Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modelling study
Gregg EW , Zhuo X , Cheng YJ , Albright AL , Narayan KM , Thompson TJ . Lancet Diabetes Endocrinol 2014 2 (11) 867-74 BACKGROUND: Diabetes incidence has increased and mortality has decreased greatly in the USA, potentially leading to substantial changes in the lifetime risk of diabetes. We aimed to provide updated estimates for the lifetime risk of development of diabetes and to assess the effect of changes in incidence and mortality on lifetime risk and life-years lost to diabetes in the USA. METHODS: We incorporated data about diabetes incidence from the National Health Interview Survey, and linked data about mortality from 1985 to 2011 for 598 216 adults, into a Markov chain model to estimate remaining lifetime diabetes risk, years spent with and without diagnosed diabetes, and life-years lost due to diabetes in three cohorts: 1985-89, 1990-99, and 2000-11. Diabetes was determined by self-report and was classified as any diabetes, excluding gestational diabetes. We used logistic regression to estimate the incidence of diabetes and Poisson regression to estimate mortality. FINDINGS: On the basis of 2000-11 data, lifetime risk of diagnosed diabetes from age 20 years was 40.2% (95% CI 39.2-41.3) for men and 39.6% (38.6-40.5) for women, representing increases of 20 percentage points and 13 percentage points, respectively, since 1985-89. The highest lifetime risks were in Hispanic men and women, and non-Hispanic black women, for whom lifetime risk now exceeds 50%. The number of life-years lost to diabetes when diagnosed at age 40 years decreased from 7.7 years (95% CI 6.5-9.0) in 1990-99 to 5.8 years (4.6-7.1) in 2000-11 in men, and from 8.7 years (8.4-8.9) to 6.8 years (6.7-7.0) in women over the same period. Because of the increasing diabetes prevalence, the average number of years lost due to diabetes for the population as a whole increased by 46% in men and 44% in women. Years spent with diabetes increased by 156% in men and 70% in women. INTERPRETATION: Continued increases in the incidence of diagnosed diabetes combined with declining mortality have led to an acceleration of lifetime risk and more years spent with diabetes, but fewer years lost to the disease for the average individual with diabetes. These findings mean that there will be a continued need for health services and extensive costs to manage the disease, and emphasise the need for effective interventions to reduce incidence. FUNDING: None. |
Lung function, 25-hydroxyvitamin D concentrations and mortality in US adults
Ford ES . Eur J Clin Nutr 2014 69 (5) 572-8 OBJECTIVE: To explore the associations between serum concentrations of vitamin D (25(OH)D) and all-cause mortality among US adults defined by lung function (LF) status, particularly among adults with obstructive LF (OLF). METHODS: Data from 10 795 adults aged 20-79 years (685 with restrictive LF (RLF) and 1309 with OLF) who participated in the Third National Health and Nutrition Examination Survey (1988-1994), had a spirometric examination, and were followed through 2006 were included. RESULTS: During 14.2 years of follow-up, 1792 participants died. Mean adjusted concentrations of 25(OH)D were 75.0 nmol/l (s.e. 0.7) for adults with normal LF (NLF), 70.4 nmol/l (s.e. 1.8) for adults with RLF, 75.5 nmol/l (s.e. 1.5) for adults with mild obstruction and 71.0 nmol/l (s.e. 1.9) among adults with moderate or worse obstruction (P=0.030). After adjustment for sociodemographic factors, lifestyle factors, clinical variables and prevalent chronic conditions, a concentration of <25 nmol/l compared with 75 nmol//l was associated with mortality only among adults with NLF (hazard ratio (HR) 1.76; 95% confidence interval (CI) 1.03, 3.00). Among participants with OLF, adjusted HRs were 0.65 (95% CI 0.29, 1.48), 1.21 (95% CI 0.89, 1.66) and 0.97 (95% CI 0.78, 1.19) among those with concentrations <25, 25-<50 and 50-<75 nmol/l, respectively. CONCLUSIONS: Baseline concentrations of 25(OH)D did not significantly predict mortality among US adults with impaired LF. |
Mental health services utilization and expenditures associated with cancer survivorship in the United States
Li C , Li C , Forsythe L , Lerro C , Soni A . J Cancer Surviv 2014 9 (1) 50-8 PURPOSE: The aim of this study is to assess mental health services utilization and expenditures associated with cancer history using a nationally representative sample in the US. METHODS: We used data from the 2008-2011 Medical Expenditure Panel Survey and multivariate regression models to assess mental health services use and expenditures among cancer survivors compared to individuals without a cancer history, stratified by age (18-64 and ≥65 years) and time since diagnosis (≤1 vs. >1 year). RESULTS: Among adults aged 18-64, compared with individuals without a cancer history, cancer survivors were more likely to screen positive for current psychological distress and depression regardless of time since diagnosis; survivors diagnosed >1 year ago were more likely to use mental health prescription drugs; those diagnosed within 1 year reported significantly lower annual per capita mental health drug expenditure and out-of-pocket mental health expenditure, while those diagnosed >1 year presented significantly higher annual per capita mental health expenditure. No significant differences in mental health expenditures were found among adults aged 65 or older. CONCLUSIONS: Mental health problems presented higher health and economic burden among younger and longer-term survivors than individuals without a cancer history. This study provides data for monitoring the impact of initiatives to enhance coverage and access for mental health services at the national level. IMPLICATIONS FOR CANCER SURVIVORS: Early detection and appropriate treatment of mental health problems may help improve quality of cancer survivorship. |
Predictors of in-hospital death and symptomatic intracranial hemorrhage in patients with acute ischemic stroke treated with thrombolytic therapy: Paul Coverdell Acute Stroke Registry 2008-2012
Tong X , George MG , Yang Q , Gillespie C . Int J Stroke 2014 9 (6) 728-34 BACKGROUND: Limited studies exist on the outcome of thrombolytic therapy of acute ischemic stroke patients outside of clinical trials. AIM: To assess the possible risk factors associated with in-hospital death and symptomatic intracerebral hemorrhage among patients who received intravenous tissue plasminogen activator. METHODS: A total of 7193 patients with a clinical diagnosis of acute ischemic stroke and a documented National Institutes of Health Stroke Scale score were treated with intravenous tissue plasminogen activator within 4.5 hours of time last known to be well. Generalized estimating equations modeling was used to assess the associations of in-hospital death and symptomatic intracerebral hemorrhage with clinical characteristics. RESULTS: Among 7193 patients treated with intravenous tissue plasminogen activator, 516 (7.2%) died during hospitalization. Factors associated with in-hospital death were older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of nonvalvular atrial fibrillation. Increasing age, higher National Institutes of Health Stroke Scale score, and history of dyslipidemia were associated with symptomatic intracerebral hemorrhage. There was no difference in the rates of in-hospital death or symptomatic intracerebral hemorrhage among patients treated with intravenous tissue plasminogen activator within three-hours of time last known to be well and those treated between three and 4.5 hours after this time. CONCLUSIONS: In this study of acute ischemic stroke patients, older age, male gender, National Institutes of Health Stroke Scale score, history of myocardial infarction or coronary artery disease, and history of atrial fibrillation were associated with increased in-hospital death among patients receiving intravenous tissue plasminogen activator. Among patients treated with intravenous tissue plasminogen activator, in-hospital mortality and symptomatic intracerebral hemorrhage rates were similar between those treated within three-hours of time last known to be well and those treated between three and 4.5 hours after this time. |
Hypertension among US adults by disability status and type, National Health and Nutrition Examination Survey, 2001-2010
Stevens A , Courtney-Long E , Gillespie C , Armour BS . Prev Chronic Dis 2014 11 E139 The prevalence of hypertension among people with disabilities is not well understood. We combined data from the 2001-2010 National Health and Nutrition Examination Survey to obtain estimates of hypertension prevalence by disability status and type (cognitive, hearing, vision, or mobility limitation) and assess the association between disability and hypertension. Overall, 34% of adults with disabilities had hypertension compared with 27% of adults without disabilities; adults with mobility limitations were more likely to have hypertension than adults without disabilities (adjusted prevalence ratio: 1.23; 95% confidence interval: 1.16-1.32). Our results suggest that adults living with disabilities are an important subpopulation to include in hypertension reporting and intervention efforts. |
Challenges in investigating the association between Agent Orange and cancer: site-specific cancer risk and accuracy of exposure assessment
Sinks TH . Cancer 2014 120 (23) 3595-7 The findings of the study by Yi and Ohrr in the current issue of Cancer add to our overall understanding of the health risks from exposures to Agent Orange. Large numbers of individuals were potentially exposed to Agent Orange during the Vietnam War, and this report reminds us of the critical importance of accurate exposure assessment and the desire for epidemiologic studies to provide scientific clarity, even in the most difficult of circumstances. | The US military in Vietnam removed vegetative cover near base camps, uncovered enemy forces hiding in thick forests, and destroyed food crops available to enemy forces by spraying herbicides, often by aircraft.1 One mixture, Agent Orange, contained 2,4,5-trichlorophenoxyacetic acid (2,4,5-T) contaminated with 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Individuals involved in mixing, spraying, maintaining, and storing Agent Orange and the other herbicide formulations containing 2,4,5-T were exposed to TCDD. Those who may have been exposed include individuals who contacted herbicide-sprayed vegetation or ingested herbicide-contaminated food or water. This included annually more than 850,000 personnel supporting the Republic of Vietnam, including 36,000 Republic of Korea troops.2 The true number of personnel from either side of the conflict and noncombatant Vietnamese actually exposed to TCDD, and the amount of their exposures, remains unknown. |
Re: "Estimated rate of reactivation of latent tuberculosis infection in the United States, overall and by population subgroup"
Sanderson JM , Meissner JS , Ahuja SD . Am J Epidemiol 2014 180 (5) 556-7 In an investigation using national data sources, Shea et al. (1) estimated the rate of reactivation tuberculosis (TB) to be 0.084 cases per 100 person-years among persons with latent TB infection (LTBI) in the United States. The authors present these findings as the overall rate of reactivation TB in the United States, and they state that the groups identified as having higher rates of reactivation TB “have increased rates of progression and will receive even greater benefit from testing and treatment” (1, p. 223) for LTBI. While this study represents an important attempt to quantify the contribution of reactivation TB to the overall TB burden in the United States, this extrapolation has significant implications for TB control programs, and we urge caution in the interpretation and application of these results. | Shea et al. (1) differentiated reactivation TB cases from primary TB cases on the basis of cluster status, with cases that clustered being considered cases of primary TB. A cluster was defined as “at least 2 cases with indistinguishable TB genotypes reported within statistically significant geospatial zones” (1, p. 217). While using genotyping to distinguish primary TB from reactivation TB is a common molecular epidemiologic technique, limitations with this method, such as sampling bias (2), unknown strain variation (3), and genotyping methods with limited discriminatory power (4), have been documented. |
Treatment for LTBI in contacts of MDR-TB patients, Federated States of Micronesia, 2009-2012
