Salma Khuwaja

Identification of Dengue Fever Cases in Houston, Texas, with Evidence of Autochthonous Transmission Between 2003 and 2005

Houston, Texas, maintains an environment conducive to dengue virus (DENV) emergence; however, surveillance is passive and diagnostic testing is not readily available. To determine if DENV is present in the area, we tested 3768 clinical specimens (2138 cerebrospinal fluid [CSF] and 1630 serum) collected from patients with suspected mosquito-borne viral disease between 2003 and 2005. We identified 47 immunoglobulin M (IgM)-positive dengue cases, including two cases that were positive for viral RNA in serum for dengue serotype 2. The majority of cases did not report any history of travel outside the Houston area prior to symptom onset. The epidemic curve suggests an outbreak occurred in 2003 with continued low-level transmission in 2004 and 2005. Chart abstractions were completed for 42 of the 47 cases; 57% were diagnosed with meningitis and/or encephalitis, and 43% met the case definition for dengue fever. Two of the 47 cases were fatal, including one with illness compatible with dengue shock syndrome. Our results support local transmission of DENV during the study period. These findings heighten the need for dengue surveillance in the southern United States.

Pakistani Ismaili Muslim Adolescent Females Living in the United States of America: Stresses Associated with the Process of Adaptation to U.S. Culture

This study examines correlates of sociopsychological post-migration depression in Pakistani Ismaili Muslim adolescent females residing in the United States using quantitative information obtained through a questionnaire. Analysis of the questionnaire included descriptive statistics, Pearson product moment correlation coefficients, and multiple regression to describe a final model of risk factors related to depression in these adolescents. Longer periods of stay in the United States, young age at migration, and speaking more English were associated with low sociopsychological stress scores. Adolescents who reported a longer period of stay in the United States and lower levels of sociopsychological stress were less likely to be depressed.

Hepatitis B outbreak associated with a home health care agency serving multiple assisted living facilities in Texas, 2008-2010

We investigated a multifacility outbreak of acute hepatitis B virus infection involving 21 residents across 10 assisted living facilities in Texas during the period January 2008 through July 2010. Epidemiologic and laboratory data suggested that these infections belonged to a single outbreak. The only common exposure was receipt of assisted monitoring of blood glucose from the same home health care agency. Improved infection control oversight and training of assisted living facility and home health care agency personnel providing assisted monitoring of blood glucose is needed.

Managing the Personal Side of Health Care among Patients with HIV/AIDS A Pilot Study of Providers’ Perspectives

The study describes the HIV care providers’ sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers’ perspectives may help enhance support services, patients’ ongoing care and retention, leading to improved health outcomes.

System and Patient Barriers to Care among People Living with HIV/AIDS in Houston/Harris County, Texas: HIV Medical Care Providers' Perspectives.

In the United States, a considerable number of people diagnosed with HIV are not receiving HIV medical care due to some barriers. Using data from the Medical Monitoring Project survey of HIV medical care providers in Houston/Harris County, Texas, we assessed the HIV medical care providers’ perspectives of the system and patient barriers to HIV care experienced by people living with HIV/AIDS (PLWHA). The study findings indicate that of the 14 HIV care barriers identified, only 1 system barrier and 7 patient barriers were considered of significant (P ≤ .05) importance, with the proportion of HIV medical care providers’ agreement to these barriers ranging from 73.9% (cost of health care) to 100% (lack of social support systems and drug abuse problems). Providers’ perception of important system and patient barriers varied significantly (P ≤ .05) by profession, race/ethnicity, and years of experience in HIV care. To improve access to and for consistent engagement in HIV care, effective intervention programs are needed to address the barriers identified especially in the context of the new health care delivery system.

Frequency and Determinants of Preventive Care Counseling by HIV Medical Care Providers during Encounters with Newly Diagnosed and Established HIV-Infected Patients

This study evaluates the frequency and determinants of preventive care counseling by HIV medical care providers (HMCPs) during encounters with newly diagnosed and established HIV-infected patients. Data used were from a probability sample of HMCPs in Houston/Harris County, Texas, surveyed in 2009. Overall, HMCPs offered more preventive care counseling to newly diagnosed than the established patients (adjusted odds ratio [AOR] = 7.28; 95% confidence interval [CI] = 2.86-16.80). They were more likely to counsel newly diagnosed patients than the established ones on medication and adherence (AOR = 14.70; 95% CI = 1.24-24.94), HIV risk reduction (AOR = 5.91; 95% CI = 0.48-7.13), and disease screening (AOR = 7.20; 95% CI = 0.72-11.81). HIV medical care providers who were less than 45 years of age, infectious disease specialists, and had less than 30 minutes of encounter time were less likely to counsel patients regardless of the status. Our findings suggest the need for HMCPs to improve their preventive care counseling efforts, in order to help patients build skills for adopting and maintaining safe behavior that could assist in reducing the risk of HIV transmission.

