Child Sexual Abuse identified in Emergency Departments Using ICD-9-CM, 2011 to 2014.

BACKGROUND: Child sexual abuse (CSA) is poorly identified due to its hidden nature and difficulty surrounding disclosure. Surveillance using emergency department (ED) data may identify victims and provide information on their demographic profile. OBJECTIVES: Study aims were to calculate the prevalence of visits assigned an explicit or suggestive medical diagnosis code (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for CSA and compare the demographic profile of ED visits by coding type. METHODS: This study examined ED data for children < 10 years of age in Connecticut from 2011 to 2014. Cases involving CSA were identified using explicit and suggestive ICD-9-CM codes and age qualifiers previously established in the literature, and compared across visit characteristics (age, race/ethnicity, sex, and primary insurance payer, and town group). RESULTS: ICD-9-CM codes for explicit CSA were identified in 110 ED visits, or 1.7 per 10,000 total ED visits. Inclusion of ICD-9-CM codes for suggestive CSA identified an additional 630 visits (9.7 per 10,000 visits). Suggestive codes identified proportionally more visits of younger (50% vs. 38%) and male (35% vs. 22%) children, compared with the explicit code (p < 0.05). CONCLUSIONS: This study demonstrates one method for identifying CSA cases, which has the potential to increase surveillance of victims in the ED. Results imply that explicit codes alone may overlook most cases, whereas use of suggestive codes may identify additional cases, and proportionally more young and male victims. As the health consequences of CSA are severe, innovative forms of surveillance must be explored to detect a higher number of cases and improve the clinical care of patients.

An Evaluation of the National Malaria Surveillance System of Bhutan, 2006-2012 as It Approaches the Goal of Malaria Elimination.

INTRODUCTION: Bhutan is progressing toward malaria elimination. The purpose of this evaluation was to assess the ability of the surveillance system from 2006 to 2012 to meet the objectives of the Bhutan Vector-borne Disease Control Program (VDCP) and to highlight priorities requiring attention as the nation transitions to elimination. METHODS: The evaluation was conducted using the Center for Disease Control guidelines for evaluating public health surveillance systems. Data sources included a search of publically available literature, VDCP program data, and interviews with malaria surveillance personnel. Blood slide quality assurance and control through formal assessment of slide preparation and measures of between-reader correlation were performed. RESULTS: Total malaria cases declined from 2006 to 2012. The average slide positivity rate decreased from 3.4% in 2006 to 0.2% in 2012. The proportion of non-residents in all cases increased to its highest value of 22.6% in 2012, and significant clustering in the border regions of India was noted, with Sarpang accounting for more cases than any other district from 2009 onward. Case detection was almost exclusively passive, but flexibility and sensitivity was demonstrated by the later addition of active case detection and specification of imported and locally acquired cases. Spatial data were limited to the village level, not allowing identification of transmission hotspots. For blood smears, statistical measures of between-reader agreement and predictive value were not computed. Blood smear quality was suboptimal by at least one criterion in over half of evaluated smears. Timeliness in reporting of cases was on a weekly to monthly basis, and did not meet the WHO goal of immediate notification. CONCLUSION: As of 2012, the national malaria surveillance system demonstrated flexibility, representativeness, simplicity, and stability. The full potential for data analysis was not yet realized. Attaining the goal of malaria elimination will require system function enhancement through increased and more accurate case detection and rapid investigation, improved health worker training and accountability, focally targeted response measures, and, in particular, the challenge of finding re-introductions of infections from India. Many such measure have been undertaken or planned as part of the next phase of the Bhutan's National Strategic Plan.

Association of influenza vaccine uptake with health, access to health care, and medical mistreatment among adults from low-income neighborhoods in New Haven, CT: a classification tree analysis.

OBJECTIVE: The aim of this study is to identify population subgroups under-vaccinated for influenza through classification tree analysis to inform interventions aimed at improving future vaccine uptake. METHOD: A cross-sectional community health needs assessment was conducted from 09/2012 through 11/2012 among randomly selected households in six low-income neighborhoods in New Haven, CT (N=1300 adults, aged 18-65). Known correlates of influenza vaccine uptake plus experience of medical mistreatment were used to develop a classification tree to identify under-vaccinated population subgroups RESULTS: Forty-five percent of respondents reported receiving the influenza vaccine. The classification tree identified healthy adults and uninsured adults at increased risk of influenza complications as subgroups with low vaccine uptake (40% and 30%, respectively). The subgroup representing insured, high-risk adults who reported experience of medical mistreatment had moderate vaccine uptake (45%). Sensitivity of the classification tree was high (83%, 95% CI=80% to 86%), indicating a strong true positive rate using these subgroups. CONCLUSION: Results highlight the need for renewed attention to promoting the influenza vaccination recommendation for all adults, particularly among healthy adults, uninsured, high-risk adults and insured, high-risk adults who have experienced medical mistreatment. Further research is needed to better understand how to reach these population subgroups.

