Strategic priorities for physical activity surveillance in the United States
Fulton JE , Carlson SA , Ainsworth BE , Berrigan D , Carlson C , Dorn JM , Heath GW , Kohl HW 3rd , Lee IM , Lee SM , Masse LC , Morrow JR Jr , Gabriel KP , Pivarnik JM , Pronk NP , Rodgers AB , Saelens BE , Sallis JF , Troiano RP , Tudor-Locke C , Wendel A . Med Sci Sports Exerc 2016 48 (10) 2057-69 PURPOSE: Develop strategic priorities to guide future physical activity surveillance in the United States. METHODS: The Centers for Disease Control and Prevention and the American College of Sports Medicine convened a Scientific Roundtable of physical activity and measurement experts. Participants summarized the current state of aerobic physical activity surveillance for adults, focusing on practice and research needs in three areas: 1) behavior, 2) human movement, and 3) community supports. Needs and challenges for each area were identified. At the conclusion of the meeting, experts identified one overarching strategy and five strategic priorities to guide future surveillance. RESULTS: The identified overarching strategy was to develop a national plan for physical activity surveillance similar to the U.S. National Physical Activity Plan for promotion. The purpose of the plan would be to enhance coordination and collaboration within and between sectors, such as transportation and public health, and to address specific strategic priorities identified at the Roundtable. These strategic priorities were: 1) identify and prioritize physical activity constructs, 2) assess the psychometric properties of instruments for physical activity surveillance, 3) provide training and technical assistance for those collecting, analyzing, or interpreting surveillance data, 4) explore accessing data from alternative sources, and 5) improve communication, translation, and dissemination about estimates of physical activity from surveillance systems. CONCLUSION: This Roundtable provided strategic priorities for physical activity surveillance in the United States. A first step is to develop a national plan for physical activity surveillance that would provide an operating framework from which to execute these priorities. |
Prevalence of doctor-diagnosed arthritis at state and county levels - United States, 2014
Barbour KE , Helmick CG , Boring M , Zhang X , Lu H , Holt JB . MMWR Morb Mortal Wkly Rep 2016 65 (19) 489-494 Doctor-diagnosed arthritis is a common chronic condition that affects approximately 52.5 million (22.7%) adults in the United States and is a leading cause of disability (1,2). The prevalence of doctor-diagnosed arthritis has been well documented at the national level (1), but little has been published at the state level and the county level, where interventions are carried out and can have their greatest effect. To estimate the prevalence of doctor-diagnosed arthritis among adults at the state and county levels, CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which found that, for all 50 states and the District of Columbia (DC) overall, the age-standardized median prevalence of doctor-diagnosed arthritis was 24% (range = 18.8%-35.5%). The age-standardized model-predicted prevalence of doctor-diagnosed arthritis varied substantially by county, with estimates ranging from 15.8% to 38.6%. The high prevalence of arthritis in all counties, and the high frequency of arthritis-attributable limitations (1) among adults with arthritis, suggests that states and counties might benefit from expanding underused, evidence-based interventions for arthritis that can reduce arthritis symptoms and improve self-management. |
Identification of Bacterial and Viral Codetections With Mycoplasma pneumoniae Using the TaqMan Array Card in Patients Hospitalized With Community-Acquired Pneumonia.
Diaz MH , Cross KE , Benitez AJ , Hicks LA , Kutty P , Bramley AM , Chappell JD , Hymas W , Patel A , Qi C , Williams DJ , Arnold SR , Ampofo K , Self WH , Grijalva CG , Anderson EJ , McCullers JA , Pavia AT , Wunderink RG , Edwards KM , Jain S , Winchell JM . Open Forum Infect Dis 2016 3 (2) ofw071 Mycoplasma pneumoniae was detected in a number of patients with community-acquired pneumonia in a recent prospective study. To assess whether other pathogens were also detected in these patients, TaqMan Array Cards were used to test 216 M pneumoniae-positive respiratory specimens for 25 additional viral and bacterial respiratory pathogens. It is interesting to note that 1 or more codetections, predominantly bacterial, were identified in approximately 60% of specimens, with codetections being more common in children. |
Reduced incidence of chikungunya virus infection in communities with ongoing Aedes aegypti mosquito trap intervention studies - Salinas and Guayama, Puerto Rico, November 2015-February 2016
Lorenzi OD , Major C , Acevedo V , Perez-Padilla J , Rivera A , Biggerstaff BJ , Munoz-Jordan J , Waterman S , Barrera R , Sharp TM . MMWR Morb Mortal Wkly Rep 2016 65 (18) 479-80 Aedes species mosquitoes transmit chikungunya virus, as well as dengue and Zika viruses, and bite most often during the day. Infectious mosquito bites frequently occur in and around homes. Caribbean countries first reported local transmission of chikungunya virus in December 2013, and soon after, chikungunya virus spread throughout the Americas. Puerto Rico reported its first laboratory-positive chikungunya case in May 2014, and subsequently identified approximately 29,000 suspected cases throughout the island by the end of 2015. Because conventional vector control approaches often fail to result in effective and sustainable prevention of infection with viruses transmitted by Aedes mosquitoes, and to improve surveillance of mosquito population densities, CDC developed an Autocidal Gravid Ovitrap (AGO) to attract and capture the female Aedes aegypti mosquitoes responsible for transmission of infectious agents to humans. The AGO trap is a simple, low-cost device that requires no use of pesticides and no servicing for an extended period of time. |
Use of the historical limits method to detect increases in primary and secondary syphilis, Arizona 2011-2014: An exploratory study
Mireles JR , Ereth R , Mickey T , May R , Taylor MM . Sex Transm Dis 2016 43 (6) 402-406 BACKGROUND: Increasing numbers of reported primary and secondary (P&S) syphilis cases in the United States suggest the need for improved surveillance methods. An outbreak detection method using reported syphilis test results, which can be counted before the conclusion of a syphilis case investigation, could lead to timelier outbreak detection. METHODS: The historical limits comparison method was used to compare the number of positive rapid plasma reagin results reported during 2011-2014 with data for the preceding 3 years. An outbreak alert was generated when the monthly count of positive rapid plasma reagin quantitative results was greater than the historical mean plus 2 standard deviations for 2 consecutive months. RESULTS: Three outbreak alerts occurred during 2011-2014. The first alert occurred in December 2012 in Maricopa County (Phoenix area). Primary and secondary cases subsequently increased from 10 in January 2013 to 15 in March followed by 5 months of consecutive increases. A second alert was generated for Maricopa County in May 2014. Primary and secondary cases increased from 29 in May to 42 in July 2014. Reported cases remained elevated for approximately 7 months after the second alert. In December 2013, an outbreak alert occurred for Pima County (Tucson area). The number of reported P&S syphilis cases in Pima County increased from 6 in February to 15 in March. Counts of reported cases remained elevated for approximately 6 months after the alert. CONCLUSIONS: Use of historical limits comparison method based on syphilis laboratory results can provide an outbreak alert before increases in reported cases of P&S syphilis. |
Progress toward polio eradication - worldwide, 2015-2016
Morales M , Tangermann RH , Wassilak SG . MMWR Morb Mortal Wkly Rep 2016 65 (18) 470-3 In 1988, the World Health Assembly resolved to eradicate poliomyelitis. Wild poliovirus (WPV) transmission persists in only two countries (Afghanistan and Pakistan) after the removal of Nigeria from the list of countries with endemic polio in September 2015.* Indigenous WPV type 2 has not been detected since 1999 and was declared eradicated by the Global Commission for the Certification of Poliomyelitis Eradication in September 2015.(dagger) Since November 2012, when the last case of WPV type 3 was detected in Nigeria, WPV type 1 has been the sole circulating type of WPV (1). This report summarizes global progress toward polio eradication during 2015-2016 and updates previous reports (2). In 2015, 74 WPV cases were reported in two countries (Afghanistan and Pakistan), a decrease of 79% from the 359 WPV cases reported in 2014 in nine countries; 12 WPV cases have been reported in 2016 (to date), compared with 23 during the same period in 2015 (3). Paralytic polio caused by circulating vaccine-derived poliovirus (cVDPV) remains a risk in areas with low oral poliovirus vaccine (OPV) coverage. Seven countries, including Pakistan, reported 32 cVDPV cases in 2015 (4). In four of these countries, ≥6 months have passed since the most recent case or isolate. One country (Laos) with VDPV transmission in 2015 has reported three additional cVDPV cases in 2016 to date. Encouraging progress toward polio eradication has been made over the last year; however, interruption of WPV transmission will require focus on reaching and vaccinating every missed child through high quality supplementary immunization activities (SIAs) and cross-border coordination between Afghanistan and Pakistan (5,6). |
Early azithromycin treatment to prevent severe lower respiratory tract illnesses in children
Fleming-Dutra KE , Friedman CR , Hicks LA . JAMA 2016 315 (19) 2121-2 The study by Dr Bacharier and colleagues1 found that using azithromycin in preschool children with a history of wheezing and respiratory tract infection (RTI) prevented progression to “severe” lower respiratory tract illness (LRTI). The authors defined severe LRTI as needing intensive rescue albuterol treatments; it was not defined as pneumonia, the classic definition of severe LRTI. While azithromycin limited the need for intensive rescue albuterol, it did not prevent urgent care or emergency visits, hospitalizations, or future RTI episodes, arguably the most important prevention outcomes. | Furthermore, randomized children who had severe LRTI, needed emergent care, had uncontrolled asthma or had respiratory-related problems at or prior to presentation with RTI were deemed “early termination”, meaning that they were not given the study medication or included in the analyses. More children (109) experienced early termination than children who received study medication and experienced LRTI (92). A more rigorous intention-to-treat (ITT) analysis may not have shown any significant difference in progression to severe LRTI between azithromycin and placebo. |
Formative work and community engagement approaches for implementing an HIV intervention in Botswana schools
Miller KS , Cham HJ , Taylor EM , Berrier FL , Duffy M , Vig J , Chipazi L , Chakalisa C , Sidibe S , Swart K , Tau NS , Clark LF . Am J Public Health 2016 106 (8) e1-e3 Providing adolescents with evidence-based sexual risk reduction interventions is critical to addressing the HIV/AIDS epidemic among adolescents in sub-Saharan Africa. Project AIM (Adult Identity Mentoring) is an innovative, evidence-based, youth development intervention that is being evaluated for the first time in Botswana through a 3-year (2015-2017), 50-school cluster randomized controlled trial, including testing for herpes simplex virus type 2 as a sexual activity biomarker. Conducting a trial of this magnitude requires the support and collaboration of government and community stakeholders. All school staff, including teachers, must be well informed about the study; dedicated staff placed at each school can help to improve school and community familiarity with the study, improve the information flow, and relieve some of the burden study activities places on schools. (Am J Public Health. Published online ahead of print May 19, 2016: e1-e3. doi:10.2105/AJPH.2016.303225). |
Higher all-cause hospitalization among patients with chronic hepatitis C: The Chronic Hepatitis Cohort Study (CHeCS), 2006-2013
Teshale EH , Xing J , Moorman A , Holmberg SD , Spradling PR , Gordon SC , Rupp LB , Lu M , Boscarino JA , Trinacity CM , Schmidt MA , Xu F . J Viral Hepat 2016 23 (10) 748-54 In the United States, hospitalization among patients with chronic hepatitis C virus (HCV) infection is high. The healthcare burden associated with hospitalization is not clearly known. We analysed data from the Chronic Hepatitis Cohort Study, an observational cohort of patients receiving care at four integrated healthcare systems, collected from 2006 to 2013 to determine all-cause hospitalization rates of patients with chronic HCV infection and the other health system patients. To compare the hospitalization rates, we selected two health system patients for each chronic HCV patient using their propensity score (PS). Propensity score matching was conducted by site, gender, race, age and household income to minimize differences attributable to these characteristics. We also compared primary reason for hospitalization between chronic HCV patients and the other health system patients. Overall, 10 131 patients with chronic HCV infection and 20 262 health system patients were selected from the 1 867 802 health system patients and were matched by PS. All-cause hospitalization rates were 27.4 (27.0-27.8) and 7.4 (7.2-7.5) per 100 persons-year (PY) for chronic HCV patients and for the other health system patients, respectively. Compared to health system patients, hospitalization rates were significantly higher by site, gender, age group, race and household income among chronic HCV patients (P < 0.001). Compared to health system patients, chronic HCV patients were more likely to be hospitalized from liver-related conditions (RR = 24.8, P < 0.001). Hence, patients with chronic HCV infection had approximately 3.7-fold higher all-cause hospitalization rate than other health system patients. These findings highlight the incremental costs and healthcare burden of patients with chronic HCV infection associated with hospitalization. |
