Permanent tooth loss and sugar-sweetened beverage intake in U.S. young adults
Kim S , Park S , Lin M . J Public Health Dent 2016 77 (2) 148-154 OBJECTIVE: In young adults, sugar-sweetened beverage (SSB) intake is associated with dental caries, which in turn is a major contributor to tooth loss. The independent role of SSB intake on tooth loss, however, has not been well-described. This cross-sectional study examined associations between tooth loss and SSB intake among U.S. young adults. METHODS: The outcome was number of permanent teeth lost because of dental caries or periodontal disease (0, 1-5, ≥6 teeth). Data from the 2012 Behavioral Risk Factor Surveillance System were used. The 22,526 adults aged 18-39 years completed the Sugar Drink Module. The exposure variable was daily frequency of SSB intake. We used multinomial logistic regression to examine the adjusted associations between tooth loss and daily SSB consumption (0, >0 to <1, 1-2, >2 times/day). RESULTS: Approximately, 26% of young adults reported losing at least one permanent tooth. Tooth loss was positively associated with SSB intake frequency; the odds of losing 1-5 teeth were higher among adults drinking SSBs >0-<1 times/day (OR = 1.44, 95%CI = 1.16-1.79), 1-2 times/day (OR = 1.58, 95%CI = 1.25-1.99), and >2 times/day (OR = 1.97, 95%CI = 1.51-2.58) than non-SSB consumers. The odds of losing ≥6 teeth were higher among adults drinking SSBs 1-2 times/day (OR = 2.20, 95%CI = 1.15-4.22) and >2 times/day (OR = 2.81, 95%CI = 1.37-5.76) than non-SSB consumers. CONCLUSIONS: Frequency of SSB consumption was positively associated with tooth loss among young adults even when the average SSB intake was less than one time per day. This study suggests that efforts to reduce SSB intake among young adults may help to decrease the risk of tooth loss. |
Response to diversification of risk-reduction strategies and reduced threat of HIV may explain increases in condomless sex
Paz-Bailey G , Wejnert C , Mendoza MC , Prejean J . AIDS 2016 30 (18) 2900-2901 We appreciate the correspondence by Kippax and Holt [1] regarding explanations for the increases in condomless sex. We agree that there may have been changes in social norms due to the effectiveness of antiretroviral therapy (ART) that are not captured by our survey. Furthermore, the measures we used for seroadaptive behaviors were based on participants’ last sex act and do not reflect the complexities of negotiations for safer sex throughout a partnership. However, we disagree with Kippax and Holt [1] who propose that the predominance of concordant condomless sex in the survey suggests an increase in seroadaptive strategies. The percentage of condomless sex partnerships that was concordant does not increase over time. Further, seroadaptive behaviors are predicated on engaging in different sexual practices according to whether partners are HIV seroconcordant or serodiscordant. The important question is not whether concordant condomless sex is more likely than discordant condomless, as suggested by Kippax and Holt [1], but whether concordant condomless sex is more likely than would be expected by chance alone. If men are consciously choosing partners of the same serostatus, there should be more positive–positive and negative– negative partnerships than would occur by chance according to the marginal probabilities dictated by HIV prevalence and the number of partnerships in our sample. Using a Z test, we compared observed and expected percentages of concordant partnerships. Among MSM reporting condomless sex at last sex using all years combined, 15% were HIV-positive, 76% were HIV-negative, and 9% had unknown HIV status. We used this distribution to compute the expected frequencies of concordant condomless sex partnerships. Among condomless sex partnerships at last sex, 52% were HIV-negative concordant and 9% were HIV-positive concordant. We found evidence suggesting that HIV-negative MSM are not serosorting; they report concordant partners less frequently than what would be expected through random mixing when they engage in condomless anal sex (52% observed vs. 57% expected, P < 0.001), possibly due to insufficient information about their partners’ HIV status. In contrast, our data suggest that HIV-positive MSM may be purposely serosorting when they engage in condomless sex (9% observed vs. 2% expected, P < 0.001). Therefore, although we found evidence to suggest that HIV-positive MSM may be serosorting, the preponderance of concordant partnerships among HIV-negative MSM is not beyond what would be expected through random mixing. |
Sexually transmitted disease testing and uptake of human papillomavirus vaccine in a large online survey of US men who have sex with men at risk for HIV infection, 2012
Kahle EM , Meites E , Sineath RC , Nasrullah M , Bowles KE , DiNenno E , Sullivan PS , Sanchez T . Sex Transm Dis 2016 44 (1) 62-66 National guidelines recommend annual human immunodeficiency virus (HIV)/sexually transmitted disease testing for sexually active men who have sex with men (MSM) and vaccination against human papillomavirus for MSM through age 26. A 2012 online survey of 2,794 MSM found that 51%, 36%, and 14% reported receiving human immunodeficiency virus testing, sexually transmitted disease testing, and human papillomavirus vaccination, respectively. |
A tale of 2 HIV outbreaks caused by unsafe injections in Cambodia and the United States, 2014-2015
Gokhale RH , Galang RR , Pitman JP , Brooks JT . Am J Infect Control 2016 45 (2) 106-107 In 2014–2015, we saw 2 large outbreaks of HIV infection related to the unsafe use of injection equipment. In Cambodia, 242 persons in one rural commune (population: approximately 8,000) received a diagnosis of HIV infection over the course of 3 months. These infections were attributed to the reuse of injection equipment by an unlicensed health care provider in the informal health care sector.1 In the U.S. State of Indiana, 181 persons in a rural southeastern town (population: approximately 4,200) received a diagnosis of HIV infection over the course of 6 months. These infections were attributed to the unsafe injection of prescription opioids2 by people who inject drugs (PWID) for recreational uses. In Cambodia and Indiana, a large percentage of the infections were determined to have occurred recently (ie, within 6–9 months of diagnosis) (Table 1).3,4 |
Viral and host characteristics of recent and established HIV-1 infections in Kisumu based on a multiassay approach
Otecko N , Inzaule S , Odhiambo C , Otieno G , Opollo V , Morwabe A , Were K , Ndiege K , Otieno F , Kim AA , Zeh C . Sci Rep 2016 6 37964 Integrated approaches provide better understanding of HIV/AIDS epidemics. We optimised a multiassay algorithm (MAA) and assessed HIV incidence, correlates of recent infections, viral diversity, plus transmission clusters among participants screened for Kisumu Incidence Cohort Study (KICoS1) (2007-2009). We performed BED-CEIA, Limiting antigen (LAg) avidity, Biorad avidity, and viral load (VL) tests on HIV-positive samples. Genotypic analyses focused on HIV-1 pol gene. Correlates of testing recent by MAA were assessed using logistic regression model. Overall, 133 (12%, 95% CI: 10.2-14.1) participants were HIV-positive, of whom 11 tested recent by MAA (BED-CEIA OD-n < 0.8 + LAg avidity OD-n < 1.5 + VL > 1000 copies/mL), giving an incidence of 1.46% (95% CI: 0.58-2.35) per year. This MAA-based incidence was similar to longitudinal KICoS1 incidence. Correlates of testing recent included sexually transmitted infection (STI) treatment history (OR = 3.94, 95% CI: 1.03-15.07) and syphilis seropositivity (OR = 10.15, 95% CI: 1.51-68.22). Overall, HIV-1 subtype A (63%), D (15%), C (3%), G (1%) and recombinants (18%), two monophyletic dyads and intrinsic viral mutations (V81I, V81I/V, V108I/V and K101Q) were observed. Viral diversity mirrored known patterns in this region, while resistance mutations reflected likely non-exposure to antiretroviral drugs. Management of STIs may help address ongoing HIV transmission in this region. |
Long-term progression of viral load and serum markers of fibrosis among treated and untreated patients with chronic hepatitis B
Li J , Gordon SC , Rupp LB , Zhang T , Trudeau S , Holmberg SD , Moorman AC , Spradling PR , Teshale EH , Boscarino JA , Daida YG , Schmidt MA , Lu M . J Gastroenterol Hepatol 2016 32 (6) 1250-1257 BACKGROUND AND AIMS: Antiviral therapy for patients with hepatitis B (HBV) infection is generally deferred for "immune inactive" patients, although longitudinal changes in viral load and liver fibrosis remain understudied in this population. Likewise, in treated patients, the temporal relationship between changes in viral load and liver fibrosis is not well-characterized. Using data from the Chronic Hepatitis Cohort Study, we investigated viral load and the Fibrosis-4 index (FIB4, a serum-based marker of liver fibrosis) trajectories in both untreated and treated HBV patients. MATERIALS AND METHODS: We applied a bivariate, piecewise, linear spline, mixed-effects modeling approach to data from 766 HBV patients (342 untreated, 424 treated). Treatment selection bias was adjusted using propensity scores. Multiple sensitivity analyses were used to confirm results in untreated patients. RESULTS: Among all untreated patients, FIB4 began to increase by 0.9% per month (11% per year) (p < 0.05) at 28 months post-index date, suggesting fibrosis progression. Significant FIB4 progression was also observed within a subgroup analysis of "immune inactive" untreated patients. In treated patients, viral load declined 31.8% per month (p < 0.05) for the first 5 months after treatment initiation, and 1.4-1.7% per month (p < 0.05) thereafter. At 5 months after treatment initiation, FIB4 began to decline 0.5% per month (p < 0.05), stabilizing at 28 months. CONCLUSION: Among untreated HBV patients, FIB4 gradually increases over time, suggesting fibrosis progression, even in those patients designated as immune inactive. In treated patients, antiviral therapy results in a rapid decline in viral load followed by a delayed decline in markers of liver fibrosis. |
Opportunities for HIV prevention communication during sexual encounters with black men who have sex with men
Aholou TM , Nanin J , Drumhiller K , Sutton MY . AIDS Patient Care STDS 2016 31 (1) 33-40 Conversations about HIV prevention before engaging in sex may result in safer sex practices and decreased HIV transmission. However, partner communication for HIV prevention has been understudied among black/African American men who have sex with men (BMSM), a group that is disproportionately affected by HIV. We explored and described encounters and perceptions about HIV prevention conversations among BMSM and their sex partner(s) in New York City. We conducted an inductive thematic analysis of semi-structured interviews with BMSM who reported sex with a man in the previous 3 months. Interviews were professionally transcribed; Nvivo was used for data analysis. Twenty-two BMSM were included in this analysis; median age = 29.1 years; 71.4% self-identified as MSM; 85.7% were ever HIV tested; and 52.6% reported no disclosure or discussion about HIV status with their previous sex partner. The main themes were: (1) missed opportunities for HIV prevention conversations (e.g., no HIV prevention conversations or HIV prevention conversations after sex had occurred); (2) barriers to HIV prevention conversations (e.g., being in the moment; not wanting to pause); (3) emotional thoughts after sex (e.g., feeling worried about possible HIV exposure); and (4) rethinking relationships and sexual health (e.g., changed sex practices by asking partners' HIV status before sex; started using condoms). These findings offer insight into HIV prevention conversations by BMSM around the time of or during sexual encounters and may inform and strengthen partner-level HIV prevention communication interventions for BMSM. |
Factors associated with primary care physician knowledge of the recommended regimen for treating gonorrhea
