Most infections with pandemic Vibrio cholerae are thought to result in subclinical disease and are not captured by surveillance. Previous estimates of the ratio of infections to clinical cases have varied widely (2 to 100). Understanding cholera epidemiology and immunity relies on the ability to translate between numbers of clinical cases and the underlying number of infections in the population. We estimated the infection incidence during the first months of an outbreak in a cholera-naive population using a Bayesian vibriocidal antibody titer decay model combining measurements from a representative serosurvey and clinical surveillance data. 3,880 suspected cases were reported in Grande Saline, Haiti, between 20 October 2010 and 6 April 2011 (clinical attack rate 18.4%). We found that more than 52.6% (95% Credible Interval (CrI) 49.4-55.7) of the population ≥2 years showed serologic evidence of infection, with a lower infection rate among children aged 2-4 years (35.5%; 95%CrI 24.2-51.6) compared with people ≥5 years (53.1%; 95%CrI 49.4-56.4). This estimated infection rate, nearly three times the clinical attack rate, with underdetection mainly seen in those ≥5 years, has likely impacted subsequent outbreak dynamics. Our findings show how seroincidence estimates improve understanding of links between cholera burden, transmission dynamics and immunity.

On December 12, 2022, a panel seminar organized by the American Journal of Field Epidemiology (AJFE) was held with the enthusiastic support of the National Institute of Health of Colombia. More than 200 professionals from Colombia, Peru, Brazil, El Salvador, Canada, the USA, Ecuador, Costa Rica, Chile, and Mexico participated. The panelists, moderated by Dr. Marjorie Pollack, member of the AJFE Editorial Board and associate editor of ProMED, presented the epidemiological characteristics of the pandemic in Colombia, Brazil, Costa Rica, Puerto Rico, Haiti, and the Dominican Republic, as well as the public health response with which it was responded to mitigate and control it. The panelists emphasized the value of the preparation provided by the existence of field epidemiology training programs, the existence of a response plan, of establishing good communication with decision makers to make them collectively. The Costa Rican experience of using epidemiology to facilitate the provision of health services to patients with COVID-19 was shared. Likewise, the panelists emphasized that the misinformation, spread on the internet and some other means, had a negative impact, and the experience of educating those working for the news media was shared. It was commented that greater agility is needed to respond early to events that could lead to a pandemic. The panelists added the pandemic highlighted, more than ever before, the importance of having appropriate communication strategies to inform the public.

Abstract Background: Healthcare workers are an exposed group for SARS-CoV-2, and this exposure is a public health priority. Transmission can occur from infected patients to staff and from infected staff to patients and co-workers, thus undermining the health care system. This study estimated the seroprevalence in this population and identified some associated factors. Methods: We analyzed the exposure of healthcare workers in ten (10) large hospitals providing care to patients with COVID-19 by testing for antibodies to SARS-CoV-2. Potential risk factors such as age, vaccination history, and barrier measures such as masking were explored through a questionnaire. Results: From December 06 to 15, 2021, among 3743 health care workers in major hospitals providing care to patients with COVID-19, a sample of 566 had received serological testing for SARS-CoV-2. The mean age was 39 years, 62% were female, and approximately 12% had hypertension. The vast majority did not reveal any signs or symptoms compatible with COVID-19, and 62% had already received the anti-COVID-19 vaccine. The national prevalence regardless of vaccination status was 44%, with a predominance of male gender, age group 60 and older, and the Western Department. The prevalenceamong unvaccinated persons was 11.59%, and never wearing masks was associated with an increased risk of developing antibodies to SARS-CoV-2. Conclusion: Among health care workers, COVID-19 affects both sexes with a female predominance. The age group over 60 years is the most affected, and not wearing a mask is a risk factor associated with virus detection.

Since 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has supported implementation and maintenance of health information systems for HIV/AIDS and related diseases, such as tuberculosis, in numerous countries. As the COVID-19 pandemic emerged, several countries conducted rapid assessments and enhanced existing PEPFAR-funded HIV and national health information systems to support COVID-19 surveillance data collection, analysis, visualization, and reporting needs. We describe efforts at the US Centers for Disease Control and Prevention (CDC) headquarters in Atlanta, Georgia, USA, and CDC country offices that enhanced existing health information systems in support COVID-19 pandemic response. We describe CDC activities in Haiti as an illustration of efforts in PEPFAR countries. We also describe how investments used to establish and maintain standards-based health information systems in resource-constrained settings can have positive effects on health systems beyond their original scope.

