The use of intravenous tissue plasminogen activator and hospital costs for acute ischemic stroke patients aged 18-64 years in the United States
Joo H , Wang G , George MG . Stroke Vasc Neurol 2016 1 (1) 8-15 INTRODUCTION: Intravenous tissue plasminogen activator (IV tPA) is a globally recommended treatment for acute ischemic stroke patients. We examined IV tPA use among patients aged 18-64 years with a primary diagnosis acute ischemic stroke in the US and inpatient costs per hospitalization by IV tPA use status among these patients. METHODS: Using 2010-2013 MarketScan Commercial Claims and Encounters Inpatient Data, we identified 39,149 hospitalizations with a primary diagnosis of acute ischemic stroke. We verified those with and without IV tPA by ICD-9 procedure code 99.10. We estimated trends in IV tPA use by applying logistic regression. The average inpatient costs per acute ischemic stroke hospitalization were assessed for sub-populations. We examined costs per acute ischemic stroke hospitalization using multivariate regression models controlling for IV tPA status, age, gender, urbanization, geographic region, Charlson Comorbidity Index, length of hospital stays (LOS) and discharge status. RESULTS: 2,546 hospitalizations (6.5%) used IV tPA. IV tPA use increased over time (2010 vs. 2013; odds ratio 1.50). Average inpatient costs per acute ischemic stroke hospitalization was $20,331 ($31,369 for IV tPA group, $19,563 for non-tPA group). From multivariate analyses, higher costs per acute ischemic stroke hospitalization were associated with longer LOS, non-home discharge destination, and IV tPA use, which might be correlated with severity of stroke. CONCLUSIONS: Findings suggest that IV tPA use increased recent years while the inpatient costs per acute ischemic stroke hospitalization using IV tPA are substantial. Those findings are useful in better understanding the overall economic burden of stroke, short-term cost implications of using IV tPA, and for estimating the accurate cost-effectiveness of stroke treatments. |
Prevalence and causes of paralysis-United States, 2013
Armour BS , Courtney-Long EA , Fox MH , Fredine H , Cahill A . Am J Public Health 2016 106 (10) e1-e3 OBJECTIVES: To estimate the prevalence and causes of functional paralysis in the United States. METHODS: We used the 2013 US Paralysis Prevalence & Health Disparities Survey to estimate the prevalence of paralysis, its causes, associated sociodemographic characteristics, and health effects among this population. RESULTS: Nearly 5.4 million persons live with paralysis. Most persons with paralysis were younger than 65 years (72.1%), female (51.7%), White (71.4%), high school graduates (64.8%), married or living with a partner (47.4%), and unable to work (41.8%). Stroke is the leading cause of paralysis, affecting 33.7% of the population with paralysis, followed by spinal cord injury (27.3%), multiple sclerosis (18.6%), and cerebral palsy (8.3%). CONCLUSIONS: According to the functional definition, persons living with paralysis represent a large segment of the US population, and two thirds of them are between ages 18 and 64 years. Targeted health promotion that uses inclusion strategies to account for functional limitations related to paralysis can be undertaken in partnership with state and local health departments. |
Preventing large birth size in women with preexisting diabetes mellitus: the benefit of appropriate gestational weight gain
Kim SY , Sharma AJ , Sappenfield W , Salihu HM . Prev Med 2016 91 164-168 OBJECTIVE: To estimate the percentage of infants with large birth size attributable to excess gestational weight gain (GWG), independent of prepregnancy body mass index, among mothers with preexisting diabetes mellitus (PDM). STUDY DESIGN: We analyzed 2004-2008 Florida linked birth certificate and maternal hospital discharge data of live, term (37-41weeks) singleton deliveries (N=641,857). We calculated prevalence of large-for-gestational age (LGA) (birth weight-for-gestational age≥90th percentile) and macrosomia (birth weight>4500g) by GWG categories (inadequate, appropriate, or excess). We used multivariable logistic regression to estimate the relative risk (RR) of large birth size associated with excess compared to appropriate GWG among mothers with PDM. We then estimated the population attributable fraction (PAF) of large birth size due to excess GWG among mothers with PDM (n=4427). RESULTS: Regardless of diabetes status, half of mothers (51.2%) gained weight in excess of recommendations. Large birth size was higher in infants of mothers with PDM than in infants of mothers without diabetes (28.8% versus 9.4% for LGA, 5.8% versus 0.9% for macrosomia). Among women with PDM, the adjusted RR of having an LGA infant was 1.7 (95% CI 1.5, 1.9) for women with excess GWG compared to those with appropriate gain; the PAF was 27.7% (95% CI 22.0, 33.3). For macrosomia, the adjusted RR associated with excess GWG was 2.1 (95% CI 1.5, 2.9) and the PAF was 38.6% (95% CI 24.9, 52.4). CONCLUSION: Preventing excess GWG may avert over one-third of macrosomic term infants of mothers with PDM. Effective strategies to prevent excess GWG are needed. |
Association between county-level characteristics and eye care use by us adults in 22 states after accounting for individual-level characteristics using a conceptual framework
Chou CF , Beckles GL , Cheng YJ , Saaddine JB . JAMA Ophthalmol 2016 134 (10) 1158-1167 Importance: Individual-level characteristics are associated with eye care use. The influence of contextual factors on vision and eye health, as well as health behavior, is unknown. Objective: To examine the association between county-level characteristics and eye care use after accounting for individual-level characteristics using a conceptual framework. Design, Setting, and Participants: This investigation was a cross-sectional study of respondents 40 years and older participating in the Behavioral Risk Factor Surveillance System surveys between 2006 and 2010 from 22 states that used the Visual Impairment and Access to Eye Care module. Multilevel regressions were used to examine the association between county-level characteristics and eye care use after adjusting for individual-level characteristics (age, sex, race/ethnicity, educational attainment, annual household income, employment status, health care insurance coverage, eye care insurance coverage, personal established physician, poor vision or eye health, and diabetes status). Data analysis was performed from March 23, 2014, to June 7, 2016. Main Outcomes and Measures: Eye care visit and receipt of a dilated eye examination in the past year. Results: Among 117295 respondents who resided in 828 counties, individual-level data were obtained from the Behavioral Risk Factor Surveillance System surveys. All county-level variables were aggregated at the county level from the Behavioral Risk Factor Surveillance System surveys except for a high geographic density of eye care professionals, which was obtained from the 2010 Area Health Resource File. After controlling for individual-level characteristics, the odds of reporting an eye care visit in the past year were significantly higher among people living in counties with high percentages of black individuals (adjusted odds ratio [aOR], 1.12; 95% CI, 1.01-1.24; P = .04) or low-income households (aOR, 1.12; 95% CI, 1.00-1.25; P = .045) or with a high density of eye care professionals (aOR, 1.18; 95% CI, 1.07-1.29; P < .001) than among those living in counties with the lowest tertile of each county-level characteristic. The odds of reporting receipt of a dilated eye examination in the past year were also higher among people living in counties with the highest percentages of black individuals (aOR, 1.20; 95% CI, 1.07-1.34; P = .002) or low-income households (aOR, 1.17; 95% CI, 1.04-1.32; P = .01). However, the odds of reported receipt of a dilated eye examination in the past year were lower in counties with the highest percentages of people with poor vision and eye health compared with counties with lower percentages (aOR, 0.85; 95% CI, 0.77-0.94; P = .002). Conclusions and Relevance: Contextual factors, measured at the county level, were associated with eye care use independent of individual-level characteristics. The findings suggest that, while individual characteristics influence health care use, it is also important to address contextual factors to improve eye care use and ultimately vision health. |
Breast cancer incidence among female flight attendants: Exposure-response analyses
Pinkerton LE , Hein MJ , Anderson JL , Little MP , Sigurdson AJ , Schubauer-Berigan MK . Scand J Work Environ Health 2016 42 (6) 538-546 OBJECTIVE: The aim of this study was to examine the association of breast cancer incidence with cosmic radiation dose and circadian rhythm disruption in a cohort of 6093 US female flight attendants. METHODS: The association of breast cancer risk with cumulative cosmic radiation dose, time spent working during the standard sleep interval, and time zones crossed (all lagged by ten years), adjusted for non-occupational breast cancer risk factors, was evaluated using Cox regression. Individual exposure estimates were derived from work history data and domicile- and era-specific exposure estimates. Breast cancers were identified from telephone interviews and state cancer registries, and covariate data were obtained from telephone interviews. RESULTS: Breast cancer incidence in the overall cohort was not associated with exposure. Positive associations in breast cancer incidence were observed with all three exposures only among the 884 women with parity of ≥3. Adjusted excess relative risks for women with parity of ≥3 were 1.6 [95% confidence interval (95% CI) 0.14-6.6], 0.99 (95% CI -0.04-4.3), and 1.5 (95% CI 0.14-6.2) per 10 mGy, per 2000 hours spent working in the standard sleep interval, and per 4600 time zones crossed (the approximate means of the fourth exposure quintiles among breast cancer cases), respectively. CONCLUSIONS: Positive exposure-response relations, although observed only in a small subset of the cohort, were robust. Future studies of breast cancer incidence among other workers with circadian rhythm disruption should assess interaction with parity to see if our findings are confirmed. |
Distinct Salmonella Enteritidis lineages associated with enterocolitis in high-income settings and invasive disease in low-income settings.
