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Issue 30, July 26, 2022

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CDC Science Clips: Volume 14, Issue 30, July 26, 2022

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

The report consists of these components:

  1. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Antimicrobial Resistance and Antibiotic Stewardship
      1. Are vancomycin non-susceptible clostridioides difficile strains emerging?
        Lutgring JD, McKay SL, Gargis AS, Halpin AL, McDonald LC.
        Clin Infect Dis. 2022 Jul 12.


    • Chronic Diseases and Conditions
      1. Prevalence of bipolar disorder in perinatal women: A systematic review and meta-analysis
        Masters GA, Hugunin J, Xu L, Ulbricht CM, Moore Simas TA, Ko JY, Byatt N.
        J Clin Psychiatry. 2022 Jul 13;83(5).
        Objective: To estimate overall prevalence of bipolar disorder (BD) and the prevalence and timing of bipolar-spectrum mood episodes in perinatal women. Data Sources: Databases (PubMed, Scopus, PsycINFO, CINAHL, Cochrane, ClincalTrials.gov) were searched from inception to March 2020. Study Selection: Included studies were original research in English that had (1) populations of perinatal participants (pregnant or within 12 months postpartum), aged ≥ 18 years, and (2) a screening/diagnostic tool for BD. Search terms described the population (eg, perinatal), illness (eg, bipolar disorder), and detection (eg, screen, identify). Data Extraction: Study design data, rates, and timing of positive screens/diagnoses and mood episodes were extracted by 3 independent reviewers. Pooled prevalences were estimated using random-effects meta-analyses. Results: Twenty-two articles were included in qualitative review and 12 in the meta-analysis. In women with no known psychiatric illness preceding the perinatal period, pooled prevalence of BD was 2.6% (95% CI, 1.2%-4.5%) and prevalence of bipolar-spectrum mood episodes (including depressed, hypomanic/manic, mixed) during pregnancy and the postpartum period was 20.1% (95% CI, 16.0%-24.5%). In women with a prior BD diagnosis, 54.9% (95% CI, 39.2%-70.2%) were found to have at least one bipolar-spectrum mood episode occurrence in the perinatal period. Conclusions: Our review suggests that the perinatal period is associated with high rates of bipolar-spectrum mood episodes and that pregnant and postpartum women represent a special risk population. This review may help to inform clinical care recommendations, thus helping to identify those who may have.

      2. OBJECTIVE: The aim of this study was to measure hypertension prevalence, awareness, treatment and control by depressive symptoms among USA adults. METHOD: Using the National Health and Nutrition Examination Survey data from 2007 to 2018 (n = 28 532), depressive symptoms were categorized as 'none or minimum', 'mild', 'moderate' and 'moderately severe or severe' by the Patient Health Questionnaire. Hypertension was assessed by history, blood pressure measures and antihypertensive medication use. Adjusted prevalence rates and adjusted prevalence ratios (APRs) of hypertension prevalence, awareness, treatment and control were measured. RESULTS: By depressive, the adjusted prevalence of hypertension (32.0, 34.2, 37.3 and 36.6%), awareness (80.6, 83.9, 85.7 and 89.8%) and treatment (73.1, 75.2, 78.6 and 83.9%) increased with advanced depressive symptoms, respectively (all P < 0.001). However, no difference in hypertension control was noted after full adjustment. Compared with those with no or minimum depressive symptoms, APRs of hypertension prevalence for mild, moderate and moderately severe or severe depressive symptom were 1.07 (1.02-1.12), 1.16 (1.107-1.262) and 1.15 (1.05-1.26), respectively. The corresponding APRs were 1.04 (1.003-1.08), 1.06 (1.01-1.11) and 1.11 (1.06-1.17) for hypertension awareness, and 1.03 (0.98-1.07), 1.08 (1.02-1.14) and 1.15 (1.08-1.22) for hypertension treatment, respectively. CONCLUSION: Among USA adults, depressive symptoms were significantly associated with hypertension prevalence, awareness and treatment, but not with hypertension control. When managing hypertension, healthcare providers should be aware of the mental health status.

      3. Cancer-associated venous thromboembolism: Incidence and features in a racially diverse population
        Raskob GE, Wendelboe AM, Campbell J, Ford L, Ding K, Bratzler DW, McCumber M, Adamski A, Abe K, Beckman MG, Reyes NL, Richardson LC.
        J Thromb Haemost. 2022 Jul 13.
        BACKGROUND: Data on the population-based incidence of cancer-associated venous thromboembolism (VTE) from racially diverse populations are limited. OBJECTIVE: To evaluate the incidence and burden of cancer-associated VTE, including demographic and racial subgroups in the general population of Oklahoma County-which closely mirrors the United States. DESIGN: Population-based prospective study. SETTING: We conducted surveillance of VTE at tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma from 2012-2014. Surveillance included reviewing all imaging reports used to diagnose VTE and identifying VTE events from hospital discharge data and death certificates. Cancer status was determined by linkage to the Oklahoma Central Cancer Registry. MEASUREMENTS: We used Poisson regression to calculate crude and age-adjusted incidences of cancer-associated VTE per 100,000 general population per year, with 95% confidence intervals (95% CI). RESULTS: The age-adjusted incidence (95% CI) of cancer-associated VTE among adults age ≥ 18 was 70.0 (65.1-75.3). The age-adjusted incidence rates (95% CI) were 85.9 (72.7-101.6) for non-Hispanic Black persons, 79.5 (13.2-86.5) for non-Hispanic White persons, 18.8 (8.9-39.4) for Native American persons, 15.6 (7.0-34.8) for Asian/Pacific Islander persons, and 15.2 (9.2-25.1) for Hispanic persons. Recurrent VTE up to 2 years after the initial diagnosis occurred in 38 of 304 patients (12.5%) with active cancer and in 34 of 424 patients (8.0%) with a history of cancer > 6 months previously. CONCLUSION: Age-adjusted incidence rates of cancer-associated VTE vary substantially by race and ethnicity. The relatively high incidences of first VTE and of recurrence warrant further assessment of strategies to prevent VTE among cancer patients.

      4. County-level variation in the prevalence of visual acuity loss or blindness in the US
        Lundeen EA, Flaxman AD, Wittenborn JS, Burke-Conte Z, Gulia R, Saaddine J, Rein DB.
        JAMA Ophthalmol. 2022 Jul 7.

      5. Prevalence and characteristics of CKD in the US Military Health System: A retrospective cohort study
        Oliver JD, Nee R, Grunwald LR, Banaag A, Pavkov ME, Burrows NR, Koehlmoos TP, Marks ES.
        Kidney Med. 2022 Jul;4(7):100487.
        RATIONALE & OBJECTIVE: The US Military Health System (MHS) is a global health care network with a diverse population that is more representative of the US population than other study cohorts and with fewer disparities in health care access. We aimed to examine the prevalence of chronic kidney disease (CKD) in the MHS and within demographic subpopulations. STUDY DESIGN: Multiple cross-sectional analyses of demographic and claims-based data extracted from the MHS Data Repository, 1 for each fiscal year from 2006-2015. SETTING & POPULATION: Multicenter health care network including active-duty military, retirees, and dependents. The average yearly sample size was 3,285,348 individuals. EXPOSURES: Age, sex, race, active-duty status, and active-duty rank (a surrogate for socioeconomic status). OUTCOME: CKD, defined as the presence of matching International Classification of Diseases, Ninth Revision, codes on either 1 or more inpatient or 2 or more outpatient encounters. ANALYTICAL APPROACH: t test for continuous variables and χ(2) test for categorical variables; multivariable logistic regression for odds ratios. RESULTS: For 2015, the mean (standard deviation) age was 38 (16). Crude CKD prevalence was 2.9%. Age-adjusted prevalence was 4.9% overall-1.9% active-duty and 5.4% non-active-duty individuals. ORs for CKD were calculated with multiple imputations to account for missing data on race. After adjustment, the ORs for CKD (all P < 0.001) were 1.63 (95% CI, 1.62-1.64) for an age greater than 40 years, 1.16 (95% CI, 1.15-1.17) for Black race, 1.15 (95% CI, 1.14-1.16) for senior enlisted rank, 0.94 (95% CI, 0.93-0.95) for women, and 0.50 (95% CI, 0.49-0.51) for active-duty status. LIMITATIONS: Retrospective study based on International Classification of Diseases, Ninth Revision, coding. CONCLUSIONS: Within the MHS, older age, Black race, and senior enlisted rank were associated with a higher risk of CKD, whereas female sex and active-duty status were associated with a lower risk.

      6. Weight gain among U.S. Adults during the COVID-19 pandemic through May 2021
        Freedman DS, Kompaniyets L, Daymont C, Zhao L, Blanck HM.
        Obesity (Silver Spring). 2022 Jul 13.
        OBJECTIVE: There have been conflicting reports concerning weight gain among adults during the COVID-19 epidemic. Although early studies reported large weight increases, several of these analyses were based on convenience samples or self-reported information. The objective of the current study is to examine the pandemic-related weight increase associated with the pandemic through May 2021. METHODS: We selected 4.25 million adults (18 to 84 y) in an electronic health record database who had at least two weight measurements between January 2019 and February 2020 and one after June 2020. We contrasted weight changes before and after March 2020 using mixed-effects regression models. RESULTS: Compared with pre-pandemic weight trend, there was a small increase (0.1 kg) in weight in the first year of the pandemic (March 2020 through March 2021). Weight changes during the pandemic varied by sex, age, and initial BMI, but the largest mean increase across these characteristics was < 1.3 kg. Weight increases were generally greatest among women, adults with a BMI of 30 or 35 kg/m(2) , and younger adults. CONCLUSION: Our results indicate that the mean weight gain among adults during the COVID-19 pandemic may be small. This article is protected by copyright. All rights reserved.

    • Communicable Diseases
      1. Tuberculosis outbreaks in state prisons, United States, 2011-2019
        Stewart RJ, Raz KM, Burns SP, Kammerer JS, Haddad MB, Silk BJ, Wortham JM.
        Am J Public Health. 2022 Aug;112(8):1170-1179.
        Objectives. To understand the frequency, magnitude, geography, and characteristics of tuberculosis outbreaks in US state prisons. Methods. Using data from the National Tuberculosis Surveillance System, we identified all cases of tuberculosis during 2011 to 2019 that were reported as occurring among individuals incarcerated in a state prison at the time of diagnosis. We used whole-genome sequencing to define 3 or more cases within 2 single nucleotide polymorphisms within 3 years as clustered; we classified clusters with 6 or more cases during a 3-year period as tuberculosis outbreaks. Results. During 2011 to 2019, 566 tuberculosis cases occurred in 41 state prison systems (a median of 3 cases per state). A total of 19 tuberculosis genotype clusters comprising 134 cases were identified in 6 state prison systems; these clusters included a subset of 5 outbreaks in 2 states. Two Alabama outbreaks during 2011 to 2017 totaled 20 cases; 3 Texas outbreaks during 2014 to 2019 totaled 51 cases. Conclusions. Only Alabama and Texas reported outbreaks during the 9-year period; only Texas state prisons had ongoing transmission in 2019. Effective interventions are needed to stop tuberculosis outbreaks in Texas state prisons. (Am J Public Health. 2022;112(8):1170-1179. https://doi.org/10.2105/AJPH.2022.306864).

