Surveillance for Malaria Elimination in Swaziland: A National Cross-Sectional Study Using Pooled PCR and Serology

BACKGROUND: To guide malaria elimination efforts in Swaziland and other countries, accurate assessments of transmission are critical. Pooled-PCR has potential to efficiently improve sensitivity to detect infections; serology may clarify temporal and spatial trends in exposure. METHODOLOGY/PRINCIPAL FINDINGS: Using a stratified two-stage cluster, cross-sectional design, subjects were recruited from the malaria endemic region of Swaziland. Blood was collected for rapid diagnostic testing (RDT), pooled PCR, and ELISA detecting antibodies to Plasmodium falciparum surface antigens. Of 4330 participants tested, three were RDT-positive yet false positives by PCR. Pooled PCR led to the identification of one P. falciparum and one P. malariae infection among RDT-negative participants. The P. falciparum-infected participant reported recent travel to Mozambique. Compared to performing individual testing on thousands of samples, PCR pooling reduced labor and consumable costs by 95.5%. Seropositivity was associated with age ≥20 years (11·7% vs 1·9%, P<0.001), recent travel to Mozambique (OR 4.4 [95% CI 1.0-19.0]) and residence in southeast Swaziland (RR 3.78, P<0.001). CONCLUSIONS: The prevalence of malaria infection and recent exposure in Swaziland are extremely low, suggesting elimination is feasible. Future efforts should address imported malaria and target remaining foci of transmission. Pooled PCR and ELISA are valuable surveillance tools for guiding elimination efforts

Abstract 17339: Racial and Ethnic Minority Groups Are Under-Represented and Under-Reported in Guideline-Informing Heart Failure Clinical Trials

Introduction: Racial/ethnic diversity in clinical trials is essential to ensure that our evidence base reflects the population. We assessed the extent of reporting and representation of race/ethnicity in heart failure (HF) clinical trials referenced in the contemporary ACC/AHA HF guidelines. Methods: All randomized trials referenced in the 2013 ACC/AHA Heart Failure Guidelines and the 2017 Focused Update were included. The prevalence of reporting of race/ethnicity, the proportions of racial/ethnic subgroups enrolled, and subgroup analysis based on intervention type - pharmacologic, device, and other - were evaluated. Results: We identified 256 trials (545 233 subjects) published between 1950 and 2018. Among these, only 95 reported any race/ethnicity (37.1%), 94 reported white race (36.7%), 58 reported black race (22.7%), 16 reported Hispanic ethnicity (6.3%), and 23 reported Asian race (9.0%). In trials reporting white, black, Hispanic, and Asian race/ethnicity respectively, 76.4% (n = 299 153 of 299872) of patients were white, 11.7% (n = 25 274 of 215 905) of patients were black, 11.2% (n = of 8863 of 79 097) of patients were Hispanic, and 10.5% (n = 14925 of 141 504) of patients were Asian. Comparison of trial population proportions with US Census population demonstrates over-representation of white subjects, and under-representation of Hispanic and black subjects (Figure). Stratification by intervention type demonstrated that no device trials referenced in the guidelines report black or Asian race, and just one reported Hispanic race. Conclusions: Trials that dictate clinical care of patients with HF through informing contemporary ACC/AHA HF guidelines under-represent black and Hispanic populations. Additionally, 2/3rds of trials fail to report any race/ ethnicity at all. There is a need for guideline and practice-informing clinical trials to adequately represent all populations, and to provide clinicians the data they need to assess generalizability. </jats:p

Abstract 094: Evaluation of Readmission and Survival Rates After Heart Failure Hospitalization in the Veterans Affairs Health Care System Between 2006 and 2013

