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CDC Science Clips: Volume 9, Issue 46, November 21, 2017

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

  1. Top Articles of the Week

    Selected weekly by a senior CDC scientist from the standard sections listed below.

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • A multi-dataset time-reversal approach to clinical trial placebo response and the relationship to natural variability in epilepsy
        Goldenholz DM, Strashny A, Cook M, Moss R, Theodore WH.
        Seizure. 2017 Oct 23;53:31-36.
        PURPOSE: Clinical epilepsy drug trials have been measuring increasingly high placebo response rates, up to 40%. This study was designed to examine the relationship between the natural variability in epilepsy, and the placebo response seen in trials. We tested the hypothesis that ‘reversing’ trial direction, with the baseline period as the treatment observation phase, would reveal effects of natural variability. METHOD: Clinical trial simulations were run with time running forward and in reverse. Data sources were: (patient reported diaries), a randomized sham-controlled TMS trial, and chronically implanted intracranial EEG electrodes. Outcomes were 50%-responder rates (RR50) and median percentage change (MPC). RESULTS: The RR50 results showed evidence that temporal reversal does not prevent large responder rates across datasets. The MPC results negative in the TMS dataset, and positive in the other two. CONCLUSIONS: Typical RR50s of clinical trials can be reproduced using the natural variability of epilepsy as a substrate across multiple datasets. Therefore, the placebo response in epilepsy clinical trials may be attributable almost entirely to this variability, rather than the “placebo effect”.

      • Novel methods and data sources for surveillance of state-level diabetes and prediabetes prevalence
        Mardon R, Marker D, Nooney J, Campione J, Jenkins F, Johnson M, Merrill L, Rolka DB, Saydah S, Geiss LS, Zhang X, Shrestha S.
        Prev Chronic Dis. 2017 Nov 02;14:E106.
        States bear substantial responsibility for addressing the rising rates of diabetes and prediabetes in the United States. However, accurate state-level estimates of diabetes and prediabetes prevalence that include undiagnosed cases have been impossible to produce with traditional sources of state-level data. Various new and nontraditional sources for estimating state-level prevalence are now available. These include surveys with expanded samples that can support state-level estimation in some states and administrative and clinical data from insurance claims and electronic health records. These sources pose methodologic challenges because they typically cover partial, sometimes nonrandom subpopulations; they do not always use the same measurements for all individuals; and they use different and limited sets of variables for case finding and adjustment. We present an approach for adjusting new and nontraditional data sources for diabetes surveillance that addresses these limitations, and we present the results of our proposed approach for 2 states (Alabama and California) as a proof of concept. The method reweights surveys and other data sources with population undercoverage to make them more representative of state populations, and it adjusts for nonrandom use of laboratory testing in clinically generated data sets. These enhanced diabetes and prediabetes prevalence estimates can be used to better understand the total burden of diabetes and prediabetes at the state level and to guide policies and programs designed to prevent and control these chronic diseases.

      • Five-year relative survival for human papillomavirus-associated cancer sites
        Razzaghi H, Saraiya M, Thompson TD, Henley SJ, Viens L, Wilson R.
        Cancer. 2017 Nov 06.
        BACKGROUND: Human papillomavirus (HPV) vaccines can potentially prevent greater than 90% of cervical and anal cancers as well as a substantial proportion of vulvar, vaginal, penile, and oropharyngeal cancers caused by certain HPV types. Because more than 38,000 HPV-associated cancers are diagnosed annually in the United States, current studies are needed to understand how relative survival varies for each of these cancers by certain demographic characteristics, such as race and age. METHODS: The authors examined high-quality data from 27 population-based cancer registries covering approximately 59% of the US population. The analyses were limited to invasive cancers that were diagnosed during 2001 through 2011 and followed through 2011 and met specified histologic criteria for HPV-associated cancers. Five-year relative survival was calculated from diagnosis until death for these cancers by age, race, and sex. RESULTS: The 5-year age-standardized relative survival rate was 64.2% for cervical carcinomas, 52.8% for vaginal squamous cell carcinomas (SCCs), 66% for vulvar SCCs, 47.4% for penile SCCs, 65.9% for anal SCCs, 56.2% for rectal SCCs, and 51.2% for oropharyngeal SCCs. Five-year relative survival was consistently higher among white patients compared with black patients for all HPV-associated cancers across all age groups; the greatest differences by race were observed for oropharyngeal SCCs among those aged <60 years and for penile SCCs among those ages 40 to 49 years compared with other age groups. CONCLUSIONS: There are large disparities in relative survival among patients with HPV-associated cancers by sex, race, and age. HPV vaccination and improved access to screening (of cancers for which screening tests are available) and treatment, especially among groups that experience higher incidence and lower survival, may reduce disparities in survival from HPV-associated cancers. Cancer 2017. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

    • Communicable Diseases
      • Testing our FAITHH: HIV stigma and knowledge after a faith-based HIV stigma reduction intervention in the rural south
        Payne-Foster P, Bradley EL, Aduloju-Ajijola N, Yang X, Gaul Z, Parton J, Sutton MY, Gaskins S.
        AIDS Care. 2017 Nov 09:1-8.
        Eliminating racial/ethnic HIV disparities requires HIV-related stigma reduction. African-American churches have a history of addressing community concerns, including health issues, but may also contribute to stigma. We developed and pilot tested a faith-based, anti-stigma intervention with 12 African-American churches in rural Alabama. We measured HIV-related stigma held by 199 adults who participated in the intervention (individual-level) and their perception of stigma among other congregants (congregational-level). Analyses of pre- and post-assessments using a linear mixed model showed the anti-stigma intervention group reported a significant reduction in individual-level stigma compared with the control group (mean difference: -.70 intervention vs. -.16 control, adjusted p < .05). Findings suggest African-American churches may be poised to aid HIV stigma-reduction efforts.

    • Disease Reservoirs and Vectors
      • Quantifying the intensity of permethrin insecticide resistance in Anopheles mosquitoes in western Kenya
        Omondi S, Mukabana WR, Ochomo E, Muchoki M, Kemei B, Mbogo C, Bayoh N.
        Parasit Vectors. 2017 Nov 06;10(1):548.
        BACKGROUND: The development and spread of resistance among local vectors to the major classes of insecticides used in Long-Lasting Insecticidal Nets (LLINs) and Indoor Residual Spraying (IRS) poses a major challenge to malaria vector control programs worldwide. The main methods of evaluating insecticide resistance in malaria vectors are the WHO tube bioassay and CDC bottle assays, with their weakness being determination of resistance at a fixed dose for variable populations. The CDC bottle assay using different insecticide dosages has proved applicable in ascertaining the intensity of resistance. METHODS: We determined the status and intensity of permethrin resistance and investigated the efficacy of commonly used LLINs (PermaNet(R) 2.0, PermaNet(R) 3.0 and Olyset(R)) against 3-5 day-old adult female Anopheles mosquitoes from four sub-counties; Teso, Bondo, Rachuonyo and Nyando in western Kenya. Knockdown was assessed to 4 doses of permethrin; 1x (21.5 mug/ml), 2x (43 mug/ml), 5x (107.5 mug/ml) and 10x (215 mug/ml) using CDC bottle assays. RESULTS: Mortality for 0.75% permethrin ranged from 23.5% to 96.1% in the WHO tube assay. Intensity of permethrin resistance was highest in Barkanyango Bondo, with 84% knockdown at the 30 min diagnostic time when exposed to the 10x dose. When exposed to the LLINs, mortality ranged between- 0-39% for Olyset(R), 12-88% for PermaNet(R) 2.0 and 26-89% for PermaNet(R) 3.0. The efficacy of nets was reduced in Bondo and Teso. Results from this study show that there was confirmed resistance in all the sites; however, intensity assays were able to differentiate Bondo and Teso as the sites with the highest levels of resistance, which coincidentally were the two sub-counties with reduced net efficacy. CONCLUSIONS: There was a reduced efficacy of nets in areas with high resistance portraying that at certain intensities of resistance, vector control using LLINs may be compromised. It is necessary to incorporate intensity assays in order to determine the extent of threat that resistance poses to malaria control.

    • Healthcare Associated Infections
      • Donor-derived Kaposi’s sarcoma in a liver-kidney transplant recipient
        Dollard SC, Douglas D, Basavaraju SV, Schmid DS, Kuehnert M, Aqel B.
        Am J Transplant. 2017 Sep 23.
        Human herpes virus 8 (HHV-8), also known as Kaposi’s sarcoma associated herpesvirus (KSHV), is an oncogenic virus that can cause Kaposi’s sarcoma (KS). KS can develop following organ transplantation through reactivation of the recipient’s latent HHV-8 infection, or less commonly through donor-derived infection which has higher risk for severe illness and mortality. We describe a case of probable donor-derived KS in the recipient of a liver-kidney transplant. The donor had multiple risk factors for HHV-8 infection. The KS was successfully treated by switching immunosuppression from tacrolimus to sirolimus. With an increasing number of human immunodeficiency virus (HIV)-positive persons seeking organ transplantation and serving as organ donors for HIV-positive recipients, HHV-8 prevalence among donors and recipients will likely increase and with that the risk for post-transplant KS. Predetermination of HHV-8 status can be useful when considering organ donors and recipients with risk factors, although there are currently no validated commercial tests for HHV-8 antibody screening.

      • Management of an outbreak of Exophiala dermatitidis bloodstream infections at an outpatient oncology clinic
        Vasquez AM, Zavasky D, Chow NA, Gade L, Zlatanic E, Elkind S, Litvintseva AP, Pappas PG, Perfect JR, Revankar SG, Lockhart SR, Chiller TM, Ackelsberg J, Vallabhaneni S.
        Clin Infect Dis. 2017 Nov 07.
        Exophiala (Wangiella) dermatitidis is a dematiaceous fungus that can grow in yeast or mold forms and is typically found in decaying organic matter. It can cause central nervous system disease, particularly in immunocompromised patients, and has been implicated as a respiratory pathogen in cystic fibrosis patients [1,2]. It has also been identified as a colonizer in the gastrointestinal tract [3]. However, bloodstream infections with this organism are exceedingly rare.

    • Laboratory Sciences
      • Segmental variations in facet joint translations during in vivo lumbar extension
        Byrne RM, Zhou Y, Zheng L, Chowdhury SK, Aiyangar A, Zhang X.
        J Biomech. 2017 Oct 19.
        The lumbar facet joint (FJ) is often associated with pathogenesis in the spine, but quantification of normal FJ motion remains limited to in vitro studies or static imaging of non-functional poses. The purpose of this study was to quantify lumbar FJ kinematics in healthy individuals during functional activity with dynamic stereo radiography (DSX) imaging. Ten asymptomatic participants lifted three known weights starting from a trunk-flexed ( approximately 75 degrees ) position to an upright position while being imaged within the DSX system. High resolution computed tomography (CT) scan-derived 3D models of their lumbar vertebrae (L2-S1) were registered to the biplane 2D radiographs using a markerless model-based tracking technique providing instantaneous 3D vertebral kinematics throughout the lifting tasks. Effects of segment level and weight lifted were assessed using mixed-effect repeated measures ANOVA. Superior-inferior (SI) translation dominated FJ translation, with L5S1 showing significantly less translation magnitudes (Median (Md) = 3.5 mm, p < 0.0001) than L2L3, L3L4, and L4L5 segments (Md = 5.9 mm, 6.3 mm and 6.6 mm respectively). Linear regression-based slopes of continuous facet translations revealed strong linearity for SI translation (r2>0.94), reasonably high linearity for sideways sliding (Z-) (r2>0.8), but much less linearity for facet gap change (X-) (r2 approximately 0.5). Caudal segments (L4-S1), particularly L5S1, displayed greater coupling compared to cranial (L2-L4) segments, revealing distinct differences overall in FJ translation trends at L5S1. No significant effect of weight lifted on FJ translations was detected. The study presents a hitherto unavailable and highly precise baseline dataset of facet translations measured during a functional, dynamic lifting task.

    • Maternal and Child Health
      • Estimates of the burden of group B streptococcal disease worldwide for pregnant women, stillbirths, and children
        Seale AC, Bianchi-Jassir F, Russell NJ, Kohli-Lynch M, Tann CJ, Hall J, Madrid L, Blencowe H, Cousens S, Baker CJ, Bartlett L, Cutland C, Gravett MG, Heath PT, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag SJ, Sobanjo-Ter Meulen A, Vekemans J, Lawn JE.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S200-s219.
        Background: We aimed to provide the first comprehensive estimates of the burden of group B Streptococcus (GBS), including invasive disease in pregnant and postpartum women, fetal infection/stillbirth, and infants. Intrapartum antibiotic prophylaxis is the current mainstay of prevention, reducing early-onset infant disease in high-income contexts. Maternal GBS vaccines are in development. Methods: For 2015 live births, we used a compartmental model to estimate (1) exposure to maternal GBS colonization, (2) cases of infant invasive GBS disease, (3) deaths, and (4) disabilities. We applied incidence or prevalence data to estimate cases of maternal and fetal infection/stillbirth, and infants with invasive GBS disease presenting with neonatal encephalopathy. We applied risk ratios to estimate numbers of preterm births attributable to GBS. Uncertainty was also estimated. Results: Worldwide in 2015, we estimated 205000 (uncertainty range [UR], 101000-327000) infants with early-onset disease and 114000 (UR, 44000-326000) with late-onset disease, of whom a minimum of 7000 (UR, 0-19000) presented with neonatal encephalopathy. There were 90000 (UR, 36000-169000) deaths in infants <3 months age, and, at least 10000 (UR, 3000-27000) children with disability each year. There were 33000 (UR, 13000-52000) cases of invasive GBS disease in pregnant or postpartum women, and 57000 (UR, 12000-104000) fetal infections/stillbirths. Up to 3.5 million preterm births may be attributable to GBS. Africa accounted for 54% of estimated cases and 65% of all fetal/infant deaths. A maternal vaccine with 80% efficacy and 90% coverage could prevent 107000 (UR, 20000-198000) stillbirths and infant deaths. Conclusions: Our conservative estimates suggest that GBS is a leading contributor to adverse maternal and newborn outcomes, with at least 409000 (UR, 144000-573000) maternal/fetal/infant cases and 147000 (UR, 47000-273000) stillbirths and infant deaths annually. An effective GBS vaccine could reduce disease in the mother, the fetus, and the infant.

    • Mining
      • Simulation and measurement of through-the-earth, extremely low-frequency signals using copper-clad steel ground rods
        Damiano NW, Yan L, Whisner B, Zhou C.
        IEEE Trans Ind Appl. 2017 ;53(5):5088-5095.
        The underground mining environment can greatly affect radio signal propagation. Understanding how the earth affects signal propagation is a key to evaluating communications systems used during a mine emergency. One type of communication system is through-the-earth, which can utilize extremely low frequencies (ELF). This paper presents the simulation and measurement results of recent National Institute for Occupational Safety and Health (NIOSH) research aimed at investigating current injection at ELF, and in particular, ground contact impedance. Measurements were taken at an outside surface testing location. The results obtained from modeling and measurement are characterized by electrode impedance, and the voltage received between two distant electrodes. This paper concludes with a discussion of design considerations found to affect low-frequency communication systems utilizing ground rods to inject a current into the earth.

