Jay K Varma

New York City Department of Health and Mental Hygiene, New York, United States

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Publications (82)443.16 Total impact

  • [Show abstract] [Hide abstract]
    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; · 19.97 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; · 1.47 Impact Factor
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    ABSTRACT: Listeria is an important foodborne pathogen with severe manifestations and high case-fatality rate. However, listeriosis is not yet a notifiable disease in China, and there is no national monitoring system for cases. We conducted a systematic review to better understand the clinical and epidemiologic features of listeriosis in China. Both electronic and manual retrieval systems were used to search Chinese literature for cases and isolates of human listeriosis reported between 1964 and 2010. We recorded and analysed demographic, clinical and laboratory information available for reported cases. A total of 147 clinical cases, 479 Listeria isolates and 82 outbreak-related cases were reported in 28 (90%) provinces in China from January 1964 to December 2010. Of the clinical cases, 45 (31%) were central nervous system infections, 68 (46%) were septicaemia and 34 (23%) were focal infections or gastroenteritis. The overall case-fatality rate was 26% (34/130) among clinical cases with known outcomes and 46% (21/46) among neonatal cases. Listeriosis cases occurred in China throughout the study period between 1964 and 2010. Case-fatality was similar to published data from other countries. China should consider requiring notification of listeriosis cases to improve estimates of incidence, identification of risk factors and design of preventive measures.
    Tropical Medicine & International Health 10/2013; 18(10):1248-56. · 2.94 Impact Factor
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    ABSTRACT: Delayed diagnosis of tuberculosis (TB) increases mortality. To evaluate whether stool culture improves the diagnosis of TB in people living with the human immunodeficiency virus (PLHIV). We analysed cross-sectional data of TB diagnosis in PLHIV in Cambodia, Thailand and Viet Nam. Logistic regression was used to assess the association between positive stool culture and TB, and to calculate the incremental yield of stool culture. A total of 1693 PLHIV were enrolled with a stool culture result. Of 228 PLHIV with culture-confirmed TB from any site, 101 (44%) had a positive stool culture; of these, 91 (90%) had pulmonary TB (PTB). After adjusting for confounding factors, a positive stool culture was associated with smear-negative (odds ratio [OR] 26, 95% confidence interval [CI] 12-58), moderately smear-positive (OR 60, 95%CI 23-159) and highly smear-positive (OR 179, 95%CI 59-546) PTB compared with no PTB. No statistically significant association existed with extra-pulmonary TB compared with no extra-pulmonary TB (OR 2, 95%CI 1-5). The incremental yield of one stool culture above two sputum cultures (5%, 95%CI 3-8) was comparable to an additional sputum culture (7%, 95%CI 4-11). Nearly half of the PLHIV with TB had a positive stool culture that was strongly associated with PTB. Stool cultures may be used to diagnose TB in PLHIV.
    The International Journal of Tuberculosis and Lung Disease 08/2013; 17(8):1023-8. · 2.76 Impact Factor
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    ABSTRACT: Drug resistance substantially increases tuberculosis (TB) mortality. This study aimed to describe the prevalence of mycobacterial drug resistance pattern and association of common resistance patterns with TB mortality in Thailand. A retrospective cohort study was conducted using TB surveillance data. A total of 9,518 culture-confirmed, pulmonary TB patients registered from 1 October 2004 to 31 December 2008 from the Thailand TB Active Surveillance Network were included in this study. Patients were followed up until TB treatment completion or death. Mycobacterial drug resistance patterns were categorized as pan-susceptible, rifampicin resistance, isoniazid monoresistance, and ethambutol/streptomycin resistance. Drug susceptibility testing (DST) was determined by Mycobacterial Growth Indicator Tube (MGIT) liquid culture systems. Survival analysis was applied. Isoniazid monoresistance was the most common pattern, while rifampicin resistance had the largest impact on mortality. Cox regression analysis showed a significantly higher risk of death among patients with rifampicin resistance (adjusted hazard ratio (aHR) 1.9, 95% confident interval (CI), 1.5-2.5) and isoniazid monoresistance (aHR 1.4, 95% CI 1.1-1.7) than those with pan-susceptible group after adjustment for age, nationality, human immunodeficiency virus (HIV) and antiretroviral therapy (ART) status, diabetes mellitus, cavitary disease on chest x-ray, treatment observation, and province. HIV co-infection was associated with higher mortality in patients both on ART (aHR 1.9, 95% CI 1.5-2.5) and not on ART (aHR 8.1, 95% CI 6.8-9.8). Rifampicin resistance and isoniazid monoresistance were associated with increased TB mortality. HIV-coinfection was associated with a higher risk of death including among those taking antiretroviral therapy.
