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1.  Effect of Rapid Influenza Diagnostic Testing on Antiviral Treatment Decisions for Patients with Influenza-Like Illness: Southwestern U.S., May–December 2009 
Public Health Reports  2014;129(4):322-327.
Rapid influenza diagnostic tests (RIDTs) had low test sensitivity for detecting 2009 pandemic influenza A (H1N1pdm09) infection, causing public health authorities to recommend that treatment decisions be based primarily upon risk for influenza complications. We used multivariate Poisson regression analysis to estimate the contribution of RIDT results and risk for H1N1pdm09 complications to receipt of early antiviral (AV) treatment among 290 people with influenza-like illness (ILI) who received an RIDT ≤48 hours after symptom onset from May to December 2009 at four southwestern U.S. facilities. RIDT results had a stronger association with receipt of early AVs (rate ratio [RR] = 3.3, 95% confidence interval [CI] 2.4, 4.6) than did the presence of risk factors for H1N1pdm09 complications (age <5 years or high-risk medical conditions) (RR=1.9, 95% CI 1.3, 2.7). Few at-risk people (28/126, 22%) who had a negative RIDT received early AVs, suggesting the need for sustained efforts by public health to influence clinician practices.
PMCID: PMC4037457  PMID: 24982534
2.  Understanding the Burden of Tuberculosis Among American Indians/Alaska Natives in the U.S.: A Validation Study 
Public Health Reports  2014;129(4):351-360.
We validated cases of active tuberculosis (TB) recorded in the Indian Health Service (IHS) National Patient Information Reporting System (NPIRS) and evaluated the completeness of TB case reporting from IHS facilities to state health departments.
We reviewed the medical records of American Indian/Alaska Native (AI/AN) patients at IHS health facilities who were classified as having active TB using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes from 2006 to 2009 for clinical and laboratory evidence of TB disease. Individuals were reclassified as having active TB disease; recent latent TB infection (LTBI); past positive tuberculin skin test (TST) only; or as having no evidence of TB, LTBI, or a past positive TST. We compared validated active TB cases with corresponding state records to determine if they were reported.
The study included 596 patients with active TB as per ICD-9-CM codes. Based on chart review, 111 (18.6%) had active TB; 156 (26.2%) had LTBI; 104 (17.4%) had a past positive TST; and 221 (37.1%) had no evidence of TB disease, LTBI, or a past positive TST. Of the 111 confirmed cases of active TB, 89 (80.2%) resided in participating states; 81 of 89 (91.2%) were verified as reported TB cases.
ICD-9-CM codes for active TB disease in the IHS NPIRS do not accurately reflect the burden of TB among AI/ANs. Most confirmed active TB cases in the IHS health system were reported to the state; the national TB surveillance system may accurately represent the burden of TB in the AI/AN population.
PMCID: PMC4037461  PMID: 24982538
3.  Influenza surveillance using electronic health records in the American Indian and Alaska Native population 
Increasing use of electronic health records (EHRs) provides new opportunities for public health surveillance. During the 2009 influenza A (H1N1) virus pandemic, we developed a new EHR-based influenza-like illness (ILI) surveillance system designed to be resource sparing, rapidly scalable, and flexible. 4 weeks after the first pandemic case, ILI data from Indian Health Service (IHS) facilities were being analyzed.
Materials and methods
The system defines ILI as a patient visit containing either an influenza-specific International Classification of Disease, V.9 (ICD-9) code or one or more of 24 ILI-related ICD-9 codes plus a documented temperature ≥100°F. EHR-based data are uploaded nightly. To validate results, ILI visits identified by the new system were compared to ILI visits found by medical record review, and the new system's results were compared with those of the traditional US ILI Surveillance Network.
The system monitored ILI activity at an average of 60% of the 269 IHS electronic health databases. EHR-based surveillance detected ILI visits with a sensitivity of 96.4% and a specificity of 97.8% based on chart review (N=2375) of visits at two facilities in September 2009. At the peak of the pandemic (week 41, October 17, 2009), the median time from an ILI visit to data transmission was 6 days, with a mode of 1 day.
