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CDC Science Clips: Volume 10, Issue 6, February 20, 2018

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 Public Health Grand Rounds
    • Chronic Diseases and Conditions – Million Hearts Initiative
      1. Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative
        Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, Shepard DS, Thomas RJ.
        Mayo Clin Proc. 2017 Feb;92(2):234-242.
        The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts’ focus on achieving more than 70% performance in the “ABCS” of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.

      2. Background -Cardiac rehabilitation is strongly recommended after myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG), but is historically underused. We sought to evaluate variation in cardiac rehabilitation participation across the United States. Methods -From administrative data from the Veterans Affairs (VA) healthcare system and a 5% Medicare sample, we used ICD-9 codes to identify patients hospitalized for MI, PCI, or CABG from 2007-2011. After excluding patients who died within 30 days of hospitalization, we calculated the percent of patients who participated in one or more outpatient visits for cardiac rehabilitation during the 12 months after hospitalization. We estimated adjusted and standardized rates of participation in cardiac rehabilitation by state using hierarchical logistic regression models. Results -Overall, participation in cardiac rehabilitation was 16.3% (23,403/143,756) in Medicare and 10.3% (9,123/88,826) in VA. However, participation rates varied widely across states, ranging from 3.2% to 41.8% in Medicare and 1.2% to 47.6% in VA. Similar regional variation was observed in both populations. Patients in the West North Central region (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota) had the highest participation, while those in the Pacific region (Alaska, California, Hawaii, Oregon, and Washington) had the lowest participation in both Medicare (33.7% vs. 10.6%) and VA (16.6% vs. 5.1%) populations. Significant hospital-level variation was also present, with participation ranging from 3-75% in Medicare and 1-43% in VA. Conclusions -Cardiac rehabilitation participation remains low overall in both Medicare and VA populations. However, there is remarkably similar regional variation, with some regions and hospitals achieving high rates of participation in both populations. This provides an opportunity to identify best practices from higher-performing hospitals and regions that could be used to improve cardiac rehabilitation participation in lower-performing hospitals and regions.

      3. Is rapid health improvement possible? Lessons from the Million Hearts Initiative
        Frieden TR, Wright JS, Conway PH.
        Circulation. 2017 May 2;135(18):1677-1680.

        [No abstract]

      4. Objective: To identify physician and practice characteristics associated with high clinical and technical performance on the electronic clinical quality measure (eCQM) that calculates the proportion of patients with hypertension who have controlled blood pressure. Materials and Methods: The study included 268 602 physicians participating in the Medicare Electronic Health Record Incentive Program between 2011 and 2014. Independent variables included delivery reform participation and physician, practice level, and area characteristics. Successful technical performance was a reported eCQM with non-zero values in both the numerator and denominator. Successful clinical performance was a reported eCQM value of >/=70% hypertension control. Results: Physicians with longer experience using certified health information technology, participants in delivery reform programs, and specialists that traditionally manage hypertension were 5%-15% more likely to achieve 70% control. Physicians in smaller and rural practices and a subset of physicians unlikely to primarily manage hypertension were more likely to submit measures with a zero value in either the numerator or denominator. Discussion: More physicians are using eCQMs to track and report their quality improvement efforts. This research presents the first examination of national eCQM data to identify physician and practice-level characteristics associated with performance. Conclusion: With careful selection of measures relevant to the clinician’s specialty, complete data entry, and support for continuous quality improvement, health care professionals can excel technically and clinically. As care delivery transitions from fee-for-service to quality- and value-based models, high performers may realize financial gains and better patient outcomes. These analyses suggest patterns that may inform steps to improve performance.

      5. Integrating health and transportation in Nashville, Tennessee, USA: From policy to projects
        Meehan LA, Whitfield GP.
        J Transp Health. 2017 Mar;4:325-333.
        The Nashville Area Metropolitan Planning Organization (MPO) is among the first MPOs in the United States to recognize the interplay of transportation and public health, particularly regarding physical activity, air pollution, and traffic crashes. The Nashville MPO has taken a multifaceted approach to simultaneously improve the transportation system, quality of life, and health status of the region’s population. The purpose of this paper is to describe the multiple programs and projects that the MPO has undertaken to this end, so that other cities might learn from Nashville’s example. The MPO’s strategy comprised six processes. First, the MPO conducted the Regional Bicycle and Pedestrian Study in 2009 and 2014 that established priority issues to be addressed by bicycle and pedestrian projects in Regional Transportation Plans. Second, the MPO responded to public opinion by adopting new transportation policies in the 2035 and 2040 Regional Transportation Plans, including increasing bicycle and pedestrian options and expanding public transit. Third, the MPO created scoring criteria for proposed roadway projects that prioritized health impacts. Fourth, the MPO reserved funding for projects selected under the new criteria and established a new funding program, the Active Transportation Program. Fifth, the MPO conducted the Middle Tennessee Transportation and Health Study, one of the first regional studies in the nation linking transportation and health. Finally, the MPO implemented the Integrated Transport and Health Impact Model which predicts and monetizes population-level health impacts of shifting the population towards active transportation modes. Recent inventories of bicycle and pedestrian infrastructure suggest these interrelated processes are increasing opportunities for walking, bicycling, and public transit use in the region. Further, each of these projects has contributed to a growing appreciation in the region of the links between transportation and health, and continued evaluation efforts can determine if transportation behaviors and health outcomes are changing.

      6. Smoking cessation in severe mental ill health: what works? an updated systematic review and meta-analysis
        Peckham E, Brabyn S, Cook L, Tew G, Gilbody S.
        BMC Psychiatry. 2017 Jul 14;17(1):252.
        BACKGROUND: People with severe mental ill health are more likely to smoke than those in the general population. It is therefore important that effective smoking cessation strategies are used to help people with severe mental ill health to stop smoking. This study aims to assess the effectiveness and cost -effectiveness of smoking cessation and reduction strategies in adults with severe mental ill health in both inpatient and outpatient settings. METHODS: This is an update of a previous systematic review. Electronic databases were searched during September 2016 for randomised controlled trials comparing smoking cessation interventions to each other, usual care, or placebo. Data was extracted on biochemically-verified, self-reported smoking cessation (primary outcome), as well as on smoking reduction, body weight, psychiatric symptom, and adverse events (secondary outcomes). RESULTS: We included 26 trials of pharmacological and/or behavioural interventions. Eight trials comparing bupropion to placebo were pooled showing that bupropion improved quit rates significantly in the medium and long term but not the short term (short term RR = 6.42 95% CI 0.82-50.07; medium term RR = 2.93 95% CI 1.61-5.34; long term RR = 3.04 95% CI 1.10-8.42). Five trials comparing varenicline to placebo showed that that the addition of varenicline improved quit rates significantly in the medium term (RR = 4.13 95% CI 1.36-12.53). The results from five trials of specialised smoking cessation programmes were pooled and showed no evidence of benefit in the medium (RR = 1.32 95% CI 0.85-2.06) or long term (RR = 1.33 95% CI 0.85-2.08). There was insufficient data to allowing pooling for all time points for varenicline and trials of specialist smoking cessation programmes. Trials suggest few adverse events although safety data were not always reported. Only one pilot study reported cost effectiveness data. CONCLUSIONS: Bupropion and varenicline, which have been shown to be effective in the general population, also work for people with severe mental ill health and their use in patients with stable psychiatric conditions. Despite good evidence for the effectiveness of smoking cessation interventions for people with severe mental ill health, the percentage of people with severe mental ill health who smoke remains higher than that for the general population.

      7. Million Hearts: Description of the national surveillance and modeling methodology used to monitor the number of cardiovascular events prevented during 2012-2016
        Ritchey MD, Loustalot F, Wall HK, Steiner CA, Gillespie C, George MG, Wright JS.
        J Am Heart Assoc. 2017 May 2;6(5).
        BACKGROUND: This study describes the national surveillance and modeling methodology developed to monitor achievement of the Million Hearts initiative’s aim of preventing 1 million acute myocardial infarctions, strokes, and other related cardiovascular events during 2012-2016. METHODS AND RESULTS: We calculate sex- and age-specific cardiovascular event rates (combination of emergency department, hospitalization, and death events) among US adults aged >/=18 from 2006 to 2011 and, based on log-linear models fitted to the rates, calculate their annual percent change. We describe 2 baseline strategies to be used to compare observed versus expected event totals during 2012-2016: (1) stable baselines assume no rate changes, with modeled 2011 rates held constant through 2016; and (2) trend baselines assume 2006-2011 rate trends will continue, with the annual percent changes applied to the modeled 2011 rates to calculate expected 2012-2016 rates. Events prevented estimates during 2012-2013 were calculated using available data: 115 210 (95% CI, 60 858, 169 562) events were prevented using stable baselines and an excess of 43 934 (95% CI, -14 264, 102 132) events occurred using trend baselines. Women aged >/=75 had the most events prevented (stable, 76 242 [42 067, 110 417]; trend, 39 049 [1901, 76 197]). Men aged 45 to 64 had the greatest number of excess events (stable, 22 912 [95% CI, 855, 44 969]; trend, 38 810 [95% CI, 15 567, 62 053]). CONCLUSIONS: Around 115 000 events were prevented during the initiative’s first 2 years compared with what would have occurred had 2011 rates remained stable. Recent flattening or reversals in some event rate trends were observed supporting intensifying national action to prevent cardiovascular events.

      8. The Kaiser Permanente Southern California (Kaiser) health care system succeeded in improving hypertension control in a multiethnic population by adopting a series of changes in health care delivery. Data from the Healthcare Effectiveness Data and Information Set (HEDIS) was used to assess blood pressure control from 2004 through 2012. Hypertension control increased overall from 54% to 86% during that period, and 80% or more in every subgroup, regardless of race/ethnicity, preferred language, or type of health insurance plan. Health care delivery changes improved hypertension control across a large multiethnic population, which indicates that health care systems can achieve a clinical target goal of 70% for hypertension control in their populations.

      9. Step it up: The Surgeon General’s call to action to promote walking and walkable communities
        US Department of Health and Human Services .
        Washington DC: US Department of Health and Human Services, Office of the Surgeon General. 2015 .
        Step It Up! The Surgeon General’s Call to Action to Promote Walking and Walkable Communities recognizes the importance of physical activity for people of all ages and abilities. It calls on Americans to be more physically active through walking and calls on the nation to better support walking and walkability. Improving walkability means that communities are created or enhanced to make it safe and easy to walk and that pedestrian activity is encouraged for all people. The purpose of the Call to Action is to increase walking across the United States by calling for improved access to safe and convenient places to walk and wheelchair roll and by creating a culture that supports these activities for people of all ages and abilities. The Call to Action includes five strategic goals to promote walking and walkable communities in the United States: make walking a national priority; design communities that make it safe and easy to walk for people of all ages and abilities; promote programs and policies to support walking where people live, learn, work, and play; provide information to encourage walking and improve walkability; and fill surveillance, research, and evaluation gaps related to walking and walkability. Action by multiple sectors of society, as well as by families and individuals, will be needed to achieve these goals.

      10. Widespread recent increases in county-level heart disease mortality across age groups
        Vaughan AS, Ritchey MD, Hannan J, Kramer MR, Casper M.
        Ann Epidemiol. 2017 Dec;27(12):796-800.
        PURPOSE: Recent national trends show decelerating declines in heart disease mortality, especially among younger adults. National trends may mask variation by geography and age. We examined recent county-level trends in heart disease mortality by age group. METHODS: Using a Bayesian statistical model and National Vital Statistics Systems data, we estimated overall rates and percent change in heart disease mortality from 2010 through 2015 for four age groups (35-44, 45-54, 55-64, and 65-74 years) in 3098 US counties. RESULTS: Nationally, heart disease mortality declined in every age group except ages 55-64 years. County-level trends by age group showed geographically widespread increases, with 52.3%, 58.5%, 69.1%, and 42.0% of counties experiencing increases with median percent changes of 0.6%, 2.2%, 4.6%, and -1.5% for ages 35-44, 45-54, 55-64, and 65-74 years, respectively. Increases were more likely in counties with initially high heart disease mortality and outside large metropolitan areas. CONCLUSIONS: Recent national trends have masked local increases in heart disease mortality. These increases, especially among adults younger than age 65 years, represent challenges to communities across the country. Reversing these trends may require intensification of primary and secondary prevention-focusing policies, strategies, and interventions on younger populations, especially those living in less urban counties.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries
        Allemani C, Matsuda T, Di Carlo V, Harewood R, Matz M, Niksic M, Bonaventure A, Valkov M, Johnson CJ, Esteve J, Ogunbiyi OJ, Azevedo ES, Chen WQ, Eser S, Engholm G, Stiller CA, Monnereau A, Woods RR, Visser O, Lim GH, Aitken J, Weir HK, Coleman MP.
        Lancet. 2018 Jan 30.
        BACKGROUND: In 2015, the second cycle of the CONCORD programme established global surveillance of cancer survival as a metric of the effectiveness of health systems and to inform global policy on cancer control. CONCORD-3 updates the worldwide surveillance of cancer survival to 2014. METHODS: CONCORD-3 includes individual records for 37.5 million patients diagnosed with cancer during the 15-year period 2000-14. Data were provided by 322 population-based cancer registries in 71 countries and territories, 47 of which provided data with 100% population coverage. The study includes 18 cancers or groups of cancers: oesophagus, stomach, colon, rectum, liver, pancreas, lung, breast (women), cervix, ovary, prostate, and melanoma of the skin in adults, and brain tumours, leukaemias, and lymphomas in both adults and children. Standardised quality control procedures were applied; errors were rectified by the registry concerned. We estimated 5-year net survival. Estimates were age-standardised with the International Cancer Survival Standard weights. FINDINGS: For most cancers, 5-year net survival remains among the highest in the world in the USA and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway, and Sweden. For many cancers, Denmark is closing the survival gap with the other Nordic countries. Survival trends are generally increasing, even for some of the more lethal cancers: in some countries, survival has increased by up to 5% for cancers of the liver, pancreas, and lung. For women diagnosed during 2010-14, 5-year survival for breast cancer is now 89.5% in Australia and 90.2% in the USA, but international differences remain very wide, with levels as low as 66.1% in India. For gastrointestinal cancers, the highest levels of 5-year survival are seen in southeast Asia: in South Korea for cancers of the stomach (68.9%), colon (71.8%), and rectum (71.1%); in Japan for oesophageal cancer (36.0%); and in Taiwan for liver cancer (27.9%). By contrast, in the same world region, survival is generally lower than elsewhere for melanoma of the skin (59.9% in South Korea, 52.1% in Taiwan, and 49.6% in China), and for both lymphoid malignancies (52.5%, 50.5%, and 38.3%) and myeloid malignancies (45.9%, 33.4%, and 24.8%). For children diagnosed during 2010-14, 5-year survival for acute lymphoblastic leukaemia ranged from 49.8% in Ecuador to 95.2% in Finland. 5-year survival from brain tumours in children is higher than for adults but the global range is very wide (from 28.9% in Brazil to nearly 80% in Sweden and Denmark). INTERPRETATION: The CONCORD programme enables timely comparisons of the overall effectiveness of health systems in providing care for 18 cancers that collectively represent 75% of all cancers diagnosed worldwide every year. It contributes to the evidence base for global policy on cancer control. Since 2017, the Organisation for Economic Co-operation and Development has used findings from the CONCORD programme as the official benchmark of cancer survival, among their indicators of the quality of health care in 48 countries worldwide. Governments must recognise population-based cancer registries as key policy tools that can be used to evaluate both the impact of cancer prevention strategies and the effectiveness of health systems for all patients diagnosed with cancer. FUNDING: American Cancer Society; Centers for Disease Control and Prevention; Swiss Re; Swiss Cancer Research foundation; Swiss Cancer League; Institut National du Cancer; La Ligue Contre le Cancer; Rossy Family Foundation; US National Cancer Institute; and the Susan G Komen Foundation.

      2. Adjusted fluoride concentrations and control ranges in 34 states – 2006-2010 and 2015
        Barker LK, Duchon KK, Lesaja S, Robison VA, Presson SM.
        J Am Water Works Assoc. 2017 Aug;109(8):13-15.
        To inform selection of a control range around the Public Health Service’s recommended 0.7 mg/L drinking water fluoride concentration to prevent tooth decay, CDC’s Water Fluoridation Reporting System data for 2006-2010 and 2015 were analyzed. Monthly average concentration data from 4,251 fluoride-adjusted community water systems for 191,266 of 255,060 system-months (2006-2010) were compared to control ranges 0.6 mg/L to 0.2 mg/L wide. Percentages of system-months within control ranges >/=0.4 mg/L wide (e.g., +/-0.2 mg/L) were >83% versus 68% for 0.2 mg/L wide (+/-0.1 mg/L). In 2015, 70% of adjusted systems maintained averages within +/-0.1 mg/L of their system’s annual average for 9 of 12 months, 67% used the 0.7 mg/L target and 45% used it with a +/-0.1 mg/L control range. Adoption of the 0.7 mg/L target was underway but not completed in 2015. Control ranges narrower than +/-0.2 mg/L may be feasible for monthly average fluoride concentration.

      3. Use of strategies to improve antihypertensive medication adherence within United States outpatient health care practices, DocStyles 2015-2016
        Chang TE, Ritchey MD, Ayala C, Durthaler JM, Loustalot F.
        J Clin Hypertens (Greenwich). 2018 Feb 4.
        Patients’ adherence to antihypertensive medications is key to controlling high blood pressure. Evidence-based strategies to improve adherence exist, but their use, individually and in combination, has not been described. 2015-2016 DocStyles data were analyzed to describe health care professionals’ and their practices’ use of 10 strategies to improve antihypertensive medication adherence across 3 categories: prescribing, education, and tracking/encouragement. Among 1590 respondents, a mean of using 5 strategies was reported, with individual strategy use ranging from 17.2% (providing patients adherence-related rewards) to 69.4% (prescribing once-daily regimens). Those with higher odds of using >/=7 strategies and strategies across all 3 categories included: (1) nurse practitioners compared to family practitioners/internists and (2) health care professionals in practices with standardized hypertension treatment protocols who routinely recommend home blood pressure monitor use compared to respondents without those characteristics. Despite using an array of evidence-based adherence-promoting strategies, additional opportunities exist for health care professionals to provide adherence support among hypertensive patients.

      4. Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma
        Cloutier MM, Salo PM, Akinbami LJ, Cohn RD, Wilkerson JC, Diette GB, Williams S, Elward KS, Mazurek JM, Spinner JR, Mitchell TA, Zeldin DC.
        J Allergy Clin Immunol Pract. 2018 Feb 2.
        BACKGROUND: The 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines. OBJECTIVE: To assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines METHODS: We analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about four cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; two overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence. RESULTS: Asthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively P<.001); home peak flow monitoring, (12.8% and 11.2%, P=.34); spirometry testing, (44.7% and 10.8%, P<.001); and repeated assessment of inhaler technique, (39.7% and 16.8%, P<.001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence. CONCLUSIONS: Agreement with and adherence to asthma guidelines was higher for specialists than primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists.

