Use of TaqMan Array Cards to Screen Outbreak Specimens for Causes of Febrile Illness in Tanzania.

We describe the deployment of a custom-designed molecular diagnostic TaqMan Array Card (TAC) to screen for 31 bacterial, protozoal, and viral etiologies in blood from outbreaks of acute febrile illness in Tanzania during 2015-2017. On outbreaks notified to the Tanzanian Ministry of Health, epidemiologists were dispatched and specimens were collected, transported to a central national laboratory, and tested by TAC within 2 days. This algorithm streamlined investigation, diagnosed a typhoid outbreak, and excluded dozens of other etiologies. This method is usable in-country and may be incorporated into algorithms for diagnosing outbreaks.

Cholera Mortality during Urban Epidemic, Dar es Salaam, Tanzania, August 16, 2015-January 16, 20161.

In 2015, a cholera epidemic occurred in Tanzania; most cases and deaths occurred in Dar es Salaam early in the outbreak. We evaluated cholera mortality through passive surveillance, burial permits, and interviews conducted with decedents' caretakers. Active case finding identified 101 suspected cholera deaths. Routine surveillance had captured only 48 (48%) of all cholera deaths, and burial permit assessments captured the remainder. We interviewed caregivers of 56 decedents to assess cholera management behaviors. Of 51 decedents receiving home care, 5 (10%) used oral rehydration solution after becoming ill. Caregivers reported that 51 (93%) of 55 decedents with known time of death sought care before death; 16 (29%) of 55 delayed seeking care for >6 h. Of the 33 (59%) community decedents, 20 (61%) were said to have been discharged from a health facility before death. Appropriate and early management of cholera cases can reduce the number of cholera deaths.

Cluster of Ebola Virus Disease Linked to a Single Funeral - Moyamba District, Sierra Leone, 2014.

As of February 17, 2016, a total of 14,122 cases (62% confirmed) of Ebola Virus Disease (Ebola) and 3,955 Ebola-related deaths had been reported in Sierra Leone since the epidemic in West Africa began in 2014. A key focus of the Ebola response in Sierra Leone was the promotion and implementation of safe, dignified burials to prevent Ebola transmission by limiting contact with potentially infectious corpses. Traditional funeral practices pose a substantial risk for Ebola transmission through contact with infected bodies, body fluids, contaminated clothing, and other personal items at a time when viral load is high; however, the role of funeral practices in the Sierra Leone epidemic and ongoing Ebola transmission has not been fully characterized. In September 2014, a sudden increase in the number of reported Ebola cases occurred in Moyamba, a rural and previously low-incidence district with a population of approximately 260,000. The Sierra Leone Ministry of Health and Sanitation and CDC investigated and implemented public health interventions to control this cluster of Ebola cases, including community engagement, active surveillance, and close follow-up of contacts. A retrospective analysis of cases that occurred during July 11-October 31, 2014, revealed that 28 persons with confirmed Ebola had attended the funeral of a prominent pharmacist during September 5-7, 2014. Among the 28 attendees with Ebola, 21 (75%) reported touching the man's corpse, and 16 (57%) reported having direct contact with the pharmacist before he died. Immediate, safe, dignified burials by trained teams with appropriate protective equipment are critical to interrupt transmission and control Ebola during times of active community transmission; these measures remain important during the current response phase.

Lung Function before and after a Large Chlorine Gas Release in Graniteville, South Carolina.

RATIONALE: On January 6, 2005 a train derailment led to an estimated 54,915-kg release of chlorine at a local textile mill in Graniteville, South Carolina. OBJECTIVES: We used the employee health spirometry records of the textile to identify enduring effects of chlorine gas exposure resulting from the incident on the lung function of workers employed at the textile mill. METHODS: Spirometry records from 1,807 mill workers (7,332 observations) were used from 4 years before and 18 months after the disaster. Longitudinal analysis using marginal regression models produced annual population mean estimates for FEV1, FVC, and FEV1/FVC ratio. Covariate adjustment was made for sex, age, smoking, height, season tested, technician, obesity, season × year interactions, and smoker × year interactions. The increased prevalence of mill workers having accelerated FEV1 decline was also evaluated after the chlorine spill. MEASUREMENTS AND MAIN RESULTS: In the year of the accident, we observed a significant reduction in mean FEV1 (-4.2% predicted; P = 0.019) when compared with the year before the incident. In the second year, partial recovery in the mean FVC % predicted level was seen, but the cohort's average FEV1/FVC ratio continued to decrease over time. Severe annual FEV1 decline was most prevalent in the year of the accident, and independent of mill worker smoking status. CONCLUSIONS: The Graniteville mill worker cohort revealed significant reductions in lung function immediately after the chlorine incident. Improvement was seen in the second year; but the proportion of mill workers experiencing accelerated FEV1 annual decline significantly increased in the 18 months after the chlorine incident.