Identification and clinical management of persons with chronic hepatitis C virus infection - Cherokee Nation, 2012-2015
Mera J , Vellozzi C , Hariri S , Carabin H , Drevets DA , Miller A , Reilley B , Essex W , Gahn D , Lyons L , Leston J , Ward JW . MMWR Morb Mortal Wkly Rep 2016 65 (18) 461-6 An estimated 3.5 million persons in the United States are living with hepatitis C virus (HCV) infection, resulting in approximately 20,000 deaths each year, primarily from cirrhosis or hepatocellular carcinoma (1,2). American Indian/Alaska Native (AI/AN) populations have the highest incidence of acute HCV infection among all U.S. racial/ethnic groups and are at greater risk for HCV-related mortality compared with the general population (3). In 2013, new antiviral drugs became available that make possible 8-12 week treatment regimens with fewer adverse events and are able to achieve sustained virologic response (SVR) in >90% of treated patients (4), equivalent to a cure of HCV infection. Also of note, HCV testing recommendations were expanded in 2012 by CDC and in 2013 by the U.S. Preventive Services Task Force to include one-time testing of persons born during 1945-1965 (the "baby boomer" cohort) in addition to anyone at increased risk for HCV infection (5,6). Given the availability of new HCV drugs, expanded testing recommendations, and high incidence of HCV infection in AI/AN populations, in October 2012, Cherokee Nation Health Services (CNHS) implemented a tribal HCV testing policy.* As part of the policy, CNHS added a reminder in the electronic health record (EHR) for clinical decision support and provided HCV education to primary care clinicians. From October 2012 to July 2015, among 92,012 persons with at least one CNHS clinic encounter, the cumulative number who received HCV screening for the first time increased from 3,337 (3.6%) to 16,772 (18.2%). The largest percentage of HCV screening was among persons born during 1945-1965. Of 715 persons who tested positive for HCV antibodies, 488 (68.3%) were tested for HCV RNA; among those 488 persons, 388 (79.5%) were RNA positive and were thus confirmed to have chronic HCV infection. Treatment was initiated for 223 (57.5%) of the 388 with chronic infection; 201 (90.1%) completed treatment, of whom 180 (89.6%) achieved SVR. CNHS has successfully increased HCV testing and treatment and is now collaborating with CDC and other external partners to develop an HCV elimination program for the Cherokee Nation that might serve as a model for similar settings. |
Improving the quality of and access to HIV rapid testing in the Caribbean region: Program implementation, outcomes, and recommendations
Alemnji GA , Guevara G , Parris K , Kalou M , Behel SK , Parekh B , Nkengasong JN , Albalak R . AIDS Res Hum Retroviruses 2016 32 (9) 879-84 In 2008 HIV rapid testing (HIV RT) was only minimally used in the Caribbean region. Collaboration with countries and international partners since then has resulted in greater availability and use of HIV RT services. Surveys were conducted in 2012 and 2014 among 11 selected Caribbean countries to inform stakeholders of progress made since 2008 and to identify strategies to further improve access and uptake of high-quality HIV RT in community- and facility-based settings in support of the UNAIDS 90-90-90 targets. Key accomplishments during this period include: 1) presence of in-country national HIV RT algorithms; 2) use of the dried tube specimen (DTS) as an external quality assessment (EQA) program; 3) use of standardized logbooks for data collection and monitoring; and, 4) use of oral fluid for HIV RT, particularly for key population surveys. Although progress has been made since 2008 to increase access and improve the quality of HIV RT among countries in the Caribbean some work remains to be done. This includes the development of new policies and implementation of existing ones, task shifting, quality and access to testing, testing strategies, and integration of HIV RT into HIV Testing Services (HTS). |
Association of hepatitis C virus with alcohol use among U.S. adults: NHANES 2003-2010
Taylor AL , Denniston MM , Klevens RM , McKnight-Eily LR , Jiles RB . Am J Prev Med 2016 51 (2) 206-215 INTRODUCTION: Excessive alcohol use exacerbates morbidity and mortality among hepatitis C virus (HCV)-infected people. The purpose of this study was to describe self-reported patterns of alcohol use and examine the association with HCV infection and other sociodemographic and health-related factors. METHODS: Data from 20,042 participants in the 2003-2010 National Health and Nutrition Examination Survey were analyzed in 2014. Estimates were derived for self-reported demographic characteristics, HCV-RNA (indicative of current HCV infection) status, and alcohol use at four levels: lifetime abstainers, former drinkers, non-excessive current drinkers, and excessive current drinkers. RESULTS: Former drinkers and excessive current drinkers had a higher prevalence of HCV infection (2.2% and 1.5%, respectively) than never or non-excessive current drinkers (0.4% and 0.9%, respectively). HCV-infected adults were estimated to ever drink five or more drinks/day almost every day at some time during their lifetime about 3.3 times more often (43.8% vs 13.7%, p<0.001) than those who were never infected with HCV. Controlling for age, sex, race/ethnicity, education, and having a usual source of health care, HCV infection was significantly associated with excessive current drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6) and former drinking (adjusted prevalence ratio, 1.3; 95% CI=1.1, 1.6). CONCLUSIONS: Chronic HCV infection is associated with both former and excessive current drinking. Public health HCV strategies should implement interventions with emphasis on alcohol abuse, which negatively impacts disease progression for HCV-infected individuals. |
Birth cohort testing for hepatitis C virus - Indian Health Service 2012-2015
Reilley B , Leston J , Hariri S , Neel L , Rudd M , Galope M , Ward J , Vellozzi C . MMWR Morb Mortal Wkly Rep 2016 65 (18) 467-9 Hepatitis C virus (HCV) infection is a substantial and largely unrecognized public health problem. An estimated 3.5 million persons in the United States are currently living with HCV infection, at least half of whom are unaware of their infection (1-3). Persons born during 1945-1965 (the "baby boomer" birth cohort) have a sixfold higher prevalence (2.6%) than adults of other ages, and represent 81% of all persons chronically infected with HCV (4). Therefore, in addition to recommending testing for all persons at risk for HCV infection, CDC and the U.S. Preventive Services Task Force (USPSTF) recommend one-time HCV testing for the birth cohort (5,6). Compared with the national average, American Indian/Alaska Native (AI/AN) persons have approximately twofold the rate of acute HCV incidence and HCV associated mortality (2). In June 2012, the Indian Health Service (IHS) implemented HCV testing in the 1945-1965 birth cohort and created a nationally standardized performance measure to monitor implementation of the recommendation. As of June 2015, the proportion of the birth cohort screened for HCV increased from a baseline of 7.9% (14,402/182,503) to 32.5% (68,514/211,014) among the AI/AN population served by IHS nationwide; provider training and the use of clinical decision tools were associated with increases in HCV testing. With this fourfold increase in testing in just 3 years, IHS needs to prepare for the challenges associated with increased identification of persons living with HCV infection. |
A case-control study evaluating the role of internet meet-up sites and mobile telephone applications in influencing a syphilis outbreak: Multnomah County, Oregon, USA 2014
DeSilva M , Hedberg K , Robinson B , Toevs K , Neblett-Fanfair R , Petrosky E , Hariri S , Schafer S . Sex Transm Infect 2016 92 (5) 353-8 OBJECTIVES: Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis. METHODS: Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression. RESULTS: Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p<0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p<0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9). CONCLUSIONS: Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals. |
Detectable HIV viral load in Kenya: Data from a population-based survey
Cherutich P , Kim AA , Kellogg TA , Sherr K , Waruru A , De Cock KM , Rutherford GW . PLoS One 2016 11 (5) e0154318 INTRODUCTION: At the individual level, there is clear evidence that Human Immunodeficiency Virus (HIV) transmission can be substantially reduced by lowering viral load. However there are few data describing population-level HIV viremia especially in high-burden settings with substantial under-diagnosis of HIV infection. The 2nd Kenya AIDS Indicator Survey (KAIS 2012) provided a unique opportunity to evaluate the impact of antiretroviral therapy (ART) coverage on viremia and to examine the risks for failure to suppress viral replication. We report population-level HIV viral load suppression using data from KAIS 2012. METHODS: Between October 2012 to February 2013, KAIS 2012 surveyed household members, administered questionnaires and drew serum samples to test for HIV and, for those found to be infected with HIV, plasma viral load (PVL) was measured. Our principal outcome was unsuppressed HIV viremia, defined as a PVL ≥ 550 copies/mL. The exposure variables included current treatment with ART, prior history of an HIV diagnosis, and engagement in HIV care. All point estimates were adjusted to account for the KAIS 2012 cluster sampling design and survey non-response. RESULTS: Overall, 61.2% (95% CI: 56.4-66.1) of HIV-infected Kenyans aged 15-64 years had not achieved virological suppression. The base10 median (interquartile range [IQR]) and mean (95% CI) VL was 4,633 copies/mL (0-51,596) and 81,750 copies/mL (59,366-104,134), respectively. Among 266 persons taking ART, 26.1% (95% CI: 20.0-32.1) had detectable viremia. Non-ART use, younger age, and lack of awareness of HIV status were independently associated with significantly higher odds of detectable viral load. In multivariate analysis for the sub-sample of patients on ART, detectable viremia was independently associated with younger age and sub-optimal adherence to ART. DISCUSSION: This report adds to the limited data of nationally-representative surveys to report population- level virological suppression. We established heterogeneity across the ten administrative and HIV programmatic regions on levels of detectable viral load. Timely initiation of ART and retention in care are crucial for the elimination of transmission of HIV through sex, needle and syringe use or from mother to child. Further refinement of geospatial mapping of populations with highest risk of transmission is necessary. |
Diagnosis and management of tickborne rickettsial iseases: Rocky mountain spotted fever and other spotted fever group rickettsioses, ehrlichioses, and anaplasmosis - United States
Biggs HM , Behravesh CB , Bradley KK , Dahlgren FS , Drexler NA , Dumler JS , Folk SM , Kato CY , Lash RR , Levin ML , Massung RF , Nadelman RB , Nicholson WL , Paddock CD , Pritt BS , Traeger MS . MMWR Recomm Rep 2016 65 (2) 1-44 Tickborne rickettsial diseases continue to cause severe illness and death in otherwise healthy adults and children, despite the availability of low-cost, effective antibacterial therapy. Recognition early in the clinical course is critical because this is the period when antibacterial therapy is most effective. Early signs and symptoms of these illnesses are nonspecific or mimic other illnesses, which can make diagnosis challenging. Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D. This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases. The CDC Rickettsial Zoonoses Branch, in consultation with external clinical and academic specialists and public health professionals, developed this report to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities. |
Duration of influenza virus shedding among HIV-infected adults in the cART era, 2010-2011
Patel P , Bush T , Kojic EM , Overton ET , Henry K , Onen N , Rhame F , Conley L , Brooks J , Fry A . AIDS Res Hum Retroviruses 2016 32 (12) 1180-1186 The duration of influenza virus shedding in HIV-infected adults is unknown and could affect quarantine and treatment recommendations. Participants were monitored for influenza-like illness (ILI), defined as fever and cough or sore throat, using weekly telephone audio computer-assisted self-interviews. Those with ILI were further evaluated at three HIV-specialty clinics. For those with influenza, we collected nasopharyngeal washes every three days after the date of confirmed influenza infection for 21-28 days; specimens underwent RT-PCR and viral culture. Duration of influenza virus shedding was the interval from the date of onset (day 0) of ILI to the date of last culture-positive specimen. Characteristics were compared between patients with and without influenza using Fisher's exact test. We used the Wilcoxon rank-sum test to examine factors that may have affected influenza virus shedding. From 10/2010 to 4/2011, we enrolled 961 participants in syndromic surveillance and diagnosed 20 patients with influenza whose characteristics were: median age 48 years (interquartile range [IQR]: 43-53), 60% male, 50% non-Hispanic black, 95% had been prescribed cART, 85% were virologically suppressed (HIV RNA <400 copies/mL), median CD4 cell count 317 cells/mm3 (IQR: 190-544), and median follow-up time 21 days (IQR: 19-22). Compared with persons without influenza, persons with influenza were more likely to be older, use injection drugs, have a lower median CD4 cell count, and were less likely to have had an influenza vaccination in the past 12 months. Median durations of shedding, PCR detection, and ILI symptoms were 3 (IQR: 0-5), 10 (IQR: 6-15), and 14 days (IQR: 12-26), respectively. Median days of shedding were similar among patients with and without any prior influenza vaccination (0 vs. 4, p=0.448), HIV viral suppression (2 vs. 6, p=0.053), and oseltamivir use (5 vs. 0, p=0.083). HIV-infected persons on cART in our study shed influenza virus for a similar duration as that reported for HIV-uninfected persons. |
