Value of a facilitated quality improvement initiative on cardiovascular disease risk: findings from an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL)
Losby JL , Osuji TA , House MJ , Davis R , Boyce SP , Greenberg MC , Whitehill JM Jr . J Eval Clin Pract 2015 21 (5) 963-70 RATIONALE, AIMS AND OBJECTIVES: In the United States, cardiovascular disease (CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors. METHODS: This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively. RESULTS: Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline. CONCLUSIONS: Findings from the AT GOAL evaluation support the value of a facilitated quality improvement (QI) initiative on managing CVD risk. |
Prevalence of disability and disability type among adults - United States, 2013
Courtney-Long EA , Carroll DD , Zhang QC , Stevens AC , Griffin-Blake S , Armour BS , Campbell VA . MMWR Morb Mortal Wkly Rep 2015 64 (29) 777-783 Understanding the prevalence of disability is important for public health programs to be able to address the needs of persons with disabilities. Beginning in 2013, to measure disability prevalence by functional type, the Behavioral Risk Factor Surveillance System (BRFSS), added five questions to identify disability in vision, cognition, mobility, self-care, and independent living. CDC analyzed data from the 2013 BRFSS to assess overall prevalence of any disability, as well as specific types of disability among noninstitutionalized U.S. adults. Across all states, disabilities in mobility and cognition were the most frequently reported types. State-level prevalence of each disability type ranged from 2.7% to 8.1% (vision); 6.9% to 16.8% (cognition); 8.5% to 20.7% (mobility); 1.9% to 6.2% (self-care) and 4.2% to 10.8% (independent living). A higher prevalence of any disability was generally seen among adults living in states in the South and among women (24.4%) compared with men (19.8%). Prevalences of any disability and disability in mobility were higher among older age groups. These are the first data on functional disability types available in a state-based health survey. This information can help public health programs identify the prevalence of and demographic characteristics associated with different disability types among U.S. adults and better target appropriate interventions to reduce health disparities. |
Identification of heart failure events in CMS-Medicare claims. The Atherosclerosis Risk in communities (ARIC) Study
Kucharska-Newton AM , Heiss G , Ni H , Stearns SC , Puccinelli-Ortega N , Wruck LM , Chambless L . J Card Fail 2015 22 (1) 48-55 BACKGROUND: We examined the accuracy of CMS Medicare HF diagnostic codes in the identification of acute decompensated and chronic stable HF (ADHF and CSHF). METHODS AND RESULTS: Hospitalizations were identified from medical discharge records for ARIC study participants with linked CMS Medicare Provider Analysis and Review (MedPAR) files for the years 2005-2009. The ARIC Study classification of ADHF and CSHF, based on adjudicated review of medical records, was considered the "gold standard". A total 8,239 ARIC medical records and MedPAR records meeting fee-for-service (FFS) criteria matched on unique participant ID and date of discharge (68.5% match). Agreement between HF diagnostic codes from the two data sources found in the matched records for codes in any position (kappa coefficient (kappa) >0.9) was attenuated for primary diagnostic codes (kappa<0.8). Sensitivity of HF diagnostic codes found in CMS Medicare claims in the identification of ADHF and CSHF was low, especially for the primary diagnostic codes. CONCLUSION: Matching of hospitalizations from CMS Medicare claims with those obtained from abstracted medical records is incomplete, even for hospitalizations meeting FFS criteria. Within matched records, HF diagnostic codes from CMS Medicare show excellent agreement with HF diagnostic codes obtained from medical record abstraction. CMS Medicare data may, however, over-estimate the occurrence of hospitalized acute decompensated or chronic stable HF. |
B-vitamin status and bone mineral density and risk of lumbar osteoporosis in older females in the United States
Bailey RL , Looker AC , Lu Z , Fan R , Eicher-Miller HA , Fakhouri TH , Gahche JJ , Weaver CM , Mills JL . Am J Clin Nutr 2015 102 (3) 687-94 BACKGROUND: Previous data suggest that elevated serum total homocysteine (tHcy) may be a risk factor for bone fracture and osteoporosis. Nutritional causes of elevated tHcy are suboptimal B-vitamin status. To our knowledge, this is the first nationally representative report on the relation of B vitamins and bone health from a population with folic acid fortification. OBJECTIVE: The purpose of this analysis was to examine the relation between B-vitamin status biomarkers and bone mineral density (BMD), risk of osteoporosis, and biomarkers of bone turnover. DESIGN: We examined the relation of tHcy, methylmalonic acid (MMA), and serum/red blood cell folate and total-body and lumbar spine BMD in women aged ≥50 y participating in the NHANES 1999-2004 (n = 2806), a nationally representative cross-sectional survey. These are the only years with concurrent measurement of tHcy and whole-body dual-energy X-ray absorptiometry. We also examined B-vitamin biomarkers relative to bone turnover markers, bone alkaline phosphatase, and urinary N-terminal cross-linked telopeptide of type I collagen in a 1999-2002 subset with available data (n = 1813). RESULTS: In comparison with optimal concentrations, women with elevated tHcy were older with lower serum vitamin B-12, red blood cell folate, and dietary micronutrient intakes and had significantly higher mean +/- SE markers of bone turnover (bone alkaline phosphatase: 15.8 +/- 0.59 vs. 14.0 +/- 0.25 mug/L; urinary N-terminal cross-linked telopeptide of type I collagen: 48.2 +/- 2.9 vs. 38.9 +/- 0.90 nmol bone collagen equivalents per mmol/L creatinine). Elevated MMA (OR: 1.88; 95% CI: 1.10, 3.18) and tHcy (OR: 2.17; 95% CI: 1.14, 4.15) were related to increased risk of lumbar osteoporosis. When examined as a continuous variable, tHcy was negatively associated, serum folates were positively associated, and MMA and vitamin B-12 were not significantly associated with lumbar and total-body BMD. CONCLUSION: In this nationally representative population of older US women with high exposure to B vitamins through food fortification and dietary supplements, only elevated tHcy and MMA were independently associated with risk of lumbar spine osteoporosis. |
Compelling evidence linking sugary drinks with diabetes
Gregg EW , Albright A . BMJ 2015 351 h4087 Global estimates of diabetes prevalence continue to outpace previous projections, as virtually all regions of the world continue to see a large and growing prevalence.1 Proposals by diabetes prevention experts for how to change these trends have included both structured programmes for adults at high risk for type 2 diabetes (the “high risk approach”) and environmental and food policies to help change risk factors in the whole population (the “population approach”).1 Promising programmes for those at high risk are already underway and need to be expanded,2 but complementary shifts in underlying risk factors in the broader population are also needed. The list of risk factors for type 2 diabetes is long, with dozens of demographic, behavioural, and genetic risk factors now identified.3 Unfortunately the list of simple, consensus based levers to change population risk factors and substantially influence the risk for type 2 diabetes remains short. | In a linked paper (doi:10.1136/bmj.h3576) Imamura and colleagues present a compelling case that beverages sweetened with sugar should be a major target for policies aimed at reducing the risk of diabetes.4 A systematic review of 17 prospective studies reported three findings; a higher intake of sugar sweetened beverages was associated with an increased incidence of type 2 diabetes, associations with juice consumption were weaker and less consistent, and the link between artificially sweetened beverages and diabetes incidence was largely explained by obesity, perhaps indicating that the association with risk of type 2 diabetes is due to obese people preferentially choosing artificially sweetened beverages.4 |
Using standardized interpretation of chest radiographs to identify adults with bacterial pneumonia - Guatemala, 2007-2012
Wortham JM , Gray J , Verani J , Contreras CL , Bernart C , Moscoso F , Moir JC , Reyes Marroquin EL , Castellan R , Arvelo W , Lindblade K , McCracken JP . PLoS One 2015 10 (7) e0133257 BACKGROUND: Bacterial pneumonia is a leading cause of illness and death worldwide, but quantifying its burden is difficult due to insensitive diagnostics. Although World Health Organization (WHO) protocol standardizes pediatric chest radiograph (CXR) interpretation for epidemiologic studies of bacterial pneumonia, its validity in adults is unknown. METHODS: Patients (age ≥15 years) admitted with respiratory infections to two Guatemalan hospitals between November 2007 and March 2012 had urine and nasopharyngeal/oropharyngeal (NP/OP) swabs collected; blood cultures and CXR were also performed at physician clinical discretion. 'Any bacterial infection' was defined as a positive urine pneumococcal antigen test, isolation of a bacterial pneumonia pathogen from blood culture, or detection of an atypical bacterial pathogen by polymerase chain reaction (PCR) of nasopharyngeal/oropharyngeal (NP/OP) specimens. 'Viral infection' was defined as detection of viral pathogens by PCR of NP/OP specimens. CXRs were interpreted according to the WHO protocol as having 'endpoint consolidation', 'other infiltrate', or 'normal' findings. We examined associations between bacterial and viral infections and endpoint consolidation. FINDINGS: Urine antigen and/or blood culture results were available for 721 patients with CXR interpretations; of these, 385 (53%) had endpoint consolidation and 253 (35%) had other infiltrate. Any bacterial infection was detected in 119 (17%) patients, including 106 (89%) pneumococcal infections. Any bacterial infection (Diagnostic Odds Ratio [DOR] = 2.9; 95% confidence Interval (CI): 1.3-7.9) and pneumococcal infection (DOR = 3.4; 95% CI: 1.5-10.0) were associated with 'endpoint consolidation', but not 'other infiltrate' (DOR = 1.7; 95% CI: 0.7-4.9, and 1.7; 95% CI: 0.7-4.9 respectively). Viral infection was not significantly associated with 'endpoint consolidation', 'other infiltrate,' or 'normal' findings. INTERPRETATION: 'Endpoint consolidation' was associated with 'any bacterial infection,' specifically pneumococcal infection. Therefore, endpoint consolidation may be a useful surrogate for studies measuring the impact of interventions, such as conjugate vaccines, against bacterial pneumonia. |
Within-gender changes in HIV prevalence among adults between 2005/6 and 2010/11 in Zimbabwe
Gonese E , Mapako T , Dzangare J , Rusakaniko S , Kilmarx PH , Postma MJ , Ngwende S , Mandisarisa J , Nyika P , Mvere DA , Mugurungi O , Tshimanga M , Hulst Mv . PLoS One 2015 10 (7) e0129611 INTRODUCTION: Zimbabwe has reported significant declines in HIV prevalence between 2005/06 and 2010/11 Demography and Health Surveys; a within-gender analysis to identify the magnitude and factors associated with this change, which can be masked, is critical for targeting interventions. METHODS: We analyzed change in HIV prevalence for 6,947 women and 5,848 men in the 2005/06 survey and 7,313 women and 6,250 men in 2010/11 surveys using 2005/06 as referent. The data was analyzed taking into consideration the survey design and therefore the svy, mean command in Stata was used in both linear and logistic regression. RESULTS: There were similar proportional declines in prevalence at national level for males (15% p=0.011) and females (16%,p=0.008). However, there were variations in decline by provincial setting, demographic variables of age, educational level and some sexual risk behaviours. In logistic regression analysis, statistically significant declines were observed among men in Manicaland, Mashonaland East and Harare (p<0.01) and for women in Manicaland, Mashonaland Central and Harare (p<0.01). Although not statistically significant, numerical increases were observed among men in Matebeleland North, Matebeleland South, Midlands and for both men and women in Bulawayo. Young women in the age range 15-34 experienced a decline in prevalence (p<0.01) while older men 30-44 had a statistically significant decline (p<0.01). Having a secondary and above education, regardless of employment status for both men and women recorded a significant decline. For sexual risk behaviours, currently in union for men and women and not in union for women there was a significant decline in prevalence. CONCLUSION: Zimbabwe has reported a significant decline among both men and women but there are important differentials across provinces, demographic characteristics and sexual risk behaviours that suggest that the epidemic in Zimbabwe is heterogeneous and therefore interventions must be targeted in order to achieve epidemic control. |
Neutralization of Enterovirus D68 isolated from the 2014 US outbreak by commercial intravenous immune globulin products
Zhang Y , Moore DD , Nix WA , Oberste MS , Weldon WC . J Clin Virol 2015 69 172-5 BACKGROUND: In 2014, an outbreak of Enterovirus D68 (EV-D68) was recorded as the largest in the US with cases confirmed in 49 states. Intravenous immune globulin (IVIG) has been used to treat enterovirus infections in neonates and is an accepted replacement therapy for immunodeficient patients. OBJECTIVES: This study aimed to detect the presence of neutralizing antibodies to EV-D68 viruses from the 2014 outbreak in commercially available IVIG products. STUDY DESIGN: Commercially available lots of IVIG preparations were obtained from five different manufacturers (2-10 preparations per manufacturer) and tested for neutralizing antibodies against the prototype EV-D68 virus and three EV-D68 isolates representing strains circulating during the 2014 outbreak. RESULTS: All lots of IVIG tested were positive for EV-D68 neutralizing antibodies, with high titers ranging from 9.5log2 to 17.5log2, and with comparable median titers to all four EV-D68 viruses. CONCLUSIONS AND DISCUSSION: Amino acid sequence differences in the regions of the predicted antigenic sites on the viral capsid may explain some of the differences in neutralization among the different strains. The neutralization titers suggests that the 2014 outbreak EV-D68 viruses share some antigenic sites with the prototype virus and also present some unique antigenic sites distinct from the prototype. However, the commercial IVIG lots tested all contained high levels of neutralizing antibodies against EV-D68. |
