Current Issue

CDC Science Clips: Volume 11, Issue 20, May 21, 2019

Science Clips is produced weekly to enhance awareness of emerging scientific knowledge for the public health community. Each article features an Altmetric Attention scoreexternal icon to track social and mainstream media mentions!

  1. CDC Public Health Grand Rounds
    • Environmental Health – Legionnaires’ Disease
      1. Legionnaires’ disease in a hotel in Missouri, 2015: The importance of environmental health expertise in understanding water systemspdf iconexternal icon
        Ahmed S, Hunter C, Mercante J, Garrison L, Turabelidze G, Kunz J, Cooley L.
        J Environ Hlth. 2019 ;81(7):8.
        During a Legionnaires’ disease outbreak at a Missouri hotel in 2015, the Centers for Disease Control and Prevention assisted state and local health departments to identify possible sources and transmission factors and to recommend improvements to water management. We performed an environmental assessment to understand the hotel’s water systems and identify areas of risk for amplification and transmission. We obtained samples from the pool, spa, and potable water systems for Legionella culture. In the potable water system, we noted temperatures ideal for Legionella amplification and areas of water stagnation. Additionally, we found inadequate documentation of pool and spa disinfection and maintenance. Of 40 water samples, Legionella pneumophila serogroup 1 that matched the sequence type of one available clinical isolate was recovered from five sink and shower fixtures. A comprehensive environmental assessment proved crucial to identifying maintenance issues in the hotel’s water systems and underscored the need for a water management program to reduce Legionnaires’ disease risk.

      2. Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experienceexternal icon
        Ambrose M, Kralovic SM, Roselle GA, Kowalskyj O, Rizzo V, Wainwright DL, Gamage SD.
        J Public Health Manag Pract. 2019 Apr 5.
        CONTEXT: The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories. PROGRAM: The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations. IMPLEMENTATION: Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness. EVALUATION: It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program. DISCUSSION: Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

      3. Healthcare-associated Legionnaires’ disease: Limitations of surveillance definitions and importance of epidemiologic investigationexternal icon
        Castellino LM, Gamage SD, Hoffman PV, Kralovic SM, Holodniy M, Bernstein JM, Roselle GA.
        J Infect Prev. 2017 Nov;18(6):307-310.
        Healthcare-associated Legionnaires’ disease (HCA LD) causes significant morbidity and mortality, with varying guidance on prevention. We describe the evaluation of a case of possible HCA LD and note the pitfalls of relying solely on an epidemiologic definition for association of a case with a facility. Our detailed investigation led to the identification of a new Legionella pneumophila serogroup 1 sequence type, confirmed a healthcare association and helped build the framework for our ongoing preventive efforts. Our experience highlights the role of routine environmental cultures in the assessment of risk for a given facility. As clinicians increasingly rely on urinary antigen testing for the detection of L. pneumophila, our investigation emphasises the importance of clinical cultures in an epidemiologic investigation.

      4. The importance of clinical surveillance in detecting legionnaires’ disease outbreaks: a large outbreak in a hospital with a Legionella disinfection system-Pennsylvania, 2011-2012external icon
        Demirjian A, Lucas CE, Garrison LE, Kozak-Muiznieks NA, States S, Brown EW, Wortham JM, Beaudoin A, Casey ML, Marriott C, Ludwig AM, Sonel AF, Muder RR, Hicks LA.
        Clin Infect Dis. 2015 Jun 1;60(11):1596-602.
        BACKGROUND: Healthcare-associated Legionnaires’ disease (LD) is a preventable pneumonia with a 30% case fatality rate. The Centers for Disease Control and Prevention guidelines recommend a high index of suspicion for the diagnosis of healthcare-associated LD. We characterized an outbreak and evaluated contributing factors in a hospital using copper-silver ionization for prevention of Legionella growth in water. METHODS: Through medical records review at a large, urban tertiary care hospital in November 2012, we identified patients diagnosed with LD during 2011-2012. Laboratory-confirmed cases were categorized as definite, probable, and not healthcare associated based on time spent in the hospital during the incubation period. We performed an environmental assessment of the hospital, including collection of samples for Legionella culture. Clinical and environmental isolates were compared by genotyping. Copper and silver ion concentrations were measured in 11 water samples. RESULTS: We identified 5 definite and 17 probable healthcare-associated LD cases; 6 case patients died. Of 25 locations (mostly potable water) where environmental samples were obtained for Legionella-specific culture, all but 2 showed Legionella growth; 11 isolates were identical to 3 clinical isolates by sequence-based typing. Mean copper and silver concentrations were at or above the manufacturer’s recommended target for Legionella control. Despite this, all samples where copper and silver concentrations were tested showed Legionella growth. CONCLUSIONS: This outbreak was linked to the hospital’s potable water system and highlights the importance of maintaining a high index of suspicion for healthcare-associated LD, even in the setting of a long-term disinfection program.

      5. Lessons From an Outbreak of Legionnaires’ Disease on a Hematology-Oncology Unitexternal icon
        Francois Watkins LK, Toews KE, Harris AM, Davidson S, Ayers-Millsap S, Lucas CE, Hubbard BC, Kozak-Muiznieks NA, Khan E, Kutty PK.
        Infect Control Hosp Epidemiol. 2017 Mar;38(3):306-313.
        OBJECTIVES To define the scope of an outbreak of Legionnaires’ disease (LD), to identify the source, and to stop transmission. DESIGN AND SETTING Epidemiologic investigation of an LD outbreak among patients and a visitor exposed to a newly constructed hematology-oncology unit. METHODS An LD case was defined as radiographically confirmed pneumonia in a person with positive urinary antigen testing and/or respiratory culture for Legionella and exposure to the hematology-oncology unit after February 20, 2014. Cases were classified as definitely or probably healthcare-associated based on whether they were exposed to the unit for all or part of the incubation period (2-10 days). We conducted an environmental assessment and collected water samples for culture. Clinical and environmental isolates were compared by monoclonal antibody (MAb) and sequence-based typing. RESULTS Over a 12-week period, 10 cases were identified, including 6 definite and 4 probable cases. Environmental sampling revealed Legionella pneumophila serogroup 1 (Lp1) in the potable water at 9 of 10 unit sites (90%), including all patient rooms tested. The 3 clinical isolates were identical to environmental isolates from the unit (MAb2-positive, sequence type ST36). No cases occurred with exposure after the implementation of water restrictions followed by point-of-use filters. CONCLUSIONS Contamination of the unit’s potable water system with Lp1 strain ST36 was the likely source of this outbreak. Healthcare providers should routinely test patients who develop pneumonia at least 2 days after hospital admission for LD. A single case of LD that is definitely healthcare associated should prompt a full investigation. Infect Control Hosp Epidemiol 2017;38:306-313.

      6. Water Safety and Legionella in Health Care: Priorities, Policy, and Practiceexternal icon
        Gamage SD, Ambrose M, Kralovic SM, Roselle GA.
        Infect Dis Clin North Am. 2016 Sep;30(3):689-712.
        Health care facility water distribution systems have been implicated in the transmission of pathogens such as Legionella and nontuberculous mycobacteria to building occupants. These pathogens are natural inhabitants of water at low numbers and can amplify in premise plumbing water, especially if conditions are conducive to their growth. Because patients and residents in health care facilities are often at heightened risk for opportunistic infections, a multidisciplinary proactive approach to water safety is important to balance the various water priorities in health care and prevent water-associated infections in building occupants.

      7. Importance: Legionnaires disease (LD) incidence is increasing in the United States. Health care facilities are a high-risk setting for transmission of Legionella bacteria from building water systems to occupants. However, the contribution of LD in health care facilities to national LD rates is not well characterized. Objectives: To determine the burden of LD in US Department of Veterans Affairs (VA) patients and to assess the amount of LD with VA exposure. Design, Setting, and Participants: Retrospective cohort study of reported LD data in VA medical facilities in a national VA LD surveillance system from January 1, 2014, to December 31, 2016. The study population included total veteran enrollees and enrollees who used the VA health care system. Main Outcomes and Measures: The primary outcome was assessment of annual LD rates, categorized by VA and non-VA exposure. Legionnaires disease rates for cases with VA exposure were determined on both population and exposure potential levels. Rates by VA exposure potential were calculated using inpatient bed days of care, long-term care resident days, or outpatient encounters. In addition, types and amounts of LD diagnostic testing were calculated. Case and testing data were analyzed nationally and regionally. Results: There were 491 LD cases in the case report surveillance system from January 1, 2014, to December 31, 2016. Most cases (447 [91%]) had no VA exposure or only outpatient VA exposure. The remaining 44 cases had VA exposure from overnight stays. Total LD rates from January 1, 2014, to December 31, 2016, increased for all VA enrollees (from 1.5 to 2.0 per 100000 enrollees; P = .04) and for users of VA health care (2.3 to 3.0 per 100000 enrollees; P = .04). The LD rate for the subset who had no VA exposure also increased (0.90 to 1.47 per 100000 enrollees; P < .001). In contrast, the LD rate for patients with VA overnight stay decreased on a population level (5.0 to 2.3 per 100000 enrollees; P < .001) and an exposure level (0.31 to 0.15 per 100000 enrollees; P < .001). Regionally, the eastern United States had the highest LD rates. The urine antigen test was the most used LD diagnostic method; 49805 tests were performed in 2015-2016 with 335 positive results (0.67%). Conclusions and Relevance: Data in the VA LD databases showed an increase in overall LD rates over the 3 years, driven by increases in rates of non-VA LD. Inpatient VA-associated LD rates decreased, suggesting that the VA’s LD prevention efforts have contributed to improved patient safety.

      8. Legionnaires’ Disease Outbreak at a Resort in Cozumel, Mexicoexternal icon
        Hampton LM, Garrison L, Kattan J, Brown E, Kozak-Muiznieks NA, Lucas C, Fields B, Fitzpatrick N, Sapian L, Martin-Escobar T, Waterman S, Hicks LA, Alpuche-Aranda C, Lopez-Gatell H.
        Open Forum Infect Dis. 2016 Sep;3(3):ofw170.
        Background. A Legionnaires’ disease (LD) outbreak at a resort on Cozumel Island in Mexico was investigated by a joint Mexico-United States team in 2010. This is the first reported LD outbreak in Mexico, where LD is not a reportable disease. Methods. Reports of LD among travelers were solicited from US health departments and the European Working Group for Legionella Infections. Records from the resort and Cozumel Island health facilities were searched for possible LD cases. In April 2010, the resort was searched for possible Legionella exposure sources. The temperature and total chlorine of the water at 38 sites in the resort were measured, and samples from those sites were tested for Legionella. Results. Nine travelers became ill with laboratory-confirmed LD within 2 weeks of staying at the resort between May 2008 and April 2010. The resort and its potable water system were the only common exposures. No possible LD cases were identified among resort workers. Legionellae were found to have extensively colonized the resort’s potable water system. Legionellae matching a case isolate were found in the resort’s potable water system. Conclusions. Medical providers should test for LD when treating community-acquired pneumonia that is severe or affecting patients who traveled in the 2 weeks before the onset of symptoms. When an LD outbreak is detected, the source should be identified and then aggressively remediated. Because LD can occur in tropical and temperate areas, all countries should consider making LD a reportable disease if they have not already done so.

      9. Current and emerging Legionella diagnostics for laboratory and outbreak investigationsexternal icon
        Mercante JW, Winchell JM.
        Clin Microbiol Rev. 2015 Jan;28(1):95-133.
        Legionnaires’ disease (LD) is an often severe and potentially fatal form of bacterial pneumonia caused by an extensive list of Legionella species. These ubiquitous freshwater and soil inhabitants cause human respiratory disease when amplified in man-made water or cooling systems and their aerosols expose a susceptible population. Treatment of sporadic cases and rapid control of LD outbreaks benefit from swift diagnosis in concert with discriminatory bacterial typing for immediate epidemiological responses. Traditional culture and serology were instrumental in describing disease incidence early in its history; currently, diagnosis of LD relies almost solely on the urinary antigen test, which captures only the dominant species and serogroup, Legionella pneumophila serogroup 1 (Lp1). This has created a diagnostic “blind spot” for LD caused by non-Lp1 strains. This review focuses on historic, current, and emerging technologies that hold promise for increasing LD diagnostic efficiency and detection rates as part of a coherent testing regimen. The importance of cooperation between epidemiologists and laboratorians for a rapid outbreak response is also illustrated in field investigations conducted by the CDC with state and local authorities. Finally, challenges facing health care professionals, building managers, and the public health community in combating LD are highlighted, and potential solutions are discussed.

