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CDC Science Clips: Volume 14, Issue 33, August 16, 2022

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. 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.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Outpatient antifungal prescribing patterns in the United States, 2018
        Benedict K, Tsay SV, Bartoces MG, Vallabhaneni S, Jackson BR, Hicks LA.
        Antimicrob Steward Healthc Epidemiol. 2022 Dec 22;1.
        BACKGROUND: Widespread inappropriate antibiotic prescribing is a major driver of resistance. Little is known about antifungal prescribing practices in the United States, which is concerning given emerging resistance in fungi, particularly to azole antifungals. OBJECTIVE: We analyzed outpatient U.S. antifungal prescribing data to inform stewardship efforts. DESIGN: Descriptive analysis of outpatient antifungal prescriptions dispensed during 2018 in the IQVIA Xponent database. METHODS: Prescriptions were summarized by drug, sex, age, geography, and healthcare provider specialty. Census denominators were used to calculate prescribing rates among demographic groups. RESULTS: Healthcare providers prescribed 22.4 million antifungal courses in 2018 (68 prescriptions per 1,000 persons). Fluconazole was the most common drug (75%), followed by terbinafine (11%) and nystatin (10%). Prescription rates were higher among females vs. males (110 vs. 25 per 1,000) and adults vs. children (82 vs. 27 per 1,000). Prescription rates were highest in the South (81 per 1,000 persons) and lowest in the West (48 per 1,000 persons). Nurse practitioners and family practitioners prescribed the most antifungals (43% of all prescriptions), but the highest prescribing rates were among obstetrician-gynecologists (84 per provider). CONCLUSIONS: Prescribing of antifungal drugs in the outpatient setting was common, with enough courses dispensed for one in every 15 U.S. residents in 2018. Fluconazole use patterns suggest vulvovaginal candidiasis as a common indication. Regional prescribing differences could reflect inappropriate use or variations in disease burden. Further study of higher antifungal use in the South could help target antifungal stewardship practices.

    • Chronic Diseases and Conditions
      1. Associations of emergency department visits for asthma with precipitation and temperature on thunderstorm days: A time-series analysis of data from Louisiana, USA, 2010-2012
        Park JH, Lee E, Fechter-Leggett ED, Williams E, Yadav S, Bakshi A, Ebelt S, Bell JE, Strosnider H, Chew GL.
        Environ Health Perspect. 2022 Aug;130(8):87003.
        BACKGROUND: Studies of thunderstorm asthma to understand risk factors using high-resolution climate data and asthma outcomes on a large scale are scarce. Moreover, thunderstorm asthma is not well studied in the United States. OBJECTIVES: We examined whether climate parameters involved in thunderstorms are associated with emergency department (ED) visits for acute asthma attacks in the United States. METHODS: We analyzed 63,789 asthma-related, daily ED visits for all age groups, and thunderstorm-associated climate data in Louisiana during 2010 through 2012. We performed time-series analyses using quasi-Poisson regression models with natural cubic splines of date, parish, holiday, day of week, season, daily maximum concentrations of ozone (O3) and fine particulate matter [PM  ≤ 2.5 μm in aerodynamic diameter (PM2.5)], and daily mean pressure, precipitation, and temperature. Because of a significant interaction effect between temperature and lightning days on asthma-related visits, we performed stratified analyses by days with/without lightning or thunderstorm (defined by any lightning and precipitation). RESULTS: On thunderstorm days, higher asthma-related ED visits were associated with higher daily mean precipitation [relative risk (RR) = 1.145 per 1 g/m2/s (95% CI: 1.009, 1.300)] and lower daily mean temperature [RR = 1.011 per 1°C change (1.000-1.021)] without carry-over effect to the next non-thunderstorm day. These higher risks were found mainly among children and adults  < 65 years of age. We observed similar results on lightning days. However, we did not find similar associations for non-thunderstorm or non-lightning days. Daily maximum O3 and PM2.5 levels were not significantly associated with asthma ED visits on thunderstorm days. DISCUSSION: Higher precipitation and lower temperature on thunderstorm days appear to contribute to asthma attacks among people with asthma, suggesting they should consider taking precautions during thunderstorms. EDs should consider preparing for a potential increase of asthma-related visits and ensuring sufficient stock of emergency medication and supplies for forecasted severe thunderstorm days. https://doi.org/10.1289/EHP10440.

      2. High-resolution mass spectrometry for the measurement of PTH and PTH fragments: Insights into PTH physiology and bioactivity
        Ulmer CZ, Kritmetapak K, Singh RJ, Vesper HW, Kumar R.
        J Am Soc Nephrol. 2022 Aug;33(8):1448-1458.
        Full-length parathyroid hormone (PTH 1-84) is crucial for the regulation of calcium and phosphate homeostasis and bone remodeling. PTH 1-84 is metabolized into various PTH fragments, which are measured with varying levels of efficiency by PTH immunoassays. These PTH fragments, which increase in serum as CKD progresses, could potentially modulate the effects of PTH 1-84 and contribute to CKD-associated bone disorders. To obtain a true biologic representation of total PTH bioactivity, it is necessary to measure not only PTH 1-84 but also PTH fragments that are present in circulation. Traditional second-generation PTH immunoassays collectively measure PTH 1-84, PTH fragments, and post-translationally modified PTH 1-84, making it difficult to accurately predict the character of underlying renal osteodystrophy. This review highlights current advances in methods available for PTH measurement and the clinical relevance of PTH fragments in CKD. We emphasize the usefulness of mass spectrometry as a potential reference method for PTH measurement.

      3. Trends in glycemia between 2002 and 2016 among incident youth cohorts early in the course of type 1 diabetes: The SEARCH for Diabetes in Youth Study
        Igudesman D, Reboussin BA, Souris KJ, Pihoker C, Dolan L, Lawrence JM, Saydah S, Dabelea D, Marcovina S, Clouet-Foraison N, Malik FS, Mayer-Davis EJ.
        J Diabetes Res. 2022 ;2022:8554991.
        OBJECTIVE: Hyperglycemia early in the course of type 1 diabetes (T1D) may increase the risk of cardiometabolic complications later in life. We tested the hypothesis that there were temporal trends in population-level glycemia and insulin pump use near T1D diagnosis among incident youth cohorts diagnosed between 2002 and 2016. METHODS: Weighted and adjusted regression models were applied to data from the SEARCH for Diabetes in Youth study to analyze trends in hemoglobin A1c (HbA1c), suboptimal glycemia (HbA1c > 9% or not), and insulin pump use among youth with T1D within 30 months of diagnosis. We tested the interaction of year with race and ethnicity, sex, and insulin regimen to assess potential disparities. RESULTS: Among the 3,956 youth with T1D, there was a small, clinically insignificant reduction in HbA1c between 2002 (7.9% ± 1.5) and 2016 (7.8% ± 2.4) (fully adjusted change by year (-0.013% [95% CI -0.026, -0.0008], p = 0.04). The proportion of youth with suboptimal glycemia increased with each year, but the adjusted odds did not change. Insulin pump use increased more than fivefold. Although interaction effects of time with race and ethnicity, sex, and insulin regimen were not detected, in 2016, suboptimal glycemia was 4.3 and 1.8 times more prevalent among Black and Hispanic than among non-Hispanic White youth, respectively. CONCLUSIONS: There was not a clinically significant population-level improvement in glycemia across incident youth cohorts early in the course of T1D, despite severalfold increases in insulin pump use. Comprehensive clinical interventions to improve glycemia early in the T1D course and address disparities are urgently needed.

      4. Chronic conditions among adults aged 18─34 years - United States, 2019
        Watson KB, Carlson SA, Loustalot F, Town M, Eke PI, Thomas CW, Greenlund KJ.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 29;71(30):964-970.
        Chronic conditions are common, costly, and major causes of death and disability.* Addressing chronic conditions and their determinants in young adulthood can help slow disease progression and improve well-being across the life course (1); however, recent prevalence estimates examining chronic conditions in young adults overall and by subgroup have not been reported. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to measure prevalence of 11 chronic conditions among adults aged 18-34 years overall and by selected characteristics, and to measure prevalence of health-related risk behaviors by chronic condition status. In 2019, more than one half (53.8%) of adults aged 18-34 years reported having at least one chronic condition, and nearly one quarter (22.3%) reported having more than one chronic condition. The most prevalent conditions were obesity (25.5%), depression (21.3%), and high blood pressure (10.7%). Differences in the prevalence of having a chronic condition were most noticeable between young adults with a disability (75.8%) and without a disability (48.3%) and those who were unemployed (62.3%) and students (45.8%). Adults aged 18-34 years with a chronic condition were more likely than those without one to report binge drinking, smoking, or physical inactivity. Coordinated efforts by public and private sectors might help raise awareness of chronic conditions among young adults and help improve the availability of evidence-based interventions, policies, and programs that are effective in preventing, treating, and managing chronic conditions among young adults (1).

    • Communicable Diseases
      1. Adherence challenges and opportunities for optimizing care through enhanced adherence counseling for adolescents with suspected HIV treatment failure in Kenya
        Gill MM, Ndimbii JN, Otieno-Masaba R, Ouma M, Jabuto S, Ochanda B.
        BMC Health Serv Res. 2022 Jul 29;22(1):962.
        BACKGROUND: Adolescents living with HIV (ALHIV) experience higher mortality and are more likely to have poor antiretroviral therapy (ART) adherence and unsuppressed viral load (VL) compared to adults. Enhanced adherence counseling (EAC) is a client-centered counseling strategy that aims to identify and address barriers to optimal ART use and can be tailored to the unique needs of adolescents. This study aimed to better understand adherence barriers among ALHIV with suspected treatment failure and their experience with EAC to inform future programming. METHODS: A qualitative study was conducted in Homa Bay and Turkana counties, Kenya in 2019 with adolescents and caregivers of children and adolescents living with HIV with suspected treatment failure after ≥6 months on ART and who had received ≥1 EAC sessions. Sixteen focus group discussions (FGDs) were conducted; five FGDs each were held with adolescents 12-14 years (n = 48) and 15-19 years (n = 36). Caregivers (n = 52) participated in six FGDs. Additionally, 17 healthcare workers providing pediatric/adolescent HIV services participated in in-depth interviews. Audio recordings were transcribed and translated from Kiswahili or Dholuo into English and coded using MAXQDA software. Data were thematically analyzed by participant group. RESULTS: Participants identified adolescents' fear of being stigmatized due to their HIV status and their relationship with and level of support provided by caregivers. This underpinned and often undermined adolescents' ART-taking behavior and progress towards more independent medication management. Adolescents were generally satisfied with EAC and perceived it to be important in improving adherence and reducing VL. However, problems were noted with facility-based, individual EAC counseling, including judgmental attitudes of providers and difficulties traveling to and keeping EAC clinic appointments. Participant-suggested improvements to EAC included peer support groups in addition to individual counseling, allowing for greater flexibility in the timing and location of sessions and greater caregiver involvement. CONCLUSIONS: The findings provide opportunities to better tailor EAC interventions to promote improved ALHIV adherence and caregiver-supported disease management. Multi-prong EAC interventions that include peer-led and community approaches and target adolescent and caregiver treatment literacy may improve EAC delivery, address issues contributing to poor adherence, and position adolescents to achieve viral suppression. TRIAL REGISTRATION: ClinicalTrials.gov : NCT04915469.

      2. Hepatitis C virus infection preceding an outbreak of HIV among persons who inject drugs- Kanawha County, West Virginia, 2019-2021
        Hudson AG, Bonacci RA, Moorman AC, Penley M, Wilson SM, Hoffman JL, Thomasson ER, Paul McClung R, Bixler D.
        Clin Infect Dis. 2022 Jul 29.
        Of 65 cases during an HIV outbreak among persons who inject drugs (PWID) in Kanawha County, West Virginia during 2019-2021, 61 (94%) had hepatitis C diagnosed at a median of 46 months prior to HIV diagnosis. Hepatitis C diagnosis among PWID should trigger improved access to prevention and treatment services.

      3. Spatiotemporal trends in norovirus outbreaks in the United States, 2009-2019
        Kambhampati AK, Calderwood L, Wikswo ME, Barclay L, Mattison CP, Balachandran N, Vinjé J, Hall AJ, Mirza SA.
        Clin Infect Dis. 2022 Aug 1.
        BACKGROUND: Globally, noroviruses cause infections year-round but have recognized winter seasonality in the northern hemisphere and yearly variations in incidence. With candidate norovirus vaccines in development, understanding temporal and geographic trends in norovirus disease is important to inform potential vaccination strategies and evaluate vaccine impact. METHODS: We analyzed data from the National Outbreak Reporting System (NORS) and CaliciNet on single-state norovirus outbreaks that occurred from August 2009-July 2019 in the contiguous United States. We defined norovirus season onset and offset as the weeks by which 10% and 90% of norovirus outbreaks in a surveillance year occurred, respectively, and duration as the difference in weeks between onset and offset. We compared norovirus seasons across surveillance years and geographic regions. RESULTS: During August 2009-July 2019, 24,995 single-state norovirus outbreaks were reported to NORS and/or CaliciNet. Nationally, median norovirus season duration was 24 weeks, with onset occurring between October-December and offset occurring between April-May. Across all years combined, we observed a west-to-east trend in seasonality, with the earliest onset (October) and latest offset (May) occurring in western regions and the latest onset (December) and earliest offset (April) occurring in northeastern regions. CONCLUSIONS: Timing and duration of the US norovirus season varied annually, but generally occurred during October-May. Norovirus wintertime seasonality was less distinct in western regions and was progressively more pronounced moving east. Further understanding the drivers of spatiotemporal dynamics of norovirus could provide insights into factors promoting virus transmission and help guide future interventions.

