Consequences of COVID-19 crisis for persons with HIV: the impact of social determinants of health.

BACKGROUND: With the indiscriminate spread of COVID-19 globally, many populations are experiencing negative consequences such as job loss, food insecurity, and inability to manage existing medical conditions and maintain preventive measures such as social distancing and personal preventative equipment. Some of the most disadvantaged in the COVID-19 era are people living with HIV/AIDS and other autoimmune diseases. DISCUSSION: As the number of new HIV infections decrease globally, many subpopulations remain at high risk of infection due to lack of or limited access to prevention services, as well as clinical care and treatment. For persons living with HIV or at higher risk of contracting HIV, including persons who inject drugs or men that have sex with men, the risk of COVID-19 infection increases if they have certain comorbidities, are older than 60 years of age, and are homeless, orphaned, or vulnerable children. The risk of COVID-19 is also more significant for those that live in Low- and Middle-Income Countries, rural, and/or poverty-stricken areas. An additional concern for those living the HIV is the double stigma that may arise if they also test positive for COVID-19. As public health and health care workers try to tackle the needs of the populations that they serve, they are beginning to realize the need for a change in the infrastructure that will include more efficient partnerships between public health, health care, and HIV programs. CONCLUSION: Persons living with HIV that also have other underlying comorbidities are a great disadvantage from the negative consequences of COVID-19. For those that may test positive for both HIV and COVID-19, the increased psychosocial burdens stemming from stress and isolation, as well as, experiencing additional barriers that inhibit access to care, may cause them to become more disenfranchised. Thus, it becomes very important during the current pandemic for these challenges and barriers to be addressed so that these persons living with HIV can maintain continuity of care, as well as, their social and mental support systems.

Retention and Predictors of Attrition Among HIV-infected Children on Antiretroviral Therapy in Côte d'Ivoire Between 2012 and 2016.

BACKGROUND: An estimated 21,000 children 0-14 years of age were living with HIV in Côte d'Ivoire in 2020, of whom only 49% have been diagnosed and are receiving antiretroviral therapy (ART). Retention in HIV care and treatment is key to optimize clinical outcomes. We evaluated pediatric retention in select care and treatment centers (CTCs) in Côte d'Ivoire. METHODS: We retrospectively reviewed medical records using 2-stage cluster sampling for children under 15 years initiated on ART between 2012 and 2016. Kaplan-Meier time-to-event analysis was done to estimate cumulative attrition rates per total person-years of observation. Cox proportional hazard regression was performed to identify factors associated with attrition. RESULTS: A total of 1198 patient records from 33 CTCs were reviewed. Retention at 12, 24, 36, 48 and 60 months after ART initiation was 91%, 84%, 74%, 72% and 70%, respectively. A total of 309 attrition events occurred over 3169 person-years of follow-up [266 children were lost to follow-up (LTFU), 29 transferred to another facility and 14 died]. LTFU determinants included attending a "public-private" CTC [adjusted hazard ratio (aHR) 6.05; 95% confidence interval (CI): 4.23-8.65], receiving care at a CTC without an on-site laboratory (aHR: 4.01; 95% CI: 1.70-9.46) or attending a CTC without an electronic medical record (EMR) system (aHR: 2.22; 95% CI: 1.59-3.12). CONCLUSIONS: In Cote d'Ivoire, patients attending a CTC that is public-private, does not have on-site laboratory or EMR system were likely to be LTFU. Decentralization of laboratory services and scaling use of EMR systems could help to improve pediatric retention.

Firth's Logistic Regression of Interruption in Treatment before and after the Onset of COVID-19 among People Living with HIV on ART in Two Provinces of DRC.

The impact of the COVID-19 pandemic extends beyond the immediate physical effects of the virus, including service adjustments for people living with the human immunodeficiency virus (PLHIV) on antiretroviral therapy (ART). Purpose: To compare treatment interruptions in the year immediately pre-COVID-19 and after the onset of COVID-19 (10 April 2020 to 30 March 2021). Methods: We analyze quantitative data covering 36,585 persons with HIV who initiated antiretroviral treatment (ART) between 1 April 2019 and 30 March 2021 at 313 HIV/AIDS care clinics in the Haut-Katanga and Kinshasa provinces of the Democratic Republic of Congo (DRC), using Firth's logistic regression. Results: Treatment interruption occurs in 0.9% of clients and tuberculosis (TB) is detected in 1.1% of clients. The odds of treatment interruption are significantly higher (adjusted odds ratio: 12.5; 95% confidence interval, CI (8.5−18.3)) in the pre-COVID-19 period compared to during COVID-19. The odds of treatment interruption are also higher for clients with TB, those receiving ART at urban clinics, those younger than 15 years old, and female clients (p < 0.05). Conclusions: The clients receiving ART from HIV clinics in two provinces of DRC had a lower risk of treatment interruption during COVID-19 than the year before COVID-19, attributable to program adjustments.

