Current Issue

CDC Science Clips: Volume 11, Issue 32, August 13, 2019

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • OBJECTIVE: Nontraumatic lower-extremity amputation (NLEA) is a complication of end-stage renal disease (ESRD) and diabetes. Although recent data show that NLEA rates in the U.S. ESRD population are declining overall, trends in diabetes and diabetes subgroups remain unclear. RESEARCH DESIGN AND METHODS: We estimated annual rates of NLEA hospitalizations during 2000-2015 among >2 million adults (>/=18 years) with ESRD from the U.S. Renal Data System. Age, sex, and race-adjusted NLEA rates were stratified by diabetes status, age, sex, race, and level of amputation (toe, foot, below the knee, and above the knee). Time trends were assessed using Joinpoint regression with annual percent changes (APC) reported. RESULTS: Among adults with diabetes, NLEA rates declined 43.8% between 2000 and 2013 (from 7.5 to 4.2 per 100 person-years; APC -4.9, P < 0.001) and then stabilized. Among adults without diabetes, rates of total NLEAs declined 25.5% between 2000 and 2013 (from 1.6 to 1.1; APC -3.0, P < 0.001) and then stabilized. These trends appear to be driven by a slowing or stagnation in declines of minor NLEAs (toe and foot) in more recent years, while major NLEAs (above the knee) continue to decline. CONCLUSIONS: Despite an initial period of decline, this analysis documents a stall in progress in NLEA trends in recent years in a high-risk population with both ESRD and diabetes. Increased attention to preventive foot care in the ESRD population should be considered, particularly for those with diabetes.

    • Communicable Diseases
      • Barriers and facilitators for antiretroviral treatment adherence among HIV-positive African American and Latino men who have sex with menexternal icon
        Carey JW, Carnes N, Schoua-Glusberg A, Kenward K, Gelaude D, Denson DJ, Gall E, Randall LA, Frew PM.
        AIDS Educ Prev. 2019 Aug;31(4):306-324.
        Some Black/African American and Hispanic/Latino men who have sex with men (MSM) living with HIV do not take antiretroviral therapy (ART). We conducted semistructured interviews with 84 adult, Black/African American and Hispanic/Latino MSM with HIV to understand ART barriers and facilitators. We used chi-square statistics to identify factors associated with ART use (p </= .05), and selected illustrative quotes. Over half (51.2%) said they followed their doctor’s instructions; however, only 27.4% reported consistently taking ART. Some men delayed ART until overcoming diagnosis denial or becoming very sick. ART use was facilitated by encouragement from others, treatment plans, side effect management, lab test improvements, pill-taking reminders, and convenient care facilities that provide “one-stop shop” services. Men were more likely to take ART when having providers who communicated effectively and were perceived to treat them with respect. Healthcare personnel can use our findings to strengthen services for MSM of color.

    • Disease Reservoirs and Vectors
      • Estimating the effectiveness of vaccine programs in dog populationsexternal icon
        Wallace RM, Undurraga EA, Gibson A, Boone J, Pieracci EG, Gamble L, Blanton JD.
        Epidemiol Infect. 2019 Jan;147:e247.
        Dogs harbor numerous zoonotic pathogens, many of which are controlled through vaccination programs. The delivery of these programs can be difficult where resources are limited. We developed a dynamic model to estimate vaccination coverage and cost-per-dog vaccinated. The model considers the main factors that affect vaccination programs: dog demographics, effectiveness of strategies, efficacy of interventions and cost. The model was evaluated on data from 18 vaccination programs representing eight countries. Sensitivity analysis was performed for dog confinement and vaccination strategies. The average difference between modelled vaccination coverage and field data was 3.8% (2.3%-5.3%). Central point vaccination was the most cost-effective vaccination strategy when &gt;88% of the dog population was confined. More active methods of vaccination, such as door-to-door or capture-vaccinate-release, achieved higher vaccination coverage in free-roaming dog populations but were more costly. This open-access tool can aid in planning more efficient vaccination campaigns in countries with limited resources.

    • Environmental Health
      • Many local health departments (LHDs) across the country coordinate with their service areas on environmental health or land reuse. The Brownfields & Reuse Opportunity Working Group (BROWN) is a multipartner land reuse stakeholder network that includes member representatives from state and local health agencies, federal agencies, environmental consultants, environmental health professionals, and academia. In 2015, BROWN provided input on five Environmental Health Resources Self Learning Modules (Epidemiology, Risk Assessment, Risk Communications, Land Reuse Sites, and Toxicology) that the Agency for Toxic Substances and Disease Registry (ATSDR) was developing. ATSDR created the educational modules as resources and self-study guides to increase LHD capacity to respond to environmental issues. Following input from BROWN members on the modules, the National Environmental Health Association independently developed a short survey to identify baseline capacity of environmental professionals, primarily LHD professionals, to address environmental health and land reuse issues. The survey results of 93 LHD personnel indicated variation in the level of education among LHD employees and how often specific environmental health and land reuse services were requested. A subset of three LHD respondents also provided input into the learning modules.

    • Genetics and Genomics
    • Global Health
      • BACKGROUND: In September 2009, the Machinga Integrated Antenatal Water Hygiene Kit Program began addressing problems of unsafe water, high infant mortality, and low antenatal care (ANC) attendance in Machinga District, Malawi. In March 2011, the supporting international non-governmental organization transitioned management of the program to the Machinga District Health Office (DHO). We evaluated maternal and HIV service use before and after program transition to the DHO. METHODS: We compared pre- and post-transition periods by examining data recorded in ANC and maternal registries in 15 healthcare facilities (HCFs) by proportion z-tests. We classified HCFs by size, using the median monthly patient volumes as the split for large or small facilities. We used logistic regression to evaluate changes in the use of ANC, maternal, and HIV services and their interactions with HCF size. RESULTS: The percentage of women attending their first ANC visit during the first trimester was similar in the pre-and post-transition periods (9.3% vs 10.2%). Although the percentage of women with >/=4 ANC visits was similar from pre- to post-transition (26.0% vs 24.8%), the odds increased among women in small facilities (OR: 1.37, 95% CI: 1.24-1.51), and decreased among women in large facilities (OR: 0.80, 95% CI: 0.75-0.85). Although a similar percentages of pregnant women were diagnosed with HIV in all HCFs in the pre- and post-transitions periods (6.4% vs 4.8%), a substantially larger proportion of women were not tested for HIV in large HCFs (OR: 6.34, 95% CI: 5.88-6.84). A larger proportion of women gave birth at both small (OR: 1.30, 95% CI: 1.16-1.45) and large HCFs (OR: 1.55, 95% CI: 1.43-1.67) in the post-transition vs. the pre-transition period. CONCLUSIONS: The evaluation results suggest that many positive aspects of this donor-supported program continued following transition of program management from a non-governmental organization to a DHO.

    • Immunity and Immunization
    • Injury and Violence
      • Psychopathy traits and violent assault among men with and without history of arrestexternal icon
        Reidy DE, Lilienfeld SO, Berke DS, Gentile B, Zeichner A.
        J Interpers Violence. 2019 Jun;34(12):2438-2457.
        Although research suggests that the antisocial behavior (ASB) facet of psychopathy generally carries the greatest predictive power for future violence, these findings are drawn primarily from forensic samples and may reflect criterion contamination between historical violence and future violence perpetration. Likewise, these findings do not negate the association of other psychopathy facets to violence or their role in the development of violence, nor do they offer practical utility in the primary prevention of violence. There are a number of empirical and theoretical reasons to suspect that the callous affect (CA) facet of psychopathy may demonstrate stronger statistical association to violence in nonforensic populations. We tested the association of CA to severe acts of violence (e.g., assault with intent to harm, injure, rape, or kill) among men with and without history of arrest ( N = 600) using both the three- and four-facet models of psychopathy. CA was robustly associated with violence outcomes across the two groups in the three-facet model. When testing the four-facet model, CA was strongly associated with violence outcomes among men with no history of arrest, but only moderately associated with assaults causing injury among men with history of arrest. These results are consistent with data from youth populations that implicate early emotional deficits in later aggressive behavior and suggest CA may help to identify individuals at risk for violence before they become violent. Implications for the public health system and the primary prevention of violence are discussed.

    • Occupational Safety and Health – Mining
      • BACKGROUND: The purpose of this study was to estimate the prevalence of hearing loss (HL) among noise-exposed US workers within the Mining, and Oil and Gas Extraction (OGE) sectors. METHODS: Audiograms of 1.9 million workers across all industries (including 9389 in Mining and 1076 in OGE) from 2006 to 2015 were examined. Prevalence and adjusted risk as compared to a reference industry (Couriers and Messengers) were estimated for all industries combined and the Mining and OGE sectors and subsectors. RESULTS: The prevalences of HL in Mining and OGE were 24% and 14%, respectively, compared with 16% for all industries combined. Many Mining and one OGE subsector exceeded these prevalences and most had an adjusted risk (prevalence ratio) significantly greater than the reference industry. Some subsectors, particularly in OGE, could not be examined due to low sample size. The prevalences in Construction Sand and Gravel Mining and Natural Gas Liquid Extraction were 36% and 28%, respectively. Workers within Support Activities for Coal Mining had double the risk of HL than workers in the reference industry. CONCLUSIONS: The many subsectors identified with high prevalences and/or worker risks for HL well above risks in the reference industry need critical attention to conserve worker hearing and maintain worker quality of life. Administrative and engineering controls can reduce worker hazardous noise exposures. Noise and ototoxic chemical exposure information is needed for many subsectors, as is audiometric testing results for OGE workers. Additional research is also needed to further characterize exposures and improve hearing conservation measures.

    • Public Health Law
      • How are telehealth laws intersecting with laws addressing the opioid overdose epidemic?external icon
        Pepin D, Hulkower R, McCord RF.
        J Public Health Manag Pract. 2019 Jul 24.
        Opioid-involved drug overdose deaths have been a growing concern in the United States for several decades. The Centers for Disease Control and Prevention identified several strategies to address the opioid overdose epidemic, including increased availability of and access to medication-assisted treatment and guidance on safer opioid prescribing practices. Telehealth offers the potential for increasing access and availability to these strategies, and laws governing telehealth have implications for their utilization. To understand how state telehealth laws intersect with the opioid overdose epidemic, we conducted a legal mapping study, a type of legal epidemiological assessment, of statutes and regulations that intersect at telehealth and opioids. This search yielded 28 laws from 17 states. These laws intersect both telehealth and the opioid overdose epidemic in different ways including prescribing limitations, opioid treatment through medication and counseling, patient plan review, and professional collaboration. Continued legal and policy surveillance is needed to be able to evaluate the impact of law in addressing opioid overdose outcomes.

