Carol Glaser

California Department of Public Health, Richmond, California, United States

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Publications (86)432.25 Total impact

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    ABSTRACT: On June 13, 2014, the California Department of Public Health (CDPH) declared that a pertussis epidemic was occurring in the state when reported incidence was more than five times greater than baseline levels. The incidence of pertussis in the United States is cyclical, with peaks every 3-5 years, as the number of susceptible persons in the population increases. The last pertussis epidemic in California occurred in 2010, when approximately 9,000 cases were reported, including 808 hospitalizations and 10 infant deaths, for a statewide incidence of 24.6 cases per 100,000 population. During January 1-November 26, 2014, a total of 9,935 cases of pertussis with onset in 2014 were reported to CDPH, for a statewide incidence of 26.0 cases per 100,000. CDPH is working closely with local health departments to prioritize public health activities, with the primary goal of preventing severe cases of pertussis, which typically occurs in infants. All prenatal care providers are being encouraged to provide tetanus, diphtheria, and acellular pertussis vaccine (Tdap) to pregnant women during each pregnancy, ideally at 27-36 weeks' gestation, as is recommended by the Advisory Committee on Immunization Practices (ACIP), or refer patients to an alternative provider, such as a pharmacy or local public health department, to receive Tdap.
    MMWR. Morbidity and mortality weekly report. 12/2014; 63(48):1129-32.
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    ABSTRACT: In August 2012, the California Department of Public Health (CDPH) was contacted by a San Francisco Bay area clinician who requested poliovirus testing for an unvaccinated man aged 29 years with acute flaccid paralysis (AFP) associated with anterior myelitis (i.e., evidence of inflammation of the spinal cord involving the grey matter including anterior horn cell bodies) and no history of international travel during the month before symptom onset. Within 2 weeks, CDPH had received reports of two additional cases of AFP with anterior myelitis of unknown etiology. Testing at CDPH's Viral and Rickettsial Disease Laboratory for stool, nasopharyngeal swab, and cerebrospinal fluid (CSF) did not detect the presence of an enterovirus (EV), the genus of the family Picornaviridae that includes poliovirus. Additional laboratory testing for infectious diseases conducted at the CDPH Viral and Rickettsial Disease Laboratory did not identify a causative agent to explain the observed clinical syndrome reported among the patients. To identify other cases of AFP with anterior myelitis and elucidate possible common etiologies, CDPH posted alerts in official communications for California local health departments during December 2012, July 2013, and February 2014. Reports of cases of neurologic illness received by CDPH were investigated throughout this period, and clinicians were encouraged to submit clinical samples for testing. A total of 23 cases of AFP with anterior myelitis of unknown etiology were identified. Epidemiologic and laboratory investigation did not identify poliovirus infection as a possible cause for the observed cases. No common etiology was identified to explain the reported cases, although EV-D68 was identified in upper respiratory tract specimens of two patients. EV infection, including poliovirus infection, should be considered in the differential diagnosis in cases of AFP with anterior myelitis and testing performed per CDC guidelines.
    MMWR. Morbidity and mortality weekly report. 10/2014; 63(40):903-906.
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    ABSTRACT: Twenty-one children with confirmed herpes simplex encephalitis were identified in the California Encephalitis Project. Noteworthy features included six (29%) patients with an initial negative herpes simplex virus CSF PCR test and 13 (59%) patients with extra-temporal lobe involvement identified by neuroimaging. Eleven cases were <4 years of age, but all four fatal cases occurred in adolescents.
