Last data update: Apr 22, 2024. (Total: 46599 publications since 2009)
Records 1-30 (of 72 Records) |
Query Trace: Varma JK [original query] |
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Quantifying the Risk and Cost of Active Monitoring for Infectious Diseases (preprint)
Reich NG , Lessler J , Varma JK , Vora NM . bioRxiv 2017 156497 During outbreaks of deadly emerging pathogens (e.g., Ebola, MERS-CoV) and bioterror threats (e.g., smallpox), actively monitoring potentially infected individuals aims to limit disease transmission and morbidity. Guidance issued by CDC on active monitoring was a cornerstone of its response to the West Africa Ebola outbreak. There are limited data on how to balance the costs and performance of this important public health activity. We present a framework that estimates the risks and costs of specific durations of active monitoring for pathogens of significant public health concern. We analyze data from New York City’s Ebola active monitoring program over a 16-month period in 2014-2016. For monitored individuals, we identified unique durations of active monitoring that minimize expected costs for those at “low (but not zero) risk” and “some or high risk”: 21 and 31 days, respectively. Extending our analysis to smallpox and MERS-CoV, we found that the optimal length of active monitoring relative to the median incubation period was reduced compared to Ebola due to less variable incubation periods. Active monitoring can save lives but is expensive. Resources can be most effectively allocated by using exposure-risk categories to modify the duration or intensity of active monitoring. |
COVID-19 Infections among Students and Staff in New York City Public Schools.
Varma JK , Thamkittikasem J , Whittemore K , Alexander M , Stephens DH , Arslanian K , Bray J , Long TG . Pediatrics 2021 147 (5) BACKGROUND: The 2019 novel coronavirus disease (COVID-19) pandemic led many jurisdictions to close in-person school instruction. METHODS: We collected data about COVID-19 cases associated with New York City (NYC) public schools from polymerase chain reaction testing performed in each school on a sample of asymptomatic students and staff and from routine reporting. We compared prevalence from testing done in schools to community prevalence estimates from statistical models. We compared cumulative incidence for school-associated cases to all cases reported to the city. School-based contacts were monitored to estimate the secondary attack rate and possible direction of transmission. RESULTS: To assess prevalence, we analyzed data from 234 132 persons tested for severe acute respiratory syndrome coronavirus 2 infection in 1594 NYC public schools during October 9 to December 18, 2020; 986 (0.4%) tested positive. COVID-19 prevalence in schools was similar to or less than estimates of prevalence in the community for all weeks. To assess cumulative incidence, we analyzed data for 2231 COVID-19 cases that occurred in students and staff compared with the 86 576 persons in NYC diagnosed with COVID-19 during the same period; the overall incidence was lower for persons in public schools compared with the general community. Of 36 423 school-based close contacts, 191 (0.5%) subsequently tested positive for COVID-19; the likely index case was an adult for 78.0% of secondary cases. CONCLUSIONS: We found that in-person learning in NYC public schools was not associated with increased prevalence or incidence overall of COVID-19 infection compared with the general community. |
Antimicrobial resistance control efforts in Africa: a survey of the role of Civil Society Organisations
Fraser JL , Alimi YH , Varma JK , Muraya T , Kujinga T , Carter VK , Schultsz C , Del Rio Vilas VJ . Glob Health Action 2021 14 (1) 1868055 Background: Antimicrobial resistance (AMR) is a growing public health threat in Africa. AMR prevention and control requires coordination across multiple sectors of government and civil society partners. Objectives: To assess the current role, needs, and capacities of CSOs working in AMR in Africa. Methods: We conducted an online survey of 35 CSOs working in 37 countries across Africa. The survey asked about priorities for AMR, current AMR-specific activities, monitoring practices, training needs, and preferences for sharing information on AMR. Further data were gathered on the main roles of the organisations, the length of time engaged in and budget spent on AMR-related activities, and their involvement in the development and implementation of National Action Plans (NAPs). Results were assessed against The Africa Centres for Disease Control and Prevention (Africa CDC) Framework for Antimicrobial Resistance (2018-2023). Results: CSOs with AMR-related activities are working in all four areas of Africa CDC's Framework: improving surveillance, delaying emergence, limiting transmission, and mitigating harm from infections caused by AMR microorganisms. Engagement with the four objectives is mainly through advocacy, followed by accountability and service delivery. There were limited monitoring activities reported by CSOs, with only seven (20%) providing an example metric used to monitor their activities related to AMR, and 27 (80%) CSOs reporting having no AMR-related strategy. Half the CSOs reported engaging with the development and implementation of NAPs; however, only three CSOs are aligning their work with these national strategies. Conclusion: CSOs across Africa are supporting AMR prevention and control, however, there is potential for more engagement. Africa CDC and other government agencies should support the training of CSOs in strategies to control AMR. Tailored training programmes can build knowledge of AMR, capacity for monitoring processes, and facilitate further identification of CSOs' contribution to the AMR Framework and alignment with NAPs and regional strategies. |
Healthcare-associated outbreaks of bacterial infections in Africa, 2009-2018: A review
