IMPORTANCE: Many recent advances in pediatric concussion care are implemented by specialists; however, children with concussion receive care across varied locations. Thus, it is critical to identify which children have access to the most up-to-date treatment strategies. OBJECTIVE: To evaluate differences in the sociodemographic and community characteristics of pediatric patients who sought care for concussion across various points of entry into a regional health care network. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included children seen for concussions across a regional US health care network from January 1, 2017, to August 4, 2023. Pediatric patients aged 0 to 18 years who received an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification code for concussion were included. The study took place at emergency department (ED) and outpatient (primary care [PC] and specialty care [SC]) settings. EXPOSURES: Age at visit, biological sex, parent-identified race and ethnicity, payer type, median income and percentage of adults with a bachelor's degree for home zip code, and overall and subdomain Child Opportunity Index (COI) score based on patient address. MAIN OUTCOMES AND MEASURES: The association of exposures with point of entry of ED, PC, and SC were examined in both bivariate analysis and a multinomial logistic regression. RESULTS: Overall, 15 631 patients were included in the study (median [IQR] age, 13 [11-15] years; 7879 [50.4%] male; 1055 [6.7%] Hispanic, 2865 [18.3%] non-Hispanic Black, and 9887 [63.7%] non-Hispanic White individuals). Race and ethnicity were significantly different across settings (1485 patients [50.0%] seen in the ED were non-Hispanic Black vs 1012 [12.0%] in PC and 368 [8.7%] in SC; P < .001) as was insurance status (1562 patients [52.6%] seen in the ED possessed public insurance vs 1624 [19.3%] in PC and 683 [16.1%] in SC; P < .001). Overall and individual COI subdomain scores were also significantly different between settings (overall COI median [IQR]: ED, 30 [9-71]; PC, 87 [68-95]; SC, 87 [69-95]; P < .001). Race, insurance status, and overall COI had the strongest associations with point of entry in the multivariable model (eg, non-Hispanic Black patients seen in the ED compared with non-Hispanic White patients: odds ratio, 2.03; 95% CI, 1.69-2.45). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, children with concussion seen in the ED setting were more likely to be non-Hispanic Black, have public insurance, and have a lower Child Opportunity Index compared with children cared for in the PC or SC setting. This highlights the importance of providing education and training for ED clinicians as well as establishing up-to-date community-level resources to optimize care delivery for pediatric patients with concussion at high risk of care inequities.

Objective: A growing body of research has investigated the human microbiota and pregnancy outcomes, especially preterm birth. Most studies of the prenatal microbiota have focused on the vagina, with fewer investigating other body sites during pregnancy. Although pregnancy involves profound hormonal, immunological and metabolic changes, few studies have investigated either shifts in microbiota composition across pregnancy at different body sites or variation in composition at any site that may be explained by maternal characteristics. The purpose of this study was to investigate: (1) the stability of the vaginal, oral, and gut microbiota from early (8-14 weeks) through later (24-30 weeks) pregnancy among African American women according to measures of socioeconomic status, accounting for prenatal antibiotic use; (2) whether measures of socioeconomic status are associated with changes in microbiota composition over pregnancy; and (3) whether exposure to prenatal antibiotics mediate any observed associations between measures of socioeconomic status and stability of the vaginal, oral, and gut microbiota across pregnancy. Methods: We used paired vaginal, oral, or gut samples available for 16S rRNA gene sequencing from two time points in pregnancy (8-14 and 24-30 weeks) to compare within-woman changes in measures of alpha diversity (Shannon and Chao1) and beta-diversity (Bray-Curtis dissimilarity) among pregnant African American women (n = 110). Multivariable linear regression was used to examine the effect of level of education and prenatal health insurance as explanatory variables for changes in diversity, considering antibiotic exposure as a mediator, adjusting for age, obstetrical history, and weeks between sampling. Results: For the oral and gut microbiota, there were no significant associations between measures of socioeconomic status or prenatal antibiotic use and change in Shannon or Chao1 diversity. For the vaginal microbiota, low level of education (high school or less) was associated with an increase in Shannon and Chao1 diversity over pregnancy, with minimal attenuation when controlling for prenatal antibiotic use. Conversely, for within-woman Bray-Curtis dissimilarity for early compared to later pregnancy, low level of education and prenatal antibiotics were associated with greater dissimilarity for the oral and gut sites, with minimal attenuation when controlling for prenatal antibiotics, and no difference in dissimilarity for the vaginal site. Conclusions: Measures of maternal socioeconomic status are variably associated with changes in diversity across pregnancy for the vaginal, oral, and gut microbiota, with minimal attenuation by prenatal antibiotic exposure. Studies that evaluate stability of the microbiota across pregnancy in association with health outcomes themselves associated with socioeconomic status (such as preterm birth) should incorporate measures of socioeconomic status to avoid finding spurious relationships.

