Publications by authors named "Caroline C Johnson"

25 Publications

  • Page 1 of 1

Adherence to buprenorphine: An analysis of prescription drug monitoring program data.

Drug Alcohol Depend 2020 11 28;216:108317. Epub 2020 Sep 28.

Philadelphia Department of Public Health, Division of Substance Use Prevention and Harm Reduction, 123 S. Broad St., Suite 1120, Philadelphia, PA 19109, USA. Electronic address:

Background: Although buprenorphine is an evidence-based treatment for opioid use disorder (OUD), many individuals discontinue treatment soon after starting. This study assesses predictors of buprenorphine adherence using Prescription Drug Monitoring Program (PDMP) data.

Methods: PDMP data for Philadelphia, Pennsylvania were used to measure 180-day adherence to buprenorphine among new initiates. Adherence was classified using percent days covered (PDC), and new initiates with PDC ≥ 0.80 were classified as adherent. Multivariable logistic regression was conducted to determine factors associated with buprenorphine adherence.

Results: Between January 2017 and December 2018, 10,669 Philadelphia residents initiated buprenorphine and 26.6 % remained adherent after 180 days. Demographic factors associated with greater odds of adherence included age category and female sex (aOR: 1.37; 95 % CI: 1.25-1.50). Those filling an opioid prescription, other than buprenorphine, during the follow-up period had lower odds of adherence than those who did not fill an opioid prescription (aOR: 0.62; 95 % CI: 0.50-0.77). Odds of adherence was greater for those on the film formulation (aOR: 1.37; 95 % CI: 1.25-1.50) than the tablet formulation. Those filling medium (aOR: 1.76; 95 % CI: 1.55-2.00) and high dose (aOR: 5.11; 95 % CI: 4.30-6.17) buprenorphine prescriptions had higher odds of adherence than those filling low dose prescriptions.

Conclusions: Individual demographics, receipt of an opioid prescription, buprenorphine formulation, and buprenorphine dose were all associated with adherence to buprenorphine. Ongoing strategies to address OUD need to prioritize increasing retention in long-term evidence-based buprenorphine treatment while also encouraging providers to regularly consult the PDMP to ensure patient compliance.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108317DOI Listing
November 2020

Correlates of experiencing and witnessing non-fatal opioid overdoses among individuals accessing harm reduction services in Philadelphia, Pennsylvania.

Subst Abus 2020 23;41(3):301-306. Epub 2019 Oct 23.

Philadelphia Department of Public Health, Office of the Health Commissioner, Philadelphia, PA, USA.

: With the dramatic increase in overdose deaths in the United States, layperson overdose education and naloxone distribution (OEND) programs serve a critical role in preventing opioid overdose fatality. This study examines associations for witnessing an opioid overdose or experiencing a non-fatal opioid overdose to identify new opportunities for expansion of OEND programs. : Cross sectional surveys were administered at the sole needle and syringe exchange program in Philadelphia, PA. Bivariate and multivariable logistic regression analyses were conducted to examine associations for witnessing an opioid overdose or experiencing a non-fatal opioid overdose in the previous 12 months. : In total, 370 individuals were identified as using opioids in the previous three months and included in the study. Factors associated with experiencing a non-fatal opioid overdose were unstable housing (aOR: 2.16; 95% CI: 1.12-3.99), recent incarceration (aOR: 2.34; 95% CI: 1.41-3.89), co-use of opioids and benzodiazepines (aOR: 2.04; 95% CI: 1.22-3.41), co-use of heroin and cocaine (aOR: 1.69; 95% CI: 1.04-2.75), drug injection (aOR: 4.25; 95% CI: 1.90-9.54), inpatient detoxification history (aOR: 2.33; 95% CI:1.27-4.43), and witnessing an overdose in the previous 12 months (aOR: 2.51; 95% CI: 1.02-6.13). Factors associated with witnessing an overdose were unstable housing (aOR: 5.14; 95% CI: 2.57-10.28), recent incarceration (aOR: 2.88; 95% CI: 1.24-6.74), and a history of being trained to use naloxone (aOR: 3.39; 95% CI: 1.63-7.04). Findings presented here show characteristics of those most likely to witness an overdose or experience a non-fatal overdose who could be served by expansion of OEND programs.
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http://dx.doi.org/10.1080/08897077.2019.1675115DOI Listing
September 2021

Increased Health and Social Vulnerability Among Hepatitis C Infected Individuals Co-infected with Hepatitis B.