      10. Legionnaires’ Disease Outbreak at a Long-Term Care Facility Caused by a Cooling Tower Using an Automated Disinfection System–Ohio, 2013external icon
        Quinn C, Demirjian A, Watkins LF, Tomczyk S, Lucas C, Brown E, Kozak-Muiznieks N, Benitez A, Garrison LE, Kunz J, Brewer S, Eitniear S, DiOrio M.
        J Environ Health. 2015 Dec;78(5):8-13.
        On July 9, 2013, an outbreak of Legionnaires’ disease (LD) was identified at Long-Term Care Facility A in central Ohio. This article describes the investigation of the outbreak and identification of the outbreak source, a cooling tower using an automated biocide delivery system. In total, 39 outbreak LD cases were identified; among these, six patients died. Water samples from a cooling tower were positive for Legionella pneumophila serogroup 1, reactive to monoclonal antibody 2, with matching sequence type to a patient isolate. An electronic control system turned off cooling tower pumps during low-demand periods, preventing delivery of disinfectant by a timed-release system, and leading to amplification of Legionella in the cooling tower. Guidelines for tower maintenance should address optimal disinfection when using automated systems.

      11. A Large Community Outbreak of Legionnaires’ Disease Associated With a Cooling Tower in New York City, 2015external icon
        Weiss D, Boyd C, Rakeman JL, Greene SK, Fitzhenry R, McProud T, Musser K, Huang L, Kornblum J, Nazarian EJ, Fine AD, Braunstein SL, Kass D, Landman K, Lapierre P, Hughes S, Tran A, Taylor J, Baker D, Jones L, Kornstein L, Liu B, Perez R, Lucero DE, Peterson E, Benowitz I, Lee KF, Ngai S, Stripling M, Varma JK.
        Public Health Rep. 2017 Mar/Apr;132(2):241-250.
        OBJECTIVES: Infections caused by Legionella are the leading cause of waterborne disease outbreaks in the United States. We investigated a large outbreak of Legionnaires’ disease in New York City in summer 2015 to characterize patients, risk factors for mortality, and environmental exposures. METHODS: We defined cases as patients with pneumonia and laboratory evidence of Legionella infection from July 2 through August 3, 2015, and with a history of residing in or visiting 1 of several South Bronx neighborhoods of New York City. We describe the epidemiologic, environmental, and laboratory investigation that identified the source of the outbreak. RESULTS: We identified 138 patients with outbreak-related Legionnaires’ disease, 16 of whom died. The median age of patients was 55. A total of 107 patients had a chronic health condition, including 43 with diabetes, 40 with alcoholism, and 24 with HIV infection. We tested 55 cooling towers for Legionella, and 2 had a strain indistinguishable by pulsed-field gel electrophoresis from 26 patient isolates. Whole-genome sequencing and epidemiologic evidence implicated 1 cooling tower as the source of the outbreak. CONCLUSIONS: A large outbreak of Legionnaires’ disease caused by a cooling tower occurred in a medically vulnerable community. The outbreak prompted enactment of a new city law on the operation and maintenance of cooling towers. Ongoing surveillance and evaluation of cooling tower process controls will determine if the new law reduces the incidence of Legionnaires’ disease in New York City.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Quality of care for the screening, diagnosis, and management of lupus nephritis across multiple healthcare settingsexternal icon
        Aggarwal I, Li J, Trupin L, Gaynon L, Katz PP, Lanata C, Criswell L, Murphy LB, Dall’Era M, Yazdany J.
        Arthritis Care Res (Hoboken). 2019 May 6.
        OBJECTIVE: We examined quality measures for screening, diagnosis and treatment of lupus nephritis (LN) among participants of the California Lupus Epidemiology Study (CLUES) across 25 different clinical sites to identify gaps in quality of care. METHODS: Data from 250 lupus participants was analyzed across three sources (medical records, physician examination, and patient interviews). Overall performance on eight quality measures was calculated separately for participants with and without LN. We used generalized estimating equations in which the outcome was performance on measures, adjusting for participant demographics, lupus disease severity and practice characteristics. RESULTS: Of 148 patients without LN, 42% had screening labs for nephritis, 38% had lupus activity serologies and 81% had blood pressure checked every 6 months. Of 102 LN patients, 67% had a timely kidney biopsy, at least 81% had appropriate treatment and 78% achieved target blood pressure within 1 year of diagnosis. Overall performance in participants across quality measures was 54% (no LN) and 80% (LN). Significantly higher overall performance for screening measures for LN was seen at academic (63.4-73%) versus community clinics (37.9-38.4%). Similarly, among those with LN, higher performance in academic (84.1-85.2%) versus community clinics (54.8-60.2%) was observed for treatment measures. CONCLUSION: In this quality of care analysis across 25 diverse clinical settings, we found relatively high performance on measures for management of LN. However, future work should focus on bridging the gaps in lupus quality of care for patients without nephritis, particularly in community settings. This article is protected by copyright. All rights reserved.

      2. Relationships between adverse childhood experiences and health status in systemic lupus erythematosusexternal icon
        DeQuattro K, Trupin L, Li J, Katz PP, Murphy LB, Yelin EH, Rush S, Lanata C, Criswell LA, Dall’Era M, Yazdany J.
        Arthritis Care Res (Hoboken). 2019 May 9.
        PURPOSE: Adverse childhood experiences (ACEs) are associated with poor adult health and immune dysregulation. The impact of ACEs on patients with autoimmune disease is unknown. We compared the prevalence of ACEs in Systemic Lupus Erythematosus (SLE) patients to population-based survey estimate and investigated relationships between ACEs and SLE outcomes. METHODS: Data derive from the California Lupus Epidemiology Study (CLUES), a sample of adult SLE patients. Participants completed a 10-item ACE questionnaire covering 3 domains (abuse, neglect, household challenges). We estimated ACEs prevalence in 269 CLUES participants compared to 2015 California Behavioral Risk Factor Surveillance System (BRFSS) geographically matched respondents, standardized (age, sex, race/ethnicity) to CLUES participant characteristics. We examined associations for patient-reported and physician-assessed health status measures with overall ACE levels and domains using multivariable linear regression, controlling for socio-demographics, nephritis, and childhood onset SLE. RESULTS: Though specific domains varied, overall ACE levels were similar for CLUES and BRFSS respondents. Among SLE patients, 63.2% had >/=1 ACE and 19.3% had >/=4. ACEs were more prevalent in those who were older, women, Latino or African American, without college degrees, and with lupus nephritis. In adjusted models, higher ACE levels and ACE domains were associated with worse patient-reported SLE activity, depression, and health status, but were not significantly associated with physician-assessed SLE activity, damage, or severity. CONCLUSIONS: Given the association between ACE levels and important patient-reported outcomes in SLE, our study reinforces the need for prevention of ACEs in childhood and for clinical interventions to promote resilience among adults who have experienced ACEs. This article is protected by copyright. All rights reserved.

      3. State-specific severe joint pain and physical inactivity among adults with arthritis – United States, 2017external icon
        Guglielmo D, Murphy LB, Boring MA, Theis KA, Helmick CG, Hootman JM, Odom EL, Carlson SA, Liu Y, Lu H, Croft JB.
        MMWR Morb Mortal Wkly Rep. 2019 May 3;68(17):381-387.
        An estimated 54.4 million (approximately one in four) U.S. adults have doctor-diagnosed arthritis (arthritis) (1). Severe joint pain and physical inactivity are common among adults with arthritis and are linked to adverse mental and physical health effects and limitations (2,3). CDC analyzed 2017 Behavioral Risk Factor Surveillance System (BRFSS) data to estimate current state-specific prevalence of arthritis and, among adults with arthritis, the prevalences of severe joint pain and physical inactivity. In 2017, the median age-standardized state prevalence of arthritis among adults aged >/=18 years was 22.8% (range = 15.7% [District of Columbia] to 34.6% [West Virginia]) and was generally highest in Appalachia and Lower Mississippi Valley regions.* Among adults with arthritis, age-standardized, state-specific prevalences of both severe joint pain (median = 30.3%; range = 20.8% [Colorado] to 45.2% [Mississippi]) and physical inactivity (median = 33.7%; range = 23.2% [Colorado] to 44.4% [Kentucky]) were highest in southeastern states. Physical inactivity prevalence among those with severe joint pain (47.0%) was higher than that among those with moderate (31.8%) or no/mild joint pain (22.6%). Self-management strategies such as maintaining a healthy weight or being physically active can reduce arthritis pain and prevent or delay arthritis-related disability. Evidence-based physical activity and self-management education programs are available that can improve quality of life among adults with arthritis.

      4. Developing a web-based cost assessment tool for colorectal cancer screening programsexternal icon
        Hoover S, Subramanian S, Tangka F.
        Prev Chronic Dis. 2019 May 2;16:E54.
        INTRODUCTION: We developed a web-based cost assessment tool (CAT) to collect cost data as an improvement from a desktop instrument to perform economic evaluations of the Centers for Disease Control and Prevention’s (CDC’s) Colorectal Cancer Control Program (CRCCP) grantees. We describe the development of the web-based CAT, evaluate the quality of the data obtained, and discuss lessons learned. METHODS: We developed and refined a web-based CAT to collect 5 years (2009-2014) of cost data from 29 CRCCP grantees. We analyzed funding distribution; costs by budget categories; distribution of costs related to screening promotion, screening provision, and overarching activities; and reporting of screenings for grantees that received funding from non-CDC sources compared with those grantees that did not. RESULTS: CDC provided 85.6% of the resources for the CRCCP, with smaller amounts from in-kind contributions (7.8%), and funding from other sources (6.6%) (eg, state funding). Grantees allocated, on average, 95% of their expenditures to specific program activities and 5% to other activities. Some non-CDC funds were used to provide screening tests to additional people, and these additional screens were captured in the CAT. CONCLUSION: A web-based tool can be successfully used to collect cost data on expenditures associated with CRCCP activities. Areas for future refinement include how to collect and allocate dollars from other sources in addition to CDC dollars.

      5. Association of glucose levels in pregnancy with use of health care servicesexternal icon
        Vesco KK, Sharma AJ, Bulkley J, Terry Kimes M, Callaghan WM, England FL, Hornbrook MC.
        Diabetes Res Clin Pract. 2019 May 4.
        AIMS: To determine whether women with abnormal gestational diabetes (GDM) screening test results short of frank GDM have increased health-services utilization compared to women with normal results. METHODS: We conducted a retrospective-cohort study among 29,999 women enrolled in Kaiser Permanente Northwest who completed GDM screening (two-step method:1-hour, 50-gram glucose-challenge test (GCT); 3-hour, 100-gram oral-glucose-tolerance test (OGTT)). Test results were categorized as normal GCT (referent, n=25,535), normal OGTT (n=2,246), abnormal OGTT but not GDM (n=1477), and GDM (n=741). Rate ratios (RRs) were calculated for utilization measures and analyses were age- and BMI-adjusted. RESULTS: Compared to women with normal GCT, rates for obstetrical ultrasound, noninvasive and invasive antenatal testing, and ambulatory visits to the obstetrics department were significantly greater among women with abnormal OGTT (RRs 1.2 [95%CI 1.1, 1.4], 1.3 [1.1, 1.4], 1.7 [1.3, 2.3], and 1.1 [1.1, 1.1], respectively) and GDM (RRs 1.8, 1.8, 2.0, and 1.3, respectively). Women with abnormal OGTT results were more likely to visit a dietician than women with normal GCT; RRs ranged from 4.0 [3.3, 4.9] for women with abnormal GCT but normal OGTT to 72.1 [64, 81] for women with GDM. CONCLUSIONS: Health-services utilization increased with severity of glucose result, even among women without GDM.