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Providers’ perspectives on treating patients with thalassemiaexternal icon
        Radke T, Paulukonis S, Hulihan MM, Feuchtbaum L.
        J Pediatr Hematol Oncol. 2019 Jul 25.
        In recent years, California has experienced a steady rise in Asian immigration which has led to a corresponding increased prevalence of clinically significant thalassemia in this state. As part of the Public Health Research, Education and Surveillance for Hemoglobinopathies emoglobinopathies project, a survey was developed to collect information from California providers who care for thalassemia patients in an effort to better understand their practice patterns, barriers to providing care, and educational needs. When asked about educational needs, providers most frequently expressed a desire for care and management guidelines (65.3%), health educational materials for patients (47.2%), and information on complications and clinical outcomes (32.1%). Only one quarter of providers (24.0%) reported that all of their thalassemia patients have a coordinated care plan. The increase in California thalassemia cases highlights the importance of provider knowledge to effectively serve the patients in their communities. Provider education and dissemination of treatment standards can not only improve knowledge about the disease but also increase awareness about the importance of coordinating care among a multidisciplinary team of specialists. Improvement in these areas will help achieve the overarching goal of better outcomes and quality of life for patients with thalassemia.

      2. Should women with gestational diabetes be screened at delivery hospitalization for type-2 diabetes?external icon
        Waters TP, Kim SY, Werner E, Dinglas C, Carter EB, Patel R, Sharma AJ, Catalano P.
        Am J Obstet Gynecol. 2019 Jul 24.
        BACKGROUND: Less than half of women with gestational diabetes mellitus (GDM) are screened for type 2 diabetes (DM) postpartum (PP). Other approaches to postpartum screening need to be evaluated including the role of screening during the delivery hospitalization OBJECTIVE: Our aim was to assess the performance of an oral glucose tolerance test (OGTT) administered during the delivery hospitalization compared to the OGTT administered at a 4-12 week PP visit. STUDY DESIGN: We conducted a combined analysis of patient-level data from four centers (six clinical sites) assessing the utility of an immediate postpartum 75g OGTT during the delivery hospitalization (PP1) for the diagnosis of DM compared to a routine 4-12 week postpartum OGTT (PP2). Eligible women underwent a 75g OGTT at both PP1 and PP2. Sensitivity, specificity, negative and positive predictive values of the PP1 test were estimated for diagnosis of DM, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT). RESULTS: 319 women completed a PP1 screening with 152 (47.6%) lost to follow up for the PP2 OGTT. None of the women with a normal PP1 OGTT (n=73) later tested as having type 2 diabetes at PP2. Overall, 12.6% of subjects (n=21) had a change from normal to IFG/IGT or a change from IFG/IGT to DM. The PP1 OGTT had 50% sensitivity (11.8-88.2), 95.7% specificity (91.3-98.2%) with a 98.1% (94.5-99.6%) negative predictive value and a 30% (95% CI 6.7-65.3) positive predictive value for DM vs normal/IFG/IGT result. The negative predictive value of having DM at PP2 compared to a normal OGTT (excluding IFT/IGT) at PP1 was 100% (95% CI, 93.5-100) with a specificity of 96.5% (95% CI, 87.9- 99.6). CONCLUSION: A normal OGTT during the delivery hospitalization appears to exclude postpartum type-2 diabetes mellitus. However the results of the immediate postpartum OGTT were mixed when including IFG or IGT. As a majority of women do not return for postpartum diabetic screening, an OGTT during the delivery hospitalization may be of use in certain circumstances where postpartum follow up is challenging and resources could be focused on women with an abnormal screening immediately after the delivery hospitalization.

      3. Cancer risk among older adults: Time for cancer prevention to go silverexternal icon
        White MC, Holman D, Goodman RA, Richardson LC.
        Gerontologist. 2019 ;59:S1-S6.
        Over two-thirds of all new cancers are diagnosed among adults aged >/=60 years. As the number of adults living to older ages continues to increase, so too will the number of new cancer cases. Can we do more as a society to reduce cancer risk and preserve health as adults enter their 60s, 70s, and beyond? Cancer development is a multi-step process involving a combination of factors. Each cancer risk factor represents a component of cancer causation, and opportunities to prevent cancer may exist at any time up to the final component, even years after the first. The characteristics of the community in which one lives often shape cancer risk-related behaviors and exposures over time, making communities an ideal setting for efforts to reduce cancer risk at a population level. A comprehensive approach to cancer prevention at older ages would lower exposures to known causes of cancer, promote healthy social and physical environments, expand the appropriate use of clinical preventive services, and engage older adults in these efforts. The collection of articles in this supplement provide innovative insights for exciting new directions in research and practice to expand cancer prevention efforts for older adults. This brief commentary sets the stage for the papers that follow.

    • Communicable Diseases
      1. Excellence in viral hepatitis elimination – lessons from Georgiaexternal icon
        Averhoff F, Lazarus JV, Sergeenko D, Colombo M, Gamkrelidze A, Tsertsvadze T, Butsashvili M, Metreveli D, Sharvadze L, Hellard M, Gnes S, Gabunia T, Nasrullah M.
        J Hepatol. 2019 Jul 4.

        [No abstract]

      2. Age-related differences in hospitalization rates, clinical presentation, and outcomes among older adults hospitalized with influenza – U.S. Influenza Hospitalization Surveillance Network (FluSurv-NET)external icon
        Czaja CA, Miller L, Alden N, Wald HL, Cummings CN, Rolfes MA, Anderson EJ, Bennett NM, Billing LM, Chai SJ, Eckel S, Mansmann R, McMahon M, Monroe ML, Muse A, Risk I, Schaffner W, Thomas AR, Yousey-Hindes K, Garg S, Herlihy RK.
        Open Forum Infect Dis. 2019 Jul 1;6(7).
        BACKGROUND: Rates of influenza hospitalizations differ by age, but few data are available regarding differences in laboratory-confirmed rates among adults aged >/=65 years. METHODS: We evaluated age-related differences in influenza-associated hospitalization rates, clinical presentation, and outcomes among 19 760 older adults with laboratory-confirmed influenza at 14 FluSurv-NET sites during the 2011-2012 through 2014-2015 influenza seasons using 10-year age groups. RESULTS: There were large stepwise increases in the population rates of influenza hospitalization with each 10-year increase in age. Rates ranged from 101-417, 209-1264, and 562-2651 per 100 000 persons over 4 influenza seasons in patients aged 65-74 years, 75-84 years, and >/=85 years, respectively. Hospitalization rates among adults aged 75-84 years and >/=85 years were 1.4-3.0 and 2.2-6.4 times greater, respectively, than rates for adults aged 65-74 years. Among patients hospitalized with laboratory-confirmed influenza, there were age-related differences in demographics, medical histories, and symptoms and signs at presentation. Compared to hospitalized patients aged 65-74 years, patients aged >/=85 years had higher odds of pneumonia (aOR, 1.2; 95% CI, 1.0-1.3; P = .01) and in-hospital death or transfer to hospice (aOR, 2.1; 95% CI, 1.7-2.6; P < .01). CONCLUSIONS: Age-related differences in the incidence and severity of influenza hospitalizations among adults aged >/=65 years can inform prevention and treatment efforts, and data should be analyzed and reported using additional age strata.

      3. Injection practices and sexual behaviors among persons with diagnosed HIV infection who inject drugs – United States, 2015-2017external icon
        Dasgupta S, Tie Y, Lemons A, Wu K, Burnett J, Shouse RL.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):653-657.
        During 2016, 6% of persons in the United States who received a diagnosis of human immunodeficiency virus (HIV) infection had their HIV infection attributed to injection drug use (1). Injection practices and sexual behaviors among HIV-positive persons who inject drugs, such as injection equipment sharing and condomless sex, can increase HIV transmission risk; nationally representative estimates of the prevalences of these behaviors are lacking. The Medical Monitoring Project (MMP) is an annual, cross-sectional survey that reports nationally representative estimates of clinical and behavioral characteristics among U.S. adults with diagnosed HIV (2). CDC used MMP data to assess high-risk injection practices and sexual behaviors among HIV-positive persons who injected drugs during the preceding 12 months and compared their HIV transmission risk behaviors with those of HIV-positive persons who did not inject drugs. During 2015-2017, approximately 10% (weighted percentage estimate) of HIV-positive persons who injected drugs engaged in distributive injection equipment sharing (giving used equipment to another person for use); nonsterile syringe acquisition and unsafe disposal methods were common. Overall, among HIV-positive persons who injected drugs, 80% received no treatment, and 57% self-reported needing drug or alcohol treatment. Compared with HIV-positive persons who did not inject drugs, those who injected drugs were more likely to have a detectable viral load (48% versus 35%; p = 0.008) and engage in high-risk sexual behaviors (p<0.001). Focusing on interventions that reduce high-risk injection practices and sexual behaviors and increase rates of viral suppression might decrease HIV transmission risk among HIV-positive persons who inject drugs. Successful substance use treatment could also lower risk for transmission and overdose through reduced injection.

      4. Previous research indicates a high burden of depression among adults living with HIV and an association between depression and poor HIV clinical outcomes. National estimates of diagnosed depression, depression treatment status, and association with HIV clinical outcomes are lacking. We used 2009-2014 data from the Medical Monitoring Project to estimate diagnosed depression, antidepressant treatment status, and associations with sustained viral suppression (all viral loads in past year < 200 copies/mL). Data were obtained through interview and medical record abstraction and were weighted to account for unequal selection probabilities and non-response. Of adults receiving HIV medical care in the U.S. and prescribed ART, 27% (95% confidence interval [CI] 25-29%) had diagnosed depression during the surveillance period; the majority (65%) were prescribed antidepressants. The percentage with sustained viral suppression was highest among those without depression (72%, CI 71-73%) and lowest among those with untreated depression (66%, CI 64-69%). Compared to those without depression, those with a depression diagnosis were less likely to achieve sustained viral suppression (aPR 0.95, CI 0.93-0.97); this association held for persons with treated depression compared to no depression (aPR 0.96, CI 0.94-0.99) and untreated depression compared to no depression (aPR 0.92, CI 0.89-0.96). The burden of depression among adults living with HIV in care is high. While in our study depression was only minimally associated with a lower prevalence of sustained viral suppression, diagnosing and treating depression in persons living with HIV remains crucial in order to improve mental health and avoid other poor health outcomes.