J Health Care Poor Underserved 2018 ;29(4):1269-1280

Hepatitis B (HBV) and hepatitis C (HCV) infections contribute significant morbidity in the United States, particularly among those with a history of incarceration, homeless-ness, and/or co-morbid mental illness. Data from the Philadelphia Department of Public Health's viral hepatitis registry were matched at the person-level to the city's shelter, jail, and mental health system datasets (vulnerability datasets), and descriptive statistics were calculated. Between January 2010 and December 2014, 29,807 cases of HCV and 133 cases of HBV/HCV were reported. Fifty-eight percent of HCV cases and 70% of HBV/HCV cases were found in at least one vulnerability dataset. Compared with HCV cases, HBV/HCV cases were more likely to have a mental health diagnosis and history of incarceration, and to have spent more days in jail, and were less likely to be receiving treatment for HCV. Data are needed to describe more adequately the trajectory of HBV/HCV co-infected individuals to improve health service planning and policy.
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http://dx.doi.org/10.1353/hpu.2018.0094DOI Listing
September 2019

Beyond the walls: Risk factors for overdose mortality following release from the Philadelphia Department of Prisons.

Drug Alcohol Depend 2018 08 5;189:108-115. Epub 2018 Jun 5.

Philadelphia Department of Public Health, Opioid Surveillance, Epidemiology, and Prevention Program, 1101 Market St., Suite 1320, Philadelphia, PA 19107, USA.

Background: High overdose mortality after release from state prison systems is well documented; however, little is known about overdose mortality following release from local criminal justice systems (CJS). The purpose of this study was to assess overdose mortality following release from a local CJS in Philadelphia, PA.

Methods: We conducted a retrospective cohort study of individuals released to the community from a local CJS between 2010 and 2016. Incarceration records were linked to overdose fatality data from the Medical Examiner's Office and death certificate records. All-cause, overdose, and non-overdose mortality were examined.

Results: Of the 82,780 individuals released between 2010 and 2016, 2,522 (3%) died from any cause, of which 837 (33%) succumbed to overdose. Individuals released from incarceration had higher risk of overdose death compared to the non-incarcerated population (Standardized Mortality Ratio [SMR]: 5.29, 95% CI 4.93-5.65), and risk was greatest during the first two weeks following release (SMR: 36.91, 95% CI: 29.92-43.90). Among released individuals, black, non-Hispanic individuals (Hazard Rate [HR]: 0.17, 95% CI: 0.14-0.19) and Hispanic individuals (HR: 0.41, 95% CI: 0.34-0.50) were at lower risk for overdose than white, non-Hispanic individuals. Individuals released with a serious mental illness (SMI) were at higher risk of overdose (HR: 1.54, 95% CI: 1.27-1.87) than those without a SMI.

Discussion: Previously incarcerated individuals are at high risk of overdose death following release from a local CJS, especially in the earliest weeks following release. Prevention measures including behavioral health treatment and referral and take-home naloxone may reduce overdose mortality after release.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.04.034DOI Listing
August 2018

Influence of birth origin and risk factor profile on hepatitis B mortality: Philadelphia, PA 2003-2013.

Ann Epidemiol 2018 03 22;28(3):169-174. Epub 2017 Dec 22.

Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA.

Purpose: Chronic hepatitis B virus (HBV) affects specific subpopulations in the United States, including individuals born in HBV-endemic countries and persons engaging in high-risk behaviors.

Methods: The 2003-2013 HBV registry data and surveillance investigations for Philadelphia, PA were matched to death certificate data to examine demographic, risk factor, and cause of death characteristics among HBV-infected populations. Bivariate analysis compared investigated foreign-born (FB) and US-born chronic HBV individuals. Multivariable logistic regression assessed associations between HBV-status, birth origin, demographic information, and liver-related death.

Results: Of 773 investigated HBV-infected individuals, 159 were US-born and 614 were FB and of primarily non-Hispanic Asian descent. Behavioral risk factors were more often reported by US-born individuals. HBV-infected FB decedents were twice as likely as US-born decedents to have a liver-related cause of death, whereas HIV/AIDS and drug overdose were more likely causes of death among those born in the United States.

Conclusions: There are two HBV-infected populations in Philadelphia: 1) FB individuals most likely infected at birth or during early childhood and 2) US-born individuals with behaviors suggestive of risk-related HBV acquisition. These findings illustrate the need for both FB and US-born individuals with ongoing risk behaviors to receive routine HBV screening, vaccination if indicated, and medical care for outcomes of chronic HBV infection.
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http://dx.doi.org/10.1016/j.annepidem.2017.12.006DOI Listing
March 2018

Risk of Fall-Related Injury due to Adverse Weather Events, Philadelphia, Pennsylvania, 2006-2011.

Public Health Rep 2017 Jul/Aug;132(1_suppl):53S-58S

1 Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA, USA.

Objectives: Following a surge in fall-related visits to local hospital emergency departments (EDs) after a severe ice storm, the Philadelphia Department of Public Health examined the association between inclement winter weather events and fall-related ED visits during a 5-year period.

