[show abstract][hide abstract] ABSTRACT: The effects of influenza on a population are attributable to the clinical severity of illness and the number of persons infected, which can vary greatly between seasons or pandemics. To create a systematic framework for assessing the public health effects of an emerging pandemic, we reviewed data from past influenza seasons and pandemics to characterize severity and transmissibility (based on ranges of these measures in the United States) and outlined a formal assessment of the potential effects of a novel virus. The assessment was divided into 2 periods. Because early in a pandemic, measurement of severity and transmissibility is uncertain, we used a broad dichotomous scale in the initial assessment to divide the range of historic values. In the refined assessment, as more data became available, we categorized those values more precisely. By organizing and prioritizing data collection, this approach may inform an evidence-based assessment of pandemic effects and guide decision making.
[show abstract][hide abstract] ABSTRACT: In response to the influenza A(H1N1)pdm09 (pH1N1) pandemic, peramivir, an investigational intravenous neuraminidase inhibitor, was made available for treatment of hospitalized patients with pH1N1 in the United States under an Emergency Use Authorization (EUA). The Centers for Disease Control and Prevention (CDC) implemented a program to manage peramivir distribution to requesting clinicians under EUA. We describe results of the CDC's peramivir program and 3 related surveys.
We analyzed data on peramivir requests made by clinicians to the CDC through an electronic request system. Three surveys were administered to enhance clinician compliance with adverse event reporting, to conduct product accountability, and to collect data on peramivir-treated patients. Descriptive analyses were performed, and 2-source capture-recapture analysis based on the 3 surveys was used to estimate the number of patients who received peramivir through the EUA.
From 23 October 2009 to 23 June 2010, CDC received 1371 clinician requests for peramivir and delivered 2129 five-day adult treatment course equivalents of peramivir to 563 hospitals. Based on survey responses, at least 1274 patients (median age, 43 years; range, 0-92 years; 49% male) received ≥1 doses of peramivir (median duration, 6 days). Capture-recapture analysis yielded estimates for the potential total number of peramivir recipients ranging from 1185 (95% confidence interval [CI], 1076-1293) to 1490 (95% CI, 1321-1659).
Approximately 1274 hospitalized patients received peramivir through EUA program during the pH1N1 pandemic. Further analyses are needed to assess the clinical effectiveness of peramivir treatment of hospitalized patients with pH1N1.
[show abstract][hide abstract] ABSTRACT: This article synthesizes and extends discussions held during an international meeting on "Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1," held at the Center for Communicable Disease Dynamics (CCDD), Harvard School of Public Health, on June 14 and 15, 2010. The meeting involved local, national, and global health authorities and academics representing 7 countries on 4 continents. We define the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. In doing so, we specify the quantitative evidence required to make informed decisions. We then describe the sources of surveillance and other population-based data that can presently--or in the future--form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. We describe other inputs to decision making besides epidemiologic and surveillance data, and we conclude with key lessons of the 2009 pandemic for designing and planning surveillance in the future.
Biosecurity and bioterrorism: biodefense strategy, practice, and science 06/2011; 9(2):89-115. · 1.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: A strong evidence base provides the foundation for planning and response strategies. Investments in pandemic preparedness included support for research that aided early detection, response, and control of the 2009 influenza A (H1N1) (pH1N1) pandemic. Scientific investigations conducted during the pandemic guided understanding of the virus, disease severity, and epidemiologic risk factors. Field investigations also produced information that strengthened guidance for the use of antivirals, identification of target populations for monovalent pH1N1 vaccine, and refinement of recommendations for social distancing measures. Communication of this evolving evidence base was important to sustaining credibility of public health. Areas where substantial controversy emerged, such as the optimal approach to respiratory protection of healthcare workers, often suffered from gaps in the evidence base. Many aspects of the 2009-2010 pandemic influenza experience provide ongoing opportunities for additional study, which will strengthen plans for future pandemic response as well as control of seasonal influenza.