Respiratory symptoms and lung function 8-10 months after community exposure to chlorine gas: a public health intervention and cross-sectional analysis.

BACKGROUND: We implemented a community based interventional health screening for individuals located within one mile of a 54 metric tons release of liquid chlorine following a 16 tanker car train derailment on 6 January, 2005 in Graniteville, South Carolina, USA. Public health intervention occurred 8-10 months after the event, and provided pulmonary function and mental health assessment by primary care providers. Its purpose was to evaluate those exposed to chlorine for evidence of ongoing impairment for medical referral and treatment. We report comparative analysis between self-report of respiratory symptoms via questionnaire and quantitative spirometry results. METHODS: Health assessments were obtained through respiratory symptom and exposure questionnaires, simple spirometry, and physical exam. Simple spirometry was used as the standard to identify continued breathing problems. Sensitivity, specificity, positive and negative predictive values were applied to evaluate the validity of the respiratory questionnaire. We also identified the direction of discrepancy between self-reported respiratory symptoms and spirometry measures. Generalized estimation equations determined prevalence ratios for abnormal spirometry based on the presence of participant persistent respiratory symptoms. Covariate adjustment was made for participant age, sex, race, smoking and educational status. RESULTS: Two hundred fifty-nine people participated in the Graniteville health screening; 53 children (mean age = 11 years, range: <1-16), and 206 adults (mean age = 50 years, range: 18-89). Of these, 220 (85%) performed spirometry maneuvers of acceptable quality. Almost 67% (n = 147) displayed abnormal spirometry, while 50% (n = 110) reported persistent new-onset respiratory symptoms. Moreover, abnormal spirometry was seen in 65 participants (29%) who did not report any discernible breathing problems. This represented a net 16.8% underreporting of symptoms. Sensitivity and specificity of questionnaire self-report of symptoms were low at 55.8% and 61.6%, respectively. Persistent cough (41%) and shortness of breath (39%) were the most frequently reported respiratory symptoms. CONCLUSION: Eight to ten months after acute chlorine exposure, the Graniteville health screening participants under-reported respiratory symptoms when compared to abnormal spirometry results. Sensitivity and specificity were low, and we determined that relying upon the self-report questionnaire was not adequate to objectively assess the lung health of our population following irritant gas exposure.

Repeat Western blot testing after receiving an HIV diagnosis and its association with engagement in care.

OBJECTIVES: To examine the prevalence of and factors associated with potentially unnecessary repeat confirmatory testing after initial HIV diagnosis and the relationship of repeat testing to medical care engagement. DESIGN: South Carolina HIV/AIDS surveillance data for 12,504 individuals who were newly diagnosed with HIV infection between January 1997 and December 2008 were used for this analysis. State law requires that all positive Western blot [WB] results be reported regardless of frequency. METHODS: HIV-infected persons, diagnosed from 1997-2008 and followed through 2009, with repeat positive WB results were compared to those who did not have repeat positive WB results. We defined repeat positive testing as documentation of one or more positive WB obtained ≥90 days following initial WB confirmatory result. HIV care engagement for the period from 2007-2009 was assessed by documentation of CD4+ T-cell/viral load reports to the South Carolina HIV/AIDS surveillance system during each six-month period of a calendar year for those individuals diagnosed prior to the assessment period and still alive at the end. Relative risk [RR] with 95% confidence intervals [CI] and multivariable general linear models were used to assess if any covariates of interest were independently associated with repeat positive confirmatory testing. RESULTS: A total of 4,237 [34%] of 12,504 HIV-infected individuals had results of repeat positive WB testing reported to the surveillance system during 1997-2008. Persons who had repeat positive WB testing were more likely than persons who did not have repeat WB testing to have progressed to AIDS >1 year following diagnosis [RR: 1.70; 95% CI: 1.61, 1.80] and to be consistently in care [RR: 1.35; 95% CI: 1.24, 1.47] or have sporadic care [RR: 1.80; 95% CI: 1.68, 1.94]. DISCUSSION: Having repeat positive WB tests may be a marker of engaging HIV care. However, given the limited resources available for care, it is important that healthcare reform policy and clinical recommendations promote improvements in communications about previous test results.

