Missed opportunities for TB diagnostic testing among people living with HIV in Zimbabwe: Cross-sectional analysis of the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey 2015-16.

Background: Using data from the Zimbabwe Population-based HIV Impact Assessment survey 2015-2016, we examined the TB care cascade and factors associated with not receiving TB diagnostic testing among adult PLHIV with TB symptoms. Methods: Statistical Analysis was limited to PLHIV aged 15 years and older in HIV care. Weighted logistic regression with not receiving TB testing as outcome was adjusted for covariates with crude odd ratios (ORs) with p < 0.25. All analyses accounted for multistage survey design. Results: Among 3507 adult PLHIV in HIV care, 2288 (59.7 %, 95 % CI:58.1-61.3) were female and 2425 (63.6 %, 95 % CI:61.1-66.1) lived in rural areas. 1197(48.7 %, 95 % CI:46.5-51.0) reported being screened for TB symptoms at their last HIV care visit. In the previous 12 months, 639 (26.0 %, 95 % CI:23.9-28.1) reported having symptoms and of those, 239 (37.8 %, 95 % CI:33.3-42.2) received TB testing. Of PLHIV tested for TB, 36 (49.5 %, 95 % CI:35.0-63.1) were diagnosed with TB; 32 (90.3 %, 95 % CI:78.9-100) of those diagnosed with TB received treatment. Never having used IPT was associated with not receiving TB testing. Conclusion: The results suggest suboptimal utilization of TB screening and diagnostic testing among PLHIV. New approaches are needed to reach opportunities missed in the HIV/TB integrated services.

Prevalence and incidence of tuberculosis infection among healthcare workers in chest diseases hospitals, Bangladesh: Putting infection control into context.

BACKGROUND: Healthcare workers (HCWs) are at increased risk of tuberculosis infection (TBI). We estimated the prevalence and incidence of TBI and risk factors among HCWs in Bangladeshi hospitals to target TB infection prevention and control (IPC) interventions. METHODS: During 2013-2016, we conducted a longitudinal study among HCWs in four chest disease hospitals. At baseline, we administered a questionnaire on sociodemographic and occupational factors for TB, tuberculin skin tests (TST) in all hospitals, and QuantiFERON ®-TB Gold in-Tube (QFT-GIT) tests in one hospital. We assessed factors associated with baseline TST positivity (induration ≥10mm), TST conversion (induration increase ≥10mm from baseline), baseline QFT-GIT positivity (interferon-gamma ≥0.35 IU/mL), and QFT-GIT conversion (interferon-gamma <0.35 IU/mL to ≥0.35 IU/mL). We included factors with a biologically plausible relationship with TBI identified in prior studies or having an association (p = <0.20) in the bivariate analyses with TST positivity or QFT-GIT positivity in multivariable generalized linear models. The Kaplan-Meier was used to estimate the cumulative TBI incidence rate per 100 person-years. RESULTS: Of the 758 HCWs invited, 732 (97%) consented to participate and 731 completed the one-step TST, 40% had a positive TST result, and 48% had a positive QFT-GIT result. In multivariable models, HCWs years of service 11-20 years had 2.1 (95% CI: 1.5-3.0) times higher odds of being TST-positive and 1.6 (95% CI 1.1-2.5) times higher odds of QFT-GIT-positivity at baseline compared with those working ≤10 years. HCWs working 11-20 years in pulmonary TB ward had 2.0 (95% CI: 1.4-2.9) times higher odds of TST positivity, and those >20 years had 2.5 (95% CI: 1.3-4.9) times higher odds of QFT-GIT-positivity at baseline compared with those working <10 years. TBI incidence was 4.8/100 person-years by TST and 4.2/100 person-years by QFT-GIT. Females had 8.5 (95% CI: 1.5-49.5) times higher odds of TST conversion than males. CONCLUSIONS: Prevalent TST and QFT-GIT positivity was associated with an increased number of years working as a healthcare worker and in pulmonary TB wards. The incidence of TBI among HCWs suggests ongoing TB exposure in these facilities and an urgent need for improved TB IPC in chest disease hospitals in Bangladesh.