      4. A 21st century appraisal of Whipple's Disease and Tropheryma whipplei
        Paddock CD, Fenollar F, Lagier JC, Raoult D.
        Clin Microbiol Newsl. 2022 ;44(14):123-129.
        Whipple's disease was formally described more than 100 years ago; nonetheless, only recently have investigators identified, cultivated, and characterized the causative agent, Tropheryma whipplei, and deciphered some of its complex associations with human hosts. The acquisition of knowledge about T. whipplei, a Gram-positive bacterium in the class Actinobacteria, accelerated at an extraordinarily rapid pace during the first two decades of the 21st century, to include the recognition of asymptomatic carriage, localized disease, and acute infections caused by this peculiar bacterium. This review discusses current knowledge of the microbiology and epidemiology of T. whipplei, the expanding clinical spectrum of disease caused by the pathogen, its treatment, and historical and diagnostic assays that facilitate the diagnosis of the various diseases caused by this enigmatic bacterium. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. © 2022 Elsevier Inc.

      5. Feasibility, acceptability, and barriers to implementing select non-pharmaceutical interventions to reduce the transmission of pandemic influenza - United States, 2019
        Ahmed F, Qualls N, Kowalczyk S, Randolph Cunningham S, Zviedrite N, Uzicanin A.
        Disaster Med Public Health Prep. 2022 Aug 1:1-22.
        OBJECTIVES: To assess feasibility and acceptability of implementing non-pharmaceutical interventions (NPIs) reserved for influenza pandemics (voluntary home quarantine; use of face masks by ill persons; childcare facility closures; school closures; and social distancing at schools, workplaces, and mass gatherings). METHODS: Public health officials in all 50 states, Washington, DC, and 8 territories, and a random sample of 822 local health departments (LHDs) were surveyed in 2019. RESULTS: The response rates for the states/territories and LHDs were 75% (44/59) and 25% (206/822), respectively. The majority of the state/territorial respondents stated that the feasibility and acceptability of implementing NPIs were high, except for K-12 school closures lasting up to 6 weeks or 6 months. The LHD respondents also indicated that feasibility and acceptability were lowest for prolonged school closures. Compared to LHD respondents in suburban or urban areas, those in rural areas expressed lower feasibility and acceptability. Barriers to implementing NPIs included financial impact, compliance and difficulty in enforcement, perceived level of disease threat, and concerns regarding political implications. CONCLUSIONS: Proactive strategies to systematically address perceived barriers and promote disease prevention ahead of a new pandemic are needed to increase receptivity and consistent adoption of NPIs and other evidence-based countermeasures.

      6. Red blood cell distribution width and pediatric community-acquired pneumonia disease severity
        Lee J, Zhu Y, Williams DJ, Self WH, Arnold SR, McCullers JA, Ampofo K, Pavia AT, Anderson EJ, Jain S, Edwards KM, Grijalva CG.
        Hosp Pediatr. 2022 Aug 4.
        BACKGROUND AND OBJECTIVES: No standardized risk assessment tool exists for community-acquired pneumonia (CAP) in children. This study aims to investigate the association between red blood cell distribution width (RDW) and pediatric CAP. METHODS: Data prospectively collected by the Etiology of Pneumonia in the Community study (2010-2012) was used. Study population was pediatric patients admitted to tertiary care hospitals in Nashville and Memphis, Tennessee with clinically and radiographically confirmed CAP. The earliest measured RDW value on admission was used, in quintiles and also as a continuous variable. Outcomes analyzed were: severe CAP (requiring ICU, mechanical ventilation, vasopressor support, or death) or moderate CAP (hospital admission only). Analysis used multivariable logistic regression and restricted cubic splines modeling. RESULTS: In 1459 eligible children, the median age was 29 months (interquartile range: 12-73), median RDW was 13.3% (interquartile range: 12.5-14.3), and 289 patients (19.8%) developed severe disease. In comparison with the lowest RDW quintile (Q1), the adjusted odds ratio (95% CI) for severe CAP in subsequent quintiles were, Q2: 1.20 (0.72-1.99); Q3: 1.28 (0.76-2.14); Q4: 1.69 (1.01-2.82); Q5: 1.25 (0.73-2.13). Consistently, RDW restricted cubic splines demonstrated an independent, nonlinear, positive association with CAP severity (P = .027), with rapid increases in the risk of severe CAP with RDW values up to 15%. CONCLUSIONS: Higher presenting RDW was associated with an increased risk of severe CAP in hospitalized children. Widely available and inexpensive, RDW can serve as an objective data point to help with clinical assessments.

      7. Safety and efficacy of a biodegradable implant releasing tenofovir alafenamide for vaginal protection in a macaque model
        Massud I, Krovi A, Nishiura K, Ruone S, Li L, Holder A, Gary J, Mills P, Mitchell J, Khalil G, Pan Y, Luecke E, Gatto G, Heneine W, Garcίa-Lerma JG, Johnson L, van der Straten A, Dobard C.
        J Antimicrob Chemother. 2022 Aug 1.
        OBJECTIVES: To advance the initiative of ending the global epidemic, long-lasting HIV protection is needed through sustained release of antiretroviral drugs for months to years. We investigated in macaques the safety and efficacy of biodegradable polycaprolactone implants releasing tenofovir alafenamide for HIV pre-exposure prophylaxis (PrEP). METHODS: Implants were administered subcutaneously in the arm using a contraceptive trocar. Efficacy against vaginal simian-HIV (SHIV) infection was investigated in six pigtailed macaques that received two tenofovir alafenamide implants (0.35 mg/day), one in each arm, for a total release rate of tenofovir alafenamide at 0.7 mg/day. Macaques were exposed to SHIV twice weekly for 6 weeks. Statistical analyses were used to compare outcome with eight untreated controls. Histological assessments were performed on skin biopsies collected near implantation sites. RESULTS: Median (range) tenofovir diphosphate level in PBMCs was 1519 (1068-1898) fmol/106 cells. All macaques with tenofovir alafenamide implants were protected against vaginal SHIV infection. In contrast, 7/8 controls were infected after a median of 4 SHIV exposures (P = 0.0047). Histological assessment of tissues near tenofovir alafenamide implant sites showed inflammation and necrosis in 5/6 animals, which were not evident by visual inspection. CONCLUSIONS: We demonstrated complete protection against vaginal SHIV infection with two implants releasing a total of 0.7 mg of tenofovir alafenamide per day. We also identified tenofovir diphosphate concentrations in PBMCs associated with complete vaginal protection. Consistent with previous findings, we observed adverse local toxicity and necrosis near the tenofovir alafenamide implant site. Improved tenofovir alafenamide implants that are safe and maintain high efficacy have the potential to provide long-lasting protection against vaginal HIV infection.

      8. Respiratory syncytial virus among children hospitalized with severe acute respiratory infection in Kashmir, a temperate region in northern India
        Koul PA, Saha S, Kaul KA, Mir H, Potdar V, Chadha M, Iuliano D, Lafond KE, Lal RB, Krishnan A.
        J Glob Health. 2022 ;12.
        Background Severe acute respiratory infections (SARI) are a leading cause of hospitalizations in children, especially due to viral pathogens. We studied the prevalence of respiratory viruses among children aged <5 years hospitalized with severe acute respiratory infections (SARI) in Kashmir, India. Methods We conducted a prospective observational study in two tertiary care hospitals from October 2013 to September 2014, systematically enrolling two children aged <5 years with SARI per day. We defined SARI as history of fever or measured fever (≥38°C) and cough with onset in the last 7 days requiring hospitalization for children aged 3-59 months and as physician-diagnosed acute lower respiratory infection for children aged <3 months. Trained study staff screened children within 24 hours of hospitalization for SARI and collected clinical data and nasopharyngeal swabs from enrolled participants. We tested for respiratory syncytial virus (RSV) A and B, influenza viruses, rhinoviruses (HRV)/enteroviruses, adenovirus (AdV), bocavirus (BoV), human metapneumovirus (hMPV) A and B, coronaviruses (OC43, NL65, C229E), and parainfluenza viruses (PIV) 1, 2, 3 and 4 using standardized duplex real-time polymerase chain reaction. Results Among 4548 respiratory illness admissions screened from October 2013 to September 2014, 1026 met the SARI case definition, and 412 were enrolled (ages = 5 days to 58 months; median = 12 months). Among enrolees, 256 (62%) were positive for any virus; RSV was the most commonly detected (n = 118, 29%) followed by HRV/enteroviruses (n = 88, 21%), PIVs (n = 31, 8%), influenza viruses (n = 18, 4%), BoV (n = 15, 4%), coronaviruses (n = 16, 4%), AdV (n = 14, 3%), and hMPV (n = 9, 2%). Fifty-four children had evidence of virus co-detection. Influenza-associated SARI was more common among children aged 1-5 years (14/18, 78%) while most RSV detections occurred in children <12 months (83/118, 70%). Of the RSV viruses typed (n = 116), the majority were type B (94, 80%). Phylogenetic analysis of G gene of RSV showed circulation of the BA9 genotype with 60bp nucleotide duplication. Conclusions Respiratory viruses, especially RSV, contributed to a substantial proportion of SARI hospitalizations among children <5 years in north India. These data can help guide clinicians on appropriate treatment and prevention strategies. © 2022. The Author(s)

      9. HIV-positive Black and Latino men who have sex with men (MSM) have substantial challenges accessing and engaging in HIV care. Findings presented here are an analysis of 14 HIV-discordant couples (N = 28) from Atlanta, GA; Baltimore, MD; Chicago, IL; Los Angeles, CA; and Washington, DC. One-hour in-depth interviews were conducted. Interviews were analyzed using a qualitative content analysis approach. Most couples reported relationship fears associated with delayed disclosure, HIV care engagement instigated by the HIV-uninfected partner, and varying knowledge and concern about the impacts of HIV infection and risk reduction. Findings suggest an opportunity to jointly educate and treat MSM of color in HIV-discordant relationships to improve engagement in ART and PrEP care and adherence.

      10. Progress toward the elimination of mother-to-child transmission of hepatitis B virus - worldwide, 2016-2021
        Khetsuriani N, Lesi O, Desai S, Armstrong PA, Tohme RA.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 29;71(30):958-963.
        Mother-to-child transmission (MTCT) of hepatitis B virus (HBV) often results in chronic HBV infection, the leading cause of cirrhosis and liver cancer (1). If not vaccinated, nine in 10 children infected at birth will become chronically infected. Globally, an estimated 6.4 million (range = 4.4-10.8 million) children aged ≤5 years are living with chronic HBV infection (2). In 2016, the World Health Assembly endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, including the elimination of MTCT of HBV (3). Elimination of MTCT of HBV can be validated by demonstrating ≤0.1% prevalence of HBV surface antigen (HBsAg) among children aged ≤5 years, as well as ≥90% coverage with hepatitis B birth dose (HepB-BD) and 3 doses of hepatitis B vaccine (HepB3) (4,5). This report describes global progress toward elimination of MTCT of HBV during 2016-2021. By December 2020, 190 (98%) of 194 World Health Organization (WHO) member states* had introduced universal infant vaccination with hepatitis B vaccine (HepB), and 110 (57%) countries provided HepB-BD to all newborns. During 2016-2020, global HepB3 coverage remained between 82% and 85%, whereas HepB-BD coverage increased from 37% to 43%. In 2020, among the 99 countries reporting both HepB3 and HepB-BD coverage, 41 (41%) achieved ≥90% coverage with both. By December 2021, serosurveys documented ≤0.1% HBsAg prevalence among children in 11 countries. Accelerating HepB-BD introduction, increasing HepB3 coverage, and monitoring programmatic and impact indicators are essential for elimination of MTCT of HBV.

      11. Tecovirimat and the treatment of Monkeypox - past, present, and future considerations
        Sherwat A, Brooks JT, Birnkrant D, Kim P.
        N Engl J Med. 2022 Aug 3.

