Spatial distribution of tuberculosis incidence in Los Angeles County.

BACKGROUND: In Los Angeles County, the tuberculosis (TB) disease incidence rate is seven times higher among non-U.S.-born persons than U.S.-born persons and varies by country of birth. But translating these findings into public health action requires more granular information, especially considering that Los Angeles County is more than 4000 mile2. Local public health authorities may benefit from data on which areas of the county are most affected, yet these data remain largely unreported in part because of limitations of sparse data. We aimed to describe the spatial distribution of TB disease incidence in Los Angeles County while addressing challenges arising from sparse data and accounting for known cofactors. METHODS: Data on 5447 TB cases from Los Angeles County were combined with stratified population estimates available from the 2005-2011 Public Use Microdata Survey. TB disease incidence rates stratified by country of birth and Public Use Microdata Area were calculated and spatial smoothing was applied using a conditional autoregressive model. We used Bayesian Poisson models to investigate spatial patterns adjusting for age, sex, country of birth and years since initial arrival in the U.S. RESULTS: There were notable differences in the crude and spatially-smoothed maps of TB disease rates for high-risk subgroups, namely persons born in Mexico, Vietnam or the Philippines. Spatially-smoothed maps showed areas of high incidence in downtown Los Angeles and surrounding areas for persons born in the Philippines or Vietnam. Areas of high incidence were more dispersed for persons born in Mexico. Adjusted models suggested that the spatial distribution of TB disease could not be fully explained using age, sex, country of birth and years since initial arrival. CONCLUSIONS: This study highlights areas of high TB incidence within Los Angeles County both for U.S.-born cases and for cases born in Mexico, Vietnam or the Philippines. It also highlights areas that had high incidence rates even when accounting for non-spatial error and country of birth, age, sex, and years since initial arrival in the U.S. Information on spatial distribution provided here complements other descriptions of local disease burden and may help focus ongoing efforts to scale up testing for TB infection and treatment among high-risk subgroups.

Economic impact of malaria-related hospitalizations in the United States, 2000-2014.

BACKGROUND: Despite its elimination in the early 1950s, about 1700 cases of malaria are reported in the US every year. Few studies have quantified the direct and indirect costs of imported malaria in the US. METHODS: Disparities in the mean and total hospital days, hospital charges, and hospital costs for malaria-related hospitalizations in the US by demographic, clinical, species, financial, geographic, and institutional characteristics were examined using the 2000-2014 Nationwide Inpatient Sample (NIS). Trends and potential predictors for length of stay and hospital charges and costs were identified using negative binomial regression and linear regression, respectively. RESULTS: From 2000 to 2014, 22,029 malaria cases resulted in 95,948 hospital days for malaria-related hospitalizations, $176,391,466 in total hospital costs, and $555,435,849 in total charges. Mean charges increased significantly over the study period. Males, Blacks, and patients aged 25-44years accounted for the highest direct and indirect costs. Older age and having severe malaria was associated with a longer length of stay. Older age, severe malaria, HIV infection, and longer lengths of stay were associated with higher charges and costs. CONCLUSIONS: Malaria resulted in substantial direct and indirect costs in the US. Primary and secondary prevention measures should be prioritized among high-risk groups to reduce the economic burden.

Challenges and solutions to estimating tuberculosis disease incidence by country of birth in Los Angeles County.