Socioeconomic status and other factors associated with HIV status among OVC in Democratic Republic of Congo (DRC).

Background: Orphans and vulnerable children (OVC) are a high-risk group for HIV infection, particularly in Sub-Saharan Africa. Purpose: This study aims to portray the socioeconomic profile of OVC and examine the association of household and parent/guardian characteristics with the HIV status of OVC. Methods: For this quantitative retrospective study, we obtained data from ICAP/DRC for a total of 1,624 OVC from households enrolled for social, financial, and clinical services between January 2017 and April 2020 in two provinces of the Democratic Republic of Congo, Haut-Katanga and Kinshasa. We computed descriptive statistics for OVC and their parents' or guardians' characteristics. We used the chi-square test to determine bivariate associations of the predictor variables with the dichotomous dependent variable, HIV positivity status. To analyze the association between these independent variables and the dichotomous dependent variable HIV status after controlling for other covariates, we performed firth's logistic regression. Results: Of the OVC included in this study, 18% were orphans, and 10.9% were HIV+. The chi-square analysis showed that among parents/guardians that were HIV+, a significantly lower proportion of OVC (11.7%) were HIV+ rather than HIV- (26.3%). In contrast, for parents/guardians with HIV- status, 9.0% of OVC were HIV-negative, and 11.7% of OVC were OVC+. The firth's logistic regression also showed the adjusted odds of HIV+ status were significantly lower for OVC with parents/guardians having HIV+ status themselves (AOR, 0.335; 95% CI, 0.171-0.656) compared with HIV-negative parents/guardians. The adjusted odds of HIV+ status were significantly lower for OVC with a monthly household income of < $30 (AOR, 0.421; 95% CI, 0.202-0.877) compared with OVC with a monthly household income > $30. Conclusions: Our results suggest that, with the exception of a few household and parent/guardian characteristics, the risk of HIV+ status is prevalent across all groups of OVC within this study, which is consistent with the existing body of evidence showing that OVC are in general vulnerable to HIV infection. With a notable proportion of children who are single or double orphans in DRC, HIV+ OVC constitute a high-risk group that merits customized HIV services. The findings of this study provide data-driven scientific evidence to guide such customization of HIV services.

Factors Associated with Retention of HIV Patients on Antiretroviral Therapy in Care: Evidence from Outpatient Clinics in Two Provinces of the Democratic Republic of the Congo (DRC).

Interruptions in the continuum of care for HIV can inadvertently increase a patient's risk of poor health outcomes such as uncontrolled viral load and a greater likelihood of developing drug resistance. Retention of people living with HIV (PLHIV) in care and determinants of attrition, such as adherence to treatment, are among the most critical links strengthening the continuum of care, reducing the risk of treatment failure, and assuring viral load suppression. Objective: To analyze the variation in, and factors associated with, retention of patients enrolled in HIV services at outpatient clinics in the provinces of Kinshasa and Haut-Katanga, Democratic Republic of the Congo (DRC). Methods: Data for the last visit of 51,286 patients enrolled in Centers for Disease Control (CDC)-supported outpatient HIV clinics in 18 health zones in Haut-Katanga and Kinshasa, DRC were extracted in June 2020. Chi-square tests and multivariable logistic regressions were performed. Results: The results showed a retention rate of 78.2%. Most patients were classified to be at WHO clinical stage 1 (42.1%), the asymptomatic stage, and only 3.2% were at stage 4, the severest stage of AIDS. Odds of retention were significantly higher for patients at WHO clinical stage 1 compared to stage 4 (adjusted odds ratio (AOR), 1.325; confidence interval (CI), 1.13−1.55), women as opposed to men (AOR, 2.00; CI, 1.63−2.44), and women who were not pregnant (vs. pregnant women) at the start of antiretroviral therapy (ART) (AOR, 2.80; CI, 2.04−3.85). Odds of retention were significantly lower for patients who received a one-month supply rather than multiple months (AOR, 0.22; CI, 0.20−0.23), and for patients in urban health zones (AOR, 0.75; CI, 0.59−0.94) rather than rural. Compared to patients 55 years of age or older, the odds of retention were significantly lower for patients younger than 15 (AOR, 0.35; CI, 0.30−0.42), and those aged 15 and <55 (AOR, 0.75; CI, 0.68−0.82). Conclusions: Significant variations exist in the retention of patients in HIV care by patient characteristics. There is evidence of strong associations of many patient characteristics with retention in care, including clinical, demographic, and other contextual variables that may be beneficial for improvements in HIV services in DRC.

