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DSHS Authors: 2015 Research Articles by DSHS Staff


The following list includes peer-reviewed research articles that have been written by staff of the Texas Department of State Health Services since its formation in September 2004. For more information about these articles or for a full-text copy, please contact the Medical and Research Library by e-mail at library@dshs.state.tx.us by calling (512) 776-7559.

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mrl-diamond2015 Articles (in date order with most recent first)

Forrester MB. Antiretroviral drug exposures reported to Texas poison centers [published online ahead of print]. J Pharm Technol.
BACKGROUND: A number of different antiretroviral drugs are used to manage patients with human immunodeficiency virus (HIV). OBJECTIVE: This study describes antiretroviral drug exposures reported to a large statewide poison center system. METHODS: Cases were all antiretroviral drug exposures reported to the Texas Poison Center Network during 2000-2014. The distribution of cases was determined for various demographic and clinical factors. RESULTS: Of 632 total exposures, the most commonly reported drugs were emtricitabine-tenofovir combination (17.1%), efavirenz-emtricitabine-tenofovir combination (13.8%), ritonavir (10.9%), lamivudine-zidovudine combination (10.3%), and efavirenz (10.1%). The annual number of antiretroviral drug exposures increased from 34 in 2000 to 67 in 2014. Males comprised 67.9% of the patients; 72.2% were 20 years or older. The exposures were 58.5% unintentional and 37.5% intentional. Only antiretroviral drugs were reported in 440 of the exposures. Of these exposures, 62.5% were managed on site, 28.0% were already at or en route to a healthcare facility when the poison center was contacted, and 8.6% were referred to a healthcare facility. The exposures were not serious in 88.7% of these cases. The most frequently reported adverse clinical effects were vomiting (5.7%), nausea (4.8%), dizziness/vertigo (3.2%), and drowsiness/lethargy (3.2%). CONCLUSIONS: The most commonly reported antiretroviral drugs were emtricitabine-tenofovir combination and efavirenz-emtricitabine-tenofovir combination. The patients were most likely to be adults and males. The exposures tended to be unintentional. Of those exposures involving only antiretroviral drugs, the majority of the exposures were not serious and could be managed outside of a healthcare facility.

O'Brien JL, Langlois PH, Lawson CC, et al. Maternal occupational exposure to polycyclic aromatic hydrocarbons and craniosynostosis among offspring in the national birth defects prevention study [published online ahead of print June 2, 2015]. Birth Defects Res A Clin Mol Teratol. doi: 10.1002/bdra.23389.
BACKGROUND: Evidence in animal models and humans suggests that exposure to polycyclic aromatic hydrocarbons (PAHs) may lead to birth defects. To our knowledge, this relationship has not been evaluated for craniosynostosis, a birth defect characterized by the premature closure of sutures in the skull. We conducted a case-control study to examine associations between maternal occupational exposure to PAHs and craniosynostosis. METHODS: We used data from craniosynostosis cases and control infants in the National Birth Defects Prevention Study (NBDPS) with estimated delivery dates from 1997 to 2002. Industrial hygienists reviewed occupational data from the computer-assisted telephone interview and assigned a yes/no rating of probable occupational PAH exposure for each job from 1 month before conception through delivery. We used logistic regression to assess the association between occupational exposure to PAHs and craniosynostosis. RESULTS: The prevalence of exposure was 5.3% in case mothers (16/300) and 3.7% in control mothers (107/2,886). We observed a positive association between exposure to PAHs during the 1 month before conception through the third month of pregnancy and craniosynostosis (odds ratio [OR] = 1.75; 95% confidence interval [CI], 1.01-3.05) after adjusting for maternal age and maternal education. The number of cases for each craniosynostosis subtype limited subtype analyses to sagittal craniosynostosis; the odds ratio remained similar (OR = 1.76, 95% CI, 0.82-3.75), but was not significant. CONCLUSION: Our findings support a moderate association between maternal occupational exposure to PAHs and craniosynostosis. Additional work is needed to better characterize susceptibility and the role PAHs may play on specific craniosynostosis subtypes. Birth Defects Research (Part A), 2015.