Feasey NA , Hadfield J , Keddy KH , Dallman TJ , Jacobs J , Deng X , Wigley P , Barquist Barquist L , Langridge GC , Feltwell T , Harris SR , Mather AE , Fookes M , Aslett M , Msefula C , Kariuki S , Maclennan CA , Onsare RS , Weill FX , Le Hello S , Smith AM , McClelland M , Desai P , Parry CM , Cheesbrough J , French N , Campos J , Chabalgoity JA , Betancor L , Hopkins KL , Nair S , Humphrey TJ , Lunguya O , Cogan TA , Tapia MD , Sow SO , Tennant SM , Bornstein K , Levine MM , Lacharme-Lora L , Everett DB , Kingsley RA , Parkhill J , Heyderman RS , Dougan G , Gordon MA , Thomson NR . Nat Genet 2016 48 (10) 1211-1217 An epidemiological paradox surrounds Salmonella enterica serovar Enteritidis. In high-income settings, it has been responsible for an epidemic of poultry-associated, self-limiting enterocolitis, whereas in sub-Saharan Africa it is a major cause of invasive nontyphoidal Salmonella disease, associated with high case fatality. By whole-genome sequence analysis of 675 isolates of S. Enteritidis from 45 countries, we show the existence of a global epidemic clade and two new clades of S. Enteritidis that are geographically restricted to distinct regions of Africa. The African isolates display genomic degradation, a novel prophage repertoire, and an expanded multidrug resistance plasmid. S. Enteritidis is a further example of a Salmonella serotype that displays niche plasticity, with distinct clades that enable it to become a prominent cause of gastroenteritis in association with the industrial production of eggs and of multidrug-resistant, bloodstream-invasive infection in Africa. |
Reply to Apolipoprotein E polymorphisms and their protective effect on Hepatitis E virus replication
Teo CG , Yesupriya A , Chang MH , Zhang L . Hepatology 2016 We appreciate the attention that Weller et al. have given to our report and findings. Weller et al. used an in vitro system based on Huh-7.5 cells silenced for endogenous apolipoprotein E (apoE) protein expression to investigate if genetic variants of the APOE gene (ϵ2, ϵ3, and ϵ4), when ectopically expressed, influence the production of intracellular hepatitis E virus (HEV) RNA and the expression of HEV open reading frame 2 (ORF2) protein after the cells were transfected with an HEV genotype 3 replicon. Finding that HEV RNA and ORF2 protein production were not affected regardless of which isoforms were expressed, they concluded that APOE polymorphisms do not affect HEV RNA replication and virus production. | HEV RNA quantification was applied by Weller et al. as an index of viral replication, and ORF2 protein quantification was used as a marker of the extent of viral particle assembly. However, HEV RNA measurement shows replication of the viral genome, not productive viral replication. Furthermore, measurement of the ORF2 protein, per se, is inadequate to indicate virion assembly; and other means of verifying if assembly has taken place are needed.(1) |
Vital Signs: Epidemiology of sepsis: Prevalence of health care factors and opportunities for prevention
Novosad SA , Sapiano MR , Grigg C , Lake J , Robyn M , Dumyati G , Felsen C , Blog D , Dufort E , Zansky S , Wiedeman K , Avery L , Dantes RB , Jernigan JA , Magill SS , Fiore A , Epstein L . MMWR Morb Mortal Wkly Rep 2016 65 (33) 864-869 BACKGROUND: Sepsis is a serious and often fatal clinical syndrome, resulting from infection. Information on patient demographics, risk factors, and infections leading to sepsis is needed to integrate comprehensive sepsis prevention, early recognition, and treatment strategies. METHODS: To describe characteristics of patients with sepsis, CDC and partners conducted a retrospective chart review in four New York hospitals. Random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock were reviewed. RESULTS: Medical records of 246 adults and 79 children (aged birth to 17 years) were reviewed. Overall, 72% of patients had a health care factor during the 30 days before sepsis admission or a selected chronic condition likely to require frequent medical care. Pneumonia was the most common infection leading to sepsis. The most common pathogens isolated from blood cultures were Escherichia coli in adults aged ≥18 years, Klebsiella spp. in children aged ≥1 year, and Enterococcus spp. in infants aged <1 year; for 106 (33%) patients, no pathogen was isolated. Eighty-two (25%) patients with sepsis died, including 65 (26%) adults and 17 (22%) infants and children. CONCLUSIONS: Infection prevention strategies (e.g., vaccination, reducing transmission of pathogens in health care environments, and appropriate management of chronic diseases) are likely to have a substantial impact on reducing sepsis. CDC, in partnership with organizations representing clinicians, patients, and other stakeholders, is launching a comprehensive campaign to demonstrate that prevention of infections that cause sepsis, and early recognition of sepsis, are integral to overall patient safety. |
Notes from the field: Cluster of tuberculosis cases among Marshallese persons residing in Arkansas - 2014-2015
Rothfeldt LL , Patil N , Haselow DT , Williams SH , Wheeler JG , Mukasa LN . MMWR Morb Mortal Wkly Rep 2016 65 (33) 882-883 During early September 2014, the Arkansas Department of Health identified an increased number of tuberculosis (TB) cases among a unique population in a well-circumscribed geographical area in northwest Arkansas. The Compact of Free Association Act of 1985 (Public Law 99-239, amended in 2003 by Public Law 108-188) established the Republic of the Marshall Islands (RMI) as an independent nation, and persons from the RMI can travel freely (with valid RMI passport) to and from the United States as nonimmigrants without visas. Marshallese started settling in northwest Arkansas during the early 1990s because of employment and educational opportunities. According to the 2010 Census, an estimated 4,300 Marshallese resided in Arkansas , mostly within one county which ranked 6th in the United States for counties with the highest percentage of Native Hawaiians and Other Pacific Islanders. It is estimated that this number has been growing steadily each year since the 2010 Census; however, obtaining an accurate count is difficult. The RMI is a TB high-incidence country, with a case-rate of 212.7 per 100,000 persons for 2014, whereas the case-rate was 3.1 per 100,000 persons in Arkansas and 2.9 per 100,000 persons in the United States. Screening for either active TB or latent TB infection (LTBI) is not required for Marshallese entry to the United States. |
Physician's knowledge, attitudes, and practices regarding seasonal influenza, pandemic influenza, and highly pathogenic avian influenza A (H5N1) virus infections of humans in Indonesia
Amalya M , Iuliano AD , Wahyuningrum Y , Praptiningsih CY , Lafond KE , Storms AD , Samaan G , Ariawan I , Soeharno N , Kreslake J , Storey D , Uyeki TM . Influenza Other Respir Viruses 2016 11 (1) 93-99 Indonesia has reported highest number of fatal human cases of highly pathogenic avian influenza (HPAI) A (H5N1) virus infection worldwide since 2005. There are limited data available on seasonal and pandemic influenza in Indonesia. During 2012, we conducted a survey of clinicians in two districts in western Java, Indonesia to assess knowledge, attitudes and practices (KAP) of clinical diagnosis, testing, and treatment of patients with seasonal influenza, pandemic influenza, or HPAI H5N1 virus infections. Overall, a very low percentage of physician participants reported ever diagnosing hospitalized patients with seasonal, pandemic, or HPAI H5N1 influenza. Use of influenza testing was low in outpatients and hospitalized patients, and use of antiviral treatment was very low for clinically-diagnosed influenza patients. Further research is needed to explore health system barriers for influenza diagnostic testing and availability of antivirals for treatment of influenza in Indonesia. |
Full House: a retrospective analysis of high sexually transmitted infection prevalence among adult film actors at a singular residence
Kendrick K , Brown V , Lords C , Matthias J , Henning I , Blackmore C , Likos A . Sex Transm Dis 2016 43 (9) 556-9 BACKGROUND: During a routine human immunodeficiency virus (HIV) investigation, Florida Department of Health staff identified a house (house A) in which over 150 individuals had resided at least briefly. Further investigation revealed that house A is used by the producer of a small adult film production company to board his actors. This report describes sexually transmitted infection (STI) prevalence among male actors in gay adult films residing in a common Florida residence. METHODS: LexisNexis Accurint was used to identify house A residents since October 2002 when the producer arrived. Information on STIs and interview data were obtained from Florida's STI surveillance system. An infection was considered to be associated with residence in house A if the date of diagnosis occurred 6 months before an individual's residence start date through 6 months after his residence end date. RESULTS: Excluding the producer, 150 men resided in house A starting from September 2003 to July 2015. Forty-six individuals had a reported case of HIV, syphilis, gonorrhea, and/or chlamydia with 92 infections total. Forty-two (46%) infections among 24 men were considered associated with residence in house A. CONCLUSIONS: LexisNexis Accurint was a useful tool for identifying house A residents, a highly mobile and highly sexually active population. There is a high prevalence of STIs among residents, but it is unclear where transmission is occurring. Settings like house A are good candidates for HIV pre-exposure prophylaxis and active STI screenings and may be an opportunity for public health officials to intervene in high-risk groups to reduce STI rates in the community. |
HIV prevalence and risk factors among male foreign migrants in Cape Town, South Africa
Giorgio M , Townsend L , Zembe Y , Cheyip M , Guttmacher S , Carter R , Mathews C . AIDS Behav 2016 21 (3) 949-961 While migration has been shown to be a risk factor for HIV, variation in HIV prevalence by subgroups of migrants needs further exploration. This paper documents the HIV prevalence and key characteristics among male foreign migrants in Cape Town, South Africa and the effectiveness of respondent-driven sampling (RDS) to recruit this population. Participants in this cross-sectional study completed a behavioral risk-factor questionnaire and provided a dried blood sample for HIV analysis. Overall HIV prevalence was estimated to be 8.7 % (CI 5.4-11.8) but varied dramatically by country of origin. After adjusting for country of origin, HIV sero-positivity was positively associated with older age (p = 0.001), completing high school (p = 0.025), not having enough money for food (p = 0.036), alcohol use (p = 0.049), and engaging in transactional sex (p = 0.022). RDS was successful in recruiting foreign migrant men. A better understanding of the timing of HIV acquisition is needed to design targeted interventions for migrant men. |
How can the health system retain women in HIV treatment for a lifetime? A discrete choice experiment in Ethiopia and Mozambique
Kruk ME , Riley PL , Palma AM , Adhikari S , Ahoua L , Arnaldo C , Belo DF , Brusamento S , Cumba LI , Dziuban EJ , El-Sadr WM , Gutema Y , Habtamu Z , Heller T , Kidanu A , Langa J , Mahagaja E , McCarthy CF , Melaku Z , Shodell D , Tsiouris F , Young PR , Rabkin M . PLoS One 2016 11 (8) e0160764 INTRODUCTION: Option B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care. METHODS: Women living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambezia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics. RESULTS: 2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important. CONCLUSIONS: Efforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling. |
Incidence of AIDS-defining opportunistic infections in a multicohort analysis of HIV-infected persons in the United States and Canada, 2000-2010
Buchacz K , Lau B , Jing Y , Bosch R , Abraham AG , Gill MJ , Silverberg MJ , Goedert JJ , Sterling TR , Althoff KN , Martin JN , Burkholder G , Gandhi N , Samji H , Patel P , Rachlis A , Thorne JE , Napravnik S , Henry K , Mayor A , Gebo K , Gange SJ , Moore RD , Brooks JT . J Infect Dis 2016 214 (6) 862-72 BACKGROUND: There are few recent data on the rates of AIDS-defining opportunistic infections (OIs) among human immunodeficiency virus (HIV)-infected patients in care in the United States and Canada. METHODS: We studied HIV-infected participants in 16 cohorts in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) during 2000-2010. After excluding 16 737 (21%) with any AIDS-defining clinical events documented before NA-ACCORD enrollment, we analyzed incident OIs among the remaining 63 541 persons, most of whom received antiretroviral therapy during the observation. We calculated incidence rates per 100 person-years of observation (hereafter, "person-years") with 95% confidence intervals (CIs) for the first occurrence of any OI and select individual OIs during 2000-2003, 2004-2007, and 2008-2010. RESULTS: A total of 63 541 persons contributed 261 573 person-years, of whom 5836 (9%) developed at least 1 OI. The incidence rate of any first OI decreased over the 3 observation periods, with 3.0 cases, 2.4 cases, and 1.5 cases per 100 person-years of observation during 2000-2003, 2004-2007, and 2008-2010, respectively (Ptrend<.001); the rates of most individual OIs decreased as well. During 2008-2010, the leading OIs included Pneumocystis jiroveci pneumonia, esophageal candidiasis, and disseminated Mycobacterium avium complex or Mycobacterium kansasii infection. CONCLUSIONS: For HIV-infected persons in care during 2000-2010, rates of first OI were relatively low and generally declined over this time. |
The association of recent incarceration and health outcomes among HIV-infected adults receiving care in the United States
Nasrullah M , Frazier E , Fagan J , Hardnett F , Skarbinski J . Int J Prison Health 2016 12 (3) 135-44 Purpose The purpose of this paper is to describe factors associated with incarceration as well as the association between recent incarceration and HIV-related sexual risk behaviors, access to insurance, healthcare utilization (emergency department (ED) and hospital use), antiretroviral therapy (ART) prescription, and viral suppression. Design/methodology/approach Using 2009-2010 data from a cross-sectional, nationally representative three-stage sample of HIV-infected adults receiving care in the USA, the authors assessed the demographic characteristics, healthcare utilization, and clinical outcomes of HIV-infected persons who had been recently incarcerated (detention for>24 hours in the past year) using bivariate analyses. The authors used multivariable logistic regression to examine associations of recent incarceration with insurance status as well as clinical and behavioral outcomes. Findings An estimated 22,949 (95 percent confidence interval (CI) 19,062-26,836) or 5.4 percent (CI: 4.7-6.1) of all HIV-infected persons receiving care were recently incarcerated. Factors associated with recent incarceration were age <50 years, being a smoker, having high school diploma or less, being homeless, income at or below the poverty guidelines, having a geometric mean of CD4 count <500 cells/ muL, and using drugs in the past 12 months. Results from multivariable modeling indicated that incarcerated persons were more likely to use ED services, and to have been hospitalized, and less likely to have achieved viral suppression. Originality/value Recent incarceration independently predicted worse health outcomes and greater use of emergency services among HIV-infected adults currently in HIV care. Options to improve the HIV continuum of care, including pre-enrollment for healthcare coverage and discharge planning, may lead to better health outcomes for HIV-infected inmates post-release. |
Availability and use of HIV monitoring and early infant diagnosis technologies in WHO Member States in 2011-2013: analysis of annual surveys at the facility level
