Epidemic Clostridioides difficile Ribotype 027 Lineages: Comparisons of Texas Versus Worldwide Strains.

BACKGROUND: The epidemic Clostridioides difficile ribotype 027 strain resulted from the dissemination of 2 separate fluoroquinolone-resistant lineages: FQR1 and FQR2. Both lineages were reported to originate in North America; however, confirmatory large-scale investigations of C difficile ribotype 027 epidemiology using whole genome sequencing has not been undertaken in the United States. METHODS: Whole genome sequencing and single-nucleotide polymorphism (SNP) analysis was performed on 76 clinical ribotype 027 isolates obtained from hospitalized patients in Texas with C difficile infection and compared with 32 previously sequenced worldwide strains. Maximum-likelihood phylogeny based on a set of core genome SNPs was used to construct phylogenetic trees investigating strain macro- and microevolution. Bayesian phylogenetic and phylogeographic analyses were used to incorporate temporal and geographic variables with the SNP strain analysis. RESULTS: Whole genome sequence analysis identified 2841 SNPs including 900 nonsynonymous mutations, 1404 synonymous substitutions, and 537 intergenic changes. Phylogenetic analysis separated the strains into 2 prominent groups, which grossly differed by 28 SNPs: the FQR1 and FQR2 lineages. Five isolates were identified as pre-epidemic strains. Phylogeny demonstrated unique clustering and resistance genes in Texas strains indicating that spatiotemporal bias has defined the microevolution of ribotype 027 genetics. CONCLUSIONS: Clostridioides difficile ribotype 027 lineages emerged earlier than previously reported, coinciding with increased use of fluoroquinolones. Both FQR1 and FQR2 ribotype 027 epidemic lineages are present in Texas, but they have evolved geographically to represent region-specific public health threats.

Systemic Delays in the Initiation of Antiretroviral Therapy for Clinically Eligible HIV-Infected Patients in Houston, Texas: The Providers' Report Card.

BACKGROUND: The current US HIV treatment guidelines support initiation of antiretroviral therapy (ART) for persons with HIV for personal health benefits and prevention of HIV transmission. However, high levels of adherence to ART are critical to maximize individual and public health benefits. We examined the nonclinical barriers to ART initiation for clinically eligible individuals and the provider- and patient-related factors associated with these barriers among HIV-infected patients in Houston/Harris County, Texas. METHODS: We analyzed data obtained from a probability sample of HIV medical care providers (HMCPs) in 13 outpatient facilities in Houston/Harris County, Texas surveyed between June and September 2009. We used an inductive thematic approach to code HMCP responses to an open-ended question that asked the main reasons why providers may delay initiating ART for clinically eligible patients. RESULTS: The reasons cited by providers for delaying ART for clinically eligible patients were adherence (42.5%; 95% confidence interval [CI]: 28.5-57.8), acceptance (30%; 95% CI: 18.1-45.4), and structural concerns (27.5%; 95% CI: 16.1-42.8), with significant variations ( P < .0001) noted across patients' race/ethnicity and transmission category. HIV medical care providers with 6 to 10 years' experience in HIV care and those providing medical care for more than 100 patients monthly were about 4 times (adjusted odds ratio [aOR]: 3.80; 95% CI: 1.20-5.92; P = .039) and 10 times (aOR: 10.36; 95% CI: 1.42-22.70; P = .019) more likely to state adherence and acceptance concerns, respectively, as reasons for delaying ART for clinically eligible patients. CONCLUSION: Our findings highlight the fact that clinical guidelines are only a starting point for medical decision-making process and that patients themselves play an important role. HMCP access to referrals for other medical issues, support services, and treatment education may help improve adherence and patient readiness for ART, thereby avoiding systemic delays.

Modeling and Forecasting Influenza-like Illness (ILI) in Houston, Texas Using Three Surveillance Data Capture Mechanisms.

