Medicaid Expenditures for Children Remaining at Home After a First Finding of Child Maltreatment.

BACKGROUND: Child maltreatment is associated with physical and mental health problems. The objective of this study was to compare Medicaid expenditures based on a first-time finding of child maltreatment by Child Protective Services (CPS). METHODS: This retrospective cohort study included children aged 0 to 14 years enrolled in Utah Medicaid between January 2007 and December 2009. The exposed group included children enrolled in Medicaid during the month of a first-time CPS finding of maltreatment not resulting in out-of-home placement. The unexposed group included children enrolled in Medicaid in the same months without CPS involvement. Quantile regression was used to describe differences in average nonpharmacy Medicaid expenditures per child-year associated with a first-time CPS finding of maltreatment. RESULTS: A total of 6593 exposed children and 39 181 unexposed children contributed 20 670 and 105 982 child-years to this analysis, respectively. In adjusted quantile regression, exposed children at the 50th percentile of health care spending had annual expenditures $78 (95% confidence interval [CI], 65 to 90) higher than unexposed children. This difference increased to $336 (95% CI, 283 to 389) and $1038 (95% CI, 812 to 1264) at the 75th and 90th percentiles of health care spending. Differences were higher among older children, children with mental health diagnoses, and children with repeated episodes of CPS involvement; differences were lower among children with severe chronic health conditions. CONCLUSIONS: Maltreatment is associated with increased health care expenditures, but these costs are not evenly distributed. Better understanding of the reasons for and outcomes associated with differences in health care costs for children with a history of maltreatment is needed.

Standard design for National Ignition Facility x-ray streak and framing cameras.

The x-ray streak camera and x-ray framing camera for the National Ignition Facility were redesigned to improve electromagnetic pulse hardening, protect high voltage circuits from pressure transients, and maximize the use of common parts and operational software. Both instruments use the same PC104 based controller, interface, power supply, charge coupled device camera, protective hermetically sealed housing, and mechanical interfaces. Communication is over fiber optics with identical facility hardware for both instruments. Each has three triggers that can be either fiber optic or coax. High voltage protection consists of a vacuum sensor to enable the high voltage and pulsed microchannel plate phosphor voltage. In the streak camera, the high voltage is removed after the sweep. Both rely on the hardened aluminum box and a custom power supply to reduce electromagnetic pulse/electromagnetic interference (EMP/EMI) getting into the electronics. In addition, the streak camera has an EMP/EMI shield enclosing the front of the streak tube.

Paleohaemoproteus burmacis gen. n., sp. n. (Haemospororida: Plasmodiidae) from an Early Cretaceous biting midge (Diptera: Ceratopogonidae).

Paleohaemoproteus burmacis gen. n., sp. n. (Haemospororida: Plasmodiidae) is described from the abdominal cavity of a female biting midge (Diptera: Ceratopogonidae) preserved in 100 million year old amber from Myanmar (Burma). The description is based on the developmental stages of oocysts and sporozoites. The fossil species differs from extant species of Haemoproteus by its wide range of oocyst sizes, small sporozoites and occurrence in an extinct species of biting midge. Numerous sporozoites in the abdominal cavity suggest that the biting midge was an effective vector of this malarial parasite. Characters of the biting midge suggest that the host was a large, cold-blooded vertebrate. This is the earliest record of a malaria parasite and first indication that Early Cretaceous reptiles were infected with haemosporidial parasites.

Theileria (Babesia) equi and Babesia caballi infections in horses in Galicia, Spain.