BACKGROUND: Among U.S. residents, tuberculosis (TB) disease disproportionally affects non-U.S.-born persons and varies substantially by country of birth. Yet TB disease incidence rates by country of birth are not routinely reported despite these large, known health disparities. This is in part due to the technical challenges of using standard regression analysis with a communicable disease. Here, we estimate tuberculosis disease incidence rates by country of birth and demonstrate methods for overcoming these challenges using TB surveillance data from Los Angeles County which has more than 3.5 million non-U.S.-born residents. METHODS: Cross-sectional data on 5,447 cases of TB disease from Los Angeles County were combined with population estimates from the American Community Survey to calculate TB disease incidence rates for 2005 through 2011. Adjusted incidence rates were modelled using Poisson and negative binomial regressions. Bayesian models were used to account for the uncertainty in population estimates. RESULTS: The unadjusted incidence rate among non-U.S.-born persons was 15 per 100,000 person-years in contrast to the rate among U.S-born persons, 2 per 100,000. The unadjusted incidence rates were 44 and 12 per 100,000 person-years among persons born in the Philippines and Mexico, respectively. In adjusted analysis, persons born in the Philippines were 2.6 (95% CI: 2.3-3.1) times as likely to be reported as a TB case than persons born in Mexico. Bayesian models showed similar results. CONCLUSION: This study confirms substantial disparities in TB disease by country of birth in Los Angeles County. Accounting for age, gender, years in residence and year of diagnosis, persons from the Philippines, Vietnam and several other countries had much higher rates of reported TB disease than other foreign countries. We demonstrated that incidence rates by country of birth can be estimated using available data despite technical challenges.

Formation and psychometric evaluation of a health-related quality of life instrument for children living with HIV in India.

In-depth interviews and focus group discussions were conducted to inform the development of an instrument to measure the health-related quality of life of children living with HIV. The QOL-CHAI instrument consists of four generic core scales of the "Pediatric Quality of Life Inventory" and two HIV-targeted scales-"symptoms" and "discrimination." A piloting exercise involving groups of children living with HIV and HIV-negative children born to HIV-infected parents provided evidence for the acceptable psychometric properties and usability of the instrument. It is expected that the QOL-CHAI can serve well as a brief, standardized, and culturally appropriate instrument for assessing health-related quality of life of Indian children living with HIV.

Risk factors for severe malaria among hospitalized patients in the United States, 2000-2014.

BACKGROUND: Factors associated with the development of severe malaria have not been well described for cases occurring in the United States (US). METHODS: Severe malaria hospitalizations data from the 2000-2014 Nationwide Inpatient Sample were analyzed. Frequencies were reported by demographic, clinical, species, financial, geographic, and institutional characteristics, and trends and disparities were identified. Logistic regression models were used to identify potential predictors for severe disease among those with malaria. RESULTS: From 2000 to 2014, there were an estimated 4823 severe malaria cases, representing 21.9% of all malaria-related hospitalizations, including 182 severe malaria deaths. Severe malaria was most common among inpatients who were male, Black, aged 45-64 years, and hospitalized in the South Atlantic division of the US. Older age was associated with higher odds of severe malaria, cerebral malaria, ARDS, severe anemia, and renal failure. Males had higher odds of developing renal failure and jaundice, while females had higher odds of developing severe anemia. HIV infection was associated with increased odds of severe malaria, severe anemia, and renal failure. CONCLUSION: Primary and secondary prevention measures, such as pre-travel consultations, chemoprophylaxis, and early diagnosis and treatment, should be emphasized and improved among high-risk prospective travelers to malaria endemic countries.

Malaria-Related Hospitalizations in the United States, 2000-2014.

Few data are available on the burden of malaria hospitalization in the United States. Study of malaria using hospital-based data can better define the impact of malaria and help inform prevention efforts. U.S. malaria cases identified from hospitalization discharge records in the 2000-2014 Nationwide Inpatient Sample were examined. Frequencies and population rates were reported by demographics, infecting species, clinical, financial, institutional, geographic, and seasonal characteristics, and disparities were identified. Time trends in malaria cases were assessed using negative binomial regression. From 2000 to 2014, there were an estimated 22,029 malaria-related hospitalizations (4.88 per 1 million population) in the United States, including 182 in-hospital deaths and 4,823 severe malaria cases. The rate of malaria-related hospitalizations did not change significantly over the study period. The largest number of malaria-related hospitalizations occurred in August. Malaria-related hospitalizations occurred disproportionately among patients who were male, black, or 25-44 years of age. Plasmodium falciparum accounted for the majority of malaria-related hospitalizations. On average, malaria patients were hospitalized for 4.36 days with charges of $25,789. Patients with a malaria diagnosis were more often hospitalized in the Middle Atlantic and South Atlantic census divisions, urban teaching, private not-for-profit, and large-bed-size hospitals. Malaria imposes a substantial disease burden in the United States. Enhanced primary and secondary prevention measures, including strategies to increase the use of pretravel consultations and prompt diagnosis and treatment are needed.

