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This article presents the feasibility and acceptability of using mobile health technology by community health workers (CHWs) in San Juan Province, Dominican Republic, to improve identification of pregnancy complications and access to care for pregnant women. Although most women in the Dominican Republic receive four antenatal care visits, poor women and adolescents in remote areas are more likely to have only one initial prenatal visit to verify the pregnancy. This community-based research began when community leaders raised concern about the numbers of their mothers who died in childbirth annually; San Juan's maternal mortality rate is 144/100,000 compared to the Caribbean rate of 85/100,000. Eight CHWs in three communities were taught to provide third-trimester antenatal assessment, upload the data on a mobile phone application, send the data to the local physician who monitored data for "red flags," and call directly if a mother had an urgent problem. Fifty-two pregnant women enrolled, 38 were followed to delivery, 95 antenatal care postintake were provided, 2 urgent complications required CHW home management of mothers, and there were 0 deaths. Stakeholders endorsed acceptability of intervention. Preliminary data suggest CHWs using mobile health technology is feasible, linking underserved and formal health care systems with provision of primary care in mothers' homes.

Aims and objectives. To investigate infant well-being as measured by feeding and sleeping and parental support following discharge from the NICU in infants following major cardiac surgery. Background. Infant feeding and sleeping have been identified as two of the most important concerns reported by parents. These concerns have been reported anecdotally for infants who have undergone cardiac surgery in the neonatal period. Design. A prospective study using questionnaires and phone interviews followed a cohort of parents of neonates who underwent surgery in the neonatal period for congenital heart disease. Methods. The study was conducted using validated questionnaires and phone interviews with a semi-structured questionnaire. The questionnaires were administered prior to discharge from the NICU and interviews took place following discharge on five occasions within nine months. Results. Fifty six infants and mothers were followed for nine months following discharge from NICU. Sixty-eight per cent were breastfeeding on discharge however the rates decline over time in line with healthy infants. Mothers were not bothered by their infant’s sleep patterns which were consistent with those of healthy infants at six months. There were 37 episodes of re-hospitalisation and the average time of further surgery was five months following discharge from their initial period of hospitalisation. Conclusion. The issues from this pilot study warrant further investigation. Factors such as multiple hospitalisations, parent education and support may vary within contexts and need to be studied to ensure optimal supports are identified for this high risk population. Relevance to clinical practice. This study identified several issues that can improve care provided to these infants and their parents. Support following discharge could include: lactation consultant to provide follow-up calls to identify concerns with breastfeeding, lactation course for paediatric nurses providing follow-up and education for Early Childhood Clinics on Congenital Heart Disease.

We reviewed adverse events following receipt of inactivated mouse brain-derived Japanese encephalitis (JE) vaccine reported to the U.S. Vaccine Adverse Event Reporting System (VAERS) from 1999 to 2009. During this period, VAERS received 300 adverse event reports following JE vaccination (24 per 100,000 doses distributed); 106 (35%) were classified as hypersensitivity reactions (8.4 per 100,000 doses) and four (1%) were classified as neurologic events (0.3 per 100,000 doses). Twenty-three (8%) reports described serious adverse events (1.8 per 100,000 doses distributed). There were no reports of encephalitis, meningitis, or Guillain-Barré syndrome. As reported previously, hypersensitivity reactions were common among persons receiving inactivated mouse brain-derived JE vaccine.

Japanese encephalitis (JE) is a severe disease and a risk for travelers who visit JE-endemic countries. We reviewed all published JE cases in travelers from non-endemic areas from 1973 through 2008, and assessed factors related to risk of infection. There were 55 cases that occurred in citizens of 17 countries. Age range of case-patients was 1–91 years (median = 34 years). Ten (18%) persons died and 24 (44%) had mild to severe sequelae. In a detailed risk assessment of 37 case-patients, 24 (65%) had spent ≥ 1 month in JE-endemic areas, and most had factors identified that may have increased infection risk. The estimate of overall JE risk was low, < 1 case/1 million travelers to JE-endemic countries. Nonetheless, for each traveler, a careful assessment of itinerary and activities, a decision on vaccination, and information on mosquito precautions are needed to reduce the risk of this disease.