Bornstein M , Ahmed F , Barrow R , Risley JF , Simmons S , Workowski KA . Sex Transm Dis 2016 44 (1) 13-16 BACKGROUND: The recommended regimen for treating uncomplicated gonorrhea has changed over time, due to the emergence of antimicrobial resistance. We assessed physician knowledge of the recommendation for treating uncomplicated urogenital gonorrhea in adolescents and adults using ceftriaxone and azithromycin dual therapy. METHODS: We analyzed DocStyles 2015 survey data from 1357 primary care physicians practicing for at least 3 years who provided screening, diagnosis, or treatment for sexually transmitted diseases to one or more patients in an average month. Logistic regression and chi analyses were used to identify factors associated with knowledge of dual therapy. RESULTS: Among the options of treatment with ceftriaxone alone, azithromycin alone, both of these, or spectinomycin plus levofloxacin, 64% of physicians correctly preferred ceftriaxone plus azithromycin. Knowledge of the recommended dual therapy decreased with increasing years of practice, ranging from 74% among physicians with 3-9 years of practice to 57% among those practicing for ≥24 years (adjusted odds ratio, ORa, for ≥24 vs 3-9 years of practice, 0.50; 95% confidence interval [CI], 0.35-0.70). Knowledge of dual therapy decreased with higher socioeconomic status of patients (ORa for high income vs poor/lower middle income patients, 0.47; 95% CI, 0.32-0.69). Physicians who pursued continuing medical education using journals, podcasts, and government health agencies were more likely to report dual therapy than those who did not use these sources (ORa, 2.09; 95% CI, 1.31-3.33). CONCLUSIONS: Knowledge of the recommended regimen for treating gonorrhea decreased with increasing years of practice and with higher socioeconomic status of patients. |
Household-level risk factors for secondary influenza-like illness in a rural area of Bangladesh
Weaver AM , Khatun EJannat K , Cercone E , Krytus K , Sohel BM , Ahmed M , Rahman M , Azziz-Baumgartner E , Yu J , Fry AM , Luby SP , Ram PK . Trop Med Int Health 2016 22 (2) 187-195 OBJECTIVE: To describe household-level risk factors for secondary Influenza-like illness (ILI), an important public health concern in the low-income population of Bangladesh. METHODS: Secondary analysis of control participants in a randomized controlled trial evaluating the effect of handwashing to prevent household ILI transmission. We recruited index-case patients with ILI-fever (<5 years); fever, cough or sore throat (≥5 years)-from health facilities, collected information on household factors, and conducted syndromic surveillance among household contacts for 10 days after resolution of index-case patients' symptoms. We evaluated the associations between household factors at baseline and secondary ILI among household contacts using negative binomial regression, accounting for clustering by household. RESULTS: Our sample was 1491 household contacts of 184 index-case patients. 71% reported that smoking occurred in their home, 27% shared a latrine with 1 other household, and 36% shared a latrine with >1 other household. A total of 114 household contacts (7.6%) had symptoms of ILI during follow-up. Smoking in the home (RRadj 1.9, 95% CI 1.2, 3.0) and sharing a latrine with 1 household (RRadj 2.1, 95% CI 1.2, 3.6) or >1 household (RRadj 3.1, 95% CI 1.8-5.2) were independently associated with increased risk of secondary ILI. CONCLUSION: Tobacco use in homes could increase respiratory illness in Bangladesh. The mechanism between use of shared latrines and household ILI transmission is not clear. It is possible that respiratory pathogens could be transmitted through fecal contact or contaminated fomites in shared latrines. This article is protected by copyright. All rights reserved. |
Associations of HIV testing, sexual risk and access to prevention among female sex workers in the Dominican Republic
Johnston LG , Bonilla L , Caballero T , Rodriguez M , Dolores Y , de la Rosa MA , Malla A , Burnett J , Terrero V , Martinez S , Morgan O . AIDS Behav 2016 21 (8) 2362-2371 The Caribbean region has one of the highest proportions of HIV in the general female population attributable to sex work. In 2008 (n = 1256) and 2012 (n = 1525) in the Dominican Republic, HIV biological and behavioral surveys were conducted among female sex workers (FSW) in four provinces using respondent driven sampling. Participants were ≥15 years who engaged in intercourse in exchange for money in the past 6 months and living/working in the study province. There were no statistically significant changes in HIV and other infections prevalence from 2008 to 2012, despite ongoing risky sexual practices. HIV testing and receiving results was low in all provinces. FSW in 2012 were more likely to receive HIV testing and results if they participated in HIV related information and education and had regular checkups at health centers. Further investigation is needed to understand barriers to HIV testing and access to prevention services. |
Challenges in educating women about human papillomavirus (HPV) and HPV screening test results: Experience from an HPV demonstration project in North-Eastern Thailand
Senkomago V , Sangrajrang S , Ketgudee L , Saraiya M . Papillomavirus Res 2016 2 190-192 Research advances have identified persistent high-risk human papillomavirus (HPV) infections as the cause of almost all cervical cancers, and allowed for the development of several HPV tests to screen for precancerous cervical lesions [1]. The World Health Organization released new cervical cancer screening guidelines in 2013, recommending the use of primary HPV testing as the preferred screening method in areas where high quality cytology-based screening programs do not already exist [2]. The incorporation of HPV tests for cervical cancer screening has several benefits: i) they have higher sensitivity than Pap tests for the detection of precancerous cervical lesions [3]; ii) HPV tests have a high negative predictive value that could enable programs to extend screening intervals [4]; iii) some HPV tests can be processed on the same day to provide rapid results and quick treatment, if needed [5]; and iv) HPV testing also allows for the possibility of self-collection of samples by women which can increase screening coverage in hard-to-reach populations or in areas with limited health professionals [6]. As cervical cancer screening programs incorporate HPV tests for primary screening, there is a need to examine HPV knowledge in women to evaluate and inform HPV education efforts. | As part of the demonstration project investigating the efficacy of primary HPV testing for cervical cancer screening in Northern Thailand described in a manuscript this issue, “Comparative accuracy of Pap smear and HPV screening using COBAS Test in Ubon Ratchathani in Thailand,” we examined HPV knowledge and attitudes toward HPV test results among Thai women. Prior to the start of the project, all the participating doctors and nurses attended a three-day workshop on HPV infection, HPV screening tests, communication of HPV test results, and study procedures of the project. Women aged 30–60 years, who were attending primary healthcare centers in Ubon Ratchathani province for routine cervical cancer screening with a Pap test, were eligible to participate in the project and receive primary HPV testing concurrently. Women who agreed to participate in the project provided consent, after which nurses at the health centers briefly educated each woman about cervical cancer and screening with high-risk HPV tests. This demonstration was approved by the ethics committee of the National Cancer Institute, Bangkok, Thailand. |
Spotted fever group rickettsiae in immature Amblyomma maculatum (Acari: Ixodidae) from Mississippi
Goddard J , Allerdice MEJ , Paddock CD , Portugal JS . J Entomol Sci 2016 51 (4) 329-331 Very little is known about the vector potential posed by larval and nymphal Amblyomma maculatum Koch (Gulf Coast ticks) to humans or other vertebrate species. Rickettsia parkeri Lackman, the causative agent of American boutonneuse fever in humans, which is transmitted by the Gulf Coast tick (Parker et al. 1939, Public Health Rep. 54: 1482–1484; Goddard 2004, Infect. Med. 21: 207–210; Paddock et al. 2004, Clin. Infect. Dis. 38: 805–811) has been detected in Mississippi on several occasions (Paddock et al. 2008, Clin. Infect. Dis. 47: 1188–1196; Ferrari et al. 2012, Emerg. Infect. Dis. 18: 1705–1707; Ekenna et al. 2014, J. Miss. State Med. Assoc. 55: 216–219), as well as other states in the United States and several countries in South America. The role played by immatures in the ecology of R. parkeri has only recently been considered. Another spotted fever group rickettsia (SFGR), “Candidatus Rickettsia andeanae,” occurs in Gulf Coast ticks from North and South America (Blair et al. 2004, J. Clin. Microbiol. 42: 4961–4967; Paddock et al. 2010, Appl. Environ. Microbiol. 76: 2689–2696; Ferrari et al. 2012). It is unknown if “Ca. R. andeanae” is a pathogen of humans; however, it is possible that this SFGR may play a role in the natural history of R. parkeri by rickettsial interference (Paddock et al. 2015, Ticks Tick Borne Dis. 6: 297–302). | Rickettsia parkeri is transmitted transovarially under laboratory conditions (Wright et al. 2015, Ticks Tick Borne Dis. 6: 568–573), and immature stages of A. maculatum have been shown to attach to humans (Goddard 2002, J. Agromed. 8: 25–32; Portugal and Goddard 2015, J. Med. Entomol. doi: 10.1093/jme/tjv185). To our knowledge, neither R. parkeri nor “Ca. R. andeanae” have ever been detected in questing immature specimens of A. maculatum (Fornadel et al. 2011, Vector Borne Zoonotic Dis. 12: 1535–1538; Florin et al. 2013, Syst. Appl. Acarol. 18: 27–29; Nadolny et al. 2014, Ticks Tick Borne Dis. 5: 53–57). This study was initiated to document rickettsial infection in questing (unfed) immature Gulf Coast ticks to better assess the relative risk posed by these stages in the transmission of R. parkeri to humans. |
Mortality among military participants at the 1957 PLUMBBOB nuclear weapons test series and from leukemia among participants at the SMOKY test
Caldwell GG , Zack MM , Mumma MT , Falk H , Heath CW , Till JE , Chen H , Boice JD . J Radiol Prot 2016 36 (3) 474-489 Health effects following low doses of ionizing radiation are uncertain. Military veterans at the Nevada test site (NTS) during the SMOKY atmospheric nuclear weapons test in 1957 were reported to be at increased risk for leukemia in 1979, but this increase was not evaluated with respect to radiation dose. The SMOKY test was one of 30 tests in 1957 within the PLUMBBOB test series. These early studies led to public laws where atomic veterans could qualify for compensation for presumptive radiogenic diseases. A retrospective cohort study was conducted of 12219 veterans at the PLUMBBOB test series, including 3020 at the SMOKY nuclear test. Mortality follow-up was through 2010 and observed causes of death were compared with expected causes based on general population rates. Radiation dose to red bone marrow was based on individual dose reconstructions, and Cox proportional hazards models were used to evaluate dose response for all leukemias other than chronic lymphocytic leukemia (non-CLL leukemia). Vital status was determined for 95.3% of the 12 219 veterans. The dose to red bone marrow was low (mean 3.2 mGy, maximum 500 mGy). Military participants at the PLUMBBOB nuclear test series remained relatively healthy after 53 years and died at a lower rate than the general population. In contrast, and in comparison with national rates, the SMOKY participants showed significant increases in all causes of death, respiratory cancer, leukemia, nephritis and nephrosis, and accidents, possibly related in part to lifestyle factors common to enlisted men who made up 81% of the SMOKY cohort. Compared with national rates, a statistically significant excess of non-CLL leukemia was observed among SMOKY participants (Standardized Mortality Ratio = 1.89, 95% 1.24-2.75, n = 27) but not among PLUMBBOB participants after excluding SMOKY (SMR = 0.87, 95% 0.64-1.51, n = 47). Leukemia risk, initially reported to be significantly increased among SMOKY participants, remained elevated, but this risk diminished over time. Despite an intense dose reconstruction, the risk for leukemia was not found to increase with increasing levels of radiation dose to the red bone marrow. Based on a linear model, the estimated excess relative risk per mGy is -0.05 (95% CI -0.14, 0.04). An explanation for the observed excess of leukemia remains unresolved but conceivably could be related to chance due to small numbers, subtle biases in the study design and/or high tobacco use among enlisted men. Larger studies should elucidate further the possible relationship between fallout radiation, leukemia and cancer among atomic veterans. |
Emergence of plasmid-mediated colistin resistance and New Delhi metallo-ß-lactamase genes in extensively drug-resistant Escherichia coli isolated from a patient in Thailand.