[show abstract][hide abstract] ABSTRACT: To calculate the burden of 2009 pandemic influenza A (pH1N1) in the United States, we extrapolated from the Centers for Disease Control and Prevention's Emerging Infections Program laboratory-confirmed hospitalizations across the entire United States, and then corrected for underreporting. From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3-89.3 million), 274,304 hospitalizations (195,086-402,719), and 12,469 deaths (8868-18,306) occurred in the United States due to pH1N1. Eighty-seven percent of deaths occurred in those under 65 years of age with children and working adults having risks of hospitalization and death 4 to 7 times and 8 to 12 times greater, respectively, than estimates of impact due to seasonal influenza covering the years 1976-2001. In our study, adults 65 years of age or older were found to have rates of hospitalization and death that were up to 75% and 81%, respectively, lower than seasonal influenza. These results confirm the necessity of a concerted public health response to pH1N1.
[show abstract][hide abstract] ABSTRACT: The United States has made considerable progress in pandemic preparedness. Limited attention, however, has been given to the challenges faced by populations that will be at increased risk of the consequences of the pandemic, including challenges caused by societal, economic, and health-related factors. This supplement to the American Journal of Public Health focuses on the challenges faced by at-risk and vulnerable populations in preparing for and responding to an influenza pandemic. Here, we provide background information for subsequent articles throughout the supplement. We summarize (1) seasonal influenza epidemiology, transmission, clinical illness, diagnosis, vaccines, and antiviral medications; (2) H5N1 avian influenza; and (3) pandemic influenza vaccines, antiviral medications, and nonpharmaceutical interventions.
American Journal of Public Health 10/2009; 99 Suppl 2:S216-24. · 3.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: Protecting vulnerable populations from pandemic influenza is a strategic imperative. The US national strategy for pandemic influenza preparedness and response assigns roles to governments, businesses, civic and community-based organizations, individuals, and families. Because influenza is highly contagious, inadequate preparedness or untimely response in vulnerable populations increases the risk of infection for the general population. Recent public health emergencies have reinforced the importance of preparedness and the challenges of effective response among vulnerable populations. We explore definitions and determinants of vulnerable, at-risk, and special populations and highlight approaches for ensuring that pandemic influenza preparedness includes these populations and enables them to respond appropriately. We also provide an overview of population-specific and cross-cutting articles in this theme issue on influenza preparedness for vulnerable populations.
American Journal of Public Health 10/2009; 99 Suppl 2:S243-8. · 3.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: Previous studies support a strong association between viral respiratory tract infections and asthma exacerbations. The effect of newly discovered viruses on asthma control is less well defined.
We sought to determine the contribution of respiratory viruses to asthma exacerbations in children with a panel of PCR assays for common and newly discovered respiratory viruses.
Respiratory specimens from children aged 2 to 17 years with asthma exacerbations (case patients, n = 65) and with well-controlled asthma (control subjects, n = 77), frequency matched by age and season of enrollment, were tested for rhinoviruses, enteroviruses, respiratory syncytial virus, human metapneumovirus, coronaviruses 229E and OC43, parainfluenza viruses 1 to 3, influenza viruses, adenoviruses, and human bocavirus.
Infection with respiratory viruses was associated with asthma exacerbations (63.1% in case patients vs 23.4% in control subjects; odds ratio, 5.6; 95% CI, 2.7- 11.6). Rhinovirus was by far the most prevalent virus (60% among case patients vs 18.2% among control subjects) and the only virus significantly associated with exacerbations (odds ratio, 6.8; 95% CI, 3.2-14.5). However, in children without clinically manifested viral respiratory tract illness, the prevalence of rhinovirus infection was similar in case patients (29.2%) versus control subjects (23.4%, P > .05). Other viruses detected included human metapneumovirus (4.6% in patients with acute asthma vs 2.6% in control subjects), enteroviruses (4.6% vs 0%), coronavirus 229E (0% vs 1.3%), and respiratory syncytial virus (1.5% vs 0%).
