Last data update: Apr 22, 2024. (Total: 46599 publications since 2009)
Records 1-30 (of 55 Records) |
Query Trace: McCracken S [original query] |
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Risk factors for recent HIV infections among adults in 14 countries in Africa identified by population-based HIV impact assessment surveys, 2015-2019
Currie DW , West CA , Patel HK , Favaloro J , Asiimwe F , Ndagije F , Silver R , Mugurungi O , Shang J , Ndongmo CB , Williams DB , Dzinotyiweyi E , Waruru A , Pasipamire M , Nuwagaba-Biribonwoha H , Dlamini S , McLeod N , Kayirangwa E , Rwibasira G , Minchella PA , Auld AF , Nyirenda R , Getaneh Y , Hailemariam AH , Tondoh-Koui I , Kohemun N , Mgomella GS , Njau PF , Kirungi WL , Dalhatu I , Stafford KA , Bodika SM , Ussery F , McCracken S , Stupp P , Brown K , Duong YT , Parekh BS , Voetsch AC . Emerg Infect Dis 2023 29 (11) 2325-2334 Identifying persons who have newly acquired HIV infections is critical for characterizing the HIV epidemic direction. We analyzed pooled data from nationally representative Population-Based HIV Impact Assessment surveys conducted across 14 countries in Africa for recent infection risk factors. We included adults 15-49 years of age who had sex during the previous year and used a recent infection testing algorithm to distinguish recent from long-term infections. We collected risk factor information via participant interviews and assessed correlates of recent infection using multinomial logistic regression, incorporating each survey's complex sampling design. Compared with HIV-negative persons, persons with higher odds of recent HIV infection were women, were divorced/separated/widowed, had multiple recent sex partners, had a recent HIV-positive sex partner or one with unknown status, and lived in communities with higher HIV viremia prevalence. Prevention programs focusing on persons at higher risk for HIV and their sexual partners will contribute to reducing HIV incidence. |
A phylogeographic description of histoplasma capsulatum in the United States
Bagal UR , Gade L , Benedict K , Howell V , Christophe N , Gibbons-Burgener S , Hallyburton S , Ireland M , McCracken S , Metobo AK , Signs K , Warren KA , Litvintseva AP , Chow NA . J Fungi (Basel) 2023 9 (9) Histoplasmosis is one of the most under-diagnosed and under-reported endemic mycoses in the United States. Histoplasma capsulatum is the causative agent of this disease. To date, molecular epidemiologic studies detailing the phylogeographic structure of H. capsulatum in the United States have been limited. We conducted genomic sequencing using isolates from histoplasmosis cases reported in the United States. We identified North American Clade 2 (NAm2) as the most prevalent clade in the country. Despite high intra-clade diversity, isolates from Minnesota and Michigan cases were predominately clustered by state. Future work incorporating environmental sampling and veterinary surveillance may further elucidate the molecular epidemiology of H. capsulatum in the United States and how genomic sequencing can be applied to the surveillance and outbreak investigation of histoplasmosis. |
The epidemiology of HIV population viral load in twelve sub-Saharan African countries
Hladik W , Stupp P , McCracken SD , Justman J , Ndongmo C , Shang J , Dokubo EK , Gummerson E , Koui I , Bodika S , Lobognon R , Brou H , Ryan C , Brown K , Nuwagaba-Biribonwoha H , Kingwara L , Young P , Bronson M , Chege D , Malewo O , Mengistu Y , Koen F , Jahn A , Auld A , Jonnalagadda S , Radin E , Hamunime N , Williams DB , Kayirangwa E , Mugisha V , Mdodo R , Delgado S , Kirungi W , Nelson L , West C , Biraro S , Dzekedzeke K , Barradas D , Mugurungi O , Balachandra S , Kilmarx PH , Musuka G , Patel H , Parekh B , Sleeman K , Domaoal RA , Rutherford G , Motsoane T , Bissek AZ , Farahani M , Voetsch AC . PLoS One 2023 18 (6) e0275560 BACKGROUND: We examined the epidemiology and transmission potential of HIV population viral load (VL) in 12 sub-Saharan African countries. METHODS: We analyzed data from Population-based HIV Impact Assessments (PHIAs), large national household-based surveys conducted between 2015 and 2019 in Cameroon, Cote d'Ivoire, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Blood-based biomarkers included HIV serology, recency of HIV infection, and VL. We estimated the number of people living with HIV (PLHIV) with suppressed viral load (<1,000 HIV-1 RNA copies/mL) and with unsuppressed viral load (viremic), the prevalence of unsuppressed HIV (population viremia), sex-specific HIV transmission ratios (number female incident HIV-1 infections/number unsuppressed male PLHIV per 100 persons-years [PY] and vice versa) and examined correlations between a variety of VL metrics and incident HIV. Country sample sizes ranged from 10,016 (Eswatini) to 30,637 (Rwanda); estimates were weighted and restricted to participants 15 years and older. RESULTS: The proportion of female PLHIV with viral suppression was higher than that among males in all countries, however, the number of unsuppressed females outnumbered that of unsuppressed males in all countries due to higher overall female HIV prevalence, with ratios ranging from 1.08 to 2.10 (median: 1.43). The spatial distribution of HIV seroprevalence, viremia prevalence, and number of unsuppressed adults often differed substantially within the same countries. The 1% and 5% of PLHIV with the highest VL on average accounted for 34% and 66%, respectively, of countries' total VL. HIV transmission ratios varied widely across countries and were higher for male-to-female (range: 2.3-28.3/100 PY) than for female-to-male transmission (range: 1.5-10.6/100 PY). In all countries mean log10 VL among unsuppressed males was higher than that among females. Correlations between VL measures and incident HIV varied, were weaker for VL metrics among females compared to males and were strongest for the number of unsuppressed PLHIV per 100 HIV-negative adults (R2 = 0.92). CONCLUSIONS: Despite higher proportions of viral suppression, female unsuppressed PLHIV outnumbered males in all countries examined. Unsuppressed male PLHIV have consistently higher VL and a higher risk of transmitting HIV than females. Just 5% of PLHIV account for almost two-thirds of countries' total VL. Population-level VL metrics help monitor the epidemic and highlight key programmatic gaps in these African countries. |
Seroprevalence of high incidence congenital infections among pregnant women in Coatepeque, Guatemala and surrounding areas, 2017-2018
Hicks VJ , Sánchez C , López MR , Gottschlich A , Grajeda LM , Balish A , Gómez A , Nuñez N , Juárez J , López B , Freitas-Ning M , Cordón-Rosales C , Sagastume M , McCracken JP , Espinosa-Bode A , Cadena L , Lo TQ . PLoS Negl Trop Dis 2023 17 (4) e0011248 Maternal infections during pregnancy can potentially cause birth defects and severe adverse effects in infants. From 2017 to 2018, we investigated the seroprevalence of five antibodies among 436 mother-infant pairs enrolled in a pregnancy cohort study in Coatepeque, Guatemala. Upon enrollment (< 20 weeks gestational age) and shortly after delivery, we measured the prevalence of IgG and IgM antibodies against Toxoplasma gondii (T. gondii), rubella, and cytomegalovirus (CMV) in mothers and newborns and used rapid tests to detect HIV and syphilis (Treponema pallidum) in mothers. The mean cohort age was 24.5 years. Maternal T. gondii IgM and IgG seropositivity was 1.9% and 69.7%, respectively. No women were positive for HIV, syphilis, or rubella IgM. Maternal rubella IgG seropositivity was 80.8% and significantly increased with age. Maternal CMV IgM and IgG seropositivity were 2.3% and 99.5%, respectively. Of the 323 women tested at both timepoints, IgM reactivation occurred in one woman for T. gondii infection and in eight for CMV. No newborn was seropositive for CMV IgM or rubella IgM. One newborn was seropositive for T. gondii IgM. Congenital T. gondii and CMV infections are important public health issues for pregnant women, newborns, and healthcare providers in Coatepeque and Guatemala. |
The state of the pediatric HIV epidemic in Lesotho: results from a population-based survey