Fraser JL , Mwatondo A , Alimi YH , Varma JK , Vilas VJDR . Int J Infect Dis 2020 103 469-477 BACKGROUND: Healthcare-associated infections (HAIs) are a major global public health problem, increasing the transmission of drug-resistant infections. In Africa, the prevalence of HAIs among all hospital inpatients is estimated to be between 3% and 15%, but outbreaks are infrequently reported. Failure to detect and/or report outbreaks can increase the risk of ongoing infections and recurrent outbreaks. METHODS: A search of the PubMed, Web of Science, Cochrane Library, and other outbreak databases was performed to identify published literature on bacterial HAI outbreaks in Africa (January 2009 to December 2018). Details of the outbreak characteristics, hospital environment, and the control measures implemented were extracted. RESULTS: Twenty-two studies published over the 10-year period were identified. These reported 31 distinct outbreaks and a total of 31 causative pathogens, including Klebsiella pneumoniae (six outbreaks, 19%), Staphylococcus aureus (six outbreaks, 19%), and Enterococcus (five outbreaks, 16%). Most outbreaks were reported from university (n = 8, 26%) and tertiary hospitals (n = 11, 55%), from South Africa (n = 9, 41%) and Tunisia (n = 4, 18%). Interventions to control the outbreaks were described in 27 (90%) outbreaks, and all instituted or recommended enhancing hand hygiene and education. CONCLUSIONS: Few facilities in Africa reported HAI outbreaks over the 10-year period, suggesting substantial under-detection and under-reporting. The quality and timeliness of reporting require improvement to ensure changes in public health practice. |
Mycobacterium tuberculosis bloodstream infection prevalence, diagnosis, and mortality risk in seriously ill adults with HIV: a systematic review and meta-analysis of individual patient data
Barr DA , Lewis JM , Feasey N , Schutz C , Kerkhoff AD , Jacob ST , Andrews B , Kelly P , Lakhi S , Muchemwa L , Bacha HA , Hadad DJ , Bedell R , van Lettow M , Zachariah R , Crump JA , Alland D , Corbett EL , Gopinath K , Singh S , Griesel R , Maartens G , Mendelson M , Ward AM , Parry CM , Talbot EA , Munseri P , Dorman SE , Martinson N , Shah M , Cain K , Heilig CM , Varma JK , Gottberg AV , Sacks L , Wilson D , Squire SB , Lalloo DG , Davies G , Meintjes G . Lancet Infect Dis 2020 20 (6) 742-752 BACKGROUND: The clinical and epidemiological significance of HIV-associated Mycobacterium tuberculosis bloodstream infection (BSI) is incompletely understood. We hypothesised that M tuberculosis BSI prevalence has been underestimated, that it independently predicts death, and that sputum Xpert MTB/RIF has suboptimal diagnostic yield for M tuberculosis BSI. METHODS: We did a systematic review and individual patient data (IPD) meta-analysis of studies performing routine mycobacterial blood culture in a prospectively defined patient population of people with HIV aged 13 years or older. Studies were identified through searching PubMed and Scopus up to Nov 10, 2018, without language or date restrictions and through manual review of reference lists. Risk of bias in the included studies was assessed with an adapted QUADAS-2 framework. IPD were requested for all identified studies and subject to harmonised inclusion criteria: age 13 years or older, HIV positivity, available CD4 cell count, a valid mycobacterial blood culture result (excluding patients with missing data from lost or contaminated blood cultures), and meeting WHO definitions for suspected tuberculosis (presence of screening symptom). Predicted probabilities of M tuberculosis BSI from mixed-effects modelling were used to estimate prevalence. Estimates of diagnostic yield of sputum testing with Xpert (or culture if Xpert was unavailable) and of urine lipoarabinomannan (LAM) testing for M tuberculosis BSI were obtained by two-level random-effect meta-analysis. Estimates of mortality associated with M tuberculosis BSI were obtained by mixed-effect Cox proportional-hazard modelling and of effect of treatment delay on mortality by propensity-score analysis. This study is registered with PROSPERO, number 42016050022. FINDINGS: We identified 23 datasets for inclusion (20 published and three unpublished at time of search) and obtained IPD from 20, representing 96.2% of eligible IPD. Risk of bias for the included studies was assessed to be generally low except for on the patient selection domain, which was moderate in most studies. 5751 patients met harmonised IPD-level inclusion criteria. Technical factors such as number of blood cultures done, timing of blood cultures relative to blood sampling, and patient factors such as inpatient setting and CD4 cell count, explained significant heterogeneity between primary studies. The predicted probability of M tuberculosis BSI in hospital inpatients with HIV-associated tuberculosis, WHO danger signs, and a CD4 count of 76 cells per muL (the median for the cohort) was 45% (95% CI 38-52). The diagnostic yield of sputum in patients with M tuberculosis BSI was 77% (95% CI 63-87), increasing to 89% (80-94) when combined with urine LAM testing. Presence of M tuberculosis BSI compared with its absence in patients with HIV-associated tuberculosis increased risk of death before 30 days (adjusted hazard ratio 2.48, 95% CI 2.05-3.08) but not after 30 days (1.25, 0.84-2.49). In a propensity-score matched cohort of participants with HIV-associated tuberculosis (n=630), mortality increased in patients with M tuberculosis BSI who had a delay in anti-tuberculosis treatment of longer than 4 days compared with those who had no delay (odds ratio 3.15, 95% CI 1.16-8.84). INTERPRETATION: In critically ill adults with HIV-tuberculosis, M tuberculosis BSI is a frequent manifestation of tuberculosis and predicts mortality within 30 days. Improved diagnostic yield in patients with M tuberculosis BSI could be achieved through combined use of sputum Xpert and urine LAM. Anti-tuberculosis treatment delay might increase the risk of mortality in these patients. FUNDING: This study was supported by Wellcome fellowships 109105Z/15/A and 105165/Z/14/A. |
Public health management of persons under investigation for Ebola virus disease in New York City, 2014-2016
Winters A , Iqbal M , Benowitz I , Baumgartner J , Vora NM , Evans L , Link N , Munjal I , Ostrowsky B , Ackelsberg J , Balter S , Dentinger C , Fine AD , Harper S , Landman K , Laraque F , Layton M , Slavinski S , Weiss D , Rakeman JL , Hughes S , Varma JK , Lee EH . Public Health Rep 2019 134 (5) 33354919870200 During 2014-2016, the largest outbreak of Ebola virus disease (EVD) in history occurred in West Africa. The New York City Department of Health and Mental Hygiene (DOHMH) worked with health care providers to prepare for persons under investigation (PUIs) for EVD in New York City. From July 1, 2014, through December 29, 2015, we classified as a PUI a person with EVD-compatible signs or symptoms and an epidemiologic risk factor within 21 days before illness onset. Of 112 persons who met PUI criteria, 74 (66%) sought medical care and 49 (44%) were hospitalized. The remaining 38 (34%) were isolated at home with daily contact by DOHMH staff members. Thirty-two (29%) PUIs received a diagnosis of malaria. Of 10 PUIs tested, 1 received a diagnosis of EVD. Home isolation minimized unnecessary hospitalization. This case study highlights the importance of developing competency among clinical and public health staff managing persons suspected to be infected with a high-consequence pathogen. |
