Electronic matching of HIV/AIDS and hepatitis C surveillance registries in three states.

OBJECTIVES: Both HIV and hepatitis C virus (HCV) can be transmitted through percutaneous exposure to blood in similar high-risk populations. HCV and HIV/AIDS surveillance databases were matched in Colorado, Connecticut, and Oregon to measure the frequency of co-infection and to characterize coinfected people. METHODS: We defined a case of HCV infection as a person with a reactive antibody for hepatitis C, medical diagnosis, positive viral-load test result, or positive genotype reported to any of three state health departments from the start of each state's hepatitis C registry through June 30, 2008. We defined a case of HIV/AIDS as a person diagnosed and living with HIV/AIDS at the start of each state's respective hepatitis C registry through June 30, 2008. HIV/AIDS and hepatitis C datasets were matched using Link King, public domain record linkage and consolidation software, and all potential matches were manually reviewed before acceptance as a match. RESULTS: The proportion of reported hepatitis C cases co-infected with HIV/ AIDS was 1.8% in Oregon, 1.9% in Colorado, and 4.9% in Connecticut. Conversely, the proportion of HIV/AIDS cases co-infected with hepatitis C was consistently higher in the three states: 4.4% in Oregon, 9.7% in Colorado, and 23.6% in Connecticut. CONCLUSIONS: Electronic matching of registries is a potentially useful and efficient way to transfer information from one registry to another. In addition, it can provide a measure of the public health burden of HIV/AIDS and hepatitis C co-infection and provide insight into prevention and medical care needs for respective states.

Diagnosis of acute HIV infection in Connecticut.

Acute HIV infection (AHI) is the earliest stage of HIV disease, when plasma HIV viremia, but not HIV antibodies, can be detected. Acute HIV infection often presents as a nonspecific viral syndrome. However, its diagnosis, which enables linkage to early medical care and limits further HIV transmission, is seldom made. We describe the experience of Yale's Center for Interdisciplinary Research on AIDS with AHI diagnosis in Connecticut, as a participating center in the National Institute of Mental Health Multisite AHI Study. We sought to identify AHI cases by clinical referrals and by screening for AHI at two substance abuse care facilities and an STD clinic. We identified one case by referral and one through screening of 590 persons. Screening for AHI is feasible and probably cost effective. Primary care providers should include AHI in the differential diagnosis when patients present with a nonspecific viral syndrome.

Surveillance programs for chronic viral hepatitis in three health departments.

Although chronic hepatitis B and chronic hepatitis C are diseases of public health importance, only a few health departments nationally have chronic viral hepatitis under surveillance; these programs rely primarily on direct reporting by medical laboratories. We conducted an evaluation to determine if lessons from these programs can guide other health departments. Between December 2002 and February 2003, we visited the Connecticut Department of Public Health, the Multnomah County Health Department in Portland, Oregon, and the Minnesota Department of Health to determine the capacity of their chronic hepatitis registries to monitor trends and provide case management. We found that the registries facilitated investigations of potentially acute cases by identifying previously known infections, and aided prevention planning by pinpointing areas where viral hepatitis was being diagnosed. For chronic cases, case management (defined as the process of ensuring that infected individuals and their partners receive medical evaluation, counseling, vaccination, and referral to specialists for treatment when indicated) was provided for hepatitis B in Multnomah County, but was limited in other programs; barriers included resource constraints, difficulties confirming chronic infection, and privacy concerns. Finding innovative ways to overcome these barriers and improve case management is important if chronic hepatitis surveillance is to realize its full potential.

Blood exposures and hepatitis C virus infections among emergency responders.

BACKGROUND: Blood exposures in the workplace may put first responders, a group which includes firefighters, emergency medical technicians, and paramedics, at increased risk for hepatitis C virus (HCV) infection. To determine the prevalence of antibody to HCV (anti-HCV) and risk factors for infection among first responders, we analyzed data from prevalence surveys conducted among first responders in Atlanta, Ga, in 1991; Connecticut in 1992; and Philadelphia, Pa, in 1999. METHODS: Serum or blood samples from participants of the 3 surveys were tested for anti-HCV. Prevalence of anti-HCV was compared with that in the general US population and among participants by occupational (Atlanta) and nonoccupational (Atlanta and Philadelphia) risk factors for infection. RESULTS: Prevalence of anti-HCV among the 2946 participants of the 3 surveys ranged from 1.3% to 3.6% and was no different than among appropriate referent groups in the general US population. First responders in Atlanta reported high rates of skin exposures to blood (174 per 100 person-years) but few mucosal or needle-stick exposures (1 and 0 per 100 person-years, respectively) during the 6 months prior to the survey. Hepatitis C virus infection was not associated with a history of skin exposures to blood (prevalence ratio [PR], 1.1; 95% confidence interval [CI], 0.3-4.2), and HCV prevalence did not increase with longer duration (>10 years) of employment (PR, 1.1; 95% CI, 0.3-4.3). Nonoccupational risk factors associated with HCV infection included history of a sexually transmitted disease (PR, 7.4; 95% CI, 1.6-35.3) among Atlanta participants and histories of illegal drug use (PR, 4.4; 95% CI, 2.6-7.2) and blood transfusion before 1992 (PR, 1.9; 95% CI, 1.1-3.3) among Philadelphia participants. CONCLUSIONS: First responders are exposed to blood in the workplace, and standard precautions should be rigorously implemented. Although risk for HCV infection related to percutaneous or mucosal exposures could not be accurately assessed, the low prevalence of HCV infection indicates that routine HCV testing of first responders as an occupational group is not warranted. Testing should routinely be offered to those requiring postexposure management and those with a history of nonoccupational risk factors indicating an increased risk for infection.

