Detection of a Human Adenovirus Outbreak, Including Some Critical Infections, Using Multipathogen Testing at a Large University, September 2022-January 2023.

Background: Human adenoviruses (HAdVs) can cause outbreaks of flu-like illness in university settings. Most infections in healthy young adults are mild; severe illnesses rarely occur. In Fall 2022, an adenovirus outbreak was identified in university students. Methods: HAdV cases were defined as university students 17-26 years old who presented to the University Health Service or nearby emergency department with flu-like symptoms (eg, fever, cough, headache, myalgia, nausea) and had confirmed adenovirus infections by polymerase chain reaction (PCR). Demographic and clinical characteristics were abstracted from electronic medical records; clinical severity was categorized as mild, moderate, severe, or critical. We performed contact investigations among critical cases. A subset of specimens was sequenced to confirm the HAdV type. Results: From 28 September 2022 to 30 January 2023, 90 PCR-confirmed cases were identified (51% female; mean age, 19.6 years). Most cases (88.9%) had mild illness. Seven cases required hospitalization, including 2 critical cases that required intensive care. Contact investigation identified 44 close contacts; 6 (14%) were confirmed HAdV cases and 8 (18%) reported symptoms but never sought care. All typed HAdV-positive specimens (n = 36) were type 4. Conclusions: While most students with confirmed HAdV had mild illness, 7 otherwise healthy students had severe or critical illness. Between the relatively high number of hospitalizations and proportion of close contacts with symptoms who did not seek care, the true number of HAdV cases was likely higher. Our findings illustrate the need to consider a wide range of pathogens, even when other viruses are known to be circulating.

Dried blood spots: An evaluation of utility in the field.

BACKGROUND: Use of dried blood spots (DBS) offers advantages over serum samples in studies conducted in resource-poor settings. The aim of this study was to compare the number of adequate spots collected across different demographic groups. METHODS: Five DBS were collected from 3316 individuals aged 0-49 years in Tianjin, China for a measles antibody study; DBS were rated "adequate" or "inadequate." Linear regression, with the number of adequate DBS on a card as the outcome variable, was used to test for predictors of DBS adequacy. RESULTS: There were 0 adequate DBS for 23% of participants and 5 adequate DBS for 24%. Mean number of adequate DBS was 1.68 in infants (<12 months), 2.57 (1-9 years), 3.49 (10-29 years), 3.08 (30-49 years). The number of adequate DBS increased over the study; the mean number of adequate DBS for the five years 2011-2015 were 1.21, 2.52, 3.40, 2.22, and 3.62, respectively. DBS quality was not related to measles IgG antibodies. CONCLUSIONS: DBS are an alternative for adults and children but pose challenges in infants, and improve with experience. In a resource-limited environment or in a scenario where more invasive techniques like venipuncture may be less accepted by the study population, DBS can be the preferred technique to efficiently obtain serum specimens for analyte testing.

Risk factors for measles among adults in Tianjin, China: Who should be controls in a case-control study?

BACKGROUND: Control groups in previous case-control studies of vaccine-preventable diseases have included people immune to disease. This study examines risk factors for measles acquisition among adults 20 to 49 years of age in Tianjin, China, and compares findings using measles IgG antibody-negative controls to all controls, both IgG-negative and IgG-positive. METHODS: Measles cases were sampled from a disease registry, and controls were enrolled from community registries in Tianjin, China, 2011-2015. Through a best subsets selection procedure, we compared which variables were selected at different model sizes when using IgG-negative controls or all controls. We entered risk factors for measles in two separate logistic regression models: one with measles IgG-negative controls and the other with all controls. RESULTS: The study included 384 measles cases and 1,596 community controls (194 IgG-negative). Visiting a hospital was an important risk factor. For specialty hospitals, the odds ratio (OR) was 4.53 (95% confidence interval (CI): 1.28, 16.03) using IgG-negative controls, and OR = 5.27 (95% CI: 2.73, 10.18) using all controls. Variables, such as age or length of time in Tianjin, were differentially selected depending on the control group. Individuals living in Tianjin ≤3 years had 2.87 (95% CI: 1.46, 5.66) times greater odds of measles case status compared to all controls, but this relationship was not apparent for IgG-negative controls. CONCLUSIONS: We recommend that case-control studies examining risk factors for infectious diseases, particularly in the context of transmission dynamics, consider antibody-negative controls as the gold standard.