Factors associated with hospitalization due to streptococcal infection in Houston, Texas 2015-2016

Objective To study the factors associated with streptococcal infection that led to hospitalization in Houston, Texas for years 2015-2016 Introduction Different studies have shown that Streptococcal infections in adults are more common among older age, blacks, and underlying chronic medical conditions like diabetes, cardiovascular and kidney diseases. In specific, other studies have demonstrated that streptococcal pyogenes can cause severe illnesses and dramatic hospital outbreaks. Furthermore, community-acquired pneumonia studies had also suggested that cardiovascular disease, severe renal disease, chronic lung disease and diabetes were associated with increased odds of hospitalization. Methods Data were extracted from Houston Electronic Disease Surveillance System (HEDSS) beginning January 1, 2015 to December 31, 2016. A total of 512 confirmed cases were investigated and analyzed during the study period. Frequencies and percentages were calculated and chi square test was used to examine the association between hospitalization and other risk factors. Odds ratio was calculated using unconditional logistic regression to determine the association of risk factors with hospitalization in streptococcal patients. Results A total of 414 patients (81 %) of the confirmed cases were hospitalized. Age, race, fever, sepsis, diabetes, cardiovascular and kidney diseases were significantly associated with hospitalization in the bivariate analysis. Logistic regression analysis adjusted for confounding factors demonstrated that among clinical characteristics, fever (OR 2.9; 95% CI 1.66-5.38) was three times more prevalent among hospitalized patients with streptococcal infection. Patients with diabetes (OR 7.92; 95% CI 3.08-20.36) were almost eight times more likely to be hospitalized than patients without diabetes among streptococcal patients, followed by cardiovascular disease (OR 2.84; CI 1.32-6.10) which was three times more likely to be present. Conclusions Common clinical sign like fever was associated with hospitalization among streptococcal patient. Similarly, risk factors like diabetes and cardiovascular diseases were significantly associated with hospitalization in streptococcal patients. Prevention strategies need to be focused on streptococcal patients with chronic risk factors like diabetes, and cardiovascular disease. References Parks t, Barret L, Jones N. Invasive streptococcal disease: a review for clinicians. British Med Bulletin, 2015; 115 (7): 77-89. Skoff TH, Farley MM, Petit S, et al. Increasing Burden of Invasive Group B Streptococcal Disease in Nonpregnant Adults, 1990-2007. CID 2009; 49 (7): 85-92.

Sources of clinical information used in HIV care and treatment: Are providers’ choices related to their demographic and practice characteristics?:

HIV medical care providers need a wide range of evidence-based clinical information resources to manage their patients’ health. We determined whether providers’ choice of information sources for HIV care and treatment are associated with their demographic and medical practice characteristics. Data used for this study were obtained from a probability sample of HIV medical care providers in 13 outpatient HIV facilities in Houston/Harris County, Texas, surveyed between June and September 2009. The mean number of information sources used by HIV medical care providers for HIV care and treatment was 5.83 (95% confidence interval: 4.90–6.75). Antiretroviral therapy guidelines (95.6%), medical journals and textbooks (82.6%), and Internet sources (69.5%) were ranked first, second, and third as sources of clinical information. At least one of the providers’ demographic or medical practice characteristics was significantly (p ⩽ 0.05) associated with six of the clinical information sources. Integration of these information resources into clinicians’ workflow may enhance efficiency of HIV care and treatment and facilitate improved patients’ care and health outcomes.

Carbapenem Resistant Enterobacteriaceae infections in Houston, Texas: An outline

Objective To examine demographic as well as clinical characteristics of the Carbapenam Resistant Enteriobacteriacae (CRE) Organisms cases in Houston, Texas, 2015-2016 Introduction According to CDC, CRE is used to describe bacteria that are non- susceptible to one or more carbapenems; doripenem, meropenem or imipenem and resistant to third generation cephalosporins like ceftriaxone, cefotaxime and ceftazidime. These organisms cause infections that are associated with high mortality rates and they have the potential to spread widely. Antibiotic resistant bacteria cause more than 2 million illnesses and at least 23,000 deaths each year in United States. CREs are found in many health care settings like acute care hospitals, long term care facilities, nursing homes, rehabilitation facilities and other health care settings. Although CREs includes a number of species, reporting in State of Texas is limited to CRE- Klebsiella species and CRE- E.coli . Methods Population-based surveillance data was generated from Houston’s electronic disease surveillance system reported to Houston Health Department (HHD) from October 2015 to July 2016. Descriptive analysis was performed to examine demographic and clinical characteristics across different age groups, gender and race/ethnicity. HHD has received a total of 463 CRE cases during the time period, out of which 72 were non-reportable and did not meet the case criteria, 187 were out of jurisdiction. The remaining 204 cases were included in this study. Results Out of a total of 204 cases, males and females were represented equally (50% each). The mean age of the cases was 67 years (age ranges from 22-98). Majority of the cases were in the older age group, 70 years and above 53 (26%), followed by 48 (24%) in age group 80 and above years. Among the different race/ethnic groups, African-Americans comprised of 82 (40%), followed by Whites 67 (33%) and Hispanics 33 (16%). Out of 204 cases, 156 (76%) were hospitalized, which included acute care hospital, long-term acute care or nursing home. Out of 156 hospitalized cases, 71 (34%) were in Intensive Care Unit (ICU) and 136 (67%) had an invasive or indwelling device. Of all the cases, 80% had CRE Klebsiella pneumoniae , followed by 11% who had CRE- E coli. The cases were distributed evenly across the city when plotted on ArcGIS with their residential addresses. Conclusions CRE cases are found to be more common among older age groups, African American population and in hospitalized patients. CRE can be a ground for increasing infectious diseases in the community and one of the reason may be unnecessary use of antimicrobial agents. This study provides a glimpse into the number of CRE cases reported in Houston since CREs are classified a separate disease in Texas. Further studies are needed to explore the occurrence of anti-microbial drug resistance among the specific population groups and how the case investigation efforts can be targeted to enhance prevention.