Missed opportunities for TB diagnostic testing among people living with HIV in Zimbabwe: Cross-sectional analysis of the Zimbabwe Population-based HIV Impact Assessment (ZIMPHIA) survey 2015-16.

Background: Using data from the Zimbabwe Population-based HIV Impact Assessment survey 2015-2016, we examined the TB care cascade and factors associated with not receiving TB diagnostic testing among adult PLHIV with TB symptoms. Methods: Statistical Analysis was limited to PLHIV aged 15 years and older in HIV care. Weighted logistic regression with not receiving TB testing as outcome was adjusted for covariates with crude odd ratios (ORs) with p < 0.25. All analyses accounted for multistage survey design. Results: Among 3507 adult PLHIV in HIV care, 2288 (59.7 %, 95 % CI:58.1-61.3) were female and 2425 (63.6 %, 95 % CI:61.1-66.1) lived in rural areas. 1197(48.7 %, 95 % CI:46.5-51.0) reported being screened for TB symptoms at their last HIV care visit. In the previous 12 months, 639 (26.0 %, 95 % CI:23.9-28.1) reported having symptoms and of those, 239 (37.8 %, 95 % CI:33.3-42.2) received TB testing. Of PLHIV tested for TB, 36 (49.5 %, 95 % CI:35.0-63.1) were diagnosed with TB; 32 (90.3 %, 95 % CI:78.9-100) of those diagnosed with TB received treatment. Never having used IPT was associated with not receiving TB testing. Conclusion: The results suggest suboptimal utilization of TB screening and diagnostic testing among PLHIV. New approaches are needed to reach opportunities missed in the HIV/TB integrated services.

Prevalence and incidence of tuberculosis infection among healthcare workers in chest diseases hospitals, Bangladesh: Putting infection control into context.

BACKGROUND: Healthcare workers (HCWs) are at increased risk of tuberculosis infection (TBI). We estimated the prevalence and incidence of TBI and risk factors among HCWs in Bangladeshi hospitals to target TB infection prevention and control (IPC) interventions. METHODS: During 2013-2016, we conducted a longitudinal study among HCWs in four chest disease hospitals. At baseline, we administered a questionnaire on sociodemographic and occupational factors for TB, tuberculin skin tests (TST) in all hospitals, and QuantiFERON ®-TB Gold in-Tube (QFT-GIT) tests in one hospital. We assessed factors associated with baseline TST positivity (induration ≥10mm), TST conversion (induration increase ≥10mm from baseline), baseline QFT-GIT positivity (interferon-gamma ≥0.35 IU/mL), and QFT-GIT conversion (interferon-gamma <0.35 IU/mL to ≥0.35 IU/mL). We included factors with a biologically plausible relationship with TBI identified in prior studies or having an association (p = <0.20) in the bivariate analyses with TST positivity or QFT-GIT positivity in multivariable generalized linear models. The Kaplan-Meier was used to estimate the cumulative TBI incidence rate per 100 person-years. RESULTS: Of the 758 HCWs invited, 732 (97%) consented to participate and 731 completed the one-step TST, 40% had a positive TST result, and 48% had a positive QFT-GIT result. In multivariable models, HCWs years of service 11-20 years had 2.1 (95% CI: 1.5-3.0) times higher odds of being TST-positive and 1.6 (95% CI 1.1-2.5) times higher odds of QFT-GIT-positivity at baseline compared with those working ≤10 years. HCWs working 11-20 years in pulmonary TB ward had 2.0 (95% CI: 1.4-2.9) times higher odds of TST positivity, and those >20 years had 2.5 (95% CI: 1.3-4.9) times higher odds of QFT-GIT-positivity at baseline compared with those working <10 years. TBI incidence was 4.8/100 person-years by TST and 4.2/100 person-years by QFT-GIT. Females had 8.5 (95% CI: 1.5-49.5) times higher odds of TST conversion than males. CONCLUSIONS: Prevalent TST and QFT-GIT positivity was associated with an increased number of years working as a healthcare worker and in pulmonary TB wards. The incidence of TBI among HCWs suggests ongoing TB exposure in these facilities and an urgent need for improved TB IPC in chest disease hospitals in Bangladesh.

Fifty-five years of international epidemic-assistance investigations conducted by CDC's disease detectives.

