Age at first HIV test for MSM at a community health clinic in Los Angeles.

Young MSM, especially ethnic and racial minority young MSM, bear a disproportionate burden of new HIV infections. This group also has the highest rates of undiagnosed infection and lowest rates of viral suppression. Previous research indicates that young MSM are testing for HIV too late, which may explain why rates of new HIV infection are rising in young Hispanic MSM and not falling in young Black and White MSM despite advances in preventive medications. Analysis of our sample showed an overall average age at first HIV test of approximately 26. The average age at first HIV test was 25.5 years for Black/African American individuals, 24.7 years for Hispanic individuals, and 28 years for White individuals. More testing resources and innovative outreach methods are needed to increase rates of testing among young MSM.

Economic impact of malaria-related hospitalizations in the United States, 2000-2014.

BACKGROUND: Despite its elimination in the early 1950s, about 1700 cases of malaria are reported in the US every year. Few studies have quantified the direct and indirect costs of imported malaria in the US. METHODS: Disparities in the mean and total hospital days, hospital charges, and hospital costs for malaria-related hospitalizations in the US by demographic, clinical, species, financial, geographic, and institutional characteristics were examined using the 2000-2014 Nationwide Inpatient Sample (NIS). Trends and potential predictors for length of stay and hospital charges and costs were identified using negative binomial regression and linear regression, respectively. RESULTS: From 2000 to 2014, 22,029 malaria cases resulted in 95,948 hospital days for malaria-related hospitalizations, $176,391,466 in total hospital costs, and $555,435,849 in total charges. Mean charges increased significantly over the study period. Males, Blacks, and patients aged 25-44years accounted for the highest direct and indirect costs. Older age and having severe malaria was associated with a longer length of stay. Older age, severe malaria, HIV infection, and longer lengths of stay were associated with higher charges and costs. CONCLUSIONS: Malaria resulted in substantial direct and indirect costs in the US. Primary and secondary prevention measures should be prioritized among high-risk groups to reduce the economic burden.

Risk factors for severe malaria among hospitalized patients in the United States, 2000-2014.

BACKGROUND: Factors associated with the development of severe malaria have not been well described for cases occurring in the United States (US). METHODS: Severe malaria hospitalizations data from the 2000-2014 Nationwide Inpatient Sample were analyzed. Frequencies were reported by demographic, clinical, species, financial, geographic, and institutional characteristics, and trends and disparities were identified. Logistic regression models were used to identify potential predictors for severe disease among those with malaria. RESULTS: From 2000 to 2014, there were an estimated 4823 severe malaria cases, representing 21.9% of all malaria-related hospitalizations, including 182 severe malaria deaths. Severe malaria was most common among inpatients who were male, Black, aged 45-64 years, and hospitalized in the South Atlantic division of the US. Older age was associated with higher odds of severe malaria, cerebral malaria, ARDS, severe anemia, and renal failure. Males had higher odds of developing renal failure and jaundice, while females had higher odds of developing severe anemia. HIV infection was associated with increased odds of severe malaria, severe anemia, and renal failure. CONCLUSION: Primary and secondary prevention measures, such as pre-travel consultations, chemoprophylaxis, and early diagnosis and treatment, should be emphasized and improved among high-risk prospective travelers to malaria endemic countries.

Malaria-Related Hospitalizations in the United States, 2000-2014.

Few data are available on the burden of malaria hospitalization in the United States. Study of malaria using hospital-based data can better define the impact of malaria and help inform prevention efforts. U.S. malaria cases identified from hospitalization discharge records in the 2000-2014 Nationwide Inpatient Sample were examined. Frequencies and population rates were reported by demographics, infecting species, clinical, financial, institutional, geographic, and seasonal characteristics, and disparities were identified. Time trends in malaria cases were assessed using negative binomial regression. From 2000 to 2014, there were an estimated 22,029 malaria-related hospitalizations (4.88 per 1 million population) in the United States, including 182 in-hospital deaths and 4,823 severe malaria cases. The rate of malaria-related hospitalizations did not change significantly over the study period. The largest number of malaria-related hospitalizations occurred in August. Malaria-related hospitalizations occurred disproportionately among patients who were male, black, or 25-44 years of age. Plasmodium falciparum accounted for the majority of malaria-related hospitalizations. On average, malaria patients were hospitalized for 4.36 days with charges of $25,789. Patients with a malaria diagnosis were more often hospitalized in the Middle Atlantic and South Atlantic census divisions, urban teaching, private not-for-profit, and large-bed-size hospitals. Malaria imposes a substantial disease burden in the United States. Enhanced primary and secondary prevention measures, including strategies to increase the use of pretravel consultations and prompt diagnosis and treatment are needed.