Paveenkittiporn W , Kerdsin A , Chokngam S , Bunthi C , Sangkitporn S , Gregory CJ . Diagn Microbiol Infect Dis 2016 87 (2) 157-159 We reported a case of Escherichia coli with colistin resistance and an extensively drug-resistant phenotype. Molecular analysis revealed that the isolate carried mcr-1 and multiple beta-lactamase genes including blaNDM1, blaCTX-M-15, blaTEM1, and blaCMY-2. This is the first report of a clinical mcr-1 isolate in Thailand highlighting the urgent need for a comprehensive antimicrobial resistance containment strategy to prevent further spread. |
Early sexual debut and associated risk behaviors among sexual minority youth
Lowry R , Dunville R , Robin L , Kann L . Am J Prev Med 2016 52 (3) 379-384 INTRODUCTION: Early sexual debut, sexual risk taking, substance use, violent victimization, and suicidal behaviors are more prevalent among sexual minority than sexual nonminority youth. Although associations between early sexual debut and these risk behaviors exist, little is known about such associations among sexual minority youth. This study examined these associations among sexual minority U.S. high school students and their sexual nonminority peers. METHODS: In 2015, the national Youth Risk Behavior Survey included questions assessing sexual orientation for the first time. In 2016, data from this nationally representative sample of 15,624 U.S. high school students were analyzed to determine if associations between early sexual debut and other health risk behaviors varied by sexual orientation, by calculating adjusted (for sex, race/ethnicity, and age) prevalence ratios (APRs). RESULTS: Associations between early sexual debut and other health risk behaviors did not vary significantly by sexual orientation. Early sexual debut (first sexual intercourse before age 13 years) was associated with sexual risk taking, substance use, violent victimization, and suicidal thoughts/attempts among students identifying as lesbian, gay, or bisexual (LGB) and among students identifying as heterosexual, for example, being currently sexually active (LGB students: APR=1.82, 95% CI=1.35, 2.45; heterosexual students: APR=2.50, 95% CI=2.22, 2.81) and not using a condom at last sexual intercourse (LGB students: APR=1.50, 95% CI=1.18, 1.91; heterosexual students: APR=1.29, 95% CI=1.09, 1.52). CONCLUSIONS: School-based sexual health programs might appropriately utilize strategies that are inclusive of sexual minority students, encourage delay of sexual intercourse, and coordinate with violence and substance use prevention programs. |
Uganda experience - Using cost assessment of an established registry to project resources required to expand cancer registration
Wabinga H , Subramanian S , Nambooze S , Amulen PM , Edwards P , Joseph R , Ogwang M , Okongo F , Parkin DM , Tangka F . Cancer Epidemiol 2016 45 Suppl 1 S30-S36 BACKGROUND: The objectives of this study are (1) to estimate the cost of operating the Kampala Cancer Registry (KCR) and (2) to use cost data from the KCR to project the resource needs and cost of expanding and sustaining cancer registration in Uganda, focusing on the recently established Gulu Cancer Registry (GCR) in rural Northern Uganda. METHODS: We used Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool) to estimate the KCR's activity-based cost for 2014. We grouped the registry activities into fixed cost, variable core cost, and variable other cost activities. After a comparison KCR and GCR characteristics, we used the cost of the KCR to project the likely ongoing costs for the new GCR. RESULTS: The KCR incurred 42% of its expenditures in fixed cost activities, 40% for variable core cost activities, and the remaining 18% for variable other cost activities. The total cost per case registered was 28,201 Ugandan shillings (approximately US $10 in 2014) to collect and report cases using a combination of passive and active cancer data collection approaches. The GCR performs only active data collection, and covers a much larger area, but serves a smaller population compared to the KCR. CONCLUSION: After identifying many differences between KCR and GCR that could potentially affect the cost of registration, our best estimate is that the GCR, though newer and in a rural area, should require fewer resources than the KCR to sustain operations as a stand-alone entity. The optimal structure of the GCR needs to be determined in the future. |
Reinvigorating influenza prevention in US adults aged 65 years and older
Schaffner W , Gravenstein S , Hopkins RH , Jernigan DB . Infect Dis Clin Pract (Baltim Md) 2016 24 (6) 303-309 Adults aged 65 years and older are disproportionately impacted by influenza, accounting for more influenza-related deaths and hospitalizations than any other age group by far. The increasing likelihood of chronic conditions with age and age-related gradual decline in the immune system (immunosenescence) result in an elevated risk of complications from infections, including influenza. Immunosenescence is also a factor in reduced vaccine efficacy in older adults. Newer vaccines approved specifically for adults aged 65 years and older are designed to provide better immune response and better efficacy. Improving immunization coverage rates among this population using new and existing influenza vaccines is essential to reduce the annual impact of influenza infections in the United States. |
Two vs three doses of human papillomavirus vaccine: New policy for the second decade of the vaccination program
Markowitz LE , Meites E , Unger ER . JAMA 2016 316 (22) 2370-2372 This year marks the 10th year of the human papillomavirus (HPV) vaccination program in the United States. In 2006, the first HPV vaccine, quadrivalent HPV vaccine, was licensed by the US Food and Drug Administration and recommended by the Advisory Committee on Immunization Practices and the US Centers for Disease Control and Prevention (CDC). In subsequent years, 2 additional HPV vaccines were licensed, bivalent HPV vaccine in 2009 and 9-valent HPV vaccine in 2014.1 All 3 vaccines were initially licensed and recommended for use in a 3-dose series. In 2006, vaccination was recommended for girls at the age of 11 or 12 years with catch-up vaccination through the age of 26 years; in 2011, the United States was the first country to include boys and men in the routine HPV vaccination program. Following national introductions of HPV vaccination, significant declines in vaccine-type HPV prevalence, genital warts, and cervical precancers have been observed in the United States and other countries.2 | For all 3 HPV vaccines, licensure was based on data from large pivotal clinical trials establishing efficacy in young adult populations; immunogenicity studies compared postvaccination HPV antibody titers in young adolescents (aged 9-15 years) with those achieved in the age group (15-26 years) for which efficacy was demonstrated.3 This immunobridging approach demonstrated that titers were not only noninferior but also consistently higher in younger age groups. Post hoc analysis of 1 early 3-dose efficacy trial suggested protection with fewer than 3 vaccine doses.4 Interest in reduced dose vaccination schedules then arose as evidence of high and durable antibody responses to vaccination accumulated.3 The rationale for the 3-dose schedule used in the efficacy trials for all 3 HPV vaccines was that 2 priming vaccine doses would be needed followed by a boosting dose at 6 months. Two-dose schedules, eliminating the second priming dose but retaining the boosting dose, were evaluated in immunogenicity trials.5-7 Based on immunobridging analyses, 2-dose schedules for quadrivalent and bivalent HPV vaccines were approved by some regulatory authorities, such as the European Medicines Agency, and recommended by the World Health Organization (WHO) in 2014.8 |
Vaccination and unexplained sudden death risk in Taiwanese infants
Huang WT , Chen RT , Hsu YC , Glasser JW , Rhodes PH . Pharmacoepidemiol Drug Saf 2016 26 (1) 17-25 PURPOSE: In March 1992, eight infants who had died within 36 hours of receiving whole-cell pertussis vaccine (diphtheria, tetanus, and whole-cell pertussis [DTwP]) prompted the Taiwan health authorities to suspend its use. We conducted an investigation of vaccination and sudden unexplained infant death (SUID) and repeated it more recently after Taiwan switched to acellular pertussis vaccine (diphtheria, tetanus, and acellular pertussis [DTaP]) in 2010. METHODS: All SUIDs aged 31-364 days during 1990-1992 and 1996-2013 were selected from the death registration databases. The case-control investigation matched each case to two controls on clinic, sex, and birth date, whereas the follow-up self-controlled case series study compared risk of death during the 30-day post-vaccination risk periods with those in the control periods within the same case. RESULTS: Sudden unexplained infant death was associated with never receiving DTwP (odds ratio 2.28, 95% confidence interval 1.25-4.15) in the case-control investigation. The odds ratios within 0-1, 2-7, 8-14, and 15-30 days of DTwP administration were 1.18, 0.26, 0.50, and 0.77. In the 1996-2013 self-controlled case series studies, this temporal shift between DTwP and SUID was consistently observed for female (incidence rate ratio 1.70, 0.75, 1.01, and 0.84) but not male or DTaP recipients. A pooled analysis showed significant risk within 2 days of receiving DTwP in female infants (incidence rate ratio 1.66, 95% confidence interval 1.05-2.60). CONCLUSIONS: Being unvaccinated and recent receipt of DTwP in female infants was significantly associated with SUID; the latter was consistent with a temporal shift pattern without overall increase in risk. The currently used pertussis vaccine, DTaP, did not increase risk of SUID. |
Scaling-up health information systems to improve HIV treatment: An assessment of initial patient monitoring systems in Mozambique
Hochgesang M , Zamudio-Haas S , Moran L , Nhampossa L , Packel L , Leslie H , Richards J , Shade SB . Int J Med Inform 2017 97 322-330 Introduction The rapid scale-up of HIV care and treatment in resource-limited countries requires concurrent, rapid development of health information systems to support quality service delivery. Mozambique, a country with an 11.5% prevalence of HIV, has developed nation-wide patient monitoring systems (PMS) with standardized reporting tools, utilized by all HIV treatment providers in paper or electronic form. Evaluation of the initial implementation of PMS can inform and strengthen future development as the country moves towards a harmonized, sustainable health information system. Objective This assessment was conducted in order to 1) characterize data collection and reporting processes and PMS resources available and 2) provide evidence-based recommendations for harmonization and sustainability of PMS. Methods This baseline assessment of PMS was conducted with eight non-governmental organizations that supported the Ministry of Health to provide 90% of HIV care and treatment in Mozambique. The study team conducted structured and semi-structured surveys at 18 health facilities located in all 11 provinces. Seventy-nine staff were interviewed. Deductive a priori analytic categories guided analysis. Results Health facilities have implemented paper and electronic monitoring systems with varying success. Where in use, robust electronic PMS facilitate facility-level reporting of required indicators; improve ability to identify patients lost to follow-up; and support facility and patient management. Challenges to implementation of monitoring systems include a lack of national guidelines and norms for patient level HIS, variable system implementation and functionality, and limited human and infrastructure resources to maximize system functionality and information use. Conclusions This initial assessment supports the need for national guidelines to harmonize, expand, and strengthen HIV-related health information systems. Recommendations may benefit other countries with similar epidemiologic and resource-constrained environments seeking to improve PMS implementation. |
US emergency department visits for outpatient adverse drug events, 2013-2014
Shehab N , Lovegrove MC , Geller AI , Rose KO , Weidle NJ , Budnitz DS . JAMA 2016 316 (20) 2115-2125 The Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts. To describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006. Active, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project. Drugs implicated in ED visits. National weighted estimates of ED visits and subsequent hospitalizations for adverse drug events. Based on data from 42585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8%-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3%-5.6%). Among older adults (aged ≥65 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events. The prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics. |
Diagnostic and prognostic value of human prion detection in cerebrospinal fluid.
