M. Barragán

Chagas disease: an impediment in achieving the Millennium Development Goals in Latin America

BackgroundAchieving sustainable economic and social growth through advances in health is crucial in Latin America within the framework of the United Nations Millennium Development Goals.DiscussionHealth-related Millennium Development Goals need to incorporate a multidimensional approach addressing the specific epidemiologic profile for each region of the globe. In this regard, addressing the cycle of destitution and suffering associated with infection with Trypanosoma cruzi, the causal agent of Chagas disease of American trypanosomiasis, will play a key role to enable the most impoverished populations in Latin America the opportunity to achieve their full potential. Most cases of Chagas disease occur among forgotten populations because these diseases persist exclusively in the poorest and the most marginalized communities in Latin America.SummaryAddressing the cycle of destitution and suffering associated with T. cruzi infection will contribute to improve the health of the most impoverished populations in Latin America and will ultimately grant them with the opportunity to achieve their full economic potential.

Low health literacy is associated with HIV test acceptance.

AbstractBACKGROUND: The Centers for Disease Control and Prevention has proposed increasing the proportion of people who learn their HIV serostatus. The health care setting represents a logical site to accomplish this goal. However, little is known about factors that determine acceptability of HIV testing in health care settings, particularly patients’ health literacy. OBJECTIVE: To evaluate the association between patients’ health literacy and acceptance of HIV testing among individuals at an urgent care center (UCC). METHODS: As part of a prospective study that sought to increase HIV testing at a UCC located in an inner-city hospital serving an indigent population, we surveyed patients who had been offered an HIV test by their providers and had accepted or refused testing. Pretest counseling was provided using a low-literacy brochure given to patients upon registration into the clinic. We measured health literacy level using the Rapid Estimate of Adult Literacy in Medicine (REALM) scale. RESULTS: Three hundred seventy-two patients were enrolled in the study. In univariate analysis, no statistically significant difference between HIV test acceptors or refusers was found for gender, race/ethnicity, marital status, income, type of health insurance, educational level, or type of test offered. Acceptors were more likely to have a low literacy level (odds ratio [OR], 1.763; 95% confidence interval [CI], 1.084 to 2.866) and be less than 40 years old (OR, 1.639; 95% CI, 1.085 to 2.475). In multivariate analysis, low health literacy was shown to be a predictor of HIV test acceptance controlling for age and education (OR, 2.017; 95% CI, 1.190 to 3.418). CONCLUSIONS: Low health literacy was shown to be a predictor of HIV test acceptance. Patients presenting to a UCC with poorer health literacy appear more willing to comply with health care providers’ recommendations to undergo HIV testing than those with adequate health literacy when an “opt-out” strategy combined with a low-literacy brochure is used.

Infectious Diseases, Non–Zero-Sum Thinking, and the Developing World

&NA; Despite some improvements in the health status of the world during the last few decades, major obstacles remain. Improvements in health outcomes have not been shared equally among countries and poverty is clearly the main reason. Infectious diseases, which remain the major cause of death worldwide, are an incalculable source of human misery and economic loss. In fact, 25% of all deaths and 30% of the global burden of disease are attributed to infectious diseases. Unfortunately, more than 95% of these deaths, most of which are preventable, occur in the developing world, where poverty is widespread. The 3 major infectious disease killers in these countries are HIV/AIDS, tuberculosis, and malaria. The principles of social justice and health as a human right in the developing world have been advocated as the main justification for health assistance from rich to poor countries. Although we do not disagree with this, we argue that a strategy that emphasizes the shared benefit to rich and poor countries would facilitate this process. We propose that the accomplishment of these challenging tasks should be viewed from the perspective of game theory, where the interests of the parties (in this case rich and poor countries) overlap. As the world becomes increasingly integrated, economic development in resource‐poor countries will increase the opportunities for richer countries to profit from investment in the developing world. Global health has political and international security implications for the developed world, as well. In view of the current health status of the developing world, we are not playing a game but facing a matter of life and death. “When health is absent, wisdom cannot reveal itself, art cannot becomes manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied” Herophilus, 325 bce (Physician to Alexander the Great) The purpose of this article is to address the relationship between health, poverty, and development in the context of game theory. We will focus on the link between economic inequalities and health outcomes, exclusively concentrating our analysis on the impact of infectious diseases. Subsequently, we will outline the game, the players, and the potential win‐win outcomes that may potentially result.

