Trends in total and low-density lipoprotein cholesterol among U.S. adults: contributions of changes in dietary fat intake and use of cholesterol-lowering medications
Ford ES , Capewell S . PLoS One 2013 8 (5) e65228 OBJECTIVE: Our aim was to examine the relative contributions of changes in dietary fat intake and use of cholesterol-lowering medications to changes in concentrations of total cholesterol among adults in the United States from 1988-1994 to 2007-2008. METHOD: We used data from adults aged 20-74 years who participated in National Health and Nutrition Examination Surveys from 1988-1994 to 2007-2008. The effect of change in dietary fat intake on concentrations of total cholesterol was estimated by the use of equations developed by Keys, Hegsted, and successors. RESULTS: Age-adjusted mean concentrations of total cholesterol were 5.60 mmol/L (216 mg/dl) during 1988-1994 falling to 5.09 mmol/L (197 mg/dl) in 2007-2008 (P<0.001). No significant changes in the intake of total fat, saturated fat, polyunsaturated fat, and dietary cholesterol were observed from 1988-1994 to 2007-2008. However, the age-adjusted use of cholesterol-lowering medications increased from 1.6% to 12.5% (P<0.001). The various equations suggested that changes in dietary fat made minimal contributions to the observed trend in mean concentrations of total cholesterol. The increased use of cholesterol-lowering medications was estimated to account for approximately 46% of the change. DISCUSSION: Mean concentrations of total cholesterol among adults in the United States have declined by approximately 4% since 1988-1994. The increased use of cholesterol-lowering medications has apparently accounted for about half of this small fall. Further substantial decreases in cholesterol might be potentially achievable by implementing effective and feasible public health interventions to promote the consumption of a more healthful diet by US adults. DISCLAIMER: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. |
Frequent insufficient sleep and anxiety and depressive disorders among U.S. community dwellers in 20 states, 2010
Chapman DP , Presley-Cantrell LR , Liu Y , Perry GS , Wheaton AG , Croft JB . Psychiatr Serv 2013 64 (4) 385-7 OBJECTIVE: This investigation examined the association of anxiety or depressive disorder and frequent insufficient sleep. METHODS: Data were obtained from a 2010 telephone survey of a population-based sample of 113,936 adults in 20 states. Respondents were asked how often they did not get enough rest or sleep and if they had ever received a diagnosis of an anxiety or depressive disorder. Frequent insufficient sleep was defined as insufficient rest or sleep during ≥ 14 of the past 30 days. RESULTS: Frequent insufficient sleep was reported by 27.0% of the sample and was significantly more common (p<.05) among respondents who reported both anxiety and depressive disorders (48.6%), depressive disorders only (39.0%), or anxiety only (37.5%) than among adults who reported neither disorder (23.1%). CONCLUSIONS: Frequent insufficient sleep is associated with depressive and anxiety disorders, and the odds of the sleep disorder are increased when both classes of psychiatric disorders are diagnosed. |
The impact of cardiovascular risk-factor profiles on blood pressure control rates in adults from Canada and the United States
McAlister FA , Robitaille C , Gillespie C , Yuan K , Rao DP , Grover S , Dai S , Johansen H , Joffres M , Loustalot F , Campbell N . Can J Cardiol 2013 29 (5) 598-605 BACKGROUND: It is unclear whether blood pressure control varies across the spectrum of atherosclerotic risk. METHODS: We used data from nonpregnant adults who had fasted laboratory samples drawn for the 2007-2009 cycle of the Canadian Health Measures Survey (CHMS) or the 2005-2008 US National Health and Nutrition Examination Survey (NHANES). RESULTS: The 1692 CHMS subjects and 3541 NHANES participants were demographically similar (aged a mean of 45 years), although NHANES participants exhibited higher obesity rates (33.8% vs 22.2%, P < 0.001). Over 80% of CHMS and NHANES subjects with hypertension had at least 1 other cardiovascular risk factor. As the number of atherosclerotic risk factors increased, hypertension prevalence increased, but blood pressure control rates improved (from 48% among hypertensives with no other risk factors in CHMS to 77% among those with 3 or more risk factors, and from 35% to 53% in NHANES). However, the converse was not true: The distribution of Framingham risk scores for those subjects with "controlled hypertension" was nearly identical to the distribution among those adults with uncontrolled hypertension in both CHMS and NHANES and substantially higher than scores in normotensive subjects. CONCLUSIONS: Although control of blood pressure was better in patients with multiple atherosclerotic risk factors, hypertensives with controlled blood pressures exhibited risk-factor profiles similar to those of participants with uncontrolled blood pressures. This suggests the need, in educational messaging and therapy decision making, for an increased focus on total atherosclerotic risk rather than just blood pressure control. |
Incidence of amyotrophic lateral sclerosis among American Indians and Alaska Natives
Gordon PH , Mehal JM , Holman RC , Rowland LP , Rowland AS , Cheek JE . JAMA Neurol 2013 70 (4) 476-80 IMPORTANCE: More thorough evaluation of amyotrophic lateral sclerosis (ALS) and motor neuron disease in unique populations could provide clues to etiologies for these idiopathic conditions, and educational programs for American Indian and Alaska Native (AI/AN) people and health care professionals on reservations could improve awareness, understanding, diagnosis, and treatment. In the ongoing search for susceptibility genes, studying particular racial groups, such as AI/ANs,might facilitate the identification of new mutations. OBJECTIVE: To provide better understanding of ALS and secondarily of motor neuron disease among AI/AN people by estimating the incidence and prevalence among AI/ANs served by the Indian Health Service health care system. DESIGN AND SETTING: Analysis of electronic records for AI/ANs with ALS and with motor neuron disease separately for the calendar years 2002-2009 using inpatient and outpatient visit data from the Indian Health Service, which provides health care to eligible AI/ANs nationwide. PARTICIPANTS: Cases were defined by at least 2 inpatient or outpatient visits with the diagnosis. MAIN OUTCOME MEASURES: Crude and age-adjusted incidence and prevalence rates were calculated. RESULTS: Seventy-one AI/ANs were diagnosed with ALS, yielding an average annual crude incidence rate of 0.63 cases per 100 000 and an age-adjusted incidence of 0.92. The median age at onset was 56.0 years and was higher among women than men (62.0 vs 55.0 years; P=.06). Age-specific incidence increased to 70 to 74 years. The crude and age-adjusted point prevalence rates were 2.00 and 4.12, respectively. The crude and age-adjusted incidence rates for motor neuron disease were 1.08 and 1.50, respectively. The annual rates were unchanged across the study period. CONCLUSIONS AND RELEVANCE: The incidence of ALS among AI/ANs appears to be lower than that reported for white populations, a finding congruent with reports of other minority populations. Community-based studies are important to confirm these findings and to examine reasons for the low rate of ALS among AI/ANs. |
Disability prevalence among healthy weight, overweight, and obese adults
Armour BS , Courtney-Long EA , Campbell VA , Wethington HR . Obesity (Silver Spring) 2013 21 (4) 852-5 OBJECTIVE: Obesity is associated with adverse health outcomes in people with and without disabilities. However, little is known about disability prevalence among people who are obese. The purpose of this study is to determine the prevalence and type of disability among adults who are obese. DESIGN AND METHODS: Pooled data from the 2003-2009 National Health Interview Survey (NHIS) were analyzed to obtain national prevalence estimates of disability, disability type and obesity. The disability prevalence was stratified by body mass index (BMI): healthy weight (BMI 18.5-<25.0), overweight (BMI 25.0-<30.0), and obese (BMI ≥ 30.0). RESULTS: In this pooled sample, among the 25.4% of US adults who were obese, 41.7% reported a disability. In contrast, 26.7% of those with a healthy weight and 28.5% of those who were overweight reported a disability. The most common disabilities among respondents with obesity were movement difficulty (32.5%) and work limitation (16.6%). CONCLUSIONS: This research contributes to the literature on obesity by including disability as a demographic in assessing the burden of obesity. Because of the high prevalence of disability among those who are obese, public health programs should consider the needs of those with disabilities when designing obesity prevention and treatment programs. |
Prevalent and incident hepatitis C virus infection among HIV-infected men who have sex with men engaged in primary care in a Boston community health center
Garg S , Taylor LE , Grasso C , Mayer KH . Clin Infect Dis 2013 56 (10) 1480-7 BACKGROUND: Sexually transmitted hepatitis C virus (HCV) infection is an emerging epidemic among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM). HCV may be underrecognized in this population, historically thought to be at low risk. METHODS: We determined the prevalence and incidence of HCV among HIV-infected men at Fenway Health between 1997 and 2009. We describe characteristics associated with HCV. RESULTS: Of 1171 HIV-infected men, of whom 96% identify as MSM, 1068 (91%) were screened for HCV and 64 (6%) had a positive HCV antibody (Ab) result at initial screening. Among the 995 men whose initial HCV Ab result was negative, 62% received no further HCV Ab testing. Among the 377 men who had ≥1 additional HCV Ab test, 23 (6%) seroconverted over 1408 person-years, for an annualized incidence of 1.63 per 100 person-years (95% confidence interval, .97-2.30). Among the 87 HIV-infected MSM diagnosed with prevalent or incident HCV, 33% reported history of injection drug use, 46% noninjection drug use (NIDU), and 70% sexually transmitted infections (STIs). Sixty-four (74%) of HCV-infected MSM developed chronic HCV; 22 (34%) initiated HCV treatment and 13 (59%) of treated persons achieved a sustained virologic response (SVR). CONCLUSIONS: Prevalent and incident HCV, primarily acquired through nonparenteral means, was common in this HIV-infected population despite engagement in care. STIs and NIDU were common among HIV/HCV-coinfected MSM. SVR rates were high among those who underwent HCV treatment. All sexually active and/or substance-using HIV-infected MSM should receive routine and repeated HCV screening to allow for early diagnosis and treatment of HCV. |
Entry and exit screening of airline travellers during the A(H1N1) 2009 pandemic: a retrospective evaluation