Reefhuis J, Gilboa SM, Anderka M, et al. The national birth defects prevention study: A review of the methods [published online ahead of print June 2, 2015]. Birth Defects Res A Clin Mol Teratol. doi: 10.1002/bdra.23384.
BACKGROUND: The National Birth Defects Prevention Study (NBDPS) is a large population-based multicenter case-control study of major birth defects in the United States. METHODS: Data collection took place from 1998 through 2013 on pregnancies ending between October 1997 and December 2011. Cases could be live born, stillborn, or induced terminations, and were identified from birth defects surveillance programs in Arkansas, California, Georgia, Iowa, Massachusetts, New Jersey, New York, North Carolina, Texas, and Utah. Controls were live born infants without major birth defects identified from the same geographical regions and time periods as cases by means of either vital records or birth hospitals. Computer-assisted telephone interviews were completed with women between 6 weeks and 24 months after the estimated date of delivery. After completion of interviews, families received buccal cell collection kits for the mother, father, and infant (if living). RESULTS: There were 47,832 eligible cases and 18,272 eligible controls. Among these, 32,187 (67%) and 11,814 (65%), respectively, provided interview information about their pregnancies. Buccal cell collection kits with a cytobrush for at least one family member were returned by 19,065 case and 6,211 control families (65% and 59% of those who were sent a kit). More than 500 projects have been proposed by the collaborators and over 200 manuscripts published using data from the NBDPS through December 2014. CONCLUSION: The NBDPS has made substantial contributions to the field of birth defects epidemiology through its rigorous design, including case classification, detailed questionnaire and specimen collection, large study population, and collaborative activities across Centers. Birth Defects Research (Part A), 2015.

Swartz MD, Cai Y, Chan W, et al. Air toxics and birth defects: a Bayesian hierarchical approach to evaluate multiple pollutants and spina bifida. Environ Health. 2015;14(1):16. doi: 10.1186/1476-069X-14-16.
BACKGROUND: While there is evidence that maternal exposure to benzene is associated with spina bifida in offspring, to our knowledge there have been no assessments to evaluate the role of multiple hazardous air pollutants (HAPs) simultaneously on the risk of this relatively common birth defect. In the current study, we evaluated the association between maternal exposure to HAPs identified by the United States Environmental Protection Agency (U.S. EPA) and spina bifida in offspring using hierarchical Bayesian modeling that includes Stochastic Search Variable Selection (SSVS). METHODS: The Texas Birth Defects Registry provided data on spina bifida cases delivered between 1999 and 2004. The control group was a random sample of unaffected live births, frequency matched to cases on year of birth. Census tract-level estimates of annual HAP levels were obtained from the U.S. EPA's 1999 Assessment System for Population Exposure Nationwide. Using the distribution among controls, exposure was categorized as high exposure (>95(th) percentile), medium exposure (5(th)-95(th) percentile), and low exposure (<5(th) percentile, reference). We used hierarchical Bayesian logistic regression models with SSVS to evaluate the association between HAPs and spina bifida by computing an odds ratio (OR) for each HAP using the posterior mean, and a 95% credible interval (CI) using the 2.5(th) and 97.5(th) quantiles of the posterior samples. Based on previous assessments, any pollutant with a Bayes factor greater than 1 was selected for inclusion in a final model. RESULTS: Twenty-five HAPs were selected in the final analysis to represent "bins" of highly correlated HAPs (ρ > 0.80). We identified two out of 25 HAPs with a Bayes factor greater than 1: quinoline (ORhigh = 2.06, 95% CI: 1.11-3.87, Bayes factor = 1.01) and trichloroethylene (ORmedium = 2.00, 95% CI: 1.14-3.61, Bayes factor = 3.79). CONCLUSIONS: Overall there is evidence that quinoline and trichloroethylene may be significant contributors to the risk of spina bifida. Additionally, the use of Bayesian hierarchical models with SSVS is an alternative approach in the evaluation of multiple environmental pollutants on disease risk. This approach can be easily extended to environmental exposures, where novel approaches are needed in the context of multi-pollutant modeling.

