Alan R. Katz

Beyond Disciplinary Boundaries: Leptospirosis as a Model of Incorporating Transdisciplinary Approaches to Understand Infectious Disease Emergence

Leptospirosis is a zoonotic infectious disease of global significance. Political, economic, demographic, ecologic, and other anthropogenically driven environmental changes have fueled the reemergence of this disease in industrialized and developing countries, and in both urban and rural settings. We argue that conventional disciplinary, even interdisciplinary, research methods are not sufficient to elucidate the complex mechanisms and causal relationships among the myriad factors responsible for infectious disease emergence. To address the significant gaps in the field of leptospirosis, an integrated research agenda is needed to guide successful public health remediation of the disease. Based on both working group analysis of literature and newly obtained information, we describe cross-disciplinary collaborative approaches that allow a novel approach to understand leptospirosis emergence with regard to mountain-to-sea ecosystems in Hawai‘i and other region-specific ecosystems. Leptospirosis research is a model for how complementary disciplines in the social, cultural, ecological, and biomedical sciences can optimally interact towards a higher understanding of emerging infectious diseases.

Cluster of Neisseria gonorrhoeae Isolates With High-level Azithromycin Resistance and Decreased Ceftriaxone Susceptibility, Hawaii, 2016

BackgroundnThe Centers for Disease Control and Prevention (CDC) currently recommends dual therapy with ceftriaxone and azithromycin for gonorrhea to ensure effective treatment and slow emergence of antimicrobial resistance. Since 2013, the prevalence of reduced azithromycin susceptibility increased in the United States; however, these strains were highly susceptible to cephalosporins. We identified a cluster of Neisseria gonorrhoeae isolates with high-level azithromycin resistance, several of which also demonstrated decreased ceftriaxone susceptibility.nnnMethodsnEight N. gonorrhoeae isolates collected from 7 patients on Oahu, Hawaii, seen 21 April 2016 through 10 May 2016 underwent routine Etest antimicrobial susceptibility testing by the Hawaii Department of Health. All demonstrated elevated azithromycin minimum inhibitory concentrations (MICs) >256 μg/mL and elevated ceftriaxone MICs (≥0.125 μg/mL). Isolates were sent to the University of Washington and CDC for confirmatory agar dilution testing; sequence data were sent to CDC for analysis. All patients were interviewed and treated, and when possible, partners were interviewed, tested, and treated.nnnResultsnAll isolates had azithromycin MICs >16 µg/mL and 5 had ceftriaxone MICs = 0.125 µg/mL by agar dilution. All isolates were β-lactamase positive and were resistant to penicillin, tetracycline, and ciprofloxacin. Genomic analysis revealed genetic relatedness. No patients reported recent travel or antibiotic use, and no male patients reported male sex partners. All patients were successfully treated.nnnConclusionsnThis cluster of genetically related gonococcal isolates with decreased ceftriaxone susceptibility and high-level azithromycin resistance may bring the threat of treatment failure in the United States with the current recommended dual therapy one step closer.

Leptospira infection prevalence in small mammal host populations on three Hawaiian islands.

We describe the geographic distribution and variation in host-pathogen specificity for Leptospira-infected small mammals collected concurrently from three Hawaiian Islands over a period of 14 years: 1990-2003. Four serogroups (Icterohaemorrhagiae, Ballum, Sejroe, and Australis) were identified from the 15,171 animals tested. Serogroup prevalence differed across host species and islands (P < 0.0001 for each), but not across years. The host associations and biogeographic patterns of Leptospira in Hawaii indicate a pathogen community shaped by ecological factors.

Site specific cancer incidence in the Republic of the Marshall Islands

There is a paucity of data about cancer in the Republic of the Marshall Islands (RMI), a former U.S. Trust Territory. This study provides the first comprehensive data analysis on the incidence rates for certain cancers in the RMI.

Chlamydia Screening of Adolescent Females: A Survey of Providers in Hawaii

Hawaii currently ranks first among states for chlamydia screening of young women based on recent Healthcare Effectiveness Data and Information Set (HEDIS) measures and has consistently ranked in the top ten states in the US for annual reported chlamydia rates since 2002. A statewide provider survey was conducted in October 2007 and March 2008 to assess chlamydia screening practices and beliefs and identify potential barriers to screening. The overall reported screening rate for 15–19xa0year old females was 66.9% with significant differences by practice specialty (obstetrician/gynecologists were more likely to screen than family practitioners or pediatricians) and practice setting (higher rates of screening in non-private practice settings). Providers who were unaware of health plan reimbursement for screening and those who targeted screening only for clients perceived to be at “high risk” were significantly less likely to routinely provide screening. The Hawaii State Department of Health is currently working in consort with health care providers and the state’s dominant health insurance carriers to address these issues through targeted provider educational interventions.

