Professor Giuseppe Satta,MD 1942–1994 Associate Editor European Journal of Epidemiology

Obituary

Professor Giuseppe Satta, MD 1942–1994 Associate Editor European Journal of Epidemiology     

Epidemiology of Tuberculosis Among US- and Foreign-Born Children and Adolescents in the United States, 1994–2007

Objectives. We examined trends in tuberculosis (TB) cases and case rates among US- and foreign-born children and adolescents and analyzed the potential effect of changes to overseas screening of applicants for immigration to the United States.Methods. We analyzed TB case data from the National Tuberculosis Surveillance System for 1994 to 2007.Results. Foreign-born children and adolescents accounted for 31% of 18 659 reported TB cases in persons younger than age 18 years from 1994 to 2007. TB rates declined 44% among foreign-born children and adolescents (20.3 per 100 00 to 11.4 per 100 000 population) and 48% (2.1 per 100 000 to 1.1 per 100 000) among those who were born in the United States. Rates were nearly 20 times as high among foreign-born as among US-born adolescents. Among foreign-born children and adolescents with known month of US entry (88%), more than 20% were diagnosed with TB within 3 months of entry.Conclusions. Marked disparities in TB morbidity persist between foreign- and US-born children and adolescents. These disparities and the high proportion of TB cases diagnosed shortly after US entry suggest a need for enhanced pre- and postimmigration screening.Tuberculosis (TB) case rates continue to decline in the United States and were recently recorded at their lowest level since national recording began in 1953.¹ Although annual TB incidence among US-born persons is declining, the number of new cases reported each year among foreign-born persons has been relatively stable over the past decade; foreign-born persons accounted for almost 60% of TB cases reported in the United States in 2008.¹ TB in foreign-born persons in the United States is largely attributable to acquisition of latent TB infection (LTBI) in TB-endemic countries of origin and subsequent activation of disease after US arrival.² The large burden of TB among foreign-born persons in the United States likely reflects the persistently large burden of TB in many other countries.³An estimated 11% of all TB cases worldwide occur in children younger than age 15 years.⁴ In TB-endemic settings, acquisition of TB infection often occurs in childhood because children are more likely to have frequent and close contact with adults with infectious TB.^5,6 Compared with adult rates of progression from infection to disease (historically 5%–10% progress to disease), rates are higher for children of all ages and highest for infants younger than 1 year (43%) and children aged 1 to 5 years (24%).^4,7,8 Furthermore, children who become infected with TB but do not progress to disease in childhood represent a potential pool for disease in adulthood.^4,7 Elucidating the epidemiology of TB in foreign-born children could therefore facilitate efforts to improve children''s health and control TB by preventing future disease.TB cases are generally reported in the broad age categories of children (defined as < 15 years) and adults (≥ 15 years).^2,9,10 However, adolescents are an important group to study because TB rates rise in adolescence following the decline seen in the elementary school years.¹¹ In addition, adolescents are more likely to present with adult-type pulmonary TB (characterized by disease in the lung apices and a tendency to form cavitary lesions).¹¹ As a result, adolescents are more likely than are younger children to transmit TB to others.^8,11As part of an effort to limit importation of TB disease, the Centers for Disease Control and Prevention in 2007 published revised requirements for overseas medical screening of applicants for US immigration.¹² All persons aged 15 years or older continue to be screened with chest radiographs. Revised technical instructions now require a tuberculin skin test (TST) for all applicants aged 2 to 14 years who live in countries with a large TB burden. Chest radiographs are performed for those whose TST is positive.¹² The potential effect of these changes is not known.We sought to describe the epidemiology of TB among foreign- and US-born children and adolescents in terms of demographic and clinical characteristics and to analyze the potential effect of the 2007 changes to the instructions for overseas screening of applicants for immigration to the United States.     

Epidemiology of Human Plague in the United States, 1900–2012

We summarize the characteristics of 1,006 cases of human plague occurring in the United States over 113 years, beginning with the first documented case in 1900. Three distinct eras can be identified on the basis of the frequency, nature, and geographic distribution of cases. During 1900–1925, outbreaks were common but were restricted to populous port cities. During 1926–1964, the geographic range of disease expanded rapidly, while the total number of reported cases fell. During 1965–2012, sporadic cases occurred annually, primarily in the rural Southwest. Clinical and demographic features of human illness have shifted over time as the disease has moved from crowded cities to the rural West. These shifts reflect changes in the populations at risk, the advent of antibiotics, and improved detection of more clinically indistinct forms of infection. Overall, the emergence of human plague in the United States parallels observed patterns of introduction of exotic plants and animals.     

