Fabienne Laraque

Unintended pregnancy among the urban poor.

This article seeks to determine the proportion of pregnancies that are unintended among poor women in New York City, compare the New York City rate to national data, and examine factors associated with unintended pregnancy in this population. Pregnancy testing data collected between June 1, 1998, and June 1, 2001, from field sites operated by the Office of Family Health, New York City Department of Health and Mental Hygiene were analyzed. Pregnancy planning (intended vs. unintended) was examined by age group, race/ethnicity, marital status, frequency of contraceptive use, number of previous pregnancies, drug and alcohol use, and smoking. Odds ratios were calculated to determine if pregnancies were more likely to be unintended among women with certain characteristics. Logistic regression was used to examine independent risk factors for unintended pregnancy. Of the 20,518 women who had a pregnancy test during the study period, 9,406 (45.8%) were pregnant. Of the pregnancies, 82% were unintended. Marital status was the strongest predictor of unintended pregnancy, increasing the risk 2.5-fold for unmarried women. Adolescents and those who drank alcohol were also at increased risk of unintended pregnancy. The extremely high percentage of pregnancies that were unintended among the study population suggests that national unintended pregnancy rates are not representative of what occurs among low-income women in an urban setting. Unintended pregnancy interventions should be tailored for the urban poor and target unmarried, young women.

Performance of Nucleic Acid Amplification Tests for Diagnosis of Tuberculosis in a Large Urban Setting

BACKGROUND A diagnosis of tuberculosis (TB) relies on acid-fast bacilli (AFB) smear and culture results. Two rapid tests that use nucleic acid amplification (NAA) have been approved by the US Food and Drug Administration for the diagnosis of TB based on detection of Mycobacterium tuberculosis from specimens obtained from the respiratory tract. We evaluated the performance of NAA testing under field conditions in a large urban setting with moderate TB prevalence. METHODS The medical records of patients with suspected TB during 2000-2004 were reviewed. Analysis was restricted to the performance of NAA on specimens collected within 7 days after the initiation of treatment for TB. The assays sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) were evaluated. RESULTS The proportion of patients with confirmed or suspected TB whose respiratory tract specimens were tested by use of NAA increased from 429 (12.9%) of 3334 patients in 2000 to 527 (15.6%) of 3386 patients in 2004; NAA testing among patients whose respiratory tract specimens tested positive for AFB increased from 415 (43.6%) of 952 patients in 2000 to 487 (55.5%) of 877 patients in 2004 (P < .001 for both trends). Of the 16,511 patients being evaluated for pulmonary TB, 4642 (28.1%) had specimens that tested positive for AFB on smear. Of those 4642 patients, 2241 (48.3%) had NAA performed on their specimens. Of those 2241 patients, 1279 (57.1%) had positive test results. Of those 1279 patients, 1262 (98.7%) were confirmed to have TB. For 1861 (40.1%) of the 4642 patients whose specimens tested positive for AFB on smear, the NAA test had a sensitivity of 96.0%, a specificity of 95.3%, a PPV of 98.0%, and an NPV of 90.9%. For 158 patients whose specimens tested negative for AFB on smear, the NAA test had a sensitivity of 79.3%, a specificity of 80.3%, a PPV of 83.1%, and an NPV of 76.0%, respectively. For the 215 specimens that tested positive for AFB by smear, we found a sensitivity, specificity, PPV, and NPV of 97.5%, 93.6%, 95.1%, and 96.8%, respectively. A high-grade smear was associated with a better test performance. CONCLUSION NAA testing was helpful for determining whether patients whose specimens tested positive for AFB on smear had TB or not. This conclusion supports the use of this test for early diagnosis of pulmonary and extrapulmonary TB.

High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic

BACKGROUND Though direct acting antivirals (DAAs) promise high cure rates, many providers and payers remain concerned about successful treatment for people who use drugs (PWUD), even among those engaged in opioid agonist treatment (OAT). The efficacy of DAAs among PWUD in real-world settings is unclear. METHODS We conducted a cohort study of patients initiating HCV treatment between January 2014 and August 2015 (n=89) at a primary care clinic in the Bronx, NY. Onsite HCV treatment with DAAs was performed by an HCV specialist, with support from a care coordinator funded by the NYC Department of Health. We identified four categories of drug use and drug treatment: (1) no active drug use/not receiving OAT (defined as non-PWUD); (2) no active drug use/receiving OAT; (3) active drug use/not receiving OAT; and (4) active drug use/receiving OAT. The primary outcome was SVR at 12 weeks post-treatment. RESULTS Overall SVR rates were 95% (n=41/43) for non-PWUD and 96% (n=44/46) for patients actively using drugs and/or receiving OAT [p=0.95]. There were no differences in SVR rates by drug use or drug treatment category. Compared to non-PWUD, those with no active drug use/receiving OAT had 100% SVR (n=15/15; p=1.0), those actively using drugs/not receiving OAT had 90% SVR (n=9/10; p=0.47), and those actively using drugs/receiving OAT had 95% SVR (20/21; p=1.0). CONCLUSION Regardless of active drug use or OAT, patients who received DAA therapy at an urban primary care clinic achieved high HCV cure rates. We found no clinical evidence to justify restricting access to HCV treatment for patients actively using drugs and/or receiving OAT.

