US pediatrician practices and attitudes concerning childhood obesity: 2006 and 2017
Belay B , Frintner MP , Liebhart JL , Lindros J , Harrison M , Sisk B , Dooyema CA , Hassink SG , Cook SR . J Pediatr 2019 211 78-84 e2 OBJECTIVE: To compare primary care pediatricians' practices and attitudes regarding obesity assessment, prevention, and treatment in children 2 years and older in 2006 and 2017. STUDY DESIGN: National, random samples of American Academy of Pediatrics members were surveyed in 2006, 2010, and 2017 on practices and attitudes regarding overweight and obesity (analytic n = 655, 592, and 558, respectively). Using logistic regression models (controlling for pediatrician and practice characteristics), we examined survey year with predicted values (PVs), including body mass index (BMI) assessment across 2006, 2010, and 2017 and practices and attitudes in 2006 and 2017. RESULTS: Pediatrician respondents in 2017 were significantly more likely than in 2006 and 2010 to report calculating and plotting BMI at every well-child visit, with 96% of 2017 pediatricians reporting they do this. Compared with 2006, in 2017 pediatricians were more likely to discuss family behaviors related to screen time, sugar-sweetened beverages, and eating meals together, P < .001 for all. There were no observed differences in frequency of discussions on parental role modeling of nutrition and activity-related behaviors, roles in food selection, and frequency of eating fast foods or eating out. Pediatricians in 2017 were more likely to agree BMI adds new information relevant to medical care (PV = 69.8% and 78.1%), they have support staff for screening (PV = 45.3% and 60.5%), and there are effective means of treating obesity (PV = 36.3% and 56.2%), P < .001 for all. CONCLUSIONS: Results from cross-sectional surveys in 2006 and 2017 suggest nationwide, practicing pediatricians have increased discussions with families on several behaviors and their awareness and practices around obesity care. |
Association between sun protection behaviors and sunburn among U.S. older adults
Holman DM , Ding H , Freeman M , Shoemaker ML . Gerontologist 2019 59 S17-s27 BACKGROUND AND OBJECTIVES: Skin cancer incidence rates are highest among U.S. older adults. However, little is known about sun protection behaviors and sunburn among adults aged 65 years and older. RESEARCH DESIGN AND METHODS: We used data from the 2015 National Health Interview Survey to examine the association between sun protection behaviors (sun avoidance, wearing protective clothing, and sunscreen use) and likelihood of having experienced sunburn in the past year. RESULTS: Just over one in ten older adults (13.2%) had experienced sunburn in the past year; sunburn prevalence was nearly twice as high (20.4%) among sun-sensitive older adults. Men, ages 65-69 years, non-Hispanic whites, and those with skin that burns or freckles after repeated sun exposure were more likely to have been sunburned in the past year compared with the respective comparison groups. The only sun protection behavior significantly associated with sunburn was sunscreen use. None of the sun protection behaviors were significantly associated with a decreased risk of sunburn. DISCUSSION AND IMPLICATIONS: The prevalence of sunburn among older adults suggests opportunities to reduce skin cancer risk within this demographic group by preventing overexposure to the sun. The lack of reduced sunburn risk among those who regularly used sun protection may be related to inadequate or inconsistent use of sun protection or the way the sun protection behaviors were measured. Multi-sector approaches to facilitate sun-safety among older adults are warranted and could include targeted efforts focused on those most likely to get sunburned, including men and those with sun-sensitive skin. |
Racial/ethnic differences in prevalence of and time to onset of SLE manifestations: The California Lupus Surveillance Project (CLSP)
Maningding E , Dall'Era M , Trupin L , Murphy LB , Yazdany J . Arthritis Care Res (Hoboken) 2019 72 (5) 622-629 OBJECTIVE: The California Lupus Surveillance Project (CLSP) is a population-based registry of individuals with SLE residing in San Francisco County, California from 2007-2009, with a special focus on Asians/Pacific Islanders (API) and Hispanics. We used retrospective CLSP data to analyze racial/ethnic differences in lupus manifestations and in the timing and risk of developing severe manifestations. METHODS: 724 patients with SLE were retrospectively identified. Prevalence ratios (PR) of SLE manifestations were calculated using Poisson regression models stratified by race/ethnicity and adjusted for sex, age at SLE diagnosis, and disease duration. We studied onset of severe SLE manifestations after SLE diagnosis using Kaplan-Meier methods to examine time-to-event and Cox proportional hazards regressions to estimate hazard ratios (HR). Whites were the referent group in all analyses. RESULTS: Blacks, APIs, and Hispanics had increased prevalence of renal manifestations [PR 1.74 (95%CI: 1.40-2.16), PR 1.68 (95%CI: 1.38-2.05), PR 1.35 (95%CI: 1.05-1.74)], respectively. Furthermore, Blacks had increased prevalence of neurologic manifestations [PR 1.49 (95%CI: 1.12-1.98)] and both Blacks [PR 1.09 (95%CI: 1.04-1.15)] and APIs [PR 1.07 (95%CI: 1.01-1.13)] had increased prevalence of hematologic manifestations. Blacks, APIs, and Hispanics, respectively, had higher risk of developing lupus nephritis [HR 2.4 (95%CI: 1.6-3.8), HR 4.3 (95%CI: 2.9-6.4), HR 2.3 (95%CI: 1.4-3.8)] and thrombocytopenia [HR 2.3 (95%CI: 1.1-4.4), HR 2.3 (95%CI: 1.3-4.2), HR 2.2 (95%CI: 1.1-4.7)]. APIs and Hispanics had higher risk of developing antiphospholipid syndrome [HR 2.5 (95%CI: 1.4-4.4), HR 2.6 (95%CI: 1.3-5.1), respectively]. CONCLUSIONS: This is the first epidemiologic study comparing lupus manifestations among four major racial/ethnic groups. We found 1) substantial differences in the prevalence of several clinical SLE manifestations among racial/ethnic groups, and 2) that Blacks, APIs, and Hispanics are at increased risk of developing several severe manifestations following SLE diagnosis. This article is protected by copyright. All rights reserved. |
Estimating GFR in the elderly - new approaches to an old problem
Pavkov ME , Nelson RG . Kidney Int Rep 2019 4 (6) 763-765 In the United States, 37 million adults (15%) have predialysis chronic kidney disease (CKD) defined by albuminuria (urine albumin:creatinine ratio ≥30 mg/g) or decreased estimated glomerular filtration rate (eGFR <60 ml/min per 1.73 m2) by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.1 Nearly half (16.3 million) of those with predialysis CKD are 65 years or older. National surveys use single random measurements of kidney markers and therefore overestimate CKD prevalence by 2 to 3 percentage points, largely due to variability in albuminuria.S1 Conversely, commonly used eGFR equations, such as the CKD-EPI or Modification of Diet in Renal Disease (MDRD), generally underestimate true glomerular filtration rate (GFR), but may overestimate it in the elderly with low muscle mass.2 Precision of eGFR can be extremely important for appropriate patient management, where diagnosis of CKD, drug dosing, and proper health care utilization often depend on accurate estimates of kidney function. Few aspects of clinical care among older adults have stirred more controversy than the accuracy and precision of GFR obtained from estimating equations. |
Cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program
Rim SH , Allaire BT , Ekwueme DU , Miller JW , Subramanian S , Hall IJ , Hoerger TJ . Cancer Causes Control 2019 30 (8) 819-826 PURPOSE: To estimate the cost-effectiveness of breast cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using a modified CISNET breast cancer simulation model, we estimated outcomes for women aged 40-64 years associated with three scenarios: breast cancer screening within the NBCCEDP, screening in the absence of the NBCCEDP (no program), and no screening through any program. We report screening outcomes, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs), and sensitivity analyses results. RESULTS: Compared with no program and no screening, the NBCCEDP lowers breast cancer mortality and improves QALYs, but raises health care costs. Base-case ICER for the program was $51,754/QALY versus no program and $50,223/QALY versus no screening. Probabilistic sensitivity analysis ICER for the program was $56,615/QALY [95% CI $24,069, $134,230/QALY] versus no program and $51,096/QALY gained [95% CI $26,423, $97,315/QALY] versus no screening. CONCLUSIONS: On average, breast cancer screening in the NBCCEDP was cost-effective compared with no program or no screening. |
The burden of non-communicable diseases and their related risk factors in the country of Georgia, 2015
Russell S , Sturua L , Li C , Morgan J , Topuridze M , Blanton C , Hagan L , Salyer SJ . BMC Public Health 2019 19 479 Background: Non-communicable diseases (NCDs), mainly cardiovascular diseases, are a substantial cause of mortality in the country of Georgia, accounting for approximately 93% of all deaths (standardized mortality rate 630.7 deaths per 100,000 persons per year) and an important threat to health security. We conducted a nationally representative survey examining the prevalence of NCDs and their risk factors as part of a 2015 Hepatitis C Virus (HCV) and Hepatitis B Virus (HBV) serosurvey. Methods: We conducted a cross-sectional serosurvey among adults aged ≥18 years using a stratified, multi-stage cluster design (n = 7000). We asked participants standardized questions from the Global Adult Tobacco Survey and the WHO STEPwise approach to Surveillance (STEPS) Survey. We also measured blood pressure and Body Mass Index for each participant. Weighted frequencies were computed for NCD and risk factor prevalence and compared to 2010 STEPS results. Results: Georgians reported high rates of smoking, alcohol use, elevated blood pressure, obesity, diabetes and cardiovascular disease. An estimated 27.1% (95% confidence interval [CI]: 25.3, 28.8%) of adults (51.5% of men and 6.0% of women) reported daily use of tobacco products and 27.5% (95% CI: 25.7, 29.2%) of adults (52.1% of men and 7.0% of women) reported binge drinking within the last 30 days. Physical measurements revealed that 37.5% (95% CI: 35.8, 39.3%) of adults had elevated blood pressure and 33.4% (95% CI: 31.8, 35.0%) had obesity. 5.4% (95% CI: 4.6, 6.2%) of adults had self-reported diagnosed diabetes and 15.3% (95% CI: 14.1, 16.6%) had self-reported diagnosed cardiovascular disease. From 2010 to 2015, the prevalence of obesity increased by 8.3 percentage points (95% CI: 5.9, 10.7%; p < 0.01) and the prevalence of elevated blood pressure increased by 4.1 percentage points (95% CI: 1.4, 6.8%; p < 0.01). Conclusions: Georgia has a high NCD burden, and results from the survey showed an increase in obesity and elevated blood pressure since 2010. The prevalence of other major NCDs have remained near levels reported in the 2010 STEPs survey. Comprehensive public health interventions are needed to control the heath security threats of major NCDs and their risk factors in the future. |
Vision impairment and subjective cognitive decline-related functional limitations - United States, 2015-2017
Saydah S , Gerzoff RB , Taylor CA , Ehrlich JR , Saaddine J . MMWR Morb Mortal Wkly Rep 2019 68 (20) 453-457 Vision impairment affects approximately 3.22 million persons in the United States and is associated with social isolation, disability, and decreased quality of life (1). Cognitive decline is more common in adults with vision impairment (2,3). Subjective cognitive decline (SCD), which is the self-reported experience of worsening or more frequent confusion or memory loss within the past 12 months, affects 11.2% of adults aged >/=45 years in the United States (4). One consequence of SCD is the occurrence of functional limitations, especially those related to usual daily activities; however, it is not known whether persons with vision impairment are more likely to have functional limitations related to SCD (4). This report describes the association of vision impairment and SCD-related functional limitations using Behavioral Risk Factor Surveillance System (BRFSS) surveys for the years 2015-2017. Adjusting for age group, sex, race/ethnicity, education level, health insurance, and smoking status, 18% of adults aged >/=45 years who reported vision impairment also reported SCD-related functional limitations, compared with only 4% of those without vision impairment. Preventing, reducing, and correcting vision impairments might lead to a decrease in SCD-related functional limitations among adults in the United States. |
Picornavirus etiology of acute infections among hospitalized infants.
Abedi GR , Messacar K , Luong W , Nix WA , Rogers S , Queen K , Tong S , Oberste MS , Watt J , Rothrock G , Dominguez S , Gerber SI , Watson JT . J Clin Virol 2019 116 39-43 BACKGROUND: Enteroviruses (EV) and parechoviruses (PeV) are ubiquitous viruses that cause a range of illness, including acute illness in children aged <1 year. OBJECTIVES: We describe EV and PeV infections among children from 2 US study sites aged <1 year and hospitalized with acute infections. For EV- and PeV-negative case-patients, we explored other viral etiologies. METHODS: Participants were aged <1 year, hospitalized during 2016, and had cerebrospinal fluid (CSF) collected for routine diagnostic testing. Demographic and clinical data were abstracted from medical charts, and residual specimens were sent to CDC for confirmatory testing and typing. RESULTS: Of 472 eligible case-patients, CSF specimen was available for 319 (67.6%). Among those, 13 (4.1%) were positive for EV and 11 (3.4%) for PeV. Most case-patients (86.8%, n = 277) were aged <2 months, as were all EV- or PeV-positive case-patients. None of the positive case-patients had underlying conditions, and the chief complaint for 91.7% (n = 22) was fever. Twelve positive case-patients were admitted to intensive care (ICU) and had brief hospital stays (median 2 days). Sequencing revealed a variety of EV types and the predominance of PeV-A3 among the PeV-positive case-patients. CONCLUSIONS: A range of EV and PeV types were associated with acute febrile illnesses leading to hospitalization in children aged <2 months. Approximately half of EV and PeV case-patients were admitted to ICU, but length of hospital stay was brief and illnesses were generally self-limiting. Clinicians should consider EV and PeV infections in infants presenting with febrile illness. |
Progress Toward Polio Eradication - Worldwide, January 2017-March 2019.
Greene SA , Ahmed J , Datta SD , Burns CC , Quddus A , Vertefeuille JF , Wassilak SGF . MMWR Morb Mortal Wkly Rep 2019 68 (20) 458-462 Since the Global Polio Eradication Initiative (GPEI) began in 1988, transmission of wild poliovirus (WPV) has been interrupted in all countries except Afghanistan, Nigeria, and Pakistan. WPV type 2 (WPV2) was declared eradicated in 2015; WPV type 3 has not been detected since 2012 (1). After the certification of the eradication of WPV2, a global switch from trivalent oral poliovirus vaccine (tOPV, containing vaccine virus types 1, 2, and 3) to bivalent oral poliovirus vaccine (bOPV, containing types 1 and 3) was completed in April 2016. Nigeria last reported WPV type 1 (WPV1) cases in 2016. This report describes global progress toward poliomyelitis eradication during January 1, 2017-March 31, 2019, and updates previous reports (1,2). Afghanistan and Pakistan reported their lowest annual number of WPV cases (22) in 2017; however, 33 WPV1 cases were reported in 2018. During January-March 2019 (as of May 3), 12 WPV1 cases had been reported worldwide, four more than the eight reported during the corresponding period in 2018. The occurrence of polio cases caused by circulating vaccine-derived poliovirus (cVDPV) is rare and occurs where oral poliovirus vaccine (OPV) coverage has been low and vaccine virus reverts to neurovirulence (3). Eight countries (Democratic Republic of the Congo [DRC], Indonesia, Mozambique, Niger, Nigeria, Papua New Guinea, Somalia, and Syria) reported 210 cVDPV cases during 2017-2019 (as of May 3). Reaching children during supplemental immunization activities (SIAs), accessing mobile populations at high risk, and variations in surveillance performance represent ongoing challenges. Innovative efforts to vaccinate every child and strengthen coordination efforts between Afghanistan and Pakistan will help achieve eradication. For cVDPV outbreak responses to promptly stop transmission, intensified programmatic improvements are needed to make the responses more effective and limit the risk for generating future outbreaks. |
Hospitalization and death among patients with influenza, Guatemala, 2008-2012
Ao T , McCracken JP , Lopez MR , Bernart C , Chacon R , Moscoso F , Paredes A , Castillo L , Azziz-Baumgartner E , Arvelo W , Lindblade KA , Peruski LF , Bryan JP . BMC Public Health 2019 19 463 Background: Influenza is a major cause of respiratory illness resulting in 3-5 million severe cases and 291,243-645,832 deaths annually. Substantial health and financial burden may be averted by annual influenza vaccine application, especially for high risk groups. Methods: We used an active facility-based surveillance platform for acute respiratory diseases in three hospitals in Guatemala, Central America, to estimate the incidence of laboratory-confirmed hospitalized influenza cases and identify risk factors associated with severe disease (defined as admission to the intensive care unit (ICU) or death). We enrolled patients presenting with signs and symptoms of acute respiratory infection (ARI) and obtained naso- and oropharyngeal samples for real-time reverse transcriptase polymerase chain reaction (RT-PCR). We used multivariable logistic regression to identify risk factors for ICU admission or death, adjusted for age and sex. Results: From May 2008 to July 2012, among 6326 hospitalized ARI cases, 446 (7%) were positive for influenza: of those, 362 (81%) had influenza A and 84 (18%) had influenza B. Fifty nine percent of patients were aged </= 5 years, and 10% were aged ≥ 65 years. The median length of hospitalization was 5 days (interquartile range: 5). Eighty of 446 (18%) were admitted to the ICU and 28 (6%) died. Among the 28 deaths, 7% were aged ≤ 6 months, 39% 7-60 months, 21% 5-50 years, and 32% ≥ 50 years. Children aged ≤ 6 months comprised 19% of cases and 22% of ICU admissions. Women of child-bearing age comprised 6% of cases (2 admitted to ICU; 1 death). In multivariable analyses, Santa Rosa site (adjusted odds ratio [aOR] = 10, 95% confidence interval [CI] = 2-50), indigenous ethnicity (aOR = 4, 95% CI = 2-13, and radiologically-confirmed pneumonia (aOR = 5, 95% CI = 3-11) were independently associated with severe disease. Adjusted for hospital utilization rate, annual incidence of hospitalized laboratory-confirmed influenza was 24/100,000 overall, 93/100,000 for children aged < 5 years and 50/100,000 for those >/= 65 years. Conclusions: Influenza is a major contributor of hospitalization and death due to respiratory diseases in Guatemala. Further application of proven influenza prevention and treatment strategies is warranted. |
Couples HIV testing and immediate antiretroviral therapy for serodiscordant HIV-positive partners: Translating evidence into programme in Vietnam
Bui DD , Do NT , Pham LT , Nadol P , Nguyen VT , Dao VQ , Nguyen LH , Duong TK , Lai AK , Hoang CX , Nguyen AH , Suthar A , Tong AL , Do HM , Mesquita F , Lo YR , Lyss S , Nguyen LT , Kato M . Int J STD AIDS 2019 30 (8) 956462418825405 Injection drug use and heterosexual transmission from male key populations to their female partners have been the dominant modes of HIV transmission in Vietnam. A demonstration project was conducted to offer immediate antiretroviral therapy (ART) (regardless of CD4 cell count) to HIV-seropositive partners in serodiscordant couples. During March-December 2013, couples HIV testing and counselling (HTC) and immediate ART were offered in two drug use-affected provinces. Of 256 couples receiving couples HTC, 146 (57%) were serodiscordant; 134 (92%) seropositive partners initiated ART irrespective of CD4 cell count. Of these, 86% were male; 57% reported ever using illicit drugs; median CD4 cell count before ART initiation was 374 cells/mm(3). Consistent condom use was reported by 58, 70 and 71% among HIV-positive partners at months 0, 3 and 12. At 12 months after ART initiation, 119 (89%) HIV-positive partners were retained in care; 96 (95% of those tested) achieved viral suppression (<1000 copies/ml). Uptake of immediate ART and viral suppression among those initiating ART were high, paving the way for ART regardless of CD4 cell count as national policy in Vietnam. |
Enhanced surveillance for severe pneumonia, Thailand 2010-2015
Bunthi C , Baggett HC , Gregory CJ , Thamthitiwat S , Yingyong T , Paveenkittiporn W , Kerdsin A , Chittaganpitch M , Ruangchira-Urai R , Akarasewi P , Ungchusak K . BMC Public Health 2019 19 472 Background: The etiology of severe pneumonia is frequently not identified by routine disease surveillance in Thailand. Since 2010, the Thailand Ministry of Public Health (MOPH) and US CDC have conducted surveillance to detect known and new etiologies of severe pneumonia. Methods: Surveillance for severe community-acquired pneumonia was initiated in December 2010 among 30 hospitals in 17 provinces covering all regions of Thailand. Interlinked clinical, laboratory, pathological and epidemiological components of the network were created with specialized guidelines for each to aid case investigation and notification. Severe pneumonia was defined as chest-radiograph confirmed pneumonia of unknown etiology in a patient hospitalized ≤48 h and requiring intubation with ventilator support or who died within 48 h after hospitalization; patients with underlying chronic pulmonary or neurological disease were excluded. Respiratory and pathological specimens were tested by reverse transcription polymerase chain reaction for nine viruses, including Middle East Respiratory Syndrome Coronavirus (MERS-CoV), and 14 bacteria. Cases were reported via a secure web-based system. Results: Of specimens from 972 cases available for testing during December 2010 through December 2015, 589 (60.6%) had a potential etiology identified; 399 (67.8%) were from children aged < 5 years. At least one viral agent was detected in 394 (40.5%) cases, with the most common of single vial pathogen detected being respiratory syncytial virus (RSV) (110/589, 18.7%) especially in children under 5 years. Bacterial pathogens were detected in 341 cases of which 67 cases had apparent mixed infections. The system added MERS-CoV testing in September 2012 as part of Thailand's outbreak preparedness; no cases were identified from the 767 samples tested. Conclusions: Enhanced surveillance improved the understanding of the etiology of severe pneumonia cases and improved the MOPH's preparedness and response capacity for emerging respiratory pathogens in Thailand thereby enhanced global health security. Guidelines for investigation of severe pneumonia from this project were incorporated into surveillance and research activities within Thailand and shared for adaption by other countries. |
