Kampong Speu to determine the prevailing beliefs around helmet use in Cambodia. RESULTS: Based on observations, the proportion of helmet wearing across all study sites was 25 percent at night and 43 percent during the day among all motorcyclists. The observed proportion was up to 10 times higher among drivers compared to passengers. The top 3 reasons for always wearing a helmet were lifesaving potential, legal duty, and police fines. Almost 60 percent of respondents said that their use or nonuse of a helmet depended on where they were driving. Helmet quality, price, style, and color were important factors influencing the decision to purchase a helmet. CONCLUSIONS: A paradox appears to exist in Cambodia; though awareness of the benefits of wearing a helmet is high, actual helmet use remains low in the country. Daytime usage is higher than nighttime, and these proportions are significantly higher among drivers compared to passengers. There is a continuing need to improve the proportion of all-day helmet wearing, especially at night and among motorcycle passengers in Cambodia. |
Community violence exposure and adolescent substance use: does monitoring and positive parenting moderate risk in urban communities?
Lee R . J Community Psychol 2012 40 (4) 406-421 This study investigates whether monitoring and positive parenting moderate the relationship between community violence exposure (CVE) and youth substance use. Analyses utilized a subsample (N = 2197) of a cross-sectional, ethnically diverse, urban school district sample. Dependent variables were any past year alcohol or drug use (AOD) and binge drinking. Independent variables were CVE, perceptions of parental monitoring, and positive parenting. Sixty-four percent of the sample witnessed beatings, 16.5% witnessed stabbings or shootings; 45% and 19.5% reported AOD consumption and binge drinking, respectively. After controlling for confounders, logistic regression models indicated that CVE was significantly and positively related to AOD and binge drinking. Parental monitoring was inversely related to AOD and binge drinking. Significant interactions between CVE and parenting variables were not found. Additional research is needed to identify factors at multiple levels of the social ecology that buffer the impact of community violence on adolescent substance use. |
T cell receptors are structures capable of initiating signaling in the absence of large conformational rearrangements
Fernandes RA , Shore DA , Vuong MT , Yu C , Zhu X , Pereira-Lopes S , Brouwer H , Fennelly JA , Jessup CM , Evans EJ , Wilson IA , Davis SJ . J Biol Chem 2012 287 (16) 13324-35 Native and non-native ligands of the T cell receptor (TCR), including antibodies, have been proposed to induce signaling in T cells via intra- or intersubunit conformational rearrangements within the extracellular regions of TCR complexes. We have investigated whether any signatures can be found for such postulated structural changes during TCR triggering induced by antibodies, using crystallographic and mutagenesis-based approaches. The crystal structure of murine CD3epsilon complexed with the mitogenic anti-CD3epsilon antibody 2C11 enabled the first direct structural comparisons of antibody-liganded and unliganded forms of CD3epsilon from a single species, which revealed that antibody binding does not induce any substantial rearrangements within CD3epsilon. Saturation mutagenesis of surface-exposed CD3epsilon residues, coupled with assays of antibody-induced signaling by the mutated complexes, suggests a new configuration for the complex within which CD3epsilon is highly exposed and reveals that no large new CD3epsilon interfaces are required to form during antibody-induced signaling. The TCR complex therefore appears to be a structure that is capable of initiating intracellular signaling in T cells without substantial structural rearrangements within or between the component subunits. Our findings raise the possibility that signaling by native ligands might also be initiated in the absence of large structural rearrangements in the receptor. |
TB-lineage: an online tool for classification and analysis of strains of Mycobacterium tuberculosis complex
