Molecular characterization of human coronaviruses and their circulation dynamics in Kenya, 2009-2012.

BACKGROUND: Human Coronaviruses (HCoV) are a common cause of respiratory illnesses and are responsible for considerable morbidity and hospitalization across all age groups especially in individuals with compromised immunity. There are six known species of HCoV: HCoV-229E, HCoV-NL63, HCoV-HKU1, HCoV-OC43, MERS-CoV and SARS-HCoV. Although studies have shown evidence of global distribution of HCoVs, there is limited information on their presence and distribution in Kenya. METHODS: HCoV strains that circulated in Kenya were retrospectively diagnosed and molecularly characterized. A total of 417 nasopharyngeal specimens obtained between January 2009 and December 2012 from around Kenya were analyzed by a real time RT-PCR using HCoV-specific primers. HCoV-positive specimens were subsequently inoculated onto monolayers of LL-CMK2 cells. The isolated viruses were characterized by RT-PCR amplification and sequencing of the partial polymerase (pol) gene. RESULTS: The prevalence of HCoV infection was as follows: out of the 417 specimens, 35 (8.4 %) were positive for HCoV, comprising 10 (2.4 %) HCoV-NL63, 12 (2.9 %) HCoV-OC43, 9 (2.1 %) HCoV-HKU1, and 4 (1 %) HCoV-229E. The Kenyan HCoV strains displayed high sequence homology to the prototypes and contemporaneous strains. Evolution analysis showed that the Kenyan HCoV-OC43 and HCoV-NL63 isolates were under purifying selection. Phylogenetic evolutionary analyses confirmed the identities of three HCoV-HKU1, five HCoV-NL63, eight HCoV-OC43 and three HCoV-229E. CONCLUSIONS: There were yearly variations in the prevalence and circulation patterns of individual HCoVs in Kenya. This paper reports on the first molecular characterization of human Coronaviruses in Kenya, which play an important role in causing acute respiratory infections among children.

No effect of mild nonconcussive injury on neurocognitive functioning in U.S. Army soldiers deployed to Iraq.

UNLABELLED: With neurocognitive testing being heavily relied on for concussion assessments in the U.S. Warfighter, there is a need to investigate the impact of nonconcussive injury on neurocognitive functioning. OBJECTIVES: To determine if a nonconcussive injury may have a negative effect on neurocognitive functioning in a deployment setting. METHODS: The current study compared scores on computerized and traditional neurocognitive tests of 166 Soldiers deployed to Iraq. Performance on a battery of tests was compared between a group of healthy deployed Soldiers (n = 102) versus a group of deployed Soldiers seeking outpatient care for mild injuries not involving the head or blast exposure (n = 62). RESULTS: The injured group's performance was not significantly lower on any of the measures administered compared to healthy Soldiers. CONCLUSIONS: The results suggest that there was no significant effect of nonconcussive injury on neurocognitive functioning. Findings lend support to feasibility of using neurocognitive tests to evaluate the effects of concussion in theater.

The ANAM lacks utility as a diagnostic or screening tool for concussion more than 10 days following injury.

Congress has mandated that the Department of Defense perform screening for concussion, or mild traumatic brain injury, on all service members redeploying from Iraq and Afghanistan. However, the retrospective diagnosis of concussion is complicated by the subjective nature of the complaints, overlap of symptoms with other conditions, and the normally rapid recovery of neurocognitive function following a concussive event. One diagnostic and screening test in current use by the Department of Defense is the Automated Neuropsychological Assessment Metrics (ANAM). A team of researchers deployed to Iraq between January and April 2009 to test the validity of the ANAM for the diagnosis of concussion in the combat environment. Performance by concussed participants on all six ANAM subtests was compared with that of controls. The ANAM appears to have no utility as an individual diagnostic or population screening tool for the detection of neurocognitive dysfunction from a single, uncomplicated concussion when administered 10 or more days following injury. Further studies are required to determine the modalities providing optimal sensitivity and specificity for use as diagnostic or screening tests beyond the first 72-hour acute postinjury period.

Perceptions of Seasonal Influenza Vaccine Among U.S. Army Civilians and Dependents in the Kaiserslautern Military Community: A Mixed-Methods Survey.