Objective The objective was to forecast and validate prediction estimates of influenza activity in Houston, TX using four years of historical influenza-like illness (ILI) from three surveillance data capture mechanisms. Background Using novel surveillance methods and historical data to estimate future trends of influenza-like illness can lead to early detection of influenza activity increases and decreases. Anticipating surges gives public health professionals more time to prepare and increase prevention efforts. Methods Data was obtained from three surveillance systems, Flu Near You, ILINet, and hospital emergency center (EC) visits, with diverse data capture mechanisms. Autoregressive integrated moving average (ARIMA) models were fitted to data from each source for week 27 of 2012 through week 26 of 2016 and used to forecast influenza-like activity for the subsequent 10 weeks. Estimates were then compared to actual ILI percentages for the same period. Results Forecasted estimates had wide confidence intervals that crossed zero. The forecasted trend direction differed by data source, resulting in lack of consensus about future influenza activity. ILINet forecasted estimates and actual percentages had the least differences. ILINet performed best when forecasting influenza activity in Houston, TX. Conclusion Though the three forecasted estimates did not agree on the trend directions, and thus, were considered imprecise predictors of long-term ILI activity based on existing data, pooling predictions and careful interpretations may be helpful for short term intervention efforts. Further work is needed to improve forecast accuracy considering the promise forecasting holds for seasonal influenza prevention and control, and pandemic preparedness.

West Nile Virus Outbreak in Houston and Harris County, Texas, USA, 2014.

Since 2002, West Nile virus (WNV) has been detected every year in Houston and the surrounding Harris County, Texas. In 2014, the largest WNV outbreak to date occurred, comprising 139 cases and causing 2 deaths. Additionally, 1,286 WNV-positive mosquito pools were confirmed, the most reported in a single mosquito season.

Managing the Personal Side of Health Care among Patients with HIV/AIDS.

The study describes the HIV care providers' sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers' perspectives may help enhance support services, patients' ongoing care and retention, leading to improved health outcomes.

Frequency and Determinants of Preventive Care Counseling by HIV Medical Care Providers during Encounters with Newly Diagnosed and Established HIV-Infected Patients.

This study evaluates the frequency and determinants of preventive care counseling by HIV medical care providers (HMCPs) during encounters with newly diagnosed and established HIV-infected patients. Data used were from a probability sample of HMCPs in Houston/Harris County, Texas, surveyed in 2009. Overall, HMCPs offered more preventive care counseling to newly diagnosed than the established patients (adjusted odds ratio [AOR] = 7.28; 95% confidence interval [CI] = 2.86-16.80). They were more likely to counsel newly diagnosed patients than the established ones on medication and adherence (AOR = 14.70; 95% CI = 1.24-24.94), HIV risk reduction (AOR = 5.91; 95% CI = 0.48-7.13), and disease screening (AOR = 7.20; 95% CI = 0.72-11.81). HIV medical care providers who were less than 45 years of age, infectious disease specialists, and had less than 30 minutes of encounter time were less likely to counsel patients regardless of the status. Our findings suggest the need for HMCPs to improve their preventive care counseling efforts, in order to help patients build skills for adopting and maintaining safe behavior that could assist in reducing the risk of HIV transmission.

Assessment of Antimicrobial Stewardship Activities in a Large Metropolitan Area.

PURPOSE: To describe antimicrobial stewardship programs (ASPs) of acute and long-term acute care (LTAC) hospitals in Houston, Texas. METHODS: Two-part survey to clinical pharmacists and pharmacy directors. All acute care and LTAC facilities from the Harris County Medical Society database were invited to participate. RESULTS: In part 1 of the telephone survey, 82 facilities within Houston, Harris county, were contacted by telephone of which 51 responded (response rate: 62%). Of respondents, 55% (n = 28) reported having an active ASP and 8% (n = 4) planned implementation within 12 months. Acute care and LTAC hospitals reported ASPs in 57% and 67% of facilities, respectively. Physician champions were involved in 71% (n = 20) of active ASPs; clinical pharmacists were involved in 75% (n = 21) of programs. In part II, 22 (43%) facilities completed the online survey; postprescription review with feedback was used in facilities with an ASP and medical training program (5 of 5) while formulary restriction was in facilities without stewardship or medical training (6 of 8). CONCLUSION: This is the first major survey of ASP in a major metropolitan area. The stewardship effort in the city of Houston is encouraging; we expect the number of stewardship programs in all facilities will continue to rise as focus on antimicrobial resistance grows.

