Addressing childhood obesity for type 2 diabetes prevention: Challenges and opportunities
Galuska DA , Gunn JP , O'Connor AE , Petersen R . Diabetes Spectr 2018 31 (4) 330-335 IN BRIEF Addressing the problem of childhood obesity is an important component of preventing type 2 diabetes. Although children and their families ultimately make decisions about diet, physical activity, and obesity management, many groups have a role in making these choices easier. They do this by providing families with tools and resources and by implementing policies and practices that support a healthy diet and physical activity in the places where children and their families spend their time. Diabetes educators are an important part of the solution. |
Co-occurrence of early diabetes-related complications in adolescents and young adults with type 1 diabetes: an observational cohort study
Sauder KA , Stafford JM , Mayer-Davis EJ , Jensen ET , Saydah S , Mottl A , Dolan LM , Hamman RF , Lawrence JM , Pihoker C , Marcovina S , D'Agostino RBJr , Dabelea D . Lancet Child Adolesc Health 2018 3 (1) 35-43 BACKGROUND: One in three adolescents and young adults with type 1 diabetes have at least one early diabetes-related complication or comorbidity. We aimed to examine the prevalence and pattern of co-occurring complications in this population, as well as the related risk factors. METHODS: This observational cohort study includes data from individuals diagnosed with type 1 diabetes before age 20 years who participated in the SEARCH for Diabetes in Youth Study across five sites in the USA. We assessed sociodemographic and metabolic risk factors at baseline and at follow-up, and diabetes complications at follow-up. A frequency analysis was done to examine the difference in observed versus expected prevalence (calculated using a contingency table assuming independence across cells) of co-occurring complications or comorbidities. A cluster analysis was done to identify unique clusters of participants based on demographic characteristics and metabolic risk factors. FINDINGS: 1327 participants who completed the follow-up visit were included in the frequency analysis. The mean age was 10.1 (SD 3.9) years at the time of type 1 diabetes diagnosis and 18.0 (4.1) years at follow-up. At a mean diabetes duration of 7.8 [SD 1.9] years, co-occurrence of any two or more complications was observed in 78 (5.9%) participants, more frequently than expected by chance alone (58 [4.4%], p=0.015). Specifically, the complications that co-occurred more frequently than expected were retinopathy and diabetic kidney disease (11 [0.8%] vs three [0.2%]; p=0.0007), retinopathy and arterial stiffness (13 [1.0%] vs four [0.3%]; p=0.0016), and arterial stiffness and cardiovascular autonomic neuropathy (24 [1.8%] vs 13 [1.0%]; p=0.015). We identified four unique clusters characterised by progressively worsening metabolic risk factor profiles (longer duration of diabetes and higher glycated haemoglobin, non-HDL cholesterol, and waist-to-height ratio). The prevalence of at least two complications increased across the clusters (six [2.3%] of 261 in the low-risk cluster, 32 [6.3%] of 509 in the moderate-risk cluster, 28 [8%] of 348 in the high-risk cluster, and five [20.8%] of 24 in the highest-risk cluster). Compared with the low-risk and moderate-risk clusters, the high-risk and highest-risk clusters were characterised by a lower proportion of participants who were non-Hispanic white, and a higher proportion of participants who had a household income below US$50 000 and did not have private health insurance. INTERPRETATION: Early complications co-occur in adolescents and young adults with type 1 diabetes more frequently than expected. Identification of individuals with adverse risk factors could enable targeted behavioural or medical interventions that reduce the likelihood of early development of lifelong diabetes-related morbidity. FUNDING: US Centers for Disease Control and Prevention, US National Institutes of Health. |
Making strides in type 2 diabetes prevention
Albright AL . Diabetes Spectr 2018 31 (4) 299-302 The prevalence of diagnosed diabetes in adults in the United States, currently at 23.1 million people, has tripled in the past two decades (1). In addition, an estimated 84 million adults have prediabetes, putting them at increased risk of type 2 diabetes, heart attack, and stroke; only 1 in 10 know they have it (2). If interventions to slow the increase in and ultimately reduce the number of new cases of diabetes are not widely implemented, projections estimate that one in three adults in the United States could have diabetes by 2050 (3). |
Nudging to change: Using behavioral economics theory to move people and their health care partners toward effective type 2 diabetes prevention
Soler RE , Proia K , Jackson MC , Lanza A , Klein C , Leifer J , Darling M . Diabetes Spectr 2018 31 (4) 310-319 IN BRIEF In 2017, 30 million Americans had diabetes, and 84 million had prediabetes. In this article, the authors focus on the journey people at risk for type 2 diabetes take when they become fully engaged in an evidence-based type 2 diabetes prevention program. They highlight potential drop-off points along the journey, using behavioral economics theory to provide possible reasons for most of the drop-off points, and propose solutions to move people toward making healthy decisions. |
Racial/ethnic differences in the utilization of chemotherapy among stage I-III breast cancer patients, stratified by subtype: Findings from ten National Program of Cancer Registries states
Zhang L , King J , Wu XC , Hsieh MC , Chen VW , Yu Q , Fontham E , Loch M , Pollack LA , Ferguson T . Cancer Epidemiol 2018 58 1-7 BACKGROUND: The study aimed to examine racial/ethnic differences in chemotherapy utilization by breast cancer subtype. METHODS: Data on female non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic stage I-III breast cancer patients diagnosed in 2011 were obtained from a project to enhance population-based National Program of Cancer Registry data for Comparative Effectiveness Research. Hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) were used to classify subtypes: HR+/HER2-; HR+/HER2+; HR-/HER2-; and HR-/HER2 + . We used multivariable logistic regression models to examine the association of race/ethnicity with three outcomes: chemotherapy (yes, no), neo-adjuvant chemotherapy (yes, no), and delayed chemotherapy (yes, no). Covariates included patient demographics, tumor characteristics, Charlson Comorbidity Index, other cancer treatment, and participating states/areas. RESULTS: The study included 25,535 patients (72.1% NHW, 13.7% NHB, and 14.2% Hispanics). NHB with HR+/HER2- (adjusted odds ratio [aOR] 1.22, 95% CI 1.04-1.42) and Hispanics with HR-/HER2- (aOR 1.62, 95% CI 1.15-2.28) were more likely to receive chemotherapy than their NHW counterparts. Both NHB and Hispanics were more likely to receive delayed chemotherapy than NHW, and the pattern was consistent across each subtype. No racial/ethnic differences were found in the receipt of neo-adjuvant chemotherapy. CONCLUSIONS: Compared to NHW with the same subtype, NHB with HR+/HER2- and Hispanics with HR-/HER2- have higher odds of using chemotherapy; however, they are more likely to receive delayed chemotherapy, regardless of subtype. Whether the increased chemotherapy use among NHB with HR+/HER2- indicates overtreatment needs further investigation. Interventions to improve the timely chemotherapy among NHB and Hispanics are warranted. |
Resurgence of diabetes-related nontraumatic lower extremity amputation in the young and middle-aged adult U.S. population
Geiss LS , Li Y , Hora I , Albright A , Rolka D , Gregg EW . Diabetes Care 2018 42 (1) 50-54 OBJECTIVES: To determine whether declining trends in lower extremity amputations have continued into the current decade. RESEARCH DESIGN AND METHODS: We calculated hospitalization rates for nontraumatic lower extremity amputation (NLEA) for the years 2000-2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes. RESULTS: Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women. CONCLUSIONS: After a two-decade decline in lower extremity amputations, the U.S. may now be experiencing a reversal in the progress particularly in young and middle-aged adults. |
Completeness of HIV nucleotide sequence ascertainment and its potential impact on understanding HIV transmission - Maryland, 2011-2013.
