Racial and Ethnic Disparities in COVID-19 Infection and Hospitalization in the Active Component US Military.

Objectives. To assess COVID-19 disparities in the active component US military with an emphasis on race and ethnicity. Methods. In this retrospective cohort study, we calculated the incidence of COVID-19 testing, infection, and hospitalization in the active component US military in calendar year 2020. Results. Overall, 61.3 per 100 population per year were tested for COVID-19, 10.4% of tests were positive, and 1.1% of infected individuals were hospitalized. Non-Hispanic Blacks and Hispanics had a rate of testing for COVID-19 similar to that of Whites but had a higher risk of infection (adjusted risk ratio [ARR] = 1.25 and 1.26, respectively) and hospitalization (ARR = 1.28 and 1.21, respectively). Conclusions. Although of lower magnitude than seen in civilian populations, racial and ethnic disparities in COVID-19 infection and hospitalizations exist in the US military despite universal eligibility for health care, similar rate of testing, and adjustment for comorbidities and other factors. Simply making health care coverage available may be insufficient to ensure health equity. Interventions to mitigate disparities in the US military should target the patient, provider, health care system, and society at large. (Am J Public Health. 2021;111(12):2194-2201. https://doi.org/10.2105/AJPH.2021.306527).

gyrA and parC mutations in fluoroquinolone-resistant Neisseria gonorrhoeae isolates from Kenya.

BACKGROUND: Phenotypic fluoroquinolone resistance was first reported in Western Kenya in 2009 and later in Coastal Kenya and Nairobi. Until recently gonococcal fluoroquinolone resistance mechanisms in Kenya had not been elucidated. The aim of this paper is to analyze mutations in both gyrA and parC responsible for elevated fluoroquinolone Minimum Inhibitory Concentrations (MICs) in Neisseria gonorrhoeae (GC) isolated from heterosexual individuals from different locations in Kenya between 2013 and 2017. METHODS: Antimicrobial Susceptibility Tests were done on 84 GC in an ongoing Sexually Transmitted Infections (STI) surveillance program. Of the 84 isolates, 22 resistant to two or more classes of antimicrobials were chosen for analysis. Antimicrobial susceptibility tests were done using E-test (BioMerieux) and the results were interpreted with reference to European Committee on Antimicrobial Susceptibility Testing (EUCAST) standards. The isolates were sub-cultured, and whole genomes were sequenced using Illumina platform. Reads were assembled de novo using Velvet, and mutations in the GC Quinolone Resistant Determining Regions identified using Bioedit sequence alignment editor. Single Nucleotide Polymorphism based phylogeny was inferred using RaxML. RESULTS: Double GyrA amino acid substitutions; S91F and D95G/D95A were identified in 20 isolates. Of these 20 isolates, 14 had an additional E91G ParC substitution and significantly higher ciprofloxacin MICs (p = 0.0044*). On the contrary, norfloxacin MICs of isolates expressing both GyrA and ParC QRDR amino acid changes were not significantly high (p = 0.82) compared to MICs of isolates expressing GyrA substitutions alone. No single GyrA substitution was found in the analyzed isolates, and no isolate contained a ParC substitution without the simultaneous presence of double GyrA substitutions. Maximum likelihood tree clustered the 22 isolates into 6 distinct clades. CONCLUSION: Simultaneous presence of amino acid substitutions in ParC and GyrA has been reported to increase gonococcal fluoroquinolone resistance from different regions in the world. Our findings indicate that GyrA S91F, D95G/D95A and ParC E91G amino acid substitutions mediate high fluoroquinolone resistance in the analyzed Kenyan GC.

Tuberculosis Screening and Control in the US Military in War and Peace.

Tuberculosis (TB) has a well-established association with military populations, but the association of increased TB risk during armed conflict is less certain. This historical review focuses on the evolution of screening practices, the changing epidemiology of TB, and the risk of TB among US military service members during armed conflict from 1885 to the present. Overall, deployed soldiers were not at increased risk for TB compared with nondeployed soldiers in any of these conflicts, and the risk of TB in the US military largely reflected that of the underlying US population. Nevertheless, there are focal risk groups with higher rates of TB in the military, including prisoners of war. Although the principles of TB control in the military conform to those used in the civilian population, unique military exposures during both times of peace and of armed conflict require additional screening, surveillance, and control measures.

