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CDC Science Clips: Volume 10, Issue 22, June 19, 2018

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

  1. CDC Public Health Grand Rounds
    • Chronic Diseases and Conditions – Cancer and Cancer Prevention
      1. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis
        Boniol M, Autier P, Boyle P, Gandini S.
        BMJ. 2012 ;345:e4757.
        OBJECTIVE: To estimate the burden of melanoma resulting from sunbed use in western Europe. DESIGN: Systematic review and meta-analysis. DATA SOURCES: PubMed, ISI Web of Science (Science Citation Index Expanded), Embase, Pascal, Cochrane Library, LILACS, and MedCarib, along with published surveys reporting prevalence of sunbed use at national level in Europe. STUDY SELECTION: Observational studies reporting a measure of risk for skin cancer (cutaneous melanoma, squamous cell carcinoma, basal cell carcinoma) associated with ever use of sunbeds. RESULTS: Based on 27 studies ever use of sunbeds was associated with a summary relative risk of 1.20 (95% confidence interval 1.08 to 1.34). Publication bias was not evident. Restricting the analysis to cohorts and population based studies, the summary relative risk was 1.25 (1.09 to 1.43). Calculations for dose-response showed a 1.8% (95% confidence interval 0% to 3.8%) increase in risk of melanoma for each additional session of sunbed use per year. Based on 13 informative studies, first use of sunbeds before age 35 years was associated with a summary relative risk of 1.87 (1.41 to 2.48), with no indication of heterogeneity between studies. By using prevalence data from surveys and data from GLOBOCAN 2008, in 2008 in the 15 original member countries of the European Community plus three countries that were members of the European Free Trade Association, an estimated 3438 cases of melanoma could be attributable to sunbed use, most (n=2341) occurring among women. CONCLUSIONS: Sunbed use is associated with a significant increase in risk of melanoma. This risk increases with number of sunbed sessions and with initial usage at a young age (<35 years). The cancerous damage associated with sunbed use is substantial and could be avoided by strict regulations.

      2. The association of indoor tanning and melanoma in adults: systematic review and meta-analysis
        Colantonio S, Bracken MB, Beecker J.
        J Am Acad Dermatol. 2014 May;70(5):847-57.e1-18.
        BACKGROUND: Tanning beds are associated with increased risk of melanoma. OBJECTIVE: We sought to update the evidence of the association of melanoma and indoor tanning focusing on frequency of use and exposure to newer tanning beds. METHODS: We searched Scopus, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature on August 14, 2013. We included all observational studies that included patients with melanoma who had indoor tanned. Odds ratios (OR) with 95% confidence intervals (CI) were extracted and combined using generic inverse variance methods assuming a random effects model. RESULTS: In all, 31 studies were included with data available on 14,956 melanoma cases and 233,106 controls. Compared with never using, the OR for melanoma associated with ever using indoor tanning beds was 1.16 (95% CI 1.05-1.28). Similar findings were identified in recent studies with enrollment occurring in the year 2000 onward (OR 1.22, 95% CI 1.03-1.45) and in subjects attending more than 10 tanning sessions (OR 1.34, 95% CI 1.05-1.71). LIMITATIONS: The quality of evidence contributing to review results ranges from poor to mediocre. CONCLUSION: Using tanning beds is associated with a subsequent melanoma diagnosis. Exposure from more than 10 tanning sessions is most strongly associated and there was no statistically significant difference in this association before and after 2000, suggesting that newer tanning technology is not safer than older models.

      3. CPSTF Findings for Cancer Prevention and Control
        Community Preventive Services Task Force .
        Page last updated: February 09, 2018. Page accessed: June 18, 2018. .
        Includes alphabetized lists of intervention approaches reviewed by the Community Preventive Services Task Force with summaries of the CPSTF finding for each.

      4. A review of human carcinogens – part D: radiation
        El Ghissassi F, Baan R, Straif K, Grosse Y, Secretan B, Bouvard V, Benbrahim-Tallaa L, et al .
        Lancet Oncol. 2009 Aug;10(8):751-2.

        [No abstract]

      5. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure
        Gandini S, Sera F, Cattaruzza MS, Pasquini P, Picconi O, Boyle P, Melchi CF.
        Eur J Cancer. 2005 Jan;41(1):45-60.
        A systematic revision of the literature was conducted in order to undertake a comprehensive meta-analysis of all published observational studies on melanoma. An extensive analysis of the inconsistencies and variability in the estimates was performed to provide some clues about its epidemiology. Following a systematic literature search, relative risks (RRs) for sun exposure were extracted from 57 studies published before September 2002. Intermittent sun exposure and sunburn history were shown to play considerable roles as risk factors for melanoma, whereas a high occupational sun exposure seemed to be inversely associated to melanoma. The country of study and adjustment of the estimates adjuste for phenotype and photo-type were significantly associated with the variability of the intermittent sun exposure estimates (P = 0.024, 0.003 and 0.030, respectively). For chronic sun exposure, inclusion of controls with dermatological diseases and latitude resulted in significantly different data (P = 0.05 and 0.031, respectively). Latitude was also shown to be important (P = 0.031) for a history of sunburn; studies conducted at higher latitudes presented higher risks for a history of sunburns. Role of country, inclusion of controls with dermatological diseases and other study features seemed to suggest that “well conducted” studies supported the intermittent sun exposure hypothesis: a positive association for intermittent sun exposure and an inverse association with a high continuous pattern of sun exposure.

      6. Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011
        Guy GP, Machlin SR, Ekwueme DU, Yabroff KR.
        Am J Prev Med. 2015 Feb;48(2):183-7.
        BACKGROUND: Skin cancer, the most common cancer in the U.S., is a major public health problem. The incidence of nonmelanoma and melanoma skin cancer is increasing; however, little is known about the economic burden of treatment. PURPOSE: To examine trends in the treated prevalence and treatment costs of nonmelanoma and melanoma skin cancers. METHODS: This study used data on adults from the 2002-2011 Medical Expenditure Panel Survey full-year consolidated files and information from corresponding medical conditions and medical event files to estimate the treated prevalence and treatment cost of nonmelanoma skin cancer, melanoma skin cancer, and all other cancer sites. Analyses were conducted in January 2014. RESULTS: The average annual number of adults treated for skin cancer increased from 3.4 million in 2002-2006 to 4.9 million in 2007-2011 (p<0.001). During this period, the average annual total cost for skin cancer increased from $3.6 billion to $8.1 billion (p=0.001), representing an increase of 126.2%, while the average annual total cost for all other cancers increased by 25.1%. During 2007-2011, nearly 5 million adults were treated for skin cancer annually, with average treatment costs of $8.1 billion each year. CONCLUSIONS: These findings demonstrate that the health and economic burden of skin cancer treatment is substantial and increasing. Such findings highlight the importance of skin cancer prevention efforts, which may result in future savings to the healthcare system.

      7. OBJECTIVE: To examine the association between demographic and behavioral characteristics and sunburn among U.S. adults. METHOD: We used 2010 National Health Interview Survey data (N=24,970) to conduct multivariable logistic regressions examining associations with having 1 or more sunburns in the past year and having 4 or more sunburns in the past year. RESULTS: Overall, 37.1% of adults experienced sunburn in the past year. The adjusted prevalence of sunburn was particularly common among adults aged 18-29years (52.0%), those who repeatedly burn or freckle after 2weeks in the sun (45.9%), whites (44.3%), indoor tanners (44.1%), those with a family history of melanoma (43.9%), and those who are US-born (39.5%). Physical activity, alcohol consumption, and overweight/obesity were positively associated with sunburn (all P<0.001); sun protection behaviors were not significantly associated with sunburn (P=0.35). Among those who were sunburned in the past year, 12.1% experienced 4 or more sunburns. CONCLUSION: Sunburn is common, particularly among younger adults, those with a more sun-sensitive skin type, whites, those with a family history of melanoma, the highly physically active, and indoor tanners. Efforts are needed to facilitate sun-safety during outdoor recreation, improve the consistency of sun protection practices, and prevent sunburn, particularly among these subgroups.

      8. Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention
        Holman DM, Fox KA, Glenn JD, Guy GP, Watson M, Baker K, Cokkinides V, et al .
        Am J Prev Med. 2013 Jun;44(6):672-81.
        Exposure to ultraviolet radiation from indoor tanning device use is associated with an increased risk of skin cancer, including risk of malignant melanoma, and is an urgent public health problem. By reducing indoor tanning, future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs. On August 20, 2012, the CDC hosted a meeting to discuss the current body of evidence on strategies to reduce indoor tanning as well as research gaps. Using the Action Model to Achieve Healthy People 2020 Overarching Goals as a framework, the current paper provides highlights on the topics that were discussed, including (1) the state of the evidence on strategies to reduce indoor tanning; (2) the tools necessary to effectively assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and (3) strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors. Although many challenges and barriers exist, a coordinated, multilevel, transdisciplinary approach has the potential to reduce indoor tanning and prevent future cases of skin cancer.

      9. DESCRIPTION: Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation statement on counseling to prevent skin cancer. METHODS: The USPSTF performed a targeted literature search for new evidence that counseling patients about sun protection reduces intermediate outcomes (such as sunburn) or skin cancer. Other key questions addressed the link between counseling and behavior change, the link between behavior change and incidence of skin cancer, and the adverse effects of counseling or sun-protective behavior changes. RECOMMENDATIONS: The USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer (B recommendation).The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than 24 years about minimizing risks to prevent skin cancer.

      10. The Surgeon General’s Call to Action to Prevent Skin Cancer
        US Department of Health and Human Services .
        Washington DC: Office of the Surgeon General. 2014 ;Available at
        This document is a Call to Action to partners in prevention from various sectors across the nation to address skin cancer as a major public health problem. Many partners are essential to this effort, including federal, state, tribal, local, and territorial governments; members of the business, health care, and education sectors; community, nonprofit, and faith-based organizations; and individuals and families. The goal of this document is to increase awareness of skin cancer and to call for actions to reduce its risk. The first section describes the problem of skin cancer and its major risk factors. It also discusses the relationship between exposure to ultraviolet (UV) radiation and health. The second section describes the current evidence on preventing skin cancer, including current initiatives in the United States and in other countries. The third section describes the gaps in research related to skin cancer prevention, highlighting areas of research where more work is needed. The fourth section identifies specific opportunities to prevent skin cancer by reducing UV exposure in the U.S. population and calls for nationwide action. This document also includes six appendices, which provide further detail about specific topics. For more information about the scope of this document and definitions of commonly used terms, see Appendix 1. Appendix 2 describes symptoms of skin cancer. Appendix 3 provides a brief discussion of skin cancer screening. Success stories in skin cancer prevention are discussed in Appendix 4, and current federal efforts on skin cancer prevention are summarized in Appendix 5. Abbreviations and acronyms are listed in Appendix 6.

      11. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement
        US Preventive Services Task Force .
        Ann Intern Med. 2009 Feb 3;150(3):188-93.
        DESCRIPTION: Update of the 2001 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for skin cancer. METHODS: To update its recommendation, the USPSTF reviewed evidence published since 2001 on studies on screening effectiveness, the stage of detection by screening, and the accuracy of whole-body examination by primary care clinicians and self-examination by patients. RECOMMENDATION: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for skin cancer by primary care clinicians or by patient skin self-examination.

      12. International prevalence of indoor tanning: a systematic review and meta-analysis
        Wehner MR, Chren MM, Nameth D, Choudhry A, Gaskins M, Nead KT, Boscardin WJ, Linos E.
        JAMA Dermatol. 2014 Apr;150(4):390-400.
        IMPORTANCE: Indoor tanning is a known carcinogen, but the scope of exposure to this hazard is not known. OBJECTIVE: To summarize the international prevalence of exposure to indoor tanning. DATA SOURCES: Studies were identified through systematic searches of PubMed (1966 to present), Scopus (1823 to present), and Web of Science (1898 to present) databases, last performed on March 16, 2013. We also hand searched reference lists to identify records missed by database searches and publicly available data not yet published in the scientific literature. STUDY SELECTION: Records reporting a prevalence of indoor tanning were eligible for inclusion. We excluded case-control studies, reports with insufficient study information, and reports of groups recruited using factors related to indoor tanning. Two independent investigators performed searches and study selection. Our search yielded 1976 unique records. After exclusions, 161 records were assessed for eligibility in full text, and 88 were included. DATA EXTRACTION AND SYNTHESIS: Two independent investigators extracted data on characteristics of study participants, inclusion/exclusion criteria, data collection format, outcomes, and statistical methods. Random-effects meta-analyses were used to summarize the prevalence of indoor tanning in different age categories. We calculated the population proportional attributable risk of indoor tanning in the United States, Europe, and Australia for nonmelanoma skin cancer (NMSC) and melanoma. MAIN OUTCOMES AND MEASURES: Ever and past-year exposure to indoor tanning. RESULTS: The summary prevalence of ever exposure was 35.7% (95% CI, 27.5%-44.0%) for adults, 55.0% (33.0%-77.1%) for university students, and 19.3% (14.7%-24.0%) for adolescents. The summary prevalence of past-year exposure was 14.0% (95% CI, 11.5%-16.5%) for adults, 43.1% (21.7%-64.5%) for university students, and 18.3% (12.6%-24.0%) for adolescents. These results included data from 406 696 participants. The population proportional attributable risk were 3.0% to 21.8% for NMSC and 2.6% to 9.4% for melanoma, corresponding to more than 450 000 NMSC cases and more than 10 000 melanoma cases each year attributable to indoor tanning in the United States, Europe, and Australia. CONCLUSIONS AND RELEVANCE: Exposure to indoor tanning is common in Western countries, especially among young persons. Given the large number of skin cancer cases attributable to indoor tanning, these findings highlight a major public health issue.