Bamrah S , Brostrom R , Dorina F , Setik L , Song R , Kawamura LM , Heetderks A , Mase S . Int J Tuberc Lung Dis 2014 18 (8) 912-918 SETTING: Few studies have shown the operational feasibility, safety, tolerability, or outcomes of multi-drug-resistant latent tuberculous infection (MDR LTBI) treatment. After two simultaneous multidrug-resistant tuberculosis (MDR-TB) outbreaks in Chuuk, Federated States of Micronesia, infected contacts were offered a 12-month fluoroquinolone (FQ) based MDR LTBI treatment regimen. DESIGN: Between January 2009 and February 2012, 119 contacts of MDR-TB patients were followed using a prospective observational study design. After MDR-TB disease was excluded, 12 months of daily FQ-based preventive treatment of MDR LTBI was provided by directly observed therapy. RESULTS: Among the 119 infected contacts, 15 refused, while 104 began treatment for MDR LTBI. Of the 104 who initiated treatment, 93 (89%) completed treatment, while 4 contacts discontinued due to adverse effects. None of the 104 contacts who undertook MDR LTBI treatment of any duration developed MDR-TB disease; however, 3 of 15 contacts who refused and 15 unidentified contacts developed MDR-TB disease. CONCLUSION: Providing treatment for MDR LTBI can be accomplished in a resource-limited setting, and contributed to preventing MDR-TB disease. The Chuuk TB program implemented treatment of MDR LTBI with an 89% completion rate. The MDR LTBI regimens were safe and well tolerated, and no TB cases occurred among persons treated for MDR LTBI. |
Measles outbreak response among adolescent and adult Somali refugees displaced by famine in Kenya and Ethiopia, 2011
Navarro-Colorado C , Mahamud A , Burton A , Haskew C , Maina GK , Wagacha JB , Ahmed JA , Shetty S , Cookson S , Goodson JL , Schilperoord M , Spiegel P . J Infect Dis 2014 210 (12) 1863-70 BACKGROUND: The refugee complexes of Dadaab, Kenya, and Dollo-Ado, Ethiopia, experienced measles outbreaks during June-November 2011, following a large influx of refugees from Somalia. METHODS: Line-lists from health facilities were used to describe the outbreak in terms of age, sex, vaccination status, arrival date, attack rates (ARs), and case fatality ratios (CFRs) for each camp. Vaccination data and coverage surveys were reviewed. RESULTS: In Dadaab, 1370 measles cases and 32 deaths (CFR, 2.3%) were reported. A total of 821 cases (60.1%) were aged ≥15 years, 906 (82.1%) arrived to the camps in 2011, and 1027 (79.6%) were unvaccinated. Camp-specific ARs ranged from 212 to 506 cases per 100 000 people. In Dollo-Ado, 407 cases and 23 deaths (CFR, 5.7%) were reported. Adults aged ≥15 years represented 178 cases (43.7%) and 6 deaths (26.0%). Camp-specific ARs ranged from 21 to 1100 cases per 100 000 people. Immunization activities that were part of the outbreak responses initially targeted children aged 6 months to 14 years and were later expanded to include individuals up to 30 years of age. CONCLUSIONS: The target age group for outbreak response-associated immunization activities at the start of the outbreaks was inconsistent with the numbers of cases among unvaccinated adolescents and adults in the new population. In displacement of populations from areas affected by measles outbreaks, health authorities should consider vaccinating adults in routine and outbreak response activities. |
Notes from the field: hospitalizations for respiratory disease among unaccompanied children from Central America - multiple states, June-July 2014
Nyangoma EN , Arriola CS , Hagan J , Socias C , Tomczyk S , Watkins LF , Westercamp M , Kim C . MMWR Morb Mortal Wkly Rep 2014 63 (32) 698-9 During October 2013-June 2014, approximately 54,000 unaccompanied children, mostly from the Central American countries of El Salvador, Guatemala, and Honduras, were identified attempting entry into the United States from Mexico, exceeding numbers reported in previous years. Once identified in the United States, U.S. Customs and Border Protection, an agency of the U.S. Department of Homeland Security, processes the unaccompanied children and transfers them to the Office of Refugee Resettlement (ORR), an office of the Administration for Children and Families, U.S. Department of Health and Human Services. ORR cares for the children in shelters until they can be released to a sponsor, typically a parent or relative, who can care for the child while their immigration case is processed. In June 2014, in response to the increased number of unaccompanied children, U.S. Customs and Border Protection expanded operations to accommodate children at a processing center in Nogales, Arizona. ORR, together with the U.S. Department of Defense, opened additional large temporary shelters for the children at Lackland Air Force Base, Texas; U.S. Army Garrison Ft. Sill, Oklahoma; and Naval Base Ventura County, California. |
Population size, HIV, and behavior among MSM in Luanda, Angola: challenges and findings in the first ever HIV and syphilis biological and behavioral survey
Kendall C , Kerr LR , Mota RM , Cavalcante S , Macena RH , Chen S , Gaffga N , Monterosso E , Bastos FI , Serrano D . J Acquir Immune Defic Syndr 2014 66 (5) 544-51 OBJECTIVES: To conduct the first population size estimation and biological and behavioral surveillance survey among men who have sex with men (MSM) in Angola. DESIGN: Population size estimation with multiplier method and a cross-sectional study using respondent-driven sampling. SETTING: Luanda Province, Angola. Study was conducted in a large hospital. PARTICIPANTS: Seven hundred ninety-two self-identified MSM accepted a unique object for population size estimation. Three hundred fifty-one MSM were recruited with respondent-driven sampling for biological and behavioral surveillance survey. METHODS: Interviews and testing for HIV and syphilis were conducted on-site. Analysis used Respondent-Driven Sampling Analysis Tool and STATA 11.0. Univariate, bivariate, and multivariate analyses examined factors associated with HIV and unprotected sex. Six imputation strategies were used for missing data for those refusing to test for HIV. MAIN OUTCOME: A population size of 6236 MSM was estimated. Twenty-seven of 351 individuals were tested positive. Adjusted HIV prevalence was 3.7% (8.7% crude). With imputation, HIV seroprevalence was estimated between 3.8% [95% confidence interval (CI): 1.6 to 6.5] and 10.5% (95% CI: 5.6 to 15.3). Being older than 25 (odds ratio = 10.8, 95% CI: 3.5 to 32.8) and having suffered episodes of homophobia (odds ratio = 12.7, 95% CI: 3.2 to 49.6) significantly increased the chance of HIV seropositivity. CONCLUSIONS: Risk behaviors are widely reported, but HIV seroprevalence is lower than expected. The difference between crude and adjusted values was mostly due to treatment of missing values in Respondent-Driven Sampling Analysis Tool. Solutions are proposed in this article. Although concerns were raised about feasibility and adverse outcomes for MSM, the study was successfully and rapidly completed with no adverse effects. |
Emerging epidemic of hepatitis C virus infections among young non-urban persons who inject drugs in the United States, 2006-2012
Suryaprasad AG , White JZ , Xu F , Eichler BA , Hamilton J , Patel A , Hamdounia SB , Church DR , Barton K , Fisher C , Macomber K , Stanley M , Guilfoyle SM , Sweet K , Liu S , Iqbal K , Tohme R , Sharapov U , Kupronis BA , Ward JW , Holmberg SD . Clin Infect Dis 2014 59 (10) 1411-9 BACKGROUND: Reports of acute hepatitis C in young persons in the United States have increased. We examined data from national surveillance and supplemental case follow-up at selected jurisdictions to describe the U.S. epidemiology of hepatitis C virus (HCV) infection among young persons (aged ≤30 years). METHODS: We examined trends in incidence of acute hepatitis C among young persons reported to CDC during 2006-2012 by state, county, and urbanicity. Socio-demographic and behavioral characteristics of HCV-infected young persons newly reported from 2011-2012 were analyzed from case interviews and provider follow-up at six jurisdictions. RESULTS: From 2006-2012, reported incidence of acute hepatitis C increased significantly in young persons-13% annually in non-urban counties (p=0.003) versus 5% annually in urban counties (p=0.028). Thirty (88%) of 34 reporting states observed higher incidence in 2012 than 2006, most noticeably in non-urban counties east of the Mississippi River. Of 1,202 newly reported HCV-infected young persons, 52% were female and 85% were white. In 635 interviews, 75% of respondents reported injection drug use. Of respondents reporting drug use, 75% had abused prescription opioids, with first use on average 2.0 years before heroin. CONCLUSION: These data indicate an emerging U.S. epidemic of HCV infection among young non-urban persons of predominantly white race. Reported incidence was higher in 2012 than 2006 in at least 30 states, with largest increases in non-urban counties east of the Mississippi River. Prescription opioid abuse at an early age was commonly reported and should be a focus for medical and public health intervention. |
Hospitalizations for severe lower respiratory tract infections
Greenbaum AH , Chen J , Reed C , Beavers S , Callahan D , Christensen D , Finelli L , Fry AM . Pediatrics 2014 134 (3) 546-54 BACKGROUND: Hospitalization for lower respiratory tract infections (LRTIs) among children have been well characterized. We characterized hospitalizations for severe LRTI among children. METHODS: We analyzed claims data from commercial and Medicaid insurance enrollees (MarketScan) ages 0 to 18 years from 2007 to 2011. LRTI hospitalizations were identified by the first 2 listed International Classification of Diseases, Ninth Revision discharge codes; those with ICU admission and/or receiving mechanical ventilation were defined as severe LRTI. Underlying conditions were determined from out- and inpatient discharge codes in the preceding year. We report insurance specific and combined rates that used both commercial and Medicaid rates and adjusted for age and insurance status. RESULTS: During 2007-2011, we identified 16 797 and 12 053 severe LRTI hospitalizations among commercial and Medicaid enrollees, respectively. The rates of severe LRTI hospitalizations per 100 000 person-years were highest in children aged <1 year (commercial: 244; Medicaid: 372, respectively), and decreased with age. Among commercial enrollees, ≥1 condition increased the risk for severe LRTI (1 condition: adjusted relative risk, 2.68; 95% confidence interval, 2.58-2.78; 3 conditions: adjusted relative risk, 4.85; 95% confidence interval, 4.65-5.07) compared with children with no medical conditions. Using commercial/Medicaid combined rates, an estimated 31 289 hospitalizations for severe LRTI occurred each year in children in the United States. CONCLUSIONS: Among children, the burden of hospitalization for severe LRTI is greatest among children aged <1 year. Children with underlying medical conditions are at greatest risk for severe LRTI hospitalization. |
The impact of home-based HIV counseling and testing on care-seeking and incidence of common infectious disease syndromes in rural western Kenya
Bigogo G , Amolloh M , Laserson KF , Audi A , Aura B , Dalal W , Ackers M , Burton D , Breiman RF , Feikin DR . BMC Infect Dis 2014 14 (1) 376 BACKGROUND: In much of Africa, most individuals living with HIV do not know their status. Home-based counseling and testing (HBCT) leads to more HIV-infected people learning their HIV status. However, there is little data on whether knowing one's HIV-positive status necessarily leads to uptake of HIV care, which could in turn, lead to a reduction in the prevalence of common infectious disease syndromes. METHODS: In 2008, Kenya Medical Research Institute (KEMRI) in collaboration with the Centers for Disease Control and Prevention (CDC) offered HBCT to individuals (aged ≥13 years) under active surveillance for infectious disease syndromes in Lwak in rural western Kenya. HIV test results were linked to morbidity and healthcare-seeking data collected by field workers through bi-weekly home visits. We analyzed changes in healthcare seeking behaviors using proportions, and incidence (expressed as episodes per person-year) of acute respiratory illness (ARI), severe acute respiratory illness (SARI), acute febrile illness (AFI) and diarrhea among first-time HIV testers in the year before and after HBCT, stratified by their test result and if HIV-positive, whether they sought care at HIV Patient Support Centers (PSCs). RESULTS: Of 9,613 individuals offered HBCT, 6,366 (66%) were first-time testers, 698 (11%) of whom were HIV-infected. One year after HBCT, 50% of HIV-infected persons had enrolled at PSCs - 92% of whom had started cotrimoxazole and 37% of those eligible for antiretroviral treatment had initiated therapy. Among HIV-infected persons enrolled in PSCs, AFI and diarrhea incidence decreased in the year after HBCT (rate ratio [RR] 0.84; 95% confidence interval [CI] 0.77 - 0.91 and RR 0.84, 95% CI 0.73 - 0.98, respectively). Among HIV-infected persons not attending PSCs and among HIV-uninfected persons, decreases in incidence were significantly lower. While decreases also occurred in rates of respiratory illnesses among HIV-positive persons in care, there were similar decreases in the other two groups. CONCLUSIONS: Large scale HBCT enabled a large number of newly diagnosed HIV-infected persons to know their HIV status, leading to a change in care seeking behavior and ultimately a decrease in incidence of common infectious disease syndromes through appropriate treatment and care. |
Isoniazid preventive treatment in children in two districts of South India: does practice follow policy?