Impact of intrapartum antibiotics on the care and evaluation of the neonate.

BACKGROUND: Management of infants whose mothers receive intrapartum antibiotic prophylaxis (IAP) is controversial. In 1996 consensus guidelines for prevention of neonatal Group B streptococcal disease included an algorithm for management of infants whose mothers received IAP. To assess practices for testing and treatment of infants, we evaluated a population-based sample of deliveries to see whether excessive evaluation and treatment occurs after IAP. METHODS: Medical records for 869 deliveries in Connecticut during 1996 were sampled. IAP was administered in 96 full term deliveries. We excluded infants <37 weeks and those with intrapartum fever. We reviewed hospital records for infants born after IAP (n = 81) and a random sample of those not exposed (n = 180). Analyses were conducted with sample weights to account for unequal probability of selection. RESULTS: Infants whose mothers received IAP were more likely to have complete blood counts, (26% vs. 9% P = 0.05) but were no more likely to receive antibiotics in the first week of life (P = 0.48), have an intravenous catheter placed (P = 0.83), or to have other invasive procedures. Mean length of hospital stay was 6 h longer for infants born by vaginal delivery to mothers who had IAP (47.0 h) than for those without IAP (41.3 h) (P = 0.06). CONCLUSION: Despite concerns that IAP guidelines would result in excessive neonatal evaluations, infants sampled whose mothers received IAP were not more likely to undergo invasive procedures or to receive antibiotics. Consistent with the guidelines, collection of complete blood counts was more common among such infants.

A population-based comparison of strategies to prevent early-onset group B streptococcal disease in neonates.

BACKGROUND: Guidelines issued in 1996 in the United States recommend either screening of pregnant women for group B streptococcal colonization by means of cultures (screening approach) or assessing clinical risk factors (risk-based approach) to identify candidates for intrapartum antibiotic prophylaxis. METHODS: In a multistate retrospective cohort study, we compared the effectiveness of the screening and risk-based approaches in preventing early-onset group B streptococcal disease (in infants less than seven days old). We studied a stratified random sample of the 629,912 live births in 1998 and 1999 in eight geographical areas where there was active surveillance for group B streptococcal infection, including all births in which the neonate had early-onset disease. Women with no documented culture for group B streptococcus were considered to have been cared for according to the risk-based approach. RESULTS: We studied 5144 births, including 312 in which the newborn had early-onset group B streptococcal disease. Antenatal screening was documented for 52 percent of the mothers. The risk of early-onset disease was significantly lower among the infants of screened women than among those in the risk-based group (adjusted relative risk, 0.46; 95 percent confidence interval, 0.36 to 0.60). Because women whose providers had no strategy for prophylaxis may have been misclassified in the risk-based group, we excluded all women with risk factors and adequate time for prophylaxis who did not receive antibiotics. The adjusted relative risk of early-onset disease associated with the screening approach in this secondary analysis was similar--0.48 (95 percent confidence interval, 0.37 to 0.63). CONCLUSIONS: Routine screening for group B streptococcus during pregnancy prevents more cases of early-onset disease than the risk-based approach. Recommendations that endorse both strategies as equivalent warrant reconsideration.

Integrated monitoring of a new group B streptococcal disease prevention program and other perinatal infections.

OBJECTIVE: To determine levels of prenatal screening for several infections, intrapartum recognition of risk factors, and prophylaxis against mother-to-child transmission of group B streptococcus. METHODS: Review of stratified random sample of hospital records for deliveries in Connecticut during 1996. SUDAAN analysis was used to adjust for the complex survey design, and weighting adjusted for the probability of being sampled and nonresponse. RESULTS: Of 992 records requested, 868 (88%) were abstracted and analyzed. Thirty-six percent of women had prenatal screening for group B streptococcus and 26% had been tested for human immunodeficiency virus (HIV), while 97-99% of women had been screened prenatally for hepatitis B surface antigen, rubella, and syphilis. Of those women tested, 17% were detected as group B streptococcus carriers, and 78% of these received intrapartum antibiotic prophylaxis. Among women who were not screened for group B streptococcus prenatally, 22% met risk-based criteria for prophylaxis, but only 45% of these received intrapartum prophylaxis. Among unscreened women with a risk factor, those with shorter hospital stays prior to delivery, admitted on evening or night shifts, or who delivered on the weekend were significantly less likely to receive intrapartum prophylaxis. CONCLUSION: In 1996, the majority of women who delivered in Connecticut were not tested prenatally for group B streptococcus and the majority of those not tested in whom there was an indication for prophylaxis were not treated. Compliance with group B streptococcus prevention recommendations can be improved through increased prenatal testing and/or better recognition of risk-based criteria for intrapartum prophylaxis.