Influenza vaccination of adults with and without high-risk health conditions in China.

Background: The World Health Organization recommends the elderly and persons with certain chronic diseases to receive an annual influenza vaccine and to be prioritized for immunization against pandemic influenza, because they are at greater risk for health complications. This paper aims to compare influenza vaccination coverage between adults in China with and without high-risk health conditions. Methods: Data were from the cross-sectional China General Social Survey, 2010. Adults were interviewed about their health, including whether they had been vaccinated against either seasonal or pandemic influenza within the past year. A multivariable logistic regression model estimated the adjusted odds of any influenza vaccination in high-risk groups compared with low-risk groups. Results: Only 10.5% (372/3592) of Chinese adults were vaccinated against influenza. In a multivariable regression model, there was no significant difference in influenza vaccine uptake between those with and without high-risk health conditions. However, healthcare attitudes and behaviours were significantly associated with vaccine uptake. Conclusions: Influenza vaccination coverage is extremely low in Chinese adults who are elderly and have chronic diseases. These two groups are at greatest risk for influenza-related morbidity and mortality and should be targets of programmes to increase positive attitudes towards vaccination and decrease barriers to uptake.

A population profile of measles susceptibility in Tianjin, China.

BACKGROUND: Measles is a highly infectious illness requiring herd immunity of 95% to interrupt transmission. Measles is targeted for elimination in China, which has not reached elimination goals despite high vaccination coverage. We developed a population profile of measles immunity among residents aged 0-49 years in Tianjin, China. METHODS: Participants were either from community population registers or community immunization records. Measles IgG antibody status was assessed using dried blood spots. We examined the association between measles IgG antibody status and independent variables including urbanicity, sex, vaccination, measles history, and age. RESULTS: 2818 people were enrolled. The proportion measles IgG negative increased from 50.7% for infants aged 1 month to 98.3% for those aged 7 months. After 8 months, the age of vaccination eligibility, the proportion of infants and children measles IgG negative decreased. Overall, 7.8% of participants 9 months of age or older lacked measles immunity including over 10% of those 20-39 years. Age and vaccination status were significantly associated with measles IgG status in the multivariable model. The odds of positive IgG status were 0.337 times as high for unvaccinated compared to vaccinated (95% CI: 0.217, 0.524). CONCLUSIONS: The proportion of persons in Tianjin, China immune to measles was lower than herd immunity threshold with less than 90% of people aged 20-39 years demonstrating protection. Immunization programs in Tianjin have been successful in vaccinating younger age groups although high immunization coverage in infants and children alone would not provide protective herd immunity, given the large proportion of non-immune adults.

The epidemiology of measles in Tianjin, China, 2005-2014.

BACKGROUND: Measles incidence in China has declined over the last decade and elimination is targeted by 2020. Despite increases in routine immunization services and supplementary immunization activities (SIAs), periodic outbreaks continue to occur. In this paper, we examine measles epidemiology during 2005-2014 in Tianjin, China. METHODS: Measles case data were extracted from a web-based communicable disease surveillance system. We examined the socio-demographic characteristics of measles case patients, including age, sex, urbanicity, residency status, and vaccination history. Demographic characteristics of cases were compared with the general population. RESULTS: From January 1, 2005 to December 31, 2014, 12,466 measles cases in Tianjin were reported. Among the cases, 7179 (57.6%) were male and 5287 (42.4%) were female. Over time, more cases occurred in adults, and for the 2711 cases in 2014, the majority were either infants <1 year (558, 20.58%) or adults ≥ 20 years (2043, 75.36%). Municipal-wide SIAs in Tianjin occurred in 2008 and 2010 with reduction in measles cases the following year for both (189 cases in 2009, and 37 cases in 2011). The number of cases rebounded to pre-SIA levels or higher within 1-3 years following each SIA: 1990 cases in 2010 and 2711 cases in 2014. Vaccination status was reported as "none" or "unknown" for 84% of all reported measles cases. CONCLUSIONS: Despite the general decline in cases, measles outbreaks continue to occur. Although the SIAs reduce numbers in their immediate aftermath, case counts rebound 1-3 years after the intervention. Continued monitoring of cases through disease surveillance activities accompanied by targeted immunization activities, including to adults, can help ensure progress toward elimination.

