Center for American Indian Health

Baltimore, MD, United States

Center for American Indian Health

Baltimore, MD, United States

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Weinberger D.M.,Harvard University | Harboe Z.B.,Statens Serum Institute | Sanders E.A.M.,University Utrecht | Ndiritu M.,Center for Geographic Medicine Research Coast | And 9 more authors.
Clinical Infectious Diseases | Year: 2010

Background. The 92 capsular serotypes of Streptococcus pneumoniae differ greatly in nasopharyngeal carriage prevalence, invasiveness, and disease incidence. There has been some debate, though, regarding whether serotype independently affects the outcome of invasive pneumococcal disease (IPD). Published studies have shown variable results with regard to case-fatality ratios for specific serotypes and the role of host factors in affecting these relationships. We evaluated whether risk of death due to IPD is a stable serotype-associated property across studies and then compared the pooled effect estimates with epidemiologic and biological correlates. Methods. We performed a systematic review and meta-analysis of serotype-specific disease outcomes for patients with pneumonia and meningitis. Study-specific estimates of risk of death (risk ratio [RR]) were pooled from 9 studies that provided serotype-specific data on pneumonia and meningitis using a random-effects method with serotype 14 as the reference. Pooled RRs were compared with RRs from adults with low comorbidity scores to evaluate potential confounding by host factors. Results. Significant differences were found in the RR estimates among serotypes in patients with bacteremic pneumonia. Overall, serotypes 1, 7F, and 8 were associated with decreased RRs, and serotypes 3, 6A, 6B, 9N, and 19F were associated with increased RRs. Outcomes among meningitis patients did not differ significantly among serotypes. Serotypes with increased RRs had a high carriage prevalence, had low invasiveness, and were more heavily encapsulated in vitro. Conclusions. These results suggest that IPD outcome, like other epidemiologic measures, is a stable serotypeassociated property. © 2010 by the Infectious Diseases Society of America. All rights reserved.


Pollack K.M.,Johns Hopkins Center for Injury Research and Policy | Pollack K.M.,Management Health Solutions | Frattaroli S.,Johns Hopkins Center for Injury Research and Policy | Young J.L.,Johns Hopkins Center for Injury Research and Policy | And 3 more authors.
Epidemiologic Reviews | Year: 2012

In the United States, the American Indian and Alaska Native (AI/AN) population has the highest motor vehicle death rate, which is significantly greater than that of any other race or ethnic group. To better understand why this significant disparity exists and how to eliminate it, the authors conducted a systematic review of the published scientific literature. Included studies were published between January 1, 1990, and January 31, 2011, and identified risk factors, or implemented and tested interventions, targeting motor vehicle deaths among the AI/AN population. Only 14 papers met the study's inclusion criteria. Most of the epidemiologic studies explored alcohol use as a risk factor for deaths of both motor vehicle occupants and pedestrians; few studies addressed risk factors specifically for pedestrians. All of the intervention studies focused on mitigating risks for motor vehicle occupants. On the basis of the authors' review, injury prevention interventions that are multifaceted and involve partnerships to change policy, the environment, and individual behavior can effectively mitigate motor-vehicle-related deaths among AI/ANs. Priority should be given to implementing interventions that address pedestrian safety and to sound investment in the states with the highest AI/AN motor vehicle death rates because reducing their burden can dramatically reduce the overall disparity. © The Author 2011. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved.


Weatherholtz R.,Center for American Indian Health | Millar E.V.,Center for American Indian Health | Moulton L.H.,Center for American Indian Health | Reid R.,Center for American Indian Health | And 5 more authors.
Clinical Infectious Diseases | Year: 2010

