Search

BACKGROUND: There is uncertainty about the burden of hospitalization associated with respiratory syncytial virus (RSV) and influenza in children, including those with underlying medical conditions. METHODS: We applied previously developed methodology to HealthCare Cost and Utilization Project (HCUP) hospitalization data and additional data related to asthma diagnosis/previous history in hospitalized children to estimate RSV and influenza-associated hospitalization rates in different subpopulations of US children between 2003–2010. RESULTS: The estimated average annual rates (per 100,000 children) of RSV-associated hospitalization with a respiratory cause (ICD-9 codes 460–519) present anywhere in the discharge diagnosis were 2381 (95% CI(2252,2515)) in children less than a year of age; 710.6(609.1,809.2) (age 1y); 395(327.7,462.4) (age 2y); 211.3(154.6,266.8) (age 3y); 111.1(62.4,160.1) (age 4y); 72.3(29.3,116.4) (ages 5–6y); 35.6(9.9,62.2) (ages 7–11y); and 39(17.5,60.6) (ages 12–17y). The corresponding rates of influenza-associated hospitalization were lower, ranging from 181(142.5,220.3) in age

Supplemental Digital Content is available in the text., Background: Parainfluenza viruses (PIV) have been shown to contribute substantially to pediatric hospitalizations in the United States. However, to date, there has been no systematic surveillance to estimate the burden among pediatric outpatients. Methods: From August 2010 through July 2014, outpatient health care providers with enumerated patient populations in 13 states and jurisdictions participating in the Influenza Incidence Surveillance Project conducted surveillance of patients with influenza-like illness (ILI). Respiratory specimens were collected from the first 10 ILI patients each week with demographic and clinical data. Specimens were tested for multiple respiratory viruses, including PIV1–4, using reverse transcriptase–polymerase chain reaction assays. Cumulative incidence was calculated using provider patient population size as the denominator. Results: PIVs 1–3 were detected in 8.0% of 7716 ILI-related outpatient specimens: 30% were PIV1, 26% PIV2 and 44% PIV3. PIV circulation varied noticeably by year and type, with PIV3 predominating in 2010–2011 (incidence 110 per 100,000 children), PIV1 in 2011–2012 (89 per 100,000), dual predominance of PIV2 and PIV3 (88 and 131 per 100,000) in 2012–2013 and PIV3 (100 per 100,000) in 2013–2014. The highest incidence of PIV detections was among patients aged

Little information is available describing the epidemiology and clinical characteristics of those12 months hospitalized with influenza, particularly at a population level.We used population-based, laboratory-confirmed influenza hospitalization surveillance data from 2003 to 2012 seasons to describe the impact of influenza by age category (3, 3 to6 and 6 to12 months). Logistic regression was used to explore risk factors for intensive care unit (ICU) admission. Adjusted age-specific, influenza-associated hospitalization rates were calculated and applied to the number of US infants to estimate national numbers of hospitalizations.Influenza was associated with an annual average of 6514 infant hospitalizations (range 1842-12,502). Hospitalization rates among infants3 months were substantially higher than the rate in older infants. Most hospitalizations occurred in otherwise healthy infants (75%) among whom up to 10% were admitted to the ICU and up to 4% had respiratory failure. These proportions were 2-3 times higher in infants with high risk conditions. Infants6 months were 40% more likely to be admitted to the ICU than older infants. Lung disease (adjusted odds ratio 1.80; 95% confidence interval 1.22-2.67), cardiovascular disease (adjusted odds ratio: 4.16; 95% confidence interval: 2.65-6.53), and neuromuscular disorder (adjusted odds ratio: 2.99; 95% confidence interval: 1.87-4.78) were risk factors for ICU admission among all infants.The impact of influenza on infants, particularly those very young or with high risk conditions, underscores the importance of influenza vaccination, especially among pregnant women and those in contact with young infants not eligible for vaccination.