Frederix K , Schwitters A , Chung G , McCracken S , Kupamundi T , Patel HK , Arpadi S , Domaoal RA , Ntene-Sealiete K , Thin K , Wiesner L , Low A . AIDS 2023 37 (9) 1377-1386 OBJECTIVE: Lesotho does not have reliable data on HIV prevalence in children, relying on estimates generated from program data. The 2016 Lesotho Population-based HIV Impact Assessment (LePHIA) aimed to determine HIV prevalence among children 0-14 years to assess the effectiveness of the prevention of mother to child transmission (PMTCT) program and guide future policy. METHODS: A nationally representative sample of children under 15 years underwent household-based, two-stage HIV testing from November 2016-May 2017. Children <18 months with a reactive screening test were tested for HIV infection using total nucleic acid (TNA) PCR. Parents (61.1%) or legal guardians (38.9%) provided information on children's clinical history. Children aged 10-14 years also answered a questionnaire on knowledge and behaviors. RESULTS: HIV prevalence was 2.1% (95% CI: 1.5-2.6%). Prevalence in 10-14 year olds (3.2%; 95% CI: 2.1%, 4.2%) was significantly greater compared to 0-4 year olds (1.0%; 95% CI: 0.5%, 1.6%). HIV prevalence in girls and boys was 2.6% (95% CI: 1.8% - 3.3%) and 1.5% (95% CI: 1.0% - 2.1%), respectively. Based on reported status and/or the presence of detectable antiretrovirals, 81.1% (95% CI: 71.7-90.4%) of HIV-positive children were aware of their status, 98.2% (95% CI: 90.7 - 100.0%) of those aware were on ART and 73.9% (95% CI: 62.1-85.8%) of those on ART were virally suppressed. CONCLUSIONS: Despite the roll-out of Option B+ in Lesotho in 2013, pediatric HIV prevalence remains high. Further research is required to understand the greater prevalence among girls, barriers to PMTCT, and how to better achieve viral suppression in children living with HIV. |
Point of care CD4 testing in national household surveys - results and quality indicators from eleven population-based HIV impact assessment (PHIA) surveys
Birhanu S , Winterhalter FS , Stupp P , Cates M , Rottinghaus E , Yavo D , Wray-Gordon F , Lupoli K , Ndongmo CB , Longwe H , Reid GA , Metz M , Saito S , McCracken S , Brown K , Voetsch AC , Duong YT , Parekh BS , Patel HK . Microbiol Spectr 2023 11 (3) e0314822 Population-based HIV Impact Assessments (PHIAs) are national household (HH) surveys that provide HIV diagnosis and CD4 testing with an immediate return of results. Accurate CD4 results improve HIV-positive participants' clinical care and inform the effectiveness of HIV programs. Here, we present CD4 results from the PHIA surveys that were conducted in 11 countries in sub-Saharan Africa between 2015 and 2018. All of the HIV-positive participants and 2 to 5% of the HIV-negative participants were offered Pima CD4 (Abbott, IL, USA) point-of-care (POC) tests. The quality of the CD4 test was ensured by conducting instrument verification, comprehensive training, quality control, a review of testing errors and an analysis of unweighted CD4 data by HIV status, age, gender, and antiretroviral (ARV) treatment status. Overall, CD4 testing was completed for 23,085 (99.5%) of the 23,209 HIV-positive and 7,329 (2.7%) of the 270,741 negative participants in 11 surveys. The instrument error rate was 11.3% (range, 4.4% to 15.7%). The median CD4 values among HIV-positive and HIV-negative participants (aged 15+) were 468 cells/mm(3) (interquartile range [IQR], 307 to 654) and 811 cells/mm(3) (IQR, 647 to 1,013), respectively (P < 0.0001). Among the HIV-positive participants (aged 15+), those with detectable ARVs had higher CD4 values (508 cells/mm(3)) than those with undetectable ARVs (385.5 cells/mm(3)). Among the HIV-positive participants (aged 15+), 11.4% (2,528/22,253) had a CD4 value of less than 200 cells/mm(3), and approximately half of them (1,225/2,528 = 48.5%) had detectable ARVs, whereas 51.5% (1,303/2,528) had no detectable ARVs. We successfully implemented high quality POC CD4 testing using Pima instruments. Our data come from nationally representative surveys in 11 countries and provide unique insights regarding the CD4 distribution among HIV-positive individuals as well as the baseline CD4 values among HIV-negative individuals. IMPORTANCE The manuscript describes CD4 levels among HIV-positive individuals and baseline CD4 levels among HIV-negative individuals from 11 sub-Saharan countries, thereby highlighting the importance of CD4 markers in the context of the HIV epidemic. Despite increased ARV access in each country, advanced HIV disease (CD4 < 200 cells/mm(3)) persists among approximately 11% of HIV-positive individuals. Therefore, it is important that our findings are shared with the scientific community to assist with similar implementations of point-of-care testing and to conduct a review of HIV programmatic gaps. |
Hazardous alcohol use and HIV indicators in six African countries: results from the Population-based HIV Impact Assessments, 2015-2017
Chang GC , West CA , Kim E , Low AJ , Lancaster KE , Behel SS , Hong SY , Miller LA , Silver R , Mgomella GS , Imaa J , Maokola WM , Carpino T , Hrusa G , Bray RM , Mwila A , Musuka G , O'Connell C , McCracken S , Voetsch AC . J Int AIDS Soc 2022 25 (11) e26029 INTRODUCTION: Hazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue. METHODS: We used weighted pooled data (2015-2017) from the nationally representative Population-based HIV Impact Assessments among adults who provided written consent aged 18-59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 indicators between PLHIV by HAU status using log-binomial regression, stratified by sex. HAU was determined using the Alcohol Use Identification Test-Consumption. RESULTS: Among the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18-1.46) compared to those who did not report HAU. For the UNAIDS 90-90-90 targets, women who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.22, 95% CI: 1.01-1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26-2.37). Men who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.56, 95% CI 1.39-1.76) and not on ART (aPR = 1.72, 95% CI: 1.30-2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex. CONCLUSIONS: PLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol-based venues, may help countries reach HIV epidemic control by 2030. |
Seroprevalence of SARS-CoV-2 in four states of Nigeria in October 2020: a population-based household survey
Audu RA , Stafford KA , Steinhardt L , Musa ZA , Iriemenam N , Ilori E , Blanco N , Mitchell A , Hamada Y , Moloney M , Iwara E , Abimiku A , Ige FA , William NE , Igumbor E , Ochu C , Omoare AA , Okunoye O , Greby SM , Rangaka MX , Copas A , Dalhatu I , Abubakar I , McCracken S , Alagi M , Mba N , Anthony A , Okoye M , Okoi C , Ezechi OC , Salako BL , Ihekweazu C . PLoS Glob Public Health 2022 2 (6) e0000363 The observed epidemiology of SARS-CoV-2 in sub-Saharan Africa has varied greatly from that in Europe and the United States, with much lower reported incidence. Population-based studies are needed to estimate true cumulative incidence of SARS-CoV-2 to inform public health interventions. This study estimated SARS-CoV-2 seroprevalence in four selected states in Nigeria in October 2020. We implemented a two-stage cluster sample household survey in four Nigerian states (Enugu, Gombe, Lagos, and Nasarawa) to estimate age-stratified prevalence of SARS-CoV-2 antibodies. All individuals in sampled households were eligible for interview, blood draw, and nasal/oropharyngeal swab collection. We additionally tested participants for current/recent malaria infection. Seroprevalence estimates were calculated accounting for the complex survey design. Across all four states, 10,629 (96.5%) of 11,015 interviewed individuals provided blood samples. The seroprevalence of SARS-CoV- 2 antibodies was 25.2% (95% CI 21.8-28.6) in Enugu State, 9.3% (95% CI 7.0-11.5) in Gombe State, 23.3% (95% CI 20.5-26.4) in Lagos State, and 18.0% (95% CI 14.4-21.6) in Nasarawa State. Prevalence of current/recent malaria infection ranged from 2.8% in Lagos to 45.8% in Gombe and was not significantly related to SARS-CoV-2 seroprevalence. The prevalence of active SARS-CoV-2 infection in the four states during the survey period was 0.2% (95% CI 0.1-0.4). Approximately eight months after the first reported COVID-19 case in Nigeria, seroprevalence indicated infection levels 194 times higher than the 24,198 officially reported COVID-19 cases across the four states; however, most of the population remained susceptible to COVID-19 in October 2020. |