      12. Modeling scenarios for mitigating outbreaks in congregate settings
        Blumberg S, Lu P, Kwan AT, Hoover CM, Lloyd-Smith JO, Sears D, Bertozzi SM, Worden L.
        PLoS Comput Biol. 2022 Jul;18(7):e1010308.
        The explosive outbreaks of COVID-19 seen in congregate settings such as prisons and nursing homes, has highlighted a critical need for effective outbreak prevention and mitigation strategies for these settings. Here we consider how different types of control interventions impact the expected number of symptomatic infections due to outbreaks. Introduction of disease into the resident population from the community is modeled as a stochastic point process coupled to a branching process, while spread between residents is modeled via a deterministic compartmental model that accounts for depletion of susceptible individuals. Control is modeled as a proportional decrease in the number of susceptible residents, the reproduction number, and/or the proportion of symptomatic infections. This permits a range of assumptions about the density dependence of transmission and modes of protection by vaccination, depopulation and other types of control. We find that vaccination or depopulation can have a greater than linear effect on the expected number of cases. For example, assuming a reproduction number of 3.0 with density-dependent transmission, we find that preemptively reducing the size of the susceptible population by 20% reduced overall disease burden by 47%. In some circumstances, it may be possible to reduce the risk and burden of disease outbreaks by optimizing the way a group of residents are apportioned into distinct residential units. The optimal apportionment may be different depending on whether the goal is to reduce the probability of an outbreak occurring, or the expected number of cases from outbreak dynamics. In other circumstances there may be an opportunity to implement reactive disease control measures in which the number of susceptible individuals is rapidly reduced once an outbreak has been detected to occur. Reactive control is most effective when the reproduction number is not too high, and there is minimal delay in implementing control. We highlight the California state prison system as an example for how these findings provide a quantitative framework for understanding disease transmission in congregate settings. Our approach and accompanying interactive website (https://phoebelu.shinyapps.io/DepopulationModels/) provides a quantitative framework to evaluate the potential impact of policy decisions governing infection control in outbreak settings.

      13. Progress towards the UNAIDS 95-95-95 targets among pregnant women in South Africa: Results from the 2017 and 2019 national Antenatal HIV Sentinel Surveys
        Woldesenbet S, Cheyip M, Lombard C, Manda S, Ayalew K, Kufa T, Puren A.
        PLoS One. 2022 ;17(7):e0271564.
        OBJECTIVES: The UNAIDS 95-95-95 global targets for epidemic control aim to ensure by 2030 that 95% of HIV-positive people know their HIV status, 95% of people diagnosed with HIV receive sustained antiretroviral therapy (ART), and 95% of people on ART have viral suppression. While data on the first and second 95 targets are routinely reported nationally, data on the third 95 target are not available for pregnant women in South Africa. The lack of data on the third 95 target limits the inclusion of low viral suppression as one of the contributing factors in MTCT root cause analyses. This study assessed progress towards the 95-95-95 targets among pregnant women between the ages of 15-49 years attending public health facilities in South Africa. METHOD: Data were obtained from two consecutive national cross-sectional antenatal HIV sentinel surveys conducted between 1 October and 15 November in both 2017 and 2019. In each survey, data on age, knowledge of HIV status, ART initiation, and geographical location (province) were extracted from medical records. A blood specimen was collected from each woman and tested for HIV. Viral load tests were performed on HIV-positive specimens. Descriptive and multiple logistic regression analyses were performed to examine association between province and viral suppression (defined as viral load <50 copies/mL) using the combined dataset (i.e., both 2017 and 2019 data combined). All analyses considered the survey design. RESULTS: Of 10 065 and 11 321 HIV-positive women included in the 2017 and 2019 surveys, respectively, 96.0% (95% confidence interval (CI): 95.6-96.4%) and 97.6% (95% CI: 97.3-97.8%) knew their HIV-positive status; 86.6% (95% CI: 85.9-87.3%) and 96.0% (95% CI: 95.6-96.4%) of those who knew their HIV status were receiving ART; while 64.2% (95% CI: 63.2-65.2%) and 66.0% (95% CI: 65.1-66.8%) of those receiving ART were virally suppressed. Achievement of the third 95 target significantly varied by province ranging from 33.9-72.6% in 2017 and 43.4-77.3% in 2019. Knowledge of HIV-positive status, ART initiation, and viral suppression increased in both 15-24 and 25-49 year age groups between 2017 and 2019. In a multivariable analysis adjusting for survey year, gravidity, and education, the odds of viral suppression significantly varied by province (except KwaZulu-Natal and Western Cape, other provinces were less likely to attain viral suppression compared to Gauteng), age (adjusted odds ratio (AOR) for 15-24 years vs 25-49 years: 0.7, 95% CI: 0.6-0.8), and timing of ART initiation (AOR for ART initiation during pregnancy vs before pregnancy: 0.4, 95% CI: 0.5-0.6). CONCLUSION: Although in 2019 the first and second 95 targets were achieved among pregnant women, meeting the third 95 target remains a challenge. This study highlighted the importance of promoting early ART initiation and the need to target young women in efforts to improve progress towards the third 95 target. Additionally, the provincial variation in viral suppression could be further investigated in future studies to identify and address the root causes underlying these differences.

      14. Creating a path forward: understanding the context of sexual health and sexually transmitted infections in American Indian/Alaska Native populations - a review
        Leston J, Wenger H, Reilley B, Craig Rushing S, Rink E, Warren H, Howe J, Bloomquist P, Tah T, Jeffries I, Iralu J, Thorpe P, Apostolou A, Taylor MM.
        Sex Health. 2022 Jun 28.
        This review assessed sexual health and sexually transmitted infection (STI) burden among American Indian/Alaska Native (AI/AN) peoples within the context of current clinical and public health services. We conducted a review of published literature about sexual health and bacterial STIs among AI/AN populations in the United States using Medline (OVID), CINAHL (EbscoHost) and Scopus. Peer-reviewed journals published during 1 January 2005-2 December 2021 were included and supplemented by other publicly available literature. A total of 138 articles from reference lists met inclusion criteria, including 85 peer-review articles and 53 additional references. Results indicate a disproportionate burden of STIs is carried by AI/AN populations compared to non-Hispanic Whites. Risk for STIs in AI/AN people has origins in historical trauma and structural and social determinants of health. STI services are available for AI/AN populations, but many barriers to care exist. Community-based sexual health programming has been successful, but has thus far focused primarily on adolescents and young adults. A myriad of factors contributes to high rates of STIs among AI/AN populations. Longstanding disparities show a clear need to increase the availability of integrated, low-barrier STI prevention and treatment services. Implementation of multi-level (individual, physician, clinic, healthcare organisation, and/or community level), culturally relevant sexual health and STI interventions should be community-based and person-centred, acknowledge social determinants of health, and grounded in deep respect and understanding of AI/AN histories and cultures.

      15. Effect of screening and treatment for gonorrhea and chlamydia on HIV incidence among men who have sex with men in the United States: A modeling analysis
        Jones J, Le Guillou A, Gift TL, Chesson H, Bernstein K, Delaney K, Lyles C, Berruti A, Sullivan PS, Jenness SM.
        Sex Transm Dis. 2022 Jul 28.
        BACKGROUND: Previous models have estimated the total population attributable fraction of NG/CT on HIV incidence among men who have sex with men (MSM), but this does not represent realistic intervention effects. We estimated the potential impact of screening for NG/CT on downstream incidence of HIV among MSM. METHODS: Using a network model, we estimated the effects of varying coverage levels for STI screening among different priority populations: all sexually active MSM regardless of HIV serostatus, MSM with multiple recent (past 6 months) sex partners regardless of serostatus, MSM without HIV, and MSM with HIV. Under the assumption that all screening events included a urethral test, we also examined the effect of increasing of the proportion of screening events that include rectal screening for NG/CT on HIV incidence. RESULTS: Increasing annual NG/CT screening among sexually active MSM by 60% averted 4.7% of HIV infections over a 10-year period (interquartile range (IQR): 2.3, 7.3). More HIV infections were averted when screening was focused on MSM with multiple recent sex partners: 60% coverage among MSM with multiple recent sex partners averted 9.8% of HIV infections (IQR: 8.1, 11.6). Increased STI screening among MSM without HIV averted more new HIV infections compared to the transmissions averted due to screening MSM with HIV, but fewer NG/CT tests were needed among MSM with HIV to avert a single new HIV infection. CONCLUSIONS: NG/CT screening among MSM is expected to lead to modest but clinically relevant reductions in HIV incidence among MSM.

    • Community Health Services
      1. OBJECTIVE: Research underscores the importance of providers having routine discussions with patients about their sexual health. We examined the occurrences and association of routine sexual health discussion practices and human immunodeficiency virus (HIV) clinical care among primary care providers (PCPs) in areas with high HIV prevalence. METHODS: We analysed data collected between April and August 2017 from an online survey that assessed PCPs knowledge, behaviours, attitudes, and practices of HIV-related care in 6 Southeast US jurisdictions (Atlanta, Baltimore, Baton Rouge, District of Columbia, Miami, and New Orleans). RESULTS: Among PCPs, we found that 39.2% routinely obtained sexual health histories, 78.5% offered HIV testing, and 16.0% ever prescribed preexposure prophylaxis (PrEP). Based on adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), the proportion of PCPs who routinely obtained sexual histories was higher among female PCPs (aPR = 1.47, 95% CI 1.04, 2.08), PCPs who had a patient population that was >50% men who have sex with men (MSM) (aPR = 1.94, 95% CI 1.72, 2.18), offered HIV testing (aPR = 3.60, 95% CI 2.23, 5.79), and ever prescribed PrEP (aPR = 1.43, 95% CI 1.06, 1.93). CONCLUSION: Improving patient-provider discussions are needed to reduce HIV-related service barriers for disproportionately affected populations. PRACTICE IMPLICATIONS: Routine discussions can reduce barriers to important HIV prevention and care services and help reduce disparities among patients living in highly prevalent HIV locations.

      2. A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam
        Pollack TM, Duong HT, Nhat Vinh DT, Phuong DT, Thuy DH, Nhung VT, Uyen NK, Linh VT, Van Truong N, Le Ai KA, Ninh NT, Nguyen A, Canh HD, Cosimi LA.
        J Int AIDS Soc. 2022 Jul;25 Suppl 1(Suppl 1):e25932.
        INTRODUCTION: Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi-pronged facility-level intervention to reduce stigma and discrimination at health facilities across three high-burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities. METHODS: From July 2018 to July 2019, we assessed HIV-related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross-sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi-square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention. RESULTS: Semi-structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self-stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p-values <0.05). Among HCWs, 672 completed the pre- and post-intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p-values <0.05). CONCLUSIONS: A multi-pronged facility-level intervention was successful at reducing healthcare-associated HIV-related stigma in Vietnam. The findings support the scale-up of this intervention in Vietnam and highlight key components potentially applicable in other settings.

      3. INTRODUCTION: Outside of pandemics, there is little information about occurrence of prolonged unplanned K-12 school closures (PUSC). We describe here the reasons, characteristics, and patterns of PUSC in the United States during 8 consecutive inter-pandemic academic years, 2011-2019. METHODS: From August 1, 2011 through June 30, 2019, daily systematic online searches were conducted to collect data on publicly announced unplanned school closures lasting ≥1 school days in the United States. Closures were categorized as prolonged when schools were closed for ≥5 unplanned days (approximating one full workweek), excluding weekends and scheduled days off per school calendars. RESULTS: During the eight academic years, a total of 22,112 PUSCs were identified, affecting over 800,000 teachers and 13 million students that resulted in 91.5 million student-days lost. A median of 62.9% of students in PUSC-affected schools were eligible for subsidized school meals. Most affected schools were in cities (35%) and suburban areas (33%). Natural disasters (47%), adverse weather conditions (35%), and budget/teacher strikes (15%) were the most frequently cited reasons for PUSC; illness accounted for 1%, and building/facility issues, environmental issues and violence together accounted for the remaining 2%. The highest number of PUSCs occurred in Health and Human Services Regions 2, 3, 4, and 6 encompassing areas that are frequently in the path of hurricanes and tropical storms. The majority of PUSCs in these regions were attributed to a handful of hurricanes during the fall season, including hurricanes Sandy, Irma, Harvey, Florence, and Matthew. CONCLUSIONS: PUSCs occur annually in the United States due to a variety of causes and are associated with a substantive loss of student-days for in-school learning. Both these prior experiences with PUSCs and those during the current COVID-19 pandemic illustrate a need for creating sustainable solutions for high-quality distance learning and innovative supplemental feeding programs nationwide, especially in disaster-prone areas.

    • Disaster Preparedness and Emergency Services
      1. Tracking hurricane-related deaths in the contiguous United States using media reports from 2012 to 2020
        Williams S, Jiva S, Hanchey A, Suárez-Soto RJ, Bayleyegn T, Schnall AH.
        Disaster Med Public Health Prep. 2022 Jul 28:1-6.
        Heavy rainfall, storm surges, and tornadoes are hazards associated with hurricanes that can cause property damages and loss of life. Disaster-related mortality surveillance encounters challenges, such as timely reporting of mortality data. This review demonstrates how tracking hurricane-related deaths using online media reports (eg, news media articles, press releases, social media posts) can enhance mortality surveillance during a response. The Centers for Disease Control and Prevention used online media reports from 2012 to 2020 to characterize hurricane-related deaths from 10 hurricanes that were declared major disasters and the flooding related to Hurricane Joaquin in the contiguous United States. Media reports showed that drowning (n = 139), blunt force trauma (n = 89), and carbon monoxide poisoning (n = 58) were the primary causes of death. Online media and social media reports are not official records. However, media mortality surveillance is useful for hurricane responses to target messaging and current incident decision-making.

