Metabolically healthy obesity and development of chronic kidney disease
Kahn HS , Pavkov ME . Ann Intern Med 2016 165 (10) 743 In their longitudinal study of metabolically healthy workers, Chang and colleagues (1) showed that higher BMI categories were associated with an increased incidence of CKD. They interpreted this finding as an adverse consequence of adiposity. However, their description of participant subgroups suggests that the association reported between elevated BMI and incident CKD was driven by relationships found primarily among older adults, men, and persons who exercise frequently. These are subgroups in which BMI status might reflect variations in the preservation or formation of muscle mass rather than the accumulation of adipose tissue. Greater muscle mass leads to increased production of creatinine, which in turn is associated with a reduced estimated glomerular filtration rate (GFR) (2) consistent with the final row of Table 1 of the article. Reduction of the estimated GFR to less than 60 mL/min/1.73 m2 was the quantitative threshold for identifying incident events of CKD. | Our curiosity leads to testable hypotheses. We suggest that Chang and colleagues use their Kangbuk Samsung Health Study to assess whether the decline in the estimated GFR might be associated more strongly with baseline lean mass rather than adipose tissue. As the authors recently reported (3), their healthy-worker cohort also provided measurements of bioelectric impedance and waist circumference. Thus, baseline values can be calculated for the percentage of fat and fat-free mass and the waist–height ratio. | Controversies exist about how to interpret BMI (4, 5). To clarify how it contributes to the decline in the estimated GFR, the authors could consider which tissue components or anatomical distributions of body mass best predict the described outcome. |
Heart disease and cancer deaths - trends and projections in the United States, 1969-2020
Weir HK , Anderson RN , Coleman King SM , Soman A , Thompson TD , Hong Y , Moller B , Leadbetter S . Prev Chronic Dis 2016 13 E157 INTRODUCTION: Heart disease and cancer are the first and second leading causes of death in the United States. Age-standardized death rates (risk) have declined since the 1960s for heart disease and for cancer since the 1990s, whereas the overall number of heart disease deaths declined and cancer deaths increased. We analyzed mortality data to evaluate and project the effect of risk reduction, population growth, and aging on the number of heart disease and cancer deaths to the year 2020. METHODS: We used mortality data, population estimates, and population projections to estimate and predict heart disease and cancer deaths from 1969 through 2020 and to apportion changes in deaths resulting from population risk, growth, and aging. RESULTS: We predicted that from 1969 through 2020, the number of heart disease deaths would decrease 21.3% among men (-73.9% risk, 17.9% growth, 34.7% aging) and 13.4% among women (-73.3% risk, 17.1% growth, 42.8% aging) while the number of cancer deaths would increase 91.1% among men (-33.5% risk, 45.6% growth, 79.0% aging) and 101.1% among women (-23.8% risk, 48.8% growth, 76.0% aging). We predicted that cancer would become the leading cause of death around 2016, although sex-specific crossover years varied. CONCLUSION: Risk of death declined more steeply for heart disease than cancer, offset the increase in heart disease deaths, and partially offset the increase in cancer deaths resulting from demographic changes over the past 4 decades. If current trends continue, cancer will become the leading cause of death by 2020. |
Investigation of a Guillain-Barre syndrome cluster in the Republic of Fiji
Pastula DM , Khan AS , Sharp TM , Biaukula VL , Naivalu TK , Rafai E , Belay E , Staples JE , Fischer M , Kosoy OI , Laven JJ , Bennett EJ , Jenney AW , Naidu RN , Lanciotti RS , Galloway RL , Nilles EJ , Sejvar JJ , Kama M . J Neurol Sci 2016 372 350-355 BACKGROUND: In 2014, we investigated a cluster of Guillain-Barre syndrome (GBS) in Fiji that occurred during a dengue epidemic. We designed a case-control study to determine the etiology. METHODS: Cases were patients meeting Brighton Collaboration criteria for GBS with onset from February 2014 to May 2014. Controls were persons without symptoms of GBS who were matched by age group and location. We collected information on demographics and potential exposures. Serum samples were tested for evidence of recent arboviral or Leptospira spp. infections. RESULTS: Nine cases of GBS were identified for an incidence of five cases per 100,000 population/year. Median age of cases was 27years (range: 0.8-52); five (56%) were male. Six (67%) reported an acute illness prior to GBS onset. Among the 9 cases and 28 controls enrolled, odds ratios for reported exposures or antibodies against various arboviruses or Leptospira spp. were not statistically significant. CONCLUSIONS: No clear etiologies were identified for this unusual GBS cluster. There was a temporal association between the GBS cluster and a dengue epidemic, but we were unable to substantiate an epidemiologic or laboratory association. Further study is needed to explore potential associations between arboviral infections and GBS. |
CDC Grand Rounds: A public health approach to detect and control hypertension
Merai R , Siegel C , Rakotz M , Basch P , Wright J , Wong B , Thorpe P . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1261-1264 Hypertension is generally defined as systolic blood pressure ≥140 mmHg, or diastolic blood pressure ≥90 mmHg. A person who currently uses blood pressure-lowering medication is also defined as having hypertension. Hypertension is a leading risk factor for cardiovascular disease and stroke. Hypertension affects nearly one third of U.S. residents aged ≥18 years (approximately 75 million persons), and in approximately one half of adults with hypertension (nearly 35 million persons), it is uncontrolled. Among these 35 million U.S. residents with uncontrolled hypertension, 33% (11.5 million persons) are not aware of their hypertension, 20% (7 million persons) are aware of their hypertension, but are not being treated for it, and approximately 47% (16.1 million persons) are aware of their hypertension and being treated for it, but treatment (by medication and/or lifestyle modification) is not adequately controlling their blood pressure. |
Disparities in the prevalence of diagnosed diabetes - United States, 1999-2002 and 2011-2014
Beckles GL , Chou CF . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1265-1269 The prevalence of diabetes mellitus has increased rapidly in the United States since the mid-1990s. By 2014, an estimated 29.1 million persons, or 9.3% of the total population, had received a diagnosis of diabetes. Recent evidence indicates that the prevalence of diagnosed diabetes among non-Hispanic black (black), Hispanic, and poorly educated adults continues to increase but has leveled off among non-Hispanic whites (whites) and persons with higher education. During 2004-2010, CDC reported marked racial/ethnic and socioeconomic position disparities in diabetes prevalence and increases in the magnitude of these disparities over time. However, the magnitude and extent of temporal change in socioeconomic position disparities in diagnosed diabetes among racial/ethnic populations are unknown. CDC used data from the National Health Interview Survey (NHIS) for the periods 1999-2002 and 2011-2014 to assess the magnitude of and change in socioeconomic position disparities in the age-standardized prevalence of diagnosed diabetes in the overall population and among blacks, whites, and Hispanics. During each period, significant socioeconomic position disparities existed in the overall population and among the assessed racial/ethnic populations. Disparities in prevalence increased with increasing socioeconomic disadvantage and widened over time among Hispanics and whites but not among blacks. The persistent widening of the socioeconomic position gap in prevalence suggests that interventions to reduce the risk for diabetes might have a different impact according to socioeconomic position. |
Viral factors in influenza pandemic risk assessment.
Lipsitch M , Barclay W , Raman R , Russell CJ , Belser JA , Cobey S , Kasson PM , Lloyd-Smith JO , Maurer-Stroh S , Riley S , Beauchemin CA , Bedford T , Friedrich TC , Handel A , Herfst S , Murcia PR , Roche B , Wilke CO , Russell CA . Elife 2016 5 The threat of an influenza A virus pandemic stems from continual virus spillovers from reservoir species, a tiny fraction of which spark sustained transmission in humans. To date, no pandemic emergence of a new influenza strain has been preceded by detection of a closely related precursor in an animal or human. Nonetheless, influenza surveillance efforts are expanding, prompting a need for tools to assess the pandemic risk posed by a detected virus. The goal would be to use genetic sequence and/or biological assays of viral traits to identify those non-human influenza viruses with the greatest risk of evolving into pandemic threats, and/or to understand drivers of such evolution, to prioritize pandemic prevention or response measures. We describe such efforts, identify progress and ongoing challenges, and discuss three specific traits of influenza viruses (hemagglutinin receptor binding specificity, hemagglutinin pH of activation, and polymerase complex efficiency) that contribute to pandemic risk. |
The rectal mucosa and condomless receptive anal intercourse in HIV-negative MSM: implications for HIV transmission and prevention.
