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CDC Science Clips: Volume 15, Issue 12, March 21, 2023

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

  1. CDC 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. Diabetes stigma and clinical outcomes in adolescents and young adults: the SEARCH for Diabetes in Youth Study
        Eitel KB, Roberts AJ, D'Agostino R, Barrett CE, Bell RA, Bellatorre A, Cristello A, Dabelea D, Dolan LM, Jensen ET, Liese AD, Mayer-Davis EJ, Reynolds K, Marcovina SM, Pihoker C.
        Diabetes Care. 2023 .
        OBJECTIVE: To examine the association between diabetes stigma and HbA1c, treatment plan and acute and chronic complications in adolescents and young adults (AYAs) with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS: The SEARCH for Diabetes in Youth study is a multicenter cohort study that collected questionnaire, laboratory, and physical examination data about AYAs with diabetes diagnosed in childhood. A five-question survey assessed frequency of perceived diabetes-related stigma, generating a total diabetes stigma score. We used multivariable linear modeling, stratified by diabetes type, to examine the association of diabetes stigma with clinical factors, adjusting for sociodemographic characteristics, clinic site, diabetes duration, health insurance, treatment plan, and HbA1c. RESULTS: Of 1,608 respondents, 78% had type 1 diabetes, 56% were female, and 48% were non-Hispanic White. The mean (SD) age at study visit was 21.7 (5.1) years (range, 10-24.9). The mean (SD) HbA1c was 9.2% (2.3%; 77 mmol/mol [2.0 mmol/mol]). Higher diabetes stigma scores were associated with female sex and higher HbA1c (P < 0.01) for all participants. No significant association between diabetes stigma score and technology use was observed. In participants with type 2 diabetes, higher diabetes stigma scores were associated with insulin use (P = 0.04). Independent of HbA1c, higher diabetes stigma scores were associated with some acute complications for AYAs with type 1 diabetes and some chronic complications for AYAs with type 1 or type 2 diabetes. CONCLUSIONS: Diabetes stigma in AYAs is associated with worse diabetes outcomes and is important to address when providing comprehensive diabetes care.

        Barrett, C. E.

      2. Recommended and observed statin use among U.S. adults - National Health and Nutrition Examination Survey, 2011-2018
        Thompson-Paul AM, Gillespie C, Wall HK, Loustalot F, Sperling L, Hong Y.
        J Clin Lipidol. 2022 .
        BACKGROUND: The American College of Cardiology/American Heart Association Blood Cholesterol Guideline was published in 2013 (2013 Cholesterol Guideline) and the Multi-society Guideline on the Management of Blood Cholesterol in 2018 (2018 Cholesterol Guideline). OBJECTIVE: To compare differences in population level estimates for statin recommendations and use between guidelines. METHODS: Using four 2-year cycles from the National Health and Nutrition Examination Survey (2011-2018), we analyzed data from 8,642 non-pregnant adults aged ≥20 years with complete information for blood cholesterol measurements and other cardiovascular risk factors used to define treatment recommendations in the 2013 or 2018 Cholesterol Guidelines. We compared the prevalence of statin recommendations and use between the guidelines, overall and among patient management groups. RESULTS: Under the 2013 Cholesterol Guideline, an estimated 77.8 million (33.6%) adults would be recommended statins, compared to 46.1 million (19.9%) recommended and 50.1 million (21.6%) considered for statins by the 2018 Cholesterol Guideline. Statin use among those recommended treatment was similar utilizing the 2018 Cholesterol Guideline (47.4%) compared to the 2013 Cholesterol Guideline (47.0%). Differences were observed across demographic and patient management groups. CONCLUSION: Compared to the 2013 Cholesterol Guideline, the prevalence of statin recommendations decreased utilizing the 2018 Cholesterol Guideline algorithm, though additional persons would be considered for treatment after risk factor assessment and patient-clinician discussion under the 2018 Cholesterol Guideline. Statin use was suboptimal (<50%) for those recommended treatment under either guideline. Optimizing patient-clinician risk discussions and shared decision making may be needed to improve treatment rates.