Background. A diagnosis of tuberculosis (TB) relies on acid-fast bacilli (AFB) smear and culture results. Two rapid tests that use nucleic acid amplification (NAA) have been approved by the US Food and Drug Administration for the diagnosis of TB based on detection of Mycobacterium tuberculosis from specimens obtained from the respiratory tract. We evaluated the performance of NAA testing under field conditions in a large urban setting with moderate TB prevalence. Methods. The medical records of patients with suspected TB during 2000-2004 were reviewed. Analysis was restricted to the performance of NAA on specimens collected within 7 days after the initiation of treatment for TB. The assay's sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) were evaluated. Results. The proportion of patients with confirmed or suspected TB whose respiratory tract specimens were tested by use of NAA increased from 429 (12.9%) of 3334 patients in 2000 to 527 (15.6%) of 3386 patients in 2004; NAA testing among patients whose respiratory tract specimens tested positive for AFB increased from 415 (43.6%) of 952 patients in 2000 to 487 (55.5%) of 877 patients in 2004 (P

This article addresses outcomes as they relate to a responsiveness-to-intervention (RTI/RtI) model used in a pre-kindergarten (pre-k) setting. The RTI model requires frequent progress monitoring of at-risk students' responses to evidence-based interventions. Treatment outcomes studies judge whether interventions are effective for their intended purpose. This article defines outcomes, describes the importance of outcomes in an RTI model, and tells how to obtain outcome data. Outcomes from a pre-k language intervention will be presented.

To the Editor: White-nose syndrome (WNS) is an emerging fungal disease in bats that was first described near Albany, New York, USA, in February 2006 (1). The causative agent, Geomyces destructans, is a psychrophilic (cold-loving) fungus that infects the skin of bats and leads to depletion of their fat stores during hibernation (2). WNS has caused dramatic cumulative mortality rates (up to 99%) in some winter hibernacula and has killed millions of bats among 6 cave-roosting species in 19 central and eastern US states and 4 Canadian provinces (3). In addition, the fungus has been identified in 2 additional US states, although bat deaths have not been associated with it. No evidence has been found that WNS is transmitted from bats to humans, although humans may play a role in translocation of the fungus between caves (4,5). Current surveillance for WNS is time- and labor-intensive. Wildlife personnel typically enter caves, inspect hibernacula, and collect bats with clinically compatible signs for testing (4). In July 2010, the National Park Service (NPS) Office of Public Health proposed an expanded WNS surveillance strategy that involved using opportunistic sampling of bats already submitted to state public health laboratories for rabies testing; the bats submitted include species known to be susceptible to WNS. The pilot study focused on the region around Mammoth Cave National Park, the world’s longest known cave system and home to 13 bat species (2 endangered), in south-central Kentucky (6). At the time of initial discussions, Kentucky was WNS-free, but the bordering state of Tennessee had recently reported its first WNS cases in spring 2010 in a cave system located

An epidemic of Zika virus (ZIKV) illness that occurred in July 2007 on Yap Island in the Federated States of Micronesia prompted entomological studies to identify both the primary vector(s) involved in transmission and the ecological parameters contributing to the outbreak. Larval and pupal surveys were performed to identify the major containers serving as oviposition habitat for the likely vector(s). Adult mosquitoes were also collected by backpack aspiration, light trap, and gravid traps at select sites around the capital city. The predominant species found on the island was Aedes (Stegomyia) hensilli. No virus isolates were obtained from the adult field material collected, nor did any of the immature mosquitoes that were allowed to emerge to adulthood contain viable virus or nucleic acid. Therefore, laboratory studies of the probable vector, Ae. hensilli, were undertaken to determine the likelihood of this species serving as a vector for Zika virus and other arboviruses. Infection rates of up to 86%, 62%, and 20% and dissemination rates of 23%, 80%, and 17% for Zika, chikungunya, and dengue-2 viruses respectively, were found supporting the possibility that this species served as a vector during the Zika outbreak and that it could play a role in transmitting other medically important arboviruses., Author Summary Arthropod-borne viruses (arboviruses) cause significant human morbidity and mortality throughout the world. Zika virus, which is reported to be transmitted by Aedes (Stegomyia) species mosquitoes, caused an outbreak on the island of Yap, in the Federated States of Micronesia in 2007. This was the first described outbreak of Zika in Oceania, which has had several arbovirus outbreaks in the past. Diagnosing the outbreak was difficult due to the similarity in clinical symptoms between disease caused by Zika virus and other viruses. This work describes the efforts to identify the mosquito species that were responsible for transmission of the virus. While no virus was isolated from any species of mosquito collected during the current study, the predominant species found was Aedes hensilli and through the complementary laboratory studies, this mosquito was implicated as a probable vector for Zika virus. In addition, this species was found to be susceptible to both the medically important dengue-2 and chikungunya viruses.