Shabbeer A , Cowan LS , Ozcaglar C , Rastogi N , Vandenberg SL , Yener B , Bennett KP . Infect Genet Evol 2012 12 (4) 789-97 This paper formulates a set of rules to classify genotypes of the Mycobacterium tuberculosis complex (MTBC) into major lineages using spoligotypes and MIRU-VNTR results. The rules synthesize prior literature that characterizes lineages by spacer deletions and variations in the number of repeats seen at locus MIRU24 (alias VNTR2687). A tool that efficiently and accurately implements this rule base is now freely available at http://tbinsight.cs.rpi.edu/run_tb_lineage.html. When MIRU24 data is not available, the system utilizes predictions made by a Naive Bayes classifier based on spoligotype data. This website also provides a tool to generate spoligoforests in order to visualize the genetic diversity and relatedness of genotypes and their associated lineages. A detailed analysis of the application of these tools on a dataset collected by the CDC consisting of 3198 distinct spoligotypes and 5430 distinct MIRU-VNTR types from 37,066 clinical isolates is presented. The tools were also tested on four other independent datasets. The accuracy of automated classification using both spoligotypes and MIRU24 is >99%, and using spoligotypes alone is >95%. This online rule-based classification technique in conjunction with genotype visualization provides a practical tool that supports surveillance of TB transmission trends and molecular epidemiological studies. |
Temporal differences in blood meal detection from the midguts of Triatoma infestans
Pinto J , Roellig DM , Gilman RH , Calderon M , Bartra C , Salazar R , Bern C , Ancca-Juarez J , Levy M , Naquira C , Cama V . Rev Inst Med Trop Sao Paulo 2012 54 (2) 83-8 We used genus/species specific PCRs to determine the temporal persistence of host DNA in Triatoma infestans experimentally fed on blood from six common vertebrate species: humans, domestic dogs, guinea pigs, chickens, mice, and pigs. Twenty third or fourth instar nymphs per animal group were allowed to feed to engorgement, followed by fasting-maintenance in the insectary. At 7, 14, 21, or 28 days post-feeding, the midgut contents from five triatomines per group were tested with the respective PCR assay. DNA from all vertebrate species was detected in at least four of five study nymphs at seven and 14 days post-feeding. DNA of humans, domestic dogs, guinea pigs, pigs, and chickens were more successfully detected (80-100%) through day 21, and less successfully (20-100%) at day 28. Findings demonstrate that species-specific PCRs can consistently identify feeding sources of T. infestans within two weeks, a biologically relevant time interval. |
Laboratory quality control in a multicentre meningococcal carriage study in Burkina Faso
Kristiansen PA , Ouedraogo AS , Sanou I , Ky Ba A , Ouedraogo CD , Sangare L , Ouedraogo R , Kandolo D , Diomande F , Kabore P , Hassan-King M , Thomas JD , Hatcher CP , Andreasson I , Clark TA , Preziosi MP , Laforce M , Caugant DA . Trans R Soc Trop Med Hyg 2012 106 (5) 289-97 To investigate the potential herd immunity effect of MenAfriVac, a new conjugate vaccine against serogroup A Neisseria meningitidis, a multiple cross-sectional carriage study was conducted in three districts in Burkina Faso in 2009, yielding a total of 20 326 oropharyngeal samples. A major challenge was the harmonisation of operational procedures and ensuring the reliability of results. Here we describe the laboratory quality control (QC) system that was implemented. Laboratory analysis performed by three local laboratories included colony morphology assessment, oxidase test, Gram stain, beta-galactosidase activity using o-nitrophenyl-beta-galactopyranoside (ONPG), gamma-glutamyl transferase (GGT) activity and slide agglutination serogrouping. Internal QC was performed on media, reagents, laboratory equipment and field conditions. Confirmation of results and molecular characterisation was performed at the Norwegian Institute of Public Health (Oslo, Norway). External QC was performed on 3% of specimens where no colonies morphologically resembling N. meningitidis had been identified and on 10% of non-ONPG-/GGT+ isolates. The QC system was a critical element: it identified logistical and operational problems in real time and ensured accuracy of the final data. The overall N. meningitidis carriage prevalence (3.98%) was probably slightly underestimated and the calculated true prevalence was 4.48%. The components of the presented QC system can easily be implemented in any other laboratory study. |
Mycobacterium tuberculosis spoligotypes that may derive from mixed strain infections are revealed by a novel computational approach