Shivaramakrishna HR , Frederick A , Shazia A , Murali L , Satyanarayana S , Nair SA , Kumar AM , Moonan PK . Int J Tuberc Lung Dis 2014 18 (8) 919-924 SETTING: Two districts of Tamil Nadu, India OBJECTIVES: To determine the proportion of household contacts aged <6 years of patients with tuberculosis (TB) with positive sputum microscopy results who initiated and completed isoniazid preventive treatment (IPT), and to determine reasons for non-initiation and non-completion of IPT. DESIGN: Household visits were conducted on a random sample of adult patients registered during January-June 2012 to identify household contacts aged <6 years. RESULTS: Among 271 children living with 691 index patients, 218 (80%) were evaluated and 9 (4%) were diagnosed with TB. Of 209 remaining contacts, 70 (33%) started IPT and 16 (22.9%) completed a full course of IPT. Of 139 contacts who did not start IPT, five developed TB disease. Reasons for non-initiation of IPT included no home visit by the field staff (19%) and no education about IPT (61%). Reasons for noncompletion included isoniazid not provided (52%) and long duration of treatment (28%). CONCLUSION: This study shows that Revised National TB Programme guidance was not being followed and IPT implementation was poor. Poor IPT uptake represents a missed opportunity to prevent future TB cases. Provision of IPT may be improved through training, improved logistics and enhanced supervision and monitoring. |
Active, population-based surveillance for rotavirus gastroenteritis in Chinese children: Beijing Municipality and Gansu Province, China
Zhang J , Liu H , Jia L , Payne DC , Hall AJ , Xu Z , Gao Z , Chang Z , Jiang B , Parashar UD , Meng L , Yu H , Duan Z . Pediatr Infect Dis J 2014 34 (1) 40-6 BACKGROUND: Estimates of population-based incidence for rotavirus inpatient and outpatient visits, as well as their associated medical costs, can provide valuable information to assess the potential benefits of rotavirus vaccination. METHODS: We conducted active surveillance for rotavirus gastroenteritis at 6 medical institutions for children under 5 years of age from July 2012 to June 2013 in Beijing Municipality and Gansu Province. We collected stool samples of diarrhea patients for testing rotavirus, and epidemiological, clinical and cost data. RESULTS: The proportion of rotavirus-positive for inpatient and outpatient visits from Beijing was 28.7% (138/481) and 19.4% (133/687); a statistically lower proportion than observed in Gansu among inpatient visits (45.2%, 245/542, P<0.001) and among outpatient visits (28.8%, 66/229, P=0.003), respectively. The G9P[8] genotype was most prevalent in Beijing (60.6%) and in Gansu (77.6%). The median Vesikari scale value was 16 for rotavirus inpatients and 15 for non-rotavirus inpatients. Population-based estimated rates of rotavirus-related hospitalizations were 14.4 (95% CI, 13-16) per 10,000 children, and the rate of rotavirus gastroenteritis in the outpatient setting was 149 (95% CI, 145-153) per 10,000 children under 5 years of age. The estimated total number of rotavirus-related inpatient visits were 3,790 (95%CI: 2,488-3,827) cases and 29,101 (95%CI: 27,748-29,279) outpatient visits. The total of cost of rotavirus infection was $1.4 million (95%CI: $0.9-1.4 million) for hospitalizations and $4.2 million (95%CI: $4.0-4.2 million) for outpatient visits per year in Beijing and Gansu. CONCLUSION: Rotavirus gastroenteritis is associated with a large disease burden in Chinese children under five years of age in Beijing and Gansu. |
Beneficial effect of isoniazid preventive therapy and antiretroviral therapy on the incidence of tuberculosis in people living with HIV in Ethiopia
Yirdaw KD , Jerene D , Gashu Z , Edginton ME , Kumar AM , Letamo Y , Feleke B , Teklu AM , Zewdu S , Weiss B , Ruff A . PLoS One 2014 9 (8) e104557 BACKGROUND: IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources. OBJECTIVES: To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia. METHODS: A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, "IPT-only," "IPT-before-ART," "IPT-and-ART started simultaneously," "ART-only," and "IPT-after-ART" on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence. RESULTS: Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of "IPT-only" (aHR = 0.36, 95% CI = 0.19-0.66) and "ART-only" (aHR = 0.32, 95% CI = 0.24-0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08-0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10-0.42) provided further reduction of TB at approximately 80%. CONCLUSIONS: IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden. |
Chlamydia screening for sexually active young women under the affordable care act: new opportunities and lingering barriers
Loosier PS , Malcarney MB , Slive L , Cramer RC , Burgess B , Hoover KW , Romaguera R . Sex Transm Dis 2014 41 (9) 538-44 The Affordable Care Act of 2010 (ACA) contains a provision requiring private insurers issuing or renewing plans on or after September 23, 2010, to provide, without cost sharing, preventive services recommended by US Preventive Services Task Force (grades A and B), among other recommending bodies. As a grade A recommendation, chlamydia screening for sexually active young women 24 years and younger and older women at risk for chlamydia falls under this requirement. This article examines the potential effect on chlamydia screening among this population across private and public health plans and identifies lingering barriers not addressed by this legislation. Examination of the impact on women with private insurance touches upon the distinction between coverage under grandfathered plans, where the requirement does not apply, and nongrandfathered plans, where the requirement does apply. Acquisition of private health insurance through health insurance Marketplaces is also discussed. For public health plans, coverage of preventive services without cost sharing differs for individuals enrolled in standard Medicaid, covered under the Medicaid expansion included in the ACA, or those enrolled under the Children's Health Insurance Program or who fall under Early, Periodic, Screening, Diagnosis and Treatment criteria. The discussion of lingering barriers not addressed by the ACA includes the uninsured, physician reimbursement, cost sharing, confidentiality, low rates of appropriate sexual history taking by providers, and disclosures of sensitive information. In addition, the role of safety net programs that provide health care to individuals regardless of ability to pay is examined in light of the expectation that they also remain a payer of last resort. |
Molecular xenomonitoring using mosquitoes to map lymphatic filariasis after mass drug administration in American Samoa.
Schmaedick MA , Koppel AL , Pilotte N , Torres M , Williams SA , Dobson SL , Lammie PJ , Won KY . PLoS Negl Trop Dis 2014 8 (8) e3087 BACKGROUND: Mass drug administration (MDA) programs have dramatically reduced lymphatic filariasis (LF) incidence in many areas around the globe, including American Samoa. As infection rates decline and MDA programs end, efficient and sensitive methods for detecting infections are needed to monitor for recrudescence. Molecular methods, collectively termed 'molecular xenomonitoring,' can identify parasite DNA or RNA in human blood-feeding mosquitoes. We tested mosquitoes trapped throughout the inhabited islands of American Samoa to identify areas of possible continuing LF transmission after completion of MDA. METHODOLOGY/PRINCIPLE FINDINGS: Mosquitoes were collected using BG Sentinel traps from most of the villages on American Samoa's largest island, Tutuila, and all major villages on the smaller islands of Aunu'u, Ofu, Olosega, and Ta'u. Real-time PCR was used to detect Wuchereria bancrofti DNA in pools of ≤20 mosquitoes, and PoolScreen software was used to infer territory-wide prevalences of W. bancrofti DNA in the mosquitoes. Wuchereria bancrofti DNA was found in mosquitoes from 16 out of the 27 village areas sampled on Tutuila and Aunu'u islands but none of the five villages on the Manu'a islands of Ofu, Olosega, and Ta'u. The overall 95% confidence interval estimate for W. bancrofti DNA prevalence in the LF vector Ae. polynesiensis was 0.20-0.39%, and parasite DNA was also detected in pools of Culex quinquefasciatus, Aedes aegypti, and Aedes (Finlaya) spp. CONCLUSIONS/SIGNIFICANCE: Our results suggest low but widespread prevalence of LF on Tutuila and Aunu'u where 98% of the population resides, but not Ofu, Olosega, and Ta'u islands. Molecular xenomonitoring can help identify areas of possible LF transmission, but its use in the LF elimination program in American Samoa is limited by the need for more efficient mosquito collection methods and a better understanding of the relationship between prevalence of W. bancrofti DNA in mosquitoes and infection and transmission rates in humans. |
Isolation of Leptospira from a phocid: acute renal failure and mortality from Leptospirosis in rehabilitated northern elephant seals (Mirounga angustirostris), California, USA
Delaney MA , Colegrove KM , Spraker TR , Zuerner RL , Galloway RL , Gulland FM . J Wildl Dis 2014 50 (3) 621-7 During rehabilitation, acute renal failure due to leptospirosis occurred in eight male northern elephant seals (Mirounga angustirostris) that stranded along the central California coast in 2011. Characteristic histologic lesions including renal tubular degeneration, necrosis, and mineralization, and mild lymphoplasmacytic interstitial nephritis were noted in the six animals examined. Immunohistochemistry, bacterial culture, and PCR were positive in 2/3, 2/3, and 3/4 seals, respectively, and 6/8 had high serum antibody titers to Leptospira interrogans serovar pomona. Pulsed-field gel electrophoresis confirmed one isolate as serovar pomona. Variable number tandem repeat (VNTR) analysis showed both elephant seal isolates were identical to each other but distinct from those isolated from California sea lions (Zalophus californianus). The time from stranding to onset of azotemia was 1 to 38 (median=24) days, suggesting some seals were infected at the rehabilitation facility. Based on temporal and spatial incidence of infection, transmission among elephant seals likely occurred during rehabilitation. Molecular (VNTR) analysis of the two isolates indicates there is a unique L. interrogans serovar pomona genotype in elephant seals, and sea lions were not the source of infection prior to or during rehabilitation. This study confirms the susceptibility of northern elephant seals to leptospirosis, indicates intraspecies transmission during rehabilitation, and reports the first isolation and preliminary characterization of leptospires from elephant seals. |
Prescription histories and dose strengths associated with overdose deaths
Hirsch A , Proescholdbell SK , Bronson W , Dasgupta N . Pain Med 2014 15 (7) 1187-1195 OBJECTIVE: Misuse, abuse, and diversion of prescription drugs are large and growing public health problems that have resulted in an overdose epidemic. We investigated whether short-acting or extended-release opioids were more frequently prescribed to those who died of an overdose and whether there was a linear relationship between dose strength and associated overdose deaths. METHODS: The study population was North Carolina residents in 2010. We conducted a retrospective, population-based, descriptive study of medication histories of overdose decedents using data from vital statistics, medical examiner records, and a prescription drug monitoring program. RESULTS: Unintentional or undetermined drug overdoses were responsible for 892 deaths. Out of 191 deaths involving methadone, only two were patients in opioid treatment programs. Immediate-release oxycodone was involved in the greatest number of opioid-related deaths. Out of 221 oxycodone deaths, 134 (61%) of the decedents filled a prescription for oxycodone in the 60 days prior to death. The most common strength dispensed within 60 days to a decedent who died of an oxycodone overdose was 10mg for immediate-release (72 prescriptions). Immediate-release oxycodone products (rho=1.00, P<0.01) and extended-release fentanyl products (rho=1.00, P<0.01) showed strong increasing linear trends between dose strength and proportion of prescriptions dispensed to decedents. CONCLUSIONS: A significant proportion of overdose decedents had been prescribed the same type of drugs that contributed to their death, especially for decedents who died from overdoses involving oxycodone, hydrocodone, and alprazolam. Higher dose strengths for certain opioids had higher associated mortality, and certain immediate-release opioids may be considered for public health prevention efforts. |
Predictors of serum polychlorinated biphenyl concentrations in Anniston residents