Rigor and reproducibility in research with transcranial electrical stimulation: An NIMH-sponsored workshop.

BACKGROUND: Neuropsychiatric disorders are a leading source of disability and require novel treatments that target mechanisms of disease. As such disorders are thought to result from aberrant neuronal circuit activity, neuromodulation approaches are of increasing interest given their potential for manipulating circuits directly. Low intensity transcranial electrical stimulation (tES) with direct currents (transcranial direct current stimulation, tDCS) or alternating currents (transcranial alternating current stimulation, tACS) represent novel, safe, well-tolerated, and relatively inexpensive putative treatment modalities. OBJECTIVE: This report seeks to promote the science, technology and effective clinical applications of these modalities, identify research challenges, and suggest approaches for addressing these needs in order to achieve rigorous, reproducible findings that can advance clinical treatment. METHODS: The National Institute of Mental Health (NIMH) convened a workshop in September 2016 that brought together experts in basic and human neuroscience, electrical stimulation biophysics and devices, and clinical trial methods to examine the physiological mechanisms underlying tDCS/tACS, technologies and technical strategies for optimizing stimulation protocols, and the state of the science with respect to therapeutic applications and trial designs. RESULTS: Advances in understanding mechanisms, methodological and technological improvements (e.g., electronics, computational models to facilitate proper dosing), and improved clinical trial designs are poised to advance rigorous, reproducible therapeutic applications of these techniques. A number of challenges were identified and meeting participants made recommendations made to address them. CONCLUSIONS: These recommendations align with requirements in NIMH funding opportunity announcements to, among other needs, define dosimetry, demonstrate dose/response relationships, implement rigorous blinded trial designs, employ computational modeling, and demonstrate target engagement when testing stimulation-based interventions for the treatment of mental disorders.

Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy.

BACKGROUND: Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. METHODS: A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. RESULTS: We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. CONCLUSIONS: This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.

Fifty-five years of international epidemic-assistance investigations conducted by CDC's disease detectives.

For more than 60 years, the Centers for Disease Control and Prevention (CDC) has used its scientific expertise to help people throughout the world live healthier, safer, longer lives through science-based health action. In 1951, CDC officially established the Epidemic Intelligence Service to help build public health capacity. During 1950-2005, CDC's Epidemic Intelligence Service officers conducted 462 international epidemiologic field investigations in 131 foreign countries and 7 territories. Investigations have included responding to emerging infectious and noninfectious disease outbreaks, assisting in disaster response, and evaluating core components of public health programs worldwide. Approximately 81% of investigations were responses to infectious disease outbreaks, but the proportion of investigations related to chronic and other noninfectious conditions increased 7-fold (6%-45%). These investigations have contributed to detecting and characterizing new pathogens (e.g., severe acute respiratory syndrome-associated coronavirus) and conditions, provided insights regarding factors that cause or contribute to disease acquisition (e.g., Ebola hemorrhagic fever), led to development of new diagnostics and surveillance technologies, and provided information upon which global health policies and regulations can be based. CDC's disease detectives will undoubtedly continue to play a critical role in global health and in responding to emerging global disease threats.

Evaluation of institutional practices for prevention of phlebotomy-associated percutaneous injuries in hospital settings.

BACKGROUND: To reduce the incidence of phlebotomy-related percutaneous injuries (PIs), factors that contribute to these injuries must be identified. This study examined institutional phlebotomy practices, policies, perceptions, and culture to identify facilitators and barriers that appear to have the greatest impact in preventing injuries. METHODS: During site visits at study hospitals, observational data were collected during the performance of phlebotomy. In addition, interviews and focus groups were conducted with hospital personnel involved in phlebotomy procedures. RESULTS: Nine hospitals participated in the study. A total of 126 phlebotomy procedures were observed. Health care personnel chose devices with safety features for the majority of observed procedures (n = 122, 97%). Recommended phlebotomy practices for handling needles after use were observed in 42% to 92% of procedures. Adherence varied by type of device, occupation, and facility PI rate. In the 23 interviews and 9 focus groups, participants identified factors that facilitated PI prevention such as the availability and use of devices with safety mechanisms, adherence to recommended safe needle-handling practices, and institutional phlebotomy training. CONCLUSION: The quantitative and qualitative data indicate that a wide array of factors can affect phlebotomy-related practices and perceptions. Prevention of PIs may require comprehensive, multifaceted intervention efforts to improve the safety culture and reduce PIs and exposure to bloodborne pathogens in health care facilities.