Notes from the field: atypical presentations of hand, foot, and mouth disease caused by coxsackievirus A6 - Minnesota, 2014
Buttery VW , Kenyon C , Grunewald S , Oberste MS , Nix WA . MMWR Morb Mortal Wkly Rep 2015 64 (29) 805 In June, 2014, the Minnesota Department of Health (MDH) was notified of a suspected varicella case in a child aged 2 years. The patient had a generalized rash with relative sparing of the trunk and was hospitalized overnight for treatment of dehydration. The child's mother, who was near the end of a pregnancy, also had a generalized rash, which included the perineal area. Identifying the cause of the rash was important to determine whether administration of varicella zoster immune globulin was indicated to prevent neonatal varicella. Enterovirus was detected in specimens from the woman and child by reverse transcriptase-polymerase chain reaction (RT-PCR) testing performed at MDH; partial genome sequencing by CDC showed that both patients were infected with coxsackievirus A6 (CVA6), one of the members of the genus Enterovirus that causes hand, foot, and mouth disease (HFMD). |
Outbreak of Mycoplasma pneumoniae-associated Stevens-Johnson Syndrome
Olson D , Watkins LK , Demirjian A , Lin X , Robinson CC , Pretty K , Benitez AJ , Winchell JM , Diaz MH , Miller LA , Foo TA , Mason MD , Lauper UL , Kupfer O , Kennedy J , Glode MP , Kutty PK , Dominguez SR . Pediatrics 2015 136 (2) e386-94 BACKGROUND: Stevens-Johnson syndrome (SJS) is an uncommon, sporadic disease and outbreaks are rare. In November 2013, an outbreak of SJS was identified at Children's Hospital Colorado. METHODS: Outbreak cases were children aged 5-21 with a discharge diagnosis of SJS admitted from September 1 to November 30, 2013. Medical charts were reviewed using standardized data collection forms. Respiratory specimens were tested for viruses and Mycoplasma pneumoniae (Mp) by polymerase chain reaction (PCR). We conducted a separate 4-year retrospective case-control study comparing hospitalized SJS cases with and without evidence of Mp infection. RESULTS: During the outbreak, 8 children met SJS criteria. Median age was 11.5 years (range 8-16 years); 5 (63%) were boys and 5 (63%) were Mp-PCR-positive. Of the 5 PCR-positive children, none had preceding medication exposure, and all had radiographic pneumonia. All outbreak Mp isolates were macrolide susceptible. The retrospective case-control analysis showed that Mp-associated SJS episodes (n = 17) were more likely to have pneumonia (odds ratio [OR] 10.0, confidence interval [CI] 1.3-5.1), preceding respiratory symptoms (OR 30.0, CI 1.6-72.6), an erythrocyte sedimentation rate ≥35 mg/dL (OR 22.8, CI 2.1-244.9), and ≤3 affected skin sites (OR 4.5, CI 1.2-17.4) than non-Mp-associated SJS episodes (n = 23). CONCLUSIONS: We report the largest outbreak of SJS in children, which was also predominately associated with Mp infection. Mp-associated SJS was associated with a distinct clinical presentation that included less extensive skin disease, an elevated erythrocyte sedimentation rate, and evidence of a preceding respiratory infection. |
Prevalence of cirrhosis in hepatitis C patients in the Chronic Hepatitis Cohort Study (CHeCS): a retrospective and prospective observational study
Gordon SC , Lamerato LE , Rupp LB , Holmberg SD , Moorman AC , Spradling PR , Teshale E , Xu F , Boscarino JA , Vijayadeva V , Schmidt MA , Oja-Tebbe N , Lu M . Am J Gastroenterol 2015 110 (8) 1169-77; quiz 1178 OBJECTIVES: The severity of liver disease in the hepatitis C virus (HCV)-infected population in the United States remains uncertain. We estimated the prevalence of cirrhosis in adults with chronic hepatitis C (CHC) using multiple parameters including liver biopsy, diagnosis/procedure codes, and a biomarker. METHODS: Patients enrolled in the Chronic Hepatitis Cohort Study (CHeCS) who received health services during 2006-2010 were included. Cirrhosis was identified through liver biopsy reports, diagnosis/procedure codes for cirrhosis or hepatic decompensation, and Fibrosis-4 (FIB-4) scores ≥5.88. Demographic and clinical characteristics associated with cirrhosis were identified through multivariable logistic modeling. RESULTS: Among 9,783 patients, 2,788 (28.5%) were cirrhotic by at least one method. Biopsy identified cirrhosis in only 661 (7%) patients, whereas FIB-4 scores and diagnosis/procedure codes for cirrhosis and hepatic decompensation identified cirrhosis in 2,194 (22%), 557 (6%), and 482 (5%) patients, respectively. Among 661 patients with biopsy-confirmed cirrhosis, only 356 (54%) had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for cirrhosis. Older age, male gender, Asian race, Hispanic ethnicity, genotype 3 infection, HIV coinfection, diabetes, history of antiviral therapy, and history of alcohol abuse were independently associated with higher odds of cirrhosis (all, P<0.05). Conversely, private health insurance coverage, black race, and HCV genotype 2 were associated with lower odds of cirrhosis. CONCLUSIONS: A high proportion of patients with biopsy-confirmed cirrhosis are not assigned ICD-9 codes for cirrhosis. Consequently, ICD-9 codes may not be reliable as the sole indicator of the prevalence of cirrhosis in cohort studies. Use of additional parameters suggests a fourfold higher prevalence of cirrhosis than is revealed by biopsy alone. These findings suggest that cirrhosis in CHC patients may be significantly underdocumented and underdiagnosed. |
Ebola infection control in Sierra Leonean health clinics: a large cross-agency cooperative project
Levy B , Rao CY , Miller L , Kennedy N , Adams M , Davis R , Hastings L , Kabano A , Bennett SD , Sesay M . Am J Infect Control 2015 43 (7) 752-5 The Ebola virus disease outbreak occurring in West Africa has resulted in at least 199 cases of Ebola in Sierra Leonean health care workers, many as a result of transmission occurring in health facilities. The Ministry of Health and Sanitation of Sierra Leone recognized that improvements in infection prevention and control (IPC) were necessary at all levels of health care delivery. To this end, the U.S. Centers for Disease Control and Prevention, United Nations Children's Fund, and multiple nongovernmental organizations implemented a national IPC training program in 1,200 peripheral health units (PHUs) in Sierra Leone. A tiered training of trainers program was used. Trainers conducted multiday trainings at PHUs and coordinated the delivery of personal protective equipment (gloves, gowns, masks, boots) and infection control supplies (chlorine, buckets, disposable rags, etc) to all PHU staff. Under the ongoing project, 4,264 health workers have already been trained, and 98% of PHUs have received their first shipment of supplies. |
Estimating the number of heterosexual persons in the United States to calculate national rates of HIV infection
Lansky A , Johnson C , Oraka E , Sionean C , Joyce MP , DiNenno E , Crepaz N . PLoS One 2015 10 (7) e0133543 BACKGROUND: This study estimated the proportions and numbers of heterosexuals in the United States (U.S.) to calculate rates of heterosexually acquired human immunodeficiency virus (HIV) infection. Quantifying the burden of disease can inform effective prevention planning and resource allocation. METHODS: Heterosexuals were defined as males and females who ever had sex with an opposite-sex partner and excluded those with other HIV risks: persons who ever injected drugs and males who ever had sex with another man. We conducted meta-analysis using data from 3 national probability surveys that measured lifetime (ever) sexual activity and injection drug use among persons aged 15 years and older to estimate the proportion of heterosexuals in the United States population. We then applied the proportion of heterosexual persons to census data to produce population size estimates. National HIV infection rates among heterosexuals were calculated using surveillance data (cases attributable to heterosexual contact) in the numerators and the heterosexual population size estimates in the denominators. RESULTS: Adult and adolescent heterosexuals comprised an estimated 86.7% (95% confidence interval: 84.1%-89.3%) of the U.S. population. The estimate for males was 84.1% (CI: 81.2%-86.9%) and for females was 89.4% (95% CI: 86.9%-91.8%). The HIV diagnosis rate for 2013 was 5.2 per 100,000 heterosexuals and the rate of persons living with diagnosed HIV infection in 2012 was 104 per 100,000 heterosexuals aged 13 years or older. Rates of HIV infection were >20 times as high among black heterosexuals compared to white heterosexuals, indicating considerable disparity. Rates among heterosexual men demonstrated higher disparities than overall population rates for men. CONCLUSIONS: The best available data must be used to guide decision-making for HIV prevention. HIV rates among heterosexuals in the U.S. are important additions to cost effectiveness and other data used to make critical decisions about resources for prevention of HIV infection. |
Evaluation of pharmacy-based HIV testing in a high-risk New York City community
Amesty S , Crawford ND , Nandi V , Perez-Figueroa R , Rivera A , Sutton M , Weidle PJ , Willis L , Smith DK , Hernandez C , Harripersaud K , Lewis CF . AIDS Patient Care STDS 2015 29 (8) 437-44 Blacks/Hispanics face limited access to HIV testing. We examined in-pharmacy HIV testing among customers in pharmacies participating in a nonprescription syringe program in New York City. Participants were recruited in two pharmacies to complete a survey and receive an optional HIV test. Bivariate and multivariable analyses were performed to examine associations of demographics and risk behaviors with receiving in-pharmacy HIV testing. Most participants were male (55%), black (80%), had used hard drugs (88%), and 39.5% received in-pharmacy HIV testing. Being female (AOR=2.24; 95% CI 1.24-4.05), having multiple sex partners (AOR=1.20; 95% CI 1.06-1.35), having an HIV test more than 12 months ago (AOS=4.06; CI 1.85-8.91), injecting drugs in last 3 months (AOR=2.73; 95% CI 1.31-5.69) and having continuous care (AOR=0.32; 95% CI 0.17-0.58) were associated with receiving in-pharmacy HIV test. These data provide evidence of in-pharmacy HIV testing reaching persons at risk of HIV. HIV testing in pharmacies may complement existing strategies. |
Human metapneumovirus-associated severe acute respiratory illness hospitalisation in HIV-infected and HIV-uninfected South African children and adults
Groome MJ , Moyes J , Cohen C , Walaza S , Tempia S , Pretorius M , Hellferscee O , Chhagan M , Haffejee S , Dawood H , Kahn K , Variava E , Cohen AL , Gottberg Av , Wolter N , Venter M , Madhi SA . J Clin Virol 2015 69 125-32 BACKGROUND: Data on human metapneumovirus (HMPV)-associated severe acute respiratory illness (SARI) are limited in settings with high human immunodeficiency virus (HIV) infection prevalence. OBJECTIVES: To describe clinical characteristics and seasonality (all sites), and incidence (Soweto only) of HMPV-associated SARI among children and adults. STUDY DESIGN: Active, prospective, hospital-based, sentinel surveillance for patients hospitalised with SARI was conducted at four sites in South Africa from February 2009-December 2013. Upper respiratory tract samples were tested by multiplex real-time polymerase chain reaction assays for HMPV and other respiratory viruses. Incidence of hospitalisation, stratified by age and HIV-infection status, was calculated for one hospital with population denominators. RESULTS: HMPV was identified in 4.1% of patients enrolled, including 5.6% (593/10503) in children and 1.7% in adults (≥18 years; 119/6934). The majority of adults (84.0%) had an underlying medical condition, including HIV infection in 87/110 (79.1%). HMPV detection occurred perennially with periods of increased detection, which varied from year to year. The incidence of HMPV-associated hospitalisation in Soweto was highest in infants (653.3 per 100,000 person years; 95% confidence interval (CI) 602.2-707.6). The incidence was higher in HIV-infected persons compared to HIV-uninfected persons in age-groups 5-17 years (RR 6.0; 1.1-20.4), 18-44 years (RR 67.6; 38.0-132.6) and 45-64 years (RR 5.3; 3.4-8.3), while not differing in other age-groups. CONCLUSIONS: The burden of HMPV-associated SARI hospitalisation among adults occurred predominantly in HIV-infected persons. Among children, infants were at highest risk, with similar burden of hospitalisation in HIV-infected and HIV-uninfected children. |
Impact of the Pneumococcal Conjugate Vaccine and Antibiotic Use on Nasopharyngeal Colonization by Antibiotic Nonsusceptible Streptococcus pneumoniae, Alaska, 2000-2010
Gounder PP , Brewster M , Bruce MG , Bruden DJ , Rudolph K , Hurlburt DA , Hennessy TW . Pediatr Infect Dis J 2015 34 (11) 1223-9 BACKGROUND: We describe the relative impact of the heptavalent pneumococcal conjugate vaccine (PCV7, introduced 2001) and antibiotic use on colonization by antibiotic resistant pneumococci in urban Alaskan children during 2000-2010. METHODS: We obtained nasopharyngeal swab specimens from a convenience sample of children aged <5 years at clinics annually during 2000-2004 and 2008-2010. PCV7 status and antibiotic use < 90 days before enrollment was determined by interview/medical records review. Pneumococci were characterized by serotype and susceptibility to penicillin (PCN). Isolates with full PCN resistance (PCN-R) or intermediate PCN resistance (PCN-I) were classified as PCN-NS. RESULTS: We recruited 3,496 children (median: 452/year). During 2000-2010, a range of 18-29%/year of children used PCN/amoxicillin (p-value for trend [p] = 0.09); the proportion age-appropriately vaccinated with PCV7 increased (0%-90%; p <0.01). Among pneumococcal isolates, the PCV7-serotype proportion decreased (53%-<1%; p <0.01) and non-PCV7-serotype proportion increased (43%-95%; p <0.01). PCN-R pneumococcal colonizationprevalence decreased (23%-9%, p <0.01) and PCN-I pneumococcal colonization prevalence increased (13%-24%, p <0.01); overall PCN-NS pneumococcalcolonizationprevalence was unchanged. PCN-NS among colonizing PCV7-type and non-PCV7-type pneumococci remained unchanged; a mean of 31%/year of PCV7-type and 10%/year of non-PCV7-type isolates were PCN-R, and 10%/year of PCV7 and 20%/year of non-PCV7-type isolates were PCN-I. CONCLUSIONS: Overall PCN-NS pneumococcal colonization remained unchanged during 2000-2010 because increased colonization by predominantly PCN-I non-PCV7 serotypes offset decreased colonization by predominantly PCN-R PCV7 serotypes. Proportion PCN-NS did not increase within colonizing pneumococcal serotype-groups (PCV7 versus non-PCV7) despite stable penicillin use in our population. |