        Thompson-Paul, A. M. Gillespie, C. Wall, H. K. Loustalot, F. Sperling, L. Hong, Y.

      3. Comparing telephone survey responses to best-corrected visual acuity to estimate the accuracy of identifying vision loss: Validation study
        Wittenborn J, Lee A, Lundeen EA, Lamuda P, Saaddine J, Su GL, Lu R, Damani A, Zawadzki JS, Froines CP, Shen JZ, Kung TH, Yanagihara RT, Maring M, Takahashi MM, Blazes M, Rein DB.
        JMIR Public Health Surveill. 2023 ;9:e44552.
        BACKGROUND: Self-reported questions on blindness and vision problems are collected in many national surveys. Recently released surveillance estimates on the prevalence of vision loss used self-reported data to predict variation in the prevalence of objectively measured acuity loss among population groups for whom examination data are not available. However, the validity of self-reported measures to predict prevalence and disparities in visual acuity has not been established. OBJECTIVE: This study aimed to estimate the diagnostic accuracy of self-reported vision loss measures compared to best-corrected visual acuity (BCVA), inform the design and selection of questions for future data collection, and identify the concordance between self-reported vision and measured acuity at the population level to support ongoing surveillance efforts. METHODS: We calculated accuracy and correlation between self-reported visual function versus BCVA at the individual and population level among patients from the University of Washington ophthalmology or optometry clinics with a prior eye examination, randomly oversampled for visual acuity loss or diagnosed eye diseases. Self-reported visual function was collected via telephone survey. BCVA was determined based on retrospective chart review. Diagnostic accuracy of questions at the person level was measured based on the area under the receiver operator curve (AUC), whereas population-level accuracy was determined based on correlation. RESULTS: The survey question, "Are you blind or do you have serious difficulty seeing, even when wearing glasses?" had the highest accuracy for identifying patients with blindness (BCVA ≤20/200; AUC=0.797). The highest accuracy for detecting any vision loss (BCVA <20/40) was achieved by responses of "fair," "poor," or "very poor" to the question, "At the present time, would you say your eyesight, with glasses or contact lenses if you wear them, is excellent, good, fair, poor, or very poor" (AUC=0.716). At the population level, the relative relationship between prevalence based on survey questions and BCVA remained stable for most demographic groups, with the only exceptions being groups with small sample sizes, and these differences were generally not significant. CONCLUSIONS: Although survey questions are not considered to be sufficiently accurate to be used as a diagnostic test at the individual level, we did find relatively high levels of accuracy for some questions. At the population level, we found that the relative prevalence of the 2 most accurate survey questions were highly correlated with the prevalence of measured visual acuity loss among nearly all demographic groups. The results of this study suggest that self-reported vision questions fielded in national surveys are likely to yield an accurate and stable signal of vision loss across different population groups, although the actual measure of prevalence from these questions is not directly analogous to that of BCVA.

        Lundeen, E. A. Saaddine, J.