  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. BACKGROUND: Negative employment consequences of arthritis are known but not fully understood. Examining transitions in and out of work can provide valuable information. OBJECTIVE: To examine associations of arthritis with employment during the Great Recession and predictors of employment transitions. METHODS: Data were for 3,277 adults ages 30-62 years with and without arthritis from the 2007 National Health Interview Survey followed in the Medical Expenditure Panel Survey 2008-2009. Employment (working vs. not working) was ascertained at baseline and five follow-ups. We estimated Kaplan Meier survival curves with 95% confidence intervals (CI) separately for time to stopping work (working at baseline) and starting work (not working at baseline) using Cox proportional hazards regression models with hazard ratios (HR). RESULTS: Arthritis was significantly associated with greater risk of stopping work (HR = 1.7, 95% CI = 1.3-2.2; adjusted HR= 1.5, 95% CI = 1.1-2.0) and significantly associated with 40% lower chance of starting work (HR = 0.6, 95% CI = 0.4-0.8); which reversed on adjustment (HR = 1.5, 95% CI = 1.0-2.2). Employment predictors were mixed by outcome. CONCLUSIONS: During the Great Recession, adults with arthritis stopped work at higher rates and started work at lower rates than those without arthritis.

    • Communicable Diseases
      1. Contribution of maternal antiretroviral therapy and breastfeeding to 24-month survival in human immunodeficiency virus-exposed uninfected children: An individual pooled analysis of African and Asian studies
        Arikawa S, Rollins N, Jourdain G, Humphrey J, Kourtis AP, Hoffman I, Essex M, Farley T, Coovadia HM, Gray G, Kuhn L, Shapiro R, Leroy V, Bollinger RC, Onyango-Makumbi C, Lockman S, Marquez C, Doherty T, Dabis F, Mandelbrot L, Le Coeur S, Rolland M, Joly P, Newell ML, Becquet R.
        Clin Infect Dis. 2018 May 17;66(11):1668-1677.
        Background: Human immunodeficiency virus (HIV)-infected pregnant women increasingly receive antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT). Studies suggest HIV-exposed uninfected (HEU) children face higher mortality than HIV-unexposed children, but most evidence relates to the pre-ART era, breastfeeding of limited duration, and considerable maternal mortality. Maternal ART and prolonged breastfeeding while on ART may improve survival, although this has not been reliably quantified. Methods: Individual data on 19 219 HEU children from 21 PMTCT trials/cohorts undertaken from 1995 to 2015 in Africa and Asia were pooled to estimate the association between 24-month mortality and maternal/infant factors, using random-effects Cox proportional hazards models. Adjusted attributable fractions of risks computed using the predict function in the R package “frailtypack” were used to estimate the relative contribution of risk factors to overall mortality. Results: Cumulative incidence of death was 5.5% (95% confidence interval, 5.1-5.9) by age 24 months. Low birth weight (LBW <2500 g, adjusted hazard ratio (aHR, 2.9), no breastfeeding (aHR, 2.5), and maternal death (aHR, 11.1) were significantly associated with increased mortality. Maternal ART (aHR, 0.5) was significantly associated with lower mortality. At the population level, LBW accounted for 16.2% of 24-month mortality, never breastfeeding for 10.8%, mother not receiving ART for 45.6%, and maternal death for 4.3%; combined, these factors explained 63.6% of deaths by age 24 months. Conclusions: Survival of HEU children could be substantially improved if public health practices provided all HIV-infected mothers with ART and supported optimal infant feeding and care for LBW neonates.

      2. More than 10 million new cases of tuberculosis (TB) are diagnosed worldwide each year. The majority of these cases occur in low- and middle-income countries where the TB epidemic is predominantly driven by transmission. Efforts to ‘end TB’ will depend upon our ability to halt ongoing transmission. However, recent studies of new approaches to interrupt transmission have demonstrated inconsistent effects on reducing population-level TB incidence. TB transmission occurs across a wide range of settings, that include households and hospitals, but also community-based settings. While home-based contact investigations and infection control programmes in hospitals and clinics have a successful track record as TB control activities, there is a gap in our knowledge of where, and between whom, community-based transmission of TB occurs. Novel tools, including molecular epidemiology, geospatial analyses and ventilation studies, provide hope for improving our understanding of transmission in countries where the burden of TB is greatest. By integrating these diverse and innovative tools, we can enhance our ability to identify transmission events by documenting the opportunity for transmission-through either an epidemiologic or geospatial connection-alongside genomic evidence for transmission, based upon genetically similar TB strains. A greater understanding of locations and patterns of transmission will translate into meaningful improvements in our current TB control activities by informing targeted, evidence-based public health interventions.

      3. The contributions and future direction of Program Science in HIV/STI prevention
        Becker M, Mishra S, Aral S, Bhattacharjee P, Lorway R, Green K, Anthony J, Isac S, Emmanuel F, Musyoki H, Lazarus L, Thompson LH, Cheuk E, Blanchard JF.
        Emerg Themes Epidemiol. 2018 ;15:7.
        Background: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. Discussion: To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. Conclusion: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

      4. Burden of severe norovirus disease in Taiwan, 2003-2013
        Burke RM, Shih SM, Yen C, Huang YC, Parashar UD, Lopman BA, Wu FT, Hsiung CA, Hall AJ.
        Clin Infect Dis. 2018 Jun 6.
        Background: Despite the increasingly recognized role of norovirus in global acute gastroenteritis (AGE), specific estimates of the associated disease burden remain sparse, primarily due to limited availability of sensitive norovirus diagnostics in the clinical setting. We sought to estimate the incidence of norovirus-associated hospitalizations by age group in Taiwan using a previously developed indirect regression method. Methods: AGE-related hospitalizations in Taiwan were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes abstracted from a national database; population data were provided from the Department of Household Registration Affairs. Population and hospitalizations were aggregated by month and year (July 2003-June 2013) and grouped by age: <5 years, 5-19 years, 20-64 years, and >/=65 years. Monthly counts of cause-unspecified AGE hospitalizations were modeled as a function of counts of known causes, and the residuals were then analyzed to estimate norovirus-associated hospitalizations. Results: Over the study period, an annual mean of 101400 gastroenteritis-associated hospitalizations occurred in Taiwan (44 per 10000 person-years), most of which (83%) had no specified cause. The overall estimated rate of norovirus-associated hospitalizations was 6.7 per 10000 person-years, with the highest rates in children aged <5 years (63.7/10000 person-years). Predicted norovirus peaked in 2006-2007 and 2012-2013. Conclusions: Our study is one of the first to generate a population-based estimate of severe norovirus disease incidence in Asia, and highlights the large burden of norovirus in Taiwan, particularly in children. Predicted peak norovirus seasons coincided with the emergence of new strains and resulting pandemics, supporting the validity of the estimates.

      5. Hepatitis C virus (HCV) infection is a global public health problem. The implementation of public health interventions (PHI) to control HCV infection could effectively interrupt HCV transmission. PHI targeting high-risk populations, e.g., people who inject drugs (PWID), are the most efficient but there is a lack of tools for prioritizing individuals within a high-risk community. Here, we present Intelligent Network DisRuption Analysis (INDRA), a targeted strategy for efficient interruption of hepatitis C transmissions.Using a large HCV transmission network among PWID in Indiana as an example, we compare effectiveness of random and targeted strategies in reducing the rate of HCV transmission in two settings: (1) long-established and (2) rapidly spreading infections (outbreak). Identification of high centrality for the network nodes co-infected with HIV or>1 HCV subtype indicates that the network structure properly represents the underlying contacts among PWID relevant to the transmission of these infections. Changes in the network’s global efficiency (GE) were used as a measure of the PHI effects. In setting 1, simulation experiments showed that a 50% GE reduction can be achieved by removing 11.2 times less nodes using targeted vs random strategies. A greater effect of targeted strategies on GE was consistently observed when networks were simulated: (1) with a varying degree of errors in node sampling and link assignment, and (2) at different levels of transmission reduction at affected nodes. In simulations considering a 10% removal of infected nodes, targeted strategies were ~2.8 times more effective than random in reducing incidence. Peer-education intervention (PEI) was modeled as a probabilistic distribution of actionable knowledge of safe injection practices from the affected node to adjacent nodes in the network. Addition of PEI to the models resulted in a 2-3 times greater reduction in incidence than from direct PHI alone. In setting 2, however, random direct PHI were ~3.2 times more effective in reducing incidence at the simulated conditions. Nevertheless, addition of PEI resulted in a ~1.7-fold greater efficiency of targeted PHI. In conclusion, targeted PHI facilitated by INDRA outperforms random strategies in decreasing circulation of long-established infections. Network-based PEI may amplify effects of PHI on incidence reduction in both settings.

      6. The etiology of vaginal discharge syndrome in Zimbabwe: Results from the Zimbabwe STI Etiology Study
        Chirenje ZM, Dhibi N, Handsfield HH, Gonese E, Tippett Barr B, Gwanzura L, Latif AS, Maseko DV, Kularatne RS, Tshimanga M, Kilmarx PH, Machiha A, Mugurungi O, Rietmeijer CA.
        Sex Transm Dis. 2018 Jun;45(6):422-428.
        INTRODUCTION: Symptomatic vaginal discharge is a common gynecological condition managed syndromically in most developing countries. In Zimbabwe, women presenting with symptomatic vaginal discharge are treated with empirical regimens that commonly cover both sexually transmitted infections (STIs) and reproductive tract infections, typically including a combination of an intramuscular injection of kanamycin, and oral doxycycline and metronidazole regimens. This study was conducted to determine the current etiology of symptomatic vaginal discharge and assess adequacy of current syndromic management guidelines. METHODS: We enrolled 200 women with symptomatic vaginal discharge presenting at 6 STI clinics in Zimbabwe. Microscopy was used to detect bacterial vaginosis and yeast infection. Nucleic acid amplifications tests were used to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. In addition, serologic testing was performed to detect human immunodeficiency virus (HIV) infection. RESULTS: Of the 200 women, 146 (73%) had an etiology detected, including bacterial vaginosis (24.7%); N. gonorrhoeae (24.0%); yeast infection (20.7%); T. vaginalis (19.0%); C. trachomatis (14.0%) and M. genitalium (7.0%). Among women with STIs (N = 90), 62 (68.9%) had a single infection, 18 (20.0%) had a dual infection, and 10 (11.1%) had 3 infections.Of 158 women who consented to HIV testing, 64 (40.5%) were HIV infected.The syndromic management regimen covered 115 (57.5%) of the women in the sample who had gonorrhea, chlamydia, M. genitalium, or bacterial vaginosis, whereas 85 (42.5%) of women were treated without such diagnosis. CONCLUSIONS: Among women presenting with symptomatic vaginal discharge, bacterial vaginosis was the most common etiology, and gonorrhea was the most frequently detected STI. The current syndromic management algorithm is suboptimal for coverage of women presenting with symptomatic vaginal discharge; addition of point of care testing could compliment the effectiveness of the syndromic approach.

      7. Update: Influenza activity in the United States during the 2017-18 season and composition of the 2018-19 influenza vaccine
        Garten R, Blanton L, Elal AI, Alabi N, Barnes J, Biggerstaff M, Brammer L, Budd AP, Burns E, Cummings CN, Davis T, Garg S, Gubareva L, Jang Y, Kniss K, Kramer N, Lindstrom S, Mustaquim D, O’Halloran A, Sessions W, Taylor C, Xu X, Dugan VG, Fry AM, Wentworth DE, Katz J, Jernigan D.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):634-642.
        The United States 2017-18 influenza season (October 1, 2017-May 19, 2018) was a high severity season with high levels of outpatient clinic and emergency department visits for influenza-like illness (ILI), high influenza-related hospitalization rates, and elevated and geographically widespread influenza activity across the country for an extended period. Nationally, ILI activity began increasing in November, reaching an extended period of high activity during January-February, and remaining elevated through March. Influenza A(H3N2) viruses predominated through February and were predominant overall for the season; influenza B viruses predominated from March onward. This report summarizes U.S. influenza activity* during October 1, 2017-May 19, 2018.(dagger).

      8. Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa
        Gross JM, McCarthy CF, Verani AR, Iliffe J, Kelley MA, Hepburn KW, Higgins MK, Kalula AT, Waudo AN, Riley PL.
        BMC Health Serv Res. 2018 Jun 4;18(1):406.
        BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one “stage” on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall’s tau = 0.56, p = 0.02), duration of technical assistance (Kendall’s tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall’s tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

      9. Variability in condom use trends by sexual risk behaviors: Findings from the 2003-2015 National Youth Risk Behavior Surveys
        Harper CR, Steiner RJ, Lowry R, Hufstetler S, Dittus PJ.
        Sex Transm Dis. 2018 Jun;45(6):400-405.
        OBJECTIVE: This study aimed to examine variability in condom use trends by sexual risk behavior among US high school students. METHODS: Data were from the 2003-2015 national Youth Risk Behavior Surveys conducted biennially among a nationally representative sample of students in grades 9 to 12. We used logistic regression to examine variability in trends of condom use during last sexual intercourse among female and male students by 4 sexual risk behaviors: drank alcohol or used drugs before last sexual intercourse, first sexual intercourse before age 13 years, 4 or more sex partners during their life, and 2 or more sex partners during the past 3 months. RESULTS: Between 2003 and 2015, significant declines in self-reported condom use were observed among black female (63.6% in 2003 to 46.7% in 2015) and white male students (69.0% in 2003 to 58.1% in 2015). Among female students, declines in self-reported condom use were significant only among those who drank or use drugs before last sexual intercourse, had 4 or more sex partners during their life, or had 2 or more sex partners during the past 3 months. There was a significant interaction between trends in condom use and first sexual intercourse before age 13 years, suggesting more pronounced declines among female students who initiated first sexual intercourse before age 13 years compared with their female peers. Trends did not vary by sexual risk behavior for male students. CONCLUSIONS: Results suggest that declines in self-reported condom use have occurred among female students at greater risk for acquiring a sexually transmitted disease.

      10. Invasive methicillin-resistant staphylococcus aureus infections among persons who inject drugs – six sites, 2005-2016
        Jackson KA, Bohm MK, Brooks JT, Asher A, Nadle J, Bamberg WM, Petit S, Ray SM, Harrison LH, Lynfield R, Dumyati G, Schaffner W, Townes JM, See I.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):625-628.
        In the United States, age-adjusted opioid overdose death rates increased by >200% during 1999-2015, and heroin overdose death rates increased nearly 300% during 2011-2015 (1). During 2011-2013, the rate of heroin use within the past year among U.S. residents aged >/=12 years increased 62.5% overall and 114.3% among non-Hispanic whites, compared with 2002-2004 (2). Increases in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections related to increases in injection drug use have been recently highlighted (3,4); likewise, invasive bacterial infections, including endocarditis, osteomyelitis, and skin and soft tissue infections, have increased in areas where the opioid epidemic is expanding (5-7). To assess the effects of the opioid epidemic on invasive methicillin-resistant Staphylococcus aureus (MRSA) infections during 2005-2016, surveillance data from CDC’s Emerging Infections Program (EIP) were analyzed (8). Persons who inject drugs were estimated to be 16.3 times more likely to develop invasive MRSA infections than others. The proportion of invasive MRSA cases that occurred among persons who inject drugs increased from 4.1% in 2011 to 9.2% in 2016. Infection types were frequently those associated with nonsterile injection drug use. Continued increases in nonsterile injection drug use are likely to result in increases in invasive MRSA infections, underscoring the importance of public health measures to curb the opioid epidemic.