Pneumocystis jiroveci Pneumonia in Patients With AIDS in the Inner City: A Persistent and Deadly Opportunistic Infection

Highly active antiretroviral therapy (HAART) has decreased the morbidity and mortality of opportunistic infections including Pneumocystis jiroveci pneumonia (PCP) among HIV-infected individuals. We performed a hospital-based retrospective cohort study among a population of medically underserved inner city persons living in Atlanta, Georgia, diagnosed with confirmed PCP to compare the epidemiology and outcomes of PCP during 2 defined periods: 1990 to 1995, or pre-HAART period, and 1996 to 2001, or HAART period. A total of 488 patients were available for analysis. The overall mortality rate was 47% during the pre-HAART era compared with 37% during the HAART era (P = 0.02). However, among those patients that required medical intensive care unit admission and mechanical ventilation, the mortality rate was particularly high, with over 80% of patients dying as a result of their episode of PCP during both periods. PCP was the initial presentation of HIV infection in 39.3% in the pre-HAART period with a mortality rate of 52%, in contrast with 37% in the HAART period, with a mortality rate of 45%, respectively (P = NS). Only 30.7% in the pre-HAART period and 31.1% of patients in the HAART period were receiving PCP prophylaxis. The overall risk of death, when we combined both groups in the analysis, was higher for those patients who did not take PCP prophylaxis, those who smoked tobacco, and those who were admitted to the medical intensive care unit and required mechanical ventilatory support. Our findings suggest that despite the availability of HAART, PCP continues to cause a significant burden of disease among inner-city HIV-infected populations.

The Untimely Misfortune of Tuberculosis Diagnosis at Death: Twelve-Year Experience at an Urban Medical Center

Introduction:Most of the burden of tuberculosis (TB) in the United States resides in underserved minorities in the inner city. Prompt diagnosis and initiation of therapy are crucial. Methods:We performed a retrospective review for a 12-year period of a major inner city hospital in the United States to identify cases of TB diagnosed at the time of death or postmortem. Results:We identified 35 cases for a 12-year period. Of these, 33 (94%) were culture-confirmed cases of TB. At the time of autopsy, 6 cases (17%) were identified. In all these cases, there was no clinical suspicion of TB. Pulmonary TB was confirmed in 27 (77%) of the 35 patients, whereas 8 (23%) of the 35 had extrapulmonary TB. Of those with extrapulmonary TB, 6 patients had disseminated TB; 1, peritoneal TB; and 1, meningeal TB. Discussion:Clinicians serving underserved populations with high human immunodeficiency virus infection/ acquired immune deficiency syndrome prevalence or other comorbidities such as diabetes and/or with currently high TB prevalence rates and high clinical suspicion of acute disseminated forms of TB even without bacteriologic confirmation, a therapeutic trial of antituberculous drugs should be entertained among those patients in whom there is strong clinical suspicion.

