A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

Objectives. We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients.Methods. We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services.Results. Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV–HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61).Conclusions. Hepatitis care coordination was efficacious in increasing adherence to HAV–HBV vaccination and HCV clinical evaluation among methadone patients.Viral hepatitis is a major public health problem among drug users in the United States. Drug users are at high risk of infection with hepatitis A, B, and C viruses (HAV, HBV, and HCV, respectively) through unsterile injection practices and high-risk sexual activity.1–3 HCV infection can be acquired rapidly by injection drug users, with prevalence rates of 70% or higher among recent-onset injectors.4,5 Cirrhosis, hepatocellular carcinoma, and death are important sequelae of HCV and chronic HBV infection.6,7 Superimposed HBV and HAV infection may exacerbate liver disease among those with chronic HCV infection.8 HIV infection can accelerate disease progression in HCV- and HBV-infected persons.9–11 Given that a significant proportion of this population remains at risk for these infections, HAV–HBV vaccination programs that effectively engage drug users are needed.2,12 Treatment options for HCV are rapidly improving with the introduction of direct-acting antivirals (e.g., telaprevir and boceprevir) and the prospect of interferon-free regimens.13–16The integration of primary medical care and case management services within drug treatment programs has been associated with increased utilization of outpatient health care services among HIV- and HCV-seropositive drug users. Studies have found increased rates of the use of HIV/AIDS- and HCV-related medical care services in the methadone treatment setting17–19; however, most drug treatment programs do not have the infrastructure to provide on-site HCV treatment.20 Despite advances in HCV treatment, many HCV-positive drug users are not engaged in HCV care,21,22 and many drug users experience missed opportunities for HAV and HBV vaccination.2,23Drug users experience multiple complex individual, social, and structural barriers to HCV evaluation and treatment. Barriers include lack of knowledge about available effective treatments, low perceived risk of potential long-term adverse health consequences, fear of possible side effects of treatment, high treatment costs, lack of insurance, negative peer norms regarding HCV medications, medical mistrust, and potential provider concerns about treating active drug users.24–31 As has been observed for HIV infection, with HCV infection there is a cascade of care, with decreasing proportions of infected persons knowing their status, having had a clinical evaluation, being engaged in care, being on treatment, completing treatment, and having an optimal virological response.21,30,32HCV drug efficacy trials focus on optimizing outcomes among those treated, whereas adherence interventions frequently focus on assisting individuals to complete initiated therapy. For drug users with HCV infection, the initial steps in the cascade of care, including screening, identifying those HCV positive, and engaging infected persons in care, remain a substantial gap.21 Care coordination approaches such as case management and patient navigation services have shown promise in engaging and retaining patients in cancer screening and care and have been used in HIV primary care with promising but inconsistent results.33–39 There is a need for rigorously designed research to examine the efficacy of care coordination approaches such as case management and patient navigation as a strategy for improving the efficiency of the HCV cascade of care.We evaluated the impact of a hepatitis care coordination model integrated in the methadone maintenance treatment (MMT) setting on the following primary outcomes: (1) receipt of the first dose of HAV–HBV vaccine and (2) adherence to an initial appointment with a hepatitis C health care provider. We hypothesized that hepatitis care coordination, including on-site screening, education and counseling, motivational interviewing, on-site vaccination, and case management, would increase rates of adherence to HAV–HBV vaccination and initial appointment with a hepatitis C health care provider more than a control intervention that reflected standard recommendations for the care of drug users.40     

Long-Term Effectiveness of Accelerated Hepatitis B Vaccination Schedule in Drug Users

Objectives. We demonstrated the effectiveness of an accelerated hepatitis B vaccination schedule in drug users.Methods. We compared the long-term effectiveness of accelerated (0–1–2 months) and standard (0–1–6 months) hepatitis B vaccination schedules in preventing hepatitis B virus (HBV) infections and anti-hepatitis B (anti-HBs) antibody loss during 2-year follow-up in 707 drug users (HIV and HBV negative at enrollment and completed 3 vaccine doses) from February 2004 to October 2009.Results. Drug users in the accelerated schedule group had significantly lower HBV infection rates, but had a similar rate of anti-HBs antibody loss compared with the standard schedule group over 2 years of follow-up. No chronic HBV infections were observed. Hepatitis C positivity at enrollment and age younger than 40 years were independent risk factors for HBV infection and antibody loss, respectively.Conclusions. An accelerated vaccination schedule was more preferable than a standard vaccination schedule in preventing HBV infections in drug users. To overcome the disadvantages of a standard vaccination schedule, an accelerated vaccination schedule should be considered in drug users with low adherence. Our study should be repeated in different cohorts to validate our findings and establish the role of an accelerated schedule in hepatitis B vaccination guidelines for drug users.One of the most common blood-borne pathogens, hepatitis B virus (HBV), has been estimated to infect approximately 2 billion people worldwide, including 350 million who live with chronic infection.1 From these chronic infections, approximately 15% to 40% will develop cirrhosis, liver failure, and hepatocellular carcinoma, which can lead to enormous medical expenses and loss of life.2 These staggering numbers are reflected in the US national HBV statistics as well, with a reported prevalence of 704 000 chronic HBV infections and 4.6% exposure in the general noninstitutionalized population during 1999 to 2008.3,4 Because of its asymptomatic progression and high infectious potential (50–100 times compared with HIV), HBV has a greater potential to spread in the population, especially in high-risk groups such as drug users.5Hepatitis B vaccine has been proved to be highly immunogenic and effective in prevention of HBV infection in infants and healthy adults since its introduction in 1984. However, despite the availability of a highly efficacious vaccine, hepatitis B still remains highly prevalent in drug users. Impairment of inhibition regarding high-risk sexual behavior, sharing needles, shooting galleries, drug–sex exchanges, and the level of infection within the locality play an important role in increasing the risk of acquiring these infections in injecting and noninjecting drug users (IDUs and NIDUs).6–8 Surprisingly, hepatitis-related awareness is low among HIV knowledgeable drug users.9 A very high prevalence of HBV (64%) has been observed among IDUs compared with the general population.10 With approximately 51 000 new cases of HBV infections per year, 16% are estimated to be IDUs, and unvaccinated IDUs have an incidence density ranging from 10 to 31 infections per 100 person-years.11 Furthermore, an increasing trend of drug users who adopt noninjected routes of heroin administration has been observed in the United States and other countries since late 1980s.12 NIDUs may consist of former injectors who may have already been infected with HIV/HCV or never injectors who may become exposed to HBV infection through unprotected sex through high-risk sex partners.13 NIDUs may serve as a potential sexual transmission bridge between high prevalence IDUs to the low prevalence general population.14 Although studies examining HBV infection in NIDUs are generally lacking, a study conducted in adult noninjecting heroin users in New York City (1996–2001) reported that 24% of never injectors and 49% of former injectors were infected with HBV.13 Therefore, both IDUs and NIDUs are among the prioritized target population for immunization in the United States.Low acceptance and adherence to the standard vaccination schedule (0, 1, 6 months) is one of the primary concerns in this unstable population. Drug users are a hard to reach and mobile population who often lack access to health care. They have multiple social, psychological, and medical needs that lead to frequent change of residence, imprisonment, or admission to a therapeutic community.15,16 Other barriers to vaccine compliance include competing needs, poor relationships with health care providers, and lack of information or education.17,18 In our recent hepatitis B vaccine intervention trial among not-in-treatment drug users, we identified that participants on an accelerated schedule (0, 1, 2 months) were significantly more likely to receive 3 doses of vaccine than those on the standard schedule (76% vs 66%, respectively; P < .05).19 Moreover, these participants also had a greater anti-hepatitis B (anti-HBs; antibody to hepatitis B surface antigen) seroconversion compared with the standard schedule group at 6 months (70% vs 46%; P < .001).20 With an earlier immune response and better adherence, the accelerated schedule seems more advantageous. Despite these encouraging results, the long-term effectiveness of this accelerated vaccination schedule remains unexamined. Because an anti-HBs level of more than 10 milli-international units per milliliter is needed to offer seroprotection against HBV, and because drug users develop a suboptimal immune response following hepatitis B vaccination (58%–77%),21 it is imperative to examine the levels of antibody protection offered by an accelerated schedule beyond 12 months.22Thus, we aimed to compare the long-term effectiveness of an accelerated vaccination schedule with a standard vaccination schedule in preventing HBV infections in cohort of 707 drug users, who were free of HIV and HBV infection at enrollment and had completed 3 doses of vaccination during our HBV vaccine intervention trial. Our secondary aim was to identify the risk factors associated with anti-HBs antibody loss and HBV infection, respectively.     