Schillie S, Walker T, Veselsky S, et al. Outcomes of Infants Born to Women Infected With Hepatitis B [published online ahead of print April 20, 2015]. Pediatrics.
BACKGROUND AND OBJECTIVES: Perinatal exposure is an important mode of hepatitis B virus (HBV) transmission, resulting in chronic disease in ∼90% of infected infants. Immunoprophylaxis recommended for infants born to hepatitis B surface antigen-positive mothers reduces up to 95% of perinatal HBV infections. We sought to identify factors associated with perinatal HBV transmission. METHODS: We analyzed prospectively collected data from 5 of 64 US-funded Perinatal Hepatitis B Prevention Programs during 2007-2013. We examined effects of maternal demographic and laboratory results, infant gestational age and birth weight, and immunoprophylactic management on perinatal HBV infection. RESULTS: Data from 17 951 mother-infant pairs were analyzed. Among 9252 (51.5%) infants for whom hepatitis B surface antigen testing results were available, 100 (1.1%) acquired perinatal HBV infection. Both hepatitis B (HepB) vaccine and hepatitis B immune globulin were administered within 12 hours of birth for 10 760 (94.9%) of 11 335 infants with information. Perinatal HBV infection was associated with younger maternal age (P = .01), Asian/Pacific Islander race (P < .01), maternal hepatitis B e-antigen positivity (P < .01), maternal antibody to hepatitis B e-antigen negativity (P < .01), maternal viral load ≥2000 IU/mL (P = .04), and infant receipt of <3 HepB vaccine doses (P = .01). Four infants born to 429 mothers with viral load testing were infected; all 4 were born to mothers with viral loads in the ninth or tenth decile. CONCLUSIONS: Perinatal HBV infection occurred among 1% of infants, most of whom received recommended immunoprophylaxis. Infants at greatest risk of infection were those born to women who were younger, hepatitis B e-antigen positive, or who had a high viral load or those infants who received <3 HepB vaccine doses.

Abanyie F, Harvey RR, Harris JR, et al. 2013 multistate outbreaks of Cyclospora cayetanensis infections associated with fresh produce: focus on the Texas investigations [published online ahead of print April 13, 2015]. Epidemiol Infect.
The 2013 multistate outbreaks contributed to the largest annual number of reported US cases of cyclosporiasis since 1997. In this paper we focus on investigations in Texas. We defined an outbreak-associated case as laboratory-confirmed cyclosporiasis in a person with illness onset between 1 June and 31 August 2013, with no history of international travel in the previous 14 days. Epidemiological, environmental, and traceback investigations were conducted. Of the 631 cases reported in the multistate outbreaks, Texas reported the greatest number of cases, 270 (43%). More than 70 clusters were identified in Texas, four of which were further investigated. One restaurant-associated cluster of 25 case-patients was selected for a case-control study. Consumption of cilantro was most strongly associated with illness on meal date-matched analysis (matched odds ratio 19·8, 95% confidence interval 4·0-∞). All case-patients in the other three clusters investigated also ate cilantro. Traceback investigations converged on three suppliers in Puebla, Mexico. Cilantro was the vehicle of infection in the four clusters investigated; the temporal association of these clusters with the large overall increase in cyclosporiasis cases in Texas suggests cilantro was the vehicle of infection for many other cases. However, the paucity of epidemiological and traceback information does not allow for a conclusive determination; moreover, molecular epidemiological tools for cyclosporiasis that could provide more definitive linkage between case clusters are needed. 

Langlois PH, Lee M, Lupo PJ, Rahbar MH, Cortez RK. Residential radon and birth defects: a population-based assessment [published online ahead of print Apr 6, 2015]. Birth Defects Res A Clin Mol Teratol. doi: 10.1002/bdra.23369.
BACKGROUND: Associations have been reported between maternal radiation exposure and birth defects. No such studies were found on radon. Our objective was to determine if there is an association between living in areas with higher radon levels and birth defects. METHODS: The Texas Birth Defects Registry provided data on all birth defects from 1999 to 2009 from the entire state. Mean radon levels by geologic region came from the Texas Indoor Radon Survey. The association between radon and birth defects was estimated using multilevel mixed effect Poisson regression. RESULTS: Birth defects overall were not associated with residential radon levels. Of the 100 other birth defect groups with at least 500 cases, 14 were significantly elevated in areas with high mean radon level in crude analyses, and 9 after adjustment for confounders. Cleft lip with/without cleft palate had an adjusted prevalence ratio of 1.16 per 1 picoCurie/liter (pCi/L) increase in exposure to region mean radon, 95% confidence interval, 1.08-1.26. Cystic hygroma / lymphangioma had an adjusted prevalence ratio of 1.22 per 1 pCi/L increase, 95% confidence interval, 1.02-1.46. Other associations were suggested but not as consistent: three skeletal defects, Down syndrome, other specified anomalies of the brain, and other specified anomalies of the bladder and urethra. CONCLUSION: In the first study of residential radon and birth defects, we found associations with cleft lip w/wo cleft palate and cystic hygroma / lymphangioma. Other associations were suggested. The ecological nature of this study and multiple comparisons suggest that our results be interpreted with caution. Birth Defects Research (Part A), 2015. 

