Digital Commons Network^™

Resolution Of Anaemia In A Cohort Of Hiv-Infected Patients With A High Prevalence And Incidence Of Tuberculosis Receiving Antiretroviral Therapy In South Africa, Andrew D. Kerkhoff, Robin Wood, Frank G. Cobelens, Ankur Gupta-Wright, Linda-Gail Bekker, Stephen D. Lawn

Medicine Faculty Publications

Background

Anaemia is frequently associated with both HIV-infection and HIV-related tuberculosis (TB) in antiretroviral therapy (ART)-naïve patients in sub-Saharan Africa and is strongly associated with poor prognosis. However, the effect of ART on the resolution of anaemia in patient cohorts with a high prevalence and incidence of tuberculosis is incompletely defined and the impact of TB episodes on haemoglobin recovery has not previously been reported. We therefore examined these issues using data from a well-characterised cohort of patients initiating ART in South Africa.

Methods

Prospectively collected clinical and haematological data were retrospectively analysed from patients receiving ART in a South …

P53 And Cancer-Associated Sialylated Glygans Are Surrogate Markers Of Cancerization Of The Bladder Associated With Schistosoma Haematobium Infection, Julio Santos, Elisabete Fernandes, Jose Alexandre Ferreira, Luis Lima, Ana Tavares, Andreia Peixoto, Beatriz Parreira, Jose Manuel Correia Da Costa, Paul J. Brindley, Carlos Lopes, Lucio L. Santos

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Background

Bladder cancer is a significant health problem in rural areas of Africa and the Middle East where Schistosoma haematobium is prevalent, supporting an association between malignant transformation and infection by this blood fluke. Nevertheless, the molecular mechanisms linking these events are poorly understood. Bladder cancers in infected populations are generally diagnosed at a late stage since there is a lack of non-invasive diagnostic tools, hence enforcing the need for early carcinogenesis markers.

Methodology/Principal Findings

Forty-three formalin-fixed paraffin-embedded bladder biopsies of S. haematobium-infected patients, consisting of bladder tumours, tumour adjacent mucosa and pre-malignant/malignant urothelial lesions, were screened for bladder …

The Mirnaome Of Opisthorchis Viverrini Induced Intrahepatic Cholangiocarcinoma, Jin Peng, Yanjun Feng, Gabriel Rinaldi, Ponlapat Yonglitthipagon, Samantha Easley, Therawach Laha, Chawalit Pairojkul, Vajarabhongsa Bhudhisawasdi, Banchob Sripa, Paul J. Brindley, Jason P. Mulvenna, Jeffrey M. Bethony, Jordan L. Plieskatt

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Intrahepatic cholangiocarcinoma (ICC) is an aggressive cancer, arising in the biliary ducts that extend into the liver. The highest incidence of ICC occurs in Southeast Asia, particularly in the Mekong River Basin countries of Thailand, Laos, Cambodia, and Vietnam, where it is strongly associated with chronic infection by the food-borne liver fluke Opisthorchis viverrini (OV), one of only three eukaryote pathogens considered Group one carcinogens. Intrahepatic cholangiocarcinoma is usually diagnosed at an advanced stage, with a poor prognosis and survival often less than 24 months. Hence, biomarkers that enable the early detection of ICC would be desirable and have a …

Profiling Mirnas In Nasopharyngeal Carcinoma Ffpe Tissue By Microarray And Next Generation Sequencing, Jin Peng, Yanjun Feng, Gabriel Rinaldi, Paul H. Levine, Samantha Easley, Elizabeth Martinez, Salman Hashmi, Nader Sadeghi, Paul J. Brindley, Jason P. Mulvenna, Jeffrey M. Bethony, Jordan L. Plieskatt

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Nasopharyngeal carcinoma (NPC) is a non-lymphomatous, squamous-cell carcinoma that occurs in the epithelial lining of the nasopharynx. Nasopharyngeal carcinoma has a geographically well-defined distribution worldwide, with the highest prevalence in China, Southeast Asia, and Northern Africa. Symptoms of nascent NPC may be unapparent or trivial, with diagnosis based on the histopathology of biopsied tissue following endoscopy of the nasopharynx. The tumor node metastasis (TNM) staging system is the benchmark for the prognosis of NPC and guides treatment strategy. However, there is a consensus that the TNM system is not sufficiently specific for the prognosis of NPC, as it does not …