      4. Trends in incidence of youth-onset type 1 and type 2 diabetes in the USA, 2002-18: results from the population-based SEARCH for Diabetes in Youth study
        Wagenknecht LE, Lawrence JM, Isom S, Jensen ET, Dabelea D, Liese AD, Dolan LM, Shah AS, Bellatorre A, Sauder K, Marcovina S, Reynolds K, Pihoker C, Imperatore G, Divers J.
        Lancet Diabetes Endocrinol. 2023 .
        BACKGROUND: The incidence of diabetes is increasing in children and young people. We aimed to describe the incidence of type 1 and type 2 diabetes in children and young people aged younger than 20 years over a 17-year period. METHODS: The SEARCH for Diabetes in Youth study identified children and young people aged 0-19 years with a physician diagnosis of type 1 or type 2 diabetes at five centres in the USA between 2002 and 2018. Eligible participants included non-military and non-institutionalised individuals who resided in one of the study areas at the time of diagnosis. The number of children and young people at risk of diabetes was obtained from the census or health plan member counts. Generalised autoregressive moving average models were used to examine trends, and data are presented as incidence of type 1 diabetes per 100 000 children and young people younger than 20 years and incidence of type 2 diabetes per 100 000 children and young people aged between 10 years and younger than 20 years across categories of age, sex, race or ethnicity, geographical region, and month or season of diagnosis. FINDINGS: We identified 18 169 children and young people aged 0-19 years with type 1 diabetes in 85 million person-years and 5293 children and young people aged 10-19 years with type 2 diabetes in 44 million person-years. In 2017-18, the annual incidence of type 1 diabetes was 22·2 per 100 000 and that of type 2 diabetes was 17·9 per 100 000. The model for trend captured both a linear effect and a moving-average effect, with a significant increasing (annual) linear effect for both type 1 diabetes (2·02% [95% CI 1·54-2·49]) and type 2 diabetes (5·31% [4·46-6·17]). Children and young people from racial and ethnic minority groups such as non-Hispanic Black and Hispanic children and young people had greater increases in incidence for both types of diabetes. Peak age at diagnosis was 10 years (95% CI 8-11) for type 1 diabetes and 16 years (16-17) for type 2 diabetes. Season was significant for type 1 diabetes (p=0·0062) and type 2 diabetes (p=0·0006), with a January peak in diagnoses of type 1 diabetes and an August peak in diagnoses of type 2 diabetes. INTERPRETATION: The increasing incidence of type 1 and type 2 diabetes in children and young people in the USA will result in an expanding population of young adults at risk of developing early complications of diabetes whose health-care needs will exceed those of their peers. Findings regarding age and season of diagnosis will inform focused prevention efforts. FUNDING: US Centers for Disease Control and Prevention and US National Institutes of Health.

        Imperatore, G.

    • Communicable Diseases
      1. Tuberculosis preventive therapy among persons living with HIV, Uganda, 2016-2022
        Lukoye D, Gustavson G, Namuwenge PM, Muchuro S, Birabwa E, Dejene S, Ssempiira J, Kalamya JN, Baveewo S, Ferroussier-Davis O, Mills LA, Dirlikov E, Nelson LJ, Turyahabwe S.
        Emerg Infect Dis. 2023 ;29(3):609-613.
        During October 2016-March 2022, Uganda increased tuberculosis (TB) preventive therapy coverage among persons living with HIV from 0.6% to 88.8%. TB notification rates increased from 881.1 to 972.5 per 100,000 persons living with HIV. Timely TB screening, diagnosis, and earlier treatment should remain high priorities for TB/HIV prevention programming.

        Lukoye, D. Gustavson, G. Ssempiira, J. Kalamya, J. N. Baveewo, S. Ferroussier-Davis, O. Mills, L. A. Dirlikov, E. Nelson, L. J.

      2. Respiratory virus circulation during the first year of the COVID-19 pandemic in the Household Influenza Vaccine Evaluation (HIVE) cohort
        Fine SR, Bazzi LA, Callear AP, Petrie JG, Malosh RE, Foster-Tucker JE, Smith M, Ibiebele J, McDermott A, Rolfes MA, Monto AS, Martin ET.
        Influenza Other Respir Viruses. 2023 ;17(3):e13106.
        BACKGROUND: The annual reappearance of respiratory viruses has been recognized for decades. COVID-19 mitigation measures taken during the pandemic were targeted at respiratory transmission and broadly impacted the burden of acute respiratory illnesses (ARIs). METHODS: We used the longitudinal Household Influenza Vaccine Evaluation (HIVE) cohort in southeast Michigan to characterize the circulation of respiratory viruses from March 1, 2020, to June 30, 2021, using RT-PCR of respiratory specimens collected at illness onset. Participants were surveyed twice during the study period, and SARS-CoV-2 antibodies were measured in serum by electrochemiluminescence immunoassay. Incidence rates of ARI reports and virus detections were compared between the study period and a preceding pre-pandemic period of similar duration. RESULTS: Overall, 437 participants reported a total of 772 ARIs; 42.6% had respiratory viruses detected. Rhinoviruses were the most frequent virus, but seasonal coronaviruses, excluding SARS-CoV-2, were also common. Illness reports and percent positivity were lowest from May to August 2020, when mitigation measures were most stringent. Seropositivity for SARS-CoV-2 was 5.3% in summer 2020 and increased to 11.3% in spring 2021. The incidence rate of total reported ARIs for the study period was 50% lower (95% CI: 0.5, 0.6; p < 0.001) than the incidence rate from a pre-pandemic comparison period (March 1, 2016, to June 30, 2017). CONCLUSIONS: The burden of ARI in the HIVE cohort during the COVID-19 pandemic fluctuated, with declines occurring concurrently with the widespread use of public health measures. Rhinovirus and seasonal coronaviruses continued to circulate even when influenza and SARS-CoV-2 circulation was low.

