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1.  Medical and Household Characteristics Associated with Methicillin Resistant Staphylococcus aureus Nasal Carriage among Patients Admitted to a Rural Tertiary Care Hospital 
PLoS ONE  2013;8(8):e73595.
Methicillin resistant Staphylococcus aureus (MRSA) poses a threat to patient safety and public health. Understanding how MRSA is acquired is important for prevention efforts. This study investigates risk factors for MRSA nasal carriage among patients at an eastern North Carolina hospital in 2011.
Using a case-control design, hospitalized patients ages 18 – 65 years were enrolled between July 25, 2011 and December 15, 2011 at Vidant Medical Center, a tertiary care hospital that screens all admitted patients for nasal MRSA carriage. Cases, defined as MRSA nasal carriers, were age and gender matched to controls, non-MRSA carriers. In-hospital interviews were conducted, and medical records were reviewed to obtain information on medical and household exposures. Multivariable conditional logistic regression was used to derive odds ratio (OR) estimates of association between MRSA carriage and medical and household exposures.
In total, 117 cases and 119 controls were recruited to participate. Risk factors for MRSA carriage included having household members who took antibiotics or were hospitalized (OR: 3.27; 95% Confidence Interval (CI): 1.24–8.57) and prior hospitalization with a positive MRSA screen (OR: 3.21; 95% CI: 1.12–9.23). A lower proportion of cases than controls were previously hospitalized without a past positive MRSA screen (OR: 0.40; 95% CI: 0.19–0.87).
These findings suggest that household exposures are important determinants of MRSA nasal carriage in hospitalized patients screened at admission.
PMCID: PMC3753306  PMID: 23991200
2.  Review of the UNC Team Epi-Aid Graduate Student Epidemiology Response Program Six Years After Implementation 
Public Health Reports  2010;125(Suppl 5):70-77.
Service learning is one way that academia can contribute to assuring the public's health. The University of North Carolina's Team Epi-Aid service-learning program started in 2003. Since then, 145 graduate student volunteers have contributed 4,275 hours working with the state and local health departments during 57 activities, including outbreak investigations, community health assessments, and emergency preparedness and response. Survey data from student participants and public health partners indicates that the program is successful in meeting its goal of creating effective partnerships among the university, the North Carolina Center for Public Health Preparedness, and state and local health departments; supplying needed surge capacity to health departments; and providing students with applied public health experience and training. In this article, we discuss the programmatic lessons learned around administration, maintaining student interest, program sustainability, and challenges since program implementation.
PMCID: PMC2966647  PMID: 21137134
5.  Team Epi-Aid: Graduate Student Assistance with Urgent Public Health Response 
Public Health Reports  2005;120(Suppl 1):35-41.
Team Epi-Aid provides graduate students with practical public health experience through participation in outbreak investigations and other applied projects with state and local health departments in North Carolina. It is an initiative of the North Carolina Center for Public Health Preparedness in the North Carolina Institute for Public Health at the University of North Carolina School of Public Health. The program allows state and local health departments access to volunteers and technical expertise from the university when they need assistance. It requires close collaboration with state and county health departments. Team Epi-Aid provides the opportunity for integrated learning with students and faculty within the departments of the School of Public Health, and through recent expansion, within the schools of Medicine and Pharmacy. Orientations are conducted each semester and formal training is provided as needed. Team Epi-Aid has been popular, with 58 active student participants contributing 1,465 hours of service during the initiative's first 21 months.
PMCID: PMC2569985  PMID: 16028330
6.  Human and Canine Pulmonary Blastomycosis, North Carolina, 2001–2002 
Emerging Infectious Diseases  2006;12(8):1242-1244.
We investigated a cluster of blastomycosis in 8 humans and 4 dogs in a rural North Carolina community. Delayed diagnosis, difficulty isolating Blastomyces dermatitidis in nature, and lack of a sensitive and specific test to assess exposure make outbreaks of this disease difficult to study.
