Molecular epidemiology of HIV transmission in a dental practice.

Human immunodeficiency virus type 1 (HIV-1) transmission from infected patients to health-care workers has been well documented, but transmission from an infected health-care worker to a patient has not been reported. After identification of an acquired immunodeficiency syndrome (AIDS) patient who had no known risk factors for HIV infection but who had undergone an invasive procedure performed by a dentist with AIDS, six other patients of this dentist were found to be HIV-infected. Molecular biologic studies were conducted to complement the epidemiologic investigation. Portions of the HIV proviral envelope gene from each of the seven patients, the dentist, and 35 HIV-infected persons from the local geographic area were amplified by polymerase chain reaction and sequenced. Three separate comparative genetic analyses--genetic distance measurements, phylogenetic tree analysis, and amino acid signature pattern analysis--showed that the viruses from the dentist and five dental patients were closely related. These data, together with the epidemiologic investigation, indicated that these patients became infected with HIV while receiving care from a dentist with AIDS.

Acquired immunodeficiency syndrome and extrapulmonary tuberculosis in the United States.

Of 48,712 acquired immunodeficiency syndrome (AIDS) cases reported to the Centers for Disease Control from October 1987 through March 1989, 1239 (2.5%) were diagnosed with extrapulmonary tuberculosis. Extrapulmonary tuberculosis was diagnosed in 1013 (2.3%) of the US-born persons with AIDS, compared with 26 (8%) of the Mexican-born, 82 (13%) of the Haitian-born, and 4 (1%) of the Cuban-born. Patients with AIDS with and without extrapulmonary tuberculosis were similar in age, except that extrapulmonary tuberculosis was relatively rare in patients with AIDS under the age 10. Compared with white homosexual/bisexual men, black race (odds ratio, 2.7), intravenous drug use (odds ratio, 2.0), heterosexual AIDS transmission category (odds ratio, 1.9), and Hispanic ethnicity (odds ratio, 1.6) were independently associated with extrapulmonary tuberculosis. In 1988, extrapulmonary tuberculosis in persons known to be human immunodeficiency virus seropositive represented 21% of national extrapulmonary tuberculosis morbidity.

Improving influenza and Tdap vaccination during pregnancy: A cluster-randomized trial of a multi-component antenatal vaccine promotion package in late influenza season.

BACKGROUND: Evidence-based interventions to improve influenza vaccine coverage among pregnant women are needed, particularly among those who remain unvaccinated late into the influenza season. Improving rates of antenatal tetanus, diphtheria and acellular pertussis (Tdap) vaccination is also needed. PURPOSE: To test the effectiveness of a practice-, provider-, and patient-focused influenza and Tdap vaccine promotion package on improving antenatal influenza and Tdap vaccination in the obstetric setting. METHODS: A cluster-randomized trial among 11 obstetric practices in Georgia was conducted in 2012-2013. Intervention practices adopted the intervention package that included identification of a vaccine champion, provider-to-patient talking points, educational brochures, posters, lapel buttons, and iPads loaded with a patient-centered tutorial. Participants were recruited from December 2012-April 2013 and included 325 unvaccinated pregnant women in Georgia. Random effects regression models were used to evaluate primary and secondary outcomes. RESULTS: Data on antenatal influenza and Tdap vaccine receipt were obtained for 300 (92.3%) and 291 (89.5%) women, respectively. Although antenatal influenza and Tdap vaccination rates were higher in the intervention group than the control group, improvements were not significant (For influenza: risk difference (RD)=3.6%, 95% confidence interval (CI): -4.0%, 11.2%; for Tdap: RD=1.3%, 95% CI: -10.7%, 13.2%). While the majority of intervention package components were positively associated with antenatal vaccine receipt, a provider's recommendation was the factor most strongly associated with actual receipt, regardless of study group or vaccine. CONCLUSIONS: The intervention package did not significantly improve antenatal influenza or Tdap vaccine coverage. More research is needed to determine what motivates women remaining unvaccinated against influenza late into the influenza season to get vaccinated. Future research should quantify the extent to which clinical interventions can bolster a provider's recommendation for vaccination. This study is registered with clinicaltrials.gov, study ID NCT01761799.

HIV wasting syndrome in the United States.

