Jay K Varma

Centers for Disease Control and Prevention, Атланта, Michigan, United States

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Publications (116)644.24 Total impact

  • Emerging infectious diseases 08/2015; 21(8). DOI:10.3201/eid2108.141837 · 7.33 Impact Factor
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    DESCRIPTION: Check Hep C was implemented in 2012-2013 by the New York City Department of Health and Mental Hygiene (DOHMH) as a year-long demonstration project designed to increase screening, diagnosis, and linkage to care for persons chronically infected with HCV in NYC.
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    ABSTRACT: In late October 2014, Ebola virus disease (Ebola) was diagnosed in a humanitarian aid worker who recently returned from West Africa to New York City (NYC). The NYC Department of Health and Mental Hygiene (DOHMH) actively monitored three close contacts of the patient and 114 health care personnel. No secondary cases of Ebola were detected. In collaboration with local and state partners, DOHMH had developed protocols to respond to such an event beginning in July 2014. These protocols included safely transporting a person at the first report of symptoms to a local hospital prepared to treat a patient with Ebola, laboratory testing for Ebola, and monitoring of contacts. In response to this single case of Ebola, initial health care worker active monitoring protocols needed modification to improve clarity about what types of exposure should be monitored. The response costs were high in both human resources and money: DOHMH alone spent $4.3 million. However, preparedness activities that include planning and practice in effectively monitoring the health of workers involved in Ebola patient care can help prevent transmission of Ebola.
    MMWR. Morbidity and mortality weekly report 04/2015; 64(12):321-3.
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    ABSTRACT: Foodborne botulism is a severe, paralytic illness caused by ingestion of preformed neurotoxins produced by Clostridium botulinum. In 2003, we conducted a population-based household survey of home canning practices to explore marked regional variations in botulism incidence in the Republic of Georgia (ROG). We designed a cluster sampling scheme and subdivided each of the 10 regions of the ROG into a variable number of strata. Households were selected from each stratum using a two-step cluster sampling methodology. We administered a questionnaire about home canning practices to household members responsible for food preparation. Using multivariate logistic regression analysis, we modeled high (eastern ROG) against low (western ROG) incidence areas. Overall, we surveyed 2,742 households nationwide. Home canning with a capping device hermetically sealing the lid covering the jar was practiced by 1,909 households (65.9%; 95% confidence interval [CI]: 59.8 to 72.1%). Canning was more prevalent in regions of low botulism incidence (34 versus 32%; P 1 tablespoon of salt per liter (aOR = 5.1; 95% CI: 1.2 to 22.6); vinegar (aOR = 2.2; 95% CI: 1.3 to 3.7), and greens (aOR = 5.6; 95% CI: 1.7 to 18.2). The following practices were associated with a decreased risk in high-botulism areas: >57 jars canned per household annually (aOR = 0.5; 95% CI: 0.3 to 0.9), covering or immersing vegetables in boiling water before placing them into the jar (aOR = 0.3 95% CI: 0.2 to 0.6), covering or immersing vegetables in boiling water after placing them into the jar (aOR = 0.4; 95% CI: 0.2 to 0.9), or adding garlic (aOR = 0.2; 95% CI: 0.1 to 0.5) or aspirin (aOR = 0.1; 95% CI: 0.1 to 0.2) to the jar at the time of preparation.
    Journal of food protection 04/2015; 78(4):746-50. DOI:10.4315/0362-028X.JFP-14-533 · 1.80 Impact Factor
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    ABSTRACT: In July 2014, as the Ebola virus disease (Ebola) epidemic expanded in Guinea, Liberia, and Sierra Leone, an air traveler brought Ebola to Nigeria and two American health care workers in West Africa were diagnosed with Ebola and later medically evacuated to a U.S. hospital. New York City (NYC) is a frequent port of entry for travelers from West Africa, a home to communities of West African immigrants who travel back to their home countries, and a home to health care workers who travel to West Africa to treat Ebola patients. Ongoing transmission of Ebolavirus in West Africa could result in an infected person arriving in NYC. The announcement on September 30 of an Ebola case diagnosed in Texas in a person who had recently arrived from an Ebola-affected country further reinforced the need in NYC for local preparedness for Ebola.
