[Show abstract][Hide abstract] ABSTRACT: One objective of the Emerging Infections Program (EIP) of the US Centers for Disease Control and Prevention is to provide training opportunities in infectious disease epidemiology. To determine the extent of training performed since the program's inception in 1995, we reviewed training efforts at the 10 EIP sites. By 2015, all sites hosted trainees (most were graduate public health students and physicians) who worked on a variety of infectious disease surveillance and epidemiologic projects. Trainee projects at all sites were used for graduate student theses or practicums. Numerous projects resulted in conference presentations and publications in peer-reviewed journals. Local public health and health care partners have also benefitted from EIP presentations and training. Consideration should be given to standardizing and documenting EIP training and to sharing useful training initiatives with other state and local health departments and academic institutions.
[Show abstract][Hide abstract] ABSTRACT: Active Bacterial Core surveillance (ABCs) was established in 1995 as part of the Centers for Disease Control and Prevention Emerging Infections Program (EIP) network to assess the extent of invasive bacterial infections of public health importance. ABCs is distinctive among surveillance systems because of its large, population-based, geographically diverse catchment area; active laboratory-based identification of cases to ensure complete case capture; detailed collection of epidemiologic information paired with laboratory isolates; infrastructure that allows for more in-depth investigations; and sustained commitment of public health, academic, and clinical partners to maintain the system. ABCs has directly affected public health policies and practices through the development and evaluation of vaccines and other prevention strategies, the monitoring of antimicrobial drug resistance, and the response to public health emergencies and other emerging infections.
[Show abstract][Hide abstract] ABSTRACT: Influenza and pneumonia combined are the leading causes of death due to infectious diseases in the United States. We describe factors associated with pneumonia among adults hospitalized with influenza.
Through the Emerging Infections Program, we identified adults ≥ 18 years, who were hospitalized with laboratory-confirmed influenza during October 2005 through April 2008, and had a chest radiograph (CXR) performed. Pneumonia was defined as the presence of a CXR infiltrate and either an ICD-9-CM code or discharge summary diagnosis of pneumonia.
Among 4,765 adults hospitalized with influenza, 1392 (29 %) had pneumonia. In multivariable analysis, factors associated with pneumonia included: age ≥ 75 years, adjusted odds ratio (AOR) 1.27 (95 % confidence interval 1.10-1.46), white race AOR 1.24 (1.03-1.49), nursing home residence AOR 1.37 (1.14-1.66), chronic lung disease AOR 1.37 (1.18-1.59), immunosuppression AOR 1.45 (1.19-1.78), and asthma AOR 0.76 (0.62-0.92). Patients with pneumonia were significantly more likely to require intensive care unit (ICU) admission (27 % vs. 10 %), mechanical ventilation (18 % vs. 5 %), and to die (9 % vs. 2 %).
Pneumonia was present in nearly one-third of adults hospitalized with influenza and was associated with ICU admission and death. Among patients hospitalized with influenza, older patients and those with certain underlying conditions are more likely to have pneumonia. Pneumonia is common among adults hospitalized with influenza and should be evaluated and treated promptly.
[Show abstract][Hide abstract] ABSTRACT: Treatment of a multi-drug resistant tuberculosis (MDR-TB) patient is clinically challenging, requiring a minimum of 18 months of therapy. Its occurrence in a systemic lupus erythromatosus (SLE) patient may complicate management of both MDR-TB and SLE. This is the first descriptive report of MDR-TB in an SLE patient.
A 19-year old female receiving long-term prednisolone for SLE was diagnosed with MDR-TB. She was started on MDR-TB treatment regimen and prednisolone was replaced with azathioprine. After an initial response to therapy, patient experienced a flare of lupus symptoms. Imaging studies revealed avascular necrosis of right femoral head. She was then treated with intravenous methyl-prednisolone, followed by maintenance corticosteroid. Azathioprine was discontinued due to hematological toxicity and failure to control SLE. Her symptoms of lupus regressed and did not re-occur for the duration of her MDR-TB treatment. Patient was declared cured of MDR-TB after 18 months of ATT. She is currently scheduled for a total hip replacement surgery.