PMCID: PMC3291202  PMID: 16965704
Blastomycosis; Blastomyces dermatitidis; humans; canine diseases; disease outbreaks; lung disease; fungal; North Carolina; dispatch
7.  Improvements in Timeliness Resulting from Implementation of Electronic Laboratory Reporting and an Electronic Disease Surveillance System 
Public Health Reports  2013;128(5):393-398.
Electronic laboratory reporting (ELR) reduces the time between communicable disease diagnosis and case reporting to local health departments (LHDs). However, it also imposes burdens on public health agencies, such as increases in the number of unique and duplicate case reports. We assessed how ELR affects the timeliness and accuracy of case report processing within public health agencies.
Using data from May–August 2010 and January–March 2012, we assessed timeliness by calculating the time between receiving a case at the LHD and reporting the case to the state (first stage of reporting) and between submitting the report to the state and submitting it to the Centers for Disease Control and Prevention (second stage of reporting). We assessed accuracy by calculating the proportion of cases returned to the LHD for changes or additional information. We compared timeliness and accuracy for ELR and non-ELR cases.
ELR was associated with decreases in case processing time (median = 40 days for ELR cases vs. 52 days for non-ELR cases in 2010; median = 20 days for ELR cases vs. 25 days for non-ELR cases in 2012; both p<0.001). ELR also allowed time to reduce the backlog of unreported cases. Finally, ELR was associated with higher case reporting accuracy (in 2010, 2% of ELR case reports vs. 8% of non-ELR case reports were returned; in 2012, 2% of ELR case reports vs. 6% of non-ELR case reports were returned; both p<0.001).
The overall impact of increased ELR is more efficient case processing at both local and state levels.
PMCID: PMC3743288  PMID: 23997286
8.  Nonrandomized Controlled Trial of Artesunate plus Sulfadoxine-Pyrimethamine with or without Primaquine for Preventing Posttreatment Circulation of Plasmodium falciparum Gametocytes 
Artemisinin combination therapies eliminate immature Plasmodium falciparum gametocytes but not mature gametocytes, which may persist for up to 1 month posttreatment. A single dose of primaquine, which is inexpensive and effective against mature gametocytes, could be added to further reduce the potential for posttreatment parasite transmission. Currently, we have few data regarding the effectiveness or safety of doing so. We collected data from 21 therapeutic efficacy trials of the National Antimalarial Drug Resistance Monitoring System of India conducted during 2009 to 2010, wherein 9 sites used single-dose primaquine (0.75 mg/kg of body weight) administered on day 2 along with artesunate plus sulfadoxine-pyrimethamine (AS+SP) while 12 did not. We estimated the effect of primaquine on posttreatment gametocyte clearance and the total number of gametocyte-weeks as determined by microscopy. We compared the median area under the curve for gametocyte density and reported adverse events. One thousand three hundred thirty-five patients completed the antimalarial drug treatment. Adjusting for region, primaquine increased the rate of gametocyte clearance (hazard ratio, 1.9; 95% confidence interval [CI], 1.1 to 3.3), prevented 45% (95% CI, 19 to 62) of posttreatment gametocyte-weeks, and decreased the area under the gametocyte density curve over the 28-day follow-up compared to AS+SP alone (P value = 0.01). The results were robust to other adjustment sets, and the estimated effect of primaquine increased during sensitivity analysis on the measurement of exposure time. No serious adverse events were detected. In conclusion, the addition of primaquine to AS+SP was effective in reducing the posttreatment presence of P. falciparum gametocytes. Primaquine was well tolerated and could be administered along with an artemisinin combination therapy as the first-line therapy.
PMCID: PMC3697316  PMID: 23587943
9.  The Association Between Oral Contraceptives, Depot-Medroxyprogesterone Acetate, and Trichomoniasis 
Sexually transmitted diseases  2009;36(6):336-340.
Hormonal contraception use by women may increase the risk of acquiring certain sexually transmitted infections. We explored the effect of hormonal contraceptive use, specifically oral contraception (OC), and depot-medroxyprogesterone acetate (DMPA) on Trichomonas vaginalis infections in women.
