Melissa A. Marx

Association of Hepatitis C Virus Infection with Sexual Exposure in Southern India

To determine the association between sexual exposure and hepatitis C virus (HCV) infection in urban Chennai, India, a random sample of adults who live in a slum community completed interviews and provided samples to test for HCV, herpes simplex virus type 2 (HSV-2), and other sexually transmitted infections (STIs). All analyses excluded recent and current injection drug users. HCV infection was not associated with the reported number of sex partners for men or women. Women were more likely to be HCV infected if they reported previous genital ulcer disease (adjusted odds ratio [AOR], 3.88; 95% confidence interval [95% CI], 0.94-16.0; marginally statistically significant). Men were more likely to be HCV infected if they were HSV-2 infected (AOR, 3.85; 95% CI, 1.18-12.6) or reported having had sex with men (AOR, 3.61; 95% CI, 1.00-13.1). Sexual transmission of HCV infection may be facilitated by ulcerative STIs and male-male sexual practices, but it appears to occur infrequently in this population.

Comparing new participants of a mobile versus a pharmacy-based needle exchange program.

Objective: To compare characteristics of first‐time needle exchange participants who enrolled at a mobile van‐based exchange site versus a fixed pharmacy‐based exchange site, in an area where both types of needle exchange programs were available. Methods: Demographic and drug use data were collected on needle exchange program participants on enrollment. Participants were included if they were first‐time participants at the Baltimore needle exchange program between December 1997 and March 1999, and if their first visit was at either one van‐based site or at one of two pharmacy‐based sites. Descriptive statistics and inferences were based on the type of needle exchange into which participants enrolled. Results: Among 286 first‐time participants, 92% were African American, 28% were women, 11% were currently employed, 55% completed high school, and the median age was 40 years. In multivariate analyses, van‐based enrollment was more common among frequent injectors (odds ratio [OR] = 2.0), but less common among African American participants (OR = 0.21). Conclusions: Our data suggest that different venues for needle exchange program settings attract different types of drug injecting participants. This suggests that offering different venue types to reach participants with differing drug use patterns will be important to optimize risk reduction strategies.

Health services utilization by injection drug users participating in a needle exchange program.

Objective: To determine the characteristics associated with health care and drug treatment utilization among a distinctly high-risk sub-population of injectors participating in a needle exchange program (NEP). Methods: Between June 1998 and May 1999, study staff collected demographic and health services utilization data on participants of the Baltimore NEP. Odds ratios and logistic regression were used to identify the participant characteristics associateds with utilizing primary health care and drug treatment during the prior 3 years. Results: Among 269 participants, 81% were African–American and 66% were male. Over half (56%) had not graduated from high school, 89% were unemployed, 70% did not have health insurance, and the median age was 39 years. Fifty-eight percent of the participants reported utilizing primary care (i.e., visited a physician or other health care provider) and 44% had utilized drug treatment during the prior 3 years. Primary care utilization was associated with age≥39 [adjusted odds ratio (AOR)=1.82], having health insurance (AOR=2.16), and exchanging a higher volume of syringes per NEP visit (AOR=2.45). Recent drug treatment utilization was associated with African–American race (AOR=0.41), unemployment (AOR=2.72), having health insurance (AOR=2.05), and exchanging a higher volume of syringes per NEP visit (AOR=0.60). Conclusions: Health insurance was significantly associated with the recent utilization of both primary care and drug treatment, yet only one-third of NEP attenders were insured. Facilitating the uptake of health insurance services at NEP sites may improve the access to health care for drug users who are currently not utilizing the health care system.

Decline in self-reported high-risk injection-related behaviors among HIV-seropositive participants in the Baltimore needle exchange program

This study was conducted to determine whether enrollment in a needle exchange program (NEP) was associated with reduction(s) in high-risk injection practices among HIV-seropositive drug users. Between August 1994 and August 1997 HIV-seropositive individuals who underwent baseline and 6-month follow-up visits in the Baltimore NEP evaluation were studied. Chi-square statistics and paired t tests were used to compare reported injection-related behaviors between visits. One hundred and twelve HIV-seropositive NEP participants completed baseline and follow-up visits. Between visits self-reported lending of used syringes to others decreased (34.0% vs. 15.5%, p = .001), borrowing syringes from others decreased (23.2% vs. 11.1%, p = .002), and reported participation in drug treatment increased (8.0% vs. 18.8%, p = .01). A decrease in the mean number of injections per syringe was reported, 11.4 vs. 4.7 (p < .001). These data suggest that NEP attendance can contribute to significant reductions in risky drug-use behaviors in HIV-seropositive drug users.