Pavuk M , Olson JR , Wattigney WA , Dutton ND , Sjodin A , Shelton C , Turner WE , Bartell SM . Sci Total Environ 2014 496 624-634 The Anniston Community Health Survey was a community-based cross-sectional study of Anniston, Alabama, residents who live in close proximity to a former PCB production facility to identify factors associated with serum PCB levels. The survey comprises 765 Anniston residents who completed a questionnaire interview and provided a blood sample for analysis in 2005-2007. Several reports based on data from the Anniston survey have been previously published, including associations between PCB exposure and diabetes and blood pressure. In this study we examine demographic, behavioral, dietary, and occupational characteristics of Anniston survey participants as predictors of serum PCB concentrations. Of the 765 participants, 54% were White and 45% were African-American; the sample was predominantly female (70%), with a mean age of 55 years. Serum PCB concentrations varied widely between participants (range for sum of 35 PCBs: 0.11-170.4ng/g wet weight). Linear regression models with stepwise selection were employed to examine factors associated with serum PCBs. Statistically significant positive associations were observed between serum PCB concentrations and age, race, residential variables, current smoking, and local fish consumption, as was a negative association with education level. Age and race were the most influential predictors of serum PCB levels. A small age by sex interaction was noted, indicating that the increase in PCB levels with age was steeper for women than for men. Significant interaction terms indicated that the associations between PCB levels and having ever eaten locally raised livestock and local clay were much stronger among African-Americans than among White participants. In summary, demographic variables and past consumption of locally produced foods were found to be the most important predictors of PCB concentrations in residents living in the vicinity of a former PCB manufacturing facility. |
Prepubertal organochlorine pesticide concentrations and age of pubertal onset among Russian boys
Lam T , Williams PL , Lee MM , Korrick SA , Birnbaum LS , Burns JS , Sergeyev O , Revich B , Altshul LM , Patterson DG Jr , Turner WE , Hauser R . Environ Int 2014 73c 135-142 BACKGROUND: In animal studies, organochlorine pesticide (OCP) exposure alters pubertal development; however, epidemiological data are limited and inconsistent. OBJECTIVE: To evaluate the associations of serum OCP concentrations [hexachlorobenzene (HCB), beta-hexachlorocyclohexane (beta-HCH), and p,p'-dichlorodiphenyldichloroethylene (p,p'-DDE)] with male pubertal onset. METHODS: In Chapaevsk, Russia, a town environmentally contaminated with OCPs, 350 8-9year old boys with measured OCPs were enrolled during 2003-2005 and were followed annually for eight years. We evaluated three measures of pubertal onset: testicular volume (TV)>3mL in either testis, or stage 2 or greater for genitalia (G2+), or pubic hair (P2+). We used multivariable interval-censored models to evaluate associations of OCPs (quartiles) with physician-assessed pubertal onset. RESULTS: In adjusted models, boys with higher HCB concentrations had later mean ages of TV>3mL and P2+ (but not G2+). Mean age at attaining TV>3mL was delayed 3.6 (95% CI: -2.6, 9.7), 7.9 (95% CI: 1.7, 14.0), and 4.7months (95% CI: -1.4, 10.9) for HCB Q2, Q3, and Q4, respectively, compared to Q1 (trend p: 0.06). Boys with higher HCB concentrations reached P2+ 0.1months earlier (95% CI: -5.8, 5.6) for Q2, 4.7months later (95% CI: -1.0, 10.3) for Q3 and 4.6months later (95% CI: -1.1, 10.3) for Q4 compared to Q1 (trend p: 0.04). There were no associations of serum beta-HCH and p,p'-DDE concentrations with age of pubertal onset. CONCLUSION: Higher prepubertal serum HCB concentrations were associated with later age of gonadarche and pubarche. |
Population-based association and gene by environment interactions in Genetic Analysis Workshop 18.
Satten GA , Biswas S , Papachristou C , Turkmen A , Konig IR . Genet Epidemiol 2014 38 Suppl 1 S49-56 In the past decade, genome-wide association studies have been successful in identifying genetic loci that play a role in many complex diseases. Despite this, it has become clear that for many traits, investigation of single common variants does not give a complete picture of the genetic contribution to the phenotype. Therefore a number of new approaches are currently being investigated to further the search for susceptibility loci or regions. We summarize the contributions to Genetic Analysis Workshop 18 (GAW18) that concern this search using methods for population-based association analysis. Many of the members of our GAW18 working group made use of data types that have only recently become available through the use of next-generation sequencing technologies, with many focusing on the investigation of rare variants instead of or in combination with common variants. Some contributors used a haplotype-based approach, which to date has been used relatively infrequently but may become more important for analyzing rare variant association data. Others analyzed gene-gene or gene-environment interactions, where novel statistical approaches were needed to make the best use of the available information without requiring an excessive computational burden. GAW18 provided participants with the chance to make use of state-of-the-art data, statistical techniques, and technology. We report here some of the experiences and conclusions that were reached by workshop participants who analyzed the GAW18 data as a population-based association study. |
Genome Sequences of 228 Shiga Toxin-Producing Escherichia coli Isolates and 12 Isolates Representing Other Diarrheagenic E. coli Pathotypes.
Trees E , Strockbine N , Changayil S , Ranganathan S , Zhao K , Weil R , MacCannell D , Sabol A , Schmidtke A , Martin H , Stripling D , Ribot EM , Gerner-Smidt P . Genome Announc 2014 2 (4) Shiga toxin-producing Escherichia coli (STEC) are a common cause for food-borne diarrheal illness outbreaks and sporadic cases. Here, we report the availability of the draft genome sequences of 228 STEC strains representing 32 serotypes with known pulsed-field gel electrophoresis (PFGE) types and epidemiological relationships, as well as 12 strains representing other diarrheagenic E. coli pathotypes. |
Horizontal transfers and gene losses in the phospholipid pathway of bartonella reveal clues about early ecological niches.
Zhu Q , Kosoy M , Olival KJ , Dittmar K . Genome Biol Evol 2014 6 (8) 2156-69 Bartonellae are mammalian pathogens vectored by blood-feeding arthropods. Although of increasing medical importance, little is known about their ecological past, and host associations are underexplored. Previous studies suggest an influence of horizontal gene transfers in ecological niche colonization by acquisition of host pathogenicity genes. We here expand these analyses to metabolic pathways of 28 Bartonella genomes, and experimentally explore the distribution of bartonellae in 21 species of blood-feeding arthropods. Across genomes, repeated gene losses and horizontal gains in the phospholipid pathway were found. The evolutionary timing of these patterns suggests functional consequences likely leading to an early intracellular lifestyle for stem bartonellae. Comparative phylogenomic analyses discover three independent lineage-specific reacquisitions of a core metabolic gene - NAD(P)H-dependent glycerol-3-phosphate dehydrogenase (gpsA) - from Gammaproteobacteria and Epsilonproteobacteria. Transferred genes are significantly closely related to invertebrate Arsenophonus-, and Serratia-like endosymbionts, and mammalian Helicobacter-like pathogens, supporting a cellular association with arthropods and mammals at the base of extant Bartonella spp. Our studies suggest that the horizontal re-acquisitions had a key impact on bartonellae lineage specific ecological and functional evolution. |
Associations of body mass index with sexual risk-taking and injection drug use among US high school students
Lowry R , Robin L , Kann L , Galuska DA . J Obes 2014 2014 816071 The purpose of this study was to determine if body mass index (BMI) is associated with behaviors that may increase risk for HIV and other sexually transmitted diseases (STDs) among US high school students. We analyzed nationally representative data from the 2005-2011 national Youth Risk Behavior Surveys (YRBS) to examine associations of BMI categories with sexual risk behaviors and injection drug use among sexually active high school students, using sex-stratified logistic regression models. Controlling for race/ethnicity and grade, among female and male students, both underweight (BMI < 5th percentile) and obesity (BMI ≥ 95th percentile) were associated with decreased odds of being currently sexually active (i.e., having had sexual intercourse during the past 3 months). However, among sexually active female students, obese females were more likely than normal weight females to have had 4 or more sex partners (odds ratio, OR = 1.59), not used a condom at last sexual intercourse (OR = 1.30), and injected illegal drugs (OR = 1.98). Among sexually active male students, overweight (85th percentile ≤ BMI < 95th percentile) was associated with not using a condom at last sexual intercourse (OR = 1.19) and obesity was associated with injection drug use (OR = 1.42). Among sexually active students, overweight and obesity may be indicators of increased risk for HIV and other STDs. |
Outbreaks of infections associated with drug diversion by US health care personnel
Schaefer MK , Perz JF . Mayo Clin Proc 2014 89 (7) 878-87 OBJECTIVE: To summarize available information about outbreaks of infections stemming from drug diversion in US health care settings and describe recommended protocols and public health actions. PATIENTS AND METHODS: We reviewed records at the Centers for Disease Control and Prevention related to outbreaks of infections from drug diversion by health care personnel in US health care settings from January 1, 2000, through December 31, 2013. Searches of the medical literature published during the same period were also conducted using PubMed. Information compiled included health care setting(s), infection type(s), specialty of the implicated health care professional, implicated medication(s), mechanism(s) of diversion, number of infected patients, number of patients with potential exposure to blood-borne pathogens, and resolution of the investigation. RESULTS: We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing. CONCLUSION: These outbreaks revealed gaps in prevention, detection, and response to drug diversion in US health care facilities. Drug diversion is best prevented by health care facilities having strong narcotics security measures and active monitoring systems. Appropriate response includes assessment of harm to patients, consultation with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies. |
Infection prevention practices in neonatal intensive care units reporting to the National Healthcare Safety Network
Hocevar SN , Lessa FC , Gallagher L , Conover C , Gorwitz R , Iwamoto M . Infect Control Hosp Epidemiol 2014 35 (9) 1126-32 BACKGROUND: Patients in the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections. Variability in reported infection rates among NICUs exists, possibly related to differences in prevention strategies. A better understanding of current prevention practices may help identify prevention gaps and areas for further research. METHODS: We surveyed infection control staff in NICUs reporting to the National Healthcare Safety Network (NHSN) to assess strategies used to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and central line-associated bloodstream infections in NICUs. RESULTS: Staff from 162 of 342 NICUs responded (response rate, 47.3%). Most (92.3%) NICUs use central line insertion and maintenance bundles, but maintenance practices varied, including agents used for antisepsis and frequency of dressing changes. Forty-two percent reported routine screening for MRSA colonization upon admission for all patients. Chlorhexidine gluconate (CHG) use for central line care for at least 1 indication (central line insertion, dressing changes, or port/cap antisepsis) was reported in 82 NICUs (51.3%). Among sixty-five NICUs responding to questions on CHG use restrictions, 46.2% reported no restrictions. CONCLUSIONS: Our survey illustrated heterogeneity of CLABSI and MRSA prevention practices and underscores the need for further research to define optimal strategies and evidence-based prevention recommendations for neonates. |
The Vaccine Safety Datalink: successes and challenges monitoring vaccine safety
McNeil MM , Gee J , Weintraub ES , Belongia EA , Lee GM , Glanz JM , Nordin JD , Klein NP , Baxter R , Naleway AL , Jackson LA , Omer SB , Jacobsen SJ , DeStefano F . Vaccine 2014 32 (42) 5390-8 The Vaccine Safety Datalink (VSD) is a collaborative project between the Centers for Disease Control and Prevention (CDC) and 9 health care organizations. Established in 1990, VSD is a vital resource informing policy makers and the public about the safety of vaccines used in the United States. Large linked databases are used to identify and evaluate adverse events in over 9 million individuals annually. VSD generates rapid, important safety assessments for both routine vaccinations and emergency vaccination campaigns. VSD monitors safety of seasonal influenza vaccines in near-real time, and provided essential information on the safety of monovalent H1N1 vaccine during the 2009 pandemic. VSD investigators have published important studies demonstrating that childhood vaccines are not associated with autism or other developmental disabilities. VSD prioritizes evaluation of new vaccines; searches for possible unusual health events after vaccination; monitors vaccine safety in pregnant women; and has pioneered development of biostatistical research methods. |
Postlicensure monitoring of HPV vaccination programmes
