Stephanie A. S. Staras

Seroprevalence of Cytomegalovirus Infection in the United States, 1988–1994

BACKGROUND Cytomegalovirus (CMV) is a leading cause of congenital illness and disability, including hearing loss and mental retardation. However, there are no nationwide estimates of CMV seroprevalence among pregnant women or the overall population of the United States. METHODS To determine CMV prevalence in a representative sample of the US population, we tested serum samples for CMV-specific immunoglobulin G from participants aged > or =6 years (n=21,639) in the third National Health and Nutrition Examination Survey (1988-1994). RESULTS The prevalence of CMV infection was 58.9% in individuals > or =6 years old. CMV seroprevalence increased gradually with age, from 36.3% in 6-11-year-olds to 90.8% in those aged > or =80 years. CMV seroprevalence differed by race and/or ethnicity as follows: 51.2% in non-Hispanic white persons, 75.8% in non-Hispanic black persons, and 81.7% in Mexican Americans. Racial and/or ethnic differences in CMV seroprevalence persisted when controlling for household income level, education, marital status, area of residence, census region, family size, country of birth, and type of medical insurance. Among women, racial and/or ethnic differences were especially significant; between ages 10-14 years and 20-24 years, seroprevalence increased 38% for non-Hispanic black persons, 7% for non-Hispanic white persons, and <1% for Mexican Americans. CONCLUSIONS On the basis of these results, we estimate that each year in the United States approximately 340,000 non-Hispanic white persons, 130,000 non-Hispanic black persons, and 50,000 Mexican American women of childbearing age experience a primary CMV infection. Given the number of women at risk and the significance of congenital disease, development of programs for the prevention of CMV infection, such as vaccination or education, is of considerable public health importance.

Incidence of cytomegalovirus infection among the general population and pregnant women in the United States

BackgroundCytomegalovirus (CMV) is a common opportunistic infection among HIV-infected individuals, a major source of serious complications among organ-transplant recipients, and a leading cause of hearing loss, vision loss, and mental retardation among congenitally infected children. Women infected for the first time during pregnancy are especially likely to transmit CMV to their fetuses. More children suffer serious disabilities caused by congenital CMV than by several better-known childhood maladies such as Down syndrome or fetal alcohol syndromeMethodsUsing CMV seroprevalence data from the nationally representative Third National Health and Nutrition Examination Survey, we estimated CMV incidence among the general United States population and among pregnant women. We employed catalytic models that used age-specific CMV seroprevalences as cumulative markers of past infections in order to derive estimates of three basic parameters: the force of infection, the basic reproductive rate, and the average age of infection. Our main focus was the force of infection, an instantaneous per capita rate of acquisition of infection that approximates the incidence of infection in the seronegative population.ResultsAmong the United States population ages 12–49 the force of infection was 1.6 infections per 100 susceptible persons per year (95% confidence interval: 1.2, 2.4). The associated basic reproductive rate of 1.7 indicates that, on average, an infected person transmits CMV to nearly two susceptible people. The average age of CMV infection was 28.6 years. Force of infection was significantly higher among non-Hispanic Blacks (5.7) and Mexican Americans (5.1) than among non-Hispanic Whites (1.4). Force of infection was significantly higher in the low household income group (3.5) than in the middle (2.1) and upper (1.5) household income groups. Based on these CMV incidence estimates, approximately 27,000 new CMV infections occur among seronegative pregnant women in the United States each year.ConclusionThese thousands of CMV infections in pregnant women, along with the sharp racial/ethnic disparities in CMV incidence, are compelling reasons for accelerating research on vaccines and other interventions for preventing congenital CMV disease. Nevertheless, the relatively low force of infection provides encouraging evidence that modestly effective vaccines and rates of vaccination could significantly reduce CMV transmission.