Latent Tuberculosis Infection Test Agreement in the National Health and Nutrition Examination Survey.

RATIONALE: Latent tuberculosis infection (LTBI) test discordance is poorly understood. OBJECTIVES: To determine the frequency and predictors of tuberculin skin test (TST) and QuantiFERON-TB Gold In-Tube test (QFT) discordance in the U.S. METHODS: We analyzed data from a representative sample of the U.S. population ages 6 years and older who participated in the 2011-2012 National Health and Nutrition Examination Survey. We determined prevalence estimates of test positivity, calculated test agreement and kappa statistics, and performed multivariable logistic regression to determine predictors of discordance. MEASUREMENTS AND MAIN RESULTS: LTBI prevalence among the U.S. born ranged from 0.6% to 2.8%, depending on how LTBI was defined, with test agreement 97.0% and kappa 0.27 (95% confidence interval, 0.18-0.36). Prevalence among the foreign born ranged from 9.1% to 20.3%, depending on how LTBI was defined, with test agreement 81.6% and kappa 0.38 (95% confidence interval, 0.33-0.44). TST(+)/QFT(-) discordance was associated with age, male sex, black race, Mexican-American ethnicity, previous TB exposure, and past LTBI treatment in U.S.-born participants, but only with higher lymphocyte count in foreign-born participants. TST(-)/QFT(+) discordance was associated with older age, previous TB exposure, and past LTBI treatment in U.S.-born participants and with older age, male sex, and past LTBI treatment in foreign-born participants. CONCLUSIONS: In the largest population-based sample of concurrently performed TST and QFT tests in a low tuberculosis incidence population, prevalence estimates depended heavily on how LTBI was defined and test agreement was only fair. We identified several predictors of discordance warranting further study.

The Prevalence of Latent Tuberculosis Infection in the United States.

RATIONALE: Individuals with latent tuberculosis infection (LTBI) represent a reservoir of infection, many of whom will progress to tuberculosis (TB) disease. A central pillar of TB control in the United States is reducing this reservoir through targeted testing and treatment. OBJECTIVES: To estimate the prevalence of LTBI in the United States using the tuberculin skin test (TST) and an IFN-γ release assay. METHODS: We used nationally representative data from the 2011-2012 National Health and Nutrition Examination Survey (n = 6,083 aged ≥6 yr). LTBI was measured by both the TST and QuantiFERON-TB Gold In-Tube test (QFT-GIT). Weighted population, prevalence, and multiple logistic regression were used. MEASUREMENTS AND MAIN RESULTS: The estimated prevalence of LTBI in 2011-2012 was 4.4% as measured by the TST and 4.8% by QFT-GIT, corresponding to 12,398,000 and 13,628,000 individuals, respectively. Prevalence declined slightly since 2000 among the U.S. born but remained constant among the foreign born. Earlier birth cohorts consistently had higher prevalence than more recent ones. Higher risk groups included the foreign born, close contact with a case of TB disease, and certain racial/ethnic groups. CONCLUSIONS: After years of decline, the prevalence of LTBI remained relatively constant between 2000 and 2011. A large reservoir of 12.4 million still exists, with foreign-born persons representing an increasingly larger proportion of this reservoir (73%). Estimates and risk factors for LTBI were generally similar between the TST and QFT-GIT. The updated estimates of LTBI and associated risk groups can help improve targeted testing and treatment in the United States.

Coverage of HIV pre-exposure prophylaxis (PrEP) within the active duty U.S. military, 2023.

Estimates of HIV pre-exposure prophylaxis (PrEP) coverage in the U.S. military, defined as the proportion of the persons taking HIV PrEP out of the estimated number of persons who had indications for it, have never been published. The objective of this study was to provide an estimate of HIV PrEP coverage comparable to U.S. civilian estimates. The population with indications for HIV PrEP was obtained from the Department of Defense 2018 Health Related Behaviors Survey, a stratified random sample of members of all military service branches. The military PrEP coverage estimate of 31.6% in 2023 was lower than the national U.S. estimate of 36.0% in 2022. Among the military population of men who have sex with men (MSM), an estimated 24.6% of service members had indications for PrEP, similar to the national estimate of 24.7%. MSM comprised 66% of all military service members with HIV PrEP indications, compared to 40% in the U.S. general population. The U.S. military should continue deliberate, sustained, and effective actions to address sexual health inequities among MSM, aligned and coordinated with societal efforts including improved coverage of HIV PrEP to prevent HIV transmission.

