Oncology social work practice behaviors: a national survey of AOSW members
Perlmutter EY , Herron FB , Rohan EA , Thomas E . J Psychosoc Oncol 2021 40 (2) 1-15 PURPOSE: Few studies have examined the practices of U.S. oncology social workers since the implementation of distress screening. This study presents data about oncology social work practice behaviors, including participation in distress screening and interdisciplinary team integration. DESIGN: Using a cross-sectional survey design, Association of Oncology Social Work (AOSW) members were invited to complete the anonymous web-based survey between June and September 2019. SAMPLE: AOSW members (N = 1116) were invited through email and listserv posts to participate in the survey with 533 (47.8%) responding. METHODS: A quantitative on-line survey was used to investigate demographics, distress screening roles and other practice behaviors. Descriptive analyses were conducted on the data. RESULTS: Respondents engaged in a range of practice behaviors consistent with the Standards and Scope of Practice published by AOSW, primarily engaging in patient-focused work. They reported viewing their role as integrated with the interdisciplinary team. Respondents were highly involved in distress screening processes, primarily receiving referrals from distress screening but also collecting/reviewing screening results and referring patients to other providers based on those results. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Knowledge about the ways that oncology social workers enact their role across settings and locations could be useful to those developing effective and integrated psychosocial oncology programs, especially distress screening protocols. Specific knowledge about the practice behaviors of oncology social workers in the U.S. may also help to delineate the role from the work of other interdisciplinary oncology team members. |
Transmitted Drug Resistance Among HIV-1 Diagnoses in the United States, 2014-2018.
McClung RP , Oster AM , Ocfemia MCB , Saduvala N , Heneine W , Johnson JA , Hernandez AL . Clin Infect Dis 2021 74 (6) 1055-1062 BACKGROUND: Transmitted HIV drug resistance can threaten the efficacy of antiretroviral therapy (ART) and preexposure prophylaxis (PrEP). Drug resistance testing is recommended at entry to HIV care in the United States and provides valuable insight for clinical decision-making and population-level monitoring. METHODS: We assessed transmitted drug resistance-associated mutation (TDRM) prevalence and predicted susceptibility to common HIV drugs among U.S. persons with HIV diagnosed during 2014-2018 who had a drug resistance test performed ≤3 months after HIV diagnosis and reported to the National HIV Surveillance System and who resided in 28 jurisdictions where ≥20% of HIV diagnoses had an eligible sequence during this period. RESULTS: Of 50,747 persons in the analysis, 9,616 (18.9%) had ≥1 TDRM. TDRM prevalence was 0.8% for integrase strand transfer inhibitors (INSTI), 4.2% for protease inhibitors, 6.9% for nucleoside reverse transcriptase inhibitors, and 12.0% for non-nucleoside reverse transcriptase inhibitors. Most individual mutations had a prevalence <1.0% including M184V (0.9%) and K65R (0.1%); K103N was most prevalent (8.6%). TDRM prevalence did not increase or decrease significantly during 2014-2018 overall, for individual drug classes, or for key individual mutations except for M184V (12.9% increase per year, 95% CI=5.6-20.6). CONCLUSIONS: TDRM prevalence overall and for individual drug classes remained stable during 2014-2018; transmitted INSTI resistance was uncommon. Continued population-level monitoring of INSTI and NRTI mutations, especially M184V and K65R, is warranted amidst expanding use of second-generation INSTI and PrEP. |
Underlying Medical Conditions and Severe Illness Among 540,667 Adults Hospitalized With COVID-19, March 2020-March 2021.
Kompaniyets L , Pennington AF , Goodman AB , Rosenblum HG , Belay B , Ko JY , Chevinsky JR , Schieber LZ , Summers AD , Lavery AM , Preston LE , Danielson ML , Cui Z , Namulanda G , Yusuf H , Mac Kenzie WR , Wong KK , Baggs J , Boehmer TK , Gundlapalli AV . Prev Chronic Dis 2021 18 E66 INTRODUCTION: Severe COVID-19 illness in adults has been linked to underlying medical conditions. This study identified frequent underlying conditions and their attributable risk of severe COVID-19 illness. METHODS: We used data from more than 800 US hospitals in the Premier Healthcare Database Special COVID-19 Release (PHD-SR) to describe hospitalized patients aged 18 years or older with COVID-19 from March 2020 through March 2021. We used multivariable generalized linear models to estimate adjusted risk of intensive care unit admission, invasive mechanical ventilation, and death associated with frequent conditions and total number of conditions. RESULTS: Among 4,899,447 hospitalized adults in PHD-SR, 540,667 (11.0%) were patients with COVID-19, of whom 94.9% had at least 1 underlying medical condition. Essential hypertension (50.4%), disorders of lipid metabolism (49.4%), and obesity (33.0%) were the most common. The strongest risk factors for death were obesity (adjusted risk ratio [aRR] = 1.30; 95% CI, 1.27-1.33), anxiety and fear-related disorders (aRR = 1.28; 95% CI, 1.25-1.31), and diabetes with complication (aRR = 1.26; 95% CI, 1.24-1.28), as well as the total number of conditions, with aRRs of death ranging from 1.53 (95% CI, 1.41-1.67) for patients with 1 condition to 3.82 (95% CI, 3.45-4.23) for patients with more than 10 conditions (compared with patients with no conditions). CONCLUSION: Certain underlying conditions and the number of conditions were associated with severe COVID-19 illness. Hypertension and disorders of lipid metabolism were the most frequent, whereas obesity, diabetes with complication, and anxiety disorders were the strongest risk factors for severe COVID-19 illness. Careful evaluation and management of underlying conditions among patients with COVID-19 can help stratify risk for severe illness. |
Hospital capacities and shortages of healthcare resources among US hospitals during the coronavirus disease 2019 (COVID-19) pandemic, National Healthcare Safety Network (NHSN), March 27-July 14, 2020.
Wu H , Soe MM , Konnor R , Dantes R , Haass K , Dudeck MA , Gross C , Leaptrot D , Sapiano MRP , Allen-Bridson K , Wattenmaker L , Peterson K , Lemoine K , Chernetsky Tejedor S , Edwards JR , Pollock D , Benin AL . Infect Control Hosp Epidemiol 2021 43 (10) 1-12 During March 27-July 14, 2020, the CDC's National Healthcare Safety Network extended its surveillance to hospital capacities responding to COVID-19 pandemic. The data showed wide variations across hospitals in case burden, bed occupancies, ventilator usage, and healthcare personnel and supply status. These data were used to inform emergency responses. |
Severe Acute Respiratory Syndrome Coronavirus 2 Testing Trends Among Persons Aged <18 Years in an Outpatient Pediatric Practice - Metropolitan Atlanta, Georgia, May-December 2020.
Miller MJ , Dasgupta S , Ruffin J , Colton K , King D , Tate JE , Kirking HL , Bryant B , Hennesy N , Plata Z , Nakayama JY , Tanner MR , Koyuncu A , Rabold E . J Adolesc Health 2021 69 (1) 144-148 PURPOSE: The purpose of this study was to analyze trends in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and test positivity among persons aged <18 years in a three-site outpatient pediatric practice in Atlanta, Georgia, serving approximately 35,000 pediatric patients. METHODS: Using electronic medical records, weekly trends in SARS-CoV-2 tests performed and the 14-day moving average of test positivity were examined, overall and by age group, during May 24-December 5, 2020. RESULTS: Among 4,995 patients who received at least 1 SARS-CoV-2 test, 6,813 total tests were completed. Overall test positivity was 5.4% and was higher among older pediatric patients (<5 years: 3.3%; 5-11 years: 4.1%; 12-17 years: 8.6%). The number of tests and test positivity increased after holidays and school breaks. CONCLUSIONS: Families might benefit from communication focused on reducing SARS-CoV-2 transmission during holidays. In addition, given higher test positivity in children aged 12-17 years, tailoring public health messaging to older adolescents could help limit SARS-CoV-2 transmission risk in this population. |
Perspectives on Sexual Health, Sexual Health Education, and HIV Prevention From Adolescent (13-18 Years) Sexual Minority Males
Cahill SR , Wang TM , Fontenot HB , Geffen SR , Conron KJ , Mayer KH , Johns MM , Avripas SA , Michaels S , Dunville R . J Pediatr Health Care 2021 35 (5) 500-508 INTRODUCTION: Adolescent sexual minority males (ASMM) are at disproportionate risk of HIV infection. The purpose of this study was to assess ASMM's attitudes about sexual health, barriers/facilitators to accessing HIV prevention, and actual versus ideal interactions for receiving sexual health care and information. METHOD: Two online and two in-person focus groups were conducted with ASMM from across the United States. Qualitative data were analyzed using content analysis. RESULTS: Twenty-one racially diverse ASMM participated (average age = 16.4 years). Online focus groups were superior for reaching the target population. Four themes emerged: ( 1: ) identity formation and sources of support, ( 2: ) challenges to obtaining sexual health information, ( 3: ) attitudes/beliefs about sex and sexual behaviors, and ( 4: ) barriers to HIV prevention. DISCUSSION: These findings illustrate current gaps in sexual health knowledge, as well as barriers and facilitators to obtaining sexual health information, sexual health care, and affirming education and support for ASMM. |
Clinical Effectiveness and Safety of Antivirals for Influenza in Pregnancy
Chow EJ , Beigi RH , Riley LE , Uyeki TM . Open Forum Infect Dis 2021 8 (6) ofab138 Seasonal influenza epidemics result in substantial health care burden annually. Early initiation of antiviral treatment of influenza has been shown to reduce the risk of complications and duration of illness. Pregnant and postpartum women may be at increased risk for influenza-associated complications; however, pregnant women have been generally excluded from clinical trials of antiviral treatment of influenza. In this review, we summarize the available evidence on the clinical effectiveness and safety of antiviral treatment of pregnant women with influenza. Observational data show a reduction of severe outcomes when pregnant and postpartum women are treated with oseltamivir and other neuraminidase inhibitors without increased risk of adverse maternal, fetal, or neonatal outcomes. Due to lack of safety and efficacy data for baloxavir treatment of pregnant and postpartum women, baloxavir is currently not recommended for use in these populations. |
Estimated time from HIV infection to diagnosis and diagnosis to first viral suppression during 2014-2018
Crepaz N , Song R , Lyss S , Hall HI . AIDS 2021 35 (13) 2181-2190 OBJECTIVE: To examine changes in the lengths of time from HIV infection to diagnosis (Infx-to-Dx) and from diagnosis to first viral suppression (Dx-to-VS), two periods during which HIV can be transmitted. DESIGN: Data from the National HIV Surveillance System (NHSS) for persons who were aged ≥13 years at the time of HIV diagnosis during 2014-2018 and resided in one of 33 U.S. jurisdictions with complete laboratory reporting. METHODS: The date of HIV infection was estimated based on a CD4-depletion model. Date of HIV diagnosis, and dates and results of first CD4 test and first viral suppression (<200 copies/mL) after diagnosis were reported to NHSS through December 2019. Trends for Infx-to-Dx and Dx-to-VS intervals were examined using estimated annual percentage change. RESULTS: During 2014-2018, among persons aged ≥13 years, 133,413 HIV diagnoses occurred. The median length of infx-to-Dx interval shortened from 43 months (2014) to 40 months (2018), a 1.5% annual decrease (7.0% relative change over the 5-year period). The median length of Dx-to-VS interval shortened from 7 months (2014) to 4 months (2018), an 11.4% annual decrease (42.9% relative change over the 5-year period). Infx-to-Dx intervals shortened in only some subgroups, while Dx-to-VS intervals shortened in all groups by sex, transmission category, race/ethnicity, age, and CD4 count at diagnosis. CONCLUSION: The shortened Infx-to-Dx and Dx-to-VS intervals suggest progress in promoting HIV testing and earlier treatment; however, diagnosis delays continue to be substantial. Further shortening both intervals and eliminating disparities are needed to achieve Ending the HIV Epidemic goals. |
Unmet needs for ancillary care services are associated with HIV clinical outcomes among adults with diagnosed HIV