Delivering laboratory results by text message and e-mail: a survey of factors associated with conceptual acceptability among STD clinic attendees.

OBJECTIVE: This study examines factors associated with the acceptability of receiving sexually transmitted disease (STD) laboratory results by text message and e-mail among clinic attendees. SUBJECTS AND METHODS: An anonymous self-administered survey was conducted with a convenience sample of STD clinic attendees in South Carolina and Mississippi in 2009-2010. In total, 2,719 individuals with a median age of 26 years (interquartile range, 21-32 years) completed the survey. RESULTS: More than 70% had Internet access at home, and 80% reported using text messaging daily. Participants preferred receiving laboratory results by text message compared with e-mail (50.2% versus 42.3%; p<0.001). Acceptability of receiving laboratory results by text message was higher with younger age (adjusted odds ratio [aOR] 1.13; 95% confidence interval [CI] 1.10-1.26), daily use of text messaging (aOR 1.30; 95% CI 1.14-1.49), and reporting cell phone and text message as the preferred choice of regular communication with the clinic (aOR 2.31; 95% CI 1.50-3.58) and was significantly lower in female subjects (aOR 0.89; 95% CI 0.81-0.98) and those with college-level education (aOR 0.88; 95% CI 0.77-0.99). CONCLUSIONS: A majority of STD clinic attendees have access to cell phones and Internet. The acceptability of receiving STD laboratory results electronically may facilitate test result delivery to patients and expedite treatment of infected individuals.

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US.

BACKGROUND: Understanding providers' perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation. METHODS: A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses. RESULTS: Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers' perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21-69.61), older age (aOR 1.14; 95% CI 1.01-1.29), and in those who agreed that "PrEP would empower women" (aOR 2.90; 95% CI 1.28-6.61); and was less likely for "other" race/ethnicity versus white (aOR 0.23; 95% CI 0.07-0.76) and in those who agreed that "PrEP, if not effective, could lead to higher HIV transmission" (aOR 0.45; 95% CI 0.27-0.75). CONCLUSIONS: To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.

Risk factors associated with inpatient hospital utilization in HIV-positive individuals and relationship to HIV care engagement.

BACKGROUND: Prompt linkage to HIV primary care may reduce the need for inpatient hospitalization. METHODS: Retrospective cohort study of South Carolina HIV-infected individuals diagnosed from January 1986 to December 2006 who utilized 62 inpatient facilities from (January 2007 to June 2010). Suboptimal primary care engagement was defined as <2 reports of a CD4T-cell count or viral load value to surveillance in each calendar year from January 2007 to June 2010. Multivariable logistic regression explored associations of HIV primary care engagement with inpatient hospitalization after accounting for sociodemographic characteristics and disease stage. Poisson and negative binominal regression examined primary care engagement, sociodemographic characteristics, and disease stage on frequency of inpatient hospitalization and total inpatient days. RESULTS: Individuals presenting to the hospital with an AIDS-defining illness had greater risk of suboptimal HIV primary care engagement [adjusted odds ratio (aOR) = 1.58; 95% confidence interval (CI): 1.23 to 2.04] more inpatient hospitalizations (incidence rate ratio [IRR] = 1.74; 95% CI: 1.65 to 1.83) and inpatient days (IRR = 2.17; 95%CI: 2.00 to 2.36). Blacks demonstrated greater suboptimal care risk (aOR = 1.61; 95% CI: 1.15 to 2.25), more inpatient visits (IRR = 1.09; 95% CI: 1.01 to 1.17), and inpatient days (IRR = 1.21; 95% CI: 1.09 to 1.34). Medicare protected against suboptimal primary care engagement (aOR = 0.66; 95% CI: 0.46 to 0.95) but was associated with more hospitalizations (IRR = 1.09; 95% CI: 1.01 to 1.18). AIDS disease stage was associated with decreased suboptimal care risk (AIDS ≤ 1 year, aOR = 0.05; 95% CI: 0.02 to 0.12; AIDS > 1 year, aOR = 0.11; 95% CI: 0.06 to 0.20) but more hospitalizations (AIDS ≤1 year, IRR = 1.12; 95% CI: 1.04 to 1.21; AIDS > 1 year, IRR = 1.12; 95% CI: 1.04 to 1.21) and inpatient days (AIDS ≤ 1 year, IRR = 1.22; 95% CI: 1.08 to 1.37; AIDS >1 year, IRR = 1.35; 95% CI: 1.21 to 1.50). CONCLUSIONS: Disease stage, race, and insurance status strongly influence HIV primary care engagement and inpatient hospitalization. Admissions may be related to general medical conditions, substance abuse, or antiretroviral therapy.