Effectiveness of the targeted hepatitis B vaccination program in Greenland

Objectives. To evaluate the effectiveness of the hepatitis B virus (HBV) vaccination program in Greenland, which targets children born to mothers who are positive for HBV surface antigen (HBsAg), we determined vaccination coverage, levels of postvaccination antibodies, and frequency of breakthrough infections in at-risk children.Methods. We conducted a population-based retrospective cohort study with data from nationwide registries. We identified all children born to HBsAg-positive mothers from 1992 to 2007 and collected data on their HBV vaccination status. In 2008 to 2010, we tested the children for HBV core antibody, HBsAg, and anti-HBsAg antibody (HBsAb).Results. Of 4050 pregnant women, 3.2% were HBsAg positive. Of 207 children born to these women, 20% received no vaccinations, and only 58% received at least 3 vaccinations. At follow-up, HBsAb levels in vaccinated children were much lower than expected, and 8 (6%) of 140 at-risk children had breakthrough infections, with 4 chronically infected (persistently HBsAg positive).Conclusions. The prevention program targeting children at risk for HBV in Greenland is ineffective. HBV vaccination should be included in the universal childhood vaccination program, and postvaccination HBsAb levels should be monitored.Hepatitis B virus (HBV) infection may cause chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma.1 Perinatal mother-to-child transmission is a major cause of chronic HBV infection in endemic areas. However, up to 90% of transmissions can be prevented with immunoglobulin given within 48 hours postpartum in conjunction with 3 or 4 HBV vaccine doses, beginning at birth and completed within 12 months.2,3 In 1992, the World Health Organization recommended that all countries include HBV vaccination in the universal childhood vaccination program by 19974; by December 2007, 171 of the world''s 193 countries had complied.5 In the remaining 22 countries, some rely on identifying high-risk groups (e.g., the low-endemic Scandinavian countries); others, mainly sub-Saharan countries where infection is endemic, have no HBV vaccination strategy.6Like other Arctic populations, the Inuit in Greenland have a high prevalence of HBV infection. Overall, 40% to 45% of the population have been infected (i.e., they test positive for HBV core antibody [HBcAb]), and 5% to 10% are chronically infected (i.e., they also test positive for HBV surface antigen [HBsAg]). The prevalence of HBsAg has not changed in the past 30 years.7–9 Reports have indicated that the incidence of cirrhosis and liver cancer is lower in Greenland than in other highly endemic countries and lower even than in Denmark, where HBV infection is not endemic.7–11 Hence, policymakers have not considered HBV infection to be a major health problem at the population level, and HBV prevention has relied on vaccination of at-risk infants.Since 1992, Greenlandic policy has been to screen all pregnant women for HBsAg and to vaccinate infants of HBsAg-positive mothers. The program recommends that children receive 200 international units intramuscular HBV-specific immunoglobulin (HBIG; Aunativ, Biovitrum AB, Stockholm, Sweden) and 4 doses of 10 micrograms intramuscular recombinant HBV vaccine (EngerixB, SmithKline, Rixensart, Belgium), with HBIG and the first vaccination given within 48 hours after birth and additional vaccinations given at ages 1, 2, and 12 months.Recently, a study reported that 3 siblings of a known chronic carrier of HBV were found to be chronically infected.12 The same study described horizontal transmission of HBV and hepatitis D among children in Greenland.12 These observations raised concern that the targeted HBV vaccination program was not fully effective and was insufficient to reduce the burden of HBV-related disease in Greenland. We carried out a retrospective population-based cohort study with data from national registries, with 3 objectives: (1) to determine HBV vaccination coverage in children of HBsAg-positive mothers; (2) to estimate the effectiveness of HBV vaccination, as measured by HBsAg antibody (HBsAb) levels; and (3) to determine the frequency of breakthrough infections in at-risk children.     

Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection

Objectives. We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.Methods. We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.Results. We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.Conclusions. Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.Hepatitis E virus (HEV) infection is endemic in Asia and many parts of Africa, where it is a leading cause of sporadic and epidemic acute hepatitis.1–3 HEV is primarily transmitted through the fecal–oral route, and outbreaks in endemic areas are typically associated with contaminated drinking water sources.4–13 Clinically, it is indistinguishable from other causes of acute viral hepatitis, and jaundice, the yellowing of the eyes and skin, is the most common clinical feature.14 Jaundice is caused by a buildup of bilirubin, a product of dying red blood cells, in the blood. The healthy liver removes bilirubin from the blood, but when the liver’s ability to process bilirubin is impaired, the buildup occurs. Additional clinical signs and symptoms include anorexia, malaise, fever, dark urine, vomiting, and stomach pain.14 Adults are more likely to have HEV disease and antibodies to HEV than are children in endemic areas, which is unexpected given the young ages at which most people are exposed to other enteric pathogens in low-income countries.15In general, fewer than 1% of patients with clinical HEV die, but case fatality ratios among pregnant women have been reported to be as high as 6% to 20%.12,14,16–18 A high case fatality rate among pregnant women is a characteristic feature of HEV that has not been observed for other etiologies of acute viral hepatitis.19 Pregnant women whose deaths are associated with HEV typically die of hemorrhage or hepatic neuropathy.20,21 The few studies that investigated vertical transmission of HEV noted that neonates born to mothers with HEV infections were frequently infected and often died from complications such as prematurity, liver failure, hypothermia, or hypoglycemia.21–25Hepatitis is not considered to be an important cause of maternal or neonatal mortality globally,26–28 but some data suggest that acute hepatitis might significantly contribute to maternal mortality in HEV endemic countries. A retrospective, community-based study of maternal mortality from southern India reported that 11% of maternal deaths were attributable to infectious hepatitis, resulting in a maternal mortality ratio of 8 per 1000 live births.29 Another record review of maternal mortality from Ethiopia concluded that 15% of maternal deaths were the result of infectious hepatitis.30 An autopsy study from India found that the most common cause of maternal deaths at 1 large hospital was acute viral hepatitis, which accounted for 42% of all maternal deaths.31 Notably, none of these studies provided evidence about the etiology of these hepatitis illnesses, so it is not known if they were caused by HEV. However, given that HEV is a particularly fatal cause of acute hepatitis among pregnant women,19 the possibility that HEV could meaningfully contribute to maternal mortality in these countries should be considered.However, to our knowledge, no studies have attempted to quantify the burden of HEV-associated maternal and neonatal mortality. In low-income countries in Asia and Africa where HEV is commonly found,1–3 population-based estimates of mortality usually come from verbal autopsy studies that use structured questionnaires to interview relatives of the deceased about signs and symptoms of illness before death, and then use coding algorithms to determine cause of death based on the interview data.32 The verbal autopsy questionnaires include questions about new onset of jaundice before death in pregnant women, or new onset of jaundice in the mother as a complication of pregnancy for neonatal deaths. Thus, data from verbal autopsy studies can be used to calculate population-based estimates of maternal and neonatal mortality associated with jaundice. However, the nature of these data precludes conclusions about deaths from specific infectious etiologies, such as HEV. Hospital-based studies can provide important information about etiologic causes of maternal and neonatal deaths associated with jaundice that occur in hospital settings of HEV endemic countries. We investigated the possible contribution of HEV to maternal and neonatal mortality by analyzing data from 4 population-based verbal autopsy studies in Bangladesh and comparing these data with the published literature from hospital-based studies of the etiologic causes of jaundice-associated deaths during pregnancy.     

