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Although evidence-based medicine (EBM) has gained increasing focus in medical education, there remains considerable need for innovative approaches to engage learners. We developed a novel online interactive fiction module "EBMQuest", where students navigate three clinical scenarios requiring use of EBM resources for successful progression. Student feedback was strongly positive, with an overall program rating of 4.64 (Good-Very Good). Online interactive fiction should be further explored as a means of delivering innovative medical education.

U.S. Immigration and Customs Enforcement (ICE) is responsible for detaining unauthorized aliens during immigration proceedings. During 2014 to 2015, adult ICE detainees at a California facility were invited to complete a survey concerning self-reported varicella history and risk factors. Participants underwent serological testing for varicella-zoster virus (VZV) IgG; susceptible individuals were offered varicella vaccination. Among 400 detainees with available serology results, 48 (12%) were susceptible to varicella. Self-reported varicella history was negatively associated with susceptibility (adjusted odds ratio = 0.16; 95% confidence interval [0.07, 0.35]). Among 196 detainees reporting a positive history, 95% had VZV IgG levels suggestive of varicella immunity. Among 44 susceptible detainees offered vaccination, 86% accepted. Given relatively high varicella susceptibility, targeted screening and vaccination among ICE detainees lacking a positive history might reduce varicella transmission risks.

Background: Maternal immunization against pertussis is a potential strategy to protect young infants from severe disease. We assessed factors associated with intention to accept pertussis vaccination among pregnant women in Karachi, Pakistan., Methods: We conducted a cross-sectional survey between May and August 2013 in pregnant women who visited healthcare centers in urban slums of Karachi city. Women completed a survey examining socio-demographic factors, vaccination history, knowledge on pertussis disease, perception of vaccine recommendation sources, and potential influences on vaccine decision-making., Results: Of the 283 participants, 259 (92%) provided their intention to either accept or decline pertussis vaccination. Eighty-three percent women were willing to accept the pertussis vaccine if offered during pregnancy. About half (53%) of the participants had ever heard of pertussis disease. Perceptions of pertussis vaccine efficacy, safety, and disease susceptibility were strongly associated with intention to accept pertussis vaccine (p<0.01). Healthcare providers, Ministry of Health, and mass media were considered as highly reliable sources of vaccine recommendation and associated with intention to accept antenatal pertussis vaccination (p<0.001). Healthcare provider recommendation was a common reason cited by respondents for pregnant women to accept antenatal pertussis vaccination (p=0.0005). However, opinion of primary decision-makers in the family (husbands and in-laws) was a crucial reason cited by respondents for pregnant women to reject pertussis vaccination in pregnancy (p=0.003)., Conclusion: Antenatal pertussis vaccination initiatives in South Asia should strongly consider inclusion of family members, healthcare providers, national health ministries, and mass media to help implement new vaccination programs., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Healthy People 2020 targets high vaccination coverage among children. Although reductions in coverage disparities by race/ethnicity have been described, data by nativity are limited. The National Immunization Survey is a random-digit-dialed telephone survey that estimates vaccination coverage among U.S. children aged 19-35 months. We assessed coverage among 52,441 children from pooled 2010-2012 data for individual vaccines and the combined 4:3:1:3*:3:1:4 series (which includes ≥4 doses of diphtheria, tetanus, and acellular pertussis vaccine/diphtheria and tetanus toxoids vaccine/diphtheria, tetanus toxoids, and pertussis vaccine, ≥3 doses of poliovirus vaccine, ≥1 dose of measles-containing vaccine, ≥3 or ≥4 doses of Haemophilus influenzae type b vaccine (depending on product type of vaccine; denoted as 3* in the series name), ≥3 doses of hepatitis B vaccine, ≥1 dose of varicella vaccine, and ≥4 doses of pneumococcal conjugate vaccine). Coverage estimates controlling for sociodemographic factors and multivariable logistic regression modeling for 4:3:1:3*:3:1:4 series completion are presented. Significantly lower coverage among foreign-born children was detected for DTaP, hepatitis A, hepatitis B, Hib, pneumococcal conjugate, and rotavirus vaccines, and for the combined series. Series completion disparities persisted after control for demographic, access-to-care, poverty, and language effects. Substantial and potentially widening disparities in vaccination coverage exist among foreign-born children. Improved immunization strategies targeting this population and continued vaccination coverage monitoring by nativity are needed.