The control of equine piroplasmosis is becoming increasingly important to maintain the international market open to the horse industry. The purpose of this study was to demonstrate the occurrence of equine piroplasmosis (Theileria equi and Babesia caballi) in Galicia, north-west Spain, and to compare haematological and serum biochemistry parameters between non-parasitaemic horses and horses parasitaemic with T. equi and B. caballi. Sixty serum samples (control group) were taken from healthy horses pastured on two farms, and examined for evidence of equine T. equi and B. caballi infection by indirect fluorescent antibody test (IFAT). Of the 60 samples, 24 (40%) and 17 (28.3%) samples were positive for T. equi and B. caballi, respectively. Twelve (20%) samples were positive for both parasites. Haematology and serum biochemistry were compared between controls and a series of 36 horses clinically affected by T. equi (25) or B. caballi (11). Compared with the healthy group, there was a 43% and 37% decrease in the haematocrit for T. equi and B. caballi infection, respectively. Parasitaemic horses presented an intense anaemia and serum biochemistry signs of liver damage. The anaemia was more severe in T. equi-infected than in B. caballi-infected horses. Our results suggest that equine piroplasmosis is widespread in the region and is a cause for concern.

Emerging tick-borne infections: rediscovered and better characterized, or truly 'new' ?

The emergence of Lyme borreliosis as a public health burden within the last two decades has stimulated renewed interest in tick-borne infections. This attention towards ticks, coupled with advances in detection technologies, has promoted the recognition of diverse emergent or potentially emerging infections, such as monocytic and granulocytic ehrlichiosis, local variants of spotted fever group rickettsioses, WA-1 babesiosis, or a Lyme disease mimic (Masters' Disease). The distribution of pathogens associated with well-described tick-borne zoonoses such as human babesiosis due to Babesia microti or B. divergens seems wider than previously thought. Bartonellae, previously known to be maintained by fleas, lice or sandflies, have been detected within ticks. Purported 'new' agents, mainly identified by sequencing of PCR products and comparison with those sequences present in GenBank, are being increasingly reported from ticks. We briefly review the diversity of these infectious agents, identify aetiological enigmas that remain to be solved, and provide a reminder about 'old friends' that should not be forgotten in our pursuit of novelty. We suggest that newly recognised agents or tick/pathogen associations receive careful scrutiny before being declared as potential public health burdens.

Enzootic Babesia microti in Maine.

Human babesiosis in the northeastern United States caused by Babesia microti (Apicomplexa: Piroplasmida) is mainly reported from coastal New England sites, where deer ticks (Ixodes dammini) are common. However, the piroplasm has been detected in microtine rodents elsewhere in association with I. angustus or other nidicolous ticks, suggesting that the agent is widely distributed but zoonotically significant only where a human-biting "bridge" vector is present. To determine whether this piroplasm may be enzootic in areas where I. dammini is absent, we surveyed small mammals collected from 2 sites in Maine, where I. angustus or I. muris is common but I. dammini is not. Of 43 chipmunks, voles, deer mice, and shrews examined, 3 (6.9, 95% confidence interval 0 to 14.5) were parasitemic, as determined by blood smear or polymerase chain reaction targeting a piroplasm-specific portion of the 18S ribosomal DNA gene. Phylogenetic analysis of the sequenced amplification products demonstrates the presence of 2 forms of B. microti. We conclude that B. microti may be enzootic in the absence of I. dammini but that human risk relates to dense infestations of this human-biting tick.

What is Babesia microti?

Babesia microti (Apicomplexa: Piroplasmida) has historically been considered a common parasite of Holarctic rodents. However, human babesiosis due to this species has generally been limited to the northeastern seaboard of the United States and Minnesota and Wisconsin. The absence of reports of B. microti babesiosis from sites where the agent is enzootic, such as in western Europe, remains unexplained. Previous work focusing on the 18S rDNA demonstrates little sequence diversity among samples from allopatric host populations across a wide geographical area. It may be that genetic diversity is underestimated due to sample size or the gene analysed. Accordingly, we collected blood or spleen samples from American or Eurasian animals with parasites that were morphologically consistent with B. microti, amplified the 18S rDNA and beta-tubulin gene, and conducted phylogenetic analysis. Surprisingly, what was considered to be 'B. microti' by microscopy appears to be a diverse species complex. We identify 3 distinct clades within this complex, including parasites from non-rodent hosts. Rodent parasites comprise 2 clades, one representing zoonotic isolates, and the other apparently maintained in microtine rodents, and therefore their morphological detection within animals from a site does not necessarily imply a risk to public health.

