Diabetes-related emergency medical service activations in 23 states, United States 2015
Benoit SR , Kahn HS , Geller AI , Budnitz DS , Mann NC , Dai M , Gregg EW , Geiss LS . Prehosp Emerg Care 2018 22 (6) 705-712 OBJECTIVE: The use of emergency medical services (EMS) for diabetes-related events is believed to be substantial but has not been quantified nationally despite the diverse acute complications associated with diabetes. We describe diabetes-related EMS activations in 2015 among people of all ages from 23 U.S. states. METHODS: We used data from 23 states that reported >/=95% of their EMS activations to the U.S. National Emergency Medical Services Information System (NEMSIS) in 2015. A diabetes-related EMS activation was defined using coded EMS provider impressions of "diabetes symptoms" and coded complaints recorded by dispatch of "diabetic problem." We described activations by type of location, urbanicity, U.S. Census Division, season, and time of day; and patient-events by age category, race/ethnicity, disposition, and treatment with glucose. Crude and age-adjusted diabetes-related EMS patient-level event rates were calculated for adults >/=18 years of age with diagnosed diabetes using the Behavioral Risk Factor Surveillance System to estimate the population denominator. RESULTS: Of 10,324,031 relevant EMS records, 241,495 (2.3%) were diabetes-related activations, which involved over 235,000 hours of service. Most activations occurred in urban or suburban environ- ments (86.4%), in the home setting (73.5%), and were slightly more frequent in the summer months. Most patients (72.6%) were >/=45 years of age and over one-half (55.4%) were transported to the emergency department. The overall age-adjusted diabetes-related EMS event rate was 33.9 per 1,000 persons with diagnosed diabetes; rates were highest in patients 18-44 years of age, males, and non-Hispanic blacks and varied by U.S. Census Division. CONCLUSIONS: Diabetes results in a substantial burden on EMS resources. Collection of more detailed diabetes complication information in NEMSIS may help facilitate EMS resource planning and prevention strategies. |
Melanoma among non-Hispanic black Americans
Culp MB , Lunsford NB . Prev Chronic Dis 2019 16 E79 INTRODUCTION: Few studies have examined melanoma incidence and survival rates among non-Hispanic black populations because melanoma risk is lower among this group than among non-Hispanic white populations. However, non-Hispanic black people are often diagnosed with melanoma at later stages, and the predominant histologic types of melanomas that occur in non-Hispanic black people have poorer survival rates than the most common types among non-Hispanic white people. METHODS: We used the US Cancer Statistics 2001-2015 Public Use Research Database to examine melanoma incidence and 5-year survival among non-Hispanic black US populations. RESULTS: From 2011 through 2015, the overall incidence of melanoma among non-Hispanic black people was 1.0 per 100,000, and incidence increased with age. Although 63.8% of melanomas in non-Hispanic black people were of unspecified histology, the most commonly diagnosed defined histologic type was acral lentiginous melanoma (16.7%). From 2001 through 2014, the relative 5-year melanoma survival rate among non-Hispanic black people was 66.2%. CONCLUSION: Although incidence of melanoma is relatively rare among non-Hispanic black populations, survival rates lag behind rates for non-Hispanic white populations. Improved public education is needed about incidence of acral lentiginous melanoma among non-Hispanic black people along with increased awareness among health care providers. |
Public health efforts to address mental health conditions among cancer survivors
Ekwueme DU , Lunsford NB , Khushalani JS , Rim SH . Am J Public Health 2019 109 S179-s180 The Centers for Disease Control and Prevention (CDC) examines mental health indicators and trends, conducts surveillance of mental health concerns, and supports programs to address the mental health needs of men, women, and children (www.cdc.gov/mentalhealth/learn/index.htm). The Healthy People 2020 objectives (www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders) and National Prevention Strategy (www.hhs.gov/sites/default/files/disease-prevention-wellness-report.pdf) offer examples of public health objectives that can improve mental health through prevention by ensuring access to appropriate, quality mental health services. |
Cardiovascular health among non-Hispanic Asian Americans: NHANES, 2011-2016
Fang J , Zhang Z , Ayala C , Thompson-Paul AM , Loustalot F . J Am Heart Assoc 2019 8 (13) e011324 Background Asian Americans are the fastest growing population in the United States, but little is known about their cardiovascular health (CVH). The objective of this study was to assess CVH among non-Hispanic Asian Americans (NHAAs) and to compare these estimates to those of non-Hispanic white (NHW) participants. Methods and Results Merging NHANES (National Health and Nutrition Examination Survey) data from 2011 to 2016, we examined 7 metrics (smoking, weight, physical activity, diet, blood cholesterol, blood glucose, and blood pressure) to assess CVH among 5278 NHW and 1486 NHAA participants aged >/=20 years. We assessed (1) the percentage meeting 6 to 7 metrics (ideal CVH), (2) the percentage meeting only 0 to 2 metrics (poor CVH), and (3) the overall mean CVH score. We compared these estimates between NHAAs and NHWs and among foreign-born NHAAs by birthplace and number of years living in the United States. The adjusted prevalence of ideal CVH was 8.7% among NHAAs and 5.9% among NHWs ( P<0.001). NHAAs were significantly more likely to have ideal CVH (adjusted prevalence ratio: 1.42; 95% CI, 1.29-1.55) compared with NHWs. Among NHAAs, there was no significant difference in ideal CVH between US- and foreign-born participants, nor by number of years living in the United States. With lower body mass index thresholds (<23, normal weight) for NHAAs, there were no statistically significant differences in the adjusted prevalence of ideal CVH (6.5% versus 5.9%, P=0.216) between NHAAs and NHWs. Conclusions NHAAs had a higher prevalence of overall ideal CVH compared with NHWs. However, when using a lower body mass index threshold for NHAAs, there was no difference in ideal CVH between the groups. |
Prevalence of indoor tanning among U.S. high school students from 2009 to 2017
Holman DM , Jones SE , Qin J , Richardson LC . J Community Health 2019 44 (6) 1086-1089 Indoor tanning exposes users to high levels of ultraviolet radiation, increasing skin cancer risk. The risk is greatest for those who begin indoor tanning at a young age. The objective of this study was to assess changes in indoor tanning prevalence over time among U.S. high school students, by sex, age, and race/ethnicity. We used cross-sectional data from the 2009, 2011, 2013, 2015, and 2017 national Youth Risk Behavior Survey to examine changes in indoor tanning prevalence from 2009 to 2017 and from 2015 to 2017. From 2009 to 2017 indoor tanning declined overall (15.6 to 5.6%; p < 0.001), across all age groups, and among white (37.4 to 10.1%; p < 0.001) and Hispanic (10.5 to 3.0%; p < 0.001) female students, and white (7.0 to 2.8%; p < 0.001) and Hispanic (5.8 to 3.4%; p < 0.001) male students. From 2015 to 2017, indoor tanning declined overall (7.3 to 5.6%; p = 0.04) and among white (15.2 to 10.1%; p = 0.03) and Hispanic (5.8 to 3.0%; p = 0.02) female students, and 16-year-old students (7.2 to 4.7%; p = 0.03). Indoor tanning has continued to decrease, particularly among white and Hispanic female students, dropping well below the Healthy People 2020 target for adolescents. However, continued efforts are needed to further reduce and sustain reductions in adolescent indoor tanning and address remaining research gaps. |
Team-based care to improve diabetes management: A Community Guide meta-analysis
Levengood TW , Peng Y , Xiong KZ , Song Z , Elder R , Ali MK , Chin MH , Allweiss P , Hunter CM , Becenti A . Am J Prev Med 2019 57 (1) e17-e26 CONTEXT: Team-based care has been increasingly used to deliver care for patients with chronic conditions, but its effectiveness for managing diabetes has not been systematically assessed. EVIDENCE ACQUISITION: RCTs were identified from two sources: a high-quality, broader review comparing 11 quality improvement strategies for diabetes management (database inception to July 2010), and an updated search using the same search strategy (July 2010-October 2015). EVIDENCE SYNTHESIS: Thirty-five studies were included in the current review; a majority focused on patients with Type 2 diabetes. Teams included patients, their primary care providers, and one or two additional healthcare professionals (most often nurses or pharmacists). Random effect meta-analysis showed that, compared with controls, team-based care was associated with greater reductions in blood glucose levels (-0.5% in HbA1c, 95% CI= -0.7, -0.3) and greater improvements in blood pressure and lipid levels. Interventions also increased the proportion of patients who reached target blood glucose, blood pressure, and lipid levels, based on American Diabetes Association guidelines available at the time. Data analysis was completed in 2016. CONCLUSIONS: For patients with Type 2 diabetes, team-based care improves blood glucose, blood pressure, and lipid levels. |
Variations in screening quality in a federal colorectal cancer screening program for the uninsured
Nadel MR , Royalty J , Joseph D , Rockwell T , Helsel W , Kammerer W , Gray SC , Shapiro JA . Prev Chronic Dis 2019 16 E67 INTRODUCTION: Screening can decrease colorectal cancer incidence and mortality and is recommended in clinical practice guidelines. Poor quality of colorectal cancer screening can negate the benefit of screening. The objective of this study was to assess the quality of screening services provided by the Centers for Disease Control and Prevention's Colorectal Cancer Control Program from July 2009 through June 2015. METHODS: We collected data from the program's 29 grantees, funded to provide colorectal cancer screening and diagnostic services to asymptomatic, low-income, and underinsured or uninsured adults aged 50 to 64. We collected data on the dates and results of all screening and diagnostic tests and, for colonoscopies, on whether the cecum was reached, whether bowel preparation was adequate, and endoscopists' recommendations for the next test. RESULTS: Overall, 82.9% (range among grantees, 50.0%-97.2%) of positive FOBTs/FITs were followed up by colonoscopy; 95.2% of colonoscopies occurred within 180 days of the positive stool test. Cecal intubation rates ranged among grantees from 94.2% to 100%. Adenoma detection rates met recommended threshold levels for almost all grantees. Recommendations for rescreening and surveillance intervals deviated from guidelines in both directions. Of clients with normal colonoscopies, 85.3% (range, 37.7%-99.7%) were told to return in 10 years, as recommended in national guidelines. Of clients with advanced adenomas, 55.2% (range, 20.0%-84.6%) were told to return in 3 years as recommended, 25.4% (range, 3.8%-56.6%) in 5 or more years, and 18.6% (range, 0%-47.2%) in less than 3 years. CONCLUSION: Although overall screening quality was good, it varied considerably. Ongoing monitoring to identify performance problems is essential for all colorectal cancer screening activities, so that efforts designed to improve performance can be targeted to individual clinicians. |
Walking as an opportunity for cardiovascular disease prevention
Omura JD , Ussery EN , Loustalot F , Fulton JE , Carlson SA . Prev Chronic Dis 2019 16 E66 INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death in the United States, and increasing physical activity can help prevent and manage disease. Walking is an easy way for most adults to be more active and may help people at risk for CVD avoid inactivity, increase their physical activity levels, and improve their cardiovascular health. To guide efforts that promote walking for CVD prevention and management, we estimated the prevalence of walking among US adults by CVD risk status. METHODS: Nationally representative data on walking from participants (N = 29,742) in the 2015 National Health Interview Survey Cancer Control Supplement were analyzed. We estimated prevalence of walking (ie, any, transportation, and leisure) overall and by CVD status. We defined CVD status as either not having CVD and not at risk for CVD; being at risk for CVD (overweight or having obesity plus 1 or more additional risk factors); or having CVD. We defined additional risk factors as diabetes, high cholesterol, or hypertension. Odds ratios were estimated by using logistic regression models adjusted for respondent characteristics. RESULTS: Prevalence of any walking decreased with increasing CVD risk (no CVD/not at risk, 66.6%; at risk: overweight or has obesity with 1 risk factor, 63.0%; with 2 risk factors, 59.5%; with 3 risk factors, 53.6%; has CVD, 50.2%). After adjusting for respondent characteristics, the odds of any walking and leisure walking decreased with increasing CVD risk. However, CVD risk was not associated with walking for transportation. CONCLUSIONS: Promoting walking may be a way to help adults avoid inactivity and encourage an active lifestyle for CVD prevention and management. |
Trends in blood pressure and usual dietary sodium intake among children and adolescents, National Health and Nutrition Examination Survey 2003 to 2016