    • Communicable Diseases
      1. Mental health, social support, and HIV-related sexual risk behaviors among HIV-negative adolescent sexual minority males: three U.S. cities, 2015external icon
        Agnew-Brune CB, Balaji AB, Mustanski B, Newcomb ME, Prachand N, Braunstein SL, Brady KA, Hoots BE, Smith JS, Paz-Bailey G, Broz D.
        AIDS Behav. 2019 May 7.
        We examined the association between mental health issues, social support, and HIV among adolescent sexual minority males (SMM), who are disproportionally affected by HIV. National HIV Behavioral Surveillance among Young Men Who Have Sex with Men (NHBS-YMSM) data among SMM aged 13-18 years were collected in three cities (Chicago, New York City, and Philadelphia). Separate log-linked Poisson regression models were used to estimate associations between mental health issues and social support (general and family), and 3 HIV-related sexual risk behavior outcomes: past-year condomless anal intercourse (CAI) with a male partner, past-year sex with >/= 4 partners, and first vaginal or anal sex before age 13. Of 547 adolescent SMM, 22% reported ever attempting suicide and 10% reported past-month suicidal ideation. The majority (52%) reported depression and anxiety. Thirty-nine percent reported CAI, 29% reported >/= 4 sex partners and 22% reported first sex before age 13. Ever attempting suicide, suicidal ideation, and depression and anxiety were associated with CAI. Separately, ever attempting suicide and lack of family support were associated with >/= 4 sex partners. None of the mental health or support measures were associated with having sex before age 13. General social support was not associated with any sexual risk behaviors. Mental health issues are common among adolescent SMM and associated with sexual risk behaviors. Including mental health support in comprehensive HIV prevention for adolescent SMM could potentially reduce HIV risk in this population.

      2. Case-case analyses of cryptosporidiosis and giardiasis using routine national surveillance data in the United States – 2005-2015external icon
        Benedict KM, Collier SA, Marder EP, Hlavsa MC, Fullerton KE, Yoder JS.
        Epidemiol Infect. 2019 Jan;147:e178.
        Understanding endemic infectious disease risk factors through traditional epidemiological tools is challenging. Population-based case-control studies are costly and time-consuming. A case-case analyses using surveillance data addresses these limitations by using resources more efficiently. We conducted a case-case analyses using routine surveillance data reported by 16 U.S. states (2005-2015), wherein reported cases of salmonellosis were used as a comparison group to identify exposure associations with reported cases of cryptosporidiosis and giardiasis. Odds ratios adjusted for age and reporting state (aOR) and 95% confidence intervals (95% CI) were calculated. A total of 10 704 cryptosporidiosis cases, 17 544 giardiasis cases, and 106 351 salmonellosis cases were included in this analyses. When compared with cases of salmonellosis, exposure to treated recreational water (aOR 4.7, 95% CI 4.3-5.0) and livestock (aOR: 3.2; 95% CI: 2.9-3.5) were significantly associated with cryptosporidiosis and exposure to untreated drinking (aOR 4.1, 95% CI 3.6-4.7) and recreational water (aOR 4.1, 95% CI 3.7-4.5) were associated with giardiasis. Our analyses shows that routine surveillance data with standardised exposure information can be used to identify associations of interest for cryptosporidiosis and giardiasis.

      3. Black women are disproportionately affected by HIV, accounting for 61% of women diagnosed in 2016. Black women with HIV are less likely to be adherent to antiretroviral therapy (ART) and virally suppressed compared to women of other racial/ethnic groups. We analyzed 2013-2014 data from 1703 black women patients in the Centers for Disease Control and Prevention’s Medical Monitoring Project to examine whether select psychological and social determinants of health (SDH) factors were associated with ART adherence and viral suppression. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to examine correlates of ART adherence and viral suppression. Women who had not been incarcerated in the past 12 months (aPR = 1.24; CI: 1.04-1.48) and had not experienced discrimination in a health care setting since their HIV diagnosis (aPR = 1.06; 1.00-1.11) were slightly more likely to be adherent to ART. Women who lived above the federal poverty level were more likely to be virally suppressed during the past 12 months (aPR = 1.09; CI: 1.01-1.18). More research is warranted to identify the best strategies to create health care settings that encourage black women’s HIV care engagement, and to address other key SDH and/or psychological factors.

      4. Disparities in incidence of human immunodeficiency virus infection among black and white women – United States, 2010-2016external icon
        Bradley EL, Williams AM, Green S, Lima AC, Geter A, Chesson HW, McCree DH.
        MMWR Morb Mortal Wkly Rep. 2019 May 10;68(18):416-418.
        Incident human immunodeficiency virus (HIV) infections among adolescent females and women declined during 2010-2016, with the largest decrease (21%) occurring among black women (1). However, in 2016, although black women accounted for 13% of the U.S. female population, 60% of new HIV infections among women were in black women, indicating persisting disparities (1). CDC used the population attributable proportion (PAP) disparity measure to describe the proportional decrease in HIV infection among black and white women combined that would be realized if the group with the higher rate (blacks) had the same rate as did the group with the lower rate (whites) (2). Analyses indicated that an estimated 3,900 of 4,200 (93%) incident HIV infections among black women in 2016 would not have occurred if rates were the same for black and white women. The PAP disparity measure decreased from 0.75 in 2010 to 0.70 in 2016, suggesting that if incidence rates for black women were the same as those for white women, the annual number of incident HIV infections among black and white women would have been 75% lower in 2010 and 70% lower in 2016. Continued efforts are needed to identify and address social and structural determinants associated with HIV-related disparities to eliminate these disparities and decrease HIV incidence among black women.

      5. Birth cohort effects in influenza surveillance data: Evidence that first influenza infection affects later influenza-associated illnessexternal icon
        Budd AP, Beacham L, Smith CB, Garten RJ, Reed C, Kniss K, Mustaquim D, Ahmad FB, Cummings CN, Garg S, Levine MZ, Fry AM, Brammer L.
        J Infect Dis. 2019 May 3.
        BACKGROUND: The evolution of influenza A viruses results in birth cohorts that have different initial influenza virus exposures. Historically, A/H3 predominant seasons have been associated with more severe influenza-associated disease; however, since the 2009 pandemic there are suggestions that some birth cohorts experience more severe illness in A/H1 predominant seasons. METHODS: U.S. influenza virologic, hospitalization and mortality surveillance data during 2000-2017 were analyzed for cohorts born between 1918 and 1989 that likely had different initial influenza virus exposures based on viruses circulating during early childhood. Relative risk/rate during H3 compared to H1 predominant seasons during pre-pandemic versus pandemic and later periods were calculated for each cohort. RESULTS: During the pre-pandemic period, all cohorts had more influenza-associated disease during H3 predominant seasons than H1 predominant seasons. During the pandemic and later period, four cohorts had higher hospitalization and mortality rates during H1 predominant seasons than H3 predominant seasons. DISCUSSION: Birth cohort differences in risk of influenza-associated disease by influenza A virus subtype can be seen in U.S. influenza surveillance data and differ between pre-pandemic and pandemic and later periods. As the population ages, the amount of influenza-associated disease may be greater in future H1 predominant seasons than H3 predominant seasons.

      6. Increase in hepatitis A virus infections – United States, 2013-2018external icon
        Foster MA, Hofmeister MG, Kupronis BA, Lin Y, Xia GL, Yin S, Teshale E.
        MMWR Morb Mortal Wkly Rep. 2019 May 10;68(18):413-415.
        Hepatitis A virus (HAV) is primarily transmitted fecal-orally after close contact with an infected person (1); it is the most common cause of viral hepatitis worldwide, typically causing acute and self-limited symptoms, although rarely liver failure and death can occur (1). Rates of hepatitis A had declined by approximately 95% during 1996-2011; however, during 2016-2018, CDC received approximately 15,000 reports of HAV infections from U.S. states and territories, indicating a recent increase in transmission (2,3). Since 2017, the vast majority of these reports were related to multiple outbreaks of infections among persons reporting drug use or homelessness (4). In addition, increases of HAV infections have also occurred among men who have sex with men (MSM) and, to a much lesser degree, in association with consumption of imported HAV-contaminated food (5,6). Overall, reports of hepatitis A cases increased 294% during 2016-2018 compared with 2013-2015. During 2016-2018, CDC tested 4,282 specimens, of which 3,877 (91%) had detectable HAV RNA; 565 (15%), 3,255 (84%), and 57 (<1%) of these specimens were genotype IA, IB, or IIIA, respectively. Adherence to the Advisory Committee on Immunization Practices (ACIP) recommendations to vaccinate populations at risk can help control the current increases and prevent future outbreaks of hepatitis A in the United States (7).

      7. BACKGROUND: Differences by sex in cardiovascular comorbid conditions among human immunodeficiency virus (HIV)-infected persons aged 50-64 years have been understudied; even fewer data are available for persons aged >/=65 years. METHODS: We used matched interview and medical record abstraction data from the 2009-2012 data cycles of the Medical Monitoring Project, a nationally representative sample of HIV-infected adults in care. We included men and women aged 50-64 and >/=65 years at time of interview. We calculated weighted prevalence estimates and used logistic regression to compute adjusted prevalence differences and 95% confidence intervals (CIs) assessing sex differences in various characteristics and cardiovascular comorbid conditions. Comorbid conditions included overweight/obesity (body mass index >/=25), abnormal total cholesterol level (defined as >/=200 mg/dL), diagnosed diabetes mellitus, or diagnosed hypertension. RESULTS: Of 7436 participants, 89.5% were aged 50-64 years and 10.4% aged >/=65 years, 75.1% were men, 40.4% (95% CI, 33.5%-47.2%) were non-Hispanic black, 72.0% (70.4%-73.6%) had HIV infection diagnosed >/=10 years earlier. After adjustment for sociodemographic and behavioral factors, women aged 50-64 years were more likely than men to be obese (adjusted prevalence difference, 8.4; 95% CI, 4.4-12.3), have hypertension (3.9; .1-7.6), or have high total cholesterol levels (9.9; 6.2-13.6). Women aged >/=65 years had higher prevalences of diabetes mellitus and high total cholesterol levels than men. CONCLUSIONS: Cardiovascular comorbid conditions were prevalent among older HIV-infected persons in care; disparities existed by sex. Closer monitoring and risk-reduction strategies for cardiovascular comorbid conditions are warranted for older HIV-infected persons, especially older women.

      8. Epidemiologic patterns of human Salmonella serotype diversity in the USA, 1996-2016external icon
        Judd MC, Hoekstra RM, Mahon BE, Fields PI, Wong KK.
        Epidemiol Infect. 2019 Jan;147:e187.
        Although researchers have described numerous risk factors for salmonellosis and for infection with specific common serotypes, the drivers of Salmonella serotype diversity among human populations remain poorly understood. In this retrospective observational study, we partition records of serotyped non-typhoidal Salmonella isolates from human clinical specimens reported to CDC national surveillance by demographic, geographic and seasonal characteristics and adapt sample-based rarefaction methods from the field of community ecology to study how Salmonella serotype diversity varied within and among these populations in the USA during 1996-2016. We observed substantially higher serotype richness in children &lt;2 years old than in older children and adults and steadily increasing richness with age among older adults. Whereas seasonal and regional variation in serotype diversity was highest among infants and young children, variation by specimen source was highest in adults. Our findings suggest that the risk for infection from uncommon serotypes is associated with host and environmental factors, particularly among infants, young children and older adults. These populations may have a higher proportion of illness acquired through environmental transmission pathways than published source attribution models estimate.

      9. Gentamicin as an alternative treatment for gonorrhoeaexternal icon
        Kirkcaldy RD, Workowski KA.
        Lancet. 2019 May 2.