    • Occupational Safety and Health
      • Enhancing worker health through clinical decision support (CDS): An introduction to a compilation
        Filios MS, Storey E, Baron S, Luensman GB, Shiffman RN.
        J Occup Environ Med. 2017 Nov;59(11):e227-e230.
        OBJECTIVE: This article outlines an approach to developing clinical decision support (CDS) for conditions related to work and health. When incorporated in electronic health records, such CDS will assist primary care providers (PCPs) care for working patients. METHODS: Three groups of Subject Matter Experts (SMEs) identified relevant clinical practice guidelines, best practices, and reviewed published literature concerning work-related asthma, return-to-work, and management of diabetes at work. RESULTS: SMEs developed one recommendation per topic that could be supported by electronic CDS. Reviews with PCPs, staff, and health information system implementers in five primary care settings confirmed that the approach was important and operationally sound. CONCLUSION: This compendium is intended to stimulate a dialogue between occupational health specialists and PCPs that will enhance the use of work information about patients in the primary care setting.

    • Reproductive Health
      • Structural intervention with school nurses increases receipt of sexual health care among male high school students
        Dittus PJ, Harper CR, Becasen JS, Donatello RA, Ethier KA.
        J Adolesc Health. 2017 Nov 02.
        PURPOSE: Adolescent males are less likely to receive health care and have lower levels of sexual and reproductive health (SRH) knowledge than adolescent females. The purpose of this study was to determine if a school-based structural intervention focused on school nurses increases receipt of condoms and SRH information among male students. METHODS: Interventions to improve student access to sexual and reproductive health care were implemented in six urban high schools with a matched set of comparison schools. Interventions included working with school nurses to improve access to sexual and reproductive health care, including the provision of condoms and information about pregnancy and sexually transmitted disease prevention and services. Intervention effects were assessed through five cross-sectional yearly surveys, and analyses include data from 13,740 male students. RESULTS: Nurses in intervention schools changed their interactions with male students who visited them for services, such that, among those who reported they went to the school nurse for any reason in the previous year, those in intervention schools reported significant increases in receipt of sexual health services over the course of the study compared with students in comparison schools. Further, these results translated into population-level effects. Among all male students surveyed, those in intervention schools were more likely than those in comparison schools to report increases in receipt of sexual health services from school nurses. CONCLUSIONS: With a minimal investment of resources, school nurses can become important sources of SRH information and condoms for male high school students.

  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. Identifying risk for type 2 diabetes in different age cohorts: does one size fit all?
        Alva ML, Hoerger TJ, Zhang P, Gregg EW.
        BMJ Open Diabetes Res Care. 2017 ;5(1):e000447.
        Objective: To estimate age-specific risk equations for type 2 diabetes onset in young, middle-aged, and older US adults, and to compare the performance of simple equations based on readily available demographic information alone, against enhanced equations that require both demographic and clinical information (fasting plasma glucose, high-density lipoprotein, and triglyceride levels). Research design and methods: We estimated the probability of developing diabetes by age group using data from the Coronary Artery Risk Development in Young Adults (for ages 18-40 years), Atherosclerosis Risk in Communities (for ages 45-64 years), and the Cardiovascular Health Study (for ages 65 years and older). Simple and enhanced equations were estimated using logistic regression models, and performance was compared by age group. Thresholds based on these risk equations were evaluated using split-sample bootstraps and calibrating the constant of one age cohort to others. Results: Simple risk equations had an area under the receiver-operating curve (AUROC) of 0.72, 0.79, 0.75, and 0.69 for age groups 18-30, 28-40, 45-64, and 65 and older, respectively. The corresponding AUROCs for enhanced equations were 0.75, 0.85, 0.85, and 0.81. Risk equations based on younger populations, when applied to older cohorts, underpredict diabetes incidence and risk. Conversely, risk equations based on older populations overpredict the likelihood of diabetes in younger cohorts. Conclusions: In general, risk equations are more successful in middle-aged adults than in young and old populations. The results demonstrate the importance of applying age-specific risk equations to identify target populations for intervention. While the predictive capacity of equations that include biomarkers is better than of those based solely on self-reported variables, biomarkers are more important in older populations than in younger ones.

      2. Greater cognitive deficits with sleep-disordered breathing among individuals with genetic susceptibility to Alzheimer disease. The Multi-Ethnic Study of Atherosclerosis
        Johnson DA, Lane J, Wang R, Reid M, Djonlagic I, Fitzpatrick AL, Rapp SR, Charles LE, O’Hara R, Saxena R, Redline S.
        Ann Am Thorac Soc. 2017 Nov;14(11):1697-1705.
        RATIONALE: There are conflicting findings regarding the link between sleep apnea and cognitive dysfunction. OBJECTIVES: Investigate associations between indicators of sleep-disordered breathing (SDB) and cognitive function in the Multi-Ethnic Study of Atherosclerosis and assess effect modification by the apolipoprotein epsilon-4 (APOE-epsilon4) allele. METHODS: A diverse population (N = 1,752) underwent type 2 in-home polysomnography, which included measurement of percentage sleep time less than 90% oxyhemoglobin saturation (%Sat < 90%) and apnea-hypopnea index (AHI). Epworth Sleepiness Scale score (ESS) and sleep apnea syndrome (SAS; AHI >/= 5 and ESS > 10) were also analyzed. Cognitive outcomes included the Cognitive Abilities Screening Instrument; Digit Symbol Coding (DSC) test; and Digit Span Tests (DST) Forward and Backward. RESULTS: Participants were 45.4% men, aged 68.1 years (SD, 9.1 yr) with a median AHI of 9.0 and mean ESS of 6.0. Approximately 9.7% had SAS, and 26.8% had at least one copy of the APOE-epsilon4 allele. In adjusted analyses, a 1-SD increase in %Sat < 90% and ESS score were associated with a poorer attention and memory assessed by the DST Forward score (beta = -0.12 [SE, 0.06] and beta = -0.13 [SE, 0.06], respectively; P </= 0.05). SAS and higher ESS scores were also associated with poorer attention and processing speed as measured by the DSC (beta = -0.69 [SE, 0.35] and beta = -1.42 [SE, 0.35], respectively; P < 0.05). The presence of APOE-epsilon4 allele modified the associations of %Sat < 90% with DST forward and of ESS with DSC (Pinteraction </= 0.05). CONCLUSIONS: Overnight hypoxemia and sleepiness were associated with cognition. The average effect estimates were small, similar to effect estimates for several other individual dementia risk factors. Associations were strongest in APOE-epsilon4 risk allele carriers. Our results (1) suggest that SDB be considered among a group of modifiable dementia risk factors, and (2) highlight the potential vulnerability of APOE-epsilon4 risk allele carriers with SDB.

      3. Cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in four US-affiliated Pacific Islands between 2007 and 2015
        Senkomago V, Royalty J, Miller JW, Buenconsejo-Lum LE, Benard VB, Saraiya M.
        Cancer Epidemiol. 2017 Oct;50(Pt B):260-267.
        BACKGROUND: Cervical cancer incidence in the US-Affiliated Pacific Islands (USAPIs) is double that of the US mainland. American Samoa, Commonwealth of Northern Mariana Islands (CNMI), Guam and the Republic of Palau receive funding from the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to implement cervical cancer screening to low-income, uninsured or under insured women. The USAPI grantees report data on screening and follow-up activities to the CDC. MATERIALS AND METHODS: We examined cervical cancer screening and follow-up data from the NBCCEDP programs in the four USAPIs from 2007 to 2015. We summarized screening done by Papanicolaou (Pap) and oncogenic human papillomavirus (HPV) tests, follow-up and diagnostic tests provided, and histology results observed. RESULTS: A total of 22,249 Pap tests were conducted in 14,206 women in the four USAPIs programs from 2007-2015. The overall percentages of abnormal Pap results (low-grade squamous intraepithelial lesions or worse) was 2.4% for first program screens and 1.8% for subsequent program screens. Histology results showed a high proportion of cervical intraepithelial neoplasia grade 2 or worse (57%) among women with precancers and cancers. Roughly one-third (32%) of Pap test results warranting follow-up had no data recorded on diagnostic tests or follow-up done. CONCLUSION: This is the first report of cervical cancer screening and outcomes of women served in the USAPI through the NBCCEDP with similar results for abnormal Pap tests, but higher proportion of precancers and cancers, when compared to national NBCCEDP data. The USAPI face significant challenges in implementing cervical cancer screening, particularly in providing and recording data on diagnostic tests and follow-up. The screening programs in the USAPI should further examine specific barriers to follow-up of women with abnormal Pap results and possible solutions to address them.

      4. Health insurance status and clinical cancer screenings among U.S. adults
        Zhao G, Okoro CA, Li J, Town M.
        Am J Prev Med. 2017 Nov 01.
        INTRODUCTION: Health insurance coverage is linked to clinical preventive service use. This study examined cancer screenings among U.S. adults by health insurance status. METHODS: The Behavioral Risk Factor Surveillance System collected data on healthcare access and cancer screenings from 42 states and the District of Columbia in 2014. Data analyses were conducted in 2016. Participants’ health insurance status during the preceding 12 months was categorized as adequately insured, underinsured, or never insured. Primary type of insurance coverage was categorized as employer-based or Medicare (aged >/=65 years), self-purchased plan, Medicaid/Medicare (aged <65 years), and other public insurance. Clinical cancer screenings were assessed following the U.S. Preventive Services Task Force recommendations. RESULTS: Compared with adequately insured adults, underinsured and never insured women were 6% (p<0.001) and 41% (p<0.001) less likely to receive breast cancer screening, respectively; 1% (p<0.05) and 19% (p<0.001) less likely to receive cervical cancer screening, respectively; and 3% (p<0.01) and 47% (p<0.001) less likely to receive colorectal cancer screening, respectively; underinsured and never insured men were 6% (p<0.001) and 52% (p<0.001) less likely to receive colorectal cancer screening, respectively. Compared with adults with employer-based insurance/Medicare (aged >/=65 years), women with all other types of insurance were less likely to receive breast and cervical cancer screenings; women and men with self-purchased plans were less likely to receive colorectal cancer screening; however, men with other public insurance were more likely to receive colorectal cancer screening. CONCLUSIONS: Disparities in cancer screenings by health insurance status and type of insurance exist among U.S. adults. Greater efforts to increase screening rates and to reduce disparities in cancer screenings are an important strategy to help improve overall population health.

    • Communicable Diseases
      1. Self-administered versus directly observed once-weekly isoniazid and rifapentine treatment of latent tuberculosis infection: A randomized trial
        Belknap R, Holland D, Feng PJ, Millet JP, Cayla JA, Martinson NA, Wright A, Chen MP, Moro RN, Scott NA, Arevalo B, Miro JM, Villarino ME, Weiner M, Borisov AS.
        Ann Intern Med. 2017 Nov 07.
        Background: Expanding latent tuberculosis treatment is important to decrease active disease globally. Once-weekly isoniazid and rifapentine for 12 doses is effective but limited by requiring direct observation. Objective: To compare treatment completion and safety of once-weekly isoniazid and rifapentine by self-administration versus direct observation. Design: An open-label, phase 4 randomized clinical trial designed as a noninferiority study with a 15% margin. Seventy-five percent or more of study patients were enrolled from the United States for a prespecified subgroup analysis. ( NCT01582711). Setting: Outpatient tuberculosis clinics in the United States, Spain, Hong Kong, and South Africa. Participants: 1002 adults (aged >/=18 years) recommended for treatment of latent tuberculosis infection. Intervention: Participants received once-weekly isoniazid and rifapentine by direct observation, self-administration with monthly monitoring, or self-administration with weekly text message reminders and monthly monitoring. Measurements: The primary outcome was treatment completion, defined as 11 or more doses within 16 weeks and measured using clinical documentation and pill counts for direct observation, and self-reports, pill counts, and medication event-monitoring devices for self-administration. The main secondary outcome was adverse events. Results: Median age was 36 years, 48% of participants were women, and 77% were enrolled at the U.S. sites. Treatment completion was 87.2% (95% CI, 83.1% to 90.5%) in the direct-observation group, 74.0% (CI, 68.9% to 78.6%) in the self-administration group, and 76.4% (CI, 71.3% to 80.8%) in the self-administration-with-reminders group. In the United States, treatment completion was 85.4% (CI, 80.4% to 89.4%), 77.9% (CI, 72.7% to 82.6%), and 76.7% (CI, 70.9% to 81.7%), respectively. Self-administered therapy without reminders was noninferior to direct observation in the United States; no other comparisons met noninferiority criteria. A few drug-related adverse events occurred and were similar across groups. Limitation: Persons with latent tuberculosis infection enrolled in South Africa would not routinely be treated programmatically. Conclusion: These results support using self-administered, once-weekly isoniazid and rifapentine to treat latent tuberculosis infection in the United States, and such treatment could be considered in similar settings when direct observation is not feasible. Primary Funding Source: Centers for Disease Control and Prevention.

      2. Surveillance for waterborne disease outbreaks associated with drinking water – United States, 2013-2014
        Benedict KM, Reses H, Vigar M, Roth DM, Roberts VA, Mattioli M, Cooley LA, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS, Hill VR.
        MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1216-1221.
        Provision of safe water in the United States is vital to protecting public health. Public health agencies in the U.S. states and territories report information on waterborne disease outbreaks to CDC through the National Outbreak Reporting System (NORS) ( During 2013-2014, 42 drinking water-associated outbreaks were reported, accounting for at least 1,006 cases of illness, 124 hospitalizations, and 13 deaths. Legionella was associated with 57% of these outbreaks and all of the deaths. Sixty-nine percent of the reported illnesses occurred in four outbreaks in which the etiology was determined to be either a chemical or toxin or the parasite Cryptosporidium. Drinking water contamination events can cause disruptions in water service, large impacts on public health, and persistent community concern about drinking water quality. Effective water treatment and regulations can protect public drinking water supplies in the United States, and rapid detection, identification of the cause, and response to illness reports can reduce the transmission of infectious pathogens and harmful chemicals and toxins.

      3. Preference of oral tenofovir disoproxil fumarate/emtricitabine versus rectal tenofovir reduced-glycerin 1% gel regimens for HIV prevention among cisgender men and transgender women who engage in receptive anal intercourse with men
        Carballo-Dieguez A, Giguere R, Dolezal C, Leu CS, Balan IC, Brown W, Rael C, Richardson BA, Piper JM, Bekker LG, Chariyalertsak S, Chitwarakorn A, Gonzales P, Holtz TH, Liu A, Mayer KH, Zorrilla CD, Lama JR, McGowan I, Cranston RD.
        AIDS Behav. 2017 Nov 08.
        Oral pre-exposure prophylaxis (PrEP) can prevent HIV transmission. Yet, some may prefer not to take systemic daily medication. MTN-017 was a 3-period, phase 2 safety and acceptability study of microbicide gel applied rectally either daily or before and after receptive anal intercourse (RAI), compared to daily oral tablet. At baseline, cisgender men and transgender women who reported RAI (N = 187) rated the daily oral regimen higher in overall liking, ease of use, and likelihood of future use than the gel regimens. After trying all three, 28% liked daily oral the least. Gel did not affect sexual enjoyment (88%) or improved it (7-8%). Most partners had no reaction to gel use. Ease of gel use improved significantly between the first and the last few times of daily use. A rectal gel used before and after RAI may constitute an attractive alternative to daily tablet. Experience with product use may increase acceptability.

