Clinical performance validation of the STANDARD G6PD test: A multi-country pooled analysis

INTRODUCTION

Screening for G6PD deficiency can inform disease management including malaria. Treatment with the antimalarial drugs primaquine and tafenoquine can be guided by point-of-care testing for G6PD deficiency.

METHODS AND FINDINGS

Data from similar clinical studies evaluating the performance of the STANDARD G6PD Test (SD Biosensor, South Korea) conducted in Bangladesh, Brazil, Ethiopia, India, Thailand, the United Kingdom, and the United States were pooled. Test performance was assessed in a retrospective analysis on capillary and venous specimens. All study sites used spectrophotometry for reference G6PD testing, and either the HemoCue or complete blood count for reference hemoglobin measurement. The sensitivity of the STANDARD G6PD Test using the manufacturer thresholds for G6PD deficient and intermediate cases in capillary specimens from 4212 study participants was 100% (95% Confidence Interval (CI): 97.5%-100%) for G6PD deficient cases with <30% activity and 77% (95% CI 66.8%-85.4%) for females with intermediate activity between 30%-70%. Specificity was 98.1% (95% CI 97.6%-98.5%) and 92.8% (95% CI 91.6%-93.9%) for G6PD deficient individuals and intermediate females, respectively. Out of 20 G6PD intermediate females with false normal results, 12 had activity levels >60% on the reference assay. The negative predictive value for females with G6PD activity >60% was 99.6% (95% CI 99.1%-99.8%) on capillary specimens. Sensitivity among 396 P. vivax malaria cases was 100% (69.2%-100.0%) for both deficient and intermediate cases. Across the full dataset, 37% of those classified as G6PD deficient or intermediate resulted from true normal cases. Despite this, over 95% of cases would receive correct treatment with primaquine, over 87% of cases would receive correct treatment with tafenoquine, and no true G6PD deficient cases would be treated inappropriately based on the result of the STANDARD G6PD Test.

CONCLUSIONS

The STANDARD G6PD Test enables safe access to drugs which are contraindicated for individuals with G6PD deficiency. Operational considerations will inform test uptake in specific settings.

Antigen concentration, viral load, and test performance for SARS-CoV-2 in multiple specimen types

The relationship between N-antigen concentration and viral load within and across different specimens guides the clinical performance of rapid diagnostic tests (RDT) in different uses. A prospective study was conducted in Porto Velho, Brazil, to investigate RDT performance in different specimen types as a function of the correlation between antigen concentration and viral load. The study included 214 close contacts with recent exposures to confirmed cases, aged 12 years and older and with various levels of vaccination. Antigen concentration was measured in nasopharyngeal swab (NPS), anterior nares swab (ANS), and saliva specimens. Reverse transcriptase (RT)-PCR was conducted on the NPS and saliva specimens, and two RDTs were conducted on ANS and one RDT on saliva. Antigen concentration correlated well with viral load when measured in the same specimen type but not across specimen types. Antigen levels were higher in symptomatic cases compared to asymptomatic/oligosymptomatic cases and lower in saliva compared to NPS and ANS samples. Discordant results between the RDTs conducted on ANS and the RT-PCR on NPS were resolved by antigen concentration values. The analytical limit-of-detection of RDTs can be used to predict the performance of the tests in populations for which the antigen concentration is known. The antigen dynamics across different sample types observed in SARS-CoV-2 disease progression support use of RDTs with nasal samples. Given lower antigen concentrations in saliva, rapid testing using saliva is expected to require improved RDT analytical sensitivity to achieve clinical sensitivity similar to rapid testing of nasal samples.

Multiplexed micronutrient, inflammation, and malarial antigenemia assessment using a plasma fractionation device

Processing and storing blood samples for future analysis of biomarkers can be challenging in resource limited environments. The preparation of dried blood spots (DBS) from finger-stick collection of whole blood is a widely used and established method as DBS are biosafe, and allow simpler field processing, storage, and transport protocols than serum or plasma. Therefore, DBS are commonly used in population surveys to assess infectious disease and/or micronutrient status. Recently, we reported that DBS can be used with the Q-plex™ Human Micronutrient 7-plex Array (MN 7-plex), a multiplexed immunoassay. This tool can simultaneously quantify seven protein biomarkers related to micronutrient deficiencies (iodine, iron and vitamin A), inflammation, and malarial antigenemia using plasma or serum. Serum ferritin, an iron biomarker, cannot be measured from DBS due to red blood cell (RBC) ferritin content confounding the results. In this study, we assess a simple blood fractionation tool that passively separates plasma from other blood components via diffusion through a membrane into a plasma collection disc (PCD). We evaluated the concordance of MN 7-plex analyte concentrations from matched panels of eighty-eight samples of PCD, DBS, and wet plasma prepared from anticoagulated venous whole blood. The results showed good correlations of >0.93 between the eluates from PCD and DBS for each analyte except ferritin; while correlations seen for plasma/PCD were weaker. However, the recovery rate of the analytes from the PCD were better than those from DBS. The serum ferritin measures from the PCD were highly correlated to wet plasma samples (0.85). This suggests that surveillance for iron status in low resource settings can be improved over the current methods restricted to only measuring sTfR in DBS. When used in combination with the MN 7-plex, all seven biomarkers can be simultaneously measured using eluates from the PCDs.

Screening for Severe Acute Respiratory Syndrome Coronavirus 2 in Close Contacts of Individuals With Confirmed Infection: Performance and Operational Considerations

BACKGROUND

Point-of-care and decentralized testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is critical to inform public health responses. Performance evaluations in priority use cases such as contact tracing can highlight trade-offs in test selection and testing strategies.

METHODS

A prospective diagnostic accuracy study was conducted among close contacts of coronavirus disease 2019 (COVID-19) cases in Brazil. Two anterior nares swabs (ANS), a nasopharyngeal swab (NPS), and saliva were collected at all visits. Vaccination history and symptoms were assessed. Household contacts were followed longitudinally. Three rapid antigen tests and 1 molecular method were evaluated for usability and performance against reference reverse-transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swab specimens.

RESULTS

Fifty index cases and 214 contacts (64 household) were enrolled. Sixty-five contacts were RT-PCR positive during ≥1 visit. Vaccination did not influence viral load. Gamma variants were most prevalent; Delta variants emerged increasingly during implementation. The overall sensitivity of evaluated tests ranged from 33% to 76%. Performance was higher among symptomatic cases and those with cycle threshold (Ct) values <34 and lower among oligosymptomatic or asymptomatic cases. Assuming a 24-hour time to results for RT-PCR, the cumulative sensitivity of an anterior nares swab rapid antigen test was >70% and almost 90% after 4 days.

CONCLUSIONS

The near-immediate time to results for antigen tests significantly offsets lower analytical sensitivity in settings where RT-PCR results are delayed or unavailable.

A multicenter analytical performance evaluation of a multiplexed immunoarray for the simultaneous measurement of biomarkers of micronutrient deficiency, inflammation and malarial antigenemia

A lack of comparative data across laboratories is often a barrier to the uptake and adoption of new technologies. Furthermore, data generated by different immunoassay methods may be incomparable due to a lack of harmonization. In this multicenter study, we describe validation experiments conducted in a single lab and cross-lab comparisons of assay results to assess the performance characteristics of the Q-plex™ 7-plex Human Micronutrient Array (7-plex), an immunoassay that simultaneously quantifies seven biomarkers associated with micronutrient (MN) deficiencies, inflammation and malarial antigenemia using plasma or serum; alpha-1-acid glycoprotein, C-reactive protein, ferritin, histidine-rich protein 2, retinol binding protein 4, soluble transferrin receptor, and thyroglobulin. Validations included repeated testing (n = 20 separately prepared experiments on 10 assay plates) in a single lab to assess precision and linearity. Seven independent laboratories tested 76 identical heparin plasma samples collected from a cohort of pregnant women in Niger using the same 7-plex assay to assess differences in results across laboratories. In the analytical validation experiments, intra- and inter-assay coefficients of variation were acceptable at <6% and <15% respectively and assay linearity was 96% to 99% with the exception of ferritin, which had marginal performance in some tests. Cross-laboratory comparisons showed generally good agreement between laboratories in all analyte results for the panel of 76 plasma specimens, with Lin's concordance correlation coefficient values averaging ≥0.8 for all analytes. Excluding plates that would fail routine quality control (QC) standards, the inter-assay variation was acceptable for all analytes except sTfR, which had an average inter-assay coefficient of variation of ≥20%. This initial cross-laboratory study demonstrates that the 7-plex test protocol can be implemented by users with some experience in immunoassay methods, but familiarity with the multiplexed protocol was not essential.

