[Show abstract][Hide abstract] ABSTRACT: Latent tuberculosis infection (LTBI) is characterised by the presence of immune responses to previously acquired Mycobacterium tuberculosis infection without clinical evidence of active tuberculosis (TB). Here we report evidence-based guidelines from the World Health Organization for a public health approach to the management of LTBI in high risk individuals in countries with high or middle upper income and TB incidence of <100 per 100 000 per year. The guidelines strongly recommend systematic testing and treatment of LTBI in people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor treatment, patients receiving dialysis, patients preparing for organ or haematological transplantation, and patients with silicosis. In prisoners, healthcare workers, immigrants from high TB burden countries, homeless persons and illicit drug users, systematic testing and treatment of LTBI is conditionally recommended, according to TB epidemiology and resource availability. Either commercial interferon-gamma release assays or Mantoux tuberculin skin testing could be used to test for LTBI. Chest radiography should be performed before LTBI treatment to rule out active TB disease. Recommended treatment regimens for LTBI include: 6 or 9 month isoniazid; 12 week rifapentine plus isoniazid; 3-4 month isoniazid plus rifampicin; or 3-4 month rifampicin alone.
European Respiratory Journal 09/2015; DOI:10.1183/13993003.01245-2015 · 7.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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-infected MSM and at-risk HIV-uninfected MSM in October 2012.
A decision analytic model estimated the cost-effectiveness of meningococcal vaccination compared to no vaccination. 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 reported data and published sources. Outcomes included costs (2012 US dollars), IMD cases averted, IMD deaths averted, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER; $/QALY). Scenarios with and without herd immunity were considered and sensitivity analyses were performed on key inputs.
Compared to no vaccination, the targeted vaccination campaign averted an estimated 2.7 IMD cases, 1.0 IMD deaths, with an ICER of $66,000/QALY when herd immunity was assumed. Without herd immunity, vaccination prevented 1.1 IMD cases, 0.4 IMD deaths, with an ICER of $177,000/QALY. In one-way sensitivity analyses, variables that exerted the greatest influence on results in order of effect were the magnitude of herd immunity, IMD case fatality ratio and IMD incidence. In probabilistic sensitivity analyses, at a cost-effectiveness threshold of $100,000/QALY, vaccination was preferred in 97% of simulations with herd immunity and 20% of simulations without herd immunity.
Vaccination during an IMD outbreak among MSM with and without HIV infection was projected to avert IMD cases and deaths and could be cost-effective depending on IMD incidence, case fatality, and herd immunity.
[Show abstract][Hide abstract] ABSTRACT: The objectives of the study were to identify dietary and medical risk factors for Vibrio parahaemolyticus (VP) infection in the coastal city Shenzhen in China.
In April-October 2012, we conducted a case-control study in two hospitals in Shenzhen, China. Laboratory-confirmed VP cases (N = 83) were matched on age, sex, and other social factors to healthy controls (N = 249). Subjects were interviewed using a questionnaire on medical history; contact with seawater; clinical symptoms and outcome; travel history over the past week; and dietary history 3 days prior to onset. Laboratory tests were used to culture, serotype, and genotype VP strains. We used logistic regression to calculate the odds ratios for the association of VP infection with potential risk factors.
In multivariate analysis, VP infection was associated with having pre-existing chronic disease (adjusted odds ratio [aOR], 6.0; 95% confidence interval [CI], 1.5-23.7), eating undercooked seafood (aOR, 8.0; 95% CI, 1.3-50.4), eating undercooked meat (aOR, 29.1; 95% CI, 3.0-278.2), eating food from a street food vendor (aOR, 7.6; 95% CI, 3.3-17.6), and eating vegetable salad (aOR, 12.1; 95% CI, 5.2-28.2).
Eating raw (undercooked) seafood and meat is an important source of VP infection among the study population. Cross-contamination of VP in other food (e.g., vegetables and undercooked meat) likely plays a more important role. Intervention should be taken to lower the risks of cross-contamination with undercooked seafood/meat, especially targeted at people with low income, transient workers, and people with medical risk factors.
Foodborne Pathogens and Disease 08/2015; DOI:10.1089/fpd.2015.1988 · 1.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In September 2012, the New York City Department of Health and Mental Hygiene identified an outbreak of Neisseria meningitidis serogroup C invasive meningococcal disease among men who have sex with men (MSM). Twenty-two case-patients and 7 deaths were identified during August 2010-February 2013. During this period, 7 cases in non-MSM were diagnosed. The slow-moving outbreak was linked to the use of websites and mobile phone applications that connect men with male sexual partners, which complicated the epidemiologic investigation and prevention efforts. We describe the outbreak and steps taken to interrupt transmission, including an innovative and wide-ranging outreach campaign that involved direct, internet-based, and media-based communications; free vaccination events; and engagement of community and government partners. We conclude by discussing the challenges of managing an outbreak affecting a discrete community of MSM and the benefits of using social networking technology to reach this at-risk population.
[Show description][Hide description] 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.
[Show abstract][Hide abstract] 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.
[Show abstract][Hide abstract] 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.
[Show abstract][Hide abstract] 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 · 5.68 Impact Factor
[Show abstract][Hide abstract] 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
[Show abstract][Hide abstract] 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 · 55.87 Impact Factor
[Show abstract][Hide abstract] 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 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Infection with hepatitis C virus (HCV) increases the risk of death from liver and nonliver-related diseases. Coinfection with human immunodeficiency virus (HIV) further increases this risk.
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.
Between 2000 and 2011, 13 307 HCV-monoinfected adults died, and 5475 adults coinfected with HCV/HIV died. Decedents with HCV monoinfection were more likely to have died of liver cancer (odds ratio [OR] = 9.2), drug-related causes (OR = 4.3), and cirrhosis (OR = 3.7), compared with persons with neither infection. HCV/HIV-coinfected decedents were more likely to have died of liver cancer (OR = 2.2) and drug-related causes (OR = 3.1), compared with persons with neither infection. Among coinfected 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, more than half died within 3 years of an HCV report to DOHMH.
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.
[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.
[Show abstract][Hide abstract] 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 · 4.55 Impact Factor
[Show abstract][Hide abstract] 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
[Show abstract][Hide abstract] 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 · 6.00 Impact Factor
[Show abstract][Hide abstract] 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 · 2.20 Impact Factor
[Show abstract][Hide abstract] 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
[Show abstract][Hide abstract] 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