Tobacco and nicotine use among active component U.S. military service members: a comparison of 2018 estimates from the Health Related Behaviors Survey and the Periodic Health Assessment.

This study compared estimates of the prevalence of and risk factors for tobacco and nicotine use obtained from the 2018 Health Related Behaviors Survey (HRBS) and Periodic Health Assessment (PHA) survey. The HRBS and the PHA are important Department of Defense sources of data on health behavior collected from U.S. military service members. While their collection methods differ, some survey questions are similar, which provides an opportunity to compare survey estimates. Active duty service members consistently reported a much lower prevalence of all types of tobacco and nicotine use on the PHA compared to the HRBS: cigarettes (11.1% vs. 18.4%), e-cigarettes (7.3% vs. 16.2%), chewing tobacco (9.7% vs. 13.4%), any tobacco or nicotine use (25.3% vs. 37.8%), and use of 2 or more tobacco or nicotine products (5.8% vs. 17.4%). Associations between tobacco and nicotine use as well as demographic and other behavioral variables were fairly similar, including age, sex, education, race and ethnicity, rank, and alcohol use. The associations with service branch, body mass index, and sleep were inconsistent. This results of this study suggest that the PHA can provide timely information on trends in military tobacco and nicotine use over time, but much higher estimates from the confidential, voluntary HRBS reported in this study suggest that the command-directed PHA may substantially underestimate the prevalence of all types of tobacco and nicotine use.

Smoking and multiple sclerosis risk in black people: A nested case-control study.

BACKGROUND: Smoking is a well-established risk factor for MS; however, it is not known whether its effect on disease risk varies by race/ethnicity. METHODS: We conducted a nested case-control study among US military personnel who have serum samples stored at the Department of Defense Serum Repository. We measured serum cotinine levels, a marker of tobacco smoke exposure, in 157 Black and 23 White individuals who developed MS during follow-up. Controls were randomly selected and matched to each case by age, sex, race/ethnicity, dates of sample collection, and branch of military service. RESULTS: Smoking was not associated with an increased risk of MS in Black people (RR: 1.08, 95 % CI: 0.63-1.85). The results remained similar in analyses restricted to smoking status at baseline, to samples collected 5 years before symptom onset, and using different cut-off levels in cotinine to define smoking status. Smoking was not statistically significantly associated with MS risk in White people, but the point estimate was similar to what has previously been reported in other studies (RR: 1.85, 95 % CI: 0.56-6.16). CONCLUSIONS: Smoking was not associated with MS risk in Black people. Given the consistent association between smoking and MS risk in predominantly White populations, this may suggest that the association between smoking and MS varies by race/ethnicity.

Serologic Response to the Epstein-Barr Virus Peptidome and the Risk for Multiple Sclerosis.

Importance: It remains unclear why only a small proportion of individuals infected with the Epstein-Barr virus (EBV) develop multiple sclerosis (MS) and what the underlying mechanisms are. Objective: To assess the serologic response to all EBV peptides before the first symptoms of MS occur, determine whether the disease is associated with a distinct immune response to EBV, and evaluate whether specific EBV epitopes drive this response. Design, Setting, and Participants: In this prospective, nested case-control study, individuals were selected among US military personnel with serum samples stored in the US Department of Defense Serum Repository. Individuals with MS had serum collected at a median 1 year before onset (reported to the military in 2000-2011) and were matched to controls for age, sex, race and ethnicity, blood collection, and military branch. No individuals were excluded. The data were analyzed between September 1, 2022, and August 31, 2023. Exposure: Antibodies (enrichment z scores) to the human virome measured using VirScan (phage-displayed immunoprecipitation and sequencing). Main Outcome and Measure: Rate ratios (RRs) for MS for antibodies to 2263 EBV peptides (the EBV peptidome) were estimated using conditional logistic regression, adjusting for total anti-EBV nuclear antigen 1 (EBNA-1) antibodies, which have consistently been associated with a higher MS risk. The role of antibodies against other viral peptides was also explored. Results: A total of 30 individuals with MS were matched with 30 controls. Mean (SD) age at sample collection was 27.8 (6.5) years; 46 of 60 participants (76.7%) were male. The antibody response to the EBV peptidome was stronger in individuals with MS, but without a discernible pattern. The antibody responses to 66 EBV peptides, the majority mapping to EBNA antigens, were significantly higher in preonset sera from individuals with MS (RR of highest vs lowest tertile of antibody enrichment, 33.4; 95% CI, 2.5-448.4; P for trend = .008). Higher total anti-EBNA-1 antibodies were also associated with an elevated MS risk (top vs bottom tertile: RR, 27.6; 95% CI, 2.3-327.6; P for trend = .008). After adjusting for total anti-EBNA-1 antibodies, risk estimates from most EBV peptides analyses were attenuated, with 4 remaining significantly associated with MS, the strongest within EBNA-6/EBNA-3C, while the association between total anti-EBNA-1 antibodies and MS persisted. Conclusion and Relevance: These findings suggest that antibody response to EBNA-1 may be the strongest serologic risk factor for MS. No single EBV peptide stood out as being selectively targeted in individuals with MS but not controls. Larger investigations are needed to explore possible heterogeneity of anti-EBV humoral immunity in MS.