Habiyambere V , Ford N , Low-Beer D , Nkengasong J , Sands A , Perez Gonzalez M , Fernandes P , Milgotina E . PLoS Med 2016 13 (8) e1002088 BACKGROUND: The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 targets have reinforced the importance of functioning laboratory services to ensure prompt diagnosis and to assess treatment efficacy. We surveyed the availability and utilization of technologies for HIV treatment monitoring and early infant diagnosis (EID) in World Health Organization (WHO) Member States. METHODS AND FINDINGS: The survey questionnaire included 14 structured questions focusing on HIV testing, cluster of differentiation 4 (CD4) testing, HIV viral load (VL) testing, and EID and was administered annually from 2012 to 2014 through WHO country offices, with each survey covering the previous 12-mo period. Across 127 targeted countries, survey response rates were 60% in 2012, 67% in 2013, and 78% in 2014. There were encouraging trends towards increased procurement of CD4 and VL/EID instruments in reporting countries. Globally, the capacity of available CD4 instruments was sufficient to meet the demand of all people living with HIV/AIDS (PLWHA), irrespective of treatment status (4.62 theoretical tests per PLWHA in 2013 [median 7.33; interquartile range (IQR) 3.44-17.75; median absolute deviation (MAD) 4.35]). The capacity of VL instruments was inadequate to cover all PLWHA in many reporting countries (0.44 tests per PLWHA in 2013 [median 0.90; IQR 0.30-2.40; MAD 0.74]). Of concern, only 13.7% of existing CD4 capacity (median 4.3%; IQR 1.1%-12.1%; MAD 3.8%) and only 36.5% of existing VL capacity (median 9.4%; IQR 2.3%-28.9%; MAD 8.2%) was being utilized across reporting countries in 2013. By the end of 2013, 7.4% of all CD4 instruments (5.8% CD4 conventional instruments and 11.0% of CD4 point of care [POC]) and 10% of VL/EID instruments were reportedly not in use because of lack of reagents, the equipment not being installed or deployed, maintenance, and staff training requirements. Major limitations of this survey included under-reporting and/or incomplete reporting in some national programmes and noncoverage of the private sector. CONCLUSION: This is the first attempt to comprehensively gather information on HIV testing technology coverage in WHO Member States. The survey results suggest that major operational changes will need to be implemented, particularly in low- and middle-income countries, if the 90-90-90 targets are to be met. |
Virulence profile: Rodney Donlan
Donlan R . Virulence 2016 8 (1) 1-3 Following graduation from Virginia Tech with a B.S. in biology, it was my great fortune to be chosen to participate in a multinational, NSF-funded research project in Antarctica as an environmental monitor for the Dry Valley Drilling Project during the 1973–74 austral summer. My team leader was Frank Morelli, a seasoned microbiologist from the Cal Tech Jet Propulsion Laboratory and the Darwin Research Institute who had spent several field seasons in the Antarctic. I had limited training and experience in microbiology (a single four credit course in general microbiology and a summer work/study job in the clinical microbiology lab of the City of Norfolk, Virginia Department of Public Health). Under Frank's guidance and patient instruction, I quickly came up to speed and was given opportunities to travel from McMurdo Station to remote drilling sites in the Dry Valleys for several weeks at a time, collecting air, soil, and water samples to assess the environmental impact of drilling operations on these environmentally sensitive areas. During whatever free time I had I'd spend in the small McMurdo Biology Lab library, reading the scientific literature, trying to broaden my understanding of the geology and biology of the Antarctic Dry Valleys. My level of interest didn't go unnoticed and Frank suggested I take the next step in my career and consider graduate school in microbiology. I returned to Virginia Tech and spent the next three years (with another three-month interlude in Antarctica) working toward a Master's degree in microbiology. The microbiology faculty at Tech were outstanding, and my training was exceptional. I think I came away from this program with a solid foundation in microbiology, a great appreciation for the scientific literature, and a good understanding of experimental design. |
Polychlorinated biphenyl and organochlorine pesticide concentrations in maternal mid-pregnancy serum samples: Association with autism spectrum disorder and intellectual disability
Lyall K , Croen LA , Sjodin A , Yoshida CK , Zerbo O , Kharrazi M , Windham GC . Environ Health Perspect 2016 125 (3) 474-480 BACKGROUND: Polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCPs) are neurodevelopmental toxicants, but few studies have examined associations with autism spectrum disorder (ASD). OBJECTIVES: To determine whether prenatal exposure to PCBs and OCPs influences offspring risk of ASD and intellectual disability without autism (ID). METHODS: We conducted a population-based case-control study among Southern California births, including children with ASD (N=545) meeting Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR criteria, ID (N=181), and general population (GP) controls (N=418). Concentrations of 11 PCB congeners and 2 OCPs measured in banked second trimester serum samples were compared between the diagnostic groups. Logistic regression was used to calculate crude and adjusted odds ratios (AOR) for associations with ASD, and separately for ID, compared to GP controls, by quartiles of analyte concentrations in primary analyses. RESULTS: Geometric mean levels of several PCB congeners were higher in the ASD group compared to ID and GP groups. ASD risk was elevated for a number of PCB congeners, particularly for the highest vs. lowest quartile of PCB138/158 (AOR=1.79, 95% CI 1.10, 2.71) and PCB153 (AOR=1.82, 95% CI 1.10, 3.02), and for highest deciles of other congeners in secondary analyses. PCB138/158 was also associated with increased ID (AOR=2.41, 95% CI 1.18, 4.91), though no trend was suggested. OCPs were not associated with increased risk of ASD in primary analyses, while non-monotonic increases in risk of ID were found with p,p'-DDE. CONCLUSIONS: Our results suggest higher levels of some organochlorine compounds during pregnancy are associated with ASD and ID. |
Executive Summary: 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis
Galgiani JN , Ampel NM , Blair JE , Catanzaro A , Geertsma F , Hoover SE , Johnson RH , Kusne S , Lisse J , MacDonald JD , Meyerson SL , Raksin PB , Siever J , Stevens DA , Sunenshine R , Theodore N . Clin Infect Dis 2016 63 (6) 717-22 It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure. |
Notes from the Field: Outbreak of Listeriosis Associated with Consumption of Packaged Salad - United States and Canada, 2015-2016.
Self JL , Conrad A , Stroika S , Jackson A , Burnworth L , Beal J , Wellman A , Jackson KA , Bidol S , Gerhardt T , Hamel M , Franklin K , Kopko C , Kirsch P , Wise ME , Basler C . MMWR Morb Mortal Wkly Rep 2016 65 (33) 879-881 In September 2015, PulseNet, the national molecular subtyping network for foodborne disease surveillance, identified a cluster of Listeria monocytogenes (Listeria) clinical isolates indistinguishable by two-enzyme pulsed-field gel electrophoresis (PFGE) pattern combination and highly related by whole-genome multilocus sequence typing (wgMLST). A case was defined as isolation of Listeria with the outbreak PFGE pattern and highly related by wgMLST with an isolation date on or after July 5, 2015, the isolate date of the earliest case in this cluster. |
Using whole genome sequencing to identify resistance determinants and predict antimicrobial resistance phenotypes for year 2015 invasive pneumococcal disease isolates recovered in the United States.
Metcalf BJ , Chochua S , Gertz RE Jr , Li Z , Walker H , Tran T , Hawkins PA , Glennen A , Lynfield R , Li Y , McGee L , Beall B . Clin Microbiol Infect 2016 22 (12) 1002 e1-1002 e8 OBJECTIVES: We assessed our whole genome sequence (WGS) pipeline for accurate prediction of current antimicrobial phenotypes. METHODS: For 2316 invasive pneumococcal isolates (IPD) recovered during 2015 we compared WGS pipeline data to broth dilution testing (BDT) for 18 antimicrobials. RESULTS: For 11 antimicrobials categorical discrepancies were assigned when WGS-predicted minimum inhibitory concentrations (MICs) and BDT MICs resulted in different predictions for susceptibility, intermediate-resistance or resistance, ranging from 0.9% (tetracycline) to 2.9% (amoxicillin). For beta-lactam antibiotics, the occurrence of >4-fold MIC differences ranged from 0.2% (meropenem) to 1.0 % (penicillin), although phenotypic retesting resolved 25 - 78% of these discrepancies. Nonsusceptibility to penicillin, predicted by penicillin binding protein types, was 2.7% (non-meningitis criteria) and 23.8% (meningitis criteria). Other common resistance determinants included mef (475 isolates), ermB (191 isolates), ermB + mef (48 isolates), tetM (261 isolates) and cat (51 isolates). Additional accessory resistance genes (tetS, tet32, aphA-3, sat4) were rarely detected (in 1- 3 isolates). Rare core genome mutations conferring erythromycin-resistance included a 2 codon rplD insertion (rplD69-KG-70) and the 23S rRNA A2061G substitution (6 total isolates). Intermediate cotrimoxazole-resistance was associated with 1-2 codon insertions within folP (238 isolates) or the folA I100L substitution (38 isolates), while full cotrimoxazole-resistance was attributed to alterations in both genes (172 isolates). Levofloxacin-resistance (2 isolates) was associated with parC and/or gyrA mutations. Of 11 remaining isolates with moderately elevated MICs to both ciprofloxacin and levofloxacin, 7 contained parC or gyrA mutations. The two rifampin-resistant isolates contained rpoB mutations. CONCLUSIONS: WGS-based MIC prediction was an informative alternative to BDT for current IPD isolates. |
Will Precision Medicine Improve Population Health?
Khoury MJ , Galea S . JAMA 2016 316 (13) 1357-1358 Announcement of the precision medicine initiative has led to a variety of responses, ranging from enthusiastic expectations1 to explicit skepticism,2 about potential health benefits, limitations, and return on investment. This Viewpoint discusses whether precision medicine is unlikely or likely to improve population health, aiming to forge a consensus that bridges disparate perspectives on the issue. The potential of precision medicine to improve the health of individuals or small groups of individuals is not addressed here because it involves a different question with different metrics. |
Evaluation of library preparation methods for Illumina next generation sequencing of small amounts of DNA from foodborne parasites.
Nascimento FS , Wei-Pridgeon Y , Arrowood MJ , Moss D , da Silva AJ , Talundzic E , Qvarnstrom Y . J Microbiol Methods 2016 130 23-26 Illumina library preparation methods for ultra-low input amounts were compared using genomic DNA from two foodborne parasites (Angiostrongylus cantonensis and Cyclospora cayetanensis) as examples. The Ovation Ultralow method resulted in libraries with the highest concentration and produced quality sequencing data, even when the input DNA was in the picogram range. |
Understanding the failure of a behavior change intervention to reduce risk behaviors for avian influenza transmission among backyard poultry raisers in rural Bangladesh: A focused ethnography
Rimi NA , Sultana R , Ishtiak-Ahmed K , Rahman MZ , Hasin M , Islam MS , Azziz-Baumgartner E , Nahar N , Gurley ES , Luby SP . BMC Public Health 2016 16 (1) 858 BACKGROUND: The spread of the highly pathogenic avian influenza (HPAI) H5N1 virus among poultry and humans has raised global concerns and has motivated government and public health organizations to initiate interventions to prevent the transmission of HPAI. In Bangladesh, H5N1 became endemic in poultry and seven human H5N1 cases have been reported since 2007, including one fatality. This study piloted messages to increase awareness about avian influenza and its prevention in two rural communities, and explored change in villagers' awareness and behaviors attributable to the intervention. METHODS: During 2009-10, a research team implemented the study in two rural villages in two districts of Bangladesh. The team used a focused ethnographic approach for data collection, including informal interviews and observations to provide detailed contextual information about community response to a newly emerging disease. They collected pre-intervention qualitative data for one month. Then another team disseminated preventive messages focused on safe slaughtering methods, through courtyard meetings and affixed posters in every household. After dissemination, the research team collected post-intervention data for one month. RESULTS: More villagers reported hearing about 'bird flu' after the intervention compared to before the intervention. After the intervention, villagers commonly recalled changes in the color of combs and shanks of poultry as signs of avian influenza, and perceived zoonotic transmission of avian influenza through direct contact and through inhalation. Consequently the villagers valued covering the nose and mouth while handling sick and dead poultry as a preventive measure. Nevertheless, the team did not observe noticeable change in villagers' behavior after the intervention. Villagers reported not following the recommended behaviors because of the perceived absence of avian influenza in their flocks, low risk of avian influenza, cost, inconvenience, personal discomfort, fear of being rebuked or ridiculed, and doubt about the necessity of the intervention. CONCLUSIONS: The villagers' awareness about avian influenza improved after the intervention, however, the intervention did not result in any measurable improvement in preventive behaviors. Low cost approaches that promote financial benefits and minimize personal discomfort should be developed and piloted. |
Chlorhexidine and mupirocin susceptibility of methicillin-resistant Staphylococcus aureus isolates in the REDUCE-MRSA trial
Hayden MK , Lolans K , Haffenreffer K , Avery TR , Kleinman K , Li H , Kaganov RE , Lankiewicz J , Moody J , Septimus E , Weinstein RA , Hickok J , Jernigan J , Perlin JB , Platt R , Huang SS . J Clin Microbiol 2016 54 (11) 2735-2742 Whether targeted or universal decolonization strategies for control of methicillin-resistant Staphylococcus aureus (MRSA) select for resistance to decolonizing agents is unresolved. The REDUCE MRSA trial provided an opportunity to investigate this question. REDUCE-MRSA was a 3-arm, cluster-randomized trial of screening and isolation without decolonization, targeted decolonization with chlorhexidine and mupirocin, or universal decolonization without screening to prevent MRSA infection in intensive care unit patients. Iisolates from baseline and intervention periods were collected and tested for susceptibility to CHG by microtiter dilution; mupirocin susceptibility was tested by E-test. Presence of qacA/B genes was determined by PCR and DNA sequence analysis. A total of 3,173 isolates were analyzed; two were non-susceptible to CHG (MICs 8 mug/mL), and 5/814 (0.6%) carried qacA/B. At baseline, 7.1% of MRSA isolates expressed low-level and 7.5% expressed high-level mupirocin resistance. In a mixed effects generalized logistic regression model, the odds of mupirocin resistance among clinical MRSA isolates or MRSA isolates acquired in ICU in intervention versus baseline periods did not differ across arms, although estimates were imprecise due to small numbers. Reduced susceptibility to chlorhexidine and carriage of qacA/B were rare among MRSA isolates in the REDUCE MRSA trial. Odds of mupirocin-resistance were no different in the intervention versus baseline periods across arms, but confidence limits were broad and results should be interpreted with caution. |
National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 Years - United States, 2015
Reagan-Steiner S , Yankey D , Jeyarajah J , Elam-Evans LD , Curtis CR , MacNeil J , Markowitz LE , Singleton JA . MMWR Morb Mortal Wkly Rep 2016 65 (33) 850-858 The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents aged 11-12 years routinely receive vaccines to prevent diseases, including human papillomavirus (HPV)-associated cancers, pertussis, and meningococcal disease (1). To assess vaccination coverage among adolescents in the United States, CDC analyzed data collected regarding 21,875 adolescents through the 2015 National Immunization Survey-Teen (NIS-Teen).* During 2014-2015, coverage among adolescents aged 13-17 years increased for each HPV vaccine dose among males, including ≥1 HPV vaccine dose (from 41.7% to 49.8%), and increased modestly for ≥1 HPV vaccine dose among females (from 60.0% to 62.8%) and ≥1 quadrivalent meningococcal conjugate vaccine (MenACWY) dose (from 79.3% to 81.3%). Coverage with ≥1 HPV vaccine dose was higher among adolescents living in households below the poverty level, compared with adolescents in households at or above the poverty level.dagger HPV vaccination coverage (≥1, ≥2, or ≥3 doses) increased in 28 states/local areas among males and in seven states among females. Despite limited progress, HPV vaccination coverage remained lower than MenACWY and tetanus, diphtheria, and acellular pertussis vaccine (Tdap) coverage, indicating continued missed opportunities for HPV-associated cancer prevention. |