Reference and point-of-care testing for G6PD deficiency: Blood disorder interference, contrived specimens, and fingerstick equivalence and precision

Certain clinical indications and treatments such as the use of rasburicase in cancer therapy and 8-aminoquinolines for Plasmodium vivax malaria treatment would benefit from a point-of-care test for glucose-6-phosphate dehydrogenase (G6PD) deficiency. Three studies were conducted to evaluate the performance of one such test: the STANDARD^™ G6PD Test (SD BIOSENSOR, South Korea). First, biological interference on the test performance was evaluated in specimens with common blood disorders, including high white blood cell (WBC) counts. Second, the test precision on fingerstick specimens was evaluated against five individuals of each, deficient, intermediate, and normal G6PD activity status. Third, clinical performance of the test was evaluated at three point-of-care settings in the United States. The test performed equivalently to the reference assay in specimens with common blood disorders. High WBC count blood samples resulted in overestimation of G6PD activity in both the reference assay and the STANDARD G6PD Test. The STANDARD G6PD Test showed good precision on multiple fingerstick specimens from the same individual. The same G6PD threshold values (U/g Hb) were applied for a semiquantitative interpretation for fingerstick- and venous-derived results. The sensitivity/specificity values (95% confidence intervals) for the test for G6PD deficiency were 100 (92.3–100.0)/97 (95.2–98.2) and 100 (95.7–100.0)/97.4 (95.7–98.5) for venous and capillary specimens, respectively. The same values for females with intermediate (> 30% to ≤ 70%) G6PD activity were 94.1 (71.3–99.9)/88.2 (83.9–91.7) and 82.4 (56.6–96.2)/87.6(83.3–91.2) for venous and capillary specimens, respectively. The STANDARD G6PD Test enables point-of-care testing for G6PD deficiency.

Evaluation of a point-of-care diagnostic to identify glucose-6-phosphate dehydrogenase deficiency in Brazil

Background

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common enzyme deficiency, prevalent in many malaria-endemic countries. G6PD-deficient individuals are susceptible to hemolysis during oxidative stress, which can occur from exposure to certain medications, including 8-aminoquinolines used to treat Plasmodium vivax malaria. Accordingly, access to point-of-care (POC) G6PD testing in Brazil is critical for safe treatment of P. vivax malaria.

Methodology/Principal findings

This study evaluated the performance of the semi-quantitative, POC STANDARD G6PD Test (SD Biosensor, Republic of Korea). Participants were recruited at clinics and through an enriched sample in Manaus and Porto Velho, Brazil. G6PD and hemoglobin measurements were obtained from capillary samples at the POC using the STANDARD and HemoCue 201+ (HemoCue AB, Sweden) tests. A thick blood slide was prepared for malaria microscopy. At the laboratories, the STANDARD and HemoCue tests were repeated on venous samples and a quantitative spectrophotometric G6PD reference assay was performed (Pointe Scientific, Canton, MI). G6PD was also assessed by fluorescent spot test. In Manaus, a complete blood count was performed.

Samples were analyzed from 1,736 participants. In comparison to spectrophotometry, the STANDARD G6PD Test performed equivalently in determining G6PD status in venous and capillary specimens under varied operating temperatures. Using the manufacturer-recommended reference value thresholds, the test’s sensitivity at the <30% threshold on both specimen types was 100% (95% confidence interval [CI] venous 93.6%–100.0%; capillary 93.8%–100.0%). Specificity was 98.6% on venous specimens (95% CI 97.9%–99.1%) and 97.8% on capillary (95% CI 97.0%–98.5%). At the 70% threshold, the test’s sensitivity was 96.9% on venous specimens (95% CI 83.8%–99.9%) and 94.3% on capillary (95% CI 80.8%–99.3%). Specificity was 96.5% (95% CI 95.0%–97.6%) and 92.3% (95% CI 90.3%–94.0%) on venous and capillary specimens, respectively.

Conclusion/Significance

The STANDARD G6PD Test is a promising tool to aid in POC detection of G6PD deficiency in Brazil.

Trial registration

This study was registered with ClinicalTrials.gov (identifier: NCT04033640).

G6PD deficiency affects an estimated 500 million people worldwide and is prevalent in many malaria-endemic settings. People with G6PD deficiency are at risk of hemolysis when exposed to certain medications, including 8-aminoquinoline drugs used to treat Plasmodium vivax malaria. Increased access to testing for G6PD deficiency at or near the point of care is critical for expanding the safe treatment of P. vivax malaria. In this study, we aimed to evaluate the performance of a point-of-care, semi-quantitative test for G6PD deficiency, the STANDARD G6PD Test, in a malaria-endemic setting in Brazil. The test was evaluated on both capillary and venous blood samples across a broad range of operating temperatures. The findings show that the STANDARD G6PD Test performed equivalently to the reference test in its ability to diagnose G6PD deficiency at the point of care. The STANDARD G6PD Test is a promising tool to aid in detecting G6PD deficiency at the point of care in Brazil.

Evaluation of diagnostic ultrasound use in a breast cancer detection strategy in Northern Peru

To evaluate the diagnostic impact of point-of-care breast ultrasound by trained primary care physicians (PCPs) as part of a breast cancer detection program using clinical breast exam in an underserved region of Peru. Medical records and breast ultrasound images of symptomatic women presenting to the Breast Cancer Detection Model (BCDM) in Trujillo, Peru were collected from 2017–2018. Performance was measured against final outcomes derived from regional cancer center medical records, fine needle aspiration results, patient follow-up (sensitivity, specificity, positive, and negative predictive values), and by percent agreement with the retrospective, blinded interpretation of images by a fellowship-trained breast radiologist, and a Peruvian breast surgeon. The diagnostic impact of ultrasound, compared to clinical breast exam (CBE), was calculated for actual practice and for potential impact of two alternative reporting systems. Of the 171 women presenting for breast ultrasound, 23 had breast cancer (13.5%). Breast ultrasound used as a triage test (current practice) detected all cancer cases (including four cancers missed on confirmatory CBE). PCPs showed strong agreement with radiologist and surgeon readings regarding the final management of masses (85.4% and 80.4%, respectively). While the triage system yielded a similar number of biopsies as CBE alone, using the condensed and full BI-RADS systems would have reduced biopsies by 60% while identifying 87% of cancers immediately and deferring 13% to six-month follow-up. Point-of-care ultrasound performed by trained PCPs improves diagnostic accuracy for managing symptomatic women over CBE alone and enhances access. Greater use of BI-RADS to guide management would reduce the diagnostic burden substantially.

Health Outcomes at 1 Year After Thermal Ablation for Cervical Precancer Among Human Papillomavirus- and Visual Inspection With Acetic Acid-Positive Women in Honduras

PURPOSE

This study aims to assess the detection of cervical intraepithelial lesions grades 2 and 3 (CIN2-3) at 1 year after treatment with thermal ablation among human papillomavirus (HPV)–positive and visual inspection with acetic acid (VIA)–positive women.

METHODS

All women screened and triaged for cervical cancer at four government health facilities in Honduras who were eligible for ablative treatment were enrolled and treated with thermal ablation. Women with confirmed CIN2-3 and a subset of women with CIN1/normal diagnoses at baseline were evaluated at 12 months. Follow-up procedures included HPV testing (careHPV), VIA, directed biopsy (if VIA-positive), and Papanicolaou test (if HPV positive, VIA negative). Outcomes at 1 year included histologic or cytologic assessment of CIN lesions among those with any abnormal test.

RESULTS

Among the 319 women treated with thermal ablation, baseline histologic diagnoses were available for 317. Two (0.6%) had invasive cancer, 36 (11.4%) had CIN3, 40 (12.6%) had CIN2, and 239 (75.4%) had CIN1/normal histology. Among the 127 women eligible for follow-up, 118 (92.9%) completed all study procedures at 1 year. Overall, 98 (83.1%) had no evidence of CIN2-3 or persistent low-grade infection, 13 (11.2%) had CIN1/atypical squamous cells of undetermined significance, six (5.1%) had CIN2/high-grade squamous intraepithelial lesion, and 1 (0.8%) had a persistent CIN3. No adverse events associated with thermal ablation at 1 year were registered.

CONCLUSION

A high proportion of women had no evidence of CIN2-3 at 1 year after thermal ablation treatment. Thermal ablation is an alternative to cryotherapy that may facilitate greater treatment coverage and prevent unnecessary deaths from cervical cancer.

Recall Efforts Successfully Increase Follow-Up for Cervical Cancer Screening Among Women With Human Papillomavirus in Honduras

A reminder phone call had a substantial impact on high rates of women returning for rescreening among those at high risk of developing cervical precancer. Scaling up routine cervical screening coverage must be accompanied by efforts to retain women throughout the screening cascade and continuum of care.