Higher mortality rate among infants of US-born mothers compared to foreign-born mothers in New York City.

This study is to compare infant mortality rates (IMRs) between US- and foreign-born mothers in New York City. The linked live birth-infant death records from 1995 to 1998 were analyzed. Overall US-born mothers had a higher IMR than foreign-born mothers, though there were great variations in IMRs by country of maternal birth among foreign-born mothers. US-born mothers had higher IMRs compared to foreign-born mothers for several maternal/infant characteristics. Logistic regression analyses indicated that infants of foreign-born mothers were less likely to die from prematurity, Sudden Infant Death Syndrome and external causes, but were more likely to die of congenital anomalies than those of US-born mothers. Further analyses on the interactions of maternal race/ethnicity and country of birth showed variations in the IMRs of leading causes of death. Infant mortality reduction strategies should be differentially targeted to minority mothers of different countries of birth, particularly for potentially preventable causes of deaths.

Disparities in community viral load among HIV-infected persons in New York City.

Objective:HIV infection is a major problem in New York City (NYC), with more than 100 000 living HIV-infected persons. Novel public health approaches are needed to control the epidemic. The NYC Department of Health and Mental Hygiene (DOHMH) analysed community viral load (CVL) for a baseline to monitor the population-level impact of HIV control interventions. Design:A cross-sectional study using routinely collected surveillance data. Methods:All HIV-infected persons reported to the NYC HIV Registry who were at least 13 years of age, with at least one viral load test result in 2008, and alive at the end of 31 December 2008 were included. CVL was defined as the mean of individual viral load means reported between January and December 2008. Detectable viral load was defined as an individual mean of more than 400 copies/ml. Differences in CVL and proportion undetectable were computed by socio-demographic characteristics and summary measures were mapped. Results:New York City CVL was 21 318 copies/ml overall (N = 62 550) and 44 749 copies/ml (N = 28 366) among persons with detectable mean viral loads. CVL varied by demographic and clinical characteristics, with statistically significant differences (P < 0.001) in all groups except race/ethnicity (P = 0.16). Men, persons aged 20–49 years, MSM, persons with AIDS, those with a CD4+ cell count of 200 cells/&mgr;l or less and persons diagnosed after 2006 had higher mean viral load. Overall, 54.7% of HIV-infected persons had a suppressed mean viral load, with individual and neighbourhood variations (P < 0.0001). Conclusion:This analysis showed strong disparities in reported CVL by individual characteristics and neighbourhoods. CVL patterns can be utilized to target interventions and track their impact.

Trends in Drug-Resistant Mycobacterium tuberculosis in New York City, 1991–2003

BACKGROUND Two drug-resistance surveys showed a very high prevalence of drug resistance among isolates obtained from patients with tuberculosis in 1991 and 1994 in New York, New York. METHODS A cross-sectional survey in April 1997 and a survey of incident cases in April-June 2003 were conducted. The trend in the proportion of drug resistance in the 4 surveys was examined separately for prevalent and incident cases. Risk factors for drug resistance in incident cases were also assessed. RESULTS The number of patients was 251 in the 1997 survey and 217 in the 2003 survey. Among prevalent cases, the percentage of cases with resistance to any antituberculosis drug decreased from 33.5% in 1991 to 23.8% in 1994 and to 21.5% in 1997 (P < .001, by test for trend); cases of multidrug-resistant tuberculosis also decreased significantly, from 19% in 1991 to 6.8% in 1997 (P < .001, by test for trend). Among incident cases in the 4 surveys, the decrease in resistance to any antituberculosis drugs was not statistically significant; however, the decrease in multidrug-resistant tuberculosis (from 9% in 1991 to 2.8% in 2003) was statistically significant (P = .002, by test for trend). However, in 2003, a worrisome increase in incident cases of multidrug-resistant tuberculosis (an increase of 23%) was seen among previously treated patients with pulmonary tuberculosis not born in the United States. Human immunodeficiency virus infection, a strong predictor for drug resistance in 1991 and 1994, was not associated with drug resistance in subsequent surveys. CONCLUSIONS Intensive case management, including directly observed therapy, adherence monitoring, and periodic medical review to ensure appropriate treatment for each patient, should be sustained to prevent acquired drug resistance.

