Rana Hajjeh - Academia.edu (original) (raw)

Papers by Rana Hajjeh

Research paper thumbnail of and the National Nosocomial Infections Surveillance System Hospitals

Research paper thumbnail of Outbreak of histoplasmosis among cavers attending the National Speleological Society Annual Convention, Texas, 1994

The American journal of tropical medicine and hygiene

In June 1994, 18 people developed serologically confirmed histoplasmosis following cave explorati... more In June 1994, 18 people developed serologically confirmed histoplasmosis following cave exploration associated with the annual National Speleological Society Convention in Bracketville, Texas. Six others had an undiagnosed illness suspected to be histoplasmosis. Two persons were hospitalized. We conducted a survey of convention attendees and a nested case-control study of those entering caves. We also conducted a histoplasmin skin test survey of a subgroup of the society, the Texas Cavers Association, who were attending a reunion in October 1994. Among the national convention attendees, exposure to two caves was identified as responsible for 22 (92%) of the 24 cases; 12 (75%) of 16 people exploring one cave (Cave A) and 10 (77%) of 13 exploring a separate cave (Cave B) developed acute histoplasmosis. Additional risk-factors included fewer years of caving experience, longer time spent in the caves, and entering a confined crawl space in Cave A. Of 113 participants in the separate ski...

Research paper thumbnail of Rapid enzyme-linked immunosorbent assay for the diagnosis of human brucellosis in surveillance and clinical settings in Egypt

Saudi medical journal

To optimize and standardize an enzyme-linked immunosorbent assay (ELISA) for rapid diagnosis of h... more To optimize and standardize an enzyme-linked immunosorbent assay (ELISA) for rapid diagnosis of human brucellosis in clinical cases identified during a surveillance study for acute febrile illness (AFI). Serum samples from patients presenting with AFI at 13 fever hospitals across Egypt between 1999 and 2003 were kept frozen at NAMRU-3 and used in this study. The assay was evaluated in 5 subject groups: brucellosis cases confirmed by blood culture (group I, n=202) 87% positive by standard tube agglutination test (TA), brucellosis cases exclusively confirmed by TA (group II, n=218), blood cultures from AFI cases positive for bacterial species other than Brucella (group III, n=103), AFI cases with unexplained etiologies (group IV, n=654), and healthy volunteers (group V, n=50). All members of groups III-V were negative for brucellosis by TA. Sensitivity and specificity of ELISA for total specific antibodies were >=96% versus 87% for TA as compared to microbial culture, the current g...

Research paper thumbnail of Risk Factors for Candidemia among Preterm Infants

Candidemia causes substantial morbidity and mortality in preterm infants. Recent surveillance rev... more Candidemia causes substantial morbidity and mortality in preterm infants. Recent surveillance revealed an extremely high rate of candidemia among black neonates (960/100,000 population) compared to the general population (10/100,000 pop.). We performed a matched case-control study to identify additional risk factors for candidemia in preterm infants. Cases were identified through active, population-based surveillance for candidemia, conducted in Baltimore City and County during 1998-2000, and were defined as the incident isolation of any Candida spp. from the bloodstream of an infant ≤3 months old. Four controls, matched by age, birthweight, and duration of hospitalization, were selected for each case. Clinical and demographic information was collected, in addition to maternal prenatal data. A total of 35 cases and 138 matched controls were enrolled, with their respective mothers (173). Cases and controls were comparable by race (83% and 75% black). Mean birthweight was 1039 grams (...

Research paper thumbnail of Lack of Correlation of Amphotericin B (AmB) MICs with Clinical Outcome in Candida Bloodstream Infections

Background There are currently no established breakpoints for AmB resistance among Candida isolat... more Background There are currently no established breakpoints for AmB resistance among Candida isolates. Furthermore, limited data exist on correlations between clinical outcome of patients with candidemia and in vitro susceptibility to AmB. We attempted to assess such a correlation by using data from population-based surveillance, conducted in MD and CT in 1998-2000. Methods We defined poor clinical outcome as death at ≤ 14 days after diagnosis of candidemia. MICs were determined by E test and M27A broth microdilution. MFCs were also measured. Candida isolates were defined as &lsquotdbl;resistant&rsquotdbl; to AmB if Etest MIC was ≥0.38 µg/ml, the M27 MIC was ≥2 μg/ml, or the MFC was ≥2 μg/ml. Multivariable forward, backward, and stepwise logistic regression was performed with variables that were significant at p<0.1 on univariate analysis. Results We identified 100 patients who were treated only with AmB or a lipid formulation for ≥7 days. Median age was 37 years (range 0-85), with...