Syringe Disposal Among Injection Drug Users in San Francisco

To assess the prevalence of improperly discarded syringes and to examine syringe disposal practices of injection drug users (IDUs) in San Francisco, we visually inspected 1000 random city blocks and conducted a survey of 602 IDUs. We found 20 syringes on the streets we inspected. IDUs reported disposing of 13% of syringes improperly. In multivariate analysis, obtaining syringes from syringe exchange programs was found to be protective against improper disposal, and injecting in public places was predictive of improper disposal. Few syringes posed a public health threat.Needlestick injuries resulting from injection drug users (IDUs) improperly disposing of syringes present a potential risk of transmission of viral infections such as hepatitis and HIV to community members, sanitation workers, law enforcement officers, and hospital workers.^1–8 There have been no reports of HIV, HBV, or HCV seroconversion among children who incurred accidental needlesticks.^6,7,9–11 Among IDUs, syringe exchange program (SEP) utilization is associated with proper disposal of used syringes.^12–16 In 2007, the San Francisco Chronicle published a series of articles containing anecdotal reports of widespread improper disposal of syringes on city streets and in Golden Gate Park. The reports implied that SEPs were responsible for improper disposal of syringes.^17–19 Concerned about public safety, the San Francisco Department of Public Health worked with other researchers to (1) determine the prevalence of improperly discarded syringes in San Francisco, and (2) examine syringe disposal practices of IDUs.     

Indications for Testing Among Reported Cases of HCV Infection From Enhanced Hepatitis Surveillance Sites in the United States, 2004–2010

Objectives. Centers for Disease Control and Prevention has recommended a 1-time HCV test for persons born from 1945 through 1965 to supplement current risk-based screening. We examined indications for testing by birth cohort (before 1945, 1945–1965, and after 1965) among persons with past or current HCV.Methods. Cases had positive HCV laboratory markers reported by 4 surveillance sites (Colorado, Connecticut, Minnesota, and New York) to health departments from 2004 to 2010. Health department staff abstracted demographics and indications for testing from cases’ medical records and compiled this information into a surveillance database.Results. Of 110 223 cases of past or current HCV infection reported during 2004–2010, 74 578 (68%) were among persons born during 1945–1965. Testing indications were abstracted for 45 034 (41%) cases; of these, 29 544 (66%) identified at least 1 Centers for Disease Control and Prevention–recommended risk factor as a testing indication. Overall, 74% of reported cases were born from 1945 to 1965 or had an injection drug use history.Conclusions. These data support augmenting the current HCV risk-based screening recommendations by screening adults born from 1945 to 1965.In the United States, an estimated 3.2 million persons are chronically infected with HCV,1 and of these, 45% to 85% are unaware of their infection.2–5 Of those infected, most were born from January 1, 1945, through December 31, 1965.6 Previous Centers for Disease Control and Prevention (CDC) screening recommendations for hepatitis C were risk-based and included testing of injection drug users, hemodialysis recipients, those with persistently abnormal alanine aminotransferase levels, blood transfusion or organ transplant recipients before 1992, health care workers exposed to HCV, and children born to HCV-positive women.7 However, research has shown that physicians are often hesitant to elicit a risk history for hepatitis; when this is combined with underreporting of risk factors by patients, there is a lack of identification and underdiagnosis in the primary care setting.8–10 A recent study that used data from the National Health and Nutrition Examination Survey showed that less than 5% of patients who knew that they were HCV-positive had been tested because of physician-identified risk factors.11As the number of persons with complications and mortality related to hepatitis C continues to increase because of undiagnosed and untreated hepatitis C infection,12–14 CDC has recently recommended a birth cohort–based screening strategy.15 Using the Grading of Recommendations Assessment, Development, and Evaluation framework,16–24 CDC recently released a recommendation for 1-time testing for HCV for persons born during 1945–1965 without previous ascertainment of HCV risk.15 The framework’s approach defines a research question, conducts systematic reviews, determines the overall quality of evidence, and provides strength of the recommendations.16–24 Recent data suggest that, compared with risk-based screening strategies, routine 1-time HCV screening of persons in the 1945–1965 birth cohort is cost-effective and could prevent 120 000 deaths when combined with direct-acting antiviral treatments.25 Other economic models have also been utilized and support birth cohort screening of this age group.26,27 In this study, we describe indications for testing by birth cohort among reported HCV cases from 4 enhanced hepatitis surveillance jurisdictions.     

Prevalence of HCV Infection Among Clients in Community-Based Health Settings in Hawaii, 2002–2010: Assessing Risk Factors

Objectives. We sought to determine the prevalence of HCV infection and identify risk factors associated with HCV infection among at-risk clients presenting to community-based health settings in Hawaii.Methods. Clients from 23 community-based sites were administered risk factor questionnaires and screened for HCV antibodies from December 2002 through May 2010. We performed univariate and multivariate logistic regression analyses.Results. Of 3306 participants included in the analysis, 390 (11.8%) tested antibody positive for HCV. Highest HCV antibody prevalence (17.0%) was in persons 45 to 64 years old compared with all other age groups. Significant independent risk factors were current or prior injection drug use (P < .001), blood transfusion prior to July 1992 (P = .002), and having an HCV-infected sex partner (P = .03). Stratification by gender revealed sexual exposure to be significant for males (P = .001).Conclusions. Despite Hawaii’s ethnic diversity, high hepatocellular carcinoma incidence, and a statewide syringe exchange program in place since the early 1990s, our HCV prevalence and risk factor findings are remarkably consistent with those reported from the mainland United States. Hence, effective interventions identified from US mainland population studies should be generalizable to Hawaii.Hepatitis C is the most prevalent chronic blood-borne viral infection in the United States, with an estimated 1.3% of the population chronically infected.1 Chronic HCV infection is often asymptomatic; approximately 75% of infected persons may be unaware that they are infected.2 Transmission is mainly through direct blood-to-blood contact, and the most common risk factor in the United States is the sharing of injection drug use equipment.1,2 Complications from HCV infection include cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease; more than one third of liver transplants in the United States can be attributed to HCV.3 There is currently no vaccine,4 and until recently, standard therapy with pegylated interferon and ribavirin achieved a sustained virologic response in only 40% to 50% of patients.5,6In May 2011, the US Food and Drug Administration approved 2 new HCV-specific protease inhibitors for the treatment of chronic genotype 1 HCV infections: boceprevir7,8 and telaprevir.9,10 In combination with standard therapy, these drugs have achieved significantly higher rates of sustained virologic response: up to 67% to 75%.7,10 Achieving sustained virologic response is key to reducing mortality, HCC, and other comorbidities.11,12 With such a large percentage of HCV-infected individuals unaware of their status and new successful treatments available, there is now increased rationale for health providers to screen their clients for chronic HCV infection.The population of Hawaii differs from that of the mainland United States on a number of key factors related to HCV and HCC. Hawaii has the highest incidence of HCC nationally.13 Asian/Pacific Islanders have the highest incidence of HCC in the United States,13 and 57% of the Hawaii’s population is Asian, either alone or in combination with other ethnic groups.14 The high HCC incidence among Asian/Pacific Islanders is attributed in large part to chronic hepatitis B virus (HBV) infection,13,15 and the identification and treatment of persons with chronic HBV or HCV infection is an important public health priority in Hawaii. In addition, Hawaii implemented a statewide syringe exchange program in the early 1990s, the first state to do so.16 The risk factor demonstrating the strongest association with HCV infection in the United States is injection drug use,1,17 and syringe exchange programs have demonstrated efficacy in reducing HCV infection among injection drug users.18,19To our knowledge, only 3 HCV prevalence studies have been conducted in Hawaii; however, each focused on a specific well-defined subgroup population: patients with HCC,20 HIV-infected persons enrolled in a state drug assistance plan,21 and adults from a homeless shelter.22The Adult Viral Hepatitis Prevention Program of the Hawaii State Department of Health, which offers risk-based HCV antibody testing based on reported national risk factors,1,23 has been collecting data on persons undergoing screening since 2002. We investigated the prevalence of HCV antibody positivity among at-risk clients of community-based health programs in Hawaii and identified demographic characteristics and independent risk factors associated with HCV infection.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Risks of Recreational Exposure to Waterborne Pathogens Among Persons With HIV/AIDS in Baltimore, Maryland