Symptomatic rhinovirus infections are an important contributor to asthma exacerbations in children.
These results support the need for therapies effective against rhinovirus as a means to decrease asthma exacerbations.
Journal of Allergy and Clinical Immunology 02/2007; 119(2):314-21. · 12.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the United States. In 2000, an estimated 10.5 million people had COPD, of which more than 7.2 million were from the under-age 65 employed population. The prevalence of COPD in the workforce population was substantial with 46.5% of current employment among adults having the disease. However, the cost burden in the employed population is unknown. We examined COPD prevalence and costs in a large employment-based population. Using claims data from 1999 to 2003, we estimated the cost associated with COPD-related hospitalizations, emergency department visits, outpatient services, and prescription drug use. Per patient use of hospital care for COPD decreased during 1999 through 2003, including a decrease in the number of hospital admissions (from 0.10 in 1999 to 0.04 in 2003) and in the length of stay in hospitals (from 0.53 in 1999 to 0.17 in 2003). The number of outpatient visits, however, increased from 3.45 in 1999 to 3.80 in 2003. COPD-related per patient total medical costs decreased from $1460 in 1999 to $1138 in 2003 largely because of a decrease in the cost of hospitalizations for COPD. In contrast, mean per patient expenditures for outpatient services increased over the same period from $243 in 1999 to $295 in 2003. The cost of COPD to employers is high, but the cost could be reduced by programs aimed at preventing new cases of COPD, reducing hospitalizations, and providing more outpatient services to COPD patients.
[show abstract][hide abstract] ABSTRACT: Several themes emerged from the information provided in this supplement. 1. Implementation of the protocol was feasible, although retention of participants was challenging and customization at each site was essential. 2. Master's degree level social workers were well suited to partnering with health care professionals to address the many issues involved in caring for children with asthma and their families. 3. Collaboration between team members and community partners was critical to successful implementation. 4. Sustainability beyond external funding is attainable if local funding is sought and outcome measures that are considered important to the community are measured and reported.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 08/2006; 97(1 Suppl 1):S4-5. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease.
To describe the ICAI's major components and implementation issues.
Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed.
Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities.
The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 08/2006; 97(1 Suppl 1):S6-10. · 3.45 Impact Factor
[show abstract][hide abstract] ABSTRACT: Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings. This report provides information on how to limit exposure to mold and how to identify and prevent mold-related health effects. Where uncertainties in scientific knowledge exist, practical applications designed to be protective of a person's health are presented. Evidence is included about assessing exposure, clean-up and prevention, personal protective equipment, health effects, and public health strategies and recommendations. The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for <48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination. For the majority of persons, undisturbed mold is not a substantial health hazard. Mold is a greater hazard for persons with conditions such as impaired host defenses or mold allergies. To prevent exposure that could result in adverse health effects from disturbed mold, persons should 1) avoid areas where mold contamination is obvious; 2) use environmental controls; 3) use personal protective equipment; and 4) keep hands, skin, and clothing clean and free from mold-contaminated dust. Clinical evaluation of suspected mold-related illness should follow conventional clinical guidelines. In addition, in the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases. The development of a public health surveillance strategy among persons repopulating areas after extensive flooding is recommended to assess potential health effects and the effectiveness of prevention efforts. Such a surveillance program will help CDC and state and local public health officials refine the guidelines for exposure avoidance, personal protection, and clean-up and assist health departments to identify unrecognized hazards.
MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 06/2006; 55(RR-8):1-27.
[show abstract][hide abstract] ABSTRACT: To evaluate the impact of a multifaceted environmental and educational intervention on the indoor environment and health in 5-12-year-old children with asthma living in urban environments.
Changes in indoor allergen levels and asthma severity measurements were compared between children who were randomized to intervention and delayed intervention groups in a 14-month prospective field trial. Intervention group households received dust mite covers, a professional house cleaning, and had roach bait and trays placed in their houses.
