Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-30 (of 76 Records) |
Query Trace: Connor T[original query] |
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Chikungunya infection in returned travellers: results from the GEOSENTINEL network, 2005-2020
Bierbrier R , Javelle E , Norman FF , Chen LH , Bottieau E , Schwartz E , Leder K , Angelo KM , Stoney R , Libman M , Hamer DH , Huits R , Connor BA , Simon F , Barkati S . J Travel Med 2024 BACKGROUND: Chikungunya is an important travel-related disease because of its rapid geographical expansion and potential for prolonged morbidity. Improved understanding of the epidemiology of travel-related chikungunya infections may influence prevention strategies including education and vaccination. METHODS: We analysed data from travellers with confirmed or probable chikungunya reported to GeoSentinel sites from 2005 to 2020. Confirmed chikungunya was defined as a compatible clinical history plus either virus isolation, positive nucleic acid test, or seroconversion/rising titre in paired sera. Probable chikungunya was defined as a compatible clinical history with a single positive serology result. RESULTS: 1202 travellers (896 confirmed and 306 probable) with chikungunya were included. The median age was 43 years (range 0-91; interquartile range [IQR]: 31-55); 707 (58.8%) travellers were female. Most infections were acquired in the Caribbean (28.8%), Southeast Asia (22.8%), South Central Asia (14.2%) and South America (14.2%). The highest numbers of chikungunya cases reported to GeoSentinel were in 2014 (28.3%), 2015 (14.3%), and 2019 (11.9%). The most frequent reasons for travel were tourism (n = 592; 49.3%) and visiting friends or relatives (n = 334; 27.7%). The median time to presentation to a GeoSentinel site was 23 days (IQR: 7-52) after symptom onset. In travellers with confirmed chikungunya and no other reported illnesses, the most frequently reported symptoms included musculoskeletal symptoms (98.8%), fever/chills/sweats (68.7%), and skin symptoms (35.5%). Among 917 travellers with information available, 296 (32.3%) had a pre-travel consultation. CONCLUSIONS: Chikungunya was acquired by international travellers in almost 100 destinations globally. Vector precautions and vaccination where recommended should be integrated into pretravel visits for travellers going to areas with chikungunya or areas with the potential for transmission.Continued surveillance of travel-related chikungunya may help public health officials and clinicians limit the transmission of this potentially debilitating disease by defining regions where protective measures (e.g. pre-travel vaccination) should be strongly considered. |
Travel-related diagnoses among U.S. nonmigrant travelers or migrants presenting to U.S. GeoSentinel Sites - GeoSentinel Network, 2012-2021
Brown AB , Miller C , Hamer DH , Kozarsky P , Libman M , Huits R , Rizwan A , Emetulu H , Waggoner J , Chen LH , Leung DT , Bourque D , Connor BA , Licitra C , Angelo KM . MMWR Surveill Summ 2023 72 (7) 1-22 PROBLEM/CONDITION: During 2012-2021, the volume of international travel reached record highs and lows. This period also was marked by the emergence or large outbreaks of multiple infectious diseases (e.g., Zika virus, yellow fever, and COVID-19). Over time, the growing ease and increased frequency of travel has resulted in the unprecedented global spread of infectious diseases. Detecting infectious diseases and other diagnoses among travelers can serve as sentinel surveillance for new or emerging pathogens and provide information to improve case identification, clinical management, and public health prevention and response. REPORTING PERIOD: 2012-2021. DESCRIPTION OF SYSTEM: Established in 1995, the GeoSentinel Network (GeoSentinel), a collaboration between CDC and the International Society of Travel Medicine, is a global, clinical-care-based surveillance and research network of travel and tropical medicine sites that monitors infectious diseases and other adverse health events that affect international travelers. GeoSentinel comprises 71 sites in 29 countries where clinicians diagnose illnesses and collect demographic, clinical, and travel-related information about diseases and illnesses acquired during travel using a standardized report form. Data are collected electronically via a secure CDC database, and daily reports are generated for assistance in detecting sentinel events (i.e., unusual patterns or clusters of disease). GeoSentinel sites collaborate to report disease or population-specific findings through retrospective database analyses and the collection of supplemental data to fill specific knowledge gaps. GeoSentinel also serves as a communications network by using internal notifications, ProMed alerts, and peer-reviewed publications to alert clinicians and public health professionals about global outbreaks and events that might affect travelers. This report summarizes data from 20 U.S. GeoSentinel sites and reports on the detection of three worldwide events that demonstrate GeoSentinel's notification capability. RESULTS: During 2012-2021, data were collected by all GeoSentinel sites on approximately 200,000 patients who had approximately 244,000 confirmed or probable travel-related diagnoses. Twenty GeoSentinel sites from the United States contributed records during the 10-year surveillance period, submitting data on 18,336 patients, of which 17,389 lived in the United States and were evaluated by a clinician at a U.S. site after travel. Of those patients, 7,530 (43.3%) were recent migrants to the United States, and 9,859 (56.7%) were returning nonmigrant travelers.Among the recent migrants to the United States, the median age was 28.5 years (range = <19 years to 93 years); 47.3% were female, and 6.0% were U.S. citizens. A majority (89.8%) were seen as outpatients, and among 4,672 migrants with information available, 4,148 (88.8%) did not receive pretravel health information. Of 13,986 diagnoses among migrants, the most frequent were vitamin D deficiency (20.2%), Blastocystis (10.9%), and latent tuberculosis (10.3%). Malaria was diagnosed in 54 (<1%) migrants. Of the 26 migrants diagnosed with malaria for whom pretravel information was known, 88.5% did not receive pretravel health information. Before November 16, 2018, patients' reasons for travel, exposure country, and exposure region were not linked to an individual diagnosis. Thus, results of these data from January 1, 2012, to November 15, 2018 (early period), and from November 16, 2018, to December 31, 2021 (later period), are reported separately. During the early and later periods, the most frequent regions of exposure were Sub-Saharan Africa (22.7% and 26.2%, respectively), the Caribbean (21.3% and 8.4%, respectively), Central America (13.4% and 27.6%, respectively), and South East Asia (13.1% and 16.9%, respectively). Migrants with diagnosed malaria were most frequently exposed in Sub-Saharan Africa (89.3% and 100%, respectively).Among nonmigrant travelers returning to the United States, the median age was 37 years (range = <19 years to 96 years); 55.7% were female, 75.3% were born in the United States, and 89.4% were U.S. citizens. A majority (90.6%) were seen as outpatients, and of 8,967 nonmigrant travelers with available information, 5,878 (65.6%) did not receive pretravel health information. Of 11,987 diagnoses, the most frequent were related to the gastrointestinal system (5,173; 43.2%). The most frequent diagnoses among nonmigrant travelers were acute diarrhea (16.9%), viral syndrome (4.9%), and irritable bowel syndrome (4.1%).Malaria was diagnosed in 421 (3.5%) nonmigrant travelers. During the early (January 1, 2012, to November 15, 2018) and later (November 16, 2018, to December 31, 2021) periods, the most frequent reasons for travel among nonmigrant travelers were tourism (44.8% and 53.6%, respectively), travelers visiting friends and relatives (VFRs) (22.0% and 21.4%, respectively), business (13.4% and 12.3%, respectively), and missionary or humanitarian aid (13.1% and 6.2%, respectively). The most frequent regions of exposure for any diagnosis among nonmigrant travelers during the early and later period were Central America (19.2% and 17.3%, respectively), Sub-Saharan Africa (17.7% and 25.5%, respectively), the Caribbean (13.0% and 10.9%, respectively), and South East Asia (10.4% and 11.2%, respectively).Nonmigrant travelers who had malaria diagnosed were most frequently exposed in Sub-Saharan Africa (88.6% and 95.9% during the early and later