Environmental distribution of Cryptococcus neoformans and Cryptococcus gattii around the Mediterranean basin
Cogliati M , D'Amicis R , Zani A , Montagna MT , Caggiano G , De Giglio O , Balbino S , De Donno A , Serio F , Susever S , Ergin C , Velegraki A , Ellabib MS , Nardoni S , Macci C , Oliveri S , Trovato L , Dipineto L , Rickerts V , McCormick-Smith I , Akcaglar S , Tore O , Mlinaric-Missoni E , Bertout S , Mallie M , Martins MD , Venca AC , Vieira ML , Sampaio AC , Pereira C , Griseo G , Romeo O , Ranque S , Al-Yasiri MH , Kaya M , Cerikcioglu N , Marchese A , Vezzulli L , Ilkit M , Desnos-Ollivier M , Pasquale V , Korem M , Polacheck I , Scopa A , Meyer W , Ferreira-Paim K , Hagen F , Theelen B , Boekhout T , Lockhart SR , Tintelnot K , Tortorano AM , Dromer F , Varma A , Kwon-Chung KJ , Inacio J , Alonso B , Colom MF . FEMS Yeast Res 2016 16 (4) In order to elucidate the distribution of Cryptococcus neoformans and C. gattii in the Mediterranean basin, an extensive environmental survey was carried out during 2012-15. A total of 302 sites located in 12 countries were sampled, 6436 samples from 3765 trees were collected, and 5% of trees were found to be colonized by cryptococcal yeasts. Cryptococcus neoformans was isolated from 177 trees and C. gattii from 13. Cryptococcus neoformans colonized 27% of Ceratonia, 10% of Olea, Platanus and Prunus trees and a lower percentage of other tree genera. The 13 C. gattii isolates were collected from five Eucalyptus, four Ceratonia, two Pinus, and two Olea trees. C. neoformans was distributed all around the Mediterranean basin, whereas C. gattii was isolated in Greece, Southern Italy, and Spain, in agreement with previous findings from both clinical and environmental sources. Among C. neoformans isolates VNI was the prevalent molecular type but VNII, VNIV and VNIII hybrid strains were also isolated. With the exception of a single VGIV isolate, all C. gattii isolates were VGI. The results confirmed the presence of both Cryptococcus species in the Mediterranean environment, and showed that both carob and olive trees represent an important niche for these yeasts. |
Factors associated with the receipt of antimicrobials among chronic hemodialysis patients
Snyder GM , Patel PR , Kallen AJ , Strom JA , Tucker JK , D'Agata EM . Am J Infect Control 2016 44 (11) 1269-1274 BACKGROUND: Antimicrobial use is common among patients receiving chronic hemodialysis (CHD) and may represent an important antimicrobial stewardship opportunity. The objective of this study is to characterize CHD patients at increased risk of receiving antimicrobials, including not indicated antimicrobials. METHODS: We conducted a prospective cohort study over a 12-month period among patients receiving CHD in 2 outpatient dialysis units. Each parenteral antimicrobial dose administered was characterized as indicated or not indicated based on national guidelines. Patient factors associated with receipt of antimicrobials and receipt of ≥1 inappropriate antimicrobial dose were analyzed. RESULTS: A total of 89 of 278 CHD patients (32%) received ≥1 antimicrobial doses and 52 (58%) received ≥1 inappropriately indicated dose. Patients with tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving CHD sessions during daytime shifts were more likely to receive antimicrobials (odds ratio [OR], 5.16; 95% confidence interval [CI], 2.72-9.80; OR, 5.43; 95% CI, 1.84-16.06; OR, 4.59; 95% CI, 1.20-17.52, respectively). Patients with tunneled catheter access, receiving CHD at dialysis unit B, and with a longer duration of CHD prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose (incidence rate ratio, 2.23; 95% CI, 1.16-4.29; incidence rate ratio, 2.67; 95% CI, 1.34-5.35; incidence rate ratio, 1.11; 95% CI, 1.01-1.23, respectively). CONCLUSIONS: This study of all types of antimicrobials administered in 2 outpatient dialysis units identified several important factors to consider when developing antimicrobial stewardship programs in this health care setting. |
Adverse drug reactions causing admission to medical wards: A cross-sectional survey at 4 hospitals in South Africa
Mouton JP , Njuguna C , Kramer N , Stewart A , Mehta U , Blockman M , Fortuin-De Smidt M , De Waal R , Parrish AG , Wilson DP , Igumbor EU , Aynalem G , Dheda M , Maartens G , Cohen K . Medicine (Baltimore) 2016 95 (19) e3437 Limited data exist on the burden of serious adverse drug reactions (ADRs) in sub-Saharan Africa, which has high HIV and tuberculosis prevalence. We determined the proportion of adult admissions attributable to ADRs at 4 hospitals in South Africa. We characterized drugs implicated in, risk factors for, and the preventability of ADR-related admissions.We prospectively followed patients admitted to 4 hospitals' medical wards over sequential 30-day periods in 2013 and identified suspected ADRs with the aid of a trigger tool. A multidisciplinary team performed causality, preventability, and severity assessment using published criteria. We categorized an admission as ADR-related if the ADR was the primary reason for admission.There were 1951 admissions involving 1904 patients: median age was 50 years (interquartile range 34-65), 1057 of 1904 (56%) were female, 559 of 1904 (29%) were HIV-infected, and 183 of 1904 (10%) were on antituberculosis therapy (ATT). There were 164 of 1951 (8.4%) ADR-related admissions. After adjustment for age and ATT, ADR-related admission was independently associated (P ≤ 0.02) with female sex (adjusted odds ratio [aOR] 1.51, 95% confidence interval [95% CI] 1.06-2.14), increasing drug count (aOR 1.14 per additional drug, 95% CI 1.09-1.20), increasing comorbidity score (aOR 1.23 per additional point, 95% CI 1.07-1.41), and use of antiretroviral therapy (ART) if HIV-infected (aOR 1.92 compared with HIV-negative/unknown, 95% CI 1.17-3.14). The most common ADRs were renal impairment, hypoglycemia, liver injury, and hemorrhage. Tenofovir disoproxil fumarate, insulin, rifampicin, and warfarin were most commonly implicated, respectively, in these 4 ADRs. ART, ATT, and/or co-trimoxazole were implicated in 56 of 164 (34%) ADR-related admissions. Seventy-three of 164 (45%) ADRs were assessed as preventable.In our survey, approximately 1 in 12 admissions was because of an ADR. The range of ADRs and implicated drugs reflect South Africa's high HIV and tuberculosis burden. Identification and management of these ADRs should be considered in HIV and tuberculosis care and treatment programs and should be emphasized in health care worker training programmes. |
Announcing the CDC guideline for prescribing opioids for chronic pain
Houry D , Baldwin G . J Safety Res 2016 57 83-4 This guideline provides recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses: (a) when to initiate or continue opioids for chronic pain; (b) opioid selection, dosage, duration, follow-up, and discontinuation; and (c) assessing risk and addressing harms of opioid use. This guideline is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including abuse, dependence, overdose, and death. |
Use of temperature sensors to determine exclusivity of improved stove use and associated household air pollution reductions in Kenya
Lozier MJ , Sircar K , Christensen B , Pillarisetti A , Pennise D , Bruce N , Stanistreet D , Naeher L , Pilishvili T , Farrar JL , Sage M , Nyagol R , Muoki J , Wofchuck T , Yip F . Environ Sci Technol 2016 50 (8) 4564-71 Household air pollution (HAP) contributes to 3.5-4 million annual deaths globally. Recent interventions using improved cookstoves (ICS) to reduce HAP have incorporated temperature sensors as stove use monitors (SUMs) to assess stove use. We deployed SUMs in an effectiveness study of 6 ICSs in 45 Kenyan rural homes. Stove were installed sequentially for 2 weeks and kitchen air monitoring was conducted for 48 h during each 2-week period. We placed SUMs on the ICSs and traditional cookstoves (TCS), and the continuous temperature data were analyzed using an algorithm to examine the number of cooking events, days of exclusive use of ICS, and how stove use patterns affect HAP. Stacking, defined as using both a TCS and an ICS in the same day, occurred on 40% of the study days, and exclusive use of the ICS occurred on 25% of study days. When researchers were not present, ICS use declined, which can have implications for long-term stove adoption in these communities. Continued use of TCSs was also associated with higher HAP levels. SUMs are a valuable tool for characterizing stove use and provide additional information to interpret HAP levels measured during ICS intervention studies. |
Bisphenol A and adiposity in an inner-city birth cohort
Hoepner LA , Whyatt RM , Widen EM , Hassoun A , Oberfield SE , Mueller NT , Diaz D , Calafat AM , Perera FP , Rundle AG . Environ Health Perspect 2016 124 (10) 1644-1650 BACKGROUND: Early life exposure to the endocrine disruptor bisphenol A (BPA) may contribute to development of obesity. Prospective evidence in humans on this topic is limited. OBJECTIVES: We examined prenatal and early childhood BPA exposures in relation to childhood measures of adiposity in the Columbia Center for Children's Environmental Health (CCCEH) New York City birth cohort. METHODS: BPA concentrations were measured in prenatal (n=375) and child ages 3 (n=408) and 5 years (n=518) spot urine samples. Childhood anthropometric and bioelectrical impedance outcomes included body mass index z-scores (BMIZ) at 5 and 7 years, and fat mass index (FMI), percent body fat (%BF), and waist circumference (WC) at 7 years. Associations were evaluated using multiple linear regression with continuous and tertile BPA concentrations. RESULTS: Prenatal urinary BPA concentrations were positively associated with child age 7 FMI (beta=0.31 kg/m2, p-value=0.04, [95%CI 0.01, 0.60]), %BF (beta=0.79, p-value=0.04, [95%CI 0.03, 1.55]), and WC (beta=1.29 cm, p-value=0.01, [95%CI 0.29, 2.30]), but not BMIZ, or change in BMIZ between ages 5 and 7 years (all p-values > 0.1). FMI results were sex-specific. Child urinary BPA concentrations were not associated with child anthropometric outcomes (all p-values > 0.05). CONCLUSIONS: Analyses of the CCCEH longitudinal birth cohort found associations between prenatal urinary BPA concentrations and FMI, %BF and WC. Our results suggest that prenatal BPA exposure may contribute to developmental origins of adiposity. These findings are consistent with several prior studies, raising concern about the pervasiveness of BPA. |
Self-reported herpes zoster, pain, and health care seeking in the Health and Retirement Study: Implications for interpretation of health care-based studies
Hales CM , Harpaz R , Bialek SR . Ann Epidemiol 2016 26 (6) 441-446 e3 PURPOSE: To describe self-reported herpes zoster (HZ) and explore factors that could impact interpretation of results from health care-based HZ studies. METHODS: We performed logistic regression using data from the 2008 Health and Retirement Study (HRS) to evaluate risk factors for having a history of HZ and experiencing severe HZ pain, and predictors for seeking health care for HZ. RESULTS: Among 14,564 respondents aged ≥55 years, women were more likely than men to report a history of HZ (15.7% vs. 11.6%, P < .01). Blacks (6.4% vs. 14.7% in whites, P < .01) and respondents with less than a high school diploma (12.2% vs.14.2% in respondents with at least a high school diploma, P = .01) were less likely to report a history of HZ. Women, blacks, Hispanics, and those with less than a high school diploma were more likely to report severe HZ pain. Most (91.1%) respondents sought health care for HZ; Hispanics (64.2% vs. 92.1% in whites, P < .001) and those with recurrent HZ were less likely to seek health care for HZ, whereas those with severe pain were more likely (95.4% vs. 87.9% in those without severe pain, P < .01). CONCLUSIONS: HRS provides a new platform for studies of HZ, one which allowed us to uncover issues that warrant particular attention when interpreting results of health care-based studies. |
Trends in mortality disparities by area-based poverty in New York City, 1990-2010
Toprani A , Li W , Hadler JL . J Urban Health 2016 93 (3) 538-50 Residing in a high-poverty area has consistently been associated with higher mortality rates, but the association between poverty and mortality can change over time. We examine the association between neighborhood poverty and mortality in New York City (NYC) during 1990-2010 to document mortality disparity changes over time and determine causes of death for which disparities are greatest. We used NYC and New York state mortality data for years 1990, 2000, and 2010 to calculate all-cause and cause-specific age-adjusted death rates (AADRs) by census tract poverty (CTP), which is the proportion of persons in a census tract living below the federal poverty threshold. We calculated mortality disparities, measured as the difference in AADR between the lowest and highest CTP groups, within and across race/ethnicity, nativity, and sex categories by year. We observed higher all-cause AADRs with higher CTP for each year for all race/ethnicities, both sexes, and US-born persons. Mortality disparities decreased progressively during 1990-2010 for the NYC population overall, for each race/ethnic group, and for the majority of causes of death. The overall mortality disparity between the highest and lowest CTP groups during 2010 was 2.55 deaths/1000 population. The largest contributors to mortality disparities were heart disease (51.52 deaths/100,000 population), human immunodeficiency virus (19.96/100,000 population), and diabetes (19.59/100,000 population). We show that progress was made in narrowing socioeconomic disparities in mortality during 1990-2010, but substantial disparities remain. Future efforts toward achieving health equity in NYC mortality should focus on areas contributing most to disparities. |
Enhanced genetic characterization of influenza A(H3N2) viruses and vaccine effectiveness by genetic group, 2014-2015.
