Adam Richards

Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma

Objectives  To estimate mortality rates for populations living in civil war zones in Karen, Karenni, and Mon states of eastern Burma.

Formative Research for a Healthy Diet Intervention Among Inner-City Adolescents : The Importance of Family, School and Neighborhood Environment

Objectives: To understand influences on diet among low-income African-American adolescents in East Baltimore. Methods: Formative research was conducted for a food store-centered healthy diet intervention targeted to inner-city youth. Family, school and neighborhood influences on eating habits and health concepts were explored. Results: Family structure, economic resources and past experiences influence what food means to adolescents. Healthy food in school and local stores is limited. Terminology to categorize foods was identified, including the term “home foods”. Conclusions: Suggested adolescent nutritional interventions include promotion of home-based eating, improving availability of healthy foods in school and neighborhood stores, and targeted educational materials.

Prevalence of plasmodium falciparum in active conflict areas of eastern Burma: a summary of cross-sectional data

BackgroundBurma records the highest number of malaria deaths in southeast Asia and may represent a reservoir of infection for its neighbors, but the burden of disease and magnitude of transmission among border populations of Burma remains unknown.MethodsPlasmodium falciparum (Pf) parasitemia was detected using a HRP-II antigen based rapid test (Paracheck-Pf®). Pf prevalence was estimated from screenings conducted in 49 villages participating in a malaria control program, and four retrospective mortality cluster surveys encompassing a sampling frame of more than 220,000. Crude odds ratios were calculated to evaluate Pf prevalence by age, sex, and dry vs. rainy season.Results9,796 rapid tests were performed among 28,410 villagers in malaria program areas through four years (2003: 8.4%, 95% CI: 8.3 – 8.6; 2004: 7.1%, 95% CI: 6.9 – 7.3; 2005:10.5%, 95% CI: 9.3 – 11.8 and 2006: 9.3%, 95% CI: 8.2 – 10.6). Children under 5 (OR = 1.99; 95% CI: 1.93 – 2.06) and those 5 to 14 years (OR = 2.24, 95% CI: 2.18 – 2.29) were more likely to be positive than adults. Prevalence was slightly higher among females (OR = 1.04, 95% CI: 1.02 – 1.06) and in the rainy season (OR = 1.48, 95% CI: 1.16 – 1.88). Among 5,538 rapid tests conducted in four cluster surveys, 10.2% were positive (range 6.3%, 95% CI: 3.9 – 8.8; to 12.4%, 95% CI: 9.4 – 15.4).ConclusionPrevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.

Molecular surveillance for drug-resistant Plasmodium falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a systematic review of resistance studies

BackgroundConfirmation of artemisinin-delayed parasite clearance in Plasmodium falciparum along the Thai-Myanmar border has inspired a global response to contain and monitor drug resistance to avert the disastrous consequences of a potential spread to Africa. However, resistance data from Myanmar are sparse, particularly from high-risk areas where limited health services and decades of displacement create conditions for resistance to spread. Subclinical infections may represent an important reservoir for resistance genes that confer a fitness disadvantage relative to wild-type alleles. This study estimates the prevalence of resistance genotypes in three previously unstudied remote populations in Myanmar and tests the a priori hypothesis that resistance gene prevalence would be higher among isolates collected from subclinical infections than isolates collected from febrile clinical patients. A systematic review of resistance studies is provided for context.MethodsCommunity health workers in Karen and Kachin States and an area spanning the Indo-Myanmar border collected dried blood spots from 988 febrile clinical patients and 4,591 villagers with subclinical infection participating in routine prevalence surveys. Samples positive for P. falciparum 18 s ribosomal RNA by real-time PCR were genotyped for P. falciparum multidrug resistance protein (pfmdr1) copy number and the pfcrt K76T polymorphism using multiplex real-time PCR.ResultsPfmdr1 copy number increase and the pfcrt K76 polymorphism were determined for 173 and 269 isolates, respectively. Mean pfmdr1 copy number was 1.2 (range: 0.7 to 3.7). Pfmdr1 copy number increase was present in 17.5%, 9.6% and 11.1% of isolates from Karen and Kachin States and the Indo-Myanmar border, respectively. Pfmdr1 amplification was more prevalent in subclinical isolates (20.3%) than clinical isolates (6.4%, odds ratio 3.7, 95% confidence interval 1.1 - 12.5). Pfcrt K76T prevalence ranged from 90-100%.ConclusionsCommunity health workers can contribute to molecular surveillance of drug resistance in remote areas of Myanmar. Marginal and displaced populations under-represented among previous resistance investigations can and should be included in resistance surveillance efforts, particularly once genetic markers of artemisinin-delayed parasite clearance are identified. Subclinical infections may contribute to the epidemiology of drug resistance, but determination of gene amplification from desiccated filter samples requires further validation when DNA concentration is low.

