The East Jakarta Project: surveillance for highly pathogenic avian influenza A(H5N1) and seasonal influenza viruses in patients seeking care for respiratory disease, Jakarta, Indonesia, October 2011-September 2012.

Indonesia has reported the most human infections with highly pathogenic avian influenza (HPAI) A(H5N1) virus worldwide. We implemented enhanced surveillance in four outpatient clinics and six hospitals for HPAI H5N1 and seasonal influenza viruses in East Jakarta district to assess the public health impact of influenza in Indonesia. Epidemiological and clinical data were collected from outpatients with influenza-like illness (ILI) and hospitalized patients with severe acute respiratory infection (SARI); respiratory specimens were obtained for influenza testing by real-time reverse transcription-polymerase chain reaction. During October 2011-September 2012, 1131/3278 specimens from ILI cases (34·5%) and 276/1787 specimens from SARI cases (15·4%) tested positive for seasonal influenza viruses. The prevalence of influenza virus infections was highest during December-May and the proportion testing positive was 76% for ILI and 36% for SARI during their respective weeks of peak activity. No HPAI H5N1 virus infections were identified, including hundreds of ILI and SARI patients with recent poultry exposures, whereas seasonal influenza was an important contributor to acute respiratory disease in East Jakarta. Overall, 668 (47%) of influenza viruses were influenza B, 384 (27%) were A(H1N1)pdm09, and 359 (25%) were H3. While additional data over multiple years are needed, our findings suggest that seasonal influenza prevention efforts, including influenza vaccination, should target the months preceding the rainy season.

Establishment of public health security in Saudi Arabia for the 2009 Hajj in response to pandemic influenza A H1N1.

Mass gatherings of people challenge public health capacities at host locations and the visitors' places of origin. Hajj--the yearly pilgrimage by Muslims to Saudi Arabia--is one of the largest, most culturally and geographically diverse mass gatherings in the world. With the 2009 pandemic influenza A H1N1 and upcoming Hajj, the Saudi Arabian Ministry of Health (MoH) convened a preparedness consultation in June, 2009. Consultants from global public health agencies met in their official capacities with their Saudi Arabian counterparts. The MoH aimed to pool and share public health knowledge about mass gatherings, and review the country's preparedness plans, focusing on the prevention and control of pandemic influenza. This process resulted in several practical recommendations, many to be put into practice before the start of Hajj and the rest during Hajj. These preparedness plans should ensure the optimum provision of health services for pilgrims to Saudi Arabia, and minimum disease transmission on their return home. Review of the implementation of these recommendations and their effect will not only inform future mass gatherings in Saudi Arabia, but will also strengthen preparedness efforts in other settings.

Case-control study to evaluate risk factors for acute hepatitis B virus infection in Egypt.

Hepatitis B virus (HBV) infection is a significant health problem in Egypt. To better define risk factors associated with HBV transmission, we conducted a case-control study among patients admitted with acute hepatitis to an infectious disease hospital in Cairo. A total of 60 cases and 120 controls were interviewed about various exposures within 6 months prior to admission. Univariate analysis revealed HBV case-patients were more likely to report providing injections to relatives or friends, injecting drug use, exposure to a household contact with hepatitis, exposure to invasive medical procedures and being in the military. Efforts should be made to implement strict infection control standards in Egypt.

Sentinel surveillance for patients with acute hepatitis in Egypt, 2001-04.

Viral hepatitis is a major problem in Egypt. To define the epidemiology of the disease, sentinel surveillance was established in 5 hospitals in diverse areas of the country in 2001. Data were completed for patients meeting the case definition for viral hepatitis. Of a total of 5909 patients evaluated, 4189 (70.9%) showed positive antibody markers for hepatitis. Out of those, 40.2% had evidence of hepatitis A virus (HAV) infection, 30.0% hepatitis B virus (HBV) and 29.8% hepatitis C virus (HCV) infection. This surveillance system was useful in identifying the variable endemicity of acute HAV infection in different regions and for better understanding the epidemiology of HBV and HCV infection.

