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Background: This mixed methods study reports on product acceptance from a Phase I clinical trial of a candidate non-nucleoside reverse transcriptase inhibitor (NNRTI) vaginal microbicide product (UC781). The product was evaluated in the context of a Phase I clinical trial in an area characterized by high HIV prevalence among minority women. The findings will inform the development of an acceptable microbicide that will address the needs of diverse women and their partners., Methods: This is a mixed methods study of 34 racially and ethnically diverse female participants and 10 male partners in Atlanta, Georgia. Chi-square tests for marginal homogeneity and kappa statistics were calculated to analyze differences between groups on product attributes and use intention. ANOVA was used to examine difference between the treatment groups. Qualitative data were analyzed via constant comparative methodology., Results: Thirty-four out of the original female cohort of 36 completed the questionnaire. Approval of future microbicide development was high at 91.2% (n=31) despite a lack of enthusiasm for the placebo and UC781 formulations. Overall female acceptability was correlated with personal protection motivation (r=1.00, p<0.001). African American women indicated greater likelihood of post-licensure microbicide use (X 2 =7.9, p=0.048) and ascribed greater importance to its potential protection against HIV (X (3) =18.7, p=0.001) and its potential for dual protection (protective against STIs and/or pregnancy) compared to white women (X 2 =11.3, p=0.024). Men and women supported development in the form of an intravaginal ring or suppository. Men were more likely to encourage female adoption of the method if it afforded HIV protection (r=0.935, p=0.001).(4) =18.7, p=0.001) and its potential for dual protection (protective against STIs and/or pregnancy) compared to white women (X 2 (4) =11.3, p=0.024). Men and women supported development in the form of an intravaginal ring or suppository. Men were more likely to encourage female adoption of the method if it afforded HIV protection (r=0.935, p=0.001)., Conclusions: Although most women agreed that the development of a microbicide was an important endeavor, quantitative and qualitative data indicated they would not use placebo or UC781 due to the objectionable viscosity, odor, and color. Male partners felt the potential protective benefit of a future microbicide product was its most important feature.

A Water Safety Plan (WSP) is a preventive, risk management approach to ensure drinking water safety. The World Health Organization (WHO) guidelines place WSPs within a larger 'framework for safe drinking-water' that links WSPs to health, creating an implicit expectation that implementation of WSPs will safeguard health in areas with acceptable drinking water quality. However, many intervening factors can come between implementation of an individual WSP and ultimate health outcomes. Evaluating the impacts of a WSP, therefore, requires a much broader analysis than simply looking at health improvements. Until recently, little guidance for the monitoring and evaluation of WSPs existed. Drawing examples from existing WSPs in various regions, this paper outlines a conceptual framework for conducting an overall evaluation of the various outcomes and impacts of a WSP. This framework can provide a common basis for implementers to objectively monitor and evaluate the range of outcomes and impacts from WSPs, as well as a common understanding of the time frames within which those results may occur. As implementers understand the various outcomes and impacts of WSPs beyond health, a strong evidence base for the effectiveness of WSPs will develop, further enabling the scaling up of WSP implementation and provision of better quality water.

Recommended childhood vaccines have typically been provided through routine immunization programs. Recently, implementation of strategies that use campaign-like features for providing all the recommended childhood immunizations have been utilized to increase vaccination coverage. Between January 2006 and January 2008, Assam, India, conducted Immunization Weeks (IWs), a periodic campaign-like approach for providing the recommended childhood vaccines generally administered through the routine Universal Immunization Program (UIP). Using data from a household vaccination coverage survey conducted in 5 districts of Assam in late-2007/early-2008 among children 12-28 months of age, a secondary analysis was conducted for a subset of children with vaccination cards to assess the impacts of implementing the IW-strategy. Sixty-five percent of the 3310 surveyed children received at least one vaccine dose through an IW. Without IWs, coverage would likely have been lower for all vaccines (e.g., 75% measles vaccine coverage including IWs doses and an estimated 61% without IWs). The proportion of children receiving at least one IW dose was significantly different depending on the child's residence; 72% in hard-to-reach char areas, 66% in rural areas and 53% in urban areas (p=0.01). Overall, 2085 (63%) of children were fully vaccinated; of these 60% received a combination of IW and UIP doses, 35% received doses only through the UIP, and 5% received doses only through IWs. A delay in administration later than the recommended ages was found for both UIP doses and for IW doses (e.g., for measles vaccine, UIP doses were 6.9 weeks delayed and IW doses 13.6 weeks delayed). Among this sample of vaccinated children, IWs appeared to increase vaccination coverage and improve access to services in hard-to-reach areas. However, the UIP appeared to be a better system for ensuring that children received all doses in the recommended vaccination series., (Published by Elsevier Ltd.)

Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs.

In September 2001, Cooperative Assistance and Relief Everywhere, Peru Country Office (CARE Peru), obtained funding from the United States Agency for International Development (USAID) to implement community-supported, condominial water and sanitation interventions in Manuel Cardozo Dávila, a settlement in Iquitos, Peru. With technical support from the Centers for Disease Control and Prevention (CDC), CARE Peru's Urban Environmental Health Models (Modelos Urbanos de Salud Ambiental [MUSA]) project built on previous work from implementing the Protocol for Assessing Community Excellence in Environmental Health in this same community. The project led to the municipal water supply distribution system being extended 1.3 kilometers into the Southern zone of Iquitos, where it connected to the condominial water system. Altogether, 1030 households were connected to the water supply system after the installation of a condominial water and sewerage system in Cardozo. Diarrheal disease decreased by 37% for children less than 5 years of age from 2003 to 2004. This paper illustrates the strategy used by CARE Peru in conjunction with the Cardozo community to assure that the local demand for improved water and sanitation was met., (Published by Elsevier GmbH.)

Background: During the Rift Valley fever (RVF) epidemic of 2006-2007 in eastern Africa, spatial mapping of the outbreaks across Kenya, Somalia, and Tanzania was performed and the RVF viruses were isolated and genetically characterized., Methods: Following confirmation of the RVF epidemic in Kenya on 19 December 2006 and in Tanzania on 2 February 2007, teams were sent to the field for case finding. Human, livestock, and mosquito specimens were collected and viruses isolated. The World Health Organization response team in Kenya worked with the WHO's polio surveillance team inside Somalia to collect information and specimens from Somalia., Results: Seven geographical foci that reported hundreds of livestock and >25 cases in humans between December 2006 and June 2007 were identified. The onset of RVF cases in each epidemic focus was preceded by heavy rainfall and flooding for at least 10 days. Full-length genome analysis of 16 RVF virus isolates recovered from humans, livestock, and mosquitoes in 5 of the 7 outbreak foci revealed 3 distinct lineages of the viruses within and across outbreak foci., Conclusion: The findings indicate that the sequential RVF epidemics in the region were caused by multiple lineages of the RVF virus, sometimes independently activated or introduced in distinct outbreak foci.

Background: The true burden of reactivation of remote latent tuberculosis infection (reactivation TB) among foreign-born persons with tuberculosis (TB) within the United States is not known. Our study objectives were to estimate the proportion of foreign-born persons with TB due reactivation TB and to describe characteristics of foreign-born persons with reactivation TB., Methods: We conducted a cross-sectional study of patients with an M. tuberculosis isolate genotyped by the U.S. National TB Genotyping Service, 2005-2009. TB cases were attributed to reactivation TB if they were not a member of a localized cluster of cases. Localized clusters were determined by a spatial scan statistic of cases with isolates with matching TB genotype results. Crude odds ratios and 95% confidence intervals were used to assess relations between reactivation TB and select factors among foreign-born persons., Main Results: Among the 36,860 cases with genotyping and surveillance data reported, 22,151 (60%) were foreign-born. Among foreign-born persons with TB, 18,540 (83.7%) were attributed to reactivation TB. Reactivation TB among foreign-born persons was associated with increasing age at arrival, incidence of TB in the country of origin, and decreased time in the U.S. at the time of TB diagnosis., Conclusions: Four out of five TB cases among foreign-born persons can be attributed to reactivation TB and present the largest challenge to TB elimination in the U.S. TB control strategies among foreign-born persons should focus on finding and treating latent tuberculosis infection prior to or shortly after arrival to the United States and on reducing the burden of LTBI through improvements in global TB control.