Markowitz LE , Hariri S . Lancet Infect Dis 2014 14 (10) 904-5 In The Lancet Infectious Diseases, Sepehr Tabrizi and colleagues1 report data from a repeat cross-sectional study of vaccine-eligible women attending family planning clinics before and after quadrivalent human papillomavirus (HPV) vaccine introduction in Australia. The investigators previously reported declines in the prevalence of vaccine-targeted HPV types (HPV 6, 11, 16, and 18) in the period after the introduction of the vaccine using data from earlier years of this study.2 In the present analysis, they confirmed earlier findings and also investigated herd effects of HPV vaccination and crossprotection against non-vaccine-targeted HPV types. Compared with the prevaccine period, Tabrizi and colleagues reported a significant decline in the prevalence of HPV 6, 11, 16, and 18 in the postvaccine period (77%), including a 92% decline in vaccinated women (from 28·7% to 2·3%) and a 35% decline in those who were not vaccinated (from 28·7% to 18·8%). | A limitation of this analysis was the absence of data on sexual behaviour and other characteristics in the prevaccine period, preventing assessment of potential differences between the samples. However, despite this limitation, the small sample sizes, and other potential biases acknowledged by the investigators, the observed herd effects are consistent with expectations, since HPV vaccines are highly efficacious and Australia has high vaccination coverage. Indeed, the first data suggesting herd effects were from Australia.3, 4, 5, 6 Those data showed marked declines in genital warts not only in women and girls, but also in young heterosexual men as early as 2 years after introduction of the female-only national HPV vaccination programme. The findings from this study support those from earlier ecological studies and add to the existing evidence by showing declines in oncogenic vaccine HPV types in unvaccinated women. Data suggest that herd effects might be occurring in other countries as well.7, 8 |
Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) - United States, 2014-15 influenza season
Grohskopf LA , Olsen SJ , Sokolow LZ , Bresee JS , Cox NJ , Broder KR , Karron RA , Walter EB . MMWR Morb Mortal Wkly Rep 2014 63 (32) 691-7 This report updates the 2013 recommendations by the Advisory Committee on Immunization Practices (ACIP) regarding use of seasonal influenza vaccines. Updated information for the 2014-15 influenza season includes 1) antigenic composition of U.S. seasonal influenza vaccines; 2) vaccine dose considerations for children aged 6 months through 8 years; and 3) a preference for the use, when immediately available, of live attenuated influenza vaccine (LAIV) for healthy children aged 2 through 8 years, to be implemented as feasible for the 2014-15 season but not later than the 2015-16 season. Information regarding issues related to influenza vaccination not addressed in this report is available in the 2013 ACIP seasonal influenza recommendations. |
Evaluation of the impact of the 2012 Rhode Island health care worker influenza vaccination regulations: implementation process and vaccination coverage
Kim H , Lindley MC , Dube D , Kalayil EJ , Paiva KA , Raymond P . J Public Health Manag Pract 2014 21 (3) E1-9 CONTEXT: In October 2012, the Rhode Island Department of Health (HEALTH) amended its health care worker (HCW) vaccination regulations to require all HCWs to receive annual influenza vaccination or wear a surgical mask during direct patient contact when influenza is widespread. Unvaccinated HCWs failing to wear a mask are subject to a fine and disciplinary action. OBJECTIVE: To describe the implementation of the 2012 Rhode Island HCW influenza vaccination regulations and examine their impact on vaccination coverage. DESIGN: Two data sources were used: (1) a survey of all health care facilities subject to the HCW regulations and (2) HCW influenza vaccination coverage data reported to HEALTH by health care facilities. Descriptive statistics and paired t tests were performed using SAS Release 9.2. SETTING AND PARTICIPANTS: For the 2012-2013 influenza season, 271 inpatient and outpatient health care facilities in Rhode Island were subject to the HCW regulations. MAIN OUTCOME MEASURE: Increase in HCW influenza vaccination coverage. RESULTS: Of the 271 facilities, 117 facilities completed the survey (43.2%) and 160 facilities reported vaccination data to HEALTH (59.0%). Between the 2011-2012 and 2012-2013 influenza seasons, the proportion of facilities having a masking policy, as required by the revised regulations, increased from 9.4% to 94.0% (P < .001). However, the proportion of facilities implementing Advisory Committee on Immunization Practices-recommended strategies to promote HCW influenza vaccination did not increase. The majority of facilities perceived benefits to collecting HCW influenza vaccination data, including strengthening infection prevention efforts (83.2%) and improving patient and coworker safety (75.2%). Concurrent with the new regulations, influenza vaccination coverage among employee HCWs in Rhode Island increased from 69.7% in the 2011-2012 influenza season to 87.2% in the 2012-2013 season. CONCLUSION: Rhode Island's experience demonstrates that statewide HCW influenza vaccination requirements incorporating mask wearing and moderate penalties for noncompliance can be effective in improving influenza vaccination coverage among HCWs. |
Increasing childhood influenza vaccination: a cluster randomized trial
Nowalk MP , Lin CJ , Hannibal K , Reis EC , Gallik G , Moehling KK , Huang HH , Allred NJ , Wolfson DH , Zimmerman RK . Am J Prev Med 2014 47 (4) 435-43 BACKGROUND: Since the 2008 inception of universal childhood influenza vaccination, national rates have risen more dramatically among younger children than older children and reported rates across racial/ethnic groups are inconsistent. Interventions may be needed to address age and racial disparities to achieve the recommended childhood influenza vaccination target of 70%. PURPOSE: To evaluate an intervention to increase childhood influenza vaccination across age and racial groups. METHODS: In 2011-2012, a total of 20 primary care practices treating children were randomly assigned to the intervention and control arms of a cluster randomized controlled trial to increase childhood influenza vaccination uptake using a toolkit and other strategies including early delivery of donated vaccine, in-service staff meetings, and publicity. RESULTS: The average vaccination differences from pre-intervention to the intervention year were significantly larger in the intervention arm (n=10 practices) than the control arm (n=10 practices); for children aged 9-18 years (11.1 pct pts intervention vs 4.3 pct pts control, p<0.05); for non-white children (16.7 pct pts intervention vs 4.6 pct pts control, p<0.001); and overall (9.9 pct pts intervention vs 4.2 pct pts control, p<0.01). In multi-level modeling that accounted for person- and practice-level variables and the interactions among age, race, and intervention, the likelihood of vaccination increased with younger age group (6-23 months); white race; commercial insurance; the practice's pre-intervention vaccination rate; and being in the intervention arm. Estimates of the interaction terms indicated that the intervention increased the likelihood of vaccination for non-white children in all age groups and white children aged 9-18 years. CONCLUSIONS: A multi-strategy intervention that includes a practice improvement toolkit can significantly improve influenza vaccination uptake across age and racial groups without targeting specific groups, especially in practices with large percentages of minority children. |
Physical dating violence victimization among sexual minority youth
Luo F , Stone DM , Tharp AT . Am J Public Health 2014 104 (10) e1-e8 OBJECTIVES: We examined (1) whether sexual minority youths (SMYs) are at increased risk for physical dating violence victimization (PDVV) compared with non-SMYs, (2) whether bisexual youths have greater risk of PDVV than lesbian or gay youths, (3) whether youths who have had sexual contact with both sexes are more susceptible to PDVV than youths with same sex-only sexual contact, and (4) patterns of PDVV among SMYs across demographic groups. METHODS: Using 2 measures of sexual orientation, sexual identity and sexual behavior, and compiling data from 9 urban areas that administered the Youth Risk Behavior Surveys from 2001 to 2011, we conducted logistic regression analyses to calculate odds of PDVV among SMYs across demographic sub-samples. RESULTS: SMYs have significantly increased odds of PDVV compared with non-SMYs. Bisexual youths do not have significantly higher odds of PDVV than gay or lesbian youths, but youths who had sexual contact with both-sexes possess significantly higher odds of PDVV than youths with same sex-only sexual contact. These patterns hold for most gender, grade, and racial/ethnic subgroups. CONCLUSIONS: Overall, SMYs have greater odds of PDVV versus non-SMYs. Among SMYs, youths who had sexual contact with both sexes have greater odds of PDVV than youths with same sex-only sexual contact. Prevention programs that consider sexual orientation, support tolerance, and teach coping and conflict resolution skills could reduce PDVV among SMYs. |
Evaluation of the Green Dot bystander intervention to reduce interpersonal violence among college students across three campuses
Coker AL , Fisher BS , Bush HM , Swan SC , Williams CM , Clear ER , DeGue S . Violence Against Women 2014 21 (12) 1507-27 Evidence suggests that interventions to engage bystanders in violence prevention increase bystander intentions and efficacy to intervene, yet the impact of such programs on violence remains unknown. This study compared rates of violence by type among undergraduate students attending a college campus with the Green Dot bystander intervention (n = 2,768) with students at two colleges without bystander programs (n = 4,258). Violent victimization rates were significantly (p < .01) lower among students attending the campus with Green Dot relative to the two comparison campuses. Violence perpetration rates were lower among males attending the intervention campus. Implications of these results for research and practice are discussed. |
Exploring policies for the reduction of child physical abuse and neglect
Klevens J , Barnett SB , Florence C , Moore D . Child Abuse Negl 2014 40 1-11 Policies can be powerful tools for prevention given their potential to affect conditions that can improve population-level health. Given the dearth of empirical research on policies' impacts on child maltreatment, this article (a) identifies 37 state policies that might have impacts on the social determinants of child maltreatment; (b) identifies available data sources documenting the implementation of 31 policies; and (c) utilizes the available data to explore effects of 11 policies (selected because they had little missing data) on child maltreatment rates. These include two policies aimed at reducing poverty, two temporary assistance to needy families policies, two policies aimed at increasing access to child care, three policies aimed at increasing access to high quality pre-K, and three policies aimed at increasing access to health care. Multi-level regression analyses between within-state trends of child maltreatment investigation rates and these 11 policies, controlling for states' childhood poverty, adults without a high school diploma, unemployment, child burden, and race/ethnicity, identified two that were significantly associated with decreased child maltreatment rates: lack of waitlists to access subsidized child care and policies that facilitate continuity of child health care. These findings are correlational and are limited by the quality and availability of the data. Future research might focus on a reduced number of states that have good quality administrative data or population-based survey data on child maltreatment or reasonable proxies for child maltreatment and where data on the actual implementation of specific policies of interest can be documented. |
Building safety into active living initiatives
Pollack K , Bailey M , Gielen A , Wolf S , Auld ME , Sleet DA , Lee KK . Prev Med 2014 69 Suppl 1 S102-5 OBJECTIVE: Efforts to promote environmental designs that facilitate opportunities for physical activity should consider the fact that injuries are the leading cause of death for Americans ages 1 to 44, with transportation-related injuries the most common cause. Drawing on the latest research and best practices in the field of injury prevention, the purpose of this article is to provide those working to promote physical activity with evidence-based recommendations on building in safety while designing active environments. METHOD: A systematic review of the peer-reviewed and gray literature published from 1995 to 2012 was conducted to identify injury prevention strategies applicable to objectives in the Active Design Guidelines (ADG), which present design strategies for active living. Injury prevention strategies were rated according to the strength of the research evidence. RESULTS: We identified 18 urban design strategies and 9 building design strategies that promote safety. Evidence was strong or emerging for 14/18 urban design strategies and 7/9 building design strategies. CONCLUSION: ADG strategies are often wholly compatible with well-accepted injury prevention principles. By partnering with architects and planners, injury prevention and public health professionals can help ensure that new and renovated spaces maximize both active living and safety. |