      2. Incidence and clinical characteristics of and risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among pregnant individuals in the United States
        Dawood FS, Varner M, Tita A, Newes-Adeyi G, Gyamfi-Bannerman C, Battarbee A, Bruno A, Daugherty M, Reichle L, Vorwaller K, Vargas C, Parks M, Powers E, Lucca-Susana M, Gibson M, Subramaniam A, Cheng YJ, Feng PJ, Ellington S, Galang RR, Meece J, Flygare C, Stockwell MS.
        Clin Infect Dis. 2022 Jul 6;74(12):2218-2226.
        BACKGROUND: Data about the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among pregnant individuals are needed to inform infection-prevention guidance and counseling for this population. METHODS: We prospectively followed a cohort of pregnant individuals during August 2020-March 2021 at 3 US sites. The 3 primary outcomes were incidence rates of any SARS-CoV-2 infection, symptomatic infection, and asymptomatic infection, during pregnancy during periods of SARS-CoV-2 circulation. Participants self-collected weekly midturbinate nasal swabs for SARS-CoV-2 reverse transcription-polymerase chain reaction testing, completed weekly illness symptom questionnaires, and submitted additional swabs with coronavirus disease 2019 (COVID-19)-like symptoms. An overall SARS-CoV-2 infection incidence rate weighted by population counts of women of reproductive age in each state was calculated. RESULTS: Among 1098 pregnant individuals followed for a mean of 10 weeks, 9% (99/1098) had SARS-CoV-2 infections during the study. Population-weighted incidence rates of SARS-CoV-2 infection were 10.0 per 1000 (95% confidence interval, 5.7-14.3) person-weeks for any infection, 5.7 per 1000 (1.7-9.7) for symptomatic infections, and 3.5 per 1000 (0-7.1) for asymptomatic infections. Among 96 participants with SARS-CoV-2 infections and symptom data, the most common symptoms were nasal congestion (72%), cough (64%), headache (59%), and change in taste or smell (54%); 28% had measured or subjective fever. Median symptom duration was 10 (interquartile range, 6-16) days. CONCLUSIONS: Pregnant individuals in this study had a 1% risk of SARS-CoV-2 infection per week, underscoring the importance of COVID-19 vaccination and other prevention measures during pregnancy while SARS-CoV-2 is circulating in the community.

      3. Tuberculosis among native Hawaiian and other Pacific Islander persons: United States and U.S.-affiliated Pacific Islands, 2010-2019
        Deutsch-Feldman M, Springer YP, Felix D, Tsang CA, Brostrom R, Haddad M.
        Health Equity. 2022 ;6(1):476-484.
        BACKGROUND: In recent years, tuberculosis (TB) incidence in the United States has declined overall but remained high among Native Hawaiian and Other Pacific Islander (NH/PI) persons. Few studies have examined the epidemiology of TB among NH/PI persons, particularly in the U.S.-Affiliated Pacific Islands (USAPI). We describe TB incidence and characteristics of NH/PI patients during 2010-2019. METHODS: We used data from the National Tuberculosis Surveillance System to characterize TB cases reported among NH/PI persons born in the 50 U.S. states (defined to include District of Columbia) and the USAPI. We calculated annual TB incidence among NH/PI patients, stratified by place of birth (U.S. states or USAPI). Using Asian persons born outside the United States-persons historically grouped with NH/PI persons as one racial category-as the reference, we compared demographic, clinical, and socio-behavioral characteristics of NH/PI TB patients. RESULTS: During 2010-2019, 4359 TB cases were reported among NH/PI patients born in the U.S. states (n=205) or the USAPI (n=4154). Median annual incidence per 100,000 persons was 6.5 cases (persons born in the U.S. states) and 150.7 cases (persons born in the USAPI). The proportion of TB patients aged <15 years was higher among NH/PI persons (U.S. states: 54%, USAPI: 24%) than among Asian persons born outside the United States (1%). CONCLUSIONS: TB incidence among NH/PI persons is high, particularly among persons born in the USAPI, emphasizing the need to enhance TB prevention strategies in these communities. Interventions should be tailored toward those who experience the highest risk, including NH/PI children and adolescents.

      4. Addressing personal protective equipment (PPE) decontamination: Methylene blue and light inactivates severe acute respiratory coronavirus virus 2 (SARS-CoV-2) on N95 respirators and medical masks with maintenance of integrity and fit
        Lendvay TS, Chen J, Harcourt BH, Scholte FE, Lin YL, Kilinc-Balci FS, Lamb MM, Homdayjanakul K, Cui Y, Price A, Heyne B, Sahni J, Kabra KB, Lin YC, Evans D, Mores CN, Page K, Chu LF, Haubruge E, Thiry E, Ludwig-Begall LF, Wielick C, Clark T, Wagner T, Timm E, Gallagher T, Faris P, Macia N, Mackie CJ, Simmons SM, Reader S, Malott R, Hope K, Davies JM, Tritsch SR, Dams L, Nauwynck H, Willaert JF, De Jaeger S, Liao L, Zhao M, Laperre J, Jolois O, Smit SJ, Patel AN, Mayo M, Parker R, Molloy-Simard V, Lemyre JL, Chu S, Conly JM, Chu MC.
        Infect Control Hosp Epidemiol. 2022 Jul;43(7):876-885.
        OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has resulted in shortages of personal protective equipment (PPE), underscoring the urgent need for simple, efficient, and inexpensive methods to decontaminate masks and respirators exposed to severe acute respiratory coronavirus virus 2 (SARS-CoV-2). We hypothesized that methylene blue (MB) photochemical treatment, which has various clinical applications, could decontaminate PPE contaminated with coronavirus. DESIGN: The 2 arms of the study included (1) PPE inoculation with coronaviruses followed by MB with light (MBL) decontamination treatment and (2) PPE treatment with MBL for 5 cycles of decontamination to determine maintenance of PPE performance. METHODS: MBL treatment was used to inactivate coronaviruses on 3 N95 filtering facepiece respirator (FFR) and 2 medical mask models. We inoculated FFR and medical mask materials with 3 coronaviruses, including SARS-CoV-2, and we treated them with 10 µM MB and exposed them to 50,000 lux of white light or 12,500 lux of red light for 30 minutes. In parallel, integrity was assessed after 5 cycles of decontamination using multiple US and international test methods, and the process was compared with the FDA-authorized vaporized hydrogen peroxide plus ozone (VHP+O(3)) decontamination method. RESULTS: Overall, MBL robustly and consistently inactivated all 3 coronaviruses with 99.8% to >99.9% virus inactivation across all FFRs and medical masks tested. FFR and medical mask integrity was maintained after 5 cycles of MBL treatment, whereas 1 FFR model failed after 5 cycles of VHP+O(3). CONCLUSIONS: MBL treatment decontaminated respirators and masks by inactivating 3 tested coronaviruses without compromising integrity through 5 cycles of decontamination. MBL decontamination is effective, is low cost, and does not require specialized equipment, making it applicable in low- to high-resource settings.

      5. Coccidioidomycosis is a fungal infection caused by Coccidioides immitis and Coccidioides posadasii. The dimorphic fungi live in the soils of arid and semi‐arid regions of the western United States, as well as parts of Mexico, Central America, and South America. Incidence of disease has risen consistently in recent years, and the geographic distribution of Coccidioides spp. appears to be expanding beyond previously known areas of endemicity. Climate factors are predicted to further extend the range of environments suitable for the growth and dispersal of Coccidioides species. Most infections are asymptomatic, though a small proportion result in severe or life‐threatening forms of disease. Primary pulmonary coccidioidomycosis is commonly mistaken for community‐acquired pneumonia, often leading to inappropriate antibacterial treatment and unnecessary healthcare costs. Diagnosis of coccidioidomycosis is challenging and often relies on clinician suspicion to pur-sue laboratory testing. Advancements in diagnostic tools and antifungal therapy developments seek to improve the early detection and effective management of infection. This review will highlight recent updates and summarize the current understanding of the epidemiology, diagnosis, and treatment of coccidioidomycosis. © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

      6. Distinct Streptococcus pneumoniae cause invasive disease in Papua New Guinea
        Mellor KC, Lo S, Yoannes M, Michael A, Orami T, Greenhill AR, Breiman RF, Hawkins P, McGee L, Bentley SD, Ford RL, Lehmann D.
        Microb Genom. 2022 Jul;8(7).
        Streptococcus pneumoniae is a key contributor to childhood morbidity and mortality in Papua New Guinea (PNG). For the first time, whole genome sequencing of 174 isolates has enabled detailed characterisation of diverse S. pneumoniae causing invasive disease in young children in PNG, 1989-2014. This study captures the baseline S. pneumoniae population prior to the introduction of 13-valent pneumococcal conjugate vaccine (PCV13) into the national childhood immunisation programme in 2014. Relationships amongst lineages, serotypes and antimicrobial resistance traits were characterised, and the population was viewed in the context of a global collection of isolates. The analyses highlighted adiverse S. pneumoniae population associated with invasive disease in PNG, with 45 unique Global Pneumococcal Sequence Clusters (GPSCs) observed amongst the 174 isolates reflecting multiple lineages observed in PNG that have not been identified in other geographic locations. The majority of isolates were from children with meningitis, of which 52% (n=72) expressed non-PCV13 serotypes. Over a third of isolates were predicted to be resistant to at least one antimicrobial. PCV13 serotype isolates had 10.1 times the odds of being multidrug-resistant (MDR) compared to non-vaccine serotype isolates, and no isolates with GPSCs unique to PNG were MDR. Serotype 2 was the most commonly identified serotype; we identified a highly clonal cluster of serotype 2 isolates unique to PNG, and a distinct second cluster indicative of long-distance transmission. Ongoing surveillance, including whole-genome sequencing, is needed to ascertain the impact of the national PCV13 programme upon the S. pneumoniae population, including serotype replacement and antimicrobial resistance traits.