Epidemiology of varicella in Haidian district,Beijing, China—2007–2015

Background1-Dose varicella vaccination was recommended for children in Beijing before November 2012. To further control school-based outbreaks and decrease incidence, a 2-dose vaccination was implemented in 2013. We described the varicella epidemiology and assessed impact of the 2-dose vaccination in Haidian district, Beijing, 2007–2015.MethodsWe examined the estimated incidence and disease characteristics of varicella during 2007–2015 and obtained the 1-dose vaccination coverage for children born during 2005–2013. Number of vaccine doses given was used to indirectly reflect the second-dose vaccination coverage. Overall and age-specific estimated incidences were compared between 2007–2012 and 2013–2015.ResultsA total of 23,497 cases were reported during 2007–2015. Of the 23,497 cases, 13,440 (57.20%) were male, and 68.40% were <20 years of age and 70.02% were students and children in kindergarten. The estimated incidence increased from 82 cases per 100,000 population in 2007 to 104 in 2011, before substantially decreasing from 86 in 2012 to 56 in 2015. The median age increased from 14 years in 2007 to 18 years in 2015. The 1-dose varicella coverage for children at ≥2 years of age gradually increased from 74.21% in 2007 to 90.06% in 2015. Compared with 2007–2012, two-fold average vaccine doses were given during 2013–2015, and the overall estimated incidence declined by 34.4%, particularly in children aged 5–9 years, with a significantly declined trend in children aged 1–9 years and older adolescents aged 15–19 years and non-significantly declined trend in adults aged ≥20 years, but a significant increasing trend in infants.ConclusionsThe overall incidence of varicella has decreased substantially in Haidian district since 2013, with largest decline in children aged 5–9 years. The 2-dose varicella vaccination might not lead to increase in incidence in adults. Long-term surveillance is needed to fully evaluate the long-term impact of the 2-dose varicella vaccination.     

Description of a large measles epidemic in Democratic Republic of Congo, 2010–2013

Background

Although measles mortality has declined dramatically in Sub-Saharan Africa, measles remains a major public health problem in countries like the Democratic Republic of Congo (DRC). Here, we describe the large measles epidemic that occurred in the Democratic Republic of Congo between 2010 and 2013 using data from the national surveillance system as well as vaccine coverage surveys to provide a snapshot of the epidemiology of measles in DRC.

Methods

Standardized national surveillance data were used to describe measles cases from 2010 to 2013. Attack rates and case fatality ratios were calculated and the temporal and spatial evolution of the epidemic described. Data on laboratory confirmation and vaccination coverage surveys as a part of routine program monitoring are also presented.

Findings

Between week 1 of 2010 and week 45 of 2013, a total of 294,455 cases and 5,045 deaths were reported. The cumulative attack rate (AR) was 0.4%. The Case Fatality Ratio (CFR) was 1.7% among cases reported in health structures through national surveillance. A total of 186,178 cases (63%) were under 5 years old, representing an estimated AR of 1.4% in this age group. Following the first mass vaccination campaigns, weekly reported cases decreased by 21.5%. Results of post-vaccination campaign coverage surveys indicated sub-optimal (under 95%) vaccination coverage among children surveyed.

Conclusions

The data reported here highlight the need to seek additional means to reinforce routine immunization as well as ensure the timely implementation of Supplementary Immunization Activities to prevent large and repeated measles epidemics in DRC. Although reactive campaigns were conducted in response to the epidemic, strategies to ensure that children are vaccinated in the routine system remains the foundation of measles control.