For more than 60 years, the Centers for Disease Control and Prevention (CDC) has used its scientific expertise to help people throughout the world live healthier, safer, longer lives through science-based health action. In 1951, CDC officially established the Epidemic Intelligence Service to help build public health capacity. During 1950-2005, CDC's Epidemic Intelligence Service officers conducted 462 international epidemiologic field investigations in 131 foreign countries and 7 territories. Investigations have included responding to emerging infectious and noninfectious disease outbreaks, assisting in disaster response, and evaluating core components of public health programs worldwide. Approximately 81% of investigations were responses to infectious disease outbreaks, but the proportion of investigations related to chronic and other noninfectious conditions increased 7-fold (6%-45%). These investigations have contributed to detecting and characterizing new pathogens (e.g., severe acute respiratory syndrome-associated coronavirus) and conditions, provided insights regarding factors that cause or contribute to disease acquisition (e.g., Ebola hemorrhagic fever), led to development of new diagnostics and surveillance technologies, and provided information upon which global health policies and regulations can be based. CDC's disease detectives will undoubtedly continue to play a critical role in global health and in responding to emerging global disease threats.

Rigor and reproducibility in research with transcranial electrical stimulation: An NIMH-sponsored workshop.

BACKGROUND: Neuropsychiatric disorders are a leading source of disability and require novel treatments that target mechanisms of disease. As such disorders are thought to result from aberrant neuronal circuit activity, neuromodulation approaches are of increasing interest given their potential for manipulating circuits directly. Low intensity transcranial electrical stimulation (tES) with direct currents (transcranial direct current stimulation, tDCS) or alternating currents (transcranial alternating current stimulation, tACS) represent novel, safe, well-tolerated, and relatively inexpensive putative treatment modalities. OBJECTIVE: This report seeks to promote the science, technology and effective clinical applications of these modalities, identify research challenges, and suggest approaches for addressing these needs in order to achieve rigorous, reproducible findings that can advance clinical treatment. METHODS: The National Institute of Mental Health (NIMH) convened a workshop in September 2016 that brought together experts in basic and human neuroscience, electrical stimulation biophysics and devices, and clinical trial methods to examine the physiological mechanisms underlying tDCS/tACS, technologies and technical strategies for optimizing stimulation protocols, and the state of the science with respect to therapeutic applications and trial designs. RESULTS: Advances in understanding mechanisms, methodological and technological improvements (e.g., electronics, computational models to facilitate proper dosing), and improved clinical trial designs are poised to advance rigorous, reproducible therapeutic applications of these techniques. A number of challenges were identified and meeting participants made recommendations made to address them. CONCLUSIONS: These recommendations align with requirements in NIMH funding opportunity announcements to, among other needs, define dosimetry, demonstrate dose/response relationships, implement rigorous blinded trial designs, employ computational modeling, and demonstrate target engagement when testing stimulation-based interventions for the treatment of mental disorders.

Sex-dependent metabolic, neuroendocrine, and cognitive responses to dietary energy restriction and excess.

Females and males typically play different roles in survival of the species and would be expected to respond differently to food scarcity or excess. To elucidate the physiological basis of sex differences in responses to energy intake, we maintained groups of male and female rats for 6 months on diets with usual, reduced [20% and 40% caloric restriction (CR), and intermittent fasting (IF)], or elevated (high-fat/high-glucose) energy levels and measured multiple physiological variables related to reproduction, energy metabolism, and behavior. In response to 40% CR, females became emaciated, ceased cycling, underwent endocrine masculinization, exhibited a heightened stress response, increased their spontaneous activity, improved their learning and memory, and maintained elevated levels of circulating brain-derived neurotrophic factor. In contrast, males on 40% CR maintained a higher body weight than the 40% CR females and did not change their activity levels as significantly as the 40% CR females. Additionally, there was no significant change in the cognitive ability of the males on the 40% CR diet. Males and females exhibited similar responses of circulating lipids (cholesterols/triglycerides) and energy-regulating hormones (insulin, leptin, adiponectin, ghrelin) to energy restriction, with the changes being quantitatively greater in males. The high-fat/high-glucose diet had no significant effects on most variables measured but adversely affected the reproductive cycle in females. Heightened cognition and motor activity, combined with reproductive shutdown, in females may maximize the probability of their survival during periods of energy scarcity and may be an evolutionary basis for the vulnerability of women to anorexia nervosa.

Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP).

This report summarizes recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) concerning influenza vaccination of health-care personnel (HCP) in the United States. These recommendations apply to HCP in acute care hospitals, nursing homes, skilled nursing facilities, physician's offices, urgent care centers, and outpatient clinics, and to persons who provide home health care and emergency medical services. The recommendations are targeted at health-care facility administrators, infection-control professionals, and occupational health professionals responsible for influenza vaccination programs and influenza infection-control programs in their institutions. HICPAC and ACIP recommend that all HCP be vaccinated annually against influenza. Facilities that employ HCP are strongly encouraged to provide vaccine to their staff by using evidence-based approaches that maximize vaccination rates.

Nationwide outbreak of red eye syndrome associated with transfusion of leukocyte-reduced red blood cell units.

OBJECTIVE: To characterize red eye reactions occurring within 24 hours after receipt of units of leukocyte-reduced red blood cells, determine their etiology, and investigate their potential link to transfusion. METHODS: We conducted a survey of transfusion facilities nationwide to determine the scope and magnitude of the reactions; performed case-control and cohort studies among transfused patients at the facility where most reactions occurred; and performed animal experiments, using cellulose acetate derivatives extracted from leukocyte-reduction filters and filter precursors, to reproduce reactions. RESULTS: From January 1, 1997, through January 15, 1998, we identified 159 reactions in 117 patients from 17 states. Reactions were characterized by conjunctival erythema or hemorrhage (in 100% of patients), eye pain (in 62%), photophobia (in 46%), and decreased visual acuity (in 32%). Symptom onset occurred 1-24 hours after initiation of transfusion and resolved within a median of 5 days. Reactions were associated with transfusion sessions that included units of red blood cells filtered with a specific brand of filter, the LeukoNet filter (HemaSure) (odds ratio, 100.4; P<.001). There was a dose-response relationship between the number of LeukoNet-filtered units transfused and the attack rate for reactions, ranging from 0.8% among sessions in which 1 unit was transfused to 27.3% among sessions in which 3 or more units were transfused (P<.001). A similar ocular syndrome was elicited in rabbits injected with cellulose acetate derivatives extracted from unused LeukoNet filters or filter precursors. No reactions were reported after LeukoNet filters were withdrawn from the market. CONCLUSIONS: This transfusion-associated red eye syndrome was linked to a specific brand of leukocyte-reduction filter and likely resulted from cellulose acetate derivatives leached from the filter membrane.

Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee.

Since 2002, 4 states have enacted legislation that requires health care organizations to publicly disclose health care-associated infection (HAI) rates. Similar legislative efforts are underway in several other states. Advocates of mandatory public reporting of HAIs believe that making such information publicly available will enable consumers to make more informed choices about their health care and improve overall health care quality by reducing HAIs. Further, they believe that patients have a right to know this information. However, others have expressed concern that the reliability of public reporting systems may be compromised by institutional variability in the definitions used for HAIs, or in the methods and resources used to identify HAIs. Presently, there is insufficient evidence on the merits and limitations of an HAI public reporting system. Therefore, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has not recommended for or against mandatory public reporting of HAI rates. However, HICPAC has developed this guidance document based on established principles for public health and HAI reporting systems. This document is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for HAIs. The document provides a framework for legislators, but does not provide model legislation. HICPAC recommends that persons who design and implement such systems 1) use established public health surveillance methods when designing and implementing mandatory HAI reporting systems; 2) create multidisciplinary advisory panels, including persons with expertise in the prevention and control of HAIs, to monitor the planning and oversight of HAI public reporting systems; 3) choose appropriate process and outcome measures based on facility type and phase in measures to allow time for facilities to adapt and to permit ongoing evaluation of data validity; and 4) provide regular and confidential feedback of performance data to healthcare providers. Specifically, HICPAC recommends that states establishing public reporting systems for HAIs select one or more of the following process or outcome measures as appropriate for hospitals or long-term care facilities in their jurisdictions: 1) central-line insertion practices; 2) surgical antimicrobial prophylaxis; 3) influenza vaccination coverage among patients and healthcare personnel; 4) central line-associated bloodstream infections; and 5) surgical site infections following selected operations. HICPAC will update these recommendations as more research and experience become available.

Monitoring health care workers after smallpox vaccination: findings from the Hospital Smallpox Vaccination-Monitoring System.