Kelley CF , Kraft CS , de Man TJ , Duphare C , Lee HW , Yang J , Easley KA , Tharp GK , Mulligan MJ , Sullivan PS , Bosinger SE , Amara RR . Mucosal Immunol 2016 10 (4) 996-1007 Most HIV transmissions among men who have sex with men (MSM), the group that accounted for 67% of new US infections in 2014, occur via exposure to the rectal mucosa. However, it is unclear how the act of condomless receptive anal intercourse (CRAI) may alter the mucosal immune environment in HIV-negative MSM. Here, we performed a comprehensive characterization of the rectal mucosal immune environment for the phenotype and production of pro-inflammatory cytokines by CD4 and CD8 T cells, global transcriptomic analyses, and the composition of microbiota in HIV-negative MSM. Our results show that compared with men who had never engaged in anal intercourse, the rectal mucosa of MSM engaging in CRAI has a distinct phenotype characterized by higher levels of Th17 cells, greater CD8+ T cell proliferation and production of pro-inflammatory cytokines, molecular signatures associated with mucosal injury and repair likely mediated by innate immune cells, and a microbiota enriched for the Prevotellaceae family. These data provide a high-resolution model of the immunological, molecular, and microbiological perturbations induced by CRAI, will have direct utility in understanding rectal HIV transmission among MSM, and will enhance the design of future biomedical prevention interventions, including candidate HIV vaccines. |
The role of the primary romantic relationship in HIV care engagement outcomes among young HIV-positive black men who have sex with men
Tan JY , Pollack L , Rebchook G , Peterson J , Huebner D , Eke A , Johnson W , Kegeles S . AIDS Behav 2016 22 (3) 774-790 The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV. |
A randomized clinical trial on the effects of progestin contraception in the genital tract of HIV-infected and uninfected women in Lilongwe, Malawi: Addressing evolving research priorities
Kourtis AP , Haddad L , Tang J , Chinula L , Hurst S , Wiener J , Ellington S , Nelson JA , Corbett A , De Paris K , King CC , Hosseinipour M , Hoffman IF , Jamieson DJ . Contemp Clin Trials 2016 52 27-34 Hormonal contraception is central in the prevention of unintended pregnancy; however there are concerns that certain methods may increase the risk of HIV acquisition and transmission. Hormonal contraceptives may modify the genital mucosa in several ways, however the mechanisms are incompletely understood. Few studies have examined genital HIV shedding prospectively before and after initiation of hormonal contraception. The effects of hormonal contraception on genital HIV shedding in the setting of antiretroviral therapy (ART) are also unknown. We designed a pilot clinical trial in which HIV-infected and uninfected women were randomized to either depot medroxyprogesterone acetate (DMPA) injectable or levonorgestrel (LNG) implant in Lilongwe, Malawi. The objectives were to: 1) assess the effect and compare the impact of type of progestin contraception (injectable versus implant) on HIV genital shedding among HIV-infected women, 2) assess the effect and compare the impact of type of progestin contraception on inflammatory/immune markers in the genital tract of both HIV-infected and uninfected women, and 3) assess the interaction of progestin contraception and ART by examining contraceptive efficacy and ART efficacy. An additional study aim was to determine the feasibility and need for a larger study of determinants of HIV transmissibility and acquisition. As injectable contraception is widely used in many parts of the world with high HIV prevalence, this study will provide important information in determining the need for and feasibility of a larger study to address these questions that can impact the lives of millions of women living with or at risk for HIV. |
Reengagement in care after a gap in HIV care among a population of privately insured persons with HIV in the United States
Byrd KK , Furtado M , Bush T , Gardner L . AIDS Patient Care STDS 2016 30 (11) 491-496 The HIV care continuum illustrates steps needed to reach HIV viral suppression, including retention in care. The continuum's retention measure does not account for gaps or reengagement in care and thus provides an incomplete picture of long-term engagement. We used a claims database to determine the proportion of privately insured persons with HIV who experienced a gap in care and subsequently reengaged between 2008 and 2012. A gap was defined as no office visit claim in >6 months and reengagement as ≥1 office visit claim after a gap. Cox proportional hazards models were conducted to determine factors associated with time to first gap and time to reengagement. Of 5142 persons in the study, 79% were males and median age was 46 years (range, 19-64 years). No race/ethnicity data were available. Thirty percent (n = 1555) experienced a gap. Median time to first gap was 15 months (IQR: 6-30). Median gap length was 3.2 months. Seventy percent with a gap reengaged; 22% reengaged more than once. Of 1086 patients who reengaged, 224 (21%) eventually had a terminal gap. Residence in the North Central region (HR 0.73, 95% CI 0.62-0.87) and having ≥1 Charlson comorbidities (HR 0.85, 95% CI 0.73-0.99) were associated with shorter time to reengagement. The majority who experienced a gap reengaged within a relatively short period and remained in the cohort at 60 months. However, 21% of those reengaging had a terminal gap by 60 months, which should alert providers to the eventual potential for loss to follow-up. The analysis was limited by inability to distinguish between HIV-specific and non-HIV-specific care visits. |
Substance use and HIV-risk behaviors among HIV-positive men who have sex with men in China: repeated measures in a cohort study design
Zhang C , Liu Y , Sun X , Wang J , Lu HY , He X , Zhang H , Ruan YH , Shao Y , Vermund SH , Qian HZ . AIDS Care 2016 29 (5) 1-10 Global literature revealed that seropositive men who have sex with men (MSM) posed an even higher risk compared to their seronegative counterparts. Identifying risk factors that contribute to HIV-risk behaviors will help to curb the rapid HIV transmission among this group. Our hypothesis was that MSM with substance use were more likely to conduct HIV-risk behaviors, even after accounting for repeated measures. In the current study, we employed a cohort study design by following a group of 367 HIV-positive MSM up to four visits for one year to collect information regarding their sexual behaviors and history of substance use in the past three months. We used Generalized Estimating Equations (GEE) models to account both within- and between-subject variation when assessing associations between substance use and HIV-risk behaviors. A total of 367 MSM were included at the baseline with a mean age of 29.6 years. After accounting for potential confounders and time-varying effects, our models indicated that drug and alcohol use increase HIV risks at the population level by increasing risks of drinking alcohol before sex, having unprotected sex with men and seropositive partners, having more lifetime female sex partners and having a higher number of male sexual partners in the past three months. The current study is one of the first studies with repeated measures to evaluate the association between substance use and sexual risk behaviors among MSM in China. Findings in the current study have several implications for future research. We call for more rigorous study design for future research to better capture changes of risky behaviors among this at-risk population. |
Tuberculosis screening at a diabetes clinic in the Republic of the Marshall Islands
Trinidad RM , Brostrom R , Morello MI , Montgomery D , Thein CC , Gajitos ML , Heetderks A , Chorba T . J Clin Tuberc Other Mycobact Dis 2016 5 4-7 Setting Tuberculosis (TB) and diabetes mellitus (DM) are prominent public health problems in the Republic of the Marshall Islands, a small island nation with high rates of tuberculosis and diabetes. Objective Evaluate the rate of active and latent TB in a Pacific Island DM clinic. Design In one DM clinic on the island of Ebeye, 213 adult patients aged 27–86 years completed tuberculin skin testing and TB work-up between April 2010 and March 2012. Results Screening for TB led to the diagnosis of 77 patients with TB infection and 11 patients with TB disease. From these data, the prevalence of TB disease among DM patients in the clinic exceeded 5% (95% CI 2.2%–8.1%). All patients who completed TB screening were at high risk of TB disease, and those with DM aged ≤ 50 years had a higher risk of TB disease than those with DM over age 50 (RR 3.1, C.I. 1.0–9.7, p = 0.05). Conclusion The experience at the Ebeye Diabetes Clinic demonstrates that screening DM patients for TB can identify significant rates of TB infection and TB disease, and should be considered for other settings with a high background TB incidence. Further assessment of TB risks should explore age, gender, and level of diabetes control. |
Pertussis-associated pneumonia in infants and children from low- and middle-income countries participating in the PERCH Study
Barger-Kamate B , Deloria Knoll M , Kagucia EW , Prosperi C , Baggett HC , Brooks WA , Feikin DR , Hammitt LL , Howie SR , Levine OS , Madhi SA , Scott JA , Thea DM , Amornintapichet T , Anderson TP , Awori JO , Baillie VL , Chipeta J , DeLuca AN , Driscoll AJ , Goswami D , Higdon MM , Hossain L , Karron RA , Maloney S , Moore DP , Morpeth SC , Mwananyanda L , Ofordile O , Olutunde E , Park DE , Sow SO , Tapia MD , Murdoch DR , O'Brien KL , Kotloff KL . Clin Infect Dis 2016 63 S187-s196 BACKGROUND: Few data exist describing pertussis epidemiology among infants and children in low- and middle-income countries to guide preventive strategies. METHODS: Children 1-59 months of age hospitalized with World Health Organization-defined severe or very severe pneumonia in 7 African and Asian countries and similarly aged community controls were enrolled in the Pneumonia Etiology Research for Child Health study. They underwent a standardized clinical evaluation and provided nasopharyngeal and oropharyngeal swabs and induced sputum (cases only) for Bordetella pertussis polymerase chain reaction. Risk factors and pertussis-associated clinical findings were identified. RESULTS: Bordetella pertussis was detected in 53 of 4200 (1.3%) cases and 11 of 5196 (0.2%) controls. In the age stratum 1-5 months, 40 (2.3% of 1721) cases were positive, all from African sites, as were 8 (0.5% of 1617) controls. Pertussis-positive African cases 1-5 months old, compared to controls, were more often human immunodeficiency virus (HIV) uninfected-exposed (adjusted odds ratio [aOR], 2.2), unvaccinated (aOR, 3.7), underweight (aOR, 6.3), and too young to be immunized (aOR, 16.1) (all P ≤ .05). Compared with pertussis-negative African cases in this age group, pertussis-positive cases were younger, more likely to vomit (aOR, 2.6), to cough ≥14 days (aOR, 6.3), to have leukocyte counts >20 000 cells/microL (aOR, 4.6), and to have lymphocyte counts >10 000 cells/microL (aOR, 7.2) (all P ≤ .05). The case fatality ratio of pertussis-infected pneumonia cases 1-5 months of age was 12.5% (95% confidence interval, 4.2%-26.8%; 5/40); pertussis was identified in 3.7% of 137 in-hospital deaths among African cases in this age group. CONCLUSIONS: In the postneonatal period, pertussis causes a small fraction of hospitalized pneumonia cases and deaths; however, case fatality is substantial. The propensity to infect unvaccinated infants and those at risk for insufficient immunity (too young to be vaccinated, premature, HIV-infected/exposed) suggests that the role for maternal vaccination should be considered along with efforts to reduce exposure to risk factors and to optimize childhood pertussis vaccination coverage. |
Epidemiology of pertussis among young Pakistani infants: A community-based prospective surveillance study