Brooks RB , Feldman KA , Blythe D , Flynn C . AIDS Care 2018 31 (5) 1-8 HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland's Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged >/=13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland's Central Region with initial CD4 counts </=500 cells/mm(3) (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness. |
Discrimination in healthcare settings among adults with recent HIV diagnoses
Baugher AR , Beer L , Fagan JL , Mattson CL , Luke Shouse R . AIDS Care 2018 31 (9) 1-6 The prevalence of discrimination in healthcare settings among HIV patients in the United States is unknown. The Medical Monitoring Project (MMP) is a complex sample survey of adults receiving HIV medical care in the United States. We analyzed nationally representative MMP data collected 2011-2015. We assessed the prevalence of self-reported healthcare discrimination, perceived reasons for discrimination, and factors associated with discrimination among persons with HIV diagnoses </=5 years before interview (n = 3,770). Overall, 14.1% of patients living with HIV (PLWH) experienced discrimination, of whom 82.2% attributed the discrimination to HIV. PLWH reporting poverty, homelessness, or attending a non-Ryan White HIV/AIDS Program (RWHAP) facility were more likely to report discrimination compared with other groups. Of patients attending non-RWHAP facilities, discrimination was higher among those in poverty (27.5%) vs. not in poverty (15.1%). Discrimination was associated with homelessness regardless of facility type, and was highest among homeless persons attending non-RWHAP facilities. Healthcare discrimination was commonly reported among PLWH, and was most often attributed to HIV status. Discrimination was higher among those reporting poverty or homelessness, particularly those attending non-RWHAP facilities. Incorporating practices, such as anti-discrimination training, in facilities may reduce healthcare discrimination. |
Disseminated gonococcal infections in patients receiving eculizumab: a case series
Crew PE , Abara WE , McCulley L , Waldron PE , Kirkcaldy RD , Weston EJ , Bernstein KT , Jones SC , Bersoff-Matcha SJ . Clin Infect Dis 2018 69 (4) 596-600 Background: Gonorrhea is the second most commonly reported notifiable condition in the United States (U.S.). Infrequently, Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI). Eculizumab, a monoclonal antibody, inhibits terminal complement activation which impairs the ability of the immune system to respond effectively to Neisseria infections. This series describes cases of N. gonorrhoeae infection among patients receiving eculizumab. Methods: Pre- and postmarketing safety reports of N.gonorrhoeae infection in patients receiving eculizumab worldwide were obtained from FDA safety databases and the medical literature, including reports from the start of pivotal clinical trials in 2004 through December 31, 2017. Included patients had at least one eculizumab dose within the three months prior to N. gonorrhoeae infection. Results: Nine cases of N. gonorrhoeae infection were identified; eight were classified as disseminated (89%). Of the disseminated cases, eight patients required hospitalization, seven had positive blood cultures, and two required vasopressor support. One patient required mechanical ventilation. N. gonorrhoeae may have contributed to complications prior to death in one patient; however, the fatality was attributed to underlying disease per the reporter. Conclusion: Patients receiving eculizumab may be at higher risk for DGI than the general population. Prescribers are encouraged to educate patients receiving eculizumab on their risk for serious gonococcal infections and perform screening for sexually transmitted diseases (STDs) per Centers for Disease Control and Prevention STD treatment guidelines or in suspect cases. If antimicrobial prophylaxis is used during eculizumab therapy, prescribers should consider trends in gonococcal antimicrobial susceptibility due to emerging resistance concerns. |
The first year of the global Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in Bangkok, Thailand, 2015-2016
Sirivongrangson P , Girdthep N , Sukwicha W , Buasakul P , Tongtoyai J , Weston E , Papp J , Wi T , Cherdtrakulkiat T , Dunne EF . PLoS One 2018 13 (11) e0206419 Antimicrobial-resistant Neisseria gonorrhoeae (NG) infection is a global public health threat, and there is a critical need to monitor patterns of resistance and risk factors. In collaboration with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the Thailand Department of Disease Control (DDC), Ministry of Public Health (MoPH) implemented the first Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in November 2015. Men presenting with urethritis at two clinical settings in Bangkok, Thailand (Bangrak Hospital [BH] and Silom Community Clinic @TropMed [SCC @TropMed]) provided demographic and behavioral information and had a urethral swab for Gram's stain and NG culture collected. The NG isolates were evaluated for antimicrobial susceptibility by the Epsilometer test (Etest) to determine minimum inhibitory concentrations (MICs) for cefixime (CFM), ceftriaxone (CRO), azithromycin (AZI), gentamicin (GEN), and ciprofloxacin (CIP). From November 2015 -October 2016, 1,102 specimens were collected from 1,026 symptomatic men; 861 (78.1%) specimens were from BH and 241 (21.9%) specimens were from SCC @TropMed. Among the 1,102 specimens, 582 (52.8%) had intracellular Gram-negative diplococci and 591 (53.6%) had NG growth (i.e., NG infection); antimicrobial susceptibility testing (AST) was performed on 590 (99.8%) NG isolates. Among all symptomatic men, 293 (28.6%) had sex with men only, 430 (41.9%) were ages 18-29 years, 349 (34.0%) had antibiotic use in the last 2 weeks, and 564 (55.0%) had NG infection. Among 23 men with repeat NG infection during this first year of surveillance, 20 (87.0%) were infected twice, 2 (8.7%) were infected three times, and 1 (4.3%) was infected more than four times. All NG isolates were susceptible to CFM and CRO, and had MICs below 2 mug/mL for AZI and below 16 mug/mL for GEN. Overall, 545 (92.4%) isolates were resistant to CIP. This surveillance activity assessed individual patients, and included demographic and behavioral data linked to laboratory data. The inclusion of both individual and laboratory information in EGASP could help identify possible persistent infection and NG treatment failures. Expansion of EGASP to additional global settings is critical to assess trends and risk factors for NG, and to monitor for the emergence of resistance. |
Increase in acute flaccid myelitis - United States, 2018
McKay SL , Lee AD , Lopez AS , Nix WA , Dooling KL , Keaton AA , Spence-Davizon E , Herlihy R , Clark TA , Hopkins SE , Pastula DM , Sejvar J , Oberste MS , Pallansch MA , Patel M , Routh JA . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1273-1275 In August 2018, CDC noted an increased number of reports of patients having symptoms clinically compatible with acute flaccid myelitis (AFM), a rare condition characterized by rapid onset of flaccid weakness in one or more limbs and spinal cord gray matter lesions, compared with August 2017. Since 2014, CDC has conducted surveillance for AFM using a standardized case definition (1,2). An Epi-X* notice was issued on August 23, 2018, to increase clinician awareness and provide guidance for case reporting. |
Infectious disease threats and opportunities for prevention
Silk BJ . J Public Health Manag Pract 2018 24 (6) 503-505 Control of infectious diseases has been recognized as a public health achievement in the United States.1 Remarkably, average life expectancy increased by 29 years during the 20th century due largely to reductions in early childhood mortality and significant advances in sanitation and hygiene, childhood vaccination, and discovery of antimicrobial therapies. However, human immunodeficiency virus (HIV) and many other pathogens with epidemic potential emerged, reemerged, or were discovered as previously unrecognized etiologies during this same period. And, 100 years after an influenza pandemic that caused more than 50 million deaths worldwide in 1918, the number of infectious disease outbreaks appears to have increased even after accounting for improvements in surveillance and communications.2 |
Respiratory viruses in returning Hajj & Umrah pilgrims with acute respiratory illness in 2014-2015
Koul PA , Mir H , Saha S , Chadha MS , Potdar V , Widdowson MA , Lal RB , Krishnan A . Indian J Med Res 2018 148 (3) 329-333 Background & objectives: Respiratory tract infections are common among Hajj and Umrah pilgrims which pose a public health risk of spread of respiratory infections. Influenza has been reported from Indian Hajj and Umrah returning pilgrims, but data on other respiratory pathogens are sparse in India. Here we report the presence of common respiratory viral pathogens in returning Hajj and Umrah pilgrims suffering from acute respiratory illness (ARI) in 2014-2015. Methods: Respiratory specimens (nasopharyngeal and throat swabs) were collected from 300 consenting pilgrims with ARI in the past one week and tested for influenza and Middle East Respiratory Syndrome coronavirus (MERS-CoV) and other respiratory viruses using in-house standardized quantitative real-time reverse-transcription polymerase chain reaction. Clinical features among the pathogen positive and negative patients were compared. The patients received symptomatic treatment and antivirals where appropriate and were followed telephonically to collect data on illness outcome. Results: Ninety seven (32.3%) of the 300 participants were tested positive for any virus, most common being influenza viruses (n=33, 11%). Other respiratory viruses that were detected included human coronaviruses [n=26, 8.7%; OC43 (n=19, 6.3%) and C229E (n=7, 2.3%)], rhinovirus (n=20, 6%), adenoviruses (n=8, 2.6%), parainfluenza viruses (n=7, 2.3%), respiratory syncytial virus (n=3, 1%) and bocaviruses (n=2, 0.6%). Clinical features observed in pathogen positive and pathogen negative patients did not differ significantly. Eighteen influenza positive patients were treated with oseltamivir. Interpretation & conclusions: Pilgrims returning from mass gatherings are often afflicted with respiratory pathogens with a potential to facilitate transmission of respiratory pathogens across international borders. The study reinforces the need for better infection prevention and control measures such as vaccination, health education on cough etiquette and hand hygiene. |