        Rolfes, M. A.

      3. Mixing among sub-populations, as well as heterogeneity in characteristics affecting their reproduction numbers, must be considered when evaluating public health interventions to prevent or control infectious disease outbreaks. In this overview, we apply a linear algebraic approach to re-derive some well-known results pertaining to preferential within- and proportionate among-group contacts in compartmental models of pathogen transmission. We give results for the meta-population effective reproduction number ([Formula: see text]) assuming different levels of vaccination in the sub-populations. Specifically, we unpack the dependency of [Formula: see text] on the fractions of contacts reserved for individuals within one's own subgroup and, by obtaining implicit expressions for the partial derivatives of [Formula: see text], we show that these increase as this preferential-mixing fraction increases in any sub-population.

        Hill, A. N. Glasser, J. W.

      4. Interim clinical treatment considerations for severe manifestations of Mpox - United States, February 2023
        Rao AK, Schrodt CA, Minhaj FS, Waltenburg MA, Cash-Goldwasser S, Yu Y, Petersen BW, Hutson C, Damon IK.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(9):232-243.
        Monkeypox (mpox) is a disease caused by infection with Monkeypox virus (MPXV), an Orthopoxvirus (OPXV) in the same genus as Variola virus, which causes smallpox. During 2022, a global outbreak involving mpox clade IIb was recognized, primarily among gay, bisexual, and other men who have sex with men.* Most affected patients have been immunocompetent and experienced ≤10 rash lesions (1). CDC has recommended supportive care including pain control.(†) However, some patients have experienced severe mpox manifestations, including ocular lesions, neurologic complications, myopericarditis, complications associated with mucosal (oral, rectal, genital, and urethral) lesions, and uncontrolled viral spread due to moderate or severe immunocompromise, particularly advanced HIV infection (2). Therapeutic medical countermeasures (MCMs) are Food and Drug Administration (FDA)-regulated drugs and biologics that are predominantly stockpiled by the U.S. government; MCMs developed for smallpox preparedness or shown to be effective against other OPXVs (i.e., tecovirimat, brincidofovir, cidofovir, trifluridine ophthalmic solution, and vaccinia immune globulin intravenous [VIGIV]) have been used to treat severe mpox. During May 2022-January 2023, CDC provided more than 250 U.S. mpox consultations. This report synthesizes data from animal models, MCM use for human cases of related OPXV, unpublished data, input from clinician experts, and experience during consultations (including follow-up) to provide interim clinical treatment considerations. Randomized controlled trials and other carefully controlled research studies are needed to evaluate the effectiveness of MCMs for treating human mpox. Until data gaps are filled, the information presented in this report represents the best available information concerning the effective use of MCMs and should be used to guide decisions about MCM use for mpox patients.

        Rao, A. K. Schrodt, C. A. Minhaj, F. S. Waltenburg, M. A. Cash-Goldwasser, S. Yu, Y. Petersen, B. W. Hutson, C. Damon, I. K.

      5. An Mpox-related death in the United States
        Alarcón J, Kim M, Terashita D, Davar K, Garrigues JM, Guccione JP, Evans MG, Hemarajata P, Wald-Dickler N, Holtom P, Garcia Tome R, Anyanwu L, Shah NK, Miller M, Smith T, Matheny A, Davidson W, Hutson CL, Lucas J, Ukpo OC, Green NM, Balter SE.
        N Engl J Med. 2023 .