      7. Factors associated with severe outcomes among immunocompromised adults hospitalized for COVID-19 - COVID-NET, 10 states, March 2020-February 2022
        Singson JR, Kirley PD, Pham H, Rothrock G, Armistead I, Meek J, Anderson EJ, Reeg L, Lynfield R, Ropp S, Muse A, Felsen CB, Sutton M, Talbot HK, Havers FP, Taylor CA, Reingold A, Chai SJ.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 8;71(27):878-884.
        Immunocompromised persons are at increased risk for severe COVID-19-related outcomes, including intensive care unit (ICU) admission and death (1). Data on adults aged ≥18 years hospitalized with laboratory-confirmed COVID-19 from 10 U.S. states in the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) were analyzed to assess associations between immunocompromise and ICU admission and in-hospital death during March 1, 2020-February 28, 2022. Associations of COVID-19 vaccination status with ICU admission and in-hospital death were also examined during March 1, 2021-February 28, 2022. During March 1, 2020-February 28, 2022, among a sample of 22,345 adults hospitalized for COVID-19, 12.2% were immunocompromised. Among unvaccinated patients, those with immunocompromise had higher odds of ICU admission (adjusted odds ratio [aOR] = 1.26; 95% CI = 1.08-1.49) and in-hospital death (aOR = 1.34; 95% CI = 1.05-1.70) than did nonimmunocompromised patients. Among vaccinated patients,* those with immunocompromise had higher odds of ICU admission (aOR = 1.40; 95% CI = 1.01-1.92) and in-hospital death (aOR = 1.87; 95% CI = 1.28-2.75) than did nonimmunocompromised patients. During March 1, 2021-February 28, 2022, among nonimmunocompromised patients, patients who were vaccinated had lower odds of death (aOR = 0.58; 95% CI = 0.39-0.86) than did unvaccinated patients; among immunocompromised patients, odds of death between vaccinated and unvaccinated patients did not differ. Immunocompromised persons need additional protection from COVID-19 and using multiple known COVID-19 prevention strategies,(†) including nonpharmaceutical interventions, up-to-date vaccination of immunocompromised persons and their close contacts,(§) early testing, and COVID-19 prophylactic (Evusheld) and early antiviral treatment,(¶) can help prevent hospitalization and subsequent severe COVID-19 outcomes among immunocompromised persons.

      8. A case series of children with acute hepatitis and human adenovirus infection
        Gutierrez Sanchez LH, Shiau H, Baker JM, Saaybi S, Buchfellner M, Britt W, Sanchez V, Potter JL, Ingram LA, Kelly D, Lu X, Ayers-Millsap S, Willeford WG, Rassaei N, Bhatnagar J, Bullock H, Reagan-Steiner S, Martin A, Rogers ME, Banc-Husu AM, Harpavat S, Leung DH, Moulton EA, Lamson DM, St George K, Hall AJ, Parashar U, MacNeil A, Tate JE, Kirking HL.
        N Engl J Med. 2022 Jul 13.
        BACKGROUND: Human adenoviruses typically cause self-limited respiratory, gastrointestinal, and conjunctival infections in healthy children. In late 2021 and early 2022, several previously healthy children were identified with acute hepatitis and human adenovirus viremia. METHODS: We used International Classification of Diseases, 10th Revision, codes to identify all children (<18 years of age) with hepatitis who were admitted to Children's of Alabama hospital between October 1, 2021, and February 28, 2022; those with acute hepatitis who also tested positive for human adenovirus by whole-blood quantitative polymerase chain reaction (PCR) were included in our case series. Demographic, clinical, laboratory, and treatment data were obtained from medical records. Residual blood specimens were sent for diagnostic confirmation and human adenovirus typing. RESULTS: A total of 15 children were identified with acute hepatitis - 6 (40%) who had hepatitis with an identified cause and 9 (60%) who had hepatitis without a known cause. Eight (89%) of the patients with hepatitis of unknown cause tested positive for human adenovirus. These 8 patients plus 1 additional patient referred to this facility for follow-up were included in this case series (median age, 2 years 11 months; age range, 1 year 1 month to 6 years 5 months). Liver biopsies indicated mild-to-moderate active hepatitis in 6 children, some with and some without cholestasis, but did not show evidence of human adenovirus on immunohistochemical examination or electron microscopy. PCR testing of liver tissue for human adenovirus was positive in 3 children (50%). Sequencing of specimens from 5 children showed three distinct human adenovirus type 41 hexon variants. Two children underwent liver transplantation; all the others recovered with supportive care. CONCLUSIONS: Human adenovirus viremia was present in the majority of children with acute hepatitis of unknown cause admitted to Children's of Alabama from October 1, 2021, to February 28, 2022, but whether human adenovirus was causative remains unclear. Sequencing results suggest that if human adenovirus was causative, this was not an outbreak driven by a single strain. (Funded in part by the Centers for Disease Control and Prevention.).

      9. Clinical characteristics, health care utilization, and outcomes among patients in a pilot surveillance system for invasive mold disease-Georgia, United States, 2017-2019
        Gold JA, Revis A, Thomas S, Perry L, Blakney RA, Chambers T, Bentz ML, Berkow EL, Lockhart SR, Lysen C, Nunnally NS, Jordan A, Kelly HC, Montero AJ, Farley MM, Oliver NT, Pouch SM, Webster AS, Jackson BR, Beer KD.
        Open Forum Infect Dis. 2022 Jul;9(7):ofac215.
        BACKGROUND: Invasive mold diseases (IMDs) cause severe illness, but public health surveillance data are lacking. We describe data collected from a laboratory-based, pilot IMD surveillance system. METHODS: During 2017-2019, the Emerging Infections Program conducted active IMD surveillance at 3 Atlanta-area hospitals. We ascertained potential cases by reviewing histopathology, culture, and Aspergillus galactomannan results and classified patients as having an IMD case (based on European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group [MSG] criteria) or a non-MSG IMD case (based on the treating clinician's diagnosis and use of mold-active antifungal therapy). We described patient features and compared patients with MSG vs non-MSG IMD cases. RESULTS: Among 304 patients with potential IMD, 104 (34.2%) met an IMD case definition (41 MSG, 63 non-MSG). The most common IMD types were invasive aspergillosis (n = 66 [63.5%]), mucormycosis (n = 8 [7.7%]), and fusariosis (n = 4 [3.8%]); the most frequently affected body sites were pulmonary (n = 66 [63.5%]), otorhinolaryngologic (n = 17 [16.3%]), and cutaneous/deep tissue (n = 9 [8.7%]). Forty-five (43.3%) IMD patients received intensive care unit-level care, and 90-day all-cause mortality was 32.7%; these outcomes did not differ significantly between MSG and non-MSG IMD patients. CONCLUSIONS: IMD patients had high mortality rates and a variety of clinical presentations. Comprehensive IMD surveillance is needed to assess emerging trends, and strict application of MSG criteria for surveillance might exclude over one-half of clinically significant IMD cases.

      10. Gestational SARS-CoV-2 infection is associated with placental expression of immune and trophoblast genes
        Lesseur C, Jessel RH, Ohrn S, Ma Y, Li Q, Dekio F, Brody RI, Wetmur JG, Gigase FA, Lieber M, Lieb W, Lynch J, Afzal O, Ibroci E, Rommel AS, Janevic T, Stone J, Howell EA, Galang RR, Dolan SM, Bergink V, De Witte LD, Chen J.
        Placenta. 2022 Jun 30;126:125-132.
        INTRODUCTION: Maternal SARS-CoV-2 infection during pregnancy is associated with adverse pregnancy outcomes and can have effects on the placenta, even in the absence of severe disease or vertical transmission to the fetus. This study aimed to evaluate histopathologic and molecular effects in the placenta after SARS-CoV-2 infection during pregnancy. METHODS: We performed a study of 45 pregnant participants from the Generation C prospective cohort study at the Mount Sinai Health System in New York City. We compared histologic features and the expression of 48 immune and trophoblast genes in placentas delivered from 15 SARS-CoV-2 IgG antibody positive and 30 IgG SARS-CoV-2 antibody negative mothers. Statistical analyses were performed using Fisher's exact tests, Spearman correlations and linear regression models. RESULTS: The median gestational age at the time of SARS-CoV-2 IgG serology test was 35 weeks. Two of the IgG positive participants also had a positive RT-PCR nasal swab at delivery. 82.2% of the infants were delivered at term (≥37 weeks), and gestational age at delivery did not differ between the SARS-CoV-2 antibody positive and negative groups. No significant differences were detected between the groups in placental histopathology features. Differential expression analyses revealed decreased expression of two trophoblast genes (PSG3 and CGB3) and increased expression of three immune genes (CXCL10, TLR3 and DDX58) in placentas delivered from SARS-CoV-2 IgG positive participants. DISCUSSION: SARS-CoV-2 infection during pregnancy is associated with gene expression changes of immune and trophoblast genes in the placenta at birth which could potentially contribute to long-term health effects in the offspring.

      11. Reported neurologic, ocular, and otic manifestations among syphilis cases - 16 states, 2019
        Jackson DA, McDonald R, Quilter LA, Weinstock H, Torrone EA.
        Sex Transm Dis. 2022 Jul 13.
        BACKGROUND: Syphilis can cause neurologic, ocular, or otic manifestations, possibly resulting in permanent disability or death. In 2018, CDC began collecting syphilis clinical manifestation data via the National Notifiable Diseases Surveillance System (NNDSS). We present the first reported U.S. syphilis neurologic, ocular, and otic manifestation prevalence estimates. METHODS: We reviewed 2019 NNDSS data to identify jurisdictions reporting ≥70% of syphilis cases ≥15 years old with clinical manifestation data (considered "complete reporting"). Among these jurisdictions, we determined reported neurologic, ocular, and otic manifestation prevalence, stratified by demographic, behavioral, and clinical characteristics. RESULTS: Among 41,187 syphilis cases in 16 jurisdictions with complete reporting, clinical manifestations were infrequently reported overall: neurologic (n = 445, 1.1%), ocular (n = 461, 1.1%), otic (n = 166, 0.4%), any (n = 807, 2.0%). Reported clinical manifestation prevalence was highest among cases ≥65 years old (neurologic: 5.1%; ocular: 3.5%; otic: 1.2%) and those reporting injection drug use (neurologic: 2.8%; ocular: 3.4%; otic: 1.6%). Although reported neurologic and ocular manifestation prevalence was slightly higher among HIV-infected vs. HIV-negative persons, approximately 40% of cases with manifestations were HIV-negative. Reported otic manifestation prevalence was similar regardless of HIV status. When stratifying by HIV status and syphilis stage, reported prevalence was highest among HIV-infected persons with unknown duration/late syphilis (neurologic: 3.0%; ocular: 2.3%; otic: 0.7%). CONCLUSIONS: Reported Neurologic, ocular, and otic manifestation prevalence was low among syphilis cases, but these data are likely an underestimate given potential underreporting. Reported clinical manifestation frequency, including among HIV-negative persons, emphasizes the importance of evaluating all syphilis cases for signs/symptoms of neurosyphilis, ocular syphilis, and otosyphilis.