HIV testing in women: missed opportunities.

OBJECTIVE: To investigate opportunities for early human immunodeficiency virus (HIV) testing of women. METHODS: A retrospective cohort study design linked case reports from HIV surveillance to several statewide health-care databases. Medical encounters occurring before the first positive HIV test (missed opportunities) were categorized by diagnosis/procedure codes to distinguish visits that were likely to have prompted an HIV test. Women were categorized as late testers (AIDS diagnosis <12 months from first HIV test date), non-late testers (no AIDS diagnosis during study period or diagnosis of AIDS >12 months of HIV diagnosis), of reproductive age (13-44 years old), and not of reproductive age (>44 years old). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to estimate risk and its statistical significance. RESULTS: Of 3303 HIV-infected women diagnosed during the study period, 2408 (73%) had missed opportunity visits. Late testers (39%) were more likely to be black than white (aOR 1.48, 95% CI 1.12-1.95), be older (>44 years old; aOR 7.85, 95% CI 4.49-13.7), and have >10 missed opportunity visits (aOR 2.17, 95% CI 1.62-2.91). Fifty-four percent of women >44 years old were also late testers. Women >44 years old had lower median initial CD4 counts (p<0.001). The top two procedures were the same for all groups of women but mammography was ranked fourth for women >44 years old and Papanicolau smear was ranked fourth for late testers. CONCLUSIONS: Feasibility and acceptability of routine HIV testing in nontraditional health-care settings, such as mammography and Papanicolau screenings, should be explored to identify late testers and older (not of reproductive age) HIV-infected women.

Predictors of time to enter medical care after a new HIV diagnosis: a statewide population-based study.

Public health benefits of expanded HIV screening will be adequately realized only if an early diagnosis is followed by prompt linkage to care. We characterized rates and factors associated with failure to enter into medical care within three months of HIV diagnosis and assessed the predictors of time to enter care over a follow-up period of up to 60 months. The study cohort included 3697 South Carolina (SC) residents' ≥13 years who were newly HIV-diagnosed in 2004-2008. Date of first laboratory report of CD4(+) T-cell count or viral load (VL) test after 30 days of confirmatory HIV diagnosis was used to define time to linkage to care. Results showed that of the total 3697 persons, 1768 (48%) entered care within three months, 1115 (30%) in four-12 months after diagnosis, and 814 (22%) failed to initiate care within 12 months of HIV diagnosis. At the end of study follow-up period of up to 60 months from the date of HIV diagnosis, 472/3697 (13%) individuals remained out of care. Multivariable Cox proportional hazards analysis showed that compared with hospitals, time to enter care was shorter in those diagnosed at state mental health/correctional facilities (adjusted hazards ratio [aHR] 1.16; 95% confidence interval [CI] 1.02-1.34) and longer in those diagnosed at county health departments (aHR 0.87; 95% CI 0.80-0.96) and at "Other/unknown" facilities (aHR 0.79; 95% CI 0.70-0.89). Time to entry into care was longer for men (aHR 0.82; 95% CI 0.75-0.89) compared with women, blacks (aHR 0.91; 95% CI 0.83-0.98) compared with whites, and males who have sex with males (MSM) (aHR 0.89; 95% CI 0.80-0.98) compared with heterosexual exposure. Delayed entry into HIV care remains a challenge in controlling HIV transmission in SC. Better integration of testing and care facilities could improve the proportion of newly HIV-diagnosed persons who enter care in a timely manner.

