Katherine Bornschlegel

The effect of maternal viral load on the risk of perinatal transmission of HIV-1

Objective:To determine the effect of maternal viral load at delivery on the risk of perinatal transmission of HIV-1. Design:A nested case–control study within a prospectively followed cohort of HIV- 1-infected pregnant women and their infants. Setting:The multicenter New York City Perinatal HIV Transmission Collaborative Study. Participants:Fifty-one women who gave birth to HIV-1-infected infants were frequency-matched within CD4+ cell count quintiles with 54 non-transmitting mothers. Main outcome measures:Maternal quantity of HIV-1 viral RNA was assayed in plasma obtained near delivery using the nucleic acid sequence-based amplification assay system. Results:Viral RNA was detected in 73 (70%) out of 105 women and the median viral load was 16 000 RNA copies/ml in transmitters and 6600 in non-transmitters (P < 0.01). When adjusted for maternal CD4+ count near delivery, women with measurable viral load were nearly sixfold more likely to transmit HIV-1 than women with viral load below detection [adjusted odds ratio (AOR), 5.8; 95% confidence interval (CI), 2.2–15.5]. The odds ratio for perinatal transmission of log10 viral load, adjusted for CD4 count was 2.7 (95% CI, 1.5–5.1). When stratified by the stage of HIV-1 disease, the only group with significant association between log10 viral load and transmission were AIDS-free women with CD4+ count > 500 x 106/l (AOR, 9.1; 95% CI, 2.6–31.5). Conclusions:High maternal viral load increases the likelihood of perinatal transmission of HIV-1 in women without AIDS and advanced immunosuppression. HIV-1-infected pregnant women without advanced disease, shown by others to have the lowest risk of perinatal transmission, may benefit the most from efforts to identify and decrease viral load at delivery.

A large outbreak of hepatitis B virus infections associated with frequent injections at a physician's office.

OBJECTIVES To determine whether hepatitis B virus (HBV) transmission occurred among patients visiting a physicians office and to evaluate potential transmission mechanisms. DESIGN Serologic survey, retrospective cohort study, and observation of infection control practices. SETTING Private medical office. PATIENTS Those visiting the office between March 1 and December 26, 2001. RESULTS We identified 38 patients with acute HBV infection occurring between February 2000 and February 2002. The cohort study, limited to the 10 months before outbreak detection, included 91 patients with serologic test results and available charts representing 18 case-patients and 73 susceptible patients. Overall, 67 patients (74%) received at least one injection during the observation period. Case-patients received a median of 14 injections (range, 2-25) versus 2 injections (range, 0-17) for susceptible patients (P < .001). Acute infections occurred among 18 (27%) of 67 who received at least one injection versus none of 24 who received no injections (RR, 13.6; CI95, 2.4-undefined). Risk of infection increased 5.2-fold (CI95, 0.6-47.3) for those with 3 to 6 injections and 20.0-fold (CI95, 2.8-143.5) for those with more than 6 injections. Typically, injections consisted of doses of atropine, dexamethasone, vitamin B12, or a combination of these mixed in one syringe. HBV DNA genetic sequences of 24 patients with acute infection and 4 patients with chronic infection were identical in the 1,500-bp region examined. Medical staff were seronegative for HBV infection markers. The same surface was used for storing multidose vials, preparing injections, and dismantling used injection equipment. CONCLUSION Administration of unnecessary injections combined with failure to separate clean from contaminated areas and follow safe injection practices likely resulted in patient-to-patient HBV transmission in a private physicians office.

Enhanced drop-in syndromic surveillance in New York City following September 11, 2001.