Injection prescribing patterns in public health care facilities in Egypt.

This study assessed the frequency of and rationale for use of injections at health care facilities in Egypt based on WHO core drug use indicators. We reviewed 1406 prescriptions in 43 randomly selected hospitals and primary health care clinics in 2 governorates in Upper and Lower Egypt in 2001. Patients received an injection at 18.1% of encounters. The most frequently prescribed parenteral drugs were anti-infectives (56.9% of injections) and analgesics (13.7%). Injections were more often prescribed in hospitals than in primary health care clinics and in rural than in urban settings. Most injections (94.7%) could have been replaced by a suitable oral preparation. Further efforts are needed to enforce the essential medicines programme in Egypt to improve rational drug prescribing.

Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States.

BACKGROUND: Hepatitis B virus (HBV) infection is a well-recognized occupational risk for health care workers (HCWs). Vaccination coverage, disease trends, and the need for booster doses after hepatitis B vaccination of adults have been the subject of intense study during the 15 years of the vaccine's availability. METHODS: Vaccination coverage of HCWs was determined from a review of medical records on a sample of employees from 113 randomly selected hospitals. The number of HBV infections among HCWs and the general US population for 1983 through 1995 was estimated from national surveillance data. Studies on long-term protection after hepatitis B vaccination of adults were reviewed. RESULTS: A total of 2837 employee medical records were reviewed; 2532 employees (90%) were eligible to receive hepatitis B vaccine, and 66.5% of them (95% confidence interval, 61.9%-70.9%) had received 3 doses of hepatitis B vaccine. Vaccination coverage was highest (75%) for personnel with frequent exposure to infectious body fluids (phlebotomists, laboratory personnel, and nursing staff) and lowest (45%) for employees at low risk for exposure (dietary and clerical staff). The number of HBV infections among HCWs declined from 17,000 in 1983 to 400 in 1995. The 95% decline in incidence observed among HCWs is 1.5-fold greater than the reduction in incidence in the general US population. Studies on long-term protection demonstrate that vaccine-induced protection persists at least 11 years even when titers of antibody to hepatitis B surface antigen decline below detectable levels. CONCLUSIONS: Although a high percentage of HCWs have been fully vaccinated with hepatitis B vaccine, efforts need to be made to improve this coverage. There has been a dramatic decrease in the number of HBV infections among HCWs who are now at lower risk of HBV infection than the general US population. Vaccine-induced protection persists at least 11 years and booster doses are not needed at this time for adults who have responded to vaccination.

Continuing risk for hepatitis B virus transmission among Southeast Asian infants in Louisiana.

OBJECTIVE: Implementation and evaluation of a hepatitis B vaccination program for Southeast Asian infants in Louisiana. METHODS: A baseline seroprevalence survey of hepatitis B virus (HBV) infection in US-born Southeast Asian children was conducted in 1991 before the implementation of a vaccination program. Hepatitis B vaccination and postvaccination serologic testing of survey participants 10 years of age and younger was performed. Eighteen months after the hepatitis B vaccine was integrated into infant immunization schedules in July 1993, a vaccination coverage survey was performed. RESULTS: Baseline serologic testing was conducted on 96% of persons from 225 randomly selected households in a Southeast Asian community in Louisiana. Of 676 US-born children, 28 (4.1%) had chronic HBV infection; 61% of children with chronic HBV infection were born to hepatitis B surface antigen (HBsAg)-negative women. Among children born to HBsAg-negative women, the prevalence of chronic HBV infection increased with age, reaching 7.3% for children 13 to 16 years of age. Children born to HBsAg-negative women and living with carriers were 5.4 times more likely to have evidence of HBV infection than were children who did not live with carriers. Before the survey, only one child had received three doses of hepatitis B vaccine. In July 1993, 43% of Southeast Asian infants 9 to 18 months of age born in Louisiana had received three doses of hepatitis B vaccine. Infants who received immunizations from private providers were more likely to be fully vaccinated than were infants who received services from public sector clinics (prevalence ratio, 2.1; 95% confidence interval, 1.4, 3.1). CONCLUSIONS: HBV transmission occurs throughout childhood in US-born Southeast Asian children, and the prevalence of chronic HBV infection approaches that of the country of origin. Few US-born Southeast Asian children have received hepatitis B vaccine. Because of the high rates of early childhood HBV transmission and the high risk of chronic infection in Asian and Pacific Islander communities, prevention efforts should be enhanced to ensure that all Asian and Pacific Islander infants receive hepatitis B vaccine in the first 12 months of life and that older children are vaccinated.

