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CDC Science Clips: Volume 10, Issue 30, August, 14, 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. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • BACKGROUND: About 2.8 million TBI-related emergency department visits, hospitalizations and deaths occurred in 2013 in the United States. Post-traumatic epilepsy (PTE) can be a disabling, life-long outcome of TBI. OBJECTIVES: The purpose of this study is to address the probability of developing PTE within 9 years after TBI, the risk factors associated with PTE, the prevalence of anti-epileptic drug (AEDs) use, and the effectiveness of using AEDs prophylactically after TBI to prevent the development of PTE. METHODS: Using MarketScan(R) databases covering commercial, Medicare Supplemental, and multi-state Medicaid enrollees from 2004 to 2014, we examined the incidence of early seizures (within seven days after TBI) and cumulative incidence of PTE, the hazard ratios (HR) of PTE by age, gender, TBI severity, early seizure and AED use (carbamazepine, clonazepam, divalproex sodium, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenytoin, pregabalin, topiramate, acetazolamide). We used backward selection to build the final Cox proportional hazard model and conducted multivariable survival analysis to obtain estimates of crude and adjusted HR (cHRs, aHRs) of PTE and 95% confidence intervals (CI). RESULTS: The incidence of early seizure among TBI patients in our study was 0.5%. The cumulative incidence of PTE increased from 1.0% in one year to 4.0% in nine years. Most patients with TBI (93%) were not prescribed any AED. Gender was not associated with PTE. The risk of PTE was higher for individuals with older age, early seizures, and more severe TBI. Only individuals using prophylactic acetazolamide had significantly lower risk of PTE (aHR = 0.6, CI 0.4-0.9) compared to those not using any AED. CONCLUSION: The probability of developing PTE increased within the study period. The risk of developing PTE significantly increased with age, early seizure and TBI severity. Most of the individuals did not receive AED after TBI. There was no evidence suggesting AEDs helped to prevent PTE with the possible exception of acetazolamide. However, further studies may be needed to test the efficacy of acetazolamide in preventing PTE.

    • Communicable Diseases
      • A call to action for mycetoma
        Beer KD, Blaney DD, Kadzik M, Asiedu KB, Shieh WJ, Bower W, Jackson BR, Walke H, Chiller T.
        Curr Fungal Infect Rep. 2018 .
        Purpose of Review: Here, we discuss the current needs and priorities for mycetoma control and prevention, highlight lessons learned from leprosy and podoconiosis, and motivate an urgent need to accelerate progress toward reducing the burden of mycetoma in endemic areas. Recent Findings: In 2015, the World Health Assembly (WHA) added mycetoma, a progressively debilitating disease caused by fungi and bacteria, to the World Health Organization (WHO) list of priority neglected tropical diseases (NTDs). Designation of other diseases as NTDs has raised awareness, enabled global partnerships, and advanced the capacity to combat disease through integrated programming. Although key mycetoma etiologic agents have been identified, many questions remain and mycetoma may similarly benefit from NTD designation. Summary: In collaboration with experts at WHO and elsewhere, we formed a global mycetoma working group to connect partners from a variety of sectors and specialties. We envision that this group will evolve into a formalized partnership that can prioritize strategic planning, advocacy, and research needs, identify funding sources, and coordinate activities related to mycetoma and other NTDs affecting the skin. The experiences gained from other NTDs can help to guide the global mycetoma working group’s activities to better address the goals set forth in the WHA resolution.

    • Disease Reservoirs and Vectors
      • Prevalence and distribution of seven human pathogens in host-seeking Ixodes scapularis (Acari: Ixodidae) nymphs in Minnesota, USA
        Johnson TL, Graham CB, Maes SE, Hojgaard A, Fleshman A, Boegler KA, Delory MJ, Slater KS, Karpathy SE, Bjork JK, Neitzel DF, Schiffman EK, Eisen RJ.
        Ticks Tick Borne Dis. 2018 Jul 20.
        In the north-central United States, the blacklegged tick (Ixodes scapularis) is currently known to vector seven human pathogens. These include five bacteria (Borrelia burgdorferi sensu stricto, Borrelia mayonii, Borrelia miyamotoi, Anaplasma phagocytophilum, Ehrlichia muris eauclairensis), one protozoan (Babesia microti) and one virus (Powassan). We sought to assess the prevalence and distribution of these pathogens in host-seeking nymphs collected throughout Minnesota, a state on the northwestern edge of the tick’s expanding range, where reported cases of I. scapularis-borne diseases have increased in incidence and geographic range over the past decade. Among the 1240 host-seeking I. scapularis nymphs that we screened from 64 sites, we detected all seven pathogens at varying frequencies. Borrelia burgdorferi s.s. was the most prevalent and geographically widespread, found in 25.24% of all nymphs tested. Anaplasma phagocytophilum and Babesia microti were also geographically widespread, but they were less prevalent than Bo. burgdorferi s.s. (detected in 6.29% and 4.68% of ticks, respectively). Spatial clusters of sites with high prevalence for these three pathogens were identified in the north-central region of the state. Prevalence was less than 1.29% for each of the remaining pathogens. Two or more pathogens were detected in 90 nymphs (7.26%); coinfections with Bo. burgdorferi s.s. and either A. phagocytophilum (51 nymphs, 4.11%) or Ba. microti (43 nymphs, 3.47%) were the most common combinations. The distribution and density of infected ticks mirrors the distribution of notifiable tick-borne diseases in Minnesota and provides information on the distribution and prevalence of recently described human pathogens.

    • Environmental Health
      • Developing an online tool for identifying at-risk populations to wildfire smoke hazards
        Vaidyanathan A, Yip F, Garbe P.
        Sci Total Environ. 2018 Apr 1;619-620:376-383.
        Wildfire episodes pose a significant public health threat in the United States. Adverse health impacts associated with wildfires occur near the burn area as well as in places far downwind due to wildfire smoke exposures. Health effects associated with exposure to particulate matter arising from wildfires can range from mild eye and respiratory tract irritation to more serious outcomes such as asthma exacerbation, bronchitis, and decreased lung function. Real-time operational forecasts of wildfire smoke concentrations are available but they are not readily integrated with information on vulnerable populations necessary to identify at-risk communities during wildfire smoke episodes. Efforts are currently underway at the Centers for Disease Control and Prevention (CDC) to develop an online tool that utilizes short-term predictions and forecasts of smoke concentrations and integrates them with measures of population-level vulnerability for identifying at-risk populations to wildfire smoke hazards. The tool will be operationalized on a national scale, seeking input and assistance from several academic, federal, state, local, Tribal, and Territorial partners. The final product will then be incorporated into CDC’s National Environmental Public Health Tracking Network (, providing users with access to a suite of mapping and display functionalities. A real-time vulnerability assessment tool incorporating standardized health and exposure datasets, and prevention guidelines related to wildfire smoke hazards is currently unavailable for public health practitioners and emergency responders. This tool could strengthen existing situational awareness competencies, and expedite future response and recovery efforts during wildfire episodes.

    • Immunity and Immunization
      • We reported previously that the annual average mortality rate in the United States in 2008-2011 for varicella listed as the underlying cause declined 87% compared with the prevaccine period (1990-1994). Here, we update the analysis with five additional years of data. We used varicella death data from the 2012-2016 Mortality Multiple Cause-of Death records to calculate mortality rates during 2012-2016 and trends since the prevaccine period and end of 1-dose vaccination program (2005-2007). The annual average age-adjusted mortality rate for varicella as the underlying cause was 0.03 per million population during 2012-2016, a 94% reduction from prevaccine years and a 47% reduction from 2005-2007. Varicella deaths continue to decline due to the varicella vaccination program in the United States.

      • Clinicians’ and pharmacists’ reported implementation of vaccination practices for adults
        Lutz CS, Kim DK, Black CL, Ball SW, Devlin RG, Srivastav A, Fiebelkorn AP, Bridges CB.
        Am J Prev Med. 2018 Jul 23.
        INTRODUCTION: Despite the proven effectiveness of immunization in preventing morbidity and mortality, adult vaccines remain underutilized. The objective of this study was to describe clinicians’ and pharmacists’ self-reported implementation of the Standards for Adult Immunization Practice (“the Standards”; i.e., routine assessment, recommendation, and administration/referral for needed vaccines, and documentation of administered vaccines, including in immunization information systems). METHODS: Two Internet panel surveys (one among clinicians and one among pharmacists) were conducted during February-March 2017 and asked respondents about their practice’s implementation of the Standards. T-tests assessed associations between clinician medical specialty, vaccine type, and each component of the Standards (March-August 2017). RESULTS: Implementation of the Standards varied substantially by vaccine and provider type. For example, >80.0% of providers, including obstetrician/gynecologists and subspecialists, assessed for and recommended influenza vaccine. However, 24.3% of obstetrician/gynecologists and 48.9% of subspecialists did not stock influenza vaccine for administration. Although zoster vaccine was recommended by >89.0% of primary care providers, <58.0% stocked the vaccine; by contrast, 91.6% of pharmacists stocked zoster vaccine. Vaccine needs assessments, recommendations, and stocking/referrals also varied by provider type for pneumococcal; tetanus, diphtheria, acellular pertussis; tetanus diphtheria; human papillomavirus; and hepatitis B vaccines. CONCLUSIONS: This report highlights gaps in access to vaccines recommended for adults across the spectrum of provider specialties. Greater implementation of the Standards by all providers could improve adult vaccination rates in the U.S. by reducing missed opportunities to recommend vaccinations and either vaccinate or refer patients to vaccine providers.

    • Injury and Violence
      • Yellowstone National Park is home to the largest bison population on public land in the United States. Although Yellowstone regulations require visitors to remain at least 23m from bison, since 1980, bison have injured more visitors to Yellowstone than any other animal. We examined a series of bison-related injuries at Yellowstone to evaluate the circumstances of these injuries and to identify common risk-enhancing behaviors that lead to injury. To do this, we analyzed narrative case incident records from law enforcement regarding bison-human encounters in Yellowstone during 2000-2015. Data regarding demographics, preencounter activities, number of persons involved, type of injury, and acknowledgement of appropriate viewing distance were extracted from the records. Bison encounters resulted in injury to 25 persons (21 visitors and 4 employees). Age range for injured persons was 7-68years (median: 49years), and 13 were female. All injuries occurred in areas of high visitor concentration. Mean visitor distance from bison before injury was 3.4m (range: 0.3-6.1m). Twenty persons (80%) actively approached bison before their injuries; 5 (20%) failed to retreat when bison approached. Fifteen persons (60%) were injured when in a group of >/=3 persons approaching bison. Twelve persons (48%) sustained injuries while photographing bison. Six persons (24%) acknowledged they were too close to bison. Education alone might not be sufficient to reduce bison-related injuries. Effective injury prevention campaigns for national parks require an understanding of the behaviors and motivations of persons who approach bison. Including behavioral science and behavior change techniques in bison injury prevention campaigns might reduce injuries at Yellowstone.

    • Laboratory Sciences
      • Inhaled bacteriophage-loaded polymeric microparticles ameliorate acute lung infections
        Agarwal R, Johnson CT, Imhoff BR, Donlan RM, McCarty NA, Garcia AJ.
        Nature Biomedical Engineering. 2018 :1-5.
        Lung infections associated with pneumonia, or cystic fibrosis caused by Pseudomonas aeruginosa or other bacteria, result in significant morbidity and mortality, in part owing to the development of multidrug resistance, also against last-resort antibiotics. Lytic bacteriophages (that is, viruses that specifically kill bacteria) can reduce lung-associated infections, yet their clinical use is hindered by difficulties in delivering active phages to the deep lung. Here, we show that phage-loaded polymeric microparticles deposit throughout the lung via dry powder inhalation and that they deliver active phages. Phage-loaded microparticles effectively reduced P. aeruginosa infections and the associated inflammation in wild-type and cystic fibrosis transmembrane-conductance-regulator knockout mice, and rescued the mice from pneumonia-associated death. These polymeric microparticles might constitute a clinically translatable therapy for eradicating hospital-acquired lung infections and infections associated with cystic fibrosis.

    • Maternal and Child Health
      • The development and testing of a module on child functioning for identifying children with disabilities on surveys. I: Background
        Loeb M, Mont D, Cappa C, De Palma E, Madans J, Crialesi R.
        Disabil Health J. 2018 Jul 18.
        This is the first of three papers that will document the development of a survey module on child functioning developed by UNICEF in collaboration with the Washington Group on Disability Statistics (WG), and demonstrate – both conceptually and through test results – the strengths of that module compared with alternative tools for identifying children with disabilities in household surveys. This first paper in the series sets the background and reviews the literature leading to the development of the UNICEF/WG Child Functioning Module (CFM) and presents the WG Short Set of questions (WG-SS) and the Ten Question Screening Instrument (TQSI) as precursors, outlining some of their shortcomings and how the UNICEF/WG CFM was designed to meet those challenges. Subsequent articles will summarize results from the cognitive and field testing of the CFM including comparisons with results derived from the TQSI and the WG-SS.

    • Zoonotic and Vectorborne Diseases
      • Surveillance for respiratory and diarrheal pathogens at the human-pig interface in Sarawak, Malaysia
        Borkenhagen LK, Mallinson KA, Tsao RW, Ha SJ, Lim WH, Toh TH, Anderson BD, Fieldhouse JK, Philo SE, Chong KS, Lindsley WG, Ramirez A, Lowe JF, Coleman KK, Gray GC.
        PLoS One. 2018 ;13(7):e0201295.
        BACKGROUND: The large livestock operations and dense human population of Southeast Asia are considered a hot-spot for emerging viruses. OBJECTIVES: To determine if the pathogens adenovirus (ADV), coronavirus (CoV), encephalomyocarditis virus (EMCV), enterovirus (EV), influenza A-D (IAV, IBV, ICV, and IDV), porcine circovirus 2 (PCV2), and porcine rotaviruses A and C (RVA and RVC), are aerosolized at the animal-interface, and if humans working in these environments are carrying these viruses in their nasal airways. STUDY: This cross-sectional study took place in Sarawak, Malaysia among 11 pig farms, 2 abattoirs, and 3 animal markets in June and July of 2017. Pig feces, pig oral secretions, bioaerosols, and worker nasal wash samples were collected and analyzed via rPCR and rRT-PCR for respiratory and diarrheal viruses. RESULTS: In all, 55 pig fecal, 49 pig oral or water, 45 bioaerosol, and 78 worker nasal wash samples were collected across 16 sites. PCV2 was detected in 21 pig fecal, 43 pig oral or water, 3 bioaerosol, and 4 worker nasal wash samples. In addition, one or more bioaerosol or pig samples were positive for EV, IAV, and RVC, and one or more worker samples were positive for ADV, CoV, IBV, and IDV. CONCLUSIONS: This study demonstrates that nucleic acids from a number of targeted viruses were present in pig oral secretions and pig fecal samples, and that several viruses were detected in bioaerosol samples or in the nasal passages of humans with occupational exposure to pigs. These results demonstrate the need for future research in strengthening viral surveillance at the human-animal interface, specifically through expanded bioaerosol sampling efforts and a seroepidemiological study of individuals with exposure to pigs in this region for PCV2 infection.

      • Persistence of Ebola virus after the end of widespread transmission in Liberia: an outbreak report
        Dokubo EK, Wendland A, Mate SE, Ladner JT, Hamblion EL, Raftery P, Blackley DJ, Laney AS, Mahmoud N, Wayne-Davies G, Hensley L, Stavale E, Fakoli L, Gregory C, Chen TH, Koryon A, Roth Allen D, Mann J, Hickey A, Saindon J, Badini M, Baller A, Clement P, Bolay F, Wapoe Y, Wiley MR, Logue J, Dighero-Kemp B, Higgs E, Gasasira A, Williams DE, Dahn B, Kateh F, Nyenswah T, Palacios G, Fallah MP.
        Lancet Infect Dis. 2018 Jul 23.
        BACKGROUND: Outbreak response efforts for the 2014-15 Ebola virus disease epidemic in west Africa brought widespread transmission to an end. However, subsequent clusters of infection have occurred in the region. An Ebola virus disease cluster in Liberia in November, 2015, that was identified after a 15-year-old boy tested positive for Ebola virus infection in Monrovia, raised the possibility of transmission from a persistently infected individual. METHODS: Case investigations were done to ascertain previous contact with cases of Ebola virus disease or infection with Ebola virus. Molecular investigations on blood samples explored a potential linkage between Ebola virus isolated from cases in this November, 2015, cluster and epidemiologically linked cases from the 2014-15 west African outbreak, according to the national case database. FINDINGS: The cluster investigated was the family of the index case (mother, father, three siblings). Ebola virus genomes assembled from two cases in the November, 2015, cluster, and an epidemiologically linked Ebola virus disease case in July, 2014, were phylogenetically related within the LB5 sublineage that circulated in Liberia starting around August, 2014. Partial genomes from two additional individuals, one from each cluster, were also consistent with placement in the LB5 sublineage. Sequencing data indicate infection with a lineage of the virus from a former transmission chain in the country. Based on serology and epidemiological and genomic data, the most plausible scenario is that a female case in the November, 2015, cluster survived Ebola virus disease in 2014, had viral persistence or recurrent disease, and transmitted the virus to three family members a year later. INTERPRETATION: Investigation of the source of infection for the November, 2015, cluster provides evidence of Ebola virus persistence and highlights the risk for outbreaks after interruption of active transmission. These findings underscore the need for focused prevention efforts among survivors and sustained capacity to rapidly detect and respond to new Ebola virus disease cases to prevent recurrence of a widespread outbreak. FUNDING: US Centers for Disease Control and Prevention, Defense Threat Reduction Agency, and WHO.

