HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities.

Coinfection with human immunodeficiency virus (HIV) and viral hepatitis is associated with high morbidity and mortality in the absence of clinical management, making identification of these cases crucial. We examined characteristics of HIV and viral hepatitis coinfections by using surveillance data from 15 US states and two cities. Each jurisdiction used an automated deterministic matching method to link surveillance data for persons with reported acute and chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections, to persons reported with HIV infection. Of the 504 398 persons living with diagnosed HIV infection at the end of 2014, 2.0% were coinfected with HBV and 6.7% were coinfected with HCV. Of the 269 884 persons ever reported with HBV, 5.2% were reported with HIV. Of the 1 093 050 persons ever reported with HCV, 4.3% were reported with HIV. A greater proportion of persons coinfected with HIV and HBV were males and blacks/African Americans, compared with those with HIV monoinfection. Persons who inject drugs represented a greater proportion of those coinfected with HIV and HCV, compared with those with HIV monoinfection. Matching HIV and viral hepatitis surveillance data highlights epidemiological characteristics of persons coinfected and can be used to routinely monitor health status and guide state and national public health interventions.

Risk behaviour, healthcare access and prevalence of infection with Chlamydia trachomatis and Neisseria gonorrhoeae in a population-based sample of adults in Barbados.

OBJECTIVES: To estimate the prevalence of urogenital infection with Chlamydia trachomatis and Neisseria gonorrhoeae in people 18 to 35 years of age in Barbados, and to examine factors associated with infection. METHODS: Cross-sectional survey of randomly selected people from the voters' register of one electoral district and the collection of urine samples for testing by PCR. RESULTS: The response rate was 82%; 408 people (195 males and 213 females) completed a questionnaire and had their urine collected. 397 urine samples were satisfactorily tested. Prevalence of C trachomatis urogenital infection was 11.3% (95% CI +/-2.9) and N gonorrhoeae 1.8% (95% CI +/-1.2) with 12.6% (95% CI +/-3.1) having either or both infections. The difference in prevalence by gender was not significant. Multivariate logistic regression showed that prevalence of C trachomatis and/or N gonorrhoeae decreased with increasing age (per year OR 0.89, 95% CI 0.84 to 0.96, p = 0.001), and decreasing time (6 months) since last medical consultation (OR 0.44, 95% CI 0.22 to 0.88, p = 0.02). Most (76%) infected people were asymptomatic. Condom use at last intercourse with a partner not being lived with was not protective (reported by 52%, p = 0.617). The usual source of health care was evenly distributed between the public and private sectors and was not associated with infection. Only 30% of people had ever heard of chlamydia, whereas 92% were aware of gonorrhoea. CONCLUSIONS: Asymptomatic infection with C trachomatis is an important reservoir of infection, which will remain undetected unless physicians and young people are made aware of this and screening is introduced.

Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm.

All members of medical staff, including students, were asked to participate in a self-administered questionnaire concerning patterns of mobile phone use and care. Participants' phones were cultured for micro-organisms. Healthcare professionals working in close proximity to sensitive equipment were surveyed concerning adverse events associated with mobile phones. Telephone operators were asked to monitor time elapsed as they attempted to contact medical staff by various methods. Of 266 medical staff and students at the time of the study, 116 completed questionnaires (response rate=44%). Almost all (98%) used mobile phones: 67% used their mobile phones for hospital-related matters; 47% reported using their phone while attending patients. Only 3% reported washing their hands after use and 53% reported never cleaning their phone. In total, 101 mobile phones were cultured for micro-organisms; 45% were culture-positive and 15% grew Gram-negative pathogens. The survey of staff working in close proximity to sensitive equipment revealed only one report of minor interference with life-saving equipment. Telephone operators were able to contact medical staff within 2 min most easily by mobile phone. Mobile phones were used widely by staff and were considered by most participants as a more efficient means of communication. However, microbial contamination is a risk associated with the infrequent cleaning of phones. Hospitals should develop policies to address the hygiene of mobile phones.