    • Environmental Health
      1. Longitudinal changes in maternal serum concentrations of per- and polyfluoroalkyl substances from pregnancy to two years postpartum
        Oh J, Bennett DH, Tancredi DJ, Calafat AM, Schmidt RJ, Hertz-Picciotto I, Shin HM.
        Environ Sci Technol. 2022 Jul 29.
        Exposure to per- and polyfluoroalkyl substances (PFAS) during pregnancy and lactation is of increasing public health concern, but little is known about longitudinal changes in maternal PFAS concentrations from pregnancy to a few years postpartum. We quantified 11 PFAS in 251 serum samples prospectively collected from 42 Northern California mothers during the first, second, and third trimesters of pregnancy and at 3, 6, and 24 months after delivery over 2009-2017. We fit separate linear mixed models during pregnancy, early postpartum, and late postpartum to estimate percent changes of PFAS for each subperiod. Among five PFAS detected in more than 99% of samples, linear and branched perfluorooctanesulfonate (n- and Sm-PFOS), linear perfluorooctanoate (n-PFOA), and perfluorononanoate (PFNA) concentrations changed -4% to -3% per month during pregnancy. During early postpartum, perfluorohexanesulfonate (PFHxS) and n-PFOA concentrations changed -6% and -5%, respectively, per month, and Sm-PFOS and PFNA concentrations changed -1% per month. During late postpartum, n-PFOS, Sm-PFOS, and PFNA concentrations changed -1% per month. Breastfeeding duration was the primary determinant of n-PFOA and PFNA concentrations during late postpartum, showing negative associations. Our findings might be useful for reconstructing reliable prenatal or early life PFAS exposures for offspring.

      2. Mycobiota and the contribution of yeasts in floor dust of 50 elementary schools characterized with sequencing internal transcribed spacer region of ribosomal DNA
        Park JH, Lemons AR, Croston TL, Park Y, Roseman J, Green BJ, Cox-Ganser JM.
        Environ Sci Technol. 2022 Jul 28.
        The assemblage of fungi including unicellular yeasts in schools is understudied. We conducted an environmental study to characterize fungal communities in classroom floor dust. We collected 500 samples from 50 elementary schools in Philadelphia, PA, and evaluated room dampness/mold conditions. Genomic DNA from dust was extracted for internal transcribed spacer 1 Illumina MiSeq sequencing to identify operational taxonomic units (OTUs) organized from DNA sequences. Differential abundance analyses were performed to examine significant differences in abundance among groups. We identified 724 genera from 1490 OTUs. The genus Epicoccum was not diverse but the most abundant (relative abundance = 18.9%). Fungi were less diverse but most dissimilar in composition in the most water-damaged classrooms compared to the least water-damaged, indicating differential effects of individual classroom water-damage on fungal compositions. We identified 62 yeast genera, representing 19.6% of DNA sequences. Cyberlindnera was the most abundant (6.1%), followed by Cryptococcus, Aureobasidium, Rhodotorula, and Candida. The average relative abundance of yeasts tended to increase with increasing dampness and mold score and was significantly (p-value = 0.048) higher in the most water-damaged classrooms (22.4%) than the least water-damaged classrooms (18.2%). Our study suggests the need for further research on the potential health effects associated with exposures to yeasts in schools.

    • Epidemiology and Surveillance
      1. Generalized Linear Mixed Model (GLMM) has been widely used in small area estimation for health indicators. Bayesian estimation is usually used to construct statistical intervals, however, its computational intensity is a big challenge for large complex surveys. Frequentist approaches, such as bootstrapping, and Monte Carlo (MC) simulation, are also applied but not evaluated in terms of the interval magnitude, width, and the computational time consumed. The 2013 Florida Behavioral Risk Factor Surveillance System data was used as a case study. County-level estimated prevalence of three health-related outcomes was obtained through a GLMM; and their 95% confidence intervals (CIs) were generated from bootstrapping and MC simulation. The intervals were compared to 95% credential intervals through a hierarchial Bayesian model. The results showed that 95% CIs for county-level estimates of each outcome by using MC simulation were similar to the 95% credible intervals generated by Bayesian estimation and were the most computationally efficient. It could be a viable option for constructing statistical intervals for small area estimation in public health practice.

      2. Mobile tablets for real-time data collection for hospital-based birth defects surveillance in Kampala, Uganda: Lessons learned
        Kalibbala D, Kakande A, Serunjogi R, Williamson D, Mumpe-Mwanja D, Namale-Matovu J, Valencia D, Nalwoga B, Namirembe C, Seyionga J, Nanfuka M, Nakimuli S, Achom MO, Mwambi K, Musoke P, Barlow-Mosha L.
        PLOS Glob Public Health. 2022 Jun 24;2(6).
        Sustainable birth defects surveillance systems provide countries with estimates of the prevalence of birth defects to guide prevention, care activities, and evaluate interventions. We used free and open-source software (Open Data Kit) to implement an electronic system to collect data for a hospital-based birth defects surveillance system at four major hospitals in Kampala, Uganda. We describe the establishment, successes, challenges, and lessons learned from using mobile tablets to capture data and photographs. After intensive training, surveillance midwives collected data using Android tablets with inbuilt logic checks; another surveillance midwife checked the quality of the data in real-time before data were securely uploaded onto a local server. Paper forms were used when needed as a backup for the electronic system. We experienced several challenges implementing the surveillance system, including forgotten passwords, unstable network, reduced tablet speed and freezing, loss of touch-screen sensitivity, decreased battery strength, and repetitive extensive retraining. We addressed these challenges by backing up and removing all photos from the tablet, uninstalling irrelevant applications to the study to increase storage space and speed, and monitoring and updating the system based mainly on feedback from the midwives. From August 2015 to December 2018, surveillance midwives documented information on 110,752 births at the participating hospitals. Of these, 110,573 (99.8%) were directly entered into the electronic data system and 179 (0.2%) were captured on paper forms. The use of mobile tablets for real-time data collection was successful in a hospital-based birth defects surveillance system in a resource-limited setting. Extensive training and follow-up can overcome challenges and are key to preparing staff for a successful data collection system.

    • Food Safety
      1. A multiple-serotype outbreak of Salmonella infections linked to kratom, United States, 2017-2018
        Schwensohn C, Nsubuga J, Cronquist L, Jose G, Mastel L, McCullough L, Smith L, Powell M, Booth H, Allen K, Classon A, Gieraltowski L.
        Foodborne Pathog Dis. 2022 Aug 1.
        In early 2018, we investigated a large national multiple-serotype Salmonella outbreak linked to contaminated kratom, a raw minimally processed botanical substance. Kratom is a plant consumed for its stimulant effects and as an opioid substitute. A case was defined as a laboratory-confirmed Salmonella infection with one of the outbreak strains (serotypes I 4,[5],12:b:-, Heidelberg, Javiana, Okatie, Weltevreden, or Thompson) with illnesses onset during January 11, 2017-May 8, 2018. State and local officials collected detailed information on product consumption and sources. Suspected products were tested for Salmonella and traceback was conducted to determine product distribution chains and suppliers. We identified 199 cases from 41 states; 54 patients were hospitalized. Early interviews indicated kratom was an exposure of interest. Seventy-six (74%) of 103 people interviewed reported consuming kratom in pills, powders, or teas. Multiple serotypes of Salmonella were detected in samples of kratom collected from the homes of the patients and from retail locations. Several companies issued recalls of kratom products due to Salmonella contamination. To the authors' knowledge, this investigation is the first to establish kratom as a vehicle for Salmonella infection. Our findings underscore the serious safety concerns regarding minimally processed botanical substances intended for oral consumption and the challenges in investigating outbreaks linked to novel outbreak vehicles.

    • Global Health
      1. Thinking about differences in the worldwide prevalence of cerebral palsy
        Paneth N, Yeargin-Allsopp M.
        Dev Med Child Neurol. 2022 Jul 28.

      2. Imported Monkeypox from international traveler, Maryland, USA, 2021
        Minhaj FS, Rao AK, McCollum AM.
        Emerg Infect Dis. 2022 Aug;28(8):1738.

      3. Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases.

      4. Low risk of acquiring melioidosis from the environment in the continental United States
        Hall CM, Romero-Alvarez D, Martz M, Santana-Propper E, Versluis L, Jiménez L, Alkishe A, Busch JD, Maness T, Stewart J, Sidwa T, Gee JE, Elrod MG, Weiner Z, Hoffmaster AR, Sahl JW, Salzer JS, Peterson AT, Kieffer A, Wagner DM.
        PLoS One. 2022 ;17(7):e0270997.
        Melioidosis is an underreported human disease of tropical and sub-tropical regions caused by the saprophyte Burkholderia pseudomallei. Although most global melioidosis cases are reported from tropical regions in Southeast Asia and northern Australia, there are multiple occurrences from sub-tropical regions, including the United States (U.S.). Most melioidosis cases reported from the continental U.S. are the result of acquiring the disease during travel to endemic regions or from contaminated imported materials. Only two human melioidosis cases from the continental U.S. have likely acquired B. pseudomallei directly from local environments and these cases lived only ~7 km from each other in rural Texas. In this study, we assessed the risk of acquiring melioidosis from the environment within the continental U.S. by surveying for B. pseudomallei in the environment in Texas where these two human melioidosis cases likely acquired their infections. We sampled the environment near the homes of the two cases and at additional sampling locations in surrounding counties in Texas that were selected based on ecological niche modeling. B. pseudomallei was not detected at the residences of these two cases or in the surrounding region. These negative data are important to demonstrate that B. pseudomallei is rare in the environment in the U.S. even at locations where locally acquired human cases likely have occurred, documenting the low risk of acquiring B. pseudomallei infection from the environment in the continental U.S.

    • Health Economics
      1. Maximizing the impact of voluntary medical male circumcision for HIV prevention in Zambia by targeting high-risk men: A pre/post program evaluation
        Lukobo-Durrell M, Aladesanmi L, Suraratdecha C, Laube C, Grund J, Mohan D, Kabila M, Kaira F, Habel M, Hines JZ, Mtonga H, Chituwo O, Conkling M, Chipimo PJ, Kachimba J, Toledo C.
        AIDS Behav. 2022 Jul 28.
        A well-documented barrier to voluntary medical male circumcision (VMMC) is financial loss due to the missed opportunity to work while undergoing and recovering from VMMC. We implemented a 2-phased outcome evaluation to explore how enhanced demand creation and financial compensation equivalent to 3 days of missed work influence uptake of VMMC among men at high risk of HIV exposure in Zambia. In Phase 1, we implemented human-centered design-informed interpersonal communication. In Phase 2, financial compensation of ZMW 200 (~ US$17) was added. The proportion of men undergoing circumcision was significantly higher in Phase 2 compared to Phase 1 (38% vs 3%). The cost of demand creation and compensation per client circumcised was $151.54 in Phase 1 and $34.93 in Phase 2. Financial compensation is a cost-effective strategy for increasing VMMC uptake among high-risk men in Zambia, and VMMC programs may consider similar interventions suited to their context.

      2. Cost of cigarette smoking‒attributable productivity losses, U.S., 2018
        Shrestha SS, Ghimire R, Wang X, Trivers KF, Homa DM, Armour BS.
        Am J Prev Med. 2022 Jul 27.
        INTRODUCTION: Information on morbidity-related productivity losses attributable to cigarette smoking, an important component of the economic burden of cigarette smoking, is limited. This study fills this gap by estimating these costs in the U.S. and by state. METHODS: A human capital approach was used to estimate the cost of the morbidity-related productivity losses (absenteeism, presenteeism, household productivity, and inability to work) attributable to cigarette smoking among adults aged ≥18 years in the U.S. and by state. A combination of data, including the 2014-2018 National Health Interview Survey, 2018 Current Population Survey Annual Social and Economic Supplement, 2018 Behavioral Risk Factor Surveillance System, 2018 value of daily housework, and literature-based estimate of lost productivity while at work (presenteeism), was used. Costs were estimated for 2018, and all analyses were conducted in 2021. RESULTS: Estimated total cost of morbidity-related productivity losses attributable to cigarette smoking in the U.S. in 2018 was $184.9 billion. Absenteeism, presenteeism, home productivity, and the inability to work accounted for $9.4 billion, $46.8 billion, $12.8 billion, and $116.0 billion, respectively. State-level total costs ranged from $291 million to $16.9 billion with a median cost of $2.7 billion. CONCLUSIONS: The cost of morbidity-related productivity losses attributable to cigarette smoking in the U.S. and in each state was substantial in 2018 and varied across the states. These estimates can guide public health policymakers and practitioners planning and evaluating interventions designed to alleviate the burden of cigarette smoking at the state and national levels.