Objectives: To assess hospitalisation risk factors and economic effects associated with a multistate hepatitis A outbreak in 2013., Study Design: Retrospective case series., Methods: Eligible outbreak-related cases confirmed by September 1, 2013, were defined as acute hepatitis symptoms and positive IgM anti-hepatitis A during March 15-August 12 among patients who consumed the food vehicle or had the outbreak genotype. We reviewed medical records, comparing demographic and clinical characteristics among hospitalized and non-hospitalized patients; we used logistic regression analysis to identify factors associated with hospitalization. We interviewed patients regarding symptom duration and healthcare usage and estimated per-patient and total costs. Health departments reported outbreak-related personnel hours., Results: Medical records were reviewed for 147/159 (92%) eligible patients; median age was 48 (range: 1-84) years, and 64 (44%) patients were hospitalized. Having any chronic medical condition was independently associated with hospitalisation (odds ratio, 3.80; 95% confidence interval, 1.68-8.62). Interviews were completed for 114 (72%) eligible patients; estimated per-patient cost of healthcare and productivity loss was $13,467 for hospitalized and $2138 for non-hospitalized patients and $1,304,648 for all 165 outbreak-related cases. State and local public health personnel expenditures included 82 h and $3221/outbreak-related case., Conclusions: Hospitalisations in this outbreak were associated with chronic medical conditions and resulted in substantial healthcare usage and lost productivity. These data can be used to inform future evaluation of expansion of hepatitis A vaccination recommendations to include adults with chronic medical conditions., (Published by Elsevier Ltd.)

Purpose: During recent pertussis epidemics, adolescents have experienced a large burden of disease. We assessed the impact of pertussis among San Diego adolescents and their households., Methods: Parents of pertussis patients aged 13-17 years were surveyed about health care utilization, missed work and school, and other factors. Costs of medical visits, medication use, and lost wages were estimated., Results: The parents of 53 (of 108 [49%]) eligible 2013 pertussis patients were interviewed; 51 (96%) of these patients previously received tetanus, diphtheria, and acellular pertussis vaccine. Medical visits included primary care (81%), urgent care (11%), and emergency department (9%); all patients received antibiotics. Forty-seven households (89%) received a post-exposure prophylaxis recommendation, and five (9%) reported ≥1 unpaid parental leave day. Thirty-eight patients (72%) missed ≥1 school day (mean = 5.4 days). Societal costs were estimated at $315.15 per household and $236,047.35 in San Diego during 2013-2014., Conclusions: Even among vaccinated adolescents, pertussis can result in considerable societal costs., (Published by Elsevier Inc.)

Background: Facilitators and barriers to influenza vaccination among pregnant women in the developing world are poorly understood, particularly in South Asia. We assessed intention to accept influenza vaccine among ethnically diverse low-income pregnant women in Pakistan., Methods: From May to August 2013, we conducted a cross-sectional survey of pregnant women who visited health centers in urban slums in Karachi city. We assessed intention to accept influenza vaccine against socio-demographic factors, vaccination history, vaccine recommendation sources, and other factors., Results: In an unvaccinated study population of 283 respondents, 87% were willing to accept the vaccine, if offered. All except two participants were aware of symptoms typically associated with influenza. Perceived vaccine safety, efficacy, and disease susceptibility were significantly associated with intention to accept influenza vaccine (p<0.05). Regardless of intention to accept influenza vaccine, 96% rated healthcare providers as highly reliable source of vaccine information. While a recommendation from a physician was critical for influenza vaccine acceptance, parents-in-law and husbands were often considered the primary decision-makers for pregnant women seeking healthcare including vaccination., Conclusions: Maternal influenza vaccination initiatives in South Asia should strongly consider counseling of key familial decision-makers and inclusion of healthcare providers to help implement new vaccination programs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Cross-border surveillance for emerging diseases such as Ebola and other infectious diseases requires effective international collaboration. We surveyed representatives from 12 multinational disease surveillance programs between January 2013 and April 2014. Our survey identified programmatic similarities despite variation in health priorities, geography, and socioeconomic context, providing a contemporary perspective on infectious disease surveillance networks., (© The American Society of Tropical Medicine and Hygiene.)

In August 2013, the County of San Diego Health and Human Services Agency was notified of a fatal case of rat-bite fever (RBF) in a previously healthy male, aged 10 years, who owned pet rats. Two days before his death, the patient experienced rigors, fevers, vomiting, headaches, and leg pains. His physician noted a fever of 102.6°F (39.2ºC), documented a normal examination, diagnosed viral gastroenteritis, and prescribed anti-nausea medication. During the next 24 hours, the patient experienced vomiting and persistent fever. He was confused and weak before collapsing at home. Paramedics reported the patient was unresponsive and had dilated pupils; resuscitation was initiated in the field and was continued for >1 hour after arrival at the emergency department but was unsuccessful. A complete blood count performed during resuscitation revealed anemia (hemoglobin 10.0 g/dL [normal = 13.5-18.0 g/dL], thrombocytopenia (platelets 40,000/µL [normal = 140,000-440,000/µL]), leukocytosis (white blood cells 17,900 cells/µL [normal = 4,000-10,500/µL]) with 16% band neutrophils; the patient also had evidence of disseminated intravascular coagulation. No rash or skin breakdown was noted. Lung, liver, and epiglottis tissue collected postmortem was positive for Streptobacillus moniliformis DNA by polymerase chain reaction.