Connecticut competency-based point of dispensing worker training needs assessment.

OBJECTIVES: In April 2006, Connecticut conducted an exercise that tested its ability to receive and dispense antibiotics from the Strategic National Stockpile. In conjunction with the exercise, a competency-based assessment was performed to determine the training needs of point of dispensing (POD) workers. METHODS: POD core competencies were developed by adapting existing preparedness materials. They were used to assess the training needs of more than 250 people who staffed a POD during the exercise. The assessment measured their confidence in their ability to perform 17 competency-based tasks. RESULTS: The vast majority needed training on 5 or fewer tasks, suggesting that they were fairly well trained. Pharmacists were particularly likely to need training on at least 5 tasks. Given their role in a POD operation, they should be a focus of further training. Almost one third of participants needed additional training on at least 1 of the 3 basic POD Incident Command System tasks. Additional training is also needed on competencies concerning POD safety and security, liability protections, and family preparedness. POD workers who are concerned about these matters may be less willing or able to staff a POD. People who participated in training both before and on the day of the exercise were best prepared to staff the POD, indicating that both types of training have value. CONCLUSIONS: When compared with the competencies, POD workers possessed many of the necessary skills to staff a POD; however, training with emphasis on areas of weakness revealed by the assessment could improve willingness to report for duty and performance.

Peridomestic Lyme disease prevention: results of a population-based case-control study.

BACKGROUND: Peridomestic Lyme disease-prevention initiatives promote personal protection, landscape modification, and chemical control. PURPOSE: A 32-month prospective age- and neighborhood-matched case-control study was conducted in Connecticut to evaluate the effects of peridomestic prevention measures on risk of Lyme disease. METHODS: The study was conducted in 24 disease-endemic Connecticut communities from 2005 to 2007. Subjects were interviewed by telephone using a questionnaire designed to elicit disease-prevention measures during the month prior to the case onset of erythema migrans. Data were analyzed in 2008 by conditional logistic regression. Potential confounders, such as occupational/recreational exposures, were examined. RESULTS: Between April 2005 and November 2007, interviews were conducted with 364 participants with Lyme disease, and 349 (96%) were matched with a suitable control. Checking for ticks within 36 hours of spending time in the yard at home was protective against Lyme disease (OR=0.55; 95% CI=0.32, 0.94). Bathing within 2 hours after spending time in the yard was also protective (OR=0.42; 95% CI=0.23, 0.78). Fencing of any type or height in the yard, whether it was contiguous or not, was protective (OR=0.54; 95% CI=0.33, 0.90). No other landscape modifications or features were significantly protective against Lyme disease. CONCLUSIONS: The results of this study suggest that practical activities such as checking for ticks and bathing after spending time in the yard may reduce the risk of Lyme disease in regions where peridomestic risk is high. Fencing did appear to protect against infection, but the mechanism of its protection is unclear.

The mortality burden of chronic liver disease may be substantially underestimated in the United States.

PURPOSE: The United States National Center for Health Statistics (NCHS) uses death certificate data to estimate the burden of serious disease. This study aimed to determine the accuracy of the NCHS method for estimating the burden of chronic liver disease (CLD). METHOD: The authors identified death certificates of New Haven County residents who died from October 1999-September 2000 that were assigned one of 115 ICD-10 codes that might indicate CLD. They reviewed medical charts, medical examiner records and a certifier questionnaire to determine whether CLD was the cause of death. RESULT: Using the authors' determination of CLD status as the gold standard, the specificity of the NCHS classification was high (86%), but the sensitivity was low (36%). The authors found that adding selected ICD-10 codes to those considered by the NCHS to be CLD (certain CLD malignancies and viral hepatitis) could improve sensitivity. Ensuring that deaths attributed by certifiers to "End Stage Liver Disease" were coded as CLD could also improve completeness. These modifications could increase sensitivity substantially with little effect on specificity. CONCLUSION: The NCHS method may understate the CLD burden substantially which could have a detrimental effect on planning for and evaluating prevention and treatment. Modifications could improve completeness.

