Nava Yeganeh

Factors influencing HPV vaccination status in a Latino population; and parental attitudes towards vaccine mandates.

We performed a retrospective cohort study in a largely Latino population in Los Angeles, surveying 95 parents of 11-17 year old girls between May and June 2008 to examine factors associated with [1] parental consent for Human Papillomavirus (HPV) immunization one year after vaccine implementation and [2] parental support of an HPV vaccine mandate for adolescents prior to middle school entry. 73% of participants had heard of the HPV vaccine and 37% of daughters had already received the vaccine. Variables associated with vaccination included Latino ethnicity, the belief that vaccines are safe, and that HPV vaccine prevents cervical cancer. The most frequent reasons for refusing vaccination included parental request for more information and missed opportunities in clinic. Variables associated with parents agreeing with a law mandating HPV vaccination included: belief in vaccine safety, recent maternal Pap Smear, HPV vaccination of participants daughter prior to survey, and Latino ethnicity. Our survey supports the work of previous studies recommending continued educational campaigns emphasizing the safety of HPV vaccine, and its efficacy in reducing cervical cancer.

Risk Factors Associated With Infant Deaths From Pertussis: A Case-Control Study

BACKGROUND In the current era, most pertussis deaths occur in infants <3 months of age. Leukocytosis with lymphocytosis and pneumonia are commonly observed among cases of severe pertussis. METHODS Risk factors associated with fatal pertussis were identified by comparing fatal pertussis cases among patients <120 days of age occurring from 1 January 1998 through 26 December 2014, matched by age (<120 days), county of residence, and closest symptom onset date with 1-4 nonfatal hospitalized cases. California Department of Public Health surveillance data were reviewed to identify cases; demographics, clinical presentation, and course were abstracted from corresponding birth and medical records. Logistic regression and classification tree analyses were used to examine the risk of fatal pertussis with respect to identified factors. RESULTS Fifty-three fatal infant pertussis cases were identified and compared with 183 nonfatal hospitalized pertussis cases. Fatal cases had significantly lower birth weight, younger gestational age, younger age at time of cough onset, and higher peak white blood cell (WBC) and lymphocyte counts. Fatal cases were less likely to have received macrolide antibiotics and more likely to have received steroids or nitric oxide and to develop pulmonary hypertension, seizures, encephalitis, and pneumonia. Additionally, exchange transfusion, extracorporeal membrane oxygenation, and intubation occurred significantly more frequently among fatal cases. In multivariate analyses, peak WBC count, birth weight, intubation, and receipt of nitric oxide were predictors of death. CONCLUSIONS Early recognition of pertussis in young infants and treatment with appropriate antibiotic therapy are important in preventing death. Several risk factors are strongly associated with fatal pertussis in infants.

Syphilis in HIV-infected mothers and infants: results from the NICHD/HPTN 040 study.

Background: Untreated syphilis during pregnancy is associated with spontaneous abortion, stillbirth, prematurity and infant mortality. Syphilis may facilitate HIV transmission, which is especially concerning in low- and middle-income countries where both diseases are common. Methods: We performed an analysis of data available from NICHD/HPTN 040 (P1043), a study focused on the prevention of intrapartum HIV transmission to 1684 infants born to 1664 untreated HIV-infected women. This analysis evaluates risk factors and outcomes associated with a syphilis diagnosis in this cohort of HIV-infected women and their infants. Results: Approximately, 10% of women (n = 171) enrolled had serological evidence of syphilis without adequate treatment documented and 1.4% infants (n = 24) were dually HIV and syphilis infected. Multivariate logistic analysis showed that compared with HIV-infected women, co-infected women were significantly more likely to self-identify as non-white (adjusted odds ratio [AOR] 2.5, 95% CI: 1.5–4.2), to consume alcohol during pregnancy (AOR 1.5, 95% CI: 1.1–2.1) and to transmit HIV to their infants (AOR 2.1, 95% CI: 1.3–3.4), with 88% of HIV infections being acquired in utero. As compared with HIV-infected or HIV-exposed infants, co-infected infants were significantly more likely to be born to mothers with venereal disease research laboratory titers ≥1:16 (AOR 3, 95% CI: 1.1–8.2) and higher viral loads (AOR 1.5, 95% CI: 1.1–1.9). Of 6 newborns with symptomatic syphilis, 2 expired shortly after birth, and 2 were HIV-infected. Conclusion: Syphilis continues to be a common co-infection in HIV-infected women and can facilitate in utero transmission of HIV to infants. Most infants are asymptomatic at birth, but those with symptoms have high mortality rates.