A Large-Scale, Rapid Public Health Response To Rabies In An Organ Recipient And The Previously Undiagnosed Organ Donor, R. M. Wallace, Danielle Stanek, S. Griese, D. Krulak, Neil M. Vora, Virginia Kan, +14 Additional Authors

Medicine Faculty Publications

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post-symptom onset. In response to an organ-transplant-related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in …

Whole Genome Sequencing Of A Methicillin-Resistant Staphylococcus Aureus Pseudo-Outbreak In A Professional Football Team., Deverick J. Anderson, Simon R. Harris, Eliot Godofsky, Todd Toriscelli, Thomas H. Rude, Kevin Elder, Daniel J. Sexton, Elliot J. Pellman, Thom Mayer, Vance G. Fowler, Sharon J. Peacock

Medicine Faculty Publications

Two American football players on the same team were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections on the same day. Our investigation, including whole genome sequencing, confirmed that players did not transmit MRSA to one another nor did they acquire the MRSA from a single source within the training facility.

The Population Genetic Structure Of Biomphalaria Choanomphala In Lake Victoria, East Africa: Implications For Schistosomiasis Transmission, Claire J. Standley, Sara L. Goodacre, Christopher M. Wade, J. Russell Stothard

Health Policy and Management Faculty Publications

Background

The freshwater snail Biomphalaria acts as the intermediate host of Schistosoma mansoni, a globally important human parasite. Understanding the population structure of intermediate host species can elucidate transmission dynamics and assist in developing appropriate control methods.

Methods

We examined levels of population genetic structure and diversity in 29 populations of Biomphalaria choanomphala collected around the shoreline of Lake Victoria in Uganda, Kenya and Tanzania, where S. mansoni is hyper-endemic. Molecular markers were utilized to estimate the degree to which snail populations are genetically differentiated from one another.

Results

High levels of snail genetic diversity were found coupled with …

Strengthening Neglected Tropical Disease Research Through Enhancing Research-Site Capacity: An Evaluation Of A Novel Web Application To Facilitate Research Collections, Tanzin Furtado, Samuel Franzen, Francois Van Loggerenberg, Gwenaelle Carn, Shannon Grahek, Megan Mcbride, Maureen Power, Barbara Savarese, Margaret Ann Snowden, Gwynn Stevens, Almarie Uys, Trudie Lang

Microbiology, Immunology, and Tropical Medicine Faculty Publications

No abstract provided.

Vitamin A, Vitamin E, Iron And Zinc Status In A Cohort Of Hiv-Infected Mothers And Their Uninfected Infants, Jacqueline Pontes Monteiro, Maria Leticia Santos Cruz, Marisa Marcia Mussi-Pinhata, Roberta Garcia Salomao, Alceu Jordao Junior, Jennifer S. Read, Jose Henrique Da Silva Pilotto, Rachel Ann Cohen, Sonia Karolina Stoszek, George Kelly Siberry

Pediatrics Faculty Publications

Introduction

We hypothesized that nutritional deficiency would be common in a cohort of postpartum, human immunodeficiency virus (HIV)-infected women and their infants.

Methods

Weight and height, as well as blood concentrations of retinol, α-tocopherol, ferritin, hemoglobin, and zinc, were measured in mothers after delivery and in their infants at birth and at 6-12 weeks and six months of age. Retinol and α-tocopherol levels were quantified by high performance liquid chromatography, and zinc levels were measured by atomic absorption spectrophotometry. The maternal body mass index during pregnancy was adjusted for gestational age (adjBMI).

Results

Among the 97 women 19.6% were underweight. …

Public Health Training In Internal Medicine Residency Programs: A National Survey, Jillian S. Catalanotti, David K. Popiel, Monique M. Duwell, Jessica Hallerman Price, Jacqueline Cole Miles

Medicine Faculty Publications

BACKGROUND:

The IOM recommends public health training for all physicians. Data characterizing such training of internal medicine (IM) residents are lacking.