The changing trends and profile of pneumocystosis mortality in the United States, 1999-2014.

Pneumocystosis (PCP) mortality in the U.S. has received less attention in recent years. This study describes recent trends in mortality and the estimated burden of PCP in the U.S., using the national multiple cause of death data during 1999-2014. PCP mortality rates were calculated for age, sex, race and year. Demographic differences were presented for decedents with and without a human immunodeficiency virus (HIV) co-diagnosis. Matched odds ratios (MOR) were generated to describe associations between non-HIV conditions and PCP mortality. In total, 11 512 PCP deaths occurred during 1999-2014. Annual age-adjusted PCP mortality decreased over this time period, from 0.479 to 0.154 per 100 000 population (1999 vs 2014 respectively). Over two-thirds of decedents were male and Blacks had the highest mortality as compared to Whites. HIV co-diagnosis accounted for 48% of all PCP deaths in 2014 vs 71% in 1999. Comorbid conditions such as connective tissue disorders (MOR=12.29; 95% confidence interval=[10.26, 14.71]) were associated with a PCP diagnosis. Productivity losses amounted to >$12 billion during the study period. Although widespread use of antiretroviral therapy and PCP prophylaxis for HIV infection likely contributed to the overall decline in PCP deaths during 1999-2014, a continual need exists to prevent and treat this fungal disease in immune-compromised populations that are not infected with HIV.

Health-related quality of life (HRQoL) and its correlates among community-recruited children living with HIV and uninfected children born to HIV-infected parents in West Bengal, India.

PURPOSE: Helping children living with HIV (CLH) to attain an optimum quality of life is an important goal for HIV programs around the world. Our principal objectives were to determine the association of HIV infection with different domains of health-related quality of life (HRQoL) among 8- to 15-year-old CLH in India and to compare the HRQoL parameters between CLH and HIV-negative children born to HIV-infected parents ("HIV-affected"). We also assessed whether antiretroviral therapy (ART) and CD4 lymphocyte counts were associated with HRQoL among CLH. METHODS: Using the "Quality of Life (health-related) of Children Living with HIV/AIDS in India" instrument, we interviewed 199 CLH and 194 HIV-affected children from three districts of West Bengal, India. Participants were asked to quantify the difficulties faced by them in six HRQoL domains: physical, emotional, social, school functioning, symptoms, and discrimination. RESULTS: The mean age of the participants was 11.6 (SD ± 2.5) years. CLH, compared to HIV-affected children, had poorer scores on all HRQoL domains except 'discrimination.' Among CLH, there were no significant differences in HRQoL domain scores (except in the 'discrimination' domain) between ART-treated and -untreated groups. CD4 lymphocyte count was found to be a significant positive predictor of the 'symptom' scale score. CONCLUSIONS: In India, interventions for CLH mostly focus on biological disease. However, the current study revealed that HRQoL among CLH was much poorer than that of a socio-demographically comparable group. Culturally and developmentally appropriate psychosocial support measures for Indian CLH are urgently needed.

Differential declines in syphilis-related mortality in the United States, 2000-2014.