Research paper thumbnail of Epidemiology of Candida Infections in the Intensive Care Unit

Perspectives on Critical Care Infectious Diseases, 2002

Over the last two decades, the incidence of many fungal diseases in the United States has increas... more Over the last two decades, the incidence of many fungal diseases in the United States has increased dramatically, mostly due to major advances in health care, as well as various demographic changes. These include aging of the population, the HIV epidemic, and the ...

Research paper thumbnail of Vaccines to prevent pneumonia and improve child survival

Bulletin of the World Health Organisation

For more than 30 years, vaccines have played an important part in pneumonia prevention. Recent ad... more For more than 30 years, vaccines have played an important part in pneumonia prevention. Recent advances have created opportunities for further improving child survival through prevention of childhood pneumonia by vaccination. Maximizing routine immunization with pertussis and measles vaccines, coupled with provision of a second opportunity for measles immunization, has rapidly reduced childhood deaths in low-income countries especially in sub-Saharan Africa. Vaccines against the two leading bacterial causes of child pneumonia deaths, Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (pneumococcus), can further improve child survival by preventing about 1,075,000 child deaths per year. Both Hib and pneumococcal conjugate vaccines have proven safety and effectiveness for prevention of radiologically confirmed pneumonia in children, including in low-income and industrializing countries. Both are recommended by WHO for inclusion in national programmes, and, at sharply tie...

Research paper thumbnail of Evidence-based decision-making for vaccine introductions: Overview of the ProVac International Working Group's experience

Research paper thumbnail of Cost-effectiveness analysis of the introduction of the human papillomavirus vaccine in Honduras

Vaccine, 2015

Cervical cancer is the leading cause of cancer deaths in Honduras. With the availability of a vac... more Cervical cancer is the leading cause of cancer deaths in Honduras. With the availability of a vaccine to prevent human papillomavirus (HPV), the causative agent for cervical cancer, the Honduran Secretary of Health undertook a cost-effectiveness analysis of introducing the HPV vaccine to support their national decision-making process. A national multidisciplinary team conducted this analysis with the CERVIVAC model, developed by the London School of Hygiene and Tropical Medicine in collaboration with the Pan American Health Organization&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s ProVac Initiative. The cumulative costs and health benefits of introducing the HPV vaccine were assessed over the lifetime of one single cohort of 11-year-old girls. We assumed a three-dose series with 95% vaccination coverage of the cohort using a mixture of school-based and facility-based delivery. To estimate national cervical cancer cases and deaths, we used United Nations demographic projections and GLOBOCAN estimates based on registry data from El Salvador, Guatemala, and Nicaragua. Based on estimates from the World Health Organization (WHO) and the Division of Intensified Cooperation with Countries (ICO), we assumed that 70% of cervical cancer would be due to vaccine types HPV16 and HPV18. We used a vaccine dose price of US$ 13.45 and evidence from the scientific literature to estimate vaccine effectiveness. National information was used to estimate health service utilization and costs of cervical cancer treatment. All costs and health benefits were discounted at 3%. Upon fully vaccinating 86,906 11-year old girls, 2250 (undiscounted) cervical cancer cases and 1336 (undiscounted) deaths would be prevented over the lifetime of the cohort. After discounting future health benefits at 3% per year, the equivalent cases and deaths prevented were 421 and 170. HPV vaccination is estimated to cost around US$ 5 million per vaccinated cohort, but this would be offset by around US$ 1 million in avoided costs borne by the government to treat cervical cancer. Furthermore, 4349 discounted disability adjusted life years (DALYs) could be avoided at a cost of US$ 926 per DALY avoided, making HPV vaccination in Honduras a highly cost-effective intervention. The net cost of HPV vaccination per DALY avoided is less than the WHO threshold for cost-effectiveness. However, at a cost of around US$ 5 million per vaccinated cohort, an important element to consider in this discussion is the budgetary implications that the introduction of the HPV vaccine would cause for the country. When comparing the costs and benefits of HPV vaccine introduction in Honduras, it is clear that this intervention would be highly cost-effective and that the intervention would greatly reduce cervical cancer disease. For these reasons, it is in the country&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s best interest to explore financing opportunities that could support the vaccine&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s introduction.

Research paper thumbnail of Cryptococcosis in Gauteng: implications for monitoring of HIV treatment programmes

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2008

Abstract: South African government authorities and non-governmental organisations have difficulty... more Abstract: South African government authorities and non-governmental organisations have difficulty measuring the burden of disease due to HIV/AIDS, or obtaining objective evidence for effectiveness of interventions such as antiretroviral therapy (ART) to mitigate its impacts.