INTRODUCTION: Influenza is a globally occurring viral respiratory infection that can lead to hospitalizations and death. An influenza outbreak can interfere with combat readiness in a military setting, as the infection can incapacitate soldiers. Vaccination remains the most effective tool to prevent and mitigate seasonal influenza. Although influenza vaccinations for U.S. Army soldiers can be monitored through military health systems, those systems cannot capture DoD civilians and Army dependents who may not use military health services. This study aims to gauge flu vaccine uptake and perceptions in U.S. Army civilians and dependents. MATERIALS AND METHODS: An online survey was e-mailed to civilian and dependent enrollees of Landstuhl Regional Medical Center. The survey contained 24 questions pertaining to demographics, vaccine history, history of the flu, and beliefs toward vaccines. Chi-square tests, t-tests, and logistic regressions were performed to investigate the association between demographic, behavior, and belief factors with vaccine uptake. Free-text answers were coded and categorized by themes. RESULTS: Over 70% of respondents were vaccinated for the flu. There were differences between vaccinated and unvaccinated respondents regarding their perceptions of barriers to vaccination, benefits of the flu vaccine, severity of flu symptoms, and personal risk of getting ill with the flu. After controlling for confounders, flu vaccination in the previous season and healthcare worker status were associated with increased vaccine uptake, while perceived barriers to influenza vaccination were associated with decreased vaccine uptake. CONCLUSIONS: Flu vaccine uptake may be increased by increasing access to vaccination, promoting vaccination and addressing concerns at the provider level, and engaging positively framed public messaging. Increasing flu vaccine uptake is of particular importance as the flu season approaches during the COVID-19 (Coronavirus disease 2019) pandemic.

Seroprevalence and distribution of arboviral infections among rural Kenyan adults: a cross-sectional study.

BACKGROUND: Arthorpod-borne viruses (arboviruses) cause wide-spread morbidity in sub-Saharan Africa, but little research has documented the burden and distribution of these pathogens. METHODS: Using a population-based, cross-sectional study design, we administered a detailed questionnaire and used ELISA to test the blood of 1,141 healthy Kenyan adults from three districts for the presence of anti-viral Immunoglobulin G (IgG) antibodies to the following viruses: dengue (DENV), West Nile (WNV), yellow fever (YFV), Chikungunya (CHIKV), and Rift Valley fever (RVFV). RESULTS: Of these, 14.4% were positive for DENV, 9.5% were WNV positive, 9.2% were YFV positive, 34.0% were positive for CHIKV and 0.7% were RVFV positive. In total, 46.6% had antibodies to at least one of these arboviruses. CONCLUSIONS: For all arboviruses, district of residence was strongly associated with seropositivity. Seroprevalence to YFV, DENV and WNV increased with age, while there was no correlation between age and seropositivity for CHIKV, suggesting that much of the seropositivity to CHIKV is due to sporadic epidemics. Paradoxically, literacy was associated with increased seropositivity of CHIKV and DENV.

Health care workers and researchers traveling to developing-world clinical settings: disease transmission risk and mitigation.

With the recent emphasis on funding and training opportunities for global health and humanitarian aid and the increased interest in the field, many health care workers and medical researchers are traveling from resource-replete to resource-limited settings. This type of travel brings unique disease risks not routinely considered for the business or vacationing traveler. This review provides practical advice for this special population of travelers, targeted to specific health care-related risks (needlestick, hemorrhagic fever viruses, severe viral respiratory disease, and tuberculosis), with suggestions for risk mitigation.

Increased prevalence of the pfdhfr/phdhps quintuple mutant and rapid emergence of pfdhps resistance mutations at codons 581 and 613 in Kisumu, Kenya.