    • Health Equity and Health Disparities
      1. Causes of death among individuals with systemic lupus erythematosus by race and ethnicity: a population-based study
        Taylor T, Anastasiou C, Ja C, Rush S, Trupin L, Dall'Era M, Katz P, Barbour KE, Greenlund KJ, Yazdany J, Gianfrancesco MA.
        Arthritis Care Res (Hoboken). 2022 Jul 29.
        OBJECTIVE: Non-white populations are at higher risk of developing systemic lupus erythematosus (SLE) and have more severe outcomes, including mortality. How specific causes of death vary by race and ethnicity has largely been unexplored, particularly for Asian and Hispanic individuals. METHODS: The California Lupus Surveillance Project included SLE cases identified among residents of San Francisco County, CA during January 1, 2007-December 31, 2009. Cases were matched to the National Death Index over a ten-year period. Logistic regression examined age-adjusted differences in causes of death by race, ethnicity, and sex. Age-standardized mortality ratios (SMRs) between individuals with SLE and the corresponding general population were calculated for the leading cause of death, and observed versus expected deaths were estimated. RESULTS: The study included 812 individuals of White (38%), Asian (36%), Black (20%), and mixed/other/unknown (5%) race; 15% identified as Hispanic. 135 deaths were recorded, with mean age at death of 62.2 (+/- 15.6) years. Cardiovascular disease (CVD) was the leading cause of death overall (33%), and across all racial and ethnic groups, followed by rheumatic disease (18%) and hematological/oncological conditions (18%). CVD as the underlying cause of death was 3.63 times higher among SLE cases than in the general population. CVD deaths for those with SLE were nearly four and six times higher for Asian and Hispanic individuals with SLE, respectively, compared to the general population. CONCLUSION: Individuals with SLE experience a disproportionate burden of CVD mortality compared to the general population, which is magnified for Asian and Hispanic groups.

      2. Determinants of colorectal cancer screening among South Asian Americans
        Mukherjea A, Shariff-Marco S, Yang J, Tseng W, Palaniappan L, Li J, Ivey SL, Somsouk M, Gomez SL.
        J Asian Health. 2022 Apr;10(e202202):1-12.
        BACKGROUND: Colorectal cancer screening rates among South Asian Americans are among the lowest of US population groups. Few population-based studies have examined determinants of screening in this population. The purpose of this study was to identify factors associated with colorectal cancer screening among South Asian Americans. METHODS: Data from the 2001-2009 California Health Interview Survey and multivariable logistic regression were used to examine determinants of being non-adherent with colorectal cancer screening recommendations. Independent variables include sociodemographic and healthcare access measures. RESULTS: Overall, 49% of 459 South Asian Americans were non-adherent to screening recommendations. Characteristics associated with non-adherence were the absence of flu shot, absence of doctor visits, sole use of non-English language at home and ≤40% life spent in the United States. In the multivariable model, screening non-adherence was associated with ≤40% life in the United States (odds ratio [95% confidence interval] 3.0 [1.4-6.5]), use of non-English at home (2.8 [1.0-7.8]) and no flu shot (2.5 [1.3-4.8]). Obese (BMI > 27.5 kg/m2) versus normal-weight patients were less likely to be non-adherent (0.4 [0.2-0.9]). CONCLUSIONS: Length of time in the United States and language spoken at home rather than English proficiency were associated with non-adherence to colorectal cancer screening, reflecting the importance of acculturation and retention of cultural values. Health conditions and behaviors reflecting more proactive healthcare utilization may reinforce the importance of provider recommendations and perceived efficacy of health prevention. Qualitative research would inform cultural tailoring necessary to improve colorectal cancer screening rates among the rapidly growing South Asian American population.

      3. Health equity guiding frameworks and indices in injury: A review of the literature
        Lennon NH, Carmichael AE, Qualters JR.
        J of Safety Res. 2022 .
        Background: In early 2021, CDC released the CORE Health Equity Strategy, which resolves to integrate a comprehensive health equity approach to the work of the Agency. One priority of the Injury Center's Division of Injury Prevention is to move health equity research in injury forward. The purpose of this research is to perform an initial exploration of health equity guiding frameworks and indices to better understand which of these has been applied to injury research topics. Methods: A PubMed and CINAHL search of meta-analysis and systematic review articles was conducted from January 1998 through April 2022. Articles of any type and additional frameworks/indices were also identified from staff knowledge of the literature. Books were also considered, where accessible. The following areas were reviewed for each resource: population addressed, guiding framework/index, other health equity variables, gaps identified, and whether the articles addressed an injury topic. Findings: The PubMed/CINAHL search produced 230 articles, and an additional 29 articles and 8 books were added from previous knowledge of the literature, resulting in a total of 267 resources for review. There were 60 frameworks/indices compiled that were relevant to health equity. Out of all the resources, three reported on an injury topic and used the PROGRESS-Plus framework, the WHO Social Determinants of Health Conceptual Framework, and a social-ecological framework. Conclusions: This study found there were many frameworks/indices for measuring health equity; however, there were few injury-related meta-analysis and systematic review articles. Some frameworks/indices may be more appropriate than others for measuring health equity in injury topic areas, depending on which social determinants of health (SDOHs) they address. Practical Applications: Measuring health equity in injury and other public health research areas can help build a foundation of evidence. Moving forward, injury researchers can consider the frameworks/indices identified through this study in their health equity injury research. © 2022

      4. High HIV prevalence and associated factors in Lesotho: Results from a population-based survey
        Schwitters A, McCracken S, Frederix K, Tierney R, Koto M, Ahmed N, Thin K, Dobbs T, Sithole S, Letsie M, Parekh B, Patel H, Birhanu S, Wiesner L, Low A.
        PLoS One. 2022 ;17(7):e0271431.
        Despite extensive global efforts, sub-Saharan Africa remains disproportionately affected by the HIV epidemic. This generalized epidemic can be seen in Lesotho which in 2014 the HIV prevalence rate of those aged 15-49 years was 24.6%, with and incidence of 1.9 new infections per 100-person-year exposures. To better understand the impact of Lesotho's national HIV response and significant predictors associated with HIV infection, the Lesotho Population-based HIV Impact Assessment was conducted. This survey provided a nationally representative sample of individuals aged 15-59 years old in which participants were tested for HIV and given an individual questionnaire that included socio-demographic and behavioral risk questions. The association of factors between survey questions and HIV incident was assessed using logistic regression. Multivariate logistic regression models for men and women were constructed for each outcome using variables known to be or plausibly associated with recent or chronic infection. Overall annualized incidence among people aged 15-49 was 1.19% (95% CI 0.73-1.65) per year. The overall prevalence of HIV was 25.6% with women having significantly higher prevalence. Multiple variables, including decreased wealth status, lower education levels, marital status, condom use at first sex, and circumcision (men only) were identified as being significantly associated with HIV infection for both men and women. In combination with improving the awareness of HIV status, an increased focus is needed on AGYW and men 35-49 years old to prevent new infections. HIV education and prevention programs should focus heavily on younger age groups prior to and soon after sexual debut to prevent HIV transmission. The findings of the survey showed significant room for improvement in increasing awareness of HIV status and reinforcing the need for continued HIV prevention and treatment efforts in Lesotho to prevent new infections.

    • Healthcare Associated Infections
      1. Carbapenem-Resistant enterobacterales in individuals with and without health care risk factors -Emerging infections program, United States, 2012-2015
        Bulens SN, Reses HE, Ansari UA, Grass JE, Carmon C, Albrecht V, Lawsin A, McAllister G, Daniels J, Lee YK, Yi S, See I, Jacob JT, Bower CW, Wilson L, Vaeth E, Lynfield R, Vagnone PS, Shaw KM, Dumyati G, Tsay R, Phipps EC, Bamberg W, Janelle SJ, Beldavs ZG, Cassidy PM, Kainer M, Muleta D, Mounsey JT, Laufer-Halpin A, Karlsson M, Lutgring JD, Walters MS.
        Am J Infect Control. 2022 May 25.
        BACKGROUND: Carbapenem-resistant Enterobacterales (CRE) are usually healthcare-associated but are also emerging in the community. METHODS: Active, population-based surveillance was conducted to identify case-patients with cultures positive for Enterobacterales not susceptible to a carbapenem (excluding ertapenem) and resistant to all third-generation cephalosporins tested at 8 US sites from January 2012 to December 2015. Medical records were used to classify cases as health care-associated, or as community-associated (CA) if a patient had no known health care risk factors and a culture was collected <3 days after hospital admission. Enterobacterales isolates from selected cases were submitted to CDC for whole genome sequencing. RESULTS: We identified 1499 CRE cases in 1194 case-patients; 149 cases (10%) in 139 case-patients were CA. The incidence of CRE cases per 100,000 population was 2.96 (95% CI: 2.81, 3.11) overall and 0.29 (95% CI: 0.25, 0.35) for CA-CRE. Most CA-CRE cases were in White persons (73%), females (84%) and identified from urine cultures (98%). Among the 12 sequenced CA-CRE isolates, 5 (42%) harbored a carbapenemase gene. CONCLUSIONS: Ten percent of CRE cases were CA; some isolates from CA-CRE cases harbored carbapenemase genes. Continued CRE surveillance in the community is critical to monitor emergence outside of traditional health care settings.

    • Immunity and Immunization
      1. Influenza vaccination coverage among Medicare fee-for-service beneficiaries
        Tsai Y, Singleton JA, Razzaghi H.
        Am J Prev Med. 2022 Jul 26.
        INTRODUCTION: Influenza vaccination is the best prevention strategy to protect against influenza infection. Determining accurate influenza vaccination coverage is critical. This study assesses the concordance between self-reported and claimed-based influenza vaccination coverage and examines vaccination disparities in the U.S. METHODS: Data from the 2016-2019 Medicare Current Beneficiary Survey linked to survey participants' influenza vaccination claims were analyzed in 2022. The study population included survey participants aged ≥65 years and enrolled in a Medicare fee-for-service plan. Sensitivity, specificity, kappa statistics, and net bias (the difference between the estimated vaccination coverage based on survey and claims data) were reported. Associations between receipt of influenza vaccine and beneficiaries' characteristics and sex, racial and ethnic, and urban‒rural disparities in influenza vaccination were examined using logistic regressions. RESULTS: The analysis included 20,854 beneficiaries. Claimed-based vaccination coverage was 60.0%, and survey-based coverage was 76.3%. The net bias was 16.3 percentage points, and kappa statistic indicated moderate data agreement. The sensitivity of self-reported influenza vaccination was 98.7%, and the specificity was 57.4%. Net bias was high among male, non-Hispanic Black and Hispanic beneficiaries, and rural residents. Sex, racial and ethnic, and urban‒rural disparities in influenza vaccination were noticeably smaller according to the survey than claims data. CONCLUSIONS: The level of data agreement differed by beneficiaries' characteristics and was low among males, racial and ethnic minority groups, and rural residents.

      2. Factors associated with delayed or missed second-dose mRNA COVID-19 vaccination among persons >12 years of age, United States
        Meng L, Murthy NC, Murthy BP, Zell E, Saelee R, Irving M, Fast HE, Roman PC, Schiller A, Shaw L, Black CL, Gibbs-Scharf L, Harris L, Chorba T.
        Emerg Infect Dis. 2022 Aug;28(8):1633-1641.
        To identify demographic factors associated with delaying or not receiving a second dose of the 2-dose primary mRNA COVID-19 vaccine series, we matched 323 million single Pfizer-BioNTech (https://www.pfizer.com) and Moderna (https://www.modernatx.com) COVID-19 vaccine administration records from 2021 and determined whether second doses were delayed or missed. We used 2 sets of logistic regression models to examine associated factors. Overall, 87.3% of recipients received a timely second dose (≤42 days between first and second dose), 3.4% received a delayed second dose (>42 days between first and second dose), and 9.4% missed the second dose. Persons more likely to have delayed or missed the second dose belonged to several racial/ethnic minority groups, were 18-39 years of age, lived in more socially vulnerable areas, and lived in regions other than the northeastern United States. Logistic regression models identified specific subgroups for providing outreach and encouragement to receive subsequent doses on time.