  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. County-level air quality and the prevalence of diagnosed chronic kidney disease in the US Medicare population
        Bragg-Gresham J, Morgenstern H, McClellan W, Saydah S, Pavkov M, Williams D, Powe N, Tuot D, Hsu R, Saran R.
        PLoS One. 2018 ;13(7):e0200612.
        BACKGROUND: Considerable geographic variation exists in the prevalence of chronic kidney disease across the United States. While some of this variability can be explained by differences in patient-level risk factors, substantial variability still exists. We hypothesize this may be due to understudied environmental exposures such as air pollution. METHODS: Using data on 1.1 million persons from the 2010 5% Medicare sample and Environmental Protection Agency air-quality measures, we examined the association between county-level particulate matter </=2.5 mum (PM2.5) and the prevalence of diagnosed CKD, based on claims. Modified Poisson regression was used to estimate associations (prevalence ratios [PR]) between county PM2.5 concentration and individual-level diagnosis of CKD, adjusting for age, sex, race/ethnicity, hypertension, diabetes, and urban/rural status. RESULTS: Prevalence of diagnosed CKD ranged from 0% to 60% by county (median = 16%). As a continuous variable, PM2.5 concentration shows adjusted PR of diagnosed CKD = 1.03 (95% CI: 1.02-1.05; p<0.001) for an increase of 4 mug/m3 in PM2.5. Investigation by quartiles shows an elevated prevalence of diagnosed CKD for mean PM2.5 levels >/=14 mug/m3 (highest quartile: PR = 1.05, 95% CI: 1.03-1.07), which is consistent with current ambient air quality standard of 12 mug/m3, but much lower than the level typically considered healthy for sensitive groups (~40 mug/m3). CONCLUSION: A positive association was observed between county-level PM2.5 concentration and diagnosed CKD. The reliance on CKD diagnostic codes likely identified associations with the most severe CKD cases. These results can be strengthened by exploring laboratory-based diagnosis of CKD, individual measures of exposure to multiple pollutants, and more control of confounding.

      2. Cervical cancer screening among women by birthplace and percent of lifetime living in the United States
        Endeshaw M, Clarke T, Senkomago V, Saraiya M.
        J Low Genit Tract Dis. 2018 Jul 30.
        OBJECTIVE: The aim of the study was to provide national estimates of Pap test receipt, by birthplace, and percent of lifetime in the United States (US). MATERIALS AND METHODS: Pooled nationally representative data (2005, 2008, 2013, 2015) from the National Health Interview Survey were used to examine differences in Pap test receipt among adult US women by birthplace and percent of lifetime in the US. Descriptive estimates were age-adjusted. Regression models were adjusted for selected sociodemographic and healthcare access and utilization factors and presented as predicted margins. RESULTS: Foreign-born women 18 years and older were more than twice as likely to have never received a Pap test compared with US-born women (18.6% vs 6.8%). Regression models showed that foreign-born women from Mexico (9.8%), South America (12.6%), Caribbean (14.6%), Southeast Asia (13.7%), Central Asia (20.4%), South Asia (22.9%), Middle East (25.0%), Africa (27.8%), Europe (16.4%), and Former Soviet Union (28.2%) were more likely to be unscreened compared with US-born women (7.6%). Foreign-born women who spent less than 25% of their life in the US had higher prevalence of never having a Pap test (20%) compared with foreign-born who spent more than 25% of their life in the US (12.7%). CONCLUSIONS: Using national survey, we found that where a woman is born and the percent of her lifetime spent residing in the US do impact whether she gets screened at least once in her lifetime. IMPACT: These findings may inform cervical cancer screening efforts targeting foreign-born women.

      3. Prospective investigation of folic acid supplements before and during early pregnancy and paediatric and adult cancers in the Chinese children and families cohort: a pilot study in a sample of rural and urban families
        Linet MS, Wang L, Wang N, Berry RJ, Chao A, Hao L, Li Z, Fang L, Yin P, Potischman N, Sun X, Meng F, Yang R, Cong S, Fan J, Kitahara CM, Liang X, Liu F, Lu X, Lv F, Mu C, Sampson J, Tang Y, Wan W, Wang B, Wang H, Zhang L, Wang Y.
        BMJ Open. 2018 Jul 30;8(7):e022394.
        OBJECTIVE: To determine the feasibility of long-term prospective follow-up and ascertainment of cancer in offspring and mothers from the 1993-1995 Chinese Community Intervention Program that provided folic acid supplements before and during early pregnancy to reduce neural tube defects. DESIGN: Feasibility pilot study for a prospective cohort study. SETTING: Families residing during 2012-2013 in one rural and one urban county from 21 counties in 3 provinces in China included in the Community Intervention Program campaign. PARTICIPANTS: The feasibility study targeted 560 families, including 280 from the rural and 280 from the urban county included in the large original study; about half of mothers in each group had taken and half had not taken folic acid supplements. INTERVENTION: The planned new study is observational. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary: incidence of paediatric cancers in offspring; secondary: other chronic diseases in offspring and chronic diseases in mothers RESULTS: Only 3.4% of pilot study families could not be found, 3.9% had moved out of the study area and 8.8% refused to participate. Interviews were completed by 82% of mothers, 79% of fathers and 83% of offspring in the 560 families. Almost all mothers and offspring who were interviewed also participated in anthropometric measurements. We found notable urban-rural differences in sociodemographic and lifestyle characteristics of the parents, but fewer differences among the offspring. In eight catchment area hospitals, we identified a broad range of paediatric cancers diagnosed during 1994-2013, although paediatric brain tumours, lymphomas and rarer cancers were likely under-represented. CONCLUSIONS: Overall, 20 years after the original Community Intervention Program, the pilot study achieved high levels of follow-up and family member interview participation, and identified substantial numbers of paediatric malignancies during 1994-2013 in catchment area hospitals. Next steps and strategies for overcoming limitations are described.

      4. Prevalence of chronic kidney disease using estimated glomerular filtration rate among diabetes patients attending a tertiary clinic in Botswana
        Rwegerera GM, Molefe-Baikai OJ, Masaka A, Shimwela M, Rivera YP, Oyewo TA, Godman BB, Massele A, Habte D.
        Hosp Pract (1995). 2018 Jul 30.
        BACKGROUND AND AIMS: Diabetes mellitus (DM) is one of the most common contributors of chronic kidney disease (CKD). The epidemiology of CKD, a concern among patients with DM, has not been studied in Botswana. The aim of this study was to estimate its prevalence among these patients to provide future guidance to both government personnel and physicians. METHODS: Observational cross-sectional study in a leading clinic in Botswana. Demographic and clinical data were obtained from patients through interviews and from their notes using a standard questionnaire. The study was conducted from July to October 2015. The estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet for Renal Disease equation. CKD was defined as an eGFR < 60 ml/min/1.73m2. Multivariable logistic regression analyses were performed to assess the associations between CKD and potential factors. RESULTS: Mean age and duration of diabetes mellitus among study participants were of 54.67 years (range 21-92 years) and 5.0 years respectively. Over half, i.e. 213/370 (57.6%) and 232/370 (62.7%), had an average blood pressure greater than 140/90mmHg and poor glycemic control (HbA1c >7%) respectively. 31/370 patients (8.4%) had CKD. However, only 18/370 (4.9%) had a diagnosis of CKD documented in their charts. Age, level of education, and duration of diabetes were independently associated with CKD. CONCLUSION: The prevalence of CKD by estimated eGFR was low compared to most previous studies. However, half of patients with CKD are not documented resulting in potential of prescription errors and drug toxicity. A substantial number of our patients had uncontrolled hypertension and poor glycemic control. Older age, low level of education and longer duration of DM were associated with CKD. There is a need to carry out prospective studies to determine association and role of glycemic and blood pressure control in CKD causation among patients with DM in Botswana.

      5. Physician characteristics associated with sugar-sweetened beverage counseling practices
        VanFrank BK, Park S, Foltz JL, McGuire LC, Harris DM.
        Am J Health Promot. 2018 Jul;32(6):1365-1374.
        PURPOSE: Frequent sugar-sweetened beverage (SSB) consumption is associated with chronic disease. Although physician counseling can positively affect patient behavior, physicians’ personal characteristics may influence counseling practices. We explored SSB-related topics physicians discuss when counseling overweight/obese patients and examined associations between physicians’ SSB-related counseling practices and their personal and medical practice characteristics. DESIGN: Cross-sectional survey. SETTING: DocStyles survey, 2014. PARTICIPANTS: A total of 1510 practicing US physicians. MEASURES: Physician’s SSB counseling on calories, added sugars, obesity/weight gain, health effects, consumption frequency, water substitution, and referral. ANALYSIS: Adjusted odds ratios (aORs) were calculated with multivariable logistic regression, adjusting for physician’s personal and medical practice characteristics. RESULTS: Most physicians (98.5%) reported SSB-related counseling. The most reported topic was obesity/weight gain (81.4%); the least reported were added sugars (53.1%) and referral (35.0%). Physicians in adult-focused specialties had lower odds than pediatricians of counseling on several topics (aOR range: 0.26-0.64). Outpatient physicians had higher odds than inpatient physicians of counseling on consumption frequency and water substitution (aOR range: 1.60-2.01). Physicians consuming SSBs >/=1 time/day (15.7%) had lower odds than nonconsumers of counseling on most topics (aOR range: 0.58-0.68). CONCLUSION: Most physicians reported SSB-related counseling; obesity/weight gain was discussed most frequently. Counseling opportunities remain in other topic areas. Opportunities also exist to strengthen SSB counseling practices in adult-focused specialties, inpatient settings, and among physicians who consume SSBs daily.

    • Communicable Diseases
      1. Condom availability programs in schools: A review of the literature
        Andrzejewski J, Liddon N, Leonard S.
        Am J Health Promot. 2018 Aug 1:890117118791118.
        OBJECTIVE: This review synthesizes findings from the peer-reviewed evaluation literature on condom availability programs (CAPs) in secondary schools. DATA SOURCE: Peer-reviewed evaluation literature indexed in MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, Sociological Abstracts, SCOPUS, and POPLINE. STUDY INCLUSION AND EXCLUSION CRITERIA: Manuscripts had to be, written in English, and report evaluation data from a US school-based CAP. DATA EXTRACTION: Articles were coded independently by 2 authors. Discrepancies were resolved through open discussion. DATA SYNTHESIS: We grouped findings into outcome evaluation and process evaluation findings. Outcome evaluation findings included sexually transmitted infections (STIs), pregnancy rates, condom use, contraception use, sexual risk, and substance use. Process evaluation findings included awareness of CAPs, attitudes toward CAPs, attitudes toward condoms, and receipt of education and instruction. RESULTS: Of the 138 citations reviewed, 12 articles published between 1995 and 2012 met the inclusion criteria, representing 8 programs. Evaluations indicate CAPs yield condom acquisition rates between 23% and 48%, have mixed results related to condom use, and are not associated with increases in sexual and other risk behaviors. One program found CAPs were associated with a decrease in a combined rate of chlamydia and gonorrhea. One program found no association between CAPs and unintended pregnancy. Students’ attitudes toward CAPs were favorable and awareness was high. CONCLUSIONS: Condom availability programs are accepted by students and can be an appropriate and relevant school-based intervention for teens. Condom availability programs can increase condom use, but more evaluations are needed on CAP impact on rates of HIV, STIs, and unintended pregnancy.

      2. Timing of respiratory syncytial virus and influenza epidemic activity in five regions of Argentina, 2007-2016
        Baumeister E, Duque J, Varela T, Palekar R, Couto P, Savy V, Giovacchini C, Haynes AK, Rha B, Arriola CS, Gerber SI, Azziz-Baumgartner E.
        Influenza Other Respir Viruses. 2018 Jul 26.
        INTRODUCTION: Within-country differences in the timing of RSV and influenza epidemics have not been assessed in Argentina, the eighth largest country in the world by area. We compared seasonality for RSV and influenza both nationally and in each of the five regions to inform Argentina’s prevention and treatment guidelines. METHOD: The Argentine National Laboratories and Health Institutes Administration collected respiratory specimens from clinical practices, outbreak investigations, and respiratory virus surveillance in 2007-2016; these were tested using immunofluorescence or RT-PCR techniques. We calculated weekly percent positive (PP) and defined season onset as >2 consecutive weeks when PP exceeded the annual mean for the respective year and region. Median season measures (onset, offset and peak) and the established mean method were calculated for each virus. RESULTS: An annual median 59,396 specimens were tested for RSV and 60,931 for influenza; 21-29% tested positive for RSV and 2-7% for influenza. National RSV activity began in April; region-specific start weeks varied by 7 weeks. Duration of RSV activity did not vary widely by region (16-18 weeks in duration). National influenza activity started in June; region-specific start weeks varied by 3 weeks. Duration of influenza epidemic activity varied more by region than that of RSV (7-13 weeks in duration). CONCLUSION: In Argentina, RSV and influenza activity overlapped during the winter months. RSV season tended to begin prior to the influenza season, and showed more variation in start week by region. Influenza seasons tended to vary more in duration than RSV seasons. This article is protected by copyright. All rights reserved.

      3. Mortality among patients with chronic hepatitis B (CHB) Infection: the Chronic Hepatitis Cohort Study (CHeCS)
        Bixler D, Zhong Y, Ly KN, Moorman AC, Spradling PR, Teshale EH, Rupp LL, Gordon SC, Boscarino JA, Schmidt MA, Daida YG, Holmberg SD.
        Clin Infect Dis. 2018 Jul 28.
        Background: According to death certificates, approximately 1800 persons die from hepatitis B annually in the United States (US); however, this figure may underestimate the true mortality from chronic hepatitis B (CHB). Methods: We analyzed data from CHB patients seen in the Chronic Hepatitis Cohort Study (CHeCS) between January 1, 2006 and December 31, 2013. We compared overall and cause-specific death rates and mean age at death between CHeCS CHB decedents and US decedents from the multiple cause of death (MCOD) file. Results: A total of 4389 CHB patients were followed for a mean of 5.38 years through December 31, 2014; 492 (11%) CHB patients died after a mean follow-up of 3.00 years. Compared to survivors, decedents were older, more likely to be White (40.6%), African-American (27.1%) or male (74.2%), and more likely to have cirrhosis (59.8%), diabetes (27.2%), alcohol abuse (17.7%), hepatocellular carcinoma (17.5%) or liver transplant (5.7%); whereas survivors were more likely to be Asian (48.8%) (all, p<0.001). CHB patients died at an average age of 59.8 years, 14 years younger than the general US population and at higher rates for all causes (RR=1.854 [95% CI, 1.851 – 1.857]) and liver-related causes (RR=15.91 [95% CI, 15.81 – 16.01]). Only 19% of CHB decedents and 40% of those dying of liver disease had hepatitis B reported on their death certificates. Conclusions: Compared to the general population, CHB patients die at a younger age and at higher rates from all causes and liver-related causes. Death certificates underrepresent the true mortality from CHB.

      4. TB control in humanitarian emergencies: Lessons from the Syria displacement crisis
        Boyd AT, Cookson ST.
        J Clin Tuberc Other Mycobact Dis. 2018 .
        The TB care for communities in emergency contexts satellite session at the 2017 48th Union World Conference on Lung Health discussed the impact of the Syrian displacement crisis on regional tuberculosis (TB) control. At the session, representatives of the affected countries and of international organizations reviewed the epidemiologic impact of Syrian displacement on regional TB control, as well as challenges and successes seen in TB control during this displacement. This discussion offered several lessons for TB control in other humanitarian emergencies. TB control in humanitarian emergencies requires increasing awareness of TB symptoms and services among healthcare workers and the affected populations. It also requires performing standardized symptom screening at borders or registration, while leveraging more widely available radiographic and diagnostic tools to find cases in high-burden settings that may be missed using symptom screening alone. Additionally, treatment completion rates can be maintained and improved through dedication of sufficient resources and innovative strategies to keep mobile populations on treatment. Finally, sustained commitment, including funding, from the international humanitarian community is necessary to improve TB control, and ultimately end TB, both in the Syria crisis and other humanitarian emergencies worldwide.

      5. Meningococcal carriage among a university student population – United States, 2015
        Breakwell L, Whaley M, Khan UI, Bandy U, Alexander-Scott N, Dupont L, Vanner C, Chang HY, Vuong JT, Martin S, MacNeil JR, Wang X, Meyer SA.
        Vaccine. 2018 Jan 2;36(1):29-35.
        OBJECTIVES: Several outbreaks of serogroup B meningococcal disease have occurred among university students in recent years. In the setting of high coverage of the quadrivalent meningococcal conjugate vaccine and prior to widespread use of serogroup B meningococcal vaccines among adolescents, we conducted surveys to characterize the prevalence and molecular characteristics of meningococcal carriage among university students. METHODS: Two cross-sectional oropharyngeal carriage surveys were conducted among undergraduates at a Rhode Island university. Isolates were characterized using slide agglutination, real-time polymerase chain reaction (rt-PCR), and whole genome sequencing. Adjusted prevalence ratios and 95% confidence intervals were calculated using Poisson regression to determine risk factors for carriage. RESULTS: A total of 1837 oropharyngeal specimens were obtained from 1478 unique participants. Overall carriage prevalence was 12.7-14.6% during the two survey rounds, with 1.8-2.6% for capsular genotype B, 0.9-1.0% for capsular genotypes C, W, or Y, and 9.9-10.8% for nongroupable strains by rt-PCR. Meningococcal carriage was associated with being male, smoking, party or club attendance, recent antibiotic use (inverse correlation), and recent respiratory infections. CONCLUSIONS: In this university setting, the majority of meningococcal carriage was due to nongroupable strains, followed by serogroup B. Further evaluation is needed to understand the dynamics of serogroup B carriage and disease among university students.