Dasgupta S , Tie Y , Beer L , Weiser J . AIDS Care 2021 34 (5) 1-9 Ancillary care services are essential for supporting care engagement and viral suppression among persons with HIV. Estimating unmet needs for ancillary care services may help address care barriers and improve clinical outcomes, but recent, nationally representative estimates are lacking. Using CDC Medical Monitoring Project data from 2015-2018, we report representative estimates of unmet needs for ancillary care services and associations with HIV clinical outcomes among U.S. adults with HIV. Data were collected through interview and medical record abstraction. We described weighted percentages for all characteristics and associations with HIV clinical outcomes using prevalence ratios with predicted marginal means, adjusting for potential confounding. Substantial unmet needs were reported; unmet needs were higher among persons with social determinants of poor health, persons who engaged in drug use or binge drinking, and those who experienced depression or anxiety. Having unmet needs for care was associated with adverseHIV clinical outcomes, with a dose response effect between number of unmet needs and outcomes. Expanding ancillary care access based on a comprehensive care model, strengthening partnerships between providers to connect patients to essential services, and tailoring services based on need may help reduce disparities in unmet needs and improve outcomes. |
Prevalence of Voluntary Medical Male Circumcision for HIV Infection Prevention - Chkw District, Mozambique, 2014-2019
Hines JZ , Thompson R , Toledo C , Nelson R , Casavant I , Pals S , Canda M , Bonzela J , Jaramillo A , Cardoso J , Ujamaa D , Tamele S , Chivurre V , Malimane I , Pathmanathan I , Heitzinger K , Wei S , Couto A , Come J , Vergara A , MacKellar D . MMWR Morb Mortal Wkly Rep 2021 70 (26) 942-946 Male circumcision is an important preventive strategy that confers lifelong partial protection (approximately 60% reduced risk) against heterosexually acquired HIV infection among males (1). In Mozambique, the prevalence of male circumcision was 51% when the voluntary medical male circumcision (VMMC) program began in 2009. The Mozambique Ministry of Health set a goal of 80% circumcision prevalence among males aged 10-49 years by 2019 (2). CDC analyzed data from five cross-sectional surveys of the Chókwè Health and Demographic Surveillance System (CHDSS) to evaluate progress toward the goal and guide ongoing needs for VMMC in Mozambique. During 2014-2019, circumcision prevalence among males aged 15-59 years increased 42%, from 50.1% to 73.5% (adjusted prevalence ratio [aPR] = 1.42). By 2019, circumcision prevalence among males aged 15-24 years was 90.2%, exceeding the national goal (2). However, circumcision prevalence among males in older age groups remained below 80%; prevalence was 62.7%, 54.5%, and 55.7% among males aged 25-34, 35-44, and 45-59 years, respectively. A multifaceted strategy addressing concerns about the safety of the procedure, cultural norms, and competing priorities that lead to lack of time could help overcome barriers to circumcision among males aged ≥25 years. |
Evaluation of point-of-care algorithms to detect diabetes during screening for latent TB infection
Largen A , Ayala A , Khurana R , Katz DJ , Venkatappa TK , Brostrom R . Int J Tuberc Lung Dis 2021 25 (7) 547-553 BACKGROUND: Individuals with both diabetes mellitus (DM) and TB infection are at higher risk of progressing to TB disease.OBJECTIVE: To determine DM prevalence in populations at high risk for latent TB infection (LTBI) and to identify the most accurate point-of-care (POC) method for DM screening.METHODS: Adults aged ≥25 years were recruited at health department clinics in Hawaii and Arizona, USA, and screened for LTBI and DM. Screening methods for DM included self-report, random blood glucose (RBG), and POC hemoglobin A1c (HbA1c). Using HbA1c ≥6.5% or self-reported history as the gold standard for DM, we compared test strategies to determine the most accurate method while keeping test costs low.RESULTS: Of 472 participants, 13% had DM and half were unaware of their diagnosis. Limiting HbA1c testing to ages ≥30 years with a RBG level of 120-180 mg/dL helped identify most participants with DM (sensitivity 85%, specificity 99%) at an average test cost of US$2.56 per person compared to US$9.56 per person using HbA1c for all patients.CONCLUSION: Self-report was insufficient to determine DM status because many participants were previously undiagnosed. Using a combination of POC RBG and HbA1c provided an inexpensive option to assess DM status in persons at high risk for LTBI. |
Bringing HIV services to key populations and their communities in Tanzania: from pilot to scale
Maruyama H , Franks J , Laki D , Msumi O , Makyao N , Rwabiyago OE , Rabkin M , Kagashe MJ , El-Sadr WM . J Int AIDS Soc 2021 24 Suppl 3 e25718 INTRODUCTION: Despite the global scale-up of HIV testing, prevention and treatment, these services remain inaccessible to groups most vulnerable to HIV. Globally, most new HIV infections are concentrated among members of key populations (KP), including female sex workers, men who have sex with men, transgender people, people who inject drugs and their sexual partners. These populations lag in access to HIV prevention and antiretroviral therapy (ART) and have less favourable HIV outcomes compared to the general population. Intersecting behavioural and structural factors contribute to these gaps in service access for at-risk KP and those living with HIV; corresponding comprehensive approaches to improving service delivery for KP are urgently needed. Differentiated service delivery (DSD) models tailor HIV programmes to the needs and preferences of specific groups but are rarely implemented at scale for KP. We describe the FIKIA Project, which implemented innovative approaches to scaling up DSD models to reach and engage KP in Tanzania. METHODS: The FIKIA Project worked with diverse KP communities in Tanzania to tailor HIV services to their needs and to pair healthcare workers with trained peer educators and expert client counsellors to expand uptake of community-based HIV testing and ART services. We analysed routine aggregate project data from 2016 to 2020 to describe project implementation, outcomes and best practices. RESULTS AND DISCUSSION: The FIKIA Project conducted 1,831,441 HIV tests in community settings; of the 98,349 (5.4%) individuals with new HIV diagnoses, 89,640 (91.1%) initiated ART. The project reached substantial numbers of KP: 203,233 received HIV tests, 28,830 (14.2%) received a new HIV diagnosis and 25,170 KP (87.3%) initiated ART at the point of diagnosis. Over time, HIV testing increased by 1.6 times overall (2.3 times among KP), HIV diagnoses increased by 8.7 times (10.9 times among KP) and ART initiation at the point of diagnosis increased from 80.0% to 95.9% overall (from 69.6% to 94.9% among KP). CONCLUSIONS: Over four years, the FIKIA Project scaled up HIV testing, diagnosis and treatment by using DSD principles to design services that meet the needs of KP and their communities. |
Chlamydia trachomatis and Neisseria gonorrhoeae in Pregnancy: Trends in United States, 2010-2018
Niles JK , Kaufman HW , Peterman TA , Tao G , Gift TL , Alagia DP . Sex Transm Dis 2021 48 (12) 932-938 BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) case surveillance relies on reported positive laboratory results. Changes in reported cases may represent changes in testing practice or infection prevalence. This study evaluated changes over time for CT and NG positivity and testing rates of pregnant persons. METHODS: Prenatal testing results from persons ages 16-40 years tested by a national reference clinical laboratory were analyzed for CT and NG testing and positivity during 2010-2018 (n = 3,270,610). RESULTS: Testing rates increased among pregnant persons for CT (from 56.3% in 2010 to 64.1% in 2018, p < 0.001) and NG (from 55.6% to 63.2%, p < 0.001). Higher CT testing rates were found in Black non-Hispanic (adjusted odds ratio [AOR] 1.58, 95% CI 1.57-1.60) and Hispanic (AOR 1.19, 95% CI 1.18-1.20) persons. NG and CT testing rates were virtually identical. Significant increasing trends in CT positivity were observed for each age group studied (p < 0.001 for all): 16-19 (from 11.7% to 13.0%); 20-24 (from 6.4% to 6.7%); 25-30 (from 1.9% to 2.4%); 31-40 years (from 0.76% to 0.92%). Black non-Hispanic persons had the highest positivity for CT (AOR 2.52, 95% CI 2.46-2.57) and NG (AOR 5.42, 95% CI 5.05-5.82). CONCLUSIONS: Testing and adjusted positivity for both CT and NG among pregnant persons increased from 2010 to 2018. Higher testing rates were observed in Black non-Hispanic and Hispanic persons (even in persons under 25 years) suggesting some testing decisions may have been based on perceived risk, in contrast to many guidelines recommending screening all pregnant persons under 25 years. |
Estimating Gains in HIV Testing by Expanding HIV Screening at Routine Checkups
Patel D , Williams WO , Heitgerd J , Taylor-Aidoo N , DiNenno EA . Am J Public Health 2021 111 (8) e1-e4 Objectives. To estimate gains in the prevalence of individuals who had ever been tested for HIV overall and by subpopulations from increases in the percentage of persons who had a routine checkup and were tested. Methods. We used data from the 2019 Behavioral Risk Factor Surveillance System to determine the prevalence of individuals who were ever tested for HIV and the prevalence of missed opportunities for HIV testing among those never tested in the United States. We assessed the effect of absolute percentage increases in having ever been tested among those who had a past-year routine checkup on increasing the overall prevalence of having ever been tested. Results. In 2019, 49.5% of US adults had ever been tested for HIV; 34.5% had a missed opportunity. A 50% increase in testing at routine checkups would increase the prevalence of having ever been tested to 84.0%. Increases in the prevalence of having ever been tested ($85%) was highest among persons aged 35 to 54 years, Black persons, persons who were female at birth, persons with health insurance, and persons reporting HIV risk behaviors. Conclusions. Fully incorporating HIV screening into primary care would greatly increase the proportion of US adults who have been tested for HIV. Public Health Implications.Continued efforts to promote HIV testing, including implementing routine screening in clinical settings, will help ensure that all US adults know their HIV status. (Am J Public Health. Published online ahead of print June 29, 2021: e1-e4. https://doi.org/10.2105/AJPH.2021.306321). |
The yield of HIV testing during pregnancy and postnatal period, Uganda, 2015-2018: analysis of surveillance data
Wibabara Y , Lukabwe I , Kyamwine I , Kwesiga B , Ario AR , Nabitaka L , Bulage L , Harris J , Mudiope P . AIDS Res Ther 2021 18 (1) 35 BACKGROUND: Uganda has registered a reduction in new HIV infections among children in recent years. However, mother-to-child transmission of HIV still occurs, especially among pregnant women who present late. To eliminate this transmission, all HIV-positive pregnant women should be identified during antenatal HIV testing. We described women newly identified HIV-positive during pregnancy and postnatal period 2015-2018. METHODS: We extracted surveillance data for women identified as HIV-positive during pregnancy and the postnatal period reported through the Health Management Information System from 2015-2018. We calculated proportions newly positive at antenatal, labor, and postnatal periods nationally and at district levels. We disaggregated data into 'tested early' (during antenatal care) and 'tested late' (during labor or postnatal period) and calculated the proportion positive. We evaluated trends in these parameters at national and district levels. RESULTS: Overall, 8,485,854 mothers were tested for HIV during this period. Of these, 2.4% tested HIV-positive for the first time. While the total number of mothers tested increased from 1,327,022 in 2015 to 2,514,212 in 2018, the proportion testing HIV-positive decreased from 3.0% in 2015 to 1.7% in 2018 (43% decline over the study period, p < 0.001). Of 6,781,047 tested early, 2.2% tested HIV-positive. The proportion positive among those tested early dropped from 2.5% in 2015 to 1.7% in 2018. Of 1,704,807 tested late, 3.2% tested HIV-positive. The proportion positive among those tested late dropped from 5.2% in 2015 to 1.6% in 2018. At the district level, Kalangala District had the highest proportion testing positive at 13% (909/11,312) in 2015; this dropped to 5.2% (169/3278) in 2018. CONCLUSION: The proportion of women newly testing HIV-positive during pregnancy and postnatal declined significantly during 2015-2018. A higher proportion of mothers who tested late vs early were HIV-positive. Failure to identify HIV early represents an increased risk of transmission. Ministry of Health should strengthen Elimination of Mother to Child Transmission (eMTCT) services to sustain this decrease through targeted interventions for poorly-performing districts. It should strengthen community-based health education on antenatal care and HIV testing and enhance the implementation of other primary prevention strategies targeting adolescents and young women. |
Estimated Latent Tuberculosis Infection Prevalence and Tuberculosis Reactivation Rates Among Non-U.S.-Born Residents in the United States, from the 2011-2012 National Health and Nutrition Examination Survey