Khan K , Eckhardt R , Brownstein JS , Naqvi R , Hu W , Kossowsky D , Scales D , Arino J , Macdonald M , Wang J , Sears J , Cetron MS . Bull World Health Organ 2013 91 (5) 368-76 OBJECTIVE: To evaluate the screening measures that would have been required to assess all travellers at risk of transporting A(H1N1)pdm09 out of Mexico by air at the start of the 2009 pandemic. METHODS: Data from flight itineraries for travellers who flew from Mexico were used to estimate the number of international airports where health screening measures would have been needed, and the number of travellers who would have had to be screened, to assess all air travellers who could have transported the H1N1 influenza virus out of Mexico during the initial stages of the 2009 A(H1N1) pandemic. FINDINGS: Exit screening at 36 airports in Mexico, or entry screening of travellers arriving on direct flights from Mexico at 82 airports in 26 other countries, would have resulted in the assessment of all air travellers at risk of transporting A(H1N1)pdm09 out of Mexico at the start of the pandemic. Entry screening of 116 travellers arriving from Mexico by direct or connecting flights would have been necessary for every one traveller at risk of transporting A(H1N1)pdm09. Screening at just eight airports would have resulted in the assessment of 90% of all air travellers at risk of transporting A(H1N1)pdm09 out of Mexico in the early stages of the pandemic. CONCLUSION: During the earliest stages of the A(H1N1) pandemic, most public health benefits potentially attainable through the screening of air travellers could have been achieved by screening travellers at only eight airports. |
Clinical characteristics, drug resistance, and treatment outcomes among tuberculosis patients with diabetes in Peru
Magee MJ , Bloss E , Shin SS , Contreras C , Huaman HA , Ticona JC , Bayona J , Bonilla C , Yagui M , Jave O , Cegielski JP . Int J Infect Dis 2013 17 (6) e404-12 OBJECTIVES: Diabetes is a risk factor for active tuberculosis (TB). Data are limited regarding the association between diabetes and TB drug resistance and treatment outcomes. We examined characteristics of TB patients with and without diabetes in a Peruvian cohort at high risk for drug-resistant TB. Among TB patients with diabetes (TB-DM), we studied the association between diabetes clinical/management characteristics and TB drug resistance and treatment outcomes. METHODS: During 2005-2008, adults with suspected TB with respiratory symptoms in Lima, Peru, who received rapid drug susceptibility testing (DST), were prospectively enrolled and followed during treatment. Bivariate and Kaplan-Meier analyses were used to examine the relationships of diabetes characteristics with drug-resistant TB and TB outcomes. RESULTS: Of 1671 adult TB patients enrolled, 186 (11.1%) had diabetes. TB-DM patients were significantly more likely than TB patients without diabetes to be older, have had no previous TB treatment, and to have a body mass index (BMI) >18.5kg/m(2) (p<0.05). In patients without and with previous TB treatment, the prevalence of multidrug-resistant TB was 23% and 26%, respectively, among patients without diabetes, and 12% and 28%, respectively, among TB-DM patients. Among 149 TB-DM patients with DST results, 104 (69.8%) had drug-susceptible TB and 45 (30.2%) had drug-resistant TB, of whom 29 had multidrug-resistant TB. There was no association between diabetes characteristics and drug-resistant TB. Of 136 TB-DM patients with outcome information, 107 (78.7%) had a favorable TB outcome; active diabetes management was associated with a favorable outcome. CONCLUSIONS: Diabetes was common in a cohort of TB patients at high risk for drug-resistant TB. Despite prevalent multidrug-resistant TB among TB-DM patients, the majority had a favorable TB treatment outcome. |
Standardizing operational vector sampling techniques for measuring malaria transmission intensity: evaluation of six mosquito collection methods in western Kenya
Wong J , Bayoh N , Olang G , Killeen GF , Hamel MJ , Vulule JM , Gimnig JE . Malar J 2013 12 143 BACKGROUND: Operational vector sampling methods lack standardization, making quantitative comparisons of malaria transmission across different settings difficult. Human landing catch (HLC) is considered the research gold standard for measuring human-mosquito contact, but is unsuitable for large-scale sampling. This study assessed mosquito catch rates of CDC light trap (CDC-LT), Ifakara tent trap (ITT), window exit trap (WET), pot resting trap (PRT), and box resting trap (BRT) relative to HLC in western Kenya to 1) identify appropriate methods for operational sampling in this region, and 2) contribute to a larger, overarching project comparing standardized evaluations of vector trapping methods across multiple countries. METHODS: Mosquitoes were collected from June to July 2009 in four districts: Rarieda, Kisumu West, Nyando, and Rachuonyo. In each district, all trapping methods were rotated 10 times through three houses in a 3 x 3 Latin Square design. Anophelines were identified by morphology and females classified as fed or non-fed. Anopheles gambiae s.l. were further identified as Anopheles gambiae s.s. or Anopheles arabiensis by PCR. Relative catch rates were estimated by negative binomial regression. RESULTS: When data were pooled across all four districts, catch rates (relative to HLC indoor) for An. gambiae s.l (95.6% An. arabiensis, 4.4% An. gambiae s.s) were high for HLC outdoor (RR = 1.01), CDC-LT (RR = 1.18), and ITT (RR = 1.39); moderate for WET (RR = 0.52) and PRT outdoor (RR = 0.32); and low for all remaining types of resting traps (PRT indoor, BRT indoor, and BRT outdoor; RR < 0.08 for all). For Anopheles funestus, relative catch rates were high for ITT (RR = 1.21); moderate for HLC outdoor (RR = 0.47), CDC-LT (RR = 0.69), and WET (RR = 0.49); and low for all resting traps (RR < 0.02 for all). At finer geographic scales, however, efficacy of each trap type varied from district to district. CONCLUSIONS: ITT, CDC-LT, and WET appear to be effective methods for large-scale vector sampling in western Kenya. Ultimately, choice of collection method for operational surveillance should be driven by trap efficacy and scalability, rather than fine-scale precision with respect to HLC. When compared with recent, similar trap evaluations in Tanzania and Zambia, these data suggest that traps which actively lure host-seeking females will be most useful for surveillance in the face of declining vector densities. |
Modeling cadmium exposures in low- and high-exposure areas in Thailand
Satarug S , Swaddiwudhipong W , Ruangyuttikarn W , Nishijo M , Ruiz P . Environ Health Perspect 2013 121 (5) 531-6 BACKGROUND: Previous U.S. population modeling studies have reported that urinary cadmium (Cd) excretion patterns differ with age, sex, and dietary exposure; associations between Cd exposures and health outcomes also have differed by age and sex. Therefore, it is important to test models used to estimate Cd exposures across an expanded Cd-exposure range. OBJECTIVES: We estimated relative Cd exposures from both diet and smoking in low- and high-exposure scenarios to provide data for improving risk assessment calculations.Methods: We used a Cd toxicokinetic-based model to estimate Cd exposures based on urinary Cd levels measured for 399 persons in a low-exposure area (Bangkok) and 6,747 persons in a high-exposure area (Mae Sot) in Thailand. RESULTS: In Bangkok, we estimated dietary Cd exposures of 50-56 microg/day for males and 21-27 microg/day for females 20-59 years of age who never smoked. In Mae Sot, we estimated dietary Cd exposures of 188-224 microg/day for males and 99-113 microg/day for females 20-59 years of age who never smoked. In Bangkok, we estimated Cd exposures from smoking to be 5.5-20.4 microg/day for male smokers 20-59 years of age. In Mae Sot, we estimated Cd exposures from smoking to be 9.8-26 microg/day for male heavy smokers and 26 microg/day for female heavy smokers. CONCLUSION: This study provides estimates of Cd exposures from diet and smoking in low- and high-exposure scenarios. Our findings suggest a relatively small safety margin between the established tolerable Cd reference exposure of 62 microg/day and exposure levels previously associated with evidence of kidney and bone effects in Mae Sot residents, where dietary Cd exposures among women were only 1.6-2.1 times the reference value. |
An environmental Sporothrix as a cause of corneal ulcer
Morrison AS , Lockhart SR , Bromley JG , Kim JY , Burd EM . Med Mycol Case Rep 2013 2 (1) 88-90 In this case we introduce Sporothrix pallida, a non-pathogenic environmental Sporothrix species as a cause of infectious keratitis in a corneal transplant recipient. Human infections caused by S. schenckii are well-known but human infection with Sporothrix pallida has not been previously reported. (2013 International Society for Human and Animal Mycology.) |
In utero DDT and DDE exposure and obesity status of 7-year-old Mexican-American children in the CHAMACOS Cohort
Warner M , Schall RA , Harley KG , Bradman A , Barr D , Eskenazi B . Environ Health Perspect 2013 121 (5) 631-6 BACKGROUND: In utero exposure to endocrine disrupting compounds including dichlorodiphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) has been hypothesized to increase risk of obesity later in life. OBJECTIVES: The Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) study is a longitudinal birth cohort of low-income Latinas living in a California agricultural community. We examined the relation of in utero DDT and DDE exposure to child obesity at 7 years of age. We also examined the trend with age (2, 3.5, 5, and 7 years) in the exposure-obesity relation. METHODS: We included 270 children with o,p -DDT, p,p -DDT, and p,p -DDE concentrations measured in maternal serum during pregnancy (nanograms per gram lipid) and complete 7-year follow-up data including weight (kilograms) and height (centimeters). Body mass index (BMI; kilograms per meter squared) was calculated and obesity was defined as ≥ 95th percentile on the sex-specific BMI-for-age Centers for Disease Control and Prevention 2000 growth charts. Results: At 7 years, 96 (35.6%) children were obese. A 10-fold increase in o,p -DDT, p,p -DDT, or p,p -DDE, was nonsignificantly associated with increased odds (OR) of obesity [o,p -DDT adjusted (adj-) OR = 1.17, 95% CI: 0.75, 1.82; p,p -DDT adj-OR = 1.19, 95% CI: 0.81, 1.74; p,p -DDE adj-OR = 1.22, 95% CI: 0.72, 2.06]. With increasing age at follow-up, we observed a significant trend toward a positive association between DDT and DDE exposure and odds of obesity. CONCLUSION: We did not find a significant positive relation between in utero DDT and DDE exposure and obesity status of 7-year-old children. However, given the observed trend with age, continued follow-up will be informative. |
Combined effects of perchlorate, thiocyanate, and iodine on thyroid function in the National Health and Nutrition Examination Survey 2007-08