Despite global recommendations for influenza vaccination of high-risk, target populations, few low and middle-income countries have national influenza vaccination programs. Between 2012 and 2017, Lao PDR planned and conducted a series of activities to develop its national influenza vaccine program as a part of its overall national immunization program. In this paper, we review the underlying strategic planning for this process, and outline the sequence of activities, research studies, partnerships, and policy decisions that were required to build Laos' influenza vaccine program. The successful development and sustainability of the program in Laos offers lessons for other low and middle-income countries interested in initiating or expanding influenza immunization.

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.

OBJECTIVE: To assess the association between maternal birth country and adherence to the American Academy of Pediatrics safe sleep recommendations in a national sample of Hispanic mothers, given that data assessing the heterogeneity of infant care practices among Hispanics are lacking. STUDY DESIGN: We used a stratified, 2-stage, clustered design to obtain a nationally representative sample of mothers from 32 US intrapartum hospitals. A total of 907 completed follow-up surveys (administered 2-6 months postpartum) were received from mothers who self-identified as Hispanic/Latina, forming our sample, which we divided into 4 subpopulations by birth country (US, Mexico, Central/South America, and Caribbean). Prevalence estimates and aORs were determined for infant sleep position, location, breastfeeding, and maternal smoking. RESULTS: When compared with US-born mothers, we found that mothers born in the Caribbean (aOR 4.56) and Central/South America (aOR 2.68) were significantly more likely to room share without bed sharing. Caribbean-born mothers were significantly less likely to place infants to sleep supine (aOR 0.41). Mothers born in Mexico (aOR 1.67) and Central/South America (aOR 2.57) were significantly more likely to exclusively breastfeed; Caribbean-born mothers (aOR 0.13) were significantly less likely to do so. Foreign-born mothers were significantly less likely to smoke before and during pregnancy. CONCLUSIONS: Among US Hispanics, adherence to American Academy of Pediatrics safe sleep recommendations varies widely by maternal birth country. These data illustrate the importance of examining behavioral heterogeneity among ethnic groups and have potential relevance for developing targeted interventions for safe infant sleep.

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.

BACKGROUND: Some studies suggest maternal influenza vaccination can improve birth outcomes. However, there are limited data from tropical settings, particularly from Southeast Asia. We conducted an observational study in Laos to assess the effect of inactivated influenza vaccination in pregnant women on birth outcomes. METHODS: We consented and enrolled a cohort of pregnant woman who delivered babies at three hospitals during Apr 2014-Feb 2015. We collected demographic and clinical information on mother and child. Influenza vaccination status was ascertained by vaccine card. Primary outcomes were the proportion of live births born small for gestational age (SGA) or preterm and mean birth weight. Multivariate models controlled for differences between vaccinated and unvaccinated women and influenza virus circulation. RESULTS: We enrolled 5,103 women (2,172 [43%] were vaccinated). Among the 4,854 who had a live birth, vaccinated women were statistically significantly less likely than unvaccinated women to have an infant born preterm during the period of high influenza virus circulation (RR=0.56, 95% CI 0.45-0.70), and the effect remained after adjusting for covariates (aRR 0.69, 95% CI=0.55-0.87). There was no effect of vaccine on the proportion of infants born SGA or mean birth weight. The population prevented fraction was 18.0%. CONCLUSIONS: In this observational study, we found indirect evidence of influenza vaccine safety during pregnancy, and women who received vaccine had a reduced risk of delivering a preterm live birth during times of high influenza virus circulation. Vaccination may prevent 1 in 5 preterm births that occur during periods of high influenza circulation.