BACKGROUND: After reaching an all time low in 2000, the rate of syphilis in the United States has been steadily increasing. Parallel benchmarking of the disease's mortality burden has not been undertaken. METHODS: Using ICD-10 classification, all syphilis-related deaths in the national Multiple Cause of Death dataset were examined for the period 2000-2014. Descriptive statistics and age-adjusted mortality rates were generated. Poisson regression was performed to analyze trends over time. A matched case-control analysis was conducted to assess the associations between syphilis-related deaths and comorbid conditions listed in the death records. RESULTS: A total of 1,829 deaths were attributed to syphilis; 32% (n = 593) identified syphilis as the underlying cause of death. Most decedents were men (60%) and either black (48%) or white (39%). Decedents aged ≥85 years had the highest average mortality rate (0.47 per 100,000 population; 95% confidence interval [CI], 0.42-0.52). For the sampled period, the average annual decline in mortality was -2.90% (95% CI, -3.93% to -1.87%). However, the average annual percent change varied across subgroups of interest. CONCLUSIONS: Declines in U.S. syphilis mortality suggest early detection and improved treatment access likely helped attenuate disease progression; however, increases in the disease rate since 2000 may be offsetting the impact of these advancements.

Salmonellosis Hospitalizations in the United States: Associated Chronic Conditions, Costs, and Hospital Outcomes, 2011, Trends 2000-2011.

Hospitalized salmonellosis patients with concurrent chronic conditions may be at increased risk for adverse outcomes, increasing the costs associated with hospitalization. Identifying important modifiable risk factors for this predominantly foodborne illness may assist hospitals, physicians, and public health authorities to improve management of these patients. The objectives of this study were to (1) quantify the burden of salmonellosis hospitalizations in the United States, (2) describe hospitalization characteristics among salmonellosis patients with concurrent chronic conditions, and (3) examine the relationships between salmonellosis and comorbidities by four hospital-related outcomes. A retrospective analysis of salmonellosis discharges was conducted using the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample for 2011. A supplemental trend analysis was performed for the period 2000-2011. Hospitalization characteristics were examined using multivariable regression modeling, with a focus on four outcome measures: in-hospital death, total amount billed by hospitals for services, length of stay, and disease severity. In 2011, there were 11,032 total salmonellosis diagnoses; 7496 were listed as the primary diagnosis, with 86 deaths (case-fatality rate = 1.2%). Multivariable regression analyses revealed a greater number of chronic conditions (≥4) among salmonellosis patients was associated with higher mean total amount billed by hospitals for services, longer length of stay, and greater disease severity (p ≤ 0.05). From 2000 to 2011, hospital discharges for salmonellosis increased by 27.2%, and the mean total amount billed by hospitals increased nearly threefold: $9,777 (2000) to $29,690 (2011). Observed increases in hospitalizations indicate the burden of salmonellosis remains substantial in the United States. The positive association between increased number of chronic conditions and the four hospital-related outcomes affirms the need for continual healthcare and public health investments to prevent and control this disease in vulnerable groups.

Legionnaires' disease and associated comorbid conditions as causes of death in the U.S., 2000-2010.

OBJECTIVE: Recent U.S. outbreaks of Legionnaires' disease (LD) underscore the virulent nature of this infectious pneumonia. To date, only a paucity of literature has described the mortality burden of LD. This study updates LD mortality using U.S. multiple-cause-of-death data from 2000-2010. METHODS: We calculated crude and age-adjusted rates for LD mortality for age, sex, race, state, Census region, and year. We conducted Poisson regression to assess seasonal and temporal trends. We generated matched odds ratios (MORs) to describe the association between LD-related deaths and other comorbid conditions listed on the death certificates. RESULTS: We identified a total of 1,171 LD-related deaths during 2000-2010. The age-adjusted mortality rate remained relatively static from 2000 (0.038 per 100,000 population, 95% confidence interval [CI] 0.031, 0.046) to 2010 (0.040 per 100,000 population, 95% CI 0.033, 0.047). The absolute number increased from 107 to 135 deaths during this period, with adults ≥45 years of age having the highest caseload. Overall, LD mortality rates were 2.2 times higher in men than in women. White people accounted for nearly 83.3% of all LD-related deaths, but the age-adjusted mortality rates for black and white people were similar. Comorbid conditions such as leukemia (MOR=4.8, 95% CI 3.5, 6.6) and rheumatoid arthritis (MOR=5.6, 95% CI 3.3, 9.4) were associated with LD diagnosis on death certificates. CONCLUSION: Comorbid conditions that could lead to an immunocompromised state were associated with fatal LD on U.S. death certificates. Characterization of LD mortality burden and related comorbidities has practice implications for clinical medicine and public health surveillance.