Lazzarini LC , Rosenfeld J , Huard RC , Hill V , Lapa ESilva JR , Desalle R , Rastogi N , Ho JL . Infect Genet Evol 2012 12 (4) 798-806 Global control of tuberculosis is increasingly dependent on rapid and accurate genetic typing of Mycobacteriumtuberculosis. Spoligotyping is a first-line genotypic fingerprinting method for M.tuberculosis isolates. An international online database (SpolDB4) of spoligotype patterns has been established wherein a clustered pattern (shared by 2 isolates) is designated a shared international type (SIT). Dual infections of single patients by distinct strains of M. tuberculosis is increasingly reported in high tuberculosis incidence areas, raising the possibility of false composite spoligotype patterns if performed upon mixed strain samples. A computational approach was applied to SpolDB4 and found that of the reported 1939 SITs, 54% could be a composite of two other SITs. Although many of the spoligotypes listed in SpolDB4 may be the product of admixing, the majority of patterns were reported with a corresponding low case frequency and so the effect of misclassification upon database integrity with these is likely minimal. Phylogenetic analysis of the five SITs most prone to be a composite demonstrated that these patterns designate nodes from which the ramifications of large families T, MANU, LAM, and EAI emerged. We illustrate how geographic context may indicate when an observed pattern could be the product of mixed infection. Importantly, when one of the most composite-prone SITs is obtained, further genetic testing by alternate methods is prudent to rule-out mixed infection, especially in high tuberculosis prevalence areas. These findings have broad practical implications for tuberculosis control and surveillance, as well as highlight the utility of a computational approach in providing solutions to biological questions in which the information can be digitalized. |
Prediction system for rapid identification of salmonella serotypes based on pulsed-field gel electrophoresis fingerprints
Zou W , Lin WJ , Hise KB , Chen HC , Keys C , Chen JJ . J Clin Microbiol 2012 50 (5) 1524-32 A classification model is presented for rapid identification of Salmonella serotypes based on pulsed-field gel electrophoresis (PFGE) fingerprints. The classification model was developed using random forest and support vector machine algorithms and was then applied to a database of 45,923 PFGE patterns, randomly selected from all submissions to CDC PulseNet from 2005 to 2010. The patterns selected included the top 20 most frequent serotypes and 12 less frequent serotypes from various sources. The prediction accuracies for the 32 serotypes ranged from 68.8% to 99.9%, with an overall accuracy of 96.0% for the random forest classification, and ranged from 67.8% to 100.0%, with an overall accuracy of 96.1% for the support vector machine classification. The prediction system improves reliability and accuracy and provides a new tool for early and fast screening and source tracking of outbreak isolates. It is especially useful to get serotype information before the conventional methods are done. Additionally, this system also works well for isolates that are serotyped as "unknown" by conventional methods, and it is useful for a laboratory where standard serotyping is not available. |
Quartz measurement in coal dust with high-flow rate samplers: laboratory study
Lee T , Lee EG , Kim SW , Chisholm WP , Kashon M , Harper M . Ann Occup Hyg 2012 56 (4) 413-425 A laboratory study was performed to measure quartz in coal dust using high-flow rate samplers (CIP10-R, GK2.69 cyclone, and FSP10 cyclone) and low-flow rate samplers [10-mm nylon and Higgins-Dewell type (BGI4L) cyclones] and to determine whether an increased mass collection from high-flow rate samplers would affect the subsequent quartz measurement by Fourier transform infrared (FTIR) and X-ray diffraction (XRD) analytical procedures. Two different sizes of coal dusts, mass median aerodynamic diameter 4.48 m (Coal Dust A) and 2.33 m (Coal Dust B), were aerosolized in a calm air chamber. The mass of coal dust collected by the samplers was measured gravimetrically, while the mass of quartz collected by the samplers was determined by FTIR (NIOSH Manual of Analytical Method 7603) and XRD (NIOSH Manual of Analytical Method 7500) after one of two different indirect preparations. Comparisons between high-flow rate samplers and low-flow rate samplers were made by calculating mass concentration ratios of coal dusts, net mass ratios of coal dusts, and quartz net mass. Mass concentrations of coal dust from the FSP10 cyclone were significantly higher than those from other samplers and mass concentrations of coal dust from 10-mm nylon cyclone were significantly lower than those from other