Emergency departments play a critical role in the public health system, particularly in times of pandemic. Infectious patients presenting to emergency departments bring a risk of cross-infection to other patients and staff through close proximity interactions or contacts. To understand factors associated with cross-infection risk, we measured close proximity interactions of emergency department staff and patients by radiofrequency identification in a working emergency department. The number of contacts (degree) is not related to patient demographic characteristics. However, the amount of time in close proximity (weighted degree) of patients with ED personnel did differ, with black patients having approximately 15 min more contact with staff than non-white patients. Patients arriving by EMS had fewer contacts with other patients than patients arriving by other means.
There are differences in the number of contacts based on staff role and arrival mode. When crowding is low, providers have the most contact time with patients, while administrative staff have the least. However, when crowding is high, this differential is reversed. The effect of arrival mode is modified by the extent of crowding. When crowding is low, patients arriving by EMS had longer contact with administrative staff, compared to patients arriving by other means. However, when crowding is high, patients arriving by EMS had less contact with administrative staff compared to patients arriving by other means. Our findings should help designers of emergency care focus on higher risk situations for transmission of dangerous pathogens in an emergency department. For instance, the effects of arrival and crowding should be considered as targets for engineering or architectural interventions that could artificially increase social distances.
by
Tori L. Cowger;
Cara C. Burns;
Salmaan Sharif;
Howard E. Gary;
Jane Iber;
Elizabeth Henderson;
Farzana Malik;
Syed Sohail Zahoor Zaidi;
Shahzad Shaukat;
Lubna Rehman;
Mark A. Pallansch;
Walter Orenstein
Background: More than 99% of poliovirus infections are non-paralytic and therefore, not detected by acute flaccid paralysis (AFP) surveillance. Environmental surveillance (ES) can detect circulating polioviruses from sewage without relying on clinical presentation. With extensive ES and continued circulation of polioviruses, Pakistan presents a unique opportunity to quantify the impact of ES as a supplement to AFP surveillance on overall completeness and timeliness of poliovirus detection. Methods: Genetic, geographic and temporal data were obtained for all wild poliovirus (WPV) isolates detected in Pakistan from January 2011 through December 2013. We used viral genetics to assess gaps in AFP surveillance and ES as measured by detection of ‘orphan viruses’ (1.5% different in VP1 capsid nucleotide sequence). We compared preceding detection of closely related circulating isolates (99% identity) detected by AFP surveillance or ES to determine which surveillance system first detected circulation before the presentation of each polio case. Findings: A total of 1,127 WPV isolates were detected by AFP surveillance and ES in Pakistan from 2011–2013. AFP surveillance and ES combined exhibited fewer gaps (i.e., % orphan viruses) in detection than AFP surveillance alone (3.3% vs. 7.7%, respectively). ES detected circulation before AFP surveillance in nearly 60% of polio cases (200 of 346). For polio cases reported from provinces conducting ES, ES detected circulation nearly four months sooner on average (117.6 days) than did AFP surveillance. Interpretation: Our findings suggest ES in Pakistan is providing earlier, more sensitive detection of wild polioviruses than AFP surveillance alone. Overall, targeted ES through strategic selection of sites has important implications in the eradication endgame strategy.
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Alice Y. Guh;
Susan Hocevar Adkins;
Qunna Li;
Sandra N. Bulens;
Monica Farley;
Zirka Smith;
Stacy M. Holzbauer;
Tory Whitten;
Erin C. Phipps;
Emily B. Hancock;
Ghinwa Dumyati;
Cathleen Concannon;
Marion A. Kainer;
Brenda Rue;
Carol Lyons;
Danyel M. Olson;
Lucy Wilson;
Rebecca Perlmutter;
Lisa G. Winston;
Erin Parker;
Wendy Bamberg;
Zintars G. Beldavs;
Valerie Ocampo;
Maria Karlsson;
Dale N. Gerding;
L. Clifford McDonald
Background: An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. Methods: We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. Results: Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. Conclusions: Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.
SETTING: Tuberculosis (TB) health care facilities throughout Georgia.
OBJECTIVE: To describe smoking behaviors among health care workers (HCWs) at TB facilities and determine HCWs' knowledge and beliefs regarding the impact of tobacco use on anti-tuberculosis treatment.DESIGN: Cross-sectional survey from May to December 2014 in Georgia. Adult HCWs (age 718 years) at TB facilities were eligible. We administered a 60-question anonymous survey about tobacco use and knowledge of the effect of smoking on anti-tuberculosis treatment.