Methods: Using a standardized set of keywords, we identified fall-related injuries in ED chief complaint logs submitted as part of Philadelphia Department of Public Health's syndromic surveillance from December 2006 through March 2011. We compared days when falls exceeded the winter fall threshold (ie, "high-fall days") with control days within the same winter season. We then conducted matched case-control analysis to identify weather and patient characteristics related to increased fall-related ED visits.

Results: Fifteen high-fall days occurred during winter months in the 5-year period. In multivariable analysis, 18- to 64-year-olds were twice as likely to receive ED care for fall-related injuries on high-fall days than on control days. The crude odds of ED visits occurring from 7:00 am to 10:59 am were 70% higher on high-fall days vs control days. Snow was a predictor of a high-fall day: the adjusted odds of snow before a high-fall day as compared with snow before a control day was 13.4.

Conclusions: The association between the number of fall-related ED visits and weather-related fall injuries, age, and timing suggests that many events occurred en route to work in the morning. Promoting work closures or delaying openings after severe winter weather would allow time for better snow or ice removal, and including "fall risk" in winter weather advisories might effectively warn morning commuters. Both strategies could help reduce the number of weather-related fall injuries.
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http://dx.doi.org/10.1177/0033354917706968DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676509PMC
July 2017

Capture-Recapture: Using Existing Data Sources to Improve Perinatal Hepatitis B Surveillance, Philadelphia, 2008-2014.

Public Health Rep 2017 May/Jun;132(3):376-380. Epub 2017 Apr 13.

1 Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA, USA.

Objective: The objective of this study was to describe the capture-recapture method used by the Philadelphia Department of Public Health to enhance surveillance of perinatal hepatitis B virus (HBV), report on results and limitations of the process, and determine why some HBV-positive mother-infant pairs were not initially identified by Philadelphia's Perinatal Hepatitis B Prevention Program (PHBPP).

Methods: We performed capture-recapture retrospectively for births in 2008 and 2009 in Philadelphia and prospectively for births from 2010 to 2014 by independently matching annual birth certificate data to PHBPP and HBV surveillance data. We compared the number of HBV-positive mother-infant pairs identified each year to the point estimates and lower-limit estimates calculated by the Centers for Disease Control and Prevention for the Philadelphia PHBPP.

Results: Of 156 605 pregnancy outcomes identified between 2008 and 2014, we found 1549 HBV-positive mother-infant pairs. Of 705 pairs that were initially determined, 358 (50.7%) were confirmed to be previously unidentified HBV-positive pairs. Reasons for failing to identify these mother-infant pairs prior to capture-recapture included internal administrative issues (n = 191, 53.4%), HBV testing and reporting issues (n = 92, 25.7%), and being lost to follow-up (n = 75, 20.9%). Each year that capture-recapture was used, the number of pairs identified by the Philadelphia PHBPP exceeded the Centers for Disease Control and Prevention's lower-limit estimates for HBV-positive mother-infant pairs.

Conclusions: Capture-recapture was useful for identifying HBV-positive pregnant women for Philadelphia's PHBPP and for highlighting inadequacies in health department protocols and HBV testing during pregnancy. Other health departments with access to similar data sources and staff members with the necessary technical skills can adapt this method.
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http://dx.doi.org/10.1177/0033354917702851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5415262PMC
June 2017

Starving for a drink: Sexual objectification is associated with food-restricted alcohol consumption among college women, but not among men.

Women Health 2018 02 6;58(2):175-187. Epub 2017 Mar 6.

b Department of Psychology , George Washington University , Washington , DC , USA.

Interpersonal sexual objectification, or being treated as an object by others, is linked to poorer body image and, in turn, engagement in weight management behaviors that promote conformity to unrealistic appearance standards while simultaneously undermining health. Although these associations emerge consistently among women, the evidence has been less clear among men. The present study introduced a novel weight control behavior, food-restricted alcohol consumption (i.e., limiting food intake prior to alcohol consumption), and examined whether sexual objectification was associated with this phenomenon and whether this association differed among women and men. During the fall of 2012 and the spring of 2013, 410 undergraduates reported how often they felt objectified by others and restricted what they ate before drinking alcohol in the past month. Controlling for past drinking, sexual objectification was significantly and positively associated with food-restricted alcohol consumption for women; however, sexual objectification was unrelated to food-restricted alcohol consumption for men. The results suggest that sexual objectification might operate differently across the sexes and particularly be related to this specific health-risk behavior among women.
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http://dx.doi.org/10.1080/03630242.2017.1292342DOI Listing
February 2018

Failure to Test and Identify Perinatally Infected Children Born to Hepatitis C Virus-Infected Women.

Clin Infect Dis 2016 Apr 20;62(8):980-5. Epub 2016 Jan 20.