Methods, outcomes, and costs of a 2.5 year comprehensive facility-and community-based HIV testing intervention in Bukoba Municipal Council, Tanzania, 2014-2017
Cham HJ , MacKellar D , Maruyama H , Rwabiyago OE , Msumi O , Steiner C , Kundi G , Weber R , Byrd J , Suraratdecha C , Mengistu T , Churi E , Pals S , Madevu-Matson C , Alexander G , Porter S , Kazaura K , Mbilinyi D , Morales F , Rutachunzibwa T , Justman J , Rwebembera A . PLoS One 2019 14 (5) e0215654 To diagnose >/=90% HIV-infected residents (diagnostic coverage), the Bukoba Combination Prevention Evaluation (BCPE) implemented provider-initiated (PITC), home- (HBHTC), and venue-based (VBHTC) HIV testing and counseling (HTC) intervention in Bukoba Municipal Council, a mixed urban and rural lake zone community of 150,000 residents in Tanzania. This paper describes the methods, outcomes, and incremental costs of these HTC interventions. PITC was implemented in outpatient department clinics in all eight public and three faith-based health facilities. In clinics, lay counselors routinely screened and referred eligible patients for HIV testing conducted by HTC-dedicated healthcare workers. In all 14 wards, community teams offered HTC to eligible persons encountered at 31,293 home visits and at 79 male- and youth-frequented venues. HTC was recommended for persons who were not in HIV care or had not tested in the prior 90 days. BCPE conducted 133,695 HIV tests during the 2.5 year intervention (PITC: 88,813, 66%; HBHTC: 27,407, 21%; VBHTC: 17,475, 13%). Compared with other strategies, PITC conducted proportionally more tests among females (65%), and VBHTC conducted proportionally more tests among males (69%) and young-adults aged 15-24 years (42%). Of 5,550 (4.2% of all tests) HIV-positive tests, 4,143 (75%) clients were newly HIV diagnosed, including 1,583 males and 881 young adults aged 15-24 years. Of HIV tests conducted 3.7%, 1.8%, and 2.1% of PITC, HBHTC, and VBHTC clients, respectively, were newly HIV diagnosed; PITC accounted for 79% of all new diagnoses. Cost per test (per new diagnosis) was $4.55 ($123.66), $6.45 ($354.44), and $7.98 ($372.67) for PITC, HBHTC, and VBHTC, respectively. In a task-shifting analysis in which lay counselors replaced healthcare workers, estimated costs per test (per new diagnosis) would have been $3.06 ($83.15), $ 4.81 ($264.04), and $5.45 ($254.52), for PITC, HBHTC, and VBHTC, respectively. BCPE models reached different target groups, including men and young adults, two groups with consistently low coverage. Implementation of multiple models is likely necessary to achieve >/=90% diagnostic coverage. |
Prevalence of chronic hepatitis B virus infection among children in Haiti, 2017
Childs L , Adrien P , Minta AA , Francois J , Phaimyr Jn Charles N , Valery B , Rey-Benito G , Vanden Eng J , Tohme RA . Am J Trop Med Hyg 2019 101 (1) 214-219 In 2016, the World Health Assembly endorsed the Global Health Sector Strategy on Viral Hepatitis, which calls for elimination of hepatitis B virus (HBV) by 2030 (definition: </= 0.1% hepatitis B surface antigen [HBsAg] prevalence among children aged 5 years). The burden of chronic HBV infection among children in Haiti is unknown. We conducted a nationally representative cross-sectional serological survey among 5- to 7-year-old children based on a two-stage cluster design with two strata: West (includes metropolitan Port-au-Prince) and non-West (all other departments). We collected demographic, socioeconomic, and vaccination history data and tested for HBsAg using a rapid point-of-care test. We estimated HBsAg prevalence and evaluated the association of HBV infection with vaccination history, demographics, and socioeconomic characteristics. Of the 1,152 children, seven (0.5%, 95% CI: 0.2-1.2) were HBsAg positive. The HBsAg prevalence varied by region (West: 0.1%, 95% CI: 0.01-0.9; non-West: 0.7%, 95% CI: 0.2-1.9) (P = 0.1), gender (males: 0.7%, 95% CI: 0.2-2.4; females: 0.2%, 95% CI: 0.05-1.1) (P = 0.3), and caregiver's education level (none: 0.8%, 95% CI: 0.2-3.1; some or completed primary: 0.5%, 95% CI: 0.1-1.8; some secondary: 0.4%, 95% CI: 0.1-1.8; secondary and higher: 0.0%, 95% CI: 0-0), although the differences were not statistically significant. None of the HBsAg-positive children had documented vaccination with hepatitis B vaccine (HepB). Haiti's chronic HBV infection prevalence among children is low; however, it is above the elimination target. To reach elimination, Haiti needs to achieve high coverage with the three HepB doses and introduce a HepB birth dose. |
Aging attenuates the association between coronary artery calcification and bone loss among HIV-infected persons
Escota G , Baker J , Bush T , Conley L , Brooks JT , Patel P , Powderly W , Presti R , Overton ET . J Acquir Immune Defic Syndr 2019 82 (1) 46-50 INTRODUCTION: Studies among HIV-uninfected persons (mostly in their sixth decade of life) show that detectable coronary artery calcium (CAC) is independently associated with low bone mineral density (BMD), suggesting a possible common pathogenic mechanism. AIM: We assessed the relationship between CAC and BMD, which has not been well described among younger to middle-aged HIV-infected persons. METHODS: We studied participants with baseline CAC and BMD measures from a prospective cohort of HIV-infected persons enrolled in the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy (SUN) during 2004-2006. We used logistic regression to assess the association between detectable CAC (>0 Agatston score) and BMD (g/cm2, T-score), and adjusted for known traditional and HIV-related risk factors. RESULTS: Among 472 participants (76% male, 30% non-Hispanic black, median age 41 years, 71% with HIV RNA <400 copies/mL), the majority had no detectable CAC (82%), but had baseline osteopenia (53%) or osteoporosis (10%). In univariate analysis, participants with detectable CAC had lower femoral neck/total hip T-scores, lower femoral neck/total hip/lumbar spine BMD, and higher rates of osteopenia/osteoporosis. After adjustment for age, all associations were no longer significant; adjustment for traditional risk factors excluding age and HIV-related variables failed to attenuate these associations. CONCLUSIONS: We found aging attenuates the association between detectable CAC and BMD in this cohort. Aging remains an important contributor to non-AIDS-defining illnesses. These data reinforce the importance of developing screening and prevention strategies for ageing HIV-infected persons given their excess risk across a wide spectrum of end-organ complications. |
The predictive performance of a pneumonia severity score in HIV-negative children presenting to hospital in seven low and middle-income countries
Gallagher KE , Knoll MD , Prosperi C , Baggett HC , Brooks WA , Feiken DR , Hammitt LL , Howie SRC , Kotloff KL , Levine OS , Madhi SA , Murdoch DR , O'Brien KL , Thea DM , Awori JO , Baillie VL , Ebruke BE , Goswami D , Kamau A , Maloney SA , Moore DP , Mwananyanda L , Olutunde EO , Seidenberg P , Sissoko S , Sylla M , Thamthitiwat S , Zaman K , Scott JAG . Clin Infect Dis 2019 70 (6) 1050-1057 BACKGROUND: In 2015, pneumonia remained the leading cause of mortality in children between 1-59 months old. METHODS: Data from 1802 HIV-negative children between 1-59 months old enrolled in the Pneumonia Etiology Research for Child Health (PERCH) study with severe or very severe pneumonia during 2011-14 were used to build a parsimonious multivariable model predicting mortality using backwards stepwise logistic regression. The PERCH severity score, derived from model coefficients, was validated on a second, temporally discrete dataset of a further 1819 cases and compared to other available scores using the c-statistic. RESULTS: Predictors of mortality, across seven low and middle-income countries, were: age <1 year, female sex, 3 or more days of illness prior to presentation to hospital, low weight-for-height, unresponsiveness, deep breathing, hypoxemia, grunting and the absence of cough. The model discriminated well between those who died and those who survived (c-statistic: 0.84), but the predictive capacity of the PERCH 5-stratum score derived from the coefficients was moderate (c=0.76). The performance of the Respiratory Index of Severity in Children (RISC) score was similar (c=0.76). The number of WHO danger signs demonstrated the highest discrimination (c=0.82; 1.5% died if no danger signs, 10% if 1 danger sign and 33% if 2 or more danger signs). CONCLUSIONS: The PERCH severity score could be used to interpret geographic variations in pneumonia mortality and etiology. The number of WHO danger signs on presentation to hospital could be the most useful, of the currently available tools, to aid clinical management of pneumonia. |
Hepatitis C prevalence and risk factors in Georgia, 2015: Setting a baseline for elimination
Hagan LM , Kasradze A , Salyer SJ , Gamkrelidze A , Alkhazashvili M , Chanturia G , Chitadze N , Sukhiashvili R , Shakhnazarova M , Russell S , Blanton C , Kuchukhidze G , Baliashvili D , Hariri S , Ko S , Imnadze P , Drobeniuc J , Morgan J , Averhoff F . BMC Public Health 2019 19 480 Background: The country of Georgia launched the world's first Hepatitis C Virus (HCV) Elimination Program in 2015 and set a 90% prevalence reduction goal for 2020. We conducted a nationally representative HCV seroprevalence survey to establish baseline prevalence to measure progress toward elimination over time. Methods: A cross-sectional seroprevalence survey was conducted in 2015 among adults aged ≥18 years using a stratified, multi-stage cluster design (n = 7000). Questionnaire variables included demographic, medical, and behavioral risk characteristics and HCV-related knowledge. Blood specimens were tested for antibodies to HCV (anti-HCV) and HCV RNA. Frequencies were computed for HCV prevalence, risk factors, and HCV-related knowledge. Associations between anti-HCV status and potential risk factors were calculated using logistic regression. Results: National anti-HCV seroprevalence in Georgia was 7.7% (95% confidence interval (CI) = 6.7, 8.9); HCV RNA prevalence was 5.4% (95% CI = 4.6, 6.4). Testing anti-HCV+ was significantly associated with male sex, unemployment, urban residence, history of injection drug use (IDU), incarceration, blood transfusion, tattoos, frequent dental cleanings, medical injections, dialysis, and multiple lifetime sexual partners. History of IDU (adjusted odds ratio (AOR) = 21.4, 95% CI = 12.3, 37.4) and blood transfusion (AOR = 4.5, 95% CI = 2.8, 7.2) were independently, significantly associated with testing anti-HCV+ after controlling for sex, age, urban vs. rural residence, and history of incarceration. Among anti-HCV+ participants, 64.0% were unaware of their HCV status, and 46.7% did not report IDU or blood transfusion as a risk factor. Conclusions: Georgia has a high HCV burden, and a majority of infected persons are unaware of their status. Ensuring a safe blood supply, implementing innovative screening strategies beyond a risk-based approach, and intensifying prevention efforts among persons who inject drugs are necessary steps to reach Georgia's HCV elimination goal. |
One size does not fit all: HIV prevalence and correlates of risk for men who have sex with men, transgender women in multiple cities in Papua New Guinea
Hakim AJ , Coy K , Badman SG , Willie B , Narokobi R , Gabuzzi J , Pekon S , Kupul M , Hou P , Aeno H , Boli RN , Nembari J , Ase S , Amos A , Dala N , Weikum D , Callens S , Kaldor JM , Vallely AJ , Kelly-Hanku A . BMC Public Health 2019 19 (1) 623 BACKGROUND: Biobehavioral data about men who have sex with men (MSM) and transgender women (TGW) in Papua New Guinea (PNG) are limited to those who sell sex. Information about those MSM and TGW who do not sell sex is necessary to guide HIV prevention and treatment efforts. METHODS: We conducted respondent-driven sampling (RDS) surveys among MSM and TGW in Port Moresby, Lae, and Mt. Hagen, PNG from in 2016 and 2017. Eligibility criteria was: aged > 12 years, born male, could speak English or Tok Pisin and had oral or anal sex with another person born male in the past 6 months. Participants were interviewed face-to-face and offered rapid HIV testing. Weighted data analysis was conducted using RDS-Analyst (v. 0.62). RESULTS: We enrolled 400 participants in Port Moresby, 352 in Lae, and 111 in Mt. Hagen. In the last six months, 73.2% of MSM/TGW in Port Moresby, 77.9% in Lae, and 75.9% in Mt. Hagen, had a concurrent sexual partnership. Upwards of 70% of MSM/TGW in all three cities had sex with a woman in the same period. Less than half of MSM/TGW had ever tested for HIV. HIV prevalence among MSM/TGW was 8.5% in Port Moresby and 6.9% in Lae. Among participants in Mt. Hagen it was 1.3%. HIV was associated with not having sex with a woman in the last six months and sexually transmitted disease symptoms in the last 12 months in Port Moresby and Lae. In Port Moresby, it was also associated with an uncut foreskin, and in Lae with earning income in the formal sector and being unable to rely on other MSM or TGW to accompany them to healthcare services. CONCLUSIONS: The large proportion of MSM and TGW with concurrent sexual partnerships, combined with the low testing coverage, indicates strong potential for the spread of HIV. The different correlates of HIV in Port Moresby and Lae highlight the importance of conducting surveys in multiple locations and using data to develop locally appropriate interventions even within a country. |
Modeling the joint effects of adolescent and adult PrEP for sexual minority males in the United States
Hamilton DT , Rosenberg ES , Jenness SM , Sullivan PS , Wang LY , Dunville RL , Barrios LC , Aslam M , Goodreau SM . PLoS One 2019 14 (5) e0217315 BACKGROUND: Pre-exposure prophylaxis (PrEP) is an effective and safe intervention approved for use to prevent HIV transmission. PrEP scale-up strategies and clinical practice are currently being informed by modeling studies, which have estimated the impact of PrEP in adult and adolescent MSM populations separately. This partitioning may miss important effects or yield biased estimates by excluding dependencies between populations. METHODS: We combined two published models of HIV transmission among adults and adolescent MSM. We simulated an HIV epidemic among MSM aged 13-39 without PrEP, with PrEP for adult MSM ages (19-39) and with the addition of PrEP for adolescents ages (16-18), comparing percent of incident infections averted (impact), the number of person-years on PrEP per infection averted (efficiency), and changes in prevalence. RESULTS: PrEP use among eligible 19-39 year old MSM averted 29.0% of infections and reduced HIV prevalence from 23.2% to 17.0% over ten years in the population as a whole. Despite being ineligible for PrEP in this scenario, prevalence among sexually active 18 year-olds declined from 6.0% to 4.3% due to reduced transmissions across age cohorts. The addition of PrEP for adolescents ages 16-18 had a small impact on the overall epidemic, further reducing overall prevalence from 17.0% to 16.8%; however prevalence among the sexually active 18 year-olds further declined from 4.3% to 3.8%. CONCLUSIONS: PrEP use among adults may significantly reduce HIV prevalence among MSM and may also have significant downstream effects on HIV incidence among adolescents; PrEP targeting adolescents remains an important intervention for HIV prevention. |
An evaluation of the hepatitis C testing, care and treatment program in the country of Georgia's corrections system, December 2013 - April 2015
Harris AM , Chokoshvili O , Biddle J , Turashvili K , Japaridze M , Burjanadze I , Tsertsvadze T , Sharvadze L , Karchava M , Talakvadze A , Chakhnashvili K , Demurishvili T , Sabelashvili P , Foster M , Hagan L , Butsashvili M , Morgan J , Averhoff F . BMC Public Health 2019 19 466 Background: The country of Georgia has a high burden of chronic hepatitis C virus (HCV) infection, and prisoners are disproportionately affected. During 2013, a novel program offering no cost screening and treatment of HCV infection for eligible prisoners was launched. Methods: The HCV treatment program implemented a voluntary opt-in anti-HCV testing policy to all prisoners. Anti-HCV positive persons received HCV RNA and genotype testing. Transient elastography was also performed on prisoners with positive HCV RNA results. Prisoners with chronic HCV infection who had ≥F2 Metavir stage for liver fibrosis and a prison sentence ≥ 6 months were eligible for interferon-based treatment, which was the standard treatment prior to 2015. We conducted an evaluation of the HCV treatment program among prisoners from the program's inception in December 2013 through April 2015 by combining data from personal interviews with corrections staff, prisoner data in the corrections database, and HCV-specific laboratory information. Results: Of an estimated 30,000 prisoners who were incarcerated at some time during the evaluation period, an estimated 13,500 (45%) received anti-HCV screening, of whom 5175 (38%) tested positive. Of these, 3840 (74%) received HCV RNA testing, 2730 (71%) tested positive, and 880 (32%) met treatment eligibility. Of these, 585 (66%) enrolled; 405 (69%) completed treatment, and 202 (50%) achieved a sustained virologic response at least 12 weeks after treatment completion. Conclusions: HCV infection prevalence among Georgian prisoners was high. Despite challenges, we determined HCV treatment within Georgian Ministry of Correction facilities was feasible. Efforts to address HCV infection among prison population is one important component of HCV elimination in Georgia. |
Burden of laboratory-confirmed shigellosis infections in Guatemala 2007-2012: Results from a population-based surveillance system
Hegde S , Benoit SR , Arvelo W , Lindblade K , López B , McCracken JP , Bernart C , Roldan A , Bryan JP . BMC Public Health 2019 19 474 Background: We describe the epidemiology and antimicrobial susceptibility patterns of culture-confirmed Shigella infections in facility-based surveillance sites in Guatemala. Current studies using quantitative molecular diagnostics suggest Shigella may contribute most to the global diarrheal disease burden. Since identification of Shigella requires culturing techniques using stool specimens and few laboratories in Guatemala routinely culture for this pathogen, little is known about the true burden of Shigella in Guatemala or, importantly, the antimicrobial resistance patterns. Methods: Clinical, epidemiological, and laboratory data were collected on 5399 patients with acute diarrhea (≥3 loose stools in 24 h) from June 2007-August 2012. Multidrug resistance (MDR) was defined as resistance to ampicillin and trimethoprim/sulfamethoxazole. Results: Five percent (261) of stool specimens yielded Shigella spp. The annual incidence of laboratory-confirmed infections ranged from 5.0 to 24.1 per 100,000 persons in Santa Rosa and 0.3 to 6.2 per 100,000 in Quetzaltenango; 58% of cases occurred in children < 5 years of age. Thirty patients were hospitalized; one patient died. Oral rehydration or intravenous solution was used to treat 72% of hospitalized and 15% of ambulatory cases. Fifty-nine percent of cases were S. flexneri and 51% of cases were MDR. Conclusions: Shigella is an important cause of bacterial diarrhea in children and prevalence of MDR highlights the importance of appropriate treatment regimens. This study demonstrates that strengthening laboratory capacity in Guatemala can help determine causes which can lead to prevention of diarrheal diseases, particularly in children. Such capacity building is also critical for rapid detection and control of public health threats at their source and therefore for global health security. |
Health beliefs and patient perspectives of febrile illness in Kilombero, Tanzania
Hercik C , Cosmas L , Mogeni OD , Kohi W , Mfinanga S , Loffredo C , Montgomery JM . Am J Trop Med Hyg 2019 101 (1) 263-270 This qualitative study assessed the knowledge and beliefs surrounding fever syndrome among adult febrile patients seeking health care in Kilombero, Tanzania. From June 11 to July 13, 2014, 10% of all adult (>/= 15 years) febrile patients enrolled in the larger syndromic study, who presented with an axillary temperature >/= 37.5 degrees C and symptom onset </= 5 days prior, were randomly selected to participate in an in-depth physician-patient interview, informed by Health Belief Model constructs. Interviews were audio recorded, translated, and transcribed. Transcripts were coded using NVivo Version 11.1, and the thematic content was analyzed by two separate researchers. Blood and nasopharyngeal/oralpharyngeal specimens were collected and analyzed using both acute febrile illness and respiratory TaqMan Array Cards for multipathogen detection of 56 potential causative agents. A total of 18 participants provided 188 discrete comments. When asked to speculate the causative agent of febrile illness, 33.3% cited malaria and the other 66.6% offered nonbiomedical responses, such as "mosquitoes" and "weather." Major themes emerging related to severity and susceptibility to health hazards included lack of bed net use, misconceptions about bed nets, and mosquito infestation. Certain barriers to treatment were cited, including dependence on traditional healers, high cost of drugs, and poor dispensary services. Overall, we demonstrate low concurrence in speculations of fever etiology according to patients, clinicians, and laboratory testing. Our findings contribute to the important, yet limited, base of knowledge surrounding patient risk perceptions of febrile illness and underscore the potential utility of community-based participatory research to inform disease control programs. |
Jaundice outbreak likely caused by HEV in Amritsar, Punjab, India, 2013