Cysticercosis-related hospitalizations in the United States, 1998-2011.

Cysticercosis has become increasingly recognized as an important infection in the United States in recent decades. Despite its potential impact, there is a lack of comprehensive information on the nationwide burden of disease. To better define the burden of cysticercosis in the United States, we analyzed in-patient records using the Nationwide Inpatient Sample for 1998-2011 to estimate cysticercosis-related hospitalizations and patient/institutional characteristics. There were an estimated 33,060 (95% confidence interval [95% CI] = 29,610.5-36,510.3) cysticercosis-related hospitalizations nationwide, representing a hospitalization rate of 8.03 per million population. The highest proportion of cases were male (54.8%), Hispanic (62.0%), aged 18-44 (58.8%), and occurred in the West (45.1%). An estimated 459 deaths occurred, representing an in-hospital case-fatality rate of 1.4%. These findings indicate the burden of cysticercosis-related hospitalizations in the United States is considerable and may be greater than currently appreciated. Cysticercosis should be a nationally reportable disease.

Seasonal influenza vaccination is the strongest correlate of cross-reactive antibody responses in migratory bird handlers.

UNLABELLED: Avian species are reservoirs of influenza A viruses and could harbor viruses with significant pandemic potential. We examined the antibody and cellular immune responses to influenza A viruses in field or laboratory workers with a spectrum of occupational exposure to avian species for evidence of zoonotic infections. We measured the seroprevalence and T cell responses among 95 individuals with various types and degrees of prior field or laboratory occupational exposure to wild North American avian species using whole blood samples collected in 2010. Plasma samples were tested using endpoint enzyme-linked immunosorbent assay (ELISA) and hemagglutination (HA) inhibition (HAI) assays to subtypes H3, H4, H5, H6, H7, H8, and H12 proteins. Detectable antibodies were found against influenza HA antigens in 77% of individuals, while 65% of individuals tested had measurable T cell responses (gamma interferon [IFN-γ] enzyme-linked immunosorbent spot assay [ELISPOT]) to multiple HA antigens of avian origin. To begin defining the observed antibody specificities, Spearman rank correlation analysis showed that ELISA responses, which measure both head- and stalk-binding antibodies, do not predict HAI reactivities, which measure primarily head-binding antibodies. This result suggests that ELISA titers can report cross-reactivity based on the levels of non-head-binding responses. However, the strongest positive correlate of HA-specific ELISA antibody titers was receipt of seasonal influenza virus vaccination. Occupational exposure was largely uncorrelated with serological measures, with the exception of individuals exposed to poultry, who had higher levels of H7-specific antibodies than non-poultry-exposed individuals. While the cohort had antibody and T cell reactivity to a broad range of influenza viruses, only occupational exposure to poultry was associated with a significant difference in antibody levels to a specific subtype (H7). There was no evidence that T cell assays provided greater specificity for the detection of zoonotic infection. However, influenza vaccination appears to promote cross-reactive antibodies and may provide enhanced protection to novel influenza viruses. IMPORTANCE: Annual vaccinations are necessary to ameliorate influenza disease due to drifted viral variants that emerge in the population. Major shifts in the antigenicity of influenza viruses can result in immunologically distinct viruses that can cause more severe disease in humans. Historically, genetic reassortment between avian, swine, or human influenza viruses has caused influenza pandemics in humans several times in the last century. Therefore, it is important to design vaccines to elicit broad protective responses to influenza infections. Because avian influenza viruses have an important role in emerging infections, we tested whether occupational exposure to birds can elicit immune responses to avian influenza viruses in humans. Instead of a specific occupational exposure, the strongest association of enhanced cross-reactive antibody responses was receipt of seasonal influenza vaccination. Therefore, individuals with preexisting immune responses to seasonal human influenza viruses have substantial cross-reactive antibody and T cell responses that may lead to enhanced protection to novel influenza viruses.

Local health department epidemiologic capacity: a stratified cross-sectional assessment describing the quantity, education, training, and perceived competencies of epidemiologic staff.