period, respectively) and VFRs (70.3% and 57.9%, respectively). Among VFRs with malaria, a majority did not receive pretravel health information (70.2% and 83.3%, respectively) or take malaria chemoprophylaxis (88.3% and 100%, respectively). INTERPRETATION: Among ill U.S. travelers evaluated at U.S. GeoSentinel sites after travel, the majority were nonmigrant travelers who most frequently received a gastrointestinal disease diagnosis, implying that persons from the United States traveling internationally might be exposed to contaminated food and water. Migrants most frequently received diagnoses of conditions such as vitamin D deficiency and latent tuberculosis, which might result from adverse circumstances before and during migration (e.g., malnutrition and food insecurity, limited access to adequate sanitation and hygiene, and crowded housing,). Malaria was diagnosed in both migrants and nonmigrant travelers, and only a limited number reported taking malaria chemoprophylaxis, which might be attributed to both barriers to acquiring pretravel health care (especially for VFRs) and lack of prevention practices (e.g., insect repellant use) during travel. The number of ill travelers evaluated by U.S. GeoSentinel sites after travel decreased in 2020 and 2021 compared with previous years because of the COVID-19 pandemic and associated travel restrictions. GeoSentinel detected limited cases of COVID-19 and did not detect any sentinel cases early in the pandemic because of the lack of global diagnostic testing capacity. PUBLIC HEALTH ACTION: The findings in this report describe the scope of health-related conditions that migrants and returning nonmigrant travelers to the United States acquired, illustrating risk for acquiring illnesses during travel. In addition, certain travelers do not seek pretravel health care, even when traveling to areas in which high-risk, preventable diseases are endemic. Health care professionals can aid international travelers by providing evaluations and destination-specific advice.Health care professionals should both foster trust and enhance pretravel prevention messaging for VFRs, a group known to have a higher incidence of serious diseases after travel (e.g., malaria and enteric fever). Health care professionals should continue to advocate for medical care in underserved populations (e.g., VFRs and migrants) to prevent disease progression, reactivation, and potential spread to and within vulnerable populations. Because both travel and infectious diseases evolve, public health professionals should explore ways to enhance the detection of emerging diseases that might not be captured by current surveillance systems that are not site based. |
Genomic epidemiology of a severe acute respiratory syndrome coronavirus 2 outbreak in a US major league soccer club: Was it travel related
Carmola LR , Turcinovic J , Draper G , Webner D , Putukian M , Silvers-Granelli H , Bombin A , Connor BA , Angelo KM , Kozarsky P , Libman M , Huits R , Hamer DH , Fairley JK , Connor JH , Piantadosi A , Bourque DL . Open Forum Infect Dis 2023 10 (6) ofad235 BACKGROUND: Professional soccer athletes are at risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). United States Major League Soccer (MLS) uses protocol-based SARS-CoV-2 testing for identification of individuals with coronavirus disease 2019. METHODS: Per MLS protocol, fully vaccinated players underwent SARS-CoV-2 real-time polymerase chain reaction testing weekly; unvaccinated players were tested every other day. Demographic and epidemiologic data were collected from individuals who tested positive, and contact tracing was performed. Whole genome sequencing (WGS) was performed on positive specimens, and phylogenetic analyses were used to identify potential transmission patterns. RESULTS: In the fall of 2021, all 30 players from 1 MLS team underwent SARS-CoV-2 testing per protocol; 27 (90%) were vaccinated. One player who had recently traveled to Africa tested positive for SARS-CoV-2; within the following 2 weeks, 10 additional players and 1 staff member tested positive. WGS yielded full genome sequences for 10 samples, including 1 from the traveler. The traveler's sample was Delta sublineage AY.36 and was closely related to a sequence from Africa. Nine samples yielded other Delta sublineages including AY.4 (n = 7), AY.39 (n = 1), and B.1.617.2 (n = 1). The 7 AY.4 sequences clustered together; suggesting a common source of infection. Transmission from a family member visiting from England to an MLS player was identified as the potential index case. The other 2 AY.4 sequences differed from this group by 1-3 nucleotides, as did a partial genome sequence from an additional team member. CONCLUSIONS: WGS is a useful tool for understanding SARS-CoV-2 transmission dynamics in professional sports teams. |
Reducing the particles generated by flushing institutional toilets
Cai C , Kim P , Connor TH , Liu Y , Floyd EL . J Occup Environ Hyg 2022 19 (5) 318-326 Airborne particles play a significant role in the transmission of SARS-CoV-2, the virus that causes COVID-19. A previous study reported that institutional flush-O-meter (FOM) toilets can generate 3-12 times as many droplets as other toilets by splashing (large droplets) and bubble bursting (fine droplets). In this study, an aerosol suppression lid was evaluated to measure the reduction of particles by size using three metrics; number, surface area, and mass concentrations. To quantify toilet flush aerosol over time, detailed particle size distributions (from 0.016-19.81 µm across 152 size bins) were measured from a FOM toilet in a controlled-environment test chamber, without ventilation, with and without use of the suppression lid. Prior to each flushing trial, the toilet bowl water was seeded with 480 mL fluorescein at 10 mg/mL. A high-speed camera was used to record the large droplet movements after flushing. An ultraviolet-visible spectrophotometer was used to analyze the wipe samples to evaluate the contamination on the lid. The particle number, surface area, and mass concentrations without a lid were elevated compared to a lid in the first 90 sec. Overall, the lid reduced 48% of total number concentration, 76% of total surface area concentration, and 66% of total mass concentration, respectively. Depending on the particle size, the number concentration reduction percentage ranged from 48-100% for particles larger than 0.1 µm. Large droplets created by splashing were captured by the high-speed camera. Similar studies can be used for future particle aerodynamic studies. The fluorescein droplets deposited on the lid back sections, which were closer to the FOM accounted for 82% of the total fluorescein. Based on two-way ANOVA analysis, there were significant differences among both the experimental flushes (p = 0.0185) and the sections on the lid (p = 0.0146). Future work should explore the aerosolization produced by flushing and the performance of the lid in real restroom environments, where feces and urine exist in the bowl water and the indoor ventilation system is in operation. |
Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis
Connor NE , Islam MS , Mullany LC , Shang N , Bhutta ZA , Zaidi AKM , Soofi S , Nisar I , Panigrahi P , Panigrahi K , Satpathy R , Bose A , Isaac R , Baqui AH , Mitra DK , Sadeq-Ur Rahman Q , Hossain T , Schrag SJ , Winchell JM , Arvay ML , Diaz MH , Waller JL , Weber MW , Hamer DH , Hibberd P , Nawshad Uddin Ahmed ASM , Islam M , Hossain MB , Qazi SA , El Arifeen S , Darmstadt GL , Saha SK . BMJ Glob Health 2022 7 (11) OBJECTIVE: Risk factors predisposing infants to community-acquired bacterial infections during the first 2 months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship. METHODS: Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59 days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection. RESULTS: Among 63 114 infants born, 14 655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99). CONCLUSION: Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials. |
Identification of small molecules with improved potency against orthopoxviruses from vaccinia to smallpox