Kumar T , Shrivastava A , Bhatia D , Mitra Y , Kumar A , Hussain S , Chauhan LS , Laserson KF , Narain JP , Kumar R , Francisco A . BMC Public Health 2019 19 464 Background: Hepatitis-E Virus (HEV) infection is endemic in Punjab, India. On 4th April 2013, public officials of Labour Colony, Amritsar reported > 20 jaundice cases occurring within several days. Methods: We performed a case-control study to identify the cause and prevent additional cases of jaundice cases in Amritsar, Punjab, India in 2013. Results: A total of 159 cases (attack rate 3.6%) and 1 death were identified in Labour and 5 adjoining colonies from January 1 to June 5, 2013. Persons with jaundice were more likely to report foul-smelling piped water (adjusted odds ratio [AOR], 4.0, 95% confidence interval [CI], 2.2-7.2) and used piped water for drinking (AOR, 5.1; 95% CI, 2.2-11.4) than persons without jaundice. Among 14 cases tested, all had anti-hepatitis E virus IgM, and none had anti-hepatitis A virus IgM. Additionally, 21/23 tap water samples from affected households had detectable fecal coliforms. An environmental investigation found that water pipelines were damaged during sewer construction and likely led to contamination of drinking water with hepatitis E virus. Conclusions: Hepatitis E outbreaks are common in India, to curb future outbreaks of hepatitis E; measures to ensure safe drinking water are urgently needed. |
A clinical score to support antiretroviral management of HIV-exposed infants on the day of birth
Nesheim SR , Rose C , Pan Y , Gray KM , Rao S , Singh S , Lampe M . Pediatr Infect Dis J 2019 38 (9) 939-943 BACKGROUND: The benefits of combination antiretroviral (ARV) prophylaxis for infants whose HIV exposure is recognized near birth have been established, and the benefits of early ARV therapy are well known. Decisions about ARVs can be supported by the probability that the child has acquired HIV. METHODS: Using 2005-2010 data from Enhanced Perinatal Surveillance of the Centers for Disease Control and Prevention, we developed a tool for use at birth to help predict HIV acquisition of HIV-exposed infants to support ARV management. A logistic regression model, fit using a fully Bayesian approach, was used to determine maternal variables predictive of infant HIV acquisition. We created a score index from these variables, established the sensitivity and specificity of each possible score, and determined the distribution of scores among infants, with and without HIV, in our study population. RESULTS: Multivariable analysis of data from 8740 HIV-exposed infants (176 infected and 8564 uninfected) yielded 4 maternal variables in the perinatal HIV acquisition prediction model: sexually transmitted infection, substance use, last HIV viral load before delivery and ARV use. Using the regression coefficient estimates, we rescaled each possible score to make the maximum score equal to 100. For each score, sensitivity and specificity were determined; the area under the receiver operating characteristic curve was 0.79. Median index scores for infants with HIV and without HIV were 43 (first quartile 27 and third quartile 60), and 12 (first quartile, 0 and thirs quartile, 29), respectively. CONCLUSIONS: Decisions to begin infants on 3 ARVs-whether considered therapeutic or prophylactic-can be supported by data available on the day of birth. |
Social support and other factors associated with HIV testing by Hispanic/Latino gay, bisexual, and other men who have sex with men in the U.S. south
Painter TM , Song EY , Mullins MM , Mann-Jackson L , Alonzo J , Reboussin BA , Rhodes SD . AIDS Behav 2019 23 251-265 Cognitive-psychosocial and other factors may affect participation in HIV testing, particularly by Hispanic/Latino gay, bisexual, and other men who have sex with men (MSM) in the U.S. South, a region hard-hit by HIV. We used univariate and multivariable logistic regression analyses to examine the association between social support and other cognitive-psychosocial factors; sociodemographic characteristics; risk behaviors; and self-reported HIV testing in a sample of 304 Hispanic/Latino MSM in North Carolina. In the multivariable logistic regression analysis, general and HIV-related social support and HIV-related knowledge were associated with greater odds of testing; speaking only Spanish was associated with reduced odds of testing. Social support and aspects of social connectedness may constitute community-based resources for use in HIV prevention efforts with Hispanic/Latino MSM. However, harnessing these resources for HIV prevention will require a better understanding of how social support relationships and processes shape HIV risks and protective actions by these vulnerable MSM. |
Change in plasma CrAg titer is not associated with survival among HIV-infected persons receiving preemptive therapy for asymptomatic cryptococcal antigenemia
Pullen MF , Kakooza F , Nalintya E , Kiragga AN , Morawski BM , Rajasingham R , Mubiru A , Manabe YC , Kaplan JE , Meya DB , Boulware DR . Clin Infect Dis 2019 70 (2) 353-355 Current World Health Organization (WHO) guidelines recommend cryptococcal antigen (CrAg) screening in blood among those human immunodeficiency virus (HIV)-infected persons not receiving effective antiretroviral therapy (ART), with CD4 values <100 cells/µL, and to consider testing those not on ART with CD4 values between 100–200 cells/µL [1]. This recommendation is based on prior studies demonstrating that a “screen-and-treat” program identifying CrAg-positive persons and giving preemptive fluconazole therapy, in combination with an ART adherence intervention, prevents invasive cryptococcal disease and death [2]. |
Tuberculosis screening, testing, and treatment of U.S. health care personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019
Sosa LE , Njie GJ , Lobato MN , Bamrah Morris S , Buchta W , Casey ML , Goswami ND , Gruden M , Hurst BJ , Khan AR , Kuhar DT , Lewinsohn DM , Mathew TA , Mazurek GH , Reves R , Paulos L , Thanassi W , Will L , Belknap R . MMWR Morb Mortal Wkly Rep 2019 68 (19) 439-443 The 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings include recommendations for baseline tuberculosis (TB) screening of all U.S. health care personnel and annual testing for health care personnel working in medium-risk settings or settings with potential for ongoing transmission (1). Using evidence from a systematic review conducted by a National Tuberculosis Controllers Association (NTCA)-CDC work group, and following methods adapted from the Guide to Community Preventive Services (2,3), the 2005 CDC recommendations for testing U.S. health care personnel have been updated and now include 1) TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement); 2) TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI); 3) no routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission; 4) encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated; 5) annual symptom screening for health care personnel with untreated LTBI; and 6) annual TB education of all health care personnel. |
Seroprevalence of hepatitis A and hepatitis E viruses among pregnant women in Haiti
Tejada-Strop A , Tohme RA , Andre-Alboth J , Childs L , Ji X , de Oliveira Landgraf de Castro V , Boncy J , Kamili S . Am J Trop Med Hyg 2019 101 (1) 230-232 Hepatitis E virus (HEV) infection is associated with a high fatality rate among pregnant women, and gestational complications have been reported among pregnant women infected with hepatitis A virus (HAV). The aim of this study was to determine the seroprevalence of HAV and HEV infections among pregnant women in Haiti. We stratified the population (n = 1,307) between West and non-West regions. Specimens were tested for total HAV antibody (anti-HAV), and IgM and IgG HEV antibody (anti-HEV). Overall, 96.8% pregnant women were positive for total anti-HAV, 10.3% for IgG anti-HEV, and 0.3% for IgM anti-HEV. The prevalence of IgG anti-HEV in the non-West region (12.3%) was significantly greater than that in the West region (5.3%) (P < 0.0001). Most pregnant women in Haiti had evidence of past exposure and immunity to HAV. The non-West region had a higher prevalence of HEV. Improvement in water and sanitation will help in the prevention and control of these infections in Haiti. |
Relationships between residential care community characteristics and overnight hospital stays and readmissions: Results from the National Study of Long-Term Care Providers
Caffrey C , Harris-Kojetin L , Rome V , Schwartz L . Seniors Hous Care J 2018 26 (1) 38-49 The Problem: Hospitalizations and subsequent readmissions can produce significant challenges when trying to reduce costs and improve quality of care. This study describes hospitalizations and readmissions using residential care community data from the 2012 National Study of Long-Term Care Providers. The Resolution: About 61.0% of residential care communities had hospitalizations, and among these communities, 39.3% had readmissions. Residential care communities in the Northeast were more likely to have had hospitalizations and readmissions. Residential care communities located in a continuing care retirement community (CCRC) had a lower likelihood of hospitalizations, and communities that provided therapeutic services had a lower likelihood of readmissions. Tips for Success: An association with a CCRC and provision of therapeutic services were found to be protective against hospitalizations and readmissions, respectively. |
Entomological efficacy of aerial ultra-low volume insecticide applications against Aedes aegypti (Diptera: Culicidae) in Mexico
Correa-Morales F , Dzul-Manzanilla F , Bibiano-Marin W , Vadillo-Sanchez J , Medina-Barreiro A , Martin-Park A , Villegas-Chim J , Elizondo-Quiroga AE , Lenhart A , Vazquez-Prokopec GM , Erales-Villamil J , Che-Mendoza A , Manrique-Saide P . J Med Entomol 2019 56 (5) 1331-1337 A cluster-randomized controlled trial quantified the entomological efficacy of aerial ultra-low volume (AULV) applications of the insecticide chlorpyrifos against Aedes aegypti in Puerto Vallarta, Mexico, during November-October 2017. The trial involved 16 large (1 x 1 km) clusters distributed between treatment-control arms. Primary endpoint was the abundance of Ae. aegypti indoors (total adults, females, and blood-fed females) collected using Prokopack aspirators. After four consecutive weekly cycles of AULV, all adult Ae. aegypti infestation indices were significantly lower in the treatment arm (OR and IRR </= 0.28). Efficacy in reducing indoor Ae. aegypti increased with each weekly application cycle from 30 to 73% (total adults), 33 to 76% (females), and 45.5 to 89% (blood-fed females). Entomological indices remained significantly lower in the treatment arm up to 2 wk after the fourth spraying round. Performing AULV spraying can have significant and lasting entomological impact on Ae. aegypti as long as multiple (ideally four) spray cycles are implemented using an effective insecticide. |
Estimating absolute indoor density of Aedes aegypti using removal sampling
Koyoc-Cardena E , Medina-Barreiro A , Cohuo-Rodriguez A , Pavia-Ruz N , Lenhart A , Ayora-Talavera G , Dunbar M , Manrique-Saide P , Vazquez-Prokopec G . Parasit Vectors 2019 12 (1) 250 BACKGROUND: Quantification of adult Aedes aegypti abundance indoors has relied on estimates of relative density (e.g. number of adults per unit of sampling or time), most commonly using traps or timed collections using aspirators. The lack of estimates of the sensitivity of collections and lack of a numerical association between relative and the absolute density of adult Ae. aegypti represent a significant gap in vector surveillance. Here, we describe the use of sequential removal sampling to estimate absolute numbers of indoor resting Ae. aegypti and to calculate calibration coefficients for timed Prokopack aspirator collections in the city of Merida, Yucatan State, Mexico. The study was performed in 200 houses that were selected based on recent occurrence of Aedes-borne viral illness in residents. Removal sampling occurred in 10-minute sampling rounds performed sequentially until no Ae. aegypti adult was collected for 3 hours or over 2 consecutive 10-minute periods. RESULTS: A total of 3439 Ae. aegypti were collected. The sensitivity of detection of positive houses in the first sampling round was 82.5% for any adult Ae. aegypti, 78.5% for females, 75.5% for males and 73.3% for blood-fed females. The total number of Ae. aegypti per house was on average ~5 times higher than numbers collected for the first sampling round. There was a positive linear relationship between the relative density of Ae. aegypti collected during the first 10-min round and the absolute density for all adult metrics. Coefficients from the linear regression were used to calibrate numbers from 10-min collections into estimates of absolute indoor Ae. aegypti density for all adults, females and males. CONCLUSIONS: Exhaustive removal sampling represents a promising method for quantification of absolute indoor Ae. aegypti density, leading to improved entomological estimates of mosquito distribution, a key measure in the assessments of the risk pathogen transmission, disease modeling and the evaluation of vector control interventions. |
Predicting spatiotemporal patterns of Lyme disease incidence from passively collected surveillance data for Borrelia burgdorferi sensu lato-infected Ixodes scapularis ticks
Little EAH , Anderson JF , Stafford KC 3rd , Eisen L , Eisen RJ , Molaei G . Ticks Tick Borne Dis 2019 10 (5) 970-980 Lyme disease is the most prevalent vector-borne disease in the United States. Ixodes scapularis, commonly referred to as the blacklegged tick, is the primary vector of Lyme disease spirochetes, Borrelia burgdorferi sensu lato (s.l.), in the eastern United States. Connecticut has pervasive populations of I. scapularis and remains a hotspot for Lyme disease. A primary aim of this study was to determine if passively collected data on human-biting I. scapularis ticks in Connecticut could serve as a useful proxy for Lyme disease incidence based on the cases reported by the Connecticut Department of Public Health (CDPH). Data for human-biting I. scapularis ticks submitted to the Tick Testing Laboratory at the Connecticut Agricultural Experiment Station (CAES-TTL), and tested for infection with B. burgdorferi s.l., were used to estimate the rate of submitted nymphs, nymphal infection prevalence, and the rate of submitted infected nymphs. We assessed spatiotemporal patterns in tick-based measures and Lyme disease incidence with generalized linear and spatial models. In conjunction with land cover and household income data, we used generalized linear mixed effects models to examine the association between tick-based risk estimates and Lyme disease incidence. Between 2007 and 2017, the CAES-TTL received 26,116 I. scapularis tick submissions and the CDPH reported 23,423 Lyme disease cases. The rate of submitted nymphs, nymphal infection prevalence, the rate of submitted infected nymphs, and Lyme disease incidence all decreased over time during this eleven-year period. The rate of submitted nymphs, the rate of submitted infected nymphs, and Lyme disease incidence were spatially correlated, but nymphal infection prevalence was not. Using a mixed modeling approach to predict Lyme disease incidence and account for spatiotemporal structuring of the data, we found the best fitting tested model included a strong, positive association with the rate of submitted infected nymphs and a negative association with the percent of developed land for each county. We show that within counties, submissions of B. burgdorferi s.l. infected nymphs were strongly and positively associated with inter-annual variation in reported Lyme disease cases. Tick-based passive surveillance programs may be useful in providing independent measures of entomological risk, particularly in settings where Lyme disease case reporting practices change substantially over time. |
Host phylogeny, geographic overlap, and roost sharing shape parasite communities in European bats
McKee CD , Krawczyk AI , Sandor AD , Gorfol T , Foldvari M , Foldvari G , Dekeukeleire D , Haarsma AJ , Kosoy MY , Webb CT , Sprong H . Front Ecol Evol 2019 7 How multitrophic relationships between wildlife communities and their ectoparasitic vectors interact to shape the diversity of vector-borne microorganisms is poorly understood. Nested levels of dependence among microbes, vectors, and vertebrate hosts may have complicated effects on both microbial community assembly and evolution. We examined Bartonella sequences from European bats and their ectoparasites with a combination of network analysis, Bayesian phylogenetics, tip-association and cophylogeny tests, and linear regression to understand the ecological and evolutionary processes that shape parasite communities. We detected seven bat-ectoparasite-Bartonella communities that can be differentiated based on bat families and roosting patterns. Tips of the Bartonella tree were significantly clustered by host taxonomy and geography. We also found significant evidence of evolutionary congruence between bat host and Bartonella phylogenies, indicating that bacterial species have evolved to infect related bat species. Exploring these ecological and evolutionary associations further, we found that sharing of Bartonella species among bat hosts was strongly associated with host phylogenetic distance and roost sharing and less strongly with geographic range overlap. Ectoparasite sharing between hosts was strongly predicted by host phylogenetic distance, roost sharing, and geographic overlap but had no additive effect on Bartonella sharing. Finally, historical Bartonella host-switching was more frequent for closely related bats after accounting for sampling bias among bat species. This study helps to disentangle the complex ecology and evolution of Bartonella bacteria in bat species and their arthropod vectors. Our work provides insight into the important mechanisms that partition parasite communities among hosts, particularly the effect of host phylogeny and roost sharing, and could help to elucidate the evolutionary patterns of other diverse vector-borne microorganisms. |
Biological and environmental exposure monitoring of volatile organic compounds among nail technicians in the Greater Boston area
Ceballos DM , Craig J , Fu X , Jia C , Chambers D , Chu MT , Fernandez AT , Fruh V , Petropoulos ZE , Allen JG , Vallarino J , Thornburg L , Webster TF . Indoor Air 2019 29 (4) 539-550 Nail technicians are exposed to volatile organic compounds (VOCs) from nail products, but no studies have previously measured VOC biomarkers for these workers. This study of 10 nail technicians aimed to identify VOCs in nail salons and explore relationships between air concentrations and biomarkers. Personal and area air samples were collected using thermal desorption tubes during a work shift and analyzed using gas chromatography/mass spectrometry (GC/MS) for 71 VOCs. Whole blood samples were collected pre-shift and post-shift, and analyzed using GC/MS for 43 VOCs. Ventilation rates were determined using continuous CO2 measurements. Predominant air VOC levels were ethyl methacrylate (median 240 microg/m(3) ), methyl methacrylate (median 205 microg/m(3) ), toluene (median 100 microg/m(3) ), and ethyl acetate (median 639 microg/m(3) ). Blood levels were significantly higher post-shift than pre-shift for toluene (median pre-shift 0.158 microg/L and post-shift 0.360 microg/L) and ethyl acetate (median pre-shift <0.158 microg/L and post-shift 0.510 microg/L); methacrylates were not measured in blood because of their instability. Based on VOCs measured in these seven nail salons, we estimated that emissions from Greater Boston area nail salons may contribute to ambient VOCs. Ventilation rates did not always meet the ASHRAE guideline for nail salons. There is a need for changes in nail product formulation and better ventilation to reduce VOC occupational exposures. |
Separating science knowledge from religious belief: Two approaches for reducing the effect of identity on survey responses
Maitland A , Tourangeau R , Sun H . Public Opin Q 2018 82 (1) 34-62 All survey items reflect some conceptual framework that might or might not be accepted by subgroups with certain personal identities. For example, respondents with certain religious identities may reject the scientific framework of questions about the development of life and origins of the universe since there are competing truth claims between religion and science on these topics. Since the late 1970s, the National Science Foundation has sponsored a series of surveys to gauge public attitudes toward and understanding of science and technology. Items that simultaneously measure knowledge and acceptance of two concepts-evolution and the "big bang"-appear to raise measurement problems for a specific subgroup that rejects the premise of the items. This paper focuses on alternative versions of the survey questions that attempt to remove the effect of religious belief on answers to these items. We investigate two approaches for removing this confounding of knowledge and acceptance. One approach is to ask what scientists think rather than what the respondents believe; the other is to remove "hot-button" features of the question likely to trigger conflicts between the religious and scientific views. We also illustrate how psychometric methods (such as confirmatory factor analysis) can help sort out which version of the questions produces the most valid answers. |
Genome-wide patterns of gene expression in a wild primate indicate species-specific mechanisms associated with tolerance to natural simian immunodeficiency virus infection.
Simons ND , Eick GN , Ruiz-Lopez MJ , Hyeroba D , Omeja PA , Weny G , Chapman CA , Goldberg TL , Zheng H , Shankar A , Switzer WM , Frost SDW , Jones JH , Sterner KN , Ting N . Genome Biol Evol 2019 11 (6) 1630-1643 Over 40 species of nonhuman primates host simian immunodeficiency viruses (SIVs). In natural hosts, infection is generally assumed to be nonpathogenic due to a long coevolutionary history between host and virus, although pathogenicity is difficult to study in wild nonhuman primates. We used whole-blood RNA-seq and SIV prevalence from 29 wild Ugandan red colobus (Piliocolobus tephrosceles) to assess the effects of SIV infection on host gene expression in wild, naturally SIV-infected primates. We found no evidence for chronic immune activation in infected individuals, suggesting that SIV is not immunocompromising in this species, in contrast to HIV in humans. Notably, an immunosuppressive gene, CD101, was upregulated in infected individuals. This gene has not been previously described in the context of nonpathogenic SIV infection. This expands the known variation associated with SIV infection in natural hosts, and may suggest a novel mechanism for tolerance of SIV infection in the Ugandan red colobus. |
Draft Genome Sequences of Leishmania ( Leishmania ) amazonensis , Leishmania ( Leishmania ) mexicana , and Leishmania ( Leishmania ) aethiopica , Potential Etiological Agents of Diffuse Cutaneous Leishmaniasis.