Case-control study of canine infection by a newly recognised Babesia microti-like piroplasm.

We did a case-control study to identify risk factors for prevalent infection of dogs by a newly recognised Babesia microti-like piroplasm. Clinical manifestations and haematology of infected dogs also were described. Forty-three laboratory-based cases and 86 individually matched controls were studied. Information on clinical signs and on risk factors was collected by a questionnaire and telephone interviews. Haematology was carried out for all the dogs. Variables were screened in a bivariable conditional logistic regression and checked for colinearity. The final multivariable model was selected by backward stepwise elimination. The odds of a case having ticks when examined at the clinic was 4 times that of a control and the odds of a case being a hunting or a house-guarding dog were, respectively, 24.2 and 2.7 times those of a control. The most consistently reported clinical signs were weakness (79%), tachycardia (43%) and haemoglobinuria (42%). Mean red-blood-cell count, haemoglobin concentration, platelet count, and mean platelet volume of infected dogs were lower than the reference values and those of non-infected dogs-but leukocyte count, mean corpuscular volume and red-blood-cell distribution width were higher.

Identification of Rickettsia spp. and Bartonella spp. in ffrom the Thai-Myanmar border.

During a survey for possible rickettsial vectors in villages of the central part of the Thai-Myanmar border from September 2001 to February 2002, four species of fleas were collected from common peridomestic animals. All fleas were tested by PCR to detect DNA of bacteria of the genera Rickettsia (gltA and ompB genes) and Bartonella (ITS and ftsZ genes). Sequencing of PCR-amplified products was done using gltA fragments for Rickettsia and ftsZ fragments for BARTONELLA: Two genotypes related to Rickettsia felis were identified in three Ctenocephalides canis and one C. felis specimen. Further, the following Bartonella spp. were detected: Bartonella henselae in two C. felis specimens; Bartonella clarridgeiae in three C. felis specimens; and a new Bartonella genotype in one Nosopsylla fasciatus specimen. Rickettsia and Bartonella may be frequently detected in fleas infesting peridomestic animals from the western border of Thailand.

Ixodes hexagonus is the main candidate as vector of Theileria annae in northwest Spain.

Babesia canis and Babesia gibsoni have, until recently, been considered the only piroplasms that parasitise dogs. However, recent reports indicate that "small" Babesia infections in Spanish dogs are surprisingly frequent and molecular phylogenetic analysis indicates that the infecting agent is closely related to Babesia microti. Because the 18SrDNA sequence was not completely identical to that of B. microti, the new name "Theileria annae" was assigned to the canine agent. No information is available regarding the possible vector of the new piroplasm, T. annae. As part of an effort to identify the tick that may transmit T. annae in northwest Spain we asked veterinary surgeons practising in the region to collect and send to our laboratory ticks from dogs visiting their clinics. Seven hundred and twenty ticks collected from dogs of unknown clinical status during 1998 and 636 ticks collected between November 2001 and March 2002 from 38 dogs infected with T. annae and 131 uninfected dogs were identified. Results from the first study indicated that among the Ixodidae, Ixodes hexagonus clearly predominates over Ixodes ricinus (26.11% versus 6.67%). This observation was consistent with results of the second study, in which I. hexagonus was detected in all infected dogs and 71.8% of non-infected dogs and I. ricinus was not detected in either the infected or non-infected dogs. Results from the 2001-2002 study also indicate that the presence of Dermacentor reticulatus adult females is significantly less frequent among infected than non-infected dogs (OR=0.44; 95% CI: 0.21-0.92). On the other hand, I. hexagonus adult females and males are 6.75 and 4.24 times more likely to be detected among infected than non-infected dogs, respectively, with the association being, in both cases, statistically significant (95% CI: 1.97-23.12 and 1.92-9.36, respectively). I. hexagonus emerges as the main candidate as vector of T. annae because it feeds on dogs more frequently than other ticks and because B. microti is transmitted by Ixodes ticks, both in North America and Europe. In the absence of definitive confirmation of this hypothesis, our observations suggest that I. hexagonus might serve the same role as does Ixodes scapularis (=Ixodes dammini), the vector of B. microti in eastern North America.