Testing the Woman Abuse Screening Tool to Identify Intimate Partner Violence in Indonesia

Intimate Partner Violence (IPV) is a global public health problem. IPV prevalence in Indonesia has been estimated to be less than 1%, based on reported cases. It is likely that IPV prevalence is underreported in Indonesia, as it is in many other countries. Screening for IPV has been found to increase IPV identification, but no screening tools are in use in Indonesia. The aim of this study was to test the translated Woman Abuse Screening Tool (WAST) for detecting IPV in Indonesia. The WAST was tested against a diagnostic interview by a trained psychologist on 240 women attending two Primary Health Centers in Jakarta. IPV prevalence and the reliability, sensitivity, and specificity of the WAST were estimated. Prevalence of IPV by diagnostic interview was 36.3%, much higher than published estimates. The most common forms of IPV identified were psychological (85%) and physical abuse (24%). Internal reliability of the WAST was high (α = .801). A WAST score of 13 (out of 24) is the recommended cutoff for identifying IPV, but only 17% of the Indonesian sample scored 13 or higher. Test sensitivity of the WAST with a cutoff score of 13 was only 41.9%, with a specificity of 96.8%. With a cutoff score of 10, the sensitivity improved to 84.9%, while the specificity decreased to 61.0%. Use of the WAST with a cutoff score of 10 provides good sensitivity and reasonable specificity and would provide a much-needed screening tool for use in Indonesia. Although a lower cutoff would yield a greater proportion of false positives, most of the true cases would be identified, increasing the possibility that women experiencing abuse would receive needed assistance.

Depression, Anxiety, and Pharmacotherapy Around the Time of Pregnancy in Hawaii

BackgroundDepression and anxiety are common conditions among pregnant and postpartum women, but population-based information is lacking on treatments and help-seeking behaviors.PurposeThis study described the prevalence of depression, anxiety, pharmaceutical treatment, and help-seeking behaviors among a multiethnic population of women with recent live births in Hawaii.MethodHawaii Pregnancy Risk Assessment Monitoring System data from 4735 respondents were weighted to be representative of all pregnancies resulting in live births in Hawaii in 2009–2011 and were used to estimate the prevalence of several indicators related to anxiety and depression before, during, and after pregnancy among women with recent live births.ResultsOf Hawaii women with live births in 2009–2011, 7.3xa0% reported visiting a healthcare worker to be checked or treated for depression or anxiety in the year before their most recent pregnancy, 4.9xa0% reported having depression in the 3xa0months before pregnancy, 5.9xa0% reported having anxiety in the same period, 9.1xa0% screened positive for postpartum depression, and 6.9xa0% reported asking a doctor, nurse, or other healthcare worker for help for anxiety postpartum. The prevalence of antianxiety and antidepressant prescription drug use was 2.3xa0% in the month before pregnancy and 1.4xa0% during pregnancy. Hawaii had lower prevalence of pre-pregnancy depression, anxiety, and depression/anxiety health visits than other US states. Pre-pregnancy depression and anxiety and postpartum anxiety help-seeking behaviors differed significantly by race/ethnicity.ConclusionDepression and anxiety are common among pregnant and postpartum women in Hawaii. More research could better inform heath care professionals and patients of the treatment options available and their potential risks and benefits.

Investigation of a Cluster of Syphilis, Gonorrhea, and Chlamydia Cases Among Heterosexual Micronesians Living on Oahu

A recent case investigation of secondary syphilis in a 27-year-old heterosexual Micronesian male and his 19-year-old chlamydia and syphilis co-infected female partner, conducted by the Hawaii State Department of Health, June to August 2007, identified a cluster of 13 case-patients with undiagnosed syphilis, chlamydia, and gonorrhea. The social network of Micronesians uncovered was characterized by having transient accommodations but a central gathering place. The critical factor in gaining access to this network was the establishment of a trusting relationship with a key social network member. Field interviews and the application of field diagnostic techniques helped to identify case-patients who otherwise would not have presented to a traditional office or clinic setting. Micronesians in Hawaii represent an at-risk population for adverse health indices including sexually transmitted diseases, based on their socioeconomic status.

False-negative syphilis treponemal enzyme immunoassay results in an HIV-infected case-patient:

We present a case report of a false-negative syphilis treponemal enzyme immunoassay test result in an HIV-infected male. While treponemal tests are widely considered to be more sensitive and specific than non-treponemal tests, our findings point to potential challenges using the reverse sequence syphilis screening algorithm.

Under-Reporting of Pelvic Inflammatory Disease in Hawaii: A Comparison of State Surveillance and Hospitalization Data

Hawaii is one of only 19 states for which pelvic inflammatory disease (PID) is a mandated notifiable disease. In order to assess the completeness of PID reporting, we compared the number of hospitalized PID cases in the state of Hawaii with the total number of PID cases reported to the Hawaii State Department of Health surveillance system from 2007 through 2010. While 828 unique PID cases were diagnosed in Hawaii hospitals, only 240 unique PID cases were reported through the state’s surveillance system. Severe PID underreporting was seen despite mandatory reporting laws.