Omer SB , Kazi AM , Bednarczyk RA , Allen KE , Quinn CP , Aziz F , Sial K , Phadke VK , Tondella ML , Williams MM , Orenstein WA , Ali SA . Clin Infect Dis 2016 63 S148-s153 BACKGROUND: Pertussis remains a cause of morbidity and mortality among young infants. There are limited data on the pertussis disease burden in this age group from low- and lower-middle-income countries, including in South Asia. METHODS: We conducted an active community-based surveillance study from February 2015 to April 2016 among 2 cohorts of young infants in 4 low-income settlements in Karachi, Pakistan. Infants were enrolled either at birth (closed cohort) or at ages up to 10 weeks (open cohort) and followed until 18 weeks of age. Nasopharyngeal swab specimens were obtained from infants who met a standardized syndromic case definition and tested for Bordetella pertussis using real-time polymerase chain reaction. We determined the incidence of pertussis using a protocol-defined case definition, as well as the US Centers for Disease Control and Prevention (CDC) definitions for confirmed and probable pertussis. RESULTS: Of 2021 infants enrolled into the study, 8 infants met the protocol-defined pertussis case definition, for an incidence of 3.96 (95% confidence interval [CI], 1.84-7.50) cases per 1000 infants. Seven of the pertussis cases met the CDC pertussis case definition (5 confirmed, 2 probable), for incidences of CDC-defined confirmed pertussis of 2.47 (95% CI, .90-5.48) cases per 1000 infants, and probable pertussis of 0.99 (95% CI, .17-3.27) cases per 1000 infants. Three of the pertussis cases were severe according to the Modified Preziosi Scale score. CONCLUSIONS: In one of the first prospective surveillance studies of infant pertussis in a developing country, we identified a moderate burden of pertussis disease in early infancy in Pakistan. |
Exposure patterns driving Ebola transmission in West Africa: a retrospective observational study
Agua-Agum J , Ariyarajah A , Aylward B , Bawo L , Bilivogui P , Blake IM , Brennan RJ , Cawthorne A , Cleary E , Clement P , Conteh R , Cori A , Dafae F , Dahl B , Dangou JM , Diallo B , Donnelly CA , Dorigatti I , Dye C , Eckmanns T , Fallah M , Ferguson NM , Fiebig L , Fraser C , Garske T , Gonzalez L , Hamblion E , Hamid N , Hersey S , Hinsley W , Jambei A , Jombart T , Kargbo D , Keita S , Kinzer M , George FK , Godefroy B , Gutierrez G , Kannangarage N , Mills HL , Moller T , Meijers S , Mohamed Y , Morgan O , Nedjati-Gilani G , Newton E , Nouvellet P , Nyenswah T , Perea W , Perkins D , Riley S , Rodier G , Rondy M , Sagrado M , Savulescu C , Schafer IJ , Schumacher D , Seyler T , Shah A , Van Kerkhove MD , Wesseh CS , Yoti Z . PLoS Med 2016 13 (11) e1002170 BACKGROUND: The ongoing West African Ebola epidemic began in December 2013 in Guinea, probably from a single zoonotic introduction. As a result of ineffective initial control efforts, an Ebola outbreak of unprecedented scale emerged. As of 4 May 2015, it had resulted in more than 19,000 probable and confirmed Ebola cases, mainly in Guinea (3,529), Liberia (5,343), and Sierra Leone (10,746). Here, we present analyses of data collected during the outbreak identifying drivers of transmission and highlighting areas where control could be improved. METHODS AND FINDINGS: Over 19,000 confirmed and probable Ebola cases were reported in West Africa by 4 May 2015. Individuals with confirmed or probable Ebola ("cases") were asked if they had exposure to other potential Ebola cases ("potential source contacts") in a funeral or non-funeral context prior to becoming ill. We performed retrospective analyses of a case line-list, collated from national databases of case investigation forms that have been reported to WHO. These analyses were initially performed to assist WHO's response during the epidemic, and have been updated for publication. We analysed data from 3,529 cases in Guinea, 5,343 in Liberia, and 10,746 in Sierra Leone; exposures were reported by 33% of cases. The proportion of cases reporting a funeral exposure decreased over time. We found a positive correlation (r = 0.35, p < 0.001) between this proportion in a given district for a given month and the within-district transmission intensity, quantified by the estimated reproduction number (R). We also found a negative correlation (r = -0.37, p < 0.001) between R and the district proportion of hospitalised cases admitted within ≤4 days of symptom onset. These two proportions were not correlated, suggesting that reduced funeral attendance and faster hospitalisation independently influenced local transmission intensity. We were able to identify 14% of potential source contacts as cases in the case line-list. Linking cases to the contacts who potentially infected them provided information on the transmission network. This revealed a high degree of heterogeneity in inferred transmissions, with only 20% of cases accounting for at least 73% of new infections, a phenomenon often called super-spreading. Multivariable regression models allowed us to identify predictors of being named as a potential source contact. These were similar for funeral and non-funeral contacts: severe symptoms, death, non-hospitalisation, older age, and travelling prior to symptom onset. Non-funeral exposures were strongly peaked around the death of the contact. There was evidence that hospitalisation reduced but did not eliminate onward exposures. We found that Ebola treatment units were better than other health care facilities at preventing exposure from hospitalised and deceased individuals. The principal limitation of our analysis is limited data quality, with cases not being entered into the database, cases not reporting exposures, or data being entered incorrectly (especially dates, and possible misclassifications). CONCLUSIONS: Achieving elimination of Ebola is challenging, partly because of super-spreading. Safe funeral practices and fast hospitalisation contributed to the containment of this Ebola epidemic. Continued real-time data capture, reporting, and analysis are vital to track transmission patterns, inform resource deployment, and thus hasten and maintain elimination of the virus from the human population. |
Effectiveness of six improved cookstoves in reducing household air pollution and their acceptability in rural western Kenya
Pilishvili T , Loo JD , Schrag S , Stanistreet D , Christensen B , Yip F , Nyagol R , Quick R , Sage M , Bruce N . PLoS One 2016 11 (11) e0165529 BACKGROUND: Household air pollution (HAP) from biomass fuel burning is linked to poor health outcomes. Improved biomass cookstoves (ICS) have the potential to improve HAP. OBJECTIVES: A pre-/post- intervention study assessed the impact of six ICS on indoor air quality and acceptability of ICS to local users in rural Western Kenya. METHODS: We measured mean personal and kitchen level concentrations of particulate matter <2.5mum in diameter (PM2.5, mug/m3) and carbon monoxide (CO, ppm) during the 48-hour period of each ICS use in 45 households. We compared these levels to those observed with traditional 3-stone fire (TSF) use. We assessed ICS acceptability through interviews and focus groups. We evaluated association of stove type, fuel use, and factors related to cooking practices with mean kitchen PM2.5 and CO using multivariable regression. RESULTS: Stove type, exclusive ICS use (vs. concurrent TSF use), and the amount of fuel used were independently associated with kitchen PM2.5 and CO levels. Reductions (95%CI) in mean PM2.5 compared to TSF, ranged by ICS from 11.9% (-2.8-24.5) to 42.3% (32.3-50.8). Reductions in kitchen CO compared to TSF, ranged by ICS from -5.8% (-21.9-8.2) to 34.5% (23.2-44.1). Mean kitchen PM2.5 ranged from 319mug/m3 to 518mug/m3 by ICS. Women thought ICS were easy to use, more efficient, produced less smoke, and cooked faster, compared to TSF. Women also reported limitations for each ICS. CONCLUSIONS: We documented reductions in HAP from ICS compared to TSF. The PM2.5 levels with ICS use were still considerably higher than WHO indoor air quality guidelines. Achieving maximal potential of ICS requires adherence to more exclusive use and addressing user reported ICS limitations. |
Associations of urinary phthalate and phenol biomarkers with menarche among a multiethnic cohort of young girls
Wolff MS , Pajak A , Pinney SM , Windham GC , Galvez M , Rybak M , Silva MJ , Ye X , Calafat AM , Kushi LH , Biro FM , Teitelbaum SL . Reprod Toxicol 2016 67 56-64 To study potential environmental influences on puberty in girls, we investigated urinary biomarkers in relation to age at menarche. Phenols and phthalates were measured at baseline (6-8 years of age). Menarche was ascertained over 11 years for 1051 girls with menarche and biomarkers. Hazards ratios were estimated from Cox models adjusted for race/ethnicity and caregiver education (aHR, 95% confidence intervals [CI] for 5th vs 1st quintile urinary biomarker concentrations). 2,5-Dichlorophenol was associated with earlier menarche (aHR 1.34 [1.06-1.71]); enterolactone was associated with later menarche (aHR 0.82 [0.66-1.03]), as was mono-3-carboxypropyl phthalate (MCPP) (aHR 0.73 [0.59-0.91]); the three p-trends were <.05. Menarche differed by 4-7 months across this range. Enterolactone and MCPP associations were stronger in girls with below-median body mass index. These analytes were also associated with age at breast development in this cohort. Findings from this prospective study suggest that some childhood exposures are associated with pubertal timing. |
National weighting of data from the Behavioral Risk Factor Surveillance System (BRFSS)
Iachan R , Pierannunzi C , Healey K , Greenlund KJ , Town M . BMC Med Res Methodol 2016 16 (1) 155 BACKGROUND: The Behavioral Risk Factor Surveillance System (BRFSS) is a network of health-related telephone surveys--conducted by all 50 states, the District of Columbia, and participating US territories-that receive technical assistance from CDC. Data users often aggregate BRFSS state samples for national estimates without accounting for state-level sampling, a practice that could introduce bias because the weighted distributions of the state samples do not always adhere to national demographic distributions. METHODS: This article examines six methods of reweighting, which are then compared with key health indicator estimates from the National Health Interview Survey (NHIS) based on 2013 data. RESULTS: Compared to the usual stacking approach, all of the six new methods reduce the variance of weights and design effect at the national level, and some also reduce the estimated bias. This article also provides a comparison of the methods based on the variances induced by unequal weighting as well as the bias reduction induced by raking at the national level, and recommends a preferred method. CONCLUSIONS: The new method leads to weighted distributions that more accurately reproduce national demographic characteristics. While the empirical results for key estimates were limited to a few health indicators, they also suggest reduction in potential bias and mean squared error. To the extent that survey outcomes are associated with these demographic characteristics, matching the national distributions will reduce bias in estimates of these outcomes at the national level. |
MRSA and multidrug-resistant Staphylococcus aureus in U.S. retail meats, 2010–2011
Ge B , Mukherjee S , Hsu CH , Davis JA , Tran TTT , Yang Q , Abbott JW , Ayers SL , Young SR , Crarey ET , Womack NA , Zhao S , McDermott PF . Food Microbiol 2017 62 289-297 Methicillin-resistant Staphylococcus aureus (MRSA) has been detected in retail meats, although large-scale studies are scarce. We conducted a one-year survey in 2010–2011 within the framework of the National Antimicrobial Resistance Monitoring System. Among 3520 retail meats collected from eight U.S. states, 982 (27.9%) contained S. aureus and 66 (1.9%) were positive for MRSA. Approximately 10.4% (107/1032) of S. aureus isolates, including 37.2% (29/78) of MRSA, were multidrug-resistant (MDRSA). Turkey had the highest MRSA prevalence (3.5%), followed by pork (1.9%), beef (1.7%), and chicken (0.3%). Whole-genome sequencing was performed for all 66 non-redundant MRSA. Among five multilocus sequence types identified, ST8 (72.7%) and ST5 (22.7%) were most common and livestock-associated MRSA ST398 was assigned to one pork isolate. Eleven spa types were represented, predominately t008 (43.9%) and t2031 (22.7%). All four types of meats harbored t008, whereas t2031 was recovered from turkey only. The majority of MRSA (84.8%) possessed SCCmec IV and 62.1% harbored Panton-Valentine leukocidin. Pulsed-field gel electrophoresis showed that all ST8 MRSA belonged to the predominant human epidemic clone USA300, and others included USA100 and USA200. We conclude that a diverse MRSA population was present in U.S. retail meats, albeit at low prevalence. |
Rapid identification of measles virus vaccine genotypes by real time PCR.