Forrester MB. Narcissus: A potentially toxic case of mistaken identity. TX Public Health J. 2015;67(2):5-6.
No abstract.

Forrester MB. Pediatric ingestions of sodium phosphate laxatives. TX Public Health J. 2015;67(2):6.
No abstract.

Forrester MB. Pediatric exposures to electronic cigarettes reported to Texas poison centers [published online ahead of print March 20, 2015]. J Emerg Med.
BACKGROUND: Electronic cigarette use is increasing. There are concerns that pediatric exposures to these products may result in serious adverse affects. OBJECTIVES: This study describes pediatric exposures to electronic cigarettes. METHODS: Cases were electronic cigarette exposures among patients age 5 years or less reported to Texas poison centers during January 2010-June 2014. The distribution by selected variables was determined. RESULTS: Of 203 exposures, two cases were reported in 2010, five in 2011, 20 in 2012, 70 in 2013, and 106 in January-June 2014. Fifty-one percent of the patients were male; 32% of the patients were aged 1 year, and 42% were 2 years of age. Ninety-six percent of the exposures occurred at the patient's own residence. The exposure routes were ingestion (93%), dermal (11%), ocular (3%), and inhalation (2%). Fifty-eight percent of the patients were managed on site. Of the patients seen at a health care facility, 69% were treated or evaluated and released. Eleven percent of the exposures were serious. The most commonly reported clinical effects were vomiting (24%), drowsiness/lethargy (2%), and cough/choke (2%). The most frequent treatments were dilution/irrigation/wash (65%) and food/snack (16%). CONCLUSIONS: Electronic cigarette exposures involving young children reported to poison centers are increasing. Such exposures are likely to involve patients ages 2-3 years, occur at the child's own residence, and occur by ingestion. Further study is needed to determine which subgroups are at risk for serious outcomes and warrant evaluation at a health care facility.

Kidd S, Zaidi A, Asbel L, et al. Comparison of antimicrobial susceptibility of pharyngeal, rectal, and urethral Neisseria gonorrhoeae isolates among men who have sex with men [published online ahead of print February 17, 2015]. Antimicrob Agents Chemother.
The United States' surveillance for Neisseria gonorrhoeae antimicrobial susceptibility is based exclusively on male urethral isolates. These data inform gonorrhea treatment guidelines, including recommendations for treatment of extra-genital infection, but data on the susceptibility of extra-genital isolates are limited. We compared the antimicrobial susceptibility of pharyngeal, rectal, and urethral gonococcal isolates collected from men who have sex with men (MSM) at five sentinel sites throughout the United States. Minimum inhibitory concentrations (MICs) were determined by the agar dilution method. Generalized linear models were used to compare (1) the proportions of isolates with elevated MICs and (2) geometric mean MICs by anatomic site adjusted for city. During December 2011-September 2013, a total of 205 pharyngeal, 261 rectal, and 976 urethral isolates were obtained. The proportion of isolates with elevated ceftriaxone MICs (≥0.125 μg/ml) did not differ by anatomic site (0.5% of pharyngeal, 1.5% of rectal, and 1.7% of urethral isolates; city-adjusted odds ratio [95% CI] 0.4 [0.0, 3.9] for pharyngeal vs. urethral isolates, 0.9 [0.2, 4.2] for rectal vs. urethral isolates). The city-adjusted geometric mean ceftriaxone MICs of pharyngeal (0.0153 μg/ml) and rectal (0.0157 μg/ml) isolates did not differ from that of urethral isolates (0.0150 μg/ml) (ratio of geometric mean MICs [95% CI] 1.02 [0.90, 117] and 1.05 [0.93, 1.19], respectively). Similar results were observed for other antimicrobials, including cefixime and azithromycin. These findings suggest that, at the population level, gonococcal antimicrobial susceptibility surveillance based on urethral isolates from MSM adequately represents the susceptibility of N. gonorrhoeae circulating among MSM.