    Global journal of health science 01/2013; 5(6):60-72.
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    Shua J Chai, Carol Y Rao, Jay K Varma
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    ABSTRACT: To the Editor: The study by Gler et al. (June 7 issue)(1) provides a needed reminder regarding the development pipeline for drugs for tuberculosis and multidrug-resistant (MDR) tuberculosis.(2) Delamanid with bedaquiline is increasing the potential for improving current regimens for tuberculosis. In their editorial in the same issue, Chaisson and Nuermberger(3) go one step further, posing the question of how these drugs should be used and highlighting the need for combination trials to maximize effectiveness and minimize negative drug interactions among new drugs for tuberculosis. These issues are of key importance. Knowing the complexity of tuberculosis control and the difficulty . . .
    New England Journal of Medicine 11/2012; 367(22):2154-6. · 54.42 Impact Factor
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    Dataset: Fujie
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  • Hongjie Yu, Weizhong Yang, Jay K Varma
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    ABSTRACT: Despite rapid economic development, China has not yet incorporated into its national childhood immunization program vaccines against Streptococcus pneumoniae and Haemophilus influenzae type b. Both vaccines can prevent pneumonia, the leading infectious disease killer of young children in China. In contrast, the other World Health Organization member nations with the ten largest birth cohorts have included H. influenzae type b in their national childhood immunization programs, and many of the world's wealthiest and poorest countries have done the same with S. pneumoniae. In this article we review what is known about S. pneumoniae and H. influenzae type b in China, and we make recommendations for how to accelerate the use of vaccines against these pathogens in that country. We propose that China adopt a "Chinese Accelerated Vaccine Initiative" modeled after other successful global programs. This broad effort would marshal the evidence and commitment needed to change vaccine policy, then develop and implement a plan for a sustainable, affordable supply of these and other new vaccines.
    Health Affairs 11/2012; 31(11):2545-53. · 4.64 Impact Factor
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    ABSTRACT: Health care workers (HCWs) are at increased risk for tuberculosis (TB) infection. In China, surveys examining TB infection among HCWs have not studied general health care facilities, compared tuberculin tests conducted using local protocols against an internationally accepted test or characterised risk factors. To measure the prevalence of and risk factors for TB infection among HCWs in Inner Mongolia, China. Between April and August 2010, we administered QuantiFERON®-TB Gold In-Tube (QFT-GIT) tests, skin tests using Chinese tuberculin (TST) and surveys among HCWs at an infectious diseases hospital and a general medical hospital. We assessed whether demographic characteristics, personal exposure and work exposure were associated with QFT-GIT and TST positivity, and assessed agreement between test results. Of 999 HCWs, 683 (68%) were QFT-GIT-positive, which was associated with greater age, longer HCW career, TB disease in a co-worker and greater daily patient exposure using multivariable analysis. TST reactions ≥ 5 mm occurred in 69% of the HCWs; agreement between test results was low ( 0.22). The prevalence of TB infection among HCWs in Inner Mongolia is high; infection was associated with occupational exposure. Results from locally conducted TST are difficult to interpret. In China, TB infection control in health care facilities should be strengthened.