BACKGROUND: The global burden of pediatric severe respiratory illness is substantial, and influenza viruses contribute to this burden. Systematic surveillance and testing for influenza among hospitalized children has expanded globally over the past decade. However, only a fraction of the data has been used to estimate influenza burden. In this analysis, we use surveillance data to provide an estimate of influenza-associated hospitalizations among children worldwide. METHODS AND FINDINGS: We aggregated data from a systematic review (n = 108) and surveillance platforms (n = 37) to calculate a pooled estimate of the proportion of samples collected from children hospitalized with respiratory illnesses and positive for influenza by age group (<6 mo, <1 y, <2 y, <5 y, 5-17 y, and <18 y). We applied this proportion to global estimates of acute lower respiratory infection hospitalizations among children aged <1 y and <5 y, to obtain the number and per capita rate of influenza-associated hospitalizations by geographic region and socio-economic status. Influenza was associated with 10% (95% CI 8%-11%) of respiratory hospitalizations in children <18 y worldwide, ranging from 5% (95% CI 3%-7%) among children <6 mo to 16% (95% CI 14%-20%) among children 5-17 y. On average, we estimated that influenza results in approximately 374,000 (95% CI 264,000 to 539,000) hospitalizations in children <1 y-of which 228,000 (95% CI 150,000 to 344,000) occur in children <6 mo-and 870,000 (95% CI 610,000 to 1,237,000) hospitalizations in children <5 y annually. Influenza-associated hospitalization rates were more than three times higher in developing countries than in industrialized countries (150/100,000 children/year versus 48/100,000). However, differences in hospitalization practices between settings are an important limitation in interpreting these findings. CONCLUSIONS: Influenza is an important contributor to respiratory hospitalizations among young children worldwide. Increasing influenza vaccination coverage among young children and pregnant women could reduce this burden and protect infants <6 mo.

METHODS: We analyzed influenza surveillance data from nine countries around southern and southeastern Asia spanning latitudinal gradient from equatorial to temperate zones to further characterize influenza type specific seasonality in the region. We calculated proportion of positives by month out of positives during that year and adjust for variation in samples tested and positivity in these countries. RESULTS: Influenza A epidemics were identified between November-March during winters in areas lying above 30o N latitude; during monsoon months of June-November in areas between 10o -30o N latitude, and no specific seasonality for influenza A virus circulation in areas lying closer to the equator. Influenza B circulation coincided with influenza A circulation in areas lying above 30o N latitude; however in areas south of 30o N Asia, influenza B circulated year round at 3-8% of annual influenza B positives during most months with less pronounced peaks during post-monsoon period. CONCLUSION: Even though influenza B circulates round the year in most areas of the tropical southern and southeastern Asia region, the most appropriate time for influenza vaccination would be prior to the monsoon season conferring protection against influenza A and B peaks using the most recent WHO recommended vaccine. This article is protected by copyright. All rights reserved.

During February 2013-March 2015, a total of 602 human cases of low pathogenic avian influenza A(H7N9) were reported; no autochthonous cases were reported outside mainland China. In contrast, since highly pathogenic avian influenza A(H5N1) reemerged during 2003 in China, 784 human cases in 16 countries and poultry outbreaks in 53 countries have been reported. Whether the absence of reported A(H7N9) outside mainland China represents lack of spread or lack of detection remains unclear. We compared epidemiologic and virologic features of A(H5N1) and A(H7N9) and used human and animal influenza surveillance data collected during April 2013-May 2014 from 4 Southeast Asia countries to assess the likelihood that A(H7N9) would have gone undetected during 2014. Surveillance in Vietnam and Cambodia detected human A(H5N1) cases; no A(H7N9) cases were detected in humans or poultry in Southeast Asia. Although we cannot rule out the possible spread of A(H7N9), substantial spread causing severe disease in humans is unlikely.

The Lao PDR, as did most countries of the Mekong Region, embarked on a pandemic vaccine initiative to counter the threat posed by influenza A(H1N1)pdm09. Overall, estimated vaccine coverage of the Lao population was 14%, with uptake in targeted health care workers and pregnant women 99% and 41%, respectively. Adverse Events Following Immunization accounted for only 6% of survey driven, reported vaccination experiences, with no severe consequences or deaths. Public acceptability of the vaccine campaign was high (98%). Challenges to vaccine deployment included: 1) no previous experience in fielding a seasonal influenza vaccine, 2) safety and efficacy concerns, and 3) late arrival of vaccine 10 months into the pandemic. The Lao success in surmounting these hurdles was in large measure attributed to the oversight assigned the National Immunization Program, and national sensitivities in responding to the avian influenza A(H5N1) crisis in the years leading up to the pandemic. The Lao "lessons learned" from pandemic vaccine deployment are made even more relevant four years on, given the many avian influenza strains circulating in the region, all with pandemic potential.