Background. Before 7-valent pneumococcal conjugate vaccine (PCV7) introduction, invasive pneumococcal disease (IPD) rates among Navajo were several-fold those of the general US population. Only 50% of IPD cases in children involved PCV7 serotypes. Methods. We conducted active, population-based surveillance for IPD for the period 1995-2006. We documented case characteristics and serotyped the isolates. Results. Over 12-year period, we identified 1508 IPD cases, 447 of which occurred in children aged <5 years. Rates of IPD due to vaccine serotypes among children aged <1 year, 1 to <2 years, and 2 to <5 years decreased from 210, 263, and 51 cases per 100,000 population, respectively in 1995-1997 to 0 cases in 2004-2006 (P<.001). Among adults aged 3=65 years, rates of IPD due to vaccine serotypes decreased 81% (95% confidence interval, -98% to -9%; P = .02). Rates of nonvaccine serotype IPD were unchanged in all age strata except for persons aged 18 to <40 years, among whom the rate decreased by 35% from 27 to 18 cases per 100,000 population (95% confidence interval, -57% to -1%; P = .03). Conclusions. Vaccine-serotype IPD has virtually been eliminated in the PCV7 era among Navajo of all ages. Overall rates of nonvaccine-serotype IPD have not increased, although increases have occurred for some individual types. Rates of all-serotype IPD among Navajo children remain 3-5-fold greater than in the general US population. © 2010 by the Infectious Diseases Society of America. All rights reserved.


Carvalho M.D.G.,Centers for Disease Control and Prevention | Pimenta F.C.,Centers for Disease Control and Prevention | Jackson D.,Centers for Disease Control and Prevention | Roundtree A.,Centers for Disease Control and Prevention | And 6 more authors.
Journal of Clinical Microbiology | Year: 2010

The measurement of pneumococcal carriage in the nasopharyngeal reservoir is subject to potential confounders that include low-density and multiple-strain colonization. To compare different methodologies, we picked a random sampling of 100 nasopharyngeal specimens recovered from infants less than 2 years of age who were previously assessed for pneumococcal carriage and serotypes by a conventional method that used direct plating from the transport/storage medium (50 specimens were culture negative and 50 specimens were culture positive for pneumococci). We used a broth enrichment approach and a conventional PCR approach (with and without broth enrichment) to determine pneumococcal carriage and serotypes, and the results were compared to the initial conventional culture-based results. Additionally, we used a lytA-targeted real-time PCR for pneumococcal detection. Broth enrichment for both the culture-based and the PCR-based methods enhanced the isolation of pneumococci and detection of serotype diversity, with the most effective serotype deduction method being one that used broth enrichment prior to sequential multiplex PCR. Similarly, we also found that broth enrichment followed by the lytA-specific real-time PCR was the most sensitive for the detection of apparent pneumococcal carriage. The broth enrichment, conventional multiplex PCR, and real-time PCR approaches used in this study were effective in detecting pneumococcal carriage in the 50 specimens that were negative by conventional direct plating from transport medium (range of numbers of positive specimens, 8/50 to 22/50 [16 to 44%]), and the three different serotyping approaches that used broth enrichment increased the number of serotype identifications from the 100 specimens (12 to 29 additional serotype identifications to be positive). A PCR-based approach that employed a broth enrichment step appeared to best enhance the detection of mixed serotypes and low-density pneumococcal carriage. Copyright © 2010, American Society for Microbiology. All Rights Reserved.


Eick A.A.,Center for American Indian Health | Eick A.A.,Armed Forces Health Surveillance Center | Uyeki T.M.,Centers for Disease Control and Prevention | Klimov A.,Centers for Disease Control and Prevention | And 4 more authors.
Archives of Pediatrics and Adolescent Medicine | Year: 2011