Role of food insecurity in outbreak of anthrax infections among humans and hippopotamuses living in a game reserve area, rural Zambia

In September 2011, a total of 511 human cases of anthrax (Bacillus anthracis) infection and 5 deaths were reported in a game management area in the district of Chama, Zambia, near where 85 hippopotamuses (Hippopotamus amphibious) had recently died of suspected anthrax. The human infections generally responded to antibiotics. To clarify transmission, we conducted a cross-sectional, interviewer-administered household survey in villages where human anthrax cases and hippopotamus deaths were reported. Among 284 respondents, 84% ate hippopotamus meat before the outbreak. Eating, carrying, and preparing meat were associated with anthrax infection. Despite the risk, 23% of respondents reported they would eat meat from hippopotamuses found dead again because of food shortage (73%), lack of meat (12%), hunger (7%), and protein shortage (5%). Chronic food insecurity can lead to consumption of unsafe foods, leaving communities susceptible to zoonotic infection. Interagency cooperation is necessary to prevent outbreaks by addressing the root cause of exposure, such as food insecurity.

National Assessment of Data Quality and Associated Systems-Level Factors in Malawi

Nearly all facility registers were available and complete. But accuracy varied, with antenatal care and HIV testing and counseling performing the best and family planning and acute respiratory infections data less well. Most facilities visibly displayed routine health data and most hospitals and district health offices had staff trained in health management information systems, but training was lacking at the facility level as were routine data quality checks and regular supervision. Nearly all facility registers were available and complete. But accuracy varied, with antenatal care and HIV testing and counseling performing the best and family planning and acute respiratory infections data less well. Most facilities visibly displayed routine health data and most hospitals and district health offices had staff trained in health management information systems, but training was lacking at the facility level as were routine data quality checks and regular supervision. ABSTRACT Background: Routine health data can guide health systems improvements, but poor quality of these data hinders use. To address concerns about data quality in Malawi, the Ministry of Health and National Statistical Office conducted a data quality assessment (DQA) in July 2016 to identify systems-level factors that could be improved. Methods: We used 2-stage stratified random sampling methods to select health centers and hospitals under Ministry of Health auspices, included those managed by faith-based entities, for this DQA. Dispensaries, village clinics, police and military facilities, tertiary-level hospitals, and private facilities were excluded. We reviewed client registers and monthly reports to verify availability, completeness, and accuracy of data in 4 service areas: antenatal care (ANC), family planning, HIV testing and counseling, and acute respiratory infection (ARI). We also conducted interviews with facility and district personnel to assess health management information system (HMIS) functioning and systems-level factors that may be associated with data quality. We compared systems and quality factors by facility characteristics using 2-sample t tests with Welchs approximation, and calculated verification ratios comparing total entries in registers to totals from summarized reports. Results: We selected 16 hospitals (of 113 total in Malawi), 90 health centers (of 466), and 16 district health offices (of 28) in 16 of Malawis 28 districts. Nearly all registers were available and complete in health centers and district hospitals, but data quality varied across service areas; median verification ratios comparing register and report totals at health centers ranged from 0.78 (interquartile range [IQR]: 0.25, 1.07) for ARI and 0.99 (IQR: 0.82, 1.36) for family planning to 1.00 (IQR: 0.96, 1.00) for HIV testing and counseling and 1.00 (IQR: 0.80, 1.23) for ANC. More than half (60%) of facilities reported receiving a documented supervisory visit for HMIS in the prior 6 months. A recent supervision visit was associated with better availability of data (P=.05), but regular district- or central-level supervision was not. Use of data by the facility to track performance toward targets was associated with both improved availability (P=.04) and completeness of data (P=.02). Half of facilities had a full-time statistical clerk, but their presence did not improve the availability or completeness of data (P=.39 and P=.69, respectively). Conclusion: Findings indicate both strengths and weaknesses in Malawis HMIS performance, with key weaknesses including infrequent data quality checks and unreliable supervision. Efforts to strengthen HMIS in low- and middle-income countries should be informed by similar assessments.