System and Patient Barriers to Care among People Living with HIV/AIDS in Houston/Harris County, Texas: HIV Medical Care Providers' Perspectives.

In the United States, a considerable number of people diagnosed with HIV are not receiving HIV medical care due to some barriers. Using data from the Medical Monitoring Project survey of HIV medical care providers in Houston/Harris County, Texas, we assessed the HIV medical care providers' perspectives of the system and patient barriers to HIV care experienced by people living with HIV/AIDS (PLWHA). The study findings indicate that of the 14 HIV care barriers identified, only 1 system barrier and 7 patient barriers were considered of significant (P ≤ .05) importance, with the proportion of HIV medical care providers' agreement to these barriers ranging from 73.9% (cost of health care) to 100% (lack of social support systems and drug abuse problems). Providers' perception of important system and patient barriers varied significantly (P ≤ .05) by profession, race/ethnicity, and years of experience in HIV care. To improve access to and for consistent engagement in HIV care, effective intervention programs are needed to address the barriers identified especially in the context of the new health care delivery system.

Survival analysis, long-term outcomes, and percentage of recovery up to 8 years post-infection among the Houston West Nile virus cohort.

In 2012, we witnessed a resurgence of West Nile virus (WNV) in the United States, with the largest outbreak of human cases reported since 2003. WNV is now endemic and will continue to produce epidemics over time, therefore defining the long-term consequences of WNV infection is critical. Over a period of eight years, we prospectively followed a cohort of 157 WNV-infected subjects in the Houston metropolitan area to observe recovery over time and define the long-term clinical outcomes. We used survival analysis techniques to determine percentage of recovery over time and the effects of demographic and co-morbid conditions on recovery. We found that 40% of study participants continued to experience symptoms related to their WNV infection up to 8 years later. Having a clinical presentation of encephalitis and being over age 50 were significantly associated with prolonged or poor recovery over time. Since the health and economic impact as a result of prolonged recovery, continued morbidity, and related disability is likely substantial in those infected with WNV, future research should be aimed at developing effective vaccines to prevent illness and novel therapeutics to minimize morbidity, mortality, and long-term complications from infection.

Likely female-to-female sexual transmission of HIV--Texas, 2012.

In August 2012, the Houston Department of Health contacted CDC regarding the rare transmission of human immunodeficiency virus (HIV) likely by sexual contact between two women. The case was investigated, and laboratory testing confirmed that the woman with newly diagnosed HIV infection had a virus virtually identical to that of her female partner, who was diagnosed previously with HIV and who had stopped receiving antiretroviral treatment in 2010. This report describes this case of HIV infection, likely acquired by female-to-female sexual transmission during the 6-month monogamous relationship of the HIV-discordant couple (one negative, one positive). The woman with newly acquired infection did not report any other recognized risk factors for HIV infection, and the viruses infecting the two women had ≥ 98% sequence identity in three genes. The couple had not received any preventive counseling before acquisition of the virus by the woman who had tested negative for HIV. HIV-discordant couples should receive counseling regarding safer sex practices, and HIV-infected partners should be linked to and retained in medical care.

Characteristics and risk of syphilis diagnosis among HIV-infected male cohort: a population-based study in Houston, Texas.