Flannery B , Zimmerman RK , Gubareva LV , Garten RJ , Chung JR , Nowalk MP , Jackson ML , Jackson LA , Monto AS , Ohmit SE , Belongia EA , McLean HQ , Gaglani M , Piedra PA , Mishin VP , Chesnokov AP , Spencer S , Thaker SN , Barnes JR , Foust A , Sessions W , Xu X , Katz J , Fry AM . J Infect Dis 2016 214 (7) 1010-9 BACKGROUND: During the 2014-15 US influenza season, expanded genetic characterization of circulating influenza A(H3N2) viruses was used to assess the impact of genetic variability of influenza A(H3N2) viruses on influenza vaccine effectiveness (VE). METHODS: A novel pyrosequencing assay was used to determine genetic group based on hemagglutinin (HA) gene sequences of influenza A(H3N2) viruses from patients enrolled US Flu Vaccine Effectiveness network sites. Vaccine effectiveness was estimated using a test-negative design comparing vaccination among patients infected with influenza A(H3N2) viruses and uninfected patients. RESULTS: Among 9710 enrollees, 1868 (19%) tested positive for influenza A(H3N2); genetic characterization of 1397 viruses showed 1134 (81%) belonged to one HA genetic group (3C.2a) of antigenically drifted H3N2 viruses. Effectiveness of 2014-15 influenza vaccination varied by A(H3N2) genetic group from 1% (95% confidence interval [CI], -14% to 14%) against illness caused by antigenically drifted A(H3N2) group 3C.2a viruses versus 44% (95% CI, 16% to 63%) against illness caused by vaccine-like A(H3N2) group 3C.3b viruses. CONCLUSION: Effectiveness of 2014-15 influenza vaccination varied by genetic group of influenza A(H3N2) virus. Changes in hemagglutinin genes related to antigenic drift were associated with reduced vaccine effectiveness. |
A qualitative comparison of susceptibility and behavior in recreational and occupational risk environments: Implications for promoting health and safety
Haas EJ , Mattson M . J Health Commun 2016 21 (6) 1-9 Although internal factors that influence risk are frequently studied to understand human behavior, external factors, including social, cultural, and institutional factors, should be better utilized to inform ways to efficiently target, tailor, and promote safety messaging to at-risk populations. Semi-structured interviews obtained data from 37 motorcyclists and 18 mineworkers about their risk perceptions and behaviors within their respective dynamic environments. A comparative thematic analysis revealed information about external factors that influence risk perceptions and behaviors. Results support the importance of qualitative approaches for assessing and targeting individuals' risk perceptions and behaviors. In addition, segmenting at-risk subgroups within target populations and tailoring messages for these at-risk groups is critical for safety behavior modification. Practitioners should utilize strategic, culture-centric risk communication that takes into account external factors when determining when, who, and what to communicate via health promotion activities to more accurately disseminate valid, empathetic, and engaging communication with a higher level of fidelity. |
Notes from the field: Probable mucormycosis among adult solid organ transplant recipients at an acute care hospital - Pennsylvania, 2014-2015
Novosad SA , Vasquez AM , Nambiar A , Arduino MJ , Christensen E , Moulton-Meissner H , Keckler MS , Miller J , Perz JF , Lockhart SR , Chiller T , Gould C , Sehulster L , Brandt ME , Weber JT , Halpin AL , Mody RK . MMWR Morb Mortal Wkly Rep 2016 65 (18) 481-2 On September 17, 2015, the Pennsylvania Department of Health (PADOH) notified CDC of a cluster of three potentially health care-associated mucormycete infections that occurred among solid organ transplant recipients during a 12-month period at hospital A. On September 18, hospital B reported that it had identified an additional transplant recipient with mucormycosis. Hospitals A and B are part of the same health care system and are connected by a pedestrian bridge. PADOH requested CDC's assistance with an on-site investigation, which started on September 22, to identify possible sources of infection and prevent additional infections. |
Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration 2016 Case #1
Hebden JN , Leaptrot D , Anttila A , Allen-Bridson K , Brooks JE , Gross C , Scalise E , Wright MO . Am J Infect Control 2016 44 (7) 761-3 This is the first case study published in a series in the American Journal of Infection Control (AJIC) since the Centers for Disease Control and Prevention/ National Healthcare Safety Network (NHSN) surveillance definition update of 2016. These cases represent some of the complex patient scenarios IPs have encountered in their daily surveillance of healthcare-associated infections (HAI) using NHSN procedural approach and definitions. Case study objectives have been previously published. (1) | With each case, a link to an online survey is provided, where you may enter answers to questions and receive immediate feedback in the form of correct answers and explanations. All individual participant answers will remain confidential, although it is the authors' intention to share a summary of the survey responses at a later date. Cases, answers, and explanations have been reviewed and approved by NHSN staff. We hope that you will take advantage of this offering, and we look forward to your active participation. |
Real-world effectiveness of pentavalent rotavirus vaccine among Bedouin and Jewish children in southern Israel
Leshem E , Givon-Lavi N , Tate JE , Greenberg D , Parashar UD , Dagan R . Clin Infect Dis 2016 62 Suppl 2 S155-60 BACKGROUND: Pentavalent rotavirus vaccine (RV5) was introduced into the Israeli National Immunization Program in January 2011. We determined RV5 vaccine effectiveness (VE) in southern Israel, a region characterized by 2 distinct populations: Bedouins living in a low- to middle-income, semirural setting, and Jews living in a high-income, urban setting. METHODS: We enrolled vaccine-eligible children who visited the emergency department (ED) or were hospitalized due to acute gastroenteritis (AGE) during the first 3 rotavirus seasons after RV5 vaccine introduction (2011-2013). Fecal specimens were tested for rotavirus by enzyme immunoassay and genotyped. Vaccination among laboratory-confirmed rotavirus cases was compared with rotavirus-negative AGE controls. Regression models were used to calculate VE estimates by age, clinical setting, and ethnicity. RESULTS: Of 515 enrolled patients, 359 (70%) were Bedouin. Overall, 185 (36%) patients were rotavirus positive; 79 of 119 (66%) were G1P[8] genotype. The adjusted VE for a full 3-dose course of RV5 against ED visit or hospitalization was 63% (95% confidence interval [CI], 38%-78%). RV5 provided G1P[8] genotype-specific effectiveness of 78% (95% CI, 58%-88%). By age, RV5 VE was 64% (95% CI, 21%-84%) and 71% (95% CI, 39%-86%) among children aged 6-11 months and 12-23 months, respectively. By clinical setting, RV5 VE was 59% (95% CI, 23%-78%) against hospitalization, and 67% (95% CI, 11%-88%) against ED visit. The adjusted VE of a full RV5 course among Bedouin children was 62% (95% CI, 29%-79%). CONCLUSIONS: RV5 significantly protected against rotavirus-associated ED visits and hospitalizations in a diverse population of vaccine-eligible children living in southern Israel. |
Reduced serologic sensitivity to influenza A virus illness among inactivated influenza vaccinees
Thompson MG , Gaglani MJ , Naleway AL , Dowell SH , Spencer S , Ball S , Levine M , Fry A . Vaccine 2016 34 (30) 3443-6 We compared ≥4-fold increases in antibody titers by hemagglutination inhibition assay to RT-PCR results among 42 adults with PCR-confirmed influenza A virus illnesses. Serologic sensitivity was higher among unvaccinated (69%, 95% confidence interval [CI]=48-90%) than vaccinated healthcare personnel (38%, 95% CI=29-46%) in a 2010-11 prospective cohort. |
Rubella immunity among pregnant women aged 15-44 years, Namibia, 2010
Jonas A , Cardemil CV , Beukes A , Anderson R , Rota PA , Bankamp B , Gary HE Jr , Sawadogo S , Patel SV , Zeko S , Muroua C , Gaeb E , Wannemuehler K , Gerber S , Goodson JL . Int J Infect Dis 2016 49 196-201 BACKGROUND: The level of rubella susceptibility among women of reproductive age in Namibia is unknown. Documenting the risk of rubella will help estimate the potential burden of disease in Namibian women and the risk of congenital rubella syndrome (CRS) in offspring, and will guide strategies for rubella vaccine introduction. METHODS: We tested 2,044 specimens from pregnant Namibian women aged 15-44 years sampled from the 2010 National HIV Sentinel Survey for rubella immunoglobulin G antibody. We determined the proportion of women seropositive for rubella by 5-year age strata and analyzed factors associated with seropositivity, including age, gravidity, HIV status, facility type, and urban/rural status, by logistic regression. RESULTS: Overall rubella seroprevalence (95% Confidence Interval [CI]) was 85% (95%CI 83%-86%). Seroprevalence varied by age group (83%-90%) and health district (71%-100%). In the multivariable model, women from urban residences had higher odds of seropositivity as compared to women from rural residences (OR 1.40; 95%CI 1.09-1.81). CONCLUSIONS: In the absence of a routine rubella immunization program, the high level of rubella seropositivity suggests rubella virus transmission in Namibia, yet 15% of pregnant Namibian women remain susceptible to rubella. Introduction of rubella vaccine will help reduce the risk of rubella in pregnant women and CRS in infants. |
Sustained reduction of childhood diarrhea-related mortality and hospitalizations in Mexico after rotavirus vaccine universalization
Sanchez-Uribe E , Esparza-Aguilar M , Parashar UD , Richardson V . Clin Infect Dis 2016 62 Suppl 2 S133-9 BACKGROUND: Mexico implemented routine childhood vaccination against rotavirus in 2007. We describe trends in hospitalization and deaths from diarrhea among children aged <5 years in Mexico before and 7 years after implementation of rotavirus vaccination. METHODS: We obtained data on deaths and hospitalizations from diarrhea, from January 2003 through December 2014, in Mexican children <5 years of age. We compared diarrhea-related mortality and hospitalizations in the postvaccine era with the prevaccine baseline from 2003 to 2006. RESULTS: Compared with the prevaccine baseline, we observed a 53% reduction (95% confidence interval [CI], 47%-58%) in diarrhea-related mortality and a 47% reduction (95% CI, 45%-48%) in diarrhea-related hospitalizations in postvaccine years, translating to 959 deaths and 5831 hospitalizations averted every year in Mexican children aged <5 years. Prevaccine peaks in diarrhea-related mortality and hospitalizations during the rotavirus season months were considerably diminished in postvaccine years, with greater declines observed during the rotavirus season compared with non-rotavirus season months. CONCLUSIONS: We document a substantial and sustained decline in diarrhea-related hospitalizations and deaths in Mexican children associated with implementation of rotavirus vaccination. These results highlight the public health benefits that could result in countries that adopt rotavirus vaccination into their national immunization programs. |
Temporal association of rotavirus vaccine introduction and reduction in all-cause childhood diarrheal hospitalizations in South Africa
Groome MJ , Zell ER , Solomon F , Nzenze S , Parashar UD , Izu A , Madhi SA . Clin Infect Dis 2016 62 Suppl 2 S188-95 BACKGROUND: The public health impact of rotavirus vaccination in African settings with a high human immunodeficiency virus (HIV) infection prevalence is yet to be established. We evaluated trends in all-cause diarrheal hospitalizations in Soweto, Johannesburg, before and after the introduction of rotavirus vaccine into South Africa's national immunization program in August 2009. METHODS: Hospitalizations in children <5 years of age with a diagnosis of diarrhea, defined byInternational Classification of Diseases, Tenth Revisioncodes A00-A05, A06.0-A06.3, A06.9, A07.0-A07.2, A07.9, and A08-A09, were identified at the Chris Hani Baragwanath Academic Hospital from 1 January 2006 to 31 December 2014. The median annual prevaccine (2006-2008) hospitalization incidence was compared to that of the vaccine era (2010-2014), and stratified by age group and HIV infection status. RESULTS: Incidence reductions (per 1000 population) were greatest in children aged <12 months: 54.4 in the prevaccine era vs 30.0, 23.6, 20.0, 18.8, and 18.9 in the postvaccine years 2010-2014, respectively (a 44.9%-65.4% reduction). Lower incidence reductions (39.8%-49.4%) were observed among children aged 12-24 months from the second year post-vaccine introduction onward. Reductions were observed in both HIV-infected and HIV-uninfected children. There was a change in the seasonal pattern of diarrheal hospitalizations post-vaccine introduction, with flattening of the autumn-winter peaks seen in the prevaccine years. CONCLUSIONS: An accelerated and sustained decline in all-cause diarrheal hospitalizations, temporally associated with rotavirus vaccine introduction, was observed in children <2 years of age. However, the impact of other interventions such as improved sanitation and changes in HIV management cannot be discounted. |
Measles outbreak associated with low vaccine effectiveness among adults in Pohnpei State, Federated States of Micronesia, 2014
Hales CM , Johnson E , Helgenberger L , Papania MJ , Larzelere M , Gopalani SV , Lebo E , Wallace G , Moturi E , Hickman CJ , Rota PA , Alexander HS , Marin M . Open Forum Infect Dis 2016 3 (2) ofw064 Background. A measles outbreak in Pohnpei State, Federated States of Micronesia in 2014 affected many persons who had received ≥1 dose of measles-containing vaccine (MCV). A mass vaccination campaign targeted persons aged 6 months to 49 years, regardless of prior vaccination. Methods. We evaluated vaccine effectiveness (VE) of MCV by comparing secondary attack rates among vaccinated and unvaccinated contacts after household exposure to measles. Results. Among 318 contacts, VE for precampaign MCV was 23.1% (95% confidence interval [CI], -425 to 87.3) for 1 dose, 63.4% (95% CI, -103 to 90.6) for 2 doses, and 95.9% (95% CI, 45.0 to 100) for 3 doses. Vaccine effectiveness was 78.7% (95% CI, 10.1 to 97.7) for campaign doses received ≥5 days before rash onset in the primary case and 50.4% (95% CI, -52.1 to 87.9) for doses received 4 days before to 3 days after rash onset in the primary case. Vaccine effectiveness for most recent doses received before 2010 ranged from 51% to 57%, but it increased to 84% for second doses received in 2010 or later. Conclusions. Low VE was a major source of measles susceptibility in this outbreak; potential reasons include historical cold chain inadequacies or waning of immunity. Vaccine effectiveness of campaign doses supports rapid implementation of vaccination campaigns in outbreak settings. |
A preliminary assessment of rotavirus vaccine effectiveness in Zambia