Overwyk KJ , Zhao L , Zhang Z , Wiltz JL , Dunford EK , Cogswell ME . Hypertension 2019 74 (2) 260-266 Over the past decade, blood pressure and sodium intake declined among children and adolescents (ie, youths) in the United States. We updated temporal trends and determined if secular changes in blood pressure might be partly associated with usual sodium intake. We included 12 249 youths aged 8 to 17 years who participated in the National Health and Nutrition Examination Survey from 2003 to 2016 and had blood pressure and dietary data. Logistic regression was used to describe secular trends and the association between usual sodium intake and blood pressure categorized according to 2017 Hypertension Guidelines. The prevalence of youths with combined elevated blood pressure/hypertension (ie, either elevated blood pressure or hypertension) significantly declined from 16.2% in 2003-2004 to 13.3% in 2015-2016 ( P<0.001 for trend), as did hypertension from 6.6% to 4.9% ( P=0.005 for trend). Across the same time period, mean usual sodium intake decreased from 3381 to 3208 mg/day ( P<0.001 for trend). Holding constant survey cycle, sex, age, race and Hispanic origin, and weight status, the adjusted odds ratio per 1000 mg/day of usual sodium intake for elevated blood pressure/hypertension was 1.18 (95% CI, 1.03-1.35) and for hypertension was 1.20 (95% CI, 0.96-1.50). From 2003 to 2016, blood pressure and usual sodium intake declined among youths. Although 1000 mg/day higher usual sodium intake was associated with approximately 20% higher odds of elevated blood pressure/hypertension and hypertension, the association with hypertension was not statistically significant. |
Awareness of stroke signs and symptoms and calling 9-1-1 among US adults: National Health Interview Survey, 2009 and 2014
Patel A , Fang J , Gillespie C , Odom E , King SC , Luncheon C , Ayala C . Prev Chronic Dis 2019 16 E78 INTRODUCTION: Early recognition of stroke symptoms and recognizing the importance of calling 9-1-1 improves the timeliness of appropriate emergency care, resulting in improved health outcomes. The objective of this study was to assess changes in awareness of stroke symptoms and calling 9-1-1 from 2009 to 2014. METHODS: We analyzed data among 27,211 adults from 2009 and 35,862 adults from 2014 using the National Health Interview Survey (NHIS). The NHIS included 5 questions in both 2009 and 2014 about stroke signs and symptoms and one about the first action to take when someone is having a stroke. We estimated the prevalence of awareness of each symptom, all 5 symptoms, the importance of calling 9-1-1, and knowledge of all 5 symptoms plus the importance of calling 9-1-1 (indicating recommended stroke knowledge). We assessed changes from 2009 to 2014 in the prevalence of awareness. Data analyses were conducted in 2016. RESULTS: In 2014, awareness of stroke symptoms ranged from 76.1% (sudden severe headache) to 93.7% (numbness of face, arm, leg, side); 68.3% of respondents recognized all 5 symptoms, and 66.2% were aware of all recommended stroke knowledge. After adjusting for sex, age, educational attainment, and race/ethnicity, logistic regression results showed a significant absolute increase of 14.7 percentage points in recommended stroke knowledge from 2009 (51.5%) to 2014 (66.2%). Among US adults, recommended stroke knowledge increased from 2009 to 2014. CONCLUSION: Stroke awareness among US adults has improved but remains suboptimal. |
The cardiometabolic risk profile of young adults with diabetes in the U.S
Saydah SH , Siegel KR , Imperatore G , Mercado C , Gregg EW . Diabetes Care 2019 42 (10) 1895-1902 OBJECTIVE: We examined young adults with and young adults without diabetes by using demographic data and cardiometabolic risk profiles and compared the risk profiles of younger versus older (aged >/=45 years) adults with diabetes. RESEARCH DESIGN AND METHODS: Data were obtained from the National Health and Nutrition Examination Survey 2007-2016. Diabetes was defined by self-report of health care provider diagnosis or by A1C levels of 6.5% or higher among those without a self-reported diagnosis. The cardiometabolic risk profile included adiposity, blood pressure, serum lipids, healthy eating, physical activity (PA), and exposure to tobacco smoke. Adjusted difference in difference was calculated as the difference among younger adults with and younger adults without diabetes minus the difference among older adults with and older adults without diabetes. RESULTS: Adults with diabetes in both age-groups had higher levels of adiposity, hypertension, and cholesterol and lower levels of healthy eating and leisure-time PA. However, the differences in high cholesterol and adiposity by diabetes status were greater among young adults compared with older adults after adjustment for demographics and health insurance status. Elevated lipids were 9.6 percentage points higher (95% CI 4.6, 14.5) and obesity was 37.3 percentage points higher (95% CI 31.8, 42.7) among young adults with diabetes compared with those without diabetes than among older adults with diabetes compared with those without diabetes. CONCLUSIONS: Young adults with diabetes have high rates of cardiometabolic risk factors, which can lead to an increased prevalence of disease and mortality rate among these individuals as they age. |
Characteristics of the provider-patient encounter associated with awareness of and willingness to take PrEP among young minority urban males in Baltimore City
Chandran A , Marcell AV , Sanders RA , Perin J , Page KR , Loosier PS , Dittus PJ , Jennings JM . AIDS Educ Prev 2019 31 (3) 237-245 We aimed to identify provider encounter characteristics associated with awareness of and willingness to take PrEP among young urban minority males at higher risk for HIV acquisition. The 74 individuals included in this analysis from a cross-sectional survey of males aged 15-24 being seen at a Baltimore city clinic were those who identified as a man who had sex with men (MSM), reported injection drug use, were in a serodiscordant relationship, had a sexually transmitted infection (STI) in the past 6 months, or reported condomless sex with a partner with unknown HIV status. Topics of provider-initiated conversations associated with willingness to take PrEP included one's sexual behavior (OR 7.35, 95% CI [2.23, 24.26]), whether one had been hurt by a partner (OR 4.71, 95% CI [1.40, 15.87]), and risk reduction (OR 6.91, 95% CI [2.10, 22.81]). This study may yield new targets for provider-level interventions for increasing PrEP uptake. |
Attitudes about the use of geosocial networking applications for HIV/STD partner notification: A qualitative study
Contesse MG , Fredericksen RJ , Wohlfeiler D , Hecht J , Kachur R , Strona FV , Katz DA . AIDS Educ Prev 2019 31 (3) 273-285 Meeting sex partners through geosocial networking (GSN) apps is common among men who have sex with men (MSM). MSM may choose not to exchange contact information with partners met through GSN apps, limiting their own and health departments' ability to notify partners of HIV/STD exposure through standard notification methods. Using online focus groups (four groups; N = 28), we explored the perspectives of U.S. MSM regarding offer of partner notification features through GSN apps. Most participants were comfortable with HIV/STD partner notification delivered via GSN apps, either by partner services staff using a health department profile or through an in-app anonymous messaging system. While most participants expressed a responsibility to notify partners on their own, app-based partner notification methods may be preferred for casual or hard-to-reach partners. However, participants indicated that health departments will need to build trust with MSM app users to ensure acceptable and effective app-based delivery of partner notification. |
Patterns of seasonal influenza activity in U.S. core-based statistical areas, described using prescriptions of oseltamivir in Medicare claims data
Dahlgren FS , Shay DK , Izurieta HS , Forshee RA , Wernecke M , Chillarige Y , Lu Y , Kelman JA , Reed C . Epidemics 2019 26 23-31 Using Medicare claims data on prescriptions of oseltamivir dispensed to people 65 years old and older, we present a descriptive analysis of patterns of influenza activity in the United States for 579 core-based statistical areas (CBSAs) from the 2010-2011 through the 2015-2016 influenza seasons. During this time, 1,010,819 beneficiaries received a prescription of oseltamivir, ranging from 45,888 in 2011-2012 to 380,745 in 2014-2015. For each season, the peak weekly number of prescriptions correlated with the total number of prescriptions (Pearson's r >/= 0.88). The variance in peak timing decreased with increasing severity (p < 0.0001). Among these 579 CBSAs, neither peak timing, nor relative timing, nor severity of influenza seasons showed evidence of spatial autocorrelation (0.02 </= Moran's I </= 0.23). After aggregating data to the state level, agreement between the seasonal severity at the CBSA level and the state level was fair (median Cohen's weighted kappa = 0.32, interquartile range = 0.26-0.39). Based on seasonal severity, relative timing, and geographic place, we used hierarchical agglomerative clustering to join CBSAs into influenza zones for each season. Seasonal maps of influenza zones showed no obvious patterns that might assist in predicting influenza zones for future seasons. Because of the large number of prescriptions, these data may be especially useful for characterizing influenza activity and geographic distribution during low severity seasons, when other data sources measuring influenza activity are likely to be sparse. |
Cryptosporidiosis outbreaks - United States, 2009-2017
Gharpure R , Perez A , Miller AD , Wikswo ME , Silver R , Hlavsa MC . MMWR Morb Mortal Wkly Rep 2019 68 (25) 568-572 Cryptosporidium is a parasite that causes cryptosporidiosis, a profuse, watery diarrhea that can last up to 3 weeks in immunocompetent patients and can lead to life-threatening malnutrition and wasting in immunocompromised patients.* Fecal-oral transmission can occur by ingestion of contaminated recreational water, drinking water, or food, or through contact with infected persons or animals. For the period 2009-2017, public health officials from 40 states and Puerto Rico voluntarily reported 444 cryptosporidiosis outbreaks resulting in 7,465 cases. Exposure to treated recreational water (e.g., in pools and water playgrounds) was associated with 156 (35.1%) outbreaks resulting in 4,232 (56.7%) cases. Other predominant outbreak exposures included contact with cattle (65 outbreaks; 14.6%) and contact with infected persons in child care settings (57; 12.8%). The annual number of reported cryptosporidiosis outbreaks overall increased an average of approximately 13% per year over time. Reversing this trend will require dissemination of prevention messages to discourage swimming or attending child care while ill with diarrhea and encourage hand washing after contact with animals. Prevention and control measures can be optimized by improving understanding of Cryptosporidium transmission through regular analysis of systematically collected epidemiologic and molecular characterization data. |
Trends in prevalence of protective levels of hepatitis B surface antibody among adults aged 18-49 years with risk factors for hepatitis B virus infection-United States, 2003-2014
King H , Xing J , Dean HD , Holtzman D . Clin Infect Dis 2019 70 (9) 1907-1915 BACKGROUND: Hepatitis B virus (HBV) infection can be prevented through vaccination; however previous data show that only about 24%-45% of U.S. adults at high risk of HBV infection are protected. Our aims were to assess prevalence and trends in protective levels of hepatitis B surface antibody from 2003-2014 and explore factors associated with protection among U.S. adults at high risk. METHODS: Data were from the 2003-2014 National Health and Nutrition Examination Surveys. Our sample included adults, aged 18-49 years, who were tested for HBV and reported at least one of the following infection risks: history of STD, sex with men (for male respondents), infection with HIV, and injection drug use. We calculated the prevalence of hepatitis B surface antibody (anti-HBs, >/=10mIU/mL), indicative of immunity from vaccination among respondents for three 4-year time intervals (2003-2006, 2007-2010, and 2011-2014) and applied the Cochran-Mantel-Haenszel test to assess trends. Using multivariable logistic regression, we examined factors associated with positive anti-HBs serology. RESULTS: From 2003-2014, the prevalence of positive anti-HBs serology was 23.4%. Prevalence increased from 2003-2006 (16.3%) to 2007-2010 (27.3%), but no change occurred from 2007-2010 (27.3%) to 2011-2014 (28.1%). Among factors predicting positive anti-HBs serology were young age, female sex, and higher education. CONCLUSIONS: By 2014, less than one-third of adults, aged 18-49 years, at risk of infection exhibited anti-HBs >/=10 mIU/mL indicative of protection. Because these adults account for a substantial proportion of unprotected adults, targeted intervention strategies are essential to achieve the goal of hepatitis B elimination. |
Trust but verify: Is there a role for active surveillance in monitoring adverse events in Zimbabwe's large-scale male circumcision program