      4. Rotavirus infection
        Crawford SE, Ramani S, Tate JE, Parashar UD, Svensson L, Hagbom M, Franco MA, Greenberg HB, O’Ryan M, Kang G, Desselberger U, Estes MK.
        Nat Rev Dis Primers. 2017 Nov 09;3:17083.
        Rotavirus infections are a leading cause of severe, dehydrating gastroenteritis in children <5 years of age. Despite the global introduction of vaccinations for rotavirus over a decade ago, rotavirus infections still result in >200,000 deaths annually, mostly in low-income countries. Rotavirus primarily infects enterocytes and induces diarrhoea through the destruction of absorptive enterocytes (leading to malabsorption), intestinal secretion stimulated by rotavirus non-structural protein 4 and activation of the enteric nervous system. In addition, rotavirus infections can lead to antigenaemia (which is associated with more severe manifestations of acute gastroenteritis) and viraemia, and rotavirus can replicate in systemic sites, although this is limited. Reinfections with rotavirus are common throughout life, although the disease severity is reduced with repeat infections. The immune correlates of protection against rotavirus reinfection and recovery from infection are poorly understood, although rotavirus-specific immunoglobulin A has a role in both aspects. The management of rotavirus infection focuses on the prevention and treatment of dehydration, although the use of antiviral and anti-emetic drugs can be indicated in some cases.

      5. Virologic suppression and CD4 cell count recovery after initiation of raltegravir- or efavirenz- containing HIV treatment regimens
        Edwards JK, Cole SR, Hall HI, Mathews WC, Moore RD, Mugavero MJ, Eron JJ.
        Aids. 2017 Nov 02.
        OBJECTIVE: To explore the effectiveness of raltegravir-based antiretroviral therapy (ART) on treatment response among ART-naive patients seeking routine clinical care. DESIGN: Cohort study of adults enrolled in HIV care in the United States. METHODS: We compared virologic suppression and CD4 cell count recovery over a 2.5 year period after initiation of an ART regimen containing raltegravir or efavirenz using observational data from a US clinical cohort, generalized to the US population of people with diagnosed HIV. We accounted for nonrandom treatment assignment, informative censoring, and nonrandom selection from the US target population using inverse probability weights. RESULTS: Of the 2843 patients included in the study, 2476 initiated the efavirenz-containing regimen and 367 initiated the raltegravir-containing regimen. In the weighted intent-to-treat analysis, patients spent an average of 74 (95% CI: 41, 106) additional days alive with a suppressed viral load on the raltegravir regimen than on the efavirenz regimen over the 2.5-year study period. CD4 cell count recovery was also superior under the raltegravir regimen. CONCLUSIONS: Patients receiving raltegravir spent more time alive and suppressed than patients receiving efavirenz, but the probability of viral suppression by 2.5 years after treatment was similar between groups. Optimizing the amount of time spent in a state of viral suppression is important to improve survival among people living with HIV and to reduce onward transmission.

      6. Accuracy of HIV risk perceptions among episodic substance-using men who have sex with men
        Hall GC, Koenig LJ, Gray SC, Herbst JH, Matheson T, Coffin P, Raiford J.
        AIDS Behav. 2017 Nov 04.
        Using the HIV Incident Risk Index for men who have sex with men-an objective and validated measure of risk for HIV acquisition, and self-perceptions of belief and worry about acquiring HIV, we identified individuals who underestimated substantial risk for HIV. Data from a racially/ethnically diverse cohort of 324 HIV-negative episodic substance-using men who have sex with men (SUMSM) enrolled in a behavioral risk reduction intervention (2010-2012) were analyzed. Two hundred and fourteen (66%) SUMSM at substantial risk for HIV were identified, of whom 147 (69%, or 45% of the total sample) underestimated their risk. In multivariable regression analyses, compared to others in the cohort, SUMSM who underestimated their substantial risk were more likely to report: a recent sexually transmitted infection diagnosis, experiencing greater social isolation, and exchanging sex for drugs, money, or other goods. An objective risk screener can be valuable to providers in identifying and discussing with SUMSM factors associated with substantial HIV risk, particularly those who may not recognize their risk.

      7. Implementation of birth-cohort testing for hepatitis C virus
        Kruger DL, Rein DB, Kil N, Jordan C, Brown KA, Yartel A, Smith BD.
        Health Promot Pract. 2017 Mar;18(2):283-289.
        Hepatitis C virus infection affects approximately 2.2 to 3.2 million Americans. In 2012, the Centers for Disease Control and Prevention recommended a one-time antibody test of all persons belonging to the 1945-1965 birth cohort. Efforts to implement this recommendation in clinical settings are in their infancy; this case study report therefore seeks to share the experiences of three sites that implemented interventions to increase birth-cohort testing through participation in the Birth-cohort Evaluation to Advance Screening and Testing for Hepatitis C. At each site, project managers completed standardized questionnaires about their implementation experiences, and a qualitative analysis was conducted of the responses. The testing interventions used in-person recruitment, mail recruitment, and an electronic health record prompt. Sites reported that early efforts to obtain stakeholder buy-in were critical to effectively implement and sustain interventions and that the intervention required additional staffing resources beyond those being used for risk-based testing. In each case, administrative barriers were more extensive than anticipated. For the electronic health record-based intervention, technological support was critical in achieving study goals. Despite these barriers, interventions in all sites were successful in increasing rates of testing and case identification, although future studies will need to evaluate the relative costs and benefits of each intervention.

      8. FDA-CDC Antimicrobial Resistance Isolate Bank: A publicly-available resource to support research, development and regulatory requirements
        Lutgring JD, Machado MJ, Benahmed FH, Conville P, Shawar RM, Patel J, Brown AC.
        J Clin Microbiol. 2017 Nov 08.
        The FDA-CDC Antimicrobial Resistance Isolate Bank was created in July 2015 as a publicly available resource to combat antimicrobial resistance. It is a curated repository of bacterial isolates with an assortment of clinically-important resistance mechanisms that have been phenotypically and genotypically characterized. In the first two years of operation, the Bank offered 14 panels comprising 496 unique isolates and had filled 486 orders from 394 institutions throughout the United States. New panels are being added.

      9. Waterborne disease outbreaks associated with environmental and undetermined exposures to water – United States, 2013-2014
        McClung RP, Roth DM, Vigar M, Roberts VA, Kahler AM, Cooley LA, Hilborn ED, Wade TJ, Fullerton KE, Yoder JS, Hill VR.
        MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1222-1225.
        Waterborne disease outbreaks in the United States are associated with a wide variety of water exposures and are reported annually to CDC on a voluntary basis by state and territorial health departments through the National Outbreak Reporting System (NORS). A majority of outbreaks arise from exposure to drinking water (1) or recreational water (2), whereas others are caused by an environmental exposure to water or an undetermined exposure to water. During 2013-2014, 15 outbreaks associated with an environmental exposure to water and 12 outbreaks with an undetermined exposure to water were reported, resulting in at least 289 cases of illness, 108 hospitalizations, and 17 deaths. Legionella was responsible for 63% of the outbreaks, 94% of hospitalizations, and all deaths. Outbreaks were also caused by Cryptosporidium, Pseudomonas, and Giardia, including six outbreaks of giardiasis caused by ingestion of water from a river, stream, or spring. Water management programs can effectively prevent outbreaks caused by environmental exposure to water from human-made water systems, while proper point-of-use treatment of water can prevent outbreaks caused by ingestion of water from natural water systems.

      10. [No abstract]

      11. Biomarkers of tuberculosis severity and treatment effect: A directed screen of 70 host markers in a randomized clinical trial
        Sigal GB, Segal MR, Mathew A, Jarlsberg L, Wang M, Barbero S, Small N, Haynesworth K, Davis JL, Weiner M, Whitworth WC, Jacobs J, Schorey J, Lewinsohn DM, Nahid P.
        EBioMedicine. 2017 Oct 24.
        More efficacious treatment regimens are needed for tuberculosis, however, drug development is impeded by a lack of reliable biomarkers of disease severity and of treatment effect. We conducted a directed screen of host biomarkers in participants enrolled in a tuberculosis clinical trial to address this need. Serum samples from 319 protocol-correct, culture-confirmed pulmonary tuberculosis patients treated under direct observation as part of an international, phase 2 trial were screened for 70 markers of infection, inflammation, and metabolism. Biomarker assays were specifically developed for this study and quantified using a novel, multiplexed electrochemiluminescence assay. We evaluated the association of biomarkers with baseline characteristics, as well as with detailed microbiologic data, using Bonferroni-adjusted, linear regression models. Across numerous analyses, seven proteins, SAA1, PCT, IL-1beta, IL-6, CRP, PTX-3 and MMP-8, showed recurring strong associations with markers of baseline disease severity, smear grade and cavitation; were strongly modulated by tuberculosis treatment; and had responses that were greater for patients who culture-converted at 8weeks. With treatment, all proteins decreased, except for osteocalcin, MCP-1 and MCP-4, which significantly increased. Several previously reported putative tuberculosis-associated biomarkers (HOMX1, neopterin, and cathelicidin) were not significantly associated with treatment response. In conclusion, across a geographically diverse and large population of tuberculosis patients enrolled in a clinical trial, several previously reported putative biomarkers were not significantly associated with treatment response, however, seven proteins had recurring strong associations with baseline radiographic and microbiologic measures of disease severity, as well as with early treatment response, deserving additional study.

      12. Characterising HIV transmission risk among US patients with HIV in care: a cross-sectional study of sexual risk behaviour among individuals with viral load above 1500 copies/mL
        Stirratt MJ, Marks G, O’Daniels C, Cachay ER, Sullivan M, Mugavero MJ, Dhanireddy S, Rodriguez AE, Giordano TP.
        Sex Transm Infect. 2017 Nov 02.
        OBJECTIVES: Viral load and sexual risk behaviour contribute to HIV transmission risk. High HIV viral loads present greater transmission risk than transient viral ‘blips’ above an undetectable level. This paper therefore characterises sexual risk behaviour among patients with HIV in care with viral loads>1500 copies/mL and associated demographic characteristics. METHODS: This cross-sectional study was conducted at six HIV outpatient clinics in USA. The study sample comprises 1315 patients with HIV with a recent viral load >1500 copies/mL. This study sample was drawn from a larger sample of individuals with a recent viral load >1000 copies/mL who completed a computer-assisted self-interview (CASI) regarding sexual risk practices in the last 2 months. The study sample was 32% heterosexual men, 38% men who have sex with men (MSM) and 30% women. RESULTS: Ninety per cent of the sample had their viral load assay within 60 days of the CASI. Thirty-seven per cent reported being sexually active (vaginal or anal intercourse) in the last 2 months. Most of the sexually active participants reported always using condoms (56.9%) or limiting condomless sex to seroconcordant partners (serosorting; 29.2% overall and 42.9% among MSM). Among sexually active participants who reported condomless anal or vaginal sex with an at-risk partner (14%), most had viral loads>10 000 copies/mL (62%). CONCLUSIONS: A relatively small number of patients with HIV in care with viral loads above 1500 copies/mL reported concurrent sexual transmission risk behaviours. Most of the individuals in this small group had markedly elevated viral loads, increasing the probability of transmission. Directing interventions to patients in care with high viral loads and concurrent risk behaviour could strengthen HIV prevention and reduce HIV infections. TRIAL REGISTRATION NUMBER: NCT02044484, completed.

      13. Reporting of false data during Ebola virus disease active monitoring – New York City, January 1, 2015-December 29, 2015
        Tate A, Ezeoke I, Lucero DE, Huang CC, Saffa A, Varma JK, Vora NM.
        Health Secur. 2017 Sep/Oct;15(5):509-518.
        The New York City Department of Health and Mental Hygiene (DOHMH) began to actively monitor people potentially exposed to Ebola virus on October 25, 2014. Active monitoring was critical to the Ebola virus disease (EVD) response and mitigated risk without restricting individual liberties. Noncompliance with active monitoring procedures has been reported. We conducted a survey of 4,075 eligible persons to evaluate (1) the frequency of reporting of false data during active monitoring, and (2) factors associated with reporting of false temperature data. A total of 393 persons (9.6%) responded to the survey. Fifty-five (14.0%) provided false temperature data, 5 (1.3%) did not report EVD-like symptoms that they had experienced, and 2 (0.5%) did not report a hospital or emergency room visit. Having visited Liberia (OR: 3.4, 95% CI: 1.4-7.9), Sierra Leone (OR: 3.4, 95% CI: 1.6-7.5), or multiple EVD-affected countries (OR: 12.9, 95% CI: 3.5-47.7); being aged <50 years (OR: 7.5, 95% CI: 1.7-33.1); and rating the importance of active monitoring as low (OR: 1.4, 95% CI: 1.1-1.8) were associated with increased odds of reporting false temperature data. Over 10% of respondents reported providing false data during EVD active monitoring. However, it remains unclear whether reporting of false data during active monitoring impedes the ability to rapidly identify EVD cases in settings with a low burden of EVD.

    • Disease Reservoirs and Vectors
      1. Diversity of Middle East respiratory syndrome coronaviruses in 109 dromedary camels based on full-genome sequencing, Abu Dhabi, United Arab Emirates
        Yusof MF, Queen K, Eltahir YM, Paden CR, Al Hammadi Z, Tao Y, Li Y, Khalafalla AI, Shi M, Zhang J, Mohamed M, Abd Elaal Ahmed MH, Azeez IA, Bensalah OK, Eldahab ZS, Al Hosani FI, Gerber SI, Hall AJ, Tong S, Al Muhairi SS.
        Emerg Microbes Infect. 2017 Nov 08;6(11):e101.
        Middle East respiratory syndrome coronavirus (MERS-CoV) was identified on the Arabian Peninsula in 2012 and is still causing cases and outbreaks in the Middle East. When MERS-CoV was first identified, the closest related virus was in bats; however, it has since been recognized that dromedary camels serve as a virus reservoir and potential source for human infections. A total of 376 camels were screened for MERS-Cov at a live animal market in the Eastern Region of the Emirate of Abu Dhabi, UAE. In all, 109 MERS-CoV-positive camels were detected in week 1, and a subset of positive camels were sampled again weeks 3 through 6. A total of 126 full and 3 nearly full genomes were obtained from 139 samples. Spike gene sequences were obtained from 5 of the 10 remaining samples. The camel MERS-CoV genomes from this study represent 3 known and 2 potentially new lineages within clade B. Within lineages, diversity of camel and human MERS-CoV sequences are intermixed. We identified sequences from market camels nearly identical to the previously reported 2015 German case who visited the market during his incubation period. We described 10 recombination events in the camel samples. The most frequent recombination breakpoint was the junctions between ORF1b and S. Evidence suggests MERS-CoV infection in humans results from continued introductions of distinct MERS-CoV lineages from camels. This hypothesis is supported by the camel MERS-CoV genomes sequenced in this study. Our study expands the known repertoire of camel MERS-CoVs circulating on the Arabian Peninsula.

