Removing the stress from selecting instruments: arming social workers to take leadership in routine distress screening implementation
Rohan EA . J Psychosoc Oncol 2012 30 (6) 667-78 Quality cancer care requires identifying and addressing the psychosocial needs of cancer patients. Oncology social workers have long been on the forefront of this endeavor. Although there has been longstanding interest in screening cancer patients for distress, it has recently been included as a quality of care metric in institutions accredited by the American College of Surgeons. Implementing routine screening for distress in oncology settings requires thoughtful planning, including assessing various screening instruments and considering a host of variables within each practice setting. Oncology social workers are best positioned to provide leadership in operationalizing this mandate and to lead their team in the choice of a distress measure for compliance with the screening guideline. This article highlights the most popular distress screening measures used in oncology and their psychometric properties. |
Tackling the global diabetes burden: will screening help?
Engelgau MM , Gregg EW . Lancet 2012 380 (9855) 1716-8 Worldwide, cases of type 2 diabetes have doubled from nearly 150 million in 1980 to almost 350 million today,1 and effective strategies to reduce the burden of disease are greatly needed. A large and highly variable proportion of cases are undiagnosed,2 and in view of the available evidence-based treatments,3 early detection through diabetes screening is worth careful consideration. Diabetes screening and diagnosis can be done with relative ease, which further escalates popular support for wide-scale screening. However, these compelling arguments overlook the screening costs, potential harms, and lack of clear evidence that screening improves health outcomes compared with current routine clinical diagnosis. In The Lancet, Rebecca Simmons and colleagues4 report their findings from the ADDITION study, the most earnest attempt to date to try to settle the diabetes screening quandary. | The ADDITION study is a clinic-level cluster randomised trial of patients aged 40–69 years who are receiving care from general practices in eastern England, and represent the top 25% of the risk distribution for undiagnosed diabetes.4 Entire clinics were randomly assigned to screening or no screening (control group). In the screening clinics, treatment focused on glycaemic control and cardiovascular risk reduction through two care patterns: intensive multifactorial diabetes treatment or standard national guideline-based diabetes care. This study has both a pragmatic public health design with intention-to-screen while integrating a clinical design of intensive versus standard treatment. Clinic-level randomisation also allowed better uniformity across the interventions. Of 16 047 individuals invited for screening, 466 (3%) were newly diagnosed with diabetes. After a 10-year follow-up, there was no significant difference in all-cause mortality between screening and control groups (hazard ratio 1·06, 95% CI 0·90–1·25). Moreover, the mortality hazard ratios for cardiovascular disease, cancer, and diabetes were similar in the intervention and control populations, leaving no evidence of long-term mortality benefits associated with screening—a finding not unlike the small non-significant reduction in cardiovascular events and death found in a similar study with a shorter follow-up period.5 Long-term microvascular benefits, such as diabetic retinopathy and kidney disease, are not reported. This study has also previously reported on screening risks for participants such as anxiety and depression, which were found to be low;6 however, it found little beneficial change in lifestyle behaviours, with the exception of modest improvement in some dietary habits.7 |
Mental and physical health-related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey
Weaver KE , Forsythe LP , Reeve BB , Alfano CM , Rodriguez JL , Sabatino SA , Hawkins NA , Rowland JH . Cancer Epidemiol Biomarkers Prev 2012 21 (11) 2108-17 BACKGROUND: Despite extensive data on health-related quality of life (HRQOL) among cancer survivors, we do not yet have an estimate of the percentage of survivors with poor mental and physical HRQOL compared with population norms. HRQOL population means for adult-onset cancer survivors of all ages and across the survivorship trajectory also have not been published. METHODS: Survivors (N = 1,822) and adults with no cancer history (N = 24,804) were identified from the 2010 National Health Interview Survey. The PROMIS(R) Global Health Scale was used to assess HRQOL. Poor HRQOL was defined as 1 SD or more below the PROMIS(R) population norm. RESULTS: Poor physical and mental HRQOL were reported by 24.5% and 10.1% of survivors, respectively, compared with 10.2% and 5.9% of adults without cancer (both P < 0.0001). This represents a population of approximately 3.3 million and 1.4 million U.S. survivors with poor physical and mental HRQOL. Adjusted mean mental and physical HRQOL scores were similar for breast, prostate, and melanoma survivors compared with adults without cancer. Survivors of cervical, colorectal, hematologic, short-survival, and other cancers had worse physical HRQOL; cervical and short-survival cancer survivors reported worse mental HRQOL. CONCLUSION: These data elucidate the burden of cancer diagnosis and treatment among U.S. survivors and can be used to monitor the impact of national efforts to improve survivorship care and outcomes.Impact: We present novel data on the number of U.S. survivors with poor HRQOL. Interventions for high-risk groups that can be easily implemented are needed to improve survivor health at a population level. (Cancer Epidemiol Biomarkers Prev; 21(11); 1-10. (c)2012 AACR.) |
Parkinson's disease among American Indians and Alaska Natives: a nationwide prevalence study
Gordon PH , Mehal JM , Holman RC , Rowland AS , Cheek JE . Mov Disord 2012 27 (11) 1456-9 BACKGROUND: The objective of this study was to determine the prevalence of Parkinson's disease (PD) among American Indian and Alaska Native (AI/AN) people. METHODS: We analyzed records for AI/AN people between 2002 and 2009 using inpatient and outpatient visit data from the Indian Health Service. Crude and age-adjusted prevalence, using the 2000 projected US population as the standard, was determined overall and by age group, sex, period, and region. RESULTS: An estimated 2613 AI/AN people carried the diagnosis of PD (crude prevalence, 143.8/100,000). Prevalence increased with age through 84 years. The age-adjusted rate was 355.7 and was higher among men than women (P < .0001). Rates differed by region (P < .0001). CONCLUSIONS: Parkinson's disease is prevalent among AI/AN people. The prevalence increases with age, varies by geographic region, and is higher among men than women. Community-based studies are needed to define incidence, examine risk factors, and determine reasons for sex and regional differences in PD among AI/AN people. ((c) 2012 Movement Disorder Society.) |
Population-based study of risk factors for coronary heart disease among HIV-infected persons
Oh JY , Greene K , He H , Schafer S , Hedberg K . Open AIDS J 2012 6 177-80 Preventing coronary heart disease (CHD) is critical to further extending survival among human immunodeficiency virus (HIV)-infected persons. Previously published findings of CHD risk factors in HIV-infected persons have been derived from facility-based cohort studies, which have limited representativeness for the HIV-infected population. State-specific, population-based surveillance data can assist health care providers and public health agencies in planning and evaluating programs that reduce CHD among HIV-infected persons. We describe CHD risk factors from the 2007-2008 Oregon Medical Monitoring Project, a population-based survey of HIV-infected persons receiving care that included both patient interview and medical record review. Among the 539 HIV-infected patients interviewed, the mean age was 45.5 years. Diagnoses from the medical record associated with CHD risk included preexisting CHD (5%), diabetes (11%), and hypertension (28%). Current smoking was reported by 46%; college graduates were less likely to smoke compared with those with lesser education (21% versus 53%, respectively; P <.0001). Obesity was present among 17%. Among the 65% of the survey group with lipid values available, 55% had high-density lipoprotein cholesterol (HDL) <40 mg/dL and 42% had triglycerides ≥ 200 mg/dL. Among the 15% of the survey group with either preexisting CHD or diabetes, 42% had a non-HDL <130 mg/dL (target goal) and 38% smoked. Risk factors for CHD among HIVinfected persons, particularly smoking and dyslipidemia, should be managed aggressively. Ongoing surveillance is warranted to monitor changes in CHD risk factors in the HIV-infected population. |
Esophageal cancer in Canada: trends according to morphology and anatomical location
Otterstatter MC , Brierley JD , De P , Ellison LF , Macintyre M , Marrett LD , Semenciw R , Weir HK . Can J Gastroenterol 2012 26 (10) 723-7 BACKGROUND: Esophageal adenocarcinoma has one of the fastest rising incidence rates and one of the lowest survival rates of any cancer type in the Western world. However, in many countries, trends in esophageal cancer differ according to tumour morphology and anatomical location. In Canada, incidence and survival trends for esophageal cancer subtypes are poorly known. METHODS: Cancer incidence and mortality rates were obtained from the Canadian Cancer Registry, the National Cancer Incidence Reporting System and the Canadian Vital Statistics Death databases for the period from 1986 to 2006. Observed trends (annual per cent change) and five-year relative survival ratios were estimated separately for esophageal adenocarcinoma and squamous cell carcinoma, and according to location (upper, middle, or lower one-third of the esophagus). Incidence rates were projected up to the year 2026. RESULTS: Annual age-standardized incidence rates for esophageal cancer in 2004 to 2006 were 6.1 and 1.7 per 100,000 for males and females, respectively. Esophageal adenocarcinoma incidence rose by 3.9% (males) and 3.6% (females) per year for the period 1986 to 2006, with the steepest increase in the lower one-third of the esophagus (4.8% and 5.0% per year among males and females, respectively). In contrast, squamous cell carcinoma incidence declined by 3.3% (males) and 3.2% (females) per year since the early 1990s. The five-year relative survival ratio for esophageal cancer was 13% between 2004 and 2006, approximately a 3% increase since the period from 1992 to 1994. Projected incidence rates showed increases of 40% to 50% for esophageal adenocarcinoma and decreases of 30% for squamous cell carcinoma by 2026. DISCUSSION: Although esophageal cancer is rare in Canada, the incidence of esophageal adenocarcinoma has doubled in the past 20 years, which may reflect the increasing prevalence of obesity and gastroesophageal reflux disease. Declines in squamous cell carcinoma may be the result of the decreases in the prevalence of smoking in Canada. Given the low survival rates and the potential for further increases in incidence, esophageal adenocarcinoma warrants close attention. |
Chronic medical conditions as risk factors for herpes zoster
Joesoef RM , Harpaz R , Leung J , Bialek SR . Mayo Clin Proc 2012 87 (10) 961-7 OBJECTIVE: To determine the degree to which chronic conditions might contribute to the unexplained burden of herpes zoster. METHODS: We conducted a case-control study using MarketScan data from January 1, 2007, through December 31, 2007, to investigate chronic conditions as risk factors for herpes zoster among persons 20 to 64 years old. Cases were enrollees with a herpes zoster diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 053.xx), and controls were those without a herpes zoster diagnosis, matched by age groups and insurance plan. We selected 10 chronic conditions based on their prevalence in the general population. We calculated the attributable fraction and created a comorbidity composite score by summing the significant coefficient of regression of chronic conditions. We used logistic regression to evaluate the associations between herpes zoster and chronic conditions. RESULTS: We identified a total of 59,173 cases and 616,177 controls for the analysis. Risk of herpes zoster was significant for 8 of the 10 study conditions (odds ratios, 1.06-1.52). Herpes zoster risk also increased as a function of comorbidity composite score. The attributable fractions for these 8 significant conditions ranged from 0.24% to 2.89%. CONCLUSION: The risk of herpes zoster may be increased in people with chronic conditions. However, this risk may not contribute substantially to the burden of herpes zoster in the population. The causes for most cases of herpes zoster remain unknown. |
Disparities in prevalence of key chronic diseases by gender and race/ethnicity among antiretroviral-treated HIV-infected adults in the US
Buchacz K , Baker RK , Palella FJ Jr , Shaw L , Patel P , Lichtenstein KA , Chmiel JS , Vellozzi C , Debes R , Henry K , Overton ET , Bush TJ , Tedaldi E , Carpenter C , Mayer KH , Brooks JT . Antivir Ther 2012 18 (1) 65-75 BACKGROUND: Certain sociodemographic subgroups of HIV-infected patients may experience more chronic disease than others due to behavioral risk factors, advanced HIV disease, or complications from extended use of combination antiretroviral therapy (cART), but recent comparative data are limited. METHODS: We studied HIV-infected adult patients in care during 2006-2010 who had been prescribed ≥ 6 months of cART. We analyzed the prevalence of selected key chronic conditions, and polymorbidity (having 2 or more out of 10 key conditions) by gender and race/ethnicity. RESULTS: Of the 3,166 HIV-infected patients (median age, 47 years; CD4+ cell count, 496 cells/mm(3); duration of cART use, 6.8 years), 21% were female, 57% were non-Hispanic white, and over half were current or former tobacco smokers. The five most frequent conditions among women (median age, 45 years) were dyslipidemia (67.3%), hypertension (57.4%), obesity (31.7%), viral hepatitis B or C coinfection (29.0%), and low HDLc (27.3%). The five most frequent conditions in men (median age, 47 years) were dyslipidemia (81.2%), hypertension (54.4%), low HDLc (41.1%), elevated triglycerides (32.3%), and elevated non-HDLc (26.8%). In multivariable analyses, Hispanic patients had higher prevalence of obesity and diabetes than white patients; black patients had higher prevalence of obesity and hypertension but lower rates of lipid abnormalities. Of all patients, 73.7% of women and 66.8% of men had polymorbidity, with no evidence of disparities by race/ethnicity. CONCLUSIONS: Among contemporary cART-treated HIV-infected adults, chronic conditions and polymorbidity were common, underscoring the importance of chronic disease prevention and management among aging HIV-infected patients. |
Human papillomavirus genotypes in high-grade cervical lesions in the United States.
Hariri S , Unger ER , Powell SE , Bauer HM , Bennett NM , Bloch KC , Niccolai LM , Schafer S , Steinau M , Markowitz LE . J Infect Dis 2012 206 (12) 1878-86 BACKGROUND: Two vaccines protect against human papillomaviruses (HPV) 16 and 18 that cause 70% of cervical cancer and 50% of cervical intraepithelial neoplasia 2/3 and adenocarcinoma in situ (CIN2+). Monitoring HPV types in CIN2+ may be used to assess HPV vaccine impact. METHODS: As part of a multi-site vaccine impact monitoring project (HPV-IMPACT), biopsy specimens used to diagnose CIN2+ were obtained for HPV DNA typing for women aged 18-39 years. RESULTS: Among 4,121 CIN2+ cases reported from 2008-2009 in 18-39 year-old women 3,058 (74.2%) were tested; 96% were HPV DNA positive. HPV16 was most common (49.1%), followed by HPV31 (10.4%) and HPV52 (9.7%). HPV18 prevalence was 5.5% overall. Proportion of CIN2+ cases associated with HPV16/18 was highest (56.3%) in 25-29 year-old women. HPV16/18-associated lesions were less common in non-Hispanic blacks (41.9%) and Hispanics (46.3%) compared to non-Hispanic whites (59.1%) (p<.0001); the difference remained significant when adjusted for covariates. Compared to non-Hispanic white, HPV35 and 58 were significantly more common in non-Hispanic black (14.5% vs. 4.2%; 12.3% vs. 3.4%) and HPV45 was higher in Hispanic cases (3.7% vs. 1.5%). CONCLUSION: Age and racial/ethnic differences in HPV type distribution may have implications for vaccine impact, and must be considered in monitoring trends. |
Selecting nonpharmaceutical strategies to minimize influenza spread: the 2009 influenza A (H1N1) pandemic and beyond
Barrios LC , Koonin LM , Kohl KS , Cetron M . Public Health Rep 2012 127 (6) 565-71 Shortly after the influenza A (H1N1) 2009 pandemic began, the U.S. government provided guidance to state and local authorities to assist decision-making for the use of nonpharmaceutical strategies to minimize influenza spread. This guidance included recommendations for flexible decision-making based on outbreak severity, and it allowed for uncertainty and course correction as the pandemic progressed. These recommendations build on a foundation of local, collaborative planning and posit a series of questions regarding epidemiology, the impact on the health-care system, and locally determined feasibility and acceptability of nonpharmaceutical strategies. This article describes recommendations and key questions for decision makers. |
So many questions, so little time
Donis RO , Cox NJ . J Infect Dis 2012 207 (2) 208-10 Fifteen years have elapsed since the first human infections with H5N1 highly pathogenic avian influenza (HPAI) virus were detected in Hong Kong SAR, China [1, 2]. Many of these human infections were fatal and represented the first documented outbreak of severe disease due to HPAI viruses. The hallmark of these H5N1 viruses is their hemagglutinin genes inherited from A/goose/Guangdong/1996, a virus first detected during an outbreak in domestic geese in China. Who could have predicted the current H5N1 situation in 1997? As of August 2012, H5N1 viruses of this lineage have caused 607 reported human cases (358 fatal), the culling of 400 million birds, and have become entrenched in poultry populations on 2 continents [3, 4]. Early expectations were that this virus would be eliminated quickly and become extinct after local bird populations were decimated by the outbreak or culled, thus recapitulating the experience with dozens of HPAI outbreaks in poultry in many countries during the past century. Rather than becoming extinct, these H5N1 viruses spread to 60 countries on 3 continents by 2006 [3]. The alarm caused by the far-ranging geographic expansion of H5N1 galvanized governments to invest resources in avian disease control. Despite many effective local and regional infection control programs in recent years, H5N1 is considered to be endemic in poultry in many countries, including Indonesia, Bangladesh, China, Vietnam, and Egypt [3]. Several of these countries also report the highest numbers of human infection. Most HPAI H5N1 human infections reported to the World Health Organization by public health authorities since 1997 were acquired by direct or indirect contact with infected birds. |
Streptococcus pneumoniae serotype 15A in psychiatric unit, Rhode Island, USA, 2010-2011
Fleming-Dutra K , Mbaeyi C , Link-Gelles R , Alexander N , Guh A , Forbes E , Beall B , Winchell JM , Carvalho MG , Pimenta F , Kodani M , Vanner C , Stevens H , Brady D , Caulcrick-Grimes M , Bandy U , Moore MR . Emerg Infect Dis 2012 18 (11) 1889-93 During a pneumococcal disease outbreak in a pediatric psychiatric unit in a hospital in Rhode Island, USA, 6 (30%) of 20 patients and staff were colonized with Streptococcus pneumoniae serotype 15A, which is not included in pneumococcal vaccines. The outbreak subsided after implementation of antimicrobial drug prophylaxis and enhanced infection control measures. |
Survival among patients with HIV infection and smear-negative pulmonary tuberculosis - United States, 1993-2006
Cavanaugh JS , Shah NS , Cain KP , Winston CA . PLoS One 2012 7 (10) e47855 BACKGROUND: In patients with HIV and tuberculosis (TB) in resource-constrained settings, smear-negative disease has been associated with higher mortality than smear-positive disease. Higher reported mortality may be due to misdiagnosis, diagnostic delays, or because smear-negative disease indicates more advanced immune suppression. METHODS: We analyzed culture-confirmed, pulmonary TB among patients with TB and HIV in the United States from 1993-2008 to calculate prevalence ratios (PRs) for smear-negative disease by demographic and clinical characteristics. Allowing two years for treatment outcome to be reported, we determined hazard ratios (HRs) for survival by smear status, adjusted for significant covariates on patients before 2006. RESULTS: Among 16,710 cases with sputum smear results, 6,739 (39%) were sputum smear-negative and 9,971 (58%) were sputum smear-positive. The prevalence of smear-negative disease was lower in male patients (PR: 0.89, 95% confidence interval [CI]: 0.86-0.93) and in those who were homeless (PR: 0.92, CI: 0.87-0.97) or used alcohol excessively (PR: 0.91, CI: 0.87-0.95), and higher in persons diagnosed while incarcerated (PR: 1.20, CI: 1.13-1.27). Patients with smear-negative disease had better survival compared to patients with smear-positive disease, both before (HR: 0.82, CI: 0.75-0.90) and after (HR: 0.81, CI: 0.71-0.92) the introduction of combination anti-retroviral therapy. CONCLUSIONS: In the United States, smear-negative pulmonary TB in patients with HIV was not associated with higher mortality, in contrast to what has been documented in high TB burden settings. Smear-negative TB can be routinely and definitively diagnosed in the United States, whereas high-burden countries often rely solely on AFB-smear microscopy. This difference could contribute to diagnostic and treatment delays in high-burden countries, possibly resulting in higher mortality. |
Tuberculosis among healthcare workers, United States, 1995-2007
Lambert LA , Pratt RH , Armstrong LR , Haddad MB . Infect Control Hosp Epidemiol 2012 33 (11) 1126-32 OBJECTIVE: We examined surveillance data to describe the epidemiology of tuberculosis (TB) among healthcare workers (HCWs) in the United States during the period 1995-2007. DESIGN: Cross-sectional descriptive analysis of existing surveillance data. SETTING AND PARTICIPANTS: TB cases reported to the Centers for Disease Control and Prevention from the 50 states and the District of Columbia from 1995 through 2007. RESULTS: Of the 200,744 reported TB cases in persons 18 years of age or older, 6,049 (3%) occurred in individuals who were classified as HCWs. HCWs with TB were more likely than other adults with TB to be women (unadjusted odds ratio [95% confidence interval], 4.1 [3.8-4.3]), be foreign born (1.3 [1.3-1.4]), have extrapulmonary TB (1.6 [1.5-1.7]), and complete TB treatment (2.5 [2.3-2.8]). CONCLUSIONS: Healthcare institutions may benefit from intensifying TB screening of HCWs upon hire, especially persons from countries with a high incidence of TB, and encouraging treatment for latent TB infection among HCWs to prevent progression to TB disease. |
Use of and adherence to antiretroviral therapy in a large U.S. sample of HIV-infected adults in care, 2007-2008
Beer L , Heffelfinger J , Frazier E , Mattson C , Roter B , Barash E , Buskin S , Rime T , Valverde E . Open AIDS J 2012 6 213-23 BACKGROUND: Antiretroviral therapy (ART) is the cornerstone of HIV clinical care and is increasingly recognized as a key component of HIV prevention. However, the benefits of ART can be realized only if HIV-infected persons maintain high levels of adherence. METHODS: We present interview data (collected from June 2007 through September 2008) from a national HIV surveillance system in the United States-the Medical Monitoring Project (MMP)-to describe persons taking ART. We used multivariate logistic regression to assess behavioral, sociodemographic, and medication regimen factors associated with three measures that capture different dimensions of nonadherence to ART: dose, schedule, and instruction. RESULTS: The use of ART among HIV-infected adults in care was high (85%), but adherence to ART was suboptimal and varied across the three measures of nonadherence. Of MMP participants currently taking ART, the following reported nonadherence during the past 48 hours: 13% to dose, 27% to schedule, and 30% to instruction. The determinants of the three measures also varied, although younger age and binge drinking were associated with all aspects of nonadherence. CONCLUSION: Our results support the measurement of multiple dimensions of medication-taking behavior in order to avoid overestimating adherence to ART. |