Risk factors for childhood enteric infection in urban Maputo, Mozambique: A cross-sectional study
Knee J , Sumner T , Adriano Z , Berendes D , de Bruijn E , Schmidt WP , Nala R , Cumming O , Brown J . PLoS Negl Trop Dis 2018 12 (11) e0006956 BACKGROUND: Enteric infections are common where public health infrastructure is lacking. This study assesses risk factors for a range of enteric infections among children living in low-income, unplanned communities of urban Maputo, Mozambique. METHODS & FINDINGS: We conducted a cross-sectional survey in 17 neighborhoods of Maputo to assess the prevalence of reported diarrheal illness and laboratory-confirmed enteric infections in children. We collected stool from children aged 1-48 months, independent of reported symptoms, for molecular detection of 15 common enteric pathogens by multiplex RT-PCR. We also collected survey and observational data related to water, sanitation, and hygiene (WASH) characteristics; other environmental factors; and social, economic, and demographic covariates. We analyzed stool from 759 children living in 425 household clusters (compounds) representing a range of environmental conditions. We detected >/=1 enteric pathogens in stool from most children (86%, 95% confidence interval (CI): 84-89%) though diarrheal symptoms were only reported for 16% (95% CI: 13-19%) of children with enteric infections and 13% (95% CI: 11-15%) of all children. Prevalence of any enteric infection was positively associated with age and ranged from 71% (95% CI: 64-77%) in children 1-11 months to 96% (95% CI: 93-98%) in children 24-48 months. We found poor sanitary conditions, such as presence of feces or soiled diapers around the compound, to be associated with higher risk of protozoan infections. Certain latrine features, including drop-hole covers and latrine walls, and presence of a water tap on the compound grounds were associated with a lower risk of bacterial and protozoan infections. Any breastfeeding was also associated with reduced risk of infection. CONCLUSIONS: We found a high prevalence of enteric infections, primarily among children without diarrhea, and weak associations between bacterial and protozoan infections and environmental risk factors including WASH. Findings suggest that environmental health interventions to limit infections would need to be transformative given the high prevalence of enteric pathogen shedding and poor sanitary conditions observed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02362932. |
An urgent need for HIV testing among men who have sex with men and transgender women in Bamako, Mali: Low awareness of HIV infection and viral suppression among those living with HIV
Hakim AJ , Coy K , Patnaik P , Telly N , Ballo T , Traore B , Doumbia S , Lahuerta M . PLoS One 2018 13 (11) e0207363 Despite the high HIV prevalence among men who have sex with men (MSM) and transgender women (TGW), there are limited data on progress on their respective HIV antiretroviral treatment (ART) cascades to identify progress and gaps in meeting UNAIDS 90-90-90 targets. We conducted a respondent-driven sampling survey of MSM and TGW in Bamako, Mali from October 2014 to February 2015. We describe the HIV treatment cascade for MSM and TGW, identify correlates of being unaware of HIV-infected status and having unsuppressed viral load levels, and estimate proportion of recent infections. We enrolled 387 MSM and 165 TGW. HIV prevalence was 13.7%. Of those living with HIV, 10.4% were aware of their serostatus, 61.2% of them self-reported being on treatment, and of them, 100% were virally suppressed. In multivariate analysis, factors associated with being unaware of HIV infection included not using free condoms in the last six months (aOR: 5.7, 95% CI: 1.1-29.5) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.4-29.9). Having unsuppressed viral load was associated with identifying as a transgender woman (aOR: 4.8, 95% CI: 1.1-20.7) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.0-40.9). Of the 79 HIV-positive participants, 5.1% had recent infections. While the proportion aware of their HIV status was low despite adjusting for viral load biomarkers, all MSM and TGW on treatment were virally suppressed. Improved testing strategies are urgently needed to achieve the first 90 of the HIV cascade among MSM and TGW in Bamako. |
Variation in identifying sepsis and organ dysfunction using administrative versus electronic clinical data and impact on hospital outcome comparisons
Rhee C , Jentzsch MS , Kadri SS , Seymour CW , Angus DC , Murphy DJ , Martin GS , Dantes RB , Epstein L , Fiore AE , Jernigan JA , Danner RL , Warren DK , Septimus EJ , Hickok J , Poland RE , Jin R , Fram D , Schaaf R , Wang R , Klompas M . Crit Care Med 2018 47 (4) 493-500 OBJECTIVES: Administrative claims data are commonly used for sepsis surveillance, research, and quality improvement. However, variations in diagnosis, documentation, and coding practices for sepsis and organ dysfunction may confound efforts to estimate sepsis rates, compare outcomes, and perform risk adjustment. We evaluated hospital variation in the sensitivity of claims data relative to clinical data from electronic health records and its impact on outcome comparisons. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of 4.3 million adult encounters at 193 U.S. hospitals in 2013-2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sepsis was defined using electronic health record-derived clinical indicators of presumed infection (blood culture draws and antibiotic administrations) and concurrent organ dysfunction (vasopressors, mechanical ventilation, doubling in creatinine, doubling in bilirubin to >/= 2.0 mg/dL, decrease in platelets to < 100 cells/microL, or lactate >/= 2.0 mmol/L). We compared claims for sepsis prevalence and mortality rates between both methods. All estimates were reliability adjusted to account for random variation using hierarchical logistic regression modeling. The sensitivity of hospitals' claims data was low and variable: median 30% (range, 5-54%) for sepsis, 66% (range, 26-84%) for acute kidney injury, 39% (range, 16-60%) for thrombocytopenia, 36% (range, 29-44%) for hepatic injury, and 66% (range, 29-84%) for shock. Correlation between claims and clinical data was moderate for sepsis prevalence (Pearson coefficient, 0.64) and mortality (0.61). Among hospitals in the lowest sepsis mortality quartile by claims, 46% shifted to higher mortality quartiles using clinical data. Using implicit sepsis criteria based on infection and organ dysfunction codes also yielded major differences versus clinical data. CONCLUSIONS: Variation in the accuracy of claims data for identifying sepsis and organ dysfunction limits their use for comparing hospitals' sepsis rates and outcomes. Using objective clinical data may facilitate more meaningful hospital comparisons. |
Restriction of Zika virus infection and transmission in Aedes aegypti mediated by an insect-specific flavivirus
Romo H , Kenney JL , Blitvich BJ , Brault AC . Emerg Microbes Infect 2018 7 (1) 181 Previous studies demonstrated an insect-specific flavivirus, Nhumirim virus (NHUV), can suppress growth of West Nile virus (WNV) and decrease transmission rates in NHUV/WNV co-inoculated Culex quinquefasciatus. To assess whether NHUV might interfere with transmission of other medically important flaviviruses, the ability of NHUV to suppress viral growth of Zika virus (ZIKV) and dengue-2 virus (DENV-2) was assessed in Aedes albopictus cells. Significant reductions in ZIKV (100,000-fold) and DENV-2 (10,000-fold) were observed in either cells concurrently inoculated with NHUV or pre-inoculated with NHUV. In contrast, only a transient 10-fold titer reduction was observed with an alphavirus, chikungunya virus. Additionally, restricted in vitro mosquito growth of ZIKV was associated with lowered levels of intracellular ZIKV RNA in NHUV co-inoculated cultures. To assess whether NHUV could modulate vector competence for ZIKV, NHUV-inoculated Aedes aegypti were orally exposed to ZIKV. NHUV-inoculated mosquitoes demonstrated significantly lower ZIKV infection rates (18%) compared to NHUV unexposed mosquitoes (51%) (p < 0.002). Similarly, lower ZIKV transmission rates were observed for NHUV/ZIKV dually intrathoracically inoculated mosquitoes (41%) compared to ZIKV only inoculated mosquitoes (78%) (p < 0.0001), suggesting that NHUV can interfere with both midgut infection and salivary gland infection of ZIKV in Ae. aegypti. These results indicate NHUV could be utilized to model superinfection exclusion mechanism(s) and to study the potential for the mosquito virome to impact transmission of medically important flaviviruses. |
Advances in optimizing the prescription of antibiotics in outpatient settings
King LM , Fleming-Dutra KE , Hicks LA . BMJ 2018 363 k3047 The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings. |
Anticoagulation across care transitions: Identifying minimum data to maximize drug safety