Objectives: Although the hepatitis C epidemic in the United States disproportionately affects correctional populations, the last national estimates of seroprevalence and disease burden among these populations are more than a decade old. We investigated routine hepatitis C surveillance conducted in state prison systems and updated previous estimates., Methods: We surveyed all U.S. state correctional departments to determine which state prison systems had performed routine hepatitis C screening since 2001. Using seroprevalence data for these prison systems, we estimated the national hepatitis C seroprevalence among prisoners in 2006 and the share of the epidemic borne by correctional populations., Results: Of at least 12 states performing routine testing from 2001 to 2012, seroprevalences of hepatitis C ranged from 9.6% to 41.1%. All but one state with multiple measurements demonstrated declining seroprevalence. We estimated the national state prisoner seroprevalence at 17.4% in 2006. Based on the estimated total U.S. correctional population size, we projected that 1,857,629 people with hepatitis C antibody were incarcerated that year. We estimated that correctional populations represented 28.5%-32.8% of the total U.S. hepatitis C cases in 2006, down from 39% in 2003., Conclusions: Our results provide an important updated estimate of hepatitis C seroprevalence and suggest that correctional populations bear a declining but still sizable share of the epidemic. Correctional facilities remain important sites for hepatitis C case finding and therapy implementation. These results may also assist future studies in projecting the societal costs and benefits of providing new treatment options in prison systems.

Objective: Adult booster vaccination against pertussis can help prevent severe infections in young infants. We examined influences on intention to accept pertussis booster vaccination among pregnant women in Mexico City., Methods: We conducted a cross-sectional survey, recruiting convenience samples of pregnant women receiving prenatal care from three public healthcare centers between March and May 2012. Our primary outcome was intention to accept pertussis vaccination during pregnancy. We examined socio-demographic factors, vaccination history, pertussis knowledge, perceptions of vaccine information sources, and other potential influences on vaccine decision-making., Results: A total of 402 pregnant women agreed to participate, of which 387 (96%) provided their intention to accept or decline pertussis vaccination. Among respondents, 57% intended to accept a pertussis booster vaccine if offered, but only 16% had ever heard of pertussis, and only 2% knew someone who had contracted this disease. Over 80% of respondents would accept pertussis vaccination if recommended by an obstetrician-gynecologist. The most frequently selected reasons to refuse pertussis vaccination were concerns that the vaccine might harm the unborn baby or pregnant woman. In multivariate analysis, rating doctors and nurses as good sources of vaccine information, and having ever heard of pertussis, were independently associated with intention to accept pertussis vaccination., Conclusions: Promoting patient awareness about pertussis disease and vaccine safety, and encouraging general practitioners, nurses and obstetricians to recommend pertussis booster vaccine, may increase vaccine uptake among pregnant women., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Insecticide resistance has limited the number of available chemical options for insect pest control. Hence there is a need for new chemistries with novel modes of action. Here we investigate the mode of action for an insecticide that has not yet been released for commercial use. The ovicidal, larvacidal and adulticidal effects of 5,5'-dimethyl -2, 2'-dipyridyl (termed Ha44), which is being developed as a treatment for head lice, were evaluated in the Drosophila melanogaster model system. Ha44 demonstrated significant activity against embryos and was capable of arresting development at a number of stages of embryogenesis. The effects of Ha44 on embryos was shown to be reversible following the addition of the metal ions Fe(II) and Fe(III), Cu and Zn. When larvae were exposed to Ha44, lethality was recorded at similar concentrations to those observed for embryos. Using an eYFP reporter system it was shown that Ha44 was able to reduce the levels of both copper and zinc in the digestive tract, confirming the binding of Ha44 to these metals in vivo. Ha44 has further been shown to inhibit a zinc containing metalloproteinase in vitro. Exposure of adult flies to Ha44 resulted in lethality, but at higher concentrations than those observed for embryos and larvae. The median lethal dose in adult flies was shown to be associated with the type of exposure, with an LD-50 of 1.57 mM being recorded following the direct contact of flies with Ha44, while an LD-50 of 12.29 mM was recorded following the ingestion of the compound. The capacity of Ha44 to act on all stages of the life-cycle and potentially via a range of targets suggests that target site resistance is unlikely to evolve.

Latitudinal body size clines in animals conforming to Bergmann's rule occur on many continents but isolating their underlying genetic basis remains a challenge. In Drosophila melanogaster, the gene Dca accounts for approximately 5-10% of the natural wing size variation (McKechnie SW, Blacket MJ, Song SV, Rako L, Carroll X, Johnson TK, Jensen LT, Lee SF, Wee CW, Hoffmann AA. 2010. A clinally varying promoter polymorphism associated with adaptive variation in wing size in Drosophila. Mol Ecol. 19:775-784). We present here functional evidence that Dca is a negative regulator of wing size. A significant negative latitudinal cline of Dca gene expression was detected in synchronized third instar larvae. In addition, we clarified the evolutionary history of the three most common Dca promoter alleles (Dca237-1, Dca237-2, and Dca247) and showed that the insertion allele (Dca247), whose frequency increases with latitude, is associated with larger wing centroid size and higher average cell number in male flies. Finally, we showed that the overall linkage disequilibrium (LD) was low in the Dca promoter and that the insertion/deletion polymorphism that defines the Dca alleles was in strong LD with two other upstream sites. Our results provide strong support that Dca is a candidate for climatic adaptation in D. melanogaster.