Trang Q. Nguyen

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.

Benefits and Barriers to Electronic Laboratory Results Reporting for Notifiable Diseases: The New York City Department of Health and Mental Hygiene Experience

OBJECTIVES Despite national support for electronic laboratory reporting (ELR), the transition from paper to electronic reporting has been slow both nationally and locally. We assessed the ELR experience of New York Citys surveillance programs to identify barriers to ELR implementation and generalizable lessons about automated electronic notifiable disease surveillance. METHODS We conducted interviews with key staff of the New York City Department of Health and Mental Hygiene to evaluate ELR implementation. A review of paper and ELR disease reports enabled a comparison of the reporting systems. RESULTS The completeness and timeliness of ELR were similar to, and sometimes better than, paper reporting for certain diseases. Incorporating electronic data into surveillance databases created new problems with data quality, shifted work demands, and required additional skills for data monitoring. ELR improved the handling of high-volume and time-sensitive diseases but did not completely automate reporting for diseases that required complicated assessments by staff. CONCLUSIONS Although ELR streamlines data processing, electronic reporting has its own limitations. A more successful use of ELR can be achieved by understanding its strengths and limitations for different disease types.

Targeted testing for acute HIV infection in North Carolina.

BACKGROUND Persons with acute HIV infection contribute disproportionately to HIV transmission. The identification of these persons is a critical public health challenge. We developed targeted approaches for detecting HIV RNA in persons with negative serological tests. METHODS Persons undergoing publicly funded HIV testing in North Carolina between October 2002 and April 2005 were included in this cross-sectional study. We used logistic regression to develop targeted testing approaches. We also assessed simple approaches based on clinic type and geography. Algorithm development used persons with recent HIV infection, determined by a detuned enzyme-linked immunosorbent assay. Validation used persons with acute HIV infection, identified with an HIV RNA pooling procedure. RESULTS Among 215 528 eligible persons, 232 persons had recent HIV infection and 44 had acute HIV infection. A combination of five indicators (testing site, sexual preference, sex with a person with HIV infection, county HIV incidence, and race) identified 92% of recent infections when testing 50% of the population. In validation among persons with acute HIV infection, this indicator combination had sensitivities of 98% in years 1 and 2 and 88% in year 3. A simple combination of testing site and county performed nearly as well [development (recent infections): sensitivity = 95%; validation (acute infections): sensitivity = 86% in years 1 and 2; 81% in year 3; cut-off established for testing 50% of population.] CONCLUSION Acute HIV infection can be identified accurately using targeted testing. Simple approaches for identifying the types of clinics and geographical areas where infections are concentrated may be logistically feasible and cost-efficient.

Population prevalence of reported and unreported HIV and related behaviors among the household adult population in New York City, 2004

Background:Surveillance for HIV likely underestimates infection among the general population: 25% of US residents are estimated to be unaware of their HIV infection. Objective:To determine the prevalence of HIV infection and risk behaviors among New York City (NYC) adults and compare these with surveillance findings. Methods:The NYC Health and Nutrition Examination Survey (HANES) provided the first opportunity to estimate population-based HIV prevalence among NYC adults. It was conducted in 2004 among a representative sample of adults > 20 years. Previously reported HIV infection was identified from the NYC HIV/AIDS Surveillance Registry. A blinded HIV serosurvey was conducted on archived blood samples of 1626 NYC HANES participants. Data were used to estimate prevalence for HIV infection, unreported infections, high-risk activities, and self-perceived risk. Results:Overall, 18.1% engaged in one or more risky sexual/needle-use behaviors, of which 92.2% considered themselves at low or no risk of HIV or another sexually transmitted disease. HIV occurred in 21 individuals (prevalence 1.4%; 95% confidence interval (CI), 0.8–2.5]; one infection (5%; 95% CI, 0.7–29.9) was not reported previously and possibly undiagnosed. HIV infection was significantly elevated in those with herpes simplex virus 2 (4%), men who have sex with men (14%), and needle-users (21%) (P < 0.01). Conclusions:Among NYC adults, HIV prevalence was consistent with surveillance findings overall. The proportion of unreported HIV was less than estimated nationally, but findings were limited by sample size. Most adults with risky behaviors perceived themselves to be at minimal risk, highlighting the need for risk reduction and routine HIV screening.