EHR-based ILI surveillance was accurate, timely, occurred at the majority of IHS facilities nationwide, and provided useful information for decision makers. EHRs thus offer the opportunity to transform public health surveillance.
PMCID: PMC3912730  PMID: 23744788
Influenza, Human; Population Surveillance; Epidemiologic Methods; Electronic Health Records; Medical Informatics Applications; Data Collection
4.  Molluscum Contagiosum in a Pediatric American Indian Population: Incidence and Risk Factors 
PLoS ONE  2014;9(7):e103419.
Molluscum contagiosum virus (MCV) causes an innocuous yet persistent skin infection in immunocompetent individuals and is spread by contact with lesions. Studies point to atopic dermatitis (AD) as a risk factor for MCV infection; however, there are no longitudinal studies that have evaluated this hypothesis.
Outpatient visit data from fiscal years 2001–2009 for American Indian and Alaska Native (AI/AN) children were examined to describe the incidence of molluscum contagiosum (MC). We conducted a case-control study of patients <5 years old at an Indian Health Service (IHS) clinic to evaluate dermatological risk factors for infection.
The incidence rate for MC in children <5 years old was highest in the West and East regions. MC cases were more likely to have a prior or co-occurring diagnosis of eczema, eczema or dermatitis, impetigo, and scabies (p<0.05) compared to controls; 51.4% of MC cases had a prior or co-occurring diagnosis of eczema or dermatitis.
The present study is the first demonstration of an association between AD and MC using a case-control study design. It is unknown if the concurrent high incidence of eczema and MC is related, and this association deserves further investigation.
PMCID: PMC4114779  PMID: 25072249
5.  Influenza Hospitalizations Among American Indian/Alaska Native People and in the United States General Population 
Open Forum Infectious Diseases  2014;1(1):ofu031.
American Indian/Alaska Native (AI/AN) people appear to be at increased risk for hospitalization from influenza illness compared with the general US population. Our results should inform policymakers on seasonal epidemic and pandemic influenza preparedness and response.
 Historically, American Indian/Alaska Native (AI/AN) people have experienced a disproportionate burden of infectious disease morbidity compared with the general US population. We evaluated whether a disparity in influenza hospitalizations exists between AI/AN people and the general US population.
 We used Indian Health Service hospital discharge data (2001–2011) for AI/AN people and 13 State Inpatient Databases (2001–2008) to provide a comparison to the US population. Hospitalization rates were calculated by respiratory year (July–June). Influenza-specific hospitalizations were defined as discharges with any influenza diagnoses. Influenza-associated hospitalizations were calculated using negative binomial regression models that incorporated hospitalization and influenza laboratory surveillance data.
 The mean influenza-specific hospitalization rate/100 000 persons/year during the 2001–2002 to 2007–2008 respiratory years was 18.6 for AI/AN people and 15.6 for the comparison US population. The age-adjusted influenza-associated hospitalization rate for AI/AN people (98.2; 95% confidence interval [CI], 51.6–317.8) was similar to the comparison US population (58.2; CI, 34.7–172.2). By age, influenza-associated hospitalization rates were significantly higher among AI/AN infants (<1 year) (1070.7; CI, 640.7–2969.5) than the comparison US infant population (210.2; CI, 153.5–478.5).
 American Indian/Alaska Native people had higher influenza-specific hospitalization rates than the comparison US population; a significant influenza-associated hospitalization rate disparity was detected only among AI/AN infants because of the wide CIs inherent to the model. Taken together, the influenza-specific and influenza-associated hospitalization rates suggest that AI/AN people might suffer disproportionately from influenza illness compared with the general US population.
PMCID: PMC4324209  PMID: 25734102
American Indian; epidemiology; healthcare disparities; influenza
6.  Severe acute respiratory infections caused by 2009 pandemic influenza A (H1N1) among American Indians—southwestern United States, May 1–July 21, 2009 
During April–July 2009, U.S. hospitalization rates for 2009 pandemic influenza A (H1N1) virus (H1N1pdm09) infection were estimated at 4·5/100 000 persons. We describe rates and risk factors for H1N1pdm09 infection among American Indians (AIs) in four isolated southwestern U.S. communities served by the Indian Health Service (IHS).