Progress toward integrating hepatitis B vaccine into routine infant immunization schedules in the United States, 1991 through 1994. Connecticut Hepatitis B Project Group.

OBJECTIVE: We assessed progress toward universal infant immunization against hepatitis B, which was first recommended in November 1991. METHODS: Multiple data sources were used to describe vaccination policies and trends in infant hepatitis B vaccine coverage. RESULTS: As of June 1993, 51% of the 63 local, state, and territorial immunization programs recommended hepatitis B vaccination of all newborns shortly after birth. The number of first dosages of hepatitis B vaccine administered to infants in public sector clinics increased rapidly from late 1992 to 1993, and at the end of 1993 was approximately two thirds the number of first dosages of other infant antigens. In a nationwide survey of hospital nurseries 47% offered hepatitis B vaccine to all newborns. Of 3982 sampled newborns in these hospitals, 36.2% had been vaccinated before discharge. In San Francisco and Connecticut, where public health officials encouraged hospitals to offer hepatitis B vaccination, first-dose coverage at discharge was 82.3% in 1994 and 69.1% in 1993, respectively. Coverage was higher in healthier infants and lower in infants of older or better-educated mothers. Results from the National Health Interview Survey demonstrate that three-dose completion at 12 months of age increased form less than 1% of children born in 1989 to 40% of children born in the fourth quarter of 1992. Vaccination at birth increased from less than 1% of infants born in 1989 to 32% of infants born in the second half of 1993. CONCLUSIONS: Infant hepatitis B vaccination has expanded rapidly since national recommendations were made; however, universal coverage has not been achieved.

United States National Cancer Institute Radiotherapy Development Program.

The United States National Cancer Institute (NCI) has long supported research in radiotherapy since its establishment by an act of Congress in 1937. One of the first grants for research awarded in 1938 was to support work in developing a cyclotron for conducting clinical research on therapeutic uses of neutrons and radioactive isotopes. Support for training cancer specialists was given high priority in the early days of NCI. In 1961, the Cancer Centers Program was instituted which included a radiation research program that became the primary source of grant support for radiotherapy clinical research centers in the US. There is a need for radiotherapy research because approximately 50-60% of people with newly diagnosed cancers will receive radiotherapy at some time during their disease. In 1979, the Radiotherapy Development Branch (RDP) assumed responsibility for all radiation program grants including radiation physics, radiobiology, and radiotherapy. The RDB manages a portfolio of grants and contracts with an annual budget of over $45 million. In fiscal year (FY) 1984, research support for individual investigator grants, program project grants, and contracts amounted to $22, 15, and 6 million, respectively. The accomplishments of NCI research grantees and contractors in radiotherapy-related areas have been considerable over the past 45 years. It is essential that NCI continue its commitment to radiotherapy research and development.

Impact of the bloodborne pathogens standard on vaccination of healthcare workers with hepatitis B vaccine.