Yelk Woodruff R , Hill A , Marks S , Navin T , Miramontes R . J Immigr Minor Health 2021 23 (4) 806-812 Increased testing and treatment of latent tuberculosis infection (LTBI) among US-residents who were born (or lived) in countries with high rates of TB can hasten progress toward TB elimination. We calculated LTBI prevalence using QuantiFERON®-TB Gold In-Tube results from the 2011 to 2012 National Health and Nutrition Examination Survey (NHANES). LTBI prevalence was highest for persons born in India (31.7%, 95% confidence interval [21.2, 44.5]). Non-Hispanic white persons had the lowest LTBI prevalence (6.3% [1.9, 18.9]). TB reactivation rate, defined as the number of TB cases not associated with recent transmission per 100 person-years of life with LTBI, was highest for persons born in Vietnam [0.183 (0.117, 0.303)]. Reactivation rates were lower among persons who had resided in the United States for ≥ 10 years than among those who had resided for < 10 years. Results among high risk populations can guide LTBI targeted testing and treatment among non-U.S.-born residents. |
Improving the Safety and Acceptability of Autocidal Gravid Ovitraps (AGO Traps)
Acevedo V , Amador M , Barrera R . J Am Mosq Control Assoc 2021 37 (2) 61-67 Gravid traps that collect eggs or adult mosquitoes use color, size, or volume as well as water or plant infusions as attractants. Biorational larvicides have been used to prevent these devices from producing adult mosquitoes within the traps. Results from field assays on the use of several biorational larvicides for various mosquito species have provided mixed results in terms of increased, neutral, or reduced attraction. We investigated the use of Bacillus thuringiensis var. israelensis, spinosad, and novaluron in field assays in Puerto Rico to evaluate the behavioral response of Aedes aegypti and Culex spp. to autocidal gravid ovitraps (AGO traps). The purpose of the study was to increase the safety of these traps by preventing accidental release of adult mosquitoes when traps are opened or damaged. We also investigated whether trap color (blue, green, terracotta) that may be more amenable for use by residents in their properties induced a similar attraction response to the original black trap color. We found that the use of biorational larvicides did not significantly change the behavioral attraction of these mosquito species to AGO traps. For Ae. aegypti, green traps yielded the lowest captures while black, terracotta, and blue produced similar higher yields. Culex spp. in black traps showed significantly higher captures compared with other colors. These results suggest that black, terracotta, or blue AGO traps can be used for the surveillance and control of Ae. aegypti. |
Prenatal exposure to organophosphate and pyrethroid insecticides and the herbicide 2,4-dichlorophenoxyacetic acid and size at birth in urban pregnant women
Balalian AA , Liu X , Herbstman JB , Daniel S , Whyatt R , Rauh V , Calafat AM , Wapner R , Factor-Litvak P . Environ Res 2021 201 111539 BACKGROUND: Organophosphate insecticides and the herbicide, 2,4-dichlorophenoxyacetic acid (2,4-D) are used to protect crops or control weeds. Pyrethroids are used to manage pests both in agriculture and in residences, and to reduce the transmission of insect-borne diseases. Several studies have reported inverse associations between exposure to organophosphates (as a larger class) and birth outcomes but these associations have not been conclusive for pyrethroids or 2,4-D, specifically. We aimed to investigate the association between birth outcomes and urinary biomarkers of pyrethroids, organophosphates and 2,4-D among healthy pregnant women living in New York City. METHODS: We quantified urinary biomarkers of 2,4-D and of organophosphate and pyrethroid insecticides from 269 women from two cohorts: a) Thyroid Disruption And Infant Development (TDID) and b) Sibling/Hermanos cohort (S/H). We used weighted quantile sum regression and multivariable linear regression models to evaluate the associations between a mixture of urinary creatinine-adjusted biomarker concentrations and birth outcomes of length, birthweight and head circumference, controlling for covariates. We also used linear regression models and further classified biomarkers concentrations into three categories (i: non-detectable; ii: between the limit of detection and median; and iii: above the median) to investigate single pesticides' association with these birth outcomes. Covariates considered were delivery mode, ethnicity, marital status, education, income, employment status, gestational age, maternal age and pre-pregnancy BMI. Analyses were conducted separately for each cohort and stratified by child sex within each cohort. RESULTS: In TDID cohort, we found a significant inverse association between weighted quantile sum of mixture of pesticides and head circumference among boys. We found that the urinary biomarkers of organophosphate chlorpyrifos, TCPy, and 2,4-D had the largest contribution to the overall mixture effect in the TDID cohort among boys (b = -0.57, 95%CI: -0.92, -0.22) (weights = 0.81 and 0.16 respectively) but not among girls. In the multivariable linear regression models, we found that among boys, for each log unit increase in 3,5,6-trichloro-2-pyridinol (TCPy, metabolite of organophosphate chlorpyrifos) in maternal urine, there was a -0.56 cm decrease in head circumference (95%CI: -0.92, -0.19). Among boys in the TDID cohort, 2,4-D was associated with smaller head circumference in the second (b = -1.57; 95%CI: -2.74, -0.39) and third (b = -1.74, 95%CI: -2.98, -0.49) concentration categories compared to the first. No associations between pyrethroid and organophosphate biomarkers and birth outcomes were observed in girls analyzed in WQS regression or individually in linear regression models in TDID cohort. In the S/H cohort, head circumference increased with higher concentrations of 3-phenoxybenzoic acid (3-PBA, a biomarker of several pyrethroids) (b = 0.53, 95%CI: 0.03, 1.04) among boys and head circumference was lower among girls in the high compared to low category of 2,4-D (b = -2.27, 95%CI: - 3.98, -0.56). Birth length was also positively associated with the highest concentration of 2,4-D compared to the lowest among boys (b = 4.01, 95%CI: 0.02,8.00). CONCLUSIONS: Weighted quantile sum of pesticides was negatively associated with head circumference among boys in one cohort. Nonetheless, due to directional homogeneity assumption in WQS no positive associations were detected. In linear regression models with individual pesticides, concentrations of TCPy were inversely associated with head circumference in boys and higher concentrations of 2,4-D was inversely associated with head circumference among girls; 2,4-D concentrations were also associated with higher birth length among boys. Concentrations of 3-PBA was positively associated with head circumference among boys. |
Prospective associations of mid-childhood plasma per- and polyfluoroalkyl substances and pubertal timing
Carwile JL , Seshasayee SM , Aris IM , Rifas-Shiman SL , Claus Henn B , Calafat AM , Sagiv SK , Oken E , Fleisch AF . Environ Int 2021 156 106729 BACKGROUND: Exposure to per- and polyfluoroalkyl substances (PFAS) may disrupt pubertal timing. Higher PFAS plasma concentrations have been associated with later pubertal timing in girls, but cross-sectional findings may be explained by reverse causation. OBJECTIVES: To assess prospective associations between PFAS plasma concentrations in mid-childhood and markers of pubertal timing in male and female adolescents. METHODS: We studied 640 children in Project Viva, a Boston-area prospective cohort. We examined associations of plasma concentrations of 6 PFAS measured at mean 7.9 (SD 0.8) years (2007-2010) with markers of pubertal timing. Parents reported a 5-item pubertal development score at early adolescence (mean 13.1 (SD 0.8) years) and reported age at menarche annually. We calculated age at peak height velocity using research and clinical measures of height. We used sex-specific linear and Cox proportional hazards regression to estimate associations of single PFAS with outcomes, and we used Bayesian Kernel Machine Regression (BKMR) to estimate associations of the PFAS mixture with outcomes. RESULTS: Plasma concentrations were highest for perfluorooctane sulfonate (PFOS) [median (IQR) 6.4(5.6) ng/mL], followed by perfluorooctanoate (PFOA) [4.4(3.0) ng/mL]. In early adolescence, girls were further along in puberty than boys [pubertal development score mean (SD) 2.9 (0.7) for girls and 2.2(0.7) for boys; age at peak height velocity mean (SD) 11.2y (1.0) for girls and 13.1y (1.0) for boys]. PFAS was associated with later markers of pubertal timing in girls only. For example, each doubling of PFOA was associated with lower pubertal development score (-0.18 units; 95% CI: -0.30, -0.06) and older age at peak height velocity (0.23 years; 95% CI: 0.06, 0.40)]. We observed similar associations for PFOS, perfluorodecanoate (PFDA), and the PFAS mixture. PFAS plasma concentrations were not associated with age at menarche or markers of pubertal timing in boys. DISCUSSION: Higher PFAS plasma concentrations in mid-childhood were associated with later onset of puberty in girls. |
Per- and Polyfluoroalkyl Substances (PFAS) and Hormone Levels during the Menopausal Transition
Harlow SD , Hood MM , Ding N , Mukherjee B , Calafat AM , Randolph JF , Gold EB , Park SK . J Clin Endocrinol Metab 2021 106 (11) e4427-e4437 CONTEXT: Per- and polyfluoroalkyl substances (PFAS) are widespread chemicals that may affect sex hormones and accelerate reproductive aging in midlife women. OBJECTIVE: To examine associations between serum PFAS concentrations at baseline (1999-2000) and longitudinal serum concentrations of follicle stimulating hormone (FSH), estradiol, testosterone, and sex hormone-binding globulin (SHBG) at baseline and through 2015-2016. DESIGN: Prospective cohort. SETTING: General community. PARTICIPANTS: 1,371 midlife women aged 45-56 years at baseline in the Study of Women's Health Across the Nation (SWAN). MAIN OUTCOME MEASURE(S): FSH, estradiol, testosterone, SHBG. RESULTS: In linear mixed models fitted with log-transformed hormones and log-transformed PFAS adjusting for age, site, race/ethnicity, smoking status, menopausal status, parity and body mass index, FSH was positively associated with linear perfluorooctanoate (n-PFOA) (3.12% (95% CI: 0.37%, 5.95%) increase for a doubling in serum concentration), linear perfluorooctane sulfonate (n-PFOS) (2.88% (0.21%, 5.63%)), branched perfluorooctane sulfonate (Sm-PFOS) (2.25% (0.02%, 4.54%)), total PFOS (3.03% (0.37%, 5.76%)), and 2-(N-ethyl-perfluorooctane sulfonamido) acetate (EtFOSAA) (1.70% (0.01%, 3.42%)). Estradiol was inversely associated with perfluorononanoate (PFNA) (-2.47% (-4.82%, -0.05%)) and n-PFOA (-2.43% (-4.97%, 0.18%)). Significant linear trends were observed in the associations between PFOS and EtFOSAA with SHBG across parity (Ps-trend≤0.01), with generally inverse associations among nulliparous women but positive associations among women with 3+ births. No significant associations were observed between PFAS and testosterone. CONCLUSIONS: This study observed positive associations of PFOA and PFOS with FSH and inverse associations of PFNA and PFOA with estradiol in midlife women during the menopausal transition, consistent with findings that PFAS affect reproductive aging. |
Chemical interactions and mixtures in public health risk assessment: An analysis of ATSDR's Interaction Profile database
Przybyla J , McClure PR , Zaccaria KJ , Pohl HR . Regul Toxicol Pharmacol 2021 125 104981 The Agency for Toxic Substances and Disease Registry (ATSDR) develops interaction profiles using binary weight of evidence (BINWOE) methodology to determine interaction directions of common environmental mixtures. We collected direction of interactions, BINWOE score determination, and BINWOE score confidence rating from 14 interaction profiles along with toxicodynamic and toxicokinetic influences on interaction direction. By doing so, we quantified the 1) direction of interaction and indeterminate evaluations; 2) characterized confidence in the BINWOE determinations; and 3) quantified toxicokinetic/toxicodynamic, and other influences on projected BINWOE interaction directions. Thirty-nine percent (130/336) of the attempts to make a BINWOE were indeterminate due to no interaction data or inadequate or conflicting evidence. Out of remaining BINWOEs ∼25% were additive, ∼9% were greater-than-additive, and 27% were less-than-additive interactions. Fifty-five percent of BINWOEs were explained by toxicokinetic interactions, 12% and 5% were explained by toxicodynamic and other explanations, respectively. High quality mixture toxicology in vivo studies along with mixture in vitro and in silico studies will lead to greater confidence in interaction directions and influences. Limitations for interpretation of the data were also included. |
Social contact patterns among employees in 3 U.S. companies during early phases of the COVID-19 pandemic, April to June 2020.