Batra D , Lin W , Narayanan V , Rowe LA , Sheth M , Zheng Y , Loparev V , de Almeida M . Microbiol Resour Announc 2019 8 (20) We present here the draft genome sequences of Leishmania (Leishmania) amazonensis, Leishmania (Leishmania) mexicana, and Leishmania (Leishmania) aethiopica, potential etiological agents of diffuse cutaneous leishmaniasis (DCL). Sequence data were obtained using PacBio and MiSeq platforms. The PacBio assemblies generated using Canu v1.6 are more contiguous than are those in the available data. |
Comparative analysis reveals conservation in genome organization among intestinal Cryptosporidium species and sequence divergence in potential secreted pathogenesis determinants among major human-infecting species.
Xu Z , Guo Y , Roellig DM , Feng Y , Xiao L . BMC Genomics 2019 20 (1) 406 BACKGROUND: Cryptosporidiosis is a major cause of gastrointestinal diseases in humans and other vertebrates. Previous analyses of invasion-related proteins revealed that Cryptosporidium parvum, Cryptosporidium hominis, and Cryptosporidium ubiquitum mainly differed in copy numbers of secreted MEDLE proteins and insulinase-like proteases and sequences of mucin-type glycoproteins. Recently, Cryptosporidium chipmunk genotype I was identified as a novel zoonotic pathogen in humans. In this study, we sequenced its genome and conducted a comparative genomic analysis. RESULTS: The genome of Cryptosporidium chipmunk genotype I has gene content and organization similar to C. parvum and other intestinal Cryptosporidium species sequenced to date. A total of 3783 putative protein-encoding genes were identified in the genome, 3525 of which are shared by Cryptosporidium chipmunk genotype I and three major human-pathogenic Cryptosporidium species, C. parvum, C. hominis, and Cryptosporidium meleagridis. The metabolic pathways are almost identical among these four Cryptosporidium species. Compared with C. parvum, a major reduction in gene content in Cryptosporidium chipmunk genotype I is in the number of telomeric genes encoding MEDLE proteins (two instead of six) and insulinase-like proteases (one instead of two). Highly polymorphic genes between the two species are mostly subtelomeric ones encoding secretory proteins, most of which have higher dN/dS ratios and half are members of multiple gene families. In particular, two subtelomeric ABC transporters are under strong positive selection. CONCLUSIONS: Cryptosporidium chipmunk genotype I possesses genome organization, gene content, metabolic pathways and invasion-related proteins similar to the common human-pathogenic Cryptosporidium species, reaffirming its human-pathogenic nature. The loss of some subtelomeric genes encoding insulinase-like proteases and secreted MEDLE proteins and high sequence divergence in secreted pathogenesis determinants could contribute to the biological differences among human-pathogenic Cryptosporidium species. |
The effects of past SARS experience and proximity on declines in numbers of travelers to the Republic of Korea during the 2015 MERS outbreak: A retrospective study
Joo H , Henry RE , Lee YK , Berro AD , Maskery BA . Travel Med Infect Dis 2019 30 54-66 BACKGROUND: The experience of previous sizable outbreaks may affect travelers' decisions to travel to an area with an ongoing outbreak. METHODS: We estimated changes in monthly numbers of visitors to the Republic of Korea (ROK) in 2015 compared to projected values by selected areas. We tested whether areas' experience of a previous SARS outbreak of >/=100 cases or distance to the ROK had a significant effect on travel to the ROK during the MERS outbreak using t-tests and regression models. RESULTS: The percentage changes in visitors from areas with a previous SARS outbreak of >/=100 cases decreased more than the percentage changes in visitors from their counterparts in June (52.4% vs. 23.3%) and July (60.0% vs. 31.4%) during the 2015 MERS outbreak. The percentage changes in visitors from the close and intermediate categories decreased more than the far category. The results from regression models and sensitivity analyses demonstrated that areas with >/=100 SARS cases and closer proximity to the ROK had significantly larger decreases in traveler volumes during the outbreak. CONCLUSIONS: During the 2015 MERS outbreak, areas with a previous sizable SARS outbreak and areas near the ROK showed greater decreases in percentage changes in visitors to the ROK. |
Ten years of global disease detection and counting: Program accomplishments and lessons learned in building global health security
Montgomery JM , Woolverton A , Hedges S , Pitts D , Alexander J , Ijaz K , Angulo F , Dowell S , Katz R , Henao O . BMC Public Health 2019 19 510 Worldwide, infectious diseases continue to emerge at an alarming pace, due to numerous factors including microbial adaptation, increasing human population migration, urbanization, conflict and instability, intensified animal-human interface, and habitat perturbation [1,2,3,4,5,6]. The litmus test for an effective national public health program is its ability to be ready to initiate an effective response for an unknown emerging or re-emerging infectious disease or public health event. The most impactful global health programs are built with the understanding that they must be able to help countries strengthen core public health capacity so that new threats can be detected and contained before they become international crises that increase morbidity and mortality, adversely impact the health and livelihoods of individuals and populations, disrupt travel, interfere with global trade and economies, or even lead to political destabilization [6, 7]. |
Progress in public health risk communication in China: Lessons learned from SARS to H7N9
Frost M , Li R , Moolenaar R , Mao Q , Xie R . BMC Public Health 2019 19 475 Background: Following the SARS outbreak, the World Health Organization revised the International Health Regulations to include risk communication as one of the core capacity areas. In 2006, the U.S. Centers for Disease Control and Prevention's Global Disease Detection [GDD] program began collaborating with China to enhance China's risk communication capacity to address gaps in the SARS communication response. This article describes tangible improvements in China's public health emergency risk communication capacity between the SARS and H7N9 outbreaks; documents U.S. CDC GDD cooperative technical assistance during 2006-2017; and shares lessons learnt to benefit other countries and contribute to enhance global health security. Method: A questionnaire based on the WHO Joint External Evaluation tool [Risk Communication section] was developed. A key communications official from the China National Health Commission [NHC] completed the questionnaire retrospectively to reflect China's capacity to manage communication response before, during and after the outbreaks of SARS in 2003, influenza H1N1 in 2009, and influenza H7N9 in 2013. A literature search was also conducted in English and Chinese to further substantiate the results of the questionnaire completed by NHC. Results: China demonstrated significantly improved risk communication capacities of pre-event, during event and post event responses to H7N9 when compared to the SARS response. China NHC improved its response through preparedness, availability of dedicated staff and resources for risk communication, internal clearance mechanisms, standard operating procedures with national response parties external to NHC, rumor management, communication with international agencies and consistent messaging with healthcare and private sectors. Correspondingly, the perceived level of trust that the public had in the NHC following outbreaks rose between the SARS and H7N9 response. Conclusion: Risk communication capacities in China have increased during the ten years between the SARS outbreak of 2003 and the H7N9 outbreak of 2013. Long-term risk communication capacity building efforts in bilateral collaborations are uncommon. The U.S. CDC GDD project was one of the first such collaborations worldwide. The lessons learned from this project may benefit lower and middle-income countries as they build their national emergency risk communication capacity. |
Updated medical care cost estimates for HPV-associated cancers: implications for cost-effectiveness analyses of HPV vaccination in the United States
Chesson HW , Meites E , Ekwueme DU , Saraiya M , Markowitz LE . Hum Vaccin Immunother 2019 15 1-7 Estimates of medical care costs for cervical and other cancers associated with human papillomavirus (HPV) are higher in studies published in recent years than in studies published before 2012. The purpose of this report is (1) to review and summarize the recent cancer cost estimates and (2) to illustrate how the estimated cost-effectiveness of HPV vaccination might change when these recent cost estimates are applied. Our literature search yielded 6 studies that provided updated medical care cost estimates for 5 HPV-associated cancers. We found that applying the current cancer cost estimates had a notable impact on the estimated medical costs averted by HPV vaccination over an extended time frame (100 years), and a moderate impact on the estimated cost per quality-adjusted life year (QALY) gained by HPV vaccination. For example, for catch-up vaccination of teenagers and young adults, applying the more recent cancer costs reduced the estimated cost per QALY gained by about $12,400. The cost studies we identified in our literature review are up-to-date and based on reliable data sources from United States settings, and can inform future studies of HPV vaccination cost-effectiveness in the United States. However, careful consideration is warranted to determine the most appropriate cost values to apply. |
The cost of influenza-associated hospitalizations and outpatient visits in Kenya
Emukule GO , Ndegwa LK , Washington ML , Paget JW , Duque J , Chaves SS , Otieno NA , Wamburu K , Ndigirigi IW , Muthoka PM , Van Der Velden K , Mott JA . BMC Public Health 2019 19 471 Background: We estimated the cost-per-episode and the annual economic burden associated with influenza in Kenya. Methods: From July 2013-August 2014, we recruited patients with severe acute respiratory illness (SARI) or influenza-like illness (ILI) associated with laboratory-confirmed influenza from 5 health facilities. A structured questionnaire was used to collect direct costs (medications, laboratory investigations, hospital bed fees, hospital management costs, transportation) and indirect costs (productivity losses) associated with an episode of influenza. We used published incidence of laboratory-confirmed influenza associated with SARI and ILI, and the national population census data from 2014, to estimate the annual national number of influenza-associated hospitalizations and outpatient visits and calculated the annual economic burden by multiplying cases by the mean cost. Results: We enrolled 275 patients (105 inpatients and 170 outpatients). The mean cost-per-episode of influenza was US$117.86 (standard deviation [SD], 88.04) among inpatients; US$114.25 (SD, 90.03) for children < 5 years, and US$137.45 (SD, 76.24) for persons aged ≥5 years. Among outpatients, the mean cost-per-episode of influenza was US$19.82 (SD, 27.29); US$21.49 (SD, 31.42) for children < 5 years, and US$16.79 (SD, 17.30) for persons aged ≥5 years. National annual influenza-associated cost estimates ranged from US$2.96-5.37 million for inpatients and US$5.96-26.35 million for outpatients. Conclusions: Our findings highlight influenza as causing substantial economic burden in Kenya. Further studies may be warranted to assess the potential benefit of targeted influenza vaccination strategies. |
Healthcare and associated costs related to type 2 diabetes in youth and adolescence: the TODAY clinical trial experience
Songer TJ , Haymond MW , Glazner JE , Klingensmith GJ , Laffel LM , Zhang P , Hirst K . Pediatr Diabetes 2019 20 (6) 702-711 The economic issues related to medical treatments in youth with type 2 diabetes (T2D) are rarely reported and thus not fully understood. The TODAY clinical trial of youth recently diagnosed with T2D collected healthcare and related cost information from the largest cohort studied to date. Costs related to medical treatments and expenses faced by caregivers were identified over a two-year period from 496 participants. Data were collected by surveys and diaries to document frequency of use of diabetes care (excluding study laboratory tests), non-diabetes care services and treatments, caregiver time, and expenses related to exercise and dietary activities recommended for patients. Economic costs were derived by applying national cost values to the reported utilization frequency data. Annual medical costs in the first year varied by treatment group, averaging $1798 in those assigned to metformin alone (M), $2971 to combination drug therapy with metformin + rosiglitazone (M+R), and $2092 to metformin + an intensive lifestyle and behavior change program (M+L). Differences were primarily due to costs related to combination drug therapy. Adult caregiver support costs were higher for participants in the lifestyle program, which was delivered in weekly sessions in the first six months. Expenses for purchases to enhance diet and exercise change did not vary by treatment assignment. In year 2, medication costs increased in M and M+L due to the initiation of insulin in subjects who failed to maintain glycemic control on the assigned treatment. Data are reported for use by researchers and those providing healthcare to this vulnerable patient population. This article is protected by copyright. All rights reserved. |
Awardee-specific economic costs of providing cancer screening and health promotional services to medically underserved women eligible in the National Breast and Cervical Cancer Early Detection Program
Subramanian S , Ekwueme DU , Miller JW , Khushalani JS , Trogdon JG , Wong FL . Cancer Causes Control 2019 30 (8) 827-834 OBJECTIVES: To estimate awardee-specific costs of delivering breast and cervical cancer screening services in their jurisdiction and to assess potential variation in the cost of key activities across awardees. METHODS: We developed the cost assessment tool to collect resource use and cost data from the National Breast and Cervical Cancer Early Detection Program awardees for 3 years between 2006 and 2010 and generated activity-based cost estimates. We estimated awardee-specific cost per woman served for all activities, clinical screening delivery services, screening promotion interventions, and overarching program support activities. RESULTS: The total cost per woman served by the awardees varied greatly from $205 (10th percentile) to $499 (90th percentile). Differences in the average (median) cost per person served for clinical services, health promotion interventions, and overarching support activities ranged from $51 to $125. CONCLUSIONS: The cost per woman served varied across awardee and likely reflected underlying differences across awardees in terms of screening infrastructure, population served, and barriers to screening uptake. Collecting information on contextual factors at the awardee, health system, provider, and individual levels may assist in understanding this variation in cost. |
An educational intervention to promote appropriate antibiotic use for acute respiratory infections in a district in Egypt- pilot study
Kandeel A , Palms DL , Afifi S , Kandeel Y , Etman A , Hicks LA , Talaat M . BMC Public Health 2019 19 498 Background: Antibiotic overuse is the most important modifiable factor contributing to antibiotic resistance. We conducted an educational campaign in Minya, Egypt targeting prescribers and the public through communications focused on appropriate antibiotic use for acute respiratory infections (ARIs). Methods: The entire population of Minya was targeted by the campaign. Physicians and pharmacists were invited to participate in the pre-intervention assessments. Acute care hospitals and a sample of primary healthcare centers in Minya were randomly selected for a pre-intervention survey and all patients exiting outpatient clinics on the day of the survey were invited to participate. The same survey methodology was conducted for the post-intervention assessments. Descriptive comparisons were made through three assessments conducted pre- and post-intervention. We quantitated antibiotic prescribing through a survey administered to patients with an ARI exiting outpatient clinics. Additionally, physicians, pharmacists, and patients were interviewed regarding their attitudes and beliefs towards antibiotic prescribing. Finally, physicians were tested on three clinical scenarios (cold, bronchitis, and sinusitis) to measure their knowledge on antibiotic use. Results: Post-intervention patient exit surveys revealed a 23.1% decrease in antibiotic prescribing for ARIs in this population (83.7 to 64.4%) and physicians and pharmacists self-reported less frequently prescribing antibiotics for ARIs on their follow-up surveys. We also found an increase in correct responses to the clinical scenarios and in attitude and belief scores for physicians, pharmacists, and patients regarding antibiotic use in the post-intervention sample. Conclusions: Overall, the samples surveyed after the community-based educational campaign reported a lower frequency of antibiotic prescribing and improved knowledge and attitudes regarding antibiotic misuse compared to the samples surveyed before the campaign. Ongoing interventions educating providers and patients are needed to decrease antibiotic misuse and reduce the spread of antibiotic resistance in Egypt. |
Notes from the Field: Verona integron-encoded metallo-beta-lactamase-producing carbapenem-resistant Pseudomonas aeruginosa infections in U.S. residents associated with invasive medical procedures in Mexico, 2015-2018
Kracalik I , Ham C , Smith AR , Vowles M , Kauber K , Zambrano M , Rodriguez G , Garner K , Chorbi K , Cassidy PM , McBee S , Stoney R , Brown AC , Moser K , Villarino ME , Walters MS . MMWR Morb Mortal Wkly Rep 2019 68 (20) 463-464 Verona integron-encoded metallo-β-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA) and other carbapenemase-producing organisms represent an emerging U.S. public health threat because of high levels of antibiotic resistance and the potential for rapid spread in health care facilities (1,2). During September 18–November 19, 2018, CDC received 31 reports of VIM-CRPA through the Antibiotic Resistance Laboratory Network. Six cases (19%) occurred in U.S. patients who had recently undergone invasive medical procedures in Mexico. To identify additional cases (defined as isolation of VIM-CRPA from a patient who had an invasive procedure in Mexico in the month preceding specimen collection), CDC and state partners posted an Epi-X alert on November 19, 2018, and issued notifications through the Emerging Infections Network and to medical professional societies. As of January 18, 2019, a total of 12 cases had been identified in seven states, including four in Utah, three in Washington, and one each in Arizona, Arkansas, Oregon, Texas, and West Virginia; specimen collection months ranged from November 2015 through December 2018 (Figure). |
A national survey of testing and management of asymptomatic carriage of C. difficile
Kutty PK , Beekmann SE , Sinkowitz-Cochran RL , Dubberke ER , Kuhar DT , McDonald LC , Polgreen PM . Infect Control Hosp Epidemiol 2019 40 (7) 1-3 A nationwide survey indicated that screening for asymptomatic carriers of C. difficile is an uncommon practice in US healthcare settings. Better understanding of the role of asymptomatic carriage in C. difficile transmission, and of the measures available to reduce that risk, are needed to inform best practices regarding the management of carriers. |
Inappropriate use of antibiotics for childhood diarrhea case management - Kenya, 2009-2016
Rhee C , Aol G , Ouma A , Audi A , Muema S , Auko J , Omore R , Odongo G , Wiegand RE , Montgomery JM , Widdowson MA , O'Reilly CE , Bigogo G , Verani JR . BMC Public Health 2019 19 468 Background: Antibiotics are essential to treat for many childhood bacterial infections; however inappropriate antibiotic use contributes to antimicrobial resistance. For childhood diarrhea, empiric antibiotic use is recommended for dysentery (bloody diarrhea) for which first-line therapy is ciprofloxacin. We assessed inappropriate antibiotic prescription for childhood diarrhea in two primary healthcare facilities in Kenya. Methods: We analyzed data from the Kenya Population Based Infectious Disease Surveillance system in Asembo (rural, malaria-endemic) and Kibera (urban slum, non-malaria-endemic). We examined records of children aged 2-59 months with diarrhea (≥3 loose stools in 24 h) presenting for care from August 21, 2009 to May 3, 2016, excluding visits with non-diarrheal indications for antibiotics. We examined the frequency of antibiotic over-prescription (antibiotic prescription for non-dysentery), under-prescription (no antibiotic prescription for dysentery), and inappropriate antibiotic selection (non-recommended antibiotic). We examined factors associated with over-prescription and under-prescription using multivariate logistic regression with generalized estimating equations. Results: Of 2808 clinic visits with diarrhea in Asembo, 2685 (95.6%) were non-dysentery visits and antibiotic over-prescription occurred in 52.5%. Of 4697 clinic visits with diarrhea in Kibera, 4518 (96.2%) were non-dysentery and antibiotic over-prescription occurred in 20.0%. Antibiotic under-prescription was noted in 26.8 and 73.7% of dysentery cases in Asembo and Kibera, respectively. Ciprofloxacin was used for 11% of dysentery visits in Asembo and 0% in Kibera. Factors associated with over- and under-prescription varied by site. In Asembo a discharge diagnosis of gastroenteritis was associated with over-prescription (adjusted odds ratio [aOR]:8.23, 95% confidence interval [95%CI]: 3.68-18.4), while malaria diagnosis was negatively associated with antibiotic over-prescription (aOR 0.37, 95%CI: 0.25-0.54) but positively associated with antibiotic under-prescription (aOR: 1.82, 95%CI: 1.05-3.13). In Kibera, over-prescription was more common among visits with concurrent signs of respiratory infection (difficulty breathing; aOR: 3.97, 95%CI: 1.28-12.30, cough: aOR: 1.42, 95%CI: 1.06-1.90) and less common among children aged < 1 year (aOR: 0.82, 95%CI: 0.71-0.94). Conclusions: Inappropriate antibiotic prescription was common in childhood diarrhea management and efforts are needed to promote rational antibiotic use. Interventions to improve antibiotic use for diarrhea should consider the influence of malaria diagnosis on clinical decision-making and address both over-prescription, under-prescription, and inappropriate antibiotic selection. |
Population-based bloodstream infection surveillance in rural Thailand, 2007-2014
Rhodes J , Jorakate P , Makprasert S , Sangwichian O , Kaewpan A , Akarachotpong T , Srisaengchai P , Thamthitiwat S , Khemla S , Yuenprakhon S , Paveenkittiporn W , Kerdsin A , Whistler T , Baggett HC , Gregory CJ . BMC Public Health 2019 19 521 Background: Bloodstream infection (BSI) surveillance is essential to characterize the public health threat of bacteremia. We summarize BSI epidemiology in rural Thailand over an eight year period. Methods: Population-based surveillance captured clinically indicated blood cultures and associated antimicrobial susceptibility results performed in all 20 hospitals in Nakhon Phanom (NP) and Sa Kaeo (SK) provinces. BSIs were classified as community-onset (CO) when positive cultures were obtained ≤2 days after hospital admission and hospital-onset (HO) thereafter. Hospitalization denominator data were available for incidence estimates for 2009-2014. Results: From 2007 to 2014 a total of 11,166 BSIs were identified from 134,441 blood cultures. Annual CO BSI incidence ranged between 89.2 and 123.5 cases per 100,000 persons in SK and NP until 2011. Afterwards, CO incidence remained stable in SK and increased in NP, reaching 155.7 in 2013. Increases in CO BSI incidence over time were limited to persons aged ≥50 years. Ten pathogens, in rank order, accounted for > 65% of CO BSIs in both provinces, all age-groups, and all years: Escherichia coli, Klebsiella pneumoniae, Burkholderia pseudomallei, Staphylococcus aureus, Salmonella non-typhi spp., Streptococcus pneumoniae, Acinetobacter spp., Streptococcus agalactiae, Streptococcus pyogenes, Pseudomonas aeruginosa. HO BSI incidence increased in NP from 0.58 cases per 1000 hospitalizations in 2009 to 0.91 in 2014, but were higher (ranging from 1.9 to 2.3) in SK throughout the study period. Extended-spectrum beta-lactamase production among E. coli isolates and multi-drug resistance among Acinetobacter spp. isolates was common (> 25% of isolates), especially among HO cases (> 50% of isolates), and became more common over time, while methicillin-resistance among S. aureus isolates (10%) showed no clear trend. Carbapenem-resistant Enterobacteriaceae were documented in 2011-2014. Conclusions: Population-based surveillance documented CO BSI incidence estimates higher than previously reported from Thailand and the region, with temporal increases seen in older populations. The most commonly observed pathogens including resistance profiles were similar to leading pathogens and resistance profiles worldwide, thus; prevention strategies with demonstrated success elsewhere may prove effective in Thailand. |
A mathematical model to describe survival among liver recipients from deceased donors with risk of transmitting infectious encephalitis pathogens