      11. Mass chemoprophylaxis for control of outbreaks of meningococcal disease
        McNamara LA, MacNeil JR, Cohn AC, Stephens DS.
        Lancet Infect Dis. 2018 May 29.
        Although vaccination is the main strategy used to control meningococcal disease outbreaks, mass chemoprophylaxis has also been used as an immediate response to outbreaks, either to supplement vaccination or when vaccination is not possible. However, public health guidelines regarding the use of mass chemoprophylaxis for outbreak control vary by country, partly because the impact of mass chemoprophylaxis on the course of an individual outbreak is difficult to assess. We have reviewed data for the use of mass chemoprophylaxis during 33 outbreaks that occurred both in military populations and in communities and non-military organisations. In most outbreaks, no additional cases of meningococcal disease occurred after mass chemoprophylaxis, or cases occurred only in individuals who had not received prophylaxis. A delay of several weeks was common before cases occurred among prophylaxis recipients. Overall, the outbreak reports that we reviewed suggest that mass chemoprophylaxis might provide temporary protection to chemoprophylaxis recipients during outbreaks.

      12. Reduction of injection-related risk behaviors after emergency implementation of a syringe services program during an HIV outbreak
        Patel MR, Foote C, Duwve J, Chapman E, Combs B, Fry A, Hall P, Roseberry J, Brooks JT, Broz D.
        J Acquir Immune Defic Syndr. 2018 Apr 1;77(4):373-382.
        OBJECTIVE: To describe injection-related HIV risk behaviors preimplementation and postimplementation of an emergency syringe services program (SSP) in Scott County, Indiana, after an HIV outbreak among persons who inject drugs (PWID). DESIGN: Mixed methods retrospective pre-post intervention analysis. METHODS: We analyzed routine SSP program data collected at first and most recent visit among clients with >/=2 visits, >/=7 days apart from April 4 to August 30, 2015, to quantify changes in injection-related risk behaviors. We also analyzed qualitative data collected from 56 PWID recruited in Scott County to understand factors contributing to these behaviors. RESULTS: SSP clients included in our analysis (n = 148, 62% of all SSP clients) reported significant (P < 0.001) reductions over a median 10 weeks (range 1-23) in syringe sharing to inject (18%-2%) and divide drugs (19%-4%), sharing other injection equipment (eg, cookers) (24%-5%), and number of uses of the same syringe [2 (interquartile range: 1-4) to 1 (interquartile range: 1-1)]. Qualitative study participants described access to sterile syringes and safer injection education through the SSP, as explanatory factors for these reductions. Injection frequency findings were mixed, but overall suggested no change. The number of syringes returned by SSP clients increased from 0 at first visit to median 57. All qualitative study participants reported using sharps containers provided by the SSP. CONCLUSIONS: Analyses of an SSP program and in-depth qualitative interview data showed rapid reduction of injection-related HIV risk behaviors among PWID post-SSP implementation. Sterile syringe access as part of comprehensive HIV prevention is an important tool to control and prevent HIV outbreaks.

      13. The finding of casual sex partners on the internet, methamphetamine use for sexual pleasure, and incidence of HIV infection among men who have sex with men in Bangkok, Thailand: an observational cohort study
        Piyaraj P, van Griensven F, Holtz TH, Mock PA, Varangrat A, Wimonsate W, Thienkrua W, Tongtoyai J, McNamara A, Chonwattana W, Nelson KE.
        Lancet HIV. 2018 May 31.
        BACKGROUND: The finding of casual sex partners on the internet and methamphetamine use have been described as risk factors for HIV infection in men who have sex with men (MSM). However, the interplay between these factors has not been studied prospectively in one design. This study aims to determine the associations between finding casual sex partners on the internet and incident methamphetamine use and HIV infection. METHODS: In this observational cohort study of Thai MSM, we recruited Bangkok residents aged 18 years or older with a history of penetrative male-to-male sex in the past 6 months. Baseline and follow-up visits were done at a dedicated study clinic in central Bangkok. Men were tested for HIV infection at every study visit and for sexually transmitted infections at baseline. Baseline demographics and HIV risk behaviour information were collected at every visit by audio computer-assisted self-interview. We used a descriptive model using bivariate odds ratios to elucidate the order of risk factors in the causal pathway to HIV incidence and methamphetamine use. We used Cox proportional hazard regression analysis to evaluate covariates for incident methamphetamine use and HIV infection. FINDINGS: From April 6, 2006, to Dec 31, 2010, 1977 men were screened and 1764 were found eligible. 1744 men were enrolled, of whom 1372 tested negative for HIV and were followed up until March 20, 2012. Per 100 person-years of follow-up, incidence of methamphetamine use was 3.8 (128 events in 3371 person-years) and incidence of HIV infection was 6.0 (212 events in 3554 person-years). In our descriptive model, methamphetamine use, anal sex, and various other behaviours cluster together but their effect on HIV incidence was mediated by the occurrence of ulcerative sexually transmitted infections. Dual risk factors for both incident methamphetamine use and HIV infection were younger age and finding casual sex partners on the internet. Having ever received money for sex was predictive for incident methamphetamine use; living alone or with a housemate, recent anal sex, and ulcerative sexually transmitted infections at baseline were predictive for incident HIV infection. INTERPRETATION: In MSM in Bangkok, casual sex partner recruitment on the internet, methamphetamine use, and sexually transmitted infections have important roles in sustaining the HIV epidemic. Virtual HIV prevention education, drug use harm reduction, and biomedical HIV prevention methods, such as pre-exposure prophylaxis, could help to reduce or revert the HIV epidemic among MSM in Bangkok. FUNDING: US Centers for Disease Control and Prevention.

      14. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015
        Rouet F, Nouhin J, Zheng DP, Roche B, Black A, Prak S, Leoz M, Gaudy-Graffin C, Ferradini L, Mom C, Mam S, Gautier C, Lesage G, Ken S, Phon K, Kerleguer A, Yang C, Killam W, Fujita M, Mean C, Fontenille D, Barin F, Plantier JC, Bedford T, Ramos A, Saphonn V.
        Clin Infect Dis. 2018 May 17;66(11):1733-1741.
        Background: In 2014-2015, 242 individuals aged 2-89 years were newly diagnosed with human immunodeficiency virus type 1 (HIV-1) in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak. Methods: We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C virus (HCV) and hepatitis B virus (HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV. We performed amplification, sequencing, and evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed healthcare practitioner were obtained from 193 cases and 1499 controls during interviews. Results: Cases were coinfected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV env C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012-July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P = .04). Fifty-nine of 153 (38.6%) tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed 3 main clades, 1 containing 34 subtypes 1b with tMRCA in 2012, and 2 with 51 subtypes 6e and tMRCAs in 2002-2003. Conclusions: Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically diverse HCV propagation.

      15. BACKGROUND: Increased HIV testing efforts have resulted in retesting previously diagnosed persons. This study examined Centers for Disease Control and Prevention (CDC)-funded HIV testing programs to evaluate how the needs of previously diagnosed persons are being addressed. METHODS: The following were examined by demographic and test setting among previously diagnosed HIV-positive persons in 2015: CDC-funded HIV testing, previously diagnosed HIV positivity, current care status, and linkage to care. In addition, trends of HIV positivity and previously diagnosed HIV-positivity were examined from 2011 to 2015. RESULTS: In 2015, CDC funded 3,026,074 HIV tests, and 27,729 were HIV-positive tests. Of those, 13,528 (48.8%) were previously diagnosed persons. Only 11.6% of previously diagnosed persons reported already being in HIV care; after excluding them, 62.1% of previously diagnosed persons were linked within 90 days. In addition, the percentage of previously diagnosed persons steadily increased from 2011 (25.9%) to 2015 (34.1%; P < 0.001). CONCLUSIONS: Almost half of all HIV-positive tests were among previously diagnosed persons, but only 11.6% were already in HIV care. Linkage is necessary among persons who already know their HIV status because they either were never linked or need to be reengaged into care. Barriers in linkage and retention among this group also need to be addressed.

      16. HIV incidence, prevalence, and undiagnosed infections in U.S. men who have sex with men
        Singh S, Song R, Johnson AS, McCray E, Hall HI.
        Ann Intern Med. 2018 May 15;168(10):685-694.
        Background: HIV infection is a persistent health concern in the United States, and men who have sex with men (MSM) continue to be the most affected population. Objective: To estimate HIV incidence and prevalence and the percentage of undiagnosed HIV infections overall and among MSM. Design: Cross-sectional analysis. Setting: National HIV Surveillance System. Participants: Persons aged 13 years or older with diagnosed HIV infection. Measurements: Data on HIV diagnoses and the first CD4 test result after diagnosis were used to model HIV incidence and prevalence and the percentage of undiagnosed HIV infections from 2008 to 2015 on the basis of a well-characterized CD4 depletion model. Results: Modeled HIV incidence decreased 14.8% overall, from 45 200 infections in 2008 to 38 500 in 2015, and among all transmission risk groups except MSM. The incidence of HIV increased 3.1% (95% CI, 1.6% to 4.5%) per year among Hispanic/Latino MSM (6300 infections in 2008, 7900 in 2015), decreased 2.7% (CI, -3.8% to -1.5%) per year among white MSM (8800 infections in 2008, 7100 in 2015), and remained stable among black MSM at about 10 000 infections. The incidence decreased by 3.0% (CI, -4.2% to -1.8%) per year among MSM aged 13 to 24 years and by 4.7% (CI, -6.2% to -3.1%) per year among those aged 35 to 44 years. Among MSM aged 25 to 34 years, HIV incidence increased 5.7% (CI, 4.4% to 7.0%) per year and among MSM aged 55 years and older, HIV increased 4.1% (CI, 0.8% to 7.4%). The percentage of undiagnosed HIV infections was higher among black, Hispanic/Latino, and younger MSM than white and older MSM, respectively. Limitation: Assumptions of the CD4 depletion model and variability of CD4 values. Conclusion: Expansion of HIV screening to reduce undiagnosed infections and increased access to care and treatment to achieve viral suppression are critical to reduce HIV transmission. Access to prevention methods, such as condoms and preexposure prophylaxis, also is needed, particularly among MSM of color and young MSM. Primary Funding Source: None.

      17. In-hospital deaths among adults with community-acquired pneumonia
        Waterer GW, Self WH, Courtney DM, Grijalva CG, Balk RA, Girard TD, Fakhran SS, Trabue C, McNabb P, Anderson EJ, Williams DJ, Bramley AM, Jain S, Edwards KM, Wunderink RG.
        Chest. 2018 May 30.
        INTRODUCTION: Adults hospitalized with community-acquired pneumonia are at high risk for short-term mortality. However, it is unclear whether improvements in in-hospital pneumonia care could substantially lower this risk. We extensively reviewed all in-hospital deaths in a large prospective CAP study to assess the cause of each death and assess the extent of potentially preventable mortality. METHODS: We enrolled adults hospitalized with CAP at five tertiary-care hospitals in the United States. Five physician investigators reviewed the medical record and study database for each patient who died to identify the cause of death, the contribution of CAP to death, and any preventable factors potentially contributing to death. RESULTS: Among 2,320 enrolled patients, 52 (2.2%) died during initial hospitalization. Among these 52 patients, 33 (63.4%) were >/=65 years old, and 32 (61.5%) had >/=2 chronic comorbidities. CAP was judged to be the direct cause of death in 27 (51.9%) patients. Ten (19.2%) patients had do-not-resuscitate orders prior to admission. Four patients were identified in whom a lapse in quality of care potentially contributed to death; pre-existing end-of-life limitations were present in two of these patients. Two patients seeking full medical care experienced a lapse in in-hospital quality of pneumonia care that potentially contributed to death. CONCLUSION: In this study of adults with CAP at tertiary-care hospitals with a low mortality rate, most in-hospital deaths did not appear to be preventable with improvements in in-hospital pneumonia care. Pre-existing end-of-life limitations in care, advanced age, and high comorbidity burden were common among those who died.

      18. 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.

      19. Using search engine data as a tool to predict syphilis
        Young SD, Torrone EA, Urata J, Aral SO.
        Epidemiology. 2018 Jul;29(4):574-578.
        BACKGROUND: Researchers have suggested that social media and online search data might be used to monitor and predict syphilis and other sexually transmitted diseases. Because people at risk for syphilis might seek sexual health and risk-related information on the internet, we investigated associations between internet state-level search query data (e.g., Google Trends) and reported weekly syphilis cases. METHODS: We obtained weekly counts of reported primary and secondary syphilis for 50 states from 2012 to 2014 from the US Centers for Disease Control and Prevention. We collected weekly internet search query data regarding 25 risk-related keywords from 2012 to 2014 for 50 states using Google Trends. We joined 155 weeks of Google Trends data with 1-week lag to weekly syphilis data for a total of 7750 data points. Using the least absolute shrinkage and selection operator, we trained three linear mixed models on the first 10 weeks of each year. We validated models for 2012 and 2014 for the following 52 weeks and the 2014 model for the following 42 weeks. RESULTS: The models, consisting of different sets of keyword predictors for each year, accurately predicted 144 weeks of primary and secondary syphilis counts for each state, with an overall average R of 0.9 and overall average root mean squared error of 4.9. CONCLUSIONS: We used Google Trends search data from the prior week to predict cases of syphilis in the following weeks for each state. Further research could explore how search data could be integrated into public health monitoring systems.

