Translating Public Health Recommendations Using the Army Design Methodology.

The U.S. Army employs over 470,000 active duty soldiers throughout the world. Although the Army also employs hundreds of public health professionals, public health recommendations are often not framed in ways that are readily actionable to senior Army leaders. This case study shows how public health findings were translated into actionable recommendations using the Army Design Methodology (ADM) and subsequently implemented by installation leadership. Following a perceived increase in suicides at Fort Wainwright, Alaska, in 2019, installation leadership requested that the U.S. Army Public Health Center conduct an epidemiological consultation. A mixed-methods approach was used to gather qualitative and quantitative data. The ADM was used to translate the findings and provide actionable recommendations for senior Army leaders. Many recommendations were implemented within a year of the report's release and included modifications to gym facilities, dining halls, and sleeping areas. Key improvements included the installation of $900,000 worth of new gym equipment in existing physical fitness facilities, increasing the basic daily food allowance by 44% to facilitate the purchase of healthy options, and the installation of blackout blinds in all barracks to ensure more restful sleep during times of peak sunlight. The ADM is well understood by senior Army leaders. Use of the ADM in future military-specific public health studies could ensure a more effective uptake and implementation of public health recommendations.

Systematically collected information at encounters with HIV-positive students: A review of 10 years of electronic medical records.

Objective: The objective of this study was to examine clinical and epidemiological information collected by Student Health Center (SHC) providers on HIV-positive students, and benchmark this information against Infectious Disease Society of America guidelines. Participants: Students who utilized the SHC and had an ICD-9 code indicating positive HIV status between 2005 and 2015 (3 = 7). Methods: In June 2016, we accessed the free-form provider notes of the SHC's electronic medical records to identify specific, recorded epidemiological and clinical information. Results: Seven unique students sought care at the SHC during the study period. Current sexual risk taking and other known behavioral risk factors were absent from all records, along with CD4 count and viral load. ART status was only available for one patient, and he was not on ART. The information collected failed to meet IDSA benchmarks. Conclusion: Clinically- and epidemiologically-relevant information is not systematically collected from HIV-positive students at SHCs.

Diagnostic sequence of cocaine use disorder in relation to other mental health conditions among college students.

Objective: Cocaine use is increasing. Comorbidities and diagnostic sequencing are needed among college students to inform treatment of cocaine use disorder (CUD). Method: Using electronic medical records from the psychiatric clinic at the student health care center of a large, public university from 2005 to 2015, patients diagnosed with CUD were identified. Their top mental health conditions were identified and assessed to see whether the first diagnosis of these conditions was made (1) before, (2) at the same time as, or (3) after the first diagnosis of CUD. Results: Among the 50 CUD patients, their most common mental health comorbidities were alcohol use disorder, anxiety, depression, and cannabis use disorder. Anxiety and depression were likely to be diagnosed before CUD; alcohol and cannabis use disorders were likely to be diagnosed concurrently with CUD. Conclusion: Diagnostic sequencing can be used to inform screening, workup, and treatment for patients with CUD.

The Common Antidiabetic Drug Metformin Reduces Odds of Developing Age-Related Macular Degeneration.

Purpose: AMD is the leading cause of irreversible blindness in older individuals in the Western world, and there are currently no therapies to halt disease progression. Studies suggest that the commonly prescribed antidiabetic drug, metformin, is associated with decreased risk of several ocular diseases, but no work has investigated the effect of metformin use on development of AMD. Thus, we aim to investigate whether metformin use is associated with decreased risk of developing AMD. Methods: In this retrospective case-control study, we used medical records from patients older than 55 who have visited a University of Florida health clinic. Three controls were matched for every AMD case, defined by International Classification of Diseases, Ninth Revision code, based on the Charlson Comorbidity Index to ensure comparable baseline overall health status. Univariate and conditional multivariable logistic regressions were used to determine the association between a variety of covariates, including metformin use, and AMD diagnosis. Results: Metformin use was associated with decreased odds of developing AMD, independently of the other covariates investigated, with an odds ratio of 0.58 and a 95% confidence interval of 0.43 to 0.79. Other medications assessed were not associated with decreased odds of developing AMD. Conclusions: Patients who had taken metformin had decreased odds of developing AMD, suggesting that metformin may have a therapeutic role in AMD development or progression in those who are at risk. Further work should include clinical trials to investigate prospectively whether metformin has a protective effect in those at risk for developing AMD.