Tick-borne diseases in transfusion medicine.

Ticks are effective vectors of viral, bacterial, rickettsial and parasitic diseases. Many of the tick-borne diseases (TBDs) are of significance to transfusion medicine, either because of the risks they pose to the blood supply or the necessity for blood products required in their treatment. The transmission of tick-borne pathogens via blood transfusion is of global concern. However, among transfusion medicine practitioners, experience with most of these microorganisms is limited. Transfusion transmission of TBDs has been documented largely by means of single case reports. A better understanding of the epidemiology, biology and management of this group of diseases is necessary in order to assess the risks they pose to the blood supply and to help guide effective prevention strategies to reduce this risk. Unique methods are required to focus on donor selection, predonation questioning, mass screening and inactivation or eradication procedures. The role of the transfusion medicine service in their treatment also needs to be better defined. This article reviews the growing body of literature pertaining to this emerging field of transfusion medicine and offers some recommendations for transfusionists in dealing with TBDs.

Life-history phenotypes in populations of Brachyrhaphis episcopi (Poeciliidae) with different predator communities.

Variation among populations in extrinsic mortality schedules selects for different patterns of investment in key life-history traits. We compared life-history phenotypes among 12 populations of the live-bearing fish Brachyrhaphis episcopi. Five populations co-occurred with predatory fish large enough to prey upon adults, while the other seven populations lacked these predators. At sites with large predatory fish, both sexes reached maturity at a smaller size. Females of small to average length that co-occurred with predators had higher fecundity and greater reproductive allotment than those from populations that lacked predators, but the fecundity and reproductive allotment of females one standard deviation larger than mean body length did not differ among sites. In populations with large predatory fish, offspring mass was significantly reduced. In each population, fecundity, offspring size and reproductive allotment increased with female body size. When controlling for maternal size, offspring mass and number were significantly negatively correlated, indicating a phenotypic trade-off. This trade-off was non-linear, however, because reproductive allotment still increased with brood size after controlling for maternal size. Similar differences in life-history phenotypes among populations with and without large aquatic predators have been reported for Brachyrhaphis rhabdophora in Costa Rica and Poecilia reticulata (a guppy) in Trinidad. This may represent a convergent adaptation in life-history strategies attributable to predator-mediated effects or environmental correlates of predator presence.

[Detection of natural foci of babesiosis and granulocytic ehrlichiosis in Russia]. / Vyiavlenie v Rossii prirodnykh ochagov babezioza i granulotsitarnogo érlikhioza.

The use of microscopy, infection of golden hamsters and the polymerase chain reaction made it possible to find out that about 30% of common red-backed voles (Clethrionomys glareolus), inhabiting the taiga forests of the southern part of the Western Urals (the Chusovskoi district of the Perm region), were infected with Babesia microti and simultaneously (a third of them) with Ehrlichia (Cytoecetes) phagocytophila, the causative agent of granulocytic ehrlichiosis. The sequencing of 18S rDNA of strain "Mys", isolated in Russia, revealed its identity to American B. microti strain GI, pathogenic for humans. The main vector supporting the circulation of B. microti in the natural foci in the region where these investigations were conducted was, seemingly, the tick Ixodes trianguliceps, Thus, for the first time the data proving the presence of reservoir hosts infected with B. microti and granulocytic E. phagocytophila, pathogenic for humans, in Russia were presented.

Risk of Lyme disease: perceptions of residents of a Lone Star tick-infested community.