      6. Circumcision status at HIV infection is not associated with plasma viral load in men: analysis of specimens from a randomized controlled trial
        Davis SM, Pals S, Yang C, Odoyo-June E, Chang J, Walters MS, Jaoko W, Bock N, Westerman L, Toledo C, Bailey RC.
        BMC Infect Dis. 2018 Jul 28;18(1):350.
        BACKGROUND: Male circumcision provides men with approximately 60% protection from acquiring HIV infection via heterosexual sex, and has become a key component of HIV prevention efforts in sub-Saharan Africa. Possible mechanisms for this protection include removal of the inflammatory anaerobic sub-preputial environment and the high concentration of Langerhans cells on the inside of the foreskin, both believed to promote local vulnerability to HIV infection. In people who do acquire HIV, viral load is partially determined by infecting partner viral load, potentially mediated by size of infecting inoculum. By removing a portal for virion entry, prior male circumcision could decrease infecting inoculum and thus viral load in men who become HIV-infected, conferring the known associated benefits of slower progression to disease and decreased infectiousness. METHODS: We performed an as-treated analysis of plasma samples collected under a randomized controlled trial of male circumcision for HIV prevention, comparing men based on their circumcision status at the time of HIV acquisition, to determine whether circumcision is associated with lower viral load. Eligible men were seroconverters who had at least one plasma sample available drawn at least 6 months after infection, reported no potential exposures other than vaginal sex and, for those who were circumcised, were infected more than 6 weeks after circumcision, to eliminate the open wound as a confounder. Initial viral load testing indicated that quality of pre-2007 samples might have been compromised during storage and they were excluded, as were those with undetectable or unquantifiable results. Log viral loads were compared between groups using univariable and multivariable linear regression, adjusting for sample age and sexually transmitted infection diagnosis with 3.5 months of seroconversion, with a random effect for intra-individual clustering for samples from the same man. A per-protocol analysis was also performed. RESULTS: There were no viral load differences between men who were circumcised and uncircumcised at the time of HIV infection (means 4.00 and 4.03 log10 copies/mL respectively, p = .88) in any analysis. CONCLUSION: Circumcision status at the time of HIV infection does not affect viral load in men. TRIAL REGISTRATION: The original RCT which provided the samples was trial NCT00059371 .

      7. Get Yourself Tested (GYT) Campaign: Investigating campaign awareness and behaviors among high school and college students
        Eastman-Mueller HP, Habel MA, Oswalt SB, Liddon N.
        Health Educ Behav. 2018 Aug 1.
        Adolescents and young adults are disproportionately affected by sexually transmitted diseases (STDs). This study examined the association of GYT: Get Yourself Tested (GYT), a sexual health social marketing campaign, with several sexual health behaviors on a nationally representative sample of high school (HS) and college students ( n = 2,329) recruited through an online panel survey. Behaviors examined were STD testing, HIV testing, and whether students had communication with health care providers and their romantic partners about STDs and STD testing. Rao-Scott chi-square tests and multivariable logistic regression models were conducted. The results indicated college students were more aware of GYT than HS students. Awareness of GYT was significantly associated with STD testing ( p < .05), HIV testing ( p < .01), and talking with romantic partners ( p < .01) for college students but only with STD testing ( p < .05) and talking to a provider ( p < .05) for HS students. The differences between HS and college students provide insight for those developing and implementing interventions across such a broad age range of youth.

      8. [No abstract]

      9. Population-based incidence of childhood pneumonia associated with viral infections in Bangladesh
        Havers FP, Fry AM, Goswami D, Nahar K, Sharmin AT, Rahman M, Brooks WA.
        Pediatr Infect Dis J. 2018 Jul 31.
        BACKGROUND: The contribution of respiratory viruses to childhood pneumonia in tropical low- and middle-income countries is poorly understood. We used population-based respiratory illness surveillance in children <5 years old in Dhaka, Bangladesh, to characterize these illnesses. METHODS: We conducted weekly home visits to children who were referred to clinic for fever or respiratory symptoms. Standardized clinical data were collected. Nasopharyngeal washes were collected for one fifth of children diagnosed with a febrile or respiratory syndrome, with virus isolation testing for influenza and RT-PCR testing for other viruses. Pneumonia was defined as age-specific tachypnea and crepitations on chest auscultation by study physicians. RESULTS: From April 2004-February 2008, 17,584 children were followed for 17,644 child-years; 6,335 children had 12,499 clinic visits with eligible illnesses, including 6,345 pneumonia episodes (incidence of 36 episodes/100 child-years). Annual incidence of pneumonia/100 child-years ranged from 88.3 for children 0-6 months to 13.1 for those 36-60 months. Of 1,248 pneumonia visits with laboratory testing, 803 (64%) had detection of viral pathogens, including 274 respiratory syncytial virus (22% of pneumonia visits with laboratory testing; incidence 7.9/100 child-years), 244 adenovirus (19%; 7.0/100 child-years), 198 human metapneumovirus (16%; 5.7/100 child-years), 174 parainfluenza (14.0%; 5.0/100 child-years), and 81 influenza (6.5%; 2.3/100 child years). CONCLUSIONS: Viral pathogens contribute to a majority of childhood pneumonia episodes in Bangladesh, a setting with high pneumonia rates, especially in children <2 years old. Developing effective prevention strategies targeting these children is a high priority. Given less sensitive laboratory method used for influenza detection, influenza rates may be underestimated.

      10. Reconciling the evaluation of co-morbidities among HIV care patients in two large data systems: the Medical Monitoring Project and CFAR Network of Integrated Clinical Systems
        Hood JE, Bradley H, Hughes JP, Golden MR, Crane HM, Buskin SE, Burkholder GA, Geng E, Kitahata MM, Mathews WC, Moore RD, Hawes SE.
        AIDS Care. 2018 Jul 27:1-9.
        The estimated burden of chronic disease among people living with HIV (PLWH) varies considerably by data source, due to differences in case definitions, analytic approaches, and underlying patient populations. We evaluated the burden of diabetes (DM) and chronic kidney disease (CKD) in two large data systems that are commonly queried to evaluate health issues affecting HIV care patients: the Medical Monitoring Project (MMP), a nationally representative sample, and the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), a clinical cohort. In order to reconcile these two data sources, we addressed issues common to observational data, including selection bias, missing data, and development of case definitions. The overall adjusted estimated prevalence of DM and CKD in MMP was 12.7% and 7.6%, respectively, and the overall prevalence of DM and CKD in CNICS was 9.9% and 8.3%, respectively; prevalence estimates increased with age in both data sources. After reconciling the approach to analyzing MMP and CNICS data, sub-group specific prevalence estimates of DM and CKD was generally similar in both data sources. Both data sources suggest a considerable burden of disease among older adults in HIV care. MMP and CNICS can provide reliable data to monitor HIV co-morbidities in the US.

      11. Per-partner condom effectiveness against HIV for men who have sex with men
        Johnson WD, O’Leary A, Flores SA.
        Aids. 2018 Jul 17;32(11):1499-1505.
        OBJECTIVE: Few studies have examined condom effectiveness for HIV prevention among MSM. We estimated condom effectiveness per partner in four cohorts of MSM during 1993-2003 (JumpStart, Vaccine Preparedness Study, VAX004 and Project Explore). METHODS: We used logistic regression to estimate the increase in odds of new HIV infection per HIV-positive partner for condom-protected receptive anal intercourse (PRAI; partners with whom condoms were always used) and condomless (unprotected) receptive anal intercourse (URAI; partners with whom condoms were sometimes or never used). To estimate condom effectiveness for preventing HIV transmission, we applied the concept of excess odds, the odds ratio minus 1. The condom failure rate was estimated as the excess odds per PRAI partner divided by the excess odds per URAI partner. Condom effectiveness was then 1 minus the failure rate. RESULTS: The excess odds of HIV infection per HIV-positive partner were 83% for URAI and 7% for PRAI. The resulting failure rate (9%) indicated per-partner condom effectiveness of 91% (95% confidence interval 69-101). CONCLUSION: The increase in odds of new HIV infection per HIV-positive partner for receptive anal intercourse was reduced by 91% for each partner with whom condoms were always used.

      12. Syphilis prevalence trends in adult women in 132 countries – estimations using the Spectrum Sexually Transmitted Infections model
        Korenromp EL, Mahiane SG, Nagelkerke N, Taylor MM, Williams R, Chico RM, Pretorius C, Abu-Raddad LJ, Rowley J.
        Sci Rep. 2018 Jul 31;8(1):11503.
        We estimated national-level trends in the prevalence of probable active syphilis in adult women using the Spectrum Sexually Transmitted Infections (STI) model to inform program planning, target-setting, and progress evaluation in STI control. The model fitted smoothed-splines polynomial regressions to data from antenatal clinic surveys and screening and representative household surveys, adjusted for diagnostic test performance and weighted by national coverage. Eligible countries had >/=1 data point from 2010 or later and >/=3 from 2000 or later from adult populations considered representative of the general female population (pregnant women or community-based studies). Between 2012 and 2016, the prevalence of probable active syphilis in women decreased in 54 (41%) of 132 eligible countries; this decrease was substantive (>/=10% proportionally, >/=0.10% percentage-point absolute difference and non-overlapping 95% confidence intervals in 2012 and 2016) in 5 countries. Restricting eligible data to prevalence measurements of dual treponemal and non-treponemal testing limited estimates to 85 countries; of these, 45 countries (53%) showed a decrease. These standardized trend estimates highlight the need for increased investment in national syphilis surveillance and control efforts if the World Health Organization target of a 90% reduction in the incidence of syphilis between 2018 and 2030 is to be met.

      13. Tenofovir disoproxil fumarate use during pregnancy and infant bone health: The tenofovir in pregnancy pilot study
        Kourtis AP, Wiener J, Wang L, Fan B, Shepherd JA, Chen L, Liu W, Shepard C, Wang L, Wang A, Bulterys M.
        Pediatr Infect Dis J. 2018 Jul 31.
        The effects of maternal tenofovir use on infant bone mineral content (BMC) and bone mineral density (BMD) were evaluated in a pilot study of HIV/Hepatitis B-coinfected pregnant women in China. BMD and BMC were assessed at age 6 months of life in 14 tenofovir-exposed and 13 unexposed infants. Trends toward lower BMC and BMD were observed in infants exposed to maternal tenofovir but were not statistically significant.

      14. Association between HIV genotype, viral load and disease progression in a cohort of Thai men who have sex with men with estimated dates of HIV infection
        Leelawiwat W, Pattanasin S, Sriporn A, Wasinrapee P, Kongpechsatit O, Mueanpai F, Tongtoyai J, Holtz TH, Curlin ME.
        PLoS One. 2018 ;13(7):e0201386.
        BACKGROUND: Differences between HIV genotypes may affect HIV disease progression. We examined infecting HIV genotypes and their association with disease progression in a cohort of men who have sex with men with incident HIV infection in Bangkok, Thailand. METHODS: We characterized the viral genotype of 189 new HIV infections among MSM identified between 2006-2014 using hybridization and sequencing. Plasma viral load (PVL) was determined by PCR, and CD4+ T-cell counts were measured by flow cytometry. We used Generalized Estimating Equations to examine factors associated with changes in CD4+ T-cell counts. Factors associated with immunologic failure were analyzed using Cox proportional hazard models. RESULTS: Among 189 MSM, 84% were infected with CRF01_AE, 11% with recombinant B/CRF01_AE and 5% with subtype B. CD4+ T-cell decline rates were 68, 65, and 46 cells/muL/year for CRF01_AE, recombinants, and subtype B, respectively, and were not significantly different between HIV subtypes. CD4+ T-cell decline rate was significantly associated with baseline PVL and CD4+ T-cell counts (p <0.001). Progression to immunologic failure was associated with baseline CD4+ T-cell </= 500 cells/muL (AHR 1.97; 95% CI 1.14-3.40, p = 0.015) and PVL > 50,000 copies/ml (AHR 2.03; 1.14-3.63, p = 0.017). There was no difference in time to immunologic failure between HIV subtypes. CONCLUSION: Among HIV-infected Thai MSM, low baseline CD4+ T-cell and high PVL are associated with rapid progression. In this cohort, no significant difference in CD4+ T-cell decline rate or time to immunologic failure was seen between CRF01_AE and other infecting HIV subtypes.

      15. BACKGROUND: Black women who are positive for human immunodeficiency virus (HIV) are more likely than other HIV-positive women to experience poor health outcomes. Given these disparities, we compared receipt of HIV testing and other preventive services among Black, White, and Hispanic women participating in HIV prevention programs funded by the Centers for Disease Control and Prevention in 2015. METHODS: Data came from 61 health department jurisdictions and 123 community-based organizations. Using Wald chi(2) tests, we assessed racial/ethnic differences in HIV testing by demographic characteristics, risk factors, HIV status, HIV service delivery, and (using unlinked data) participation in evidence-based HIV prevention interventions among women. We also assessed temporal changes in Black women’s receipt of preventive services (2012-2015). RESULTS: In 2015, there were 1,326,589 HIV testing events (single sessions in which one or more HIV tests are performed to determine HIV status) that occurred among Black, White, and Hispanic women, resulting in 4,868 positive diagnoses. Proportionally fewer Black (vs. White and Hispanic) women were linked to HIV medical care within 90 days (64.4% vs. 69.1% and 73.7%), interviewed for partner services (50.4% vs. 54.4% and 63.5%), and referred to risk reduction services (55.5% vs. 57.7% and 59.8%). From 2012 to 2015, HIV testing events among Black women decreased by 15.2%, but linkage to care within 90 days increased by 30.6% and participation in one or more evidence-based intervention increased by 46.8% among HIV-positive Black women. CONCLUSIONS: Black HIV-positive women were less likely than White and Hispanic women to receive services that prevent HIV-related morbidity and mortality. Additional programmatic efforts are needed to increase the proportion of HIV-positive Black women who are linked to services to reduce HIV disparities among women.

      16. Notes from the Field: Toxigenic Vibrio cholerae O141 in a Traveler to Florida – Nebraska, 2017
        Loeck BK, Roberts A, Craney AR, King S, Im MS, Safranek TJ, Iwen PC, Carlson AV, Pedati C.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):838-839.

        [No abstract]

      17. Progress toward poliomyelitis eradication – Afghanistan, January 2017-May 2018
        Martinez M, Shukla H, Ahmadi M, Inulin J, Widodo MS, Ahmed J, Mbaeyi C, Jabra J, Gerhardt D.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):833-837.
        Afghanistan, Pakistan, and Nigeria remain the only countries where transmission of endemic wild poliovirus type 1 (WPV1) continues (1). This report describes polio eradication activities, progress, and challenges to eradication in Afghanistan during January 2017-May 2018 and updates previous reports (2, 3). Fourteen WPV1 cases were confirmed in Afghanistan in 2017, compared with 13 in 2016; during January-May 2018, eight WPV1 cases were reported, twice the number reported during January-May 2017. To supplement surveillance for acute flaccid paralysis (AFP) and laboratory testing of stool samples, environmental surveillance (testing of sewage samples) was initiated in 2013 and includes 20 sites, 15 of which have detected WPV1 circulation. The number of polio-affected districts increased from six in 2016 to 14 in 2017 (including WPV1 cases and positive environmental samples). Access to children for supplementary immunization activities (SIAs) (mass campaigns targeting children aged <5 years with oral poliovirus vaccine [OPV], regardless of vaccination history), which improved during 2016 to early 2018, worsened in May 2018 in security-challenged areas of the southern and eastern regions. To achieve WPV1 eradication, measures to maintain and regain access for SIAs in security-challenged areas, strengthen oversight of SIAs in accessible areas to reduce the number of missed children, and coordinate with authorities in Pakistan to track and vaccinate mobile populations at high risk in their shared transit corridors must continue.

      18. Seasonality and clinical impact of human parainfluenza viruses
        Maykowski P, Smithgall M, Zachariah P, Oberhardt M, Vargas C, Reed C, Demmer RT, Stockwell M, Saiman L.
        Influenza Other Respir Viruses. 2018 Jul 26.
        BACKGROUND: Widespread availability of rapid diagnostic testing for respiratory viruses allows more in-depth studies of human parainfluenza viruses (HPIV). OBJECTIVES: This study aimed to assess seasonality of HPIV types 1-4, clinical outcomes by HPIV type, and risk factors for illness severity. PATIENTS/METHODS: This retrospective study was performed from January 2013 to December 2015 in children and adults with HPIV, detected by multiplex reverse transcription polymerase chain reaction, participating in a community surveillance study of acute respiratory infections (ARIs) in New York City and patients admitted to a tertiary care center in the same neighborhood. Seasonality trends by HPIV type were compared between the community and hospital groups. The associations between HPIV type, demographics, clinical characteristics, and illness severity were assessed. RESULTS: HPIV was detected in 69 (4%) of 1753 community-surveillance participants (median age 9.2 years) and 680 hospitalized patients (median age 6.8 years). Seasonality for HPIV types 1-3 agreed with previously described patterns; HPIV-4 occurred annually in late summer and fall. In the community cohort, 22 (32%) participants sought medical care, 9 (13%) reported antibiotic use, and 20 (29%) reported > 1 day of missed work or school. Among hospitalized patients, 24% had >4 chronic conditions. Multivariable ordinal logistic regression demonstrated that increased severity of illness was significantly associated with HPIV-4 and chronic cardiovascular and respiratory conditions in children and with age >65 years and chronic respiratory conditions in adults. CONCLUSIONS: HPIV-4 presented late summer and early fall annually and was associated with increased severity of illness in hospitalized children. This article is protected by copyright. All rights reserved.