Epilepsy and antiepileptic drug use in elderly people as risk factors for dementia.

OBJECTIVE: To assess the role of epilepsy and antiepileptic drugs (AEDs) as risk factors for probable Alzheimer's disease (AD) and for all dementias in the Canadian Study of Health and Aging (CSHA). A secondary objective was to isolate the effect of the AED phenytoin on the development of dementia and AD. METHODS: The cohort consists of 5376 participants aged 65 years or older with no evidence of dementia, defined as Modified Mini-Mental State (3MS) score > or =78. Primary exposure was self-report or clinical diagnosis of epilepsy at baseline (n=39), or self-report of AED therapy (n=67). Primary outcomes were development of dementia, defined as 3MS<78, or AD, determined by clinical examination using standard criteria, during a 5-year follow-up period. People whose 3MS score remained > or =78 served as the comparison group. RESULTS: People reporting AED use at baseline had an age, sex and baseline 3MS adjusted odds ratio (OR) of 2.11 (95% CI 1.11 to 4.01) for developing dementia compared to those not taking AEDs at baseline. The association remained significant using only phenytoin as the exposure. No significant association was found between AED use and development of AD, nor between epilepsy and development of either AD or dementia. CONCLUSIONS: Older adults taking AEDs are at a significantly higher relative risk of developing dementia than those not taking AEDs. Further investigation of this finding is warranted.

Trends in the uptake of antenatal voluntary counselling and testing for HIV and HIV prevalence among childbearing women in Barbados, 1993-2004: evidence to gauge the effectiveness of HIV prevention measures.

OBJECTIVES: To describe the long term trends on the uptake of antenatal voluntary counselling and testing (VCT) for Human Immunodeficiency Virus (HIV) and on the HIV prevalence among pregnant women. These data were used to gauge the impact of the National Acquired Immunodeficiency Syndrome (AIDS) Intervention Programme on preventing mother-to-child transmission (PMTCT) in Barbados. METHODS: This was a population based study. Data for this report were drawn from the HIV Surveillance Programme for the mother-to-child transmission of HIV The study population comprised all pregnant women who attended the various antenatal care clinics throughout Barbados during the period between 1993 and 2004. RESULT: The uptake of the VCT for HIV among the pregnant women in Barbados has increased from 39.9% in 1993 to over 89.7% in 2004 (p < 0.0001). Mean annual HIV prevalence decreased from 10.53 per thousand women screened in 1993-1996 to 8.23 during 2001-2004 (p = 0.121). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women declined from 8.83 per thousand women screened during 1993-1996 to 4.53 per thousand pregnant women screened during 2001-2004 (p = 0.004). Mean annual incidence rate of newly diagnosed HIV infection among the pregnant women aged less than 25 years during the corresponding period declined from 10.17 per thousand women aged less than 25 years screened to 4.75 per thousand women screened (p = 0.003). CONCLUSION: There has been a significant decline in the prevalence and incidence of HIV since the late-1990s. Although new infections are still occurring, the numbers are small. The decline may partly be explained by the impact of PMTCT and the general preventive measures on the spread of HIV among this population.

Waiting and interaction times for patients in a developing country accident and emergency department.

OBJECTIVE: To determine the interaction and waiting times of patients in Barbados Queen Elizabeth Hospital Accident and Emergency Department (A&E), identify their determinants, and compare them to international benchmarks. METHODS: Trained research assistants monitored all patients attending A&E during a one week period in 2003. The time in and out of each step in the process of care was recorded along with demographic data, diagnosis, and acuity. Time elapsed was calculated for various steps in care and compared to international benchmarks. Determinants of timely care were identified. RESULTS: Of 882 eligible A&E patients, 675 (77%) had accurate data and were entered into the study. Interaction times were short, with median total interaction time 13 (IQR 9-21) minutes. Waiting times were long ranging from median 6.5 (IQR 2-22) minutes for registration to 213 (IQR 154-316) minutes for lab results. Of concern was a median wait of 10 (IQR 2-46) minutes for triage and 178 (IQR 105-305) minutes to be seen by a doctor. Mean total length of stay was 377 (SD 261) minutes compared to US benchmark of 90 minutes. All other waiting times were at least twice US benchmarks. Paediatrics cases and children aged 0-11 years had the shortest waiting times and length of stay, whereas medicine patients and those over 49 years had the longest. Those with highest acuity had the shortest waiting times and length of stay. CONCLUSIONS: The A&E could improve patient care processes by shortening waiting times, especially for laboratory results, triage, and seeing a doctor, particularly for older medicine patients.