Steinmaus C , Miller MD , Cushing L , Blount BC , Smith AH . Environ Res 2013 123 17-24 Perchlorate, thiocyanate, and low iodine intake can all decrease iodide intake into the thyroid gland. This can reduce thyroid hormone production since iodide is a key component of thyroid hormone. Previous research has suggested that each of these factors alone may decrease thyroid hormone levels, but effect sizes are small. We hypothesized that people who have all three factors at the same time have substantially lower thyroid hormone levels than people who do not, and the effect of this combined exposure is substantially larger than the effects seen in analyses focused on only one factor at a time. Using data from the 2007-2008 National Health and Nutrition Examination Survey, subjects were categorized into exposure groups based on their urinary perchlorate, iodine, and thiocyanate concentrations, and mean serum thyroxine concentrations were compared between groups. Subjects with high perchlorate (n=1939) had thyroxine concentrations that were 5.0% lower (mean difference=0.40mcg/dl, 95% confidence interval=0.14-0.65) than subjects with low perchlorate (n=2084). The individual effects of iodine and thiocyanate were even smaller. Subjects with high perchlorate, high thiocyanate, and low iodine combined (n=62) had thyroxine concentrations 12.9% lower (mean difference=1.07mcg/dl, 95% confidence interval=0.55-1.59) than subjects with low perchlorate, low thiocyanate, and adequate iodine (n=376). Potential confounders had little impact on results. Overall, these results suggest that concomitant exposure to perchlorate, thiocyanate, and low iodine markedly reduces thyroxine production. This highlights the potential importance of examining the combined effects of multiple agents when evaluating the toxicity of thyroid-disrupting agents. |
The use of US health insurance data for surveillance of rare disorders: hereditary hemorrhagic telangiectasia.
Grosse SD , Boulet SL , Grant AM , Hulihan MM , Faughnan ME . Genet Med 2013 16 (1) 33-9 Purpose:To assess the utility of US health insurance data for surveillance of hereditary hemorrhagic telangiectasia, an autosomal-dominant blood vasculature disorder with an estimated prevalence of 1.5-2.0 per 10,000 persons worldwide.Methods:We used 2005-2010 MarketScan Research Databases to identify individuals with employer-sponsored health insurance and International Classification of Disease, 9th Revision, Clinical Modification codes of 448.0 present in either one inpatient claim or two outpatient claims 30 days apart to define hereditary hemorrhagic telangiectasia. We examined frequencies of International Classification of Disease, 9th Revision, Clinical Modification codes for conditions that are complications of hereditary hemorrhagic telangiectasia among individuals with hereditary hemorrhagic telangiectasia and the general population to identify combinations of codes associated with hereditary hemorrhagic telangiectasia.Results:Excluding observations from one state, the average prevalence of hereditary hemorrhagic telangiectasia was 0.3 per 10,000 persons. The reported prevalence rose with age from ~0.1 per 10,000 at ages <30 years to 1.0-1.1 per 10,000 at ages 70 years and above. The condition codes that were most specific to presumed hereditary hemorrhagic telangiectasia were lung arteriovenous malformations and upper gastrointestinal angiodysplasia. Combinations of those codes and codes for brain arteriovenous malformation and epistaxis were highly predictive of reporting of hereditary hemorrhagic telangiectasia, with 20-57% of enrollees with those codes also meeting the study definition for hereditary hemorrhagic telangiectasia.Conclusion:Hereditary hemorrhagic telangiectasia is underrecognized in US administrative data. Administrative health data can be used to identify individuals with combinations of signs that are suggestive of hereditary hemorrhagic telangiectasia. Studies are needed to test the hypothesis that referral for evaluation of individuals with administrative records suggestive of undiagnosed hereditary hemorrhagic telangiectasia could lead to diagnosis and access to life-saving treatments for both them and affected family members.Genet Med advance online publication 23 May 2013Genetics in Medicine (2013); doi:10.1038/gim.2013.66. |
Genome Sequence of Salmonella enterica Serotype Tennessee Strain CDC07-0191, Implicated in the 2006-2007 Multistate Food-Borne Outbreak Linked to Peanut Butter in the United States.
Deng X , Salazar JK , Frezet S , Maccannell D , Ribot EM , Fields PI , Fricke WF , Zhang W . Genome Announc 2013 1 (3) Salmonella enterica serotype Tennessee strain CDC07-0191 was isolated from the 2006-2007 multistate food-borne outbreak linked to peanut butter in the United States. Here we report a high-quality draft assembly of the genome sequence of this strain, derived from a patient. This is the first reported high-quality draft genome sequence for S. enterica serotype Tennessee, which will enable in-depth studies of its transmission and virulence. |
Complete nucleotide sequences of plasmids pACK2 and pACK5 from Staphylococcus simulans biovar staphylolyticus.
Gargis AS , Heath LS , Heath HE , Leblanc PA , Gargis SR , Harris TH , Sloan GL . Plasmid 2013 69 (3) 257-62 Staphylococcus simulans biovar staphylolyticus contains five plasmids, designated pACK1-pACK5. Recently, the nucleotide sequences of three of these plasmids, pACK1, pACK3, and pACK4, were reported. In order to complete the characterization of these five plasmids, the nucleotide sequences of the two remaining plasmids, pACK2 (37683bp) and pACK5 (3191bp), were determined. pACK5 is comprised of two regions, one with 85% identity at the nucleotide level to a region of pWBG1773 and another region with an ORF that shares no significant similarity to sequences previously described in GenBank. pACK2 encodes proteins for cadmium resistance and enhanced biofilm formation. The similarities at the nucleotide level among regions of the plasmids of S. simulans bv. staphylolyticus suggest that these plasmids have undergone multiple intermolecular rearrangements. |
Relapse of fungal meningitis associated with contaminated methylprednisolone
Smith RM , Tipple M , Chaudry MN , Schaefer MK , Park BJ . N Engl J Med 2013 368 (26) 2535-6 TO THE EDITOR: Since September 2012, the Centers for Disease Control and Prevention (CDC) and state and local health departments have been investigating an outbreak of fungal infections associated with injections from three lots of contaminated methylprednisolone acetate produced at a single compounding pharmacy. As of May 6, 2013, a total of 741 cases have been reported in 20 states, with 55 deaths. The primary pathogen isolated from patient specimens has been Exserohilum rostratum, which has also been recovered from sealed vials of methylprednisolone acetate. Before this outbreak, human infections with E. rostratum were rarely reported. Little is known about the management of E. rostratum infections, especially when the disease involves the central nervous system. |
Varicella immunity in vaccinated healthcare workers
Behrman A , Lopez AS , Chaves SS , Watson BM , Schmid DS . J Clin Virol 2013 57 (2) 109-14 BACKGROUND: Nosocomial spread of varicella-zoster virus (VZV) infection can cause severe disease among vulnerable patient-populations and healthcare personnel (HCP). Limited data are available on duration of varicella vaccine-induced protection among adults and to what extent cell-mediated immunity (CMI) and antibody avidity contribute to protection. OBJECTIVE: Evaluate humoral and cell-mediated immune responses of HCP who received a 2-dose regimen of varicella vaccine, and observe the responses to a 3rd vaccine dose among HCP who were seronegative after vaccination. STUDY DESIGN: A convenience sample of HCP with documented 2 doses of varicella vaccine was used to assess acquired VZV immune parameters (cytokine production, IgG avidity). HCP seronegative after 2 doses of vaccine were offered a third dose and evaluated further. Vaccine recipients' immune responses were compared with responses from persons with history of wild-type VZV infection. RESULTS: The convenience sample consisted of 101 HCP with documented 2 doses of varicella vaccine; 12 (11.9%) were seronegative post-vaccination. 11.5% of 61 seropositive 2-dose recipients produced low avidity antibody, suggesting suboptimal response to vaccine. Seven 2-dose vaccinees who were VZV seronegative seroconverted after a third dose; however, 3/7 (42.9%) produced low avidity IgG. 142 persons with a history of varicella were all VZV IgG seropositive, and all had moderate to high avidity IgG. CONCLUSIONS: Measurements of serum IgG titers alone may not accurately reflect vaccine protection. Varicella vaccination of HCP remains important but further studies are needed to evaluate CMI and antibody avidity responses in HCP vaccinated with two doses of varicella vaccine. |
Influenza vaccine effectiveness in the community and the household
Ohmit SE , Petrie JG , Malosh RE , Cowling BJ , Thompson MG , Shay DK , Monto AS . Clin Infect Dis 2013 56 (10) 1363-9 BACKGROUND: There is a recognized need to determine influenza vaccine effectiveness on an annual basis and a long history of studying respiratory illnesses in households. METHODS: We recruited 328 households with 1441 members, including 839 children, and followed them during the 2010-2011 influenza season. Specimens were collected from subjects with reported acute respiratory illnesses and tested by real-time reverse transcriptase polymerase chain reaction. Receipt of influenza vaccine was defined based on documented evidence of vaccination in medical records or an immunization registry. The effectiveness of 2010-2011 influenza vaccination in preventing laboratory-confirmed influenza was estimated using Cox proportional hazards models adjusted for age and presence of high-risk condition, and stratified by prior season (2009-2010) vaccination status. RESULTS: Influenza was identified in 78 (24%) households and 125 (9%) individuals; the infection risk was 8.5% in the vaccinated and 8.9% in the unvaccinated (P = .83). Adjusted vaccine effectiveness in preventing community-acquired influenza was 31% (95% confidence interval [CI], -7% to 55%). In vaccinated subjects with no evidence of prior season vaccination, significant protection (62% [95% CI, 17%-82%]) against community-acquired influenza was demonstrated. Substantially lower effectiveness was noted among subjects who were vaccinated in both the current and prior season. There was no evidence that vaccination prevented household transmission once influenza was introduced; adults were at particular risk despite vaccination. CONCLUSIONS: Vaccine effectiveness estimates were lower than those demonstrated in other observational studies carried out during the same season. The unexpected findings of lower effectiveness with repeated vaccination and no protection given household exposure require further study. |
Assessing parents' knowledge and attitudes towards seasonal influenza vaccination of children before and after a seasonal influenza vaccination effectiveness study in low-income urban and rural Kenya, 2010--2011