OBJECTIVE: To describe the characteristics of individuals > or = 13 years of age with HIV wasting syndrome in the United States and US territories. DESIGN: Retrospective review of national AIDS case surveillance data. METHODS: Data for the 147,225 individuals with AIDS reported to the Centers for Disease Control from 1 September 1987 to 31 August 1991 were reviewed. The frequency of HIV wasting syndrome and its association with demographic and exposure category variables and with other AIDS-indicator diseases were assessed. RESULTS: A total of 10,525 (7.1%) had wasting syndrome as the only AIDS-indicator condition, and 15,726 (10.7%) had wasting syndrome plus at least one other AIDS-indicator condition. Patients with wasting syndrome as the only AIDS diagnosis were more likely to be female, to be black or Hispanic, and to have a mode of HIV exposure reported as injecting drug use, heterosexual contact, or transfusion/hemophilia. The proportion of AIDS patients reported with wasting syndrome varied by geographic distribution, ranging from 11% in the northeastern United States to 47% in Puerto Rico. The association between HIV wasting syndrome and Hispanic ethnicity was due to the much higher prevalence of wasting syndrome reported in Puerto Rican AIDS patients. The other AIDS-indicator conditions most strongly associated with wasting syndrome were isosporiasis, pulmonary candidiasis, esophageal candidiasis, HIV encephalopathy, chronic mucocutaneous herpes simplex, and coccidioidomycosis. CONCLUSIONS: The association between HIV wasting syndrome and injecting drug use, and the significant racial/ethnic and geographic differences in prevalence of this AIDS diagnosis may reflect differences in diagnostic and reporting practices and/or access to medical care.

The geographic and ethnic diversity of AIDS incidence trends in homosexual/bisexual men in the United States.

We examined geographic and racial/ethnic variation in acquired immune deficiency syndrome (AIDS) incidence in homosexual and bisexual men (i.e., men who report sex with men: MSWM) not using i.v. drugs in the United States. The AIDS incidence in these men has continued to increase in the United States. Incidence increased much less rapidly after 1986 in the three metropolitan statistical areas (MSAs) with the most cases, New York City, Los Angeles, and San Francisco, and may have reached a plateau in these areas. This change in incidence occurred in non-Hispanic black and Hispanic MSWM as well as in non-Hispanic whites in these MSAs, but earlier in whites. There have been similar changes in incidence (but later in time) in all other MSAs with a population of at least 1,000,000 combined, with more tendency toward a plateau in whites than in non-whites. In contrast, incidence increased linearly through 1989 in MSAs with a population less than 1,000,000 and in rural areas, with no change in trend after 1986. Changes in human immunodeficiency virus (HIV) infection incidence before 1985, better therapy and medical care, and migration all contributed to these changes in incidence, as may have changes in reporting. Continued HIV seroconversions among MSWM show that efforts to prevent HIV infection must be continued in all areas of the United States.

The completeness of AIDS surveillance.

AIDS surveillance data are widely used in setting HIV intervention policies, and the effectiveness of these data depend on their completeness. We reviewed studies conducted by state and local health departments on the completeness of AIDS reporting. These studies identified AIDS cases through alternate data sources, such as death certificates, hospital discharge records, disease registries, or medication records. In most instances greater than 80% of AIDS cases detected through these studies had been reported, although lower levels of reporting were found in some outpatient settings. A comparison of vital records and AIDS surveillance confirmed that AIDS surveillance is identifying 70-90% of all HIV-related deaths in men 25-44 years of age. Historically, AIDS surveillance has emphasized reporting from hospitals. Efforts to maintain current levels of reporting, or to improve reporting, are challenged by the growth of the epidemic and by the increasing role of outpatient diagnosis of AIDS.

Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States.

To measure the impact of the 1987 expansion of the definition of acquired immune deficiency syndrome on the number and characteristics of cases in the United States, we reviewed the 28,920 cases diagnosed since the revision and reported through 1988. The proportion meeting only new criteria was 28% overall, with a range of 0 to 82% in different states and territories. This proportion was 26% in the last quarter of 1987 and increased to 31% in the last quarter of 1988. It was higher in heterosexual intravenous drug abusers (IVDAs) (43%) and lower in homosexual male non-IVDAs (21%) than in other groups. The new criteria, but not earlier (pre-1985) criteria, generally require a positive test for human immunodeficiency virus (HIV) infection; however, use of HIV testing varies among states, as demonstrated by differences in the percentage of pre-1985-criteria cases with a reported HIV test (39 to greater than 95%). The revision has changed the distribution of characteristics of cases (e.g., heterosexual IVDAs composed 18% of cases meeting old criteria, 35% of cases meeting only new criteria, and 23% of all cases). Interpretation of trends in both the number and characteristics of cases should take into account the variable impact of the revision on reporting.