Research paper thumbnail of Global invasive bacterial vaccine-preventable diseases surveillance--2008-2014

MMWR. Morbidity and mortality weekly report, Jan 12, 2014

Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infec... more Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infected with Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis, and Haemophilus influenzae causing a large proportion of disease. Vaccines are available to prevent many of the common types of these infections. S. pneumoniae was estimated to have caused 11% of deaths in children aged <5 years globally in the pre-pneumococcal conjugate vaccine (PCV) era. Since 2007, the World Health Organization (WHO) has recommended inclusion of PCV in childhood immunization programs worldwide, especially in countries with high child mortality. As of November 26, 2014, a total of 112 (58%) of all 194 WHO member states and 44 (58%) of the 76 member states ever eligible for support from Gavi, the Vaccine Alliance (Gavi), have introduced PCV. Invasive pneumococcal disease (IPD) surveillance that includes data on serotypes, along with meningitis and pneumonia syndromic surveillance, provides impo...

Research paper thumbnail of enthusiasm for the intervention

Research paper thumbnail of A large outbreak of histoplasmosis among American travelers associated with a hotel in Acapulco, Mexico, spring 2001

The American journal of tropical medicine and hygiene, 2003

During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illn... more During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illness after returning from spring break vacation in Acapulco, Mexico. Acute pulmonary histoplasmosis was presumptively diagnosed and the cluster of illness was reported to the Centers of Disease Control and Prevention. A large investigation then ensued, which included finding student-travelers for interviews and requesting sera for histoplasmosis testing. We defined a clinical case by fever and at least one of the following: cough, shortness of breath, chest pain, or headache, in an Acapulco traveler during March-May 2001. A laboratory-confirmed case had positive serology. An initial study determined that the likely site of histoplasmosis exposure was Hotel H; we therefore performed a large cohort study among travelers who stayed at Hotel H. Of 757 contacted, 262 (36%) met the clinical case definition. Of 273 serum specimens tested, 148 (54%) were positive. Frequent use of Hotel H's st...

Research paper thumbnail of A Large Histoplasmosis Outbreak Among High School Students in Indiana, 2001

The Pediatric Infectious Disease Journal, 2004

Methods: To describe the risk factors for this outbreak, we conducted a cohort study of all avail... more Methods: To describe the risk factors for this outbreak, we conducted a cohort study of all available students and staff (N ϭ 682) and an environmental investigation. Results: Of the 523 (77%) persons who displayed serologic evidence of recent Histoplasma capsulatum infection, 355 (68%) developed symptoms consistent with acute pulmonary histoplasmosis. Rototilling of soil in a school courtyard known to be a bird roosting site had been performed during school hours on November 12, 2001, 14 days before both the peak of the onset of illness and a rise in student absenteeism. Being a student (odds ratio, 3.3; 95% confidence interval, 2.2-5.0) and being a student in a classroom near the courtyard during the rototilling (odds ratio, 3.1; 95% confidence interval, 1.8 -5.2) were independently associated with infection and symptomatic illness. H. capsulatum was isolated from environmental samples, including soil from the courtyard and dust collected from a filter of a heating, ventilating and air-conditioning system. Conclusions: Soil-disrupting activities within a school courtyard caused the largest outbreak to date of histoplasmosis among adolescents. Improved efforts are needed to educate the community in endemic areas about histoplasmosis to prevent the occurrence of such outbreaks in the future. In addition, increased awareness among health care providers of this disease would facilitate appropriate diagnosis and treatment.

Research paper thumbnail of The epidemiology of pneumococcal, meningococcal, and Haemophilus disease in the Middle East and North Africa (MENA) Region—Current status and needs

Vaccine, 2007

Information about the burden and epidemiological characteristics of meningitis and other invasive... more Information about the burden and epidemiological characteristics of meningitis and other invasive disease caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis is of great value to healthcare decision makers to prioritize public health interventions. A group of regional experts in the Eastern Mediterranean and North African regions formed the MENA Vaccine-Preventable Diseases Regional Advisory Group to collate and discuss such information on an annual basis. This paper provides an up-to-date summary of the available epidemiological data regarding these pathogens in these regions. In doing so, it highlights the need for additional surveillance studies to better measure the burden of these diseases, as well as the potential impact of introduction of new vaccines against these pathogens. Published by Elsevier Ltd.