Oria PA , Arunga G , Lebo E , Wong JM , Emukule G , Muthoka P , Otieno N , Mutonga D , Breiman RF , Katz MA . BMC Public Health 2013 13 (1) 391 BACKGROUND: Influenza vaccine is rarely used in Kenya, and little is known about attitudes towards the vaccine. From June-September 2010, free seasonal influenza vaccine was offered to children between 6 months and 10 years old in two Population-Based Infectious Disease Surveillance (PBIDS) sites. This survey assessed attitudes about influenza, uptake of the vaccine and experiences with childhood influenza vaccination. METHODS: We administered a questionnaire and held focus group discussions with parents of children of enrollment age in the two sites before and after first year of the vaccine campaign. For pre-vaccination focus group discussions, we randomly selected mothers and fathers who had an eligible child from the PBIDS database to participate. For the post-vaccination focus group discussions we stratified parents whose children were eligible for vaccination into fully vaccinated, partially vaccinated and non-vaccinated groups. RESULTS: Overall, 5284 and 5755 people completed pre and post-vaccination questionnaires, respectively, in Kibera and Lwak. From pre-vaccination questionnaire results, among parents who were planning on vaccinating their children, 2219 (77.6%) in Kibera and 1780 (89.6%) in Lwak said the main reason was to protect the children from seasonal influenza. In the pre-vaccination discussions, no parent had heard of the seasonal influenza vaccine. At the end of the vaccine campaign, of 18,652 eligible children, 5,817 (31.2%) were fully vaccinated, 2,073 (11.1%) were partially vaccinated and, 10,762 (57.7%) were not vaccinated. In focus group discussions, parents who declined vaccine were concerned about vaccine safety or believed seasonal influenza illness was not severe enough to warrant vaccination. Parents who declined the vaccine were mainly too busy [251(25%) in Kibera and 95 (10.5%) in Lwak], or their child was away during the vaccination period [199(19.8%) in Kibera; 94(10.4%) in Lwak]. CONCLUSION: If influenza vaccine were to be introduced more broadly in Kenya, effective health messaging will be needed on vaccine side effects and frequency and potential severity of influenza infection. |
Association between Guillain-Barre syndrome and influenza A (H1N1) 2009 monovalent inactivated vaccines in the USA: a meta-analysis
Salmon DA , Proschan M , Forshee R , Gargiullo P , Bleser W , Burwen DR , Cunningham F , Garman P , Greene SK , Lee GM , Vellozzi C , Yih WK , Gellin B , Lurie N . Lancet 2013 381 (9876) 1461-8 BACKGROUND: The influenza A (H1N1) 2009 monovalent vaccination programme was the largest mass vaccination initiative in recent US history. Commensurate with the size and scope of the vaccination programme, a project to monitor vaccine adverse events was undertaken, the most comprehensive safety surveillance agenda in the USA to date. The adverse event monitoring project identified an increased risk of Guillain-Barre syndrome after vaccination; however, some individual variability in results was noted. Guillain-Barre syndrome is a rare but serious health disorder in which a person's own immune system damages their nerve cells, causing muscle weakness, sometimes paralysis, and infrequently death. We did a meta-analysis of data from the adverse event monitoring project to ascertain whether influenza A (H1N1) 2009 monovalent inactivated vaccines used in the USA increased the risk of Guillain-Barre syndrome. METHODS: Data were obtained from six adverse event monitoring systems. About 23 million vaccinated people were included in the analysis. The primary analysis entailed calculation of incidence rate ratios and attributable risks of excess cases of Guillain-Barre syndrome per million vaccinations. We used a self-controlled risk-interval design. FINDINGS: Influenza A (H1N1) 2009 monovalent inactivated vaccines were associated with a small increased risk of Guillain-Barre syndrome (incidence rate ratio 2.35, 95% CI 1.42-4.01, p=0.0003). This finding translated to about 1.6 excess cases of Guillain-Barre syndrome per million people vaccinated. INTERPRETATION: The modest risk of Guillain-Barre syndrome attributed to vaccination is consistent with previous estimates of the disorder after seasonal influenza vaccination. A risk of this small magnitude would be difficult to capture during routine seasonal influenza vaccine programmes, which have extensive, but comparatively less, safety monitoring. In view of the morbidity and mortality caused by 2009 H1N1 influenza and the effectiveness of the vaccine, clinicians, policy makers, and those eligible for vaccination should be assured that the benefits of inactivated pandemic vaccines greatly outweigh the risks. FUNDING: US Federal Government. |
Broadly protective adenovirus-based multivalent vaccines against highly pathogenic avian influenza viruses for pandemic preparedness
Vemula SV , Ahi YS , Swaim AM , Katz JM , Donis R , Sambhara S , Mittal SK . PLoS One 2013 8 (4) e62496 Recurrent outbreaks of H5, H7 and H9 avian influenza viruses in domestic poultry accompanied by their occasional transmission to humans have highlighted the public health threat posed by these viruses. Newer vaccine approaches for pandemic preparedness against these viruses are needed, given the limitations of vaccines currently approved for H5N1 viruses in terms of their production timelines and the ability to induce protective immune responses in the absence of adjuvants. In this study, we evaluated the feasibility of an adenovirus (AdV)-based multivalent vaccine approach for pandemic preparedness against H5, H7 and H9 avian influenza viruses in a mouse model. Replication-defective AdV vectors expressing hemagglutinin (HA) from different subtypes and nucleoprotein (NP) from one subtype induced high levels of humoral and cellular immune responses and conferred protection against virus replication following challenge with H5, H7 and H9 avian influenza virus subtypes. Inclusion of HA from the 2009 H1N1 pandemic virus in the vaccine formulation further broadened the vaccine coverage. Significantly high levels of HA stalk-specific antibodies were observed following immunization with the multivalent vaccine. Inclusion of NP into the multivalent HA vaccine formulation resulted in the induction of CD8 T cell responses. These results suggest that a multivalent vaccine strategy may provide reasonable protection in the event of a pandemic caused by H5, H7, or H9 avian influenza virus before a strain-matched vaccine can be produced. |
Differences in adult influenza vaccine-seeking behavior: the roles of race and attitudes
Groom HC , Zhang F , Fisher AK , Wortley PM . J Public Health Manag Pract 2013 20 (2) 246-50 BACKGROUND: Racial/ethnic disparities in influenza vaccination among adults are longstanding, and research suggests they result from multiple factors. Influenza vaccine-seeking behavior may be an important aspect to consider when evaluating disparities in vaccination coverage. OBJECTIVE: To determine whether there are differences between blacks and whites in influenza vaccine-seeking behavior among adults 65 years and older. METHODS: Data were analyzed from a national sample of 3138 adults 65 years and older collected through the adult module of the 2007 National Immunization Survey, a random digit dialing telephone survey, which included an oversample of non-Hispanic blacks. Analysis included influenza vaccination rate, location of vaccination, and whether vaccinated individuals specifically went to the location to receive the vaccine (vaccine seekers) by race. The relationship between attitudes about influenza vaccination and vaccine-seeking behavior by race was also examined. RESULTS: White adults 65 years and older were significantly more likely to receive influenza vaccine than blacks, during the 2006-2007 influenza season (68% +/- 4% vs 54% +/- 3%, respectively), and a significantly higher proportion of vaccinated whites reported seeking out the vaccine than vaccinated blacks (66% +/- 4% vs 47% +/- 4%, respectively). Blacks were less likely to be vaccine seekers, regardless of education or poverty levels. Among persons vaccinated in a doctor's office, 52% of whites specifically went there to get vaccinated, compared with 37% of blacks. Among persons who believe the vaccine is very effective, 66% +/- 5% of whites versus 50% +/- 6% of blacks were vaccine seekers. CONCLUSIONS: This study points to the importance of improving our understanding of what factors, in addition to beliefs about vaccination, lead to vaccine seeking and reinforces the need for systematically offering vaccine. |
Years of potential life lost from unintentional child and adolescent injuries - United States, 2000-2009
Borse NN , Rudd RA , Dellinger AM , Sleet DA . J Safety Res 2013 45 127-31 INTRODUCTION: Quantifying years of potential life lost (YPLL) highlights childhood causes of mortality and provides a simple method to identify important causes of premature death. METHODS: CDC analyzed data from the National Vital Statistics System multiple cause of death files for 2000-2009. RESULTS: An average of 890YPLL were lost each year due to unintentional injuries for every 100,000 persons aged 0-19 years. YPLL rates differed by sex, age group, race/ethnicity, injury mechanism and state. CONCLUSIONS: This report provides new information which can be used to prioritize interventions and identify subgroups of the population most at risk. |
A national survey of childhood physical abuse among females in Swaziland
Breiding MJ , Mercy JA , Gulaid J , Reza A , Hleta-Nkambule N . J Epidemiol Glob Health 2013 3 (2) 73-81 OBJECTIVE: This study describes the scope and characteristics of childhood physical abuse in a nationally representative sample of 13-24 year-old females in Swaziland. The current study also examined health consequences and risk factors of childhood physical abuse. METHODS: The study utilized a two-stage cluster sampling design in order to conduct the household survey. Retrospective reports of childhood physical abuse and relevant risk factors were collected from 1292 females. Bivariate and multivariate logistic regression models examined associations between childhood physical abuse and both health consequences and risk factors. RESULTS: Nearly 1 in 5 females in Swaziland has experienced childhood physical abuse in their lifetime, with nearly 1 in 20 having experienced abuse that was so severe that it required medical attention. A number of risk factors for lifetime childhood physical abuse were identified including: maternal death prior to age 13; having lived with three or more families during their childhood; and having experienced emotional abuse prior to age 13. CONCLUSIONS: Preventing childhood physical abuse in Swaziland may be addressed through: promoting safe, stable, and nurturing relationships between children and their caretakers; addressing social norms that contribute to harsh physical punishment; and addressing underlying stressors associated with severe social and economic disadvantage. |
Systems analysis of genetic variation in MPTP neurotoxicity in mice.