We examined data from a prospective case–control study of women with trichomoniasis and noninfected female patients recruited from 3 public sexually transmitted disease clinics. Women with positive wet mount microscopy or T. vaginalis culture results were classified as having trichomoniasis. Participants underwent physical examinations, sexually transmitted infections testing and completed questionnaires which included information about demographics, sexual behavior, douching and contraceptive use. We assessed the association between hormonal contraceptives and trichomoniasis using bivariable and multivariable analysis and estimated exposure odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs).
We identified 427 women with trichomoniasis and 144 uninfected women who had information reported about contraception use. Compared with nonhormonal contraceptive use, OC use was negatively associated with trichomoniasis in bivariable analysis (OR: 0.5; 95% CI: 0.3–0.8). This association was no longer statistically significant after adjusting for demographic variables, douching and condom use (aOR: 0.9; 95% CI: 0.5–1.6). Use of DMPA, compared with nonhormonal contraceptive use, was not associated with trichomoniasis in bivariable or multivariable analyses (OR: 1.0, 95% CI: 0.5–2.1; aOR = 1.4, 95% CI: 0.6–3.4, respectively).
Although OC use appeared to have a protective effect in the bivariable analysis, the hormonal contraceptives OC and DMPA were not associated with T. vaginalis infection after adjustment for other factors.
PMCID: PMC3790269  PMID: 19556926
10.  Integration of Syndromic Surveillance Data into Public Health Practice at State and Local Levels in North Carolina 
Public Health Reports  2012;127(3):310-317.
We sought to describe the integration of syndromic surveillance data into daily surveillance practice at local health departments (LHDs) and make recommendations for the effective integration of syndromic and reportable disease data for public health use.
Structured interviews were conducted with local health directors and communicable disease nursing staff from a stratified random sample of LHDs from May through September 2009. Interviews captured information on direct access to the North Carolina syndromic surveillance system and on the use of syndromic surveillance information for outbreak management, program management, and the creation of reports. We analyzed syndromic surveillance system data to assess the number of signals resulting in a public health response.
Syndromic surveillance data were used for outbreak investigation (19% of respondents) and program management and report writing (43% of respondents); a minority reported use of both syndromic and reportable disease data for these purposes (15% and 23%, respectively). Receiving data from frequent system users was associated with using data for these purposes (p=0.016 and p=0.033, respectively, for syndromic and reportable disease data). A small proportion of signals (<25%) resulted in a public health response.
Use of syndromic surveillance data by North Carolina local public health authorities resulted in meaningful public health action, including both case investigation and program management. While useful, the syndromic surveillance data system was oriented toward sensitivity rather than efficiency. Successful incorporation of new surveillance data is likely to require systems that are oriented toward efficiency.
PMCID: PMC3314075  PMID: 22547862
11.  Developing a Predictive Model to Prioritize HIV Partner Notification in North Carolina 
Sexually transmitted diseases  2012;39(1):65-71.
Disease Intervention Specialists (DIS) in North Carolina (NC) have less time to conduct partner notification due to competing responsibilities while simultaneously facing increased case loads due to increased HIV testing. We developed a model to predict undiagnosed HIV infection in sexual partners to prioritize DIS interviews.
We abstracted demographic, behavioral, and partnership data from DIS records of HIV-infected persons reported in two NC surveillance regions between January 1, 2003 and December 31, 2007. Multiple logistic regression with generalized estimating equations was used to develop a predictive model and risk scores among newly diagnosed persons and their partners. Sensitivities and specificities of the risk scores at different cutoffs were used to examine algorithm performance.
Five factors predicted a partnership between a person with newly diagnosed HIV infection and an undiagnosed partner—four weeks or fewer between HIV diagnosis and DIS interview, no history of crack use, no anonymous sex, fewer total sexual partners reported to DIS, and sexual partnerships between an older index case and younger partner. Using this model, DIS could choose an appropriate cutoff for locating a particular partner by determining the weight of false negatives relative to false positives.