Roy F , Mendoza L , Hiebert J , McNall RJ , Bankamp B , Connolly S , Ludde A , Friedrich N , Mankertz A , Rota PA , Severini A . J Clin Microbiol 2016 55 (3) 735-743 During measles outbreaks, it is important to be able to rapidly distinguish between measles cases and vaccine reactions to avoid unnecessary outbreak response measures such as case isolation and contact investigations. We have developed a real-time RT-PCR method specific for genotype A measles virus (MeVA RT-qPCR), that can identify measles vaccine strains rapidly, with high throughput, and without the need for sequencing to determine the genotype. We have evaluated the method independently in three measles reference laboratories using two platforms, the Roche Lightcycler(R) 480 and the Applied Biosystems (ABI) 7500 Real-Time PCR System. In comparison to the standard real time RT-PCR method, the MeVA RT-qPCR showed 99.5% specificity for genotype A and 94% sensitivity for both platforms. The new assay was able to detect RNA from five currently used vaccine strains, AIK-C, CAM-70, Edmonston-Zagreb, Moraten, and Shanghai-191. The MeVA RT qPCR assay has been used successfully for measles surveillance in reference laboratories and it could be readily deployed to national and subnational laboratories on a wide scale. |
Evaluation of the Acceptance Journeys social marketing campaign to reduce homophobia
Hull SJ , Davis CR , Hollander G , Gasiorowicz M , Jeffries WLth , Gray S , Bertolli J , Mohr A . Am J Public Health 2016 107 (1) e1-e7 OBJECTIVES: To evaluate the effectiveness of the Acceptance Journeys social marketing campaign to reduce homophobia in the Black community in Milwaukee, Wisconsin. METHODS: We assessed the campaign's effectiveness using a rolling cross-sectional survey. Data were collected annually online between 2011 and 2015. Each year, a unique sample of Black and White adults, aged 30 years and older, were surveyed in the treatment city (Milwaukee) and in 2 comparison cities that did not have antihomophobia campaigns (St. Louis, MO, and Cleveland, OH; for total sample, n = 3592). RESULTS: Black self-identification and Milwaukee residence were significantly associated with exposure to the campaign, suggesting successful message targeting. The relationship between exposure and acceptance of gay men was significantly mediated through attitudes toward gay men, perceptions of community acceptance, and perceptions of the impact of stigma on gay men, but not through rejection of stereotypes. This model accounted for 39% of variance in acceptance. CONCLUSIONS: This evidence suggests that the Acceptance Journeys model of social marketing may be a promising strategy for addressing homophobia in US Black communities. |
Getting beyond impressions: An evaluation of engagement with breast cancer-related Facebook content
Theiss SK , Burke RM , Cory JL , Fairley TL . Mhealth 2016 2 (41) BACKGROUND: Reaching young adults with health messages has been a documented challenge in public health. Public health researchers have initiated studies to assess how social media are changing health communication. In 2014, the Centers for Disease Control and Prevention (CDC) launched social media-based health education initiatives on Facebook to increase knowledge of breast health and breast cancer among women under age 45 and those at higher risk for developing the disease. The current study used digital analytics and metrics to describe the impact of these social media efforts on health communication. METHODS: Engagement rate was calculated by taking the average engagement rate for 574 posts published by the CDC Breast Cancer Facebook page in multiple categories, including CDC campaign specificity, content type, time of day, and year posted. Linear regression was used to model the effect of campaign content. RESULTS: Engagement rate (ER) was highest for content shared for the Know:BRCA campaign posts (ER=6.4), followed by the non-campaign related posts (ER=5.5), and the Bring Your Brave posts (ER=4.6). Overall engagement rate decreased from 2014-2016. Photos consistently produced the most significant engagement rate overall. CONCLUSIONS: We found that users were more likely to click, share, comment, or like the content of the post that had photos. These data suggest that that branded, visual content is more effective in facilitating engagement. These findings will be used to adjust both free and paid social media efforts for the CDC Breast Cancer Facebook page. |
Estimating the cost of operating cancer registries: Experience in Colombia
de Vries E , Pardo C , Arias N , Bravo LE , Navarro E , Uribe C , Yepez MC , Jurado D , Garci LS , Pineros M , Edwards P , Beebe MC , Tangka F , Subramanian S . Cancer Epidemiol 2016 45 Suppl 1 S13-S19 BACKGROUND: Maintaining population-based registries requires adequate and sustained resources; however, to date there has been no systematic evaluation to identify the resource needs for cancer registration in most countries, including Colombia. A systematic assessment of the costs can quantify the funding required and identify processes to improve efficiency of cancer registries. METHODS: The Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool) was tailored specifically for the Colombian registries and was used to collect resource use data from five regional population-based cancer registries: Barranquilla, Bucaramanga, Cali, Manizales, and Pasto. The registries provided cost data for the year 2013 and cancer cases corresponding to the year 2010. RESULTS: We identified an almost threefold variation in the average cost per case (77,932 to 214,082 Colombian pesos or US $41 to US $113 in 2013) across the registries, but there were also substantial differences in data collection approaches, types of data collected, and activities performed. Cost per inhabitant varied between 95 and 415 Colombian pesos (US $0.05 to US $0.22). Between 20% and 45% of the total cost was due to fixed cost activities. CONCLUSIONS: The detailed economic information presented in this study constitutes a valuable source of activity-based cost data that registries can use to compare operations, assess key factors that lead to differences in cost per case, and identify potential approaches to improve efficiencies. Furthermore, the knowledge gained from studying the Colombian registries can help inform the planning and operations of other registries in the region. |
Notes from the field: Fungal bloodstream infections associated with a compounded intravenous medication at an outpatient oncology clinic - New York City, 2016
Vasquez AM , Lake J , Ngai S , Halbrook M , Vallabhaneni S , Keckler MS , Moulton-Meissner H , Lockhart SR , Lee CT , Perkins K , Perz JF , Antwi M , Moore MS , Greenko J , Adams E , Haas J , Elkind S , Berman M , Zavasky D , Chiller T , Ackelsberg J . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1274-1275 On May 24, 2016, the New York City Department of Health and Mental Hygiene notified CDC of two cases of Exophiala dermatitidis bloodstream infections among patients with malignancies who had received care from a single physician at an outpatient oncology facility (clinic A). Review of January 1-May 31, 2016 microbiology records identified E. dermatitidis bloodstream infections in two additional patients who also had received care at clinic A. All four patients had implanted vascular access ports and had received intravenous (IV) medications, including a compounded IV flush solution containing saline, heparin, vancomycin, and ceftazidime, compounded and administered at clinic A. |
Early-life farm exposures and adult asthma and atopy in the Agricultural Lung Health Study
House JS , Wyss AB , Hoppin JA , Richards M , Long S , Umbach DM , Henneberger P , Beane Freeman LE , Sandler DP , Long O'Connell E , Barker Cummings C , London SJ . J Allergy Clin Immunol 2016 140 (1) 249-256 e14 BACKGROUND: Previous studies, mostly from Europe, suggest that early-life farming exposures protect against childhood asthma and allergy; few data exist on asthma and allergy in adults. OBJECTIVE: To examine associations between early-life farming exposures and current asthma and atopy in an older adult US farming population. METHODS: We analyzed data from 1,746 farmers and 1,555 spouses (mean age=63) from a case-control study nested within the Agricultural Health Study. Current asthma and early-life farming exposures were assessed via questionnaires. We defined atopy based on specific IgE>0.70 IU/ml to at least one of ten allergens measured in blood. We used logistic regression, adjusted for age, sex, race, state (Iowa or North Carolina), and smoking (pack-years), to estimate associations between early-life exposures and asthma (1,198 cases and 2,031 non-cases) or atopy (578 cases and 2,526 non-cases). RESULTS: Exposure to the farming environment in utero and in early childhood had little or no association with asthma but was associated with reduced odds of atopy. The strongest association was seen for having a mother who performed farm activities while pregnant (Odds Ratio=0.60, 95% Confidence Interval=0.48-0.74) and remained significant in models with correlated early-life exposures including early childhood farm animal contact and raw milk consumption. CONCLUSIONS: In a large US farming population, early-life farm exposures, particularly maternal farming activities while pregnant, were strongly associated with reduced risk of atopy in adults. These results extend previous work done primarily on childhood outcomes and suggest that protective associations of early-life farming exposures on atopy endure across the life-course. |
Exposure to extreme heat events is associated with increased hay fever prevalence among nationally representative sample of US adults: 1997-2013
Upperman CR , Parker JD , Akinbami LJ , Jiang C , He X , Murtugudde R , Curriero FC , Ziska L , Sapkota A . J Allergy Clin Immunol Pract 2016 5 (2) 435-441 e2 BACKGROUND: Warmer temperature can alter seasonality of pollen as well as pollen concentration, and may impact allergic diseases such as hay fever. Recent studies suggest that extreme heat events will likely increase in frequency, intensity, and duration in coming decades in response to changing climate. OBJECTIVE: The overall objective of this study was to investigate if extreme heat events are associated with hay fever. METHODS: We linked National Health Interview Survey (NHIS) data from 1997 to 2013 (n = 505,386 respondents) with extreme heat event data, defined as days when daily maximum temperature (TMAX) exceeded the 95th percentile values of TMAX for a 30-year reference period (1960-1989). We used logistic regression to investigate the associations between exposure to annual and seasonal extreme heat events and adult hay fever prevalence among the NHIS respondents. RESULTS: During 1997-2013, hay fever prevalence among adults 18 years and older was 8.43%. Age, race/ethnicity, poverty status, education, and sex were significantly associated with hay fever status. We observed that adults in the highest quartile of exposure to extreme heat events had a 7% increased odds of hay fever compared with those in the lowest quartile of exposure (odds ratios: 1.07, 95% confidence interval: 1.02-1.11). This relationship was more pronounced for extreme heat events that occurred during spring season, with evidence of an exposure-response relationship (Ptrend < .01). CONCLUSIONS: Our data suggest that exposure to extreme heat events is associated with increased prevalence of hay fever among US adults. |
Post-licensure surveillance of 13-valent pneumococcal conjugate vaccine (PCV13) in adults aged ⩾19years old in the United States, Vaccine Adverse Event Reporting System (VAERS), June 1, 2012-December 31, 2015.
Haber P , Arana J , Pilishvili T , Lewis P , Moro PL , Cano M . Vaccine 2016 34 (50) 6330-6334 BACKGROUND: The 13-valent pneumococcal conjugate vaccine (PCV13) was first recommended for use in adults aged 19years with immunocompromising conditions in June 2012. On August 2014, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of PCV13 among adults aged 65 years. METHODS: We assessed adverse events (AEs) reports following PCV13 in adults aged 19 years reported to the Vaccine Adverse Event Reporting System (VAERS) from June 2012 to December 2015. VAERS is a national spontaneous reporting system for monitoring AEs following vaccination. Our assessment included automated data analysis, clinical review of all serious reports and reports of special interest. We conducted empirical Bayesian data mining to assess for disproportionate reporting. RESULTS: VAERS received 2976 US PCV13 adult reports; 2103 (71%) of these reports were from PCV13 administered alone. Fourteen percent were in persons aged 19-64 years and 86% were in persons aged 65 years. Injection site erythema (28%), injection site pain (24%) and fever (22%) were the most frequent AEs among persons aged 19-64 years; injection site erythema (30%), erythema (20%) and injection site swelling (18%) were the most frequent among persons aged 65 years who were given the vaccine alone. The most frequently reported AEs among non-death serious reports were injection site reactions and general malaise among persons 19-64 years old; injection site reactions, general malaise and Guillain-Barre syndrome among those 65 years. Data mining did not detect disproportional reporting for any unexpected AE. CONCLUSIONS: The results of this study were consistent with safety data from pre-licensure studies of PCV13. We did not detect any new or unexpected AEs. |
Non-neutralizing antibodies induced by seasonal influenza vaccine prevent, not exacerbate A(H1N1)pdm09 disease
Kim JH , Reber AJ , Kumar A , Ramos P , Sica G , Music N , Guo Z , Mishina M , Stevens J , York IA , Jacob J , Sambhara S . Sci Rep 2016 6 37341 The association of seasonal trivalent influenza vaccine (TIV) with increased infection by 2009 pandemic H1N1 (A(H1N1)pdm09) virus, initially observed in Canada, has elicited numerous investigations on the possibility of vaccine-associated enhanced disease, but the potential mechanisms remain largely unresolved. Here, we investigated if prior immunization with TIV enhanced disease upon A(H1N1)pdm09 infection in mice. We found that A(H1N1)pdm09 infection in TIV-immunized mice did not enhance the disease, as measured by morbidity and mortality. Instead, TIV-immunized mice cleared A(H1N1)pdm09 virus and recovered at an accelerated rate compared to control mice. Prior TIV immunization was associated with potent inflammatory mediators and virus-specific CD8 T cell activation, but efficient immune regulation, partially mediated by IL-10R-signaling, prevented enhanced disease. Furthermore, in contrast to suggested pathological roles, pre-existing non-neutralizing antibodies (NNAbs) were not associated with enhanced virus replication, but rather with promoted antigen presentation through FcR-bearing cells that led to potent activation of virus-specific CD8 T cells. These findings provide new insights into interactions between pre-existing immunity and pandemic viruses. |
Factors related to pertussis and tetanus vaccination status among foreign-born adults living in the United States