Objectives: Between January and March of 2006, over 35 000 diarrhea cases and 532 deaths were reported among children aged <5 years in Botswana. We conducted an investigation to characterize the outbreak, identify risk factors for diarrhea, and recommend control strategies., Methods: We enrolled children <5 years of age presenting to the emergency department between March 2 and March 20, 2006. Cases had ≥3 loose stools per day and no antecedent diarrhea among household members. Controls had had no diarrhea since January 1, 2006. We conducted a multivariate logistic regression analysis controlling for socioeconomic status, age, and maternal HIV status., Results: Forty-nine cases with median age of 12 months (range 0-45 months) and 61 controls with median age of 24 months (range 0-59 months) were enrolled; 33 (30%) were born to HIV-positive mothers. Case-parents were more likely to report storing household drinking water (adjusted odds ratios (AOR) 3.9, 95% confidence interval (CI) 1.2-15.7). Lack of hand washing after using the toilet or latrine (AOR 4.2, 95% CI 1.1-20.4) was more likely to be reported by case-parents. Case-children were less likely to be currently breastfeeding (AOR 30.3, 95% CI 2.0-1000.0). Five (10%) case-patients and no control-patients died. Multiple causal pathogens were identified., Conclusions: During this diarrhea outbreak in a country with a national program to prevent mother-to-child transmission of HIV, ill children were less likely to be breastfed and more likely to have been exposed to environmental factors associated with fecal contamination. These findings underscore the importance of adequate access to safe water, sanitation, hygiene, and nutrition education among populations using breast milk substitutes., (Copyright © 2010. Published by Elsevier Ltd.)

No studies have quantified the impact of pre-culture antibiotic use on the recovery of individual blood-borne pathogens or on population-level incidence estimates for Streptococcus pneumoniae. We conducted bloodstream infection surveillance in Thailand during November 2005-June 2008. Pre-culture antibiotic use was assessed by reported use and by serum antimicrobial activity. Of 35,639 patient blood cultures, 27% had reported pre-culture antibiotic use and 24% (of 24,538 tested) had serum antimicrobial activity. Pathogen isolation was half as common in patients with versus without antibiotic use; S. pneumoniae isolation was 4- to 9-fold less common (0.09% versus 0.37% by reported antibiotic use; 0.05% versus 0.45% by serum antimicrobial activity, P < 0.01). Pre-culture antibiotic use by serum antimicrobial activity reduced pneumococcal bacteremia incidence by 32% overall and 39% in children < 5 years of age. Our findings highlight the limitations of culture-based detection methods to estimate invasive pneumococcal disease incidence in settings where pre-culture antibiotic use is common.

Foodborne outbreaks from contaminated fresh produce have been increasingly recognized in many parts of the world. This reflects a convergence of increasing consumption of fresh produce, changes in production and distribution, and a growing awareness of the problem on the part of public health officials. The complex biology of pathogen contamination and survival on plant materials is beginning to be explained. Adhesion of pathogens to surfaces and internalization of pathogens limits the usefulness of conventional processing and chemical sanitizing methods in preventing transmission from contaminated produce. Better methods of preventing contamination on the farm, or during packing or processing, or use of a terminal control such as irradiation could reduce the burden of disease transmission from fresh produce. Outbreak investigations represent important opportunities to evaluate contamination at the farm level and along the farm-to-fork continuum. More complete and timely environmental assessments of these events and more research into the biology and ecology of pathogen-produce interactions are needed to identify better prevention strategies.