Clinical and Epidemiologic Patterns of Chikungunya Virus Infection and Coincident Arboviral Disease in a School Cohort in Haiti, 2014-2015.

BACKGROUND: Beginning in December 2013, an epidemic of chikungunya virus (CHIKV) infection spread across the Caribbean and into virtually all countries in the Western hemisphere, with >2.4 million cases reported through the end of 2017. METHODS: We monitored a cohort of school children in rural Haiti from May 2014, through February 2015, for occurrence of acute undifferentiated febrile illness, with clinical and laboratory data available for 252 illness episodes. RESULTS: Our findings document passage of the major CHIKV epidemic between May and July 2014, with 82 laboratory-confirmed cases. Subsequent peaks of febrile illness were found to incorporate smaller outbreaks of dengue virus serotypes 1 and 4 and Zika virus, with identification of additional infections with Mayaro virus, enterovirus D68, and coronavirus NL63. CHIKV and dengue virus serotype 1 infections were more common in older children, with a complaint of arthralgia serving as a significant predictor for infection with CHIKV (odds ratio, 16.2; 95% confidence interval, 8.0-34.4; positive predictive value, 66%; negative predictive value, 80%). CONCLUSIONS: Viral/arboviral infections were characterized by a pattern of recurrent outbreaks and case clusters, with the CHIKV epidemic representing just one of several arboviral agents moving through the population. Although clinical presentations of these agents are similar, arthralgias are highly suggestive of CHIKV infection.

The role of benzathine penicillin G in predicting and preventing all-cause acute respiratory disease in military recruits: 1991-2017.

The adenovirus vaccine and benzathine penicillin G (BPG) have been used by the US military to prevent acute respiratory diseases (ARD) in trainees, though these interventions have had documented manufacturing problems. We fit Poisson regression and random forest models (RF) to 26 years of weekly ARD incidence data to explore the impact of the adenovirus vaccine and BPG prophylaxis on respiratory disease burden. Adenovirus vaccine availability was among the most important predictors of ARD in the RF, while BPG was the ninth most important. BPG was a significant protective factor against ARD (incidence rate ratio (IRR) = 0.68; 95% confidence interval (CI) 0.67-0.70), but less so than either the old or new adenovirus vaccine (IRR = 0.39, 95% CI 0.38-0.39 and IRR = 0.11, 95% CI 0.11-0.11), respectively. These results suggest that BPG is moderately predictive of, and significantly protective against ARD, though to a lesser extent than either the old or new adenovirus vaccine.

Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the West African Ebola epidemic.

The goal of this study was to assess morbidity, mortality, and health-seeking behaviours during the 2014 Ebola outbreak in Monrovia, Liberia. This study examined commonly reported symptoms of illness, pre-clinical diagnostic practices, typical healthcare-seeking strategies, and health resources available to populations, in order to identify salient needs and gaps in healthcare that would inform local emergency response efforts. Semi-structured interviews were conducted with household members in four Monrovia neighbourhoods. Researchers used a multi-stage cluster approach to recruit participants. Within 555 households sampled, 505 individuals were reported sick (69%) or recently sick (38%) or deceased (7%). Common self-diagnoses included malaria, hypertension, influenza, typhoid, and Ebola. The most cited health-seeking strategy was to purchase medications from the private sector. Respondents also obtained healthcare from community members known to have medical experience. Findings suggest that non-formal healthcare systems played an important role in managing morbidity during the West African Ebola virus disease (EVD) outbreak. Lay community members engaged in complex assessments of health symptoms and sought biomedical care at rates perhaps higher than anticipated during the response. This study highlights how informal networks of healthcare providers can play an important role in preventing and curbing future emerging disease outbreaks.

Clinical and spatial features of Zika virus in Mexico.