      3. HPV type-specific trends in cervical precancers in the United States, 2008-2016
        Gargano JW, McClung N, Lewis RM, Park IU, Whitney E, Castilho JL, Pemmaraju M, Niccolai LM, Brackney M, Debess E, Ehlers S, Bennett NM, Scahill M, Cleveland AA, Querec TD, Unger ER, Markowitz LE.
        Int J Cancer. 2022 Jul 29.
        Declines in cervical intraepithelial neoplasia grades 2-3 and adenocarcinoma in situ (CIN2+) observed among young women suggest impact from human papillomavirus (HPV) vaccination. To further evaluate vaccine impact including cross-protection and type replacement, we described high-risk (HR)-HPV type-specific cervical precancer incidence rates among women aged 20-39 years, 2008-2016. We analyzed cross-sectional population-based data on 18,344 cases of CIN2+ from a 5-site surveillance system. Diagnostic specimens were tested for individual HPV types, including 14 HR-HPV types (HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68). We estimated age-specific annual HR-HPV type-specific CIN2+ incidence per 100,000 screened women for individual types, vaccine HR-HPV types (HPV16/18) and non-vaccine HR-HPV types (non-HPV16/18). We evaluated trends using average annual percent changes (AAPC) and 95% confidence intervals (CI), and estimated total declines by comparing 2015-2016 to 2008-2009 using incidence rate ratios. Among 20-24-year-olds, HPV16/18-CIN2+ declined from 2008 through 2016 (AAPC: -21.3%, 95% CI: -28.1%, -13.8%), whereas no trend was observed for non-HPV16/18-CIN2+ (AAPC: -1.8%, 95% CI: -8.1%, 4.9%). After 2010, CIN2+ among 20-24-year-olds was more often caused by non-vaccine versus vaccine HR-HPV types. No significant declining trends were observed in older age groups. In 2015-2016 compared to 2008-2009, HPV16-CIN2+ declined 78%, HPV18-CIN2+ 72%, and HPV31-CIN2+ 51% among 20-24-year-olds; no increases were observed in type-specific CIN2+ incidence. Among 25-29-year-olds, HPV16-CIN2+ declined 18%; CIN2+ attributed to seven nonvaccine types increased significantly. No significant declines were observed in older groups. Significant declines in HPV16/18-CIN2+ in 20-24-year-olds and HPV16-CIN2+ in 25-29-year-olds corroborate impact of HPV vaccination. A declining trend in HPV31-CIN2+ is consistent with cross-protection from vaccination.

      4. COVID-19 vaccine effectiveness against SARS-CoV-2 infection in the United States prior to the Delta and Omicron-associated surges: a retrospective cohort study of repeat blood donors
        Grebe E, Yu EA, Bravo MD, Welte A, Bruhn RL, Stone M, Green V, Williamson PC, Feldstein LR, Jones JM, Busch MP, Custer B.
        J Infect Dis. 2022 Aug 3.
        To inform public health policy, it is critical to monitor COVID-19 vaccine effectiveness (VE), including against acquiring infection. We estimated VE using self-reported vaccination in a retrospective cohort of repeat blood donors who donated during the first half of 2021, demonstrating a viable approach for monitoring of VE via serological surveillance. Using Poisson regression, we estimated an overall VE of 88.8% (95% CI: 86.2-91.1), adjusted for demographic covariates and variable baseline risk. Time since first reporting vaccination, age, race-ethnicity, region, and calendar time were statistically significant predictors of incident infection.

      5. COVID-19 vaccination intentions, concerns, and facilitators among US parents of children ages 6 months through 4 years
        Scherer AM, Gidengil CA, Gedlinske AM, Parker AM, Askelson NM, Woodworth KR, Petersen CA, Lindley MC.
        JAMA Netw Open. 2022 Aug 1;5(8):e2227437.
        IMPORTANCE: Children aged 6 months through 4 years have become eligible for COVID-19 vaccination, but little is known about parental intentions regarding, concerns about, or facilitators to COVID-19 vaccination for this age group. OBJECTIVES: To evaluate parental intentions, concerns, and facilitators for COVID-19 vaccination for children aged 6 months through 4 years and to help inform the US Centers for Disease Control and Prevention Advisory Committee on Immunization Practices' deliberations and recommendations for COVID-19 vaccination for children aged 6 months through 4 years. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study fielded an online survey from February 2 to 10, 2022, among a nonprobability sample of US parents of children aged 6 months through 4 years who were recruited through Qualtrics using quota-based sampling for respondent gender, race and ethnicity, and child age group. MAIN OUTCOMES AND MEASURES: COVID-19 vaccination intentions, time to COVID-19 vaccination, COVID-19 vaccination concerns and facilitators, and trusted COVID-19 vaccination locations for children aged 6 months through 4 years. RESULTS: The final weighted sample of 2031 participants (73.5% participation rate) had more respondents who identified as male (985; weighted percentage, 54.8%) or White (696; weighted percentage, 66.2%), were aged 25 to 49 years (1628; weighted percentage, 85.6%), had at least a bachelor's degree (711; weighted percentage, 40.0%), lived in a metropolitan area (1743; weighted percentage, 82.9%) or the South (961; weighted percentage, 43.4%), or received at least 1 dose of a COVID-19 vaccine (1205; weighted percentage, 59.8%). Half of respondents (645; weighted percentage, 45.6%) indicated that they "definitely" or "probably" will vaccinate their child aged 6 months through 4 years once they became eligible. However, only one-fifth (396; weighted percentage, 19.0%) indicated they would get a COVID-19 vaccine for their child in this age group within 3 months of them becoming eligible for vaccination. Vaccine safety and efficacy were parents' top concerns, and receiving more information about safety and efficacy were the top facilitators to COVID-19 vaccination for this age group. A doctor's office or clinic and local pharmacy were the most trusted COVID-19 vaccination locations for this age group. CONCLUSIONS AND RELEVANCE: These results suggest that only a minority of parents of children in this age group are eager to vaccinate their children within the first few months of eligibility, with widespread concerns about COVID-19 vaccination for this age group. Thus, considerable efforts to increase parental COVID-19 vaccine confidence for children aged 6 months through 4 years may be needed to maximize COVID-19 vaccination for this age group in the United States.

      6. Addressing immunizations in nursing education: Immunization resources for undergraduate nursing
        Buckner S, Gallego R, McNaughton D, Brasher S, Stanley J, Jacobs A, Hamborsky J, Schillie S, Hunsaker S, Kyler KJ, Lewis AL, Page D.
        Journal of Professional Nursing. 2022 ;42:173-177.
        Nursing faculty are challenged to integrate immunization content in prelicensure nursing curricula. Historically, most immunization content has been delivered in pediatrics courses, with less emphasis on other populations across the lifespan. Skills related to vaccine administration may be prioritized over the most current immunization science, such as pathophysiology, immunology, and epidemiology. As the most trusted profession rated by the public (Saad, 2020), nurses are ideally suited to address vaccine hesitancy and promote vaccination in the communities they serve. Nurses apply active listening, problem solving, and communication skills with patients and their families, contributing to a person's confidence in their decision to be vaccinated. The Centers for Disease Control and Prevention and the Association for Prevention Teaching and Research collaborated to develop a framework for immunization content and teaching resources, Immunization Resources for Undergraduate Nursing (IRUN), for faculty to use in designing the nursing curricula. Content includes a curriculum framework, curriculum mapping tool, multiple teaching resources, and a dedicated website (IRUNursing.org). The framework provides guidance for faculty on integrating immunization content into a curriculum. Teaching resources include case studies, simulation scenarios, and PowerPoint slide decks. Although primarily focused on prelicensure nursing education, resources are also relevant to advanced professional nursing education. © 2022 Elsevier Inc.

      7. Safety monitoring of COVID-19 mRNA vaccine second booster doses among adults aged ≥50 years - United States, March 29, 2022-July 10, 2022
        Hause AM, Baggs J, Marquez P, Abara WE, Baumblatt J, Blanc PG, Su JR, Hugueley B, Parker C, Myers TR, Gee J, Shimabukuro TT, Shay DK.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 29;71(30):971-976.
        The Advisory Committee on Immunization Practices (ACIP) recommends that all persons aged ≥5 years receive 1 booster dose of a COVID-19 vaccine after completion of their primary series.* On March 29, 2022, the Food and Drug Administration (FDA) authorized a second mRNA booster dose ≥4 months after receipt of a first booster dose for adults aged ≥50 years and persons aged ≥12 years with moderate to severe immunocompromise (1,2). To characterize the safety of a second mRNA booster dose among persons aged ≥50 years, CDC reviewed adverse events and health impact assessments reported to v-safe and the Vaccine Adverse Event Reporting System (VAERS) after receipt of a second mRNA booster dose during March 29-July 10, 2022. V-safe is a voluntary smartphone-based U.S. active surveillance system that monitors adverse events occurring after COVID-19 vaccination. VAERS is a U.S. passive surveillance system for monitoring adverse events after vaccination, managed by CDC and FDA (3). During March 29-July 10, 2022, approximately 16.8 million persons in the United States aged ≥50 years received a fourth dose.(†) Among 286,380 v-safe registrants aged ≥50 years who reported receiving a second booster of an mRNA vaccine, 86.9% received vaccines from the same manufacturer for all 4 doses (i.e., homologous vaccination). Among registrants who reported homologous vaccination, injection site and systemic reactions were less frequent after the second booster dose than after the first booster dose. VAERS received 8,515 reports of adverse events after second mRNA booster doses among adults aged ≥50 years, including 8,073 (94.8%) nonserious and 442 (5.1%) serious events. CDC recommends that health care providers and patients be advised that local and systemic reactions are expected after a second booster dose, and that serious adverse events are uncommon.

      8. Risk of myocarditis and pericarditis following BNT162b2 and mRNA-1273 COVID-19 vaccination
        Goddard K, Lewis N, Fireman B, Weintraub E, Shimabukuro T, Zerbo O, Boyce TG, Oster ME, Hanson KE, Donahue JG, Ross P, Naleway A, Nelson JC, Lewin B, Glanz JM, Williams JT, Kharbanda EO, Katherine Yih W, Klein NP.
        Vaccine. 2022 Jul 12.
        BACKGROUND: Evidence indicates that mRNA COVID-19 vaccination is associated with risk of myocarditis and possibly pericarditis, especially in young males. It is not clear if risk differs between mRNA-1273 versus BNT162b2. We assessed if risk differs using comprehensive health records on a diverse population. METHODS: Members 18-39 years of age at eight integrated healthcare-delivery systems were monitored using data updated weekly and supplemented with medical record review of myocarditis and pericarditis cases. Incidence of myocarditis and pericarditis events that occurred among vaccine recipients 0 to 7 days after either dose 1 or 2 of a messenger RNA (mRNA) vaccine was compared with that of vaccinated concurrent comparators who, on the same calendar day, had received their most recent dose 22 to 42 days earlier. Rate ratios (RRs) were estimated by conditional Poisson regression, adjusted for age, sex, race and ethnicity, health plan, and calendar day. Head-to-head comparison directly assessed risk following mRNA-1273 versus BNT162b2 during 0-7 days post-vaccination. RESULTS: From December 14, 2020 - January 15, 2022 there were 41 cases after 2,891,498 doses of BNT162b2 and 38 cases after 1,803,267 doses of mRNA-1273. Cases had similar demographic and clinical characteristics. Most were hospitalized for ≤1 day; none required intensive care. During days 0-7 after dose 2 of BNT162b2, the incidence was 14.3 (CI: 6.5-34.9) times higher than the comparison interval, amounting to 22.4 excess cases per million doses; after mRNA-1273 the incidence was 18.8 (CI: 6.7-64.9) times higher than the comparison interval, amounting to 31.2 excess cases per million doses. In head-to-head comparisons 0-7 days after either dose, risk was moderately higher after mRNA-1273 than after BNT162b2 (RR: 1.61, CI 1.02-2.54). CONCLUSIONS: Both vaccines were associated with increased risk of myocarditis and pericarditis in 18-39-year-olds. Risk estimates were modestly higher after mRNA-1273 than after BNT162b2.

    • Informatics
      1. Insights on the differentiation of stillbirths and early neonatal deaths: A study from the Child Health and Mortality Prevention Surveillance (CHAMPS) network
        Quincer E, Philipsborn R, Morof D, Salzberg NT, Vitorino P, Ajanovic S, Onyango D, Ogbuanu I, Assefa N, Sow SO, Mutevedzi P, El Arifeen S, Tippet Barr BA, Scott JA, Mandomando I, Kotloff KL, Jambai A, Akelo V, Cain CJ, Chowdhury AI, Gure T, Igunza KA, Islam F, Keita AM, Madrid L, Mahtab S, Mehta A, Mitei PK, Ntuli C, Ojulong J, Rahman A, Samura S, Sidibe D, Thwala BN, Varo R, Madhi SA, Bassat Q, Gurley ES, Blau DM, Whitney CG.
        PLoS One. 2022 ;17(7):e0271662.
        INTRODUCTION: The high burden of stillbirths and neonatal deaths is driving global initiatives to improve birth outcomes. Discerning stillbirths from neonatal deaths can be difficult in some settings, yet this distinction is critical for understanding causes of perinatal deaths and improving resuscitation practices for live born babies. METHODS: We evaluated data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network to compare the accuracy of determining stillbirths versus neonatal deaths from different data sources and to evaluate evidence of resuscitation at delivery in accordance with World Health Organization (WHO) guidelines. CHAMPS works to identify causes of stillbirth and death in children <5 years of age in Bangladesh and 6 countries in sub-Saharan Africa. Using CHAMPS data, we compared the final classification of a case as a stillbirth or neonatal death as certified by the CHAMPS Determining Cause of Death (DeCoDe) panel to both the initial report of the case by the family member or healthcare worker at CHAMPS enrollment and the birth outcome as stillbirth or livebirth documented in the maternal health record. RESULTS: Of 1967 deaths ultimately classified as stillbirth, only 28 (1.4%) were initially reported as livebirths. Of 845 cases classified as very early neonatal death, 33 (4%) were initially reported as stillbirth. Of 367 cases with post-mortem examination showing delivery weight >1000g and no maceration, the maternal clinical record documented that resuscitation was not performed in 161 cases (44%), performed in 14 (3%), and unknown or data missing for 192 (52%). CONCLUSION: This analysis found that CHAMPS cases assigned as stillbirth or neonatal death after DeCoDe expert panel review were generally consistent with the initial report of the case as a stillbirth or neonatal death. Our findings suggest that more frequent use of resuscitation at delivery and improvements in documentation around events at birth could help improve perinatal outcomes.