Foutz A , Appleby BS , Hamlin C , Liu X , Yang S , Cohen Y , Chen W , Blevins J , Fausett C , Wang H , Gambetti P , Zhang S , Hughson A , Tatsuoka C , Schonberger LB , Cohen ML , Caughey B , Safar JG . Ann Neurol 2016 81 (1) 79-92 Objective-Several prion amplification systems have been proposed for detection of prions in cerebrospinal fluid (CSF), most recently, the measurements of prion seeding activity with second-generation real-time quaking-induced conversion (RT-QuIC). The objective of this study was to investigate the diagnostic performance of the RT-QuIC prion test in the broad phenotypic spectrum of prion diseases. Methods- We performed CSF RT-QuIC testing in 2,141 patients who had rapidly progressive neurological disorders, determined diagnostic sensitivity and specificity in 272 cases which were autopsied, and evaluated the impact of mutations and polymorphisms in the PRNP gene, and Type 1 or Type 2 of human prions on diagnostic performance. Results-The 98.5% diagnostic specificity and 92% sensitivity of CSF RT-QuIC in a blinded retrospective analysis matched the 100% specificity and 95% sensitivity of a blind prospective study. The CSF RT-QuIC differentiated 94% of cases of sporadic Creutzfeldt-Jakob disease (sCJD) MM1 from the sCJD MM2 phenotype, and 80% of sCJD VV2 from sCJD VV1. The mixed prion type 1-2 and cases heterozygous for codon 129 generated intermediate CSF RT-QuIC patterns, while genetic prion diseases revealed distinct profiles for each PRNP gene mutation. Interpretation-The diagnostic performance of the improved CSF RT-QuIC is superior to surrogate marker tests for prion diseases such as 14-3-3 and Tau proteins and together with PRNP gene sequencing, the test allows the major prion subtypes to be differentiated in vivo. This differentiation facilitates prediction of the clinicopathological phenotype and duration of the disease-two important considerations for envisioned therapeutic interventions. |
Spectral analysis of hearing protector impulsive insertion loss
Fackler CJ , Berger EH , Murphy WJ , Stergar ME . Int J Audiol 2016 56 1-9 OBJECTIVE: To characterise the performance of hearing protection devices (HPDs) in impulsive-noise conditions and to compare various protection metrics between impulsive and steady-state noise sources with different characteristics. DESIGN: HPDs were measured per the impulsive test methods of ANSI/ASA S12.42- 2010 . Protectors were measured with impulses generated by both an acoustic shock tube and an AR-15 rifle. The measured data were analysed for impulse peak insertion loss (IPIL) and impulsive spectral insertion loss (ISIL). These impulsive measurements were compared to insertion loss measured with steady-state noise and with real-ear attenuation at threshold (REAT). STUDY SAMPLE: Tested HPDs included a foam earplug, a level-dependent earplug and an electronic sound-restoration earmuff. RESULTS: IPIL for a given protector varied between measurements with the two impulse noise sources, but ISIL agreed between the two sources. The level-dependent earplug demonstrated level-dependent effects both in IPIL and ISIL. Steady-state insertion loss and REAT measurements tended to provide a conservative estimate of the impulsively-measured attenuation. CONCLUSIONS: Measurements of IPIL depend strongly on the source used to measure them, especially for HPDs with less attenuation at low frequencies. ISIL provides an alternative measurement of impulse protection and appears to be a more complete description of an HPD's performance. |
Vertebrate host susceptibility to Heartland virus
Bosco-Lauth AM , Calvert AE , Root JJ , Gidlewski T , Bird BH , Bowen RA , Muehlenbachs A , Zaki SR , Brault AC . Emerg Infect Dis 2016 22 (12) 2070-2077 Heartland virus (HRTV) is a recently described phlebovirus initially isolated in 2009 from 2 humans who had leukopenia and thrombocytopenia. Serologic assessment of domestic and wild animal populations near the residence of 1 of these persons showed high exposure rates to raccoons, white-tailed deer, and horses. To our knowledge, no laboratory-based assessments of viremic potential of animals infected with HRTV have been performed. We experimentally inoculated several vertebrates (raccoons, goats, chickens, rabbits, hamsters, C57BL/6 mice, and interferon-alpha/beta/gamma receptor-deficient [Ag129]) mice with this virus. All animals showed immune responses against HRTV after primary or secondary exposure. However, neutralizing antibody responses were limited. Only Ag129 mice showed detectable viremia and associated illness and death, which were dose dependent. Ag129 mice also showed development of mean peak viral antibody titers >8 log10 PFU/mL, hemorrhagic hepatic lesions, splenomegaly, and large amounts of HRTV antigen in mononuclear cells and hematopoietic cells in the spleen. |
Vibration characteristics of golf club heads in their handheld grinding process and potential approaches for reducing the vibration exposure
Chen Q , Lin H , Xiao B , Welcome DE , Lee J , Chen G , Tang S , Zhang D , Xu G , Yan M , Yan H , Xu X , Qu H , Dong RG . Int J Ind Ergon 2016 62 27-41 To control vibration-induced white finger among workers performing the fine grinding of golf club heads, the aims of this study are to clarify the major vibration sources in the grinding process, to identify and understand the basic characteristics of the club head vibration, and to propose potential approaches for reducing the vibration exposure. The vibrations on two typical club heads and two belt grinding machines were measured at a workplace. A simulated test station was also constructed and used to help examine some influencing factors of the club head vibration. This study found that the club head vibration was the combination of the vibration transmitted from the grinding machines and that generated in the grinding process. As a result, any factor that affects the machine vibration, the grinding vibration, and/or the dynamic response of the club head can influence the vibration exposure of the fingers or hands holding the club head in the grinding process. The significant influencing factors identified in the study include testing subject, grinding machine, machine operation speed, drive wheel condition, club head model, mechanical constraints imposed on the club head during the grinding, and machine foot pad. These findings suggest that the vibration exposure can be controlled by reducing the grinding machine vibration, changing the workpiece dynamic properties, and mitigating the vibration transmission in its pathway. Many potential methods for the control are proposed and discussed. Relevance to industry: Vibrations on handheld workpieces can be effectively transmitted to the hands, especially the fingers. As a result, a major component of the hand-arm vibration syndrome - vibration-induced white finger - has been observed among some workers performing the grinding and/or polishing tasks of the handheld workpieces such as golf club heads. The results of this study can be used to develop more effective methods and technologies to control the vibration exposure of these workers. This may help effectively control this occupational disease. |
Quantitative analysis of the role of fiber length on phagocytosis and inflammatory response by alveolar macrophages
Padmore T , Stark C , Turkevich LA , Champion JA . Biochim Biophys Acta 2016 1861 (2) 58-67 BACKGROUND: In the lung, macrophages attempt to engulf inhaled high aspect ratio pathogenic materials, secreting inflammatory molecules in the process. The inability of macrophages to remove these materials leads to chronic inflammation and disease. How the biophysical and biochemical mechanisms of these effects are influenced by fiber length remains undetermined. This study evaluates the role of fiber length on phagocytosis and molecular inflammatory responses to non-cytotoxic fibers, enabling development of quantitative length-based models. METHODS: Murine alveolar macrophages were exposed to short and long populations of JM-100 glass fibers, produced by successive sedimentation and repeated crushing, respectively. Interactions between fibers and macrophages were observed using time-lapse video microscopy, and quantified by flow cytometry. Inflammatory biomolecules (TNF-alpha, IL-1alpha, COX-2, PGE2) were measured. RESULTS: Uptake of short fibers occurred more readily than for long, but long fibers were more potent stimulators of inflammatory molecules. Stimulation resulted in dose-dependent secretion of inflammatory biomolecules but no cytotoxicity or strong ROS production. Linear cytokine dose-response curves evaluated with length-dependent potency models, using measured fiber length distributions, resulted in identification of critical fiber lengths that cause frustrated phagocytosis and increased inflammatory biomolecule production. CONCLUSION: Short fibers played a minor role in the inflammatory response compared to long fibers. The critical lengths at which frustrated phagocytosis occurs can be quantified by fitting dose-response curves to fiber distribution data. GENERAL SIGNIFICANCE: The single physical parameter of length can be used to directly assess the contributions of length against other physicochemical fiber properties to disease endpoints. |
Evaluation of immunoglobulin g responses to Plasmodium falciparum and Plasmodium vivax in Malian school children using multiplex bead assay
Rogier E , Moss DM , Chard AN , Trinies V , Doumbia S , Freeman MC , Lammie PJ . Am J Trop Med Hyg 2016 96 (2) 312-318 Malaria serology through assaying for IgG against Plasmodium spp. antigens provides evidence into the infection history for an individual. The multiplex bead assay (MBA) allows for detection of IgG against multiple Plasmodium spp., and can be especially useful in many regions where Plasmodium falciparum is of primary clinical focus, but other species are co-endemic. Dried blood spots were collected from 805 Malian children attending 42 elementary schools in the regions of Mopti, Sikasso, Koulikoro, and Bamako capital district, and IgG assayed by MBA. As southern Mali is known to be holoendemic for P. falciparum, merozoite surface protein 1 19-kDa subunit (MSP-142) and apical membrane antigen 1 (AMA-1) antigens were included for serology against this parasite. Responses to these antigens both provided high estimates for lifetime exposure, with 730 (90%) children with IgG antibodies for MSP-142, 737 (91%) for AMA-1, and 773 (96%) positive for either or both. Also included was the antigen Plasmodium vivax MSP-119, against which 140 (17.4%) children were found to have antibodies. Increases in antibody titers with older age were clearly seen with the P. falciparum antigens, but not with the P. vivax antigen, likely indicating more of a sporadic, rather than sustained transmission for this species. The MBA provides effective opportunities to evaluate malaria transmission through serological analysis for multiple Plasmodium species. |
In vitro toxicity evaluation of lignin-(un)coated cellulose based nanomaterials on human A549 and THP-1 cells