      6. BACKGROUND: Rapid linkage to HIV medical care, ideally within seven days of a person's diagnosis with HIV infection, is a vital strategy of the Ending the HIV Epidemic (EHE) initiative in the United States. We analyzed HIV testing data to evaluate the prevalence of and factors associated with rapid linkage to HIV medical care. METHODS: We used HIV testing data reported by CDC-funded 60 state and local health departments and 29 community-based organizations during 2019-2020. Variables analyzed include rapid linkage to HIV medical care (within seven days of diagnosis), demographic/population characteristics, geographic region, test site type, and test year. Multivariable Poisson regression analysis was conducted to evaluate the characteristics associated with rapid linkage to HIV medical care. RESULTS: A total of 3,678,070 HIV tests were conducted, and 11,337 persons were newly diagnosed with HIV infection. Only 4,710 (41.5%) persons received rapid linkage to HIV medical care, which was more likely among men who have sex with men or persons who were diagnosed in Phase I EHE jurisdictions and less likely among persons diagnosed in STD clinics or the South region. CONCLUSIONS: Less than one-half of persons newly diagnosed with HIV infection in CDC-funded HIV testing programs were linked to HIV medical care within seven days of diagnosis. Rapid linkage to care varied significantly by population characteristics and setting. Identifying and removing potential individual, social, or structural barriers to rapid linkage to care can help improve HIV-related health equity and contribute to the national goal of ending the HIV epidemic.

        Song, W. Mulatu, M. S.

    • Disaster Preparedness and Emergency Services
      1. Counseling women of reproductive age about emergency preparedness - Provider attitudes and practices
        Meeker JR, Simeone R, Shapiro-Mendoza CK, Snead M, Hall R, Ellington S, Galang RR.
        Prev Med. 2023 :107473.
        We report healthcare provider attitudes and practices on emergency preparedness counseling for women of reproductive age (WRA), including pregnant, postpartum, and lactating women (PPLW), for disasters and weather emergencies. DocStyles is a web-based panel survey of primary healthcare providers in the United States. During March 17-May 17, 2021, obstetricians-gynecologists, family practitioners, internists, nurse practitioners, and physician assistants were asked about the importance of emergency preparedness counseling, level of confidence, frequency, barriers to providing counseling, and preferred resources to support counseling among WRA and PPLW. We calculated frequencies of provider attitudes and practices, and prevalence ratios with 95% CIs for questions with binary responses. Among 1503 respondents (family practitioners (33%), internists (34%), obstetrician-gynecologists (17%), nurse practitioners (8%), and physician assistants (8%)), 77% thought emergency preparedness was important, and 88% thought counseling was necessary for patient health and safety. However, 45% of respondents did not feel confident providing emergency preparedness counseling, and most (70%) had never talked to PPLW about this topic. Respondents cited not having time during clinical visits (48%) and lack of knowledge (34%) as barriers to providing counseling. Most respondents (79%) stated they would use emergency preparedness educational materials for WRA, and 60% said they were willing to take an emergency preparedness training. Healthcare providers have opportunities to provide emergency preparedness counseling; however, many have not, noting lack of time and knowledge as barriers. Emergency preparedness resources combined with training may improve healthcare provider confidence and increase delivery of emergency preparedness counseling.

        Meeker, J. R. Simeone, R. Shapiro-Mendoza, C. K. Snead, M. Hall, R. Ellington, S. Galang, R. R.

    • Drug Safety
      1. Acute kidney injury among children likely associated with diethylene glycol-contaminated medications - The Gambia, June-September 2022
        Bastani P, Jammeh A, Lamar F, Malenfant JH, Adewuyi P, Cavanaugh AM, Calloway K, Crisp C, Fofana N, Hallett TC, Jallow A, Muoneke U, Nyassi M, Thomas J, Troeschel A, Yard E, Yeh M, Bittaye M.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(9):217-222.
        On July 26, 2022, a pediatric nephrologist alerted The Gambia's Ministry of Health (MoH) to a cluster of cases of acute kidney injury (AKI) among young children at the country's sole teaching hospital, and on August 23, 2022, MoH requested assistance from CDC. CDC epidemiologists arrived in The Gambia, a West African country, on September 16 to assist MoH in characterizing the illness, describing the epidemiology, and identifying potential causal factors and their sources. Investigators reviewed medical records and interviewed caregivers to characterize patients' symptoms and identify exposures. The preliminary investigation suggested that various contaminated syrup-based children's medications contributed to the AKI outbreak. During the investigation, MoH recalled implicated medications from a single international manufacturer. Continued efforts to strengthen pharmaceutical quality control and event-based public health surveillance are needed to help prevent future medication-related outbreaks.