Surveillance of vaccine-related adverse events in the first year of life: a Manitoba cohort study.

This study used data from the population database through which the province of Manitoba, Canada, administers its universal health insurance plan. Enrollment, hospitalization, and immunization files from children born in the 1987-1989 period were linked using the unique identification number assigned to each population member. Analysis of these linked data successfully identified serious potential adverse events in the first year of life and the timing of events around immunization. Not only is population-based active surveillance for immunization-related events feasible, but the techniques described, applied to years of data accumulated through surveillance, offer powerful research tools. Baseline population incidences of adverse events were calculated, temporal relationships between events and immunization assessed, and incidences for events showing true temporal associations determined. Eventual goals are the quantification of vaccine-related risk and the gathering of evidence concerning casual associations. The approach could be used readily by several other Canadian provinces and by health maintenance organizations in the United States.

Quantitative ultrasound of the calcaneus in Arabian women: relation to anthropometric and lifestyle factors.

OBJECTIVES: To determine factors influencing quantitative ultrasound (QUS) parameters of the calcaneus in a population-based sample of United Arab Emirates (UAE) women, and to compare QUS parameters of the calcaneus for healthy young UAE women with the manufacturer's reference ranges for other populations. METHODS: All subjects completed a questionnaire on reproductive and life style factors. Height and weight were measured, and body composition was determined by bioelectric impedence. Estimated bone mineral density (BMD), Speed of sound (SOS), broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) of the right calcaneus were determined by Sahara ultrasound. RESULTS: In premenopausal women (n=330), age, weight, body mass index (BMI), lean weight, fat weight, education, age at menarche, and number of pregnancies, correlated significantly with QUS parameters. Multiple regression analysis showed that age at menarche, number of pregnancies, and BMI, were the best predictors of QUS parameters although these factors explained only small amounts of the variance (R(2)=0.05). In postmenopausal women (n=81), age, BMI and physical activity were the best predictors of BUA (R(2)=0.35), SOS (R(2)=0.39), and QUI (R(2)=0.43). Mean estimated BMD, QUI and SOS for healthy young UAE women were significantly lower than the manufacturer's reference ranges for U.S. Caucasian, European Caucasian, and Chinese Asian healthy young women of the same age range (P<0.001 for all comparisons). Mean BUA was not significantly different, however. CONCLUSIONS: Menopausal status, age, BMI and physical activity are strong predictors of QUS parameters of the calcaneus in Arabian women. Healthy young Arabian women have lower estimated calcaneal BMD compared with the manufacturer's reference ranges for other populations.

Correlation of quantitative ultrasound parameters of the calcaneus with bone density of the spine and hip in women with prevalent hypovitaminosis D.