      5. OBJECTIVES: Within the context of rising rates of reportable STIs in the USA, we used national survey data to examine temporal trends in high-risk factors that indicate need for STI/HIV preventive services among key subpopulations with disproportionate STI rates. METHODS: We used data from the 2002 (n=12 571), 2006-2010 (n=22 682) and 2011-2015 (n=20 621) National Survey of Family Growth (NSFG). NSFG is a national probability survey of 15-44 year olds living in US households. We examined STI risk factors among sexually active men who have sex with men (MSM) and Hispanic, non-Hispanic black, 15-19 year old, 20-24 year old, and 25-29 year old women who have sex with men (WSM) and men who have sex with women (MSW). Risk behaviours included: received money or drugs for sex, gave money or drugs for sex, partner who injected drugs, partner who has HIV, non-monogamous partner (WSM, MSW only) and male partner who had sex with other men (WSM only). Endorsement of any of these behaviours was recoded into a composite variable focusing on factors indicating increased STI risk (yes/no). We used chi-squares and logistic regression (calculating predicted marginals to estimate adjusted prevalence ratios (aPRs)) to examine STI risk factors over time among the key subpopulations. RESULTS: From 2002 to 2011-2015, reported STI risk factors did not change or declined over time among key subpopulations in the USA. In adjusted analyses comparing 2002 to 2011-2015, we identified significant declines among WSM: Hispanics (aPR=0.84 (0.68-1.04), non-Hispanic blacks (aPR=0.69 (0.58-0.82), adolescents (aPR=0.71 (0.55-0.91) and 25-29 year olds (aPR=0.76 (0.58-0.98); among MSW: Hispanics (aPR=0.53 (0.40-0.70), non-Hispanic blacks (aPR=0.74 (0.59-0.94) and adolescents (aPR=0.63 (0.49-0.82); and among MSM (aPR=0.53 (0.34-0.84). CONCLUSIONS: While reported STIs have increased, STI risk factors among key subpopulations were stable or declined. Condom use related to these risk factors, sexual mixing patterns and STI testing should be examined.

      6. Threefold increases in population HIV viral load suppression among men and young adults – Bukoba Municipal Council, Tanzania, 2014-2017external icon
        MacKellar D, Steiner C, Rwabiyago OE, Cham HJ, Pals S, Maruyama H, Msumi O, Kundi G, Byrd J, Weber R, Madevu-Matson C, Kazaura K, Rutachunzibwa T, Mmari E, Morales F, Justman J, Cain K, Rwebembera A.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):658-663.
        Reducing HIV-related morbidity and mortality, and effectively eliminating HIV transmission risk, depends on use of antiretroviral therapy (ART) to achieve and maintain viral load suppression (VLS)* (1,2). By 2020, sub-Saharan African countries are working to achieve VLS among 90% of persons using ART and 73% of all persons living with HIV infection (1). In Tanzania, a country with 1.4 million persons with HIV infection, 49.6% of HIV-positive persons aged 15-49 years had achieved VLS in 2017, including only 21.5% of men and 44.6% of women aged 25-29 years (3). To identify interventions that might increase VLS in Tanzania, and reduce VLS-associated sex and age-group disparities, the Bukoba Combination Prevention Evaluation (BCPE) scaled up new HIV testing, linkage to care, and retention on ART interventions throughout Bukoba Municipal Council (Bukoba), Tanzania, during October 2014-March 2017 (4,5). Located on the western shore of Lake Victoria, Bukoba is a mixed urban and rural municipality of 150,000 persons and capital of Kagera Region. Of the 31 regions of Tanzania, Kagera has the fourth highest prevalence of HIV infection (6.8%) among residents aged 15-49 years (3). CDC analyzed data from BCPE preintervention and postintervention surveys and found that VLS prevalence among HIV-positive Bukoba residents aged 18-49 years increased approximately twofold overall (from 28.6% to 64.8%) and among women (33.3% to 67.8%) and approximately threefold among men (20.5% to 59.1%) and young adults aged 18-29 years (15.6% to 56.7%). During 2017, BCPE facility-based testing and linkage interventions were approved as new service delivery models by the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children (4,5). After a successful rollout to 208 facilities in 11 regions in 2018, BCPE interventions are being scaled up in all regions of Tanzania in 2019 with support from the United States President’s Emergency Plan for AIDS Relief (PEPFAR).

      7. Declining incidence of invasive meningococcal disease in South Africa: 2003-2016external icon
        Meiring S, Cohen C, de Gouveia L, du Plessis M, Kularatne R, Hoosen A, Lekalakala R, Lengana S, Seetharam S, Naicker P, Quan V, Reubenson G, Tempia S, von Mollendorf C, von Gottberg A.
        Clin Infect Dis. 2018 Oct 23.
        Background: Invasive meningococcal disease (IMD) is endemic to South Africa, where vaccine use is negligible. We describe the epidemiology of IMD in South Africa. Methods: IMD cases were identified through a national laboratory-based surveillance programme, GERMS-SA, from 2003-2016. Clinical data on outcome and HIV status were available from 26 sentinel hospital sites. We conducted space-time analysis to detect clusters of serogroup-specific IMD. Results: Over 14 years, 5249 IMD cases were identified. Incidence was 0.97 cases per 100000 persons in 2003, peaked at 1.4 in 2006 and declined to 0.23 in 2016. Serogroup was confirmed in 3917 (75%) cases – serogroup A 5%, B 23%, C 9%, W 50%, Y 12%, X 0.3%, Z 0.1% and non-groupable 0.4%. Eight serogroup-specific geo-temporal clusters of disease were identified. Isolate susceptibility was 100% to ceftriaxone, 95% penicillin and 99.9% ciprofloxacin. In-hospital case-fatality was 17% (247/1479). Of those tested, 36% (337/947) were HIV-infected. IMD incidence in HIV-infected persons was higher for all age categories with age-adjusted relative risk ratio (aRRR) of 2.5 (95% CI 2.2-2.8, P<0.001) from 2012-2016. No patients reported previous meningococcal vaccine exposure. Patients with serogroup W were 3 times more likely to present with severe disease than those with serogroup B (aRRR 2.7 (95% CI 1.1-6.3)); HIV coinfection was twice as common with W and Y disease (aRRR W=1.8 (95% CI 1.1-2.9), Y=1.9 (95% CI 1.0-3.4)). Conclusion: In the absence of significant vaccine use, IMD in South Africa decreased by 76% from 2003-2016. HIV was associated with increased risk of IMD, especially serogroup W and Y disease.

      8. Respiratory syncytial virus hospitalisations among young children: a data linkage studyexternal icon
        Prasad N, Newbern EC, Trenholme AA, Wood T, Thompson MG, Aminisani N, Huang QS, Grant CC.
        Epidemiol Infect. 2019 Jan;147:e246.
        We aimed to provide comprehensive estimates of laboratory-confirmed respiratory syncytial virus (RSV)-associated hospitalisations. Between 2012 and 2015, active surveillance of acute respiratory infection (ARI) hospitalisations during winter seasons was used to estimate the seasonal incidence of laboratory-confirmed RSV hospitalisations in children aged &lt;5 years in Auckland, New Zealand (NZ). Incidence rates were estimated by fine age group, ethnicity and socio-economic status (SES) strata. Additionally, RSV disease estimates determined through active surveillance were compared to rates estimated from hospital discharge codes. There were 5309 ARI hospitalisations among children during the study period, of which 3923 (73.9%) were tested for RSV and 1597 (40.7%) were RSV-positive. The seasonal incidence of RSV-associated ARI hospitalisations, once corrected for non-testing, was 6.1 (95% confidence intervals 5.8-6.4) per 1000 children &lt;5 years old. The highest incidence was among children aged &lt;3 months. Being of indigenous Maori or Pacific ethnicity or living in a neighbourhood with low SES independently increased the risk of an RSV-associated hospitalisation. RSV hospital discharge codes had a sensitivity of 71% for identifying laboratory-confirmed RSV cases. RSV infection is a leading cause of hospitalisation among children in NZ, with significant disparities by ethnicity and SES. Our findings highlight the need for effective RSV vaccines and therapies.

      9. BACKGROUND: Hepatitis B virus (HBV) can transmit through needle sharing. National HBV infection prevalence in persons who inject drugs remains ill-defined. We estimated the prevalence of total HBV core antibody (anti-HBc) positivity, indicating previous or ongoing HBV infection, among adults aged 20-59 years with injection drug use (IDU) history. We compared select characteristics by anti-HBc status. METHODS: Using 2001-2016 National Health and Nutrition Examination Survey data, we calculated anti-HBc+ prevalence among adults with IDU history and among the general US population. For adults with IDU history, we compared sex, age group, birth cohort, race/ethnicity, health insurance coverage, and hepatitis A immunity by anti-HBc status. Using marginal structural models, we calculated model-adjusted prevalence rates and ratios to determine characteristics associated with anti-HBc positivity among adults with IDU history. RESULTS: From 2001-2016, anti-HBc+ prevalence was 19.7% (95% CI, 16.0%-24.0%) among those with IDU history compared with 4.6% (95% CI, 4.3%-5.0%) in the general population. HBsAg+ prevalence was 0.4% (95% CI, 0.3%-0.5%) in the general population. Among adults with IDU history, 19.8% reported past year IDU and 28.5% had hepatitis A immunity. CONCLUSION: One-fifth of adults with IDU history had previous or ongoing HBV infection, which was over four times higher than the prevalence in the general population. One-fifth of adults with IDU history reported past year use. Programs promoting safe IDU practices, drug treatment, and hepatitis A and B vaccination should be key components of viral hepatitis prevention.

      10. Measles outbreak at a privately operated detention facility: Arizona, 2016external icon
        Venkat H, Briggs G, Brady S, Komatsu K, Hill C, Leung J, Patel M, Livar E, Su CP, Kassem A, Sowers SB, Mercader S, Rota PA, Elson D, Timme E, Robinson S, Fitzpatrick K, Franco J, Hickman C, Gastanaduy PA.
        Clin Infect Dis. 2019 May 30;68(12):2018-2025.
        BACKGROUND: We describe a measles outbreak and control measures implemented at a privately operated detention facility housing US Immigration and Customs Enforcement detainees in 2016. METHODS: Case-patients reported fever and rash and were either laboratory-confirmed or had an epidemiological link to a laboratory-confirmed case-patient. Immunoglobulin G (IgG) avidity and plaque reduction neutralization tests distinguished between primary acute and reinfection case-patients. Measles-specific IgG was measured to assess detainee immunity levels. We compared attack rates (ARs) among detainees and staff, between IgG-negative and IgG-positive detainees, and by detainee housing units and sexes. RESULTS: We identified 32 measles case-patients (23 detainees, 9 staff); rash onsets were during 6 May-26 June 2016. High IgG avidity and neutralizing-antibody titers >40000 to measles (indicating reinfection) were identified in 18 (95%) and 15 (84%) of 19 tested case-patients, respectively. Among 205 unit A detainees tested for presumptive immunity, 186 (91%) had detectable IgG. Overall, the AR was 1.65%. ARs were significantly higher among detainees in unit A (7.05%) compared with units B-F (0.59%), and among male (2.33%) compared with female detainees (0.38%); however, ARs were not significantly different between detainees and staff or between IgG-negative and IgG-positive detainees. Control measures included the vaccination of 1424 of 1425 detainees and 190 of 510 staff, immunity verification for 445 staff, case-patient isolation, and quarantine of affected units. CONCLUSIONS: Although ARs were low, measles outbreaks can occur in intense-exposure settings, despite a high population immunity, underscoring the importance of high vaccination coverage and containment in limiting measles transmission.