Marongwe P , Gonouya P , Madoda T , Murenje V , Tshimanga M , Balachandra S , Mandisarisa J , Sidile-Chitimbire V , Xaba S , Makunike-Chikwinya B , Holec M , Barnhart S , Feldacker C . PLoS One 2019 14 (6) e0218137 INTRODUCTION: Ensuring quality service provision is fundamental to ZAZIC's voluntary medical male circumcision (MC) program in Zimbabwe. From October, 2014 to September, 2017, ZAZIC conducted 205,847 MCs. Passive surveillance recorded a combined moderate and severe adverse event (AE) rate of 0.3%; reported adherence to follow-up was 95%, suggesting program safety. Despite encouraging passive surveillance data, verification of data quality and accuracy would increase confidence in AE identification. METHODS: From May to August, 2017, ZAZIC implemented a focused quality assurance (QA) study on AE ascertainment and documentation at 6 purposively-selected, high-volume MC sites. ZAZIC Gold-Standard (GS) clinicians prospectively observed 100 post-MC follow-ups per site in tandem with facility-based MC providers to confirm and characterize AEs, providing mentoring in AE management when needed. GS clinicians also retrospectively reviewed site-based, routine MC data, comparing recorded to reported AEs, and held brief qualitative interviews with site leadership on AE-related issues. RESULTS: Observed AE rates varied from 1-8%, potentially translating to thousands of unidentified AEs if observed AE rates were applied to previous MC performance. Most observed AEs were infections among younger clients. Retrospective review found discrepancies in AE documentation and reporting. Interviews suggest human resource and transport issues challenge MC follow-up visit attendance. Post-operative self-care appears to produce generally good results for adults; however, younger clients and guardians need additional attention to ensure quality care. There was no evidence of missed severe AEs resulting in permanent impairment or morbidity. CONCLUSIONS: Although results cannot be generalized, active surveillance suggests that AEs may be higher and follow-up lower than reported. In response, ZAZIC's Quality Assurance Task Force will replicate this QA study in other sites; increase training in AE identification, management, and documentation for clinical and data teams; and improve post-operative counseling for younger clients. Additional nurses and vehicles, especially in rural health clinics, could be beneficial. |
HIV diagnoses and viral suppression among US women in rural and nonrural areas, 2010-2017
Nwangwu-Ike N , Saduvala N , Watson M , Panneer N , Oster AM . J Rural Health 2019 36 (2) 217-223 BACKGROUND: Women in rural areas face challenges to HIV diagnosis and care, including limited access to testing and treatment facilities. Recent declines in HIV diagnosis rates among women in the United States are encouraging. However, few studies have addressed how HIV diagnosis and care differ by rurality. METHODS: We analyzed National HIV Surveillance System data for women aged >/=13 years with diagnosed HIV infection. We examined diagnoses in the United States during 2010-2017. Then, for women living with diagnosed HIV in 40 jurisdictions with complete laboratory reporting, we assessed viral suppression (viral load <200 copies/mL). Analyses were stratified by rural-urban category: rural (population <50,000), metropolitan (population 50,000-499,000), and metropolitan statistical areas (MSA, population >/=500,000). RESULTS: Among 64,004 women who received a diagnosis of HIV infection during 2010-2017, 4.2% resided in a rural area, 15% resided in a metropolitan area, and 80% resided in an MSA. Rural women had the highest percentage of stage 3 infection (acquired immune deficiency syndrome) at diagnosis (rural 30%, metropolitan 27%, MSA 25%). Of 190,735 women living with diagnosed HIV, viral suppression was lower in rural areas (rural 55%, metropolitan 59%, MSA 58%). CONCLUSIONS: During 2010-2017, most HIV diagnoses occurred among women residing in nonrural areas. However, women in rural areas had slightly higher levels of late diagnosis and lower levels of viral suppression, which might have resulted from differences in access to testing and treatment services. Interventions are needed to increase HIV testing, care, and viral suppression among women in rural areas. |
HIV testing in 50 local jurisdictions accounting for the majority of new HIV diagnoses and seven states with disproportionate occurrence of HIV in rural areas, 2016-2017
Pitasi MA , Delaney KP , Brooks JT , DiNenno EA , Johnson SD , Prejean J . MMWR Morb Mortal Wkly Rep 2019 68 (25) 561-567 Since 2006, CDC has recommended universal screening for human immunodeficiency virus (HIV) infection at least once in health care settings and at least annual rescreening of persons at increased risk for infection (1,2), but data from national surveys and HIV surveillance demonstrate that these recommendations have not been fully implemented (3,4). The national Ending the HIV Epidemic initiative* is intended to reduce the number of new infections by 90% from 2020 to 2030. The initiative focuses first on 50 local jurisdictions (48 counties, the District of Columbia, and San Juan, Puerto Rico) where the majority of new diagnoses of HIV infection in 2016 and 2017 were concentrated and seven states with a disproportionate occurrence of HIV in rural areas relative to other states (i.e., states with at least 75 reported HIV diagnoses in rural areas that accounted for >/=10% of all diagnoses in the state).(dagger) This initial geographic focus will be followed by wider implementation of the initiative within the United States. An important goal of the initiative is the timely identification of all persons with HIV infection as soon as possible after infection (5). CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS)( section sign) to assess the percentage of adults tested for HIV in the United States nationwide (38.9%), in the 50 local jurisdictions (46.9%), and in the seven states (35.5%). Testing percentages varied widely by jurisdiction but were suboptimal and generally low in jurisdictions with low rates of diagnosis of HIV infection. To achieve national goals and end the HIV epidemic in the United States, strategies must be tailored to meet local needs. Novel screening approaches might be needed to reach segments of the population that have never been tested for HIV. |
Rifampin-resistant tuberculosis in the United States, 1998-2014
Sharling L , Marks SM , Goodman M , Chorba T , Mase S . Clin Infect Dis 2019 70 (8) 1596-1605 BACKGROUND: Monoresistance to rifamycins necessitates longer and more toxic regimens for tuberculosis (TB). We examined characteristics and mortality associated with rifampin-monoresistant (RMR) TB in the United States. METHODS: We analyzed Mycobacterium tuberculosis culture-positive cases reported to the National TB Surveillance System (excluding California because HIV infection was not reported to CDC during 2005-2010) between 1998 and 2014. We defined: (1) RMR TB found on initial drug susceptibility testing (DST), and (2) possible acquired rifampin-resistant (ARR) TB. We assessed temporal trends in RMR TB. For both classifications of rifampin resistance, we calculated adjusted risk ratios (adjRR) and 95% confidence intervals (CI) for social and clinical characteristics associated with mortality when compared to drug-susceptible TB in multivariable models using backwards selection. RESULTS: Of 180,329 TB cases, 126,431 (70%) cases were eligible for analysis, with 359 (0.28%) of eligible cases reported as RMR. The percentage of RMR TB cases with HIV declined 4% annually during 1998-2014. Persons with HIV and prior TB were more likely to have RMR TB (adjRR=25.9, CI=17.6-38.1), as were persons with HIV and no prior TB (adjRR=3.1, CI=2.4-4.1), versus those without either characteristic, controlling for other statistically significant variables. RMR cases had greater mortality (adjRR=1.4, CI=1.04-1.8), controlling for HIV and other variables. Persons with HIV had greater risk of ARR than persons without HIV (adjRR=9.6, CI=6.9-13.3) and ARR was also associated with increased mortality, controlling for HIV and other variables. CONCLUSIONS: All forms of rifampin resistance were positively associated with HIV infection and increased mortality. |
The relationship between insecticide resistance, mosquito age and malaria prevalence in Anopheles gambiae s.l. from Guinea.
Collins E , Vaselli NM , Sylla M , Beavogui AH , Orsborne J , Lawrence G , Wiegand RE , Irish SR , Walker T , Messenger LA . Sci Rep 2019 9 (1) 8846 Insecticide resistance across sub-Saharan Africa may impact the continued effectiveness of malaria vector control. We investigated the association between carbamate and pyrethroid resistance with Anopheles gambiae s.l. parity, Plasmodium falciparum infection, and molecular insecticide resistance mechanisms in Guinea. Pyrethroid resistance was intense, with field populations surviving ten times the insecticidal concentration required to kill susceptible individuals. The L1014F kdr-N1575Y haplotype and I1527T mutation were significantly associated with mosquito survival following permethrin exposure (Prevalence Ratio; PR = 1.92, CI = 1.09-3.37 and PR = 2.80, CI = 1.03-7.64, respectively). Partial restoration of pyrethroid susceptibility following synergist pre-exposure suggests a role for mixed-function oxidases. Carbamate resistance was lower and significantly associated with the G119S Ace-1 mutation. Oocyst rates were 6.8% and 4.2% among resistant and susceptible mosquitoes, respectively; survivors of bendiocarb exposure were significantly more likely to be infected. Pyrethroid resistant mosquitoes had significantly lower parity rates than their susceptible counterparts (PR = 1.15, CI = 1.10-1.21). Our findings emphasize the need for additional studies directly assessing the influence of insecticide resistance on mosquito fitness. |
Metabolomics of childhood exposure to perfluoroalkyl substances: a cross-sectional study
Kingsley SL , Walker DI , Calafat AM , Chen A , Papandonatos GD , Xu Y , Jones DP , Lanphear BP , Pennell KD , Braun JM . Metabolomics 2019 15 (7) 95 INTRODUCTION: Exposure to perfluoroalkyl substances (PFAS), synthetic and persistent chemicals used in commercial and industrial processes, are associated with cardiometabolic dysfunction and related risk factors including reduced birth weight, excess adiposity, and dyslipidemia. Identifying the metabolic changes induced by PFAS exposure could enhance our understanding of biological pathways underlying PFAS toxicity. OBJECTIVE: To identify metabolic alterations associated with serum concentrations of four PFAS in children using a metabolome-wide association study. METHODS: We performed untargeted metabolomic profiling by liquid chromatography with ultra-high-resolution mass spectrometry, and separately quantified serum concentrations of perfluorooctanoic acid, perfluorooctanesulfonic acid, perfluorononanoic acid, and perfluorohexanesulfonic acid (PFHxS) for 114 8-year old children from Cincinnati, OH. We evaluated associations between each serum PFAS concentration and 16,097 metabolic features using linear regression adjusted for child age, sex, and race with a false discovery rate < 20%. We annotated PFAS-associated metabolites and conducted pathway enrichment analyses. RESULTS: Serum PFAS concentrations were associated with metabolic features annotated primarily as lipids and dietary factors. Biological pathways associated with all four PFAS included arginine, proline, aspartate, asparagine, and butanoate metabolism. CONCLUSIONS: In this cross-sectional study, childhood serum PFAS concentrations were correlated with metabolic pathways related to energy production and catabolism. Future studies should determine whether these pathways mediate associations between PFAS exposure and childhood cardiometabolic health. |
Urinary concentrations of environmental phenols and their associations with breast cancer incidence and mortality following breast cancer
Parada H Jr , Gammon MD , Ettore HL , Chen J , Calafat AM , Neugut AI , Santella RM , Wolff MS , Teitelbaum SL . Environ Int 2019 130 104890 BACKGROUND: Environmental phenols, compounds used widely in personal care and consumer products, are known endocrine disruptors. Few epidemiologic studies have examined the association of phenol biomarkers with breast cancer incidence and, to our knowledge, none have considered associations with mortality following breast cancer. We examined seven urinary phenol biomarkers in association with breast cancer incidence and subsequent mortality, and examined effect measure modification by body mass index (BMI). METHODS: Participants included 711 women with breast cancer and 598 women without breast cancer who were interviewed for the population-based Long Island Breast Cancer Study Project. Among women with breast cancer, phenol biomarkers were quantified in spot urine samples collected on average within three months of a first diagnosis of primary in situ or invasive breast cancer in 1996-1997. Women with breast cancer were monitored for vital status using the National Death Index. After a median follow-up of 17.6years, we identified 271 deaths, including 98 deaths from breast cancer. We examined creatinine-corrected phenol concentrations and the sum of parabens (Sigmaparabens) in association with breast cancer incidence using logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs), and with mortality using Cox regression to estimate hazard ratios (HRs) and 95% CIs. We evaluated multiplicative effect measure modification using cross-product terms in nested models. RESULTS: The highest (vs lowest) quintiles of urinary methylparaben, propylparaben, and Sigmaparabens were associated with risk of breast cancer with ORs ranging from 1.31 to 1.50. Methylparaben, propylparaben, and Sigmaparabens were also associated with all-cause mortality HRs ranging from 0.68 to 0.77. Associations for breast cancer incidence were more pronounced among women with BMI<25.0kg/m(2) than among women with BMI>/=25.0kg/m(2); however, associations for mortality were more pronounced among women with BMI>/=25kg/m(2) than among women with BMI<25kg/m(2). CONCLUSIONS: Select parabens may have differential associations with risk of developing breast cancer and mortality following breast cancer. |