BackgroundHaiti's first COVID-19 cases were confirmed on March 18, 2020, and subsequently spread throughout the country. The objective of this study was to describe clinical manifestations of COVID-19 in Haitian outpatients and to identify risk factors for severity of clinical manifestations. MethodsWe conducted a retrospective study of COVID-19 outpatients diagnosed from March 18-August 4, 2020, using demographic, epidemiological, and clinical data reported to the Ministry of Health (MoH). We used univariate and multivariate analysis, including multivariable logistic regression, to explore the risk factors and specific symptoms related to persons with symptomatic COVID-19 and the severity of symptomatic COVID-19 disease. ResultsOf 5,389 cases reported to MOH during the study period, 1,754 (32.5%) were asymptomatic. Amongst symptomatic persons 2,747 (75.6%) had mild COVID-19 and 888 (24.4%) had moderate-to-severe disease; the most common symptoms were fever (69.6%), cough (51.9%), and myalgia (45.8%). The odds of having moderate-to-severe disease were highest among persons with hypertension (aOR = 1.72, 95% Confidence Interval [CI] (1.34, 2.20), chronic pulmonary disease (aOR = 3.93, 95% CI (1.93, 8.17)) and tuberculosis (aOR = 3.44, 95% CI (1.35, 9.14)) compared to persons without those conditions. The odds of having moderate-to-severe disease increased with age but was also seen among children aged 0-4 years (OR: 1.73, 95% CI (0.93, 3.08)), when using 30-39 years old as the reference group. All of the older age groups, 50-64 years, 65-74 years, 75-84 years, and 85+ years, had significantly higher odds of having moderate-to-severe COVID-19 compared with ages 30-39 years. Diabetes was associated with elevated odds of moderate-to-severe disease in bivariate analysis (OR = 2.17, 95% CI (1.58,2.98) but, this association did not hold in multivariable analyses (aOR = 1.22,95%CI (0.86,1.72)). ConclusionThese findings from a resource-constrained country highlight the importance of surveillance systems to track emerging infections and their risk factors. In addition to co-morbidities described elsewhere, tuberculosis was a risk factor for moderate-to-severe COVID-19 disease.

BACKGROUND:Streptococcus pneumoniae, or pneumococcus, is a leading cause of morbidity and mortality in children worldwide. Pneumococcal conjugate vaccines (PCV) reduce carriage in the nasopharynx, preventing disease. We conducted a pneumococcal carriage study to estimate the prevalence of pneumococcal colonization, identify risk factors for colonization, and describe antimicrobial susceptibility patterns among pneumococci colonizing young children in Port-au-Prince, Haiti, before introduction of 13-valent PCV (PCV13).METHODS:We conducted a cross-sectional study of children aged 6-24 months at an immunization clinic in Port-au-Prince between September 2015 and January 2016. Consenting parents were interviewed about factors associated with pneumococcal carriage; nasopharyngeal swabs were collected from each child and cultured for pneumococcus after broth enrichment. Pneumococcal isolates were serotyped and underwent antimicrobial susceptibility testing. We compared frequency of demographic, clinical, and environmental factors among pneumococcus-colonized children (carriers) to those who were not colonized (noncarriers) using unadjusted bivariate analysis and multivariate logistic regression.RESULTS:Pneumococcus was isolated from 308 of the 685 (45.0%) children enrolled. Overall, 157 isolates (50.8%) were PCV13 vaccine-type serotypes; most common were 6A (13.3%), 19F (12.6%), 6B (9.7%), and 23F (6.1%). Vaccine-type isolates were significantly more likely to be nonsusceptible to ≥1 antimicrobial (63.1% vs 45.4%, P = .002). On bivariate analysis, carriers were significantly more likely than noncarriers to live in a household without electricity or running water, to share a bedroom with ≥3 people, to have a mother or father who did not complete secondary education, and to have respiratory symptoms in the 24 hours before enrollment (P < .05 for all comparisons). On multivariable analysis, completion of the pentavalent vaccination series (targeting diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenzae type b) remained significantly more common among noncarriers.CONCLUSIONS:Nearly a quarter of healthy children surveyed in Haiti were colonized with vaccine-type pneumococcal serotypes. This baseline carriage study will enable estimation of vaccine impact following nationwide introduction of PCV13.