INTRODUCTION: Local health departments (LHDs) must have sufficient numbers of staff functioning in an epidemiologic role with proper education, training, and skills to protect the health of communities they serve. This pilot study was designed to describe the composition, training, and competency level of LHD staff and examine the hypothesis that potential disparities exist between LHDs serving different sized populations. MATERIALS AND METHODS: Cross-sectional surveys were conducted with directors and epidemiologic staff from a sample of 100 LHDs serving jurisdictions of varied sizes. Questionnaires included inquiries regarding staff composition, education, training, and measures of competency modeled on previously conducted studies by the Council of State and Territorial Epidemiologists. Number of epidemiologic staff, academic degree distribution, epidemiologic training, and both director and staff confidence in task competencies were calculated for each LHD size strata. RESULTS: Disparities in measurements were observed in LHDs serving different sized populations. LHDs serving small populations reported a smaller average number of epidemiologic staff than those serving larger jurisdictions. As size of population served increased, percentages of staff and directors holding bachelors' and masters' degrees increased, while those holding RN degrees decreased. A higher degree of perceived competency of staff in most task categories was reported in LHDs serving larger populations. DISCUSSION: LHDs serving smaller populations reported fewer epidemiologic staff, therefore might benefit from additional resources. Differences observed in staff education, training, and competencies suggest that enhanced epidemiologic training might be particularly needed in LHDs serving smaller populations. RESULTS can be used as a baseline for future research aimed at identifying areas where training and personnel resources might be particularly needed to increase the capabilities of LHDs.

A national study of individuals who handle migratory birds for evidence of avian and swine-origin influenza virus infections.

BACKGROUND: Persons with occupational or recreational exposure to migratory birds may be at risk for infection with highly pathogenic avian influenza and other avian influenza viruses since wild birds are the natural reservoir of influenza A. Additionally, bird handlers may host avian and swine-origin influenza (pH1N1) virus co-infections, which generate reassortant viruses with high pathogenicity in mammals. OBJECTIVES: We assessed the prevalence of avian and swine influenza viruses in US-based bird handlers and estimated their exposure to different orders of wild birds including waterfowl (Anseriformes), songbirds (Passeriformes), and shorebirds (Charadriiformes). STUDY DESIGN: Cross-sectional serologic survey accompanied by a questionnaire to estimate behavioral risk factors. This is first survey of US-based bird handlers who also work at international sites. RESULTS: 401 participants were recruited and tested over the course of 3 years. One participant with occupational exposure to migratory birds had evidence of past infections with a H5N2 virus antigenically related to A/Nopi/MN/07/462960-02, which is the first case of this influenza subtype in a human host associated with exposure to wild rather than domestic birds. We detected no avian and swine-origin influenza virus co-infections. The exposure of bird handlers to songbirds was four times greater than to shorebirds or waterfowl. CONCLUSIONS: Though rare, the transmission of avian influenza viruses from migratory birds to US-based bird handlers has potentially significant public health and economic consequences.

Evaluation of the seroprevalence of influenza A(H1N1) 2009 on a university campus: a cross-sectional study.

BACKGROUND: Human infection with influenza A(H1N1) 2009 was first identified in the United States on 15 April 2009 and on 11 June 2009, WHO declared that the rapidly spreading swine-origin influenza virus constituted a global pandemic. We evaluated the seroprevalence of influenza A(H1N1) 2009 virus on a large public University campus, as well as disparities in demographic, symptomatic and vaccination characteristics of participants. METHODS: Using a cross-sectional study design, sera was collected from volunteers and then tested for the presence of antibodies to the virus using a ≥ 1:40 dilution cut-off by hemagglutination inhibition assay. In conjunction, participants were asked to complete a questionnaire allowing us to estimate risk factors for infection in this population, as well as distinguish artificially derived antibodies from naturally derived antibodies. RESULTS: 300 total participants were recruited and tested. 158 (52.6%) tested positive for influenza A(H1N1) 2009 via hemagglutination inhibition assay using a ≥ 1:40 dilution cut-off. 86 people (54.4%) tested positive for H1N1 but did not report experiencing symptoms during the pandemic meeting the May 2010 CDC definition of influenza-like illness. Furthermore, of those individuals who reported that they had received the H1N1 vaccine, 16% did not test positive. CONCLUSIONS: Overall, 52.7% of the total study population tested positive for influenza A(H1N1) 2009. 54.4% of those who tested positive for influenza A(H1N1) 2009 using the ≥ 1:40 dilution cut-off on the hemagglutination inhibition assay in this study population did not report experiencing symptoms during the pandemic meeting the May 2010 CDC definition of influenza-like illness. 16% of those who reported receiving the H1N1 vaccine did not test positive by HAI. We also found that vaccination coverage for H1N1 vaccine was poor among Blacks and Latinos, despite the fact that vaccine was readily available at no cost.

Viability of Baylisascaris procyonis Eggs.

Infection with Baylisascaris procyonis roundworms is rare but often fatal and typically affects children. We attempted to determine parameters of viability and methods of inactivating the eggs of these roundworms. Loss of viability resulted when eggs were heated to 62°C or desiccated for 7 months but not when frozen at -15°C for 6 months.