Shehab N , Greenwald JL , Budnitz DS . Jt Comm J Qual Patient Saf 2018 44 (11) 627-629 Adverse drug events (ADEs) are one of the most common and costly causes of iatrogenic patient harm, and anticoagulants are the leading cause of acute, serious ADEs among hospitalized patients, long term care residents, and older outpatients.1–5 In the United States, hospitalization costs associated with anticoagulant ADEs have been estimated at more than $2.5 billion,6 and in 2016 more than $5 billion was spent on anticoagulants in Medicare Part D claims.7 Accordingly, reducing patient harm associated with anticoagulation has been a Joint Commission National Patient Safety Goal (NPSG.03.05.01) since 2008,8,9 is one of three main focus areas of the 2014 Department of Health and Human Services National Action Plan for Adverse Drug Event Prevention,10 and is a key component of the ongoing Centers for Medicare & Medicaid Services Quality Innovation Network and Hospital Improvement Innovation Network efforts to improve patient safety.11,12 An article, “Defining Minimum Necessary Anticoagulation-Related Communication at Discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition,” in this issue of The Joint Commission Journal on Quality and Patient Safety, Triller and colleagues take another important step on the long road to achieving safer and more effective anticoagulation by proposing the core information that needs to be communicated among providers as patients treated with anticoagulants make the transition between health care settings.13 |
Community-wide recreational water-associated outbreak of cryptosporidiosis and control strategies - Maricopa County, Arizona, 2016
Iverson SA , Fowle N , Epperson G , Collins J , Zusy S , Narang J , Matthews J , Hlavsa MC , Roellig D , Sylvester T , Klein R , Sunenshine R . J Environ Health 2018 81 (4) 14-21 We describe a 2016 community-wide recreational water-associated cryptosporidiosis outbreak investigation and response in Maricopa County, Arizona. Persons with a laboratory-confirmed illness were interviewed using a standardized questionnaire that assessed exposures 2 weeks before symptom onset. A convenience sample of managers and operators of chlorine-treated public aquatic facilities was surveyed regarding permanent supplemental treatment systems for Cryptosporidium. Among 437 cases identified (median age 12, range <1-75 years), 260 persons were interviewed. Public-treated recreational water was the most frequently reported exposure (177, 68%) of interviewed persons; almost 1 in 5 (43, 17%) swam when diarrhea was ongoing. After the 2016 outbreak, managers of some facilities expressed intentions to install supplementary water treatment systems, and by May 2017, at least one large facility installed an ultraviolet light system. Strategies to prevent additional illness included community messaging, education, and targeted remediation of affected facilities on the basis of interviews. Challenges to remediation during a cryptosporidiosis outbreak in a large jurisdiction with primarily outdoor pools underscore the importance of promoting healthy swimming practices that help prevent contamination from occurring. |
Evaluation of the National Healthcare Safety Network Hemovigilance Module for transfusion-related adverse reactions in the United States
Edens C , Haass KA , Cumming M , Osinski A , O'Hearn L , Passanisi K , Eaton L , Visintainer P , Savinkina A , Kuehnert MJ , Basavaraju SV , Andrzejewski C . Transfusion 2018 59 (2) 524-533 INTRODUCTION: The National Healthcare Safety Network (NHSN) Hemovigilance Module (HM) collects data on the frequency, severity, and imputability of transfusion-associated adverse events. These events contribute to significant morbidity and mortality among transfusion patients. We report results from the first systematic assessment of eight attributes of the HM. MATERIALS AND METHODS: Standard methods were used to assess the HM. Evaluation data included training materials, system modification history, and facility survey information. A concordance analysis was performed using data from the Baystate Medical Center's (Boston, MA) electronic transfusion reporting system. RESULTS: In 2016, system representativeness remained low, with 6% (277 of 4690) of acute care facilities across 43 jurisdictions enrolled in the HM. In 2016, 48% (2147 of 4453) and 89% (3969 of 4,453) of adverse reactions were reported within 30 and 90 days of the reaction date, respectively, compared to 21% (109 of 511) and 56% (284 of 511) in 2010, demonstrating improved reporting timeliness. Data quality from most reactions was adequate, with 10% (45 of 442) misclassified transfusion-associated circulatory overload reactions, and no incomplete transfusion-transmitted infection data reported from 2010 to 2013. When compared to the Baystate system to assess concordance, 43% (24 of 56) of NHSN-reported febrile reactions were captured in both systems (unweighted kappa value, 0.47; confidence interval, 0.33-0.61). CONCLUSION: Since the 2010 HM pilot, improvements have led to enhanced simplicity, timeliness, and strengthened data quality. The HM serves an important and unique role despite incomplete adoption nationwide. Facility efforts to track and prevent transfusion-associated adverse events through systems like the NHSN HM are a key step toward improving transfusion safety in the United States. |
State health department validations of central line-associated bloodstream infection events reported via the National Healthcare Safety Network
Bagchi S , Watkins J , Pollock DA , Edwards JR , Allen-Bridson K . Am J Infect Control 2018 46 (11) 1290-1295 BACKGROUND: Numerous state health departments (SHDs) have validated central line-associated bloodstream infection (CLABSI) data, and results from these studies provide important insights into the accuracy of CLABSI reporting to the National Healthcare Safety Network (NHSN) and remediable shortcomings in adherence to the CLABSI definition and criteria. METHODS: State CLABSI validation results were obtained from peer-reviewed publications, reports on SHD Web sites, and via personal communications with the SHD health care-associated infections coordinator. Data accuracy measures included pooled mean sensitivity, specificity, positive predictive value, and negative predictive value. Total CLABSI error rate was computed as the proportion of mismatches among total records reviewed. When available, reasons for CLABSI misclassification reported by SHDs were reviewed. RESULTS: At least 23 SHDs that have completed CLABSI validations indicated sensitivity (pooled mean, 82.9%), specificity (pooled mean, 98.5%), positive predictive value (pooled mean, 94.1%), and negative predictive value (pooled mean, 95.9%) of CLABSI reporting. The pooled error rate of CLABSI reporting was 4.4%. Reasons for CLABSI misclassification included incorrect secondary bloodstream infection attribution, misapplication of CLABSI definition, missed case finding, applying clinical over surveillance definitions, misapplication of laboratory-confirmed bloodstream infection 2 definition, and misapplication of general NHSN definitions. CONCLUSIONS: CLABSI underreporting remains a major concern; validations conducted by SHDs provide an important impetus for improved reporting. SHDs are uniquely positioned to engage facilities in collaborative validation reviews that allow transparency, education, and relationship building. |
Global routine vaccination coverage - 2017
VanderEnde K , Gacic-Dobo M , Diallo MS , Conklin LM , Wallace AS . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1261-1264 Endorsed by the World Health Assembly in 2012, the Global Vaccine Action Plan 2011-2020 (GVAP) (1) calls on all countries to reach >/=90% national coverage with all vaccines in the country's national immunization schedule by 2020. This report updates previous reports (2,3) and presents global, regional, and national vaccination coverage estimates and trends as of 2017. It also describes the number of infants surviving to age 1 year (surviving infants) who did not receive the third dose of diphtheria and tetanus toxoids and pertussis-containing vaccine (DTP3), a key indicator of immunization program performance (4,5), with a focus on the countries with the highest number of children who did not receive DTP3 in 2017. Based on the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) estimates, global DTP3 coverage increased from 79% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). In 2017, among the 19.9 million children who did not receive DTP3 in the first year of life, 62% (12.4 million) lived in 10 countries. From 2007 to 2017, the number of children who had not received DTP3 decreased in five of these 10 countries and remained stable or increased in the other five. Similar to DTP3 coverage, global coverage with the first measles-containing vaccine dose (MCV1) increased from 80% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). Coverage with the third dose of polio vaccine (Pol3) has remained stable at 84%-85% since 2010. From 2007 to 2017, estimated global coverage with the second MCV dose (MCV2) increased from 33% to 67%, as did coverage with the completed series of rotavirus (2% to 28%), pneumococcal conjugate (PCV) (4% to 44%), rubella (26% to 52%), Haemophilus influenzae type b (Hib) (25% to 72%) and hepatitis B (HepB) (birth dose: 24% to 43%; 3-dose series: 63% to 84%) vaccines. Targeted, context-specific strategies are needed to reach and sustain high vaccination coverage, particularly in countries with the highest number of unvaccinated children. |
Influenza vaccine effectiveness among patients with high-risk medical conditions in the United States, 2012-2016