    • Environmental Health
      1. Prenatal and early life triclosan and parabens exposure and allergic outcomes
        Lee-Sarwar K, Hauser R, Calafat AM, Ye X, O’Connor GT, Sandel M, Bacharier LB, Zeiger RS, Laranjo N, Gold DR, Weiss ST, Litonjua AA, Savage JH.
        J Allergy Clin Immunol. 2017 Oct 27.
        BACKGROUND: In cross-sectional studies, triclosan and parabens, ubiquitous ingredients in personal care and other products, are associated with allergic disease. OBJECTIVES: We investigated the association between prenatal and early life triclosan and parabens exposure and childhood allergic disease in a prospective, longitudinal study. METHODS: Subjects were enrollees in VDAART, the Vitamin D Antenatal Asthma Reduction Trial. Triclosan, methyl paraben and propyl paraben concentrations were quantified in maternal plasma samples pooled from first and third trimesters and urine samples from children at age 3 or 4 years. Outcomes were parental report of physician-diagnosed asthma or recurrent wheezing, and allergic sensitization to food or environmental antigens based on serum specific IgE levels at age 3 in high-risk children. RESULTS: Analysis included 467 mother-child pairs. Overall, there were no statistically significant associations of maternal plasma or child urine triclosan or parabens concentrations with asthma or recurrent wheeze, food or environmental sensitization at age 3. A trend toward an inverse association between triclosan and parabens exposure and allergic sensitization was observed. There was evidence of effect measure modification by sex, with higher odds of environmental sensitization associated with increasing concentrations of parabens in males compared to females. CONCLUSIONS: We did not identify a consistent association between prenatal and early life triclosan or parabens concentrations and childhood asthma, recurrent wheeze or allergic sensitization in the overall study population. The differential effects of triclosan or parabens exposure on allergic sensitization by sex observed in this study warrants further exploration.

      2. BACKGROUND: Use of organophosphate flame retardants (OPFRs) including tris(1,3-dichloro-2-propyl) phosphate, triphenyl phosphate, tris(1-chloro-2-propyl) phosphate, and tris-2-chloroethyl phosphate, in consumer products is on the rise because of the recent phase out of polybrominated diphenyl ether (PBDE) flame retardants. Some of these chemicals are also used as plasticizers or lubricants in many consumer products. OBJECTIVES: To assess human exposure to these chlorinated and non-chlorinated organophosphates, and non-PBDE brominated chemicals in a representative sample of the U.S. general population 6years and older from the 2013-2014 National Health and Nutrition Examination Survey (NHANES). METHODS: We used solid-phase extraction coupled to isotope dilution high-performance liquid chromatography-tandem mass spectrometry after enzymatic hydrolysis of conjugates to analyze 2666 NHANES urine samples for nine biomarkers: diphenyl phosphate (DPHP), bis(1,3-dichloro-2-propyl) phosphate (BDCIPP), bis-(1-chloro-2-propyl) phosphate (BCIPP), bis-2-chloroethyl phosphate (BCEP), di-n-butyl phosphate (DNBP), di-p-cresylphosphate (DpCP), di-o-cresylphosphate (DoCP), dibenzyl phosphate (DBzP), and 2,3,4,5-tetrabromobenzoic acid (TBBA). We calculated the geometric mean (GM) and distribution percentiles for the urinary concentrations (both in micrograms per liter [mug/L] and in micrograms per gram of creatinine). We only calculated GMs for analytes with an overall weighted frequency of detection >60%. For those analytes, we also a) determined weighted Pearson correlations among the log10-transformed concentrations, and b) used regression models to evaluate associations of various demographic parameters with urinary concentrations of these biomarkers. RESULTS: We detected BDCIPP and DPHP in approximately 92% of study participants, BCEP in 89%, DNBP in 81%, and BCIPP in 61%. By contrast, we detected the other biomarkers much less frequently: DpCP (13%), DoCP (0.1%), TBBA (5%), and did not detect DBzP in any of the participants. Concentration ranges were highest for DPHP (<0.16-193mug/L), BDCIPP (<0.11-169mug/L), and BCEP (<0.08-110mug/L). Regardless of race/ethnicity, 6-11year old children had significantly higher BCEP adjusted GMs than other age groups. Females had significantly higher DPHP and BDCIPP adjusted GM than males, and were more likely than males to have DPHP concentrations above the 95th percentile (odds ratio=3.61; 95% confidence interval, 2.01-6.48). CONCLUSIONS: Our results confirm findings from previous studies suggesting human exposure to OPFRs, and demonstrate, for the first time, widespread exposure to several OPFRs among a representative sample of the U.S. general population 6years of age and older. The observed differences in concentrations of certain OPFRs biomarkers by race/ethnicity, in children compared to other age groups, and in females compared to males may reflect differences in lifestyle and exposure patterns. These NHANES data can be used to stablish a nationally representative baseline of exposures to OPFRs and when combined with future 2-year survey data, to evaluate exposure trends.

    • Epidemiology and Surveillance
      1. Epidemiological surveillance of land borders in North and South America: a case study
        Bruniera-Oliveira R, Horta MA, Varan A, Montiel S, Carmo EH, Waterman SH, Verani JF.
        Rev Inst Med Trop Sao Paulo. 2017 Nov 06;59:e68.
        This study aims to analyze the different binational/multinational activities, programs, and structures taking place on the borders of Brazil and the U.S. between 2013 and 2015. A descriptive exploratory study of two border epidemiological surveillance (BES) systems has been performed. Two approaches were used to collect data: i) technical visits to the facilities involved with border surveillance and application of a questionnaire survey; ii) application of an online questionnaire survey. It was identified that, for both surveillance systems, more than 55% of the technicians had realized that the BES and its activities have high priority. Eighty percent of North American and 71% of Brazilian border jurisdictions reported an exchange of information between countries. Less than half of the jurisdictions reported that the necessary tools to carry out information exchange were available. Operational attributes of completeness, feedback, reciprocity, and quality of information were identified as weak or of low quality in both systems. Statements, guidelines, and protocols to develop surveillance activities are available at the U.S.-Mexico border area. The continuous systematic development of surveillance systems at these borders will create more effective actions and responses.

    • Genetics and Genomics
      1. Twelve complete reference genomes of clinical isolates in the Capnocytophaga genus
        Villarma A, Gulvik CA, Rowe LA, Sheth M, Juieng P, Nicholson AC, Loparev VN, McQuiston JR.
        Genome Announc. 2017 Nov 02;5(44).
        We report here 1 near-complete genome sequence and 12 complete genome sequences for clinical Capnocytophaga isolates. Total read coverages ranged from 211x to 737x, and genome sizes ranged from 2.41 Mb to 3.10 Mb. These genomes will enable a more comprehensive taxonomic evaluation of the Capnocytophaga genus.

    • Immunity and Immunization
      1. Risk of nontargeted infectious disease hospitalizations among US children following inactivated and live vaccines, 2005-2014
        Bardenheier BH, McNeil MM, Wodi AP, McNicholl JM, DeStefano F.
        Clin Infect Dis. 2017 Sep 01;65(5):729-737.
        Background: Recent studies have shown that some vaccines have beneficial effects that cannot be explained solely by the prevention of their respective targeted disease(s). Methods: We used the MarketScan US Commercial Claims Databases for 2005 to 2014 to assess the risk of hospital admission for nontargeted infectious (NTI) diseases in children aged 16 through 24 months according to the last vaccine type (live and/or inactivated). We included children continuously enrolled within a month of birth through 15 months who received at least 3 doses of diphtheria-tetanus-acellular pertussis vaccine by the end of 15 months of age. We used Cox regression to estimate hazard ratios (HRs), stratifying by birthdate to control for age, year, and seasonality and adjusting for sex, chronic diseases, prior hospitalizations, number of outpatient visits, region of residence, urban/rural area of domicile, prematurity, low birth weight, and mother’s age. Results: 311663 children were included. In adjusted analyses, risk of hospitalization for NTI from ages 16 through 24 months was reduced for those who received live vaccine alone compared with inactivated alone or concurrent live and inactivated vaccines (HR, 0.50; 95% confidence interval [CI], 0.43, 0.57 and HR, 0.78; 95% CI, 0.67, 0.91, respectively) and for those who received live and inactivated vaccines concurrently compared with inactivated-only (HR, 0.64; 95% CI, 0.58, 0.70). Conclusions: We found lower risk of NTI disease hospitalizations from age 16 through 24 months among children whose last vaccine received was live compared with inactivated vaccine, as well as concurrent receipt compared with inactivated vaccine.

      2. Temporal association of rotavirus vaccination and genotype circulation in South Africa: Observations from 2002 to 2014
        Page NA, Seheri LM, Groome MJ, Moyes J, Walaza S, Mphahlele J, Kahn K, Kapongo CN, Zar HJ, Tempia S, Cohen C, Madhi SA.
        Vaccine. 2017 Oct 27.
        BACKGROUND: Rotavirus vaccination has reduced diarrhoeal morbidity and mortality globally. The monovalent rotavirus vaccine was introduced into the public immunization program in South Africa (SA) in 2009 and led to approximately 50% reduction in rotavirus hospitalization in young children. The aim of this study was to investigate the rotavirus genotype distribution in SA before and after vaccine introduction. MATERIALS AND METHODS: In addition to pre-vaccine era surveillance conducted from 2002 to 2008 at Dr George Mukhari Hospital (DGM), rotavirus surveillance among children <5years hospitalized for acute diarrhoea was established at seven sentinel sites in SA from April 2009 to December 2014. Stool specimens were screened by enzyme immunoassay and rotavirus positive specimens genotyped using standardised methods. RESULTS: At DGM, there was a significant decrease in G1 strains from pre-vaccine introduction (34%; 479/1418; 2002-2009) compared to post-vaccine introduction (22%; 37/170; 2010-2014; p for trend <.001). Similarly, there was a significant increase in non-G1P[8] strains at this site (p for trend <.001). In expanded sentinel surveillance, when adjusted for age and site, the odds of rotavirus detection in hospitalized children with diarrhoea declined significantly from 2009 (46%; 423/917) to 2014 (22%; 205/939; p<.001). The odds of G1 detection declined significantly from 2009 (53%; 224/421) to 2010-2011 (26%; 183/703; aOR=0.5; p<.001) and 2012-2014 (9%; 80/905; aOR=0.1; p<.001). Non-G1P[8] strains showed a significant increase from 2009 (33%; 139/421) to 2012-2014 (52%; 473/905; aOR=2.5; p<.001). CONCLUSIONS: Rotavirus vaccination of children was associated with temporal changes in circulating genotypes. Despite these temporal changes in circulating genotypes, the overall reduction in rotavirus disease in South Africa remains significant.

      3. Efficacy of trivalent influenza vaccine against laboratory-confirmed influenza among young children in a randomized trial in Bangladesh
        Rolfes MA, Goswami D, Sharmeen AT, Yeasmin S, Parvin N, Nahar K, Rahman M, Barends M, Ahmed D, Rahman MZ, Bresee J, Luby S, Moulton LH, Santosham M, Fry AM, Brooks WA.
        Vaccine. 2017 Oct 31.
        BACKGROUND: Few trials have evaluated influenza vaccine efficacy (VE) in young children, a group particularly vulnerable to influenza complications. We aimed to estimate VE against influenza in children aged <2years in Bangladesh; a subtropical setting, where influenza circulation can be irregular. METHODS: Children aged 6-23months were enrolled 1:1 in a parallel, double-blind, randomized controlled trial of trivalent inactivated influenza vaccine (IIV3) versus inactivated polio vaccine (IPV); conducted August 2010-March 2014 in Dhaka, Bangladesh. Children received two pediatric doses of vaccine, one month apart, and were followed for one year for febrile and respiratory illness. Field assistants conducted weekly home-based, active surveillance and ill children were referred to the study clinic for clinical evaluation and nasopharyngeal wash specimen collection. Analysis included all children who received a first vaccine dose and compared yearly incidence of reverse transcription polymerase chain reaction (RT-PCR)-confirmed influenza between trial arms. The VE was estimated as 1-(rate ratio of illness)x100%, using unadjusted Poisson regression. The trial was registered with, number NCT01319955. RESULTS: Across four vaccination rounds, 4081 children were enrolled and randomized, contributing 2576 child-years of observation to the IIV3 arm and 2593 child-years to the IPV arm. Influenza incidence was 10 episodes/100 child-years in the IIV3 arm and 15 episodes/100 child-years in the IPV arm. Overall, the VE was 31% (95% confidence interval 18, 42%) against any RT-PCR-confirmed influenza. The VE varied by season, but was similar by influenza type/subtype and participant age and sex. CONCLUSIONS: Vaccination of young children with IIV3 provided a significant reduction in laboratory-confirmed influenza; however, exploration of additional influenza vaccine strategies, such as adjuvanted vaccines or standard adult vaccine doses, is warranted to find more effective influenza vaccines for young children in low-income countries.

      4. Country immunization information system assessments – Kenya, 2015 and Ghana, 2016
        Scott C, Clarke KE, Grevendonk J, Dolan SB, Ahmed HO, Kamau P, Ademba PA, Osadebe L, Bonsu G, Opare J, Diamenu S, Amenuvegbe G, Quaye P, Osei-Sarpong F, Abotsi F, Ankrah JD, MacNeil A.
        MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1226-1229.
        The collection, analysis, and use of data to measure and improve immunization program performance are priorities for the World Health Organization (WHO), global partners, and national immunization programs (NIPs). High quality data are essential for evidence-based decision-making to support successful NIPs. Consistent recording and reporting practices, optimal access to and use of health information systems, and rigorous interpretation and use of data for decision-making are characteristics of high-quality immunization information systems. In 2015 and 2016, immunization information system assessments (IISAs) were conducted in Kenya and Ghana using a new WHO and CDC assessment methodology designed to identify root causes of immunization data quality problems and facilitate development of plans for improvement. Data quality challenges common to both countries included low confidence in facility-level target population data (Kenya = 50%, Ghana = 53%) and poor data concordance between child registers and facility tally sheets (Kenya = 0%, Ghana = 3%). In Kenya, systemic challenges included limited supportive supervision and lack of resources to access electronic reporting systems; in Ghana, challenges included a poorly defined subdistrict administrative level. Data quality improvement plans (DQIPs) based on assessment findings are being implemented in both countries. IISAs can help countries identify and address root causes of poor immunization data to provide a stronger evidence base for future investments in immunization programs.

      5. Severe influenza is characterized by prolonged immune activation: results from the SHIVERS cohort study
        Wong SS, Oshansky CM, Guo XJ, Ralston J, Wood T, Reynolds G, Seeds R, Newbern C, Waite B, Widdowson MA, Huang QS, Webby RJ, Thomas PG.
        J Infect Dis. 2017 Nov 03.
        Background: The immunologic factors underlying severe influenza are poorly understood. To address this, we compared the immune responses of influenza-confirmed hospitalized individuals with severe acute respiratory illness (SARI) to those of non-hospitalized individuals with influenza-like illness (ILI). Methods: Peripheral blood lymphocytes were collected from ILI (N=27) and SARI-patients (N=27) at time of enrollment and then two weeks later. Innate and adaptive cellular immune responses were assessed by flow-cytometry and serum cytokines were assessed by bead-based assay. Results: During the acute phase, SARI was associated with significantly reduced numbers of circulating myeloid dendritic cells, CD192+ monocytes, and influenza-specific CD8+ and CD4+ T-cells compared to ILI. By convalescence however, most SARI cases displayed continued immune activation characterized by increased numbers of CD16+ monocytes and proliferating, and influenza-specific, CD8+ T -cells compared to ILI. SARI was also associated with, reduced amounts of cytokines that regulate T-cell responses (IL4, IL13, IL12, IL10, TNFbeta) and hematopoiesis (IL3, GM-CSF) but increased amounts of a pro-inflammatory cytokine (TNFalpha), chemotactic cytokines (MDC, MCP1, GRO, Fractalkine) and growth-promoting cytokines (PDGFBB/AA, VEGF, EGF) compared to ILI. Conclusions: Severe influenza cases showed a delay in the peripheral immune activation that likely led prolonged inflammation compared to mild influenza.