HIV viral load suppression before and after COVID-19 in Kinshasa and Haut Katanga, Democratic Republic of the Congo.

Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in unique programmatic opportunities to test hypotheses related to the initiation of antiretroviral treatment (ART) and viral load (VL) suppression during a global health crisis, which would not otherwise have been possible. Objectives: To generate practice-relevant evidence on the impact of initiating ART pre-COVID-19 versus during the COVID-19 pandemic on HIV VL. Method: Logistic regression was performed on data covering 6596 persons with HIV whose VL data were available, out of 36 585 persons who were initiated on ART between 01 April 2019 and 30 March 2021. Results: After controlling for covariates such as age, gender, duration on ART, tuberculosis status at the time of the last visit, and rural vs urban status, the odds of having a VL < 1000 copies/mL were significantly higher for clients who started ART during the COVID-19 pandemic than the year before COVID-19 (adjusted odds ratio [AOR]: 2.50; confidence interval [CI]: 1.55-4.01; P < 0.001). Odds of having a VL < 1000 copies/mL were also significantly higher among female participants than male (AOR: 1.23; CI: 1.02-1.48), among patients attending rural clinics compared to those attending urban clinics (AOR: 1.83; CI: 1.47-2.28), and in clients who were 15 years or older at the time of their last visit (AOR: 1.50; CI: 1.07-2.11). Conclusion: Viral loads did not deteriorate despite pandemic-induced changes in HIV services such as the expansion of multi-month dispensing (MMD), which may have played a protective role regardless of the general negative impacts of response to the COVID-19 crises on communities and individuals. What this study adds: This research capitalises on the natural experiment of COVID-19-related changes in HIV services and provides new practice-relevant research evidence.

Disparities in HIV Clinical Stages Progression of Patients at Outpatient Clinics in Democratic Republic of Congo.

CONTEXT: In this era of patient-centered care, it is increasingly important for HIV/AIDS care and treatment programs to customize their services according to patients' clinical stage progression and other risk assessments. To enable such customization of HIV care and treatment delivery, the research evidence explaining factors associated with patients' clinical stages is needed. OBJECTIVES: The primary objective of this study was to produce such scientific evidence by analyzing the most recent data for patients at outpatient clinics in the provinces of Kinshasa and Haut-Katanga and to examine the patient characteristics associated with WHO stages of disease progression. METHODS: Using a quantitative retrospective cohort study design, we analyzed data from 49,460 people living with HIV (PLHIV) on antiretroviral therapy (ART) from 241 HIV/AIDS clinics located in Haut-Katanga and Kinshasa provinces of the Democratic Republic of Congo. We performed Chi-square and multinomial logistic regression analyses. RESULTS: A small proportion (i.e., 4.4%) of PLHIV were at WHO's clinical progression stage 4, whereas 30.7% were at clinical stage 3, another 22.9% at stage 2, and the remaining 41.9% were at stage 1, the least severe stage. After controlling for other demographic and clinical factors included in the model, the likelihood of being at stage 1 rather than stage 3 or 4 was significantly higher (at p ≤ 0.05) for patients with no tuberculosis (TB) than those with TB co-infection (adjusted odds ratio or AOR, 5.73; confidence interval or CI, 4.98-6.59). The odds of being at stage 1 were significantly higher for female patients (AOR, 1.35; CI, 1.29-1.42), and those with the shorter duration on ART (vs. greater than 40.37 months). Patents in rural health zones (AOR, 0.32) and semi-rural health zones (AOR, 0.79) were less likely to be at stage 1, compared to patients in urban health zones. CONCLUSIONS: Our study showed that TB co-infection raised the risk for PLHIV to be at the severe stages of clinical progression of HIV. Such variation supports the thesis that customized HIV management approaches and clinical regimens may be imperative for this high-risk population. We also found significant variation in HIV clinical progression stages by geographic location and demographic characteristics. Such variation points to the need for more targeted efforts to address the disparities, as the programs attempt to improve the effectiveness of HIV care and treatment. The intersectionality of vulnerabilities from HIV, TB, and COVID-19-related hardships has elevated the need for customized care and treatment even more in the COVID-19 era.