        Bastani, P. Lamar, F. Malenfant, J. H. Cavanaugh, A. M. Calloway, K. Crisp, C. Hallett, T. C. Thomas, J. Troeschel, A. Yard, E. Yeh, M.

    • Environmental Health
      1. Burkholderia thailandensis isolated from the environment, United States
        Hall CM, Stone NE, Martz M, Hutton SM, Santana-Propper E, Versluis L, Guidry K, Ortiz M, Busch JD, Maness T, Stewart J, Sidwa T, Gee JE, Elrod MG, Petras JK, Ty MC, Gulvik C, Weiner ZP, Salzer JS, Hoffmaster AR, Rivera-Garcia S, Keim P, Kieffer A, Sahl JW, Soltero F, Wagner DM.
        Emerg Infect Dis. 2023 ;29(3):618-621.
        Burkholderia thailandensis, an opportunistic pathogen found in the environment, is a bacterium closely related to B. pseudomallei, the cause of melioidosis. Human B. thailandensis infections are uncommon. We isolated B. thailandensis from water in Texas and Puerto Rico and soil in Mississippi in the United States, demonstrating a potential public health risk.

        Gee, J. E. Elrod, M. G. Petras, J. K. Ty, M. C. Gulvik, C. Weiner, Z. P. Salzer, J. S. Hoffmaster, A. R.

      2. Associations of urinary metabolite concentrations of phthalates and phthalate replacements with body composition from mid-childhood to early adolescence
        Rokoff LB, Seshasayee SM, Carwile JL, Rifas-Shiman SL, Botelho JC, Gordon CM, Hauser R, James-Todd T, Young JG, Rosen CJ, Calafat AM, Oken E, Fleisch AF.
        Environ Res. 2023 :115629.
        BACKGROUND: Phthalates may adversely influence body composition by lowering anabolic hormones and activating peroxisome-proliferator activated receptor gamma. However, data are limited in adolescence when body mass distributions rapidly change and bone accrual peaks. Also, potential health effects of certain phthalate/replacements [e.g., di-2-ethylhexyl terephthalate (DEHTP)] have not been well studied. METHODS: Among 579 children in the Project Viva cohort, we used linear regression to evaluate associations of urinary concentrations of 19 phthalate/replacement metabolites from mid-childhood (median: 7.6 years; 2007-2010) with annualized change in areal bone mineral density (aBMD) and lean, total fat, and truncal fat mass as measured by dual-energy X-ray absorptiometry between mid-childhood and early adolescence (median: 12.8 years). We used quantile g-computation to assess associations of the overall chemical mixture with body composition. We adjusted for sociodemographics and tested for sex-specific associations. RESULTS: Urinary concentrations were highest for mono-2-ethyl-5-carboxypentyl phthalate [median (IQR): 46.7 (69.1) ng/mL]. We detected metabolites of most replacement phthalates in a relatively small number of participants [e.g., 28% for mono-2-ethyl-5-hydrohexyl terephthalate (MEHHTP; metabolite of DEHTP)]. Detectable (vs. non-detectable) MEHHTP was associated with less bone and greater fat accrual in males and greater bone and lean mass accrual in females [e.g., change in aBMD Z-score/year (95% CI): -0.049 (-0.085, -0.013) in males versus 0.042 (0.007, 0.076) in females; p(interaction)<0.01]. Children with higher concentrations of mono-oxo-isononyl phthalate and mono-3-carboxypropyl phthalate (MCPP) had greater bone accrual. Males with higher concentrations of MCPP and mono-carboxynonyl phthalate had greater accrual of lean mass. Other phthalate/replacement biomarkers, and their mixtures, were not associated with longitudinal changes in body composition. CONCLUSIONS: Concentrations of select phthalate/replacement metabolites in mid-childhood were associated with changes in body composition through early adolescence. As use of phthalate replacements such as DEHTP may be increasing, further investigation can help better understand the potential effects of early-life exposures.