BACKGROUND: Zika virus (ZIKV) is an emerging arbovirus transmitted to humans by Aedes mosquitoes, the same vectors that transmit dengue virus and chikungunya. Recent work has suggested that prior infection with dengue could lead to more severe clinical disease in ZIKV patients. Here, we describe the spatial distribution of and clinical symptoms experienced by ZIKV cases in Mexico. METHODS: We performed Fisher's Exact test and Pearson's Chi-Square tests on data from Mexico's national surveillance system on the demographic and clinical characteristics of ZIKV patients (N=84), and then a multivariate logistic regression analysis to determine demographic risk factors for patients presenting with at least 9 symptoms. We also mapped the cases to describe the spatial distribution of ZIKV in Mexico. RESULTS: Results from the multivariate logistic regression analysis indicate that, controlling for all covariates, sex (male) is a significant protective factor in reporting a high number of symptoms (OR=0.36, 95% CI: 0.14, 0.92), and that a one-year increase in age is associated with a 4% increase in odds of having at least 9 symptoms (95% CI: 1.00, 1.08). Spatial analysis revealed more than 50% cases reported within 50km of railways. CONCLUSION: We found that sex and age are both significant risk factors for ZIKV infection severity, using number of reported symptoms as a proxy. The presence of cases along railways indicates that transportation networks within Mexico may be relevant for the national and international spread of the disease.

Shifts in endocrine homeostasis and preventive hormone replacement therapy: extending the Women's Health Initiative globally.

BACKGROUND: Reducing disease risk for women after menopause is global health issue. A major portion of the Women's Health Initiative (WHI) consisted of two clinical trials involving 161,809 post-menopausal women aged 50-79 that tested the effect of hormone replacement therapy (HRT) on reducing cardiovascular disease and other secondary outcomes. Previous analyses of the data reveal that HRT should not be recommended for post-menopausal women, but show potential benefits for younger women. Thus, there may be a critical period just prior to or during the early stages of menopause where HRT could be both safe and beneficial. MAIN BODY: Menopause marks the beginning of a process of non-reversible reduction in estrogen by which estrogen levels decline progressively, followed by a reduction in estrogen receptors. This results in periods of hormone-receptor imbalances, exacerbating the effects of lower serum estrogen and is considered the primarily endocrinal source of menopause symptoms. Eventually a hormone-receptor balance is achieved at a lower level.Here, we purport that the negative outcomes from WHI trials were primarily due to the fact preventive HRT was initiated in women who had already achieved hormone-receptor equilibrium at lower hormonal levels. CONCLUSION: We argue for further HRT clinical trials in women at varying stages of menopause, including pre-menopause and early menopause, and in women from different countries. Variation across countries and subgroups in how women experience menopause and perceive menopause symptoms suggest that biocultural differences should be considered in both study design and measurement approaches to test the effectiveness of HRT. Particularly, we recommend longitudinal studies to assess changes in hormonal level over time, and to detect the "most effective period" for HRT to reduce health risk for women going through the whole menopause period.

Dengue fever outbreaks in Eritrea, 2005-2015: A case for strengthening surveillance, control and reporting.

BACKGROUND: The geographic distribution and burden of dengue is increasing globally. This study aims to evaluate dengue outbreaks and to substantiate the need for strengthened surveillance, reporting and control in Eritrea. METHODS: Data from two cross-sectional dengue epidemic investigations in 2005 and 2010 were analyzed. Samples were tested for dengue virus-specific IgM and IgG antibodies using capture enzyme-linked immunosorbent assays. Dengue vectors' breeding attributes were characterized and epidemic risk indices determined. National routine surveillance weekly reports from 2005 to the second quarter of 2015 were analyzed for spatiotemporal trends. RESULTS: Dengue outbreaks increased in Eritrea from 2005 to 2015 with clinical presentation varying markedly among patients. The house and container indices for Aedes aegypti were 40 and 39.6 % respectively, with containers having A. aeqypti varying significantly (P < 0.04). Serum from 33.3 % (n = 15) and 88 % (n = 26) of clinical dengue cases in Aroget sub-Zoba (district) of Gash Barka Zoba (region) contained anti-DENV IgM antibody in 2005 and 2006, respectively. The national surveillance data from 2005 to 2015 indicate an overall spatiotemporal increase of dengue fever. CONCLUSIONS: The increase in dengue outbreaks has been confirmed in Eritrea and necessitates strengthening of surveillance and health worker and laboratory capacity, as well as targeted vector control interventions.