Yanamala N , Kisin ER , Menas AL , Farcas MT , Khaliullin TO , Vogel U , Shurin GV , Schwegler-Berry D , Fournier PM , Star A , Shvedova AA . Biomacromolecules 2016 17 (11) 3464-3473 A significant amount of research towards commercial development of cellulose based nanomaterials (CNM) is now in progress with some potential applications. Using human A549 and THP-1 cells, we evaluated the biological responses of various CNMs, made out of similar material but with functional and morphological variations. While A549 cells displayed minimal or no cytotoxic responses following exposure to CNMs, THP-1 cells were more susceptible to cytotoxicity, cellular damage and inflammatory responses. Further analysis of these biological responses evaluated using hierarchical clustering approaches was effective in discriminating (dis)-similarities of various CNMs studied and identified potential inflammatory factors contributing to cytotoxicity. No correlation between cytotoxicity and surface properties of CNMs was found. This study clearly highlights that in addition to the source and characteristics of CNMs, cell type-specific differences in the recognition/uptake of CNMs along with their inherent capability to respond to external stimuli, are crucial for assessing the toxicity of CNMs. |
A retrospective review of birth outcomes at the Mother and Child Health Hospital in Lao People's Democratic Republic, 2004-2013
Olsen SJ , Vetsaphong P , Vonglokham P , Mirza S , Khanthamaly V , Chanthalangsy T , Chittanavanh S , Syhavong B , Moen A , Bresee J , Corwin A , Xeuatvongsa A . BMC Pregnancy Childbirth 2016 16 (1) 379 BACKGROUND: The Lao People's Democratic Republic (Lao PDR) is a lower-middle income country making steady progress improving maternal and child health outcomes. We sought to ascertain if there have been improvements in three specific birth outcomes (low birth weight, preterm birth and small for gestational age) over the last decade. METHODS: We retrospectively reviewed birth records between 2004 and 2013 at the Mother and Child Health (MCH) hospital in Vientiane. We defined preterm birth as gestation <37 weeks and low birth weight as <2,500 g. We calculated small for gestational age (SGA). We describe birth outcomes over time and compare proportions using Chi square. RESULTS: Between 2004 and 2013, the annual average number of newborns delivered each year was 4,322 and the frequency of low birth weight ranged from 9.5 to 12%, preterm births from 6.3 to 10%, and infants born SGA from 25 to 35%. There were no improvements in these frequencies over time. Women <18 years at delivery had a statistically significantly higher frequency of babies born with a low birth weight (15.3 vs. 10.8%, p < 0.02) or preterm (16.4 vs. 7.8%, p < 0.01) than those aged >18. There was no difference in the frequency of babies born SGA by age (26.8% in women <18 years vs. 29.7% in women >18 years, p = 0.30). CONCLUSIONS: At the largest maternal and child hospital in Lao PDR, we found a high frequency of poor birth outcomes with no improvements over the last decade. |
Using insurance claims data to identify and estimate critical periods in pregnancy: An application to antidepressants
Ailes EC , Simeone RM , Dawson AL , Petersen EE , Gilboa SM . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 927-934 BACKGROUND: Health insurance claims are a rich data source to examine medication use in pregnancy. Our objective was to identify pregnant women, their pregnancy outcomes, and date of their last menstrual period (LMP), and to estimate antidepressant dispensations in pregnancy. METHODS: From a literature search, we identified diagnosis and procedure codes indicating the end of a pregnancy. Using Truven Health MarketScan(R) Commercial Claims and Encounters Databases, we identified all inpatient admissions and outpatient service claims with these codes. We developed an algorithm to assign: (1) pregnancy outcome (ectopic pregnancy, induced or spontaneous abortion, live birth, or stillbirth), and (2) estimated gestational age, to each inpatient or outpatient visit. For each pregnancy outcome, we estimated the LMP as the admission (for inpatient visits) or service (for outpatient visits) date minus the gestational age. To differentiate visits associated with separate pregnancies, we required ≥ 2 months between one pregnancy outcomes and the LMP of the next pregnancy. We used this algorithm to identify pregnancies in 2013 and to estimate the proportion of women who filled a prescription for an antidepressant from an outpatient pharmacy at various time points in pregnancy. RESULTS: We identified 488,887 pregnancies in 2013; 79% resulted in a live birth. A prescription for an antidepressant was filled in 6.2% of pregnancies. Dispensations varied throughout pregnancy and were lowest (3.1%) during the second trimester. CONCLUSION: This work will inform future efforts to estimate medication dispensations during critical periods of preconception, interconception, and pregnancy using health insurance claims data. |
Using state and provincial surveillance programs to reduce risk of recurrence of neural tube defects in the United States and Canada: A missed opportunity?
Flood TJ , Rienks CM , Flores AL , Mai CT , Frohnert BK , Rutkowski RE , Evans JA , Kirby RS . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 875-880 BACKGROUND: Once a woman has had a fetus or infant affected with a neural tube defect (NTD), the risk of recurrence is approximately 3%. This risk can be significantly reduced by folic acid supplement consumption during the periconceptional period; however, this requires women at risk to be adequately informed about the appropriate dosage and timing of supplement intake before planning another pregnancy. As birth defects surveillance programs are tasked with identifying and documenting NTD-affected pregnancies and births, they are in a unique position to support recurrence prevention activities. METHODS: In 2015, we surveyed state and provincial birth defects surveillance programs to assess their NTD recurrence prevention activities. The online survey was sent to programs in 52 United States (U.S.) jurisdictions and all 13 provinces and territories in Canada. Findings were compared with a similar survey conducted in 2005 among U.S. programs. RESULTS: In 2015, of the 44 U.S. and Canadian surveillance programs that responded, only 9 programs (7 U.S. and 2 Canadian) reported currently having activities specifically directed toward preventing NTD recurrence. Compared with a 2005 survey of U.S. programs, the number of U.S. programs working on NTD recurrence prevention decreased by almost 50% (from 13 to 7 programs). CONCLUSION: The number of birth defects surveillance programs with NTD recurrence prevention activities has decreased over the past decade due to a range of barriers, most notably a lack of resources. However, while some recurrence prevention activities require part-time staff, other activities could be accomplished using minimal resources. |
Maternal autoimmune disease and birth defects in the National Birth Defects Prevention Study
Howley MM , Browne ML , Van Zutphen AR , Richardson SD , Blossom SJ , Broussard CS , Carmichael SL , Druschel CM . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 950-962 BACKGROUND: Little is known about the association between maternal autoimmune disease or its treatment and the risk of birth defects. We examined these associations using data from the National Birth Defects Prevention Study, a multi-site, population-based, case-control study. METHODS: Analyses included 25,116 case and 9897 unaffected control infants with estimated delivery dates between 1997 and 2009. Information on autoimmune disease, medication use, and other pregnancy exposures was collected by means of telephone interview. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for birth defects with five or more exposed cases; crude ORs and exact 95% CIs were estimated for birth defects with three to four exposed cases. RESULTS: Autoimmune disease was reported by 373 mothers (279 case and 94 control mothers). The majority of birth defects evaluated were not associated with autoimmune disease; however, a statistically significant association between maternal autoimmune disease and encephalocele was observed (OR, 4.64; 95% CI, 1.95-11.04). Eighty-two mothers with autoimmune disease used an immune modifying/suppressing medication during pregnancy; this was associated with encephalocele (OR, 7.26; 95% CI, 1.37-24.61) and atrial septal defects (OR, 3.01; 95% CI, 1.16-7.80). CONCLUSION: Our findings suggest maternal autoimmune disease and treatment are not associated with the majority of birth defects, but may be associated with some defects, particularly encephalocele. Given the low prevalence of individual autoimmune diseases and the rare use of specific medications, we were unable to examine associations of specific autoimmune diseases and medications with birth defects. Other studies are needed to confirm these findings. |
Maternal exposure to ozone and PM2.5 and the prevalence of orofacial clefts in four U.S. states
Zhou Y , Gilboa SM , Herdt ML , Lupo PJ , Flanders WD , Liu Y , Shin M , Canfield MA , Kirby RS . Environ Res 2016 153 35-40 BACKGROUND: While there is some evidence that maternal exposure to ambient air pollution is associated with orofacial clefts in offspring, the epidemiologic studies have been largely equivocal. We evaluated whether maternal exposure to elevated county-level ambient fine particulate matter with aerodynamic diameter ≤2.5microm (PM2.5) and ozone during early gestation was associated with a higher prevalence of orofacial clefts. METHODS: Birth data consisting of 4.7 million births from 2001 to 2007 were obtained from National Birth Defects Prevention Network for four states - Arizona, Florida, New York (excluding New York City), and Texas. The air pollution exposure assessment for gestational weeks 5-10 was based on county-level average concentrations of PM2.5 and ozone data generated using a Bayesian fusion model available through CDC's Environmental Public Health Tracking Network. Two outcomes were analyzed separately: cleft lip with or without cleft palate, cleft palate alone. In logistic regression analyses, we adjusted for factors that were suspected confounders or modifiers of the association between the prevalence of orofacial clefts and air pollution, i.e., infant sex, race-ethnicity, maternal education, smoking status during pregnancy, whether this was mother's first baby, maternal age. RESULTS: Each 10microg/m3 increase in PM2.5 concentration was significantly associated with cleft palate alone (OR =1.43, 95% CI: 1.11-1.86). There was no significant association between PM2.5 concentration and cleft lip with or without cleft palate. No associations were observed between ozone exposure and the two outcomes of orofacial clefts. CONCLUSIONS: Our study suggests that PM2.5 significantly increased the risk of cleft palate alone, but did not change the incidence of cleft lip with or without palate. Ozone levels did not correlate with incidence of orofacial clefts. |
Paternal and joint parental occupational pesticide exposure and spina bifida in the National Birth Defects Prevention Study, 1997 to 2002