Risk Factors for TB/HIV Coinfection and Consequences for Patient Outcomes: Evidence from 241 Clinics in the Democratic Republic of Congo.

(1) Background: In resource-limited countries, patients with tuberculosis (TB)/HIV coinfection commonly face economic, sociocultural, and behavioral barriers to effective treatment. These barriers manifest from low treatment literacy, poverty, gender inequality, malnutrition, societal stigmas regarding HIV, and an absence of available care. It is critical for intervention programs to understand and assist in overcoming these barriers and any additional risks encountered by patients with TB/HIV coinfection. This study analyzes variation in TB/HIV coinfection and risks of negative outcomes among patients with TB/HIV coinfection compared to those without coinfection. (2) Methods: This quantitative study used data from 49,460 patients receiving ART from 241 HIV/AIDS clinics in Haut-Katanga and Kinshasa, two provinces in the Democratic Republic of Congo. Chi-square and logistic regression analysis were performed. (3) Results: Significantly higher proportions of patients with TB/HIV coinfection were men (4.5%; women, 3.3%), were new patients (3.7%; transferred-in, 1.6%), resided in the Kinshasa province (4.0%; Haut-Katanga, 2.7%), and were in an urban health zone (3.9%) or semi-rural health zone (3.1%; rural, 1.2%). Logistic regression analysis showed that after controlling for demographic and clinical variables, TB/HIV coinfection increased the risk of death (adjusted odds ratio (AOR), 2.26 (95% confidence interval (CI): 1.94-2.64)) and LTFU (AOR, 2.06 (95% CI: 1.82-2.34)). TB/HIV coinfection decreased the odds of viral load suppression (AOR, 0.58 (95% CI: 0.46-0.74)). (4) Conclusions: TB/HIV coinfection raises the risk of negative outcomes such as death, LTFU, and lack of viral load suppression. Our findings can help HIV clinics in Democratic Republic of Congo and other African countries to customize their interventions to improve HIV care and reduce care disparities among patients.

HIV Viral Suppression among People Living with HIV on Antiretroviral Therapy in Haut-Katanga and Kinshasa Provinces of Democratic Republic of Congo.

Human immunodeficiency virus (HIV) infections and less-than-optimal care of people living with HIV (PLHIV) continue to challenge public health and clinical care organizations in the communities that are most impacted by HIV. In the era of evidence-based public health, it is imperative to monitor viral load (VL) in PLHIV according to global and national guidelines and assess the factors associated with variation in VL levels. PURPOSE: This study had two objectives-(a) to describe the levels of HIV VL in persons on antiretroviral therapy (ART), and (b) to analyze the significance of variation in VL by patients' demographic and clinical characteristics, outcomes of HIV care, and geographic characteristics of HIV care facilities. METHODS: The study population for this quantitative study was 49,460 PLHIV in the Democratic Republic of Congo (DRC) receiving ART from 241 CDC-funded HIV/AIDS clinics in the Haut-Katanga and Kinshasa provinces of the DRC. Analysis of variance (ANOVA) was performed, including Tamhane's T2 test for pairwise comparisons using de-identified data on all patients enrolled in the system by the time the data were extracted for this study by the HIV programs in May 2019. RESULTS: The VL was undetectable (<40 copies/mL) for 56.4% of the patients and 24.7% had VL between 40 copies/mL and less than 1000 copies per mL, indicating that overall, 81% had VL < 1000 and were virologically suppressed. The remaining 19% had a VL of 1000 copies/mL or higher. The mean VL was significantly (p < 0.001) higher for males than for females (32,446 copies/mL vs. 20,786, respectively), persons <15 years of age compared to persons of ages ≥ 15 years at the time of starting ART (45,753 vs. 21,457, respectively), patients who died (125,086 vs. 22,090), those who were lost to follow-up (LTFU) (69,882 vs. 20,018), those with tuberculosis (TB) co-infection (64,383 vs. 24,090), and those who received care from urban clinics (mean VL = 25,236) compared to rural (mean VL = 3291) or semi-rural (mean VL = 26,180) clinics compared to urban. WHO clinical stages and duration on ART were not statistically significant at p ≤ 0.05 in this cohort. CONCLUSIONS: The VL was >1000 copies/mL for 19% of PLHIV receiving ART, indicating that these CDC-funded clinics and programs in the Haut-Katanga and Kinshasa provinces of DRC have more work to do. Strategically designed innovations in services are desirable, with customized approaches targeting PLHIV who are younger, male, those LTFU, with HIV/TB co-infection, and those receiving care from urban clinics.

