With the recent emphasis on funding and training opportunities for global health and humanitarian aid and the increased interest in the field, many health care workers and medical researchers are ...traveling from resource-replete to resource-limited settings. This type of travel brings unique disease risks not routinely considered for the business or vacationing traveler. This review provides practical advice for this special population of travelers, targeted to specific health care-related risks (needlestick, hemorrhagic fever viruses, severe viral respiratory disease, and tuberculosis), with suggestions for risk mitigation.
Background. The interferon-γ release assays (IGRAs) are increasingly being used as an alternative to the tuberculin skin test (TST). Although IGRAs may have better specificity and certain logistic ...advantages to the TST, their use may contribute to overtesting of low-prevalence populations if testing is not targeted. The objective of this study was to evaluate the accuracy of a risk factor questionnaire in predicting a positive test result for latent tuberculosis infection using the 3 commercially available diagnostics. Methods. A cross-sectional comparison study was performed among recruits undergoing Army basic training at Fort Jackson, South Carolina, from April through June 2009. The tests performed included: (1) a risk factor questionnaire; (2) the QuantiFERON Gold In-Tube test (Cellestis Limited, Carnegie, Victoria, Australia); (3) the T-SPOT.TB test (Oxford Immunotec Limited, Abingdon, United Kingdom); and (4) the TST (Sanofi Pasteur Ltd., Toronto, Ontario, Canada). Prediction models used logistic regression to identify factors associated with positive test results. RFQ prediction models were developed independently for each test. Results. Use of a 4-variable model resulted in 79% sensitivity, 92% specificity, and a c statistic of 0.871 in predicting a positive TST result. Targeted testing using these risk factors would reduce testing by >90%. Models predicting IGRA outcomes had similar specificities as the skin test but had lower sensitivities and c statistics. Conclusions. As with the TST, testing with IGRAs will result in false-positive results if the IGRAs are used in low-prevalence populations. Regardless of the test used, targeted testing is critical in reducing unnecessary testing and treatment. Clinical Trial Registration. NCT00804713.
Healthcare and humanitarian workers who travel to work where the incidence of multidrug-resistant tuberculosis (MDR TB) is high and potential transmission may occur are at risk of infection and ...disease due to these resistant strains. Transmission occurs due to inadequate transmission control practices and the inability to provide timely and accurate diagnosis and treatment of persons with MDR TB. Patients risk exposure if active TB is unrecognized in workers after they return to lower-risk settings. Guidance for risk reduction measures for workers in high-risk areas is limited, and no studies confirm the efficacy of treatment regimens for latent TB infection due to MDR TB. Bacille Calmette-Guérin (BCG) vaccination decreases the risk of active TB and possibly latent infection. IFN-γ release assays differentiate TB infection from BCG vaccination effect. A series of risk reduction measures are provided as a potential strategy. These measures include risk reductions before travel, including risk assessment, TB screening, education, respirator fit testing, and BCG vaccination. Measures during travel include use of respirators in settings where this may not be common practice, transmission control practices, triaging of patients with consistent symptoms, providing education for good cough etiquette, and provision of care in well-ventilated areas, including open air areas. Risk reduction measures after return include TB screening 8 to 10 weeks later and recommendations for management of latent TB infection in areas where the likelihood of MDR TB exposure is high.
To study the safety and feasibility of T-cell reconstitution in HIV-infected individuals, we adoptively transferred activated autologous CD4+ T cells. Polyclonal peripheral blood CD4+ cells were ...costimulated ex vivo and subjects were given infusions of up to 3 x 1010 activated CD4+ cells. Dose-dependent increases in CD4+ cell counts and in the CD4:CD8 ratio were observed. Sustained increases in the fraction of cytokine-secreting T cells and decreases in the percentage of CD4+CCR5+ cells were noted in vivo, suggesting enhanced function and resistance to HIV infection. The frequency of CD4+Ki-67+ cells increased whereas CD4+ T cells containing T cell-receptor rearrangement excision circles (TRECs) decreased. These findings indicate that expansion of the peripheral T-cell pool mediated the increase in CD4 counts and suggest that approaches to reconstitute CD4 helper cell activity and decrease CCR5 expression may augment natural immunity to HIV infection.
The rK39 test is a serologic assay for the rapid diagnosis of visceral leishmaniasis (VL). Serum from a North American cohort of 59 otherwise asymptomatic soldiers with cutaneous leishmaniasis (CL) ...was tested with the rK39 dipstick and ELISA assays, and 10.2% and 28.8% had positive results, respectively. CL is associated with a reactive rK39 assay result in some patients without clinical evidence of VL.
To describe the demographics, risk behaviors, and HIV-1 subtypes in a large cohort of recently HIV-infected military personnel.
Descriptive, cross-sectional study.
US military personnel with recent ...HIV seroconversion from six medical referral centers were enrolled with a self-administered questionnaire, CD4 cell counts, syphilis and hepatitis B serologies, plasma viral RNA levels, and HIV-1 subtype nucleic acid sequencing.
Between February 1997 and May 2000, 520 patients were enrolled. Most 488 (94.3%) were infected with HIV-1 subtype B. The most prevalent non-B subtype was a circulating recombinant form (CRF01_AE) 17 (61%); however, two pure subtypes (C and D), as well as CRF02_AG, CRF09_cpx and a BE recombinant were identified. The likely area of HIV-1 acquisition was the United States for 70% of the volunteers. At least three non-B subtype infections (two subtype C, one subtype CRF01_AE) were apparently acquired domestically. Risk behaviors and comorbid sexually transmitted diseases were reported during the seroconversion period. Volunteers with non-B subtype HIV infection were more likely to report heterosexual contacts 92% vs. 39%; odds ratio (OR), 10.0, including contacts with commercial sex workers (41% vs. 13%; OR, 4.9). The Roche Amplicor version 1.0 assay was less sensitive for non-B subtype infections than the Roche Amplicor version 1.5 assay.