Beres LK , Tate JE , Njobvu L , Chibwe B , Rudd C , Guffey MB , Stringer JS , Parashar UD , Chilengi R . Clin Infect Dis 2016 62 Suppl 2 S175-82 BACKGROUND: Diarrhea is the third leading cause of child death in Zambia. Up to one-third of diarrhea cases resulting in hospitalization and/or death are caused by vaccine-preventable rotavirus. In January 2012, Zambia initiated a pilot introduction of the Rotarix live, oral rotavirus vaccine in all public health facilities in Lusaka Province. METHODS: Between July 2012 and October 2013, we conducted a case-control study at 6 public sector sites to estimate rotavirus vaccine effectiveness (VE) in age-eligible children presenting with diarrhea. We computed the odds of having received at least 1 dose of Rotarix among children whose stool was positive for rotavirus antigen (cases) and children whose stool was negative (controls). We adjusted the resulting odds ratio (OR) for patient age, calendar month of presentation, and clinical site, and expressed VE as (1 - adjusted OR) x 100. RESULTS: A total of 91 rotavirus-positive cases and 298 rotavirus-negative controls who had under-5 card-confirmed vaccination status and were ≥6 months of age were included in the case-control analysis. Among rotavirus-positive children who were age-eligible to be vaccinated, 20% were hospitalized. Against rotavirus diarrhea of all severity, the adjusted 2-dose VE was 26% (95% confidence interval [CI], -30% to 58%) among children ≥6 months of age. VE against hospitalized children ≥6 months of age was 56% (95% CI, -34% to 86%). CONCLUSIONS: We observed a higher point estimate for VE against increased severity of illness compared with milder disease, but were not powered to detect a low level of VE against milder disease. |
Early evidence of impact of monovalent rotavirus vaccine in Togo
Tsolenyanu E , Mwenda JM , Dagnra A , Leshem E , Godonou M , Nassoury I , Landoh D , Tate JE , Atakouma Y , Parashar UD . Clin Infect Dis 2016 62 Suppl 2 S196-9 Togo introduced monovalent rotavirus vaccine starting 19 June 2014. We compared all-cause acute gastroenteritis (AGE) hospitalizations and rotavirus-associated hospitalizations during the prevaccine period (July 2008-June 2014) to 1 year after vaccine introduction (July 2014-June 2015). The proportion of children with AGE who tested positive for rotavirus declined from 53% (645/1223) in prevaccine years to 36% (68/187) in the postvaccine year (P< .01). The decline only occurred in children <1 year of age who were eligible for vaccination and was greatest during the rotavirus season months, supporting that it was associated with vaccine implementation. |
Impact and effectiveness of monovalent rotavirus vaccine against severe rotavirus diarrhea in Ghana
Armah G , Pringle K , Enweronu-Laryea CC , Ansong D , Mwenda JM , Diamenu SK , Narh C , Lartey B , Binka F , Grytdal S , Patel M , Parashar U , Lopman B . Clin Infect Dis 2016 62 Suppl 2 S200-7 BACKGROUND: Ghana was among the first African nations to introduce monovalent rotavirus vaccine (RV1) into its childhood immunization schedule in April 2012. We aimed to assess the impact of vaccine introduction on rotavirus and acute gastroenteritis (AGE) hospitalizations and to estimate vaccine effectiveness (VE). METHODS: Using data from 2 teaching hospitals, monthly AGE and rotavirus admissions by age were examined 40 months before and 31 months after RV1 introduction using interrupted time-series analyses. From January 2013, we enrolled children <2 years of age who were eligible for RV1 from a total of 7 sentinel sites across the country. To estimate VE, we fit unconditional logistic regression models to calculate odds ratios of vaccination by rotavirus case-patient status, controlling for potential confounders. RESULTS: Vaccine coverage ranged from 95% to 100% for dose 1 and 93% to 100% for dose 2. In the first 3 years after vaccine introduction, the percentage of hospital admissions positive for rotavirus fell from 48% in the prevaccine period to 28% (49% adjusted rate reduction; 95% confidence interval [CI], 32%-63%) postvaccination among <5-year-olds. With high vaccine coverage, it was not possible to arrive at robust VE estimates; any-dose VE against rotavirus hospitalization was estimated at 60% (95% CI, -2% to 84%;P= .056). CONCLUSIONS: Results from the first 3 years following RV1 introduction suggest substantial reductions of pediatric diarrheal disease as a result of vaccination. Our VE estimate is consistent with the observed rotavirus decrease and with efficacy estimates from elsewhere in sub-Saharan Africa. |
Impact of rotavirus vaccination on diarrheal hospitalizations in children aged <5 years in Lusaka, Zambia
Mpabalwani EM , Simwaka CJ , Mwenda JM , Mubanga CP , Monze M , Matapo B , Parashar UD , Tate JE . Clin Infect Dis 2016 62 Suppl 2 S183-7 BACKGROUND: Monovalent rotavirus vaccine was introduced in the routine public health immunization program in Lusaka, Zambia, in January 2012 and was rolled out countrywide in November 2013. We examined the effect of rotavirus vaccination on hospitalization for all-cause acute gastroenteritis (AGE) and rotavirus-specific AGE at a large referral hospital in Lusaka. METHODS: Data were derived from ongoing hospital-based AGE surveillance from January 2009 to December 2014. Pre-rotavirus vaccine introduction (2009-2011) and post-rotavirus vaccine introduction (2013-2014) periods were compared for annual changes in hospitalizations for AGE and rotavirus; 2012 was excluded as a transition year. Hospital administrative discharge data were used to compare trends in all-cause diarrhea discharges and in-hospital diarrhea deaths captured by HIMS pre- and post-rotavirus vaccine introduction. RESULTS: Between January 2009 and December 2014, 5937 children <5 years of age presenting with AGE had their stools collected and tested for rotavirus by enzyme immunoassay. The rotavirus positivity rate declined from 40.1% (449/1121) in prevaccine years to 30.2% (250/828;P< .001) in 2013 and 24.7% (157/635;P< .001) in 2014. The greatest reduction was noted in infants, with the rotavirus positivity rate in this age group declining from 40.9% in prevaccine years to 34.0% (P= .009) in 2013 and 26.2% (P< .001) in 2014. Following rotavirus vaccine introduction, seasonal peaks of rotavirus and all-cause AGE were dwarfed. From HIMS data, compared to the prevaccine era, reductions of 18%-29% in all-cause diarrhea hospitalizations and 27%-33% in-hospital diarrhea deaths among children <1 year of age were observed in 2013 and 2014. CONCLUSIONS: We observed a significant reduction in AGE-associated in-hospital morbidity and mortality following rotavirus vaccine introduction. The greatest reduction was seen in infants <1 year who accounted for 84.4% of rotavirus hospitalizations prior to vaccine introduction. |
Impact of rotavirus vaccination on hospitalizations and deaths from childhood gastroenteritis in Botswana
Enane LA , Gastanaduy PA , Goldfarb DM , Pernica JM , Mokomane M , Moorad B , Masole L , Tate JE , Parashar UD , Steenhoff AP . Clin Infect Dis 2016 62 Suppl 2 S168-74 BACKGROUND: A monovalent human rotavirus vaccine (RV1) was introduced in Botswana in July 2012. We assessed the impact of RV1 vaccination on childhood gastroenteritis-related hospitalizations and deaths in 2013 and 2014. METHODS: We obtained data from registers of 4 hospitals in Botswana on hospitalizations and deaths from gastroenteritis, regardless of cause, among children <5 years of age. Gastroenteritis hospitalizations and deaths during the prevaccine period (January 2009-December 2012) were compared to the postvaccine period (January 2013-December 2014). Vaccine coverage was estimated from data collected through a concurrent vaccine effectiveness study at the same hospitals. RESULTS: By December 2014, coverage with ≥1 dose of RV1 was an estimated 90% among infants <1 year of age and 76% among children 12-23 months of age. In the prevaccine period, the annual median number of gastroenteritis-related hospitalizations in children <5 years of age was 1212, and of gastroenteritis-related deaths in children <2 years of age was 77. In the postvaccine period, gastroenteritis-related hospitalizations decreased by 23% (95% confidence interval [CI], 16%-29%) to 937, and gastroenteritis-related deaths decreased by 22% (95% CI, -9% to 44%) to 60. Declines were most prominent during the rotavirus season (May-October) and among infants <1 year of age, with reductions of 43% (95% CI, 34%-51%) in gastroenteritis hospitalizations and 48% (95% CI, 11%-69%) in gastroenteritis deaths. CONCLUSIONS: Following introduction of RV1 into the national immunization program, significant declines in hospitalizations and deaths from gastroenteritis were observed among children in Botswana, suggestive of the beneficial public health impact of rotavirus vaccination. |
Boosting BCG-primed responses with a subunit Apa vaccine during the waning phase improves immunity and imparts protection against Mycobacterium tuberculosis
Nandakumar S , Kannanganat S , Dobos KM , Lucas M , Spencer JS , Amara RR , Plikaytis BB , Posey JE , Sable SB . Sci Rep 2016 6 25837 Heterologous prime-boosting has emerged as a powerful vaccination approach against tuberculosis. However, optimal timing to boost BCG-immunity using subunit vaccines remains unclear in clinical trials. Here, we followed the adhesin Apa-specific T-cell responses in BCG-primed mice and investigated its BCG-booster potential. The Apa-specific T-cell response peaked 32-52 weeks after parenteral or mucosal BCG-priming but waned significantly by 78 weeks. A subunit-Apa-boost during the contraction-phase of BCG-response had a greater effect on the magnitude and functional quality of specific cellular and humoral responses compared to a boost at the peak of BCG-response. The cellular response increased following mucosal BCG-prime-Apa-subunit-boost strategy compared to Apa-subunit-prime-BCG-boost approach. However, parenteral BCG-prime-Apa-subunit-boost by a homologous route was the most effective strategy in-terms of enhancing specific T-cell responses during waning in the lung and spleen. Two Apa-boosters markedly improved waning BCG-immunity and significantly reduced Mycobacterium tuberculosis burdens post-challenge. Our results highlight the challenges of optimization of prime-boost regimens in mice where BCG drives persistent immune-activation and suggest that boosting with a heterologous vaccine may be ideal once the specific persisting effector responses are contracted. Our results have important implications for design of prime-boost regimens against tuberculosis in humans. |
Commentary: Assessing the impact of temporally associated adverse events on neonatal hepatitis B vaccination
Wiesen E , Li X . Int J Epidemiol 2016 45 (2) 449-50 A loss of confidence in vaccine safety, due to rumours or coincidental adverse events after vaccination, is a major and ongoing issue that has resulted in many documented instances of under-vaccination potentially putting large numbers of people at risk of vaccine-preventable disease and death, as well as requiring costly outbreak response activities. 1,–4 Stringent regulatory standards to ensure the safety and quality of vaccines are essential to maintain public confidence in vaccines. Swift investigation, response and communication with the public are alsoimportant to prevent a loss in public confidence following reports of adverse events following immunization (AEFI). Hepatitis B vaccination at birth is particularly prone to association with coincidental deaths because infant mortality is highest during the early neonatal period. 5 | Diverse methods have been used to investigate the impact of reported AEFIs, including modelling the impact on disease, 4 in-depth qualitative studies 6 and monitoring vaccination coverage. The comprehensive approach taken by Yu et al.7 (and presented in this edition of the journal) warrants particular consideration in investigating the impact of similar incidents in the future. |
Contributions and challenges for worldwide vaccine safety: The Global Advisory Committee on Vaccine Safety at 15 years
Asturias EJ , Wharton M , Pless R , MacDonald NE , Chen RT , Andrews N , Salisbury D , Dodoo AN , Hartigan-Go K , Zuber PL . Vaccine 2016 34 (29) 3342-9 In 1999, the Global Advisory Committee on Vaccine Safety (GACVS) was established by the World Health Organization (WHO) to provide independent scientific advice on issues relating to the safety of vaccines and immunization. Fifteen years onward, we conducted a multi-faceted review to evaluate the impact, reach and challenges facing GACVS, including the role GACVS plays in informing global, regional and WHO member state vaccine policy. The methods included measures of organizational structure, citation impact, themes approached, and a discussion by previous and current members to evaluate past, present and future challenges. Given the increasing range of data sources and the deployment of many new vaccines, the Committee is facing the complex task of identifying the best available evidence for recommendations on vaccine safety. To help meet the increased demand for public transparency in decision making, GACVS-structured methodology for evidence-based decisions is evolving. GACVS also promotes best practices and capacity building for timely and accurate risk assessment; risk communications; outreach to help countries maintain and, if needed, rebuild public trust in vaccines; and advocacy for bridging the major gaps in vaccine safety capacity globally. |
Methods employed in monitoring and evaluating field and laboratory systems in the ANISA study: Ensuring quality
Connor NE , Islam MS , Arvay ML , Baqui AH , Zaidi AK , Soofi SB , Panigrahi P , Bose A , Islam M , Arifeen SE , Saha SK , Qazi SA . Pediatr Infect Dis J 2016 35 S39-44 BACKGROUND: The Aetiology of Neonatal Infection in South Asia (ANISA) study maintains operations in Bangladesh, India and Pakistan. We developed and deployed a multilayered monitoring system to measure performance indicators of field sites and laboratory operations. This system allows for real-time provision of feedback to study site teams and project stakeholders. The goal of this monitoring and evaluation system is to promote optimal performance and consistency in protocol application at all sites over the course of the study, thereby safeguarding the validity of project findings. This article describes each of the interdependent monitoring layers that were conceptualized, developed and employed by the ANISA coordination team. METHODS: Layers of monitoring include site-level, central and database-related activities along with periodic site visitation. We provide a number of real-world examples of how feedback from the ANISA monitoring system directly informs a number of crucial decisions and course corrections during the project. CONCLUSION: The ANISA monitoring system represents a transparent, understandable and practical resource for development of project monitoring systems in complex multisite health research projects. |
Development and implementation of the ANISA labeling and tracking system for biological specimens
Connor NE , Hossain T , Rahman QS , Islam MS , Islam M , Hossain B , McGee L , Diaz MH , Schrag SJ , Arifeen SE , Saha SK . Pediatr Infect Dis J 2016 35 S29-34 BACKGROUND: The Aetiology of Neonatal Infection in South Asia study is a major effort to determine the causes of community-acquired neonatal infections. It involves collecting epidemiological, clinical and laboratory data in 5 sites in 3 countries. The field and laboratory research operations are streamlined to maintain integrity and validity while operating in complex and variable environments. We developed a customized system for implementation of labeling and tracking biological specimen in both rural and urban community settings and integrated into all study laboratories. This report outlines the development and implementation of this harmonized system. DESIGN: The system links and tracks specimens with study participants and results generated from laboratory tests. Each biological specimen and its aliquots are tracked through key steps of the protocol, from collection and transport through molecular testing and long-term storage. CONCLUSION: The labeling and tracking system allows for standardization and monitoring of laboratory processes and improves the accuracy of Aetiology of Neonatal Infection in South Asia data. Community-based scientific projects could greatly benefit by adopting this, or a similar, system for specimen tracking and data linkage. |
MPTP Neurotoxicity is Highly Concordant Between the Sexes Among BXD Recombinant Inbred Mouse Strains.