Sanchez-Gonzalez L , Rodriguez-Lainz A , O'Halloran A , Rowhani-Rahbar A , Liang JL , Lu PJ , Houck PM , Verguet S , Williams WW . J Community Health 2016 42 (3) 573-582 Pertussis is a common vaccine-preventable disease (VPD) worldwide. Its reported incidence has increased steadily in the United States, where it is endemic. Tetanus is a rare but potentially fatal VPD. Foreign-born adults have lower tetanus-diphtheria-pertussis (Tdap) and tetanus-diphtheria (Td) vaccination coverage than do U.S.-born adults. We studied the association of migration-related, socio-demographic, and access-to-care factors with Tdap and Td vaccination among foreign-born adults living in the United States. The 2012 and 2013 National Health Interview Survey data for foreign-born respondents were analyzed. Multivariable logistic regression was conducted to calculate prevalence ratios and 95% confidence intervals, and to identify variables independently associated with Tdap and Td vaccination among foreign-born adults. Tdap and Td vaccination status was available for 9316 and 12,363 individuals, respectively. Overall vaccination coverage was 9.1% for Tdap and 49.8% for Td. Younger age, higher education, having private health insurance (vs. public insurance or uninsured), having visited a doctor in the previous year, and region of residence were independently associated with Tdap and Td vaccination. Among those reporting a doctor visit, two-thirds had not received Tdap. This study provides further evidence of the need to enhance access to health care and immunization services and reduce missed opportunities for Tdap and Td vaccination for foreign-born adults in the United States. These findings apply to all foreign-born, irrespective of their birthplace, citizenship, language and years of residence in the United States. Addressing vaccination disparities among the foreign-born will help achieve national vaccination goals and protect all communities in the United States. |
Global routine vaccination coverage, 2015
Casey RM , Dumolard L , Danovaro-Holliday MC , Gacic-Dobo M , Diallo MS , Hampton LM , Wallace AS . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1270-1273 In 1974, the World Health Organization (WHO) established the Expanded Program on Immunization* to provide protection against six vaccine-preventable diseases through routine infant immunization (1). Based on 2015 WHO and United Nations Children's Fund (UNICEF) estimates, global coverage with the third dose of diphtheria-tetanus-pertussis vaccine (DTP3), the first dose of measles-containing vaccine (MCV1) and the third dose of polio vaccine (Pol3) has remained stable (84%-86%) since 2010. From 2014 to 2015, estimated global coverage with the second MCV dose (MCV2) increased from 39% to 43% by the end of the second year of life and from 58% to 61% when older age groups were included. Global coverage was higher in 2015 than 2010 for newer or underused vaccines, including rotavirus vaccine, pneumococcal conjugate vaccine (PCV), rubella vaccine, Haemophilus influenzae type b (Hib) vaccine, and 3 doses of hepatitis B (HepB3) vaccine. Coverage estimates varied widely by WHO Region, country, and district; in addition, for the vaccines evaluated (MCV, DTP3, Pol3, HepB3, Hib3), wide disparities were found in coverage by country income classification. Improvements in equity of access are necessary to reach and sustain higher coverage and increase protection from vaccine-preventable diseases for all persons. |
An assessment of the cocooning strategy for preventing infant pertussis-United States, 2011
Blain AE , Lewis M , Banerjee E , Kudish K , Liko J , McGuire S , Selvage D , Watt J , Martin SW , Skoff TH . Clin Infect Dis 2016 63 S221-s226 BACKGROUND: Infants are at greatest risk for severe pertussis. In 2006, the Advisory Committee on Immunization Practices recommended that adolescents and adults, especially those with infant contact, receive a single dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine). To assess the effectiveness of cocooning, we conducted a case-control evaluation of infant close contacts. METHODS: Pertussis cases aged <2 months with onset between 1 January 2011 and 31 December 2011 were identified in Emerging Infections Program Network sites. For each case, we recruited 3 controls from birth certificates and interviewed identified adult close contacts (CCs) or parents of CCs aged <18 years. Pertussis vaccination was verified through medical providers and/or immunization registries. RESULTS: Forty-two cases were enrolled, with 154 matched controls. Around enrolled infants, 859 CCs were identified (600 adult and 259 nonadult). An average of 5.4 CCs was identified per case and 4.1 CCs per control. Five hundred fifty-four (64.5%) CCs were enrolled (371 adult and 183 non-adult CCs); 119 (32.1% of enrolled) adult CCs had received Tdap. The proportion of Tdap-vaccinated adult CCs was similar between cases and controls (P = .89). The 600 identified adult CCs comprised 172 potential cocoons; 71 (41.3%) potential cocoons had all identified adult CCs enrolled. Of these, 9 were fully vaccinated and 43.7% contained no Tdap-vaccinated adults. The proportion of fully vaccinated case (4.8%) and control (10.0%) cocoons was similar (P = .43). CONCLUSIONS: Low Tdap coverage among adult CCs reinforces the difficulty of implementing the cocooning strategy and the importance of vaccination during pregnancy to prevent infant pertussis. |
Notes from the Field: cardiac dysrhythmias after loperamide abuse - New York, 2008-2016
Eggleston W , Marraffa JM , Stork CM , Mercurio-Zappala M , Su MK , Wightman RS , Cummings KR , Schier JG . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1276-1277 Loperamide is an over-the-counter antidiarrheal with opioid-receptor agonist properties. Recommended over-the-counter doses (range = 2-8 mg daily) do not produce opioid effects in the central nervous system because of poor oral bioavailability and P-glycoprotein efflux of the medication; recent reports suggest that large doses (50-300 mg) of loperamide produce euphoria, central nervous system depression, and cardiotoxicity. Abuse of loperamide for its euphoric effect or for self-treatment of opioid withdrawal is increasing. Cases of loperamide abuse reported to the Upstate New York Poison Center and New York City Poison Control Center were analyzed for demographic, exposure, clinical, and laboratory characteristics. Cases of intentional loperamide abuse reported to the National Poison Database System (NPDS) also were analyzed for demographic, dose, formulation, and outcome information. |
Parental perceptions of teen driving: Restrictions, worry and influence
Jewett A , Shults RA , Bhat G . J Safety Res 2016 59 119-123 INTRODUCTION: Parents play a critical role in preventing crashes among teens. Research of parental perceptions and concerns regarding teen driving safety is limited. We examined results from the 2013 Summer ConsumerStyles survey that queried parents about restrictions placed on their teen drivers, their perceived level of "worry" about their teen driver's safety, and influence of parental restrictions regarding their teen's driving. METHODS: We produced frequency distributions for the number of restrictions imposed, parental "worry," and influence of rules regarding their teen's driving, reported by teen's driving license status (learning to drive or obtained a driver's license). Response categories were dichotomized because of small cell sizes, and we ran separate log-linear regression models to explore whether imposing all four restrictions on teen drivers was associated with either worry intensity ("a lot" versus "somewhat, not very much or not at all") or perceived influence of parental rules ("a lot" versus "somewhat, not very much or not at all"). RESULTS: Among the 456 parent respondents, 80% reported having restrictions for their teen driver regarding use of safety belts, drinking and driving, cell phones, and text messaging while driving. However, among the 188 parents of licensed teens, only 9% reported having a written parent-teen driving agreement, either currently or in the past. Worrying "a lot" was reported less frequently by parents of newly licensed teens (36%) compared with parents of learning teens (61%). CONCLUSIONS AND PRACTICAL APPLICATIONS: Parents report having rules and restrictions for their teen drivers, but only a small percentage formalize the rules and restrictions in a written parent-teen driving agreement. Parents worry less about their teen driver's safety during the newly licensed phase, when crash risk is high as compared to the learning phase. Further research is needed into how to effectively support parents in supervising and monitoring their teen driver. |
Antecedents of suicide among youth aged 11-15: A multistate mixed methods analysis
Holland KM , Vivolo-Kantor AM , Logan JE , Leemis RW . J Youth Adolesc 2016 46 (7) 1598-1610 Suicide is the second leading cause of death for youth aged 11 to 15, taking over 5,500 lives from 2003 to 2014. Suicide among this age group is linked to risk factors such as mental health problems, family history of suicidal behavior, biological factors, family problems, and peer victimization and bullying. However, few studies have examined the frequency with which such problems occur among youth suicide decedents or the context in which decedents experience these risk factors and the complex interplay of risk that results in a decedent's decision to take his/her own life. Data from a random sample of 482 youth (ages 11-15) suicide cases captured in the National Violent Death Reporting System from 2003 to 2014 were analyzed. The sample had fewer girls than boys (31 vs. 69 %) and comprised primarily White youth (79 %), but also African Americans (13 %), Asians (4 %), and youth of other races (4 %). Narrative data from coroner/medical examiner and law enforcement investigative reports were coded and analyzed to identify common behavioral patterns that preceded suicide. Emergent themes were quantified and examined using content and constant comparative analysis. Themes regarding antecedents across multiple levels of the social ecology emerged. Relationship problems, particularly with parents, were the most common suicide antecedent. Also, a pattern demonstrating a consistent progression toward suicidal behavior emerged from the data. Narratives indicated that youth were commonly exposed to one or more problems, often resulting in feelings of loneliness and burdensomeness, which progressed toward thoughts and sometimes plans for or attempts at suicide. Continued exposure to negative experiences and thoughts/plans about suicide, and/or self-injurious acts resulted in an acquired capacity to self-harm, eventually leading to suicide. These findings provide support for theories of suicidal behavior and highlight the importance of multi-level, comprehensive interventions that address individual cognitions and build social connectedness and support, as well as prevention strategies that increase awareness of the warning signs and symptoms of suicide, particularly among family members of at-risk youth. |
Characterization of chemical suicides in the United States and its adverse impact on responders and bystanders
Anderson AR . West J Emerg Med 2016 17 (6) 680-683 INTRODUCTION: A suicide trend that involves mixing household chemicals to produce hydrogen sulfide or hydrogen cyanide, commonly referred to as a detergent, hydrogen sulfide, or chemical suicide is a continuing problem in the United States (U.S.). Because there is not one database responsible for tracking chemical suicides, the actual number of incidents in the U.S. is unknown. To prevent morbidity and mortality associated with chemical suicides, it is important to characterize the incidents that have occurred in the U.S. METHODS: The author analyzed data from 2011-2013 from state health departments participating in the Agency for Toxic Substances and Disease Registry's National Toxic Substance Incidents Program (NTSIP). NTSIP is a web-based chemical incident surveillance system that tracks the public health consequences (e.g., morbidity, mortality) from acute chemical releases. Reporting sources for NTSIP incidents typically include first responders, hospitals, state environmental agencies, and media outlets. To find chemical suicide incidents in NTSIP's database, the author queried open text fields in the comment, synopsis, and contributing factors variables for potential incidents. RESULTS: Five of the nine states participating in NTSIP reported a total of 22 chemical suicide incidents or attempted suicides during 2011-2013. These states reported a total of 43 victims: 15 suicide victims who died, seven people who attempted suicide but survived, eight responders, and four employees working at a coroner's office; the remainder were members of the general public. None of the injured responders reported receiving HazMat technician-level training, and none had documented appropriate personal protective equipment. CONCLUSION: Chemical suicides produce lethal gases that can pose a threat to responders and bystanders. Describing the characteristics of these incidents can help raise awareness among responders and the public about the dangers of chemical suicides. Along with increased awareness, education is also needed on how to protect themselves. |
Child safety and booster seat use in five tribal communities, 2010-2014
Billie H , Crump CE , Letourneau RJ , West BA . J Safety Res 2016 59 113-117 PROBLEM: Motor-vehicle crashes are a leading cause of death for American Indian/Alaska Natives (AI/AN) including AI/AN children. Child safety seats prevent injury and death among children in a motor-vehicle crash, yet use is low among AI/AN children. METHODS: To increase the use of child safety seats (CSS; car seats and booster seats), five tribal communities implemented evidence-based strategies from the Guide to Community Preventive Services during 2010-2014. Increased CSS use was evaluated through direct observational surveys and CSS event data. CSS events are used to check the installation, use, and safety of CSS and new CSS can be provided. RESULTS: CSS use increased in all five programs (ranging from 6% to 40%). Four out of five programs exceeded their goals for increased use. Among the five communities, a total of 91 CSS events occurred resulting in 1417 CSS checked or provided. CONCLUSIONS AND PRACTICAL APPLICATIONS: Evidence-based child passenger safety interventions are both feasible in and transferable to tribal communities. |
Childhood sexual abuse and sociodemographic factors prospectively associated with intimate partner violence perpetration among South African heterosexual men
Teitelman AM , Bellamy SL , Jemmott JB 3rd , Icard L , O'Leary A , Ali S , Ngwane Z , Makiwane M . Ann Behav Med 2016 51 (2) 170-178 BACKGROUND: Intimate partner violence directed at women by men continues to be a global concern. However, little is known about the factors associated with perpetrating intimate partner violence among heterosexual men. PURPOSE: History of childhood sexual abuse and other sociodemographic variables were examined as potential factors associated with severe intimate partner violence perpetration toward women in a sample of heterosexual men in South Africa. METHODS: Longitudinal logistic generalized estimating equations examined associations of childhood sexual abuse and sociodemographic variables at baseline with intimate partner violence perpetration at subsequent time points. RESULTS: Among participants with a steady female partner, 21.81 % (190/ 871) reported perpetrating intimate partner violence in the past year at baseline. Having a history of childhood sexual abuse (p < .001), binge drinking (p = .002), being employed (p = .050), and more difficulty controlling sexual impulses in order to use a condom (p = .006) at baseline were associated with self-reported intimate partner violence perpetration in the past year at subsequent time points. CONCLUSIONS: With high levels of recent severe physical and/or sexual intimate partner violence perpetration in South Africa, comprehensive interventions are urgently needed. To more fully address gender-based violence, it is important to address associated factors, including exposure to childhood sexual abuse that could impact behavior later in life and that have long-lasting and deleterious effects on men and their female partners. |
Host associations and genomic diversity of Borrelia hermsii in an endemic focus of tick-borne relapsing fever in western North America.