Influenza sentinel surveillance among patients with influenza-like-illness and severe acute respiratory illness within the framework of the National Reference Laboratory, Niger, 2009-2013
Mainassara HB , Lagare A , Tempia S , Sidiki A , Issaka B , Abdou Sidikou B , Ouwe Missi Oukem-Boyer O . PLoS One 2015 10 (7) e0133178 BACKGROUND: Little is known about the epidemiology of influenza in Africa, including Niger. We documented the epidemiology of seasonal and pandemic influenza among outpatients with influenza-like-illness (ILI) and inpatients with severe acute respiratory illness (SARI) presenting at selected sentinel sites in Niger from April 2009 through April 2013. METHODS: Patients meeting the ILI or the SARI case definitions and presenting at the outpatient or inpatient departments of selected sentinel sites were enrolled. Epidemiological data and nasopharyngeal swabs were collected. The respiratory samples were tested by real-time reverse transcription polymerase chain reaction. RESULTS: From April 2009 to April 2013, laboratory results were obtained from 1176 ILI and 952 SARI cases, of which 146 (12%) and 54 (6%) tested positive for influenza virus, respectively. The influenza positivity rate was highest in the 5-14 year age-group (32/130; 24% among ILI patients and 6/61; 10% among SARI patients) followed by the 1-4 year age-group (69/438; 16% among ILI patients and 32/333; 9% among SARI patients). Of the 200 influenza positive cases 104 (52%) were A(H1N1)pdm09, 62 (31%) were A(H3N2) and 34 (17%) were B. Influenza viruses were detected predominantly from November to April with peak viral activity observed in February. CONCLUSIONS: The Niger sentinel surveillance system allowed to monitor the circulation of seasonal influenza as well as the introduction and spread of influenza A(H1N1)pdm09 in the country. Continuous influenza surveillance is needed to better understand the epidemiology of seasonal influenza and monitor the emergence of influenza strains with pandemic potential. |
Antituberculosis drug resistance survey in Lesotho, 2008-2009: lessons learned
Maama-Maime LB , Mareka M , Ershova JV , Tlali TE , Kao K , Phalatse M , Polansky L , Beres LK , Letsie M , Holtz TH . PLoS One 2015 10 (7) e0133808 SETTING: Drug resistance is an increasing threat to tuberculosis (TB) control worldwide. The World Health Organization advises monitoring for drug resistance, with either ongoing surveillance or periodic surveys. METHODS: The antituberculosis drug resistance survey was conducted in Lesotho in 2008-2009. Basic demographic and TB history information was collected from individuals with positive sputum smear results at 17 diagnostic facilities. Additional sputum sample was sent to the national TB reference laboratory for culture and drug susceptibility testing. RESULTS: Among 3441 eligible smear-positive persons, 1121 (32.6%) were not requested to submit sputum for culture. Among 2320 persons submitted sputum, 1164 (50.2%) were not asked for clinical information or did not have valid sputum samples for testing. In addition, 445/2320 (19.2%) were excluded from analysis because of other laboratory or data management reasons. Among 984/3441 (28.6%) persons who had data available for analysis, MDR-TB was present in 24/773 (3.1%) of new and 25/195 (12.8%) of retreatment TB cases. Logistical, operational and data management challenges affected survey results. CONCLUSION: MDR-TB is prevalent in Lesotho, but limitations reduced the reliability of our findings. Multiple lessons learned during this survey can be applied to improve the next drug resistance survey in Lesotho and other resource constrained countries may learn how to avoid these bottlenecks. |
A comparison of South African national HIV incidence estimates: a critical appraisal of different methods
Rehle T , Johnson L , Hallett T , Mahy M , Kim A , Odido H , Onoya D , Jooste S , Shisana O , Puren A , Parekh B , Stover J . PLoS One 2015 10 (7) e0133255 BACKGROUND: The interpretation of HIV prevalence trends is increasingly difficult as antiretroviral treatment programs expand. Reliable HIV incidence estimates are critical to monitoring transmission trends and guiding an effective national response to the epidemic. METHODS AND FINDINGS: We used a range of methods to estimate HIV incidence in South Africa: (i) an incidence testing algorithm applying the Limiting-Antigen Avidity Assay (LAg-Avidity EIA) in combination with antiretroviral drug and HIV viral load testing; (ii) a modelling technique based on the synthetic cohort principle; and (iii) two dynamic mathematical models, the EPP/Spectrum model package and the Thembisa model. Overall, the different incidence estimation methods were in broad agreement on HIV incidence estimates among persons aged 15-49 years in 2012. The assay-based method produced slightly higher estimates of incidence, 1.72% (95% CI 1.38 - 2.06), compared with the mathematical models, 1.47% (95% CI 1.23 - 1.72) in Thembisa and 1.52% (95% CI 1.43 - 1.62) in EPP/Spectrum, and slightly lower estimates of incidence compared to the synthetic cohort, 1.9% (95% CI 0.8 - 3.1) over the period from 2008 to 2012. Among youth aged 15-24 years, a declining trend in HIV incidence was estimated by all three mathematical estimation methods. CONCLUSIONS: The multi-method comparison showed similar levels and trends in HIV incidence and validated the estimates provided by the assay-based incidence testing algorithm. Our results confirm that South Africa is the country with the largest number of new HIV infections in the world, with about 1 000 new infections occurring each day among adults aged 15-49 years in 2012. |
Demographic and clinical characteristics of deaths associated with influenza A(H1N1) pdm09 in Central America and Dominican Republic 2009-2010
Chacon R , Mirza S , Rodriguez D , Paredes A , Guzman G , Moreno L , Then CJ , Jara J , Blanco N , Bonilla L , Clara WA , Minaya P , Palekar R , Azziz-Baumgartner E . BMC Public Health 2015 15 (1) 734 BACKGROUND: The demographic characteristics of pandemic influenza decedents among middle and low-income tropical countries are poorly understood. We explored the demographics of persons who died with influenza A (H1N1)pdm09 infection during 2009-2010, in seven countries in the American tropics. METHODS: We used hospital-based surveillance to identify laboratory-confirmed influenza deaths in Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and Dominican Republic. An influenza death was defined as a person who died within two weeks of a severe acute respiratory infection (SARI) defined as sudden onset of fever >38 degrees C, cough or sore-throat, and shortness of breath, or difficulty breathing requiring hospitalization, and who tested positive for influenza A (H1N1)pdm09 virus by real time polymerase chain reaction. We abstracted the demographic and clinical characteristics of the deceased from their medical records. RESULTS: During May 2009-June 2010, we identified 183 influenza deaths. Their median age was 32 years (IQR 18-46 years). One-hundred and one (55 %) were female of which 20 (20 %) were pregnant and 7 (7 %) were in postpartum. One-hundred and twelve decedents (61 %) had pre-existing medical conditions, (15 % had obesity, 13 % diabetes, 11 % asthma, 8 % metabolic disorders, 5 % chronic obstructive pulmonary disease, and 10 % neurological disorders). 65 % received oseltamivir but only 5 % received it within 48 h of symptoms onset. CONCLUSIONS: The pandemic killed young adults, pregnant women and those with pre-existing medical conditions. Most sought care too late to fully benefit from oseltamivir. We recommend countries review antiviral treatment policies for people at high risk of developing complications. |
Selecting quality service dogs (part 1): morphological and health considerations
Parenti L , Wilson M , Foreman AM , Wirth O , Meade BJ . APDT Chron Dog 2015 2015 71-77 Service dogs include dogs for mobility, vision, hearing, developmental disabilities, diabetic alert, seizure alert, and psychiatric support. They are trained to "provide work or perform tasks related to an individual's disability." When accompanied by a service dog, the individual with a disability is afforded some public access protections (Parenti, Foreman, Meade, and Wirth, 2013). Current demand for service dogs outweighs supply (M. Winkle, Crowe, and Hendrix, 2012), and average wait times of up to three years for a well-trained dog are not uncommon. Service dogs are generally trained for a minimum of 18 months, and training can cost anywhere from $10,000 to $20,000 (Allen and Blascovich, 1996. According to some estimates, only 50% of dogs entering training progress to the level of service dog (Batt, Batt, Baguley, and McGreevy, 2008), increasing the cost of training and limiting the number of available dogs. Hereditary diseases and behavioral problems are the most common reasons for a dog to be released from a training program (Wahl, Herbst, Tsai, and Murphy, 2008). Targeted selection and breeding of physically and behaviorally healthy dogs would allow organizations to allocate their resources more efficiently, reduce training costs, and increase the supply of service dogs to those in need. Service dog training programs nationwide can benefit from selecting and breeding dogs based on characteristics relevant to their service dog specialty. This is the first of three articles on the selection and breeding of dogs for service work. The current article addresses morphological and health considerations; the remaining articles will focus on behavior and temperament characteristics and research in the field of service dog training. |
APDT research spotlight: project Rover's survey of assistance dog providers
Baughman P , Foreman A , Parenti L , Scotti JR , Meade BJ , Wilson ME , Wirth O . APDT Chron Dog 2015 2015 25-30 With the increasing demand for assistance dogs by individuals with physical and/or psychiatric disabilities (Nondiscrimination on the Basis of disability in State and Local Government Services, 2010), rapid growth is expected in the number of provider organizations that acquire, breed, train, and place dogs with individuals with disabilities. Unfortunately, there is a lack of information about this burgeoning service industry. For example, little is known about how many providers exist, the populations served by these organizations, the breeds of dogs used, and the specific tasks the dogs are trained to perform. To address these and other questions, a web-based survey of assistance dog provider organizations was conducted. This survey is part of Project ROVER (Returning Our Veterans to employment and Reintegration) which is a research collaboration between the National Institute for Occupational Safety and Health (NIOSH) and West Virginia University (WVU). The focus of Project ROVER is on the role that pets and assistance dogs may play in helping U.S. veterans reintegrate into civilian life and return to work. One objective is to obtain more information about how service dogs are aiding this process for veterans with disabilities. Psychiatric service dogs are of particular interest because veterans with post-traumatic stress disorder (PTSD) have lower rates of employment (Chan, Cheadle, Reiber, Untzer and Chaney, 2009) and service dogs for psychiatric disabilities are increasing in number (Smith, Esnayre and Love, 2003). A preliminary review of the professional literature and other media reports on assistance dog organizations revealed an absence of information on organizational characteristics, the services offered, the populations served, the types and breeds of dogs used, and the supply of trained dogs. This information is lacking not only for organizations serving veterans, but also for organizations serving other populations. Therefore this survey targeted all types of assistance dog organizations, regardless of the populations served. |
Live animal markets in Minnesota: a potential source for emergence of novel influenza A viruses and interspecies transmission.
Choi MJ , Torremorell M , Bender JB , Smith K , Boxrud D , Ertl JR , Yang M , Suwannakarn K , Her D , Nguyen J , Uyeki TM , Levine M , Lindstrom S , Katz JM , Jhung M , Vetter S , Wong KK , Sreevatsan S , Lynfield R . Clin Infect Dis 2015 61 (9) 1355-62 BACKGROUND: Live animal markets have been implicated in transmission of influenza A viruses (IAVs) from animals to people. We sought to characterize IAVs at two live animal markets in Minnesota to assess potential routes of occupational exposure and risk for interspecies transmission. METHODS: We implemented surveillance for IAVs among employees, swine, and environment (air and surfaces) during a 12-week period (October 2012-January 2013) at two markets epidemiologically associated with persons with swine-origin IAV (variant) infections. Real-time reverse transcription polymerase chain reaction (rRT-PCR), viral culture, and whole genome sequencing were performed on respiratory and environmental specimens, and serology on sera from employees at beginning and end of surveillance. RESULTS: Nasal swabs from 11 (65%) of 17 employees tested positive for IAVs by rRT-PCR; seven employees tested positive on multiple occasions and one employee reported influenza-like illness. Eleven (73%) of 15 employees had baseline hemagglutination-inhibition antibody titers ≥40 to swine-origin IAVs, but only one demonstrated a 4-fold titer increase to both swine-origin, and pandemic A/Mexico/4108/2009 IAVs. IAVs were isolated from swine (72/84), air (30/45) and pen railings (5/21). Whole genome sequencing of 122 IAVs isolated from swine and environmental specimens revealed multiple strains and subtype codetections. Multiple gene segment exchanges among and within subtypes were observed, resulting in new genetic constellations and reassortant viruses. Genetic sequence similarities of 99%-100% among IAVs of one market customer and swine indicated interspecies transmission. CONCLUSIONS: At markets where swine and persons are in close contact, swine-origin IAVs are prevalent and potentially provide conditions for novel IAV emergence. |
The Chagas disease domestic transmission cycle in Guatemala: parasite-vector switches and lack of mitochondrial co-diversification between Triatoma dimidiata and Trypanosoma cruzi subpopulations suggest non-vectorial parasite dispersal across the Motagua valley.