High rates of baseline antiretroviral resistance among HIV-infected pregnant women in an HIV referral centre in Rio de Janeiro, Brazil

In order to understand antiretroviral resistance during pregnancy and its impact on HIV vertical transmission, we performed a cross-sectional analysis of 231 HIV-infected pregnant women who fulfilled Brazilian guidelines for antiretroviral testing and had antiretroviral genotypic testing performed between April 2010 and October 2012. At entry into prenatal care, the mean CD4 cell count for this cohort of patients was 406 cells/mm3 (95% CI: 373–438 cells/mm3), while the mean HIV RNA was 24,394 copies/ml (95% CI: 18,275–30,513 copies/ml). Thirty-six women (16%) had detectable antiretroviral-resistant mutations. By 34 weeks gestation, 75% had achieved HIV RNA <400 copies/ml. Our logistic regression model showed the odds of harbouring antiretroviral-resistant virus with a baseline CD4 cell count of <200 cells/mm3 was eight times that of subjects with CD4 cell counts >500 CD4 cells/mm3 (95% CI 1.5–42.73). Six infants were HIV infected, four born to mothers with detectable viraemia at 34 weeks and two born to mothers who were lost to follow up. Antiretroviral resistance is common in prenatal care but did not increase vertical transmission if viral load was appropriately suppressed. Genotyping should be considered in Brazil in order to assist initiation of appropriate combination antiretroviral therapy during pregnancy to suppress viral load to avoid vertical transmission.

Audio computer-assisted survey instrument versus face-to-face interviews: optimal method for detecting high-risk behaviour in pregnant women and their sexual partners in the south of Brazil.

Summary Audio computer-assisted survey instrument (ACASI) has been shown to decrease under-reporting of socially undesirable behaviours, but has not been evaluated in pregnant women at risk of HIV acquisition in Brazil. We assigned HIV-negative pregnant women receiving routine antenatal care at in Porto Alegre, Brazil and their partners to receive a survey regarding high-risk sexual behaviours and drug use via ACASI (n = 372) or face-to-face (FTF) (n = 283) interviews. Logistic regression showed that compared with FTF, pregnant women interviewed via ACASI were significantly more likely to self-report themselves as single (14% versus 6%), having >5 sexual partners (35% versus 29%), having oral sex (42% versus 35%), using intravenous drugs (5% versus 0), smoking cigarettes (23% versus 16%), drinking alcohol (13% versus 8%) and using condoms during pregnancy (32% versus 17%). Therefore, ACASI may be a useful method in assessing risk behaviours in pregnant women, especially in relation to drug and alcohol use.

Enteric Fever in a 6-Year-Old Traveler Caused by Salmonella enterica Serotypes Typhi and Paratyphi A: Laboratory Detection Strategies and Treatment Options

ABSTRACT We report the first pediatric case of enteric fever caused by Salmonella enterica serotypes Typhi and Paratyphi A. Mixed infections are infrequently reported, potentially because detection of two different Salmonella serotypes in blood cultures is technically challenging. We suggest laboratory strategies to aid in the recognition of mixed infections.

