Attitudes toward newborn screening for cytomegalovirus infection

OBJECTIVE

Newborns are not routinely screened for cytomegalovirus (CMV), the leading infectious cause of developmental disability. Congenital CMV satisfies a number of criteria for inclusion in newborn screening, and screening potentially offers benefits. Screening could also introduce harms such as anxiety and unnecessary costs for the families of the substantial proportion of CMV-infected children who never develop CMV-related disabilities. Our objective was to assess attitudes toward newborn screening for CMV.

METHODS

We analyzed responses to 5 statements about CMV and newborn screening from 3922 participants in the 2009 HealthStyles survey, a national mail survey designed to include a group similar to the US population with respect to gender, age, race/ethnicity, income, and household size. Two-step cluster analysis was performed to identify clusters of parental attitudes.

RESULTS

The majority of respondents strongly or somewhat agreed that they would want to have their newborn tested for CMV even if it was not performed routinely (84%), they had to pay $20 (87%), or CMV-related problems never developed (84%). Nearly half (47%) of them "would worry that the CMV test would lead to unneeded doctor visits and expenses," and 32% "think CMV problems are too rare to worry about." Three clusters of parent respondents were identified on the basis of their attitudes toward CMV screening: "strongly in favor" (31%), "moderately in favor" (49%), and "weakly opposed" (20%).

CONCLUSIONS

Among most parents, costs, worry, and anxiety associated with newborn screening for CMV would be acceptable. Although attitudes were generally favorable, a minority of the parents were weakly opposed to newborn screening for CMV.

Herpes zoster and postherpetic neuralgia surveillance using structured electronic data

OBJECTIVE

To develop electronic algorithms for rapid, automated surveillance for herpes zoster and postherpetic neuralgia (PHN) using codified electronic health data.

PATIENTS AND METHODS

We attempted to identify every case of herpes zoster and PHN arising between January 1 and December 31, 2008, within the electronic medical record of a 560,000-patient ambulatory practice using an array of diagnosis codes; intervals between herpes zoster encounters; and prescriptions for analgesics, anticonvulsants, and antidepressants. We assessed the sensitivity and positive predictive value (PPV) of each screening criterion by medical record review and then integrated multiple criteria into combination algorithms to optimize sensitivity and PPV. We applied the optimized algorithms to the practice's historical data spanning January 1, 1996, to December 31, 2008, to assess for changes in the annual incidence of PHN.

RESULTS

The International Classification of Diseases, Ninth Revision, code 053 detected herpes zoster with 98% sensitivity and 93% PPV. A combination algorithm including diagnosis codes, visit intervals, and prescriptions detected PHN with 86% sensitivity and 78% PPV. Between 1996 and 2008, the age- and sex-adjusted annual incidence of PHN rose from 0.18 to 0.47 cases per 1000 patients, and the proportion of herpes zoster patients progressing to PHN rose from 5.4% to 17.6%.

CONCLUSION

Novel algorithms incorporating multiple streams of electronic health data can reasonably detect herpes zoster and PHN. These algorithms could facilitate meaningful public health surveillance using electronic health data. The incidence of PHN may be increasing.

Cytomegalovirus survival on common environmental surfaces: opportunities for viral transmission

Congenital cytomegalovirus (CMV) affects ~1 of 150 births and is a leading cause of hearing loss and intellectual disability. It has been suggested that transmission may occur via contaminated surfaces. CMV AD169 in filtered human saliva, applied to environmental surfaces, was recovered at various time points. Samples were evaluated by culture and real-time polymerase chain reaction. CMV was found viable on metal and wood to 1 hour, glass and plastic to 3 hours, and rubber, cloth, and cracker to 6 hours. CMV was cultured from 83 of 90 wet and 5 of 40 dry surfaces. CMV was more likely to be isolated from wet, highly absorbent surfaces at earlier time points.