        [No abstract]

      10. Pilot study of markers for high-grade anal dysplasia in a southern cohort from the Women’s Interagency HIV Study (WIHS)external icon
        Lahiri CD, Nguyen ML, Mehta CC, Mosunjac M, Tadros T, Unger ER, Rajeevan MS, Richards J, Ofotokun I, Flowers L.
        Clin Infect Dis. 2019 May 6.
        BACKGROUND: Anal cancer rates have increased, particularly in HIV-positive (HIV+) women. We assessed factors associated with anal precancer in HIV+ and at-risk HIV-negative (ARHIVN) women from the Atlanta Women’s Interagency HIV Study Cohort. METHODS: All participants underwent high resolution anoscopy, anal cytology (AC) and had anal (AS) and cervical (CS) samples collected. Specimens were tested for 37 HPV types and for FAM19A4 and microRNA124-2 promoter methylation. Binary logistic regression and multivariate analysis were conducted with histologic anal high grade squamous intraepithelial lesion (A-HSIL) as the dependent variable. RESULTS: Seventy-five women enrolled: 52(69%) were HIV+ with three-fourths having undetectable viral load, 64(86%) were black, with mean age 49+/-8 years. Forty-nine (65%) AC samples were abnormal, and 38(51%) of AS were positive for at least one of 13 high-risk HPV (hrHPV) types. Thirteen (18%) anal biopsies identified A-HSIL. Hypermethylation of FAM19A4 and/or microRNA124-2 was found in 69 (95%) AS and 19(26%) CS. In multivariate analyses, the odds of having A-HSIL were over 6 times higher in women with anal hrHPV (aOR 6.08, 95% CI 1.27-29.18, p=0.02) and with positive cervical methylation (aOR 6.49, 95% CI 1.66-25.35, p=0.007), but not significantly higher in women with positive anal methylation. CONCLUSIONS: Anal hrHPV and promoter hypermethylation in the cervix show promise as biomarkers for anal cancer screening in HIV+ and ARHIVN women. Greater understanding of gene silencing by promoter hypermethylation in anal carcinogenesis is needed.

      11. Varicella in Tshuapa Province, Democratic Republic of Congo, 2009-2014external icon
        Leung J, McCollum AM, Radford K, Hughes C, Lopez AS, Guagliardo SA, Nguete B, Likafi T, Kabamba J, Malekani J, Lushima RS, Pukuta E, Karhemere S, Tamfum JJ, Reynolds MG, Okitolonda EW, Schmid DS, Marin M.
        Trop Med Int Health. 2019 May 6.
        OBJECTIVE: To describe varicella cases in Tshuapa Province of the Democratic Republic of the Congo identified during monkeypox surveillance. METHODS: Demographic, clinical, and epidemiological data were collected from each suspected monkeypox case 2009-2014. Samples were tested by PCR for both Orthopoxviruses and varicella-zoster virus (VZV); a subset of VZV positive samples were genotyped. We defined a varicella case as a rash illness with laboratory-confirmed VZV. RESULTS: 366 varicella cases were identified; 66% were </=19 years old. Most patients had non-typical varicella rash with lesions reported as the same size and stage of evolution (86%), deep and profound (91%), on palms of hands and/or soles of feet (86%), and not itchy (49%). Many had non-typical signs and symptoms, such as lymphadenopathy (70%) and sensitivity to light (23%). A higher proportion of persons aged >/=20 years than persons aged </=19 years had >/=50 lesions (79% versus 65%, p = 0.007) and were bedridden (15% versus 9%, p = 0.056). All VZV isolates genotyped from 79 varicella cases were clade 5. During the surveillance period, one possible VZV-related death occurred in a 7 year-old child. CONCLUSIONS: A large proportion of patients presented with nontypical varicella rash and clinical signs and symptoms, highlighting challenges identifying varicella in an area with endemic monkeypox. Continued surveillance and laboratory diagnosis will help in rapid identification and control of both monkeypox and varicella and improve our understanding of varicella epidemiology in Africa. This article is protected by copyright. All rights reserved.

      12. High levels of HIV-1 drug resistance in children who acquired HIV infection through mother to child transmission in the era of Option B+, Haiti, 2013 to 2014external icon
        Louis FJ, Segaren N, Desinor O, Beard RS, Jean-Louis R, Chang J, Boisson S, Hulland EN, Wagar N, DeVos J, Francois K, Buteau J, Boncy J, Marston BJ, Domercant JW, Yang C, Charles M.
        Pediatr Infect Dis J. 2019 May;38(5):503-507.
        BACKGROUND: The main objective of this study was to determine the frequency and patterns of HIV drug resistance-associated mutations among children under 18 months of age born to HIV-1-positive mothers enrolled in the prevention of mother-to-child transmission services in Haiti. METHODS: Between January 1, 2013 and December 31, 2014, HIV-positive remnant dried blood spots collected from children under 18 months of age for Early Infant Diagnosis at the National Public Health Laboratory were used for HIV-1 genotyping. HIV drug resistance mutations were analyzed using the Stanford Drug Resistance HIVdb program. RESULTS: Of the 3555 dried blood spots collected for Early Infant Diagnosis, 360 (10.1%) were HIV-positive and 355 were available for genotyping. Of these, 304 (85.6%) were successfully genotyped and 217 (71.4%) had >/=1 drug resistance mutation. Mutations conferring resistance to nucleoside reverse transcriptase inhibitor (NRTIs) and non-NRTIs were present in 40.5% (123) and 69.1% (210), respectively. The most frequent mutations were K103N/S (48.0%), M184V (37.5%), G190A/S (15.1%), and Y181C/G/V (14.1%). Predicted drug resistance analysis revealed that 68.8% of the children had high-level resistance to non-NRTIs and 11.5% had intermediate to high-level resistance to abacavir. CONCLUSIONS: This study showed high rates of resistance to NRTIs and non-NRTIs among newly HIV-diagnosed children in Haiti, suggesting that in the era of “Option B+” (initiation of lifelong combination antiretroviral therapy to pregnant women with HIV), the majority of children who acquire HIV infection through mother-to-child transmission of HIV have resistant HIV. These results have led the National HIV Program to revise the pediatric guidelines to include protease inhibitors in first-line regimens for all HIV-positive newborns.

      13. Evaluation of Vietnam’s post-exposure prophylaxis delivery system, 2017external icon
        Nguyen HT, Le ND, Pham TN, Urabe MI, Afriyie DO, Otsu S, Tran DN, Tran HG, Nguyen HV, Le HT, Tran CH.
        Vaccine. 2019 .
        Background: Canine-mediated human rabies deaths typically occur in poor and rural populations with limited access to rabies biologics: vaccine and immunoglobulin. A critical aspect of reducing rabies deaths is understanding how these countries procure, deliver, and forecast rabies biologics. Vietnam is one of the few endemic countries where biologics is widely available. However, a formal evaluation of its current rabies biologics distribution system has not been conducted. Methods: In 2017, we conducted a formal evaluation of Vietnam’s rabies biologics distribution system. Our goals were (1)to identify centers providing rabies biologics (2)identify costs to the patient and centers and (3)assess the rabies biologic procurement and delivery system at eligible district and provincial centers (provides and orders biologics for itself and other centers directly from the manufacture). To conduct the formal evaluation, we developed a standardized survey that was distributed to centers. Results: Of the 780 designated rabies biologics centers in Vietnam, 659 (84%) of them provide rabies immunoglobulin (eRIG), vaccine, or both. Of the 177 eligible centers, 90% (160)responded to the survey. The average costs to patients were $8.45 (range: 5.43-12.77) for one dose of IM injection, $13.90 (range: 11.86-16.71)for domestic eRIG, and $23 (21.11-27.11)for imported eRIG. Respondents reported experiencing delays in receiving vaccine in 50 centers and eRIG in 14 centers within the past year. Respondents stated their top three challenges in providing biologics were: delays or shortages from manufactures, lack of funds to pay for biologics, and the high cost of biologics. Conclusions and relevance: Despite the wide availability of biologics in Vietnam, more work is needed to provide affordable and reliable supply of biologics to patients. This includes the expansion of ID injection use throughout the country to lower vaccine demand, and decrease the costs to centers and patients. Furthermore, a more coordinated effort to share biologics among centers, possibly through a more centralized system at the provincial level may alleviate delays and shortages.

      14. Multidrug-resistant tuberculosis outbreak associated with poor treatment adherence and delayed treatment: Arua District, Uganda, 2013-2017external icon
        Okethwangu D, Birungi D, Biribawa C, Kwesiga B, Turyahabwe S, Ario AR, Zhu BP.
        BMC Infect Dis. 2019 May 7;19(1):387.
        BACKGROUND: In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities’ capacity to manage MDR-TB, and recommend evidence-based control measures. METHODS: We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013-2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January-August 2017 with the same months in 2013-2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities’ capacity to manage TB. RESULTS: We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January-August 2017 was 10, compared with 3-4 cases in January-August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p < 0.01), as were cases >/=18 years old compared to those < 18 years (8.7 vs 0.21/100,000, p < 0.01). In the case-control study, poor adherence to first-line anti-TB treatment (aOR = 9.2, 95% CI: 2.3-37) and initiating treatment > 15 months from symptom onset (aOR = 11, 95% CI: 1.5-87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients. CONCLUSION: The number of cases during January-August in 2017 was significantly higher than during the same months in 2013-2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH.

      15. Increase in measles cases – United States, January 1-April 26, 2019external icon
        Patel M, Lee AD, Redd SB, Clemmons NS, McNall RJ, Cohn AC, Gastanaduy PA.
        MMWR Morb Mortal Wkly Rep. 2019 May 3;68(17):402-404.
        As of April 26, 2019, CDC had reported 704 cases of measles in the United States since the beginning of 2019, representing the largest number of cases reported in the country in a single year since 1994, when 963 cases occurred, and since measles was declared eliminated* in 2000 (1,2). Measles is a highly contagious, acute viral illness characterized by fever and a maculopapular rash; complications include pneumonia, encephalitis, and death. Among the 704 cases, 503 (71%) were in unvaccinated persons and 689 (98%) occurred in U.S. residents. Overall, 66 (9%) patients were hospitalized. Thirteen outbreaks have been reported in 2019, accounting for 663 cases, 94% of all reported cases. Six of the 13 outbreaks were associated with underimmunized close-knit communities and accounted for 88% of all cases. High 2-dose measles vaccination coverage in the United States has been critical to limiting transmission (3). However, increased global measles activity poses a risk to U.S. elimination, particularly when unvaccinated travelers acquire measles abroad and return to communities with low vaccination rates (4). Health care providers should ensure persons are up to date with measles, mumps, rubella (MMR) vaccine, including before international travel, and rapidly report all suspected cases of measles to public health authorities.

      16. Assessing uncertainty in an anatomical site-specific gonorrhea transmission model of men who have sex with menexternal icon
        Spicknall IH, Mayer KH, Aral SO, Romero-Severson EO.
        Sex Transm Dis. 2019 May;46(5):321-328.
        BACKGROUND: Increased gonorrhea detection highlights the need for additional prevention efforts. Gonorrhea may only be acquired when there is contact between infected and uninfected anatomical sites. With 3 sites of infection, this leads to 7 plausible routes of men who have sex with men (MSM) transmission: urethra-to-rectum, rectum-to-urethra, urethra-to-oropharynx, rectum-to-oropharynx, oropharynx-to-urethra, oropharynx-to-rectum, and oropharynx-to-oropharynx. We characterize the uncertainty and potential importance of transmission from each anatomical site using a deterministic compartmental mathematical model. METHODS: We developed a model of site-specific gonococcal infection, where individuals are infected at 0, 1, 2, or all 3 sites. Sexual behavior and infection duration parameters were fixed similar to a recent model analysis of Australian MSM. Markov chain Monte Carlo methods were used to sample the posterior distribution of transmission probabilities that were consistent with site-specific prevalence in American MSM populations under specific scenarios. Scenarios were defined by whether transmission routes may or may not transmit by constraining specific transmission probabilities to zero rather than fitting them. RESULTS: Transmission contributions from each site have greater uncertainty when more routes may transmit; in the most extreme case, when all routes may transmit, the oropharynx can contribute 0% to 100% of all transmissions. In contrast, when only anal or oral sex may transmit, transmission from the oropharynx can account for only 0% to 25% of transmission. Intervention effectiveness against transmission from each site also has greater uncertainty when more routes may transmit. CONCLUSIONS: Even under ideal conditions (ie, when site-specific gonococcal prevalence, relative rates of specific sex acts, and duration of infection at each anatomical site are known and do not vary), the relative importance of different anatomical sites for gonococcal infection transmission cannot be inferred with precision. Additional data informing per act transmissibility are needed to understand site-specific gonococcal infection transmission. This understanding is essential for predicting population-specific intervention effectiveness.