BACKGROUND: Understanding how hospitals functioned during the 2009 influenza A(H1N1)pdm09 pandemic may improve future public health emergency response, but information about its impact on US hospitals remains largely unknown. RESEARCH DESIGN: We matched hospital and emergency department (ED) discharge data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project with community-level influenza-like illness activity during each hospital’s pandemic period in fall 2009 compared with a corresponding calendar baseline period. We compared inpatient mortality for sentinel conditions at high-surge versus nonsurge hospitals. RESULTS: US hospitals experienced a doubling of pneumonia and influenza ED visits during fall 2009 compared with prior years, along with an 18% increase in overall ED visits. Although no significant increase in total inpatient admissions occurred overall, approximately 10% of all study hospitals experienced high surge, associated with higher acute myocardial infarction and stroke case fatality rates. These hospitals had similar characteristics to other US hospitals except that they had higher mortality for acute cardiac illnesses before the pandemic. After adjusting for 2008 case fatality rates, the association between high-surge hospitals and increased mortality for acute myocardial infarction and stroke patients persisted. CONCLUSIONS: The fall 2009 pandemic period substantially impacted US hospitals, mostly through increased ED visits. For a small proportion of hospitals that experienced a high surge in inpatient admissions, increased mortality from selected clinical conditions was associated with both prepandemic outcomes and surge, high-lighting the linkage between daily hospital operations and disaster preparedness.

Reports of hepatitis B virus (HBV) and hepatitis C virus (HCV) transmission associated with unsafe medical practices have been increasing in the United States. However, the contribution of healthcare exposures to the burden of new infections is poorly understood outside of recognized outbreaks. We conducted a case-control study at three health departments that perform enhanced viral hepatitis surveillance in New York and Oregon. Reported cases of symptomatic acute hepatitis B and hepatitis C occurring in persons ≥55 years of age from 2006 to 2008 were enrolled. Controls were identified using telephone directories and matched to individual cases by age group (55-59, 60-69, and ≥70 years) and residential postal code. Data collection covered exposures within 6 months before symptom onset (cases) or date of interview (controls). Forty-eight (37 hepatitis B and 11 hepatitis C) case and 159 control patients were enrolled. Case patients were more likely than controls to report one or more behavioral risk exposures, including sexual or household contact with an HBV or HCV patient, >1 sex partner, illicit drug use, or incarceration (21% of cases versus 4% of controls exposed; matched odds ratio [mOR] = 7.1; 95% confidence interval [CI]: 2.1, 24.1). Case patients were more likely than controls to report hemodialysis (8% of cases; mOR = 13.0; 95% CI: 1.5, 115), injections in a healthcare setting (58%; mOR = 2.7; 95% CI: 1.3, 5.3), and surgery (33%; mOR = 2.3; 95% CI: 1.1, 4.7). In a multivariate model, behavioral risks (adjusted OR [aOR] = 5.4; 95% CI: 1.5, 19.0; 17% attributable risk), injections (aOR = 2.7; 95% CI: 1.3, 5.8; 37% attributable risk), and hemodialysis (aOR = 11.5; 95% CI: 1.2, 107; 8% attributable risk) were associated with case status. Conclusion: Healthcare exposures may represent an important source of new HBV and HCV infections among older adults. (HEPATOLOGY 2013)

Influenza causes substantial morbidity in children in the United States each year. The 2009 influenza A (H1N1) pandemic disproportionately affected the pediatric population and resulted in a substantially increased number of hospitalizations and deaths among children. Early influenza antiviral treatment reduces the duration of illness, frequency of complications, antibiotic use, and health care utilization costs attributable to influenza. A comprehensive strategy to reduce influenza-associated hospitalizations and deaths among children should include empiric antiviral treatment for suspected or confirmed influenza of any severity in children who are hospitalized; who have severe, complicated, or progressive illness; or who are at high risk for influenza complications. Here, we summarize data on the burden of influenza among children in the United States, the indications for influenza antiviral treatment among children, the available evidence for influenza antiviral treatment, and antiviral treatment considerations, including resistance and adverse events.

Pneumonia is one of the most common complications in children hospitalized with influenza. We describe hospitalized children with influenza-associated pneumonia and associated risk indicators.Through Emerging Infections Program Network population based surveillance, children aged18 years hospitalized with laboratory confirmed influenza with a chest radiograph during hospitalization were identified during the 2003-2008 influenza seasons. A case with radiologically confirmed influenza-associated pneumonia was defined as a child from the surveillance area hospitalized with: (1) laboratory-confirmed influenza and (2) evidence of new pneumonia on chest radiograph during hospitalization. Hospitalized children with pneumonia were compared with those without pneumonia by univariate and multivariate analysis.Overall, 2992 hospitalized children with influenza with a chest radiograph were identified; 1072 (36%) had influenza-associated pneumonia.When compared with children hospitalized with influenza without pneumonia, hospitalized children with influenza-associated pneumonia were more likely to require intensive care unit admission (21% vs. 11%, P0.01), develop respiratory failure (11% versus 3%, P0.01), and die(0.9% vs. 0.3% P 0.01). In multivariate analysis, age 6 to 23 months(adjusted OR: 2.1, CI: 1.6 -2.8), age 2 to 4 years (adjusted OR: 1.7, CI:1.3-2.2), and asthma (adjusted OR: 1.4, CI: 1.1-1.8) were significantly associated with influenza-associated pneumonia.Hospitalized children with influenza-associated pneumonia were more likely to have a severe clinical course than other hospitalized children with influenza, and children aged 6 months to 4 years and those with asthma were more likely to have influenza-associated pneumonia.Identifying children at greater risk for influenza-associated pneumonia will inform prevention and treatment strategies targeting children at risk for influenza complications.