      5. Introductory overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the impact of US health policies and practices to prevent diabetes and its complications
        Duru OK, Mangione CM, Rodriguez HP, Ross-Degnan D, Wharam JF, Black B, Kho A, Huguet N, Angier H, Mayer V, Siscovick D, Kraschnewski JL, Shi L, Nauman E, Gregg EW, Ali MK, Thornton P, Clauser S.
        Curr Diab Rep. 2018 Feb 5;18(2):8.
        PURPOSE OF REVIEW: Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS: NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.

      6. The evolving epidemiology of atherosclerotic cardiovascular disease in people with diabetes
        Pasquel FJ, Gregg EW, Ali MK.
        Endocrinol Metab Clin North Am. 2018 Mar;47(1):1-32.
        Atherosclerotic cardiovascular disease (ASCVD) is a leading global cause of death and accounts for most deaths among individuals with diabetes. This article reviews the latest observational and trial data on changes in the relationship between diabetes and ASCVD risk, remaining gaps in how the role of each risk factor is understood, and current knowledge about specific interventions. Differences between high-income countries and low-income and middle-income countries are examined, barriers and facilitators are discussed, and a discussion around the concept of ideal cardiovascular health factors (Life’s Simple 7) is focused on.

      7. Sunscreen use in schools: a content analysis of U.S. state laws
        Patel RR, Holman DM.
        J Am Acad Dermatol. 2018 Jan 30.

        [No abstract]

      8. Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India
        Sivaram S, Majumdar G, Perin D, Nessa A, Broeders M, Lynge E, Saraiya M, Segnan N, Sankaranarayanan R, Rajaraman P, Trimble E, Taplin S, Rath GK, Mehrotra R.
        Lancet Oncol. 2018 Feb;19(2):e113-e122.
        The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.

      9. Vital Signs: Asthma in children – United States, 2001-2016
        Zahran HS, Bailey CM, Damon SA, Garbe PL, Breysse PN.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):149-155.
        BACKGROUND: Asthma is the most common chronic lung disease of childhood, affecting approximately 6 million children in the United States. Although asthma cannot be cured, most of the time, asthma symptoms can be controlled by avoiding or reducing exposure to asthma triggers (allergens and irritants) and by following recommendations for asthma education and appropriate medical care. METHODS: CDC analyzed asthma data from the 2001-2016 National Health Interview Survey for children aged 0-17 years to examine trends and demographic differences in health outcomes and health care use. RESULTS: Asthma was more prevalent among boys (9.2%) than among girls (7.4%), children aged >/=5 years (approximately 10%) than children aged <5 years (3.8%), non-Hispanic black (black) children (15.7%) and children of Puerto Rican descent (12.9%) than among non-Hispanic white (white) children (7.1%), and children living in low income families (10.5%) than among those living in families with income >/=250% of the Federal Poverty Level (FPL) (approximately 7%). Asthma prevalence among children increased from 8.7% in 2001 to 9.4% in 2010, and then decreased to 8.3% in 2016. Although not all changes were statistically significant, a similar pattern was observed among subdemographic groups studied, with the exception of Mexican/Mexican-American children, among whom asthma prevalence increased from 5.1% in 2001 to 6.5% in 2016. Among children with asthma, the percentage who had an asthma attack in the past 12 months declined significantly from 2001 to 2016. Whereas asthma prevalence was lower among children aged 0-4 years than among older children, the prevalence of asthma attacks (62.4%), emergency department or urgent care center (ED/UC) visits (31.1%), and hospitalization (10.4%) were higher among children with asthma aged 0-4 years than among those aged 12-17 years (44.8%, 9.6%, and 2.8%, respectively). During 2013, children with asthma aged 5-17 years missed 13.8 million days of school per year (2.6 days per child). Compared with 2003, in 2013, the prevalence of adverse health outcomes and health care use were significantly lower and the prevalence of having an action plan to manage asthma was higher. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Asthma remains an important public health and medical problem. The health of children with asthma can be improved by promoting asthma control strategies, including asthma trigger reduction, appropriate guidelines-based medical management, and asthma education for children, parents, and others involved in asthma care.

    • Communicable Diseases
      1. Incidence and clinical profile of norovirus disease in Guatemala, 2008-2013
        Bierhoff M, Arvelo W, Estevez A, Bryan J, McCracken JP, Lopez MR, Lopez B, Parashar UD, Lindblade KA, Hall AJ.
        Clin Infect Dis. 2018 Feb 6.
        Background: Acute gastroenteritis (AGE) is a leading infectious cause of morbidity worldwide, particularly among children in developing countries. With the decline of rotavirus disease rates following introduction of rotavirus vaccines, the relative importance of norovirus will likely increase. The objectives of this study were to determine the incidence and clinical profile of norovirus disease in Guatemala. Methods: We analyzed data from a population-based surveillance study conducted in Guatemala from 2008-2013. Demographics information, clinical data, and stool samples were collected from patients presenting with AGE (>/=3 liquid stools within 24-hours that initiated 7 days before presentation). Estimated incidence of hospitalized, outpatient, and total community norovirus disease was calculated using surveillance data and household surveys of healthcare utilization. Results: We included 999 AGE hospitalizations and 3,189 AGE outpatient visits at facilities, of which 164 (16%) and 370 (12%), respectively, were positive for norovirus. Severity of norovirus was milder than rotavirus. Community incidence of norovirus ranged between 2068-4954 per 100,000 person-years (py) in children <5 years of age. Children <5 years also had higher incidence of norovirus-associated hospitalization (51-105 per 100,000 py) compared with patients aged >/=5 years (0-1.6 per 100,000 py and 49-80 per 100,000 py, respectively). Conclusion: This study highlights the burden of norovirus disease in Guatemala, especially among young children. These data can help prioritize development of control strategies, including the potential use of vaccines, and provide a baseline to evaluate the impact of such interventions.

      2. Primary amebic meningoencephalitis associated with rafting on an artificial whitewater river: Case report and environmental investigation
        Cope JR, Murphy J, Kahler A, Gorbett DG, Ali I, Taylor B, Corbitt L, Roy S, Lee N, Roellig D, Brewer S, Hill VR.
        Clin Infect Dis. 2018 Feb 1;66(4):548-553.
        Background: Naegleria fowleri is a thermophilic ameba found in freshwater that causes primary amebic meningoencephalitis (PAM) when it enters the nose and migrates to the brain. Patient exposure to water containing the ameba typically occurs in warm freshwater lakes and ponds during recreational water activities. In June 2016, an 18-year-old woman died of PAM after traveling to North Carolina, where she participated in rafting on an artificial whitewater river. Methods: We conducted an epidemiologic and environmental investigation to determine the water exposure that led to the death of this patient. Results: The case patient’s most probable water exposure occurred while rafting on an artificial whitewater river during which she was thrown out of the raft and submerged underwater. The approximately 11.5 million gallons of water in the whitewater facility were partially filtered, subjected to ultraviolet light treatment, and occasionally chlorinated. Heavy algal growth was noted. Eleven water-related samples were collected from the facility; all were positive for N. fowleri. Of 5 samples collected from the nearby natural river, 1 sediment sample was positive for N. fowleri. Conclusions: This investigation documents a novel exposure to an artificial whitewater river as the likely exposure causing PAM in this case. Conditions in the whitewater facility (warm, turbid water with little chlorine and heavy algal growth) rendered the water treatment ineffective and provided an ideal environment for N. fowleri to thrive. The combination of natural and engineered elements at the whitewater facility created a challenging environment to control the growth of N. fowleri.

      3. Background: Preventing mother-to-child transmission of human immunodeficiency virus transmission (MTCT) depends on early initiation of antiretroviral therapy (ART). We report the 18-month MTCT risk during the transition from Option A to Option B+ in Zimbabwe, and assess whether ART preconception could eliminate MTCT in breastfeeding populations. Methods: In 2013, we consecutively recruited a nationally representative sample of 6051 infants aged 4-12 weeks and their mothers from 151 immunization clinics using a multistage stratified cluster sampling method. We identified 1172 human immunodeficiency virus (HIV)-exposed infants and evaluated them at baseline and every 3 months until the child became HIV-infected, died, or reached age 18 months. Results: The cumulative MTCT risk through 18 months postdelivery was 7.0%. Of the HIV-infected mothers, 35.3% started ART preconception, 28.9% during pregnancy, and 9.7% after delivery, and 16.0% received zidovudine during pregnancy. Compared to mothers without antiretroviral drug use, MTCT among those starting ART preconception and during pregnancy was lower by 88% (adjusted hazard ratio [aHR], 0.12; 95% confidence interval [CI], .06-.24) and 75% (aHR, 0.25; 95% CI, .14-.45), respectively. HIV-exposed infants with birth weight <2.5 kg (low birth weight) were 2.6-fold more likely to acquire HIV infection compared to those with birth weight >/=2.5 kg (aHR, 2.57; 95% CI, 1.44-4.59). Controlling for other factors, breastfeeding was not significantly associated with MTCT. Conclusions: ART preconception has the highest impact on reducing MTCT, indicating that HIV-infected, reproductive-age women should be prioritized in “treat-all” strategies. HIV-infected mothers without ART use should be identified at the first immunization visit and treatment initiated to reduce postdelivery MTCT. MTCT risk is higher in mothers with low-birth-weight deliveries.

      4. Revision of clinical case definitions: influenza-like illness and severe acute respiratory infection
        Fitzner J, Qasmieh S, Mounts AW, Alexander B, Besselaar T, Briand S, Brown C, Clark S, Dueger E, Gross D, Hauge S, Hirve S, Jorgensen P, Katz MA, Mafi A, Malik M, McCarron M, Meerhoff T, Mori Y, Mott J, Olivera M, Ortiz JR, Palekar R, Rebelo-de-Andrade H, Soetens L, Yahaya AA, Zhang W, Vandemaele K.
        Bull World Health Organ. 2018 Feb 1;96(2):122-128.
        The formulation of accurate clinical case definitions is an integral part of an effective process of public health surveillance. Although such definitions should, ideally, be based on a standardized and fixed collection of defining criteria, they often require revision to reflect new knowledge of the condition involved and improvements in diagnostic testing. Optimal case definitions also need to have a balance of sensitivity and specificity that reflects their intended use. After the 2009-2010 H1N1 influenza pandemic, the World Health Organization (WHO) initiated a technical consultation on global influenza surveillance. This prompted improvements in the sensitivity and specificity of the case definition for influenza – i.e. a respiratory disease that lacks uniquely defining symptomology. The revision process not only modified the definition of influenza-like illness, to include a simplified list of the criteria shown to be most predictive of influenza infection, but also clarified the language used for the definition, to enhance interpretability. To capture severe cases of influenza that required hospitalization, a new case definition was also developed for severe acute respiratory infection in all age groups. The new definitions have been found to capture more cases without compromising specificity. Despite the challenge still posed in the clinical separation of influenza from other respiratory infections, the global use of the new WHO case definitions should help determine global trends in the characteristics and transmission of influenza viruses and the associated disease burden.

      5. Daily and nondaily oral preexposure prophylaxis in men and transgender women who have sex with men: The Human Immunodeficiency Virus Prevention Trials Network 067/ADAPT Study
        Grant RM, Mannheimer S, Hughes JP, Hirsch-Moverman Y, Loquere A, Chitwarakorn A, Curlin ME, Li M, Amico KR, Hendrix CW, Anderson PL, Dye BJ, Marzinke MA, Piwowar-Manning E, McKinstry L, Elharrar V, Stirratt M, Rooney JF, Eshleman SH, McNicholl JM, van Griensven F, Holtz TH.
        Clin Infect Dis. 2018 Feb 6.
        Background: Nondaily dosing of oral preexposure prophylaxis (PrEP) may provide equivalent coverage of sex events compared with daily dosing. Methods: At-risk men and transgender women who have sex with men were randomly assigned to 1 of 3 dosing regimens: 1 tablet daily, 1 tablet twice weekly with a postsex dose (time-driven), or 1 tablet before and after sex (event-driven), and were followed for coverage of sex events with pre- and postsex dosing measured by weekly self-report, drug concentrations, and electronic drug monitoring. Results: From July 2012 to May 2014, 357 participants were randomized. In Bangkok, the coverage of sex events was 85% for the daily arm compared with 84% for the time-driven arm (P = .79) and 74% for the event-driven arm (P = .02). In Harlem, coverage was 66%, 47% (P = .01), and 52% (P = .01) for these groups. In Bangkok, PrEP medication concentrations in blood were consistent with use of >/=2 tablets per week in >95% of visits when sex was reported in the prior week, while in Harlem, such medication concentrations occurred in 48.5% in the daily arm, 30.9% in the time-driven arm, and 16.7% in the event-driven arm (P < .0001). Creatinine elevations were more common in the daily arm (P = .050), although they were not dose limiting. Conclusions: Daily dosing recommendations increased coverage and protective drug concentrations in the Harlem cohort, while daily and nondaily regimens led to comparably favorable outcomes in Bangkok, where participants had higher levels of education and employment. Clinical Trials Registration: NCT01327651.

      6. The state of sexual health services at U.S. colleges and universities
        Habel MA, Caccamo A, Beltran O, Becasen J, Pearson WS, Dittus P.
        J Am Coll Health. 2018 Feb 6:0.
        OBJECTIVE: To describe the array of sexual health care services provided at US colleges and universities. PARTICIPANTS: During 2014-2015, 885 colleges were surveyed about their provision of sexual health services. METHODS: 55% of colleges responded. Data were weighted and stratified by minority-serving institutions (MSIs), 2-year and 4-year institutions. RESULTS: 70.6% of colleges reported having a health center (HC), of which 73.0% offered STI diagnosis/treatment (4y vs. 2y; 77.9% vs. 53.1%) and contraceptive services (70.1% vs. 46.4%), all p<.001. HCs less frequently offered LARC (19.7%), express STI testing (24.4%) and self-collection (31.4%). Condoms were available on 66.8% of campuses. HPV vaccination was available at more 4-year colleges (73.7% vs. 48.5%, p<.003) and non-MSIs (74.4% vs. 58.5, p = .019). Regarding MSM-targeted services, 54.6% offered pharyngeal and 51.8% rectal STI testing. CONCLUSIONS: 2-year colleges may require additional support with providing sexual health care. Improvements could entail increasing express testing, extra-genital STI testing, and LARC.

      7. Symptom screening for active tuberculosis in pregnant women living with HIV
        Lacourse SM, Cranmer LM, Bekker A, Steingart KR, Black D, Horne DJ, Oren E, Pals S, Modi S, Mathad J.
        Cochrane Database of Systematic Reviews. 2018 24 Jan;2018 (1)(CD012934).
        This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To assess the accuracy of the four-symptom screen (cough, fever, night sweats, or weight loss) for identifying active TB in pregnant PLHIV who are screened in an outpatient or community setting. To investigate potential sources of heterogeneity of the accuracy of the four-symptom screen between studies including: ART status, CD4 cell count, gestational age, pregnancy stage (pregnancy vs. postpartum), screening test definition of cough (any cough vs. cough greater than 2 weeks). To describe the accuracy of single symptoms included within the four-symptom screen, additional symptoms or symptom combinations, for identifying active TB in pregnant PLHIV. For example, additional symptoms may include failure to gain weight or fatigue.

      8. Evaluation of hepatitis B virus screening, vaccination, and linkage to care among newly arrived refugees in four states, 2009-2011
        Mitruka K, Pezzi C, Baack B, Burke H, Cochran J, Matheson J, Urban K, Ramos M, Byrd K.
        J Immigr Minor Health. 2018 Feb 7.
        Many U.S.-bound refugees originate from countries with intermediate or high hepatitis B virus (HBV) infection prevalence and have risk for severe liver disease. We evaluated HBV screening and vaccination of newly arrived refugees in four states to identify program improvement opportunities. Data on HBV testing at domestic health assessments (1/1/2009-12/31/2011) were abstracted from state refugee health surveillance systems. Logistic regression identified correlates of infection. Over 95% of adults aged >/=19 years (N = 24,647) and 50% of children (N = 12,249) were tested. Among 32,107 refugees with valid results, the overall infection prevalence was 2.9% (0.76-9.25%); HBV prevalence reflected the burden in birth countries. Birth in the Western Pacific region carried the greatest infection risk (adjusted prevalence ratio = 4.8, CI 2.9, 7.9). Care linkage for infection was unconfirmed. Of 7409 susceptible persons, 38% received 3 doses of hepatitis B vaccine. Testing children, documenting care linkage, and completing 3-dose vaccine series were opportunities for improvement.

      9. Exposure to latent tuberculosis treatment during pregnancy: The PREVENT TB and the iAdhere Trials
        Moro RN, Scott NA, Vernon A, Tepper NK, Goldberg SV, Schwartzman K, Leung CC, Schluger NW, Belknap RW, Chaisson RE, Narita M, Machado ES, Lopez M, Sanchez J, Villarino ME, Sterling TR.
        Ann Am Thorac Soc. 2018 Feb 2.
        RATIONALE: Data are limited regarding the safety of 12-dose once-weekly isoniazid (900 mg) plus rifapentine (900 mg) (3HP) for latent tuberculosis infection (LTBI) treatment during pregnancy. OBJECTIVE: To assess safety and pregnancy outcomes among pregnant women who were inadvertently exposed to study medications in two LTBI trials (PREVENT TB or iAdhere) evaluating 3HP and 9 months of daily isoniazid (300 mg) (9H). METHODS: Data from reproductive age (15-51 years) women who received >/=1 study dose of 3HP or 9H in either trial were analyzed. Drug exposure during pregnancy occurred if the estimated date of conception was on or before the last dose date. RESULTS: Of 126 pregnancies (125 participants) that occurred during treatment or follow-up, 87 were exposed to study drugs. Among these, fetal loss was reported for 4/31 (13%) and 8/56 (14%), 3HP and 9H, respectively (difference 13% – 14% = -1%; 95% CI -17% to +18%); and congenital anomalies in 0/20 and 2/41 (5%) live births, 3HP and 9H, respectively (difference 0 – 5% = -5%; 95% CI -18% to +16%). All fetal losses occurred in pregnancies <20 weeks. Of the total 126 pregnancies, fetal loss was reported in 8/54 (15%) and 9/72 (13%), 3HP and 9H, respectively; and congenital anomalies in 1/37 (3%) and 2/56 (4%) live births, 3HP and 9H, respectively. The overall proportion of fetal loss (17/126 [13%]) and anomalies (3/93 [3%]) were similar to those estimated for the United States, 17% and 3%, respectively. CONCLUSION: Among reported pregnancies in these two LTBI trials, there was no unexpected fetal loss or congenital anomalies. These data offer some preliminary reassurance to clinicians and patients in circumstances when these drugs and regimens are the best option in pregnancy or in women of child-bearing potential. Clinical trial registered with (NCT00023452 and NCT01582711).