Objectives. We assessed the prevalence of recreational activities in the waterways of Baltimore, MD, and the risk of exposure to Cryptosporidium among persons with HIV/AIDS.Methods. We studied patients at the Johns Hopkins Moore Outpatient AIDS Clinic. We conducted oral interviews with a convenience sample of 157 HIV/AIDS patients to ascertain the sites used for recreational water contact within Baltimore waters and assess risk behaviors.Results. Approximately 48% of respondents reported participating in recreational water activities (fishing, crabbing, boating, and swimming). Men and women were almost equally likely to engage in recreational water activities (53.3% versus 51.3%). Approximately 67% (105 of 157) ate their own catch or that of friends or family members, and a majority (61%, or 46 of 75) of respondents who reported recreational water contact reported consumption of their own catch.Conclusions. Baltimoreans with HIV/AIDS are engaging in recreational water activities in urban waters that may expose them to waterborne pathogens and recreational water illnesses. Susceptible persons, such as patients with HIV/AIDS, should be cautioned regarding potential microbial risks from recreational water contact with surface waters.Persons with HIV/AIDS are at high risk for increased morbidity and mortality associated with a range of opportunistic infections, some of which are caused by Cryptosporidium. Cryptosporidium species are of particular public health and medical importance because they are prevalent in surface waters of the United States,^1–7 are efficiently transmitted via water,⁸ and can be consumed in foods contaminated by fecal matter.^9–11 Exposures to Cryptosporidium are common in the US population,¹² and past studies have demonstrated that Cryptosporidium infections significantly contribute to illness and mortality in persons with HIV/AIDS.^13–15 In the 1980s, Cryptosporidium was identified as a major opportunistic pathogen.^16–21 Infection continues to be frequently diagnosed in persons with HIV/AIDS.^22–27 Before the advent of highly active antiretroviral therapy, Cryptosporidium was a relatively common opportunistic infection even in developed countries.^28,29Cryptosporidiosis manifests as an acute gastroenteritis, accompanied by cramps, anorexia, vomiting, abdominal pains, fever, and chills²⁹ and by histological presentation of gastrointestinal mucosal injury.^30,31 Persons with AIDS who become infected with this parasite are at increased risk of developing chronic and often life-threatening diarrhea, biliary tract diseases, pancreatitis, colitis, and chronic asymptomatic infection and recurrence. These developments are especially likely in those who are severely immunosuppressed (CD4 counts < 150 cells/mL).^29,32–35 Infection is diagnosed by the presence of oocysts in unpreserved or preserved stools.³⁶ Histological and ultrastructural examination of biopsy material for different Cryptosporidium life stages, detection of Cryptosporidium DNA and antigens, and identification of species through molecular techniques can also aid in diagnosis.^36–38Cryptosporidium species are enteric protozoan organisms and are prevalent in US watersheds, especially in urban waters.^1,6,39 These parasites have natural hosts in domestic and wild animals such as cattle (especially newborn calves), horses, fish, and birds.^5,40–42 These parasites cause cryptosporidiosis by infecting and damaging the cells of the small intestine and other organs.^13,41 For persons with HIV/AIDS, increased risk for infection by Cryptosporidium has been related to sexual practices such as engaging in sexual intercourse within the past 2 years, having multiple partners during that time, and engaging in anal intercourse.⁴³ Use of spas and saunas has also been identified as a risk factor.⁴³In the United States, Cryptosporidium is the most commonly identified pathogen in cases of recreationally acquired gastroenteritis⁴⁴; the majority of those affected are children. Increased risk of cryptosporidiosis in persons with HIV/AIDS has been associated with swimming.^45,46 US residents make an estimated 360 million annual visits to recreational water venues such as swimming pools, spas, and lakes; swimming is the second most popular physical activity in the country and the most popular among children.⁴⁷Recreational swimming, even in highly chlorinated water, carries a high risk of exposure to enteric pathogens, including Cryptosporidium, Norovirus, Shigella, Escherichia coli, and Giardia.⁴⁸ Cryptosporidiosis and some other enteric illnesses are seasonal, with spikes in occurrence in the summer months from contact with recreational water venues.⁴⁹ Extreme precipitation⁵⁰ and high ambient temperatures⁵¹ can also affect patterns of disease outbreaks. Because not all infections with Cryptosporidium lead to apparent illness or symptoms, infected persons may unknowingly transmit these pathogens to others, such as household members and other recreationists.^12,52 Cryptosporidiosis from swimming, wading, and splashing is prevalent in the United States.^44,46,53,54Risks from the presence of pathogens in waterways include (1) waterborne gastroenteritis and other recreational water illnesses in anglers and other recreationists^44,55–59; (2) transmission of pathogens to humans from caught seafood acting as fomites, or surface carriers⁶⁰; (3) food-borne gastroenteritis from consumption of raw or improperly cooked fish and shellfish^61,62; and (4) hand-to-mouth transmission of pathogens while eating, drinking, or smoking during activities such as fishing and crabbing.⁷Recreational water activities in the Baltimore, Maryland, area take place in Jones Falls and Baltimore Harbor. These and other waterways are used for angling, crabbing, swimming, kayaking, and boating (including paddle boating).^7,63 In addition, Baltimore-area residents often catch and consume fish and crabs from the Baltimore Harbor and local waterways, many of which are already highly contaminated by persistent chemicals such as mercury and polychlorinated biphenyls.⁶⁴ These activities are known to increase risks of exposure to waterborne pathogens through direct contact with contaminated waters or through contact with or handling and consumption of caught seafood (fish, crabs, oysters).^7,65,66To investigate the potential contribution of recreational water contact to Cryptosporidium exposures among persons with HIV/AIDS, we carried out a cross-sectional study at the Johns Hopkins Moore Outpatient AIDS Clinic. The Baltimore metropolitan area has a high prevalence rate of HIV/AIDS among both men and women,⁶⁷ and its population makes intensive recreational use of a contaminated watershed. In addition, laboratory experiments have indicated that crabs can become superficially contaminated by Cryptosporidium and transfer the pathogen to hands.⁶⁸ Local anglers are at risk from Cryptosporidium on wild-caught fish.⁷Our objective was to address the risks of exposure to Cryptosporidium for an urban subpopulation, persons with HIV/AIDS, as a result of recreational contact with Baltimore waterways. We also assessed the patterns and locations of recreational water activities in Baltimore waters.     

Risk Assessment and Screening for Sexually Transmitted Infections, HIV, and Hepatitis Virus Among Long-Distance Truck Drivers in New Mexico, 2004�C2006

Objectives. We examined sexually transmitted infection (STI), HIV, and hepatitis virus prevalence and risk behaviors among truck drivers.Methods. We asked participants about their risk behaviors, and we screened them for STIs, HIV, and hepatitis infections. We used logistic regression to identify factors associated with outcomes.Results. Of the 652 enrolled participants, 21% reported sex with sex workers or casual partners in the prior year. Driving solo (odds ratio [OR] = 15.04; 95% confidence interval [CI] = 1.92, 117.53; P = .01), history of injection drug use (IDU; OR = 2.69; 95% CI = 1.19, 6.12; P = .02), and history of an STI (OR = 2.47; 95% CI = 1.19, 5.09; P = .01) were independently associated with high-risk sexual behaviors. Fourteen percent of participants reported drug use in the previous year, and 11% reported having ever injected drugs. Participants tested positive as follows: 54 for HCV antibodies (8.5%), 66 for hepatitis B anticore (anti-HBc) antibodies (10.4%), 8 for chlamydia (1.3%), 1 for gonorrhea (0.2%), 1 for syphilis (0.2%), and 1 for HIV (0.2%). History of injecting drugs (OR = 26.91; 95% CI = 11.61, 62.39; P < .01) and history of anti-HBc antibodies (OR = 7.89; 95% CI = 3.16, 19.68; P < .01) were associated with HCV infection.Conclusions. Our results suggest a need for hepatitis C screening and STI risk-reduction interventions in this population.Studies in Africa, Southeast Asia, Eastern Europe, and South America have linked long-distance truck drivers and commercial sex workers with the dissemination of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection.^1–15 Evidence suggests that the spread of HIV throughout central Africa was facilitated by truck traffic along the Kinshasa-Mombasa highway.^1,2 High rates of STIs and HIV have been observed among long-distance truck drivers in India and Bangladesh, where truck drivers are implicated in the spread of STIs and HIV into rural areas and areas surrounding international border crossings.^7–11 Results from studies in Eastern Europe suggest risky behavior and increased syphilis rates among truck drivers.^12,13 Additionally, studies among truck drivers in Brazil show low levels of perceived risk of infection despite high rates of syphilis and high levels of risky behaviors, e.g., unprotected sex with multiple partners, including commercial sex workers, and high levels of drug use.^14,15Little is known about the roles that long-distance truck drivers and sex workers at truck stops might play in spreading STIs or HIV in the United States. An ecological study in North Carolina examining reported syphilis cases during an outbreak found that the counties along interstate highways had higher syphilis rates than other counties in the state.¹⁶ The authors theorized that truck drivers and sex workers might have played a role in this finding, but there were no data to support this. A 1995 ethnographic study in Florida examining STI risk behaviors of truck drivers found low levels of perceived STI or HIV risk but high levels of risky behaviors.¹⁷ However, no laboratory studies were conducted; therefore, there are no data estimating the prevalence of STIs among long-distance truck drivers in the United States.To examine the environments in which STIs, HIV, and hepatitis virus are transmitted, and to assess the prevalence of STIs, HIV infection, and hepatitis virus infection and risk behaviors among truck drivers, we conducted a risk assessment and screening for STIs, HIV, and hepatitis among truck drivers traveling through New Mexico.     