Scaling up coverage of routine cervical screening in low-resource settings must be accompanied by efforts to retain women throughout the screening cascade and continuum of care, including adequate follow-up of abnormal results. The Scale-Up Project implemented human papillomavirus (HPV) testing for cervical cancer screening within public-sector health facilities in Honduras between 2015 and 2019. Women who were HPV-positive but did not have visually confirmed cervical lesions upon visual inspection with acetic acid (VIA-negative) were instructed to return to the health center after 1 year for repeat HPV testing. The current evaluation assessed the effectiveness of recall strategies to prompt women to return for retesting. Clinic staff placed reminder phone calls and followed up with short message service (SMS) or home visits, if needed. We summarized number of contacts, type of contacts, and time elapsed until return to the clinic, and used log-binomial regression to identify factors associated with return to the clinic. We identified 558 women who were initially HPV-positive VIA-negative from 8 clinics as needing repeat HPV testing 1 year later. Mean age was 43.2 years. Nearly all women (98.6%) were successfully contacted and 75.1% completed repeat HPV testing. The majority of contacts (65.4%) were phone calls, and nearly half of women who returned to the clinic (42.9%) did so after 1 contact. Mean days between contact and presentation at the clinic was 10.7 (standard deviation: 14.7). Women who required 3 or more contacts were 21% less likely to return for repeat HPV testing (prevalence ratio: 0.79; 95% confidence interval=0.69,0.90; P<.001) as compared to women who received only 1 contact. Reminder phone calls were highly successful at recalling women for HPV retesting in Honduras. This low-touch intervention should be included as part of standard follow-up to retain women throughout the continuum of cervical cancer screening and treatment.

Quantification of glucose-6-phosphate dehydrogenase activity by spectrophotometry: A systematic review and meta-analysis

BACKGROUND

The radical cure of Plasmodium vivax and P. ovale requires treatment with primaquine or tafenoquine to clear dormant liver stages. Either drug can induce haemolysis in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency, necessitating screening. The reference diagnostic method for G6PD activity is ultraviolet (UV) spectrophotometry; however, a universal G6PD activity threshold above which these drugs can be safely administered is not yet defined. Our study aimed to quantify assay-based variation in G6PD spectrophotometry and to explore the diagnostic implications of applying a universal threshold.

METHODS AND FINDINGS

Individual-level data were pooled from studies that used G6PD spectrophotometry. Studies were identified via PubMed search (25 April 2018) and unpublished contributions from contacted authors (PROSPERO: CRD42019121414). Studies were excluded if they assessed only individuals with known haematological conditions, were family studies, or had insufficient details. Studies of malaria patients were included but analysed separately. Included studies were assessed for risk of bias using an adapted form of the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Repeatability and intra- and interlaboratory variability in G6PD activity measurements were compared between studies and pooled across the dataset. A universal threshold for G6PD deficiency was derived, and its diagnostic performance was compared to site-specific thresholds. Study participants (n = 15,811) were aged between 0 and 86 years, and 44.4% (7,083) were women. Median (range) activity of G6PD normal (G6PDn) control samples was 10.0 U/g Hb (6.3-14.0) for the Trinity assay and 8.3 U/g Hb (6.8-15.6) for the Randox assay. G6PD activity distributions varied significantly between studies. For the 13 studies that used the Trinity assay, the adjusted male median (AMM; a standardised metric of 100% G6PD activity) varied from 5.7 to 12.6 U/g Hb (p < 0.001). Assay precision varied between laboratories, as assessed by variance in control measurements (from 0.1 to 1.5 U/g Hb; p < 0.001) and study-wise mean coefficient of variation (CV) of replicate measures (from 1.6% to 14.9%; p < 0.001). A universal threshold of 100% G6PD activity was defined as 9.4 U/g Hb, yielding diagnostic thresholds of 6.6 U/g Hb (70% activity) and 2.8 U/g Hb (30% activity). These thresholds diagnosed individuals with less than 30% G6PD activity with study-wise sensitivity from 89% (95% CI: 81%-94%) to 100% (95% CI: 96%-100%) and specificity from 96% (95% CI: 89%-99%) to 100% (100%-100%). However, when considering intermediate deficiency (<70% G6PD activity), sensitivity fell to a minimum of 64% (95% CI: 52%-75%) and specificity to 35% (95% CI: 24%-46%). Our ability to identify underlying factors associated with study-level heterogeneity was limited by the lack of availability of covariate data and diverse study contexts and methodologies.

CONCLUSIONS

Our findings indicate that there is substantial variation in G6PD measurements by spectrophotometry between sites. This is likely due to variability in laboratory methods, with possible contribution of unmeasured population factors. While an assay-specific, universal quantitative threshold offers robust diagnosis at the 30% level, inter-study variability impedes performance of universal thresholds at the 70% level. Caution is advised in comparing findings based on absolute G6PD activity measurements across studies. Novel handheld quantitative G6PD diagnostics may allow greater standardisation in the future.

HPV-based cervical cancer screening in Nicaragua: from testing to treatment

BACKGROUND

In Nicaragua, cervical cancer is the leading cause of cancer death among women. Human papillomavirus (HPV) testing, primarily using self-sampling, was introduced between 2014 and 2018 in three provinces. We analyzed data from the HPV screening program with the goal of describing key characteristics including reach, HPV prevalence, triage and treatment, and factors associated with follow-up completion.

METHODS

We analyzed individual-level data from routinely collected forms for women attending HPV-based cervical cancer screening. HPV-positive women were triaged with Pap or visual inspection with acetic acid (VIA) prior to treatment. Logistic regression was used to identify factors associated with receiving triage and treatment; analyses were adjusted for province, age, and self- vs. provider-collected sampling.

RESULTS

Forty-four thousand six hundred thirty-five women were screened with HPV testing; 96.6% of women used self-sampling. Six thousand seven hundred seventy-six women were HPV positive (15.2%), 54.0% of screen-positive women received triage, and 53.1% of triage-positive women were treated, primarily with cryotherapy. If women lost at triage are included, the overall treatment percentage was 27.8%. Province and provider sampling were significantly associated with completing triage. Province and triage type were significantly associated with receiving treatment. The odds of receiving treatment after Pap triage as compared to VIA was significantly lower (aOR: 0.05, 95% CI: 0.04-0.08, p < 0.001), and the relative proportion of women receiving treatment after Pap triage versus VIA was 0.29.

CONCLUSIONS

Introduction of HPV testing resulted in a substantial number of women screened, and acceptance of self-sampling was high. Management of screen-positive women remained a challenge, particularly with Pap triage. Our results can inform other developing countries as they work to reach World Health Organization (WHO) elimination targets.

Potential new tool for anemia screening: An evaluation of the performance and usability of the TrueHb Hemometer

In low- and middle-income countries, many women experience anemia during pregnancy due to insufficient dietary intake of key micronutrients, parasitic infections, hemoglobinopathies, and chronic infections. Maternal anemia increases perinatal risks for both mothers and infants, and slow progress to reduce the prevalence may be due in part to the lack of affordable tools to quantify hemoglobin levels in antenatal care (ANC) clinics. A simple, inexpensive, accurate, and robust diagnostic is needed to measure hemoglobin in ANC. This study evaluated the performance and usability of the TrueHb Hemometer. A cross-sectional diagnostic accuracy study was conducted to compare the accuracy of the TrueHb and the HemoCue® 201+ using capillary samples. Next, analytical performance (precision, coefficient of variation, R²) of the TrueHb was evaluated in varying environmental conditions using linearity panels with serial dilutions of venous blood samples. Lastly, the usability of the TrueHb Hemometer was assessed across three domains (effectiveness, efficiency, and satisfaction) by 20 ANC providers in Ghana. Capillary blood test results were not well correlated (R² = 0.35) between the TrueHB and HemoCue201+, but 80% of TrueHb measurements were within +/-1.0 g/dl of the HemoCue® 201+ hemoglobin values. Precision tests indicated similar mean values across the three environmental conditions (CV<6%). At 21°C, the TrueHb follows a linear relationship (R²≥0.96) but does not generate accurate readings below 4.0 g/dl. At 30°C and 37°C, the TrueHb follows a linear relationship (R² > 0.90) but begins to underestimate the hemoglobin concentration below 7.0 g/dl. The usability study identified potential failure modes due to inadequate instructions and device feedback. With some modifications, both to the product and to the instructions for use, the TrueHb may be suitable for use in ANC settings to help fill the diagnostic gap for anemia screening during pregnancy. Further testing is required with anemic populations in LMIC settings.

Acceptability and safety of thermal ablation for the treatment of precancerous cervical lesions in Honduras

Objective

To evaluate the acceptability and safety of thermal ablation (TA) for the treatment of precancerous cervical lesions in women in Honduras.