Division of Disease Control, Philadelphia Department of Public Health, Pennsylvania.

Background: Vertical transmission of hepatitis C virus (HCV) is the most common route of pediatric HCV infection. Approximately 5% of children born to HCV-infected mothers develop chronic infection. Recommendations employ risk-based HCV testing of pregnant women, and screening children at a young age. This study assesses testing rates of children born to mothers tested HCV-positive in a major US city with a high burden of HCV infection.

Methods: HCV surveillance data reported to the Philadelphia Department of Public Health are housed in the Hepatitis Registry. Additional tests, including negative results, were retrospectively collected. HCV data were matched with 2011-2013 birth certificates of children aged ≥20 months to identify mothers tested HCV-positive and screened children. The observed perinatal HCV seropositivity rate was compared to the expected rate (5%).

Results: A total of 8119 females aged 12-54 years tested HCV-positive and in the Hepatitis Registry. Of these, 500 (5%) had delivered ≥1 child, accounting for 537 (1%) of the 55 623 children born in Philadelphia during the study period. Eighty-four (16%) of these children had HCV testing; 4 (1% of the total) were confirmed cases. Twenty-three additional children are expected to have chronic HCV infection, but were not identified by 20 months of age.

Conclusions: These findings illustrate that a significant number of women giving birth in Philadelphia test positive for HCV and that most of their at-risk children remain untested. To successfully identify all HCV-infected children and integrate them into HCV-specific care, practices for HCV screening of pregnant women and their children should be improved.
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http://dx.doi.org/10.1093/cid/ciw026DOI Listing
April 2016

Demographic, risk factor, and provider characteristics associated with confirmatory hepatitis C testing.

Ann Epidemiol 2016 Feb 13;26(2):157-159. Epub 2015 Dec 13.

Philadelphia Department of Public Health, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.annepidem.2015.11.011DOI Listing
February 2016

Influence of Insurance Status and Demographic Features on Recognition of Symptomatic and Asymptomatic Gonorrhea Cases.

Sex Transm Dis 2015 Aug;42(8):419-21

From the Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA.

A random sample of individuals diagnosed as having gonorrhea from 2009 to 2013 were interviewed. Demographic and clinical features for asymptomatic and symptomatic individuals were examined to elucidate trends in medical care. Age, race, and sexually transmitted disease history had no association with the absence of symptoms (e.g., infection found by screening), whereas insurance coverage did for women.
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http://dx.doi.org/10.1097/OLQ.0000000000000308DOI Listing
August 2015

Mental health first aid training for the Bhutanese refugee community in the United States.

Int J Ment Health Syst 2015 9;9:20. Epub 2015 May 9.

Division of General Pediatrics, PolicyLab, The Children's Hospital of Philadelphia, 36th and Market Street, Philadelphia, PA 19104 USA.

Background: The aim of this study was to investigate the impact of Mental Health First Aid (MHFA) training for Bhutanese refugee community leaders in the U.S. We hypothesized that training refugee leaders would improve knowledge of mental health problems and treatment process and decrease negative attitudes towards people with mental illness.

Methods: One hundred and twenty community leaders participated in MHFA training, of whom 58 had sufficient English proficiency to complete pre- and post-tests. The questionnaires assessed each participant's ability to recognize signs of depression, knowledge about professional help and treatment, and attitudes towards people with mental illness.

Results: Between the pre- and post-test, participants showed significant improvement in the recognition of symptoms of depression and expressed beliefs about treatment that became more concordant with those of mental health professionals. However, there was no reduction in negative attitudes towards people with mental illness.

Conclusions: MHFA training course is a promising program for Bhutanese refugee communities in the U.S. However, some adaptations may be necessary to ensure that MHFA training is optimized for this community.
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http://dx.doi.org/10.1186/s13033-015-0012-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4435851PMC
May 2015

Comparison of risk-based hepatitis C screening and the true seroprevalence in an urban prison system.

J Urban Health 2015 Apr;92(2):379-86

Philadelphia Department of Public Health, Division of Disease Control, 500 S. Broad St., Philadelphia, PA, 19146, USA,