    • Injury and Violence
      1. Preventing falls among older adults in primary care: A mixed methods process evaluation using the RE-AIM framework
        Johnston YA, Reome-Nedlik C, Parker EM, Bergen G, Wentworth L, Bauer M.
        Gerontologist. 2022 Aug 2.
        BACKGROUND AND OBJECTIVES: Falls are a leading cause of injuries and injury deaths for older adults. The Centers for Disease Control and Prevention's Stopping Elderly Accidents Deaths and Injuries (STEADI) initiative, a multifactorial approach to fall prevention, was adapted for implementation within the primary care setting of a health system in upstate New York. The purpose of this paper is to: (a) report process evaluation results for this implementation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and (b) examine the utility of RE-AIM for assessing barriers and facilitators. RESEARCH DESIGN AND METHODS: This evaluation used mixed methods. Qualitative evaluation involved semi-structured interviews with key stakeholders and intercept interviews with healthcare providers and clinic staff. Quantitative methods utilized surveys with clinic staff. Process evaluation tools were developed based on the AIM dimensions of the RE-AIM framework. The study was conducted over a 2-month period approximately 18 months post-implementation and complements previously published results of the program's reach and effectiveness. RESULTS: Primary barriers by RE-AIM construct included competing organizational priorities (Adoption); competing patient care demands (Implementation); and staff turnover (Maintenance). Primary facilitators included having a physician champion (Adoption); preparing and training staff (Implementation); and communicating about STEADI and recognizing accomplishments (Maintenance). DISCUSSION AND IMPLICATIONS: Results revealed a high degree of concordance between qualitative and quantitative analyses. The framework supported assessments of various stakeholders, multiple organizational levels, and the sequence of practice change activities. Mixed methods yielded rich data to inform future implementations of STEADI-based fall prevention.

      2. BACKGROUND: Medication poisoning is a common form of self-harm injury, and increases in injuries due to self-harm, including suicide attempts, have been reported over the last two decades. METHODS: Cross-sectional (2016-2019) data from 60 emergency departments (EDs) participating in an active, nationally representative public health surveillance system were analysed and US national estimates of ED visits for medication-related self-harm injuries were calculated. RESULTS: Based on 18 074 surveillance cases, there were an estimated 269 198 (95% CI 222 059 to 316 337) ED visits for medication-related self-harm injuries annually in 2016-2019 compared with 1 404 090 visits annually from therapeutic use of medications. Population rates of medication-related self-harm ED visits were highest among persons aged 11-19 years (58.5 (95% CI 45.0 to 72.0) per 10 000) and lowest among those aged ≥65 years (6.6 (95% CI 4.4 to 8.8) per 10 000). Among persons aged 11-19 years, the ED visit rate for females was four times that for males (95.4 (95% CI 74.2 to 116.7) vs 23.0 (95% CI 16.4 to 29.6) per 10 000). Medical or psychiatric admission was required for three-quarters (75.1%; 95% CI 70.0% to 80.2%) of visits. Concurrent use of alcohol or illicit substances was documented in 40.2% (95% CI 36.8% to 43.7%) of visits, and multiple medication products were implicated in 38.6% (95% CI 36.8% to 40.4%). The most frequently implicated medication categories varied by patient age. CONCLUSIONS: Medication-related self-harm injuries are an important contributor to the overall burden of ED visits and hospitalisations for medication-related harm, with the highest rates among adolescent and young adult females. These findings support continued prevention efforts targeting patients at risk of self-harm.

      3. Introduction: During the COVID-19 pandemic, one study in Australia showed an increase in drowning deaths in certain settings, while a study in China showed a decrease in drowning deaths. The impact of the COVID-19 pandemic on drowning deaths in the United States is unknown. Objective: To report on unintentional drowning deaths among U.S. persons aged ≤29 years by demographic characteristics and compare 2020 fatal drowning rates with rates from 2010 to 2019. Methods: Data from CDC WONDER were analyzed to calculate unintentional drowning death rates among persons aged ≤29 years by age group, sex, race/ethnicity, and location of drowning. These rates were compared to drowning death rates for the previous 10 years (2010–2019). Results: In 2020, 1.26 per 100,000 persons aged ≤29 years died from unintentional drowning, a 16.79% increase from 2019. Drowning death rates decreased 1.81% per year on average (95% CI: −3.02%, −0.59%) from 2010 to 2019. The largest increases in unintentional drowning deaths from 2019 to 2020 occurred among young adults aged 20 to 24 years (44.12%), Black or African American persons (23.73%), and males (19.55%). The location with the largest increase in drowning was natural water (26.44%). Conclusion: Drowning death rates among persons aged ≤29 years significantly increased from 2019 to 2020. Further research is needed to understand the impacts of the COVID-19 pandemic on drowning and identify how drowning prevention strategies can be adapted and strengthened. Practical applications: Drowning remains a leading cause of injury death among persons aged ≤29 years. However, drowning is preventable. Interventions such as learning basic swimming and water safety skills, and consistent use of lifejackets on boats and among weaker swimmers in natural water, have the potential to reduce drowning deaths. Developing strategies that ensure equitable access to these interventions may prevent future drowning. © 2022 National Safety Council and Elsevier Ltd

      4. Background: Falls, with or without an injury, often affect the health of older adults (65+). Methods: We used the 2018 Healthcare Cost and Utilization Project to describe older adults’ fall-related ED visits. We defined fall-related ED visits as those with a fall external cause of morbidity code and fall-injury related ED visits as those with an injury diagnosis code and a fall external cause of morbidity code. Percentages of fall-related and fall-injury related ED visits were analyzed by select characteristics. Results: Over 86% of fall-related ED visits were fall-injury related. A higher percentage of females (87%) and rural (88%) older adults’ fall-related ED visits were fall-injury related compared to males (85%) and urban older adults (86%). A higher percentage of fall-related ED visits without a coded injury (33%) were hospitalized compared to those with a coded injury (29%). Conclusion: The majority of fall-related ED visits included an injury diagnosis. Practical applications: Researchers can consider which method of measuring ED visits related to falls is most appropriate for their study. Limiting fall-related ED visits to only those where an injury diagnosis is also present may underestimate the number of fall-related ED visits but may be appropriate for researchers specifically interested in fall injuries. © 2022 National Safety Council and Elsevier Ltd

      5. Gun carrying among youths, by demographic characteristics, associated violence experiences, and risk behaviors - United States, 2017-2019
        Simon TR, Clayton HB, Dahlberg LL, David-Ferdon C, Kilmer G, Barbero C.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 29;71(30):953-957.
        Suicide and homicide are the second and third leading causes of death, respectively, among youths aged 14-17 years (1); nearly one half (46%) of youth suicides and most (93%) youth homicides result from firearm injuries (1). Understanding youth gun carrying and associated outcomes can guide prevention initiatives (2). This study used the updated measure of gun carrying in the 2017 and 2019 administrations of CDC's Youth Risk Behavior Survey* (YRBS) to describe the national prevalence of gun carrying for reasons other than hunting or sport among high school students aged <18 years and to examine the associations between gun carrying and experiencing violence, suicidal ideation or attempts, or substance use. Gun carrying during the previous 12 months was reported by one in 15 males and one in 50 females. Gun carrying was significantly more likely among youths with violence-related experiences (adjusted prevalence ratio [aPR] range = 1.5-10.1), suicidal ideation or attempts (aPR range = 1.8-3.5), or substance use (aPR range = 4.2-5.6). These results underscore the importance of comprehensive approaches to preventing youth violence and suicide, including strategies that focus on preventing youth substance use and gun carrying (3).

    • Laboratory Sciences
      1. Evaluation of a wearable consumer noise measurement device in a laboratory setting
        Roberts B, Jacobs N, Mathis C, Reamer H, Kardous C, Gaffney S, L. Neitzel RN.
        J Acoust Soc Am. 2022 ;152(1):547-552.
        Exposure to noise occurs throughout daily life and, depending on the intensity, duration, and context, can lead to hearing loss, disturbed sleep, decreased academic achievement, and other negative health outcomes. Recently, smartwatches that use the device's onboard microphone to measure noise levels were released. This study evaluated the accuracy of these smartwatches in a controlled laboratory setting. For broadband pink noise, a total of 11 441 measurements were collected. The results showed that, on average, the smartwatch reported 3.4 dBA lower than the reference system on average. For the octave-band, a total of 18 449 measurements were collected. The smartwatch measured lower than the reference microphone from the 125 Hz to 1000 Hz octave bands, were somewhat in agreement at 2000 Hz, measured higher sound pressure levels than the reference microphone at 4000 Hz, and then lower at 8000 Hz. Despite not meeting the ANSI criteria for sound level meters, in some cases, these smartwatches still provide a reasonable degree of accuracy and have the potential for use in studies that require the measurement of personal noise exposure over an extended period. © 2022 Acoustical Society of America.

      2. Success in harmonization of laboratory measurements, yet more to be done
        Vesper HW, Sugahara O, Pokuah F, Danilenko U, Lyle AN.
        J Appl Lab Med. 2022 Jul 28.

    • Maternal and Child Health
      1. Trends and distribution of in-hospital mortality among pregnant and postpartum individuals by pregnancy period
        Admon LK, Ford ND, Ko JY, Ferre C, Kroelinger CD, Kozhimannil KB, Kuklina EV.
        JAMA Netw Open. 2022 Jul 1;5(7):e2224614.

      2. Breastfeeding and post-perinatal infant deaths in the United States, A national prospective cohort analysis
        Li R, Ware J, Chen A, Nelson JM, Kmet JM, Parks SE, Morrow AL, Chen J, Perrine CG.
        Lancet Reg Health Am. 2022 Jan;5.
        BACKGROUND: Reducing infant mortality is a major public health goal. The potential impact of breastfeeding on infant deaths is not well studied in the United States (US). METHODS: We analyzed linked birth-death certificates for 3,230,500 US births that occurred in 2017, including 6,969 post-perinatal deaths from 7-364 days of age as the primary outcome, further specified as late-neonatal (7-27 days) or post-neonatal (28-364 days) deaths. The primary exposure was 'ever breastfed' obtained from birth certificates. Multiple logistic regression examined associations of ever breastfeeding with post-perinatal deaths and specific causes of deaths, controlling for maternal and infant factors. FINDINGS: We observed an adjusted reduced odds ratio (AOR)= 0·74 with 95% confidence intervals (CI)=0·70-0·79 for the association of breastfeeding initiation with overall infant deaths (7-364 days), AOR=0·60 (0·54-0·67) for late-neonatal deaths, and AOR=0·81 (0·76-0·87) for post-neonatal deaths. In race/ethnicity-stratified analysis, significant associations of breastfeeding initiation with reduced odds of overall infant deaths were observed for Hispanics [AOR=0·64 (0·55-0·74)], non-Hispanic Whites [AOR=0·75 (0·69-0·81)], non-Hispanic Blacks [AOR=0·83 (0·75-0·91)], and non-Hispanic Asians [AOR=0·51 (0·36-0·72)]. Across racial/ethnic groups, effect sizes for late-neonatal deaths were consistently larger than those for post-neonatal deaths. Significant effects of breastfeeding initiation were observed for deaths due to infection [AOR=0·81(0·69-0·94)], Sudden Unexpected Infant Death [AOR=0·85 (0·78-0·92)], and necrotizing enterocolitis [AOR=0·67 (0·49-0·90)]. INTERPRETATION: Breastfeeding initiation is significantly associated with reduced odds of post-perinatal infant deaths in multiple racial and ethnic groups within the US population. These findings support efforts to improve breastfeeding in infant mortality reduction initiatives.

