Pia D.M. MacDonald

The unexpected movement of the HIV epidemic in the Southeastern United States: transmission among college students.

Background:Approximately 16 million people are enrolled in institutions of higher learning in the United States. However, college students have not been perceived as at high risk for HIV infection. In early 2003, acute HIV infection was diagnosed in 2 men attending college in North Carolina. We describe an epidemiologic investigation of newly diagnosed HIV infection in men attending college in North Carolina. Methods:We reviewed state surveillance records examining new HIV diagnoses in men 18-30 years old between January 1, 2000 and December 31, 2003, living in 69 North Carolina counties. Risk behavior and demographic information for HIV-infected men enrolled in college were compared with HIV-infected male nonenrollees. Results:Of the 735 records available for review, 84 (11%) were college men. Eighty-seven percent of college men were African American and 92% were men who have sex with men (MSM) or men who have sex with men and women (MSM/W). Compared with noncollege men, college men were more likely to be African American (odds ratio 3.70, 95% CI = 1.86-7.54), to report meeting sex partners at bars or dance clubs (odds ratio 3.01, 95% CI = 1.77-5.10) or on the Internet/chat lines (odds ratio 4.95, 95% CI = 2.53-9.64), or to report use of “ecstasy” or club drugs (odds ratio 4.51, 95% CI = 1.15-15.40). Newly diagnosed HIV infection was found in men in 37 colleges located in North Carolina or surrounding states and a sexual partner network investigation linked 21 colleges, 61 students, and 8 partners of students. Conclusion:We describe an epidemic of HIV infection occurring in North Carolina college students, primarily involving African American MSM and MSM/W. College students represent an at-risk, accessible population, which deserves further HIV prevention interventions.

Men who have sex with men and women: A unique risk group for HIV transmission on North Carolina college campuses

Objective: To better understand the role that men who have sex with men and women (MSM/W) play in the spread of HIV in young adults in North Carolina, we determined the prevalence of MSM/W among newly diagnosed HIV-infected men, compared social and behavioral characteristics of this group with MSM and MSW, and examined the sexual networks associated with HIV-infected college students among these groups. Methods: We reviewed state HIV surveillance records for all new diagnoses of HIV in males 18 to 30 years living in North Carolina between January 1, 2000, and December 31, 2004. Results: Of 1105 records available for review, 15% were MSM/W and 13% were college students. Compared with MSM, MSM/W were more likely to be enrolled in college, to report >10 sex partners in the year before diagnosis, or have sex partners who were also MSM/W. Sexual network analysis of the HIV-infected college students revealed that MSM/W occupied a central position. Of 20 individuals who described themselves as either MSW or abstinent at the time of their initial voluntary counseling and testing visit, 80% reported that they were either MSM or MSM/W during follow up. Discussion: MSM/W represent a unique risk group within the population of MSM that deserve further investigation. College MSM/W appear to occupy a unique, central place in the network of HIV-infected students.

Molecular Epidemiology of Foodborne Hepatitis A Outbreaks in the United States, 2003

BACKGROUND Molecular epidemiologic investigations can link geographically separate foodborne hepatitis A outbreaks but have not been used while field investigations are in progress. In 2003, outbreaks of foodborne hepatitis A were reported in multiple states. METHODS Case-control studies were conducted in 3 states. Hepatitis A virus was sequenced from serologic specimens from individuals associated with outbreaks and from individuals concurrently ill with hepatitis A in non-outbreak settings in the United States and Mexico. RESULTS Case-control studies in Tennessee (TN), North Carolina (NC), and Georgia (GA) found green onions to be associated with illness among restaurant patrons (TN: odds ratio [OR], 65.5 [95% confidence interval {CI}, 8.9-482.5; NC: OR, 2.4 [95% CI, 0.3-21.9]; GA: OR, 20.9 [95% CI, 3.9-110.3]). Viral sequences from TN case patients differed by 2 nt, compared with those from case patients in NC and GA. A third sequence, differing from the TN and GA/NC sequences by 1 nt, was identified among case patients in a subsequent outbreak in Pennsylvania. Each outbreak sequence was identical to > or =1 sequence isolated from northern Mexican resident(s) with hepatitis A. The sources of green onions served in restaurants in TN and GA were 3 farms in northern Mexico. CONCLUSIONS Ongoing viral strain surveillance facilitated the rapid implementation of control measures. Incorporation of molecular epidemiologic methods into routine hepatitis A surveillance would improve the detection of hepatitis A outbreaks and increase our understanding of hepatitis A epidemiology in the United States.

Intent to Receive Pandemic Influenza A (H1N1) Vaccine, Compliance with Social Distancing and Sources of Information in NC, 2009