HIV testing of male partners of pregnant women in Porto Alegre, Brazil: A potential strategy for reduction of HIV seroconversion during pregnancy

Pregnant women have a significantly higher risk of HIV acquisition during gestation than their non-pregnant counterparts due to behavioral and biological factors. Acute seroconversion during gestation results in increased HIV mother-to-child transmission rates and has been identified as a major public health challenge. In order to address potential HIV seroconversion in our pregnant patients, we conducted a prospective cohort study to evaluate the acceptability of offering HIV testing to sexual partners of HIV-negative pregnant women receiving antenatal care at two hospitals in Porto Alegre, Brazil. Over a 14-month study period, HIV-negative pregnant women at two hospital-based clinic sites were encouraged to bring their stable sexual partner for HIV voluntary counseling and testing during prenatal care. Women were re-interviewed following delivery to measure success of the intervention. Of the 1223 HIV-negative pregnant women enrolled in the study, 663 (54%) of their male sexual partners received HIV testing during antenatal care and 4 (0.6%) were diagnosed with HIV infection. A total of 645 women were interviewed at the time of delivery, with 620 (97%) confirming that HIV testing was suggested to their partner. The most common reason provided by women as to why partners did not come for testing was work (69%) and lack of perceived risk (14%). Independent predictors of successful partner testing included being white (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.18–2.12), married (OR 1.78, 95% CI 1.08–2.94), having an older age of sexual debut (OR 0.94, 95% CI 0.9–0.98), and being recruited at Hospital Conceiçao (OR 2.1, 95% CI 1.52–2.88). We conclude that HIV partner testing during prenatal care is acceptable, rendering this intervention attractive to public health programs targeting prevention of sexually transmitted infections.

Combined evaluation of sexually transmitted infections in HIV-infected pregnant women and infant HIV transmission

Background Sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and cytomegalovirus (CMV) may lead to adverse pregnancy and infant outcomes. The role of combined maternal STIs in HIV mother-to-child transmission (MTCT) was evaluated in mother-infant pairs from NICHD HPTN 040. Methodology Urine samples from HIV-infected pregnant women during labor were tested by polymerase chain reaction (PCR) for CT, NG, and CMV. Infant HIV infection was determined by serial HIV DNA PCR testing. Maternal syphilis was tested by VDRL and confirmatory treponemal antibodies. Results A total of 899 mother-infant pairs were evaluated. Over 30% had at least one of the following infections (TP, CT, NG, and/or CMV) detected at the time of delivery. High rates of TP (8.7%), CT (17.8%), NG (4%), and CMV (6.3%) were observed. HIV MTCT was 9.1% (n = 82 infants). HIV MTCT was 12.5%, 10.3%, 11.1%, and 26.3% among infants born to women with CT, TP, NG or CMV respectively. Forty-two percent of HIV-infected infants were born to women with at least one of these 4 infections. Women with these infections were nearly twice as likely to have an HIV-infected infant (aOR 1.9, 95% CI 1.1–3.0), particularly those with 2 STIs (aOR 3.4, 95% CI 1.5–7.7). Individually, maternal CMV (aOR 4.4 1.5–13.0) and infant congenital CMV (OR 4.1, 95% CI 2.2–7.8) but not other STIs (TP, CT, or NG) were associated with an increased risk of HIV MTCT. Conclusion HIV-infected pregnant women identified during labor are at high risk for STIs. Co-infection with STIs including CMV nearly doubles HIV MTCT risk. CMV infection appears to confer the largest risk of HIV MTCT. Trial registration NCT00099359.

HIV antiretroviral resistance and transmission in mother-infant pairs enrolled in a large perinatal study