Africa Centres for Disease Control and Prevention's framework for antimicrobial resistance control in Africa
Varma JK , Oppong-Otoo J , Ondoa P , Perovic O , Park BJ , Laxminarayan R , Peeling RW , Schultsz C , Li H , Ihekweazu C , Sall AA , Jaw B , Nkengasong JN . Afr J Lab Med 2018 7 (2) 830 Antimicrobial resistant (AMR) organisms are increasing globally, threatening to render existing treatments ineffective against many infectious diseases.1,2 AMR strains of bacteria, fungi, parasites, and viruses prolong illness, increase case fatality, facilitate transmission, and increase treatment costs.3,4 In Africa where many health systems are weak, the likelihood of AMR increasing and the consequences of AMR infections are particularly high, and drug resistance has already been documented for HIV and the pathogens that cause malaria, tuberculosis, typhoid, cholera, meningitis, gonorrhoea, and dysentery.5 Patients in these countries have limited access to accurate diagnosis and adequate antimicrobial treatment, which can lead to sepsis and other life-threatening complications.6,7 |
Geospatial cluster analyses of pneumonia-associated hospitalisations among adults in New York City, 2010-2014
Kache PA , Julien T , Corrado RE , Vora NM , Daskalakis DC , Varma JK , Lucero DE . Epidemiol Infect 2018 147 1-10 Pneumonia is a leading cause of death in New York City (NYC). We identified spatial clusters of pneumonia-associated hospitalisation for persons residing in NYC, aged 18 years during 2010-2014. We detected pneumonia-associated hospitalisations using an all-payer inpatient dataset. Using geostatistical semivariogram modelling, local Moran's I cluster analyses and chi2 tests, we characterised differences between 'hot spots' and 'cold spots' for pneumonia-associated hospitalisations. During 2010-2014, there were 141 730 pneumonia-associated hospitalisations across 188 NYC neighbourhoods, of which 43.5% (N = 61 712) were sub-classified as severe. Hot spots of pneumonia-associated hospitalisation spanned 26 neighbourhoods in the Bronx, Manhattan and Staten Island, whereas cold spots were found in lower Manhattan and northeastern Queens. We identified hot spots of severe pneumonia-associated hospitalisation in the northern Bronx and the northern tip of Staten Island. For severe pneumonia-associated hospitalisations, hot-spot patients were of lower mean age and a greater proportion identified as non-Hispanic Black compared with cold spot patients; additionally, hot-spot patients had a longer hospital stay and a greater proportion experienced in-hospital death compared with cold-spot patients. Pneumonia prevention efforts within NYC should consider examining the reasons for higher rates in hot-spot neighbourhoods, and focus interventions towards the Bronx, northern Manhattan and Staten Island. |
Active Monitoring of Travelers for Ebola Virus Disease-New York City, October 25, 2014-December 29, 2015
Saffa A , Tate A , Ezeoke I , Jacobs-Wingo J , Iqbal M , Baumgartner J , Fine A , Perri BR , McIntosh N , Levy Stennis N , Lee K , Peterson E , Jones L , Helburn L , Heindrichs C , Guthartz S , Chamany S , Starr D , Scaccia A , Raphael M , Varma JK , Vora NM . Health Secur 2018 16 (1) 8-13 The CDC recommended active monitoring of travelers potentially exposed to Ebola virus during the 2014 West African Ebola virus disease outbreak, which involved daily contact between travelers and health authorities to ascertain the presence of fever or symptoms for 21 days after the travelers' last potential Ebola virus exposure. From October 25, 2014, to December 29, 2015, the New York City Department of Health and Mental Hygiene (DOHMH) monitored 5,359 persons for Ebola virus disease, corresponding to 5,793 active monitoring events. Most active monitoring events were in travelers classified as low (but not zero) risk (n = 5,778; 99%). There were no gaps in contact with DOHMH of ≥2 days during 95% of active monitoring events. Instances of not making any contact with travelers decreased after CDC began distributing mobile telephones at the airport. Ebola virus disease-like symptoms or a temperature ≥100.0°F were reported in 122 (2%) active monitoring events. In the final month of active monitoring, an optional health insurance enrollment referral was offered for interested travelers, through which 8 travelers are known to have received coverage. Because it is possible that active monitoring will be used again for an infectious threat, the experience we describe might help to inform future such efforts. |
Pneumonia-associated hospitalizations, New York City, 2001-2014
Gu CH , Lucero DE , Huang CC , Daskalakis D , Varma JK , Vora NM . Public Health Rep 2018 133 (5) 584-592 OBJECTIVES: Death certificate data indicate that the age-adjusted death rate for pneumonia and influenza is higher in New York City than in the United States. Most pneumonia and influenza deaths are attributed to pneumonia rather than influenza. Because most pneumonia deaths occur in hospitals, we analyzed hospital discharge data to provide insight into the burden of pneumonia in New York City. METHODS: We analyzed data for New York City residents discharged from New York State hospitals with a principal diagnosis of pneumonia, or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis, during 2001-2014. We calculated mean annual age-adjusted pneumonia-associated hospitalization rates per 100 000 population and 95% confidence intervals (CIs). We examined data on pneumonia-associated hospitalizations by sociodemographic characteristics and colisted conditions. RESULTS: During 2001-2014, a total of 495 225 patients residing in New York City were hospitalized for pneumonia, corresponding to a mean annual age-adjusted pneumonia-associated hospitalization rate of 433.8 per 100 000 population (95% CI, 429.3-438.3). The proportion of pneumonia-associated hospitalizations with in-hospital death was 12.0%. The mean annual age-adjusted pneumonia-associated hospitalization rate per 100 000 population increased as area-based poverty level increased, whereas the percentage of pneumonia-associated hospitalizations with in-hospital deaths decreased with increasing area-based poverty level. The proportion of pneumonia-associated hospitalizations that colisted an immunocompromising condition increased from 18.7% in 2001 to 33.1% in 2014. CONCLUSION: Sociodemographic factors and immune status appear to play a role in the epidemiology of pneumonia-associated hospitalizations in New York City. Further study of pneumonia-associated hospitalizations in at-risk populations may lead to targeted interventions. |
Invasive Streptococcus pneumoniae infection among hospitalized patients in Jingzhou city, China, 2010-2012