      10. New biomarkers of innate and adaptive immunity in infectious diseases
        Morzunov S, Deyde V, Abrahamyan L.
        J Immunol Res. 2017 ;2017:7047405.

        [No abstract]

      11. Preparing for the chlamydia and gonorrhea self-test
        Peterman TA, Kreisel K, Habel MA, Pearson WS, Dittus PJ, Papp JR.
        Sex Transm Dis. 2018 Mar;45(3):e7-e9.
        New technology may soon allow individuals to test themselves for chlamydia and gonorrhea. These new self-tests might help increase screening, but they will also bring new issues for treatment, prevention, and surveillance. Providers will need to decide how to respond to patients who present after a positive screening test and how to approach partner testing and treatment. Research will be needed to identify approaches to increase screening using these tests. Laboratory-based surveillance will not capture infections if testing does not involve a laboratory, so new surveillance techniques will be needed. Self-tests are new tools that will soon be available. We should be prepared to use them.

      12. Norovirus illnesses in children and adolescents
        Shah MP, Hall AJ.
        Infect Dis Clin North Am. 2018 Mar;32(1):103-118.
        Norovirus is a leading cause of childhood vomiting and diarrhea in the United States and globally. Although most illnesses caused by norovirus are self-resolving, severe outcomes may occur from dehydration, including hospitalization and death. A vast majority of deaths from norovirus occur in developing countries. Immunocompromised children are at risk for more severe outcomes. Treatment of norovirus illness is focused on early correction of dehydration and maintenance of fluid status and nutrition. Hand hygiene, exclusion of ill individuals, and environmental cleaning are important for norovirus outbreak prevention and control, and vaccines to prevent norovirus illness are currently under development.

      13. Diagnostic pathways and direct medical costs incurred by new adult pulmonary tuberculosis patients prior to anti-tuberculosis treatment – Tamil Nadu, India
        Veesa KS, John KR, Moonan PK, Kaliappan SP, Manjunath K, Sagili KD, Ravichandra C, Menon PA, Dolla C, Luke N, Munshi K, George K, Minz S.
        PLoS One. 2018 ;13(2):e0191591.
        BACKGROUND: Tuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India. METHODS: This descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures. RESULTS: Of 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3-11 IQR) of time to treatment initiation and 21 days (10-30 IQR) of health systems delay. Age </= 40 years (aOR: 1.73; CI: 1.22-2.44), diabetes (aOR: 1.63; CI: 1.08-2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1-26.4) were associated with higher direct OOP medical costs, while age </= 40 years (aOR: 0.64; CI: 0.48-0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34-2.39) were associated with health systems delay. CONCLUSION: The majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

      14. Sexually transmitted diseases among pregnant women: 5 states, United States, 2009-2011
        Williams CL, Harrison LL, Llata E, Smith RA, Meites E.
        Matern Child Health J. 2018 Feb 7.
        Introduction Screening for specific sexually transmitted diseases (STDs) during pregnancy has been a longstanding public health recommendation. Prior studies have described associations between these infections and socioeconomic factors such as race/ethnicity and education. Objectives We evaluated the prevalence of STDs and the correlation socioeconomic factors have with the presence of these infections among pregnant women in the United States. Methods We conducted an analysis using self-reported data from 12,948 recently pregnant women from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 5 states during 2009-2011. Responses to questions about curable STDs (chlamydia, gonorrhea, syphilis, trichomoniasis) diagnosed during pregnancy were utilized to calculate weighted STD prevalence estimates and 95% confidence intervals (CI). A logistic regression was also conducted to identify maternal socioeconomic characteristics significantly associated with STDs; results are displayed as adjusted prevalence ratios (aPR). The PRAMS protocol was approved at PRAMS participating sites and by CDC’s Institutional Review Board. Results Overall, 3.3% (CI 2.9-3.7) reported >/= 1 curable STD during her most recent pregnancy. The adjusted STD prevalence was higher among women with younger age (aPR, 2.4; CI 1.8-3.4), non-Hispanic black race/ethnicity (aPR, 3.3; CI 2.4-4.1), unmarried status (aPR, 2.1; CI 1.4-3.0), no college education (aPR, 1.4; CI 1.0-1.9), annual income < $25,000 (aPR, 2.0; CI 1.3-3.2), and no pre-pregnancy health insurance (aPR, 1.4; CI 1.1-1.8). Conclusions for Practice This is the largest study of prevalence of self-reported curable STDs among U.S. pregnant women. Differences in STD prevalence highlight the association between certain socioeconomic factors and the presence of STDs.

      15. Risk communication and Ebola-specific knowledge and behavior during 2014-2015 outbreak, Sierra Leone
        Winters M, Jalloh MF, Sengeh P, Jalloh MB, Conteh L, Bunnell R, Li W, Zeebari Z, Nordenstedt H.
        Emerg Infect Dis. 2018 Feb;24(2):336-344.
        We assessed the effect of information sources on Ebola-specific knowledge and behavior during the 2014-2015 Ebola virus disease outbreak in Sierra Leone. We pooled data from 4 population-based knowledge, attitude, and practice surveys (August, October, and December 2014 and July 2015), with a total of 10,604 respondents. We created composite variables for exposures (information sources: electronic, print, new media, government, community) and outcomes (knowledge and misconceptions, protective and risk behavior) and tested associations by using logistic regression within multilevel modeling. Exposure to information sources was associated with higher knowledge and protective behaviors. However, apart from print media, exposure to information sources was also linked to misconceptions and risk behavior, but with weaker associations observed. Knowledge and protective behavior were associated with the outbreak level, most strongly after the peak, whereas risk behavior was seen at all levels of the outbreak. In future outbreaks, close attention should be paid to dissemination of information.

    • Disease Reservoirs and Vectors
      1. Fly reservoir associated with Wohlfahrtiimonas bacteremia in a human
        Bonwitt JH, Tran M, Dykstra EA, Eckmann K, Bell ME, Leadon M, Sixberry M, Glover WA.
        Emerg Infect Dis. 2018 Feb;24(2):370-373.
        Wohlfahrtiimonas species bacteria were isolated from the bloodstream of a patient with septicemia and wound myiasis. Environmental investigations identified a Wohlfahrtiimonas sp. among insects in the Americas and in a previously undescribed vector, the green bottle fly (Lucilia sericata). The isolates possibly represent a new species within the genus Wohlfahrtiimonas.

      2. The blacklegged tick, Ixodes scapularis, is the primary vector to humans in the eastern United States of the deer tick virus lineage of Powassan virus (Powassan virus disease); the protozoan parasite Babesia microti (babesiosis); and multiple bacterial disease agents including Anaplasma phagocytophilum (anaplasmosis), Borrelia burgdorferi and Borrelia mayonii (Lyme disease), Borrelia miyamotoi (relapsing fever-like illness, named Borrelia miyamotoi disease), and Ehrlichia muris eauclairensis (a minor causative agent of ehrlichiosis). With the notable exception of Powassan virus, which can be transmitted within minutes after attachment by an infected tick, there is no doubt that the risk of transmission of other I. scapularis-borne pathogens, including Lyme disease spirochetes, increases with the length of time (number of days) infected ticks are allowed to remain attached. This review summarizes data from experimental transmission studies to reinforce the important disease-prevention message that regular (at least daily) tick checks and prompt tick removal has strong potential to reduce the risk of transmission of I. scapularis-borne bacterial and parasitic pathogens from infected attached ticks. The most likely scenario for human exposure to an I. scapularis-borne pathogen is the bite by a single infected tick. However, recent reviews have failed to make a clear distinction between data based on transmission studies where experimental hosts were fed upon by a single versus multiple infected ticks. A summary of data from experimental studies on transmission of Lyme disease spirochetes (Bo. burgdorferi and Bo. mayonii) by I. scapularis nymphs indicates that the probability of transmission resulting in host infection, at time points from 24 to 72h after nymphal attachment, is higher when multiple infected ticks feed together as compared to feeding by a single infected tick. In the specific context of risk for human infection, the most relevant experimental studies therefore are those where the probability of pathogen transmission at a given point in time after attachment was determined using a single infected tick. The minimum duration of attachment by single infected I. scapularis nymphs required for transmission to result in host infection is poorly defined for most pathogens, but experimental studies have shown that Powassan virus can be transmitted within 15min of tick attachment and both A. phagocytophilum and Bo. miyamotoi within the first 24h of attachment. There is no experimental evidence for transmission of Lyme disease spirochetes by single infected I. scapularis nymphs to result in host infection when ticks are attached for only 24h (despite exposure of nearly 90 experimental rodent hosts across multiple studies) but the probability of transmission resulting in host infection appears to increase to approximately 10% by 48h and reach 70% by 72h for Bo. burgdorferi. Caveats to the results from experimental transmission studies, including specific circumstances (such as re-attachment of previously partially fed infected ticks) that may lead to more rapid transmission are discussed.

      3. Host preferences support the prominent role of Hyalomma ticks in the ecology of Crimean-Congo hemorrhagic fever
        Spengler JR, Estrada-Pena A.
        PLoS Negl Trop Dis. 2018 Feb 8;12(2):e0006248.
        Crimean-Congo hemorrhagic fever virus (CCHFV) is a tick-borne zoonotic agent that is maintained in nature in an enzootic vertebrate-tick-vertebrate cycle. Hyalomma genus ticks have been implicated as the main CCHFV vector and are key in maintaining silent endemic foci. However, what contributes to their central role in CCHFV ecology is unclear. To assess the significance of host preferences of ticks in CCHFV ecology, we performed comparative analyses of hosts exploited by 133 species of ticks; these species represent 5 genera with reported geographical distribution over the range of CCHFV. We found that the composition of vertebrate hosts on which Hyalomma spp. feed is different than for other tick genera. Immatures of the genus Hyalomma feed preferentially on species of the orders Rodentia, Lagomorpha, and the class Aves, while adults concentrate mainly on the family Bovidae. With the exception of Aves, these hosts include the majority of the vertebrates consistently reported to be viremic upon CCHFV infection. While other tick genera also feed on these hosts, Hyalomma spp. almost completely concentrate their populations on them. Hyalomma spp. feed on less phylogenetically diverse hosts than any other tick genus, implying that this network of hosts has a low resilience. Indeed, removing the most prominent hosts quickly collapsed the network of parasitic interactions. These results support the intermittent activity of CCHFV foci: likely, populations of infected Hyalomma spp. ticks exceed the threshold of contact with humans only when these critical hosts reach adequate population density, accounting for the sporadic occurence of clinical tick-transmitted cases. Our data describe the association of vertebrate host preferences with the role of Hyalomma spp. ticks in maintaining endemic CCHFV foci, and highlight the importance of host-tick dynamics in pathogen ecology.

      4. Amblyomma americanum (Acari: Ixodidae) ticks are not vectors of the Lyme disease agent, Borrelia burgdorferi (Spirocheatales: Spirochaetaceae): A review of the evidence
        Stromdahl EY, Nadolny RM, Hickling GJ, Hamer SA, Ogden NH, Casal C, Heck GA, Gibbons JA, Cremeans TF, Pilgard MA.
        J Med Entomol. 2018 Jan 31.
        In the early 1980s, Ixodes spp. ticks were implicated as the key North American vectors of Borrelia burgdorferi (Johnson, Schmid, Hyde, Steigerwalt and Brenner) (Spirocheatales: Spirochaetaceae), the etiological agent of Lyme disease. Concurrently, other human-biting tick species were investigated as potential B. burgdorferi vectors. Rashes thought to be erythema migrans were observed in patients bitten by Amblyomma americanum (L.) (Acari: Ixodidae) ticks, and spirochetes were visualized in a small percentage of A. americanum using fluorescent antibody staining methods, sparking interest in this species as a candidate vector of B. burgdorferi. Using molecular methods, the spirochetes were subsequently described as Borrelia lonestari sp. nov. (Spirocheatales: Spirochaetaceae), a transovarially transmitted relapsing fever Borrelia of uncertain clinical significance. In total, 54 surveys from more than 35 research groups, involving more than 52,000 ticks, have revealed a low prevalence of B. lonestari, and scarce B. burgdorferi, in A. americanum. In Lyme disease-endemic areas, A. americanum commonly feeds on B. burgdorferi-infected hosts; the extremely low prevalence of B. burgdorferi in this tick results from a saliva barrier to acquiring infection from infected hosts. At least nine transmission experiments involving B. burgdorferi in A. americanum have failed to demonstrate vector competency. Advancements in molecular analysis strongly suggest that initial reports of B. burgdorferi in A. americanum across many states were misidentified B. lonestari, or DNA contamination, yet the early reports continue to be cited without regard to the later clarifying studies. In this article, the surveillance and vector competency studies of B. burgdorferi in A. americanum are reviewed, and we conclude that A. americanum is not a vector of B. burgdorferi.

    • Drug Safety
      1. Exploring the nurses’ role in antibiotic stewardship: A multisite qualitative study of nurses and infection preventionists
        Carter EJ, Greendyke WG, Furuya EY, Srinivasan A, Shelley AN, Bothra A, Saiman L, Larson EL.
        Am J Infect Control. 2018 Jan 30.
        BACKGROUND: There is a growing recognition of the need to partner with nurses to promote effective antibiotic stewardship. In this study, we explored the attitudes of nurses and infection preventionists toward 5 nurse-driven antibiotic stewardship practices: 1) questioning the need for urine cultures; 2) ensuring proper culturing technique; 3) recording an accurate penicillin drug allergy history; 4) encouraging the prompt transition from intravenous (IV) to oral (PO) antibiotics; and 5) initiating an antibiotic timeout. METHODS: Nine focus groups and 4 interviews with 49 clinical nurses, 5 nurse managers, and 7 infection preventionists were conducted across 2 academic pediatric and adult hospitals. RESULTS: Nurse-driven antibiotic stewardship was perceived as an extension of the nurses’ role as patient advocate. Three practices were perceived most favorably: questioning the necessity of urinary cultures, ensuring proper culturing techniques, and encouraging the prompt transition from IV to PO antibiotics. Remaining recommendations were perceived to lack relevance or to challenge traditionally held nursing responsibilities. Prescriber and family engagement were noted to assist the implementation of select recommendations. Infection preventionists welcomed the opportunity to assist in providing nurse stewardship education. CONCLUSIONS: Nurses appeared to be enthusiastic about participating in antibiotic stewardship. Efforts to engage nurses should address knowledge needs and consider the contexts in which nurse-driven antibiotic stewardship occurs.

      2. The Standardized Antimicrobial Administration Ratio: A new metric for measuring and comparing antibiotic use
        van Santen KL, Edwards JR, Webb AK, Pollack LA, O’Leary E, Neuhauser MM, Srinivasan A, Pollock DA.
        Clin Infect Dis. 2018 Feb 2.
        Background: To provide a standardized, risk-adjusted method for summarizing antibiotic use (AU) and to enable hospitals to track their AU over time and compare their AU data to national benchmarks, CDC developed a new metric, the Standardized Antimicrobial Administration Ratio (SAAR). Methods: Hospitals reporting to the National Healthcare Safety Network (NHSN) AU Option collect and submit aggregated AU data electronically as antimicrobial days of therapy per patient days present. SAARs were developed for specific NHSN adult and pediatric patient care locations and cover five antimicrobial agent categories: (1) broad-spectrum agents predominantly used for hospital-onset/multi-drug resistant bacteria, (2) broad-spectrum agents predominantly used for community-acquired infections, (3) anti-MRSA agents, (4) agents predominantly used for surgical site infection prophylaxis, and (5) all antibiotic agents. The SAAR is an observed-to-predicted use ratio in which the predicted use is estimated from a statistical model; a SAAR of 1 indicates that observed use and predicted use are equal. Results: Most location-level SAARs were statistically significantly different than 1; in adult locations up to 52% lower than 1 and up to 41% higher than 1. Median SAARs in adult and pediatric ICUs had a range of 0.667- 1.119. SAAR distributions serve as an external comparison to national SAARs. Conclusion: This is the first aggregate AU metric that uses point-of-care, antimicrobial administration data electronically reported to a national surveillance system to enable risk adjusted, AU comparisons across multiple hospitals. The SAAR metric is endorsed by the National Quality Forum and provides a set of AU benchmarks that stewardship programs can use to identify higher than predicted AU to help drive improvements.

    • Environmental Health
      1. Distribution and predictors of urinary concentrations of phthalate metabolites and phenols among pregnant women in the Healthy Start Study
        Polinski KJ, Dabelea D, Hamman RF, Adgate JL, Calafat AM, Ye X, Starling AP.
        Environ Res. 2018 Jan 30;162:308-317.
        BACKGROUND: Phthalates and phenols are suspected endocrine disrupting chemicals that may adversely impact fetal outcomes following in utero exposure. Understanding predictors of exposure to phthalates and phenols during the prenatal period is important. METHODS: We measured urinary concentrations of 15 phthalate metabolites and 11 phenols in 446 pregnant women enrolled in the Healthy Start pre-birth cohort. Creatinine-adjusted geometric means (GM) for each urinary biomarker were compared across categories of potential sociodemographic and dietary predictors. To assess the independent relationship between each significant food group predictor and biomarker we used multivariable models, adjusted for sociodemographic predictors. RESULTS: The phthalate metabolites with the highest concentrations were monoethyl phthalate (GM: 41.1microg/g creatinine) and monocarboxyisooctyl phthalate (GM: 20.5microg/g creatinine). Benzophenone-3 (GM: 124.6microg/g creatinine) and methyl paraben (GM: 119.9microg/g creatinine) were the phenols with the highest concentrations. Concentrations of the metabolites of di-n-butyl phthalate and di(2-ethylhexyl) phthalate were significantly higher in younger, unmarried or unemployed mothers, those who were overweight or obese, those with lower educational attainment, or those of minority race/ethnicity (p-values < 0.05). Metabolites of di-n-butyl phthalate concentrations were 18% lower in those who consumed milk >/= 7 times per week (95% CI: 30-4%). Benzophenone-3 and triclosan concentrations were significantly higher in older, married, or employed mothers, those with normal body mass index, higher educational attainment, higher household income, or who were non-Hispanic white (p-values < 0.05). Benzophenone-3 concentrations were 62% higher in those who consumed seafood >/= 5 times per month (95% CI: 16-127%). CONCLUSIONS: We observed differences in urinary concentrations of phthalates and phenol biomarkers by sociodemographic predictors in an ethnically diverse cohort of pregnant women. These results and future analyses from this prospective cohort will help inform targeted interventions to reduce exposure to these potential endocrine disrupting chemicals during pregnancy.