Methods

Human papillomavirus (HPV) and visual inspection with acetic acid (VIA) screen‐positive eligible women received TA. After treatment, women rated the level of pain experienced during treatment using the Wong‐Baker FACES® pain‐rating scale from 0 to 10. Short‐term safety outcomes that could require medical attention were assessed one month after treatment.

Results

A total of 319 women received TA treatment. The average pain rating was 2.5 (95% CI: 2.3–2.8), and 85% rated their pain levels as less than 6. No significant differences in low (below 6) or high (6 and above) pain were found by age or number of biopsies performed, but there was a significant difference by the number of TA applications (P < 0.01). When asked if they would recommend this treatment, all women said they would. At the one‐month follow‐up visit, the most common reported discomforts were bleeding (10%) and cramping (8.4%); 11 women reported severe lower abdominal pain, and none required medical attention.

Conclusions

TA is safe and acceptable to patients as a treatment option for precancerous cervical lesions in low‐resource settings.

Evaluation of a Novel Quantitative Test for Glucose-6-Phosphate Dehydrogenase Deficiency: Bringing Quantitative Testing for Glucose-6-Phosphate Dehydrogenase Deficiency Closer to the Patient

Glucose-6-phosphate dehydrogenase (G6PD) deficiency, a common genetic blood condition, can result in kernicterus at birth, and later in life as severe hemolysis on exposure to certain infections, foods, and drugs. The unavailability of point-of-care tests for G6PD deficiency is a barrier to routine curative treatment of Plasmodium vivax malaria with 8-aminoquinolines, such as primaquine. Two quantitative reference tests (Trinity Biotech, Bray, Ireland and Pointe Scientific, Canton, MI; Cat No. G7583) and the point-of-care STANDARD^™ G6PD test (SD Biosensor, Suwon, South Korea) were evaluated. The STANDARD G6PD test was evaluated at multiple temperatures, in anticoagulated venous and capillary samples, including 79 G6PD-deficient and 66 intermediate samples and across two laboratories, one in the United States and one in Thailand. The STANDARD test performed equivalently to a reference assay for its ability to diagnose G6PD deficiency (< 30% normal) with a sensitivity of 100% (0.95 confidence interval [CI]: 95.7–100) and specificity of 97% (0.95 CI: 94.5–98.5), and could reliably identify females with less than 70% normal G6PD activity with a sensitivity of 95.5% (0.95 CI: 89.7–98.5) and specificity of 97% (0.95 CI: 94.5–98.6). The STANDARD G6PD product represents an opportunity to diagnose G6PD deficiency equally for males and females in basic clinical laboratories in high- and low-resource settings. This quantitative point-of-care diagnostic test for G6PD deficiency can provide equal access to safe radical cure of P. vivax cases in high- and low-resource settings, for males and females and may support malaria elimination, in countries where P. vivax is endemic.

Measurement of micronutrient deficiency associated biomarkers in dried blood spots using a multiplexed immunoarray

Simplifying blood collection is often critical when collecting specimens in remote and/or austere settings. The use of dried blood spots (DBS) offers a practical collection method suitable for a wide variety of analytes. A small volume of whole blood can be obtained rapidly through a minimally invasive heel- or finger-stick using a disposable safety lancet. Once dried, the samples require no further processing, are stable for months or longer, pose minimal risk of disease transmission, and are easy to ship. DBS are often used in demographic health surveys to assess infectious disease status in vulnerable populations. These samples can be used to screen biomarkers of micronutrient deficiency (MND) and inflammation. We recently described a multiplexed immunoarray, the Q-plex human micronutrient array, which can simultaneously quantify seven biomarkers related to MND, inflammation and malarial antigenemia using plasma (alpha-1-acid glycoprotein, C-reactive protein, ferritin, histidine-rich protein 2, retinol binding protein, soluble transferrin receptor, and thyroglobulin). In this work, we present a protocol for preparing eluates from DBS samples and their measurement using a modified protocol for this new tool. We evaluated the concordance of analyte concentrations (excluding ferritin) from a panel ninety samples of DBS prepared from anticoagulated venous blood and paired K2-EDTA plasma. The results show high correlation between DBS eluates and wet plasma for five of the six analytes screened, suggesting the Q-plex human micronutrient array can be used with DBS samples, but also highlighting that anticoagulants can have a negative effects on some test components.

Malaria case investigation with reactive focal testing and treatment: operational feasibility and lessons learned from low and moderate transmission areas in Amhara Region, Ethiopia

BACKGROUND

When malaria transmission is very low, investigation of passively detected malaria cases and reactive focal testing and treatment (FTAT) in the case and neighbouring households can identify and contain the source and spread of infections.

METHODS

Case investigation with reactive FTAT for malaria was implemented in 10 villages in Amhara Region, Ethiopia during the 2014/2015 malaria transmission season. Intervention villages were purposively selected based on the incidence of passively detected Plasmodium falciparum and mixed infections (P. falciparum and Plasmodium vivax) during the 2013 transmission season. A passively detected P. falciparum or mixed index case triggered an investigation that targeted the index case household and the closest 10 neighbouring households in a 100-m radius. All consenting household members received a rapid diagnostic test (RDT) and RDT-positive individuals received artemether-lumefantrine (P. falciparum, mixed) or chloroquine (P. vivax).

RESULTS

From October 2014 to February 2015, 407 P. falciparum or mixed index cases (approximately 6.5 per 1000 population) were passively detected. Of these, 220 (54.1%) were investigated, of which 87.3% were male, 61.8% were age 20-39 years [median age: 27 years (range 1-90)], and 58.6% spent ≥ 1 night away from home in the past month (ranging from 0.0 to 94.1% by village). Among the 4077 residents in the 914 households investigated, 3243 (79.5%) received an RDT and 127 (3.9%) were RDT-positive (2.2% P. falciparum, 0.5% P. vivax, 1.2% mixed). Three epidemiological patterns were found. In six villages, there were almost no cases, with less than 10 index and secondary cases. In three villages, most index cases had a history of travel (> 62%), but there were a small number of secondary cases (< 10). Lastly, in one village none of the index cases had a history of recent travel and there was a large number of secondary cases (n = 105).

CONCLUSIONS

Three types of malaria transmission patterns were observed: (1) low importation and low local transmission; (2) high importation and low local transmission; and, (3) low importation and high local transmission. To achieve malaria elimination in Amhara Region, intervention strategies targeting these different patterns of transmission and population movement are required.

Validation of the quantitative point-of-care CareStart biosensor for assessment of G6PD activity in venous blood

INTRODUCTION

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymopathy in the human population affecting an estimated 8% of the world population, especially those living in areas of past and present malaria endemicity. Decreased G6PD enzymatic activity is associated with drug-induced hemolysis and increased risk of severe neonatal hyperbilirubinemia leading to brain damage. The G6PD gene is on the X chromosome therefore mutations cause enzymatic deficiency in hemizygote males and homozygote females while the majority of heterozygous females have an intermediate activity (between 30-80% of normal) with a large distribution into the range of deficiency and normality. Current G6PD qualitative tests are unable to diagnose G6PD intermediate activities which could hinder wide use of 8-aminoquinolines for Plasmodium vivax elimination. The aim of the study was to assess the diagnostic performances of the new Carestart G6PD quantitative biosensor.

METHODS

A total of 150 samples of venous blood with G6PD deficient, intermediate and normal phenotypes were collected among healthy volunteers living along the north-western Thailand-Myanmar border. Samples were analyzed by complete blood count, by gold standard spectrophotometric assay using Trinity kits and by the latest model of Carestart G6PD biosensor which analyzes both G6PD and hemoglobin.

RESULTS

Bland-Altman comparison of the CareStart normalized G6PD values to that of the gold standard assay showed a strong bias in values resulting in poor area under-the-curve values for both 30% and 80% thresholds. Performing a receiver operator curve identified threshold values for the CareStart product equivalent to the 30% and 80% gold standard values with good sensitivity and specificity values, 100% and 92% (for 30% G6PD activity) and 92% and 94% (for 80% activity) respectively.

CONCLUSION

The Carestart G6PD biosensor represents a significant improvement for quantitative diagnosis of G6PD deficiency over previous versions. Further improvements and validation studies are required to assess its utility for informing radical cure decisions in malaria endemic settings.

Current and cumulative malaria infections in a setting embarking on elimination: Amhara, Ethiopia

Background

Since 2005, Ethiopia has aggressively scaled up malaria prevention and case management. As a result, the number of malaria cases and deaths has significantly declined. In order to track progress towards the elimination of malaria in Amhara Region, coverage of malaria control tools and current malaria transmission need to be documented.