Pettigrew SM , Bell EM , Van Zutphen AR , Rocheleau CM , Shaw GM , Romitti PA , Olshan A , Lupo PJ , Soim A , Makelarski JA , Michalski AM , Sanderson W . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 963-971 BACKGROUND: Because of persistent concerns over the association between pesticides and spina bifida, we examined the role of paternal and combined parental occupational pesticide exposures in spina bifida in offspring using data from a large population-based study of birth defects. METHODS: Occupational information from fathers of 291 spina bifida cases and 2745 unaffected live born control infants with estimated dates of delivery from 1997 to 2002 were collected by means of maternal report. Two expert industrial hygienists estimated exposure intensity and frequency to insecticides, herbicides, and fungicides. Multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for exposure to any pesticide and to any class of pesticide (yes/no; and by median), and exposure to combinations of pesticides (yes/no) and risk of spina bifida. Adjusted odds ratios were also estimated by parent exposed to pesticides (neither, mother only, father only, both parents). RESULTS: Joint parental occupational pesticide exposure was positively associated with spina bifida (aOR, 1.5; 95% CI, 0.9-2.4) when compared with infants with neither maternal nor paternal exposures; a similar association was not observed when only one parent was exposed. There was a suggested positive association between combined paternal insecticide and fungicide exposures and spina bifida (aOR, 1.5; 95% CI, 0.8-2.8), however, nearly all other aORs were close to unity. CONCLUSION: Overall, there was little evidence paternal occupational pesticide exposure was associated with spina bifida. However, the small numbers make it difficult to precisely evaluate the role of pesticide classes, individually and in combination. |
Population-based microcephaly surveillance in the United States, 2009 to 2013: An analysis of potential sources of variation
Cragan JD , Isenburg JL , Parker SE , Alverson CJ , Meyer RE , Stallings EB , Kirby RS , Lupo PJ , Liu JS , Seagroves A , Ethen MK , Cho SJ , Evans M , Liberman RF , Fornoff J , Browne ML , Rutkowski RE , Nance AE , Anderka M , Fox DJ , Steele A , Copeland G , Romitti PA , Mai CT . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 972-982 BACKGROUND: Congenital microcephaly has been linked to maternal Zika virus infection. However, ascertaining infants diagnosed with microcephaly can be challenging. METHODS: Thirty birth defects surveillance programs provided data on infants diagnosed with microcephaly born 2009 to 2013. The pooled prevalence of microcephaly per 10,000 live births was estimated overall and by maternal/infant characteristics. Variation in prevalence was examined across case finding methods. Nine programs provided data on head circumference and conditions potentially contributing to microcephaly. RESULTS: The pooled prevalence of microcephaly was 8.7 per 10,000 live births. Median prevalence (per 10,000 live births) was similar among programs using active (6.7) and passive (6.6) methods; the interdecile range of prevalence estimates was wider among programs using passive methods for all race/ethnicity categories except Hispanic. Prevalence (per 10,000 live births) was lowest among non-Hispanic Whites (6.5) and highest among non-Hispanic Blacks and Hispanics (11.2 and 11.9, respectively); estimates followed a U-shaped distribution by maternal age with the highest prevalence among mothers <20 years (11.5) and ≥40 years (13.2). For gestational age and birth weight, the highest prevalence was among infants <32 weeks gestation and infants <1500 gm. Case definitions varied; 41.8% of cases had an HC ≥ the 10th percentile for sex and gestational age. CONCLUSION: Differences in methods, population distribution of maternal/infant characteristics, and case definitions for microcephaly can contribute to the wide range of observed prevalence estimates across individual birth defects surveillance programs. Addressing these factors in the setting of Zika virus infection can improve the quality of prevalence estimates. |
Prenatal phthalate, triclosan, and bisphenol A exposures and child visual-spatial abilities
Braun JM , Bellinger DC , Hauser R , Wright RO , Chen A , Calafat AM , Yolton K , Lanphear BP . Neurotoxicology 2016 58 75-83 INTRODUCTION: During fetal development, sex steroids influence sexually dimorphic behaviors, such as visual-spatial abilities. Thus, endocrine disrupting chemicals that impact sex steroids during gestation may affect these behaviors. OBJECTIVE: We investigated the relationship between prenatal urinary phthalate metabolite, triclosan, and BPA concentrations and visual-spatial abilities in a prospective cohort of 198 mother-child dyads. METHODS: Data are from a prospective cohort in Cincinnati, OH (HOME Study). We measured nine phthalate metabolites, triclosan, and BPA in maternal urine samples collected at 16 and 26 weeks of gestation. We assessed children's visual-spatial abilities at 8 years of age using the Virtual Morris Water Maze (VMWM), a computerized version of the rodent Morris Water Maze. We quantified the covariate-adjusted change in the time or distance to complete the VMWM and time spent in the correct quadrant during a probe trial with an interquartile range increase in chemical concentrations using linear mixed models and linear regression, respectively. RESULTS: Boys completed the VMWM faster (4.1s; 95% CI:-7.1, -1.2) and in less distance (1.4 units; 95% CI:-2.8, 0) than girls. Overall, children with higher mono-n-butyl (MnBP), mono-benzyl (MBzP), and mono-carboxypropyl phthalate concentrations completed the VMWM in less time and distance than children with lower concentrations. For example, children with higher MnBP concentrations completed the VMWM in 0.9 less distance units (95% CI:-1.8, -0.0). Child sex modified the association between MnBP and VMWM performance. In girls, higher MnBP concentrations were associated with longer time (1.7s; 95% CI: -0.7, 4.1) and shorter distance (-1.7 units; 95% CI: -2.8, -0.5), whereas in boys, it was associated with shorter time (-3.0s; 95% CI:-5.6, -0.4), but not distance (-0.1 units; 95% CI:1.4, 1.0). Other phthalate metabolites, triclosan, and BPA were not associated with VMWM performance, and sex did not consistently modify these associations. CONCLUSIONS: In this cohort, greater prenatal urinary concentrations of some phthalate metabolites were associated with improved VMWM performance, particularly among boys. Future studies should confirm these findings and determine if phthalates affect other hormonally sensitive aspects of child neurobehavior. |
Proportion of selected congenital heart defects attributable to recognized risk factors
Simeone RM , Tinker SC , Gilboa SM , Agopian AJ , Oster ME , Devine OJ , Honein MA . Ann Epidemiol 2016 26 (12) 838-845 PURPOSE: To assess the contribution of multiple risk factors for two congenital heart defects-hypoplastic left heart syndrome (HLHS) and tetralogy of Fallot (TOF). METHODS: We used data from the National Birth Defects Prevention Study (1997-2011) to estimate average adjusted population attributable fractions for several recognized risk factors, including maternal prepregnancy overweight-obesity, pregestational diabetes, age, and infant sex. RESULTS: There were 594 cases of isolated simple HLHS, 971 cases of isolated simple TOF, and 11,829 controls in the analysis. Overall, 57.0% of HLHS cases and 37.0% of TOF cases were estimated to be attributable to risk factors included in our model. Among modifiable HLHS risk factors, maternal prepregnancy overweight-obesity accounted for the largest proportion of cases (6.5%). Among modifiable TOF risk factors, maternal prepregnancy overweight-obesity and maternal age of 35 years or older accounted for the largest proportions of cases (8.3% and 4.3%, respectively). CONCLUSIONS: Approximately half of HLHS cases and one-third of TOF cases were estimated to be attributable to risk factors included in our models. Interventions targeting factors that can be modified may help reduce the risk of HLHS and TOF development. Additional research into the etiology of HLHS and TOF may reveal other modifiable risk factors that might contribute to primary prevention efforts. |
A quality assessment of reporting sources for microcephaly in Utah, 2003 to 2013
Steele A , Johnson J , Nance A , Satterfield R , Alverson CJ , Mai C . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 983-988 BACKGROUND: Obtaining accurate microcephaly prevalence is important given the recent association between microcephaly and Zika virus. Assessing the quality of data sources can guide surveillance programs as they focus their data collection efforts. The Utah Birth Defect Network (UBDN) has monitored microcephaly by data sources since 2003. The objective of this study was to examine the impact of reporting sources for microcephaly surveillance. METHODS: All reported cases of microcephaly among Utah mothers from 2003 to 2013 were clinically reviewed and confirmed. The UBDN database was linked to state vital records and hospital discharge data for analysis. Reporting sources were analyzed for positive predictive value and sensitivity. RESULTS: Of the 477 reported cases of microcephaly, 251 (52.6%) were confirmed as true cases. The UBDN identified 94 additional cases that were reported to the surveillance system as another birth defect, but were ultimately determined to be true microcephaly cases. The prevalence for microcephaly based on the UBDN medical record abstraction and clinical review was 8.2 per 10,000 live births. Data sources varied in the number and accuracy of reporting, but a case was more likely to be a true case if identified from multiple sources than from a single source. CONCLUSION: While some reporting sources are more likely to identify possible and true microcephaly cases, maintaining a multiple source methodology allows for more complete case ascertainment. Surveillance programs should conduct periodic assessments of data sources to ensure their systems are capturing all possible birth defects cases. |
ICD-10-based expanded code set for use in cleft lip/palate research and surveillance
Allori AC , Cragan JD , Cassell CH , Marcus JR . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 905-914 BACKGROUND: On October 1, 2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. The ICD-10-CM code set is limited to gross categories for cleft lip and/or cleft palate (using only four of a possible seven characters). METHODS: Herein, a clinically useful expansion of the ICD-10-CM code set is proposed to improve the diagnostic accuracy necessary for individual clinical, research, and statistical projects that require it. (This is similar to how the Centers for Disease Control and Prevention/British Paediatric Association Code served to extend the ICD-9 code base.) RESULTS: Our proposed expansion does not replace the required use of ICD-10-CM for clinical, administrative, or financial transactions. Rather, it is offered as an optional set of cleft codes that could be used in parallel to document true classification-level data with phenotypic accuracy. CONCLUSION: The expanded set is "collapsible" into the official ICD-10-CM codes; this improves compatibility of the expanded codes that would be contained in research and epidemiologic databases with the standard codes from hospital electronic medical record systems and administrative billing data. |