      19. Genetic diversity of noroviruses circulating in a pediatric cohort in Bangladesh
        Nelson MI, Mahfuz M, Chhabra P, Haque R, Seidman JC, Hossain I, McGrath M, Ahmed AM, Knobler S, Vinje J, Ahmed T.
        J Infect Dis. 2018 Jul 23.
        Noroviruses are a leading cause of diarrhea in children <5yo worldwide. We genotyped 88 viruses collected by active surveillance in a birth cohort of children <2yo in Dhaka, Bangladesh, during 2010-2013. Twenty-five (81%) of 31 established GI and GII genotypes were detected, with GII.4 as the predominant genotype (20%). Our results show that children in Bangladesh are infected with a great diversity of norovirus strains. Re-infections are common, but not with closely related genotypes. Birth cohort studies are critical to understand cross-protective immunity and advance the development of pediatric norovirus vaccines.

      20. HIV infection among MSM who inject methamphetamine in 8 US cities
        Nerlander LM, Hoots BE, Bradley H, Broz D, Thorson A, Paz-Bailey G.
        Drug Alcohol Depend. 2018 Jul 20;190:216-223.
        BACKGROUND AND AIMS: Men who have sex with men (MSM) and inject drugs are at risk for HIV infection. Although research exists on non-injection methamphetamine (meth) use and sexual risk among MSM, less is known about meth injection and its association with HIV infection among MSM who inject drugs. METHODS: We analyzed data from men aged >/=18 years who reported injecting drugs and male-to-male sexual contact. Men were recruited using respondent-driven sampling, interviewed, and tested for HIV during the 2012 and 2015 cycles of National HIV Behavioral Surveillance among persons who inject drugs. We included data from 8 cities where >/=10 MSM reported meth as the primary drug injected. We assessed differences in demographic characteristics, past 12 months risk behaviors, and HIV infection between MSM who primarily injected meth and those who primarily injected another drug. RESULTS: Among 961 MSM, 33.7% reported meth as the drug they injected most often. Compared to MSM who primarily injected other drugs, MSM who primarily injected meth were more likely to have had >/=5 condomless anal sex partners, have been diagnosed with syphilis, and were less likely to report sharing syringes. In multivariable analysis, injecting meth was associated with being HIV-positive (adjusted prevalence ratio 1.48; 95% confidence interval 1.08-2.03). Including number of condomless anal sex partners in mediation analysis rendered this association no longer significant. CONCLUSIONS: HIV prevalence among MSM who primarily injected meth was almost 50% higher than among MSM who primarily injected other drugs, and this association was mediated by sexual risk.

      21. Assessing differences in CDC-funded HIV testing by urbanicity, United States, 2016
        Patel D, Taylor-Aidoo N, Marandet A, Heitgerd J, Maciak B.
        J Community Health. 2018 Aug 1.
        HIV prevention efforts have contributed to a decline in annual HIV infections in the United States. However, progress has been uneven and certain groups and geographic areas continue to be disproportionately affected. Subsequent to implementation of CDC’s high-impact HIV prevention approach to reducing new infections, we analyzed national-level CDC-funded HIV test data from 2016 to describe the population being reached in three urbanicity settings (metropolitan: >/= 1,000,000 population; urban: 50,000-999,999; rural: < 50,000). Over 70% of CDC-funded HIV tests and almost 80% of persons newly diagnosed with HIV as a result of CDC-funded testing occurred in metropolitan areas. Nonetheless, CDC-funded testing efforts are reaching urban and rural areas, especially in the South, providing opportunities to identify persons unaware of their HIV status and link those with newly diagnosed HIV to medical care and prevention services. While CDC-funded testing efforts have continued to focus on population subgroups and geographic areas at greatest risk, efforts should also continue in rural areas and among groups in need with a low national burden.

      22. Report from the International Viral Hepatitis Elimination Meeting (IVHEM), 17-18 November 2017, Amsterdam, the Netherlands: gaps and challenges in the WHO 2030 hepatitis C elimination framework
        Popping S, El-Sayed M, Feld J, Hatzakis A, Hellard M, Lesi O, Ninburg M, Ward J, Boucher C.
        J Virus Erad. 2018 Jul 1;4(3):193-195.
        The current global burden of hepatitis C (HCV) is estimated at 71 million people. The World Health Organization (WHO) has stated that HCV could be eliminated as a public health threat by 2030. A key recommendation to reach this elimination goal is to reduce new infections by 90% and liver-related mortality by 65%. Countries are encouraged by the WHO to develop their own national elimination programmes in order to reach these goals. However, various gaps and challenges, such as the lack of high-quality epidemiological data, stigmatisation, and optimisation of the cascade of care, have arisen in the WHO strategic framework. The International Viral Hepatitis Elimination Meeting (IVHEM) has therefore established an expert panel made of clinicians, virologists, and public health specialists to discuss and address these challenges. This review highlights the outcome and proposed solutions to attempt at facilitating HCV elimination.

      23. A retrospective study of laboratory-based enteric fever surveillance, Pakistan, 2012-2014
        Qamar FN, Yousafzai MT, Sultana S, Baig A, Shakoor S, Hirani F, Wassay A, Khushboo S, Mehmood J, Freeman A, Date K, Garrett D.
        J Infect Dis. 2018 Jul 27.
        Introduction: The Surveillance for Enteric Fever in Asia Project (SEAP) is a multisite surveillance study designed to capture morbidity and mortality burden of enteric fever (typhoid and paratyphoid) in Bangladesh, Nepal, and Pakistan. We aim to describe enteric fever disease burden, severity of illness, and antimicrobial resistance trends in Pakistan. Methods: In this retrospective, cross-sectional study, laboratory records of hospitalized patients who received a blood culture in any of 3 Aga Khan University hospitals in Karachi and Hyderabad, Pakistan, from 2012 to 2014 were reviewed. A case was defined as having a positive blood culture for Salmonella Typhi (S. Typhi) or Salmonella Paratyphi (S. Paratyphi). Antimicrobial sensitivity patterns were characterized for all S. Typhi and S. Paratyphi isolates. Medical records were available for abstraction (demographics, clinical features, complications) only among hospitalized cases. Results: Of the 133017 blood cultures completed during the study period, 2872 (2%) were positive-1979 (69%) for S. Typhi and 893 (31%) for S. Paratyphi. Fluoroquinolone resistance was present in >90% of both the S. Typhi and the S. Paratyphi isolates; almost none of the isolates were resistant to cephalosporins. Multidrug resistance (resistance to ampicillin, chloramphenicol, and cotrimoxazole) was observed in 1035 (52%) S. Typhi isolates and 14 (2%) S. Paratyphi isolates. Among S. Typhi and S. Paratyphi isolates, 666 (23%) were linked to hospitalized patients with medical records. Of the 537 hospitalized S. Typhi cases, 280 (52%) were aged 5-15 years, 133 (25%) were aged 2-4 years, 114 (21%) were aged >15 years, and 10 (2%) were aged 0-1 years. Among the 129 hospitalized S. Paratyphi cases, 73 (57%) were aged >15 years, 41 (32%) were aged 5-15 years, 13 (10%) were aged 2-4 years, and 2 (2%) were aged 0-1 years. Significant differences in symptomology between S. Typhi and S. Paratyphi cases were observed for nausea/vomiting, diarrhea, loss of appetite, and headache. Leukopenia, thrombocytopenia, and encephalopathy were the most commonly reported complications among enteric fever cases. No deaths were reported. Conclusion: Evidence of high antimicrobial resistance levels and disease severity support the need for continued surveillance and improved diagnostics for typhoid. Further prospective studies on vaccination as a tool for prevention of enteric fever in Pakistan are needed to inform disease intervention strategies.

      24. Toward a generation free of tuberculosis: TB disease and infection in individuals of college age in the United States
        Shah NS, Flood-Bryzman A, Jeffries C, Scott J.
        J Am Coll Health. 2018 Jan;66(1):17-22.
        OBJECTIVES: To assess the magnitude of active TB disease and latent TB infection (LTBI) in young adults of college age. PARTICIPANTS: Individuals who were aged 18-24 years in 2011 were used as a proxy for college students. METHODS: Active TB cases reported to the 2011 US National TB Surveillance System (NTSS) were included. LTBI prevalence was calculated from the 2011-2012 National Health and Nutrition Examination Survey. The 2011 American Community Survey was used to calculate population denominators. Analyses were stratified by nativity. RESULTS: Active TB disease incidence among persons aged 18-24 years was 2.82/100,000, 18.8/100,000 among foreign-born individuals and 0.9/100,000 among US-born individuals. In 2011, 878 TB cases were reported; 629 (71.6%) were foreign-born. LTBI prevalence among persons of 18-24 years was 2.5%: 8.7% and 1.3% among foreign-born and US-born, respectively. CONCLUSION: Active screening and treatment programs for foreign-born young adults could identify TB cases earlier and provide an opportunity for prevention efforts.

      25. Serological susceptibility to Varicella among U.S. Immigration and Customs Enforcement detainees
        Varan AK, Lederman ER, Stous SS, Elson D, Freiman JL, Marin M, Lopez AS, Stauffer WM, Joseph RH, Waterman SH.
        J Correct Health Care. 2018 Jan;24(1):84-95.
        U.S. Immigration and Customs Enforcement (ICE) is responsible for detaining unauthorized aliens during immigration proceedings. During 2014 to 2015, adult ICE detainees at a California facility were invited to complete a survey concerning self-reported varicella history and risk factors. Participants underwent serological testing for varicella-zoster virus (VZV) IgG; susceptible individuals were offered varicella vaccination. Among 400 detainees with available serology results, 48 (12%) were susceptible to varicella. Self-reported varicella history was negatively associated with susceptibility (adjusted odds ratio = 0.16; 95% confidence interval [0.07, 0.35]). Among 196 detainees reporting a positive history, 95% had VZV IgG levels suggestive of varicella immunity. Among 44 susceptible detainees offered vaccination, 86% accepted. Given relatively high varicella susceptibility, targeted screening and vaccination among ICE detainees lacking a positive history might reduce varicella transmission risks.

    • Disaster Control and Emergency Services
      1. Deaths related to Hurricane Irma – Florida, Georgia, and North Carolina, September 4-October 10, 2017
        Issa A, Ramadugu K, Mulay P, Hamilton J, Siegel V, Harrison C, Campbell CM, Blackmore C, Bayleyegn T, Boehmer T.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):829-832.
        Three powerful and devastating hurricanes from the 2017 Atlantic hurricane season (Harvey [August 17-September 1], Irma [August 30-September 13], and Maria [September 16-October 2]) resulted in the deaths of hundreds of persons. Disaster-related mortality surveillance is critical to an emergency response because it provides government and public health officials with information about the scope of the disaster and topics for prevention messaging. CDC’s Emergency Operations Center collaborated with state health departments in Florida, Georgia, and North Carolina to collect and analyze Hurricane Irma-related mortality data to understand the main circumstances of death. The most common circumstance-of-death categories were exacerbation of existing medical conditions and power outage. Further analysis revealed two unique subcategories of heat-related and oxygen-dependent deaths in which power outage contributed to exacerbation of an existing medical condition. Understanding the need for subcategorization of disaster-related circumstances of death and the possibility of overlapping categories can help public health practitioners derive more effective public health interventions to prevent deaths in future disasters.

      2. School district crisis preparedness, response, and recovery plans – United States, 2006, 2012, and 2016
        Kruger J, Brener N, Leeb R, Wolkin A, Avchen RN, Dziuban E.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):809-814.
        Children spend the majority of their time at school and are particularly vulnerable to the negative emotional and behavioral impacts of disasters, including anxiety, depressive symptoms, impaired social relationships, and poor school performance (1). Because of concerns about inadequate school-based emergency planning to address the unique needs of children and the adults who support them, Healthy People 2020 includes objectives to improve school preparedness, response, and recovery plans (Preparedness [PREP]-5) (2). To examine improvements over time and gaps in school preparedness plans, data from the 2006, 2012, and 2016 School Health Policies and Practices Study (SHPPS) were analyzed to assess changes in the percentage of districts meeting PREP-5 objectives. Findings from these analyses indicate that districts met the PREP-5 objective for requiring schools to include post-disaster mental health services in their crisis preparedness plans for the first time in 2016. However, trend analyses did not reveal statistically significant increases from 2006 to 2016 in the percentage of districts meeting any of the PREP-5 objectives. Differences in preparedness were detected in analyses stratified by urbanicity and census region, highlighting strengths and challenges in emergency planning for schools. To promote the health and safety of faculty, staff members, children, and families, school districts are encouraged to adopt and implement policies to improve school crisis preparedness, response, and recovery plans.

    • Disease Reservoirs and Vectors
      1. Distribution and establishment of the Lone Star tick in Connecticut and implications for range expansion and public health
        Stafford KC, Molaei G, Little EA, Paddock CD, Karpathy SE, Labonte AM.
        J Med Entomol. 2018 Jul 25.
        In the United States, the lone star tick, Amblyomma americanum (L.) (Acari: Ixodidae), is an aggressive southeastern species whose range has reportedly been steadily expanding northward. The number of A. americanum specimens submitted to the Tick Testing Laboratory (TTL) at the Connecticut Agricultural Experiment Station (CAES) increased by 58% from the period of 1996-2006 (n = 488) to 2007-2017 (n = 773), mainly from Fairfield County in the southwestern corner of the state. The greatest numbers of A. americanum submissions to the CAES-TTL were from the City of Norwalk and a few adjacent municipalities. We also report the discovery of a large infestation of adult and nymphal lone star ticks detected on a dead male white-tailed deer, Odocoileus virginianus (Zimmerman) (Artiodactyla: Cervidae), on Manresa Island, Norwalk, in June 2017, indicating a long established, undetected population along the southwestern coast. A sample of nymphal and adult host-seeking A. americanum collected July 2017 from Manresa Island were tested and a proportion were positive for Ehrlichia chaffeensis, Ehrlichia ewingii, and Anaplasma phagocytophilum. The A. americanum tick and its associated disease pathogens are expected to become an increasing public health concern in southern New England.

    • Drug Safety
      1. Characteristics of tianeptine exposures reported to the National Poison Data System – United States, 2000-2017
        El Zahran T, Schier J, Glidden E, Kieszak S, Law R, Bottei E, Aaron C, King A, Chang A.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):815-818.
        Tianeptine (marketed as Coaxil or Stablon) is an atypical tricyclic drug used as an antidepressant in Europe, Asia, and Latin America. In the United States, tianeptine is not approved by the Food and Drug Administration (FDA) for medical use and is an unscheduled pharmaceutical agent* (1). Animal and human studies show that tianeptine is an opioid receptor agonist (2). Several case studies have reported severe adverse effects and even death from recreational abuse of tianeptine (3-5). To characterize tianeptine exposures in the United States, CDC analyzed all exposure calls related to tianeptine reported by poison control centers to the National Poison Data System (NPDS)(dagger) during 2000-2017. Tianeptine exposure calls, including those for intentional abuse or misuse, increased across the United States during 2014-2017, suggesting a possible emerging public health risk. Most tianeptine exposures occurred among persons aged 21-40 years and resulted in moderate outcomes. Neurologic, cardiovascular, and gastrointestinal signs and symptoms were the most commonly reported health effects, with some effects mimicking opioid toxicity. A substantial number of tianeptine exposure calls also reported clinical effects of withdrawal. Among 83 tianeptine exposures with noted coexposures, the most commonly reported coexposures were to phenibut, ethanol, benzodiazepines, and opioids.

    • Environmental Health
      1. Assessing heat-related mortality risks among rural populations: A systematic review and meta-analysis of epidemiological evidence
        Odame EA, Li Y, Zheng S, Vaidyanathan A, Silver K.
        Int J Environ Res Public Health. 2018 Jul 27;15(8).
        Most epidemiological studies of high temperature effects on mortality have focused on urban settings, while heat-related health risks in rural areas remain underexplored. To date there has been no meta-analysis of epidemiologic literature concerning heat-related mortality in rural settings. This study aims to systematically review the current literature for assessing heat-related mortality risk among rural populations. We conducted a comprehensive literature search using PubMed, Web of Science, and Google Scholar to identify articles published up to April 2018. Key selection criteria included study location, health endpoints, and study design. Fourteen studies conducted in rural areas in seven countries on four continents met the selection criteria, and eleven were included in the meta-analysis. Using the random effects model, the pooled estimates of relative risks (RRs) for all-cause and cardiovascular mortality were 1.030 (95% CI: 1.013, 1.048) and 1.111 (95% CI: 1.045, 1.181) per 1 degrees C increase in daily mean temperature, respectively. We found excess risks in rural settings not to be smaller than risks in urban settings. Our results suggest that rural populations, like urban populations, are also vulnerable to heat-related mortality. Further evaluation of heat-related mortality among rural populations is warranted to develop public health interventions in rural communities.