Discordance among commercially available diagnostics for latent tuberculosis infection.

RATIONALE: There is uncertainty regarding how to interpret discordance between tests for latent tuberculosis infection. OBJECTIVES: The objective of this study was to assess discordance between commercially available tests for latent tuberculosis in a low-prevalence population, including the impact of nontuberculous mycobacteria. METHODS: This was a cross-sectional comparison study among 2,017 military recruits at Fort Jackson, South Carolina, from April to June 2009. Several tests were performed simultaneously with a risk factor questionnaire, including (1) QuantiFERON-TB Gold In-Tube test, (2) T-SPOT.TB test, (3) tuberculin skin test, and (4) Battey skin test using purified protein derivative from the Battey bacillus. MEASUREMENTS AND MAIN RESULTS: In this low-prevalence population, the specificities of the three commercially available diagnostic tests were not significantly different. Of the 88 subjects with a positive test, only 10 (11.4%) were positive to all three tests; 20 (22.7%) were positive to at least two tests. Bacille Calmette-Guérin vaccination, tuberculosis prevalence in country of birth, and Battey skin test reaction size were associated with tuberculin skin test-positive, IFN-γ release assay-negative test discordance. Increasing agreement between the three tests was associated with epidemiologic criteria indicating risk of infection and with quantitative test results. CONCLUSIONS: For most positive results the three tests identified different people, suggesting that in low-prevalence populations most discordant results are caused by false-positives. False-positive tuberculin skin test reactions associated with reactivity to nontuberculous mycobacteria and bacille Calmette-Guérin vaccination may account for a proportion of test discordance observed.

Perceived Health Status and Medical Conditions Among US Active-Duty Service Members.

Purpose: This paper investigates the association between self-reported perceived health status and doctor-informed medical conditions among US active duty service members (ADSM). Methods: Data are from the 2018 Health-Related Behaviors Survey - a cross-sectional survey weighted to represent the US military (N = 17166). Perceived good health status was defined as having a response choice of "good", "very good", or "excellent" to the question: Would you say your overall physical health is ___? Medical conditions were based on self-reported presence of nine clinical conditions. Analysis included weighted prevalence and log-binomial regression models to explore relationships between ADSM characteristics with perceived good health status as well as concordance between perceived status and medical conditions. Results: ADSM rated their health to be excellent (14.6%), very good (37.7%), good (36.2%), fair (9.7%) and poor (1.7%). About 88.5% perceived a good (to excellent) health status. Perceived good health status was negatively associated with the number of medical conditions present (adjusted odds ratio (aOR): ranging from 0.78 to 0.92) as well as several health behaviors (aOR): ranging from 0.86 to 0.98) and other sociodemographic factors. Among all ADSMs, 51% perceived good health in the absence of medical conditions, while 8% perceived poor health status in the presence of medical conditions. Concordance between perceived health status and medical conditions was significantly lower among ADSM who were older (aOR: 0.61; 95% CI: 0.54-0.69), with dependent children (aOR: 0.89; 95% CI: 0.84-0.95), or had been deployed (aOR: 0.89, 95% CI: 0.84-0.95). Conclusion: The prevalence of perceived good health status among ADSMs was consistent with those documented in the general US population. The interrelationships between ADSM's perceptions, medical conditions and sociodemographic characteristics may have implications for their health literacy and utilization of health services. Study findings suggest that interventions promoting healthy behaviors, health literacy and treatment-seeking may influence perceived health status and mitigate medical conditions among ADSM, thus improving the US Military readiness, resilience and mission success.