After the 2001 World Trade Center disaster, the New York City Department of Health was under heightened alert for bioterrorist attacks in the city. An emergency department (ED) syndromic surveillance system was implemented with the assistance of the Centers for Disease Control and Prevention to ensure early recognition of an increase or clustering of disease syndromes that might represent a disease outbreak, whether natural or intentional. The surveillance system was based on data collected 7 days a week at area EDs. Data collected were translated into syndromes, entered into an electronic database, and analyzed for aberrations in space and time within 24 hours. From September 14–27, personnel were stationed at 15 EDs on a 24-hour basis (first staffing period); from September 29–October 12, due to resource limitations, personnel were stationed at 12 EDs on an 18-hour basis (second staffing period). A standardized form was used to obtain demographic information and classify each patient visit into 12 syndrome categories. Seven of these represented early manifestations of bioterrorist agents. Data transfer and analysis for time and space clustering (alarms) by syndrome and age occurred daily. Retrospective analyses examined syndrome trends, differences in reporting between staffing periods, and the staff’s experience during the project. A total of 67,536 reports were received. The system captured 83.9% of patient visits during the first staffing period, and 60.8% during the second staffing period (P<01). Five syndromes each accounted for more than 1% of visits: trauma, asthma, gastrointestinal illness, upper/lower respiratory infection with fever, and anxiety. Citywide temporal alarms occurred eight times for three of the major bioterrorism-related syndromes. Spatial clustering alarms occurred 16 time by hospital location and 9 times by ZIP code for the same three syndromes. No outbreaks were detected. On-site staffing to facilitate data collection and entry, supported by daily analysis of ED visits, is a feasible short-term approach to syndromic surveillance during high-profile events. The resources required to operate such a system, however, cannot be sustained for the long term. This system was changed to an electronic-based ED syndromic system using triage log data that remains in operation.

Tuberculosis in human immunodeficiency virus-infected and human immunodeficiency virus-exposed children in New York City.

Background. Tuberculosis disease incidence increased sharply in New York City (NYC) in the late 1980s in children and adults. The relationship of tuberculosis disease in adults with the coincident epidemic of immunosuppression caused by HIV disease has been well-documented. This paper examines the relationship of tuberculosis and HIV in children in NYC. Methods. Information on tuberculosis was collected by retrospective chart abstraction in a cohort of HIV-exposed and infected children enrolled in a longitudinal study of HIV. Tuberculosis cases were ascertained by chart review or by matching HIV-infected and -exposed children to NYC Tuberculosis Registry cases. NYC Tuberculosis Registry data on children reported from 1989 to 1995, and not reported as HIV-infected, were used for comparison. Results. Tuberculosis disease was found in 45 (3%) of 1426 HIV-infected children (0.61 per 100 child years of observation) and in 5 (0.5%) of 1085 HIV-exposed uninfected children (0.2 per 100 child years). 30% of children were evaluated for HIV only after presenting with tuberculosis. Children with tuberculosis and HIV were more likely than other age-matched HIV-infected children to have decreased CD4+ T lymphocyte counts (66%vs. 37%, P = 0.02) and more likely than other NYC children with tuberculosis to have culture-confirmed and extrapulmonary tuberculosis. In this series 8 of 21 deaths in HIV-infected children with tuberculosis appeared to be related to tuberculosis. Conclusions. During a period of high tuberculosis incidence in NYC, 3% of HIV-infected children in our cohort had tuberculosis, higher than the rate in uninfected children born to HIV-positive mothers in the same cohort. Because of this association, HIV-infected children with pulmonary illness should be tested for tuberculosis; and all children with tuberculosis should be tested for HIV.

Case-control study of hepatitis B and hepatitis C in older adults: Do healthcare exposures contribute to burden of new infections?