Respirable uranyl-vanadate-containing particulate matter derived from a legacy uranium mine site exhibits potentiated cardiopulmonary toxicity
Zychowski KE , Kodali V , Harmon M , Tyler CR , Sanchez B , Ordonez Suarez Y , Herbert G , Wheeler A , Avasarala S , Cerrato JM , Kunda NK , Muttil P , Shuey C , Brearley A , Ali AM , Lin Y , Shoeb M , Erdely A , Campen MJ . Toxicol Sci 2018 164 (1) 101-114 Exposure to windblown particulate matter (PM) arising from legacy uranium (U) mine sites in the Navajo Nation may pose a human health hazard due to their potentially high metal content, including U and vanadium (V). To assess the toxic impact of PM derived from Claim 28 (a priority U mine) compared with background PM, and consider the putative role of metal species U and V. Two representative sediment samples from Navajo Nation sites (Background PM and Claim 28 PM) were obtained, characterized in terms of chemistry and morphology, and fractioned to the respirable (</= 10 mum) fraction. Mice were dosed with either PM sample, uranyl acetate, or vanadyl sulfate via aspiration (100 microg), with assessments of pulmonary and vascular toxicity 24 h later. Particulate matter samples were also examined for in vitro effects on cytotoxicity, oxidative stress, phagocytosis, and inflammasome induction. Claim 28 PM10 was highly enriched with U and V and exhibited a unique nanoparticle ultrastructure compared with background PM10. Claim 28 PM10 exhibited enhanced pulmonary and vascular toxicity relative to background PM10. Both U and V exhibited complementary pulmonary inflammatory potential, with U driving a classical inflammatory cytokine profile (elevated interleukin [IL]-1beta, tumor necrosis factor-alpha, and keratinocyte chemoattractant/human growth-regulated oncogene) while V preferentially induced a different cytokine pattern (elevated IL-5, IL-6, and IL-10). Claim 28 PM10 was more potent than background PM10 in terms of in vitro cytotoxicity, impairment of phagocytosis, and oxidative stress responses. Resuspended PM10 derived from U mine waste exhibit greater cardiopulmonary toxicity than background dusts. Rigorous exposure assessment is needed to gauge the regional health risks imparted by these unremediated sites. |
Analysis of an epidemiological model structured by time-since-last-infection
Alfaro-Murillo JA , Feng Z , Glasser JW . J Differ Equ 2019 267 (10) 5631-5661 Modeling time-since-last-infection (TSLI) provides a means of formulating epidemiological models with fewer state variables (or epidemiological classes) and more flexible descriptions of infectivity after infection and susceptibility after recovery than usual. The model considered here has two time variables: chronological time (t) and the TSLI (τ), and it has only two classes: never infected (N) and infected at least once (i). Unlike most age-structured epidemiological models, in which the i equation is formulated using [Formula presented], ours uses a more general differential operator. This allows weaker conditions for the infectivity and susceptibility functions, and thus, is more generally applicable. We reformulate the model as an age dependent population problem for analysis, so that published results for these types of problems can be applied, including the existence and regularity of model solutions. We also show how other coupled models having two types of time variables can be stated as age dependent population problems. |
Interpretation of Whole-Genome Sequencing for Enteric Disease Surveillance and Outbreak Investigation.
Besser JM , Carleton HA , Trees E , Stroika SG , Hise K , Wise M , Gerner-Smidt P . Foodborne Pathog Dis 2019 16 (7) 504-512 The routine use of whole-genome sequencing (WGS) as part of enteric disease surveillance is substantially enhancing our ability to detect and investigate outbreaks and to monitor disease trends. At the same time, it is revealing as never before the vast complexity of microbial and human interactions that contribute to outbreak ecology. Since WGS analysis is primarily used to characterize and compare microbial genomes with the goal of addressing epidemiological questions, it must be interpreted in an epidemiological context. In this article, we identify common challenges and pitfalls encountered when interpreting sequence data in an enteric disease surveillance and investigation context, and explain how to address them. |
PulseNet: Entering the Age of Next-Generation Sequencing.
Ribot EM , Freeman M , Hise KB , Gerner-Smidt P . Foodborne Pathog Dis 2019 16 (7) 451-456 Since 1996, PulseNet has served as the national laboratory-based surveillance system for the rapid detection of outbreaks caused by foodborne bacterial pathogens in the United States. For the past two decades, pulsed-field gel electrophoresis was the gold standard subtyping method for the pathogens tracked by PulseNet. A new gold standard is now being implemented with the introduction of cost-effective whole genome sequencing (WGS) for analysis of all the organisms tracked by PulseNet. This transformation is a major undertaking that touches every functional aspect of PulseNet, including laboratory workflows, data storage, analysis management and data interpretation, and language used to communicate information (sequence profile nomenclature system). The benefits of implementing WGS go beyond improved discrimination and precision of the data; it provides an opportunity to determine strain characteristics typically obtained through resource-intensive traditional methodologies, for example, species identification, serotyping, virulence, and antimicrobial resistance profiling, all of which can be consolidated into a single WGS workflow. Such a strategy represents a major shift in the workflows currently practiced in most public health laboratories, but one that brings opportunities for streamlining surveillance activities for the network as a whole. In this study, we provide a brief summary of PulseNet's evolution the past decade along with a general description of the challenges and opportunities that lie ahead. |
One hypervirulent clone, sequence type 283, accounts for a large proportion of invasive Streptococcus agalactiae isolated from humans and diseased tilapia in Southeast Asia.
Barkham T , Zadoks RN , Azmai MNA , Baker S , Bich VTN , Chalker V , Chau ML , Dance D , Deepak RN , van Doorn HR , Gutierrez RA , Holmes MA , Huong LNP , Koh TH , Martins E , Mehershahi K , Newton P , Ng LC , Phuoc NN , Sangwichian O , Sawatwong P , Surin U , Tan TY , Tang WY , Thuy NV , Turner P , Vongsouvath M , Zhang D , Whistler T , Chen SL . PLoS Negl Trop Dis 2019 13 (6) e0007421 BACKGROUND: In 2015, Singapore had the first and only reported foodborne outbreak of invasive disease caused by the group B Streptococcus (GBS; Streptococcus agalactiae). Disease, predominantly septic arthritis and meningitis, was associated with sequence type (ST)283, acquired from eating raw farmed freshwater fish. Although GBS sepsis is well-described in neonates and older adults with co-morbidities, this outbreak affected non-pregnant and younger adults with fewer co-morbidities, suggesting greater virulence. Before 2015 ST283 had only been reported from twenty humans in Hong Kong and two in France, and from one fish in Thailand. We hypothesised that ST283 was causing region-wide infection in Southeast Asia. METHODOLOGY/PRINCIPAL FINDINGS: We performed a literature review, whole genome sequencing on 145 GBS isolates collected from six Southeast Asian countries, and phylogenetic analysis on 7,468 GBS sequences including 227 variants of ST283 from humans and animals. Although almost absent outside Asia, ST283 was found in all invasive Asian collections analysed, from 1995 to 2017. It accounted for 29/38 (76%) human isolates in Lao PDR, 102/139 (73%) in Thailand, 4/13 (31%) in Vietnam, and 167/739 (23%) in Singapore. ST283 and its variants were found in 62/62 (100%) tilapia from 14 outbreak sites in Malaysia and Vietnam, in seven fish species in Singapore markets, and a diseased frog in China. CONCLUSIONS: GBS ST283 is widespread in Southeast Asia, where it accounts for a large proportion of bacteraemic GBS, and causes disease and economic loss in aquaculture. If human ST283 is fishborne, as in the Singapore outbreak, then GBS sepsis in Thailand and Lao PDR is predominantly a foodborne disease. However, whether transmission is from aquaculture to humans, or vice versa, or involves an unidentified reservoir remains unknown. Creation of cross-border collaborations in human and animal health are needed to complete the epidemiological picture. |
Adolescent connectedness and adult health outcomes
Steiner RJ , Sheremenko G , Lesesne C , Dittus PJ , Sieving RE , Ethier KA . Pediatrics 2019 144 (1) BACKGROUND: Because little is known about long-term effects of adolescent protective factors across multiple health domains, we examined associations between adolescent connectedness and multiple health-related outcomes in adulthood. METHODS: We used weighted data from Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 14 800). Linear and logistic models were used to examine associations between family and school connectedness in adolescence and self-reported health risk behaviors and experiences in adulthood, including emotional distress, suicidal thoughts and attempts, physical violence victimization and perpetration, intimate partner physical and sexual violence victimization, multiple sex partners, condom use, sexually transmitted infection (STI) diagnosis, prescription drug misuse, and other illicit drug use. RESULTS: In multivariable analyses, school connectedness in adolescence had independent protective associations in adulthood, reducing emotional distress and odds of suicidal ideation, physical violence victimization and perpetration, multiple sex partners, STI diagnosis, prescription drug misuse, and other illicit drug use. Similarly, family connectedness had protective effects for emotional distress, all violence indicators, including intimate partner violence, multiple sex partners, STI diagnosis, and both substance use indicators. Compared to individuals with low scores for each type of connectedness, having high levels of both school and family connectedness was associated with 48% to 66% lower odds of health risk behaviors and experiences in adulthood, depending on the outcome. CONCLUSIONS: Family and school connectedness may have long-lasting protective effects across multiple health outcomes related to mental health, violence, sexual behavior, and substance use. Increasing both family and school connectedness during adolescence has the potential to promote overall health in adulthood. |
Insurance reimbursements for human papillomavirus vaccination in the private sector, 2007-2014
Tsai Y , Lindley MC , Zhou F , Stokley S . Prev Med Rep 2019 15 100917 This study aims to assess payments to private providers for HPV vaccination. We used the 2007-2014 MarketScan Commercial Claims and Encounters Database and included 3,456,180 HPV vaccination visits made by adolescents aged 11-17years and enrolled in a non-capitated insurance plan in 37 states. We examined insurance reimbursements and its time trend for vaccine purchase and vaccine administration. Using the vaccine purchase price published by the Centers for Disease Control and Prevention (CDC) and the vaccination payment recommended by the American Academy of Pediatrics (AAP), we evaluated the financial concerns of administering HPV vaccines among private providers. In 2007-2014, the mean vaccine purchase reimbursement was $159.17 and the mean vaccine administration reimbursement was $23.91. During the study period, vaccine purchase reimbursements did not significantly change, but vaccine administration reimbursements increased. On average, 89.9% of the HPV claims received vaccine purchase reimbursements greater than the CDC-published price and 14.1% of HPV claims received vaccine purchase reimbursements above the AAP-recommended payment. Our results suggest that private providers are likely to receive sufficient reimbursements to cover the costs of administering HPV vaccines. However, the profit margin is likely to be small. |
Role of cancer history and gender in major health insurance transitions: A longitudinal nationally representative study