    • Community Health Services
      1. Experiences and perceptions of care-seeking for febrile illness among caregivers, pregnant women, and health providers in eight districts of Madagascar
        Favero R, Dentinger CM, Rakotovao JP, Kapesa L, Andriamiharisoa H, Steinhardt LC, Randrianarisoa B, Sethi R, Gomez P, Razafindrakoto J, Razafimandimby E, Andrianandraina R, Andriamananjara MN, Ravaoarinosy A, Mioramalala SA, Rawlins B.
        Malar J. 2022 Jul 7;21(1):212.
        BACKGROUND: Prompt diagnosis and treatment of malaria contributes to reduced morbidity, particularly among children and pregnant women; however, in Madagascar, care-seeking for febrile illness is often delayed. To describe factors influencing decisions for prompt care-seeking among caregivers of children aged < 15 years and pregnant women, a mixed-methods assessment was conducted with providers (HP), community health volunteers (CHV) and community members. METHODS: One health district from each of eight malaria-endemic zones of Madagascar were purposefully selected based on reported higher malaria transmission. Within districts, one urban and one rural community were randomly selected for participation. In-depth interviews (IDI) and focus group discussions (FGD) were conducted with caregivers, pregnant women, CHVs and HPs in these 16 communities to describe practices and, for HPs, system characteristics that support or inhibit care-seeking. Knowledge tests on malaria case management guidelines were administered to HPs, and logistics management systems were reviewed. RESULTS: Participants from eight rural and eight urban communities included 31 HPs from 10 public and 8 private Health Facilities (HF), five CHVs, 102 caregivers and 90 pregnant women. All participants in FGDs and IDIs reported that care-seeking for fever is frequently delayed until the ill person does not respond to home treatment or symptoms become more severe. Key care-seeking determinants for caregivers and pregnant women included cost, travel time and distance, and perception that the quality of care in HFs was poor. HPs felt that lack of commodities and heavy workloads hindered their ability to provide quality malaria care services. Malaria commodities were generally more available in public versus private HFs. CHVs were generally not consulted for malaria care and had limited commodities. CONCLUSIONS: Reducing cost and travel time to care and improving the quality of care may increase prompt care-seeking among vulnerable populations experiencing febrile illness. For patients, perceptions and quality of care could be improved with more reliable supplies, extended HF operating hours and staffing, supportive demeanors of HPs and seeking care with CHVs. For providers, malaria services could be improved by increasing the reliability of supply chains and providing additional staffing. CHVs may be an under-utilized resource for sick children.

    • Disease Reservoirs and Vectors
      1. Origins of high latitude introductions of Aedes aegypti to Nebraska and Utah during 2019
        Gloria-Soria A, Faraji A, Hamik J, White G, Amsberry S, Donahue M, Buss B, Pless E, Cosme LV, Powell JR.
        Infect Genet Evol. 2022 Jul 8:105333.
        Aedes aegypti (L.), the yellow fever mosquito, is also an important vector of dengue and Zika viruses, and an invasive species in North America. Aedes aegypti inhabits tropical and sub-tropical areas of the world and in North America, is primarily distributed throughout the southern US states and Mexico. The northern range of Ae. aegypti is limited by cold winter months and establishment in these areas has been mostly unsuccessful. However, frequent introductions of Ae. aegypti to temperate, non-endemic areas during the warmer months can lead to seasonal activity and disease outbreaks. Two Ae. aegypti incursions were reported in the late summer of 2019 into York, Nebraska and Moab, Utah. These states had no history of established populations of this mosquito and no evidence of previous seasonal activity. We genotyped a subset of individuals from each location at 12 microsatellite loci and ~ 14,000 single nucleotide polymorphic markers to determine their genetic affinities to other populations worldwide and investigate their potential source of introduction. Our results support a single origin for each of the introductions from different sources. Aedes aegypti from Utah likely derived from Tucson, Arizona, or a nearby location. Nebraska specimen results were not as conclusive, but point to an origin from southcentral or southeastern US. In addition to an effective, efficient, and sustainable control of invasive mosquitoes, such as Ae. aegypti, identifying the potential routes of introduction will be key to prevent future incursions and assess their potential health threat based on the ability of the source population to transmit a particular virus and its insecticide resistance profile, which may complicate vector control.

      2. First national-scale evaluation of temephos resistance in Aedes aegypti in Peru
        Palomino M, Pinto J, Yañez P, Cornelio A, Dias L, Amorim Q, Martins AJ, Lenhart A, Lima JB.
        Parasit Vectors. 2022 Jul 11;15(1):254.
        BACKGROUND: The development of resistance against insecticides in Aedes aegypti can lead to operational failures in control programs. Knowledge of the spatial and temporal trends of this resistance is needed to drive effective monitoring campaigns, which in turn provide data on which vector control decision-making should be based. METHODS: Third-stage larvae (L3) from the F1 and F2 generations of 39 Peruvian field populations of Ae. aegypti mosquitoes from established laboratory colonies were evaluated for resistance against the organophosphate insecticide temephos. The 39 populations were originally established from eggs collected in the field with ovitraps in eight departments of Peru during 2018 and 2019. Dose-response bioassays, at 11 concentrations of the insecticide, were performed following WHO recommendations. RESULTS: Of the 39 field populations of Ae. aegypti tested for resistance to temephos , 11 showed high levels of resistance (resistance ratio [RR] > 10), 16 showed moderate levels of resistance (defined as RR values between 5 and 10) and only 12 were susceptible (RR < 5). The results segregated the study populations into two geographic groups. Most of the populations in the first geographic group, the coastal region, were resistant to temephos, with three populations (AG, CR and LO) showing RR values > 20 (AG 21.5, CR 23.1, LO 39.4). The populations in the second geographic group, the Amazon jungle and the high jungle, showed moderate levels of resistance, with values ranging between 5.1 (JN) and 7.1 (PU). The exception in this geographic group was the population from PM, which showed a RR value of 28.8 to this insecticide. CONCLUSIONS: The results of this study demonstrate that Ae. aegypti populations in Peru present different resistance intensities to temephos, 3 years after temephos use was discontinued. Resistance to this larvicide should continue to be monitored because it is possible that resistance to temephos could decrease in the absence of routine selection pressures.

    • Epidemiology and Surveillance
      1. Methods for conducting trends analysis: roadmap for comparing outcomes from three national HIV Population-based household surveys in Kenya (2007, 2012, and 2018)
        Achia T, Cervantes IF, Stupp P, Musingila P, Muthusi J, Waruru A, Schmitz M, Bronson M, Chang G, Bore J, Kingwara L, Mwalili S, Muttunga J, Gitonga J, De Cock KM, Young P.
        BMC Public Health. 2022 Jul 13;22(1):1337.
        BACKGROUND: For assessing the HIV epidemic in Kenya, a series of independent HIV indicator household-based surveys of similar design can be used to investigate the trends in key indicators relevant to HIV prevention and control and to describe geographic and sociodemographic disparities, assess the impact of interventions, and develop strategies. We developed methods and tools to facilitate a robust analysis of trends across three national household-based surveys conducted in Kenya in 2007, 2012, and 2018. METHODS: We used data from the 2007 and 2012 Kenya AIDS Indicator surveys (KAIS 2007 and KAIS 2012) and the 2018 Kenya Population-based HIV Impact Assessment (KENPHIA 2018). To assess the design and other variables of interest from each study, variables were recoded to ensure that they had equivalent meanings across the three surveys. After assessing weighting procedures for comparability, we used the KAIS 2012 nonresponse weighting procedure to revise normalized KENPHIA weights. Analyses were restricted to geographic areas covered by all three surveys. The revised analysis files were then merged into a single file for pooled analysis. We assessed distributions of age, sex, household wealth, and urban/rural status to identify unexpected changes between surveys. To demonstrate how a trend analysis can be carried out, we used continuous, binary, and time-to-event variables as examples. Specifically, temporal trends in age at first sex and having received an HIV test in the last 12 months were used to demonstrate the proposed analytical approach. These were assessed with respondent-specific variables (age, sex, level of education, and marital status) and household variables (place of residence and wealth index). All analyses were conducted in SAS 9.4, but analysis files were created in Stata and R format to support additional analyses. RESULTS: This study demonstrates trends in selected indicators to illustrate the approach that can be used in similar settings. The incidence of early sexual debut decreased from 11.63 (95% CI: 10.95-12.34) per 1,000 person-years at risk in 2007 to 10.45 (95% CI: 9.75-11.2) per 1,000 person-years at risk in 2012 and to 9.58 (95% CI: 9.08-10.1) per 1,000 person-years at risk in 2018. HIV-testing rates increased from 12.6% (95% CI: 11.6%-13.6%) in 2007 to 56.1% (95% CI: 54.6%-57.6%) in 2012 but decreased slightly to 55.6% [95% CI: 54.6%-56.6%) in 2018. The decrease in incidence of early sexual debut could be convincingly demonstrated between 2007 and 2012 but not between 2012 and 2018. Similarly, there was virtually no difference between HIV Testing rates in 2012 and 2018. CONCLUSIONS: Our approach can be used to support trend comparisons for variables in HIV surveys in low-income settings. Independent national household surveys can be assessed for comparability, adjusted as appropriate, and used to estimate trends in key indicators. Analyzing trends over time can not only provide insights into Kenya's progress toward HIV epidemic control but also identify gaps.

    • Food Safety
      1. Listeria monocytogenes illness and deaths associated with ongoing contamination of a multi-regional brand of ice cream products, United States, 2010-2015
        Conrad AR, Tubach S, Cantu V, Webb LM, Stroika S, Moris S, Davis M, Hunt DC, Bradley KK, Kucerova Z, Strain E, Doyle M, Fields A, Neil KP, Gould LH, Jackson KA, Wise ME, Griffin PM, Jackson BR.
        Clin Infect Dis. 2022 Jul 7.
        BACKGROUND: Frozen foods have rarely been linked to Listeria monocytogenes illness. We describe an outbreak investigation prompted both by hospital clustering of illnesses and product testing. METHODS: We identified outbreak-associated listeriosis cases using whole-genome sequencing (WGS), product testing results, and epidemiologic linkage to cases in the same Kansas hospital. We reviewed hospital medical and dietary records, product invoices, and molecular subtyping results. Federal and state officials tested product and environmental samples for L. monocytogenes. RESULTS: Kansas officials were investigating five cases of listeriosis at a single hospital when, simultaneously, unrelated sampling for a study in South Carolina identified L. monocytogenes in Company A ice cream products made in Texas. Isolates from four patients and Company A products were closely related by WGS, and the four patients with known exposures had consumed milkshakes made with Company A ice cream while hospitalized. Further testing identified L. monocytogenes in ice cream produced in a second Company A production facility in Oklahoma; these isolates were closely related by WGS to those from five patients in three other states. These ten illnesses, involving three deaths, occurred from 2010 through 2015. Company A ultimately recalled all products. CONCLUSION: In this U.S. outbreak of listeriosis linked to a widely distributed brand of ice cream, WGS and product sampling helped link cases spanning five years to two production facilities, indicating longstanding contamination. Comprehensive sanitation controls and environmental and product testing for L. monocytogenes, with regulatory oversight, should be implemented for ice cream production.