Global health experiences of U.S. Physicians: a mixed methods survey of clinician-researchers and health policy leaders

BackgroundInterest and participation in global health activities among U.S. medical trainees has increased sharply in recent decades, yet the global health activities of physicians who have completed residency training remain understudied. Our objectives were to assess associations between individual characteristics and patterns of post-residency global health activities across the domains of health policy, education, and research.MethodsCross-sectional, mixed methods national survey of 521 physicians with formal training in clinical and health services research and policy leadership. Main measures were post-residency global health activity and characteristics of this activity (location, funding, products, and perceived synergy with domestic activities).ResultsMost respondents (73%) hold faculty appointments across 84 U.S. medical schools and a strong plurality (46%) are trained in internal medicine. Nearly half of all respondents (44%) reported some global health activity after residency; however, the majority of this group (73%) reported spending ≤10% of professional time on global health in the past year. Among those active in global health, the majority (78%) reported receiving some funding for their global health activities, and most (83%) reported at least one scholarly, educational, or other product resulting from this work. Many respondents perceived synergies between domestic and global health activities, with 85% agreeing with the statement that their global health activities had enhanced the quality of their domestic work and increased their level of involvement with vulnerable populations, health policy advocacy, or research on the social determinants of health. Despite these perceived synergies, qualitative data from in-depth interviews revealed personal and institutional barriers to sustained global health involvement, including work-family balance and a lack of specific avenues for career development in global health.ConclusionsPost-residency global health activity is common in this diverse, multi-specialty group of physicians. Although those with global health experience describe synergies with their domestic work, the lack of established career development pathways may limit the benefits of this synergy for individuals and their institutions.

Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling

Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution.

Cross-border malaria control for internally displaced persons: observational results from a pilot programme in eastern Burma/Myanmar.

Objectives  To document the feasibility of a cross‐border community based integrated malaria control programme implemented by internally displaced persons in eastern Burma/Myanmar.

Health and human rights in eastern Myanmar prior to political transition: a population-based assessment using multistaged household cluster sampling

Background Myanmar transitioned to a nominally civilian parliamentary government in March 2011. Qualitative reports suggest that exposure to violence and displacement has declined while international assistance for health services has increased. An assessment of the impact of these changes on the health and human rights situation has not been published. Methods and Findings Five community-based organizations conducted household surveys using two-stage cluster sampling in five states in eastern Myanmar from July 2013-September 2013. Data was collected from 6, 178 households on demographics, mortality, health outcomes, water and sanitation, food security and nutrition, malaria, and human rights violations (HRV). Among children aged 6-59 months screened, the prevalence of global acute malnutrition (representing moderate or severe malnutrition) was 11.3% (8.0 – 14.7). A total of 250 deaths occurred during the year prior to the survey. Infant deaths accounted for 64 of these (IMR 94.2; 95% CI 66.5-133.5) and there were 94 child deaths (U5MR 141.9; 95% CI 94.8-189.0). 10.7% of households (95% CI 7.0-14.5) experienced at least one HRV in the past year, while four percent reported 2 or more HRVs. Household exposure to one or more HRVs was associated with moderate-severe malnutrition among children (14.9 vs. 6.8%; prevalence ratio 2.2, 95% CI 1.2-4.2). Household exposure to HRVs was associated with self-reported fair or poor health status among respondents (PR 1.3; 95% CI 1.1 – 1.5). Conclusion This large survey of health and human rights demonstrates that two years after political transition, vulnerable populations of eastern Myanmar are less likely to experience human rights violations compared to previous surveys. However, access to health services remains constrained, and risk of disease and death remains higher than the country as a whole. Efforts to address these poor health indicators should prioritize support for populations that remain outside the scope of most formal government and donor programs.