Gonadal transcriptome alterations in response to dietary energy intake: sensing the reproductive environment.

Reproductive capacity and nutritional input are tightly linked and animals' specific responses to alterations in their physical environment and food availability are crucial to ensuring sustainability of that species. We have assessed how alterations in dietary energy intake (both reductions and excess), as well as in food availability, via intermittent fasting (IF), affect the gonadal transcriptome of both male and female rats. Starting at four months of age, male and female rats were subjected to a 20% or 40% caloric restriction (CR) dietary regime, every other day feeding (IF) or a high fat-high glucose (HFG) diet for six months. The transcriptional activity of the gonadal response to these variations in dietary energy intake was assessed at the individual gene level as well as at the parametric functional level. At the individual gene level, the females showed a higher degree of coherency in gonadal gene alterations to CR than the males. The gonadal transcriptional and hormonal response to IF was also significantly different between the male and female rats. The number of genes significantly regulated by IF in male animals was almost 5 times greater than in the females. These IF males also showed the highest testosterone to estrogen ratio in their plasma. Our data show that at the level of gonadal gene responses, the male rats on the IF regime adapt to their environment in a manner that is expected to increase the probability of eventual fertilization of females that the males predict are likely to be sub-fertile due to their perception of a food deficient environment.

Assessment of health care personnel needs for training in infection control: one size does not fit all.

To guide development of infection control education, we conducted a pilot needs assessment to determine current infection control knowledge, identify potential gaps between knowledge and practice, and identify perceived training needs among a varied group of health care personnel. A total of 23 health care personnel from various disciplines and health care settings completed the self-administered Web-based survey. Differences in knowledge and self-identified training needs were found among disciplines. Future research may well focus on further exploring specific needs of different disciplines. These results will be used to inform topics to cover in infection control curricula for clinicians, public health professionals, and allied health personnel.

Dermatologists' perceptions and practices related to community-associated methicillin-resistant Staphylococcus aureus infections.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections frequently present as skin and soft tissue infections, and, as a result, dermatologists may encounter patients with these infections. Three focus groups were conducted with dermatologists who attended the American Academy of Dermatology annual meeting in July 2005. Participants (N = 18) had a median of 20 (range, 5-29) years in practice. All perceived CA-MRSA as a problem nationally and 50% in their practice. Seventeen (94%) reported treating > or =1 (median, 15; range, 0-150) CA-MRSA infection(s) in the past year. Participants reported obtaining cultures in 99% to 100% of cases but only performed incision and drainage in a median of 42% of cases (range, 0%-100%). Understanding dermatologists' perceptions and practices about CA-MRSA infections is important to guide the development of educational interventions related to the prevention and control of these infections.

Reprocessing and reuse of single-use medical devices used during hemodynamic procedures in Brazil: a widespread and largely overlooked problem.