The Relationship Between Marijuana Use and Intimate Partner Violence in a Nationally Representative, Longitudinal Sample

Intimate partner violence is a significant public health problem, as these behaviors have been associated with a number of negative health outcomes including illicit drug use, physical injury, chronic pain, sexually transmitted diseases, depression, and posttraumatic stress disorder. The current study examined the association between marijuana use and intimate partner violence using a longitudinal survey of adolescents and young adults ages 15 to 26 years. Data were obtained from 9,421 adolescents in the National Longitudinal Study of Adolescent Health (Add Health) Waves 1 through 4 (1995-2008). Marijuana use was measured in the past year at each wave and participants were categorized as “users” or “nonusers.” Partner violence was constructed using six items (three pertaining to victimization and three concerning perpetration) from Wave 4 (2007-2008). Using these six items, participants were categorized as “victims only,” “perpetrators only,” or “victims and perpetrators.” Survey multinomial regression was used to examine the relationship between marijuana use and intimate partner violence. Consistent use of marijuana during adolescence was most predictive of intimate partner violence (OR = 2.08, p < .001). Consistent marijuana use (OR = 1.85, p < .05) was related to an increased risk of intimate partner violence perpetration. Adolescent marijuana use, particularly consistent use throughout adolescence, is associated with perpetration or both perpetration of and victimization by intimate partner violence in early adulthood. These findings have implications for intimate partner violence prevention efforts, as marijuana use should be considered as a target of early intimate partner violence intervention and treatment programming.

Influence of Sexual Activity on Cytomegalovirus Seroprevalence in the United States, 1988-1994

Background: Sexual and nonsexual transmission of cytomegalovirus (CMV) occurs, but the frequency of sexual transmission in the general population of the United States is unknown. Methods: Using data from 15- to 44-year-old (n = 7883) participants of the Third National Health and Nutrition Examination Survey (1988–1994), we examined the association between CMV seroprevalence and sexual activity markers. Using logistic regression, we calculated standardized prevalence differences (PDs)—the weighted average CMV prevalence among higher sexual risk groups minus CMV prevalence among the lowest sexual risk group—for each of several sexual activity markers (ever had sex, number of sex partners [lifetime and past year], age at first intercourse, potential years of sexual activity, ever use oral contraceptives, herpes simplex virus type 2 antibody, and a calculated composite marker). Results: Even after controlling for covariates, we found associations between CMV seroprevalence and sexual activity among non-Hispanic black [all PDs for sexual activity markers were positive and composite PD = 8.5%, 95% confidence interval (CI) = 4.0%–13.1%] and non-Hispanic white women (15 of 18 PDs for sexual activity markers were positive and composite PD = 10.8%, 95% CI = 3.1%–18.5%). We found a borderline significant association among Mexican American women (13 of 18 PDs for sexual activity markers were positive and composite PD = 3.5%, 95% CI = −0.7% to 7.6%). We found little or no association within each racial/ethnic group of men. Conclusions: Sexual activity measurably influences CMV seroprevalence among women of childbearing age, indicating that congenital CMV prevention messages should include strategies to reduce sexual transmission of CMV among pregnant women.

National prevalence estimates for cytomegalovirus IgM and IgG avidity and association between high IgM antibody titer and low IgG avidity.

ABSTRACT Primary cytomegalovirus (CMV) infection of the mother during pregnancy presents risk of CMV infection of the fetus with resulting permanent disability. CMV IgM antibody is generated following primary CMV infection but also can appear during nonprimary CMV infection and is thus of limited diagnostic use by itself. In contrast, the presence of low CMV IgG avidity has been shown to be a unique and reliable serologic indicator of primary CMV infection. We measured CMV IgG and IgM antibody levels and IgG avidity in sera from a population sample of 6,067 U.S. women aged 12 to 49 years from NHANES (National Health and Nutrition Examination Survey). The CMV IgG prevalence was 58% overall and increased strongly with age. The CMV IgM prevalence was 3.0% overall and remained relatively flat across age groups. The prevalence of low IgG avidity was 2.0% overall, decreased sharply with age, and was seen mainly among IgM-positive sera. Fourteen to 18% of the CMV IgM-positive sera were low IgG avidity, presumably representing primary CMV infection. High CMV IgM antibody titer was a strong predictor of low IgG avidity. The ability to reliably identify primary CMV infection during pregnancy is important for management of the pregnancy, including possible treatment options for the fetus. Both IgM and IgG avidity measurements provide useful clinical information for evaluating primary CMV infection, although commercial tests for CMV IgG avidity are not yet widely available in the United States.