      17. Notes from the field: Outbreak of multidrug-resistant Shigella sonnei infections in a retirement community – Vermont, October-November 2018external icon
        Strysko J, Fialkowski V, Marsh Z, Wadhwa A, Collins J, Gharpure R, Kelso P, Friedman CR, Fullerton KE.
        MMWR Morb Mortal Wkly Rep. 2019 May 3;68(17):405-406.

        [No abstract]

      18. Factors associated with recruitment, surveillance participation, and retention in an observational study of pregnant women and influenzaexternal icon
        Thompson MG, Li DK, Naleway AL, Ferber JR, Henninger ML, Shifflett P, Sokolow LZ, Odouli R, Kauffman TL, Fink RV, Bulkley J, Cragan JD, Bozeman S.
        BMC Pregnancy Childbirth. 2019 May 8;19(1):161.
        BACKGROUND: This report describes the results of recruitment efforts and the subsequent participation of pregnant women in study activities in a 2010-2012 observational study focused on influenza illness and vaccination in California and Oregon, USA. METHODS: Socio-demographic and health characteristics extracted from electronic medical records were compared among pregnant women who enrolled in the study, refused to participate, or were never reached for study invitation. These characteristics plus additional self-reported information were compared between women who enrolled in two study tracks: a prospective cohort vs. women enrolled following an acute respiratory illness (ARI) medical encounter. The characteristics of women who participated in weekly ARI surveillance (cohort enrollees, year one) and a 6-month follow-up interview (all enrollees) were also examined. RESULTS: In year one, we reached 51% (6938/13,655) of the potential participants we tried to contact by telephone, and 20% (1374/6938) of the women we invited agreed to join the prospective cohort. Women with chronic medical conditions, pregnancy complications, and medical encounters for ARI (prior to pregnancy or during the study period) were more likely to be reached for recruitment and more likely to enroll in the cohort. Twenty percent of cohort enrollees never started weekly surveillance reports; among those who did, reports were completed for 55% of the surveillance weeks. Receipt of the influenza vaccine was higher among women who joined the cohort (76%) than those who refused (56%) or were never reached (54%). In contrast, vaccine uptake among medical enrollees in year one (54%; 53/98) and two (52%; 79/151) was similar to other pregnant women in those years. Study site, white race, non-Hispanic ethnicity, and not having a child aged < 13 years at home were most consistently associated with joining as a cohort or medical enrollee and completing study activities after joining. CONCLUSIONS: We observed systematic differences in socio-demographic and health characteristics across different levels of participant engagement and between cohort and medical enrollees. More methodological research and innovation in conducting prospective observational studies in this population are needed, especially when extended participant engagement and ongoing surveillance are required.

      19. Factors associated with fatal cases of acute respiratory infection (ARI) among hospitalized patients in Guatemalaexternal icon
        Tomczyk S, McCracken JP, Contreras CL, Lopez MR, Bernart C, Moir JC, Escobar K, Reyes L, Arvelo W, Lindblade K, Peruski L, Bryan JP, Verani JR.
        BMC Public Health. 2019 May 3;19(1):499.
        BACKGROUND: Acute respiratory infection (ARI) is an important cause of mortality in children and adults. However, studies assessing risk factors for ARI-related deaths in low- and middle-income settings are limited. We describe ARI-related death and associated factors among children aged < 2 years and adults aged >/=18 years hospitalized with ARI in Guatemala. METHODS: We used respiratory illness surveillance data in Guatemala from 2007 to 2013. ARI was defined as evidence of acute infection and >/= 1 sign/symptom of respiratory disease in hospitalized patients. Clinical, sociodemographic, and follow-up data were gathered. Nasopharyngeal/oropharyngeal swabs were collected from patients with ARI and tested for 6 respiratory viruses; urine was collected only from adults with ARI and tested for pneumococcal antigen. Blood cultures and chest radiographs were performed at the physician’s discretion. Radiographs were interpreted per World Health Organization guidelines to classify endpoint pneumonia (i.e. suggestive of bacterial pneumonia). Multivariable logistic regression was used to compare characteristics of patients with fatal cases, including those who died in-hospital or were discharged in a moribund state, with those of patients with non-fatal cases. RESULTS: Among 4109 ARI cases identified in hospitalized children < 2 years old, 174 (4%) were fatal. Median age at admission was 4 and 6 months for children with fatal and non-fatal cases, respectively. Factors associated with fatality included low weight-for-age, low family income, heart disease, and endpoint pneumonia; breastfeeding and respiratory syncytial virus (RSV) detection were negatively associated with fatality. Among 1517 ARI cases identified in hospitalized adults >/=18 years, 181 (12%) episodes were fatal. Median age at admission was 57 years for adults with fatal and non-fatal cases. Low body mass index, male sex, kidney disease, and endpoint pneumonia were significantly more common among patients with fatal versus non-fatal cases. CONCLUSIONS: Our findings highlight some of the factors that must be addressed in order to reduce ARI-related mortality, including promotion of good nutrition, breastfeeding, management and prevention of chronic comorbidities, and poverty reduction. Although no specific pathogen increased risk for death, endpoint pneumonia was significantly associated with fatality, suggesting that the pneumococcal conjugate vaccine could contribute to future reductions in ARI-related mortality.

      20. Risk factors for community-associated Clostridioides difficile infection in young childrenexternal icon
        Weng MK, Adkins SH, Bamberg W, Farley MM, Espinosa CC, Wilson L, Perlmutter R, Holzbauer S, Whitten T, Phipps EC, Hancock EB, Dumyati G, Nelson DS, Beldavs ZG, Ocampo V, Davis CM, Rue B, Korhonen L, McDonald LC, Guh AY.
        Epidemiol Infect. 2019 Jan;147:e172.
        The majority of paediatric Clostridioides difficile infections (CDI) are community-associated (CA), but few data exist regarding associated risk factors. We conducted a case-control study to evaluate CA-CDI risk factors in young children. Participants were enrolled from eight US sites during October 2014-February 2016. Case-patients were defined as children aged 1-5 years with a positive C. difficile specimen collected as an outpatient or 3 days of hospital admission, who had no healthcare facility admission in the prior 12 weeks and no history of CDI. Each case-patient was matched to one control. Caregivers were interviewed regarding relevant exposures. Multivariable conditional logistic regression was performed. Of 68 pairs, 44.1% were female. More case-patients than controls had a comorbidity (33.3% vs. 12.1%; P = 0.01); recent higher-risk outpatient exposures (34.9% vs. 17.7%; P = 0.03); recent antibiotic use (54.4% vs. 19.4%; P &lt; 0.0001); or recent exposure to a household member with diarrhoea (41.3% vs. 21.5%; P = 0.04). In multivariable analysis, antibiotic exposure in the preceding 12 weeks was significantly associated with CA-CDI (adjusted matched odds ratio, 6.25; 95% CI 2.18-17.96). Improved antibiotic prescribing might reduce CA-CDI in this population. Further evaluation of the potential role of outpatient healthcare and household exposures in C. difficile transmission is needed.

      21. OBJECTIVES: The effect of incarceration on HIV risk-related behaviors among at-risk heterosexual men is understudied. The objective of our study was to examine the association between incarceration and HIV risk-related behaviors among a sample of predominantly non-Hispanic black and Hispanic heterosexual men residing in urban areas in the United States with a high prevalence of AIDS. METHODS: We analyzed data from the 2013 National HIV Behavioral Surveillance system on 5321 at-risk heterosexual men using log-linked Poisson regression models, adjusted for demographic characteristics and clustered on city. RESULTS: Of 5321 men, 1417 (26.6%) had recently been incarcerated (in the past 12 months), 2781 (52.3%) had ever been incarcerated but not in the past 12 months, and 1123 (21.1%) had never been incarcerated. Recent incarceration was associated with multiple casual female sexual partners (adjusted prevalence ratio [aPR] = 1.23; 95% confidence interval [CI], 1.05-1.44), condomless sex with multiple female sexual partners (aPR = 1.32; 95% CI, 1.06-1.66), injection drug use (aPR = 3.75; 95% CI, 2.64-5.32), and having sexual partners who were more likely to have ever injected drugs (aPR = 1.84; 95% CI, 1.48-2.28), been incarcerated (aPR = 2.28; 95% CI, 2.01-2.59), or had a concurrent sexual partner (aPR = 1.08; 95% CI, 1.05-1.11), as compared with never-incarcerated men. CONCLUSIONS: Incarceration history was associated with HIV risk-related behaviors among heterosexual men from urban areas in the United States. Correctional rehabilitation initiatives are needed to promote strategies that mitigate HIV risk-related behaviors and promote healthy reentry into communities among heterosexual men at high risk for HIV.

      22. Influenza-associated hospitalization in children younger than 5 years of age in Suzhou, China, 2011-2016external icon
        Yu J, Zhang X, Shan W, Gao J, Hua J, Tian J, Ding Y, Zhang J, Chen L, Song Y, Zhou S, Iuliano AD, Greene CM, Zhang T, Zhao G.
        Pediatr Infect Dis J. 2019 May;38(5):445-452.
        BACKGROUND: Studying the burden and risk factors associated with severe illness from influenza infection in young children in eastern China will contribute to future cost-effectiveness analyses of local influenza vaccine programs. METHODS: We conducted prospective, severe acute respiratory infection (SARI) surveillance at Suzhou University-Affiliated Children’s Hospital to estimate influenza-associated hospitalizations in Suzhou University-Affiliated Children’s Hospital by month in children younger than 5 years of age from October 2011 to September 2016. SARI was defined as fever (measured axillary temperature >/= 38 degrees C) and cough or sore throat or inflamed/red pharynx in the 7 days preceding hospitalization. We combined SARI surveillance data with healthcare utilization survey data to estimate and characterize the burden of influenza-associated SARI hospitalizations in Suzhou within this age group in the 5-year period. RESULTS: Of the 36,313 SARI cases identified, 2,297 from respiratory wards were systematically sampled; of these, 259 (11%) were influenza positive. Estimated annual influenza-associated SARI hospitalization rates per 1,000 children younger than 5 years of age ranged from 4 (95% confidence interval [CI], 2-5) in the 2012-2013 season to 16 (95% CI, 14-19) in the 2011-2012 season. The predominant viruses were A/H3N2 (59%) in 2011-12, both A/H1N1pdm09 (42%) and B (46%) in 2012-13, A/H3N2 (71%) in 2013-14, A/H3N2 (55%) in 2014-15 and both A/H1N1pdm09 (50%) and B (50%) in 2015-16. The age-specific influenza-associated SARI hospitalization rates for the 5-year period were 11 (95% CI, 8-15) per 1,000 children 0-5 months of age; 8 (95% CI, 7-10) per 1,000 children 6-23 months of age and 5 (95% CI, 4-5) per 1,000 children 24-59 months of age, respectively. CONCLUSIONS: From 2011 to 2016, influenza-associated SARI hospitalization rates in children aged younger than 5 years of age in Suzhou, China, were high, particularly among children 0-5 months of age. Higher hospitalization rates were observed in years where the predominant circulating virus was influenza A/H3N2. Immunization for children > 6 months, and maternal and caregiver immunization for those < 6 months, could reduce influenza-associated hospitalizations in young children in Suzhou.

    • Environmental Health
      1. Good pool chemistry keeps swimming healthy and safeexternal icon
        Hlavsa MC, Laco JP, Hill VR.
        J Environ Health. 2019 ;81(9):32-34.