Hepatitis C virus (HCV) is the most common blood-borne infection in the USA, though seroprevalence is elevated in certain high-risk groups such as inmates. Correctional facility screening protocols vary from universal testing to opt-in risk-based testing. This project assessed the success of a risk-based HCV screening strategy in the Philadelphia Prison System (PPS) by comparing results from current testing practices during 2011-2012 (Risk-Based Screening Group) to a September 2012 blinded seroprevalence study (Philadelphia Department of Public Health (PDPH) Study Cohort). PPS processed 51,562 inmates in 2011-2012; 2,727 were identified as high-risk and screened for HCV, of whom 57 % tested HCV antibody positive. Twelve percent (n = 154) of the 1,289 inmates in the PDPH Study Cohort were anti-HCV positive. Inmates ≥30 years of age had higher rates of seropositivity in both groups. Since only 5.3 % of the prison population was included in the Risk-Based Screening Group, an additional 4,877 HCV-positive inmates are projected to have not been identified in 2011-2012. Gaps in case identification exist when risk-based testing is utilized by PPS. A more comprehensive screening model such as opt-out universal testing should be considered to identify HCV-positive inmates. Identification of these individuals is an important opportunity to aid underserved high-risk populations and to provide medical care and secondary prevention.
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http://dx.doi.org/10.1007/s11524-015-9945-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411325PMC
April 2015

The continuum of hepatitis C testing and care.

Hepatology 2015 Mar 30;61(3):783-9. Epub 2015 Jan 30.

Philadelphia Department of Public Health, Philadelphia, PA.

Unlabelled: A hepatitis C virus (HCV)-infected person will ideally have access to quality health care and move through the HCV continuum of care (CoC) from HCV antibody (Ab) screening, HCV-RNA confirmation, engagement and retention in medical care, and treatment. Unfortunately, studies show that many patients do not progress through this continuum. Because these studies may not be generalizable, we assessed the HCV CoC in Philadelphia from January 2010 to December 2013 at the population level. The expected HCV seroprevalence in Philadelphia during 2010-2013 was calculated by applying National Health and Nutrition Examination Survey prevalences to age-specific census data approximations and published estimates of homeless and incarcerated populations. HCV laboratory results reported to the Philadelphia Department of Public Health and enhanced surveillance data were used to determine where individuals fell on the continuum. HCV CoC was defined as follows: stage 1: HCV Ab screening; stage 2: HCV Ab and RNA testing; stage 3: RNA confirmation and continuing care; and stage 4: RNA confirmation, care, and HCV treatment. Of approximately 1,584,848 Philadelphia residents, 47,207 (2.9%) were estimated to have HCV. Positive HCV results were received for 13,596 individuals, of whom 6,383 (47%) had a positive HCV-RNA test. Of these, 1,745 (27%) were in care and 956 (15%) had or were currently receiving treatment.

Conclusion: This continuum provides a real-life snapshot of how this disease is being managed in a major U.S. urban center. Many patients are lost at each stage, highlighting the need to raise awareness among health care professionals and at-risk populations about appropriate hepatitis testing, referral, support, and care.
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http://dx.doi.org/10.1002/hep.27584DOI Listing
March 2015

Use of first-line treatment for Neisseria gonorrhoeae after treatment guideline changes.

Sex Transm Dis 2014 Jan;41(1):64-6

From the *Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA; and †Division of STD Prevention, US. Centers for Disease Control and Prevention, Atlanta, GA.

After 2 notices with treatment recommendation changes for Neisseria gonorrhoeae, the Philadelphia Department of Public Health documented medical therapy for 92% (3279/3551) of cases; 3001 (92%) received a recommended therapy. Nonrecommended therapies were documented in 8% of cases. Providers diagnosing 2 or less N. gonorrhoeae cases were more likely to use nonrecommended therapy.
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http://dx.doi.org/10.1097/OLQ.0000000000000061DOI Listing
January 2014

Adolescent sexually transmitted infections and risk for subsequent HIV.

Am J Public Health 2013 Oct 15;103(10):1874-81. Epub 2013 Aug 15.

The authors are with the Philadelphia Department of Public Health, Philadelphia, PA. At the time of the study, Melinda E. Salmon and Andrew De Los Reyes were also with Centers for Disease Control and Prevention, Atlanta, GA.

Objectives: We estimated the risk of HIV associated with sexually transmitted infection (STI) history during adolescence.

Methods: We retrospectively studied a cohort of adolescents (n = 75 273, born in 1985-1993) who participated in the Philadelphia High School STD Screening Program between 2003 and 2010. We matched the cohort to STI and HIV surveillance data sets and death certificates and performed Poisson regression to estimate the association between adolescent STI exposures and subsequent HIV diagnosis.

Results: Compared with individuals reporting no STIs during adolescence, adolescents with STIs had an increased risk for subsequent HIV infection (incidence rate ratio [IRR] for adolescent girls = 2.6; 95% confidence interval [CI] = 1.5, 4.7; IRR for adolescent boys = 2.3; 95% CI = 1.7, 3.1). Risk increased with number of STIs. The risk of subsequent HIV infection was more than 3 times as high among those with multiple gonococcal infections during adolescence as among those with none.

Conclusions: Effective interventions that reduce adolescent STIs are needed to avert future STI and HIV acquisition. Focusing on adolescents with gonococcal infections or multiple STIs might have the greatest impact on future HIV risk.
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http://dx.doi.org/10.2105/AJPH.2013.301463DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780747PMC
October 2013

Knowledge, attitudes, and practices for diagnosing breakthrough varicella in the outpatient setting.