      2. Impact of home remediation and household education on indoor air quality, respiratory visits and symptoms in Alaska Native children
        Singleton R, Salkoski AJ, Bulkow L, Fish C, Dobson J, Albertson L, Skarada J, Ritter T, Kovesi T, Hennessy TW.
        Int J Circumpolar Health. 2018 Dec;77(1):1422669.
        Alaska Native children experience high rates of lower respiratory tract infections (LRTIs) and lung conditions, which are associated with substandard indoor air quality (IAQ). We conducted an intervention of home remediation and education to assess the impact on IAQ, respiratory symptoms and LRTI visits. We enrolled households of children 1-12 years of age with lung conditions. Home remediation included improving ventilation and replacing leaky woodstoves. We provided education about IAQ and respiratory health. We monitored indoor airborne particles (PM2.5), CO2, relative humidity and volatile organic compounds (VOCs), and interviewed caregivers about children’s symptoms before, and for 1 year after intervention. We evaluated the association between children’s respiratory visits, symptoms and IAQ indicators using multiple logistic regression. A total of 60 of 63 homes completed the study. VOCs decreased (coefficient = -0.20; p < 0.001); however, PM2.5 (coeff. = -0.010; p = 0.89) did not decrease. Burning wood for heat, VOCs and PM2.5 were associated with respiratory symptoms. After remediation, parents reported decreases in runny nose, cough between colds, wet cough, wheezing with colds, wheezing between colds and school absences. Children had an age-adjusted decrease in LRTI visits (coefficient = -0.33; p = 0.028). Home remediation and education reduced respiratory symptoms, LRTI visits and school absenteeism in children with lung conditions.

    • Food Safety
      1. Outbreak of fluoroquinolone-resistant Campylobacter jejuni infections associated with raw milk consumption from a herdshare dairy – Colorado, 2016
        Burakoff A, Brown K, Knutsen J, Hopewell C, Rowe S, Bennett C, Cronquist A.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):146-148.
        In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy. In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1). Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

      2. Disparities in severe shigellosis among adults – Foodborne Diseases Active Surveillance Network, 2002-2014
        McCrickard LS, Crim SM, Kim S, Bowen A.
        BMC Public Health. 2018 Feb 7;18(1):221.
        BACKGROUND: Shigella causes approximately 500,000 illnesses, 6000 hospitalizations, and 40 deaths in the United States annually, but incidence and populations at risk for severe shigellosis among adults are unclear. This study describes severe shigellosis among US adults. METHODS: We analyzed Foodborne Diseases Active Surveillance Network data for infections caused by Shigella among adults >/=18 years old during 2002-2014. Criteria to define severe shigellosis included hospitalization, bacteremia, or death. We estimated annual incidence of shigellosis per 100,000 among adult populations, and conducted multivariable mixed-effects logistic regression to assess associations between severe shigellosis, demographic factors and Shigella species among adults with shigellosis. RESULTS: Among 9968 shigellosis cases, 2764 (28%) were severe. Restricting to cases due to S. sonnei and S. flexneri, median annual incidence of severe shigellosis among adults was 0.56 and highest overall incidence was among black males 18-49 years old (1.58). Among adults with shigellosis, odds of severe disease were higher among males than females aged 18-49 years old (OR [95% CI] = 1.32 [1.15-1.52], p < 0.001) and among males than females with S. flexneri infections (OR [95% CI] =1.39 [1.10-1.75], p = 0.005). The odds of severe shigellosis were higher among blacks than whites (OR [95% CI] = 1.36 [1.22-1.52], p < 0.001). CONCLUSIONS: Among adults, men 18-49 years old, particularly blacks, have the highest incidence of severe shigellosis. Among adults with shigellosis, severe shigellosis was associated with being male in age group 18-49 years, with infections caused by S. flexneri, and with black race. Future research should assess associations between severe shigellosis and sexual practices, antimicrobial resistance, comorbidities, and access to care.

    • Global Health
      1. Frontline field epidemiology training programs as a strategy to improve disease surveillance and response
        Andre AM, Lopez A, Perkins S, Lambert S, Chace L, Noudeke N, Fall A, Pedalino B.
        Emerg Infect Dis. 2017 Dec;23(13).
        Since 1980, Field Epidemiology Training Programs (FETPs) have trained highly qualified field epidemiologists to work for ministries of health (MOH) around the world. However, the 2013-2015 Ebola epidemic in West Africa, which primarily affected Guinea, Liberia, and Sierra Leone, demonstrated a lack of field epidemiologists at the local levels. Trained epidemiologists at these levels could have detected the Ebola outbreak earlier. In 2015, the US Centers for Disease Control and Prevention (CDC) launched FETP-Frontline, a 3-month field training program targeting local MOH staff in 24 countries to augment local public health capacity. As of December 2016, FETP-Frontline has trained 1,354 graduates in 24 countries. FETP-Frontline enhances global health security by training local public health staff to improve surveillance quality in their jurisdictions, which can be a valuable strategy to strengthen the capacity of countries to more rapidly detect, respond to, and contain public health emergencies at the source.

      2. Progress and opportunities for strengthening global health security
        Angulo FJ, Cassell CH, Tappero JW, Bunnell RE.
        Emerg Infect Dis. 2017 ;23:S1-S4.

        [No abstract]

      3. Sustainable model for public health emergency operations centers for global settings
        Balajee SA, Pasi OG, Etoundi AG, Rzeszotarski P, Do TT, Hennessee I, Merali S, Alroy KA, Phu TD, Mounts AW.
        Emerg Infect Dis. 2017 Oct;23(13).
        Capacity to receive, verify, analyze, assess, and investigate public health events is essential for epidemic intelligence. Public health Emergency Operations Centers (PHEOCs) can be epidemic intelligence hubs by 1) having the capacity to receive, analyze, and visualize multiple data streams, including surveillance and 2) maintaining a trained workforce that can analyze and interpret data from real-time emerging events. Such PHEOCs could be physically located within a ministry of health epidemiology, surveillance, or equivalent department rather than exist as a stand-alone space and serve as operational hubs during nonoutbreak times but in emergencies can scale up according to the traditional Incident Command System structure.

      4. Zoonotic disease programs for enhancing global health security
        Belay ED, Kile JC, Hall AJ, Barton-Behravesh C, Parsons MB, Salyer S, Walke H.
        Emerg Infect Dis. 2017 Dec;23(13).
        Most infectious diseases that recently emerged in humans originated in animals. Besides close contact between animals and humans, other factors probably contribute to the cross-species transmission of infectious diseases. It is critical to establish effective mechanisms for coordination and collaboration between the animal, human, and environmental health sectors before new threats emerge by bringing the different sectors together to tackle endemic zoonotic diseases of greatest concern. Such multisectoral partnerships should begin by identifying priority zoonotic diseases for national engagement with equal input from the different sectors. Improvements in surveillance and data sharing for prioritized zoonotic diseases and enhancements of laboratory testing and joint outbreak response capacities in the human and animal health sectors will create and strengthen the mechanisms necessary to effectively detect and respond to emerging health threats, and thereby enhance global health security.

      5. Centers for Disease Control and Prevention public health response to humanitarian emergencies, 2007-2016
        Boyd AT, Cookson ST, Anderson M, Bilukha OO, Brennan M, Handzel T, Hardy C, Husain F, Cardozo BL, Colorado CN, Shahpar C, Talley L, Toole M, Gerber M.
        Emerg Infect Dis. 2017 Dec;23(13).
        Humanitarian emergencies, including complex emergencies associated with fragile states or areas of conflict, affect millions of persons worldwide. Such emergencies threaten global health security and have complicated but predictable effects on public health. The Centers for Disease Control and Prevention (CDC) Emergency Response and Recovery Branch (ERRB) (Division of Global Health Protection, Center for Global Health) contributes to public health emergency responses by providing epidemiologic support for humanitarian health interventions. To capture the extent of this emergency response work for the past decade, we conducted a retrospective review of ERRB’s responses during 2007-2016. Responses were conducted across the world and in collaboration with national and international partners. Lessons from this work include the need to develop epidemiologic tools for use in resource-limited contexts, build local capacity for response and health systems recovery, and adapt responses to changing public health threats in fragile states. Through ERRB’s multisector expertise and ability to respond quickly, CDC guides humanitarian response to protect emergency-affected populations.

      6. CDC support for global public health emergency management
        Brencic DJ, Pinto M, Gill A, Kinzer MH, Hernandez L, Pasi OG.
        Emerg Infect Dis. 2017 Dec;23(13).
        Recent pandemics and rapidly spreading outbreaks of infectious diseases have illustrated the interconnectedness of the world and the importance of improving the international community’s ability to effectively respond. The Centers for Disease Control and Prevention (CDC), building on a strong foundation of lessons learned through previous emergencies, international recognition, and human and technical expertise, has aspired to support nations around the world to strengthen their public health emergency management (PHEM) capacity. PHEM principles streamline coordination and collaboration in responding to infectious disease outbreaks, which align with the core capacities outlined in the International Health Regulations 2005. CDC supports PHEM by providing in-country technical assistance, aiding the development of plans and procedures, and providing fellowship opportunities for public health emergency managers. To this end, CDC partners with US agencies, international partners, and multilateral organizations to support nations around the world to reduce illness and death from outbreaks of infectious diseases.

      7. Surveillance training for Ebola preparedness in Cote d’Ivoire, Guinea-Bissau, Senegal, and Mali
        Caceres VM, Sidibe S, Andre M, Traicoff D, Lambert S, King M, Kazambu D, Lopez A, Pedalino B, Guibert DJ, Wassawa P, Cardoso P, Assi B, Ly A, Traore B, Angulo FJ, Quick L.
        Emerg Infect Dis. 2017 Dec;23(13).
        The 2014-2015 epidemic of Ebola virus disease in West Africa primarily affected Guinea, Liberia, and Sierra Leone. Several countries, including Mali, Nigeria, and Senegal, experienced Ebola importations. Realizing the importance of a trained field epidemiology workforce in neighboring countries to respond to Ebola importations, the Centers for Disease Control and Prevention Field Epidemiology Training Program unit implemented the Surveillance Training for Ebola Preparedness (STEP) initiative. STEP was a mentored, competency-based initiative to rapidly build up surveillance capacity along the borders of the at-risk neighboring countries Cote d’Ivoire, Mali, Senegal, and Guinea-Bissau. The target audience was district surveillance officers. STEP was delivered to 185 participants from 72 health units (districts or regions). Timeliness of reporting and the quality of surveillance analyses improved 3 months after training. STEP demonstrated that mentored, competency-based training, where learners attain competencies while delivering essential public health services, can be successfully implemented in an emergency response setting.

      8. Real-time surveillance in emergencies using the Early Warning Alert and Response Network
        Cordes KM, Cookson ST, Boyd AT, Hardy C, Malik MR, Mala P, El Tahir K, Everard M, Jasiem M, Husain F.
        Emerg Infect Dis. 2017 Nov;23(13).
        Humanitarian emergencies often result in population displacement and increase the risk for transmission of communicable diseases. To address the increased risk for outbreaks during humanitarian emergencies, the World Health Organization developed the Early Warning Alert and Response Network (EWARN) for early detection of epidemic-prone diseases. The US Centers for Disease Control and Prevention has worked with the World Health Organization, ministries of health, and other partners to support EWARN through the implementation and evaluation of these systems and the development of standardized guidance. Although protocols have been developed for the implementation and evaluation of EWARN, a need persists for standardized training and additional guidance on supporting these systems remotely when access to affected areas is restricted. Continued collaboration between partners and the Centers for Disease Control and Prevention for surveillance during emergencies is necessary to strengthen capacity and support global health security.

      9. Contributions of the US Centers for Disease Control and Prevention in implementing the global health security agenda in 17 partner countries
        Fitzmaurice AG, Mahar M, Moriarty LF, Bartee M, Hirai M, Li W, Gerber AR, Tappero JW, Bunnell R.
        Emerg Infect Dis. 2017 Dec;23(13).
        The Global Health Security Agenda (GHSA), a partnership of nations, international organizations, and civil society, was launched in 2014 with a mission to build countries’ capacities to respond to infectious disease threats and to foster global compliance with the International Health Regulations (IHR 2005). The US Centers for Disease Control and Prevention (CDC) assists partner nations to improve IHR 2005 capacities and achieve GHSA targets. To assess progress through these CDC-supported efforts, we analyzed country activity reports dating from April 2015 through March 2017. Our analysis shows that CDC helped 17 Phase I countries achieve 675 major GHSA accomplishments, particularly in the cross-cutting areas of public health surveillance, laboratory systems, workforce development, and emergency response management. CDC’s engagement has been critical to these accomplishments, but sustained support is needed until countries attain IHR 2005 capacities, thereby fostering national and regional health protection and ensuring a world safer and more secure from global health threats.

      10. Use of a diagonal approach to health system strengthening and measles elimination after a large nationwide outbreak in Mongolia
        Hagan JE, Greiner A, Luvsansharav UO, Lake J, Lee C, Pastore R, Takashima Y, Sarankhuu A, Demberelsuren S, Smith R, Park B, Goodson JL.
        Emerg Infect Dis. 2017 Dec;23(13).
        Measles is a highly transmissible infectious disease that causes serious illness and death worldwide. Efforts to eliminate measles through achieving high immunization coverage, well-performing surveillance systems, and rapid and effective outbreak response mechanisms while strategically engaging and strengthening health systems have been termed a diagonal approach. In March 2015, a large nationwide measles epidemic occurred in Mongolia, 1 year after verification of measles elimination in this country. A multidisciplinary team conducted an outbreak investigation that included a broad health system assessment, organized around the Global Health Security Agenda framework of Prevent-Detect-Respond, to provide recommendations for evidence-based interventions to interrupt the epidemic and strengthen the overall health system to prevent future outbreaks of measles and other epidemic-prone infectious threats. This investigation demonstrated the value of evaluating elements of the broader health system in investigating measles outbreaks and the need for using a diagonal approach to achieving sustainable measles elimination.

      11. Capacity development through the US President’s Malaria Initiative-Supported Antimalarial Resistance Monitoring in Africa Network
        Halsey ES, Venkatesan M, Plucinski MM, Talundzic E, Lucchi NW, Zhou Z, Mandara CI, Moonga H, Hamainza B, Beavogui AH, Kariuki S, Samuels AM, Steinhardt LC, Mathanga DP, Gutman J, Denon YE, Uwimana A, Assefa A, Hwang J, Shi YP, Dimbu PR, Koita O, Ishengoma DS, Ndiaye D, Udhayakumar V.
        Emerg Infect Dis. 2017 Dec;23(13).
        Antimalarial drug resistance is an evolving global health security threat to malaria control. Early detection of Plasmodium falciparum resistance through therapeutic efficacy studies and associated genetic analyses may facilitate timely implementation of intervention strategies. The US President’s Malaria Initiative-supported Antimalarial Resistance Monitoring in Africa Network has assisted numerous laboratories in partner countries in acquiring the knowledge and capability to independently monitor for molecular markers of antimalarial drug resistance.

      12. Building global epidemiology and response capacity with field epidemiology training programs
        Jones DS, Dicker RC, Fontaine RE, Boore AL, Omolo JO, Ashgar RJ, Baggett HC.
        Emerg Infect Dis. 2017 Dec;23(13).
        More than ever, competent field epidemiologists are needed worldwide. As known, new, and resurgent communicable diseases increase their global impact, the International Health Regulations and the Global Health Security Agenda call for sufficient field epidemiologic capacity in every country to rapidly detect, respond to, and contain public health emergencies, thereby ensuring global health security. To build this capacity, for >35 years the US Centers for Disease Control and Prevention has worked with countries around the globe to develop Field Epidemiology Training Programs (FETPs). FETP trainees conduct surveillance activities and outbreak investigations in service to ministry of health programs to prevent and control infectious diseases of global health importance such as polio, cholera, tuberculosis, HIV/AIDS, malaria, and emerging zoonotic infectious diseases. FETP graduates often rise to positions of leadership to direct such programs. By training competent epidemiologists to manage public health events locally and support public health systems nationally, health security is enhanced globally.

      13. Synergies between communicable and noncommunicable disease programs to enhance global health security
        Kostova D, Husain MJ, Sugerman D, Hong Y, Saraiya M, Keltz J, Asma S.
        Emerg Infect Dis. 2017 Dec;23(13).
        Noncommunicable diseases are the leading cause of death and disability worldwide. Initiatives that advance the prevention and control of noncommunicable diseases support the goals of global health security in several ways. First, in addressing health needs that typically require long-term care, these programs can strengthen health delivery and health monitoring systems, which can serve as necessary platforms for emergency preparedness in low-resource environments. Second, by improving population health, the programs might help to reduce susceptibility to infectious outbreaks. Finally, in aiming to reduce the economic burden associated with premature illness and death from noncommunicable diseases, these initiatives contribute to the objectives of international development, thereby helping to improve overall country capacity for emergency response.

      14. Ebola response impact on public health programs, West Africa, 2014-2017
        Marston BJ, Dokubo EK, van Steelandt A, Martel L, Williams D, Hersey S, Jambai A, Keita S, Nyenswah TG, Redd JT.
        Emerg Infect Dis. 2017 Dec;23(13).
        Events such as the 2014-2015 West Africa epidemic of Ebola virus disease highlight the importance of the capacity to detect and respond to public health threats. We describe capacity-building efforts during and after the Ebola epidemic in Liberia, Sierra Leone, and Guinea and public health progress that was made as a result of the Ebola response in 4 key areas: emergency response, laboratory capacity, surveillance, and workforce development. We further highlight ways in which capacity-building efforts such as those used in West Africa can be accelerated after a public health crisis to improve preparedness for future events.

      15. Cholera mortality during urban epidemic, Dar es Salaam, Tanzania, August 16, 2015-January 16, 2016
        McCrickard LS, Massay AE, Narra R, Mghamba J, Mohamed AA, Kishimba RS, Urio LJ, Rusibayamila N, Magembe G, Bakari M, Gibson JJ, Eidex RB, Quick RE.
        Emerg Infect Dis. 2017 Dec;23(13).
        In 2015, a cholera epidemic occurred in Tanzania; most cases and deaths occurred in Dar es Salaam early in the outbreak. We evaluated cholera mortality through passive surveillance, burial permits, and interviews conducted with decedents’ caretakers. Active case finding identified 101 suspected cholera deaths. Routine surveillance had captured only 48 (48%) of all cholera deaths, and burial permit assessments captured the remainder. We interviewed caregivers of 56 decedents to assess cholera management behaviors. Of 51 decedents receiving home care, 5 (10%) used oral rehydration solution after becoming ill. Caregivers reported that 51 (93%) of 55 decedents with known time of death sought care before death; 16 (29%) of 55 delayed seeking care for >6 h. Of the 33 (59%) community decedents, 20 (61%) were said to have been discharged from a health facility before death. Appropriate and early management of cholera cases can reduce the number of cholera deaths.