Virgo KS , Lin CC , Davidoff A , Guy GP Jr , de Moor JS , Ekwueme DU , Kent EE , Chawla N , Yabroff KR . Res Sociol Health Care 2018 36 59-84 Purpose -: To examine associations by gender between cancer history and major health insurance transitions (gains and losses), and relationships between insurance transitions and access to care. Methodology -: Longitudinal 2008-2013 Medical Expenditure Panel Survey data pooled yielding 2,223 cancer survivors and 50,692 individuals with no cancer history ages 18-63 years upon survey entry, with gender-specific sub-analyses. Access-to-care implications of insurance loss or gain were compared by cancer history and gender. Findings -: Initially uninsured cancer survivors were significantly more likely to gain insurance coverage than individuals with no cancer history (RR: 1.25; 95% CI: 1.08-1.44). Females in particular were significantly more likely to gain insurance (unmarried RR: 1.16; 95% CI: 1.06-1.28; married RR: 1.09; 95% CI: 1.02-1.16). Significantly higher rates of difficulty accessing needed medical care and prescription medications were reported by those remaining uninsured, those who lost insurance, and women in general. Remaining uninsured, losing insurance, and male gender were associated with lack of a usual source of care. Research implications -: Additional outreach to disadvantaged populations is needed to improve access to affordable insurance and medical care. Future longitudinal studies should assess whether major Affordable Care Act (ACA) provisions enacted after the 2008-2013 study period (or those of ACA's replacement) are addressing these important issues. Originality -: Loss of health insurance coverage can reduce health care access resulting in poor health outcomes. Cancer survivors may be particularly at risk of insurance coverage gaps due to the long-term chronic disease trajectory. This study is novel in exploring associations between cancer history by gender and health insurance transitions, both gains and losses, in a national non-elderly adult sample. |
Association between Medicaid coverage and income status on health care use and costs among hypertensive adults after enactment of the Affordable Care Act
Zhang D , Ritchey MR , Park C , Li J , Chapel J , Wang G . Am J Hypertens 2019 32 (10) 1030-1038 BACKGROUND: Hypertension is highly prevalent among the low-income population in the United States. This study assessed the association between Medicaid coverage and health care service use and costs among hypertensive adults following the enactment of the Patient Protection and Affordable Care Act (ACA), by income status level. METHODS: A nationally representative sample of 2,866 nonpregnant hypertensive individuals aged 18-64 years with income up to 138% of the federal poverty level (FPL) were selected from the 2014 and 2015 Medical Expenditure Panel Survey. Regression analyses were performed to examine the association of Medicaid coverage with outpatient (outpatient visits and prescription medication fills), emergency, and acute healthcare service use and costs among those potentially eligible for Medicaid by income status - the very low-income (FPL </=100%) and the moderately low-income (100%>FPL</=138%). RESULTS: Among the study population, 70.1% were very low-income and 29.9% were moderately low-income. Full-year Medicaid coverage was higher among the very low-income group (41.0%) compared with those moderately low-income (29.1%). For both income groups, having full-year Medicaid coverage was associated with increased healthcare service use and higher overall annual medical costs ($13,085 compared with $7,582 without Medicaid); costs were highest among moderately low-income patients ($17,639). CONCLUSION: Low-income individuals with hypertension, who were potentially newly eligible for Medicaid under the ACA may benefit from expanded Medicaid coverage by improving their access to outpatient services that can support chronic disease management. However, to realize decreases in medical expenditures, efforts to decrease their use of emergency and acute care services are likely needed. |
Outbreak of nontuberculous mycobacteria joint prosthesis infections, Oregon, USA, 2010-2016
Buser GL , Laidler MR , Cassidy PM , Moulton-Meissner H , Beldavs ZG , Cieslak PR . Emerg Infect Dis 2019 25 (5) 849-855 We investigated a cluster of Mycobacterium fortuitum and M. goodii prosthetic joint surgical site infections occurring during 2010-2014. Cases were defined as culture-positive nontuberculous mycobacteria surgical site infections that had occurred within 1 year of joint replacement surgery performed on or after October 1, 2010. We identified 9 cases by case finding, chart review, interviews, surgical observations, matched case-control study, pulsed-field gel electrophoresis of isolates, and environmental investigation; 6 cases were diagnosed >90 days after surgery. Cases were associated with a surgical instrument vendor representative being in the operating room during surgery; other potential sources were ruled out. A tenth case occurred during 2016. This cluster of infections associated with a vendor reinforces that all personnel entering the operating suite should follow infection control guidelines; samples for mycobacterial culture should be collected early; and postoperative surveillance for <90 days can miss surgical site infections caused by slow-growing organisms requiring specialized cultures, like mycobacteria. |
Public health importance of invasive methicillin-sensitive Staphylococcus aureus infections: Surveillance in 8 US counties, 2016
Jackson KA , Gokhale RH , Nadle J , Ray SM , Dumyati G , Schaffner W , Ham DC , Magill SS , Lynfield R , See I . Clin Infect Dis 2019 70 (6) 1021-1028 BACKGROUND: Public health and infection control prevention and surveillance efforts in the United States have primarily focused on methicillin-resistant Staphylococcus aureus (MRSA). We describe the public health importance of methicillin-susceptible S. aureus (MSSA) in selected communities. METHODS: We analyzed Emerging Infections Program surveillance data for invasive S. aureus (SA) infections (isolated from a normally sterile body site) in 8 counties in 5 states during 2016. Cases were considered healthcare-associated if culture was obtained >3 days after hospital admission; if associated with dialysis, hospitalization, surgery, or long-term care facility (LTCF) residence within 1 year prior; or if a central venous catheter was present </=2 days prior. Incidence per 100 000 census population was calculated, and a multivariate logistic regression model with random intercepts was used to compare MSSA risk factors with those of MRSA. RESULTS: Invasive MSSA incidence (31.3/100 000) was 1.8 times higher than MRSA (17.5/100 000). Persons with MSSA were more likely than those with MRSA to have no underlying medical conditions (adjusted odds ratio [aOR], 2.06; 95% confidence interval [CI], 1.26-3.39) and less likely to have prior hospitalization (aOR, 0.70; 95% CI, 0.60-0.82) or LTCF residence (aOR, 0.37; 95% CI, 0.29-0.47). MSSA accounted for 59.7% of healthcare-associated cases and 60.1% of deaths. CONCLUSIONS: Although MRSA tended to be more closely associated with healthcare exposures, invasive MSSA is a substantial public health problem in the areas studied. Public health and infection control prevention efforts should consider MSSA prevention in addition to MRSA. |
Candida auris and multidrug resistance: defining the new normal
Lockhart SR . Fungal Genet Biol 2019 131 103243 Candida auris is an emerging species of yeast characterized by colonization of skin, persistence in the healthcare environment, and antifungal resistance. C. auris was first described in 2009 from a single isolate but has since been reported in more than 25 countries worldwide. Resistance to fluconazole and amphotericin B is common, and resistance to the echinocandins is emerging in some countries. Antifungal resistance has been shown to be acquired rather than intrinsic and the primary mechanisms of resistance to the echinocandins and azoles have been determined. There are a number of new antifungal agents in phase 2 and phase 3 clinical trials and many have activity against C. auris. This review will discuss what is currently known about antifungal resistance in C. auris, limitations to antifungal susceptibility testing, the mechanisms of resistance, and the new antifungals that are on the horizon. |
Antimicrobial resistance in Cambodia: a review
Reed TAN , Krang S , Miliya T , Townell N , Letchford J , Bun S , Sar B , Osbjer K , Seng S , Chou M , By Y , Vanchinsuren L , Nov V , Chau D , Phe T , de Lauzanne A , Ly S , Turner P . Int J Infect Dis 2019 85 98-107 OBJECTIVES: Following the launch of the Global Antimicrobial Resistance Surveillance System (GLASS), antimicrobial resistance (AMR) rates in many countries remain poorly described. This review provides an overview of published AMR data from Cambodia in the context of recently initiated national human and food-animal surveillance. METHODS: PubMed and the Cochrane Database of Systematic Reviews were searched for articles published from 2000 to 2018, which reported antimicrobial susceptibility testing (AST) data for GLASS specific organisms isolated from Cambodia. Articles were screened using strict inclusion/exclusion criteria. AST data was extracted, with medians and ranges of resistance rates calculated for specific bug-drug combinations. RESULTS: Twenty-four papers were included for final analysis, with 20 describing isolates from human populations. Escherichia coli was the most commonly described organism, with median resistance rates from human isolates of 92.8% (n=6 articles), 46.4% (n=4), 55.4% (n=8), and 46.4% (n=5) to ampicillin, 3(rd) generation cephalosporins, fluoroquinolones, and gentamicin respectively. CONCLUSIONS: Whilst resistance rates are high for several GLASS organisms, there were insufficient data to draw robust conclusions about the AMR situation in Cambodia. The recently implemented national AMR surveillance systems will begin to address this data gap. |
An online decision tree for vaccine efficacy trial design during infectious disease epidemics: The InterVax-Tool
Bellan SE , Eggo RM , Gsell PS , Kucharski AJ , Dean NE , Donohue R , Zook M , Edmunds WJ , Odhiambo F , Longini IM Jr , Brisson M , Mahon BE , Henao-Restrepo AM . Vaccine 2019 37 (31) 4376-4381 BACKGROUND: Licensed vaccines are urgently needed for emerging infectious diseases, but the nature of these epidemics causes challenges for the design of phase III trials to evaluate vaccine efficacy. Designing and executing rigorous, fast, and ethical, vaccine efficacy trials is difficult, and the decisions and limitations in the design of these trials encompass epidemiological, logistical, regulatory, statistical, and ethical dimensions. RESULTS: Trial design decisions are complex and interrelated, but current guidance documents do not lend themselves to efficient decision-making. We created InterVax-Tool (http://vaxeval.com), an online, interactive decision-support tool, to help diverse stakeholders navigate the decisions in the design of phase III vaccine trials. InterVax-Tool offers high-level visual and interactive assistance through a set of four decision trees, guiding users through selection of the: (1) Primary Endpoint, (2) Target Population, (3) Randomization Scheme, and, (4) Comparator. We provide guidance on how key considerations - grouped as Epidemiological, Vaccine-related, Infrastructural, or Sociocultural - inform each decision in the trial design process. CONCLUSIONS: InterVax-Tool facilitates structured, transparent, and collaborative discussion of trial design, while recording the decision-making process. Users can save and share their decisions, which is useful both for comparing proposed trial designs, and for justifying particular design choices. Here, we describe the goals and features of InterVax-Tool as well as its application to the design of a Zika vaccine efficacy trial. |
Opportunities to improve vaccination coverage in a country with a fledgling health system: Findings from an assessment of missed opportunities for vaccination among health center attendees-Timor Leste, 2016
Li AJ , Peiris TSR , Sanderson C , Lochlainn LN , Mausiry M , da Silva Rbjbm , Ogbuanu IU . Vaccine 2019 37 (31) 4281-4290 INTRODUCTION: Since its independence in 2002, Timor Leste has made significant strides in improving childhood vaccination coverage. However, coverage is still below national targets, and children continue to have missed opportunities for vaccination (MOV), when eligible children have contact with the health system but are not vaccinated. Timor Leste implemented the updated World Health Organization methodology for assessing MOV in 2016. METHODS: The MOV data collection included quantitative (caregiver exit interviews and health worker knowledge, attitudes, practices surveys (KAP)) and qualitative arms (focus group discussions (FGDs) with caregivers and health workers and in-depth interviews (IDIs) with health administrators). During a four-day period, health workers and caregivers with children <24months of age attending the selected eight facilities in Dili Municipality were invited to participate. The researchers calculated the proportion of MOV and timeliness of vaccine doses among children with documented vaccination histories (i.e., from a home-based record or facility register) and thematically analyzed the qualitative data. RESULTS: Researchers conducted 365 caregiver exit interviews, 169 health worker KAP surveys, 4 FGDs with caregivers, 2 FGDs with health workers, and 2 IDIs with health administrators. Among eligible children with documented vaccination histories (n=199), 41% missed an opportunity for vaccination. One-third of health workers (33%) believed their knowledge of immunization practices to be insufficient. Qualitative results showed vaccines were not available at all selected health facilities, and some facilities reported problems with their cold chain equipment. CONCLUSION: This study demonstrates that many children in Timor Leste miss opportunities for vaccination during health service encounters. Potential interventions to reduce MOV include training of health workers, improving availability of vaccines at more health facilities, and replacing unusable cold chain equipment. Timor Leste should continue to scale up successful MOV interventions beyond Dili Municipality to improve vaccination coverage nationally and strengthen the health system overall. |