    • Genetics and Genomics
      1. Use of large-scale genomics to identify the role of animals and foods as potential sources of extraintestinal pathogenic Escherichia coli that cause human illness
        Harrison L, Tyson GH, Strain E, Lindsey RL, Strockbine N, Ceric O, Fortenberry GZ, Harris B, Shaw S, Tillman G, Zhao S, Dessai U.
        Foods. 2022 Jul 3;11(13).
        Extraintestinal pathogenic Escherichia coli (ExPEC) cause urinary tract and potentially life-threatening invasive infections. Unfortunately, the origins of ExPEC are not always clear. We used genomic data of E. coli isolates from five U.S. government organizations to evaluate potential sources of ExPEC infections. Virulence gene analysis of 38,032 isolates from human, food animal, retail meat, and companion animals classified the subset of 8142 non-diarrheagenic isolates into 40 virulence groups. Groups were identified as low, medium, and high relative risk of containing ExPEC strains, based on the proportion of isolates recovered from humans. Medium and high relative risk groups showed a greater representation of sequence types associated with human disease, including ST-131. Over 90% of food source isolates belonged to low relative risk groups, while &gt;60% of companion animal isolates belonged to medium or high relative risk groups. Additionally, 18 of the 26 most prevalent antimicrobial resistance determinants were more common in high relative risk groups. The associations between antimicrobial resistance and virulence potentially limit treatment options for human ExPEC infections. This study demonstrates the power of large-scale genomics to assess potential sources of ExPEC strains and highlights the importance of a One Health approach to identify and manage these human pathogens.

      2. Gut microbiome changes occurring with norovirus infection and recovery in infants enrolled in a longitudinal birth cohort in Leon, Nicaragua
        Cannon JL, Seabolt MH, Xu R, Montmayeur A, Suh SH, Diez-Valcarce M, Bucardo F, Becker-Dreps S, Vinjé J.
        Viruses. 2022 ;14(7).
        Noroviruses are associated with one fifth of diarrheal illnesses globally and are not yet preventable with vaccines. Little is known about the effects of norovirus infection on infant gut microbiome health, which has a demonstrated role in protecting hosts from pathogens and a possible role in oral vaccine performance. In this study, we characterized infant gut microbiome changes occurring with norovirus-associated acute gastroenteritis (AGE) and the extent of recovery. Metage-nomic sequencing was performed on the stools of five infants participating in a longitudinal birth cohort study conducted in León, Nicaragua. Taxonomic and functional diversities of gut micro-biomes were profiled at time points before, during, and after norovirus infection. Initially, the gut microbiomes resembled those of breastfeeding infants, rich in probiotic species. When disturbed by AGE, Gammaproteobacteria dominated, particularly Pseudomonas species. Alpha diversity in-creased but the genes involved in carbohydrate metabolism and glycan biosynthesis decreased. After the symptoms subsided, the gut microbiomes rebounded with their taxonomic and functional communities resembling those of the pre-infection microbiomes. In this study, during disruptive norovirus-associated AGE, the gut microbiome was temporarily altered, returning to a pre-infection composition a median of 58 days later. Our study provides new insights for developing probiotic treatments and furthering our understanding of the role that episodes of AGE have in shaping the infant gut microbiome, their long-term outcomes, and implications for oral vaccine effectiveness. © 2022 by the authors. Licensee MDPI, Basel, Switzerland.

    • Health Behavior and Risk
      1. Sexual practice changes post-HIV diagnosis among men who have sex with men in the United States: A systematic review and meta-analysis
        Malekinejad M, Jimsheleishvili S, Barker EK, Hutchinson AB, Shrestha RK, Volberding P, Kahn JG.
        AIDS Behav. 2022 Jul 12.
        Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

    • Health Communication and Education
      1. Coaching and communication training for HPV vaccination: A cluster randomized trial
        Gilkey MB, Grabert BK, Heisler-MacKinnon J, Bjork A, Boynton MH, Kim K, Alton Dailey S, Liu A, Todd KG, Schauer SL, Sill D, Coley S, Brewer NT.
        Pediatrics. 2022 Jul 12.
        BACKGROUND AND OBJECTIVES: US health departments routinely conduct in-person quality improvement (QI) coaching to strengthen primary care clinics' vaccine delivery systems, but this intervention achieves only small, inconsistent improvements in human papillomavirus (HPV) vaccination. Thus, we sought to evaluate the effectiveness of combining QI coaching with remote provider communication training to improve impact. METHODS: With health departments in 3 states, we conducted a pragmatic 4-arm cluster randomized clinical trial with 267 primary care clinics (76% pediatrics). Clinics received in-person QI coaching, remote provider communication training, both interventions combined, or control. Using data from states' immunization information systems, we assessed HPV vaccination among 176 189 patients, ages 11 to 17, who were unvaccinated at baseline. Our primary outcome was the proportion of those, ages 11 to 12, who had initiated HPV vaccination at 12-month follow-up. RESULTS: HPV vaccine initiation was 1.5% points higher in the QI coaching arm and 3.8% points higher in the combined intervention arm than in the control arm, among patients ages 11 to 12, at 12-month follow-up (both P < .001). Improvements persisted at 18-month follow-up. The combined intervention also achieved improvements for other age groups (ages 13-17) and vaccination outcomes (series completion). Remote communication training alone did not outperform the control on any outcome. CONCLUSIONS: Combining QI coaching with remote provider communication training yielded more consistent improvements in HPV vaccination uptake than QI coaching alone. Health departments and other organizations that seek to support HPV vaccine delivery may benefit from a higher intensity, multilevel intervention approach.

    • Health Equity and Health Disparities
      1. Racial‒ethnic disparities of buprenorphine and vivitrol receipt in Medicaid
        Dunphy CC, Zhang K, Xu L, Guy GP.
        Am J Prev Med. 2022 Jul 5.
        INTRODUCTION: Expanding access to medications for opioid use disorder is a cornerstone to addressing the opioid overdose epidemic. However, recent research suggests that the distribution of medications for opioid use disorder has been inequitable. This study analyzes the racial‒ethnic disparities in the receipt of medications for opioid use disorder among Medicaid patients diagnosed with opioid use disorder. METHODS: Medicaid claims data from the Transformed Medicaid Statistical Information System for the years 2017-2019 were used for the analysis. Logistic regression models estimated the odds of receiving buprenorphine and Vivitrol within 180 days after initial opioid use disorder diagnosis on the basis of race‒ethnicity. Analysis was conducted in 2022. RESULTS: Non-Hispanic Black people, non-Hispanic American Indian or Alaskan Native/Asian/Hawaiian/Pacific Islander people, and Hispanic people had 42%, 12%, and 22% lower odds of buprenorphine receipt and 47%, 12%, and 20% lower odds of Vivitrol receipt, respectively, than non-Hispanic White people, controlling for clinical and demographic patient variables. CONCLUSIONS: This study suggests that there are racial‒ethnic disparities in the receipt of buprenorphine and Vivitrol among Medicaid patients diagnosed with opioid use disorder after adjusting for demographic, geographic, and clinical characteristics. The potential strategies to address these disparities include expanding the workforce of providers who can prescribe medications for opioid use disorder in low-income communities and communities of color and allocating resources to address the stigma in medications for opioid use disorder treatment.

      2. Homelessness poses a direct threat to public health in the US as many individuals face debilitating health outcomes and barriers to adequate health care. Access to STI care for the homeless Medicaid population of USA has not been well-studied using administrative claims data. Our study aims to compare health services utilization, STI screening and diagnoses among people experiencing homelessness (PEH) vs. those who are non-PEH using ICD10 codes. We used 2019 MarketScan Medicaid claims data to analyze men and women aged 15-44 years with a diagnosis code for PEH (Z59.0), non-PEH (without Z59.0) and assessed their emergency department and outpatient visits and STI/HIV diagnoses and screening rates. We identified 5135 PEH men and 3571 PEH women among 1.3 million men and 2.1 million women in the 2019 US Medicaid database. PEH patients were more likely to have ED visits (94.80% vs 33.04%) and ≥ 20 outpatient clinic visits (60.29% vs 16.16%) than non-PEH patients in 2019. Higher diagnoses were observed for syphilis 1.57% (CI 1.32-1.86) vs 0.11% (CI 0.11-0.11), HIV 3.93% (CI 3.53-4.36) vs 0.41% (CI 0.41-0.42), chlamydia 1.94% (CI 1.66-2.25) vs 0.85% (CI 0.84-0.86) and gonorrhea 1.26% (CI 1.04-1.52) vs. 0.33% (CI 0.33-0.34) (p < 0.0001) among PEH compared to non-PEH. Among PEH, higher STI/HIV diagnoses rates indicate an increase in STI burden and suboptimal STI testing indicates an underutilization of STI services despite having a higher percentage of health care visits compared to non-PEH patients. Focused STI/HIV interventions are needed to address health care needs of PEH patients.

      3. County-level chlamydia and gonorrhea rates by social vulnerability, United States, 2014-2018
        Copen CE, Haderxhanaj LT, Renfro KJ, Loosier PS.
        Sex Transm Dis. 2022 Jul 3.
        We examined mean chlamydia and gonorrhea case rates from 2014-2018 by categorizing U.S counties by social vulnerability. Overall, these rates were approximately 1.0 to 2.4 times higher in high vulnerability counties than low vulnerability counties. Percentage change in case rates from low to high social vulnerability counties varied by sex, geographic region, and urbanicity.

    • Immunity and Immunization
      1. Human papillomavirus vaccine beliefs and practice characteristics in rural and urban adolescent care providers
        Goessl CL, Christianson B, Hanson KE, Polter EJ, Olson SC, Boyce TG, Dunn D, Williams CL, Belongia EA, McLean HQ, VanWormer JJ.
        BMC Public Health. 2022 Jul 9;22(1):1322.
        BACKGROUND: The human papillomavirus (HPV) vaccine is recommended for all adolescents age 11-12 years. HPV vaccine coverage remains suboptimal in the United States though, particularly in rural areas. We surveyed adolescent immunization providers in two Midwestern states to assess rural vs. urban differences in HPV vaccine resources, practices, and attitudes. METHODS: A cross-sectional survey was sent to all licensed adolescent care providers in a subset of urban and rural counties in Minnesota and Wisconsin during 2019. Multivariable regression was used to identify attitudes and practices that differentiated rural vs. urban providers. RESULTS: There were 437 survey respondents (31% rural). Significantly fewer rural providers had evening/weekend adolescent vaccination appointments available (adjusted odds ratio (aOR) = 0.21 [95% confidence interval (CI): 0.12, 0.36]), had prior experience with adolescent vaccine quality improvement projects (aOR = 0.52 [95% CI: 0.28, 0.98]), and routinely recommended HPV vaccine during urgent/acute care visits (aOR = 0.37 [95% CI: 0.18, 0.79]). Significantly more rural providers had standing orders to administer all recommended adolescent vaccines (aOR = 2.81 [95% CI: 1.61, 4.91]) and reported giving HPV vaccine information to their patients/families before it is due (aOR = 3.10 [95% CI: 1.68, 5.71]). CONCLUSIONS: Rural vs. urban differences in provider practices were mixed in that rural providers do not implement some practices that may promote HPV vaccination, but do implement other practices that promote HPV vaccination. It remains unclear how the observed differences would affect HPV vaccine attitudes or adolescent vaccination decisions for parents in rural areas.