TUBERCULOSIS DIAGNOSIS AT DEATH AT AN URBAN MEDICAL CENTER: MISSED OPPORTUNITIES.: 229

Background Tuberculosis (TB) cases in the United States are concentrated among underserved populations in the inner city. Grady Memorial Hospital (GMH) cares for 80% of patients with TB in Atlanta and 20% of all TB cases in Georgia. An unfortunate consequence of late diagnosis is that some patients are initially diagnosed with TB very late in their disease process, resulting in an unacceptably high mortality rate shortly thereafter. Regretfully, TB is sometimes diagnosed postmortem. Delayed diagnosis has major public health implications with regard to the persistent transmission of TB in the community and in hospital settings. Methods As part of a larger TB mortality study, we identified patients seen at Grady Memorial Hospital, a 1,000-bed inner-city university-affiliated public hospital in Atlanta, GA, who were diagnosed with TB postmortem by performing a retrospective review of medical records from June 1993 to June 2004. Death at diagnosis was confirmed by postmortem culture results, autopsy findings, and/or dying within 72 hours of presentation. Results In a preliminary study, over an 11-year period, 20 cases of missed diagnoses of TB were identified. All of the patients were African American, 13 (65%) were male, and the mean age at death was 47.8 (range 24-81). Eighteen (90%) were culture confirmed, whereas 2 (10%) were clinical cases. Of these 18, 13 (72%) had pulmonary TB, whereas 5 had extrapulmonary TB; among these 5, 4 had disseminated TB, whereas 1 had pleural. Five (25%) cases were identified at autopsy. Eleven (55%) were HIV positive with a mean CD4 of 89.8, median 51.5 (range 8-290). Eight (40%) patients were in the ICU, and 6 of the 8 (75%) were on ventilators. Radiologic findings at admission (n = 18) were as follows: miliary (2, 11%), interstitial (5, 28%), cavitary (1, 0.06%), lobar infiltrate (1, 0.06%), pleural effusion (8, 44%), and normal (1, 0.06%). Despite radiologic findings and admission diagnoses of AIDS, pneumonia, weight loss, or dyspnea, TB was considered for 8 patients and only 6 received presumptive therapy within 72 hours prior to death. Conclusions In areas of high prevalence, TB is frequently underdiagnosed. Furthermore, given the protean clinical features of TB and its ability to mimic other diseases, its diagnosis may be missed or overlooked. Our results demonstrate that in many cases, TB is diagnosed late or even at autopsy. Among these cases, there were many missed opportunities to diagnose and treat TB. Clinicians treating patients with TB risk factors should have a low threshold of suspicion in diagnosing TB and should consider treating empirically while awaiting the results of smears, cultures, and molecular tests in some cases.

340 THE ETIOLOGY OF BACTERIAL MENINGITIS AT A CHILDREN'S HOSPITAL IN TBILISI, REPUBLIC OF GEORGIA.

Background H. influenzae, N. meningitidis, and S. pneumoniae continue to be the leading causes of childhood bacterial meningitis, especially in regions where vaccination against these pathogens are not available. The etiology of meningitis has not been established in Tbilisi, Republic of Georgia. This study was carried out in an effort to assess the laboratory capacity and the etiology of bacterial meningitis among patients receiving care at the Children9s Central Hospital, a referral pediatric hospital in Georgia. Methods A retrospective laboratory-based study was carried out and included those patients who had a CSF culture submitted between January 2004 and May 2006. Results Of 693 CSF cultures performed during the study period, 77 (11%) were positive. Complete medical records were available and reviewed for 60 patients with a positive CSF culture. Among the 60 children with positive cultures, the following organisms were identified: CNS (11, 18.3%); S. pneumoniae (4, 6.7%); H. influenzae (3, 5%); gram-negative rods (26, 43.3%); gram-positive cocci (4, 6.7%); N. meningitidis (2, 3.3%); yeast (5, 8.3%); nonhemolytic Streptococcus spp. (1, 1.7%); Salmonella spp. (1, 1.7%); Pseudomonas spp. (2, 3.3%); and Klebsiella spp. (1, 1.7%). Fifty-eight percent (35) of the patients were male, and the mean age was 1.75 (range 0-13) years. The median CSF WBC was 304/mm3 (0-16,000); median protein was 575 mg/dL (33-4,310); and median glucose was 50 mg/dL (3-157). Mortality was quite high, with 20 (33%) children dying. Among those who died, the majority (18/20, 90%, p = .018) were under the age of 1 and had a median CSF WBC of 500/mm3, a CSF protein of 660 mg/dL (33-4,310), and a CSF glucose of 35 mg/dL (2.7-156.67). Death was primarily attributed to gram-negative rods, which could not be further characterized (12, 60%), followed by CNS, S. pneumonia, and yeast with 2 each (10%), and Pseudomonas and Klebsiella were each recovered from 1 patient who died (5%). Conclusions Microbiologic identification of common organisms known to cause meningitis in children is difficult in the Republic of Georgia due to limited resources available at the microbiology laboratory. Vaccine-preventable pathogens (H. influenzae, S. pneumoniae, N. meningitidis) accounted for 15% of positive CSF cultures, but it is likely that cases of bacterial meningitis due to vaccine-preventable pathogens are underdiagnosed due to laboratory capacity. Improving the infrastructure of diagnostic microbiology laboratories in resource-limited countries is critical to improve patient care by conducting appropriate surveillance.