samplers, while the CIP10-R, GK2.69, and BGI4L samplers did not show significant difference in the comparison of mass concentration of coal dusts. The BGI4L cyclone showed larger mass concentration of 9% compared to the 10-mm nylon cyclone. All cyclones provided dust mass concentrations that can be used in complying with the International Standard Organization standard for the determination of respirable dust concentration. The amount of coal dust collected from the high-flow rate samplers was found to be higher with a factor of 2-8 compared to the low-flow rate samplers but not in direct proportion of increased flow rates. The high-flow rate samplers collected more quartz compared to low-flow rate samplers in the range of 2-10. There was no significant difference between the per cent (%) quartz in coal dust between the FTIR and XRD analyses. The findings of this study indicated that the increased mass of quartz collected with high-flow rate samplers would provide precise analytical results (i.e. significantly above the limit of detection and/or limit of quantification) compared to the mass collected with low-flow rate samplers, especially in environments with low concentrations of quartz or where short sampling times are desired. (2011 The Author.) |
Evaluation of mycobacterial interspersed repetitive-unit-variable-number tandem-repeat genotyping as performed in laboratories in Canada, France, and the United States
Cowan LS , Hooks DP , Christianson S , Sharma MK , Alexander DC , Guthrie JL , Jamieson FB , Supply P , Allix-Beguec C , Cruz L , Desmond E , Kramer R , Lugo S , Rudrik J . J Clin Microbiol 2012 50 (5) 1830-1 The external quality assessment of 24-locus mycobacterial interspersed repetitive-unit–variable-number tandem-repeat (MIRU-VNTR) genotyping by de Beer et al. reveals issues with its international performance (5). Detailed analysis of the data was confounded by the complexity of the participants. The five genotyping laboratories in Canada and the United States participating in this study use similar typing protocols based on the standardized protocol proposed by Supply et al. (8) and developed in collaboration with each other. Systems for routine handling of samples and data management are well established. Quality control (QC) and assurance measures include routine testing of the Mycobacterium tuberculosis strain H37Rv and repeat testing of 1% of isolates at an external laboratory. The laboratorians conducting the analysis have at a minimum 5 years of experience performing MIRU-VNTR typing. This cohesiveness allows for a more in-depth analysis of the data collected by de Beer et al. | Each laboratory reported 24-locus MIRU-VNTR results for the proficiency testing panel of 30 DNA samples (including 10 pairs of duplicates), and their performance is summarized in Table 1. Reproducibility as calculated at the sample level and disregarding missing results ranged from 93% to 100%, and typeability as calculated by the percentage of loci with a reportable result ranged from 98.9% to 100%. Here we present a detailed description of the 38 observed discrepancies to provide a more complete understanding of the performance of MIRU-VNTR typing in our laboratories. |
A humanized IgG but not IgM antibody is effective in prophylaxis and therapy of yellow fever infection in an AG129/17D-204 peripheral challenge mouse model
Thibodeaux BA , Garbino NC , Liss NM , Piper J , Schlesinger JJ , Blair CD , Roehrig JT . Antiviral Res 2012 94 (1) 1-8 Yellow fever virus (YFV), a member of the genus Flavivirus, is a mosquito-borne virus found in tropical regions of Africa and South America that causes severe hepatic disease and death in humans. Despite the availability of effective vaccines, YFV is responsible for an estimated 200,000 cases and 30,000 deaths annually. There are currently no prophylactic or therapeutic strategies approved for use in human YFV infections. Furthermore, implementation of YFV 17D-204 vaccination campaigns has become problematic due to an increase in reported post-vaccinal adverse events. We have created human/murine chimeric MAbs of a YFV-reactive murine monoclonal antibody (mMAb), 2C9, that was previously shown to protect mice from lethal YFV infection and to have therapeutic activity. The new chimeric (cMAbs) were constructed by fusion of the m2C9 IgG gene variable regions with the constant regions of human IgG and IgM and expressed in Sp2 murine myelomas. The 2C9 cMAbs (2C9-cIgG and 2C9-cIgM) reacted with 17D-204 vaccine strain in an enzyme-linked immunosorbent assay and neutralized virus in vitro similarly to the parent m2C9. Both m2C9 and 2C9-cIgG when administered prophylactically 24h prior to infection protected AG129 mice from peripheral 17D-204 challenge at antibody concentrations 1.27mcg/mouse; however, the 2C9-cIgM did not protect even at a dose of 127mcg/mouse. The 17D-204 infection of AG129 mice is otherwise uniformly lethal. While the m2C9 was shown previously to be therapeutically effective in YFV-infected BALB/c mice at day 4 post-infection, the m2C9 and 2C9-cIgG demonstrated therapeutic activity only when administered 1 day post-infection in 17D-204-infected AG129 mice. |