Epidemiology of human immunodeficiency virus infection and acquired immunodeficiency syndrome.

As of December 31, 1988, 82,764 cases of acquired immunodeficiency syndrome (AIDS) and more than 46,000 AIDS-related deaths had been reported in the United States. In 1987, AIDS deaths accounted for 9% of the total mortality among men 25 to 34 years of age. Projections suggest that the impact of human immunodeficiency virus (HIV) infection on morbidity and mortality in young adults and children will continue to increase, with an estimated 50,000 cases projected to be diagnosed in 1989. The mean latency period between infection and diagnosis of AIDS is estimated to be more than seven years, and 78% to 100% of persons infected with HIV are predicted to develop AIDS within 15 years of onset of infection. Rates of seroconversions have been decreasing since 1984 among cohorts of homosexual HIV-seronegative men, and the proportion of AIDS cases among homosexual men is decreasing. In contrast, the proportion of AIDS cases attributed to intravenous drug use is increasing, with 33% of AIDS cases reported in 1988 occurring among intravenous drug users, their sex partners, or children of women who are intravenous drug users or sex partners of intravenous drug users. Worldwide, the differences in the epidemiology of HIV infection and AIDS are primarily due to differences in the proportions of the modes of transmission and in the time in which HIV infection was introduced.

Public health surveillance of non-infectious chronic diseases: the potential to detect rapid changes in disease burden.

The usefulness of surveillance in relating chronic disease trends to recent changes in risk exposures is often questioned on the grounds that these trends respond slowly, reflecting long periods between aetiological exposures and clinical onset of disease. We challenge this preconception on the basis of a review of several important risk factors and diseases: alcohol and liver cirrhosis; tobacco and stroke, cardiovascular disease, and lung cancer; and oestrogens and endometrial cancer. Data from cohort, cross-sectional, and modelling studies demonstrate that the time between removal of exposures and the onset of decline in morbidity or mortality is not defined by the time between initial exposure and disease occurrence. Rather, the pattern of lifetime exposures (with recent exposures often having a dominant effect), the dynamics of the disease process, and the segment of the population with reduced exposures determine how soon the decline begins.

Emerging infectious diseases in the United States, Improved surveillance, a requisite for prevention.

Emerging infectious diseases such as prolonged diarrheal illness due to water-borne Cryptosporidium, hemorrhagic colitis and renal failure from food-borne E. coli O157:H7, and rodent-borne hantavirus pulmonary syndrome as well as reemerging infections such as tuberculosis, pertussis, and cholera vividly illustrate that we remain highly vulnerable to the microorganisms with which we share our environment. Prompt detection of new and resurgent infectious disease threats depends on careful monitoring by modern surveillance systems. This article focuses on five important elements of improved surveillance for emerging infections: 1) strengthening the national notifiable disease system, 2) establishing sentinel surveillance networks, 3) establishing population-based emerging infections programs, 4) developing a system for enhanced global surveillance, and 5) applying new tools and novel approaches to surveillance.

Methodological alternatives for measuring premature mortality.

Although crude and age-adjusted mortality statistics are frequently used to quantify public health problems, they are heavily influenced by the underlying disease processes of the elderly. Alternative measures have been developed to reflect the mortality experience of younger age groups (i.e., premature mortality). We evaluated four different methods for tabulating premature mortality, one method weighted by the remaining life expectancy at death and three methods with constant end points using age spans from birth to 65 years, birth to 75 years, and 1 to 65 years. These alternatives provide dramatically different descriptions of premature mortality in the United States in 1984. In general, the constant end-point methods emphasize the different pattern of mortality among younger persons, while premature mortality computed by the remaining life expectancy method more closely resembles the pattern of crude mortality. Although no single method is preferable for all purposes, the constant end-point method best differentiates the leading causes of premature death.

Fatal injuries and alcohol.

We reviewed fatal injuries in Fulton County, Georgia, in collaboration with the medical examiner's office. This county encompasses most of the city of Atlanta and has a population of approximately 600,000 persons. Information collected for 1981 and 1982 was analyzed; and the results of blood alcohol content (BAC) testing and toxic screens were reviewed for all victims of homicide, suicide, and unintentional fatal injuries who died within six hours of being injured. Seventy-one percent of 271 homicide victims had been drinking, and 51 percent had BACs greater than or equal to 0.1 mg/dL. Of 153 suicide victims, 37 percent had been drinking and 20 percent had BACs greater than or equal to 0.1 mg/dL. Of 54 drivers who died in single-vehicle collisions, 78 percent had been drinking; 54 percent of 162 victims of nonvehicular unintentional fatal injuries had positive blood alcohol levels. There was little evidence of the use of psychotropic drugs among victims of fatal injury. Most of the victims of homicide and unintentional fatal injuries who had positive toxic screens also had a positive blood alcohol tests.