Quantifying the burden of chronic viral hepatitis-related cirrhosis hospitalizations in New Haven County, Connecticut.

Chronic viral hepatitis can cause cirrhosis. Viral hepatitis-related cirrhosis may be causing an increasing health burden since exposure to hepatitis B virus and hepatitis C virus in the United States increased starting in the 1960s. Using hospital discharge data, we estimated the number of adult New Haven County residents hospitalized for cirrhosis and examined the proportion caused by chronic viral hepatitis. Data on etiology were obtained from hospital discharge records, death certificate information, and New Haven County Liver Study records. From 1 October 1999 to 30 September 2000, 269 adult New Haven County residents were hospitalized for cirrhosis in a New Haven County hospital, for an incidence of 43.2 per 100,000 population. The burden of viral hepatitis-related cirrhosis was 15.9 per 100,000. Hepatitis C virus was the most common viral etiology. Given the long period between initial infection and clinical decompensation, screening and treatment programs aimed at reducing viral hepatitis-related morbidity should reduce hospitalization rates.

Measurement of serum D-arabinitol/creatinine ratios for initial diagnosis and for predicting outcome in an unselected, population-based sample of patients with Candida fungemia.

D-Arabinitol (DA) is a useful diagnostic marker for candidiasis in patients with neutropenia and other high-risk groups, but its use in unselected patients with a broad range of underlying diseases and conditions has not been studied. We used an automated enzymatic fluorometric assay to measure serum DA/creatinine ratios (DA/cr's) in 30 healthy adults, 100 hospitalized controls without Candida fungemia, and 83 patients from a study of all Candida fungemias in Connecticut between October 1998 and September 1999. Sixty-three of 83 (76%) fungemic patients and 11 of 100 (11%) nonfungemic controls had serum DA/cr's >or=3.9 microM/mg/dl (mean + 3 standard deviations for 30 healthy adults). High serum DA/cr's were less frequent in patients with cancer or fungemia caused by the DA nonproducer Candida glabrata than in patients with cancer or fungemia caused by a DA producer, C. albicans, C. tropicalis, or C. parapsilosis. The serum DA/cr was first >or=3.9 microM/mg/dl before, on the same day as, or after the first positive blood culture was drawn for 30 (36%), 22 (27%), and 11 (13%) fungemia patients, respectively. Mortality did not differ significantly among the patients with high or normal initial or peak serum DA/cr's, but mortality was higher if any serum DA/cr value was >or=3.9 microM/mg/dl 3 or more days after the onset of fungemia (18/27 versus 4/24 patients, respectively; P < 0.001). We conclude that serum DA/cr's are useful both for the initial diagnosis of Candida fungemia and for prognostic purposes for unselected patients with a broad range of underlying diseases and conditions.

Estimating the prevalence of syringe-borne and sexually transmitted diseases among injection drug users in St Petersburg, Russia.

Injection drug users (IDUs) are the vanguard of the human immunodeficiency virus (HIV) epidemic in Russia. We sought a non-invasive method to estimate a point prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis and risk behaviours in IDUs attending the syringe exchange programme (SEP) in St Petersburg, Russia. One hundred and one IDUs returning syringes to the St Petersburg SEP were invited to complete a questionnaire requesting demographic, knowledge, and behavioural information, and to provide their syringes for antibody testing. The median age of IDUs was 23 years. Syringe prevalences were: 10.9% for HIV, 78.2% for HCV, 15.8% for HBV, and 6.9% for syphilis. All respondents recognized drug-related risk factors for getting AIDS. Only two-thirds of subjects recognized condoms to prevent sexually transmitted infections and half knew that oil-based lubricants are not appropriate for condoms. The IDU population studied was young and requires additional interventions to encourage safer sexual behaviours.

Human papillomavirus type 16 and immune status in human immunodeficiency virus-seropositive women.