Setting: Banteay Meanchey Province, Cambodia., Objective: Cambodia has the highest incidence of tuberculosis (TB) in Asia. Not all TB patients are tested for human immunodeficiency virus (HIV). We assessed the association between distance to HIV testing facility and HIV testing rates., Methods: We analyzed data on TB patients from 11 clinics to determine the proportion tested for HIV infection. We categorized each TB clinic as having a voluntary confidential counseling and testing (VCCT) center onsite, or being at <15 min, 15-30 min or >30 min driving distance to the nearest VCCT., Results: Of 1017 TB patients not previously tested for HIV, 708 (70%) were tested. Of 481 TB patients without onsite VCCT, 297 (62%) were tested, compared to 410 (77%) of 535 TB patients with onsite VCCT (RR 0.6, 95%CI 0.5-0.7). When the VCCT site was >15 min from the TB clinic, HIV testing occurred only half as frequently as when onsite VCCT was available., Conclusion: TB patients treated at clinics without onsite or nearby HIV testing are less commonly tested for HIV infection. Making HIV testing available to TB patients without the necessity of traveling to a distant HIV testing site is likely to increase HIV testing rates.

Setting: Thailand's Tuberculosis (TB) Active Surveillance Network in four provinces in Thailand., Objective: As treatment default is common in mobile and foreign populations, we evaluated risk factors for default among non-Thai TB patients in Thailand., Design: Observational cohort study using TB program data. Analysis was restricted to patients with an outcome categorized as cured, completed, failure or default. We used multivariate analysis to identify factors associated with default, including propensity score analysis, to adjust for factors associated with receiving directly observed treatment (DOT)., Results: During October 2004-September 2006, we recorded data for 14359 TB patients, of whom 995 (7%) were non-Thais. Of the 791 patients analyzed, 313 (40%) defaulted. In multivariate analysis, age>or=45 years (RR 1.47, 95%CI 1.25-1.74), mobility (RR 2.36, 95%CI 1.77-3.14) and lack of DOT (RR 2.29, 95%CI 1.45-3.61) were found to be significantly associated with default among non-Thais. When controlling for propensity to be assigned DOT, the risk of default remained increased in those not assigned DOT (RR 1.99, 95%CI 1.03-3.85)., Conclusion: In non-Thai TB patients, DOT was the only modifiable factor associated with default. Using DOT may help improve TB treatment outcomes in non-Thai TB patients.

Setting: Integrated tuberculosis (TB) and human immunodeficiency virus (HIV) services in a resource-constrained setting., Objective: Pilot provider-initiated HIV testing and counselling (PITC) for TB patients and suspects., Design: Through partnerships, resources were mobilised to establish and support services. After community sensitisation and staff training, PITC was introduced to TB patients and then to TB suspects from December 2003 to December 2005., Results: Of 5457 TB suspects who received PITC, 89% underwent HIV testing. Although not statistically significant, TB suspects with TB disease had an HIV prevalence of 61% compared to 63% for those without. Of the 614 suspects who declined HIV testing, 402 (65%) had TB disease. Of 2283 patients referred for cotrimoxazole prophylaxis, 1951 (86%) were enrolled, and of 1727 patients assessed for antiretroviral treatment (ART), 1618 (94%) were eligible and 1441 (83%) started treatment., Conclusions: PITC represents a paradigm shift and is feasible and acceptable to TB patients and TB suspects. Clear directives are nevertheless required to change practice. When offered to TB suspects, PITC identifies large numbers of persons requiring HIV care. Community sensitisation, staff training, multitasking and access to HIV care contributed to a high acceptance of HIV testing. Kenya is using this experience to inform national response and advocate wide PITC implementation in settings faced with the TB-HIV epidemic.