HIV Testing Among Young Adults in the United States: Associations with Financial Resources and Geography

We estimated prevalence and odds ratios for self-reported HIV testing among sexually experienced young adults using nationally representative data obtained from Wave III of the National Longitudinal Study of Adolescent Health (Add Health). The prevalence of testing in the past year was 18.8%. Young adults who had private or no health insurance were less likely to report testing than were young adults who had public health insurance, particularly in the South. Respondents with functional income were less likely to report testing than were those without functional income, particularly in the South and Northeast. Variable HIV testing based on finances and insurance should be addressed.

Infrequent Chlamydial Testing Among Young Adults: Financial and Regional Differences

Objectives: Chlamydia prevalence varies regionally but is highest in the South, which could be the result of regional differences in testing behavior. We describe the national and regional prevalence of self-reported chlamydial infection (Ct) testing and examine how financial resources might be associated with Ct testing. Methods: We conducted a cross-sectional analysis of data from 12,334 sexually experienced young adults who participated in wave III of the National Longitudinal Study of Adolescent Health (2001–2002). We estimated the prevalence of Ct testing by region and gender, and calculated prevalence odds ratios for the relationship between income or insurance status and Ct testing. Results: Among women, Ct testing in the past year was low (27.3%; 95% CI, 25.5–29.2) and lowest in the South (24.8%). Compared with publicly insured females, privately insured (OR, 0.72; 95% CI, 0.57–0.92) and uninsured females (OR, 0.63; 95% CI, 0.48–0.88) were less likely to report testing. Young women with low income were more likely to report testing than those with a higher income (OR, 1.36; 95% CI, 1.12–1.66). Men reported similar testing patterns. Conclusions: The South has the highest chlamydia prevalence and the lowest levels of Ct testing in the United States. Reducing infection prevalence and regional disparities in the burden of this infection requires region-focused funding and innovative strategies to increase testing and treatment programs.

Disparities in the severity of influenza illness: a descriptive study of hospitalized and nonhospitalized novel H1N1 influenza-positive patients in New York City: 2009-2010 influenza season.

OBJECTIVE To investigate the association between socioeconomic status (SES) and hospitalization for 2009 H1N1 influenza, independently of access to care and known risk factors for severe influenza illness, among New York City residents during the 2009-2010 influenza season. DESIGN We used a 1:2 case-control study design, matching by age group and month of diagnosis. Cases were defined as laboratory-confirmed patients with 2009 H1N1 influenza who were hospitalized during their illness. Controls were defined as nonhospitalized laboratory-confirmed influenza A patients. Participants were contacted for a telephone interview to collect relevant clinical and demographic data. We used conditional logistic regression to analyze the association between SES and hospitalization. SETTING New York City. PARTICIPANTS Of the 171 hospitalized cases who were identified between October 2009 and February 2010, a total of 128 completed telephone interviews. A total of 640 nonhospitalized controls were contacted, and of these, 337 completed interviews. MAIN OUTCOME MEASURES The main outcome of interest was whether or not a patient was hospitalized during his or her 2009 H1N1 influenza illness. Socioeconomic status was measured using education and neighborhood poverty. RESULTS We identified a gradient in the odds of hospitalization for 2009 H1N1 influenza by education level among adults. This association could not be entirely explained by access to care and underlying risk factors. An inverse association between odds of hospitalization and neighborhood poverty was also identified among adults and children. CONCLUSIONS This study suggests that individuals of lower SES were more vulnerable to severe illness during the 2009 H1N1 pandemic. Additional research is needed to help guide interventions to protect this population during future influenza pandemics.