Of 981 eligible children, 410 (42%) were enrolled; 161 (40%) completed baseline activities and were randomized: 84 to intervention and 77 to delayed intervention groups. At the study's end, dust mite levels were 163% higher than at baseline for the delayed intervention group. Overall asthma severity scores did not change. However, the median functional severity score (FSS) component of the severity score improved more in the intervention group (33% vs. 20%) than in the delayed intervention group. At the study's end, the median FSSs for the intervention group improved 25% compared with the delayed intervention group, (p<0.01). Differences between groups for medication use, emergency department (ED) visits or hospitalization were not significant.
Despite low retention, the intervention resulted in decreased dust mite allergen levels and increased FSSs among the intervention group. The interventions probably contributed to the improvements, especially among the more severely affected children. This study highlights the complexities of designing and assessing the outcomes from a multifaceted asthma intervention.
Journal of the National Medical Association 03/2006; 98(2):249-60. · 0.91 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the relation between body mass index and the development of asthma in children.
Prospective study of 4393 asthma-free children followed for up to 14 years.
Children of participants in the National Longitudinal Survey of Youth.
Analysis was limited to children who were followed from birth and were asthma-free during the first 24 months of life. The outcome was the development of asthma during follow-up (incident asthma). Body mass index (BMI) was our main predictor of interest. Survival analyses, using time to development of asthma as the main endpoint, were stratified by sex and controlled for race/ethnicity, poverty status, and prenatal maternal smoking.
Asthma developed in 218 (5.0 %) children during the follow-up period. The relation between BMI and incident asthma varied by sex. A BMI > or =85th percentile at age 2-3 years was a risk factor for subsequent asthma development in boys (hazard ratio (HR) 1.6 95% confidence interval (CI) 1.1, 2.4) but not girls (HR 0.8, 95% CI 0.5, 1.4). Similarly, boys with BMIs always > or =85th percentile were at increased risk for subsequent asthma development (HR 2.4, 95% CI 1.4, 4.4) but not girls (HR 1.5, 95% CI 0.7, 2.9).
Boys with high body masses may be at an increased risk for developing asthma.
International Journal of Obesity 01/2006; 30(1):6-13. · 5.22 Impact Factor
[show abstract][hide abstract] ABSTRACT: We assessed the sex differences in asthma prevalence and asthma-control characteristics within eight states.
We analyzed data from the 2001 Behavioral Risk Factor Surveillance System survey.
Lifetime and current asthma prevalence were higher for females in each of the eight states compared to males. Adult onset of asthma was reported more often by females with current asthma, and childhood onset was reported more often by males. Sex differences were identified for the eight asthma-control characteristics.
Females in eight states presented higher asthma risk and poorer asthma profiles than males. State surveillance data can be used to identify disparities and to develop appropriate public health interventions.
Journal of Asthma 12/2005; 42(9):777-82. · 1.85 Impact Factor
[show abstract][hide abstract] ABSTRACT: COPD is one of the leading causes of mortality and morbidity in the United States, yet little is known about the prevalence of comorbid conditions and mortality in hospitalized patients with COPD.
From the National Hospital Discharge Survey, 1979 to 2001, we evaluated whether or not COPD in adults > or = 25 years old is associated with increased prevalence and in-hospital mortality of several comorbidities.
During 1979 to 2001, there were an estimated total of 47,404,700 hospital discharges (8.5% of all hospitalizations in adults > 25 years old) of patients with COPD; 37,540,374 discharges (79.2%) were made with COPD as a secondary diagnosis, and 9,864,278 discharges (20.8%) were made with COPD as the primary diagnosis. The prevalence and in-hospital mortality for pneumonia, congestive heart failure, ischemic heart disease, thoracic malignancies, and respiratory failure were larger in hospital discharges with any mention of COPD.
In a nationally representative sample of hospitalizations, any mention of COPD in the discharge diagnosis is associated with higher hospitalization prevalence and in-hospital mortality from other comorbidities. These results highlight the fact that the burden of disease associated with COPD is likely underestimated.