      16. Responding to communicable diseases in internationally mobile populations at points of entry and along porous borders, Nigeria, Benin, and Togo
        Merrill RD, Rogers K, Ward S, Ojo O, Kakai CG, Agbeko TT, Garba H, MacGurn A, Oppert M, Kone I, Bamsa O, Schneider D, Brown C.
        Emerg Infect Dis. 2017 Dec;23(13).
        Recent multinational disease outbreaks demonstrate the risk of disease spreading globally before public health systems can respond to an event. To ensure global health security, countries need robust multisectoral systems to rapidly detect and respond to domestic or imported communicable diseases. The US Centers for Disease Control and Prevention International Border Team works with the governments of Nigeria, Togo, and Benin, along with Pro-Health International and the Abidjan-Lagos Corridor Organization, to build sustainable International Health Regulations capacities at points of entry (POEs) and along border regions. Together, we strengthen comprehensive national and regional border health systems by developing public health emergency response plans for POEs, conducting qualitative assessments of public health preparedness and response capacities at ground crossings, integrating internationally mobile populations into national health surveillance systems, and formalizing cross-border public health coordination. Achieving comprehensive national and regional border health capacity, which advances overall global health security, necessitates multisectoral dedication to the aforementioned components.

      17. CDC safety training course for Ebola virus disease healthcare workers
        Narra R, Sobel J, Piper C, Gould D, Bhadelia N, Dott M, Fiore A, Fischer WA, Frawley MJ, Griffin PM, Hamilton D, Mahon B, Pillai SK, Veltus EF, Tauxe R, Jhung M.
        Emerg Infect Dis. 2017 Dec;23(13).
        Response to sudden epidemic infectious disease emergencies can demand intensive and specialized training, as demonstrated in 2014 when Ebola virus disease (EVD) rapidly spread throughout West Africa. The medical community quickly became overwhelmed because of limited staff, supplies, and Ebola treatment units (ETUs). Because a mechanism to rapidly increase trained healthcare workers was needed, the US Centers for Disease Control and Prevention developed and implemented an introductory EVD safety training course to prepare US healthcare workers to work in West Africa ETUs. The goal was to teach principles and practices of safely providing patient care and was delivered through lectures, small-group breakout sessions, and practical exercises. During September 2014-March 2015, a total of 570 participants were trained during 16 course sessions. This course quickly increased the number of clinicians who could provide care in West Africa ETUs, showing the feasibility of rapidly developing and implementing training in response to a public health emergency.

      18. Assessment of National Public Health and Reference Laboratory, Accra, Ghana, within framework of global health security
        Ogee-Nwankwo A, Opare D, Boateng G, Nyaku M, Haynes LM, Balajee SA, Conklin L, Icenogle JP, Rota PA, Waku-Kouomou D.
        Emerg Infect Dis. 2017 Dec;23(13).
        The Second Year of Life project of the Global Health Security Agenda aims to improve immunization systems and strengthen measles and rubella surveillance, including building laboratory capacity. A new laboratory assessment tool was developed by the Centers for Disease Control and Prevention to assess the national laboratory in Ghana to improve molecular surveillance for measles and rubella. Results for the tool showed that the laboratory is well organized, has a good capacity for handling specimens, has a good biosafety system, and is proficient for diagnosis of measles and rubella by serologic analysis. However, there was little knowledge about molecular biology and virology activities (i.e., virus isolation on tissue culture was not available). Recommendations included training of technical personnel for molecular techniques and advocacy for funding for laboratory equipment, reagents, and supplies.

      19. Enhancing laboratory response network capacity in South Korea
        Parker JT, Juren AC, Lowe L, Santibanez S, Rhie GE, Merlin TL.
        Emerg Infect Dis. 2017 Oct;23(13).
        Laboratory Response Network (LRN) laboratories help protect populations from biological and chemical public health threats. We examined the role of LRN biological laboratories in enhancing capacity to detect and respond to public health infectious disease emergencies in South Korea. The model for responding to infectious disease emergencies leverages standardized laboratory testing procedures, a repository of standardized testing reagents, laboratory testing cooperation among hospital sentinel laboratories and reference laboratories, and maintenance of a trained workforce through traditional and on-demand training. Cooperation among all network stakeholders helps ensure that laboratory response is an integrated part of the national response. The added laboratory testing capacity provided by the US Centers for Disease Control and Prevention LRN assets helps protect persons who reside in South Korea, US military personnel and civilians in South Korea, and those who reside in the continental United States.

      20. Expanding pertussis epidemiology in 6 Latin America countries through the Latin American Pertussis Project
        Pinell-McNamara VA, Acosta AM, Pedreira MC, Carvalho AF, Pawloski L, Tondella ML, Briere E.
        Emerg Infect Dis. 2017 Dec;23(13).
        The Latin American Pertussis Project (LAPP), established in 2009, is a collaboration between the Centers for Disease Control and Prevention, Pan American Health Organization, Sabin Vaccine Institute, and the ministries of health of 6 countries in Latin America. The project goal is to expand understanding of pertussis epidemiology in Latin America to inform strategies for control and prevention. Here we describe LAPP structure and activities. After an initial surveillance evaluation, LAPP activities are tailored to individual country needs. LAPP activities align with Global Health Security Agenda priorities and have focused on expanding laboratory diagnostic capacity, implementing a laboratory quality control and quality assurance program, and providing epidemiologic support to strengthen reporting of pertussis surveillance data. Lessons learned include that ongoing mentoring is key to the successful adoption of new technologies and that sustainability of laboratory diagnostics requires a regional commitment to procure reagents and related supplies.

      21. Global disease detection-achievements in applied public health research, capacity building, and public health diplomacy, 2001-2016
        Rao CY, Goryoka GW, Henao OL, Clarke KR, Salyer SJ, Montgomery JM.
        Emerg Infect Dis. 2017 Nov;23(13).
        The Centers for Disease Control and Prevention has established 10 Global Disease Detection (GDD) Program regional centers around the world that serve as centers of excellence for public health research on emerging and reemerging infectious diseases. The core activities of the GDD Program focus on applied public health research, surveillance, laboratory, public health informatics, and technical capacity building. During 2015-2016, program staff conducted 205 discrete projects on a range of topics, including acute respiratory illnesses, health systems strengthening, infectious diseases at the human-animal interface, and emerging infectious diseases. Projects incorporated multiple core activities, with technical capacity building being most prevalent. Collaborating with host countries to implement such projects promotes public health diplomacy. The GDD Program continues to work with countries to strengthen core capacities so that emerging diseases can be detected and stopped faster and closer to the source, thereby enhancing global health security.

      22. Zoonotic diseases represent critical threats to global health security. Effective mitigation of the impact of endemic and emerging zoonotic diseases of public health importance requires multisectoral collaboration and interdisciplinary partnerships. The US Centers for Disease Control and Prevention created the One Health Zoonotic Disease Prioritization Tool to help countries identify zoonotic diseases of greatest national concern using input from representatives of human health, agriculture, environment, and wildlife sectors. We review 7 One Health Zoonotic Disease Prioritization Tool workshops conducted during 2014-2016, highlighting workshop outcomes, lessons learned, and shared themes from countries implementing this process. We also describe the tool’s ability to help countries focus One Health capacity-building efforts to appropriately prevent, detect, and respond to zoonotic disease threats.

      23. CDC activities for improving implementation of human papillomavirus vaccination, cervical cancer screening, and surveillance worldwide
        Senkomago V, Duran D, Loharikar A, Hyde TB, Markowitz LE, Unger ER, Saraiya M.
        Emerg Infect Dis. 2017 Dec;23(13).
        Cervical cancer incidence and mortality rates are high, particularly in developing countries. Most cervical cancers can be prevented by human papillomavirus (HPV) vaccination, screening, and timely treatment. The US Centers for Disease Control and Prevention (CDC) provides global technical assistance for implementation and evaluation of HPV vaccination pilot projects and programs and laboratory-related HPV activities to assess HPV vaccines. CDC collaborates with global partners to develop global cervical cancer screening recommendations and manuals, implement screening, create standardized evaluation tools, and provide expertise to monitor outcomes. CDC also trains epidemiologists in cancer prevention through its Field Epidemiology Training Program and is working to improve cancer surveillance by supporting efforts of the World Health Organization in developing cancer registry hubs and assisting countries in estimating costs for developing population-based cancer registries. These activities contribute to the Global Health Security Agenda action packages to improve immunization, surveillance, and the public health workforce globally.

      24. Frameworks for preventing, detecting, and controlling zoonotic diseases
        Shiferaw ML, Doty JB, Maghlakelidze G, Morgan J, Khmaladze E, Parkadze O, Donduashvili M, Wemakoy EO, Muyembe JJ, Mulumba L, Malekani J, Kabamba J, Kanter T, Boulanger LL, Haile A, Bekele A, Bekele M, Tafese K, McCollum AA, Reynolds MG.
        Emerg Infect Dis. 2017 Dec;23(13).
        Preventing zoonotic diseases requires coordinated actions by government authorities responsible for human and animal health. Constructing the frameworks needed to foster intersectoral collaboration can be approached in many ways. We highlight 3 examples of approaches to implement zoonotic disease prevention and control programs. The first, rabies control in Ethiopia, was implemented using an umbrella approach: a comprehensive program designed for accelerated impact. The second, a monkeypox program in Democratic Republic of the Congo, was implemented in a stepwise manner, whereby incremental improvements and activities were incorporated into the program. The third approach, a pathogen discovery program, applied in the country of Georgia, was designed to characterize and understand the ecology, epidemiology, and pathogenesis of a new zoonotic pathogen. No one approach is superior, but various factors should be taken into account during design, planning, and implementation.

      25. Establishment of CDC Global Rapid Response Team to Ensure Global Health Security
        Stehling-Ariza T, Lefevre A, Calles D, Djawe K, Garfield R, Gerber M, Ghiselli M, Giese C, Greiner AL, Hoffman A, Miller LA, Moorhouse L, Navarro-Colorado C, Walsh J, Bugli D, Shahpar C.
        Emerg Infect Dis. 2017 Dec;23(13).
        The 2014-2016 Ebola virus disease epidemic in West Africa highlighted challenges faced by the global response to a large public health emergency. Consequently, the US Centers for Disease Control and Prevention established the Global Rapid Response Team (GRRT) to strengthen emergency response capacity to global health threats, thereby ensuring global health security. Dedicated GRRT staff can be rapidly mobilized for extended missions, improving partner coordination and the continuity of response operations. A large, agencywide roster of surge staff enables rapid mobilization of qualified responders with wide-ranging experience and expertise. Team members are offered emergency response training, technical training, foreign language training, and responder readiness support. Recent response missions illustrate the breadth of support the team provides. GRRT serves as a model for other countries and is committed to strengthening emergency response capacity to respond to outbreaks and emergencies worldwide, thereby enhancing global health security.

      26. US Centers for Disease Control and Prevention and its partners’ contributions to global health security
        Tappero JW, Cassell CH, Bunnell RE, Angulo FJ, Craig A, Pesik N, Dahl BA, Ijaz K, Jafari H, Martin R.
        Emerg Infect Dis. 2017 Dec;23(13).
        To achieve compliance with the revised World Health Organization International Health Regulations (IHR 2005), countries must be able to rapidly prevent, detect, and respond to public health threats. Most nations, however, remain unprepared to manage and control complex health emergencies, whether due to natural disasters, emerging infectious disease outbreaks, or the inadvertent or intentional release of highly pathogenic organisms. The US Centers for Disease Control and Prevention (CDC) works with countries and partners to build and strengthen global health security preparedness so they can quickly respond to public health crises. This report highlights selected CDC global health protection platform accomplishments that help mitigate global health threats and build core, cross-cutting capacity to identify and contain disease outbreaks at their source. CDC contributions support country efforts to achieve IHR 2005 compliance, contribute to the international framework for countering infectious disease crises, and enhance health security for Americans and populations around the world.

      27. Enhancing surveillance and diagnostics in anthrax-endemic countries
        Vieira AR, Salzer JS, Traxler RM, Hendricks KA, Kadzik ME, Marston CK, Kolton CB, Stoddard RA, Hoffmaster AR, Bower WA, Walke HT.
        Emerg Infect Dis. 2017 Dec;23(13).
        Naturally occurring anthrax disproportionately affects the health and economic welfare of poor, rural communities in anthrax-endemic countries. However, many of these countries have limited anthrax prevention and control programs. Effective prevention of anthrax outbreaks among humans is accomplished through routine livestock vaccination programs and prompt response to animal outbreaks. The Centers for Disease Control and Prevention uses a 2-phase framework when providing technical assistance to partners in anthrax-endemic countries. The first phase assesses and identifies areas for improvement in existing human and animal surveillance, laboratory diagnostics, and outbreak response. The second phase provides steps to implement improvements to these areas. We describe examples of implementing this framework in anthrax-endemic countries. These activities are at varying stages of completion; however, the public health impact of these initiatives has been encouraging. The anthrax framework can be extended to other zoonotic diseases to build on these efforts, improve human and animal health, and enhance global health security.

      28. US federal travel restrictions for persons with higher-risk exposures to communicable diseases of public health concern
        Vonnahme LA, Jungerman MR, Gulati RK, Illig P, Alvarado-Ramy F.
        Emerg Infect Dis. 2017 Dec;23(13).
        Published guidance recommends controlled movement for persons with higher-risk exposures (HREs) to communicable diseases of public health concern; US federal public health travel restrictions (PHTRs) might be implemented to enforce these measures. We describe persons eligible for and placed on PHTRs because of HREs during 2014-2016. There were 160 persons placed on PHTRs: 142 (89%) involved exposure to Ebola virus, 16 (10%) to Lassa fever virus, and 2 (1%) to Middle East respiratory syndrome coronavirus. Most (90%) HREs were related to an epidemic. No persons attempted to travel; all persons had PHTRs lifted after completion of a maximum disease-specific incubation period or a revised exposure risk classification. PHTR enforced controlled movement and removed risk for disease transmission among travelers who had contacts who refused to comply with public health recommendations. PHTRs are mechanisms to mitigate spread of communicable diseases and might be critical in enhancing health security during epidemics.

      29. Lessons learned from emergency response vaccination efforts for cholera, typhoid, yellow fever, and Ebola
        Walldorf JA, Date KA, Sreenivasan N, Harris JB, Hyde TB.
        Emerg Infect Dis. 2017 Dec;23(13).
        Countries must be prepared to respond to public health threats associated with emergencies, such as natural disasters, sociopolitical conflicts, or uncontrolled disease outbreaks. Rapid vaccination of populations vulnerable to epidemic-prone vaccine-preventable diseases is a major component of emergency response. Emergency vaccination planning presents challenges, including how to predict resource needs, expand vaccine availability during global shortages, and address regulatory barriers to deliver new products. The US Centers for Disease Control and Prevention supports countries to plan, implement, and evaluate emergency vaccination response. We describe work of the Centers for Disease Control and Prevention in collaboration with global partners to support emergency vaccination against cholera, typhoid, yellow fever, and Ebola, diseases for which a new vaccine or vaccine formulation has played a major role in response. Lessons learned will help countries prepare for future emergencies. Integration of vaccination with emergency response augments global health security through reducing disease burden, saving lives, and preventing spread across international borders.

      30. Enhancing workforce capacity to improve vaccination data quality, Uganda
        Ward K, Mugenyi K, Benke A, Luzze H, Kyozira C, Immaculate A, Tanifum P, Kisakye A, Bloland P, MacNeil A.
        Emerg Infect Dis. 2017 Dec;23(13).
        In Uganda, vaccine dose administration data are often not available or are of insufficient quality to optimally plan, monitor, and evaluate program performance. A collaboration of partners aimed to address these key issues by deploying data improvement teams (DITs) to improve data collection, management, analysis, and use in district health offices and health facilities. During November 2014-September 2016, DITs visited all districts and 89% of health facilities in Uganda. DITs identified gaps in awareness and processes, assessed accuracy of data, and provided on-the-job training to strengthen systems and improve healthcare workers’ knowledge and skills in data quality. Inaccurate data were observed primarily at the health facility level. Improvements in data management and collection practices were observed, although routine follow-up and accountability will be needed to sustain change. The DIT strategy offers a useful approach to enhancing the quality of health data.

      31. Monitoring trends in antimicrobial drug-resistant Neisseria gonorrhoeae is a critical public health and global health security activity because the number of antimicrobial drugs available to treat gonorrhea effectively is rapidly diminishing. Current global surveillance methods for antimicrobial drug-resistant N. gonorrhoeae have many limitations, especially in countries with the greatest burden of disease. The Enhanced Gonococcal Antimicrobial Surveillance Program is a collaboration between the World Health Organization and the Centers for Disease Control and Prevention. The program aims to monitor trends in antimicrobial drug susceptibilities in N. gonorrhoeae by using standardized sampling and laboratory protocols; to improve the quality, comparability, and timeliness of gonococcal antimicrobial drug resistance data across multiple countries; and to assess resistance patterns in key populations at highest risk for antimicrobial drug-resistant gonorrhea so country-specific treatment guidelines can be informed.

    • Health Economics
      1. Population level outcomes and cost-effectiveness of expanding the recommendation for age-based hepatitis C testing in the United States
        Barocas JA, Tasillo A, Eftekhari Yazdi G, Wang J, Vellozzi C, Hariri S, Isenhour C, Randall L, Ward JW, Mermin J, Salomon JA, Linas BP.
        Clin Infect Dis. 2018 Feb 6.
        Background: The U.S. Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born 1945-1965 and targeted testing for high-risk persons. This strategy targets HCV testing to a prevalent population at high risk for HCV morbidity and mortality, but does not include younger populations with high incidence. To address this gap and improve access to HCV testing, age-based strategies should be considered. Methods: We used a simulation of HCV to estimate the effectiveness and cost-effectiveness of HCV testing strategies: 1) standard of care (SOC) – recommendation for one-time testing for all persons born 1945-1965, 2) recommendation for one-time testing for adults >/=40 years (>/=40 strategy), 3) >/=30 years (>/=30 strategy), and 4) >/=18 years (>/=18 strategy). All strategies assumed targeted testing of high-risk persons. Inputs were derived from national databases, observational cohorts and clinical trials. Outcomes included quality-adjusted life expectancy, costs, and cost-effectiveness. Results: Expanded age-based testing strategies increased U.S. population lifetime case identification and cure rates. Greatest increases were observed in the >/=18 strategy. Compared to the SOC, this strategy resulted in an estimated 256,000 additional infected persons identified and 280,000 additional cures at the lowest cost per QALY gained (ICER = $28,000/QALY). Conclusions: In addition to risk-based testing, one-time HCV testing of persons 18 and older appears to be cost-effective, leads to improved clinical outcomes and identifies more persons with HCV than the current birth cohort recommendations. These findings could be considered for future recommendation revisions.