OBJECTIVE: In 2012, Lao PDR introduced seasonal influenza vaccine in pregnant women, persons aged ≥50 years, persons with chronic diseases, and healthcare personnel. We assessed adverse events following immunization (AEFI). METHODS: We used a multistage randomized cluster sample design to interview vaccine recipients. FINDINGS: Between April and May 2012, 355 902 were vaccinated. Of 2089 persons interviewed, 261 (12.5%) reported one or more AEFI. The most commonly reported AEFIs were local reactions. No hospitalizations or deaths were reported; 16% sought medical care. Acceptance and awareness of vaccination were high. CONCLUSIONS: Following the introduction of seasonal influenza vaccine in Lao PDR, self-reported adverse events were mild.

BACKGROUND: Use of potentially hazardous bedding, as defined by the American Academy of Pediatrics (eg, pillows, quilts, comforters, loose bedding), is a modifiable risk factor for sudden infant death syndrome and unintentional sleep-related suffocation. The proportion of US infants sleeping with these types of bedding is unknown. METHODS: To investigate the US prevalence of and trends in bedding use, we analyzed 1993-2010 data from the National Infant Sleep Position study. Infants reported as being usually placed to sleep with blankets, quilts, pillows, and other similar materials under or covering them in the last 2 weeks were classified as bedding users. Logistic regression was used to describe characteristics associated with bedding use. RESULTS: From 1993 to 2010, bedding use declined but remained a widespread practice (moving average of 85.9% in 1993-1995 to 54.7% in 2008-2010). Prevalence was highest for infants of teen-aged mothers (83.5%) and lowest for infants born at term (55.6%). Bedding use was also frequently reported among infants sleeping in adult beds, on their sides, and on a shared surface. The rate of decline in bedding use was markedly less from 2001-2010 compared with 1993-2000. For 2007 to 2010, the strongest predictors (adjusted odds ratio: ≥1.5) of bedding use were young maternal age, non-white race and ethnicity, and not being college educated. CONCLUSIONS: Bedding use for infant sleep remains common despite recommendations against this practice. Understanding trends in bedding use is important for tailoring safe sleep interventions.

OBJECTIVE: To characterize influenza seasonality and identify the best time of the year for vaccination against influenza in tropical and subtropical countries of southern and south-eastern Asia that lie north of the equator. METHODS: Weekly influenza surveillance data for 2006 to 2011 were obtained from Bangladesh, Cambodia, India, Indonesia, the Lao People's Democratic Republic, Malaysia, the Philippines, Singapore, Thailand and Viet Nam. Weekly rates of influenza activity were based on the percentage of all nasopharyngeal samples collected during the year that tested positive for influenza virus or viral nucleic acid on any given week. Monthly positivity rates were then calculated to define annual peaks of influenza activity in each country and across countries. FINDINGS: Influenza activity peaked between June/July and October in seven countries, three of which showed a second peak in December to February. Countries closer to the equator had year-round circulation without discrete peaks. Viral types and subtypes varied from year to year but not across countries in a given year. The cumulative proportion of specimens that tested positive from June to November was > 60% in Bangladesh, Cambodia, India, the Lao People's Democratic Republic, the Philippines, Thailand and Viet Nam. Thus, these tropical and subtropical countries exhibited earlier influenza activity peaks than temperate climate countries north of the equator. CONCLUSION: Most southern and south-eastern Asian countries lying north of the equator should consider vaccinating against influenza from April to June; countries near the equator without a distinct peak in influenza activity can base vaccination timing on local factors.