Objective: To assess the effect of seasonal influenza vaccination during pregnancy on laboratory-confirmed influenza in infants to 6 months of age. Design: Nonrandomized, prospective, observational cohort study. Setting: Navajo and White Mountain Apache Indian reservations, including 6 hospitals on the Navajo reservation and 1 on the White Mountain Apache reservation. Participants: A total of 1169 mother-infant pairs with mothers who delivered an infant during 1 of 3 influenza seasons. Main Exposure: Maternal seasonal influenza vaccination. Main Outcome Measures: In infants, laboratory-confirmed influenza, influenzalike illness (ILI), ILI hospitalization, and influenza hemagglutinin inhibition antibody titers. Results: A total of 1160 mother-infant pairs had serum collected and were included in the analysis. Among infants, 193 (17%) had an ILI hospitalization, 412 (36%) had only an ILI outpatient visit, and 555 (48%) had no ILI episodes. The ILI incidence rate was 7.2 and 6.7 per 1000 person-days for infants born to unvaccinated and vaccinated women, respectively. There was a 41% reduction in the risk of laboratory-confirmed influenza virus infection (relative risk, 0.59; 95% confidence interval, 0.37-0.93) and a 39% reduction in the risk of ILI hospitalization (relative risk, 0.61; 95% confidence interval, 0.45-0.84) for infants born to influenza-vaccinated women compared with infants born to unvaccinated mothers. Infants born to influenza-vaccinated women had significantly higher hemagglutinin inhibition antibody titers at birth and at 2 to 3 months of age than infants of unvaccinated mothers for all 8 influenza virus strains investigated. Conclusions: Maternal influenza vaccination was significantly associated with reduced risk of influenza virus infection and hospitalization for an ILI up to 6 months of age and increased influenza antibody titers in infants through 2 to 3 months of age. ©2011 American Medical Association. All rights reserved.


Cwik M.F.,Center for American Indian Health | Barlow A.,Center for American Indian Health | Goklish N.,Center for American Indian Health | Larzelere-Hinton F.,Center for American Indian Health | And 4 more authors.
American Journal of Public Health | Year: 2014

The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and selfinjurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.


Mehtala J.,Finnish National Institute for Health and Welfare | Antonio M.,Medical Research Council Unit | Kaltoft M.S.,Statens Serum Institute | O'Brien K.L.,Center for American Indian Health | Auranen K.,Finnish National Institute for Health and Welfare
Epidemiology | Year: 2013

BACKGROUND:: Vaccine-induced replacement by nonvaccine serotypes in pneumococcal colonization and disease poses a threat to the long-term effectiveness of pneumococcal vaccination. One of the main drivers for serotype replacement is likely to be the competitive interactions between pneumococcal serotypes. METHODS:: We used longitudinal datasets of pneumococcal colonization among infants (American Indian and The Gambia) and toddlers (Denmark) to study the strength and mechanism of competition between pneumococcal serotypes. We characterized the strength of competition as the relative reduction in the expected time spent colonized with two serotypes (double colonization) as compared with colonization with no competition. We also assessed the mechanism of competition, that is, whether reduction in double colonization is due to reduced rate of acquisition or enhanced clearance of colonization. The three datasets were analyzed assuming both perfect (100%) and imperfect (50%) sensitivity in detection of double colonization. RESULTS:: Each dataset showed strong between-serotype competition, and competition in acquisition was clearly identified. These findings remained in the secondary analysis assuming only 50% sensitivity to detect double colonization. Inferences about enhanced clearance due to competition were susceptible to the assumed sensitivity of detection. CONCLUSIONS:: Strong competition between pneumococcal serotypes can explain the prompt replacement by the nonvaccine serotypes in vaccinated persons and populations. The main mechanism of between-serotype interaction was identified as competition in acquisition, which suggests that replacement in pneumococcal disease depends largely on propensities of the replacing serotypes to cause disease through acquisition of colonization. Copyright © 2013 by Lippincott Williams & Wilkins.


Davis S.M.,International Vaccine Access Center | Deloria-Knoll M.,International Vaccine Access Center | Kassa H.T.,International Vaccine Access Center | O'Brien K.L.,International Vaccine Access Center | O'Brien K.L.,Center for American Indian Health
Vaccine | Year: 2013