        [No abstract]

      2. Childhood polybrominated diphenyl ether (PBDE) serum concentration and reading ability at ages 5 and 8 years: The HOME Studyexternal icon
        Liang H, Vuong AM, Xie C, Webster GM, Sjodin A, Yuan W, Miao M, Braun JM, Dietrich KN, Yolton K, Lanphear BP, Chen A.
        Environ Int. 2019 Jan;122:330-339.
        BACKGROUND: Polybrominated diphenyl ethers (PBDEs) exist extensively in the environment and human beings. PBDE concentrations are higher in children than adults. A previous study found that prenatal PBDE exposure was associated with decreased reading skills in children; however, evidence is limited on the potential impact of childhood exposure to PBDEs. The study examined the association between childhood PBDE exposures and reading ability in children at ages 5 and 8years. METHODS: The study included 230 children from an ongoing prospective pregnancy and birth cohort study, the Health Outcomes and Measures of Environment (HOME) Study, conducted in Cincinnati, Ohio. Children’s serum concentrations of eleven PBDE congeners were measured at 1, 2, 3, 5, and 8years. The Woodcock-Johnson Tests of Achievement – III and the Wide Range Achievement Test – 4 were administered to assess children’s reading skills at ages 5 and 8years, respectively. We used multiple informant models to examine the associations between repeated measures of PBDEs and reading scores at ages 5 and 8years. We also estimated the betas and 95% CIs of the association of PBDE measure at each age by including interaction terms between PBDE concentrations and child age in the models. RESULTS: All childhood BDE-153 concentrations were inversely associated with reading scores at 5 and 8years, but associations were not statistically significant after covariate adjustment. For example, a 10-fold increase in BDE-153 concentrations at ages 3 and 5years was associated with a -5.0 (95% confidence interval (CI): -11.0, 1.0) and -5.5 (95% CI: -12.5, 1.4) point change in Basic Reading score at age 5years, respectively. Similarly, the estimates for Brief Reading score at age 5years were -4.5 (95% CI: -10.5, 1.5) and -5.2 (95% CI: -12.2, 1.7) point changes, respectively. Serum concentration of BDE-47, -99, -100, and Sum4PBDEs (sum of BDE-47, 99, 100, and 153) at every age were inversely associated with reading scores at ages 5 and 8years in unadjusted analyses. While the adjusted estimates were much attenuated and became non-significant, the direction of most of the associations was not altered. CONCLUSION: Our study has shown a suggestive but non-significant trend of inverse associations between childhood PBDE serum concentrations, particularly BDE-153, and children’s reading skills. Future studies with a larger sample size are needed to examine these associations.

      3. Obesity in relation to serum persistent organic pollutant concentrations in CHAMACOS womenexternal icon
        Warner M, Rauch S, Coker ES, Harley K, Kogut K, Sjodin A, Eskenazi B.
        Environ Epidemiol. 2018 December;2 (4) (e032).
        Background: Environmental exposure to endocrine-disrupting chemicals (EDCs), including persistent organic pollutants (POPs), has been hypothesized to increase risk of obesity. Using data from the Center for Health Assessment of Mothers and Children of Salinas (CHAMACOS) study, we examined the longitudinal relationship between serum concentrations of a POPs mixture and several obesity measures. Method(s): Concentrations of 17 POPs were measured in serum collected in 2009-2011 from 468 CHAMACOS women. Anthropometry measurements and personal interviews were completed at up to three study visits between 2009 and 2014. We assessed the relationship of serum POPs concentrations with adiposity measures longitudinally using generalized estimation equation (GEE) models. We implemented Bayesian Kernel Machine Regression (BKMR) to elucidate the effects of joint exposure to the POPs mixture. Result(s): In GEE models, positive associations with body mass index were found for dichlorodiphenyltrichloroethane (Q4 vs. Q1: adjusted beta = 3.2kg/m<sup>2</sup>; 95% CI = 1.5, 4.9), beta-hexachlorocyclohexane (Q4 vs. Q1: adjusted beta = 3.6kg/m<sup>2</sup>; 95% CI = 2.0, 5.2), and polybrominated diphenyl ether (PBDE)-47 (Q4 vs. Q1: adjusted beta = 1.9kg/m<sup>2</sup>; 95% CI = 0.3, 3.5), while PBDE-153 was inversely associated (Q4 vs. Q1: adjusted beta = -2.8kg/m<sup>2</sup>; 95% CI = -4.4, -1.2). BKMR results, while largely consistent with single pollutant models, revealed the shape and direction of the exposure-response relationships, as well as interactions among pollutants within the mixture, that could not be discovered by single-pollutant models. Conclusion(s): In summary, we found significant associations of serum POPs with several adiposity measures using both conventional regressions and BKMR. Our results provide support for the chemical obesogen hypothesis, that exposure to EDCs may alter risk for later obesity.

    • Food Safety
      1. An overview of PulseNet USA Databasesexternal icon
        Tolar B, Joseph LA, Schroeder MN, Stroika S, Ribot EM, Hise KB, Gerner-Smidt P.
        Foodborne Pathog Dis. 2019 May 8.
        PulseNet USA is the molecular surveillance network for foodborne disease in the United States. The network consists of state and local public health laboratories, as well as food regulatory agencies, that follow PulseNet’s standardized protocols to perform pulsed-field gel electrophoresis (PFGE) and whole genome sequencing (WGS) and analyze the results using standardized software. The raw sequences are uploaded to the GenomeTrakr or PulseNet bioprojects at the National Center for Biotechnology Information. The PFGE patterns and analyzed sequence data are uploaded in real time with associated demographic data to the PulseNet national databases managed at the Centers for Disease Control and Prevention. The PulseNet databases are organism specific and provide a central storage location for molecular and demographic data related to an isolate. Sequences are compared in the databases, thereby facilitating the rapid detection of clusters of foodborne diseases that may represent widespread outbreaks. WGS genotyping data, for example, antibiotic resistance and virulence profiles, are also uploaded in real time to the PulseNet databases to improve food safety surveillance activities.

    • Health Communication and Education
      1. Background: The dissemination of positive messages about mental health is a key goal of organizations and individuals. Aims: Our aim was to examine factors that predict increased dissemination of such messages. Method: We analyzed 10,998 positive messages authored on Twitter and studied factors associated with messages that are shared (re-tweeted) using logistic regression. Characteristics of the account, message, linguistic style, sentiment, and topic were examined. Results: Less than one third of positive messages (31.7%) were shared at least once. In adjusted models, accounts that posted a greater number of messages were less likely to have any single message shared. Messages about military-related topics were 60% more likely to be shared (adjusted odds ratio [AOR] = 1.6, 95% CI [1.1, 2.1]) as well as messages containing achievement-related keywords (AOR = 1.6, 95% CI [1.3, 1.9]). Conversely, positive messages explicitly addressing eating/food, appearance, and sad affective states were less likely to be shared. Multiple other message characteristics influenced sharing. Limitations: Only messages on a single platform and over a focused period of time were analyzed. Conclusion: A knowledge of factors affecting dissemination of positive mental health messages may aid organizations and individuals seeking to promote such messages online.

    • Health Disparities
      1. Racial disparities in mortality associated with systemic lupus erythematosus – Fulton and DeKalb Counties, Georgia, 2002-2016external icon
        Lim SS, Helmick CG, Bao G, Hootman J, Bayakly R, Gordon C, Drenkard C.
        MMWR Morb Mortal Wkly Rep. 2019 May 10;68(18):419-422.
        Systemic lupus erythematosus (SLE) is a chronic, systemic autoimmune disease with often nonspecific symptoms that can lead to a delay in diagnosis. The disease disproportionately affects women and minorities. Blacks with SLE also have more severe disease and develop it at an earlier age (1). Despite an increase in the 5-year survival rate from 50% in 1955 to approximately 90% in the 2000s, attributed largely to advances in management of SLE (2), premature mortality among SLE patients persists, often as a result of disease severity, infections, and cardiovascular disease. Because existing SLE mortality estimates based on death certificate data are known to underestimate SLE deaths (3), SLE mortality was analyzed using 2002-2004 data from the population-based Georgia Lupus Registry (1). Incident and prevalent SLE cases matched to the National Death Index through 2016 identified 97 and 401 deaths, respectively. Standardized mortality ratios adjusted for age group, sex, and race were two to three times higher among persons with SLE relative to expected deaths in the general population. Blacks had significantly higher cumulative mortality than did whites, and blacks with both incident and prevalent cases were significantly younger at death (mean age 51.8 and 52.3 years, respectively) than were whites (mean age 64.4 and 65.0 years, respectively). Whites had lower mortality after diagnosis than did blacks; among incident cases, mortality among whites did not occur until 5 years after SLE diagnosis, whereas blacks had significantly and persistently higher mortality from the time of diagnosis. There were no significant differences by sex. Current CDC-supported efforts encourage early detection, diagnosis, and treatment, and enhanced self-management skills to mitigate racial disparities and improve outcomes overall among persons with SLE.

    • Healthcare Associated Infections
      1. Identification of a carbapenemase-producing hypervirulent Klebsiella pneumoniae isolate, United Statesexternal icon
        Karlsson M, Stanton RA, Ansari U, McAllister G, Chan MY, Sula E, Grass JE, Duffy N, Anacker ML, Witwer ML, Rasheed JK, Elkins CA, Halpin AL.
        Antimicrob Agents Chemother. 2019 May 6.
        We report on a carbapenemase-producing hypervirulent Klebsiella pneumoniae (CP-hvKP) collected from a U.S. patient at an outpatient clinic. The isolate was identified as K. pneumoniae serotype K1, sequence type 23 and included both a hypervirulence (with rmpA, rmpA2 iroBCDN, peg-344 and iucABCD-iutA genes) and a carbapenemase-encoding (bla KPC-2) plasmid. The emergence of CP-hvKP underscores the importance of clinical awareness of this pathotype and the need for continued monitoring of CP-hvKP in the United States.

      2. Outbreak investigation of Pseudomonas aeruginosa infections in a neonatal intensive care unitexternal icon
        Weng MK, Brooks RB, Glowicz J, Keckler MS, Christensen BE, Tsai V, Mitchell CS, Wilson LE, Laxton R, Moulton-Meissner H, Fagan R.
        Am J Infect Control. 2019 Apr 29.
        A Pseudomonas aeruginosa outbreak was investigated in a neonatal intensive care unit that had experienced a prior similar outbreak. The 8 cases identified included 2 deaths. An investigation found the cause of the outbreak: tap water from contaminated hospital plumbing which was used for humidifier reservoirs, neonatal bathing, and nutritional preparation. Our findings reinforce a recent Centers for Medicare & Medicaid Services memo recommending increased attention to water management to improve awareness, identification, mitigation, and prevention of water-associated, health care-associated infections.

    • Immunity and Immunization
      1. [No abstract]

      2. Vaccine safety in HIV-infected adults within the Vaccine Safety Datalink Projectexternal icon
        Hechter RC, Qian L, Tartof SY, Sy LS, Klein NP, Weintraub E, Mercado C, Naleway A, McLean HQ, Jacobsen SJ.
        Vaccine. 2019 May 4.
        OBJECTIVES: We evaluate safety of routine vaccination among adults infected with human immunodeficiency virus (HIV) in five healthcare organizations in the United States. METHODS: We conducted a retrospective cohort study of HIV-infected adults who received inactivated influenza vaccines, hepatitis B vaccines, pneumococcal vaccines, or tetanus, diphtheria, and acellular pertussis vaccines between 2002 and 2013. We conducted self-controlled case series analysis to estimate the relative risk (RR) for 11 pre-specified adverse events (AEs) requiring medical attention. RESULTS: Among 20,417 HIV-infected adults (90.2% male), a total of 137,674 vaccine doses were administered. Based on ICD-9 codes, we detected an increased risk of cellulitis and infection (RR: 1.18, 95% CI: 1.03-1.35) among all patients, and an increased risk of stroke/cerebrovascular diseases among patients with an HIV viral load >10,000 copies/ml (adjusted RR: 3.94, 95% CI: 1.32-11.72). Further analyses on chart confirmed cases of stroke/cerebrovascular diseases indicated no statistically significant increased risk (adjusted RR: 1.72, 95% CI: 0.41-7.24). There was no evidence of increased risk for other AEs following routine vaccination in HIV-infected adults. CONCLUSIONS: Routinely administered vaccines are generally safe for HIV-infected adults.