Neutralizing antibody responses to antigenically drifted influenza A(H3N2) viruses among children and adolescents following 2014-15 inactivated and live attenuated influenza vaccination
Levine MZ , Martin JM , Gross FL , Jefferson S , Cole KS , Archibald C , Nowalk MP , Susick M , Moehling K , Spencer S , Chung JR , Flannery B , Zimmerman RK . Clin Vaccine Immunol 2016 23 (10) 831-839 Human influenza A(H3N2) viruses that predominated during the moderately severe 2014-15 influenza season differed antigenically from the vaccine component, resulting in reduced vaccine effectiveness (VE). To examine antibody responses to 2014-2015 inactivated influenza vaccine (IIV) and live-attenuated influenza vaccine (LAIV) among children and adolescents, we collected sera before and after vaccination from 150 children aged 3-17 years enrolled at health care facilities. Hemagglutination inhibition assays (HI) were used to assess the antibody responses to vaccines strains. We evaluated cross-reactive antibody responses against two representative A(H3N2) viruses that were antigenically drifted from the A(H3N2) vaccine component using microneutralization (MN) assays. Post vaccination antibody titers to drifted A(H3N2) viruses were higher following receipt of IIV (MN GMT 63-68, 38-45% achieved seroconversion) versus LAIV (MN GMT 22, only 3-5% achieved seroconversion). In 9-17 year olds, highest MN titers were observed among IIV-vaccinated individuals who received LAIV in the previous season. Among all IIV recipients aged 3-17 years, the strongest predictor of antibody responses to the drifted viruses was the pre-vaccination titers to the vaccine strain. Our study suggests that in an antigenically drifted season, vaccination still induced cross-reactive antibody responses to drifted circulating A(H3N2) viruses, although higher antibody titers may be required for protection. Antibody responses to drifted A(H3N2) viruses following vaccination were influenced by multiple factors including vaccine type and pre-existing antibodies from prior exposure. |
Obstetrical and neonatal case definitions for immunization safety data
Moro PL , Chen RT . Vaccine 2016 34 (49) 5991-5992 Administering vaccines specifically to pregnant women as part of a disease prevention strategy has not been routinely practiced, with the major exception of protecting against neonatal tetanus. Pregnancy continues to be a contraindication for receipt of most live viral (e.g., measles, mumps, rubella, varicella) vaccines. In the wake of the thalidomide tragedy [1], real or perceived risks of teratogenicity have served as a deterrent to administration of many medicines during pregnancy. Little is known about the effects of new medications or vaccines on pregnant women since they are often excluded from clinical research designed to determine safety. In recent years, however, a groundswell of public and provider opinion has developed urging reconsideration of the practice of excluding pregnant women from drug safety studies for some vaccines. The morbidity and mortality following some infections (e.g., influenza and pertussis) can be disproportionally greater among infants and pregnant women [2], [3]. Consequently, the Advisory Committee on Immunization Practices (ACIP) has recommended routine immunization of pregnant women with influenza vaccine since 1997 [2] and a dose of Tdap during every pregnancy since 2012 [4]. Future vaccines for use in pregnancy may include group B streptococcal, Zika, and respiratory syncytial virus vaccines. The challenges and opportunities for maternal immunization have begun to be addressed in various vaccine stakeholder meetings. For example, the US National Vaccine Advisory Committee (NVAC formed a Maternal Immunization Working Group in 2012 and issued a report in 2014 on “Reducing Patient and Provider Barriers to Maternal Immunizations” [6]. |
Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2016–17 Influenza Season
Grohskopf LA , Sokolow LZ , Broder KR , Olsen SJ , Karron RA , Jernigan DB , Bresee JS . MMWR Recomm Rep 2016 65 (5) 1-54 This report updates the 2015-16 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines (Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season. MMWR Morb Mortal Wkly Rep 2015;64:818-25). Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. For the 2016-17 influenza season, inactivated influenza vaccines (IIVs) will be available in both trivalent (IIV3) and quadrivalent (IIV4) formulations. Recombinant influenza vaccine (RIV) will be available in a trivalent formulation (RIV3). In light of concerns regarding low effectiveness against influenza A(H1N1)pdm09 in the United States during the 2013-14 and 2015-16 seasons, for the 2016-17 season, ACIP makes the interim recommendation that live attenuated influenza vaccine (LAIV4) should not be used. Vaccine virus strains included in the 2016-17 U.S. trivalent influenza vaccines will be an A/California/7/2009 (H1N1)-like virus, an A/Hong Kong/4801/2014 (H3N2)-like virus, and a B/Brisbane/60/2008-like virus (Victoria lineage). Quadrivalent vaccines will include an additional influenza B virus strain, a B/Phuket/3073/2013-like virus (Yamagata lineage).Recommendations for use of different vaccine types and specific populations are discussed. A licensed, age-appropriate vaccine should be used. No preferential recommendation is made for one influenza vaccine product over another for persons for whom more than one licensed, recommended product is otherwise appropriate. This information is intended for vaccination providers, immunization program personnel, and public health personnel. Information in this report reflects discussions during public meetings of ACIP held on October 21, 2015; February 24, 2016; and June 22, 2016. These recommendations apply to all licensed influenza vaccines used within Food and Drug Administration-licensed indications, including those licensed after the publication date of this report. Updates and other information are available at CDC's influenza website (http://www.cdc.gov/flu). Vaccination and health care providers should check CDC's influenza website periodically for additional information. |
Fractional-dose inactivated poliovirus vaccine immunization campaign - Telangana state, India, June 2016
Bahl S , Verma H , Bhatnagar P , Haldar P , Satapathy A , Kumar KN , Horton J , Estivariz CF , Anand A , Sutter R . MMWR Morb Mortal Wkly Rep 2016 65 (33) 859-863 Wild poliovirus type 2 was declared eradicated in September 2015 (1). In April 2016, India, switched from use of trivalent oral poliovirus vaccine (tOPV; containing types 1, 2, and 3 polio vaccine viruses), to bivalent OPV (bOPV; containing types 1 and 3), as part of a globally synchronized initiative to withdraw Sabin poliovirus type 2 vaccine. Concurrently, inactivated poliovirus vaccine (IPV) was introduced into India's routine immunization program to maintain an immunity base that would mitigate the number of paralytic cases in the event of epidemic transmission of poliovirus type 2 (2,3). After cessation of use of type 2 Sabin vaccine, any reported isolation of vaccine-derived poliovirus type 2 (VDPV2) would be treated as a public health emergency and might need outbreak response with monovalent type 2 oral vaccine, IPV, or both (4). In response to identification of a VDPV2 isolate from a sewage sample collected in the southern state of Telangana in May 2016, India conducted a mass vaccination campaign in June 2016 using an intradermal fractional dose (0.1 ml) of IPV (fIPV). Because of a global IPV supply shortage, fIPV, which uses one fifth of regular intramuscular (IM) dose administered intradermally, has been recommended as a response strategy for VDPV2 (5). Clinical trials have demonstrated that fIPV is highly immunogenic (6,7). During the 6-day campaign, 311,064 children aged 6 weeks-3 years were vaccinated, achieving an estimated coverage of 94%. With appropriate preparation, an emergency fIPV response can be promptly and successfully implemented. Lessons learned from this campaign can be applied to successful implementation of future outbreak responses using fIPV. |
Intussusception rates before and after the introduction of rotavirus vaccine
Tate JE , Yen C , Steiner CA , Cortese MM , Parashar UD . Pediatrics 2016 138 (3) BACKGROUND: Recent US studies have identified a small increased risk of intussusception after rotavirus vaccination, mainly after the first dose. We examined trends in intussusception hospitalizations before (2000-2005) and after (2007-2013) rotavirus vaccine introduction to assess whether this observed temporal risk translates into more hospitalized cases at the population level. METHODS: Intussusception hospitalizations in children <12 months of age were abstracted from the State Inpatient Database maintained by the Healthcare Cost and Utilization Project for 26 states that provided data from 2000 to 2013. Rates were calculated using bridged-race postcensal population estimates. Trends were analyzed by age groups (6-14 weeks, 15-24 weeks, and 25-34 weeks) based on the recommended ages for vaccine administration as well as 8-11 weeks when the majority of first doses are given. Rate ratios were calculated by using Poisson regression. RESULTS: No consistent change in intussusception hospitalization rates was observed among all children <12 months of age and among children 15 to 24 weeks and 25 to 34 weeks of age. The intussusception hospitalization rate for children aged 8 to 11 weeks was significantly elevated by 46% to 101% (range: 16.7-22.9 per 100 000) in all postvaccine years except 2011 and 2013 compared with the prevaccine baseline (11.7 per 100 000). CONCLUSIONS: The increase in the intussusception hospitalization rate in children 8 to 11 weeks when the majority of first doses of vaccine are given is consistent with recent US postlicensure studies. Given the magnitude of declines in rotavirus disease compared with this small increase in intussusception, the benefits of rotavirus vaccination outweigh the increase risk of intussusception. |
Knowledge, attitudes, and practices regarding diarrhea and cholera following an oral cholera vaccination campaign in the Solomon Islands
Burnett E , Dalipanda T , Ogaoga D , Gaiofa J , Jilini G , Halpin A , Dietz V , Date K , Mintz E , Hyde T , Wannemuehler K , Yen C . PLoS Negl Trop Dis 2016 10 (8) e0004937 BACKGROUND: In response to a 2011 cholera outbreak in Papua New Guinea, the Government of the Solomon Islands initiated a cholera prevention program which included cholera disease prevention and treatment messaging, community meetings, and a pre-emptive cholera vaccination campaign targeting 11,000 children aged 1-15 years in selected communities in Choiseul and Western Provinces. METHODOLOGY AND PRINCIPAL FINDINGS: We conducted a post-vaccination campaign, household-level survey about knowledge, attitudes, and practices regarding diarrhea and cholera in areas targeted and not targeted for cholera vaccination. Respondents in vaccinated areas were more likely to have received cholera education in the previous 6 months (33% v. 9%; p = 0.04), to know signs and symptoms (64% vs. 22%; p = 0.02) and treatment (96% vs. 50%; p = 0.02) of cholera, and to be aware of cholera vaccine (48% vs. 14%; p = 0.02). There were no differences in water, sanitation, and hygiene practices. CONCLUSIONS: This pre-emptive OCV campaign in a cholera-naive community provided a unique opportunity to assess household-level knowledge, attitudes, and practices regarding diarrhea, cholera, and water, sanitation, and hygiene (WASH). Our findings suggest that education provided during the vaccination campaign may have reinforced earlier mass messaging about cholera and diarrheal disease in vaccinated communities. |
Case-centered analysis of optic neuritis after vaccines
Baxter R , Lewis E , Fireman B , DeStefano F , Gee J , Klein NP . Clin Infect Dis 2016 63 (1) 79-81 We evaluated the risk of optic neuritis (ON) after vaccines, using a case-centered analysis, comparing the time since vaccination for the patients with ON with that for all similar vaccinees in a large integrated health plan population. We did not detect any association between ON and receipt of any type of vaccine. |
Methodological and design considerations in evaluating the impact of prevention programs on violence and related health outcomes
Massetti GM , Simon TR , Smith DG . Prev Sci 2016 17 (7) 779-84 Drawing on research that has identified specific predictors and trajectories of risk for violence and related negative outcomes, a multitude of small- and large-scale preventive interventions for specific risk behaviors have been developed, implemented, and evaluated. One of the principal challenges of these approaches is that a number of separate problem-specific programs targeting different risk areas have emerged. However, as many negative health behaviors such as substance abuse and violence share a multitude of risk factors, many programs target identical risk factors. There are opportunities to understand whether evidence-based programs can be leveraged for potential effects across a spectrum of outcomes and over time. Some recent work has documented longitudinal effects of evidence-based interventions on generalized outcomes. This work has potential for advancing our understanding of the effectiveness of promising and evidence-based prevention strategies. However, conducting longitudinal follow-up of established interventions presents a number of methodological and design challenges. To answer some of these questions, the Centers for Disease Control and Prevention convened a panel of multidisciplinary experts to discuss opportunities to take advantage of evaluations of early prevention programs and evaluating multiple long-term outcomes. This special section of the journal Prevention Science includes a series of papers that begin to address the relevant considerations for conducting longitudinal follow-up evaluation research. This collection of papers is intended to inform our understanding of the challenges and strategies for conducting longitudinal follow-up evaluation research that could be used to drive future research endeavors. |
Familial influences on dating violence victimization among Latino youth
McNaughton Reyes HL , Foshee VA , Klevens J , Tharp AT , Chapman M , Chen M , Ennett ST . J Aggress Maltreat Trauma 2016 25 (8) 773-792 Despite theoretical and empirical evidence suggesting that the family environment plays a central role in Latino youth development, relatively little is known about how family processes influence dating violence victimization among Latino adolescents. To address this gap in the literature, we used data from 210 Latino parents and their 13- to 15-year-old adolescents to examine associations between several different family processes, including both parenting practices (parent monitoring, parent–adolescent communication) and aspects of the family relational climate (family cohesion, family conflict, acculturation conflict) and psychological, physical, and sexual dating violence victimization. Consistent with expectations, lower levels of family cohesion and higher levels of family and acculturation conflict were associated with risk for dating violence victimization, although associations varied depending on victimization type. In contrast, neither parental monitoring nor parent–adolescent communication was significantly associated with any type of dating violence victimization. In addition, we found that parent, but not teen, Anglo-American acculturation was associated with higher dating violence victimization risk. Findings suggest that family-based dating abuse prevention programs for Latino youth should seek to increase family cohesion and decrease family conflict, including acculturation-based conflict. |
Spirochaete flagella hook proteins self-catalyse a lysinoalanine covalent crosslink for motility