OBJECTIVES: To evaluate the impact of Occupational Safety and Health Administration (OSHA) regulations on the vaccination of healthcare workers (HCWs), to assess interpretation of these regulations, and to evaluate changes in hospital vaccination policies. DESIGN: Between June 1, 1992, and August 15, 1992, a telephone survey was conducted among 150 hospitals selected randomly from participants in the American Hospital Association 1991 annual survey. RESULTS: Of the 150 hospitals, 96 (64%) provided information on hepatitis B vaccination coverage of their employees. Of the 103,419 employees in these hospitals, 77,302 (75%) were eligible to receive the hepatitis B vaccine, and 38,850 (51%) of these were vaccinated completely (had received 3 doses of vaccine). Following issuance of the final regulations, 73% of hospitals reported greater employee acceptance of hepatitis B vaccine, and hospitals were more likely to offer hepatitis B vaccine to maintenance workers, security personnel, dietary staff, and clerical personnel. Seventy-five hospitals (50%) reported conducting postvaccination serologic testing on all hospital employees, 12 (8%) as a result of OSHA regulations. Twenty-three hospitals (16%) reported administering routine booster doses of hepatitis B vaccine at 3, 5, or 7 years. CONCLUSIONS: The new OSHA standard resulted in a greater awareness of risk for HBV infection among HCWs and an increase in the number of HCWs receiving hepatitis B vaccine; however, vaccination coverage remained suboptimal. Postvaccination serologic testing of employees with negligible risk and the routine administration of vaccine booster doses may be diverting resources and preventing comprehensive coverage of high-risk employees.

Hospital-based evaluation of programs to prevent perinatal hepatitis B virus transmission.

OBJECTIVE: To evaluate the frequency of hepatitis B surface antigen (HBsAg) screening of pregnant women in the United States and factors associated with the lack of screening. DESIGN: A random sample of 200 hospitals with 100 or more births per year was surveyed with regard to policy and practices. Each hospital was also asked to provide maternal screening and infant follow-up data for the first 25 infants who were born on or after March 1, 1993. RESULTS: Of 183 participating hospitals, 137 (75%) had maternal HBsAg screening policies, and 102 (56%) had standing orders for HBsAg testing of pregnant women who were admitted without prior screening. Hospitals that were located in states with laws that required maternal HBsAg screening were more likely to have a written screening policy (prevalence ratio [PR], 1.7; 95% confidence interval [CI], 1.2-2.4) and a standing order (PR, 1.7; 95% CI, 1.4-2.2). A lack of screening was related to delivery in hospitals without screening policies (PR, 3.4; 95% CI, 1.3-8.9) or standing orders (PR, 2.8; 95% CI, 1.2-6.2), and to the infant's provider being a family practitioner (PR, 1.7; 95% CI, 1.1-2.7). Among the 3982 infants for whom data were available, 3342 (84%) were born to mothers who had undergone screening for HBsAg. CONCLUSIONS: These findings suggest that hospitals should develop specific policies for HBsAg screening, states should enact laws that require maternal screening, and additional education of health care providers is needed with regard to the screening of all pregnant women for HBsAg.

Immunogenicity of hepatitis B Vaccines. Implications for persons at occupational risk of hepatitis B virus infection.

OBJECTIVE: To assess risk factors for decreased immunogenicity among adults vaccinated with hepatitis B vaccine and to determine the importance of differences in immunogenicity between vaccines among health care workers (HCWs). DESIGN: Randomized clinical trial and decision analysis. PARTICIPANTS: HCSw. MAIN OUTCOME MEASURES: Development of seroprotective levels of antibody to hepatitis B surface antigen (anti-HBs) and the number of expected chronic hepatitis B virus (HBV) infections associated with lack of protection. RESULTS: Overall, 88% of HCWs developed seroprotection. Risk factors associated with failure to develop seroprotection included increasing age, obesity, smoking and male gender (P < .05). Presence of a chronic disease was associated with lack of seroprotection only among persons > or = 40 years of age (P < .05). The two vaccines studied differed in their overall seroprotection rates (90% vs. 86%; P < .05), however, this difference was restricted to persons > or = 40 years of age (87% vs. 81%; P < .01). Among HCWs > or = 40 years of age, the decision analysis found 44 (0.34/100,000 person-years) excess chronic HBV infections over the working life of the cohort associated with use of the less immunogenic vaccine compared to the other. CONCLUSIONS: He patitis B vaccines are highly immunogenic, but have decreased immunogenicity associated with increasing age, obesity, smoking, and male gender; and among older adults, the presence of a chronic disease. One of the two available vaccines is more immunogenic among older adults; however, this finding has little clinical or public health importance. Hepatitis B vaccines should be administered to persons at occupational risk for HBV infection early in their career, preferably while they are still in their training.