High HIV prevalence and associated factors in Lesotho: Results from a population-based survey
Schwitters A , McCracken S , Frederix K , Tierney R , Koto M , Ahmed N , Thin K , Dobbs T , Sithole S , Letsie M , Parekh B , Patel H , Birhanu S , Wiesner L , Low A . PLoS One 2022 17 (7) e0271431 Despite extensive global efforts, sub-Saharan Africa remains disproportionately affected by the HIV epidemic. This generalized epidemic can be seen in Lesotho which in 2014 the HIV prevalence rate of those aged 15-49 years was 24.6%, with and incidence of 1.9 new infections per 100-person-year exposures. To better understand the impact of Lesotho's national HIV response and significant predictors associated with HIV infection, the Lesotho Population-based HIV Impact Assessment was conducted. This survey provided a nationally representative sample of individuals aged 15-59 years old in which participants were tested for HIV and given an individual questionnaire that included socio-demographic and behavioral risk questions. The association of factors between survey questions and HIV incident was assessed using logistic regression. Multivariate logistic regression models for men and women were constructed for each outcome using variables known to be or plausibly associated with recent or chronic infection. Overall annualized incidence among people aged 15-49 was 1.19% (95% CI 0.73-1.65) per year. The overall prevalence of HIV was 25.6% with women having significantly higher prevalence. Multiple variables, including decreased wealth status, lower education levels, marital status, condom use at first sex, and circumcision (men only) were identified as being significantly associated with HIV infection for both men and women. In combination with improving the awareness of HIV status, an increased focus is needed on AGYW and men 35-49 years old to prevent new infections. HIV education and prevention programs should focus heavily on younger age groups prior to and soon after sexual debut to prevent HIV transmission. The findings of the survey showed significant room for improvement in increasing awareness of HIV status and reinforcing the need for continued HIV prevention and treatment efforts in Lesotho to prevent new infections. |
Burden of Diarrheagenic Escherichia coli in Santa Rosa, Guatemala in active health-services surveillance during 2008-2009 and 2014-2015.
Jarquin C , Morales O , McCracken JP , Lopez MR , Lopez B , Reyes L , Gmez GA , Bryan JP , Peruski LF , Pattabiraman V , Parsons MB . Trop Med Int Health 2022 27 (4) 408-417 OBJECTIVE: To describe the epidemiology of laboratory-confirmed Diarrheagenic Escherichia coli (DEC) cases from active facility-based surveillance in Guatemala. METHODS: We collected clinical and risk factor data on enrolled patients (aged 0-52 years) with acute diarrhea at government healthcare facilities (1 hospital and 6 clinics) in Santa Rosa, Guatemala, during 2008-2009 and 2014-2015. Stool samples were analyzed and E. coli identified through culture and biochemical tests, PCR amplification of genes encoding pathotype-specific virulence factors identified specific DEC pathotypes. Healthcare-seeking adjusted incidence rates were calculated. RESULTS: 3041 diarrhea cases were captured by surveillance (647 hospitalizations (H), 2394 clinic visits (CV)); general E. coli prevalence was 17.9%. DEC pathotypes were identified in 19% (n=95/497) and 21% (n=450/2113) in diarrhea H and CV, respectively. Enteropathogenic E. coli (EPEC) was most frequently isolated (8.2% (n=41) in diarrhea H, 12.0% (n =255) in diarrhea CV), followed by ETEC (6.8% (n=34) in H, 6% (n=128) in CV) and STEC (0.6% (n=3) in H, 0.6% (n=13) in CV). We did not find evidence of a difference in severity between DEC and non-DEC diarrhea. Incidence of DEC clinic visits and hospitalizations was 648.0 and 29.3, respectively, per 10,000 persons aged 5 years and 36.8 and 0.4, respectively, per 10,000 persons aged >5 years. CONCLUSIONS: DEC pathotypes, especially EPEC and ETEC, were detected frequently from patients presenting with diarrheal illness in Santa Rosa, Guatemala. Our findings suggest that preventive interventions should be prioritized for young children. |
Migration in Namibia and its association with HIV acquisition and treatment outcomes
Low A , Sachathep K , Rutherford G , Nitschke AM , Wolkon A , Banda K , Miller LA , Solmo C , Jackson K , Patel H , McCracken S , Findley S , Mutenda N . PLoS One 2021 16 (9) e0256865 BACKGROUND: In the 21st century, understanding how population migration impacts human health is critical. Namibia has high migration rates and HIV prevalence, but little is known about how these intersect. We examined the association between migration and HIV-related outcomes using data from the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA). METHODS AND FINDINGS: The NAMPHIA survey selected a nationally representative sample of adults in 2017. All adults aged 15-64 years were invited to complete an interview and home-based HIV test. Recent infection (<130 days) was measured using HIV-1 LAg avidity combined with viral load (>1000 copies/mL) and antiretroviral analyte data. Awareness of HIV status and antiretroviral use were based on self-report and/or detectable antiretrovirals in blood. Viremia was defined as having a viral load ≥1000 copies/mL, including all participants in the denominator regardless of serostatus. We generated community viremia values as a weighted proportion at the EA level, excluding those classified as recently infected. Significant migrants were those who had lived outside their current region or away from home >one month in the past three years. Recent cross-community in-migrants were those who had moved to the community <two years ago. Separate analyses were done to compare significant migrants to non-migrants and recent cross-community in-migrants to those who in-migrated >two years ago to determine the association of migration and timing with recent infection or viral load suppression (VLS). All proportions are weighted. Of eligible adults, we had HIV results and migration data on 9,625 (83.9%) of 11,474 women and 7,291 (73.0%) of 9,990 men. Most respondents (62.5%) reported significant migration. Of cross-community in-migrants, 15.3% were recent. HIV prevalence was 12.6% and did not differ by migration status. Population VLS was 77.4%. Recent cross-community in-migration was associated with recent HIV infection (aOR: 4.01, 95% CI 0.99-16.22) after adjusting for community viremia. Significant migration (aOR 0.73, 95% CI: 0.55-0.97) and recent cross-community in-migration (aOR 0.57, 95% CI: 0.35-0.92) were associated with lower VLS, primarily due to lack of awareness of HIV infection. The study was limited by lack of precise data on trajectory of migration. CONCLUSIONS: Despite a high population-level VLS, Namibia still has migrant populations that are not accessing effective treatment for HIV. Targeting migrants with effective prevention and testing programs in communities with viremia could enable further epidemic control. |
Lessons From Rapid Field Implementation of an HIV Population-Based Survey in Nigeria, 2018