Using HIV surveillance data to monitor missed opportunities for linkage and engagement in HIV medical care
Bertolli J , Shouse RL , Beer L , Valverde E , Fagan J , Jenness SM , Wogayehu A , Johnson C , Neaigus A , Hillman D , Courogen M , Brady KA , Bolden B . Open AIDS J 2012 6 131-41 Monitoring delayed entry to HIV medical care is needed because it signifies that opportunities to prevent HIV transmission and mitigate disease progression have been missed. A central question for population-level monitoring is whether to consider a person linked to care after receipt of one CD4 or VL test. Using HIV surveillance data, we explored two definitions for estimating the number of HIV-diagnosed persons not linked to HIV medical care. We used receipt of at least one CD4 or VL test (definition 1) and two or more CD4 or VL tests (definition 2) to define linkage to care within 12 months and within 42 months of HIV diagnosis. In five jurisdictions, persons diagnosed from 12/2006-12/2008 who had not died or moved away and who had zero, or less than two reported CD4 or VL tests by 7/31/2010 were considered not linked to care under definitions 1 and 2, respectively. Among 13,600 persons followed up for 19-42 months; 1,732 (13%) had no reported CD4 or VL tests; 2,332 persons (17%) had only one CD4 or VL test and 9,536 persons (70%) had two or more CD4 or VL tests. To summarize, after more than 19 months, 30% of persons diagnosed with HIV had less than two CD4 or VL tests; more than half of them were considered to have entered care if entering care is defined as having one CD4 or VL test. Defining linkage to care as a single CD4 or VL may overestimate entry into care, particularly for certain subgroups. |
Mumps outbreak in Orthodox Jewish communities in the United States
Barskey AE , Schulte C , Rosen JB , Handschur EF , Rausch-Phung E , Doll MK , Cummings KP , Alleyne EO , High P , Lawler J , Apostolou A , Blog D , Zimmerman CM , Montana B , Harpaz R , Hickman CJ , Rota PA , Rota JS , Bellini WJ , Gallagher KM . N Engl J Med 2012 367 (18) 1704-13 BACKGROUND: By 2005, vaccination had reduced the annual incidence of mumps in the United States by more than 99%, with few outbreaks reported. However, in 2006, a large outbreak occurred among highly vaccinated populations in the United States, and similar outbreaks have been reported worldwide. The outbreak described in this report occurred among U.S. Orthodox Jewish communities during 2009 and 2010. METHODS: Cases of salivary-gland swelling and other symptoms clinically compatible with mumps were investigated, and demographic, clinical, laboratory, and vaccination data were evaluated. RESULTS: From June 28, 2009, through June 27, 2010, a total of 3502 outbreak-related cases of mumps were reported in New York City, two upstate New York counties, and one New Jersey county. Of the 1648 cases for which clinical specimens were available, 50% were laboratory-confirmed. Orthodox Jewish persons accounted for 97% of case patients. Adolescents 13 to 17 years of age (27% of all patients) and males (78% of patients in that age group) were disproportionately affected. Among case patients 13 to 17 years of age with documented vaccination status, 89% had previously received two doses of a mumps-containing vaccine, and 8% had received one dose. Transmission was focused within Jewish schools for boys, where students spend many hours daily in intense, face-to-face interaction. Orchitis was the most common complication (120 cases, 7% of male patients ≥12 years of age), with rates significantly higher among unvaccinated persons than among persons who had received two doses of vaccine. CONCLUSIONS: The epidemiologic features of this outbreak suggest that intense exposures, particularly among boys in schools, facilitated transmission and overcame vaccine-induced protection in these patients. High rates of two-dose coverage reduced the severity of the disease and the transmission to persons in settings of less intense exposure. |
Prevalence of seropositivity to pandemic influenza A/H1N1 virus in the United States following the 2009 pandemic
Reed C , Katz JM , Hancock K , Balish A , Fry AM . PLoS One 2012 7 (10) e48187 BACKGROUND: 2009 pandemic influenza A/H1N1 (A(H1N1)pdm09) was first detected in the United States in April 2009 and resulted in a global pandemic. We conducted a serologic survey to estimate the cumulative incidence of A(H1N1)pdm09 through the end of 2009 when pandemic activity had waned in the United States. METHODS: We conducted a pair of cross sectional serologic surveys before and after the spring/fall waves of the pandemic for evidence of seropositivity (titer $40) using the hemagglutination inhibition (HI) assay. We tested a baseline sample of 1,142 serum specimens from the 2007-2008 National Health and Nutrition Examination Survey (NHANES), and 2,759 serum specimens submitted for routine screening to clinical diagnostic laboratories from ten representative sites. RESULTS: The age-adjusted prevalence of seropositivity to A(H1N1)pdm09 by year-end 2009 was 36.9% (95%CI: 31.7-42.2%). After adjusting for baseline cross-reactive antibody, pandemic vaccination coverage and the sensitivity/specificity of the HI assay, we estimate that 20.2% (95%CI: 10.1-28.3%) of the population was infected with A(H1N1)pdm09 by December 2009, including 53.3% (95%CI: 39.0-67.1%) of children aged 5-17 years. CONCLUSIONS: By December 2009, approximately one-fifth of the US population, or 61.9 million persons, may have been infected with A(H1N1)pdm09, including around half of school-aged children. |
Epidemiology of a mumps outbreak in a highly vaccinated island population and use of a third dose of measles-mumps-rubella vaccine for outbreak control- Guam 2009-2010
Nelson GE , Aguon A , Valencia E , Oliva R , Guerrero ML , Reyes R , Lizama A , Diras D , Mathew A , Camacho EJ , Monforte MN , Chen TH , Mahamud A , Kutty PK , Hickman C , Bellini WJ , Seward JF , Gallagher K , Fiebelkorn AP . Pediatr Infect Dis J 2012 32 (4) 374-80 BACKGROUND: Despite high two-dose measles-mumps-rubella (MMR) vaccine coverage, a large mumps outbreak occurred on the U.S. Territory of Guam during 2009-2010, primarily in school-aged children. METHODS: We implemented active surveillance in April 2010 during the outbreak peak and characterized the outbreak epidemiology. We administered third doses of MMR vaccine to eligible students aged 9-14 years in 7 schools with the highest attack rates (ARs) between 5/18/2010-5/21/2010. Baseline surveys, follow-up surveys, and case-reports were used to determine mumps vaccine ARs. Adverse events post-vaccination were monitored. RESULTS: Between 12/1/2009-12/31/2010, 505 mumps cases were reported. Self-reported Pohnpeians and Chuukese had the highest relative risks (54.7 and 19.7, respectively) and highest crowding indices (mean: 3.1 and 3.0 persons/bedroom, respectively). Among 287 (57%) school-aged case-patients, 270 (93%) had ≥2 MMR doses. A third MMR dose was administered to 1068 (33%) eligible students. Three-dose vaccinated students had an AR of 0.9/1000 compared with 2.4/1000 among students vaccinated with ≤2 doses more than1 incubation period pos-intervention, but the difference was not significant (p= 0.67). No serious adverse events were reported. CONCLUSIONS: This mumps outbreak occurred in a highly vaccinated population. The highest ARs occurred in ethnic minority populations with the highest household crowding indices. After the third dose MMR intervention in highly affected schools, three-dose recipients had an AR 60% lower than students with ≤2 doses, but the difference was not statistically significant and the intervention occurred after the outbreak peaked. This outbreak may have persisted due to crowding at home and high student contact rates. |
The first reported cases of Q fever endocarditis in Thailand
Pachirat O , Fournier PE , Pussadhamma B , Taksinachanekij S , Lulitanond V , Baggett HC , Thamthitiwat S , Watt G , Raoult D , Maloney SA . Infect Dis Rep 2012 4 (1) 17-18 We describe the first two reported cases of Q fever endocarditis in Thailand. Both patients were male, had pre-existing heart valve damage and had contact with cattle. Heightened awareness of Q fever could improve diagnosis and case management and stimulate efforts to identify risk factors and preventive measures. |
Hand, foot, and mouth disease caused by Coxsackievirus A6
Flett K , Youngster I , Huang J , McAdam A , Sandora TJ , Rennick M , Smole S , Rogers SL , Nix WA , Oberste MS , Gellis S , Ahmed AA . Emerg Infect Dis 2012 18 (10) 1702-4 TO THE EDITOR: Coxsackievirus A6 (CVA6) is a human enterovirus associated with herpangina in infants. In the winter of 2012, we evaluated a cluster of 8 patients, 4 months-3 years of age, who were brought for treatment at Boston Children's Hospital (Boston, MA, USA) with a variant of hand, foot, and mouth disease (HFMD) that has now been linked to CVA6 (Table). During this same period, the Boston Public Health Commission's syndromic surveillance system detected a 3.3-fold increase in emergency department discharge diagnoses of HFMD. In the United States, HFMD typically occurs in the summer and early autumn and is characterized by a febrile enanthem of oral ulcers and macular or vesicular lesions on the palms and soles; the etiologic agents are most often CVA16 and enterovirus 71. |
Infectious disease mortality rates, Thailand, 1958-2009
Aungkulanon S , McCarron M , Lertiendumrong J , Olsen SJ , Bundhamcharoen K . Emerg Infect Dis 2012 18 (11) 1794-801 To better define infectious diseases of concern in Thailand, trends in the mortality rate during 1958-2009 were analyzed by using data from public health statistics reports. From 1958 to the mid-1990s, the rate of infectious disease-associated deaths declined 5-fold (from 163.4 deaths/100,000 population in 1958 to 29.5/100,000 in 1997). This average annual reduction of 3.2 deaths/100,000 population was largely attributed to declines in deaths related to malaria, tuberculosis, pneumonia, and gastrointestinal infections. However, during 1998-2003, the mortality rate increased (peak of 70.0 deaths/100,000 population in 2003), coinciding with increases in mortality rate from AIDS, tuberculosis, and pneumonia. During 2004-2009, the rate declined to 41.0 deaths/100,000 population, coinciding with a decrease in AIDS-related deaths. The emergence of AIDS and the increase in tuberculosis- and pneumonia-related deaths in the late twentieth century emphasize the need to direct resources and efforts to the control of emerging and re-emerging infectious diseases. |
Assessing the assumptions of respondent-driven sampling in the National HIV Behavioral Surveillance System among injecting drug users
Lansky A , Drake A , Wejnert C , Pham H , Cribbin M , Heckathorn DD . Open AIDS J 2012 6 77-82 Several assumptions determine whether respondent-driven sampling (RDS) is an appropriate sampling method to use with a particular group, including the population being recruited must know one another as members of the group (i.e., injection drug users [IDUs] must know each other as IDUs) and be networked and that the sample size is small relative to the overall size of the group. To assess these three assumptions, we analyzed city-specific data collected using RDS through the US National HIV Behavioral Surveillance System among IDUs in 23 cities. Overall, 5% of non-seed participants reported that their recruiter was "a stranger." 20 cities with multiple field sites had ≥1 cross-recruitment, a proxy for linked networks. Sample sizes were small in relation to the IDU population size (median = 2.3%; range: 0.6%- 8.0%). Researchers must evaluate whether these three assumptions were met to justify the basis for using RDS to sample specific populations. |
Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region
Beard CB , Nelson CA , Mead PS , Petersen LR . Emerg Infect Dis 2012 18 (11) 1918-9 TO THE EDITOR: We believe the recent article by Maggi et al. (1) contains serious flaws in content and underlying message, including a poorly defined study population, lack of appropriate controls, improper use of the term bacteremia, and incongruent laboratory findings. Selection criteria were vague: the authors state only that participants were a "biased" collection of "patients selected by a rheumatologist," with no control population included for comparison. The diagnosis of Lyme disease and other previously diagnosed conditions was solely by self-report. Although blood samples were collected from every participant, the authors apparently neglected to perform standardized testing for Borrelia burgdorferi or other conditions. |
Burden of Clostridium difficile infection in long-term care facilities in Monroe County, New York
Pawar D , Tsay R , Nelson DS , Elumalai MK , Lessa FC , McDonald LC , Dumyati G . Infect Control Hosp Epidemiol 2012 33 (11) 1107-12 BACKGROUND: Long-term care facility (LTCF) residents are at increased risk of Clostridium difficile infection (CDI). However, little is known about the incidence, recurrence, and severity of CDI in LTCFs or the extent to which acute care exposure contributes to CDI in LTCFs. We describe the epidemiology of CDI in a cohort of LTCF residents in Monroe County, New York, where recent estimates suggest a CDI incidence in hospitals of 9.2 cases per 10,000 patient-days. DESIGN: Population-based surveillance study. SETTING: Monroe County, New York. PATIENTS: LTCF residents with onset of CDI while in the LTCF or less than 4 calendar-days after hospital admission from the LTCF from January 1 through December 31, 2010. METHODS: We conducted surveillance for CDI in residents of 33 LTCFs. A CDI case was defined as a stool specimen positive for C. difficile obtained from a patient without a C. difficile-positive specimen in the previous 8 weeks; recurrence was defined as a stool specimen positive for C. difficile obtained between 2 and 8 weeks after the last C. difficile-positive stool specimen. RESULTS: There were 425 LTCF-onset cases and 184 recurrences, which yielded an incidence of 2.3 cases per 10,000 resident-days (interquartile range [IQR], 1.2-3.3) and a recurrence rate of 1.0 case per 10,000 resident-days (IQR, 0.3-1.4). The cases occurred in 394 LTCF residents, and 52% of these residents developed CDI within 4 weeks after hospital discharge. Hospitalization for CDI occurred in 70 cases (16%). Of those cases that involved hospitalization for CDI, 70% were severe CDI, and 23% ended in death within 30 days after hospital admission. CONCLUSION: CDI incidence in Monroe County LTCFs is one-fourth the incidence among hospitalized patients. Approximately 50% of LTCF-onset cases occurred more than 4 weeks after hospital discharge, which emphasizes that prevention of CDI transmission should go beyond acute care settings. |
Call to action on World Pneumonia Day
Hajjeh R , Whitney CG . Emerg Infect Dis 2012 18 (11) 1898-9 This month, on November 12, the world will recognize the fourth annual World Pneumonia Day. First launched in 2009 by a coalition of global health leaders (1), World Pneumonia Day aims to raise awareness about pneumonia's toll on the world's children and to promote interventions to protect against, treat, and prevent the disease. Pneumonia continues to be the leading killer of young children around the world, causing approximately 14% of all deaths in children 1 month to 5 years of age (2). It is a critical disease for countries to conquer in order to reach Millennium Development Goal 4: reducing the child mortality rate by two thirds from 1990 to 2015 (3). Most children who die from pneumonia live in developing countries, where such factors as malnutrition, crowding, and lack of access to quality health care increase the risk for death. Pneumonia kills few children in industrialized countries, although it remains among the top 10 causes of deaths in the United States, for example, because of deaths in older adults (4). |
Constant transmission properties of variant Creutzfeldt-Jakob disease in 5 countries
Diack AB , Ritchie D , Bishop M , Pinion V , Brandel JP , Haik S , Tagliavini F , Van Duijn C , Belay ED , Gambetti P , Schonberger LB , Piccardo P , Will RG , Manson JC . Emerg Infect Dis 2012 18 (10) 1574-9 Variant Creutzfeldt-Jakob disease (vCJD) has been reported in 12 countries. We hypothesized that a common strain of agent is responsible for all vCJD cases, regardless of geographic origin. To test this hypothesis, we inoculated strain-typing panels of wild-type mice with brain material from human vCJD case-patients from France, the Netherlands, Italy, and the United States. Mice were assessed for clinical disease, neuropathologic changes, and glycoform profile; results were compared with those for 2 reference vCJD cases from the United Kingdom. Transmission to mice occurred from each sample tested, and data were similar between non-UK and UK cases, with the exception of the ranking of mean clinical incubation times of mouse lines. These findings support the hypothesis that a single strain of infectious agent is responsible for all vCJD infections. However, differences in incubation times require further subpassage in mice to establish any true differences in strain properties between cases. |
Rickettsia parkeri and Candidatus Rickettsia andeanae in Gulf Coast ticks, Mississippi, USA
Ferrari FA , Goddard J , Paddock CD , Varela-Stokes AS . Emerg Infect Dis 2012 18 (10) 1705-7 TO THE EDITOR: Rickettsia parkeri, a spotted fever group Rickettsia (SFGR) bacterium, is transmitted by Amblyomma maculatum, the Gulf Coast tick (1). The prevalence of R. parkeri in Gulf Coast ticks has been reported as <42% in the United States, which is higher than reported rates of R. rickettsii (the cause of Rocky Mountain spotted fever) in Dermacentor species ticks. Misdiagnosis among SFGR infections is not uncommon, and R. parkeri rickettsiosis can cause symptoms similar to those for mild Rocky Mountain spotted fever (1). We evaluated infection rates of R. parkeri and Candidatus Rickettsia andeanae, a recently identified but incompletely characterized SFGR, in Gulf Coast ticks in Mississippi, USA. |
Seasonal pulses of Marburg virus circulation in juvenile Rousettus aegyptiacus bats coincide with periods of increased risk of human infection
Amman BR , Carroll SA , Reed ZD , Sealy TK , Balinandi S , Swanepoel R , Kemp A , Erickson BR , Comer JA , Campbell S , Cannon DL , Khristova ML , Atimnedi P , Paddock CD , Kent Crockett RJ , Flietstra TD , Warfield KL , Unfer R , Katongole-Mbidde E , Downing R , Tappero JW , Zaki SR , Rollin PE , Ksiazek TG , Nichol ST , Towner JS . PLoS Pathog 2012 8 (10) e1002877 Marburg virus (family Filoviridae) causes sporadic outbreaks of severe hemorrhagic disease in sub-Saharan Africa. Bats have been implicated as likely natural reservoir hosts based most recently on an investigation of cases among miners infected in 2007 at the Kitaka mine, Uganda, which contained a large population of Marburg virus-infected Rousettus aegyptiacus fruit bats. Described here is an ecologic investigation of Python Cave, Uganda, where an American and a Dutch tourist acquired Marburg virus infection in December 2007 and July 2008. More than 40,000 R. aegyptiacus were found in the cave and were the sole bat species present. Between August 2008 and November 2009, 1,622 bats were captured and tested for Marburg virus. Q-RT-PCR analysis of bat liver/spleen tissues indicated approximately 2.5% of the bats were actively infected, seven of which yielded Marburg virus isolates. Moreover, Q-RT-PCR-positive lung, kidney, colon and reproductive tissues were found, consistent with potential for oral, urine, fecal or sexual transmission. The combined data for R. aegyptiacus tested from Python Cave and Kitaka mine indicate low level horizontal transmission throughout the year. However, Q-RT-PCR data show distinct pulses of virus infection in older juvenile bats ( approximately six months of age) that temporarily coincide with the peak twice-yearly birthing seasons. Retrospective analysis of historical human infections suspected to have been the result of discrete spillover events directly from nature found 83% (54/65) events occurred during these seasonal pulses in virus circulation, perhaps demonstrating periods of increased risk of human infection. The discovery of two tags at Python Cave from bats marked at Kitaka mine, together with the close genetic linkages evident between viruses detected in geographically distant locations, are consistent with R. aegyptiacus bats existing as a large meta-population with associated virus circulation over broad geographic ranges. These findings provide a basis for developing Marburg hemorrhagic fever risk reduction strategies. |
Transmission ecology of Sin Nombre hantavirus in naturally infected North American deermouse populations in outdoor enclosures
Bagamian KH , Towner JS , Kuenzi AJ , Douglass RJ , Rollin PE , Waller LA , Mills JN . PLoS One 2012 7 (10) e47731 Sin Nombre hantavirus (SNV), hosted by the North American deermouse (Peromyscus maniculatus), causes hantavirus pulmonary syndrome (HPS) in North America. Most transmission studies in the host were conducted under artificial conditions, or extrapolated information from mark-recapture data. Previous studies using experimentally infected deermice were unable to demonstrate SNV transmission. We explored SNV transmission in outdoor enclosures using naturally infected deermice. Deermice acquiring SNV in enclosures had detectable viral RNA in blood throughout the acute phase of infection and acquired significantly more new wounds (indicating aggressive encounters) than uninfected deermice. Naturally-infected wild deermice had a highly variable antibody response to infection, and levels of viral RNA sustained in blood varied as much as 100-fold, even in individuals infected with identical strains of virus. Deermice that infected other susceptible individuals tended to have a higher viral RNA load than those that did not infect other deermice. Our study is a first step in exploring the transmission ecology of SNV infection in deermice and provides new knowledge about the factors contributing to the increase of the prevalence of a zoonotic pathogen in its reservoir host and to changes in the risk of HPS to human populations. The techniques pioneered in this study have implications for a wide range of zoonotic disease studies. |
Entomologic investigations during an outbreak of West Nile virus disease in Maricopa County, Arizona, 2010
Godsey MS Jr , Burkhalter K , Young G , Delorey M , Smith K , Townsend J , Levy C , Mutebi JP . Am J Trop Med Hyg 2012 87 (6) 1125-31 Entomologic investigations were conducted during an intense outbreak of West Nile virus (WNV) disease in Maricopa County, Arizona during July 31-August 9, 2010. The investigations compared the East Valley outbreak area, and a demographically similar control area in northwestern metropolitan Phoenix where no human cases were reported. Five mosquito species were identified in each area, and species composition was similar in both areas. Significantly more Culex quinquefasciatus females were collected by gravid traps at Outbreak sites (22.2 per trap night) than at control sites (8.9 per trap night), indicating higher Cx. quinquefasciatus abundance in the outbreak area. Twenty-eight WNV TaqMan reverse transcription polymerase chain reaction-positive mosquito pools were identified, including 24 of Cx. quinquefasciatus, 3 of Psorophora columbiae, and 1 of Culex sp. However, Cx. quinquefasciatus WNV infection rates did not differ between outbreak and control sites. At outbreak sites, 30 of 39 engorged Cx. quinquefasciatus had fed on birds, 8 of 39 on humans, and 1 of 39 on a lizard. At control sites, 20 of 20 identified blood meals were from birds. Data suggest that Cx. quinquefasciatus was the primary enzootic and epidemic vector of this outbreak. The most important parameters in the outbreak were vector abundance and blood meal analysis, which suggested more frequent contact between Cx. quinquefasciatus and human hosts in the outbreak area compared with the control area. |
Anthroponotic enteric parasites in monkeys in public park, China
Ye J , Xiao L , Ma J , Guo M , Liu L , Feng Y . Emerg Infect Dis 2012 18 (10) 1640-3 Cryptosporidium spp., Giardia duodenalis, and Enterocytozoon bieneusi were detected in 45, 35, and 116 of 411 free-range rhesus monkeys, respectively, in a popular public park in the People's Republic of China. Most genotypes and subtypes detected were anthroponotic, indicating these animals might be reservoirs for human cryptosporidiosis, giardiasis, and microsporidiosis. |
Risk reduction assessment of waterborne Salmonella and Vibrio by a chlorine contact disinfectant point-of-use device.