Cytomegalovirus seroprevalence and childhood sources of infection: A population-based study among pre-adolescents in the United States

BACKGROUND Among pre-adolescents, the importance of different sources of cytomegalovirus (CMV) infection is unclear. OBJECTIVE To assess the importance of several CMV sources among pre-adolescent children. STUDY DESIGN We used data from a United States population-based sample conducted from 1988 to 1994: 4-10-year-old participants (n=3386) of the Third National Health and Nutrition Examination Survey. We tested available sera for CMV-specific-IgG and assessed CMV prevalence differences by surrogates for exposure to childhood CMV sources (maternal CMV serostatus, breast-feeding, older sibling CMV serostatus, and child care center attendance). RESULTS CMV infection was more prevalent (70%) among Mexican American children with foreign-born householders than among children with native-born householders (31% non-Hispanic White, 39% non-Hispanic Black, and 37% Mexican American children). Childs serostatus was associated with their mothers (prevalence difference range (PDR)=33-40%) and older siblings serostatus (PDR=39-50%). Breast-feeding was associated with CMV in some racial/ethnic and householder groups (PDR=-5.1% to 22.7%). There was little difference in CMV seroprevalence by child care center attendance (PDR=-6.5% to -0.4%). CONCLUSIONS This study expands understanding of CMV by identifying the importance of householder nativity and demonstrating the importance of family transmission among the general population of pre-adolescents.

Sexual partner characteristics and sexually transmitted diseases among adolescents and young adults.

Background: Among adolescents and young adults, the extent that partner characteristics account for sexually transmitted diseases (STDs) in context of individual sexual activities and demographic characteristics is unclear. Methods: Sexual partner characteristics, individual sexual activities, and STD diagnosis were assessed among 15 to 24-year-old STD clinic attendees from 1999 to 2002 (n = 412). We used exact logistic regression to calculate odds ratios (OR) for several sexual partner characteristics (age discordance, incarceration, STD diagnosis, other partners, alcohol problem, marijuana problem, and a calculated composite variable) adjusting for demographics and individual sexual activities, including condom use. Results: Sexual partner characteristics associated with STD diagnosis were ≥5 years age discordance [OR = 2.6 (95% confidence interval (CI) = 1.6, 4.5)] and STD in the past year [OR = 3.4 (95% CI = 2.0, 5.7)]. Even when considering individual sexual activities, composite partner risk was associated with STD diagnosis [intermediate to low OR = 2.1 (95% CI = 1.0, 4.2) and high to low OR = 3.4 (95% CI = 1.6, 7.0)]. Composite individual sexual activities was associated with STD diagnosis when considering demographics [intermediate to low OR = 1.8 (95% CI = 1.0, 3.2), high to low OR = 2.3 (95% CI = 1.2, 4.5)], but not when also considering partner characteristics [intermediate to low OR = 1.6 (95% CI = 0.9, 2.8), high to low OR = 1.8 (95% CI = 0.8, 3.9)]. Conclusions: Among this sample of 15 to 24-year-olds, sexual partner characteristics identified individuals at increased risk of prevalent STDs and were more predictive of STDs than an individuals sexual activities.

Perceived racial/ethnic discrimination, problem behaviors, and mental health among minority urban youth