BACKGROUND: Human papillomavirus (HPV) type 16 is etiologically associated with approximately half of all cervical cancers. It is important, therefore, to determine the characteristics that distinguish HPV16 from other HPV types. A preliminary result based on cross-sectional baseline data in the Women's Interagency Human Immunodeficiency Virus (HIV) Study (WIHS) suggested that the prevalence of HPV16 might have a weaker association with immune status in HIV-seropositive women than that of other HPV types. To address this issue, we examined HPV test results from repeated study visits in the WIHS and from an independent study, the HIV Epidemiology Research Study (HERS). METHODS: HIV-seropositive women in the WIHS (n = 2058) and in the HERS (n = 871) were assessed semiannually. HPV DNA was detected in cervicovaginal lavage specimens by using polymerase chain reaction assays. Prevalence ratios were used to compare the prevalence of each HPV type in women with the lowest CD4+ T-cell counts (<200 T cells/mm3) with that of women with the highest CD4+ T-cell counts (> or =500 T cells/mm3). A summary prevalence ratio for each HPV type (i.e., across visits and studies) was estimated using generalized estimating equations. The association of CD4+ T-cell stratum with type-specific HPV incidence was measured using multivariable Cox regression models. All statistical tests were two-sided. RESULTS: The prevalence ratio for HPV16 was low compared with that of other HPV types at every study visit in both cohorts. The generalized estimating equation summary prevalence ratio for HPV16 (1.25, 95% confidence interval [CI] = 0.97 to 1.62) was the smallest measured, and it was statistically significantly lower than that of all other HPV types combined (P =.01). The association of CD4+ T-cell stratum with HPV16 incidence was also among the smallest measured (hazard ratio = 1.69, 95% CI = 1.01 to 2.81). CONCLUSIONS: The prevalent and incident detection of HPV16 is more weakly associated with immune status in HIV-seropositive women than that of other HPV types, suggesting that HPV16 may be better at avoiding the effects of immune surveillance, which could contribute to HPV16's strong association with cervical cancer.

Incidence of anal cytological abnormalities in a cohort of human immunodeficiency virus-infected women.

Little is known about the natural history of anal human papillomavirus (HPV) infection in HIV-infected women because, to date, no longitudinal studies have been reported in the scientific literature. This article estimates the incidence of anal cytological abnormalities in a cohort of HIV-infected women. It also examines potential risk factors for the development of an anal cytological abnormality. A cohort of HIV-infected women underwent interview, anal cytology, and anogenital HPV DNA testing. Women with a normal baseline anal cytology were followed for the development of an anal cytological abnormality. The incidence of an abnormality was calculated. Survival analyses were performed to examine risk factors for the development of an abnormality. Fourteen of 100 HIV-infected women had an abnormal anal cytology at baseline. Among the 86 women with a normal baseline cytology, the incidence of an abnormality was 22 [95% confidence interval (CI), 14-33] per 100 person-years. In a multivariate analysis, women were at increased risk if, at baseline, they had a CD4+ T-cell count of <500 cells/mm(3) [relative hazard (RH) = 4.11; 95% CI, 1.18-14.25], high-risk type anal HPV infection (RH = 2.54; 95% CI, 0.91-7.14) or were cigarette smokers (RH = 3.88; 95% CI, 1.12-13.42). The incidence of anal cytological abnormalities was high among this cohort of HIV-infected women, indicating that they are at high risk of anal squamous intraepithelial lesions. HIV-infected women are likely to be at higher risk than their HIV-uninfected counterparts because immune suppression conferred substantially increased risk. Continued research on the association between smoking and the development of squamous intraepithelial lesions in HIV-infected women is warranted.

Sexual functioning among HIV-infected women.

The influence of HIV on sexual activity and functioning presents a unique set of issues. HIV transmissibility, partner disclosure, potential vertical transmission and, for some HIV-infected women, problems associated with illicit drug use, may affect sexuality. Few studies have examined HIV-infected women's sexuality and none have studied the relationship between HIV symptoms, HIV illness stage, quality of life, meaning of illness and sexual functioning. This descriptive study examines sexual activity, sexual functioning and safer sex behavior among 101 HIV-seropositive women. Results indicate that (1) the majority of women continue to be sexually active after testing HIV positive, (2) sexual functioning does not change as a result of HIV disease progression, and (3) few women report that HIV itself caused worsening of their sexual functioning. Those women with better mental health, more positive meaning attributed to life with HIV infection, better quality of life, fewer HIV-related symptoms and who never used injection drugs had higher levels of sexual functioning. Greater focus on sexual functioning as an integral part of clinical assessment is needed. Patterns of sexual behavior among HIV-infected women require continued study as we search for more effective means to prevent secondary HIV transmission.