Investigation of aerosol surface area estimation from number and mass concentration measurements: particle density effect
Ku BK , Evans DE . Aerosol Sci Technol 2012 46 (4) 473-484 For nanoparticles with nonspherical morphologies, e.g., open agglomerates or fibrous particles, it is expected that the actual density of agglomerates may be significantly different from the bulk material density. It is further expected that using the material density may upset the relationship between surface area and mass when a method for estimating aerosol surface area from number and mass concentrations (referred to as Maynard's estimation method) is used. Therefore, it is necessary to quantitatively investigate how much the Maynard's estimation method depends on particle morphology and density. In this study, aerosol surface area estimated from number and mass concentration measurements was evaluated and compared with values from two reference methods: a method proposed by Lall and Friedlander for agglomerates and a mobility based method for compact nonspherical particles using well-defined polydisperse aerosols with known particle densities. Polydisperse silver aerosol particles were generated by an aerosol generation facility. Generated aerosols had a range of morphologies, count median diameters (CMD) between 25 and 50 nm, and geometric standard deviations (GSD) between 1.5 and 1.8. The surface area estimates from number and mass concentration measurements correlated well with the two reference values when gravimetric mass was used. The aerosol surface area estimates from the Maynard's estimation method were comparable to the reference method for all particle morphologies within the surface area ratios of 3.31 and 0.19 for assumed GSDs 1.5 and 1.8, respectively, when the bulk material density of silver was used. The difference between the Maynard's estimation method and surface area measured by the reference method for fractal-like agglomerates decreased from 79% to 23% when the measured effective particle density was used, while the difference for nearly spherical particles decreased from 30% to 24%. The results indicate that the use of particle density of agglomerates improves the accuracy of the Maynard's estimation method and that an effective density should be taken into account, when known, when estimating aerosol surface area of nonspherical aerosol such as open agglomerates and fibrous particles. (2012 Copyright Taylor and Francis Group, LLC.) |
Characterization of Neisseria meningitidis isolates from Egypt using multilocus sequence typing
Klena JD , Wasfy MO , Nada RA , Ahmed SF , Maksoud MA , Marfin A , Pimentel G . Trans R Soc Trop Med Hyg 2012 106 (5) 309-14 To characterize Neisseria meningitidis isolates collected from cerebrospinal fluid of meningitis cases in Egypt (1998-2003) as part of surveillance studies, 67 isolates were serogrouped, tested for antibiotic sensitivity and analyzed using multilocus sequence typing (MLST). Results show that isolates expressing serogroup B (50.7%) and serogroup A (34.3%) antigens were predominant in Egypt during the surveillance period, possibly due to suppression of other serogroups by meningococcal vaccines in current use. Intermediate resistance to penicillin was observed in 71% of the isolates, suggesting a need for physicians to shift to third-generation cephalosporins during the empirical treatment of infection. Recurrent lineages of N. meningitidis in Egypt appear to originate from Europe and other Middle Eastern countries. Of 19 sequence types detected, five were unique to Africa and 10 were not observed previously in the MLST database. The information obtained illustrates the changing dynamics of meningitis after vaccine introduction in Egypt. |
Risk of bottle-feeding for rapid weight gain during the first year of life