Seroprevalence and correlates of hepatitis a among HIV-negative American men who have sex with men

BACKGROUND

Hepatitis A outbreaks are well documented among men who have sex with men (MSM). This analysis examines characteristics associated with hepatitis A virus (HAV) infection among a large group of young adult MSM from five USA cities.

METHODS

The Young Men's Survey was a cross-sectional prevalence study of HIV infection and related behavioural risk factors among MSM aged 15-29 years during 1994-2000. Serum specimens from HIV-negative participants were retrospectively tested for antibodies to HAV (anti-HAV). Data were stratified by ethnicity and analysed with logistic regression.

RESULTS

Overall anti-HAV prevalence was 18.4% among the 2708 participants, and varied by ethnicity from 6.9 to 45.3% and was highest among Hispanic and Asian men (P < 0.001). Prevalence increased with age across all racial/ethnic groups. Among white men, anti-HAV positivity was associated with having 20 or more lifetime male sex partners for those aged 15-22 years (adjusted odds ratio (AOR)=2.1, 95% confidence interval (CI)=1.0-4.1) and ever having had unprotected anal sex for those aged 23-29 years (AOR=2.4, 95% CI=1.2-4.5).

CONCLUSIONS

Factors associated with a history of HAV infection among MSM in non-outbreak settings are probably similar to those among non-MSM. MSM are still at risk for HAV infection as a result of outbreaks occurring in MSM communities. Additional studies of hepatitis A vaccination coverage are needed to determine if strategies to vaccinate MSM are adequate.

Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease

CONTEXT

Approximately 1 million episodes of herpes zoster occur annually in the United States. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions.

OBJECTIVE

To evaluate risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study from January 1, 2007, through December 31, 2009, of individuals enrolled in the Kaiser Permanente Southern California health plan. Participants were immunocompetent community-dwelling adults aged 60 years or older. The 75,761 members in the vaccinated cohort were age matched (1:3) to 227,283 unvaccinated members.

MAIN OUTCOME MEASURE

Incidence of herpes zoster.

RESULTS

Herpes zoster vaccine recipients were more likely to be white, women, with more outpatient visits, and fewer chronic diseases. The number of herpes zoster cases among vaccinated individuals was 828 in 130,415 person-years (6.4 per 1000 person-years; 95% confidence interval [CI], 5.9-6.8), and for unvaccinated individuals it was 4606 in 355,659 person-years (13.0 per 1000 person-years; 95% CI, 12.6-13.3). In adjusted analysis, vaccination was associated with a reduced risk of herpes zoster (hazard ratio [HR], 0.45; 95% CI, 0.42-0.48); this reduction occurred in all age strata and among individuals with chronic diseases. Risk of herpes zoster differed by vaccination status to a greater magnitude than the risk of unrelated acute medical conditions, suggesting results for herpes zoster were not due to bias. Ophthalmic herpes zoster (HR, 0.37; 95% CI, 0.23-0.61) and hospitalizations coded as herpes zoster (HR, 0.35; 95% CI, 0.24-0.51) were less likely among vaccine recipients.

CONCLUSIONS

Among immunocompetent community-dwelling adults aged 60 years or older, receipt of the herpes zoster vaccine was associated with a lower incidence of herpes zoster. The risk was reduced among all age strata and among individuals with chronic diseases.

The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance

OBJECTIVES

Chronic liver disease (CLD) is an important cause of morbidity and mortality, but the epidemiology is not well described. We conducted prospective population-based surveillance to estimate newly diagnosed CLD incidence, characterize etiology distribution, and determine disease stage.

METHODS

We identified cases of CLD newly diagnosed during 1999-2001 among adult county residents seen in any gastroenterology practice in New Haven County, Connecticut; Multnomah County, Oregon; and Northern California Kaiser Permanente Medical Care Program (KPMCP, Oakland, California [total population 1.48 million]). We defined CLD as abnormal liver tests of at least 6 months' duration or pathologic, clinical, or radiologic evidence of CLD. Consenting patients were interviewed, a blood specimen obtained, and the medical record reviewed.