While the overall predictive power of the model is low, it is possible to reduce the number of partners that need to be located and interviewed while maintaining high sensitivity. If DIS continue to pursue all partners, the model would be useful in identifying partners in which to invest more resources for locating.
PMCID: PMC3244826  PMID: 22183850
HIV; partner notification; modeling; decision
12.  Social support and delays seeking care after HIV diagnosis, North Carolina, 2000–2006 
AIDS care  2009;21(9):1148-1156.
Many adults in the United States enter primary care late in the course of HIV infection, countering the clinical benefits of timely HIV services and missing opportunities for risk reduction. Our objective was to determine if perceived social support was associated with delay entering care after an HIV diagnosis. Two hundred sixteen patients receiving primary care at a large, university-based HIV outpatient clinic in North Carolina were included in the study. Dimensions of functional social support (emotional/informational, tangible, affectionate and positive social interaction) were quantified with a modified Medical Outcomes Study Social Support Scale and included in proportional hazard models to determine their effect on delays seeking care. The median delay between diagnosis and entry to primary care was 5.9 months. Levels of social support were high but only positive social interaction was moderately associated with delayed presentation in adjusted models. The effect of low perceived positive social interaction on the time to initiation of primary care differed by history of alcoholism (no history of alcoholism, hazard ratio (HR): 1.43, 95% confidence interval (CI): 0.88, 2.34; history of alcoholism, HR: 0.71, 95% CI: 0.40, 1.28). Ensuring timely access to HIV care remains a challenge in the southeastern United States. Affectionate, tangible, and emotional/informational social support were not associated with the time from diagnosis to care. The presence of positive social interaction may be an important factor influencing care seeking behavior after diagnosis.
PMCID: PMC3529165  PMID: 20024774
HIV infection; social support; time factors; delivery of health care; southeastern United States
13.  Barriers and Facilitators to HIV Testing and Linkage to Primary Care: Narratives of People with Advanced HIV in the Southeast 
AIDS care  2009;21(10):1313-1320.
Persons with unrecognized HIV infection forgo timely clinical intervention and may unknowingly transmit HIV to partners. However, in the United States, unrecognized infection and late diagnosis are common. To understand barriers and facilitators to HIV testing and care, we conducted a qualitative study of 24 HIV infected persons attending a Southeastern HIV clinic who presented with clinically advanced illness. The primary barrier to HIV testing prior to diagnosis was perception of risk; consequently, most participants were diagnosed after the onset of clinical symptoms. While most patients were anxious to initiate care rapidly after diagnosis, some felt frustrated by the passive process of connecting to specialty care. The first visit with an HIV care provider was identified as critical in the coping process for many patients. Implications for the implementation of recent CDC HIV routine screening guidelines are discussed.
PMCID: PMC3509799  PMID: 20024708
HIV Infection; Voluntary Counseling and Testing; Delivery of Health Care; Southeastern United States; Social Support
15.  Recurrent Plasmodium falciparum Malaria Infections in Kenyan Children Diminish T-Cell Immunity to Epstein Barr Virus Lytic but Not Latent Antigens 
PLoS ONE  2012;7(3):e31753.
Plasmodium falciparum malaria (Pf-malaria) and Epstein Barr Virus (EBV) infections coexist in children at risk for endemic Burkitt's lymphoma (eBL); yet studies have only glimpsed the cumulative effect of Pf-malaria on EBV-specific immunity. Using pooled EBV lytic and latent CD8+ T-cell epitope-peptides, IFN-γ ELISPOT responses were surveyed three times among children (10 months to 15 years) in Kenya from 2002–2004. Prevalence ratios (PR) and 95% confidence intervals (CI) were estimated in association with Pf-malaria exposure, defined at the district-level (Kisumu: holoendemic; Nandi: hypoendemic) and the individual-level. We observed a 46% decrease in positive EBV lytic antigen IFN-γ responses among 5–9 year olds residing in Kisumu compared to Nandi (PR: 0.54; 95% CI: 0.30–0.99). Individual-level analysis in Kisumu revealed further impairment of EBV lytic antigen responses among 5–9 year olds consistently infected with Pf-malaria compared to those never infected. There were no observed district- or individual-level differences between Pf-malaria exposure and EBV latent antigen IFN-γ response. The gradual decrease of EBV lytic antigen but not latent antigen IFN-γ responses after primary infection suggests a specific loss in immunological control over the lytic cycle in children residing in malaria holoendemic areas, further refining our understanding of eBL etiology.