Miller MR , Miller KA , Bian J , James ME , Zhang S , Lynch MJ , Callery PS , Hettick JM , Cockburn A , Liu J , Li C , Crane BR , Charon NW . Nat Microbiol 2016 (10) 16134 Spirochaetes are bacteria responsible for several serious diseases, including Lyme disease (Borrelia burgdorferi), syphilis (Treponema pallidum) and leptospirosis (Leptospira interrogans), and contribute to periodontal diseases (Treponema denticola) 1. These spirochaetes employ an unusual form of flagella-based motility necessary for pathogenicity; indeed, spirochaete flagella (periplasmic flagella) reside and rotate within the periplasmic space 2-11. The universal joint or hook that links the rotary motor to the filament is composed of ∼120-130 FlgE proteins, which in spirochaetes form an unusually stable, high-molecular-weight complex 9,12-17. In other bacteria, the hook can be readily dissociated by treatments such as heat 18. In contrast, spirochaete hooks are resistant to these treatments, and several lines of evidence indicate that the high-molecular-weight complex is the consequence of covalent crosslinking 12,13,17. Here, we show that T. denticola FlgE self-catalyses an interpeptide crosslinking reaction between conserved lysine and cysteine, resulting in the formation of an unusual lysinoalanine adduct that polymerizes the hook subunits. Lysinoalanine crosslinks are not needed for flagellar assembly, but they are required for cell motility and hence infection. The self-catalytic nature of FlgE crosslinking has important implications for protein engineering, and its sensitivity to chemical inhibitors provides a new avenue for the development of antimicrobials targeting spirochaetes. |
Lyme borreliosis serology: Performance with several commonly used laboratory diagnostic tests and a large resource panel of well-characterized atient samples
Molins CR , Delorey MJ , Sexton C , Schriefer ME . J Clin Microbiol 2016 54 (11) 2726-2734 Current recommendation for the laboratory confirmation of Lyme disease is serology-based diagnostics. Specifically, a standardized two-tiered testing (STTT) algorithm is applied that utilizes a first-tier immunofluorescence assay (IFA) or enzyme immunoassay (EIA) that if positive or equivocal is followed by second-tier immunoblotting. Despite the standardization and performance achievements, STTT is considered technically complex and subjective, as well as insensitive for early acute infection. These issues have prompted development of novel algorithms and testing platforms. In this study, we evaluated the performance of several commonly used assays for STTT. Several modified two-tiered testing (MTTT) algorithms, including a 2-EIA algorithm and modified criteria for second-tier IgG immunoblots, were also evaluated. All tests were performed on sera from a recently available, well-defined archive of positive and negative control patients. Our study demonstrated differences in the results between individual first- and second-tier tests although the overall agreement of the different STTT algorithms used was strong. Additionally, the MTTT algorithm utilizing 2-EIAs was found to be equivalent to all STTT algorithms tested, with agreement ranging from 94 to 97%. The 2-EIA MTTT algorithm slightly enhanced sensitivity in early disease as compared to the STTT algorithms evaluated. Furthermore, these data add to the mounting evidence that a 2-EIA-based MTTT algorithm, where immunoblotting is replaced by the C6 EIA, performs equally well or better than STTT. |
Prevalence of active and latent yaws in the Solomon Islands 18 months after azithromycin mass drug administration for trachoma
Marks M , Sokana O , Nachamkin E , Puiahi E , Kilua G , Pillay A , Bottomley C , Solomon AW , Mabey DC . PLoS Negl Trop Dis 2016 10 (8) e0004927 INTRODUCTION: Both yaws and trachoma are endemic in the Pacific. Mass treatment with azithromycin is the mainstay of the WHO strategy for both the eradication of yaws and the elimination of trachoma as a public health problem, but the dose recommended for trachoma is lower than that for yaws. In countries where both diseases are endemic, there is a potential for synergy between yaws and trachoma control programs if mass treatment with the lower dose of azithromycin was shown to be effective for the treatment of yaws. In an earlier study, we demonstrated a profound reduction in the clinical and serological prevalence of yaws following a single round of mass treatment with azithromycin 20 mg/kg undertaken for the purposes of trachoma elimination. METHODS: This survey was conducted 18 months following a single round of azithromycin mass treatment in the same communities in which we had conducted our previous six-month follow-up survey. We examined children aged 1-14 years and took blood and lesion samples for yaws diagnosis using the Treponema pallidum particle agglutination assay (TPPA) and the non-treponemal Rapid Plasma Reagin (RPR) test. RESULTS: A total of 1,284 children were enrolled in the study. Amongst children aged 5-14 years, 223 had a positive TPPA (27.5%, 95% CI 13.6-47.7%). The TPPA seroprevalence amongst this age group did not differ significantly from either our pre-mass treatment survey or our initial follow-up survey. Thirty-five children had positive TPPA and positive RPR (4.3%, 95% CI 2.1-8.7%), and this did not differ significantly from our initial post-mass drug administration (MDA) follow-up survey (4.3% versus 3.5%, p = 0.43) but remained significantly lower than our initial pre-MDA survey (4.3% vs 21.7%, p <0.0001). Village-level MDA coverage was strongly associated with dual-seropositivity (p = 0.005). Amongst children aged 1-4 years, 16 had a positive TPPA (3.5%, 95% CI 1.6-7.1%). This did not differ significantly from the seroprevalence in this age group that had been predicted based on our previous surveys (3.5% vs 5%, p = 0.11). Fourteen children (1.1%) were considered to have a skin lesion clinically consistent with yaws, but none of these individuals was seropositive for yaws. Of nine cases where a swab could be collected for PCR, all were negative for Treponema pallidum subsp. pertenue DNA. DISCUSSION: In this study we have shown that the benefit of a single round of mass treatment with azithromycin 20mg/kg appears to extend to 18 months without any further intervention. The lack of a significant change in seroprevalence from 6 to 18 months after mass treatment might suggest that interventions could be spaced at yearly intervals without a significant loss of impact, and that this might facilitate integration of yaws eradication with other neglected tropical disease (NTD) control programmes. MDA coverage above 90% was associated with significantly better outcomes than coverages lower than this threshold, and strategies to improve coverage at all stages of yaws eradication efforts should be investigated. |
A comparison of facemask and respirator filtration test methods
Rengasamy S , Shaffer R , Williams B , Smit S . J Occup Environ Hyg 2016 14 (2) 0 NIOSH published a Federal Register Notice to explore the possibility of incorporating FDA required filtration tests for surgical masks (SMs) in the 42 CFR Part 84 respirator certification process. There have been no published studies comparing the filtration efficiency test methods used for NIOSH certification of N95 filtering facepiece respirators (N95 FFRs) with those used by the FDA for clearance of SMs. To address this issue, filtration efficiencies of "N95 FFRs" including six N95 FFR models and three surgical N95 FFR models, and three SM models were measured using the NIOSH NaCl aerosol test method, and FDA required particulate filtration efficiency (PFE) and bacterial filtration efficiency (BFE) methods, and viral filtration efficiency (VFE) method. Five samples of each model were tested using each method. Both PFE and BFE tests were done using unneutralized particles as per FDA guidance document. PFE was measured using 0.1 microm size polystyrene latex particles and BFE with approximately 3.0 microm size particles containing Staphylococcus aureus bacteria. VFE was obtained using approximately 3.0 microm size particles containing phiX 174 as the challenge virus and Escherichia coli as the host. Results showed that the efficiencies measured by the NIOSH NaCl method for "N95 FFRs" were from 98.15 to 99.68% compared to 99.74 to 99.99% for PFE, 99.62 to 99.9% for BFE and 99.8 to 99.9% for VFE methods. Efficiencies by the NIOSH NaCl method were significantly (p = <0.05) lower than the other methods. SMs showed lower efficiencies (54.72 to 88.40%) than "N95 FFRs" measured by the NIOSH NaCl method, while PFE, BFE and VFE methods produced no significant difference. The above results show that the NIOSH NaCl method is relatively conservative and is able to identify poorly performing filtration devices. The higher efficiencies obtained using PFE, BFE and VFE methods show that adding these supplemental particle penetration methods will not improve respirator certification. |
Cross-species prediction of human survival probabilities for accelerated anthrax vaccine absorbed (AVA) regimens and the potential for vaccine and antibiotic dose sparing
Stark GV , Sivko GS , VanRaden M , Schiffer J , Taylor KL , Hewitt JA , Quinn CP , Nuzum EO . Vaccine 2016 34 (51) 6512-6517 Anthrax vaccine adsorbed (AVA, BioThrax) was recently approved by the Food and Drug Administration (FDA) for a post-exposure prophylaxis (PEP) indication in adults 18-65 years of age. The schedule is three doses administered subcutaneous (SC) at 2-week intervals (0, 2, and 4weeks), in conjunction with a 60-day course of antimicrobials. The Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) developed an animal model to support assessment of a shortened antimicrobial PEP duration following Bacillus anthracis exposure. A nonhuman primate (NHP) study was completed to evaluate the efficacy of a two dose anthrax vaccine absorbed (AVA) schedule (0, 2weeks) aerosol challenged with high levels of B. anthracis spores at week4- the time point at which humans would receive the third vaccination of the approved PEP schedule. Here we use logistic regression models to combine the survival data from the NHP study along with serum anthrax lethal toxin neutralizing activity (TNA) and anti-PA IgG measured by enzyme linked immunosorbent assay (ELISA) data to perform a cross-species analysis to estimate survival probabilities in vaccinated human populations at this time interval (week4 of the PEP schedule). The bridging analysis demonstrated that high levels of NHP protection also yield high predicted probability of human survival just 2weeks after the second dose of vaccine with the full or half antigen dose regimen. The absolute difference in probability of human survival between the full and half antigen dose was estimated to be at most approximately 20%, indicating that more investigation of the half-antigen dose for vaccine dose sparing strategies may be warranted. |
Development of two FhSAP2 recombinant-based assays for immunodiagnosis of human chronic fascioliasis
Shin SH , Hsu A , Chastain HM , Cruz LA , Elder ES , Sapp SG , McAuliffe I , Espino AM , Handali S . Am J Trop Med Hyg 2016 95 (4) 852-855 In the United States, infection with Fasciola hepatica has been identified as an emerging disease, primarily in immigrants, refugees, and travelers. The laboratory test of choice for the diagnosis of fascioliasis detection of disease-specific antibodies, most commonly uses excretory-secretory antigens for detection of IgG antibodies. Recently, recombinant proteins such as F. hepatica antigen (FhSAP2) have been used to detect IgG antibodies. The glutathione S-transferase (GST)-FhSAP2 recombinant antigen was used to develop Western blot (WB) and fluorescent bead-based (Luminex) assays to detect F. hepatica total IgG and IgG4 antibodies. The sensitivity and specificity of GST-FhSAP2 total IgG and IgG4 WB were similar at 94% and 98%, respectively. For the IgG Luminex assay, the sensitivity and specificity were 94% and 97%, and for the IgG4, the values were 100% and 99%, respectively. In conclusion, the GST-FhSAP2 antigen performs well in several assay formats and can be used for clinical diagnosis. |
Racial and ethnic disparities in ADHD diagnosis and treatment
Coker TR , Elliott MN , Toomey SL , Schwebel DC , Cuccaro P , Tortolero Emery S , Davies SL , Visser SN , Schuster MA . Pediatrics 2016 138 (3) OBJECTIVES: We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children. METHODS: We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms. RESULTS: Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis. CONCLUSIONS: Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children. |
Severe maternal morbidity: screening and review
Kilpatrick SK , Ecker JL , Callaghan WM . Am J Obstet Gynecol 2016 215 (3) B17-22 This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important, for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria, such as having received 4 or more units of blood or having been admitted to an ICU, or create their own list of outcomes that merit review. |
Time to think about nutrient needs in chronic disease
Stover PJ , Berry RJ , Field MS . JAMA Intern Med 2016 176 (10) 1451-1452 There is renewed interest in health benefits of folic acid supplementation since the China Stroke Prevention Primary Prevention Trial (CSPPT) showed the potential benefits of folic acid in preventing stroke in Chinese adults with hypertension.1 It has long been known that folic acid prevents neural tube defects, which are among the most severe and debilitating congenital birth defects worldwide. The CSPPT was terminated early when 800 μg of folic acid in combination with 10 mg of enalapril significantly reduced primary stroke incidence compared with the enalapril alone treatment arm. This finding was unexpected as other studies had failed to find a preventive effect of folic acid supplementation on cardiovascular events.2 In this issue of JAMA Internal Medicine, Xu et al3 report findings from a prespecified CSPPT substudy that demonstrated that the folic acid–enalapril combination was more effective than enalapril alone in the secondary prevention of renal function decline among Chinese adults with hypertension across a spectrum of mild to moderate chronic kidney disease (CKD). | Folic acid is commonly administered to treat hyperhomocysteinemia, but the benefits of homocysteine lowering on the prevention or management of most chronic diseases associated with hyperhomocysteinemia remains unproven.2 In the renal substudy of the CSPPT,3 Xu and colleagues report that 42% of participants with CKD exhibited hyperhomocysteinemia (serum homocysteine ≥15 μM) and 24% had diabetes, compared with only 26% with hyperhomocysteinemia and 12% with diabetes in those without CKD. Individuals who were homozygous for the MTHFR C677T polymorphism, a genetic variant that expresses an enzyme with reduced 5-methyltetra-hydrofolate synthesis activity, exhibited the greatest reduction in serum homocysteine following folic acid–enalapril treatment because their baseline levels of circulating homocysteine were higher. This finding is consistent with other studies suggesting that the current recommended dietary intake for folate may not be adequate for individuals homozygous for the MTHFR 677T variant when homocysteine lowering is used as the functional biomarker to assess folate status.4 |
An educational video game for nutrition of young people: theory and design
Ledoux T , Griffith M , Thompson D , Nguyen N , Watson K , Baranowski J , Buday R , Abdelsamad D , Baranowski T . Simul Gaming 2016 47 (4) 490-516 BACKGROUND: Playing Escape from DIAB (DIAB) and Nanoswarm (NANO), epic video game adventures, increased fruit and vegetable consumption among a multi-ethnic sample of 10-12 year old children during pilot testing. Key elements of both games were educational mini-games embedded in the overall game that promoted knowledge acquisition regarding diet, physical activity and energy balance. 95-100% of participants demonstrated mastery of these mini-games suggesting knowledge acquisition. AIM: This article describes the process of designing and developing the educational mini-games. A secondary purpose was to explore the experience of children while playing the games. METHOD: The educational games were based on Social Cognitive and Mastery Learning Theories. A multidisciplinary team of behavioral nutrition, PA, and video game experts designed, developed, and tested the mini-games. RESULTS: Alpha testing revealed children generally liked the mini-games and found them to be reasonably challenging. Process evaluation data from pilot testing revealed almost all participants completed nearly all educational mini-games in a reasonable amount of time suggesting feasibility of this approach. CONCLUSIONS: Future research should continue to explore the use of video games in educating children to achieve healthy behavior changes. |
Do lower calorie or lower fat foods have more sodium than their regular counterparts?