There is a high prevalence and diversity of non-B HIV subtypes in this large cohort. Efficient diagnosis of acute primary HIV-1 infection was identified as a goal for prevention programs. Modifiable risk behaviors and target populations for intervention were identified.
Abstract Infectious diseases and war have been intertwined throughout history. Trauma-related complications, food- and water-borne diseases, endemic zoonoses, and respiratory and vector-borne ...infections characterize specific types of challenges to the health of the American Forces during Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan). This review centers on subacute infections that may present or persist upon redeployment to the United States and those that may be less familiar to the American medical community. These include Q fever, tuberculosis, malaria, leishmaniasis, brucellosis, endemic arboviruses, diarrhea, and wound infections with multidrug-resistant gram-negative bacteria.
Abstract
Background
Bacille Calmette Guerin (BCG) vaccine’s protective effect against tuberculosis (TB) is established. BCG vaccine also has off-target effects, perhaps due to long-lasting trained ...immunity. BCG provides unanticipated beneficial effects against other infectious/non-infectious diseases, including respiratory infections, diabetes mellitus, dementia, and cancer. We aimed to determine if there was differential mortality over a lifetime in those receiving BCG versus placebo. We analyzed all cause and infectious diseases (ID) mortality in a longitudinal cohort study of American Indians and Alaska Natives (AI/AN) enrolled in a BCG efficacy clinical trial.
Methods
2963 AI/AN participants were enrolled median age 7.6 years (range 0.1-20) in a saline placebo-controlled BCG trial between 1935-8 in five US geographic regions, with prospective follow up through 1948. Retrospective data collection was completed from 1992-8. Mortality data was supplemented by National Death Index search in 2006, pending 2023. Demographics, medical and mortality history were collected blinded to vaccine arm. Differences in mortality were analyzed by vaccine, demographic and death characteristics via bivariate association using chi-square, t-test and logistic regression with STATA.
Results
1540 BCG, 1423 placebo participants enrolled. At 71 years from the trial start, 1600/2963 (54.0%) participants were deceased; 1171 (73.2%) to non-ID, 94 (5.9%) TB, 217 (13.6%) other infections, and 118 (7.3%) were unknown. Median age at death was similar (BCG 55.0 years, placebo 54.0). BCG vaccinated participants had a 31% decreased odds of death vs. placebo for ID not-TB (CI=0.52-0.93, p = 0.014) and 74% decreased odds of death due to TB (CI=0.16-0.42, p=.000). Adjusted logistic regression analysis showed BCG decreased odds of all cause death by 14% (p = 0.04). Male sex (OR 1.77) and living in Arizona (OR 2.53) or Wyoming (2.24) were associated with increased all cause mortality (p< 0.001).
Conclusion
In this cohort, BCG vaccine conferred a mortality benefit against TB but also other infections. Male sex and certain geographic regions were associated with higher odds of death. These findings suggest that childhood vaccination with BCG vaccine may reduce mortality beyond preventing TB deaths.
Disclosures
Lee Harrison, MD, GSK: Advisor/Consultant|Merck: Advisor/Consultant|Pfizer: Advisor/Consultant|Sanofi: Advisor/Consultant Naomi E. Aronson, MD, british medical journal: Honoraria|British Medical Journal: honoraria for writing chapter for Best Evidence|Elsevier: royallties serve as textbook editor|Elsevier: Royalties as text editor|UpTo Date: royalties for writing chapters|UpToDate: royalties for writing chapters|Wellcome Foundation: Honoraria|Wellcome Foundation: program advisory board|Wellcome Trust: Honoraria|Wellcome Trust: program advisory board Naomi E. Aronson, MD, british medical journal: Honoraria|British Medical Journal: honoraria for writing chapter for Best Evidence|Elsevier: royallties serve as textbook editor|Elsevier: Royalties as text editor|UpTo Date: royalties for writing chapters|UpToDate: royalties for writing chapters|Wellcome Foundation: Honoraria|Wellcome Foundation: program advisory board|Wellcome Trust: Honoraria|Wellcome Trust: program advisory board
Cutaneous leishmaniasis is acquired from the bite of an infected sand fly and can result in chronic skin lesions that develop within weeks to months after a bite. Local trauma has been implicated as ...a precipitating event in the development of skin lesions in patients who have been infected with Leishmania species. Here we report a case series and review the literature on patients who developed cutaneous leishmaniasis after local trauma, which may familiarize clinicians with this presentation.
The efficacy and toxicity of sodium stibogluconate (SSG) at a dosage of 20 mg/(kg×d) for either 20 days (for cutaneous disease) or 28 days (for visceral, mucosal, or viscerotropic disease) in the ...treatment of leishmaniasis is reported. Ninety-six U.S. Department of Defense health care beneficiaries with parasitologically confirmed leishmaniasis were prospectively followed for 1 year. One patient was infected with human immunodeficiency virus; otherwise, comorbidity was absent. Clinical cure occurred in 91% of 83 cases of cutaneous disease and 93% of 13 cases of visceral/viscerotropic disease. Adverse effects were common and necessitated interruption of treatment in 28% of cases, but they were generally reversible. These included arthralgias and myalgias (58%), pancreatitis (97%), transaminitis (67%), headache (22%), hematologic suppression (44%), and rash (9%). No subsequent mucosal leishmaniasis was identified, and there were no deaths attributable to SSG or leishmaniasis.
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