Pennington PM , Messenger LA , Reina J , Juarez JG , Lawrence GG , Dotson EM , Llewellyn MS , Cordon-Rosales C . Acta Trop 2015 151 80-7 Parasites transmitted by insects must adapt to their vectors and reservoirs. Chagas disease, an American zoonosis caused by Trypanosoma cruzi, is transmitted by several species of triatomines. In Central America, Triatoma dimidiata is a widely dispersed vector found in sylvatic and domestic habitats, with distinct populations across the endemic region of Guatemala. Our aim was to test the strength of association between vector and parasite genetic divergence in domestic environments. Microsatellite (MS) loci were used to characterize parasites isolated from T. dimidiata (n=112) collected in domestic environments. Moderate genetic differentiation was observed between parasites north and south of the Motagua Valley, an ancient biogeographic barrier (FST 0.138, p=0.009). Slightly reduced genotypic diversity and increased heterozygosity in the north (Allelic richness (Ar)=1.00-6.05, FIS -0.03) compared to the south (Ar=1.47-6.30, FIS 0.022) suggest either a selective or demographic process during parasite dispersal. Based on parasite genotypes and geographic distribution, 15 vector specimens and their parasite isolates were selected for mitochondrial co-diversification analysis. Genetic variability and phylogenetic congruence were determined with mitochondrial DNA sequences (10 parasite maxicircle gene fragments and triatomine ND4+CYT b). A Mantel test as well as phylogenetic, network and principal coordinates analyses supported at least three T. dimidiata haplogroups separated by geographic distance across the Motagua Valley. Maxicircle sequences showed low T. cruzi genetic variability (pi nucleotide diversity 0.00098) with no evidence of co-diversification with the vector, having multiple host switches across the valley. Sylvatic Didelphis marsupialis captured across the Motagua Valley were found to be infected with T. cruzi strains sharing MS genotypes with parasites isolated from domiciliated triatomines. The current parasite distribution in domestic environments can be explained by multiple parasite-host switches between vector populations and selection or bottleneck processes across the Motagua Valley, with a possible role for didelphids in domestic transmission. |
Genotype-specific variation in West Nile virus dispersal in California.
Duggal NK , Reisen WK , Fang Y , Newman RM , Yang X , Ebel GD , Brault AC . Virology 2015 485 79-85 West Nile virus (WNV) is an arbovirus that was first reported in North America in New York in 1999 and, by 2003, had spread more than 4000km to California. However, variation in viral genetics associated with spread is not well understood. Herein, we report sequences for more than 100 WNV isolates made from mosquito pools that were collected from 2003 to 2011 as part of routine surveillance by the California Mosquito-borne Virus Surveillance System. We performed phylogeographic analyses and demonstrated that 5 independent introductions of WNV (1 WN02 genotype strain and 4 SW03 genotype strains) occurred in California. The SW03 genotype of WNV was constrained to the southwestern U.S. and had a more rapid rate of spread. In addition, geographic constraint of WNV strains within a single region for up to 6 years suggest viral maintenance has been driven by resident, rather than migratory, birds and overwintering in mosquitoes. |
Modeling the present and future geographic distribution of the Lone Star Tick, Amblyomma americanum (Ixodida: Ixodidae), in the continental United States
Springer YP , Jarnevich CS , Barnett DT , Monaghan AJ , Eisen RJ . Am J Trop Med Hyg 2015 93 (4) 875-90 The Lone star tick (Amblyomma americanum L.) is the primary vector for pathogens of significant public health importance in North America, yet relatively little is known about its current and potential future distribution. Building on a published summary of tick collection records, we used an ensemble modeling approach to predict the present-day and future distribution of climatically suitable habitat for establishment of the Lone star tick within the continental United States. Of the nine climatic predictor variables included in our five present-day models, average vapor pressure in July was by far the most important determinant of suitable habitat. The present-day ensemble model predicted an essentially contiguous distribution of suitable habitat extending to the Atlantic coast east of the 100th western meridian and south of the 40th northern parallel, but excluding a high elevation region associated with the Appalachian Mountains. Future ensemble predictions for 2061-2080 forecasted a stable western range limit, northward expansion of suitable habitat into the Upper Midwest and western Pennsylvania, and range contraction along portions of the Gulf coast and the lower Mississippi river valley. These findings are informative for raising awareness of A. americanum-transmitted pathogens in areas where the Lone Star tick has recently or may become established. |
Heat stress illness emergency department visits in National Environmental Public Health Tracking states, 2005-2010
Fechter-Leggett ED , Vaidyanathan A , Choudhary E . J Community Health 2015 41 (1) 57-69 Variability of heat stress illness (HSI) by urbanicity and climate region has rarely been considered in previous HSI studies. We investigated temporal and geographic trends in HSI emergency department (ED) visits in CDC Environmental Public Health Tracking Network (Tracking) states for 2005-2010. We obtained county-level HSI ED visit data for 14 Tracking states. We used the National Center for Health Statistics Urban-Rural Classification Scheme to categorize counties by urbanicity as (1) large central metropolitan (LCM), (2) large fringe metropolitan, (3) small-medium metropolitan, or (4) nonmetropolitan (NM). We also assigned counties to one of six US climate regions. Negative binomial regression was used to examine trends in HSI ED visits over time across all counties and by urbanicity for each climate region, adjusting for pertinent variables. During 2005-2010, there were 98,462 HSI ED visits in the 14 states. ED visits for HSI decreased 3.0 % (p < 0.01) per year. Age-adjusted incidence rates of HSI ED visits increased from most urban to most rural. Overall, ED visits were significantly higher for NM areas (IRR = 1.41, p < 0.01) than for LCM areas. The same pattern was observed in all six climate regions; compared with LCM, NM areas had from 14 to 90 % more ED visits for HSI. These findings of significantly increased HSI ED visit rates in more rural settings suggest a need to consider HSI ED visit variability by county urbanicity and climate region when designing and implementing local HSI preventive measures and interventions. |
Autism spectrum disorder prevalence and proximity to industrial facilities releasing arsenic, lead or mercury
Dickerson AS , Rahbar MH , Han I , Bakian AV , Bilder DA , Harrington RA , Pettygrove S , Durkin M , Kirby RS , Wingate MS , Tian LH , Zahorodny WM , Pearson DA , Moye LA 3rd , Baio J . Sci Total Environ 2015 536 245-251 Prenatal and perinatal exposures to air pollutants have been shown to adversely affect birth outcomes in offspring and may contribute to prevalence of autism spectrum disorder (ASD). For this ecologic study, we evaluated the association between ASD prevalence, at the census tract level, and proximity of tract centroids to the closest industrial facilities releasing arsenic, lead or mercury during the 1990s. We used 2000 to 2008 surveillance data from five sites of the Autism and Developmental Disabilities Monitoring (ADDM) network and 2000 census data to estimate prevalence. Multi-level negative binomial regression models were used to test associations between ASD prevalence and proximity to industrial facilities in existence from 1991 to 1999 according to the US Environmental Protection Agency Toxics Release Inventory (USEPA-TRI). Data for 2489 census tracts showed that after adjustment for demographic and socio-economic area-based characteristics, ASD prevalence was higher in census tracts located in the closest 10th percentile compared of distance to those in the furthest 50th percentile (adjusted RR=1.27, 95% CI: (1.00, 1.61), P=0.049). The findings observed in this study are suggestive of the association between urban residential proximity to industrial facilities emitting air pollutants and higher ASD prevalence. |
Characterization of air manganese exposure estimates for residents in two Ohio towns
Colledge MA , Julian JR , Gocheva VV , Beseler CL , Roels HA , Lobdell DT , Bowler RM . J Air Waste Manag Assoc 2015 65 (8) 948-57 This study was conducted to derive receptor-specific outdoor exposure concentrations of total suspended particulate (TSP) and respirable (dae ≤ 10 microm) air manganese (air-Mn) for East Liverpool and Marietta (Ohio) in the absence of facility emissions data, but where long-term air measurements were available. Our "site-surface area emissions method" used U.S. Environmental Protection Agency's (EPA) AERMOD (AMS/EPA Regulatory Model) dispersion model and air measurement data to estimate concentrations for residential receptor sites in the two communities. Modeled concentrations were used to create ratios between receptor points and calibrated using measured data from local air monitoring stations. Estimated outdoor air-Mn concentrations were derived for individual study subjects in both towns. The mean estimated long-term air-Mn exposure levels for total suspended particulate were 0.35 mug/m(3) (geometric mean [GM]) and 0.88 mug/m(3) (arithmetic mean [AM]) in East Liverpool (range: 0.014-6.32 mug/m(3)) and 0.17 mug/m(3) (GM) and 0.21 mug/m(3) (AM) in Marietta (range: 0.03-1.61 mug/m(3)). Modeled results compared well with averaged ambient air measurements from local air monitoring stations. Exposure to respirable Mn particulate matter (PM10; PM <10 mum) was higher in Marietta residents. IMPLICATIONS: Few available studies evaluate long-term health outcomes from inhalational manganese (Mn) exposure in residential populations, due in part to challenges in measuring individual exposures. Local long-term air measurements provide the means to calibrate models used in estimating long-term exposures. Furthermore, this combination of modeling and ambient air sampling can be used to derive receptor-specific exposure estimates even in the absence of source emissions data for use in human health outcome studies. |
Notes from the field: large outbreak of botulism associated with a church potluck meal - Ohio, 2015
McCarty CL , Angelo K , Beer KD , Cibulskas-White K , Quinn K , Fijter S , Bokanyi R , Germain ES , Baransi K , Barlow K , Shafer G , Hanna L , Spindler K , Walz E , DiOrio M , Jackson BR , Luquez C , Mahon BE , Basler C , Curran K , Matanock A , Walsh K , Slifka KJ , Rao AK . MMWR Morb Mortal Wkly Rep 2015 64 (29) 802-803 On April 21, 2015, the Fairfield Medical Center (FMC) and Fairfield Department of Health contacted the Ohio Department of Health (ODH) about a patient suspected of having botulism in Fairfield County, Ohio. Botulism is a severe, potentially fatal neuroparalytic illness.* A single case is a public health emergency, because it can signal an outbreak. Within 2 hours of health department notification, four more patients with similar clinical features arrived at FMC's emergency department. Later that afternoon, one patient died of respiratory failure shortly after arriving at the emergency department. All affected persons had eaten at the same widely attended church potluck meal on April 19. CDC's Strategic National Stockpile sent 50 doses of botulinum antitoxin to Ohio. FMC, the Fairfield Department of Health, ODH, and CDC rapidly responded to confirm the diagnosis, identify and treat additional patients, and determine the source. |
Genomic characterization of a persistent rubella virus from a case of Fuch' uveitis syndrome in a 73 year old man.