      3. Progress toward measles elimination – European Region, 2009-2018external icon
        Zimmerman LA, Muscat M, Singh S, Ben Mamou M, Jankovic D, Datta S, Alexander JP, Goodson JL, O’Connor P.
        MMWR Morb Mortal Wkly Rep. 2019 May 3;68(17):396-401.
        In 2010, all 53 countries* in the World Health Organization (WHO) European Region (EUR) reconfirmed their commitment to eliminating measles and rubella and congenital rubella syndrome (1); this goal was included as a priority in the European Vaccine Action Plan 2015-2020 (2). The WHO-recommended elimination strategies in EUR include 1) achieving and maintaining >/=95% coverage with 2 doses of measles-containing vaccine (MCV) through routine immunization services; 2) providing measles and rubella vaccination opportunities, including supplementary immunization activities (SIAs), to populations susceptible to measles or rubella; 3) strengthening surveillance by conducting case investigations and confirming suspected cases and outbreaks with laboratory results; and 4) improving the availability and use of evidence for the benefits and risks associated with vaccination (3). This report updates a previous report (4) and describes progress toward measles elimination in EUR during 2009-2018. During 2009-2017, estimated regional coverage with the first MCV dose (MCV1) was 93%-95%, and coverage with the second dose (MCV2) increased from 73% to 90%. In 2017, 30 (57%) countries achieved >/=95% MCV1 coverage, and 15 (28%) achieved >/=95% coverage with both doses. During 2009-2018, >16 million persons were vaccinated during SIAs in 13 (24%) countries. Measles incidence declined to 5.8 per 1 million population in 2016, but increased to 89.5 in 2018, because of large outbreaks in several EUR countries. To achieve measles elimination in EUR, measures are needed to strengthen immunization programs by ensuring >/=95% 2-dose MCV coverage in every district of each country, offering supplemental measles vaccination to susceptible adults, maintaining high-quality surveillance for rapid case detection and confirmation, and ensuring effective outbreak preparedness and response.

    • Injury and Violence
      1. Evaluation of a hospital-based injury surveillance system for monitoring road traffic deaths in Phuket, Thailandexternal icon
        Nittayasoot N, Peterson AB, Thammawijaya P, Parker EM, Sathawornwiwat A, Boonthanapat N, Chantian T, Voradetwitaya L, Jiraphongsa C, Sagarasaeranee O, Sansilapin C, Rattanathamsakul T, Ketgudee L, Tantiworrawit P.
        Traffic Inj Prev. 2019 May 3:1-7.
        OBJECTIVES: The objective of this study was to evaluate and injury surveillance (IS) system’s ability to monitor road traffic deaths and the coverage of road traffic injury and death surveillance in Phuket, Thailand. METHODS: U.S. Centers for Disease Control and Prevention guidelines on surveillance system evaluation were used to qualitatively and quantitatively evaluate IS. Interviews with key stakeholders focused on IS’s usefulness, simplicity, flexibility, acceptability, and stability. Active case finding of 2014 road traffic deaths in all paper and electronic hospital record systems was used to assess system sensitivity, positive predictive value, and data quality. Electronic data matching software was used to determine the implications of combining IS data with other provincial-level data sources (e.g., death certificates, electronic vehicle insurance claim system). RESULTS: Evaluation results indicated that IS was useful, flexible, acceptable, and stable, with a high positive predictive value (99%). Simplicity was limited due to the burden of collecting data on all injuries and use of paper-based data collection forms. Sensitivity was low, with IS only identifying 55% of hospital road traffic death cases identified during active case finding; however, IS cases were representative of cases identified. Data accuracy and completeness varied across data fields. Combining IS with active case finding, death certificates, and the electronic vehicle insurance claim system more than doubled the number of road traffic death cases identified in Phuket. CONCLUSION: An efficient and comprehensive road traffic injury and death surveillance system is critical for monitoring Phuket’s road traffic burden. The hospital-based IS system is a useful system for monitoring road traffic deaths and assessing risk behaviors. However, the complexity of data collection and limited coverage hinders the ability of IS to fully represent road traffic deaths in Phuket Province. Combining data sources could improve coverage and should be considered.

    • Laboratory Sciences
      1. Taxonomy of the order Bunyavirales: update 2019external icon
        Abudurexiti A, Adkins S, Alioto D, Alkhovsky SV, Avsic-Zupanc T, Ballinger MJ, Bente DA, Beer M, Bergeron E, Blair CD, Briese T, Buchmeier MJ, Burt FJ, Calisher CH, Chang C, Charrel RN, Choi IR, Clegg JC, de la Torre JC, de Lamballerie X, Deng F, Di Serio F, Digiaro M, Drebot MA, Duan X, Ebihara H, Elbeaino T, Ergunay K, Fulhorst CF, Garrison AR, Gao GF, Gonzalez JJ, Groschup MH, Gunther S, Haenni AL, Hall RA, Hepojoki J, Hewson R, Hu Z, Hughes HR, Jonson MG, Junglen S, Klempa B, Klingstrom J, Kou C, Laenen L, Lambert AJ, Langevin SA, Liu D, Lukashevich IS, Luo T, Lu C, Maes P, de Souza WM, Marklewitz M, Martelli GP, Matsuno K, Mielke-Ehret N, Minutolo M, Mirazimi A, Moming A, Muhlbach HP, Naidu R, Navarro B, Nunes MR, Palacios G, Papa A, Pauvolid-Correa A, Paweska JT, Qiao J, Radoshitzky SR, Resende RO, Romanowski V, Sall AA, Salvato MS, Sasaya T, Shen S, Shi X, Shirako Y, Simmonds P, Sironi M, Song JW, Spengler JR, Stenglein MD, Su Z, Sun S, Tang S, Turina M, Wang B, Wang C, Wang H, Wang J, Wei T, Whitfield AE, Zerbini FM, Zhang J, Zhang L, Zhang Y, Zhang YZ, Zhang Y, Zhou X, Zhu L, Kuhn JH.
        Arch Virol. 2019 May 7.
        In February 2019, following the annual taxon ratification vote, the order Bunyavirales was amended by creation of two new families, four new subfamilies, 11 new genera and 77 new species, merging of two species, and deletion of one species. This article presents the updated taxonomy of the order Bunyavirales now accepted by the International Committee on Taxonomy of Viruses (ICTV).

    • Maternal and Child Health
      1. Maternal occupational oil mist exposure and birth defects, National Birth Defects Prevention Study, 1997(-)2011external icon
        Siegel M, Rocheleau CM, Johnson CY, Waters MA, Lawson CC, Riehle-Colarusso T, Reefhuis J.
        Int J Environ Res Public Health. 2019 May 4;16(9).
        Workers in various industries can be exposed to oil mists when oil-based fluids are aerosolized during work processes. Oil mists can be inhaled or deposited on the skin. Little research exists on the reproductive effects of oil mist exposure in pregnant workers. We aimed to investigate associations between occupational oil mist exposure in early pregnancy and a spectrum of birth defects using data from 22,011 case mothers and 8140 control mothers in the National Birth Defects Prevention Study. In total, 150 mothers were rated as exposed. Manufacturing jobs, particularly apparel manufacturing, comprised the largest groups of exposed mothers. Mothers of infants with septal heart defects (odds ratio (OR): 1.8, 95% confidence interval (CI): 1.0-3.3), and especially perimembranous ventricular septal defects (OR: 2.5, CI: 1.2-5.2), were more likely to be occupationally exposed to oil mists in early pregnancy than control mothers; and their rater-estimated cumulative exposure was more likely to be higher. This was the first U.S. study evaluating associations between oil mist exposure and a broad spectrum of birth defects. Our results are consistent with previous European studies, supporting a potential association between oil-based exposures and congenital heart defects. Further research is needed to evaluate the reproductive effects of occupational oil mist exposure.

    • Nutritional Sciences
      1. Public perception of quality and support for required access to drinking water in schools and parksexternal icon
        Long MW, Gortmaker SL, Patel AI, Onufrak SJ, Wilking CL, Cradock AL.
        Am J Health Promot. 2018 Jan;32(1):72-74.
        PURPOSE: We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water. DESIGN: Cross-sectional survey of the US public collected from August to November 2011. SETTING: Random digit-dialed telephone survey. PARTICIPANTS: Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states. MEASURES: Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings. ANALYSIS: Survey-adjusted perceived safety and taste as well as support for required access were estimated. RESULTS: There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%). CONCLUSION: This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.

    • Occupational Safety and Health
      1. The association between job insecurity and engagement of employees at workexternal icon
        Getahun Asfaw A, Chang CC.
        J Workplace Behav Health. 2019 .
        This study examined the association between employees’ perceived job insecurity and employee engagement. Using Gallup-Sharecare Well-Being Index (2008-2014) data, we applied logistic regressions to examine the association between job insecurity and engagement, controlling for covariates. The job insecurity variable was also interacted with the supervisor support variable. We found that perceived job insecurity was associated with reduced engagement and that this may be moderated by supervisor support. This is the first study using nationally representative data to examine the role of supervisor support in mitigating the negative impact of job insecurity on engagement.

      2. Hypersensitivity pneumonitis mortality by industry and occupationexternal icon
        Hall NB, Wood JM, Laney AS, Blackley DJ.
        Am J Respir Crit Care Med. 2019 May 3.

        [No abstract]

    • Parasitic Diseases
      1. Quality of malaria services offered in public health facilities in three provinces of Mozambique: a cross-sectional studyexternal icon
        Candrinho B, Plucinski MM, Colborn JM, da Silva M, Mathe G, Dimene M, Chico AR, Castel-Branco AC, Brito F, Andela M, Ponce de Leon G, Saifodine A, Zulliger R.
        Malar J. 2019 May 6;18(1):162.
        BACKGROUND: Fever associated with malaria is the leading cause of health care-seeking in Mozambique, yet there is limited evidence on the quality of malaria case management. This study evaluated the quality of malaria service provision offered in public health facilities in Mozambique. METHODS: A cross-sectional assessment was conducted in April-May 2018 in three provinces of Mozambique: Maputo Province (low malaria burden), Cabo Delgado (high), and Zambezia (high). The study included all secondary and tertiary facilities and a random sample of primary facilities in each province. Data collection included exit interviews and re-examinations of 20 randomly selected outpatient service patients, interviews with up to five health care providers and the health facility director, a stockroom inventory and routine data abstraction. RESULTS: A total of 319 health care providers and 1840 patients from 117 health facilities were included. Of these, 1325 patients (72%) had suspected malaria (fever/history of fever) and 550 (30%) had febrile, confirmed malaria with the highest burden in Cabo Delgado (43%), followed by Zambezia (34%) and Maputo Province (2%). Appropriate management of malaria cases, defined as testing malaria suspects and treating confirmed cases with the correct dose of anti-malarial, was highest in Zambezia and Cabo Delgado where 52% (95% CI 42-62) and 49% (42-57) of febrile malaria cases were appropriately managed, respectively. Only 14% (5-34) of febrile cases in Maputo Province were appropriately managed. The biggest gap in the malaria case management pathway was failure to test febrile patients, with only 46% of patients with this indication tested for malaria in Maputo Province. Additionally, anti-malarial treatment of patients with a negative malaria test result was common, ranging from 8% (2-23) in Maputo Province to 22% (14-32) of patients with a negative test in Zambezia. Only 58-62% of patients prescribed an anti-malarial correctly recited dosing instructions. Provider training and malaria knowledge was low outside of Zambezia and supervision rates were low in all provinces. Factors associated with correct case management varied by province and included patient age, facility type, treatment and testing availability, supervision, and training. CONCLUSION: These findings underscore the need to strengthen provider testing of all patients with fever, provider adherence to negative test results, and effective counselling of patients across epidemiological settings in Mozambique.