      11. Methods to include persons living with HIV not receiving HIV care in the Medical Monitoring Projectexternal icon
        Wei SC, Messina L, Hood J, Hughes A, Jaenicke T, Johnson K, Mena L, Scheer S, Udeagu CC, Wohl A, Robertson M, Prejean J, Chen M, Tang T, Bertolli J, Johnson CH, Skarbinski J.
        PLoS One. 2019 ;14(8):e0219996.
        The Medical Monitoring Project (MMP) is an HIV surveillance system that provides national estimates of HIV-related behaviors and clinical outcomes. When first implemented, MMP excluded persons living with HIV not receiving HIV care. This analysis will describe new case-surveillance-based methods to identify and recruit persons living with HIV who are out of care and at elevated risk for mortality and ongoing HIV transmission. Stratified random samples of all persons living with HIV were selected from the National HIV Surveillance System in five public health jurisdictions from 2012-2014. Sampled persons were located and contacted through seven different data sources and five methods of contact to collect interviews and medical record abstractions. Data were weighted for non-response and case reporting delay. The modified sampling methodology yielded 1159 interviews (adjusted response rate, 44.5%) and matching medical record abstractions for 1087 (93.8%). Of persons with both interview and medical record data, 264 (24.3%) would not have been included using prior MMP methods. Significant predictors were identified for successful contact (e.g., retention in care, adjusted Odds Ratio [aOR] 5.02; 95% Confidence Interval [CI] 1.98-12.73), interview (e.g. moving out of jurisdiction, aOR 0.24; 95% CI: 0.12-0.46) and case reporting delay (e.g. rural residence, aOR 3.18; 95% CI: 2.09-4.85). Case-surveillance-based sampling resulted in a comparable response rate to existing MMP methods while providing information on an important new population. These methods have since been adopted by the nationally representative MMP surveillance system, offering a model for public health program, research and surveillance endeavors seeking inclusion of all persons living with HIV.

      12. The management of multidrug-resistant tuberculosis (MDR TB) is notably complex among patients with HIV. TB treatment recommendations typically include very little information specific to HIV and MDR TB, which often is derived from clinical trials conducted in low-resource settings. Mortality rates among patients with HIV and MDR TB remain high. We reviewed the published literature and recommendations to synthesize possible patient management approaches demonstrated to improve treatment outcomes in high-resourced countries for patients with MDR TB and HIV. Approaches to diagnostic testing, impact and timing of antiretroviral therapy (ART) on mortality, anti-MDR TB and antiretroviral drug interactions and the potential role for short-course MDR TB therapy are examined. The combination of ART with expanded TB drug therapy, along with the management of immunologic reconstitution inflammatory syndrome (IRIS), other potential HIV-associated opportunistic diseases and drug toxicities, necessitate an integrated multidisciplinary patient care approach utilizing public health case management and provider expertise in drug-resistant TB and HIV management.

    • Disaster Control and Emergency Services
      1. Identifying areas with disproportionate local health department services relative to opioid overdose, HIV and hepatitis C diagnosis rates: A study of rural Illinoisexternal icon
        McLuckie C, Pho MT, Ellis K, Navon L, Walblay K, Jenkins WD, Rodriguez C, Kolak MA, Chen YT, Schneider JA, Zahnd WE.
        Int J Environ Res Public Health. 2019 Mar 19;16(6).
        Background: U.S. rural populations have been disproportionately affected by the syndemic of opioid-use disorder (OUD) and the associated increase in overdoses and risk of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) transmission. Local health departments (LHDs) can play a critical role in the response to this syndemic. We utilized two geospatial approaches to identify areas of discordance between LHD service availability and disease burden to inform service prioritization in rural settings. Methods: We surveyed rural Illinois LHDs to assess their OUD-related services, and calculated county-level opioid overdose, HIV, and hepatitis C diagnosis rates. Bivariate choropleth maps were created to display LHD service provision relative to disease burden in rural Illinois counties. Results: Most rural LHDs provided limited OUD-related services, although many LHDs provided HIV and HCV testing. Bivariate mapping showed rural counties with limited OUD treatment and HIV services and with corresponding higher outcome/disease rates to be dispersed throughout Illinois. Additionally, rural counties with limited LHD-offered hepatitis C services and high hepatitis C diagnosis rates were geographically concentrated in southern Illinois. Conclusions: Bivariate mapping can enable geographic targeting of resources to address the opioid crisis and related infectious disease by identifying areas with low LHD services relative to high disease burden.

      2. Insights into the National Institute for Occupational Safety and Health’s emergency preparedness and response programexternal icon
        Victory KR, Shugart J, Burrer S, Dowell CH, Delaney LJ.
        J Environ Health. 2019 ;82(1):30-32.
        NEHA strives to provide up-to-date and relevant information on environmental health and to build partnerships in the profession. In pursuit of these goals, we feature this column on environmental health services from the Centers for Disease Control and Prevention (CDC) in every issue of the Journal. In these columns, authors from CDC’s Water, Food, and Environmental Health Services Branch, as well as guest authors, will share insights and information about environmental health programs, trends, issues, and resources. The conclusions in these columns are those of the author(s) and do not necessarily represent the official position of CDC. Kerton Victory is an environmental health specialist and emergency coordinator with the National Institute for Occupational Safety and Health’s (NIOSH) Emergency Preparedness and Response Office (EPRO). Jill Shugart is a senior environmental health specialist and the Emergency Responder Health Monitoring and Surveillance coordinator with NIOSH EPRO. Sherry Burrer is a senior epidemiologist and emergency coordinator with NIOSH EPRO. Chad Dowell is the NIOSH deputy associate director for emergency preparedness and response. Lisa Delaney is the NIOSH associate director for emergency preparedness and response.

    • Disease Reservoirs and Vectors
      1. Reported county-level distribution of the American dog tick (Acari: Ixodidae) in the contiguous United Statesexternal icon
        Lehane A, Parise C, Evans C, Beati L, Nicholson WL, Eisen RJ.
        J Med Entomol. 2019 Aug 1.
        In the United States, tick-borne diseases are increasing in incidence and cases are reported over an expanding geographical area. Avoiding tick bites is a key strategy in tick-borne disease prevention, and this requires current and accurate information on where humans are at risk for exposure to ticks. Based on a review of published literature and records in the U.S. National Tick Collection and National Ecological Observatory Network databases, we compiled an updated county-level map showing the reported distribution of the American dog tick, Dermacentor variabilis (Say). We show that this vector of the bacterial agents causing Rocky Mountain spotted fever and tularemia is widely distributed, with records derived from 45 states across the contiguous United States. However, within these states, county-level records of established tick populations are limited. Relative to the range of suitable habitat for this tick, our data imply that D. variabilis is currently underreported in the peer-reviewed literature, highlighting a need for improved surveillance and documentation of existing tick records.

      2. Rabies is preventable through vaccination, but the need to mount annual canine vaccination campaigns presents major challenges in rabies control and prevention. The development of a rabies vaccine that ensures lifelong immunity and animal population management in one dose could be extremely advantageous. A nonsurgical alternative to spay/neuter is a high priority for animal welfare, but irreversible infertility in one dose has not been achieved. Towards this goal, we developed a rabies virus-vectored immunocontraceptive vaccine ERA-2GnRH, which protected against rabies virus challenge and induced >80% infertility in mice after three doses in a live, liquid-vaccine formulation (Wu et al., 2014). To improve safety and use, we formulated an inactivated vaccine in a thermo-responsive chitosan hydrogel for one-dose delivery and studied the immune responses in mice. The hydrogel did not cause any injection site reactions, and the killed ERA-2GnRH vaccine induced high and persistent rabies virus neutralizing antibodies (rVNA) in mice. The rVNA in the hydrogel group reached an average of 327.40 IU/mL, more than 200 times higher than the liquid vaccine alone. The Gonadotropin-releasing hormone (GnRH) antibodies were also present and lasted longer in the hydrogel group, but did not prevent fertility in mice, reflecting a possible threshold level of GnRH antibodies for contraception. In conclusion, the hydrogel facilitated a high and long-lasting immunity, and ERA-2GnRH is a promising dual vaccine candidate. Future studies will focus on rabies protection in target species and improving the anti-GnRH response.

    • Environmental Health
      1. Proposed key characteristics of male reproductive toxicants as an approach for organizing and evaluating mechanistic evidence in human health hazard assessmentsexternal icon
        Arzuaga X, Smith MT, Gibbons CF, Skakkebaek NE, Yost EE, Beverly BE, Hotchkiss AK, Hauser R, Pagani RL, Schrader SM, Zeise L, Prins GS.
        Environ Health Perspect. 2019 Jun;127(6):65001.
        BACKGROUND: Assessing chemicals for their potential to cause male reproductive toxicity involves the evaluation of evidence obtained from experimental, epidemiological, and mechanistic studies. Although mechanistic evidence plays an important role in hazard identification and evidence integration, the process of identifying, screening and analyzing mechanistic studies and outcomes is a challenging exercise due to the diversity of research models and methods and the variety of known and proposed pathways for chemical-induced toxicity. Ten key characteristics of carcinogens provide a valuable tool for organizing and assessing chemical-specific data by potential mechanisms for cancer-causing agents. However, such an approach has not yet been developed for noncancer adverse outcomes. OBJECTIVES: The objective in this study was to identify a set of key characteristics that are frequently exhibited by exogenous agents that cause male reproductive toxicity and that could be applied for identifying, organizing, and summarizing mechanistic evidence related to this outcome. DISCUSSION: The identification of eight key characteristics of male reproductive toxicants was based on a survey of known male reproductive toxicants and established mechanisms and pathways of toxicity. The eight key characteristics can provide a basis for the systematic, transparent, and objective organization of mechanistic evidence relevant to chemical-induced effects on the male reproductive system.

    • Food Safety
      1. Multistate outbreak of listeriosis associated with packaged leafy green salads, United States and Canada, 2015-2016external icon
        Self JL, Conrad A, Stroika S, Jackson A, Whitlock L, Jackson KA, Beal J, Wellman A, Fatica MK, Bidol S, Huth PP, Hamel M, Franklin K, Tschetter L, Kopko C, Kirsch P, Wise ME, Basler C.
        Emerg Infect Dis. 2019 Aug;25(8):1461-1468.
        We investigated an outbreak of listeriosis detected by whole-genome multilocus sequence typing and associated with packaged leafy green salads. Nineteen cases were identified in the United States during July 5, 2015-January 31, 2016; isolates from case-patients were closely related (median difference 3 alleles, range 0-16 alleles). Of 16 case-patients interviewed, all reported salad consumption. Of 9 case-patients who recalled brand information, all reported brands processed at a common US facility. The Public Health Agency of Canada simultaneously investigated 14 cases of listeriosis associated with this outbreak. Isolates from the processing facility, packaged leafy green salads, and 9 case-patients from Canada were closely related to US clinical isolates (median difference 3 alleles, range 0-16 alleles). This investigation led to a recall of packaged leafy green salads made at the processing facility. Additional research is needed to identify best practices and effective policies to reduce the likelihood of Listeria monocytogenes contamination of fresh produce.