BACKGROUND: The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee recommended that hospitals establish on-site, daily assessments of health care workers vaccinated with smallpox vaccine. The Hospital Smallpox Vaccination Monitoring System (HSVMS) was 1 component of the smallpox vaccination plan to monitor adverse events on-site in hospitals. This report presents findings from February to August 2003. METHODS: All US institutions participating in the smallpox vaccination program were eligible to enroll in and use HSVMS through the Internet-based Centers for Disease Control Secure Data Network. RESULTS: Of the 730 enrolled vaccinees, 341 (47%) were nurses; 122 (17%) physicians; 75 (10%) laboratory, patient care, radiology, or other technicians; 39 (5%) administrators; 22 (3%) housekeepers; 21 (3%) physical or respiratory therapists; 20 (3%) infection control professionals; 19 (3%) safety or security staff; and 17 (2%) epidemiologists; and 54 (7%) were workers in other job categories. Most (86%) vaccinees had been previously vaccinated. Postvaccination signs and symptoms were frequent: itching (75.2%), pain at the vaccination site (31.6%), swollen or tender lymph nodes (26.4%), fatigue (26.2%), and headache (20.8%). Symptoms were highest during the first week after vaccination; symptoms were more frequently reported among vaccinees without previous vaccination. Adherence to recommended vaccination site care was reported in 2732 of 3091 (88.4%) follow-up visits among workers with patient contact. Of the 4379 days workers planned to work, during 31 (0.7 per 100) days, workers performed restricted activities, and, in 60 (1.4 per 100) days, workers were absent. CONCLUSIONS: Findings from HSVMS indicate that adherence to post-smallpox vaccination site care was high and that the number of days of work affected was low.

Low frequency of fires from alcohol-based hand rub dispensers in healthcare facilities.

We administered a web-based questionnaire to SHEA, APIC, and EIN members to assess the frequency of fires associated with alcohol-based hand rub (ABHR) dispensers in healthcare settings. None of the 798 responding facilities using ABHRs reported a dispenser-related fire; 766 facilities had accrued an estimated 1,430 hospital-years of ABHR use.

Improving water quality can reduce pyrogenic reactions associated with reuse of cardiac catheters.

OBJECTIVE: To report the results of our preintervention investigation and subsequent 19-month three-phase intervention study designed to reduce pyrogenic reactions among patients undergoing cardiac catheterization using reprocessed catheters. DESIGN: A case-control study for the preintervention period and a prospective cohort study for the intervention period. SETTING: A 400-bed hospital in Belo Horizonte, Brazil. PARTICIPANTS: Any patient undergoing cardiac catheterization in the hospital. INTERVENTIONS: Three intervention phases were implemented to improve the quality of the water supplied to the cardiac catheter reprocessing laboratory. Standard operating procedures for reprocessing cardiac catheters were established and reprocessing staff were trained and educated. RESULTS: The rate of pyrogenic reactions decreased significantly during the intervention phases, from 12.8% (159 of 1,239) in phase 1 to 5.3% (38 of 712) in phase 2 to 0.5% (4 of 769) in phase 3 (chi-square test for linear trend, 97.5; P < .001). CONCLUSION: Improving water quality and using standard operating procedures for reprocessing catheters can prevent pyrogenic reactions in hospitalized patients.

Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis center.

OBJECTIVE: To determine the cause of acute illness on August 30, 2000, among patients at an outpatient dialysis center (center A). DESIGN: We performed a cohort study of all patients receiving dialysis on August 30, 2000; reviewed dialysis procedures; and analyzed dialysis water samples using microbiologic and chemical assays. SETTING: Dialysis center (center A). PATIENTS: A case-patient was defined as a patient who developed chills within 5 hours after starting hemodialysis at center A on August 30, 2000. RESULTS: Sixteen (36%) of 44 patients at center A met the case definition. All case-patients were hospitalized; 2 died. Besides chills, 15 (94%) of the case-patients experienced nausea; 12 (75%), vomiting; and 4 (25%), fever. Illness was more frequent on the second than the first dialysis shift (16 of 20 vs 0 of 24, P < .001); no other risk factors were identified. The center's water treatment system had received inadequate maintenance and disinfection and a sulfurous odor was noted during sampling of the water from the reverse osmosis (RO) unit. The water had elevated bacterial counts. Volatile sulfur-containing compounds (ie, methanethiol, carbon disulfide, dimethyldisulfide, and sulfur dioxide) were detected by gas chromatography and mass spectrometry in 8 of 12 water samples from the RO unit and in 0 of 28 samples from other areas (P < .001). Results of tests for heavy metals and chloramines were within normal limits. CONCLUSIONS: Parenteral exposure to volatile sulfur-containing compounds, produced under anaerobic conditions in the RO unit, could have caused the outbreak. This investigation demonstrates the importance of appropriate disinfection and maintenance of water treatment systems in hemodialysis centers.