Research paper thumbnail of Haemophilus influenzae type b disease in HIV-infected children: A review of the disease epidemiology and effectiveness of Hib conjugate vaccines

Vaccine, 2010

The paper reviews the literature on the epidemiology of Hib disease and the effectiveness of Hib ... more The paper reviews the literature on the epidemiology of Hib disease and the effectiveness of Hib conjugate vaccine (HibCV) in HIV-infected children. The current three-dose primary Hib conjugate vaccine schedule in low-income settings has had a striking impact on the incidence of Hib disease. However, HIV-infected children have an almost 6-fold higher risk of Haemophilus influenzae type b (Hib) invasive disease than HIV-uninfected children and HibCV effectiveness is lower in this population. HIV-related HibCV failures are difficult to detect without well functioning surveillance systems and HIV testing of cases. Breakthrough Hib cases have been noted in vaccinated HIV-infected children in South Africa. A HibCV booster dose in addition to the three-dose primary schedule is routine in many, but not all, high-income countries. In order to determine whether a booster dose should be given to HIV-infected children in developing countries, well-designed studies need to be conducted to better determine the persistence of protective antibody concentrations, response to booster doses of vaccine as well as timing of and risk factors for vaccine failure in HIV-infected children both treated and naive to antiretroviral drug therapy (ART). Meanwhile, physicians and public health personnel should be especially vigilant at ensuring that HIV-infected infants receive their primary doses of HibCV, ART and co-trimoxazole prophylaxis. Until more definitive evidence is available, physicians may also need to consider a booster dose for such children irrespective of ART status. In any updating of vaccine schedules, HIV-infected children need particular consideration.

Research paper thumbnail of Supporting new vaccine introduction decisions: Lessons learned from the Hib Initiative experience

Vaccine, 2010

The introduction of Haemophilus influenzae type b (Hib) vaccine in developing countries has suffe... more The introduction of Haemophilus influenzae type b (Hib) vaccine in developing countries has suffered from a long delay. Between 2005 and 2009, a surge in Hib vaccine adoption took place, particularly among GAVIeligible countries. Several factors contributed to the increase in Hib vaccine adoption, including support provided by the Hib Initiative, a project funded by the GAVI Alliance in 2005 to accelerate evidenceinformed decisions for use of Hib vaccine. This paper reviews the strategy adopted by the Hib Initiative and the lessons learned in the process, which provide a useful model to accelerate uptake of other new vaccines.

Research paper thumbnail of TRIVAC decision-support model for evaluating the cost-effectiveness of Haemophilus influenzae type b, pneumococcal and rotavirus vaccination

Vaccine, 2013

The TRIVAC decision support model has been used widely in Latin America and other regions to help... more The TRIVAC decision support model has been used widely in Latin America and other regions to help national teams evaluate the cost-effectiveness of Haemophilus influenzae type b (Hib) vaccine, pneumococcal conjugate vaccine (PCV) and rotavirus vaccine (RV). We describe the structure and functioning of this model, and identify the parameters with the greatest influence on the results.

Research paper thumbnail of Global use of Haemophilus influenzae type b conjugate vaccine

Vaccine, 2010

Haemophilus influenzae type b (Hib) conjugate vaccines have been underutilized globally. We repor... more Haemophilus influenzae type b (Hib) conjugate vaccines have been underutilized globally. We report progress in global use of Hib vaccines included in national immunization schedules. The number of countries using Hib vaccine increased from 89/193 (46%) in 2004 to 158/193 (82%) by the end of 2009. The increase was greatest among low-income countries eligible for financial support from the GAVI Alliance [13/75 (17%) in 2004, 60/72 (83%) by the end of 2009], and can be attributed to various factors. Additional efforts are still needed to increase vaccine adoption in lower middle income countries [20/31 (65%) by the end of 2009].

Research paper thumbnail of Outbreak of invasive aspergillosis among renal transplant recipients

Transplantation, 2003

Invasive aspergillosis (IA) is rare among renal transplant recipients (RTRs). We investigated a c... more Invasive aspergillosis (IA) is rare among renal transplant recipients (RTRs). We investigated a cluster of IA among RTRs at a California hospital from January to February 2001, when construction was ongoing. We conducted a cohort study among RTRs who were hospitalized between January 1 and February 5, 2001, to determine risk factors for IA. IA was defined using established guidelines. Four IA cases occurred among 40 RTRs hospitalized during the study period. Factors associated with an increased risk of IA included prolonged hemodialysis, lengthy corticosteroid treatment posttransplant, and use of sirolimus alone or with mycophenolate (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). After the study period, three additional RTRs developed IA; two Aspergillus isolates recovered from these patients had indistinguishable profiles by DNA fingerprinting, suggesting common-source exposure. This study suggests that immunosuppressed RTRs can be at an increased risk for IA. Measures to prevent IA in these patients should be taken during hospital construction.