Kiti MC , Aguolu OG , Liu CY , Mesa AR , Regina R , Woody M , Willebrand K , Couzens C , Bartelsmeyer T , Nelson KN , Jenness S , Riley S , Melegaro A , Ahmed F , Malik F , Lopman BA , Omer SB . Epidemics 2021 36 100481 We measured contact patterns using online diaries for 304 employees of 3 U.S. companies working remotely. The median number of daily contacts was 2 (IQR 1-4); majority were conversation (55 %), occurred at home (64 %) and lasted >4 h (38 %). These data are crucial for modeling outbreak control among the workforces. |
Impact of a Health Communication Campaign on Uptake of Contraceptive Services during the 2016-2017 Zika Virus Outbreak in Puerto Rico
August EM , Powell R , Morris E , Romero L , Zapata LB , Lathrop E . Health Commun 2021 38 (2) 1-8 The Zika Contraception Access Network (Z-CAN) was established during the 2016-2017 Zika virus outbreak in Puerto Rico as a short-term emergency response program providing client-centered contraceptive counseling and same-day access to the full range of reversible contraceptive methods at no cost to women wishing to delay pregnancy. An evidence-based communication campaign, Ante La Duda, Pregunta (ALDP), was launched to encourage utilization of Z-CAN services. We assessed the effectiveness of campaign tactics in increasing awareness of Z-CAN among women in Puerto Rico. Data on campaign exposure and awareness were obtained through a self-administered online survey approximately two weeks after an initial Z-CAN visit, while the number of searches for participating clinics were obtained from monitoring the campaign website. Findings demonstrated that the most common ways survey respondents learned about Z-CAN were through friends or family (38.3%), social media (23.9%), a clinical encounter (12.7%), and website (11.7%). Nearly two-thirds (61.1%) of respondents had heard of the ALDP campaign. Over the campaign's duration, there were 27,273 searches for Z-CAN clinics. Findings suggest that evidence-based communication campaigns may increase awareness of needed public health services during emergencies. Word of mouth, social media, and digital engagement may be appropriate communication tactics for emergency response mobilization. |
High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017
Park J , Zhang P , Wang Y , Zhou X , Look KA , Bigman ET . Diabetes Care 2021 44 (8) 1797-1804 OBJECTIVE: We examined the magnitude of and trends in the burden of out-of-pocket (OOP) costs among Medicare beneficiaries age 65 years or older with diabetes overall, by income level, by race/ethnicity, and compared with beneficiaries without diabetes. RESEARCH DESIGN AND METHODS: Using data from the 1999-2017 Medicare Current Beneficiary Survey, we estimated average annual per capita OOP costs and percentage of beneficiaries experiencing high OOP burden, defined as OOP costs >10% or >20% of household income. We used joinpoint regression to examine the trends and generalized linear model and logistic regression for comparisons between beneficiaries with and without diabetes. Cost and income estimates were adjusted to 2017 USD. RESULTS: Total OOP costs were $3,609-$5,283, with significant increases until 2005 followed by a leveling off. The prevalence of high OOP burden was 57%-72% at the 10% income threshold and 29%-41% at the 20% threshold, with significant increasing trends until 2003 followed by decreases. Total OOP costs were the highest in the ≥75% income quartile, whereas prevalence of high OOP burden was highest in the <25% and 25-50% income quartiles. Non-Hispanic Whites had the highest OOP costs and prevalence of high OOP burden. Beneficiaries with diabetes had significantly higher OOP costs ($498, P < 0.01) and were more likely to have high OOP burden than those without diabetes (odds ratios 1.32 and 1.25 at >10% and >20% thresholds, respectively, P < 0.01). CONCLUSIONS: Over the past two decades, Medicare beneficiaries age 65 years or older with diabetes have faced substantial OOP burden, with large income-related disparities. |
Patterns of antibiotic nonsusceptibility among invasive group A Streptococcus infections-United States, 2006-2017.
Fay K , Onukwube J , Chochua S , Schaffner W , Cieslak P , Lynfield R , Muse A , Smelser C , Harrison LH , Farley M , Petit S , Alden N , Apostal M , Vagnone PS , Nanduri S , Beall B , Van Beneden CA . Clin Infect Dis 2021 73 (11) 1957-1964 BACKGROUND: Treatment of severe group A streptococcal infections requires timely and appropriate antibiotic therapy. We describe the epidemiology of antimicrobial-resistant invasive group A streptococcal (iGAS) infections in the U.S. METHODS: We analyzed population-based iGAS surveillance data at 10 U.S. sites from 2006-2017. Cases were defined as infection with GAS isolated from normally sterile sites or wounds in patients with necrotizing fasciitis or streptococcal toxic shock syndrome. GAS isolates were emm typed. Antimicrobial susceptibility was determined using broth microdilution or whole genome sequencing. We compared characteristics among patients infected with erythromycin nonsusceptible (EryNS) and clindamycin nonsusceptible (CliNS) strains to those with susceptible infections. We analyzed proportions of EryNS and CliNS among isolates by site, year, risk factors and emm type. RESULTS: Overall, 17,179 iGAS cases were reported; 14.5% were EryNS. Among isolates tested for both inducible and constitutive CliNS (2011-2017), 14.6% were CliNS. Most (99.8%) CliNS isolates were EryNS. Resistance was highest in 2017 (EryNS: 22.8%; CliNS: 22.0%). All isolates were susceptible to beta-lactams. EryNS and CliNS infections were most frequent among persons aged 18-34 years and in persons residing in long-term care facilities, experiencing homelessness, incarcerated, or who injected drugs. Patterns varied by site. Patients with nonsusceptible infections were significantly less likely to die. Emm types with >30% EryNS or CliNS included: 77, 58, 11, 83, 92. CONCLUSION: Increasing prevalence of EryNS and CliNS iGAS infections in the U.S. is predominantly due to expansion of several emm types. Clinicians should consider local resistance patterns when treating iGAS infections. |
Clade distribution of Candida auris in South Africa using whole genome sequencing of clinical and environmental isolates.
Naicker SD , Maphanga TG , Chow NA , Allam M , Kwenda S , Ismail A , Govender NPfor Germs- SA . Emerg Microbes Infect 2021 10 (1) 1300-1308 In South Africa, Candida auris was the third most common cause of candidemia in 2016-2017. We performed single nucleotide polymorphism (SNP) genome-wide analysis of 115 C. auris isolates collected between 2009 and 2018 from national laboratory-based surveillance, an environmental survey at four hospitals and a colonization study during a neonatal unit outbreak. The first known South African C. auris strain from 2009 clustered in clade IV. Overall, 98 strains clustered within clade III (85%), 14 within clade I (12%) and three within clade IV (3%). All environmental and colonizing strains clustered in clade III. We also identified known clade-specific resistance mutations in the ERG11 and FKS1 genes. Identification of clade I strains between 2016 and 2018 suggests introductions from South Asia followed by local transmission. SNP analysis characterized most C. auris strains into clade III, the clade first reported from South Africa, but the presence of clades I and IV strains also suggest early introductions from other regions. |
Outpatient Healthcare Personnel Knowledge and Attitudes Towards Infection Prevention Measures for Protection from Respiratory Infections
Bessesen MT , Rattigan S , Frederick J , Cummings DAT , Gaydos CA , Gibert CL , Gorse GJ , Nyquist AC , Price CS , Reich NG , Simberkoff MS , Brown AC , Radonovich LJ Jr , Perl TM , Rodriguez-Barradas MC . Am J Infect Control 2021 49 (11) 1369-1375 BACKGROUND: Healthcare personnel (HCP) knowledge and attitudes toward infection control measures are important determinants of practices that can protect them from transmission of infectious diseases. METHODS: Healthcare personnel were recruited from Emergency Departments and outpatient clinics at seven sites. They completed knowledge surveys at the beginning and attitude surveys at the beginning and end of each season of participation. Attitudes toward infection prevention and control measures, especially medical masks and N95 respirators, were compared. The proportion of participants who correctly identified all components of an infection control bundle for seven clinical scenarios was calculated. RESULTS: The proportion of participants in the medical mask group who reported at least one reason to avoid using medical masks fell from 88.5% on the pre-season survey to 39.6% on the post-season survey (odds ratio [OR] for preseason vs. postseason 0.11, 95% CI 0.10-0.14). Among those wearing N95 respirators, the proportion fell from 87.9% to 53.6% (OR 0.24, 95% CI 0.21-0.28). Participants correctly identified all components of the infection control bundle for 4.9% to 38.5% of scenarios. CONCLUSIONS: Attitudes toward medical masks and N95 respirators improved significantly between the beginning and end of each season. The proportion of HCP who correctly identified the infection control precautions needed for clinical scenarios was low, but it improved over successive years of participation in the study. |
Donor-derived Cryptococcus gattii sensu stricto infection in two kidney transplant recipients, southeastern United States
Natarajan P , Lockhart SR , Basavaraju SV , Anjan S , Lindsley MD , McGrath MM , Oh DH , Jackson BR . Am J Transplant 2021 21 (11) 3780-3784 Cryptococcus gattii infection is a rare cause of severe pulmonary disease and meningoencephalitis that has only recently been detected in the southeastern United States. We describe organ transplant-associated outbreak of C. gattii infection involving an HIV-negative immunosuppressed donor in this region who died following new-onset headache and seizure of unknown cause. Retrospective cryptococcal antigen (CrAg) testing of donor serum was positive. Two of three transplant recipients developed severe C. gattii infection 11 and 12 weeks following transplantation. One recipient died from severe pulmonary infection, identified on autopsy, and the other ill recipient survived following treatment for cryptococcal meningitis. This outbreak underscores the importance of considering cryptococcosis in patients with clinical findings suggestive of subacute meningitis or other central nervous system (CNS) pathology, and the potential benefit of routine pre-transplant donor CrAg screening using lateral flow assay to guide recipient antifungal prophylaxis. The case also adds to emerging evidence that C. gattii is a potential threat in the southeastern United States. |
Myocarditis Occurring After Immunization With mRNA-Based COVID-19 Vaccines.
Shay DK , Shimabukuro TT , DeStefano F . JAMA Cardiol 2021 6 (10) 1115-1117 Two reports in the current issue of JAMA Cardiology describe cases of acute myocarditis that occurred among persons who received the BNT162b2-mRNA (Pfizer-BioNTech) or mRNA-1273 (Moderna) messenger RNA (mRNA)–based COVID-19 vaccines authorized for use in the US.1,2 During the clinical evaluations of these patients, alternative etiologies for myocarditis were not detected. | | The first report describes 4 cases of myocarditis with symptom onset 1 to 5 days after receipt of a second dose of mRNA-based COVID-19 vaccine (2 receiving the BNT162b2-mRNA vaccine and 2 receiving the mRNA-1273 vaccine) who were evaluated in a single tertiary care medical center (Duke University Medical Center) that attempted to define its catchment population.1 Three cases occurred in men aged 23 to 36 years and the fourth in a 70-year-old woman; details about the medical history of the fourth patient were not provided, but she received coronary angiography during her evaluation and no atherosclerosis was found. All presented with severe acute chest pain, had abnormal electrocardiogram results, and had evidence of myocardial injury demonstrated by elevated troponin levels. Cardiac magnetic resonance imaging was performed in these 4 patients on days 3 through 5 after vaccine receipt, and the findings were consistent with acute myocarditis as defined by recent expert consensus guidelines.3 |
Prevention and Attenuation of Covid-19 with the BNT162b2 and mRNA-1273 Vaccines.
Thompson MG , Burgess JL , Naleway AL , Tyner H , Yoon SK , Meece J , Olsho LEW , Caban-Martinez AJ , Fowlkes AL , Lutrick K , Groom HC , Dunnigan K , Odean MJ , Hegmann K , Stefanski E , Edwards LJ , Schaefer-Solle N , Grant L , Ellingson K , Kuntz JL , Zunie T , Thiese MS , Ivacic L , Wesley MG , Mayo Lamberte J , Sun X , Smith ME , Phillips AL , Groover KD , Yoo YM , Gerald J , Brown RT , Herring MK , Joseph G , Beitel S , Morrill TC , Mak J , Rivers P , Poe BP , Lynch B , Zhou Y , Zhang J , Kelleher A , Li Y , Dickerson M , Hanson E , Guenther K , Tong S , Bateman A , Reisdorf E , Barnes J , Azziz-Baumgartner E , Hunt DR , Arvay ML , Kutty P , Fry AM , Gaglani M . N Engl J Med 2021 385 (4) 320-329 BACKGROUND: Information is limited regarding the effectiveness of the two-dose messenger RNA (mRNA) vaccines BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) in preventing infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and in attenuating coronavirus disease 2019 (Covid-19) when administered in real-world conditions. METHODS: We conducted a prospective cohort study involving 3975 health care personnel, first responders, and other essential and frontline workers. From December 14, 2020, to April 10, 2021, the participants completed weekly SARS-CoV-2 testing by providing mid-turbinate nasal swabs for qualitative and quantitative reverse-transcriptase-polymerase-chain-reaction (RT-PCR) analysis. The formula for calculating vaccine effectiveness was 100% × (1 - hazard ratio for SARS-CoV-2 infection in vaccinated vs. unvaccinated participants), with adjustments for the propensity to be vaccinated, study site, occupation, and local viral circulation. RESULTS: SARS-CoV-2 was detected in 204 participants (5%), of whom 5 were fully vaccinated (≥14 days after dose 2), 11 partially vaccinated (≥14 days after dose 1 and <14 days after dose 2), and 156 unvaccinated; the 32 participants with indeterminate vaccination status (<14 days after dose 1) were excluded. Adjusted vaccine effectiveness was 91% (95% confidence interval [CI], 76 to 97) with full vaccination and 81% (95% CI, 64 to 90) with partial vaccination. Among participants with SARS-CoV-2 infection, the mean viral RNA load was 40% lower (95% CI, 16 to 57) in partially or fully vaccinated participants than in unvaccinated participants. In addition, the risk of febrile symptoms was 58% lower (relative risk, 0.42; 95% CI, 0.18 to 0.98) and the duration of illness was shorter, with 2.3 fewer days spent sick in bed (95% CI, 0.8 to 3.7). CONCLUSIONS: Authorized mRNA vaccines were highly effective among working-age adults in preventing SARS-CoV-2 infection when administered in real-world conditions, and the vaccines attenuated the viral RNA load, risk of febrile symptoms, and duration of illness among those who had breakthrough infection despite vaccination. (Funded by the National Center for Immunization and Respiratory Diseases and the Centers for Disease Control and Prevention.). |
Effectiveness of monovalent rotavirus vaccine against hospitalizations due to all rotavirus and equine-like G3P[8] genotypes in Haiti 2014-2019.