BACKGROUND: Several medical devices used during hemodynamic procedures, particularly angiographic diagnostic and therapeutic cardiac catheters, are manufactured for single use only. However, reprocessing and reuse of these devices has been reported, to determine the frequency of reuse and reprocessing of single-use medical devices used during hemodynamic procedures in Brazil and to evaluate how reprocessing is performed. DESIGN: National survey, conducted from December 1999 to July 2001. METHODS: Most of the institutions affiliated with the Brazilian Society of Hemodynamic and Interventional Cardiology were surveyed by use of a questionnaire sent in the mail. RESULTS: The questionnaire response rate was 50% (119 of 240 institutions). Of the 119 institutions that responded, 116 (97%) reported reuse of single-use devices used during hemodynamic procedures, and only 26 (22%) reported use of a standardized reprocessing protocol. Cleaning, flushing, rinsing, drying, sterilizing and packaging methods varied greatly and were mostly inadequate. Criteria for discarding reused devices varied widely. Of the 119 institutions that responded, 80 (67%) reported having a surveillance system for adverse events associated with the reuse of medical devices, although most of these institutions did not routinely review the data, and only 38 (32%) described a training program for the personnel who reprocessed single-use devices. CONCLUSIONS: The reuse of single-use devices used during hemodynamic procedures was very frequent in hospitals in Brazil. Basic guidance on how to reuse and reprocess single-use medical devices is urgently needed, because, despite the lack of studies to support reusing and reprocessing single-use medical devices, such devices are necessary in limited-resource areas in which these practices are current.

Conserved and differential effects of dietary energy intake on the hippocampal transcriptomes of females and males.

The level of dietary energy intake influences metabolism, reproductive function, the development of age-related diseases, and even cognitive behavior. Because males and females typically play different roles in the acquisition and allocation of energy resources, we reasoned that dietary energy intake might differentially affect the brains of males and females at the molecular level. To test this hypothesis, we performed a gene array analysis of the hippocampus in male and female rats that had been maintained for 6 months on either ad libitum (control), 20% caloric restriction (CR), 40% CR, intermittent fasting (IF) or high fat/high glucose (HFG) diets. These diets resulted in expected changes in body weight, and circulating levels of glucose, insulin and leptin. However, the CR diets significantly increased the size of the hippocampus of females, but not males. Multiple genes were regulated coherently in response to energy restriction diets in females, but not in males. Functional physiological pathway analyses showed that the 20% CR diet down-regulated genes involved in glycolysis and mitochondrial ATP production in males, whereas these metabolic pathways were up-regulated in females. The 40% CR diet up-regulated genes involved in glycolysis, protein deacetylation, PGC-1alpha and mTor pathways in both sexes. IF down-regulated many genes in males including those involved in protein degradation and apoptosis, but up-regulated many genes in females including those involved in cellular energy metabolism, cell cycle regulation and protein deacetylation. Genes involved in energy metabolism, oxidative stress responses and cell death were affected by the HFG diet in both males and females. The gender-specific molecular genetic responses of hippocampal cells to variations in dietary energy intake identified in this study may mediate differential behavioral responses of males and females to differences in energy availability.

Sex-dependent metabolic, neuroendocrine, and cognitive responses to dietary energy restriction and excess.

Females and males typically play different roles in survival of the species and would be expected to respond differently to food scarcity or excess. To elucidate the physiological basis of sex differences in responses to energy intake, we maintained groups of male and female rats for 6 months on diets with usual, reduced [20% and 40% caloric restriction (CR), and intermittent fasting (IF)], or elevated (high-fat/high-glucose) energy levels and measured multiple physiological variables related to reproduction, energy metabolism, and behavior. In response to 40% CR, females became emaciated, ceased cycling, underwent endocrine masculinization, exhibited a heightened stress response, increased their spontaneous activity, improved their learning and memory, and maintained elevated levels of circulating brain-derived neurotrophic factor. In contrast, males on 40% CR maintained a higher body weight than the 40% CR females and did not change their activity levels as significantly as the 40% CR females. Additionally, there was no significant change in the cognitive ability of the males on the 40% CR diet. Males and females exhibited similar responses of circulating lipids (cholesterols/triglycerides) and energy-regulating hormones (insulin, leptin, adiponectin, ghrelin) to energy restriction, with the changes being quantitatively greater in males. The high-fat/high-glucose diet had no significant effects on most variables measured but adversely affected the reproductive cycle in females. Heightened cognition and motor activity, combined with reproductive shutdown, in females may maximize the probability of their survival during periods of energy scarcity and may be an evolutionary basis for the vulnerability of women to anorexia nervosa.

Nationwide outbreak of red eye syndrome associated with transfusion of leukocyte-reduced red blood cell units.