Shang M , Chung JR , Jackson ML , Jackson LA , Monto AS , Martin ET , Belongia EA , McLean HQ , Gaglani M , Murthy K , Zimmerman RK , Nowalk MP , Fry AM , Flannery B . Vaccine 2018 36 (52) 8047-8053 BACKGROUND: Annual influenza vaccination has been recommended for persons with high-risk conditions since the 1960s. However, few estimates of influenza vaccine effectiveness (VE) for persons with high-risk conditions are available. METHODS: Data from the U.S. Influenza Vaccine Effectiveness Network from 2012 to 2016 were analyzed to compare VE of standard-dose inactivated vaccines against medically-attended influenza among patients aged >/=6months with and without high-risk medical conditions. Patients with acute respiratory illness were tested for influenza by RT-PCR. Presence of high-risk conditions and vaccination status were obtained from medical records. VE by influenza virus type/subtype and age group was calculated for patients with and without high-risk conditions using the test-negative design. Interaction terms were used to test for differences in VE by high-risk conditions. RESULTS: Overall, 9643 (38%) of 25,369 patients enrolled during four influenza seasons had high-risk conditions; 2213 (23%) tested positive for influenza infection. For all ages, VE against any influenza was lower among patients with high-risk conditions (41%, 95% CI: 35-47%) than those without (48%, 95% CI: 43-52%; P-for-interaction=0.02). For children aged <18years, VE against any influenza was 51% (95% CI: 39-61%) and 52% (95% CI: 39-61%) among those with and without high-risk conditions, respectively (P-for-interaction=0.54). For adults aged >/=18years, VE against any influenza was 38% (95% CI: 30-45%) and 44% (95% CI: 38-50%) among those with and without high-risk conditions, respectively (P-for-interaction=0.21). For both children aged <18 and adults aged >/=18years, VEs against illness related to influenza A(H3N2), A(H1N1)pdm09, and influenza B virus infection were similar among those with and without high-risk conditions. CONCLUSIONS: Influenza vaccination provided protection against medically-attended influenza among patients with high-risk conditions, at levels approaching those observed among patients without high-risk conditions. Results from our analysis support recommendations of annual vaccination for patients with high-risk conditions. |
Preparing for safety monitoring after rotavirus vaccine introduction - assessment of baseline epidemiology of intussusception among children < 2 years of age in four Asian countries
Burnett E , Van Trang N , Rayamajhi A , Yousafzai MT , Satter SM , Anh DD , Thapa A , Qazi SH , Heffelfinger JD , Hung PH , Rayamajhi AK , Saddal N , Flora MS , Canh TM , Ali SA , Gurley ES , Tate JE , Yen C , Parashar UD . Vaccine 2018 36 (50) 7593-7598 Intussusception is the invagination of one segment of the bowel into a distal segment, characterized by symptoms of bloody stool, vomiting, and abdominal pain. Previous studies have found regional differences in incidence but the etiology of most intussusception cases is unknown. Rotavirus vaccines were associated with a slightly of increased risk of intussusception in post-licensure evaluations in high- and middle-income countries, but not in low income African countries. To describe the baseline epidemiology of intussusception in young children prior to rotavirus vaccine implementation, active sentinel hospital surveillance for intussusception in children<2years of age was conducted in 4 low income Asian countries (Bangladesh, Nepal, Pakistan and Vietnam). Over a 24-month period, 15 sites enrolled 1,415 intussusception cases, of which 70% were enrolled in Vietnam. Overall, 61% of cases were male and 1% (n=16) died, ranging from 8% in Pakistan to 0% in Vietnam. The median age of cases enrolled ranged from 6months in Bangladesh and Pakistan to 12months in Vietnam. The proportion of cases receiving surgical management was 100% in Bangladesh, 88% in Pakistan, 61% in Nepal, and 1% in Vietnam. The high proportion of males and median age of cases around 6months of age found in this regional surveillance network are consistent with previous descriptions of the epidemiology of intussusception in these countries and elsewhere. Differences in management and the fatality rate of cases between the countries likely reflect differences in access to healthcare and availability of diagnostic modalities. These baseline data will be useful for post-rotavirus vaccine introduction safety monitoring. |
Updated framework for development of evidence-based recommendations by the Advisory Committee on Immunization Practices
Lee G , Carr W . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1271-1272 The Advisory Committee on Immunization Practices (ACIP)* is a federal advisory committee that provides expert advice to the Director of CDC and the Secretary of the U.S. Department of Health and Human Services in the form of recommendations on the use of vaccines and related agents for control of vaccine-preventable diseases in the U.S. civilian population (1,2). Work groups that gather, analyze, and prepare scientific information assist in the recommendation formulation process and present options for recommendations based on the scientific evidence they have assessed. Recommendations that are approved by a majority of ACIP's voting members are then reviewed by the Director of CDC and published in MMWR if approved by the director. This report briefly summarizes an update to the ACIP process for developing evidence-based recommendations that ACIP adopted at its February 2018 meeting. |
The Nigerian health information system policy review of 2014 - the need, content, expectations and progress
Meribole EC , Makinde OA , Oyemakinde A , Oyediran KA , Atobatele A , Fadeyibi FA , Azeez A , Ogbokor D , Adebayo O , Adebayo W , Abatta E , Adoghe A , Adebayo SB , Mahmoud Z , Ashefor G , Adebayo SB , Yisa IO , Balogun A , Chukwujekwu O , Dalhatu I , Jahun I , Bamidele S , Johnson DO , Ibrahim M , Akpan F , Aiyenigba B , Omaha OI , Terpase A , Ottih C , Adelakin O , Mullen S , Orobaton N . Health Info Libr J 2018 35 (4) 285-297 BACKGROUND: Nigeria's national health information system (HIS) data sources are grouped into institutional and population based data that traverse many government institutions. Communication and collaboration between these institutions are limited, fraught with fragmentation and challenges national HIS functionality. OBJECTIVES: The objective of this paper was to share insights from and the implications of a recent review of Nigeria's HIS policy in 2014 that resulted in its substantial revision. We also highlight some subsequent enactments. REVIEW PROCESS AND OUTCOMES: In 2013, Nigeria's Federal Ministry of Health launched an inter-ministerial and multi-departmental review of the National Health Management Information System policy of 2006. The review was guided by World Health Organization's 'Framework and Standards for Country Health Information Systems'. The key finding was a lack of governance mechanisms in the execution of the policy, including an absent data management governance process. The review also found a multiplicity of duplicative, parallel reporting tools and platforms. CONCLUSION: Recommendations for HIS Policy revisions were proposed to and implemented by the Federal Government of Nigeria. The revised HIS policy now provides for a strong framework for the leadership and governance of the HIS with early results. |
Proportion of violent injuries unreported to law enforcement
Wu DT , Moore JC , Bowen DA , Mercer Kollar LM , Mays EW , Simon TR , Sumner SA . JAMA Intern Med 2018 179 (1) 111-112 Interpersonal violence is a leading cause of death and injury in the United States.1 Although many cities rely on official law enforcement data to determine the magnitude, patterns, and prevention strategies for violence, data from the National Crime Victimization Survey conducted by the US Department of Justice indicates that a large number (52.6%) of violent crimes resulting in injury goes unreported to law enforcement.2 Consequently, because of incomplete data, cities are limited in their ability to effectively prevent and respond to violence. |
Suicide rates by major occupational group - 17 states, 2012 and 2015
Peterson C , Stone DM , Marsh SM , Schumacher PK , Tiesman HM , McIntosh WL , Lokey CN , Trudeau AT , Bartholow B , Luo F . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1253-1260 During 2000-2016, the suicide rate among the U.S. working age population (persons aged 16-64 years) increased 34%, from 12.9 per 100,000 population to 17.3 (https://www.cdc.gov/injury/wisqars). To better understand suicide among different occupational groups and inform suicide prevention efforts, CDC analyzed suicide deaths by Standard Occupational Classification (SOC) major groups for decedents aged 16-64 years from the 17 states participating in both the 2012 and 2015 National Violent Death Reporting System (NVDRS) (https://www.cdc.gov/violenceprevention/nvdrs). The occupational group with the highest male suicide rate in 2012 and 2015 was Construction and Extraction (43.6 and 53.2 per 100,000 civilian noninstitutionalized working persons, respectively), whereas the group with the highest female suicide rate was Arts, Design, Entertainment, Sports, and Media (11.7 [2012] and 15.6 [2015]). The largest suicide rate increase among males from 2012 to 2015 (47%) occurred in the Arts, Design, Entertainment, Sports, and Media occupational group (26.9 to 39.7) and among females, in the Food Preparation and Serving Related group, from 6.1 to 9.4 (54%). CDC's technical package of strategies to prevent suicide is a resource for communities, including workplace settings (1). |
Concordance analysis between different methodologies used for identification of oral isolates of Candida species
Zuluaga A , Arango-Bustamante K , Caceres DH , Sanchez-Quitian ZA , Velasquez V , Gomez BL , Parra-Giraldo CM , Maldonado N , Cano LE , de Bedout C , Rivera RE . Colomb Med (Cali) 2018 49 (3) 193-200 Background: The yeasts species determination is fundamental not only for an accurate diagnosis but also for establishing a suitable patient treatment. We performed a concordance study of five methodologies for the species identification of oral isolates of Candida in Colombia. Methods: Sixty-seven Candida isolates were tested by; API(R) 20C-AUX, Vitek(R)2 Compact, Vitek(R)MS, Microflex(R) and a molecular test (panfungal PCR and sequencing). The commercial cost and processing time of the samples was done by graphical analysis. Results: Panfungal PCR differentiated 12 species of Candida, Vitek(R)MS and Microflex(R) methods identified 9 species, and API(R) 20C-AUX and Vitek(R)2 Compact methods identified 8 species each. Weighted Kappa (wK) showed a high agreement between Panfungal PCR, Vitek(R)MS, Microflex(R) and API(R) 20C-AUX (wK 0.62-0.93). The wK that involved the Vitek(R)2 Compact method presented moderate or good concordances compared with the other methods (wK 0.56-0.73). Methodologies based on MALDI TOF MS required 4 minutes to generate results and the Microflex(R) method had the lowest selling price. Conclusion: The methods evaluated showed high concordance in their results, being higher for the molecular methods and the methodologies based on MALDI TOF. The latter are faster and cheaper, presenting as promising alternatives for the routine identification of yeast species of the genus Candida. |