Coulliette AD , Enger KS , Weir MH , Rose JB . Int J Hyg Environ Health 2012 216 (3) 355-61 Unsafe drinking water continues to burden developing countries despite improvements in clean water delivery and sanitation, in response to Millennium Development Goal 7. Salmonella serotype Typhi and Vibrio cholerae bacteria can contaminate drinking water, causing waterborne typhoid fever and cholera, respectively. Household water treatment (HWT) systems are widely promoted to consumers in developing countries but it is difficult to establish their benefits to the population for specific disease reduction. This research uses a laboratory assessment of halogenated chlorine beads treating contaminated water to inform a quantitative microbial risk assessment (QMRA) of S. Typhi and V. cholerae disease in a developing country community of 1000 people. Laboratory challenges using seeded well water resulted in log(10) reductions of 5.44 (+/-0.98 standard error (SE)) and 6.07 (+/-0.09 SE) for Salmonella serotype Typhimurium and V. cholerae, respectively. In well water with 10% sewage and seeded bacteria, the log(10) reductions were 6.06 (+/-0.62 SE) and 7.78 (+/-0.11 SE) for S. Typhimurium and V. cholerae, respectively. When one infected individual was contributing to the water contamination through fecal material leaking into the water source, the risk of disease associated with drinking untreated water was high according to a Monte Carlo analysis: a median of 0.20 (interquartile range [IQR] 0.017-0.54) for typhoid fever and a median of 0.11 (IQR 0.039-0.20) for cholera. If water was treated, risk greatly decreased, to a median of 4.1x10(-7) (IQR 1.6x10(-8) to 1.1x10(-5)) for typhoid fever and a median of 3.5x10(-9) (IQR 8.0x10(-10) to 1.3x10(-8)) for cholera. Insights on risk management policies and strategies for public health workers were gained using a simple QMRA scenario informed by laboratory assessment of HWT. |
Lactational exposure to polybrominated diphenyl ethers and its relation to social and emotional development among toddlers
Hoffman K , Adgent M , Goldman BD , Sjodin A , Daniels JL . Environ Health Perspect 2012 120 (10) 1438-42 BACKGROUND: Polybrominated diphenyl ethers (PBDEs) have been widely used as flame retardants and are ubiquitous environmental contaminants. PBDEs have been linked to adverse neurodevelopment in animals and humans. OBJECTIVES: We investigated the association between breast milk PBDE levels and social and emotional development in toddlers. METHODS: The Pregnancy Infection and Nutrition (PIN) and PIN Babies studies followed a cohort of North Carolina pregnant women and their children through 36 months of age. Breast milk samples obtained at 3 months postpartum were analyzed for PBDEs. The Infant-Toddler Social and Emotional Assessment (ITSEA) was completed by mothers when children were approximately 30 months of age (n = 222). We assessed the relationship between breast milk concentrations of five PBDE congeners-BDEs 28, 47, 99, 100, and 153-and children's social and emotional development, adjusting for other factors. RESULTS: A small, imprecise, yet consistent positive association was apparent between BDEs 47, 99, and 100 and increased externalizing behaviors, specifically activity/impulsivity behaviors. Externalizing domain T-scores ranged from 30 to 87 with a mean of 47.8. Compared with those with BDE-47 concentrations below the median, adjusted externalizing behavior domain scores were 1.6 [95% confidence interval (CI): -1.2, 4.4] and 2.8 (95% CI -0.1, 5.7) points higher for children born to women with breast milk concentrations in the 3rd and 4th quartiles, respectively. PBDEs were not associated with other social and emotional developmental domains. CONCLUSION: Our results, although imprecise, suggest a subtle association between early-life PBDE exposure and increased activity/impulsivity behaviors in early childhood. Confirmation of these results is needed in other longitudinal studies. |
Maternal concentrations of polyfluoroalkyl compounds during pregnancy and fetal and postnatal growth in British girls
Maisonet M , Terrell ML , McGeehin MA , Christensen KY , Holmes A , Calafat AM , Marcus M . Environ Health Perspect 2012 120 (10) 1432-7 BACKGROUND: Prenatal exposures to polyfluoroalkyl compounds (PFCs) may be associated with adverse changes in fetal and postnatal growth. OBJECTIVE: We explored associations of prenatal serum concentrations of perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and perfluorohexane sulfonate (PFHxS) with fetal and postnatal growth in girls. METHODS: We studied a sample of 447 singleton girls and their mothers participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Data on weight and length were obtained at birth and at 2, 9, and 20 months. Serum samples were obtained in 1991-1992, from mothers during pregnancy. We explored associations between prenatal PFC concentrations and weight at birth as well as longitudinal changes in weight-for-age SD scores between birth and 20 months. RESULTS: PFOS (median, 19.6 ng/mL), PFOA (median, 3.7 ng/mL), and PFHxS (median, 1.6 ng/mL) were detected in 100% of samples. On average, girls born to mothers with prenatal concentrations of PFOS in the upper tertile weighed 140 g less [95% confidence interval (CI): -238, -42] at birth than girls born to mothers with concentrations in the lower tertile in adjusted models. Similar patterns were seen for PFOA (-133 g; 95% CI: -237, -30) and PFHxS (-108 g; 95% CI: -206, -10). At 20 months, however, girls born to mothers with prenatal concentrations of PFOS in the upper tertile weighed 580 g more (95% CI: 301, 858) when compared with those in the lower tertile. No differences in weight were found for PFOA and PFHxS. CONCLUSIONS: Girls with higher prenatal exposure to each of the PFCs examined were smaller at birth than those with lower exposure. In addition, those with higher exposure to PFOS were larger at 20 months. |
Prenatal exposure to butylbenzyl phthalate and early eczema in an urban cohort
Just AC , Whyatt RM , Perzanowski MS , Calafat AM , Perera FP , Goldstein IF , Chen Q , Rundle AG , Miller RL . Environ Health Perspect 2012 120 (10) 1475-80 BACKGROUND: Recent cross-sectional studies suggest a link between butylbenzyl phthalate (BBzP) in house dust and childhood eczema. OBJECTIVES: We aimed to evaluate whether concentrations of monobenzyl phthalate (MBzP), the main BBzP metabolite in urine, during pregnancy are associated prospectively with eczema in young children, and whether this association varies by the child's sensitization to indoor allergens or serological evidence of any allergies. METHODS: MBzP was measured in spot urine samples during the third trimester of pregnancy from 407 African-American and Dominican women residing in New York City in 1999-2006. Repeated questionnaires asked mothers whether their doctor ever said their child had eczema. Child blood samples at 24, 36, and 60 months of age were analyzed for total, anti-cockroach, dust mite, and mouse IgE. Relative risks (RR) were estimated with multivariable modified Poisson regression. Analyses included a multinomial logistic regression model for early- and late-onset eczema versus no eczema through 60 months of age. RESULTS: MBzP was detected in > 99% of samples (geometric mean = 13.6; interquartile range: 5.7-31.1 ng/mL). By 24 months, 30% of children developed eczema, with the proportion higher among African Americans (48%) than among Dominicans (21%) (p < 0.001). An interquartile range increase in log MBzP concentration was associated positively with early-onset eczema (RR = 1.52 for eczema by 24 months; 95% confidence interval: 1.21, 1.91, p = 0.0003, n = 113 reporting eczema/376 total sample), adjusting for urine specific gravity, sex, and race/ethnicity. MBzP was not associated with allergic sensitization, nor did seroatopy modify consistently the MBzP and eczema association. CONCLUSIONS: Prenatal exposure to BBzP may influence the risk of developing eczema in early childhood. |
Preventing maritime transfer of toxigenic Vibrio cholerae
Cohen NJ , Slaten DD , Marano N , Tappero JW , Wellman M , Albert RJ , Hill VR , Espey D , Handzel T , Henry A , Tauxe RV . Emerg Infect Dis 2012 18 (10) 1680-2 Organisms, including Vibrio cholerae, can be transferred between harbors in the ballast water of ships. Zones in the Caribbean region where distance from shore and water depth meet International Maritime Organization guidelines for ballast water exchange are extremely limited. Use of ballast water treatment systems could mitigate the risk for organism transfer. |
The food-water nexus: irrigation water quality, risks to food safety, and the need for a systems-based preventive approach
Gelting RJ , Baloch MA . J Environ Health 2012 75 (3) 40-41 This year’s World Water Day focused on | the food-water nexus with the theme | “Water and Food Security: The World is | Thirsty Because We are Hungry.” While much | of the emphasis under this theme focused on | the quantities of water used for food production, the quality of water is also important to | that function. Water quality can also have significant effects on health. In this context, the | quality of irrigation water can have profound | impacts on the microbiological integrity of | food. Irrigation water has been implicated as a | possible source of pathogens in produce linked | to major disease outbreaks in the U.S. and Europe. Many sources of irrigation water are subject to inputs of pathogenic loads from point | and nonpoint sources stemming from multiple | land uses in watersheds (Pachepsky, Shelton, | Mclain, Patel, & Mandrell, 2011). Research on | the potential effects of irrigation water quality on food safety therefore requires a systemsbased environmental assessment on the watershed scale that accounts for various factors that | may influence irrigation water quality. |
From conversation to action: implementation of the National Conversation on Public Health and Chemical Exposures
Nielsen JA . J Environ Health 2012 75 (3) 38-39 As our society has advanced, chemicals | have become increasingly present in | our air, water, food and homes; thus, | a key responsibility of environmental health | professionals is to protect the public from these | chemical exposures. In 2009, the Centers for | Disease Control and Prevention (CDC) and | the Agency for Toxic Substances and Disease | Registry (ATSDR) launched the National Conversation on Public Health and Chemical Exposures project to help address national concerns about toxic exposures (Frumkin, 2009). | The goal of the National Conversation was to | develop an Action Agenda with clear, achievable recommendations to help government | agencies and other organizations strengthen | their efforts to protect the public from harmful chemical exposures. CDC and ATSDR | engaged a broad range of groups and individuals—government agencies, professional | organizations, tribal groups, community and | nonprofit organizations, health professionals, | business and industry leaders, and members | of the public—to assist with this undertaking. This group developed the Action Agenda | (“Addressing Public Health and Chemical Exposures: An Action Agenda”— www.national | conversation.us/action-agenda) and released it | in June 2011. |
Analysis of selected maternal exposures and non-syndromic atrioventricular septal defects in the National Birth Defects Prevention Study, 1997-2005
Patel SS , Burns TL , Botto LD , Riehle-Colarusso TJ , Lin AE , Shaw GM , Romitti PA . Am J Med Genet A 2012 158A (10) 2447-2455 Although the descriptive epidemiology of atrioventricular septal defects (AVSDs), a group of serious congenital heart defects (CHDs), has been recently reported, non-genetic risk factors have not been consistently identified. Using data (1997-2005) from the National Birth Defects Prevention Study, an ongoing multisite population-based case-control study, the association between selected non-genetic factors and non-syndromic AVSDs was examined. Data on periconceptional exposures to such factors were collected by telephone interview from 187 mothers of AVSD case infants and 6,703 mothers of unaffected infants. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated from logistic regression models. Mothers who reported cigarette smoking during the periconceptional period were more likely to have infants with AVSDs compared with non-smokers, independent of maternal age, periconceptional alcohol consumption, infant gestational age, family history of CHDs, and study site (aOR 1.5, 95% CI 1.1-2.4). The association was strongest in mothers who smoked more than 25 cigarettes/day. In addition, mothers with periconceptional passive smoke exposure were more likely to have infants with AVSDs than unexposed mothers, independent of maternal age, active periconceptional smoking, infant gestational age, and family history of CHDs (aOR 1.4, 95% CI 1.0-2.0). No associations were observed between AVSDs and maternal history of a urinary tract infection or pelvic inflammatory disease, maternal use of a wide variety of medications, maternal occupational exposure, parental drug use, or maternal alcohol consumption. If the results of this preliminary study can be replicated, minimizing maternal active and passive smoke exposure may decrease the incidence of AVSDs. ((c) 2012 Wiley Periodicals, Inc.) |
Climbing the evidentiary hierarchy for environmental infection control
McDonald LC , Arduino M . Clin Infect Dis 2012 56 (1) 36-9 Increasing concern over multidrug-resistant organisms (MDROs), especially vancomycin-resistant enterococci (VRE), Clostridium difficile, and multidrug-resistant gram-negative bacteria (MDR-GNB), has led to increasing attention being paid to the role of high touch environmental surfaces in transmission. Our current understanding of the roles of environmental surfaces in MDRO transmission include the following: 1) a primary role with transmission from source patient to environmental surface to subsequent patient and, 2) a secondary role from source patient to environmental surface to hands of healthcare personnel to subsequent patient. Either a prior room occupant or a contemporaneous patient sharing reusable medical equipment is the source patient in most primary transmission events. | Standard environmental cleaning and disinfection entails manual cleaning and application of a disinfectant, often utilizing a detergent disinfectant. In addition to new disinfectants with greater potency and shorter contact times, new technological advances include ‘non-touch disinfection’ (NTD) methods, the most developed of which are hydrogen peroxide vapor (HPV), and automated germicidal ultraviolet irradiation. Both methods appear highly efficacious in inactivating the microbial bioburden present on surfaces and both remove much of the variance inherent in human cleaning activity via a high degree of automation and feedback loops for verification that contact or irradiation times are adequate.1–3 |
Consumption of pesticide-treated wheat seed by a rural population in Malawi
Schier JG , Sejvar JJ , Lutterloh E , Likaka A , Katsoudas E , Karaseva YD , Tippett Barr B , Redwood Y , Monroe S . J Expo Sci Environ Epidemiol 2012 22 (6) 569-73 An outbreak of typhoid fever in rural Malawi triggered an investigation by the Malawi Ministry of Health and the Centers for Disease Control and Prevention in July 2009. During the investigation, villagers were directly consuming washed, donated, pesticide-treated wheat seed meant for planting. The objective of this study was to evaluate the potential for pesticide exposure and health risk in the outbreak community. A sample of unwashed (1430 g) and washed (759 g) wheat seed donated for planting, but which would have been directly consumed, was tested for 365 pesticides. Results were compared with each other (percentage change), the US Environmental Protection Agency's (EPA) health guidance values and estimated daily exposures were compared with their Reference dose (RfD). Unwashed and washed seed samples contained, respectively: carboxin, 244 and 57 p.p.m.; pirimiphos methyl, 8.18 and 8.56 p.p.m.; total permethrin, 3.62 and 3.27 p.p.m.; and carbaryl, 0.057 and 0.025 p.p.m.. Percentage change calculations (unwashed to washed) were as follows: carboxin, -76.6%; pirimiphos methyl, +4.6%; total permethrin, -9.7%; and carbaryl -56.1%. Only carboxin and total permethrin concentration among washed seed samples exceeded US EPA health guidance values (285 x and seven times, respectively). Adult estimated exposure scenarios (1 kg seed) exceeded the RfD for carboxin (8 x ) and pirimiphos methyl (12 x ). Adult villagers weighing 70 kg would have to consume 0.123, 0.082, 1.06, and 280 kg of washed seed daily to exceed the RfD for carboxin, pirimiphos methyl, permethrins, and carbaryl, respectively. Carboxin, pirimiphos methyl, permethrins, and carbaryl were detected in both unwashed and washed samples of seed. Carboxin, total permethrin, and carbaryl concentration were partially reduced by washing. Health risks from chronic exposure to carboxin and pirimiphos methyl in these amounts are unclear. The extent of this practice among food insecure communities receiving relief seeds and resultant health impact needs further study. (Journal of Exposure Science and Environmental Epidemiology advance online publication, 10 October 2012; doi:10.1038/jes.2012.47.) |
Time-series analyses of count data to estimate the burden of seasonal infectious diseases
Thompson WW , Ridenhour BL , Barile JP , Shay DK . Epidemiology 2012 23 (6) 839-42 In this issue of EPIDEMIOLOGY, Goldstein and colleagues1 present “a new statistical method for estimating influenza-related mortality” using recent US mortality and influenza data sources. They propose that their method is an advance over previous methods2–13 for estimating influenza disease burden. Strengths of their approach include: (1) the accommodation of nonlinear mortality effects of specific influenza types and subtypes over time; (2) the use of a logical method to model exposure to influenza; and (3) an assessment of autocorrelation in the time series. There are also some limitations, which include (1) questionable statistical assumptions in the use of linear regression models for weekly data with low frequency counts; (2) neglect of recent advances in time-series modeling; (3) a complex and nonparsimonious model; and (4) lack of comparisons of influenza-associated mortality estimates with those from the published literature using similar outcomes. |
A national case-control study identifies human socio-economic status and activities as risk factors for tick-borne encephalitis in Poland
Stefanoff P , Rosinska M , Samuels S , White DJ , Morse DL , Randolph SE . PLoS One 2012 7 (9) e45511 BACKGROUND: Tick-borne encephalitis (TBE) is endemic to Europe and medically highly significant. This study, focused on Poland, investigated individual risk factors for TBE symptomatic infection. METHODS AND FINDINGS: In a nation-wide population-based case-control study, of the 351 TBE cases reported to local health departments in Poland in 2009, 178 were included in the analysis. For controls, of 2704 subjects (matched to cases by age, sex, district of residence) selected at random from the national population register, two were interviewed for each case and a total of 327 were suitable for the analysis. Questionnaires yielded information on potential exposure to ticks during the six weeks (maximum incubation period) preceding disease onset in each case. Independent associations between disease and socio-economic factors and occupational or recreational exposure were assessed by conditional logistic regression, stratified according to residence in known endemic and non-endemic areas. Adjusted population attributable fractions (PAF) were computed for significant variables. In endemic areas, highest TBE risk was associated with spending ≥10 hours/week in mixed forests and harvesting forest foods (adjusted odds ratio 19.19 [95% CI: 1.72-214.32]; PAF 0.127 [0.064-0.193]), being unemployed (11.51 [2.84-46.59]; 0.109 [0.046-0.174]), or employed as a forester (8.96 [1.58-50.77]; 0.053 [0.011-0.100]) or non-specialized worker (5.39 [2.21-13.16]; 0.202 [0.090-0.282]). Other activities (swimming, camping and travel to non-endemic regions) reduced risk. Outside TBE endemic areas, risk was greater for those who spent ≥10 hours/week on recreation in mixed forests (7.18 [1.90-27.08]; 0.191 [0.065-0.304]) and visited known TBE endemic areas (4.65 [0.59-36.50]; 0.058 [-0.007-0.144]), while travel to other non-endemic areas reduced risk. CONCLUSIONS: These socio-economic factors and associated human activities identified as risk factors for symptomatic TBE in Poland are consistent with results from previous correlational studies across eastern Europe, and allow public health interventions to be targeted at particularly vulnerable sections of the population. |