      2. Cost of tobacco-related cancer hospitalizations in the U.S., 2014
        Tai EW, Guy GP, Steele CB, Henley SJ, Gallaway MS, Richardson LC.
        Am J Prev Med. 2018 Jan 31.
        INTRODUCTION: Smoking has been causally linked to 12 tobacco-related cancers: oral cavity and pharynx, esophagus, stomach, colon and rectum, liver, pancreas, larynx, lung, cervix, bladder, kidney, and acute myeloid leukemia. Tobacco-related cancers-related morbidity and mortality have been well described, but little is known about the prevalence of tobacco-related cancer hospitalizations and associated costs. This study estimates the annual number of tobacco-related cancer hospitalizations and their associated direct medical costs in the U.S. METHODS: This study examined data from the 2014 National Inpatient Sample, the largest publicly available all-payer inpatient care database in the U.S. The authors calculated number of hospitalizations, total costs, length of stay, and cost per stay for tobacco-related cancer hospitalizations and cancer hospitalizations not related to tobacco. RESULTS: In 2014, there were an estimated 461,295 annual tobacco-related cancer hospitalizations at a cost of $8.2 billion in the U.S. Tobacco-related cancers accounted for 45% of total cancer hospitalizations and cancer hospitalization costs. Compared with cancer hospitalizations not related to tobacco, tobacco-related cancer hospitalizations had a longer mean length of stay (6.8 vs 5.7 days). CONCLUSIONS: The burden of tobacco-related cancer hospitalizations is substantial in the U.S. These findings highlight the importance of tobacco prevention and cessation efforts to decrease the burden of tobacco-related cancers in the U.S.

    • Healthcare Associated Infections
      1. Multistate outbreak of an emerging Burkholderia cepacia complex strain associated with contaminated oral liquid docusate sodium
        Akinboyo IC, Sick-Samuels AC, Singeltary E, Fackler J, Ascenzi J, Carroll KC, Maldonado Y, Brooks RB, Benowitz I, Wilson LE, LiPuma JJ, Milstone AM.
        Infect Control Hosp Epidemiol. 2018 Feb;39(2):237-239.

        [No abstract]

      2. Healthcare-associated measles following a nationwide outbreak in Mongolia
        Lake JG, Luvsansharav UO, Hagan JE, Goodson JL, Jigjidsuren N, Gombojamts N, Park BJ, Smith R.
        Clin Infect Dis. 2018 Jan 31.
        Measles virus is highly infectious and can spread rapidly through healthcare settings where vaccine coverage is low and isolation precautions are suboptimal. We describe healthcare-associated measles transmission during the large 2015-2016 measles outbreak in Mongolia, describe observed infection prevention gaps, and outline practical strategies to prevent healthcare-associated measles transmission.

    • Immunity and Immunization
      1. Updates on influenza vaccination in children
        Campbell AJ, Grohskopf LA.
        Infect Dis Clin North Am. 2018 Mar;32(1):75-89.
        Influenza vaccination is recommended for all children 6 months of age and older who do not have contraindications. This article provides an overview of information concerning burden of influenza among children in the United States; US-licensed influenza vaccines; vaccine immunogenicity, effectiveness, and safety; and recent updates relevant to use of these vaccines in pediatric populations. Influenza antiviral medications are discussed. Details concerning vaccine-related topics may be found in the current US Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices recommendations for use of influenza vaccines ( Additional information on influenza antivirals is located at

      2. In October 2017, the Advisory Committee on Immunization Practices (ACIP) voted to approve the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2018. The 2018 adult immunization schedule summarizes ACIP recommendations in two figures and a table of contraindications and precautions for vaccines recommended for adults, and is intended is to assist health care providers in implementing the current ACIP recommendations for vaccinating adults. The schedule can be found at* The full ACIP recommendations for each vaccine are available at The 2018 adult immunization schedule has also been approved by the American College of Physicians (, the American Academy of Family Physicians (, the American College of Obstetricians and Gynecologists (, and the American College of Nurse-Midwives ( The ACIP-recommended use of each vaccine is developed after an in-depth review of vaccine-related data, including data on disease epidemiology, vaccine efficacy and effectiveness, vaccine safety, feasibility of program implementation, and economic aspects of immunization policy (1).

      3. Association of health insurance status and vaccination coverage among adolescents 13-17 years of age
        Lu PJ, Yankey D, Jeyarajah J, O’Halloran A, Fredua B, Elam-Evans LD, Reagan-Steiner S.
        J Pediatr. 2018 Feb 2.
        OBJECTIVE: To assess selected vaccination coverage among adolescents by health insurance status and other access-to-care characteristics. STUDY DESIGN: The 2015 National Immunization Survey-Teen data were used to assess vaccination coverage disparities among adolescents by health insurance status and other access-to-care variables. Multivariable logistic regression analysis and a predictive marginal modeling were conducted to evaluate associations between health insurance status and vaccination coverage. RESULTS: Overall, vaccination coverage was significantly lower among uninsured compared with insured adolescents for all vaccines assessed for except >/=3 doses of human papillomavirus vaccine (HPV) among male adolescents. Among adolescents 13-17 years of age, vaccination of uninsured compared with insured adolescents, respectively, for tetanus toxoid, reduced content diphtheria toxoid, and acellular pertussis vaccine was 77.4% vs 86.8%; for >/=1 dose of meningococcal conjugate vaccine was 72.9% vs 81.7%; for >/=1 dose of HPV was 38.8% vs 50.2% among male and 42.9% vs 63.8% among female adolescents; for 3 doses of HPV was 24.9% vs 42.8% among female adolescents. In addition, vaccination coverage differed by the following: type of insurance among insured adolescents, having a well-child visit at 11-12 years of age, and number of healthcare provider contacts in the past year. Uninsured were less likely than insured adolescents to be vaccinated for HPV (female: >/=1 dose and 3 doses; and male: >/=1 doses) after adjusting for confounding variables. CONCLUSIONS: Overall, vaccination coverage was lower among uninsured adolescents. HPV vaccination coverage was lower than tetanus toxoid, reduced content diphtheria toxoid, and acellular pertussis vaccine Tdap and meningococcal conjugate vaccine in both insured and uninsured adolescents. Wider implementation of effective evidence-based strategies is needed to help improve vaccination coverage among adolescents, particularly for those who are uninsured. Limitation of current federally funded vaccination programs or access to healthcare would be expected to erode vaccine coverage of adolescents.

      4. Vaccine-associated hypersensitivity
        McNeil MM, DeStefano F.
        J Allergy Clin Immunol. 2018 Feb;141(2):463-472.
        Vaccine-associated hypersensitivity reactions are not infrequent; however, serious acute-onset, presumably IgE-mediated or IgG and complement-mediated anaphylactic or serious delayed-onset T cell-mediated systemic reactions are considered extremely rare. Hypersensitivity can occur because of either the active vaccine component (antigen) or one of the other components. Postvaccination acute-onset hypersensitivity reactions include self-limited localized adverse events and, rarely, systemic reactions ranging from urticaria/angioedema to full-blown anaphylaxis with multisystem involvement. Risk of anaphylaxis after all vaccines is estimated to be 1.31 (95% CI, 0.90-1.84) per million vaccine doses, respectively. Serious hypersensitivity reactions after influenza vaccines are particularly important because of the large number of persons vaccinated annually. Influenza vaccines are unique in requiring annual changes in the vaccines’ antigenic composition to match the predicted circulating influenza strains. Recently, novel influenza vaccine types were introduced in the United States (recombinant vaccines, some with higher antigen content and a new adjuvanted vaccine). Providers should be aware of changing recommendations on the basis of recent published evidence for persons with a history of egg allergy to receive annual influenza vaccination. Further research is needed to elucidate the pathophysiology and risk factors for reported vaccine-associated adverse events. Further research is also needed to determine whether repeated annual inactivated influenza vaccination, the number of vaccine antigens administered at the same time, and the current timing of routine infant vaccinations are optimal for overall population well-being.

      5. Vaccine delivery to newly arrived refugees and estimated costs in selected U.S. clinics, 2015
        Pezzi C, McCulloch A, Joo H, Cochran J, Smock L, Frerich E, Mamo B, Urban K, Hughes S, Payton C, Scott K, Maskery B, Lee D.
        Vaccine. 2018 Jan 26.
        BACKGROUND: Newly arrived refugees are offered vaccinations during domestic medical examinations. Vaccination practices and costs for refugees have not been described with recent implementation of the overseas Vaccination Program for U.S.-bound Refugees (VPR). We describe refugee vaccination during the domestic medical examination and the estimated vaccination costs from the US government perspective in selected U.S. clinics. METHODS: Site-specific vaccination processes and costs were collected from 16 clinics by refugee health partners in three states and one private academic institution. Vaccination costs were estimated from the U.S. Vaccines for Children Program and Medicaid reimbursement rates during fiscal year 2015. RESULTS: All clinics reviewed overseas vaccination records before vaccinating, but all records were not transferred into state immunization systems. Average vaccination costs per refugee varied from $120 to $211 by site. The total average cost of domestic vaccination was 15% less among refugees arriving from VPR- vs. nonVPR-participating countries during a single domestic visit. CONCLUSION: Our findings indicate that immunization practices and costs vary between clinics, and that clinics adapted their vaccination practices to accommodate VPR doses, yielding potential cost savings.

      6. Use of data to drive pneumococcal conjugate vaccine policy
        Pilishvili T, Whitney CG.
        Lancet Infect Dis. 2018 Jan 25.

        [No abstract]

      7. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger – United States, 2018
        Robinson CL, Romero JR, Kempe A, Pellegrini C, Szilagyi P.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):156-157.
        In October 2017, the Advisory Committee on Immunization Practices (ACIP) approved the Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger – United States, 2018. The 2018 child and adolescent immunization schedule summarizes ACIP recommendations, including several changes from the 2017 immunization schedules, in three figures and footnotes to the figures. These documents can be found on the CDC immunization schedule website ( These immunization schedules are approved by ACIP (, the American Academy of Pediatrics (, the American Academy of Family Physicians (, and the American College of Obstetricians and Gynecologists ( Health care providers are advised to use the figures and the footnotes together. The full ACIP recommendations for each vaccine, including contraindications and precautions, can be found at Providers should be aware that changes in recommendations for specific vaccines can occur between annual updates to the childhood/adolescent immunization schedules. If errors or omissions are discovered within the child and adolescent schedule, CDC posts revised versions on the CDC immunization schedule website.

      8. Influenza vaccine effectiveness in older adults compared with younger adults over five seasons
        Russell K, Chung JR, Monto AS, Martin ET, Belongia EA, McLean HQ, Gaglani M, Murthy K, Zimmerman RK, Nowalk MP, Jackson ML, Jackson LA, Flannery B.
        Vaccine. 2018 Feb 2.
        BACKGROUND: There have been inconsistent reports of decreased vaccine effectiveness (VE) against influenza viruses among older adults (aged>/=65years) compared with younger adults in the United States. A direct comparison of VE over multiple seasons is needed to assess the consistency of these observations. METHODS: We performed a pooled analysis of VE over 5 seasons among adults aged>/=18years who were systematically enrolled in the U.S. Flu VE Network. Outpatients with medically-attended acute respiratory illness (cough with illness onset</=7days prior to enrollment) were tested for influenza by reverse transcription polymerase chain reaction. We compared differences in VE and vaccine failures among older adult age group (65-74, >/=75, and>/=65years) to adults aged 18-49years by influenza type and subtype using interaction terms to test for statistical significance and stratified by prior season vaccination status. RESULTS: Analysis included 20,022 adults aged>/=18years enrolled during the 2011-12 through 2015-16 influenza seasons; 4,785 (24%) tested positive for influenza. VE among patients aged>/=65years was not significantly lower than VE among patients aged 18-49years against any subtype with no significant interaction of age and vaccination. VE against A(H3N2) viruses was 14% (95% confidence interval [CI] -14% to 36%) for adults>/=65years and 21% (CI 9-32%) for adults 18-49years. VE against A(H1N1)pdm09 was 49% (95% CI 22-66%) for adults>/=65years and 48% (95% CI 41-54%) for adults 18-49years and against B viruses was 62% (95% CI 44-74%) for adults>/=65years and 55% (95% CI 45-63%) for adults 18-49years. There was no significant interaction of age and vaccination for separate strata of prior vaccination status. CONCLUSIONS: Over 5 seasons, influenza vaccination provided similar levels of protection among older and younger adults, with lower levels of protection against influenza A(H3N2) in all ages.

      9. Evidence of the impact of monovalent rotavirus vaccine on childhood acute gastroenteritis hospitalization in Togo
        Tsolenyanu E, Djadou KE, Fiawoo M, Akolly DA, Mwenda JM, Leshem E, Tate JE, Aliabadi N, Koudema W, Guedenon KM, Godonou M, Dagnra A, Gbadoe AD, Boko A, Landoh D, Atakouma Y, Parashar UD.
        Vaccine. 2018 Jan 31.
        BACKGROUND: Monovalent rotavirus vaccine (RV1) was introduced in the immunization schedule of Togo in June 2014. We evaluated the impact of rotavirus vaccines on acute gastroenteritis (AGE) and rotavirus-associated hospitalizations in Togolese children. METHODS: Sentinel surveillance for AGE (defined as >/=3 liquid or semi-liquid stools/24h lasting <7days) hospitalizations among children <5years of age was conducted in two sites in the capital city, Lome. ELISA was used for diagnosis of rotavirus infection in children with AGE. Additionally, review of hospitalization registers was performed at five hospitals to assess trends in AGE hospitalizations among children aged <5years. For the vaccine impact assessment, pre-rotavirus vaccine introduction (July 2010-June 2014) and post-rotavirus vaccine introduction (July 2014-June 2016) periods were compared for annual changes in proportions of hospitalizations associated with AGE and rotavirus. RESULTS: During the pre-vaccine period, sentinel surveillance showed that 1017 patients were enrolled and 57% (range, 53-62%) tested positive for rotavirus, declining to 42% (23% reduction) in the first post-vaccine year and to 26% (53% reduction) in the second post-vaccine year; declines were most marked among infants. The patient register review showed that, compared with pre-vaccine rotavirus seasons, declines in hospitalizations due to all-cause AGE during post-vaccine rotavirus seasons were 48% among <1year age-group in both first and second years following vaccine introduction. Among 1-4year olds no reduction was noted in the first year and a 19% decline occurred in the second year. CONCLUSIONS: We report rapid and marked reduction in the number of AGE hospitalizations and the proportion of AGE hospitalizations attributable to rotavirus in the first two years post- RV1 implementation in Togo. It is necessary to monitor long-term vaccine impact on rotavirus disease burden through continued surveillance.

      10. Maternal immunization against Group B streptococcus: World Health Organization research and development technological roadmap and preferred product characteristics
        Vekemans J, Moorthy V, Friede M, Alderson MR, Sobanjo-Ter Meulen A, Baker CJ, Heath PT, Madhi SA, Mehring-Le Doare K, Saha SK, Schrag S, Kaslow DC.
        Vaccine. 2018 Feb 2.
        Group B streptococcus, found in the vagina or lower gastrointestinal tract of about 10-40% of women of reproductive age, is a leading cause of early life invasive bacterial disease, potentially amenable to prevention through maternal immunization during pregnancy. Following a consultation process with global stakeholders, the World Health Organization is herein proposing priority research and development pathways and preferred product characteristics for GBS vaccines, with the aim to facilitate and accelerate vaccine licensure, policy recommendation for wide scale use and implementation.

      11. Hepatitis A and hepatitis B vaccination coverage among adults with chronic liver disease
        Yue X, Black CL, O’Halloran A, Lu PJ, Williams WW, Nelson NP.
        Vaccine. 2018 Feb 21;36(9):1183-1189.
        BACKGROUND: Infection with hepatitis A and hepatitis B virus can increase the risk of morbidity and mortality in persons with chronic liver disease (CLD). The Advisory Committee on Immunization Practices recommends hepatitis A (HepA) and hepatitis B (HepB) vaccination for persons with CLD. METHODS: Data from the 2014 and 2015 National Health Interview Surveys (NHIS), nationally representative, in-person interview surveys of the non-institutionalized US civilian population, were used to assess self-reported HepA (>/=1 and>/=2 doses) and HepB vaccination (>/=1 and>/=3 doses) coverage among adults who reported a chronic or long-term liver condition. Multivariable logistic regression was used to identify factors independently associated with HepA and HepB vaccination among adults with CLD. RESULTS: Overall, 19.4% and 11.5% of adults aged>/=18years with CLD reported receiving >/=1 dose and >/=2 doses of HepA vaccine, respectively, compared with 14.7% and 9.1% of adults without CLD (p<.05 comparing those with and without CLD, >/=1dose). Age, education, geographic region, and international travel were associated with receipt of>/=2 doses HepA vaccine among adults with CLD. Overall, 35.7% and 29.1% of adults with CLD reported receiving>/=1 dose and>/=3 doses of HepB vaccine, respectively, compared with 30.2% and 24.7% of adults without CLD (p<.05 comparing those with and without CLD, >/=1 dose). Age, education, and receipt of influenza vaccination in the past 12months were associated with receipt of >/=3 doses HepB vaccine among adults with CLD. Among adults with CLD and >/=10 provider visits, only 13.8% and 35.3% had received >/=2 doses HepA and >/=3 doses HepB vaccine, respectively. CONCLUSIONS: HepA and HepB vaccination among adults with CLD is suboptimal and missed opportunities to vaccinate occurred. Providers should adhere to recommendations to vaccinate persons with CLD to increase vaccination among this population.

    • Informatics
      1. Modernizing Centers for Disease Control and Prevention informatics using surveillance data platform shared services
        Lee B, Martin T, Khan A, Fullerton K, Duck W, Kinley T, Stoutenburg S, Hall J, Crum M, Garcia MC, Iademarco MF, Richards CL.
        Public Health Rep. 2018 Jan 1:33354917751130.

        [No abstract]

    • Injury and Violence
      1. Nonfatal assaults among persons aged 10-24 years – United States, 2001-2015
        David-Ferdon CF, Haileyesus T, Liu Y, Simon TR, Kresnow MJ.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):141-145.
        In 2015, persons aged 10-24 years who were treated for nonfatal assault injuries in emergency departments (EDs) in the United States accounted for 32% of the approximately 1.5 million patients of all ages that EDs treated for nonfatal assault injuries (1). CDC analyzed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) to examine 2001-2015 trends in nonfatal assault injuries among youths treated in EDs, by sex and age group, and to assess current rates by sex, age group, mechanism of injury, and disposition (1). Rates for 2001-2015 were significantly higher among males than among females and among young adults aged 20-24 years than among youths aged 10-14 and 15-19 years. During 2011-2015, rates declined for all groups. The 2015 rate among persons aged 10-24 years was 753.2 per 100,000 population, the lowest in the 15-year study period. Despite encouraging trends, the assault rate among young persons remains high. Rates in 2015 were higher among males, persons aged 20-24 years, and those who incurred intentional strike or hit injuries. Nearly one in 10 patients were admitted to the hospital, transferred to another hospital, or held for observation. Youth violence prevention strategies, including primary prevention approaches that build individual skills, strengthen family relationships, or connect young persons treated in EDs to immediate and ongoing support, can be implemented to decrease injuries and fatalities (2).