    • Disease Reservoirs and Vectors
      1. The prevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) antibodies in dromedary camels in Israel
        Harcourt JL, Rudoler N, Tamin A, Leshem E, Rasis M, Giladi M, Haynes LM.
        Zoonoses Public Health. 2018 May 31.
        Middle East respiratory syndrome coronavirus, MERS-CoV, was identified in Saudi Arabia in 2012, and as of January 29, 2018, there were 2,123 laboratory-confirmed MERS-CoV cases reported to WHO (WHO, 2018, Multiple studies suggest that dromedary camels are a source for human MERS-CoV infection. MERS-CoV-specific antibodies have been detected in the serum of dromedary camels across Northern Africa and across the Arabian Peninsula. Israel’s geographic location places Israel at risk for MERS-CoV infection. To date, MERS-CoV-related illness has not been reported and the burden of MERS-CoV infection in the Israeli population is unknown. The seroprevalence of MERS-CoV-specific antibodies in Israeli dromedary camels is unknown. The objective of this study was to determine the prevalence of MERS-CoV seropositivity in dromedary camels in Israel. The prevalence of MERS-CoV antibodies in Israeli camels was examined in 71 camel sera collected from four farms across Israel by MERS-CoV-specific microneutralization (Mnt) assay and confirmed by MERS-CoV-specific immunofluorescence assay (IFA). Although this study cannot rule out potential antibody cross-reactivity by IFA, the presence of bovine coronavirus-specific antibodies do not appear to impact detection of MERS-CoV antibodies by Mnt. MERS-CoV neutralizing antibodies were detectable in 51 (71.8%) camel sera, and no association was observed between the presence of neutralizing antibodies and camel age or gender. These findings extend the known range of MERS-CoV circulation in Middle Eastern camels. The high rate of MERS-CoV-specific antibody seropositivity in dromedary camels in the absence of any reported human MERS cases suggests that there is still much to be learned about the dynamics of camel-to-human transmission of MERS-CoV.

    • Environmental Health
      1. [No abstract]

      2. [No abstract]

      3. Innovative safe water program improvement e-learning for environmental health professionals
        Sabogal R, Kalis M, Hubbard B, Oeffinger J, Baddour LJ, Tate C, Shorter C.
        J Environ Health. 2018 ;80(10):38-40.

        [No abstract]

    • Health Disparities
      1. OBJECTIVES: Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP. METHODS: We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as “substantial” (ie, one of </=3 foci of the article) or “minimal” (ie, one of >/=4 foci of the article). RESULTS: Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%). CONCLUSIONS: This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

    • Health Economics
      1. Trends in health insurance coverage of Title X Family Planning Program clients, 2005-2015
        Decker EJ, Ahrens KA, Fowler CI, Carter M, Gavin L, Moskosky S.
        J Womens Health (Larchmt). 2018 May;27(5):684-690.
        BACKGROUND: The federal Title X Family Planning Program supports the delivery of family planning services and related preventive care to 4 million individuals annually in the United States. The implementation of the 2010 Affordable Care Act’s (ACA’s) Medicaid expansion and provisions expanding access to health insurance, which took effect in January 2014, resulted in higher rates of health insurance coverage in the U.S. population; the ACA’s impact on individuals served by the Title X program has not yet been evaluated. METHODS: Using administrative data we examined changes in health insurance coverage among Title X clinic patients during 2005-2015. RESULTS: We found that the percentage of clients without health insurance decreased from 60% in 2005 to 48% in 2015, with the greatest annual decrease occurring between 2013 and 2014 (63% to 54%). Meanwhile, between 2005 and 2015, the percentage of clients with Medicaid or other public health insurance increased from 20% to 35% and the percentage of clients with private health insurance increased from 8% to 15%. CONCLUSIONS: Although clients attending Title X clinics remained uninsured at substantially higher rates compared with the national average, the increase in clients with health insurance coverage aligns with the implementation of ACA-related provisions to expand access to affordable health insurance.

      2. Systematic review of health care costs related to mental health conditions among cancer survivors
        Khushalani JS, Qin J, Cyrus J, Buchanan Lunsford N, Rim SH, Han X, Yabroff KR, Ekwueme DU.
        Expert Rev Pharmacoecon Outcomes Res. 2018 Jun 5.
        INTRODUCTION: This systematic review examines healthcare costs associated with mental health conditions among cancer survivors in the United States. Areas covered: Ten published studies were identified. Studies varied substantially in terms of population, mental health conditions examined, data collection methods, and type of cost reported. Cancer survivors with mental health conditions incurred significantly higher total medical costs and costs of most service types compared to cancer survivors without a mental health condition. Additionally, the total healthcare expenditure related to mental health was higher among cancer survivors compared with people without history of cancer. Expert commentary: Mental health conditions are associated with increased healthcare costs among cancer survivors. Future examination of other components of economic burden, including patient out-of-pocket costs, non-medical costs, such as transportation, childcare, and productivity losses for patients and their caregivers, will be important. Additionally, evaluation of economic burden by cancer site, stage at diagnosis, duration of survivorship, and treatment(s) will increase understanding of the overall impact of mental health conditions on cancer survivors and on the healthcare system.

      3. BACKGROUND: The Xpert((R)) MTB/RIF (Xpert) test has been shown to be effective and cost-effective for diagnosing tuberculosis (TB) under conditions with high HIV prevalence and HIV-TB co-infection but less is known about Xpert’s cost in low HIV prevalence settings. Cambodia, a country with low HIV prevalence (0.7%), high TB burden, and low multidrug-resistant (MDR) TB burden (1.4% of new TB cases, 11% of retreatment cases) introduced Xpert into its TB diagnostic algorithms for people living with HIV (PLHIV) and people with presumptive MDR TB in 2012. The study objective was to estimate these algorithms’ costs pre- and post-Xpert introduction in four provinces of Cambodia. METHODS: Using a retrospective, ingredients-based microcosting approach, primary cost data on personnel, equipment, maintenance, supplies, and specimen transport were collected at four sites through observation, records review, and key informant consultations. RESULTS: Across the sample facilities, the cost per Xpert test was US$33.88-US$37.11, clinical exam cost US$1.22-US$1.84, chest X-ray cost US$2.02-US$2.14, fluorescent microscopy (FM) smear cost US$1.56-US$1.93, Ziehl-Neelsen (ZN) smear cost US$1.26, liquid culture test cost US$11.63-US$22.83, follow-on work-up for positive culture results and Mycobacterium tuberculosis complex (MTB) identification cost US$11.50-US$14.72, and drug susceptibility testing (DST) cost US$44.26. Specimen transport added US$1.39-US$5.21 per sample. Assuming clinician adherence to the algorithms and perfect test accuracy, the normative cost per patient correctly diagnosed under the post-Xpert algorithms would be US$25-US$29 more per PLHIV and US$34-US$37 more per person with presumptive MDR TB (US$41 more per PLHIV when accounting for variable test sensitivity and specificity). CONCLUSIONS: Xpert test unit costs could be reduced through lower cartridge prices, longer usable life of GeneXpert((R)) (Cepheid, USA) instruments, and increased test volumes; however, epidemiological and test eligibility conditions in Cambodia limit the number of specimens received at laboratories, leading to sub-optimal utilization of current instruments. Improvements to patient referral and specimen transport could increase test volumes and reduce Xpert test unit costs in this setting.

    • Immunity and Immunization
      1. Seasonal influenza vaccine effectiveness against laboratory-confirmed influenza hospitalizations – Latin America, 2013
        El Omeiri N, Azziz-Baumgartner E, Thompson MG, Clara W, Cerpa M, Palekar R, Mirza S, Ropero-Alvarez AM.
        Vaccine. 2018 Jun 7;36(24):3555-3566.
        BACKGROUND: Despite widespread utilization of influenza vaccines, effectiveness (VE) has not been routinely measured in Latin America. METHODS: We used a case test-negative control design to estimate trivalent inactivated influenza VE against laboratory-confirmed influenza among hospitalized children aged 6months-5years and adults aged >/=60years which are age-groups targeted for vaccination. We sought persons with severe acute respiratory infections (SARI), hospitalized at 71 sentinel hospitals in Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Honduras, Panama, and Paraguay during January-December 2013. Cases had an influenza virus infection confirmed by real-time reverse transcription PCR (rRT-PCR); controls had a negative rRT-PCR result for influenza viruses. We used a two-stage random effects model to estimate pooled VE per target age-group, adjusting for the month of illness onset, age and preexisting medical conditions. RESULTS: We identified 2620 SARI patients across sites: 246 influenza cases and 720 influenza-negative controls aged </=5years and 448 cases and 1206 controls aged >/=60years. The most commonly identified subtype among participants (48%) was the influenza A(H1N1)pdm09 virus followed by influenza A(H3N2) (34%) and influenza B (18%) viruses. Among children, the adjusted VE of full vaccination (one dose for previously vaccinated or two if vaccine naive) against any influenza virus SARI was 47% (95% confidence interval [CI]: 14-71%); VE was 58% (95% CI: 16-79%) against influenza A(H1N1)pdm09, and 65% (95% CI: -9; 89%) against influenza A(H3N2) viruses associated SARI. Crude VE of full vaccination against influenza B viruses associated SARI among children was 3% (95% CI: -150; 63). Among adults aged >/=60years, adjusted VE against any influenza SARI was 48% (95% CI: 34-60%); VE was 54% (95% CI: 37-69%) against influenza A(H1N1)pdm09, 43% (95% CI: 18-61%) against influenza A(H3N2) and 34% (95% CI: -4; 58%) against B viruses associated SARI. CONCLUSION: Influenza vaccine provided moderate protection against severe influenza illness among fully vaccinated young children and older adults, supporting current vaccination strategies.

      2. Update: ACIP Recommendations for the use of quadrivalent live attenuated influenza vaccine (LAIV4) – United States, 2018-19 influenza season
        Grohskopf LA, Sokolow LZ, Fry AM, Walter EB, Jernigan DB.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):643-645.
        Intranasally administered live attenuated influenza vaccine (LAIV) was initially licensed in the United States in 2003 as a trivalent formulation (LAIV3) (FluMist, MedImmune, LLC). Quadrivalent live attenuated influenza vaccine (LAIV4) (FluMist Quadrivalent, MedImmune) has been licensed in the United States since 2012 and was first available during the 2013-14 influenza season, replacing LAIV3. During the 2016-17 and 2017-18 influenza seasons, the Advisory Committee on Immunization Practices (ACIP) recommended that LAIV4 not be used because of concerns about low effectiveness against influenza A(H1N1)pdm09-like viruses circulating in the United States during the 2013-14 and 2015-16 seasons (1,2). On February 21, 2018, ACIP recommended that LAIV4 be an option for influenza vaccination of persons for whom it is appropriate for the 2018-19 season (3). This document provides an overview of the information discussed in the decision-making process leading to this recommendation. A description of methodology and data reviewed will be included in the background materials that will supplement the 2018-19 ACIP Influenza Recommendations, which will replace the 2017-18 ACIP influenza statement (2), and which will also contain guidance for the use of LAIV4.

      3. Safety of repeated doses of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine in adults and adolescents
        Jackson ML, Yu O, Nelson JC, Nordin JD, Tartof SY, Klein NP, Donahue JG, Irving SA, Glanz JM, McNeil MM, Jackson LA.
        Pharmacoepidemiol Drug Saf. 2018 Jun 3.
        In light of waning immunity to pertussis following receipt of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine, maintaining protection may require repeated Tdap vaccination. We evaluated the safety of repeated doses of tetanus-containing vaccine in 68 915 nonpregnant adolescents and adults in the Vaccine Safety Datalink population who had received an initial dose of Tdap. Compared with 7521 subjects who received a subsequent dose of tetanus toxoid, reduced diphtheria (Td) vaccine, the 61 394 subjects who received a subsequent dose of Tdap did not have significantly elevated risk of medical visits for seizure, cranial nerve disorders, limb swelling, pain in limb, cellulitis, paralytic syndromes, or encephalopathy/encephalitis/meningitis. These results suggest that repeated Tdap vaccination has acceptable safety relative to Tdap vaccination followed by Td vaccination.

      4. Background: Mother-to-child transmission of hepatitis B can be prevented with vaccination and screening. Foreign-born women living in the United States may have lower vaccination coverage and greater lifetime exposure to hepatitis B virus than US-born women. Objective: To determine if self-reported hepatitis B vaccination and screening differ between US-born and foreign-born women of reproductive age and examine predictors. Methods: National Health Interview Survey data from 2013-2015 were pooled to estimate prevalence of lifetime history of hepatitis B vaccination and screening self-reported by women aged 18-44 years who were born in the United States or elsewhere (foreign-born). Significance of world region of birth, birth cohort, and immigration-related characteristics were considered. Results: Among women of reproductive age (n= 24,216), reported hepatitis B vaccination was 33% lower for foreign-born (27.3%) than US-born (40.9%) women (t-test P < .05). Vaccination coverage was low for women who were born in Mexico and other parts of Central America, including the Caribbean islands (18.4%), South America (25.3%), and the Indian subcontinent (31.7%). Factors associated with vaccination in both groups included education, income, and health insurance coverage. Screening was reported by 28.5% of foreign-born vs. 31.9% of US-born women (t-test P < .05). The lowest reported screening prevalence occurred among foreign-born Hispanic or Latina Mexican (21.0%) and Puerto Rican (21.9%) women. Factors associated with screening prevalence among foreign-born women included English fluency, recent US residency, and citizenship. Conclusions: Foreign-born women of reproductive age had lower hepatitis B vaccination and screening coverage compared to US-born women of reproductive age.

      5. Safety surveillance of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines
        Moro PL, Perez-Vilar S, Lewis P, Bryant-Genevier M, Kamiya H, Cano M.
        Pediatrics. 2018 Jun 4.
        OBJECTIVE: To assess the safety of currently licensed diphtheria-tetanus-acellular pertussis (DTaP) vaccines in the United States by using data from the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting surveillance system. METHODS: We searched VAERS for US reports of DTaP vaccinations occurring from January 1, 1991, through December 31, 2016, and received by March 17, 2017. We reviewed available medical records for all death reports and a random sample of reports classified as nondeath serious. We used Empirical Bayesian data mining to identify adverse events that were disproportionally reported after DTaP vaccination. RESULTS: VAERS received 50 157 reports after DTaP vaccination; 43 984 (87.7%) of them reported concomitant administration of other vaccines, and 5627 (11.2%) were serious. Median age at vaccination was 19 months (interquartile range 35 months). The most frequently reported events were injection site erythema (12 695; 25.3%), pyrexia (9913; 19.8%), injection site swelling (7542; 15.0%), erythema (5599; 11.2%), and injection site warmth (4793; 9.6%). For 3 of the DTaP vaccines, we identified elevated values for vaccination errors using Empirical Bayesian data mining. CONCLUSIONS: No new or unexpected adverse events were detected. The observed disproportionate reporting for some nonserious vaccination errors calls for better education of vaccine providers on the specific indications for each of the DTaP vaccines.

      6. OBJECTIVE: To quantify vaccinations administered outside minimum and maximum recommended ages and to determine attendant costs of revaccination by analyzing immunization information system (IIS) records. STUDY DESIGN: We analyzed deidentified records of doses administered during 2014 to persons aged <18 years within 6 IIS sentinel sites (10% of the US population). We quantified doses administered outside of recommended ages according to the Advisory Committee on Immunization Practices childhood immunization schedule and prescribing information in package inserts, and calculated revaccination costs. To minimize misreporting bias, we analyzed publicly funded doses for which reported lot numbers and vaccine types were consistent. RESULTS: Among 3 394 047 doses with maximum age recommendations, 9755 (0.3%) were given after the maximum age. One type of maximum age violation required revaccination: 1344 (0.7%) of 194 934 doses of the 0.25-mL prefilled syringe formulation of quadrivalent inactivated influenza vaccine (Fluzone Quadrivalent, Sanofi Pasteur, Swiftwater, PA) were administered at age >/=36 months (revaccination cost, $111 964). We identified a total of 7 529 165 childhood, adolescent, and lifespan doses with minimum age recommendations, 9542 of which (0.1%) were administered before the minimum age. The most common among these violations were quadrivalent injectable influenza vaccines (3835, or 0.7% of 526 110 doses administered before age 36 months) and Kinrix (GlaxoSmithKline Biologicals, Rixensart, Belgium; DTaP-IPV) (2509, or 1.2% of 208 218 doses administered before age 48 months). The cost of revaccination for minimum age violations (where recommended) was $179 179. CONCLUSION: Administration of vaccines outside recommended minimum and maximum ages is rare, reflecting a general adherence to recommendations. Error rates were higher for several vaccines, some requiring revaccination. Vaccine schedule complexity and confusion among similar products might contribute to errors. Minimization of errors reduces wastage, excess cost, and inconvenience for parents and patients.

    • Injury and Violence
      1. Preventing intimate partner violence through paid parental leave policies
        D’Inverno AS, Reidy DE, Kearns MC.
        Prev Med. 2018 May 30;114:18-23.
        Paid parental leave policies have the potential to strengthen economic supports, reduce family discord, and provide opportunities to empower women (Basile et al., 2016; Niolon et al., 2017). In this article, we present a theory of change and evidence to suggest how paid parental leave may impact intimate partner violence (IPV). In doing so, we present three mechanisms of change (i.e., reduction in financial stress, increase in egalitarian parenting practices, and promotion of child/parent bonding) through which paid parental leave could reduce rates of IPV. We also describe limitations of the current state of knowledge in this area, as well as opportunities for future research. Ultimately, our goal is to facilitate the identification and implementation of approaches that have the potential to reduce violence at the population level. Paid parental leave embodies the potential of policies to change societal-level factors and serve as an important prevention strategy for IPV.

      2. Healthcare access and cancer screening among victims of intimate partner violence
        Massetti GM, Townsend JS, Thomas CC, Basile KC, Richardson LC.
        J Womens Health (Larchmt). 2018 May;27(5):607-614.
        BACKGROUND: Intimate partner violence (IPV) victims often experience substantial and persistent mental and physical health problems, including increased risk for chronic disease and barriers to healthcare access. This study investigated the association between IPV and cancer screening. MATERIALS AND METHODS: Behavioral Risk Factor Surveillance System data from the eight states and one U.S. territory that administered the optional IPV module in 2006 were analyzed to examine demographic characteristics, health behaviors, health status, healthcare coverage, use of health services, and cancer screening among men and women who reported IPV victimization compared with those among men and women who did not. IPV victimization included physical violence, threats, and sexual violence. RESULTS: In the nine jurisdictions that administered the IPV module, 23.6% of women and 11.3% of men experienced IPV. Fewer women and men reporting IPV victimization had health insurance, a personal doctor or healthcare provider, or regular checkups within the past 2 years than nonvictims. More male and female IPV victims were current tobacco users and engaged in binge drinking in the past month. IPV victims of both sexes also had poorer health status, lower life satisfaction, less social and emotional support, and more days with poor physical and mental health in the past month than nonvictims. IPV victimization was associated with lower rates of mammography and colorectal cancer screening but not cervical cancer screening in women and was not associated with colorectal cancer screening in men. In multivariable logistic regression results presented as adjusted proportions controlling for demographics, health status, and healthcare access, only the association with mammography screening remained significant, and the magnitude of this association was modest. CONCLUSIONS: There were consistent differences between IPV victims and nonvictims in nearly every measure of healthcare access, health status, and preventive service use. Much of this association seems explained by population characteristics associated with both IPV and lower use of preventive service use, including differences in demographic characteristics, health status, and healthcare access. Healthcare providers could take steps to identify populations at high risk for lack of access or use of preventive services and IPV victimization.

      3. Vital Signs: Trends in state suicide rates – United States, 1999-2016 and circumstances contributing to suicide – 27 states, 2015
        Stone DM, Simon TR, Fowler KA, Kegler SR, Yuan K, Holland KM, Ivey-Stephenson AZ, Crosby AE.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):617-624.
        INTRODUCTION: Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS: Trends in age-adjusted suicide rates among persons aged >/=10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS: During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS: Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

    • Laboratory Sciences
      1. T helper (Th) 2-dependent type 2 immune pathways have been recognized as an important driver for the development of fibrosis. Upon stimulation, activated Th2 immune cells and type 2 cytokines interact with inflammatory and tissue repair functions to stimulate an overzealous reparative response to tissue damage, leading to organ fibrosis and destruction. In this connection, type 2 pathways are activated by a variety of insults and pathological conditions to modulate the response. Carbon nanotubes (CNTs) are nanomaterials with a wide range of applications. However, pulmonary exposure to CNTs causes a number of pathologic outcomes in animal lungs, dominated by inflammation and fibrosis. These findings, alongside the rapidly expanding production and commercialization of CNTs and CNT-containing materials in recent years, have raised concerns on the health risk of CNT exposure in humans. The CNT-induced pulmonary fibrotic lesions resemble those of human fibrotic lung diseases, such as idiopathic pulmonary fibrosis and pneumoconiosis, to a certain extent with regard to disease development and pathological features. In fibrotic scenarios, immune cells are activated including varying immune pathways, ranging from innate immune cell activation to autoimmune disease. These events often precede and/or accompany the occurrence of fibrosis. Upon CNT exposure, significant induction and activation of Th2 cells and type 2 cytokines in the lungs are observed. Moreover, type 2 pathways are shown to play important roles in promoting CNT-induced lung fibrosis by producing type 2 pro-fibrotic factors and inducing the reparative phenotypes of macrophages in response to CNTs. In light of the vastly increased demand for nanosafety and the apparent induction and multiple roles of type 2 immune pathways in lung fibrosis, we review the current literature on CNT-induced lung fibrosis, with a focus on the induction and activation of type 2 responses by CNTs and the stimulating function of type 2 signaling on pulmonary fibrosis development. These analyses provide new insights into the mechanistic understanding of CNT-induced lung fibrosis, as well as the potential of using type 2 responses as a monitoring target and therapeutic strategy for human fibrotic lung disease.

      2. Characterization of real-time microarrays for simultaneous detection of HIV-1, HIV-2, and hepatitis viruses
        Granade TC, Kodani M, Wells SK, Youngpairoj AS, Masciotra S, Curtis KM, Kamili S, Owen SM.
        J Virol Methods. 2018 Jun 3.
        Real-time PCR assays for nucleic acid testing (NAT) of hepatitis viruses A-E and for HIV-1 and HIV-2 have been developed; however, a multiplex assay that can simultaneously detect all of these agents is not yet available. Standardized TaqMan assays for detection of hepatitis viruses A-E have been described and applied to TaqMan Array Cards (TAC) which are capable of multiple pathogen detection using a single set of optimized PCR conditions. Assays for three gene regions of HIV-1 (long-terminal repeat (LTR), gag, and polymerase) and HIV-2 (overlap of LTR and gag, protease and integrase) were designed using the hepatitis assay conditions. Nucleic acid extracts of HIV-1-infected samples (44 plasma, 41 whole blood, 20 HIV-1 viral stocks) were tested on the TAC cards; 98 were reactive (92%) with 70 in multiple gene regions. Twenty-four of the 27 (89%) HIV-2 specimens (10 plasma, 1 PBMC lysate, 6 whole blood and 10 plasmids containing HIV-2 polymerase) were detected on TAC. No HIV or hepatitis virus sequences were detected in 30 HIV-negative samples (specificity 100%). Three HBV and 18 HCV co-infections were identified in the HIV-1-infected specimens. Multi-pathogen detection using TAC could provide a rapid, sensitive and more efficient method of surveying for a variety of infectious disease nucleic acids.

      3. Malaria diagnostic practices in United States laboratories, 2017
        Prestel C, Tan KR, Abanyie F, Jerris R, Gutman JR.
        J Clin Microbiol. 2018 Jun 6.
        Background: In the United States (US), the gold standard for malaria diagnosis is microscopic blood smear examination. Because malaria is not endemic in the US, diagnostic capabilities may be limited, causing delays in diagnosis and increased morbidity and mortality.Methods: A survey of US laboratories was conducted from June to July, 2017 of their malaria diagnostic practices; members of the American Society for Microbiology’s listserv received a questionnaire inquiring about malaria diagnostic test availability, techniques, and reporting. Results were assessed using the Clinical and Laboratory Standards Institute (CLSI) guidelines for malaria diagnostics.Results: After excluding incomplete and duplicate responses, responses representing 175 laboratories were included. Most (99%) labs received at least one specimen for malaria diagnosis annually and 31% reported receiving only 1-10 specimens. The majority (74%) diagnosed five or fewer cases of malaria per year. Most (90%) performed blood smears on-site. Two-thirds (70%) provided initial blood smear results within 4 hours. Although diagnostic testing for malaria was available 24/7 at 74% (141) of responding laboratories, only 12% (17) met criteria for analysis and reporting of malaria testing, significantly higher than reported in a similar survey in 2010 (3%; p<0.05).Conclusion: The majority of laboratories surveyed had the capability for timely diagnosis of malaria; few comply with CLSI guidelines. Inexperience may factor into this non-compliance; many laboratories see few to no cases of malaria per year. Although reported adherence to CLSI guidelines was higher than in 2010, there is a need to further improve laboratory compliance with recommendations.

      4. Quantitative HPLC-MS/MS analysis of toxins in soapberry seeds: Methylenecyclopropylglycine and hypoglycin A
        Sanford AA, Isenberg SL, Carter MD, Mojica MA, Mathews TP, Harden LA, Takeoka GR, Thomas JD, Pirkle JL, Johnson RC.
        Food Chem. 2018 Oct 30;264:449-454.
        Methylenecyclcopropylglycine (MCPG) and hypoglycin A (HGA) are naturally occurring amino acids found in various soapberry (Sapindaceae) fruits. These toxins have been linked to illnesses worldwide and were recently implicated in Asian outbreaks of acute hypoglycemic encephalopathy. In a previous joint agricultural and public health investigation, we developed an analytical method capable of evaluating MCPG and HGA concentrations in soapberry fruit arils as well as a clinical method for the urinary metabolites of the toxins. Since the initial soapberry method only analyzed the aril portion of the fruit, we present here the extension of the method to include the fruit seed matrix. This work is the first method to quantitate both MCPG and HGA concentrations in the seeds of soapberry fruit, including those collected during a public health investigation. Further, this is the first quantitation of HGA in litchi seeds as well as both toxins in mamoncillo and longan seeds.

      5. PET-PCR for detection of Plasmodium falciparum Plasmepsin 2 Gene copy number
        Santos Souza S, L’Episcopia M, Severini C, Udhayakumar V, Lucchi NW.
        Antimicrob Agents Chemother. 2018 Jun 4.
        Piperaquine is an important partner drug used in artemisinin-based combination therapies (ACTs). An increase in the plasmepsin 2 and 3 gene copy number has been associated with decreased susceptibility of Plasmodium falciparum to piperaquine in Cambodia. Here, we developed a photo- induced electron transfer real-time PCR (PET-PCR) assay to quantify the copy number of plasmepsin 2 (PfPM2) that can be used in endemic countries to enhance molecular surveillance.

      6. Antigenic characterization of highly pathogenic avian influenza A(H5N1) viruses with chicken and ferret antisera reveals clade-dependent variation in hemagglutination inhibition profiles
        Thi Nguyen D, Shepard SS, Burke DF, Jones J, Thor S, Nguyen LV, Nguyen TD, Balish A, Hoang DN, To TL, Iqbal M, Wentworth DE, Spackman E, van Doorn HR, Davis CT, Bryant JE.
        Emerg Microbes Infect. 2018 May 31;7(1):100.
        Highly pathogenic avian influenza (HPAI) A(H5N1) viruses pose a significant economic burden to the poultry industry worldwide and have pandemic potential. Poultry vaccination against HPAI A(H5N1) viruses has been an important component of HPAI control measures and has been performed in Vietnam since 2005. To systematically assess antigenic matching of current vaccines to circulating field variants, we produced a panel of chicken and ferret antisera raised against historical and contemporary Vietnamese reference viruses representing clade variants that were detected between 2001 and 2014. The antisera were used for hemagglutination inhibition (HI) assays to generate data sets for analysis by antigenic cartography, allowing for a direct comparison of results from chicken or ferret antisera. HI antigenic maps, developed with antisera from both hosts, revealed varying patterns of antigenic relationships and clustering of viruses that were dependent on the clade of viruses analyzed. Antigenic relationships between existing poultry vaccines and circulating field viruses were also aligned with in vivo protection profiles determined by previously reported vaccine challenge studies. Our results establish the feasibility and utility of HPAI A(H5N1) antigenic characterization using chicken antisera and support further experimental and modeling studies to investigate quantitative relationships between genetic variation, antigenic drift and correlates of poultry vaccine protection in vivo.