Timing of birth as an emergent risk factor for rotavirus hospitalization and vaccine performance in the postvaccination era in the United States
Lopman B , Dahl R , Shah M , Parashar UD . Am J Epidemiol 2018 187 (8) 1745-1751 Rotavirus vaccines were introduced in the United States in 2006, and in the years since they have fundamentally altered the seasonality of rotavirus infection and have shifted disease outbreaks from annual epidemics to biennial epidemics. We investigated whether season and year of birth have emerged as risk factors for rotavirus or have affected vaccine performance. We constructed a retrospective birth cohort of US children under age 5 years using the 2001-2014 MarketScan database (Truven Health Analytics, Chicago, Illinois). We evaluated the associations of season of birth, even/odd year of birth, and interactions with vaccination. We fitted Cox proportional hazards models to estimate the hazard of rotavirus hospitalization according to calendar year of birth and season of birth assessed for interaction with vaccination. After the introduction of rotavirus vaccine, we observed monotonically decreasing rates of rotavirus hospitalization for each subsequent birth cohort but a biennial incidence pattern by calendar year. In the postvaccine period, children born in odd calendar years had a higher hazard of rotavirus hospitalization than those born in even years. Children born in winter had the highest hazard of hospitalization but also had greater vaccine effectiveness than children born in spring, summer, or fall. With the emergence of a strong biennial pattern of disease following vaccine introduction, the timing of a child's birth has become a risk factor for rotavirus infection. |
Meningococcal conjugate vaccine in the United States: Remaining challenges for adolescent vaccination
Mbaeyi S , Stokley S . J Adolesc Health 2019 65 (1) 11-12 Meningococcal disease is a serious bacterial infection caused by Neisseria meningitidis that can lead to meningitis and sepsis. Overall, 10%–15% of patients die despite appropriate antimicrobial therapy and among survivors, 10%–20% experience long-term sequelae such as hearing loss, cognitive deficits, or limb amputations [1]. Although rates of disease are highest in infants, older adolescents and young adults have an increased incidence of invasive meningococcal disease and the highest rates of asymptomatic oropharyngeal colonization and thus are likely the main source of transmission of the organism to other age groups [2,3]. For these reasons, adolescents are the primary group recommended for meningococcal vaccination in the United States. |
Strengths, pitfalls, and lessons learned in implementing electronic collection of childhood vaccination data in Zambia: The SmartCare experience
Clarke KEN , Phiri Chibawe C , Essiet-Gibson I , Dien Mwansa F , Jacenko S , Rhee C , Kwendakwape M , Kashoka A , MacNeil A . Int J Med Inform 2019 129 146-153 Background: Despite widespread interest in computerized vaccination information systems, evaluation of the data quality in these systems and their acceptability to frontline healthcare workers in low and middle-income countries aren't well addressed in the literature. Objective(s): Evaluation of vaccination data quality and facility-level staff perspectives on the strengths and challenges of a vaccination data module in a widely used electronic health record (EHR) system in Zambia. Method(s): After a desk review of data from two provinces, a cross-sectional mixed methods study was designed, including quantitative analysis of data quality and qualitative analysis of the module's acceptability to facility staff, using the Information System Success model as the framework for evaluation of system quality, service quality, and information quality. Data were collected from 10 purposively sampled health facilities. Result(s): There was low current use of the vaccination module by facilities in the study area (2%). Daily power outages presented a practical challenge. Staff who had used previous EHRs had concerns about sustainability. System quality: While the module was user-friendly, there were concerns about EHR compatibility with vaccination workflow and outreach settings, where vaccines are commonly administered to older children. Service quality: The module was viewed as dependable; perceptions were influenced by computer literacy. Information quality: The database contained incomplete and incongruous data. Staff perceived data as accurate but incomplete; easy access to data was a strength. Conclusion(s): Potential benefits of the vaccination module were frequently unrealized due to infrastructure, workflow, and data flow challenges that resulted in low module use and poor information quality. Elements to optimize vaccination information system implementation could include robust engagement of facility-level staff in system design, system suitability to the vaccination setting and workflow, and comprehensive planning for data flow, sustainability, data monitoring and feedback. Adaptability to the outreach setting might be increasingly important as vaccination schedules extend past infancy. |
GIScience and cancer: State of the art and trends for cancer surveillance and epidemiology
Sahar L , Foster SL , Sherman RL , Henry KA , Goldberg DW , Stinchcomb DG , Bauer JE . Cancer 2019 125 (15) 2544-2560 Maps are well recognized as an effective means of presenting and communicating health data, such as cancer incidence and mortality rates. These data can be linked to geographic features like counties or census tracts and their associated attributes for mapping and analysis. Such visualization and analysis provide insights regarding the geographic distribution of cancer and can be important for advancing effective cancer prevention and control programs. Applying a spatial approach allows users to identify location-based patterns and trends related to risk factors, health outcomes, and population health. Geographic information science (GIScience) is the discipline that applies Geographic Information Systems (GIS) and other spatial concepts and methods in research. This review explores the current state and evolution of GIScience in cancer research by addressing fundamental topics and issues regarding spatial data and analysis that need to be considered. GIScience, along with its health-specific application in the spatial epidemiology of cancer, incorporates multiple geographic perspectives pertaining to the individual, the health care infrastructure, and the environment. Challenges addressing these perspectives and the synergies among them can be explored through GIScience methods and associated technologies as integral parts of epidemiologic research, analysis efforts, and solutions. The authors suggest GIScience is a powerful tool for cancer research, bringing additional context to cancer data analysis and potentially informing decision-making and policy, ultimately aimed at reducing the burden of cancer. |
Psychoactive medication use among older community-dwelling Americans
Haddad YK , Luo F , Karani MV , Marcum ZA , Lee R . J Am Pharm Assoc (2003) 2019 59 (5) 686-690 BACKGROUND: Falls are a common and serious health issue among older Americans. A common fall risk factor is the use of psychoactive medications. There is limited recent information on the national prevalence of psychoactive medication use among older Americans. OBJECTIVES: To estimate the prevalence of psychoactive medication use among community-dwelling older Americans and compare it with previous estimates from 1996. METHODS: The data source was the 2013 Cost and Use Data files combining Medicare claims data and survey data from the Medicare Current Beneficiary Survey, an in-person nationally representative survey of Medicare beneficiaries. Participants were included if they were 65 years of age and older, lived in the community, and had a complete year of prescription use data. Medication use was examined for 7 classes of psychoactive medications categorized by the 2015 American Geriatric Society Beers criteria as increasing fall risk. These include opioids, benzodiazepines, selective serotonin reuptake inhibitors, anticonvulsants, nonbenzodiazepine sedative hypnotics, antipsychotics, and tricyclic antidepressants. Data on participant demographic factors were also collected. RESULTS: Among the 6959 community-dwelling older adults studied, representing 33,268,104 community-dwelling Medicare beneficiaries, 53.3% used at least 1 psychoactive medication linked to falls in 2013. The most frequently used medication classes were opioids (34.9%), benzodiazepines (15.4%), selective serotonin reuptake inhibitors (14.3%), and anticonvulsants (13.3%). These estimates are considerably higher for all classes except tricyclic antidepressants than previous reports from 1996 that used the same data source. Among most psychoactive medication classes observed, women had higher usage than men. CONCLUSION: More than half of all older Americans used at least 1 psychoactive medication in 2013. Health care providers, including pharmacists, play a vital role in managing older adults' exposure to psychoactive medications. Medication management can optimize health and reduce older adult falls. |
Increased discrimination of Treponema pallidum strains by subtyping with a four-component system incorporating a mononucleotide tandem repeat in rspA.
Pillay A , Lee MK , Slezak T , Katz SS , Sun Y , Chi KH , Morshed M , Philip S , Ballard RC , Chen CY . Sex Transm Dis 2019 46 (4) e42-e45 A guanine mononucleotide repeat in the rpsA (tp0279) gene was evaluated for improved strain discrimination using 72 Treponema pallidum-positive specimens. The tandem repeat combined with the enhanced Centers for Disease Control and Prevention typing system resulted in increased discrimination and should be useful for molecular epidemiologic studies on syphilis especially in outbreaks and among men who have sex with men. |
A Laboratory Medicine Best Practices Systematic Review and Meta-analysis of Nucleic Acid Amplification Tests (NAATs) and Algorithms Including NAATs for the Diagnosis of Clostridioides ( Clostridium ) difficile in Adults.
Kraft CS , Parrott JS , Cornish NE , Rubinstein ML , Weissfeld AS , McNult P , Nachamkin I , Humphries RM , Kirn TJ , Dien Bard J , Lutgring JD , Gullett JC , Bittencourt CE , Benson S , Bobenchik AM , Sautter RL , Baselski V , Atlas MC , Marlowe EM , Miller NS , Fischer M , Richter SS , Gilligan P , Snyder JW . Clin Microbiol Rev 2019 32 (3) SUMMARYThe evidence base for the optimal laboratory diagnosis of Clostridioides (Clostridium) difficile in adults is currently unresolved due to the uncertain performance characteristics and various combinations of tests. This systematic review evaluates the diagnostic accuracy of laboratory testing algorithms that include nucleic acid amplification tests (NAATs) to detect the presence of C. difficile The systematic review and meta-analysis included eligible studies (those that had PICO [population, intervention, comparison, outcome] elements) that assessed the diagnostic accuracy of NAAT alone or following glutamate dehydrogenase (GDH) enzyme immunoassays (EIAs) or GDH EIAs plus C. difficile toxin EIAs (toxin). The diagnostic yield of NAAT for repeat testing after an initial negative result was also assessed. Two hundred thirty-eight studies met inclusion criteria. Seventy-two of these studies had sufficient data for meta-analysis. The strength of evidence ranged from high to insufficient. The uses of NAAT only, GDH-positive EIA followed by NAAT, and GDH-positive/toxin-negative EIA followed by NAAT are all recommended as American Society for Microbiology (ASM) best practices for the detection of the C. difficile toxin gene or organism. Meta-analysis of published evidence supports the use of testing algorithms that use NAAT alone or in combination with GDH or GDH plus toxin EIA to detect the presence of C. difficile in adults. There is insufficient evidence to recommend against repeat testing of the sample using NAAT after an initial negative result due to a lack of evidence of harm (i.e., financial, length of stay, or delay of treatment) as specified by the Laboratory Medicine Best Practices (LMBP) systematic review method in making such an assessment. Findings from this systematic review provide clarity to diagnostic testing strategies and highlight gaps, such as low numbers of GDH/toxin/PCR studies, in existing evidence on diagnostic performance, which can be used to guide future clinical research studies. |
Whole-gene analysis of inter-genogroup reassortant rotaviruses from the Dominican Republic: Emergence of equine-like G3 strains and evidence of their reassortment with locally-circulating strains.