Group II innate lymphoid cells and microvascular dysfunction from pulmonary titanium dioxide nanoparticle exposure
Abukabda AB , McBride CR , Batchelor TP , Goldsmith WT , Bowdridge EC , Garner KL , Friend S , Nurkiewicz TR . Part Fibre Toxicol 2018 15 (1) 43 BACKGROUND: The cardiovascular effects of pulmonary exposure to engineered nanomaterials (ENM) are poorly understood, and the reproductive consequences are even less understood. Inflammation remains the most frequently explored mechanism of ENM toxicity. However, the key mediators and steps between lung exposure and uterine health remain to be fully defined. The purpose of this study was to determine the uterine inflammatory and vascular effects of pulmonary exposure to titanium dioxide nanoparticles (nano-TiO2). We hypothesized that pulmonary nano-TiO2 exposure initiates a Th2 inflammatory response mediated by Group II innate lymphoid cells (ILC2), which may be associated with an impairment in uterine microvascular reactivity. METHODS: Female, virgin, Sprague-Dawley rats (8-12 weeks) were exposed to 100 mug of nano-TiO2 via intratracheal instillation 24 h prior to microvascular assessments. Serial blood samples were obtained at 0, 1, 2 and 4 h post-exposure for multiplex cytokine analysis. ILC2 numbers in the lungs were determined. ILC2s were isolated and phosphorylated nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) levels were measured. Pressure myography was used to assess vascular reactivity of isolated radial arterioles. RESULTS: Pulmonary nano-TiO2 exposure was associated with an increase in IL-1ss, 4, 5 and 13 and TNF- alpha 4 h post-exposure, indicative of an innate Th2 inflammatory response. ILC2 numbers were significantly increased in lungs from exposed animals (1.66 +/- 0.19%) compared to controls (0.19 +/- 0.22%). Phosphorylation of the transactivation domain (Ser-468) of NF-kappaB in isolated ILC2 and IL-33 in lung epithelial cells were significantly increased (126.8 +/- 4.3% and 137 +/- 11% of controls respectively) by nano-TiO2 exposure. Lastly, radial endothelium-dependent arteriolar reactivity was significantly impaired (27 +/- 12%), while endothelium-independent dilation (7 +/- 14%) and alpha-adrenergic sensitivity (8 +/- 2%) were not altered compared to control levels. Treatment with an anti- IL-33 antibody (1 mg/kg) 30 min prior to nano-TiO2 exposure resulted in a significant improvement in endothelium-dependent dilation and a decreased level of IL-33 in both plasma and bronchoalveolar lavage fluid. CONCLUSIONS: These results provide evidence that the uterine microvascular dysfunction that follows pulmonary ENM exposure may be initiated via activation of lung-resident ILC2 and subsequent systemic Th2-dependent inflammation. |
Trends in Q fever serologic testing by immunofluorescence from four large reference laboratories in the United States, 2012-2016
Miller HK , Binder AM , Peterson A , Theel ES , Volpe JM , Couturier MR , Cherry CC , Kersh GJ . Sci Rep 2018 8 (1) 16670 Laboratory testing for Q fever (Coxiella burnetii) is essential for a differential diagnosis, yet little is known about Q fever diagnostic testing practices in the United States. We retrospectively analyzed Q fever immunoglobulin G (IgG) indirect immunofluorescence assay (IFA) testing data between 1/1/2012-10/31/2016 from ARUP, LabCorp, Mayo Medical Laboratories, and Quest Diagnostics. Data included IgG phase I and phase II titers, patient age and sex, and state and date of specimen collection. On average, 12,821 specimens were tested for Q fever annually by the participating laboratories. Of 64,106 total specimens, 84.1% tested negative for C. burnetii-specific antibodies. Positive titers ranged from 16 to 262,144 against both phase I and phase II antigens. Submission of specimens peaked during the summer months, and more specimens were submitted from the West North Central division. Testing occurred more frequently in males (53%) and increased with age. In conclusion, few U.S. Q fever cases are reported, despite large volumes of diagnostic specimens tested. Review of commercial laboratory data revealed a lack of paired serology samples and patterns of serology titers that differ from case reporting diagnostic criteria. |
Triplex real-time PCR assay for the detection of Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae directly from clinical specimens without extraction of DNA
Ouattara M , Whaley MJ , Jenkins LT , Schwartz SB , Traore RO , Diarra S , Collard JM , Sacchi CT , Wang X . Diagn Microbiol Infect Dis 2018 93 (3) 188-190 This study presents a triplex real-time PCR assay that allows for the direct detection of Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae in one reaction without DNA extraction, with similar sensitivity and specificity to singleplex assays. This approach saves time, specimen volume and reagents while achieving a higher testing throughput. |
The multiple hit hypothesis for Gulf War Illness: Self-reported chemical/biological weapons exposure and mild traumatic brain injury
Janulewicz P , Krengel M , Quinn E , Heeren T , Toomey R , Killiany R , Zundel C , Ajama J , O'Callaghan J , Steele L , Klimas N , Sullivan K . Brain Sci 2018 8 (11) The Gulf War Illness Consortium (GWIC) was designed to identify objective biomarkers of Gulf War Illness (GWI) in 1991 Gulf War veterans. The symptoms of GWI include fatigue, pain, cognitive problems, gastrointestinal, respiratory, and skin problems. Neurotoxicant exposures during deployment, such as pesticides, sarin, and pyridostigmine bromide pills have been identified as contributors to GWI. We have also found an association between mild traumatic brain injury (mTBI) and increased rates of GWI. However, the combined impact of these physical and chemical exposures has not yet been explored in GWI. The objective of this study was to examine both self-reported mTBI and exposure to chemical/biological weapons (CBW) as a multiple or two hit model for increased risk of GWI and other chronic health conditions. The study population included 125 Gulf War (GW) veterans from the Boston GWIC. Exposure to CBW was reported in 47.2% of the study population, and 35.2% reported sustaining a mTBI during the war. Results confirmed that those with both exposures (mTBI and CBW) had higher rates of comorbid chronic health conditions while rates of GWI were equivalent for mTBI and CBW or mTBI alone. The timing of exposure to mTBI was found to be strikingly different between those with GWI and those without it. Correspondingly, 42.3% of GWI cases reported experiencing a mTBI during military service while none of the controls did (p = 0.0002). Rates of mTBI before and after the war did not differ between the cases and controls. In addition, 54% of cases compared to 14.3% of controls (p = <0.001) reported being exposed to CBW during military service. The current study examined the relation of the separate and combined effects of exposure to mTBI and CBW in 1991 GW veterans. The findings from this study suggest that both exposure to mTBI and CBW are associated with the development of GWI and multiple chronic health conditions and that combined exposure appears to lead to higher risk of chronic health effects. |
The dietary supplement label database: Recent developments and applications
Dwyer JT , Bailen RA , Saldanha LG , Gahche JJ , Costello RB , Betz JM , Davis CD , Bailey RL , Potischman N , Ershow AG , Sorkin BC , Kuszak AJ , Rios-Avila L , Chang F , Goshorn J , Andrews KW , Pehrsson PR , Gusev PA , Harnly JM , Hardy CJ , Emenaker NJ , Herrick KA . J Nutr 2018 148 1428S-1435S Although many Americans use dietary supplements, databases of dietary supplements sold in the United States have not been widely available. The Dietary Supplement Label Database (DSLD), an easily accessible public-use database, was created in 2008 to provide information on dietary supplement composition for use by researchers and consumers. We describe in this article the history, key features, recent enhancements, and common applications of the DSLD. Accessing current information easily and quickly is crucial for documenting exposures to dietary supplements because they contain nutrients and other bioactive ingredients that may have beneficial or adverse effects on human health. This article details recent developments with the DSLD to achieve this goal, and provides examples of how the DSLD has been used. With periodic updates to track changes in product composition and capture new products entering the market, the DSLD currently contains >71,000 dietary supplement labels. Following usability testing with consumer and researcher user groups completed in 2016, improvements to the DSLD interface were made. As of 2018, both a desktop and mobile device version are available. Since its inception in 2008, the DSLD has been used for research, exposure monitoring, and for other purposes by users in the public and private sectors. Further refinement of the user interface and search features is planned to facilitate ease of use for stakeholders. The DSLD can be used to track changes in product composition and capture new products entering the market. With >71,000 dietary supplement labels, it is a unique resource that policymakers, researchers, clinicians, and consumers may find valuable for multiple applications. |
Federal monitoring of dietary supplement use in the resident, civilian, noninstitutionalized US Population: National Health and Nutrition Examination Survey