      7. Collaborative method performance study of the measurement of nicotine, its metabolites, and total nicotine equivalents in human urine
        Wang L, Bernert JT, Benowitz NL, Feng J, Jacob P, McGahee E, Caudill SP, Scherer G, Scherer M, Pluym N, Doig MV, Newland K, Murphy SE, Caron NJ, Sander LC, Shimizu M, Yamazaki H, Kim S, Langman LJ, Pritchett JS, Sniegoski LT, Li Y, Blount B, Pirkle JL.
        Cancer Epidemiol Biomarkers Prev. 2018 May 31.
        BACKGROUND: Biomarkers of tobacco exposure have a central role in studies of tobacco use and nicotine intake. The most significant exposure markers are nicotine itself and its metabolites in urine. Therefore, it is important to evaluate the performance of laboratories conducting these biomarker measurements. METHODS: This report presents the results from a method performance study involving 11 laboratories from 6 countries which are currently active in this area. Each laboratory assayed blind replicates of 7 human urine pools at various concentrations on 3 separate days. The samples included 5 pools blended from smoker and nonsmoker urine sources, and 2 additional blank urine samples fortified with pure nicotine, cotinine and hydroxycotinine standards. All laboratories used their own methods, and all were based on some form of liquid chromatography / tandem mass spectrometry. RESULTS: Overall, good agreement was found among the laboratories in this study. Intralaboratory precision was good, and in the fortified pools the mean bias observed was &lt; + 3.5% for nicotine, approximately 1.2% for hydroxycotinine, and less than 1% for cotinine (1 outlier excluded in each case). Both indirect and direct methods for analyzing the glucuronides gave comparable results. CONCLUSIONS: This evaluation indicates that the experienced laboratories participating in this study can produce reliable and comparable human urinary nicotine metabolic profiles in samples from people with significant recent exposure to nicotine. IMPACT: This work supports the reliability and agreement of an international group of established laboratories measuring nicotine and its metabolites in urine in support of nicotine exposure studies.

    • Maternal and Child Health
      1. Leveraging resources to establish equitable breastfeeding support across Alabama
        Barrera CM, Whatley G, Stratton A, Kahin S, Roberts Ayers D, Grossniklaus D, MacGowan C.
        J Hum Lact. 2018 Jun 1:890334418775631.

        [No abstract]

      2. Case definitions for conditions identified by newborn screening public health surveillance
        Sontag MK, Sarkar D, Comeau AM, Hassell K, Botto LD, Parad R, Rose SR, Wintergerst KA, Smith-Whitley K, Singh S, Yusuf C, Ojodu J, Copeland S, Hinton CF.
        Int J Neonatal Screen. 2018 ;4(2):16.
        Newborn screening (NBS) identifies infants with rare conditions to prevent death or the onset of irreversible morbidities. Conditions on the Health and Human Services Secretary’s Recommended Uniform Screening Panel have been adopted by most state NBS programs, providing a consistent approach for identification of affected newborns across the United States. Screen-positive newborns are identified and referred for confirmatory diagnosis and follow-up. The designation of a clinically significant phenotype precursor to a clinical diagnosis may vary between clinical specialists, resulting in diagnostic variation. Determination of disease burden and birth prevalence of the screened conditions by public health tracking is made challenging by these variations. This report describes the development of a core group of new case definitions, along with implications, plans for their use, and links to the definitions that were developed by panels of clinical experts. These definitions have been developed through an iterative process and are piloted in NBS programs. Consensus public health surveillance case definitions for newborn screened disorders will allow for consistent categorization and tracking of short- and long-term follow-up of identified newborns at the local, regional, and national levels.

    • Mining
      1. Coal rib response during bench mining: A case study
        Sears MM, Rusnak J, Van Dyke M, Rashed G, Mohamed K, Sloan M.
        Int J Min Sci Technol. 2018 Jan;28(1):107-113.
        In 2016, room-and-pillar mining provided nearly 40% of underground coal production in the United States. Over the past decade, rib falls have resulted in 12 fatalities, representing 28% of the ground fall fatalities in U.S. underground coal mines. Nine of these 12 fatalities (75%) have occurred in room-and-pillar mines. The objective of this research is to study the geomechanics of bench room-and-pillar mining and the associated response of high pillar ribs at overburden depths greater than 300 m. This paper provides a definition of the bench technique, the pillar response due to loading, observational data for a case history, a calibrated numerical model of the observed rib response, and application of this calibrated model to a second site.

    • Nutritional Sciences
      1. Biomarkers of Nutrition for Development (BOND) – Iron review
        Lynch S, Pfeiffer CM, Georgieff MK, Brittenham G, Fairweather-Tait S, Hurrell RF, McArdle HJ, Raiten DJ.
        J Nutr. 2018 Jun 1;148(suppl_1):1001s-1067s.
        This is the fifth in the series of reviews developed as part of the Biomarkers of Nutrition for Development (BOND) program. The BOND Iron Expert Panel (I-EP) reviewed the extant knowledge regarding iron biology, public health implications, and the relative usefulness of currently available biomarkers of iron status from deficiency to overload. Approaches to assessing intake, including bioavailability, are also covered. The report also covers technical and laboratory considerations for the use of available biomarkers of iron status, and concludes with a description of research priorities along with a brief discussion of new biomarkers with potential for use across the spectrum of activities related to the study of iron in human health.The I-EP concluded that current iron biomarkers are reliable for accurately assessing many aspects of iron nutrition. However, a clear distinction is made between the relative strengths of biomarkers to assess hematological consequences of iron deficiency versus other putative functional outcomes, particularly the relationship between maternal and fetal iron status during pregnancy, birth outcomes, and infant cognitive, motor and emotional development. The I-EP also highlighted the importance of considering the confounding effects of inflammation and infection on the interpretation of iron biomarker results, as well as the impact of life stage. Finally, alternative approaches to the evaluation of the risk for nutritional iron overload at the population level are presented, because the currently designated upper limits for the biomarker generally employed (serum ferritin) may not differentiate between true iron overload and the effects of subclinical inflammation.

      2. Re-emergence of thiamine deficiency disease in the Pacific islands (2014-15): A case-control study
        Nilles EJ, Manaia A, Ruaia B, Huppatz C, Ward C, George P, Sies C, Cangiano A, Sejvar J, Reiffer A, Tira T.
        PLoS One. 2018 ;13(6):e0198590.
        BACKGROUND: From late 2014 multiple atolls in Kiribati reported an unusual and sometimes fatal illness. We conducted an investigation to identify the etiology of the outbreak on the most severely affected atoll, Kuria, and identified thiamine deficiency disease as the cause. Thiamine deficiency disease has not been reported in the Pacific islands for >5 decades. We present the epidemiological, clinical, and laboratory findings of the investigation. METHODOLOGY/PRINCIPAL FINDINGS: We initially conducted detailed interviews and examinations on previously identified cases to characterize the unknown illness and develop a case definition. Active and passive surveillance was then conducted to identify additional cases. A questionnaire to identify potential risk factors and blood samples to assay biochemical indices were collected from cases and asymptomatic controls. Thiamine hydrochloride treatment was implemented and the response to treatment was systematically monitored using a five-point visual analogue scale and by assessing resolution of previously abnormal neurological examination findings. Risk factors and biochemical results were assessed by univariate and multivariate analyses. 69 cases were identified on Kuria (7% attack rate) including 34 confirmed and 35 unconfirmed. Most were adults (median age 28 years [range 0-62]) and 83% were male. Seven adult males and two infants died (13% case fatality rate). Resolution of objective clinical signs (78%) or symptoms (94%) were identified within one week of starting treatment. Risk factors included having a friend with thiamine deficiency disease and drinking kava; drinking yeast alcohol reduced the risk of disease. Higher chromium (p<0.001) but not thiamine deficiency (p = 0.66) or other biochemical indices were associated with disease by univariate analyses. Chromium (p<0.001) and thiamine deficiency (p = 0.02) were associated with disease by multivariate analysis. CONCLUSIONS/SIGNIFICANCE: An outbreak of thiamine deficiency disease (beriberi) in Kiribati signals the re-emergence of a classic nutritional disease in the Pacific islands after five decades. Although treatment is safe and effective, the underlying reason for the re-emergence remains unknown. Chromium was highly and positively correlated with disease in this study raising questions about the potential role of factors other than thiamine in the biochemistry and pathophysiology of clinical disease.

      3. [No abstract]

    • Occupational Safety and Health
      1. Sleep quality and the cortisol awakening response (CAR) among law enforcement officers: The moderating role of leisure time physical activity
        Fekedulegn D, Innes K, Andrew ME, Tinney-Zara C, Charles LE, Allison P, Violanti JM, Knox SS.
        Psychoneuroendocrinology. 2018 May 28;95:158-169.
        OBJECTIVE: The goal of this study was to investigate the role of leisure time physical activity (LTPA) on the association between sleep quality and the cortisol awakening response (CAR) in people with an occupation that exposes them to high levels of stress. METHODS: Participants were 275 police officers (age=42 years +/- 8.3, 27% women) enrolled in the Buffalo Cardio-Metabolic Occupational Police Stress (BCOPS) study (conducted between 2004 and 2009). Officers provided four salivary cortisol samples (on awakening and 15, 30, and 45min after awakening). Hours of leisure time physical activity were assessed using the Seven-Day Physical Activity Recall questionnaire. Sleep quality (good/poor) was evaluated using the Pittsburgh Sleep Quality Index (PSQI) scale. Analysis of covariance and repeated measures models were used to examine the association of sleep quality to the two aspects of CAR: cortisol levels (total area under the curve (AUCG), mean, and peak cortisol) and cortisol profiles (the overall pattern in cortisol level during the 45min period following awakening, the increase in cortisol from baseline to average of post awakening values (mean increase), and area under the curve with respect to increase (AUCI)). Analyses were stratified by participant level of reported LTPA (sufficiently vs. insufficiently active, defined as >/= 150 vs.<150min/week of moderate intensity activity, respectively). Since cortisol activity is known to be influenced by gender, we conducted additional analyses also stratified by gender. RESULTS: Overall, results demonstrated that LTPA significantly moderated the association of sleep quality with CAR. Among participants who were sufficiently active, CAR did not differ by sleep quality. However, in those who were insufficiently active during their leisure time, poor sleep quality was associated with a significantly reduced level of total awakening cortisol secretion (AUCG (a.u.)=777.4+/-56 vs. 606.5+/-45, p=0.02; mean cortisol (nmol/l)=16.7+/-1.2 vs. 13.3+/-0.9, p=0.03; peak cortisol (nmol/l)=24.0+/-1.8 vs. 18.9+/-1.5, p=0.03 for good vs. poor sleep quality, respectively). The normal rise in cortisol after awakening was also significantly lower in inactive officers with poor sleep quality than in those with good sleep quality (mean increase (nmol/l)=6.7+/-1.5 vs. 2.3+/-1.2, p=0.03; AUCI (a.u.)=249.3+/-55 vs. 83.3+/-44, p=0.02 for those with good vs. poor sleep quality, respectively). While findings for male officers were consistent with the overall results, CAR did not differ by sleep quality in female officers regardless of LTPA level. CONCLUSION: Findings of this study suggest that poor sleep quality is associated with diminished awakening cortisol levels and dysregulated cortisol patterns over time, but only among officers who were inactive or insufficiently active during their leisure time. In contrast, sleep quality was not associated with any measures of CAR in officers who reported sufficient activity, suggesting a potential protective effect of LTPA. In analyses stratified by gender, findings for male officers were similar to those in the pooled sample, although we found no evidence for a modifying effect of LTPA in women. Future longitudinal studies in a larger population are needed to confirm these findings and further elucidate the relationships between LTPA, sleep quality, and cortisol response.

      2. Use of nanomaterials in animals
        Howard J, Murashov V.
        Applied Biosafety. 2018 .
        Nanotechnology is predicted to be a transformative technology and lead to improvements in many aspects of human life. Accumulating scientific evidence from experimental animal studies indicates that exposure to some engineered nanomaterials may cause adverse health effects. Despite efforts to move away from using animals for toxicity and biological testing, the use of animals in nanomaterial testing raises the potential for harmful occupational exposure to researchers, laboratory technicians, and custodial personnel. The risks to workers from such unintentional exposures can be reduced or eliminated through identification of the hazards arising from the use nanomaterials in animals, assessment of all potential worker exposures, and implementation of effective exposure control measures. Proactive guidelines for safe handling of nanomaterials in laboratories are available from both public and private sector bodies and should be consulted regularly to ensure awareness of the newest, actionable nanomaterial risk prevention information.

      3. Ambulance disinfection using Ultraviolet Germicidal Irradiation (UVGI): Effects of fixture location and surface reflectivity
        Lindsley WG, McClelland TL, Neu DT, Martin SB, Mead KR, Thewlis RE, Noti JD.
        J Occup Environ Hyg. 2018 Jan;15(1):1-12.
        Ambulances are frequently contaminated with infectious microorganisms shed by patients during transport that can be transferred to subsequent patients and emergency medical service workers. Manual decontamination is tedious and time-consuming, and persistent contamination is common even after cleaning. Ultraviolet germicidal irradiation (UVGI) has been proposed as a terminal disinfection method for ambulance patient compartments. However, no published studies have tested the use of UVGI in ambulances. The objectives of this study were to investigate the efficacy of a UVGI system in an ambulance patient compartment and to examine the impact of UVGI fixture position and the UV reflectivity of interior surfaces on the time required for disinfection. A UVGI fixture was placed in the front, middle, or back of an ambulance patient compartment, and the UV irradiance was measured at 49 locations. Aluminum sheets and UV-reflective paint were added to examine the effects of increasing surface reflectivity on disinfection time. Disinfection tests were conducted using Bacillus subtilis spores as a surrogate for pathogens. Our results showed that the UV irradiance varied considerably depending upon the surface location. For example, with the UVGI fixture in the back position and without the addition of UV-reflective surfaces, the most irradiated location received a dose of UVGI sufficient for disinfection in 16 s, but the least irradiated location required 15 hr. Because the overall time required to disinfect all of the interior surfaces is determined by the time required to disinfect the surfaces receiving the lowest irradiation levels, the patient compartment disinfection times for different UVGI configurations ranged from 16.5 hr to 59 min depending upon the UVGI fixture position and the interior surface reflectivity. These results indicate that UVGI systems can reduce microbial surface contamination in ambulance compartments, but the systems must be rigorously validated before deployment. Optimizing the UVGI fixture position and increasing the UV reflectivity of the interior surfaces can substantially improve the performance of a UVGI system and reduce the time required for disinfection.