Brown LE , Seitz S , Kondas AV , Marcyk PT , Filone CM , Hossain MM , Schaus SE , Olson VA , Connor JH . Antimicrob Agents Chemother 2022 66 (11) e0084122 The genus Orthopoxvirus contains several human pathogens, including vaccinia, monkeypox, cowpox, and variola virus, the causative agent of smallpox. Although there are a few effective vaccines, widespread prophylactic vaccination has ceased and is unlikely to resume, making therapeutics increasingly important to treat poxvirus disease. Here, we described efforts to improve the potency of the anti-poxvirus small molecule CMLDBU6128. This class of small molecules, referred to as pyridopyrimidinones (PDPMs), showed a wide range of biological activities. Through the synthesis and testing of several exploratory chemical libraries based on this molecule, we identified several compounds that had increased potency from the micromolar into the nanomolar range. Two compounds, designated (12) and (16), showed inhibitory concentrations of 326 nM and 101 nM, respectively, which was more than a 10-fold increase in potency to CMLDBU6128 with an inhibitory concentration of around 6 μM. We also expanded our investigation of the breadth of action of these molecules and showed that they can inhibit the replication of variola virus, a related orthopoxvirus. Together, these findings highlighted the promise of this new class of antipoxviral agents as broad-spectrum small molecules with significant potential to be developed as antiviral therapy. This would add a small molecule option for therapy of spreading diseases, including monkeypox and cowpox viruses, that would also be expected to have efficacy against smallpox. |
Infectious aetiologies of neonatal illness in South Asia classified using WHO definitions: a primary analysis of the ANISA study
Arvay ML , Shang N , Qazi SA , Darmstadt GL , Islam MS , Roth DE , Liu A , Connor NE , Hossain B , Sadeq-Ur Rahman Q , El Arifeen S , Mullany LC , Zaidi AKM , Bhutta ZA , Soofi SB , Shafiq Y , Baqui AH , Mitra DK , Panigrahi P , Panigrahi K , Bose A , Isaac R , Westreich D , Meshnick SR , Saha SK , Schrag SJ . Lancet Glob Health 2022 10 (9) e1289-e1297 BACKGROUND: Globally, neonatal mortality accounts for almost half of all deaths in children younger than 5 years. Aetiological agents of neonatal infection are difficult to identify because the clinical signs are non-specific. Using data from the Aetiology of Neonatal Infections in south Asia (ANISA) cohort, we aimed to describe the spectrum of infectious aetiologies of acute neonatal illness categorised post-hoc using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast breathing only. METHODS: Eligible infants were aged 0-59 days with possible serious bacterial infection and healthy infants enrolled in the ANISA study in Bangladesh, India, and Pakistan. We applied a partial latent class Bayesian model to estimate the prevalence of 27 pathogens detectable on PCR, pathogens detected by blood culture only, and illness not attributed to any infectious aetiology. Infants with at least one clinical specimen available were included in the analysis. We assessed the prevalence of these aetiologies according to WHO's case definitions of critically ill, clinical severe infection, and infants with late onset, isolated fast breathing. For the clinical severe definition, we compared the prevalence of signs by bacterial versus viral aetiology. FINDINGS: There were 934 infants (992 episodes) in the critically ill category, 3769 (4000 episodes) in the clinical severe infection category, and 738 (771 episodes) in the late-onset isolated fast breathing category. We estimated the proportion of illness attributable to bacterial infection was 32·7% in infants in the critically ill group, 15·6% in the clinical severe infection group, and 8·8% among infants with late-onset isolated fast breathing group. An infectious aetiology was not identified in 58-82% of infants in these categories. Among 4000 episodes of clinical severe infection, those with bacterial versus viral attribution had higher proportions of hypothermia, movement only when stimulated, convulsions, and poor feeding. INTERPRETATION: Our modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions. FUNDING: The Bill and Melinda Gates Foundation. |
Future-proofing and maximizing the utility of metadata: The PHA4GE SARS-CoV-2 contextual data specification package.
Griffiths EJ , Timme RE , Mendes CI , Page AJ , Alikhan NF , Fornika D , Maguire F , Campos J , Park D , Olawoye IB , Oluniyi PE , Anderson D , Christoffels A , da Silva AG , Cameron R , Dooley D , Katz LS , Black A , Karsch-Mizrachi I , Barrett T , Johnston A , Connor TR , Nicholls SM , Witney AA , Tyson GH , Tausch SH , Raphenya AR , Alcock B , Aanensen DM , Hodcroft E , Hsiao WWL , Vasconcelos ATR , MacCannell DR . Gigascience 2022 11 BACKGROUND: The Public Health Alliance for Genomic Epidemiology (PHA4GE) (https://pha4ge.org) is a global coalition that is actively working to establish consensus standards, document and share best practices, improve the availability of critical bioinformatics tools and resources, and advocate for greater openness, interoperability, accessibility, and reproducibility in public health microbial bioinformatics. In the face of the current pandemic, PHA4GE has identified a need for a fit-for-purpose, open-source SARS-CoV-2 contextual data standard. RESULTS: As such, we have developed a SARS-CoV-2 contextual data specification package based on harmonizable, publicly available community standards. The specification can be implemented via a collection template, as well as an array of protocols and tools to support both the harmonization and submission of sequence data and contextual information to public biorepositories. CONCLUSIONS: Well-structured, rich contextual data add value, promote reuse, and enable aggregation and integration of disparate datasets. Adoption of the proposed standard and practices will better enable interoperability between datasets and systems, improve the consistency and utility of generated data, and ultimately facilitate novel insights and discoveries in SARS-CoV-2 and COVID-19. The package is now supported by the NCBI's BioSample database. |
Acute hepatitis A in international travelers: A GeoSentinel analysis, 2008-2020
Balogun O , Brown A , Angelo DoKm , Hochberg NS , Barnett ED , Nicolini LA , Asgeirsson H , Grobusch MP , Leder K , Salvador F , Chen L , Odolini S , Daz-Menndez M , Gobbi F , Connor BA , Libman M , Hamer DH . J Travel Med 2022 29 (2) BACKGROUND: Non-immune international travelers are at risk of acquiring hepatitis A. Although hepatitis A vaccination is recommended for unvaccinated travelers to high or intermediate hepatitis A virus endemicity, compliance with this recommendation is not universal. OBJECTIVE: To describe the demographic and travel characteristics of international travelers infected with hepatitis A during travel. METHODS: Available data on travelers with confirmed (positive molecular test) or probable (symptomatic individuals with a single positive IgM test) hepatitis A diagnosed during and after travel from January 2008 to December 2020 were obtained from the GeoSentinel Surveillance Network database. We analyzed demographic and travel characteristics of infected travelers. RESULTS: Among 254 travelers with hepatitis A (185 confirmed and 69 probable), the median age was 28years (interquartile range: 19-40), 150 (59%) were male, and among 54 travelers with information available, 53 (98%) were unvaccinated. The most common reasons for travel included tourism (n=120; 47%) and visiting friends or relatives (VFR) (n=72; 28%). About two-thirds of VFR travelers with hepatitis A (n=50; 69%) were younger than 20years old. Hepatitis A was acquired most frequently in South-Central Asia (n=63; 25%) and sub-Saharan Africa (n=61; 24%), but 16 travelers (6%) acquired hepatitis A in regions with low endemicity including Western Europe (n=7; 3%), the Caribbean (n=6; 2%), and North America (n=3; 1%). Median duration from illness onset to GeoSentinel site presentation was approximately 7days (IQR: 4-14days). Among 88 travelers with information available, 59% were hospitalized. CONCLUSION: Despite availability of highly effective vaccines, travelers still acquire hepatitis A, even when traveling to low-endemicity destinations. Providing pre-departure hepatitis A vaccine to susceptible travelers is crucial to reducing travel-associated hepatitis A and should be offered to all travelers as part of the pre-travel consultation, regardless of destination. |
The association between air pollution and childhood asthma: United States, 2010-2015