Association between antibiotic use among pregnant women with urinary tract infections in the first trimester and birth defects, National Birth Defects Prevention Study 1997 to 2011
Ailes EC , Gilboa SM , Gill SK , Broussard CS , Crider KS , Berry RJ , Carter TC , Hobbs CA , Interrante JD , Reefhuis J . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 940-949 BACKGROUND: Previous studies noted associations between birth defects and some antibiotics (e.g., nitrofurantoin, sulfonamides) but not others (e.g., penicillins). It is unclear if previous findings were due to antibiotic use, infections, or chance. To control for potential confounding by indication, we examined associations between antibiotic use and birth defects, among women reporting urinary tract infections (UTIs). METHODS: The National Birth Defects Prevention Study is a multi-site, population-based case-control study. Case infants/fetuses have any of over 30 major birth defects and controls are live-born infants without major birth defects. We analyzed pregnancies from 1997 to 2011 to estimate the association between maternally reported periconceptional (month before conception through the third month of pregnancy) use of nitrofurantoin, trimethoprim-sulfamethoxazole, or cephalosporins and specific birth defects, among women with periconceptional UTIs. Women with periconceptional UTIs who reported penicillin use served as the comparator. RESULTS: Periconceptional UTIs were reported by 7.8% (2029/26,068) of case and 6.7% (686/10,198) of control mothers. Most (68.2% of case, 66.6% of control mothers) also reported antibiotic use. Among 608 case and 231 control mothers reporting at least one periconceptional UTI and certain antibiotic use, compared with penicillin, nitrofurantoin use was associated with oral clefts in the offspring (adjusted odds ratio, 1.97 [95% confidence interval, 1.10-3.53]), trimethoprim-sulfamethoxazole use with esophageal atresia (5.31 [1.39-20.24]) and diaphragmatic hernia (5.09 [1.20-21.69]), and cephalosporin use with anorectal atresia/stenosis (5.01 [1.34-18.76]). CONCLUSION: Periconceptional exposure to some antibiotics might increase the risk for certain birth defects. However, because individual birth defects are rare, absolute risks should drive treatment decisions., |
Databases for congenital heart defect public health studies across the lifespan
Riehle-Colarusso TJ , Bergersen L , Broberg CS , Cassell CH , Gray DT , Grosse SD , Jacobs JP , Jacobs ML , Kirby RS , Kochilas L , Krishnaswamy A , Marelli A , Pasquali SK , Wood T , Oster ME . J Am Heart Assoc 2016 5 (11) e004148 In a 2012 meeting at the Centers for Disease Control and Prevention (CDC), key experts and stakeholders identified public health knowledge gaps about congenital heart defects (CHDs), namely prevalence of CHDs across the life span, long‐term outcomes of persons with CHDs, and health services delivery for persons with CHDs.1 These gaps, and strategies to address them, formed the basis of a CHD public health science agenda. The strategies included leveraging information in existing databases to examine the epidemiology, health outcomes, and health service utilization of the CHD population.1 Many databases with CHD data exist and are managed by hospitals, specialty organizations, partnerships, and public health and other governmental entities. Researchers may be familiar with some databases but not others. Anyone planning studies to address public health knowledge gaps may benefit from an understanding of this complex constellation of databases. | The Congenital Heart Public Health Consortium (CHPHC) was formed in 2009 as a collaboration of stakeholders with its mission to prevent CHDs and improve outcomes for affected individuals.2 The CHPHC created a database workgroup to increase awareness of opportunities to contribute to the public health science agenda for CHDs using existing databases. The workgroup, consisting of experts in various disciplines (cardiologists, surgeons, epidemiologists, health service researchers), identified databases located in Canada or the United States (US) with information on CHDs from 1990 onward. The goals of this article are to provide an overview of database types and to list examples of databases that may be used to address CHD public health knowledge gaps. IRB approval was not deemed necessary for this review. |
Implementation of ICRP 116 Dose Conversion Coefficients for Reconstructing Organ Dose in a Radiation Compensation Program.
Taulbee TD , McCartney KA , Traub R , Smith MH , Neton JW . Radiat Prot Dosimetry 2016 173 131-137 Since 2000, National Institute for Occupational Safety and Health (NIOSH) has used dose conversion coefficients published by the International Commission on Radiation Protection in report 74 (ICRP 74) to determine organ dose from external radiation sources. In 2010, the ICRP issued publication 116 using more realistic phantoms than ICRP 74. NIOSH has developed a Monte Carlo method to sample the energy-organ-specific distribution of the ICRP 116 conversion coefficients to determine the organ dose and the associated uncertainty. Using Monte Carlo methods, irradiation geometry factors (IGFs) were developed to convert the measured dosemeter dose on the front of the body to values that are compatible with ICRP 116 organ dose conversion coefficients. Specific IGFs were developed for (1) both neutrons and photon exposures, (2) to male and female workers and (3) for rotational and isotropic exposure geometries. The computed mean organ dose and the associated uncertainty are used in the probability of causation calculation for compensation. |
Non-chemical risk assessment for lifting and low back pain based on Bayesian threshold models
Pandalai SP , Wheeler MW , Lu M . Saf Health Work 2017 8 (2) 206-211 AbstractBackground Self-reported low back pain (LBP) has been evaluated in relation to material handling lifting tasks, but little research has focused on relating quantifiable stressors to LBP at the individual level. The National Institute for Occupational Safety and Health (NIOSH) Composite Lifting Index (CLI) has been used to quantify stressors for lifting tasks. A chemical exposure can be readily used as an exposure metric or stressor for chemical risk assessment (RA). Defining and quantifying lifting nonchemical stressors and related adverse responses is more difficult. Stressor–response models appropriate for CLI and LBP associations do not easily fit in common chemical RA modeling techniques (e.g., Benchmark Dose methods), so different approaches were tried. Methods This work used prospective data from 138 manufacturing workers to consider the linkage of the occupational stressor of material lifting to LBP. The final model used a Bayesian random threshold approach to estimate the probability of an increase in LBP as a threshold step function. Results Using maximal and mean CLI values, a significant increase in the probability of LBP for values above 1.5 was found. Conclusion A risk of LBP associated with CLI values > 1.5 existed in this worker population. The relevance for other populations requires further study. |
Occupational exposure limits for manufactured nanomaterials, a systematic review
Mihalache R , Verbeek J , Graczyk H , Murashov V , Broekhuizen PV . Nanotoxicology 2016 11 (1) 1-35 BACKGROUND: The toxicological properties of manufactured nanomaterials (MNMs) can be different from their bulk-material and uncertainty remains about the adverse health effects they may have on humans. Proposals for OELs have been put forward which can be useful for risk management and workers' protection. We performed a systematic review of proposals for OELs for MNMs to better understand the extent of such proposals, as well as their derivation methods. METHODS: We searched PubMed and Embase with an extensive search string and also assessed the references in the included studies. Two authors extracted data independently. RESULTS: We identified 20 studies that proposed in total 56 OEL values. Of these, two proposed a generic level for all MNMs, 14 proposed a generic OEL for a category of MNMs and 40 proposed an OEL for a specific nanomaterial. For specific fibres, four studies proposed a similar value but for carbon nanotubes (CNTs) the values differed with a factor ranging from 30 to 50 and for metals with a factor from 100 to 300. The studies did not provide explanations for this variation. We found that exposure to MNMs measured at selected workplaces may exceed even the highest proposed OEL. This indicates that the application and use of OELs may be useful for exposure reduction. CONCLUSION: OELs can provide a valuable reference point for exposure reduction measures in workplaces. There is a need for more and better supported OELs based on a more systematic approach to OEL derivation. |
The International Nuclear Workers Study (Inworks): A Collaborative epidemiological study to improve knowledge about health effects of protracted low-dose exposure
Laurier D , Richardson DB , Cardis E , Daniels RD , Gillies M , O'Hagan J , Hamra GB , Haylock R , Leuraud K , Moissonnier M , Schubauer-Berigan MK , Thierry-Chef I , Kesminiene A . Radiat Prot Dosimetry 2016 173 21-25 INWORKS is a multinational cohort study, gathering 308 297 workers in the nuclear industry in France, the United Kingdom and the United States of America, with detailed individual monitoring data for external exposure to ionising radiation. Over a mean duration of follow-up of 27 y, the number of observed deaths was 66 632, including 17 957 deaths due to solid cancers, 1791 deaths due to haematological cancers and 27 848 deaths due to cardiovascular diseases. Mean individual cumulative external dose over the period 1945-2005 was 25 mSv. Analyses demonstrated a significant association between red bone marrow dose and the risk of leukaemia (excluding chronic lymphocytic leukaemia) and between colon dose and the risk of solid cancers. INWORKS assembled some of the strongest evidence to strengthen the scientific basis for the protection of adults from low dose, low-dose rate, exposures to ionising radiation. |
Effectiveness of insecticide-treated bednets in malaria prevention in Haiti: a case-control study