Gahche JJ , Bailey RL , Potischman N , Ershow AG , Herrick KA , Ahluwalia N , Dwyer JT . J Nutr 2018 148 (8) 1436S-1444S This review summarizes the current and previous data on dietary supplement (DS) use collected from participants in the NHANES, describes the NHANES DS database used to compute nutrient intakes from DSs, discusses recent developments and future directions, and describes many examples to show the utility of these data in informing nutrition research and policy. Since 1971, NHANES has been collecting information on the use of DSs from participants. These data are critical to national nutrition surveillance and have been used to characterize usage patterns, examine trends over time, assess the percentage of the population meeting or exceeding nutrient recommendations, and help to elucidate the sources contributing nutrients to the diet of the US population. More than half of adults and approximately one-third of children in the United States currently use ≥1 DS in the course of 30 d. DSs contribute to the dietary intake of nutrients and bioactive compounds in the United States and therefore need to be assessed when monitoring nutritional status of the population and when studying diet-health associations. With the recent development and availability of the Dietary Supplement Label Database, a comprehensive DS database that will eventually contain labels for all products marketed in the United States, NHANES DS data will be more easily linked to product information to estimate nutrient intake from DSs. NHANES provides a rich source of nationally representative data on the usage of dietary supplements in the United States. Over time, NHANES has both expanded and improved collection methods. The continued understanding of sources of error in collection methods will continue to be explored and is critical to improved accuracy. |
Characterization and workplace exposure assessment of nanomaterial released from a carbon nanotube-enabled anti-corrosive coating
Brame JA , Alberts EM , Schubauer-Berigan MK , Dunn KH , Babik KR , Barnes E , Moser R , Poda AR , Kennedy AJ . NanoImpact 2018 12 58-68 Improvement of methods to quantify the release and characterization of engineered nanomaterials (ENMs) from nano-enabled products is essential to enhance the accuracy and usability of environmental health and safety evaluations. An anticorrosive coating containing multi-wall carbon nanotubes (MWCNTs) was analyzed for nano-scale material and workplace exposure potential. Worker breathing zone measurements for elemental carbon (EC) and electron-microscopy-based structure counts showed negligible MWCNT exposure to workers during laboratory and spray-painting operations over the course of two 8-hour shifts (arithmetic mean inhalable EC and electron microscopy structure count concentrations were 6.47 g/m3 and 0.084 structures/cm3 respectively). UV weathering prior to abrasion testing increased the nano-size fraction of released material as measured by a fast mobility particle sizer (FMPS) and visual inspection by SEM indicated increased presence of exposed MWCNTs embedded in the polymer matrix. However, no free MWCNTs were identified, despite evidence of MWCNTs embedded in airborne particles. TiO2, used as a pigment in the coating and not anticipated as a candidate for nano-specific scrutiny, contained a small fraction (3.5% in number) of nano-sized constituents (100 nm). This work emphasizes need for rigorous characterization of additive materials to properly assess potential health hazards and to better our understanding of what qualifies as nano. |
Firefighter hood contamination: Efficiency of laundering to remove PAHs and FRs
Mayer AC , Fent KW , Bertke S , Horn GP , Smith DL , Kerber S , La Guardia MJ . J Occup Environ Hyg 2018 16 (2) 1-32 Firefighters are occupationally exposed to products of combustion containing polycyclic aromatic hydrocarbons (PAHs) and flame retardants (FRs), potentially contributing to their increased risk for certain cancers. Personal protective equipment (PPE), including firefighter hoods, helps to reduce firefighters' exposure to toxic substances during fire responses by providing a layer of material on which contaminants deposit prior to reaching the firefighters skin. However, over time hoods that retain some contamination may actually contribute to firefighters' systemic dose. We investigated the effectiveness of laundering to reduce or remove contamination on the hoods, specifically PAHs and three classes of FRs: polybrominated diphenyl ethers (PBDEs), non-PBDE flame retardants (NPBFRs), and organophosphate flame retardants (OPFRs). Participants in the study were grouped into crews of 12 firefighters who worked in pairs by job assignment while responding to controlled fires in a single family residential structure. For each pair of firefighters, one hood was laundered after every scenario and one was not. Bulk samples of the routinely laundered and unlaundered hoods from five pairs of firefighters were collected and analyzed. Residual levels of OPFRs, NPBFRs, and PAHs were lower in the routinely laundered hoods, with total levels of each class of chemicals being 56-81% lower, on average, than the unlaundered hoods. PBDEs, on average, were 43% higher in the laundered hoods, most likely from cross contamination. After this initial testing, four of the five unlaundered exposed hoods were subsequently laundered with other heavily exposed (unlaundered) and unexposed (new) hoods. Post-laundering evaluation of these hoods revealed increased levels of PBDEs, NPBFRs, and OPFRs in both previously exposed and unexposed hoods, indicating cross contamination. For PAHs, there was little evidence of cross contamination and the exposed hoods were significantly less contaminated after laundering (76% reduction; p = 0.011). Further research is needed to understand how residual contamination on hoods could contribute to firefighters' systemic exposures. |
Workers' compensation injury claims among workers in the private ambulance services industry - Ohio, 2001-2011
Reichard AA , Al-Tarawneh IS , Konda S , Wei C , Wurzelbacher SJ , Meyers AR , Bertke SJ , Bushnell PT , Tseng CY , Lampl MP , Robins DC . Am J Ind Med 2018 61 (12) 986-996 BACKGROUND: Ambulance service workers frequently transfer and transport patients. These tasks involve occupational injury risks such as heavy lifting, awkward postures, and frequent motor vehicle travel. METHODS: We examined Ohio workers' compensation injury claims among state-insured ambulance service workers working for private employers from 2001 to 2011. Injury claim counts and rates are presented by claim types, diagnoses, and injury events; only counts are available by worker characteristics. RESULTS: We analyzed a total of 5882 claims. The majority were medical-only (<8 days away from work). The overall injury claim rate for medical-only and lost-time cases was 12.1 per 100 full-time equivalents. Sprains and strains accounted for 60% of all injury claims. Overexertion from patient handling was the leading injury event, followed by motor vehicle roadway incidents. CONCLUSIONS: Study results can guide the development or improvement of injury prevention strategies. Focused efforts related to patient handling and vehicle incidents are needed. |
Progress toward global eradication of dracunculiasis - January 2017-June 2018
Hopkins DR , Ruiz-Tiben E , Weiss AJ , Roy SL , Zingeser J , Guagliardo SAJ . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1265-1270 Dracunculiasis (Guinea worm disease), caused by the parasite Dracunculus medinensis, is acquired by drinking water containing copepods (water fleas) infected with its larvae. The worm typically emerges through the skin on a lower limb approximately 1 year after infection, causing pain and disability (1). The worldwide eradication campaign began at CDC in 1980. In 1986, the World Health Assembly called for dracunculiasis elimination, and the global Guinea Worm Eradication Program (GWEP), led by the Carter Center in partnership with the World Health Organization (WHO), United Nations Children's Fund (UNICEF), CDC, and others, began assisting ministries of health in countries with dracunculiasis. There is no vaccine or medicine to treat the disease; the GWEP relies on case containment* to prevent water contamination and other interventions to prevent infection, including health education, water filtration, chemical treatment of water, and provision of safe drinking water (1,2). In 1986, an estimated 3.5 million cases(dagger) occurred each year in 20( section sign) African and Asian countries (3,4). This report, based on updated health ministry data (3), describes progress during January 2017-June 2018 and updates previous reports (1,4). In 2017, 30 cases were reported from Chad and Ethiopia, and 855 infected animals (mostly dogs) were reported from Chad, Ethiopia, and Mali, compared with 25 cases and 1,049 animal infections reported in 2016. During January-June 2018, the number of cases declined to three cases each in Chad and South Sudan and one in Angola, with 709 infected animals reported, compared with eight cases and 547 animal infections during the same period of 2017. With only five affected countries, the eradication goal is near, but is challenged by civil unrest, insecurity, and lingering epidemiologic and zoologic questions. |
Specificity of the IgG antibody response to Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale MSP119 subunit proteins in multiplexed serologic assays