BACKGROUND: Southeast Asia is a region with great potential for the emergence of a pandemic influenza virus. Global efforts to improve influenza surveillance in this region have documented the burden and seasonality of influenza viruses and have informed influenza prevention strategies, but little information exists about influenza vaccination guidelines and vaccine sales. METHODS: To ascertain the existence of influenza vaccine guidelines and define the scope of vaccine sales, we sent a standard three-page questionnaire to the ten member nations of the Association of Southeast Asian Nations. We also surveyed three multinational manufacturers who supply influenza vaccines in the region. RESULTS: Vaccine sales in the private sector were <1000 per 100,000 population in the 10 countries. Five countries reported purchasing vaccine for use in the public sector. In 2011, Thailand had the highest combined reported rate of vaccine sales (10,333 per 100,000). In the 10 countries combined, the rate of private sector sales during 2010-2011 (after the A(H1N1)2009pdm pandemic) exceeded 2008 pre-pandemic levels. Five countries (Indonesia, Malaysia, Singapore, Thailand and Vietnam) had guidelines for influenza vaccination but only two were consistent with global guidelines. Four recommended vaccination for health care workers, four for elderly persons, three for young children, three for persons with underlying disease, and two for pregnant women. CONCLUSIONS: The rate of vaccine sales in Southeast Asia remains low, but there was a positive impact in sales after the A(H1N1)2009pdm pandemic. Low adherence to global vaccine guidelines suggests that more work is needed in the policy arena.

The Lao People's Democratic Republic (PDR) committed to pandemic detection and response preparations when faced with the threat of avian influenza. Since 2006, the National Center for Laboratory and Epidemiology of Lao PDR has developed credible laboratory, surveillance, and epidemiological (human) capacity and as a result was designated a World Health Organization National Influenza Center in 2010. The Lao PDR experience in building influenza capacities provides a case study of the considerable crossover effect of such investments to augment the capacity to combat emerging and re-emerging diseases other than influenza.

Cardiorespiratory events (CREs), including bradycardia and apnea, in infants are a major concern for physicians and families. Our hypothesis was that there is a difference in the heart rate variability (HRV) of infants who have CREs when compared to normal control infants. The purpose of this study was to develop CRE prediction models based on HRV measured during a polysomnographic (PSG) recording. ANCOVA analysis accounting for factors such as age and sleep state show a relationship between HRV variables and CRE. Prediction models, including neural networks and support vector machines, were developed to predict CRE within either (a) 1-week or (b) 1-month after the PSG. The support vector machine prediction accuracy, for CRE susceptibility one month after the PSG on an independent testing dataset, was 50.0% sensitivity and 82.6% specificity. Although the developed prediction models were not sufficiently accurate for clinical decision making, these results support the potential role of abnormalities in autonomic control of heart rate among infants at risk for CREs. (C) 2011 Elsevier Ltd. All rights reserved.

BACKGROUND: Influenza causes yearly seasonal epidemics and periodic pandemics. Global systems have been established to monitor the evolution and impact of influenza viruses, yet regional analysis of surveillance findings has been limited. This study describes epidemiological and virological characteristics of influenza during 2006-2010 in the World Health Organization's Western Pacific Region. METHODOLOGY/PRINCIPAL FINDINGS: Influenza-like illness (ILI) and influenza virus data were obtained from the 14 countries with National Influenza Centres. Data were obtained directly from countries and from FluNet, the web-based tool of the Global Influenza Surveillance and Response System. National influenza surveillance and participation in the global system increased over the five years. Peaks in ILI reporting appeared to be coincident with the proportion of influenza positive specimens. Temporal patterns of ILI activity and the proportion of influenza positive specimens were clearly observed in temperate countries: Mongolia, Japan and the Republic of Korea in the northern hemisphere, and Australia, New Zealand, Fiji and New Caledonia (France) in the southern hemisphere. Two annual peaks in activity were observed in China from 2006 through the first quarter of 2009. A temporal pattern was less evident in tropical countries, where influenza activity was observed year-round. Influenza A viruses accounted for the majority of viruses reported between 2006 and 2009, but an equal proportion of influenza A and influenza B viruses was detected in 2010. CONCLUSIONS/SIGNIFICANCE: Despite differences in surveillance methods and intensity, commonalities in ILI and influenza virus circulation patterns were identified. Patterns suggest that influenza circulation may be dependent on a multitude of factors including seasonality and population movement. Dominant strains in Southeast Asian countries were later detected in other countries. Thus, timely reporting and regional sharing of information about influenza may serve as an early warning, and may assist countries to anticipate the potential severity and burden associated with incoming strains.