Jones BC , Miller DB , O'Callaghan JP , Lu L , Unger EL , Alam G , Williams RW . Neurotoxicology 2013 37C 26-34 We analyzed genetic variation in severity of neuronal damage using the known dopaminergic neurotoxicant, MPTP, as a prototypical chemical denervation agent. Male mice from ten members of the BXD family of recombinant inbred strains received 12.5mg/kg MPTP s.c. (vs. saline) and 48h later brains were taken for multiple related biochemical analyses. Striatal dopamine (DA) and its metabolites, DOPAC and HVA, and serotonin and its metabolite, 5-HIAAA, were analyzed by HPLC. DA turnover was assessed using DOPAC/DA and HVA/DA ratios. Striatal tyrosine hydroxylase (TH), glial fibrilary acidic protein (GFAP), and iron content in ventral midbrain were quantified. All dopamine measures, as well as TH and GFAP, demonstrated wide, genotype-dependent differences in response to MPTP. Serotonin was largely unaffected. Principal components analysis (PC) on difference values, saline minus MPTP, for DA, DOPAC, HVA, and TH, yielded a dominant principal component. The PC trait residuals for each genotype were compared against complementary expression data for striatum of the same strains. Three transcripts representing Mtap2, Lancl 1, and Kansl1l were highly correlated with the PC, as was the difference score, MPTP minus saline for GFAP. This systems approach to the study of environmental neurotoxicants holds promise to define individual genetic differences that contribute to variability in susceptibility to risk factors for diseases such as Parkinson's disease. |
Stabilities of hemoglobins A and S in dried blood spots stored under controlled conditions
Adam BW , Chafin DL , De Jesus VR . Clin Biochem 2013 46 (12) 1089-1092 OBJECTIVE: We aimed to measure separately the contributions of heat and humidity to changes in levels of hemoglobins A and S in dried-blood-spot (DBS) samples. DESIGN AND METHODS: We stored paired sets of DBSs at 37 degrees C for predetermined intervals in low-humidity and high-humidity environments. Hemoglobin A and S levels of all samples in each complete set were measured in a single high performance liquid chromatography run. RESULTS: During the one-month storage intervals, both hemoglobin species lost about 35% of initial levels in low-humidity storage and almost all of initial levels in high-humidity storage. CONCLUSIONS: Minimizing both humidity and temperature in the transportation and storage environments of DBS samples is essential to maintaining the integrity of the hemoglobin tetramer molecules. |
Lyme disease spirochetes possess an aggrecan-binding protease with aggrecanase activity
Russell TM , Johnson BJ . Mol Microbiol 2013 90 (2) 228-40 Connective tissues are the most common area of colonization for the Lyme disease spirochete Borrelia burgdorferi. Colonization is aided by the interaction between numerous bacterial adhesins with components of the extracellular matrix (ECM). Here we describe a novel interaction between B. burgdorferi and the major ECM proteoglycan found in joints, aggrecan. Using affinity chromatography and mass spectrometry we identify two borrelial aggrecan-binding proteins: the known ECM ligand Bgp (BB0588) and an uncharacterized protease BbHtrA (BB0104). Proteinase K studies demonstrate that BbHtrA is surface exposed. Immunoblots using sera from patients with both early and late Lyme disease establish that BbHtrA is expressed during human disease, immunogenic, and conserved in the three major Lyme disease spirochete species. Consequences of the interaction between aggrecan and BbHtrA were examined by proteolysis assays. BbHtrA cleaves aggrecan at a site known to destroy aggrecan function and which has been previously observed in the synovial fluid of patients with Lyme arthritis. These data demonstrate that B. burgdorferi possess aggrecan-binding proteins which may provide the organism with additional capability to colonize connective tissues. Moreover, our studies provide the first evidence that B. burgdorferi possess proteolytic activity which may contribute to the pathogenesis of Lyme arthritis. |
A pilot study using residual newborn dried blood spots to assess the potential role of cytomegalovirus and toxoplasma gondii in the etiology of congenital hydrocephalus
Simeone RM , Rasmussen SA , Mei JV , Dollard SC , Frias JL , Shaw GM , Canfield MA , Meyer RE , Jones JL , Lorey F , Honein MA . Birth Defects Res A Clin Mol Teratol 2013 97 (7) 431-6 BACKGROUND: Congenital hydrocephalus is a condition characterized by accumulation of cerebrospinal fluid in the ventricles of the brain. Prenatal infections are risk factors for some birth defects. This pilot study investigated whether residual dried blood spots (DBS) could be used to assess infections as risk factors for birth defects by examining the associations between prenatal infection with Toxoplasma gondii (T. gondii) or cytomegalovirus (CMV) with congenital hydrocephalus. METHODS: Case-infants with hydrocephalus (N = 410) were identified among live-born infants using birth defects surveillance systems in California, North Carolina, and Texas. Control-infants without birth defects were randomly selected from the same geographic areas and time periods as case-infants (N = 448). We tested residual DBS from case- and control-infants for T. gondii immunoglobulin M and CMV DNA. When possible, we calculated crude odds ratios (cORs) and confidence intervals (CIs). RESULTS: Evidence for prenatal T. gondii infection was more common among case-infants (1.2%) than control-infants (0%; p = 0.11), and evidence for prenatal CMV infection was higher among case-infants (1.5%) than control-infants (0.7%; cOR: 2.3; 95% CI: 0.48, 13.99). CONCLUSIONS: Prenatal infections with T. gondii and CMV occurred more often among infants with congenital hydrocephalus than control-infants, although differences were not statistically significant. This pilot study highlighted some challenges in using DBS to examine associations between certain infections and birth defects, particularly related to reduced sensitivity and specimen storage conditions. Further study with increased numbers of specimens and higher quality specimens should be considered to understand better the contribution of these infections to the occurrence of congenital hydrocephalus. (Birth Defects Research (Part A), 2013. (c) 2013 Wiley Periodicals, Inc.) |
PK assays for antibody-drug conjugates: case study with ado-trastuzumab emtansine
Dere R , Yi JH , Lei C , Saad OM , Huang C , Li Y , Baudys J , Kaur S . Bioanalysis 2013 5 (9) 1025-40 BACKGROUND: Antibody-drug conjugates (ADCs) combine the characteristics of large-molecule biologics and small-molecule drugs and are heterogeneous mixtures that can biotransform in vivo, resulting in additional complexity. ADC bioanalytical strategies require novel analytical methods, as well as existing large- and small-molecule methods. Because ADCs in late-stage clinical development are relatively new, regulatory guidelines and standard industry best practices for developing strategies for bioanalytical PK assays are still being established. RESULTS: A PK assay strategy was developed that included comprehensive novel reagent and assay characterization approaches for the ADC ado-trastuzumab emtansine (T-DM1). CONCLUSION: The bioanalytical strategy was successfully applied to the drug development of T-DM1 and ensured that key analytes were accurately measured in support of nonclinical and clinical development. |
Effect of calibration environment on the performance of direct-reading organic vapor monitors