    American Journal of Transplantation 10/2014; 63(41):934-936. DOI:10.1111/ajt.13114 · 6.19 Impact Factor
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    ABSTRACT: Background: To control an outbreak of invasive meningococcal disease (IMD) among men who have sex with men (MSM) in New York City (NYC), the NYC Department of Health and Mental Hygiene (DOHMH) recommended vaccination of all HIV-positive MSM and HIV-negative MSM with intimate contact with a man met through an online Web site, digital application or at a bar or party Methods: We used a decision analytic model to estimate the effectiveness and cost-effectiveness of the meningococcal quadrivalent conjugate vaccination campaign as compared to no vaccination. We estimated approximately 60,000 NYC MSM to be targeted through DOHMH recommendations based on NYC Community Health Survey and NYC HIV/AIDS surveillance registry data. Model inputs, including IMD incidence of 20.5 per 100,000 HIV-positive MSM (42% fatal) and 7.6 per 100,000 HIV-negative MSM (20% fatal), were from DOHMH data and published sources. Outcome measures included costs (2012 US dollars), IMD cases averted, IMD deaths averted, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios ($/QALY). Sensitivity analyses were performed on key inputs including herd immunity (base case 20% protection in all unvaccinated MSM). Results: Compared to no vaccination, the targeted vaccination campaign averted an estimated 2.7 IMD cases (modeled range 0.9-6.0) and 1.0 IMD deaths (modeled range 0.2-2.5) and had an incremental cost-effectiveness ratio of $60,100/QALY. At a cost-effectiveness threshold of $100,000/QALY, vaccination remained cost-effective at an IMD incidence as low as 10 per 100,000 persons or at a case fatality rate greater than 13% in all MSM. At a societal willingness to pay consistent with adopted meningococcal vaccination guidelines for adolescents ($230,000/QALY), vaccination was cost-effective at an IMD incidence as low as 5 per 100,000 persons. Results were sensitive to assumptions regarding herd immunity (Figure). Conclusion: Vaccination during a community-wide IMD outbreak among MSM in NYC was projected to avert IMD cases and deaths and had an incremental cost-effectiveness ratio less than $100,000/QALY. Cost-effectiveness was highly dependent on herd immunity.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
  • 2014 Council of State and Territorial Epidemiologists Annual Conference; 06/2014
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    ABSTRACT: In New York City, which was the epicenter of the U.S. tuberculosis epidemic in the 1990s, funding for tuberculosis control has been cut by more than 50%, and in 2014 the city reported its first increase in cases after a decade of continuous reductions.
    New England Journal of Medicine 06/2014; 370(25):2362-2365. DOI:10.1056/NEJMp1402147 · 54.42 Impact Factor
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    ABSTRACT: Integration of public health surveillance data within health departments is important for public health activities and cost-efficient coordination of care. Access to and use of surveillance data are governed by public health law and by agency confidentiality and security policies. In New York City, we examined public health laws and agency policies for data sharing across HIV, sexually transmitted disease, tuberculosis, and viral hepatitis surveillance programs. We found that recent changes to state laws provide greater opportunities for data sharing but that agency policies must be updated because they limit increased data integration. Our case study can help other health departments conduct similar reviews of laws and policies to increase data sharing and integration of surveillance data.
    American Journal of Public Health 06/2014; 104(6):993-7. DOI:10.2105/AJPH.2013.301775 · 4.23 Impact Factor
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    ABSTRACT: Background. Infection with hepatitis C virus (HCV) increases the risk of death from liver and non-liver related diseases. Co-infection with HIV further increases this risk. Methods. Surveillance data (2000-2010) and mortality data (2000 - 2011) maintained by the New York City Department of Health and Mental Hygiene (DOHMH) were deterministically cross-matched. Factors associated with and causes of death among HCV-infected adult decedents were analyzed. Results. Between 2000 and 2011, 13,307 HCV mono-infected adults died, and 5,475 adults co-infected with HCV/HIV died. Decedents with HCV mono-infection were more likely to have died of liver cancer (OR=9.2), drug-related causes (OR=4.3), and cirrhosis (OR=3.7) as compared with persons with neither infection. HCV/HIV co-infected decedents were more likely to have died of liver cancer (OR=2.2) and drug-related causes (OR=3.1) as compared with persons with neither infection. Among co-infected decedents, 53.6% of deaths were attributed to HIV/AIDS; and 94% of deaths occurred prematurely, before age 65. Among persons with HCV who died, over half died within three years of a hepatitis C report to DOHMH. Conclusion. HCV-infected adults were at increased risk of dying and of dying prematurely, particularly from conditions associated with HCV, such as HIV/AIDS or drug use. The short interval between HCV report and death suggests a need for earlier testing and improved treatment.