BACKGROUND: Lone Star ticks (Amblyomma americanum) have been suggested as a vector of the agent of Lyme disease (Borrelia burgdorferi sensu lato) in the USA, based on associations with an infection manifesting mainly as erythema migrans. In laboratory experiments, however, they failed to transmit B. burgdorferi sensu stricto. METHODS: In this study, carried out from 1994 to 1996, we determined the seroprevalences of B. burgdorferi (1.2%), Ehrlichia chaffeensis (7%), E. phagocytophila (0%), Rickettsia rickettsii (0%), R. typhi (0%), Coxiella burneti (0%), Francisella tularensis (0%), and Babesia microti (0%) by standard serological methods for 325 residents (97% of the total population) of Gibson Island, coastal Maryland, USA, where 15% of the residents reported having had Lyme disease within a recent 5-year span. FINDINGS: Of the 167 seronegative individuals who were followed up prospectively for 235 person-years of observation, only 2 (0.85%) seroconverted for B. burgdorferi. Of 1556 ticks submitted from residents, 95% were identified as Lone Star ticks; only 3% were deer ticks (Ixodes dammini), the main American vector of Lyme disease. B. burgdorferi s.s. infected 20% of host-seeking immature deer ticks, and borreliae ("B. lonestari") were detected in 1-2% of Lone Star ticks. Erythema migrans was noted in 65% of self-reports of Lyme disease, but many such reports indicated that the rash was present while the tick was still attached, suggesting a reaction to the bite itself rather than true Lyme disease. Sera from individuals reporting Lyme disease generally failed to react to B. burgdorferi or any other pathogen antigens. CONCLUSION: The residents of Gibson Island had an exaggerated perception of the risk of Lyme disease because they were intensely infested with an aggressively human-biting and irritating nonvector tick. In addition, a Lyme disease mimic of undescribed etiology (named Masters' disease) seems to be associated with Lone Star ticks, and may confound Lyme disease surveillance. The epidemiological and entomological approach used in this study might fruitfully be applied wherever newly emergent tickborne zoonoses have been discovered.

Infection of dogs in north-west Spain with a Babesia microti-like agent.

During 1996 a small, ring-shaped, piroplasm was observed in blood smears from 157 dogs in north-west Spain. None of them had previously been in areas endemic for Babesia gibsoni, which was until recently the only small piroplasm known to parasitise dogs. Haematological and serum biochemistry analyses showed that almost all the dogs had an intense regenerative haemolytic anaemia and that in some cases there was evidence of renal failure. A molecular study was made of a sample of the parasite obtained in June 2000. The phylogenetic analysis showed an identity of 100 per cent with the new piroplasm, provisionally denominated as Theileria annae, and 99 per cent with Babesia microti and B. microti-Japan. The results confirm the previous observation of a new form of piroplasm (Theileria annae) which causes disease in dogs in Europe and suggest that it is endemic among the canine population in north-west Spain.

Haemogregarine specificity in two communities of Florida snakes, with descriptions of six new species of Hepatozoon (Apicomplexa: Hepatozoidae) and a possible species of Haemogregarina (Apicomplexa: Haemogregarinidae).

Five species of snakes in Florida, from Palm Beach County in the south and Alachua County 450 km to the north, occur in similar habitat but have distinctive Hepatozoon species characteristic of each host species. In Palm Beach County, Diadophis punctatus is host to Hepatozoon punctatus n. sp., Thamnophis sauritus sackenii to Hepatozoon sauritus n. sp., and Nerodia fasciata pictiventris to Hepatozoon pictiventris n. sp. In Alachua County, N. fasciata pictiventris is parasitized by Hepatozoon fasciatae n. sp., Seminatrix p. pygaea by Hepatozoon seminatrici n. sp., and Thamnophis s. sirtalis by Hepatozoon sirtalis n. sp. Each Hepatozoon sp. has distinctive gamonts and sporogonic characters and, in the 4 species where known, meronts. Nerodia floridana is host to Haemogregarina floridana n. sp. in both localities, with generic identification tentative, based upon presence of erythrocytic meronts. The presence of sporocysts in the proboscis of 31% of Aedes aegypti infected by H. pictiventris is the first report of infective stages of a reptilian Hepatozoon species within the mouthparts of a dipteran vector. This study suggests that in Florida, at least, the diversity of the Hepatozoon community not only equals but probably exceeds the diversity of the snake communities present, and that host specificity in nature may be much greater than that postulated from previous studies.

Human babesiosis in Japan: isolation of Babesia microti-like parasites from an asymptomatic transfusion donor and from a rodent from an area where babesiosis is endemic.