PMCID: PMC3299627  PMID: 22427806
16.  Completeness of Communicable Disease Reporting, North Carolina, USA, 1995–1997 and 2000–2006 
Emerging Infectious Diseases  2011;17(1):23-29.
Reporting proportions were <50% for 49 of the 53 diseases evaluated.
Despite widespread use of communicable disease surveillance data to inform public health intervention and control measures, the reporting completeness of the notifiable disease surveillance system remains incompletely assessed. Therefore, we conducted a comprehensive study of reporting completeness with an analysis of 53 diseases reported by 8 health care systems across North Carolina, USA, during 1995–1997 and 2000–2006. All patients who were assigned an International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis code for a state-required reportable communicable disease were matched to surveillance records. We used logistic regression techniques to estimate reporting completeness by disease, year, and health care system. The completeness of reporting varied among the health care systems from 2% to 30% and improved over time. Disease-specific reporting completeness proportions ranged from 0% to 82%, but were generally low even for diseases with great public health importance and opportunity for interventions.
PMCID: PMC3204630  PMID: 21192850
Infectious disease surveillance; surveillance; notifiable diseases; communicable diseases; bacteria; viruses; disease notification; epidemiology; research
17.  Identifying People with Acute HIV Infection (AHI) – Demographic Features, Risk Factors, and Use of Health Care among Individuals with AHI in North Carolina 
AIDS and behavior  2009;13(6):1075-1083.
Identifying and counseling individuals with Acute HIV Infection (AHI) offers a critical opportunity to avert preventable HIV transmission, however opportunities to recognize these individuals may be missed. We surveyed 32 adults diagnosed with AHI during voluntary HIV testing from 1/1/03 to 2/28/05 in publicly funded testing sites in NC to describe their clinical, social, and behavioral characteristics. Eighty-one percent of participants were men; 59% were African American. Seventy-five percent experienced symptoms consistent with acute retroviral syndrome; although 83% sought medical care for these symptoms, only 15% were appropriately diagnosed at that initial medical visit, suggesting opportunities to diagnose these individuals earlier were missed. Eighty-five percent of the men engaged in sex with men. More than 50% of the participants thought they were infected with HIV by a steady partner. This study yields important information to assist in identifying populations at risk for or infected with AHI and designing both primary and secondary prevention interventions.
PMCID: PMC2787774  PMID: 19127422
Acute HIV Infection (AHI); North Carolina (NC); HIV/AHI screening; AHI Epidemiology; HIV Risk Factors
18.  Intent to Receive Pandemic Influenza A (H1N1) Vaccine, Compliance with Social Distancing and Sources of Information in NC, 2009 
PLoS ONE  2010;5(6):e11226.
Public adherence to influenza vaccination recommendations has been low, particularly among younger adults and children under 2, despite the availability of safe and effective seasonal vaccine. Intention to receive 2009 pandemic influenza A (H1N1) vaccine has been estimated to be 50% in select populations. This report measures knowledge of and intention to receive pandemic vaccine in a population-based setting, including target groups for seasonal and H1N1 influenza.