Burnett E , Juin S , Esona MD , Desormeaux AM , Aliabadi N , Pierre M , Andre-Alboth J , Leshem E , Etheart MD , Patel R , Dely P , Fitter D , Jean-Denis G , Kalou M , Katz MA , Bowen MD , Grant-Greene Y , Boncy J , Parashar UD , Joseph GA , Tate JE . Vaccine 2021 39 (32) 4458-4462 BACKGROUND: Rotavirus vaccines are effective in preventing severe rotavirus. Haiti introduced 2-dose monovalent (G1P[8]) rotavirus vaccine recommended for infants at 6 and 10 weeks of age in 2014. We calculated the effectiveness of rotavirus vaccine against hospitalization for acute gastroenteritis in Haiti. METHODS: We enrolled children 6-59 months old admitted May 2014-September 2019 for acute watery diarrhea at any sentinel surveillance hospital. Stool was tested for rotavirus using enzyme immunoassay (EIA) and genotyped with multiplex one-step RT-PCR assay and Sanger sequencing for stratification by genotype. We used a case-negative design where cases were children positive for rotavirus and controls were negative for rotavirus. Only children eligible for vaccination were included and a child was considered vaccinated if vaccine was given ≥ 14 days before enrollment. We used unconditional logistic regression to calculate odds ratios and calculated 2-dose and 1-dose vaccine effectiveness (VE) as (1 - odds ratio) * 100. RESULTS: We included 129 (19%) positive cases and 543 (81%) negative controls. Among cases, 77 (60%) were positive for equine-like G3P[8]. Two doses of rotavirus vaccine were 66% (95% CI: 44, 80) effective against hospitalizations due to any strain of rotavirus and 64% (95% CI: 33, 81) effective against hospitalizations due to the equine-like G3P[8] genotype. CONCLUSIONS: These findings are comparable to other countries in the Americas region. To the best of our knowledge, this is the first VE estimate both against the equine-like G3P[8] genotype and from a Caribbean country. Overall, these results support rotavirus vaccine use and demonstrate the importance of complete vaccination. |
The CAPACITI Decision-Support Tool for National Immunization Programs
Botwright S , Giersing BK , Meltzer MI , Kahn AL , Jit M , Baltussen R , El Omeiri N , Biey JNM , Moore KL , Thokala P , Mwenda JM , Bertram M , Hutubessy RCW . Value Health 2021 24 (8) 1150-1157 Objectives: Immunization programs in low-income and middle-income countries (LMICs) are faced with an ever-growing number of vaccines of public health importance recommended by the World Health Organization, while also financing a greater proportion of the program through domestic resources. More than ever, national immunization programs must be equipped to contextualize global guidance and make choices that are best suited to their setting. The CAPACITI decision-support tool has been developed in collaboration with national immunization program decision makers in LMICs to structure and document an evidence-based, context-specific process for prioritizing or selecting among multiple vaccination products, services, or strategies. Methods: The CAPACITI decision-support tool is based on multi-criteria decision analysis, as a structured way to incorporate multiple sources of evidence and stakeholder perspectives. The tool has been developed iteratively in consultation with 12 countries across Africa, Asia, and the Americas. Results: The tool is flexible to existing country processes and can follow any type of multi-criteria decision analysis or a hybrid approach. It is structured into 5 sections: decision question, criteria for decision making, evidence assessment, appraisal, and recommendation. The Excel-based tool guides the user through the steps and document discussions in a transparent manner, with an emphasis on stakeholder engagement and country ownership. Conclusions: Pilot countries valued the CAPACITI decision-support tool as a means to consider multiple criteria and stakeholder perspectives and to evaluate trade-offs and the impact of data quality. With use, it is expected that LMICs will tailor steps to their context and streamline the tool for decision making. © 2021 ISPOR–The Professional Society for Health Economics and Outcomes Research |
Syndromic surveillance of vaccine-associated adverse events in U.S. emergency departments
Radhakrishnan L , Stein Z , DeVies J , Smith A , Sheppard M , Hartnett KP , Kite-Powell A , Adjemian J , Rodgers LE . Vaccine 2021 39 (31) 4250-4255 The Centers for Disease Control and Prevention explored use of emergency department (ED) visit data, during 2018-2020, from the National Syndromic Surveillance Program to monitor vaccine-associated adverse events (VAE) among all age groups. A combination of chief complaint terms and administrative diagnosis codes were used to detect VAE-related ED visits. Postvaccination fever was among the top 10 most frequently noted diagnoses. VAE annual trends demonstrated seasonality; visits trended upward starting in September of each year, coinciding with the administration of seasonal influenza vaccines. The 2020 VAE-related visit trend declined below the 2018 and 2019 baselines during March 22-September 5, 2020, before returning to the seasonal pattern. VAE-related visits declined in children aged 3-18 years in 2020 compared with 2018-2019, especially in the back-to-school months. These findings demonstrate that syndromic surveillance can complement traditional VAE reporting systems without an additional demand on data collection resources. |
Knowledge, attitude/perception, and practice related to seasonal influenza vaccination among caregivers of young Thai children: A cross-sectional study
Thanee C , Kittikraisak W , Sinthuwattanawibool C , Roekworachai K , Klinklom A , Kornsitthikul K , Jirasakpisarn S , Srirompotong U , Chittaganpitch M , Dawood FS , Suntarattiwong P , Mott JA , Chotpitayasunondh T . PLoS One 2021 16 (6) e0253561 BACKGROUND: Seasonal influenza vaccination uptake among young children in Thailand is low despite national recommendation for vaccination. We implemented a knowledge, attitude/perception, and practice survey to understand determinants of influenza vaccination in children aged six months to two years. METHODS: Using a cross-sectional design, we interviewed caregivers of 700 children in seven hospitals using a structured questionnaire to collect information on caregivers' and children's demographic characteristics, and caregivers' knowledge of influenza illness and national vaccine recommendation, attitude/perception toward influenza vaccine, and information sources. We verified children's influenza vaccination status against medical records (vaccinated vs. unvaccinated). Logistic regression was used to examine factors independently associated with children receiving influenza vaccination in the 2018 season using the dataset restricted to only children's parents. Variables associated with vaccination at p-value ≤0.20 were included in subsequent multivariable logistic models. Significant independent determinants of children's influenza vaccination and collinearity of covariates were assessed. The final model was constructed using a stepwise backward elimination approach with variables significant at p-value <0.05 retained in the model. RESULTS: During August 2018-February 2019, 700 children's caregivers completed the questionnaire; 61 (9%) were caregivers of vaccinated children. Caregivers of the vaccinated children were statistically more likely to have higher education (61% vs. 38%; p-value<0.01) and to know of influenza illness (93% vs. 76%; p-value = 0.03) than those of the unvaccinated group. Factors associated with children receiving influenza vaccination were identifying healthcare providers as a primary source of information about influenza illness for parents (adjusted odds ratio [aOR], 2.8; 95% confidence interval [CI], 1.3-6.0), parents' strongly agreeing with the national recommendation for influenza vaccination in young children (aOR, 2.9; 95% CI, 1.5-5.9), using health insurance provided by the government or parent's employer for children's doctor visits (aOR, 2.6; 95% CI, 1.1-6.6), and the children's history of receiving influenza vaccination in the 2017 season or earlier (aOR, 3.2; 95% CI, 1.4-7.8). CONCLUSION: The majority of caregivers of children in this study had knowledge of influenza illness and influenza vaccine. Caregivers reported various sources of information regarding influenza illness and the vaccine, but healthcare providers remained the most trusted source. Children's history of influenza vaccination in prior season(s) was the strongest determinant of children being vaccinated for influenza in the current season. |
Exoproteomic analysis of two MLST clade 2 strains of Clostridioides difficile from Latin America reveal close similarities.
de Melo Pacífico D , Costa CL , Moura H , Barr JR , Maia GA , Filho VB , Moreira RS , Wagner G , Domingues Rmcp , Quesada-Gómez C , de Oliveira Ferreira E , de Castro Brito GA . Sci Rep 2021 11 (1) 13273 Clostridioides difficile BI/NAP1/ribotype 027 is an epidemic hypervirulent strain found worldwide, including in Latin America. We examined the genomes and exoproteomes of two multilocus sequence type (MLST) clade 2 C. difficile strains considered hypervirulent: ICC-45 (ribotype SLO231/UK[CE]821), isolated in Brazil, and NAP1/027/ST01 (LIBA5756), isolated during a 2010 outbreak in Costa Rica. C. difficile isolates were cultured and extracellular proteins were analyzed using high-performance liquid chromatography-tandem mass spectrometry. Genomic analysis revealed that these isolates shared most of the gene composition. Only 83 and 290 NAP1/027 genes were considered singletons in ICC-45 and NAP1/027, respectively. Exoproteome analysis revealed 197 proteins, of which 192 were similar in both strains. Only five proteins were exclusive to the ICC-45 strain. These proteins were involved with catalytic and binding functions and indirectly interacted with proteins related to pathogenicity. Most proteins, including TcdA, TcdB, flagellin subunit, and cell surface protein, were overrepresented in the ICC-45 strain; 14 proteins, including mature S-layer protein, were present in higher proportions in LIBA5756. Data are available via ProteomeXchange with identifier PXD026218. These data show close similarity between the genome and proteins in the supernatant of two strains with hypervirulent features isolated in Latin America and underscore the importance of epidemiological surveillance of the transmission and emergence of new strains. |
Application of MALDI-TOF mass spectrometry, and DNA sequencing-based SLST and MLST analysis for the identification of Cronobacter spp. isolated from environmental surveillance samples.
Sulaiman IM , Tang K , Segars K , Miranda N , Sulaiman N , Simpson S . Arch Microbiol 2021 203 (8) 4813-4820 Cronobacter spp. are emerging infectious foodborne bacteria that can cause acute meningitis and necrotizing enterocolitis in neonates and immunocompromised individuals. Although, little is known about its reservoirs or transmission routes, it has been linked to powdered infant formula worldwide. Three Cronobacter spp. (C. sakazakii, C. malonaticus, and C. turicensis) have been described as more virulent, and isolated frequently from infant meningitis cases. The estimated mortality rates are as high as 80% in infants. Thus, surveillance and typing of Cronobacter spp. isolated from food and environmental samples is essential to prevent contamination and spread of this pathogen. In this study, we have characterized 83 Cronobacter isolates recovered from various environmental samples by conventional microbiologic protocols. Species identification was accomplished by VITEK 2 system and real-time PCR analysis. Subsequently, these isolates were analyzed using VITEK MS system. Single locus sequence typing (SLST) was achieved by characterizing the regions of 16S rRNA and rpoB genes. Multilocus sequence typing (MLST) was performed by sequence characterization of seven housekeeping genes (atpD, fusA, glnS, gltB, gyrB, infB, and pps) using ABI 3500XL Genetic Analyzer. VITEK MS system identified, the majority of isolates as Cronobacter sakazakii with a high confidence value (99.9%). MLST analysis ascertained 12 distinct clonal complexes (CC1, CC4, CC8, CC13, CC17, CC21, CC31, CC40, CC52, CC64, CC73, and CC83) for the recovered C. sakazakii isolates. The results suggest that the MALDI-TOF MS is a reliable diagnostic tool for rapid species identification whereas 7-loci MLST is a powerful technique to discriminate and differentiate Cronobacter spp. isolates. |
Comparison of Mid-Turbinate and Nasopharyngeal Specimens for Molecular Detection of SARS-CoV-2 Among Symptomatic Outpatients at a Pediatric Drive-Through Testing Site.