Piloting a system for behavioral surveillance among heterosexuals at increased risk of HIV in the United States
DiNenno EA , Oster AM , Sionean C , Denning P , Lansky A . Open AIDS J 2012 6 169-76 OBJECTIVES: During the past decade, the number and proportion of reported HIV cases in the United States acquired through heterosexual contact has increased markedly. CDC employs the National HIV Behavioral Surveillance System (NHBS) to monitor risk behaviors and HIV prevalence in high-risk populations. To identify a target population for conducting NHBS among heterosexuals at increased risk for HIV (NHBS-HET), CDC designed, implemented and evaluated a pilot study. METHODS: The pilot study was conducted in 25 US metropolitan statistical areas in 2006-7. We recruited men and women who reported sex with at least one opposite-sex partner during the past year for a behavioral survey and HIV test. We investigated the relationship between newly diagnosed HIV infection and individual risk behaviors, sexual network characteristics, and social-structural characteristics to arrive at a definition of a heterosexual at increased risk of HIV. RESULTS: Of 14,750 participants in the analysis, 207 (1.4%) had newly diagnosed HIV infection. Using low socioeconomic status (SES) as a criterion for defining a heterosexual at increased risk for HIV resulted in optimal rates of HIV prevalence, specificity, sensitivity and practicality. CONCLUSIONS: Results from the NHBS pilot study underscore the key role of social factors as determinants of HIV infection risk among U.S. heterosexuals, and low SES was incorporated into the definition of a heterosexual at increased risk for HIV in NHBS-HET cycles. Future cycles of NHBS-HET will help tailor prevention programs for those populations most at risk of HIV in the US. |
Prostate cancer screening practices of African-American and non-African-American US primary care physicians: a cross-sectional survey
Richards TB , Rim SH , Hall IJ , Richardson LC , Ross LE . Int J Gen Med 2012 5 775-80 PURPOSE: We explored whether African-American (AA) primary care physicians (PCPs) have different prostate cancer screening practices compared to non-AA PCPs, after adjustment for potential confounding factors such as the proportion of AA patients in PCP practices. METHODS: We used SAS/SUDAAN to compare weighted responses from AA PCPs (n = 604) with those from non-AA PCPs (n = 647) in the 2007-2008 National Survey of Primary Care Physician Practices Regarding Prostate Cancer Screening. We used multivariate logistic regression to calculate the weighted odds ratios (OR) and 95% confidence intervals (CI). RESULTS: We found that AA PCPs had higher odds of working in practices with above-the-median (≥ 21%) proportions of AA male patients (OR, 9.02; 95% CI: 5.85-13.91). A higher proportion of AA PCPs (53.5%; 95% CI: 49.5-57.4) reported an above-the-median proportion (≥ 91%) of PSA testing during health maintenance exams as compared to non-AA PCPs (39.4%; 95% CI: 35.5-43.4; P < 0.0002). After adjusting for the proportion of AA patients and other factors, we found that AA PCPs had higher odds of using PSA tests to screen men (OR, 1.74; 95% CI: 1.11-2.73). CONCLUSION: This study quantifies the magnitude of the differences reported in previous focus group studies. Our results may be helpful in hypothesis generation and in planning future research studies. |
Enhanced collection of laboratory data in HIV surveillance smong 5 states with confidential name-based HIV infection reporting, 2005-2006
Gray KM , Kajese T , Crandell-Alden E , Anderson BJ , Wendell D , Crutchfield A , Jackson T , Hall HI . Open AIDS J 2012 6 90-7 Laboratory data reported through HIV surveillance can provide information about disease severity and linkage to care; however these measures are only as accurate as the quality and completeness of data reported. Using data from five states that implemented enhanced collection of laboratory data in HIV surveillance from 2005-2006, we determined completeness of reporting, stage of disease at diagnosis, the most common opportunistic illnesses (OI) at diagnosis, and linkage to medical care. Methods to enhance laboratory reporting included increasing active surveillance efforts, identifying laboratories not reporting to HIV surveillance, increasing electronic reporting, and using laboratory results from auxiliary databases. Of 3,065 persons ≥13 years of age diagnosed with HIV, 35.5% were diagnosed with stage 3 (AIDS) and 37.7% progressed to stage 3 within 12-months after diagnosis. Overall, 78.5% were linked to care within 3 months; however, a higher proportion of persons with ≥1 CD4 or viral load test was found among whites compared with blacks/African Americans (82.1% vs 73.6%, p<0.001). Few (12.3%) had an OI within 3 months of diagnosis. The completeness of laboratory data collected through surveillance was improved with enhanced reporting and provided a more accurate picture of stage of disease and gaps in linkage to care. Additional interventions are needed to meet the goals of the National HIV/AIDS Strategy on linkage to care and the reduction of HIV-related disparities. |
HIV screening in the health care setting: status, barriers, and potential solutions
Rizza SA , MacGowan RJ , Purcell DW , Branson BM , Temesgen Z . Mayo Clin Proc 2012 87 (9) 915-24 Thirty years into the human immunodeficiency virus (HIV) epidemic in the United States, an estimated 50,000 persons become infected each year: highest rates are in black and Hispanic populations and in men who have sex with men. Testing for HIV has become more widespread over time, with the highest rates of HIV testing in populations most affected by HIV. However, approximately 55% of adults in the United States have never received an HIV test. Because of the individual and community benefits of treatment for HIV, in 2006 the Centers for Disease Control and Prevention recommended routine screening for HIV infection in clinical settings. The adoption of this recommendation has been gradual owing to a variety of issues: lack of awareness and misconceptions related to HIV screening by physicians and patients, barriers at the facility and legislative levels, costs associated with testing, and conflicting recommendations concerning the value of routine screening. Reducing or eliminating these barriers is needed to increase the implementation of routine screening in clinical settings so that more people with unrecognized infection can be identified, linked to care, and provided treatment to improve their health and prevent new cases of HIV infection in the United States. |
Internet-based methods may reach higher-risk men who have sex with men not reached through venue-based sampling
Sanchez T , Smith A , Denson D , Dinenno E , Lansky A . Open AIDS J 2012 6 83-9 BACKGROUND: Internet-based sampling methods may reach men who have sex with men (MSM) who don't attend physical venues frequented by MSM and may be at higher risk of HIV infection. METHODS: Multivariate logistic regression was used to examine characteristics of adult MSM participants in 2 studies conducted in the same 5 U.S. cities: the 2003-2005 National HIV Behavioral Surveillance System (NHBS) which used sampling from physical MSM venues (e.g., bars, clubs) and the 2007 Web-based HIV Behavioral Surveillance (WHBS) pilot which used sampling through online banner advertisements. RESULTS: Among 5024 WHBS MSM, 95% attended a physical MSM venue in the past 12 months, and 75% attended weekly. WHBS MSM who were black, aged 18-21 years, not college educated, bisexual- or heterosexual-identifying, and reported unknown HIV serostatus were less likely to have attended a physical MSM venue in the past 12 months (all p<0.01). Compared to NHBS MSM, WHBS MSM were more likely to be white, younger, college-educated, report unknown HIV serostatus, report unprotected anal intercourse with a casual partner, and have first met that partner online (all p<0.0001). WHBS MSM were less likely to have been under the influence of drugs during most recent sex (p=0.01) or not know their sex partner's HIV serostatus (p<0.0001). CONCLUSIONS: Many MSM recruited online also attended physical venues, but attendance varied by sub-group. Participants in WHBS and NHBS differed, and WHBS may represent a group of MSM at higher risk of HIV infection. These findings suggest that an internet-based method may be a useful supplement to NHBS. |
Assessing measurement error in Medicare coverage from the National Health Interview Survey
Gindi R , Cohen RA . Medicare Medicaid Res Rev 2012 2 (2) E1-E15 OBJECTIVES: Using linked administrative data, to validate Medicare coverage estimates among adults aged 65 or older from the National Health Interview Survey (NHIS), and to assess the impact of a recently added Medicare probe question on the validity of these estimates. DATA SOURCES: Linked 2005 NHIS and Master Beneficiary Record and Payment History Update System files from the Social Security Administration (SSA). STUDY DESIGN: We compared Medicare coverage reported on NHIS with 'benchmark' benefit records from SSA. PRINCIPAL FINDINGS: With the addition of the probe question, more reports of coverage were captured, and the agreement between the NHIS-reported coverage and SSA records increased from 88% to 95%. Few additional overreports were observed. CONCLUSIONS: Increased accuracy of the Medicare coverage status of NHIS participants was achieved with the Medicare probe question. Though some misclassification remains, data users interested in Medicare coverage as an outcome or correlate can use this survey measure with confidence. |
Chest radiography for tuberculosis screening is back on the agenda
Iademarco MF , O'Grady J , Lonnroth K . Int J Tuberc Lung Dis 2012 16 (11) 1421-2 TO SOME, the title may seem overstated and to others perhaps ironic, from a total lung health perspective. In 1974, following similar policy changes in many | countries, the World Health Organization (WHO) | Committee on Tuberculosis concluded that case fi nding by mass screening using chest radiography should | be abandoned.1 The WHO Committee placed a strong | emphasis on pursuing a diagnosis among symptomatic patients by sputum smear microscopy because | chest radiography could not be used independently | for diagnosis and was too expensive. Even after such | recommendations, and although it was often criticized | over the decades for its insuffi cient specifi city and sensitivity, the use of chest radiography was maintained | in clinical practice, including in many low-resource | country settings, as part of the diagnostic algorithm. | Chest radiography screening has been used for | prevalence surveys, and more recently it has been revived using targeted approaches among high-risk | populations. Its importance is being recognized again, | including in persons infected with the human immunodefi ciency virus and in children with tuberculosis. | As early as 1992, the WHO’s Essential Technologies | group made recommendations that stressed the role | of and access to chest radiographs (and ultrasound) | at the primary referral level.2 With the advent of digital technology, the operational and expense barriers | are declining for radiography as they are with mycobacterial culture, including in low-resource countries. | In 2006, the International Standards for Tuberculosis | Care carefully defi ned the role of chest radiography | in a clinical context,3 and the International Union | Against Tuberculosis and Lung Disease has also been | active in this area.* The use of mobile digital technology, dedicated expertise, and emerging techniques for | computer-aided reading may help address the challenges with observer error and experience |
Comparison of acute viral hepatitis data quality using two methodologies, 2005-2007
Iqbal K , Klevens RM , Jiles R . Public Health Rep 2012 127 (6) 591-7 OBJECTIVE: We compared the quality of data reported to the Centers for Disease Control and Prevention (CDC) from sites that received funding for acute viral hepatitis surveillance through CDC's Emerging Infections Program (EIP) with sites that have electronic infrastructure to collect data but do not receive funding from CDC to support viral hepatitis surveillance. METHODS: Descriptive analysis was conducted on acute hepatitis A, B, and C cases reported from EIP sites and National Electronic Disease Surveillance System (NEDSS)-based states (NBS) sites from 2005 to 2007. Data were compared for (1) completeness of demographic and risk behavior/exposure information; (2) adherence to CDC/Council of State and Territorial Epidemiologists (CSTE) case definition for confirmed cases of acute hepatitis A, B, and C; and (3) timeliness of reporting to the health department. RESULTS: Data reported for sex and age were at least 98% complete for both EIP and NBS sites and race/ethnicity was more complete for EIP sites. For acute hepatitis A, B, and C, case reports from EIP sites were more likely than those from NBS sites to include a "yes" response to at least one risk behavior/exposure variable and were more likely to meet the CDC/CSTE case definition. EIP sites received case reports in a more timely fashion than did NBS sites. The case definition for acute hepatitis C proved problematic for both EIP and NBS sites. CONCLUSIONS: Data from the EIP sites were more complete and reported in a more timely way to health departments than data from the NBS sites. Funding for follow-up activities is essential to providing surveillance data of higher quality for decision-making and public health response. |
Multistate outbreak of Escherichia coli O157:H7 infections associated with in-store sampling of an aged raw-milk gouda cheese, 2010
McCollum JT , Williams NJ , Beam SW , Cosgrove S , Ettestad PJ , Ghosh TS , Kimura AC , Nguyen L , Stroika SG , Vogt RL , Watkins AK , Weiss JR , Williams IT , Cronquist A . J Food Prot 2012 75 (10) 1759-65 In 2010, 41 patients ill with Escherichia coli O157:H7 isolates determined to be indistinguishable by pulsed-field gel electrophoresis were identified among residents of five Southwestern U.S. states. A majority of patients reported consuming complimentary samples of aged raw-milk Gouda cheese at national warehouse chain store locations; sampling Gouda cheese was significantly associated with illness (odds ratio, 9.0; 95 % confidence interval, 1.7 to 47). Several Gouda samples yielded the O157:H7 outbreak strain, confirming the food vehicle and source of infections. Implicated retail food-sampling operations were inconsistently regulated among affected states, and sanitation deficiencies were common among sampling venues. Inspection of the cheese manufacturer indicated deficient sanitation practices and insufficient cheese curing times. Policymakers should continue to reexamine the adequacy and enforcement of existing rules intended to ensure the safety of raw-milk cheeses and retail food sampling. Additional research is necessary to clarify the food safety hazards posed to patrons who consume free food samples while shopping. |
Genetic diversity among Clostridium botulinum strains harboring bont/A2 and bont/A3 genes.
Luquez C , Raphael BH , Joseph LA , Meno SR , Fernandez RA , Maslanka SE . Appl Environ Microbiol 2012 78 (24) 8712-8 Clostridium botulinum type A strains are known to be genetically diverse and widespread throughout the world. Genetic diversity studies have focused mainly on strains harboring one type A botulinum toxin gene, bont/A1, although all reported bont/A gene variants have been associated with botulism cases. Our study provides insight into the genetic diversity of C. botulinum type A strains which contain bont/A2 (N=42) and bont/A3 (N=4) isolated from diverse samples and geographic origins. Genetic diversity was assessed using bont nucleotide sequencing, content analysis of the bont gene clusters, multi-locus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE). Sequences of bont genes obtained in this study showed 99.9-100% identity with other bont/A2 or bont/A3 gene sequences available in public databases. The neurotoxin gene clusters of the A2 and A3 strains analyzed in this study were similar in gene content. C. botulinum strains harboring bont/A2 and bont/A3 genes were divided into six and two MLST profiles, respectively. Four groups of strains shared a similarity of at least 95% by PFGE; the largest group included 21 out of 46 strains. The strains analyzed in this study showed relatively limited genetic diversity using either MLST or PFGE. |
Opportunities and challenges associated with clinical diagnostic genome sequencing: a report of the association for molecular pathology
Schrijver I , Aziz N , Farkas DH , Furtado M , Gonzalez AF , Greiner TC , Grody WW , Hambuch T , Kalman L , Kant JA , Klein RD , Leonard DG , Lubin IM , Mao R , Nagan N , Pratt VM , Sobel ME , Voelkerding KV , Gibson JS . J Mol Diagn 2012 14 (6) 525-40 This report of the Whole Genome Analysis group of the Association for Molecular Pathology illuminates the opportunities and challenges associated with clinical diagnostic genome sequencing. With the reality of clinical application of next-generation sequencing, technical aspects of molecular testing can be accomplished at greater speed and with higher volume, while much information is obtained. Although this testing is a next logical step for molecular pathology laboratories, the potential impact on the diagnostic process and clinical correlations is extraordinary and clinical interpretation will be challenging. We review the rapidly evolving technologies; provide application examples; discuss aspects of clinical utility, ethics, and consent; and address the analytic, postanalytic, and professional implications. |
Risk behaviors and STI prevalence among people with HIV in El Salvador
Paz-Bailey G , Shah N , Creswell J , Guardado M , Nieto A , Estrada M , Cedillos R , Pascale J , Monterroso E . Open AIDS J 2012 6 205-12 To date, there are no studies from El Salvador among people with HIV to inform prevention programs. We conducted a study in El Salvador in 2008 among people with HIV using audio computer-assisted interviews on risk behaviors and access to health care. Blood was tested for syphilis and herpes simplex type 2 (HSV-2). Active syphilis was defined as RPR titer ≥1:8. Genital specimens were tested for other sexually transmitted infections (STI) by PCR. We evaluated factors associated with unprotected sex with last stable partner of HIV-negative or unknown status among those reporting a stable partner. A total of 811 HIV-positive individuals participated: 413 men and 398 women. Prevalence of Chlamydia and gonorrhea was low (≤1%), while prevalence of other STI was high: Mycoplasma genitalium (14%), syphilis (15% seropositivity, active syphilis 3%) and HSV-2 (85%). In multivariate analysis, disclosing HIV status to partner (OR 0.2, 95% CI: 0.1-0.3, p<0.001), participation in HIV support groups (OR 0.3, 95% CI: 0.1-0.8, p=0.01), easy access to condoms (OR 0.4, 95% CI: 0.2-0.9, p=0.04) were protective factors for unprotected sex. Reporting a casual partner in the last 12 months (OR 3.6, 95% CI: 1.5-8.5, p=0.004). and having an STI (OR 2.6, 95% CI:1.3-5.5, p=0.02) were associated with an increased odds of unprotected sex. Prevention interventions among HIV-positives in El Salvador should focus on increasing condom access, promoting HIV disclosure and couples testing and reducing the number of partners. The positive role of support groups should be used to enhance behavioral change. |
WHO recommendations for the viruses to be used in the 2012 Southern Hemisphere Influenza Vaccine: epidemiology, antigenic and genetic characteristics of influenza A(H1N1)pdm09, A(H3N2) and B influenza viruses collected from February to September 2011.