Rotavirus is responsible for 26% of diarrheal deaths in Latin America and the Caribbean. Haiti introduced the monovalent rotavirus vaccine in April 2014. The objective of this analysis is to describe the impact of the rotavirus vaccine on hospitalizations among Haitian children younger than 5 years old during the first 5 years after introduction. This analysis includes all children with diarrhea who were enrolled as part of a sentinel surveillance system at two hospitals from May 2013 to April 2019. We compare the proportion of rotavirus-positive specimens in each post-vaccine introduction year to the pre-vaccine period. To account for the potential dilution of the proportion of rotavirus-positive specimens from a waning cholera outbreak, we also analyzed annual trends in the absolute number of positive stools, fit a two-component finite mixture model to the negative specimens, and fit a negative binomial time series model to the pre-vaccine rotavirus-positive specimens to predict the number of rotavirus diarrhea hospital admissions in the absence of rotavirus vaccination. The overall percentage of rotavirus-positive specimens declined by 22% the first year after introduction, increased by 17% the second year, and declined by 33% to 50% the subsequent 3 years. All sensitivity analyses confirmed an overall decline. We observed a clear annual rotavirus seasonality before and after vaccine introduction, with the greatest activity in December through April, and a biennial pattern, with high sharp peaks and flatter longer periods of increased rotavirus activity in alternating years, consistent with suboptimal vaccination coverage. Overall, our study shows evidence that the introduction of the rotavirus vaccine reduced the burden of severe rotavirus diarrhea.

This study describes the apparent discontinuation of cholera transmission in Haiti since February 2019. Because vulnerabilities persist and vaccination remains limited, our findings suggest that case-area targeted interventions conducted by rapid response teams played a key role. We question the presence of environmental reservoirs in Haiti and discuss progress toward elimination.

The dissemination of COVID-19 around the globe has been followed by an increased consumption of antibiotics. This is related to the concern for bacterial superinfection in COVID-19 patients. The identification of bacterial pathogens is challenging in low and middle income countries (LMIC), as there are no readily-available and cost-effective clinical or biological markers that can effectively discriminate between bacterial and viral infections. Fortunately, faced with the threat of COVID-19 spread, there has been a growing awareness of the importance of antimicrobial stewardship programs, as well as infection prevention and control measures that could help reduce the microbial load and hence circulation of pathogens, with a reduction in dissemination of antimicrobial resistance. These measures should be improved particularly in developing countries. Studies need to be conducted to evaluate the worldwide evolution of antimicrobial resistance during the COVID-19 pandemic, because pathogens do not respect borders. This issue takes on even greater importance in developing countries, where data on resistance patterns are scarce, conditions for infectious pathogen transmission are optimal, and treatment resources are suboptimal.

Background An effective laboratory system is an essential component of a public health system caring for patients with communicable and non-communicable diseases. Unfortunately, in developing countries this system is often sub-optimal, which negatively impacts health care. This paper describes the current situation of the clinical laboratory sector in Haiti and highlights challenges that exist in Haiti and other developing countries as they try to establish a clinical laboratory system. Method A cross-sectional survey was conducted in 30 laboratories across Haiti from January 19 to February 4, 2016. The laboratories surveyed were public or mixed public-private sector facilities belonging to different levels of the healthcare hierarchy. Labs were visited and directors of the health care institutions, lab managers, and members of their teams were interviewed and National Public Health Laboratory documents and information about the legal framework of the laboratory system was reviewed. Results The National Laboratory of Public Health is the reference lab for the national lab network and plays a key role in epidemiologic surveillance. Investigators felt that that the general conditions in the nation’s labs (83%) are good, but numerous deficiencies are identified. Electricity is often limited and 86% of facilities have mixed energy system. Bacterial cultures and susceptibilities are not performed. Most of the lab technologists (88.2%) have received only 2 two-year training certificates, while only the remainder (11.8%) had completed three-year programs training. Few continuing education opportunities are available. Equipment repair is available in more facilities (83%) than routine maintenance (63%) and is complicated by the diversity of brands employed. A total of 93% of the labs participate in the quality control program run by the National Lab. Conclusion The establishment of an effective national laboratory system requires coordination and input from many areas, including regulation of the sector, training of the technicians, sound infrastructure (including a stable supply of electricity) and dependable communications. Achieving this in developing countries will only be possible if different actors, national and international, coordinate their efforts.