Abstract Background Detection of antiretroviral (ARV) resistance in HIV-infected individuals is not uncommon and may be particularly problematic in HIV-infected pregnant women as it can lead to infant infection with resistant strains. To better evaluate the effect of drug resistance mutations (DRMs) on HIV mother-to-child transmission (MTCT), we determined the prevalence of DRMs in a subset of mother–infant pairs enrolled in a multi-center trial of infant prophylaxis among women not receiving ARVs during the current pregnancy. Methods A case–control design of 1:4 (1 transmitter to 4 nontransmitters) was utilized to evaluate ARV resistance as a predictor of HIV MTCT in specimens obtained from mother–infant pairs. Secondary objectives included identification of potential risk factors associated with the presence of DRMs. Viroseq HIV-1 Genotyping System was performed on mother–infant specimens to assess for mutations that might result in a substantial reduction in drug susceptibility and clinical outcome, as determined by the Stanford HIV Drug Resistance Database. Results One hundred and forty infants were infected. Of these, 123 HIV infected mother–infant pairs and 483 of 560 women who did not transmit HIV had amplifiable HIV nucleic acid enabling ARV resistance testing. A wide variety of DRMs were detected (Figure 1). Sixty (10%) of 606 women had clinically relevant DRMs; 12 (2%) had DRMs against more than 1 ARV class. Among 123 HIV− infected infants, 13 (11%) had clinically relevant DRMs with 3 (2%) harboring DRMs against more than 1 ARV class. Of 13 infants with DRMs, 10 (77%) were infected in utero. In univariate and multivariate analyses, DRMs in mothers were not associated with increased risk of HIV MTCT (AOR 0.79, 95% CI 0.38–1.5). Log HIV viral load was the only predictor of MTCT (OR 1.4, 95% CI 1.2−1.6). The presence of DRMs in mothers who transmitted was strongly associated with the presence of DRMs in infants (P < 0.001). Conclusion In infected pregnant women without ARV exposure during their current gestation, the presence of pre-existing DRMs with a wide diversity was noted. DRMs do not increase the risk of HIV MTCT. However, if women with DRMs are not virologically suppressed they are likely to transmit resistant mutations even without selective ARV pressure, thus complicating treatment options. Disclosures All authors: No reported disclosures.

Visual diagnosis: stool passage of a white ribbonlike object in an adventurous eater.

1. Nurul I. Hariadi, MD* 2. Nava Yeganeh, MD† 3. Jennifer Dien Bard, PhD‡ 4. Natascha Ching, MD§ 1. *Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, MI. 2. †Department of Pediatrics, Division of Pediatric Infectious Diseases, UCLA Medical Center, Los Angeles, CA. 3. ‡Department of Pathology and Molecular Medicine, Queens University School of Medicine, Kingston, Ontario, Canada. 4. §Pediatric Infectious Diseases, ‘Specially For Children, Dell Childrens Medical Center of Central Texas, Austin, TX. A previously healthy 5-year old boy passes white ribbonlike objects in a bowel movement that are removed in multiple segments (Fig. 1). The specimens are sent to the microbiology laboratory, and the patient is seen in the pediatric infectious diseases clinic. Before the episode, he had normal appetite with no abdominal pain, diarrhea, constipation, flatulence, cough, or any other constitutional symptoms. He complains of intermittent periumbilical pain after the episode but has no other symptoms. Figure 1. Multiple white ribbonlike segments measuring approximately to 3 to 10 in. Further questioning of the patient and family reveals sophisticated and adventurous eating habits. He has been eating raw fish for 1 year before presentation, including salmon and tuna sushi and sashimi. He eats rare beef and lamb and tries delicacies such as cooked crickets, ants, and scorpions. He has three cats with fleas and feeds Koi fish in a pond but has no contact with other animals. During recent travel to Sierra, California, he swam in a cave pond but did not drink its water. He also visited Kauai, Hawaii, 2 months ago but did not consume sushi, sashimi, or Hawaiian delicacies of raw fish there. Findings on his physical examination are normal, his weight is at the 25th percentile, and his height is between the 10th and 25th percentiles. Complete blood cell count reveals no evidence of anemia. The white blood cell count is 9.6×103/μL (9.6×109/L) with a normal differential count, hemoglobin is 13.0 g/dL (130 g/L), hematocrit is 38.2% (0.38), and platelet count is 258×103/μL (258×109/L). Mean corpuscular volume is 84.1 …