Demographic characteristics and behavioral risk factors of HIV infection and association with survival among individuals 50 years or older.

OBJECTIVES: To investigate the association of socio-behavioral characteristics and viro-immunological status with survival in a cohort of HIV-infected individuals by age in South Carolina (SC). METHODS: Logistic regression was used to compare the characteristics of individuals' ≥50 years old to individuals 20-49 years old at HIV diagnosis who were reported to SC enhanced HIV/AIDS Reporting System (eHARS) from January 1998 to December 2009. Cox proportional hazards analysis was used to examine the time to death after HIV diagnosis over the study period. RESULTS: Of the 7531 participants, 1204 (16%) were ≥50 years old. Multivariable analyses suggested that individuals ≥50 years old were more likely to have simultaneous AIDS (aOR 1.80, 95% CI 1.54-2.10). For individuals ≥50 years old, the risk of death was more than three times when compared to the younger age group (HR: 3.46, 95% CI 2.27, 5.30). CONCLUSION: Routine HIV screening may decrease late-stage diagnosis and improved linkage to care may decrease mortality in older adults.

Follow-up assessment of health consequences after a chlorine release from a train derailment--Graniteville, SC, 2005.

INTRODUCTION: After a train derailment released chlorine gas in Graniteville, South Carolina, in 2005, a multiagency team performed an epidemiologic assessment of chlorine exposure and resulting health effects. Five months later, participants were resurveyed to determine their health status and needs and to assist in planning additional interventions in the community. METHODS: Questionnaires were mailed to 279 patients interviewed in the initial assessment; follow-up telephone calls were made to nonresponders. The questionnaire included questions regarding duration of symptoms experienced after exposure and a posttraumatic stress disorder (PTSD) assessment tool. RESULTS: Ninety-four questionnaires were returned. Seventy-six persons reported chronic symptoms related to the chlorine exposure, 47 were still under a doctor's care, and 49 were still taking medication for chlorine-related problems. Agreement was poor between the first and second questionnaires regarding symptoms experienced after exposure to the chlorine (κ=0.30). Forty-four respondents screened positive for PTSD. PTSD was associated with post-exposure hospitalization for three or more nights [relative risk (RR) = 1.7; 95% confidence interval (CI)=1.1-2.6] and chronic symptoms (RR=9.1; 95% CI=1.3-61.2), but not with a moderate-to-extreme level of chlorine exposure (RR=1.2; 95% CI=0.8-1.8). CONCLUSIONS: Some victims of this chlorine exposure event continued to experience physical symptoms and continued to require medical care 5 months later. Chronic mental health symptoms were prevalent, especially among persons experiencing the most severe or persistent physical health effects. Patients should be interviewed as soon as possible after an incident because recall of acute symptoms experienced can diminish within months.

Transmitted antiretroviral drug resistance in individuals with newly diagnosed HIV infection: South Carolina 2005-2009.