Measles vaccine coverage and series completion among children 0-8 years of age in Tianjin, China.

BACKGROUND: The World Health Organization (WHO) targeted China for measles elimination by 2012. Although China made significant progress, transmission continues, warranting examination of China's measles vaccination program. The World Health Organization recommends that children receive at least 2 doses of a measles containing vaccine (MCV) to ensure protection. In Tianjin, China, MCV is given in 3 doses: 8 months [measles vaccine (MV)], 18-24 months [measles-mumps-rubella (MMR)-1] and 5 years MMR-2). MMR-2 is important because of the young age for MV administration. This study describes MCV coverage, assesses administration timeliness and evaluates completion of the MCV series for children living in Tianjin, China. METHODS: In July 2012, immunization records were selected from Tianjin's Immunization Information Management System. Records were abstracted for children born from 2004 to 2011, who were aged 8 months or older. Descriptive statistics characterized the study population and assessed timeliness and coverage for each MCV dose. RESULTS: We examined records of 205,982 children living in Tianjin, China. Among children who were age-appropriate for each vaccine, 98.6% received MV, 97.6% received MMR-1 and 76.9% received MMR-2. Of the children who were old enough to receive MMR-2, 78.8% received the complete series and 71.6% were fully immunized for measles by age 6 years. CONCLUSIONS: Tianjin has high rates of MV and MMR-1 coverage, with lower levels for MMR-2. Most children who completed the series did so on time. Maintaining high coverage and timely administration of MV and MMR-1 and increasing coverage of MMR-2 are necessary for China to attain the goal of national measles elimination.

Timely measles vaccination in Tianjin, China: a cross-sectional study of immunization records and mothers.

BACKGROUND: Measles is a highly infectious disease, and timely administration of two doses of vaccine can ensure adequate protection against measles for all ages in a population. This study aims to estimate the proportion of children aged 8 months to 6 years vaccinated on time with measles-containing vaccines (MCV) and vaccinated during the 2008 and 2010 measles supplementary immunization activities. This study also characterizes differences in mean age at vaccination and vaccination timeliness by demographic characteristics, and describes maternal knowledge of measles vaccination. METHODS: Immunization records were selected from a convenience sample of immunization clinics in Tianjin, China. From the records, overall vaccination coverage and timely vaccination coverage were calculated for different demographic groups. Mothers were also interviewed at these clinics to ascertain their knowledge of measles vaccination. RESULTS: Within the 329 immunization clinic records, child's birth year and district of residence were found to be significant predictors of different measures of vaccine timeliness. Children born in 2009 had a lower age at MCV dose 2 administration (17.96 months) than children born in 2005 (22.00 months). Children living in Hebei, a district in the urban center of Tianjin were less likely to be vaccinated late than children living in districts further from the urban core of Tianjin. From the 31 interviews with mothers, most women believed that timely vaccination was very important and more than one dose was very necessary; most did not know whether their child needed another dose. CONCLUSIONS: When reviewing MCV coverage in China, most studies do not consider timeliness. However, this study shows that overall vaccination coverage can greatly overestimate vaccination coverage within certain segments of the population, such as young infants.

The impact of residency and urbanicity on Haemophilus influenzae Type b and pneumococcal immunization in Shanghai Children: a Retrospective Cohort Study.