Background Japanese encephalitis (JE) vaccine is recommended for travelers to Asia whose itineraries increase their risk of exposure to JE virus. The numbers of travelers with such itineraries and the proportion of those who receive JE vaccine are unknown. We performed a survey to estimate the proportion of US travelers to Asia who receive JE vaccine according to the Advisory Committee on Immunization Practices (ACIP) recommendations. Methods We surveyed US residents ≥18 years old departing on 38 flights to Asia selected through a stratified random sample of all direct flights to JE-endemic countries from three US airports. We asked participants about planned itineraries and activities, sources of travel health information, JE vaccination status, and potential barriers to vaccination. Participants planning to spend ≥30 days in Asia or at least half of their time in rural areas were defined as “higher JE risk” travelers for whom vaccination should have been considered. Results Of 2,341 eligible travelers contacted, 1,691(72%) completed the survey. Among these 1,691 participants, 415 (25%) described itineraries for which JE vaccination should have been considered. Of these 415 higher JE risk travelers, only 47 (11%) reported receiving ≥1 dose of JE vaccine. Of the 164 unvaccinated higher JE risk travelers who visited a health care provider before their trip, 113 (69%) indicated that they had never heard of JE vaccine or their health care provider had not offered or recommended JE vaccine. Conclusions A quarter of surveyed US travelers to Asia reported planned itineraries for which JE vaccination should have been considered. However, few of these at-risk travelers received JE vaccine.

BACKGROUND In 2007, physicians on Yap Island reported an outbreak of illness characterized by rash, conjunctivitis, and arthralgia. Although serum from some patients had IgM antibody against dengue virus, the illness seemed clinically distinct from previously detected dengue. Subsequent testing with the use of consensus primers detected Zika virus RNA in the serum of the patients but no dengue virus or other arboviral RNA. No previous outbreaks and only 14 cases of Zika virus disease have been previously documented. METHODS We obtained serum samples from patients and interviewed patients for information on clinical signs and symptoms. Zika virus disease was confirmed by a finding of Zika virus RNA or a specific neutralizing antibody response to Zika virus in the serum. Patients with IgM antibody against Zika virus who had a potentially cross-reactive neutralizing-antibody response were classified as having probable Zika virus disease. We conducted a household survey to estimate the proportion of Yap residents with IgM antibody against Zika virus and to identify possible mosquito vectors of Zika virus. RESULTS We identified 49 confirmed and 59 probable cases of Zika virus disease. The patients resided in 9 of the 10 municipalities on Yap. Rash, fever, arthralgia, and conjunctivitis were common symptoms. No hospitalizations, hemorrhagic manifestations, or deaths due to Zika virus were reported. We estimated that 73% (95% confidence interval, 68 to 77) of Yap residents 3 years of age or older had been recently infected with Zika virus. Aedes hensilli was the predominant mosquito species identified. CONCLUSIONS This outbreak of Zika virus illness in Micronesia represents transmission of Zika virus outside Africa and Asia. Although most patients had mild illness, clinicians and public health officials should be aware of the risk of further expansion of Zika virus transmission.

BACKGROUND. There has been a gradual decrease in the proportion of children covered by private health insurance in Colorado and the United States with a commensurate increase in those with public insurance or having no insurance which may impact access to care and outcomes.OBJECTIVE. The purpose of this work was to determine whether children with public or no health insurance have differences in hospital admission rates, morbidity, mortality, and/or charges that might be improved if standards of primary care comparable to those of children with private insurance could be achieved.METHODS. We conducted a retrospective comparison of hospitalization-related outcomes for children RESULTS. Compared with those with private insurance, children in Colorado and the United States with public or no insurance have significantly higher rates of total hospital admission, as well as admission for chronic illness, asthma, diabetes, vaccine-preventable disease, psychiatric disease, and ruptured appendix. These children have higher mortality rates, higher severity of illness, are more likely to be admitted through the emergency department and have significantly higher hospital charges per insured child. Higher hospitalization rates occur in children who are nonwhite and/or Hispanic and those who are younger. If children with public or no health insurance in the United States in 2000 had the same hospitalization outcomes as children with private insurance, $5.3 billion in hospital charges could have been saved.CONCLUSIONS. There is an opportunity to achieve improved health outcomes and decreased hospitalization costs for children with public or no health insurance if private insurance standards of health care could be achieved for all US children.