      2. Ascertainment of vaccination status by self-report versus source documentation: Impact on measuring COVID-19 vaccine effectiveness
        Stephenson M, Olson SM, Self WH, Ginde AA, Mohr NM, Gaglani M, Shapiro NI, Gibbs KW, Hager DN, Prekker ME, Gong MN, Steingrub JS, Peltan ID, Martin ET, Reddy R, Busse LW, Duggal A, Wilson JG, Qadir N, Mallow C, Kwon JH, Exline MC, Chappell JD, Lauring AS, Baughman A, Lindsell CJ, Hart KW, Lewis NM, Patel MM, Tenforde MW.
        Influenza Other Respir Viruses. 2022 Jul 11.
        BACKGROUND: During the COVID-19 pandemic, self-reported COVID-19 vaccination might facilitate rapid evaluations of vaccine effectiveness (VE) when source documentation (e.g., immunization information systems [IIS]) is not readily available. We evaluated the concordance of COVID-19 vaccination status ascertained by self-report versus source documentation and its impact on VE estimates. METHODS: Hospitalized adults (≥18 years) admitted to 18 U.S. medical centers March-June 2021 were enrolled, including COVID-19 cases and SARS-CoV-2 negative controls. Patients were interviewed about COVID-19 vaccination. Abstractors simultaneously searched IIS, medical records, and other sources for vaccination information. To compare vaccination status by self-report and documentation, we estimated percent agreement and unweighted kappa with 95% confidence intervals (CIs). We then calculated VE in preventing COVID-19 hospitalization of full vaccination (2 doses of mRNA product ≥14 days prior to illness onset) independently using data from self-report or source documentation. RESULTS: Of 2520 patients, 594 (24%) did not have self-reported vaccination information to assign vaccination group; these patients tended to be more severely ill. Among 1924 patients with both self-report and source documentation information, 95.0% (95% CI: 93.9-95.9%) agreement was observed, with a kappa of 0.9127 (95% CI: 0.9109-0.9145). VE was 86% (95% CI: 81-90%) by self-report data only and 85% (95% CI: 81-89%) by source documentation data only. CONCLUSIONS: Approximately one-quarter of hospitalized patients could not provide self-report COVID-19 vaccination status. Among patients with self-report information, there was high concordance with source documented status. Self-report may be a reasonable source of COVID-19 vaccination information for timely VE assessment for public health action.

      3. Single dose vaccination among infants and toddlers provides modest protection against influenza illness which wanes after 5 months
        Wagner AL, Sanchez N, Kubale J, Kuan G, Gresh L, Lopez R, Ojeda S, Azziz-Baumgartner E, Balmaseda A, Gordon A.
        J Infect Dis. 2022 Jul 7.
        In their first season of vaccination, young children are recommended 2 doses of influenza vaccine, but a two-dose schedule might be difficult to implement in many countries. Within a cohort study of 742 children aged 6 to <24 months in Managua, Nicaragua, this study estimated effectiveness of partial vaccination from 3 to 9 months post-vaccination. Vaccine effectiveness (VE) was 74% (95% CI: 24%, 91%) within 3 months and 55% (95% CI: 10%, 77%) within 4 months. There was not significant protection beyond 5 months. Partial vaccination might confer some benefits but should be followed by a second dose.

      4. Inactivated poliovirus vaccine closing the type 2 immunity gap in Vietnam
        Huyen DT, Anh DD, Trung NT, Hong DT, Thanh TT, Truong LN, Jeyaseelan V, Lopez Cavestany R, Hendley WS, Mainou BA, Mach O.
        J Pediatric Infect Dis Soc. 2022 Jul 8.
        This was a cross-sectional community-based serological survey of polio antibodies assessing the immunogenicity of inactivated poliovirus vaccine (IPV) focusing on poliovirus serotype 2. IPV was administered to 5-month-old children. Type 2 antibody seroprevalence when measured 1 month after IPV administration was >95%. One IPV dose successfully closed the immunity gap.

      5. SARS-CoV-2 infection risk among vaccinated and unvaccinated household members during the Alpha variant surge - Denver, Colorado, and San Diego, California, January-April 2021
        McCormick DW, Konkle SL, Magleby R, Chakrabarti AK, Cherney B, Lindell K, Namageyo-Funa A, Visser S, Soto RA, Donnelly MA, Stringer G, Austin B, Beatty ME, Stous S, Albanese BA, Chu VT, Chuey M, Dietrich EA, Drobeniuc J, Folster JM, Killerby ME, Lehman JA, McDonald EC, Ruffin J, Schwartz NG, Sheldon SW, Sleweon S, Thornburg NJ, Hughes LJ, Petway M, Tong S, Whaley MJ, Kirking HL, Tate JE, Hsu CH, Matanock A.
        Vaccine. 2022 Jul 4.
        BACKGROUND: COVID-19 vaccination reduces SARS-CoV-2 infection and transmission. However, evidence is emerging on the degree of protection across variants and in high-transmission settings. To better understand the protection afforded by vaccination specifically in a high-transmission setting, we examined household transmission of SARS-CoV-2 during a period of high community incidence with predominant SARS-CoV-2 B.1.1.7 (Alpha) variant, among vaccinated and unvaccinated contacts. METHODS: We conducted a household transmission investigation in San Diego County, California, and Denver, Colorado, during January-April 2021. Households were enrolled if they had at least one person with documented SARS-CoV-2 infection. We collected nasopharyngeal swabs, blood, demographic information, and vaccination history from all consenting household members. We compared infection risks (IRs), RT-PCR cycle threshold values, SARS-CoV-2 culture results, and antibody statuses among vaccinated and unvaccinated household contacts. RESULTS: We enrolled 493 individuals from 138 households. The SARS-CoV-2 variant was identified from 121/138 households (88%). The most common variants were Alpha (75/121, 62%) and Epsilon (19/121, 16%). There were no households with discordant lineages among household members. One fully vaccinated secondary case was symptomatic (13%); the other 5 were asymptomatic (87%). Among unvaccinated secondary cases, 105/108 (97%) were symptomatic. Among 127 households with a single primary case, the IR for household contacts was 45% (146/322; 95% Confidence Interval [CI] 40-51%). The observed IR was higher in unvaccinated (130/257, 49%, 95% CI 45-57%) than fully vaccinated contacts (6/26, 23%, 95% CI 11-42%). A lower proportion of households with a fully vaccinated primary case had secondary cases (1/5, 20%) than households with an unvaccinated primary case (66/108, 62%). CONCLUSIONS: Although SARS-CoV-2 infections in vaccinated household contacts were reported in this high transmission setting, full vaccination protected against SARS-CoV-2 infection. These findings further support the protective effect of COVID-19 vaccination and highlight the need for ongoing vaccination among eligible persons.

    • Injury and Violence
      1. Urban and rural child deaths from motor vehicle crashes: United States, 2015-2019
        Shaw KM, West B, Kendi S, Zonfrillo MR, Sauber-Schatz E.
        J Pediatr. 2022 Jul 6.
        OBJECTIVE(S): To examine child deaths in motor vehicle crashes by rurality, restraint use, and state child passenger restraint laws. STUDY DESIGN: 2015-2019 Fatality Analysis Reporting System data were analyzed to determine deaths and rates by passenger and crash characteristics. Optimal restraint use was defined using age and type of restraint according to child passenger safety recommendations. RESULTS: Death rates per 100,000 population were highest for non-Hispanic Black (1.96; [1.84,2.07]) and American Indian or Alaska Native children (2.67; [2.14,3.20]) and lowest for Asian or Pacific Islander children (0.57; [0.47,0.67]). Death rates increased with rurality with the lowest rate (0.88; [0.84,0.92]) in the most urban counties and the highest rate (4.47; [3.88,5.06]) in the most rural counties. Children who were not optimally restrained had higher deaths rates compared with optimally restrained children (0.84; [0.81,0.87] vs. 0.44; [0.42,0.46], respectively). The death rate was higher in counties where states only required child passenger restraint use for passengers aged ≤6 years (1.64; [1.50,1.78]) compared with those requiring child passenger restraint use for passengers age ≤7 or ≤8 (1.06; [1.01,1.12]). CONCLUSIONS: Proper restraint use and extending the ages covered by child passenger restraint laws reduce the risk for child crash deaths. Additionally, racial and geographic disparities in crash deaths were identified, especially among Black and Hispanic children in rural areas. Decision makers can consider extending the ages covered by child passenger restraint laws until at least age 9 to increase proper child restraint use and reduce crash injuries and deaths.

      2. County-level social vulnerability and emergency department visits for firearm injuries - 10 U.S. jurisdictions, January 1, 2018-December 31, 2021
        Van Dyke ME, Chen MS, Sheppard M, Sharpe JD, Radhakrishnan L, Dahlberg LL, Simon TR, Zwald ML.
        MMWR Morb Mortal Wkly Rep. 2022 Jul 8;71(27):873-877.
        At least 100,000 persons in the United States experience a fatal or nonfatal firearm injury each year.* CDC examined rates of firearm injury emergency department (ED) visits by community social vulnerability using data from CDC's Firearm Injury Surveillance Through Emergency Rooms (FASTER) program.(†) ED visit data, shared with CDC's National Syndromic Surveillance Program (NSSP)(§) during 2018-2021, were analyzed for 647 counties in 10 FASTER-funded jurisdictions.(¶) County-level social vulnerability data were obtained from the 2018 Social Vulnerability Index (SVI).** Rates of ED visits for firearm injuries (number of firearm injury ED visits per 100,000 ED visits) were calculated across tertile levels of social vulnerability. Negative binomial regression models were used to estimate rate ratios (RRs) and associated 95% CIs comparing rates of ED visits across social vulnerability levels. During 2018-2021, compared with rates in counties with low overall social vulnerability, the firearm injury ED visit rate was 1.34 times as high in counties with medium social vulnerability and 1.80 times as high in counties with high social vulnerability. Similar patterns were observed for the SVI themes of socioeconomic status and housing type and transportation, but not for the themes of household composition and disability status or racial and ethnic minority status and language proficiency. More timely data(††) on firearm injury ED visits by social vulnerability can help identify communities disproportionately experiencing elevated firearm injury rates. States and communities can use the best available evidence to implement comprehensive prevention strategies that address inequities in the social and structural conditions that contribute to risk for violence, including creating protective community environments, strengthening economic supports, and intervening to reduce harms and prevent future risk (e.g., with hospital-based violence intervention programs) (1,2).