Methods

A cross-sectional household survey oversampling children under 5 years of age was conducted during the dry season in 2013. A bivalent rapid diagnostic test (RDT) detecting both Plasmodium falciparum and Plasmodium vivax and serology assays using merozoite antigens from both these species were used to assess the prevalence of malaria infections and exposure to malaria parasites in 16 woredas (districts) in Amhara Region.

Results

7878 participants were included, with a mean age of 16.8 years (range 0.5–102.8 years) and 42.0% being children under 5 years of age. The age-adjusted RDT-positivity for P. falciparum and P. vivax infection was 1.5 and 0.4%, respectively, of which 0.05% presented as co-infections. Overall age-adjusted seroprevalence was 30.0% for P. falciparum, 21.8% for P. vivax, and seroprevalence for any malaria species was 39.4%. The prevalence of RDT-positive infections varied by woreda, ranging from 0.0 to 8.3% and by altitude with rates of 3.2, 0.7, and 0.4% at under 2000, 2000–2500, and >2500 m, respectively. Serological analysis showed heterogeneity in transmission intensity by area and altitude and evidence for a change in the force of infection in the mid-2000s.

Conclusions

Current and historic malaria transmission across Amhara Region show substantial variation by age and altitude with some settings showing very low or near-zero transmission. Plasmodium vivax infections appear to be lower but relatively more stable across geography and altitude, while P. falciparum is the dominant infection in the higher transmission, low-altitude areas. Age-dependent seroprevalence analyses indicates a drop in transmission occurred in the mid-2000s, coinciding with malaria control scale-up efforts. As malaria parasitaemia rates get very low with elimination efforts, serological evaluation may help track progress to elimination.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1884-y) contains supplementary material, which is available to authorized users.

Validation of G6PD Point-of-Care Tests among Healthy Volunteers in Yangon, Myanmar

Primaquine and other 8-amnoquinoline based anti-malarials can cause haemolysis in subjects with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Correct diagnosis of G6PD status in patients is crucial for safe treatment of both relapsing stages of Plasmodium vivax and transmitting forms of Plasmodium falciparum. Lack of suitable point-of-care tests has hampered a much needed wide use of primaquine for malaria elimination. In this study we have assessed the performances of two qualitative tests, the fluorescent spot test (FST) and the G6PD CareStart test (CST), against the gold standard quantitative spectrophotometric assay in a population of 1000 random adult healthy volunteers living in Yangon, Myanmar. The prevalence of G6PD deficiency in the Bamar, Karen and in the whole sample set was 6.6% (10.1% in males), 9.2% (21.0% in males) and 6.8% (11.1% in males) respectively. The FST and CST showed comparable performances with sensitivity over 95% and specificity over 90%, however for cases with severe G6PD activity the FTS had improved performance. If used with a conservative interpretation of the signal, the CareStart test has the potential to be used in the field and, by allowing a wider use of primaquine, to help malaria elimination.

Impact of Health Insurance Type on Trends in Newborn Circumcision, United States, 2000 to 2010

OBJECTIVES

We explored how changes in insurance coverage contributed to recent nationwide decreases in newborn circumcision.

METHODS

Hospital discharge data from the 2000-2010 Nationwide Inpatient Sample were analyzed to assess trends in circumcision incidence among male newborn birth hospitalizations covered by private insurance or Medicaid. We examined the impact of insurance coverage on circumcision incidence.

RESULTS

Overall, circumcision incidence decreased significantly from 61.3% in 2000 to 56.9% in 2010 in unadjusted analyses (P for trend = .008), but not in analyses adjusted for insurance status (P for trend = .46) and other predictors (P for trend = .55). Significant decreases were observed only in the South, where adjusted analyses revealed decreases in circumcision overall (P for trend = .007) and among hospitalizations with Medicaid (P for trend = .005) but not those with private insurance (P for trend = .13). Newborn male birth hospitalizations covered by Medicaid increased from 36.0% (2000) to 50.1% (2010; P for trend < .001), suggesting 390,000 additional circumcisions might have occurred nationwide had insurance coverage remained constant.

CONCLUSIONS

Shifts in insurance coverage, particularly toward Medicaid, likely contributed to decreases in newborn circumcision nationwide and in the South. Barriers to the availability of circumcision should be revisited, particularly for families who desire but have less financial access to the procedure.

Suitability of capillary blood for quantitative assessment of G6PD activity and performances of G6PD point-of-care tests

The use of primaquine and other 8-aminoquinolines for malaria elimination is hampered by, among other factors, the limited availability of point-of-care tests for the diagnosis of glucose-6-phosphate dehydrogenase (G6PD) deficiency. Historically, the most used source of blood for G6PD analyses is venous blood, whereas diagnostic devices used in the field require the use of capillary blood; data have shown that the two sources of blood often differ with respect to hemoglobin concentration and number of red blood cells. Therefore, we have analyzed, in both capillary and venous blood drawn from the same healthy donors, the correlation of G6PD activity assessed by two qualitative tests (the Fluorescent Spot test and the CareStart test) with the gold standard quantitative spectrophotometric assay. Results obtained on 150 subjects with normal, intermediate, and deficient G6PD phenotypes show that, although differences exist between the aforementioned characteristics in capillary and venous blood, these do not impact on the quantitative assessment of G6PD activity after corrected for hemoglobin concentration or red blood cell count. Furthermore, we have assessed the sensitivity and specificity of the two qualitative tests against the gold standard spectrophotometric assay at different activity thresholds of residual enzymatic activity in both blood sources.

Comparison of quantitative and qualitative tests for glucose-6-phosphate dehydrogenase deficiency

A barrier to eliminating Plasmodium vivax malaria is inadequate treatment of infected patients. 8-Aminoquinoline–based drugs clear the parasite; however, people with glucose-6-phosphate dehydrogenase (G6PD) deficiency are at risk for hemolysis from these drugs. Understanding the performance of G6PD deficiency tests is critical for patient safety. Two quantitative assays and two qualitative tests were evaluated. The comparison of quantitative assays gave a Pearson correlation coefficient of 0.7585 with significant difference in mean G6PD activity, highlighting the need to adhere to a single reference assay. Both qualitative tests had high sensitivity and negative predictive value at a cutoff G6PD value of 40% of normal activity if interpreted conservatively and performed under laboratory conditions. The performance of both tests dropped at a cutoff level of 45%. Cytochemical staining of specimens confirmed that heterozygous females with > 50% G6PD-deficient cells can seem normal by phenotypic tests.

Acceptability of self-collection sampling for HPV-DNA testing in low-resource settings: a mixed methods approach

BACKGROUND

Vaginal self-sampling with HPV-DNA tests is a promising primary screening method for cervical cancer. However, women's experiences, concerns and the acceptability of such tests in low-resource settings remain unknown.

METHODS

In India, Nicaragua, and Uganda, a mixed-method design was used to collect data from surveys (N = 3,863), qualitative interviews (N = 72; 20 providers and 52 women) and focus groups (N = 30 women) on women's and providers' experiences with self-sampling, women's opinions of sampling at home, and their future needs.

RESULTS

Among surveyed women, 90% provided a self- collected sample. Of these, 75% reported it was easy, although 52% were initially concerned about hurting themselves and 24% were worried about not getting a good sample. Most surveyed women preferred self-sampling (78%). However it was not clear if they responded to the privacy of self-sampling or the convenience of avoiding a pelvic examination, or both. In follow-up interviews, most women reported that they didn't mind self-sampling, but many preferred to have a provider collect the vaginal sample. Most women also preferred clinic-based screening (as opposed to home-based self-sampling), because the sample could be collected by a provider, women could receive treatment if needed, and the clinic was sanitary and provided privacy. Self-sampling acceptability was higher when providers prepared women through education, allowed women to examine the collection brush, and were present during the self-collection process. Among survey respondents, aids that would facilitate self-sampling in the future were: staff help (53%), additional images in the illustrated instructions (31%), and a chance to practice beforehand with a doll/model (26%).

CONCLUSION

Self-and vaginal-sampling are widely acceptable among women in low-resource settings. Providers have a unique opportunity to educate and prepare women for self-sampling and be flexible in accommodating women's preference for self-sampling.

A prospective study of age trends of high-risk human papillomavirus infection in rural China

BACKGROUND

In China, high-risk human papillomavirus (HR-HPV) prevalence is unexpectedly high in older women, but the possible reasons have not been well studied yet. This study investigated the age trends of HR-HPV infection in a prospective study.

METHODS

A total of 7397 women aged 25-65 years without cervical precancer or cancer were evaluated during 2010-2011 with a stratified sample of 2791 women re-evaluated after one year. Test results for careHPV and careHPV16/18/45 were used to describe the HR-HPV prevalence, incidence and clearance. Risk factors associated with HR-HPV infections were explored using a logistic regression model.