Poor performance of the determine HIV-1/2 Ag/Ab combo fourth-generation rapid test for detection of acute infections in a National Household Survey in Swaziland
Duong YT , Mavengere Y , Patel H , Moore C , Manjengwa J , Sibandze D , Rasberry C , Mlambo C , Li Z , Emel L , Bock N , Moore J , Nkambule R , Justman J , Reed J , Bicego G , Ellenberger DL , Nkengasong JN , Parekh BS . J Clin Microbiol 2014 52 (10) 3743-8 Fourth-generation HIV rapid tests (RTs) claim to detect both p24 antigen (Ag) and HIV antibodies (Ab) for early identification of acute infections, important for targeted prevention and reducing HIV transmission. In a nationally representative household survey in Swaziland, 18,172 adults, age 18-49 years, received home-based HIV rapid testing in 2010-2011. Of the 18,172 individuals, 5,822 (32.0%) were Ab+ by Determine HIV-1/2 Ab/Ab Combo and of those, 5,789 (99.4%) were confirmed reactive by Uni-Gold. Determine Combo identified 12 individuals as acute infections (Ag+/Ab-); however, none had detectable HIV-1 RNA and 8 of 12 remained HIV negative at 6-week follow-up visits (4 lost to follow up). All RT non-reactive samples were pooled and tested by nucleic acid amplification testing (NAAT) to identify acute infections. NAAT identified 13 (0.1%) of the 12,338 HIV antibody-negative specimens as HIV RNA positive with RNA levels ranging from 300 to >10,000,000 copies/mL. However, none of them were Ag+ on Determine Combo. Follow-up testing of 12 of the 13 NAAT-positive individuals at 6 months demonstrated 12 seroconversions (1 lost to follow-up). Therefore, the Combo test had a sensitivity of 0% (95% CI 0%-28%) and positive predictive value of 0% for the detection of acute infections. The ability of Determine 4th Generation Combo to detect antigen was very poor in Swaziland. Thus, Determine Combo does not add any value to the current testing algorithm; rather it adds additional costs and complexity to HIV diagnosis. The detection of acute HIV infections may need to rely on other testing strategies. |
A highly specific monoclonal antibody against monkeypox virus detects the heparin binding domain of A27
Hughes LJ , Goldstein J , Pohl J , Hooper JW , Lee Pitts R , Townsend MB , Bagarozzi D , Damon IK , Karem KL . Virology 2014 464-465c 264-273 The eradication of smallpox and the cessation of global vaccination led to the increased prevalence of human infections in Central Africa. Serologic and protein-based diagnostic assay for MPXV detection is difficult due to cross-reactive antibodies that do not differentiate between diverse orthopoxvirus (OPXV) species. A previously characterized monoclonal antibody (mAb 69-126-3-7) against MPXV [1] was retested for cross-reactivity with various OPXVs. The 14.5kDa band protein that reacted with mAb 69-126-3 was identified to be MPXV A29 protein (homolog of vaccinia virus Copenhagen A27). Amino acid sequence analysis of the MPXV A29 with other OPXV homologs identified four amino acid changes. Peptides corresponding to these regions were designed and evaluated for binding to mAb 69-126-3 by ELISA and BioLayer Interferometry (BLI). Further refinement and truncations mapped the specificity of this antibody to a single amino acid difference in a 30-mer peptide compared to other OPXV homologs. This particular residue is proposed to be essential for heparin binding by VACV A27 protein. Despite this substitution, MPXV A29 bound to heparin with similar affinity to that of VACV A27 protein, suggesting flexibility of this motif for heparin binding. Although binding of mAb 69-126-3-7 to MPXV A29 prevented interaction with heparin, it did not have any effect on the infectivity of MPXV. Characterization of 69-126-3-7 mAb antibody allows for the possibility of the generation of a serological based species-specific detection of OPXVs despite high proteomic homology. |
Characterization of drug-resistant influenza A(H7N9) variant viruses isolated from an oseltamivir-treated patient in Taiwan
Marjuki H , Mishin VP , Chesnokov AP , Jones J , De La Cruz JA , Sleeman K , Tamura D , Nguyen HT , Wu HS , Chang FY , Liu MT , Fry AM , Cox NJ , Villanueva JM , Davis CT , Gubareva LV . J Infect Dis 2014 211 (2) 249-57 BACKGROUND: Patients contracting influenza A(H7N9) often developed severe disease causing respiratory failure. Neuraminidase (NA) inhibitors (NAIs) are the primary option for treatment, but information on drug-resistance markers for A(H7N9) is limited. METHODS: Four NA variants of A/Taiwan/1/2013 (H7N9) virus containing a single substitution (NA-E119 V, NA-I222 K, NA-I222R or NA-R292 K), recovered from an oseltamivir-treated patient, were tested for NAI susceptibility in vitro; their replicative fitness was evaluated in cell culture, mice and ferrets. RESULTS: NA-R292 K led to highly reduced inhibition by oseltamivir and peramivir, while NA-E119 V, NA-I222 K and NA-I222R caused reduced inhibition by oseltamivir. Mice infected with any virus showed severe clinical signs with high mortality rates. NA-I222 K virus was the most virulent in mice, whereas virus lacking NA change (NA-WT) and NA-R292 K virus seemed the least virulent. Sequence analysis suggests that PB2-S714N increased virulence of the NA-I222 K virus in mice; NS1-K126R, alone or in combination with PB2-V227M, produced contrasting effects in NA-WT and NA-R292 K viruses. In ferrets, all viruses replicated to high titers in the upper respiratory tract, but produced only mild illness. NA-R292 K virus, showed reduced replicative fitness in this animal model. CONCLUSIONS: Our data highlight challenges in assessment of replicative fitness of H7N9 NA variants emerged in NAI-treated patients. |
Collection and characterization of samples for the establishment of a serum repository for Lyme disease diagnostic test development and evaluation
Molins CR , Sexton C , Young JW , Ashton LV , Pappert R , Beard CB , Schriefer ME . J Clin Microbiol 2014 52 (10) 3755-62 Serological assays and a two-tiered test algorithm are recommended for laboratory confirmation of Lyme disease. In the U.S. the sensitivity of two-tiered testing using commercially available serology-based assays is dependent on the stage of infection and ranges from 30% in the early localized disease to near 100% in late stage disease. Other variables, including subjectivity in reading Western blots, compliance with two-tiered recommendations, use of different first and second tier test combinations, and use of different test samples, all contribute to variation in two-tiered test performance. The availability and use of sample sets from well-characterized Lyme disease patients and controls are needed to better assess the performance of existing tests and for development of improved assays. To address this need, the Centers for Disease Control and Prevention and the National Institutes of Health prospectively collected sera from patients at all stages of Lyme disease, as well as healthy donors and patients with look-alike diseases. Patients and healthy controls were recruited using strict inclusion and exclusion criteria. Samples from all included patients were retrospectively characterized by two-tiered testing. The results from two-tiered testing corroborated the need for novel and improved diagnostics, particularly for laboratory diagnosis of earlier stages of infection. Furthermore, the two-tier results provide a baseline with samples from well-defined patients that can be used in comparing the sensitivity and specificity of novel diagnostics. Panels of sera and accompanying clinical and laboratory testing results are now available to Lyme disease serological test users and researchers developing novel tests. |
Severity of influenza and non-influenza acute respiratory illness among pregnant women, 2010-12
Sokolow LZ , Naleway AL , Li DK , Shifflett P , Reynolds S , Henninger ML , Ferber JR , Odouli R , Irving SA , Thompson MG . Am J Obstet Gynecol 2014 212 (2) 202 e1-11 OBJECTIVE: To identify characteristics of influenza illness contrasted with non-influenza acute respiratory illnesses (ARI) in pregnant women. STUDY DESIGN: ARI among pregnant women was identified through daily surveillance during two influenza seasons (2010-12). Within 8 days of illness onset, nasopharyngeal swabs were collected, and an interview was conducted for symptoms and other characteristics. A follow-up telephone interview was conducted 1-2 weeks later, and medical records were extracted. Severity of illness was evaluated by self-assessment of 12 illness symptoms, subjective ratings of overall impairment, highest reported temperature, illness duration, and medical utilization. RESULTS: Of 292 pregnant women with ARI, 100 tested positive for influenza viruses. Women with influenza illnesses reported higher symptom severity than those with non-influenza ARI (median score: 18 vs. 16 out of 36; p<.05) and were more likely to report severe subjective feverishness (18% vs. 5%; p<.001), myalgia (28% vs 14%; p<.005), cough (46% vs 30%; p<.01), and chills (25% vs. 13%; p<.01). More influenza illnesses were associated with fever >38.9oC (20% vs. 5%; p<.001) and higher subjective impairment (mean score 5.9 vs. 4.8; p<.001). Differences in overall symptom severity, fever, cough, chills, early healthcare-seeking behavior, and impairment remained significant in multivariate models after adjusting for study site, season, age, vaccination status, and number of days since illness onset. CONCLUSION: Influenza had a greater negative impact on pregnant women than non-influenza ARIs, as indicated by symptom severity and greater likelihood of elevated temperature. These results highlight the importance of preventing and treating influenza illnesses in pregnant women. |
Trends in racial and ethnic disparities in infant mortality rates in the United States, 1989-2006
Rossen LM , Schoendorf KC . Am J Public Health 2014 104 (8) 1549-56 OBJECTIVES: We sought to measure overall disparities in pregnancy outcome, incorporating data from the many race and ethnic groups that compose the US population, to improve understanding of how disparities may have changed over time. METHODS: We used Birth Cohort Linked Birth-Infant Death Data Files from US Vital Statistics from 1989-1990 and 2005-2006 to examine multigroup indices of racial and ethnic disparities in the overall infant mortality rate (IMR), preterm birth rate, and gestational age-specific IMRs. We calculated selected absolute and relative multigroup disparity metrics weighting subgroups equally and by population size. RESULTS: Overall IMR decreased on the absolute scale, but increased on the population-weighted relative scale. Disparities in the preterm birth rate decreased on both the absolute and relative scales, and across equally weighted and population-weighted indices. Disparities in preterm IMR increased on both the absolute and relative scales. CONCLUSIONS: Infant mortality is a common bellwether of general and maternal and child health. Despite significant decreases in disparities in the preterm birth rate, relative disparities in overall and preterm IMRs increased significantly over the past 20 years. |
Evaluation of the 2012 18th Maternal and Child Health (MCH) Epidemiology and 22nd CityMatCH MCH Urban Leadership Conference: six month impact on science, program, and policy
Arellano DE , Goodman DA , Howlette T , Kroelinger CD , Law M , Phillips D , Jones J , Brantley MD , Fitzgerald M . Matern Child Health J 2014 18 (7) 1565-71 The 18th Maternal and Child Health (MCH) Epidemiology and 22nd CityMatCH MCH Urban Leadership Conference took place in December 2012, covering MCH science, program, and policy issues. Assessing the impact of the Conference on attendees' work 6 months post-Conference provides information critical to understanding the impact and the use of new partnerships, knowledge, and skills gained during the Conference. Evaluation assessments, which included collection of quantitative and qualitative data, were administered at two time points: at Conference registration and 6 months post-Conference. The evaluation files were merged using computer IP address, linking responses from each assessment. Percentages of attendees reporting Conference impacts were calculated from quantitative data, and common themes and supporting examples were identified from qualitative data. Online registration was completed by 650 individuals. Of registrants, 30 % responded to the 6 month post-Conference assessment. Between registration and 6 month post-Conference evaluation, the distribution of respondents did not significantly differ by organizational affiliation. In the 6 months following the Conference, 65 % of respondents reported pursuing a networking interaction; 96 % shared knowledge from the Conference with co-workers and others in their agency; and 74 % utilized knowledge from the Conference to translate data into public health action. The Conference produced far-reaching impacts among Conference attendees. The Conference served as a platform for networking, knowledge sharing, and attaining skills that advance the work of attendees, with the potential of impacting organizational and workforce capacity. Increasing capacity could improve MCH programs, policies, and services, ultimately impacting the health of women, infants, and children. |