Evaluation of an intervention program in the control of an urban outbreak of shigellosis.

Community-wide outbreaks of shigellosis are a persistent public health problem. We evaluated the effect of a household-based intervention program on the control of an urban outbreak of S. sonnei gastroenteritis. During the intervention we attempted to contact all households with culture-confirmed S. sonnei and provide education in methods to prevent spread of Shigella. Subsequently we conducted a survey of intervention (n = 43) and nonintervention (n = 33) households. We also conducted a serosurvey of children three to five years of age. The number of new cases of S. sonnei infection declined steadily over several months after the intervention began. Members of the intervention households were more knowledgeable about handwashing (rate ratio [RR] 4.7, 95% confidence interval [CI] = 2.1-10.8) and others methods of S. sonnei transmission and control than members of nonintervention households. However, intervention households had higher attack rates of Shigella-associated diarrhea in susceptible household members (RR 1.4, 95% CI = 1.0-2.0). During the intervention we were able to contact only 25% of households by the eighth day after onset of diarrhea in the index case, when 90% of intrahousehold transmission of Shigella had already occurred. Two months after the outbreak ended, 42% of children in the outbreak community had elevated antibody titers against S. sonnei; an additional 19% had borderline elevated titers. The intervention program improved knowledge but may have occurred too late to prevent intrahousehold transmission of Shigella. Exhaustion of susceptible hosts, rather than the education program, likely accounted for the decline in shigellosis cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental nitrous oxide exposure as a model system for evaluating neurobehavioral tests.

A recent study reported that a minimally suprathreshold dose of 20% nitrous oxide significantly affected performance on 3 of 9 computer-administered neurobehavioral tests. Performance decrements were observed in that study on 3 tests of psychomotor speed while other neurobehavioral functions such as visuospatial ability, verbal learning and mood were not significantly affected. The current study was undertaken to assess the reproducibility of these earlier results. Its experimental design was expanded to include an additional dose of the anesthetic and a more complex reaction time task implemented by the authors since the earlier study. Fifteen males aged 24-34 years were tested with the Neurobehavioral Evaluation System (NES) test battery on 4 separate occasions. An initial training session was followed by randomly presented control, 20%, and 40% drug sessions. Drug-induced decrements in performance were observed in the current study at the 20% dose for 2 of the 3 tests of psychomotor speed which had shown effects in the earlier study, and average decrement in performance on the third approached statistical significance in the current study (P = 0.055). Performance on a complex reaction time task was significantly affected at the low dose. The higher dose of nitrous oxide impaired performance on 8 of the 9 tests administered, and impairment on the ninth test was nearly significant (P = 0.055). Overall, these data are consistent with those in the previous study and with other reports that higher doses of nitrous oxide produce impairments in more cognitive CNS functions. Owing to its relative safety at low dosages, ease of administration, and ready acceptance by experimental subjects, nitrous oxide appears to be a useful model for evaluating the validity of neurobehavioral tests.

Fast neutron therapy clinical trials in the United States.