Methodology and Principal Findings
On August 28–29, 2009, we conducted a population-based survey in 2 counties in North Carolina. The survey used the 30×7 two-stage cluster sampling methodology to identify 210 target households. Prevalence ratios (PR) and 95% confidence intervals (CI) were estimated. Knowledge of pandemic influenza A (H1N1) vaccine was high, with 165 (80%) aware that a vaccine was being prepared. A total of 133 (64%) respondents intended to receive pandemic vaccine, 134 (64%) intended to receive seasonal vaccine, and 109 (53%) intended to receive both. Reporting great concern about H1N1 infection (PR 1.55; 95%CI: 1.30, 1.85), receiving seasonal influenza vaccine in 2008–09 (PR 1.47; 95%CI: 1.18, 1.82), and intending to receive seasonal influenza vaccine in 2009–10 (PR 1.27; 95%CI: 1.14, 1.42) were associated with intention to receive pandemic vaccine. Not associated were knowledge of vaccine, employment, having children under age 18, gender, race/ethnicity and age. Reasons cited for not intending to get vaccinated include not being at risk for infection, concerns about vaccine side effects and belief that illness caused by pandemic H1N1 would be mild. Forty-five percent of households with children under 18 and 65% of working adults reported ability to comply with self-isolation at home for 7–10 days if recommended by authorities.
Conclusions and Significance
This is the first report of a population based rapid assessment used to assess knowledge and intent to receive pandemic vaccine in a community sample. Intention to receive pandemic and seasonal vaccines was higher than previously published reports. To reach persons not intending to receive pandemic vaccine, public health communications should focus on the perceived risk of infection and concerns about vaccine safety.
PMCID: PMC2887902  PMID: 20585462
19.  Sexually Transmitted Infections among Patients with Acute HIV in North Carolina 
Sexually transmitted diseases  2009;36(6):372-374.
PMCID: PMC2708082  PMID: 19387421
HIV transmission; acute HIV infection; sexually transmitted infections; viral load; Southeastern United States
21.  10 Guiding Principles of a Comprehensive Internet-Based Public Health Preparedness Training and Education Program 
Public Health Reports  2010;125(Suppl 5):51-60.
Distance learning is an effective strategy to address the many barriers to continuing education faced by the public health workforce. With the proliferation of online learning programs focused on public health, there is a need to develop and adopt a common set of principles and practices for distance learning. In this article, we discuss the 10 principles that guide the development, design, and delivery of the various training modules and courses offered by the North Carolina Center for Public Health Preparedness (NCCPHP). These principles are the result of 10 years of experience in Internet-based public health preparedness educational programming. In this article, we focus on three representative components of NCCPHP's overall training and education program to illustrate how the principles are implemented and help others in the field plan and develop similar programs.
PMCID: PMC2966645  PMID: 21137132
22.  An Academic/Government Partnership to Provide Technical Assistance with Pandemic Influenza Planning to Local Health Departments in North Carolina 
Public Health Reports  2010;125(Suppl 5):92-99.
In 2006, the North Carolina Division of Public Health (NC DPH) required all 85 local health departments (LHDs) in North Carolina to develop a pandemic influenza plan. Because few LHDs had experience in developing such plans, NC DPH engaged in a unique partnership with an academic center, the North Carolina Center for Public Health Preparedness (NCCPHP), to provide technical assistance to local planners. This article describes the technical assistance program implemented by NCCPHP, the use of technical assistance by local planners, subsequent completeness of local pandemic influenza plans, and lessons learned throughout the program. We discuss selected topic areas (surveillance, vaccine/antiviral, and vulnerable populations) observed within local pandemic influenza plans to highlight the variability in planning approaches and identify potential opportunities for state and local standardization.
PMCID: PMC2966650  PMID: 21137135
23.  Development and Implementation of a Public Health Workforce Training Needs Assessment Survey in North Carolina 
Public Health Reports  2005;120(Suppl 1):28-34.
Assessing the training needs of local public health workers is an important step toward providing appropriate training programs in emergency preparedness and core public health competencies. The North Carolina Public Health Workforce Training Needs Assessment survey was implemented through the collaboration of several organizations, including the North Carolina Center for Public Health Preparedness at the North Carolina Institute for Public Health, the outreach and service unit of the University of North Carolina School of Public Health, the Office of Public Health Preparedness and Response in the North Carolina Division of Public Health Epidemiology Section, and local health departments across the state.
PMCID: PMC2569984  PMID: 16028329

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