Klimov AI , Garten R , Russell C , Barr IG , Besselaar TG , Daniels R , Engelhardt OG , Grohmann G , Itamura S , Kelso A , McCauley J , Odagiri T , Smith D , Tashiro M , Xu X , Webby R , Wang D , Ye Z , Yuelong S , Zhang W , Cox N . Vaccine 2012 30 (45) 6461-71 In February and September each year the World Health Organisation (WHO) recommends influenza viruses to be included in influenza vaccines for the forthcoming winters in the Northern and Southern Hemispheres respectively. These recommendations are based on data collected by National Influenza Centres (NIC) through the Global Influenza Surveillance and Response System (GISRS) and a more detailed analysis of representative and potential antigenically variant influenza viruses from the WHO Collaborating Centres for Influenza (WHO CCs) and Essential Regulatory Laboratories (ERLs). This article provides a detailed summary of the antigenic and genetic properties of viruses and additional background data used by WHO experts during development of the recommendations for the 2012 Southern Hemisphere influenza vaccine composition. |
Removing the age restrictions for rotavirus vaccination: a benefit-risk modeling analysis
Patel MM , Clark AD , Sanderson CF , Tate J , Parashar UD . PLoS Med 2012 9 (10) e1001330 BACKGROUND: To minimize potential risk of intussusception, the World Health Organization (WHO) recommended in 2009 that rotavirus immunization should be initiated by age 15 weeks and completed before 32 weeks. These restrictions could adversely impact vaccination coverage and thereby its health impact, particularly in developing countries where delays in vaccination often occur. METHODS AND FINDINGS: We conducted a modeling study to estimate the number of rotavirus deaths prevented and the number of intussusception deaths caused by vaccination when administered on the restricted schedule versus an unrestricted schedule whereby rotavirus vaccine would be administered with DTP vaccine up to age 3 years. Countries were grouped on the basis of child mortality rates, using WHO data. Inputs were estimates of WHO rotavirus mortality by week of age from a recent study, intussusception mortality based on a literature review, predicted vaccination rates by week of age from USAID Demographic and Health Surveys, the United Nations Children's Fund (UNICEF) Multiple Indicator Cluster Surveys (MICS), and WHO-UNICEF 2010 country-specific coverage estimates, and published estimates of vaccine efficacy and vaccine-associated intussusception risk. On the basis of the error estimates and distributions for model inputs, we conducted 2,000 simulations to obtain median estimates of deaths averted and caused as well as the uncertainty ranges, defined as the 5th-95th percentile, to provide an indication of the uncertainty in the estimates. We estimated that in low and low-middle income countries a restricted schedule would prevent 155,800 rotavirus deaths (5th-95th centiles, 83,300-217,700) while causing potentially 253 intussusception deaths (76-689). In contrast, vaccination without age restrictions would prevent 203,000 rotavirus deaths (102,000-281,500) while potentially causing 547 intussusception deaths (237-1,160). Thus, removing the age restrictions would avert an additional 47,200 rotavirus deaths (18,700-63,700) and cause an additional 294 (161-471) intussusception deaths, for an incremental benefit-risk ratio of 154 deaths averted for every death caused by vaccine. These extra deaths prevented under an unrestricted schedule reflect vaccination of an additional 21%-25% children, beyond the 63%-73% of the children who would be vaccinated under the restricted schedule. Importantly, these estimates err on the side of safety in that they assume high vaccine-associated risk of intussusception and do not account for potential herd immunity or non-fatal outcomes. CONCLUSIONS: Our analysis suggests that in low- and middle-income countries the additional lives saved by removing age restrictions for rotavirus vaccination would far outnumber the potential excess vaccine-associated intussusception deaths. Please see later in the article for the Editors' Summary. |
Immunogenicity and safety of a new meningococcal A conjugate vaccine in Indian children aged 2-10 years: a phase II/III double-blind randomized controlled trial
Hirve S , Bavdekar A , Pandit A , Juvekar S , Patil M , Preziosi MP , Tang Y , Marchetti E , Martellet L , Findlow H , Elie C , Parulekar V , Plikaytis B , Borrow R , Carlone G , Kulkarni PS , Goel A , Suresh K , Beri S , Kapre S , Jadhav S , Preaud JM , Viviani S , Laforce FM . Vaccine 2012 30 (45) 6456-60 This study compares the immunogenicity and safety of a single dose of a new meningococcal A conjugate vaccine (PsA-TT, MenAfriVac, Serum Institute of India Ltd., Pune) against the meningococcal group A component of a licensed quadrivalent meningococcal polysaccharide vaccine (PsACWY, Mencevax ACWY((R)), GSK, Belgium) 28 days after vaccination in Indian children. This double-blind, randomized, controlled study included 340 Indian children aged 2-10 years enrolled from August to October 2007; 169 children received a dose of PsA-TT while 171 children received a dose of PsACWY. Intention-to-treat analysis showed that 95.2% of children in PsA-TT group had a ≥4-fold response in serum bactericidal titers (rSBA) 28 days post vaccination as compared to 78.2% in the PsACWY group. A significantly higher rSBA GMT (11,209, 95%CI 9708-12,942) was noted in the PsA-TT group when compared to PsACWY group (2838, 95%CI 2368-3401). Almost all children in both vaccine groups had a ≥4-fold response in group A-specific IgG concentration but the IgG GMC was significantly greater in the PsA-TT group (89.1mug/ml, 95%CI 75.5-105.0) when compared to the PsACWY group (15.3mug/ml, 95%CI 12.3-19.2). Local and systemic reactions during the 4 days after immunization were similar for both vaccine groups except for tenderness (30.2% in PsA-TT group vs 12.3% in PsACWY group). None of the adverse events or serious adverse events was related to the study vaccines. We conclude that MenAfriVac is well tolerated and significantly more immunogenic when compared to a licensed polysaccharide vaccine, in 2-to-10-year-old Indian children. |
Adverse events following a third dose of measles, mumps, and rubella vaccine in a mumps outbreak
Abedi GR , Mutuc JD , Lawler J , Leroy ZC , Hudson JM , Blog DS , Schulte CR , Rausch-Phung E , Ogbuanu IU , Gallagher K , Kutty PK . Vaccine 2012 30 (49) 7052-8 During a 2009-2010 mumps outbreak in a New York State village, a third dose of measles, mumps, and rubella (MMR) vaccine was administered to children in three schools as a control measure. Information on local and systemic adverse events (AE) was collected by a self-report survey distributed to all children in grades 6-12. A comprehensive search for AE following MMR vaccination was conducted using physician records and the Vaccine Adverse Events Reporting System (VAERS). A literature search was performed for published reports pertaining to AE associated with mumps-containing vaccine, using the Jeryl-Lynn strain, from 1969 to 2011. A total of 1755 individuals received the third dose; 1597 (91.0%) returned the survey. Of those, 115 (7.2%) reported at least one local or systemic AE in the 2 weeks following vaccination. The most commonly reported AE were "pain, redness, or swelling at the injection site" (3.6%) and "joint or muscle aches" (1.8%). No serious AE were reported in the survey, physician records or through VAERS. The proportions of AE found in the present study were lower than or within the range of those reported in prior studies of first- and second-dose MMR vaccine studies. The results of this study suggest that a third dose of MMR vaccine administered in an outbreak setting is safe, with injection site reactions reported more frequently than systemic reactions. However, to assess risk for rare or serious AE after a third dose of MMR vaccine, longer term studies would be required. |
Detection of anti-yellow fever virus immunoglobulin M antibodies at 3-4 years following yellow fever vaccination
Gibney KB , Edupuganti S , Panella AJ , Kosoy OI , Delorey MJ , Lanciotti RS , Mulligan MJ , Fischer M , Staples JE . Am J Trop Med Hyg 2012 87 (6) 1112-5 The duration of anti-yellow fever (YF) virus immunoglobulin M (IgM) antibodies following YF vaccination is unknown, making it difficult to interpret positive IgM antibody results in previously vaccinated travelers. We evaluated the frequency and predictors of YF IgM antibody positivity 3-4 years following YF vaccination. Twenty-nine (73%) of 40 participants had YF IgM antibodies 3-4 years postvaccination. No demographic or exposure variables were predictive of YF IgM positivity. However, persons who were YF IgM positive at 3-4 years postvaccination had earlier onset viremia and higher neutralizing antibody geometric mean titers at 1 month and 3-4 years postvaccination compared with persons who were YF IgM negative. Detection of YF IgM antibodies several years postvaccination might reflect remote YF vaccination rather than recent YF vaccination or YF virus infection. |
Detection of pathogenic Leptospira spp. through real-time PCR (qPCR) targeting the LipL32 gene.
Stoddard RA . Methods Mol Biol 2013 943 257-66 Rapid diagnosis of leptospirosis, through culture and/or serology, can be difficult without proper expertise and is often delayed due to the length of time required to obtain results. Polymerase chain reaction (PCR), more specifically the real-time detection of the amplified PCR product, is a methodology that can provide a diagnosis in a timelier manner compared to culture and serology. There are a limited number of real-time PCR (qPCR) assays for detecting Leptospira and not all of these assays are able to distinguish pathogenic from nonpathogenic species. In addition, there are a variety of probe technologies and qPCR instruments that are utilized with these assays. This chapter presents a qPCR assay that targets lipL32, a gene which is present only in pathogenic Leptospira spp. This assay utilizes a TaqMan probe and instructions for use on either the Lightcycler 1.2 (Roche Diagnostics, Indianapolis, IN) or the ABI 7500 (Applied Biosystems, Foster City, CA) are provided. |
Multi-platform comparison of ten commercial master mixes for probe-based real-time polymerase chain reaction detection of bioterrorism threat agents for surge preparedness.
Buzard GS , Baker D , Wolcott MJ , Norwood DA , Dauphin LA . Forensic Sci Int 2012 223 292-7 The Centers for Disease Control and Prevention and United States Army Research Institute for Infectious Diseases have developed real-time PCR assays for the detection of bioterrorism threat agents. These assays all rely on a limited number of approved real-time PCR master mixes. Because the availability of these reagents is a critical element of bioterrorism preparedness, we undertook a joint national preparedness exercise to address the potential surge needs resulting from a large-scale bio-emergency. We identified 9 commercially-available potential alternatives to an existing approved master mix (LightCycler FastStart DNA Master HybProbes): the TaqMan Fast Universal PCR master mix, OmniMix HS, FAST qPCR master mix, EXPRESS qPCR SuperMix kit, QuantiFast Probe PCR kit, LightCycler FastStart DNA Master(PLUS) HybProbe, Brilliant II FAST qPCR master mix, ABsolute Fast QPCR Mix and the HotStart IT Taq master mix. The performances of these kits were evaluated by the use of real-time PCR assays for four bioterrorism threat agents: Bacillus anthracis, Brucella melitensis, Burkholderia mallei and Francisella tularensis. The master mixes were compared for target-specific detection levels, as well as consistency of results among three different real-time PCR platforms (LightCycler, SmartCycler and 7500 Fast Dx). Real-time PCR analysis revealed that all ten kits performed well for agent detection on the 7500 Fast Dx instrument; however, the QuantiFast Probe PCR kit yielded the most consistently positive results across multiple real-time PCR platforms. We report that certain combinations of commonly used master mixes and instruments are not as reliable as others at detecting low concentrations of target DNA. Furthermore, our study provides laboratories the option to select from the commercial kits we evaluated to suit their preparedness needs. |
Detection of Mycoplasma pneumoniae by real-time PCR.
Winchell JM , Mitchell SL . Methods Mol Biol 2013 943 149-58 Mycoplasma pneumoniae is a significant cause of respiratory disease, accounting for approximately 20% of cases of community-acquired pneumonia. Although several diagnostic methods exist to detect M. pneumoniae in respiratory specimens, real-time PCR has emerged as a significant improvement for the rapid diagnosis of this pathogen. The method described herein details the procedure for the detection of M. pneumoniae by real-time PCR (qPCR). The qPCR assay described can be performed with three targets specific for M. pneumoniae (Mp181, Mp3, and Mp7) and one marker for the detection of the RNaseP gene found in human nucleic acid as an internal control reaction. Recent studies have demonstrated the ability of this procedure to reliably identify this agent and facilitate the timely recognition of an outbreak. |
Utilization of multiple real-time PCR assays for the diagnosis of Bordetella spp. in clinical specimens.
Tatti KM , Tondella ML . Methods Mol Biol 2013 943 135-47 Bordetella pertussis causes an upper respiratory infection in infants, adolescents, and adults. Diagnosis of pertussis, a vaccine-preventable disease, can be difficult, but recent implementation of real-time PCR assays in laboratories has hastened the ability of clinicians to make an accurate diagnosis. In this paper we describe the method of nasopharyngeal specimen collection, extraction of DNA, and real-time PCR assays that will allow the detection and identification of Bordetella spp. in clinical specimens. |
Species identification of invasive yeasts including Candida in Pakistan: limitations of phenotypic methods
Farooqi J , Jabeen K , Saeed N , Zafar A , Brandt ME , Hasan R . J Pak Med Assoc 2012 62 (10) 995-998 OBJECTIVE: To compare phenotypic and genotypic methods of yeast identification. METHODS: The in-vitro cross-sectional study was conducted from January 2006 to May 2009. Invasive yeasts isolated at the clinical microbiology laboratory at the Aga Khan University (AKU), Karachi, Pakistan, were identified. Speciation by phenotypic and molecular methods was compared. All yeasts isolated during the study period from blood and other invasive sites were identified using standard methods. Isolates were shipped to Mycotic Diseases Branch, Centres for Disease Control and Prevention, Atlanta, Georgia, USA, for identification by Luminex flow cytometric multianalyte profiling (xMAP) system. Ribosomal ITS2 DNA sequencing was performed on isolates not identified by Luminex. RESULT: Of the 214 invasive yeasts evaluated, Candida species were 209 (97.7%) while the frequency of non-Candida species was 5 (2.3%). Overall agreement between phenotypic and molecular identification was 81.3%, 90.3% amongst the more common Candida species, and only 38.8% amongst the uncommon yeasts. CONCLUSION: Phenotypic methods of identification proved adequate for common Candida species, but were deficient in recognising rare Candida and non-Candida yeasts, highlighting the importance of molecular methods for identification. |
Miniature dual-corona ionizer for bipolar charging of aerosol
Qi C , Kulkarni P . Aerosol Sci Technol 2012 47 (1) 81-92 A corona-based bipolar charger has been developed for use in compact, field-portable mobility size spectrometers. The charger employs an aerosol flow cavity exposed to two corona ionizers producing ions of opposite polarity. Each corona ionizer houses two electrodes in parallel needle-mesh configuration and is operated at the same magnitude of corona current. Experimental measurement of detailed charge distribution of near-monodisperse particles of different diameter in the submicrometer size range showed that the charger is capable of producing well-defined, consistent bipolar charge distributions for flow rates up to 1.5 L/min and aerosol concentration up to 107 per cm(3). For particles with pre-existing charge of +1, 0, and -1, the measured charge distributions agreed well with the theoretical distributions within the range of experimental and theoretical uncertainties. The transmission efficiency of the charger was measured to be 80% for 10 nm particles (at 0.3 L/min and 5 micro Amp corona current) and increased with increasing diameter beyond this size. Measurement of uncharged fractions at various combinations of positive and negative corona currents showed the charger performance to be insensitive to fluctuations in corona current. Ion concentrations under positive and negative unipolar operation were estimated to be 8.2 x 10(7)and 3.37 x 10(8)cm(-3)for positive and negative ions; the n·t product value under positive corona operation was independently stimated to be 8.5 x 10(5) s/cm(3). The ion concentration estimates indicate the charger to be capable of "neutralizing" typical atmospheric and industrial aerosols in most measurement applications. The miniature size, simple and robust operation makes the charger suitable for portable mobility spectrometers. |
Optimization of a small tropomyosin-related kinase B (TrkB) agonist 7,8-dihydroxyflavone active in mouse models of depression
Liu X , Chan CB , Qi Q , Xiao G , Luo HR , He X , Ye K . J Med Chem 2012 55 (19) 8524-37 Structure-activity relationship study shows that the catechol group in 7,8-dihdyroxyflavone, a selective small TrkB receptor agonist, is critical for agonistic activity. To improve the poor pharmacokinetic profiles intrinsic to catechol-containing molecules and to elevate the agonistic effect of the lead compound, we initiated the lead optimization campaign by synthesizing various bioisosteric derivatives. Here we show that the optimized 2-methyl-8-(4'-(pyrrolidin-1-yl)phenyl)chromeno[7,8-d]imidazol-6(1H)-one derivative possesses enhanced TrkB stimulatory activity. Chronic oral administration of this compound significantly reduces the immobility in forced swim test and tail suspension test, two classical antidepressant behavioral animal models, which is accompanied by robust TrkB activation in hippocampus of mouse brain. Further, in vitro ADMET studies demonstrate that this compound possesses the improved features compared to the previous lead compound. Hence, this optimized compound may act as a promising lead candidate for in-depth drug development for treating various neurological disorders including depression. |
Organic and elemental carbon filter sets: preparation method and interlaboratory results
Chai M , Birch ME , Deye G . Ann Occup Hyg 2012 56 (8) 959-67 Carbonaceous aerosols play an important role in climate, visibility, air quality, and human health effects, and they have been routinely monitored in workplace and environmental settings. Different thermal analysis methods have been applied to determine the carbon content of carbonaceous aerosols. Good agreement between results for total carbon (TC) generally has been found, but the organic and elemental carbon (OC and EC) fractions determined by different methods often disagree. Measurement uncertainty is mainly due to pyrolysis and charring of OC sample components. Lack of reference materials has impeded progress on method standardization and understanding method biases. A relatively simple method for generating matched filter sets having known OC-EC contents is reported. After generation and analysis of each set to confirm agreement between filters, the filter sets were distributed to six laboratories for an interlaboratory comparison. Analytical results indicate a uniform carbon distribution for the filter sets and good agreement between the participating laboratories. Relative standard deviations (RSDs) for mean TC (OC + EC), OC, and EC results for seven laboratories were <10, 11, and 12% (respectively). Except for one EC result (RSD = 16%), RSDs reported by individual laboratories for TC, OC, and EC were <12%. The method of filter generation is generally applicable and reproducible. Depending on the application, different filter loadings and types of OC materials can be employed. Matched filter sets prepared by the described approach can be used for determining the accuracy of OC-EC methods and thereby contribute to method standardization. |
Endolysins of Bacillus anthracis bacteriophages recognize unique carbohydrate epitopes of vegetative cell wall polysaccharides with high affinity and selectivity
Mo KF , Li X , Li H , Low LY , Quinn CP , Boons GJ . J Am Chem Soc 2012 134 (37) 15556-62 Bacteriophages express endolysins which are the enzymes that hydrolyze peptidoglycan resulting in cell lysis and release of bacteriophages. Endolysins have acquired stringent substrate specificities, which have been attributed to cell wall binding domains (CBD). Although it has been realized that CBDs of bacteriophages that infect Gram-positive bacteria target cell wall carbohydrate structures, molecular mechanisms that confer selectivity are not understood. A range of oligosaccharides, derived from the secondary cell wall polysaccharides of Bacillus anthracis, has been chemically synthesized. The compounds contain an alpha-d-GlcNAc-(1-->4)-beta-d-ManNAc-(1-->4)-beta-d-GlcNAc backbone that is modified by various patterns of alpha-d-Gal and beta-d-Gal branching points. The library of compounds could readily be prepared by employing a core trisaccharide modified by the orthogonal protecting groups N(alpha)-9-fluorenylmethyloxycarbonate (Fmoc), 2-methylnaphthyl ether (Nap), levulinoyl ester (Lev) and dimethylthexylsilyl ether (TDS) at key branching points. Dissociation constants for the binding the cell wall binding domains of the endolysins PlyL and PlyG were determined by surface plasmon resonance (SPR). It was found that the pattern of galactosylation greatly influenced binding affinities, and in particular a compound having a galactosyl moiety at C-4 of the nonreducing GlcNAc moiety bound in the low micromolar range. It is known that secondary cell wall polysaccharides of various bacilli may have both common and variable structural features and in particular differences in the pattern of galactosylation have been noted. Therefore, it is proposed that specificity of endolysins for specific bacilli is achieved by selective binding to a uniquely galactosylated core structure. |
Impairment of coronary arteriolar endothelium-dependent dilation after multi-walled carbon nanotube inhalation: a time-course study
Stapleton P , Minarchick V , Cumpston A , McKinney W , Chen B , Sager T , Frazer D , Mercer R , Scabilloni J , Andrew M , Castranova V , Nurkiewicz T . Int J Mol Sci 2012 13 (11) 13781-13803 Engineered nanomaterials have been developed for widespread applications due to many highly unique and desirable characteristics. The purpose of this study was to assess pulmonary inflammation and subepicardial arteriolar reactivity in response to multi-walled carbon nanotube (MWCNT) inhalation and evaluate the time course of vascular alterations. Rats were exposed to MWCNT aerosols producing pulmonary deposition. Pulmonary inflammation via bronchoalveolar lavage and MWCNT translocation from the lungs to systemic organs was evident 24 h post-inhalation. Coronary arterioles were evaluated 24-168 h post-exposure to determine microvascular response to changes in transmural pressure, endothelium-dependent and -independent reactivity. Myogenic responsiveness, vascular smooth muscle reactivity to nitric oxide, and a-adrenergic responses all remained intact. However, a severe impact on endothelium-dependent dilation was observed within 24 h after MWCNT inhalation, a condition which improved, but did not fully return to control after 168 h. In conclusion, results indicate that MWCNT inhalation not only leads to pulmonary inflammation and cytotoxicity at low lung burdens, but also a low level of particle translocation to systemic organs. MWCNT inhalation also leads to impairments of endothelium-dependent dilation in the coronary microcirculation within 24 h, a condition which does not fully dissipate within 168 h. The innovations within the field of nanotechnology, while exciting and novel, can only reach their full potential if toxicity is first properly assessed. |