First detected Helicobacter pylori infection in infancy modifies the association between diarrheal disease and childhood growth in Peru
Jaganath D , Saito M , Gilman RH , Queiroz DM , Rocha GA , Cama V , Cabrera L , Kelleher D , Windle HJ , Crabtree JE , Checkley W . Helicobacter 2014 19 (4) 272-9 BACKGROUND: In endemic settings, Helicobacter pylori infection can occur shortly after birth and may be associated with a reduction in childhood growth. MATERIALS AND METHODS: This study investigated what factors promote earlier age of first H. pylori infection and evaluated the role of H. pylori infection in infancy (6-11 months) versus early childhood (12-23 months) on height. We included 183 children near birth from a peri-urban shanty town outside of Lima, Peru. Field-workers collected data on socioeconomic status (SES), daily diarrheal and breast-feeding history, antibiotic use, anthropometrics, and H. pylori status via carbon 13-labeled urea breath test up to 24 months after birth. We used a proportional hazards model to assess risk factors for earlier age at first detected infection and linear mixed-effects models to evaluate the association of first detected H. pylori infection during infancy on attained height. RESULTS: One hundred and forty (77%) were infected before 12 months of age. Lower SES was associated with earlier age at first detected H. pylori infection (low vs middle-to-high SES Hazard ratio (HR) 1.59, 95% CI 1.16, 2.19; p = .004), and greater exclusive breast-feeding was associated with reduced likelihood (HR 0.63, 95% CI 0.40, 0.98, p = .04). H. pylori infection in infancy was not independently associated with growth deficits (p = .58). However, children who had their first detected H. pylori infection in infancy (6-11 months) versus early childhood (12-23 months) and who had an average number of diarrhea episodes per year (3.4) were significantly shorter at 24 months (-0.37 cm, 95% CI, -0.60, -0.15 cm; p = .001). DISCUSSION: Lower SES was associated with a higher risk of first detected H. pylori infection during infancy, which in turn augmented the adverse association of diarrheal disease on linear growth. |
Age-specific chlamydial infection among pregnant women in the United States: evidence for updated recommendations
Tao G , Hoover KW , Nye MB , Body BA . Sex Transm Dis 2014 41 (9) 556-9 BACKGROUND: In the United States, chlamydia screening has been recommended for all pregnant women by the Centers for Disease Control and Prevention (CDC) but only for pregnant women who are at increased risk by the US Preventive Services Task Force (USPSTF). Very limited evidence, such as age-specific chlamydia positivity in pregnant women, has been used to develop these recommendations. METHODS: We analyzed data from a large commercial laboratory corporation in the United States in 2013. At the first prenatal visit made by women aged 15 to 44 years for whom a chlamydia test was performed between June 2008 and July 2010, we estimated positivity of chlamydia by age, insurance coverage, geographic region, and test type. RESULTS: Of 601,001 pregnant women aged 15 to 44 years who had routine prenatal care, 62.9% had private insurance and 32.9% had Medicaid coverage, 60.3% resided in the South region, and 43.2% were aged 15 to 24 years, 26.8% were aged 25 to 29 years, and 19.1% were aged 30 to 34 years. Chlamydia positivity was 3.6% overall, and significantly decreased as age increased (15-19 years: 9.6 %; 20-24 years: 5.2%; 25-29 years: 1.8%; 30-34 years: 0.9%; and 35-44 years: 0.6%; P < 0.05). CONCLUSIONS: Our findings of higher positivity among younger pregnant women suggest that the yield is likely to be greater from screening younger pregnant women than from screening older pregnant women to identify chlamydia infection. The benefits of harmonizing CDC and USPSTF recommendations for pregnant women could be explored by reviewing age-specific positivity data and estimating the frequency of prenatal adverse health outcomes caused by chlamydia to develop consensus regarding the age limit for pregnant women who should be screened. |
Balancing competing risks: perinatal exposure to macrolides increases the risk of infantile hypertrophic pyloric stenosis
Honein MA , Cragan JD . Evid Based Med 2014 19 (6) 239 Infantile hypertrophic pyloric stenosis (IHPS) is a potentially life-threatening condition for which surgical treatment is effective with excellent patient outcomes.1 However, the etiology of IHPS remains elusive. Prior studies have implicated early neonatal exposure to erythromycin as a strong risk factor for IHPS,2 but it is less clear whether maternal use in late pregnancy or while breastfeeding also poses a risk. Perinatal exposure to macrolide antibiotics is not uncommon. About 1% of pregnant women report use in the third trimester,3 and while no macrolides are licensed by the U.S. Food and Drug Administration for use in infants less than 6 months of age, they are recommended both for prophylaxis and treatment of pertussis in this age group.4 Particularly for neonatal pertussis, the severity and potential mortality of disease clearly outweigh the risk of IHPS with macrolide use. However, a full understanding of the risks of perinatal macrolide exposure is critical to an informed risk-benefit evaluation of treatment options for less severe conditions with effective therapeutic alternatives. |
Congenital syphilis investigation processes and timing in Louisiana
Bradley H , Gruber D , Introcaso CE , Foxhood J , Wendell D , Rahman M , Ewell J , Kirkcaldy RD , Weinstock HS . Sex Transm Dis 2014 41 (9) 560-3 BACKGROUND: Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants. METHODS: We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing. RESULTS: Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days. CONCLUSIONS: Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts. |
Sugar-sweetened beverage consumption among adults - 18 States, 2012
Kumar GS , Pan L , Park S , Lee-Kwan SH , Onufrak S , Blanck HM . MMWR Morb Mortal Wkly Rep 2014 63 (32) 686-90 Reducing consumption of calories from added sugars is a recommendation of the 2010 Dietary Guidelines for Americans and an objective of Healthy People 2020. Sugar-sweetened beverages (SSB) are major sources of added sugars in the diets of U.S. residents. Daily SSB consumption is associated with obesity and other chronic health conditions, including diabetes and cardiovascular disease. U.S. adults consumed an estimated average of 151 kcal/day of SSB during 2009-2010, with regular (i.e., nondiet) soda and fruit drinks representing the leading sources of SSB energy intake. However, there is limited information on state-specific prevalence of SSB consumption. To assess regular soda and fruit drink consumption among adults in 18 states, CDC analyzed data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS). Among the 18 states surveyed, 26.3% of adults consumed regular soda or fruit drinks or both ≥1 times daily. By state, the prevalence ranged from 20.4% to 41.4%. Overall, consumption of regular soda or fruit drinks was most common among persons aged 1834 years (24.5% for regular soda and 16.6% for fruit drinks), men (21.0% and 12.3%), non-Hispanic blacks (20.9% and 21.9%), and Hispanics (22.6% and 18.5%). Persons who want to reduce added sugars in their diets can decrease their consumption of foods high in added sugars such as candy, certain dairy and grain desserts, sweetened cereals, regular soda, fruit drinks, sweetened tea and coffee drinks, and other SSBs. States and health departments can collaborate with worksites and other community venues to increase access to water and other healthful beverages. |
Vitamin D status and associated factors of deficiency among Jordanian children of preschool age
Nichols EK , Khatib IM , Aburto NJ , Serdula MK , Scanlon KS , Wirth JP , Sullivan KM . Eur J Clin Nutr 2014 69 (1) 90-5 BACKGROUND/OBJECTIVES: Vitamin D deficiency in children remains a global concern. Although literature exists on the vitamin D status and its risk factors among children in the Middle East, findings have yielded mixed results, and large, representative community studies are lacking. SUBJECTS/METHODS: In a nationally representative survey of 1077 Jordanian children of preschool age (12-59 months) in Spring 2010, we measured 25(OH)D3 concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with various factors. RESULTS: Results showed 19.8% (95% confidence interval (CI): 16.4-23.3%) deficiency (<12 ng/ml) and 56.5% (95% CI: 52.0-61.0%) insufficiency (<20 ng/ml). In adjusted models, prevalence of deficiency was higher for females compared with males (prevalence ratio (PR)=1.74, 95% CI: 1.22-2.47, P=0.002) and lower for children 24-35 months of age (PR=0.64, 95% CI: 0.44-0.92, P=0.018) compared with children 12-23 months of age. In rural areas, there was no difference in prevalence of vitamin D deficiency between those whose mothers had/did not have vitamin D deficiency (P=0.312); however, in urban areas, prevalence of vitamin D deficiency was 3.18 times greater among those whose mothers were vitamin D deficient compared with those whose mothers were not deficient (P=0.000). CONCLUSIONS: Vitamin D deficiency and insufficiency pose significant public health problems in Jordanian children with female children disproportionately affected. Strong associations between vitamin D status in children and urban residency and maternal vitamin D status suggest that the behaviors related to sun exposure in urban mothers likely also affect the sun exposure and thus vitamin D status of their children. |
Notes from the field: malnutrition and elevated mortality among refugees from South Sudan - Ethiopia, June-July 2014
Andresen E , Bilukha OO , Menkir Z , Gayford M , Kavosa M , Wtsadik M , Maina G , Gose M , Nyagucha I , Shahpar C . MMWR Morb Mortal Wkly Rep 2014 63 (32) 700-1 As a result of armed civil conflict in South Sudan that started in mid-December of 2013, an estimated 1.1 million persons were internally displaced, and approximately 400,000 refugees fled South Sudan to neighboring countries (primarily to Ethiopia, Uganda, Sudan, and Kenya). Refugees from South Sudan arriving in Ethiopia are sheltered in three refugee camps located in Gambella region: Leitchuor, Kule, and Tierkidi. The camps were established during January-May 2014 and have estimated refugee populations of 47,000, 51,000, and 50,000, respectively. Reports from health clinics and humanitarian agencies providing assistance to refugees suggested poor nutritional status of arriving refugees and elevated mortality rates. To assess the nutritional status of refugee children aged 6-59 months and mortality rates (crude [all ages] and aged <5 years), the Administration for Refugee and Returnee Affairs (an Ethiopian government aid agency), the United Nations High Commissioner for Refugees, World Food Programme, and United Nations Children's Fund, in collaboration with CDC, conducted cross-sectional population-representative surveys in Leitchuor, Kule, and Tierkidi camps during June-July 2014. Anthropometric measurements in children were taken using standard procedures, and nutritional status was classified based on 2006 World Health Organization (WHO) growth standards. Hemoglobin was measured using HemoCue Hb 301. Anemia was diagnosed according to WHO thresholds. Retrospective mortality rates in Leitchuor and Kule were measured using a household census method. |
Middle East Respiratory Syndrome (MERS)
Phillips JA . Workplace Health Saf 2014 62 (7) 308 Occupational and environmental health nurses must monitor credible sources for accurate information, provide timely education to workers, and ensure adequate workplace policies to protect their workforce against Middle East Respiratory Syndrome (MERS). |
Influenza vaccination coverage among school employees: assessing knowledge, attitudes, and behaviors
de Perio MA , Wiegand DM , Brueck SE . J Sch Health 2014 84 (9) 586-92 BACKGROUND: Influenza can spread among students, teachers, and staff in school settings. Vaccination is the most effective method to prevent influenza. We determined 2012-2013 influenza vaccination coverage among school employees, assessed knowledge and attitudes regarding the vaccine, and determined factors associated with vaccine receipt. METHODS: We surveyed 412 (49%) of 841 employees at 1 suburban Ohio school district in March 2013. The Web-based survey assessed personal and work characteristics, vaccine receipt, and knowledge and attitudes regarding the vaccine. RESULTS: Overall, 238 (58%) respondents reported getting the 2012-2013 influenza vaccine. The most common reason for getting the vaccine was to protect oneself or one's family (87%). Beliefs that the vaccine was not needed (32%) or that it was not effective (21%) were the most common reasons for not getting it. Factors independently associated with vaccine receipt were having positive attitudes toward the vaccine, feeling external pressure to get it, and feeling personal control over whether to get it. CONCLUSIONS: Influenza vaccine coverage among school employees should be improved. Messages encouraging school employees to get the vaccine should address misconceptions about the vaccine. Employers should use methods to maximize employee vaccination as part of a comprehensive influenza prevention program. |
Cryptosporidium species in humans and animals: current understanding and research needs.