Research paper thumbnail of and the National Nosocomial Infections Surveillance System Hospitals

Research paper thumbnail of Outbreak of histoplasmosis among cavers attending the National Speleological Society Annual Convention, Texas, 1994

The American journal of tropical medicine and hygiene

In June 1994, 18 people developed serologically confirmed histoplasmosis following cave explorati... more In June 1994, 18 people developed serologically confirmed histoplasmosis following cave exploration associated with the annual National Speleological Society Convention in Bracketville, Texas. Six others had an undiagnosed illness suspected to be histoplasmosis. Two persons were hospitalized. We conducted a survey of convention attendees and a nested case-control study of those entering caves. We also conducted a histoplasmin skin test survey of a subgroup of the society, the Texas Cavers Association, who were attending a reunion in October 1994. Among the national convention attendees, exposure to two caves was identified as responsible for 22 (92%) of the 24 cases; 12 (75%) of 16 people exploring one cave (Cave A) and 10 (77%) of 13 exploring a separate cave (Cave B) developed acute histoplasmosis. Additional risk-factors included fewer years of caving experience, longer time spent in the caves, and entering a confined crawl space in Cave A. Of 113 participants in the separate ski...

Research paper thumbnail of Rapid enzyme-linked immunosorbent assay for the diagnosis of human brucellosis in surveillance and clinical settings in Egypt

Saudi medical journal

To optimize and standardize an enzyme-linked immunosorbent assay (ELISA) for rapid diagnosis of h... more To optimize and standardize an enzyme-linked immunosorbent assay (ELISA) for rapid diagnosis of human brucellosis in clinical cases identified during a surveillance study for acute febrile illness (AFI). Serum samples from patients presenting with AFI at 13 fever hospitals across Egypt between 1999 and 2003 were kept frozen at NAMRU-3 and used in this study. The assay was evaluated in 5 subject groups: brucellosis cases confirmed by blood culture (group I, n=202) 87% positive by standard tube agglutination test (TA), brucellosis cases exclusively confirmed by TA (group II, n=218), blood cultures from AFI cases positive for bacterial species other than Brucella (group III, n=103), AFI cases with unexplained etiologies (group IV, n=654), and healthy volunteers (group V, n=50). All members of groups III-V were negative for brucellosis by TA. Sensitivity and specificity of ELISA for total specific antibodies were >=96% versus 87% for TA as compared to microbial culture, the current g...

Research paper thumbnail of Risk Factors for Candidemia among Preterm Infants

Candidemia causes substantial morbidity and mortality in preterm infants. Recent surveillance rev... more Candidemia causes substantial morbidity and mortality in preterm infants. Recent surveillance revealed an extremely high rate of candidemia among black neonates (960/100,000 population) compared to the general population (10/100,000 pop.). We performed a matched case-control study to identify additional risk factors for candidemia in preterm infants. Cases were identified through active, population-based surveillance for candidemia, conducted in Baltimore City and County during 1998-2000, and were defined as the incident isolation of any Candida spp. from the bloodstream of an infant ≤3 months old. Four controls, matched by age, birthweight, and duration of hospitalization, were selected for each case. Clinical and demographic information was collected, in addition to maternal prenatal data. A total of 35 cases and 138 matched controls were enrolled, with their respective mothers (173). Cases and controls were comparable by race (83% and 75% black). Mean birthweight was 1039 grams (...

Research paper thumbnail of Lack of Correlation of Amphotericin B (AmB) MICs with Clinical Outcome in Candida Bloodstream Infections

Background There are currently no established breakpoints for AmB resistance among Candida isolat... more Background There are currently no established breakpoints for AmB resistance among Candida isolates. Furthermore, limited data exist on correlations between clinical outcome of patients with candidemia and in vitro susceptibility to AmB. We attempted to assess such a correlation by using data from population-based surveillance, conducted in MD and CT in 1998-2000. Methods We defined poor clinical outcome as death at ≤ 14 days after diagnosis of candidemia. MICs were determined by E test and M27A broth microdilution. MFCs were also measured. Candida isolates were defined as &lsquotdbl;resistant&rsquotdbl; to AmB if Etest MIC was ≥0.38 µg/ml, the M27 MIC was ≥2 μg/ml, or the MFC was ≥2 μg/ml. Multivariable forward, backward, and stepwise logistic regression was performed with variables that were significant at p<0.1 on univariate analysis. Results We identified 100 patients who were treated only with AmB or a lipid formulation for ≥7 days. Median age was 37 years (range 0-85), with...

