Infectious Disease Alert Updates
By Carol A. Kemper, MD, FACP
Van Wagoner N, Et al. Clin Infect Dis 2014; 58(2):295-9.
A cross-sectional analysis of persons newly presenting for HIV care was performed at a University HIV clinic in Alabama GA, examining risk factors for delayed presentation. Part of the initial intake was an assessment of church attendance, which was compared with self-reported sexual behavior (including men who have sex with men [MSM], men who have sex with women [MSW], and women who have sex with men [WSM] — men who have sex with both were included in MSM). A total of 508 people were included in the survey (60% MSM, 21% MSW, and 18%WSM). The median age was 33 yrs; and 62% were African American. More than half (56%) attended church on a regular basis. One-third had a CD4 count < 200 cells/mm3 (AIDS by CD4 count) at presentation.
There was a statistically significant correlation observed between church attendance and presentation with AIDS (p=.02). Church-going MSM were statistically more likely to present with more advanced disease, as defined by CD4 count < 200 cells/mm3, than non-church goers (34% vs 20%, adjusted OR = 2.2, p= .01). Church-going MSM were also statistically less likely to have been previously HIV tested (79% vs 88%, p = .041). The opposite was observed in WSM. Non-church going women were less likely to report prior HIV testing than church-going women (41% vs 68%, p=.01).
I suspect very different results might be observed if this analysis were performed in a part of the country other than the South, and the type of religion may have some bearing on the results. Nonetheless, I have heard many time from several of my black HIV+ MSM their concerns about being ostracized from their community, should their HIV+ status be revealed.
Average survival time of chocolate: 55 min
Gajendragadkar PR, et al. BMJ 2013; 347:f7198.
I love being on call for the Holidays — it's not so busy, and there are goodies and boxes of See's chocolate at every nursing station (despite our Infection Control provision against having food at the nursing station, which is largely ignored, especially at the holidays). It's no wonder Warren Buffet bought See's candies in 1972.
These rascals in the Department of Cardiology at Bedford Hospital in the United Kingdom surveyed the rate of chocolate consumption on nursing units at 3 different hospitals. Two different types of boxed chocolates were deployed (a total of 8 boxes, 2 per unit, with a total of 258 chocolates). The boxes were "kept under covert surveillance", and the time to consumption recorded. Three-fourths of the chocolates were observed being eaten.
The medium time to opening the first box of chocolate, once it arrived at the nursing station, was 12 minutes (range, 0 to 25 minutes). The average survival time of chocolate was 55 minutes. Chocolate consumption was non-linear, with a burst of chocolate eating activity followed by slower ingestion. Using an exponential decay model, the survival half-life for a box of chocolates was 99 minutes. One brand of chocolates survived longer than the other. Nurses and health care assistants consumed most of the chocolates, while only 15% fell victim to physicians.
Non-Medical Exemptions in California Contributing to Pertussis
Atwell, JE et al. Nonmedical vaccine exemptions and pertussis in California, 2010. Pediatrics 2013; 132: 624-630.
There were more cases of pertussis reported to the California Department of Public Health in 2010 than in the previous 50 years. The CDPH collects data on confirmed, probable and suspect cases of pertussis (a total of 9143 such cases were reported in 2010). A confirmed or suspect case is defined as cough illness > 2 weeks and > 1 week of paroxysms of cough, inspiratory whoop, or posttussive vomiting, with confirmation by Bordetella pertussis PCR, or a consistent cough illness epidemiologically linked to a confirmed case.
Reported pertussis cases in 2010 varied from <100 cases in January to >1000 cases in August. Data on gender, race, ethnicity, and address was examined and "geocoded" for a geographic cluster analysis. A total of 39 geographic clusters of pertussis cases were identified (using SatScan). Two of the largest clusters spanned several months, including a cluster of 880 cases in San Diego County from July to November, and 3,783 cases in Central California from May to October.
This geographic cluster analysis of pertussis cases was then compared with census tract data, and school data for non-medical exemptions for pertussis vaccination. Specifically, medical exemption and non-medical exemptions (NME) for children starting kindergarten between 2005-2010 was collected. ME/NME data is publically available for any public school with 10 or more children. NME exemptions increased from 1.6% during the 2005-2006 school year to 2.4% in the 2009-2010 school year. Clusters of pertussis cases were 2.5 times more likely to occur in area of higher NME. Geographic areas with both clusters of pertussis cases and higher rates of NME were associated with factors suggesting higher socioeconomic status, including higher medium income, lower population density, fewer children within a family, and lower incidence of minorities.
These findings suggest that geographic areas with greater numbers of pertussis cases also have a higher than expected rates of non-medical exemption from vaccination. In other words, it directly points the finger at parents who decline vaccination for their children, as partly responsible for the current resurgence of pertussis in their community. Data suggests that at least 85% of the population must have existing immunity to thwart sustained transmission of diseases like pertussis and measles. Although the process for medical and non-medical exemption from vaccination is apparently more difficult in other states, California requires only a signed form from a parent, indicating non-medical philosophical or religious exemptions in a category called "personal belief exemption". No physician consultation or input is required.