BACKGROUND: This population-based study assessed the characteristics, timing, and risk of syphilis diagnoses among HIV-infected males in Houston, Texas. METHODS: A retrospective cohort of males newly diagnosed as having HIV between January 2000 and December 2002 was constructed using HIV surveillance data. These individuals were cross-referenced to sexually transmitted disease surveillance data to ascertain early syphilis diagnoses for the subsequent 10 years. Multivariable Cox regression was used to identify risk factors for syphilis diagnosis while controlling for the effects of covariates. RESULTS: Approximately 6% of the HIV-infected male cohort received early syphilis diagnoses during a 10-year period. Of these comorbid individuals, 40.8% received an incident syphilis diagnosis 5 years or more after their HIV diagnosis. Men who have sex with men (MSM) transmission risk was associated with significantly increased hazard of having a syphilis diagnosis in multivariable analysis (adjusted hazard ratio [HR] of a syphilis diagnosis, 5.24; 95% confidence interval, 3.41-8.05). Compared with men who were older than 40 years at HIV diagnosis, those 13 to 19 years old were 4.06 (2.18-7.55) times more likely to obtain a syphilis diagnosis. The HRs of having an HIV-syphilis comorbidity decreased as age increased. Compared with whites, non-Hispanic African Americans had 1.59 (1.11-2.26) times increased risk of having a subsequent syphilis diagnosis. Risk-stratified HRs showed that MSM had an increased risk of contracting syphilis in all race/ethnicity and age groups. CONCLUSIONS: This study suggests that HIV-positive African Americans, youth, and MSM had increased risk of having a subsequent syphilis diagnosis. Targeting these groups with STI prevention messaging may be beneficial to reducing comorbidity.

Identification of dengue fever cases in Houston, Texas, with evidence of autochthonous transmission between 2003 and 2005.

Houston, Texas, maintains an environment conducive to dengue virus (DENV) emergence; however, surveillance is passive and diagnostic testing is not readily available. To determine if DENV is present in the area, we tested 3768 clinical specimens (2138 cerebrospinal fluid [CSF] and 1630 serum) collected from patients with suspected mosquito-borne viral disease between 2003 and 2005. We identified 47 immunoglobulin M (IgM)-positive dengue cases, including two cases that were positive for viral RNA in serum for dengue serotype 2. The majority of cases did not report any history of travel outside the Houston area prior to symptom onset. The epidemic curve suggests an outbreak occurred in 2003 with continued low-level transmission in 2004 and 2005. Chart abstractions were completed for 42 of the 47 cases; 57% were diagnosed with meningitis and/or encephalitis, and 43% met the case definition for dengue fever. Two of the 47 cases were fatal, including one with illness compatible with dengue shock syndrome. Our results support local transmission of DENV during the study period. These findings heighten the need for dengue surveillance in the southern United States.

Determinants of fruits and vegetables consumption among persons with doctor-diagnosed chronic diseases.

OBJECTIVE: The objective of this study was to examine the factors associated with fruits and vegetables consumption pattern among persons with doctor-diagnosed chronic diseases. METHOD: The authors examined cross-sectional, random-digit-dialed health survey data collected in 2008 in Houston, Texas, a city with a diverse ethnic population. The survey sample, which was designed to represent all households with telephones, was drawn using standard list-assisted random-digit-dialing methodology from telephone exchanges that serve the study area. A total of 1001 households were interviewed, and data obtained were subjected to both bivariate and multivariate analyses. RESULTS: Findings from this study indicate that fruits and vegetables consumption for persons with single chronic disease was significantly predicted (R (2) = 0.83) by the participants' age, educational level, and insurance status. None of the covariates considered in the study were significant predictors of fruits and vegetables consumption pattern among persons who had multiple chronic diseases. But when the subpopulation with any number of chronic diseases was considered, only gender (P < .05) and marital status (P < .001) were noted as the significant predictors of fruits and vegetables (R (2) = 0.34). CONCLUSION: More public health efforts are needed to make individuals with chronic diseases aware of the importance of consumption of fruits and vegetables. Clinicians and health care professionals should be encouraged to emphasize the importance of consumption of fruits and vegetables in their routine practice to the patients with chronic disease(s), especially to those who are unmarried and male.