    Clinical Infectious Diseases 02/2014; DOI:10.1093/cid/ciu075 · 9.42 Impact Factor
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    ABSTRACT: Hand, foot, and mouth disease is a common childhood illness caused by enteroviruses. Increasingly, the disease has a substantial burden throughout east and southeast Asia. To better inform vaccine and other interventions, we characterised the epidemiology of hand, foot, and mouth disease in China on the basis of enhanced surveillance. We extracted epidemiological, clinical, and laboratory data from cases of hand, foot, and mouth disease reported to the Chinese Center for Disease Control and Prevention between Jan 1, 2008, and Dec 31, 2012. We then compiled climatic, geographical, and demographic information. All analyses were stratified by age, disease severity, laboratory confirmation status, and enterovirus serotype. The surveillance registry included 7 200 092 probable cases of hand, foot, and mouth disease (annual incidence, 1·2 per 1000 person-years from 2010-12), of which 267 942 (3·7%) were laboratory confirmed and 2457 (0·03%) were fatal. Incidence and mortality were highest in children aged 12-23 months (38·2 cases per 1000 person-years and 1·5 deaths per 100 000 person-years in 2012). Median duration from onset to diagnosis was 1·5 days (IQR 0·5-2·5) and median duration from onset to death was 3·5 days (2·5-4·5). The absolute number of patients with cardiopulmonary or neurological complications was 82 486 (case-severity rate 1·1%), and 2457 of 82486 patients with severe disease died (fatality rate 3·0%); 1617 of 1737 laboratory confirmed deaths (93%) were associated with enterovirus 71. Every year in June, hand, foot, and mouth disease peaked in north China, whereas southern China had semiannual outbreaks in May and September-October. Geographical differences in seasonal patterns were weakly associated with climate and demographic factors (variance explained 8-23% and 3-19%, respectively). This is the largest population-based study up to now of the epidemiology of hand, foot, and mouth disease. Future mitigation policies should take into account the heterogeneities of disease burden identified. Additional epidemiological and serological studies are warranted to elucidate the dynamics and immunity patterns of local hand, foot, and mouth disease and to optimise interventions. China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases, WHO, The Li Ka Shing Oxford Global Health Programme and Wellcome Trust, Harvard Center for Communicable Disease Dynamics, and Health and Medical Research Fund, Government of Hong Kong Special Administrative Region.
    The Lancet Infectious Diseases 01/2014; 14(4). DOI:10.1016/S1473-3099(13)70342-6 · 19.45 Impact Factor
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    ABSTRACT: For nearly a decade, interest groups, from politicians to economists to physicians, have touted digitization of the nation's health information. One frequently mentioned benefit is the transmission of information electronically from laboratories to public health personnel, allowing them to rapidly analyze and act on these data. Switching from paper to electronic laboratory reports (ELRs) was thought to solve many public health surveillance issues, including workload, accuracy, and timeliness. However, barriers remain for both laboratories and public health agencies to realize the full benefits of ELRs. The New York City experience highlights several successes and challenges of electronic reporting and is supported by peer-reviewed literature. Lessons learned from ELR systems will benefit efforts to standardize electronic medical records reporting to health departments. (Am J Public Health. Published online ahead of print January 16, 2014: e1-e6. doi:10.2105/AJPH.2013.301753).
    American Journal of Public Health 01/2014; 104(3). DOI:10.2105/AJPH.2013.301753 · 4.23 Impact Factor
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    ABSTRACT: In 2012, the New York City Department of Health and Mental Hygiene matched HIV, tuberculosis, viral hepatitis, and sexually transmitted disease surveillance data to identify the burden of infection with multiple diseases. HIV, tuberculosis, hepatitis B, hepatitis C, chlamydia, gonorrhea, and syphilis surveillance data from 2000 to 2010 were matched using a deterministic method. Data on deaths from the Department of Health and Mental Hygiene's Office of Vital Statistics were also matched. The final data set contained 840,248 people; 13% had 2 or more diseases. People with a report of syphilis had the highest proportion of matches with other diseases (64%), followed by gonorrhea (52%), HIV (31%), tuberculosis (23%), hepatitis C (20%), chlamydia (16%), and hepatitis B (11%). The findings indicate several possible infectious disease syndemics in New York City and highlight the need to integrate surveillance data from different infectious disease programs. Conducting the match brought surveillance programs together to work collaboratively and has resulted in ongoing partnerships on programmatic activities that address multiple diseases.