Reports of hepatitis B virus (HBV) and hepatitis C virus (HCV) transmission associated with unsafe medical practices have been increasing in the United States. However, the contribution of healthcare exposures to the burden of new infections is poorly understood outside of recognized outbreaks. We conducted a case‐control study at three health departments that perform enhanced viral hepatitis surveillance in New York and Oregon. Reported cases of symptomatic acute hepatitis B and hepatitis C occurring in persons ≥55 years of age from 2006 to 2008 were enrolled. Controls were identified using telephone directories and matched to individual cases by age group (55‐59, 60‐69, and ≥70 years) and residential postal code. Data collection covered exposures within 6 months before symptom onset (cases) or date of interview (controls). Forty‐eight (37 hepatitis B and 11 hepatitis C) case and 159 control patients were enrolled. Case patients were more likely than controls to report one or more behavioral risk exposures, including sexual or household contact with an HBV or HCV patient, >1 sex partner, illicit drug use, or incarceration (21% of cases versus 4% of controls exposed; matched odds ratio [mOR] = 7.1; 95% confidence interval [CI]: 2.1, 24.1). Case patients were more likely than controls to report hemodialysis (8% of cases; mOR = 13.0; 95% CI: 1.5, 115), injections in a healthcare setting (58%; mOR = 2.7; 95% CI: 1.3, 5.3), and surgery (33%; mOR = 2.3; 95% CI: 1.1, 4.7). In a multivariate model, behavioral risks (adjusted OR [aOR] = 5.4; 95% CI: 1.5, 19.0; 17% attributable risk), injections (aOR = 2.7; 95% CI: 1.3, 5.8; 37% attributable risk), and hemodialysis (aOR = 11.5; 95% CI: 1.2, 107; 8% attributable risk) were associated with case status. Conclusion: Healthcare exposures may represent an important source of new HBV and HCV infections among older adults. (HEPATOLOGY 2013)

Estimating the prevalence of hepatitis C infection in New York City using surveillance data.

SUMMARY Hepatitis C virus is the most common chronic blood-borne infection in the USA. Based on results of a serosurvey, national prevalence is estimated to be 1·3% or 3·2 million people. Sub-national estimates are not available for most jurisdictions. Hepatitis C surveillance data was adjusted for death, out-migration, under-diagnosis, and undetectable blood RNA, to estimate prevalence in New York City (NYC). The prevalence of hepatitis C infection in adults aged ⩾20 years in NYC is 2·37% (range 1·53–4·90%) or 146 500 cases of hepatitis C. This analysis presents a mechanism for generating prevalence estimates using local surveillance data accounting for biases and difficulty in accessing hard to reach populations. As the cohort of patients with hepatitis C age and require additional medical care, local public health officials will need a method to generate prevalence estimates to allocate resources. This approach can serve as a guideline for generating local estimates using surveillance data that is less resource prohibitive.

Prevalence of Hepatitis C Infection in New York City, 2004

Hepatitis C virus (HCV) is the leading cause of chronic liver disease in the United States. Accurate hepatitis C prevalence estimates are important to guide local public health programs but are usually unavailable to local health jurisdictions. National surveys may not reflect local variation, a particular challenge for urban settings with disproportionately large numbers of residents in high-risk population groups. In 2004, the New York City Department of Health and Mental Hygiene conducted the NYC Health and Nutrition Examination Survey, a population-based household survey of non-institutionalized NYC residents ages 20 and older. Study participants were interviewed and blood specimens were tested for antibody to HCV (anti-HCV); positive participants were re-contacted to ascertain awareness of infection and to provide service referrals. Of 1,786 participants with valid anti-HCV results, 35 were positive for anti-HCV, for a weighted prevalence of 2.2% (95% confidence interval [CI] 1.5% to 3.3%). Anti-HCV prevalence was high among participants with a lifetime history of injection drug use (64.5%, 95% CI 39.2% to 83.7%) or a lifetime history of incarceration as an adult (8.4%, 95% CI 4.3% to 15.7%). There was a strong correlation with age; among participants born between 1945 and 1954, the anti-HCV prevalence was 5.8% (95% CI 3.3% to 10.0%). Of anti-HCV positive participants contacted (51%), 28% (n = 5) first learned of their HCV status from this survey. Continued efforts to prevent new infections in known risk behavior groups are essential, along with expansion of HCV screening and activities to prevent disease progression in people with chronic HCV.