BACKGROUND: Haemophilus influenzae type b (Hib) vaccine and pneumococcal conjugate vaccine (PCV) are relatively expensive, newly introduced vaccines in China. This study evaluates the impact of residency and urbanicity on Hib vaccine and PCV coverage for children aged 2 to 7 years living in Shanghai, China, in August 2012. METHODS: In this exploratory cohort study, a sample of children aged 2 to 7 years, all of whom were eligible to have received the complete series of Hib vaccine and PCV, was obtained from the Shanghai Immunization Program Information System. Three measures of vaccination coverage for Hib vaccine and PCV were examined: dose 1 coverage, series completion, and timeliness of dose 1 vaccination. Multivariable binomial regression was used to estimate the difference in vaccination coverage between locals and the floating population. RESULTS: Dose 1 coverage was 50.9% for Hib vaccine and 11.4% for PCV for the 28,141 abstracted pediatric records. For both vaccines, dose 1 coverage was higher in locals than in the floating population. The disparity in coverage between locals and the floating population was greater in suburban areas than urban areas. Of all children who received dose 1, 79.7% completed the Hib vaccine series, and 91.3% completed the PCV series. Timely dose 1 coverage was 8.2% for Hib vaccine and 0.5% for PCV. CONCLUSION: Low vaccination coverage and extremely low levels of timely dose 1 vaccination indicate that current vaccination efforts are inadequate to reduce the burden of Hib and pneumococcal disease among Chinese children, especially infants. Government funding of the Hib vaccine and PCV through the Expanded Program on Immunization would increase uptake and could also ensure that improvement in the timeliness of administration and series completion is targeted for all demographic groups.

State government organization of health services, 1990-2009: correlates and consequences.

OBJECTIVES: To describe changes in the organizational structure of state health-related departments/agencies between 1990 and 2009; to identify factors associated with key organizational structures; and to investigate their relationship with different resource allocations across health policy areas, as represented by state budgets. DESIGN: Original data collection on the organization of state health-related departments/agencies from 1990 to 2009. Analyses included descriptive statistics, logistic regression, and time-series regression modeling. SETTING AND PARTICIPANTS: All 50 states. MAIN OUTCOMES MEASURES: Organizational structure of state government related to health in 4 areas (Medicaid, public health, mental health, human services); coupling of Medicaid and public health in the same agency; state budget changes in health policy areas, including Medicaid, public health, and hospitals. RESULTS: The housing of 2 or more health-related functions in the same unit was common, with 21 states combining public health and Medicaid at 1 or more points in time. Eighteen states (36%) reorganized their health agencies/departments during the study period. Controlling for numerous economic, social, and political factors, when the state agency responsible for public health is consolidated with Medicaid, the share of the state budget allocated to Medicaid declined significantly, while public health allocations were unchanged. However, consolidating Medicaid with other services did not impact state Medicaid spending. CONCLUSIONS: Government organizational structure related to health varies greatly across states and is somewhat dynamic. When Medicaid and public health functions are consolidated in the same stage agency, public health does not "lose" in terms of its share of the state budget. However, this could change as Medicaid costs continue to grow and with the implementation the Patient Protection and Affordable Care Act of 2010.

Promoting practice in public health academia: assessing impact on student education.

This article reviews the activities of an office of public health practice in a school of public health (SPH) and assesses their impact on master's of public health student training and education. The University of Michigan SPH established a Practice Office in 2005 to develop programs in community-based public health, workforce development, student training, and practice-based research. Student training objectives included increasing practice activity offerings and participation rates, ensuring participant satisfaction with activities, and raising the number of students seeking public health practice employment. According to student survey results from the 2007-2008 and 2008-2009 academic years, the Practice Office achieved mixed success in meeting objectives. Approximately 50% of students participated in at least 1 activity, nearly 50% of students reported that the activities impacted their decision to pursue a practice career, and approximately 75% of students reported moderate to extensive public health practice experience on graduation, compared with 30% at the beginning of their degree program, although this change was not significantly different for those who had participated in Practice Office activities. Initiation of a systematic process to evaluate the impact of practice-based activities early in program development is recommended for all Practice Offices.

Trends in Michigan early adolescent immunization: 2006-2008.