    • Occupational Safety and Health
      1. Elevated exposures to respirable crystalline silica among engineered stone fabrication workers in California, January 2019-February 2020
        Surasi K, Ballen B, Weinberg JL, Materna BL, Harrison R, Cummings KJ, Heinzerling A.
        Am J Ind Med. 2022 Jul 28.
        BACKGROUND: Workers fabricating engineered stone face high risk for exposure to respirable crystalline silica (RCS) and subsequent development of silicosis. In response, the California Division of Occupational Safety and Health (Cal/OSHA) performed targeted enforcement inspections at engineered stone fabrication worksites. We investigated RCS exposures and employer adherence to Cal/OSHA's RCS and respiratory protection standards from these inspections to assess ongoing risk to stone fabrication workers. METHODS: We extracted employee personal air sampling results from Cal/OSHA inspection files and calculated RCS exposures. Standards require that employers continue monitoring employee RCS exposures and perform medical surveillance when exposures are at or above the action level (AL; 25 μg/m(3) ); exposures above the permissible exposure limit (PEL; 50 μg/m(3) ) are prohibited. We obtained RCS and respiratory protection standard violation citations from a federal database. RESULTS: We analyzed RCS exposures for 152 employees at 47 workplaces. Thirty-eight (25%) employees had exposures above the PEL (median = 89.7 μg/m(3) ; range = 50.7-670.7 μg/m(3) ); 17 (11%) had exposures between the AL and PEL. Twenty-four (51%) workplaces had ≥1 exposure above the PEL; 7 (15%) had ≥1 exposure between the AL and PEL. Thirty-four (72%) workplaces were cited for ≥1 RCS standard violation. Twenty-seven (57%) workplaces were cited for ≥1 respiratory protection standard violation. CONCLUSIONS: Our investigation demonstrates widespread RCS overexposure among workers and numerous employer Cal/OSHA standard violation citations. More enforcement and educational efforts could improve employer compliance with Cal/OSHA standards and inform employers and employees of the risks for RCS exposure and strategies for reducing exposure.

      2. Hazardous dusts from the fabrication of countertop: a review
        Mandler WK, Qi C, Qian Y.
        Arch Environ Occup Health. 2022 Aug 1:1-9.
        Artificial countertop materials, including solid surface composites (SSC) and engineered stone (ES) may pose significant pulmonary health risks for workers who manipulate them. These materials have rapidly become popular in the multibillion-dollar countertop industry, rivaling that of natural materials such as granite and marble due to their variety of desirable esthetic qualities and reduced costs. Both SSC and ES consist of a mineral substrate bound together in a polymer matrix. For SSC the mineral is about 70% aluminum trihydrate (ATH) while ES contains up to 95% crystalline silica by weight. Both materials emit airborne dusts when being manipulated with power tools during the fabrication process. Several deaths and dozens of cases of silicosis have been identified worldwide in workers who fabricate ES, while a single case of fatal pulmonary fibrosis has been associated with SCC dust exposure. This review examines the current state of knowledge for both SSC and ES regarding the composition, particle emission characteristics, workplace exposure data, particle constituent toxicity, and possible methods for reducing worker exposure.

      3. Investigation of COVID-19 outbreak among wildland firefighters during wildfire response, Colorado, USA, 2020
        Metz AR, Bauer M, Epperly C, Stringer G, Marshall KE, Webb LM, Hetherington-Rauth M, Matzinger SR, Totten SE, Travanty EA, Good KM, Burakoff A.
        Emerg Infect Dis. 2022 Aug;28(8):1551-1558.
        A COVID-19 outbreak occurred among Cameron Peak Fire responders in Colorado, USA, during August 2020-January 2021. The Cameron Peak Fire was the largest recorded wildfire in Colorado history, lasting August-December 2020. At least 6,123 responders were involved, including 1,260 firefighters in 63 crews who mobilized to the fire camps. A total of 79 COVID-19 cases were identified among responders, and 273 close contacts were quarantined. State and local public health investigated the outbreak and coordinated with wildfire management teams to prevent disease spread. We performed whole-genome sequencing and applied social network analysis to visualize clusters and transmission dynamics. Phylogenetic analysis identified 8 lineages among sequenced specimens, implying multiple introductions. Social network analysis identified spread between and within crews. Strategies such as implementing symptom screening and testing of arriving responders, educating responders about overlapping symptoms of smoke inhalation and COVID-19, improving physical distancing of crews, and encouraging vaccinations are recommended.

      4. Practices and activities among healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection working in different healthcare settings-ten Emerging Infections Program sites, April-November 2020
        Chea N, Eure T, Penna AR, Brown CJ, Nadle J, Godine D, Frank L, Czaja CA, Johnston H, Barter D, Miller BF, Angell K, Marshall K, Meek J, Brackney M, Carswell S, Thomas S, Wilson LE, Perlmutter R, Marceaux-Galli K, Fell A, Lim S, Lynfield R, Davis SS, Phipps EC, Sievers M, Dumyati G, Concannon C, McCullough K, Woods A, Seshadri S, Myers C, Pierce R, Ocampo VL, Guzman-Cottrill JA, Escutia G, Samper M, Pena SA, Adre C, Groenewold M, Thompson ND, Magill SS.
        Infect Control Hosp Epidemiol. 2022 Aug;43(8):1058-1062.
        Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.

    • Parasitic Diseases
      1. Onchocerciasis: Target product profiles of in vitro diagnostics to support onchocerciasis elimination mapping and mass drug administration stopping decisions
        Biamonte MA, Cantey PT, Coulibaly YI, Gass KM, Hamill LC, Hanna C, Lammie PJ, Kamgno J, Nutman TB, Oguttu DW, Sankara DP, Stolk WA, Unnasch TR.
        PLoS Negl Trop Dis. 2022 Aug 3;16(8):e0010682.
        In June 2021, the World Health Organization (WHO), recognizing the need for new diagnostics to support the control and elimination of onchocerciasis, published the target product profiles (TPPs) of new tests that would support the two most immediate needs: (a) mapping onchocerciasis in areas of low prevalence and (b) deciding when to stop mass drug administration programs. In both instances, the test should ideally detect an antigen specific for live, adult O. volvulus female worms. The preferred format is a field-deployable rapid test. For mapping, the test needs to be ≥ 60% sensitive and ≥ 99.8% specific, while to support stopping decisions, the test must be ≥ 89% sensitive and ≥ 99.8% specific. The requirement for extremely high specificity is dictated by the need to detect with sufficient statistical confidence the low seroprevalence threshold set by WHO. Surveys designed to detect a 1-2% prevalence of a given biomarker, as is the case here, cannot tolerate more than 0.2% of false-positives. Otherwise, the background noise would drown out the signal. It is recognized that reaching and demonstrating such a stringent specificity criterion will be challenging, but test developers can expect to be assisted by national governments and implementing partners for adequately powered field validation.

    • Public Health Leadership and Management
      1. The development of task sharing policy and guidelines in Kenya
        Kinuthia R, Verani A, Gross J, Kiriinya R, Hepburn K, Kioko J, Langat A, Katana A, Waudo A, Rogers M.
        Hum Resour Health. 2022 Jul 29;20(1):61.
        BACKGROUND: The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. CASE PRESENTATION: The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. CONCLUSIONS: Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.

    • Substance Use and Abuse
      1. Defining opioid-related problems using a health care safety net institution's inpatient electronic health records: Limitations of diagnosis-based definitions
        Arifkhanova A, Prieto JT, Davidson AJ, Al-Tayyib A, Hawkins E, Kraus E, McEwen D, Podewils LJ, Foldy S, Gillespie E, Taub J, Shlay JC.
        J Addict Med. 2022 Aug 1.
        BACKGROUND: Measuring clinically relevant opioid-related problems in health care systems is challenging due to the lack of standard definitions and coding practices. Well-defined, opioid-related health problems (ORHPs) would improve prevalence estimates and evaluation of clinical interventions, crisis response, and prevention activities. We sought to estimate prevalence of opioid use disorder (OUD), opioid misuse, and opioid poisoning among inpatients at a large, safety net, health care institution. METHODS: Our study included events documented in the electronic health records (EHRs) among hospitalized patients at Denver Health Medical Center during January 1, 2017 to December 31, 2018. Multiple EHR markers (ie, opioid-related diagnostic codes, clinical assessment, laboratory results, and free-text documentation) were used to develop diagnosis-based and extended definitions for OUD, opioid misuse, and opioid poisoning. We used these definitions to estimate number of hospitalized patients with these conditions. RESULTS: During a 2-year study period, 715 unique patients were identified solely using opioid-related diagnostic codes; OUD codes accounted for the largest proportion (499/715, 69.8%). Extended definitions identified an additional 973 unique patients (~136% increase), which includes 155/973 (15.9%) who were identified by a clinical assessment marker, 1/973 (0.1%) by a laboratory test marker, and 817/973 (84.0%) by a clinical documentation marker. CONCLUSIONS: Solely using diagnostic codes to estimate prevalence of clinically relevant ORHPs missed most patients with ORHPs. More inclusive estimates were generated using additional EHR markers. Improved methods to estimate ORHPs among a health care system's patients would more fully estimate organizational and economic burden to more efficiently allocate resources and ensure capacity to provide clinical services.

    • Veterinary Medicine
      1. Toxigenic corynebacterium diphtheriae infection in cat, Texas, USA
        Tyler R, Rincon L, Weigand MR, Xiaoli L, Acosta AM, Kurien D, Ju H, Lingsweiler S, Prot EY.
        Emerg Infect Dis. 2022 Aug;28(8):1686-1688.
        We report a toxigenic strain of Corynebacterium diphtheriae isolated from an oozing dermal wound in a pet cat in Texas, USA. We also describe the epidemiologic public health efforts conducted to identify potential sources of infection and mitigate its spread and the molecular and genetic studies performed to identify the bacterium.

    • Zoonotic and Vectorborne Diseases
      1. Prevalence of individual brain and eye defects potentially related to Zika virus in pregnancy in 22 U.S. states and territories, January 2016 to June 2017
        Delaney A, Olson SM, Roth NM, Cragan JD, Godfred-Cato S, Smoots AN, Fornoff J, Nestoridi E, Eckert V, Forkner A, Stolz A, Crawford K, Cho SJ, Elmore A, Langlois P, Nance A, Denson L, Forestieri N, Leedom VO, Tran T, Valencia-Prado M, Romitti P, Barton JE, St John K, Mann S, Orantes L, DeWilde L, Tong VT, Gilboa SM, Moore CA, Honein MA.
        Birth Defects Res. 2022 Jul 30.
        During the Centers for Disease Control and Prevention's Zika Virus Response, birth defects surveillance programs adapted to monitor birth defects potentially related to Zika virus (ZIKV) infection during pregnancy. Pregnancy outcomes occurring during January 2016 to June 2017 in 22 U.S. states and territories were used to estimate the prevalence of those brain and eye defects potentially related to ZIKV. Jurisdictions were divided into three groups: areas with widespread ZIKV transmission, areas with limited local ZIKV transmission, and areas without local ZIKV transmission. Prevalence estimates for selected brain and eye defects and microcephaly per 10,000 live births were estimated. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated using Poisson regression for areas with widespread and limited ZIKV transmission compared with areas without local ZIKV transmission. Defects with significantly higher prevalence in areas of widespread transmission were pooled, and PRs were calculated by quarter, comparing subsequent quarters to the first quarter (January-March 2016). Nine defects had significantly higher prevalence in areas of widespread transmission. The highest PRs were seen in intracranial calcifications (PR = 12.6, 95% CI [7.4, 21.3]), chorioretinal abnormalities (12.5 [7.1, 22.3]), brainstem abnormalities (9.3 [4.7, 18.4]), and cerebral/cortical atrophy (6.7 [4.2, 10.8]). The PR of the nine pooled defects was significantly higher in three quarters in areas with widespread transmission. The largest difference in prevalence was observed for defects consistently reported in infants with congenital ZIKV infection. Birth defects surveillance programs could consider monitoring a subset of birth defects potentially related to ZIKV in pregnancy.

      2. Emergence of dengue virus serotype 2 cosmopolitan genotype, Brazil
        Giovanetti M, Pereira LA, Santiago GA, Fonseca V, Mendoza MP, de Oliveira C, de Moraes L, Xavier J, Tosta S, Fristch H, de Castro Barbosa E, Rodrigues ES, Figueroa-Romero D, Padilla-Rojas C, Cáceres-Rey O, Mendonça AF, de Bruycker Nogueira F, Venancio da Cunha R, de Filippis AM, Freitas C, Peterka CR, de Albuquerque CF, Franco L, Méndez Rico JA, Muñoz-Jordán JL, Lemes da Silva V, Alcantara LC.
        Emerg Infect Dis. 2022 Aug;28(8):1725-1727.
        We used nanopore sequencing and phylogenetic analyses to identify a cosmopolitan genotype of dengue virus serotype 2 that was isolated from a 56-year-old male patient from the state of Goiás in Brazil. The emergence of a cosmopolitan genotype in Brazil will require risk assessment and surveillance to reduce epidemic potential.

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