     

Dengue epidemic in Belém, Pará, Brazil, 1996-97

We describe clinical and epidemiologic findings during the first epidemic of dengue fever in Belém, Pará State, Brazil, in 1996-97. Of 40,237 serum samples, 17,440 (43%) were positive for dengue by virus isolation or serologic testing. No hemorrhagic cases or deaths were reported. Mycobacterium tuberculosis     

Epidemiology of Histoplasmosis Outbreaks,United States, 1938–2013

Histoplasmosis has been described as the most common endemic mycosis in the United States. However, histoplasmosis is not nationally notifiable. Its presumed geographic distribution is largely derived from skin test surveys performed during the 1940s, and information about its local features comes primarily from outbreak investigations. We conducted a literature review to assess epidemiologic features of histoplasmosis outbreaks in the United States. During 1938–2013, a total of 105 outbreaks involving 2,850 cases were reported in 26 states and the territory of Puerto Rico. Common exposure settings were chicken coops and buildings or other structures undergoing renovation or demolition. Birds, bats, or their droppings were reported to be present in 77% of outbreak settings, and workplace exposures were reported in 41% of outbreaks. The continued occurrence of histoplasmosis outbreaks, particularly work-related ones involving known disturbance of bird or bat droppings, highlights the need to increase awareness of the disease.     

Genetic characterization of historical epidemic mumps viruses in northern Spain, 1987–1990

The mumps virus (MuV) is genetically diverse and is divided into 12 genotypes. The World Health Organization has recommended expanding virological surveillance for MuV, and therefore molecular characterization of circulating strains (i.e. genotypes) is increasingly performed. Nevertheless, little is known about the genotypes circulating before the massive vaccination of children and adolescents. The present study analyzed the strains causing the 1988–1989 mumps epidemic in the Basque Country, northern Spain, which occurred in the early vaccination period, before the endemic circulation of mumps virus was blocked. The epidemic reached an annual incidence rate of more than 400 cases/100,000 inhabitants, and caused a large number of cases of mumps meningitis. MuV RNA was amplified from the cerebrospinal fluid of 15 infected patients during the epidemic and from three more patients affected shortly before or after this epidemic (1987, early 1988 and 1990). Genotyping of the complete small hydrophobic gene (316 nucleotides), amplified in the 18 strains, as well as of the entire hemagglutinin-neuraminidase gene (1749 nucleotides), amplified in four strains, assigned all strains to genotype K, a genotype infrequently detected at present. Although the putative HN protein sequence differed by 4.8–5.5% in relation to Jeryl Lynn 5 strain (the main strain used in the vaccination program in this region), the vaccine was effective, and dramatically reduced the incidence of mumps over the following years. The presence of genotype K strains in Spain in the 1980s, together with their contemporary detection in Scandinavia, suggests that this genotype could have caused the Spanish epidemic and was also circulating widely in Europe at that time.     

The rapidly changing location of death in Canada, 1994–2004

This 2008 study assessed location-of-death changes in Canada during 1994–2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994–2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%–60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.     

Immunogenicity and safety of diphtheria–tetanus vaccine in pre-adolescent and adolescent South Koreans

This study was conducted to compare the immunogenicity and safety of diphtheria–tetanus (Td) vaccine between pre-adolescents aged 11–12 years and adolescents aged 13–18 years. A total of 277 subjects (132 pre-adolescents and 145 adolescents) participated. After vaccination, all subjects (100%) in both groups exhibited seroprotective antibody levels (≥0.1 IU/mL) against diphtheria or tetanus toxoids. Although local adverse events following vaccination were more frequently observed in the pre-adolescent group than in the adolescent group (p = 0.006), these events resolved within 7 days. Our study shows Td vaccination at age 11–12 years to be immunogenic and tolerable.     

Penicillin resistance in laboratory isolates of Streptococcus pneumoniae, in Western Australia, 1990–1994

Increasing frequency of penicillin resistance in Streptococcus pneumoniae has been reported worldwide. We report on clinical isolates of penicillin-resistant pneumococci (PRP) in Western Australia (WA) from 1990–1994. A retrospective survey of laboratories performing susceptibility testing, or receiving isolates referred from rural areas found resistant on oxacillin disc screening, was undertaken. Four of 11 laboratories could provide data for the five year time period inclusive. Information was provided on susceptibility to penicillin, type of specimen, date of isolation and; age, sex and race of individuals with PRP. Penicillin resistance increased from 1.3% to 9.0% over the five year period. PRP were rarely invasive. Highest age specific rates per 100,000 were found in children < 5 years (19.4) and adults 60 years (5.1). Aboriginal ethnicity was associated with resistance. The increasing frequency of PRP in WA indicates the need for surveillance systems for their detection.     