Quantitative ultrasound (QUS) of the calcaneus correlates modestly with axial dual-energy X-ray absorptiometry (DXA). Because bone mineral density (BMD) might be influenced by vitamin D status, we assessed the correlation between both techniques in 56 Arabian women, a population with high prevalence of hypovitaminosis D. The speed of sound (SOS), broadband ultrasound attenuation (BUA), and estimated BMD of the right calcaneus were determined by QUS. Spine and right hip BMD were measured by DXA scan. The serum 25-hydroxyvitamin D (25OHD) level was measured by radioimmunoassay. The correlations of QUS parameters (estimated calcaneal BMD, BUA, and SOS) with spine and hip BMD were modest (r = 0.50, r = 0.53, r = 0.41 for the spine and r = 0.54, r = 0.56, and r = 0.46 for the hip, respectively; p < 0.01 for all comparisons), but stronger in postmenopausal women. All postmenopausal women with low estimated calcaneal BMD (T-score pound -1) had a T-score pound -1 by DXA of the spine or hip. Of the 21 premenopausal women with spine or hip T-score pound -1 who had 25OHD measurements, 20 (95.2%) had levels below 50 nmol/L and 12 (57%) had levels below 30 nmol/L. The subgroup with 25OHD < 30 nmol/L had significantly lower spine (p < 0.01) and hip BMD (p < 0.05) than the subgroup with 25OHD >/= 30 nmol/L. QUS parameters were not significantly different between the two subgroups. The QUS and DXA correlated modestly well in women with prevalent hypovitaminosis D. QUS could be used in postmenopausal women with hypovitaminosis D to identify those at risk for osteoporotic fracture.

Eradication of indigenous poliomyelitis in Canada: impact of immunization strategies.

During the period 1950-1954, surveillance for paralytic poliomyelitis in Canada revealed an average of 1,914 cases (13.2 cases per 100,000) annually. The licensing and widespread use of inactivated poliovirus vaccine (IPV) in 1955 coincided with a marked decline in disease rates. Due to incomplete vaccine coverage of the population, a resurgence began in 1958 and peaked in 1959, despite an observed vaccine efficacy of 96% for 3 doses of IPV. The introduction and widespread use of oral poliovirus vaccine (OPV) started in 1960 and coincided with a decline in disease rates. Virtual elimination of the natural disease was achieved in the 1970s in all provinces regardless of the specific immunization program chosen (IPV or OPV alone or combined). From 1965 to 1988, 51 cases of paralytic poliomyelitis were reported in Canada. Thirty-five of these cases, all but one occurring before 1980, were attributed to wild virus infection, (14 caused by imported virus and 21 assumed to be endemic). Sixteen cases were OPV-associated: 4 in vaccine recipients and 12 in contacts of OPV recipients. Vaccine-associated paralysis in recipients and contacts occurred at the rate of one case per 9.5 million and 3.2 million vaccine doses distributed, respectively. The risk of paralysis attributable to OPV therefore is small compared to the overall benefit of the vaccine. Both IPV and OPV appear equally effective, and theoretically, a combination of the two (IPV followed by OPV) provides the best risk benefit ratio. Occasional exposure of the Canadian population to imported wild virus requires that high levels of population immunity be maintained.

[Public health surveillance: historical origin, methods, and assessment]. / Sorveglianza di sanità pubblica: origini storiche, metodi e valutazione.

In the last three decades disease surveillance has grown into a complete discipline, quite distinct from epidemiology. This expansion into a separate scientific area within public health has not been accompanied by parallel growth in the literature about its principles and methods. The development of the fundamental concepts of surveillance systems provides a basis on which to build a better understanding of the subject. In addition, the concepts have practical value as they can be used in designing new systems as well as understanding or evaluating currently operating systems. This article reviews the principles of surveillance, beginning with an historical survey of the roots and evolution of surveillance, and discusses the goals of the public health surveillance. Methods for data collection, data analysis, interpretation, and dissemination are then presented, together with proposed procedures for evaluating and improving a surveillance system. Finally, some points to be considered in establishing a new surveillance system are presented.

Bone density estimates and risk factors for osteoporosis in young women.

The bone mineral density (BMD) of the calcaneus was estimated in 185 young women from the United Arab Emirates, using SAHARA ultrasound. All participants completed a questionnaire on factors potentially associated with osteoporosis. In all, 29 (15.7%) of the women were classified as having osteopenia and none as having osteoporosis. Participants with osteopenia were more likely to have had a later onset of menarche, irregular periods, lower body mass index, and a positive family history of osteoporosis. Only late menarche and low body mass index, however, were independent predictors of osteopenia.

Immunological and virological responses to highly active antiretroviral therapy in a non-clinical trial setting in a developing Caribbean country.