Ryan U , Fayer R , Xiao L . Parasitology 2014 141 (13) 1-19 Cryptosporidium is increasingly recognized as one of the major causes of moderate to severe diarrhoea in developing countries. With treatment options limited, control relies on knowledge of the biology and transmission of the members of the genus responsible for disease. Currently, 26 species are recognized as valid on the basis of morphological, biological and molecular data. Of the nearly 20 Cryptosporidium species and genotypes that have been reported in humans, Cryptosporidium hominis and Cryptosporidium parvum are responsible for the majority of infections. Livestock, particularly cattle, are one of the most important reservoirs of zoonotic infections. Domesticated and wild animals can each be infected with several Cryptosporidium species or genotypes that have only a narrow host range and therefore have no major public health significance. Recent advances in next-generation sequencing techniques will significantly improve our understanding of the taxonomy and transmission of Cryptosporidium species, and the investigation of outbreaks and monitoring of emerging and virulent subtypes. Important research gaps remain including a lack of subtyping tools for many Cryptosporidium species of public and veterinary health importance, and poor understanding of the genetic determinants of host specificity of Cryptosporidium species and impact of climate change on the transmission of Cryptosporidium. |
Follow-up on anterior chamber angiostrongyliasis
Galor A , Eberhard ML . JAMA Ophthalmol 2014 132 (8) 1029-30 We would like to provide follow-up information on our Clinical Challenge titled “Anterior Chamber Angiostrongyliasis.”1 The Parasitic Diseases Branch of the Centers for Disease Control and Prevention reviewed the published photographs as well as original digital images and expressed concern at our final diagnosis of an anterior chamber worm. Specifically, in the photographs, they believed there were no specific morphologic features that could definitively identify the foreign object as a worm (eg, internal structures such as gut or reproductive tubes, body wall composed of cuticle and muscles, oral or anal opening). While clinically the object appeared wormlike, it was found to be in poor condition after removal, perhaps due to long-standing nonviability in the eye. Unfortunately, the specimen has since been disposed of and no further investigations are possible. |
Using the exhibited generalization approach to evaluate a carbon monoxide alarm ordinance
Chen HT , Yip F , Lavonas EJ , Iqbal S , Turner N , Cobb B , Garbe P . Eval Program Plann 2014 47c 35-44 Current interests in enhancing the focus of external validity or transferability call for developing practical evaluation approaches and illustrating their applications in this area for meeting the need. This study takes the challenge by introducing an innovative evaluation approach, named the exhibited generalization approach, and applying it in evaluating the carbon monoxide (CO) alarm ordinance passed by Mecklenburg County, North Carolina. The stakeholders specifically asked evaluators to determine the answers to the following two questions: (1) Does the alarm ordinance work? (2) What generalizable information can the Mecklenburg experience provide to other jurisdictions trying to decide if the alarm ordinance's planning, implementation, adoption, and outcomes are transferable to their communities? This study illustrates how to apply the exhibited generalization approach to provide the stakeholders with answers to these questions. Our results indicate that the alarm ordinance was effective in increasing CO alarm ownerships and reducing CO poisoning cases. The evaluation provides potential users and other interested parties with the necessary information on contextual factors and the causal mechanism underlying the CO alarm ordinance, so that these parties and users could decide whether the Mecklenburg alarm ordinance would be transferable to their own communities. Discussions include implications of this study for contributing in further advancing evaluation theory in addressing transferability or external validity issues. |
Using the principles of complex systems thinking and implementation science to enhance maternal and child health program planning and delivery
Kroelinger CD , Rankin KM , Chambers DA , Diez Roux AV , Hughes K , Grigorescu V . Matern Child Health J 2014 18 (7) 1560-4 Traditionally, epidemiologic methodologies have focused on measurement of exposures, outcomes, and program impact through reductionistic, yet complex statistical modeling. Although not new to the field of epidemiology, two frameworks that provide epidemiologists with a foundation for understanding the complex contexts in which programs and policies are implemented were presented to maternal and child health (MCH) professionals at the 2012 co-hosted 18th Annual MCH Epidemiology Conference and 22nd CityMatCH Urban Leadership Conference. The complex systems approach offers researchers in MCH the opportunity to understand the functioning of social, medical, environmental, and behavioral factors within the context of implemented public health programs. Implementation science provides researchers with a framework to translate the evidence-based program interventions into practices and policies that impact health outcomes. Both approaches offer MCH epidemiologists conceptual frameworks with which to re-envision how programs are implemented, monitored, evaluated, and reported to the larger public health audience. By using these approaches, researchers can begin to understand and measure the broader public health context, account for the dynamic interplay of the social environment, and ultimately, develop more effective MCH programs and policies. |
Establishing an enteric bacteria reference laboratory in Sierra Leone
Chattaway MA , Kamara A , Rhodes F , Kaffeta K , Jambai A , Alemu W , Islam MS , Freeman MM , Welfare W , Harding D , Samba AF , Abu M , Kamanda S , Grant K , Jenkins C , Nair S , Connell S , Siorvanes L , Desai S , Allen C , Frost M , Hughes D , Jeffrey Z , Gill N , Salter M . J Infect Dev Ctries 2014 8 (7) 933-41 In 2012, Sierra Leone experienced its worst cholera outbreak in over 15 years affecting 12 of the country's 13 districts. With limited diagnostic capability, particularly in bacterial culture, the cholera outbreak was initially confirmed by microbiological testing of clinical specimens outside of Sierra Leone. During 2012 - 2013, in direct response to the lack of diagnostic microbiology facilities, and to assist in investigating and monitoring the cholera outbreak, diagnostic and reference services were established in Sierra Leone at the Central Public Health Reference Laboratory focusing specifically on isolating and identifying Vibrio cholerae and other enteric bacterial pathogens. Sierra Leone is now capable of confirming cholera cases by reference laboratory testing. |
Median and quantile tests under complex survey design using SAS and R
Pan Y , Caudill SP , Li R , Caldwell KL . Comput Methods Programs Biomed 2014 117 (2) 292-7 Techniques for conducting hypothesis testing on the median and other quantiles of two or more subgroups under complex survey design are limited. In this paper, we introduce programs in both SAS and R to perform such a test. A detailed illustration of the computations, macro variable definitions, input and output for the SAS and R programs are also included in the text. Urinary iodine data from National Health and Nutrition Examination Survey (NHANES) are used as examples for comparing medians between females and males as well as comparing the 75th percentiles among three salt consumption groups. |
Potential sensitivity of bias analysis results to incorrect assumptions of nondifferential or differential binary exposure misclassification
Johnson CY , Flanders WD , Strickland MJ , Honein MA , Howards PP . Epidemiology 2014 25 (6) 902-9 BACKGROUND: Results of bias analyses for exposure misclassification are dependent on assumptions made during analysis. We describe how adjustment for misclassification is affected by incorrect assumptions about whether sensitivity and specificity are the same (nondifferential) or different (differential) for cases and noncases. METHODS: We adjusted for exposure misclassification using probabilistic bias analysis, under correct and incorrect assumptions about whether exposure misclassification was differential or not. First, we used simulated data sets in which nondifferential and differential misclassification were introduced. Then, we used data on obesity and diabetes from the National Health and Nutrition Examination Survey (NHANES) in which both self-reported (misclassified) and measured (true) obesity were available, using literature estimates of sensitivity and specificity to adjust for bias. The ratio of odds ratio (ROR; observed odds ratio divided by true odds ratio) was used to quantify magnitude of bias, with ROR = 1 signifying no bias. RESULTS: In the simulated data sets, under incorrect assumptions (eg, assuming nondifferential misclassification when it was truly differential), results were biased, with RORs ranging from 0.18 to 2.46. In NHANES, results adjusted based on incorrect assumptions also produced biased results, with RORs ranging from 1.26 to 1.55; results were more biased when making these adjustments than when using the misclassified exposure values (ROR = 0.91). CONCLUSIONS: Making an incorrect assumption about nondifferential or differential exposure misclassification in bias analyses can lead to more biased results than if no adjustment is performed. In our analyses, incorporating uncertainty using probabilistic bias analysis was not sufficient to overcome this problem. |
Blood cadmium and depressive symptoms in young adults (aged 20-39 years).
Scinicariello F , Buser MC . Psychol Med 2014 45 (4) 1-9 BACKGROUND: Genetic and environmental factors contribute to the risk of depression and several studies have noted an association between tobacco smoke and depression. Cadmium is a neurotoxicant and the main source of non-occupational exposure is tobacco smoke. METHOD: We conducted a cross-sectional analysis of data from 2892 young adult (aged 20-39 years) participants of the National Health and Nutrition Examination Survey (NHANES) 2007-2010. Multivariate logistic regressions, adjusted for age, sex, race/ethnicity, education, poverty income ratio (PIR), obesity, alcohol intake, blood lead (BPb) and smoking status, were used to analyze the association between blood cadmium (BCd) and depressive symptoms, as determined by the score on the nine-item Patient Health Questionnaire (PHQ-9). RESULTS: Individuals in the highest BCd quartile had higher odds of having depressive symptoms [odds ratio (OR) 2.79, 95% confidence interval (CI) 1.84-4.25] than those in the lowest BCd quartile. Smoking status, but not BPb, was statistically significantly associated with depressive symptoms. Stratification by smoking status found that BCd was significantly associated with depressive symptoms in both non-smokers (OR 2.91, 95% CI 1.12-7.58) and current smokers (OR 2.69, 95% CI 1.13-6.42). CONCLUSIONS: This is the first study to report an association between BCd levels and depressive symptoms using a nationally representative sample. The association of cadmium with depressive symptoms was independent of smoking status. If this association is further confirmed, the continued efforts at reducing cadmium exposures, mainly through tobacco smoking cessation programs, may decrease the incidence of depression. |
Relationship between frequency and intensity of cigarette smoking and TTFC/C among students of the GYTS in select countries, 2007-2009
Lam E , Giovino GA , Shin M , Lee KA , Rolle I , Asma S . J Sch Health 2014 84 (9) 549-58 BACKGROUND: This study assessed the construct validity of a measure of nicotine dependence that was used in the Global Youth Tobacco Survey (GYTS). METHODS: Using 2007-2009 data from the GYTS, subjects from 6 countries were used to assess current smokers' odds of reporting time to first cigarette or craving positive (TTFC/C+) by the number of cigarette smoking days per month (DPM) and the number of cigarettes smoked per day (CPD). RESULTS: The percentage of GYTS smokers who reported TTFC/C+ ranged from 58.0% to 69.7%. Compared with students who smoked on 1-2 DPM, those who smoked on 3-9 DPM had 3 times the adjusted odds of reporting TTFC/C+. The adjusted odds of reporting TTFC/C+ were 3 to 7 times higher among those who smoked 10-29 DPM and 6 to 20 times higher among daily smokers. Similarly, the adjusted odds of TTFC/C+ were 3-6 times higher among those who smoked 2-5 CPD and 6 to 20 times higher among those who smoked >6 CPD, compared to those who smoked <1 CPD. CONCLUSION: Associations of TTFC/C+ prevalence with both frequency and intensity of cigarette smoking provide a construct validation of the GYTS question used to assess respondents' TTFC/C status. |
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