LeBouf RF , Slaven JE , Coffey CC . J Air Waste Manag Assoc 2013 63 (5) 528-533 The performance of two direct-reading organic vapor monitors (monitors) when calibrated at different environmental conditions was compared with charcoal tube results. Three MIRAN SapphIRe portable ambient air analyzers (SAP) and three Century portable toxic vapor analyzers (TVAs) were evaluated. Prior to sampling, the monitors were calibrated per the manufacturer's instructions using methane for the TVA flame ionization detector (FID) and isobutylene for the photoionization detector (PID), whereas the SapphIRe instruments were zeroed and the instrument's manufacturer-supplied library was used. For the first series of tests (Part 1Same condition), the monitors were calibrated under the same environmental conditions as those present during sampling. They were then challenged with four cyclohexane concentrations (30, 150, 300, and 475 ppm) under two extreme environmental conditions: 5 degrees C and 30% relative humidity (RH) (same/cold) and 38 degrees C and 90% RH (same/hot). For the second series of tests (Part 2Different condition), the monitors were calibrated at approximately normal indoor environmental conditions (21 degrees C and 50% RH) and sampled at extreme environmental conditions (different/cold and different/hot). The monitor readings from the two methods were compared with the actual cyclohexane concentration determined from charcoal tubes using ratios and root mean square errors. A number of monitor failures, both below detection limit values in the presence of a known challenge concentration and erroneously high measurements, occurred in each part: same condition 20.7% (149/720) and different condition 42.4% (305/720), with a majority of the failures (>78%) during the hot and humid conditions. All monitors performed best at the same/cold, followed by the same/hot, in terms of closeness to the reference standard method and low within-monitor variability. The ranked choice of monitors for same/cold is PID > SAP > FID; for different/cold FID > PID > SAP; for same/hot SAP > PID > FID; and for different/hot PID > SAP (FID not included due to 100% failure rate). Implications: Direct-reading organic vapor monitors are used for assessing the concentrations of volatile organic compounds in the air at varying environmental conditions. Typical calibration is performed at laboratory temperature and pressure. The monitors may be used in atmospheres that differ from that during calibration. An understanding of the effect of calibration environment on monitor performance may provide valuable information on the reliability and appropriateness of certain monitor types for industrial hygienists, emergency responders, and exposure assessment practitioners. Results of the study indicate monitor calibration should be performed at the same environmental conditions as sampling. |
Evaluation of a multiplex assay for estimation of HIV-1 incidence
Curtis KA , Hanson DL , Kennedy MS , Owen SM . PLoS One 2013 8 (5) e64201 OBJECTIVES: Accurate methods of estimating HIV-1 incidence are critical for monitoring the status of the epidemic and the impact of prevention strategies. Although several laboratory-based tests have been developed strictly for this purpose, several limitations exist and improved methods or technologies are needed. We sought to further optimize a previously described bead-based, HIV-1-specific multiplex assay with the capability of measuring multiple immune responses for determining recent infection. METHODS: We refined the customized HIV-1 Bio-Plex assay by determining cutoffs and mean durations of recency (MDR), based on the reactivity to longitudinal seroconversion specimens (n = 1347) from 311 ART-naive, HIV-1-infected subjects. False-recent rates (FRRs) were calculated for various long-term cohorts, including AIDS patients, individuals on ART, and subtype C specimens. Incidence was estimated for each individual assay analyte from a simulated population with a known incidence of 1%. For improved incidence estimates, multi-analyte algorithms based on combinations of 3 to 6 analytes were evaluated and compared to the performance of each individual analyte. RESULTS: The MDR for the six analytes varied from 164.2 to 279.4 days, while the multi-analyte algorithm MDRs were less variable with a minimum and maximum value of 228.4 and 277.9 days, respectively. The FRRs for the 7 multi-analyte algorithms evaluated in this study varied from 0.3% to 3.1%, in a population of ART-naive, long-term individuals. All algorithms yielded improved incidence estimates as compared to the individual analytes, predicting an incidence of 0.95% to 1.02%. CONCLUSIONS: The HIV-specific multiplex assay described here measures several distinct immune responses in a single assay, allowing for the consideration of multi-analyte algorithms for improved HIV incidence estimates. |
An in vitro evaluation of disinfection protocols used for needleless connectors of central venous catheters
Mazher MA , Kallen A , Edwards JR , Donlan RM . Lett Appl Microbiol 2013 57 (4) 282-7 A repeatable and sensitive method to evaluate the effect of three antiseptics and two disinfection techniques on viable microorganisms on luer-activated catheter needleless connectors (NCs) was developed. NCs were inoculated with Staphylococcus epidermidis or Klebsiella pneumoniae and disinfected with 3.15% chlorhexidine gluconate + 70% isopropanol (CGI), 70% isopropanol (IPA), or 10% PVP povidone iodine (PI) antiseptic pads using: a) scrubbing the NC septum and threaded external surfaces or b) wiping only the surface of the septum. Treatments were also evaluated against NCs pretreated with human serum and exposed for 18 hours to S. epidermidis prior to testing. Viable cells were quantified by plate count. The method for inoculation and recovery of luminal microorganisms was repeatable (SD, 0.31; n=28). IPA disinfection provided an approximate 3 log10 CFU reduction; CGI and PI provided 3 - 4 log10 reductions. PI and CGI were more effective than IPA (p<0.05), but differences between CGI and PI were not significant for either disinfection method. IPA, but not CGI and PI was also less effective (p<0.05) against NCs inoculated with K. pneumoniae than S. epidermidis. Pretreatment with serum and prolonged S. epidermidis inoculation removed the advantage seen with CGI and PI; log10 reductions were 1.80, 1.73, and 2.50 for CGI, PI, and IPA, respectively. PI or CGI may be more effective than IPA for NC disinfection but effectiveness may be reduced on NCs contaminated with blood or serum. (This article is protected by copyright. All rights reserved.) |
Analysis of finite dose dermal absorption data: implications for dermal exposure assessment
Frasch HF , Dotson GS , Bunge AL , Chen CP , Cherrie JW , Kasting GB , Kissel JC , Sahmel J , Semple S , Wilkinson S . J Expo Sci Environ Epidemiol 2013 24 (1) 65-73 A common dermal exposure assessment strategy estimates the systemic uptake of chemical in contact with skin using the fixed fractional absorption approach: the dermal absorbed dose is estimated as the product of exposure and the fraction of applied chemical that is absorbed, assumed constant for a given chemical. Despite the prominence of this approach there is little guidance regarding the evaluation of experiments from which fractional absorption data are measured. An analysis of these experiments is presented herein, and limitations to the fixed fractional absorption approach are discussed. The analysis provides a set of simple algebraic expressions that may be used in the evaluation of finite dose dermal absorption experiments, affording a more data-driven approach to dermal exposure assessment. Case studies are presented that demonstrate the application of these tools to the assessment of dermal absorption data. (Journal of Exposure Science and Environmental Epidemiology advance online publication, 29 May 2013; doi:10.1038/jes.2013.23.) |
Conservation of binding epitopes for monoclonal antibodies on the rabies virus glycoprotein
Kuzmina NA , Kuzmin IV , Ellison JA , Rupprecht CE . J Antivir Antiretrovir 2013 5 (2) 037-043 The global need for rabies immune globulin (RIG) for post-exposure prophylaxis (PEP) is significant. The cost of RIG, either of equine or human origin, is prohibitive for most patients in developing countries. Limitations of supply may occur worldwide. Several virus-neutralizing monoclonal antibodies (MAbs), binding to the rabies virus glycoprotein have been proposed as a replacement of conventional RIG in human PEP due to the ability of largescale production at a reduced cost. In the present study we analyzed 1,042 rabies virus glycoprotein sequences, generated de novo and retrieved from GenBank, to determine the conservation of binding epitopes for several well characterized rabies virus-neutralizing MAbs. Our analysis demonstrated that the use of a single MAb for rabies PEPis inappropriate, because certain viral sequences had critical amino acid substitutions in binding epitopes for each MAb. Rather, a cocktail of MAbs, targeting non-overlapping epitopes, offers a reliable alternative, as no sequences from our study harbored critical substitutions in binding sites for two or more MAbs simultaneously. (2013 Kuzmina NA, et al.) |
Permanent neonatal diabetes mellitus: prevalence and genetic diagnosis in the SEARCH for Diabetes in Youth Study.