OBJECTIVE: Few data exist on the efficacy of antiretroviral therapy in individuals infected with HIV in the Caribbean. We evaluated the virological and immunological responses of HIV-infected adults starting highly active antiretroviral therapy (HAART). DESIGN: This was a prospective observational cohort study. METHODS: A total of 158 antiretroviral-naive patients who initiated HAART between January 2002 and March 2003, and completed at least 6 months of treatment and follow up, were included in the analysis. The response to therapy was assessed by changes in CD4 cell counts and viral loads from baseline. The mean increase in CD4 cell count, the rate of virological success (a viral load of <50 HIV-1 RNA copies/mL) and the rate of immunological success (an increase in CD4 cell count of > or =50 cells/microL over the baseline value) after commencing HAART were measured. RESULTS: In total, 82% of patients (123 of 150) achieved viral loads of <50 copies/mL after 6 months of therapy. Viral success rate after 6 months of HAART was similar irrespective of gender, pre-HAART CD4 cell count and pre-HAART viral load. However, patients older than 40 years were significantly more likely to achieve virological success than those younger than 40 years. At 6 months after starting HAART, 79.5% of patients were estimated to have achieved immunological success and 17.9% had an increase in CD4 cell count of > or =200 cells/microL over the baseline value. The median increase in CD4 cell count for the 156 patients who had CD4 cell counts at baseline and at 6 months of therapy was 122 cells/microL. CONCLUSION: In this cohort of antiretroviral-naive HIV-infected adults, there was a high rate of virological and immunological success after 6 months of HAART, irrespective of the pre-HAART viral load and CD4 cell count.

Congenital toxoplasmosis: epidemiologic features and control.

Toxoplasmosis is caused by the parasite Toxoplasma gondii. It is acquired from undercooked meat or from food or fomites contaminated by cat feces. The disease can be transmitted to the fetus only during maternal parasitemia, which is associated with primary infection. Extrapolation from current data suggests that there are 140 to 1400 cases of congenital toxoplasmosis per year in Canada and that 70 to 280 of the infants are severely affected at birth; many of the others suffer sequelae later in life. Serologic diagnosis of primary infection in the mother is quite sensitive and specific. Diagnosis in the infant is more difficult and may take several months. Prenatal treatment of the woman and postnatal treatment of the infant are hampered by the lack of proven efficacy as well as ethical and compliance problems. Preventive serologic screening and prophylaxis have the same drawbacks. Educating young women to avoid infection is an inexpensive, low-risk intervention that would be the preferred preventive strategy if it could be shown to be effective. Immunization may prove to be the most cost-effective method of preventing congenital toxoplasmosis if a safe and effective vaccine is developed.

Public health surveillance: historical origins, methods and evaluation.

In the last three decades, disease surveillance has grown into a complete discipline, quite distinct from epidemiology. This expansion into a separate scientific area within public health has not been accompanied by parallel growth in the literature about its principles and methods. The development of the fundamental concepts of surveillance systems provides a basis on which to build a better understanding of the subject. In addition, the concepts have practical value as they can be used in designing new systems as well as understanding or evaluating currently operating systems. This article reviews the principles of surveillance, beginning with a historical survey of the roots and evolution of surveillance, and discusses the goals of public health surveillance. Methods for data collection, data analysis, interpretation, and dissemination are presented, together with proposed procedures for evaluating and improving a surveillance system. Finally, some points to be considered in establishing a new surveillance system are presented.

Meningococcal disease in Canada. Surveillance summary to 1987.

Meningococcal disease continues to occur in Canada at endemic levels, with minor fluctuations. The incidence of the disease, in general, has changed very little over the past 3 decades.

Hepatitis B Infection in Canada: Epidemiology and implications for control.

A review of Canadian surveillance data for the past decade indicates that the incidence of reported hepatitis B cases has increased despite the availability of safe and effective vaccine. Sexual transmission (particularly heterosexual transmission) is the major route of virus spread in North America. Because of this fact, and because immunization of selected high-risk groups has failed to control disease, universal immunization is the strategy of choice.