Background: Invasive disease due to Streptococcus pneumoniae remains an important worldwide cause of morbidity and mortality, particularly in young children and the elderly. The development and use of pneumococcal conjugate vaccines (PCVs) have had a dramatic impact on rates of vaccine-type invasive pneumococcal disease (IPD) not only in the pediatric population targeted for vaccination but in non-vaccinated age-groups as well. This indirect effect is directly mediated by a reduction of vaccine-type nasopharyngeal carriage and thus transmission by vaccinated children. Current PCV licensing procedures do not take into consideration nasopharyngeal carriage impact, and thus the indirect effect. This review summarizes the evidence for the indirect effect of PCV on vaccine-type disease and its correlation with changes in carriage among unvaccinated populations, to assess the basis for inclusion of carriage in the PCV licensing process. Methods: Randomized controlled trials, surveillance and other observational studies published between 1994 and 2013 were systematically identified from global, regional and review databases and conference abstracts. We included as primary evidence, studies in non-vaccinated groups addressing changes in both vaccine-type IPD and carriage between pre- and post-PCV introduction periods; studies missing one of these four components were included as supporting rather than primary evidence. Results: We identified studies from 14 countries, nearly all developed countries. Vaccine-type IPD and carriage in non-targeted populations consistently decreased after PCV introduction, with the magnitude of decrease growing over time. Where IPD and carriage were observed in the same population, VT-decreases occurred contemporaneously. These relationships held true across age-groups and between indigenous and non-indigenous populations in the US and Australia. Conclusions: Indirect PCV impact on VT-IPD and VT-carriage has been significant. Impact on carriage should be considered for inclusion in the PCV licensure process as a predictor of indirect effects. © 2013.


Harer M.W.,University of Wisconsin - Madison | Yaeger J.P.,Center for American Indian Health
Wisconsin Medical Journal | Year: 2014

Background: Cardiopulmonary resuscitation (CPR) can increase survival in instances of sudden cardiac arrest. Nationally, high school coaches are the first responders to sudden cardiac arrest in up to one-third of high school athlete collapses, but little is known about the status of their CPR certification. The primary goal of this study was to assess the proportion of Wisconsin high school coaches that are certified in CPR. Methods: A prospective web-based survey was developed and distributed to high school athletic directors in Wisconsin. Results: Seventy-eight percent of respondents reported that coaches are the primary responders to a collapse. The majority of high schools do not require CPR certification and only 50% of coaches are currently CPR certified. Athletic directors with greater than 12 years of experience were the most likely to have an emergency action plan in place (P = 0.004). Conclusion: In Wisconsin, the proportion of coaches who act as the primary responder to a collapse is greater than previously reported. Although the majority of coaches in Wisconsin serve as the primary responder to an episode of sudden cardiac arrest, only about 50% are CPR certified. Due to the severe consequences of sudden cardiac arrest, CPR certification among coaches should be required. © 2014 Wisconsin Medical Society.


Goldblatt D.,University College London | Ramakrishnan M.,Independent Consultant | O'Brien K.,Center for American Indian Health
Vaccine | Year: 2013

An international consultation was convened in March 2012 to provide feedback on the Case for Carriage, a summary statement by the Pneumococcal Carriage Consortium (PneumoCarr) proposing nasopharyngeal (NP) colonization as a supplementary or alternative endpoint in vaccine licensure. PneumoCarr members provided information to vaccine manufacturers, regulators and the WHO on the evidence for NP carriage as a precursor to pneumococcal disease, standardization of laboratory methods for the detection of multiple serotype carriage, definition and estimation of pneumococcal vaccine efficacy against carriage (VE-col), and the direct and indirect impact of vaccination on carriage. Manufacturers and regulators had the opportunity to respond to the information compiled by PneumoCarr and share their perspectives. VE-col as a licensure endpoint may be more useful for the next generation pneumococcal vaccine products, particularly those for which the immunological correlate of protection is not established, whereas it may be less needed for pneumococcal conjugate vaccines which have an established licensure pathway. The consultation supported the importance of NP carriage data as a critical element linking vaccine impact on the individual direct risk of disease to the population-level impact: indirect effects such as herd protection and serotype replacement. The indirect effects of vaccination, however, are not currently established as part of the licensure process and to include them would be a paradigm shift for regulatory agencies who currently consider this information in the post-licensure setting. More discussion and consensus-building is needed around the rationale and optimal mechanism to include carriage data in the licensure pathway for new pneumococcal vaccines. The WHO and national advisory groups on immunization policy may have an important role in considering the evidence for the indirect benefit of vaccination as informed by its impact on NP carriage. © 2013 Elsevier Ltd.

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