Jiang H , Huai Y , Chen H , Uyeki TM , Chen M , Guan X , Liu S , Peng Y , Yang H , Luo J , Zheng J , Huang J , Peng Z , Xiang N , Zhang Y , Klena JD , Hu DJ , Rainey JJ , Huo X , Xiao L , Xing X , Zhan F , Yu H , Varma JK . PLoS One 2018 13 (8) e0201312 BACKGROUND: Streptococcus pneumoniae (Sp) is a leading cause of bacterial pneumonia, meningitis, and sepsis and a major source of morbidity and mortality worldwide. Invasive pneumococcal disease (IPD) is defined as isolation of Sp from a normally sterile site, including blood or cerebrospinal fluid. The aim of this study is to describe outcomes as well as clinical and epidemiological characteristics of hospitalized IPD case patients in central China. METHODS: We conducted surveillance for IPD among children and adults from April 5, 2010 to September 30, 2012, in four major hospitals in Jingzhou City, Hubei Province. We collected demographic, clinical, and outcome data for all enrolled hospitalized patients with severe acute respiratory infection (SARI) or meningitis, and collected blood, urine, and cerebrospinal fluid (CSF) for laboratory testing for Sp infections. Collected data were entered into Epidata software and imported into SPSS for analysis. RESULTS: We enrolled 22,375 patients, including 22,202 (99%) with SARI and 173 (1%) with meningitis. One hundred and eighteen (118, 3%) with either SARI or meningitis were Sp positive, 32 (0.8%) from blood/CSF culture, and 87 (5%) from urine antigen testing. Of those 118 patients, 57% were aged >/=65 years and nearly 100% received antibiotics during hospitalization. None were previously vaccinated with 7-valent pneumococcal conjugate vaccine (PCV 7), 23-valent pneumococcal polysaccharide vaccine, or seasonal influenza vaccine. The main serotypes identified were 14, 12, 3, 1, 19F, 4, 5, 9V, 15 and 18C, corresponding to serotype coverage rates of 42%, 63%, and 77% for PCV7, PCV10, and PCV13, respectively. CONCLUSIONS: Further work is needed to expand access to pneumococcal vaccination in China, both among children and potentially among the elderly, and inappropriate use of antibiotics is a widespread and serious problem in China. |
Sensitivity and positive predictive value of death certificate data among deaths caused by Legionnaires' Disease in New York City, 2008-2013
Tran OC , Lucero DE , Balter S , Fitzhenry R , Huynh M , Varma JK , Vora NM . Public Health Rep 2018 133 (5) 33354918782494 OBJECTIVES: Death certificates are an important source of information for understanding life expectancy and mortality trends; however, misclassification and incompleteness are common. Although deaths caused by Legionnaires' disease might be identified through routine surveillance, it is unclear whether Legionnaires' disease is accurately recorded on death certificates. We evaluated the sensitivity and positive predictive value of death certificates for identifying deaths from confirmed or suspected Legionnaires' disease among adults in New York City. METHODS: We deterministically matched death certificate data from January 1, 2008, through December 31, 2013, on New York City residents aged >/=18 years to surveillance data on confirmed and suspected cases of Legionnaires' disease from January 1, 2008, through October 31, 2013. We estimated sensitivity and positive predictive value by using surveillance data as the reference standard. RESULTS: Of 294 755 deaths, 27 (<0.01%) had an underlying cause of death of Legionnaires' disease and 33 (0.01%) had any mention of Legionnaires' disease on the death certificate. Of 1211 confirmed or suspected cases of Legionnaires' disease, 267 (22.0%) matched to a record in the death certificate data set. The sensitivity of death certificates that listed Legionnaires' disease as the underlying cause of death was 17.3% and of death certificates with any mention of Legionnaires' disease was 20.9%. The positive predictive value of death certificates that listed Legionnaires' disease as the underlying cause of death was 70.4% and of death certificates with any mention of Legionnaires' disease was 69.7%. CONCLUSIONS: Death certificates had limited ability to identify confirmed or suspected deaths with Legionnaires' disease. Provider trainings on the diagnosis of Legionnaires' disease, particularly hospital settings, and proper completion of death certificates might improve the sensitivity of death certificates for people who die of Legionnaires' disease. |
Deaths from pneumonia - New York City, 1999-2015
Cordoba E , Maduro G , Huynh M , Varma JK , Vora NM . Open Forum Infect Dis 2018 5 (2) ofy020 Background. "Pneumonia and influenza" are the third leading cause of death in New York City. Since 2012, pneumonia and influenza have been the only infectious diseases listed among the 10 leading causes of death in NYC. Most pneumonia and influenza deaths in NYC list pneumonia as the underlying cause of death, not influenza. We therefore analyzed death certificate data for pneumonia in NYC during 1999-2015. Methods. We calculated annualized pneumonia death rates (overall and by sociodemographic subgroup) and examined the etiologic agent listed. Results. There were 41 400 pneumonia deaths during the study period, corresponding to an annualized age-adjusted death rate of 29.7 per 100 000 population. Approximately 17.5% of pneumonia deaths specified an etiologic agent. Age-adjusted pneumonia death rate declined over the study period and across each borough. Males had an annualized age-adjusted pneumonia death rate 1.5 (95% confidence interval [CI], 1.5-1.5) times that of females. Non-Hispanic blacks had an annualized age-adjusted pneumonia death rate 1.2 (95% CI, 1.2-1.2) times that of non-Hispanic whites. The annualized pneumonia death rate increased with age group above 5-24 years and neighborhood-level poverty. Staten Island had an annualized age-adjusted pneumonia death rate 1.3 (95% CI, 1.2-1.3) times that of Manhattan. In the multivariable analysis, pneumonia deaths were more likely to occur among males, non-Hispanic blacks, persons aged ≥65 years, residents of neighborhoods with higher poverty levels, and in Staten Island. Conclusions. While the accuracy of death certificates is unknown, investigation is needed to understand why certain populations are disproportionately recorded as dying from pneumonia in NYC. |
Evaluating a framework for tuberculosis screening among healthcare workers in clinical settings, Inner Mongolia, China