ETIOLOGY AND OUTCOMES OF BLOODSTREAM INFECTIONS AT A CHILDRENʼS HOSPITAL IN TBILISI, REPUBLIC OF GEORGIA.: 343

Background H. influenzae and S. pneumoniae are leading cause of childhood bloodstream infections (BSIs) in areas where vaccination is not available for these organisms. The prevalence of H. influenzae and S. pneumoniae BSI has not been established in Tbilisi, Republic of Georgia. This study attempts to determine the prevalence and outcomes of BSI in children at Children9s Central Hospital (CCH), a referral pediatric hospital. Methods We carried out a retrospective study of laboratory and medical records from January of 2004 to June of 2006. Patients with positive blood cultures were initially chosen for the study. Community-acquired (CA) BSIs were within the first 48 hours of admission and hospital acquired (HA) were 48 hours or greater. Results Of 1,693 cultures performed in the study period, 339 (20%) were positive. Twenty-nine of these were omitted from the analysis due to incomplete medical records. Among the 310 children with positive cultures, the following organisms were identified: gram-negative rods (GNRs) (135, 43.6%); coagulase-negative S. aureus (CNS) (111, 35.8%); Klebsiella (17, 5.5%); S. aureus (12, 4.9%); Pseudomonas (10, 3.2%); yeast (9, 2.9%); Streptococcus spp. (5, 1.6%); Enterococcus (4, 1.3%); gram-positive rods (GPRs) (2, 0.7%); Listeria (2, 0.7%); Salmonella spp. (2, 0.7%); and Mixed (S. aureus and Klebsiella; 1, 0.3%). One hundred eighty-four (59%) patients with BSI were male; mean age was 0.4 (0-14) years. Ninety-three (30%) children with a BSI died, 90 of whom were under 1 year of age. CA BSI was present in 87 of 93 patients who died (p = .005). Death was primarily attributed to GNRs (59, 63%), followed by CNS (18, 19%), Pseudomonas (5, 5%), Klebsiella (4, 4%), and Enterococcus and yeast with 2 each (2%), and Listeria, S. aureus, and GPRs were responsible for one death each (1%). Any GNR BSI was significantly associated with mortality versus all none GNR BSI (OR = 3.4, 95% CI = 2.0, 5.7). No positive identifications were made for either H. influenzae or S. pneumoniae. Conclusions Microbiologic identification of common organisms known to cause BSI in children is difficult in the Republic of Georgia due to limited resources available in the microbiology laboratory in the leading children9s hospital. It is likely that causes of BSI due to vaccine-preventable etiologies are underdiagnosed due to laboratory capacity. Improving the infrastructure of diagnostic microbiology laboratories in resource-limited areas is critical to conduct appropriate surveillance and improve patient care.