Association of Depressive Symptoms and Substance Use With Risky Sexual Behavior and Sexually Transmitted Infections Among African American Female Adolescents Seeking Sexual Health Care

Objectives. We examined how depression and substance use interacted to predict risky sexual behavior and sexually transmitted infections (STIs) among African American female adolescents.Methods. We measured depressive symptoms, substance use, sexual behavior, and STIs in 701 African American female adolescents, aged 14 to 20 years, at baseline and at 6-month intervals for 36 months in Atlanta, Georgia (2005–2007). We used generalized estimating equation models to examine effects over the 36-month follow-up period.Results. At baseline, more than 40% of adolescents reported significant depressive symptoms; 64% also reported substance use in the 90 days before assessment. Depression was associated with recently incarcerated partner involvement, sexual sensation seeking, unprotected sex, and prevalent STIs (all P < .001). In addition, adolescents with depressive symptoms who reported any substance use (i.e., marijuana, alcohol, Ecstasy) were more likely to report incarcerated partner involvement, sexual sensation seeking, unprotected sex, and have an incident STI over the 36-month follow-up (all P < .05).Conclusions. African American female adolescents who reported depressive symptoms and substance use were more likely to engage in risky behavior and acquire incident STIs. This population might benefit from future prevention efforts targeting the intersection of depression and substance use.Although self-exploration and identity seeking are healthy aspects of adolescence, certain adverse behaviors, such as substance use and risky sexual behavior, have also been associated with adolescence. HIV, other sexually transmitted infections (STIs), and adolescent pregnancy are significant contributors to female adolescents’ morbidity and mortality in the United States.1 Adolescents aged 15 to 24 years account for approximately 50% of new STI cases each year,2 and it is estimated that 24.1% of adolescent girls aged 14 to 19 years have 1 of 5 commonly reported STIs (herpes simplex virus, trichomonaisis, chlamydia, gonorrhea, and human papilloma virus).3 Minority adolescents are disproportionately at higher risk for HIV and other STIs relative to their White counterparts.4 For example, African American adolescents account for 65% of HIV diagnoses among individuals aged 13 to 24 years.5 Among African American female adolescents aged 14 to 19 years, a national study found that 44% had at least 1 STI.3 Because African American female adolescents are at heightened risk for engaging in risky sexual behavior and STI acquisition, it is important to gain a better understanding of factors that may be associated with these risks. Two such factors are depressive symptoms and substance use or abuse.6–15In a national survey, 4.3% of youths, aged 12 to 17 years, reported current depression, and girls, regardless of age, were more likely to report depression than boys (6.7% vs 4.0%).16 In addition, 1 study found that among adolescents in mental health treatment, girls were more likely to use condoms inconsistently and were more than 9 times likely to contract an STI than were boys.17 The National Longitudinal Study of Adolescent Health found that 19.7% of African American female adolescents reported recent and chronic depressive symptoms compared with 13% among White female adolescents.18 Other studies found rates of depressive symptoms ranging from 40% to 55% among African American female adolescents.6,7,19 Previous research among African American female adolescents reported that depressive symptoms were associated with inconsistent condom use,6,10,12 multiple sexual partners,7,9,10 risky male sexual partners,6 sexual contact while high on alcohol or drugs,6,7,9,11 low frequency of sexual communication,6,7 fear of communication about condoms,6,7 self-reported previous or current STI,7,8,10 and biologically confirmed STIs.6With regards to substance use, a national survey revealed that among African American female 9th to 12th graders, 31.3% reported current alcohol use (vs 35.7% for White and 39.7% for Hispanic), 11.5% reported 5 or more drinks in a sitting (vs 21.1% for White and 22.6% for Hispanic), 27.1% reported current marijuana use (vs 18% for White and 27.4% for Hispanic), and 2.1% reported ever using Ecstasy (vs 4.6% for White and 10.1% for Hispanic).20 Another study found that approximately 27% of African American female adolescents reported having 3 or more drinks in a sitting.13 Substance use often co-occurred with sexual risk behaviors,20 placing adolescents at increased risk for less condom use. Among young African American women, substance use was associated with inconsistent condom use,13,15 sexual sensation seeking,13 multiple sexual partners,13,15 risky sexual partners,15 having sexual intercourse while high on alcohol or drugs,13 and STIs.13–15Previous studies established the relationship between depression, substance use, and risky sexual behavior, and although limited, some studies examined the longitudinal effects of depressive symptoms and substance use on sexual risk-taking among African American female adolescents.7,11–13,15 However, to our knowledge, there is scant research available on the interaction of depressive symptoms and substance use to longitudinally predict sexual risk-taking and STIs among this population. A previous study found that substance use mediated the relationship between depression and substance use, but this effect was only significant for male adolescents and not for female adolescents.8 In addition, this previous study sample included adolescents from multiple ethnicities; thus, the findings might not be applicable to African American adolescents.Because of the impact of these 2 factors on sexual risk-taking, combined with increased HIV/STI vulnerability among African American female adolescents, we aimed to expand upon the existing literature on depression, substance use, and risky sexual behavior in African American female adolescents. To advance the current knowledge and inform HIV/STI prevention efforts among this group, we examined the longitudinal effects of depression and substance use on risky sexual behavior and STI contraction, as well as the interaction between these 2 factors among a clinic-based sample of African American female adolescents over an extended period (36-month follow-up).     

The Epidemic of Zika Virus–Related Microcephaly in Brazil: Detection,Control, Etiology,and Future Scenarios

We describe the epidemic of microcephaly in Brazil, its detection and attempts to control it, the suspected causal link with Zika virus infection during pregnancy, and possible scenarios for the future. In October 2015, in Pernambuco, Brazil, an increase in the number of newborns with microcephaly was reported. Mothers of the affected newborns reported rashes during pregnancy and no exposure to other potentially teratogenic agents. Women delivering in October would have been in the first trimester of pregnancy during the peak of a Zika epidemic in March. By the end of 2015, 4180 cases of suspected microcephaly had been reported. Zika spread to other American countries and, in February 2016, the World Health Organization declared the Zika epidemic a public health emergency of international concern. This unprecedented situation underscores the urgent need to establish the evidence of congenital infection risk by gestational week and accrue knowledge. There is an urgent call for a Zika vaccine, better diagnostic tests, effective treatment, and improved mosquito-control methods.Less than a year after the first identification, in April 2015, of Zika virus (ZIKV) in Brazil,1 there was an outbreak of an exanthematous disease in its northeastern region tentatively attributed to ZIKV. ZIKV was later detected in 20 of the 27 states in Brazil2 and in 18 countries in America.3 A sharp increase in microcephaly is expected among the offspring of women who were pregnant and infected during the subsequent outbreaks give birth.Microcephaly is an abnormally small head at birth because of defective brain development. It can have genetic or environmental causes. Environmental exposures include radiation, drugs, fetal alcohol syndrome, and infections. Well-known agents of congenital infections include toxoplasmosis, rubella, cytomegalovirus, herpesvirus, and syphilis (TORCHES).4,5 Until November 2015, ZIKV has never been considered to be a cause of congenital infections or microcephaly.6ZIKV is an RNA arbovirus, Flaviviridae family (genus Flavivirus), transmitted by the Aedes mosquito (which is also the vector for dengue). Because dengue and Zika share a vector, Zika could establish itself in any country where dengue is present. ZIKV is genetically close to dengue, West Nile, yellow fever, and Japanese encephalitis viruses.7 One study suggests that most (80%) ZIKV infections appear to be asymptomatic.8 When clinical features are present, they are similar to those of dengue and chikungunya7—both arboviruses that are circulating in Brazil.8 The force of transmission of ZIKV can be very high, as 73% of the population was estimated to have been infected in the 2007 outbreak in Yap, Federated States of Micronesia8; the rate of clinical cases was estimated to be 12% in the 2013–2014 outbreak in French Polynesia.9ZIKV was isolated in Uganda in 1947, and only sporadic cases and small outbreaks were reported in Africa and Asia during the 1960s until early in the 21st century.7,10 In 2007, an outbreak was detected on Yap Island8; in 2013, an outbreak was detected in French Polynesia.9 In April 2015, ZIKV was identified in Brazil, and assessed to be the etiological agent of outbreaks of an acute exanthematous illness, which started in late 2014 in many cities of the northeast region.1,11     