To examine 2009 H1N1 influenza illness severity and the effect of antiviral treatment on the severity of illness among pregnant women.We abstracted medical records from hospitalized pregnant (n=62) and nonpregnant (n=74) women with laboratory-confirmed 2009 H1N1 influenza in New York City, May through June 2009. We compared characteristics of pregnant and nonpregnant women and of severe and moderate influenza illness among pregnant women, with severe defined as illness resulting in intensive care admission or death.The 2009 H1N1 hospitalization rate was significantly higher among pregnant than nonpregnant women (55.3 compared with 7.7 per 100,000 population). Eight pregnant (including two deaths) and 16 nonpregnant (including four deaths) cases were severe. Pregnant women represented 6.4% of hospitalized cases and 4.3% of deaths caused by 2009 H1N1 influenza. Only 1 in 30 (3.3%) pregnant women who received oseltamivir treatment within 2 days of symptom onset had severe illness compared with 3 of 14 (21.4%) and four of nine (44.4%) pregnant women who started treatment 3-4 days and 5 days or more after symptom onset, respectively (P=.002 for trend). Severe and moderate 2009 H1N1 influenza illness occurred in all pregnancy trimesters, but most women (54.8%) were in the third trimester. Twenty-two women delivered during their influenza hospitalization, and severe neonatal outcomes (neonatal intensive care unit admission or death) occurred among five of six (83.3%) women with severe illness compared with 2 of 16 (12.5%) women with moderate illness (P=.004).Our findings highlight the potential for severe illness and adverse neonatal outcomes among pregnant 2009 H1N1 influenza-infected women and suggest the benefit of early oseltamivir treatment.II.

Background: Syphilis seroprevalence data can be used as an independent measure of syphilis trends and to augment syphilis case report data for program planning. The prevalence of reactive syphilis serology in jails, delivery rooms, and drug treatment centers was examined from 1995 to 1999. Prevalence was evaluated by age and gender at each site and compared with county primary and secondary syphilis case rates. Annual prevalence of high titer-reactive serology in jails was compared with primary and secondary syphilis case rates. Goal: The goal was to examine trends in syphilis seroprevalence and to evaluate the relationship of trends in seroprevalence to reported cases. Study Design: This was a cross-sectional survey. Results: Prevalence of reactive serology and high titer-reactive serology was lowest among women in delivery rooms (2.9% and 0.4%, respectively) and highest among women in jails (11.1% and 4.1%, respectively), indicating substantial recently treated or active infection among women in jails. Trends in high titer-reactive serology were similar to primary and secondary syphilis case rates. Conclusion: The prevalence of high titer-reactive serology can provide valuable information about community syphilis morbidity for use in prevention and control programs.

Syphilis rates began to decline in 1991 and have decreased every year since. In 1998, 6,993 cases of primary and secondary syphilis were reported in the United States, for a national incidence of 2.6 cases per 100,000 population. Although syphilis rates are at an historic low, focal outbreaks still occur. On October 7, 1999, the Division of Sexually Transmitted Disease Prevention of the Centers for Disease Control and Prevention, in collaboration with federal and community partners, presented the National Plan for Elimination of Syphilis from the United States. One of the five key strategies of the plan is rapid outbreak response.Methods for outbreak assessment and response were reviewed in the literature, synthesized, and adapted for use in syphilis outbreaks.Key elements of outbreak assessment and response are detection, surveillance data review, hypothesis generation, intervention development, and the evaluation of clinical, public health, and laboratory services.Outbreak response necessitates community participation and a coordinated interdisciplinary effort to determine social and behavioral contributors to the outbreak and to develop targeted interventions.