Katz EM , Esona MD , Betrapally NS , De La Cruz De Leon LA , Neira YR , Rey GJ , Bowen MD . Virology 2019 534 114-131 Inter-genogroup reassortant group A rotavirus (RVA) strains possessing a G3 VP7 gene of putative equine origin (EQL-G3) have been detected in humans since 2013. Here we report detection of EQL-G3P[8] RVA strains from the Dominican Republic collected in 2014-16. Whole-gene analysis of RVA in stool specimens revealed 16 EQL-G3P[8] strains, 3 of which appear to have acquired an N1 NSP1 gene from locally-circulating G9P[8] strains and a novel G2P[8] reassortant possessing 7 EQL-G3-associated genes and 3 genes from a locally-circulating G2P[4] strain. Phylogenetic/genetic analyses of VP7 gene sequences revealed nine G3 lineages (I-IX) with newly-assigned lineage IX encompassing all reported human EQL-G3 strains along with the ancestral equine strain. VP1 and NSP2 gene phylogenies suggest that EQL-G3P[8] strains were introduced into the Dominican Republic from Thailand. The emergence of EQL-G3P[8] strains in the Dominican Republic and their reassortment with locally-circulating RVA could have implications for current vaccination strategies. |
Lessons from the reestablishment of Public Health Laboratory activities in Puerto Rico after Hurricane Maria
Hardy MC , Stinnett RC , Kines KJ , Rivera-Nazario DM , Lowe DE , Mercante AM , Gonzalez Jimenez N , Cuevas Ruiz RI , Rivera Arbolay HI , Gonzalez Pena RL , Toro M , Trujillo AA , Pappas CL , Llewellyn AC , Candal F , Burgos Garay M , Gomez GA , Concepcion Acevedo J , Ansbro M , Moura H , Shaw MW , Muehlenbachs A , Romanoff LC , Sunshine BJ , Rose DA , Patel A , Shapiro CN , Luna-Pinto SC , Pillai SK , O'Neill E . Nat Commun 2019 10 (1) 2720 Public Health Laboratories (PHLs) in Puerto Rico did not escape the devastation caused by Hurricane Maria. We implemented a quality management system (QMS) approach to systematically reestablish laboratory testing, after evaluating structural and functional damage. PHLs were inoperable immediately after the storm. Our QMS-based approach began in October 2017, ended in May 2018, and resulted in the reestablishment of 92% of baseline laboratory testing capacity. Here, we share lessons learned from the historic recovery of the largest United States' jurisdiction to lose its PHL capacity, and provide broadly applicable tools for other jurisdictions to enhance preparedness for public health emergencies. |
Astrocyte-specific transcriptome analysis using the ALDH1L1 bacTRAP mouse reveals novel biomarkers of astrogliosis in response to neurotoxicity
Michalovicz LT , Kelly KA , Vashishtha S , Ben-Hamo R , Efroni S , Miller JV , Locker AR , Sullivan K , Broderick G , Miller DB , O'Callaghan JP . J Neurochem 2019 150 (4) 420-440 Neurotoxicology is hampered by the inability to predict regional and cellular targets of toxicant-induced damage. Evaluating astrogliosis overcomes this problem because reactive astrocytes highlight the location of toxicant-induced damage. While enhanced expression of glial fibrillary acidic protein is a hallmark of astrogliosis, few other biomarkers have been identified. However, bacterial artificial chromosome, translating ribosome affinity purification (bacTRAP) technology allows for characterization of the actively translating transcriptome of a particular cell type; use of this technology in aldehyde dehydrogenase 1 family member L1 (ALDH1L1) bacTRAP mice can identify genes selectively expressed in astrocytes. The aim of this study was to characterize additional biomarkers of neurotoxicity-induced astrogliosis using ALDH1L1 bacTRAP mice. The known dopaminergic neurotoxicant 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP; 12.5 mg/kg s.c.) was used to induce astrogliosis. Striatal tissue was obtained 12, 24, and 48 hours following exposure for the isolation of actively translating RNA. Subsequently, MPTP-induced changes in this RNA pool were analyzed by microarray and 184 statistically significant, differentially expressed genes were identified. The data set was interrogated by gene ontology, pathway, and co-expression network analyses, which identified novel genes, as well as those with known immune and inflammatory functions. Using these analyses, we were directed to several genes associated with reactive astrocytes. Of these, TIMP1 and miR-147 were identified as candidate biomarkers due to their robust increased expression following both MPTP and trimethyl tin exposures. Thus, we have demonstrated that bacTRAP can be used to identify new biomarkers of astrogliosis and aid in the characterization of astrocyte phenotypes induced by toxicant exposures. This article is protected by copyright. All rights reserved. |
Reexamination of hemoglobin adjustments to define anemia: altitude and smoking
Sharma AJ , Addo OY , Mei Z , Suchdev PS . Ann N Y Acad Sci 2019 1450 (1) 190-203 The correct interpretation of hemoglobin (Hb) to identify anemia requires adjusting for altitude and smoking. Current adjustments were derived using data collected before 1985, from low-income preschool-aged children (PSC) in the United States and indigenous men in Peru for altitude, and from White women of reproductive age (WRA) in the United States for smoking. Given the oldness and limited representativeness of these data, we reexamined associations between Hb and altitude and/or smoking using 13 population-based surveys and 1 cohort study each conducted after 2000. All WHO regions except South-East Asia were represented. The dataset included 68,193 observations among PSC (6-59 months) and nonpregnant WRA (15-49 years) with data on Hb and altitude (-28 to 4000 m), and 19,826 observations among WRA with data on Hb and smoking (status or daily cigarette quantity). Generalized linear models were used to assess the robustness of associations under varying conditions, including controlling for inflammation-corrected iron and vitamin A deficiency. Our study confirms that Hb should be adjusted for altitude and/or smoking; these adjustments are additive. However, recommendations for Hb adjustment likely need updating. Notably, current recommendations may underadjust Hb for light smokers and for those residing at lower altitudes and overadjust Hb for those residing at higher altitudes. |
Community-based service use in preschool children with autism spectrum disorder and associations with insurance status
Rubenstein E , Croen L , Lee LC , Moody E , Schieve LA , Soke GN , Thomas K , Wiggins L , Daniels J . Res Autism Spectr Disord 2019 66 (101410) Background: ASD-related services can improve outcomes for children, but less is known about service outside of school settings during preschool age. We aimed to describe amount and category of community-based service use among 3-5-year-old children with ASD and examine differences by health insurance. Method(s): We used cross-sectional data on 792 children with ASD diagnoses in the Study to Explore Early Development, a community-based study of neurodevelopment with enrollment between 2012-2016. Mothers reported current child service use and insurance status at study entry. We used log-Poisson and logistic regression to compare service use by insurance group. Result(s): Nearly 40% of children were not receiving community-based services at study entry. Children with public insurance had fewer total services than children with private or both insurances. After adjustment for sociodemographic confounders, insurance status was not associated with amount of different categories of community-based services. However, children with public insurance alone were least likely to receive community-based behavioral therapy and most likely to receive psychotropic medication compared to other insurances. Conclusion(s): Many preschool-aged children do not receive community-based services, with receipt of some service types associated with insurance type. Increasing access and availability for evidence-based service, especially for beneficiaries of public insurance, may improve service use and outcomes. |
Calibration of the cloud and aerosol spectrometer for coal dust composition and morphology
Barone TL , Hesse E , Seaman CE , Baran AJ , Beck TW , Harris ML , Jaques PA , Lee T , Mischler SE . Adv Powder Technol 2019 30 (9) 1805-1814 The cloud and aerosol spectrometer (CAS) was calibrated to enable CAS sizing of coal dust for studies on flammable dust control. Coal dust sizes were determined by light-scattering theories for irregular particles that account for particle composition and morphology in computing coal dust diameters. Coal dust size computations were compared with test dust that was generated by cyclone separation and air-jet sieving and characterized by aerodynamic particle sizer (APS) and computer-controlled scanning electron microscopy (CCSEM) measurements. For test dust in the range of 0.5–32 μm, coal dust size distributions were consistent with cyclone-separated and sieve-segregated sizes. For the 3–20 μm size range, the coal dust size distribution had a mass median diameter that was 14% larger than that of the APS. This difference was reasonable considering that the basic calibration for glass spheres had 13% uncertainty. For the 20–32 μm and 32–45 μm test dusts, mass median diameters differed from CCSEM measurements by only 4% and 5%, respectively. Overall, the results suggest agreement between test dust sizes and computations for coal dust. Alternatively, using conventional Mie theory computations for spheres, coal dust mass median diameters were 35% and 40% larger than APS and CCSEM measurements, respectively. |
Operators' views of mobile equipment ingress and egress safety
Pollard J , Kosmoski C , Porter WL , Kocher L , Whitson A , Nasarwanji M . Int J Ind Ergon 2019 72 272-280 A large proportion of non-fatal slips, trips, and falls (STFs) at surface mining facilities are associated with mobile equipment. Ingress and egress from mobile equipment can pose a fall risk to mobile equipment operators. The objective of this study was to determine mobile equipment operators' views of STF risks from mobile equipment, and to ascertain what factors, tasks, and conditions they perceive as contributing to these risks. A thematic analysis of 23 individual interviews and 2 group interviews was conducted, with 10 overarching themes identified from the transcripts. Mobile equipment operators indicated that being unable to see their feet or the ladder rungs during descent and the presence of contaminants on the ladders caused by normal operation make egress more dangerous than ingress. The flexible rails and high heights of the lower rungs identified over 40 years ago as issues for mobile equipment operators still pose a perceived STF risk. Further, the requirements of routine maintenance tasks such as oil and filter changes, greasing, and cleaning windows pose fall risks due to inadequate access and the need to carry supplies up and down equipment ladders. In addition to the mobile equipment, hazardous ground conditions and insufficient lighting were found to be key issues around the mobile equipment and in parking areas. The findings of this work indicate that mobile equipment operators feel at risk for STFs due to the design and condition of their equipment, and would like to see ladders replaced with safer stairways as the primary ingress/egress system. |
Development of molecular assays to detect target-site mechanisms associated with insecticide resistance in malaria vectors from Latin America.