      3. Violence perpetration prevalence among Colorado (United States) high school students across gender, racial/ethnic, and sexual identities
        Espelage DL, Liu GS, Valido A, Kuehl T, Basile KC, Nickodem KK.
        Prev Med. 2022 Jul 7:107146.
        Adolescent violence, including sexual violence, homophobic name-calling, and teen dating violence, are public health problems that cause harm to many adolescents in the United States. Although research on the perpetration of these forms of adolescent violence has increased in recent years, little is known about perpetration rates across gender, race/ethnicity, and sexual orientation. To address this gap, the current study descriptively examined perpetration rates between and across different identities, including self-identified race/ethnicity, sexual identity, and gender identity. In Fall 2017, 9th - 11th grade students (N = 4782) at 20 high schools in Colorado (United States) completed a survey that assessed demographics (e.g., race/ethnicity, sexual identity, and gender identity) and various forms of violence perpetration. Compared to female adolescents, male adolescents reported significantly higher perpetration rates for: any sexual violence (27% vs. 17%); sexual harassment (26% vs. 15%); unwanted sexual contact (8% vs. 4%); and homophobic name-calling (61% vs. 38%). Differences in perpetration rates were also observed among various racial/ethnic, sexual, and gender minority students compared to non-minority students. This emphasizes a need for more research on how minority stress that results from the dynamics of intersecting identities and societal systems of power-including racism, sexism, homophobia, and transphobia-contributes to violence perpetration. Evidence-based violence prevention approaches, particularly strategies targeted at changing social norms about violence, gender, and sexuality, need to be tailored and evaluated for students with diverse cultural and social identities to ensure safe school climates for all students.

    • Laboratory Sciences
      1. Accuracy of a handheld 3D imaging system for child anthropometric measurements in population-based household surveys and surveillance platforms: an effectiveness validation study in Guatemala, Kenya, and China
        Bougma K, Mei Z, Palmieri M, Onyango D, Liu J, Mesarina K, Akelo V, Mwando R, Zhou Y, Meng Y, Jefferds ME.
        Am J Clin Nutr. 2022 Jul 6;116(1):97-110.
        BACKGROUND: An efficacy evaluation of the AutoAnthro system to measure child (0-59 months) anthropometry in the United States found 3D imaging performed as well as gold-standard manual measurements for biological plausibility and precision. OBJECTIVES: We conducted an effectiveness evaluation of the accuracy of the AutoAnthro system to measure 0- to 59-month-old children's anthropometry in population-based surveys and surveillance systems in households in Guatemala and Kenya and in hospitals in China. METHODS: The evaluation was done using health or nutrition surveillance system platforms among 600 children aged 0-59 months (Guatemala and Kenya) and 300 children aged 0-23 months (China). Field team anthropometrists and their assistants collected manual and scan anthropometric measurements, including length or height, midupper arm circumference (MUAC), and head circumference (HC; China only), from each child. An anthropometry expert and assistant later collected both manual and scan anthropometric measurements on the same child. The expert manual measurements were considered the standard compared to field team scans. RESULTS: Overall, in Guatemala, Kenya, and China, for interrater accuracy, the average biases for length or height were -0.3 cm, -1.9 cm, and -6.2 cm, respectively; for MUAC were 0.9 cm, 1.2 cm, and -0.8 cm, respectively; and for HC was 2.4 cm in China. The inter-technical errors of measurement (inter-TEMs) for length or height were 2.8 cm, 3.4 cm, 5.5 cm, respectively; for MUAC were 1.1 cm, 1.5 cm, and 1.0 cm, respectively; and for HC was 2.8 cm in China. For intrarater precision, the absolute mean difference and intra-TEM (interrater, intramethod TEM) were 0.1 cm for all countries for all manual measurements. For scans, overall, absolute mean differences for length or height were 0.4-0.6 cm; for MUAC were 0.1-0.1 cm; and for HC was 0.4 cm. For the intra-TEM, length or height was 0.5 cm in Guatemala and China and 0.7 cm in Kenya, and other measurements were ≤0.3 cm. CONCLUSIONS: Understanding the factors that cause the many poor scan results and how to correct them will be needed prior to using this instrument in routine, population-based survey and surveillance systems.

      2. Error rates that have been published in recent open black box studies of forensic firearms examiner performance have been very low, typically below one percent. These low error rates have been challenged, however, as not properly taking into account one of the categories, "Inconclusive", that examiners can reach in comparing a pair of bullets or cartridges. These challenges have themselves been challenged; how to consider the inconclusives and their effect on error rates is currently a matter of sharp debate. We review several viewpoints that have been put forth, and then examine the impact of inconclusives on error rates from three fresh statistical perspectives: (a) an ideal perspective using objective measurements combined with statistical algorithms, (b) basic sampling theory and practice, and (c) standards of experimental design in human studies. Our conclusions vary with the perspective: (a) inconclusives can be simple errors (or, on the other hand, simply correct or at least well justified); (b) inconclusives need not be counted as errors to bring into doubt assessments of error rates; (c) inconclusives are potential errors, more explicitly, inconclusives in studies are not necessarily the equivalent of inconclusives in casework and can mask potential errors in casework. From all these perspectives, it is impossible to simply read out trustworthy estimates of error rates from those studies which have been carried out to date. At most, one can put reasonable bounds on the potential error rates. These are much larger than the nominal rates reported in the studies. To get straightforward, sound estimates of error rates requires a challenging but critical improvement to the design of firearms studies. A proper study-one in which inconclusives are not potential errors, and which yields direct, sound estimates of error rates-will require new objective measures or blind proficiency testing embedded in ordinary casework.

      3. Wastewater sequencing reveals early cryptic SARS-CoV-2 variant transmission
        Karthikeyan S, Levy JI, De Hoff P, Humphrey G, Birmingham A, Jepsen K, Farmer S, Tubb HM, Valles T, Tribelhorn CE, Tsai R, Aigner S, Sathe S, Moshiri N, Henson B, Mark AM, Hakim A, Baer NA, Barber T, Belda-Ferre P, Chacón M, Cheung W, Cresini ES, Eisner ER, Lastrella AL, Lawrence ES, Marotz CA, Ngo TT, Ostrander T, Plascencia A, Salido RA, Seaver P, Smoot EW, McDonald D, Neuhard RM, Scioscia AL, Satterlund AM, Simmons EH, Abelman DB, Brenner D, Bruner JC, Buckley A, Ellison M, Gattas J, Gonias SL, Hale M, Hawkins F, Ikeda L, Jhaveri H, Johnson T, Kellen V, Kremer B, Matthews G, McLawhon RW, Ouillet P, Park D, Pradenas A, Reed S, Riggs L, Sanders A, Sollenberger B, Song A, White B, Winbush T, Aceves CM, Anderson C, Gangavarapu K, Hufbauer E, Kurzban E, Lee J, Matteson NL, Parker E, Perkins SA, Ramesh KS, Robles-Sikisaka R, Schwab MA, Spencer E, Wohl S, Nicholson L, McHardy IH, Dimmock DP, Hobbs CA, Bakhtar O, Harding A, Mendoza A, Bolze A, Becker D, Cirulli ET, Isaksson M, Schiabor Barrett KM, Washington NL, Malone JD, Schafer AM, Gurfield N, Stous S, Fielding-Miller R, Garfein RS, Gaines T, Anderson C, Martin NK, Schooley R, Austin B, MacCannell DR, Kingsmore SF, Lee W, Shah S, McDonald E, Yu AT, Zeller M, Fisch KM, Longhurst C, Maysent P, Pride D, Khosla PK, Laurent LC, Yeo GW, Andersen KG, Knight R.
        Nature. 2022 Jul 7.
        As SARS-CoV-2 continues to spread and evolve, detecting emerging variants early is critical for public health interventions. Inferring lineage prevalence by clinical testing is infeasible at scale, especially in areas with limited resources, participation, or testing/sequencing capacity, which can also introduce biases(1-3). SARS-CoV-2 RNA concentration in wastewater successfully tracks regional infection dynamics and provides less biased abundance estimates than clinical testing(4,5). Tracking virus genomic sequences in wastewater would improve community prevalence estimates and detect emerging variants. However, two factors limit wastewater-based genomic surveillance: low-quality sequence data and inability to estimate relative lineage abundance in mixed samples. Here, we resolve these critical issues to perform a high-resolution, 295-day wastewater and clinical sequencing effort, in the controlled environment of a large university campus and the broader context of the surrounding county. We develop and deploy improved virus concentration protocols and deconvolution software that fully resolve multiple virus strains from wastewater. We detect emerging variants of concern up to 14 days earlier in wastewater samples, and identify multiple instances of virus spread not captured by clinical genomic surveillance. Our study provides a scalable solution for wastewater genomic surveillance that allows early detection of SARS-CoV-2 variants and identification of cryptic transmission.

    • Occupational Safety and Health
      1. A rapid review of collision avoidance and warning technologies for mining haul trucks
        Hrica J, Bellanca J, Benbourenane I, Carr J, Homer J, Stabryla K.
        Min Metall Explor. 2022 .
        Given the recent focus on powered haulage incidents within the US mining sector, an appraisal of collision avoidance/warning systems (CXSs) through the lens of the available research literature is timely. This paper describes a rapid review that identifies, characterizes, and classifies the research literature to evaluate the maturity of CXS technology through the application of a Technology Readiness Assessment. Systematic search methods were applied to three electronic databases, and relevant articles were identified through the application of inclusion and exclusion criteria. Sixty-four articles from 2000 to 2020 met these criteria and were categorized into seven CXS technology categories. Review and assessment of the articles indicates that much of the literature-based evidence for CXS technology lies within lower levels of maturity (i.e., components and prototypes tested under laboratory conditions and in relevant environments). However, less evidence exists for CXS technology at higher levels of maturity (i.e., complete systems evaluated within operational environments) despite the existence of commercial products in the marketplace. This lack of evidence at higher maturity levels within the scientific literature highlights the need for systematic peer-reviewed research to evaluate the performance of CXS technologies and demonstrate the efficacy of prototypes or commercial products, which could be fostered by more collaboration between academia, research institutions, manufacturers, and mining companies. Additionally, results of the review reveal that most of the literature relevant to CXS technologies is focused on vehicle-to-vehicle interactions. However, this contrasts with haul truck fatal accident statistics that indicate that most haul truck fatal accidents are due to vehicle-to-environment interactions (e.g., traveling through a berm). Lastly, the relatively small amount of literature and segmented nature of the included studies suggests that there is a need for incremental progress or more stepwise research that would facilitate the improvement of CXS technologies over time. This progression over time could be achieved through continued long-term interest and support for CXS technology research. 2022, This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

      2. Evolution and applications of recent sensing technology for occupational risk assessment: A rapid review of the literature
        Fanti G, Spinazzè A, Borghi F, Rovelli S, Campagnolo D, Keller M, Borghi A, Cattaneo A, Cauda E, Cavallo DM.
        Sensors (Basel). 2022 Jun 27;22(13).
        Over the last decade, technological advancements have been made available and applied in a wide range of applications in several work fields, ranging from personal to industrial enforcements. One of the emerging issues concerns occupational safety and health in the Fourth Industrial Revolution and, in more detail, it deals with how industrial hygienists could improve the risk-assessment process. A possible way to achieve these aims is the adoption of new exposure-monitoring tools. In this study, a systematic review of the up-to-date scientific literature has been performed to identify and discuss the most-used sensors that could be useful for occupational risk assessment, with the intent of highlighting their pros and cons. A total of 40 papers have been included in this manuscript. The results show that sensors able to investigate airborne pollutants (i.e., gaseous pollutants and particulate matter), environmental conditions, physical agents, and workers' postures could be usefully adopted in the risk-assessment process, since they could report significant data without significantly interfering with the job activities of the investigated subjects. To date, there are only few "next-generation" monitors and sensors (NGMSs) that could be effectively used on the workplace to preserve human health. Due to this fact, the development and the validation of new NGMSs will be crucial in the upcoming years, to adopt these technologies in occupational-risk assessment.