RESULTS: Of the 431 HCWs at TB facilities who participated, 377 (87.5%) were female; the median age was 50 years (range 20-77). Overall, 59 (13.7%) HCWs were current smokers and 35 (8.1%) were past smokers.Prevalence of current smoking was more common among physicians than among nurses (18.6% vs.7.9%, P , 0.0001). Among HCWs, 115 (26.7%) believed smoking does not impact anti-tuberculosis treatment, and only 25.3% of physicians/nurses received formal training in smoking cessation approaches.Physicians who smoked were significantly more likely to believe that smoking does not impact anti-tuberculosis treatment than non-smoking physicians (aOR 5.11, 95%CI 1.46-17.90).
CONCLUSION: Additional education about the effect of smoking on TB treatment outcomes is needed for staff of TB health care facilities in Georgia. Nurses and physicians need more training about smoking cessation approaches for patients with TB.
In 2010, a new entity, characterized by the classical signs and symptoms of Kaposi sarcoma herpesvirus-associated multicentric Castleman's disease (KSHV-MCD) in the absence of pathologic evidence of MCD, was described in individuals living with HIV. This syndrome was named KSHV inflammatory cytokine syndrome (KICS). It carries mortality rates of up to 60%. To date, there are no standard therapies. Treatment regimens studied in clinical trials for MCD disease are used in cases of KICS.
Background The failure to consider travel-related diagnoses, the lack of diagnostic capacity for specialized laboratory testing, and the declining number of autopsies may affect the diagnosis and management of travel-related infections. Pre- and post-mortem pathology can help determine causes of illness and death in international travelers. Methods We conducted a retrospective review of biopsy and autopsy specimens sent to the Infectious Diseases Pathology Branch laboratory (IDPBL) at the Centers for Disease Control and Prevention (CDC) for diagnostic testing from 1995 through 2015. Cases were included if the specimen submitted for diagnosis was from a traveler with prior international travel during the disease incubation period and the cause of illness or death was unknown at the time of specimen submission. Results Twenty-one travelers, six (29%) with biopsy specimens and 15 (71%) with autopsy specimens, met the inclusion criteria. Among the 15 travelers who underwent autopsies, the most common diagnoses were protozoal infections (7 travelers; 47%), including five malaria cases, followed by viral infections (6 travelers; 40%). Conclusions Biopsy or autopsy specimens can assist in diagnosing infectious diseases in travelers, especially from pathogens not endemic in the U.S. CDC's IDPBL provides a useful resource for clinicians considering infectious diseases in returned travelers.
Background: We examined whether waist circumference (WC) and self-reported abdominal size changes can estimate visceral adipose tissue (VAT) changes for those initiating antiretroviral therapy (ART). Methods: Prospectively collected data from ACTG A5257 and its metabolic substudy, A5260s, were used for this analysis. ART-naive HIV-infected participants were randomized to one of three contemporary ART regimens. Changes in abdominal CT-measured VAT and total adipose tissue (TAT) and DXA-measured trunk fat were tested for association with WC changes (by Pearson correlation) and categories of self-reported abdominal size changes (by ANOVA) between entry and week 96. Linear models compared WC and self-reported changes. Results: The study population (n=328) was predominantly male (90%) and White non-Hispanic (44%) with a baseline median age of 36 years and body mass index of 25 kg/m 2 . At week 96, median WC change was +2.8 cm. Of those reporting at week 96, 53% indicated ‘no change/lost’, 39% ‘gained some/somewhat larger’ and 8% ‘gained a lot/much larger’ as their self-reported changes. Trunk fat, VAT and TAT changes differed across self-reported groups (ANOVA P < 0.0001 for all), and the group ordering was as expected. WC changes were strongly correlated with CT and DXA changes (trunk fat: r=0.72, p < 0.0001; VAT: r=0.52, p < 0.0001; TAT: r=0.62, p < 0.0001). While WC changes explained a greater proportion of VAT, TAT and trunk fat variation, self-reported changes remained a significant predictor after controlling for WC (p < 0.05). Conclusions: WC and self-reported abdominal changes each correlated directly with imaging-derived abdominal fat measures, and can be used as reliable, affordable tools for central adiposity assessment.