      2. US campus fraternities and sororities and the young adult injury burden
        Peterson C, Foster SL, Xu L, Hartnett WM, Florence C, Haileyesus T.
        J Am Coll Health. 2018 Feb 6:0.
        OBJECTIVE: To investigate whether the presence of fraternities and sororities was associated with a higher local injury rate among undergraduate-age youth. METHODS: In 2016 we compared the rate of 2010-2013 youth (18-24 years) emergency department (ED) visits for injuries in Hospital Service Areas (HSA) with and without fraternities and sororities. ED visits were identified in the State Emergency Department Database (n=1,560 hospitals, 1,080 HSAs, 16 states). US Census Bureau and National Center for Education Statistics sources identified HSA population and campus (n=659) characteristics. A proprietary database identified campuses with fraternities and sororities (n=287). ED visits explicitly linked to fraternities and sororities in the National Electronic Injury Surveillance System-All Injury Program were used to identify injury causes for sub-group analysis. RESULTS: HSAs serving campuses with fraternities and sororities had lower age 18-24 injury rates for all causes except firearm injuries (no difference). CONCLUSIONS: Fraternities and sororities were not associated with a higher injury rate at the population level among undergraduate-age youth. A major limitation is not being able to observe campus health services utilization.

      3. The degree to which child maltreatment interacts with other household adversities to exacerbate risk for poor adult socioeconomic outcomes is uncertain. Moreover, the effects of residential, school, and caregiver transitions during childhood on adult outcomes are not well understood. This study examined the relation between household adversity and transitions in childhood with adult income problems, education, and unemployment in individuals with or without a childhood maltreatment history. The potential protective role of positive relationship quality in buffering these risk relationships was also tested. Data were from the Lehigh Longitudinal Study (n=457), where subjects were assessed at preschool, elementary, adolescent, and adult ages. Multiple group path analysis tested the relationships between childhood household adversity; residential, school, and caregiver transitions; and adult socioeconomic outcomes for each group. Caregiver relationship quality was included as a moderator, and gender as a covariate. Household adversity was negatively associated with education level and positively associated with income problems for non-maltreated children only. For both groups, residential transitions was negatively associated with education level and caregiver transitions was positively associated with unemployment problems. Relationship quality was positively associated with education level only for non-maltreated children. For children who did not experience maltreatment, reducing exposure to household adversity is an important goal for prevention. Reducing exposure to child maltreatment for all children remains an important public health priority. Results underscore the need for programs and policies that promote stable relationships and environments.

    • Laboratory Sciences
      1. Simultaneous quantitation of multiple contraceptive hormones in human serum by LC-MS/MS
        Blue SW, Winchell AJ, Kaucher AV, Lieberman RA, Gilles CT, Pyra MN, Heffron R, Hou X, Coombs RW, Nanda K, Davis NL, Kourtis AP, Herbeck JT, Baeten JM, Lingappa JR, Erikson DW.
        Contraception. 2018 Jan 30.
        OBJECTIVE: To develop a method to simultaneously quantify five commonly used hormonal contraceptives (HC) and 2 endogenous sex steroids by liquid chromatography-tandem triple quadrupole mass spectrometry (LC-MS/MS) and apply this method to human serum samples. STUDY DESIGN: We developed a method to simultaneously analyze ethinyl estradiol (EE2), etonogestrel (ENG), levonorgestrel (LNG), medroxyprogesterone acetate (MPA), and norethisterone (NET), along with estradiol (E2) and progesterone (P4) in human serum for a Shimadzu Nexera-LCMS-8050 LC-MS/MS platform. We analyzed serum collected from women self-reporting use of oral contraceptives, contraceptive implants or injectable contraceptives (n=14) and normally cycling women using no HC (n=15) as well as pooled samples from women administered various HC (ENG, n=6; LNG, n=14; MPA, n=7; NET, n=5). RESULTS: Limits of quantitation were 0.010ng/ml for E2, EE2, and P4; 0.020ng/ml for ENG, LNG, and MPA; and 0.040ng/ml for NET. Precisions for all assays, as indicated by coefficient of variation (CV) were less than or equal to 12.1%. Accuracies for all assays were in the range of 95-108%. Endogenous hormone values obtained from analysis of human serum samples are in agreement with levels previously reported in the literature for normally cycling women as well as for women taking the appropriate HC. CONCLUSIONS: We have developed a robust, accurate, and sensitive method for simultaneously analyzing commonly used contraceptive steroids and endogenous sex steroids in human serum. IMPLICATIONS: This analytical method can be used for quantitating contraceptive steroid levels in women for monitoring systemic exposure to determine drug interactions, nonadherence, misreporting, and proper dosing.

      2. BACKGROUND: Dengue, caused by one of the four serologically distinct dengue viruses (DENV-1 to – 4), is a mosquito-borne disease of serious global health significance. Reliable and cost-effective diagnostic tests, along with effective vaccines and vector-control strategies, are highly required to reduce dengue morbidity and mortality. Evaluation studies revealed that many commercially available NS1 antigen (Ag) tests have limited sensitivity to DENV-4 serotype compared to the other three serotypes. These studies indicated the need for development of new NS1 Ag detection test with improved sensitivity to DENV-4. An NS1 capture enzyme linked immunoassay (ELISA) specific to DENV-4 may improve the detection of DENV-4 cases worldwide. In addition, a serotype-specific NS1 Ag test identifies both DENV and the infecting serotype. METHODS: In this study, we used a small-ubiquitin-like modifier (SUMO*) cloning vector to express a SUMO*-DENV-4 rNS1 fusion protein to develop NS1 DENV-4 specific monoclonal antibodies (MAbs). These newly developed MAbs were then optimized for use in an anti-NS1 DENV-4 capture ELISA. The serotype specificity and sensitivity of this ELISA was evaluated using (i) supernatants from DENV (1-4)-infected Vero cell cultures, (ii) rNS1s from all the four DENV (1-4) and, (iii) rNS1s of related flaviviruses (yellow fever virus; YFV and West Nile virus; WNV). RESULTS: From the evaluation studies of the newly developed MAbs, we identified three DENV-4 specific anti-NS1 MAbs: 3H7A9, 8A6F2 and 6D4B10. Two of these MAbs were optimal for use in a DENV-4 serotype-specific NS1 capture ELISA: MAb 8A6F2 as the capture antibody and 6D4B10 as a detection antibody. CONCLUSION: This ELISA was sensitive and specific to DENV-4 with no cross-reactivity to other three DENV (1-3) serotypes and other heterologous flaviviruses. Taken together these data indicated that our MAbs are useful reagents for the development of DENV-4 immunodiagnostic tests.

      3. Quantitation of trans-fatty acids in human blood via isotope dilution-gas chromatography-negative chemical ionization-mass spectrometry
        Kuiper HC, Wei N, McGunigale SL, Vesper HW.
        J Chromatogr B Analyt Technol Biomed Life Sci. 2018 Feb 15;1076:35-43.
        Trans-fatty acids (TFA) are geometric isomers of naturally occurring cis-fatty acids. High dietary TFA intake has been associated with risk factors for cardiovascular disease. However, little is known about TFA levels in humans. To address this data need, we developed and validated a new isotope dilution-gas chromatography-negative chemical ionization-mass spectrometry (ID-GC-NCI-MS) method for quantitation of 27 fatty acids (FA) including 4 major TFA in human plasma, serum, and red blood cells (RBC) from 66 donors. Quantitation was performed with 18 isotope labeled internal standards and results are presented in muM and % of total FA. This method has high sensitivity and specificity due to use of pentafluorobenzyl-bromide derivatization combined with NCI-MS and a 200m column to optimize positional and geometric FA isomer separation. The four major TFA, palmitelaidic acid, elaidic acid, trans-vaccenic acid, and linoelaidic acid, were detected in all samples, with median total TFA concentrations of 17.7muM in plasma, 19.6muM in serum, and 21.5muM in RBC. The % of total FA for the TFA was 0.20% in plasma, 0.20% in serum, and 0.30% in RBC. Patterns for % FA are similar to those reported in other studies. We developed a highly specific, ID-GC-NCI-MS method to quantitate TFA and other FA in humans.

    • Maternal and Child Health
      1. Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care, emergency management, psychosocial care, and transitions of care across the lifespan
        Birnkrant DJ, Bushby K, Bann CM, Apkon SD, Blackwell A, Colvin MK, Cripe L, Herron AR, Kennedy A, Kinnett K, Naprawa J, Noritz G, Poysky J, Street N, Trout CJ, Weber DR, Ward LM.
        Lancet Neurol. 2018 Feb 1.
        Improvements in the function, quality of life, and longevity of patients with Duchenne muscular dystrophy (DMD) have been achieved through a multidisciplinary approach to management across a range of health-care specialties. In part 3 of this update of the DMD care considerations, we focus on primary care, emergency management, psychosocial care, and transitions of care across the lifespan. Many primary care and emergency medicine clinicians are inexperienced at managing the complications of DMD. We provide a guide to the acute and chronic medical conditions that these first-line providers are likely to encounter. With prolonged survival, individuals with DMD face a unique set of challenges related to psychosocial issues and transitions of care. We discuss assessments and interventions that are designed to improve mental health and independence, functionality, and quality of life in critical domains of living, including health care, education, employment, interpersonal relationships, and intimacy.

      2. This study uses nationally representative survey data to describe differences in characteristics, adverse family experiences, and child well-being among children in kinship care with varying levels of involvement with the child welfare system. Well-being is examined in the domains of physical and mental health, education, and permanency. Comparisons provide insight on kinship care arrangements inside and outside the child welfare system, as well as the variability among nonfoster kinship care arrangements.

      3. Valganciclovir use among commercially and Medicaid-insured infants with congenital CMV infection in the United States, 2009-2015
        Leung J, Dollard SC, Grosse SD, Chung W, Do T, Patel M, Lanzieri TM.
        Clin Ther. 2018 Jan 31.
        PURPOSE: The aim of this study was to assess the clinical characteristics and trends in valganciclovir use among infants diagnosed with congenital cytomegalovirus (CMV) disease in the United States. METHODS: We analyzed data from medical claims dated 2009-2015 from the Truven Health MarketScan((R)) Commercial Claims and Encounters and Medicaid databases. We identified infants with a live birth code in the first claim who were continuously enrolled for at least 45 days. Among infants diagnosed with congenital CMV disease, identified by an ICD-9-CM or ICD-10-CM code for congenital CMV infection or CMV disease within 45 days of birth, we assessed data from claims containing codes for any CMV-associated clinical condition within the same period, and data from claims for hearing loss and/or valganciclovir within the first 180 days of life. FINDINGS: In the commercial and Medicaid databases, we identified 257 (2.5/10,000) and 445 (3.3/10,000) infants, respectively, diagnosed with congenital CMV disease, among whom 135 (53%) and 282 (63%) had >/=1 CMV-associated condition, 30 (12%) and 32 (7%) had hearing loss, and 41 (16%) and 78 (18%) had a claim for valganciclovir. Among infants with congenital CMV disease who had a claim for valganciclovir, 37 (90%) among commercially insured infants and 68 (87%) among Medicaid-insured infants had >/=1 CMV-associated condition and/or hearing loss. From 2009 to 2015, the percentages with a claim for valganciclovir increased from 0% to 29% among commercially insured infants and from 4% to 37% among Medicaid-insured infants (P < 0.0001). IMPLICATIONS: During 2009-2015, there was a strong upward trend in valganciclovir claims among insured infants who were diagnosed with congenital CMV disease, the majority of whom had CMV-associated conditions and/or hearing loss.

      4. Infant feeding-related maternity care practices and maternal report of breastfeeding outcomes
        Nelson JM, Perrine CG, Freedman DS, Williams L, Morrow B, Smith RA, Dee DL.
        Birth. 2018 Feb 7.
        BACKGROUND: Evidence-based maternity practices and policies can improve breastfeeding duration and exclusivity. Maternity facilities report practices through the Maternity Practices in Infant Nutrition and Care (mPINC) survey, but individual outcomes, such as breastfeeding duration and exclusivity, are not collected. METHODS: mPINC data on maternity care practices for 2009 were linked to data from the 2009 Pregnancy Risk Assessment Monitoring System (PRAMS), which collects information on mothers’ behaviors and experiences around pregnancy. We calculated total mPINC scores (range 0-100). PRAMS data on any and exclusive breastfeeding at 8 weeks were examined by total mPINC score quartile. RESULTS: Of 15 715 women in our sample, 53.7% were breastfeeding any at 8 weeks, and 29.3% were breastfeeding exclusively. They gave birth at 1016 facilities that had a mean total mPINC score of 65/100 (range 19-99). Care dimension subscores ranged from 41 for facility discharge care to 81 for breastfeeding assistance. In multivariable analysis adjusting for covariates, a positive relationship was found between total mPINC score quartile and both any breastfeeding (quartile 2: odds ratio [OR] 1.40 [95% confidence interval {CI} 1.08-1.83], quartile 3: OR 1.50 [95% CI 1.15-1.96], quartile 4: OR 2.12 [95% CI 1.61-2.78] vs quartile 1) and exclusive breastfeeding (quartile 3: OR 1.41 [95% CI 1.04-1.90], quartile 4: OR 1.89 [95% CI 1.41-2.55] vs quartile 1) at 8 weeks. CONCLUSIONS: These data demonstrate that evidence-based maternity care practices and policies are associated with better breastfeeding outcomes. Maternity facilities may evaluate their practices and policies to ensure they are helping mothers achieve their breastfeeding goals.

    • Occupational Safety and Health
      1. Framework for considering productive aging at work
        Schulte PA, Grosch J, Scholl JC, Tamers SL.
        J Occup Environ Med. 2018 Feb 7.
        OBJECTIVES: The U.S. population is experiencing a demographic transition resulting in an aging workforce. The objective of this article is to elucidate and expand an approach to keep that workforce safe, healthy and productive. METHODS: This article elucidates the framework for the National Center for Productive Aging at Work of the National Institute for Occupational Safety and Health. Subject matter experts used a snowball method to review published literature to substantiate elements in the framework. RESULTS: Evidence-based literature supports a productive aging framework for the workforce involving the following elements: 1) life span perspective; 2) comprehensive and integrated approaches to occupational safety and health; 3) emphasis on positive outcomes for both workers and organizations; and 4) supportive work culture for multigenerational issues. CONCLUSIONS: The productive aging framework provides a foundational and comprehensive approach for addressing the aging workforce.

      2. Nonfatal injuries to law enforcement officers: A rise in assaults
        Tiesman HM, Gwilliam M, Konda S, Rojek J, Marsh S.
        Am J Prev Med. 2018 Jan 26.
        INTRODUCTION: Limited studies exist that describe nonfatal work-related injuries to law enforcement officers. The aim of this study is to provide national estimates and trends of nonfatal injuries to law enforcement officers from 2003 through 2014. METHODS: Nonfatal injuries were obtained from the National Electronic Injury Surveillance System-Occupational Supplement. Data were obtained for injuries treated in U.S. emergency departments from 2003 to 2014. Nonfatal injury rates were calculated using denominators from the Current Population Survey. Negative binomial regression was used to analyze temporal trends. Data were analyzed in 2016-2017. RESULTS: Between 2003 and 2014, an estimated 669,100 law enforcement officers were treated in U.S. emergency departments for nonfatal injuries. The overall rate of 635 per 10,000 full-time equivalents was three times higher than all other U.S. workers rate (213 per 10,000 full-time equivalents). The three leading injury events were assaults and violent acts (35%), bodily reactions and exertion (15%), and transportation incidents (14%). Injury rates were highest for the youngest officers, aged 21-24 years. Male and female law enforcement officers had similar nonfatal injury rates. Rates for most injuries remained stable; however, rates for assault-related injuries grew among law enforcement officers between 2003 and 2011. CONCLUSIONS: National Electronic Injury Surveillance System-Occupational Supplement data demonstrate a significant upward trend in assault injuries among U.S. law enforcement officers and this warrants further investigation. Police-citizen interactions are dynamic social encounters and evidence-based policing is vital to the health and safety of both police and civilians. The law enforcement community should energize efforts toward the study of how policing tactics impact both officer and citizen injuries.

    • Occupational Safety and Health – Mining
      1. Progressive massive fibrosis in coal miners from 3 clinics in Virginia
        Blackley DJ, Reynolds LE, Short C, Carson R, Storey E, Halldin CN, Laney AS.
        Jama. 2018 Feb 6;319(5):500-501.

        [No abstract]

    • Parasitic Diseases
      1. Whole metagenome sequencing reveals links between mosquito microbiota and insecticide resistance in malaria vectors
        Dada N, Sheth M, Liebman K, Pinto J, Lenhart A.
        Sci Rep. 2018 Feb 1;8(1):2084.
        In light of the declining global malaria burden attained largely due to insecticides, a deeper understanding of the factors driving insecticide resistance is needed to mitigate its growing threat to malaria vector control programs. Following evidence of microbiota-mediated insecticide resistance in agricultural pests, we undertook a comparative study of the microbiota in mosquitoes of differing insecticide resistance status. The microbiota of wild-caught Anopheles albimanus, an important Latin American malaria vector, that were resistant (FEN_Res) or susceptible (FEN_Sus) to the organophosphate (OP) insecticide fenitrothion were characterized and compared using whole metagenome sequencing. Results showed differing composition of the microbiota and its functions between FEN_Res and FEN_Sus, with significant enrichment of OP-degrading bacteria and enzymes in FEN_Res compared to FEN_Sus. Lower bacterial diversity was observed in FEN_Res compared to FEN_Sus, suggesting the enrichment of bacterial taxa with a competitive advantage in response to insecticide selection pressure. We report and characterize for the first time whole metagenomes of An. albimanus, revealing associations between the microbiota and phenotypic resistance to the insecticide fenitrothion. This study lays the groundwork for further investigation of the role of the mosquito microbiota in insecticide resistance.