PURPOSE:

To describe the current state of public health education at IM residency programs, characterize programs offering public health education, and quantify interest in expanding training opportunities.

METHODS:

IM residency program directors from the 380 Accreditation Council for Graduate Medical Education-accredited residency programs in the U.S were invited to participate in a cross-sectional survey. Responses were received from 127 programs (33%). Data were collected July-December 2012 and analyzed in January 2013. Participants were queried on domestic public health training …

Death Patterns During The 1918 Influenza Pandemic In Chile, Gerardo Chowell, Lone Simonsen, Jose Flores, Mark A. Miller, Cecile G. Viboud

Global Health Faculty Publications

Scarce information about the epidemiology of historical influenza pandemics in South America prevents complete understanding of pandemic patterns throughout the continent and across different climatic zones. To fill gaps with regard to spatiotemporal patterns of deaths associated with the 1918 influenza pandemic in Chile, we reviewed archival records. We found evidence that multiple pandemic waves at various times of the year and of varying intensities occurred during 1918-1921 and that influenza-related excess deaths peaked during July-August 1919. Pandemic-associated mortality rates were elevated for all age groups, including for adults >50 years of age; elevation from baseline was highest for young …

The Burden Of Underweight And Overweight Among Women In Addis Ababa, Ethiopia, Yibeltal Tebekaw, Charles Teller, Uriyoan Colón-Ramos

Global Health Faculty Publications

Background

Obesity and overweight are rising worldwide while underweight rates persist in low-income countries. The aim of this study was to examine changes in the prevalence of underweight and overweight/obesity among non-pregnant women aged 15-49 years, and its socio-demographic correlates in Addis Ababa, Ethiopia.

Methods

The data are from 2000, 2005 and 2011 nationally representative Ethiopian Demographic and Health Surveys in Addis Ababa. The dependent variable was women’s nutritional status measured in terms of body mass index coded in binary outcomes to examine risk of being underweight (<18.5 kg/m² vs. ≥18.5 kg/m²) or overweight/obese (>25 kg/m^{2 …}

Hiv Testing Implementation In Two Urban Cities: Practice, Policy And Perceived Barriers, Camden J. Hallmark, Jennifer Skillicorn, Thomas P. Giordano, Jessica A. Davila, Marlene Mcneese, Nestor Rocha, Avemaria Smith, Stacey Cooper, Amanda D. Castel

Epidemiology Faculty Publications

Background

Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown.

Methods

We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions.

Results

In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% …

Assessment Of Anthelmintic Efficacy Of Mebendazole In School Children In Six Countries Where Soil-Transmitted Helminths Are Endemic, Bruno Levecke, Antonio Montresor, Marco Albonico, Shaali M. Ame, Jerzy M. Behnke, Jeffrey M. Bethony, +15 Additional Authors

Microbiology, Immunology, and Tropical Medicine Faculty Publications

BACKGROUND:

Robust reference values for fecal egg count reduction (FECR) rates of the most widely used anthelmintic drugs in preventive chemotherapy (PC) programs for controlling soil-transmitted helminths (STHs; Ascaris lumbricoides, Trichuris trichiura, and hookworm) are still lacking. However, they are urgently needed to ensure detection of reduced efficacies that are predicted to occur due to growing drug pressure. Here, using a standardized methodology, we assessed the FECR rate of a single oral dose of mebendazole (MEB; 500 mg) against STHs in six trials in school children in different locations around the world. Our results are compared with those previously obtained …

Hiv Infection And Cardiovascular Disease In Women, Julie A. Womack, Chung-Chou H. Chang, Kaku A. So-Armah, Charles Alcorn, Jason V. Baker, Cynthia L. Gibert, +17 Additional Authors

Medicine Faculty Publications

Background HIV infection is associated with increased risk of cardiovascular disease (CVD) in men. Whether HIV is an independent risk factor for CVD in women has not yet been established.