    • Reproductive Health
      1. Severe maternal morbidity, a tale of 2 states using Data for Action – Ohio and Massachusettsexternal icon
        Conrey EJ, Manning SE, Shellhaas C, Somerville NJ, Stone SL, Diop H, Rankin K, Goodman D.
        Matern Child Health J. 2019 May 4.
        Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

      2. Health care provider attitudes toward safety of selected hormonal contraceptives in breastfeeding womenexternal icon
        Mayhew A, Ermias Y, Zapata LB, Pagano HP, Tepper NK.
        Matern Child Health J. 2019 May 8.
        OBJECTIVES: Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women. METHODS: Using a nationwide survey, associations were analyzed between provider characteristics and perception of safety of combined oral contraceptives (COCs) in breastfeeding women >/= 1 month postpartum without other venous thrombosis risk factors and depot medroxyprogesterone acetate (DMPA) in breastfeeding women < 1 month postpartum and >/= 1 month postpartum. RESULTS: Approximately 68% of public-sector providers considered COCs safe for breastfeeding women >/= 1 month postpartum without other venous thrombosis risk factors, with lower odds among non-physicians versus physicians (adjusted odds ratios [aOR] range 0.34-0.51) and those with a focus on adolescent health/pediatrics versus reproductive health (aOR 0.68, 95% confidence interval [CI] 0.47-0.99). Most public-sector providers considered DMPA safe for breastfeeding women during any time postpartum, with lower odds among non-physicians versus physicians (aOR range 0.20-0.54) and those with primary clinical focus other than reproductive health (aOR range 0.26-0.65). The majority of office-based physicians considered COCs safe for breastfeeding women >/= 1 month postpartum without other venous thrombosis risk factors, with lower odds among those who did not use, versus those who used, CDC’s contraceptive guidance (aOR 0.40, 95% CI 0.21-0.77). Most office-based physicians also considered DMPA safe for breastfeeding women during any time postpartum. CONCLUSIONS FOR PRACTICE: A high proportion of providers considered use of selected hormonal contraceptives safe for breastfeeding women, consistent with evidence-based guidelines. However, certain provider groups might benefit from education regarding the safety of these methods for breastfeeding women.

      3. Vital Signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017external icon
        Petersen EE, Davis NL, Goodman D, Cox S, Mayes N, Johnston E, Syverson C, Seed K, Shapiro-Mendoza CK, Callaghan WM, Barfield W.
        MMWR Morb Mortal Wkly Rep. 2019 May 10;68(18):423-429.
        BACKGROUND: Approximately 700 women die from pregnancy-related complications in the United States every year. METHODS: Data from CDC’s national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors. RESULTS: For 2011-2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care. CONCLUSIONS: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels.

    • Substance Use and Abuse
      1. Drug overdose deaths involving cocaine and psychostimulants with abuse potential – United States, 2003-2017external icon
        Kariisa M, Scholl L, Wilson N, Seth P, Hoots B.
        MMWR Morb Mortal Wkly Rep. 2019 May 3;68(17):388-395.
        In 2016, a total of 63,632 persons died from drug overdoses in the United States (1). Drug overdose deaths involving cocaine, psychostimulants with abuse potential (psychostimulants), or both substances combined increased 42.4% from 12,122 in 2015 to 17,258 in 2016.* Psychostimulants with abuse potential include drugs such as methamphetamine, 3,4-methylenedioxy-methamphetamine (MDMA), dextroamphetamine, levoamphetamine, methylphenidate (Ritalin), and caffeine. From 2015 to 2016, cocaine-involved and psychostimulant-involved death rates increased 52.4% and 33.3%, respectively (1). A total of 70,237 persons died from drug overdoses in the United States in 2017; approximately two thirds of these deaths involved an opioid (2). CDC analyzed 2016-2017 changes in age-adjusted death rates involving cocaine and psychostimulants by demographic characteristics, urbanization levels, U.S. Census region, 34 states, and the District of Columbia (DC). CDC also examined trends in age-adjusted cocaine-involved and psychostimulant-involved death rates from 2003 to 2017 overall, as well as with and without co-involvement of opioids. Among all 2017 drug overdose deaths, 13,942 (19.8%) involved cocaine, and 10,333 (14.7%) involved psychostimulants. Death rates increased from 2016 to 2017 for both drug categories across demographic characteristics, urbanization levels, Census regions, and states. In 2017, opioids were involved in 72.7% and 50.4% of cocaine-involved and psychostimulant-involved overdoses, respectively, and the data suggest that increases in cocaine-involved overdose deaths from 2012 to 2017 were driven primarily by synthetic opioids. Conversely, increases in psychostimulant-involved deaths from 2010 to 2017 occurred largely independent of opioids, with increased co-involvement of synthetic opioids in recent years. Provisional data from 2018 indicate that deaths involving cocaine and psychostimulants are continuing to increase.(dagger) Increases in stimulant-involved deaths are part of a growing polysubstance landscape. Increased surveillance and evidence-based multisectoral prevention and response strategies are needed to address deaths involving cocaine and psychostimulants and opioids. Enhancing linkage to care, building state and local capacity, and public health/public safety collaborations are critical components of prevention efforts.

      2. Comparative analysis of diet and tobacco use among households in Bangladeshexternal icon
        Virk-Baker M, Husain MJ, Parascandola M.
        Tob Prev Cessat. 2019 Mar;5:12.
        INTRODUCTION: While studies from developed countries have reported dietary differences between tobacco users and non-users, less is known about the influence of tobacco on diet in developing countries where malnutrition is a major public health challenge. METHODS: In this study we used the nationally representative Household Income Expenditure Survey 2010 from Bangladesh. Detailed household-level food consumption data including both ethnic and region-specific foods were collected over 14 days, consisting of 7 visits each collecting two days of dietary recall information. RESULTS: Out of 12240 households, 2061 consumed smoking tobacco only (16.8%), 3284 consumed smokeless tobacco only (26.8%), and 3348 consumed both (27.4%). Overall, 71% of the households reported expenditure on tobacco (smoking and/or smokeless) and were considered any-tobacco use households. Our results indicate that after controlling for household expenditure, household size, household child to adult ratio, place of residence (urban/rural), and region fixed effects, any-tobacco households consumed significantly lower amounts (g/day) of milk and dairy products (beta = -17.11, p<0.01) and oil/fat (beta = -10.30, p<0.01) compared to tobacco non-use households (beta: adjusted mean difference in food amount g/day/household). Conversely, consumption of cereal grains (beta = 152.46, p<0.0001) and sugar (beta = 8.16, p<0.0001) were significantly higher among any-tobacco households compared to non-tobacco households. We observed similar patterns for smoking-only, smokeless-only, and dual tobacco product households. CONCLUSION: Evidence of dietary differences between tobacco-use and non-use households may play an important role in developing strategies to address poor diet and malnutrition among tobacco-use households in a developing country like Bangladesh. This study provides one of the first reports addressing diet in relation to tobacco use from a developing country, particularly using nationally representative data. The finding that tobacco-use households have poorer dietary consumption than non-use households suggests that it is important to address tobacco use in the context of nutrition and development programs in low-income environments.

    • Zoonotic and Vectorborne Diseases
      1. A computational method for the identification of Dengue, Zika and Chikungunya virus species and genotypesexternal icon
        Fonseca V, Libin PJ, Theys K, Faria NR, Nunes MR, Restovic MI, Freire M, Giovanetti M, Cuypers L, Nowe A, Abecasis A, Deforche K, Santiago GA, Siqueira IC, San EJ, Machado KC, Azevedo V, Filippis AM, Cunha RV, Pybus OG, Vandamme AM, Alcantara LC, de Oliveira T.
        PLoS Negl Trop Dis. 2019 May 8;13(5):e0007231.
        In recent years, an increasing number of outbreaks of Dengue, Chikungunya and Zika viruses have been reported in Asia and the Americas. Monitoring virus genotype diversity is crucial to understand the emergence and spread of outbreaks, both aspects that are vital to develop effective prevention and treatment strategies. Hence, we developed an efficient method to classify virus sequences with respect to their species and sub-species (i.e. serotype and/or genotype). This ArboTyping tool provides an easy-to-use software implementation of this new method and was validated on a large dataset assessing the classification performance with respect to whole-genome sequences and partial-genome sequences. Available online:

      2. Transmission of Nipah virus – 14 years of investigations in Bangladeshexternal icon
        Nikolay B, Salje H, Hossain MJ, Khan A, Sazzad HM, Rahman M, Daszak P, Stroher U, Pulliam JR, Kilpatrick AM, Nichol ST, Klena JD, Sultana S, Afroj S, Luby SP, Cauchemez S, Gurley ES.
        N Engl J Med. 2019 May 9;380(19):1804-1814.
        BACKGROUND: Nipah virus is a highly virulent zoonotic pathogen that can be transmitted between humans. Understanding the dynamics of person-to-person transmission is key to designing effective interventions. METHODS: We used data from all Nipah virus cases identified during outbreak investigations in Bangladesh from April 2001 through April 2014 to investigate case-patient characteristics associated with onward transmission and factors associated with the risk of infection among patient contacts. RESULTS: Of 248 Nipah virus cases identified, 82 were caused by person-to-person transmission, corresponding to a reproduction number (i.e., the average number of secondary cases per case patient) of 0.33 (95% confidence interval [CI], 0.19 to 0.59). The predicted reproduction number increased with the case patient’s age and was highest among patients 45 years of age or older who had difficulty breathing (1.1; 95% CI, 0.4 to 3.2). Case patients who did not have difficulty breathing infected 0.05 times as many contacts (95% CI, 0.01 to 0.3) as other case patients did. Serologic testing of 1863 asymptomatic contacts revealed no infections. Spouses of case patients were more often infected (8 of 56 [14%]) than other close family members (7 of 547 [1.3%]) or other contacts (18 of 1996 [0.9%]). The risk of infection increased with increased duration of exposure of the contacts (adjusted odds ratio for exposure of >48 hours vs. </=1 hour, 13; 95% CI, 2.6 to 62) and with exposure to body fluids (adjusted odds ratio, 4.3; 95% CI, 1.6 to 11). CONCLUSIONS: Increasing age and respiratory symptoms were indicators of infectivity of Nipah virus. Interventions to control person-to-person transmission should aim to reduce exposure to body fluids. (Funded by the National Institutes of Health and others.).

      3. Assessing health systems in Guinea for prevention and control of priority zoonotic diseases: A One Health approachexternal icon
        Standley CJ, Carlin EP, Sorrell EM, Barry AM, Bile E, Diakite AS, Keita MS, Koivogui L, Mane S, Martel LD, Katz R.
        One Health. 2019 Jun;7:100093.
        To guide One Health capacity building efforts in the Republic of Guinea in the wake of the 2014-2016 Ebola virus disease (EVD) outbreak, we sought to identify and assess the existing systems and structures for zoonotic disease detection and control. We partnered with the government ministries responsible for human, animal, and environmental health to identify a list of zoonotic diseases – rabies, anthrax, brucellosis, viral hemorrhagic fevers, trypanosomiasis and highly pathogenic avian influenza – as the country’s top priorities. We used each priority disease as a case study to identify existing processes for prevention, surveillance, diagnosis, laboratory confirmation, reporting and response across the three ministries. Results were used to produce disease-specific systems “maps” emphasizing linkages across the systems, as well as opportunities for improvement. We identified brucellosis as a particularly neglected condition. Past efforts to build avian influenza capabilities, which had degraded substantially in less than a decade, highlighted the challenge of sustainability. We observed a keen interest across sectors to reinvigorate national rabies control, and given the regional and global support for One Health approaches to rabies elimination, rabies could serve as an ideal disease to test incipient One Health coordination mechanisms and procedures. Overall, we identified five major categories of gaps and challenges: (1) Coordination; (2) Training; (3) Infrastructure; (4) Public Awareness; and (5) Research. We developed and prioritized recommendations to address the gaps, estimated the level of resource investment needed, and estimated a timeline for implementation. These prioritized recommendations can be used by the Government of Guinea to plan strategically for future One Health efforts, ideally under the auspices of the national One Health Platform. This work demonstrates an effective methodology for mapping systems and structures for zoonotic diseases, and the benefit of conducting a baseline review of systemic capabilities prior to embarking on capacity building efforts.

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