Alam G , Miller DB , O'Callaghan JP , Lu L , Williams RW , Jones BC . Neurotoxicology 2016 55 40-47 Continuing our previous work in which we showed wide-ranging strain differences in MPTP neurotoxicity in male mice among ten BXD recombinant inbred strains, we replicated our work in females from nine of the same strains. Mice received a single s.c. injection of 12.5mg/kg MPTP or saline. Forty-eight hours later the striatum was dissected for neurochemical analysis. Striatal dopamine (DA) and its metabolites, DOPAC and HVA, striatal serotonin (5-HT) and its metabolite, 5-HIAA, were analyzed using HPLC. Tyrosine hydroxylase (TH) and glial fibrillary acidic protein (GFAP), an astrocytic protein that increases during the astroglial response to neural injury, were measured using ELISA. There were wide genetic variations in the DA, DOPAC, HVA, TH and GFAP responses to MPTP. We also performed principal component analysis (PCA) on the difference values, saline minus MPTP, for DA, DOPAC, HVA and TH and mapped the dominant principal component to a suggestive QTL on chromosome 1 at the same location that we observed previously for males. Moreover, there were significant correlations between the sexes for the effect of MPTP on DA, HVA, and TH. Our findings suggest that the systems genetic approach as utilized here can help researchers understand the role of sex in individual differences. The same approach can pave the way to understand and pinpoint the genetic bases for individual differences in pathology attributable to toxicants. Such systems genetics approach has broad implications for elucidating gene-environment contributions to neurodegenerative diseases. |
Self-collected genital swabs compared with cervicovaginal lavage for measuring HIV-1 and HSV-2 and the effect of acyclovir on viral shedding
McNicholl JM , Leelawiwat W , Whitehead S , Hanson DL , Evans-Strickfaden T , Cheng CY , Chonwattana W , Mueanpai F , Kittinunvorakoon C , Markowitz L , Dunne EF . Int J STD AIDS 2016 28 (4) 372-379 HIV-1 and HSV-2 are frequent genital co-infections in women. To determine how self-collected genital swabs compare to provider-collected cervicovaginal lavage, paired self-collected genital swabs and cervicovaginal lavage from women co-infected with HIV-1 and HSV-2 were evaluated. Women were in an acyclovir clinical trial and their samples were tested for HIV-1 RNA (361 samples) and HSV-2 DNA (378 samples). Virus shedding, quantity and acyclovir effect were compared. HIV-1 and HSV-2 were more frequently detected in self-collected genital swabs: 74.5% of self-collected genital swabs and 63.6% of cervicovaginal lavage had detectable HIV-1 (p ≤ 0.001, Fisher's exact test) and 29.7% of self-collected genital swabs and 19.3% of cervicovaginal lavage had detectable HSV-2 (p ≤ 0.001) in the placebo month. Cervicovaginal lavage and self-collected genital swabs virus levels were correlated (Spearman's rho, 0.68 for HIV; 0.61 for HSV-2) and self-collected genital swabs levels were generally higher. In multivariate modeling, self-collected genital swabs and cervicovaginal lavage could equally detect the virus-suppressive effect of acyclovir: for HIV-1, proportional odds ratios were 0.42 and 0.47 and for HSV-2, they were 0.10 and 0.03 for self-collected genital swabs and cervicovaginal lavage, respectively. Self-collected genital swabs should be considered for detection and measurement of HIV-1 and HSV-2 in clinical trials and other studies as they are a sensitive method to detect virus and can be collected in the home with frequent sampling. |
Laboratory methods for determining etiology of neonatal infection at population-based sites in South Asia: The ANISA study
Saha SK , Islam MS , Qureshi SM , Hossain B , Islam M , Zaidi AK , Modak JK , Al-Emran HM , Diaz MH , McGee L , Winchell JM . Pediatr Infect Dis J 2016 35 S16-22 BACKGROUND: The Aetiology of Neonatal Infection in South Asia (ANISA) study aims to determine the etiology of neonatal infections in 5 population-based sites in Bangladesh, India and Pakistan. METHODS: The main laboratory challenges in ANISA were selection and consistent implementation of laboratory methods at participating sites with varied infrastructure. The other specific challenges included (1) specimen collection and transport to designated study laboratories and timely processing in rural settings; (2) minimal or nonexistent laboratory facilities at the field sites; (3) obtaining sufficient volumes of blood from enrolled infants aged 0-59 days and (4) caregivers' concerns about collection of clinical specimens from young infants. An additional challenge was selecting an appropriate molecular platform from multiple available options, all with limited field validation, for use in determining infection in young infants. CONCLUSIONS: This article describes how the challenges of specimen collection, transport and processing and implementation of laboratory methods have been addressed in the ANISA study. It also describes the measures taken to improve detection of microorganisms causing young infant infections by enhancing the sensitivity of existing laboratory methods for pathogen detection. |
Maternal serum perfluoroalkyl substances during pregnancy and duration of breastfeeding
Romano ME , Xu Y , Calafat AM , Yolton K , Chen A , Webster GM , Eliot MN , Howard CR , Lanphear BP , Braun JM . Environ Res 2016 149 239-246 BACKGROUND: Perfluoroalkyl substances (PFAS) may affect breast development and decrease duration of breastfeeding, thus interfering with the health benefits of breastfeeding. We investigated the association between maternal PFAS exposure and breastfeeding duration. METHODS: We measured PFAS concentrations in maternal serum collected during pregnancy in 2003-2006. After delivery, women (n=336) completed standardized breastfeeding surveys every 3 months until ending breastfeeding or 36 months postpartum. We estimated relative risks (RRs) for ending any breastfeeding within 3-6 months postpartum by Poisson regression, adjusted for relevant confounding factors. RESULTS: Women in the 4th quartile of perfluorooctanoic acid (PFOA) serum concentration had 1.77 times the risk of ending any breastfeeding by 3 months (95% confidence interval (CI): 1.23, 2.54; p-trend=0.003) and 1.41 times the risk of ending any breastfeeding by 6 months (95%CI: 1.06, 1.87; p-trend=0.038), compared with women in the first quartile. Women in the 4th quartile of perfluorooctane sulfonic acid serum concentration had a marginally increased risk of discontinuing any breastfeeding by 3 months (RR=1.32; 95%CI: 0.97, 1.79; p-trend=0.065). CONCLUSIONS: Maternal serum PFOA concentrations were inversely related to duration of any breastfeeding in this cohort, even after controlling for prior breastfeeding. These findings suggest that PFOA exposure may adversely affect breastfeeding duration and highlight the need to consider the potential adverse effects of maternal environmental chemical exposure on breastfeeding. |
Oblitimonas alkaliphila gen. nov., sp. nov., a novel genus in the Pseudomonadaceae family recovered from a historical collection of previously unidentified clinical strains
Drobish AM , Emery BD , Whitney AM , Lauer AC , Metcalfe MG , McQuiston JR . Int J Syst Evol Microbiol 2016 66 (8) 3063-3070 Eight Gram-negative bacteria (B4199T, C6819, C6918, D2441, D3318, E1086, E1148 and E5571) were identified during a retrospective study of unidentified strains from a historical collection held in the Special Bacteriology Reference Laboratory at the Centers for Disease Control and Prevention. The strains were isolated from eight patients: five female, two male and one not specified. No ages were indicated for the patients. The sources were urine (3), leg tissue (2), foot wound, lung tissue and deep liver. The strains originated from seven different states across the United States of America (Colorado, Connecticut (2), Indiana, North Carolina, Oregon and Pennsylvania). The strains grew at 10 to 42 degrees C, were non-motile, alkalitolerant, slightly halophilic, microaerophilic, catalase and oxidase positive. The DNA G + C content was 47.3 to 47.8 mol%. The major cellular fatty acids were tetradecanoic acid (C14:0), hexadecanoic acid (C16:0) and 11-octadecenoic acid (C18:1omega7c). Polar lipids detected were phosphatidylglycerol (PG), phosphatidylethanolamine (PE), diphosphatidylglycerol (DPG) and an unknown phospholipid; the only respiratory quinone detected was the ubiquinone Q-9 (100 %). 16S rRNA gene sequence analysis produced results with 95.6 % similarity to Pseudomonas caeni (DSM 24390T) and 95.2 % similarity to Thiopseudomonas denitrificans (X2T). The results of the biochemical, chemotaxonomic and phylogenetic analyses between the study strains and some related type strains indicate that these strains represent a novel species of a new genus within the family Pseudomonadaceae, for which the name Oblitimonas alkaliphila gen. nov., sp. nov. is proposed. The type strain is B4199T (=DSM 100830T = CCUG 67636T). |
Effect of storage time and storage conditions on antibody detection in blood samples collected on filter paper
Bevins S , Pappert R , Young J , Schmit B , Kohler D , Baeten L . J Wildl Dis 2016 52 (3) 478-83 Using filter paper to collect blood from wildlife for antibody analysis can be a powerful technique to simplify the collection, transport, and storage of blood samples. Despite these advantages, there are limited data that detail how long these samples can be stored and how storage conditions affect antibody longevity. We used blood samples collected on filter paper from coyotes experimentally infected with Yersinia pestis to determine optimum sample storage conditions over time. Blood samples collected on filter paper were stored for 454 d or more in four groups: 1) at ambient temperature and at ambient relative humidity, 2) at ambient temperature with desiccant, 3) at 4 C with desiccant, and 4) at -20 C with desiccant. Samples stored at 4 C or -20 C with desiccant had detectable antibody for a longer period of time than the samples stored at room temperature. |
Evaluation of gowns and coveralls used by medical personnel working with ebola patients against simulated bodily fluids using an elbow lean test
Jaques PA , Gao P , Kilinc-Balci S , Portnoff L , Weible R , Horvatin M , Strauch A , Shaffer R . J Occup Environ Hyg 2016 13 (11) 1-37 Gowns and coveralls are important components of protective ensembles used during the management of known or suspected Ebola patients. In this study, an Elbow Lean Test was used to obtain a visual semi-quantitative measure of the resistance of medical protective garments to the penetration of two bodily fluid simulants. Tests were done on swatches of continuous and discontinuous regions of fabrics cut from five gowns and four coveralls at multiple elbow pressure levels (2 - 44 PSI). Swatches cut from the continuous regions of one gown and two coveralls did not have any strike-through. For discontinuous regions, only the same gown consistently resisted fluid strike-through. As hypothesized, with the exception of one garment, fluid strike-through increased with higher applied elbow pressure, was higher for lower fluid surface tension, and was higher for the discontinuous regions of the protective garments. |
Identifying risk factors for recent HIV infection in Kenya using a recent infection testing algorithm: Results from a nationally representative population-based survey
Kim AA , Parekh BS , Umuro M , Galgalo T , Bunnell R , Makokha E , Dobbs T , Murithi P , Muraguri N , De Cock KM , Mermin J . PLoS One 2016 11 (5) e0155498 INTRODUCTION: A recent infection testing algorithm (RITA) that can distinguish recent from long-standing HIV infection can be applied to nationally representative population-based surveys to characterize and identify risk factors for recent infection in a country. MATERIALS AND METHODS: We applied a RITA using the Limiting Antigen Avidity Enzyme Immunoassay (LAg) on stored HIV-positive samples from the 2007 Kenya AIDS Indicator Survey. The case definition for recent infection included testing recent on LAg and having no evidence of antiretroviral therapy use. Multivariate analysis was conducted to determine factors associated with recent and long-standing infection compared to HIV-uninfected persons. All estimates were weighted to adjust for sampling probability and nonresponse. RESULTS: Of 1,025 HIV-antibody-positive specimens, 64 (6.2%) met the case definition for recent infection and 961 (93.8%) met the case definition for long-standing infection. Compared to HIV-uninfected individuals, factors associated with higher adjusted odds of recent infection were living in Nairobi (adjusted odds ratio [AOR] 11.37; confidence interval [CI] 2.64-48.87) and Nyanza (AOR 4.55; CI 1.39-14.89) provinces compared to Western province; being widowed (AOR 8.04; CI 1.42-45.50) or currently married (AOR 6.42; CI 1.55-26.58) compared to being never married; having had ≥ 2 sexual partners in the last year (AOR 2.86; CI 1.51-5.41); not using a condom at last sex in the past year (AOR 1.61; CI 1.34-1.93); reporting a sexually transmitted infection (STI) diagnosis or symptoms of STI in the past year (AOR 1.97; CI 1.05-8.37); and being aged <30 years with: 1) HSV-2 infection (AOR 8.84; CI 2.62-29.85), 2) male genital ulcer disease (AOR 8.70; CI 2.36-32.08), or 3) lack of male circumcision (AOR 17.83; CI 2.19-144.90). Compared to HIV-uninfected persons, factors associated with higher adjusted odds of long-standing infection included living in Coast (AOR 1.55; CI 1.04-2.32) and Nyanza (AOR 2.33; CI 1.67-3.25) provinces compared to Western province; being separated/divorced (AOR 1.87; CI 1.16-3.01) or widowed (AOR 2.83; CI 1.78-4.45) compared to being never married; having ever used a condom (AOR 1.61; CI 1.34-1.93); and having a STI diagnosis or symptoms of STI in the past year (AOR 1.89; CI 1.20-2.97). Factors associated with lower adjusted odds of long-standing infection included using a condom at last sex in the past year (AOR 0.47; CI 0.36-0.61), having no HSV2-infection at aged <30 years (AOR 0.38; CI 0.20-0.75) or being an uncircumcised male aged <30 years (AOR 0.30; CI 0.15-0.61). CONCLUSION: We identified factors associated with increased risk of recent and longstanding HIV infection using a RITA applied to blood specimens collected in a nationally representative survey. Though some false-recent cases may have been present in our sample, the correlates of recent infection identified were epidemiologically and biologically plausible. These methods can be used as a model for other countries with similar epidemics to inform targeted combination prevention strategies aimed to drastically decrease new infections in the population. |