    • Injury and Violence
      1. The experience of violence against children in domestic servitude in Haiti: Results from the Violence Against Children Survey, Haiti 2012
        Gilbert L, Reza A, Mercy J, Lea V, Lee J, Xu L, Marcelin LH, Hast M, Vertefeuille J, Domercant JW.
        Child Abuse Negl. 2017 Nov 04;76:184-193.
        BACKGROUND: There have been estimates that over 150,000 Haitian children are living in servitude. Child domestic servants who perform unpaid labor are referred to as “restaveks.” Restaveks are often stigmatized, prohibited from attending school, and isolated from family placing them at higher risk for experiencing violence. In the absence of national data on the experiences of restaveks in Haiti, the study objective was to describe the sociodemographic characteristics of restaveks in Haiti and to assess their experiences of violence in childhood. METHODS: The Violence Against Children Survey was a nationally representative, cross-sectional household survey of 13-24year olds (n=2916) conducted May-June 2012 in Haiti. A stratified three-stage cluster design was used to sample households and camps containing persons displaced by the 2010 earthquake. Respondents were interviewed to assess lifetime prevalence of physical, emotional, and sexual violence occurring before age 18. Chi-squared tests were used to assess the association between having been a restavek and experiencing violence in childhood. FINDINGS: In this study 17.4% of females and 12.2% of males reported having been restaveks before age 18. Restaveks were more likely to have worked in childhood, have never attended school, and to have come from a household that did not have enough money for food in childhood. Females who had been restaveks in childhood had higher odds of reporting childhood physical (OR 2.04 [1.40-2.97]); emotional (OR 2.41 [1.80-3.23]); and sexual violence (OR 1.86 [95% CI 1.34-2.58]) compared to females who had never been restaveks. Similarly, males who had ever been restaveks in childhood had significantly increased odds of emotional violence (OR 3.06 [1.99-4.70]) and sexual violence (OR 1.85 [1.12-3.07]) compared to males who had never been restaveks, but there was no difference in childhood physical violence. INTERPRETATION: This study demonstrates that child domestic servants in Haiti experience higher rates of childhood violence and have less access to education and financial resources than other Haitian children. These findings highlight the importance of addressing both the lack of human rights law enforcement and the poor economic circumstances that allow the practice of restavek to continue in Haiti.

      2. The incidence of traumatic intracranial hemorrhage in head-injured older adults transported by EMS with and without anticoagulant or antiplatelet use
        Nishijima DK, Gaona SD, Waechter T, Maloney R, Blitz A, Elms AR, Farrales RD, Montoya J, Bair T, Howard C, Gilbert M, Trajano R, Hatchel K, Faul M, Bell JM, Coronado V, Vinson DR, Ballard DW, Tancredi DJ, Garzon H, Mackey KE, Shahlaie K, Holmes JF.
        J Neurotrauma. 2017 Nov 06.
        Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by EMS with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at 5 EMS agencies and 11 hospitals. Older adults (>/=55 years) with head trauma and transported by EMS from Aug 2015 to Sept 2016 were eligible. EMS providers completed standardized data forms and patients were followed through ED or hospital discharge. We enrolled 1,304 patients; 1147 (88%) received a cranial CT scan and were eligible for analysis. 434 (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95%CI 8-14%) and without (9%, 95%CI 7-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%) while the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need.

    • Laboratory Sciences
      1. Changes in the metabolome and microRNA levels in biological fluids might represent biomarkers of neurotoxicity: A trimethyltin study
        Imam SZ, He Z, Cuevas E, Rosas-Hernandez H, Lantz SM, Sarkar S, Raymick J, Robinson B, Hanig JP, Herr D, MacMillan D, Smith A, Liachenko S, Ferguson S, O’Callaghan J, Miller D, Somps C, Pardo ID, Slikker W, B. Pierson J, Roberts R, Gong B, Tong W, Aschner M, J. Kallman M, Calligaro D, Paule MG.
        Exp Biol Med (Maywood). 2017 Jan 01:1535370217739859.
        Neurotoxicity has been linked with exposure to a number of common drugs and chemicals, yet efficient, accurate, and minimally invasive methods to detect it are lacking. Fluid-based biomarkers such as those found in serum, plasma, urine, and cerebrospinal fluid have great potential due to the relative ease of sampling but at present, data on their expression and translation are lacking or inconsistent. In this pilot study using a trimethyl tin rat model of central nervous system toxicity, we have applied state-of-the-art assessment techniques to identify potential individual biomarkers and patterns of biomarkers in serum, plasma, urine or cerebral spinal fluid that may be indicative of nerve cell damage and degeneration. Overall changes in metabolites and microRNAs were observed in biological fluids that were associated with neurotoxic damage induced by trimethyl tin. Behavioral changes and magnetic resonance imaging T2 relaxation and ventricle volume changes served to identify animals that responded to the adverse effects of trimethyl tin. Impact statement These data will help design follow-on studies with other known neurotoxicants to be used to assess the broad applicability of the present findings. Together this approach represents an effort to begin to develop and qualify a set of translational biochemical markers of neurotoxicity that will be readily accessible in humans. Such biomarkers could prove invaluable for drug development research ranging from preclinical studies to clinical trials and may prove to assist with monitoring of the severity and life cycle of brain lesions.

      2. The effect of inspiratory resistance on exercise performance and perception in moderate normobaric hypoxia
        Seo Y, Vaughan J, Quinn TD, Followay B, Roberge R, Glickman EL, Kim JH.
        High Alt Med Biol. 2017 Nov 07.
        Seo, Yongsuk, Jeremiah Vaughan, Tyler D. Quinn, Brittany Followay, Raymond Roberge, Ellen L. Glickman, and Jung-Hyun Kim. The effect of inspiratory resistance on exercise performance and perception in moderate normobaric hypoxia. High Alt Med Biol. 00:000-000, 2017. PURPOSE: Respirators are simple and efficient in protecting workers against toxic airborne substances; however, their use may limit the physical performance of workers. The purpose of this study was to determine the effect of inspiratory resistance on physical performance and breathing perception in normobaric hypoxia. METHOD: Nine healthy men wore a tight-fitting respiratory mask outfitted with one of four different inspiratory resistors (R) (0, 1.5, 4.5, 7.5 cm H2O/L/Sec) while exercising at normobaric hypoxia (17% O2) at submaximal exercise workloads of 50, 100, and 150 W on a cycle ergometer for 10 minutes each, followed by a maximal oxygen uptake (VO2max) test to exhaustion. RESULTS: Maximal power output at R7.5 was significantly lower than R0 (p = 0.016) and R1.5 (p = 0.035). Respiration rate was significantly reduced at R4.5 (p = 0.011) and R7.5 (p </= 0.001) compared with R0. Minute ventilation was significantly decreased in R7.5 compared with R0 (p = 0.003), R1.5 (p = 0.010), and R4.5 (p = 0.016), whereas VO2 was not significantly changed. Breathing comfort (BC) and breathing effort (BE) were significantly impaired in R7.5 (BC: p = 0.025, BE: p = 0.001) and R4.5 (BC: p = 0.007, BE: p = 0.001) compared with R0, but rating of perceived exertion (RPE) remained unchanged. CONCLUSIONS: Added inspiratory resistance limited maximal power output and increased perceptions of BC and BE in normobaric hypoxia. However, low-to-moderate inspiratory resistance did not have a deleterious effect on VO2 or RPE at submaximal or maximal exercise. Perceptual and physiological characteristics of respirators of varying inspiratory resistances should be considered by manufacturers and end users during design and respirator selection processes.

      3. Multicenter evaluation of the modified Carbapenem Inactivation Method and the Carba NP for detection of carbapenemase-producing Pseudomonas aeruginosa and Acinetobacter baumannii
        Simner PJ, Johnson JK, Brasso WB, Anderson K, Lonsway DR, Pierce VM, Bobenchik AM, Lockett ZC, Charnot-Katsikas A, Westblade LF, Yoo BB, Jenkins SG, Limbago BM, Das S, Roe-Carpenter DE.
        J Clin Microbiol. 2017 Nov 08.
        The purpose of this study was to develop the modified Carbapenem Inactivation Method (mCIM) for the detection of carbapenemase-producing (CP) Pseudomonas aeruginosa (PA) and Acinetobacter baumannii (AB) and perform a multicenter evaluation of the mCIM and Carba NP tests for these non-fermenters. Thirty P. aeruginosa and 30 A. baumannii isolates previously characterized by whole genome sequencing from the CDC-FDA Antibiotic Resistance Isolate Bank were evaluated, including carbapenemase-producers (CP; Ambler Class A, B, and D), non-carbapenemase-producing (non-CP) carbapenem-resistant isolates, and carbapenem-susceptible isolates. Initial comparison of a 1 microl versus 10 microl loop inoculum for the mCIM was performed by two testing sites and showed that 10 microl was required for reliable detection of carbapenemase production among PA and AB. Ten testing sites then evaluated the mCIM using a 10 microl loop inoculum. Overall, the mean sensitivity and specificity of the mCIM for detection of CP-PA across all ten sites were 98.0% (95% CI: 94.3-99.6; range: 86.7-100) and 95% (95% CI: 89.8-97.7; range: 93.3-100), whereas the mean sensitivity and specificity among CP-AB were 79.8% (95% CI: 74.0-84.9; range: 36.3-95.7) and 52.9% (95% CI: 40.6- 64.9; range: 28.6-100), respectively. At three sites that evaluated the performance of the Carba NP using the same set of isolates, the mean sensitivity and specificity of the Carba NP were 97.8% (95% CI: 88.2-99.9; range: 93.3-100) and 97.8% (95% CI: 88.2-99.9; range: 93.3-100) for PA and 18.8% (95%CI: 10.4-30.1; range: 8.7-26.1) and 100% (95% CI: 83.9-100; range: 100) for AB. Overall, we found both the mCIM and the Carba NP to be accurate for detection of carbapenemases among PA and less reliable for use with AB isolates.

      4. Are circulating type 2 vaccine-derived polioviruses (VDPVs) genetically distinguishable from immunodeficiency-associated VDPVs?
        Zhao K, Jorba J, Shaw J, Iber J, Chen Q, Bullard K, Kew OM, Burns CC.
        Comput Struct Biotechnol J. 2017 ;15:456-462.
        Public health response to vaccine-derived poliovirus (VDPV) that is transmitted from person to person (circulating VDPV [cVDPV]) differs significantly from response to virus that replicates in individuals with primary immunodeficiency (immunodeficiency-associated VDPV [iVDPV]). cVDPV outbreaks require a community immunization response, whereas iVDPV chronic infections require careful patient monitoring and appropriate individual treatment. To support poliovirus outbreak response, particularly for type 2 VDPV, we investigated the genetic distinctions between cVDPV2 and iVDPV2 sequences. We observed that simple genetic measurements of nucleotide and amino acid substitutions are sufficient for distinguishing highly divergent iVDPV2 from cVDPV2 sequences, but are insufficient to make a clear distinction between the two categories among less divergent sequences. We presented quantitative approaches using genetic information as a surveillance tool for early detection of VDPV outbreaks. This work suggests that genetic variations between cVDPV2 and iVDPV2 may reflect differences in viral micro-environments, host-virus interactions, and selective pressures during person-to-person transmission compared with chronic infections in immunodeficient patients.

      5. Assessment of reactive oxygen species generated by electronic cigarettes using acellular and cellular approaches
        Zhao J, Zhang Y, Sisler JD, Shaffer J, Leonard SS, Morris AM, Qian Y, Bello D, Demokritou P.
        J Hazard Mater. 2017 Oct 29;344:549-557.
        Electronic cigarettes (e-cigs) have fast increased in popularity but the physico-chemical properties and toxicity of the generated emission remain unclear. Reactive oxygen species (ROS) are likely present in e-cig emission and can play an important role in e-cig toxicity. However, e-cig ROS generation is poorly documented. Here, we generated e-cig exposures using a recently developed versatile exposure platform and performed systematic ROS characterization on e-cig emissions using complementary acellular and cellular techniques: 1) a novel acellular Trolox-based mass spectrometry method for total ROS and hydrogen peroxide (H2O2) detection, 2) electron spin resonance (ESR) for hydroxyl radical detection in an acellular and cellular systems and 3) in vitro ROS detection in small airway epithelial cells (SAEC) using the dihydroethidium (DHE) assay. Findings confirm ROS generation in cellular and acellular systems and is highly dependent on the e-cig brand, flavor, puffing pattern and voltage. Trolox method detected a total of 1.2-8.9nmol H2O2eq./puff; H2O2 accounted for 12-68% of total ROS. SAEC cells exposed to e-cig emissions generated up to eight times more ROS compared to control. The dependency of e-cig emission profile on e-cig features and operational parameters should be taken into consideration in toxicological studies.

    • Maternal and Child Health
      1. Preterm birth associated with group B streptococcus maternal colonization worldwide: Systematic review and meta-analyses
        Bianchi-Jassir F, Seale AC, Kohli-Lynch M, Lawn JE, Baker CJ, Bartlett L, Cutland C, Gravett MG, Heath PT, Ip M, Le Doare K, Madhi SA, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Rubens CE.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S133-s142.
        Background: Preterm birth complications are the leading cause of deaths among children <5 years of age. Studies have suggested that group B Streptococcus (GBS) maternal rectovaginal colonization during pregnancy may be a risk factor for preterm delivery. This article is the fifth of 11 in a series. We aimed to assess the association between GBS maternal colonization and preterm birth in order to inform estimates of the burden of GBS. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data from investigator groups on the association of preterm birth (<37 weeks’ gestation) and maternal GBS colonization (GBS isolation from vaginal, cervical, and/or rectal swabs; with separate subanalysis on GBS bacteriuria). We did meta-analyses to derive pooled estimates of the risk and odds ratios (according to study design), with sensitivity analyses to investigate potential biases. Results: We identified 45 studies for inclusion. We estimated the risk ratio (RR) for preterm birth with maternal GBS colonization to be 1.21 (95% confidence interval [CI], .99-1.48; P = .061) in cohort and cross-sectional studies, and the odds ratio to be 1.85 (95% CI, 1.24-2.77; P = .003) in case-control studies. Preterm birth was associated with GBS bacteriuria in cohort studies (RR, 1.98 [95% CI, 1.45-2.69]; P < .001). Conclusions: From this review, there is evidence to suggest that preterm birth is associated with maternal GBS colonization, especially where there is evidence of ascending infection (bacteriuria). Several biases reduce the chance of detecting an effect. Equally, however, results, including evidence for the association, may be due to confounding, which is rarely addressed in studies. Assessment of any effect on preterm delivery should be included in future maternal GBS vaccine trials.