Predicting hospitalization and mortality in end-stage renal disease (ESRD) patients using an Index of Coexisting Disease (ICED)-based risk stratification model.

We evaluated the use of an additive Index of Coexisting Diseases (ICED)-based stratification schema to determine subsequent hospitalization and mortality in a hemodialysis population. Patients from five commercial health plans were stratified into low-, medium-, and high-risk groups and followed for up to 1 year. Patients were reassessed and restratified at 90-day intervals and censored when disease management ceased. Outcome measures collected through selfreports and health plan records were captured in an active database. Survival to first hospitalization/ mortality was compared by Kaplan Meier curves, survivor function differences by the Wilcoxon test, and group comparisons by ANOVA and chi square. Population characteristics included mean age of 63.0, 57.7% male, and 58.8% diabetic. Mortality was 13.0% per patient year (standardized mortality ratio 0.43) and the hospitalization rate was 0.59 per patient year (standardized hospitalization ratio 0.24). Survival curves demonstrated differences in mortality and hospitalization between the patients in different initial risk categories (p < 0.01). Mean hospitalizations were 0.81 +/- 1.53 per patient year (high risk), 0.45 +/- 0.99 (medium risk), and 0.15 +/- 0.51 for the low-risk group (p < 0.001). Stratification was dynamic; 47.3% decreased and 4.7% increased risk level between the first and second assessment. These changes were associated with survival differences for initial low (p = 0.06) or medium patients (p < 0.01), and hospital-free survival for initial medium (p = 0.08) or high patients (p < 0.05). In conclusion, this ICED-based stratification schema predicted mortality and hospitalization for hemodialysis patients participating in our disease management program.

The effect of community-based support services on clinical efficacy and health-related quality of life in HIV/AIDS patients in resource-limited settings in sub-Saharan Africa.

Antiretroviral therapy (ART) for HIV/AIDS in developing countries has been rapidly scaled up through directed public and private resources. Data on the efficacy of ART in developing countries are limited, as are operational research studies to determine the effect of selected nonmedical supportive care services on health outcomes in patients receiving ART. We report here on an investigation of the delivery of medical care combined with community-based supportive services for patients with HIV/AIDS in four resource-limited settings in sub-Saharan Africa, carried out between 2005 and 2007. The clinical and health-related quality of life (HRQOL) efficacy of ART combined with community support services was studied in a cohort of 377 HIV-infected patients followed for 18 months, in community-based clinics through patient interviews, clinical evaluations, and questionnaires. Patients exposed to community-based supportive services experienced a more rapid and greater overall increase in CD4 cell counts than unexposed patients. They also had higher levels of adherence, attributed primarily to exposure to home-based care services. In addition, patients receiving home-based care and/or food support services showed greater improvements in selected health-related QOL indicators. This report discusses the feasibility of effective ART in a large number of patients in resource-limited settings and the added value of concomitant community-based supportive care services.

Prevalence and risk factors of gallstone disease in an adult population of Taiwan: an epidemiological survey.