This case highlights the challenges of simultaneously managing MDR-TB and SLE in a patient due to their over-lapping signs and symptoms, drug-drug interactions, and the need for use of immunomodulatory agents in the absence of standard guidelines and documented previous experiences. Our experience underscores the importance of appropriate selection of treatment regimens for both MDR-TB and SLE.
BMC Research Notes 08/2015; 8(1):337. DOI:10.1186/s13104-015-1302-x
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to assess risk factors associated with low levels of HIV testing among MSM recruited through respondent driven sampling (RDS) in Brazil. Of 3,617 participants, 48.4% had never tested previously for HIV. A logistic model indicated that younger age, lower socioeconomic class, education, poor HIV/AIDS knowledge, no history of cruising, and having been tested during the study were characteristics independently associated with low levels of previous HIV testing. The HIV testing rate among MSM in Brazil is still low in spite of the availability of a large number services providing universal and free access to HIV/AIDS diagnosis and treatment. To respond to low utilization, the authors propose a higher priority for testing for key populations such as MSM, expanded education, expanding testing sites and a welcoming and nonjudgmental environment in health services.
PLoS ONE 06/2015; 10(6). DOI:10.1371/journal.pone.0130445 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A healthy vaginal environment is predominated by certain Lactobacillus species, which lead to the prevention of infections of the reproductive tract. This study examined the characteristics of cultivable Lactobacillus species between healthy women and women with bacterial vaginosis (BV). Between November 2011 and Sept 2013, 139 women attending a women's clinic in Mysore, India were diagnosed for BV in a cross-sectional study. BV was diagnosed using Amsel's criteria: homogeneous vaginal discharge, vaginal pH > 4.5, production of amines, and presence of 'clue' cells. Those with three or more of the characteristics were considered to have BV. Vaginal swabs were then cultured in Rogosa agar, de Man-Rogosa-Sharpe broth. Gram-positive lactobacilli generating 600- 800bp amplicon by16 sRNA were further characterized by sequencing. Cultivable vaginal samples were obtained from 132 (94.9%) women. According to Amsel criteria, 83(62.1%) women were healthy and 49(37.1%) women had BV. Eleven different Lactobacillus species were isolated from 47 women. The common lactobacilli species found in this sample included L. crispatus (39.6%), L. gasseri (45.8%), and L. jensenii (14.6%). Lactobacilli were isolated from 39 healthy and 8 women with BV. L. gasseri was cultured from 18.8% of healthy and 6.1% of women with BV. The presence of L. reuteri was significantly associated with normal vaginal microbiota (p-value = 0.026). These results further our understanding of vaginal lactobacilli colonisation and richness in this particular population. Our findings showed lactobacilli species present in healthy vagina of women in India do not differ from those reported from other countries.
Journal of Medical Microbiology 04/2015; 64(6). DOI:10.1099/jmm.0.000070 · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Some studies suggest that influenza vaccination might be protective against severe influenza outcomes in vaccinated persons who become infected. We used data from a large surveillance network to further investigate the effect of influenza vaccination on influenza severity in adults aged ≥50 years who were hospitalized with laboratory-confirmed influenza.
We analyzed influenza vaccination and influenza severity using Influenza Hospitalization Surveillance Network (FluSurv-NET) data for the 2012-2013 influenza season. Intensive care unit (ICU) admission, death, diagnosis of pneumonia, and hospital and ICU lengths of stay served as measures of disease severity. Data were analyzed by multivariable logistic regression, parametric survival models, and propensity score matching (PSM).
Overall, no differences in severity were observed in the multivariable logistic regression model. Using PSM, adults aged 50-64 years (but not other age groups) who were vaccinated against influenza had a shorter length of ICU stay than those who were unvaccinated (hazard ratio for discharge, 1.84; 95% confidence interval, 1.12-3.01).
Our findings show a modest effect of influenza vaccination on disease severity. Analysis of data from seasons with different predominant strains and higher estimates of vaccine effectiveness are needed.