Priest JW , Plucinski MM , Huber CS , Rogier E , Mao B , Gregory CJ , Candrinho B , Colborn J , Barnwell JW . Malar J 2018 17 (1) 417 BACKGROUND: Multiplex bead assays (MBA) that measure IgG antibodies to the carboxy-terminal 19-kDa sub-unit of the merozoite surface protein 1 (MSP119) are currently used to determine malaria seroprevalence in human populations living in areas with both stable and unstable transmission. However, the species specificities of the IgG antibody responses to the malaria MSP119 antigens have not been extensively characterized using MBA. METHODS: Recombinant Plasmodium falciparum (3D7), Plasmodium malariae (China I), Plasmodium ovale (Nigeria I), and Plasmodium vivax (Belem) MSP119 proteins were covalently coupled to beads for MBA. Threshold cut-off values for the assays were estimated using sera from US citizens with no history of foreign travel and by receiver operator characteristic curve analysis using diagnostic samples. Banked sera from experimentally infected chimpanzees, sera from humans from low transmission regions of Haiti and Cambodia (N = 12), and elutions from blood spots from humans selected from a high transmission region of Mozambique (N = 20) were used to develop an antigen competition MBA for antibody cross-reactivity studies. A sub-set of samples was further characterized using antibody capture/elution MBA, IgG subclass determination, and antibody avidity measurement. RESULTS: Total IgG antibody responses in experimentally infected chimpanzees were species specific and could be completely suppressed by homologous competitor protein at a concentration of 10 mug/ml. Eleven of 12 samples from the low transmission regions and 12 of 20 samples from the high transmission area had antibody responses that were completely species specific. For 7 additional samples, the P. falciparum MSP119 responses were species specific, but various levels of incomplete heterologous competition were observed for the non-P. falciparum assays. A pan-malaria MSP119 cross-reactive antibody response was observed in elutions of blood spots from two 20-30 years old Mozambique donors. The antibody response from one of these two donors had low avidity and skewed almost entirely to the IgG3 subclass. CONCLUSIONS: Even when P. falciparum, P. malariae, P. ovale, and P. vivax are co-endemic in a high transmission setting, most antibody responses to MSP119 antigens are species-specific and are likely indicative of previous infection history. True pan-malaria cross-reactive responses were found to occur rarely. |
The Physical Activity Guidelines for Americans
Piercy KL , Troiano RP , Ballard RM , Carlson SA , Fulton JE , Galuska DA , George SM , Olson RD . JAMA 2018 320 (19) 2020-2028 Importance: Approximately 80% of US adults and adolescents are insufficiently active. Physical activity fosters normal growth and development and can make people feel, function, and sleep better and reduce risk of many chronic diseases. Objective: To summarize key guidelines in the Physical Activity Guidelines for Americans, 2nd edition (PAG). Process and Evidence Synthesis: The 2018 Physical Activity Guidelines Advisory Committee conducted a systematic review of the science supporting physical activity and health. The committee addressed 38 questions and 104 subquestions and graded the evidence based on consistency and quality of the research. Evidence graded as strong or moderate was the basis of the key guidelines. The Department of Health and Human Services (HHS) based the PAG on the 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Recommendations: The PAG provides information and guidance on the types and amounts of physical activity to improve a variety of health outcomes for multiple population groups. Preschool-aged children (3 through 5 years) should be physically active throughout the day to enhance growth and development. Children and adolescents aged 6 through 17 years should do 60 minutes or more of moderate-to-vigorous physical activity daily. Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. They should also do muscle-strengthening activities on 2 or more days a week. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week. Adults with chronic conditions or disabilities, who are able, should follow the key guidelines for adults and do both aerobic and muscle-strengthening activities. Recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial. Conclusions and Relevance: The Physical Activity Guidelines for Americans, 2nd edition, provides information and guidance on the types and amounts of physical activity that provide substantial health benefits. Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population. |
Prevalence of children walking to school and related barriers - United States, 2017
Omura JD , Hyde ET , Watson KB , Sliwa SA , Fulton JE , Carlson SA . Prev Med 2018 118 191-195 Children and adolescents can engage in an active lifestyle by walking to school; however, several barriers may limit this behavior. This study estimates the prevalence of walking to school and related barriers as reported by U.S. parents. Data from the 2017 SummerStyles, a Web-based survey conducted on a nationwide sample of U.S. adults, were analyzed in 2017. Parents of children aged 5-18years (n=1137) were asked whether their youngest child walked to or from school during a usual school week and what barriers make this difficult. Frequencies are presented overall and by parent characteristics. About 1 in 6 parents (16.5%) reported their youngest child walks to or from school at least once during a usual week. Prevalence differed by parental race/ethnicity, marital status, region, and distance from school. The most common barrier was living too far away (51.3%), followed by traffic-related danger (46.2%), weather (16.6%), "other" barrier (14.7%), crime (11.3%), and school policy (4.7%). The frequency at which parents reported certain barriers varied by their child's walking status, distance to school, age of youngest child, race/ethnicity, education level, household income, and metropolitan statistical area status. However, the relative ranking of barriers did not differ by these characteristics. Prevalence of walking to school is low in the U.S., and living too far away and traffic-related danger are common barriers reported by parents. Implementing Safe Routes to School programs and other initiatives that utilize strategies to overcome locally-relevant barriers could help increase the prevalence of children walking to school. |
Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students - United States, 2011-2018
Cullen KA , Ambrose BK , Gentzke AS , Apelberg BJ , Jamal A , King BA . MMWR Morb Mortal Wkly Rep 2018 67 (45) 1276-1277 Electronic cigarettes (e-cigarettes) are battery-powered devices that provide nicotine and other additives to the user in the form of an aerosol (1). E-cigarettes entered the U.S. marketplace in 2007 (1), and by 2014, e-cigarettes were the most commonly used tobacco product among U.S. youths (2). Data from the 2011–2018 National Youth Tobacco Survey (NYTS), a cross-sectional, voluntary, school-based, self-administered, pencil-and-paper survey of U.S. middle and high school students, were analyzed to determine the prevalence of current use (≥1 day in past 30 days) of e-cigarettes,* current use of any tobacco product,† frequency of (number of days during the preceding 30 days) e-cigarette use, and current use (any time during preceding 30 days) of any flavored e-cigarettes among U.S. middle school (grades 6–8) and high school (grades 9–12) students. Logistic regression (2011–2018) and t-tests (2017–2018) were performed to determine statistically significant differences (p<0.05). |
Licensed chikungunya virus vaccine: a possibility
Powers AM . Lancet 2018 392 (10165) 2660-2661 Arthropod-borne viruses (arboviruses) are some of the most important human pathogens in the world yet developing countermeasures to them is challenging and rarely leads to licensed products. A small number of arbovirus vaccines, including yellow fever and Japanese encephalitis vaccines, have long been used to prevent disease.1, 2 In 2016, a dengue vaccine was licensed to aid the control of dengue virus infections, which are responsible for an estimated 2 million severe disease cases and 21 000 deaths each year.3 Another virus transmitted by Aedes aegypti, chikungunya virus, has recently emerged as a global pathogen, with about 50% of the world's population at risk of infection.4 Although chikungunya virus infection is not associated with a high mortality rate, the severe and chronic clinical manifestations associated with the infection have led to the desire for rapid development of vaccines against the virus.5, 6, 7 |
Rabies vaccine initiation and adherence among animal-bite patients in Haiti, 2015
Tran CH , Kligerman M , Andrecy LL , Etheart MD , Adrien P , Blanton JD , Millien M , Wallace RM . PLoS Negl Trop Dis 2018 12 (11) e0006955 BACKGROUND: Approximately 59,000 people die from rabies worldwide annually. Haiti is one of the last remaining countries in the Western Hemisphere with endemic canine rabies. Canine-mediated rabies deaths are preventable with post-exposure prophylaxis (PEP): wound treatment, immunoglobulin, and vaccination. In countries where PEP is available, variability in healthcare seeking behaviors and lack of adherence to recommended treatment guidelines could also contribute to these deaths. Yet, few studies have addressed these issues. METHODS: We examined animal-bite reporting and assessed adherence to treatment guidelines at nine healthcare facilities in Haiti. We analyzed individual-level, de-identified patient data (demographic characteristics, geographic location, healthcare facility type, vaccine administration, and bite injury information) using descriptive analyses and logistic regression to examine factors associated with receiving PEP. FINDINGS: During the 6 month study period, we found 2.5 times more animal-bite case-patients than reported by the national surveillance system (690 versus 274). Of the 690 animal-bite patients identified, 498 (72%) sought care at six PEP providing facilities. Of the case-patients that sought care, 110 (22%) received at least one rabies vaccine. Of the 110 patients, 60 (55%) received all five doses. Delays were observed for three events: when patients presented to a facility after an animal-bite (3.0 days, range: 0-34 days), when patients received their fourth dose (16.1 days, range: 13-52 days), and when patients received their fifth dose (29 days, range: 26-52). When comparing vaccination status and patient characteristics, we found a significant association for bite location (p < .001), severity rank score (p < .001), geographic location (p < .001), and healthcare facility type (p = .002) with vaccination. CONCLUSION: High levels of underreporting identified here are of concern since vaccine distribution may, in part, be based on the number of animal-bite cases reported. Given that the Haitian government provides PEP to the population for free and we found animal-bite victims are seeking care in a timely manner horizontal line reducing rabies deaths is an achievable goal. |
Content Index (Achived Edition)
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- Environmental Health
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