Predictors of Active Injection Drug Use in a Cohort of Patients Infected With Hepatitis C Virus

Objectives. We investigated potential risk factors for active injection drug use (IDU) in an inner-city cohort of patients infected with hepatitis C virus (HCV).Methods. We used log-binomial regression to identify factors independently associated with active IDU during the first 3 years of follow-up for the 289 participants who reported ever having injected drugs at baseline.Results. Overall, 142 (49.1%) of the 289 participants reported active IDU at some point during the follow-up period. In a multivariate model, being unemployed (prevalence ratio [PR] = 1.93; 95% confidence interval [CI] = 1.24, 3.03) and hazardous alcohol drinking (PR = 1.67; 95% CI = 1.34, 2.08) were associated with active IDU. Smoking was associated with IDU but this association was not statistically significant. Patients with all 3 of those factors were 3 times as likely to report IDU during follow-up as those with 0 or 1 factor (PR = 3.3; 95% CI = 2.2, 4.9). Neither HIV coinfection nor history of psychiatric disease was independently associated with active IDU.Conclusions. Optimal treatment of persons with HCV infection will require attention to unemployment, alcohol use, and smoking in conjunction with IDU treatment and prevention.Hepatitis C virus (HCV) infection is a major cause of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma. About 130 million people are estimated to be infected worldwide with HCV,1 including 3.2 million in the United States,2 and mortality from HCV in the United States is increasing.3 Injection drug use (IDU) is the single most important risk factor for HCV infection in the United States 2,4 with an estimated 40% to 50% of infections attributable to IDU.5 Of increasing concern is the substantial proportion of HCV-infected patients who are coinfected with HIV.6 Because HIV and HCV are each transmitted by blood-contaminated needles and syringes, approximately 30% of all HIV-infected individuals are also infected with HCV1,7; in cohorts of intravenous drug users, the proportion of HCV-infected persons with HIV coinfection can be as high as 41%.8Because IDU is a significant risk factor for HCV transmission, ongoing drug abuse is common in HCV-infected populations. Such ongoing drug use has been documented as a potential barrier in managing the infection.9,10 Moreover, former IDUs can be concerned about relapse with performing self-injection as part of interferon treatment.11 Thus, understanding factors associated with active IDU may inform pragmatic approaches to improving acceptability of HCV treatment and increasing patients’ chances of successfully treating their disease.Other barriers to treatment of HCV infection have been described and are associated with IDU, such as alcohol use, psychiatric disease, and HIV coinfection.9,10,12–14 Concurrent alcohol abuse has, in some studies, distinguished persistence of IDU from cessation of IDU; however, in other reports, the association of heavy alcohol use did not remain after adjustment for known risk factors.15,16 Co-occurring mental disorders are frequently associated with poorer health and worse treatment outcomes among drug users and may lead to an increased level of drug use and riskier drug use behavior.17 HIV infection has been hypothesized to be associated with IDU in contrasting ways. Those who are HIV-infected may have more frequent contact with health services and thus referral to drug treatment; conversely, increased depression following diagnosis may lead to increased drug use.16Individual patterns of drug use vary over time. Whereas some studies have indicated a trend toward decreased IDU over time in longer-term cohort studies, others have found that many injection drug users are unable to maintain sustained cessation of IDU.17–23 In addition to the direct morbidity and mortality associated with IDU, continued use may make it more difficult for patients to effectively manage their disease. Evaluating predictors of ongoing IDU in these populations may help identify avenues to facilitate long-term cessation of IDU. Our goals were to investigate risk factors for active IDU in a cohort of patients infected with hepatitis C, with specific focus on alcohol use, smoking, psychiatric disease, and HIV coinfection.     

Hepatitis C Testing,Infection, and Linkage to Care Among Racial and Ethnic Minorities in the United States, 2009–2010

Objectives. We estimated rates and determinants of hepatitis C virus (HCV) testing, infection, and linkage to care among US racial/ethnic minorities.Methods. We analyzed the Racial and Ethnic Approaches to Community Health Across the US Risk Factor Survey conducted in 2009–2010 (n = 53 896 minority adults).Results. Overall, 19% of respondents were tested for HCV. Only 60% of those reporting a risk factor were tested, with much lower rates among Asians reporting injection drug use (40%). Odds of HCV testing decreased with age and increased with higher education. Of those tested, 8.3% reported HCV infection. Respondents with income of $75 000 or more were less likely to report HCV infection than those with income less than $25 000. College-educated non-Hispanic Blacks and Asians had lower odds of HCV infection than those who did not finish high school. Of those infected, 44.4% were currently being followed by a physician, and 41.9% had taken HCV medications.Conclusions. HCV testing and linkage to care among racial/ethnic minorities are suboptimal, particularly among those reporting HCV risk factors. Socioeconomic factors were significant determinants of HCV testing, infection, and access to care. Future HCV testing and prevention activities should be directed toward racial/ethnic minorities, particularly those of low socioeconomic status.Hepatitis C virus (HCV) infection affects almost 3 million Americans and is the leading cause of death associated with liver disease in the United States.1,2 Racial disparities in the prevalence of HCV infection have previously been documented: Non-Hispanic Blacks have the highest prevalence of HCV infection in the United States, about twice that reported among non-Hispanic Whites.1 Fewer data exist on the prevalence of hepatitis C among the Latino population, and they have been derived mainly from the National Health and Nutrition Examination Survey, in which only Mexican Americans were represented.1,3,4 Even more limited data are available on the prevalence of HCV infection among Asians and American Indians/Alaska Natives (AI/ANs), with most of the studies localized to specific states or facilities.5–8 More important is the dearth of data regarding the prevalence of hepatitis C testing and access to care—information critical to public health planning and policy—among racial/ethnic minorities in the United States. Early identification and treatment of hepatitis C infection are essential to prevent liver cancer and associated health care costs.9,10 Over the 10-year period from 2010 to 2019, the direct medical cost of chronic HCV infection is projected to exceed $10.7 billion, and the societal cost of premature mortality is estimated at $54.2 billion.11Studies have reported that several minority communities have disproportionately lower socioeconomic status, greater barriers to access to health care, and greater risks for and burden of disease compared with Whites or the general population living in the same geographical area.12–14 Socioeconomic factors have been postulated to play a role in access to care and treatment of hepatitis C.15–17 However, very few studies have assessed the role played by socioeconomic factors in hepatitis C testing and infection among racial/ethnic minorities. Not all racial/ethnic minorities were included in these studies, and the majority failed to control for traditional HCV infection risk factors.1,4,18 The Centers for Disease Control and Prevention’s recommendations for HCV testing are based on presence of HCV risk factors, hence the need to control for them while assessing the determinants of hepatitis C testing and infection.19In 2006, 1 of every 4 US residents identified themselves as being a racial/ethnic minority,20 and the US Census Bureau has projected that by 2050 minority populations will make up approximately 50% of the US population.21 Thus, a need exists for more information about hepatitis C among the different racial/ethnic groups in the United States to be able to design evidence-based prevention interventions and avoid the projected increases in medical expenses.11The objectives of this study were to assess hepatitis C testing, infection, and access to health care and treatment among racial/ethnic minorities in the United States and to examine whether demographic, socioeconomic, and hepatitis C risk factors influence hepatitis C testing, infection, and access to care in this population.     