      2. Maternal disease with group B streptococcus and serotype distribution worldwide: Systematic review and meta-analyses
        Hall J, Adams NH, Bartlett L, Seale AC, Lamagni T, Bianchi-Jassir F, Lawn JE, Baker CJ, Cutland C, Heath PT, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Gravett MG.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S112-s124.
        Background: Infections such as group B Streptococcus (GBS) are an important cause of maternal sepsis, yet limited data on epidemiology exist. This article, the third of 11, estimates the incidence of maternal GBS disease worldwide. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data on invasive GBS disease in women pregnant or within 42 days postpartum. We undertook meta-analyses to derive pooled estimates of the incidence of maternal GBS disease. We examined maternal and perinatal outcomes and GBS serotypes. Results: Fifteen studies and 1 unpublished dataset were identified, all from United Nations-defined developed regions. From a single study with pregnancies as the denominator, the incidence of maternal GBS disease was 0.38 (95% confidence interval [CI], .28-.48) per 1000 pregnancies. From 3 studies reporting cases by the number of maternities (pregnancies resulting in live/still birth), the incidence was 0.23 (95% CI, .09-.37). Five studies reported serotypes, with Ia being the most common (31%). Most maternal GBS disease was detected at or after delivery. Conclusions: Incidence data on maternal GBS disease in developing regions are lacking. In developed regions the incidence is low, as are the sequelae for the mother, but the risk to the fetus and newborn is substantial. The timing of GBS disease suggests that a maternal vaccine given in the late second or early third trimester of pregnancy would prevent most maternal cases.

      3. To better understand the impact that nonresponse for specimen collection has on the validity of estimates of association, we examined associations between self-reported maternal periconceptional smoking, folic acid use, or pregestational diabetes mellitus and six birth defects among families who did and did not submit buccal cell samples for DNA following a telephone interview as part of the National Birth Defects Prevention Study (NBDPS). Analyses included control families with live born infants who had no birth defects (N = 9,465), families of infants with anorectal atresia or stenosis (N = 873), limb reduction defects (N = 1,037), gastroschisis (N = 1,090), neural tube defects (N = 1,764), orofacial clefts (N = 3,836), or septal heart defects (N = 4,157). Estimated dates of delivery were between 1997 and 2009. For each exposure and birth defect, odds ratios and 95% confidence intervals were calculated using logistic regression stratified by race-ethnicity and sample collection status. Tests for interaction were applied to identify potential differences between estimated measures of association based on sample collection status. Significant differences in estimated measures of association were observed in only four of 48 analyses with sufficient sample sizes. Despite lower than desired participation rates in buccal cell sample collection, this validation provides some reassurance that the estimates obtained for sample collectors and noncollectors are comparable. These findings support the validity of observed associations in gene-environment interaction studies for the selected exposures and birth defects among NBDPS participants who submitted DNA samples.

      4. Neurodevelopmental impairment in children after group B streptococcal disease worldwide: Systematic review and meta-analyses
        Kohli-Lynch M, Russell NJ, Seale AC, Dangor Z, Tann CJ, Baker CJ, Bartlett L, Cutland C, Gravett MG, Heath PT, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, O’Sullivan C, Nakwa F, Ben Hamouda H, Soua H, Giorgakoudi K, Ladhani S, Lamagni T, Rattue H, Trotter C, Lawn JE.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S190-s199.
        Background: Survivors of infant group B streptococcal (GBS) disease are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified. This is the 10th of 11 articles estimating the burden of GBS disease. Here we aimed to estimate NDI in survivors of infant GBS disease. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data on the risk of NDI after invasive GBS disease in infants <90 days of age. We did meta-analyses to derive pooled estimates of the percentage of infants with NDI following GBS meningitis. Results: We identified 6127 studies, of which 18 met eligibility criteria, all from middle- or high-income contexts. All 18 studies followed up survivors of GBS meningitis; only 5 of these studies also followed up survivors of GBS sepsis and were too few to pool in a meta-analysis. Of meningitis survivors, 32% (95% CI, 25%-38%) had NDI at 18 months of follow-up, including 18% (95% CI, 13%-22%) with moderate to severe NDI. Conclusions: GBS meningitis is an important risk factor for moderate to severe NDI, affecting around 1 in 5 survivors. However, data are limited, and we were unable to estimate NDI after GBS sepsis. Comparability of studies is difficult due to methodological differences including variability in timing of clinical reviews and assessment tools. Follow-up of clinical cases and standardization of methods are essential to fully quantify the total burden of NDI associated with GBS disease, and inform program priorities.

      5. Group B streptococcal disease worldwide for pregnant women, stillbirths, and children: Why, what, and how to undertake estimates?
        Lawn JE, Bianchi-Jassir F, Russell NJ, Kohli-Lynch M, Tann CJ, Hall J, Madrid L, Baker CJ, Bartlett L, Cutland C, Gravett MG, Heath PT, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Seale AC.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S89-s99.
        Improving maternal, newborn, and child health is central to Sustainable Development Goal targets for 2030, requiring acceleration especially to prevent 5.6 million deaths around the time of birth. Infections contribute to this burden, but etiological data are limited. Group B Streptococcus (GBS) is an important perinatal pathogen, although previously focus has been primarily on liveborn children, especially early-onset disease. In this first of an 11-article supplement, we discuss the following: (1) Why estimate the worldwide burden of GBS disease? (2) What outcomes of GBS in pregnancy should be included? (3) What data and epidemiological parameters are required? (4) What methods and models can be used to transparently estimate this burden of GBS? (5) What are the challenges with available data? and (6) How can estimates address data gaps to better inform GBS interventions including maternal immunization? We review all available GBS data worldwide, including maternal GBS colonization, risk of neonatal disease (with/without intrapartum antibiotic prophylaxis), maternal GBS disease, neonatal/infant GBS disease, and subsequent impairment, plus GBS-associated stillbirth, preterm birth, and neonatal encephalopathy. We summarize our methods for searches, meta-analyses, and modeling including a compartmental model. Our approach is consistent with the World Health Organization (WHO) Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER), published in The Lancet and the Public Library of Science (PLoS). We aim to address priority epidemiological gaps highlighted by WHO to inform potential maternal vaccination.

      6. Intrapartum antibiotic chemoprophylaxis policies for the prevention of group B streptococcal disease worldwide: Systematic review
        Le Doare K, O’Driscoll M, Turner K, Seedat F, Russell NJ, Seale AC, Heath PT, Lawn JE, Baker CJ, Bartlett L, Cutland C, Gravett MG, Ip M, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Kampmann B.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S143-s151.
        Background: Intrapartum antibiotic chemoprophylaxis (IAP) prevents most early-onset group B streptococcal (GBS) disease. However, there is no description of how IAP is used around the world. This article is the sixth in a series estimating the burden of GBS disease. Here we aimed to review GBS screening policies and IAP implementation worldwide. Methods: We identified data through (1) systematic literature reviews (PubMed/Medline, Embase, Literature in the Health Sciences in Latin America and the Caribbean [LILACS], World Health Organization library database [WHOLIS], and Scopus) and unpublished data from professional societies and (2) an online survey and searches of policies from medical societies and professionals. We included data on whether an IAP policy was in use, and if so whether it was based on microbiological or clinical risk factors and how these were applied, as well as the estimated coverage (percentage of women receiving IAP where indicated). Results: We received policy information from 95 of 195 (49%) countries. Of these, 60 of 95 (63%) had an IAP policy; 35 of 60 (58%) used microbiological screening, 25 of 60 (42%) used clinical risk factors. Two of 15 (13%) low-income, 4 of 16 (25%) lower-middle-income, 14 of 20 (70%) upper-middle-income, and 40 of 44 (91%) high-income countries had any IAP policy. The remaining 35 of 95 (37%) had no national policy (25/33 from low-income and lower-middle-income countries). Coverage varied considerably; for microbiological screening, median coverage was 80% (range, 20%-95%); for clinical risk factor-based screening, coverage was 29% (range, 10%-50%). Although there were differences in the microbiological screening methods employed, the individual clinical risk factors used were similar. Conclusions: There is considerable heterogeneity in IAP screening policies and coverage worldwide. Alternative global strategies, such as maternal vaccination, are needed to enhance the scope of global prevention of GBS disease.

      7. Infant group B streptococcal disease incidence and serotypes worldwide: Systematic review and meta-analyses
        Madrid L, Seale AC, Kohli-Lynch M, Edmond KM, Lawn JE, Heath PT, Madhi SA, Baker CJ, Bartlett L, Cutland C, Gravett MG, Ip M, Le Doare K, Rubens CE, Saha SK, Sobanjo-Ter Meulen A, Vekemans J, Schrag S.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S160-s172.
        Background: Group B Streptococcus (GBS) remains a leading cause of neonatal sepsis in high-income contexts, despite declines due to intrapartum antibiotic prophylaxis (IAP). Recent evidence suggests higher incidence in Africa, where IAP is rare. We investigated the global incidence of infant invasive GBS disease and the associated serotypes, updating previous estimates. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data regarding invasive GBS disease in infants aged 0-89 days. We conducted random-effects meta-analyses of incidence, case fatality risk (CFR), and serotype prevalence. Results: We identified 135 studies with data on incidence (n = 90), CFR (n = 64), or serotype (n = 45). The pooled incidence of invasive GBS disease in infants was 0.49 per 1000 live births (95% confidence interval [CI], .43-.56), and was highest in Africa (1.12) and lowest in Asia (0.30). Early-onset disease incidence was 0.41 (95% CI, .36-.47); late-onset disease incidence was 0.26 (95% CI, .21-.30). CFR was 8.4% (95% CI, 6.6%-10.2%). Serotype III (61.5%) dominated, with 97% of cases caused by serotypes Ia, Ib, II, III, and V. Conclusions: The incidence of infant GBS disease remains high in some regions, particularly Africa. We likely underestimated incidence in some contexts, due to limitations in case ascertainment and specimen collection and processing. Burden in Asia requires further investigation.

      8. Maternal colonization with group B streptococcus and serotype distribution worldwide: Systematic review and meta-analyses
        Russell NJ, Seale AC, O’Driscoll M, O’Sullivan C, Bianchi-Jassir F, Gonzalez-Guarin J, Lawn JE, Baker CJ, Bartlett L, Cutland C, Gravett MG, Heath PT, Le Doare K, Madhi SA, Rubens CE, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Saha SK, Ip M.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S100-s111.
        Background: Maternal rectovaginal colonization with group B Streptococcus (GBS) is the most common pathway for GBS disease in mother, fetus, and newborn. This article, the second in a series estimating the burden of GBS, aims to determine the prevalence and serotype distribution of GBS colonizing pregnant women worldwide. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus), organized Chinese language searches, and sought unpublished data from investigator groups. We applied broad inclusion criteria to maximize data inputs, particularly from low- and middle-income contexts, and then applied new meta-analyses to adjust for studies with less-sensitive sampling and laboratory techniques. We undertook meta-analyses to derive pooled estimates of maternal GBS colonization prevalence at national and regional levels. Results: The dataset regarding colonization included 390 articles, 85 countries, and a total of 299924 pregnant women. Our adjusted estimate for maternal GBS colonization worldwide was 18% (95% confidence interval [CI], 17%-19%), with regional variation (11%-35%), and lower prevalence in Southern Asia (12.5% [95% CI, 10%-15%]) and Eastern Asia (11% [95% CI, 10%-12%]). Bacterial serotypes I-V account for 98% of identified colonizing GBS isolates worldwide. Serotype III, associated with invasive disease, accounts for 25% (95% CI, 23%-28%), but is less frequent in some South American and Asian countries. Serotypes VI-IX are more common in Asia. Conclusions: GBS colonizes pregnant women worldwide, but prevalence and serotype distribution vary, even after adjusting for laboratory methods. Lower GBS maternal colonization prevalence, with less serotype III, may help to explain lower GBS disease incidence in regions such as Asia. High prevalence worldwide, and more serotype data, are relevant to prevention efforts.

      9. Risk of early-onset neonatal group B streptococcal disease with maternal colonization worldwide: Systematic review and meta-analyses
        Russell NJ, Seale AC, O’Sullivan C, Le Doare K, Heath PT, Lawn JE, Bartlett L, Cutland C, Gravett M, Ip M, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Baker CJ.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S152-s159.
        Background: Early-onset group B streptococcal disease (EOGBS) occurs in neonates (days 0-6) born to pregnant women who are rectovaginally colonized with group B Streptococcus (GBS), but the risk of EOGBS from vertical transmission has not been systematically reviewed. This article, the seventh in a series on the burden of GBS disease, aims to estimate this risk and how it varies with coverage of intrapartum antibiotic prophylaxis (IAP), used to reduce the incidence of EOGBS. Methods: We conducted systematic reviews (Pubmed/Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data from investigator groups on maternal GBS colonization and neonatal outcomes. We included articles with >/=200 GBS colonized pregnant women that reported IAP coverage. We did meta-analyses to determine pooled estimates of risk of EOGBS, and examined the association in risk of EOGBS with IAP coverage. Results: We identified 30 articles including 20328 GBS-colonized pregnant women for inclusion. The risk of EOGBS in settings without an IAP policy was 1.1% (95% confidence interval [CI], .6%-1.5%). As IAP increased, the risk of EOGBS decreased, with a linear association. Based on linear regression, the risk of EOGBS in settings with 80% IAP coverage was predicted to be 0.3% (95% CI, 0-.9). Conclusions: The risk of EOGBS among GBS-colonized pregnant women, from this first systematic review, is consistent with previous estimates from single studies (1%-2%). Increasing IAP coverage was linearly associated with decreased risk of EOGBS disease.

      10. Effect of breastfeeding and additional household children on cytomegalovirus seroprevalence among U.S. children 1 to 5 years of age
        Schmink S, Kruszon-Moran D, Dollard SC, Lanzieri TM.
        Clin Vaccine Immunol. 2017 Nov;24(11).

        [No abstract]

      11. Stillbirth with group B streptococcus disease worldwide: Systematic review and meta-analyses
        Seale AC, Blencowe H, Bianchi-Jassir F, Embleton N, Bassat Q, Ordi J, Menendez C, Cutland C, Briner C, Berkley JA, Lawn JE, Baker CJ, Bartlett L, Gravett MG, Heath PT, Ip M, Le Doare K, Rubens CE, Saha SK, Schrag S, Meulen AS, Vekemans J, Madhi SA.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S125-s132.
        Background: There are an estimated 2.6 million stillbirths each year, many of which are due to infections, especially in low- and middle-income contexts. This paper, the eighth in a series on the burden of group B streptococcal (GBS) disease, aims to estimate the percentage of stillbirths associated with GBS disease. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Literatura Latino-Americana e do Caribe em Ciencias da Saude, World Health Organization Library Information System, and Scopus) and sought unpublished data from investigator groups. Studies were included if they reported original data on stillbirths (predominantly >/=28 weeks’ gestation or >/=1000 g, with GBS isolated from a sterile site) as a percentage of total stillbirths. We did meta-analyses to derive pooled estimates of the percentage of GBS-associated stillbirths, regionally and worldwide for recent datasets. Results: We included 14 studies from any period, 5 with recent data (after 2000). There were no data from Asia. We estimated that 1% (95% confidence interval [CI], 0-2%) of all stillbirths in developed countries and 4% (95% CI, 2%-6%) in Africa were associated with GBS. Conclusions: GBS is likely an important cause of stillbirth, especially in Africa. However, data are limited in terms of geographic spread, with no data from Asia, and cases worldwide are probably underestimated due to incomplete case ascertainment. More data, using standardized, systematic methods, are critical, particularly from low- and middle-income contexts where the highest burden of stillbirths occurs. These data are essential to inform interventions, such as maternal GBS vaccination.