Jahun I , Greby SM , Adesina T , Agbakwuru C , Dalhatu I , Yakubu A , Jelpe T , Okoye M , Ikpe S , Ehoche A , Abimiku A , Aliyu G , Charurat M , Greenwell G , Bronson M , Patel H , McCracken S , Voetsch AC , Parekh B , Swaminathan M , Adewole I , Aliyu S . J Acquir Immune Defic Syndr 2021 87 S36-s42 BACKGROUND: The need for accurate HIV annual program planning data motivated the compressed timeline for the 2018 Nigerian HIV/AIDS Indicator and Impact Survey (NAIIS). The survey team used stakeholder cooperation and responsive design, using survey process and paradata to refine survey implementation, to quickly collect high-quality data. We describe processes that led to generation of data for program and funding decisions, ensuring HIV services were funded in 2019. SETTING: Nigeria is the most populous country in Africa, with approximately 195 million people in 36 states and the Federal Capital Territory. Challenges include multiple security threats, poor infrastructure, seasonal rains, and varied health system capacity. METHODS: Stakeholders worked together to plan and implement NAIIS. Methods from other population-based HIV impact assessments were modified to meet challenges and the compressed timeline. Data collection was conducted in 6 webs. Responsive design included reviewing survey monitoring paradata and laboratory performance. Costs required to correct data errors, for example, staff time and transportation, were tracked. RESULTS: NAIIS data collection was completed in 23 weeks, ahead of the originally scheduled 24 weeks. Responsive design identified and resolved approximately 68,000 interview errors, affecting approximately 62,000 households, saving about US$4.4 million in costs. Biweekly field laboratory test quality control improved from 50% to 100% throughout NAIIS. CONCLUSIONS: Cooperation across stakeholders and responsive design ensured timely release of NAIIS results and informed planning for HIV epidemic control in Nigeria. Based on NAIIS results, funds were provided to place an additional 500,000 HIV-positive Nigerians on antiretroviral therapy by the end of 2020, pushing Nigeria toward epidemic control. |
Improving Sampling Efficiency for Determining Pediatric HIV Prevalence in National Surveys: Evidence From 8 Sub-Saharan African Countries
Reid G , Voetsch AC , Stupp P , McCracken S , Kalton G , Dlamini S , McOllogi Juma J , Kalua T , Kirungi W , Koto M , Mugurungi O , Mulenga L , Mutenda N , Marum L , Saito S . J Acquir Immune Defic Syndr 2021 87 S43-s51 BACKGROUND: Measurement of mother-to-child HIV transmission through population-based surveys requires large sample sizes because of low HIV prevalence among children. We estimate potential improvements in sampling efficiency resulting from a targeted sample design. SETTING: Eight countries in sub-Saharan Africa with completed Population-based HIV Impact Assessment (PHIA) surveys as of 2017. METHODS: The PHIA surveys used a geographically stratified 2-stage sample design with households sampled from randomly selected census enumeration areas. Children (0-14 years of age) were eligible for HIV testing within a random subsample of households (usually 50%). Estimates of child HIV prevalence in each country were calculated using jackknife replicate weights. We compared sample sizes and precision achieved using this design with a 2-phase disproportionate sample design applied to strata defined by maternal HIV status and mortality. RESULTS: HIV prevalence among children ranged from 0.4% (95% confidence interval: 0.2 to 0.6) in Tanzania to 2.8% (95% confidence interval: 2.2 to 3.4) in Eswatini with achieved relative standard errors between 11% and 21%. The expected precision improved in the targeted design in all countries included in the analysis, with proportionate reductions in mean squared error ranging from 27% in Eswatini to 61% in Tanzania, assuming an equal sample size. CONCLUSIONS: Population-based surveys of adult HIV prevalence that also measure child HIV prevalence should consider targeted sampling of children to reduce required sample size, increase precision, and increase the number of positive children tested. The findings from the PHIA surveys can be used as baseline data for informing future sample designs. |
HIV-1 Recent Infection Testing Algorithm With Antiretroviral Drug Detection to Improve Accuracy of Incidence Estimates
Voetsch AC , Duong YT , Stupp P , Saito S , McCracken S , Dobbs T , Winterhalter FS , Williams DB , Mengistu A , Mugurungi O , Chikwanda P , Musuka G , Ndongmo CB , Dlamini S , Nuwagaba-Biribonwoha H , Pasipamire M , Tegbaru B , Eshetu F , Biraro S , Ward J , Aibo D , Kabala A , Mgomella GS , Malewo O , Mushi J , Payne D , Mengistu Y , Asiimwe F , Shang JD , Dokubo EK , Eno LT , Zoung-Kanyi Bissek AC , Kingwara L , Junghae M , Kiiru JN , Mwesigwa RCN , Balachandra S , Lobognon R , Kampira E , Detorio M , Yufenyuy EL , Brown K , Patel HK , Parekh BS . J Acquir Immune Defic Syndr 2021 87 S73-s80 BACKGROUND: HIV-1 incidence calculation currently includes recency classification by HIV-1 incidence assay and unsuppressed viral load (VL ≥ 1000 copies/mL) in a recent infection testing algorithm (RITA). However, persons with recent classification not virally suppressed and taking antiretroviral (ARV) medication may be misclassified. SETTING: We used data from 13 African household surveys to describe the impact of an ARV-adjusted RITA on HIV-1 incidence estimates. METHODS: HIV-seropositive samples were tested for recency using the HIV-1 Limiting Antigen (LAg)-Avidity enzyme immunoassay, HIV-1 viral load, ARVs used in each country, and ARV drug resistance. LAg-recent result was defined as normalized optical density values ≤1.5. We compared HIV-1 incidence estimates using 2 RITA: RITA1: LAg-recent + VL ≥ 1000 copies/mL and RITA2: RITA1 + undetectable ARV. We explored RITA2 with self-reported ARV use and with clinical history. RESULTS: Overall, 357 adult HIV-positive participants were classified as having recent infection with RITA1. RITA2 reclassified 55 (15.4%) persons with detectable ARV as having long-term infection. Those with detectable ARV were significantly more likely to be aware of their HIV-positive status (84% vs. 10%) and had higher levels of drug resistance (74% vs. 26%) than those without detectable ARV. RITA2 incidence was lower than RITA1 incidence (range, 0%-30% decrease), resulting in decreased estimated new infections from 390,000 to 341,000 across the 13 countries. Incidence estimates were similar using detectable or self-reported ARV (R2 > 0.995). CONCLUSIONS: Including ARV in RITA2 improved the accuracy of HIV-1 incidence estimates by removing participants with likely long-term HIV infection. |
Effectiveness of gas and chimney biomass stoves for reducing household air pollution pregnancy exposure in Guatemala: Sociodemographic effect modifiers
Grajeda LM , Thompson LM , Arriaga W , Canuz E , Omer SB , Sage M , Azziz-Baumgartner E , Bryan JP , McCracken JP . Int J Environ Res Public Health 2020 17 (21) Household air pollution (HAP) due to solid fuel use during pregnancy is associated with adverse birth outcomes. The real-life effectiveness of clean cooking interventions has been disappointing overall yet variable, but the sociodemographic determinants are not well described. We measured personal 24-h PM(2.5) (particulate matter <2.5 µm in aerodynamic diameter) thrice in pregnant women (n = 218) gravimetrically with Teflon filter, impactor, and personal pump setups. To estimate the effectiveness of owning chimney and liquefied petroleum gas (LPG) stoves (i.e., proportion of PM(2.5) exposure that would be prevented) and to predict subject-specific typical exposures, we used linear mixed-effects models with log (PM(2.5)) as dependent variable and random intercept for subject. Median (IQR) personal PM(2.5) in µg/m(3) was 148 (90-249) for open fire, 78 (51-125) for chimney stove, and 55 (34-79) for LPG stoves. Adjusted effectiveness of LPG stoves was greater in women with ≥6 years of education (49% (95% CI: 34, 60)) versus <6 years (26% (95% CI: 5, 42)). In contrast, chimney stove adjusted effectiveness was greater in women with <6 years of education (50% (95% CI: 38, 60)), rural residence (46% (95% CI: 34, 55)) and lowest SES (socio-economic status) quartile (59% (95% CI: 45, 70)) than ≥6 years education (16% (95% CI: 22, 43)), urban (23% (95% CI: -164, 42)) and highest SES quartile (-44% (95% CI: -183, 27)), respectively. A minority of LPG stove owners (12%) and no chimney owner had typical exposure below World Health Organization Air Quality guidelines (35 μg/m(3)). Although having a cleaner stove alone typically does not lower exposure enough to protect health, understanding sociodemographic determinants of effectiveness may lead to better targeting, implementation, and adoption of interventions. |
The epidemiology and estimated etiology of pathogens detected from the upper respiratory tract of adults with severe acute respiratory infections in multiple countries, 2014-2015.