284 TUBERCULOSIS MENINGITIS AT AN ACADEMIC INNER-CITY HOSPITAL.

Background Tuberculosis (TB) in the US is primarily an inner-city disease and TB meningitis has historically been a dreaded complication of TB with a high mortality rate. Methods We examined the epidemiology of TB meningitis at Grady Memorial Hospital (GMH), a 1,000-bed inner-city academic hospital in Atlanta, GA, by performing a retrospective chart review. Cases of TB meningitis were identified in the TB database maintained by the GMH Hospital Epidemiology Department. Results During a 20.5-year period 97 patients were diagnosed with TB meningitis either by microbiological or clinical diagnosis. The median age was 36 years old, 72 (74%) were male, and 74 (76%) were of black race. Fifty-four (56%) were HIV positive and 24 (25%) were HIV status unknown. No significant differences were seen in the clinical presentation and laboratory results among HIV-positive and HIV-negative patients except HIV-positive patients had a lower median CSF white blood cell count of 68/mm3 versus 145/mm3 in HIV-negative patients. Mortality was striking in our study that overall, 32 (33%) patients died. HIV-positive patients (n = 25) were statistically more likely to die than HIV-negative patients (p = .005). The mean CD4 count for these was 141/mm3 and the mean CSF WBC was 1,898/mm3. Of the 97 patients who died, 79 (82%) were on four-drug TB therapy and 53 (59%) of 80 received steroids. Conclusions Despite the availability of appropriate chemotherapy for TB meningitis, this disease remains a devastating disease with a high mortality rate among this cohort of inner-city patients. HIV-positive patients are at an even increased risk of dying from this form of TB.

285 EPIDEMIOLOGY OF MYCOBACTERIUM KANSASII DISEASE AMONG PATIENTS PRESENTING TO AN URBAN INNER-CITY HOSPITAL.

Background Mycobacterium kansasii (MK) is an important cause of nontuberculous mycobacterial infection especially in the immunocompromised patient, but the clinical significance of positive cultures has been questioned in the past. Over the past decade, the number of patients at our institution with positive cultures for MK increased from < 10 per year (0.18/1,000 admissions) to over 25 per year (1.9/1,000 adm). Over this time period there was no change in the respiratory isolation policy to account for the increase. In October 2000 we instituted the use of an Mtb PCR assay on all smear-positive respiratory samples. Purpose To examine the epidemiological, clinical, and radiologic features of M. kansasii infection over a 10-year period from 1994 to 2004. Methods Chart review of any patient with a culture positive for M. kansasii between 1994 and 2004. Results During the study period, 320 cultures grew MK from 178 patients. Culture sources for the 320 isolates were respiratory in 303 (94.5%) and 144 (47.5%) of these were AFB smear positive. Other sources included 9 (2.8%) blood and 1 each urine, thigh, stool, pancreas, and perirectal abscess. Among 178 MK patients, 133 (74.7%) were male, 165 (92.7%) were black, and median age was 39 yrs (range 22-79 yrs). Most (159 [89%]) were HIV positive and median CD4 was 19 cells/μL. Twelve (7%) of patients died prior to discharge. Of 102 patients with a single positive culture, 66 (65%) were smear-negative c/w 31 (41%) of 76 patients with multiple positive cultures (p < .005). Abnormal CXRs were found in 121 (72%) of 167 cases; 30 (18%) of these were consistent with PCP. For patients with abnormal CXRs and + smears, discharge TB or MK Rx was no less likely after use of Mtb PCR (13 of 30 prior to 10/2000 vs 8 of 21 after 10/2000). Conclusion M. kansasii infection increased at this institution over the last 10 years despite the advent of highly active antiretroviral therapy during this period. This infection predominantly affected severely immunocompromised patients as evidenced by the very low median CD4 count. Less than 50% of patients were discharged on TB or MK Rx at time of diagnosis, making it very unlikely that the majority of cases received the recommended 18-month course of therapy. This proportion was not affected by Mtb PCR testing. Mtb PCR testing may have affected length of stay. Long-term outcome for these patients is under review.