    Journal of public health management and practice: JPHMP 12/2013; 20(5). DOI:10.1097/PHH.0b013e3182a95607 · 1.47 Impact Factor
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    ABSTRACT: Severe acute respiratory illness (SARI) surveillance began in Jingzhou City, China, in 2010. A subset of 511 children aged <5 years enrolled in the SARI study during 2011 were tested for influenza and noninfluenza respiratory viral infection by real-time reverse-transcription polymerase chain reaction. Respiratory syncytial virus (RSV) was most commonly detected. Children aged 12–23 and 24–60 months were equally likely to test positive for RSV. Although cases of RSV infection could be detected throughout the year, the greatest numbers were detected from autumn to early winter.
    The Journal of Infectious Diseases 11/2013; 208(suppl 3):S184-S188. DOI:10.1093/infdis/jit518 · 5.78 Impact Factor
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    ABSTRACT: Published data on influenza in severe acute respiratory infection (SARI) patients are limited. We conducted SARI surveillance in central China and estimated hospitalization rates of SARI attributable to influenza by viral type/subtype. Surveillance was conducted at four hospitals in Jingzhou, China from 2010 to 2012. We enrolled hospitalized patients who had temperature ≥37·3°C and at least one of: cough, sore throat, tachypnea, difficulty breathing, abnormal breath sounds on auscultation, sputum production, hemoptysis, chest pain, or chest radiograph consistent with pneumonia. A nasopharyngeal swab was collected from each case-patient within 24 hours of admission for influenza testing by real-time reverse transcription PCR. Of 17 172 SARI patients enrolled, 90% were aged <15 years. The median duration of hospitalization was 5 days. Of 16 208 (94%) SARI cases tested, 2057 (13%) had confirmed influenza, including 1427 (69%) aged <5 years. Multiple peaks of influenza occurred during summer, winter, and spring months. Influenza was associated with an estimated 115 and 142 SARI hospitalizations per 100 000 during 2010-2011 and 2011-2012 [including A(H3N2): 55 and 44 SARI hospitalizations per 100 000; pandemic A(H1N1): 33 SARI hospitalizations per 100 000 during 2010-2011; influenza B: 26 and 98 hospitalizations per 100 000], with the highest rate among children aged 6-11 months (3603 and 3805 hospitalizations per 100 000 during 2010-2011 and 2011-2012, respectively). In central China, influenza A and B caused a substantial number of hospitalizations during multiple periods each year. Our findings strongly suggest that young children should be the highest priority group for annual influenza vaccination in China.
    Influenza and Other Respiratory Viruses 11/2013; 8(1). DOI:10.1111/irv.12205 · 1.90 Impact Factor
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    ABSTRACT: Objectives: A syndemic is infection with two or more diseases which interact to worsen the health impact of either disease alone. We sought to identify syndemics in NYC by matching the HIV, TB, viral hepatitis, and STD surveillance databases. Methods: Deterministic matching was used to link cases of disease reported to the NYC Department of Health and Mental Hygiene (DOHMH). We included incident cases of TB, chlamydia, gonorrhea, and syphilis diagnosed between 1/1/00 and 12/31/10; and prevalent and incident cases of HIV, hepatitis B, and hepatitis C, excluding those known to have died before 2000. A line-listed, de-identified dataset was created for analysis, including non-matching and matching records. Results: 955,944 non-unique individuals were in the analytic dataset; 12% matched to at least one other disease. Persons with syphilis were most likely to match to at least one other disease (64%), and those with hepatitis B were the least likely to match (11%). Four diseases had the highest percentage of matches with HIV: syphilis (50% matching to HIV), hepatitis C (15%), TB (14%), hepatitis B (5%). People with a reported case of gonorrhea had the highest percentage of matches with chlamydia (46%); and chlamydia had the highest percentages of matches with gonorrhea (14%). People with HIV had the greatest overlap with hepatitis C (16%). Conclusions: In the absence of integrated surveillance systems, matching surveillance data can help us understand the prevalence of infectious disease syndemics, and to appropriately target services to address them. Matching can also create opportunities for collaboration between disease-specific programs within health departments.