    The International Journal of Tuberculosis and Lung Disease 09/2012; 16(11):1485-91. · 2.76 Impact Factor
  • Kevin P Cain, Jay K Varma
    The International Journal of Tuberculosis and Lung Disease 09/2012; 16(9):1138. · 2.76 Impact Factor
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    ABSTRACT: Tuberculin skin test (TST) identifies patients highly likely to benefit from isoniazid preventive therapy and tuberculosis (TB) prevalence may differ by TST status. We evaluated latent and active TB screening and diagnosis strategies among people living with HIV (PLHIV) incorporating TST as the initial screening step. PLHIV attending services at the Thai Red Cross Anonymous Clinic during September 2006 to January 2008 were enrolled. TB disease was defined as any positive Mycobacterium tuberculosis (MTB) specimen culture from sputum, urine, stool, lymph node aspiration, and blood. The performance of symptom screening (>1 of: any cough, any fever, night sweats lasting 3 or more weeks in the preceding 4 weeks) and laboratory screening (sputum smear followed by chest radiography and CD4 count) for active TB disease were evaluated according to TST status. We enrolled 604 PLHIV. TST was positive in 151 PLHIV (25.0%). TB disease was diagnosed in 33 PLHIV, including 22 (14.6%) TST-positive and 11 (2.4%) TST-negative PLHIV. We found that an approach of performing MTB culture for all TST-positive PLHIV and symptom screening followed by laboratory screening for all TST-negative PLHIV would identify 196 (32.4%) of 604 PLHIV who would need MTB culture to correctly diagnose 29 (87.9%) of 33 active TB cases. TST can be used as an initial screening test among PLHIV to identify those at highest risk of active TB disease. Access to MTB culture or other sensitive tests to exclude TB disease is urgently needed to improve TB screening and prevention in resource-limited settings.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2012; 60(4):384-92. · 4.65 Impact Factor
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    ABSTRACT: Tuberculosis (TB) is the leading cause of death among people living with HIV and frequently transmitted among this susceptible group. Transmission can be reduced by infection control practices. Simple evidence-based methods to identify patients who should be isolated are not well described in the literature. We sought to identify a simple, sensitive symptom or symptom combination that healthcare providers in resource-limited settings can use to identify and isolate persons living with HIV with highly infectious TB. Participants from 8 outpatient facilities in Cambodia, Thailand, and Vietnam underwent an extensive evaluation for TB. Patients with ≥1 positive sputum smear and Mycobacterium tuberculosis culture growth from a pulmonary site were defined as having highly infectious TB. We calculated sensitivity and prevalence of individual symptoms and >1000 symptom combinations. Of 1980 participants, 272 (14%) had TB. Forty percent (n = 109) were highly infectious. Sensitivity for detecting highly infectious TB was highest for having the following symptoms in the past month as follows: weight loss (84%), cough (83%), fever (81%), and fatigue (78%); however, these symptoms were found in 46%-54% of all participants. Having 2 or 3 of 4 symptoms (prevalence, 26%-47%)-weight loss, fever, current cough, and night sweats-was 72%-90% sensitive for highly infectious TB. The 2 or 3 of 4 symptom combinations of weight loss, fever, current cough, and night sweats, which are the same symptoms comprising the current World Health Organization-recommended TB diagnostic screen, are sensitive for detecting highly infectious TB in people living with HIV.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2012; 60(5):519-24. · 4.65 Impact Factor
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    ABSTRACT: Tuberculosis causes >1.7 million deaths worldwide each year and is frequently transmitted in hospitals. Outbreaks of multidrug-resistant tuberculosis have led to illness and death among health care workers (HCWs) in many countries. Some countries, such as the United States, implemented occupational health policies that substantially reduced tuberculosis rates among HCWs. Inadequate tuberculosis infection control in China may contribute to its high burden of tuberculosis and multidrug-resistant tuberculosis, which are both the second highest worldwide. Occupational health policies in China for tuberculosis control can be strengthened.We reviewed the development and content of tuberculosis infection control policies in the United States and China. Sources included published academic literature, Chinese Ministry of Health policies, US government agency reports, legal databases, personal observations of hospitals, review of internet discussion sites, and discussions with HCWs and health care and law experts.In the United States, slow acceptance of the tuberculosis problem in HCWs resulted in decades of inaction. Tuberculosis infection control policies, based mostly on expert opinion, were implemented only after tuberculosis resurged in the 1980s. Effective evidence-based policies were developed only after multiple cycles of policy implementation, evaluation and revision. These policies have now substantially reduced occupational tuberculosis. In China, tuberculosis has not been formally recognized as an occupational disease, and data regarding the burden in HCWs are sparse. Vagueness of current labour laws and suboptimal alignment of infection control authority and expertise result in varied and sometimes absent protection of HCWs against tuberculosis. Formal evaluations of occupational tuberculosis policies have not been reported.By collecting data on its current HCW tuberculosis burden and infection control practices, refining policies, continually evaluating its policies based on accumulated evidence and rapidly identifying unsuspected tuberculosis cases, China can develop a more comprehensive strategy to ensure the health of HCWs and reduce transmission of tuberculosis and multidrug-resistant tuberculosis.
    Health Policy and Planning 03/2012; · 2.65 Impact Factor
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    ABSTRACT: SUMMARYContaminated water is one of the main sources of norovirus (NoV) gastroenteritis outbreaks globally. Waterborne NoV outbreaks are infrequently attributed to GII.4 NoV. In September 2009, a NoV outbreak affected a small school in Guangdong Province, China. Epidemiological investigations indicated that household use water, supplied by a well, was the probable source (relative risk 1·9). NoV nucleic acid material in concentrated well-water samples was detected using real-time RT-PCR. Nucleotide sequences of NoV extracted from diarrhoea and well-water specimens were identical and had the greatest sequence identity to corresponding sequences from the epidemic strain GII.4-2006b. Our report documents the first laboratory-confirmed waterborne outbreak caused by GII.4 NoV genotype in China. Our investigations indicate that well water, intended exclusively for household use but not for consumption, caused this outbreak. The results of this report serve as a reminder that private well water intended for household use should be tested for NoV.