RESULTS

We identified 2,353 patients with newly diagnosed CLD (63.9 cases/100,000 population), including 1,225 hepatitis C patients (33.2 cases/100,000). Men aged 45-54 yr had the highest hepatitis C incidence rate (111.3/100,000). Among 1,040 enrolled patients, the median age was 48 yr (range 19-86 yr). Hepatitis C, either alone (442 [42%]) or in combination with alcohol-related liver disease (ALD) (228 [22%]), accounted for two-thirds of the cases. Other etiologies included nonalcoholic fatty liver disease (NAFLD, 95 [9%]), ALD (82 [8%]), and hepatitis B (36 [3%]). Other identified etiologies each accounted for <3% of the cases. A total of 184 patients (18%) presented with cirrhosis, including 44% of patients with ALD.

CONCLUSIONS

Extrapolating from this population-based surveillance network to the adult U.S. population, approximately 150,000 patients with CLD were diagnosed in gastroenterology practices each year during 1999-2001. Most patients had hepatitis C; heavy alcohol consumption among these patients was common. Almost 20% of patients, an estimated 30,000 per year, had cirrhosis at presentation. These results provide population-level baseline data to evaluate trends in identification of patients with CLD in gastroenterology practices.

Use of Molecular Epidemiology to Confirm a Multistate Outbreak of Hepatitis a Caused by Consumption of Oysters

The 39 oyster consumption-related cases of hepatitis A reported in 2005 represent the first large outbreak of hepatitis A associated with shellfish consumption in the United States in >15 years. This is the first outbreak investigation in which an identical hepatitis A virus sequence was obtained from both the implicated food product and case patients.

Molecular confirmation of oysters as the vector for hepatitis A in a 2005 multistate outbreak

Numerous hepatitis A outbreaks were linked to the consumption of raw molluscan shellfish in the United States between 1960 and 1989. However, there had been no major molluscan shellfish-associated hepatitis A outbreaks reported in the United States for more than a decade (1989 to 2004). Beginning in late August 2005, at least 10 clusters of hepatitis A illnesses, totaling 39 persons, occurred in four states among restaurant patrons who ate oysters. Epidemiologic data indicated that oysters were the source of the outbreak. Traceback information showed that the implicated oysters were harvested from specific Gulf Coast areas. A voluntary recall of oysters was initiated in September. Hepatitis A virus (HAV) was detected in multiple 25-g portions in one of two recalled samples, indicating that as many as 1 of every 15 oysters from this source was contaminated. Comparing 315 nucleotides within the HAV VPl-2B region, 100% homology was found among four amplicons recovered from a total of six independent experiments of the implicated oysters, and an identical HAV sequence was detected in sera from all 28 patient serum specimens tested. Ten percent heterogeneity over 315 nucleotides (31 variants) was observed between the outbreak strain (subgenotype 1A) and an HM-175 strain (subgenotype 1B) used in the laboratory where the oysters were processed. To our knowledge, this investigation is the first in the United States to identify an HAV-identical strain in persons with hepatitis A as well as in the food that was implicated as the source of their infections.

The changing epidemiology and natural history of hepatitis C virus infection

Injection drug use remains the predominant mode of transmission of hepatitis C virus (HCV) infection. Growing numbers of persons who have been chronically infected with HCV for 20 or more years are coming to medical attention and are at risk for serious complications of chronic infection, including cirrhosis and hepatocellular carcinoma. Factors linked with the development of advanced fibrosis and cirrhosis include age at infection, duration of infection, heavy alcohol use, coinfections with HIV or hepatitis B virus, and male sex. Emerging risk factors for disease progression include steatosis, insulin resistance (and factors associated with the metabolic syndrome), and host genetics.

An outbreak of hepatitis B virus infection among methamphetamine injectors: the role of sharing injection drug equipment

AIM

To identify risk factors for acute hepatitis B virus (HBV) infection among Wyoming methamphetamine injectors.