    The Pediatric Infectious Disease Journal 06/2014; · 3.57 Impact Factor
  • Arun Venkatesan, Carol Glaser
    Clinical Infectious Diseases 02/2014; · 9.37 Impact Factor
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    ABSTRACT: The California Department of Public Health (CDPH) conducts surveillance on severe influenza illness among California residents aged <65 years. Severe cases are defined as those resulting in admission to an intensive care unit (ICU) or death; reporting of ICU cases is voluntary, and reporting of fatal cases is mandatory. This report describes the epidemiologic, laboratory, and clinical characteristics of ICU and fatal influenza cases with symptom onset on or after September 29, 2013, and reported by January 18, 2014 of the 2013-14 influenza season. At the time of this report, local health jurisdictions (LHJs) in California had reported 94 deaths and 311 ICU admissions of patients with a positive influenza test result. The 405 reports of severe cases (i.e., fatal and ICU cases combined) were more than in any season since the 2009 pandemic caused by the influenza A (H1N1)pdm09 (pH1N1) virus. The pH1N1 virus is the predominant circulating influenza virus this season. Of 405 ICU and fatal influenza cases, 266 (66%) occurred among patients aged 41-64 years; 39 (10%) severe influenza illnesses occurred among children aged <18 years. Only six (21%) of 28 patients with fatal illness whose vaccination status was known had received 2013-14 seasonal influenza vaccine ≥2 weeks before symptom onset. Of 80 patients who died for whom sufficient information was available, 74 (93%) had underlying medical conditions known to increase the risk for severe influenza, as defined by the Advisory Committee on Immunization Practices (ACIP). Of 47 hospitalized patients with fatal illness and known symptom onset and antiviral therapy dates, only eight (17%) received neuraminidase inhibitors within 48 hours of symptom onset. This report supports previous recommendations that vaccination is important to prevent influenza virus infections that can result in ICU admission or death, particularly in high-risk populations, and that empiric antiviral treatment should be promptly initiated when influenza virus infection is suspected in hospitalized patients, despite negative results from rapid diagnostic tests.
    MMWR. Morbidity and mortality weekly report 02/2014; 63(7):143-7.
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    ABSTRACT: In five prospectively diagnosed patients with relapsing post-herpes simplex encephalitis (HSE), NMDAR-antibodies were identified. Antibody synthesis started 1-4 weeks post-HSE, preceding the neurological relapse. Three of five patients improved post-immunotherapy, one spontaneously, and one has started to improve. Two additional patients with NMDAR-antibodies, 9 with unknown neuronal surface-antibodies, and one with NMDAR and unknown antibodies were identified during retrospective assessment of 34 HSE-patients; the frequency of autoantibodies increased over time (serum p=0.004, CSF p=0.04). The three retrospectively identified NMDAR-antibody positive patients also had evidence of relapsing post-HSE. Overall, these findings indicate that HSE triggers NMDAR-antibodies and potentially other brain autoimmunity. ANN NEUROL 2013. © 2013 American Neurological Association.
    Annals of Neurology 12/2013; · 11.19 Impact Factor
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    ABSTRACT: Background: Temporal lobe (TL) abnormalities on magnetic resonance imaging (MRI) are a common radiologic finding in encephalitis, particularly in cases of herpes simplex virus encephalitis (HSE). While bilateral TL involvement was once thought to be pathognomonic for HSE, other etiologies have been described. We examined cases with TL abnormalities on MRI from the California Encephalitis Project (CEP) to identify clinical and radiologic features that distinguish HSE from other etiologies of encephalitis. Methods: We retrospectively reviewed clinical and radiological data from adult encephalitis cases with MRI TL abnormalities from the CEP between 1998 and 2012. We excluded cases in which TL abnormalities were chronic or normal variants. χ2 or Fisher’s exact tests were used to compare categorical variables between HSE and non-HSE cases. We constructed a multivariate logistic regression model to identify radiological predictors of non-HSE etiologies in cases with TL abnormalities. Results: Of 3965 cases, 251 (6%) met criteria for TL abnormalities on MRI. 148 (59%) cases had an identified etiology; 105 were attributed to infectious agents and 60 (41%) to HSE. Other etiologies included tuberculosis (8), varicella-zoster virus (7), Balamuthia (4), enterovirus (4), Creutzfeld-Jakob (3), acute disseminated encephalomyelitis (4), neoplasm (9), paraneoplastic/autoimmune (8), vasculitis (6) and stroke (4). Among cases with an identified etiology, presenting > 1 week after symptom onset (42% vs 12%, p<0.001) and absence of fever (49% vs 20%, p=0.001) were associated with non-HSE etiologies. 