Abernathy E , Peairs RR , Chen MH , Icenogle J , Namdari H . J Clin Virol 2015 69 104-9 BACKGROUND: Many cases of Fuchs' uveitis have been associated with persistent rubella virus infection. A 73-year-old male patient with typical Fuchs' Uveitis Syndrome (FUS) first experienced heterochromia of the left eye at the age fourteen, when rubella was endemic in the US. OBJECTIVES: The purposes of this report are to describe the patient's FUS clinical presentations and to characterize the virus detected in the vitreous fluid. STUDY DESIGN: The patient underwent a therapeutic pars plana vitrectomy in May 2013. A real-time RT-PCR assay for rubella virus was performed on the vitreous fluid by Focus Diagnostics. Additional real-time RT-PCR assays for rubella virus detection and RT-PCR assays for generation of templates for sequencing were performed at the Centers for Disease Control and Prevention (CDC). RESULTS: The results from Focus Diagnostics were positive for rubella virus RNA. Real-time RT-PCR assays at CDC were also positive for rubella virus. A rubella virus sequence of 739 nucleotides was determined and phylogenetic analysis showed that the virus was the sole member of a new phylogenetic group when compared to reference virus sequences. CONCLUSIONS: While FUS remains a clinical diagnosis, findings in this case support the association between rubella virus and the disease. Phylogenetic analysis provided evidence that this rubella virus was likely a previously undetected genotype which is no longer circulating. Since the patient had rubella prior to 1955, this sequence is from the earliest rubella virus yet characterized. |
Health care-associated infections studies project case #1: A 2015 American Journal of Infection Control and National Healthcare Safety Network data quality collaboration
Gross C , Allen-Bridson K , Anttila A , Brooks JE , Hebden JN , Leaptrot D , Morabit S , Wright MO . Am J Infect Control 2015 43 (9) 987-8 This is the first case study published in a series in the American Journal of Infection Control since the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) surveillance definition update of 2015. These cases reflect some of the complex patient scenarios infection control professionals (ICPs) have encountered in their daily surveillance of health care-associated infections (HAI) using NHSN definitions. |
Health care-associated infections studies project case #2: a 2015 American Journal of Infection Control and National Healthcare Safety Network data quality collaboration
Allen-Bridson K , Anttila A , Brooks JE , Gross C , Hebden JN , Leaptrot D , Morabit S , Wright MO . Am J Infect Control 2015 43 (10) 1099-101 This is the second case study published in a series in the American Journal of Infection Control since the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) surveillance definition update of 2015. These cases reflect some of the complex patient scenarios infection control professionals (ICPs) have encountered in their daily surveillance of health care-associated infections (HAIs) using NHSN definitions |
Safety monitoring in the Vaccine Adverse Event Reporting System (VAERS)
Shimabukuro TT , Nguyen M , Martin D , DeStefano F . Vaccine 2015 33 (36) 4398-405 The Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) conduct post-licensure vaccine safety monitoring using the Vaccine Adverse Event Reporting System (VAERS), a spontaneous (or passive) reporting system. This means that after a vaccine is approved, CDC and FDA continue to monitor safety while it is distributed in the marketplace for use by collecting and analyzing spontaneous reports of adverse events that occur in persons following vaccination. Various methods and statistical techniques are used to analyze VAERS data, which CDC and FDA use to guide further safety evaluations and inform decisions around vaccine recommendations and regulatory action. VAERS data must be interpreted with caution due to the inherent limitations of passive surveillance. VAERS is primarily a safety signal detection and hypothesis generating system. Generally, VAERS data cannot be used to determine if a vaccine caused an adverse event. VAERS data interpreted alone or out of context can lead to erroneous conclusions about cause and effect as well as the risk of adverse events occurring following vaccination. CDC makes VAERS data available to the public and readily accessible online. We describe fundamental vaccine safety concepts, provide an overview of VAERS for healthcare professionals who provide vaccinations and might want to report or better understand a vaccine adverse event, and explain how CDC and FDA analyze VAERS data. We also describe strengths and limitations, and address common misconceptions about VAERS. Information in this review will be helpful for healthcare professionals counseling patients, parents, and others on vaccine safety and benefit-risk balance of vaccination. |
Temporal trends and clonal diversity of penicillin non-susceptible pneumococci from meningitis cases from 1996 to 2012, in Salvador, Brazil
Dos Santos MS , Azevedo J , Menezes AP , Cordeiro SM , Escobar EC , Lima JB , Campos LC , Carvalho MDGS , Reis MG , Ko AI , Reis JN . BMC Infect Dis 2015 15 302 BACKGROUND: Hospital-based surveillance for pneumococcal meningitis has been conducted since January 1996 in the city of Salvador, Brazil. The purpose of this study was to describe the temporal evolution of Penicillin Non-Susceptible Streptococcus pneumoniae (PNSSP) in regards to serotype distributions and clonal diversity recovered from meningitis cases over 17 years. METHODS: Broth microdilution was used to identify pneumococcal isolates that were PNSSP (Minimum Inhibitory Concentration > 0.12 mug/ml). The annual incidence rate of meningitis cases was calculated. Serotyping was defined using multiplex polymerase chain reaction assays and quellung reaction. Genetic diversity of PNSSP isolates was assessed using both pulsed-field gel electrophoresis (PFGE) and Multilocus Sequence Typing (MLST) analyses. RESULTS: A total of 854 cerebrospinal fluid (CSF) culture pneumococcal isolates were tested by broth microdilution method and serotyped. A total of 173 (20.3 %) were penicillin non-susceptible (PNSSP) (Minimum Inhibitory concentration ≥ 0.12 mug/ml). The annual incidence of meningitis cases declined from 1.65/100,000 population (1996) to 0.2/100,000 population in 2012 and the rate due to PNSSP declined 82 % over the 17-years of surveillance. PNSSP isolates were restricted to 13 serotypes, being the most common ones serotypes14 (45.1 %; 78/173), 23 F (19.1 %; 33/173), 6B (14.4 %; 25/173), 19 F (9.2 %; 16/173) and 19A (5.2 %; 9/173). Among the PNSSP isolates, 94 % had serotypes represented in the 10-valent conjugate vaccine (PCV10). The predominant serotype 14 clonal groups were identified as PFGE group A/multilocus sequence type 66 (ST66) [35.3 % (61/173)] and PFGE group GK/ST156 [4.6 % (8/173)], the latter one associated with high level resistance to penicillin and ceftriaxone. CONCLUSIONS: Our results show sustained reductions in pneumococcal meningitis cases in the Metropolitan region of Salvador from 1996 to 2012. This might reflect a beneficial impact of conjugate vaccines. Continued surveillance and further studies need to be conducted to better understanding on PCV10 vaccine impact. |
Vaccine safety resources for nurses
Miller ER , Shimabukuro TT , Hibbs BF , Moro PL , Broder KR , Vellozzi C . Am J Nurs 2015 115 (8) 55-8 Nurses are on the front lines of health care delivery, and many of them routinely administer immunizations. The authors describe the Centers for Disease Control and Prevention's (CDC) vaccine safety monitoring systems, explaining how nurses can access inquiry channels and other immunization information resources. Examples of recent vaccine safety inquiries are also provided. |
National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 Years - United States, 2014
Reagan-Steiner S , Yankey D , Jeyarajah J , Elam-Evans LD , Singleton JA , Curtis CR , MacNeil J , Markowitz LE , Stokley S . MMWR Morb Mortal Wkly Rep 2015 64 (29) 784-792 Routine immunization is recommended for adolescents aged 11-12 years by the Advisory Committee on Immunization Practices (ACIP) for protection against diseases including pertussis, meningococcal disease, and human papillomavirus (HPV)-associated cancers. To assess vaccination coverage among adolescents, CDC analyzed data collected regarding 20,827 adolescents through the 2014 National Immunization Survey-Teen (NIS-Teen). From 2013 to 2014, coverage among adolescents aged 13-17 years increased for all routinely recommended vaccines: from 84.7% to 87.6% for ≥1 tetanus-diphtheria-acellular pertussis (Tdap) vaccine dose, from 76.6% to 79.3% for ≥1 meningococcal conjugate (MenACWY) vaccine dose, from 56.7% to 60.0% and from 33.6% to 41.7% for ≥1 HPV vaccine dose among females and males, respectively.dagger Coverage differed by state and local area. Despite overall progress in vaccination coverage among adolescents, HPV vaccination coverage continues to lag behind Tdap and MenACWY coverage at state and national levels. Seven public health jurisdictions achieved significant increases in ≥1- or ≥3-dose HPV vaccination coverage among females in 2014, demonstrating that substantial improvement in HPV vaccination coverage is feasible. |
Progress toward norovirus vaccines: considerations for further development and implementation in potential target populations
Aliabadi N , Lopman BA , Parashar UD , Hall AJ . Expert Rev Vaccines 2015 14 (9) 1-13 Human norovirus infection causes significant medical and financial costs in the USA and abroad. Some populations, including young children, the elderly, and the immunocompromised, are at heightened risk of infection with this virus and subsequent complications, while others, such as healthcare workers and food handlers are at increased risk of transmitting it, and some are at risk of both. Human noroviruses are heterogeneous with new strains emerging periodically. In addition to viral diversity, incompletely understood characteristics, such as virus-host cell binding and duration of immunity after infection add to the challenges of creating a norovirus vaccine. Although much progress has been made in recent years, many questions remain to be answered. In this review, we discuss the important areas and relevant literature in considering human norovirus vaccine development and potential targets for implementation. |
Decline in pneumococcal nasopharyngeal carriage of vaccine serotypes after the introduction of the 13-valent pneumococcal conjugate vaccine in children in Atlanta, Georgia
Desai AP , Sharma D , Crispell EK , Baughman W , Thomas S , Tunali A , Sherwood L , Zmitrovich A , Jerris R , Satola S , Beall B , Moore MR , Jain S , Farley MM . Pediatr Infect Dis J 2015 34 (11) 1168-74 BACKGROUND: Streptococcus pneumoniae (SP) serotype distribution among nasopharyngeal (NP) carriage isolates changed significantly after the introduction of the seven-valent pneumococcal conjugate vaccine (PCV7). We evaluated the impact on NP carriage and invasive disease of SP after the introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in March 2010. METHODS: NP swabs were collected from children 6-59 months of age in an emergency department from July 2010-June 2013. After broth enrichment, samples were cultured for SP and isolates were serotyped. Clinical and immunization records were reviewed. Findings during six sequential 6-month study periods were compared. Surveillance isolates of invasive disease isolates were reviewed. RESULTS: A total of 2,048 children were enrolled and 656 (32%) were SP carriers. Mean age of carriers was 27 months, 54% were males. Carriage was higher among daycare attendees (p<0.01) and children with respiratory tract illnesses (p<0.5) and otitis media (p<0.01). Commonly carried serotypes included 35B (15.2%), 15B/C (14.2%), 19A (9.6%), 11A (8%), 23B (5.6%), 6C (5.3%), 21 (5%), and 15A (5%); 13.9% were PCV13 serotypes. The proportion of children with SP carriage remained stable but the serotype distribution changed over the study period. Among carriers, PCV13 serotypes declined from 29% (36/124) to 3% (3/99) (p<0.0001), predominantly due to decline of serotype 19A from 25.8% (32/124) to 3% (3/99) (p<0.0001); non-PCV13 serotypes (excluding 6C) increased from 68.4% (78/114) to 97% (95/98) (p<0.0001); serotype 35B significantly increased from 8.9% (11/124) to 25.3% (25/99) (p<0.05). Nonsusceptibility to ceftriaxone declined from 22.6% (28/124) to 0% (0/99) (p<0.0001), with a similar decline in penicillin nonsusceptibility. CONCLUSIONS: Introduction of PCV13 for universal infant use was associated with significant reductions in nasopharyngeal carriage of PCV13 serotypes and resistant strains. Carriage of non-PCV13 serotypes increased modestly, particularly serotype 35B. Further investigation is warranted to determine whether non-vaccine pneumococcal serotypes carried in the nasopharynx are associated with significant replacement disease. |
Demographic characteristics of members of the Vaccine Safety Datalink (VSD): a comparison with the United States population
Sukumaran L , McCarthy NL , Li R , Weintraub E , Jacobsen SJ , Hambidge SJ , Jackson LA , Naleway AL , Chan B , Tao B , Gee J . Vaccine 2015 33 (36) 4446-50 BACKGROUND: The Vaccine Safety Datalink (VSD) is a collaboration between CDC and nine integrated health care systems that serve as a cornerstone of US post-licensure vaccine safety monitoring. Given concerns that potential differences between the insured VSD population and the US population could limit the generalizability of VSD study findings, we performed a comparison of the demographic characteristics between the two populations. METHODS: We collected data from medical records and administrative files at VSD sites in 2010 to compare sex, age, race, ethnicity, income, and educational attainment to the 2010 US census population. We also compared data on the 2012 VSD Medicaid population to 2012 US Medicaid data. RESULTS: The VSD population included over eight million individuals in 2010, which represented 2.6% of the total US population. All major demographic groups were represented in the VSD. We found no major differences in comparing sex, race, ethnicity, and educational attainment between the VSD and the US population. Middle income populations were comparable between the VSD and the US. While the percentage of lower income populations was less in the VSD compared to the US, the VSD had over two million individuals in this group. Additionally, there were over 600,000 Medicaid members in the VSD in 2012, which represented 1.1% of the US Medicaid population. CONCLUSIONS: We found that the VSD population is representative of the general US population on several key demographic and socioeconomic variables. Despite a few specific groups being underrepresented in the VSD compared to the US, the absolute number of VSD members is large enough to ensure significant representation of these groups in vaccine safety studies that use VSD data. |
RIG-I mediates an antiviral response to Crimean-Congo hemorrhagic fever virus.
Spengler JR , Patel JR , Chakrabarti AK , Zivcec M , Garcia-Sastre A , Spiropoulou CF , Bergeron E . J Virol 2015 89 (20) 10219-29 In the cytoplasm, the retinoic acid-inducible gene I (RIG-I) senses the RNA genomes of several RNA viruses. RIG-I binds to viral RNA, eliciting an antiviral response via the cellular adaptor MAVS. Crimean-Congo hemorrhagic fever virus (CCHFV), a negative sense RNA virus with a 5' -monophosphorylated genome, is a highly pathogenic zoonotic agent with significant public health and clinical implications. We found that, during CCHFV infection, RIG-I mediated a type-I interferon (IFN) response via MAVS. Interfering with RIG-I signaling reduced IFN production and IFN-stimulated gene expression, and increased viral replication. Immunostimulatory RNA was isolated from CCHFV-infected cells and from virion preparations, and RIG-I co-immunoprecipitation of infected cell lysates isolated immunostimulatory CCHFV RNA. This report serves as the first description of a pattern recognition receptor for CCHFV and highlights a critical signaling pathway in the antiviral response to CCHFV. IMPORTANCE: Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne virus with significant public health and clinical impact. In order for cells to respond to virus infection, they must recognize the virus as foreign and initiate antiviral signaling. To date, the receptors involved in recognition of CCHFV are not known. Herein we investigate and identify retinoic acid-inducible gene I (RIG-I) as a receptor involved in initiating an antiviral response to CCHFV. This receptor was initially not expected to play a role in CCHFV recognition because of characteristics of the viral genome. These findings are important in understanding the antiviral response to CCHFV and support continued investigation into the spectrum of potential viruses recognized by RIG-I. |
Application of bioinformatics in probe design enables detection of enteroviruses on different taxonomic levels by advanced in situ hybridization technology.