Objective: Evaluate trends in readmission and mortality rates after heart failure (HF) hospitalization among veterans in the era of improved utilization of guideline directed therapy and nation-wide focus on decreasing hospital readmission rates. Background: In the past decade, a strong emphasis has been placed on decreasing HF readmissions. Concurrently, adherence to guideline directed therapy has improved. A 2002 to 2006 evaluation of the Veterans Affairs Health Care System (VAHCS) showed stagnant HF readmission rates, but declining mortality rates. It is unclear to what extent the recent focus on decreasing readmission and following guidelines has affected these outcomes. Methods: The 30-day mortality and 30-day readmission rates of patients admitted with a first diagnosis of HF from 2006 to 2013 in the VAHCS were assessed for temporal trends. Odds ratios for these outcomes were adjusted for patient demographics, medical history, and laboratory data. Results: This study included 119,261 patients admitted to VAHCS institutions between 2006 and 2013 with a new diagnosis of HF. Among these patients, 116,849 were male, the mean age was 71.1 years, 80,497 were white, 24,753 were black, and 6,548 were Hispanic. During the two years preceding admission, the incidence of renal disease, ischemic heart disease, diabetes, malignancy, hypertension, COPD, CVD, and acute myocardial infarction were 46.1% (54,984 of 119,261), 73.5% (87,640 of 119,261), 56.1% (66,883 of 119,261), 16.2% (19,257 of 119,261), 92.8% (110,687 of 119,261), 53.7% (64,064 of 119,261), 22.9% (27,268 of 119,261), and 26.5% (31,619 of 119,261), respectively. During the study period, the 30-day readmission rate declined from 19.56% (3852 of 19,694) to 13.76% (1420 of 10,317, p &lt; 0.0001) with an adjusted odds ratio of 30-day readmission in 2013 (vs 2006) of 0.66 (95% CI: 0.66 to 0.76) (Figure 1). Conversely, the 30-day mortality rate was stable at 5.62% (1107 of 19,694) in 2006 and 5.30% (547 of 10,317) in 2013 (p = 0.45) with an adjusted odds ratio of 30-day mortality in 2013 (vs 2006) of 1.22 (95% CI: 1.09 to 1.37). This odds ratio was stable from 2007 through 2013. Conclusions: Despite the observed decline in 30-day readmission rates, 30-day mortality rates have been unaffected by the recent focus on preventing readmission and improved guideline adherence. </jats:p

Spatiotemporal Analysis of Malaria in Urban Ahmedabad (Gujarat), India: Identification of Hot Spots and Risk Factors for Targeted Intervention

The world population, especially in developing countries, has experienced a rapid progression of urbanization over the last half century. Urbanization has been accompanied by a rise in cases of urban infectious diseases, such as malaria. The complexity and heterogeneity of the urban environment has made study of specific urban centers vital for urban malaria control programs, whereas more generalizable risk factor identification also remains essential. Ahmedabad city, India, is a large urban center located in the state of Gujarat, which has experienced a significant Plasmodium vivax and Plasmodium falciparum disease burden. Therefore, a targeted analysis of malaria in Ahmedabad city was undertaken to identify spatiotemporal patterns of malaria, risk factors, and methods of predicting future malaria cases. Malaria incidence in Ahmedabad city was found to be spatially heterogeneous, but temporally stable, with high spatial correlation between species. Because of this stability, a prediction method utilizing historic cases from prior years and seasons was used successfully to predict which areas of Ahmedabad city would experience the highest malaria burden and could be used to prospectively target interventions. Finally, spatial analysis showed that normalized difference vegetation index, proximity to water sources, and location within Ahmedabad city relative to the dense urban core were the best predictors of malaria incidence. Because of the heterogeneity of urban environments and urban malaria itself, the study of specific large urban centers is vital to assist in allocating resources and informing future urban planning

County-Level Factors Associated With Cardiovascular Mortality by Race/Ethnicity.

Background Persistent racial/ethnic disparities in cardiovascular disease (CVD) mortality are partially explained by healthcare access and socioeconomic, demographic, and behavioral factors. Little is known about the association between race/ethnicity-specific CVD mortality and county-level factors. Methods and Results Using 2017 county-level data, we studied the association between race/ethnicity-specific CVD age-adjusted mortality rate (AAMR) and county-level factors (demographics, census region, socioeconomics, CVD risk factors, and healthcare access). Univariate and multivariable linear regressions were used to estimate the association between these factors; R2 values were used to assess the factors that accounted for the greatest variation in CVD AAMR by race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx individuals). There were 659 740 CVD deaths among non-Hispanic White individuals in 2698 counties; 100 475 deaths among non-Hispanic Black individuals in 717 counties; and 49 493 deaths among Hispanic/Latinx individuals across 267 counties. Non-Hispanic Black individuals had the highest mean CVD AAMR (320.04 deaths per 100 000 individuals), whereas Hispanic/Latinx individuals had the lowest (168.42 deaths per 100 000 individuals). The highest CVD AAMRs across all racial/ethnic groups were observed in the South. In unadjusted analyses, the greatest variation (R2) in CVD AAMR was explained by physical inactivity for non-Hispanic White individuals (32.3%), median household income for non-Hispanic Black individuals (24.7%), and population size for Hispanic/Latinx individuals (28.4%). In multivariable regressions using county-level factor categories, the greatest variation in CVD AAMR was explained by CVD risk factors for non-Hispanic White individuals (35.3%), socioeconomic factors for non-Hispanic Black (25.8%), and demographic factors for Hispanic/Latinx individuals (34.9%). Conclusions The associations between race/ethnicity-specific age-adjusted CVD mortality and county-level factors differ significantly. Interventions to reduce disparities may benefit from being designed accordingly