Respiratory syncytial virus (RSV) infection might facilitate bacterial infection. We describe 5 patients with RSV among 30 children admitted to pediatric hospitals in Atlanta between October 1, 2006 and April 30, 2007 with community-onset Staphylococcus aureus pneumonia. RSV-S. aureus patients were younger and had less medical comorbidity than those without RSV.

Although the national rate of gonorrhea declined 68% from 1975 to 1995, rates remain high in many inner-city areas. In 1995, the gonorrhea rate in Newark, NJ, was five times the US rate.To determine factors associated with acquisition of gonorrhea by men in Newark.A case-control study conducted at the sexually transmitted disease (STD) clinic in Newark, comparing males 15 to 29 years with culture-confirmed gonorrhea to controls with no STD.Compared with controls, males with gonorrhea more frequently reported at least 1 casual sex partner within the preceding month (adjusted odds ratio [OR], 3.2; 95% CI, 1.8-5.7), sex after using marijuana during the preceding month (OR, 2.4; 95% CI, 1.1-5.3), and a history of incarceration (OR, 2.1; 95% CI, 1.2-3.7). Of males with casual partners, having a new casual sexual relationship (onset within the past month) was particularly risky for gonorrhea (OR, 3.9; 95% CI, 1.2-12.7). Incorrect condom use was highly prevalent for both cases and controls. Many persons with gonorrhea reported that they were not willing to consistently use condoms or to have only one partner.Sex with casual partners is associated with gonorrhea in males, and may be a difficult practice to change. Condoms are often used incorrectly, if at all, in this population. Prevention strategies, in addition to the promotion of condom use and monogamy, may be necessary.

Background and Objectives: Sexually transmitted diseases (STDs) comprise the majority of national infectious disease morbidity reported, yet the number of epidemiologists working in state and local STD programs is estimated to be small. Even less is known about the training and activities of those epidemiologists. Goals: To determine the number, training, and affiliation of epidemiologists working with STD programs and the level of satisfaction with epidemiologic support available. Study Design: Survey of 65 program managers in state and local health departments. Results: Program managers named 146 people working on epidemiologic activities, and 84 of those people were classified as epidemiologist by the criteria we applied. The median number of full-time equivalent (FTE) epidemiologists working in or with STD programs was 0.5; one quarter of all STD program had no epidemiologists. There was a significant association between number of FTE epidemiologist and population, with most programs with more than 0.5 epidemiologists located in areas with at least 1,000,000 population. State Epidemiologists do not provide technical support to most state STD programs. Almost half (45%) of all program managers indicated that they have inadequate epidemiologic support for routine program activities. Conclusions: The current level of epidemiologic support available to most STD programs is inadequate to perform surveillance and data analyses, interpret data to develop program objectives, and perform program evaluation. An essential next step is the delineation of set of critical, analytic STD field epidemiology functions to define appropriate standards against which epidemiologic capacity can be more precisely measured.

Routine surveillance for bacterial colonization has been used for the past three decades as a tool for the prediction of nosocomial infection in low birth weight infants; however, its usefulness has never been proven. A prospective cohort study was conducted to examine the utility of surveillance for pharyngeal colonization in detection and control of serious bacterial illness in low birth weight infants. One hundred fifty-four infants who weighed less than 1750 g and who were admitted to the Neonatal Intensive Care Unit were enrolled and followed for a total of 5620 infant-days. Pharyngeal cultures were collected at the time of enrollment and then weekly. All infants had bacterial pharyngeal colonization by the third day of life. Coagulase-negative staphylococci were the most common organisms cultured from the pharynx, followed by viridans streptococci and Staphylococcus aureus. More than 90% of the pharyngeal cultures grew multiple isolates. Gram-positive organisms, particularly coagulase-negative staphylococci, were the most prevalent organism recovered from blood and cerebrospinal fluid cultures. Fifty-two episodes of bacteremia and 6 episodes of cerebrospinal fluid infection occurred in 42 infants. Among infants with viridans streptococci in pharyngeal cultures, the subsequent risk of serious bacterial illness was significantly reduced (odds ratio = 0.16). However, pharyngeal cultures were poor predictors of the causative organism in an episode of serious bacterial illness. Pharyngeal and blood/cerebrospinal fluid cultures were concordant in only 11% of invasive infections. We conclude that pharyngeal surveillance cultures provide little clinically meaningful information and have no apparent utility in the Neonatal Intensive Care Unit setting.