      4. Factors associated with crewmember survival of commercial fishing vessel sinkings in Alaska
        Lucas DL, Case SL, Lincoln JM, Watson JR.
        Saf Sci. 2018 Jan;101:190-196.
        Occupational fatality surveillance has identified that fishing vessel disasters, such as sinkings and capsizings, continue to contribute to the most deaths among crewmembers in the US fishing industry. When a fishing vessel sinks at sea, crewmembers are at risk of immersion in water and subsequent drowning. This study examined survival factors for crewmembers following cold water immersion after the sinking of decked commercial fishing vessels in Alaskan waters during 2000-2014. Two immersion scenarios were considered separately: immersion for any length of time, and long-term immersion defined as immersion lasting over 30 minutes. Logistic regression was used to predict the odds of crewmember survival. Of the 617 crewmembers onboard 187 fishing vessels that sank in Alaska during 2000-2014, 557 (90.3%) survived and 60 died. For crewmembers immersed for any length of time, the significant adjusted predictors of survival were: entering a life-raft, sinking within three miles of shore, the sinking not being weather-related, and working as a deckhand. For crewmembers immersed for over 30 minutes, the significant adjusted predictors of survival were: wearing an immersion suit, entering a life-raft, working as a deckhand, and the sinking not being weather-related. The results of this analysis demonstrate that in situations where cold water immersion becomes inevitable, having access to well-maintained, serviceable lifesaving equipment and the knowledge and skills to use it properly are critical.

      5. Carpal tunnel syndrome prevalence: an evaluation of workers at a raw poultry processing plant
        Musolin KM, Ramsey JG.
        Int J Occup Environ Health. 2018 Jun 6:1-9.
        OBJECTIVES: Evaluate the prevalence of carpal tunnel syndrome (CTS) among workers at a raw poultry processing plant and categorize jobs on the basis of hand activity and force. METHODS: A cross-sectional survey among 191 workers assessed CTS defined by self-reported CTS symptoms, a hand symptom diagram, and measurements of nerve conduction parameters. We categorized jobs based on American Conference of Governmental Industrial Hygienists’ (ACGIH(R)) limits for hand activity and force, and examined the relationships with CTS occurrence. RESULTS: A total of 64 workers (34%) had CTS after adjusting for non-occupational factors. Overall, 81% of jobs were above the ACGIH action limit; 59% were above the ACGIH threshold limit value(R). CTS prevalence did not differ significantly between exposure groups (PR = 0.82, p = 0.35). CONCLUSIONS: These findings suggest that poultry processing jobs continue to be hazardous with workers at risk for CTS. Recommendations for the study population were provided to reduce exposure and CTS risk among workers.

    • Occupational Safety and Health – Mining
      1. Mineworker fatigue: A review of what we know and future decisions
        Bauerle T, Dugdale Z, Poplin G.
        Min Eng. 2018 Mar;70(3):33.

        [No abstract]

      2. Mineworkers are continually introduced to protective technologies on the job. Yet, their perceptions toward the technologies are often not addressed until they are actively trying to use them, which may halt safe technology adoption and associated work practices. This study explored management and worker perspectives toward three technologies to forecast adoption and behavioral intention on the job. Interviews and focus groups were conducted with 21 mineworkers and 19 mine managers to determine the adoption process stage algorithm for workers and managers, including perceived barriers to using new safety and health technologies. Differences between workers and managers were revealed in terms of readiness, perceptions, and initial trust in using technologies. Workers, whether they had or had not used a particular technology, still had negative perceptions toward its use in the initial introduction and integration at their mine site, indicating a lengthy time period needed for full adoption. The key finding from these results is that a carefully considered and extended introduction of technology for workers in Stage 3 (undecided to act) is most important to promote progression to Stage 5 (decided to act) and to avoid Stage 4 (decided not to act). In response, organizational management may need to account for workers’ particular stage algorithm, using the Precaution Adoption Process Model, to understand how to tailor messages about protective technologies, administer skill-based trainings and interventions that raise awareness and knowledge, and ultimately encourage safe adoption of associated work practices.

    • Parasitic Diseases
      1. Design, implementation, and evaluation of a school insecticide-treated net distribution program in Cross River State, Nigeria
        Acosta A, Obi E, Ato Selby R, Ugot I, Lynch M, Maire M, Belay K, Okechukwu A, Inyang U, Kafuko J, Greer G, Gerberg L, Fotheringham M, Koenker H, Kilian A.
        Glob Health Sci Pract. 2018 Jun 6.
        BACKGROUND: In 2013, the World Health Organization recommended distribution through schools, health facilities, community health workers, and mass campaigns to maintain coverage with insecticide-treated nets (ITNs). We piloted school distribution in 3 local government areas (LGAs) of Cross River State, Nigeria. METHODS: From January to March 2011, all 3 study sites participated in a mass ITN campaign. Baseline data were collected in June 2012 (N=753 households) and school distribution began afterward. One ITN per student was distributed to 4 grades once a year in public schools. Obubra LGA distributed ITNs in 2012, 2013, and 2014 and Ogoja LGA in 2013 and 2014 while Ikom LGA served as a comparison site. Pregnant women in all sites were eligible to receive ITNs through standard antenatal care (ANC). Endline survey data (N=1,450 households) were collected in March 2014. Data on ITN ownership, population access to an ITN, and ITN use were gathered and analyzed. Statistical analysis used contingency tables and chi-squared tests for univariate analysis, and a concentration index was calculated to assess equity in ITN ownership. RESULTS: Between baseline and endline, household ownership of at least 1 ITN increased in the intervention sites, from 50% (95% confidence interval [CI]: 44.7, 54.3) to 76% (95% CI: 71.2, 81.0) in Ogoja and from 51% (95% CI: 35.3, 66.7) to 78% (95% CI: 71.5, 83.1) in Obubra, as did population access to ITN, from 36% (95% CI: 32.0, 39.5) to 53% (95% CI: 48.0, 58.0) in Ogoja and from 34% (95% CI: 23.2, 45.6) to 55% in Obubra (95% CI: 48.4, 60.9). In contrast, ITN ownership declined in the comparison site, from 64% (95% CI: 56.4, 70.8) to 43% (95% CI: 37.4, 49.4), as did population ITN access, from 47% (95% CI: 40.0, 53.7) to 26% (95% CI: 21.9, 29.9). Ownership of school ITNs was nearly as equitable (concentration index 0.06 [95% CI: 0.02, 0.11]) as for campaign ITNs (-0.03 [95% CI: -0.08, 0.02]), and there was no significant oversupply or undersupply among households with ITNs. Schools were the most common source of ITNs at endline and very few households (<2%) had nets from both school and ANC. CONCLUSION: ITN distribution through schools and ANC provide complementary reach and can play an effective role in achieving and maintaining universal coverage. More research is needed to evaluate the cost-effectiveness of such continuous distribution channels in combination with, or as a potential replacement for, subsequent mass campaigns.

      2. Laboratory diagnosis of neurocysticercosis/Taenia solium
        Garcia HH, O’Neal SE, Noh J, Handali S.
        J Clin Microbiol. 2018 Jun 6.
        Neurocysticercosis accounts for approximately 30% of all epilepsy cases in most developing countries. Immunodiagnosis of cysticercosis is complex and strongly influenced by the course of infection, the disease burden and cyst location, and the immune response of the host. The main approach to immunodiagnosis should thus be to evaluate whether the serological results are consistent with the diagnosis suggested by imaging. Antibody detection is performed using lentil-lectin purified parasite antigens in an enzyme-linked immunoelectrotransfer blot format while antigen detection uses a monoclonal antibody-based ELISA. Promising new assay configurations have been developed for detection of both antibody and antigen, including assays based on synthetic or recombinant antigens that may reduce costs and improve assay reproducibility, and multiplex bead based assays that may provide simultaneous quantitative results for several target antigens or antibodies.

      3. Dracunculiasis eradication: Are we there yet?
        Hopkins DR, Ruiz-Tiben E, Eberhard ML, Weiss A, Withers PC, Roy SL, Sienko DG.
        Am J Trop Med Hyg. 2018 Jun 4.
        This report summarizes the status of the global Dracunculiasis Eradication Program as of the end of 2017. Dracunculiasis (guinea worm disease) has been eliminated from 19 of 21 countries where it was endemic in 1986, when an estimated 3.5 million cases occurred worldwide. Only Chad and Ethiopia reported cases in humans, 15 each, in 2017. Infections of animals, mostly domestic dogs, with Dracunculus medinensis were reported in those two countries and also in Mali. Insecurity and infections in animals are the two main obstacles remaining to interrupting dracunculiasis transmission completely.

      4. A case of Prototheca zopfii Genotype 1 infection in a dog (Canis lupus familiaris)
        Silveira CS, Cesar D, Keating MK, DeLeon-Carnes M, Armien AG, Luhers M, Riet-Correa F, Giannitti F.
        Mycopathologia. 2018 Jun 6.
        Protothecosis is a rare disease caused by environmental algae of the genus Prototheca. These are saprophytic, non-photosynthetic, aerobic, colorless algae that belong to the Chlorellaceae family. Seven different species have been described. Prototheca zopfii genotype 2 and P. wickerhamii are most commonly involved in pathogenic infections in humans and animals. The objective of this work is to describe, for the first time, a case of protothecosis caused by P. zopfii genotype 1 in a dog. The dog, a 4-year-old mix bred male, was presented to a veterinary clinic in Montevideo, Uruguay, with multiple skin nodules, one of which was excised by surgical biopsy. The sample was examined histologically and processed by PCR, DNA sequencing, and restriction fragments length polymorphisms for the detection and genotyping of P. zopfii. In addition, transmission electron microscopy and scanning electron microscopy were performed. Histology showed severe ulcerative granulomatous dermatitis and panniculitis with myriads of pleomorphic algae. Algal cells were 4-17 microm in size, with an amphophilic, 2-4-microm-thick wall frequently surrounded by a clear halo, contained flocculant material and a deeply basophilic nucleus, and internal septae with daughter cells (endospores) consistent with endosporulation. Ultrastructurally, algal cells/endospores at different stages of development were found within parasitophorous vacuoles in macrophages. Prototheca zopfii genotype 1 was identified by molecular testing, confirming the etiologic diagnosis of protothecosis.

    • Physical Activity
      1. Supporting active living through community plans: The association of planning documents with design standards and features
        Peterson EL, Carlson SA, Schmid TL, Brown DR, Galuska DA.
        Am J Health Promot. 2018 Jan 1:890117118779011.
        PURPOSE: The purpose of this study was to examine the association between the presence of supportive community planning documents in US municipalities with design standards and requirements supportive of active living. DESIGN: Cross-sectional study using data from the 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living. SETTING: Nationally representative sample of US municipalities. PARTICIPANTS: Respondents are 2005 local officials. MEASURES: Assessed: (1) The presence of design standards and feature requirements and (2) the association between planning documents and design standards and feature requirements supportive of active living in policies for development. ANALYSIS: Using logistic regression, significant trends were identified in the presence of design standards and feature requirements by plan and number of supportive objectives present. RESULTS: Prevalence of design standards ranged from 19% (developer dedicated right-of-way for bicycle infrastructure development) to 50% (traffic-calming features in areas with high pedestrian and bicycle volume). Features required in policies for development ranged from 14% (short/medium pedestrian-scale block sizes) to 44% (minimum sidewalk widths of 5 feet) of municipalities. As the number of objectives in municipal plans increased, there was a significant and positive trend ( P < .05) in the prevalence of each design standard and requirement. CONCLUSIONS: Municipal planning documents containing objectives supportive of physical activity are associated with design standards and feature requirements supportive of activity-friendly communities.

    • Reproductive Health
      1. Contraceptive use at last intercourse among reproductive-aged women with disabilities: an analysis of population-based data from seven states
        Haynes RM, Boulet SL, Fox MH, Carroll DD, Courtney-Long E, Warner L.
        Contraception. 2018 Jun;97(6):538-545.
        OBJECTIVE: To assess patterns of contraceptive use at last intercourse among women with physical or cognitive disabilities compared to women without disabilities. STUDY DESIGN: We analyzed responses to 12 reproductive health questions added by seven states to their 2013 Behavioral Risk Factor Surveillance System questionnaire. Using responses from female respondents 18-50 years of age, we performed multinomial regression to calculate estimates of contraceptive use among women at risk for unintended pregnancy by disability status and type, adjusted for age, race/ethnicity, marital status, education, health insurance status, and parity. RESULTS: Women with disabilities had similar rates of sexual activity as women without disabilities (90.0% vs. 90.6%, p=.76). Of 5995 reproductive-aged women at risk for unintended pregnancy, 1025 (17.1%) reported one or more disabilities. Contraceptive use at last intercourse was reported by 744 (70.1%) of women with disabilities compared with 3805 (74.3%) of those without disabilities (p=.22). Among women using contraception, women with disabilities used male or female permanent contraception more often than women without disabilities (333 [29.6%] versus 1337 [23.1%], p<.05). Moderately effective contraceptive (injection, oral contraceptive, patch, or ring) use occurred less frequently among women with cognitive (13.1%, n=89) or independent living (13.9%, n=40) disabilities compared to women without disabilities (22.2%, n=946, p<.05). CONCLUSIONS: The overall prevalence of sexual activity and contraceptive use was similar for women with and without physical or cognitive disabilities. Method use at last intercourse varied based on presence and type of disability, especially for use of permanent contraception. IMPLICATIONS: Although women with disabilities were sexually active and used contraception at similar rates as women without disabilities, contraception use varied by disability type, suggesting the importance of this factor in reproductive health decision-making among patients and providers, and the value of further research to identify reasons why this occurs.

