Evidence of impact: health, psychological and social effects of adult HIV on children.

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

AIDS-defining opportunistic illnesses in the HAART era in New York City.

Despite widespread availability of HAART, opportunistic illnesses (OIs) still occur and result in an increased risk of mortality among persons with AIDS. We estimated the incidence of OIs among all new adult AIDS cases in New York City in 2000 overall and in demographic and clinical subgroups and identified factors associated with occurrence of an AIDS-defining OI versus AIDS diagnosis based on low CD4+ values only. In 2000, 5,451 new AIDS cases were reported to the New York City Department of Health and Mental Hygiene. Of these 27.4% (95% CI: 22.8-32.6) had at least one OI, most frequent being Pneumocystis jiroveci pneumonia (12.2%) and M. tuberculosis (5.3%); 47.1% (41.7-52.5) had a late HIV diagnosis (i.e.< or =6 months before AIDS diagnosis). Persons with a late HIV diagnosis not in recent care had a 3.5-fold increased odds (1.29-9.63) of an OI, compared to non-late testers in care. Other predictors of an OI were injection drug use and older age. We conclude that OIs remain prevalent in the HAART era and late testers not in care are especially likely to develop an OI. Our results support comprehensive HIV programs promoting early HIV testing and linkage to care to prevent OI-related morbidity and mortality.

Observational study of the use of infection control interventions for Mycobacterium tuberculosis in pediatric facilities.

INTRODUCTION: Hospital transmission of Mycobacterium tuberculosis (TB) is a problem in US facilities where adults are treated. However, specific guidelines for facilities in which pediatric patients are cared for have never been defined, nor has any study attempted to assess pediatric health care worker (HCW) compliance with TB infection control (IC) guidelines. METHODS: An observational study was performed in two pediatric inpatient hospitals from May, 1996, to December, 1997. A trained observer tallied persons (i.e. professional HCWs, ancillary HCWs and non-HCWs) entering and leaving occupied TB isolation rooms and recorded adherence with IC practices (e.g. proper use of respirators, prompt door closures, door signage). RESULTS: Thirty children with confirmed or suspected TB were admitted during the study period and observed for a total of 242 h during which 656 visits by professional (n = 391) and ancillary (n = 131) HCWs and by family members (n = 134) were recorded. During 30% of visits doors remained open an average of 10 min, and during 20% of visits no respiratory protection was worn. In all, visitors wore the correct respiratory protection appropriately only 55% of the time. HCWs were more likely to wear respiratory protection when caring for children with a positive acid-fast bacillus smear than family members, but professional staff were no more likely than ancillary staff to do so. CONCLUSIONS: This is the first study to quantify compliance with IC practices for TB in pediatric hospitals. The majority of visitors entering TB isolation rooms occupied by children with confirmed or suspected TB complied with IC guidelines, but discrepancies were seen. Rather than relying on TB IC guidelines designed for adult facilities, guidelines specific for pediatric facilities that consider the local epidemiology of TB should be developed.

Physician response to surveys. A review of the literature.

OBJECTIVE: Physician-specific surveys are a frequently used tool in health services research, but attempts at ensuring adequate response rates are rarely reported. We reviewed literature of survey methodology specific to physician surveys and report those found to be most effective. DATA SOURCES: Studies were identified by searching MEDLINE and PSYCHInfo from 1967 through February 1999. We included all English-language studies that randomized physician survey respondents to an experimental or control group. The authors independently extracted data from 24 studies examining survey methodology of physician-specific surveys. We included Mantel-Haenszel chi-squares comparing treatment groups, if present. If not, these were calculated from study data. RESULTS: Pre-notification of survey recipients, personalizing the survey mailout package, and nonmonetary incentives were not associated with increased response rates. Monetary incentives, the use of stamps on both outgoing and return envelopes, and short questionnaires did increase response rates. Few differences were reported in response rates of phone surveys compared with mail surveys and between the demographics and practice characteristics of early survey respondents and late respondents. CONCLUSIONS: We report some simple approaches that may significantly increase response rates of mail surveys. Surprisingly, the response rates of mail surveys of physicians compared favorably with those from telephone and personal interview surveys. Nonresponse bias may be of less concern in physician surveys than in surveys of the general public. Future research steps include specifically testing the more compelling results to allow for better control of confounders.

Reporting of vancomycin-resistant enterococci in Connecticut: implementation and validation of a state-based surveillance system.