Milucky J , Pondo T , Gregory CJ , Iuliano D , Chaves SS , McCracken J , Mansour A , Zhang Y , Aleem MA , Wolff B , Whitaker B , Whistler T , Onyango C , Lopez MR , Liu N , Rahman MZ , Shang N , Winchell J , Chittaganpitch M , Fields B , Maldonado H , Xie Z , Lindstrom S , Sturm-Ramirez K , Montgomery J , Wu KH , Van Beneden CA . PLoS One 2020 15 (10) e0240309 INTRODUCTION: Etiology studies of severe acute respiratory infections (SARI) in adults are limited. We studied potential etiologies of SARI among adults in six countries using multi-pathogen diagnostics. METHODS: We enrolled both adults with SARI (acute respiratory illness onset with fever and cough requiring hospitalization) and asymptomatic adults (adults hospitalized with non-infectious illnesses, non-household members accompanying SARI patients, adults enrolled from outpatient departments, and community members) in each country. Demographics, clinical data, and nasopharyngeal and oropharyngeal specimens were collected from both SARI patients and asymptomatic adults. Specimens were tested for presence of 29 pathogens utilizing the Taqman® Array Card platform. We applied a non-parametric Bayesian regression extension of a partially latent class model approach to estimate proportions of SARI caused by specific pathogens. RESULTS: We enrolled 2,388 SARI patients and 1,135 asymptomatic adults from October 2013 through October 2015. We detected ≥1 pathogen in 76% of SARI patients and 67% of asymptomatic adults. Haemophilus influenzae and Streptococcus pneumoniae were most commonly detected (≥23% of SARI patients and asymptomatic adults). Through modeling, etiology was attributed to a pathogen in most SARI patients (range among countries: 57.3-93.2%); pathogens commonly attributed to SARI etiology included influenza A (14.4-54.4%), influenza B (1.9-19.1%), rhino/enterovirus (1.8-42.6%), and RSV (3.6-14.6%). CONCLUSIONS: Use of multi-pathogen diagnostics and modeling enabled attribution of etiology in most adult SARI patients, despite frequent detection of multiple pathogens in the upper respiratory tract. Seasonal flu vaccination and development of RSV vaccine would likely reduce the burden of SARI in these populations. |
Enhanced surveillance for histoplasmosis - 9 states, 2018-2019
Benedict K , McCracken S , Signs K , Ireland M , Amburgey V , Serrano JA , Christophe N , Gibbons-Burgener S , Hallyburton S , Warren KA , Keyser Metobo A , Odom R , Groenewold MR , Jackson BR . Open Forum Infect Dis 2020 7 (9) ofaa343 BACKGROUND: Histoplasmosis is often described as the most common endemic mycosis in the United States, but much remains unknown about its epidemiology among the general population. METHODS: We conducted enhanced surveillance in 9 states during 2018-2019 by identifying cases through routine surveillance and interviewing 301 patients about their clinical features and exposures. RESULTS: Before being tested for histoplasmosis, 60% saw a health care provider ≥3 times, and 53% received antibacterial medication. The median time from seeking health care to diagnosis (range) was 23 (0-269) days. Forty-nine percent were hospitalized, and 69% said that histoplasmosis interfered with their daily activities (median [range], 56 [2-3960] days). Possible exposures included handling plants (48%) and bird or bat droppings (24%); 22% reported no specific exposures. Only 15% had heard of histoplasmosis before their illness. CONCLUSIONS: Histoplasmosis can be severe and prolonged. Additional educational efforts to increase public and provider awareness and reduce delays in diagnosis are needed. |
Inverse association between dengue, chikungunya, and Zika virus infection and indicators of household air pollution in Santa Rosa, Guatemala: A case-control study, 2011-2018
Madewell ZJ , Lopez MR , Espinosa-Bode A , Brouwer KC , Sanchez CG , McCracken JP . PLoS One 2020 15 (6) e0234399 BACKGROUND: Dengue, chikungunya, and Zika viruses are increasingly important public health problems. Burning vegetation, leaves, and other plant products have been shown to be effective mosquito repellents for their vector, Aedes spp., but there has been scant research on whether firewood cooking smoke in households influences mosquito populations or mosquito-borne diseases. About 2.9 billion people worldwide use biomass fuel for household cooking and heating, resulting in an estimated 1.6 million deaths annually from household air pollution (HAP)-related diseases. Global health agencies now encourage households to transition from biomass to clean fuels, but it is unclear whether such interventions may actually increase risk for mosquito-borne diseases. This retrospective case-control study evaluated associations between arboviral infections and cooking with firewood in Santa Rosa, Guatemala. METHOD: Vigilancia Integrada Comunitaria (VICo) was a prospective public health surveillance system for bacterial, parasitic, and viral causes of diarrheal, neurological, respiratory, and febrile illnesses in hospitals and clinics in the department of Santa Rosa, Guatemala. Enrolled VICo in-patients and out-patients during 2011-2018 were interviewed using standardized questionnaires on demographics and household characteristics. Blood and stool specimens were collected and tested to identify the etiologies presenting symptoms. Cases were defined as laboratory-positive for dengue, chikungunya, or Zika virus infections. Controls were laboratory-positive for bacterial and viral diarrheal illnesses (e.g., Salmonella, Shigella, Campylobacter, Escherichia coli, rotavirus, norovirus, sapovirus, or astrovirus). Cooking with firewood, kitchen location, stove type, and firewood cooking frequency were the independent exposure variables. Logistic regression models were used to analyze unadjusted and adjusted associations between arboviral infections and exposures of interest. RESULT: There were 311 arboviral cases and 1,239 diarrheal controls. Arboviral infections were inversely associated with cooking with firewood in the main house (AOR: 0.22; 95% CI: 0.08-0.57), cooking with firewood on an open hearth (AOR: 0.50; 95% CI: 0.33-0.78), and cooking with firewood >/=5 times per week (AOR: 0.54; 95% CI: 0.36-0.81), adjusting for age, sex, ethnicity, socioeconomic status index, number of people per household, community population density, community elevation, recruitment location, season, and admission year. CONCLUSION: Several primary determinants of HAP exposure were inversely associated with arboviral infections. Additional studies are needed to understand whether interventions to reduce HAP might actually increase risk for mosquito-borne infectious diseases, which would warrant improved education and mosquito control efforts in conjunction with fuel interventions. |
Global burden of respiratory infections associated with seasonal influenza in children under 5 years in 2018: a systematic review and modelling study