      12. Neonatal encephalopathy with group B streptococcal disease worldwide: Systematic review, investigator group datasets, and meta-analysis
        Tann CJ, Martinello KA, Sadoo S, Lawn JE, Seale AC, Vega-Poblete M, Russell NJ, Baker CJ, Bartlett L, Cutland C, Gravett MG, Ip M, Le Doare K, Madhi SA, Rubens CE, Saha SK, Schrag S, Sobanjo-Ter Meulen A, Vekemans J, Heath PT.
        Clin Infect Dis. 2017 Nov 06;65(suppl_2):S173-s189.
        Background: Neonatal encephalopathy (NE) is a leading cause of child mortality and longer-term impairment. Infection can sensitize the newborn brain to injury; however, the role of group B streptococcal (GBS) disease has not been reviewed. This paper is the ninth in an 11-article series estimating the burden of GBS disease; here we aim to assess the proportion of GBS in NE cases. Methods: We conducted systematic literature reviews (PubMed/Medline, Embase, Latin American and Caribbean Health Sciences Literature [LILACS], World Health Organization Library Information System [WHOLIS], and Scopus) and sought unpublished data from investigator groups reporting GBS-associated NE. Meta-analyses estimated the proportion of GBS disease in NE and mortality risk. UK population-level data estimated the incidence of GBS-associated NE. Results: Four published and 25 unpublished datasets were identified from 13 countries (N = 10436). The proportion of NE associated with GBS was 0.58% (95% confidence interval [CI], 0.18%-.98%). Mortality was significantly increased in GBS-associated NE vs NE alone (risk ratio, 2.07 [95% CI, 1.47-2.91]). This equates to a UK incidence of GBS-associated NE of 0.019 per 1000 live births. Conclusions: The consistent increased proportion of GBS disease in NE and significant increased risk of mortality provides evidence that GBS infection contributes to NE. Increased information regarding this and other organisms is important to inform interventions, especially in low- and middle-resource contexts.

    • Nutritional Sciences
      1. State laws are associated with school lunch duration and promotion practices
        Turner L, Leider J, Piekarz-Porter E, Schwartz MB, Merlo C, Brener N, Chriqui JF.
        J Acad Nutr Diet. 2017 Oct 27.
        BACKGROUND: The changes in school meal programs stemming from the Healthy, Hunger-Free Kids Act of 2010 have expanded interest in strategies that increase student participation in school lunch and reduce plate waste. However, it remains unclear what factors are associated with schools’ use of such strategies. OBJECTIVE: This study examines whether state laws are associated with two types of school meal-related practices: (a) using promotional strategies (ie, taste tests, using posters or announcements) and (b) duration of lunch periods. DESIGN: This cross-sectional study utilized the nationally representative 2014 School Health Policies and Practices Study, combined with corresponding state laws gathered by the National Wellness Policy Study. School data were available from 414 public schools in 43 states. MAIN OUTCOME MEASURES: Outcome measures included 16 strategies to promote school meals and the amount of time students had to eat lunch after being seated. STATISTICAL ANALYSES PERFORMED: Multivariate logistic regression and Poisson regression were used to examine associations between state laws and school practices, after accounting for school demographic characteristics. RESULTS: Compared to schools in states with no law about engaging stakeholders in meal programs, schools in states with a law were more likely to conduct taste tests (64% vs 44%, P=0.016), collect suggestions from students (67% vs 50%, P=0.017), and invite family members to a school meal (71% vs 53%, P=0.015). Schools used more promotion strategies in states with a law than in states without a law (mean=10.4 vs 8.8, P=0.003). Schools were more likely to provide students at least 30 minutes to eat lunch after being seated in states with laws that addressed a minimum amount of time for lunch duration (43% vs 27%, P=0.042). CONCLUSIONS: State-level policy provisions are associated with school practices. Policy development in more states may support school practices that promote lunch participation and consumption.

    • Occupational Safety and Health
      1. Development of a diabetes mellitus knowledge resource for clinical decision support assisting primary care physicians with work-related issues
        Allen A, Welch L, Kirkland K, Trout D, Baron S.
        J Occup Environ Med. 2017 Nov;59(11):e236-e239.
        OBJECTIVE: The aim of this study was to describe the process by which a group of subject matter experts (SMEs) in the area of occupational health and primary care developed a clinical decision support (CDS) tool addressing work-related issues, which are important in the care of patients with diabetes mellitus (DM). The CDS is intended for primary care clinicians caring for employed adults with DM. METHODS: The SME’s selected guidelines for the management of DM in working adults, reviewed pertinent literature, and developed specific recommendations for action in the clinical setting. RESULTS: Multiple factors at work may adversely affect DM management. Clinicians can support working patients through education and care strategies to improve control. CONCLUSION: Improved recognition of factors at work that can have an impact on DM care provides opportunities for improved management of DM among working adults.

      2. OBJECTIVE: The aim of this study was to determine the perceived value and feasibility of increased access to information about workers’ health for primary care providers (PCPs) by evaluating the need for clinical decision support (CDS) related to worker health in primary care settings. METHODS: Qualitative methods, including semi-structured interviews and observations, were used to evaluate the value and feasibility of three examples of CDS relating work and health in five primary care settings. RESULTS: PCPs and team members wanted help addressing patients’ health in relation to their jobs; the proposed CDS examples were perceived as valuable because they provided useful information, promoted standardization of care, and were considered technically feasible. Barriers included time constraints and a perceived inability to act on the findings. CONCLUSION: PCPs recognize the importance and impact of work on their patients’ health but often lack accessible knowledge at the right time. Occupational health providers can play an important role through contributions to the development of CDS that assists PCPs in recognizing and addressing patients’ health, as well as through the provision of referral guidelines.

      3. OBJECTIVE: The purpose was to estimate the prevalence of hearing loss for noise-exposed U.S. workers within the Healthcare and Social Assistance (HSA) sector. METHODS: Audiograms for 1.4 million workers (8,702 within HSA) from 2003-2012 were examined. Prevalences and adjusted risks for hearing loss as compared with a reference industry were estimated for the HSA sector and all industries combined. RESULTS: While the overall HSA sector prevalence for hearing loss was 19%, the prevalences in the Medical Laboratories sub-sector and the Offices of All Other Miscellaneous Health Practitioners sub-sector were 31% and 24%, respectively. The Child Day Care Services sub-sector had a 52% higher risk than the reference industry. CONCLUSIONS: High risk industries for hearing loss exist within the HSA sector. Further work is needed to identify the sources of noise exposure and protect worker hearing.

      4. [No abstract]

    • Occupational Safety and Health – Mining
      1. Coal miner participation in a job transfer program designed to prevent progression of pneumoconiosis, United States, 1986-2016
        Reynolds L, Halldin CN, Laney AS, Blackley DJ.
        Arch Environ Occup Health. 2017 Nov 08:0.
        The Part 90 program was designed to prevent progression of pneumoconiosis in U.S. coal miners by establishing their right to transfer to a less dusty job in the mine. We calculated the proportion of Part 90-eligible miners who participated during 1986-2016, examined participation by region, and compared characteristics of miners by participation status. Of the 3,547 eligible miners, 14.4% exercised their Part 90 option. Miners working in states outside central Appalachia, and those with more severe pneumoconiosis, were more likely to participate. The primary goal of respiratory health surveillance of coal miners is early detection of disease so that preventive action can be taken. Future studies should seek to better understand factors influencing Part 90 program participation.

    • Parasitic Diseases
      1. Serology reflects a decline in the prevalence of trachoma in two regions of The Gambia
        Migchelsen SJ, Sepulveda N, Martin DL, Cooley G, Gwyn S, Pickering H, Joof H, Makalo P, Bailey R, Burr SE, Mabey DC, Solomon AW, Roberts CH.
        Sci Rep. 2017 Nov 08;7(1):15040.
        Trachoma is caused by Chlamydia trachomatis (Ct). It is targeted for global elimination as a public health problem. In 2014, a population-based cross-sectional study was performed in two previously trachoma-endemic areas of The Gambia. Participants of all ages from Lower River Region (LRR) (N = 1028) and Upper River Region (URR) (N = 840) underwent examination for trachoma and had blood collected for detection of antibodies against the Ct antigen Pgp3, by ELISA. Overall, 30 (1.6%) individuals had active trachoma; the prevalence in children aged 1-9 years was 3.4% (25/742) with no statistically significant difference in prevalence between the regions. There was a significant difference in overall seroprevalence by region: 26.2% in LRR and 17.1% in URR (p < 0.0001). In children 1-9 years old, seroprevalence was 4.4% in LRR and 3.9% in URR. Reversible catalytic models using information on age-specific seroprevalence demonstrated a decrease in the transmission of Ct infection in both regions, possibly reflecting the impact of improved access to water, health and sanitation as well as mass drug administration campaigns. Serological testing for antibodies to Ct antigens is potentially useful for trachoma programmes, but consideration should be given to the co-endemicity of sexually transmitted Ct infections.

      2. Malaria surveys using rapid diagnostic tests and validation of results using post hoc quantification of Plasmodium falciparum histidine-rich protein 2
        Plucinski M, Dimbu R, Candrinho B, Colborn J, Badiane A, Ndiaye D, Mace K, Chang M, Lemoine JF, Halsey ES, Barnwell JW, Udhayakumar V, Aidoo M, Rogier E.
        Malar J. 2017 Nov 07;16(1):451.
        BACKGROUND: Rapid diagnostic test (RDT) positivity is supplanting microscopy as the standard measure of malaria burden at the population level. However, there is currently no standard for externally validating RDT results from field surveys. METHODS: Individuals’ blood concentration of the Plasmodium falciparum histidine rich protein 2 (HRP2) protein were compared to results of HRP2-detecting RDTs in participants from field surveys in Angola, Mozambique, Haiti, and Senegal. A logistic regression model was used to estimate the HRP2 concentrations corresponding to the 50 and 90% level of detection (LOD) specific for each survey. RESULTS: There was a sigmoidal dose-response relationship between HRP2 concentration and RDT positivity for all surveys. Variation was noted in estimates for field RDT sensitivity, with the 50% LOD ranging between 0.076 and 6.1 ng/mL and the 90% LOD ranging between 1.1 and 53 ng/mL. Surveys conducted in two different provinces of Angola using the same brand of RDT and same study methodology showed a threefold difference in LOD. CONCLUSIONS: Measures of malaria prevalence estimated using population RDT positivity should be interpreted in the context of potentially large variation in RDT LODs between, and even within, surveys. Surveys based on RDT positivity would benefit from external validation of field RDT results by comparing RDT positivity and antigen concentration.

      3. Molecular detection of Cyclospora cayetanensis in human stool specimens using UNEX-based DNA extraction and real-time PCR
        Qvarnstrom Y, Benedict T, Marcet PL, Wiegand RE, Herwaldt BL, da Silva AJ.
        Parasitology. 2017 Nov 08:1-6.
        Cyclospora cayetanensis is a coccidian parasite associated with diarrheal illness. In the USA, foodborne outbreaks of cyclosporiasis have been documented almost every year since the mid-1990s. The typical approach used to identify this parasite in human stools is an examination of acid-fast-stained smears under bright-field microscopy. UV fluorescence microscopy of wet mounts is more sensitive and specific than acid-fast staining but requires a fluorescence microscope with a special filter not commonly available in diagnostic laboratories. In this study, we evaluated a new DNA extraction method based on the Universal Nucleic Acid Extraction (UNEX) buffer and compared the performances of four published real-time polymerase chain reaction (PCR) assays for the specific detection of C. cayetanensis in stool. The UNEX-based method had an improved capability to recover DNA from oocysts compared with the FastDNA stool extraction method. The best-performing real-time PCR assay was a C. cayetanensis-specific TaqMan PCR that targets the 18S ribosomal RNA gene. This new testing algorithm should be useful for detection of C. cayetanensis in human stool samples.

    • Physical Activity
      1. Driven to support: Individual- and county-level factors associated with public support for active transportation policies
        Cradock AL, Barrett JL, Chriqui JF, Evenson KR, Goins KV, Gustat J, Heinrich KM, Perry CK, Scanze M, Schmid TL, Tabak RG, Umstattd Meyer MR, Valko C.
        Am J Health Promot. 2017 Jan 01:890117117738758.
        PURPOSE: To assess predictors of stated support for policies promoting physically active transportation. DESIGN: Cross-sectional. SETTING: US counties selected on county-level physical activity and obesity health status. PARTICIPANTS: Participants completing random-digit dialed telephone survey (n = 906). MEASURES: Survey measures assessed stated support for 5 policies to promote physically active transportation, access to active transportation facilities, and time spent in a car. County-level estimates included household car dependence and funding for bicycle-pedestrian projects. ANALYSIS: Multivariable generalized linear mixed models using binary distribution and logit link, accounting for clustering within county. RESULTS: Respondents supported policies for accommodating bicyclists and pedestrians through street improvements (89%), school active transportation programs (75%), employer-funded active commuting incentives (67%), and allocation of public funding (68%) and tax support (56%) for building and maintaining public transit. Residents spending >2 h/d (vs <0.7 hours) in cars were more likely to support street (odds ratio [OR]: 1.87; confidence interval [CI]: 1.09-3.22) and public transit (OR: 1.85; CI: 1.24-2.77) improvements. Residents in counties investing >$1.6 million in bicycle and pedestrian improvements expressed greater support for funding (OR: 1.71; CI: 1.04-2.83) and tax increases (OR: 1.73; CI: 1.08-2.75) for transit improvements compared to those with lower prior investments (<$276 100). CONCLUSION: Support for policies to enable active transportation is higher where relevant investments in active transportation infrastructure are large (>$1.6 M), public transit is nearby, and respondents drive >2 h/d.

    • Public Health Leadership and Management
      1. The public health workforce taxonomy: Revisions and recommendations for implementation
        Beck AJ, Coronado F, Boulton ML, Merrill JA.
        J Public Health Manag Pract. 2017 Nov 02.
        Public health workforce size and composition have been difficult to accurately determine because of the wide variety of methods used to define job title terms, occupational categories, and worker characteristics. In 2014, a preliminary consensus-based public health workforce taxonomy was published to standardize the manner in which workforce data are collected and analyzed by outlining uniform categories and terms. We summarize development of the taxonomy’s 2017 iteration and provide guidelines for its implementation in public health workforce development efforts. To validate its utility, the 2014 taxonomy was pilot tested through quantitative and qualitative methods to determine whether further refinements were necessary. Pilot test findings were synthesized, themed by axis, and presented for review to an 11-member working group drawn from the community of experts in public health workforce development who refined the taxonomy content and structure through a consensus process. The 2017 public health workforce taxonomy consists of 287 specific classifications organized along 12 axes, intended for producing standardized descriptions of the public health workforce. The revised taxonomy provides enhanced clarity and inclusiveness for workforce characterization and will aid public health workforce researchers and workforce planning decision makers in gathering comparable, standardized data to accurately describe the public health workforce.