OBJECTIVE: To assess state-based surveillance for isolation from a sterile site of vancomycin-resistant enterococci (VRE) in Connecticut. DESIGN: Clinical laboratory reporting (passive surveillance) of VRE isolates to the Connecticut Department of Public Health (CDPH) was followed by state-initiated validation, laboratory proficiency testing, and review of hospital demographic characteristics. SETTINGS: All 45 clinical laboratories and all 37 (36 for 1995 and 1996) acute-care hospitals in Connecticut were included in the study. MAIN OUTCOME MEASURES: The outcome measures included determination of the statewide incidence of VRE and the accuracy of passive reporting, determination of clinical laboratory proficiency in detecting VRE, and analysis of hospital characteristics that might be associated with an increased incidence of VRE. RESULTS: During 1994 through 1996, 29 (78%) of 37 hospital-affiliated clinical laboratories and 1 (11%) of 9 commercial or other laboratories in Connecticut reported to the CDPH the isolation of VRE from sterile sites; 158 isolates were reported for these 3 years. Based on verification, we discovered that these laboratories actually detected 58 VRE isolates in 1994, 104 in 1995, and 104 in 1996 (total, 266). The age-standardized incidence rate of VRE was 14.1 cases per million population in 1994 and 26.8 cases per million population for both 1995 and 1996. Laboratory proficiency testing revealed that high-level vancomycin resistance was identified accurately and that low- and moderate-level resistance was not detected. The incidence of VRE isolates was three times greater in hospitals with over 300 beds compared with categories of hospitals with fewer beds. Increases in the number of VRE isolates were at least twice as likely in hospitals located in areas with a higher population density, or with a residency program or trauma center in the hospital. CONCLUSIONS: Passive reporting of VRE isolates from sterile sites markedly underestimated the actual number of iso lates, as determined in a statewide reporting system. Statewide passive surveillance systems for routine or emerging pathogens must be validated and laboratory proficiency ensured if results are to be accurate and substantial underreporting is to be corrected.

The costs of healthcare worker respiratory protection and fit-testing programs.

OBJECTIVE: We studied hospital costs associated with healthcare worker (HCW) respiratory protection and respirator fit-testing programs recommended by the Centers for Disease Control and Prevention (CDC) and mandated by the Occupational Safety and Health Administration to decrease nosocomial or occupational Mycobacterium tuberculosis (TB). DESIGN: The number and cost of high-efficiency particulate air (HEPA)-filter and dust-mist (DM) respirators for 1989 to 1994 were obtained from study hospital purchasing departments, and the costs of HCW fit-testing and education programs for 1994 were estimated from information provided by infection control practitioners. Costs of N-class respirator programs were estimated for study hospitals using retrospective cost analysis and an observational study. SETTING: Four urban hospitals with, and one rural community hospital without, documented nosocomial or occupational transmission of multidrug-resistant TB. RESULTS: During the study period, four of five hospitals introduced HEPA and DM respirators and respirator education and fit-testing programs. Median costs in 1994 were $83,900 (range, $2,000-$223,000) for respirators and $17,187 (range, $8,736-$26,175) for respiratory fit-testing programs. The projected median annual cost of N95 respirators was $62,023 (range, $270-$422,526). CONCLUSIONS: Compliance with CDC TB guidelines may require a substantial investment. However, outlays for respirators and education and fit-testing programs are more reasonable than would be suggested by analyses that estimated the costs of preventing one case of nosocomial TB.

APIC and CDC survey of Mycobacterium tuberculosis isolation and control practices in hospitals caring for children. Part 1: Patient and family isolation policies and procedures. Association for Professionals in Infection and Epidemiology, Inc.

BACKGROUND: The 1994 Centers for Disease Control and Prevention draft Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities did not exempt pediatric facilities from instituting controls to prevent nosocomial tuberculosis (TB) transmission. Many researchers contend that TB disease in children does not require such rigid controls. We surveyed acute-care pediatric facilities in the United States to determine adherence to patient and family isolation policies and procedures. METHODS: The study included 4 mailings of a survey to infection control professionals at 284 US children's hospitals and adult acute-care hospitals with > 30 pediatric beds. RESULTS: The overall response rate was 69%. Only 41% of respondents reported having a written TB policy specifically designed for pediatric patients. Whereas 98% of respondents isolated pediatric patients with confirmed pulmonary TB, only 69% reported isolation of patients with miliary TB, and 79% reported isolation of patients with positive gastric aspirates. TB isolation policies for adult visitors were in place at 69% of hospitals, and 50% of hospitals evaluated adults for TB as part of the child's TB treatment plan. A median of 3 contact investigations occurred at each of 47% of respondent hospitals in the preceding 5 years. CONCLUSIONS: Isolation and infection control policies for children with pulmonary TB largely conformed to published guidelines but varied for children with nonpulmonary TB. Because the greatest risk of nosocomial TB transmission in pediatric facilities comes from adults with TB, a rapid TB screening process for parents and adult contacts accompanying affected children should be instituted at facilities caring for children.