Johnson TL , Fischer RJ , Raffel SJ , Schwan TG . Parasit Vectors 2016 9 (1) 575 BACKGROUND: An unrecognized focus of tick-borne relapsing fever caused by Borrelia hermsii was identified in 2002 when five people became infected on Wild Horse Island in Flathead Lake, Montana. The terrestrial small mammal community on the island is composed primarily of pine squirrels (Tamiasciurus hudsonicus) and deer mice (Peromyscus maniculatus), neither of which was known as a natural host for the spirochete. Thus a 3-year study was performed to identify small mammals as hosts for B. hermsii. METHODS: Small mammals were captured alive on two island and three mainland sites, blood samples were collected and examined for spirochetes, and serological tests performed to detect anti-B. hermsii antibodies. Ornithodoros hermsi ticks were collected and fed on laboratory mice to assess infection. Genomic DNA samples from spirochetes isolated from infected mammals and ticks were analyzed by multilocus sequence typing. RESULTS: Eighteen pine squirrels and one deer mouse had detectable spirochetemias when captured, from which 12 isolates of B. hermsii were established. Most pine squirrels were seropositive, and the five species of sciurids combined had a significantly higher prevalence of seropositive animals than did the other six small mammal species captured. The greater diversity of small mammals on the mainland in contrast to the islands demonstrated that other species in addition to pine squirrels were also involved in the maintenance of B. hermsii at Flathead Lake. Ornithodoros hermsi ticks produced an additional 12 isolates of B. hermsii and multilocus sequence typing identified both genomic groups of B. hermsii described previously, and identified a new genomic subdivision. Experimental infections of deer mice with two strains of B. hermsii demonstrated that these animals were susceptible to infection with spirochetes belonging to Genomic Group II but not Genomic Group I. CONCLUSIONS: Pine squirrels are the primary hosts for the maintenance of B. hermsii on the islands in Flathead Lake, however serological evidence showed that numerous additional species are also involved on the mainland. Future studies testing the susceptibility of several small mammal species to infection with different genetic types of B. hermsii will help define their role as hosts in this and other endemic foci. |
Detection and Differentiation of Leishmania spp. in Clinical Specimens Using a SYBR Green-Based Real-Time PCR Assay.
de Almeida ME , Koru O , Steurer F , Herwaldt BL , da Silva AJ . J Clin Microbiol 2016 55 (1) 281-290 Leishmaniasis in humans is caused by Leishmania spp. in the subgenera Leishmania and Viannia Species identification often has clinical relevance. Until recently, our laboratory relied on conventional PCR amplification of the Internal Transcribed Spacer 2 (ITS2) followed by sequencing analysis of the PCR product to differentiate Leishmania spp. Here we describe a novel real-time quantitative PCR (qPCR) approach based on SYBR green technology (LSG-qPCR), which uses genus-specific primers that target the ITS1 region and amplify DNA from at least 10 Leishmania spp., followed by melting temperature (Tm) analysis of the amplicons on qPCR platforms (Mx3000P qPCR System [Stratagene-Agilent] and 7500 Real-Time PCR System [ABI-Life Technologies]). We initially evaluated the assay by testing reference Leishmania isolates and comparing the results with those from the conventional ITS2-PCR approach. Then we compared the results from the real-time and conventional molecular approaches for clinical specimens from 1,051 patients submitted to our laboratory for Leishmania diagnostic testing: specimens from 477 patients tested positive for Leishmania spp. with the LSG-qPCR assay, 465 of which also tested positive with the conventional ITS2-PCR approach, 10 of which had positive results because of retesting prompted by LSG-qPCR positivity. On the basis of the Tm values of LSG-qPCR amplicons from reference and clinical specimens, we were able to differentiate four groups of Leishmania parasites: the Viannia subgenus in aggregate; the L. (L.) donovani spp. complex in aggregate; the species L. (L.) tropica; and the spp. L. (L.) mexicana, L. (L.) amazonensis, L. (L.) major, and L. (L.) aethiopica in aggregate. |
Lipoprotein biomarkers and risk of cardiovascular disease: A Laboratory Medicine Best Practices (LMBP) systematic review
Sandhu PK , Musaad SM , Remaley AT , Buehler SS , Strider S , Derzon JH , Vesper HW , Ranne A , Shaw CS , Christenson RH . J Appl Lab Med 2016 1 (2) 214-229 BACKGROUND: Controversy exists about the incremental utility of nontraditional lipid biomarkers [e.g., apolipoprotein (apo) B, apo A-I, and non-HDL-C] in improving cardiovascular disease (CVD) risk prediction when added to a conventional model of traditional risk factors (e.g., total cholesterol, LDL cholesterol, HDL cholesterol, sex, age, smoking status, and blood pressure). Here we present a systematic review that was conducted to assess the use of nontraditional lipid biomarkers including apo B, apo A-I, apo B/A-I ratio, and non-HDL-C in improving CVD risk prediction after controlling for the traditional risk factors in populations at risk for cardiovascular events. CONTENT: This systematic review used the Laboratory Medicine Best Practices (LMBP) A-6 methods. A total of 9 relevant studies published before and including July 2015 comprised the evidence base for this review. Results from this systematic review indicated that after the adjustment for standard nonlipid and lipid CVD risk factors, nontraditional apolipoprotein biomarkers apo B (overall effect = relative risk: 1.31; 95% CI, 1.22-1.40; 4 studies) and apo B/apo A-I ratio (overall effect = relative risk: 1.31; 95% CI, 1.11-1.38; 7 studies) resulted in significant improvement in long-term CVD risk assessment. SUMMARY: Available evidence showed that nontraditional lipid biomarkers apo B and apo B/apo I ratio can improve the risk prediction for cardiovascular events after controlling for the traditional risk factors for the populations at risk. However, because of insufficient evidence, no conclusions could be made for the effectiveness of apo A-I and non-HDL-C lipid markers to predict the CVD events, indicating a need for more research in this field. |
The National Disease Research Interchange and collaborators on: What are the major hurdles to the recovery of human tissue to advance research?
VonDran M , Thomas JA , Freund MP , Ritsick M , Orr M , Kaye WE , Bakker A , Knight P . Biopreserv Biobank 2016 A standardized method to reduce analytic variables for the collection of human tissue is essential for investigators seeking to advance findings from basic disease research to new therapies for patients. When designing experiments involving human tissue samples, researchers must define specific donor criteria and preservation requirements useful for their analysis. Access to tissue from donors who fit specific criteria can be problematic if the donor profile or disease is not widespread. The biggest challenge facing human tissue research is identifying a significant number of donors who match specific eligibility criteria to add value to studies seeking cures or treatments for devastating diseases. Both diseased and nondiseased tissues are needed for comparison to understand the mechanisms of dysfunction, to seek potential biomarkers, or to evaluate potential therapies for disorders. The key to mitigating the challenge facing human tissue research is establishing a wide donor screening and recovery network to maximize donation opportunities that meet donor eligibility requirements and tissue collection parameters. The National Disease Research Interchange (NDRI) has developed several novel approaches to serve these specific scientific needs. To support uniform human tissue collection programs, NDRI has become accredited by the College of American Pathologists as a biorepository to enhance the reproducibility of our recovery network. | One method that NDRI uses to capture these very important human biospecimens is partnerships with organ procurement organizations (OPOs) for the screening and recovery of donors throughout the United States. The landscape of organ and tissue donation for transplant has changed significantly in the past 35 years, which has led to great opportunities for human tissue research efforts. Following the National Organ and Transplant Act passed by Congress in 1984, the Organ Procurement Transplantation Network was established to manage the organ matching process at 58 OPOs throughout the country. Currently, about 1.4 million deaths that occur in acute clinical care settings in the United States are referred to these OPOs for consideration for transplant. As not all organs and tissues from these donors are eligible for transplant, there are opportunities for donation of tissue for research through the same mechanism. The NDRI, a 501(c)3 not-for-profit, uses the extensive screening and authorization in place at the OPOs to provide high-quality, highly annotated, nondiseased, and diseased tissues for research. |
Quantification of three chlorinated dialkyl phosphates, diphenyl phosphate, 2,3,4,5-tetrabromobenzoic acid, and four other organophosphates in human urine by solid phase extraction-high performance liquid chromatography-tandem mass spectrometry
Jayatilaka NK , Restrepo P , Williams L , Ospina M , Valentin-Blasini L , Calafat AM . Anal Bioanal Chem 2016 409 (5) 1323-1332 Polybrominated diphenyl ethers (PBDEs), produced as flame retardants worldwide, have been phased-out in many countries, and chlorinated and non-chlorinated organophosphates and non-PBDE brominated formulations (e.g., Firemaster 550 (FM550)) have entered the consumers' market. Recent studies show that components of organophosphate esters and FM550 are frequently detected in many products common to human environments. Therefore, urinary metabolites of these compounds can be used as human exposure biomarkers. We developed a method to quantify nine compounds in 0.4 mL urine: diphenyl phosphate (DPhP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), bis-(1-chloro-2-propyl) phosphate, bis-2-chloroethyl phosphate, di-p-cresylphosphate, di-o-cresylphosphate (DoCP), di-n-butyl phosphate, dibenzyl phosphate (DBzP), and 2,3,4,5-tetrabromobenzoic acid. The method relies on an enzymatic hydrolysis of urinary conjugates of the target analytes, automated off-line solid phase extraction, reversed phase high performance liquid chromatography separation, and isotope dilution-electrospray ionization tandem mass spectrometry detection. The method is high-throughput (96 samples/day) with detection limits ranging from 0.05 to 0.16 ng mL-1. Spiked recoveries were 90-113 %, and interday imprecision was 2-8 %. We assessed the suitability of the method by analyzing urine samples collected from a convenience sample of adults (n = 76) and from a group of firefighters (n = 146). DPhP (median, 0.89; range, 0.26-5.6 ng mL-1) and BDCPP (median, 0.69; range, 0.31-6.8 ng mL-1) were detected in all of the non-occupationally exposed adult samples and all of the firefighter samples (DPhP [median, 2.9; range, 0.24-28 ng mL-1], BDCPP [median, 3.4; range, 0.30-44 ng mL-1]); DBzP and DoCP were not detected in any samples. |
Comparison of coarse coal dust sampling techniques in a laboratory-simulated longwall section