Guidelines for the prevention of intravascular catheter-related infections.

BACKGROUND: Although many catheter-related bloodstream infections (CRBSIs) are preventable, measures to reduce these infections are not uniformly implemented. OBJECTIVE: To update an existing evidenced-based guideline that promotes strategies to prevent CRBSIs. DATA SOURCES: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. STUDIES INCLUDED: Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations. OUTCOME MEASURES: Reduction in CRBSI, catheter colonization, or catheter-related infection. SYNTHESIS: The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). CONCLUSION: Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Anthrax and the mail: the making of an educational video for mail workers.

The anthrax bioterrorist attacks in 2001 affected millions of people who process, sort, and deliver mail. To more effectively communicate information intended to protect the health of these workers, the Centers for Disease Control and Prevention produced a short-format educational video in December 2001 that targets this diverse group. This report illustrates how an educational video can be rapidly produced to translate and disseminate public health recommendations as part of a public health emergency response.

Guidelines for the prevention of intravascular catheter-related infections.

BACKGROUND: Although many catheter-related bloodstream infections (CR-BSIs) are preventable, measures to reduce these infections are not uniformly implemented. OBJECTIVE: To update an existing evidenced-based guideline that promotes strategies to prevent CR-BSIs. DATA SOURCES: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles.Studies Included: Laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiological investigations. OUTCOME MEASURES: Reduction in CR-BSI, catheter colonization, or catheter-related infection. SYNTHESIS: The recommended preventive strategies with the strongest supportive evidence are education and training of healthcare providers who insert and maintain catheters; maximal sterile barrier precautions during central venous catheter insertion; use of a 2% chlorhexidine preparation for skin antisepsis; no routine replacement of central venous catheters for prevention of infection; and use of antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e. education and training, maximal sterile barrier precautions and 2% chlorhexidine for skin antisepsis). CONCLUSION: Successful implementation of these evidence-based interventions can reduce the risk for serious catheter-related infection.

Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy.

BACKGROUND: Morgellons is a poorly characterized constellation of symptoms, with the primary manifestations involving the skin. We conducted an investigation of this unexplained dermopathy to characterize the clinical and epidemiologic features and explore potential etiologies. METHODS: A descriptive study was conducted among persons at least 13 years of age and enrolled in Kaiser Permanente Northern California (KPNC) during 2006-2008. A case was defined as the self-reported emergence of fibers or materials from the skin accompanied by skin lesions and/or disturbing skin sensations. We collected detailed epidemiologic data, performed clinical evaluations and geospatial analyses and analyzed materials collected from participants' skin. RESULTS: We identified 115 case-patients. The prevalence was 3.65 (95% CI = 2.98, 4.40) cases per 100,000 enrollees. There was no clustering of cases within the 13-county KPNC catchment area (p = .113). Case-patients had a median age of 52 years (range: 17-93) and were primarily female (77%) and Caucasian (77%). Multi-system complaints were common; 70% reported chronic fatigue and 54% rated their overall health as fair or poor with mean Physical Component Scores and Mental Component Scores of 36.63 (SD = 12.9) and 35.45 (SD = 12.89), respectively. Cognitive deficits were detected in 59% of case-patients and 63% had evidence of clinically significant somatic complaints; 50% had drugs detected in hair samples and 78% reported exposure to solvents. Solar elastosis was the most common histopathologic abnormality (51% of biopsies); skin lesions were most consistent with arthropod bites or chronic excoriations. No parasites or mycobacteria were detected. Most materials collected from participants' skin were composed of cellulose, likely of cotton origin. CONCLUSIONS: This unexplained dermopathy was rare among this population of Northern California residents, but associated with significantly reduced health-related quality of life. No common underlying medical condition or infectious source was identified, similar to more commonly recognized conditions such as delusional infestation.