Interlaboratory standardization of the sandwich enzyme-linked immunosorbent assay designed for MATS, a rapid, reproducible method for estimating the strain coverage of investigational vaccines
Plikaytis BD , Stella M , Boccadifuoco G , Detora LM , Agnusdei M , Santini L , Brunelli B , Orlandi L , Simmini I , Giuliani M , Ledroit M , Hong E , Taha MK , Ellie K , Rajam G , Carlone GM , Claus H , Vogel U , Borrow R , Findlow J , Gilchrist S , Stefanelli P , Fazio C , Carannante A , Oksnes J , Fritzsonn E , Klem AM , Caugant DA , Abad R , Vazquez JA , Rappuoli R , Pizza M , Donnelly JJ , Medini D . Clin Vaccine Immunol 2012 19 (10) 1609-17 The meningococcal antigen typing system (MATS) sandwich enzyme-linked immunosorbent assay (ELISA) was designed to measure the immunologic cross-reactivity and quantity of antigens in target strains of a pathogen. It was first used to measure the factor H-binding protein (fHbp), neisserial adhesin A (NadA), and neisserial heparin-binding antigen (NHBA) content of serogroup B meningococcal (MenB) isolates relative to a reference strain, or "relative potency" (RP). With the PorA genotype, the RPs were then used to assess strain coverage by 4CMenB, a multicomponent MenB vaccine. In preliminary studies, MATS accurately predicted killing in the serum bactericidal assay using human complement, an accepted correlate of protection for meningococcal vaccines. A study across seven laboratories assessed the reproducibility of RPs for fHbp, NadA, and NHBA and established qualification parameters for new laboratories. RPs were determined in replicate for 17 MenB reference strains at laboratories A to G. The reproducibility of RPs among laboratories and against consensus values across laboratories was evaluated using a mixed-model analysis of variance. Interlaboratory agreement was very good; the Pearson correlation coefficients, coefficients of accuracy, and concordance correlation coefficients exceeded 99%. The summary measures of reproducibility, expressed as between-laboratory coefficients of variation, were 7.85% (fHbp), 16.51% (NadA), and 12.60% (NHBA). The overall within-laboratory measures of variation adjusted for strain and laboratory were 19.8% (fHbp), 28.8% (NHBA), and 38.3% (NadA). The MATS ELISA was successfully transferred to six laboratories, and a further laboratory was successfully qualified. |
Additional diagnostic yield of adding serology to PCR in diagnosing viral acute respiratory infections in Kenyan patients 5 years of age and older
Feikin DR , Njenga MK , Bigogo G , Aura B , Gikunju S , Balish A , Katz MA , Erdman D , Breiman RF . Clin Vaccine Immunol 2012 20 (1) 113-4 The role of serology in the setting of PCR-based diagnosis of acute respiratory infections (ARI) is unclear. We found acute- and convalescent-phase paired serologic testing increased the diagnostic yield beyond PCR of naso/oropharyngeal swabs for influenza virus, RSV, human metapneumovirus, adenovirus and parainfluenza viruses, by 0.4%-10.7%. Although still limited for clinical use, serology, along with PCR, can maximize etiologic diagnosis in epidemiologic studies. |
Brain organochlorines and Lewy pathology: the Honolulu-Asia Aging Study
Ross GW , Duda JE , Abbott RD , Pellizzari E , Petrovitch H , Miller DB , O'Callaghan JP , Tanner CM , Noorigian JV , Masaki K , Launer L , White LR . Mov Disord 2012 27 (11) 1418-24 Although organochlorines have been reported more frequently in Parkinson's disease (PD) brains than in controls, the association with brain Lewy pathology is unknown. Honolulu-Asia Aging Study (HAAS) participants, exposed to organochlorines from a variety of sources during midlife, represent a population well suited to determining the relationship of brain organochlorines with Lewy pathology in decedents from the longitudinal HAAS. The study design included the measurement of 21 organochlorine levels in frozen occipital lobe samples from HAAS decedents. Alpha-synuclein immunostaining performed on 225 brains was used to identify Lewy bodies and Lewy neurites. With the potential for spurious associations to appear between Lewy pathology and 17 organochlorine compounds found in at least 1 brain, initial assessments identified heptachlor epoxide isomer b, methoxychlor, and benzene hexachloride b as being most important. The prevalence of Lewy pathology was 75% (6 of 8) among brains with any 2 of the 3 compounds, 48.8% (79 of 162) among those with 1, and 32.7% (18 of 55) for those with neither (P = .007 test for trend). Although findings persisted after removing cases with PD and dementia with Lewy bodies and after adjustment for age at death, body mass index, pack-years of cigarette smoking, and coffee intake (P = .013), the results were insignificant when correcting for multiple testing. Although consistent with earlier accounts of an association between organochlorines and clinical PD, associations with Lewy pathology warrant further study. ((c) 2012 Movement Disorder Society.) |
Characterization of Corynebacterium species in macaques
Venezia J , Cassiday PK , Marini RP , Shen Z , Buckley EM , Peters Y , Taylor N , Dewhirst FE , Tondella ML , Fox JG . J Med Microbiol 2012 61 1401-8 Bacteria of the genus Corynebacterium are important primary and opportunistic pathogens. Many are zoonotic agents. In this report, phenotypic (API Coryne analysis), genetic (rpoB and 16S rRNA gene sequencing), and physical methods (MS) were used to distinguish the closely related diphtheroid species Corynebacterium ulcerans and Corynebacterium pseudotuberculosis, and to definitively diagnose Corynebacterium renale from cephalic implants of rhesus (Macaca mulatta) and cynomolgus (Macaca fascicularis) macaques used in cognitive neuroscience research. Throat and cephalic implant cultures yielded 85 isolates from 43 macaques. Identification by API Coryne yielded C. ulcerans (n = 74), Corynebacterium pseudotuberculosis (n = 2), C. renale or most closely related to C. renale (n = 3), and commensals and opportunists (n = 6). The two isolates identified as C. pseudotuberculosis by API Coryne required genetic and MS analysis for accurate characterization as C. ulcerans. Of three isolates identified as C. renale by 16S rRNA gene sequencing, only one could be confirmed as such by API Coryne, rpoB gene sequencing and MS. This study emphasizes the importance of adjunct methods in identification of coryneforms and is the first isolation of C. renale from cephalic implants in macaques. |
Severe maternal morbidity among delivery and postpartum hospitalizations in the United States
Callaghan WM , Creanga AA , Kuklina EV . Obstet Gynecol 2012 120 (5) 1029-36 OBJECTIVES: To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009. METHODS: Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998-2009. International Classification of Diseases, 9 Revision codes indicating severe complications were used to identify hospitalizations with severe maternal morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data. RESULTS: Severe morbidity rates for delivery and postpartum hospitalizations for the 2008-2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998-1999 period, severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P<.05). CONCLUSIONS: Severe maternal morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe maternal morbidity can provide an opportunity to identify points of intervention for quality improvement in maternal care. LEVEL OF EVIDENCE: III. |
Legacy for Children
Perou R , Elliott MN , Visser SN , Claussen AH , Scott KG , Beckwith LH , Howard J , Katz LF , Smith C . BMC Public Health 2012 12 (1) 691 BACKGROUND: One in five Americans under age 18 lives in a family below the Federal poverty threshold. These more than 15 million children are at increased risk of a wide variety of adverse long-term health and developmental outcomes. The early years of life are critical to short- and long-term health and well-being. The Legacy for Children(TM) model was developed in response to this need and marries the perspectives of epidemiology and public health to developmental psychology theory in order to better address the needs of children at environmental risk for poor developmental outcomes. METHODS/DESIGN: The Legacy for Children(TM) group-based parenting intervention model was evaluated as a pair of randomized controlled trials among low-income families in Miami and Los Angeles. The study was designed to allow for site-stratified analysis in order to evaluate each model implementation separately. Evaluation domains include comprehensive assessments of family, maternal, and child characteristics, process outcomes, and prospective programmatic cost. Data collection began prenatally or at birth and continues into school-age. DISCUSSION: The societal costs of poor developmental outcomes are substantial. A concerted effort from multiple sectors and disciplines, including public health, is necessary to address these societal concerns. Legacy uses a public health model to engage parents and promote overall child well-being in families in poverty through rigorous evaluation methodologies and evidence-based intervention strategies. This study collects rich and modular information on maternal and child outcomes, process, and cost that will enable a detailed understanding of how Legacy works, how it can be refined and improved, and how it can be translated and disseminated. Taken together, these results will inform public policy and help to address issues of health disparities among at-risk populations. TRIAL REGISTRATION: NCT00164697. |
Modelling fortification of corn masa flour with folic acid and the potential impact on Mexican-American women with lower acculturation
Hamner HC , Tinker SC , Flores AL , Mulinare J , Weakland AP , Dowling NF . Public Health Nutr 2012 16 (5) 1-9 OBJECTIVE: Hispanics with lower acculturation may be at higher risk for neural tube defects compared with those with higher acculturation due to lower total folic acid intake or other undetermined factors. Modelling has indicated that fortification of corn masa flour with folic acid could selectively target Mexican Americans more than other race/ethnicities. We assessed whether fortification of corn masa flour with folic acid could selectively increase folic acid intake among Mexican-American women with lower acculturation, as indicated by specific factors (language preference, country of origin, time living in the USA). DESIGN: We used dietary intake and dietary supplement data from the National Health and Nutrition Examination Survey 2001-2008, to estimate the amount of additional total folic acid that could be consumed if products considered to contain corn masa flour were fortified at 140 mcg of folic acid per 100 g of corn masa flour. SETTING: USA. SUBJECTS: Non-pregnant women aged 15-44 years (n 5369). RESULTS: Mexican-American women who reported speaking Spanish had a relative percentage change in usual daily total folic acid intake of 30.5 (95 % CI 27.8, 33.4) %, compared with 8.3 (95 % CI 7.3, 9.4) % for Mexican-American women who reported speaking English. We observed similar results for other acculturation factors. An increase of 6.0 percentage points in the number of Mexican-American women who would achieve the recommended intake of ≥400 mcg folic acid/d occurred with fortification of corn masa flour; compared with increases of 1.1 percentage points for non-Hispanic whites and 1.3 percentage points for non-Hispanic blacks. An even greater percentage point increase was observed among Mexican-American women who reported speaking Spanish (8.2). CONCLUSIONS: Fortification of corn masa flour could selectively increase total folic acid intake among Mexican-American women, especially targeting Mexican-American women with lower acculturation, and result in a decrease in the number of pregnancies affected by neural tube defects. |
Febrile illness with papular and vesicular exanthem and ulceronecrotic plaques
Castelo-Soccio LA , Nguyen J , Rubin AI , Paddock CD , Shah KN . Pediatr Dermatol 2012 29 (6) 765-6 An 11-year-old Caucasian boy presented to our dermatology clinic with a 1-year history of a mildly pru-ritic, scaly, erythematous, edematous plaque involving the entire penis and scrotum. Potassium hydroxide preparation was negative for fungi. Clinical impression at that time was psoriasis, and he improved somewhat with topical corticosteroids, but over the next 2 years, he developed more nontender edema and erythema of the scrotum and the penis. He remained otherwise healthy without any fever, chills, or weight loss. Family history was positive for psoriasis and eczema. Physical examination of the groin and genitalia revealed scrotal and penile edema and erythema without increased warmth or signs of infection. Overlying the erythema were multiple scaly papules extending from the distal shaft of the penis to the scrotum and then under the raphe and up the gluteal cleft (Figs. 1 and 2). The rest of skin examination was unremarkable. A 4-mm punch biopsy of the scrotum was performed. The histopathologic features are illustrated in Figs. 3 and 4. |
Cytokines and posthemorrhagic ventricular dilation in premature infants
Ambalavanan N , Carlo WA , McDonald SA , Das A , Schendel DE , Thorsen P , Hougaard DM , Skogstrand K , Higgins RD . Am J Perinatol 2012 29 (9) 731-740 OBJECTIVE: To determine in extremely low-birth-weight infants if elevated blood interferon-gamma (IFN-gamma), interleukin (IL)-1beta, IL-18, tumor necrosis factor-alpha (TNF-alpha), and transforming growth factor-beta are associated with need for shunt following severe intraventricular hemorrhage (IVH) or with ventricular dilation following milder grades/no IVH. STUDY DESIGN: Whole blood cytokines were measured on postnatal days 1, 3, 7, 14, and 21. Maximum IVH grade in the first 28 days, and shunt surgery or ventricular dilation on subsequent ultrasound (28 days' to 36 weeks' postmenstrual age) were determined. RESULTS: Of 902 infants in the National Institute of Child Health and Human Development Neonatal Research Network Cytokine study who survived to 36 weeks or discharge, 3.1% had shunts. Of the 12% of infants with severe (grade III to IV) IVH, 26% had a shunt associated with elevated TNF-alpha. None of the infants without IVH (69%) or with grade I (12%) or II (7%) IVH received shunts, but 8.4% developed ventricular dilation, associated with lower IFN-gamma and higher IL-18. CONCLUSION: Statistically significant but clinically nondiscriminatory alterations in blood cytokines were noted in infants with severe IVH who received shunts and in those without severe IVH who developed ventricular dilation. Blood cytokines are likely associated with brain injury but may not be clinically useful as biomarkers for white matter damage. |
The relationship of perceptions of tap water safety with intake of sugar-sweetened beverages and plain water among US adults
Onufrak SJ , Park S , Sharkey JR , Sherry B . Public Health Nutr 2012 17 (1) 1-7 OBJECTIVE: Research is limited on whether mistrust of tap water discourages plain water intake and leads to a greater intake of sugar-sweetened beverages (SSB). The objective of the present study was to examine demographic differences in perceptions of tap water safety and determine if these perceptions are associated with intake of SSB and plain water. DESIGN: The study examined perceptions of tap water safety and their cross-sectional association with intake of SSB and plain water. Racial/ethnic differences in the associations of tap water perceptions with SSB and plain water intake were also examined. SETTING: Nationally weighted data from the 2010 HealthStyles Survey (n 4184). SUBJECTS: US adults aged ≥18 years. RESULTS: Overall, 13.0% of participants disagreed that their local tap water was safe to drink and 26.4% of participants agreed that bottled water was safer than tap water. Both mistrust of tap water safety and favouring bottled water differed by region, age, race/ethnicity, income and education. The associations of tap water mistrust with intake of SSB and plain water were modified by race/ethnicity (P < 0.05). Non-white racial/ethnic groups who disagreed that their local tap water was safe to drink were more likely to report low intake of plain water. The odds of consuming ≥1 SSB/d among Hispanics who mistrusted their local tap water was twice that of Hispanics who did not (OR = 2.0; 95% CI 1.2, 3.3). CONCLUSIONS: Public health efforts to promote healthy beverages should recognize the potential impact of tap water perceptions on water and SSB intake among minority populations. |
Let's move salad bars to schools: a public-private partnership to increase student fruit and vegetable consumption
Harris DM , Seymour J , Grummer-Strawn L , Cooper A , Collins B , DiSogra L , Marshall A , Evans N . Child Obes 2012 8 (4) 294-7 Few school-age youth consume the recommended amounts of fruits and vegetables, and increasing fruit and vegetable intake in children and adolescents is an important public health goal to maintain long-term good health and to decrease risk of chronic disease and obesity. School salad bars are an important tool to promote fruit and vegetable consumption among schoolchildren. Studies show that introduction of school salad bars increases the amount and variety of fruits and vegetables consumed by children in schools. However, many schools cannot afford the capital investment in the salad bar equipment. In 2010, the National Fruit & Vegetable Alliance (NFVA), United Fresh Produce Association Foundation, the Food Family Farming Foundation, and Whole Foods Market launched Let's Move Salad Bars to Schools (LMSB2S) in support of First Lady Michelle Obama's Let's Move! initiative. The goal of LMSB2S is to place 6000 salad bars in schools over 3 years. As of June, 2012, over 1400 new salad bar units have been delivered to schools across the United States, increasing access to fruits and vegetables for over 700,000 students. Any K through 12 school district participating in the National School Lunch Program is eligible to submit an application at www.saladbars2schools.org/. Requests for salad bar units ($2625 each unit) are fulfilled through grassroots fund raising in the school community and through funds raised by the LMSB2S partners from corporate and foundation sources. LMSB2S is a model for coalition-building across many government, nonprofit, and industry partners to address a major public health challenge. |
Factors associated with low water intake among US high school students-National Youth Physical Activity and Nutrition Study, 2010
Park S , Blanck HM , Sherry B , Brener N , O'Toole T . J Acad Nutr Diet 2012 112 (9) 1421-7 Drinking plain water instead of sugar-sweetened beverages is one approach for reducing energy intake. Only a few studies have examined characteristics associated with plain water intake among US youth. The purpose of our cross-sectional study was to examine associations of demographic characteristics, weight status, dietary habits, and other behavior-related factors with plain water intake among a nationally representative sample of US high school students. The 2010 National Youth Physical Activity and Nutrition Study data for 11,049 students in grades 9 through 12 were used. Multivariable logistic regression analysis was used to calculate adjusted odds ratios (ORs) and 95% CIs for variables associated with low water intake (<3 times/day). Nationwide, 54% of high school students reported drinking water <3 times/day. Variables significantly associated with a greater odds for low water intake were age ≤15 years (OR 1.1), consuming <2 glasses/day of milk (OR 1.5), nondiet soda ≥1 time/day (OR 1.6), other sugar-sweetened beverages ≥1 time/day (OR 1.4), fruits and 100% fruit juice <2 times/day (OR 1.7), vegetables <3 times/day (OR 2.3), eating at fast-food restaurants 1 to 2 days/week and ≥3 days/week (OR 1.3 and OR 1.4, respectively), and being physically active ≥60 minutes/day on <5 days/week (OR 1.6). Being obese was significantly associated with reduced odds for low water intake (OR 0.7). The findings of these significant associations of low water intake with poor diet quality, frequent fast-food restaurant use, and physical inactivity may be used to tailor intervention efforts to increase plain water intake as a substitute for sugar-sweetened beverages and to promote healthy lifestyles. |
Food insecurity is associated with obesity among US adults in 12 states
Pan L , Sherry B , Njai R , Blanck HM . J Acad Nutr Diet 2012 112 (9) 1403-9 A redesigned food insecurity question that measured food stress was included in the 2009 Behavioral Risk Factor Surveillance System in the Social Context optional module. The objective of our study was to examine the association between food stress and obesity using this question as a surrogate for food insecurity. Our analytic sample included 66,553 adults from 12 states. Food insecurity was determined by response (always/usually/sometimes) to the question, "How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?" T tests were used to compare prevalence differences between groups, and logistic regression was used to examine the association between food insecurity and obesity. Among the 12 states, the prevalence of obesity was 27.1% overall, 25.2% among food secure adults, and 35.1% among food insecure adults. Food insecure adults had 32% increased odds of being obese compared to food secure adults. Compared with food secure adults, food insecure adults had significantly higher prevalence of obesity in the following population subgroups: adults ages ≥30 years, women, non-Hispanic whites, non-Hispanic blacks, adults with some college education or a college degree, a household income of <$25,000 or $50,000 to $74,999, and adults with none or two children in their households. One in three food insecure adults were obese. Food insecurity was associated with obesity in the overall population and most population subgroups. These findings are consistent with previous research and highlight the importance of increasing access to affordable healthy foods for all adults. |
Serial evaluations at an indium-tin oxide production facility
Cummings KJ , Suarthana E , Edwards N , Liang X , Stanton ML , Day GA , Saito R , Kreiss K . Am J Ind Med 2012 56 (3) 300-7 BACKGROUND: We evaluated the effectiveness of workplace changes to prevent indium lung disease, using 2002-2010 surveillance data collected by an indium-tin oxide production facility. METHODS: We assessed pulmonary function using lower limits of normal. Blood indium concentration and personal air sampling data were used to estimate exposure. RESULTS: Abnormalities were uncommon at hire. After hire, prevalence of spirometric restriction was 31% (n = 14/45), about fourfold higher than expected. Excessive decline in FEV1 was elevated at 29% (n = 12/41). Half (n = 21/42) had blood indium ≥5 microg/l. More recent hires had fewer abnormalities. There was a suggestion that abnormalities were more common among workers with blood indium ≥5 microg/l, but otherwise an exposure-response relationship was not evident. Peak dust concentrations were obscured by time averaging. CONCLUSIONS: Evolving lung function abnormalities consistent with subclinical indium lung disease appeared common and merit systematic investigation. Traditional measures of exposure and response were not illustrative, suggesting fresh approaches will be needed. Workplace changes seemed to have had a positive though incomplete impact; novel preventive interventions are warranted. (Am. J. Ind. Med. Published 2012. This article is a U.S. Government work and is in the public domain in the USA.) |