OBJECTIVES: We have described vaccine coverage of Michigan young adolescents immunized with tetanus, diphtheria, and pertussis; meningococcal conjugate; and human papillomavirus vaccines during 2006-2008. METHODS: We obtained data from the Michigan Care Improvement Registry, a state-based immunization information system that included more than 57 million vaccination records. We examined 3 overlapping cohorts of 11- and 12-year-old children (n > 350 000 in each) to assess temporal trends in vaccination coverage, characteristics of those immunized, funding sources, and vaccination sites. RESULTS: Vaccine uptake increased during 2006 through 2008, peaking in the summer months. More than half of children receiving more than 1 vaccine received the vaccines simultaneously. Older age, receipt of Medicaid, and prior completion of early childhood immunizations were associated with greater odds of vaccination. CONCLUSIONS: Vaccine coverage among Michigan young adolescents is increasing but continues to be relatively low. Coverage of 11- and 12-year-old children may improve with efforts to encourage vaccination at all health care visits, an increase in public funding in support of adolescent vaccination, and continued monitoring of adolescent vaccination levels through school-based assessments.

Did H1N1 influenza prevention messages reach the vulnerable population along the Mississippi Gulf Coast?

OBJECTIVE: To identify the primary sources of information utilized by a vulnerable population during the 2009 influenza pandemic and examine disease prevention behaviors related to reports of local H1N1 influenza transmission. DESIGN: Cross-sectional study. SETTING: Between May 2009 and December 2009, face-to-face interviews were conducted in towns located in 3 Mississippi counties along the Gulf Coast. PARTICIPANTS: Two hundred sixteen residents of the Mississippi Gulf Coast were interviewed. MAIN OUTCOME MEASURES: Analysis of the interview results described awareness of the influenza outbreak/pandemic and sources of information about the situation. Chi-square tests were used to examine differences in reported disease-preventive behaviors taken by Mississippi Gulf Coast residents before and after H1N1 influenza transmission was confirmed locally. RESULTS: Most subjects were aware of H1N1 influenza at the time of interview (n = 212; 98%). Television (n = 145; 69%), newspaper (n = 40; 19%), and the Internet (n = 19; 9%) were the most common sources of information regarding H1N1 influenza. Hand hygiene (n = 85; 41%) was the most reported preventive measure adopted by study subjects and increased following the confirmation of the first H1N1 influenza cases in Harrison County (χ= 4.46, p= 0.04). CONCLUSIONS: The Centers for Disease Control and Prevention's emphasis on providing health information about H1N1 primarily through the Internet may not have been effective in reaching the public. Provision of health messages through various mediums, especially television, may better inform the public of disease-related prevention messages during a developing influenza pandemic.

Mapping student response team activities to public health competencies: are we adequately preparing the next generation of public health practitioners?

This article compares activities of the University of Michigan School of Public Health Public Health Action Support Team (PHAST) to the Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Applied Epidemiology Competencies (AECs) to determine the utility of using the competencies to assess extracurricular student training. We mapped the activities from eight PHAST trips occurring from 2006 to 2009 to the 34 AECs for Tier 1 epidemiologists by examining project activities to determine how closely they aligned with the AECs. PHAST trips provided students with opportunities to address 65% of the AECs; 29% of the AECs were addressed by all eight trips. The domains of AECs most often addressed by PHAST trips were leadership and systems thinking, cultural competency, and community dimensions of practice. Mapping PHAST trips to the AECs was useful for all public health students, not just epidemiologists in training.

From Survey to Assessment: Characterizing Michigan's Public Health Workforce.

OBJECTIVE:: To plan for continuity of operations, it is important to know which types of position vacancies within health departments are likely to occur and the kind of training needed to ensure protection of the public's health. METHODS:: To describe anticipated gaps in the public health workforce and to identify specific areas of training needed to ensure a highly skilled workforce, the authors surveyed Michigan state employees with public health responsibilities in spring 2007. RESULTS:: More than half (54%) of surveyed public health professionals reported they plan to leave the workforce within 10 years. Preparedness-specific topics were generally viewed as less important than more general public health topics. Some preparedness-funded tools have become integrated into daily operations, whereas others were viewed as more important in an everyday, rather than emergency preparedness, context. CONCLUSIONS:: Framing preparedness activities beyond the scope of preparedness to directly relate them to daily public health operations would encourage public health professionals to perceive them as more important. For public health preparedness to be fully realized, it must be considered a central component of public health operations, allowing for seamless integration during emergencies small and large.