Li R , Magadia J , Fein SB , Grummer-Strawn LM . Arch Pediatr Adolesc Med 2012 166 (5) 431-6 OBJECTIVE: To better understand the mechanisms behind breastfeeding and childhood obesity, we assessed the association of weight gain with the mode of milk delivery aside from the type of milk given to infants. DESIGN: A longitudinal study of infants followed up from birth to age 1 year. Multilevel analyses were conducted to estimate infant weight gain by type of milk and feeding mode. SETTING: Pregnant women were recruited from a consumer mail panel throughout the United States between May 2005 and June 2007. PARTICIPANTS: One thousand eight hundred ninety nine infants with at least 3 weight measurements reported during the first year. MAIN EXPOSURES: Six mutually exclusive feeding categories and proportions of milk feedings given as breastmilk or by bottle. MAIN OUTCOME MEASURES: Weight measurements reported on 3-, 5-, 7-, and 12-month surveys. RESULTS: Compared with infants fed at the breast, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only (P < .001) or human milk only (P = .02), respectively. Weight gain was negatively associated with proportion of breastmilk feedings, but it was positively associated with proportion of bottle-feedings among those who received mostly breastmilk. Among infants fed only breastmilk, monthly weight gain increased from 729 g when few feedings were by bottle to 780 g when most feedings were by bottle. CONCLUSIONS: Infant weight gain might be associated not only with type of milk consumed but also with mode of milk delivery. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain. |
Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006
Boss EF , Marsteller JA , Simon AE . J Pediatr 2012 160 (5) 814-9 OBJECTIVES: To examine geographic and demographic variation for outpatient tonsillectomy in children nationally. STUDY DESIGN: The 2006 National Survey of Ambulatory Surgery was analyzed to describe outpatient tonsillectomy in children. Rates by age, sex, region, urban/rural residence, and payment source were calculated with 2006 population estimates from the Census Bureau and the National Health Interview Survey as denominators. Rates were compared with Z tests. RESULTS: In 2006, approximately 583 000 (95% CI, 370,000-796,000) outpatient tonsillectomy procedures were performed in children in the United States. Rates per 10,000 children were lower in children 13 to 17 years old (33.8 per 10,000) than in both children 7 to 12 years old (91.3; P < .05) and children 0 to 6 years old (102.9; P < .001). Compared with the South, tonsillectomy rates were lower in the West (29 per 10,000 versus 125 per 10,000; P < .01) and not significantly different in other regions. Compared with large central metropolitan areas, tonsillectomy rates were higher in small/medium metropolitan areas (118 per 10,000 versus 42 per 10,000; P < .05), and not significantly different in large fringe or non-metropolitan areas. Tonsillectomy rates were similar for children insured by Medicaid compared with those insured by private sources. Compared with older children (13-17 years), children in the younger age groups (0-6 years, 7-12 years) underwent tonsillectomy more commonly for airway obstruction (69.5% and 59.2% versus 34.3%, P < .05 for both). Compared with older children, younger children (0-6 years) underwent tonsillectomy less commonly for infection (40.4% versus 61.0% [7-12 years] and 72.2% [13-17 years], P < .001 for both). CONCLUSIONS: Use of tonsillectomy in the ambulatory setting varies across age groups, geographic regions, levels of urbanization, and indication. Further research is warranted to examine these differences. |
Prevention of venous thromboembolism in pregnancy: a review of guidelines, 2000-2011
Okoroh EM , Azonobi IC , Grosse SD , Grant AM , Atrash HK , James AH . J Womens Health (Larchmt) 2012 21 (6) 611-5 INTRODUCTION: Pregnant women are four to five times more likely than nonpregnant women to develop venous thromboembolism (VTE). The aim of this review is to provide an overview of guidelines in the literature on VTE risk assessment, screening for thrombophilias, and thromboprophylaxis dissemination among pregnant women. METHODS: We performed a review of the published literature to identify evidence-based guidelines published between the years 2000 and 2011. We searched for guidelines from U.S. and international organizations that identified clinically based practice recommendations to healthcare providers on how VTE risk should be assessed, thrombophilias screened, and thromboprophylaxis disseminated among pregnant women. RESULTS: We found nine guidelines that met our requirements for assessing VTE risk and found