Disparities in fruits and vegetables consumption in houston, Texas: implications for health promotion.

BACKGROUND: The consumption of the recommended amount of fruits and vegetables is believed to help prevent nutrient deficiency disorders and lower the risk of several chronic diseases. Information on the disparity of fruit and vegetable consumption may be useful in designing targeted health promotion programs for increasing fruit and vegetable consumption. The objective of this pilot study was to examine disparities in fruit and vegetable consumption among Houston residents based on sociodemographic characteristics. METHODS: The authors conducted bivariate and multivariate analyses to examine the associations between sociodemographic characteristics and fruit and vegetable consumption using a random digit dialing (RDD) health survey data (N = 1001) collected in Houston, Texas. RESULTS: Bivariate analysis showed that there were significant associations between fruit and vegetable consumption and education (P < .01); race/ethnicity (P < .001); marital status (P < .001); and employment status (P < .05). Multivariate analysis indicated that fruit and vegetable consumption pattern could be significantly (P ≤ .05) predicted by gender, race, and marital status. Respondents who were of other race category were less likely than whites to consume fruits and vegetables, while married respondents and women were more likely to consume fruits and vegetables compared to the unmarried and men, respectively. IMPLICATIONS: Health promotion programs aimed at increasing the consumption of fruits and vegetables should consider developing targeted intervention for men, people with less formal education, minority race/ethnicity, people who are unemployed, and those who are unmarried.

Pulsed-field gel electrophoresis for Salmonella infection surveillance, Texas, USA, 2007.

To identify sources of transmission for area clusters, in 2007 the Houston Department of Health and Human Services conducted an 8-month study of enhanced surveillance of Salmonella infection. Protocol included patient interviews and linking the results of interviews to clusters of pulsed-field gel electrophoresis patterns detected by the local PulseNet laboratory.

Late HIV diagnosis in Houston/Harris County, Texas, 2000-2007.

This cross-sectional study aimed to evaluate the prevalence and predictive factors associated with late HIV diagnoses in Houston, Texas using surveillance data. Study subjects were Houston/Harris County residents, 13 years or older, diagnosed with HIV and reported to the Houston Department of Health and Human Services. Late HIV diagnosis was defined as an AIDS diagnosis within three months of an HIV diagnosis. Logistic regression was used to investigate the association between late HIV diagnoses and predictive factors. We found 31% of the study population had late HIV diagnoses. The Hispanic population, men, older individuals, heterosexuals, and those diagnosed in private facilities were more likely to receive late HIV diagnoses. Sensitivity analysis was conducted to evaluate the effect of time from HIV to AIDS diagnosis on the prevalence of a late diagnosis, and on the predictors of late diagnosis. The sensitivity analysis showed time affects prevalence, but not the odds ratios of the risk factors for late diagnosis. This finding suggests HIV prevention programs should specifically target these populations at risk for late HIV diagnosis to encourage frequent HIV testing.

Self-reported health, functional status and chronic disease in community dwelling older adults: untangling the role of demographics.

Self-reported health, a widely used measure of general health status in population studies, can be affected by certain demographic variables such as gender, race/ethnicity and education. This cross-sectional assessment of the current health status of older adult residents was conducted in an inner-city Houston neighborhood in May, 2007. A survey instrument, with questions on chronic disease prevalence, health limitations/functional status, self-reported subjective health status in addition to demographic data on households was administered to a systematic random sample of residents. Older adults (>60 years of age) were interviewed (weighted N = 127) at their homes by trained interviewers. The results indicated that these residents, with low literacy levels, low household income and a high prevalence of frequently reported chronic diseases (hypertension, diabetes and arthritis) also reported non-participation in community activities, volunteerism and activities centered on organized religion, thus, potentially placing them at risk for social isolation. Women reported poorer self-reported health and appeared to fare worse in all health limitation indicators and reported greater structural barriers in involvement with their community. Blacks reported worse health outcomes on all indicators than other sub-groups, an indication that skills training in chronic disease self-management and in actively eliciting support from various sources may be beneficial for this group. Therefore, the use of self-reported health with a broad brush as an indicator of "true" population health status is not advisable. Sufficient consideration should be given to the racial/ethnic and gender differences and these should be accounted for.