Sahni LC , Avadhanula V , Ortiz CS , Feliz KE , John RE , Brown CA , Lively JY , Rha B , Munoz FM , Piedra PA , Dunn JJ , Boom JA . J Pediatric Infect Dis Soc 2021 10 (8) 872-879 BACKGROUND: Nasopharyngeal (NP) specimen testing by reverse transcriptase polymerase chain reaction (RT-PCR) is the standard of care for detecting SARS-CoV-2. Data comparing the sensitivity and specificity of the NP specimen to the less invasive, mid-turbinate (MT) nasal specimen in children are limited. METHODS: Paired clinical NP and research MT specimens were collected from children <18 years with respiratory symptoms and tested by molecular assays to detect SARS-CoV-2 RNA. Sensitivity, specificity, and agreement (Cohen's kappa [κ]) were calculated for research MT specimens compared to the clinical NP specimens. RESULTS: Out of 907 children, 569 (62.7%) had parental consent and child assent when appropriate to participate and provided paired MT and NP specimens a median of 4 days after symptom onset (range 1-14 days). 16.5% (n = 94) of MT specimens were positive for SARS-CoV-2 compared with 20.0% (n = 114) of NP specimens. The sensitivity of research MT compared to clinical NP specimens was 82.5% (95% CI: 74.2%, 88.9%), specificity was 100.0% (95% CI: 99.2%, 100.0%), and overall agreement was 96.1% (κ = 0.87). The sensitivity of MT specimens decreased with time from 100% (95% CI: 59.0%, 100.0%) on day 1 of illness to 82.1% (95% CI: 73.8%, 88.7%) within 14 days of illness onset; sensitivity was generally >90% when specimens were collected within the first week of illness. CONCLUSION: MT specimens, particularly those collected within the first week of illness, have moderately reduced sensitivity and equivalent specificity to less-tolerated NP specimens in pediatric outpatients. MT specimen use in children may represent a viable alternative to NP specimen collection. |
Considerations for quality assurance of multiplex malaria antigen detection assays with large sample sets
Alvarado R , van den Hoogen LL , Iriemenam NC , Akinmulero OO , Thomas AN , Tamunonengiyeofori I , Erasogie E , Chimaoge AC , Dawurung AB , Esiekpe MK , Okoli MU , Mba N , Ogunniyi A , Abimiku A , Maire M , Bassey OO , Okoye M , Swaminathan M , Greby SM , Ndodo N , Ihekweazu C , Abubakar A , Steinhardt L , Rogier E . Sci Rep 2021 11 (1) 13248 Multiplex assays for malaria antigen detection can gather data from large sample sets, but considerations for the consistency and quality assurance (QA) of mass testing lack evaluation. We present a QA framework for a study occurring November 2019 to March 2020 involving 504 assay plates detecting four Plasmodium antigens: pan-Plasmodium aldolase and lactate dehydrogenase (LDH), histidine-rich protein 2 (HRP2), P. vivax LDH (PvLDH). Controls on each plate included buffer blank, antigen negative blood, and 4-point positive dilution curve. The blank and negative blood provided consistently low signal for all targets except for pAldolase, which showed variability. Positive curve signals decreased throughout the 5-month study duration but retained a coefficient of variation (CV) of < 5%, with the exception of HRP2 in month 5 (CV of 11%). Regression fittings for inter-plate control signals provided mean and standard deviations (SDs), and of 504 assay plates, 6 (1.2%) violated the acceptable deviation limits and were repeated. For the 40,272 human blood samples assayed in this study, of 161,088 potential data points (each sample × 4 antigens), 160,641 (99.7%) successfully passed quality checks. The QA framework presented here can be utilized to ensure quality of laboratory antigen detection for large sample sets. |
Influenza Virus Infects and Depletes Activated Adaptive Immune Responders
Bohannon CD , Ende Z , Cao W , Mboko WP , Ranjan P , Kumar A , Mishina M , Amoah S , Gangappa S , Mittal SK , Lovell JF , García-Sastre A , Pfeifer BA , Davidson BA , Knight P , Sambhara S . Adv Sci (Weinh) 2021 8 (16) e2100693 Influenza infections cause several million cases of severe respiratory illness, hospitalizations, and hundreds of thousands of deaths globally. Secondary infections are a leading cause of influenza's high morbidity and mortality, and significantly factored into the severity of the 1918, 1968, and 2009 pandemics. Furthermore, there is an increased incidence of other respiratory infections even in vaccinated individuals during influenza season. Putative mechanisms responsible for vaccine failures against influenza as well as other respiratory infections during influenza season are investigated. Peripheral blood mononuclear cells (PBMCs) are used from influenza vaccinated individuals to assess antigen-specific responses to influenza, measles, and varicella. The observations made in humans to a mouse model to unravel the mechanism is confirmed and extended. Infection with influenza virus suppresses an ongoing adaptive response to vaccination against influenza as well as other respiratory pathogens, i.e., Adenovirus and Streptococcus pneumoniae by preferentially infecting and killing activated lymphocytes which express elevated levels of sialic acid receptors. These findings propose a new mechanism for the high incidence of secondary respiratory infections due to bacteria and other viruses as well as vaccine failures to influenza and other respiratory pathogens even in immune individuals due to influenza viral infections. |
Determining seropositivity-A review of approaches to define population seroprevalence when using multiplex bead assays to assess burden of tropical diseases
Chan Y , Fornace K , Wu L , Arnold BF , Priest JW , Martin DL , Chang MA , Cook J , Stresman G , Drakeley C . PLoS Negl Trop Dis 2021 15 (6) e0009457 BACKGROUND: Serological surveys with multiplex bead assays can be used to assess seroprevalence to multiple pathogens simultaneously. However, multiple methods have been used to generate cut-off values for seropositivity and these may lead to inconsistent interpretation of results. A literature review was conducted to describe the methods used to determine cut-off values for data generated by multiplex bead assays. METHODOLOGY/PRINCIPAL FINDINGS: A search was conducted in PubMed that that included articles published from January 2010 to January 2020, and 291 relevant articles were identified that included the terms "serology", "cut-offs", and "multiplex bead assays". After application of exclusion of articles not relevant to neglected tropical diseases (NTD), vaccine preventable diseases (VPD), or malaria, 55 articles were examined based on their relevance to NTD or VPD. The most frequently applied approaches to determine seropositivity included the use of presumed unexposed populations, mixture models, receiver operating curves (ROC), and international standards. Other methods included the use of quantiles, pre-exposed endemic cohorts, and visual inflection points. CONCLUSIONS/SIGNIFICANCE: For disease control programmes, seropositivity is a practical and easily interpretable health metric but determining appropriate cut-offs for positivity can be challenging. Considerations for optimal cut-off approaches should include factors such as methods recommended by previous research, transmission dynamics, and the immunological backgrounds of the population. In the absence of international standards for estimating seropositivity in a population, the use of consistent methods that align with individual disease epidemiological data will improve comparability between settings and enable the assessment of changes over time. |
Laboratory Techniques for Identifying Causes of Allergic Dermatitis
Chipinda I , Anderson SE , Siegel PD . Immunol Allergy Clin North Am 2021 41 (3) 423-438 This article reviews the laboratory's role in identifying causes of chemical-induced allergic dermatitis. Several topics will be discussed. Allergen hazard identification refers to testing of chemicals for their sensitization potential. Animal-based, in silico, in chemico, and in vitro tests have been developed to identify the skin sensitization hazard of potential chemical allergens, but only a few of these are accepted by regulatory agencies. Laboratory investigations have also evaluated the stability of several commercially available allergic contact dermatitis patch tests. Such studies are considered product testing and are usually conducted in analytical chemistry laboratories. |
Evaluation of the Abbott ARCHITECT HIV Ag/Ab combo assay for determining recent HIV-1 infection
Curtis KA , Rudolph DL , Pan Y , Delaney K , Anastos K , DeHovitz J , Kassaye SG , Hanson CV , French AL , Golub E , Adimora AA , Ofotokun I , Bolivar H , Kempf MC , Peters PJ , Switzer WM . PLoS One 2021 16 (7) e0242641 BACKGROUND: Given the challenges and costs associated with implementing HIV-1 incidence assay testing, there is great interest in evaluating the use of commercial HIV diagnostic tests for determining recent HIV infection. A diagnostic test with the capability of providing reliable data for the determination of recent HIV infection without substantial modifications to the test protocol would have a significant impact on HIV surveillance. The Abbott ARCHITECT HIV Ag/Ab Combo Assay is an antigen/antibody immunoassay, which meets the criteria as the first screening test in the recommended HIV laboratory diagnostic algorithm for the United States. METHODS: In this study, we evaluated the performance characteristics of the ARCHITECT HIV Ag/Ab Combo signal-to-cutoff ratio (S/Co) for determining recent infection, including estimation of the mean duration of recent infection (MDRI) and false recent rate (FRR), and selection of recency cutoffs. RESULTS: The MDRI estimates for the S/Co recency cutoff of 400 is within the 4 to 12 months range recommended for HIV incidence assays, and the FRR rate for this cutoff was 1.5%. Additionally, ARCHITECT Combo S/Co values were compared relative to diagnostic test results from two prior prospective HIV-1 diagnostic studies in order to validate the use of the S/Co for both diagnostic and recency determination. CONCLUSION: Dual-use of the ARCHITECT Combo assay data for diagnostic and incidence purposes would reduce the need for separate HIV incidence testing and allow for monitoring of recent infection for incidence estimation and other public health applications. |
Respiratory and intestinal epithelial cells exhibit differential susceptibility and innate immune responses to EV-D68
Freeman MC , Wells AI , Ciomperlik-Patton J , Myerburg MM , Yang L , Konopka-Anstadt J , Coyne C . Elife 2021 10 Enterovirus D68 (EV-D68) has been implicated in outbreaks of severe respiratory illness and is associated with acute flaccid myelitis (AFM). EV-D68 is often detected in patient respiratory samples but has also been detected in stool and wastewater, suggesting the potential for both respiratory and enteric routes of transmission. Here, we used a panel of EV-D68 isolates, including a historical pre-2014 isolate and multiple contemporary isolates from AFM outbreak years, to define the dynamics of viral replication and the host response to infection in primary human airway cells and stem cell-derived enteroids. We show that some recent EV-D68 isolates have decreased sensitivity to acid and temperature compared with earlier isolates and that the respiratory, but not intestinal, epithelium induces a robust type III interferon (IFN) response that restricts infection. Our findings define the differential responses of the respiratory and intestinal epithelium to contemporary EV-D68 isolates and suggest that a subset of isolates have the potential to target both the human airway and gastrointestinal tracts. |
The chromogenic Bethesda assay and the Nijmegen-Bethesda assay for factor VIII inhibitors in hemophilia A patients: Are they equivalent
Miller CH , Boylan B . J Thromb Haemost 2021 19 (7) 1835-1837 We previously described in this journal a modified Nijmegen-Bethesda assay (NBA) for factor VIII (FVIII) inhibitors in hemophilia A (HA) that uses preanalytical heat inactivation of infused or endogenous FVIII to allow inhibitor measurement postinfusion1 and compared that assay with a chromogenic Bethesda assay (CBA) that is identical except for use of an FVIII chromogenic substrate assay (CSA) rather than a one-stage assay (OSA) as the endpoint for inhibitor detection.2 Our primary focus was on use of the CBA as a confirmatory test for low positive NBA results. Introduction of the non-FVIII treatment product emicizumab (Hemlibra) has brought increased interest in inhibitor assays using CSA because emicizumab interferes with the OSA and thus with Bethesda assays for FVIII inhibitors using the OSA.3-5 CSA for FVIII that use bovine factor X (FX) are insensitive to emicizumab,5 and a CBA using such CSA has been successfully used for inhibitor testing in its presence.6, 7 Clinical laboratories providing inhibitor testing have the option of maintaining two inhibitor assays and choosing the correct one for each patient depending on the product used or switching to a CBA to accommodate testing on all patients. Clinical adoption of a new assay methodology requires demonstration that the new method is equivalent to the old. Recent reexamination of the dataset of paired NBA and CBA results from our original paper2 revealed differences that may influence such comparisons and that, if not considered, could hinder validation of the CBA for clinical use. |
Recognition of Diagnostic Gaps for Laboratory Diagnosis of Fungal Diseases: Expert Opinion from the Fungal Diagnostics Laboratories Consortium (FDLC)
Zhang SX , Babady NE , Hanson KE , Harrington AT , Larkin PMK , Leal SM Jr , Luethy PM , Martin IW , Pancholi P , Procop GW , Riedel S , Seyedmousavi S , Sullivan KV , Walsh TJ , Lockhart SR . J Clin Microbiol 2021 59 (7) e0178420 Fungal infections are a rising threat to our immunocompromised patient population, as well as other nonimmunocompromised patients with various medical conditions. However, little progress has been made in the past decade to improve fungal diagnostics. To jointly address this diagnostic challenge, the Fungal Diagnostics Laboratory Consortium (FDLC) was recently created. The FDLC consists of 26 laboratories from the United States and Canada that routinely provide fungal diagnostic services for patient care. A survey of fungal diagnostic capacity among the 26 members of the FDLC was recently completed, identifying the following diagnostic gaps: lack of molecular detection of mucormycosis; lack of an optimal diagnostic algorithm incorporating fungal biomarkers and molecular tools for early and accurate diagnosis of Pneumocystis pneumonia, aspergillosis, candidemia, and endemic mycoses; lack of a standardized molecular approach to identify fungal pathogens directly in formalin-fixed paraffin-embedded tissues; lack of robust databases to enhance mold identification with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry; suboptimal diagnostic approaches for mold blood cultures, tissue culture processing for Mucorales, and fungal respiratory cultures for cystic fibrosis patients; inadequate capacity for fungal point-of-care testing to detect and identify new, emerging or underrecognized, rare, or uncommon fungal pathogens; and performance of antifungal susceptibility testing. In this commentary, the FDLC delineates the most pressing unmet diagnostic needs and provides expert opinion on how to fulfill them. Most importantly, the FDLC provides a robust laboratory network to tackle these diagnostic gaps and ultimately to improve and enhance the clinical laboratory's capability to rapidly and accurately diagnose fungal infections. |
Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic - United States, March-April 2021.