The Journal of Infectious Diseases 03/2015; 212(8). DOI:10.1093/infdis/jiv200 · 6.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Incidence of invasive pneumococcal disease (IPD) dramatically declined among children and adults after 7-valent pneumococcal conjugate vaccine (PCV7) introduction for children in 2000. In February 2010, 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7. We evaluated PCV13 impact on IPD rates among children and adults.
Methods: IPD cases (isolation of pneumococcus from sterile sites) were identified through 10 Active Bacterial Core surveillance (ABCs) sites during July 2006–June 2013. Isolates were serotyped at reference laboratories. To distinguish the incremental effect of PCV13, we focused on the 5 serotypes (PCV5 types) not affected by PCV7. We used pre-PCV13 observed cases in time-series models to forecast post-PCV13 incidence in the absence of PCV13. PCV13 impact was the difference between forecasted and observed incidence.
Results: ABCs identified 3,355 and 21,747 IPD cases among children and adults, respectively; 90% of isolates had serotyping results. Incidence of PCV5-type IPD declined in all age groups after PCV13 introduction with the largest decline among children <5 years (Table). Reductions in PCV5-type IPD were driven by serotypes 19A and 7F. No significant increase was seen in non-PCV13 serotypes, except among 50–64 year olds in 2012–2013 (percent change, 26; 95% interval estimate (IE): 13–44).
Table. Changes in incidence of PCV5-type IPD, by age
Percent Change Compared to
Incidence Expected in Absence of PCV13 (95% IE)
Age group (years)
-66 (-70, -61)
-88 (-89, -86)
-93 (-94, -91)
-35 (-45, -21)
-59 (-66, -48)
-75 (-80, -67)
-33 (-38, -26)
-64 (-68, -60)
-72 (-75, -69)
-23 (-28, -18)
-54 (-57, -50)
-62 (-65, -59)
-23 (-31, -13)
-46 (-52, -39)
-58 (-64, -52)
Conclusion: Dramatic reductions in PCV5-type IPD were evident among children and adults after 3 years of PCV13 use. Continued surveillance is needed to monitor for serotype replacement.
IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
[Show abstract][Hide abstract] ABSTRACT: Prevention of Antimicrobial-Resistant Infections Among Children Aged <5 Years with the 13-valent Pneumococcal Conjugate Vaccine Selected U.S. Areas, 20052013
S. Tomczyk, J. Jorgensen, R. Lynfield, W. Schaffner, D. Aragon, L. Harrison, M. Nichols, S. Petit, A. Thomas, A. Reingold, MM. Farley, S. Zansky, B. Beall, L. McGee, L. Kim
Background: Following introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) in 2000, antimicrobial-resistant (AR) invasive pneumococcal disease (IPD) decreased in the U.S. In 2010, a 13-valent PCV (PCV13) replaced PCV7. We evaluated the impact of PCV13 on AR IPD and progress towards the Healthy People (HP) 2020 goal to reduce AR IPD to 6.0 cases per 100,000 among children <5 years in the U.S.
Methods: IPD cases (isolation of pneumococcus from sterile sites) were identified from 10 Active Bacterial Core surveillance (ABCs) sites during 20052013 in children <5 years. Isolates were serotyped, and antimicrobial susceptibility testing was performed at reference laboratories. AR was defined as a bacterial isolate exhibiting intermediate or resistant patterns to ≥1 antimicrobial class (i.e. penicillins, macrolides, cephalosporins, and tetracyclines) according to the Clinical and Laboratory Standards Institute's minimum inhibitory concentration breakpoints. Multidrug resistance (MR) was defined as resistance to ≥3 antimicrobial classes. We calculated overall incidence rates during 20052013 of AR and MR IPD. We also stratified overall AR by PCV5-type (i.e. the 5 serotypes not protected by PCV7) and non-vaccine type IPD (i.e. not included in PCV7 or PCV13).
Results: We identified 745 resistant cases pre-PCV13 (20052009) and 378 resistant cases post-PCV13 (20102013). Overall incidence of AR IPD decreased from 9.3 to 3.5 per 100,000 in 2009 and 2013, respectively (percent change, -62) (Figure 1). Similarly, PCV5-type AR and MR IPD decreased by 93% and 86% from 2009 to 2013, respectively. Non-vaccine type AR IPD increased from 2.5 to 3.1 per 100,000 (Figure).