    Epidemiology and Infection 03/2012; · 2.87 Impact Factor
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    ABSTRACT: Salmonella is one of the most common foodborne pathogens in humans. Laboratory-based surveillance for non-typhoidal Salmonella infection was conducted in Guangdong Province, China to improve understanding about the disease burden and detection of dispersed outbreaks. Salmonella isolated from patients with diarrhea were sent from 16 sentinel hospitals to local public health laboratories for confirmation, serotyping, antimicrobial susceptibility testing, and pulsed-field gel electrophoresis (PFGE). PFGE patterns were analyzed to identify clusters representing potential outbreaks. Between September 2009 and October 2010, 352 (4%) Salmonella isolates were obtained from 9167 stool specimens. Salmonella enterica serotype Typhimurium (45%) and Salmonella enterica serotype Enteritidis (13%) were the most common serotypes, and multidrug resistance was high, especially in Salmonella Typhimurium isolates. PFGE patterns of obtained Salmonella isolates were found to be diverse, but a unique PFGE pattern comprising 53 Salmonella Typhimurium isolates were found to occur almost exclusively in infants. Epidemiologic studies are ongoing to determine whether a common exposure is the source of the Salmonella Typhimurium strain frequently isolated from infants.
    Foodborne Pathogens and Disease 02/2012; 9(4):305-12. · 2.28 Impact Factor
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    ABSTRACT: Although nontuberculous mycobacteria (NTM) are widely documented as a cause of illness among HIV-infected people in the developed world, studies describing the prevalence of NTM disease among HIV-infected people in most resource-limited settings are rare. To evaluate the prevalence of mycobacterial disease in HIV-infected patients in Southeast Asia. We enrolled people with HIV from three countries in Southeast Asia and collected pulmonary and extrapulmonary specimens to evaluate the prevalence of mycobacterial disease. We adapted American Thoracic Society/Infectious Disease Society of America guidelines to classify patients into NTM pulmonary disease, NTM pulmonary disease suspects, NTM disseminated disease, and no NTM categories. In Cambodia, where solid media alone was used, NTM was rare. Of 1,060 patients enrolled in Thailand and Vietnam, where liquid culture was performed, 124 (12%) had tuberculosis and 218 (21%) had NTM. Of 218 patients with NTM, 66 (30%) were classified as NTM pulmonary disease suspects, 9 (4%) with NTM pulmonary disease, and 10 (5%) with NTM disseminated disease. The prevalence of NTM disease was 2% (19 of 1,060). Of 51 patients receiving antiretroviral therapy (ART), none had NTM disease compared with 19 (2%) of 1,009 not receiving ART. Although people with HIV frequently have sputum cultures positive for NTM, few meet a strict case definition for NTM disease. Consistent with previous studies, ART was associated with lower odds of having NTM disease. Further studies of NTM in HIV-infected individuals in tuberculosis-endemic countries are needed to develop and validate case definitions.