Background: Rotavirus vaccines are effective in preventing severe rotavirus. Haiti introduced 2-dose monovalent (G1P[8]) rotavirus vaccine recommended for infants at 6 and 10 weeks of age in 2014. We calculated the effectiveness of rotavirus vaccine against hospitalization for acute gastroenteritis in Haiti. Methods: We enrolled children 6-59 months old admitted May 2014-September 2019 for acute watery diarrhea at any sentinel surveillance hospital. Stool was tested for rotavirus using enzyme immunoassay (EIA) and genotyped with multiplex one-step RT-PCR assay and Sanger sequencing for stratification by genotype. We used a case-negative design where cases were children positive for rotavirus and controls were negative for rotavirus. Only children eligible for vaccination were included and a child was consid-ered vaccinated if vaccine was given >= 14 days before enrollment. We used unconditional logistic regres-sion to calculate odds ratios and calculated 2-dose and 1-dose vaccine effectiveness (VE) as (1 -odds ratio) * 100. Results: We included 129 (19%) positive cases and 543 (81%) negative controls. Among cases, 77 (60%) were positive for equine-like G3P[8]. Two doses of rotavirus vaccine were 66% (95% CI: 44, 80) effective against hospitalizations due to any strain of rotavirus and 64% (95% CI: 33, 81) effective against hospital-izations due to the equine-like G3P[8] genotype. Conclusions: These findings are comparable to other countries in the Americas region. To the best of our knowledge, this is the first VE estimate both against the equine-like G3P[8] genotype and from a Caribbean country. Overall, these results support rotavirus vaccine use and demonstrate the importance of complete vaccination. Published by Elsevier Ltd.

Background: Inappropriate use of antibiotics in hospitalized settings contributes to the selection and emergence of antimicrobial-resistant pathogens. This trend is particularly challenging in resource-constrained settings where the high burden of infectious diseases, combined with suboptimal infection prevention and control measures, are further complicated by limited access to reliable microbiological services to inform antimicrobial prescription at the patient level. In this study, we describe the use of antibiotics in selected Haitian hospitals; we aimed to create a baseline to inform antimicrobial stewardship interventions. Methods: WHO/PAHO Hospital Antibiotic Use Point Prevalence Survey (HAMU-PPS) were conducted in 6 acute-care Haitian hospitals: La-Paix and Hospital-Albert (June 2019) and Hospital-Universitaire-Justinien, Hospital-Bienfaisance-de-Pignon, Hospital-Sacre-Coeur-de-Milot, and Hospital Immaculee-Conception-des-Cayes (July-August 2019) in 6 different cities. Trained data collectors completed electronic forms using REDCap software including data related to antibiotic use, indications, and utilization of laboratory services from medical records of all inpatients meeting study inclusion criteria. Analyses were done using Microsoft Excel software (v2016). Results: In total, 510 inpatients records were surveyed. Patients ages ranged from 0 to 92, with median age of 27 years (IQR, 4–47); 269 were women (57.7%) and 239 were men (46.9%). The prevalence of antibiotic use was 73% (95% CI, 68.2%–81.8 %); this prevalence was 74.5% among men (178 of 239) and 70.6% among women (190 of 269). The highest antibiotic use was observed among children aged <1 year (98 of 108, 90.7%). Of the patients on antibiotics, 63% were treated with >1 antibiotic. In addition, 384 indications for antibiotic prescription were reported. Of the indications for antibiotics therapy, 49.7% (191 of 384) were for treatment, and 49% (188 of 384) were for prophylaxis. Of the treatments, 92% were empiric with 6% reported as targeted. Only 13% (50 of 370) of the patient records indicated that samples were taken for microbiological identification. Of those, 9 had results for culture, and 1 had results for drug susceptibility. The most commonly reported antibiotic was ceftriaxone (n = 110, 23%) followed by ampicillin (n = 153, 21.4%) and metronidazole (n = 135, 20%). Conclusions: This study shows high use of antibiotics among hospitalized patients in Haitian hospitals, especially in children aged <1 year. Almost all the antibiotics were prescribed as either empiric or prophylaxis therapy, with very few microbiology samples collected. These results suggest limited laboratory corroboration across hospitals to inform antibiotic use. Implementation of antimicrobial stewardship interventions is recommended to optimize antibiotic therapy and to mitigate antimicrobial resistance in hospital care settings, but adaptation of the methodology should be done in settings with limited laboratory capacity. Funding: None Disclosures: None