      3. Biological effects of inhaled crude oil vapor. II. Pulmonary effects
        Fedan JS, Thompson JA, Russ KA, Dey RD, Reynolds JS, Kashon ML, Jackson MC, McKinney W.
        Toxicol Appl Pharmacol. 2022 Jul 5;450:116154.
        Workers involved in oil exploration and production in the upstream petroleum industry are exposed to crude oil vapor (COV). COV levels in the proximity of workers during production tank gauging and opening of thief hatches can exceed regulatory standards, and several deaths have occurred after opening thief hatches. There is a paucity of information regarding the effects of COV inhalation in the lung. To address these knowledge gaps, the present hazard identification study was undertaken to investigate the effects of an acute, single inhalation exposure (6 h) or a 28 d sub-chronic exposure (6 h/d × 4 d/wk × 4 wks) to COV (300 ppm; Macondo well surrogate oil) on ventilatory and non-ventilatory functions of the lung in a rat model 1 and 28 d after acute exposure, and 1, 28 and 90 d following sub-chronic exposure. Basal airway resistance was increased 90 d post-sub-chronic exposure, but reactivity to methacholine (MCh) was unaffected. In the isolated, perfused trachea preparation the inhibitory effect of the airway epithelium on reactivity to MCh was increased at 90 d post-exposure. Efferent cholinergic nerve activity regulating airway smooth muscle was unaffected by COV exposure. Acute exposure did not affect basal airway epithelial ion transport, but 28 d after sub-chronic exposure alterations in active (Na(+) and Cl¯) and passive ion transport occurred. COV treatment did not affect lung vascular permeability. The findings indicate that acute and sub-chronic COV inhalation does not appreciably affect ventilatory properties of the rat, but transient changes in airway epithelium occur.

    • Parasitic Diseases
      1. Diagnostic performance of loop-mediated isothermal amplification and ultra-sensitive rapid diagnostic tests for malaria screening among pregnant women in Kenya
        Samuels AM, Towett O, Seda B, Wiegand RE, Otieno K, Chomba M, Lucchi N, Ljolje D, Schneider K, Gt P, Kwambai TK, Slutsker L, Ter Kuile FO, Kariuki SK.
        J Infect Dis. 2022 Jul 11.
        BACKGROUND: Screen-and-treat strategies with sensitive diagnostic tests may reduce malaria-associated adverse pregnancy outcomes. We conducted a diagnostic accuracy study to evaluate new point-of-care tests to screen pregnant women for malaria at their first antenatal visit in western Kenya. METHODS: Consecutively women were tested for Plasmodium infection by expert-microscopy, conventional rapid diagnostic test (cRDT), ultra-sensitive RDT (usRDT), and loop-mediated isothermal amplification (LAMP). Photo-induced electron-transfer polymerase-chain-reaction (PET-PCR) served as the reference standard. Diagnostic performance was calculated and modelled at low parasite densities. RESULTS: Between May-September 2018, 172 out of 482 screened participants (35.7%) were PET-PCR positive. Relative to PET-PCR, expert-microscopy was least sensitive (40.1%, 95% CI 32.7-47.9), followed by cRDT (49.4%, 41.7-57.1), usRDT (54.7%, 46.9-62.2), and LAMP (68.6%, 61.1-75.5). Test sensitivities were comparable in febrile women (N = 90). Among afebrile women (N = 392), the geometric-mean parasite density was 29 parasites/µL and LAMP (sensitivity = 61.9%) and usRDT (43.2%) detected 1.74 (1.31-2.30) and 1.21 (0.88-2.21) more infections than cRDT (35.6%). Per our model, tests performed similarly at densities >200 parasites/µL. At 50 parasites/µL, the sensitivities were 45%, 56%, 62% and 74% with expert-microscopy, cRDT, usRDT, and LAMP, respectively. CONCLUSIONS: This first-generation usRDT provided moderate improvement in detecting low-density infections in afebrile pregnant women compared to cRDTs.

    • Physical Activity
      1. Effect of cloth masks and N95 respirators on maximal exercise performance in collegiate athletes
        Darnell ME, Quinn TD, Carnahan SP, Carpenter T, Meglino N, Yorio PL, Doperak JM.
        Int J Environ Res Public Health. 2022 Jun 21;19(13).
        This study compared exercise performance and comfort while wearing an N95 filtering facepiece respirator (N95), cloth mask, or no intervention control for source control during a maximal graded treadmill exercise test (GXT). Twelve Division 1 athletes (50% female, age = 20.1 ± 1.2, BMI = 23.5 ± 1.6) completed GXTs under three randomized conditions (N95, cloth mask, control). GXT duration, heart rate (HR), respiration rate (RR), transcutaneous oxygen saturation (SpO(2)), transcutaneous carbon dioxide (TcPCO(2)), rating of perceived exertion (RPE), and perceived comfort were measured. Participants ran significantly longer in control (26.06 min) versus N95 (24.20 min, p = 0.03) or cloth masks (24.06 min, p = 0.04). No differences occurred in the slope of HR or SpO(2) across conditions (p &gt; 0.05). TcPCO(2) decreased faster in control (B = -0.89) versus N95 (B = 0.14, p = 0.02) or cloth masks (B = -0.26, p = 0.03). RR increased faster in control (B = 8.32) versus cloth masks (B = 6.20, p = 0.04). RPE increased faster in the N95 (B = 1.91) and cloth masks (B = 1.79) versus control (B = 1.59, p &lt; 0.001 and p = 0.05, respectively). Facial irritation/itching/pinching was higher in the N95 versus cloth masks, but sweat/moisture buildup was lower (p &lt; 0.05 for all). Wearing cloth masks or N95s for source control may impact exercise performance, especially at higher intensities. Significant physiological differences were observed between cloth masks and N95s compared to control, while no physiological differences were found between cloth masks and N95s; however, comfort my differ.

      2. The relationship between resistance training frequency and muscle quality in adolescents
        Naimo MA, Gu JK.
        Int J Environ Res Public Health. 2022 Jul 1;19(13).
        Previous research has established the role of resistance training (RT) on muscle function in adolescents, but a lack of evidence to optimize RT for enhancing muscle quality (MQ) exists. This study examined whether RT frequency is associated with MQ in a nationally representative adolescent cohort. A total of 605 adolescents (12-15 year) in NHANES were stratified based on RT frequency. MQ was calculated as combined handgrip strength divided by arm lean mass (via dual-energy X-ray absorptiometry). Analysis of covariance was adjusted for sex, race/ethnicity, and arm fat percentage; p &lt; 0.05 was considered significant. RT frequency was associated with MQ for 2-7 day/week but not 1 day/week. When no RT was compared to 1-2 and 3-7 day/week, associations were present for 3-7 day/week but not 1-2 day/week. When comparing no RT to 1-4 and 5-7 day/week, associations existed for 5-7 day/week but not 1-4 day/week. Next, no RT was compared to 1, 2-3, and 4-7 day/week; associations were found for 4-7 day/week, while 2-3 day/week had a borderline association (p = 0.06); there were no associations for 1 day/week. Finally, no RT was compared to 1, 2, 3, 4, and 5-7 day/week; associations were present for all except 1 and 3 day/week. These prospective data suggest a minimum RT frequency of 2 day/week is associated with MQ in adolescents as indicated by the lack of differences in MQ between 1 day/week RT versus no RT.

    • Reproductive Health
      1. Declines in pregnancies among US adolescents from 2007 to 2017: Behavioral contributors to the trend
        Goodreau SM, Pollock ED, Wang LY, Li J, Aslam MV, Katz DA, Hamilton DT, Rosenberg ES.
        J Pediatr Adolesc Gynecol. 2022 Jul 10.
        STUDY OBJECTIVES: Adolescents in the United States have undergone dramatic declines in pregnancies and births in recent decades. We aimed to estimate the contribution of changes in three proximal behaviors to these declines among 14-18-year-olds for 2007-2017: 1) delays in age at first sexual intercourse, 2) declines in number of sexual partners, and 3) changes in contraceptive use, particularly uptake of long-acting reversible contraception (LARC). DESIGN: We adapted an existing iterative dynamic population model and parameterized it using six waves of the Centers for Disease Control and Prevention's Youth Risk Behavior Survey. We compared pregnancies from observed behavioral trends with counterfactual scenarios that assumed constant behaviors over the decade. We calculated outcomes by cause, year and age. RESULTS: We found that changes in these behaviors could explain reductions of 496,200, 78,500, and 40,700 pregnancies over the decade, respectively, with total medical and societal cost savings of $9.71 billion, $1.54 billion, and $796 million. LARC adoption, particularly among 18-year-olds, could explain much of the improvements from contraception use. The three factors together did not fully explain observed birth declines; adding a 50% decline in sex acts per partner did. CONCLUSIONS: Delays in first sexual intercourse contributed the most to declining births over this decade, although all behaviors considered had major effects. Differences from earlier models may result from differences in years and ages covered. Evidence-based teen pregnancy prevention programs, including comprehensive sex education, youth-friendly reproductive health services and parental and community support can continue to address these drivers and reduce teen pregnancy.

    • Substance Use and Abuse

    • Zoonotic and Vectorborne Diseases
      1. Heterogeneity in dog population characteristics contributes to chronic under-vaccination against rabies in Guatemala
        Moran D, Alvarez D, Cadena L, Cleaton J, Salyer SJ, Pieracci EG, Camposeco LR, Bernal S, Wallace RM.
        PLoS Negl Trop Dis. 2022 Jul 7;16(7):e0010522.
        Guatemala has held dog rabies mass vaccination campaigns countrywide since 1984, yet the virus remains endemic. To eliminate dog-mediated human rabies, dog vaccination coverage must reach at least 70%. The Guatemala rabies program uses a 5:1 human:dog ratio (HDR) to estimate the vaccination coverage; however, this method may not accurately reflect the heterogeneity of dog ownership practices in Guatemalan communities. We conducted 16 field-based dog population estimates in urban, semi-urban and rural areas of Guatemala to determine HDR and evaluate the standard 5:1. Our study-derived HDR estimates varied from 1.7-11.4:1 (average 4.0:1), being higher in densely populated sites and lowest in rural communities. The community-to-community heterogeneity observed in dog populations could explain the persistence of rabies in certain communities. To date, this is the most extensive dog-population evaluation conducted in Guatemala, and can be used to inform future rabies vaccination campaigns needed to meet the global 2030 rabies elimination targets.


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