Background Public adherence to influenza vaccination recommendations has been low, particularly among younger adults and children under 2, despite the availability of safe and effective seasonal vaccine. Intention to receive 2009 pandemic influenza A (H1N1) vaccine has been estimated to be 50% in select populations. This report measures knowledge of and intention to receive pandemic vaccine in a population-based setting, including target groups for seasonal and H1N1 influenza. Methodology and Principal Findings On August 28–29, 2009, we conducted a population-based survey in 2 counties in North Carolina. The survey used the 30×7 two-stage cluster sampling methodology to identify 210 target households. Prevalence ratios (PR) and 95% confidence intervals (CI) were estimated. Knowledge of pandemic influenza A (H1N1) vaccine was high, with 165 (80%) aware that a vaccine was being prepared. A total of 133 (64%) respondents intended to receive pandemic vaccine, 134 (64%) intended to receive seasonal vaccine, and 109 (53%) intended to receive both. Reporting great concern about H1N1 infection (PR 1.55; 95%CI: 1.30, 1.85), receiving seasonal influenza vaccine in 2008–09 (PR 1.47; 95%CI: 1.18, 1.82), and intending to receive seasonal influenza vaccine in 2009–10 (PR 1.27; 95%CI: 1.14, 1.42) were associated with intention to receive pandemic vaccine. Not associated were knowledge of vaccine, employment, having children under age 18, gender, race/ethnicity and age. Reasons cited for not intending to get vaccinated include not being at risk for infection, concerns about vaccine side effects and belief that illness caused by pandemic H1N1 would be mild. Forty-five percent of households with children under 18 and 65% of working adults reported ability to comply with self-isolation at home for 7–10 days if recommended by authorities. Conclusions and Significance This is the first report of a population based rapid assessment used to assess knowledge and intent to receive pandemic vaccine in a community sample. Intention to receive pandemic and seasonal vaccines was higher than previously published reports. To reach persons not intending to receive pandemic vaccine, public health communications should focus on the perceived risk of infection and concerns about vaccine safety.

Utility of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Communicable Disease Surveillance

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been proposed as a method of public health surveillance and are widely used in public health and clinical research. However, ICD-9-CM codes have been found to have variable accuracy for both health-care billing and disease classification, and they have never been comprehensively validated for use in public health surveillance. Therefore, the authors undertook a comprehensive analysis of the positive predictive values (PPVs) of ICD-9-CM codes for communicable diseases in 6 North Carolina health-care systems for the year 2003. Stratified random samples of patient charts with ICD-9-CM diagnoses for communicable diseases were reviewed and evaluated for their concordance with the Centers for Disease Control and Prevention surveillance case definitions. Semi-Bayesian hierarchical regression techniques were employed on the ensemble of disease-specific PPVs in order to reduce the overall mean squared error. The authors found that for the majority for diseases with higher incidence and straightforward laboratory-based diagnoses, the PPVs were high (>80%), with the important exception of tuberculosis, which had a PPV of 28.6% (95% uncertainty interval: 15.6, 46.5).

Barriers and Facilitators to HIV Testing and Linkage to Primary Care: Narratives of People with Advanced HIV in the Southeast

Abstract Persons with unrecognized HIV infection forgo timely clinical intervention and may unknowingly transmit HIV to partners. However, in the USA, unrecognized infection and late diagnosis are common. To understand barriers and facilitators to HIV testing and care, we conducted a qualitative study of 24 HIV infected persons attending a Southeastern HIV clinic who presented with clinically advanced illness. The primary barrier to HIV testing prior to diagnosis was perception of risk; consequently, most participants were diagnosed after the onset of clinical symptoms. While most patients were anxious to initiate care rapidly after diagnosis, some felt frustrated by the passive process of connecting to specialty care. The first visit with an HIV care provider was identified as critical in the coping process for many patients. Implications for the implementation of Centers for Disease Control and Prevention HIV routine screening guidelines are discussed.

Completeness of Communicable Disease Reporting, North Carolina, USA, 1995–1997 and 2000–2006

Reporting proportions were <50% for 49 of the 53 diseases evaluated.

What predicts local public health agency performance improvement? A pilot study in North Carolina.

Local public health agencies (LPHAs) are faced with many challenges in their role as an integral part of the public health system. It is important to better understand the demands on and the capacity of LPHAs to respond to these challenges. Determining what factors can improve LPHA performance is critical to helping LPHAs face their challenges.The objective of this study was to determine what factors are associated with LPHA performance improvement in North Carolina from 1999 to 2004. In North Carolina, several data sources regarding predictors of LPHA performance, including LPHA workforce, LPHA characteristics, public health expenditures, and population characteristics, are available. Improvement in LPHA performance was measured by nine indicators across diverse services that were collected over multiple years. Linear regression was used to evaluate the significance of predictor variables.Our findings indicate that workforce characteristics such as occupational classification and experience of the workforce, LPHA characteristics such as number of full-time employees, as well as population characteristics are important predictors of LPHA performance.This study provides insight into what is needed to better address LPHA performance improvement. More importantly, study findings indicate which workforce characteristics can be targeted to enhance LPHA performance improvement over time.

Severe Histoplasmosis in Travelers to Nicaragua

We investigated an outbreak of unexpectedly severe histoplasmosis among 14 healthy adventure travelers from the United States who visited a bat-infested cave in Nicaragua. Although histoplasmosis has rarely been reported to cause serious illness among travelers, this outbreak demonstrates that cases may be severe among travelers, even young, healthy persons.

Development and implementation of a public health workforce training needs assessment survey in North Carolina

Assessing the training needs of local public health workers is an important step toward providing appropriate training programs in emergency preparedness and core public health competencies. The North Carolina Public Health Workforce Training Needs Assessment survey was implemented through the collaboration of several organizations, including the North Carolina Center for Public Health Preparedness at the North Carolina Institute for Public Health, the outreach and service unit of the University of North Carolina School of Public Health, the Office of Public Health Preparedness and Response in the North Carolina Division of Public Health Epidemiology Section, and local health departments across the state.