      2. Succession planning in state health agencies in the United States: A brief report
        Harper E, Leider JP, Coronado F, Beck AJ.
        J Public Health Manag Pract. 2017 Nov 02.
        OBJECTIVE: Approximately 25% of the public health workforce plans to retire by 2020. Succession planning is a core capability of the governmental public health enterprise; however, limited data are available regarding these efforts in state health agencies (SHAs). METHODS: We analyzed 2016 Workforce Gaps Survey data regarding succession planning in SHAs using the US Office of Personnel Management’s (OPM’s) succession planning model, including 6 domains and 27 activities. Descriptive statistics were calculated for all 41 responding SHAs. RESULTS: On average, SHAs self-reported adequately addressing 11 of 27 succession planning activities, with 93% of SHAs adequately addressing 1 or more activities and 61% adequately addressing 1 or more activities in each domain. CONCLUSIONS: The majority of OPM-recommended succession planning activities are not being addressed, and limited succession planning occurs across SHAs. Greater activity in the OPM-identified succession planning domains may help SHAs contend with significant turnover and better preserve institutional knowledge.

    • Substance Use and Abuse
      1. Text to Quit China: An mHealth smoking cessation trial
        Augustson E, Engelgau MM, Zhang S, Cai Y, Cher W, Li R, Jiang Y, Lynch K, Bromberg JE.
        Am J Health Promot. 2017 May;31(3):217-225.
        PURPOSE: To assess the feasibility, acceptability, and efficacy of a text message-based smoking cessation intervention in China. DESIGN: Study design was a randomized control trial with a 6-month follow-up assessment of smoking status. SETTING: Zhejiang, Heilongjiang, and Shaanxi provinces in China provided the study setting. SUBJECTS: A total of 8000 adult smokers in China who used Nokia Life Tools and participated in phase 2 (smoking education via text message) of the study were included. INTERVENTION: The high-frequency text contact (HFTC) group received one to three messages daily containing smoking cessation advice, encouragement, and health education information. The low-frequency text contact (LFTC) group received one weekly message with smoking health effects information. MEASURES: Our primary outcome was smoking status at 0, 1, 3, and 6 months after intervention. Secondary outcomes include participant perceptions of the HFTC intervention, and factors associated with smoking cessation among HFTC participants. ANALYSIS: Descriptive and chi2 analyses were conducted to assess smoking status and acceptability. Factors associated with quitting were assessed using multiple logistic regression analyses. RESULTS: Quit rates were high in both the HFTC and LFTC groups (HFTC: 0 month, 27.9%; 1 month, 30.5%; 3 months, 26.7%; and 6 months, 27.7%; LFTC: 0 month, 26.7%; 1 month, 30.4%; 3 months, 28.1%; and 6 months, 27.7%), with no significant difference between the two groups in an intent-to-treat analysis. Attitudes toward the HFTC intervention were largely positive. CONCLUSION: Our findings suggest that a text message-based smoking cessation intervention can be successfully delivered in China and is acceptable to Chinese smokers, but further research is needed to assess the potential impact of this type of intervention.

      2. Race/ethnic variations in quitline use among US adult tobacco users in 45 states, 2011-2013
        Marshall LL, Zhang L, Malarcher AM, Mann NH, King BA, Alexander RL.
        Nicotine Tob Res. 2017 Nov 07;19(12):1473-1481.
        Introduction: State quitlines provide free telephone-based cessation services and are available in all states. However, quitlines presently reach 1% of US cigarette smokers. We assessed variations in quitline reach by race/ethnicity across 45 US states included in the National Quitline Data Warehouse, a repository on non-identifiable data reported by state quitlines. Methods: During 2011 to 2013, we analyzed 1 220 171 records from the National Quitline Data Warehouse. Annual quitline reach was defined as the proportion of cigarette smokers and smokeless tobacco users who utilized quitline services during each year, and was calculated by dividing the number of state-specific quitline registrants in each year by the number of adult cigarette smokers and smokeless tobacco users in the state. Results: Average annual reach ranged from: 0.08% (Tennessee) to 3.42% (Hawaii) among non-Hispanic whites; 0.17% (Tennessee) to 3.85% (Delaware) among non-Hispanic blacks; 0.27% (Nevada) to 9.98% (Delaware) among non-Hispanic American Indians/Alaska Native; 0.03% (Alabama) to 2.43% (Hawaii) among non-Hispanic Asian/Pacific Islanders; and from 0.08% (Tennessee) to 3.18% (Maine) among Hispanics. Average annual reach was highest among non-Hispanic American Indians/Alaska Native in 27 states, non-Hispanic blacks in 14 states, and non-Hispanic whites in four states. Conclusions: Quitlines appear to be reaching minority populations; however, overall reach remains low and variations in quitline reach exist by race/ethnicity. Opportunities exist to increase the utilization of quitlines and other effective cessation treatments among racial/ethnic minority populations. Implications: Some studies have assessed quitline reach across demographic groups in individual states; however, no studies have provided multistate data about quitline reach across race/ethnic groups. Ongoing monitoring of the use of state quitlines can help guide targeted outreach to particular race/ethnic groups with the goal of increasing the overall proportion and number of tobacco users that use quitlines. These efforts should be complemented by comprehensive tobacco control initiatives that increase cessation including mass media campaigns, smoke-free policies, increased tobacco prices, expansion of health insurance coverage, and health systems change.

      3. Tobacco product use among adults – United States, 2015
        Phillips E, Wang TW, Husten CG, Corey CG, Apelberg BJ, Jamal A, Homa DM, King BA.
        MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1209-1215.
        Tobacco use remains the leading cause of preventable disease and death in the United States (1). Despite declining cigarette smoking prevalence among U.S. adults, shifts in the tobacco product landscape have occurred in recent years (2,3). Previous estimates of tobacco product use among U.S. adults were obtained from the National Adult Tobacco Survey, which ended after the 2013-2014 cycle. This year, CDC and the Food and Drug Administration (FDA) assessed the most recent national estimates of tobacco product use among adults aged >/=18 years using, for the first time, data from the 2015 National Health Interview Survey (NHIS), an annual, nationally representative, in-person survey of the noninstitutionalized U.S. civilian population. The 2015 NHIS adult core questionnaire included 33,672 adults aged >/=18 years, reflecting a 55.2% response rate. Data were weighted to adjust for differences in selection probability and nonresponse, and to provide nationally representative estimates. In 2015, 20.1 % of U.S. adults currently (every day or some days) used any tobacco product, 17.6% used any combustible tobacco product, and 3.9% used >/=2 tobacco products. By product, 15.1% of adults used cigarettes; 3.5% used electronic cigarettes (e-cigarettes); 3.4% used cigars, cigarillos, or filtered little cigars; 2.3% used smokeless tobacco; and 1.2% used regular pipes, water pipes, or hookahs.* Current use of any tobacco product was higher among males; persons aged <65 years; non-Hispanic American Indian/Alaska natives (AI/AN), whites, blacks, and persons of multiple races; persons living in the Midwest; persons with a General Educational Development (GED) certificate; persons with annual household income of <$35,000; persons who were single, never married, or not living with a partner or divorced, separated, or widowed; persons who were insured through Medicaid or uninsured; persons with a disability; and persons who identified as lesbian, gay, or bisexual (LGB). Current use of any tobacco product was 47.2% among adults with serious psychological distress compared with 19.2% among those without serious psychological distress. Proven population-level interventions that focus on the diversity of tobacco product use are important to reducing tobacco-related disease and death in the United States (1).

    • Zoonotic and Vectorborne Diseases
      1. A Zika vaccine targeting NS1 protein protects immunocompetent adult mice in a lethal challenge model
        Brault AC, Domi A, McDonald EM, Talmi-Frank D, McCurley N, Basu R, Robinson HL, Hellerstein M, Duggal NK, Bowen RA, Guirakhoo F.
        Sci Rep. 2017 Nov 07;7(1):14769.
        Zika virus (ZIKV) is a mosquito-borne flavivirus that has rapidly extended its geographic range around the world. Its association with abnormal fetal brain development, sexual transmission, and lack of a preventive vaccine have constituted a global health concern. Designing a safe and effective vaccine requires significant caution due to overlapping geographical distribution of ZIKV with dengue virus (DENV) and other flaviviruses, possibly resulting in more severe disease manifestations in flavivirus immune vaccinees such as Antibody-Dependent Enhancement (ADE, a phenomenon involved in pathogenesis of DENV, and a risk associated with ZIKV vaccines using the envelope proteins as immunogens). Here, we describe the development of an alternative vaccine strategy encompassing the expression of ZIKV non-structural-1 (NS1) protein from a clinically proven safe, Modified Vaccinia Ankara (MVA) vector, thus averting the potential risk of ADE associated with structural protein-based ZIKV vaccines. A single intramuscular immunization of immunocompetent mice with the MVA-ZIKV-NS1 vaccine candidate provided robust humoral and cellular responses, and afforded 100% protection against a lethal intracerebral dose of ZIKV (strain MR766). This is the first report of (i) a ZIKV vaccine based on the NS1 protein and (ii) single dose protection against ZIKV using an immunocompetent lethal mouse challenge model.

      2. Meeting summary: State and local implementation strategies for increasing access to contraception during Zika preparedness and response – United States, September 2016
        Kroelinger CD, Romero L, Lathrop E, Cox S, Morgan I, Frey MT, Warner L, Curtis KM, Pazol K, Barfield WD, Meaney-Delman D, Jamieson DJ.
        MMWR Morb Mortal Wkly Rep. 2017 Nov 10;66(44):1230-1235.
        Zika virus infection during pregnancy is a cause of microcephaly and other serious brain abnormalities. To support state and territory response to the threat of Zika, CDC’s Interim Zika Response Plan outlined activities for vector control; clinical management of exposed pregnant women and infants; targeted communication about Zika virus transmission among women and men of reproductive age; and primary prevention of Zika-related adverse pregnancy and birth outcomes by prevention of unintended pregnancies through increased access to contraception.* The most highly effective,dagger reversible contraception includes intrauterine devices and implants, known as long-acting reversible contraception (LARC). On September 28, 2016, the Association of Maternal and Child Health Programs (AMCHP) and CDC facilitated a meeting in Atlanta, Georgia, of representatives from 15 states to identify state-led efforts to implement seven CDC-published strategies aimed at increasing access to contraception in the context of Zika virus. Qualitative data were collected from participating jurisdictions. The number of states reporting implementation of each strategy ranged from four to 11. Participants identified numerous challenges, particularly for strategies implemented less frequently. Examples of barriers were discussed and presented with corresponding approaches to address each barrier. Addressing these barriers could facilitate increased access to contraception, which might decrease the number of unintended pregnancies affected by Zika virus.

      3. Human case of bubonic plague resulting from the bite of a wild Gunnison’s prairie dog during translocation from a plague-endemic area
        Melman SD, Ettestad PE, VinHatton ES, Ragsdale JM, Takacs N, Onischuk LM, Leonard PM, Master SS, Lucero VS, Kingry LC, Petersen JM.
        Zoonoses Public Health. 2017 Nov 06.
        Plague is a zoonotic disease (transmitted mainly by fleas and maintained in nature by rodents) that causes severe acute illness in humans. We present a human plague case who became infected by the bite of a wild Gunnison’s prairie dog, and a good practical example of the One Health approach that resulted in a rapid public health response. The exposure occurred while the animal was being transported for relocation to a wildlife refuge after being trapped in a plague enzootic area. This is the first report of a human plague case resulting from the bite of a Gunnison’s prairie dog. Additionally, we present an observation of a longer incubation period for plague in captive prairie dogs, leading to a recommendation for a longer quarantine period for prairie dogs during translocation efforts.

      4. Surveillance for Lyme disease – United States, 2008-2015
        Schwartz AM, Hinckley AF, Mead PS, Hook SA, Kugeler KJ.
        MMWR Surveill Summ. 2017 Nov 10;66(22):1-12.
        PROBLEM/CONDITION: Lyme disease is the most commonly reported vectorborne disease in the United States but is geographically focal. The majority of Lyme disease cases occur in the Northeast, mid-Atlantic, and upper Midwest regions. Lyme disease can cause varied clinical manifestations, including erythema migrans, arthritis, facial palsy, and carditis. Lyme disease occurs most commonly among children and older adults, with a slight predominance among males. REPORTING PERIOD: 2008-2015. DESCRIPTION OF SYSTEM: Lyme disease has been a nationally notifiable condition in the United States since 1991. Possible Lyme disease cases are reported to local and state health departments by clinicians and laboratories. Health department staff conduct case investigations to classify cases according to the national surveillance case definition. Those that qualify as confirmed or probable cases of Lyme disease are reported to CDC through the National Notifiable Diseases Surveillance System. States with an average annual incidence during this reporting period of >/=10 confirmed Lyme disease cases per 100,000 population were classified as high incidence. States that share a border with those states or that are located between areas of high incidence were classified as neighboring states. All other states were classified as low incidence. RESULTS: During 2008-2015, a total of 275,589 cases of Lyme disease were reported to CDC (208,834 confirmed and 66,755 probable). Although most cases continue to be reported from states with high incidence in the Northeast, mid-Atlantic, and upper Midwest regions, case counts in most of these states have remained stable or decreased during the reporting period. In contrast, case counts have increased in states that neighbor those with high incidence. Overall, demographic characteristics associated with confirmed cases were similar to those described previously, with a slight predominance among males and a bimodal age distribution with peaks among young children and older adults. Yet, among the subset of cases reported from states with low incidence, infection occurred more commonly among females and older adults. In addition, probable cases occurred more commonly among females and with a higher modal age than confirmed cases. INTERPRETATION: Lyme disease continues to be the most commonly reported vectorborne disease in the United States. Although concentrated in historically high-incidence areas, the geographic distribution is expanding into neighboring states. The trend of stable to decreasing case counts in many states with high incidence could be a result of multiple factors, including actual stabilization of disease incidence or artifact due to modifications in reporting practices employed by some states to curtail the resource burden associated with Lyme disease surveillance. PUBLIC HEALTH ACTION: This report highlights the continuing public health challenge of Lyme disease in states with high incidence and demonstrates its emergence in neighboring states that previously experienced few cases. Educational efforts should be directed accordingly to facilitate prevention, early diagnosis, and appropriate treatment. As Lyme disease emerges in neighboring states, clinical suspicion of Lyme disease in a patient should be based on local experience rather than incidence cutoffs used for surveillance purposes. A diagnosis of Lyme disease should be considered in patients with compatible clinical signs and a history of potential exposure to infected ticks, not only in states with high incidence but also in areas where Lyme disease is known to be emerging. These findings underscore the ongoing need to implement personal prevention practices routinely (e.g., application of insect repellent and inspection for and removal of ticks) and to develop other effective interventions.

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  • Onnalee Gomez, MS, Health Scientist
  • Jarvis Sims, MIT, MLIS, Librarian


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