We reviewed clinical and demographic information from medical records of AIs hospitalized during May 1–July 21, 2009 with severe acute respiratory infection (SARI). Hospitalization rates were determined using denominator data provided by IHS. H1N1pdm09 infection was confirmed with polymerase chain reaction, rapid tests, or convalescent serology. Risk factors for more severe (SARI) versus milder [influenza‐like illness (ILI)] illness were determined by comparing confirmed SARI patients with outpatients with ILI.
Among 168 SARI‐hospitalized patients, 52% had confirmed H1N1pdm09 infection and 93% had >1 high‐risk condition for influenza complications. The H1N1pdm09 SARI hospitalization rate was 131/100 000 persons [95% confidence interval (CI), 102–160] and was highest among ages 0–4 years (353/100 000; 95% CI, 215–492). Among children, asthma (adjusted odds ratio [aOR] 3·2; 95% CI, 1·2–8·4) and age <2 years (aOR 3·8; 95% CI, 1·4–10·0) were associated with H1N1pdm09 SARI‐associated hospitalization, compared with outpatient ILI. Among adults, diabetes (aOR 3·1; 95% CI, 1·5–6·4) was associated with hospitalization after controlling for obesity.
H1N1pdm09 hospitalization rates among this isolated AI population were higher than reported for other U.S. populations. Almost all case patients had high‐risk health conditions. Prevention strategies for future pandemics should prioritize AIs, particularly in isolated rural areas.
PMCID: PMC4634245  PMID: 23721100
American Indians; H1N1 subtype; hospitalizations; influenza viruses
7.  Lymphocytic Choriomeningitis Virus Infections among American Indians 
Emerging Infectious Diseases  2013;19(2):328-329.
PMCID: PMC3559050  PMID: 23460992
lymphocytic choriomeningitis virus; LCMV; viruses; lymphocytic choriomeningitis; American Indians; incidence; electronic diagnostic codes; chart review; International Classification of Diseases; ICD-9
8.  Increasing trend in the rate of infectious disease hospitalisations among Alaska Native people 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.20994.
To examine the epidemiology of infectious disease (ID) hospitalisations among Alaska Native (AN) people.
Hospitalisations with a first-listed ID diagnosis for American Indians and ANs residing in Alaska during 2001–2009 were selected from the Indian Health Service direct and contract health service inpatient data. ID hospitalisations to describe the general US population were selected from the Nationwide Inpatient Sample. Annual and average annual (2007–2009) hospitalization rates were calculated.
During 2007–2009, IDs accounted for 20% of hospitalisations among AN people. The 2007–2009 average annual age-adjusted ID hospitalisation rate (2126/100,000 persons) was higher than that for the general US population (1679/100,000; 95% CI 1639–1720). The ID hospitalisation rate for AN people increased from 2001 to 2009 (17%, p<0.001). Although the rate during 2001–2009 declined for AN infants (<1 year of age; p=0.03), they had the highest 2007–2009 average annual rate (15106/100,000), which was 3 times the rate for general US infants (5215/100,000; 95% CI 4783–5647). The annual rates for the age groups 1–4, 5–19, 40–49, 50–59 and 70–79 years increased (p<0.05). The highest 2007–2009 age-adjusted average annual ID hospitalisation rates were in the Yukon-Kuskokwim (YK) (3492/100,000) and Kotzebue (3433/100,000) regions; infant rates were 30422/100,000 and 26698/100,000 in these regions, respectively. During 2007–2009, lower respiratory tract infections accounted for 39% of all ID hospitalisations and approximately 50% of ID hospitalisations in YK, Kotzebue and Norton Sound, and 74% of infant ID hospitalisations.
The ID hospitalisation rate increased for AN people overall. The rate for AN people remained higher than that for the general US population, particularly in infants and in the YK and Kotzebue regions. Prevention measures to reduce ID morbidity among AN people should be increased in high-risk regions and for diseases with high hospitalisation rates.