71% of cases with bilateral TL involvement were due to non-HSE etiologies. Other MRI features associated with non-HSE etiologies were presence of lesions outside the TL/insula (61% vs 33%, p=0.002) and enhancement (53% vs 33%, p=0.02). In an age-adjusted multivariate logistic regression model, bilateral TL involvement (OR 0.42, 95%CI 0.18-0.95, p=0.04), abnormalities outside the TL/insula (OR 0.41, 95%CI 0.19-0.89 p=0.02) and enhancement (OR 0.41, 95%CI 0.18-0.91, p=0.03) decreased the odds of HSE. Conclusion: A substantial number of cases with TL abnormalities, including bilateral TL involvement, were not caused by HSE. Specific MRI characteristics in encephalitis cases with TL abnormalities may help distinguish HSE from other etiologies.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013
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    ABSTRACT: OBJECTIVE:To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)-associated North American enterovirus outbreak of 2011-2012.METHODS:We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers. Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings). We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results.RESULTS:Eighty patients were included in this study (median age 1.5 years, range 4 months-16 years). Seventeen patients were CVA6-positive, and 63 met clinical inclusion criteria. Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving >10% body surface area. The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks. In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed "eczema coxsackium." Other morphologies included Gianotti-Crosti-like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation. There were no patients with serious systemic complications.CONCLUSIONS:The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.
    PEDIATRICS 06/2013; · 4.47 Impact Factor
  • 2013 Council of State and Territorial Epidemiologists Annual Conference; 06/2013
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    ABSTRACT: We describe the clinical course of the first three pediatric cases infectedwith Rickettsia sp. 364D. While the pathogen was identified in California ticks decades ago, only recently have human cases been documented. Clinical features are generally mild, characterized by eschar, fever, headache, malaise, and lymphadenopathy. Antigenic similarity among rickettsiae leads to cross-reactive antibody responses; definitive diagnosis requires molecular methods.
    The Pediatric Infectious Disease Journal 04/2013; · 3.57 Impact Factor
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    ABSTRACT: BACKGROUND:: Pediatric encephalitis is a devastating diagnosis with little guidance regarding prognostic indicators early in the hospitalization. METHODS:: This is a retrospective cohort study of patients with encephalitis referred to the California Encephalitis Project (CEP) from Children's Hospital & Research Center Oakland (CHRCO) from 1998 to 2010. Demographic, clinical, laboratory, and neuroimaging data were collected by CEP and chart review. Outcomes were classified into "recovery" or "incomplete recovery" and evaluated at discharge and other times (7-10 days post-admission, 3 and 12 months post-discharge). Using logistic regression, predictors associated with recovery were identified. RESULTS:: Of 190 patients with outcomes available at discharge, 128 patients (67.4%) recovered, while 62 (32.6%) had an incomplete recovery, including 13 deaths (6.8%). Variables predictive of outcomes at discharge in the bivariate and multivariable analyses included Asian/Pacific Islander (API) race, neuroimaging results, and Glasgow Coma Score (GCS). API patients were less likely to recover than patients of other races (adjusted Odds Ratio (aOR)=0.43, p value 0.046). Patients with normal neuroimaging studies were more likely to recover than patients with abnormal neuroimaging (aOR=2.54, p=0.008). Patients with GCS > 7 were more likely to recover than patients with GCS < 7 (aOR=5.82, p value <0.001). In a multivariable analysis, similar statistically significant findings were noted at all other analyzed times. Results were similar using a different population for validation, however, due to the small number of API patients, this finding could not be validated. CONCLUSIONS:: This study is unique in identification of race/ethnicity as an independent predictor of pediatric encephalitis outcomes. Additional variables may be useful ancillary tools in determining prognosis.