Cheng S , Tollefson D , He G , Li Y , Guo H , Chai S , Gao F , Gao F , Han G , Ren L , Ren Y , Li J , Wang L , Varma JK , Hu D , Fan H , Zhao F , Bloss E , Wang Y , Rao CY . J Occup Med Toxicol 2018 13 11 Background: Health care workers are at high risk for tuberculosis (TB). China, a high burden TB country, has no policy on medical surveillance for TB among healthcare workers. In this paper, we evaluate whether China's national TB diagnostic guidelines could be used as a framework to screen healthcare workers for pulmonary TB disease in a clinical setting in China. Methods: Between April-August 2010, healthcare workers from 28 facilities in Inner Mongolia Autonomous Region, China were eligible for TB screening, comprised of symptom check, chest X-ray and tuberculin skin testing. Healthcare workers were categorized as having presumptive, confirmed, or clinically-diagnosed pulmonary TB, using Chinese national guidelines. Results: All healthcare workers (N=4347) were eligible for TB screening, of which 4285 (99%) participated in at least one TB screening test. Of the healthcare workers screened, 2% had cough for >/= 14 days, 3% had a chest X-ray consistent with TB, and 10% had a tuberculin skin test induration >/= 20 mm. Of these, 124 healthcare workers were identified with presumptive TB (i.e., cough for >/= 14 days in the past 4 weeks or x-ray consistent with TB). Twelve healthcare workers met the case definition for clinically-diagnosed pulmonary TB, but none were diagnosed with TB during the study period. Conclusion: A substantial proportion of healthcare workers in Inner Mongolia had signs, symptoms, or test results suggestive of TB disease that could have been identified using national TB diagnostic guidelines as a screening framework. However, achieving medical surveillance in China will require a framework that increases the ease, accuracy, and acceptance of TB screening in the medical community. Routine screening with improved diagnostics should be considered to detect tuberculosis disease among healthcare workers and reduce transmission in health care settings in China. |
Zika virus preparedness and response efforts through the collaboration between a health care delivery system and a local public health department
Madad S , Tate A , Rand M , Quinn C , Vora NM , Allen M , Cagliuso NV , Rakeman JL , Studer S , Masci J , Varma JK , Wilson R . Disaster Med Public Health Prep 2018 12 (6) 1-3 The Zika virus was largely unknown to many health care systems before the outbreak of 2015. The unique public health threat posed by the Zika virus and the evolving understanding of its pathology required continuous communication between a health care delivery system and a local public health department. By leveraging an existing relationship, NYC Health+Hospitals worked closely with New York City Department of Health and Mental Hygiene to ensure that Zika-related processes and procedures within NYC Health+Hospitals facilities aligned with the most current Zika virus guidance. Support given by the public health department included prenatal clinical and laboratory support and the sharing of data on NYC Health+Hospitals Zika virus screening and testing rates, thus enabling this health care delivery system to make informed decisions and practices. The close coordination, collaboration, and communication between the health care delivery system and the local public health department examined in this article demonstrate the importance of working together to combat a complex public health emergency and how this relationship can serve as a guide for other jurisdictions to optimize collaboration between external partners during major outbreaks, emerging threats, and disasters that affect public health. (Disaster Med Public Health Preparedness. 2018;page 1 of 3). |
Quantifying the risk and cost of active monitoring for infectious diseases
Reich NG , Lessler J , Varma JK , Vora NM . Sci Rep 2018 8 (1) 1093 During outbreaks of deadly emerging pathogens (e.g., Ebola, MERS-CoV) and bioterror threats (e.g., smallpox), actively monitoring potentially infected individuals aims to limit disease transmission and morbidity. Guidance issued by CDC on active monitoring was a cornerstone of its response to the West Africa Ebola outbreak. There are limited data on how to balance the costs and performance of this important public health activity. We present a framework that estimates the risks and costs of specific durations of active monitoring for pathogens of significant public health concern. We analyze data from New York City's Ebola active monitoring program over a 16-month period in 2014-2016. For monitored individuals, we identified unique durations of active monitoring that minimize expected costs for those at "low (but not zero) risk" and "some or high risk": 21 and 31 days, respectively. Extending our analysis to smallpox and MERS-CoV, we found that the optimal length of active monitoring relative to the median incubation period was reduced compared to Ebola due to less variable incubation periods. Active monitoring can save lives but is expensive. Resources can be most effectively allocated by using exposure-risk categories to modify the duration or intensity of active monitoring. |
Reporting of false data during Ebola virus disease active monitoring - New York City, January 1, 2015-December 29, 2015
Tate A , Ezeoke I , Lucero DE , Huang CC , Saffa A , Varma JK , Vora NM . Health Secur 2017 15 (5) 509-518 The New York City Department of Health and Mental Hygiene (DOHMH) began to actively monitor people potentially exposed to Ebola virus on October 25, 2014. Active monitoring was critical to the Ebola virus disease (EVD) response and mitigated risk without restricting individual liberties. Noncompliance with active monitoring procedures has been reported. We conducted a survey of 4,075 eligible persons to evaluate (1) the frequency of reporting of false data during active monitoring, and (2) factors associated with reporting of false temperature data. A total of 393 persons (9.6%) responded to the survey. Fifty-five (14.0%) provided false temperature data, 5 (1.3%) did not report EVD-like symptoms that they had experienced, and 2 (0.5%) did not report a hospital or emergency room visit. Having visited Liberia (OR: 3.4, 95% CI: 1.4-7.9), Sierra Leone (OR: 3.4, 95% CI: 1.6-7.5), or multiple EVD-affected countries (OR: 12.9, 95% CI: 3.5-47.7); being aged <50 years (OR: 7.5, 95% CI: 1.7-33.1); and rating the importance of active monitoring as low (OR: 1.4, 95% CI: 1.1-1.8) were associated with increased odds of reporting false temperature data. Over 10% of respondents reported providing false data during EVD active monitoring. However, it remains unclear whether reporting of false data during active monitoring impedes the ability to rapidly identify EVD cases in settings with a low burden of EVD. |
Legionnaires' Disease Outbreak Caused by Endemic Strain of Legionella pneumophila, New York, New York, USA, 2015.