Unintended pregnancy among U.S. military active duty servicemembers: Estimates for 2018 and trends since 2005.

OBJECTIVES: To evaluate the prevalence of and factors associated with unintended pregnancy in the past 12 months among women and men in the United States (U.S.) military in 2018, as well as trends in unintended pregnancy between 2005 and 2018. STUDY DESIGN: This was a cross-sectional study using the 2018 Department of Defense Health Related Behaviors Survey of active duty servicemembers. We selected a stratified random sample from members of all military service branches and used weighted logistic regression models to identify associated independent factors. A 9.6% weighted response rate to the online survey resulted in 16,806 active duty servicemembers analyzed; 4993 women aged 17 to 44 years and 11,813 men aged 17 to 45+ years. We used data from five independent surveys: 2005, 2008, 2011, 2015, and 2018 to examine trends over time. RESULTS: A total of 5.6% (95% CI: 4.5%-6.7%) of servicewomen reported unintended pregnancy and 2.4% (95% CI: 1.9%-2.9%) of servicemen reported to have caused unintended pregnancy. Unintended pregnancy was associated with contraception nonuse, younger age, and being either married or cohabiting. CONCLUSION: The decrease in prevalence of unintended pregnancy among U.S. servicemembers since 2005 mirrors the general U.S. POPULATION: Differing contraception policies during basic training across military services may influence rates of unintended pregnancy. Unintended pregnancies place a large burden on the military healthcare system, as the majority of women serving in the military are of reproductive age, and thus require care before, during, and for years after giving birth. IMPLICATIONS: Unintended pregnancy among U.S. military servicewomen relatively mirrors that seen in the U.S. POPULATION: Contraceptive policies affect unintended pregnancy throughout servicemembers' duration of service. As they are more likely to live in states which restrict access to abortion services, servicewomen with unintended pregnancy may face increased obstacles to care.

COVID-19 Booster Vaccination in the U.S. Military, August 2021-January 2022.

INTRODUCTION: A booster dose of messenger RNA vaccine protects against severe COVID-19 outcomes. This study examined the incidence of COVID-19 booster vaccination among active-duty U.S. military servicemembers between August 2021 and January 2022, factors associated with vaccination uptake, and trends over time. METHODS: This was a retrospective cohort study of active-duty military personnel using data from the Defense Medical Surveillance System. Participants were included if they served in the active component from August 2021 through January 2022 and were eligible to receive a COVID-19 booster dose by January 2022. Adjusted hazard ratio estimates of time to booster vaccination were calculated using Cox proportional hazards regression. RESULTS: Lower booster vaccine uptake was seen in the U.S. military (25%) than among the general U.S. population at the same time (45%). Booster vaccination increased with older age, with greater education, with higher income, among women, and among those stationed overseas; it decreased with previous COVID-19 infection and use of the Janssen vaccine. There were no significant racial or ethnic disparities in booster vaccination. CONCLUSIONS: In the absence of a compulsory vaccination policy, lower booster vaccine uptake was seen among servicemembers than among the general U.S. population, particularly among members who were younger, were male, Marines, and had a previous history of infection. Low vaccination rates not only increase the risk of acute and long-term health effects from COVID-19 among servicemembers, but they also degrade the overall readiness of the U.S. military.

Suicidal Behaviors Among Active-Duty US Service Members: Data from the 2018 Health-Related Behaviors Survey.

Background: This study aimed to 1) determine the prevalence of past-year suicidal ideation (SI) and attempts (SA) among active-duty SMs; 2) determine whether differences exist by age, sex, and race; and 3) assess whether prevalence estimates vary by risk profiles of mental health conditions and substance use. Methods: Data were from the 2018 Health-Related Behavior Survey (HRBS), a cross-sectional survey of active-duty SMs (n = 17,166). We used the logistic model to identify the factors of SI and SA and latent class analysis (LCA) to identify the risk profiles. Results: Among active duty SMs, 8.26% had SI and 1.25% had SA in the past year. Gender and age have been shown to influence how race might contribute to suicidal behaviors. Mental health conditions were associated with higher odds of SI and SA, as were younger ages; LGB identity; being separated, divorced, or widowed; use of e-cigarettes, dual use of e-cigarettes and cigarettes, or drugs; and history of deployment of less than 12 months. Frequencies of cigarette and e-cigarette use were also associated with SI and SA, indicating the odds were increasing by 0.3% for every additional cigarette or e-cigarette used. Five risk profiles were identified: class 1 (illegal drug use), class 2 (mental health needs with tobacco and alcohol use), class 3 (mental health conditions only), class 4 ("low risk" SMs with low levels of illegal drug use, mental health visits, tobacco use, and alcohol use), and class 5 (alcohol use). Compared to class 4 ("low risk"), all other risk profiles were associated with increased odds of suicidal behaviors. Conclusion: Despite the resources and increased access provided for mental health support, the prevalence of SI among active-duty SMs is greater than in the general population of the same age, likely due to additional military exposures and stressors.