Public Health Rep 2012 Nov-Dec;127(6):585-90

Philadelphia Department of Public Health, Division of Disease Control, Philadelphia, PA, USA.

Objectives: We assessed provider knowledge, attitudes, and practices for the management of breakthrough varicella and identified barriers to implementation of laboratory testing and reporting.

Methods: We surveyed 145 health-care providers (HCPs) from 30 pediatric practices in Philadelphia who did not have a history of laboratory testing for breakthrough varicella. The self-administered survey instrument collected information on clinicians' practices for management of children presenting with rash, infection-control strategies, reporting to public health agencies, and laboratory testing.

Results: Among the 144 HCPs who completed the survey, 73 (51%) had practiced for more than 10 years. While 115 HCPs (80%) would elect to evaluate a child with rash in the office, only 19 (13%) would submit diagnostics. When patients had a known recent exposure to varicella, 84 HCPs (58%) would use laboratory tests: 40% would use direct fluorescent antibody staining on a specimen from a cutaneous lesion, 24% would use polymerase chain reaction on a lesion specimen, 21% would use acute and convalescent serology, and 10% would use other tests. While waiting for test results, 82 HCPs (57%) would advise that the child be kept at home, 39 (27%) would notify the local health department, and 33 (23%) would inform the school nurse.

Conclusion: As varicella becomes increasingly uncommon, laboratory confirmation becomes more critical for appropriate diagnosis, similar to poliomyelitis and measles. Our findings suggest that HCPs need further education regarding laboratory confirmation, containment, and reporting of breakthrough varicella.
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http://dx.doi.org/10.1177/003335491212700608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3461849PMC
January 2013

Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women.

J Adolesc Health 2012 Jul 22;51(1):80-5. Epub 2012 Feb 22.

Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA 19146, USA.

Purpose: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are typically asymptomatic, but, if untreated, can lead to sequelae including pelvic inflammatory disease (PID) and ectopic pregnancy. The objective was to describe trends of these sequelae in Philadelphia after implementing citywide screening in a high-morbidity population (>6% positivity).

Methods: In this ecologic study, which used data from 1996 to 2007, multivariable linear regression analysis was used to assess the association between the number of annual CT/GC screening tests by gender and the number of women aged 14-30 years hospitalized for PID or ectopic pregnancy. A standardized hospitalization database provided the number of admissions with a discharge diagnosis of PID or ectopic pregnancy. Positive CT/GC laboratory results reported by hospitals and emergency departments (EDs) were used as a proxy for outpatient PID.

Results: Between 1996 and 2007, CT/GC screening increased by 188%, whereas declines were noted in hospitalized PID cases (36%, -173 cases), ectopic pregnancy (38%, -119 cases), and ED-diagnosed CT/GC cases (39%, -727 cases). Screening 10,000 females for CT/GC corresponded with 26.1 fewer hospitalized PID cases (95% confidence interval 11.2-41.1), whereas screening 10,000 males corresponded to 10.4 (95% CI: 2.6-18.2) fewer cases. Although male screening was not significantly associated with ectopic pregnancy, screening 10,000 females was associated with 28.6 fewer ectopic pregnancies (95% CI: 7.4-49.8).

Conclusions: This ecologic analysis found a correlation between large-scale CT/GC screening in a high-morbidity population and reductions in hospitalized PID, ectopic pregnancies, and ED-diagnosed CT/GC.
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http://dx.doi.org/10.1016/j.jadohealth.2011.11.002DOI Listing
July 2012

Let the sun shine in: effects of ultraviolet radiation on invasive pneumococcal disease risk in Philadelphia, Pennsylvania.

BMC Infect Dis 2009 Dec 4;9:196. Epub 2009 Dec 4.

Child Health Evaluative Sciences, Research Institute of the Hospital for Sick Children, 123 Edward Street, Toronto M4V 1X6, Canada.

Background: Streptococcus pneumoniae is a common cause of community acquired pneumonia and bacteremia. Excess wintertime mortality related to pneumonia has been noted for over a century, but the seasonality of invasive pneumococcal disease (IPD) has been described relatively recently and is poorly understood. Improved understanding of environmental influence on disease seasonality has taken on new urgency due to global climate change.

Methods: We evaluated 602 cases of IPD reported in Philadelphia County, Pennsylvania, from 2002 to 2007. Poisson regression models incorporating seasonal smoothers were used to identify associations between weekly weather patterns and case counts. Associations between acute (day-to-day) environmental fluctuations and IPD occurrence were evaluated using a case-crossover approach. Effect modification across age and sex strata was explored, and meta-regression models were created using stratum-specific estimates for effect.