seven guidelines addressing thrombophilia screening. Seven of the nine agreed that all women should undergo a risk factor assessment for VTE either in early pregnancy or in the preconception period. Seven of the nine agreed that pregnant women with more than one additional VTE risk factor be considered for thromboprophylaxis, and five of the seven groups addressing thrombophilia screening agreed that selected at-risk populations should be considered for thrombophilia screening. CONCLUSIONS: There is some agreement between U.S. and international guidelines that women should be assessed for VTE risk during preconception and again in pregnancy. Although there is agreement that the general population of women should not be screened for thrombophilias, no agreement exists as to the clinical subgroups for which screening should be done. |
Motivating ergonomic computer workstation setup: sometimes training is not enough
Sigurdsson SO , Artnak M , Needham M , Wirth O , Silverman K . Int J Occup Saf Ergon 2012 18 (1) 27-33 Musculoskeletal disorders lead to pain and suffering and result in high costs to industry. There is evidence to suggest that whereas conventional ergonomics training programs result in knowledge gains, they may not necessarily translate to changes in behavior. There were 11 participants in an ergonomics training program, and a subsample of participants received a motivational intervention in the form of incentives for correct workstation setup. Training did not yield any changes in ergonomics measures for any participant. Incentives resulted in marked and durable changes in targeted workstation measures. The data suggest that improving worker knowledge about ergonomically correct workstation setup does not necessarily lead to correct workstation setup, and that motivational interventions may be needed to achieve lasting behavior change. |
Comparison of work-related symptoms and visual contrast sensitivity between employees at a severely water-damaged school and a school without significant water damage
Thomas G , Burton NC , Mueller C , Page E , Vesper S . Am J Ind Med 2012 55 (9) 844-54 BACKGROUND: The National Institute for Occupational Safety and Health (NIOSH) conducted a health hazard evaluation (HHE) of a water-damaged school in New Orleans (NO), Louisiana. Our aim in this evaluation was to document employee health effects related to exposure to the water-damaged school, and to determine if VCS testing could serve as a biomarker of effect for occupants who experienced adverse health effects in a water-damaged building. METHODS: NIOSH physicians and staff administered a work history and medical questionnaire, conducted visual contrast sensitivity (VCS) testing, and collected sticky-tape, air, and dust samples at the school. Counting, culturing, and/or a DNA-based technology, called mold-specific quantitative PCR (MSQPCR), were also used to quantify the molds. A similar health and environmental evaluation was performed at a comparable school in Cincinnati, Ohio which was not water-damaged. RESULTS: Extensive mold contamination was documented in the water-damaged school and employees (n = 95) had higher prevalences of work-related rashes and nasal, lower respiratory, and constitutional symptoms than those at the comparison school (n = 110). VCS values across all spatial frequencies were lower among employees at the water-damaged school. CONCLUSIONS: Employees exposed to an extensively water-damaged environment reported adverse health effects, including rashes and nasal, lower respiratory, and constitutional symptoms. VCS values were lower in the employees at the water-damaged school, but we do not recommend using it in evaluation of people exposed to mold. (Am. J. Ind. Med. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.) |
Cardiorespiratory fitness and proximity to commercial physical activity facilities among 12th grade girls