Lol JC , Castaneda D , Mackenzie-Impoinvil L , Romero CG , Lenhart A , Padilla NR . Malar J 2019 18 (1) 202 BACKGROUND: Malaria remains an important public health problem in Latin America, and the development of insecticide resistance in malaria vectors poses a major threat to malaria elimination efforts. Monitoring of insecticide susceptibility and the determination of the mechanisms involved in insecticide resistance are needed to effectively guide the deployment of appropriate vector control measures. Here, molecular assays have been developed to screen for mutations associated with insecticide resistance on the voltage-gated sodium channel (VGSC) and acetylcholinesterase-1 (Ace-1) genes in four malaria vectors from Latin America. METHODS: Degenerate primers were designed to amplify a partial fragment on the VGSC and Ace-1 genes. Wild-caught individuals for Anopheles albimanus (also historical samples and individuals from a laboratory strain), Anopheles darlingi, Anopheles vestitipennis and Anopheles pseudopunctipennis were used to optimize the PCR assays. All samples were sequenced to validate the PCR results and DNA alignments were constructed for each gene using the unique haplotypes observed. RESULTS: Primers designed successfully amplified the VGSC gene in An. albimanus, An. darlingi, An. vestitipennis and An. pseudopunctipennis, and the Ace-1 gene in both An. albimanus and An. darlingi. DNA sequencing revealed that compared with Anopheles gambiae, there were a total of 29, 28, 21 and 24 single nucleotide polymorphisms (SNPs) on the VGSC gene for An. albimanus (308 bp), An. darlingi (311 bp), An. pseudopunctipennis (263 bp) and An. vestitipennis (254 bp), respectively. On the 459 bp fragment of the Ace-1 gene, a total of 70 SNPs were detected in An. darlingi and 59 SNPs were detected in An. albimanus compared with An. gambiae. The SNPs detected on the VGSC gene were all synonymous. On the Ace-1 gene, non-synonymous substitutions were identified on three different codons. All species showed the homozygous wild-type kdr allele (coding for leucine) at codon 995 (formerly reported as codon 1014) on the VGSC gene, but one sample was heterozygous at codon 280 (formerly reported as codon 119) on the Ace-1 gene, coding for both the resistant (serine) and susceptible (glycine) amino acids. CONCLUSIONS: New molecular assays to amplify and screen the regions of the VGSC and Ace-1 genes associated with insecticide resistance are reported for An. albimanus, An. darlingi, An. vestitipennis, and An. pseudopunctipennis. The development of these PCR assays presents an important advance in the analysis of target-site resistance in malaria vectors in the Americas, and will further facilitate the characterization of insecticide resistance mechanisms in these species. |
Safety of atovaquone-proguanil during pregnancy
Mayer RC , Tan KR , Gutman JR . J Travel Med 2019 26 (4) BACKGROUND: Malaria during pregnancy increases the risk of maternal and foetal complications. There are very limited options for prophylaxis in pregnant travellers. Atovaquone-Proguanil (AP or Malarone(R)) is an effective and well-tolerated antimalarial medication, but is not recommended for use in pregnancy due to limited data on safety. Passively reported adverse event data may provide additional information on the safety of AP during pregnancy. METHODS: We analysed adverse event data on pregnancy and birth outcomes following accidental exposures to AP during pregnancy, which were passively reported to GlaxoSmithKline LLC (GSK) between 13 May 1997 and 15 August 2017. Birth outcomes of interest included live birth, miscarriage, and stillbirth. Adverse outcomes of interest were defined as any of the following: small for gestational age (SGA), low birth weight (LBW, <2500 gm), congenital anomalies, and a composite 'poor live birth outcome,' including preterm birth (PTB), LBW or SGA. RESULTS: Among 198 women who received AP during pregnancy or breastfeeding, 96.5% occurred in women taking malaria prophylaxis, and 79.8% of exposures occurred in the first trimester. Among 195 with available birth outcome data, 18.5% resulted in miscarriage and 11.8% were elective terminations. Available adverse outcomes included SGA in 3.5% (3/85), LBW in 7.0% of infants (6/86), and the composite 'poor live birth outcome' in 13.7% (14/102). Congenital anomalies were reported in 30/124 (24.2%), with no specific pattern to suggest an effect related to AP. CONCLUSIONS: These data provide a description of outcomes in the pregnancies reported to this dataset, and it should be noted that there is likely a bias towards reporting cases resulting in poor outcomes. While there was no specific signal to suggest a teratogenic effect of AP, AP data during pregnancy were too limited to determine AP's safety with confidence. As inadvertent exposures are not infrequent, better data are needed. |
An assessment of human rights-based approaches to health knowledge, attitudes, and practices among Centers for Disease Control and Prevention locally employed staff
McKinnon I , Lor A , Evans DP . Health Hum Rights 2019 21 (1) 33-44 Despite the increasing use of human rights-based approaches to health, the Centers for Disease Control and Prevention (CDC) does not routinely train its staff in the use of such approaches as a part of public health practice. We conducted a training needs assessment among CDC locally employed staff working outside of the United States through eight key informant interviews and an online survey from June to December 2015. Key informants revealed an awareness that rights violations negatively affect access to health services and supported implementation of formal training among CDC staff. Most (82%) survey respondents felt that the CDC should do more to address health and human rights issues in its programs, policies and research. However, 72% of respondents did not feel they had adequate knowledge to address human rights in their work. In particular, 86% of participants had no knowledge of the Siracusa Principles (criteria for human rights restrictions) and only 2% of participants had received any training on international human rights treaties related to the duties of public health professionals. Our findings inform and support the need to design a training on human rights-based approaches to health, focused on the knowledge and skill needs of CDC locally employed staff. |
Hypertensive disorders in pregnancy and maternal and neonatal outcomes in Haiti: the importance of surveillance and data collection
Bridwell M , Handzel E , Hynes M , Jean-Louis R , Fitter D , Hogue C , Grand-Pierre R , Pierre H , Pearce B . BMC Pregnancy Childbirth 2019 19 (1) 208 BACKGROUND: This study aims to determine reported prevalence of hypertensive disorders in pregnancy (HDP) and maternal and neonatal outcomes associated with these disorders among women delivering at selected hospitals across Haiti. METHODS: A retrospective review of 8822 singleton deliveries between January 2012 and December 2014 was conducted at four hospitals in separate Departments across Haiti. Researchers examined the proportion of women with reported HDP (hypertension, preeclampsia, eclampsia) and the association between women with HDP and three neonatal outcomes: low birth weight, preterm birth, and stillbirths; and two maternal outcomes: placental abruption and maternal death in Hopital Albert Schweitzer (HAS). Odds ratios for associations between HDP and perinatal outcomes at HAS were assessed using logistic regression, adjusting for potential confounders. RESULTS: Of the 8822 singleton births included in the study, 510 (5.8%) had a reported HDP (including 285 (55.9%) preeclampsia, 119 (23.3%) eclampsia, and 106 (20.8%) hypertension). Prevalence of HDP among each hospital was: HAS (13.5%), Hopital Immaculee Conception des Cayes (HIC) (3.2%), Fort Liberte (4.3%), and Hopital Sacre Coeur de Milot (HSC) (3.0%). Among women at HAS with HDP, the adjusted odds of having a low birth weight baby was four times that of women without HDP (aOR 4.17, 95% CI 3.19-5.45), more than three times that for stillbirths (aOR 3.51, 95% CI 2.43-5.06), and five times as likely to result in maternal death (aOR 5.13, 95% CI 1.53-17.25). Among the three types of HDP, eclampsia was associated with the greatest odds of adverse events with five times the odds of having a low birth weight baby (aOR 5.00, 95% CI 2.84-8.79), six times the odds for stillbirths (aOR 6.34, 95% CI 3.40-11.82), and more than twelve times as likely to result in maternal death (aOR 12.70, 95% CI 2.33-69.31). CONCLUSIONS: A high prevalence of HDP was found among a cohort of Haitian mothers. HDP was associated with higher rates of adverse maternal and neonatal outcomes in HAS, which is comparable to studies of HDP conducted in high-income countries. |
Confidentiality matters but how do we improve implementation in adolescent sexual and reproductive health care
Pampati S , Liddon N , Dittus PJ , Adkins SH , Steiner RJ . J Adolesc Health 2019 65 (3) 315-322 Confidentiality protections are a key component of high-quality adolescent sexual and reproductive health (SRH) care. Research has shown that adolescents value confidentiality and are more likely to seek care and provide honest information when confidentiality protections are implemented. However, many adolescents do not receive confidential SRH care. We synthesize studies of adolescents, parents, and providers to identify confidentiality-related factors that may explain why adolescents do not seek care or receive confidential services when they do access care. We present themes relevant to each population that address individual-level knowledge, attitudes, and behaviors, as well as clinic-level characteristics such as protocols, billing mechanisms, and clinic type. These findings have the potential to inform intervention efforts to improve the delivery of confidential SRH care for young people. |
Evaluation of a safer opioid prescribing protocol (SOPP) for patients being discharged from a trauma service
Baird J , Faul M , Green TC , Howland J , Adams CAJr , Hodne MJ , Bohlen N , Mello MJ . J Trauma Nurs 2019 26 (3) 113-120 The aims of this study were to evaluate the effects on opioid medication prescribing, patient opioid safety education, and prescribing of naloxone following implementation of a Safer Opioid Prescribing Protocol (SOPP) as part of the electronic health record (EHR) system at a Level I trauma center. This was a prospective observational study of the EHR of trauma patients pre- (n = 191) and post-(n = 316) SOPP implementation between 2014 and 2016. At a comparison Level I trauma site not implementing SOPP, EHRs for the same time period were assessed for any historical trends in opioid and naloxone prescribing. After SOPP implementation, the implementation site increased the use of nonnarcotic pain medication, decreased dispensing high opioid dose (≥100 MME [milligram morphine equivalent]), significantly increased the delivery of opioid safety education to patients, and initiated prescribing naloxone. These changes were not found in the comparison site. Opioid prescribing for acute pain can be effectively reduced in a busy trauma setting with a guideline intervention incorporated into an EHR. Guidelines can increase the use of nonnarcotic medications for the treatment of acute pain and increase naloxone coprescription for patients with a higher risk of overdose. |
Targeting youth to prevent later substance use disorder: An underutilized response to the US opioid crisis
Compton WM , Jones CM , Baldwin GT , Harding FM , Blanco C , Wargo EM . Am J Public Health 2019 109 S185-s189 The evolving US opioid crisis is complex and requires myriad different interventions. These include reducing opioid overprescribing and curtailing the supply of illicit opioids, overdose rescue interventions, and treatment and recovery support services for those with opioid use disorders. To date, more distal primary prevention strategies that have an evidence base are underutilized. Yet, the impact of early environments on later substance use disorder risk is increasingly well understood, including knowledge of the mechanistic linkages between brain development and subsequent risk behaviors. Applying this developmental framework to prevention shows promise, and some middle-school interventions have demonstrated significant reductions in prescription opioid misuse. Reducing these risks of initial misuse of opioids may be the "ounce of prevention" that makes a substantial difference in a society now reeling from the worst drug crisis our country has seen. The challenge is to continue to develop and test promising distal interventions and to support implementation fidelity through frameworks that ensure their cultural appropriateness and sustainability. In addition, research is needed to develop new prevention strategies for adults, including patients with pain at risk for transitioning from prescription to illicit opioids. |
USA's experience with sudden unexpected infant death and sudden death in the young case registries
Shapiro-Mendoza CK , Cottengim C . Arch Dis Child 2019 104 (10) 927-928 We read with great interest, ‘A national registry for sudden unexpected deaths of infants and children in England: why do we need one and do families want one?’1 In the USA’s experience, getting feedback from parents and other stakeholders was an important first step to implementing sudden unexpected infant death (SUID) and sudden death in the young (SDY) registries.2,3 Starting a registry in England is key to better understanding the causes of these tragic deaths so they can be prevented. |
Impact of population displacement and forced movements on the transmission and outbreaks of Aedes-borne viral diseases: Dengue as a model
Abdul-Ghani R , Mahdy MAK , Al-Eryani SMA , Fouque F , Lenhart AE , Alkwri A , Al-Mikhlafi AM , Wilke ABB , Thabet AAQ , Beier JC . Acta Trop 2019 197 105066 Population displacement and other forced movement patterns following natural disasters, armed conflicts or due to socioeconomic reasons contribute to the global emergence of Aedes-borne viral disease epidemics. In particular, dengue epidemiology is critically affected by situations of displacement and forced movement patterns, particularly within and across borders. In this respect, waves of human movements have been a major driver for the changing epidemiology and outbreaks of the disease on local, regional and global scales. Both emerging dengue autochthonous transmission and outbreaks in countries known to be non-endemic and co-circulation and hyperendemicity with multiple dengue virus serotypes have led to the emergence of severe disease forms such as dengue hemorrhagic fever and dengue shock syndrome. This paper reviews the emergence of dengue outbreaks driven by population displacement and forced movements following natural disasters and conflicts within the context of regional and sub-regional groupings. |
Increase in reports of tick-borne rickettsial diseases in the United States
Binder AM , Armstrong PA . Am J Nurs 2019 119 (7) 20-21 New resources for diagnosis and treatment from the CDC. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Disease Reservoirs and Vectors
- Environmental Health
- Epidemiology and Surveillance
- Food Safety
- Health Behavior and Risk
- Health Economics
- Healthcare Associated Infections
- Immunity and Immunization
- Informatics
- Injury and Violence
- Laboratory Sciences
- Maternal and Child Health
- Occupational Safety and Health - Mining
- Parasitic Diseases
- Public Health Leadership and Management
- Reproductive Health
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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
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