    The Pediatric Infectious Disease Journal 03/2013; · 3.57 Impact Factor
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    ABSTRACT: Background Seizures are a known complication of encephalitis. We sought to determine the incidence of seizures and the relative utility of routine and continuous electroencephalography in children with suspected encephalitis. Methods Records from all 217 children (ages 0-20 years, enrolled 2004-2011) from our institution who had diagnostic samples sent to the California Encephalitis Project were reviewed. Results One-hundred children (46%) had at least one seizure observed clinically or recorded on EEG. Diffuse abnormalities (e.g., generalized slowing) were more common than focal or epileptiform abnormalities (88.9% vs 63.2% and 57.3%, respectively; p<0.0001), but focal and epileptiform abnormalities were more correlated with seizures (91.0% [p=0.04] and 89.2% [p=0.05], respectively vs 76.9%). Fifty-four patients (25%) had at least one day of continuous EEG. When used, continuous EEG recorded a seizure in more than half of patients. Six children had no recognized seizure (clinical or electrographic) before the continuous EEG was performed. Twenty-two children (10%) had a seizure recorded by continuous EEG after routine EEG did not record a seizure. Overall, continuous EEG was more likely to capture a seizure, capture a subclinical seizure, or rule out a concerning event as a seizure than routine EEG (all comparisons p<0.0001). Conclusions Children with suspected encephalitis are at high risk for seizures. Continuous EEG is better able than routine EEG to determine whether seizures are present. Further, continuous EEG can guide treatment by classifying a clinical event as seizure or seizure-mimic. Our findings support the expanded use of continuous EEG in children with suspected encephalitis.
    Pediatric Neurology 01/2013; · 1.42 Impact Factor
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    ABSTRACT: BACKGROUND: Anti-NMDA receptor (NMDAR) encephalitis is an autoimmune disorder in which the use of immunotherapy and the long-term outcome have not been defined. We aimed to assess the presentation of the disease, the spectrum of symptoms, immunotherapies used, timing of improvement, and long-term outcome. METHODS: In this multi-institutional observational study, we tested for the presence of NMDAR antibodies in serum or CSF samples of patients with encephalitis between Jan 1, 2007, and Jan 1, 2012. All patients who tested positive for NMDAR antibodies were included in the study; patients were assessed at symptom onset and at months 4, 8, 12, 18, and 24, by use of the modified Rankin scale (mRS). Treatment included first-line immunotherapy (steroids, intravenous immunoglobulin, plasmapheresis), second-line immunotherapy (rituximab, cyclophosphamide), and tumour removal. Predictors of outcome were determined at the Universities of Pennsylvania (PA, USA) and Barcelona (Spain) by use of a generalised linear mixed model with binary distribution. RESULTS: We enrolled 577 patients (median age 21 years, range 8 months to 85 years), 211 of whom were children (<18 years). Treatment effects and outcome were assessable in 501 (median follow-up 24 months, range 4-186): 472 (94%) underwent first-line immunotherapy or tumour removal, resulting in improvement within 4 weeks in 251 (53%). Of 221 patients who did not improve with first-line treatment, 125 (57%) received second-line immunotherapy that resulted in a better outcome (mRS 0-2) than those who did not (odds ratio [OR] 2.69, CI 1.24-5.80; p=0.012). During the first 24 months, 394 of 501 patients achieved a good outcome (mRS 0-2; median 6 months, IQR 2-12) and 30 died. At 24 months' follow-up, 203 (81%) of 252 patients had good outcome. Outcomes continued to improve for up to 18 months after symptom onset. Predictors of good outcome were early treatment (0.62, 0.50-0.76; p<0.0001) and no admission to an intensive care unit (0.12, 0.06-0.22; p<0.0001). 45 patients had one or multiple relapses (representing a 12% risk within 2 years); 46 (67%) of 69 relapses were less severe than initial episodes (p<0.0001). In 177 children, predictors of good outcome and the magnitude of effect of second-line immunotherapy were similar to those of the entire cohort. INTERPRETATION: Most patients with anti-NMDAR encephalitis respond to immunotherapy. Second-line immunotherapy is usually effective when first-line treatments fail. In this cohort, the recovery of some patients took up to 18 months. FUNDING: The Dutch Cancer Society, the National Institutes of Health, the McKnight Neuroscience of Brain Disorders award, The Fondo de Investigaciones Sanitarias, and Fundacio la Marato de TV3.