An Assessment of the Performance of Self-Reported Vaccination Status for Hepatitis B,National Health and Nutrition Examination Survey 1999–2008

Objectives. We sought to assess the performance of self-reported vaccination with hepatitis B vaccine (HepB) compared with serological status for hepatitis B markers in the general US civilian population.Methods. Using 1999 through 2008 National Health and Nutrition Examination Survey data, we calculated 3 measures of agreement between self-reported HepB vaccination status and serological status: percent concordance, and positive (PPV) and negative predictive values (NPV) of self-report. Logistic regression was used to identify factors associated with agreement between self-report and serological status.Results. Overall agreement was 83% (95% CI = 82.3, 83.7), NPV of self-report was high (0.95; 95% CI = 0.93, 0.95) and PPV was low (0.53; 95% CI = 0.51, 0.54). Birth year relative to the 1991 recommendation for universal infant HepB vaccination had a strong association with agreement, however, the association was positive for those who reported receiving at least 3 doses and negative for those who reported receiving no doses.Conclusions. Although the low PPV in our study could be attributable in part to waning of vaccine-induced anti-HBs over time, national adult HepB vaccination coverage may be lower than previously estimated because national estimates usually depend on self-report of vaccine receipt.Hepatitis B virus (HBV) infection is associated with an estimated 600 000 annual deaths worldwide.1 In the United States, during 2007 alone, hepatitis B was listed as either the underlying or contributing cause of 1815 deaths.2 During the period 1999 to 2006, there were an estimated 730 000 US residents with active, chronic HBV infection.3HBV infection is vaccine-preventable. In the United States, vaccination was first recommended for all infants in 1991.4 Along with disease incidence, vaccination coverage is an essential component of surveillance, and both are used to guide national vaccination programs5 by identifying populations at risk and in need of vaccination. Serological surveys supplement case-surveillance data, providing a measure of prevalence of chronic infection in the population. Furthermore, serological surveys can measure and distinguish between naturally acquired and vaccine-induced immunity, and are often considered the most reliable method of determining vaccination status outside of provider records. However, there are limitations to use of serological surveys to determine hepatitis B vaccination status because antibodies wane over time,6 and vaccinated individuals may, therefore, appear unvaccinated as time since vaccination increases. Because serological surveys are costly to implement, public health practitioners frequently rely on self-reported vaccination status to assess immunity.Self-reported vaccination coverage is used widely in public health to guide vaccination programs. Validation studies have found high levels of agreement between self-reported vaccination status (pneumococcal 79%7; influenza 89%8) and vaccination documented in medical records. Although some studies comparing self-reported receipt of hepatitis B vaccine (HepB) with serological status have been conducted in special populations such as injection-drug users, HIV-infected individuals and adolescents, to the best of our knowledge, no studies have assessed the performance of self-reported receipt of HepB with serological status as a measure of vaccination coverage in the general US civilian population. This was our objective in the current analysis.     

Lack of predictability at work and risk of acute myocardial infarction: an 18-year prospective study of industrial employees

Objectives. We examined whether the distinctive components of job control—decision authority, skill discretion, and predictability—were related to subsequent acute myocardial infarction (MI) events in a large population of initially heart disease–free industrial employees.Methods. We prospectively examined the relation between the components of job control and acute MI among private-sector industrial employees. During an 18-year follow-up, 56 fatal and 316 nonfatal events of acute MI were documented among 7663 employees with no recorded history of cardiovascular disease at baseline (i.e., 1986).Results. After adjustment for demographics, psychological distress, prevalent medical conditions, lifestyle risk factors, and socioeconomic characteristics, low decision autonomy (P < .53) and skill discretion (P < .10) were not significantly related to subsequent acute MI. By contrast, low predictability at work was associated with elevated risk of acute MI (P = .02). This association was driven by the strong effect of predictability on acute MI among employees aged 45 to 54 years.Conclusions. Prospective evidence suggests that low predictability at work is an important component of job control, increasing long-term risk of acute MI among middle-aged employees.Cardiovascular diseases account for approximately 40% of deaths in developed countries.¹ Acute myocardial infarctions (MIs) account for nearly half of all the cardiovascular mortality.² According to current knowledge, acute MI is predicted by not only well-known risk factors, such as smoking and lack of physical activity, but also psychosocial factors.³Most working-age adults in industrialized countries spend about one third of their waking hours at work during an average period of more than 30 years.⁴ Work environments often entail various stressful characteristics.⁵ Correspondingly, recent reviews proposed that adverse work-related psychosocial risk factors may contribute to poor cardiac health.^6,7In occupational epidemiology, the job strain model⁸ has dominated research on cardiovascular risk factors. This model postulates that a combination of high work demands and low control at work (i.e., job strain), if prolonged, increases the risk of heart disease. Although some follow-up studies have supported this model,^9,10 many large-scale prospective studies with null findings also have been reported.^11–14 Poor job control may be more detrimental to heart health than high job demands,¹⁵ but evidence on the independent predictive role of job control in coronary heart disease is scarce and mixed.^13,16,17Several factors may explain the conflicting findings. First, dimensions of job control, such as decision authority (i.e., decision latitude concerning one''s work pace and phases, and independence from other workers while carrying out tasks) and skill discretion (i.e., the level of cognitive challenges and variety of tasks at work), could contribute differently to health outcomes.¹⁸ Predictability on the job (i.e., the clarity of work goals and opportunity to foresee changes and problems at one''s work) has been suggested to represent a further component of job control, but empirical research on this component is largely lacking.^19–21 Predictability involves relatively high stability of work and a lack of unexpected changes, which characterized the earlier industrial era which had stable production systems.²² Predictable outcomes are less common in today''s turbulent work life; thus, lack of predictability may represent a salient health hazard^23,24 and may contribute to myocardial risk.²⁵Second, research indicates that physiological stress, especially exposure to long-term environmental stressors, can cause detrimental prolonged neurohormonal reactions as well as pathological physiological changes by adversely affecting the process of atherosclerosis,^16,26,27 thereby increasing the risk of acute MI.^28,29 However, most prospective studies on stressful work environment and subsequent cardiovascular disease have used follow-up periods of less than 10 years^6,7 or have studied all-cause cardiovascular outcomes rather than mortality and morbidity resulting from acute MI.⁹ Thus, potential long-term effects of work-related psychosocial factors on acute MI events have not been examined.Third, age may play a role in the association between job strain and acute MI risk. Weaker effects have been found among older workers; plausible reasons for this are healthy worker survivor bias; retirement during follow-up may remove job strain and cause exposure misclassification (i.e., healthier older employees survive, retire, and are no longer exposed to work-related characteristics); and an increasing number of other age-related causes of acute MI.³⁰ Among younger employees, job strain may be associated with shorter exposures to harmful job characteristics than among middle-aged employees. Long-term prospective age-specific studies are therefore needed to determine whether current psychosocial risks of work environment predict acute MI events and whether the influence of work characteristics is stronger among middle-aged employees.The objective of our 18-year follow-up study was to examine whether the distinctive components of job control—decision authority, skill discretion, and predictability—were related to subsequent acute MI events in a large population of initially heart disease–free industrial employees after the effects of established risk factors were taken into account. We further tested age-specific vulnerability among these employees.     