Connor EM , Zablotsky B . J Asthma 2021 59 (10) 1-16 Objective: The current population-based study examines the association between county-level ambient air pollution and childhood asthma.Methods: Data from the nationally representative 2010-2015 National Health Interview Survey were linked to nationwide fine particulate matter (PM(2.5)) air pollution data at the county-level from the National Environmental Public Health Tracking Network which utilizes air quality monitoring stations and modeled PM(2.5) measurements (Downscaler model data) and adjusted by county-level socioeconomic characteristics data from the 2010-2015 American Community Survey. Multilevel modeling techniques were used to assess the association between PM(2.5) annual concentrations (quartiles <8.11, 8.11-9.50, 9.51-10.59, ≥ 10.60 µg/m(3)) and current childhood asthma along with two asthma outcomes (episode in the past year, emergency room (ER) visit due to asthma).Results: From 2010-2015, there were significant declines in PM(2.5) concentrations and asthma outcomes. In unadjusted models, children living in areas with higher PM(2.5) concentrations were more likely to have current asthma, ≥1 asthma episode in the past year, and ≥1 ER visit due to asthma compared with children living in areas with the lowest quartile (< 8.11 µg/m(3)). After adjusting for characteristics at the county, geographic, and child and family-level, significant associations remained for asthma episode, and ER visit among children living in areas with PM(2.5) annual concentrations between 9.51-10.59 µg/m(3) (3rd quartile) compared with children living in areas with the lowest quartile.Conclusions: This study adds to the limited literature by incorporating nationally representative county-, child-, and family-level data to provide a multi-level analysis of the associations between air pollution and childhood asthma in the U.S. |
HIV and syphilis prevalence among transgender women and men who have sex with men, Silom Community Clinic, Bangkok, Thailand, 2017-2019
Pattanasin S , Griensven FV , Mock PA , Sukwicha W , Kongpechsatit O , Krasan C , O'Connor S , Hickey AC , Ungsedhapand C , Woodring JV , Connor S , Chitwarakorn A , Dunne EF . AIDS Care 2021 34 (10) 1-9 We assessed HIV and syphilis infection among MSM and TGW attending Silom Community Clinic from 2017 to 2019. Walk-in and referral clients completed a registration application including a question on gender identity. We compared the prevalence of HIV, syphilis, and HIV and syphilis coinfection among TGW and MSM. In a total of 1050 clients, 276 (26.3%) were TGW and 774 (74.7%) were MSM. Among TGW clients, HIV prevalence was 29.8%, syphilis prevalence was 38.4%, and coinfection prevalence was 18.5%. Comparing prevalence among TGW to MSM, the adjusted prevalence ratio (aPR) for HIV was 1.8 (95% CI:1.4-2.3), for syphilis was 1.2 (95% CI:1.0-1.4), and for HIV and syphilis coinfection was 2.1 (95% CI:1.4-2.9). The prevalence of syphilis was higher than HIV among TGW, with a PR of 1.3 (95% CI:1.1-1.6), and among MSM, with a PR of 1.4 (95% CI:1.2-1.7). TGW age 15-21 years had an HIV prevalence of 16.9% and syphilis prevalence of 30.8%. After adjusting for age, referral, and sexual behaviors, TGW remain significantly associated with HIV and syphilis prevalence. There is a substantial burden of HIV and HIV/syphilis co-infection among TGW. HIV/STI prevention are needed for TGW, including linkage to HIV care. |
Secular trends in breast cancer risk among women with HIV initiating aRT in North America
Coburn SB , Shiels M , Silverberg M , Horberg M , Gill MJ , Brown TT , Visvanathan K , Connor AE , Napravnik S , Marcus J , Moore RD , Mathews WC , Mayor AM , Sterling T , Li J , Rabkin C , D'Souza G , Lau B , Althoff KN . J Acquir Immune Defic Syndr 2021 87 (1) 663-670 BACKGROUND: Studies suggest lower risk of breast cancer in women with versus without HIV. These estimates may be biased by lower life expectancy and younger age distribution of women with HIV. Our analysis evaluated this bias and characterized secular trends in breast cancer among women with HIV initiating ART. We hypothesized breast cancer risk would increase over time as mortality decreased. SETTING: Women with HIV prescribed ART in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) from 1997-2016. METHODS: We estimated breast cancer hazard (cause-specific hazard ratios [csHR]) and cumulative incidence accounting for competing risks (subdistribution hazard ratios [sdHR]) to assess changes in breast cancer risk over time. This was assessed overall (1997-2016) and within/across calendar periods. Analyses were adjusted for race/ethnicity and inverse probability weighted for cohort. Cumulative incidence was graphically assessed by calendar period and race/ethnicity. RESULTS: We observed 11,587 women during 1997-2016, contributing 63 incident breast cancer diagnoses and 1,353 deaths (73,445 person-years [median follow-up=4.5 years]). Breast cancer cumulative incidence was 3.2% for 1997-2016. We observed no secular trends in breast cancer hazard or cumulative incidence. There were annual declines in the hazard and cumulative incidence of death (csHR and sdHR: 0.89, 95% CI 0.87, 0.91) which remained within and across calendar periods. CONCLUSION: These findings contradict the hypothesis of increasing breast cancer risk with declining mortality over time among women with HIV, suggesting limited impact of changing mortality on breast cancer risk. Additional inquiry is merited as survival improves among women with HIV. |
Epidemiological, and clinical characteristics of international travelers with enteric fever and antibiotic resistance profiles of their isolates: A GeoSentinel Analysis
Hagmann SHF , Angelo KM , Huits R , Plewes K , Eperon G , Grobusch MP , McCarthy A , Libman M , Caumes E , Leung DT , Asgeirsson H , Jensenius M , Schwartz E , Sánchez-Montalvá A , Kelly P , Pandey P , Leder K , Bourque DL , Yoshimura Y , Mockenhaupt FP , van Genderen PJJ , Odolini S , Schlagenhauf P , Connor BA , Hamer DH . Antimicrob Agents Chemother 2020 64 (11) Background. Enteric fever, caused by Salmonella enterica serovar Typhi (S. Typhi) and Paratyphi (S. Paratyphi), is a common travel-related illness. Limited data are available on their antimicrobial resistance (AMR) patterns among travelers. Methods. Records with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed. Isolates were classified as 'non-susceptible' if intermediate or resistant, or 'susceptible' in accordance with participating site's national guidelines. Results. A total of 889 travelers (S. Typhi, n=474; S. Paratyphi, n=414; co-infection, n=1) were included; 114 (13%) were children <18 years. Most (41%) traveled to visit friends and relatives (VFRs) and acquired the infection in South Asia (71%). Child travelers with S. Typhi were most frequently VFRs (77%). The median trip duration was 31 days (interquartile range: 18-61 days) and 448 of 691 (65%) had no pre-travel consultation. Of 143 S. Typhi and 75 S. Paratyphi isolates with susceptibility data, non-susceptibility to antibiotics varied (fluoroquinolones: 65% vs 56% respectively; cotrimoxazole: 13% vs 0%; macrolides: 8% vs 16%). Two S. Typhi isolates (1.5%) from India were non-susceptible to 3(rd)-generation cephalosporins. S. Typhi fluoroquinolone non-susceptibility was highest when infection was acquired in South Asia (70 of 90; 78%) and sub-Saharan Africa (6 of 10; 60%). Conclusions. Enteric fever is an important travel-associated illness complicated by AMR. Our data contributes to a better understanding of region-specific AMR helping inform empirical treatment options. Prevention measures need to focus on high-risk travelers including VFRs and children. |
Travel-related hepatitis E: a two decade GeoSentinel analysis