The science of public health surveillance.

Improved public health surveillance can lead to earlier implementation of prevention and control measures. Better surveillance data lead to a more rational establishment of priorities. More timely and accurate data facilitate earlier epidemic detection and control. With better surveillance data, the impact of intervention activities and other public health programs can be evaluated more accurately. In this paper we describe how to improve the science of surveillance in terms of data collection, analysis, and dissemination and its application to public health practice. We then discuss the potential benefits and costs of such efforts and suggest methods for evaluating alternative approaches. The argument for science in surveillance, on the other hand, may be subject to excess. Surveillance is not an end unto itself, but rather a tool. This tool should be refined and modified to adapt to the goals of a particular public health program. It is the development of methods to apply creative ideas to surveillance, and the rigorous assessment of the process, that will benefit from the application of scientific principles.

Assessing the diagnostic accuracy and efficacy of selected antepartum fetal surveillance techniques.

Published studies on the contraction stress test (CST), the nonstress test (NST), and monitoring of fetal movement were reviewed to assess the accuracy and efficacy of these techniques. The false-negativity and false-positivity rates, sensitivity, and specificity of these tests were assessed with use of perinatal mortality and various measures of morbidity as outcomes. Both the CST and the NST generally demonstrated low sensitivity and high rates of false positivity. No randomized controlled trials have been conducted that are of sufficient size to demonstrate whether there is a significant difference in outcome following use of the CST or the NST. A single nonrandomized, controlled trial evaluating fetal-movement monitoring suggested clinical benefit. Direct costs of NSTs and CSTs in the United States were estimated to exceed $200 million per year. Yet the CST and the NST have not been demonstrated to be useful diagnostic tests. The CST, the NST, and fetal-movement monitoring are potentially useful screening tests. However, they require critical evaluation, with large randomized, controlled trials, to determine their efficacy and safety before their further diffusion into obstetrical practice.

Emerging and reemerging infectious diseases: a multidisciplinary perspective.

Predictions that infectious diseases would be eliminated as a major threat to human health have been shattered by emerging and reemerging infections, among them acquired immunodeficiency syndrome (AIDS), hemorrhagic fevers, marked increases in infections caused by antimicrobial-resistant bacteria, and the resurgence of tuberculosis and malaria. Understanding the dynamics of emerging and reemerging infections is critical to efforts to reduce the morbidity and mortality of such infections, to establish policy related to preparedness for infectious threats, and for decisions on where to use limited resources in the fight against infections. In order to offer a multidisciplinary perspective, 23 infectious disease specialists, epidemiologists, geneticists, microbiologists, and population biologists participated in an open forum at Emory University on emerging and reemerging infectious diseases. As summarized below, the group addressed questions about the definition, the identification, the factors responsible for, and multidisciplinary approaches to emerging and reemerging infections.

The reporting of race and ethnicity in the National Notifiable Diseases Surveillance System.

The authors used 1987 data from the Epidemiologic Surveillance Project (ESP) of the Centers for Disease Control to examine the completeness of race-ethnicity reporting in the National Notifiable Diseases Surveillance System. And, to the extent possible, they used ESP to assess racial and ethnic disparities in the occurrence of selected notifiable infectious diseases. For the 30 reporting areas (29 States and the District of Columbia) that provided data to ESP for all of calendar year 1987, approximately 60 percent of case reports were accompanied by specified race-ethnicity for affected persons. This percentage varied widely by disease and State. In general, non-Hispanic whites had morbidity rates (cases per 100,000 population per year) that were among the lowest compared with rates for other groups, and Native Americans commonly had rates that were among the highest. The ranking of morbidity rates among blacks, Hispanics, and Asians and Pacific Islanders varied by disease, although the last group had strikingly higher rates for malaria and tuberculosis. The age distribution of persons with cases was often lower among minority groups than among non-Hispanic whites, but the authors were unable to calculate age-specific or age-adjusted rates. Potential biases that limit interpretation of the findings are reviewed. Efforts to eliminate racial-ethnic disparities in the occurrence of infectious diseases would be aided by effective surveillance data. For the ESP to meet its potential in this regard, however, substantial improvements in the reporting of race-ethnicity for notifiable diseases are needed.