Methods and Results We analyzed data from the Veterans Aging Cohort Study on 2187 women (32% HIV infected [HIV⁺]) who were free of CVD at baseline. Participants were followed from their first clinical encounter on or after April 01, 2003 until a CVD event, death, or the last follow‐up date (December 31, 2009). The primary outcome was CVD (acute myocardial infarction [AMI], unstable angina, ischemic stroke, and heart …

Risk Assessment For Healthcare Workers After A Sentinel Case Of Rabies And Review Of The Literature, Virginia L. Kan, Patrick Joyce, Debra A. Benator, Kathleen Agnes, Janet Gill, Monica Irmler, Arlene Clark, George Giannakos, Audrey Gabourel, Fred M. Gordin

Medicine Faculty Publications

Background. After a case of rabies, healthcare workers (HCWs) had fear of contagion from the infected patient. Although transmission of rabies to HCWs has never been documented, high-risk exposures theoretically include direct contact of broken skin and/or mucosa with saliva, tears, oropharyngeal secretions, cerebrospinal fluid, and neural tissue. Urine/kidney exposure posed a concern, as our patient's renal transplant was identified as the infection source.

Methods. Our risk assessment included (1) identification of exposed HCWs; (2) notification of HCWs; (3) risk assessment using a tool from the local health department; (4) supplemental screening for urine/kidney exposure; and (5) postexposure prophylaxis (PEP) …

Medicine + Health, Fall 2014, George Washington University, School Of Medicine And Health Sciences, Office Of Communications And Marketing

Medicine + Health Magazine

No abstract provided.

The Association Of Meningococcal Disease With Influenza In The United States, 1989-2009, Jessica Hartman Jacobs, Cecile Viboud, Eric Tchetgen Tchetgen, Joel Schwartz, Claudia Steiner, Lone Simonsen, Marc Lipsitch

Global Health Faculty Publications

Importance and Objective

Prior influenza infection is a risk factor for invasive meningococcal disease. Quantifying the fraction of meningococcal disease attributable to influenza could improve understanding of viral-bacterial interaction and indicate additional health benefits to influenza immunization.

Design, Setting and Participants

A time series analysis of the association of influenza and meningococcal disease using hospitalizations in 9 states from 1989–2009 included in the State Inpatient Databases from the Agency for Healthcare Research and Quality and the proportion of positive influenza tests by subtype reported to the Centers for Disease Control. The model accounts for the autocorrelation of meningococcal disease and …

Differential Spatial Repositioning Of Activated Genes In Biomphalaria Glabrata Snails Infected With Schistosoma Mansoni, Halime D. Arican-Goktas, Wannaporn Ittiprasert, Joanna M. Bridger, Matty Knight

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Schistosomiasis is an infectious disease infecting mammals as the definitive host and fresh water snails as the intermediate host. Understanding the molecular and biochemical relationship between the causative schistosome parasite and its hosts will be key to understanding and ultimately treating and/or eradicating the disease. There is increasing evidence that pathogens that have co-evolved with their hosts can manipulate their hosts' behaviour at various levels to augment an infection. Bacteria, for example, can induce beneficial chromatin remodelling of the host genome. We have previously shown in vitro thatBiomphalaria glabrata embryonic cells co-cultured with schistosome miracidia display genes changing their …

Seasonality Of Birth Outcomes In Rural Sarlahi District, Nepal: A Population-Based Prospective Cohort, Michelle M. Hughes, Joanne Katz, Luke C. Mullany, Subarna K. Khatry, Steven C. Leclerq, Gary L. Darmstadt, James M. Tielsch

Global Health Faculty Publications

Background

While seasonality of birth outcomes has been documented in a variety of settings, data from rural South Asia are lacking. We report a descriptive study of the seasonality of prematurity, low birth weight, small for gestational age, neonatal deaths, and stillbirths in the plains of Nepal.

Methods

Using data collected prospectively during a randomized controlled trial of neonatal skin and umbilical cord cleansing with chlorhexidine, we analyzed a cohort of 23,662 babies born between September 2002 and January 2006. Project workers collected data on birth outcomes at the infant’s household. Supplemental data from other studies conducted at the same …

Diminished Humoral Responses Against And Reduced Gene Expression Levels Of Human Endogenous Retrovirus-K (Herv-K) In Psoriasis, Rashmi Gupta, Henri-Alexandre Michaud, Xue Zeng, Maya Debbaneh, Sarah T. Arron, R. Brad Jones, Christopher E. Ormsby, Douglas F. Nixon, Wilson Liao

Microbiology, Immunology, and Tropical Medicine Faculty Publications

No abstract provided.