RESULTS

The overall HR-HPV prevalence was 13.1% at baseline, with a peak of 19.3% in women aged 55-59 years. The prevalence of HR-HPV (p for trends < 0.001), HPV16/18/45 (p for trends = 0.002), and HR-HPV other than HPV16/18/45 (p for trends = 0.002) generally increased with increasing age. Number of infections that cleared was generally greater than number of incident infections within age groups. One-year clearance rate decreased with increasing age (p for trends < 0.001), however, incidence rate was unrelated to age (p for trends = 0.159). Risk factors that associated with HR-HPV infection differed between younger and older women.

CONCLUSIONS

The greater HR-HPV prevalence in older versus younger women in rural China may be explained by a cohort effect, higher than expected incidence, and/or poorer clearance at older age.

Lower cost strategies for triage of human papillomavirus DNA-positive women

Using human papillomavirus (HPV) testing for cervical cancer screening in lower-resource settings (LRS) will result in a significant number of screen-positive women. This analysis compares different triage strategies for detecting cervical precancer and cancer among HPV-positive women in LRS. This was a population-based study of women aged 25-65 years living in China (n = 7,541). Each woman provided a self-collected and two clinician-collected specimens. The self-collected and one clinician-collected specimen were tested by two HPV DNA tests-careHPV™ and Hybrid Capture 2; the other clinician-collected specimen was tested for HPV16/18/45 E6 protein. CareHPV™-positive specimens were tested for HPV16/18/45 DNA. HPV DNA-positive women underwent visual inspection with acetic acid (VIA) and then colposcopic evaluation with biopsies. The performance for detection of cervical intraepithelial neoplasia grade 3 or cancer (CIN3+) among HPV DNA-positive women was assessed for different triage strategies: HPV16/18/45 E6 or DNA detection, VIA, colposcopic impression, or higher signal strength (≥10 relative light units/positive control [rlu/pc]). The percent triage positive ranges were 14.8-17.4% for VIA, 17.8-20.9% for an abnormal colposcopic impression; 7.9-10.5% for HPV16/18/45 E6; 23.4-28.4% for HPV16/18/45 DNA; and 48.0-62.6% for higher signal strength (≥10 rlu/pc), depending on the HPV test/specimen combination. The positivity for all triage tests increased with severity of diagnosis. HPV16/18/45 DNA detection was approximately 70% sensitive and had positive predictive values (PPV) of approximately 25% for CIN3+. HPV16/18/45 E6 detection was approximately 50% sensitive with a PPV of nearly 50% for CIN3+. Different triage strategies for HPV DNA-positive women provide important tradeoffs in colposcopy or treatment referral percentages and sensitivity for prevalent CIN3+.

G6PD testing in support of treatment and elimination of malaria: recommendations for evaluation of G6PD tests

Malaria elimination will be possible only with serious attempts to address asymptomatic infection and chronic infection by both Plasmodium falciparum and Plasmodium vivax. Currently available drugs that can completely clear a human of P. vivax (known as "radical cure"), and that can reduce transmission of malaria parasites, are those in the 8-aminoquinoline drug family, such as primaquine. Unfortunately, people with glucose-6-phosphate dehydrogenase (G6PD) deficiency risk having severe adverse reactions if exposed to these drugs at certain doses. G6PD deficiency is the most common human enzyme defect, affecting approximately 400 million people worldwide.Scaling up radical cure regimens will require testing for G6PD deficiency, at two levels: 1) the individual level to ensure safe case management, and 2) the population level to understand the risk in the local population to guide Plasmodium vivax treatment policy. Several technical and operational knowledge gaps must be addressed to expand access to G6PD deficiency testing and to ensure that a patient's G6PD status is known before deciding to administer an 8-aminoquinoline-based drug.In this report from a stakeholder meeting held in Thailand on October 4 and 5, 2012, G6PD testing in support of radical cure is discussed in detail. The focus is on challenges to the development and evaluation of G6PD diagnostic tests, and on challenges related to the operational aspects of implementing G6PD testing in support of radical cure. The report also describes recommendations for evaluation of diagnostic tests for G6PD deficiency in support of radical cure.

Epidemiology and prevention of stroke: a worldwide perspective

This paper reviews how epidemiological studies during the last 5 years have advanced our knowledge in addressing the global stroke epidemic. The specific objectives were to review the current evidence supporting management of ten major modifiable risk factors for prevention of stroke: hypertension, current smoking, diabetes, obesity, poor diet, physical inactivity, atrial fibrillation, excessive alcohol consumption, abnormal lipid profile and psychosocial stress/depression.

Maternal and fetal outcomes among women with depression

OBJECTIVE

To compare maternal and fetal outcomes among women with and without diagnosed depression at the time of delivery.

METHODS

Hospital discharge data from the 1998-2005 Nationwide Inpatient Sample (NIS) were used to examine delivery-related hospitalizations for select maternal and fetal outcomes by depression diagnosis.

RESULTS

The rate of depression per 1000 deliveries increased significantly from 2.73 in 1998 to 14.1 in 2005 (p < 0.001). Women diagnosed with depression were significantly more likely to have cesarean delivery, preterm labor, anemia, diabetes, and preeclampsia or hypertension compared with women without depression. Fetal outcomes significantly associated with maternal depression were fetal growth restriction, fetal abnormalities, fetal distress, and fetal death.

CONCLUSIONS

These findings suggest that depression is associated with adverse maternal and fetal outcomes. Our results provide additional impetus to screen for depression among women of reproductive age, especially those who plan to become pregnant.

Depression, diabetes, and chronic disease risk factors among US women of reproductive age

INTRODUCTION

Depression and chronic disease have implications for women's overall health and future pregnancies. The objective of this study was to estimate the prevalence and predictors of diabetes and chronic disease risk factors among reproductive-age women with depression.

METHODS

We used population-based data from the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System to examine prevalence of diabetes and prediabetes, binge and heavy drinking, smoking, overweight and obesity, and physical inactivity among 69,043 women aged 18 to 44 years with current major or minor depression, a past depression diagnosis, or no depression. In a multivariable logistic regression model, we calculated adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of 1, 2, and 3 or more chronic disease risk factors by depression status.

RESULTS

We found that 12.8% of reproductive-aged women experienced both current depression and 1 or more chronic disease risk factors. Compared to women with no depression, currently depressed women and those with a past diagnosis had higher prevalence of diabetes, smoking, binge or heavy drinking, obesity, and physical inactivity (P < .001 for all). Odds of 3 or more chronic conditions and risk factors were elevated among women with major (AOR, 5.7; 95% CI, 4.3-7.7), minor (AOR, 4.7; 95% CI, 3.7-6.1), and past diagnosis of depression (AOR, 2.8; 95% CI, 2.4-3.4).

CONCLUSION

Depressed women of reproductive age have high rates of chronic disease risk factors, which may affect their overall health and future pregnancies.

Trends in Pregnancy Hospitalizations That Included a Stroke in the United States From 1994 to 2007

Background and Purpose—

Stroke is an important contributor to maternal morbidity and mortality, but there are no recent data on trends in pregnancy-related hospitalizations that have involved a stroke. This report describes stroke hospitalizations for women in the antenatal, delivery, and postpartum periods from 1994 to 1995 to 2006 to 2007 and analyzes the changes in these hospitalizations over time.

Methods—

Hospital discharge data were obtained from the Nationwide Inpatient Sample, developed as part of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Pregnancy-related hospitalizations with stroke were identified according to the International Classification of Diseases, Ninth Revision. All statistical analyses accounted for the complex sampling design of the data source.

Results—

Between 1994 to 1995 and 2006 to 2007, the rate of any stroke (subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, transient ischemic attack, cerebral venous thrombosis, or unspecified) among antenatal hospitalizations increased by 47% (from 0.15 to 0.22 per 1000 deliveries) and among postpartum hospitalizations by 83% (from 0.12 to 0.22 per 1000 deliveries) while remaining unchanged at 0.27 for delivery hospitalizations. In 2006 to 2007, ≈32% and 53% of antenatal and postpartum hospitalizations with stroke, respectively, had concurrent hypertensive disorders or heart disease. Changes in the prevalence of these 2 conditions from 1994 to 1995 to 2006 to 2007 explained almost all of the increase in postpartum hospitalizations with stroke during the same period.

Conclusions—

Our results have demonstrated an increasing trend in the rate of pregnancy-related hospitalizations with stroke in the United States, especially during the postpartum period, from 1994 to 1995 to 2006 to 2007.