Toward developing a new occupational exposure metric approach for characterization of diesel aerosols
Cauda EG , Ku BK , Miller AL , Barone TL . Aerosol Sci Technol 2012 46 (12) 1370-1381 The extensive use of diesel-powered equipment in mines makes the exposure to diesel aerosols a serious occupational issue. The exposure metric currently used in U.S. underground noncoal mines is based on the measurement of total carbon (TC) and elemental carbon (EC) mass concentration in the air. Recent toxicological evidence suggests that the measurement of mass concentration is not sufficient to correlate ultrafine aerosol exposure with health effects. This urges the evaluation of alternative measurements. In this study, the current exposure metric and two additional metrics, the surface area and the total number concentration, were evaluated by conducting simultaneous measurements of diesel ultrafine aerosols in a laboratory setting. The results showed that the surface area and total number concentration of the particles per unit of mass varied substantially with the engine operating condition. The specific surface area (SSA) and specific number concentration (SNC) normalized with TC varied two and five times, respectively. This implies that miners, whose exposure is measured only as TC, might be exposed to an unknown variable number concentration of diesel particles and commensurate particle surface area. Taken separately, mass, surface area, and number concentration did not completely characterize the aerosols. A comprehensive assessment of diesel aerosol exposure should include all of these elements, but the use of laboratory instruments in underground mines is generally impracticable. The article proposes a new approach to solve this problem. Using SSA and SNC calculated from field-type measurements, the evaluation of additional physical properties can be obtained by using the proposed approach. (Copyright 2012 American Association for Aerosol Research.) |
The Upper Midwest Health Study: gliomas and occupational exposure to chlorinated solvents
Ruder AM , Yiin JH , Waters MA , Carreon T , Hein MJ , Butler MA , Calvert GM , Davis-King KE , Schulte PA , Mandel JS , Morton RF , Reding DJ , Rosenman KD , Stewart PA . Occup Environ Med 2012 70 (2) 73-80 OBJECTIVES: Occupational exposure to chlorinated aliphatic solvents has been associated with an increased cancer risk, including brain cancer. However, many of these solvents remain in active, large-volume use. We evaluated glioma risk from non-farm occupational exposure (ever/never and estimated cumulative exposure) to any of the six chlorinated solvents-carbon tetrachloride, chloroform, methylene chloride, trichloroethylene, tetrachloroethylene or 1,1,1-trichloroethane-among 798 cases and 1175 population-based controls, aged 18-80 years and non-metropolitan residents of Iowa, Michigan, Minnesota and Wisconsin. METHODS: Solvent use was estimated based on occupation, industry and era, using a bibliographic database of published exposure levels and exposure determinants. Unconditional logistic regression was used to calculate ORs adjusted for frequency matching variables age group and sex, and age and education. Additional analyses were limited to 904 participants who donated blood specimens (excluding controls reporting a previous diagnosis of cancer) genotyped for glutathione-S-transferases GSTP1, GSTM3 and GSTT1. Individuals with functional GST genes might convert chlorinated solvents crossing the blood-brain barrier into cytotoxic metabolites. RESULTS: Both estimated cumulative exposure (ppm-years) and ever exposure to chlorinated solvents were associated with decreased glioma risk and were statistically significant overall and for women. In analyses comparing participants with a high probability of exposure with the unexposed, no associations were statistically significant. Solvent-exposed participants with functional GST genes were not at increased risk of glioma. CONCLUSIONS: We observed no associations of glioma risk and chlorinated solvent exposure. Large pooled studies are needed to explore the interaction of genetic pathways and environmental and occupational exposures in glioma aetiology. |
The value of periodic spirometry for early recognition of long-term excessive lung function decline in individuals
Hnizdo E . J Occup Environ Med 2012 54 (12) 1506-12 OBJECTIVE: To establish the value of workplace spirometry monitoring methods for early recognition of long-term excessive lung function decline in individuals. METHODS: Sensitivity, specificity, and positive likelihood ratio were calculated to determine the predictive value of the linear regression slope and limits of longitudinal decline for early prediction of long-term excessive forced expiratory volume in 1 second (FEV1) decline (> 90 mL/yr established over 9 to 11 years) in ongoing spirometry monitoring programs (firefighters and construction workers) and a historical program (paper-pulp mill workers). The longitudinal limits account for the expected FEV1 within-person variability. RESULTS: The longitudinal limits achieved clinical "usefulness" (positive likelihood ratio 10 or higher) from the fourth to fifth year of follow-up, whereas the linear regression slope was less useful. The usefulness depended on data precision and measurement frequency. CONCLUSION: The limits of longitudinal decline are more useful for early recognition of long-term excessive FEV1 decline than the linear regression slope. |
Workplace safety equals patient safety
Spratt D , Cowles CE Jr , Berguer R , Dennis V , Waters TR , Rodriguez M , Spry C , Groah L . AORN J 2012 96 (3) 235-44 For many years, AORN has been a leader in creating a safe environment for the patient in the OR and other procedural areas. Perioperative nurses provide care that adheres to the AORN standards and recommended practices. AORN provides orientation tools like Periop 101: A Core Curriculum™. Collaborations among AORN staff members, member volunteers, and representatives of other organizations have resulted in tool kits to address safety factors such as surgical briefings, time out, and debriefings. | I believe that workplace safety is an integral part of patient safety. There are many pieces to creating a safe work environment, and much work has been done by AORN in cooperation with experts in various fields and health care organizations. Therefore, I have asked my colleagues to discuss a variety of topics related to workplace safety, including fire safety, sharps safety, safe patient handling, and smoke in the OR environment. I have also solicited general discussions on workplace safety in the OR and the sterile processing department and on workplace safety issues from AORN’s perspective. I posed the following question: | From your professional perspective, what work related to workplace safety have we done, and what has been its impact on the surgical team? |
Needlestick injuries among employees at a nationwide retail pharmacy chain, 2000-2011
de Perio MA . Infect Control Hosp Epidemiol 2012 33 (11) 1156-8 We reviewed a nationwide retail pharmacy chain's centralized needlestick injury reports. From 2000 to 2011, 33 needlestick injuries were reported by 31 different pharmacy locations and were likely preventable. The annual incidence of needlestick injuries ranged from 0 to 3.62 per 100,000 vaccinations and ranged from 0 to 5.65 per 1,000 immunizing pharmacists. |
Effects of common agricultural tasks on measures of hearing loss
Humann MJ , Sanderson WT , Gerr F , Kelly KM , Merchant JA . Am J Ind Med 2012 55 (10) 904-16 BACKGROUND: Among agricultural populations, hearing loss caused by excessive noise exposure is common. However, examinations of associations between exposure to agricultural tasks and hearing loss are limited. METHODS: Audiometry and lifetime exposure to 11 agricultural tasks were analyzed among 1,568 participants. Gender stratified multivariable linear regression was used to estimate associations between exposure duration and three hearing loss metrics. RESULTS: Among men, significant associations were observed between hearing loss and hunting or target shooting, all-terrain vehicle (ATV) or motorcycle riding, chain saw use, electric or pneumatic tool use, living on a farm, and all agricultural tasks combined. When all significant exposure metrics were included in a single model, associations remained for hunting or target shooting, electric or pneumatic tool use and living on a farm. Significant associations were sparse among women, and in all cases paradoxical. CONCLUSIONS: Despite imprecise estimation of noise exposure, specific agricultural tasks were associated with hearing loss. (Am. J. Ind. Med. 55:904-916, 2012. (c) 2012 Wiley Periodicals, Inc.) |
Employer perceptions of stress and resilience intervention
Spangler NW , Koesten J , Fox MH , Radel J . J Occup Environ Med 2012 54 (11) 1421-9 OBJECTIVE: To understand employers' perceived organizational strengths in addressing stress and resilience-building to help expand theoretical knowledge and guide interventions. METHODS: Interviews and discussion groups with 46 employer representatives using grounded theory methodology for sampling and analysis of narrative data. RESULTS: Participants detailed three levels of approaches: (1) preventing stress/building resilience; (2) providing information, resources, and benefits to employees; and (3) intervening actively with troubled employees. Preventing stress through trusting work relationships and trust in stability of organizational structures emerged as a core concept explaining effectiveness of these approaches. Results are discussed using positive organizational scholarship, systems, and well-being frameworks. CONCLUSIONS: Psychosocial distress has unfavorable effects on human health and work performance. Greater attention to the systemic development and maintenance of trust in workplace relationships and systems is suggested. |
Evaluation of N95 respirator use with a surgical mask cover: effects on breathing resistance and inhaled carbon dioxide
Sinkule EJ , Powell JB , Goss FL . Ann Occup Hyg 2012 57 (3) 384-98 OBJECTIVE: For pandemic influenza outbreaks, the Institute of Medicine has recommended using a surgical mask cover (SM) over N95 filtering facepiece respirators (FFRs) among healthcare workers as one strategy to avoid surface contamination of the FFR which would extend its efficacy and reduce the threat of exhausting FFR supplies. The objective of this investigation was to measure breathing air quality and breathing resistance when using FFRs with US Food and Drug Administration-cleared SM and without SM. METHODS: Thirty National Institute for Occupational Safety and Health (NIOSH)-approved FFR models with and without SM were evaluated using the NIOSH Automated Breathing and Metabolic Simulator (ABMS) through six incremental work rates. RESULTS: Generally, concentrations of average inhaled CO(2) decreased and average inhaled O(2) increased with increasing O(2) consumption for FFR+SM and FFR-only. For most work rates, peak inhalation and exhalation pressures were statistically higher in FFR+SM as compared with FFR-only. The type of FFR and the presence of exhalation valves (EVs) had significant effects on average inhaled CO(2), average inhaled O(2), and breathing pressures. The evidence suggests that placement of an SM on one type of FFR improved inhaled breathing gas concentrations over the FFR without SM; the placement of an SM over an FFR+EV probably will prevent the EV from opening, regardless of activity intensity; and, at lower levels of energy expenditure, EVs in FFR do not open either with or without an SM. CONCLUSIONS: The differences in inhaled gas concentrations in FFR+SM and FFR-only were significant, especially at lower levels of energy expenditure. The orientation of the SM on the FFR may have a significant effect on the inhaled breathing quality and breathing resistance, although the measurable inhalation and exhalation pressures caused by SM over FFR for healthcare users probably will be imperceptible at lower activity levels. |
Associations of long-term shift work with waking salivary cortisol concentration and patterns among police officers
Fekedulegn D , Burchfiel CM , Violanti JM , Hartley TA , Charles LE , Andrew ME , Miller DB . Ind Health 2012 50 (6) 476-86 The objective of this study was to evaluate whether long-term shift work is associated with both the total hormonal secretion after awakening and the pattern of the cortisol levels during the first hour following awakening, among 65 randomly selected police officers who represent a high stress occupation. Dominant shift (Day, Afternoon, or Midnight) was ascertained using daily payroll records of each participant's work activities during the 6-8 prior to saliva sampling. Four salivary samples were collected at 15 minute intervals upon first awakening. After accounting for potential confounders, salivary cortisol concentrations averaged across all four time points and total area under the curve differed significantly across shift with midnight shift workers showing suppressed awakening cortisol response relative to the afternoon and day shift. The percent of hours worked on midnight shift was inversely correlated with total awakening cortisol output. In contrast, the pattern of cortisol secretion during the first hour following waking appeared not to be affected as no significant interaction effect was found between time since awakening and shift work. The results show that long-term midnight shift work is associated with decreased absolute mean level and total volume of cortisol released over the waking period. |
A critical evaluation of material safety data sheets (MSDSs) for engineered nanomaterials
Eastlake A , Hodson L , Geraci C , Crawford C . J Chem Health Saf 2012 19 (5) 1-8 Material safety data sheets (MSDSs) provide employers, employees, emergency responders, and the general public with basic information about the hazards associated with chemicals that are used in the workplace and are a part of every-day commerce. They are a primary information resource used by health, safety, and environmental professionals in communicating the hazards of chemicals and in making risk management decisions. Engineered nanomaterials represent a growing class of materials being manufactured and introduced into multiple business sectors. MSDSs were obtained from a total of 44 manufacturers using Internet search engines, and a simple ranking scheme was developed to evaluate the content of the data sheets. The MSDSs were reviewed using the ranking scheme, and categorized on the quality and completeness of information as it pertains to hazard identification, exposure controls, personal protective equipment (PPE), and toxicological information being communicated about the engineered nanomaterial. The ranking scheme used to evaluate the MSDSs for engineered nanomaterials was based on the determination that the data sheet should include information on specific physical properties, including particle size or particle size distribution, and physical form; specific toxicological and health effects; and protective measures that can be taken to control potential exposures. The first MSDSs for nanomaterials began to appear around 2006, so these were collected in the time period of 2007-2008. Comparison of MSDSs and changes over time were evaluated as MSDSs were obtained again in 2010-2011. The majority (67%) of the MSDSs obtained in 2010-2011 still provided insufficient data for communicating the potential hazards of engineered nanomaterials. |
Differences in folic acid use, prenatal care, smoking, and drinking in early pregnancy by occupation
Agopian AJ , Lupo PJ , Herdt-Losavio ML , Langlois PH , Rocheleau CM , Mitchell LE . Prev Med 2012 55 (4) 341-345 OBJECTIVE: To describe differences in four high risk periconceptional behaviors (lack of folic acid supplementation, lack of early prenatal care, smoking, and drinking) by maternal occupation. METHODS: Analyses were conducted among women in the National Birth Defects Prevention Study who delivered liveborn infants without birth defects. Periconceptional occupational data were collected using a computer-assisted telephone interview and occupational coding was performed using the 2000 Standard Occupational Classification System. Logistic regression analyses were conducted to determine whether prevalence of behaviors differed between occupational groups. RESULTS: Subjects included 5153 women employed during early pregnancy from 1997 to 2007. Compared to women in management, business, science, and arts occupations, women in other occupations (e.g., service occupations) were significantly more likely to engage in all four high risk behaviors. Specifically, women in food preparation/serving-related occupations were significantly more likely to engage in all four behaviors compared to women in all other occupational groups (odds ratios: 1.8-3.0), while women in education/training/library occupations were significantly less likely to do so (odds ratios: 0.2-0.5). CONCLUSION: We identified several occupational groups with an increased prevalence of high-risk maternal behaviors during pregnancy. Our findings could aid in developing interventions targeted towards women in these occupational groups. |
Ocular zoonotic Onchocerca infection in a resident of Oregon
Eberhard ML , Sims AC , Bishop HS , Mathison BA , Hoffman RS . Am J Trop Med Hyg 2012 87 (6) 1073-5 A long, slender filarial nematode was removed from the left anterior chamber of a resident of Oregon after several days of pain and blurred vision. The worm was identified as an Onchocerca, but it could not be further identified. This worm is the third zoonotic Onchocerca removed from the anterior chamber and the second case reported from the United States. Cases of zoonotic onchocerciasis continue to garner attention, and those cases affecting the eye are of particular interest. |
Tattooing regulations in U.S. states, 2011
Carlson VP , Lehman EJ , Armstrong M . J Environ Health 2012 75 (3) 30-37 Tattooing's popularity has led to regulatory concerns because medical complications linked to unsanitary practices can have a lasting health impact. The authors' study sought to determine whether existing state tattooing laws and regulations (rules) effectively protect public health. A 10-item checklist was created for each of three types of rules (sanitation, training, and infection control) identified as having the greatest public health impact. State rules were classified as effective if the state scored ≥7 on all three categories, moderate if ≥4 in all three categories, minimal if <4 in one or more categories, and ineffective if ≤2 in all three categories. Forty-one states have at least one state statute regulating tattooing practice. On the basis of the authors' study criteria, 36 states regulate sanitation effectively; 15 states regulate training effectively; and 26 states regulate infection control effectively. Fourteen states meet the criteria for regulating all three categories effectively. Specific rules vary substantially by state. Public health agencies should encourage states to adopt and enforce effective, evidence-based tattooing rules. |
Experience and education of home health administrators and nursing home administrators and the relationship to establishment ownership
Decker FH , Decker SL . J Health Hum Serv Adm 2012 35 (2) 149-69 Administrators in long-term care may have an important influence on quality of care. Limited prior research has described the characteristics of nursing home administrators. Despite growing emphasis on home health care as an alternative to nursing homes, almost no research has described the characteristics of administrators of home health agencies. Using the 2004 National Nursing Home Survey and the 2007 National Home and Hospice Care Survey, we describe the career experience of administrators, and examine the relationship between experience and education of administrators both within and across the nursing home and home health sectors. We also explore the characteristics of nursing homes and home health agencies, including establishment ownership (e.g., nonchain not-for-profit), that are associated with being able to attract administrators with the most experience. We find that home health administrators have, on average, less experience than nursing home administrators. Among home health agencies, administrators with the least experience also tend to have less education. In nursing homes, administrators with less experience tend to have more education. Results from multivariate analysis suggest that chain for-profits may be the least able to attract experienced administrators. More research on the effects of different levels of experience and education among administrators is needed. |
Appropriate antibiotic use: family physicians have the power of the pen
Roberts RM , Hicks LA . Am Fam Physician 2012 86 (9) 810 In this issue of American Family Physician, Zoorob and colleagues summarize guidelines for the treatment of acute upper respiratory tract infections (URIs).1 Visits for acute URIs account for more than one-half of all antibiotic prescriptions for outpatients, and these infections lead to more unnecessary and inappropriate antibiotic prescriptions than any other infectious syndrome.2–4 All antibiotic use, whether indicated or not, exerts selective pressure on bacteria that can lead to resistance. Studies have shown that geographic areas with high antibiotic prescribing rates also tend to have a higher prevalence of antibiotic-resistant infections.5–7 Every antibiotic prescription matters. Given their continuity of care, family physicians are well poised to minimize the spread of antibiotic resistance by practicing antibiotic stewardship and educating patients about the importance of using antibiotics appropriately. | Patients have a role in this growing problem. Too many patients and parents expect their physicians to prescribe antibiotics for viral URIs. Physicians are more likely to prescribe an antibiotic if they think a patient or parent expects one.8 Clearly, there is a need to facilitate communication between physicians and patients, but ultimately, physicians have the power to make the right decision. |
National Bone Health Alliance Bone Turnover Marker Project: current practices and the need for US harmonization, standardization, and common reference ranges