Dowda M , Pfeiffer KA , Lobelo F , Porter DE , Pate RR . J Adolesc Health 2012 50 (5) 497-502 PURPOSE: To investigate the relationship between proximity to commercial physical activity (PA) facilities and cardiorespiratory fitness of 12th grade girls. METHODS: Adolescent girls (n = 786, 60% African American, mean age = 17.6 +/- .6 years) performed a submaximal fitness test (Physical Work Capacity 170 test). Commercial PA facilities were mapped and counted within a .75-mile street-network buffer around girls' homes using Geographic Information Systems. Sedentary activities and vigorous physical activity (≥6 metabolic equivalents) were determined by the average number of 30-minute blocks reported per day on the 3-Day Physical Activity Recall. Mixed model regressions were calculated using school as a random variable. RESULTS: Girls had higher weight-relative Physical Work Capacity 170 test scores if there was a commercial PA facility (n = 186, 12.4 +/- 4.2 kg m/min/kg) within a .75-mile street-network buffer of home as compared with girls without a nearby facility (n = 600, 11.2 +/- 3.6 kg m/min/kg). After adjusting for demographic variables, sports participation, sedentary behaviors, and vigorous physical activity, having one or more commercial PA facilities within a .75-mile street-network buffer of homes was significantly related to cardiorespiratory fitness. CONCLUSIONS: Both with and without adjustment for covariates, the presence of a commercial PA facility within a .75-mile street-network buffer of a girl's home was associated with higher cardiorespiratory fitness. |
Implementation of school policies to prevent youth tobacco use in Alabama
Geiger BF , Vaid I , Beeson D , Riddle B . J Sch Health 2012 82 (6) 277-284 BACKGROUND: Public health professionals must monitor the effectiveness of school policies and programs to prevent youth initiation, promote quitting, and eliminate secondhand smoke. This analysis of school tobacco policies was preliminary to release of a state tobacco prevention and control plan for 2010-2015. METHODS: University health educators collaborated with the state health agency to review policies of 33 school systems in 5 Metropolitan Statistical Areas and 9 public health areas. Authors developed a systematic approach of 8 steps useful to rate implementation of school tobacco control and prevention policies and discuss implications for health education program planning. RESULTS: Thirty school policies prohibited possession and use of tobacco by students, faculty and campus visitors, and 26 of 33 specified disciplinary measures following violations. Only 4 public education agencies included 3 of the 6 elements of a model tobacco prevention and control policy as suggested by the state public health agency. None featured all 6 elements. None specified establishing school-community partnerships for tobacco prevention and control. CONCLUSIONS: Preparing smoke-free youth requires implementing and evaluating tobacco education in grades K-12 including use of model guidelines from federal agencies and professional organizations. Determining the focus of existing school tobacco policies is an initial step to encourage adoption of comprehensive policies to reduce youth use of tobacco. Youth health advocates may act together with school administrators and legislators to strengthen policies to be consistent with model guidelines for tobacco prevention and control. |
Racial and ethnic disparities in preconception risk factors and preconception care
Denny CH , Floyd RL , Green PP , Hayes DK . J Womens Health (Larchmt) 2012 21 (7) 720-9 OBJECTIVE: At-risk drinking, cigarette smoking, obesity, diabetes, and frequent mental distress, as well as their co-occurrence in childbearing aged women, are risk factors for adverse pregnancy outcomes. This study estimated the prevalence of these five risk factors individually and in combination among nonpregnant women aged 18-44 years by demographic and psychosocial characteristics, with a focus on racial and ethnic disparities. METHODS: Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) on nonpregnant women aged 18-44 years (n=54,612) were used to estimate the prevalences of five risk factors, pairs of co-occurring risk factors, and multiple risk factors for poor pregnancy outcomes. RESULTS: The majority of women had at least one risk factor, and 18.7% had two or more risk factors. Having two or more risk factors was highest among women who were American Indian and Alaska Native (34.4%), had less than a high school education (28.7%), were unable to work (50.1%), were unmarried (23.3%), and reported sometimes, rarely, or never receiving sufficient social and emotional support (32.8%). The most prevalent pair of co-occurring risk factors was at-risk drinking and smoking (5.7%). CONCLUSIONS: The high proportion of women of childbearing age with preconception risk factors highlights the need for preconception care. The common occurrence of multiple risk factors suggests the importance of developing screening tools and interventions that address risk factors that can lead to poor pregnancy outcomes. Increased attention should be given to high-risk subgroups. |
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