    • Genetics and Genomics
      1. A collaborative translational research framework for evaluating and implementing the appropriate use of human genome sequencing to improve health
        Khoury MJ, Feero WG, Chambers DA, Brody LE, Aziz N, Green RC, Janssens A, Murray MF, Rodriguez LL, Rutter JL, Schully SD, Winn DM, Mensah GA.
        PLoS Med. 2018 Aug;15(8):e1002631.
        In a Policy Forum, Muin Khoury and colleagues discuss research on the clinical application of genome sequencing data.

      2. Comparative genomics of Salmonella enterica serovar Montevideo reveals lineage-specific gene differences that may influence ecological niche association
        Nguyen SV, Harhay DM, Bono JL, Smith TP, Fields PI, Dinsmore BA, Santovenia M, Wang R, Bosilevac JM, Harhay GP.
        Microb Genom. 2018 Jul 27.
        Salmonella enterica serovar Montevideo has been linked to recent foodborne illness outbreaks resulting from contamination of products such as fruits, vegetables, seeds and spices. Studies have shown that Montevideo also is frequently associated with healthy cattle and can be isolated from ground beef, yet human salmonellosis outbreaks of Montevideo associated with ground beef contamination are rare. This disparity fuelled our interest in characterizing the genomic differences between Montevideo strains isolated from healthy cattle and beef products, and those isolated from human patients and outbreak sources. To that end, we sequenced 13 Montevideo strains to completion, producing high-quality genome assemblies of isolates from human patients (n=8) or from healthy cattle at slaughter (n=5). Comparative analysis of sequence data from this study and publicly available sequences (n=72) shows that Montevideo falls into four previously established clades, differentially occupied by cattle and human strains. The results of these analyses reveal differences in metabolic islands, environmental adhesion determinants and virulence factors within each clade, and suggest explanations for the infrequent association between bovine isolates and human illnesses.

    • Health Communication and Education
      1. Developing a motion comic for HIV/STD prevention for young people ages 15-24, part 1: Listening to your target audience
        Willis LA, Kachur R, Castellanos TJ, Spikes P, Gaul ZJ, Gamayo AC, Durham M, Jones S, Nichols K, Han Barthelemy S, LaPlace L, Staatz C, Hogben M, Robinson S, Brooks JT, Sutton MY.
        Health Commun. 2018 Feb;33(2):212-221.
        Young people (15-24 years) in the United States are disproportionately affected by infection with human immunodeficiency virus (HIV) and sexually transmitted diseases (STD). Shortfalls in HIV/STD-related knowledge, attitudes, beliefs, and behavioral intentions (KABI) likely contribute to this discrepancy. In this report we describe our experience developing a novel means of health communication combining entertainment-education theory and recent technological advances to create a HIV/STD-focused “motion comic.” We also report the audience satisfaction and acceptance of the intervention. We used the Health Belief Model (HBM), entertainment-education (EE) principles, and the Sabido Method (SM) and conducted three rounds of focus groups to develop a 38-minute HIV/STD focused motion comic for young people between the ages 15 and 24 years. Participants indicated that motion comics were an acceptable method of delivering HIV/STD prevention messages. They also expressed satisfaction with motion comics plot, story settings, the tone of humor, and drama. Our results suggest that motion comics are a viable new method of delivering health communication messages about HIV/STD and other public health issues, and warrant further development and broader evaluation.

    • Health Disparities
      1. Processes and outcomes of a community-based participatory research-driven health needs assessment: A tool for moving health disparity reporting to evidence-based action
        Akintobi TH, Lockamy E, Goodin L, Hernandez ND, Slocumb T, Blumenthal D, Braithwaite R, Leeks L, Rowland M, Cotton T, Hoffman L.
        Prog Community Health Partnersh. 2018 ;12(1s):139-147.
        BACKGROUND: The community-based participatory research (CBPR)-driven health needs assessment was a tool used to inform community-led, -implemented, and -sustained research and prevention strategies. METHODS: The Morehouse School of Medicine Prevention Research Center (MSM PRC) research and prevention initiatives are implemented in direct response to priorities identified through this process and tool. Led by a community-majority coalition board, the assessment coupled state and city secondary data with primary survey data collected by and from community residents. RESULTS: Hypertension, diabetes, obesity, and sexually transmitted infections were most frequently cited individual and community health priorities. Lack of social and family cohesion, limited or no opportunities to exercise, poor nutrition and lack of awareness and knowledge about diseases, and insufficient access to affordable health care were cited determinants of health priorities. CONCLUSIONS: The CBPR-driven community health needs assessment (CHNA) informed and established a data-driven community engaged research agenda, policy, systems and environmental change approaches, community-led grants and job creation leveraging neighborhood contexts and strengths.

    • Healthcare Associated Infections
      1. Difficult-to-treat resistance in gram-negative bacteremia at 173 US hospitals: Retrospective cohort analysis of prevalence, predictors, and outcome of resistance to all first-line agents
        Kadri SS, Adjemian J, Lai YL, Spaulding AB, Ricotta E, Prevots DR, Palmore TN, Rhee C, Klompas M, Dekker JP, Powers JH, Suffredini AF, Hooper DC, Fridkin S, Danner RL.
        Clin Infect Dis. 2018 Jul 23.
        Background: Resistance to all first-line antibiotics necessitates the use of less effective or more toxic “reserve” agents. Gram-negative bloodstream infections (GNBSIs) harboring such difficult-to-treat resistance (DTR) may have higher mortality than phenotypes that allow for >/=1 active first-line antibiotic. Methods: The Premier Database was analyzed for inpatients with select GNBSIs. DTR was defined as intermediate/resistant in vitro to all ss-lactam categories, including carbapenems and fluoroquinolones. Prevalence and aminoglycoside resistance of DTR episodes were compared with carbapenem-resistant, extended-spectrum cephalosporin-resistant, and fluoroquinolone-resistant episodes using CDC definitions. Predictors of DTR were identified. The adjusted relative risk (aRR) of mortality was examined for DTR, CDC-defined phenotypes susceptible to >/=1 first-line agent, and graded loss of active categories. Results: Between 2009-2013, 471 (1%) of 45011 GNBSI episodes at 92 (53.2%) of 173 hospitals exhibited DTR, ranging from 0.04% for Escherichia coli to 18.4% for Acinetobacter baumannii. Among patients with DTR, 79% received parenteral aminoglycosides, tigecycline, or colistin/polymyxin-B; resistance to all aminoglycosides occurred in 33%. Predictors of DTR included urban healthcare and higher baseline illness. Crude mortality for GNBSIs with DTR was 43%; aRR was higher for DTR than for carbapenem-resistant (1.2; 95% confidence interval, 1.0-1.4; P = .02), extended-spectrum cephalosporin-resistant (1.2; 1.1-1.4; P = .001), or fluoroquinolone-resistant (1.2; 1.0-1.4; P = .008) infections. The mortality aRR increased 20% per graded loss of active first-line categories, from 3-5 to 1-2 to 0. Conclusion: Nonsusceptibility to first-line antibiotics is associated with decreased survival in GNBSIs. DTR is a simple bedside prognostic measure of treatment-limiting coresistance.

      2. A tale of two healthcare-associated infections: Clostridium difficile coinfection among patients with Candidemia
        Tsay S, Williams SR, Benedict K, Beldavs Z, Farley M, Harrison L, Schaffner W, Dumyati G, Blackstock A, Guh A, Vallabhaneni S.
        Clin Infect Dis. 2018 Jul 27.
        Candidemia and Clostridium difficile infection (CDI) are important healthcare-associated infections that share certain risk factors. We sought to describe candidemia-CDI coinfection using population-based surveillance data. We found that nearly one in ten patients with candidemia had CDI coinfection.

    • Immunity and Immunization
      1. In 2016, the Immunization Technical Advisory Group of the South-East Asia Region (SEAR) endorsed a regional goal to achieve </=1% prevalence of hepatitis B surface antigen (HBsAg) among 5-year-old children by 2020. Chronic hepatitis B virus (HBV) infection is largely preventable with a birth dose of hepatitis B vaccine (HepB-BD) followed by two to three additional doses. We reviewed the progress towards hepatitis B control through vaccination in SEAR during 1992-2015. We summarized hepatitis B vaccination data and reviewed the literature to determine the prevalence of chronic HBV infection pre- and post-vaccine introduction. We used a mathematical model to determine post-vaccine prevalence of HBsAg among 5year olds in countries lacking national serosurvey data and estimated the impact of vaccination on disease burden. Regional coverage with three doses of hepatitis B vaccine (HepB3) increased from 56% in 2011 to 87% in 2015. By 2016, 7 of 11 countries had introduced universal HepB-BD. Regional HepB-BD coverage increased from 9% in 2011 to 34% in 2015. In 2015, estimated HBsAg among 5year olds was 1.1% with variability among countries. Myanmar (3.8%), Timor-Leste (2.7%), Indonesia (1.8%), and India (1%) had the highest prevalence of HBsAg. During 1992-2015, vaccination prevented approximately 16 million chronic HBV infections and 2.6 million related deaths. In 2015, around 197,640 perinatal HBV infections occurred in SEAR with majority occurring in India (62%), Bangladesh (24%), and Myanmar (8%). Myanmar had the highest rate of perinatal chronic HBV infections at 16 per 1000 live births. Despite significant progress in the control of HBV, SEAR needs to secure political commitment for elimination and consider additional strategies, such as promoting health facility births, universal birth dose administration, developing strong coordination between health sectors, and using alternative vaccine delivery methods, to improve HepB-BD coverage and subsequently achieve HBV control and elimination.

      2. Knowledge, attitudes, and practices of private sector immunization service providers in Gujarat, India
        Hagan JE, Gaonkar N, Doshi V, Patni A, Vyas S, Mazumdar V, Kosambiya JK, Gupta S, Watkins M.
        Vaccine. 2018 Jan 2;36(1):36-42.
        BACKGROUND: India is responsible for 30% of the annual global cohort of unvaccinated children worldwide. Private practitioners provide an estimated 21% of vaccinations in urban centers of India, and are important partners in achieving high vaccination coverage. METHODS: We used an in-person questionnaire and on-site observation to assess knowledge, attitudes, and practices of private immunization service providers regarding delivery of immunization services in the urban settings of Surat and Baroda, in Gujarat, India. We constructed a comprehensive sampling frame of all private physician providers of immunization services in Surat and Baroda cities, by consulting vaccine distributors, local branches of physician associations, and published lists of private medical practitioners. All providers were contacted and asked to participate in the study if they provided immunization services. Data were collected using an in-person structured questionnaire and directly observing practices; one provider in each practice setting was interviewed. RESULTS: The response rate was 82% (121/147) in Surat, and 91% (137/151) in Baroda. Of 258 participants 195 (76%) were pediatricians, and 63 (24%) were general practitioners. Practices that were potential missed opportunities for vaccination (MOV) included not strictly following vaccination schedules if there were concerns about ability to pay (45% of practitioners), and not administering more than two injections in the same visit (60%). Only 22% of respondents used a vaccination register to record vaccine doses, and 31% reported vaccine doses administered to the government. Of 237 randomly selected vaccine vials, 18% had expired vaccine vial monitors. CONCLUSIONS: Quality of immunization services in Gujarat can be strengthened by providing training and support to private immunization service providers to reduce MOVs and improve quality and safety; other more context specific strategies that should be evaluated may involve giving feedback to providers on quality of services delivered and working through professional societies to adopt standards of practice.

      3. BACKGROUND: The safety of hepatitis B vaccination during pregnancy has not been well studied. OBJECTIVE: We characterized adverse events (AEs) after hepatitis B vaccination of pregnant women reported to the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system. METHODS: We searched VAERS for AEs reports involving pregnant women who received hepatitis B vaccine from January 1, 1990-June 30, 2016. All reports and available medical records were reviewed by physicians. Observed AEs were compared to expected AEs and known rates of pregnancy outcomes to assess for any unexpected safety concern. RESULTS: We found 192 reports involving pregnant women following hepatitis B vaccination of which 110 (57.3%) described AEs; 12 (6.3%) were classified as serious; one newborn death was identified in a severely premature delivery, and there were no maternal deaths. Eighty-two (42.7%) reports did not describe any AEs. Among pregnancies for which gestational age was reported, most women were vaccinated during the first trimester, 86/115 (74.7%). Among reports describing an AE, the most common pregnancy-specific outcomes included spontaneous abortion in 23 reports, preterm delivery in 7 reports, and elective termination in 5 reports. The most common non-pregnancy specific outcomes were general disorders and administration site conditions, such as injection site and systemic reactions, in 21 reports. Among 22 reports describing an AE among infants born to women vaccinated during pregnancy, 5 described major birth defects each affecting different organ systems. CONCLUSION: Our analysis of VAERS reports involving hepatitis B vaccination during pregnancy did not identify any new or unexpected safety concerns.

    • Laboratory Sciences
      1. Detection of alpha-, beta-, and gamma-amanitin in urine by LC-MS/MS using (15)N10-alpha-amanitin as the internal standard
        Abbott NL, Hill KL, Garrett A, Carter MD, Hamelin EI, Johnson RC.
        Toxicon. 2018 Jul 30.
        The majority of fatalities from poisonous mushroom ingestion are caused by amatoxins. To prevent liver failure or death, it is critical to accurately and rapidly diagnose amatoxin exposure. We have developed an liquid chromatography tandem mass spectrometry method to detect alpha-, beta-, and gamma-amanitin in urine to meet this need. Two internal standard candidates were evaluated, including an isotopically labeled (15)N10-alpha-amanitin and a modified amanitin methionine sulfoxide synthetic peptide. Using the (15)N10-alpha-amanitin internal standard, precision and accuracy of alpha-amanitin in pooled urine was </=5.49% and between 100 and 106%, respectively, with a reportable range from 1-200 ng/mL. beta- and gamma-Amanitin were most accurately quantitated in pooled urine using external calibration, resulting in precision </=17.2% and accuracy between 99 and 105% with calibration ranges from 2.5-200ng/mL and 1.0-200ng/mL, respectively. The presented urinary diagnostic test is the first method to use an isotopically labeled alpha-amanitin with the ability to detect and confirm human exposures to alpha-, beta-, and gamma-amanitin.

      2. Transcriptional analysis of viral mRNAs reveals common transcription patterns in cells infected by five different filoviruses
        Albarino CG, Wiggleton Guerrero L, Chakrabarti AK, Nichol ST.
        PLoS One. 2018 ;13(8):e0201827.
        Filoviruses are notorious viral pathogens responsible for high-consequence diseases in humans and non-human primates. Transcription of filovirus mRNA shares several common features with transcription in other non-segmented negative-strand viruses, including differential expression of genes located across the viral genome. Transcriptional patterns of Ebola virus (EBOV) and Marburg virus (MARV) have been previously described using traditional, laborious methods, such as northern blots and in vivo labeling of viral mRNAs. More recently, however, the availability of the next generation sequencing (NGS) technology has offered a more straightforward approach to assess transcriptional patterns. In this report, we analyzed the transcription patterns of four ebolaviruses-EBOV, Sudan (SUDV), Bundibugyo (BDBV), and Reston (RESTV) viruses-in two different cell lines using standard NGS library preparation and sequencing protocols. In agreement with previous reports mainly focused on EBOV and MARV, the remaining filoviruses used in this study also showed a consistent transcription pattern, with only minor variations between the different viruses. We have also analyzed the proportions of the three mRNAs transcribed from the GP gene, which are characteristic of the genus Ebolavirus and encode the glycoprotein (GP), the soluble GP (sGP), and the small soluble GP (ssGP). In addition, we used NGS methodology to analyze the transcription pattern of two previously described recombinant MARV. This analysis allowed us to correct our construction design, and to make an improved version of the original MARV expressing reporter genes.

      3. Improving laboratory efficiency in the Caribbean to attain the World Health Organization HIV Treat All Recommendations
        Alemnji G, Chase M, Branch S, Guevara G, Nkengasong J, Albalak R.
        AIDS Res Hum Retroviruses. 2018 Feb;34(2):132-139.
        Scientific evidence showing the benefits of early initiation of antiretroviral therapy (ART) prompted World Health organization (WHO) to recommend that all persons diagnosed as HIV positive should commence ART irrespective of CD4 count and disease progression. Based on this recommendation, countries should adopt and implement the HIV “Treat All” policy to achieve the UNAIDS 90-90-90 targets and ultimately reach epidemic control. Attaining this goal along the HIV treatment cascade depends on the laboratory to monitor progress and measure impact. The laboratory plays an important role in HIV diagnosis to attain the first 90 and in viral load (VL) and HIV drug resistance testing to reinforce adherence, improve viral suppression, and measure the third 90. Countries in the Caribbean region have endorsed the WHO HIV “Treat all” recommendation; however, they are faced with diminishing financial resources to support laboratory testing, seen as a rate-limiting factor to achieving this goal. To improve laboratory coverage with fewer resources in the Caribbean there is the need to optimize laboratory operations to ensure the implementation of high quality, less expensive evidence-based approaches that will result in more efficient and effective service delivery. Suggested practical and innovative approaches to achieve this include: (1) targeted testing within HIV hotspots; (2) strengthening sample referral systems for VL; (3) better laboratory data collection systems; and (4) use of treatment cascade data for programmatic decision-making. Furthermore, strengthening quality improvement and procurement systems will minimize diagnostic errors and guarantee a continuum of uninterrupted testing which is critical for routine monitoring of patients to meet the stated goal.