Active Surveillance of Maternal Mortality in New York City

OBJECTIVES This study examined the usefulness of computer-assisted active surveillance in identifying maternal deaths in New York City. METHODS Computerized searches of hospital discharge and autopsy record databases were conducted for maternal deaths occurring in 1997. RESULTS Active surveillance revealed 14 new maternal deaths not previously reported, an 88% increase. Nine of these deaths were found through the hospital discharge database search, 1 was found through the autopsy record search, and 4 were found in both searches. Overall maternal mortality ratios associated with active surveillance and routine surveillance were 24.3 and 13.0 deaths per 100 000 live births, respectively. CONCLUSIONS Active surveillance of maternal mortality is useful in identifying new maternal deaths. Existing databases can be used relatively easily to augment routine surveillance of maternal mortality.

From Care to Cure: Demonstrating a Model of Clinical Patient Navigation for Hepatitis C Care and Treatment in High-Need Patients

The NYC Department of Health implemented a patient navigation program, Check Hep C, to address patient and provider barriers to HCV care and potentially lifesaving treatment. Services were delivered at two clinical care sites and two sites that linked patients to off-site care. Working with a multidisciplinary care team, patient navigators provided risk assessment, health education, treatment readiness and medication adherence counseling, and medication coordination. Between March 2014 and January 2015, 388 participants enrolled in Check Hep C, 129 (33%) initiated treatment, and 119 (91% of initiators) had sustained virologic response (SVR). Participants receiving on-site clinical care had higher odds of initiating treatment than those linked to off-site care. Check Hep C successfully supported high-need participants through HCV care and treatment, and SVR rates demonstrate the real-world ability of achieving high cure rates using patient navigation care models.

The impact of monitoring tuberculosis reporting delays in New York City.

Public health departments rely on the timely receipt of tuberculosis (TB) reports to promptly initiate patient management and contact investigations. In 2003, 43% of persons in New York City with confirmed or suspected TB were reported 4 or more days late. An intervention to increase the timeliness of TB reporting was initiated in 2004. A list of patients who were reported late and had a smear positive for acid-fast bacilli, a pathology finding consistent with TB, or who initiated 2 or more anti-TB medications was generated quarterly. Health care providers and laboratories were contacted to determine the reasons for reporting late and were educated on TB reporting requirements. To assess the effectiveness of the intervention, we evaluated the trend in delayed reports between 2003 and 2006, using the Jonckheere-Terpstra test for trend. The proportion of patients who were reported late decreased from 43% (942/2183) in 2003 to 20% (386/1930) in 2006 (Ptrend < .0001). There were improvements in reporting timeliness for all 3 reporting criteria included in the evaluation and all provider types (all Ptrend < .0001); however, private providers consistently had a higher proportion of delayed reporting (22% reported late in 2006). This relatively simple intervention was very effective in improving the timeliness of TB reporting and could be utilized for other reportable diseases where prompt reporting is critical.

Increasing breastfeeding rates in New York City, 1980–2000

Our objective was to determine temporal patterns of breastfeeding among women delivering infants in New York City (NYC) and compare national breastfeeding trends. All hospitals in NYC with obstetric units were contacted in May and June 2000 to provide information on the method of infant feeding during the mother’s admission for delivery. Feeding was categorized as “exclusive breastfeeding,” “breast and formula,” or “exclusive formula.” The first two categories were further grouped into “any breastfeeding” in the analysis. Hospitals were classified as “public” and “private,” and patients were classified by insurance type as “service” and “private.” Data between public and private hospitals and service and private patients were compared. Breastfeeding trends over time were compared by using previous iterations of the same survey. Of 16,932 newborns, representing approximately 80.0% of all reported live births in the city during the study period, 5,305 (31.3%) were exclusively breastfed, 6,189 (36.6%) were fed a combination of breast milk and formula, and the remaining 5,438 (32.1%) were exclusively formula-fed. Infants born in private hospitals were 1.6 times more likely to be exclusively breastfed compared with infants discharged from public hospitals (33% vs. 21%, respectively). Similarly, private patients were more likely than service patients to exclusively breastfeed their infants (39.6% vs. 22.9%, respectively) and to use a combination of breast and formula (i.e., any breastfeeding) (73.6% vs. 62.0%, respectively). From 1980 to 2000, the proportion of exclusive breastfeeding increased from 25.0% to 31.0%, the percentage of combined feeding increased from 8.0% to 37.0%, and the percentage of any breastfeeding increased from 33.0% to 68.0%. NYC has more than doubled the rate of breastfeeding since 1980. However, there is much progress to be made, and continued efforts are vital to maintain current gains in breastfeeding, improve the rates further, and prolong the duration of breastfeeding.