Patts JR , Barone TL . J Occup Environ Hyg 2016 14 (5) 323-334 Airborne coal dust generated during mining can deposit and accumulate on mine surfaces, presenting a dust explosion hazard. When assessing dust hazard mitigation strategies for airborne dust reduction, sampling is done in high-velocity ventilation air, which is used to purge the mining face and gallery tunnel. In this environment, the sampler inlet velocity should be matched to the air stream velocity (isokinetic sampling) to prevent oversampling of coarse dust at low sampler-to-air velocity ratios. Low velocity ratios are often encountered when using low flow rate, personal sampling pumps approved for use in underground mines. In this study, with a goal of employing mine-ready equipment, a personal sampler was adapted for area sampling of coarse coal dust in high-velocity ventilation air. This was done by adapting an isokinetic nozzle to the inlet of an Institute of Occupational Medicine (Edinburgh, Scotland) sampling cassette (IOM). Collected dust masses were compared for the modified IOM isokinetic sampler (IOM-MOD), the IOM without the isokinetic nozzle, and a conventional dust sampling cassette without the cyclone on the inlet. All samplers were operated at a flow rate typical of personal sampling pumps, 2 L/min. To ensure differences between collected masses could be attributed to sampler design and were not influenced by artifacts from dust concentration gradients, relatively uniform and repeatable dust concentrations were demonstrated in the sampling zone of the National Institute for Occupational Safety and Health experimental mine gallery. Consistent with isokinetic theory, greater differences between isokinetic and non-isokinetic sampled masses were found for larger dust volume-size distributions and higher ventilation air velocities. Since isokinetic sampling is conventionally used to determine total dust concentration, and isokinetic sampling made a difference in collected masses, the results suggest when sampling for coarse coal dust the IOM-MOD may improve airborne coarse dust assessments over "off-the-shelf" sampling cassettes. |
Progress in standardization of reporting and analysis of data from early hearing detection and intervention (EHDI) programs
Alam S , Satterfield A , Mason CA , Deng X . J Early Hear Detect Interv 2016 1 (2) 2-7 Congenital hearing loss affects one to three of every 1,000 live born infants. If left undetected, it may negatively impact children through delayed speech and language development. To help avoid developmental delays and ensure that deaf or hard of hearing (DHH) infants are identified and receiving services as early as possible, complete and accurate data are crucial. Despite substantial progress made over the years, some children are still delayed in identification and/or lost to the early hearing detection and intervention (EHDI) surveillance and tracking systems. Lack of standardization in data reporting contributes to this issue. This article discusses reasons for lack of standardization in data reporting and gives suggestions for how the situation could be improved. |
Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies
Clark SL , Romero R , Dildy GA , Callaghan WM , Smiley RM , Bracey AW , Hankins GD , D'Alton ME , Foley M , Pacheco LD , Vadhera RB , Herlihy JP , Berkowitz RL , Belfort MA . Am J Obstet Gynecol 2016 215 (4) 408-12 Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition. |
Interpreting the prevalence of mental disorders in children: Tribulation and triangulation
Holbrook JR , Bitsko RH , Danielson ML , Visser SN . Health Promot Pract 2016 18 (1) 5-7 Knowledge on the prevalence of mental disorders among children informs the work of many health care providers, public health researchers, educators, and policy makers, and any single data source and study methodology can provide valuable insight. However, it is only after prevalence estimates from complementary studies are considered together that distinctions can be made to more deeply inform an assessment of community needs, including diagnosed prevalence versus underlying prevalence, differences between insured and uninsured populations, and how estimates change over time. National surveys, community-based studies, and administrative claims data each provide a different type of information that builds broad understanding. This article presents some of the overarching complexities of the issue, discusses strengths and weaknesses of some common data sources and methodologies used to generate epidemiological estimates, and describes ways in which these data sources complement one another and contribute to a better understanding of the prevalence of pediatric mental disorders. |
Trends in obesity among participants aged 2-4 years in the Special Supplemental Nutrition Program for Women, Infants, and Children - United States, 2000-2014
Pan L , Freedman DS , Sharma AJ , Castellanos-Brown K , Park S , Smith RB , Blanck HM . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1256-1260 Childhood obesity is associated with negative health consequences in childhood that continue into adulthood, putting adults at risk for type 2 diabetes, cardiovascular disease, and certain cancers. Obesity disproportionately affects children from low-income families. Through a collaboration with the United States Department of Agriculture (USDA), CDC has begun to use data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants and Program Characteristics (WIC PC) to replace the Pediatric Nutrition Surveillance System (PedNSS) for obesity surveillance among young children from low-income families. CDC examined trends in obesity prevalence during 2000-2014 among WIC participants aged 2-4 years using WIC PC data. Overall obesity prevalence increased from 14.0% in 2000 to 15.5% in 2004 and 15.9% in 2010, and then decreased to 14.5% in 2014. During 2010-2014, the prevalence of obesity decreased significantly overall, among non-Hispanic whites, non-Hispanic blacks, Hispanics, American Indian/Alaska Natives and Asians/Pacific Islanders, and among 34 (61%) of the 56 WIC state agencies in states, the District of Columbia, and U.S. territories. Despite these declines, the obesity prevalence among children aged 2-4 years in WIC remains high compared with the national prevalence of 8.9% among children aged 2-5 years in 2011-2014. Continued initiatives to work with parents and other stakeholders to promote healthy pregnancies, breastfeeding, quality nutrition, and physical activity for young children in multiple settings are needed to ensure healthy child development. |
Barriers to and facilitators of stocking healthy food options: Viewpoints of Baltimore city small storeowners
Kim M , Budd N , Batorsky B , Krubiner C , Manchikanti S , Waldrop G , Trude A , Gittelsohn J . Ecol Food Nutr 2016 56 (1) 1-14 Receptivity to strategies to improve the food environment by increasing access to healthier foods in small food stores is underexplored. We conducted 20 in-depth interviews with small storeowners of different ethnic backgrounds as part of a small-store intervention trial. Store owners perceived barriers and facilitators to purchase, stock, and promote healthy foods. Barriers mentioned included customer preferences for higher fat and sweeter taste and for lower prices; lower wholesaler availability of healthy food; and customers' lack of interest in health. Most store owners thought positively of taste tests, free samples, and communication interventions. However, they varied in terms of their expectations of the effect of these strategies on customers' healthy food purchases. The findings reported add to the limited data on motivating and working with small-store owners in low-income urban settings. |
TIMP1 promotes multi-walled carbon nanotube-induced lung fibrosis by stimulating fibroblast activation and proliferation.
Dong J , Ma Q . Nanotoxicology 2016 11 (1) 1-26 Pulmonary exposure to multi-walled carbon nanotubes (MWCNTs) may cause fibrosing lesions in animal lungs, raising health concerns about such exposure in humans. The mechanisms underlying fibrosis development remain unclear, but they are believed to involve the dysfunction of fibroblasts and myofibroblasts. Using a mouse model of MWCNT exposure, we found that the tissue inhibitor of metalloproteinase 1 (Timp1) gene was rapidly and highly induced in the lungs by MWCNTs in a time- and dose-dependent manner. Concomitantly, a pronounced elevation of secreted TIMP1 was observed in the bronchoalveolar lavage fluid and serum. Knockout of Timp1 in mice caused a significant reduction in fibrotic focus formation, collagen fiber deposition, recruitment of fibroblasts, and differentiation of fibroblasts into myofibroblasts in the lungs, indicating that TIMP1 plays a critical role in the pulmonary fibrotic response to MWCNTs. At the molecular level, MWCNT exposure significantly increased the expression of the cell proliferation markers Ki-67 and PCNA and a panel of cell cycle-controlling genes in the lungs in a TIMP1-dependent manner. MWCNT-stimulated cell proliferation was most prominent in fibroblasts but not myofibroblasts. Furthermore, MWCNTs elicited a significant induction of CD63 and integrin beta1 in lung fibroblasts, leading to the formation of a TIMP1/CD63/integrin beta1 complex on the surface of fibroblasts in vivo and in vitro, which triggered the phosphorylation and activation of Erk1/2. Our study uncovers a new pathway by which induced TIMP1 critically modulates the pulmonary fibrotic response to MWCNTs by promoting fibroblast activation and proliferation via the TIMP1/CD63/integrin beta1 axis and ERK signaling. |
Experimental analysis of using examples and non-examples in safety training
Taylor MA , Wirth O , Olvina M , Alvero AM . J Safety Res 2016 59 97-104 INTRODUCTION: The effects of training content consisting of examples and/or non-examples was studied on the acquisition of safety-related skills. METHOD: Participants (N=160) were randomly assigned to first receive computer-based training on office ergonomics that included either no examples of safe or at-risk postures, safe examples only, at-risk examples only, or both safe and at-risk examples. Participants then attempted to classify as safe or at-risk various postures depicted in short video clips and demonstrate with their own posture the range of safe postures. RESULTS: Groups that were trained with both safe and at-risk examples showed greater classification accuracy and less error in their demonstration of safe postures. Training with only safe or at-risk examples resulted in a moderate amount of error and a consistent underestimation of risk. CONCLUSION: Training content consisting of both examples and non-examples improved acquisition of safety-related skills. PRACTICAL APPLICATIONS: The strategic selection of training content may improve identification of risks and safe work practices. |
Impact of occupational exposures on exacerbation of asthma: A population-based asthma cohort study
Kim JL , Henneberger PK , Lohman S , Olin AC , Dahlman-Hoglund A , Andersson E , Toren K , Holm M . BMC Pulm Med 2016 16 (1) 148 BACKGROUND: Asthma is a prevalent chronic disease and occupation contributes to approximately 15 % of cases among adults. However, there are still few studies on risk factors for work-exacerbated asthma. The current study investigated the association between asthma exacerbations and occupational exposures. METHODS: The study comprised all currently working adults (n = 1356) who reported ever asthma in prior population-based cohorts. All subjects completed a questionnaire about exposures, occupations and exacerbations of asthma. Exposure to high and low molecular weight agents, irritating agents and asthmagens were classified using the asthma-specific job exposure matrix for northern Europe (N-JEM). Severe exacerbation of asthma was defined as sought emergency care at a hospital, admitted to a hospital overnight, or made an urgent visit to a primary care physician or district medical office due to breathing problems during the last 12 months. Moderate exacerbation was defined as both being not severe exacerbation and an additional visit to a primary care physician or district medical office, or had extra treatments with corticosteroid tablets. Mild exacerbation was defined as being neither severe nor moderate exacerbation, and increasing usage of inhaled corticosteroids. Multiple logistic regression was applied to investigate the association between exacerbation of asthma and occupational exposures while adjusting for potential confounders. RESULTS: Approximately 26 % of the working asthmatics reported exacerbation, and more than two-thirds of them had moderate or severe exacerbation. From 23 to 49 % of the asthmatics reported occupational exposure to a variety of different types of agents. Exposure to any gas, smoke or dust (OR 1.7[95 % CI 1.2-2.6]) was associated with severe exacerbation of asthma, as were organic dust (OR 1.7[1.2-2.5]), dampness and mold (OR 1.8[1.2-2.7]), cold conditions (OR 1.7[1.1-2.7]), and a physically strenuous job (OR 1.6[1.03-2.3]). Asthmagens and low molecular weight agents classified by the N-JEM were associated with mild exacerbation, with OR 1.6[1.1-2.5] and OR 2.2[1.1-4.4], respectively. CONCLUSIONS: Self-reported exposure to any gas, smoke or dust, organic dust, dampness and mold, cold conditions and physically strenuous work, and jobs handling low molecular weight agents were associated with exacerbation of asthma. Reduction of these occupational exposures may help to reduce exacerbation of asthma. |