      4. Evaluation of an OV-16 IgG4 enzyme-linked immunosorbent assay in humans and its application to determine the dynamics of antibody responses in a non-human primate model of Onchocerca volvulus infection
        Cama VA, McDonald C, Arcury-Quandt A, Eberhard M, Jenks MH, Smith J, Feleke SM, Abanyie F, Thomson L, Wiegand RE, Cantey PT.
        Am J Trop Med Hyg. 2018 Jul 30.
        Onchocerciasis is a neglected parasitic disease targeted for elimination. Current World Health Organization guidelines for elimination include monitoring antibody responses to the recombinant Onchocerca volvulus antigen OV-16 in children to demonstrate the absence of transmission. We report the performance characteristics of a modified OV-16 enzyme-linked immunosorbent assay (ELISA) and describe anti-OV-16 responses in serum samples from laboratory-inoculated nonhuman primates (NHPs) in relation to microfilariae (mf) in skin snip biopsies. This OV-16 IgG4 ELISA had sensitivity and specificity of 88.2% and 99.7%, respectively, as determined by receiver operator characteristic analysis using a serum panel of 110 positive and 287 negative samples from people infected with other filariae or other parasitic infections. Anti-OV-16 responses in inoculated NHP (N = 9) were evaluated at quarterly intervals for IgM and the four IgG subclasses. Enzyme-linked immunosorbent assay results showed a well-defined IgG4 reactivity pattern and moderate IgG1 antibody responses. Meanwhile, the reactivity by IgG2, IgG3, or IgM did not show a clear pattern. Temporal evolution of IgG4 reactivity was evaluated through monthly testing, showing that NHPs developed anti-OV-16 IgG4 on average at 15 months postinoculation (range: 10-18 months). The average time to detectable mf was also 15 months (range: 11-25). The OV-16 ELISA used in this study was robust and allowed the detection of IgG4 responses, which were observed only among animals with detectable mf (N = 5), four of which showed declines in antibody responses once mf cleared. These findings also confirmed that the most informative antibody subclass responses to OV-16 are IgG4.

      5. Antibody-based epidemiologic surveillance to determine population-level exposure to sexually transmitted infections could help inform public health fertility preservation strategies. We compared the performance of three platforms to detect antibodies against the Chlamydia trachomatis (CT) antigen Pgp3 – multiplex bead array (MBA), enzyme-linked immunosorbent assay (ELISA), and lateral flow assay (LFA) – on sera from adolescents and young adults (AYAs) with pelvic inflammatory disease (PID). Ninety-five of 118 AYAs diagnosed with PID (80.5%) had positive antibody response to Pgp3 antigen by at least one test, and 78 (66.1%) tested positive by all three tests. Among 27 individuals with infection detected using nucleic acid amplification testing, 92.6% were positive by MBA (25/27), 77.8% (21/27) were positive by ELISA, and 74.1% (20/27) were positive by LFA. These data suggest that the MBA was the most sensitive of the three tests and could be useful in seroepidemiologic studies designed to assess population-level exposure to CT.

      6. Inhalation of iron-abundant gas metal arc welding-mild steel fume promotes lung tumors in mice
        Falcone LM, Erdely A, Kodali V, Salmen R, Battelli LA, Dodd T, McKinney W, Stone S, Donlin M, Leonard HD, Cumpston JL, Cumpston JB, Andrews RN, Kashon ML, Antonini JM, Zeidler-Erdely PC.
        Toxicology. 2018 Jul 25;409:24-32.
        Welding fumes were reclassified as a Group 1 carcinogen by the International Agency for Research on Cancer in 2017. Gas metal arc welding (GMAW) is a process widely used in industry. Fume generated from GMAW-mild steel (MS) is abundant in iron with some manganese, while GMAW-stainless steel (SS) fume also contains significant amounts of chromium and nickel, known carcinogenic metals. It has been shown that exposure to GMAW-SS fume in A/J mice promotes lung tumors. The objective was to determine if GMAW-MS fume, which lacks known carcinogenic metals, also promotes lung tumors in mice. Male A/J mice received a single intraperitoneal injection of corn oil or the initiator 3-methylcholanthrene (MCA; 10 mug/g) and, one week later, were exposed by whole-body inhalation to GMAW-MS aerosols for 4 hours/day x 4 days/week x 8 weeks at a mean concentration of 34.5 mg/m(3). Lung nodules were enumerated by gross examination at 30 weeks post-initiation. GMAW-MS fume significantly increased lung tumor multiplicity in mice initiated with MCA (21.86 +/- 1.50) compared to MCA/air-exposed mice (8.34 +/- 0.59). Histopathological analysis confirmed these findings and also revealed an absence of inflammation. Bronchoalveolar lavage analysis also indicated a lack of lung inflammation and toxicity after short-term inhalation exposure to GMAW-MS fume. In conclusion, this study demonstrates that inhalation of GMAW-MS fume promotes lung tumors in vivo and aligns with epidemiologic evidence that shows MS welders, despite less exposure to carcinogenic metals, are at an increased risk for lung cancer.

      7. Characterization of the epitopes on antigen recognized by monoclonal antibodies (mAb) is useful for the development of therapeutic antibodies, diagnostic tools, and vaccines. Epitope mapping also provides functional information for sequence-based repertoire analysis of antibody response to pathogen infection and/or vaccination. However, development of mapping strategies has lagged behind mAb discovery. We have developed a site-directed mutagenesis approach that can be used in conjunction with bio-layer interferometry (BLI) biosensors to map mAb epitopes. By generating a panel of single point mutants in the recombinant hemagglutinin (HA) and neuraminidase (NA) proteins of influenza A viruses, we have characterized the epitopes of hundreds of mAbs targeting the H1 and H3 subtypes of HA and the N9 subtype of NA.

      8. High-throughput computational X-ray absorption spectroscopy
        Mathew K, Zheng C, Winston D, Chen C, Dozier A, Rehr JJ, Ong SP, Persson KA.
        Sci Data. 2018 Jul 31;5:180151.
        X-ray absorption spectroscopy (XAS) is a widely-used materials characterization technique. In this work we present a database of computed XAS spectra, using the Green’s formulation of the multiple scattering theory implemented in the FEFF code. With more than 500,000 K-edge X-ray absorption near edge (XANES) spectra for more than 40,000 unique materials, this database constitutes the largest existing collection of computed XAS spectra to date. The data is openly distributed via the Materials Project, enabling researchers across the world to access it for free and use it for comparisons with experiments and further analysis.

      9. Direct detection of carbapenem-resistant organisms from environmental samples using the GeneXpert Molecular Diagnostic System
        Perry KA, Daniels JB, Reddy SC, Kallen AJ, Halpin AL, Rasheed JK, Noble-Wang JA.
        mSphere. 2018 Aug 1;3(4).
        In this pilot study, traditional culture and PCR methods were compared to the Cepheid GeneXpert IV molecular diagnostic system with the Xpert Carba-R assay (Carba-R assay) for detection of carbapenem resistance genes in primary environmental samples collected during a health care-related outbreak. Overall, traditional culture-dependent PCR and the Carba-R assay demonstrated 75% agreement. The Carba-R assay detected carbapenemase genes in five additional samples and in two samples that had additional genes when compared to culture-dependent PCR. The Carba-R assay could be useful for prioritizing further testing of environmental samples during health care-related outbreaks.IMPORTANCE Use of the Carba-R assay for detection of carbapenem-resistant Gram-negative organisms (CROs) can provide data for implementation of a rapid infection control response to minimize the spread of CROs in the health care setting.

      10. Quantification of hypoglycin A and methylenecyclopropylglycine in human plasma by HPLC-MS/MS
        Sanford AA, Isenberg SL, Carter MD, Mojica MA, Mathews TP, Laughlin S, Thomas JD, Pirkle JL, Johnson RC.
        J Chromatogr B Analyt Technol Biomed Life Sci. 2018 Jul 20;1095:112-118.
        Hypoglycin A (HGA) and methylenecyclopropylglycine (MCPG) are naturally-occurring amino acids known to cause hypoglycemia and encephalopathy. Exposure to one or both toxins through the ingestion of common soapberry (Sapindaceae) fruits are documented in illness outbreaks throughout the world. Jamaican Vomiting Sickness (JVS) and seasonal pasture myopathy (SPM, horses) are linked to HGA exposure from unripe ackee fruit and box elder seeds, respectively. Acute toxic encephalopathy is linked to HGA and MCPG exposures from litchi fruit. HGA and MCPG are found in several fruits within the soapberry family and are known to cause severe hypoglycemia, seizures, and death. HGA has been directly quantified in horse blood in SPM cases and in human gastric juice in JVS cases. This work presents a new diagnostic assay capable of simultaneous quantification of HGA and MCPG in human plasma, and it can be used to detect patients with toxicity from soapberry fruits. The assay presented herein is the first quantitative method for MCPG in blood matrices.

      11. The S genome segment is sufficient to maintain pathogenicity in intra-clade Lassa virus reassortants in a guinea pig model
        Welch SR, Scholte FE, Albarino CG, Kainulainen MH, Coleman-McCray JD, Guerrero LW, Chakrabarti AK, Klena JD, Nichol ST, Spengler JR, Spiropoulou CF.
        Front Cell Infect Microbiol. 2018 ;8:240.
        Genome reassortment in Lassa virus (LASV) has been reported in nature, but phenotypic consequences of this phenomenon are not well described. Here we characterize, both in vitro and in vivo, reassortment between 2 LASV strains: the prototypic 1976 Josiah strain and a more recently isolated 2015 Liberian strain. In vitro analysis showed that although cis- and trans-acting elements of viral RNA synthesis were compatible between strains, reassortants demonstrated different levels of viral replication. These differences were also apparent in vivo, as reassortants varied in pathogenicity in the guinea pig model of LASV infection. The reassortant variant containing the Josiah S segment retained the virulence of the parental Josiah strain, but the reassortant variant containing the S segment of the Liberian isolate was highly attenuated compared to both parental strains. Contrary to observations in reassortants between LASV and other arenavirus species, which suggest that L segment-encoded factors are responsible for virulence, these studies highlight a role for S segment-encoded virulence factors in disease, and also suggest that inefficient interactions between proteins of heterologous strains may limit the prevalence of reassortant LASV variants in nature.

      12. Laboratory assays that can accurately distinguish recent (occurring within the past year) from long-standing (>1 year) HIV infection are crucial for understanding HIV transmission dynamics in a population. However, often these efforts are confounded by inaccurate HIV diagnosis and the presence of HIV-2 in the population being surveyed. This study describes development of a multiplex assay that can simultaneously perform HIV diagnosis, HIV serotyping and detection of recent HIV-1 infection in a single well. HIV diagnosis and HIV-2 serotyping were accomplished by coupling beads with an HIV-1 p24-gp41 fusion protein and HIV-2 peptide from gp36 immunodominant region, respectively. HIV-1 recent infection detection was accomplished by coupling beads with limiting amounts of multi-subtype gp41 immunodominant protein, rIDR-M. Assay conditions, including concentration of coupled antigens, were systematically optimized using well-characterized specimens with known HIV-status (positive or negative), HIV-2 specimens, and recent or long-term HIV-1 classification based on LAg-Avidity EIA in a stepwise manner. Beads were then combined in a multiplex assay to evaluate its performance using large panel of specimens (n=1500) that included HIV-1 positive (n=570, recent = 78, long-term= 492), HIV-2 positive (n= 31) and seronegative individuals (n=899). The diagnostic component of the assay performed with high sensitivity (99.8%) and specificity (99.7%), while the HIV-2 serotyping sensitivity and specificity were 96.7% and 100%, respectively. There was a high correlation (R=0.84) between the LAg-Avidity EIA and the multiplex assay for recent infection detection. The assay showed high inter- and intra- assay reproducibility with % coefficient of variation of <10% in the dynamic range. The multiplex assay has the ability to diagnose HIV infection, perform serotyping and detect and distinguish recent from long-term HIV infections, all in a single well. This novel assay has the potential to simplify HIV surveillance by reducing the multiple steps that are otherwise required.

    • Maternal and Child Health
      1. The development and testing of a module on child functioning for identifying children with disabilities on surveys. III: Field testing
        Cappa C, Mont D, Loeb M, Misunas C, Madans J, Comic T, de Castro F.
        Disabil Health J. 2018 Jul 18.
        BACKGROUND: A module on child functioning developed by UNICEF and the Washington Group on Disability Statistics (WG) for use in censuses and surveys reflects current thinking around disability measurement and is intended to produce internationally comparable data. The Child Functioning Module (CFM) was developed in response to limitations of the Ten Question Screening Instrument (TQSI) for use in surveys and builds on the WG Short Set (WG-SS) of questions that was designed to capture disability in censuses, particularly among the adult population. OBJECTIVE: This paper documents the testing of the module and summarizes its results, including a description of prevalence levels across countries using different cut-offs, and comparisons with prevalence levels obtained using the TQSI and the WG-SS. METHODS: Field tests were conducted in Samoa as part of the 2014 Demographic and Health Survey and in Mexico as part of the 2015 National Survey of Boys, Girls and Women. The module was also implemented in Serbia as part of a dedicated survey conducted in the province of Vojvodina, in February 2016. RESULTS: Using the recommended cut-offcut-off, the percentage of children reported as having functional difficulty ranges from 1.1% in Serbia to 2% in Mexico among children aged 2-4 years, and from 3.2% in Samoa to 11.2% in Mexico among children aged 5-17 years. Across all three countries, the prevalence of functional difficulty was highest in the socio-emotional domains. A comparison of the prevalence levels obtained using the WG-SS and the CFM shows that, except for the question on cognition/learning, the WG-SS and the CFM are relatively close for children aged 5-17 years for the domains that are included in both question sets, but the WG-SS excludes many children identified by the CFM in other domains. The comparison between the TQSI and the CFM shows that, while the prevalence estimates are similar for seeing and hearing, significant differences affect other domains, particularly cognition/learning and communication. CONCLUSIONS: The CFM addresses a full range of functional domains that are important for child development. The module represents an improvement on the TQSI in that it allows for scaled responses to determine the degree of difficulty, and so can separate out many potential false positives. The module is also preferred over the WG-SS for collecting data on children, first, because most of the questions in the WG-SS are not suitable for children under the age of 5 years, and second, because the WG-SS leaves out important functional domains for children aged 5-17 years, namely those related to developmental disabilities and behavioural issues.

      2. Muscular Dystrophy Surveillance, Tracking, and Research Network pilot: Population-based surveillance of major muscular dystrophies at four U.S. sites, 2007-2011
        Do TN, Street N, Donnelly J, Adams MM, Cunniff C, Fox DJ, Weinert RO, Oleszek J, Romitti PA, Westfield CP, Bolen J.
        Birth Defects Res. 2018 Aug 2.
        BACKGROUND: For 10 years, the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) conducted surveillance for Duchenne and Becker muscular dystrophy (DBMD). We piloted expanding surveillance to other MDs that vary in severity, onset, and sources of care. METHODS: Our retrospective surveillance included individuals diagnosed with one of nine eligible MDs before or during the study period (January 2007-December 2011), one or more health encounters, and residence in one of four U.S. sites (Arizona, Colorado, Iowa, or western New York) at any time within the study period. We developed case definitions, surveillance protocols, and software applications for medical record abstraction, clinical review, and data pooling. Potential cases were identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 359.0, 359.1, and 359.21 and International Classification of Diseases, Tenth Revision (ICD-10) codes G71.0 and G71.1. Descriptive statistics were compared by MD type. Percentage of MD cases identified by each ICD-9-CM code was calculated. RESULTS: Of 2,862 cases, 32.9% were myotonic, dystrophy 25.8% DBMD, 9.7% facioscapulohumeral MD, and 9.1% limb-girdle MD. Most cases were male (63.6%), non-Hispanic (59.8%), and White (80.2%). About, half of cases were genetically diagnosed in self (39.1%) or family (6.2%). About, half had a family history of MD (48.9%). The hereditary progressive MD code (359.1) was the most common code for identifying eligible cases. The myotonic code (359.21) identified 83.4% of eligible myotonic dystrophy cases (786/943). CONCLUSIONS: MD STARnet is the only multisite, population-based active surveillance system available for MD in the United States. Continuing our expanded surveillance will contribute important epidemiologic and health outcome information about several MDs.

      3. Socioeconomic status and pediatric neurologic disorders: Current evidence
        Durkin MS, Yeargin-Allsopp M.
        Semin Pediatr Neurol. 2018 .
        Socioeconomic status (SES) is an important risk factor for many neurological disorders and a determinant of health outcomes and quality of life, especially for individuals with neurologic disorders and developmental disabilities. This article focuses on the relationship between SES and pediatric epilepsy, cerebral palsy, autism spectrum disorder, and intellectual disability. Disparities in the prevalence and long-term impact of SES on functioning in persons with disabilities are observed worldwide. Clinicians can use the information presented in the article to target early identification and interventions for improving outcomes in populations most at risk for these disorders and for poor health, social, and economic outcomes.