Kanakatti Shankar R , Pihoker C , Dolan LM , Standiford D , Badaru A , Dabelea D , Rodriguez B , Black MH , Imperatore G , Hattersley A , Ellard S , Gilliam LK . Pediatr Diabetes 2013 14 (3) 174-80 BACKGROUND: Neonatal diabetes mellitus (NDM) is defined as diabetes with onset before 6 months of age. Nearly half of individuals with NDM are affected by permanent neonatal diabetes mellitus (PNDM). Mutations in KATP channel genes (KCNJ11, ABCC8) and the insulin gene (INS) are the most common causes of PNDM. OBJECTIVE: To estimate the prevalence of PNDM among SEARCH for Diabetes in Youth (SEARCH) study participants (2001-2008) and to identify the genetic mutations causing PNDM. METHODS: SEARCH is a multicenter population-based study of diabetes in youth <20 yr of age. Participants diagnosed with diabetes before 6 months of age were invited for genetic testing for mutations in the KCNJ11, ABCC8, and INS genes. RESULTS: Of the 15,829 SEARCH participants with diabetes, 39 were diagnosed before 6 months of age. Thirty-five of them had PNDM (0.22% of all diabetes cases in SEARCH), 3 had transient neonatal diabetes that had remitted by 18 months and 1 was unknown. The majority of them (66.7%) had a clinical diagnosis of type1 diabetes by their health care provider. Population prevalence of PNDM in youth <20 yr was estimated at 1 in 252,000. Seven participants underwent genetic testing; mutations causing PNDM were identified in five (71%), (two KCNJ11, three INS). CONCLUSIONS: We report the first population-based frequency of PNDM in the US based on the frequency of PNDM in SEARCH. Patients with NDM are often misclassified as having type1 diabetes. Widespread education is essential to encourage appropriate genetic testing and treatment of NDM. |
Reliability of gestational weight gain reported postpartum: a comparison to the birth certificate
Hinkle SN , Sharma AJ , Schieve LA , Ramakrishnan U , Swan DW , Stein AD . Matern Child Health J 2013 17 (4) 756-65 Gestational weight gain (GWG) is an important predictor of short- and long-term adverse maternal and child outcomes. As interest in long-term outcomes increases, utilization of maternal postpartum report is likely to also increase. There is little data available examining the reliability and identifying predictors of bias in GWG recalled by mothers postpartum. We used data from the Early Childhood Longitudinal Study-Birth Cohort, a national study of U.S. children born in 2001, to compare GWG recalled by mothers approximately 10 months postpartum to GWG recorded on the birth certificate, among 5,650 records. On average, the postpartum estimates were 2.1 lbs higher (standard error, 0.2 lbs.) than the birth certificate report; 54.7% were within 5 lbs, 27.2% were overreported by more than 5 lbs, and 18.2% were underreported by more than 5 lbs. The difference between the two sources increased with GWG reported postpartum and was significantly greater among mothers who were obese prior to pregnancy, had inadequate prenatal care, or were multiparous. Bias also differed by birth outcome, indicating the potential for recall bias. When categorized by adequacy of the 2009 Institute of Medicine GWG recommendations, 70% of women were similarly categorized, and associations between GWG adequacy and small- and large-birthweight-for-gestational-age did not differ meaningfully by source of GWG data. These results suggest that for future studies, mothers' estimates of their GWG, obtained within approximately 1 year postpartum, may be a reliable substitute when birth certificate GWG data are unavailable. |
Pregnancy dose Tdap and postpartum cocooning to prevent infant pertussis: a decision analysis
Terranella A , Asay GR , Messonnier ML , Clark TA , Liang JL . Pediatrics 2013 131 (6) e1748-56 BACKGROUND: Infants <2 months of age are at highest risk of pertussis morbidity and mortality. Until recently, the US Advisory Committee on Immunization Practices (ACIP) recommended protecting young infants by "cocooning" or vaccination of postpartum mothers and other close contacts with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) booster vaccine. ACIP recommends pregnancy vaccination as a preferred and safe alternative to postpartum vaccination. The ACIP cocooning recommendation has not changed. METHODS: We used a cohort model reflecting US 2009 births and the diphtheria-tetanus-acellular pertussis schedule to simulate a decision and cost-effectiveness analysis of Tdap vaccination during pregnancy compared with postpartum vaccination with or without vaccination of other close contacts (ie, cocooning). We analyzed infant pertussis cases, hospitalizations, and deaths, as well as direct disease, indirect, and public health costs for infants in the first year of life. All costs were updated to 2011 US dollars. RESULTS: Pregnancy vaccination could reduce annual infant pertussis incidence by more than postpartum vaccination, reducing cases by 33% versus 20%, hospitalizations by 38% versus 19%, and deaths by 49% versus 16%. Additional cocooning doses in a father and 1 grandparent could avert an additional 16% of cases but at higher cost. The cost per quality-adjusted life-year saved for pregnancy vaccination was substantially less than postpartum vaccination ($414,523 vs $1,172,825). CONCLUSIONS: Tdap vaccination during pregnancy could avert more infant cases and deaths at lower cost than postpartum vaccination, even when postpartum vaccination is combined with additional cocooning doses. Pregnancy dose vaccination is the preferred alternative to postpartum vaccination for preventing infant pertussis. |
Breast milk-acquired cytomegalovirus infection and disease in VLBW and premature infants
Lanzieri TM , Dollard SC , Josephson CD , Schmid DS , Bialek SR . Pediatrics 2013 131 (6) e1937-45 BACKGROUND: Very low birth weight (VLBW) and premature infants are at risk for developing postnatal cytomegalovirus (CMV) disease, including CMV-related sepsis-like syndrome (CMV-SLS) for which in the United States are lacking. METHODS: We performed a systematic review and meta-analysis to estimate the pooled proportions (and 95% confidence intervals) of VLBW and premature infants born to CMV-seropositive women with breast milk-acquired CMV infection and CMV-SLS. We combined these proportions with population-based rates of CMV seropositivity, breast milk feeding, VLBW, and prematurity to estimate annual rates of breast milk-acquired CMV infection and CMV-SLS in the United States. RESULTS: In our meta-analysis, among 299 infants fed untreated breast milk, we estimated 19% (11%-32%) acquired CMV infection and 4% (2%-7%) developed CMV-SLS. Assuming these proportions, we estimated a rate of breast milk-acquired CMV infection among VLBW and premature infants in the United States of 6.5% (3.7%-10.9%) and 1.4% (0.7%-2.4%) of CMV-SLS, corresponding to 600 infants with CMV-SLS in 2008. Among 212 infants fed frozen breast milk, our meta-analysis proportions were 13% (7%-24%) for infection and 5% (2%-12%) for CMV-SLS, yielding slightly lower rates of breast milk-acquired CMV infection (4.4%; 2.4%-8.2%) but similar rates of CMV-SLS (1.7%; 0.7%-4.1%). CONCLUSIONS: Breast milk-acquired CMV infection presenting with CMV-SLS is relatively rare. Prospective studies to better define the burden of disease are needed to refine guidelines for feeding breast milk from CMV-seropositive mothers to VLBW and premature infants. |
Calcium and vitamin D requirements of enterally fed preterm infants
Abrams SA , Bhatia JJS , Corkins MR , De Ferranti SD , Golden NH , Silverstein J , Grummer-Strawn L , Hubbard V , Marchand V , Silverman BM , Soto V , Burrowes DL . Pediatrics 2013 131 (5) e1676-e1683 Bone health is a critical concern in managing preterm infants. Key nutrients of importance are calcium, vitamin D, and phosphorus. Although human milk is critical for the health of preterm infants, it is low in these nutrients relative to the needs of the infants during growth. Strategies should be in place to fortify human milk for preterm infants with birth weight <1800 to 2000 g and to ensure adequate mineral intake during hospitalization and after hospital discharge. Biochemical monitoring of very low birth weight infants should be performed during their hospitalization. Vitamin D should be provided at 200 to 400 IU/day both during hospitalization and after discharge from the hospital. Infants with radiologic evidence of rickets should have efforts made to maximize calcium and phosphorus intake by using available commercial products and, if needed, direct supplementation with these minerals. (Copyright 2013 by the American Academy of Pediatrics.) |
Maternal occupational exposure to polycyclic aromatic hydrocarbons and risk of oral cleft-affected pregnancies
Langlois PH , Hoyt AT , Lupo PJ , Lawson CC , Waters MA , Desrosiers TA , Shaw GM , Romitti PA , Lammer EJ . Cleft Palate Craniofac J 2013 50 (3) 337-46 OBJECTIVE: To evaluate whether there is an association between maternal occupational exposure to polycyclic aromatic hydrocarbons and oral clefts in offspring. This is the first human study of polycyclic aromatic hydrocarbons and clefts of which the authors are aware. DESIGN: Case-control study. SETTING, PARTICIPANTS: Data for 1997 to 2002 from the National Birth Defects Prevention Study, a large population-based case-control study in the United States, were analyzed. Maternal telephone interviews yielded information on jobs held in the month before through 3 months after conception. Two industrial hygienists independently assessed occupational exposure to polycyclic aromatic hydrocarbons; all jobs rated as exposed or with rating difficulty were reviewed with a third industrial hygienist to reach consensus on all exposure parameters. Logistic regression estimated crude and adjusted odds ratios with 95% confidence intervals for cleft lip with or without cleft palate and cleft palate alone. RESULTS: There were 2989 controls (3.5% exposed), 805 cases of cleft lip with or without cleft palate (5.8% exposed), and 439 cases of cleft palate alone (4.6% exposed). The odds of maternal occupational exposure to polycyclic aromatic hydrocarbons (any versus none) during pregnancy was increased for cleft lip with or without cleft palate cases as compared with controls (odds ratio, 1.69; 95% confidence interval, 1.18 to 2.40); the odds ratio was 1.47 (95% confidence interval 1.02 to 2.12) when adjusted for maternal education. There was a statistically significant adjusted exposure-response relationship for cleft lip with or without cleft palate (Ptrend = .02). Odd ratios for cleft palate alone were not statistically significant. CONCLUSIONS: Maternal occupational exposure to polycyclic aromatic hydrocarbons was associated with increased risk of cleft lip with or without cleft palate in offspring. |
Mortality among 24,865 workers exposed to polychlorinated biphenyls (PCBs) in three electrical capacitor manufacturing plants: a ten-year update