Classification of blood culture isolates into contaminants and pathogens on the basis of clinical and laboratory data
Hossain B , Weber MW , Hamer DH , Hibberd PL , Ahmed AS , Marzan M , Islam M , Connor NE , Islam MS , Zaidi AK , Baqui AH , Bhutta ZA , Qureshi SM , Rafiqullah I , McGee L , Saha SK . Pediatr Infect Dis J 2016 35 S52-4 The multisite community-based study, Aetiology of Neonatal Infection in South Asia (ANISA), uses blood culture as the gold standard for identifying the etiology of neonatal infection. Considering the importance of this age-old diagnostic tool and the risk of contamination, ANISA has employed rigorous measures to prevent contamination at all stages of blood collection, processing and culture. Because contamination may still occur, an independent expert group evaluates the routinely collected clinical and laboratory data to determine whether a blood culture isolate is a contaminant or a true pathogen. This article describes the methodology used by ANISA to determine whether a blood culture isolate is likely to be a true pathogen or a contaminant in neonatal sepsis. |
School factors associated with the percentage of students who walk or bike to school, school health policies and practices study, 2014
Everett Jones S , Sliwa S . Prev Chronic Dis 2016 13 E63 INTRODUCTION: Active school transport, such as by walking or biking, increases physical activity levels, which has health and academic benefits for children. We examined school demographic and other characteristics to determine their association with the percentage of students who walk or bike to school. METHODS: We analyzed data from the Centers for Disease Control and Prevention's 2014 School Health Policies and Practices Study. The response rate for the module containing questions about transportation was 70% (N = 577). Multivariate logistic regression models examined whether certain school characteristics were associated with a school having 26% or more of students who walk or bike to school in the morning on an average school day. RESULTS: In most (61.5%) schools, 10% or fewer students walked or biked to school in the morning on an average school day; in 22.7% of schools, 26% or more students did so. Although having crossing guards (adjusted odds ratio [AOR] = 3.3; 95% confidence interval [CI], 1.9-6.0), having bicycle racks (AOR = 2.7; 95% CI, 1.2-5.8), and providing promotional materials to students or families on walking or biking to school (AOR = 2.9; 95% CI, 1.7-5.1) were associated with having 26% or more students who walk or bike to school, only 47.7% of schools had crossing guards, 62.4% had bicycle racks, and 33.3% provided promotional materials. CONCLUSION: Several low-cost or no-cost strategies were associated with having 26% or more students who walked or biked to school, but these strategies are not commonly used in schools. |
Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011
Hwang SS , Smith RA , Barfield WD , Smith VC , McCormick MC , Williams MA . J Perinatol 2016 36 (9) 787-93 OBJECTIVE: Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants. STUDY DESIGN: We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants. RESULTS: Prevalence of SSP varied by GA: 27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P<0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants. CONCLUSIONS: All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP. |
Mapping geographic variation in infant mortality and related black-white disparities in the U.S
Rossen LM , Khan D , Schoendorf KC . Epidemiology 2016 27 (5) 690-6 BACKGROUND: In the U.S., black infants remain more than twice as likely as white infants to die in the first year of life. Prior studies of geographic variation in infant mortality disparities have been limited to large metropolitan areas where stable estimates of infant mortality rates by race can be determined, leaving much of the U.S. unexplored. METHODS: The objective of this analysis was to describe geographic variation in county-level racial disparities in infant mortality rates across the 48 contiguous U.S. states and District of Columbia using national linked birth and infant death period files (2004-2011). We implemented Bayesian shared component models in OpenBUGS, borrowing strength across both spatial units and racial groups. We mapped posterior estimates of mortality rates for black and white infants as well as relative and absolute disparities. RESULTS: Black infants had higher infant mortality rates than white infants in all counties, but there was geographic variation in the magnitude of both relative and absolute disparities. The mean difference between black and white rates was 5.9 per 1,000 (median: 5.8, interquartile range 5.2 to 6.6 per 1,000), while those for black infants were 2.2 times higher than for white infants (median: 2.1, interquartile range 1.9 to 2.3). One quarter of the county-level variation in rates for black infants was shared with white infants. CONCLUSIONS: Examining county-level variation in infant mortality rates among black and white infants and related racial disparities may inform efforts to redress inequities and reduce the burden of infant mortality in the U.S. |
Factors associated with the timeliness of postnatal surgical repair of spina bifida
Radcliff E , Cassell CH , Laditka SB , Thibadeau JK , Correia J , Grosse SD , Kirby RS . Childs Nerv Syst 2016 32 (8) 1479-87 PURPOSE: Clinical guidelines recommend repair of open spina bifida (SB) prenatally or within the first days of an infant's life. We examined maternal, infant, and health care system factors associated with time-to-repair among infants with postnatal repair. METHODS: This retrospective, statewide, population-based study examined infants with SB born in Florida 1998-2007, ascertained by the Florida Birth Defects Registry. We used procedure codes from hospital discharge records to identify the first recorded myelomeningocele repair (ICD-9 CM procedure code 03.52) among infants with birth hospitalizations. Using Poisson multivariable regression, we examined time-to-repair by hydrocephalus, SB type (isolated [no other coded major birth defect] versus non-isolated), and other selected factors. RESULTS: Of 199 infants with a recorded birth hospitalization and coded myelomeningocele repair, 87.9 % had hydrocephalus and 19.6 % had non-isolated SB. About 76.4 % of infants had repair by day 2 of life. In adjusted analyses, infants with hydrocephalus were more likely to have timely repair (adjusted prevalence ratio (aPR) = 1.48, 95 % confidence interval (CI) 1.02-2.14) than infants without hydrocephalus. SB type was not associated with repair timing. Infants born in lower level nursery care hospitals with were less likely to have timely repairs (aPR = 0.71, 95 % CI 0.52-0.98) than those born in higher level nursery care hospitals. CONCLUSIONS: Most infants with SB had surgical repair in the first 2 days of life. Lower level birth hospital nursery care was associated with later repairs. Prenatal diagnosis can facilitate planning for a birth hospital with higher level of nursery care, thus improving opportunities for timely repair. |
Aetiology of neonatal infection in South Asia (ANISA): An initiative to identify appropriate program priorities to save newborns
Saha SK , Arifeen SE , Schrag SJ . Pediatr Infect Dis J 2016 35 S6-8 The global commitment to reduce child mortality was further augmented in 2000 with the declaration of the millennium development goals (MDGs). Combined efforts by countries, United Nations organizations, donors, civil society, private sector organizations and child health researchers have led to remarkable success in reducing child mortality worldwide. The number of under-5 deaths has been reduced from 12.7 million in 1990 to 6.3 million in 2013, which translates to 17,000 fewer deaths per day in 2013 compared with 1990. The rate of reduction has accelerated over time: 4.0% per year between 2005 and 2013 compared with 1.2% between 1990 and 1995 (http://www.unicef.org/media/files/Levels_and_Trends_in_Child_Mortality_2014.pdf). | However, the story is not as gratifying when achievement is further categorized by region. This is specifically true for South Asia and sub-Saharan Africa. Most of the countries in these regions performed suboptimally, particularly in preventing neonatal deaths, leading to an increased share of under-5 deaths that occur in the newborn period. In South Asia, neonatal deaths accounted for 54% of all under-5 deaths in 2013, a 33% increase from 1990. These figures demonstrate the failure of many countries to achieve MDG4, and challenge our efforts to adhere to global commitments. Saving neonatal lives is not an isolated challenge; it is deeply embedded in the overall reduction of child mortality, the achievement of Sustainable Development Goal 3 (ensure healthy lives and promote well-being for all at all ages; https://sustainabledevelopment.un.org/topics) and making the “Every Woman Every Child” (http://www.everywomaneverychild.org/) initiative a reality. |
Clinical follow-up for Duchenne muscular dystrophy newborn sreening: A proposal
Kwon JM , Abdel-Hamid HZ , Al-Zaidy SA , Mendell JR , Kennedy A , Kinnett K , Cwik VA , Street N , Bolen J , Day JW , Connolly AM . Muscle Nerve 2016 54 (2) 186-91 New developments in the rapid diagnosis and treatment of boys with Duchenne muscular dystrophy (DMD) have led to growing enthusiasm for instituting DMD newborn screening (NBS) in the United States. Our group has been interested in developing clinical guidance to be implemented consistently in specialty care clinics (SCC) charged with the care of pre-symptomatically identified newborns referred after DMD-NBS. We reviewed the existing literature covering patient-centered clinical follow-up after NBS, educational material from public health and advocacy sites, and federal recommendations on effective newborn screening follow-up. We discussed the review as a group and added our own experience to develop materials suitable for initial parent and primary care provider education. These materials and a series of templates for subspecialist encounters could be used to provide consistent care across centers and serve as the basis for ongoing quality improvement. |
Mortality from neurodegenerative diseases in a cohort of US flight attendants
Pinkerton LE , Hein MJ , Grajewski B , Kamel F . Am J Ind Med 2016 59 (7) 532-7 BACKGROUND: Concern exists about the potential chronic neurological effects among aircrew of exposure to chemical contaminants from engine oil in aircraft cabin air. We evaluated mortality from neurodegenerative diseases among 11,311 former US flight attendants. METHODS: Vital status was ascertained through 2007, and life table analyses were conducted to obtain standardized mortality ratios (SMRs). RESULTS: Amyotrophic lateral sclerosis (ALS) mortality was over twice as high in the cohort as in the US general population, based on nine observed ALS deaths. There was no clear pattern in risk when SMRs for ALS were stratified by exposure duration. Mortality from other neurodegenerative diseases was not elevated. CONCLUSIONS: Our findings are limited due to small numbers of observed deaths and reliance on mortality data, but suggest that flight attendants may have an increased risk of ALS. Additional research is needed. |
Emission of particulate matter from a desktop three-dimensional (3D) printer