John KA , Maalouf J , BBarsness C , Yuan K , Cogswell ME , Gunn JP . Nutrients 2016 8 (8) The objective of this study was to compare the sodium content of a regular food and its lower calorie/fat counterpart. Four food categories, among the top 20 contributing the most sodium to the US diet, met the criteria of having the most matches between regular foods and their lower calorie/fat counterparts. A protocol was used to search websites to create a list of "matches", a regular and comparable lower calorie/fat food(s) under each brand. Nutrient information was recorded and analyzed for matches. In total, 283 matches were identified across four food categories: savory snacks (N = 44), cheese (N = 105), salad dressings (N = 90), and soups (N = 44). As expected, foods modified from their regular versions had significantly reduced average fat (total fat and saturated fat) and caloric profiles. Mean sodium content among modified salad dressings and cheeses was on average 8%-12% higher, while sodium content did not change with modification of savory snacks. Modified soups had significantly lower mean sodium content than their regular versions (28%-38%). Consumers trying to maintain a healthy diet should consider that sodium content may vary in foods modified to be lower in calories/fat. |
Precautionary practices for administering anesthetic gases: a survey of physician anesthesiologists, nurse anesthetists and anesthesiologist assistants
Boiano JM , Steege AL . J Occup Environ Hyg 2016 13 (10) 782-93 Scavenging systems and administrative and work practice controls for minimizing occupational exposure to waste anesthetic gases have been recommended for many years. Anesthetic gases and vapors that are released or leak out during medical procedures are considered waste anesthetic gases. To better understand the extent recommended practices are used, the NIOSH Health and Safety Practices Survey of Healthcare Workers was conducted in 2011 among members of professional practice organizations representing anesthesia care providers including physician anesthesiologists, nurse anesthetists, and anesthesiologist assistants. This national survey is the first to examine self-reported use of controls to minimize exposure to waste anesthetic gases among anesthesia care providers. The survey was completed by 1,783 nurse anesthetists, 1,104 physician anesthesiologists, and 100 anesthesiologist assistants who administered inhaled anesthetics in the seven days prior to the survey. Working in hospitals and outpatient surgical centers, respondents most often administered sevoflurane and, to a lesser extent desflurane and isoflurane, in combination with nitrous oxide. Use of scavenging systems was nearly universal, reported by 97% of respondents. However, adherence to other recommended practices was lacking to varying degrees and differed among those administering anesthetics to pediatric (P) or adult (A) patients. Examples of practices which increase exposure risk, expressed as percent of respondents, included: using high (fresh gas) flow anesthesia only (17% P, 6% A), starting anesthetic gas flow before delivery mask or airway mask was applied to patient (35% P; 14% A); not routinely checking anesthesia equipment for leaks (4% P, 5% A), and using a funnel-fill system to fill vaporizers (16%). Respondents also reported that facilities lacked safe handling procedures (19%) and hazard awareness training (18%). Adherence to precautionary work practices was generally highest among nurse anesthetists compared to the other anesthesia care providers. Successful management of waste anesthetic gases should include scavenging systems, hazard awareness training, availability of standard procedures to minimize exposure, regular inspection of anesthesia delivery equipment for leaks, prompt attention to spills and leaks, and medical surveillance. |
Pulmonary exposure to cellulose nanocrystals caused deleterious effects to reproductive system in male mice
Farcas MT , Kisin ER , Menas AL , Gutkin DW , Star A , Reiner RS , Yanamala N , Savolainen K , Shvedova AA . J Toxicol Environ Health A 2016 79 (21) 1-14 Over the past several years there has been an increased number of applications of cellulosic materials in many sectors, including the food industry, cosmetics, and pharmaceuticals. However, to date, there are few studies investigating the potential adverse effects of cellulose nanocrystals (CNC). The objective of this study was to determine long-term outcomes on the male reproductive system of mice upon repeated pharyngeal aspiration exposure to CNC. To achieve this, cauda epididymal sperm samples were analyzed for sperm concentration, motility, morphological abnormalities, and DNA damage. Testicular and epididymal oxidative damage was evaluated, as well as histopathology examination of testes. In addition, changes in levels of testosterone in testes and serum and of luteinizing hormone (LH) in serum were determined. Three months after the last administration, CNC exposure significantly altered sperm concentration, motility, cell morphology, and sperm DNA integrity. These parameters correlated with elevated proinflammatory cytokines levels and myeloperoxidase (MPO) activity in testes, as well as oxidative stress in both testes and epididymis. Exposure to CNC also produced damage to testicular structure, as evidenced by presence of interstitial edema, frequent dystrophic seminiferous tubules with arrested spermatogenesis and degenerating spermatocytes, and imbalance in levels of testosterone and LH. Taken together, these results demonstrate that pulmonary exposure to CNC induces sustained adverse effects in spermatocytes/spermatozoa, suggesting male reproductive toxicity. |
Evolution of welding-fume aerosols with time and distance from the source: a study was conducted on the spatiotemporal variability in welding-fume concentrations for the characterization of first- and second-hand exposure to welding fumes
Cena LG , Chen BT , Keane MJ . Weld J 2016 95 280s-285s Gas metal arc welding fumes were generated from mild-steel plates and measured near the arc (30 cm), representing first-hand exposure of the welder, and farther away from the source (200 cm), representing second-hand exposure of adjacent workers. Measurements were taken during 1-min welding runs and at subsequent 5-min intervals after the welding process was stopped. Number size distributions were measured in real time. Particle mass distributions were measured using a micro-orifice uniform deposition impactor, and total mass concentrations were measured with polytetrafluorothylene filters. Membrane filters were used for collecting morphology samples for electron microscopy. Average mass concentrations measured near the arc were 45 mg/m3 and 9 mg/m3 at the farther distance. The discrepancy in concentrations at the two distances was attributed to the presence of spatter particles, which were observed only in the morphology samples near the source. As fumes aged over time, mass concentrations at the farther distance decreased by 31% (6.2 mg/m3) after 5 min and an additional 13% (5.4 mg/m3) after 10 min. Particle number and mass distributions during active welding were similar at both distances, indicating similar exposure patterns for welders and adjacent workers. Exceptions were recorded for particles smaller than 50 nm and larger than 3 mum, where concentrations were higher near the arc, indicating higher exposures of welders. These results were confirmed by microscopy analysis. As residence time increased, number concentrations decreased dramatically. In terms of particle number concentrations, second-hand exposures to welding fumes during active welding may be as high as first-hand exposures. |
Assessment of submicroscopic infections and gametocyte carriage of Plasmodium falciparum during peak malaria transmission season in a community-based cross-sectional survey in western Kenya, 2012.
Zhou Z , Mitchell RM , Kariuki S , Odero C , Otieno P , Otieno K , Onyona P , Were V , Wiegand RE , Gimnig JE , Walker ED , Desai M , Shi YP . Malar J 2016 15 (1) 421 BACKGROUND: Although malaria control intervention has greatly decreased malaria morbidity and mortality in many African countries, further decline in parasite prevalence has stagnated in western Kenya. In order to assess if malaria transmission reservoir is associated with this stagnation, submicroscopic infection and gametocyte carriage was estimated. Risk factors and associations between malaria control interventions and gametocyte carriage were further investigated in this study. METHODS: A total of 996 dried blood spot samples were used from two strata, all smear-positives (516 samples) and randomly selected smear-negatives (480 samples), from a community cross-sectional survey conducted at peak transmission season in 2012 in Siaya County, western Kenya. Plasmodium falciparum parasite presence and density were determined by stained blood smear and by 18S mRNA transcripts using nucleic acid sequence-based amplification assay (NASBA), gametocyte presence and density were determined by blood smear and by Pfs25 mRNA-NASBA, and gametocyte diversity by Pfg377 mRNA RT-PCR and RT-qPCR. RESULTS: Of the randomly selected smear-negative samples, 69.6 % (334/480) were positive by 18S-NASBA while 18S-NASBA detected 99.6 % (514/516) smear positive samples. Overall, 80.2 % of the weighted population was parasite positive by 18S-NASBA vs 30.6 % by smear diagnosis and 44.0 % of the weighted population was gametocyte positive by Pfs25-NASBA vs 2.6 % by smear diagnosis. Children 5-15 years old were more likely to be parasitaemic and gametocytaemic by NASBA than individuals >15 years old or children <5 years old while gametocyte density decreased with age. Anaemia and self-reported fever within the past 24 h were associated with increased odds of gametocytaemia. Fever was also positively associated with parasite density, but not with gametocyte density. Anti-malarial use within the past 2 weeks decreased the odds of gametocytaemia, but not the odds of parasitaemia. In contrast, recent anti-malarial use was associated with lowered parasite density, but not the gametocyte density. Use of ITNs was associated with lower odds for parasitaemia in part of the study area with a longer history of ITN interventions. In the same part of study area, the odds of having multiple gametocyte alleles were also lower in individuals using ITNs than in those not using ITNs and parasite density was positively associated with gametocyte diversity. CONCLUSION: A large proportion of submicroscopic parasites and gametocytes in western Kenya might contribute to the stagnation in malaria prevalence, suggesting that additional interventions targeting the infectious reservoir are needed. As school aged children and persons with anaemia and fever were major sources for gametocyte reservoir, these groups should be targeted for intervention and prevention to reduce malaria transmission. Anti-malarial use was associated with lower parasite density and odds of gametocytaemia, but not the gametocyte density, indicating a limitation of anti-malarial impact on the transmission reservoir. ITN use had a protective role against parasitaemia and gametocyte diversity in western Kenya. |
Non-falciparum malaria in Dakar: a confirmed case of Plasmodium ovale wallikeri infection.