Associations between sleep disorders, sleep duration, quality of sleep, and hypertension: results from the National Health and Nutrition Examination Survey, 2005 to 2008

Sleep is a contributing factor to optimal health and vitality. However, to date, no national study has evaluated the simultaneous relationship between sleep disorders, quality, and duration with hypertension. Using data from National Health and Nutrition Examination Survey (NHANES) (2005 to 2008), hypertension was defined by current use of antihypertensive medication or systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Self-reported sleep disorders and duration were categorized from a single household interview question, and sleep quality was determined from several questions on sleeping habits. The prevalence of hypertension was 30.2% and 7.5%, and 33.0% and 52.1% reported having sleep disorders, short sleep, and poor sleep, respectively. After adjustment for demographic characteristics and comorbidities, having sleep disorders only was not significantly associated with hypertension (odds ratio [OR], 1.65; 95% confidence interval [CI], 0.73-3.77). However, this association was modified by sleep duration: significant associations were observed among adults with concurrent sleep disorders and short sleep (OR, 2.30; 95% CI, 1.49-3.56) and with sleep disorders, short sleep, and poor sleep (OR, 1.84; 95% CI, 1.13-2.98). These findings indicate an association between a combination of sleep problems and hypertension, but prospective studies are needed to understand the complex interplay between them.

Diabetes trends among delivery hospitalizations in the U.S., 1994-2004

OBJECTIVE

To examine trends in the prevalence of diabetes among delivery hospitalizations in the U.S. and to describe the characteristics of these hospitalizations.

RESEARCH DESIGN AND METHODS

Hospital discharge data from 1994 through 2004 were obtained from the Nationwide Inpatient Sample. Diagnosis codes were selected for gestational diabetes mellitus (GDM), type 1 diabetes, type 2 diabetes, and unspecified diabetes. Rates of delivery hospitalization with diabetes were calculated per 100 deliveries.

RESULTS

Overall, an estimated 1,863,746 hospital delivery discharges contained a diabetes diagnosis, corresponding to a rate of 4.3 per 100 deliveries over the 11-year period. GDM accounted for the largest proportion of delivery hospitalizations with diabetes (84.7%), followed by type 1 (7%), type 2 (4.7%), and unspecified diabetes (3.6%). From 1994 to 2004, the rates for all diabetes, GDM, type 1 diabetes, and type 2 diabetes significantly increased overall and within each age-group (15-24, 25-34, and > or =35 years) (P < 0.05). The largest percent increase for all ages was among type 2 diabetes (367%). By age-group, the greatest percent increases for each diabetes type were among the two younger groups. Significant predictors of diabetes at delivery included age > or =35 years vs. 15-24 years (odds ratio 4.80 [95% CI 4.72-4.89]), urban versus rural location (1.14 [1.11-1.17]), and Medicaid/Medicare versus other payment sources (1.29 [1.26-1.32]).

CONCLUSIONS

Given the increasing prevalence of diabetes among delivery hospitalizations, particularly among younger women, it will be important to monitor trends in the pregnant population and target strategies to minimize risk for maternal/fetal complications.

Trends in hospitalizations with psychiatric diagnoses among HIV-infected women in the USA, 1994-2004

Psychiatric illnesses commonly co-occur with HIV infection and such illnesses have been linked to women's poorer medication adherence and suicide. Using hospital discharge data from the 1994-2004 Nationwide Inpatient Sample, we conducted this study to describe hospitalizations with psychiatric diagnoses from 1994 through 2004 and evaluate the association of specific psychiatric disorders among hospitalized HIV-infected women in the USA with their lack of adherence to medical treatment and suicide attempt. Multivariable logistic regression analyses were used to examine trends in hospitalizations with psychiatric diagnoses among nonpregnant HIV-infected women and the association between specific disorders and women's lack of adherence to medical treatment and suicide attempt. Between 1994 and 2004, the estimated number of all hospitalizations among nonpregnant HIV-infected women increased by 8%, while the number of hospitalizations with a psychiatric diagnosis in this population increased by 73%. After adjusting for demographic factors and alcohol/substance abuse, we found that HIV-infected women were more likely to be hospitalized for mood (odds ratio (OR): 2.35; 95% confidence interval (CI): 1.93-2.88), anxiety (OR: 2.24, 95%CI: 1.74-2.88), and psychotic (OR: 1.45, 95%CI: 1.10-1.90) disorders in 2004 than in 1994. There was a significant association of alcohol/substance abuse with mood, adjustment, anxiety, personality, and psychotic disorders. Noncompliance with medical treatment was significantly associated with psychotic disorders, whereas suicide attempt/self-inflicted injury was significantly associated with mood, adjustment, anxiety, personality, and psychotic disorders. The number of hospitalizations with a psychiatric diagnosis among HIV-infected women in the USA has increased substantially. As HIV-infected women live longer, these results highlight the need for targeted public health interventions to address mental health issues in this population.

Diabetes trends in hospitalized HIV-infected persons in the United States, 1994-2004

The prevalence of diabetes in the United States is rising. As HIV-infected people live longer, they become more susceptible to chronic diseases such as diabetes. Additionally, some antiretroviral agents have been linked to impaired glucose tolerance and increased diabetes risk. To estimate the burden and trends of diabetes among hospitalized HIV-infected persons in the United States, we used data from the 1994-2004 Nationwide Inpatient Sample, a nationally representative survey of inpatient hospitalizations. Odds ratios (OR) and 95% confidence intervals (CI) were adjusted for demographic and hospital characteristics using logistic regression. Between 1994 and 2004, the rate of hospitalizations with a diabetes code per 100 hospitalizations increased from 3.9 to 8.4 (2.2 fold) among HIV-infected persons. Among HIV-uninfected people, the corresponding rate increased from 12.8 to 17.7 (1.4 fold). Since 1998, the mean age of HIV-infected hospitalized people with a diabetes diagnosis rose from 45 to 66 years and became similar to that of HIV-uninfected people. Compared to 1994-1996, in 2002-2004 the probability of hospitalizations with diabetes increased among both HIV-infected and HIV-uninfected persons (OR, 1.92, 95% CI, 1.79-2.05 and OR, 1.38, 95% CI, 1.36-1.40, respectively). Given the increasing prevalence of diabetes in hospitalized HIV-infected persons, it will be important to monitor the trends closely in addition to the effects of different types of antiretroviral regimens, in order to optimize comprehensive long-term care of HIV-infected persons.

Trends in hospitalizations of HIV-infected children and adolescents in the United States: analysis of data from the 1994-2003 Nationwide Inpatient Sample

OBJECTIVE

The objective of this study was to describe trends in hospital use by HIV-infected children and adolescents in the United States in the 10 years from 1994 (before highly active antiretroviral therapy) to 2003 (widespread use of highly active antiretroviral therapy).

METHODS

Data from the Nationwide Inpatient Sample database were used. The most frequent diagnoses were evaluated by year, and trends in hospitalizations for selected diagnoses and procedures were examined by multivariate logistic regression.

RESULTS

In 2003, there were an estimated 3419 hospitalizations of HIV-infected children who were 18 years or younger, compared with 11785 such hospitalizations in 1994 (a 71% decrease). This decrease was more marked among infants and children who were younger than 5 years (94% for boys and 92% for girls) than among adolescents (decrease of 47% for boys and increase of 23% for girls 15-18 years of age). The inpatient fatality rate among HIV-infected children decreased from 5.0% in 1994 to 1.8% in 2003. The number of hospitalizations among HIV-infected children in the highly active antiretroviral therapy era decreased significantly compared with before highly active antiretroviral therapy (1994-1996) for Pneumocystis jiroveci, bacterial infection, or sepsis; fungal infection; encephalopathy; failure to thrive; and lymphocytic interstitial pneumonia. No significant change in the number of hospitalizations for Pneumococcus or cytomegalovirus was observed.

CONCLUSIONS

Dramatic decreases in the number of hospitalizations among HIV-infected children occurred since the advent of highly active antiretroviral therapy in the United States. However, this trend is not seen in hospitalizations of adolescents, particularly girls. Hospitalizations for several HIV-related conditions are less frequent in the highly active antiretroviral therapy era, but for certain other conditions, the hospitalization burden remains high.