Vinikoor-Imler LC, Stewart TG, Luben TJ, Davis JA, Langlois PH. An exploratory analysis of the relationship between ambient ozone and particulate matter concentrations during early pregnancy and selected birth defects in Texas [published online ahead of print March 14, 2015]. Environ Pollut. 2015;202:1-6. doi: 10.1016/j.envpol.2015.03.001.
We performed an exploratory analysis of ozone (O3) and fine particulate matter (PM2.5) concentrations during early pregnancy and multiple types of birth defects. Data on births were obtained from the Texas Birth Defects Registry (TBDR) and the National Birth Defects Prevention Study (NBDPS) in Texas. Air pollution concentrations were previously determined by combining modeled air pollution concentrations with air monitoring data. The analysis generated hypotheses for future, confirmatory studies; although many of the observed associations were null. The hypotheses are provided by an observed association between O3 and craniosynostosis and inverse associations between PM2.5 and septal and obstructive heart defects in the TBDR. Associations with PM2.5 for septal heart defects and ventricular outflow tract obstructions were null using the NBDPS. Both the TBDR and the NBPDS had inverse associations between O3 and septal heart defects. Further research to confirm the observed associations is warranted.

Forrester MB, Bojes H. Adolescent pesticide exposures reported to Texas poison centers [published online ahead of print March 7, 2015]. Int J Adolesc Med Health. doi: 10.1515/ijamh-2014-0072
Abstract: BACKGROUND: Pesticides, particularly when misused, can cause serious morbidity and mortality. There is limited literature on pesticide exposures among adolescents. OBJECTIVE: The purpose of this study was to describe adolescent pesticide exposures reported to poison centers and compare them to adult exposures. SUBJECTS: Pesticide exposures reported to Texas poison centers during 2000-2013 where the patient was age 13 years or greater. METHODS: Cases were divided into adolescents (13-19 years) and adults (20 years or more). The distribution of the cases was determined for various factors, and comparisons were made between the two age groups. RESULTS: There were 2772 adolescent and 33,573 adult pesticide exposures. The most common types of pesticide among adolescent and adult cases, respectively, were insecticides (71% vs. 76%), herbicides (6% vs. 9%), repellents (11% vs. 8%), and rodenticides (10% vs. 5%). Adolescent patients were 56% male and 43% female; adult patients were 45% male and 55% female. The most common exposure routes among adolescent and adult cases, respectively, were dermal (29% vs. 38%), inhalation (22% vs. 33%), ingestion (47% vs. 29%), and ocular (14% vs. 13%). The exposure reason for adolescent and adult exposures, respectively, were unintentional (82% vs. 89%), intentional (13% vs. 7%), adverse reaction (2% vs. 3%), and other/unknown (3% vs. 1%). CONCLUSION: Compared to adult exposures, adolescent pesticide exposures were more likely to involve repellents and rodenticides, involve males, occur by ingestion, and be intentional.