Smalley HK , Anand N , Buczek D , Buczek N , Lin T , Rajore T , Wacker M , Basavaraju SV , Gurbaxani BM , Hammett T , Keskinocak P , Sokol J , Kuehnert MJ . Transpl Infect Dis 2019 21 (4) e13115 BACKGROUND: Between 2002 and 2013, the organs of thirteen deceased donors with infectious encephalitis were transplanted, causing infections in 23 recipients. As a consequence, organs from donors showing symptoms of encephalitis (increased probability of infectious encephalitis (IPIE) organs) might be declined. We had previously characterized the risk of IPIE organs using data available to most transplant teams and not requiring special diagnostic tests. If the probability of infection is low, the benefits of a transplant from a donor with suspected infectious encephalitis might outweigh the risk and could be lifesaving for some transplant candidates. METHODS: Using organ transplant data and Cox Proportional Hazards models, we determined liver donor and recipient characteristics predictive of post-transplant or waitlist survival and generated 5-year survival probability curves. We also calculated expected waiting times for an organ offer based on transplant candidate characteristics. Using a limited set of actual cases of infectious encephalitis transmission via transplant, we estimated post-transplant survival curves given an organ from an IPIE donor. RESULTS: 54% (1,256) of patients registered from 2002-2006 who died or were removed from the waiting list due to deteriorated condition within 1 year could have had an at least marginal estimated benefit by accepting an IPIE liver with some probability of infection, with the odds increasing to 86% of patients if the probability of infection was low (5% or less). Additionally, 54% (1,252) were removed from the waiting list prior to their estimated waiting time for a non-IPIE liver and could have benefited from an IPIE liver. CONCLUSION: Improved allocation and utilization of IPIE livers could be achieved by evaluating the patient-specific trade-offs between (i) accepting an IPIE liver and (ii) remaining on the waitlist and accepting a non-IPIE liver after the estimated waiting time. This article is protected by copyright. All rights reserved. |
Broadening the infection prevention and control network globally; 2017 Geneva IPC-think tank (part 3)
Zingg W , Storr J , Park BJ , Jernigan JA , Harbarth S , Grayson ML , Tacconelli E , Allegranzi B , Cardo D , Pittet D . Antimicrob Resist Infect Control 2019 8 (1) 74 Background: Healthcare-associated infection (HAI) is a major challenge for patient safety worldwide, and is further complicated by antimicrobial resistance (AMR) due to excessive antimicrobial use in both humans and animals. Existing infection prevention and control (IPC) networks must be strengthened and adapted to better address the global challenges presented by emerging AMR. Methods: In June 2017, 42 international experts convened in Geneva, Switzerland, to discuss two key areas for strengthening the global IPC network: 1) broadening collaboration in IPC; and 2) how to bring the fields IPC and AMR control together. Results: The US Centers for Disease Prevention and Control, the European Centre for Disease Prevention and Control, and the World Health Organization (WHO) convened together with international experts to discuss collaboration and networks, demonstrating the participating organizations' commitment to close collaboration in IPC. The challenge of emerging AMR can only be addressed by strengthening this collaboration across international organisations and between public health and academia. The WHO SAVE LIVES: Clean Your Hands initiative is an example of a successful collaboration between multiple global stakeholders including academia and international public health organisations; it can be used as a model. IPC-strategies are included within the four pillars to combat AMR: surveillance, IPC, antimicrobial and diagnostic stewardship, research and development. The prevention of transmission of multidrug-resistant microorganisms is a patient safety issue, and must be strengthened in the fight against AMR. Conclusions: The working group determined that international organisations should take the lead in creating new networks, which will in turn attract academia and other stakeholders to join. At the same time, they should invest in bringing existing IPC and AMR networks under one umbrella. Transmission of multidrug-resistant microorganisms in hospitals and in the community threatens the success of antimicrobial stewardship programmes, and thus, research and development in IPC should be addressed as an enhanced global priority. |
Finding inhabited settlements and tracking vaccination progress: the application of satellite imagery analysis to guide the immunization response to confirmation of previously-undetected, ongoing endemic wild poliovirus transmission in Borno State, Nigeria
Higgins J , Adamu U , Adewara K , Aladeshawe A , Aregay A , Barau I , Berens A , Bolu O , Dutton N , Iduma N , Jones B , Kaplan B , Meleh S , Musa M , Wa Nganda G , Seaman V , Sud A , Vouillamoz S , Wiesen E . Int J Health Geogr 2019 18 (1) 11 BACKGROUND: Four wild polio-virus cases were reported in Borno State, Nigeria 2016, 1 year after Nigeria had been removed from the list of polio endemic countries by the World Health Organization. Resulting from Nigeria's decade long conflict with Boko Haram, health officials had been unable to access as much as 60% of the settlements in Borno, hindering vaccination and surveillance efforts. This lack of accessibility made it difficult for the government to assess the current population distribution within Borno. This study aimed to use high resolution, visible band satellite imagery to assess the habitation of inaccessible villages in Borno State. METHODS: Using high resolution (31-50 cm) imagery from DigitalGlobe, analysts evaluated the habitation status of settlements in Borno State identified by Nigeria's Vaccination Tracking System. The analysts looked at imagery of each settlement and, using vegetation (overgrowth vs. cleared) as a proxy for human habitation, classified settlements into three categories: inhabited, partially abandoned, and abandoned. Analysts also classified the intact percentage of each settlement starting at 0% (totally destroyed since last assessment) and increasing in 25% intervals through 100% (completely intact but not expanded) up to 200+% (more than doubled in size) by looking for destroyed buildings. These assessments were then used to adjust previously established population estimates for each settlement. These new population distributions were compared to vaccination efforts to determine the number of children under 5 unreached by vaccination teams. RESULTS: Of the 11,927 settlements assessed 3203 were assessed as abandoned (1892 of those completely destroyed), 662 as partially abandoned, and 8062 as fully inhabited as of December of 2017. Comparing the derived population estimates from the new assessments to previous assessment and the activities of vaccination teams shows that an estimated 180,155 of the 337,411 under five children who were unreached in 2016 were reached in 2017 (70.5% through vaccination efforts in previously inaccessible areas, 29.5% through displacement to accessible areas). CONCLUSIONS: This study's methodology provides important planning and situation awareness information to health workers in Borno, Nigeria, and may serve as a model for future data gathering efforts in inaccessible regions. |
Extended delivery of vaccines to the skin improves immune responses.
Joyce JC , Sella HE , Jost H , Mistilis MJ , Esser ES , Pradhan P , Toy R , Collins ML , Rota PA , Roy K , Skountzou I , Compans RW , Oberste MS , Weldon WC , Norman JJ , Prausnitz MR . J Control Release 2019 304 135-145 Vaccines prevent 2-3 million childhood deaths annually; however, low vaccine efficacy and the resulting need for booster doses create gaps in immunization coverage. In this translational study, we explore the benefits of extended release of licensed vaccine antigens into skin to increase immune responses after a single dose in order to design improved vaccine delivery systems. By administering daily intradermal injections of inactivated polio vaccine according to six different delivery profiles, zeroth-order release over 28days resulted in neutralizing antibody titers equivalent to two bolus vaccinations administered one month apart. Vaccinations following this profile also improved immune responses to tetanus toxoid and subunit influenza vaccine but not a live-attenuated viral vaccine, measles vaccine. Finally, using subunit influenza vaccine, we demonstrated that daily vaccination by microneedle patch induced a potent, balanced humoral immunity with an increased memory response compared to bolus vaccination. We conclude that extended presentation of antigen in skin via intradermal injection or microneedle patch can enhance immune responses and reduce the number of vaccine doses, thereby enabling increased vaccination efficacy. |
HPV vaccine status and sexual behavior among young sexually-active women in the US: evidence from the National Health and Nutrition Examination Survey, 2007-2014
Leidner AJ , Chesson HW , Talih M . Health Econ Policy Law 2019 15 (4) 1-19 Concern has been expressed that human papillomavirus (HPV) vaccination programs might promote risky sexual behavior through mechanisms such as risk compensation, behavioral disinhibition, or perceived endorsement of sexual activity. This study assesses whether HPV vaccination status is associated with any differences in selected sexual behaviors among young sexually-active women in the US. Our dataset includes young, adult female respondents from questionnaire data collected in the National Center for Health Statistics' National Health and Nutrition Examination Survey from 2007 to 2014. The empirical approach implements a doubly robust estimation procedure, based on inverse probability of treatment weighting. For robustness, we implement several specifications for the propensity model and the outcomes model. We find no consistent association between HPV vaccination and condom usage or frequency of sex. Specifically, we find no evidence that HPV vaccination is associated with condom usage or with whether a person had sex more than 52 or more than 104 times per year. We find inconsistent evidence that HPV vaccination is associated with a person having sex more than 12 times per year. As in previous research, HPV vaccination does not appear to have a substantive effect on sexual behavior among young sexually-active women in the US. |
Increasing HPV vaccination rates through national provider partnerships
Mitchell K , Saraiya M , Bhatt A . J Womens Health (Larchmt) 2019 28 (6) 747-751 Human papillomavirus (HPV) vaccine is routinely recommended for adolescents at age 11 or 12 years for protection from cancers and other diseases caused by HPV infection. In 2012, only 53.8% of females and 20.8% of males aged 13-17 received one or more doses of HPV vaccine. Due to low vaccination uptake, the Centers for Disease Control and Prevention supported the efforts of several national partner organizations to help raise HPV vaccination rates. National partners include the Academic Pediatric Association, the American Academy of Pediatrics, the American Cancer Society, the National Area Health Education Centers Organization, and the National Association of County and City Health Officials. These national partners have focused on improving provider education on effective HPV vaccine recommendations, prioritizing HPV vaccination, forming strong partnerships, developing and disseminating HPV vaccination resources for members and the public, and quality improvement. |
Comparison of a frailty short interview to a validated frailty index in adults hospitalized for acute respiratory illness
Petrie JG , Martin ET , Zhu Y , Wyatt DG , Kaniclides A , Ferdinands JM , Monto AS , Trabue C , Talbot HK . Vaccine 2019 37 (29) 3849-3855 BACKGROUND: Frailty is an important physiologic factor in studies of influenza and influenza vaccines carried out in older adults and hospitalized populations. Unfortunately, comprehensive assessments of frailty requiring physical assessments and extensive medical record review are not often feasible in time- and resource-limited settings common to studies of influenza and influenza vaccines. METHODS: We developed a 5-question frailty short interview, and implemented it in a multicenter, hospital-based study of influenza over two years. Frailty status defined by the frailty short interview was compared to a validated frailty index based on medical record review of 59 parameters. Agreement between the two frailty measures was assessed, and multivariable linear regression models were used to explore differences between the measures. The association between each frailty measure and likelihood of influenza vaccination was also assessed. RESULTS: During the 2015-2016 and 2016-2017 influenza seasons, 2070 adult patients hospitalized with acute respiratory illness were enrolled and included in analyses. Frailty was frequently identified in the study population; 43% of participants were defined as frail by the frailty short interview and 32% by frailty index. Responses to the frailty short interview were only moderately correlated with the frailty index, and agreement between the two frailty measures was low. Women were more likely to be defined as frail by the frailty short interview than men. White individuals were more likely than other races to be defined as frail by the frailty index. Increasing frailty index was associated with increased likelihood of influenza vaccination, but the frailty short interview was not associated with vaccination. CONCLUSIONS: The frailty short interview provided a feasible and consistent measure of frailty across study hospitals and study years. However, its modest correlation with the frailty index and differential association with likelihood of influenza vaccination highlight differences in the conceptualization of frailty. |
Immunogenicity of full and fractional dose of inactivated poliovirus vaccine for use in routine immunisation and outbreak response: an open-label, randomised controlled trial
Snider CJ , Zaman K , Estivariz CF , Yunus M , Weldon WC , Wannemuehler KA , Oberste MS , Pallansch MA , Wassilak SG , Bari TIA , Anand A . Lancet 2019 393 (10191) 2624-2634 BACKGROUND: Intradermal administration of fractional inactivated poliovirus vaccine (fIPV) is a dose-sparing alternative to the intramuscular full dose. We aimed to compare the immunogenicity of two fIPV doses versus one IPV dose for routine immunisation, and also assessed the immunogenicity of an fIPV booster dose for an outbreak response. METHODS: We did an open-label, randomised, controlled, inequality, non-inferiority trial in two clinics in Dhaka, Bangladesh. Healthy infants were randomly assigned at 6 weeks to one of four groups: group A received IPV at age 14 weeks and IPV booster at age 22 weeks; group B received IPV at age 14 weeks and fIPV booster at age 22 weeks; group C received IPV at age 6 weeks and fIPV booster at age 22 weeks; and group D received fIPV at 6 weeks and 14 weeks and fIPV booster at age 22 weeks. IPV was administered by needle-syringe as an intramuscular full dose (0.5 mL), and fIPV was administered intradermally (0.1 mL of the IPV formulation was administered using the 0.1 mL HelmJect auto-disable syringe with a Helms intradermal adapter). Both IPV and fIPV were administered on the outer, upper right thigh of infants. The primary outcome was vaccine response to poliovirus types 1, 2, and 3 at age 22 weeks (routine immunisation) and age 26 weeks (outbreak response). Vaccine response was defined as seroconversion from seronegative (<1:8) at baseline to seropositive (>/=1:8) or four-fold increase in reciprocal antibody titres adjusted for maternal antibody decay and was assessed in the modified intention-to-treat population (infants who received polio vaccines per group assignment and polio antibody titre results to serotypes 1, 2, and 3 at 6, 22, 23, and 26 weeks of age). The non-inferiority margin was 12.5%. This trial is registered with ClinicalTrials.gov, number NCT02847026. FINDINGS: Between Sept 1, 2016 and May 2, 2017, 1076 participants were randomly assigned and included in the modified intention-to-treat analysis: 271 in Group A, 267 in group B, 268 in group C, and 270 in group D. Vaccine response at 22 weeks to two doses of fIPV (group D) was significantly higher (p<0.0001) than to one dose of IPV (groups A and B) for all three poliovirus serotypes: the type 1 response comprised 212 (79% [95% CI 73-83]) versus 305 (57% [53-61]) participants, the type 2 response comprised 173 (64% [58-70]) versus 249 (46% [42-51]) participants, and the type 3 response comprised 196 (73% [67-78]) versus 196 (36% [33-41]) participants. At 26 weeks, the fIPV booster was non-inferior to IPV (group B vs group A) for serotype 1 (-1.12% [90% CI -2.18 to -0.06]), serotype 2 (0.40%, [-2.22 to 1.42]), and serotype 3 (1.51% [-3.23 to -0.21]). Of 129 adverse events, 21 were classified as serious including one death; none were attributed to IPV or fIPV. INTERPRETATION: fIPV appears to be an effective dose-sparing strategy for routine immunisation and outbreak responses. FUNDING: US Centers for Disease Control and Prevention. |
Automated detection of sudden unexpected death in epilepsy risk factors in electronic medical records using natural language processing
Barbour K , Hesdorffer DC , Tian N , Yozawitz EG , McGoldrick PE , Wolf S , McDonough TL , Nelson A , Loddenkemper T , Basma N , Johnson SB , Grinspan ZM . Epilepsia 2019 60 (6) 1209-1220 OBJECTIVE: Sudden unexpected death in epilepsy (SUDEP) is an important cause of mortality in epilepsy. However, there is a gap in how often providers counsel patients about SUDEP. One potential solution is to electronically prompt clinicians to provide counseling via automated detection of risk factors in electronic medical records (EMRs). We evaluated (1) the feasibility and generalizability of using regular expressions to identify risk factors in EMRs and (2) barriers to generalizability. METHODS: Data included physician notes for 3000 patients from one medical center (home) and 1000 from five additional centers (away). Through chart review, we identified three SUDEP risk factors: (1) generalized tonic-clonic seizures, (2) refractory epilepsy, and (3) epilepsy surgery candidacy. Regular expressions of risk factors were manually created with home training data, and performance was evaluated with home test and away test data. Performance was evaluated by sensitivity, positive predictive value, and F-measure. Generalizability was defined as an absolute decrease in performance by <0.10 for away versus home test data. To evaluate underlying barriers to generalizability, we identified causes of errors seen more often in away data than home data. To demonstrate how small revisions can improve generalizability, we removed three "boilerplate" standard text phrases from away notes and repeated performance. RESULTS: We observed high performance in home test data (F-measure range = 0.86-0.90), and low to high performance in away test data (F-measure range = 0.53-0.81). After removing three boilerplate phrases, away performance improved (F-measure range = 0.79-0.89) and generalizability was achieved for nearly all measures. The only significant barrier to generalizability was use of boilerplate phrases, causing 104 of 171 errors (61%) in away data. SIGNIFICANCE: Regular expressions are a feasible and probably a generalizable method to identify variables related to SUDEP risk. Our methods may be implemented to create large patient cohorts for research and to generate electronic prompts for SUDEP counseling. |
National health information systems for achieving the Sustainable Development Goals
Suthar AB , Khalifa A , Joos O , Manders EJ , Abdul-Quader A , Amoyaw F , Aoua C , Aynalem G , Barradas D , Bello G , Bonilla L , Cheyip M , Dalhatu IT , De Klerk M , Dee J , Hedje J , Jahun I , Jantaramanee S , Kamocha S , Lerebours L , Lobognon LR , Lote N , Lubala L , Magazani A , Mdodo R , Mgomella GS , Monique LA , Mudenda M , Mushi J , Mutenda N , Nicoue A , Ngalamulume RG , Ndjakani Y , Nguyen TA , Nzelu CE , Ofosu AA , Pinini Z , Ramirez E , Sebastian V , Simanovong B , Son HT , Son VH , Swaminathan M , Sivile S , Teeraratkul A , Temu P , West C , Xaymounvong D , Yamba A , Yoka D , Zhu H , Ransom RL , Nichols E , Murrill CS , Rosen D , Hladik W . BMJ Open 2019 9 (5) e027689 OBJECTIVES: Achieving the Sustainable Development Goals will require data-driven public health action. There are limited publications on national health information systems that continuously generate health data. Given the need to develop these systems, we summarised their current status in low-income and middle-income countries. SETTING: The survey team jointly developed a questionnaire covering policy, planning, legislation and organisation of case reporting, patient monitoring and civil registration and vital statistics (CRVS) systems. From January until May 2017, we administered the questionnaire to key informants in 51 Centers for Disease Control country offices. Countries were aggregated for descriptive analyses in Microsoft Excel. RESULTS: Key informants in 15 countries responded to the questionnaire. Several key informants did not answer all questions, leading to different denominators across questions. The Ministry of Health coordinated case reporting, patient monitoring and CRVS systems in 93% (14/15), 93% (13/14) and 53% (8/15) of responding countries, respectively. Domestic financing supported case reporting, patient monitoring and CRVS systems in 86% (12/14), 75% (9/12) and 92% (11/12) of responding countries, respectively. The most common uses for system-generated data were to guide programme response in 100% (15/15) of countries for case reporting, to calculate service coverage in 92% (12/13) of countries for patient monitoring and to estimate the national burden of disease in 83% (10/12) of countries for CRVS. Systems with an electronic component were being used for case reporting, patient monitoring, birth registration and death registration in 87% (13/15), 92% (11/12), 77% (10/13) and 64% (7/11) of responding countries, respectively. CONCLUSIONS: Most responding countries have a solid foundation for policy, planning, legislation and organisation of health information systems. Further evaluation is needed to assess the quality of data generated from systems. Periodic evaluations may be useful in monitoring progress in strengthening and harmonising these systems over time. |
Nighttime seat belt use among front seat passengers: Does the driver's belt use matter
Boakye KF , Shults RA , Everett JD . J Safety Res 2019 70 13-17 Introduction and Method: We explored the relationship between nighttime seat belt use of right-front passengers and their drivers using observational data from 33,310 vehicles in east Tennessee during March 2015 – May 2017. Results: Overall, nighttime passenger seat belt use varied by 50 percentage points from 92% when drivers were belted to 42% when drivers were not belted, suggesting that part-time seat belt users can be heavily influenced by the seat belt status of their traveling companions. When stratified by vehicle type and sex, passenger seat belt use by driver seat belt status varied as much as 74 percentage points from 96% to 22%. Passenger seat belt use was typically lower when riding with unbelted same-sex drivers than when riding with unbelted drivers of the opposite sex. Conclusions and Practical Applications: This finding suggests that the role of peer influence in decision-making about seat belt use may differ depending on the sex of a vehicle driver and his or her passengers. Further research is warranted to explore this finding as well as other social and cultural influences that have not been fully examined in seat belt research. |
Risk of repeat concussion among patients diagnosed at a pediatric care network
Curry AE , Arbogast KB , Metzger KB , Kessler RS , Breiding MJ , Haarbauer-Krupa J , DePadilla L , Greenspan A , Master CL . J Pediatr 2019 210 13-19 e2 OBJECTIVE: To quantify the risk of repeat concussions for children and identify demographic and clinical aspects of the index concussion associated with repeat injury. STUDY DESIGN: For this retrospective cohort study, we queried the Children's Hospital of Philadelphia healthcare network's unified electronic health record to identify all 5- to 15-year-old patients who had their first clinical visit for an index concussion at a Children's Hospital of Philadelphia location from July 2012 through June 2013. A 25% random sample (n = 536) were selected. Clinical data were abstracted for their index concussion and all concussion-related visits for 2 years following the index concussion. RESULTS: Overall, 16.2% (n = 87) of patients experienced at least 1 repeat concussion within 2 years of their index concussion. The risk of repeat concussion increased with patient age (9.5% for ages 5-8 years; 10.7% for ages 9-11 years; and 19.8% for ages 12-15 years). After we adjusted for other factors, risk was particularly heightened among patients whose index concussion had a longer clinical course (>30 vs 0-7 days, adjusted risk ratio 1.65 [1.01-2.69]) and greater symptom burden (>11 vs 0-2 symptoms, adjusted risk ratio 2.12 [1.12-3.72]). CONCLUSIONS: We estimate that 1 in 6 youth diagnosed with a concussion are diagnosed with a subsequent concussion within 2 years and that several clinical characteristics of the index concussion increase this risk. Identifying factors associated with a repeat injury is essential to inform the clinical management of concussion and direct injury prevention efforts. |
Effectiveness of the US Centers for Disease Control and Prevention HEADS UP coaches online training as an educational intervention
Daugherty J , DePadilla L , Sarmiento K . Health Educ J 2019 78 (7) 784-797 Background: Concussions are common among youth athletes. Responsibility for the recognition and management of concussion is often put on coaches. To equip coaches with appropriate knowledge and skills, the US Centers for Disease Control and Prevention (CDC) launched the HEADS UP: Concussion in Youth Sports online training. Objectives: To determine whether HEADS UP coaches’ training improves knowledge, attitudes and behavioural intentions. Methods: Knowledge questions were grouped into scales by level of difficulty. Differences between pre- and post-test scores were calculated based on the Wilcoxon Signed Rank Test Z-score and effect sizes were interpreted. Results: Coaches displayed a high level of knowledge in the pre-test. While lower difficulty questions did not show improvement from pre- to post-test, moderate and high difficulty questions did. Use of the training was associated with improved knowledge about symptom resolution, return-to-play recommendations and under-reporting of incidents of concussion. Coaches demonstrated improvement in five of the seven concussion-related attitude and behavioural intention items post training. Conclusion: HEADS UP training improved coaches’ knowledge on select topics and helped them feel more comfortable about responding to concussion among their athletes. This study provides insight into how to better focus future HEADS UP concussion health education efforts to fit coaches’ informational needs. |
A ten-year China-US laboratory collaboration: improving response to influenza threats in China and the world, 2004-2014.