Results: IPD incidence was greatest in the wintertime, and spectral decomposition revealed a peak at 51.0 weeks, consistent with annual periodicity. After adjustment for seasonality, yearly increases in reporting, and temperature, weekly incidence was found to be associated with clear-sky UV index (IRR per unit increase in index: 0.70 [95% CI 0.54-0.91]). The effect of UV index was highest among young strata and decreased with age. At shorter time scales, only an association with increases in ambient sulphur oxides was linked to disease risk (OR for highest tertile of exposure 0.75, 95% CI 0.60 to 0.93).

Conclusion: We confirmed the wintertime predominance of IPD in a major urban center. The major predictor of IPD in Philadelphia is extended periods of low UV radiation, which may explain observed wintertime seasonality. The mechanism of action of diminished light exposure on disease occurrence may be due to direct effects on pathogen survival or host immune function via altered 1,25-(OH)2-vitamin-D metabolism. These findings may suggest less diminution in future IPD risk with climate change than would be expected if wintertime seasonality was driven by temperature.
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http://dx.doi.org/10.1186/1471-2334-9-196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797517PMC
December 2009

Going with the flow: legionellosis risk in Toronto, Canada is strongly associated with local watershed hydrology.

Ecohealth 2008 Dec 16;5(4):482-90. Epub 2009 Apr 16.

Research Institute of the Hospital for Sick Children, Toronto, Canada.

Legionella species are increasingly recognized as a cause of both healthcare- and community-acquired pneumonia (so-called "Legionnaire's disease"). These pathogens are ubiquitous in the environment, but environmental factors in the occurrence of sporadic legionellosis remain poorly understood. We analyzed all legionellosis cases identified in the Greater Toronto Area of Ontario from 1978 to 2006, and evaluated seasonal and environmental patterns in legionellosis case occurrence by using both negative binomial models and case-crossover analysis. A total of 837 cases were reported during the study period. After adjusting for seasonal effects, changes in the local watershed, rather than weather, were the strongest contributors to legionellosis risk. A 3.6-fold increase (95% confidence interval (CI), 2.4-5.3) in odds of disease was identified with decreasing watershed levels approximately 4 weeks before case-occurrence. We also found a 33% increase (95% CI, 8-64%) in odds of disease with decreasing lake temperature during the same period and a 34% increase (95% CI, 14-57%) with increasing humidity 5 weeks before case-occurrence. We conclude that local watershed ecology influences the risk of legionellosis, notwithstanding the availability of advanced water treatment capacity in Toronto. Enhancement of risk might occur through direct contamination of water sources or via introduction of micronutrients or commensal organisms into residential and hospital water supplies. These observations suggest testable hypotheses for future empiric studies.
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http://dx.doi.org/10.1007/s10393-009-0218-0DOI Listing
December 2008

Environmental exposures and invasive meningococcal disease: an evaluation of effects on varying time scales.

Am J Epidemiol 2009 Mar 22;169(5):588-95. Epub 2009 Jan 22.

Research Institute of the Hospital for Sick Children, Toronto, Ontario, Canada.

Invasive meningococcal disease (IMD) is an important cause of meningitis and bacteremia worldwide. Seasonal variation in IMD incidence has long been recognized, but mechanisms responsible for this phenomenon remain poorly understood. The authors sought to evaluate the effect of environmental factors on IMD risk in Philadelphia, Pennsylvania, a major urban center. Associations between monthly weather patterns and IMD incidence were evaluated using multivariable Poisson regression models controlling for seasonal oscillation. Short-term weather effects were identified using a case-crossover approach. Both study designs control for seasonal factors that might otherwise confound the relation between environment and IMD. Incidence displayed significant wintertime seasonality (for oscillation, P < 0.001), and Poisson regression identified elevated monthly risk with increasing relative humidity (per 1% increase, incidence rate ratio = 1.04, 95% confidence interval: 1.004, 1.08). Case-crossover methods identified an inverse relation between ultraviolet B radiation index 1-4 days prior to onset and disease risk (odds ratio = 0.54, 95% confidence interval: 0.34, 0.85). Extended periods of high humidity and acute changes in ambient ultraviolet B radiation predict IMD occurrence in Philadelphia. The latter effect may be due to decreased pathogen survival or virulence and may explain the wintertime seasonality of IMD in temperate regions of North America.
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http://dx.doi.org/10.1093/aje/kwn383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640162PMC
March 2009

Screening for Chlamydia trachomatis and Neisseria gonorrhoeae among adolescents in Family Court, Philadelphia, Pennsylvania.

Sex Transm Dis 2008 Nov;35(11 Suppl):S24-7

Philadelphia Department of Public Health, National Center for HIV, Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention, Philadelphia, PA, USA.