Background: The human immunodeficiency virus (HIV) fuels tuberculosis (TB) epidemics. In controlled clinical trials, antiretroviral therapy (ART) reduces TB incidence in HIV-infected patients. In this study we determine if, under programmatic conditions, Brazil's policy of universal ART access has impacted TB incidence among HIV-infected patients., Methods: We abstracted clinical information from records of HIV-infected patients managed in the public sector in 11 Brazilian states between 1/1/1995 and 12/31/2001. Case ascertainment (TB and HIV) utilized guidelines (with added stringency) published by Brazil's Ministry of Health. We determined TB incidence and hazards ratio (HR) for ART-naïve and ART-treated [including highly active ART (HAART)] patients employing Cox proportional hazards analysis., Results: Information from 463 HIV-infected patients met study criteria. The median age of the study population was 34 years, 70% were male, and mean follow-up to primary endpoints--TB, death, and last clinic visit--was 330, 1059, and 1125 days, respectively. Of the 463 patients, 76 (16%) remained ART-naïve. Of the patients who never received HAART (n = 157) 81 were treated with ART non-HAART. Of the patients who received any ART (n = 387), 306 were treated with HAART (includes those patients who later switched from ART non-HAART to HAART). Tuberculosis developed in 39/463 (8%) patients. Compared to HAART- and ART non-HAART-treated patient groups, TB incidence was 10- (p<0.001) and 2.5-fold (p = 0.03) higher in ART-naïve patients, respectively. The median baseline absolute CD4+ T-lymphocyte count for patients who developed TB was not significantly different from that of patients who remained TB free. In multivariate analysis, the incidence of TB was statistically significantly lower in HAART-treated [HR 0.2; 95% (CI 0.1, 0.6); p<0.01] compared to ART naïve patients. A baseline CD4+ T-lymphocyte count <200 cells/mm(3) [HR 2.5; (95% CI 1.2, 5.4); p<0.01], prior hospitalization [HR 4.2; (95% CI 2.0, 8.8); p<0.001], prior incarceration [HR 4.1; 95% CI 1.6, 10.3); p<0.01], and a positive tuberculin skin test [HR 3.1; (95% CI 1.1, 9.0); p = 0.04] were independently and positively associated with incident TB., Conclusion: In this population-based study we demonstrate an 80% reduction in incident TB, under programmatic conditions, in HAART-treated HIV-infected patients compared to ART-naïve patients.

Purpose: This study assessed the contraceptive outcomes of the Partners Against Risk-Taking: A Networking, Evaluation and Research Study (PARTNERS). The PARTNERS project developed and evaluated a 3-session intervention to help young women and their male partners reduce their risk for unintended pregnancies, and HIV and other STDs., Methods: Participating couples were randomly assigned to the 3-session intervention or a 1-session information session for couples. Changes in psychosocial factors related to women's motivation to use contraception and relationship factors were assessed using analysis of variance with repeated measures. Changes in contraceptive outcomes were assessed using logistic regression with generalized estimating equations., Results: Comparison of changes from baseline to 6 months among women who participated in the 3-session intervention with those who participated in the information session showed no significant intervention effect on reports of contraceptive use. Instead, contraceptive use increased in both conditions. Both groups exhibited similar changes in the psychosocial variable measuring the importance of avoiding pregnancy and in the relationship variable measuring women's participation in contraceptive decision making. Members of the intervention group, however, showed greater improvement in the psychosocial variable measuring positive expectations pertaining to partner's support for contraception., Conclusion: These findings raise questions for further investigation to better understand couples behavior, and whether and how to intervene with couples.

Objective: To estimate direct medical costs and average lifetime cost per case of pelvic inflammatory disease (PID)., Methods: We estimated the direct medical expenditures for PID and its three major sequelae (chronic pelvic pain, ectopic pregnancy, and infertility) and determined the average lifetime cost of a case of PID and its sequelae. We analyzed 3 years of claims data of privately insured individuals to determine costs, and 3 years of national survey data to determine number of cases of PID, chronic pelvic pain, and ectopic pregnancy. We developed a probability model to determine the average lifetime cost of a case of PID., Results: Direct medical expenditures for PID and its sequelae were estimated at $1.88 billion in 1998: $1.06 billion for PID, $166 million for chronic pelvic pain, $295 million for ectopic pregnancy, and $360 million for infertility associated with PID. The expected lifetime cost of a case of PID was $1167 in 1998 dollars. The majority of those costs ($843 per case) represent care for acute PID rather than diagnosis and treatment of sequelae. Approximately 73% of cases will not accrue costs beyond the treatment of acute PID., Conclusion: The direct medical cost of PID is still substantial. The majority of PID related costs are incurred in the treatment of acute PID. Because most PID-related costs arise in the first year from treatment of acute PID infection, strategies that prevent PID are likely to be cost-effective within a single year.