Epidemiology Of Patients Presenting To The Emergency Centre Of Princess Marina Hospital In Gaborone, Botswana, Amit Chandra, Paul C. Mullan, Ari Ho-Foster, Antanoid Langeveldt, Ngaire Caruso, Joseph Motsumi, Andrew Kestler

Pediatrics Faculty Publications

No abstract provided.

Origin And Evolution Of European Community-Acquired Methicillin-Resistant Staphylococcus Aureus, Marc Stegger, Thierry Wirth, Paal S. Andersen, Robert L. Skov, Anna De Grassi, Lance B. Price, +23 Additional Authors

Environmental and Occupational Health Faculty Publications

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) was recognized in Europe and worldwide in the late 1990s. Within a decade, several genetically and geographically distinct CA-MRSA lineages carrying the small SCCmec type IV and V genetic elements and the Panton-Valentine leukocidin (PVL) emerged around the world. In Europe, the predominant CA-MRSA strain belongs to clonal complex 80 (CC80) and is resistant to kanamycin/amikacin and fusidic acid. CC80 was first reported in 1993 but was relatively rare until the late 1990s. It has since been identified throughout North Africa, the Middle East, and Europe, with recent sporadic reports in sub-Saharan Africa. While …

Incidence And Trends Of Blastomycosis-Associated Hospitalizations In The United States, Amy E. Seitz, Naji Younes, Claudia A. Steiner, Rebecca Prevots

Epidemiology Faculty Publications

We used the State Inpatient Databases from the United States Agency for Healthcare Research and Quality to provide state-specific age-adjusted blastomycosis-associated hospitalization incidence throughout the entire United States. Among the 46 states studied, states within the Mississippi and Ohio River valleys had the highest age-adjusted hospitalization incidence. Specifically, Wisconsin had the highest age-adjusted hospitalization incidence (2.9 hospitalizations per 100,000 person-years). Trends were studied in the five highest hospitalization incidence states. From 2000 to 2011, blastomycosis-associated hospitalizations increased significantly in Illinois and Kentucky with an average annual increase of 4.4% and 8.4%, respectively. Trends varied significantly by state. Overall, 64% of …

Clinical Pathoscope: Rapid Alignment And Filtration For Accurate Pathogen Identification In Clinical Samples Using Unassembled Sequencing Data, Allyson L. Byrd, Joseph F. Perez-Rogers, Solaiappan Manimaran, Eduardo Castro-Nallar, Ian Toma, Timothy A. Mccaffrey, Marc O. Siegel, Gary Benson, Keith Crandall, William Evan Johnson

Medicine Faculty Publications

Background

The use of sequencing technologies to investigate the microbiome of a sample can positively impact patient healthcare by providing therapeutic targets for personalized disease treatment. However, these samples contain genomic sequences from various sources that complicate the identification of pathogens.

Results

Here we present Clinical PathoScope, a pipeline to rapidly and accurately remove host contamination, isolate microbial reads, and identify potential disease-causing pathogens. We have accomplished three essential tasks in the development of Clinical PathoScope. First, we developed an optimized framework for pathogen identification using a computational subtraction methodology in concordance with read trimming and ambiguous read reassignment. Second, …

Prognostic Value Of A Quantitative Analysis Of Lipoarabinomannan In Urine From Patients With Hiv-Associated Tuberculosis, Andrew D. Kerkhoff, Robin Wood, Monica Vogt, Stephen D. Lawn

Medicine Faculty Publications

Background

Detection of the mycobacterial cell wall antigen lipoarabinomannan (LAM) in urine can be used to diagnose HIV-associated tuberculosis (TB) using a qualitative (positive/negative) read-out. However, it is not known whether the quantity of LAM present in urine provides additional prognostic information.