Conclusion: Substantial decreases in overall, PCV5-type, and MR IPD occurred after PCV13 introduction in children <5 years. The HP 2020 goal was met in 2011, 9 years earlier than the target year. The use of appropriate antimicrobials remains important in addition to sustained high use of PCV13.
IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
[Show abstract][Hide abstract] ABSTRACT: Since the introduction of the Haemophilus influenzae serotype b vaccine, H influenzae epidemiology has shifted. In the United States, the largest burden of disease is now in adults aged ≥65 years. However, few data exist on risk factors for disease severity and outcome in this age group.
A retrospective case-series review of invasive H influenzae infections in patients aged ≥65 years was conducted for hospitalized cases reported to Active Bacterial Core surveillance in 2011.
There were 299 hospitalized cases included in the analysis. The majority of cases were caused by nontypeable H influenzae, and the overall case fatality ratio (CFR) was 19.5%. Three or more underlying conditions were present in 63% of cases; 94% of cases had at least 1. Patients with chronic heart conditions (congestive heart failure, coronary artery disease, and/or atrial fibrillation) (odds ratio [OR], 3.27; 95% confidence interval [CI], 1.65-6.46), patients from private residences (OR, 8.75; 95% CI, 2.13-35.95), and patients who were not resuscitate status (OR, 2.72; 95% CI, 1.31-5.66) were more likely to be admitted to the intensive care unit (ICU). Intensive care unit admission (OR, 3.75; 95% CI, 1.71-8.22) and do not resuscitate status (OR, 12.94; 95% CI, 4.84-34.55) were significantly associated with death.
Within this age group, burden of disease and CFR both increased significantly as age increased. Using ICU admission as a proxy for disease severity, our findings suggest several conditions increased risk of disease severity and patients with severe disease were more likely to die. Further research is needed to determine the most effective approach to prevent H influenzae disease and mortality in older adults.
[Show abstract][Hide abstract] ABSTRACT: Lactobacillus plays an integral part in the health of the vaginal microbiota. We compared vaginal Lactobacillus species in women with and without bacterial vaginosis (BV) from India and the US. Between July 2009 and November 2010, a cross-sectional study was conducted among 40 women attending a women's health clinic in Mysore, India, and STD clinic in San Francisco, USA. Women were diagnosed for BV by Amsel's criteria and Nugent Score. Lactobacillus 16SrDNA was sequenced to speciate the cultured isolates. Ten Indian and 10 American women without BV were compared to an equal number of women with BV. Lactobacilli were isolated from all healthy women but only 10% of Indian, and 50% of US women with BV. 16SrDNA from 164 Lactobacillus colonies were sequenced from healthy women (126 colonies) and women with BV (38 colonies). Seven cultivable Lactobacillus species were isolated from 11 Indian women, and 9 species from 15 US women. The majority of Lactobacillus colonies in Indian women were L. crispatus (25%), L. jensenii (25%), and L. reuteri (16.7%). Among US women, L. crispatus (32.0%), L. jensenii (20.0%), and L. coleohominis (12.0%) predominated. L. jensenii and L. crispatus dominated the vaginal flora of healthy Indian and US women. Indian women appeared to have a higher percentage of obligative heterofermentative species suggesting the need for a larger degree of metabolic flexibility and a more challenging vaginal environment.
Journal of Medical Microbiology 05/2014; 63(Pt_7). DOI:10.1099/jmm.0.073080-0 · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Young children are at increased risk of severe outcomes from influenza illness, including hospitalization. We conducted a case-control study to identify risk factors for influenza-associated hospitalizations among children in U.S. Emerging Infections Program sites.
Cases were children 6-59 months of age hospitalized for laboratory-confirmed influenza infections during 2005-08. Age- and zip-code-matched controls were enrolled. Data on child, caregiver, and household characteristics were collected from parents and medical records. Conditional logistic regression was used to identify independent risk factors for hospitalization.