To determine the source of infection for the Japanese index case of human babesiosis, we analyzed blood samples from an asymptomatic individual whose blood had been transfused into the patient. In addition, we surveyed rodents collected from near the donor's residence. Examination by microscopy and PCR failed to detect the parasite in the donor's blood obtained 8 months after the donation of the blood that was transfused. However, we were able to isolate Babesia parasites by inoculating the blood sample into SCID mice whose circulating red blood cells (RBCs) had been replaced with human RBCs. A Babesia parasite capable of propagating in human RBCs was also isolated from a field mouse (Apodemus speciosus) captured near the donor's residential area. Follow-up surveys over a 1-year period revealed that the donor continued to be asymptomatic but had consistently high immunoglobulin G (IgG) titers in serum and low levels of parasitemia which were microscopically undetectable yet which were repeatedly demonstrable by inoculation into animals. The index case patient's sera contained high titers of IgM and, subsequently, rising titers of IgG antibodies, both of which gradually diminished with the disappearance of the parasitemia. Analysis of the parasite's rRNA gene (rDNA) sequence and immunodominant antigens revealed the similarity between donor and patient isolates. The rodent isolate also had an rDNA sequence that was identical to that of the human isolates but that differed slightly from that of the human isolates by Western blot analysis. We conclude that the index case patient acquired infection by transfusion from a donor who became infected in Japan, that parasitemia in an asymptomatic carrier can persist for more than a year, and that A. speciosus serves as a reservoir of an agent of human babesiosis in Japan.

Lone star tick-infecting borreliae are most closely related to the agent of bovine borreliosis.

Although Borrelia theileri, the agent of bovine borreliosis, was described at the turn of the century (in 1903), its relationship with borreliae causing Lyme disease or relapsing fever remains undescribed. We tested the previously published hypothesis that spirochetes infecting Lone Star ticks (Amblyomma americanum) may comprise B. theileri by analyzing the 16S ribosomal DNAs (rDNAs) and flagellin genes of these spirochetes. B. theileri, the Amblyomma agent, and B. miyamotoi formed a natural group or clade distinct from but most closely related to that of the relapsing fever spirochetes. B. theileri and the Amblyomma agent were 97 and 98% similar at the nucleotide level within the analyzed portions of the 16S rDNA and the flagellin gene respectively, suggesting a recent divergence. The agent of bovine borreliosis might be explored as a surrogate antigen for the as-yet-uncultivatable Amblyomma agent in studies designed to explore the etiology of a Lyme disease-like infection associated with Lone Star ticks.

Issues in public health entomology.

Public health entomology focuses on the population biology of vector-borne infections, seeking to understand how such pathogens perpetuate over time and attempting to devise methods for reducing the burden that they impose on human health. As public health entomology passes its centennial, a series of pervasive research themes and spirited debates characterize the discipline, many reflecting a tension between field and laboratory research. In particular, institutional support for population-based research and training programs has fallen behind that for those using modern lab-based approaches. Discussion of modes of intervention against vector-borne infections (such as deployment of genetically modified vectors, the role of DDT in malaria control, host-targeted acaricides for Lyme disease risk reduction, and truck-mounted aerosol spraying against West Nile virus transmission) illustrates the discipline's need for strengthening population-based research programs. Even with the advent of molecular methods for describing population structure, the basis for anophelism without malaria (or its eastern North American counterpart, ixodism without borreliosis) remains elusive. Such methods have not yet been extensively used to examine the phylogeography and geographical origins of zoonoses such as Lyme disease. Basic ecological questions remain poorly explored: What regulates vector populations? How may mixtures of pathogens be maintained by a single vector? What factors might limit the invasion of Asian mosquitoes into North American sites? Putative effects of "global warming" remain speculative given our relative inability to answer such questions. Finally, policy and administrative issues such as the "no-nits" dictum in American schools, the Roll Back Malaria program, and legal liability for risk due to vector-borne infections serve to demonstrate further the nature of the crossroads that the discipline of public health entomology faces at the start of the 21st Century.