Social and mental health needs assessment of Katrina evacuees.

Hurricane Katrina made landfall along the Gulf Coast as a Category 3 storm on August 29, 2005. Many residents were evacuated to neighboring cities owing to massive destruction. Working with the City of Houston Health Department, researchers conducted a medical and psychological needs assessment of 124 Hurricane Katrina evacuees in Houston shelters from September 4-12, 2005. Among those willing to talk about their experiences, 41% were afraid they would die, 16% saw someone close to them injured or die, 17% saw violence, and 6% directly experienced physical violence. When using a version of the Impact of Stress Experiences scale, the majority of evacuees scored as experiencing moderate (38.6%) to severe (23.9%) post-traumatic stress disorder (PTSD) symptoms. These data suggest that in addition to challenges in finding loved ones, housing, and jobs, many Katrina survivors have experienced significant psychological trauma that may lead to future PTSD.

Services oriented architectures and rapid deployment of ad-hoc health surveillance systems: lessons from Katrina relief efforts.

During the Hurricane Katrina relief efforts, a new city was born overnight within the City of Houston to provide accommodation and health services for thousands of evacuees deprived of food, rest, medical attention, and sanitation. The hurricane victims had been exposed to flood water, toxic materials, physical injury, and mental stress. This scenario was an invitation for a variety of public health hazards, primarily infectious disease outbreaks. Early detection and monitoring of morbidity and mortality among evacuees due to unattended health conditions was an urgent priority and called for deployment of real-time surveillance to collect and analyze data at the scene, and to enable and guide appropriate response and planning activities. The University of Texas Health Science Center at Houston (UTHSC) and the Houston Department of Health and Human Services (HDHHS) deployed an ad hoc surveillance system overnight by leveraging Internet-based technologies and Services Oriented Architecture (SOA). The system was post-coordinated through the orchestration of Web Services such as information integration, natural language processing, syndromic case finding, and online analytical processing (OLAP). Here we will report the use of Internet-based and distributed architectures in providing timely, novel, and customizable solutions on demand for unprecedented events such as natural disasters.

The utility of geographic information systems (GIS) in rapid epidemiological assessments following weather-related disasters: methodological issues based on the Tropical Storm Allison Experience.

Flooding is the most common natural disaster worldwide, and is the leading cause of weather-related deaths in the United States. Tropical storm Allison hit landfall near Galveston, Texas on June 5, 2001, causing the most severe flood-related damage ever recorded in the Houston metropolitan area. This devastating storm dumped 37 in of rain in 24h on parts of the city, killing 22 people and causing more than $5 billion in damage. The main goal of the public health response to tropical storm Allison was to rapidly evaluate the immediate health needs of the community. Geographical information system (GIS) technology was instrumental to the timeliness of this effort. We conducted a rapid needs assessment in the areas most affected by flooding using modified cluster sampling facilitated by GIS methodology. Of the 420 households participating in the survey, we found a significant increase in illness (OR, 5.1; 95% CI, 2.7-9.4), injuries (OR, 4.8; 95% CI, 1.9-12.8), and immediate health needs (OR, 3.3; 95% CI, 1.7-6.1) among persons living in flooded homes compared to non-flooded homes. There were 60 households reporting serious damage, 24 of which were outside the 500-year flood plain. We also obtained reliable estimates of the extent of damage and household needs to help guide relief efforts. These findings underscore the usefulness of rapid needs assessment as a tool to identify actual health threats and to facilitate delivery of resources to those with the greatest and most immediate need. Our ability to swiftly plan and implement a rapid needs assessment over a large geographical region within 1 week following the damage would not have been possible without the utilization of GIS methodology and the availability of skilled personnel and timely data resources.