Cysticercosis-related hospitalizations in the United States, 1998-2011.

Cysticercosis has become increasingly recognized as an important infection in the United States in recent decades. Despite its potential impact, there is a lack of comprehensive information on the nationwide burden of disease. To better define the burden of cysticercosis in the United States, we analyzed in-patient records using the Nationwide Inpatient Sample for 1998-2011 to estimate cysticercosis-related hospitalizations and patient/institutional characteristics. There were an estimated 33,060 (95% confidence interval [95% CI] = 29,610.5-36,510.3) cysticercosis-related hospitalizations nationwide, representing a hospitalization rate of 8.03 per million population. The highest proportion of cases were male (54.8%), Hispanic (62.0%), aged 18-44 (58.8%), and occurred in the West (45.1%). An estimated 459 deaths occurred, representing an in-hospital case-fatality rate of 1.4%. These findings indicate the burden of cysticercosis-related hospitalizations in the United States is considerable and may be greater than currently appreciated. Cysticercosis should be a nationally reportable disease.

Blastomycosis mortality rates, United States, 1990-2010.

Blastomycosis is a potentially fatal fungal infection endemic to parts of North America. We used national multiple-cause-of-death data and census population estimates for 1990-2010 to calculate age-adjusted mortality rates and rate ratios (RRs). We modeled trends over time using Poisson regression. Death occurred more often among older persons (RR 2.11, 95% confidence limit [CL] 1.76, 2.53 for those 75-84 years of age vs. 55-64 years), men (RR 2.43, 95% CL 2.19, 2.70), Native Americans (RR 4.13, 95% CL 3.86, 4.42 vs. whites), and blacks (RR 1.86, 95% CL 1.73, 2.01 vs. whites), in notably younger persons of Asian origin (mean = 41.6 years vs. 64.2 years for whites); and in the South (RR 18.15, 95% CL 11.63, 28.34 vs. West) and Midwest (RR 23.10, 95% CL14.78, 36.12 vs. West). In regions where blastomycosis is endemic, we recommend that the diagnosis be considered in patients with pulmonary disease and that it be a reportable disease.

Trends, productivity losses, and associated medical conditions among toxoplasmosis deaths in the United States, 2000-2010.

Few studies have quantified toxoplasmosis mortality, associated medical conditions, and productivity losses in the United States. We examined national multiple cause of death data and estimated productivity losses caused by toxoplasmosis during 2000-2010. A matched case-control analysis examined associations between comorbid medical conditions and toxoplasmosis deaths. In total, 789 toxoplasmosis deaths were identified during the 11-year study period. Blacks and Hispanics had the highest toxoplasmosis mortality compared with whites. Several medical conditions were associated with toxoplasmosis deaths, including human immunodeficiency virus (HIV), lymphoma, leukemia, and connective tissue disorders. The number of toxoplasmosis deaths with an HIV codiagnosis declined from 2000 to 2010; the numbers without such a codiagnosis remained static. Cumulative disease-related productivity losses for the 11-year period were nearly $815 million. Although toxoplasmosis mortality has declined in the last decade, the infection remains costly and is an important cause of preventable death among non-HIV subgroups.

Cryptococcosis-related deaths and associated medical conditions in the United States, 2000-2010.