Asthma surveillance using medicaid administrative data: A call for a national framework

Connecticut, Michigan, and New York have successfully used Medicaid administrative data to conduct surveillance of asthma prevalence, related health service utilization and costs, and quality of asthma care. Since these assessments utilize beneficiary-level data, a wide range of population-based summaries is feasible. Opportunities exist to build upon the collective experiences of these three states to establish a national framework for asthma surveillance using Medicaid administrative data. This framework could be designed to respond to each states unique data considerations and asthma management priorities, while establishing standardized criteria to enhance the comparability of asthma surveillance data among states. Importantly, a common asthma case definition using comparable methods is necessary to enable comparisons of prevalence estimates between states. Case definitions that could serve as the foundation for such a framework are presented. Mechanisms to foster sharing of methodologies and experiences will be instrumental for broad implementation across states. This collaboration will be of increasing importance as states experience mounting financial pressures due to increasing Medicaid enrollment and dwindling resources.

Description of a School Nurse Visit Syndromic Surveillance System and Comparison to Emergency Department Visits, New York City

OBJECTIVES We compared school nurse visit syndromic surveillance system data to emergency department (ED) visit data for monitoring illness in New York City schoolchildren. METHODS School nurse visit data recorded in an electronic health record system are used to conduct daily surveillance of influenza-like illness, fever-flu, allergy, asthma, diarrhea, and vomiting syndromes. We calculated correlation coefficients to compare the percentage of syndrome visits to the school nurse and ED for children aged 5 to 14 years, from September 2006 to June 2011. RESULTS Trends in influenza-like illness correlated significantly (correlation coefficient = 0.89; P < .001) and 72% of school signals occurred on days that ED signaled. Trends in allergy (correlation coefficient = 0.73; P < .001) and asthma (correlation coefficient = 0.56; P < .001) also correlated and school signals overlapped with ED signals on 95% and 51% of days, respectively. Substantial daily variation in diarrhea and vomiting visits limited our ability to make comparisons. CONCLUSIONS Compared with ED syndromic surveillance, the school nurse system identified similar trends in influenza-like illness, allergy, and asthma syndromes. Public health practitioners without school-based surveillance may be able to use age-specific analyses of ED syndromic surveillance data to monitor illness in schoolchildren.

Public Reporting of Hospital-Specific Breastfeeding Measures A Qualitative Study of Hospital Staff and Administrators

Background: Establishing breastfeeding in the first days of an infant’s life is important for longer term success in breastfeeding. In 2009, New York State (NYS) was the second state to require maternity care facilities to collect infant feeding information and to publicly disseminate hospital-specific infant feeding statistics. Public reporting of these statistics as performance measures is a strategy to prompt hospitals to improve breastfeeding support. Objective: This qualitative study sought to explore how maternity care administrators and clinical staff responded to the mandate for publicly reported performance measures and whether they used this information to improve maternity care practices. Methods: This study used a stratified random sample of NYS hospitals with maternity care units. Participants were recruited by email and telephone calls. A total of 25 hospitals participated in the study, and 37 hospital administrators and staff completed in-depth interviews by telephone. The interviews were analyzed using an explanatory framework in NVivo 8. Results: Publicly reported hospital-specific breastfeeding measures increased attention to breastfeeding performance. Hospital administrators and staff reported comparing their relative rankings to other hospitals in the state. Some hospitals used publicly reported breastfeeding measures to monitor performance, whereas others were prompted to generate additional measures for more frequent monitoring. Hospitals with relatively low breastfeeding statistics took certain actions to improve their maternity care practices to support breastfeeding. Limitations of the usefulness of publicly reported measures were reported by interview participants. Conclusion: Publicly reported, hospital-specific breastfeeding measures may prompt hospitals to monitor and improve maternity care practices related to supporting breastfeeding.