Trends in Racial/Ethnic and Nativity Disparities in Cardiovascular Health Among Adults Without Prevalent Cardiovascular Disease in the United States, 1988 to 2014

Cardiovascular disease (CVD), including heart disease and stroke, is a leading cause of morbidity and mortality in the United States and disproportionately affects minority adults at an earlier age than whites (1, 2). Several modifiable risk factors, both biological and behavioral, contribute to premature CVD in African American and Latino adults, and the higher prevalence in these groups is expected to continue (3, 4). Cardiovascular disease is also a major contributor to the economic burden of U.S. health disparities (5). To reduce disparities, CVD prevention through control of biological and behavioral risk factors is increasingly emphasized. One such effort is Lifes Simple 7 (LS7), a set of goals developed by the American Heart Association to define, monitor, and enhance cardiovascular health through primary prevention of heart disease and stroke (6). The LS7 score summarizes control of the following 7 health factors and behaviors: blood pressure, serum lipids, blood glucose, weight, physical activity, diet, and smoking. Lower scores are associated with higher all-cause and CVD-related death (7) and higher incidence of CVD (8), stroke (9, 10), heart failure (11), diabetes (12), cognitive impairment (13), depressive symptoms (14), and end-stage renal disease (15). The LS7 score is also easier for patients and providers to use to identify targets for change than other measures of cardiovascular and stroke risk. Despite national efforts to improve cardiovascular health and reduce related disparities (16, 17), trends in these measures remain inadequately understood among African Americans, Latinos, other racial/ethnic groups, and immigrant populations (3, 18), even as the United States becomes increasingly diverse (19, 20). We used data from NHANES (National Health and Nutrition Examination Survey) between 1988 and 2014 to examine overall trends in the LS7 components and overall score by race/ethnicity and nativity. Understanding these changes may help identify and prioritize approaches to improving health in both the population overall and vulnerable subgroups. Methods The NHANES consists of cross-sectional, multistage, stratified, clustered probability samples of noninstitutionalized U.S. civilians. Each wave is a representative sample of the U.S. population. We used data from NHANES III (1988 to 1994) and four 4-year waves of the continuous NHANES from 1999 to 2014 to create 5 periods for these analyses: 1988 to 1994, 1999 to 2002, 2003 to 2006, 2007 to 2010, and 2011 to 2014 (21). The resulting sample sizes provided at least 80% power at a type I error rate of 5% to detect a clinically meaningful reduction of 5% in a binary outcome between whites and the other racial/ethnic and nativity groups across periods, assuming that the percentage of white participants with optimal cardiovascular health ranged from 18.5% to 31.4%. We analyzed data from adults aged 25 years or older who reported their race/ethnicity as non-Hispanic white (white), non-Hispanic African American (African American), or Mexican American. We distinguished Mexican Americans by nativity: born in the United States (U.S.-born) versus born in Mexico (nonU.S.-born). Before 2007, NHANES included too few Hispanics who were not Mexican American to calculate reliable estimates for other groups (22). Persons with prevalent CVDdefined as self-reported stroke, myocardial infarction, angina, or heart failurewere excluded. We also excluded Mexican Americans who indicated that they were born outside of Mexico and the United States or whose birthplace was unknown or missing (Appendix Figure). We categorized age into the following 3 groups: 20 to 44 years, 45 to 64 years, and 65 years or older. Appendix Figure. Study flow diagram. Prior CVD event included self-reported stroke, myocardial infarction, heart failure, or angina. CVD = cardiovascular disease; MEC = mobile examination center; NHANES = National Health and Nutrition Examination Survey. The primary outcomes were the 7 health factors and behaviors and a composite variable representing optimal cardiovascular health. The Table defines poor, intermediate, and ideal levels for each LS7 component (blood pressure, total cholesterol, hemoglobin A1c [HbA1c], body mass index [BMI], physical activity, diet, and smoking) (6, 23). To score each component, we assigned 2 points for the ideal category, 1 point for intermediate values, and 0 points for the poor category. The study collected data on blood pressure, cholesterol level, HbA1c level, body weight, and height. Blood pressure was read 3 times during the visit; the first reading was discarded, and the mean of the 2 remaining was used for these analyses. During an interview, participants reported cigarette smoking, medications, and frequency and duration of participation in leisure-time physical activity over the prior 30 days (21). Diet was assessed using a single 24-hour recall questionnaire for 1988 to 1994 and 1999 to 2002 or the average of 2 questionnaires for 2003 to 2014. The healthy diet measure included 4 components from the 2005 Healthy Eating Index (fruits, vegetables, whole grains, and sodium) (24). Table. Cardiovascular Health Metrics and Definitions As in prior studies (10), each participants total LS7 score was calculated by summing the scores for all 7 components (range, 0 to 14 points). We categorized a