Research paper thumbnail of Epidemiology of Candida Infections in the Intensive Care Unit

Perspectives on Critical Care Infectious Diseases, 2002

Over the last two decades, the incidence of many fungal diseases in the United States has increas... more Over the last two decades, the incidence of many fungal diseases in the United States has increased dramatically, mostly due to major advances in health care, as well as various demographic changes. These include aging of the population, the HIV epidemic, and the ...

Research paper thumbnail of Vaccines to prevent pneumonia and improve child survival

Bulletin of the World Health Organisation

For more than 30 years, vaccines have played an important part in pneumonia prevention. Recent ad... more For more than 30 years, vaccines have played an important part in pneumonia prevention. Recent advances have created opportunities for further improving child survival through prevention of childhood pneumonia by vaccination. Maximizing routine immunization with pertussis and measles vaccines, coupled with provision of a second opportunity for measles immunization, has rapidly reduced childhood deaths in low-income countries especially in sub-Saharan Africa. Vaccines against the two leading bacterial causes of child pneumonia deaths, Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (pneumococcus), can further improve child survival by preventing about 1,075,000 child deaths per year. Both Hib and pneumococcal conjugate vaccines have proven safety and effectiveness for prevention of radiologically confirmed pneumonia in children, including in low-income and industrializing countries. Both are recommended by WHO for inclusion in national programmes, and, at sharply tie...

Research paper thumbnail of Evidence-based decision-making for vaccine introductions: Overview of the ProVac International Working Group's experience

Research paper thumbnail of Cost-effectiveness analysis of the introduction of the human papillomavirus vaccine in Honduras

Vaccine, 2015

Cervical cancer is the leading cause of cancer deaths in Honduras. With the availability of a vac... more Cervical cancer is the leading cause of cancer deaths in Honduras. With the availability of a vaccine to prevent human papillomavirus (HPV), the causative agent for cervical cancer, the Honduran Secretary of Health undertook a cost-effectiveness analysis of introducing the HPV vaccine to support their national decision-making process. A national multidisciplinary team conducted this analysis with the CERVIVAC model, developed by the London School of Hygiene and Tropical Medicine in collaboration with the Pan American Health Organization&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s ProVac Initiative. The cumulative costs and health benefits of introducing the HPV vaccine were assessed over the lifetime of one single cohort of 11-year-old girls. We assumed a three-dose series with 95% vaccination coverage of the cohort using a mixture of school-based and facility-based delivery. To estimate national cervical cancer cases and deaths, we used United Nations demographic projections and GLOBOCAN estimates based on registry data from El Salvador, Guatemala, and Nicaragua. Based on estimates from the World Health Organization (WHO) and the Division of Intensified Cooperation with Countries (ICO), we assumed that 70% of cervical cancer would be due to vaccine types HPV16 and HPV18. We used a vaccine dose price of US$ 13.45 and evidence from the scientific literature to estimate vaccine effectiveness. National information was used to estimate health service utilization and costs of cervical cancer treatment. All costs and health benefits were discounted at 3%. Upon fully vaccinating 86,906 11-year old girls, 2250 (undiscounted) cervical cancer cases and 1336 (undiscounted) deaths would be prevented over the lifetime of the cohort. After discounting future health benefits at 3% per year, the equivalent cases and deaths prevented were 421 and 170. HPV vaccination is estimated to cost around US$ 5 million per vaccinated cohort, but this would be offset by around US$ 1 million in avoided costs borne by the government to treat cervical cancer. Furthermore, 4349 discounted disability adjusted life years (DALYs) could be avoided at a cost of US$ 926 per DALY avoided, making HPV vaccination in Honduras a highly cost-effective intervention. The net cost of HPV vaccination per DALY avoided is less than the WHO threshold for cost-effectiveness. However, at a cost of around US$ 5 million per vaccinated cohort, an important element to consider in this discussion is the budgetary implications that the introduction of the HPV vaccine would cause for the country. When comparing the costs and benefits of HPV vaccine introduction in Honduras, it is clear that this intervention would be highly cost-effective and that the intervention would greatly reduce cervical cancer disease. For these reasons, it is in the country&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s best interest to explore financing opportunities that could support the vaccine&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s introduction.

Research paper thumbnail of Cryptococcosis in Gauteng: implications for monitoring of HIV treatment programmes

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde, 2008

Abstract: South African government authorities and non-governmental organisations have difficulty... more Abstract: South African government authorities and non-governmental organisations have difficulty measuring the burden of disease due to HIV/AIDS, or obtaining objective evidence for effectiveness of interventions such as antiretroviral therapy (ART) to mitigate its impacts.