We enrolled 290 (64%) of 454 eligible cases and 1,089 (49%) of 2,204 eligible controls. Risk for influenza hospitalization increased with maternal age <26 years (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-2.9); household income below the poverty threshold (OR 2.2, CI 1.4-3.6); smoking by >50% of household members (OR 2.9, CI 1.4-6.6); lack of household influenza vaccination (OR 1.8, CI 1.2-2.5); and presence of chronic illnesses, including hematologic/oncologic (OR 11.8, CI 4.5-31.0), pulmonary (OR 2.9, CI 1.9-4.4), and neurologic (OR 3.8, CI 1.6-9.2) conditions. Full influenza immunization decreased the risk among children aged 6-23 months (OR 0.5, CI 0.3-0.9) but not among those 24-59 months of age (OR 1.5, CI 0.8-3.0; p-value for difference = 0.01).
Chronic illnesses, young maternal age, poverty, household smoking, and lack of household influenza vaccination increased the risk of influenza hospitalization. These characteristics may help providers to identify young children who are at greatest risk for severe outcomes from influenza illness.
[Show abstract][Hide abstract] ABSTRACT: Background:
Before the introduction of 7-valent pneumococcal conjugate vaccine (PCV7), invasive pneumococcal disease (IPD) rates among blacks were twice the rates in whites. We measured the effects of trends in PCV7-type and non-PCV7-type IPD rates on racial disparities in overall IPD and estimated the proportion of IPD caused by serotypes included in the 13-valent pneumococcal conjugate vaccine (PCV13).
We analyzed data from the Active Bacterial Core surveillance system, which performs active, laboratory- and population-based surveillance for IPD for 29.2 million people in the United States, for the period 1998-2009. For patients with unknown race, we multiplied imputed race to calculate age-, race-, and serotype-specific IPD incidence rates.
During 1998-2009, 47 449 IPD cases were identified; race was unknown for 5419 (11%). After multiple imputation, 31 981 (67%) patients were considered white and 13 750 (29%) black. PCV7-type IPD rates in all ages in both races decreased to <1 case per 100 000, whereas there were no decreases in overall IPD rates after 2002. By 2009, PCV13 serotypes caused 71% of cases among whites aged <5 years compared with 58% among blacks (P < .01). PCV13 serotypes caused 50% of IPD cases in whites aged ≥5 years compared with 43% among blacks (P < .01).
Despite near elimination of PCV7-type IPD in both races, overall disparities in IPD rates persisted because non-PCV7-type IPD rates are higher among blacks. Whereas PCV13 introduction may reduce racial disparities in IPD, higher valency conjugate vaccines and strategies to directly address underlying causes are needed to eliminate IPD disparities.
[Show abstract][Hide abstract] ABSTRACT: Little information is available describing the epidemiology and clinical characteristics of those <12 months hospitalized with influenza, particularly at a population level.
We used population-based, laboratory-confirmed influenza hospitalization surveillance data from 2003-2012 seasons to describe the impact of influenza by age category (<3, 3 to <6 and 6 to <12 months). Logistic regression was used to explore risk factors for intensive care unit (ICU) admission. Adjusted age specific influenza-associated hospitalization rates were calculated and applied to the number of U.S. infants to estimate national numbers of hospitalizations.
Influenza was associated with an annual average of 6,514 infant hospitalizations (range 1,842- 12,502). Hospitalization rates among infants <3 months were substantially higher than the rate in older infants. Most hospitalizations occurred in otherwise healthy infants (75%) among whom up to 10% were admitted to the ICU and up to 4% had respiratory failure. These proportions were 2-3 times higher in infants with high risk conditions. Infants <6 months were 40% more likely to be admitted to the ICU than older infants. Lung disease (adjusted odds ratio [aOR] 1.80; 95% confidence interval [CI] 1.22, 2.67), cardiovascular disease (aOR 4.16; 95% CI 2.65, 6.53), and neuromuscular disorder (aOR 2.99; 95% CI 1.87, 4.78) were risk factors for ICU admission among all infants.
The impact of influenza on infants, particularly those very young or with high risk conditions, underscore the importance of influenza vaccination, especially among pregnant women and those in contact with young infants not eligible for vaccination.