      2. Sex and age differences in food preferences may be reflected in the demographics of outbreaks. Outbreaks from 1998-2015 with a single confirmed implicated food source in the Centers for Disease Control and Prevention Foodborne Disease Outbreak Surveillance System were analysed using logistic regression to assess associations between a food category, sex and age. Males were more likely to be involved in outbreaks attributed to beef, pork, game, dairy and shellfish; females were more likely to be involved in grains-beans, nuts-seeds, fruits, sprouts and vegetable row crops outbreaks. Children &lt;5-years-old were more likely than other age groups to be involved in dairy outbreaks, children 5-19-years-old were most likely to be involved in beef and game outbreaks, adults 20-49-years-old were most likely to be involved in fish, shellfish and sprout outbreaks and adults 50-years-old were most likely to be involved in turkey outbreaks. Age and sex are associated with specific food categories in outbreaks. This information may be useful in helping to identify sources of foodborne disease outbreaks.

    • Genetics and Genomics
      1. Draft genome sequences of antimicrobial-resistant Shigella clinical isolates from Pakistanexternal icon
        Lomonaco S, Lascols C, Crawford MA, Anderson K, Hodge DR, Fisher DJ, Pillai SP, Morse SA, Khan E, Hughes MA, Allard MW, Sharma SK.
        Microbiol Resour Announc. 2019 Jul 25;8(30).
        Shigella spp. are the most common cause of dysentery in developing countries and the second leading cause of diarrheal deaths worldwide. Multidrug-resistant (MDR) Shigella spp. are a serious threat to global health. Herein, we report draft genome sequences for three MDR Shigella isolates from Pakistan, two Shigella flexneri isolates and one Shigella sonnei isolate.

    • Health Disparities
      1. Disparities in neonatal intensive care: Context mattersexternal icon
        Barfield WD, Cox S, Henderson ZT.
        Pediatrics. 2019 Jul 29.

        [No abstract]

      2. Polygenic risk scores (PRS) are an emerging precision medicine tool based on multiple gene variants that, taken alone, have weak associations with disease risks, but collectively may enhance disease predictive value in the population. However, the benefit of PRS may not be equal among non-European populations, as they are under-represented in genome-wide association studies (GWAS) that serve as the basis for PRS development. In this perspective, we discuss a path forward, which includes: 1) inclusion of underrepresented populations in PRS research; 2) global efforts to build capacity for genomic research; 3) equitable implementation of these tools in clinical practice; and 4) traditional public health approaches to reduce risk of adverse health outcomes as an important component to precision health. As precision medicine is implemented in clinical care, researchers must ensure that advances from PRS research will benefit all.

    • Healthcare Associated Infections
      1. Leading Practices in Antimicrobial Stewardship: Conference Summaryexternal icon
        Baker DW, Hyun D, Neuhauser MM, Bhatt J, Srinivasan A.
        Jt Comm J Qual Patient Saf. 2019 Jul;45(7):517-523.
        The Joint Commission’s hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors’ experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS: The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS: The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician’s perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION: The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.

      2. Candida auris in a U.S. patient with carbapenemase-producing organisms and recent hospitalization in Kenyaexternal icon
        Brooks RB, Walters M, Forsberg K, Vaeth E, Woodworth K, Vallabhaneni S.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):664-666.
        Candida auris is an emerging drug-resistant yeast that causes outbreaks in health care facilities; cases have been reported from approximately 30 countries. U.S. cases of C. auris are likely the result of importation from abroad followed by extensive local transmission in health care settings (1). Early detection of Candida auris is key to preventing its spread. C. auris frequently co-occurs with carbapenemase-producing organisms (CPOs), like carbapenem-resistant Enterobacteriaceae (CRE), organisms for which testing and public health response capacity substantially increased beginning in 2017. In September 2018, the Maryland Department of Health (MDH) was notified of a hospitalized resident with CPO infection and colonization and recent hospitalization in Kenya. In light of this history, the patient was screened for C. auris and found to be colonized. Public health responses to CPOs can aid in the early identification of C. auris. As part of CPO investigations, health departments should assess whether the patient has risk factors for C. auris and ensure that patients at risk are tested promptly.

      3. A guide to investigating suspected outbreaks of mucormycosis in healthcareexternal icon
        Hartnett KP, Jackson BR, Perkins KM, Glowicz J, Kerins JL, Black SR, Lockhart SR, Christensen BE, Beer KD.
        J Fungi (Basel). 2019 Jul 24;5(3).
        This report serves as a guide for investigating mucormycosis infections in healthcare. We describe lessons learned from previous outbreaks and offer methods and tools that can aid in these investigations. We also offer suggestions for conducting environmental assessments, implementing infection control measures, and initiating surveillance to ensure that interventions were effective. While not all investigations of mucormycosis infections will identify a single source, all can potentially lead to improvements in infection control.

      4. Candida auris: An emerging antimicrobial resistance threatexternal icon
        Vallabhaneni S, Jackson BR, Chiller TM.
        Ann Intern Med. 2019 Jul 30.

        [No abstract]

      5. Notes from the Field: Clinical Klebsiella pneumoniae isolate with three carbapenem resistance genes associated with urology procedures – King County, Washington, 2018external icon
        Vannice K, Benoliel E, Kauber K, Brostrom-Smith C, Montgomery P, Kay M, Walters M, Tran M, D’Angeli M, Duchin J.
        MMWR Morb Mortal Wkly Rep. 2019 Aug 2;68(30):667-668.

        [No abstract]

    • Immunity and Immunization
      1. Japanese Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practicespdf iconexternal icon
        Hills SL, Walter EB, Atmar RL, Fischer M.
        MMWR Recommendations & Reports. 2019 ;68(2):1-27.
        This report updates the 2010 recommendations from the CDC Advisory Committee on Immunization Practices (ACIP) regarding prevention of Japanese encephalitis (JE) among U.S. travelers and laboratory workers (Fischer M, Lindsey N, Staples JE, Hills S. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2010;59[No. RR-1]). The report summarizes the epidemiology of JE, describes the JE vaccine that is licensed and available in the United States, and provides recommendations for its use among travelers and laboratory workers. JE virus, a mosquitoborne flavivirus, is the most common vaccine-preventable cause of encephalitis in Asia. JE occurs throughout most of Asia and parts of the western Pacific. Approximately 20%–30% of patients die, and 30%–50% of survivors have neurologic, cognitive, or behavioral sequelae. No antiviral treatment is available. Inactivated Vero cell culture–derived JE vaccine (Ixiaro [JE-VC]) is the only JE vaccine that is licensed and available in the United States. In 2009, the U.S. Food and Drug Administration (FDA) licensed JE-VC for use in persons aged >/=17 years; in 2013, licensure was extended to include children aged >/=2 months. Most travelers to countries where the disease is endemic are at very low risk for JE. However, some travelers are at increased risk for infection on the basis of their travel plans. Factors that increase the risk for JE virus exposure include 1) traveling for a longer period; 2) travel during the JE virus transmission season; 3) spending time in rural areas; 4) participating in extensive outdoor activities; and 5) staying in accommodations without air conditioning, screens, or bed nets. All travelers to countries where JE is endemic should be advised to take precautions to avoid mosquito bites to reduce the risk for JE and other vectorborne diseases. For some persons who might be at increased risk for JE, the vaccine can further reduce the risk for infection. The decision about whether to vaccinate should be individualized and consider the 1) risks related to the specific travel itinerary, 2) likelihood of future travel to countries where JE is endemic, 3) high morbidity and mortality of JE, 4) availability of an effective vaccine, 5) possibility (but low probability) of serious adverse events after vaccination, and 6) the traveler’s personal perception and tolerance of risk. JE vaccine is recommended for persons moving to a JE-endemic country to take up residence, longer-term (e.g., >/=1 month) travelers to JE-endemic areas, and frequent travelers to JE-endemic areas. JE vaccine also should be considered for shorter-term (e.g., <1 month) travelers with an increased risk for JE on the basis of planned travel duration, season, location, activities, and accommodations and for travelers to JE-endemic areas who are uncertain about their specific travel duration, destinations, or activities. JE vaccine is not recommended for travelers with very low-risk itineraries, such as shorter-term travel limited to urban areas or outside of a well-defined JE virus transmission season.

      2. Use of a choice survey to identify adult, adolescent and parent preferences for vaccination in the United Statesexternal icon
        Lavelle TA, Messonnier M, Stokley S, Kim D, Ramakrishnan A, Gebremariam A, Simon NE, Rose AM, Prosser LA.
        J Patient Rep Outcomes. 2019 Jul 29;3(1):51.
        BACKGROUND: Adult and adolescent vaccination rates are far below coverage targets in the United States. Our objective was to identify the most influential factors related to vaccine uptake among adults, adolescents, and parents of adolescents (parents) in the United States. METHODS: We used a fractional factorial design to create a binary choice survey to evaluate preferences for vaccination. The national survey was fielded to a sample of adults, adolescents ages 13-17 years, and parents, using a national probability-based online research panel in November 2015. Respondents were presented with 5 profiles of a hypothetical vaccine and asked in a series of questions whether they would accept each vaccine. We analyzed the binary choice data using logistic regression in STATA v13 (College Station, TX) to calculate the odds that a participant would choose to accept the vaccine. RESULTS: We received completed responses from 334 (51%) of 652 adults, 316 (21%) of 1516 adolescents, and 339 (33%) of 1030 parents. Respondents were generally representative of the U.S. POPULATION: Vaccine effectiveness was the most influential factor in the choice to vaccinate for all groups. Other most influential factors were primary care provider (PCP) recommendation and the out-of-pocket cost of the vaccine. Other factors such as risk of illness, risk of vaccine side effects, vaccination location, and time for vaccination were not important in the decision to get vaccinated. CONCLUSIONS: Adults, adolescents, and parents are most sensitive to vaccine effectiveness, PCP recommendation, and out-of-pocket cost for vaccination in their decision to get vaccinated. Strong PCP recommendations that focus on vaccine effectiveness and health care policies that minimize out-of-pocket costs for vaccinations may increase vaccine uptake by adults and adolescents.