Nicolini LA , Stoney RJ , Vecchia AD , Grobusch M , Gautret P , Angelo KM , van Genderen PJJ , Bottieau E , Leder K , Asgeirsson H , Leung D , Connor B , Pandey P , Toscanini F , Gobbi F , Castelli F , Bassetti M , Hamer DH . J Travel Med 2020 27 (7) BACKGROUND: Hepatitis E virus (HEV) is widely distributed worldwide and is endemic in developing countries. Travel-related HEV infection has been reported at national levels, but global data are missing. Moreover, the global availability of HEV diagnostic testing has not been explored so far. The aim of this study is to describe the epidemiology of hepatitis E virus (HEV) infections in returning travelers and availability of HEV diagnostic testing in the GeoSentinel surveillance network. METHODS: This was a multicenter retrospective cross-sectional study. All confirmed and probable HEV travel-related infections reported in the GeoSentinel Network between 1999 and 2018 were evaluated. GeoSentinel sites were asked to complete a survey in 2018 to assess the availability and accessibility of HEV diagnostic procedures (i.e. serology and molecular tests) throughout the study period. RESULTS: Overall, 165 travel related HEV infections were reported, mainly since 2010 (60%) and in tourists (50%). Travelers were exposed to hepatitis E in 27 countries; most travellers (62%) were exposed to HEV in South Asia. One patient was pregnant at the time of HEV infection and 14 had a concomitant gastrointestinal infection. No deaths were reported. In the 51% of patients with information available, there was no pre-travel consultation. Among 44 GeoSentinel sites that responded to the survey, 73% have access to HEV serology at a local level, while 55% could perform (at a local or central level) molecular diagnostics. CONCLUSION: Reported access to HEV diagnostic testing is suboptimal among sites that responded to the survey; this could negatively affect diagnosing HEV. Pre-travel consultations before travel to South Asia and other low income and high prevalence areas with a focus on food and water precautions could be helpful in preventing hepatitis E infection. Improved HEV diagnostic capacity should be implemented to prevent and correctly diagnose travel-related HEV infection. |
A randomized phase 4 study of immunogenicity and safety following monovalent oral type 2 Sabin polio vaccine challenge in IPV-vaccinated children in Lithuania
Bandyopadhyay AS , Gast C , Brickley EB , Ruttimann R , Clemens R , Oberste MS , Weldon WC , Ackerman ME , Connor RI , Wieland-Alter WF , Wright P , Usonis V . J Infect Dis 2020 223 (1) 119-127 BACKGROUND: Understanding immunogenicity and safety of monovalent type-2 oral polio vaccine (mOPV2) in inactivated polio vaccine (IPV)-immunized children is of major importance to inform global policy to control circulating vaccine-derived poliovirus (cVDPV) outbreaks. METHODS: In this open-label, phase 4 study (NCT02582255) in 100 IPV-vaccinated Lithuanian 1-5-year-olds we measured humoral and intestinal type-2 polio neutralizing antibodies before and 28 days after one or two mOPV2 doses given 28 days apart, and stool viral shedding after each dose. Parents recorded solicited adverse events (AE) for 7 days after each dose and unsolicited AEs for 6 weeks postvaccination. RESULTS: After one mOPV2 challenge the type-2 seroprotection rate increased from 98% to 100%. Approximately 28 days after mOPV2 challenge 34 of 68 (50%, 95% CI: 38-62) children were shedding virus; 9 of 37 (24%, 12-41) were shedding 28 days after a second challenge. Before challenge type-2 intestinal immunity was undetectable in IPV-primed children, but 28 of 87 (32%) had intestinal neutralizing titers >/= 32 after one mOPV2 dose. No vaccine-related serious or severe AEs were reported. CONCLUSIONS: High viral excretion following mOPV2 among exclusively IPV-vaccinated children was substantially lower following a subsequent dose, indicating induction of intestinal immunity against type-2 poliovirus. |
Zika among international travelers presenting to GeoSentinel sites, 2012-2019: implications for clinical practice
Angelo KM , Stoney RJ , Brun-Cottan G , Leder K , Grobusch MP , Hochberg N , Kuhn S , Bottieau E , Schlagenhauf P , Chen L , Hynes NA , Perez CP , Mockenhaupt FP , Molina I , Crespillo-Andujar C , Malvy D , Caumes E , Plourde P , Shaw M , McCarthy AE , Piper-Jenks N , Connor BA , Hamer DH , Wilder-Smith A . J Travel Med 2020 27 (4) INTRODUCTION: International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travelers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveler characteristics, and assess ZIKV diagnostic testing by site. METHODS: Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date, were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility, and utilization of ZIKV diagnostic tests at GeoSentinel sites. RESULTS: GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, 8 cases were reported; all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean; a large decline in ZIKV cases occurred in 2018-19.Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean; peak reporting to these regions occurred in 2016 (330 cases [78%]). The median age was 36 years (range: 3-92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travelers were pregnant during or after travel; one had a sexually-acquired ZIKV infection. There was one case of fetal anomaly and two travelers with Guillain-Barre syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively. CONCLUSION: ZIKV should remain a consideration for travelers returning from areas with risk of ZIKV transmission. Travelers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken. |
International mass gatherings and travel-associated illness: A GeoSentinel cross-sectional, observational study
Gautret P , Angelo KM , Asgeirsson H , Duvignaud A , van Genderen PJJ , Bottieau E , Chen LH , Parker S , Connor BA , Barnett ED , Libman M , Hamer DH . Travel Med Infect Dis 2019 32 101504 BACKGROUND: Travelers to international mass gatherings may be exposed to conditions which increase their risk of acquiring infectious diseases. Most existing data come from single clinical sites seeing returning travelers, or relate to single events. METHODS: Investigators evaluated ill travelers returning from a mass gathering, and presenting to a GeoSentinel site between August 2015 and April 2019, and collected data on the nature of the event and the relation between final diagnoses and the mass gathering. RESULTS: Of 296 ill travelers, 51% were female and the median age was 54 years (range: 1-88). Over 82% returned from a religious mass gathering, most frequently Umrah or Hajj. Only 3% returned from the Olympics in Brazil or South Korea. Other mass gatherings included other sporting events, cultural or entertainment events, and conferences. Respiratory diseases accounted for almost 80% of all diagnoses, with vaccine preventable illnesses such as influenza and pneumonia accounting for 26% and 20% of all diagnoses respectively. This was followed by gastrointestinal illnesses, accounting for 4.5%. Sixty-three percent of travelers reported having a pre-travel encounter with a healthcare provider. CONCLUSIONS: Despite this surveillance being limited to patients presenting to GeoSentinel sites, our findings highlight the importance of respiratory diseases at mass gatherings, the need for pre-travel consultations before mass gatherings, and consideration of vaccination against influenza and pneumococcal disease.. |
Cardiovascular risk factors associated with venous thromboembolism
Gregson J , Kaptoge S , Bolton T , Pennells L , Willeit P , Burgess S , Bell S , Sweeting M , Rimm EB , Kabrhel C , Zoller B , Assmann G , Gudnason V , Folsom AR , Arndt V , Fletcher A , Norman PE , Nordestgaard BG , Kitamura A , Mahmoodi BK , Whincup PH , Knuiman M , Salomaa V , Meisinger C , Koenig W , Kavousi M , Volzke H , Cooper JA , Ninomiya T , Casiglia E , Rodriguez B , Ben-Shlomo Y , Despres JP , Simons L , Barrett-Connor E , Bjorkelund C , Notdurfter M , Kromhout D , Price J , Sutherland SE , Sundstrom J , Kauhanen J , Gallacher J , Beulens JWJ , Dankner R , Cooper C , Giampaoli S , Deen JF , Gomez de la Camara A , Kuller LH , Rosengren A , Svensson PJ , Nagel D , Crespo CJ , Brenner H , Albertorio-Diaz JR , Atkins R , Brunner EJ , Shipley M , Njolstad I , Lawlor DA , van der Schouw YT , Selmer RM , Trevisan M , Verschuren WMM , Greenland P , Wassertheil-Smoller S , Lowe GDO , Wood AM , Butterworth AS , Thompson SG , Danesh J , Di Angelantonio E , Meade T . JAMA Cardiol 2019 4 (2) 163-173 Importance: It is uncertain to what extent established cardiovascular risk factors are associated with venous thromboembolism (VTE). Objective: To estimate the associations of major cardiovascular risk factors with VTE, ie, deep vein thrombosis and pulmonary embolism. Design, Setting, and Participants: This study included individual participant data mostly from essentially population-based cohort studies from the Emerging Risk Factors Collaboration (ERFC; 731728 participants; 75 cohorts; years of baseline surveys, February 1960 to June 2008; latest date of follow-up, December 2015) and the UK Biobank (421537 participants; years of baseline surveys, March 2006 to September 2010; latest date of follow-up, February 2016). Participants without cardiovascular disease at baseline were included. Data were analyzed from June 2017 to September 2018. Exposures: A panel of several established cardiovascular risk factors. Main Outcomes and Measures: Hazard ratios (HRs) per 1-SD higher usual risk factor levels (or presence/absence). Incident fatal outcomes in ERFC (VTE, 