      2. Prevention of malaria in pregnancy
        Desai M, Hill J, Fernandes S, Walker P, Pell C, Gutman J, Kayentao K, Gonzalez R, Webster J, Greenwood B, Cot M, Ter Kuile FO.
        Lancet Infect Dis. 2018 Jan 30.
        Malaria remains one of the most preventable causes of adverse birth outcomes. Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine is used to prevent malaria, but resistance to this drug combination has decreased its efficacy and new alternatives are needed. In Africa, a meta-analysis showed three-course or monthly IPTp with sulfadoxine-pyrimethamine to be safe and more effective than the original two-course sulfadoxine-pyrimethamine strategy, prompting WHO to update its policy in 2012. Although resistance to sulfadoxine-pyrimethamine reduces the parasitological efficacy of IPTp, this drug combination remains associated with reduced incidence of low birthweight in areas where prevalence of parasites with quintuple Plasmodium falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthetase (Pfdhps) mutations is greater than 90%. Nevertheless, its effectiveness is compromised in women infected with sextuple mutant parasites. Six trials of IPTp showed that neither amodiaquine, mefloquine, nor chloroquine-azithromycin are suitable replacements for sulfadoxine-pyrimethamine because of poor tolerability. Furthermore, four trials showed that intermittent screening and treatment with the current generation of malaria rapid diagnostic tests was not a suitable alternative strategy to IPTp with sulfadoxine-pyrimethamine, even in areas with high prevalence of quintuple mutations. Two trials showed that IPTp with dihydroartemisinin-piperaquine was well tolerated, effective, and acceptable for IPTp, with monthly regimens being the most effective. Coverage of IPTp and insecticide-treated nets continues to lag behind targets. The key barriers to uptake are well documented, and many are open to intervention. Outside of Africa, a single trial suggests a potential role for integrated approaches that combine sulfadoxine-pyrimethamine with azithromycin for IPTp in areas of Papua New Guinea where malaria transmission is high. Modelling analysis suggests the importance of the prevention of malaria early in pregnancy and the need to protect pregnant women declines more slowly than the rate at which transmission declines. Improved funding has led to an increase in the number of prevention trials in the past decade, showing the value of more sustained protection with monthly IPTp regimens. There is a need for confirmatory trials of the safety, efficacy, and feasibility of IPTp with dihydroartemisinin-piperaquine, for studies of intermittent screening and treatment with more sensitive rapid diagnostic tests, for studies of integrated strategies for malaria and other co-infections, and for studies of prevention strategies for malaria in pregnant women who are HIV-positive and living outside of Africa. Additional research is required on how to improve uptake of WHO’s updated policy on IPTp with sulfadoxine-pyrimethamine and insecticide-treated nets.

      3. Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem
        Rogerson SJ, Desai M, Mayor A, Sicuri E, Taylor SM, van Eijk AM.
        Lancet Infect Dis. 2018 Jan 30.
        Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.

    • Public Health, General
      1. Reporting the methods used in public health research and practice
        Stroup DF, Smith CK, Truman BI.
        J Public Health Emerg. 2017 Dec;1.
        The methods section of a scientific article often receives the most scrutiny from journal editors, peer reviewers, and skeptical readers because it allows them to judge the validity of the results. The methods section also facilitates critical interpretation of study activities, explains how the study avoided or corrected for bias, details how the data support the answer to the study question, justifies generalizing the findings to other populations, and facilitates comparison with past or future studies. In 2006, the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Programme began collecting and disseminating guidelines for reporting health research studies. In addition, guidelines for reporting public health investigations not classified as research have also been developed. However, regardless of the type of study or scientific report, the methods section should describe certain core elements: the study design; how participants were selected; the study setting; the period of interest; the variables and their definitions used for analysis; the procedures or instruments used to measure exposures, outcomes, and their association; and the analyses. Specific requirements for each study type should be consulted during the project planning phase and again when writing begins. We present requirements for reporting methods for public health activities, including outbreak investigations, public health surveillance programs, prevention and intervention program evaluations, research, surveys, systematic reviews, and meta-analyses.

    • Reproductive Health
      1. Concordance of self-reported hormonal contraceptive use and presence of exogenous hormones in serum among African women
        Pyra M, Lingappa JR, Heffron R, Erikson DW, Blue SW, Patel RC, Nanda K, Rees H, Mugo NR, Davis NL, Kourtis AP, Baeten JM.
        Contraception. 2018 Feb 2.
        OBJECTIVES: Studies that rely on self-report to investigate the relationship between hormonal contraceptive use and HIV acquisition and transmission, as well as other health outcomes, could have compromised results due to misreporting. We determined the frequency of misreported hormonal contraceptive use among African women with and at risk for HIV. STUDY DESIGN: We tested 1102 archived serum samples from 664 African women who had participated in prospective HIV prevention studies. Using a novel high-performance liquid chromatography mass-spectrometry assay, we quantified exogenous hormones for injectables (medroxyprogesterone acetate or norethisterone), oral contraceptives (OC) (levonorgestrel or ethinyl estradiol), and implants (levonorgestrel or etonogestrel) and compared them to self-reported use. RESULTS: Among women reporting hormonal contraceptive use, 258/358 (72%) of samples were fully concordant with self-report, as were 642/744 (86%) of samples from women reporting no hormonal contraceptive use. However, 42/253 (17%) of samples from women reporting injectable use, 41/66 (62%) of samples from self-reported OC users, and 3/39 (8%) of samples from self-reported implant users had no quantifiable hormones. Among self-reported non-users, 102/744 (14%) had>/=1 hormone present. Concordance between self-reported method and exogenous hormones did not differ by HIV status. CONCLUSION: Among African women with and at risk for HIV, testing of exogenous hormones revealed agreement with self-reported contraceptive use for most women. However, unexpected exogenous hormones were identified among self-reported hormonal contraceptive users and non-users, and an important fraction of women reporting hormonal contraceptive use had no hormones detected; absence of oral contraceptive hormones could be due, at least in part, to samples taken during the hormone-free interval. Misreporting of hormonal contraceptive use could lead to biased results in observational studies of the relationship between contraceptive use and health outcomes. IMPLICATIONS: Research studies investigating associations between hormonal contraceptive use and HIV should consider validating self-reported use by objective measures; because both over- and under-reporting of use occurs, potential misclassification based on self-report could lead to biased results in directions that cannot be easily predicted.

    • Substance Use and Abuse
      1. Crotonaldehyde exposure in U.S. tobacco smokers and nonsmokers: NHANES 2005-2006 and 2011-2012
        Bagchi P, Geldner N, deCastro BR, De Jesus VR, Park SK, Blount BC.
        Environ Res. 2018 Feb 3;163:1-9.
        INTRODUCTION: Crotonaldehyde is an alpha,beta-unsaturated carbonyl compound that is a potent eye, respiratory, and skin irritant. Crotonaldehyde is a major constituent of tobacco smoke and its exposure can be quantified using its urinary metabolite N-acetyl-S-(3-hydroxypropyl-1-methyl)-L-cysteine (HPMM). A large-scale biomonitoring study is needed to determine HPMM levels, as a measure of crotonaldehyde exposure, in the general U.S. POPULATION: MATERIALS AND METHODS: Urine samples were obtained as part of the National Health and Nutrition Examination Survey 2005-2006 and 2011-2012 from participants who were at least six-years-old (N = 4692). Samples were analyzed for HPMM using ultra performance liquid chromatography – tandem mass spectrometry. Exclusive tobacco smokers were distinguished from non- tobacco users through a combination of self-reporting and serum cotinine data. RESULTS: Detection rate of HPMM among eligible samples was 99.9%. Sample-weighted, median urinary HPMM levels for smokers and non-users were 1.61 and 0.313mg/g creatinine, respectively. Multivariable regression analysis among smokers showed that HPMM was positively associated with serum cotinine, after controlling for survey year, urinary creatinine, age, sex, race, poverty level, body mass index, pre-exam fasting time, and food intake. Other significant predictors of urinary HPMM include sex (female > male), age (children > non-user adults), race (non-Hispanic Blacks < non-Hispanic Whites). CONCLUSIONS: This study characterizes U.S. population exposure to crotonaldehyde and confirms that tobacco smoke is a major exposure source. Urinary HPMM levels were significantly higher among exclusive combusted tobacco users compared to non-users, and serum cotinine and cigarettes per day were significant predictors of increased urinary HPMM. This study also found that sex, age, ethnicity, pre-exam fasting time, and fruit consumption are related to urinary HPMM levels.

      2. Community readiness to prevent opioid overdose
        Ringwalt C, Sanford C, Dasgupta N, Alexandridis A, McCort A, Proescholdbell S, Sachdeva N, Mack K.
        Health Promot Pract. 2018 Feb 1.
        Effective community-based actions are urgently needed to combat the ongoing epidemic of opioid overdose. Community readiness (CR) has been linked to communities’ support for collective action, which in turn has been associated with the success of community-wide prevention strategies and resulting behavior change. Our study, conducted in North Carolina, assessed the relationship between CR and two indices of opioid overdose. County-level data included a survey of health directors that assessed CR to address drug overdose prevention programs, surveillance measures of opioid overdose collected from death records and emergency departments, and two indicators of general health-related status. We found that counties’ rates of CR were positively associated with their opioid-related mortality (but not morbidity) and that this relationship persisted when we controlled for health status. North Carolina counties with the highest opioid misuse problems appear to be the most prepared to respond to them.

      3. Predictors and psychological pathways for binge drinking among South African men
        Zhang J, Jemmott JB, Icard LD, Heeren GA, Ngwane Z, Makiwane M, O’Leary A.
        Psychol Health. 2018 Feb 7:1-17.
        OBJECTIVE: To develop targeted interventions for high-risk drinkers among South African men, we assessed whether sociodemographic factors and history of childhood sexual abuse predicted binge drinking at six-month follow-up assessment and their psychological pathways according to the extended Theory of Reasoned Action (TRA). DESIGN: Survey responses with a sample of 1181 South African men from randomly selected neighbourhoods in Eastern Cape Province were collected at baseline and six-month follow-up. Multiple logistic regression analysis examined the baseline predictors of binge drinking. Serial multiple mediation analysis examined the psychological pathways. MAIN OUTCOME MEASUREMENTS: Binge drinking at six-month follow-up. RESULTS: Age (OR = 1.03, 95% CI: 1.01, 1.05), religious participation (OR = .73, CI: .65, .82) and history of childhood sexual abuse (OR = 1.82, CI: 1.32, 2.51) were significant predictors of binge drinking. Predictions of religious participation and history of childhood sexual abuse were partially mediated through attitude, subjective norm, descriptive norm and intention to binge drinking. CONCLUSION: South African men with childhood sexual abuse experience and low religious participation were at higher risk for binge drinking. The extended TRA model explains the associations of these factors to binge drinking and can contribute to the design and evaluation of interventions.

    • Zoonotic and Vectorborne Diseases
      1. Recent large-scale chikungunya virus (CHIKV) and Zika virus epidemics in the Americas pose a growing public health threat. Given that mosquito bite prevention and vector control are the main prevention methods available to reduce transmission of these viruses, we assessed adherence to these methods in the United States Virgin Islands (USVI). We interviewed 334 USVI residents between December 2014 and February 2015 to measure differences in mosquito prevention practices by gender, income, presence of CHIKV symptoms, and age. Only 27% (91/334) of participants reported having an air conditioner, and of the 91 with air-conditioners, 18 (20%) reported never using it. Annual household income > $50,000 was associated with owning and using an air conditioner (41%; 95% confidence interval [CI]: 28-53% compared with annual household income </= $50,000: 17%; 95% CI: 12-22%). The majority of participants reported the presence of vegetation in their yard or near their home (79%; 265) and a cistern on their property (78%; 259). Only 52 (16%) participants reported wearing mosquito repellent more than once per week. Although the majority (80%; 268) of participants reported having screens on all of their windows and doors, most (82%; 273) of those interviewed still reported seeing mosquitoes in their homes. Given the uniformly low adherence to household- and individual-level mosquito bite prevention measures in the USVI, these findings emphasize the need for improved public health messaging and investment in therapeutic and vaccine research to mitigate vector-borne disease outbreaks.

      2. Outbreak of Seoul virus among rats and rat owners – United States and Canada, 2017
        Kerins JL, Koske SE, Kazmierczak J, Austin C, Gowdy K, Dibernardo A.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 2;67(4):131-134.
        In December 2016, the Wisconsin Department of Health Services (WDHS) notified CDC of a patient hospitalized with fever, leukopenia, elevated transaminases, and proteinuria. The patient owned and operated an in-home rattery, or rat-breeding facility, with approximately 100 Norway rats, primarily bred as pets. A family member developed similar symptoms 4 weeks later, but was not hospitalized. Because both patients were known to have rodent contact, they were tested for hantavirus infections. In January 2017, CDC confirmed recent, acute Seoul virus infection in both patients. An investigation was conducted to identify additional human and rat infections and prevent further transmission. Ultimately, the investigation identified 31 facilities in 11 states with human and/or rat Seoul virus infections; six facilities also reported exchanging rats with Canadian ratteries. Testing of serum samples from 183 persons in the United States and Canada identified 24 (13.1%) with Seoul virus antibodies; three (12.5%) were hospitalized and no deaths occurred. This investigation, including cases described in a previously published report from Tennessee (1), identified the first known transmission of Seoul virus from pet rats to humans in the United States and Canada. Pet rat owners should practice safe rodent handling to prevent Seoul virus infection (2).

      3. Spumaretroviruses: Updated taxonomy and nomenclature
        Khan AS, Bodem J, Buseyne F, Gessain A, Johnson W, Kuhn JH, Kuzmak J, Lindemann D, Linial ML, Lochelt M, Materniak-Kornas M, Soares MA, Switzer WM.
        Virology. 2018 Feb 1;516:158-164.
        Spumaretroviruses, commonly referred to as foamy viruses, are complex retroviruses belonging to the subfamily Spumaretrovirinae, family Retroviridae, which naturally infect a variety of animals including nonhuman primates (NHPs). Additionally, cross-species transmissions of simian foamy viruses (SFVs) to humans have occurred following exposure to tissues of infected NHPs. Recent research has led to the identification of previously unknown exogenous foamy viruses, and to the discovery of endogenous spumaretrovirus sequences in a variety of host genomes. Here, we describe an updated spumaretrovirus taxonomy that has been recently accepted by the International Committee on Taxonomy of Viruses (ICTV) Executive Committee, and describe a virus nomenclature that is generally consistent with that used for other retroviruses, such as lentiviruses and deltaretroviruses. This taxonomy can be applied to distinguish different, but closely related, primate (e.g., human, ape, simian) foamy viruses as well as those from other hosts. This proposal accounts for host-virus co-speciation and cross-species transmission.

      4. Exploring an alternative approach to Lyme disease surveillance in Maryland
        Rutz H, Hogan B, Hook S, Hinckley A, Feldman K.
        Zoonoses Public Health. 2018 Feb 6.
        In Maryland, Lyme disease (LD) is a reportable disease and all laboratories and healthcare providers are required to report to the local health department. Given the volume of LD reports and effort required for investigation, surveillance for LD is burdensome and subject to underreporting. We explored the utility of International Classification of Diseases, 9th Revision, Clinical Modification (administrative) codes for use with LD surveillance. We aimed to collect the administrative codes for a 10% sample of 2009 LD reports (n = 474) from 292 facilities stratified by case classification (confirmed, probable, suspected and not a case). Sixty-three per cent (n = 184) of facilities responded to the survey, and 341 different administrative codes were obtained for 91% (n = 430) of sampled reports. The administrative code for Lyme disease (088.81) was the most commonly reported code (133/430 patients) among sampled reports; while it was used for 62 of 151 (41%) confirmed cases, it was also used for 48 of 192 (25%) not a case reports (sensitivity 41% and specificity 73%). A combination of nine codes was developed with sensitivity of 74% and specificity of 37% when compared to not a case reports. We conclude that the administrative code for LD alone has low ability to identify LD cases in Maryland. Grouping certain codes improved sensitivity, but our results indicate that administrative codes alone are not a viable surveillance alternative for a disease with complex manifestations such as LD.

      5. Notes from the Field: Assessment of rabies exposure risk among residents of a university sorority house – Indiana, February 2017
        Schroeder B, Boland A, Pieracci EG, Blanton JD, Peterson B, Brown J.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):166.

        [No abstract]

      6. Potential confounding of diagnosis of rabies in patients with recent receipt of intravenous immune globulin
        Vora NM, Orciari LA, Bertumen JB, Damon I, Ellison JA, Fowler VG, Franka R, Petersen BW, Satheshkumar PS, Schexnayder SM, Smith TG, Wallace RM, Weinstein S, Williams C, Yager P, Niezgoda M.
        MMWR Morb Mortal Wkly Rep. 2018 Feb 9;67(5):161-165.
        Rabies is an acute encephalitis that is nearly always fatal. It is caused by infection with viruses of the genus Lyssavirus, the most common of which is Rabies lyssavirus. The Council of State and Territorial Epidemiologists (CSTE) defines a confirmed human rabies case as an illness compatible with rabies that meets at least one of five different laboratory criteria.* Four of these criteria do not depend on the patient’s rabies vaccination status; however, the remaining criterion, “identification of Lyssavirus-specific antibody (i.e. by indirect fluorescent antibody…test or complete [Rabies lyssavirus] neutralization at 1:5 dilution) in the serum,” is only considered diagnostic in unvaccinated patients. Lyssavirus-specific antibodies include Rabies lyssavirus-specific binding immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies and Rabies lyssavirus neutralizing antibodies (RLNAs). This report describes six patients who were tested for rabies by CDC and who met CSTE criteria for confirmed human rabies because they had illnesses compatible with rabies, had not been vaccinated for rabies, and were found to have serum RLNAs (with complete Rabies lyssavirus neutralization at a serum dilution of 1:5). An additional four patients are described who were tested for rabies by CDC who were found to have serum RLNAs (with incomplete Rabies lyssavirus neutralization at a serum dilution of 1:5) despite having not been vaccinated for rabies. None of these 10 patients received a rabies diagnosis; rather, they were considered to have been passively immunized against rabies through recent receipt of intravenous immune globulin (IVIG). Serum RLNA test results should be interpreted with caution in patients who have not been vaccinated against rabies but who have recently received IVIG.

      7. Clusters of human infection and human-to-human transmission of avian influenza A(H7N9) virus, 2013-2017
        Zhou L, Chen E, Bao C, Xiang N, Wu J, Wu S, Shi J, Wang X, Zheng Y, Zhang Y, Ren R, Greene CM, Havers F, Iuliano AD, Song Y, Li C, Chen T, Wang Y, Li D, Ni D, Zhang Y, Feng Z, Uyeki TM, Li Q.
        Emerg Infect Dis. 2018 Feb;24(2).
        To detect changes in human-to-human transmission of influenza A(H7N9) virus, we analyzed characteristics of 40 clusters of case-patients during 5 epidemics in China in 2013-2017. Similarities in number and size of clusters and proportion of clusters with probable human-to-human transmission across all epidemics suggest no change in human-to-human transmission risk.

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