Congenital cytomegalovirus mortality in the United States, 1990-2006.

BACKGROUND: Congenital cytomegalovirus (CMV) infection is the most common intrauterine infection in the United States disproportionately affecting minority races and those of lower socio-economic class. Despite its importance there is little information on the burden of congenital CMV-related mortality in the US. To measure congenital CMV-associated mortality in the US and assess possible racial/ethnic disparities, we reviewed national death certificate data for a 17-year period. METHODS: Congenital CMV-associated deaths from 1990 through 2006 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. RESULTS: A total of 777 congenital CMV-associated deaths occurred over the 17-year study period resulting in 56,355 years of age-adjusted years of potential life lost. 71.7% (557) of congenital CMV-associated deaths occurred in infants (age less than 1 year). Age-adjusted mortality rates stratified by race/ethnicity revealed mortality disparities. Age-adjusted rate ratios were calculated for each racial/ethnic group using whites as the reference. Native Americans and African Americans were 2.34 (95% CI, 2.11-2.59) and 1.89 (95% CI, 1.70-2.11) times respectively, more likely to die from congenital CMV than whites. Asians and Hispanics were 0.54 (95% CI, 0.44-0.66) and 0.96 (95% CI, 0.83-1.10) times respectively, less likely to die from congenital CMV than whites. CONCLUSIONS/SIGNIFICANCE: Congenital CMV infection causes appreciable mortality in the US exacting a particular burden among African Americans and Native Americans. Enhanced surveillance and increased screening are necessary to better understand the epidemiology of congenital CMV infection in addition to acceleration of vaccine development efforts.

Current issues and considerations regarding trichomoniasis and human immunodeficiency virus in African-Americans.

Trichomonas vaginalis has long been recognized as one of the most prevalent sexually transmitted infections. However, it is only in recent years that it has been appreciated that Trichomonas may play a critical role in amplifying human immunodeficiency virus (HIV) transmission. Given the evidence that T. vaginalis likely promotes HIV infection, the apparent high level of Trichomonas infection in the African-American community is cause for concern. Even if T. vaginalis increases the risk of HIV transmission by a small or modest amount, it translates into a sizable population effect since Trichomonas is so common in this community. Therefore, control of trichomoniasis may represent an important avenue of control for the prevention of HIV transmission, particularly among African-Americans.

A novel method to increase the viability of Trichomonas vaginalis in urine.

OBJECTIVES: Two of the major diagnostic methods for Trichomonas vaginalis, wet mount and culture, rely on the continued viability of the organism. Methods to increase the viability of T. vaginalis in urine are needed. GOAL: The goal of this study was to develop a method that increases the time of viability of T. vaginalis in urine. STUDY DESIGN: Urine samples were inoculated with trichomonads, held at either room temperature or 37 degrees C, and processed through a column and frit, which was then placed in either a tube of culture medium containing antibiotics or a TV InPouch. RESULTS: The column and polyethylene frit system was found to increase the duration of viability for T. vaginalis from urine specimens at least 6-fold. CONCLUSION: This novel method, which uses a column and frit system to increase the duration of viability of the organism, has the potential to increase the sensitivity of diagnostic tests.

Viability of Trichomonas vaginalis in urine: epidemiologic and clinical implications.

The impact of the viability of Trichomonas vaginalis in urine on wet mount, culture, and PCR methods was assessed. To minimize the chance of false-negative results, urine specimens should be processed within 30 min of specimen collection and maintained at 37 degrees C, since temperature appears to affect the viability of Trichomonas.

Central nervous system and eye manifestations of infection with Baylisascaris procyonis.

Baylisascaris procyonis, a parasitic infection of raccoons, causes severe neurologic and ocular disease in humans when infectious eggs from raccoon feces are ingested. In the absence of a serologic test, definitive diagnosis is challenging but can be made by isolation of larvae in brain biopsy, direct visualization of the worm in the eye, or exclusion of other potential causes of eosinophilic meningoencephalitis. Currently, no effective treatment has been identified, making preventive efforts critical.

Severe and fatal central nervous system disease in humans caused by Baylisascaris procyonis, the common roundworm of raccoons: a review of current literature.

Baylisascaris procyonis, a parasitic infection of raccoons, causes severe neurologic disease in humans when infective eggs from raccoon feces are ingested. Definitive diagnosis is challenging, but can be made by isolation of larvae in brain biopsy or exclusion of other potential causes of eosinophilic meningoencephalitis. Prevention efforts are critical due to the lack of effective treatment.