Viral hepatitis C, active component, U.S. Armed Forces, 2011-2020.

This study reports updated numbers and incidence rates of hepatitis C virus (HCV) infection among active component members of the U.S. military using a revised case definition during a 10-year surveillance period between 2011 and 2020. During the surveillance period, there were 547 incident cases of HCV infection, resulting in an overall incidence rate of 4.1 per 100,000 person years (p-yrs), which was much lower than that seen in the general U.S. population. The incidence rate trended downward from 4.8 per 100,000 p-yrs in 2011 to 1.6 per 100,000 p-yrs in 2020. Incidence of HCV infection was higher in males, those identifying as non-Hispanic White, Navy members, those in healthcare occupations, and among those in the youngest age category (17-19 years). When stratified by year of birth, the incidence of hepatitis C was highest among those born in 1964 or prior; however, when stratified by time in service, incidence was highest among those with less than 2 years of military service. The updated incidence of and factors associated with HCV infection in the U.S. military provided in this report may be useful in evaluating the impact of current HCV screening policies and in guiding updates to them.

Evaluation of the MSMR Surveillance Case Definition for Incident Cases of Hepatitis C.

The validity of military hepatitis C virus (HCV) surveillance data is uncertain due to the potential for misclassification introduced when using administrative databases for surveillance purposes. The objectives of this study were to assess the validity of the surveillance case definition used by the Medical Surveillance Monthly Report (MSMR) for HCV, the over and underestimation of cases from surveillance data, and the true burden of HCV disease in the U.S. military. This was a validation study of all potential HCV cases in the active component U.S. military from calendar year 2019 obtained using several different data sources: 1) outpatient, inpatient, and reportable medical event (RME) records in the Defense Medical Surveillance System, 2) Health Level 7 (HL7) laboratory data obtained from the Navy Marine Corps Public Health Center, and 3) chart review of the electronic medical records of all potential HCV cases, to include those from privately-sourced care. The sensitivity of the MSMR case definition was 83.6% and the positive predictive value (PPV) was 60.0%. This study suggests that the U.S. military should have confidence that the previous estimates derived using the MSMR surveillance case definition were moderately close to the true burden of incident chronic HCV infection (the true incidence of chronic disease being about 27% lower), but these reports likely dramatically overestimate the incidence of acute HCV. Since HCV was selected as an RME to guide public health action, it is most suitable to invest public health efforts in strengthening the use of confirmed RMEs as the surveillance case definition.

Spatial and Spatio-Temporal Distribution of Human Respiratory Syncytial Virus, Human Parainfluenza Virus, and Human Adenoviruses Cases in Kenya 2007-2013.

Background: Human Respiratory Syncytial Virus (HRSV), Human Parainfluenza Virus (HPIV), and Human Adenovirus (HAdV) epidemics differ in geographical location, time, and virus type. Regions prone to infections can be identified using geographic information systems (GIS) and available methods for detecting spatial and time clusters. We sought to find statistically significant spatial and time clusters of HRSV, HPIV, and HAdV cases in different parts of Kenya. Methods: To analyse retrospective data, we used a geographical information system (GIS) and the spatial scan statistic. The information was gathered from surveillance sites and aggregated at the county level in order to identify purely spatial and Spatio-temporal clusters. To detect the presence of spatial autocorrelation, the local Moran's I test was used. To detect the spatial clusters of HRSV, HPIV, and HAdV cases, we performed the purely spatial scan statistic. Furthermore, space-time clusters were identified using space-time scan statistics. Both spatial and space-time analyses were based on the discrete Poisson model with a pre-specified statistical significance levelof p<0.05. Results: The findings showed that HRSV, HPIV, and HAdV cases had significant autocorrelation within the study areas. Furthermore, in the Western region of the country, the three respiratory viruses had local clusters with significant positive autocorrelation (p<0.05). Statistically, the Western region had significant spatial clusters of HRSV, HPIV, and HAdV occurrence. Furthermore, the space-time analysis revealed that the HPIV primary cluster persisted in the Western region from 2007 to 2013. However, primary clusters of HRSV and HAdV were observed in the Coastal region in 2009-11 and 2008-09, respectively. Conclusion: Human respiratory syncytial virus (HRSV), human parainfluenza virus (HPIV), and human adenovirus (HAdV) hotspots (clusters) occurred in Kenya's Western and Coastal regions from 2007 to 2013. The Western region appeared to be more prone to the occurrence of allthree respiratory viruses throughout the study period. Strategic mitigation should focus on these locations to prevent future clusters of HRSV, HPIV, and HAdV infections that could lead to epidemics.