Cryptococcosis is an invasive mycotic infection primarily affecting immunocompromised individuals. The objective of this study was to describe cryptococcosis mortality and associated medical conditions in the US for the period 2000-2010. Cryptococcosis-related deaths were identified from the national multiple-cause-of-death dataset. Mortality trends and comparison analyses were performed on overall cases of cryptococcosis and by subset [i.e. clinical manifestations of disease and human immunodeficiency virus (HIV) status]. A matched case-control analysis was also conducted to describe the associations between this disease and comorbid medical conditions. A total of 3210 cryptococcosis-related deaths were identified. Cerebral cryptococcosis was the most commonly reported clinical manifestation of the disease. Approximately one-fifth of the decedents (n = 616) had a co-diagnosis of HIV. Mortality rates were highest among men, blacks, Hispanics, Native Americans and older adults. Poisson regression analysis indicated a 6.52% annual decrease in mortality rates for the study period. HIV (MOR = 35.55, 95% CI 27.95-45.22) and leukaemia (MOR = 16.10, 95% CI 11.24-23.06) were highly associated with cryptococcosis-related deaths. Cryptococcosis mortality declined significantly during 2000-2010. However, the disease continues to cause appreciable mortality in the US. With the majority of decedents having no HIV co-diagnosis, there is still much to be learned about the epidemiology of this mycosis.

Neglected parasitic infections in the United States: cysticercosis.

Cysticercosis is a potentially fatal and preventable neglected parasitic infection caused by the larval form of Taenia solium. Patients with symptomatic disease usually have signs and symptoms of neurocysticercosis, which commonly manifest as seizures or increased intracranial pressure. Although there are many persons living in the United States who emigrated from highly disease-endemic countries and there are foci of autochthonous transmission of the parasite in the United States, little is known about burden and epidemiology of the disease in this country. In addition, despite advances in the diagnosis and management of neurocysticercosis, there remain many unanswered questions. Improving our understanding and management of neurocysticercosis in the United States will require improved surveillance or focused prospective studies in appropriate areas and allocation of resources towards answering some of the key questions discussed in this report.

Melanoma-related mortality and productivity losses in the USA, 1990-2008.

Melanoma remains among the deadliest cancers in the USA, ranking presently as the leading cause of death from skin disease in this country. The present analysis presents national statistics on the health burden (mortality) and productivity losses attributable to this cancer over a 19-year period. Melanoma-related deaths and mortality rates from 1990 through 2008 were identified and calculated using multiple-cause-of-death data and data from the 2000 US Census. Productivity losses were estimated using previously published methods that accounted for life expectancy, labor force participation, productivity growth, and the imputed values of caregiving and housekeeping activities. A total of 155,571 melanoma-related deaths occurred during 1990-2008, resulting in 1,811,701 years of potential life lost. Age-adjusted mortality rates stratified by sex and race/ethnicity revealed differences: whites had the highest rate (3.55 per 100 000 population; 95% confidence interval 3.54, 3.57) and male individuals were 2.21 times more likely than female individuals to succumb to the disease. Cumulatively, the numbers of death for blacks, Hispanics, Asian/Pacific Islanders, and American Indians/Alaskan Natives exceeded 6000 deaths. The total productivity losses attributable to melanoma-related mortality during the sampled period were ∼$66.9 billion. The burden and economic consequences of melanoma-related deaths in the USA are not inconsequential. Understanding the mortality trends and productivity losses attributed to this skin cancer is important for evaluating the feasibility and trade-offs of public health and behavioral counseling interventions that focus on promoting skin cancer prevention.

Coccidioidomycosis-associated Deaths, United States, 1990-2008.

Coccidioidomycosis is endemic to the Americas; however, data on deaths caused by this disease are limited. To determine the rate of coccidioidomycosis-associated deaths in the United States, we examined multiple cause-coded death records for 1990-2008 for demographics, secular trends, and geographic distribution. Deaths were identified by International Classification of Diseases, 9th and 10th Revision, codes, and mortality rates were calculated. Associations of deaths among persons with selected concurrent conditions were examined and compared with deaths among a control group who did not have coccidioidomycosis. During the 18-year period, 3,089 coccidioidomycosis-associated deaths occurred among US residents. The overall age-adjusted mortality rate was 0.59 per 1 million person-years; 55,264 potential life-years were lost. Those at highest risk for death were men, persons >65 years, Hispanics, Native Americans, and residents of California or Arizona. Common concurrent conditions were HIV and other immunosuppressive conditions. The number of deaths from coccidioidomycosis might be greater than currently appreciated.