Shu Y , Song Y , Wang D , Greene CM , Moen A , Lee CK , Chen Y , Xu X , McFarland J , Xin L , Bresee J , Zhou S , Chen T , Zhang R , Cox N . BMC Public Health 2019 19 520 The emergence of severe acute respiratory syndrome (SARS) underscored the importance of influenza detection and response in China. From 2004, the Chinese National Influenza Center (CNIC) and the United States Centers for Disease Control and Prevention (USCDC) initiated Cooperative Agreements to build capacity in influenza surveillance in China. From 2004 to 2014, CNIC and USCDC collaborated on the following activities: 1) developing human technical expertise in virology and epidemiology in China; 2) developing a comprehensive influenza surveillance system by enhancing influenza-like illness (ILI) reporting and virological characterization; 3) strengthening analysis, utilization and dissemination of surveillance data; and 4) improving early response to influenza viruses with pandemic potential. Since 2004, CNIC expanded its national influenza surveillance and response system which, as of 2014, included 408 laboratories and 554 sentinel hospitals. With support from USCDC, more than 2500 public health staff from China received virology and epidemiology training, enabling > 98% network laboratories to establish virus isolation and/or nucleic acid detection techniques. CNIC established viral drug resistance surveillance and platforms for gene sequencing, reverse genetics, serologic detection, and vaccine strains development. CNIC also built a bioinformatics platform to strengthen data analysis and utilization, publishing weekly on-line influenza surveillance reports in English and Chinese. The surveillance system collects 200,000-400,000 specimens and tests more than 20,000 influenza viruses annually, which provides valuable information for World Health Organization (WHO) influenza vaccine strain recommendations. In 2010, CNIC became the sixth WHO Collaborating Centre for Influenza. CNIC has strengthened virus and data sharing, and has provided training and reagents for other countries to improve global capacity for influenza control and prevention. The collaboration's successes were built upon shared mission and values, emphasis on long-term capacity development and sustainability, and leadership commitment. |
A monoclonal antibody specific for japanese encephalitis virus with high neutralizing capability for inclusion as a positive control in diagnostic neutralization tests
Calvert AE , Bennett SL , Dixon KL , Blair CD , Roehrig JT . Am J Trop Med Hyg 2019 101 (1) 233-236 Japanese encephalitis virus (JEV) is the most common cause of viral encephalitis in Asia, and it is increasingly a global public health concern because of its recent geographic expansion. Although commercial vaccines are available and used in some endemic countries, JEV continues to cause illness, with more than 60,000 cases reported annually. To develop a reproducible positive control antibody useable in diagnosis of JEV infections, murine hybridomas were developed from mice inoculated with a combination of IXIARO JEV vaccine and JEV domain III of the envelope protein (E-DIII). Monoclonal antibodies (MAbs) were characterized for their ability to neutralize virus in vitro. Monoclonal antibody 17BD3-2 was found to be JEV specific and highly neutralizing, with a plaque reduction neutralization test (PRNT)90 endpoint titer of 1.25 mug/mL. The functional epitopes were mapped using virus neutralization escape variants to amino acid residues S309, K312, and G333 in E-DIII. This MAb may be substituted for human immune sera used as a positive control in PRNT for distribution to public health laboratories worldwide in potential future outbreaks of JEV. |
Longitudinal analysis of the human B cell response to Ebola virus infection
Davis CW , Jackson KJL , McElroy AK , Halfmann P , Huang J , Chennareddy C , Piper AE , Leung Y , Albarino CG , Crozier I , Ellebedy AH , Sidney J , Sette A , Yu T , Nielsen SCA , Goff AJ , Spiropoulou CF , Saphire EO , Cavet G , Kawaoka Y , Mehta AK , Glass PJ , Boyd SD , Ahmed R . Cell 2019 177 (6) 1566-1582 e17 Ebola virus (EBOV) remains a public health threat. We performed a longitudinal study of B cell responses to EBOV in four survivors of the 2014 West African outbreak. Infection induced lasting EBOV-specific immunoglobulin G (IgG) antibodies, but their subclass composition changed over time, with IgG1 persisting, IgG3 rapidly declining, and IgG4 appearing late. Striking changes occurred in the immunoglobulin repertoire, with massive recruitment of naive B cells that subsequently underwent hypermutation. We characterized a large panel of EBOV glycoprotein-specific monoclonal antibodies (mAbs). Only a small subset of mAbs that bound glycoprotein by ELISA recognized cell-surface glycoprotein. However, this subset contained all neutralizing mAbs. Several mAbs protected against EBOV disease in animals, including one mAb that targeted an epitope under evolutionary selection during the 2014 outbreak. Convergent antibody evolution was seen across multiple donors, particularly among VH3-13 neutralizing antibodies specific for the GP1 core. Our study provides a benchmark for assessing EBOV vaccine-induced immunity. |
Building laboratory capacity to detect and characterize pathogens of public and global health security concern in Kenya
Hunsperger E , Juma B , Onyango C , Ochieng JB , Omballa V , Fields BS , Njenga MK , Mwangi J , Bigogo G , Omore R , Otieno N , Chaves SS , Munyua P , Njau DM , Verani J , Lowther S , Breiman RF , Montgomery JM , De Cock KM , Widdowson MA . BMC Public Health 2019 19 477 Since 1979, multiple CDC Kenya programs have supported the development of diagnostic expertise and laboratory capacity in Kenya. In 2004, CDC's Global Disease Detection (GDD) program within the Division of Global Health Protection in Kenya (DGHP-Kenya) initiated close collaboration with Kenya Medical Research Institute (KEMRI) and developed a laboratory partnership called the Diagnostic and Laboratory Systems Program (DLSP). DLSP built onto previous efforts by malaria, human immunodeficiency virus (HIV) and tuberculosis (TB) programs and supported the expansion of the diagnostic expertise and capacity in KEMRI and the Ministry of Health. First, DLSP developed laboratory capacity for surveillance of diarrheal, respiratory, zoonotic and febrile illnesses to understand the etiology burden of these common illnesses and support evidenced-based decisions on vaccine introductions and recommendations in Kenya. Second, we have evaluated and implemented new diagnostic technologies such as TaqMan Array Cards (TAC) to detect emerging or reemerging pathogens and have recently added a next generation sequencer (NGS). Third, DLSP provided rapid laboratory diagnostic support for outbreak investigation to Kenya and regional countries. Fourth, DLSP has been assisting the Kenya National Public Health laboratory-National Influenza Center and microbiology reference laboratory to obtain World Health Organization (WHO) certification and ISO15189 accreditation respectively. Fifth, we have supported biosafety and biosecurity curriculum development to help Kenyan laboratories safely and appropriately manage infectious pathogens. These achievements, highlight how in collaboration with existing CDC programs working on HIV, tuberculosis and malaria, the Global Health Security Agenda can have significantly improve public health in Kenya and the region. Moreover, Kenya provides an example as to how laboratory science can help countries detect and control of infectious disease outbreaks and other public health threats more rapidly, thus enhancing global health security. |
Challenges and solutions for instituting an efficient maintenance program for laboratory equipment in Central Asian, and developing world, countries
Ikranbegiin R , Schmid G , Hoos D , Young A , Della-Latta P , Spearman P , Ramos A , Alemayehu B , Achmetova B , Nauryzova G , Albetkova A . BMC Public Health 2019 19 476 We review the current state of quality assurance in laboratories of the five Central Asia Republics (CARs), focusing on laboratory equipment, and compare quality assurance approaches with CLSI standards. The laboratories of the CARs faced exceptional challenges including highly-structured laboratory systems that retain centralized and outmoded Soviet-era approaches to quality assurance, considerably jeopardizing the validity of laboratory tests. The relative isolation of the CARs, based on geography and almost exclusive use of the Russian language, further hamper change. CARs must make high-level government decisions to widely implement quality assurance programs within their laboratory systems, within which approaches to the management of laboratory equipment will be a prominent part. |
Capacity assessment of the health laboratory system in two resource-limited provinces in China
Liu B , Ma F , Rainey JJ , Liu X , Klena J , Liu X , Kan B , Yan M , Wang D , Zhou Y , Tang G , Wang M , Zhao C . BMC Public Health 2019 19 467 Background: Strong laboratory capacity is essential for detecting and responding to emerging and re-emerging global health threats. We conducted a quantitative laboratory assessment during 2014-2015 in two resource-limited provinces in southern China, Guangxi and Guizhou in order to guide strategies for strengthening core capacities as required by the International Health Regulations (IHR 2005). Methods: We selected 28 public health and clinical laboratories from the provincial, prefecture and county levels through a quasi-random sampling approach. The 11-module World Health Organization (WHO) laboratory assessment tool was adapted to the local context in China. At each laboratory, modules were scored 0-100% through a combination of paper surveys, in-person interviews, and visual inspections. We defined module scores as strong (> = 85%), good (70-84%), weak (50-69%), and very weak (< 50%). We estimated overall capacity and compared module scores across the provincial, prefecture, and county levels. Results: Overall, laboratories in both provinces received strong or good scores for 10 of the 11 modules. These findings were primarily driven by strong and good scores from the two provincial level laboratories; prefecture and county laboratories were strong or good for only 8 and 6 modules, respectively. County laboratories received weak scores in 4 modules. The module, 'Public Health Functions' (e.g., surveillance and reporting practices) lagged far behind all other modules (mean score = 46%) across all three administrative levels. Findings across the two provinces were similar. Conclusions: Laboratories in Guangxi and Guizhou are generally performing well in laboratory capacity as required by IHR. However, we recommend targeted interventions particularly for county-level laboratories, where we identified a number of gaps. Given the importance of surveillance and reporting, addressing gaps in public health functions is likely to have the greatest positive impact for IHR requirements. The quantitative WHO laboratory assessment tool was useful in identifying both comparative strengths and weaknesses. However, prior to future assessments, the tool may need to be aligned with the new WHO IHR monitoring and evaluation framework. |
Agreement between ELISA and plaque reduction neutralisation assay in detection of respiratory syncytial virus specific antibodies in a birth cohort from Kilifi, coastal Kenya
Nyiro JU , Kiyuka PK , Mutunga MN , Sande CJ , Munywoki PK , Scott JAG , Nokes DJ . Wellcome Open Res 2019 4 33 Background: Severe disease associated with respiratory syncytial virus (RSV) infection occurs predominantly among infants under 6 months of age. Vaccines for prevention are in clinical development. Assessment of the vaccine effectiveness in large epidemiological studies requires serological assays which are rapid, economical and standardised between laboratories. The objective of this study was to assess the agreement between two enzyme linked immunosorbent assays (ELISA) and the plaque reduction neutralisation test (PRNT) in quantifying RSV specific antibodies. Methods: Archived sera from 99 participants of the Kilifi Birth Cohort (KBC) study (conducted 2002-2007) were screened for RSV antibodies using 3 methods: ELISA using crude RSV lysate as antigen, a commercial RSV immunoglobulin G (IgG) ELISA kit from IBL International GmbH, and PRNT. Pearson correlation, Bland-Altman plots and regression methods were used in analysis. Results: There was high positive correlation between the IBL RSV IgG ELISA and PRNT antibodies (Pearson r=0.75), and moderate positive correlation between the crude RSV lysate IgG ELISA and PRNT antibodies (r= 0.61). Crude RSV lysate IgG ELISA showed a wider 95% limit of agreement (-1.866, 6.157) with PRNT compared to the IBL RSV IgG ELISA (1.392, 7.595). Mean PRNT titres were estimated within a width of 4.8 log 2PRNT and 5.6 log 2PRNT at 95% prediction interval by IBL RSV IgG and crude RSV lysate IgG ELISA, respectively. Conclusion: Although, the IBL RSV IgG ELISA is observed to provide a reasonable correlate for PRNT assay in detecting RSV specific antibodies, it does not provide an accurate prediction for neutralizing antibody levels. An RSV neutralising antibody level is likely to fall within 2.4 fold higher and 2.4 fold lower than the true value if IBL RSV IgG ELISA is used to replace PRNT assay. The utility of an ELISA assay in vaccine studies should be assessed independent of the PRNT method. |
Technology-enabled outreach to patients taking high-risk medications reduces a quality gap in completion of clinical laboratory testing
Raebel MA , Shetterly SM , Bhardwaja B , Sterrett AT , Schroeder EB , Chorny J , Hagen TP , Silverman DJ , Astles R , Lubin IM . Popul Health Manag 2019 23 (1) 3-11 Clinical laboratory quality improvement (QI) efforts can include population test utilization. The authors used a health care organization's Medical Data Warehouse (MDW) to characterize a gap in guideline-concordant laboratory testing recommended for safe use of antirheumatic agents, then tested the effectiveness of laboratory-led, technology-enabled outreach to patients at reducing this gap. Data linkages available through the Kaiser Permanente Colorado MDW and electronic health record were used to identify ambulatory adults taking antirheumatic agents who were due/overdue for alanine aminotransferase (ALT), aspartate aminotransferase (AST), complete blood count (CBC), or serum creatinine (SCr) testing. Outreach was implemented using an interactive voice response system to send patients text or phone call reminders. Interrupted time series analysis was used to estimate reminder effectiveness. Rates of guideline-concordant testing and testing timeliness in baseline vs. intervention periods were determined using generalized linear models for repeated measures. Results revealed a decrease in percentage of 3763 patients taking antirheumatic agents due/overdue for testing at any given time: baseline 24.3% vs. intervention 17.5% (P < 0.001). Among 3205 patients taking conventional antirheumatic agents, concordance for all ALT testing was baseline 52.8% vs. intervention 65.4% (P < 0.001) among patients chronically using these agents and baseline 20.6% vs. intervention 26.1% (P < 0.001) among patients newly starting these agents. The 95(th) percentiles for days to ALT testing were baseline 149 vs. intervention 117 among chronic users and baseline 134 vs. intervention 92 among new starts. AST, CBC, and SCr findings were similar. Technology-enabled outreach reminding patients to obtain laboratory testing improves health care system outcomes. |
Mixing it up: New insights into interspecies recombination between herpes simplex virus type 1 and 2
Schmid DS . J Infect Dis 2019 221 (8) 1208-1209 Herpes simplex viruses (HSV-1 and HSV-2) are closely related alphaherpesviruses, with more than 80% identity at the deoxyribonucleic acid (DNA) sequence level [1]. More than two thirds of the world's population is estimated to have been infected with one or both viruses. The divergence of the common ancestor to these viruses is thought to have coincided with the separation of the human and chimpanzee lineages approximately 6 million years ago, leading to separate evolution of HSV-1 and HSV-2, respectively. Zoonotic transmission of HSV-2 to an extinct early hominid occurred approximately one and a half million years ago [2]. No other primate species are known to serve as common hosts for 2 distinct herpes simplex species. |
Creating a national specimen referral system in Guinea: Lessons from initial development and implementation
Standley CJ , Muhayangabo R , Bah MS , Barry AM , Bile E , Fischer JE , Heegaard W , Koivogui L , Lakiss SK , Sorrell EM , VanSteelandt A , Dahourou AG , Martel LD . Front Public Health 2019 7 83 In the wake of the 2014-2016, West Africa Ebola virus disease (EVD) outbreak, the Government of Guinea recognized an opportunity to strengthen its national laboratory system, incorporating capacity and investments developed during the response. The Ministry of Health (MOH) identified creation of a holistic, safe, secure, and timely national specimen referral system as a priority for improved detection and confirmation of priority diseases, in line with national Integrated Disease Surveillance and Response guidelines. The project consisted of two parts, each led by different implementing partners working collaboratively together and with the Ministry of Health: the development and approval of a national specimen referral policy, and pilot implementation of a specimen referral system, modeled on the policy, in three prefectures. This paper describes the successful execution of the project, highlighting the opportunities and challenges of building sustainable health systems capacity during and after public health emergencies, and provides lessons learned for strengthening national capabilities for surveillance and disease diagnosis. |
Trace metals screening process of devices used for the collection, analysis, and storage of biological specimens
Ward CD , Williams RJ , Mullenix K , Syhapanha K , Jones RL , Caldwell K . At Spectrosc 2018 39 (6) 219-228 The Centers for Disease Control and Prevention’s (CDC) Environmental Health Laboratory uses modified versions of inductively coupled plasma mass spectrometry (ICP-MS) analytical methods to quantify metals contamination present in items that will come into contact with patient samples during the preanalytical, analytical, and postanalytical stages. This lot screening process allows us to reduce the likelihood of introducing contamination which can lead to falsely elevated results. This is particularly important when looking at biomonitoring levels in humans which tend to be near the limit of detection of many methods. The fundamental requirements for a lot screening program in terms of facilities and processes are presented along with a discussion of sample preparation techniques used for lot screening. The criteria used to evaluate the lot screening data to determine the acceptability of a particular manufacturing lot is presented as well. As a result of lot testing, unsuitable manufactured lots are identified and excluded from use. |
Preventive care services and health behaviors in children with fragile X syndrome.