Epidemiology of acute diarrhea caused by rotavirus in sentinel surveillance sites of Vietnam, 2012–2015

A prospective, multicentre study was conducted in four sentinel surveillance hospitals to assess the trend and epidemiology of acute diarrhea caused by Rotavirus in Vietnam. During the period 2012–2015, a total 8,889 children under 5 years of age were enrolled in the surveillance, and 8689 stool samples were collected. Of these cases, Rotavirus was most common pathogen 46.7% (4054 cases); in which 26.6% (1117) rotavirus-positive stool samples were evaluated to identify genotypes. The proportion of rotavirus positive specimens decreased annually from 54.7% in 2012 to 36.6% in 2015. Rotavirus was detected year-round, but most rotavirus gastroenteritis cases (77.1%) occurred between December and May, corresponding to the rotavirus seasonality. It is found that the peaks varied by regions. Rotavirus positivities varied between the youngest and oldest age, but children 6–11 months old (38.8%) and 12–23 months old (38.4%) counted for most cases. A significant higher number of diarrhea within 24 hours (8.3 times, 95%CI: 8.1–8.4 times) and higher proportion of severe dehydration (12.9%) in Rotavirus positive group than that in Rotavirus negative group (7.7 times, 95%CI: 7.6–7.9 times; and 9.7%, respectively). A downtrend of prevalence of G1P[8] was observed from 82% in 2013 to 15% in 2015. However, G2P[4] was found in 5% of samples in 2012, 9% in 2013, 36% in 2014, and 28% in 2015. Rotavirus infection is the most important cause of acute diarrhea among hospitalized children in Vietnam, and a rotavirus vaccination program for children may significantly reduce this disease.     

Epidemiology of Epidemic Ebola Virus Disease in Conakry and Surrounding Prefectures,Guinea, 2014–2015

In 2014, Ebola virus disease (EVD) in West Africa was first reported during March in 3 southeastern prefectures in Guinea; from there, the disease rapidly spread across West Africa. We describe the epidemiology of EVD cases reported in Guinea’s capital, Conakry, and 4 surrounding prefectures (Coyah, Dubreka, Forecariah, and Kindia), encompassing a full year of the epidemic. A total of 1,355 EVD cases, representing ≈40% of cases reported in Guinea, originated from these areas. Overall, Forecariah had the highest cumulative incidence (4× higher than that in Conakry). Case-fatality percentage ranged from 40% in Conakry to 60% in Kindia. Cumulative incidence was slightly higher among male than female residents, although incidences by prefecture and commune differed by sex. Over the course of the year, Conakry and neighboring prefectures became the EVD epicenter in Guinea.     

Dietary Boron Intake in the United States: CSFII 1994–1996

We have developed a Boron Nutrient Database and estimated dietary boron intake using the Continuing Survey of Food Intakes by Individuals (CSFII) 1994–1996. Boron intakes were calculated for each CSFII 1994–1996 respondent who completed two 24-h dietary recall interviews (n=15 267). Means, percentiles, and associated standard errors of usual intake were estimated using statistical methods of Nusser et al. (1996). Mean boron intakes for school-age children and adolescents ranged from 0.80 ± 0.01 mg/d (S.E.) for 4–8-year olds to 1.02 ± 0.04 mg/d for males aged 14–18. For female and male adults, the mean intakes were 1.00 ± 0.01 and 1.28 ± 0.02 mg/d, respectively. The 5th and 95th percentiles were 0.43 and 1.29 mg/d for 4–8-year olds, 0.47 and 1.79 mg/d for males aged 14–18, 0.41 and 1.87 mg/d for adult females and 0.53 and 2.40 mg/d for adult males. Food groups contributing the most to boron intake of respondents age 4 and older were fruits (25.1% of boron intake), beverages (19.5%), vegetables (18.1%) and grains (14.1%). These boron intake estimates from a U.S. representative sample are within the range of previous estimates. Boron intake was calculated for each person at the individual food level, enabling more detailed analyses of intakes and food sources.     

Descriptive Epidemiology of Prion Disease in Japan: 1999–2012

Background

Epidemiologic features of prion diseases in Japan, in particular morbidity and mortality, have not been clarified.