The National Cancer Institute (NCI) began supporting clinical fast neutron clinical studies in the United States beginning in the early 1970s using physics-based cyclotrons and linear accelerators at a number of locations and facilities. The early work pointed out the handicaps imposed by the limitations of horizontal beams and low energy neutrons. This, combined with some encouraging, clinical results using neutrons and photons in a mixed mode of therapy, prompted the NCI in 1979 to initiate a 10-year contract program to design, develop, and build hospital-based neutron therapy machines and to conduct phase III clinical trials. As we approach the end of the 10-year effort, three hospital-based neutron facilities are currently operational-at the University of Washington, Seattle; University of California at Los Angeles: and M. D. Anderson Hospital at University of Texas System Cancer Center, Houston. Phase III trials are in progress in four sites: head and neck, prostate, and lung tumors, and cancers of radioresistant histologies, such as melanoma, renal cell carcinoma, and sarcomas of the soft tissue and bone. The contractors will continue to receive limited NCI support to complete the clinical studies.

Neurobehavioral effects of acute styrene exposure in fiberglass boatbuilders.

A field investigation of the effects of acute exposure to styrene among fiberglass boatbuilders was performed. Personal samples of styrene in breathing zone air and postshift urinary mandelic acid were collected for 105 workers exposed and not exposed to styrene in 6 fiberglass boatbuilding companies in New England. Three tests from the computerized Neurobehavioral Evaluation System (NES) were performed by the subjects in the morning before exposure to styrene, near midday, and at the end of the work day. Duration of exposure averaged 2.9 years (SD = 4.6), 8-hour TWA styrene exposure averaged 29.9 ppm (SD = 36.2), and urinary mandelic acid averaged 347 mg/g creatinine (SD = 465). Regression analyses indicated a statistically significant relationship between postshift performance on the Symbol-Digit test and both acute styrene exposure and mandelic acid. Other analyses comparing workers exposed to less than 50 ppm and greater than 50 ppm styrene also showed a significant effect on Symbol-Digit performance. All three NES tests showed test-retest correlation coefficients above .80, and ease of use for collection of neurobehavioral data under field conditions was demonstrated.

A hepatitis B vaccination program targeting adolescents.

PURPOSE: To determine the effectiveness of using a middle school for hepatitis B vaccination of adolescents. METHODS: An immunization program was designed to educate parents and students about hepatitis B virus (HBV) infection and hepatitis B vaccination using science class presentations and mailings. Students were given at each visit and on vaccination series completion. Costs were calculated and divided by the number of students completing the series to obtain per student cost. RESULTS: Of the 654 students, 519 (79%) received at least one dose of hepatitis B vaccine, 497 (76%) two doses, and 425 (65%) three doses. Student participation did not vary by grade level, gender, or income. Per student vaccination cost was $77.23 for those receiving three doses of hepatitis B vaccine and $66.04 when those receiving at least two doses were included. Of 103 students with postvaccination serologic testing, three had evidence of previous hepatitis B virus infection, four had no evidence of vaccine induced immunity, and 96 (96% of susceptible students) developed protective levels of antibodies against hepatitis B surface antigen. The geometric mean antibody titer among persons responding to vaccination was 661 mIU. CONCLUSION: Hepatitis B vaccination of adolescents can be successfully integrated into a middle school setting.

Factors associated with student participation in a school-based hepatitis B immunization program.

This study examined the relationship between participation in a school-based hepatitis B immunization program and teacher attitudes toward school-based health care and student socioeconomic factors. A survey addressing teachers' attitudes was administered to all teachers participating in the program. Information regarding student participation in school lunch programs and scores on national standardized tests were collected. Of the 4,874 fifth-grade students targeted for the program, 3,483 (72%) consented to be vaccinated and 3,232 (93% of 3,483) received all three doses of vaccine. Socioeconomic factors were the most important predictors of student participation in this school-based immunization program. Participation was significantly lower among students in schools with a high proportion of students receiving free or reduced-price school lunch and with low test scores. The only teacher factor associated with student participation was whether the teacher had returned the questionnaire. Strategies to increase immunization coverage in school-based programs should target children of low socioeconomic status.