Case-area targeted interventions (CATIs) against cholera are conducted by rapid response teams, and may include various activities like water, sanitation, hygiene measures. However, their real-world effectiveness has never been established. We conducted a retrospective observational study in 2015-2017 in the Centre department of Haiti. Using cholera cases, stool cultures and CATI records, we identified 238 outbreaks that were responded to. After adjusting for potential confounders, we found that a prompt response could reduce the number of accumulated cases by 76% (95% confidence interval, 59 to 86) and the outbreak duration by 61% (41 to 75) when compared to a delayed response. An intense response could reduce the number of accumulated cases by 59% (11 to 81) and the outbreak duration by 73% (49 to 86) when compared to a weaker response. These results suggest that prompt and repeated CATIs were significantly effective at mitigating and shortening cholera outbreaks in Haiti.

Background - Case-area targeted interventions (CATIs) conducted by rapid response teams are recommended by the Global Task Force on Cholera Control (GTFCC) to contain cholera outbreaks. They may include various combinations of water, sanitation, and hygiene measures, prophylactic antibiotics, and/or oral cholera vaccine. However, their effectiveness has never been established in a real-world setting. Haiti has implemented CATIs as a national coordinated strategy against cholera since July 2013. Methods - We thus conducted a quasi-experimental study from January 2015 to December 2017 in the Centre department of Haiti. Using case and stool cultures records, together with daily CATI reports of mobile teams, we identified and characterized cholera outbreaks at the locality scale, and then studied the outcome of outbreaks according to the response promptness. First, we compared the number of cases from the 4th day of outbreak between classes of time to the first complete CATI using generalized linear mixed models. Second, we compared the duration of outbreaks using Cox models for Andersen-Gill counting process. CATI effectiveness estimates were adjusted for potential confounders. Findings - We identified 456 cholera outbreaks across 290 different localities, including 176 responded to by at least one complete CATI. Compared to a first complete CATI >7 days after outbreak onset, a first complete CATI ≤1 day reduced accumulated cases by 74% (58 to 84), and outbreak duration by 64% (42 to 78). Interpretation - These results strongly suggest that a coordinated CATI strategy was significantly effective in mitigating and shortening cholera outbreaks in Haiti. Further research is required to confirm such findings, to study the respective effectiveness of each CATI component, to economically evaluate CATI efficiency and to better position CATI with other cholera control tools in a multi-sectoral approach. Funding - United Nations Children's Fund (UNICEF)-Haiti and Assistance Publique - Hopitaux de Marseille (APHM). Declaration of Interest: Authors working for the United Nations Children's Fund, Haiti (UNICEF-Haiti): SB, GB UNICEF-Haiti worked with the Haitian Ministry of Health and Population (MSPP) to implement the CATI response strategy against cholera in Haiti. For this, UNICEF-Haiti received funds from ECHO (European Commission Humanitarian Office), DFID (UK Government's Department for International Development) and CERF (Central Emergency Response Funds of United Nations). These three institutions had no involvement in study design, collection analysis and interpretation of data, in the writing of the report, and in the decision to submit the paper for publication. Authors working for Assistance Publique – Hopitaux de Marseille (APHM): JG, SR, RP (until 2017) Authors working for Assistance Publique – Hopitaux de Paris (AP-HP): RP (since 2017) AP-HP, a French university-hospital, has been mandated by the Haitian Ministry of Health and UNICEF-Haiti, and granted by UNICEF-Haiti, to provide the CATI response strategy against cholera with prospective epidemiological analyses and evaluations. Authors working for Ministry of Public Health and Population (MSPP): EM, JB, PD To implement the CATI response strategy against cholera in Haiti, MSPP has received material and financial support from UNICEF-Haiti. This study aimed to present and assess this strategy. Author with 335 no competing interest: MP Ethical Approval: The study protocol received authorization #1718-24 from the National Bioethics Committee of Haiti MSPP