1041; coronary heart disease [CHD], 25131) and incident fatal/nonfatal outcomes in UK Biobank (VTE, 2321; CHD, 3385). Hazard ratios were adjusted for age, sex, smoking status, diabetes, and body mass index (BMI). Results: Of the 731728 participants from the ERFC, 403396 (55.1%) were female, and the mean (SD) age at the time of the survey was 51.9 (9.0) years; of the 421537 participants from the UK Biobank, 233699 (55.4%) were female, and the mean (SD) age at the time of the survey was 56.4 (8.1) years. Risk factors for VTE included older age (ERFC: HR per decade, 2.67; 95% CI, 2.45-2.91; UK Biobank: HR, 1.81; 95% CI, 1.71-1.92), current smoking (ERFC: HR, 1.38; 95% CI, 1.20-1.58; UK Biobank: HR, 1.23; 95% CI, 1.08-1.40), and BMI (ERFC: HR per 1-SD higher BMI, 1.43; 95% CI, 1.35-1.50; UK Biobank: HR, 1.37; 95% CI, 1.32-1.41). For these factors, there were similar HRs for pulmonary embolism and deep vein thrombosis in UK Biobank (except adiposity was more strongly associated with pulmonary embolism) and similar HRs for unprovoked vs provoked VTE. Apart from adiposity, these risk factors were less strongly associated with VTE than CHD. There were inconsistent associations of VTEs with diabetes and blood pressure across ERFC and UK Biobank, and there was limited ability to study lipid and inflammation markers. Conclusions and Relevance: Older age, smoking, and adiposity were consistently associated with higher VTE risk. |
CE: Original research: Antineoplastic drug administration by pregnant and nonpregnant nurses: An exploration of the use of protective gloves and gowns
Lawson CC , Johnson CY , Nassan FL , Connor TH , Boiano JM , Rocheleau CM , Chavarro JE , Rich-Edwards JW . Am J Nurs 2018 119 (1) 28-35 Findings from this cross-sectional study indicate a need for expanded training in safe handling practices. Background: Many antineoplastic (chemotherapeutic) drugs are known or probable human carcinogens, and many have been shown to be reproductive toxicants in cancer patients. Evidence from occupational exposure studies suggests that health care workers who have long-term, low-level occupational exposure to antineoplastic drugs have an increased risk of adverse reproductive outcomes. It's recommended that, at minimum, nurses who handle or administer such drugs should wear double gloves and a nonabsorbent gown to protect themselves. But it's unclear to what extent nurses do. PURPOSE: This study assessed glove and gown use by female pregnant and nonpregnant nurses who administer antineoplastic drugs in the United States and Canada. METHODS: We used data collected from more than 40,000 nurses participating in the Nurses' Health Study 3. The use of gloves and gowns and administration of antineoplastic drugs within the past month (among nonpregnant nurses) or within the first 20 weeks of pregnancy (among pregnant nurses) were self-reported via questionnaire. RESULTS: Administration of antineoplastic drugs at any time during their career was reported by 36% of nonpregnant nurses, including 27% who reported administering these drugs within the past month. Seven percent of pregnant nurses reported administering antineoplastic drugs during the first 20 weeks of pregnancy. Twelve percent of nonpregnant nurses and 9% of pregnant nurses indicated that they never wore gloves when administering antineoplastic drugs, and 42% of nonpregnant nurses and 38% of pregnant nurses reported never using a gown. The percentage of nonpregnant nurses who reported not wearing gloves varied by type of administration: 32% of those who administered antineoplastic drugs only as crushed pills never wore gloves, compared with 5% of those who administered such drugs only via infusion. CONCLUSIONS: Despite longstanding recommendations for the safe handling of antineoplastic and other hazardous drugs, many nurses-including those who are pregnant-reported not wearing protective gloves and gowns, which are considered the minimum protective equipment when administering such drugs. These findings underscore the need for further education and training to ensure that both employers and nurses understand the risks involved and know which precautionary measures will minimize such exposures. |
Intestinal immunity to poliovirus following sequential trivalent inactivated polio vaccine/bivalent oral polio vaccine and trivalent inactivated polio vaccine-only immunization schedules: Analysis of an open-label, randomized, controlled trial in Chilean infants
Brickley EB , Wieland-Alter W , Connor RI , Ackerman ME , Boesch AW , Arita M , Weldon WC , O'Ryan MG , Bandyopadhyay AS , Wright PF . Clin Infect Dis 2018 67 S42-s50 Background: Identifying polio vaccine regimens that can elicit robust intestinal mucosal immunity and interrupt viral transmission is a key priority of the polio endgame. Methods: In a 2013 Chilean clinical trial (NCT01841671) of trivalent inactivated polio vaccine (IPV) and bivalent oral polio vaccine (bOPV; targeting types 1 and 3), infants were randomized to receive IPV-bOPV-bOPV, IPV-IPV-bOPV, or IPV-IPV-IPV at 8, 16, and 24 weeks of age and challenged with monovalent oral polio vaccine type 2 (mOPV2) at 28 weeks. Using fecal samples collected from 152 participants, we investigated the extent to which IPV-bOPV and IPV-only immunization schedules induced intestinal neutralizing activity and immunoglobulin A against polio types 1 and 2. Results: Overall, 37% of infants in the IPV-bOPV groups and 26% in the IPV-only arm had detectable type 2-specific stool neutralization after the primary vaccine series. In contrast, 1 challenge dose of mOPV2 induced brisk intestinal immune responses in all vaccine groups, and significant rises in type 2-specific stool neutralization titers (P < .0001) and immunoglobulin A concentrations (P < 0.0001) were measured 2 weeks after the challenge. In subsidiary analyses, duration of breastfeeding also appeared to be associated with the magnitude of polio-specific mucosal immune parameters measured in infant fecal samples. Conclusions: Taken together, these results underscore the concept that mucosal and systemic immune responses to polio are separate in their induction, functionality, and potential impacts on transmission and, specifically, provide evidence that primary vaccine regimens lacking homologous live vaccine components are likely to induce only modest, type-specific intestinal immunity. |
Illness among US resident student travelers after return to the United States: A GeoSentinel Analysis, 2007-2017
Angelo KM , Haulman NJ , Terry AC , Leung DT , Chen LH , Barnett ED , Hagmann SHF , Hynes NA , Connor BA , Anderson S , McCarthy A , Shaw M , Van Genderen PJJ , Hamer DH . J Travel Med 2018 25 (1) BACKGROUND: The number of US students studying abroad more than tripled during the past 20 years. As study abroad programs' destinations diversify, students increasingly travel to resource-limited countries, placing them at risk for infectious diseases. Data describing infections acquired by US students while traveling internationally are limited. We describe illnesses among students who returned from international travel and suggest how to prevent illness among these travelers. METHODS: GeoSentinel is a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. This study included records of US resident student international travelers, 17-24 years old, who returned to the United States, had a confirmed travel-related illness at one of 15 US GeoSentinel sites during 2007-2017, and had a documented exposure region. Records were analyzed to describe demographic and travel characteristics and diagnoses. RESULTS: The study included 432 students. The median age was 21 years; 69% were female. More than 70% had a pre-travel consultation with a healthcare provider. The most common exposure region was sub-Saharan Africa (112; 26%). Students were most commonly exposed in India (44; 11%), Ecuador (28; 7%), Ghana (25; 6%), and China (24; 6%). The median duration of travel abroad was 40 days (range: 1-469) and presented to a GeoSentinel site a median of 8 days (range: 0-181) after travel; 98% were outpatients. Of 581 confirmed diagnoses, the most common diagnosis category was gastrointestinal (45%). Acute diarrhea was the most common gastrointestinal diagnosis (113 of 261; 43%). Thirty-one (7%) students had vector-borne diseases [14 (41%) malaria and 11 (32%) dengue]. Three had vaccine-preventable diseases (two typhoid; one hepatitis A); two had acute HIV. CONCLUSIONS: Students experienced travel-related infections, despite the majority having a pre-travel consultation. US students should receive pre-travel advice, vaccinations, and chemoprophylaxis to prevent gastrointestinal, vector-borne, sexually transmitted, and vaccine-preventable infections. |
Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study
Saha SK , Schrag SJ , El Arifeen S , Mullany LC , Shahidul Islam M , Shang N , Qazi SA , Zaidi AKM , Bhutta ZA , Bose A , Panigrahi P , Soofi SB , Connor NE , Mitra DK , Isaac R , Winchell JM , Arvay ML , Islam M , Shafiq Y , Nisar I , Baloch B , Kabir F , Ali M , Diaz MH , Satpathy R , Nanda P , Padhi BK , Parida S , Hotwani A , Hasanuzzaman M , Ahmed S , Belal Hossain M , Ariff S , Ahmed I , Ibne Moin SM , Mahmud A , Waller JL , Rafiqullah I , Quaiyum MA , Begum N , Balaji V , Halen J , Nawshad Uddin Ahmed ASM , Weber MW , Hamer DH , Hibberd PL , Sadeq-Ur Rahman Q , Mogan VR , Hossain T , McGee L , Anandan S , Liu A , Panigrahi K , Abraham AM , Baqui AH . Lancet 2018 392 (10142) 145-159 BACKGROUND: More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia. METHODS: From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples. FINDINGS: 6022 pSBI episodes were identified among 63 114 babies (95.4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13.2 (95% credible interval [CrI] 11.2-15.6) per 1000 livebirths and of viral infections was 10.1 (9.4-11.6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5.4, 95% CrI 4.8-6.3 episodes per 1000 livebirths), followed by Ureaplasma spp (2.4, 1.6-3.2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs. INTERPRETATION: Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal. FUNDING: Bill & Melinda Gates Foundation. |
Ideas from the field
Connor BP , Gallick J . Coal Age 2018 123 (3) 32-34 In a mine emergency, chaos can lead to tragedy. To take charge in an emergency, by law (30 CFR 75.1501), coal mines must designate an on-site “responsible person” (RP). The RP’s duties include ordering miners to evacuate, notifying the Mine Safety and Health Administration (MSHA) and others for help, and establishing an orderly overall response. Analyzing past disasters, MSHA reasoned that mines could achieve better outcomes if everyone at the mine knows who is in charge and if that person knows current mine conditions and sound emergency management practices. |
Business travel-associated illness: a GeoSentinel analysis
Chen LH , Leder K , Barbre KA , Schlagenhauf P , Libman M , Keystone J , Mendelson M , Gautret P , Schwartz E , Shaw M , MacDonald S , McCarthy A , Connor BA , Esposito DH , Hamer D , Wilson ME . J Travel Med 2018 25 (1) Background: Analysis of a large cohort of business travelers will help clinicians focus on frequent and serious illnesses. We aimed to describe travel-related health problems in business travelers. Methods: GeoSentinel Surveillance Network consists of 64 travel and tropical medicine clinics in 29 countries; descriptive analysis was performed on ill business travelers, defined as persons traveling for work, evaluated after international travel 1 January 1997 through 31 December 2014. Results: Among 12 203 business travelers seen 1997-2014 (14 045 eligible diagnoses), the majority (97%) were adults aged 20-64 years; most (74%) reported from Western Europe or North America; two-thirds were male. Most (86%) were outpatients. Fewer than half (45%) reported a pre-travel healthcare encounter. Frequent regions of exposure were sub-Saharan Africa (37%), Southeast Asia (15%) and South Central Asia (14%). The most frequent diagnoses were malaria (9%), acute unspecified diarrhea (8%), viral syndrome (6%), acute bacterial diarrhea (5%) and chronic diarrhea (4%). Species was reported for 973 (90%) of 1079 patients with malaria, predominantly Plasmodium falciparum acquired in sub-Saharan Africa. Of 584 (54%) with malaria chemoprophylaxis information, 92% took none or incomplete courses. Thirteen deaths were reported, over half of which were due to malaria; others succumbed to pneumonia, typhoid fever, rabies, melioidosis and pyogenic abscess. Conclusions: Diarrheal illness was a major cause of morbidity. Malaria contributed substantial morbidity and mortality, particularly among business travelers to sub-Saharan Africa. Underuse or non-use of chemoprophylaxis contributed to malaria cases. Deaths in business travelers could be reduced by improving adherence to malaria chemoprophylaxis and targeted vaccination for vaccine-preventable diseases. Pre-travel advice is indicated for business travelers and is currently under-utilized and needs improvement. |
Intestinal immune responses to type 2 oral polio vaccine (OPV) challenge in infants previously immunized with bivalent OPV and either high-dose or standard inactivated polio vaccine
Brickley EB , Strauch CB , Wieland-Alter WF , Connor RI , Lin S , Weiner JA , Ackerman ME , Arita M , Oberste MS , Weldon WC , Saez-Llorens X , Bandyopadhyay AS , Wright PF . J Infect Dis 2018 217 (3) 371-380 Background: The impact of inactivated polio vaccines (IPVs) on intestinal mucosal immune responses to live poliovirus is poorly understood. Methods: In a 2014 phase 2 clinical trial, Panamanian infants were immunized at 6, 10, and 14 weeks of age with bivalent oral polio vaccine (bOPV) and randomized to receive either a novel monovalent high-dose type 2-specific IPV (mIPV2HD) or a standard trivalent IPV at 14 weeks. Infants were challenged at 18 weeks with a monovalent type 2 oral polio vaccine (mOPV2). Infants' intestinal immune responses during the 3 weeks following challenge were investigated by measuring poliovirus type-specific neutralization and immunoglobulin (Ig) A, IgA1, IgA2, IgD, IgG, and IgM antibodies in stool samples. Results: Despite mIPV2HD's 4-fold higher type 2 polio D-antigen content and heightened serum neutralization profile, mIPV2HD-immunized infants' intestinal immune responses to mOPV2 challenge were largely indistinguishable from those receiving standard IPV. Mucosal responses were tightly linked to evidence of active infection and, in the 79% of participants who shed virus, robust type 2-specific IgA responses and stool neutralization were observed by 2 weeks after challenge. Conclusions: Enhancing IPV-induced serum neutralization does not substantively improve intestinal mucosal immune responses or limit viral shedding on mOPV2 challenge. Clinical Trials Registration: NCT02111135. |
A case study exploring field-level risk assessments as a leading safety indicator
Haas EJ , Connor BP , Vendetti J , Heiser R . Trans Soc Min Metall Explor Inc 2017 342 22-28 Health and safety indicators help mine sites predict the likelihood of an event, advance initiatives to control risks, and track progress. Although useful to encourage individuals within the mining companies to work together to identify such indicators, executing risk assessments comes with challenges. Specifically, varying or inaccurate perceptions of risk, in addition to trust and buy-in of a risk management system, contribute to inconsistent levels of participation in risk programs. This paper focuses on one trona mine's experience in the development and implementation of a field-level risk assessment program to help its organization understand and manage risk to an acceptable level. Through a transformational process of ongoing leadership development, support and communication, Solvay Green River fostered a culture grounded in risk assessment, safety interactions and hazard correction. The application of consistent risk assessment tools was critical to create a participatory workforce that not only talks about safety but actively identifies factors that contribute to hazards and potential incidents. In this paper, reflecting on the mine's previous process of risk-assessment implementation provides examples of likely barriers that sites may encounter when trying to document and manage risks, as well as a variety of mini case examples that showcase how the organization worked through these barriers to facilitate the identification of leading indicators to ultimately reduce incidents. |
Meta-analysis of chromosomal aberrations as a biomarker of exposure in healthcare workers occupationally exposed to antineoplastic drugs