OBJECTIVE: To characterize red eye reactions occurring within 24 hours after receipt of units of leukocyte-reduced red blood cells, determine their etiology, and investigate their potential link to transfusion. METHODS: We conducted a survey of transfusion facilities nationwide to determine the scope and magnitude of the reactions; performed case-control and cohort studies among transfused patients at the facility where most reactions occurred; and performed animal experiments, using cellulose acetate derivatives extracted from leukocyte-reduction filters and filter precursors, to reproduce reactions. RESULTS: From January 1, 1997, through January 15, 1998, we identified 159 reactions in 117 patients from 17 states. Reactions were characterized by conjunctival erythema or hemorrhage (in 100% of patients), eye pain (in 62%), photophobia (in 46%), and decreased visual acuity (in 32%). Symptom onset occurred 1-24 hours after initiation of transfusion and resolved within a median of 5 days. Reactions were associated with transfusion sessions that included units of red blood cells filtered with a specific brand of filter, the LeukoNet filter (HemaSure) (odds ratio, 100.4; P<.001). There was a dose-response relationship between the number of LeukoNet-filtered units transfused and the attack rate for reactions, ranging from 0.8% among sessions in which 1 unit was transfused to 27.3% among sessions in which 3 or more units were transfused (P<.001). A similar ocular syndrome was elicited in rabbits injected with cellulose acetate derivatives extracted from unused LeukoNet filters or filter precursors. No reactions were reported after LeukoNet filters were withdrawn from the market. CONCLUSIONS: This transfusion-associated red eye syndrome was linked to a specific brand of leukocyte-reduction filter and likely resulted from cellulose acetate derivatives leached from the filter membrane.

Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP).

This report summarizes recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) concerning influenza vaccination of health-care personnel (HCP) in the United States. These recommendations apply to HCP in acute care hospitals, nursing homes, skilled nursing facilities, physician's offices, urgent care centers, and outpatient clinics, and to persons who provide home health care and emergency medical services. The recommendations are targeted at health-care facility administrators, infection-control professionals, and occupational health professionals responsible for influenza vaccination programs and influenza infection-control programs in their institutions. HICPAC and ACIP recommend that all HCP be vaccinated annually against influenza. Facilities that employ HCP are strongly encouraged to provide vaccine to their staff by using evidence-based approaches that maximize vaccination rates.

Monitoring health care workers after smallpox vaccination: findings from the Hospital Smallpox Vaccination-Monitoring System.

BACKGROUND: The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee recommended that hospitals establish on-site, daily assessments of health care workers vaccinated with smallpox vaccine. The Hospital Smallpox Vaccination Monitoring System (HSVMS) was 1 component of the smallpox vaccination plan to monitor adverse events on-site in hospitals. This report presents findings from February to August 2003. METHODS: All US institutions participating in the smallpox vaccination program were eligible to enroll in and use HSVMS through the Internet-based Centers for Disease Control Secure Data Network. RESULTS: Of the 730 enrolled vaccinees, 341 (47%) were nurses; 122 (17%) physicians; 75 (10%) laboratory, patient care, radiology, or other technicians; 39 (5%) administrators; 22 (3%) housekeepers; 21 (3%) physical or respiratory therapists; 20 (3%) infection control professionals; 19 (3%) safety or security staff; and 17 (2%) epidemiologists; and 54 (7%) were workers in other job categories. Most (86%) vaccinees had been previously vaccinated. Postvaccination signs and symptoms were frequent: itching (75.2%), pain at the vaccination site (31.6%), swollen or tender lymph nodes (26.4%), fatigue (26.2%), and headache (20.8%). Symptoms were highest during the first week after vaccination; symptoms were more frequently reported among vaccinees without previous vaccination. Adherence to recommended vaccination site care was reported in 2732 of 3091 (88.4%) follow-up visits among workers with patient contact. Of the 4379 days workers planned to work, during 31 (0.7 per 100) days, workers performed restricted activities, and, in 60 (1.4 per 100) days, workers were absent. CONCLUSIONS: Findings from HSVMS indicate that adherence to post-smallpox vaccination site care was high and that the number of days of work affected was low.