Yi J , LeBouf RF , Duling MG , Nurkiewicz T , Chen BT , Schwegler-Berry D , Virji MA , Stefaniak AB . J Toxicol Environ Health A 2016 79 (11) 1-13 Desktop three-dimensional (3D) printers are becoming commonplace in business offices, public libraries, university labs and classrooms, and even private homes; however, these settings are generally not designed for exposure control. Prior experience with a variety of office equipment devices such as laser printers that emit ultrafine particles (UFP) suggests the need to characterize 3D printer emissions to enable reliable risk assessment. The aim of this study was to examine factors that influence particulate emissions from 3D printers and characterize their physical properties to inform risk assessment. Emissions were evaluated in a 0.5-m3 chamber and in a small room (32.7 m3) using real-time instrumentation to measure particle number, size distribution, mass, and surface area. Factors evaluated included filament composition and color, as well as the manufacturer-provided printer emissions control technologies while printing an object. Filament type significantly influenced emissions, with acrylonitrile butadiene styrene (ABS) emitting larger particles than polylactic acid (PLA), which may have been the result of agglomeration. Geometric mean particle sizes and total particle (TP) number and mass emissions differed significantly among colors of a given filament type. Use of a cover on the printer reduced TP emissions by a factor of 2. Lung deposition calculations indicated a threefold higher PLA particle deposition in alveoli compared to ABS. Desktop 3D printers emit high levels of UFP, which are released into indoor environments where adequate ventilation may not be present to control emissions. Emissions in nonindustrial settings need to be reduced through the use of a hierarchy of controls, beginning with device design, followed by engineering controls (ventilation) and administrative controls such as choice of filament composition and color. |
Flame retardant contamination of firefighter personal protective clothing - a potential health risk for firefighters
Alexander BM , Baxter CS . J Occup Environ Hyg 2016 13 (9) 1-26 There is a high incidence of cardiovascular disease and certain cancers in firefighters that may be related to their occupational exposure to hazardous substances. Exposure may result from contaminated personal protective gear, as well as from direct exposure at fire scenes. This study characterized flame retardant contamination on firefighter personal protective clothing to assess exposure of firefighters to these chemicals. Samples from used and unused firefighter protective clothing, including gloves, hoods and a coat wristlet, were extracted with methylene chloride and analyzed by EPA method 8270D Specific Ion Method (SIM) for polybrominated diphenyl ethers (PBDEs). Until recently PBDEs were some of the most common flame retardant chemicals used in the US. Fifteen of the seventeen PBDEs for which analysis was performed were found on at least one clothing swatch. Every clothing sample, including an unused hood and all three layers of an unused glove, held a detectable concentration of at least one PBDE. These findings, along with previous research, suggest that firefighters are exposed to PBDE flame retardants at levels much higher than the general public. PBDEs are found widely dispersed in the environment and still persist in existing domestic materials such as clothing and furnishings. Firefighter exposure to flame retardants therefore merits further study. |
Plasmodium vivax malaria recurrence after radical treatment with chloroquine-primaquine standard regimen in Turbo, Colombia: Results from a prospective study.
Zuluaga-Idarraga L , Blair S , Akinyi Okoth S , Udhayakumar V , Marcet P , Escalante AA , Alexander N , Rojas C . Antimicrob Agents Chemother 2016 60 (8) 4610-9 BACKGROUND: Plasmodium vivax recurrences help maintain malaria transmission. They are caused by recrudescence, reinfection or relapse, which are not easily differentiated. METHODS: A longitudinal observational study took place in Turbo municipality, Colombia. Participants with uncomplicated P. vivax infection received supervised concomitantly treatment with chloroquine 25 mg/Kg and primaquine 0.25 mg/Kg/day for 14 days. Incidence of recurrence was assessed over 180 days. Samples were genotyped and origins of recurrences were established. RESULTS: 134 participants were enrolled between February 2012 and July 2013, and 87 were followed for 180 days in which 29 recurrences were detected. Cumulative incidence of first recurrence was 24.1% (21/87) (CI 95% 14.6 to 33.7) and 86% (18/21) of them occurred between days 51 and 110. High genetic diversity of P. vivax was found and 12.5% (16/128) of the infections were polyclonal. Among detected recurrences 93.1% were genotyped as genetically identical to the one from the previous episode and 65.5% (19/29) were classified as relapses. CONCLUSION: Our results indicate that there is a high incidence of P. vivax malaria recurrence after treatment in Turbo municipality, Colombia, a large majority of which are likely relapses from the previous infection. We attribute this to the primaquine regimen currently used in Colombia, which may be insufficient to eliminate hypnozoites. |
Rethinking dosing regimen selection of piperaquine for malaria chemoprevention: A simulation study
Sambol NC , Tappero JW , Arinaitwe E , Parikh S . PLoS One 2016 11 (5) e0154623 BACKGROUND: The combination of short-acting dihydroartemisinin and long-acting piperaquine (DP) is among the first-line therapies for the treatment of uncomplicated Plasmodium falciparum malaria. Population pharmacokinetic models of piperaquine (PQ) based on data from acute treatment of young children can be used to predict exposure profiles of piperaquine under different DP chemoprevention regimens. The purpose of our study was to make such predictions in young children. METHODS: Based on a prior population pharmacokinetic model of PQ in young Ugandan children, we simulated capillary plasma concentration-time profiles (including their variability) of candidate chemoprevention regimens for a reference population of 1-2 year olds weighing at least 11 kg. Candidate regimens that were tested included monthly administration of standard therapeutic doses, bimonthly dosing, and weekly dosing (with and without a loading dose). RESULTS: Once daily doses of 320 mg for three days (960 mg total) at the beginning of each month are predicted to achieve an average steady-state trough capillary piperaquine concentration of 35 ng/mL, with 60% achieving a level of 30 ng/mL or higher. In contrast, weekly dosing of 320 mg (i.e., 33% higher amount per month) is predicted to approximately double the average steady-state trough concentration, increase the percent of children predicted to achieve 30 ng/mL or higher (94%), while at the same time lowering peak concentrations. Exposure at steady-state, reached at approximately 3 months of multiple dosing, is expected to be approximately 2-fold higher than exposure following initial dosing, due to accumulation. A loading dose improves early exposure, thereby reducing the risk of breakthrough infections at the initiation of chemoprevention. CONCLUSIONS: Once weekly chemoprevention of DP predicts favourable exposures with respect to both trough and peak concentrations. These predictions need to be verified, as well as safety evaluated, in field-based clinical studies of young children. Simulations based on prior knowledge provide a systematic information-driven approach to evaluate candidate DP chemopreventive regimens for future trial designs. |
Declining blood collection and utilization in the United States
Chung KW , Basavaraju SV , Mu Y , van Santen KL , Haass KA , Henry R , Berger J , Kuehnert MJ . Transfusion 2016 56 (9) 2184-92 BACKGROUND: The Department of Health and Human Services National Blood Collection and Utilization Survey (NBCUS) has been conducted biennially since 1997. Data are used to estimate national blood collection and utilization. STUDY DESIGN AND METHODS: The 2013 Department of Health and Human Services NBCUS is a cross-sectional survey of all US blood collection centers and hospitals as listed in the 2012 American Hospital Association Annual Survey database that perform at least 100 inpatient surgical procedures annually. The study objective was to estimate, with 95% confidence intervals (CIs), the number of blood and blood components collected and transfused in the United States. RESULTS: In 2013, a total of 14,237,000 whole blood and apheresis red blood cell (RBC) units (95% CI, 13,639,000-14,835,000) were collected with 13,395,000 available for transfusion. Of these, 13,180,000 (95% CI, 12,389,000-13,972,000) whole blood and RBC units were transfused. This represented a 4.4% decline in the number of transfused units compared to 2011. Outdated (i.e., expired without being transfused) whole blood and RBC units declined by 17.3%. Apheresis (2,318,000; 95% CI, 2,154,000-2,482,000) and whole blood-derived platelet (PLT; 130,000; 95% CI, 23,000-237,000) distribution declined in 2013. Total PLT transfusions increased in 2013 (2,281,000) in comparison to 2011 (2,169,000). Total plasma units distributed (4,338,000) and transfused (3,624,000) declined. CONCLUSION: Both blood collection and utilization have declined, but the gap between collection and utilization is narrowing. As collections decline further and hospitals decrease transfusions and manage products more efficiently, the decline in surplus inventory may be a concern for disaster preparedness or other unexpected utilization needs. |
Ten things I wish someone had told me when I became a health officer
Frieden TR . Am J Public Health 2016 106 (7) e1-e5 Public health, like politics, is the art of the possible. To maximize effectiveness, public health officers in any jurisdiction should (1) get good data and ensure timely and effective dissemination; (2) prioritize and tackle more difficult initiatives first; (3) find, fight, and win winnable battles in areas where progress is possible but not ensured without focused, strategic effort; (4) support and hire great people and protect them so they can do their jobs; (5) address communicable diseases and environmental health effectively; (6) do not cede the clinical realm-public health programs depend on clinical care and on effective coordination between health care and public health; (7) learn and manage the budget cycle; (8) manage the context; (9) never surprise their boss; and (10) follow core principles. (Am J Public Health. |
Assisted reproductive technology and perinatal outcomes: conventional versus discordant-sibling design
Dhalwani NN , Boulet SL , Kissin DM , Zhang Y , McKane P , Bailey MA , Hood ME , Tata LJ . Fertil Steril 2016 106 (3) 710-716 e2 OBJECTIVE: To compare risks of adverse perinatal outcomes between assisted reproductive technology (ART) and naturally conceived singleton births using a dual design approach. DESIGN: Discordant-sibling and conventional cross-sectional general population comparison. SETTING: Not applicable. PATIENT(S): All singleton live births, conceived naturally or via ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Birth weight, gestational age, low birth weight, preterm delivery, small for gestational age (SGA), low Apgar score. RESULT(S): A total of 32,762 (0.8%) of 3,896,242 singleton live births in the three states were conceived via ART. In 6,458 sibling pairs, ART-conceived singletons were 33 g lighter (adjusted beta = -33.40, 95% confidence interval [CI], -48.60, -18.21) and born half a day sooner (beta = -0.58, 95% CI, -1.02, -0.14) than singletons conceived naturally. The absolute risk of low birth weight and preterm birth was 6.8% and 9.7%, respectively, in the ART group and 4.9% and 7.9%, respectively, in the non-ART group. The odds of low birth weight were 33% higher (adjusted odds ratio [aOR] = 1.33; 95% CI, 1.13, 1.56) and 20% higher for preterm birth (aOR = 1.20; 95% CI, 1.07, 1.34). The odds of SGA and low Apgar score were not significantly different in both groups (aOR = 1.22; 95% CI, 0.88, 1.68; and aOR = 0.75; 95% CI, 0.54, 1.05, respectively). Results of conventional analyses were similar, although the magnitude of risk was higher for preterm birth (aOR, 1.51; 95% CI 1.46, 1.56). CONCLUSION(S): Despite some inflated risks in the general population comparison, ART remained associated with an increased likelihood of low birth weight and preterm birth when underlying maternal factors were kept constant using discordant-sibling comparison. |
Racial discrimination as a correlate of African American mothers' emotion talk to young children
Odom Erika C , Garrett-Peters Patricia , Vernon-Feagans Lynne . J Fam Issues 2016 37 (7) 970-996 The current study was designed to test hypotheses derived from an ecological framework regarding the association between perceived racial discrimination and maternal emotion talk among a sample of 415 African American mothers living in the rural South. Mothers reported on experiences with racial discrimination when her child was 24 months old. Additionally, maternal emotion awareness was assessed by mothers' use of emotion words during an emotion-laden picture book interaction with her young child. Hierarchical regression analysis revealed that mothers' perception of racism was a significant positive predictor of mothers' emotion words, even after controlling for a variety of distal demographics and maternal and child characteristics. However, this main effect was qualified by significant interactions. Specifically, the strength of the association between perceived discrimination and mothers' emotion words was reduced in the presence of maternal psychological supports, including greater life satisfaction and knowledge of child development. |
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