DESIGN

A case-control study conducted in the setting of an outbreak.

SETTING

A county in central Wyoming, United States.

PARTICIPANTS

Cases were identified through surveillance and contact tracing and were defined as Natrona County, Wyoming, residents who were either symptomatic or confirmed serologically to be acutely infected with HBV during January-August, 2003. Controls were susceptible to HBV infection. All participants identified themselves as methamphetamine injectors.

MEASUREMENTS

Participants were administered a survey that inquired about risk factors for HBV infection, including drug use practices and sexual behaviors. Controls were also tested serologically for acute HBV infection.

FINDINGS

Among the 18 case-patients and 49 controls who participated in the study, sharing water used to prepare injections and/or rinse syringes was associated with HBV infection (94% of case-participants versus 44% of controls; OR = 21.9, 95% CI: 2.7, 177.8), as was sharing cotton filters (89% of case-participants versus 52% of controls; OR = 7.4, 95% CI: 1.5, 35.6); sharing syringes was not statistically associated. In logistic regression models adjusted for age, sex, and interview site, sharing rinse water and sharing cotton remained statistically associated.

CONCLUSIONS

Methamphetamine use has become increasingly prevalent in the United States. Our findings highlight the need for awareness of risks associated with injection drug use and sharing behaviors. Enhanced hepatitis B vaccination programs and educational campaigns that target methamphetamine injectors specifically, including those living in rural areas, should be developed and implemented.

Risk factors for hepatitis B in an outbreak of hepatitis B and D among injection drug users

During January-April, 2000, 12 cases of acute hepatitis B were reported in Pierce County, Washington, compared with seven in all of 1999. Seven (58.3%) case patients were injection drug users (IDUs), three of whom were coinfected with hepatitis D virus (HDV) and died of fulminant hepatitis. Vaccination clinics were implemented at the local health department and needle exchange program to control the outbreak. We investigated this outbreak to determine risk factors for hepatitis B virus (HBV) transmission among IDUs. Hepatitis B cases were ascertained through routine surveillance and prevaccination testing at vaccination clinics. We conducted a case-control study comparing IDU case patients with HBV-susceptible IDUs identified at the vaccination clinics. Fifty-eight case patients were identified during January-December, 2000, 20 (34.5%) of whom were coinfected with HDV. Thirty-eight case patients (65.5%) reported current IDU. In the case-control study, the 17 case patients were more likely than the 141 controls to report having more than one sex partner [odds ratio (OR) =4.8, 95% confidence interval (CI) =1.5-15.0], injecting more than four times a day (OR = 4.5, 95% CI =1.2-15.6) and sharing drug cookers with more than two people (58.8% vs. 14.0%, OR =14.0, 95% CI =2.4-81.5). Results were similar after controlling for syringe sharing in multivariable analysis. IDUs should be vaccinated against hepatitis B and should be advised against sharing drug injection equipment.

Hepatitis A incidence and hepatitis a vaccination among American Indians and Alaska Natives, 1990-2001

OBJECTIVES

We assessed the effect on trends in hepatitis A incidence of the 1996 recommendation for routine hepatitis A vaccination of American Indian/Alaska Native (AIAN) children.

METHODS

We examined trends in hepatitis A incidence among AIAN peoples during 1990-2001 and vaccination coverage levels among children on the largest American Indian reservation.

RESULTS

Hepatitis A rates among AIANs declined 20-fold during 1997-2001. Declines in hepatitis A incidence occurred among AIANs in reservation and metropolitan areas. Among 1956 children living on the Navajo Nation whose medical records were reviewed, 1508 (77.1%) had received at least one dose of hepatitis A vaccine, and 1020 (52.1%) had completed the vaccine series.

CONCLUSIONS

Hepatitis A rates among AIAN peoples have declined dramatically coincident with implementation of routine hepatitis A vaccination of AIAN children.