    American Journal of Respiratory and Critical Care Medicine 02/2012; 185(9):981-8. · 11.04 Impact Factor
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    ABSTRACT: Aim: Although China has the second highest burden of TB in the world and faces a burgeoning HIV epidemic, the epidemiology and 12‑month clinical outcomes of HIV-infected TB patients have not previously been reported. Methods: We reviewed records of all HIV-infected adults diagnosed with culture-confirmed TB from four HIV clinics in Guangxi, China from August 2006 to December 2008. Factors associated with patients’ survival within 12 months after TB diagnosis were evaluated in Cox proportional hazards models. Results: Among the 201 patients included, 47 (23%) died within 12 months. Median CD4 count at TB diagnosis was 37 cells/mm3 (interquartile range: 16–102). Receiving HAART (adjusted hazard ratio [AHR]: 4.2; 95% CI: 1.6–10.8), receiving TB treatment (AHR: 9.0; 95% CI: 1.5–53.5) and baseline BMI ≥ 18.5 (AHR: 8.4; 95% CI: 1.9–35.8) were independently associated with survival. Among 171 (85%) patients who received TB treatment, receiving HAART (HR: 5.1; 95% CI: 2.4–10.7) was the only factor significantly associated with survival. Conclusion: HIV-infected Chinese patients diagnosed with TB in Guangxi are at high risk of death within 12 months, a risk that is strongly mitigated by antiretroviral therapy. Improving survival from HIV-associated TB in China will require the integration of TB and HIV programs to improve access to treatment for both diseases. Keywords n
    Future Virology 01/2012; · 0.96 Impact Factor
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    ABSTRACT: Although international clinical guidelines generally recommend performing bacterial stool culture in patients with acute diarrhea and fever and discourage routine antibiotic prescribing, clinical practice varies. Understanding practice patterns can help health officials assess the sensitivity of laboratory-based enteric infection surveillance systems and the need to improve antibiotic prescribing practices. We surveyed physicians in Guangdong province, China, to measure their practices for patients with acute diarrhea. A standardized questionnaire was used to interview physicians working in hospitals participating in a Salmonella surveillance system in Guangdong, China. The questionnaire asked physicians about their routine practice for patients with diarrhea, including how they managed the last patient they had seen with acute diarrhea. We calculated the odds ratio and 95% confidence interval for factors associated with ordering a stool culture and for prescribing antibiotics. We received surveys from 237 physicians across 22 hospitals in Guangdong. For the last patient with diarrhea whom they had evaluated, 134 (57%) reported ordering a stool culture. The most common reasons for not ordering a stool culture included that it takes too long to receive the result, that the patient is not willing to pay for the test, and that the patient's illness was too mild to warrant testing. Most physicians prescribed at least one medication for the last patient with diarrhea whom they had evaluated. Of the 237 physicians surveyed, 153 (65%) prescribed antibiotics, 135 (57%) probiotics, and 115 (49%), a gastric mucosal protective drug. In conclusion, physicians in Guangdong, China, reported high rates of ordering bacterial stool cultures from patients with diarrhea, possibly associated with their hospital's participation in a special surveillance project. The high rate of antibiotic prescribing suggests that efforts to promote judicious antibiotic use, such as physician education, are needed.
    Foodborne Pathogens and Disease 01/2012; 9(1):47-53. · 2.28 Impact Factor
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    Jay K Varma, Shuyu Wu, Zijian Feng
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    ABSTRACT: In the past 50 years, the United States has made major advances in human health surveillance, research and outbreak investigation that have helped reduce microbial contamination of food. In China, food safety has emerged as one of the country's most prominent domestic concerns, but there has been limited investment in surveillance, inter-agency coordination, outbreak investigation and data synthesis. After large outbreaks of Salmonella in the 1960s and E. coli O157:H7 in the 1990s, the United States transformed its approach to detecting and investigating foodborne infections, including deployment of a national, laboratory-based surveillance system that uses molecular subtyping. In China, the absence of a national, laboratory-based surveillance system means that it is difficult to rapidly detect a widely dispersed foodborne infection outbreak or the emergence of new foodborne infections. Based on lessons learned in the United States, we propose policy and administrative changes that China can adopt to strengthen detection and control of foodborne infections.
    Global Public Health 12/2011; 7(7):766-78. · 0.92 Impact Factor

Publication Stats

1k Citations
443.16 Total Impact Points

Institutions

  • 2014
    • New York City Department of Health and Mental Hygiene
      New York, United States
  • 2011–2013
    • Beijing Centers for Disease Control and Prevention
      Peping, Beijing, China
    • Chinese Center For Disease Control And Prevention
      • Office for Disease Control and Emergence Response
      Peping, Beijing, China
    • World Health Organization WHO
      Islāmābād, Islāmābād, Pakistan
  • 2012
    • Guangdong Center for Disease Control and Prevention
      Shengcheng, Guangdong, China
  • 2004–2012
    • Centers for Disease Control and Prevention
      • • Division of Tuberculosis Elimination
      • • Division of Bacterial Diseases
      Atlanta, Michigan, United States
  • 2010
    • Institute of Tropical Medicine
      Antwerpen, Flanders, Belgium
  • 2008–2010
    • Bangkok Metropolitan Administration
      Krung Thep, Bangkok, Thailand
    • University of California, Berkeley
      Berkeley, California, United States
    • Centers for Disease Control, Lesotho
      Maseru, Maseru, Lesotho
  • 2007–2010
    • Ministry of Public Health, Thailand
      Krung Thep, Bangkok, Thailand
  • 2009
    • Vachira Phuket Hospital
      Amphoe Muang Phuket, Phuket Province, Thailand
    • Ubon Ratchathani University
      Muang Ubon, Changwat Ubon Ratchathani, Thailand
  • 2003–2005
    • National Institute of Allergy and Infectious Diseases
      Maryland, United States