Diallo MA , Badiane AS , Diongue K , Deme A , Lucchi NW , Gaye M , Ndiaye T , Ndiaye M , Sene LK , Diop A , Gaye A , Ndiaye YD , Samb D , Yade MS , Ndir O , Udhayakumar V , Ndiaye D . Malar J 2016 15 (1) 429 BACKGROUND: Plasmodium ovale is rarely described in Senegal. A case of clinical malaria due to P. ovale wallikeri in West Central of Senegal is reported. CASE: A 34-year-old male baker in Dakar, with no significant previous medical history, was admitted to a health clinic with fever and vomiting. Fever had been lasting for 4 days with peaks every 48 h. As monospecific Plasmodium falciparum HRP-2 RDT was negative, he was treated with antibiotics. However, owing to persisting symptoms, he was referred to the emergency unit of the Youssou Mbargane Diop Hospital, Dakar, Senegal. Clinical examination found impaired general condition. All other physical examinations were normal. Laboratory tests showed anaemia (haemoglobin 11.4 g/dl), severe thrombocytopaenia (platelets 30 x 10(9)/mm(3)), leukopenia (3650/mm(3)), lymphocytopenia (650/mm(3)). Renal function was normal as indicated by creatininaemia and uraemia (11 mg/l and 0.25 g/l, respectively) and liver enzymes were slightly elevated (aspartate aminotransferase 77 UI/l and alanine aminotransferase 82 UI/l). Blood smear evaluations in Parasitology Laboratory of Aristide Le Dantec Hospital showed malaria parasites of the species P. ovale with a 0.08 % parasitaemia. Molecular confirmation was done by real time PCR targeting the 18S rRNA gene. The P. ovale infection was further analysed to species level targeting the potra gene and was identified as P. ovale wallikeri. According to the hospital's malaria treatment guidelines for severe malaria, treatment consisted of intravenous quinine at hour 0 (start of treatment) and 24 h after initial treatment, followed by artemether-lumefantrine 24 h later. A negative microscopy was noted on day 3 post-treatment and the patient reported no further symptoms. CONCLUSION: Malaria due to non-falciparum species is probably underestimated in Senegal. RDTs specific to non-falciparum species and/or pan specific RDTs should be included as tools of diagnosis to fight against malaria in Senegal. In addition, a field-deployable molecular tool such as the loop-mediated isothermal amplification can be considered as an additional useful tool to detect low malaria parasite infections and for speciation. In addition, national malaria control policies should consider other non-falciparum species in treatment guidelines, including the provision of primaquine for the treatment of relapsing parasites. |
Efficacy of chloroquine and primaquine for the treatment of uncomplicated Plasmodium vivax malaria in Cruzeiro do Sul, Brazil
Negreiros S , Farias S , Viana GM , Okoth SA , Chenet SM , de Souza TM , Marchesini P , Udhayakumar V , Povoa MM , Santelli AC , de Oliveira AM . Am J Trop Med Hyg 2016 95 (5) 1061-1068 We evaluated the efficacy of chloroquine and primaquine on uncomplicated Plasmodium vivax malaria in Cruzeiro do Sul, Brazil, in 2014. Patients ≥ 5 years of age with either fever or history of fever, and laboratory-confirmed P. vivax monoinfection received chloroquine (total dose = 25 mg/kg) and primaquine (total dose = 3.5 mg/kg), and were followed up for 168 days (24 weeks). We used microsatellite genotyping to differentiate recurrent infections caused by heterologous parasites from those caused by homologous ones. No new P. vivax episode occurred by Day 28 among 119 enrolled patients, leading to Day 28, with adequate clinical and parasitological response (ACPR) of 100% (95% confidence interval [CI] = 96.7-100%). Twenty-eight P. vivax episodes occurred by Day 168, with uncorrected ACPR of 69.9% (95% CI = 59.5-79.0%). Fifteen of these episodes were caused by either homologous haplotypes or haplotypes that could not be determined. Excluding the 13 recurrent episodes caused by heterologous parasites, Day 168 microsatellite-corrected ACPR was estimated at 81.2% (95% CI = 71.0-89.1%). Chloroquine and primaquine remain efficacious to treat acute uncomplicated P. vivax infection, but moderate recurrence rates were observed within 24 weeks of follow-up. |
Evaluating the burden of lymphedema due to lymphatic filariasis in 2005 in Khurda district, Odisha state, India
Walsh V , Little K , Wiegand R , Rout J , Fox LM . PLoS Negl Trop Dis 2016 10 (8) e0004917 BACKGROUND: Over 1.1 billion people worldwide are at risk for lymphatic filariasis (LF), and the global burden of LF-associated lymphedema is estimated at 16 million affected people, yet country-specific estimates are poor. METHODOLOGY/PRINCIPAL FINDINGS: A house-to-house morbidity census was conducted to assess the burden and severity of lymphedema in a population of 1,298,576 persons living in the LF-endemic district of Khurda in Odisha State, India. The burden of lymphedema in Khurda is widespread geographically, and 1.3% (17,036) of the total population report lymphedema. 51.3% of the patients reporting lymphedema were female, mean age 49.4 years (1-99). Early lymphedema (Dreyer stages 1 & 2) was reported in two-thirds of the patients. Poisson regression analysis was conducted in order to determine risk factors for advanced lymphedema (Dreyer stages 4-7). Increasing age was significantly associated with advanced lymphedema, and persons 70 years and older had a prevalence three times greater than individuals ages 15-29 (aPR: 3.21, 95% CI 2.45, 4.21). The number of adenolymphangitis (ADL) episodes reported in the previous year was also significantly associated with advanced lymphedema (aPR 4.65, 95% CI 2.97-7.30). This analysis is one of the first to look at potential risk factors for advanced lymphedema using morbidity census data from an entire district in Odisha State, India. SIGNIFICANCE: These data highlight the magnitude of lymphedema in LF-endemic areas and emphasize the need to develop robust estimates of numbers of individuals with lymphedema in order to identify the extent of lymphedema management services needed in these regions. |
Adherence to malaria diagnosis and treatment guidelines among healthcare workers in Ogun State, Nigeria
Bamiselu OF , Ajayi I , Fawole O , Dairo D , Ajumobi O , Oladimeji A , Steven Y . BMC Public Health 2016 16 (1) 828 BACKGROUND: Malaria case management remains a vital component of malaria control strategies. Despite the introduction of national malaria treatment guidelines and scale-up of malaria control interventions in Nigeria, anecdotal evidence shows some deviations from the guidelines in malaria case management. This study assessed factors influencing adherence to malaria diagnosis and treatment guidelines among healthcare workers in public and private sectors in Ogun State, Nigeria. METHODS: A comparative cross-sectional study was carried out among 432 (216 public and 216 private) healthcare workers selected from nine Local Government Areas using a multistage sampling technique. A pre-tested interviewer administered questionnaire was used to collect information on availability and use of malaria Rapid Diagnostic Test (mRDT) and artemisinin combination therapy (ACT), for management of uncomplicated malaria. Adherence was defined as when choice of antimalarials for parasitological confirmed malaria cases was restricted to recommended antimalarial medicines. Association between adherence and independent variables were tested using Chi-square at 5 % level of significance. RESULTS: Malaria RDT was available in 81.9 % of the public health facilities and 19.4 % of the private health facilities (p = 0.001). Its use was higher among public healthcare workers (85.2 %) compared to 32.9 % in private facilities (p = 0.000). Presumptive diagnosis of malaria was higher among private healthcare workers (94.9 %) compared to 22.7 % public facilities (p = <0.0001). The main reason for non-usage of mRDT among private healthcare workers was its perceived unreliability of mRDT (40.9 %). Monotherapy including artesunate (58.3 % vs 12.5 %), amodiaquine (38.9 % vs 8.3 %) and chloroquine (26.4 % vs 4.2 %) were significantly more available in private than public health facilities, respectively. Adherence to guidelines was significantly higher among public healthcare workers (60.6 %) compared to those in private facilities (27.3 %). Availability of antimalarial medicine was the main factor that influenced treatment prescription in both healthcare settings (p = 0.27). However, drug promotion by manufactures (45.8 %) has a major influence on private healthcare workers' prescription practice. CONCLUSION: The findings of this study demonstrate significant difference between public and private healthcare workers on adherence to national malaria diagnosis and treatment guidelines. Interventions to improve private sector engagement in implementation of the guidelines, training and supply of recommended antimalarial medicines should be intensified. |
Variation in US outpatient antibiotic prescribing quality measures according to health plan and geography
Roberts RM , Hicks LA , Bartoces M . Am J Manag Care 2016 22 (8) 519-23 OBJECTIVES: Antibiotic prescribing has become increasingly viewed as an issue related to patient safety and quality of care. The objective of this study was to better understand the differences between health plan reporting and the geographic variation seen in quality measures related to antibiotic use. STUDY DESIGN: We focused on 3 measures from the Healthcare Effectiveness Data and Information Set (HEDIS) related to antibiotic prescribing and testing to guide antibiotic prescribing. METHODS: We analyzed data for 3 relevant measures for the years 2008 to 2012, including only commercial health plans. We analyzed the following 3 HEDIS measures: 1) "Appropriate Testing for Children With Pharyngitis," 2) "Appropriate Treatment for Children With Upper Respiratory Infections," and 3) "Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis." RESULTS: Out of these 3 measures, health plans consistently performed poorly on the adult bronchitis measure. Performance was better on the 2 measures focused on the pediatric population. We also saw geographic variation between measures when looking at Census divisions across all years. CONCLUSIONS: There is wide variation between individual health plan performance on the measures related to antibiotic use. Geographic differences were also observed on these measures, with health plans in the South Central Census division performing worse than other parts of the country. Stakeholders, such as public health, advocacy groups, foundations, and professional societies, interested in improving the quality of care that patients receive related to antibiotic use in the outpatient setting should consider how existing measures and working with health plans could be used to improve prescribing. |
Methods for assessing the reliability of quality of life based on SF-36
Pan Y , Barnhart HX . Stat Med 2016 35 (30) 5656-5665 The 36-Item Short Form Health Survey (SF-36) has been widely used to measure quality of life. Reliability has been traditionally assessed by intraclass correlation coefficient (ICC), which is equivalent to Cronbach's alpha theoretically. However, it is a scaled assessment of reliability and does not indicate the extent of differences because of measurement error. In this paper, total deviation index (TDI) is used to interpret the magnitude of measurement error for SF-36, and a new formula for computing TDI for average item score is proposed. The interpretation based on TDI is simple and intuitive by providing, with a high probability, the expected difference that is because of measurement error. We also show that a high value of ICC does not always correspond to a smaller magnitude of measurement error, which indicates that ICC can sometimes provide a false sense of high reliability. The methodology is illustrated with reported SF-36 data from the literature and from real data in the Arthritis Self-Management Program. |
Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths - 27 states, 2013-2014
Gladden RM , Martinez P , Seth P . MMWR Morb Mortal Wkly Rep 2016 65 (33) 837-843 In March and October 2015, the Drug Enforcement Administration (DEA) and CDC, respectively, issued nationwide alerts identifying illicitly manufactured fentanyl (IMF) as a threat to public health and safety. IMF is unlawfully produced fentanyl, obtained through illicit drug markets, includes fentanyl analogs, and is commonly mixed with or sold as heroin. Starting in 2013, the production and distribution of IMF increased to unprecedented levels, fueled by increases in the global supply, processing, and distribution of fentanyl and fentanyl-precursor chemicals by criminal organizations. Fentanyl is a synthetic opioid 50-100 times more potent than morphine. Multiple states have reported increases in fentanyl-involved overdose (poisoning) deaths (fentanyl deaths). This report examined the number of drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) and synthetic opioid-involved deaths other than methadone (synthetic opioid deaths), which include fentanyl deaths and deaths involving other synthetic opioids (e.g., tramadol). Fentanyl deaths are not reported separately in national data. Analyses also were conducted on data from 27 states with consistent death certificate reporting of the drugs involved in overdoses. Nationally, the number of fentanyl submissions and synthetic opioid deaths increased by 426% and 79%, respectively, during 2013-2014; among the 27 analyzed states, fentanyl submission increases were strongly correlated with increases in synthetic opioid deaths. Changes in fentanyl submissions and synthetic opioid deaths were not correlated with changes in fentanyl prescribing rates, and increases in fentanyl submissions and synthetic opioid deaths were primarily concentrated in eight states (high-burden states). Reports from six of the eight high-burden states indicated that fentanyl-involved overdose deaths were primarily driving increases in synthetic opioid deaths. Increases in synthetic opioid deaths among high-burden states disproportionately involved persons aged 15-44 years and males, a pattern consistent with previously documented IMF-involved deaths. These findings, combined with the approximate doubling in fentanyl submissions during 2014-2015 (from 5,343 to 13,882), underscore the urgent need for a collaborative public health and law enforcement response. |
Increases in fentanyl-related overdose deaths - Florida and Ohio, 2013-2015
Peterson AB , Gladden RM , Delcher C , Spies E , Garcia-Williams A , Wang Y , Halpin J , Zibbell J , McCarty CL , DeFiore-Hyrmer J , DiOrio M , Goldberger BA . MMWR Morb Mortal Wkly Rep 2016 65 (33) 844-849 In March and October 2015, the Drug Enforcement Administration (DEA) and CDC issued nationwide alerts identifying fentanyl, particularly illicitly manufactured fentanyl (IMF), as a threat to public health and safety (1,2). IMF is pharmacologically similar to pharmaceutical fentanyl (PF), but is unlawfully produced in clandestine laboratories, obtained via illicit drug markets, and includes fentanyl analogs. Fentanyl is a synthetic opioid 50-100 times more potent than morphine and approved for the management of surgical/postoperative pain, severe chronic pain, and breakthrough cancer pain.* DEA's National Forensic Laboratory Information System (NFLIS) collects drug identification results from drug cases analyzed by federal, state, and local forensic laboratories throughout the United States.dagger In 2014, 80% of fentanyl submissions (i.e., drug products obtained by law enforcement that tested positive for fentanyl) in NFLIS were identified from 10 states, including Florida and Ohio (2), and seven of these 10 states reported sharp increases in fentanyl-related overdose deaths (fentanyl deaths) (3). This report presents findings of increased fentanyl deaths during 2013-2015 from investigations conducted by the University of Florida and the Ohio Department of Public Health, in collaboration with CDC. Analyses examined the association between trends in fentanyl-related law enforcement submissions and fentanyl deaths and describes groups at risk for fentanyl death using medical examiner and coroner reports. The marked increases in fentanyl death in Florida and Ohio during 2013-2015 were closely associated with parallel increases in fentanyl submissions, with the largest impact on persons who use heroin, consistent with reports that IMF is commonly mixed with or sold as heroin (1,4). In Ohio, circumstances associated with fentanyl deaths included a current diagnosed mental health disorder section sign and recent release from an institution such as a jail, rehabilitation facility, or hospital. |
West Nile Virus Temperature Sensitivity and Avian Virulence Are Modulated by NS1-2B Polymorphisms.