Objectives. We examined perceived frequency and intensity of racial/ethnic discrimination and associations with high-risk behaviors/conditions among adolescents. Design. With surveys from 2490 racial/ethnic minority adolescents primarily with low socioeconomic status, we used regression analysis to examine associations between racial/ethnic discrimination and behavioral health outcomes (alcohol use, marijuana use, physical aggression, delinquency, victimization, depression, suicidal ideation, and sexual behaviors). Results. Most adolescents (73%) experienced racial/ethnic discrimination and 42% of experiences were ‘somewhat-’ or ‘very disturbing.’ Adolescents reporting frequent and disturbing racial/ethnic discrimination were at increased risk of all measured behaviors, except alcohol and marijuana use. Adolescents who experienced any racial/ethnic discrimination were at increased risk for victimization and depression. Regardless of intensity, adolescents who experienced racial/ethnic discrimination at least occasionally were more likely to report greater physical aggression, delinquency, suicidal ideation, younger age at first oral sex, unprotected sex during last intercourse, and more lifetime sexual partners. Conclusion. Most adolescents had experienced racial/ethnic discrimination due to their race/ethnicity. Even occasional experiences of racial/ethnic discrimination likely contribute to maladaptive behavioral and mental health outcomes among adolescents. Prevention and coping strategies are important targets for intervention.

Parent perceptions important for HPV vaccine initiation among low income adolescent girls.

OBJECTIVE The study aims were to assess the influence of provider recommendations on parental vaccine perceptions and identify the most potent parent vaccine perceptions for HPV vaccine series initiation considering provider recommendation strength. METHODS We administered a questionnaire and assessed HPV vaccine claims among a stratified-random sample of parents of 9-17 year old girls enrolled in Floridas Medicaid and the Childrens Health Insurance Program. Using multivariate analyses, we evaluated the associations between: (1) parent vaccine perceptions and provider recommendation strength, and (2) parent vaccine perceptions and HPV vaccine series initiation (≥1 vaccine claim or positive parental report) controlling for provider recommendation strength. RESULTS The majority of the 2422 participating parents agreed that the HPV vaccine was safe (61%), would not make girls more likely to have sex (69%), and prevented cervical cancer (71%). About half (44%) reported receiving a strong provider recommendation. Compared to parents without recommendations, parents with strong recommendations had 2 to 7 times higher odds of agreeing that: vaccines are safe, the HPV vaccine is safe, not concerned about side effects, and the vaccine prevents cervical cancer. Even when considering provider recommendation strength, HPV vaccine series initiation was more likely among girls of parents who agreed rather than disagreed that the HPV vaccine was safe [odds ratio (OR)=5.8, 95% confidence interval (CI)=3.1, 11.1], does not cause sex (OR=2.0, 95% CI=1.2, 3.4), prevents cervical cancer (OR=2.0, 95% CI=1.0, 3.4), and prevents HPV infections (OR=1.8, 95% CI=1.0, 3.0). CONCLUSIONS Parent concerns about HPV vaccine are similar to their concerns about other vaccines. Providers should focus HPV vaccine discussions with parents on vaccine safety and illness prevention.

Disparities in Human Papillomavirus Vaccine Series Initiation Among Adolescent Girls Enrolled in Florida Medicaid Programs, 2006–2008

PURPOSE To better understand the human papillomavirus (HPV) vaccine series initiation among 9-17-year-old female Medicaid beneficiaries in Florida programs between June 2006 and December 2008 (n = 237,015). METHODS Among the Florida Medicaid enrollees with itemized claims collected (non-managed care organization enrollees), we assessed the association between HPV vaccine series initiation (≥1 vaccine claim) and important demographic characteristics (age, race/ethnicity, program enrollment, area of residence, and length of enrollment). RESULTS Among 11-17-year-olds, vaccine initiation increased over time from <1% by December 2006 to nearly 19% by December 2008. By December 2008, HPV vaccine initiation increased with respect to age from 9 (1.6%) to 13 years (22.9%), remained relatively stable from ages 13 to 15 years (between 21% and 22%), and decreased among 16- (18.6%) and 17-year-olds (15.7%). Compared with girls in Pilot or Fee for Service programs, the girls in MediPass or Childrens Medical Service Network programs were more likely to have initiated the vaccine series. Within three of the four programs, Hispanics were more likely than non-Hispanic white and black girls to have initiated the vaccine series. CONCLUSIONS This study expands the understanding of HPV vaccine initiation to low-income adolescents eligible for free vaccine through the Federal Vaccine for Children program. Increased understanding of reasons for the observed differences, especially by program and race/ethnicity, will aid in developing interventions to improve HPV vaccine initiation.