    The Lancet Neurology 01/2013; · 23.92 Impact Factor
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    ABSTRACT: Background. Encephalitis is a severe neurological syndrome with devastating consequences. Despite extensive testing, the etiology often remains unknown. Involvement of the thalamus or basal ganglia (T/BG) occurs in a subset of patients with encephalitis and may be an important etiological clue. In order to improve diagnosis of T/BG patients, we reviewed this subgroup within the California Encephalitis Project (CEP).Methods. Data from T/BG cases enrolled in CEP were retrospectively reviewed. Cases were grouped by etiological classification: infectious, post-infectious, and non-infectious, and stratified by age. Neuroimaging reports were examined and compared between etiologies.Results. T/BG neuroimaging abnormalities were reported in 6% of 3,236 CEP cases. An etiology was found in 76%: 37% infectious, 16% post-infectious, and 23% non-infectious. The most frequently identified infectious agent was respiratory viruses, accounting for 31%, predominantly in children. Other infections more common in the T/BG group included Creutzfeldt-Jakob Disease, arbovirus, and Mycobacterium tuberculosis (MTB). Infectious and post-infectious cases had higher median CSF white blood cell count than non-infectious etiologies. Notably, T/BG neuroimaging characteristics were associated with distinct etiologies. In particular, symmetric hemorrhagic abnormalities involving the thalamus were most frequently found within the respiratory virus group.Conclusions. T/BG involvement in patients with suspected encephalitis was associated with specific etiologies. In addition to agents with established predilection for the T/BG such as MTB and arboviruses, a surprisingly high number of cases were potentially associated with respiratory viruses, especially in children. Neuroimaging abnormalities in such patients can aid clinicians in narrowing the etiological scope and in guiding testing.
    Clinical Infectious Diseases 11/2012; · 9.37 Impact Factor
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    ABSTRACT: Reported influenza-associated neurologic complications are generally limited to case series or case reports. We conducted a population-based study of neurologic manifestations associated with severe and fatal influenza A(H1N1)pdm09 (2009 H1N1) cases. Medical records of patients with fatal or severe (hospitalized in intensive care unit) laboratory-confirmed 2009 H1N1 reported to the California Department of Public Health from 15 April 2009 through 31 December 2009 were reviewed to identify those with primary neurological manifestations. Cases with secondary neurologic manifestations (eg, hypoxia) were excluded. Primary influenza-associated neurologic complications (INCs) were classified into 4 groups: encephalopathy/encephalitis, seizures, meningitis, and other. Severe 2009 H1N1-associated neurologic incidence was calculated by using estimates of 2009 H1N1 illnesses in California. Of 2069 reported severe or fatal 2009 H1N1 cases, 419 (20%) had neurologic manifestations. Of these, 77 (18%) met our definition of INCs: encephalopathy/encephalitis (n = 29), seizures (n = 44), meningitis (n = 3), and other (Guillain-Barré Syndrome) (n = 1). The median age was 9 years (range, 4 months-92 years); the highest rate of disease was among pediatric Asian/Pacific Islanders (12.79 per 1,000,000) compared with pediatric white, non-Hispanics (3.09 per 1,000,000), Hispanics (4.58 per 1,000,000), and blacks (6.57 per 1,000,000). The median length of stay (LOS) was 4 days (range, 1-142), and there were 4 fatalities. The estimated incidence of INCs was 1.2 per 100,000 symptomatic 2009 H1N1 illnesses. Influenza-associated neurologic complications were observed in 4% of patients with fatal or severe 2009 H1N1. They were observed most often in pediatric patients, and Asian/Pacific Islanders appear to be overrepresented compared with the California population. Most patients with INCs had a relatively short LOS, and there were few fatalities.