BACKGROUND: Information on influenza virology and epidemiology from Lao PDR is limited and the seasonal patterns of influenza have not been previously described. OBJECTIVES: To describe epidemiological and virologic characteristics of influenza in Lao PDR to recommend public health interventions, including improvements in surveillance and response. PATIENTS/METHODS: We performed a descriptive analysis of samples taken from patients with influenza-like-illness (ILI) (fever >38 degrees C with cough and/or sore throat) presenting at seven sentinel hospitals in three regions of Lao PDR, January 2008-December 2010. A nasopharyngeal (NP) swab or combined nasal with oropharyngeal swab was collected from patients with ILI. Samples were tested for influenza by either Luminex RVP, conventional reverse transcriptase PCR (RT-PCR) (January 2008-2009), or by real-time PCR (rRT-PCR) using US CDC reagents (February 2009 onward). RESULTS: Of 2346 samples tested from patients with ILI, 523 (22%) were positive for influenza. The median age of those positive was 12 years (range, <1-60 year). The percentage of samples that were influenza positive was similar over the 3 years (20-23%). Each year 3-4 types/subtypes cocirculated with differing predominant type/subtype. Influenza was detected year-round with the highest proportion of positive specimens in the 3rd and 4th quarter. CONCLUSIONS: Similar to other countries in the region, we found that influenza is present year-round and has a peak activity from July to December. Dominant types or subtypes vary by year. A large proportion of patients with ILI are not influenza positive. ILI surveillance is critical for weighing disease burden, both morbidity and mortality, against the costs of advancing influenza vaccine delivery strategy.

BACKGROUND: Transmission of bloodborne pathogens due to breaches in infection control is becoming increasingly recognized as greater emphasis is placed on reducing health care-associated infections. Two women, aged 60 and 77 years, were diagnosed with acute hepatitis B virus (HBV) infection; both received chemotherapy at the same physician's office. Due to suspicion of health care-associated HBV transmission, a multidisciplinary team initiated an investigation of the hematology-oncology office practice. METHODS: We performed an onsite inspection and environmental assessment, staff interviews, records review, and observation of staff practices. Patients who visited the office practice between January 1, 2006 and March 3, 2009 were advised to seek testing for bloodborne pathogens. Patients and medical providers were interviewed. Specimens from HBV-infected patients were sent to the Centers for Disease Control and Prevention for HBV DNA testing and phylogenic analysis. RESULTS: Multiple breaches in infection control were identified, including deficient policies and procedures, improper hand hygiene, medication preparation in a blood processing area, common-use saline bags, and reuse of single-dose vials. The office practice was closed, and the physician's license was suspended. Out of 2,700 patients notified, test results were available for 1,394 (51.6%). Twenty-nine outbreak-associated HBV cases were identified. Specimens from 11 case-patients demonstrated 99.9%-100% nucleotide identity on phylogenetic analysis. CONCLUSION: Systematic breaches in infection control led to ongoing transmission of HBV infection among patients undergoing invasive procedures at the office practice. This investigation underscores the need for improved regulatory oversight of outpatient health care settings, improved infection control and injection safety education for health care providers, and the development of mechanisms for ongoing communication and cooperation among public health agencies.

Background Prior to 2007, little information was available about the burden of influenza in Laos. We report data from the first laboratory-based influenza surveillance system established in the Lao People's Democratic Republic. Methods Three hospitals in the capital city of Vientiane began surveillance for influenza-like illness (ILI) in outpatients in 2007 and expanded to include hospitalized pneumonia patients in 2008. Nasal/throat swab specimens were collected and tested for influenza and other respiratory viruses by multiplex ID-TagTM respiratory viral panel (RVP) assay on a Luminex (R) 100x MAP IS instrument (Qiagen, Singapore). Results During January 2007 to December 2008, 287 of 526 (54 center dot 6%) outpatients with ILI were positive for at least one respiratory virus. Influenza was most commonly identified, with 63 (12 center dot 0%) influenza A and 92 (17 center dot 5%) influenza B positive patients identified. In 2008, six of 79 (7 center dot 6%) hospitalized pneumonia patients were positive for influenza A and four (5 center dot 1%) were positive for influenza B. Children < 5 years represented 19% of viral infections in outpatients and 38% of pneumonia inpatients. Conclusion Our results provide the first documentation of influenza burden among patients with febrile respiratory illness and pneumonia requiring hospitalization in Laos. Implementing laboratory-based influenza surveillance requires substantial investments in infrastructure and training. However, continuing outbreaks of avian influenza A/H5N1 in poultry and emergence of the 2009 influenza A(H1N1) pandemic strain further underscore the importance of establishing and maintaining influenza surveillance in developing countries.