APIC and CDC survey of Mycobacterium tuberculosis isolation and control practices in hospitals caring for children. Part 2: Environmental and administrative controls. Association for Professionals in Infection control and Epidemiology, Inc.

BACKGROUND: The 1994 Centers for Disease Control and Prevention draft Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities did not exempt pediatric facilities from instituting controls to prevent nosocomial tuberculosis (TB) transmission. Many researchers contend that TB disease in children does not require such rigid controls. We surveyed acute-care pediatric facilities in the United States to determine adherence to environmental and administrative control recommendations. METHODS: The study included 4 mailings of a survey to infection control professionals at 284 US children's hospitals and adult acute-care hospitals with > 30 pediatric beds. RESULTS: Isolation rooms (IRs) generally conformed to recommended guidelines; 92% of respondents reported IRs with > or = 6 air changes per hour, 90% reported 1-pass air and negative pressure, and 89% reported that IRs were private rooms. A sufficient number of inpatient IRs were reported by 88%, but only 42% had IRs in outpatient areas, and 19% had IRs in off-site clinics. Employee tuberculin skin-test programs were in place at 98% of facilities, but policies pertaining to implementation varied. Employees' use of personal respirators increased at respondent hospitals from 1991 to 1994, but as late as 1994, nearly one third still used surgical masks for high-risk procedures. CONCLUSIONS: Environmental and administrative controls used by respondent hospitals largely conformed to published guidelines. Because definitive studies that quantify the risk of nosocomial M tuberculosis transmission in pediatric settings have yet to be performed, pediatric facilities are required to have the same protections in place as do their adult counterparts.

Transverse shape characteristics of cardiac myocytes from rats and humans.

The shape of the cardiac myocyte is complex; but, in general, it resembles that of an elliptical cylinder. Quantitative data, however, are lacking and adaptive changes in cross-sectional shape are unknown. The major and minor transverse diameters of myocytes from adult rats were measured using three independent methods: profile tracings of intact isolated myocytes, sectioned isolated myocytes, and whole-sectioned tissue. Values for major and minor diameters were virtually identical with all three methods. Using profile tracings of intact isolated myocytes, major and minor diameters were examined in isolated myocytes from freshly explanted human hearts. Five were non-failing donor hearts regarded as unsuitable for transplantation, of which 2 were normal hearts and 3 had concentric hypertrophy. Six were dilated, failing human hearts with ischemic cardiomyopathy. Major and minor diameters from the normal hearts were similar to those from normal rats. Although the number of patients was limited, the minor diameter was largest in myocytes from patients with concentric hypertrophy while the major diameter was greatest in cells from patients with ischemic cardiomyopathy. We conclude that the cross-sectional shape of structurally-intact myocytes is not altered by cell isolation. The data suggest that the transverse shape of normal human cardiac myocytes is similar to that found in rats, and that it may be altered in hypertrophy and failure.

Structural remodeling of cardiac myocytes in patients with ischemic cardiomyopathy.

BACKGROUND: Chronic ischemic heart disease may lead to ventricular dilation and congestive heart failure (ischemic cardiomyopathy [ICM]). The changes in cardiac myocyte shape associated with this dilation, however, are not known. METHODS AND RESULTS: Left ventricular myocyte dimensions were assessed in cells isolated from explanted human hearts obtained from patients with ICM (n = 6) who were undergoing heart transplantation. Cells were also examined from three nonfailing donor hearts with normal coronary arteries (NCA). Compared with cells from patients with NCA, myocyte length was 40% longer in hearts from patients with ICM (197 +/- 8 versus 141 +/- 9 microns, p less than 0.01), cell width was not significantly different, and cell length/width ratio was 49% greater (11.2 +/- 0.9 versus 7.5 +/- 0.6, p less than 0.01). Sarcomere length was the same in myocytes from both groups. The extent of myocyte lengthening is comparable to the increase in end-diastolic diameter commonly reported in patients with ICM. CONCLUSIONS: These data suggest that increased myocyte length (an intracellular event), instead of myocyte slippage (an extracellular event), is largely responsible for the chamber dilation in ICM. Furthermore, maladaptive remodeling of myocyte shape (e.g., increased myocyte length/width ratio) may contribute to the elevated wall stress (e.g., increased chamber radius/wall thickness) in ICM.