    141st APHA Annual Meeting and Exposition 2013; 11/2013
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    ABSTRACT: Background: Persons with hepatitis C (HCV)/HIV co-infection are at greater risk of death than those with HCV only, but the impact of HIV on mortality among people with HCV has not been well studied in New York City (NYC). We analyzed mortality trends and risk of death among persons with HCV alone, and HCV/HIV-co-infection in NYC. Methods: The NYC Department of Health and Mental Hygiene (DOHMH) implemented CDC's Program Collaboration and Service Integration initiative to better understand the interaction between infectious diseases in NYC. We conducted a retrospective, deterministic cross-match of HIV and HCV surveillance databases with data from 2000-2010, and NYC death registry data from 2000-2011. We examined changes in the proportion of HCV cases with HIV over time, and used survival analysis to compare progression to death in the two groups over the 10-year period, controlling for age. Results: Of persons diagnosed with HCV in 2000, 8% were diagnosed with HIV. This proportion of co-infected HCV cases increased to 17% in 2010. During the study period, 19% of HCV/HIV co-infected persons died within 3 years of their HCV diagnosis, compared with 9% of persons with HCV only (<.0001). The annual risk of death was 5.5 times higher for co-infected cases compared with the HCV-only group (p<.0001). Conclusion: Given the higher risk of death among persons with HCV/HIV co-infection, the NYC DOHMH is developing a strategy to improve HCV testing among people with HIV, and to prioritize linkage to medical care for co-infected persons who are not in care.
    141st APHA Annual Meeting and Exposition 2013; 11/2013
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    ABSTRACT: Background: One-quarter of all deaths of people living with HIV (PLHIV) are due to tuberculosis (TB). Extrapulmonary TB, common in PLHIV, is associated with negative sputum test result, delayed diagnosis and increased mortality, especially among severely immunocompromised persons. We evaluated urine testing for TB in PLHIV, because urine is the easiest specimen to obtain and does not generate infectious aerosols. Methods: We examined the diagnostic yield of urine culture (UC) from a cross-sectional study of PLHIV in Cambodia, Thailand, and Vietnam during 2006–2008. Sputum, blood, urine, stool, and lymph node specimens (for those with a lymph node >1cm) were obtained for mycobacterial culture from all patients. TB was confirmed if at least one specimen culture was positive for Mycobacterium tuberculosiscomplex. Logistic regression was performed to assess associations with positive UC among all patients with confirmed TB. Results: Of 1,898 PLHIV, 253 (13%) had confirmed TB; of these, 138 (55%) had a positive extrapulmonary culture result. Of the 138, 46 (33%) had a positive UC result; of these, 30 (65%) had a CD4+ T-lymphocyte (CD4) count of <50 cells/µL. Among those with confirmed TB, PLHIV with a positive UC result were more likely to have a CD4 count of <50 cells/µL (odds ratio [OR]: 11.2; confidence interval [CI]: 3.7–33.6) and a fever (OR: 11.2; CI: 2.6–47.7). Of the 8 patients with only extrapulmonary TB and CD4 <50 cell/µl, 3 (38%) were diagnosed exclusively by UC. Conclusion: Mycobacterial UC identified a substantial proportion of HIV-infected TB patients with CD4 <50 cells/µL whose TB would not otherwise have been diagnosed. UC may increase confirmation of TB disease in PLHIV with severe immune compromise.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013
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    ABSTRACT: Background: Outbreaks of hepatitis C virus infection (HCV) among HIV-infected MSM have been reported in New York and other cities, suggesting that MSM may be at risk of acquiring HCV sexually. We examined trends and characteristics of persons with both an HIV and HCV report in NYC, comparing MSM to non-MSM. Methods: The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented CDC’s Program Collaboration and Service Integration (PCSI) initiative to improve understanding of infectious diseases in NYC. We conducted a retrospective, deterministic cross-match of NYC’s HIV and chronic HCV surveillance data from 2000-2010, and vital statistics data from 2000-2011. We restricted our analysis to persons diagnosed and living with HIV/AIDS (PLWHA) who were alive as of January 1, 2000 and subsequently diagnosed with HCV. We analyzed demographic