Introduction: As international travel increases, travellers may be at increased risk of acquiring infectious diseases not endemic in their home countries. Many journal articles and reference books related to travel medicine cite that between 22-64% of international travellers become ill during or after travel; however, this information is minimal, outdated and limited by poor generalizability. We aim to provide a current and more accurate estimate of the proportion of international travellers who acquire a travel-related illness.Methods: We identified studies via PubMed or travel medicine experts, published between January 1, 1976-December 31, 2016 that included the number of international travellers acquiring a travel-related illness. We excluded studies that focused on a single disease or did not determine a rate based on the total number of travellers. We abstracted information on traveller demographics, trip specifics, study enrollment and follow-up and number of ill travellers and their illnesses.Results: Of 743 studies, nine met the inclusion criteria. The data sources were from North America (four studies) and Europe (five studies). Most travellers were tourists, the most frequent destination regions were Asia and Africa, and the median trip duration ranged from 8-21 days. Six studies enrolled participants at the travellers' pre-travel consultation. All studies collected data through either extraction from the medical record, weekly diaries, or pre- and post-travel questionnaires. Data collection timeframes varied by study. Between 6-87% of travellers became ill across all studies. Four studies provided the best estimate: between 43-79% of travellers who frequently visited developing nations (e.g. India, Tanzania, and Kenya) became ill; travellers most frequently reported diarrhoea.Conclusion: This is the most comprehensive assessment available on the proportion of international travellers that develop a travel-related illness. Additional cohort studies would provide needed data to more precisely determine the rates of illness in international travellers.Keywords: International travel, travel, illness.
Background: HIV incidence among US young, black men who have sex with men (YBMSM) is high, and structural barriers (eg lack of health insurance) may limit access to Pre-exposure prophylaxis (PrEP). Research studies conducted with YBMSM must ensure access to the best available HIV prevention methods, including PrEP. Methods: We implemented an optional, nonincentivized PrEP program in addition to the standard HIV prevention services in a prospective, observational cohort of HIV-negative YBMSM in Atlanta, GA. Provider visits and laboratory costs were covered; participant insurance plans and/or the manufacturer assistance program were used to obtain drugs. Factors associated with PrEP initiation were assessed with prevalence ratios and time to PrEP initiation with Kaplan-Meier methods. Results: Of 192 enrolled YBMSM, 4% were taking PrEP at study entry. Of 184 eligible men, 63% indicated interest in initiating PrEP, 10% reported no PrEP interest, and 27% wanted to discuss PrEP again at a future study visit. Of 116 interested men, 46% have not attended a PrEP initiation appointment. Sixty-three men (63/184; 34%) initiated PrEP; 11/63 (17%) subsequently discontinued PrEP. The only factor associated with PrEP initiation was reported sexually transmitted infection in the previous year (prevalence ratio 1.50, 95% confidence interval: 1.002 to 2.25). Among interested men, median time to PrEP initiation was 16 weeks (95% confidence interval: 7 to 36). Conclusions: Despite high levels of interest, PrEP uptake may be suboptimal among YBMSM in our cohort even with amelioration of structural barriers that can limit use. PrEP implementation as the standard of HIV prevention care in observational studies is feasible; however, further research is needed to optimize uptake for YBMSM.
INTRODUCTION: HIV-infected pregnant and breastfeeding adolescents are a particularly vulnerable group that require special attention and enhanced support to achieve optimal maternal and infant outcomes. The objective of this paper is to review published evidence about antenatal care (ANC) service delivery and outcomes for HIV-infected pregnant adolescents in low-income country settings, identify gaps in knowledge and programme services and highlight the way forward to improve clinical outcomes of this vulnerable group. DISCUSSION: Emerging data from programmes in sub-Saharan Africa highlight that HIV-infected pregnant adolescents have poorer prevention of mother-to-child HIV transmission (PMTCT) service outcomes, including lower PMTCT service uptake, compared to HIV-infected pregnant adults. In addition, the limited evidence available suggests that there may be higher rates of mother-to-child HIV transmission among infants of HIV-infected pregnant adolescents. CONCLUSIONS: While the reasons for the inferior outcomes among adolescents in ANC need to be further explored and addressed, there is sufficient evidence that immediate operational changes are needed to address the unique needs of this population. Such changes could include integration of adolescent-friendly services into PMTCT settings or targeting HIV-infected pregnant adolescents with enhanced retention and follow-up activities.