BACKGROUND AND AIMS: The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population-based screening study. METHODS: A cross-sectional community study in a rural village of Taiwan was conducted in 3333 Chinese adults (aged > or = 18 years) undergoing ultrasonography. A questionnaire on personal history was completed to ascertain whether the removed gallbladder contained stones in all cholecystectomized subjects, the dietary habits (vegetarian/non-vegetarian diet), the history of GSD in the participant's first-degree relatives, the history of gastrointestinal surgery (vagotomy, gastrectomy for peptic ulcer disease, or ileal resection), parity, and use of oral contraceptives. The demographic characteristics and biochemical parameters were recorded. RESULTS: The overall prevalence of GSD was 5.0% (4.6% in men, 5.4% in women) with no significant sex differences (men/women: odds ratio [OR] 0.71, 95% confidence interval [CI] 0.50-1.01, P = 0.058). Logistic regression analysis showed that increasing age (men: 40-64 years, OR 7.38, 95% CI 2.59-21.01, P < 0.001 and > or = 65 years, OR 14.16, 95% CI 4.84-41.47, P < 0.001; women: 40-64 years, OR 4.08, 95% CI 1.90-8.75, P < 0.001 and > or = 65 years, OR 6.78, 95% CI 2.97-15.46, P < 0.001) and the presence of fatty liver evidenced by ultrasonography (men: OR 2.24, 95% CI 1.32-3.80, P = 0.003; women: OR 2.13, 95% CI 1.33-3.42, P = 0.002) were risk factors for GSD. Additionally, fasting plasma glucose > or = 126 mg/dL (OR 2.11, 95% CI 1.16-3.83, P = 0.014), history of GSD in the first-degree relatives (OR 7.47, 95% CI 2.22-25.12, P = 0.001), and use of oral contraceptives (OR 10.71, 95% CI 3.06-37.49, P < 0.001) were risk factors for GSD in women, but fasting plasma glucose > or = 126 mg/dL was only correlated to GSD without controlling for other confounding factors in men. Other demographic characteristics and biochemical parameters, such as high body mass index (> or = 25 kg/m2), increased parity, hypercholesterolemia, hypertriglyceridemia, hyperuricemia, hepatitis C infection and cirrhosis, did not exhibit any correlation to GSD in logistic regression analysis, although they appeared to be related to GSD in women in univariate analysis. CONCLUSIONS: Age and fatty liver in both sexes were found to be risk factors for GSD in the study population. The finding of a correlation between fatty liver and GSD is an important addition to the literature concerning the risk factors of GSD. Diabetes mellitus, history of GSD in the first-degree relatives, and use of oral contraceptives were also risk factors for GSD in women.

The roles of cats and dogs in the transmission of Toxoplasma infection in Kuna and Embera children in eastern Panama.

OBJECTIVE: To examine the relationship between antibody status and various hypothesized risk factors for Toxoplasma gondii infection among two different Amerindian populations in eastern Panama. Following up on earlier research that we conducted, we now explore the role of dogs in the natural transmission of Toxoplasma, the role that dogs play in promoting transmission, the interactive effect of cats and dogs, and the accessibility of infective material to children. METHODS: In 1991, 10 Panamanian medical students conducted interviews and took blood samples from 760 Kuna and Embera children aged 2 through 12 years in the Upper Bayano River Basin and the San Blas Islands. Serologic assays were performed using direct agglutination. The data analyses in the 1990s included univariate, bivariate, and multivariate analyses, without regard to data on dogs. Further bivariate and multivariate analyses were performed in 2003 to examine the contribution of dogs. RESULTS: In communities with high Toxoplasma antibody prevalence in children, logistic regression suggested that the factors predictive of antibody presence were: compacted soil floors of huts (P = 0.001), having a dog (P = 0.038), and the interviewer seeing a cat in the house (P = 0.049). Our results suggest that the villagers' dogs play a significant role in facilitating the transmission of Toxoplasma gondii to humans, most often in the presence of cats in the houses, and only in those communities with higher Toxoplasma seroprevalence in children. CONCLUSIONS: Dogs may act as mechanical vectors, by rolling in foul-smelling substances and by ingesting fecal material. In areas of high Toxoplasma prevalence in children and where dogs and cats are plentiful, immunocompromised individuals and pregnant women should be warned of the possibility of acquiring Toxoplasma gondii from dogs as well as from soil contaminated by cats. People should be encouraged to wash their hands after contact with soil, dogs, or cats as well as before eating.

Familial disability patterns in individuals with chronic work-related spine injury/illness.