Methods/Findings

Consecutively recruited adult outpatients initiating antiretroviral therapy (ART) in South Africa were investigated for TB regardless of clinical symptoms using sputum smear microscopy and liquid culture (reference standard). Urine samples were tested using the Clearview TB-ELISA for LAM and the Xpert MTB/RIF assay. The ELISA optical densities (OD) were used as a quantitative assessment of urine LAM. …

Demonstrating The Use Of High-Volume Electronic Medical Claims Data To Monitor Local And Regional Influenza Activity In The Us, Cecile G. Viboud, Vivek Charu, Donald R. Olson, Sebastien Ballesteros, Julia R. Gog, Farid Khan, Bryan T. Grenfell, Lone Simonsen

Global Health Faculty Publications

Introduction

Fine-grained influenza surveillance data are lacking in the US, hampering our ability to monitor disease spread at a local scale. Here we evaluate the performances of high-volume electronic medical claims data to assess local and regional influenza activity.

Material and Methods

We used electronic medical claims data compiled by IMS Health in 480 US locations to create weekly regional influenza-like-illness (ILI) time series during 2003–2010. IMS Health captured 62% of US outpatient visits in 2009. We studied the performances of IMS-ILI indicators against reference influenza surveillance datasets, including CDC-ILI outpatient and laboratory-confirmed influenza data. We estimated correlation in weekly …

The Semen Microbiome And Its Relationship With Local Immunology And Viral Load In Hiv Infection, Cindy M. Liu, Brendan J.W. Osborne, Bruce A. Hungate, Kamnoosh Shahabi, Sanja Huibner, Richard Lester, Michael G. Dwan, Colin Kovacs, Tania L. Contente-Cuomo, Erika Benko, Maliha Aziz, Lance B. Price

Environmental and Occupational Health Faculty Publications

Semen is a major vector for HIV transmission, but the semen HIV RNA viral load (VL) only correlates moderately with the blood VL. Viral shedding can be enhanced by genital infections and associated inflammation, but it can also occur in the absence of classical pathogens. Thus, we hypothesized that a dysregulated semen microbiome correlates with local HIV shedding. We analyzed semen samples from 49 men who have sex with men (MSM), including 22 HIV-uninfected and 27 HIV-infected men, at baseline and after starting antiretroviral therapy (ART) using 16S rRNA gene-based pyrosequencing and quantitative PCR. We studied the relationship of semen …

Genome-Wide Analysis Of Regulatory Proteases Sequences Identified Through Bioinformatics Data Mining In Taenia Solium, Hong-Bin Yan, Zhong-Zi Lou, Li Li, Paul J. Brindley, Yadong Zheng, Xuenong Luo, Junling Hou, Aijiang Guo, Wan-Zhong Jia, Xuepeng Cai

Microbiology, Immunology, and Tropical Medicine Faculty Publications

Background

Cysticercosis remains a major neglected tropical disease of humanity in many regions, especially in sub-Saharan Africa, Central America and elsewhere. Owing to the emerging drug resistance and the inability of current drugs to prevent re-infection, identification of novel vaccines and chemotherapeutic agents against Taenia solium and related helminth pathogens is a public health priority. The T. solium genome and the predicted proteome were reported recently, providing a wealth of information from which new interventional targets might be identified. In order to characterize and classify the entire repertoire of protease-encoding genes of T. solium, which act fundamental biological roles in …

Spatial Transmission Of 2009 Pandemic Influenza In The Us, Julia R. Gog, Sebastien Ballesteros, Cecile G. Viboud, Lone Simonsen, Ottar N. Bjornstad, Jeffrey Shaman, Dennis L. Chao, Farid Khan, Bryan T. Grenfell

Global Health Faculty Publications

The 2009 H1N1 influenza pandemic provides a unique opportunity for detailed examination of the spatial dynamics of an emerging pathogen. In the US, the pandemic was characterized by substantial geographical heterogeneity: the 2009 spring wave was limited mainly to northeastern cities while the larger fall wave affected the whole country. Here we use finely resolved spatial and temporal influenza disease data based on electronic medical claims to explore the spread of the fall pandemic wave across 271 US cities and associated suburban areas. We document a clear spatial pattern in the timing of onset of the fall wave, starting in …