Bauer D , Krege J , Lane N , Leary E , Libanati C , Miller P , Myers G , Silverman S , Vesper HW , Lee D , Payette M , Randall S . Osteoporos Int 2012 23 (10) 2425-33 This position paper reviews how the National Bone Health Alliance (NBHA) will execute a project to help assure health professionals of the clinical utility of bone turnover markers; the current clinical approaches concerning osteoporosis and the status and use of bone turnover markers in the USA; the rationale for focusing this effort around two specific bone turnover markers; the need to standardize bone marker sample collection procedures, reference ranges, and bone turnover marker assays in clinical laboratories; and the importance of harmonization for future research of bone turnover markers. INTRODUCTION: Osteoporosis is a major global health problem, with the prevalence and incidence of osteoporosis for at-risk populations estimated to be 44 million Americans. The potential of bone markers as an additional tool for health care professionals to improve patient outcomes and impact morbidity and mortality is crucial in providing better health care and addressing rising health care costs. This need to advance the field of bone turnover markers has been recognized by a number of organizations, including the International Osteoporosis Foundation (IOF), National Osteoporosis Foundation, International Federation of Clinical Chemistry, and Laboratory Medicine (IFCC), and the NBHA. METHODS: This position paper elucidates how this project will standardize bone turnover marker sample collection procedures in the USA, establish a USA reference range for one bone formation (serum procollagen type I N propeptide, s-PINP) and one bone resorption (serum C-terminal telopeptide of type I collagen, s-CTX) marker, and standardize bone turnover marker assays used in clinical laboratories. This effort will allow clinicians from the USA to have confidence in their use of bone turnover markers to help monitor osteoporosis treatment and assess future fracture risk. This project builds on the recommendations of the IOF/IFCC Bone Marker Standards Working Group by developing USA reference standards for s-PINP and s-CTX, the markers identified as most promising for use as reference markers. RESULTS: The goals of this project will be realized through the NBHA and will include its governmental, academic, for-profit, and non-profit sector stakeholders as well as major academic and commercial laboratories. Upon completion, a parallel effort will be pursued to make bone turnover marker measurements reliable and accepted by all health care professionals for facilitating treatment decisions and ultimately be reimbursed by all health insurance payers. CONCLUSIONS: Successful completion of this project will help assure health professionals from the USA of the clinical utility of bone turnover markers and ties in with the parallel effort of the IOF/IFCC to develop worldwide bone turnover reference ranges. |
Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review
Tepper NK , Steenland MW , Gaffield ME , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 655-60 BACKGROUND: Women using intrauterine devices (IUDs) are not protected against acquiring pelvic inflammatory disease (PID). If a woman has an IUD in place when she is diagnosed with PID, there is a theoretical concern that presence of an IUD might impact the course of treatment. This review was conducted to evaluate the evidence regarding whether an IUD should be retained or removed if a woman develops PID. STUDY DESIGN: The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language concerning PID in women using IUDs. Articles were included if they examined women with IUDs who developed PID and compared the clinical course of women in whom the IUD was retained versus women in whom the IUD was removed. Articles were excluded if the infection was diagnosed before or at the time of IUD insertion. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Four fair-quality studies met inclusion criteria for this review. One randomized controlled trial showed that women with IUDs removed had longer hospitalizations than those with IUD retention (15% versus 4%, p<.01), although there were no differences in PID recurrences or subsequent pregnancies. Another randomized controlled trial showed no differences in laboratory parameters among women who retained the IUD when compared with women in whom the IUD was removed. One prospective cohort study showed that there were no differences in clinical or laboratory parameters during hospitalization; however, the IUD removal group had a higher proportion hospitalized for more than 2 weeks compared with the IUD retention group (33% versus 19%, p<.05). One randomized controlled trial showed that women who had the IUD removed experienced improved recovery in most clinical signs and symptoms compared with women who retained the IUD. CONCLUSIONS: Three fair-quality studies showed no difference in clinical or laboratory outcomes among women who retained IUDs when compared with women who had IUDs removed, and two of these studies showed that women who had IUDs removed had longer hospitalizations. In contrast, one fair quality study showed improved clinical signs and symptoms among women who had IUDs removed. Overall, women who retained their IUDs had similar or better outcomes than women who had their IUDs removed. |
Treatment of unscheduled bleeding in women using extended- or continuous-use combined hormonal contraception: a systematic review
Godfrey EM , Whiteman MK , Curtis KM . Contraception 2012 87 (5) 567-75 BACKGROUND: Unscheduled uterine bleeding is common among women who choose extended or continuous combined hormonal contraception and may subsequently lead to method discontinuation. This systematic review evaluates the evidence on treatments for unscheduled bleeding for women using continuous or extended combined hormonal contraception. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that were published in any language from inception of the database through January 2012 and were relevant to therapeutic or prophylactic treatments for unscheduled uterine bleeding during extended or continuous combined hormonal contraception use. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: Four articles met the inclusion criteria. Evidence from two randomized controlled trials, both of fair quality, suggested that a short hormone-free interval of 3 or 4 days improved a current unscheduled bleeding episode. Evidence from one randomized controlled trial of fair quality suggested that oral doxycycline (100 mg twice daily) did not improve a current unscheduled bleeding episode. One good quality randomized controlled trial suggested that prophylactic treatment with a daily low dose of oral doxycycline (40 mg) caused earlier onset of amenorrhea in new extended combined oral contraceptive users. CONCLUSIONS: Limited evidence suggests that introducing a short hormone-free interval when unscheduled bleeding occurs during continuous or extended hormonal contraceptive use may reduce unscheduled bleeding days; one study suggests that twice-daily oral doxycycline initiated at the time of unscheduled bleeding is an ineffective treatment. Limited data suggest that prophylactic low-dose daily oral doxycycline may induce earlier amenorrhea among new extended combined hormonal contraceptive users. |
Use of a checklist to rule out pregnancy: a systematic review
Tepper NK , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 661-5 BACKGROUND: Safe initiation of contraceptive methods requires that pregnancy be excluded. The World Health Organization has developed a list of criteria to assess pregnancy status. This review was conducted to evaluate the evidence regarding these criteria in excluding pregnancy. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning the performance of a pregnancy checklist compared to urine pregnancy tests. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Four analyses of data from three studies met inclusion criteria as direct evidence. All were diagnostic accuracy studies of fair quality that evaluated the performance of a pregnancy checklist compared with urine pregnancy test to rule out pregnancy. The performance of the checklist varied, with sensitivity ranging from 55-100% and specificity ranging from 39-89%. The negative predictive value was consistent across studies at 99-100%. CONCLUSION: All four analyses demonstrated high (99-100%) negative predictive value for the pregnancy checklist. |
Laboratory screening prior to initiating contraception: a systematic review
Tepper NK , Steenland MW , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 645-9 BACKGROUND: Certain contraceptive methods may increase the risk of adverse events for women with certain medical conditions, including some women with diabetes, hyperlipidemia, liver disease, cervical cancer, sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). This review was conducted to evaluate the evidence regarding health outcomes among women with and without laboratory testing to identify certain medical conditions prior to initiating contraceptives. STUDY DESIGN: The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language evaluating health outcomes among women who initiated certain contraceptive methods and who had or had not received glucose, lipid, liver enzyme, cervical cytology, STI or HIV screening. RESULTS: The systematic review did not identify any relevant direct evidence. CONCLUSIONS: While certain methods of hormonal contraception may not be safe for use by some women with diabetes, hyperlipidemia or liver disease, there is little value in screening for these conditions in asymptomatic women prior to initiation of contraceptive methods due to the low prevalence of these conditions among women of reproductive age. Although intrauterine devices (IUDs) and cervical caps should not be initiated in women with cervical cancer, the high rates of cervical screening and low incidence of cervical cancer in the United States make this scenario unlikely. Although some women at risk for, or infected with, STIs or HIV should not undergo IUD insertion, if women have been screened for STIs or HIV according to guidelines, additional screening at the time of IUD insertion is not warranted. Requiring unnecessary laboratory screening prior to initiation of contraceptive methods may impose barriers to contraceptive access, and efforts to remove such barriers are critical in reducing unintended pregnancy. |
Patient understanding of oral contraceptive pill instructions related to missed pills: a systematic review
Zapata LB , Steenland MW , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 674-84 BACKGROUND: Instructions on what to do after pills are missed are critical to reducing unintended pregnancies resulting from patient non-adherence to oral contraceptive (OC) regimens. Missed pill instructions have previously been criticized for being too complex, lacking a definition of what is meant by "missed pills," and for being confusing to women who may not know the estrogen content of their formulation. To help inform the development of missed pill guidance to be included in the forthcoming US Selected Practice Recommendations, the objective of this systematic review was to evaluate the evidence on patient understanding of missed pill instructions. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that examined patient understanding of OC pill instructions that were published in any language from inception of the database through March 2012. We included studies that examined women's knowledge and understanding of missed pill instructions after exposure to some written material (e.g., patient package insert, brochure), as well as studies that compared different types of missed pill instructions on women's comprehension. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 1620 articles, nine studies met our inclusion criteria. Evidence from one randomized controlled trial (RCT) and two descriptive studies found that more women knew what to do after missing 1 pill than after missing 2 or 3 pills (Level I, good, to Level II-3, poor), and two descriptive studies found that more women knew what to do after missing 2 pills than after missing 3 pills (Level II-3, fair). Data from two descriptive studies documented the difficulty women have understanding missed pill instructions contained in patient package inserts (Level II-3, poor), and evidence from two RCTs found that providing written brochures with information on missed pill instructions in addition to contraceptive counseling significantly improved knowledge of how to manage missed pills for up to three months compared to contraceptive counseling alone (Level I, fair). Evidence from one RCT found that graphic-based missed pill instructions were better than text-only instructions (Level I, good), and data from two RCTs found that less information resulted in improved comprehension (Level I, good to fair). Evidence from one descriptive study found that many women missing pills did not intend to follow recommended actions per missed pill instructions despite understanding the guidance (Level II-3, poor). CONCLUSIONS: There is wide variability in the percent of women having correct knowledge on what to do when pills are missed after exposure to written missed pills instructions, with more women knowing what to do after missing 1 pill than after missing 2 or 3 pills. Women have difficulty understanding missed pill instructions contained in patient package inserts. Providing written brochures with information on missed pill instructions in addition to contraceptive counseling may improve knowledge of how to manage missed pills. Graphic-based missed pill instructions and those containing less information may result in improved comprehension. Even with clear instructions, many women missing pills may choose not to follow the recommended actions. |
Preconception health of reproductive aged women of the Mississippi River Delta
Bish CL , Farr S , Johnson D , McAnally R . Matern Child Health J 2012 16 Suppl 2 250-7 Optimal preconception health (PCH) may improve maternal and infant outcomes, priority issues in Mississippi (MS). Our study objective was to compare the PCH of women in the MS Delta to other regions. We analyzed Behavioral Risk Factor Surveillance System data from 2005, 2007, and 2009, and limited analyses to 171,612 non-pregnant black and white women 18-44 years of age. Region was defined as 14 MS Delta counties (MS Delta), remainder of MS (MS non-Delta), Delta states (LA, AR, TN), and non-Delta US states. We calculated adjusted prevalence ratios (aPR) to assess associations between region and 16 indicators of optimal PCH, controlling for demographic characteristics. Healthy PCH factors such as consuming ≥5 fruits and vegetables daily and normal body mass index (18.5 kg/m(2) to <25 kg/m(2)), respectively, were more prevalent in the MS non-Delta (aPR = 1.3; 95 % CI: 1.0,1.7 and aPR = 1.2; 95 % CI: 1.0,1.4), non-MS Delta (aPR = 1.5; 95 % CI: 1.2,2.0 and aPR = 1.3; 95 % CI: 1.1,1.5) and non-Delta states (aPR = 1.7; 95 % CI: 1.3,2.2 and aPR = 1.4; 95 % CI: 1.2,1.6) compared to the MS Delta. Physical activity levels were higher among non-Delta US states compared to the MS Delta (aPR = 1.3; 95 % CI: 1.1,1.4). Household income and race confounded the associations between region and PCH. Reproductive aged women in the MS Delta had poorer PCH, particularly for physical activity and nutrition, than women in other regions. MS Delta service providers and public health practitioners should consider implementing or enhancing lifestyle, nutrition, and physical activity interventions, with a special focus on reducing income-based and racial disparities. |
The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use
Steenland MW , Zapata LB , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 625-30 BACKGROUND: We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use. STUDY DESIGN: We searched the PubMed database for all peer-reviewed articles in any language published from database inception through May 2012 that examined the effect of a structured follow-up schedule of visits or contacts on contraceptive use. We included studies that compared women who initiated a method of contraception with a certain follow-up schedule compared to women with a different follow-up schedule or no follow-up at all. To be included, studies must have compared groups on a measure of contraceptive use (e.g., pregnancy, correct use, consistent use, method discontinuation including expulsion). Though not ideally suited to answer our review question, studies in which women used a variety of contraceptive methods but results were not stratified by method type were included. RESULTS: Four studies met our inclusion criteria (Level I, poor to II-2, poor). Two studies examined the effect of a specific follow-up visit schedule on intrauterine device (IUD) continuation: one examining frequency of visits and one examining the timing of the first follow-up visit. Women with more frequent follow-up visits did not have a statistically significant difference in proportion of removals for medical reasons compared with women who had fewer follow-up visits; among women who had their IUDs removed for medical reasons, those who had more frequent follow-up visits had a longer mean time of use prior to removal. The other study found more removals and shorter continuation among women with a follow-up visit at 1 week compared to women with a follow-up visit at 1 month after IUD insertion (no statistical tests reported). Two studies examined the effect of follow-up phone calls compared to no follow-up phone calls after an initial family planning visit among adolescents initiating a variety of contraceptive methods. Neither of the two studies found any differences in method continuation or correct use between study groups. CONCLUSIONS: It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates. |
Hemoglobin measurement prior to initiating copper intrauterine devices: a systematic review
Tepper NK , Steenland MW , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 639-44 BACKGROUND: Women using copper intrauterine devices (IUDs) frequently experience bleeding abnormalities. This review was conducted to evaluate the evidence regarding whether hemoglobin levels should be measured prior to copper IUD insertion. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning hemoglobin changes among women with anemia who have copper IUDs inserted. Articles were included if they reported changes in hemoglobin among anemic women over a specified period of time following copper IUD insertion. Articles were excluded in which there were no women with anemia at baseline or outcomes among women with anemia were not reported separately. For indirect evidence, articles were included which addressed hemoglobin changes among women without anemia who had copper IUDs inserted. The quality of each direct study was assessed using the US Preventive Services Task Force grading system. RESULTS: Four level I to II-2 studies of fair quality met inclusion criteria as direct evidence. Evidence from one randomized trial and one prospective cohort study showed no statistically significant changes in hemoglobin among copper IUD users with anemia, while two prospective cohort studies showed a statistically significant, but clinically small, mean decrease in hemoglobin levels over 12 months of follow-up. We also identified 21 studies examining changes in hemoglobin among healthy women using copper IUDs as indirect evidence; this body of evidence was not graded. These studies generally showed no clinically significant changes in hemoglobin levels with up to 5 years of follow-up. CONCLUSIONS: Limited fair-quality evidence was mixed but generally showed no clinically significant changes in hemoglobin among women with anemia who used copper IUDs for up to 12 months. Indirect evidence among healthy women using copper IUDs did not show clinically significant changes in hemoglobin levels when followed for up to 5 years of use. |
How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review
Steenland MW , Rodriguez MI , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 605-10 BACKGROUND: The review was conducted to examine studies that assess whether the number of pill packs dispensed, or prescribed, affects method continuation and other measures of use. STUDY DESIGN: PubMed database was searched from inception through March 2012 for all peer-reviewed articles, in any language, that examined the effect of the number of oral contraceptive pill packs dispensed on method continuation, and other measures of use. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Four studies met the inclusion criteria for this review. Studies that compared 1 vs. 12, 1 vs. 12-13, or 3 vs. 7 packs found increased method continuation. However, one study that examined the difference between providing one and then three packs versus providing four packs all at once did not find a difference in continuation. In addition to continuation, evidence from the individual studies included found that a greater number of pill packs was associated with fewer pregnancy tests, fewer pregnancies and less cost per client. A greater number of pill packs was, however, also associated with increased pill wastage. CONCLUSIONS: A small body of evidence suggests that dispensing a greater number of oral contraceptive pill packs may increase continuation of use. |
Adaptation of the World Health Organization's Selected Practice Recommendations for Contraceptive Use for the United States
Curtis KM , Tepper NK , Jamieson DJ , Marchbanks PA . Contraception 2012 87 (5) 513-6 BACKGROUND: The Centers for Disease Control and Prevention (CDC) recently adapted global guidance on contraceptive use from the World Health Organization (WHO) to create the US Selected Practice Recommendations for Contraceptive Use (US SPR). The WHO guidance includes evidence-based recommendations on common, yet sometimes complex, contraceptive management questions. STUDY DESIGN: We determined the need and scope for the adaptation, conducted 30 systematic reviews of the scientific evidence and convened a meeting of health care professionals to discuss translation of the evidence into recommendations. RESULTS: The US SPR provides recommendations on contraceptive management issues such as how to initiate contraceptive methods, what regular follow-up is needed, and how to address problems, including missed pills and side effects such as unscheduled bleeding. CONCLUSION: The US SPR is intended to serve as a source of clinical guidance for providers in assisting women and men to initiate and successfully use contraception to prevent unintended pregnancy. |
Estimation with vanishing baseline risk
Park RM . Epidemiology 2012 23 (6) 937-8 Diseases associated with specific exposures may have little or no observable background rate in the absence of the exposure. Examples include mesothelioma (environmental asbestos), aplastic anemia (benzene), bronchiolitis obliterans (artificial butter flavorings), Reye’s syndrome (aspirin in children), and angiosarcoma of the liver (vinyl chloride). Relative-rate models of exposure-response produce unstable near-zero baseline risk and unbounded coefficients, especially when age confounding requires baseline age dependence. The same problem arises in a proportional-hazards context. Baseline risk volatility also threatens meta-analyses, a procedure that assumes uniformity. | Using Poisson regression,1 we investigated two methods: (1) fixing the intercept at a small value corresponding to 1% of attributable cases and (2) generating random sets of new cases across observation time independent of any predictor, possibly preempting true cases. Although models can be reliably fit using randomly generated cases, repetition would reduce variability in parameter estimates. We performed simulations with fixed intercepts (1,000) and with simulated populations (100) each with 100 random baselines. Hypothetical populations, constructed iteratively, consisted of 500 subjects with an exposure that could extend up to 200 time units. Exposure duration was random, favoring shorter durations to represent typical environmental or occupational exposures. Individual average exposure levels were randomly assigned and then randomly varied across time. We generated attributable cases with probability proportional to cumulative exposure, at which time follow-up ceased. Numbers of attributable or baseline cases averaged ~60–70. The analyses were implemented using an R algorithm2 that called specific FORTRAN and EPICURE3 steps with an indexing seed for random number generation. Additional information is included in the eAppendix (http://links.lww.com/EDE/A619). |
Content Index (Achived Edition)
- Chronic Diseases and Conditions
- Communicable Diseases
- Disease Reservoirs and Vectors
- Environmental Health
- Epidemiology and Surveillance
- Food Safety
- Genetics and Genomics
- Health Behavior and Risk
- Immunity and Immunization
- Laboratory Sciences
- Maternal and Child Health
- Nutritional Sciences
- Occupational Safety and Health
- Parasitic Diseases
- Public Health Law
- Public Health Leadership and Management
- Public Health, General
- Reproductive Health
- Statistics as Topic
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