A case-control study was conducted to evaluate two main questions: 1) which specific sex- and drug-use behaviors are associated with the acquisition of early syphilis; and 2) whether changes in sex- and drug-use behaviors from 1987-1990 associated with acquisition of early syphilis. Risk factors associated with significant odds ratio were greater than four sex partners and lack of condom use in the past 3 months. Crack use within the past 3 months was the only specific drug-related risk factor with a significantly elevated odds ratio. However, a number of risk factors associated with both sex and drugs had significantly elevated odds ratios: number of drug-using partners, number of partners exchanging sex for drugs and money, and number of partners with whom the respondent shares sex and drugs. Risk estimates for early syphilis were uniformly higher for women as compared with men. Women appeared to be at higher risk of syphilis than men when engaged in the same high-risk activities. From 1987-1990, there was a significant change from lower-risk to higher-risk behaviors among patients. Patients showed an increase in their number of sex partners, in drug use, and in other high-risk activities. Increasing rates of syphilis can be attributed to a particular set of sex- and drug-related behaviors, and an increase in the adoption of these behaviors has probably contributed significantly to the increased rate of early syphilis in Trenton, NJ, during the period from 1987-1990.

THE PAST DECADE has witnessed a revolution in strategies for sexually transmitted disease (STD) control. When outbreaks of syphilis in hard-to-reach populations such as drug users and sex workers revealed the limitations of traditional approaches to case finding, public health was compelled to move beyond STD and family planning clinics, and into the community. A new tenet guiding STD control is to go to the very places where persons at high risk for STD congregate, and to facilities such as prisons and jails that house persons at high risk for STD, even though their primary purpose is entirely nonclinical. The development of noninvasive urine tests for Chlamydia trachomatis, and Neisseria gonorrhoeae, and the availability of single dose, oral antimicrobial therapy for both of these infections has made screening and treatment in these non-clinical venues feasible. STD prevention programs have routinized screening for chlamydial infection and gonorrhea in many jails and prisons, and some have begun to screen for chlamydial infection in schools and community settings.1,2 A substantial amount of experience and data have accumulated to support such screening, although few studies have examined the cost-effectiveness of these approaches. Somewhat surprisingly, the move from traditional, clinical venues to nontraditional, nonclinical venues has largely skipped over emergency departments (EDs). Why is this? Data are now accumulating to suggest that EDs may represent high-yield screening venues, although implementation of ED screening raises unique operational and feasibility issues. The article by Mehta et al in this issue of Sexually Transmitted Diseases contributes more data to the body of evidence indicating that ED screening may identify a substantial number of persons with STD. In their article entitled “Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: A critical population for STD control intervention,” Mehta and colleagues describe chlamydia and gonorrhea testing in an ED population that has a high STD prevalence and risk behaviors associated with the acquisition of STD and HIV.3 Testing for STD in this population was appealing for several reasons. The ED may serve as a point of contact for persons who are uninsured, with little or no access to a regular source of health care, and who are at high risk for STD. In an earlier study in the same ED, 65% of men and 34% of women queried reported that they had no regular source of health care, and approximately half of those men and women had an STD in the past year.4 In a study of persons living in an urban area with high STD incidence, Farley and colleagues found that while few had access to regular sources of health care almost 60% had visited a public or private ED in the past 12 months5; 70% of participants in this study had multiple partners and 30% had unprotected casual sex.5 The Mehta study and others have demonstrated the high prevalence of both STD and HIV infection in urban EDs.3,6–9 The prevalence of infection in recent studies has ranged from 8% to 11% for Chlamydia trachomatis,6–8,10 2% to 9% for gonorrhea,6,7 2% to 8% for syphilis,9,11,12 and 4% to 6% for HIV.9,13 Although ED screening for STD is likely to be high yield, it is unclear whether routine STD testing by ED staff is Correspondence: Julia A Schillinger, MD, MSc, Division of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC, Mailstop E-02, 1600 Clifton Road, NE, Atlanta, GA 30333. E-mail: jus8@cdc.gov Reprint requests: Julia A. Schillinger, Information Services, National Center for HIV, STD, and TB Prevention, CDC, Mailstop E-06, Atlanta, GA 30333. Received for publication October 10, 2000 and accepted October 23, 2000. From the *Surveillance and Special Studies Section and the Epidemiology Research Section, Epidemiology and Surveillance Branch, and the Office of the Director, Division of STD Prevention, National Center for HIV, STD, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia