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.

Trends in infectious diseases mortality in the United States.

OBJECTIVE: To evaluate recent trends in infectious diseases mortality in the United States. DESIGN: Descriptive study of infectious disease mortality, classifying International Classification of Diseases, Ninth Revision codes as infectious diseases, consequence of infectious diseases, or not infectious diseases. Multiple cause-of-death tapes from the National Center for Health Statistics for the years 1980 through 1992 were used, with a focus on underlying cause-of-death data and on codes that exclusively represent infectious diseases. SETTING: United States. SUBJECTS: All persons who died between 1980 and 1992. MAIN OUTCOME MEASURE: Death. RESULTS: Between 1980 and 1992, the death rate due to infectious diseases as the underlying cause of death increased 58%, from 41 to 65 deaths per 100,000 population in the United States. Age-adjusted mortality from infectious diseases increased 39% during the same period. Infectious diseases mortality increased 25% among those aged 65 years and older (from 271 to 338 per 100,000), and 6.3 times among 25- to 44-year-olds (from six to 38 deaths per 100,000). Mortality due to respiratory tract infections increased 20%, from 25 to 30 deaths per 100,000, deaths attributed to human immunodeficiency virus increased from virtually none to 13 per 100,000 in 1992, and the rate of death due to septicemia increased 83% from 4.2 to 7.7 per 100,000. CONCLUSIONS: Despite historical predictions that infectious diseases would wane in the United States, these data show that infectious diseases mortality in the United States has been increasing in recent years.

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.

Emerging infectious diseases in the United States, 1993.

Three outbreaks of disease in the United States in 1993 caused by Escherichia coli O157:H7, Cryptosporidium organisms, and a previously unrecognized hantavirus clearly illustrate the increasing challenges posed by emerging infectious diseases. The largest US outbreak of E. coli O157:H7 infection reported occurred as a result of contaminated hamburgers served at a fast-food restaurant chain. The largest recorded waterborne disease outbreak in US history was due to contamination of a municipal water supply with cryptosporidia. In the southwestern United States, hantavirus was first recognized as the cause of a pulmonary syndrome with a mortality rate exceeding 50%. The detection of and response to these outbreaks document the need for a strong partnership between the clinical and public health sectors to prevent and control diseases. Health care reform in the United States provides an opportunity to address critical needs, such as improved surveillance and diagnosis, to ensure timely detection of and rapid response to newly emerging infectious diseases.

Gender differences in reported AIDS-indicative diagnoses.

To compare AIDS-defining conditions in women and men, US adult AIDS cases diagnosed between January 1988 and June 1991 and reported to the Centers for Disease Control and Prevention through June 1992 were examined. For most AIDS-defining conditions, the prevalence was similar for women and men when differences in race/ethnicity and mode of transmission were accounted for. Pneumocystis carinii pneumonia was the most prevalent condition (> 50%) regardless of gender, race/ethnicity, or mode of transmission. By logistic regression analysis, among injection drug users, conditions reported significantly more frequently in women than in men include esophageal candidiasis (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.40-1.62), herpes simplex virus (HSV) disease (OR, 1.68; CI, 1.46-1.94), and cytomegalovirus (CMV) disease (OR, 1.43; CI, 1.18-1.73). More knowledge of the interrelationships in women between HIV infection and secondary opportunistic infections, including candidiasis and sexually transmitted disease (e.g., HSV and CMV) is needed.

Increasing frequency of heterosexually transmitted AIDS in southern Florida: artifact or reality?

Acquired immunodeficiency syndrome (AIDS) cases reported as the result of heterosexual contact have been increasing in the United States, with Florida reporting a disproportionate number. We investigated 168 such AIDS cases from southern Florida. After follow-up, 50 (30%) patients were reclassified into other transmission categories. The data suggest that the increased rate of heterosexually acquired AIDS cases reported from southern Florida was partially related to misclassification of risk.

Mammography use and outcomes in a community. The Greater Lansing Area Mammography Study.

BACKGROUND: Mammography is widely known to reduce morbidity and mortality from breast cancer, but a population-based assessment of mammography use and follow-up of mammography findings has not been reported previously. METHODS: An observational, population-based, follow-up study was conducted of all women having mammograms in the Greater Lansing, Michigan, metropolitan area, between June 1987 and June 1988. A total of 17,811 Greater Lansing women participated. The adherence of women to mammography screening guidelines was estimated, and mammography's utility to detect breast cancer was assessed through follow-up review of breast biopsy results. RESULTS: Thirty-seven percent of the expected number of women 35 years of age and older had mammograms. Adherence to screening guidelines declined with age, and less than 5% (302 of 6700) of women 55 years of age and older reporting having annual mammograms. Seventy-six percent of women reported that their physicians prompted the examination. The predictive value of a positive mammogram was 21.9% for women without symptoms and 32.4% for women with symptoms. Mammography's sensitivity and specificity for breast cancer detection were 71% and 98%, respectively. CONCLUSIONS: The study highlights the need to target mammography to women 50 years of age and older, underscores the importance of physicians in promoting mammography, and demonstrates the analytic value and limitation of mammography in clinical decision-making.

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.

Acquired immunodeficiency syndrome in the United States associated with injecting drug use, 1981-1991.

As of June 30, 1991, 182,834 AIDS cases in the United States had been reported to the Centers for Disease Control, of which 58,879 (32.2%) were associated with illicit drug use. Of these, 39,904 (70.0%) were in both women and heterosexual men reported as injecting drug users (IDUs), 11,823 (20.7%) in men who have sex with men who are also IDUs, 5,305 (9.3%) in sex partners of IDUs, and 1,847 (3.1%) in children whose mothers were either IDUs or sex partners of IDUs. From 1989 to 1990, the increase in the number of United States AIDS cases associated with IDU either directly or indirectly was higher in all regions compared with the Northeast. The highest percentage increases were in the South, U.S. territories, and the North Central. From 1989 to 1990, the percentage of AIDS cases attributed directly to IDU increased in women and men (15.3 and 5.9%, respectively); however, the increase in sex partners of IDUs was much larger (34.5% in men and 29.1% in women). Increases were also higher in sex partners of IDUs than in IDUs when compared by race/ethnicity and by region of residence. Because HIV can spread rapidly among IDUs and their sex partners, there is an immediate need for targeting effective HIV prevention messages to all IDUs and their sex partners in communities with high HIV infection rates.

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.

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.

A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer.

To quantify the effect of estrogen replacement therapy on breast cancer risk, we combined dose-response slopes of the relative risk of breast cancer against the duration of estrogen use across 16 studies. Using this summary dose-response slope, we calculated the proportional increase in risk of breast cancer for each year of estrogen use. For women who experienced any type of menopause, risk did not appear to increase until after at least 5 years of estrogen use. After 15 years of estrogen use, we found a 30% increase in the risk of breast cancer (relative risk, 1.3; 95% confidence interval [CI], 1.2 to 1.6). The increase in risk was largely due to results of studies that included premenopausal women or women using estradiol (with or without progestin), studies for which the estimated relative risk was 2.2 (CI, 1.4 to 3.4) after 15 years. Among women with a family history of breast cancer, those who had ever used estrogen replacement had a significantly higher risk (3.4; CI, 2.0 to 6.0) than those who had not (1.5; CI, 1.2 to 1.7).

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.