        Botelho, J. C. Calafat, A. M.

      3. Community resources for contaminants of concern in private wells
        Hubbard B, Sabogal R, Zarate-Bermudez M.
        J Environ Health. 2023 ;85(7):36-39.

      4. Assessment of chemical exposures investigation after fire at an industrial chemical facility in Winnebago County, Illinois
        Nakayama JY, Surasi K, Owen LR, Johnson M, Martell S, Kittler A, Lopatin P, Patrick S, Mertzlufft C, Horton DK, Orr M.
        J Environ Health. 2023 ;85(7):8-15.
        After a chemical fire, an investigation assessed health effects by using syndromic surveillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders. A total of four separate multivariable logistic regression models were developed to examine associations between reported exposure to smoke, dust, debris, or odor with any reported symptom in the general public. Syndromic surveillance identified areas with increased ED visits. Among general health survey respondents, 45.1% (911 out of 2,020) reported at least one symptom. Respondents reporting exposure to smoke, dust, debris, or odor had 4.5 (95% confidence interval (CI) [3.7, 5.5]), 4.6 (95% CI [3.6, 5.8]), 2.0 (95% CI [1.7, 2.5]), or 5.8 (95% CI [4.7, 7.3]) times the odds of reporting any symptom compared with respondents not reporting exposure to smoke, dust, debris, or odor, respectively. First responders commonly reported contact with material and being within 1 mi of the fire ≥5 hr; 10 out of 31 of first responders reported at least one symptom. There was high symptom burden reported after the fire. Results from our investigation might assist the directing of public health resources to effectively address immediate community needs and prepare for future incidents. © 2023, National Environmental Health Association. All rights reserved.

        Nakayama, J. Y. Surasi, K. Owen, L. R. Johnson, M. Mertzlufft, C. Horton, D. K. Orr, M.

      5. Large-scale agricultural burning and cardiorespiratory emergency department visits in the U.S. state of Kansas
        Pennington AF, Vaidyanathan A, Ahmed FS, Manangan A, Mirabelli MC, Sircar KD, Yip F, Flanders WD.
        J Expo Sci Environ Epidemiol. 2023 .
        BACKGROUND: Prescribed agricultural burning is a common land management practice, but little is known about the health effects from the resulting smoke exposure. OBJECTIVE: To examine the association between smoke from prescribed burning and cardiorespiratory outcomes in the U.S. state of Kansas. METHODS: We analyzed a zip code-level, daily time series of primary cardiorespiratory emergency department (ED) visits for February-May (months when prescribed burning is common in Kansas) in the years 2009-2011 (n = 109,220). Given limited monitoring data, we formulated a measure of smoke exposure using non-traditional datasets, including fire radiative power and locational attributes from remote sensing data sources. We then assigned a population-weighted potential smoke impact factor (PSIF) to each zip code, based on fire intensity, smoke transport, and fire proximity. We used Poisson generalized linear models to estimate the association between PSIF on the same day and in the past 3 days and asthma, respiratory including asthma, and cardiovascular ED visits. RESULTS: During the study period, prescribed burning took place on approximately 8 million acres in Kansas. Same-day PSIF was associated with a 7% increase in the rate of asthma ED visits when adjusting for month, year, zip code, meteorology, day of week, holidays, and correlation within zip codes (rate ratio [RR]: 1.07; 95% confidence interval [CI]: 1.01, 1.13). Same-day PSIF was not associated with a combined outcome of respiratory ED visits (RR [95% CI]: 0.99 [0.97, 1.02]), or cardiovascular ED visits (RR [95% CI]: 1.01 [0.98, 1.04]). There was no consistent association between PSIF during the past 3 days and any of the outcomes. SIGNIFICANCE: These results suggest an association between smoke exposure and asthma ED visits on the same day. Elucidating these associations will help guide public health programs that address population-level exposure to smoke from prescribed burning.