Lapierre P , Nazarian E , Zhu Y , Wroblewski D , Saylors A , Passaretti T , Hughes S , Tran A , Lin Y , Kornblum J , Morrison SS , Mercante JW , Fitzhenry R , Weiss D , Raphael BH , Varma JK , Zucker HA , Rakeman JL , Musser KA . Emerg Infect Dis 2017 23 (11) 1784-1791 During the summer of 2015, New York, New York, USA, had one of the largest and deadliest outbreaks of Legionnaires' disease in the history of the United States. A total of 138 cases and 16 deaths were linked to a single cooling tower in the South Bronx. Analysis of environmental samples and clinical isolates showed that sporadic cases of legionellosis before, during, and after the outbreak could be traced to a slowly evolving, single-ancestor strain. Detection of an ostensibly virulent Legionella strain endemic to the Bronx community suggests potential risk for future cases of legionellosis in the area. The genetic homogeneity of the Legionella population in this area might complicate investigations and interpretations of future outbreaks of Legionnaires' disease. |
Legionnaires' disease outbreaks and cooling towers, New York City, New York, USA
Fitzhenry R , Weiss D , Cimini D , Balter S , Boyd C , Alleyne L , Stewart R , McIntosh N , Econome A , Lin Y , Rubinstein I , Passaretti T , Kidney A , Lapierre P , Kass D , Varma JK . Emerg Infect Dis 2017 23 (11) 1769-76 The incidence of Legionnaires' disease in the United States has been increasing since 2000. Outbreaks and clusters are associated with decorative, recreational, domestic, and industrial water systems, with the largest outbreaks being caused by cooling towers. Since 2006, 6 community-associated Legionnaires' disease outbreaks have occurred in New York City, resulting in 213 cases and 18 deaths. Three outbreaks occurred in 2015, including the largest on record (138 cases). Three outbreaks were linked to cooling towers by molecular comparison of human and environmental Legionella isolates, and the sources for the other 3 outbreaks were undetermined. The evolution of investigation methods and lessons learned from these outbreaks prompted enactment of a new comprehensive law governing the operation and maintenance of New York City cooling towers. Ongoing surveillance and program evaluation will determine if enforcement of the new cooling tower law reduces Legionnaires' disease incidence in New York City. |
Outbreak of influenza A(H7N2) among cats in an animal shelter with cat-to-human transmission - New York City, 2016
Lee CT , Slavinski S , Schiff C , Merlino M , Daskalakis D , Liu D , Rakeman JL , Misener M , Thompson C , Leung YL , Varma JK , Fry A , Havers F , Davis T , Newbury S , Layton M . Clin Infect Dis 2017 65 (11) 1927-1929 We describe the first case of cat-to-human transmission of influenza A(H7N2), an avian-lineage influenza A virus, that occurred during an outbreak among cats in New York City animal shelters. We describe the public health response and investigation. |
Burden of pneumonia-associated hospitalizations: United States, 2001-2014
Hayes BH , Haberling DL , Kennedy J , Varma JK , Fry AM , Vora NM . Chest 2017 153 (2) 427-437 BACKGROUND: The epidemiology of pneumonia has likely evolved in recent years, reflecting an aging population, changes in population immunity, and socioeconomic disparities. METHODS: Using the National (Nationwide) Inpatient Sample (NIS), estimated numbers and rates of pneumonia-associated hospitalizations for 2001-2014 were calculated. A pneumonia-associated hospitalization was defined as one in which the discharge record listed a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis. RESULTS: There were an estimated 20,361,181 (SE: 95,601) pneumonia-associated hospitalizations in the United States during 2001-2014 (average annual age-adjusted pneumonia-associated hospitalization rate of 464.8 per 100,000 population [95% CI: 462.5-467.1]). The average annual age-adjusted pneumonia-associated hospitalization rate decreased over the study period. In-hospital death occurred in 7.4% (SE: 0.03) of pneumonia-associated hospitalizations. Non-Hispanic American Indian/Alaskan Natives and non-Hispanic blacks had the highest average annual age-adjusted rates of pneumonia-associated hospitalization of all race/ethnicities at 439.2 (95% CI: 415.9-462.5) and 438.6 (95% CI: 432.5-444.7) per 100,000 population, respectively. During 2001-2014, the proportion of pneumonia-associated hospitalizations co-listing an immunocompromising condition increased from 18.7% (SE: 0.2) in 2001 to 29.5% (SE: 0.2) in 2014. Total charges for pneumonia-associated hospitalizations in 2014 were over $84 billion. CONCLUSIONS: Pneumonia is a major cause of morbidity and mortality in the United States. Differences in rates and outcomes of pneumonia-associated hospitalizations between sociodemographic groups warrant further investigation. The immunocompromised population has emerged as a group experiencing a disproportionate burden of pneumonia-associated hospitalizations. |
Burden of adult community-acquired, healthcare-associated, hospital-acquired, and ventilator-associated pneumonia - New York City, 2010-2014
Corrado RE , Lee D , Lucero DE , Varma JK , Vora NM . Chest 2017 152 (5) 930-942 BACKGROUND: Although pneumonia is a leading cause of death in New York City (NYC), limited data exist about the settings in which pneumonia is acquired across NYC. Pneumonia acquired in community settings are more likely to be preventable with vaccines and treatable with first-line antibiotics than those acquired in non-community settings. Our objective was to estimate the burden of hospitalizations associated with community-acquired (CAP)-, healthcare-associated (HCAP)-, hospital-acquired (HAP)-, and ventilator-associated (VAP) pneumonia during 2010-2014. METHODS: We performed a retrospective analysis of an all-payer reporting system of hospital discharges that included NYC residents aged ≥18 years. Pneumonia-associated hospitalizations were defined as any hospitalization that included a diagnostic code for pneumonia among any of the discharge diagnoses. Using published clinical guidelines, we classified hospitalizations into mutually exclusive categories of CAP, HCAP, HAP, and VAP and defined pneumonia acquired in the community setting as the combination of CAP and HCAP. RESULTS: Of 4,614,108 hospitalizations during the reporting period, 283,927 (6.2%) involved pneumonia. Among pneumonia-associated hospitalizations, 154,158 (54.3%) were CAP, 85,656 (30.2%) HCAP, 39,712 (14.0%) HAP, and 4,401 (1.6%) VAP. Death during hospitalization occurred in 7.9% of CAP-associated hospitalizations, compared with 15.7% of HCAP-associated hospitalizations, 20.7% of HAP-associated hospitalizations, and 21.6% of VAP-associated hospitalizations. CONCLUSIONS: Most pneumonia-associated hospitalizations in NYC involve pneumonias acquired in the community setting. Only 15.6% of pneumonia-associated hospitalizations were categorized as HAP or VAP, yet these pneumonias accounted for >25% of deaths from pneumonia-associated hospitalizations. Public health pneumonia prevention efforts need to target both community and hospital settings. |