    Clinical Infectious Diseases 05/2012; 55(4):514-20. · 9.37 Impact Factor
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    ABSTRACT: In 2007, the California Encephalitis Project (CEP), which was established to study the epidemiology of encephalitis, began identifying cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis. Increasing numbers of anti-NMDAR encephalitis cases have been identified at the CEP, and this form rivals commonly known viral etiologies as a causal agent. We report here the relative frequency and differences among encephalitides caused by anti-NMDAR and viral etiologies within the CEP experience. Demographic, frequency, and clinical data from patients with anti-NMDAR encephalitis are compared with those with viral encephalitic agents: enterovirus, herpes simplex virus type 1 (HSV-1), varicella-zoster virus (VZV), and West Nile virus (WNV). All examined cases presented to the CEP between September 2007 and February 2011 and are limited to individuals aged ≤30 years because of the predominance of anti-NMDAR encephalitis in this group. The diagnostic costs incurred in a single case are also included. Anti-NMDAR encephalitis was identified >4 times as frequently as HSV-1, WNV, or VZV and was the leading entity identified in our cohort. We found that 65% of anti-NMDAR encephalitis occurred in patients aged ≤18 years. This disorder demonstrated a predilection, which was not observed with viral etiologies, for females (P < .01). Seizures, language dysfunction, psychosis, and electroencephalographic abnormalities were significantly more frequent in patients with anti-NMDAR encephalitis (P < .05), and autonomic instability occurred exclusively in this group. Anti-NMDAR encephalitis rivals viral etiologies as a cause of encephalitis within the CEP cohort. This entity deserves a prominent place on the encephalitic differential diagnosis to avoid unnecessary diagnostic and treatment costs, and to permit a more timely treatment.
    Clinical Infectious Diseases 04/2012; 54(7):899-904. · 9.37 Impact Factor
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    ABSTRACT: We describe the clinical courses of 3 children with a psychochoreiform encephalitis associated with anti-N-methyl D-aspartate receptor autoantibodies. These cases, including the most severely medically complicated survivor to date, illustrate the challenges of diagnosis, supportive care, and immune-modulating therapy. Clinical and laboratory features are similar to those of viral encephalitis, and the condition is often reversible with appropriate diagnosis and treatment.
    The Pediatric Infectious Disease Journal 11/2011; 31(2):202-4. · 3.57 Impact Factor
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    ABSTRACT: A number of new and combination vaccines have been introduced for children in the past two decades. Encephalitis cases occurring within defined time windows following administration of pertussis- or measles-containing vaccines are eligible for compensation by the Vaccine Injury Compensation Program. Due to increased parental concerns about vaccine safety and potential neurologic adverse events following immunization with new and multiple vaccines administered at the same visit, our aim was to determine whether immunizations are associated with an increased risk of encephalitis within defined risk windows. We reviewed immunization records from 246 pediatric encephalitis cases referred to the California Encephalitis Project between July 1998 and December 2008. We included data on 110 cases who had been immunized in the year prior to the onset of encephalitis (observation period) and had complete immunization records. We used the case-centered method to test whether cases were more likely to have developed encephalitis in defined risk windows-42, 30 and 21 days after any vaccination, 3 days after pertussis-containing vaccines and 5-15 days after measles-virus containing vaccines-compared with the rest of the observation period. All vaccines recommended in the current immunization schedule were represented in our sample. No increased risk of encephalitis was seen following administration of pertussis-containing vaccines, measles-containing vaccines or any number of vaccines administered in a single visit (vaccine episode); the odds ratios and 95% confidence intervals for encephalitis after a vaccine episode were: 1.0 (0.6-1.8) in a 42-day risk window, 0.9 (0.5-1.6) in a 30-day risk window and 1.2 (0.7-2.2) in a 21-day risk window. No association between receipt of currently recommended immunizations and subsequent development of encephalitis was observed in this study.