Bryant-Genevier J , Rao CY , Lopes-Cardozo B , Kone A , Rose C , Thomas I , Orquiola D , Lynfield R , Shah D , Freeman L , Becker S , Williams A , Gould DW , Tiesman H , Lloyd G , Hill L , Byrkit R . MMWR Morb Mortal Wkly Rep 2021 70 (26) 947-952 Increases in mental health conditions have been documented among the general population and health care workers since the start of the COVID-19 pandemic (1-3). Public health workers might be at similar risk for negative mental health consequences because of the prolonged demand for responding to the pandemic and for implementing an unprecedented vaccination campaign. The extent of mental health conditions among public health workers during the COVID-19 pandemic, however, is uncertain. A 2014 survey estimated that there were nearly 250,000 state and local public health workers in the United States (4). To evaluate mental health conditions among these workers, a nonprobability-based online survey was conducted during March 29-April 16, 2021, to assess symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation among public health workers in state, tribal, local, and territorial public health departments. Among 26,174 respondents, 53.0% reported symptoms of at least one mental health condition in the preceding 2 weeks, including depression (32.0%), anxiety (30.3%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms of a mental health condition was among respondents aged ≤29 years (range = 13.6%-47.4%) and transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages (range = 30.4%-65.5%). Public health workers who reported being unable to take time off from work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. Implementing prevention and control practices that eliminate, reduce, and manage factors that cause or contribute to public health workers' poor mental health might improve mental health outcomes during emergencies. |
Maternal occupation as a nail technician or hairdresser during pregnancy and birth defects, National Birth Defects Prevention Study, 1997-2011
Siegel MR , Rocheleau CM , Broadwater K , Santiago-Colón A , Johnson CY , Herdt ML , Chen IC , Lawson CC . Occup Environ Med 2021 79 (1) 17-23 OBJECTIVE: Nail technicians and hairdressers may be exposed to chemicals with potential reproductive effects. While studies have examined birth defects in children of hairdressers, those in children of nail technicians have not been evaluated. We investigated associations between selected birth defects and maternal occupation as a nail technician or hairdresser versus a non-cosmetology occupation during pregnancy. METHODS: We analysed population-based case-control data from the multisite National Birth Defects Prevention Study, 1997-2011. Cases were fetuses or infants with major structural birth defects; controls were live-born infants without major birth defects. Expert raters classified self-reported maternal jobs as nail technician, combination nail technician-hairdresser, hairdresser, other cosmetology work or non-cosmetology work. We used logistic regression to calculate adjusted ORs and 95% CIs for associations between occupation during pregnancy and birth defects, controlling for age, smoking, education and race/ethnicity. RESULTS: Sixty-one mothers worked as nail technicians, 196 as hairdressers, 39 as combination nail technician-hairdressers and 42 810 as non-cosmetologists. The strongest associations among nail technicians included seven congenital heart defect (CHD) groups (ORs ranging from 2.7 to 3.5) and neural tube defects (OR=2.6, CI=0.8 to 8.4). Birth defects most strongly associated with hairdressing included anotia/microtia (OR=2.1, CI=0.6 to 6.9) and cleft lip with cleft palate (OR=2.0, CI=1.1 to 3.7). All oral cleft groups were associated with combination nail technician-hairdresser work (ORs ranging from 4.2 to 5.3). CONCLUSIONS: Small samples resulted in wide CIs. Still, results suggest associations between maternal nail technician work during pregnancy and CHDs and between hairdressing work and oral clefts. |
Comparison of ISO work of breathing and NIOSH breathing resistance measurements for air-purifying respirators
Xu SS , King WP , McClain C , Zhuang Z , Rottach DR . J Occup Environ Hyg 2021 18 (8) 1-9 The National Institute for Occupational Safety and Health's methods and requirements for air-purifying respirator breathing resistance in 42 CFR Part 84 do not include work of breathing. The International Organization for Standardization Technical Committee 94, Subcommittee 15 utilized work of breathing to evaluate airflow resistance for all classes of respiratory protective devices as part of their development of performance standards regarding respiratory protective devices. The objectives of this study were: (1) to evaluate the relationship between the International Organization for Standardization's work of breathing measurements and the National Institute for Occupational Safety and Health's breathing resistance test results; (2) to provide scientific bases for standard development organizations to decide if work of breathing should be adopted; and (3) to establish regression equations for manufacturers and test laboratories to estimate work of breathing measurements using breathing resistance data. A total of 43 respirators were tested for work of breathing at minute ventilation rates of 10, 35, 65, 105, and 135 liters per minute. Breathing resistance obtained at a constant flow rate of 85 liters per minute per National Institute of Occupational Safety and Health protocol was correlated to each of the parameters (total work of breathing, inhalation, and exhalation) obtained from the work of breathing tests. The ratio of work of breathing exhalation to work of breathing inhalation for all air-purifying respirators is similar to the ratio of exhalation to inhalation resistance when tested individually. The ratios were about 0.8 for filtering facepiece respirators, 0.5 for half-masks, and 0.25 for full-facepiece respirators. The National Institute for Occupational Safety and Health's breathing resistance is close to work of breathing's minute ventilation of 35 liters per minute, which represents the common walking/working pace in most workplaces. The work of breathing and the National Institute of Occupational Safety and Health's breathing resistance were found to be strongly and positively correlated (r values of 0.7-0.9) at each work rate for inhalation and exhalation. In addition, linear and multiple regression models (R-squared values of 0.5-0.8) were also established to estimate work of breathing using breathing resistance. Work of breathing was correlated higher to breathing resistance for full-facepiece and half-mask elastomeric respirators than filtering facepiece respirators for inhalation. For exhalation, filtering facepiece respirators were correlated much better than full-facepiece and half-mask elastomeric respirators. Therefore, the National Institute for Occupational Safety and Health's breathing resistance may reasonably be used to predict work of breathing for air-purifying respirators. The results could also be used by manufacturers for product development and evaluation. |
Healthcare provider and pregnant women's perspectives on the implementation of intermittent screening and treatment with dihydroartemisinin-piperaquine for malaria in pregnancy in western Kenya: a qualitative study
Hoyt J , Hill J , Achieng F , Ouma P , Kariuki S , Desai M , Webster J . Malar J 2021 20 (1) 291 BACKGROUND: In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin-piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women's perceptions. METHODS: Qualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study. RESULTS: Women were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks. CONCLUSION: In ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers' lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC. |
Opening the 'black box' of collaborative improvement: a qualitative evaluation of a pilot intervention to improve quality of malaria surveillance data in public health centres in Uganda
Hutchinson E , Nayiga S , Nabirye C , Taaka L , Westercamp N , Rowe AK , Staedke SG . Malar J 2021 20 (1) 289 BACKGROUND: Demand for high-quality surveillance data for malaria, and other diseases, is greater than ever before. In Uganda, the primary source of malaria surveillance data is the Health Management Information System (HMIS). However, HMIS data may be incomplete, inaccurate or delayed. Collaborative improvement (CI) is a quality improvement intervention developed in high-income countries, which has been advocated for low-resource settings. In Kayunga, Uganda, a pilot study of CI was conducted in five public health centres, documenting a positive effect on the quality of HMIS and malaria surveillance data. A qualitative evaluation was conducted concurrently to investigate the mechanisms of effect and unintended consequences of the intervention, aiming to inform future implementation of CI. METHODS: The study intervention targeted health workers, including brief in-service training, plus CI with 'plan-do-study-act' (PDSA) cycles emphasizing self-reflection and group action, periodic learning sessions, and coaching from a CI mentor. Health workers collected data on standard HMIS out-patient registers. The qualitative evaluation (July 2015 to September 2016) included ethnographic observations at each health centre (over 12-14 weeks), in-depth interviews with health workers and stakeholders (n = 20), and focus group discussions with health workers (n = 6). RESULTS: The results suggest that the intervention did facilitate improvement in data quality, but through unexpected mechanisms. The CI intervention was implemented as planned, but the PDSA cycles were driven largely by the CI mentor, not the health workers. In this context, characterized by a rigid hierarchy within the health system of limited culture of self-reflection and inadequate training and supervision, CI became an effective form of high-quality training with frequent supervisory visits. Health workers appeared motivated to improve data collection habits by their loyalty to the CI mentor and the potential for economic benefits, rather than a desire for self-improvement. CONCLUSIONS: CI is a promising method of quality improvement and could have a positive impact on malaria surveillance data. However, successful scale-up of CI in similar settings may require deployment of highly skilled mentors. Further research, focusing on the effectiveness of 'real world' mentors using robust study designs, will be required to determine whether CI can be translated effectively and sustainably to low-resource settings. |
Effectiveness of in-service training plus the collaborative improvement strategy on the quality of routine malaria surveillance data: results of a pilot study in Kayunga District, Uganda
Westercamp N , Staedke SG , Maiteki-Sebuguzi C , Ndyabakira A , Okiring JM , Kigozi SP , Dorsey G , Broughton E , Hutchinson E , Massoud MR , Rowe AK . Malar J 2021 20 (1) 290 BACKGROUND: Surveillance data are essential for malaria control, but quality is often poor. The aim of the study was to evaluate the effectiveness of the novel combination of training plus an innovative quality improvement method-collaborative improvement (CI)-on the quality of malaria surveillance data in Uganda. METHODS: The intervention (training plus CI, or TCI), including brief in-service training and CI, was delivered in 5 health facilities (HFs) in Kayunga District from November 2015 to August 2016. HF teams monitored data quality, conducted plan-do-study-act cycles to test changes, attended periodic learning sessions, and received CI coaching. An independent evaluation was conducted to assess data completeness, accuracy, and timeliness. Using an interrupted time series design without a separate control group, data were abstracted from 156,707 outpatient department (OPD) records, laboratory registers, and aggregated monthly reports (MR) for 4 time periods: baseline-12 months, TCI scale-up-5 months; CI implementation-9 months; post-intervention-4 months. Monthly OPD register completeness was measured as the proportion of patient records with a malaria diagnosis with: (1) all data fields completed, and (2) all clinically-relevant fields completed. Accuracy was the relative difference between: (1) number of monthly malaria patients reported in OPD register versus MR, and (2) proportion of positive malaria tests reported in the laboratory register versus MR. Data were analysed with segmented linear regression modelling. RESULTS: Data completeness increased substantially following TCI. Compared to baseline, all-field completeness increased by 60.1%-points (95% confidence interval [CI]: 46.9-73.2%) at mid-point, and clinically-relevant completeness increased by 61.6%-points (95% CI: 56.6-66.7%). A relative - 57.4%-point (95% confidence interval: - 105.5, - 9.3%) change, indicating an improvement in accuracy of malaria test positivity reporting, but no effect on data accuracy for monthly malaria patients, were observed. Cost per additional malaria patient, for whom complete clinically-relevant data were recorded in the OPD register, was $3.53 (95% confidence interval: $3.03, $4.15). CONCLUSIONS: TCI improved malaria surveillance completeness considerably, with limited impact on accuracy. Although these results are promising, the intervention's effectiveness should be evaluated in more HFs, with longer follow-up, ideally in a randomized trial, before recommending CI for wide-scale use. |
Toward a New Strategic Public Health Science for Policy, Practice, Impact, and Health Equity.