Steinhardt LC , Jean YS , Impoinvil D , Mace KE , Wiegand R , Huber CS , Alexandre JS , Frederick J , Nkurunziza E , Jean S , Wheeler B , Dotson E , Slutsker L , Kachur SP , Barnwell JW , Lemoine JF , Chang MA . Lancet Glob Health 2016 5 (1) e96-e103 BACKGROUND: Insecticide-treated bednets (ITNs) are effective in preventing malaria where vectors primarily bite indoors and late at night, but their effectiveness is uncertain where vectors bite outdoors and earlier in the evening. We studied the effectiveness of ITNs following a mass distribution in Haiti from May to September, 2012, where the Anopheles albimanus vector bites primarily outdoors and often when people are awake. METHODS: In this case-control study, we enrolled febrile patients presenting to outpatient departments at 17 health facilities throughout Haiti from Sept 4, 2012, to Feb 27, 2014, who were tested with malaria rapid diagnostic tests (RDTs), and administered questionnaires on ITN use and other risk factors. Cases were defined by positive RDT and controls were febrile patients from the same clinic with a negative RDT. Our primary analysis retrospectively matched cases and controls by age, sex, location, and date, and used conditional logistic regression on the matched sample. A sensitivity analysis used propensity scores to match patients on ITN use propensity and analyse malaria among ITN users and non-users. Additional ITN bioefficacy and entomological data were collected. FINDINGS: We enrolled 9317 patients, including 378 (4%) RDT-positive cases. 1202 (13%) patients reported ITN use. Post-hoc matching of cases and controls yielded 362 cases and 1201 matched controls, 19% (333) of whom reported consistent campaign net use. After using propensity scores to match on consistent campaign ITN use, 2298 patients, including 138 (7%) RDT-positive cases, were included: 1149 consistent campaign ITN users and 1149 non-consistent campaign ITN users. Both analyses revealed that ITNs did not significantly protect against clinical malaria (odds ratio [OR]=0.95, 95% CI 0.68-1.32, p=0.745 for case-control analysis; OR=0.95, 95% CI 0.45-1.97, p=0.884 for propensity score analysis). ITN and entomological data indicated good ITN physical integrity and bioefficacy, and no permethrin resistance among local mosquitoes. INTERPRETATION: We found no evidence that mass ITN campaigns reduce clinical malaria in this observational study in Haiti; alternative malaria control strategies should be prioritised. FUNDING: The Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the US-based Centers for Disease Control and Prevention (CDC). |
A reporting tool for practice guidelines in health care: The right statement
Chen Y , Yang K , Marusic A , Qaseem A , Meerpohl JJ , Flottorp S , Akl EA , Schunemann HJ , Chan ES , Falck-Ytter Y , Ahmed F , Barber S , Chen C , Zhang M , Xu B , Tian J , Song F , Shang H , Tang K , Wang Q , Norris SL . Ann Intern Med 2016 166 (2) 128-132 The quality of reporting practice guidelines is often poor, and there is no widely accepted guidance or standards for such reporting in health care. The international RIGHT (Reporting Items for practice Guidelines in HealThcare) Working Group was established to address this gap. The group followed an existing framework for developing guidelines for health research reporting and the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach. It developed a checklist and an explanation and elaboration statement. The RIGHT checklist includes 22 items that are considered essential for good reporting of practice guidelines: basic information (items 1 to 4), background (items 5 to 9), evidence (items 10 to 12), recommendations (items 13 to 15), review and quality assurance (items 16 and 17), funding and declaration and management of interests (items 18 and 19), and other information (items 20 to 22). The RIGHT checklist can assist developers in reporting guidelines, support journal editors and peer reviewers when considering guideline reports, and help health care practitioners understand and implement a guideline. |
Inference for probability of selection with dependently truncated data using a Cox model
Zhang X , Li J , Liu Y . Commun Stat Simul Comput 2016 46 (3) 1944-1957 A truncated sample consists of realizations of two variables L and T subject to the constraint L < T. One simple solution to dependently truncated data is to take L as a covariate of T in the Cox model. We aimed at studying the probability of selection, P(L < T), in this framework. We proposed the point estimator and derived its asymptotic distribution. Both truncated-only data and censored and truncated data were generated in the simulation study. The proposed point and variance estimators showed good performance in various simulated settings. The bone marrow transplant registry data were analyzed as the illustrative example. |
Developmental toxicity of nicotine: A transdisciplinary synthesis and implications for emerging tobacco products
England LJ , Aagaard K , Bloch M , Conway K , Cosgrove K , Grana R , Gould TJ , Hatsukami D , Jensen F , Kandel D , Lanphear B , Leslie F , Pauly JR , Neiderhiser J , Rubinstein M , Slotkin TA , Spindel E , Stroud L , Wakschlag L . Neurosci Biobehav Rev 2016 72 176-189 While the health risks associated with adult cigarette smoking have been well described, effects of nicotine exposure during periods of developmental vulnerability are often overlooked. Using MEDLINE and PubMed literature searches, books, reports and expert opinion, a transdisciplinary group of scientists reviewed human and animal research on the health effects of exposure to nicotine during pregnancy and adolescence. A synthesis of this research supports that nicotine contributes critically to adverse effects of gestational tobacco exposure, including reduced pulmonary function, auditory processing defects, impaired infant cardiorespiratory function, and may contribute to cognitive and behavioral deficits in later life. Nicotine exposure during adolescence is associated with deficits in working memory, attention, and auditory processing, as well as increased impulsivity and anxiety. Finally, recent animal studies suggest that nicotine has a priming effect that increases addiction liability for other drugs. The evidence that nicotine adversely affects fetal and adolescent development is sufficient to warrant public health measures to protect pregnant women, children, and adolescents from nicotine exposure. |
Travel-associated Zika virus disease acquired in the Americas through February 2016: A GeoSentinel analysis
Hamer DH , Barbre KA , Chen LH , Grobusch MP , Schlagenhauf P , Goorhuis A , van Genderen PJ , Molina I , Asgeirsson H , Kozarsky PE , Caumes E , Hagmann SH , Mockenhaupt FP , Eperon G , Barnett ED , Bottieau E , Boggild AK , Gautret P , Hynes NA , Kuhn S , Lash RR , Leder K , Libman M , Malvy DJ , Perret C , Rothe C , Schwartz E , Wilder-Smith A , Cetron MS , Esposito DH . Ann Intern Med 2016 166 (2) 99-108 Background: Zika virus has spread rapidly in the Americas and has been imported into many nonendemic countries by travelers. Objective: To describe clinical manifestations and epidemiology of Zika virus disease in travelers exposed in the Americas. Design: Descriptive, using GeoSentinel records. Setting: 63 travel and tropical medicine clinics in 30 countries. Patients: Ill returned travelers with a confirmed, probable, or clinically suspected diagnosis of Zika virus disease seen between January 2013 and 29 February 2016. Measurements: Frequencies of demographic, trip, and clinical characteristics and complications. Results: Starting in May 2015, 93 cases of Zika virus disease were reported. Common symptoms included exanthema (88%), fever (76%), and arthralgia (72%). Fifty-nine percent of patients were exposed in South America; 71% were diagnosed in Europe. Case status was established most commonly by polymerase chain reaction (PCR) testing of blood and less often by PCR testing of other body fluids or serology and plaque-reduction neutralization testing. Two patients developed Guillain-Barre syndrome, and 3 of 4 pregnancies had adverse outcomes (microcephaly, major fetal neurologic abnormalities, and intrauterine fetal death). Limitation: Surveillance data collected by specialized clinics may not be representative of all ill returned travelers, and denominator data are unavailable. Conclusion: These surveillance data help characterize the clinical manifestations and adverse outcomes of Zika virus disease among travelers infected in the Americas and show a need for global standardization of diagnostic testing. The serious fetal complications observed in this study highlight the importance of travel advisories and prevention measures for pregnant women and their partners. Travelers are sentinels for global Zika virus circulation and may facilitate further transmission. Primary Funding Source: Centers for Disease Control and Prevention, International Society of Travel Medicine, and Public Health Agency of Canada. |
Locally acquired eastern equine encephalitis virus disease, Arkansas, USA
Garlick J , Lee TJ , Shepherd P , Linam WM , Pastula DM , Weinstein S , Schexnayder SM . Emerg Infect Dis 2016 22 (12) 2216-2217 Eastern equine encephalitis virus (EEEV) is an arbovirus (family Togaviridae, genus Alphavirus) transmitted to humans primarily from Aedes, Coquillettidia, and Culex mosquitoes. EEEV is maintained in a transmission cycle between Culiseta melanura mosquitoes and birds in freshwater hardwood swamps (1). Affected humans and horses are considered to be dead-end hosts; that is, they usually do not develop sufficient levels of viremia to infect mosquitoes. Although human EEEV disease is rare, it has a case-fatality rate of >30% and >50% of survivors may have permanent neurologic sequelae (2–5). Cases occur sporadically each year, primarily along the eastern and Gulf coasts of North America, but no cases have been previously reported in Arkansas (1). We report a locally acquired case of human EEEV disease in Arkansas. | In October 2013, a male teenager from southwestern Arkansas sought care at a local hospital after 3 days of headache and 3 new-onset focal seizures. He had a history of recent multiple mosquito bites and no history of recent travel. Initial laboratory studies on postsymptom onset day (PSOD) 3 showed normal peripheral leukocyte count, electrolytes, and liver function tests. Cerebrospinal fluid (CSF) exam showed 5 leukocytes/mm3 (reference 0–5), 7 erythrocytes/mm3 (reference 0), 55 mg/dL glucose (reference 45–80), and 36 mg/dL protein (reference 15–40). Noncontrast computed tomography (CT) of the head was normal. He was transferred to a regional academic pediatric hospital on PSOD 3. |
Investigation of and response to 2 plague cases, Yosemite National Park, California, USA, 2015
Danforth M , Novak M , Petersen J , Mead P , Kingry L , Weinburke M , Buttke D , Hacker G , Tucker J , Niemela M , Jackson B , Padgett K , Liebman K , Vugia D , Kramer V . Emerg Infect Dis 2016 22 (12) 2045-53 In August 2015, plague was diagnosed for 2 persons who had visited Yosemite National Park in California, USA. One case was septicemic and the other bubonic. Subsequent environmental investigation identified probable locations of exposure for each patient and evidence of epizootic plague in other areas of the park. Transmission of Yersinia pestis was detected by testing rodent serum, fleas, and rodent carcasses. The environmental investigation and whole-genome multilocus sequence typing of Y. pestis isolates from the patients and environmental samples indicated that the patients had been exposed in different locations and that at least 2 distinct strains of Y. pestis were circulating among vector-host populations in the area. Public education efforts and insecticide applications in select areas to control rodent fleas probably reduced the risk for plague transmission to park visitors and staff. |
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