total score of 10 or higher as optimal cardiovascular health (11). Although no cut point for optimal LS7 score has been validated, prior literature shows that scores of 10 or 11 or greater are associated with lower incident and prevalent CVD, stroke, and mortality than lower scores (10, 25, 26). We calculated weighted, unadjusted percentages of participants with optimal cardiovascular health using both cut points and plotted the percentages by age group, cohort, and race/ethnicity and nativity. Visual inspection of the graphs showed similar patterns between the 2 cutoffs. However, because the 11-or-higher cut point requires an ideal score for at least 4 items, some groups in the analysis had no participants at the optimal level. For these reasons, we selected the cut point of 10 or higher. Statistical Analysis Frequency distributions of sample characteristics and adjusted, weighted percentages of participants with poor scores on each LS7 component were summarized and plotted by race/ethnicity and nativity for the 3 age groups across the 5 periods. Total scores were estimated and used to calculate the optimal cardiovascular health scores, which were similarly summarized and plotted. We estimated racial/ethnic and nativity differences and changes by period in each age group for poor scores on each LS7 component and for the optimal cardiovascular health score. We used generalized linear regression models with a probit link for binary outcomes or identity link for continuous outcomes, using the SAS survey procedures (PROC SURVEYLOGISTIC and SURVEYREG) with appropriate sample weights accounting for unequal probabilities of selection, oversampling, and nonresponse. The base 3-way model included 3 main effects (race/ethnicity and nativity, age, and period), three 2-way interactions between the main effects, and the 3-way interaction of the main effects. Adjusted models also included age, sex, education, and incomepoverty ratio, a ratio of self-reported family income to the poverty threshold for the period. For NHANES III (1988 to 1994), all adults aged 90 years or older were assigned an age value of 90 years; for 1999 to 2014, all adults aged 85 years or older were assigned a value of 85 years (27). Age category alone may not fully explain the association between age and outcome variable, so we added the individual age to improve model fit. The amount of missing data on incomepoverty ratio varied across race/ethnicity and nativity. Thus, a multiple imputation approach accounting for survey sample weights and design structure was used to impute missing incomepoverty ratios and to combine results from 5 imputation data sets (SAS PROC MI and MIANALYZE) (28). The absolute differences in probabilities for prespecified comparisons of interest were estimated through model contrasts. Corresponding 95% CIs were calculated using a bootstrap method with 1000 iterations (29). All analyses were done using SAS, version 9.4 (SAS Institute), and figures were generated using Microsoft Excel. Role of the Funding Source The funders had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. Results The final sample comprised 21003 whites, 10426 African Americans, 3961 U.S.-born Mexican Americans, and 5486 nonU.S.-born Mexican Americans, all with no prior CVD events (Appendix Figure). Across all 5 periods, whites had a higher mean age, more years of education, and a higher incomepoverty ratio than participants from the other racial/ethnic groups (Appendix Table 1). NonU.S.-born Mexican Americans were younger and had a higher proportion of male participants, fewer years of education, and a lower incomepoverty ratio than the other groups. Appendix Table 1. Characteristics of Participants in NHANES, by Period, Race/Ethnicity, and Nativity In weighted, adjusted models, the percentage of participants who had poor control for each LS7 component varied substantially by race, ethnicity, and nativity for the 5 periods (Figure 1 and Appendix Tables 2 and 3). In general, disparities persisted between whites and all other groups in high BMI and poor levels of HbA1c and physical activity. Disparities in percentages of participants with poor scores on blood pressure, cholesterol, diet, and smoking were not consistent by race/ethnicity and nativity. Over time, whitesand to a lesser extent, U.S.-born Mexican Americanshad disproportionate increases in poor levels of physical activity and diet relative to most other group

Disparities in the Quality of Cardiovascular Care Between HIV‐Infected Versus HIV‐Uninfected Adults in the United States: A Cross‐Sectional Study

Background Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline‐recommended cardiovascular care during office visits among HIV‐infected versus HIV‐uninfected adults. Methods and Results We analyzed data from a nationally representative sample of HIV‐infected and HIV‐uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline‐recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV‐infected patients and 226 862 visits by HIV‐uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV‐infected versus HIV‐uninfected adults with aspirin/antiplatelet therapy when patients met guideline‐recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV‐infected versus HIV‐uninfected patients, respectively. Conclusions Physicians generally underused guideline‐recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV‐infected patients at increased risk—findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV‐infected patients receive.