Epidemiology competencies and preventive medicine residencies: do they mix and map?

OBJECTIVES: [corrected] This article maps the program requirements of the University of Michigan preventive medicine residency (PMR) to the newly established Centers for Disease Control and Prevention/Council of State and Territorial Epidemiologists Competencies for Applied Epidemiologists in Governmental Public Health Agencies (AECs) to determine the feasibility and utility of using these competencies to assess the training of physician epidemiologists. METHODS: The academic and practicum requirements of the PMR are mapped against the 38 AECs for Tier 2, or mid-level epidemiologists. The process of mapping was done by reviewing academic course syllabi/content and practicum tasks to determine how closely they aligned with the AECs. This process allowed us to identify competencies that are relative training strengths and weaknesses of the residency. RESULTS: Overall, the current program requirements of the PMR generally satisfy the AECs, although one competency was not met in either the academic or practicum year, and another was only met in a single, required academic course. The areas in which AECs were fulfilled by many activities in the residency were in domain 1 (assessment and analysis) and domain 2 (basic public health sciences). The areas in which competencies were met by few activities were primarily in domain 6 (financial and operational planning and management) and domain 7 (leadership and systems thinking). CONCLUSIONS: We found that the process of mapping an academically rigorous epidemiology training program (the PMR) to the AEC was feasible and useful. It permitted us to identify training strengths and gaps in our program and consider modifications that will strengthen the level of competency of our physician graduates.

Pregnancy and other factors associated with higher CD4+ T-cell counts at HIV diagnosis in Southeast Michigan, 1992-2002.

BACKGROUND: Early diagnosis of HIV infection provides the opportunity for treatment to prevent progression to AIDS and for intervention to prevent further transmission. The impact of routine screening of pregnant women and other factors on the stage of HIV disease at diagnosis were evaluated. METHODS: Data were collected in 1992-2002 from the medical records of persons presenting for HIV-related care at 2 major medical centers in Detroit, Michigan. Patients were included in the analysis if they had a CD4+ T-cell count recorded within 6 months of their first positive HIV test (N = 1858). RESULTS: Half of the patients (49%) had a first CD4+ T-cell count of < 200 cells/mm3 and 19% had an AIDS-defining illness at the time of HIV diagnosis. In the multivariate model, pregnant women were less likely than nonpregnant women to enter care with a CD4+ T-cell count of < 200 cells/mm3 (odds ratio, .24; 95% confidence interval, .14-.41). Even after adjusting for pregnancy, female sex was protective, as was age < 30 years. HIV-transmission risk factors, race, and time period of HIV diagnosis were not significantly associated with first CD4+ T-cell counts of < 200 cells/mm3. CONCLUSION: Routinely offering HIV testing in prenatal care, as required by Michigan law, resulted in earlier diagnoses of HIV in pregnant women, as indicated by their higher CD4+ T-cell counts. Increasing routine HIV testing of all persons seeking medical care may increase the overall proportion of HIV diagnoses that are made early in the disease process.

AIDS-related primary brain lymphoma in Michigan, January 1990 to December 2000.

To examine the effect of highly active antiretroviral therapy (HAART) on the occurrence of primary brain lymphoma (PBL), determine the risk factors for PBL, and assess the difference in survival between individuals who did and did not develop PBL, data were analyzed from the Michigan Adult/Adolescent Spectrum of HIV Disease project (ASD). Among 4,026 HIV-infected individuals enrolled in ASD between January 1990 and December 2000, 64 (1.6%) were diagnosed with PBL. The incidence rate of PBL declined from 5.6 cases per 1000 person-year in the pre-HAART era to 2.1 cases per 1000 person-year in post-HAART era. In the multivariate analysis, individuals whose CD4 count at entry in ASD was either <50 cells/microL (OR: 5.0) or 50-200 cells/microL (OR: 2.3) were significantly more likely to develop PBL than those with a CD4 count >/= 200 cells/microL. PBL was a terminal condition in these patients. The median survival time was consistently shorter among individuals who developed PBL than those who did not, regardless of their CD4 count at entry into ASD.