      3. Heterogeneous susceptibility to rotavirus infection and gastroenteritis in two birth cohort studies: Parameter estimation and epidemiological implicationsexternal icon
        Lewnard JA, Lopman BA, Parashar UD, Bennett A, Bar-Zeev N, Cunliffe NA, Samuel P, Guerrero ML, Ruiz-Palacios G, Kang G, Pitzer VE.
        PLoS Comput Biol. 2019 Jul 26;15(7):e1007014.
        Cohort studies, randomized trials, and post-licensure studies have reported reduced natural and vaccine-derived protection against rotavirus gastroenteritis (RVGE) in low- and middle-income countries. While susceptibility of children to rotavirus is known to vary within and between settings, implications for estimation of immune protection are not well understood. We sought to re-estimate naturally-acquired protection against rotavirus infection and RVGE, and to understand how differences in susceptibility among children impacted estimates. We re-analyzed data from studies conducted in Mexico City, Mexico and Vellore, India. Cumulatively, 573 rotavirus-unvaccinated children experienced 1418 rotavirus infections and 371 episodes of RVGE over 17,636 child-months. We developed a model that characterized susceptibility to rotavirus infection and RVGE among children, accounting for aspects of the natural history of rotavirus and differences in transmission rates between settings. We tested whether model-generated susceptibility measurements were associated with demographic and anthropometric factors, and with the severity of RVGE symptoms. We identified greater variation in susceptibility to rotavirus infection and RVGE in Vellore than in Mexico City. In both cohorts, susceptibility to rotavirus infection and RVGE were associated with male sex, lower birth weight, lower maternal education, and having fewer siblings; within Vellore, susceptibility was also associated with lower socioeconomic status. Children who were more susceptible to rotavirus also experienced higher rates of rotavirus-negative diarrhea, and higher risk of moderate-to-severe symptoms when experiencing RVGE. Simulations suggested that discrepant estimates of naturally-acquired immunity against RVGE can be attributed, in part, to between-setting differences in susceptibility of children, but result primarily from the interaction of transmission rates with age-dependent risk for infections to cause RVGE. We found that more children in Vellore than in Mexico City belong to a high-risk group for rotavirus infection and RVGE, and demonstrate that unmeasured individual- and age-dependent susceptibility may influence estimates of naturally-acquired immune protection against RVGE.

      4. [No abstract]

    • Informatics
      1. Design and implementation of a comprehensive surveillance system for venous thromboembolism in a defined region using electronic and manual approachesexternal icon
        Ortel TL, Arnold K, Beckman M, Brown A, Reyes N, Saber I, Schulteis R, Singh BP, Sitlinger A, Thames EH.
        Appl Clin Inform. 2019 May;10(3):552-562.
        BACKGROUND: Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. OBJECTIVES: This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. METHODS: The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans’ Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. RESULTS: Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. CONCLUSION: We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.

    • Injury and Violence
      1. Social distance and texting while driving: A behavioral economic analysis of social discountingexternal icon
        Foreman AM, Hayashi Y, Friedel JE, Wirth O.
        Traffic Inj Prev. 2019 Jul 29:1-6.
        Objective: Texting while driving is a dangerous behavior. Drivers continue to engage in the behavior despite knowing its risks, and the factors responsible for the decision to text while driving are poorly understood. This study examined how the relationship of the sender to the driver, in addition to the delay to the destination, may affect the decision to text while driving with the use of a social- and delay-discounting paradigm. Methods: Ninety-four (N = 94) undergraduate students completed a hypothetical social- and delay-discounting task in which they rated their likelihood of replying to a text message immediately versus waiting to reply until arriving at a destination. The social distance of the sender and the delay to the destination were varied across trials. Results: For both social and delay discounting, the likelihood of replying and waiting, respectively, decreased as a function of social distance and delay to the destination. Participants were more likely to text while driving as the social distance of the sender decreased and the delay to the destination increased. Social discounting varied inversely as a function of delay to the destination: The shorter the delay to the destination, the greater the social discounting. Conclusion: The findings indicate that social distance of the sender is an important factor involved in the decision to text while driving. Participants were more likely to reply to a text while driving if the sender was less socially distant. When they were closer to their destination, they were less likely to reply to socially distant people than those closer to them. The roles that social consequences play in drivers’ decision making to text while driving are discussed.

      2. Strengthening the evidence base: Recommendations for future research identified through the development of CDC’s Pediatric Mild TBI Guidelineexternal icon
        Suskauer SJ, Yeates KO, Sarmiento K, Benzel EC, Breiding MJ, Broomand C, Haarbauer-Krupa J, Turner M, Weissman B, Lumba-Brown A.
        J Head Trauma Rehabil. 2019 Jul/Aug;34(4):215-223.
        OBJECTIVE: The recently published Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury (mTBI) was developed following an extensive review of the scientific literature. Through this review, experts identified limitations in existing pediatric mTBI research related to study setting and generalizability, mechanism of injury and age of cohorts studied, choice of control groups, confounding, measurement issues, reporting of results, and specific study design considerations. This report summarizes those limitations and provides a framework for optimizing the future quality of research conduct and reporting. RESULTS: Specific recommendations are provided related to diagnostic accuracy, population screening, prognostic accuracy, and therapeutic interventions. CONCLUSION: Incorporation of the recommended approaches will increase the yield of eligible research for inclusion in future systematic reviews and guidelines for pediatric mTBI.

    • Laboratory Sciences
      1. Work-related Trypanosoma cruzi exposuresexternal icon
        Budnick LD, Bocco BW, Montgomery SP.
        J Occup Environ Med. 2019 Jul 16.

        [No abstract]

      2. Efficacy of oral tenofovir alafenamide/emtricitabine combination or single agent tenofovir alafenamide against vaginal SHIV infection in macaquesexternal icon
        Massud I, Cong ME, Ruone S, Holder A, Dinh C, Nishiura K, Khalil G, Pan Y, Lipscomb J, Johnson R, Deyounks F, Rooney JF, Babusis D, Park Y, McCallister S, Callebaut C, Heneine W, Garcia-Lerma JG.
        J Infect Dis. 2019 Jul 31.
        BACKGROUND: Tenofovir alafenamide (TAF)-based regimens are being evaluated for pre-exposure prophylaxis (PrEP). We used a macaque model of repeated exposures to SHIV to investigate if TAF alone or the combination of TAF and emtricitabine (FTC) can prevent vaginal infection. METHODS: Pigtail macaques were exposed vaginally to SHIV162p3 once a week for up to 15 weeks. Animals received clinical doses of FTC/TAF (n=6) or TAF (n=9) orally 24h before and 2h after each weekly virus exposure. Infection was compared with 21 untreated controls. RESULTS: Five of the 6 animals in the FTC/TAF and 4 of the 9 animals in the TAF alone group were protected against infection (p=0.001 and p=0.049, respectively). The calculated efficacy of FTC/TAF and TAF was 91% (95% CI=[34.9%, 98.8%]) and 57.8% [-8.7%, 83.6%]), respectively. Infection in FTC/TAF but not TAF-treated macaques was delayed relative to controls (p=0.005 and p=0.114). Median tenofovir diphosphate (TFV-DP) levels in PBMCs were similar among infected and uninfected macaques receiving TAF PrEP (351 and 143 fmols/106 cells, respectively; p=0.921). CONCLUSIONS: FTC/TAF provided a level of protection against vaginal challenge similar to FTC/tenofovir disoproxil fumarate combination in the macaque model. Our results support the clinical evaluation of FTC/TAF for PrEP in women.

      3. Reagent substitution in the chromogenic Bethesda assay for factor VIII inhibitorsexternal icon
        Payne AB, Miller CH, Ellingsen D, Driggers J, Boylan B, Bean CJ.
        Haemophilia. 2019 Jul 29.

        [No abstract]

      4. Heteroresistance to the model antimicrobial peptide polymyxin B in the emerging Neisseria meningitidis lineage 11.2 urethritis clade: mutations in the pilMNOPQ operonexternal icon
        Tzeng YL, Berman Z, Toh E, Bazan JA, Turner AN, Retchless AC, Wang X, Nelson DE, Stephens DS.
        Mol Microbiol. 2019 Jan;111(1):254-268.
        Clusters of Neisseria meningitidis (Nm) urethritis among primarily heterosexual males in multiple US cities have been attributed to a unique non-encapsulated meningococcal clade (the US Nm urethritis clade, US_NmUC) within the hypervirulent clonal complex 11. Resistance to antimicrobial peptides (AMPs) is a key feature of urogenital pathogenesis of the closely related species, Neisseria gonorrhoeae. The US_NmUC isolates were found to be highly resistant to the model AMP, polymyxin B (PmB, MICs 64-256 microg ml(-1) ). The isolates also demonstrated stable subpopulations of heteroresistant colonies that showed near total resistant to PmB (MICs 384-1024 microg ml(-1) ) and colistin (MIC 256 microg ml(-1) ) as well as enhanced LL-37 resistance. This is the first observation of heteroresistance in N. meningitidis. Consistent with previous findings, overall PmB resistance in US_NmUC isolates was due to active Mtr efflux and LptA-mediated lipid A modification. However, whole genome sequencing, variant analyses and directed mutagenesis revealed that the heteroresistance phenotypes and very high-level AMP resistance were the result of point mutations and IS1655 element movement in the pilMNOPQ operon, encoding the type IV pilin biogenesis apparatus. Cross-resistance to other classes of antibiotics was also observed in the heteroresistant colonies. High-level resistance to AMPs may contribute to the pathogenesis of US_NmUC.

    • Maternal and Child Health
      1. Prenatal diagnosis and prevalence of critical congenital heart defects: an international retrospective cohort studyexternal icon
        Bakker MK, Bergman JE, Krikov S, Amar E, Cocchi G, Cragan J, de Walle HE, Gatt M, Groisman B, Liu S, Nembhard WN, Pierini A, Rissmann A, Chidambarathanu S, Sipek A, Szabova E, Tagliabue G, Tucker D, Mastroiacovo P, Botto LD.
        BMJ Open. 2019 Jul 2;9(7):e028139.
        OBJECTIVES: To assess international trends and patterns of prenatal diagnosis of critical congenital heart defects (CCHDs) and their relation to total and live birth CCHD prevalence and mortality. SETTING: Fifteen birth defect surveillance programmes that participate in the International Clearinghouse for Birth Defects Surveillance and Research from 12 countries in Europe, North and South America and Asia. PARTICIPANTS: Live births, stillbirths and elective terminations of pregnancy for fetal anomaly diagnosed with 1 of 12 selected CCHD, ascertained by the 15 programmes for delivery years 2000 to 2014. RESULTS: 18 243 CCHD cases were reported among 8 847 081 births. The median total prevalence was 19.1 per 10 000 births but varied threefold between programmes from 10.1 to 31.0 per 10 000. CCHD were prenatally detected for at least 50% of the cases in one-third of the programmes. However, prenatal detection varied from 13% in Slovak Republic to 87% in some areas in France. Prenatal detection was consistently high for hypoplastic left heart syndrome (64% overall) and was lowest for total anomalous pulmonary venous return (28% overall). Surveillance programmes in countries that do not legally permit terminations of pregnancy tended to have higher live birth prevalence of CCHD. Most programmes showed an increasing trend in prenatally diagnosed CCHD cases. DISCUSSION AND CONCLUSIONS: Prenatal detection already accounts for 50% or more of CCHD detected in many programmes and is increasing. Local policies and access likely account for the wide variability of reported occurrence and prenatal diagnosis. Detection rates are high especially for CCHD that are more easily diagnosed on a standard obstetric four-chamber ultrasound or for fetuses that have extracardiac anomalies. These ongoing trends in prenatal diagnosis, potentially in combination with newborn pulse oximetry, are likely to modify the epidemiology and clinical outcomes of CCHD in the near future.