Research paper thumbnail of Global invasive bacterial vaccine-preventable diseases surveillance--2008-2014

MMWR. Morbidity and mortality weekly report, Jan 12, 2014

Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infec... more Meningitis and pneumonia are leading causes of morbidity and mortality in children globally infected with Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis, and Haemophilus influenzae causing a large proportion of disease. Vaccines are available to prevent many of the common types of these infections. S. pneumoniae was estimated to have caused 11% of deaths in children aged <5 years globally in the pre-pneumococcal conjugate vaccine (PCV) era. Since 2007, the World Health Organization (WHO) has recommended inclusion of PCV in childhood immunization programs worldwide, especially in countries with high child mortality. As of November 26, 2014, a total of 112 (58%) of all 194 WHO member states and 44 (58%) of the 76 member states ever eligible for support from Gavi, the Vaccine Alliance (Gavi), have introduced PCV. Invasive pneumococcal disease (IPD) surveillance that includes data on serotypes, along with meningitis and pneumonia syndromic surveillance, provides impo...

Research paper thumbnail of enthusiasm for the intervention

Research paper thumbnail of A large outbreak of histoplasmosis among American travelers associated with a hotel in Acapulco, Mexico, spring 2001

The American journal of tropical medicine and hygiene, 2003

During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illn... more During spring 2001, college students from Pennsylvania reported an acute febrile respiratory illness after returning from spring break vacation in Acapulco, Mexico. Acute pulmonary histoplasmosis was presumptively diagnosed and the cluster of illness was reported to the Centers of Disease Control and Prevention. A large investigation then ensued, which included finding student-travelers for interviews and requesting sera for histoplasmosis testing. We defined a clinical case by fever and at least one of the following: cough, shortness of breath, chest pain, or headache, in an Acapulco traveler during March-May 2001. A laboratory-confirmed case had positive serology. An initial study determined that the likely site of histoplasmosis exposure was Hotel H; we therefore performed a large cohort study among travelers who stayed at Hotel H. Of 757 contacted, 262 (36%) met the clinical case definition. Of 273 serum specimens tested, 148 (54%) were positive. Frequent use of Hotel H's st...

Research paper thumbnail of A Large Histoplasmosis Outbreak Among High School Students in Indiana, 2001

The Pediatric Infectious Disease Journal, 2004

Methods: To describe the risk factors for this outbreak, we conducted a cohort study of all avail... more Methods: To describe the risk factors for this outbreak, we conducted a cohort study of all available students and staff (N ϭ 682) and an environmental investigation. Results: Of the 523 (77%) persons who displayed serologic evidence of recent Histoplasma capsulatum infection, 355 (68%) developed symptoms consistent with acute pulmonary histoplasmosis. Rototilling of soil in a school courtyard known to be a bird roosting site had been performed during school hours on November 12, 2001, 14 days before both the peak of the onset of illness and a rise in student absenteeism. Being a student (odds ratio, 3.3; 95% confidence interval, 2.2-5.0) and being a student in a classroom near the courtyard during the rototilling (odds ratio, 3.1; 95% confidence interval, 1.8 -5.2) were independently associated with infection and symptomatic illness. H. capsulatum was isolated from environmental samples, including soil from the courtyard and dust collected from a filter of a heating, ventilating and air-conditioning system. Conclusions: Soil-disrupting activities within a school courtyard caused the largest outbreak to date of histoplasmosis among adolescents. Improved efforts are needed to educate the community in endemic areas about histoplasmosis to prevent the occurrence of such outbreaks in the future. In addition, increased awareness among health care providers of this disease would facilitate appropriate diagnosis and treatment.

Research paper thumbnail of The epidemiology of pneumococcal, meningococcal, and Haemophilus disease in the Middle East and North Africa (MENA) Region—Current status and needs

Vaccine, 2007

Information about the burden and epidemiological characteristics of meningitis and other invasive... more Information about the burden and epidemiological characteristics of meningitis and other invasive disease caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis is of great value to healthcare decision makers to prioritize public health interventions. A group of regional experts in the Eastern Mediterranean and North African regions formed the MENA Vaccine-Preventable Diseases Regional Advisory Group to collate and discuss such information on an annual basis. This paper provides an up-to-date summary of the available epidemiological data regarding these pathogens in these regions. In doing so, it highlights the need for additional surveillance studies to better measure the burden of these diseases, as well as the potential impact of introduction of new vaccines against these pathogens. Published by Elsevier Ltd.