STUDY DESIGN: A case control study of familial disability patterns and other potential risk factors identified in a group of individuals with work-related spine injury/illness. OBJECTIVES: The objective of the present study is to provide information on the relationship between a disabled family member and work-related spine injuries or illnesses leading to disability among another family member. SUMMARY OF BACKGROUND DATA: Extensive studies have been conducted to identify the medical and nonmedical factors associated with prolonged disability after work-related spine injury/illness. Many of the relevant nonmedical factors are psychosocial and are dependent to some degree on family of origin environment and experience. Although similar recurring pain behaviors have been described in certain families, no recent study has been conducted of coexisting family disabilities in individuals with work-related spine injury/illness. METHODS: A case-control investigation examining nine potential risk factors, including familial disability patterns, for the development of disability following work-related spine injury/illness was conducted. The case group (n = 88) consisted of individuals disabled from any and all gainful employment, whereas the controlled group (n = 40) continued working in spite of their spine complaints. RESULTS: In this study, gender, number of spinal areas involved, current injury considerations/severity, and having a primary family member or spouse similarly disabled were found to be significant predictors of disability following work-related spine injury/illness. However, further analysis revealed that having an associated family disability was the greatest predictor of disability in the study group. CONCLUSIONS: These data suggest that the presence of a primary family member or spouse with a work-related spine disability may be a risk factor for the development of disability in individuals sustaining a work-related spine injury.

Epidemiology of cancer in the Republic of Kiribati.

Little is known about cancer epidemiology in Kiribati. Between November 1998 and December 1999, trained medical record abstractors visited 8 Micronesian jurisdictions including the Republic of Kiribati to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. The Republic of Kiribati has identified many prevalent preventable cancers. The lack of a robust cancer data tracking and surveillance system, as well as the lack of resources to institute a technologically and medically sustainable cancer control system was apparent. The implementation or existence of a national comprehensive cancer control strategic plan would facilitate greater identification, prevention, and treatment of cancer patients. The health sector and Government of Kiribati are working towards this end.

Epidemiology of cancer in the Republic of Nauru.

Between November 1998 and December 1999, the Republic of Nauru was one of 8 Micronesian jurisdictions visited by trained medical record abstractors to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. There is likely incomplete ascertainment of cancer cases in the Republic of Nauru because of historical events, and the lack of a robust cancer registry and a systematic cancer surveillance system. A national comprehensive cancer control strategic plan and the implementation of that plan would facilitate greater prevention, treatment and control of cancer. The government of Nauru is working towards this end.

The roles of cats and dogs in the transmission of Toxoplasma infection in Kuna and Embera children in eastern Panama

OBJETIVO: Examinar la relación entre la presencia o ausencia de anticuerpos y los diversos factores de riesgo hipotéticos asociados con la infección por Toxoplasma gondii en dos poblaciones amerindias diferentes del este de Panamá. Como secuela a una investigación preliminar, en este trabajo se explora el papel de los perros en la transmisión natural de Toxoplasma y en la facilitación de la transmisión, así como el efecto interactivo de los perros y gatos y el acceso de los niños a materiales infecciosos. MÉTODOS: En 1991, 10 estudiantes de medicina panameños llevaron a cabo entrevistas y les tomaron muestras de sangre a 760 niños kunas y emberas de 2 a 12 años de edad en la cuenca superior del río Bayano y en las islas de San Blas. Se hicieron pruebas serológicas mediante aglutinación directa. Todos los datos, menos los de los perros, se estudiaron mediante análisis unifactorial, bifactorial y multifactorial. En 2003 se efectuaron nuevos análisis bifactoriales y multifactoriales para examinar la contribución de los perros. RESULTADOS: En comunidades con una alta prevalencia de anticuerpos contra Toxoplasma en niños, la regresión logística indicó que los siguientes factores tenían valor pronóstico en relación con la presencia de anticuerpos: pisos de tierra compacta en las chozas (P = 0,001), tener perro (P = 0,038), y que el investigador hubiera visto un gato dentro de la vivienda (P = 0,049). Según nuestros resultados, los perros de los habitantes de las aldeas desempeñan un papel importante en la facilitación de la transmisión de Toxoplasma gondii a los seres humanos, la mayor parte de las veces en presencia de gatos dentro de la vivienda y solamente en comunidades con una alta seroprevalencia de Toxoplasma en niños. CONCLUSIONES: Los perros pueden ser vectores mecánicos debido a su hábito de revolcarse en sustancias fétidas y de comer heces. En zonas donde la prevalencia de Toxoplasma en niños es alta y donde hay muchos perros y gatos, a las personas inmunodeprimidas y las mujeres embarazadas se les debe advertir del peligro de infectarse con Toxoplasma gondii por contacto con perros o con tierra contaminada por gatos. Se debe alentar a las personas a lavarse las manos después de tocar tierra, perros o gatos y antes de comer.