    • Substance Use and Abuse
      1. Rules to prohibit the use of electronic vapor products inside homes and personal vehicles among adults in the U.S., 2017
        Gentzke AS, Homa DM, Kenemer JB, Gomez Y, King BA.
        Prev Med. 2018 May 30;114:47-53.
        Most U.S. adults have voluntary rules prohibiting the use of smoked tobacco products in their homes and vehicles. However, the prevalence of similar rules for electronic vapor products (EVPs) is uncertain. This study assessed the prevalence and correlates of rules prohibiting EVP use inside homes and vehicles. Data from a 2017 Internet-based panel survey of U.S. adults aged >/=18years (n=4107) were analyzed. For homes and vehicles, prevalence of reporting that EVP use was not allowed, partially allowed, fully allowed, or unknown was assessed overall and by covariates. Correlates of prohibiting EVP use was assessed by multivariable logistic regression. In homes, 58.6% of adults did not allow EVP use, 7.7% partially allowed use, 10.1% fully allowed use, and 23.6% were unsure of the rules. In vehicles, 63.8% of respondents did not allow EVP use, 6.0% partially allowed use, 8.9% fully allowed use, and 21.4% were unsure of the rules. Following multivariable adjustment, prohibiting EVP use inside homes and vehicles was more likely among respondents with higher income and education, and with a child aged <18years. Users of EVPs and other tobacco products, and respondents living with users of EVPs and other tobacco products, were less likely to prohibit EVP use in these locations. These findings show that about 6 in 10U.S. adults have rules prohibiting EVP use inside homes and vehicles, but variations exist by population subgroups. Voluntary smoke-free rules in homes and vehicles that include EVPs can help protect children and non-users from secondhand EVP aerosol exposure.

      2. BACKGROUND: Internalized homonegativity may promote substance use among U.S. men who have sex with men only (MSMO) and men who have sex with men and women (MSMW). However, studies have produced mixed findings, used non-representative samples, and not adequately examined MSMW. OBJECTIVES: We investigated (1) internalized homonegativity in relation to substance use and (2) the extent of temporal change in internalized homonegativity among MSMO and MSMW. METHODS: Using merged 2002, 2006-2010, and 2011-2013 cycles of the National Survey of Family Growth-a nationally representative U.S. sample of persons aged 15-44 years-we acquired subsamples of MSMO (n = 419) and MSMW (n = 195). Rao-Scott chi-square tests examined internalized homonegativity in relation to past-month binge drinking and use of marijuana. These tests examined past-year use of any illicit substance, cocaine, crack, injection drugs, and methamphetamine. Multivariable logistic regression models controlled for covariates. Rao-Scott chi-square tests examined temporal changes in internalized homonegativity. RESULTS: Among MSMO, internalized homonegativity was associated with increased odds of using any illicit substance, cocaine, and methamphetamine. Among MSMW, however, internalized homonegativity was associated with decreased odds of using any illicit substance, cocaine, crack, injection drugs, and methamphetamine. The proportion of MSMO and MSMW who expressed internalized homonegativity did not significantly change during 2002-2013. Conclusions/Importance: Internalized homonegativity may be positively associated with substance use among MSMO, but negatively associated with substance use among MSMW. Future studies should seek to better understand internalized homonegativity and other determinants of substance use among MSMO and MSMW.

      3. Trends in sales of flavored and menthol tobacco products in the United States during 2011-2015
        Kuiper NM, Gammon D, Loomis B, Falvey K, Wang TW, King BA, Rogers T.
        Nicotine Tob Res. 2018 May 3;20(6):698-706.
        Introduction: Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels. Methods: Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change. Results: Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland). Conclusions: Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption. Implications: Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

      4. Systemic absorption of nicotine following acute secondhand exposure to electronic cigarette aerosol in a realistic social setting
        Melstrom P, Sosnoff C, Koszowski B, King BA, Bunnell R, Le G, Wang L, Thanner MH, Kenemer B, Cox S, DeCastro BR, McAfee T.
        Int J Hyg Environ Health. 2018 Jun;221(5):816-822.
        Evidence suggests exposure of nicotine-containing e-cigarette aerosol to nonusers leads to systemic absorption of nicotine. However, no studies have examined acute secondhand exposures that occur in public settings. Here, we measured the serum, saliva and urine of nonusers pre- and post-exposure to nicotine via e-cigarette aerosol. Secondarily, we recorded factors affecting the exposure. Six nonusers of nicotine-containing products were exposed to secondhand aerosol from ad libitum e-cigarette use by three e-cigarette users for 2h during two separate sessions (disposables, tank-style). Pre-exposure (baseline) and post-exposure peak levels (Cmax) of cotinine were measured in nonusers’ serum, saliva, and urine over a 6-hour follow-up, plus a saliva sample the following morning. We also measured solution consumption, nicotine concentration, and pH, along with use behavior. Baseline cotinine levels were higher than typical for the US population (median serum session one=0.089ng/ml; session two=0.052ng/ml). Systemic absorption of nicotine occurred in nonusers with baselines indicative of no/low tobacco exposure, but not in nonusers with elevated baselines. Median changes in cotinine for disposable exposure were 0.007ng/ml serum, 0.033ng/ml saliva, and 0.316ng/mg creatinine in urine. For tank-style exposure they were 0.041ng/ml serum, 0.060ng/ml saliva, and 0.948ng/mg creatinine in urine. Finally, we measured substantial differences in solution nicotine concentrations, pH, use behavior and consumption. Our data show that although exposures may vary considerably, nonusers can systemically absorb nicotine following acute exposure to secondhand e-cigarette aerosol. This can particularly affect sensitive subpopulations, such as children and women of reproductive age.

      5. Impact of the Tips From Former Smokers Campaign on population-level smoking cessation, 2012-2015
        Murphy-Hoefer R, Davis KC, Beistle D, King BA, Duke J, Rodes R, Graffunder C.
        Prev Chronic Dis. 2018 May 31;15:E71.
        This study provides estimates of the long-term cumulative impact of the Centers for Disease Control and Prevention’s national tobacco education campaign, Tips From Former Smokers (Tips), on population-level smoking cessation. We used recently published estimates of the association between increased Tips campaign media doses and quit attempts to calculate campaign-attributable population sustained (6-month) quits during 2012-2015. Tips led to approximately 522,000 sustained quits during 2012-2015. These findings indicate that the Tips campaign’s comprehensive approach to combining evidence-based messages with the promotion of cessation resources was successful in achieving substantial long-term cigarette cessation at the population level over multiple years.

      6. Tobacco product use among middle and high school students – United States, 2011-2017
        Wang TW, Gentzke A, Sharapova S, Cullen KA, Ambrose BK, Jamal A.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):629-633.
        Tobacco use is the leading cause of preventable disease and death in the United States, and nearly all tobacco use begins during youth and young adulthood (1,2). CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2017 National Youth Tobacco Surveys (NYTS)* to determine patterns of current (past 30-day) use of seven tobacco product types among U.S. middle school (grades 6-8) and high school (grades 9-12) students and estimate use nationwide. Among high school students, current use of any tobacco product decreased from 24.2% (estimated 3.69 million users) in 2011 to 19.6% (2.95 million) in 2017. Among middle school students, current use of any tobacco product decreased from 7.5% (0.87 million) in 2011 to 5.6% (0.67 million) in 2017. In 2017, electronic cigarettes (e-cigarettes) were the most commonly used tobacco product among high (11.7%; 1.73 million) and middle (3.3%; 0.39 million) school students. During 2016-2017, decreases in current use of hookah and pipe tobacco occurred among high school students, while decreases in current use of any tobacco product, e-cigarettes, and hookah occurred among middle school students. Current use of any combustible tobacco product, >/=2 tobacco products, cigarettes, cigars, smokeless tobacco, and bidis did not change among middle or high school students during 2016-2017. Comprehensive and sustained strategies can help prevent and reduce the use of all forms of tobacco products among U.S. youths (1,2).

    • Zoonotic and Vectorborne Diseases
      1. Incidence of human brucellosis in the Kilimanjaro Region of Tanzania in the periods 2007-2008 and 2012-2014
        Carugati M, Biggs HM, Maze MJ, Stoddard RA, Cash-Goldwasser S, Hertz JT, Halliday JE, Saganda W, Lwezaula BF, Kazwala RR, Cleaveland S, Maro VP, Rubach MP, Crump JA.
        Trans R Soc Trop Med Hyg. 2018 Mar 1;112(3):136-143.
        Background: Brucellosis causes substantial morbidity among humans and their livestock. There are few robust estimates of the incidence of brucellosis in sub-Saharan Africa. Using cases identified through sentinel hospital surveillance and health care utilization data, we estimated the incidence of brucellosis in Moshi Urban and Moshi Rural Districts, Kilimanjaro Region, Tanzania, for the periods 2007-2008 and 2012-2014. Methods: Cases were identified among febrile patients at two sentinel hospitals and were defined as having either a 4-fold increase in Brucella microscopic agglutination test titres between acute and convalescent serum or a blood culture positive for Brucella spp. Findings from a health care utilization survey were used to estimate multipliers to account for cases not seen at sentinel hospitals. Results: Of 585 patients enrolled in the period 2007-2008, 13 (2.2%) had brucellosis. Among 1095 patients enrolled in the period 2012-2014, 32 (2.9%) had brucellosis. We estimated an incidence (range based on sensitivity analysis) of brucellosis of 35 (range 32-93) cases per 100 000 persons annually in the period 2007-2008 and 33 (range 30-89) cases per 100 000 persons annually in the period 2012-2014. Conclusions: We found a moderate incidence of brucellosis in northern Tanzania, suggesting that the disease is endemic and an important human health problem in this area.

      2. Notes from the Field: Crimean-Congo hemorrhagic fever outbreak – Central Uganda, August-September 2017
        Kizito S, Okello PE, Kwesiga B, Nyakarahuka L, Balinandi S, Mulei S, Kyondo J, Tumusiime A, Lutwama J, Ario AR, Ojwang J, Zhu BP.
        MMWR Morb Mortal Wkly Rep. 2018 Jun 8;67(22):646-647.

        [No abstract]

      3. Risk factors for human acute leptospirosis in northern Tanzania
        Maze MJ, Cash-Goldwasser S, Rubach MP, Biggs HM, Galloway RL, Sharples KJ, Allan KJ, Halliday JE, Cleaveland S, Shand MC, Muiruri C, Kazwala RR, Saganda W, Lwezaula BF, Mmbaga BT, Maro VP, Crump JA.
        PLoS Negl Trop Dis. 2018 Jun;12(6):e0006372.
        INTRODUCTION: Leptospirosis is a major cause of febrile illness in Africa but little is known about risk factors for human infection. We conducted a cross-sectional study to investigate risk factors for acute leptospirosis and Leptospira seropositivity among patients with fever attending referral hospitals in northern Tanzania. METHODS: We enrolled patients with fever from two referral hospitals in Moshi, Tanzania, 2012-2014, and performed Leptospira microscopic agglutination testing on acute and convalescent serum. Cases of acute leptospirosis were participants with a four-fold rise in antibody titers, or a single reciprocal titer >/=800. Seropositive participants required a single titer >/=100, and controls had titers <100 in both acute and convalescent samples. We administered a questionnaire to assess risk behaviors over the preceding 30 days. We created cumulative scales of exposure to livestock urine, rodents, and surface water, and calculated odds ratios (OR) for individual behaviors and for cumulative exposure variables. RESULTS: We identified 24 acute cases, 252 seropositive participants, and 592 controls. Rice farming (OR 14.6), cleaning cattle waste (OR 4.3), feeding cattle (OR 3.9), farm work (OR 3.3), and an increasing cattle urine exposure score (OR 1.2 per point) were associated with acute leptospirosis. CONCLUSIONS: In our population, exposure to cattle and rice farming were risk factors for acute leptospirosis. Although further data is needed, these results suggest that cattle may be an important source of human leptospirosis. Further investigation is needed to explore the potential for control of livestock Leptospira infection to reduce human disease.

      4. Few studies have been able to provide experimental evidence of the ability of fleas to maintain rodent-associated Bartonella infections and excrete these bacteria. These data are important for understanding the transmission cycles and prevalence of these bacteria in hosts and vectors. We used an artificial feeding approach to expose groups of the oriental rat flea (Xenopsylla cheopis Rothschild; Siphonaptera, Pulicidae) to rat blood inoculated with varying concentrations of Bartonella elizabethae Daly (Bartonellaceae: Rhizobiales). Flea populations were maintained by membrane feeding on pathogen-free bloodmeals for up to 13 d post infection. Individual fleas and pools of flea feces were tested for the presence of Bartonella DNA using molecular methods (quantitative and conventional polymerase chain reaction [PCR]). The threshold number of Bartonellae required in the infectious bloodmeal for fleas to be detected as positive was 106 colony-forming units per milliliter (CFU/ml). Individual fleas were capable of harboring infections for at least 13 d post infection and continuously excreted Bartonella DNA in their feces over the same period. This experiment demonstrated that X. cheopis are capable of acquiring and excreting B. elizabethae over several days. These results will guide future work to model and understand the role of X. cheopis in the natural transmission cycle of rodent-borne Bartonella species. Future experiments using this artificial feeding approach will be useful for examining the horizontal transmission of B. elizabethae or other rodent-associated Bartonella species to naive hosts and for determining the viability of excreted bacteria.

      5. Arboviral surveillance among pediatric patients with acute febrile illness in Houston, Texas
        Sahni LC, Fischer RS, Gorchakov R, Berry RM, Payne DC, Murray KO, Boom JA.
        Am J Trop Med Hyg. 2018 Jun 4.
        We instituted active surveillance among febrile patients presenting to the largest Houston-area pediatric emergency department to identify acute infections of dengue virus (DENV), West Nile virus (WNV), and chikungunya virus (CHIKV). In 2014, 1,063 children were enrolled, and 1,015 (95%) had blood and/or cerebrospinal fluid specimens available for DENV, WNV, and CHIKV testing. Almost half (49%) reported recent mosquito bites, and 6% (N = 60) reported either recent international travel or contact with an international traveler. None were positive for acute WNV; three had false-positive CHIKV results; and two had evidence of DENV. One DENV-positive case was an acute infection associated with international travel, whereas the other was identified as a potential secondary acute infection, also likely travel-associated. Neither of the DENV-positive cases were clinically recognized, highlighting the need for education and awareness. Health-care professionals should consider the possibility of arboviral disease among children who have traveled to or from endemic areas.

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