Hepatitis A cases among food handlers: A local health department response - New York City, 2013
Ridpath A , Reddy V , Layton M , Misener M , Scaccia A , Starr D , Stavinsky F , Varma JK , Waechter H , Zucker JR , Balter S . J Public Health Manag Pract 2017 23 (6) 571-576 During 2013, the New York City Department of Health and Mental Hygiene (DOHMH) received reports of 6 hepatitis A cases among food handlers. We describe our decision-making process for public notification, type of postexposure prophylaxis (PEP) offered, and lessons learned. For 3 cases, public notification was issued and DOHMH offered only hepatitis A vaccine as PEP. Subsequent outbreaks resulted from 1 case for which no public notification was issued or PEP offered, and 1 for which public notification was issued and PEP was offered too late. DOHMH continues to use environmental assessments to guide public notification decisions and offer only hepatitis A vaccine as PEP after public notification but recognizes the need to evaluate each situation individually. The PEP strategy employed by DOHMH should be considered because hepatitis A vaccine is immunogenic in all age groups, can be obtained by local jurisdictions more quickly, and is logistically easier to administer in mass clinics than immunoglobulin. |
A Large Community Outbreak of Legionnaires' Disease Associated With a Cooling Tower in New York City, 2015.
Weiss D , Boyd C , Rakeman JL , Greene SK , Fitzhenry R , McProud T , Musser K , Huang L , Kornblum J , Nazarian EJ , Fine AD , Braunstein SL , Kass D , Landman K , Lapierre P , Hughes S , Tran A , Taylor J , Baker D , Jones L , Kornstein L , Liu B , Perez R , Lucero DE , Peterson E , Benowitz I , Lee KF , Ngai S , Stripling M , Varma JK . Public Health Rep 2017 132 (2) 33354916689620 OBJECTIVES: Infections caused by Legionella are the leading cause of waterborne disease outbreaks in the United States. We investigated a large outbreak of Legionnaires' disease in New York City in summer 2015 to characterize patients, risk factors for mortality, and environmental exposures. METHODS: We defined cases as patients with pneumonia and laboratory evidence of Legionella infection from July 2 through August 3, 2015, and with a history of residing in or visiting 1 of several South Bronx neighborhoods of New York City. We describe the epidemiologic, environmental, and laboratory investigation that identified the source of the outbreak. RESULTS: We identified 138 patients with outbreak-related Legionnaires' disease, 16 of whom died. The median age of patients was 55. A total of 107 patients had a chronic health condition, including 43 with diabetes, 40 with alcoholism, and 24 with HIV infection. We tested 55 cooling towers for Legionella, and 2 had a strain indistinguishable by pulsed-field gel electrophoresis from 26 patient isolates. Whole-genome sequencing and epidemiologic evidence implicated 1 cooling tower as the source of the outbreak. CONCLUSIONS: A large outbreak of Legionnaires' disease caused by a cooling tower occurred in a medically vulnerable community. The outbreak prompted enactment of a new city law on the operation and maintenance of cooling towers. Ongoing surveillance and evaluation of cooling tower process controls will determine if the new law reduces the incidence of Legionnaires' disease in New York City. |
Using a call center to coordinate Zika virus testing-New York City, 2016
Jacobs-Wingo J , Ezeoke I , Saffa A , Tate A , Lee D , Johnson K , Whittemore K , Illescas A , Collins A , Rand M , Rakeman JL , Varma JK , Vora NM . J Emerg Manag 2016 14 (6) 391-395 BACKGROUND: After local testing criteria for Zika virus expanded to include asymptomatic pregnant women who traveled to areas with active Zika virus transmission while pregnant, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) experienced a surge in test requests and subsequent testing delays due to factors such as incorrectly completed laboratory requisition forms. The authors describe how DOHMH addressed these issues by establishing the Zika Testing Call Center (ZTCC). METHODS: Using a case study approach, the authors illustrate how DOHMH leveraged protocols, equipment, and other resources used previously during DOHMH&s Ebola emergency response to meet NYC's urgent Zika virus testing needs. To request Zika virus testing, providers call the ZTCC; if patients meet testing criteria, the ZTCC collects data necessary to complete requisition forms and sends the forms back to providers. The ZTCC also provides guidance on specimens needed for Zika virus testing. Providers submit completed requisition forms and appropriate specimens to DOHMH for testing. RESULTS: During March 21 through July 21, 2016, testing for 3,866 patients was coordinated through the ZTCC. CONCLUSION: The ZTCC exemplifies how a health department, using previous emergency response experiences, can quickly address local testing needs for an emerging infectious disease. |
Zika virus knowledge among pregnant women who were in areas with active transmission
Whittemore K , Tate A , Illescas A , Saffa A , Collins A , Varma JK , Vora NM . Emerg Infect Dis 2017 23 (1) 164-166 We surveyed women in New York, New York, USA, who were in areas with active Zika virus transmission while pregnant. Of 99 women who were US residents, 30 were unaware of the government travel advisory to areas with active Zika virus transmission while pregnant, and 37 were unaware of their pregnancies during travel. |
Preparing the health system to respond to Ebola Virus Disease in New York City, 2014