Laiho JE , Oikarinen S , Oikarinen M , Larsson PG , Stone VM , Hober D , Oberste S , Flodstrom-Tullberg M , Isola J , Hyoty H . J Clin Virol 2015 69 165-71 BACKGROUND: Enteroviral infections are common, affecting humans across all age groups. RT-PCR is widely used to detect these viruses in clinical samples. However, there is a need for sensitive and specific in situ detection methods for formalin-fixed tissues, allowing for the anatomical localization of the virus and identification of its serotype. OBJECTIVES: The aim was to design novel enterovirus probes, assess the impact of probe design for the detection and optimize the new single molecule in situ hybridization technology for the detection of enteroviruses in formalin-fixed paraffin-embedded samples. STUDY DESIGN: Four enterovirus RNA-targeted oligonucleotide RNA probes - two probes for wide range enterovirus detection and two for serotype-targeted detection of Coxsackievirus B1 (CVB1) - were designed and validated for the commercially available QuantiGene ViewRNA in situ hybridization method. The probe specificities were tested using a panel of cell lines infected with different enterovirus serotypes and CVB infected mouse pancreata. RESULTS: The two widely reactive probe sets recognized 19 and 20 of the 20 enterovirus serotypes tested, as well as 27 and 31 of the 31 CVB1 strains tested. The two CVB1 specific probe sets detected 30 and 14 of the 31 CVB1 strains, with only minor cross-reactivity to other serotypes. Similar results were observed in stained tissues from CVB -infected mice. CONCLUSIONS: These novel in-house designed probe sets enable the detection of enteroviruses from formalin-fixed tissue samples. Optimization of probe sequences makes it possible to tailor the assay for the detection of enteroviruses on the serotype or species level. |
Multiplexed one-step RT-PCR VP7 and VP4 genotyping assays for rotaviruses using updated primers.
Esona MD , Gautam R , Tam KI , Williams A , Mijatovic-Rustempasic S , Bowen MD . J Virol Methods 2015 223 96-104 The current two-step VP7 and VP4 genotyping RT-PCR assays for rotaviruses have been linked consistently to genotyping failure in an estimated 30% of RVA positive samples worldwide. We have developed a VP7 and VP4 multiplexed one-step genotyping assays using updated primers generated from contemporary VP7 and VP4 sequences. To determine assay specificity and sensitivity, 17 reference virus strains, 6 non-target gastroenteritis viruses and 725 clinical samples carrying the most common VP7 (G1, G2, G3, G4, G9, and G12) and VP4 (P[4], P[6], P[8], P[9] and P[10]) genotypes were tested in this study. All reference RVA strain targets yielded amplicons of the expected sizes and non-target genotypes and gastroenteritis viruses were not detected by either assay. Out of the 725 clinical samples tested, the VP7 and VP4 assays were able to assigned specific genotypes to 711 (98.1%) and 714 (98.5%), respectively. The remaining unassigned samples were re-tested for RVA antigen using EIA and qRT-PCR assays and all were found to be negative. The overall specificity, sensitivity and limit of detection of the VP7 assay were in the ranges of 99.0-100%, 94.0-100% and 8.6x101 - 8.6x102 copies of RNA/reaction, respectively. For the VP4 assay, the overall specificity, sensitivity and limit of detection assay were in the ranges of 100%, 94.0-100% and ≤ 1 - 8.6x102 copies of RNA/reaction, respectively. Here we report two highly robust, accurate, efficient, affordable and documentable gel-based genotyping systems which are capable of genotyping 97.8% of the six common VP7 and 98.3% of the five common VP4 genotypes of RVA strains which are responsible for approximately 88.2% of all RVA infections worldwide. |
Recombinant H7 hemagglutinin forms subviral particles that protect mice and ferrets from challenge with H7N9 influenza virus
Pushko P , Pujanauski LM , Sun X , Pearce M , Hidajat R , Kort T , Schwartzman LM , Tretyakova I , Chunqing L , Taubenberger JK , Tumpey TM . Vaccine 2015 33 (38) 4975-82 A novel avian-origin influenza A H7N9 virus emerged in China in 2013 and continues to cause sporadic human infections with mortality rates approaching 35%. Currently there are no approved human vaccines for H7N9 virus. Recombinant approaches including hemagglutinin (HA) and virus-like particles (VLPs) have resulted in experimental vaccines with advantageous safety and manufacturing characteristics. While high immunogenicity of VLP vaccines has been attributed to the native conformation of HA arranged in the regular repeated patterns within virus-like structures, there is limited data regarding molecular organization of HA within recombinant HA vaccine preparations. In this study, the full-length recombinant H7 protein (rH7) of A/Anhui/1/2013 (H7N9) virus was expressed in Sf9 cells. We showed that purified full-length rH7 retained functional ability to agglutinate red blood cells and formed oligomeric pleomorphic subviral particles (SVPs) of approximately 20nm in diameter composed of approximately 10 HA0 molecules. No significant quantities of free monomeric HA0 were observed in rH7 preparation by size exclusion chromatography. Immunogenicity and protective efficacy of rH7 SVPs was confirmed in the mouse and ferret challenge models suggesting that SVPs can be used for vaccination against H7N9 virus. |
Theoretical foundation, methods, and criteria for calibrating human vibration models using frequency response functions
Dong RG , Welcome DE , McDowell TW , Wu JZ . J Sound Vib 2015 356 195-216 While simulations of the measured biodynamic responses of the whole human body or body segments to vibration are conventionally interpreted as summaries of biodynamic measurements, and the resulting models are considered quantitative, this study looked at these simulations from a different angle: model calibration. The specific aims of this study are to review and clarify the theoretical basis for model calibration, to help formulate the criteria for calibration validation, and to help appropriately select and apply calibration methods. In addition to established vibration theory, a novel theorem of mechanical vibration is also used to enhance the understanding of the mathematical and physical principles of the calibration. Based on this enhanced understanding, a set of criteria was proposed and used to systematically examine the calibration methods. Besides theoretical analyses, a numerical testing method is also used in the examination. This study identified the basic requirements for each calibration method to obtain a unique calibration solution. This study also confirmed that the solution becomes more robust if more than sufficient calibration references are provided. Practically, however, as more references are used, more inconsistencies can arise among the measured data for representing the biodynamic properties. To help account for the relative reliabilities of the references, a baseline weighting scheme is proposed. The analyses suggest that the best choice of calibration method depends on the modeling purpose, the model structure, and the availability and reliability of representative reference data. |
A meta-analysis of the performance of the Pima(TM) CD4 for point of care testing
Scott LE , Campbell J , Westerman L , Kestens L , Vojnov L , Kohastsu L , Nkengasong J , Peter T , Stevens W . BMC Med 2015 13 168 BACKGROUND: The Alere point-of-care (POC) Pima CD4 analyzer allows for decentralized testing and expansion to testing antiretroviral therapy (ART) eligibility. A consortium conducted a pooled multi-data technical performance analysis of the Pima CD4. METHODS: Primary data (11,803 paired observations) comprised 22 independent studies between 2009-2012 from the Caribbean, Asia, Sub-Saharan Africa, USA and Europe, using 6 laboratory-based reference technologies. Data were analyzed as categorical (including binary) and numerical (absolute) observations using a bivariate and/or univariate random effects model when appropriate. RESULTS: At a median reference CD4 of 383 cells/mul the mean Pima CD4 bias is -23 cells/mul (average bias across all CD4 ranges is 10 % for venous and 15 % for capillary testing). Sensitivity of the Pima CD4 is 93 % (95 % confidence interval [CI] 91.4 % - 94.9 %) at 350 cells/mul and 96 % (CI 95.2 % - 96.9 %) at 500 cells/mul, with no significant difference between venous and capillary testing. Sensitivity reduced to 86 % (CI 82 % - 89 %) at 100 cells/mul (for Cryptococcal antigen (CrAg) screening), with a significant difference between venous (88 %, CI: 85 % - 91 %) and capillary (79 %, CI: 73 % - 84 %) testing. Total CD4 misclassification is 2.3 % cases at 100 cells/mul, 11.0 % at 350 cells/mul and 9.5 % at 500 cells/mul, due to higher false positive rates which resulted in more patients identified for treatment. This increased by 1.2 %, 2.8 % and 1.8 %, respectively, for capillary testing. There was no difference in Pima CD4 misclassification between the meta-analysis data and a population subset of HIV+ ART naive individuals, nor in misclassification among operator cadres. The Pima CD4 was most similar to Beckman Coulter PanLeucogated CD4, Becton Dickinson FACSCalibur and FACSCount, and less similar to Partec CyFlow reference technologies. CONCLUSIONS: The Pima CD4 may be recommended using venous-derived specimens for screening (100 cells/mul) for reflex CrAg screening and for HIV ART eligibility at 350 cells/mul and 500 cells/mul thresholds using both capillary and venous derived specimens. These meta-analysis findings add to the knowledge of acceptance criteria of the Pima CD4 and future POC tests, but implementation and impact will require full costing analysis. |
Production of a Sindbis/Eastern Equine Encephalitis chimeric virus inactivated cell culture antigen
Goodman CH , Russell BJ , Velez JO , Laven JJ , Bagarozzi DA Jr , Moon JL , Bedi K , Johnson BW . J Virol Methods 2015 223 19-24 Eastern Equine Encephalitis virus (EEEV) is a medically important pathogen that can cause severe encephalitis in humans, with mortality rates ranging from 30 to 80%. Unfortunately there are no antivirals or licensed vaccines available for human use, and laboratory diagnosis is essential to differentiate EEEV infection from other pathogens with similar clinical manifestations. The Arboviral Diseases Branch (ADB) reference laboratory at the CDC Division of Vector-Borne Diseases (DVBD) produces reference antigens used in serological assays such as the EEEV immunoglobulin M antibody-capture enzyme-linked immunosorbent assay (MAC-ELISA). However, EEEV is classified as a HHS select agent and requires biosafety level (BSL) three containment, limiting EEEV antigen production in non-select agent and BSL-2 laboratories. A recombinant Sindbis virus (SINV)/EEEV has been constructed for use under BSL-2 conditions and is not regulated as a select agent. Cell culture production of inactivated EEEV antigen from SINV/EEEV for use in the EEEV MAC-ELISA is reported here. Cell culture conditions and inactivation procedures were analyzed for SINV/EEEV using a recently developed antigen production algorithm, with the MAC-ELISA as the performance indicator. |
Ebola virus diagnostics: the US Centers for Disease Control and Prevention laboratory in Sierra Leone, August 2014 to March 2015
Flint M , Goodman CH , Bearden S , Blau DM , Amman BR , Basile AJ , Belser JA , Bergeron E , Bowen MD , Brault AC , Campbell S , Chakrabarti AK , Dodd KA , Erickson BR , Freeman MM , Gibbons A , Guerrero LW , Klena JD , Lash RR , Lo MK , McMullan LK , Momoh G , Massally JL , Goba A , Paddock CD , Priestley RA , Pyle M , Rayfield M , Russell BJ , Salzer JS , Sanchez AJ , Schuh AJ , Sealy TK , Steinau M , Stoddard RA , Taboy C , Turnsek M , Wang D , Zemtsova GE , Zivcec M , Spiropoulou CF , Stroher U , Towner JS , Nichol ST , Bird BH . J Infect Dis 2015 212 Suppl 2 S350-8 In August 2014, the Viral Special Pathogens Branch of the US Centers for Disease Control and Prevention established a field laboratory in Sierra Leone in response to the ongoing Ebola virus outbreak. Through March 2015, this laboratory tested >12 000 specimens from throughout Sierra Leone. We describe the organization and procedures of the laboratory located in Bo, Sierra Leone. |
Effects of amorphous silica coating on cerium oxide nanoparticles induced pulmonary responses
Ma J , Mercer RR , Barger M , Schwegler-Berry D , Cohen JM , Demokritou P , Castranova V . Toxicol Appl Pharmacol 2015 288 (1) 63-73 Recently cerium compounds have been used in a variety of consumer products, including diesel fuel additives, to increase fuel combustion efficiency and decrease diesel soot emissions. However, cerium oxide (CeO2) nanoparticles have been detected in the exhaust, which raises a health concern. Previous studies have shown that exposure of rats to nanoscale CeO2 by intratracheal instillation (IT) induces sustained pulmonary inflammation and fibrosis. In the present study, male Sprague-Dawley rats were exposed to CeO2 or CeO2 coated with a nano layer of amorphous SiO2 (aSiO2/CeO2) by a single IT and sacrificed at various times post-exposure to assess potential protective effects of the aSiO2 coating. The first acellular bronchoalveolar lavage (BAL) fluid and BAL cells were collected and analyzed from all exposed animals. At the low dose (0.15mg/kg), CeO2 but not aSiO2/CeO2 exposure induced inflammation. However, at the higher doses, both particles induced a dose-related inflammation, cytotoxicity, inflammatory cytokines, matrix metalloproteinase (MMP)-9, and tissue inhibitor of MMP at 1day post-exposure. Morphological analysis of lung showed an increased inflammation, surfactant and collagen fibers after CeO2 (high dose at 3.5mg/kg) treatment at 28days post-exposure. aSiO2 coating significantly reduced CeO2-induced inflammatory responses in the airspace and appeared to attenuate phospholipidosis and fibrosis. Energy dispersive X-ray spectroscopy analysis showed Ce and phosphorous (P) in all particle-exposed lungs, whereas Si was only detected in aSiO2/CeO2-exposed lungs up to 3days after exposure, suggesting that aSiO2 dissolved off the CeO2 core, and some of the CeO2 was transformed to CePO4 with time. These results demonstrate that aSiO2 coating reduce CeO2-induced inflammation, phospholipidosis and fibrosis. |
Is PCR the next reference standard for the diagnosis of Schistosoma in stool? A comparison with microscopy in Senegal and Kenya