Ruder AM , Hein MJ , Hopf NB , Waters MA . Int J Hyg Environ Health 2013 217 176-87 The objective of this analysis was to evaluate mortality among a cohort of 24,865 capacitor-manufacturing workers exposed to polychlorinated biphenyls (PCBs) at plants in Indiana, Massachusetts, and New York and followed for mortality through 2008. Cumulative PCB exposure was estimated using plant-specific job-exposure matrices. External comparisons to US and state-specific populations used standardized mortality ratios, adjusted for gender, race, age and calendar year. Among long-term workers employed 3 months or longer, within-cohort comparisons used standardized rate ratios and multivariable Poisson regression modeling. Through 2008, more than one million person-years at risk and 8749 deaths were accrued. Among long-term employees, all-cause and all-cancer mortality were not elevated; of the a priori outcomes assessed only melanoma mortality was elevated. Mortality was elevated for some outcomes of a priori interest among subgroups of long-term workers: all cancer, intestinal cancer and amyotrophic lateral sclerosis (women); melanoma (men); melanoma and brain and nervous system cancer (Indiana plant); and melanoma and multiple myeloma (New York plant). Standardized rates of stomach and uterine cancer and multiple myeloma mortality increased with estimated cumulative PCB exposure. Poisson regression modeling showed significant associations with estimated cumulative PCB exposure for prostate and stomach cancer mortality. For other outcomes of a priori interest - rectal, liver, ovarian, breast, and thyroid cancer, non-Hodgkin lymphoma, Alzheimer disease, and Parkinson disease - neither elevated mortality nor positive associations with PCB exposure were observed. Associations between estimated cumulative PCB exposure and stomach, uterine, and prostate cancer and myeloma mortality confirmed our previous positive findings. |
Origin of the St. Elizabeth strain of Plasmodium vivax
Collins W . Am J Trop Med Hyg 2013 88 (4) 726 The St. Elizabeth strain of Plasmodium vivax originated in the South Carolina State Hospital instead of the St. Elizabeth Hospital in Washington, DC. |
In vivo efficacy of artemether-lumefantrine and chloroquine against Plasmodium vivax: a randomized open label trial in central Ethiopia
Hwang J , Alemayehu BH , Reithinger R , Tekleyohannes SG , Takele Teshi , Birhanu SG , Demeke L , Hoos D , Melaku Z , Kassa M , Jima D , Malone JL , Nettey H , Green M , Poe A , Akinyi S , Udhayakumar V , Kachur SP , Filler S . PLoS One 2013 8 (5) e63433 BACKGROUND: In vivo efficacy assessments of antimalarials are essential for ensuring effective case management. In Ethiopia, chloroquine (CQ) without primaquine is the first-line treatment for Plasmodium vivax in malarious areas, but artemether-lumefantrine (AL) is also commonly used. METHODS AND FINDINGS: In 2009, we conducted a 42-day efficacy study of AL or CQ for P. vivax in Oromia Regional State, Ethiopia. Individuals with P. vivax monoinfection were enrolled. Primary endpoint was day 28 cure rate. In patients with recurrent parasitemia, drug level and genotyping using microsatellite markers were assessed. Using survival analysis, uncorrected patient cure rates at day 28 were 75.7% (95% confidence interval (CI) 66.8-82.5) for AL and 90.8% (95% CI 83.6-94.9) for CQ. During the 42 days of follow-up, 41.6% (47/113) of patients in the AL arm and 31.8% (34/107) in the CQ arm presented with recurrent P. vivax infection, with the median number of days to recurrence of 28 compared to 35 days in the AL and CQ arm, respectively. Using microsatellite markers to reclassify recurrent parasitemias with a different genotype as non-treatment failures, day 28 cure rates were genotype adjusted to 91.1% (95% CI 84.1-95.1) for AL and to 97.2% (91.6-99.1) for CQ. Three patients (2.8%) with recurrent parasitemia by day 28 in the CQ arm were noted to have drug levels above 100 ng/ml. CONCLUSIONS: In the short term, both AL and CQ were effective and well-tolerated for P. vivax malaria, but high rates of recurrent parasitemia were noted with both drugs. CQ provided longer post-treatment prophylaxis than AL, resulting in delayed recurrence of parasitemia. Although the current policy of species-specific treatment can be maintained for Ethiopia, the co-administration of primaquine for treatment of P. vivax malaria needs to be urgently considered to prevent relapse infections. TRIAL REGISTRATION: ClinicalTrials.gov NCT01052584. |
Presidential promotion of health-related behaviors through words and example
Safran MA . Mil Med 2013 178 (4) 432-7 This article addresses a topic that is part of the public consciousness yet is seldom explored in the public health literature: presidential promotion of health-related behaviors through words and example. The article explores the history of what some American presidents, as individuals, have conveyed to the population about health through their own actions (presidential modeling of health behavior) and words. The nature of such messages and how they are received has changed with advances in technology and will likely continue to evolve. |
Autism training in pediatric residency: evaluation of a case-based curriculum
Major NE , Peacock G , Ruben W , Thomas J , Weitzman CC . J Autism Dev Disord 2013 43 (5) 1171-7 Despite recent studies indicating the high prevalence of autism spectrum disorders (ASDs), there has been little focus on improving ASD education during pediatric residency training. The objective of this study was to evaluate a new curriculum developed in partnership with the Centers for Disease Control and Prevention and the Maternal and Child Health Bureau about ASDs. "Autism Case Training (ACT): A Developmental-Behavioral Pediatrics Curriculum" consists of 7 case-based teaching modules. Modules were facilitated by faculty at 26 pediatric residency programs and data were obtained on 114 residents. Pre- and post-test data revealed significant short-term improvements in residents' knowledge and self-assessed competence regarding ASDs. Findings suggest that the ACT curriculum is effective in enhancing training about ASDs in pediatric residency programs. |
Urinary follicle-stimulating hormone as a measure of natural fertility in a community cohort
Steiner AZ , Long DL , Herring AH , Kesner JS , Meadows JW , Baird DD . Reprod Sci 2013 20 (5) 549-56 High serum follicle-stimulating hormone (FSH) levels have been associated with diminished ovarian reserve; however, the association between high urinary FSH and reduced natural fertility has yet to be established. We sought to characterize the relationship between a single or multiple measurements of early follicular phase urinary FSH and fertility. Women (n = 209), 30 to 44 years old with no history of infertility, who had been trying to conceive for less than 3 months, provided early follicular phase urine. Participants subsequently kept a diary to record bleeding and intercourse and conducted standardized pregnancy testing for up to 6 months. A subset of women (N = 95) collected urine on cycle day 3 for up to 6 cycles. Urine was analyzed for FSH and creatinine (cr) corrected. Proportional hazard models were used to calculate fecundability ratios (FRs). Urinary FSH levels across cycles from the same woman were highly correlated (adjusted intraclass correlation = .77); within-woman variance was 3-fold lower than variance among women. Women with an initial urinary FSH level <7 mIU/mg cr exhibited a nonsignificant reduction in the probability of pregnancy (adjusted FR 0.71, 95% confidence interval [CI]: 0.45-1.13), as did women with elevated urinary FSH (≥12 mIU/mg cr; adjusted FR 0.78, 95% CI: 0.46-1.32). Using the most recent or maximum urinary FSH value did not strengthen the association. In the general population, urinary FSH levels appear to be nonlinearly associated with fertility; however, broad CIs indicate a lack of statistical significance. Repetitive testing appears to be of little benefit. |
Socioeconomic disadvantage and developmental delay among US children aged 18 months to 5 years
Simon AE , Pastor PN , Avila RM , Blumberg SJ . J Epidemiol Community Health 2013 67 (8) 689-95 BACKGROUND: Few studies have examined the relationship between sociodemographic factors and a population-based measure of developmental delay in US children. We identify sociodemographic factors associated with unlikely, probable and possible developmental delay in preschool US children using nationally representative data. METHODS: All children aged 18 months to 5 years in the 2007 National Survey of Children's Health were categorised into three groups based on the likelihood of developmental delay (unlikely delay, possible delay and probable delay) using a modified survey version of the Parents' Evaluation of Developmental Status questionnaire. Bivariate and multivariate multinomial logistic regressions were used to assess relations between sociodemographic variables and risk of developmental delay. RESULTS: Children had increased odds of probable delay (compared with unlikely delay) if they were older (adjusted OR (aOR)=1.41/additional year above the youngest age group (18 months-2 years), p<0.001), male (aOR=1.55, p<0.001), low birth weight (aOR=2.08, p<0.001), non-Hispanic black (aOR=1.50, p<0.01) or Hispanic in a non-English-speaking household (aOR=2.53, p<0.001) versus non-Hispanic white, had lower household income (aOR=1.33 for each decreasing category of poverty level, p<0.001), or received >10 h/week of care at another family's home (aOR=1.71, p<0.05). Only four characteristics (being older, male, low birth weight and Hispanic living in a non-English-speaking household) were associated with increased odds of possible delay compared with unlikely delay. CONCLUSIONS: Multiple factors, including demographic characteristics and indicators of social disadvantage, distinguish children with probable developmental delay from those unlikely to have developmental delay. Fewer factors identify children with possible delay. |
Invited commentary: can changes in the distributions of and associations between education and income bias estimates of temporal trends in health disparities?
Talih M . Am J Epidemiol 2013 177 (9) 882-4 Chen et al. (Am J Epidemiol. 2013) develop a simulation study for comparing various measures of socioeconomic health disparities when bias can arise from temporal changes in the bivariate distribution of education and income. In this commentary, I argue that, in relation to health, the "meaning" of education cannot be reduced to its socioeconomic value; improved health literacy, for instance, can result in important health benefits. Further, I suggest that unless there is a substantial prior understanding of the data-generating mechanism, directed acyclic graph models should be avoided because causal relationships cannot be inferred from regression. An alternative is to resort to conditional independence graphs, which use only undirected edges. Finally, although the slope index of inequality can, in some specific cases, be seen to reduce bias in temporal comparisons of socioeconomic health disparities, it was not designed for causal inference. The slope index of inequality simply describes the average change in the proportion in poor health when the population is ordered by socioeconomic status. |
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