Roussel C , Witt KL , Shaw PB , Connor TH . Mutat Res Rev Mutat Res 2017 781 207-217 Many antineoplastic drugs used to treat cancer, particularly alkylating agents and topoisomerase inhibitors, are known to induce genetic damage in patients. Elevated levels of chromosomal aberrations, micronuclei, and DNA damage have been documented in cancer patients. Elevations in these same biomarkers of genetic damage have been reported in numerous studies of healthcare workers, such as nurses and pharmacists, who routinely handle these drugs, but results vary across studies. To obtain an overall assessment of the exposure effect, we performed a meta-analysis on data obtained from peer-reviewed publications reporting chromosomal aberration levels in healthcare workers exposed to antineoplastic drugs. A literature search identified 39 studies reporting on occupational exposure to antineoplastic drugs and measurement of chromosomal aberrations in healthcare workers. After applying strict inclusion criteria for data quality and presentation, data from 17 studies included in 16 publications underwent meta-analysis using Hedges' bias-corrected g and a random-effects model. Results showed the level of chromosomal aberrations in healthcare workers exposed to antineoplastic drugs was significantly higher than in controls. The standardized mean differences (difference of means divided by within sd) from all studies were pooled, yielding a value 1.006 (unitless) with p< 0.001. Thus, in addition to the documented genotoxic effects of antineoplastic drugs in cancer patients, this meta-analysis confirmed a significant association between occupational exposure to antineoplastics during the course of a normal work day and increases in chromosomal aberrations in healthcare workers. Based on the studies reviewed, we were unable to accurately assess whether appropriate use of protective measures might reduce the incidence of genetic damage in healthcare workers. However, given the potential for increased cancer risk linked to increases in chromosomal aberrations, the results of this study support the need to limit occupational exposure of healthcare workers to antineoplastic drugs as much as possible. |
Survey of guidelines and current practices for safe handling of antineoplastic and other hazardous drugs used in 24 countries
Mathias PI , MacKenzie BA , Toennis CA , Connor TH . J Oncol Pharm Pract 2017 25 (1) 1078155217726160 Purpose A survey of guidelines and current practices was conducted to examine the safe handling procedures for antineoplastic and other hazardous drugs that are used in 24 countries including the Americas, Europe, the Mideast, Far East, and Australia. Methods Subject experts were asked to complete a brief survey regarding safe handling guidelines and practices for hazardous drugs in their countries. Questions addressed practices for handling monoclonal antibodies, the use of closed-system transfer devices, medical surveillance practices, and measurements of compliance with existing guidelines. Results Responses from 37 subject experts representing 24 countries revealed considerable variation in the content and scope of safe handling guidelines and pharmacy practices among the participating countries. Guidelines in the majority of countries used the term "cytotoxics," while others referred to "hazardous" or "antineoplastic" drugs. The International Society of Oncology Pharmacy Practice standard was cited by six countries, and five cited the National Institute for Occupational Safety and Health Alert. Others cited international guidelines other than International Society of Oncology Pharmacy Practice, or they have created their own guidelines. Approximately half reported that their guidelines were mandatory under federal, state, or provincial legislation. Only 11 countries reported that monoclonal antibodies were covered in their guidelines. Closed-system drug-transfer devices are widely used, but were not specifically recommended in four countries, while one country required their use. Medical surveillance programs are in place in 20 countries, but only in The Netherlands is surveillance mandatory. Nine countries reported that they have completed recent updates or revisions of guidelines, and the measures for their adoption have been initiated. Conclusions Although the overall goals in the participating countries were similar, the approaches taken to assure safe handling of hazardous drugs varied considerably in some cases. |
Resilience mediates the relationship between social support and post-traumatic stress symptoms in police officers
McCanlies EC , Gu JK , Andrew ME , Burchfiel CM , Violanti JM . J Emerg Manag 2017 15 (2) 107-116 OBJECTIVE: Police officers in the New Orleans geographic area faced a number of challenges following Hurricane Katrina in 2005. DESIGN: This cross-sectional study examined gratitude, resilience, and satisfaction with life as mediators in the association between social support and post-traumatic stress disorder (PTSD) symptoms in 82 male and 31 female police officers. The Gratitude Questionnaire, Connor-Davidson Resilience Scale, Satisfaction with Life Scale, and the Interpersonal Support Evaluation List were used to measure gratitude, resilience, satisfaction with life, and social support, respectively. PTSD symptoms were measured using the PTSD Checklist-Civilian (PCL-C). Ordinary least square regression mediation analysis was used to estimate direct and indirect effects among gratitude, resilience, satisfaction with life, social support, and PTSD symptoms. All models were adjusted for age, alcohol, race, and previous military experience. RESULTS: Mean PCL-C symptoms were 29.1 (standard deviation [SD] = 14.4) for females and 27.9 (SD = 12.1) for males. There was no direct relationship between social support and PTSD symptoms (c9 = -0.041; 95% confidence interval [CI] = -0.199, 0.117) independent of the indirect effect through resilience (effect = -0.038; 95%CI = -0.099, -0.002). Neither gratitude (effect = -0.066; 95% CI = -0.203, 0.090) nor satisfaction with life (effect = -0.036, 95% CI = -0.131, 0.046) contribute to the indirect effect. CONCLUSIONS: These results indicate that resilience mediates the relationship between social support and symp-toms of PTSD. Targeting social support and resilience in officers may facilitate reduction of PTSD symptoms. |
The Usefulness of Individual-Level HIV Surveillance Data to Initiate Statewide HIV Partner Services: Experiences From Hawaii and New Mexico
Beltrami J , Gans A , Wozniak M , Murphy J , Puesta B , Kennebrew D , Angie Allen M , OʼConnor K . J Public Health Manag Pract 2018 24 (6) 519-525 CONTEXT: Partner services are a broad array of services that should be offered to persons with human immunodeficiency virus (HIV) and that are based on a process through which HIV-infected persons are interviewed to elicit information about their sex and needle-sharing partners. Human immunodeficiency virus testing of partners can result in a high yield of newly diagnosed HIV positivity, but despite this yield and the benefits of partners knowing their exposures and HIV status, partner services are often not conducted. OBJECTIVE: We sought to determine the newly diagnosed HIV positivity and benefits to 2 health departments that conducted demonstration projects that focused on statewide HIV partner services. DESIGN: The main sources of information used for this case study analysis included the health department funding applications, progress reports and final reports submitted to the Centers for Disease Control and Prevention, and records of communications between Centers for Disease Control and Prevention and the health departments. Required quantitative reporting included the number of partners tested and the number of partners with newly diagnosed confirmed HIV infection. Required qualitative reporting included how health departments benefited from their demonstration project activities. SETTING: Hawaii and New Mexico. PARTICIPANTS: Sex and needle-sharing partners of persons who were newly diagnosed with HIV infection. INTERVENTION: The use of HIV surveillance data to initiate statewide HIV partner services. MAIN OUTCOME MEASURE: Newly diagnosed HIV positivity. RESULTS: During 2012-2015, the newly diagnosed HIV positivity among partners was 18% (78/427): 16% (17/108) in Hawaii and 19% (61/319) in New Mexico. The health departments benefited from improved collaborations among HIV prevention program and surveillance staff and among the health departments, providers, and AIDS service organizations. CONCLUSIONS: Hawaii and New Mexico each achieved a high newly diagnosed HIV positivity and benefited from improved local collaborations. As a result of the success of these projects, both health departments have continued the activities since the end of category C funding by securing alternative funding sources. |
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