Meurs L , Brienen E , Mbow M , Ochola EA , Mboup S , Karanja DM , Secor WE , Polman K , van Lieshout L . PLoS Negl Trop Dis 2015 9 (7) e0003959 BACKGROUND: The current reference test for the detection of S. mansoni in endemic areas is stool microscopy based on one or more Kato-Katz stool smears. However, stool microscopy has several shortcomings that greatly affect the efficacy of current schistosomiasis control programs. A highly specific multiplex real-time polymerase chain reaction (PCR) targeting the Schistosoma internal transcriber-spacer-2 sequence (ITS2) was developed by our group a few years ago, but so far this PCR has been applied mostly on urine samples. Here, we performed more in-depth evaluation of the ITS2 PCR as an alternative method to standard microscopy for the detection and quantification of Schistosoma spp. in stool samples. METHODOLOGY/PRINCIPAL FINDINGS: Microscopy and PCR were performed in a Senegalese community (n = 197) in an area with high S. mansoni transmission and co-occurrence of S. haematobium, and in Kenyan schoolchildren (n = 760) from an area with comparatively low S. mansoni transmission. Despite the differences in Schistosoma endemicity the PCR performed very similarly in both areas; 13-15% more infections were detected by PCR when comparing to microscopy of a single stool sample. Even when 2-3 stool samples were used for microscopy, PCR on one stool sample detected more infections, especially in people with light-intensity infections and in children from low-risk schools. The low prevalence of soil-transmitted helminthiasis in both populations was confirmed by an additional multiplex PCR. CONCLUSIONS/SIGNIFICANCE: The ITS2-based PCR was more sensitive than standard microscopy in detecting Schistosoma spp. This would be particularly useful for S. mansoni detection in low transmission areas, and post-control settings, and as such improve schistosomiasis control programs, epidemiological research, and quality control of microscopy. Moreover, it can be complemented with other (multiplex real-time) PCRs to detect a wider range of helminths and thus enhance effectiveness of current integrated control and elimination strategies for neglected tropical diseases. |
Resistance to synthetic blood penetration of National Institute for Occupational Safety and Health-approved N95 filtering facepiece respirators and surgical N95 respirators
Rengasamy S , Sbarra D , Nwoko J , Shaffer R . Am J Infect Control 2015 43 (11) 1190-6 BACKGROUND: Surgical N95 filtering facepiece respirators (FFRs), certified by the National Institute for Occupational Safety and Health (NIOSH) as a respirator and cleared by the Food and Drug Administration (FDA) as a surgical mask, are often used to protect from the inhalation of infectious aerosols and from splashes/sprays of body fluids in health care facilities. A shortage of respirators can be expected during a pandemic. The availability of surgical N95 FFRs can potentially be increased by incorporating FDA clearance requirements in the NIOSH respirator approval process. METHODS: Fluid resistance of NIOSH-approved N95 FFRs, and FDA-cleared surgical N95 FFRs and surgical masks was tested using the ASTM F1862 method at 450 and 635 cm/sec velocities and compared with the results from a third-party independent laboratory. Blood penetration through different layers of filter media of masks were also analyzed visually. RESULTS: Four N95 FFR models showed no test failures at both velocities. The penetration results obtained in the NIOSH laboratory were comparable to those from the third-party independent laboratory. The number of respirator samples failing the test increased with increasing test velocity. CONCLUSIONS: The results indicate that several NIOSH-approved N95 FFR models would likely pass FDA clearance requirements for resistance to synthetic blood penetration. |
Precautionary practices of respiratory therapists and other health-care practitioners who administer aerosolized medications
Tsai RJ , Boiano JM , Steege AL , Sweeney MH . Respir Care 2015 60 (10) 1409-17 BACKGROUND: Respiratory therapists (RTs) and other health-care workers are potentially exposed to a variety of aerosolized medications. The National Institute for Occupational Safety and Health (NIOSH) Health and Safety Practices Survey of Healthcare Workers describes current exposure control practices and barriers to using personal protective equipment during administration of selected aerosolized medications. METHODS: An anonymous, multi-module, web-based survey was conducted among members of health-care professional practice organizations representing RTs, nurses, and other health-care practitioners. A module on aerosolized medications included submodules for antibiotics (amikacin, colistin, and tobramycin), pentamidine, and ribavirin. RESULTS: The submodules on antibiotics, pentamidine, and ribavirin were completed by 321, 227, and 50 respondents, respectively, most of whom were RTs. The relatively low number of ribavirin respondents precluded meaningful interpretation of these data and may reflect the rare use of this drug. Consequently, analysis focused on pentamidine, classified by NIOSH as a hazardous drug, and the antibiotics amikacin, colistin, and tobramycin, which currently lack authoritative safe handling guidelines. Respondents who administered pentamidine were more likely to adhere to good work practices compared with those who administered the antibiotics. Examples included training received on safe handling procedures (75% vs 52%), availability of employer standard procedures (82% vs 55%), use of aerosol delivery devices equipped with an expiratory filter (96% vs 53%) or negative-pressure rooms (61% vs 20%), and always using respiratory protection (51% vs 13%). CONCLUSIONS: Despite the availability of safe handling guidelines for pentamidine, implementation was not universal, placing workers, co-workers, and even family members at risk of exposure. Although the antibiotics included in this study lack authoritative safe handling guidelines, prudence dictates that appropriate exposure controls be used to minimize exposure to the antibiotics and other aerosolized medications. Employers and employees share responsibility for ensuring that precautionary measures are taken to keep exposures to all aerosolized medications as low as practicable. |
Aviation-related wildland firefighter fatalities - United States, 2000-2013
Butler CR , O'Connor MB , Lincoln JM . MMWR Morb Mortal Wkly Rep 2015 64 (29) 793-796 Airplanes and helicopters are integral to the management and suppression of wildfires, often operating in high-risk, low-altitude environments. To update data on aviation-related wildland firefighting fatalities, identify risk factors, and make recommendations for improved safety, CDC's National Institute for Occupational Safety and Health (NIOSH) analyzed reports from multiple data sources for the period 2000-2013. Among 298 wildland firefighter fatalities identified during 2000-2013, 78 (26.2%) were aviation-related occupational fatalities that occurred during 41 separate events involving 42 aircraft. Aircraft crashes accounted for 38 events. Pilots, copilots, and flight engineers represented 53 (68%) of the aviation-related fatalities. The leading causes of fatal aircraft crashes were engine, structure, or component failure (24%); pilot loss of control (24%); failure to maintain clearance from terrain, water, or objects (20%); and hazardous weather (15%). To reduce fatalities from aviation-related wildland firefighting activities, stringent safety guidelines need to be followed during all phases of firefighting, including training exercises. Crew resource management techniques, which use all available resources, information, equipment, and personnel to achieve safe and efficient flight operations, can be applied to firefighting operations. |
Measuring patient adherence to malaria treatment: a comparison of results from self-report and a customised electronic monitoring device
Bruxvoort K , Festo C , Cairns M , Kalolella A , Mayaya F , Kachur SP , Schellenberg D , Goodman C . PLoS One 2015 10 (7) e0134275 BACKGROUND: Self-report is the most common and feasible method for assessing patient adherence to medication, but can be prone to recall bias and social desirability bias. Most studies assessing adherence to artemisinin-based combination therapies (ACTs) have relied on self-report. In this study, we use a novel customised electronic monitoring device-termed smart blister packs-to examine the validity of self-reported adherence to artemether-lumefantrine (AL) in southern Tanzania. METHODS: Smart blister packs were designed to look identical to locally available AL blister packs and to record the date and time each tablet was removed from packaging. Patients obtaining AL at randomly selected health facilities and drug stores were followed up at home three days later and interviewed about each dose of AL taken. Blister packs were requested for pill count and extraction of smart blister pack data. RESULTS: Data on adherence from both self-report verified by pill count and smart blister packs were available for 696 of 1,204 patients. There was no difference between methods in the proportion of patients assessed to have completed treatment (64% and 67%, respectively). However, the percentage taking the correct number of pills for each dose at the correct times (timely completion) was higher by self-report than smart blister packs (37% vs. 24%; p<0.0001). By smart blister packs, 64% of patients completing treatment did not take the correct number of pills per dose or did not take each dose at the correct time interval. CONCLUSION: Smart blister packs resulted in lower estimates of timely completion of AL and may be less prone to recall and social desirability bias. They may be useful when data on patterns of adherence are desirable to evaluate treatment outcomes. Improved methods of collecting self-reported data are needed to minimise bias and maximise comparability between studies. |
Novel serologic biomarkers provide accurate estimates of recent Plasmodium falciparum exposure for individuals and communities
Helb DA , Tetteh KK , Felgner PL , Skinner J , Hubbard A , Arinaitwe E , Mayanja-Kizza H , Ssewanyana I , Kamya MR , Beeson JG , Tappero J , Smith DL , Crompton PD , Rosenthal PJ , Dorsey G , Drakeley CJ , Greenhouse B . Proc Natl Acad Sci U S A 2015 112 (32) E4438-47 Tools to reliably measure Plasmodium falciparum (Pf) exposure in individuals and communities are needed to guide and evaluate malaria control interventions. Serologic assays can potentially produce precise exposure estimates at low cost; however, current approaches based on responses to a few characterized antigens are not designed to estimate exposure in individuals. Pf-specific antibody responses differ by antigen, suggesting that selection of antigens with defined kinetic profiles will improve estimates of Pf exposure. To identify novel serologic biomarkers of malaria exposure, we evaluated responses to 856 Pf antigens by protein microarray in 186 Ugandan children, for whom detailed Pf exposure data were available. Using data-adaptive statistical methods, we identified combinations of antibody responses that maximized information on an individual's recent exposure. Responses to three novel Pf antigens accurately classified whether an individual had been infected within the last 30, 90, or 365 d (cross-validated area under the curve = 0.86-0.93), whereas responses to six antigens accurately estimated an individual's malaria incidence in the prior year. Cross-validated incidence predictions for individuals in different communities provided accurate stratification of exposure between populations and suggest that precise estimates of community exposure can be obtained from sampling a small subset of that community. In addition, serologic incidence predictions from cross-sectional samples characterized heterogeneity within a community similarly to 1 y of continuous passive surveillance. Development of simple ELISA-based assays derived from the successful selection strategy outlined here offers the potential to generate rich epidemiologic surveillance data that will be widely accessible to malaria control programs. |
Prevalence and Impact of Chagas Disease Among Latin American Immigrants With Nonischemic Cardiomyopathy in Los Angeles, California
Traina MI , Sanchez DR , Hernandez S , Bradfield JS , Labedi MR , Ngab TA , Steurer F , Montgomery SP , Meymandi SK . Circ Heart Fail 2015 BACKGROUND: Chagas disease (CD) is a well-known cause of cardiomyopathy in Latin America, however, 300,000 individuals are estimated to have CD in the United States (US). This study examined the prevalence and impact of Chagas cardiomyopathy (CCM) in a US population. We hypothesized that patients with CCM would have increased morbidity and mortality as compared to patients with non-CCM. METHODS AND RESULTS: This is a single-center, prospective cohort study. Enrollment criteria were new diagnosis of non-ischemic CM (left ventricular ejection fraction ≤ 40%) and previous residence in Latin America for at least 12 months. Serologic testing for Trypanosoma cruzi was performed at enrollment. The primary end point was all-cause mortality or heart transplantation. The secondary end point was heart failure (HF)-related hospitalization. A total of 135 patients were enrolled, with a median of 43 months of follow-up. CD was diagnosed in 25 (19%) patients. The primary end point occurred in 9 patients (36%) in the CCM group and in 11 patients (10%) in the non-CCM group (hazard ratio [HR]: 4.46, 95% confidence interval [CI]: 1.8 to 10.8, p = 0.001). The secondary end point occurred in 13 patients (52%) in the CCM group and in 35 patients (32%) in the non-CCM group (HR: 2.22, 95% CI: 1.2 to 4.2, p = 0.01). CONCLUSIONS: There is a high prevalence of CD among Latin American immigrants diagnosed with non-ischemic CM in Los Angeles. Advanced CCM portends a poor prognosis and is associated with increased all-cause mortality/heart transplantation and HF-related hospitalization. |
Imported malaria in pregnant women: a retrospective pooled analysis
Kaser AK , Arguin PM , Chiodini PL , Smith V , Delmont J , Jimenez BC , Farnert A , Kimura M , Ramharter M , Grobusch MP , Schlagenhauf P . Travel Med Infect Dis 2015 13 (4) 300-10 BACKGROUND: Data on imported malaria in pregnant women are scarce. METHOD: A retrospective, descriptive study of pooled data on imported malaria in pregnancy was done using data from 1991 to 2014 from 8 different collaborators in Europe, the United States and Japan. National malaria reference centres as well as specialists on this topic were asked to search their archives for cases of imported malaria in pregnancy. A total of 631 cases were collated, providing information on Plasmodium species, region of acquisition, nationality, country of residence, reason for travel, age, gestational age, prophylactic measures and treatment used, as well as on complications and outcomes in mother and child. RESULTS: Datasets from some sources were incomplete. The predominant Plasmodium species was P. falciparum (78.5% of cases). Among the 542 cases where information on the use of chemoprophylaxis was known, 464 (85.6%) did not use chemoprophylaxis. The main reason for travelling was "visiting friends and relatives" VFR (57.8%) and overall, most cases of malaria were imported from West Africa (57.4%). Severe anaemia was the most frequent complication in the mother. Data on offspring outcome were limited, but spontaneous abortion was a frequently reported foetal outcome (n = 14). A total of 50 different variants of malaria treatment regimens were reported. CONCLUSIONS: Imported cases of malaria in pregnancy are mainly P. falciparum acquired in sub-Saharan Africa. Malaria prevention and treatment in pregnant travellers is a challenge for travel medicine due to few data on medication safety and maternal and foetal outcomes. International, collaborative efforts are needed to capture standardized data on imported malaria cases in pregnant women. |
Reduced risk of breast cancer associated with recreational physical activity varies by HER2 status.