Gilbertson KE , Jackson HL , Dziuban EJ , Sherman SL , Berry-Kravis EM , Erickson CA , Valdez R . Disabil Health J 2019 12 (4) 564-573 BACKGROUND: This is the first description of preventive care services specifically received by children and young adults with fragile X syndrome (FXS). We compare these rates to those of other pediatric populations and identify care disparities within our cohort. OBJECTIVE: Describe the frequency of preventive care services and health behaviors by young people with FXS, and identify disparities in care. METHODS: We assessed four preventive care outcomes and the total number of preventive care guidelines met among individuals under 21 years from the ongoing Fragile X Online Registry with Accessible Research Database (N=406) using data from 2012 to 2015. We used adjusted odds ratios (AORs) from multiple logistic regression models to describe associations between demographic factors and preventive care outcomes. RESULTS: Seventy-five percent of our sample met dental care guidelines, 55.4% met influenza vaccination guidelines, 92.1% met immunization guidelines, and 24.4% met physical activity (PA) guidelines. Compared to children six to 10 years, younger children were less likely to have seen a dentist as recommended (AOR: 0.26) and young adults aged 16-20 were less likely to have received immunizations (AOR: 0.14) or to have engaged in recommended PA (AOR: 0.29). Black participants (AOR: 0.25) were less likely to have received an influenza vaccination than white participants. Individuals with autism (AOR: 0.25) were less likely to have sufficient PA, while individuals with hypersensitivity were more likely to have sufficient PA (AOR: 2.37) than unaffected individuals. CONCLUSIONS: The proportion of young people with FXS that meet basic recommendations in preventive care guidelines varies according to health condition and demographic characteristics. This proportion could be increased for some groups, particularly in the cases of influenza vaccination and physical activity. |
Screening for neonatal hyperbilirubinemia - first do no harm
Grosse SD , Prosser LA , Botkin JR . JAMA Pediatr 2019 173 (7) 617-618 Screening of newborn infants for hyperbilirubinemia (NHB) is a common clinical practice in the United States. Since 2004, the American Academy of Pediatrics has endorsed either universal or risk-based predischarge screening of bilirubin levels in newborns of 35 weeks’ gestational age or older to evaluate the risk for NHB using a nomogram standardized to age in hours and follow-up management using consensus-based treatment guidelines.1 The anticipated benefits of screening for NHB, followed by phototherapy and/or exchange transfusion when indicated, are to prevent acute bilirubin encephalopathy, which has a direct burden of morbidity and can also progress to chronic bilirubin encephalopathy (CBE) with devastating neurodevelopmental consequences (also known as kernicterus). However, it is important to consider the balance of benefits and harms of screening and treatment; newly published evidence2 that treatment of NHB is associated with elevated risks of epilepsy might lead hospitals to reevaluate the balance of benefits and risks of referring newborns for phototherapy on the basis of screening for NHB. |
Local government retail incentives for healthier food retailers in the USA, 2014
Lange SJ , Moore LV , Galuska DA . Public Health Nutr 2019 22 (13) 1-9 OBJECTIVE: National public health organizations recommend that local governments improve access to healthy foods. One way is by offering incentives for food retailer development and operation, but little is known about incentive use nationwide. We aimed to describe the national prevalence of local government reported incentives to increase access to healthy food options in three major food retail settings (farmers' markets, supermarkets, and convenience or corner (smaller) stores) overall and by municipality characteristics. DESIGN: Cross-sectional study using data from the 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. SETTING: USA, nationally representative survey of 2029 municipalities. PARTICIPANTS: Municipal officials (e.g. city/town managers or planners; n 1853). RESULTS: Overall, 67 % of municipalities reported incentives to support farmers' markets, 34 % reported incentives to encourage opening new supermarkets, and 14 % reported incentives to help existing convenience or corner stores. Municipality characteristics significantly associated with incentive use were larger population size (all settings), location in Midwest v. West (supermarkets, smaller stores), higher poverty level (farmers' markets) and </=50 % of the population non-Hispanic White (supermarkets, smaller stores). The most commonly reported individual incentives were permission of sales on city property for farmers' markets, tax credits for supermarkets and linkage to revitalization projects for smaller stores. CONCLUSIONS: Most municipalities offered food retail incentives for farmers' markets, but fewer used incentives to open new supermarkets or assist existing smaller stores. National data can set benchmarks, provide relative comparisons for communities and identify areas for improvement. |
Determination of iodine content in dairy products by inductively coupled plasma mass spectrometry
Vance KA , Makhmudov A , Shakirova G , Roenfanz H , Jones RL , Caldwell KL . At Spectrosc 2018 39 (3) 95-99 A probing study to establish a reliable and robust method for determining the iodine concentration using the ELAN DRC II ICP-MS was performed in combination with a sample digestion and filtration step. Dairy products from locally available sources were evaluated to help determine the possibility and need for further evaluations in relation to the U.S. population’s iodine intake. Prior to analysis, the samples were aliquoted and digested for 3 hours at 90+/-3 C. Dilution and filtration were performed, following the digestion. The sample extract was analyzed, and the results were confirmed with NIST SRM 1549a Whole Milk Powder. Further experimentation will need to be performed to optimize the method for projected sample concentration and throughput. |
Assessment of respirator fit capability test criteria for full-facepiece air-purifying respirators
Bergman MS , Zhuang Z , Xu SS , Rengasamy S , Lawrence RB , Boutin B , Harris JR . J Occup Environ Hyg 2019 16 (7) 1-9 An ASTM International subcommittee on Respiratory Protection, F23.65 is currently developing a consensus standard for assessing respirator fit capability (RFC) criteria of half-facepiece air-purifying particulate respirators. The objective of this study was to evaluate if the test methods being developed for half-facepiece respirators can reasonably be applied to nonpowered full-facepiece-air-purifying respirators (FF-APR). Benchmark RFC test data were collected for three families of FF-APRs (a one-size-only family, a two-size family, and a three-size family). All respirators were equipped with P100 class particulate filters. Respirators were outfitted with a sampling probe to collect an in-mask particle concentration sample in the breathing zone of the wearer. Each of the six respirator facepieces was tested on the National Institute for Occupational Safety and Health 25-subject Bivariate Panel. The RFC test assessed face seal leakage using a PortaCount fit test. Subjects followed the corresponding Occupational Safety and Health Administration-accepted fit test protocol. Two donnings per subject/respirator model combination were performed. The panel passing rate (PPR) (number or percentage of subjects in the panel achieving acceptable fit on at least one of two donnings) was determined for each respirator family at specified fit factor passing levels of 500, 1,000, and 2,000. As a reasonable expectation based on a previous analysis of alpha and beta fit test errors for various panel sizes, the selected PPR benchmark for our study was >75%. At the fit factor passing level of 500 obtained on at least one of two donnings, the PPRs for three-, two-, and one-size families were 100, 79, and 88%, respectively. As the fit factor passing criterion increased from 500 to 1,000 or 2,000, PPRs followed a decreasing trend. Each of the three tested families of FF-APRs are capable of fitting >/=75% of the intended user population at the 500 fit factor passing level obtained on at least one of two donnings. The methods presented here can be used as a reference for standards development organizations considering developing RFC test requirements. |
Work experiences of Latino building cleaners: An exploratory study
Eggerth DE , Ortiz B , Keller BM , Flynn MA . Am J Ind Med 2019 62 (7) 600-608 BACKGROUND: There are roughly 3.8 million cleaning workers in the United States. The cleaning workforce is largely composed of women, immigrants, and ethnic minorities who receive low wages and have low education levels. They are exposed to physical, chemical, biological, and psychosocial hazards. METHODS: Qualitative methodology was used to investigate how Latino immigrants experience work as building cleaners. A grounded theory coding approach was used to analyze focus group data from 77 participants. RESULTS: Three major themes were identified: economic vulnerability, psychosocial stressors, and health and safety effects. Although workers are aware of the safety hazards associated with their jobs, they believe their immigration status limits employment opportunities leading them to accept poor working conditions. They work through injuries and cope psychologically through minimizing negative health impacts and normalizing work-related injuries and illnesses. CONCLUSIONS: The findings suggest that interventions for these workers should recognize the hostile organizational and psychosocial contexts within which immigrants often work. |
Assessment of spray polyurethane foam worker exposure to organophosphate flame retardants through measures in air, hand wipes, and urine
Estill CF , Slone J , Mayer AC , Phillips K , Lu J , Chen IC , Christianson A , Streicher R , Guardia MJ , Jayatilaka N , Ospina M , Calafat AM . J Occup Environ Hyg 2019 16 (7) 1-12 Tris(1-chloro-2-propyl) phosphate (TCPP, also referenced as TCIPP), a flame retardant used in spray polyurethane foam insulation, increases cell toxicity and affects fetal development. Spray polyurethane foam workers have the potential to be exposed to TCPP during application. In this study, we determined exposure to TCPP and concentrations of the urinary biomarker bis(1-chloro-2-propyl) phosphate (BCPP) among 29 spray polyurethane foam workers over 2 work days. Work was conducted at residential or commercial facilities using both open-cell (low density) and closed-cell (high density) foam. Study participants provided two personal air samples (Day 1 and Day 2), two hand wipe samples (Pre-shift Day 2 and Post-shift Day 2), and two spot urine samples (Pre-shift Day 1 and Post-shift Day 2). Bulk samples of cured spray foam were also analyzed. Sprayers were found to have significantly higher TCPP geometric mean (GM) concentration in personal air samples (87.1 mug/m(3)), compared to helpers (30.2 mug/m(3); p = 0.025). A statistically significant difference was observed between TCPP pre- and post-shift hand wipe GM concentrations (p = 0.004). Specifically, TCPP GM concentration in post-shift hand wipe samples of helpers (106,000 ng/sample) was significantly greater than pre-shift (27,300 ng/sample; p < 0.001). The GM concentration of the urinary biomarker BCPP (23.8 mug/g creatinine) was notably higher than the adult male general population (0.159 mug/g creatinine, p < 0.001). Urinary BCPP GM concentration increased significantly from Pre-shift Day 1 to Post-shift Day 2 for sprayers (p = 0.013) and helpers (p = 0.009). Among bulk samples, cured open-cell foam had a TCPP GM concentration of 9.23% by weight while closed-cell foam was 1.68%. Overall, post-shift BCPP urine concentrations were observed to be associated with TCPP air and hand wipe concentrations, as well as job position (sprayer vs. helper). Spray polyurethane foam workers should wear personal protective equipment including air-supplied respirators, coveralls, and gloves during application. |
Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States
Ferguson SA , Merryweather A , Thiese MS , Hegmann KT , Lu ML , Kapellusch JM , Marras WS . BMC Musculoskelet Disord 2019 20 (1) 243 BACKGROUND: Low back pain (LBP) is a common and costly problem throughout the United States. To achieve a greater understanding of the occupational risk factors, the National Institute for Occupational Safety and Health (NIOSH) funded a low back health effects consortium, which performed several surveillance studies throughout the United States. This study combines data from the consortium research groups resulting in a data set with nearly 2000 workers in various regions of the country. The purpose of this paper is to examine prevalence and personal risk factors of low back health effects among these workers. METHODS: There were three common questions regarding history of low back health effects in the past 12 months including 1) have you had LBP lasting 7 days, 2) have you sought medical care for LBP, and 3) have you taken time off work due to LBP. The questionnaire included demographic questions. There were five data collections institutions or sites including NIOSH, Ohio State University, University of Wisconsin-Milwaukee, Texas A&M University, and University of Utah. RESULTS: The 12-month period prevalence of low back pain lasting 7 days, seeking medical care, and lost time due to LBP were 25, 14 and 10%, respectively. There were no statistically significant differences in gender, age or weight between cases and non-cases for any prevalence measure. The height of workers was significantly greater in the cases compared to non-cases for all three prevalence definitions. There were significant differences among the sites on the prevalence of seeking medical care for LBP and lost time due to LBP. The Ohio State University had significantly higher prevalence rates for seeking medical care and lost time due to LBP than University of Wisconsin, University of Utah, or Texas A&M University. CONCLUSION: LBP, the least severe low back health effect studied, had the highest prevalence (25%) and lost time due to LBP, the most severe low back health effect studied, had the lowest prevalence (10%) among nearly 2000 US manual material handling workers. There was a significant site or regional influence in prevalence rates for seeking medical care and lost time due to LBP. |
Using a modified theory of planned behavior to examine teachers' intention to implement a work safety and health curriculum
Guerin RJ , Toland MD , Okun AH , Rojas-Guyler L , Baker DS , Bernard AL . J Sch Health 2019 89 (7) 549-559 BACKGROUND: Workplace safety and health is a major public health concern, but largely absent from the school health curriculum. Little is known about teachers' perceptions of teaching workplace safety and health topics. METHODS: We administered a 41-item questionnaire reflecting the theory of planned behavior, modified to measure knowledge, to 242 middle and high school teachers in career and technical education and academic subjects. We conducted confirmatory factor analysis to assess the measures' psychometric properties and factorial ANOVAs to compare differences among participants' knowledge, attitude toward, self-efficacy, and intention (to teach) workplace safety and health by sex, prior work injury, and main subject taught. RESULTS: Confirmatory factor analyses indicated the measures reflected the theory. Factorial ANOVAs suggested female teachers had statistically significantly lower mean self-efficacy scores than did male teachers to teach workplace safety and health. Male occupational career and technical education teachers demonstrated higher mean knowledge scores than male teachers in other subjects. Participants not injured at work had higher knowledge scores than those who had been injured. CONCLUSION: Self-efficacy (influenced by sex) and knowledge (influenced by subject taught and previous workplace injury) revealed factors that may affect teachers' provision of workplace safety and health education, a critical yet overlooked component of school health. |
Effect of firefighting intervention on occupant tenability during a residential fire
Kerber S , Regan JW , Horn GP , Fent KW , Smith DL . Fire Technol 2019 55 (6) 2289-2316 This study examines the impact of firefighting intervention on occupant tenability to provide actionable guidance for selecting firefighting tactics that are based upon empirical rather than anecdotal evidence. Twelve fire experiments were conducted utilizing a full-sized residential structure to assess the impact of firefighting tactics on occupant exposure. Six groups of firefighters, recruited from fire departments throughout the country, participated in two experiments each. Two attack tactics were examined: (1) interior attack—water applied from the interior while a search team searched for simulated trapped occupants, and (2) transitional attack—exterior water application before transitioning to the interior while a search team searched for simulated trapped occupants. Gas concentration and temperature measurements were analyzed using a fractional effective dose (FED) approach to determine the impact of firefighter tactics on the exposure for potential trapped occupants. Water application by the fire attack teams resulted in a rapid drop in temperatures throughout the structure, followed shortly afterward by a decrease in the FED rate. There was no significant difference between the magnitude of the temperature decrease or the time until the inflection point in the FED curve between transitional attack and interior attack. As the removal time for the occupant increased, the toxic exposure to the occupant increased, despite the decreasing FED rate due to suppression. Occupant tenability analysis showed that the most threatened occupants are not always closest to the seat of the fire, while occupants near the fire but behind closed doors may have received a low exposure. As such, the results emphasized the need for rapid removal of occupants and coordination of suppression and ventilation tactics to limit toxic exposures. |
Inter-assessor agreement for TREXMO and its models outside the translation framework
Savic N , Lee EG , Gasic B , Vernez D . Ann Work Expo Health 2019 63 (7) 814-820 Within the framework of Registration, Evaluation, Authorization, and restriction of CHemicals (REACH), occupational exposure models are often used to predict the levels of exposure at a workplace. Poor inter-assessor agreement with their use poses a concern that may lead to different and dangerous risk conclusions. TREXMO (v1, 2016), a web tool providing parameter translations between six exposure models under REACH, is expected to improve the inter-assessor agreement. In this study, 18 assessors performed exposure assessment for six exposure situations within and outside the framework of this translation tool. In more than half of the evaluated cases, the results showed better agreement between assessors selecting the exposure parameters within the framework of TREXMO than when manually coding. The most affected were the parameters related to activity (such as "handling types" of Stoffenmanager) and exposure control (such as local controls). Furthermore, the agreement between the estimates calculated by different assessors was also improved when performing the translations between the models. For Stoffenmanager, for example, the relative standard deviation of 70-121%, obtained for vapors without applying the translation system, was 29-94% with the translations from ART. These findings showed a potential of TREXMO to impact the inter-assessor agreement. Because the study was limited to 18 assessors and only six exposure situations were assessed, further investigations are suggested. |
Patterns of progressive massive fibrosis on modern coal miner chest radiographs
Halldin CN , Blackley DJ , Markle T , Cohen RA , Laney AS . Arch Environ Occup Health 2019 75 (3) 1-7 Clinical teaching generally asserts that large opacities of progressive massive fibrosis (PMF) on chest radiographs present primarily bilaterally in the upper lung zones, and with an elevated background profusion of small opacities. However, the contemporary basis for these descriptions is limited. Radiographs taken for the Coal Workers' Health Surveillance Program during 2000-2015 and previously determined to have large opacities ("PMF radiographs", n = 204), and a random sample previously deemed free of large opacities (n =22), were independently reevaluated by three National Institute for Occupational Safety and Health (NIOSH) B Readers. Large opacities were noted primarily in the upper right (41%) or upper left (28%) lung zone, but 31% were in middle or lower zones. Unilateral involvement was observed in 34% of readings, with right lung predominance (82%). The median small opacity profusion category for the radiographs with PMF was 2/1. The number of large opacities was not correlated with small opacity profusion category. The "classic" descriptions of PMF as bilateral, associated with elevated background profusions of small pneumoconiotic opacities, were each absent in a third of miners. |
Malaria Surveillance - United States, 2016.