      4. BACKGROUND: This paper is part of a series of articles documenting the development of a module on child functioning by UNICEF in collaboration with the Washington Group on Disability Statistics (WG). This paper documents the contribution of Cognitive Interview (CI) question evaluation methods to the development of the final module. OBJECTIVE: The overall goal of this project was to develop a cross-nationally comparable module to measure child functioning and disability. Specifically, the goals of the question evaluation study were to investigate question interpretation, sources of error and bias and to use the results iteratively in the development of the final module. METHODS: As is standard in CI studies, data were gathered through one-one-one, in-depth interviews. A total of four rounds of testing, comprising 385 Cognitive Interviews, were conducted across six countries. Qualitative data analysis methods were used to identify patterns of question interpretation and areas of potential error and bias among sub-groups of respondents. RESULTS: Through an iterative process of testing and revision, analytic findings from these interviews were used to guide decisions on question inclusion, revision and deletion. Four types of revisions were made: 1) changing, deleting or adding specific words; 2) moving, deleting or adding clarifying phrases; 3) revising or deleting items for conceptual clarity; and 4) adding examples. CONCLUSIONS: These efforts to reduce error and bias resulted in a validated module that can provide cross-nationally comparable measures of child functioning.

      5. Self-injurious behaviors in children with autism spectrum disorder enrolled in the Study to Explore Early Development
        Soke GN, Rosenberg SA, Rosenberg CR, Vasa RA, Lee LC, DiGuiseppi C.
        Autism. 2018 Jul;22(5):625-635.
        We assessed potential factors associated with “current” or “ever” self-injurious behaviors, reported in the Autism Diagnostic Interview-Revised, among children with autism spectrum disorder (n = 692) from the Study to Explore Early Development. Data on factors examined were obtained from questionnaires, standardized clinical instruments, and birth certificates. We employed a log-binomial regression to assess these associations. Although most associations were quite similar for currently and ever exhibiting self-injurious behaviors, a few differences were noted. We documented previously unreported associations of current self-injurious behaviors with maternal age and cesarean delivery, and ever self-injurious behaviors with maternal age, child sex, gestational age, and maternal race. We also confirmed previously reported associations with adaptive skills, somatic conditions (sleep, gastrointestinal, and sensory abnormalities), and other behavioral problems. These findings are informative for clinical practice and future research.

    • Medicine
      1. Estimating Tanzania’s national met and unmet blood demand from a survey of a representative sample of hospitals
        Drammeh B, De A, Bock N, Pathak S, Juma A, Kutaga R, Mahmoud M, Haule D, Sembucha S, Chang K, Nkya E, Kuehnert M, Marfin AA.
        Transfus Med Rev. 2018 Jan;32(1):36-42.
        Estimating blood demand to determine collection goals challenges many low-income countries. We sampled Tanzanian hospitals to estimate national blood demand. A representative sample based on probability proportional to size sampling of 42 of 273 (15%) Tanzanian transfusing hospitals was selected. Blood bank registers, patient medical records, and blood component disposition records were reviewed prospectively from June to September 2013 to determine the number of components requested and the number and proportion issued, not issued due to nonavailability, and not issued for other reasons. Data were estimated for an annual national estimate. Of an estimated 278 371 components requested in 2013, 6648 (2.4%) were not issued due to nonavailability, 34 591 (12.4%) were not issued for other reasons, and 244 535 (87.8%) were issued. Of these 278 371 components, 86 753 (31.2%) were requested by adult medical, 74 499 (26.8%) by pediatric medical, and 57 312 (20.6%) by obstetric units. In these 3 units, the proportion of units not issued due to nonavailability was 1.8%. Private (4.1%) and large (6%) hospitals had the largest proportion of units not issued because of nonavailability. Of 244 535 issued components, 91 690 (37.5%) were collected, tested, and issued from blood banks that are not part of the Tanzania National Blood Transfusion Services (TNBTS). Nearly 98% of blood component demand was met. However, a large portion of the blood supply for the hospitals came from non-TNBTS blood banks. TNBTS could increase availability of safe blood through assuring the quality of donor selection and donation testing at non-TNBTS blood banks.

    • Nutritional Sciences
      1. Prevalence and correlates of missing meals among high school students – United States, 2010
        Demissie Z, Eaton DK, Lowry R, Nihiser AJ, Foltz JL.
        Am J Health Promot. 2018 Jan;32(1):89-95.
        PURPOSE: To determine the prevalence and correlates of missing meals among adolescents. DESIGN: The 2010 National Youth Physical Activity and Nutrition Study, a cross-sectional study. SETTING: School based. PARTICIPANTS: A nationally representative sample of 11 429 high school students. MEASURES: Breakfast, lunch, and dinner consumption; demographics; measured and perceived weight status; physical activity and sedentary behaviors; and fruit, vegetable, milk, sugar-sweetened beverage, and fast-food intake. ANALYSIS: Prevalence estimates for missing breakfast, lunch, or dinner on >/=1 day during the past 7 days were calculated. Associations between demographics and missing meals were tested. Associations of lifestyle and dietary behaviors with missing meals were examined using logistic regression controlling for sex, race/ethnicity, and grade. RESULTS: In 2010, 63.1% of students missed breakfast, 38.2% missed lunch, and 23.3% missed dinner; the prevalence was highest among female and non-Hispanic black students. Being overweight/obese, perceiving oneself to be overweight, and video game/computer use were associated with increased risk of missing meals. Physical activity behaviors were associated with reduced risk of missing meals. Students who missed breakfast were less likely to eat fruits and vegetables and more likely to consume sugar-sweetened beverages and fast food. CONCLUSION: Breakfast was the most frequently missed meal, and missing breakfast was associated with the greatest number of less healthy dietary practices. Intervention and education efforts might prioritize breakfast consumption.

      2. Food service guideline policies on state government-controlled properties
        Zaganjor H, Bishop Kendrick K, Warnock AL, Onufrak S, Whitsel LP, Ralston Aoki J, Kimmons J.
        Am J Health Promot. 2018 Jul;32(6):1340-1352.
        PURPOSE: Food service guideline (FSG) policies can impact millions of daily meals sold or provided to government employees, patrons, and institutionalized persons. This study describes a classification tool to assess FSG policy attributes and uses it to rate FSG policies. DESIGN: Quantitative content analysis. SETTING: State government facilities in the United States. PARTICIPANTS: Participants were from 50 states and District of Columbia in the United States. MEASURES: Frequency of FSG policies and percentage alignment to tool. ANALYSIS: State-level policies were identified using legal research databases to assess bills, statutes, regulations, and executive orders proposed or adopted by December 31, 2014. Full-text reviews were conducted to determine inclusion. Included policies were analyzed to assess attributes related to nutrition, behavioral supports, and implementation guidance. RESULTS: A total of 31 policies met the inclusion criteria; 15 were adopted. Overall alignment ranged from 0% to 86%, and only 10 policies aligned with a majority of the FSG policy attributes. Western states had the most FSG policies proposed or adopted (11 policies). The greatest number of FSG policies were proposed or adopted (8 policies) in 2011, followed by the years 2013 and 2014. CONCLUSION: The FSG policies proposed or adopted through 2014 that intended to improve the food and beverage environment on state government property vary considerably in their content. This analysis offers baseline data on the FSG landscape and information for future FSG policy assessments.

    • Occupational Safety and Health
      1. Acoustic reflexes are common but not pervasive: evidence using a diagnostic middle ear analyser
        McGregor KD, Flamme GA, Tasko SM, Deiters KK, Ahroon WA, Themann CL, Murphy WJ.
        Int J Audiol. 2018 Feb;57(sup1):S42-s50.
        OBJECTIVE: The objective of this study is to determine whether acoustic reflexes are pervasive (i.e. known with 95% confidence to be observed in at least 95% of people) by examining the frequency of occurrence using a friction-fit diagnostic middle ear analyser. DESIGN: Adult participants with very good hearing sensitivity underwent audiometric and middle ear testing. Acoustic reflexes were tested ipsilaterally and contralaterally in both ears across a range of elicitor frequencies. Reflex elicitors were 700 ms tones presented at maximum level of 100 dB HL. Two automated methods were used to detect the presence of an acoustic reflex. STUDY SAMPLE: A group of 285 adult volunteers with normal hearing. RESULTS: There were no conditions in which the proportion of participants exhibiting acoustic reflexes was high enough to be deemed pervasive. Ipsilateral reflexes were more likely to be observed than contralateral reflexes and reflexes were more common at 0.5 and 1 kHz elicitor frequencies as compared with 2 and 4 kHz elicitor frequencies. CONCLUSIONS: Acoustic reflexes are common among individuals with good hearing. However, acoustic reflexes are not pervasive and should not be included in damage risk criteria and health hazard assessments for impulsive noise.

      2. Worksite food and physical activity environments and wellness supports reported by employed adults in the United States, 2013
        Onufrak SJ, Watson KB, Kimmons J, Pan L, Khan LK, Lee-Kwan SH, Park S.
        Am J Health Promot. 2018 Jan;32(1):96-105.
        PURPOSE: To examine the workplace food and physical activity (PA) environments and wellness culture reported by employed United States adults, overall and by employer size. DESIGN: Cross-sectional study using web-based survey on wellness policies and environmental supports for healthy eating and PA. SETTING: Worksites in the United States. PARTICIPANTS: A total of 2101 adults employed outside the home. MEASURES: Survey items were based on the Centers for Disease Control and Prevention Worksite Health ScoreCard and Checklist of Health Promotion Environments and included the availability and promotion of healthy food items, nutrition education, promotion of breast-feeding, availability of PA amenities and programs, facility discounts, time for PA, stairwell signage, health promotion programs, and health risk assessments. ANALYSIS: Descriptive statistics were used to examine the prevalence of worksite environmental and facility supports by employer size (<100 or >/=100 employees). Chi-square tests were used to examine the differences by employer size. RESULTS: Among employed respondents with workplace food or drink vending machines, approximately 35% indicated the availability of healthy items. Regarding PA, 30.9% of respondents reported that their employer provided opportunities to be physically active and 17.6% reported worksite exercise facilities. Wellness programs were reported by 53.2% working for large employers, compared to 18.1% for smaller employers. CONCLUSION: Employee reports suggested that workplace supports for healthy eating, PA, and wellness were limited and were less common among smaller employers.

    • Occupational Safety and Health – Mining
      1. Mine worker fatigue and circadian rhythms
        Martell M.
        Coal Age. 2018 ;123(4):38-39.

        [No abstract]

      2. Coal workers’ pneumoconiosis (CWP) is a preventable occupational lung disease caused by inhaling coal mine dust that can lead to premature* death (1,2). To assess trends in premature mortality attributed to CWP (3), CDC analyzed underlying(dagger) causes of death data from 1999 to 2016, the most recent years for which complete data are available. Years of potential life lost to life expectancy (YPLL) and years of potential life lost before age 65 years (YPLL65)( section sign) were calculated (4). During 1999-2016, a total of 38,358 YPLL (mean per decedent = 8.8 years) and 2,707 YPLL65 (mean per decedent = 7.3 years) were attributed to CWP. The CWP-attributable YPLL decreased from 3,300 in 1999 to 1,813 in 2007 (p<0.05). No significant change in YPLL occurred after 2007. During 1996-2016, however, the mean YPLL per decedent significantly increased from 8.1 to 12.6 per decedent (p<0.001). Overall, CWP-attributable YPLL65 did not change. The mean YPLL65 per decedent decreased from 6.5 in 1999 to 4.3 in 2002 (p<0.05), sharply increased to 8.9 in 2005, and then gradually decreased to 6.5 in 2016 (p<0.001). Increases in YPLL per decedent during 1999-2016 indicate that over time decedents aged >/=25 years with CWP lost more years of life relative to their life expectancies, suggesting increased CWP severity and rapid disease progression. This finding underscores the need for strengthening proven prevention measures to prevent premature CWP-associated mortality.

      3. LED lighting for improving trip object detection for a walk-thru roof bolter
        Sammarco JJ, Macdonald BD, Demich B, Rubinstein EN, Martell MJ.
        Light Res Technol. 2018 .
        Proper lighting plays a critical role in enabling miners to detect hazards when operating a roof bolter, one of the most dangerous mining machines to operate; however, there has not been any lighting research to address the walk-thru type of roof bolter commonly used today. To address this, the Saturn light was designed to directly address walk-thru roof bolter safety by improving trip hazard illumination. The visual performances of 30 participants that comprised three age groups were quantified by measuring each participant’s visual performance in detecting trip objects positioned on the two floor locations within the machine’s interior working space. The lighting conditions were the existing compact fluorescent lights (CFLs) and the Saturn LED area light developed by NIOSH researchers. Three intensities of the Saturn lights were used, 100%, 75%, and 50%, all of which resulted in better visual performance, and up to a 48% reduction in average trip detection time compared to the CFL. For the Saturn trip object miss rates were <0.5% for all age groups in contrast to the CFL, which ranged between 32.5% for the youngest group and 50.4% for the oldest group.

    • Parasitic Diseases
      1. Malaria risk in travellers: a holistic approach is needed
        Davlantes EA, Tan KR, Arguin PM.
        J Travel Med. 2018 Jul 1;25(1).

        [No abstract]

      2. A renewed focus on preventing malaria in pregnancy
        Ferenchick EK, Roman E, Wolf K, Florey L, Youll S, Mangiaterra V, Agarwal K, Gutman J.
        Reprod Health. 2018 Jul 27;15(1):131.
        While much progress has been achieved globally in the fight against malaria, the significant financial investments made to date have not translated into scaled-up malaria in pregnancy (MiP) prevention efforts. Mothers and newborns remain at risk, and now is the time to refocus efforts. Against the backdrop of a new global health architecture embodied by the principles of Every Women, Every Child and driven by the work of the H6 Partnership, Global Financing Facility, strong bilaterals and key financiers, there is a new and timely juncture to advocate for MiP. Recent updates in the WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience present an opportunity to strengthen MiP as a core maternal and child health issue and position MiP prevention as a priority.

      3. Rat lungworm infection associated with central nervous system disease – eight U.S. States, January 2011-January 2017
        Liu EW, Schwartz BS, Hysmith ND, DeVincenzo JP, Larson DT, Maves RC, Palazzi DL, Meyer C, Custodio HT, Braza MM, Al Hammoud R, Rao S, Qvarnstrom Y, Yabsley MJ, Bradbury RS, Montgomery SP.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 3;67(30):825-828.
        Angiostrongyliasis is caused by infection and migration to the brain of larvae of the parasitic nematode Angiostrongylus cantonensis, or rat lungworm. Adult A. cantonensis reside in the lungs of the definitive wild rodent host, where they produce larvae passed in feces, which are then ingested by snails and slugs (gastropods). Human infection typically occurs when gastropods containing mature larvae are inadvertently ingested by humans. Although human infection often is asymptomatic or involves transient mild symptoms, larval migration to the brain can lead to eosinophilic meningitis, focal neurologic deficits, coma, and death. The majority of cases of human angiostrongyliasis occur in Asia and the Pacific Islands, including Hawaii, but autochthonous and imported cases have been reported in the continental United States (1,2), underscoring the importance of provider recognition to ensure prompt identification and treatment. The epidemiologic and clinical features of 12 angiostrongyliasis cases in the continental United States were analyzed. These cases were identified through A. cantonensis polymerase chain reaction (PCR) testing (3) of cerebrospinal fluid (CSF) submitted to CDC from within the continental United States. Six cases were likely a result of autochthonous transmission in the southern United States. All 12 patients had CSF pleocytosis and eosinophilia, consistent with eosinophilic meningitis. Health care providers need to be aware of the possibility of angiostrongyliasis in patients with eosinophilic meningitis, especially in residents in the southern United States or persons who have traveled outside the continental United States and have a history of ingestion of gastropods or contaminated raw vegetables.

      4. Impact of ivermectin mass drug administration for lymphatic filariasis on scabies in eight villages in Kongwa District, Tanzania
        Martin D, Wiegand R, Goodhew B, Lammie P, Mkocha H, Kasubi M.
        Am J Trop Med Hyg. 2018 Jul 30.
        Scabies was recently added to the World Health Organization list of neglected tropical diseases. The ability to treat scabies with oral ivermectin makes a mass drug administration (MDA) campaign a feasible option for scabies control. Ivermectin MDA in communities endemic for lymphatic filariasis (LF) or onchocerciasis may already be having an impact on scabies. We examined the effect of ivermectin MDA for LF on scabies prevalence over 4 years in eight Tanzanian villages. At baseline, 4.4% (95% confidence interval [CI]: 3.7-5.4) of individuals tested positive for scabies, decreasing to 0.84% (95% CI: 0.51-1.4) after one round of ivermectin MDA but increased in Year 3 (2.5% [95% CI: 1.9-3.3]) and Year 4 (2.9% [95% CI: 2.2-3.8]). Most scabies cases were seen in children younger than 15 years. The data suggest that single-dose ivermectin MDA may not be effective in attaining long-term decreases when scabies prevalence is less than 5%.