Wang X , Li Y , O'Brien KL , Madhi SA , Widdowson MA , Byass P , Omer SB , Abbas Q , Ali A , Amu A , Azziz-Baumgartner E , Bassat Q , Abdullah Brooks W , Chaves SS , Chung A , Cohen C , Echavarria M , Fasce RA , Gentile A , Gordon A , Groome M , Heikkinen T , Hirve S , Jara JH , Katz MA , Khuri-Bulos N , Krishnan A , de Leon O , Lucero MG , McCracken JP , Mira-Iglesias A , Moisi JC , Munywoki PK , Ourohire M , Polack FP , Rahi M , Rasmussen ZA , Rath BA , Saha SK , Simoes EA , Sotomayor V , Thamthitiwat S , Treurnicht FK , Wamukoya M , Yoshida LM , Zar HJ , Campbell H , Nair H . Lancet Glob Health 2020 8 (4) e497-e510 BACKGROUND: Seasonal influenza virus is a common cause of acute lower respiratory infection (ALRI) in young children. In 2008, we estimated that 20 million influenza-virus-associated ALRI and 1 million influenza-virus-associated severe ALRI occurred in children under 5 years globally. Despite this substantial burden, only a few low-income and middle-income countries have adopted routine influenza vaccination policies for children and, where present, these have achieved only low or unknown levels of vaccine uptake. Moreover, the influenza burden might have changed due to the emergence and circulation of influenza A/H1N1pdm09. We aimed to incorporate new data to update estimates of the global number of cases, hospital admissions, and mortality from influenza-virus-associated respiratory infections in children under 5 years in 2018. METHODS: We estimated the regional and global burden of influenza-associated respiratory infections in children under 5 years from a systematic review of 100 studies published between Jan 1, 1995, and Dec 31, 2018, and a further 57 high-quality unpublished studies. We adapted the Newcastle-Ottawa Scale to assess the risk of bias. We estimated incidence and hospitalisation rates of influenza-virus-associated respiratory infections by severity, case ascertainment, region, and age. We estimated in-hospital deaths from influenza virus ALRI by combining hospital admissions and in-hospital case-fatality ratios of influenza virus ALRI. We estimated the upper bound of influenza virus-associated ALRI deaths based on the number of in-hospital deaths, US paediatric influenza-associated death data, and population-based childhood all-cause pneumonia mortality data in six sites in low-income and lower-middle-income countries. FINDINGS: In 2018, among children under 5 years globally, there were an estimated 109.5 million influenza virus episodes (uncertainty range [UR] 63.1-190.6), 10.1 million influenza-virus-associated ALRI cases (6.8-15.1); 870 000 influenza-virus-associated ALRI hospital admissions (543 000-1 415 000), 15 300 in-hospital deaths (5800-43 800), and up to 34 800 (13 200-97 200) overall influenza-virus-associated ALRI deaths. Influenza virus accounted for 7% of ALRI cases, 5% of ALRI hospital admissions, and 4% of ALRI deaths in children under 5 years. About 23% of the hospital admissions and 36% of the in-hospital deaths were in infants under 6 months. About 82% of the in-hospital deaths occurred in low-income and lower-middle-income countries. INTERPRETATION: A large proportion of the influenza-associated burden occurs among young infants and in low-income and lower middle-income countries. Our findings provide new and important evidence for maternal and paediatric influenza immunisation, and should inform future immunisation policy particularly in low-income and middle-income countries. FUNDING: WHO; Bill & Melinda Gates Foundation. |
Safety, immunogenicity, and efficacy of intramuscular and oral delivery of ERA-g333 recombinant rabies virus vaccine to big brown bats (Eptesicus fuscus)
Gilbert AT , Wu X , Jackson FR , Franka R , McCracken GF , Rupprecht CE . J Wildl Dis 2020 56 (3) 620-630 Attenuated strains of rabies virus (RABV) have been used for oral vaccination of wild carnivores in Europe and North America. However, some RABV vaccines caused clinical rabies in target animals. To improve the safety of attenuated RABV as an oral vaccine for field use, strategies using selection of escape mutants under monoclonal antibody neutralization pressure and reverse genetics-defined mutations have been used. We tested the safety, immunogenicity, and efficacy of one RABV construct, ERA-g333, developed with reverse genetics by intramuscular (IM) or oral (PO) routes in big brown bats (Eptesicus fuscus). Twenty-five bats received 5x10(6) mouse intracerebral median lethal doses (MICLD50) of ERA-g333 by IM route, 10 received 5x10(6) MICLD50 of ERA-g333 by PO route, and 22 bats served as unvaccinated controls. Twenty-one days after vaccination, 44 bats were infected by IM route with 10(2.9) MICLD50 of E. fuscus RABV. We report both the immunogenicity and efficacy of ERA-g333 delivered by the IM route; no induction of humoral immunity was detected in bats vaccinated by the PO route. Two subsets of bats vaccinated IM (n=5) and PO (n=3) were not challenged, and none developed clinical rabies from ERA-g333. Scarce reports exist on the evaluation of oral rabies vaccines in insectivorous bats, although the strategy evaluated here may be feasible for future application to these important RABV reservoirs. |
Incidence and etiology of infectious diarrhea from a facility-based surveillance system in Guatemala, 2008-2012
Arvelo W , Hall AJ , Henao O , Lopez B , Bernart C , Moir JC , Reyes L , Montgomery SP , Morgan O , Estevez A , Parsons MB , Lopez MR , Gomez G , Vinje J , Gregoricus N , Parashar U , Mintz ED , McCracken J , Bryan JP , Lindblade KA . BMC Public Health 2019 19 (1) 1340 BACKGROUND: Diarrhea is a major cause of morbidity and mortality, yet incidence and etiology data are limited. We conducted laboratory-based diarrhea surveillance in Guatemala. METHODS: A diarrhea case was defined as >/=3 loose stools in a 24-h period in a person presenting to the surveillance facilities. Epidemiologic data and stool specimens were collected. Specimens were tested for bacterial, parasitic, and viral pathogens. Yearly incidence was adjusted for healthcare seeking behaviors determined from a household survey conducted in the surveillance catchment area. RESULTS: From November 2008 to December 2012, the surveillance system captured 5331 diarrhea cases; among these 1381 (26%) had specimens tested for all enteric pathogens of interest. The adjusted incidence averaged 659 diarrhea cases per 10,000 persons per year, and was highest among children aged < 5 years, averaging 1584 cases per 10,000 children per year. Among 1381 (26%) specimens tested for all the pathogens of interest, 235 (17%) had a viral etiology, 275 (20%) had a bacterial, 50 (4%) had parasites, and 86 (6%) had co-infections. Among 827 (60%) specimens from children aged < 5 years, a virus was identified in 196 (23%) patients; 165 (20%) had norovirus and 99 (12%) rotavirus, including co-infections. Among 554 patients aged >/=5 years, 103 (19%) had a bacterial etiology, including diarrheagenic Escherichia coli in 94 (17%) cases, Shigella spp. in 31 (6%), Campylobacter spp. in 5 (1%), and Salmonella spp. in 4 (1%) cases. Detection of Giardia and Cryptosporidium was infrequent (73 cases; 5%). CONCLUSIONS: There was a substantial burden of viral and bacterial diarrheal diseases in Guatemala, highlighting the importance of strengthening laboratory capacity for rapid detection and control and for evaluation of public health interventions. |
Progress toward HIV epidemic control in Lesotho: results from a population-based survey
Thin K , Frederix K , McCracken S , Letsie M , Low A , Patel H , Parekh B , Motsoane T , Ahmed N , Justman J , Callaghan L , Tembo S , Schwitters A . AIDS 2019 33 (15) 2393-2401 OBJECTIVE: The Lesotho Population-based HIV Impact Assessment (LePHIA) survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9,403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral (ARV) analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or ARV biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA < 1000 copies per mL. RESULTS: Overall, 25.6% of adults ages 15-59 were HIV-positive. Among seropositive adults, 81.0% (male: 76.6%, female: 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male: 91.6%, female: 92.0%) who reported knowing their status reporting taking ARVs, and 87.7% (male and female: 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related intervention is critical to achieving epidemic control. |
Progress toward HIV epidemic control in Lesotho: results from a population-based survey