OBJECTIVES: The transmission of drug-resistant human immunodeficiency virus 1 (HIV-1) has important implications for the antiretroviral management of newly diagnosed individuals, increasing the risk of suboptimal treatment outcomes. The study objective was to characterize rates and factors associated with transmitted drug-resistant HIV-1 infection among newly diagnosed South Carolina (SC) residents. METHODS: This study utilized surveillance genotypic data from antiretroviral therapy (ART)-naïve individuals newly diagnosed with HIV-1 infection from June 2005 through December 2009. Multivariable negative binomial regression was used to model the association between the presence of major mutations and sociodemographic characteristics. RESULTS: Of the 1,277 study participants, 14.4% (184/1,277) had HIV-1 variants with major antiretroviral drug mutations. Of these individuals, 126 had non-nucleoside reverse transcriptase inhibitor-associated mutations (NNRTI), 54 had nucleos(t)ide reverse transcriptase inhibitor-associated mutations (NRTI), 37 had protease inhibitor-associated mutations (PI). Nineteen (10.3%) individuals had dual class-associated mutations (NNRTI and PI in seven, NNRTI and NRTI in seven, and NRTI and PI in five individuals), and seven (3.8%) individuals had triple drug class-associated mutations (PI, NNRTI, and NRTI). The multivariable negative binomial regression models indicated that age at HIV diagnosis had a significant negative association with total number of mutations (rate ratio [RR] 0.88, 95% confidence interval [CI] 0.80-0.96, P value=0.005) and total number of reverse transcriptase (RT) mutations (RR 0.88, 95% CI 0.80-0.97, P value=0.006) present. CONCLUSION: Prevalence of transmitted drug resistance is consistently high among newly diagnosed HIV-infected individuals in SC. It is important to continue genotypic surveillance to facilitate effective HIV treatment and empiric post-exposure prophylaxis regimens.

The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study.

Current literature on retention in HIV care fails to account for patients who continually/simultaneously access different providers. This statewide study examined retention in early HIV medical care and its impact on viro-immunological improvement and survival outcomes. It was a retrospective study of South Carolina residents ≥13 years old who were diagnosed with HIV infection in 2004-2007 and initially entered in care. CD4 count/percent and viral load (VL) tests that must be reported to the South Carolina HIV surveillance database were used as a proxy for a clinical visit. Retention was defined as at least one visit in each of four 6-month periods over 2 years postlinkage. Retention rates were categorized as "optimal" (visits in four intervals), "suboptimal" (visits in three intervals), sporadic (visits in two or one intervals), and "dropout" (no visits). Logistic regression and Cox proportional analyses were used to examine retention. Of the 2197 persons, about 50% failed to maintain optimal retention in care postlinkage. Male gender, nonwhite race/ethnicity, younger age, delayed linkage, and HIV-only status were significant predictors of lower rate of retention. Mean decrease in baseline log(10) VL was greater among those with optimal compared to suboptimal (-1.81 vs. -1.42; p < 0.001) and sporadic retention (-1.81 vs. -0.70; p < 0.001). Mean increase in baseline CD4 count was greater in optimal retention compared to suboptimal (169.70 vs. 107.5; p < 0.001) and sporadic retention (169.70 vs. 2.43; p < 0.001). Increased risk of mortality was associated with sporadic retention (aHR 2.91; 95% CI 1.54-5.50) and "dropout" (aHR 4.00; 95% CI 1.50-10.65). Rate of poor retention in early HIV medical care was relatively higher than reported in clinic-based data. Increasing the rate of retention in early HIV care could substantially improve viro-immunological parameters and survival outcomes.

Associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis, South Carolina 2001-2005.

CONTEXT: Rural areas in the southern United States face many challenges, including limited access to health care services and stigma, which may lead to later HIV diagnosis among rural residents. PURPOSE: To investigate the associations of rural residence with timing of HIV diagnosis and stage of disease at diagnosis. METHODS: Timing of HIV diagnosis was categorized as a diagnosis of acquired immune deficiency syndrome within 1 year of a first positive HIV test or HIV-only. Stage of disease was based on initial CD4+ T-cell count taken within 1 year of diagnosis. County of residence at HIV diagnosis was classified as urban if the population of the largest city was at least 25,000; it was classified as rural otherwise. Logistic regression was used to analyze timing of HIV diagnosis, and analysis of covariance was used to analyze stage of disease. FINDINGS: From 2001 to 2005, 4,137 individuals were diagnosed with HIV infection. Of these, 1,129 (27%) were rural and 3,008 (73%) were urban residents. Among rural residents, 533 (47%) were diagnosed late, compared with 1,258 (42%) urban residents. Rural residents were significantly more likely to be diagnosed late (OR 1.19 [95% CI, 1.02-1.38]). Rural residence was associated with lower initial CD4+ T-cell count in crude analysis (P= .01) but not after adjustment (P > .05). CONCLUSIONS: Rural residence is a risk factor for late HIV diagnosis. This may lead to reduced treatment response to antiretroviral medications, increased morbidity and mortality, and greater HIV transmission risks among rural residents. New testing strategies are needed that address challenges to HIV testing and diagnosis specific to rural areas.