      5. Molecular characterization of Cryptosporidium spp. and Giardia duodenalis in children in Egypt
        Naguib D, El-Gohary AH, Roellig D, Mohamed AA, Arafat N, Wang Y, Feng Y, Xiao L.
        Parasit Vectors. 2018 Jul 11;11(1):403.
        BACKGROUND: The transmission of Cryptosporidium spp. and Giardia duodenalis into humans varies according to species/genotypes of the pathogens. Although infections with both parasites are recorded in Egypt, few data are available on the distribution of Cryptosporidium species and G. duodenalis genotypes. The present study assessed the occurrence and genetic diversity of Cryptosporidium spp. and G. duodenalis in Egyptian children. METHODS: In the present study, 585 fecal specimens were collected from children eight years old and younger in three provinces (El-Dakahlia, El-Gharbia and Damietta) during March 2015 to April 2016. PCR-RFLP analysis of the small subunit rRNA gene and sequence analysis of the 60 kDa glycoprotein gene were used to detect and subtype Cryptosporidium spp., respectively, whereas PCR and sequence analyses of the triose phosphate isomerase, glutamate dehydrogenase and beta-giardin genes were used to detect and genotype Giardia duodenalis. RESULTS: The overall infection rates of Cryptosporidium spp. and G. duodenalis were 1.4% and 11.3%, respectively. The Cryptosporidium species identified included C. hominis and C. parvum, each with three subtype families. The C. hominis subtypes were IbA6G3 (n = 2), IdA17 (n = 1), IdA24 (n = 1) and IfA14G1R5 (n = 1), while C. parvum subtypes were IIdA20G1 (n = 1), IIaA15G2R1 (n = 1), and IIcA5G3a (n = 1). The G. duodenalis identified included both assemblages A (n = 31) and B (n = 34). All G. duodenalis assemblage A belonged to the anthroponotic sub-assemblage AII, while a high genetic heterogeneity was seen within assemblage B. CONCLUSIONS: Data from this study are useful in our understanding of the genetic diversity of Cryptosporidium spp. and G. duodenalis in Egypt and the potential importance of anthroponotic transmission in the epidemiology of both pathogens.

    • Public Health Leadership and Management
      1. Improving health worker performance: an ongoing challenge for meeting the sustainable development goals
        Rowe AK, Labadie G, Jackson D, Vivas-Torrealba C, Simon J.
        Bmj. 2018 Jul 30;362:k2813.

        [No abstract]

    • Reproductive Health
      1. OBJECTIVE: We sought to determine the prevalence of postpartum contraceptive use among women with postpartum depressive symptoms (PDS) and examine the association between PDS and contraceptive method. STUDY DESIGN: We evaluated data from 16,357 postpartum women participating in the 2009-2011 Pregnancy Risk Assessment Monitoring System. PDS was defined as an additive score of >/=10 for three questions on depression, hopelessness, and feeling physically slowed. Contraceptive use was categorized as permanent, long-acting reversible contraception (LARC), user-dependent hormonal, and user-dependent non-hormonal. Logistic regression models compared postpartum contraceptive use and method by PDS status. RESULTS: In total, 12.3% of women with a recent live birth reported PDS. Large percentages of women with (69.4%) and without (76.1%) PDS, used user-dependent or no contraceptive method. There were no associations between PDS and use of any postpartum contraception (adjusted Prevalence Ratio (aPR)=1.00, 95% CI 0.98-1.03) or permanent contraception (aPR=1.05, 95% CI 0.88-1.27). LARC use was elevated, but not significantly, among women with PDS compared to those without (aPR=1.16, 95% CI: 1.00-1.34). CONCLUSIONS: Large percentages of women with and without PDS used user-dependent or no contraception. Since depression may be associated with misuse of user-dependent methods, counseling women about how to use methods more effectively, as well as the effectiveness of non-user dependent methods, may be beneficial. IMPLICATIONS: A large percentage of women with PDS are either not using contraception or using less effective user-dependent methods. Since depression may be associated with misuse of user-dependent contraceptive methods, counseling women about how to use methods more effectively, as well as non-user dependent options, such as LARC, may be beneficial.

      2. OBJECTIVE: This study assesses provider communication with adolescent and young women about birth control, emergency contraception and condoms during sexual and reproductive health visits. STUDY DESIGN: Using data from sexually active 15-24-year-old women in the 2011-2015 National Survey of Family Growth, we examined provider communication about contraception and condoms at sexual and reproductive health services in the past year and assessed differences by demographics, sexual behavior and source of care. RESULTS: Approximately two thirds of women received provider communication about condoms (65.0%) and birth control (64.0%-66.8%). Communication was higher among Title-X-funded clinic vs. private providers. Differences by age, race/ethnicity, mother’s education, number of partners and condom use were also found. CONCLUSION: Most sexually active young women attending sexual and reproductive health visits received provider communication about condoms and birth control, but communication is not universal and varies by source of care, demographics and sexual behavior.

    • Substance Use and Abuse
      1. National and state patterns of concept-flavoured cigar sales, USA, 2012-2016
        Gammon DG, Rogers T, Coats EM, Nonnemaker JM, Marynak KL, Kuiper NM, King BA.
        Tob Control. 2018 Aug 1.
        INTRODUCTION: Cigar sales have increased in the USA in recent years. A growing proportion of cigar sales are of flavoured varieties, many bearing ambiguous or ‘concept’ flavour descriptions (eg, Jazz). This study assessed US cigar sales by flavour category (ie, concept flavoured, characterising flavoured and tobacco), at national, regional and state levels. METHODS: Sales of cigarillos, large cigars and little cigars from chain, franchise and convenience stores, mass merchandisers, supermarkets, drug, dollar and club stores, and military commissaries during 2012-2016 were acquired from the Nielsen Company. US national-level and state-level sales, including District of Columbia, were analysed by flavour category. Flavour descriptors were classified as ‘tobacco’, ‘characterising’ or ‘concept’, based on Universal Product Code (UPC)-linked characteristics and brand website and consumer review descriptions. RESULTS: Cigar sales increased by 29% during 2012-2016, driven by a 78% increase in cigarillo sales. The proportion of concept-flavoured sales increased from 9% to 15%, while the proportion of sales decreased for tobacco (50% to 49%) and characterising flavours (eg, cherry) (41% to 36%). Cigarillos had the greatest increase in unique concept flavour descriptions (17 to 46 unique UPCs), with most sales occurring among Sweet, Jazz and Green Sweets concept flavours. By US region, total and concept-flavoured cigarillo sales were highest in the South. CONCLUSIONS: Flavoured cigars are increasingly labelled with concept flavours, including in areas with flavoured tobacco sales restrictions. Cigarillos are driving recent increases in US cigar and concept-flavoured cigar sales. It is important to consider concept flavours when addressing flavoured tobacco product sales and use.

      2. Increase in drug overdose deaths involving fentanyl – Rhode Island, January 2012-March 2014
        Mercado MC, Sumner SA, Spelke MB, Bohm MK, Sugerman DE, Stanley C.
        Pain Med. 2018 Mar 1;19(3):511-523.
        Objective: This study identified sociodemographic, substance use, and multiple opioid prescriber and dispenser risk factors among drug overdose decedents in Rhode Island, in response to an increase in overdose deaths (ODs) involving fentanyl. Methods: This cross-sectional investigation comprised all ODs reviewed by Rhode Island’s Office of the State Medical Examiners (OSME) during January 2012 to March 2014. Data for 536 decedents were abstracted from OSME’s charts, death certificates, toxicology reports, and Prescription Monitoring Program (PMP) databases. Decedents whose cause of death involved illicit fentanyl (N = 69) were compared with decedents whose causes of death did not involve fentanyl (other drug decedents; N = 467). Results: Illicit-fentanyl decedents were younger than other drug decedents (P = 0.005). While more other-drug decedents than illicit fentanyl decedents had postmortem toxicological evidence of consuming heroin (31.9% vs 19.8%, P < 0.001) and various pharmaceutical substances (P = 0.002-0.027), third party reports indicated more recent heroin use among illicit fentanyl decedents (62.3% vs 45.6%, P = 0.002). Approximately 35% of decedents filled an opioid prescription within 90 days of death; of these, one-third had a mean daily dosage greater than 100 morphine milligram equivalents (MME/day). Most decedents’ opioid prescriptions were filled at one to two dispensers (83.9%) and written by one to two prescribers (75.8%). Notably, 29.2% of illicit fentanyl and 10.5% of other drug decedents filled prescriptions for buprenorphine, which is used to treat opioid use disorders. Conclusions: Illicit-fentanyl deaths frequently involved other illicit drugs (e.g., cocaine, heroin). The proportion of all decedents acquiring greater than 100 MME/day prescription dosages written and/or filled by few prescribers and dispensers is concerning. To protect patients, prescribers and dispensers should review PMP records and substance abuse history prior to providing opioids.

    • Veterinary Medicine
      1. Age patterns of Cryptosporidium species and Giardia duodenalis in dairy calves in Egypt
        Naguib D, El-Gohary AH, Mohamed AA, Roellig DM, Arafat N, Xiao L.
        Parasitol Int. 2018 Jul 25.
        Little is known of the occurrence and age patterns of species/genotypes and subtypes of Cryptosporidium spp. and Giardia duodenalis in calves in Egypt. In this study, 248 fecal specimens were collected from dairy calves aged 1day to 6months on eight farms in three provinces during March 2015 to April 2016. Cryptosporidium spp. were detected and genotyped by using PCR-RFLP analysis of the small subunit rRNA (SSU rRNA) gene, while G. duodenalis was detected and genotyped by using PCR and sequence analyses of the triose phosphate isomerase (tpi), glutamate dehydrogenase (gdh) and beta-giardin (bg) genes. The overall infection rates of Cryptosporidium spp. and G. duodenalis were 9.7 and 13.3%, respectively. The highest Cryptosporidium infection rate (26.7%) was in calves of age</=1month while the highest G. duodenalis infection rate (44.4%) was in calves of 2months. Three Cryptosporidium spp. were identified, including C. parvum (n=16), C. bovis (n=5) and C. ryanae (n=3), with the former being almost exclusively found in calves of </=3months of age and the latter two being only found in calves of over 3months. Subtyping of C. parvum by PCR-sequence analysis of the 60kDa glycoprotein gene identified subtypes IIaA15G1R1 (n=15) and IIaA15G2R1 (n=1). The G. duodenalis identified included both assemblages E (n=32) and A (n=1), with the latter belonging to the anthroponotic subtype A2. These data provide new insights into the genetic diversity and age patterns of Cryptosporidium spp. and G. duodenalis in calves in Egypt.

    • Zoonotic and Vectorborne Diseases
      1. Possible congenital Zika syndrome in older children due to earlier circulation of Zika virus
        Chu V, Petersen LR, Moore CA, Meaney-Delman D, Nelson G, Christian Sonne D, Dodge NN, Glaser C, Rasmussen SA.
        Am J Med Genet A. 2018 Aug 2.
        Congenital Zika syndrome (CZS) was identified following a large Zika virus (ZIKV) outbreak in Brazil in 2015. Two children with clinical presentations consistent with CZS, ages 7 and 8 years old, are described. Both mothers lived in Cambodia, a region with known ZIKV, during their pregnancies and reported fever and rash in the second trimester. The infants were born with severe microcephaly. Testing for congenital infection at birth and genetic testing were unremarkable. In 2017, serologic testing for both mothers were consistent with prior ZIKV infection. Review of infant neuroimaging demonstrated ventriculomegaly, severe cerebral atrophy, and subcortical calcifications consistent with CZS. Given the maternal symptoms suggesting ZIKV infection during pregnancy and the combination of clinical and radiological features unique to CZS, CZS is strongly suspected in these children, suggesting that CZS occurred before the 2013-2014 French Polynesia outbreak. As such, CZS should be considered in older children with congenital microcephaly of unknown etiology and a history consistent with possible ZIKV exposure.

      2. Investigation and characterization of Brucella canis infections in pet-quality dogs and associated human exposures during a 2007-2016 outbreak in Michigan
        Johnson CA, Carter TD, Dunn JR, Baer SR, Schalow MM, Bellay YM, Guerra MA, Frank NA.
        J Am Vet Med Assoc. 2018 Aug 1;253(3):322-336.
        OBJECTIVE To estimate Brucella canis seropositivity rates for purebred dogs being bred by noncommercial breeders, describe epidemiological findings in infected commercial dog-production facilities, and characterize B canis infection in pet dogs and the risk to human health. DESIGN Retrospective descriptive study. SAMPLE 2,799 canine specimens submitted to the Michigan State University Veterinary Diagnostic Laboratory for B canis testing and records of B canis reports provided to the Michigan Department of Agriculture and Rural Development from 2007 through 2016. PROCEDURES Results of B canis laboratory tests and epidemiological findings for reported cases of B canis were reviewed and summarized. Federal and state public health officials were interviewed regarding human B canis infection. State veterinarians were interviewed regarding canine brucellosis reporting and control procedures. RESULTS Estimated B canis seropositivity was 0.4% among purebred Michigan dogs owned by noncommercial breeders. Infection was confirmed in dogs from 17 commercial dog-production facilities, 3 shelters, and 1 rescue agency. Estimated infection prevalence in production facilities ranged from 2 of 22 (9%) to 5 of 6 (83%). Transfer of infected dogs involved 22 Michigan counties and 11 states. Seven of 20 privately owned infected dogs had diskospondylitis; I also had uveitis. Fifty-three veterinary hospital or diagnostic laboratory personnel had inadvertent exposure to the pathogen. Brucella canis was isolated from 1 commercial production facility owner. CONCLUSIONS AND CLINICAL RELEVANCE B canis was uncommon in purebred dogs being bred by noncommercial breeders but endemic in Michigan commercial facilities producing dogs destined to become household pets. Infected pet dogs caused human B canis exposure, and several pet dogs had debilitating disease not associated with the reproductive system.

      3. Case report: Imported case of Lassa fever – New Jersey, May 2015
        Kulkarni PA, Chew D, Youssef-Bessler M, Hamdi HA, Montoya LA, Cervantes KB, Mazur NL, Lucas D, Wells JW, Cennimo D, Sutherland A, Di Domenico LM, Miller LP, Pierre-Louis F, Rokosz G, Nazir A, de Perio MA, Lowe L, Manning C, Mead KR, Christensen BE, Albarino CG, Stroher U, Glover M, Lifshitz EI, Tan CG, Rollin PE, Semple S.
        Am J Trop Med Hyg. 2018 Jul 30.
        We report a fatal case of Lassa fever diagnosed in the United States in a Liberian traveler. We describe infection control protocols and public health response. One contact at high risk became symptomatic, but her samples tested negative for Lassa virus; no secondary cases occurred among health care, family, and community contacts.

      4. Infection of epididymal epithelial cells and leukocytes drives seminal shedding of Zika virus in a mouse model
        McDonald EM, Duggal NK, Ritter JM, Brault AC.
        PLoS Negl Trop Dis. 2018 Aug 2;12(8):e0006691.
        While primarily a mosquito-borne virus, Zika virus (ZIKV; genus Flavivirus in the Flaviviridae family) is capable of being sexually transmitted. Thirty to fifty percent of men with confirmed ZIKV infection shed ZIKV RNA in their semen, and prolonged viral RNA shedding in semen can occur for more than 6 months. The cellular reservoir of ZIKV in semen is unknown, although spermatozoa have been shown to contain ZIKV RNA and antigen. Yet, spermatozoa are not a requisite for sexual transmission, as at least one case of ZIKV sexual transmission involved a vasectomized man. To determine the cellular reservoirs of ZIKV in semen, an established animal model of sexual transmission was used. The majority of virus detected in the seminal fluid of infected mice during the peak timing of sexual transmission was from the supernatant fraction, suggesting cell-free ZIKV may be largely responsible for sexual transmission. However, some ZIKV RNA was cell-associated. In the testes and epididymides of infected mice, intracellular staining of ZIKV RNA was more pronounced in spermatogenic precursors (spermatocytes and spermatogonia) than in spermatids. Visualization of intracellular negative strand ZIKV RNA demonstrated ZIKV replication intermediates in leukocytes, immature spermatids and epididymal epithelial cells in the male urogenital tract. Epididymal epithelial cells were the principal source of negative-strand ZIKV RNA during the peak timing of sexual transmission potential, indicating these cells may be the predominant source of infectious cell-free ZIKV in seminal fluid. These data promote a more complete understanding of sexual transmission of ZIKV and will inform further model development for future studies on persistent ZIKV RNA shedding.

      5. Duration of infectious Zika virus in semen and serum
        Medina FA, Torres G, Acevedo J, Fonseca S, Casiano L, De Leon-Rodriguez CM, Santiago GA, Doyle K, Sharp TM, Alvarado LI, Paz-Bailey G, Munoz-Jordan JL.
        J Infect Dis. 2018 Jul 27.
        Zika virus (ZIKV) has recently caused a large epidemic in the Americas associated with birth defects. Although ZIKV is primarily transmitted by Aedes spp. mosquitoes, ZIKV RNA is detectable in blood and semen of infected individuals for weeks or months, during which time sexual and other modes of transmission are possible. However, viral RNA is usually detectable for longer than infectious virus is present. We determined the frequency of isolation of infectious virus from semen and serum samples prospectively obtained from a cohort of patients in Puerto Rico. We confirmed positive isolation by tissue culture cytopathic effect, increase in virus genome copy equivalents (GCE), immunofluorescence, and quantitation of infected cells by flow cytometry. These criteria confirmed infectious virus in semen from 8 of 97 patients for up to 38 days after initial detection when virus loads are higher than 1.4×106 GCE/mL. Two serum isolates were obtained from 296 patients. These findings can help guide important prevention guidelines for persons that may potentially be infectious and transmit ZIKV sexually.

      6. Zika preparedness and response in Viet Nam
        Nguyen DT, Do HT, Le HX, Le NT, Vien MQ, Nguyen TB, Phan LT, Nguyen TV, Luong QC, Phan HC, Diep HT, Pham QD, Nguyen TV, Huynh LK, Nguyen DC, Pham HT, Ly KK, Tran HN, Tran PD, Dang TQ, Pham H, Vu LN, Mounts A, Balajee SA, Nolen LD.
        Western Pac Surveill Response J. 2018 Apr-Jun;9(2):1-3.
        This article describes Viet Nam Ministry of Health?s (VMoH) activities to prepare for and respond to the threat Zika virus (ZIKV), including the adaptation of existing surveillance systems to encompass ZIKV surveillance.

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