Quality and Integrated Service Delivery: A Cross-Sectional Study of the Effects of Malaria and Antenatal Service Quality on Malaria Intervention Use in Sub-Saharan Africa.

Using regionally linked facility and household surveys, we measured the quality of integrated antenatal care and malaria in pregnancy services in Kenya, Namibia, Senegal, and Tanzania. We examined country heterogeneities for the association of integrated antenatal and malaria service quality scores with insecticide-treated bed net (ITN) use in pregnant women and children under-five and intermittent preventive treatment in pregnancy (IPTp-2) uptake. Malaria in pregnancy service quality was low overall. Our findings suggest modest, positive associations between malaria in pregnancy quality and ITN use and IPTp-2 uptake across pooled models and for most studied countries, with evidence of heterogeneity in the strength of associations and relevant confounding factors. Antenatal care quality generally was not associated with the study outcomes, although a positive interaction with malaria in pregnancy quality was present for pooled ITN use models. The improved quality of malaria services delivered during formal antenatal care can help address low coverage and usage rates of preventive malaria interventions in pregnancy and childhood. Study findings may be used to target quality improvement efforts at the sub-national level. Study methods may be adapted to identify low-performing facilities for intervention and adaption to other areas of care, such as HIV/AIDS, child immunizations, and postnatal care.

Impact of targeted testing for latent tuberculosis infection using commercially available diagnostics.

BACKGROUND: The interferon-γ release assays (IGRAs) are increasingly being used as an alternative to the tuberculin skin test (TST). Although IGRAs may have better specificity and certain logistic advantages to the TST, their use may contribute to overtesting of low-prevalence populations if testing is not targeted. The objective of this study was to evaluate the accuracy of a risk factor questionnaire in predicting a positive test result for latent tuberculosis infection using the 3 commercially available diagnostics. METHODS: A cross-sectional comparison study was performed among recruits undergoing Army basic training at Fort Jackson, South Carolina, from April through June 2009. The tests performed included: (1) a risk factor questionnaire; (2) the QuantiFERON Gold In-Tube test (Cellestis Limited, Carnegie, Victoria, Australia); (3) the T-SPOT.TB test (Oxford Immunotec Limited, Abingdon, United Kingdom); and (4) the TST (Sanofi Pasteur Ltd., Toronto, Ontario, Canada). Prediction models used logistic regression to identify factors associated with positive test results. RFQ prediction models were developed independently for each test. RESULTS: Use of a 4-variable model resulted in 79% sensitivity, 92% specificity, and a c statistic of 0.871 in predicting a positive TST result. Targeted testing using these risk factors would reduce testing by >90%. Models predicting IGRA outcomes had similar specificities as the skin test but had lower sensitivities and c statistics. CONCLUSIONS: As with the TST, testing with IGRAs will result in false-positive results if the IGRAs are used in low-prevalence populations. Regardless of the test used, targeted testing is critical in reducing unnecessary testing and treatment. CLINICAL TRIAL REGISTRATION: NCT00804713.

Deployment-related testing and treatment for latent tuberculosis infection, Part I.

Current Topics in Military Tropical Medicine is a Continuing Medical Education series, which updates military medical personnel on questions related to clinical practice while deployed. This issue is Part I of a two-part series on the approach to decision to test, testing and management of latent tuberculosis infection. A representative case is explored in both parts to highlight how to approach service members and their units with regards to latent tuberculosis infection screening and intervention.