Methods

Since 1999, the Research Committee has been conducting surveillance of prion diseases, and the surveillance data were used to assess incident cases of prion diseases. For the observation of fatal cases, vital statistics were used.

Results

Both incidence and mortality rates of prion diseases increased during the 2000s in Japan. However, this increase was observed only in relatively old age groups.

Conclusions

The increased number of patients among old age groups might be due to increased recognition of the diseases. If so, the number of cases should plateau in the near future.Key words: prion diseases, Creutzfeldt-Jakob syndrome, incidence, mortality, secular trends     

The Epidemiology of Acute Poisonings in Women of Reproductive Age and During Pregnancy,California, 2000–2004

The aims of this study were to describe and compare the epidemiology of acute poisoning hospital discharges in women of reproductive age and during pregnancy (aged between 15 and 44) to include the incidence rate, risk factors, substances involved, rates of intentional versus unintentional poisonings, and in pregnant women, distribution over trimesters. Through a cohort study design, the California patient discharge dataset and linked vital statistics-patient discharge database were used to identify cases of acute poisoning hospital discharges from 2000 to 2004 among women of reproductive age and among pregnant women. Odds ratios (OR) were calculated to identify risk factors using logistic regression. Of 4,436,019 hospital discharges in women of reproductive age, 1% were for an acute poisoning (115.3/100,000 person-years). There were 2,285,540 deliveries and 833 hospital discharges for an acute poisoning during pregnancy (48.6/100,000 person-years). Pregnancy was associated with a lower risk of acute poisoning (OR = 0.89, P = 0.0007). Poisonings were greatest among young black women regardless of pregnancy status and among those with substance abuse or mental health problems. Analgesic and psychiatric medications were most commonly implicated. The majority of poisonings among women of reproductive age (69.6%) and among pregnant women (61.6%) were self-inflicted. Efforts to reduce acute poisonings among women of reproductive age should include education regarding the use of over-the-counter medications and interventions to reduce self-inflicted harm.     

Epidemiology and economic burden of rotavirus gastroenteritis in hospitals and paediatric clinics in Taiwan, 2005–2006

Baseline estimates of rotavirus disease burden and epidemiology are useful for the evaluation of newly introduced rotavirus vaccination programs. Prospective, cross-sectional surveillance for acute gastroenteritis (AGE) was conducted in hospitals and outpatient paediatric clinics in Taiwan to assess the prevalence of rotavirus gastroenteritis and associated medical costs prior to rotavirus vaccine introduction. Faecal specimens were collected from 1130 children <5 years of age from December 2004 to June 2006. The year-round rate of rotavirus detection in faecal specimens was 46% for children seen in hospitals and 14% for children seen in paediatric clinics. In the winter season, the burden was higher, reaching a peak of 60% and 21% in hospitals and paediatric clinics, respectively. The rotavirus genotype distributions were 39% (G1), 34% (G9), 12% (G2), 15% (G3), and 0.3% (G5). Total medical and nonmedical costs were US $754 for a rotavirus hospitalisation and US $60 for an outpatient clinic visit. Parental work loss averaged 4.0 days per hospital visit and 1.3 days per paediatric clinic visit. These data show that rotavirus was associated with a substantial proportion of AGE medical visits and had considerable medical costs prior to rotavirus vaccine introduction.     

Epidemiology of Human Mycobacterium bovis Disease,California, USA, 2003–2011

We conducted a retrospective review of California tuberculosis (TB) registry and genotyping data to evaluate trends, analyze epidemiologic differences between adult and child case-patients with Mycobacterium bovis disease, and identify risk factors for M. bovis disease. The percentage of TB cases attributable to M. bovis increased from 3.4% (80/2,384) in 2003 to 5.4% (98/1,808) in 2011 (p = 0.002). All (6/6) child case-patients with M. bovis disease during 2010–2011 had >1 parent/guardian who was born in Mexico, compared with 38% (22/58) of child case-patients with M. tuberculosis disease (p = 0.005). Multivariate analysis of TB case-patients showed Hispanic ethnicity, extrapulmonary disease, diabetes, and immunosuppressive conditions, excluding HIV co-infection, were independently associated with M. bovis disease. Prevention efforts should focus on Hispanic binational families and adults with immunosuppressive conditions. Collection of additional risk factors in the national TB surveillance system and expansion of whole-genome sequencing should be considered.