Estimating the Prevalence of Chronic Hepatitis B Virus Infection—New York City, 2008

Chronic hepatitis B virus (HBV) infection is a preventable cause of liver failure, cirrhosis, and liver cancer; estimated chronic HBV infection prevalence is 0.3–0.5% in the USA. Prevalence in New York City (NYC) is likely higher because foreign-born persons, who represent 36% of NYC’s population versus 11% nationwide, bear a disproportionate burden of chronic HBV infection. However, because no comprehensive, population-based survey of chronic HBV infection has been conducted in NYC, a reliable prevalence estimate is unavailable. We used two approaches to estimate chronic HBV infection prevalence in NYC: (1) a census-based estimate, combining local and national prevalence data for specific populations, and (2) a surveillance-based estimate, using data from NYC’s Department of Health and Mental Hygiene Hepatitis B Surveillance Registry and adjusting for out-migration and deaths. Results from both the census-based estimate and the surveillance-based estimate were similar, with an estimated prevalence of chronic HBV in NYC of 1.2%. This estimate is two to four times the estimated prevalence for the USA as a whole. According to the census-based estimate, >93% of all cases in NYC are among persons who are foreign-born, and approximately half of those are among persons born in China. These findings underscore the importance of local data for tailoring programmatic efforts to specific foreign-born populations in NYC. In particular, Chinese-language programs and health education materials are critical. Reliable estimates are important for policymakers in local jurisdictions to better understand their own population’s needs and can help target primary care services, prevention materials, and education.

Half a Diagnosis: Gap in Confirming Infection among Hepatitis C Antibody-positive Patients

BACKGROUND Recent guidelines recommend testing all individuals born during 1945-1965 for hepatitis C virus (HCV) antibody. For antibody-positive patients, subsequent RNA testing is necessary to determine current infection status. This study aimed to assess whether clinicians order HCV RNA tests as recommended for antibody-positive patients and to identify barriers to such testing. METHODS We sampled individuals newly reported to the New York City Department of Health and Mental Hygienes HCV surveillance system and collected information from clinicians. For patients without RNA test results, we asked the reason an RNA test was not ordered and requested that the clinician order the test. RESULTS Of 245 antibody-positive patients, 67% were tested for HCV RNA (for 21% of these, the test was ordered only after our request); 33% had no RNA testing despite our request. Patients without RNA testing were seen in medical facilities (47%), detox facilities (30%), and jail/prison (15%). Reasons RNA testing was not done were that the patient did not return for follow-up (35%), the facility does not do RNA testing (22%), and the patient was tested in jail (15%). CONCLUSIONS In our study, one third of patients did not get complete testing for accurate diagnosis of HCV, which is essential for medical management. Additional education for clinicians about the importance of RNA testing may help. However, with improved antiviral treatments now available for HCV, it is time for reflex HCV RNA testing for positive antibody tests to become routine, just as reflex Western blot testing is standard for human immunodeficiency virus.

Deaths Among People With Hepatitis C in New York City, 2000–2011

BACKGROUND Infection with hepatitis C virus (HCV) increases the risk of death from liver and nonliver-related diseases. Coinfection with human immunodeficiency virus (HIV) further increases this risk. METHODS Surveillance data (2000-2010) and mortality data (2000-2011) maintained by the New York City Department of Health and Mental Hygiene (DOHMH) were deterministically cross-matched. Factors associated with and causes of death among HCV-infected adult decedents were analyzed. RESULTS Between 2000 and 2011, 13 307 HCV-monoinfected adults died, and 5475 adults coinfected with HCV/HIV died. Decedents with HCV monoinfection were more likely to have died of liver cancer (odds ratio [OR] = 9.2), drug-related causes (OR = 4.3), and cirrhosis (OR = 3.7), compared with persons with neither infection. HCV/HIV-coinfected decedents were more likely to have died of liver cancer (OR = 2.2) and drug-related causes (OR = 3.1), compared with persons with neither infection. Among coinfected decedents, 53.6% of deaths were attributed to HIV/AIDS, and 94% of deaths occurred prematurely (before age 65). Among persons with HCV who died, more than half died within 3 years of an HCV report to DOHMH. CONCLUSIONS HCV-infected adults were at increased risk of dying and of dying prematurely, particularly from conditions associated with HCV, such as HIV/AIDS or drug use. The short interval between HCV report and death suggests a need for earlier testing and improved treatment.