BACKGROUND: Anti-malarial drug resistance in Kenya prompted two drug policy changes within a decade: sulphadoxine-pyrimethamine (SP) replaced chloroquine (CQ) as the first-line anti-malarial in 1998 and artemether-lumefantrine (AL) replaced SP in 2004. Two cross-sectional studies were conducted to monitor changes in the prevalence of molecular markers of drug resistance over the period in which SP was used as the first-line anti-malarial. The baseline study was carried out from 1999-2000, shortly after implementation of SP, and the follow-up study occurred from 2003-2005, during the transition to AL. MATERIALS AND METHODS: Blood was collected from malaria smear-positive, symptomatic patients presenting to outpatient centers in Kisumu, Kenya, during the baseline and follow-up studies. Isolates were genotyped at codons associated with SP and CQ resistance. In vitro IC50 values for antifolates and quinolones were determined for isolates from the follow-up study. RESULTS: The prevalence of isolates containing the pfdhfr N51I/C59R/S108N/pfdhps A437G/K540E quintuple mutant associated with SP-resistance rose from 21% in the baseline study to 53% in the follow-up study (p < 0.001). Isolates containing the pfdhfr I164L mutation were absent from both studies. The pfdhps mutations A581G and A613S/T were absent from the baseline study but were present in 85% and 61%, respectively, of isolates from the follow-up study. At follow-up, parasites with mutations at five pfdhps codons, 436, 437, 540, 581, and 613, accounted for 39% of isolates. The CQ resistance-associated mutations pfcrt K76T and pfmdr1 N86Y rose from 82% to 97% (p = 0.001) and 44% to 76% (p < 0.001), respectively, from baseline to follow-up. CONCLUSIONS: During the period in which SP was the first-line anti-malarial in Kenya, highly SP-resistant parasites emerged, including isolates harboring pfdhps mutations not previously observed there. SP continues to be widely used in Kenya; however, given the highly resistant genotypes observed in this study, its use as a first-line anti-malarial should be discouraged, particularly for populations without acquired immunity to malaria. The increase in the pfcrt K76T prevalence, despite efforts to reduce CQ use, suggests that either these efforts are not adequate to alleviate CQ pressure in Kisumu, or that drug pressure is derived from another source, such as the second-line anti-malarial amodiaquine.

Evaluation of the Military Acute Concussion Evaluation for use in combat operations more than 12 hours after injury.

The diagnosis and management of concussion can be difficult in a combat environment, especially in the absence of loss of consciousness or post-traumatic amnesia. As no validated test exists to diagnose or grade neurocognitive impairment from a concussion, the military currently employs the Military Acute Concussion Evaluation (MACE) in Iraq. This is a two-part test, which incorporates the standardized assessment of concussion (SAC) as its objective score, although it has not been shown to be valid unless administered shortly after injury. A research team deployed to Iraq between January and April 2009 to examine the validity of several tests of neurocognitive function following a concussion, including the MACE. When administered more than 12 hours after the concussive injury, the MACE lacked sufficient sensitivity and specificity to be clinically useful.

The importance of militaries from developing countries in global infectious disease surveillance.

Military forces from developing countries have become increasingly important as facilitators of their government's foreign policy, taking part in peacekeeping operations, military exercises and humanitarian relief missions. Deployment of these forces presents both challenges and opportunities for infectious disease surveillance and control. Troop movements may cause or extend epidemics by introducing novel agents to susceptible populations. Conversely, military units with disease surveillance and response capabilities can extend those capabilities to civilian populations not served by civilian public health programmes, such as those in remote or post-disaster settings. In Peru and Thailand, military health organizations in partnership with the military of the United States use their laboratory, epidemiological, communications and logistical resources to support civilian ministry of health efforts. As their role in international affairs expands, surveillance capabilities of militaries from developing countries should be enhanced, perhaps through partnerships with militaries from high-income countries. Military-to-military and military-to-civilian partnerships, with the support of national and international civilian health organizations, could also greatly strengthen global infectious disease surveillance, particularly in remote and post-disaster areas where military forces are present.

Outcomes From U.S. Military-Supported Overseas Training Rotations in Tropical Medicine and Global Health, 2006-2015.