Impact of Rurality,Broiler Operations,and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

Objectives. We evaluated the combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis.Methods. We obtained Campylobacter case data (2002–2010; n = 3694) from the Maryland Foodborne Diseases Active Surveillance Network. We obtained community-level socioeconomic and environmental data from the 2000 US Census and the 2007 US Census of Agriculture. We linked data by zip code. We derived incidence rate ratios by Poisson regressions. We mapped a subset of zip code–level characteristics.Results. In zip codes that were 100% rural, incidence rate ratios (IRRs) of campylobacteriosis were 6 times (IRR = 6.18; 95% confidence interval [CI] = 3.19, 11.97) greater than those in urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times greater than those in zip codes without broilers (IRR = 1.45; 95% CI = 1.34, 1.58). We also observed higher rates in zip codes whose populations were predominantly White and had high median incomes.Conclusions. The community and environment in which one lives may significantly influence the risk of campylobacteriosis.Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world.1,2 In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, such as Guillain-Barré syndrome, a demyelinating autoimmune disorder that can sometimes lead to death.3 Scallan et al.4 estimated that Campylobacter causes approximately 845 000 domestically acquired illnesses in the United States each year, along with 8463 hospitalizations and 76 deaths. Although the majority of these illnesses are estimated to be foodborne,4 attributing specific infections to specific sources has been challenging.Commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry,5 unpasteurized milk,6,7 and contaminated water.8 Eating in restaurants,9 not observing proper food preparation practices,10 and traveling abroad9,11 have also been associated with both outbreaks and sporadic (nonoutbreak) cases of campylobacteriosis. Additional risk factors for sporadic infections include contact with pets,5,12 contact with farm animals and livestock,13,14 and contact with animal feces.15 Significant associations of living in rural areas with risk of campylobacteriosis also have been identified in Europe and Canada.16–18 Moreover, a specific feature of rural environments—animal density—has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand.16,17Several sociodemographic risk factors for campylobacteriosis have also been identified, the 2 most consistent being gender (males) and age (< 5 years).8,16–19 Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection, and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status.16,20 Moreover, Samuel et al.21 reported that the incidence of campylobacteriosis among African Americans was lower than that among other ethnic groups across multiple sites in the United States, although hospitalization rates for this group were higher. These findings, however, may be influenced by differentials in illness reporting among varying races and ethnic groups.Nonetheless, these previous reports have largely resulted from population-based case–control studies focused on individual-level data. To our knowledge, no US study has examined the combined effect of community-level environmental and socioeconomic risk factors on the risk of campylobacteriosis. Such an analysis can be useful in (1) identifying (and possibly predicting) “hot spot” communities that bear high burdens of this illness, and (2) addressing significant research gaps concerning potential health disparities in the risk of infectious diseases.22 We linked Maryland Foodborne Diseases Active Surveillance (FoodNet) data to US Census data and US Department of Agriculture Census of Agriculture data at the zip code level to evaluate associations between community-level environmental and socioeconomic risk factors and the incidence of Campylobacter infections in Maryland.     

Hand Washing Among School Children in Bogotá, Colombia

Objectives. We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices.Methods. Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted.Results. Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR] = 6.0; 95% confidence interval [CI] = 4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR = 0.8; 95% CI = 0.6, 0.9) or previous-year school absenteeism (OR = 0.7; 95% CI = 0.6, 0.9).Conclusions. Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.Remarkable improvements have been made in the past century in the fight against communicable diseases, yet a significant amount of mortality and morbidity worldwide can still be attributed to these conditions.¹ Respiratory infections and diarrheal diseases—the 2 leading causes of disease burden globally—are responsible for half of all child deaths each year.¹ The burden of communicable disease remains predominantly acute in developing regions of the world,² and children remain particularly vulnerable.³Recent estimates in Colombia indicate that acute respiratory and intestinal infections are the main cause of mortality among children aged 1 to 4 years, the second leading cause of death among girls aged 5 to 14 years, and the third leading cause of infant mortality.⁴ According to a recent national household survey in Colombia, 14.1% and 9.6% of children younger than 5 years had experienced diarrhea or an acute respiratory infection, respectively, in the 2 weeks before the survey.⁴Despite much evidence supporting the effectiveness of measures such as vaccination,^5,6 improvement in sanitary conditions,^3,6 and basic hygiene practices^3–7 in controlling communicable diseases, many developing nations have yet to achieve effective vaccination coverage⁶ and remain plagued with poor sanitary conditions. Basic personal hygiene behaviors, such as hand washing, are still not widely practiced.⁷Diverse health behavior and social marketing theories have been applied in the design and implementation of behavioral change interventions that promote infection-control practices.^8,9 The theory of reasoned action and planned behavior,^10,11 for example, suggests that a person''s behavior is determined by her or his intention to perform the behavior. Intention, in turn, is a function of the person''s attitudes toward the behavior, beliefs concerning benefits or harms of adopting or not adopting the behavior, subjective norms and normative beliefs, and perceived control over the opportunities, resources, and skills necessary to perform the behavior.^9,10 More recently, ecological approaches have been incorporated into behavioral theories to disentangle independent effects of individual and contextual factors on health behavior.¹² The underlying premise of such models is a bidirectional relation between environmental modifications and behavioral change.^12,13Bearing in mind that school children have been consistently implicated in the spread of communicable diseases¹⁴ and that the school has been recognized as a vital setting for health promotion, we assessed the prevalence and individual and contextual determinants of proper hand-washing behavior and positive hand-washing intentions among school children in Bogotá, Colombia.     

Improving Adult Immunization Practices Using a Team Approach in the Primary Care Setting

Objectives. The objective of this study was to improve the immunization rates of primary care practices using a team approach.Methods. Practices performed 35 random chart abstractions at 2 time points and completed a survey about immunizations at baseline and 12 months after intervention. Data were collected for the following immunizations: influenza, pneumococcal, tetanus diphtheria (Td)/tetanus diphtheria pertussis (Tdap), hepatitis A, hepatitis B, meningococcal, varicella, herpes zoster, and human papilloma virus. Between baseline and after intervention, practice teams were given feedback reports and access to an online educational tool, and attended quality improvement coaching conference calls.Results. Statistically significant improvements were seen for Td/Tdap (45.6% pre-intervention, 55.0% post-intervention; P ≤ .01), herpes zoster (12.3% pre-intervention, 19.3% post-intervention; P ≤ .01), and pneumococcal (52.2% pre-intervention, 74.5% post-intervention; P ≤ .01) immunizations. Data also revealed an increase in the number of physicians who discussed herpes zoster and pneumococcal vaccinations with their patients (23.2% pre-intervention, 43.3% post-intervention; P ≤ .01 and 19.9% pre-intervention, 43.0% post-intervention; P ≤ .01, respectively) as well as an increase in physicians using the Centers for Disease Control and Prevention immunization schedule (52.9% pre-intervention, 88.2% post-intervention; P ≤ .02).Conclusions. The immunization rates of the primary care practices involved in this study improved.The need for improving quality is pervasive in the primary care setting, involving physicians, their practice teams, and administrative staff. The issue of low quality is well documented1–3 and is not partial to any 1 disease condition.4–15 Poor quality is a result of our medical system’s orientation to the urgent, its focus on acute and not chronic care, lack of adherence to evidence-based guidelines, and an increasing number of patients with complex medical conditions.2 Quality is characterized as a systems issue rather than an individual one,16 which has led efforts to focus on the practice team. Practice teams have been shown to improve quality in primary care.17,18 The issues with poor quality in primary care extend to the practice of adult immunizations.19 It is estimated that between 50 000 and 70 000 US adults die each year because of diseases that could be prevented by vaccination.20 For example, influenza is the sixth leading cause of death for adults and contributes to at least 200 000 hospitalizations and 36 000 deaths annually.21,22 Economic costs associated with influenza are projected to be $87.1 billion.23Adult vaccination guidelines, such as those published by the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices,24 are increasingly evidence-based and are a good reference for practices to measure themselves against when doing immunization practice redesign work. Although childhood vaccinations have become a public health success, adult vaccination rates are low, prompting the movement toward “lifespan immunizations.”20,25 However, quality gaps and missed opportunities for vaccination exist between the number of patients who are recommended to receive vaccinations and those who actually receive them.26–30 A variety of barriers at the practice, patient, economic, and social level help explain these missed opportunities. For instance, only 60% of physicians reported using CDC and Advisory Committee on Immunization Practice guidelines as their reference for adult immunizations, and most often reported recommending vaccinations at well visits compared with sick visits.31 Physicians also reported multiple barriers to vaccinating patients, including lack of health insurance, fear of needles, and misconception of the safety and efficacy of vaccinations.31 In turn, patients consistently reported that their physicians do not recommend vaccinations.31,32A comprehensive quality approach was considered to be more effective than mere guideline dissemination because the latter has not been shown to be successful alone in changing practice patterns.33,34 The American College of Physicians (ACP) developed this quality improvement program to help physicians and practice teams learn about the current recommendations and best practices for adult immunization. The goal of this prospective study was to improve the immunization practices of primary care practices by using a team approach.