    • Nutritional Sciences
      1. This report provides an update from the U.S. Department of Agriculture – Centers for Disease Control and Prevention Sentinel Foods Surveillance Program, exploring changes in sodium and related nutrients (energy, potassium, total and saturated fat, and total sugar) in popular, sodium-contributing, commercially processed and restaurant foods with added sodium. In 2010-2013, we obtained 3432 samples nationwide and chemically analyzed 1654 composites plus label information for 125 foods, to determine baseline laboratory and label sodium concentrations, respectively. In 2014-2017, we re-sampled and chemically analyzed 43 of the Sentinel Foods (1181 samples), tested for significant changes of at least +/-10% (p < 0.05), in addition to tracking changes in labels for 108 Sentinel Foods. Our results show that the label sodium levels of a majority of the Sentinel Foods had not changed since baseline (~1/3rd of the products reported changes, with twice as many reductions as increases). Laboratory analyses of the 43 Sentinel Foods show that eight foods had significant changes (p < 0.05); sodium content continues to be high and variable, and there was no consistent pattern of changes in related nutrients. Comparisons of changes in labels and laboratory sodium shows consistency for 60% of the products, i.e., similar changes (or no changes) in laboratory and label sodium content. The data from this monitoring program may help public health officials to develop strategies to reduce and monitor sodium trends in the food supply.

    • Occupational Safety and Health
      1. Use of aqueous film-forming foams and knowledge of perfluorinated compounds among Florida firefightersexternal icon
        Caban-Martinez AJ, Solle NS, Feliciano PL, Griffin K, Santiago KM, Lee DJ, Daunert S, Deo SK, Fent K, Calkins M, Burgess JL, Kobetz EN.
        J Occup Environ Med. 2019 May;61(5):e227-e231.

        [No abstract]

      2. Understanding outcome metrics of the revised NIOSH lifting equationexternal icon
        Fox RR, Lu ML, Occhipinti E, Jaeger M.
        Applied Ergonomics. 2019 ;81.
        The interpretation of the calculated result of the revised NIOSH Lifting Equation (RNLE) has been problematic because the relationship of the calculated result to back injury risk has not always been either well understood nor consistently interpreted. During the revision of the ISO standard 112281 (Manual lifting, lowering and carrying), an extensive literature review was conducted on validation studies of the RNLE. A systematic review of exposure-risk associations between the LI metrics and various low-back health outcomes from peer-reviewed epidemiological studies was conducted. Risk interpretations for different levels of calculated result of the RNLE are added to the ISO standard. Rationale for the risk interpretations is presented in this paper. 2019 Elsevier Ltd

      3. Modeling the Effect of the 2018 Revised ACGIH((R)) Hand Activity Threshold Limit Value((R)) (TLV) at Reducing Risk for Carpal Tunnel Syndromeexternal icon
        Yung M, Dale AM, Kapellusch J, Bao S, Harris-Adamson C, Meyers AR, Hegmann KT, Rempel D, Evanoff BA.
        J Occup Environ Hyg. 2019 Jul 30:1-6.
        Recent studies have shown the 2001 American Conference of Governmental Industrial Hygienists (ACGIH((R))) Threshold Limit Value (TLV((R))) for Hand Activity was not sufficiently protective for workers at risk of carpal tunnel syndrome (CTS). These studies led to a revision of the TLV and Action Limit. This study compares the effect of applying the 2018 TLV vs. the 2001 TLV to predict incident CTS within a large occupational pooled cohort study (n = 4,321 workers). Time from study enrollment to first occurrence of CTS was modeled using Cox proportional hazard regression. Adjusted and unadjusted hazard ratios for incident CTS were calculated using three exposure categories: below the Action Limit, between the Action Limit and TLV, and above the TLV. Workers exposed above the 2001 Action Limit demonstrated significant excess risk of carpal tunnel syndrome, while the 2018 TLV demonstrated significant excess risk only above the TLV. Of 186 total cases of CTS, 52 cases occurred among workers exposed above the 2001 TLV vs. 100 among those exposed above the 2018 value. Eliminating exposures above the 2001 TLV might have prevented 11.2% of all cases of CTS seen in our pooled cohort, vs. 25.1% of cases potentially prevented by keeping exposures below the 2018 value. The 2018 revision of the TLV better protects workers from CTS, a recognized occupational health indicator important to public health. A significant number of workers are currently exposed to forceful repetitive hand activity above these guidelines. Public health professionals should promulgate these new guidelines and encourage employers to reduce hand intensive exposures to prevent CTS and other musculoskeletal disorders.

    • Occupational Safety and Health – Mining
      1. Influence of temperature on generator current and magnetic field of a proximity detection systemexternal icon
        Li J, Smith A, Carr JB, Whisner B.
        Min Metall Explor. 2019 ;36(3):541-545.
        Electromagnetic-based proximity detection systems (PDSs) are utilized on mining machinery to protect workers from being pinned or struck. These systems generate magnetic fields covering the space around a machine, and a miner-wearable component (MWC) detects the field. The PDS determines the distance of miners relative to the machine based on the detected magnetic flux density in the magnetic field. This information is used to establish warning and shutdown zones around the machine. Maintaining a stable magnetic field is essential for system accuracy. However, components used to generate magnetic fields can be influenced by temperature changes. Depending on ventilation conditions and seasonal alternation, a PDS can be subject to significant temperature fluctuation. To better understand and quantify this phenomenon, researchers from the National Institute for Occupational Safety and Health (NIOSH) developed an experimental apparatus to study the influence of temperature on magnetic field generator circuits used in PDSs. Results from the study show that the electric current through a generator can be influenced by both ambient and internal temperatures, modifying the magnetic field that is produced. These findings show that temperature can significantly influence the ability of PDSs, used in underground coal mines, to accurately determine a workers position in relation to mining machine. 2019, This is a U.S. government work and its text is not subject to copyright protection in the United States; however, its text may be subject to foreign copyright protection.

      2. Performance comparison of real-time light scattering dust monitors across dust types and humidity levelsexternal icon
        Patts JR, Tuchman DP, Rubinstein EN, Cauda EG, Cecala AB.
        Min Metall Explor. 2019 2019/08/01;36(4):741-749.
        Video techniques for monitoring exposure, such as NIOSH’s “Helmet-CAM,” employ both real-time dust monitors and mobile video cameras to assess workers’ respirable dust exposures. Many real-time personally worn dust monitors utilize light scattering sensing elements, which are subject to measurement biases as a function of dust type (size, composition, shape factor) and environmental conditions such as relative humidity. These biased and inaccurate dust measurements impair the monitor’s ability to properly represent actual respirable dust concentrations. In the testing described, instrument mass concentration data was collected using three different types of commonly used commercial off-the-shelf personal dust monitors and compared to a reference standard. This testing was performed in a calm air (Marple) dust chamber in which three units of each make and model (for a total of nine monitors) were used for each test. Equivalency factors (EF, a multiplier to match the Thermo TEOM 1400a reference instrument) ranged between 0.746 and 1.879 across all dusts and environmental conditions tested, and between 0.821 and 1.519 on the ISO test dust.

      3. Due to the successful application of roof bolter canopy air curtains (CACs) to protect roof bolter operators from high levels of coal mine respirable dust, a shuttle car CAC is currently being developed. Since a shuttle car consistently trams from the continuous miner to the feeder and back at a speed up to 9.66 kph (6 mph) or 2.68 m/s (528 fpm), it is thought that the shuttle car may encounter very high air velocities (mine ventilation air velocity + max shuttle speed (2.68 m/s (528 fpm)). Past research and preliminary lab testing showed that CAC protection in high interference air velocities is difficult to achieve. Therefore, testing was conducted at a Midwestern US coal mine to determine the air velocities their shuttle car actually encounters. This mine used ram dump cars as their shuttle cars. Results showed that coal mine dust exposure is generally very low at the feeder and when tramming. Elevated concentrations are encountered at the ram dump car operator position when the car is being loaded by the continuous miner. Recorded air velocities while tramming did not reach the max air velocity of mine ventilation air velocity + 2.68 m/s (528 fpm) calculated as 3.32 m/s (653 fpm). High velocities, while encountered, were of low frequency and associated with low respirable coal mine dust concentrations. Therefore, using this new information, designing the shuttle car CAC for maximum interference air velocity may not be as important as previously thought.

    • Parasitic Diseases
      1. The haematological consequences of Plasmodium vivax malaria after chloroquine treatment with and without primaquine: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysisexternal icon
        Commons RJ, Simpson JA, Thriemer K, Chu CS, Douglas NM, Abreha T, Alemu SG, Anez A, Anstey NM, Aseffa A, Assefa A, Awab GR, Baird JK, Barber BE, Borghini-Fuhrer I, D’Alessandro U, Dahal P, Daher A, de Vries PJ, Erhart A, Gomes MS, Grigg MJ, Hwang J, Kager PA, Ketema T, Khan WA, Lacerda MV, Leslie T, Ley B, Lidia K, Monteiro WM, Pereira DB, Phan GT, Phyo AP, Rowland M, Saravu K, Sibley CH, Siqueira AM, Stepniewska K, Taylor WR, Thwaites G, Tran BQ, Hien TT, Vieira JL, Wangchuk S, Watson J, William T, Woodrow CJ, Nosten F, Guerin PJ, White NJ, Price RN.
        BMC Med. 2019 Aug 1;17(1):151.
        BACKGROUND: Malaria causes a reduction in haemoglobin that is compounded by primaquine, particularly in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. The aim of this study was to determine the relative contributions to red cell loss of malaria and primaquine in patients with uncomplicated Plasmodium vivax. METHODS: A systematic review identified P. vivax efficacy studies of chloroquine with or without primaquine published between January 2000 and March 2017. Individual patient data were pooled using standardised methodology, and the haematological response versus time was quantified using a multivariable linear mixed effects model with non-linear terms for time. Mean differences in haemoglobin between treatment groups at day of nadir and day 42 were estimated from this model. RESULTS: In total, 3421 patients from 29 studies were included: 1692 (49.5%) with normal G6PD status, 1701 (49.7%) with unknown status and 28 (0.8%) deficient or borderline individuals. Of 1975 patients treated with chloroquine alone, the mean haemoglobin fell from 12.22 g/dL [95% CI 11.93, 12.50] on day 0 to a nadir of 11.64 g/dL [11.36, 11.93] on day 2, before rising to 12.88 g/dL [12.60, 13.17] on day 42. In comparison to chloroquine alone, the mean haemoglobin in 1446 patients treated with chloroquine plus primaquine was – 0.13 g/dL [- 0.27, 0.01] lower at day of nadir (p = 0.072), but 0.49 g/dL [0.28, 0.69] higher by day 42 (p < 0.001). On day 42, patients with recurrent parasitaemia had a mean haemoglobin concentration – 0.72 g/dL [- 0.90, – 0.54] lower than patients without recurrence (p < 0.001). Seven days after starting primaquine, G6PD normal patients had a 0.3% (1/389) risk of clinically significant haemolysis (fall in haemoglobin > 25% to < 7 g/dL) and a 1% (4/389) risk of a fall in haemoglobin > 5 g/dL. CONCLUSIONS: Primaquine has the potential to reduce malaria-related anaemia at day 42 and beyond by preventing recurrent parasitaemia. Its widespread implementation will require accurate diagnosis of G6PD deficiency to reduce the risk of drug-induced haemolysis in vulnerable individuals. TRIAL REGISTRATION: This trial was registered with PROSPERO: CRD42016053312. The date of the first registration was 23 December 2016.