characteristics and timing of diagnoses of persons with reports of HIV and HCV. Using survival analysis, we compared progression to death between the MSM and non-MSM groups over the 10-year period, controlling for demographic factors. Results: There were 140,685 PLWHA in NYC in 2000; 16% of these (N=23,101) were reported with a HCV diagnosis during the study period. In 2000, 8% of PLWHA diagnosed with HCV were MSM; in 2010, 31% were MSM. Among persons with HIV and HCV infection, 34% of MSM were white compared with 12% of non-MSM; 47% of MSM cases lived in Manhattan compared with 25% of non-MSM. MSM cases were more likely to have other sexually transmitted diseases such as hepatitis B and syphilis. MSM cases were less likely to have died (18%) during the study period than non-MSM (37%). In survival analysis, MSM were half as likely to progress to death as non-MSM (p<.0001). Conclusion: The prevalence of HCV co-infection is increasing among HIV-infected MSM, although this may partly be because they live longer than co-infected persons with other HIV risk factors such as injection drug use. Future research is necessary to confirm if sexual transmission of HCV is increasing among HIV-infected MSM.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013
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    ABSTRACT: Background: Nationally and in New York City, the number of hepatitis C virus (HCV)-related deaths is projected to continue to rise. HCV infection is strongly associated with excess mortality due to viral hepatitis infection, liver cancer, and cirrhosis. We identified factors associated with dying of these causes among people with HCV infection in NYC. Methods: The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented CDC’s Program Collaboration and Service Integration (PCSI) initiative to improve understanding of infectious diseases in NYC. We conducted a retrospective, deterministic cross-match of HIV and HCV surveillance data from 2000-2010, and vital statistics data from 2000-2011. HCV is a reportable disease; all positive antibody tests are included in the dataset. For this analysis, we examined trends in deaths due to liver cancer, cirrhosis, and viral hepatitis, all of which may be caused or exacerbated by HCV infection. Cox proportional hazard models were used to estimate multivariate-adjusted hazard ratios (HR) and 95% confidence intervals of demographic determinants associated with specific causes of deaths for people with HCV infection. Results: Among all persons with a positive HCV test in NYC, viral hepatitis, liver cancer, and cirrhosis deaths have been increasing from 2000 to 2010. Among HCV-diagnosed persons that died, younger age at death was associated with viral hepatitis and cirrhosis (<.01 for both comparisons), while older age at death was associated with liver cancer (<.01). HCV-diagnosed men were more likely than HCV-diagnosed women to die from liver cancer, cirrhosis, and illicit drugs (p<0.05 for all comparisons). Asian/Pacific Islanders were at higher risk of liver cancer and viral hepatitis than whites (p<.01 for both comparisons). Conclusion: Demographic factors are associated with different causes of death from HCV-related conditions. Among people with HCV infection, older Asian/Pacific Islander men may particularly benefit from screening for liver cancer.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013

Publication Stats

2k Citations
644.24 Total Impact Points

Institutions

  • 2004–2015
    • Centers for Disease Control and Prevention
      • • Division of Tuberculosis Elimination
      • • Division of Bacterial Diseases
      Атланта, Michigan, United States
  • 2012–2014
    • New York City Department of Health and Mental Hygiene
      לאנג איילענד סיטי, New York, United States
    • Guangdong Center for Disease Control and Prevention
      Shengcheng, Guangdong, China
  • 2012–2013
    • Beijing Centers for Disease Control and Prevention
      Peping, Beijing, China
  • 2011
    • Chinese Center For Disease Control And Prevention
      Peping, Beijing, China
  • 2008–2010
    • Ministry of Public Health, Thailand
      Krung Thep, Bangkok, Thailand
  • 2009
    • Ubon Ratchathani University
      Muang Ubon, Changwat Ubon Ratchathani, Thailand
    • Bangkok Metropolitan Administration
      Krung Thep, Bangkok, Thailand
  • 2005
    • Statens Serum Institut
      København, Capital Region, Denmark
  • 2003
    • National Institute of Allergy and Infectious Diseases
      Maryland, United States