GRACE: public health recovery methods following an environmental disaster.

Different approaches are necessary when community-based participatory research (CBPR) of environmental illness is initiated after an environmental disaster within a community. Often such events are viewed as golden scientific opportunities to do epidemiological studies. However, the authors believe that in such circumstances, community engagement and empowerment needs to be integrated into the public health service efforts in order for both those and any science to be successful, with special care being taken to address the immediate health needs of the community first, rather than the pressing needs to answer important scientific questions. The authors will demonstrate how they have simultaneously provided valuable public health service, embedded generalizable scientific knowledge, and built a successful foundation for supplemental CBPR through their on-going recovery work after the chlorine gas disaster in Graniteville, South Carolina.

Missed opportunities for early HIV diagnosis in correctional facilities.

To quantify the extent that South Carolina HIV/AIDS cases could have been diagnosed during a prior arrest we designed a retrospective population-based cohort study linking case reports from HIV/AIDS Reporting System (HARS) and the South Carolina Law Enforcement Division database. Data from individuals newly diagnosed between January 2001 and December 2005 were linked with statewide arrest records from April 1991 through November 2005. Criminal history data for this report were derived from 28 state prisons and more than 250 law enforcement agencies (jails, lockups, detention centers). Odds ratios and 95% confidence intervals were used to determine how demographic variables and arrest reasons affects receipt of HIV testing. There were 1961/4036 (48.6%) incident cases of HIV diagnosis that had at least one arrest prior to their first positive HIV test. When restricted to 1286/1961 (65.6%) individuals most likely to have been HIV-infected at the time of arrest, 592 (46%) were early testers (no AIDS within 1 year) and 694 (54%) developed AIDS more than 1 year of testing (late testers). After controlling for gender, age, race, behavioral risk and source of HIV report, the odds of being a late tester increased with age (p < 0.001). Overall, 3750 separate arrests were recorded for these 1286 individuals and 491 (13%) arrests were for drug and alcohol or sex crimes. Individuals with 4 or more arrests were more likely to be late testers when compared to those with fewer than 4 arrests (adjusted odds ratio [AOR] 3.30; 95% confidence [CI] 2.28, 4.72). Correctional facilities present considerable opportunities to identify individuals with undiagnosed HIV infection. Providing correctional facilities with the infrastructure for implementation of routine HIV testing would consequently have a significant impact on the health status of the entire community.

Pre-treatment syphilis titers: distribution and evaluation of their use to distinguish early from late latent syphilis and to prioritize contact investigations.

BACKGROUND: Treatment, contact investigation, and reporting decisions for syphilis cases are based on the stage of disease. Because of limitations of current staging protocols, the rapid plasma reagin (RPR) titer has been proposed as an alternative priority marker for contact investigation. METHODS: We describe the RPR titers and stages for 10,021 syphilis cases reported between 1997 and 1999 in Columbia, South Carolina; Houston, Texas; and Jackson, Mississippi. We constructed receiver operating characteristic curves (ROC curves) to compare titer and stage. We calculated the number of infected contacts to evaluate the use of titer to prioritize contact investigation. RESULTS: RPR titers differed by stage, with 67% of primary, 95% of secondary, 78% of early latent, and 41% of late latent and unknown duration having titers >1:8; however, there was considerable overlap in titer distributions. The ROC curve based on titer values demonstrated good agreement between titer and latent stage. Prioritization by titer (> or =1:8) of latent cases would result in a similar number of cases interviewed and contacts located as stage prioritization, although different cases are prioritized. CONCLUSION: Titer distributions meaningfully but imperfectly distinguish populations with different stages. Recent analyses and anecdotal reports indicate the difficulty and inconsistency of staging latent syphilis. Over time, titer could provide a more objective and reliable historical record of syphilis trends. Titer may be a useful alternative or adjunct to stage in prioritizing latent syphilis cases for investigation.