Bunnell R , Ryan J , Kent C . Am J Public Health 2021 111 (8) e1-e8 The COVID-19 pandemic and its social and health impact have underscored the need for a new strategic science agenda for public health. To optimize public health impact, high-quality strategic science addresses scientific gaps that inform policy and guide practice. At least 6 scientific gaps emerge fromthe US experience with COVID-19: health equity science, data science and modernization, communication science, policy analysis and translation, scientific collaboration, and climate science. Addressing these areas within a strategic public health science agenda will accelerate achievement of public health goals. Public health leadership and scientists have an unprecedented opportunity to use strategic science to guide a new era of improved and equitable public health. (Am J Public Health. Published online ahead of print July 1, 2021: e1-e8. https://doi.org/10.2105/AJPH.2021.306355). |
Local Health Department Revenue Diversification and Revenue Volatility: Can One Be Used to Manage the Other
Viall AH , Bekemeier B , Yeager VA , Carton T . J Public Health Manag Pract 2021 28 (1) E226-E234 OBJECTIVE: Revenue volatility-particularly in the form of sudden and significant reductions in funding-has been shown to negatively affect local health departments (LHDs) by impacting the amount and type of services delivered. This study examined the potential effectiveness of revenue diversification as a means of managing LHD financial risk. More specifically, we examine the relationship between revenue diversification and revenue volatility among LHDs in Washington State. DESIGN AND SETTING: We applied fixed-effects linear regression models with robust standard errors to revenue data reported during 1998-2014 by all LHDs operating in Washington State. We also assessed the robusticity of our results to alternative specifications for revenue diversification and volatility. MAIN OUTCOME MEASURES: LHD revenue and revenue volatility. RESULTS: Between 1998 and 2014, LHDs in Washington State were exposed to considerable upside and downside fiscal risks. While average revenue volatility was close to 0 (0.2%), observed values ranged from -35% to 63%. LHD revenues were already highly diversified: as measured using a reversed Herfindahl-Hirschman Index, diversification values ranged between 0.56 and 1.00. There is little evidence to suggest the existence of a statistically significant relationship between revenue diversification and volatility. CONCLUSIONS: Revenue volatility presents LHDs with important short- and long-term operational challenges. Our models suggest that revenue diversification did not reduce revenue volatility among Washington State LHDs in 1998-2014. Further research will need to examine whether revenue diversification reduces LHD financial risk in other settings. |
Condom Decision Making Among Latino and Black Adolescent Males: Social Neurobiological and Paternal Influences
Guilamo-Ramos V , Benzekri A , Thimm-Kaiser M , Rivera M , Fuller TR , Warner L , Koumans EHA . Res Soc Work Pract 2021 31 (8) 814-825 Purpose: We explored mechanisms of paternal influence associated with adolescent male condom decision making and behavior within an integrated framework of social neurobiological and behavioral theories of condom use. Method: Self-administered surveys from Latino and Black adolescent males aged 15–19 years (n = 191) and their fathers were obtained. Dyads were recruited using area sampling methodology. Analyses included multivariable logistic and ordinary least squares regression examining direct and indirect associations of adolescent decision-analytic and paternal influence factors with adolescent condomless sex in the past 3 months. Results: Notions of masculinity, low-risk perception, partner approval of, and self-efficacy for condomless sex were associated with engaging in unprotected sex. Adolescent males reported reduced odds of engaging in condomless sex when indicating greater levels of father–son communication, relationship satisfaction, and paternal monitoring. Conclusion: Father-based interventions grounded in integrated theoretical frameworks of behavioral decision making and neuroscience have the potential to promote condom use among adolescent males. © The Author(s) 2021. |
Pregnancy Intention: Associations with Maternal Behaviors and Experiences During and After Pregnancy
Robbins CL , Zapata LB , D'Angelo D , Brewer LI , Pazol K . J Womens Health (Larchmt) 2021 30 (10) 1440-1447 Background: The associations between levels of pregnancy intention and adverse behaviors or experiences during pregnancy and postpartum have not been well described. Materials and Methods: We used 2018 Pregnancy Risk Assessment Monitoring System data from 31 jurisdictions in the United States (n = 32,777) to estimate prevalence of inadequate prenatal care (PNC), inappropriate gestational weight gain, depression during pregnancy, intimate partner violence (IPV) during pregnancy, third trimester smoking, no breastfeeding, no postpartum visit, postpartum depressive symptoms, and postpartum smoking by categories of pregnancy intention: unwanted, ambivalent (i.e., unsure), mistimed (i.e., wanted later), or wanted (i.e., wanted then/sooner). Regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) of associations between pregnancy intention and maternal behaviors or experiences. Results: Approximately 16% of women reported pregnancy ambivalence. Women with pregnancy ambivalence (versus wanted pregnancies) had higher prevalence of all adverse maternal behaviors and experiences. Separate models found women with unwanted pregnancy (vs. ambivalent) had higher prevalence for depression during pregnancy (aPR: 1.40, 95% CI: 1.21-1.63), IPV (aPR: 1.75, 95% CI: 1.11-2.77), no breastfeeding (aPR: 1.22, 95% CI: 1.04-1.44), no postpartum visit (aPR: 1.28, 95% CI: 1.06-1.55), and postpartum depressive symptoms (aPR: 1.19, 95% CI: 1.00-1.42); Women with mistimed pregnancy (vs. ambivalent) had lower prevalence for inadequate PNC (aPR: 0.89, 95% CI: 0.81-0.98), third trimester smoking (aPR: 0.68, 95% CI: 0.57-0.80), no breastfeeding (aPR: 0.85, 95% CI: 0.74-0.98), and postpartum smoking (aPR: 0.83, 95% CI: 0.73-0.95). Discussion: The results emphasize the importance of recommended screening and care during the preconception, prenatal, and postpartum periods. |
Primary care physicians' preparedness to treat opioid use disorder in the United States: A cross-sectional survey.
Foti K , Heyward J , Tajanlangit M , Meek K , Jones C , Kolodny A , Alexander GC . Drug Alcohol Depend 2021 225 108811 BACKGROUND: Efforts to increase opioid use disorder (OUD) treatment have focused on primary care. We assessed primary care physicians' preparedness to identify and treat individuals with OUD and barriers to increasing buprenorphine prescribing. METHODS: We conducted a cross-sectional survey from January-August 2020 which assessed perceptions of the opioid epidemic; comfort screening, diagnosing, and treating individuals with OUD with medications; and barriers to obtaining a buprenorphine waiver and prescribing buprenorphine in their practice. Primary care physicians were sampled from the American Medical Association Physician Master File (n = 1000) and contacted up to 3 times, twice by mail and once by e-mail. RESULTS: Overall, 173 physicians (adjusted response rate 27.3 %) responded. While most were somewhat or very comfortable screening (80.7 %) and diagnosing (79.3 %) OUD, fewer (36.9 %) were somewhat or very comfortable treating OUD with medications. One third of respondents were in a practice where they or a colleague were waivered and 10.7 % of respondents had a buprenorphine waiver. The most commonly cited barriers to both obtaining a waiver and prescribing buprenorphine included lack of access to addiction, behavioral health, or psychiatric co-management, lack of experience treating OUD, preference not to be inundated with requests for buprenorphine, and the buprenorphine training requirement. CONCLUSIONS: While most primary care physicians reported comfort screening and diagnosing OUD, fewer were comfortable treating OUD with medications such as buprenorphine and even fewer were waivered to do so. Addressing provider self-efficacy and willingness, and identifying effective, coordinated, and comprehensive models of care may increase OUD treatment with buprenorphine. |
A Thematic Analysis of Overdose Prevention and Response Efforts in States Experiencing Declines in Rates of Opioid-Involved Overdose Deaths
Robinson AB , Ali N , Costa O , Rooks-Peck C , Sorensen-Alawad A , Ballard J , Lowerre K , Fondario A . Public Health Rep 2021 137 (4) 333549211026816 OBJECTIVE: To address the opioid overdose epidemic, it is important to understand the broad scope of efforts under way in states, particularly states in which the rate of opioid-involved overdose deaths is declining. The primary objective of this study was to examine core elements of overdose prevention activities in 4 states with a high rate of opioid-involved overdose deaths that experienced a decrease in opioid-involved overdose deaths from 2016 to 2017. METHODS: We identified 5 states experiencing decreases in age-adjusted mortality rates for opioid-involved overdoses from 2016 to 2017 and examined their overdose prevention programs via program narratives developed with collaborators from each state's overdose prevention program. These program narratives used 10 predetermined categories to organize activities: legislative policies; strategic planning; data access, capacity, and dissemination; capacity building; public-facing resources (eg, web-based dashboards); training resources; enhancements and improvements to prescription drug monitoring programs; linkage to care; treatment; and community-focused initiatives. Using qualitative thematic analysis techniques, core elements and context-specific activities emerged. RESULTS: In the predetermined categories of programmatic activities, we identified the following core elements of overdose prevention and response: comprehensive state policies; strategic planning; local engagement; data access, capacity, and dissemination; training of professional audiences (eg, prescribers); treatment infrastructure; and harm reduction. CONCLUSIONS: The identification of core elements and context-specific activities underscores the importance of implementation and adaptation of evidence-based prevention strategies, interdisciplinary partnerships, and collaborations to address opioid overdose. Further evaluation of these state programs and other overdose prevention efforts in states where mortality rates for opioid-involved overdoses declined should focus on impact, optimal timing, and combinations of program activities during the life span of an overdose prevention program. |
Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic
Rowe CL , Eagen K , Ahern J , Faul M , Hubbard A , Coffin P . J Gen Intern Med 2021 37 (1) 117-124 BACKGROUND: After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. OBJECTIVE: To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014. DESIGN: Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. PATIENTS: 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018. INTERVENTIONS: Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. MAIN MEASURES: Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. KEY RESULTS: The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. CONCLUSIONS: Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change. |
Changing Trends in Age and Sex Distributions of Lyme Disease-United States, 1992-2016
Kugeler KJ , Mead PS , Schwartz AM , Hinckley AF . Public Health Rep 2021 137 (4) 333549211026777 Lyme disease is the most common vector-borne disease in the United States and is characterized by a bimodal age distribution and male predominance. We examined trends in reported cases during a 25-year period to describe changes in the populations most affected by Lyme disease in the United States. We examined demographic characteristics of people with confirmed cases of Lyme disease reported to the Centers for Disease Control and Prevention during 1992-2016 through the National Notifiable Diseases Surveillance System. We grouped cases into 5-year periods (1992-1996, 1997-2001, 2002-2006, 2007-2011, 2012-2016). We calculated the average annual incidence by age and sex and used incidence rate ratios (IRRs) to describe changes in Lyme disease incidence by age and sex over time. We converted patient age at time of illness into patient birth year to ascertain disease patterns according to birth cohorts. The incidence of Lyme disease in the United States doubled from 1992-1996 to 2012-2016 (IRR = 1.74; 95% CI, 1.70-1.78) and increased disproportionately among males; IRRs were 39%-89% higher among males than among females for most age groups. During the study period, children aged 5-9 years were most frequently and consistently affected. In contrast, the average age of adults with Lyme disease increased over time; of all adults, people born during 1950-1964 were the most affected by Lyme disease. Our findings suggest that age-related behaviors and susceptibilities may drive infections among children, and the shifting peak among adults likely reflects a probability proportional to the relative size of the baby boom population. These findings can inform targeted and efficient public health education and intervention efforts. |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
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- Epidemiology and Surveillance
- Health Communication and Education
- Health Economics
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- Immunity and Immunization
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