BACKGROUND: Since 2006, the Division of Tropical Public Health at the Uniformed Services University (USU) has sponsored the Tropical Medicine Training Program (TMTP). Despite practice guidelines stating that global health education should include the collection and evaluation of data on the impact of the training experiences, no quantitative evaluation of program outcomes had previously occurred. The objective of this report was to evaluate TMTP outcomes to guide program improvement. METHODS: We developed an anonymous, web-based survey to assess program outcomes as part of routine program evaluation. The survey addressed four main areas of potential TMTP impact: (1) career engagement, (2) military service contributions, (3) scholarly activity, and (4) acquisition of knowledge and skills. In February 2016, we sent the survey electronically to 222 program participants between Fiscal Years 2006 and 2015 who had e-mails available in DoD administrative systems. FINDINGS: Ninety-eight (44%) of these responded to the survey. TMTP demonstrated impact in several areas. Increased knowledge and skills were reported by 81% of trainees, and 70% reported increased interest in serving at military overseas medical research laboratories. Subsequent career engagement by trainees included seven assignments to overseas research laboratories, 71 military deployments, and 193 short-term military missions. The ability to achieve many of the desired outcomes was associated with time elapsed since completion of formal medical education, including 24% who were still enrolled in graduate medical education. DISCUSSION/IMPACT/RECOMMENDATIONS: The TMTP has improved the U.S. military's ability to perform surveillance for emerging tropical and infectious diseases and has contributed to force health protection and readiness. Although many of the outcomes, such as service in the overseas research laboratories and military deployments, are dependent on military service requirements, these results remain perhaps the most relevant ways that the TMTP meets global health requirements of the US military and the nation. Additional outcomes from this training are expected to accrue as these participants complete their medical postgraduate training programs.

DoD-Supported Overseas Training Rotations in Tropical Medicine and Global Health, 2000-2015.

In 1999, the Department of Defense developed a tropical medicine training program (TMTP) to train military physicians, medical students, and scientists in performing surveillance activities in an overseas environment. This review describes the competencies, educational approach, program participants, institutional collaborations, and process outcomes of the TMTP from 2000 to 2015. TMTP-sponsored rotations addressed a wide variety of interdisciplinary competencies, many of which have military-unique applications. Rotations consisted of both didactic and experiential (overseas) components. The program provided 282 rotations for 260 trainees between 2006 and 2015, the years for which data were available. The Department of Defense accrues benefits from this training program in three main ways: (1) building a cadre of health care professionals who will go on to work at the overseas research laboratories, (2) supporting force health protection and readiness through experiential tropical medicine training, and (3) engaging in global health collaborations and partnerships. The primary challenges include funding, health and security, trainee and site heterogeneity, supervision, trainee engagement, and burden on the host institution. The program will continue to focus on improvement in these areas, with special attention to trainee preparation, communication with both trainees and host sites, and increasing reciprocity with host sites and their faculty.

Literacy and recent history of diarrhoea are predictive of Plasmodium falciparum parasitaemia in Kenyan adults.

BACKGROUND: Malaria is one of the most serious health problems in Kenya. In 2004, the Kenya Medical Research Institute and the US Army Medical Research Unit--Kenya surveyed adults in Samburu, Malindi, and Busia districts to determine socioeconomic risk factors for infection. METHODS: Sociodemographic, health, and antimalarial data were collected along with blood for malaria testing. A smear was considered negative only if no Plasmodium falciparum parasites were observed in 100 high-powered fields. Univariate analysis was performed with Pearson's Chi-square test and univariate logistic regression. A multivariate logistic regression model was then created which included only variables found to be at least marginally significant in univariate analysis. RESULTS: A total of 1,141 subjects were recruited: 238 from Samburu, 442 from Malindi, and 461 from Busia. Smear positivities for P. falciparum were 1.7% in Samburu, 7.2% in Malindi and 22.3% in Busia. Interdistrict differences were statistically significant (p < 0.001) in univariate analysis and in a multivariate logistic regression model which included district, literacy, occupation, and recent illness as independent variables. In the model, literacy and recent diarrhoeal illness were positively and at least marginally significantly associated with parasitaemia (p = 0.023 and p = 0.067, respectively). Neither age, sex, occupation, history of malaria in the previous three months, nor use of antimalarials in the previous four weeks were significantly associated with parasitaemia. CONCLUSION: While district of residence was the variable most highly predictive for parasitaemia among Kenyan adults surveyed, both a recent history of diarrhoeal illness and literacy were at least marginally statistically significant predictors.