Haiti, a Caribbean country of 10.5 million people, is estimated to have the highest burden of canine-mediated human rabies deaths in the Western Hemisphere, and one of the highest rates of human rabies deaths in the world. Haiti is also the poorest country in the Western Hemisphere and has numerous economic and health priorities that compete for rabies-control resources. As a result, primary rabies-control actions, including canine vaccination programs, surveillance systems for human and animal rabies, and appropriate postbite treatment, have not been fully implemented at a national scale. After the 2010 earthquake that further hindered the development of public health program infrastructure and services, the U.S. Centers for Disease Control and Prevention worked with the Ministry of Public Health and Population and key health development partners (including the Pan-American Health Organization) to provide technical expertise and funding for general disease surveillance systems, laboratory capacity, and selected disease control programs; including rabies. In 2011, a cross-ministerial rabies consortium was convened with participation from multiple international rabies experts to develop a strategy for successful rabies control in Haiti. The consortium focused on seven pillars: 1) enhancement of laboratory diagnostic capacity, 2) development of comprehensive animal surveillance system, 3) development of comprehensive human rabies surveillance system, 4) educational outreach, 5) sustainable human rabies biologics supply, 6) achievement of sustained canine vaccination rates of ≥ 70%, and 7) finalization of a national rabies control strategy. From 2010 until 2015, Haiti has seen improvements in the program infrastructure for canine rabies control. The greatest improvements were seen in the area of animal rabies surveillance, in support of which an internationally recognized rabies laboratory was developed thereby leading to an 18-fold increase in the detection of rabid animals. Canine rabies vaccination practices also improved, from a 2010 level of approximately 12% to a 2015 dog population coverage level estimated to be 45%. Rabies vaccine coverage is still below the goal of 70%, however, the positive trend is encouraging. Gaps exist in the capacity to conduct national surveillance for human rabies cases and access to human rabies vaccine is lacking in many parts of the country. However, control has improved over the past 5 years as a result of the efforts of Haiti's health and agriculture sectors with assistance from multiple international organizations. Haiti is well situated to eliminate canine-mediated human rabies deaths in the near future and should serve as a great example to many developing countries struggling with similar barriers and limitations.

Haiti's health system has faced many challenges over the years, with competing health priorities in the context of chronic financial and human resource limitations. As a result, the existing notifiable disease surveillance system was unable to provide the most basic epidemiologic data for public health decision-making and action. In the wake of the January 2010 earthquake, the Haitian Ministry of Public Health and Population collaborated with the U.S. Centers for Disease Control and Prevention, the Pan American Health Organization, and other local and international partners to implement a functional national surveillance system. More than 7 years later, it is important to take the opportunity to reflect on progress made on surveillance and response in Haiti, including disease detection, reporting, outbreak investigation, and response. The national epidemiologic surveillance network that started with 51 sites in 2010 has been expanded to 357 sites as of December 2015. Disease outbreaks identified via the surveillance system, or other surveillance approaches, are investigated by epidemiologists trained by the Ministry of Health's Field Epidemiology Training Program. Other related surveillance modules have been developed on the same model and electronic platform, allowing the country to document the impact of interventions, track progress, and monitor health problems. Sustainability remains the greatest challenge since most of the funding for surveillance come from external sources.

Malaria continues to persist in Haiti, with 17,583 reported cases in 2015. The island of Hispaniola, the last locale of malaria in the Caribbean, recently adopted a bi-national agreement between the Dominican Republic and Haiti with the goal of eliminating malaria by 2020. In January 2015, the Laboratoire National de Santé Publique and Henry Ford Health System, in close collaboration with the Direction d’Epidemiologie, de Laboratoire et de Recherches, and the Programme National de Contrôle de la Malaria, hosted a Scientific Conference in Port-au-Prince, focusing on “Elimination Strategies for Malaria in Haiti.” One year after this important conference, this article aims to evaluate the progress of malaria elimination in Haiti since new advanced strategies have been implemented, as well as to offer solutions to achieve this goal. Correspondence to: Marcus J Zervos, Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202, USA and Wayne State University, Detroit, MI 48201, USA; Tel: +1-313-916-2573; Fax: +1-313-916-2993; E-mail: mzervos1@hfhs.org