      2. Community-based intermittent mass testing and treatment for malaria in an area of high transmission intensity, western Kenya: development of study site infrastructure and lessons learnedexternal icon
        Odero NA, Samuels AM, Odongo W, Abong’o B, Gimnig J, Otieno K, Odero C, Obor D, Ombok M, Were V, Sang T, Hamel MJ, Kachur SP, Slutsker L, Lindblade KA, Kariuki S, Desai M.
        Malar J. 2019 Jul 29;18(1):255.
        BACKGROUND: Malaria transmission is high in western Kenya and the asymptomatic infected population plays a significant role in driving the transmission. Mathematical modelling and simulation programs suggest that interventions targeting asymptomatic infections through mass testing and treatment (MTaT) or mass drug administration (MDA) have the potential to reduce malaria transmission when combined with existing interventions. OBJECTIVE: This paper describes the study site, capacity development efforts required, and lessons learned for implementing a multi-year community-based cluster-randomized controlled trial to evaluate the impact of MTaT for malaria transmission reduction in an area of high transmission in western Kenya. METHODS: The study partnered with Kenya’s Ministry of Health (MOH) and other organizations on community sensitization and engagement to mobilize, train and deploy community health volunteers (CHVs) to deliver MTaT in the community. Within the health facilities, the study availed staff, medical and laboratory supplies and strengthened health information management system to monitor progress and evaluate impact of intervention. RESULTS: More than 80 Kenya MOH CHVs, 13 clinical officers, field workers, data and logistical staff were trained to carry out MTaT three times a year for 2 years in a population of approximately 90,000 individuals. A supply chain management was adapted to meet daily demands for large volumes of commodities despite the limitation of few MOH facilities having ideal storage conditions. Modern technology was adapted more to meet the needs of the high daily volume of collected data. CONCLUSIONS: In resource-constrained settings, large interventions require capacity building and logistical planning. This study found that investing in relationships with the communities, local governments, and other partners, and identifying and equipping the appropriate staff with the skills and technology to perform tasks are important factors for success in delivering an intervention like MTaT.

    • Public Health Leadership and Management
      1. CDC Partnerships With Tribal Epidemiology Centers to Improve the Health of American Indian and Alaska Native Communitiesexternal icon
        Groom A, Espey D, Allison A, Thomas C.
        J Public Health Manag Pract. 2019 Sep/Oct;25 Suppl 5:S5-s6.

        [No abstract]

      2. South Africa field epidemiology training program: developing and building applied epidemiology capacity, 2007-2016external icon
        Reddy C, Kuonza L, Ngobeni H, Mayet NT, Doyle TJ, Williams S.
        BMC Public Health. 2019 ;19(3):N.PAG-N.PAG.

        [No abstract]

    • Reproductive Health
      1. OBJECTIVE: The US Medical Eligibility Criteria for Contraceptive Use (USMEC) is the first national guidance containing evidence-based recommendations for contraception. We describe provider attitudes about contraceptive safety before and after the 2010 USMEC release. STUDY DESIGN: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and Title X clinic providers before (2009-2010) and after (2013-2014) the USMEC release. We compared the proportion of providers reporting select contraceptive methods as safe for women with specific characteristics or medical conditions before and after the USMEC release and conducted multivariable logistic regression to adjust for provider characteristics. RESULTS: For the following select characteristics for which the USMEC classifies specific contraceptive methods as safe (Category 1 or 2), a significantly (p<.05) higher proportion of providers reported the method safe after versus before the USMEC release: intrauterine devices (IUDs) for adolescents (79.8% versus 60.2%), IUDs for women with HIV (72.4% versus 50.6%), depot medroxyprogesterone acetate (DMPA) for women with obesity (89.5% versus 76.1%), and DMPA for women with history of bariatric surgery (87.6% versus 73.9%). These differences remained significant after adjustment for provider characteristics. CONCLUSIONS: While we observed many positive changes in health care provider attitudes related to contraception safety after the USMEC release, gaps remain. Continuing education and evidence-based training for providers, and ensuring office and health center protocols address medical eligibility for contraception for the full range of characteristics included in the USMEC might bridge remaining gaps and increase delivery of high-quality contraception care. IMPLICATIONS: Gaps between evidence and provider attitudes remain that can inform future efforts to improve contraceptive service delivery.

    • Substance Use and Abuse
      1. Mouth level nicotine in a clinical setting versus non-clinical settingexternal icon
        Watson CV, Richter P, Yao L, Phillips T, Pickworth WB, deCastro BR, Potts J, Watson C.
        Am J Health Behav. 2019 ;43(3):229-241.
        Objective: Our objective was to improve understanding of the differences in cigarette use behavior and exposure for participants smoking their own brand of cigarettes in a clinical setting versus smoking under natural conditions. Methods: Adult daily smokers (N = 163) attended 2 clinic visits where they smoked through a CReSS topography device. Participants collected cigarette butts smoked without a CReSS device and completed a diary of location, mood, and activity for each cigarette smoked. Cigarette butts were used to determine mouth level nicotine (MLN). Least square means (LSMs) were estimated from mixed effects models. Results: The LSM for MLN was higher among participants who smoked cigarettes in the clinical setting. LSM MLN was 1.589 [95% CI: 1.312, 1.924] mg/cig for cigarettes smoked in the clinic and 1.087 [95% CI: 0.902, 1.310] mg/cig for cigarettes smoked outside of the clinic; we found differences between race and sex. Conclusions: Our results show nicotine intake and some smoking behavior are significantly biased upwards when studied in a clinical setting. Therefore, tobacco smoke exposure determinations in a clinical setting may not be completely generalizable to smoke exposure determinations in naturalistic settings.

    • Zoonotic and Vectorborne Diseases
      1. Patients with laboratory evidence of West Nile virus disease without reported feverexternal icon
        Landry K, Rabe IB, Messenger SL, Hacker JK, Salas ML, Scott-Waldron C, Haydel D, Rider E, Simonson S, Brown CM, Smole SC, Neitzel DF, Schiffman EK, Strain AK, Vetter S, Fischer M, Lindsey NP.
        Epidemiol Infect. 2019 Jan;147:e219.
        In 2013, the national surveillance case definition for West Nile virus (WNV) disease was revised to remove fever as a criterion for neuroinvasive disease and require at most subjective fever for non-neuroinvasive disease. The aims of this project were to determine how often afebrile WNV disease occurs and assess differences among patients with and without fever. We included cases with laboratory evidence of WNV disease reported from four states in 2014. We compared demographics, clinical symptoms and laboratory evidence for patients with and without fever and stratified the analysis by neuroinvasive and non-neuroinvasive presentations. Among 956 included patients, 39 (4%) had no fever; this proportion was similar among patients with and without neuroinvasive disease symptoms. For neuroinvasive and non-neuroinvasive patients, there were no differences in age, sex, or laboratory evidence between febrile and afebrile patients, but hospitalisations were more common among patients with fever (P &lt; 0.01). The only significant difference in symptoms was for ataxia, which was more common in neuroinvasive patients without fever (P = 0.04). Only 5% of non-neuroinvasive patients did not meet the WNV case definition due to lack of fever. The evidence presented here supports the changes made to the national case definition in 2013.

      2. Prior dengue virus infection is associated with increased viral load in patients infected with dengue but not Zika virusexternal icon
        Santiago GA, Sharp TM, Rosenberg E, Sosa Cardona I, Alvarado L, Paz-Bailey G, Munoz-Jordan JL.
        Open Forum Infect Dis. 2019 Jul 1;6(7).
        To evaluate potential enhancement of Zika virus (ZIKV) infection among patients with prior dengue virus (DENV) infection, we compared loads of viral RNA among patients infected with ZIKV (n = 1070), DENV-2 (n = 312), or DENV-3 (n = 260). Compared to patients without prior DENV infection, patients with prior DENV infection had significantly higher mean loads of viral RNA if infected with DENV-2 (10.6 vs 11.6 log10 GCE/mL, respectively; t test, P < .0001) or DENV-3 (10.3 vs 10.9 log10 GCE/mL; P < .0001), but not ZIKV (4.7 vs 4.7 log10 GCE/mL; P = .959). These findings provide evidence against in vivo enhancement of ZIKV by anti-DENV antibodies.

      3. Serological data shows low levels of chikungunya exposure in Senegalese nomadic pastoralistsexternal icon
        Seck MC, Badiane AS, Thwing J, Moss D, Fall FB, Gomis JF, Deme AB, Diongue K, Sy M, Mbaye A, Ndiaye T, Gaye A, Ndiaye YD, Diallo MA, Ndiaye D, Rogier E.
        Pathogens. 2019 Jul 27;8(3).
        The chikungunya virus (CHIKV) is spread by Aedes aegypti and Ae. albopictus mosquitos worldwide; infection can lead to disease including joint pain, fever, and rash, with some convalescent persons experiencing chronic symptoms. Historically, CHIKV transmission has occurred in Africa and Asia, but recent outbreaks have taken place in Europe, Indonesia, and the Americas. From September to October 2014, a survey was undertaken with nomadic pastoralists residing in the northeast departments of Senegal. Blood dried on filter paper (dried blood spots; DBS) were collected from 1465 participants of all ages, and assayed for Immunoglobulin G (IgG) antibodies against CHIKV E1 antigen by a bead-based multiplex assay. The overall seroprevalence of all participants to CHIKV E1 was 2.7%, with no persons under 10 years of age found to be antibody positive. Above 10 years of age, clear increases of seroprevalence and IgG levels were observed with increasing age; 7.6% of participants older than 50 years were found to be positive for anti-CHIKV IgG. Reported net ownership, net usage, and gender were all non-significant explanatory variables of seropositivity. These data show a low-level historical exposure of this pastoralist population to CHIKV, with no evidence of recent CHIKV transmission in the past decade.

      4. Lessons learned from dengue surveillance and research, Puerto Rico, 1899-2013pdf iconexternal icon
        Sharp TM, Ryff KR, Santiago GA, Margolis HS, Waterman SH.
        Emerg Infect Dis. 2019 ;25(8):1522-1530.

        [No abstract]

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DISCLAIMER: Articles listed in the CDC Science Clips are selected by the Stephen B. Thacker CDC Library to provide current awareness of the public health literature. An article's inclusion does not necessarily represent the views of the Centers for Disease Control and Prevention nor does it imply endorsement of the article's methods or findings. CDC and DHHS assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinion, findings and conclusions expressed by the original authors of items included in the Clips, or persons quoted therein, are strictly their own and are in no way meant to represent the opinion or views of CDC or DHHS. References to publications, news sources, and non-CDC Websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS.

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