PMCID: PMC3753132  PMID: 23984284
Alaska Native; infectious disease; hospitalisations; Alaska; lower respiratory tract infection
9.  Changing Trends in Viral Hepatitis-Associated Hospitalizations in the American Indian/Alaska Native Population, 1995–2007 
Public Health Reports  2011;126(6):816-825.
We described the changing epidemiology of viral hepatitis among the American Indian/Alaska Native (AI/AN) population that uses Indian Health Service (IHS) health care.
We used hospital discharge data from the IHS National Patient Information Reporting System to determine rates of hepatitis A-, B-, and C-associated hospitalization among AI/ANs using IHS health care from 1995–2007 and summary periods 1995–1997 and 2005–2007.
Hepatitis A-associated hospitalization rates among AI/AN people decreased from 4.9 per 100,000 population during 1995–1997 to 0.8 per 100,000 population during 2005–2007 (risk ratio [RR] = 0.2, 95% confidence interval [CI] 0.1, 0.2). While there was no significant change in the overall hepatitis B-associated hospitalization rate between time periods, the average annual rate in people aged 45–64 years increased by 109% (RR=2.1, 95% CI 1.4, 3.2). Between the two time periods, the hepatitis C-associated hospitalization rate rose from 13.0 to 55.0 per 100,000 population (RR=4.2, 95% CI 3.8, 4.7), an increase of 323%. The hepatitis C-associated hospitalization rate was highest among people aged 45–64 years, males, and those in the Alaska region.
Hepatitis A has decreased to near-eradication levels among the AI/AN population using IHS health care. Hepatitis C-associated hospitalizations increased significantly; however, there was no significant change in hepatitis B-associated hospitalizations. Emphasis should be placed on continued universal childhood and adolescent hepatitis B vaccination and improved vaccination of high-risk adults. Prevention and education efforts should focus on decreasing hepatitis C risk behaviors and identifying people with hepatitis C infection so they may be referred for treatment.
PMCID: PMC3185317  PMID: 22043097
10.  Tuberculosis in Indigenous Peoples in the U.S., 2003–2008 
Public Health Reports  2011;126(5):677-689.
We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs).
We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File.
Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (−27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (−3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma.
There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.
PMCID: PMC3151185  PMID: 21886328
11.  Disparities in Infectious Disease Hospitalizations for American Indian/Alaska Native People 
Public Health Reports  2011;126(4):508-521.
We described disparities in infectious disease (ID) hospitalizations for American Indian/Alaska Native (AI/AN) people.
We analyzed hospitalizations with an ID listed as the first discharge diagnosis in 1998–2006 for AI/AN people from the Indian Health Service National Patient Information Reporting System and compared them with records for the general U.S. population from the Nationwide Inpatient Survey.
The ID hospitalization rate for AI/AN people declined during the study period. The 2004–2006 mean annual age-adjusted ID hospitalization rate for AI/AN people (1,708 per 100,000 populiation) was slightly higher than that for the U.S. population (1,610 per 100,000 population). The rate for AI/AN people was highest in the Southwest (2,314 per 100,000 population), Alaska (2,063 per 100,000 population), and Northern Plains West (1,957 per 100,000 population) regions, and among infants (9,315 per 100,000 population). ID hospitalizations accounted for approximately 22% of all AI/AN hospitalizations. Lower-respiratory--tract infections accounted for the largest proportion of ID hospitalizations among AI/AN people (35%) followed by skin and soft tissue infections (19%), and infections of the kidney, urinary tract, and bladder (11%).
Although the ID hospitalization rate for AI/AN people has declined, it remains higher than that for the U.S. general population, and is highest in the Southwest, Northern Plains West, and Alaska regions. Lower-respiratory-tract infections; skin and soft tissue infections; and kidney, urinary tract, and bladder infections contributed most to these health disparities. Future prevention strategies should focus on high-risk regions and age groups, along with illnesses contributing to health disparities.
PMCID: PMC3115210  PMID: 21800745

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