No Significant Acute and Subacute Differences between Blast and Blunt Concussions across Multiple Neurocognitive Measures and Symptoms in Deployed Soldiers.

Seventy-one deployed U.S. Army soldiers who presented for concussion care due to either blast or blunt mechanisms within 72 h of injury were assessed using the Military Acute Concussion Evaluation, the Automated Neuropsychological Assessment Metrics (ANAM), traditional neuropsychological tests, and health status questionnaires. Follow-up ANAM testing was performed 10 d after initial testing (±5 d). Twenty-one soldiers were excluded: two for poor effort and 19 who had combined blast/blunt injuries. Of the remaining 50 male participants, 34 had blast injuries and 16 had blunt injuries. There were no statistically significant differences between blast injury and blunt injury participants in demographic, physical, or psychological health factors, concussive symptoms, or automated and traditional neurocognitive testing scores within 72 h post-injury. In addition, follow-up ANAM scores up to 15 d post-injury were not significantly different (available on 21 blast-injured and 13 blunt-injured subjects). Pre-injury baseline ANAM scores were compared where available, and revealed no statistically significant differences between 22 blast injury and eight blunt injury participants. These findings suggest there are no significant differences between mechanisms of injury during both the acute and subacute periods in neurobehavioral concussion sequelae while deployed in a combat environment. The current study supports the use of sports/mechanical concussion models for early concussion management in the deployed setting and exploration of variability in potential long-term outcomes.

No Effect of Deployment Environment in Establishing Baseline Neurocognitive Scores in U.S. Army Soldiers.

With heavy reliance on neurocognitive testing for concussion status assessments in the U.S. warfighter, there is a need to investigate the impact of testing environment on neurocognitive functioning. The current study compared scores on computerized neurocognitive tests of 166 soldiers who were deployed to Iraq. Predeployment baseline scores (n = 53) were compared to baseline scores collected while deployed (n = 113) on the battery of tests. There was no significant difference between baseline scores acquired from the predeployment group versus the deployed group. Furthermore, only one subtest revealed a significant difference in change scores from the follow-up test session when comparing the location of initial baseline testing. The results suggest that testing environment does not significantly influence baseline neurocognitive testing. The findings also provide support for the use of neurocognitive testing in a deployment environment.

Assessment of acute concussion in the combat environment.

Despite the prevalence of concussion in soldiers deployed to Iraq and Afghanistan, neuropsychological tests used to assist in concussion management have not been validated on the battlefield. This study evaluated the validity of the Automated Neuropsychological Assessment Metrics (ANAM) in the combat environment. Cases meeting criteria for concussion, healthy controls, and injured controls were assessed. Soldiers were administered the ANAM, traditional neuropsychological tests, and a background questionnaire. Cases were enrolled within 72 h of concussion. Cases exhibited poorer performance than controls on all ANAM subtests, with significant differences on simple reaction time (SRT), procedural reaction time (PRT), code substitution, and matching to sample (p<.001). Discriminant ability of scores on SRT and PRT subtests was 71%, which improved to 76% when pre-deployment baseline scores were available. An exploratory clinical decision tool incorporating ANAM scores and symptoms improved discriminant ability to 81%. Results provide initial validation of the ANAM for detecting acute effects of battlefield concussion.

Personality Assessment Inventory profiles of deployed combat troops: an empirical investigation of normative performance.

The present study examined the normative scores and psychometric properties of the Personality Assessment Inventory (PAI; Morey, 1991) within a non-treatment-seeking sample of soldiers deployed to combat zones in Iraq, compared with a sample of community adults matched with respect to age and gender. Results indicate the scores and properties of the PAI scales were generally quite similar in the Iraq and community samples, with modest differences emerging on only 3 subscales addressing antisocial behavior, issues with close relationships, and interpersonal vigilance. These results suggest that standard normative interpretation of PAI scales is appropriate even when the instrument is administered in a combat zone. In comparison with prior research, the results may suggest that documented mental health issues among combat veterans, when present, may be particularly likely to emerge postdeployment.