Prevalence of Self‐Reported High Blood Pressure Awareness, Advice Received From Health Professionals, and Actions Taken to Reduce High Blood Pressure Among US Adults—Healthstyles 2002

High blood pressure awareness, advice received from health care providers, and adoption of heart-healthy behaviors were assessed using the Healthstyles 2002 survey. About 20% of respondents reported that they had high blood pressure, and 53% of these were currently taking medications to lower blood pressure. Black men had the highest adjusted prevalence of high blood pressure (32%). Medication use among persons with high blood pressure was lower among Hispanics (45%) than among blacks (54%) and whites (54%). Persons reporting having high blood pressure were five times more likely to report having received advice from a health care professional to go on a diet or change eating habits (p<0.05) and reduce salt or sodium in their diet (p<0.05), but five times less likely to have received advice to exercise (p<0.05) than those reporting not having high blood pressure, after adjustment for differences in sex, race/ethnicity, and age. Persons with self-reported high blood pressure were also more likely to be making these modifications (p<0.05). Among people with high blood pressure, current medication use was associated with both receiving and following advice for diet change and salt reduction (p<0.05). Future initiatives are needed to improve the proportion of Hispanics and blacks taking prescribed medications to improve high blood pressure control and reduce risk for serious sequelae such as heart disease and stroke.

Hospitalizations of pregnant HIV-infected women in the United States in the era of highly active antiretroviral therapy (HAART)

Highly active antiretroviral therapy (HAART) has improved the outlook of HIV-infected patients, but it has several side effects, particularly when it is used during pregnancy. Prior to the advent of HAART, HIV-infected women were at increased risk for adverse pregnancy outcomes. This report describes hospital use among pregnant HIV-infected women in the United States in the HAART era and compares hospitalizations for select morbidities in pregnant HIV-infected vs. uninfected women. In 2003, the majority of HIV-infected pregnant women were hospitalized in urban hospitals in the South and had Medicare or Medicaid as the expected payer. HIV-infected pregnant women had longer hospitalizations and incurred higher hospitalization charges than uninfected women. In addition, HIV-infected pregnant women were more likely to be hospitalized for major puerperal sepsis, sexually transmitted infections, urinary tract infections, bacterial infections, liver disorders, and preterm labor/delivery than uninfected women, even after adjusting for sociodemographic factors and comorbid conditions. No significant differences were observed in the rates of preeclampsia and antepartum hemorrhage in the two groups. HIV-infected pregnant women in the United States in the era of HAART remain at higher risk for several morbidities and adverse obstetrical outcomes than uninfected women.

Children with sickle cell disease and human immunodeficiency virus-1 infection: use of inpatient care services in the United States

BACKGROUND

The purpose of this study was to describe hospital use patterns of children with sickle cell disease (SCD) and human immunodeficiency virus type-1 (HIV) infection in the United States.

METHODS

Hospital discharges of children with 1 or both of the 2 conditions (SCD and HIV infection) were analyzed using nationally weighted data from the 1994 to 2003 Nationwide Inpatient Databases of the Healthcare Cost and Utilization Project. Demographic and hospital characteristics, length of stay, charges and the most frequent diagnoses and procedures performed during the hospitalization were compared. Multivariate logistic regression was used to analyze the effects of age, sex and HIV infection on number of hospitalizations for selected conditions.

RESULTS

There were an estimated 686 hospitalizations of children with SCD and HIV infection in the United States in the 10-year period 1994-2003; these hospitalizations aggregated in the South (78.2%) and their expected payer was mostly Medicaid/Medicare (82.0%). Their average length of stay was longer than that of children with SCD alone (8.0 days vs. 4.3 days, respectively), and the mean charges associated with the hospitalization were also higher ($18,291 vs. $9584). Compared with patients with SCD without HIV, HIV infection conferred a higher risk for hospitalizations for bacterial infections and sepsis (odds ratio 2.75; 95% CI, 1.66-4.6), but less of a risk for vaso-occlusive crises (odds ratio 0.32; 95% CI, 0.22-0.48). Inpatient case-fatality rate of children with SCD and HIV was no different from that of children with SCD alone, but lower than that of the rest of children with HIV infection.

CONCLUSIONS

Hospitalized children with SCD and HIV infection have higher odds of infection than those with SCD alone. Their inpatient case-fatality rate is lower than that of children with HIV infection alone. These findings should be considered in designing appropriate interventions for this population.

Breast milk CD4+ T cells express high levels of C chemokine receptor 5 and CXC chemokine receptor 4 and are preserved in HIV-infected mothers receiving highly active antiretroviral therapy

BACKGROUND

Transmission of human immunodeficiency virus (HIV) to the infant through breast-feeding is a major problem worldwide; however, the biological circumstances of such transmission remain unclear. Little characterization of breast milk CD4(+) T lymphocytes has been done so far.

METHODS

We performed a detailed immunophenotypic analysis of T lymphocytes in the breast milk, compared with the blood, of HIV-uninfected (n=9) and HIV-infected (n=10) women receiving highly active antiretroviral therapy, by use of multiparameter flow cytometry. Descriptive statistics and nonparametric comparisons were performed using SAS software (version 9.1; SAS Institute).

RESULTS

In uninfected women, 44%-78% of breast milk CD4(+) T cells expressed the C chemokine receptor 5 (CCR5), whereas 26%-73% of cells coexpressed CCR5 and CXC chemokine receptor 4 (CXCR4). In contrast, only 7%-20% of peripheral blood CD4(+) T cells expressed CCR5 and 1%-20% coexpressed CCR5 and CXCR4. The level of CCR5 expression in CD4(+) T cells in breast milk was higher than in blood. In HIV-infected women, the high frequency of CD4(+)CCR5(+) T cells in breast milk was preserved.

CONCLUSIONS

A majority of CD4(+) T cells in breast milk express high levels of CCR5 and CXCR4. Unlike other mucosal immune sites, in which CD4(+)CCR5(+) T cells are rapidly eliminated by HIV, these cells are preserved in breast milk during HIV infection.

Hospitalizations of pregnant HIV-infected women in the USA prior to and during the era of HAART, 1994-2003

BACKGROUND

The literature on whether HIV infection and its complex antiretroviral treatments confer a higher risk for adverse pregnancy outcomes is controversial.

OBJECTIVE

We compared rates of hospitalization for select morbidities among HIV-infected and uninfected pregnant women in the USA.

DESIGN AND METHODS

Using data from the 1994-2003 Nationwide Inpatient Sample, we used descriptive statistics and multivariate logistic regression to examine socio-demographic characteristics, morbidity outcomes and time trends.

RESULTS

There were approximately 6000 hospitalizations per year of HIV-infected pregnant women in the USA. HIV-infected women were more likely to be hospitalized in urban hospitals, in the South, have Medicaid as the expected payer, have longer hospitalizations and incur higher charges than uninfected women. Hospitalizations for major puerperal sepsis, genitourinary infections, influenza, bacterial infections, preterm labor/delivery, and liver disorders were more frequent among pregnant HIV-infected women than their uninfected counterparts. However, rates of pre-eclampsia and antepartum hemorrhage were not significantly different. While rates of inpatient mortality and various infectious conditions decreased between 1994 and 2003, the rate of gestational diabetes increased among HIV-infected pregnant women.

CONCLUSIONS

HIV-infected pregnant women in the USA continue to be at higher risk for morbidity and adverse obstetric outcomes. With the introduction of antiretroviral therapy, rates of most of the conditions examined have either decreased or remained stable, hence current antiretroviral regimens do not seem to be associated with major adverse pregnancy outcomes on a population basis. The increase in gestational diabetes among HIV-infected women may be associated, in part, with antiretroviral therapy and merits further attention.

Health-related information on the Web: results from the HealthStyles Survey, 2002-2003

INTRODUCTION

The World Wide Web is being used increasingly as a resource for accessing health-related information. In our study, we identified types of health-related Web sites visited most often, determined how often patients shared Web-accessed health information with their doctors, and examined factors that encouraged Internet use for locating health-related information. We also compared health-related Internet use among people who did not have any type of chronic disease with people who reported having one or more chronic diseases.

METHODS

We merged data from the 2002 and 2003 HealthStyles surveys to generate frequency and descriptive statistics and used multivariate logistic regression to estimate odds ratios.

RESULTS

Approximately 35% of survey participants reported using the Internet to search for health-related information. Among them, the Web sites visited most often included health information portals, government agencies, and nonprofit organizations. About 53% reported that they "sometimes" shared Internet information with their doctors. The most important features of the Internet that would encourage its use for health information were ease of finding and using the information and clarity of the information provided. Internet use differed by sex and age and was strongly associated with income and education. Respondents who reported having a chronic disease (odds ratio [OR] = 1.30; 95% confidence interval [CI], 1.16-1.45) were more likely to use the Internet to access health-related information, especially among those with depression (OR = 1.47; 95% CI, 1.27-1.71) and high cholesterol (OR = 1.18; 95% CI, 1.02-1.37). In addition, respondents who reported having two or more chronic diseases (OR = 1.35; 95% CI, 1.16-1.56) were more likely to search for online health information than respondents who reported having no chronic disease.

CONCLUSION

Public health professionals have a unique opportunity to use the Internet as a tool to complement and supplement the health information that the public receives from health care professionals.