Objectives: To evaluate the use of the Family Court System as a venue for screening adolescents, especially males for sexually transmitted diseases (STD).

Goal: To identify, treat, and describe the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infections among adolescents on probation under the jurisdiction of the Family Court System of Philadelphia from April 2004 through December 2006.

Study Design: We analyzed data from the first several years of this program, which offered education and voluntary noninvasive screening for CT and GC to adolescents adjudicated delinquent and placed on probation through the Family Court of Philadelphia.

Results: Between April 1, 2004 and December 31, 2006, 2270 adolescents were counseled about STDs, of whom 1605 voluntarily submitted a urine specimen for STD testing. Among the 1594 unique individuals with a valid test result, 13.9% (44 of 317) of females, 7.0% (90 of 1277) of males, and 8.4% overall (134 of 1594) were found to be positive for either or both STD. In total, treatment was confirmed for 93.3% (84/90) of males and 100% (44/44) of females testing positive.

Conclusions: Noninvasive STD testing was well accepted by adolescents in the Family Court System. Over several years of study, infection rates were found to be persistently high in both males and females. The Family Court is an effective venue to identify and treat adolescent males and females with chlamydia and/or gonorrhea infection.
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http://dx.doi.org/10.1097/OLQ.0b013e318177ec4aDOI Listing
November 2008

Ocular vaccinia infection in laboratory worker, Philadelphia, 2004.

Emerg Infect Dis 2006 Jan;12(1):134-7

Philadelphia Department of Public Health, Philadelphia, Pennsylvania 19146, USA.

We report a case of ocular vaccinia infection in an unvaccinated laboratory worker. The patient was infected by a unique strain used in an experiment performed partly outside a biosafety cabinet. Vaccination should continue to be recommended, but laboratories with unvaccinated workers should also implement more stringent biosafety practices.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291406PMC
http://dx.doi.org/10.3201/eid1201.051126DOI Listing
January 2006

Effect of comparative data feedback on intensive care unit infection rates in a Veterans Administration Hospital Network System.

Am J Infect Control 2003 Nov;31(7):397-404

Department of Medicine, Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.

Background: Infection control surveillance is not performed with standardized methodology within the Veterans Affairs (VA) health system. The purposes of this study were (1) to provide network hospitals with a standardized intensive care unit (ICU) surveillance system developed by the Centers for Disease Control and Prevention (CDC); (2) to compare ICU infection rates in hospitals that receive comparative data with those that do not; and (3) to compare network device-associated infection trends to national trends.

Methods: One VA Medical Center served as the central coordination site where surveillance data were analyzed with CDC's criteria and reported back to the sites. During 1999, the experimental group received risk-adjusted infection rates with national comparative data, and the control group received only risk-adjusted infection rates without comparative data. In 2000, hospitals in both groups received risk-adjusted infection rates accompanied by national data.

Results: In 1999, the device-associated infection rates were significantly higher in the control group compared with the experimental group. In the control group, the device-associated infection rates were significantly higher than the national comparative CDC rates; in the experimental group, the device-associated infection rates were not significantly different from the national comparative CDC rates. In 2000, the control group device-associated infection rates were not significantly different from the experimental group. The observed rates in both groups were not significantly different from the CDC rates.

Conclusions: Study results suggest that infection rate outcomes may be reduced when national comparative data are provided. The study may serve as an infection control surveillance model for VA hospital networks.
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http://dx.doi.org/10.1067/mic.2003.46DOI Listing
November 2003

Outbreak of cyclosporiasis associated with imported raspberries, Philadelphia, Pennsylvania, 2000.

Emerg Infect Dis 2002 Aug;8(8):783-8

Philadelphia Department of Public Health, Philadelphia, Pennsylvania 19146, USA.

An outbreak of cyclosporiasis occurred in attendees of a wedding reception held in Philadelphia, Pennsylvania, on June 10, 2000. In a retrospective cohort study, 54 (68.4%) of the 79 interviewed guests and members of the wedding party met the case definition. The wedding cake, which had a cream filling that included raspberries, was the food item most strongly associated with illness (multivariate relative risk, 5.9; 95% confidence interval, 3.6 to 10.5). Leftover cake was positive for Cyclospora DNA by polymerase chain reaction analyses. Sequencing of the amplified fragments confirmed that the organism was Cyclospora cayetanensis. The year 2000 was the fifth year since 1995 that outbreaks of cyclosporiasis definitely or probably associated with Guatemalan raspberries have occurred in the spring in North America. Additionally, this is the second documented U.S. outbreak, and the first associated with raspberries, for which Cyclospora has been detected in the epidemiologically implicated food item.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2732521PMC
http://dx.doi.org/10.3201/eid0808.020012DOI Listing
August 2002
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