Research paper thumbnail of Haemophilus influenzae type b disease in HIV-infected children: A review of the disease epidemiology and effectiveness of Hib conjugate vaccines

Vaccine, 2010

The paper reviews the literature on the epidemiology of Hib disease and the effectiveness of Hib ... more The paper reviews the literature on the epidemiology of Hib disease and the effectiveness of Hib conjugate vaccine (HibCV) in HIV-infected children. The current three-dose primary Hib conjugate vaccine schedule in low-income settings has had a striking impact on the incidence of Hib disease. However, HIV-infected children have an almost 6-fold higher risk of Haemophilus influenzae type b (Hib) invasive disease than HIV-uninfected children and HibCV effectiveness is lower in this population. HIV-related HibCV failures are difficult to detect without well functioning surveillance systems and HIV testing of cases. Breakthrough Hib cases have been noted in vaccinated HIV-infected children in South Africa. A HibCV booster dose in addition to the three-dose primary schedule is routine in many, but not all, high-income countries. In order to determine whether a booster dose should be given to HIV-infected children in developing countries, well-designed studies need to be conducted to better determine the persistence of protective antibody concentrations, response to booster doses of vaccine as well as timing of and risk factors for vaccine failure in HIV-infected children both treated and naive to antiretroviral drug therapy (ART). Meanwhile, physicians and public health personnel should be especially vigilant at ensuring that HIV-infected infants receive their primary doses of HibCV, ART and co-trimoxazole prophylaxis. Until more definitive evidence is available, physicians may also need to consider a booster dose for such children irrespective of ART status. In any updating of vaccine schedules, HIV-infected children need particular consideration.

Research paper thumbnail of Supporting new vaccine introduction decisions: Lessons learned from the Hib Initiative experience

Vaccine, 2010

The introduction of Haemophilus influenzae type b (Hib) vaccine in developing countries has suffe... more The introduction of Haemophilus influenzae type b (Hib) vaccine in developing countries has suffered from a long delay. Between 2005 and 2009, a surge in Hib vaccine adoption took place, particularly among GAVIeligible countries. Several factors contributed to the increase in Hib vaccine adoption, including support provided by the Hib Initiative, a project funded by the GAVI Alliance in 2005 to accelerate evidenceinformed decisions for use of Hib vaccine. This paper reviews the strategy adopted by the Hib Initiative and the lessons learned in the process, which provide a useful model to accelerate uptake of other new vaccines.

Research paper thumbnail of TRIVAC decision-support model for evaluating the cost-effectiveness of Haemophilus influenzae type b, pneumococcal and rotavirus vaccination

Vaccine, 2013

The TRIVAC decision support model has been used widely in Latin America and other regions to help... more The TRIVAC decision support model has been used widely in Latin America and other regions to help national teams evaluate the cost-effectiveness of Haemophilus influenzae type b (Hib) vaccine, pneumococcal conjugate vaccine (PCV) and rotavirus vaccine (RV). We describe the structure and functioning of this model, and identify the parameters with the greatest influence on the results.

Research paper thumbnail of Global use of Haemophilus influenzae type b conjugate vaccine

Vaccine, 2010

Haemophilus influenzae type b (Hib) conjugate vaccines have been underutilized globally. We repor... more Haemophilus influenzae type b (Hib) conjugate vaccines have been underutilized globally. We report progress in global use of Hib vaccines included in national immunization schedules. The number of countries using Hib vaccine increased from 89/193 (46%) in 2004 to 158/193 (82%) by the end of 2009. The increase was greatest among low-income countries eligible for financial support from the GAVI Alliance [13/75 (17%) in 2004, 60/72 (83%) by the end of 2009], and can be attributed to various factors. Additional efforts are still needed to increase vaccine adoption in lower middle income countries [20/31 (65%) by the end of 2009].

Research paper thumbnail of Outbreak of invasive aspergillosis among renal transplant recipients

Transplantation, 2003

Invasive aspergillosis (IA) is rare among renal transplant recipients (RTRs). We investigated a c... more Invasive aspergillosis (IA) is rare among renal transplant recipients (RTRs). We investigated a cluster of IA among RTRs at a California hospital from January to February 2001, when construction was ongoing. We conducted a cohort study among RTRs who were hospitalized between January 1 and February 5, 2001, to determine risk factors for IA. IA was defined using established guidelines. Four IA cases occurred among 40 RTRs hospitalized during the study period. Factors associated with an increased risk of IA included prolonged hemodialysis, lengthy corticosteroid treatment posttransplant, and use of sirolimus alone or with mycophenolate (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). After the study period, three additional RTRs developed IA; two Aspergillus isolates recovered from these patients had indistinguishable profiles by DNA fingerprinting, suggesting common-source exposure. This study suggests that immunosuppressed RTRs can be at an increased risk for IA. Measures to prevent IA in these patients should be taken during hospital construction.