Varma JK , Prezant DJ , Wilson R , Quinn C , Asaeda G , Cagliuso NV , Rakeman JL , Raphael M . Disaster Med Public Health Prep 2016 11 (3) 1-5 The world's largest outbreak of Ebola virus disease began in West Africa in 2014. Although few cases were identified in the United States, the possibility of imported cases led US public health systems and health care facilities to focus on preparing the health care system to quickly and safely identify and respond to emerging infectious diseases. In New York City, early, coordinated planning among city and state agencies and the health care delivery system led to a successful response to a single case diagnosed in a returned health care worker. In this article we describe public health and health care system preparedness efforts in New York City to respond to Ebola and conclude that coordinated public health emergency response relies on joint planning and sustained resources for public health emergency response, epidemiology and laboratory capacity, and health care emergency management. |
Incidence and predictors of HIV infection among men who have sex with men attending public sexually transmitted disease clinics, New York City, 2007-2012
Pathela P , Jamison K , Braunstein SL , Schillinger JA , Varma JK , Blank S . AIDS Behav 2016 21 (5) 1444-1451 We examined five annual cohorts (2007-2011) of men who have sex with men (MSM) attending New York City STD clinics who had negative HIV-1 nucleic acid amplification tests (NAATs) on the day of clinic visit. Annual HIV incidence was calculated using HIV diagnoses within 1 year of negative NAAT, determined by matching with the citywide HIV registry. Predictors (demographic; behavioral; bacterial STD from citywide STD registry match) of all new HIV diagnoses through 2012 were calculated from Cox proportional hazards models. Among 10,487 HIV NAAT-negative MSM, 371 had an HIV diagnosis within 1 year. Annual incidence was 2.4/100 person-years, and highest among non-Hispanic black MSM (4.1/100 person-years) and MSM aged <20 years (5.7/100 person-years). Characteristics associated with all 648 new HIV diagnoses included: black race (aHR 2.2; 95 % CI 1.6-3.1), condomless receptive anal sex (aHR 2.1; 95 % CI 1.5-2.8), condomless insertive anal sex (aHR 1.3; 95 % CI 1.1-1.8), and incident STD diagnosis (aHR 1.6; 95 % CI 1.3-1.9). MSM attending STD clinics have substantial HIV incidence and report risk behaviors that are highly associated with HIV acquisition. Increased uptake of effective interventions, e.g., pre- and post-exposure prophylaxis, is needed. |
Clinical characteristics and factors associated with severe acute respiratory infection and influenza among children in Jingzhou, China
Huai Y , Guan X , Liu S , Uyeki TM , Jiang H , Klena J , Huang J , Chen M , Peng Y , Yang H , Luo J , Zheng J , Peng Z , Huo X , Xiao L , Chen H , Zhang Y , Xing X , Feng L , Hu DJ , Yu H , Zhan F , Varma JK . Influenza Other Respir Viruses 2016 11 (2) 148-156 BACKGROUND: Influenza is an important cause of respiratory illness in children, but data are limited on hospitalized children with laboratory-confirmed influenza in China. METHODS: We conducted active surveillance for severe acute respiratory infection (SARI) (fever and at least one sign or symptom of acute respiratory illness) among hospitalized pediatric patients in Jingzhou, Hubei province from April 2010 to April 2012. Data were collected from enrolled SARI patients on demographics, underlying health conditions, clinical course of illness, and outcomes. Nasal swabs were collected and tested for influenza viruses by RT-PCR. We described the clinical and epidemiological characteristics of children with influenza, and analyzed the association between potential risk factors and SARI patients with influenza. RESULTS: During the study period, 15,354 children aged <15 years with signs and symptoms of SARI were enrolled at hospital admission.. SARI patients aged 5-15 years with confirmed influenza (H3N2) infection were more likely than children without influenza to have radiographic diagnosis of pneumonia (11/31, 36% vs 15/105, 14%. p-value<0.05). Only 16% (1,116/7,145) of enrolled patients had received seasonal trivalent influenza vaccination within 12 months of hospital admission.Non-vaccinated influenza cases were more likely than vaccinated influenza cases to have pneumonia (31/133, 23% vs 37/256, 15%, p-value<0.05). SARI cases aged 5-15 years diagnosed with influenza were also more likely to have a household member who smoked cigarettes compared to SARI cases without a smoking household member (54/208, 26% vs 158/960, 16%, p-value<0.05) CONCLUSIONS: Influenza A (H3N2) virus infection was an important contributor to pneumonia requiring hospitalization. Our results highlight the importance of surveillance in identifying factors for influenza hospitalization, monitoring adherence to influenza prevention and treatment strategies, and evaluating the disease burden among hospitalized pediatric SARI patients. Influenza vaccination promotion should target children. |
Zika virus surveillance and preparedness - New York City, 2015-2016
Lee CT , Vora NM , Bajwa W , Boyd L , Harper S , Kass D , Langston A , McGibbon E , Merlino M , Rakeman JL , Raphael M , Slavinski S , Tran A , Wong R , Varma JK . MMWR Morb Mortal Wkly Rep 2016 65 (24) 629-35 Zika virus has rapidly spread through the World Health Organization's Region of the Americas since being identified in Brazil in early 2015. Transmitted primarily through the bite of infected Aedes species mosquitoes, Zika virus infection during pregnancy can cause spontaneous abortion and birth defects, including microcephaly (1,2). New York City (NYC) is home to a large number of persons who travel frequently to areas with active Zika virus transmission, including immigrants from these areas. In November 2015, the NYC Department of Health and Mental Hygiene (DOHMH) began developing and implementing plans for managing Zika virus and on February 1, 2016, activated its Incident Command System. During January 1-June 17, 2016, DOHMH coordinated diagnostic laboratory testing for 3,605 persons with travel-associated exposure, 182 (5.0%) of whom had confirmed Zika virus infection. Twenty (11.0%) confirmed patients were pregnant at the time of diagnosis. In addition, two cases of Zika virus-associated Guillain-Barre syndrome were diagnosed. DOHMH's response has focused on 1) identifying and diagnosing suspected cases; 2) educating the public and medical providers about Zika virus risks, transmission, and prevention strategies, particularly in areas with large populations of immigrants from areas with ongoing Zika virus transmission; 3) monitoring pregnant women with Zika virus infection and their fetuses and infants; 4) detecting local mosquito-borne transmission through both human and mosquito surveillance; and 5) modifying existing Culex mosquito control measures by targeting Aedes species of mosquitoes through the use of larvicides and adulticides. |
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