Creating a taxonomy of local boards of health based on local health departments' perspectives
Shah GH , Sotnikov S , Leep CJ , Ye J , Van Wave TW . Am J Public Health 2016 107 (1) e1-e9 OBJECTIVES: To develop a local board of health (LBoH) classification scheme and empirical definitions to provide a coherent framework for describing variation in the LBoHs. METHODS: This study is based on data from the 2015 Local Board of Health Survey, conducted among a nationally representative sample of local health department administrators, with 394 responses. The classification development consisted of the following steps: (1) theoretically guided initial domain development, (2) mapping of the survey variables to the proposed domains, (3) data reduction using principal component analysis and group consensus, and (4) scale development and testing for internal consistency. RESULTS: The final classification scheme included 60 items across 6 governance function domains and an additional domain-LBoH characteristics and strengths, such as meeting frequency, composition, and diversity of information sources. Application of this classification strongly supports the premise that LBoHs differ in their performance of governance functions and in other characteristics. CONCLUSIONS: The LBoH taxonomy provides an empirically tested standardized tool for classifying LBoHs from the viewpoint of local health department administrators. Future studies can use this taxonomy to better characterize the impact of LBoHs. |
Updated guidance for safe and effective use of contraception
Tepper NK , Curtis KM , Jatlaoui TC , Whiteman MK . J Womens Health (Larchmt) 2016 25 (11) 1097-1101 Progress has been made in efforts to reduce unintended pregnancy; however, unintended pregnancy remains a public health issue in the United States. A key component of reducing unintended pregnancy is to increase correct and consistent use of contraception by reducing barriers to access and use. The CDC has recently updated its guidance for the safe and effective use of contraception. The U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), 2016, and U.S. Selected Practice Recommendations for Contraceptive Use (US SPR), 2016, are intended for healthcare providers to help patients choose a method that is safe and can be used effectively. The recommendations aim to reduce certain barriers to contraception and thus help women, men, and couples to control timing of pregnancies. |
Cryopreserved oocyte versus fresh oocyte assisted reproductive technology cycles, United States, 2013
Crawford S , Boulet SL , Kawwass JF , Jamieson DJ , Kissin DM . Fertil Steril 2016 107 (1) 110-118 OBJECTIVE: To compare characteristics, explore predictors, and compare assisted reproductive technology (ART) cycle, transfer, and pregnancy outcomes of autologous and donor cryopreserved oocyte cycles with fresh oocyte cycles. DESIGN: Retrospective cohort study from the National ART Surveillance System. SETTING: Fertility treatment centers. PATIENT(S): Fresh embryo cycles initiated in 2013 utilizing embryos created with fresh and cryopreserved, autologous and donor oocytes. INTERVENTION(S): Cryopreservation of oocytes versus fresh. MAIN OUTCOMES MEASURE(S): Cancellation, implantation, pregnancy, miscarriage, and live birth rates per cycle, transfer, and/or pregnancy. RESULT(S): There was no evidence of differences in cancellation, implantation, pregnancy, miscarriage, or live birth rates between autologous fresh and cryopreserved oocyte cycles. Donor cryopreserved oocyte cycles had a decreased risk of cancellation before transfer (adjusted risk ratio [aRR] 0.74, 95% confidence interval [CI] 0.57-0.96) as well as decreased likelihood of pregnancy (aRR 0.88, 95% CI 0.81-0.95) and live birth (aRR 0.87, 95% CI 0.80-0.95); however, there was no evidence of differences in implantation, pregnancy, or live birth rates when cycles were restricted to those proceeding to transfer. Donor cryopreserved oocyte cycles proceeding to pregnancy had a decreased risk of miscarriage (aRR 0.75, 95% CI 0.58-0.97) and higher live birth rate (aRR 1.05, 95% CI 1.01-1.09) with the transfer of one embryo, but higher miscarriage rate (aRR 1.28, 95% CI 1.07-1.54) and lower live birth rate (aRR 0.95, 95% CI 0.92-0.99) with the transfer of two or more. CONCLUSION(S): There was no evidence of differences in ART outcomes between autologous fresh and cryopreserved oocyte cycles. There was evidence of differences in per-cycle and per-pregnancy outcomes between donor cryopreserved and fresh oocyte cycles, but not in per-transfer outcomes. |
Potentially preventable deaths among the five leading causes of death - United States, 2010 and 2014
Garcia MC , Bastian B , Rossen LM , Anderson R , Minino A , Yoon PW , Faul M , Massetti G , Thomas CC , Hong Y , Iademarco MF . MMWR Morb Mortal Wkly Rep 2016 65 (45) 1245-1255 Death rates by specific causes vary across the 50 states and the District of Columbia.* Information on differences in rates for the leading causes of death among states might help state health officials determine prevention goals, priorities, and strategies. CDC analyzed National Vital Statistics System data to provide national and state-specific estimates of potentially preventable deaths among the five leading causes of death in 2014 and compared these estimates with estimates previously published for 2010. Compared with 2010, the estimated number of potentially preventable deaths changed (supplemental material at https://stacks.cdc.gov/view/cdc/42472); cancer deaths decreased 25% (from 84,443 to 63,209), stroke deaths decreased 11% (from 16,973 to 15,175), heart disease deaths decreased 4% (from 91,757 to 87,950), chronic lower respiratory disease (CLRD) (e.g., asthma, bronchitis, and emphysema) deaths increased 1% (from 28,831 to 29,232), and deaths from unintentional injuries increased 23% (from 36,836 to 45,331). A better understanding of progress made in reducing potentially preventable deaths in the United States might inform state and regional efforts targeting the prevention of premature deaths from the five leading causes in the United States. |
Use of household cluster investigations to identify factors associated with chikungunya virus infection and frequency of case reporting in Puerto Rico
Bloch D , Roth NM , Caraballo EV , Munoz-Jordan J , Hunsperger E , Rivera A , Perez-Padilla J , Rivera Garcia B , Sharp TM . PLoS Negl Trop Dis 2016 10 (10) e0005075 BACKGROUND: Chikungunya virus (CHIKV) is transmitted by Aedes species mosquitoes and is the cause of an acute febrile illness characterized by potentially debilitating arthralgia. After emerging in the Caribbean in late 2013, the first locally-acquired case reported to public health authorities in Puerto Rico occurred in May 2014. During June-August 2014, household-based cluster investigations were conducted to identify factors associated with infection, development of disease, and case reporting. METHODOLOGY/PRINCIPAL FINDINGS: Residents of households within a 50-meter radius of the residence of laboratory-positive chikungunya cases that had been reported to Puerto Rico Department of Health (PRDH) were offered participation in the investigation. Participants provided a serum specimen and answered a questionnaire that collected information on demographic factors, household characteristics, recent illnesses, healthcare seeking behaviors, and clinical diagnoses. Current CHIKV infection was identified by rRT-PCR, and recent CHIKV infection was defined by detection of either anti-CHIKV IgM or IgG antibody. Among 250 participants, 74 (30%) had evidence of CHIKV infection, including 12 (5%) with current and 62 (25%) with recent CHIKV infection. All specimens from patients with CHIKV infection that were collected within four days, two weeks, and three weeks of illness onset were positive by RT-PCR, IgM ELISA, and IgG ELISA, respectively. Reporting an acute illness in the prior three months was strongly associated with CHIKV infection (adjusted odds ratio [aOR] = 21.6, 95% confidence interval [CI]: 9.24-50.3). Use of air conditioning (aOR = 0.50, 95% CI = 0.3-0.9) and citronella candles (aOR = 0.4, 95% CI = 0.1-0.9) were associated with protection from CHIKV infection. Multivariable analysis indicated that arthralgia (aOR = 51.8, 95% CI = 3.8-700.8) and skin rash (aOR = 14.2, 95% CI = 2.4-84.7) were strongly associated with CHIKV infection. Hierarchical cluster analysis of signs and symptoms reported by CHIKV-infected participants demonstrated that fever, arthralgia, myalgia, headache, and chills tended to occur simultaneously. Rate of symptomatic CHIKV infection (defined by arthralgia with fever or skin rash) was 62.5%. Excluding index case-patients, 22 (63%) participants with symptomatic CHIKV infection sought medical care, of which 5 (23%) were diagnosed with chikungunya and 2 (9%) were reported to PRDH. CONCLUSIONS/SIGNIFICANCE: This investigation revealed high rates of CHIKV infection among household members and neighbors of chikungunya patients, and that behavioral interventions such as use of air conditioning were associated with prevention of CHIKV infection. Nearly two-thirds of patients with symptomatic CHIKV infection sought medical care, of which less than one-quarter were reportedly diagnosed with chikungunya and one-in-ten were reported to public health authorities. These findings emphasize the need for point-of-care rapid diagnostic tests to optimize identification and reporting of chikungunya patients. |
Duration of Borrelia mayonii infectivity in an experimental mouse model for feeding Ixodes scapularis larvae
Dolan MC , Breuner NE , Hojgaard A , Hoxmeier JC , Pilgard MA , Replogle AJ , Eisen L . Ticks Tick Borne Dis 2016 8 (1) 196-200 A novel species within the Borrelia burgdorferi sensu lato complex, Borrelia mayonii, was recently described and found to be associated with Lyme borreliosis in the Upper Midwest of the United States. The blacklegged tick, Ixodes scapularis, is naturally infected with B. mayonii in the Upper Midwest and has been experimentally demonstrated to serve as a vector for this spirochete. Natural vertebrate reservoirs for B. mayonii remain unknown. In this study, we demonstrate that an experimental spirochete host, the CD-1 strain outbred white mouse, can maintain active infection with B. mayonii for up to 1year: infected mice consistently yielded ear biopsies containing motile spirochetes from 29 to 375days after they were first infected via tick bite. Infection rates in resultant nymphal ticks varied greatly both over time for larvae fed on the same individual mouse at different time points after infection (2-42%) and for larvae fed on different mice at a given time point up to 8 months after infection (0-48%). Infection rates were lower in nymphs fed as larvae on mice 10-12 months after infection (2-3% for 5 mice and 9.8% for 1 mouse). In addition to ear biopsies, B. mayonii was detected from bladder, heart, and spinal cord of infected mice when they were sacrificed 163-375days after initial infection via tick bite. Examination of blood from mice determined to be infected with B. mayonii by ear biopsy did not produce evidence of B. mayonii DNA in blood taken 8-375days after the mice were first infected via tick bite. |
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