Dietrich EA , Langevin SA , Huang CY , Maharaj PD , Delorey MJ , Bowen RA , Kinney RM , Brault AC . PLoS Negl Trop Dis 2016 10 (8) e0004938 West Nile virus (WNV) replicates in a wide variety of avian species, which serve as reservoir and amplification hosts. WNV strains isolated in North America, such as the prototype strain NY99, elicit a highly pathogenic response in certain avian species, notably American crows (AMCRs; Corvus brachyrhynchos). In contrast, a closely related strain, KN3829, isolated in Kenya, exhibits a low viremic response with limited mortality in AMCRs. Previous work has associated the difference in pathogenicity primarily with a single amino acid mutation at position 249 in the helicase domain of the NS3 protein. The NY99 strain encodes a proline residue at this position, while KN3829 encodes a threonine. Introduction of an NS3-T249P mutation in the KN3829 genetic background significantly increased virulence and mortality; however, peak viremia and mortality were lower than those of NY99. In order to elucidate the viral genetic basis for phenotype variations exclusive of the NS3-249 polymorphism, chimeric NY99/KN3829 viruses were created. We show herein that differences in the NS1-2B region contribute to avian pathogenicity in a manner that is independent of and additive with the NS3-249 mutation. Additionally, NS1-2B residues were found to alter temperature sensitivity when grown in avian cells. |
Estimating the Number of Pregnant Women Infected With Zika Virus and Expected Infants With Microcephaly Following the Zika Virus Outbreak in Puerto Rico, 2016.
Ellington SR , Devine O , Bertolli J , Martinez Quinones A , Shapiro-Mendoza CK , Perez-Padilla J , Rivera-Garcia B , Simeone RM , Jamieson DJ , Valencia-Prado M , Gilboa SM , Honein MA , Johansson MA . JAMA Pediatr 2016 170 (10) 940-945 Importance: Zika virus (ZIKV) infection during pregnancy is a cause of congenital microcephaly and severe fetal brain defects, and it has been associated with other adverse pregnancy and birth outcomes. Objective: To estimate the number of pregnant women infected with ZIKV in Puerto Rico and the number of associated congenital microcephaly cases. Design, Setting, and Participants: We conducted a modeling study from April to July 2016. Using parameters derived from published reports, outcomes were modeled probabilistically using Monte Carlo simulation. We used uncertainty distributions to reflect the limited information available for parameter values. Given the high level of uncertainty in model parameters, interquartile ranges (IQRs) are presented as primary results. Outcomes were modeled for pregnant women in Puerto Rico, which currently has more confirmed ZIKV cases than any other US location. Exposure: Zika virus infection in pregnant women. Main Outcomes and Measures: Number of pregnant women infected with ZIKV and number of congenital microcephaly cases. Results: We estimated an IQR of 5900 to 10300 pregnant women (median, 7800) might be infected during the initial ZIKV outbreak in Puerto Rico. Of these, an IQR of 100 to 270 infants (median, 180) may be born with microcephaly due to congenital ZIKV infection from mid-2016 to mid-2017. In the absence of a ZIKV outbreak, an IQR of 9 to 16 cases (median, 12) of congenital microcephaly are expected in Puerto Rico per year. Conclusions and Relevance: The estimate of 5900 to 10300 pregnant women that might be infected with ZIKV provides an estimate for the number of infants that could potentially have ZIKV-associated adverse outcomes. Including baseline cases of microcephaly, we estimated that an IQR of 110 to 290 total cases of congenital microcephaly, mostly attributable to ZIKV infection, could occur from mid-2016 to mid-2017 in the absence of effective interventions. The primary limitation in this analysis is uncertainty in model parameters. Multivariate sensitivity analyses indicated that the cumulative incidence of ZIKV infection and risk of microcephaly given maternal infection in the first trimester were the primary drivers of both magnitude and uncertainty in the estimated number of microcephaly cases. Increased information on these parameters would lead to more precise estimates. Nonetheless, the results underscore the need for urgent actions being undertaken in Puerto Rico to prevent congenital ZIKV infection and prepare for affected infants. |
Update: Interim guidance for the evaluation and management of infants with possible congenital zika virus infection - United States, August 2016
Russell K , Oliver SE , Lewis L , Barfield WD , Cragan J , Meaney-Delman D , Staples JE , Fischer M , Peacock G , Oduyebo T , Petersen EE , Zaki S , Moore CA , Rasmussen SA . MMWR Morb Mortal Wkly Rep 2016 65 (33) 870-878 CDC has updated its interim guidance for U.S. health care providers caring for infants born to mothers with possible Zika virus infection during pregnancy. Laboratory testing is recommended for 1) infants born to mothers with laboratory evidence of Zika virus infection during pregnancy and 2) infants who have abnormal clinical or neuroimaging findings suggestive of congenital Zika syndrome and a maternal epidemiologic link suggesting possible transmission, regardless of maternal Zika virus test results. Congenital Zika syndrome is a recently recognized pattern of congenital anomalies associated with Zika virus infection during pregnancy that includes microcephaly, intracranial calcifications or other brain anomalies, or eye anomalies, among others. Recommended infant laboratory evaluation includes both molecular (real-time reverse transcription-polymerase chain reaction [rRT-PCR]) and serologic (immunoglobulin M [IgM]) testing. Initial samples should be collected directly from the infant in the first 2 days of life, if possible; testing of cord blood is not recommended. A positive infant serum or urine rRT-PCR test result confirms congenital Zika virus infection. Positive Zika virus IgM testing, with a negative rRT-PCR result, indicates probable congenital Zika virus infection. In addition to infant Zika virus testing, initial evaluation of all infants born to mothers with laboratory evidence of Zika virus infection during pregnancy should include a comprehensive physical examination, including a neurologic examination, postnatal head ultrasound, and standard newborn hearing screen. Infants with laboratory evidence of congenital Zika virus infection should have a comprehensive ophthalmologic exam and hearing assessment by auditory brainstem response (ABR) testing before 1 month of age. Recommendations for follow-up of infants with laboratory evidence of congenital Zika virus infection depend on whether abnormalities consistent with congenital Zika syndrome are present. Infants with abnormalities consistent with congenital Zika syndrome should have a coordinated evaluation by multiple specialists within the first month of life; additional evaluations will be needed within the first year of life, including assessments of vision, hearing, feeding, growth, and neurodevelopmental and endocrine function. Families and caregivers will also need ongoing psychosocial support and assistance with coordination of care. Infants with laboratory evidence of congenital Zika virus infection without apparent abnormalities should have ongoing developmental monitoring and screening by the primary care provider; repeat hearing testing is recommended. This guidance will be updated when additional information becomes available. |
Prioritization of zoonotic diseases in Kenya, 2015
Munyua P , Bitek A , Osoro E , Pieracci EG , Muema J , Mwatondo A , Kungu M , Nanyingi M , Gharpure R , Njenga K , Thumbi SM . PLoS One 2016 11 (8) e0161576 INTRODUCTION: Zoonotic diseases have varying public health burden and socio-economic impact across time and geographical settings making their prioritization for prevention and control important at the national level. We conducted systematic prioritization of zoonotic diseases and developed a ranked list of these diseases that would guide allocation of resources to enhance their surveillance, prevention, and control. METHODS: A group of 36 medical, veterinary, and wildlife experts in zoonoses from government, research institutions and universities in Kenya prioritized 36 diseases using a semi-quantitative One Health Zoonotic Disease Prioritization tool developed by Centers for Disease Control and Prevention with slight adaptations. The tool comprises five steps: listing of zoonotic diseases to be prioritized, development of ranking criteria, weighting criteria by pairwise comparison through analytical hierarchical process, scoring each zoonotic disease based on the criteria, and aggregation of scores. RESULTS: In order of importance, the participants identified severity of illness in humans, epidemic/pandemic potential in humans, socio-economic burden, prevalence/incidence and availability of interventions (weighted scores assigned to each criteria were 0.23, 0.22, 0.21, 0.17 and 0.17 respectively), as the criteria to define the relative importance of the diseases. The top five priority diseases in descending order of ranking were anthrax, trypanosomiasis, rabies, brucellosis and Rift Valley fever. CONCLUSION: Although less prominently mentioned, neglected zoonotic diseases ranked highly compared to those with epidemic potential suggesting these endemic diseases cause substantial public health burden. The list of priority zoonotic disease is crucial for the targeted allocation of resources and informing disease prevention and control programs for zoonoses in Kenya. |
Incidence and risk factors for developing dengue-associated hemophagocytic lymphohistiocytosis in Puerto Rico, 2008 - 2013
Ellis EM , Sharp TM , Perez-Padilla J , Gonzalez L , Poole-Smith BK , Lebo E , Baker C , Delorey MJ , Torres-Velasquez B , Ochoa E , Rivera-Garcia B , Diaz-Pinto H , Clavell L , Puig-Ramos A , Janka GE , Tomashek KM . PLoS Negl Trop Dis 2016 10 (8) e0004939 BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal disorder characterized by fever, pancytopenia, hepatosplenomegaly, and increased serum ferritin. HLH is being increasingly reported as a complication of dengue, a common tropical acute febrile illness. METHODOLOGY/PRINCIPAL FINDINGS: After a cluster of pediatric dengue-associated HLH patients was identified during the 2012-2013 dengue epidemic in Puerto Rico, active surveillance and a case-control investigation was conducted at four referral hospitals to determine the incidence of HLH in children and identify risk factors for HLH following dengue. Patients with dengue-associated HLH (cases) were matched by month of illness onset and admission hospital to dengue patients that did not develop HLH (controls). During 2008-2013, a total of 33 HLH patients were identified, of which 22 (67%) were associated with dengue and 1 died (dengue-associated HLH case-fatality rate: 4.5%). Two patients with dengue-associated HLH had illness onset in 2009, none had illness onset during the 2010 dengue epidemic, and 20 had illness onset during the 2012-2013 epidemic. Frequency of infection with either dengue virus (DENV)-1 or DENV-4 did not differ between cases and controls. Cases were younger than controls (median age: 1 vs. 13 years, p < 0.01), were hospitalized longer (18 vs. 5 days, p < 0.01), and were admitted more frequently to pediatric intensive care units (100% vs. 16%, p < 0.01). Cases had co-infection (18.2% vs. 4.5%, p = 0.04), recent influenza-like illness (54.5% vs. 25.0%, p = 0.01), and longer duration of fever (7 vs. 5 days; p < 0.01). Cases were more likely to have lymphadenopathy, hepatomegaly, splenomegaly, anemia, and elevated liver transaminases (p ≤ 0.02). CONCLUSIONS/SIGNIFICANCE: During this cluster of dengue-associated HLH cases that was temporally associated with the 2012-2013 epidemic, most patients with dengue-associated HLH were infants and had higher morbidity than dengue inpatients. Physicians throughout the tropics should be aware of HLH as a potential complication of dengue, particularly in patients with anemia and severe liver injury. |
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