Ma H , Xu X , Ursin G , Simon MS , Marchbanks PA , Malone KE , Lu Y , McDonald JA , Folger SG , Weiss LK , Sullivan-Halley J , Deapen DM , Press MF , Bernstein L . Cancer Med 2015 4 (7) 1122-35 Convincing epidemiologic evidence indicates that physical activity is inversely associated with breast cancer risk. Whether this association varies by the tumor protein expression status of the estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), or p53 is unclear. We evaluated the effects of recreational physical activity on risk of invasive breast cancer classified by the four biomarkers, fitting multivariable unconditional logistic regression models to data from 1195 case and 2012 control participants in the population-based Women's Contraceptive and Reproductive Experiences Study. Self-reported recreational physical activity at different life periods was measured as average annual metabolic equivalents of energy expenditure [MET]-hours per week. Our biomarker-specific analyses showed that lifetime recreational physical activity was negatively associated with the risks of ER-positive (ER+) and of HER2-negative (HER2-) subtypes (both Ptrend ≤ 0.04), but not with other subtypes (all Ptrend > 0.10). Analyses using combinations of biomarkers indicated that risk of invasive breast cancer varied only by HER2 status. Risk of HER2-breast cancer decreased with increasing number of MET-hours of recreational physical activity in each specific life period examined, although some trend tests were only marginally statistically significant (all Ptrend ≤ 0.06). The test for homogeneity of trends (HER2- vs. HER2+ ) reached statistical significance only when evaluating physical activity during the first 10 years after menarche (Phomogeneity = 0.03). Our data suggest that physical activity reduces risk of invasive breast cancers that lack HER2 overexpression, increasing our understanding of the biological mechanisms by which physical activity acts. |
The influence of exercise on cognitive performance in normobaric hypoxia
Seo Y , Burns K , Fennell C , Kim JH , Gunstad J , Glickman E , McDaniel J . High Alt Med Biol 2015 16 (4) 298-305 Although previous reports indicate that exercise improves cognitive function in normoxia, the influence of exercise on cognitive function in hypoxia is unknown. The purpose of this study was to determine if the impaired cognitive function in hypoxia can be restored by low to moderate intensity exercise. Sixteen young healthy men completed the ANAM versions of the Go/No-Go task (GNT) and Running Memory Continuous Performance Task (RMCPT) in normoxia to serve as baseline (B-Norm) (21% O2). Following 60 minutes of exposure to normobaric hypoxia (B-Hypo) (12.5% O2), these tests were repeated at rest and during cycling exercise at 40% and 60% of adjusted Vo2max. At B-Hypo, the % correct (p≤0.001) and throughput score (p≤0.001) in RMCPT were significantly impaired compared to B-Norm. During exercise at 40% (p=0.023) and 60% (p=0.006) of adjusted Vo2max, the throughput score in RMCPT improved compared to B-Hypo, and there was no significant difference in throughput score between the two exercise intensities. Mean reaction time also improved at both exercise intensities compared to B-Hypo (p≤0.028). Both peripheral oxygen saturation (Spo2) and regional cerebral oxygen saturation (rSo2) significantly decreased during B-Hypo (p≤0.001) and further decreased at 40% (p≤0.05) and 60% (p≤0.039) exercise. There was no significant difference in Spo2 or rSo2 between two exercise intensities. These data indicate that low to moderate exercise (i.e., 40%-60% adjusted Vo2max) may attenuate the risk of impaired cognitive function that occurs in hypoxic conditions. |
Health care for Americans with disabilities - 25 years after the ADA
Peacock G , Iezzoni LI , Harkin TR . N Engl J Med 2015 373 (10) 892-3 Twenty-five years ago, on July 26, 1990, President George H.W. Bush signed the Americans with Disabilities Act (ADA), designed to meet four goals for people with disabilities: equal opportunity, full participation in the community, independent living, and economic self-sufficiency. This landmark civil rights law aimed to prevent employment discrimination and give equal access to public and private services for all people with disabilities. At the signing ceremony, Bush exclaimed, “Let the shameful wall of exclusion finally come tumbling down.” | Since the passage of the ADA, there have been extensive gains in access to public services, the built environment (e.g., cross-walks with curb cuts for wheel-chair access and accessible pedestrian signals to assist people who are blind or have low vision), and attitudes toward and understanding of the abilities of people with disabilities. The ADA established a right to equal access to public services offered by governments and private providers and has demonstrated the importance of contributions that people with disabilities can make to our economy. |
Urinary bisphenol A concentrations and association with in vitro fertilization outcomes among women from a fertility clinic
Minguez-Alarcon L , Gaskins AJ , Chiu YH , Williams PL , Ehrlich S , Chavarro JE , Petrozza JC , Ford JB , Calafat AM , Hauser R . Hum Reprod 2015 30 (9) 2120-8 STUDY QUESTION: Are urinary BPA concentrations associated with in vitro fertilization (IVF) outcomes among women attending an academic fertility center? SUMMARY ANSWER: Urinary BPA concentrations were not associated with adverse reproductive and pregnancy outcomes among women from a fertility clinic. WHAT IS KNOWN ALREADY: Bisphenol A (BPA), an endocrine disruptor, is detected in the urine of most Americans. Although animal studies have demonstrated that BPA reduces female fertility through effects on the ovarian follicle and uterus, data from human populations are scarce and equivocal. STUDY DESIGN, SIZE AND DURATION: This prospective cohort study between 2004 and 2012 at the Massachusetts General Hospital Fertility Center included 256 women (n = 375 IVF cycles) who provided up to two urine samples prior to oocyte retrieval (total N = 673). PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Study participants were women enrolled in the Environment and Reproductive Health (EARTH) Study. Intermediate and clinical end-points of IVF treatments were abstracted from electronic medical records. We used generalized linear mixed models with random intercepts to evaluate the association between urinary BPA concentrations and IVF outcomes adjusted by age, race, body mass index, smoking status and infertility diagnosis. MAIN RESULTS AND THE ROLE OF CHANCE: The specific gravity-adjusted geometric mean of BPA was 1.87 microg/l, which is comparable to that for female participants in the National Health and Nutrition Examination Survey, 2011-2012. Urinary BPA concentrations were not associated with endometrial wall thickness, peak estradiol levels, proportion of high quality embryos or fertilization rates. Furthermore, there were no associations between urinary BPA concentrations and implantation, clinical pregnancy or live birth rates per initiated cycle or per embryo transfer. Although we did not find any associations between urinary BPA concentrations and IVF outcomes, the relation between BPA and endometrial wall thickness was modified by age. Younger women (<37 years old) had thicker endometrial thickness across increasing quartiles of urinary BPA concentrations, while older women (≥37 years old) had thinner endometrial thickness across increasing quartiles of urinary BPA concentrations. LIMITATIONS, REASONS FOR CAUTION: Limitations to this study include a possible misclassification of BPA exposure and difficulties in extrapolating the findings to the general population. WIDER IMPLICATIONS OF THE FINDINGS: Data on the relation between urinary BPA concentrations and reproductive outcomes remain scarce and additional research is needed to clarify its role in human reproduction. STUDY FUNDING/COMPETING INTERESTS: This work was supported by NIH grants R01ES022955, R01ES009718 and R01ES000002 from the National Institute of Environmental Health Sciences (NIEHS) and grant T32DK00770316 from the National Institute of Child Health and Human Development (NICHD). None of the authors has any conflicts of interest to declare. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. |
Secondhand smoke exposure and illness severity among children hospitalized with pneumonia
Ahn A , Edwards KM , Grijalva CG , Self WH , Zhu Y , Chappell JD , Arnold SR , McCullers JA , Ampofo K , Pavia AT , Bramley AM , Jain S , Williams DJ . J Pediatr 2015 167 (4) 869-874 e1 OBJECTIVE: To assess the relationship between secondhand smoke (SHS) exposure and disease severity among children hospitalized with community-acquired pneumonia (CAP). STUDY DESIGN: Children hospitalized with clinical and radiographic CAP were enrolled between January 1, 2010, and June 30, 2012 at 3 hospitals in Tennessee and Utah as part of the Centers for Disease Control and Prevention's Etiology of Pneumonia in the Community study. Household SHS exposure was defined based on the number of smokers in the child's home. Outcomes included hospital length of stay, intensive care unit admission, and mechanical ventilation. Proportional hazards and logistic regression models were used to assess associations between SHS exposure and outcomes. All models were adjusted for age, sex, race/ethnicity, household education level, government insurance, comorbidities, enrollment site, year, and season. RESULTS: Of the 2219 children included in the study, SHS exposure was reported in 785 (35.4%), including 325 (14.8%) with ≥2 smokers in the home. Compared with nonexposed children, the children exposed to ≥2 smokers had longer length of stay (median, 70.4 hours vs 64.4 hours; adjusted hazard ratio, 0.85; 95% CI, 0.75-0.97) and were more likely to receive intensive care (25.2% vs 20.9%; aOR, 1.44; 95% CI, 1.05-1.96), but not mechanical ventilation. Outcomes in children exposed to only 1 household smoker were similar to those in nonexposed children. CONCLUSION: Children hospitalized with CAP from households with ≥2 smokers had a longer length of stay and were more likely to require intensive care compared with children from households with no smokers, suggesting that they experienced greater pneumonia severity. |
Smoking duration, respiratory symptoms, and COPD in adults aged ≥45 years with a smoking history
Liu Y , Pleasants RA , Croft JB , Wheaton AG , Heidari K , Malarcher AM , Ohar JA , Kraft M , Mannino DM , Strange C . Int J Chron Obstruct Pulmon Dis 2015 10 1409-1416 BACKGROUND: The purpose of this study was to assess the relationship of smoking duration with respiratory symptoms and history of chronic obstructive pulmonary disease (COPD) in the South Carolina Behavioral Risk Factor Surveillance System survey in 2012. METHODS: Data from 4,135 adults aged ≥45 years with a smoking history were analyzed using multivariable logistic regression that accounted for sex, age, race/ethnicity, education, and current smoking status, as well as the complex sampling design. RESULTS: The distribution of smoking duration ranged from 19.2% (1-9 years) to 36.2% (≥30 years). Among 1,454 respondents who had smoked for ≥30 years, 58.3% were current smokers, 25.0% had frequent productive cough, 11.2% had frequent shortness of breath, 16.7% strongly agreed that shortness of breath affected physical activity, and 25.6% had been diagnosed with COPD. Prevalence of COPD and each respiratory symptom was lower among former smokers who quit ≥10 years earlier compared with current smokers. Smoking duration had a linear relationship with COPD (P<0.001) and all three respiratory symptoms (P<0.001) after adjusting for smoking status and other covariates. While COPD prevalence increased with prolonged smoking duration in both men and women, women had a higher age-adjusted prevalence of COPD in the 1-9 years, 20-29 years, and ≥30 years duration periods. CONCLUSION: These state population data confirm that prolonged tobacco use is associated with respiratory symptoms and COPD after controlling for current smoking behavior. |
Current cigarette smoking among workers in accommodation and food services - United States, 2011-2013
Syamlal G , Jamal A , Mazurek JM . MMWR Morb Mortal Wkly Rep 2015 64 (29) 797-801 Tobacco use is the leading cause of preventable disease and death in the United States. One of the Healthy People 2020 objectives calls for reducing the proportion of U.S. adults who smoke cigarettes to ≤12% (objective TU-1.1). Despite progress in reducing smoking prevalence over the past several decades, nearly one in five U.S. adults, including millions of workers, still smoke cigarettes. During 2004-2010, nearly one fifth (19.6%) of U.S. working adults aged ≥18 years smoked cigarettes, and of all the industry sectors, current smoking prevalence among the accommodation and food services sector workers (30%) was the highest. CDC analyzed National Health Interview Survey (NHIS) data for 2011-2013 to estimate current cigarette smoking prevalence among adults working in the accommodation and food services sector, and found that these workers had higher cigarette smoking prevalence (25.9%) than all other workers (17.3%). Among workers in accommodation and food services sector, the highest smoking prevalences were observed among males, non-Hispanic whites, those aged 25-44 years, those with a high school diploma or a General Educational Development (GED) certificate and no college education, those with an annual family income <$35,000, those with no health insurance, and those working in the food services and drinking places industry. These results indicate a need to better understand the reasons for higher smoking prevalence observed among accommodation and food services workers (e.g., workplace culture), so that appropriate intervention strategies can be developed and implemented. Evidence suggests that smoke-free worksites and workplace cessation programs, including comprehensive worksite smoke-free policies, health promotion, access to smoking cessation programs, and increasing the cost of tobacco products, can substantially reduce smoking among workers. |
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