Thin K , Frederix K , McCracken S , Letsie M , Low A , Patel H , Parekh B , Motsoane T , Ahmed N , Justman J , Callaghan L , Tembo S , Schwitters A . AIDS 2019 33 (15) 2393-2401 OBJECTIVE: The Lesotho Population-based HIV Impact Assessment (LePHIA) survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9,403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral (ARV) analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or ARV biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA < 1000 copies per mL. RESULTS: Overall, 25.6% of adults ages 15-59 were HIV-positive. Among seropositive adults, 81.0% (male: 76.6%, female: 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male: 91.6%, female: 92.0%) who reported knowing their status reporting taking ARVs, and 87.7% (male and female: 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related intervention is critical to achieving epidemic control. |
Correlates of HIV infection in adolescent girls and young women in Lesotho: results from a population-based survey
Low A , Thin K , Davia S , Mantell J , Koto M , McCracken S , Ramphalla P , Maile L , Ahmed N , Patel H , Parekh B , Fida N , Schwitters A , Frederix K . Lancet HIV 2019 6 (9) e613-e622 BACKGROUND: HIV acquisition remains high among adolescent girls and young women (AGYW, aged 15-24 years) in sub-Saharan Africa. We aimed to estimate prevalence and incidence of HIV in AGYW and to identify correlates of HIV infection by using data from the Lesotho Population-based HIV Impact Assessment (LePHIA). METHODS: LePHIA was a nationally representative survey of adults and children based on a multistage cluster sampling method with random selection of enumeration areas and households. All adults aged 15 years and older who had slept in the household the night before were eligible for participation; participants completed an interview and HIV testing. We estimated incidence with the HIV-1 limiting antigen avidity enzyme immunoassay combined with viral load and examined the association between demographic and behavioural variables (including characteristics of cohabitating mothers and sexual partners, when available) and prevalence and incidence among AGYW using logistic regression, incorporating survey weights. FINDINGS: We interviewed 8824 households, including 2358 AGYW who were tested for HIV infection. Weighted HIV prevalence was 11.1% (95% CI 9.7-12.5) in the overall population (273 of 2358 AGYW), 5.7% (4.1-7.2) in adolescent girls aged 15-19 years (64 of 1156), and 16.7% (14.4-19.0) in women aged 20-24 years (209 of 1212). Annualised HIV incidence was 1.8% (0.8-2.8). Correlates of prevalent infection include reporting a history of anal sex (adjusted odds ratio [aOR] 3.08, 1.11-8.57), having lived outside Lesotho in the past year (1.86, 1.01-3.42), having a partner suspected or known to be HIV positive (11.7, 6.0-22.5), and having two or more lifetime sexual partners (1.84, 1.21-2.78, for 2-3 lifetime sexual partners; 2.44, 1.45-4.08, for >/=4 lifetime sexual partners). For the 570 AGYW living with their mothers, maternal education was negatively associated with HIV prevalence in their daughters (aOR 0.36, 0.15-0.82, per increase in level attended). For AGYW with a cohabitating partner, the factors associated with AGYW infection were partner age (OR 4.54, 1.30-15.80, for partners aged 35-49 years, although the OR was no longer significant when adjusted for HIV status of partner), HIV status (aOR 11.22, 4.05-31.05), lack of viral load suppression (OR 0.16, 0.04-0.66), and partner employment in the past year (aOR 3.41, 1.12-10.42). INTERPRETATION: The findings confirm the importance of improving the treatment cascade in male partners and targeting preventive interventions to AGYW who are at increased risk. A regional approach to prevention could mitigate the effect of migration on transnational spread of HIV. FUNDING: President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention. |
Hospitalization and death among patients with influenza, Guatemala, 2008-2012
Ao T , McCracken JP , Lopez MR , Bernart C , Chacon R , Moscoso F , Paredes A , Castillo L , Azziz-Baumgartner E , Arvelo W , Lindblade KA , Peruski LF , Bryan JP . BMC Public Health 2019 19 463 Background: Influenza is a major cause of respiratory illness resulting in 3-5 million severe cases and 291,243-645,832 deaths annually. Substantial health and financial burden may be averted by annual influenza vaccine application, especially for high risk groups. Methods: We used an active facility-based surveillance platform for acute respiratory diseases in three hospitals in Guatemala, Central America, to estimate the incidence of laboratory-confirmed hospitalized influenza cases and identify risk factors associated with severe disease (defined as admission to the intensive care unit (ICU) or death). We enrolled patients presenting with signs and symptoms of acute respiratory infection (ARI) and obtained naso- and oropharyngeal samples for real-time reverse transcriptase polymerase chain reaction (RT-PCR). We used multivariable logistic regression to identify risk factors for ICU admission or death, adjusted for age and sex. Results: From May 2008 to July 2012, among 6326 hospitalized ARI cases, 446 (7%) were positive for influenza: of those, 362 (81%) had influenza A and 84 (18%) had influenza B. Fifty nine percent of patients were aged </= 5 years, and 10% were aged ≥ 65 years. The median length of hospitalization was 5 days (interquartile range: 5). Eighty of 446 (18%) were admitted to the ICU and 28 (6%) died. Among the 28 deaths, 7% were aged ≤ 6 months, 39% 7-60 months, 21% 5-50 years, and 32% ≥ 50 years. Children aged ≤ 6 months comprised 19% of cases and 22% of ICU admissions. Women of child-bearing age comprised 6% of cases (2 admitted to ICU; 1 death). In multivariable analyses, Santa Rosa site (adjusted odds ratio [aOR] = 10, 95% confidence interval [CI] = 2-50), indigenous ethnicity (aOR = 4, 95% CI = 2-13, and radiologically-confirmed pneumonia (aOR = 5, 95% CI = 3-11) were independently associated with severe disease. Adjusted for hospital utilization rate, annual incidence of hospitalized laboratory-confirmed influenza was 24/100,000 overall, 93/100,000 for children aged < 5 years and 50/100,000 for those >/= 65 years. Conclusions: Influenza is a major contributor of hospitalization and death due to respiratory diseases in Guatemala. Further application of proven influenza prevention and treatment strategies is warranted. |
Burden of laboratory-confirmed shigellosis infections in Guatemala 2007-2012: Results from a population-based surveillance system
Hegde S , Benoit SR , Arvelo W , Lindblade K , López B , McCracken JP , Bernart C , Roldan A , Bryan JP . BMC Public Health 2019 19 474 Background: We describe the epidemiology and antimicrobial susceptibility patterns of culture-confirmed Shigella infections in facility-based surveillance sites in Guatemala. Current studies using quantitative molecular diagnostics suggest Shigella may contribute most to the global diarrheal disease burden. Since identification of Shigella requires culturing techniques using stool specimens and few laboratories in Guatemala routinely culture for this pathogen, little is known about the true burden of Shigella in Guatemala or, importantly, the antimicrobial resistance patterns. Methods: Clinical, epidemiological, and laboratory data were collected on 5399 patients with acute diarrhea (≥3 loose stools in 24 h) from June 2007-August 2012. Multidrug resistance (MDR) was defined as resistance to ampicillin and trimethoprim/sulfamethoxazole. Results: Five percent (261) of stool specimens yielded Shigella spp. The annual incidence of laboratory-confirmed infections ranged from 5.0 to 24.1 per 100,000 persons in Santa Rosa and 0.3 to 6.2 per 100,000 in Quetzaltenango; 58% of cases occurred in children < 5 years of age. Thirty patients were hospitalized; one patient died. Oral rehydration or intravenous solution was used to treat 72% of hospitalized and 15% of ambulatory cases. Fifty-nine percent of cases were S. flexneri and 51% of cases were MDR. Conclusions: Shigella is an important cause of bacterial diarrhea in children and prevalence of MDR highlights the importance of appropriate treatment regimens. This study demonstrates that strengthening laboratory capacity in Guatemala can help determine causes which can lead to prevention of diarrheal diseases, particularly in children. Such capacity building is also critical for rapid detection and control of public health threats at their source and therefore for global health security. |
Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemala
Tomczyk S , McCracken JP , Contreras CL , Lopez MR , Bernart C , Moir JC , Escobar K , Reyes L , Arvelo W , Lindblade K , Peruski L , Bryan JP , Verani JR . BMC Public Health 2019 19 (1) 499 BACKGROUND: Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged >/=18 years hospitalized with ARI in Guatemala. METHODS: We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and >/= 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician's discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases. RESULTS: Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults >/=18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases. CONCLUSIONS: Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality. |
Notes from the Field: Multistate coccidioidomycosis outbreak in U.S. residents returning from community service trips to Baja California, Mexico - July-August 2018
Toda M , Gonzalez FJ , Fonseca-Ford M , Franklin P , Huntington-Frazier M , Gutelius B , Kawakami V , Lunquest K , McCracken S , Moser K , Oltean H , Ratner AJ , Raybern C , Signs K , Zaldivar A , Chiller TM , Jackson BR , McCotter O . MMWR Morb Mortal Wkly Rep 2019 68 (14) 332-333 On August 8, 2018, the New York City Department of Health and Mental Hygiene notified CDC about two high school students hospitalized for pneumonia of unknown etiology who had recently returned from community service trips constructing houses near Tijuana in Baja California, Mexico. Patients had developed fever 9 and 11 days after travel, followed by rash and lower respiratory symptoms. Symptoms did not improve with multiple courses of antibacterial medications, and the patients subsequently received diagnoses of coccidioidomycosis, a fungal disease commonly known as valley fever. |
Prevalence and genetic diversity of viral gastroenteritis viruses in children younger than 5 years of age in Guatemala, 2014-2015.
Diez-Valcarce M , Lopez MR , Lopez B , Morales O , Sagastume M , Cadena L , Kaydos-Daniels S , Jarquin C , McCracken JP , Bryan JP , Vinje J . J Clin Virol 2019 114 6-11 BACKGROUND: Acute diarrhea is an important cause of morbidity and mortality in children and is associated with approximately 500,000 deaths/year globally. Rotavirus and norovirus are leading causes of acute diarrhea accounting for more than half of this burden. OBJECTIVE/STUDY DESIGN: To determine the prevalence and genotype distribution of acute diarrhea caused by rotavirus, norovirus, sapovirus and astrovirus among children <5 years of age at two departments in Guatemala from January 2014 to December 2015, we tested 471 stool specimens (202 samples from hospitalized children and 269 samples from children in ambulatory clinics) by real-time reverse transcription-PCR and genotyped positive samples. RESULTS: Rotavirus was detected in 20.4%, norovirus in 18.5%, sapovirus in 7% and astrovirus in 4.2% of the samples. Co-infection of rotavirus and norovirus was found in 2.6% of the samples. Most norovirus (87.4%) and rotavirus (81.3%) infections were detected in children in the 6-12 months age group. The proportion of patients with rotavirus (34%) and norovirus (23%) was higher in hospitalized patients compared to ambulatory patients, whereas the prevalence of sapovirus and astrovirus was similar in both settings. Of the 40 genotyped norovirus strains, 62.5% were GII.4 and 15% GII.3. Sapovirus genotypes included GI.1 (15.4%), GII.2 (15.4%), GII.5 (38.5%) and GIV.1 (30.8%). CONCLUSIONS: Our data demonstrate that in 2014-2015, gastroenteritis viruses account for 50% of acute diarrhea in children younger than 5 years of age in Guatemala, highlighting the importance of continuous surveillance to guide impact of the current rotavirus vaccine and formulation of future norovirus vaccines. |
Association between severe drought and HIV prevention and care behaviors in Lesotho: A population-based survey 2016-2017
Low AJ , Frederix K , McCracken S , Manyau S , Gummerson E , Radin E , Davia S , Longwe H , Ahmed N , Parekh B , Findley S , Schwitters A . PLoS Med 2019 16 (1) e1002727 BACKGROUND: A previous analysis of the impact of drought in Africa on HIV demonstrated an 11% greater prevalence in HIV-endemic rural areas attributable to local rainfall shocks. The Lesotho Population-Based HIV Impact Assessment (LePHIA) was conducted after the severe drought of 2014-2016, allowing for reevaluation of this relationship in a setting of expanded antiretroviral coverage. METHODS AND FINDINGS: LePHIA selected a nationally representative sample between November 2016 and May 2017. All adults aged 15-59 years in randomly selected households were invited to complete an interview and HIV testing, with one woman per household eligible to answer questions on their experience of sexual violence. Deviations in rainfall for May 2014-June 2016 were estimated using precipitation data from Climate Hazards Group InfraRed Precipitation with Station Data (CHIRPS), with drought defined as <15% of the average rainfall from 1981 to 2016. The association between drought and risk behaviors as well as HIV-related outcomes was assessed using logistic regression, incorporating complex survey weights. Analyses were stratified by age, sex, and geography (urban versus rural). All of Lesotho suffered from reduced rainfall, with regions receiving 1%-36% of their historical rainfall. Of the 12,887 interviewed participants, 93.5% (12,052) lived in areas that experienced drought, with the majority in rural areas (7,281 versus 4,771 in urban areas). Of the 835 adults living in areas without drought, 520 were in rural areas and 315 in urban. Among females 15-19 years old, living in a rural drought area was associated with early sexual debut (odds ratio [OR] 3.11, 95% confidence interval [CI] 1.43-6.74, p = 0.004), and higher HIV prevalence (OR 2.77, 95% CI 1.19-6.47, p = 0.02). It was also associated with lower educational attainment in rural females ages 15-24 years (OR 0.44, 95% CI 0.25-0.78, p = 0.005). Multivariable analysis adjusting for household wealth and sexual behavior showed that experiencing drought increased the odds of HIV infection among females 15-24 years old (adjusted OR [aOR] 1.80, 95% CI 0.96-3.39, p = 0.07), although this was not statistically significant. Migration was associated with 2-fold higher odds of HIV infection in young people (aOR 2.06, 95% CI 1.25-3.40, p = 0.006). The study was limited by the extensiveness of the drought and the small number of participants in the comparison group. CONCLUSIONS: Drought in Lesotho was associated with higher HIV prevalence in girls 15-19 years old in rural areas and with lower educational attainment and riskier sexual behavior in rural females 15-24 years old. Policy-makers may consider adopting potential mechanisms to mitigate the impact of income shock from natural disasters on populations vulnerable to HIV transmission. |
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