Mace KE , Arguin PM , Lucchi NW , Tan KR . MMWR Surveill Summ 2019 68 (5) 1-35 PROBLEM/CONDITION: Malaria in humans is caused by intraerythrocytic protozoa of the genus Plasmodium. These parasites are transmitted by the bite of an infective female Anopheles species mosquito. The majority of malaria infections in the United States occur among persons who have traveled to regions with ongoing malaria transmission. However, malaria is occasionally acquired by persons who have not traveled out of the country through exposure to infected blood products, congenital transmission, laboratory exposure, or local mosquitoborne transmission. Malaria surveillance in the United States is conducted to provide information on its occurrence (e.g., temporal, geographic, and demographic), guide prevention and treatment recommendations for travelers and patients, and facilitate transmission control measures if locally acquired cases are identified. PERIOD COVERED: This report summarizes confirmed malaria cases in persons with onset of illness in 2016 and summarizes trends in previous years. DESCRIPTION OF SYSTEM: Malaria cases diagnosed by blood film microscopy, polymerase chain reaction, or rapid diagnostic tests are reported to local and state health departments by health care providers or laboratory staff members. Case investigations are conducted by local and state health departments, and reports are transmitted to CDC through the National Malaria Surveillance System (NMSS), the National Notifiable Diseases Surveillance System (NNDSS), or direct CDC consultations. CDC reference laboratories provide diagnostic assistance and conduct antimalarial drug resistance marker testing on blood samples submitted by health care providers or local or state health departments. This report summarizes data from the integration of all NMSS and NNDSS cases, CDC reference laboratory reports, and CDC clinical consultations. RESULTS: CDC received reports of 2,078 confirmed malaria cases with onset of symptoms in 2016, including two congenital cases, three cryptic cases, and one case acquired through blood transfusion. The number of malaria cases diagnosed in the United States has been increasing since the mid-1970s. However, in 2015 a decrease occurred in the number of cases, specifically from the region of West Africa, likely due to altered travel related to the Ebola virus disease outbreak. The number of confirmed malaria cases in 2016 represents a 36% increase compared with 2015, and the 2016 total is 153 more cases than in 2011, which previously had the highest number of cases (1,925 cases). In 2016, a total of 1,729 cases originated from Africa, and 1,061 (61.4%) of these came from West Africa. P. falciparum accounted for the majority of the infections (1,419 [68.2%]), followed by P. vivax (251 [12.1%]). Fewer than 2% of patients were infected by two species (23 [1.1%]). The infecting species was not reported or was undetermined in 10.8% of cases. CDC provided diagnostic assistance for 12.1% of confirmed cases and tested 10.8% of specimens with P. falciparum infections for antimalarial resistance markers. Of the U.S. resident patients who reported reason for travel, 69.4% were travelers who were visiting friends and relatives. The proportion of U.S. residents with malaria who reported taking any chemoprophylaxis in 2016 (26.3%) was similar to that in 2015 (26.6%), and adherence was poor among those who took chemoprophylaxis. Among the 964 U.S. residents with malaria for whom information on chemoprophylaxis use and travel region were known, 94.0% of patients with malaria did not adhere to or did not take a CDC-recommended chemoprophylaxis regimen. Among 795 women with malaria, 50 were pregnant, and one had adhered to mefloquine chemoprophylaxis. Forty-one (2.0%) malaria cases occurred among U.S. military personnel in 2016, a comparable proportion to that in 2015 (23 cases [1.5%]). Among all reported cases in 2016, a total of 306 (14.7%) were classified as severe illnesses, and seven persons died. In 2016, CDC analyzed 144 P. falciparum-positive and nine P. falciparum mixed species samples for surveillance of antimalarial resistance markers (although certain loci were untestable in some samples); genetic polymorphisms associated with resistance to pyrimethamine were identified in 142 (97.9%), to sulfadoxine in 98 (70.5%), to chloroquine in 67 (44.7%), to mefloquine in six (4.3%), and to atovaquone in one (<1.0%). The completeness of key variables (e.g., species, country of acquisition, and resident status) was 79.4% in 2016 and 75.7% in 2015. INTERPRETATION: The number of reported malaria cases in 2016 continued a decades-long increasing trend and is the highest since 1972. The importation of malaria reflects the overall increase in global travel trends to and from areas where malaria is endemic; a transient decrease in the acquisition of cases, predominantly from West Africa, occurred in 2015. In 2016, more cases (absolute number) originated from regions of the world with widespread malaria transmission. Since the early 2000s, worldwide interventions to reduce malaria have been successful; however, progress has plateaued in recent years, the disease remains endemic in many regions, and the use of appropriate prevention measures by travelers remains inadequate. PUBLIC HEALTH ACTIONS: The best way to prevent malaria is to take chemoprophylaxis medication during travel to a country where malaria is endemic. Malaria infections can be fatal if not diagnosed and treated promptly with antimalarial medications appropriate for the patient's age and medical history, the likely country of malaria acquisition, and previous use of antimalarial chemoprophylaxis. In 2018, two tafenoquine-based antimalarials were approved by the Food and Drug Administration (FDA) for use in the United States. Arakoda was approved for use by adults for chemoprophylaxis and is available as a weekly dosage that is convenient during travel, which might improve adherence and also can prevent relapses from P. vivax and P. ovale infections. Krintafel was approved for radical cure of P. vivax infections in those >16 years old. In April 2019, intravenous artesunate became the first-line medication for treatment of severe malaria in the United States. Because intravenous artesunate is not FDA approved, it is available from CDC under an investigational new drug protocol. Detailed recommendations for preventing malaria are available to the general public at the CDC website (https://www.cdc.gov/malaria/travelers/drugs.html). Health care providers should consult the CDC Guidelines for Treatment of Malaria in the United States and contact the CDC's Malaria Hotline for case management advice when needed. Malaria treatment recommendations are available online (https://www.cdc.gov/malaria/diagnosis_treatment) and from the Malaria Hotline (770-488-7788 or toll-free at 855-856-4713). Persons submitting malaria case reports (care providers, laboratories, and state and local public health officials) should provide complete information because incomplete reporting compromises case investigations and efforts to prevent infections and examine trends in malaria cases. Adherence to recommended malaria prevention strategies is low among U.S. travelers; reasons for nonadherence include prematurely stopping after leaving the area where malaria was endemic, forgetting to take the medication, and experiencing a side effect. Molecular surveillance of antimalarial drug resistance markers (https://www.cdc.gov/malaria/features/ars.html) enables CDC to track, guide treatment, and manage drug resistance in malaria parasites both domestically and internationally. More samples are needed to improve the completeness of antimalarial drug resistance analysis; therefore, CDC requests that blood specimens be submitted for all cases of malaria diagnosed in the United States. |
Condom use with long-acting reversible contraception vs non-long-acting reversible contraception hormonal methods among postpartum adolescents
Kortsmit K , Williams L , Pazol K , Smith RA , Whiteman M , Barfield W , Koumans E , Kourtis A , Harrison L , Bauman B , Warner L . JAMA Pediatr 2019 173 (7) 663-670 Importance: Increased use of long-acting reversible contraception (LARC; intrauterine devices [IUDs] and implants) has likely contributed to declining US teenage pregnancy and birth rates, yet sexually transmitted infection (STI) rates among teenagers remain high. While LARC methods are highly effective for pregnancy prevention, they, as with all nonbarrier methods, do not protect against STIs, including HIV. Studies of the general adolescent population suggest condom use is lower among LARC vs non-LARC hormonal methods users (birth control pill, contraceptive patch, vaginal ring, or injection). Despite the high use of LARC among postpartum teenagers, no studies have examined whether condom use differs by contraceptive method in this population. Objective: To compare condom use among sexually active postpartum teenagers using LARC vs those using non-LARC hormonal methods. Design, Setting, and Participants: Cross-sectional analysis using 2012 to 2015 data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a multisite and population-based surveillance system that collects data on maternal attitudes, behaviors, and experiences before, during, and shortly after pregnancy. We used data from 37 sites. Using multivariable survey-weighted logistic regression, we assessed the association of condom use by contraceptive methods. Participants were teenage mothers (</=19 years) with a recent live birth reporting LARC or non-LARC hormonal method use. Data were analyzed between March 2018 and April 2018. Main Outcomes and Measures: Condom use with LARC vs condom use with non-LARC hormonal methods. Results: Among the 5480 (weighted N = 245847) postpartum teenage mothers in our sample, most were aged 18 to 19 years, unmarried, had current Medicaid coverage, were first-time mothers, had reported their pregnancy was unintended, and almost half were non-Hispanic white. Overall, condom use was reported by 28.8% of these teenagers. Users of LARC compared with non-LARC hormonal methods were half as likely to use condoms (17.8% vs 35.6%; adjusted prevalence ratio [aPR], 0.50; 95% CI, 0.41-0.60). Users of IUDs (15.1%) were less likely to report condom use than those using an implant (21.5%; aPR, 0.70; 95% CI, 0.51-0.98), patch, ring, or injection users (24.9%; aPR, 0.61; 95% CI, 0.47-0.79), and pill users (47.2%; aPR, 0.32; 95% CI, 0.25-0.40). Conclusions and Relevance: Self-reported condom use was low overall among postpartum teenage mothers and lower among users of LARC vs non-LARC hormonal methods. Given the high rates of STIs among teenage mothers combined with higher use of LARC among postpartum teenaged mothers, interventions to promote condom use for STI/HIV prevention during the postpartum period are critically important. |
Associations between public e-cigarette use and tobacco-related social norms among youth
Agaku IT , Perks SN , Odani S , Glover-Kudon R . Tob Control 2019 29 (3) 332-340 IMPORTANCE: E-cigarette use in public places may renormalise tobacco use. OBJECTIVE: To measure associations between e-cigarette use in public places and social norms among youth. DESIGN: Cross-sectional survey. SETTING: School-based. PARTICIPANTS: 24 353 never tobacco users in US 6th-12th grades who completed the 2016-2017 National Youth Tobacco Surveys. EXPOSURE: Individuals were classified as exposed in public places within the past 30 days to: (1) neither e-cigarette secondhand aerosol (SHA) nor combustible tobacco secondhand smoke (SHS); (2) SHA only; (3) SHS only; and (4) both SHA and SHS. OUTCOMES: Outcomes were overestimation of peer e-cigarette use (a measure of descriptive norms), harm perception and susceptibility. Data were analysed using descriptive statistics and logistic regression (p<0.05). RESULTS: Overall prevalence of SHS and SHA exposure in public places was 46.6% and 18.3%, respectively. SHA exposure in public places was associated with increased odds of overestimating peer e-cigarette use (adjusted OR (AOR): 1.83; 95% CI 1.29 to 2.58) and decreased odds of perceiving e-cigarettes as harmful (AOR: 0.63; 95% CI 0.51 to 0.79), compared with those exposed to neither emission. SHA exposure in public places was also associated with increased susceptibility to using e-cigarettes (AOR: 2.26; 95% CI 1.82 to 2.81) and cigarettes (AOR: 1.51; 95% CI 1.20 to 1.90). E-cigarette harm perception was lower among students in jurisdictions with no comprehensive clean indoor air laws (AOR: 0.79; 95% CI 0.71 to 0.88) or cigarette-only laws (AOR: 0.88; 95% CI 0.78 to 0.99) than in those prohibiting both cigarette and e-cigarette use in public places. CONCLUSIONS: Prohibiting both e-cigarette and cigarette use in public places could benefit public health. |
Opioid-related US hospital discharges by type, 1993-2016
Peterson C , Xu L , Florence C , Mack KA . J Subst Abuse Treat 2019 103 9-13 Objective: To classify and compare US nationwide opioid-related hospital inpatient discharges over time by discharge type: 1) opioid use disorder (OUD) diagnosis without opioid overdose, detoxification, or rehabilitation services, 2) opioid overdose, 3) OUD diagnosis or opioid overdose with detoxification services, and 4) OUD diagnosis or opioid overdose with rehabilitation services. Methods: Survey-weighted national analysis of hospital discharges in the Healthcare Cost and Utilization Project National Inpatient Sample yielded age-adjusted annual rates per 100,000 population. Annual percentage change (APC) in the rate of opioid-related discharges by type during 1993–2016 was assessed. Results: The annual rate of hospital discharges documenting OUD without opioid overdose, detoxification, or rehabilitation services quadrupled during 1993–2016, and at an increased rate (8% annually) during 2003–2016. The discharge rate for all types of opioid overdose increased an average 5–9% annually during 1993–2010; discharges for non-heroin overdoses declined 2010–2016 (3–12% annually) while heroin overdose discharges increased sharply (23% annually). The rate of discharges including detoxification services among OUD and overdose patients declined (−4% annually) during 2008–2016 and rehabilitation services (e.g., counselling, pharmacotherapy) among those discharges decreased (−2% annually) during 1993–2016. Conclusions: Over the past two decades, the rate of both OUD diagnoses and opioid overdoses increased substantially in US hospitals while rates of inpatient detoxification and rehabilitation services identified by diagnosis codes declined. It is critical that inpatients diagnosed with OUD or treated for opioid overdose are linked effectively to substance use disorder treatment at discharge. |
Measures to control protracted large Lassa fever outbreak in Nigeria, 1 January to 28 April 2019
Dan-Nwafor CC , Furuse Y , Ilori EA , Ipadeola O , Akabike KO , Ahumibe A , Ukponu W , Bakare L , Okwor TJ , Joseph G , Mba NG , Akano A , Olayinka AT , Okoli I , Okea RA , Makava F , Ugbogulu N , Oladele S , Namara G , Muwanguzi EN , Naidoo D , Mutbam SK , Okudo I , Woldetsadik SF , Lasuba CL , Ihekweazu C . Euro Surveill 2019 24 (20) Lassa fever cases have increased in Nigeria since 2016 with the highest number, 633 cases, reported in 2018. From 1 January to 28 April 2019, 554 laboratory-confirmed cases including 124 deaths were reported in 21 states in Nigeria. A public health emergency was declared on 22 January by the Nigeria Centre for Disease Control. We describe the various outbreak responses that have been implemented, including establishment of emergency thresholds and guidelines for case management. |
Reassessing serosurvey-based estimates of the symptomatic proportion of Zika virus infections
Mitchell PK , Mier-Y-Teran-Romero L , Biggerstaff BJ , Delorey MJ , Aubry M , Cao-Lormeau VM , Lozier MJ , Cauchemez S , Johansson MA . Am J Epidemiol 2019 188 (1) 206-213 Since the 2007 Zika epidemic in the Micronesian state of Yap, it has been apparent that not all people infected with Zika virus (ZIKV) experience symptoms. However, the proportion of infections that result in symptoms remains unclear. Existing estimates have varied in their interpretation of symptoms due to other causes and the case definition used, and they have assumed perfect test sensitivity and specificity. Using a Bayesian model and data from ZIKV serosurveys in Yap (2007), French Polynesia (2013-2014), and Puerto Rico (2016), we found that assuming perfect sensitivity and specificity generally led to lower estimates of the symptomatic proportion. Incorporating reasonable assumptions for assay sensitivity and specificity, we estimated that 27% (95% credible interval (CrI): 15, 37) (Yap), 44% (95% CrI: 26, 66) (French Polynesia), and 50% (95% CrI: 34, 92) (Puerto Rico) of infections were symptomatic, with variation due to differences in study populations, study designs, and case definitions. The proportion of ZIKV infections causing symptoms is critical for surveillance system design and impact assessment. Here, we accounted for key uncertainties in existing seroprevalence data and found that estimates for the symptomatic proportion ranged from 27% to 50%, suggesting that while the majority of infections are asymptomatic or mildly symptomatic, symptomatic infections might be more common than previously estimated. |
Successes and challenges of the One Health approach in Kenya over the last decade
Munyua PM , Njenga MK , Osoro EM , Onyango CO , Bitek AO , Mwatondo A , Muturi MK , Musee N , Bigogo G , Otiang E , Ade F , Lowther SA , Breiman RF , Neatherlin J , Montgomery J , Widdowson MA . BMC Public Health 2019 19 465 More than 75% of emerging infectious diseases are zoonotic in origin and a transdisciplinary, multi-sectoral One Health approach is a key strategy for their effective prevention and control. In 2004, US Centers for Disease Control and Prevention office in Kenya (CDC Kenya) established the Global Disease Detection Division of which one core component was to support, with other partners, the One Health approach to public health science. After catalytic events such as the global expansion of highly pathogenic H5N1 and the 2006 East African multi-country outbreaks of Rift Valley Fever, CDC Kenya supported key Kenya government institutions including the Ministry of Health and the Ministry of Agriculture, Livestock, and Fisheries to establish a framework for multi-sectoral collaboration at national and county level and a coordination office referred to as the Zoonotic Disease Unit (ZDU). The ZDU has provided Kenya with an institutional framework to highlight the public health importance of endemic and epidemic zoonoses including RVF, rabies, brucellosis, Middle East Respiratory Syndrome Coronavirus, anthrax and other emerging issues such as anti-microbial resistance through capacity building programs, surveillance, workforce development, research, coordinated investigation and outbreak response. This has led to improved outbreak response, and generated data (including discovery of new pathogens) that has informed disease control programs to reduce burden of and enhance preparedness for endemic and epidemic zoonotic diseases, thereby enhancing global health security. Since 2014, the Global Health Security Agenda implemented through CDC Kenya and other partners in the country has provided additional impetus to maintain this effort and Kenya's achievement now serves as a model for other countries in the region. Significant gaps remain in implementation of the One Health approach at subnational administrative levels; there are sustainability concerns, competing priorities and funding deficiencies. |
A cutaneous anthrax outbreak in Koraput District of Odisha-India 2015
Nayak P , Sodha SV , Laserson KF , Padhi AK , Swain BK , Hossain SS , Shrivastava A , Khasnobis P , Venkatesh SR , Patnaik B , Dash KC . BMC Public Health 2019 19 470 Background: Cutaneous anthrax in humans is associated with exposure to infected animals or animal products and has a case fatality rate of up to 20% if untreated. During May to June 2015, an outbreak of cutaneous anthrax was reported in Koraput district of Odisha, India, an area endemic for anthrax. We investigated the outbreak to identify risk factors and recommend control measures. Method: We defined a cutaneous anthrax case as skin lesions (e.g., papule, vesicle or eschar) in a person residing in Koraput district with illness onset between February 1 and July 15, 2015. We established active surveillance through a house to house survey to ascertain additional cases and conducted a 1:2 unmatched case control study to identify modifiable risk factors. In case control study, we included cases with illness onset between May 1 and July 15, 2015. We defined controls as neighbours of case without skin lesions since last 3 months. Ulcer exudates and rolled over swabs from wounds were processed in Gram stain in the Koraput district headquarter hospital laboratory. Result: We identified 81 cases (89% male; median age 38 years [range 5-75 years]) including 3 deaths (case fatality rate = 4%). Among 37 cases and 74 controls, illness was significantly associated with eating meat of ill cattle (OR: 14.5, 95% CI: 1.4-85.7) and with close handling of carcasses of ill animals such as burying, skinning, or chopping (OR: 342, 95% CI: 40.5-1901.8). Among 20 wound specimens collected, seven showed spore-forming, gram positive bacilli, with bamboo stick appearance suggestive of Bacillus anthracis. Conclusion: Our investigation revealed significant associations between eating and handling of ill animals and presence of anthrax-like organisms in lesions. We immediately initiated livestock vaccination in the area, educated the community on safe handling practices and recommended continued regular anthrax animal vaccinations to prevent future outbreaks. |
Risk factors associated with the occurrence of anthrax outbreaks in livestock in the country of Georgia: A case-control investigation 2013-2015
Rao S , Traxler R , Napetavaridze T , Asanishvili Z , Rukhadze K , Maghlakelidze G , Geleishvili M , Broladze M , Kokhreidze M , Reynolds D , Shadomy S , Salman M . PLoS One 2019 14 (5) e0215228 INTRODUCTION: Anthrax is considered endemic in livestock in Georgia. In 2007, the annual vaccination became the responsibility of livestock owners, while contracting of private veterinarians was not officially required. Six years later, due to increase in human outbreaks associated with livestock handling, there is a need to find out the risk factors of livestock anthrax in Georgia. OBJECTIVE: To identify exposures and risk factors associated with livestock anthrax. METHODS: A matched case-control study design was used to recruit the owners of individual livestock anthrax cases that occurred between June 2013 and May 2015, and owners of unaffected livestock from within ("village control") and outside the village ("area control"). We collected data about the case and control livestock animals' exposure and risk factors within the one-month prior to the disease onset of the case livestock (or matched case for the controls). We used logistic regression analysis (univariate and multivariable) to calculate the odds ratios of exposures and risk factors. RESULTS: During the study period, 36 anthrax cases met the case definition and were enrolled in the study; 67 matched village control livestock and 71 matched area control livestock were also enrolled. The findings from multivariable logistic regression analysis demonstrate that vaccination within the last two years significantly reduced the odds of anthrax in cattle (OR = 0.014; 95% Confidence interval = <0.001, 0.99). The other factors that were significantly protective against anthrax were 'animals being in covered fence area/barn' (OR = 0.065; p-value = 0.036), and 'female animal being pregnant or milking compared to heifer' (OR = 0.006; p-value = 0.037). CONCLUSIONS: The information obtained from this study has involved and been presented to decision makers, used to build technical capacity of veterinary staff, and to foster a One Health approach to the control of zoonotic diseases which will optimize prevention and control strategies. Georgia has embedded the knowledge and specific evidence that vaccination is a highly protective measure to prevent anthrax deaths among livestock, to which primary emphasis of the anthrax control program will be given. Education of livestock keepers in Georgia is an overriding priority. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Community Health Services
- Disease Reservoirs and Vectors
- Environmental Health
- Epidemiology and Surveillance
- Genetics and Genomics
- Global Health
- Health Communication and Education
- Health Economics
- Healthcare Associated Infections
- Immunity and Immunization
- Informatics
- Injury and Violence
- Laboratory Sciences
- Maternal and Child Health
- Nutritional Sciences
- Occupational Safety and Health
- Occupational Safety and Health - Mining
- Parasitic Diseases
- Reproductive Health
- Substance Use and Abuse
- Zoonotic and Vectorborne Diseases
About
CDC Science Clips is an online, continuously updated, searchable database of scientific literature published by CDC authors. Each article features an Altmetric Attention Score to track social and mainstream media mentions. If you are aware of a CDC-authored publication that does not appear in this database, please let us know.
- Page last reviewed:Feb 1, 2024
- Page last updated:Apr 22, 2024
- Content source:
- Powered by CDC PHGKB Infrastructure