[Show abstract][Hide abstract] ABSTRACT: Children are highly susceptible to tuberculosis; thus, there is need for safe and effective preventive interventions. Our objective was to evaluate the efficacy of isoniazid in prevention of tuberculosis morbidity and mortality in children aged 15 years or younger by performing a meta-analysis of randomized controlled trials. To our knowledge, this is the first meta-analysis evaluating efficacy of isoniazid prophylaxis in prevention of tuberculosis in children.
A systematic search of the literature was done to identify randomized controlled trials evaluating isoniazid prophylaxis efficacy among children. Each study was evaluated for relevance and validity for inclusion in the analysis. Subgroup analyses were conducted based on study quality, HIV status, tuberculosis endemicity, type of prophylaxis and age of participants.
Eight studies comprising 10,320 participants were included in this analysis. Upon combining data from all eight studies, isoniazid prophylaxis was found to be efficacious in preventing development of tuberculosis, with a pooled RR of 0.65 (95% CI 0.47, 0.89) p = 0.004 , with confidence intervals adjusted for heterogeneity. Among the sub-group analyses conducted, only age of the participants yielded dramatic differences in the summary estimate of efficacy, suggesting that age might be an effect modifier of the efficacy of isoniazid among children, with no effect realised in children initiating isoniazid at four months of age or earlier and an effect being present in older children. Excluding studies in which isoniazid was initiated at four months of age or earlier yielded an even stronger effect (RR = 0.41 (95% CI 0.31, 0.55) p <0.001). Data on the effect of isoniazid on all-cause mortality, excluding studies in which isoniazid was initiated in infants, yielded an imprecise estimate of mortality benefit (RR = 0.58 (95% CI 0.31, 1.09) p = 0.092).
Isoniazid prophylaxis reduces the risk of developing tuberculosis by 59% among children aged 15 years or younger excluding children initiated during early infancy for primary prophylaxis (RR = 0.41, 95% CI 0.31, 0.55 p < 0.001) . However, further studies are needed to assess effects on mortality and to determine prophylaxis effectiveness in very young children and among HIV-infected children.
[Show abstract][Hide abstract] ABSTRACT: The detection of meningococcal outbreaks relies on serogrouping and epidemiologic definitions. Advances in molecular epidemiology have improved the ability to distinguish unique Neisseria meningitidis strains, enabling the classification of isolates into clones. Around 98% of meningococcal cases in the United States are believed to be sporadic.
Meningococcal isolates from 9 Active Bacterial Core surveillance sites throughout the United States from 2000 through 2005 were classified according to serogroup, multilocus sequence typing, and outer membrane protein (porA, porB, and fetA) genotyping. Clones were defined as isolates that were indistinguishable according to this characterization. Case data were aggregated to the census tract level and all non-singleton clones were assessed for non-random spatial and temporal clustering using retrospective space-time analyses with a discrete Poisson probability model.
Among 1,062 geocoded cases with available isolates, 438 unique clones were identified, 78 of which had ≥2 isolates. 702 cases were attributable to non-singleton clones, accounting for 66.0% of all geocoded cases. 32 statistically significant clusters comprised of 107 cases (10.1% of all geocoded cases) were identified. Clusters had the following attributes: included 2 to 11 cases; 1 day to 33 months duration; radius of 0 to 61.7 km; and attack rate of 0.7 to 57.8 cases per 100,000 population. Serogroups represented among the clusters were: B (n = 12 clusters, 45 cases), C (n = 11 clusters, 27 cases), and Y (n = 9 clusters, 35 cases); 20 clusters (62.5%) were caused by serogroups represented in meningococcal vaccines that are commercially available in the United States.
Around 10% of meningococcal disease cases in the U.S. could be assigned to a geotemporal cluster. Molecular characterization of isolates, combined with geotemporal analysis, is a useful tool for understanding the spread of virulent meningococcal clones and patterns of transmission in populations.
PLoS ONE 12/2013; 8(12):e82048. DOI:10.1371/journal.pone.0082048 · 3.23 Impact Factor