Wang Y, Liu G, Canfield MA, et al. Racial/Ethnic differences in survival of United States children with birth defects: a population-based study. J Pediatr. pii: S0022-3476(14)01194-9. doi: 10.1016/j.jpeds.2014.12.025.
OBJECTIVES: To examine racial/ethnic-specific survival of children with major birth defects in the US. STUDY DESIGN: We pooled data on live births delivered during 1999-2007 with any of 21 birth defects from 12 population-based birth defects surveillance programs. We used the Kaplan-Meier method to calculate cumulative survival probabilities and Cox proportional hazards models to estimate mortality risk. RESULTS: For most birth defects, there were small-to-moderate differences in neonatal (<28 days) survival among racial/ethnic groups. However, compared with children born to non-Hispanic white mothers, postneonatal infant (28 days to <1 year) mortality risk was significantly greater among children born to non-Hispanic black mothers for 13 of 21 defects (hazard ratios [HRs] 1.3-2.8) and among children born to Hispanic mothers for 10 of 21 defects (HRs 1.3-1.7). Compared with children born to non-Hispanic white mothers, a significantly increased childhood (≤8 years) mortality risk was found among children born to Asian/Pacific Islander mothers for encephalocele (HR 2.6), tetralogy of Fallot, and atrioventricular septal defect (HRs 1.6-1.8) and among children born to American Indian/Alaska Native mothers for encephalocele (HR 2.8), whereas a significantly decreased childhood mortality risk was found among children born to Asian/Pacific Islander mothers for cleft lip with or without cleft palate (HR 0.6). CONCLUSION: Children with birth defects born to non-Hispanic black and Hispanic mothers carry a greater risk of mortality well into childhood, especially children with congenital heart defect. Understanding survival differences among racial/ethnic groups provides important information for policy development and service planning.

Forrester MB, Hinson D. Ebola goes viral: Google Trends pattern of Ebola searches during recent Ebola outbreak in Texas. TX Public Health J. 2015;67(1):4-6.
No abstract.

Ordonez JE, Kleinschmidt KC, Forrester MB. Electronic cigarette exposures reported to Texas poison centers. Nicotine Tob Res. 2015;17(2):209-11. doi: 10.1093/ntr/ntu223.

INTRODUCTION: Exposure to the liquid nicotine solutions in electronic cigarettes (e-cigs) may be dangerous because they are highly concentrated. Little is known about the impact of exposure on public health. This study describes e-cig exposures reported to poison centers. METHODS: All e-cig exposures reported to Texas poison centers during 2009 to February 2014 were identified. Exposures involving other substances in addition to e-cigs and exposures not followed to a final medical outcome were included. The distributions of exposures by demographic and clinical factors were determined. RESULTS: Of 225 total exposures, 2 were reported in January 2009, 6 in 2010, 11 in 2011, 43 in 2012, 123 in 2013, and 40 through February 2014. Fifty-three percent (n = 119) occurred among individuals aged <5 years old, 41% (n = 93) occurred among individuals aged >20 years old, and 6% (n = 13) occurred among individuals aged 6-19 years. Fifty percent were female. The route of exposure was 78% ingestion. Eighty-seven percent of the exposures were unintentional, and 5% were intentional. The exposures occurred at patients' own residences in 95% of the cases. The clinical effects reported most often were vomiting (20%), nausea (10%), headache (4%), ocular irritation (5%), dizziness (5%), and lethargy (2%). CONCLUSION: E-cig exposures reported to poison centers are increasing. Most of the patients are young children, and the exposures most frequently occur through ingestion. Reported exposures often do not have serious outcomes.

Yazdy MM, Werler MM, Anderka M, Langlois PH, Vieira VM. Spatial analysis of gastroschisis in Massachusetts and Texas. Ann Epidemiol. 2015;25(1):7-14. doi: 10.1016/j.annepidem.2014.10.001.
PURPOSE: Previous research has suggested gastroschisis, a congenital malformation, may be linked to environmental or infectious factors and cases can occur in clusters. The objective of this study was to identify geographic areas of elevated gastroschisis risk. METHODS: Cases of gastroschisis were identified from birth defect registries in Massachusetts and Texas. Random samples of live births were selected as controls. Generalized additive models were used to create a continuous map surface of odds ratios (ORs) by smoothing over latitude and longitude. Maternal age, race/ethnicity, education, cigarette smoking, and insurance status (MA only) were assessed for confounding. We used permutation tests to identify statistically significant areas of increased risk. RESULTS: An area of increased risk was identified in North Central Massachusetts but was not significant after adjustment (P value = .07; OR = 2.0). In Texas, two statistically significant areas of increased risk were identified after adjustment (P value = .02; OR = 1.3 and 1.2). Texas had sufficient data to assess the combination of space and time, which identified an increased risk in 2003 and 2004. CONCLUSIONS: This study suggests there were areas of elevated gastroschisis risk in Massachusetts and Texas, which cannot be explained by the risk factors we assessed. Additional exploration of underlying artifactual, environmental, infectious, or behavioral factors may further our understanding of gastroschisis.

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Last updated June 15, 2015