    Vaccine 11/2011; 30(2):247-53. · 3.77 Impact Factor
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    ABSTRACT: Background: Childhood encephalitis is a frustrating and sometimes devastating condition with an unpredictable prognosis. Little guidance exists for discussing potential outcomes with families. The purpose of this study is to identify predictors of outcome in pediatric encephalitis. Methods: This is a retrospective cohort study focusing on patients with encephalitis referred to the California Encephalitis Project (CEP) from Children’s Hospital & Research Center Oakland (CHRCO) from January 1 1998 to December 31 2009. Demographic, clinical, laboratory, and neuroimaging data were collected by CEP. All other data were obtained by medical chart review. Outcomes were then classified into “recovered” (defined by complete or near complete neurologic recovery) or “not recovered” (defined by moderate-severe deficits or death). Outcomes were evaluated at 7-10 days after admission, at discharge, and at 3 and 12 months after discharge. Logistic regression was used to identify predictors associated with recovery. Results: Evaluable outcomes were available at discharge for 158 of 197 patients (80%). One hundred and ten patients (70.0%) recovered at discharge, while 48 (30.0%) did not recover with 12 deaths (7.6%). Through logistic regression, Asian ethnicity, abnormal neuroimaging, and Glasgow Coma Score (GCS) were found to be significantly associated with outcomes at discharge. Specifically, patients of Asian ethnicity were less likely to recover when compared to patients of other ethnicities (RR=0.20, p value <0.01). Patients with abnormal neuroimaging studies were less likely to recover compared to patients with normal neuroimaging (RR=0.41, p=0.01). Finally, patients with GCS > 5 were more likely to recover than patients with GCS < 6 (RR=7.98, p value <0.01). In a multivariable analysis, similar statistically significant findings were noted at 7-10 days after admission and at 3 and 12 months after discharge. Conclusion: This study is unique in identification of ethnicity as an independent predictor of pediatric encephalitis outcomes. The association of Asian race with poor outcome is intriguing. Additional variables examined in this study may be useful ancillary tools to aid in predicting outcomes among children hospitalized with encephalitis.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011
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    ABSTRACT: Background: West Nile virus (WNV) infection acquired through solid organ transplantation can result in severe disease. Of the 10 cases reported to public health agencies in the United States, 7 patients had encephalitis and 3 died. In 2010, the California Encephalitis Project identified a case of WNV encephalitis that occurred shortly after organ transplantation in a kidney recipient. We report the findings of the investigation. Methods: We reviewed recent local WNV activity (human and ecologic), medical records, and transfusion history for the deceased organ donor and three organ recipients. Patients’ blood and cerebrospinal fluid (CSF) were tested for WNV infection by serology and nucleic acid amplification test (NAT), and tissues by NAT and immunohistochemical staining. Results: Kidney recipient A, a 73 year-old male, developed encephalitis on post-transplant day (PTD) 8 and died 13 weeks later. WNV infection was confirmed by WNV IgM and neutralizing antibodies in serum and CSF collected between 17-49 days after illness onset, and later by NAT on post-mortem brain tissue. He received one unit of packed red blood cells (PRBC) prior to illness onset. The donor of the PRBCs, which had screened negative for WNV RNA by minipool-NAT, had no detectable WNV IgM antibodies 113 days after donation. The organ donor was identified as the source of WNV infection by retrospective NAT on serum collected 3 days prior to organ recovery; WNV was detected in mosquitoes in his home county 2 weeks prior to his death. Kidney recipient B, a 52 year-old female, reported intermittent headache but was afebrile and otherwise asymptomatic; lumbar puncture was not performed. She had evidence of acute WNV infection by NAT on serum and urine collected up to PTD 181. The liver recipient, a 47 year-old male, was asymptomatic and had serologic evidence of prior flavivirus infection of indeterminate timing. Conclusion: Clinicians should have a high index of suspicion for WNV as a cause of encephalitis in organ transplant patients and report suspected cases to public health departments to enable a prompt public health response. Donors may be viremic at time of organ recovery and further evaluation is needed to determine if routine screening of organ donors results in a net benefit for transplant outcomes.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011

Publication Stats

2k Citations
432.25 Total Impact Points

Institutions

  • 2009–2013
    • California Department of Public Health
      Richmond, California, United States
    • Stanford Medicine
      Stanford, California, United States
    • Naval Medical Center San Diego
      • Department of Pediatrics
      San Diego, California, United States
    • Boston Children's Hospital
      • Division of Infectious Diseases
      Boston, MA, United States
  • 2003–2012
    • State of California
      California City, California, United States
  • 2008
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2007
    • Vanderbilt University
      Nashville, Michigan, United States
  • 2002–2003
    • Children's Hospital & Research Center Oakland
      Oakland, California, United States