        Pennington, A. F. Vaidyanathan, A. Manangan, A. Mirabelli, M. C. Sircar, K. D. Yip, F. Flanders, W. D.

      6. A mixed methods assessment of knowledge, attitudes and practices related to aflatoxin contamination and exposure among caregivers of children under five years in Western Kenya
        Awuor A, Wambura G, Ngere I, Hunsperger E, Onyango C, Bigogo G, Blum LS, Munyua P, Njenga MK, Widdowson MA.
        Public Health Nutr. 2023 :1-29.
        OBJECTIVE: Identifying factors that may influence aflatoxin exposure in children under five years of age living in farming households in western Kenya. DESIGN: We used a mixed methods design. The quantitative component entailed serial cross-sectional interviews in 250 farming households to examine crop processing and conservation practices, household food storage and consumption, and local understandings of aflatoxins. Qualitative data collection included focus group discussions (N=7) and key informant interviews (N=13) to explore explanations of harvesting and post-harvesting techniques and perceptions of crop spoilage. SETTING: The study was carried out in Asembo, a rural community where high rates of child stunting exist. PARTICIPANTS: A total of 250 female primary caregivers of children under five years of age and 13 experts in farming and food management participated. RESULTS: Study results showed that from a young age, children routinely ate maize-based dishes. Economic constraints and changing environmental patterns guided the application of sub-optimal crop practices involving early harvest, poor drying, mixing spoiled with good cereals, and storing cereals in polypropylene bags in confined quarters occupied by humans and livestock, raising risks of aflatoxin contamination. Most (80%) smallholder farmers were unaware of aflatoxins and their harmful economic and health consequences. CONCLUSIONS: Young children living in subsistence farming households may be at risk of exposure to aflatoxins and consequent ill health and stunting. Sustained efforts to increase awareness of the risks of aflatoxins and control measures among subsistence farmers could help to mitigate practices that raise exposure.

        Awuor, A. Hunsperger, E. Onyango, C. Munyua, P. Widdowson, M. A.

    • Epidemiology and Surveillance
      1. Surveillance systems for monitoring vaccination coverage with vaccines recommended for pregnant women, United States
        Meghani M, Razzaghi H, Kahn KE, Hung MC, Srivastav A, Lu PJ, Ellington S, Zhou F, Weintraub E, Black CL, Singleton JA.
        J Womens Health (Larchmt). 2023 ;32(3):260-270.
        Pregnant women* and their infants are at increased risk for serious influenza, pertussis, and COVID-19-related complications, including preterm birth, low-birth weight, and maternal and fetal death. The advisory committee on immunization practices recommends pregnant women receive tetanus-toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during pregnancy, and influenza and COVID-19 vaccines before or during pregnancy. Vaccination coverage estimates and factors associated with maternal vaccination are measured by various surveillance systems. The objective of this report is to provide a detailed overview of the following surveillance systems that can be used to assess coverage of vaccines recommended for pregnant women: Internet panel survey, National Health Interview Survey, National Immunization Survey-Adult COVID Module, Behavioral Risk Factor Surveillance System, Pregnancy Risk Assessment Monitoring System, Vaccine Safety Datalink, and MarketScan. Influenza, Tdap, and COVID-19 vaccination coverage estimates vary by data source, and select estimates are presented. Each surveillance system differs in the population of pregnant women, time period, geographic area for which estimates can be obtained, how vaccination status is determined, and data collected regarding vaccine-related knowledge, attitudes, behaviors, and barriers. Thus, multiple systems are useful for a more complete understanding of maternal vaccination. Ongoing surveillance from the various systems to obtain vaccination coverage and information regarding disparities and barriers related to vaccination are needed to guide program and policy improvements.

        Meghani, M. Razzaghi, H. Kahn, K. E. Hung, M. C. Srivastav, A. Lu, P. J. Ellington, S. Zhou, F. Weintraub, E. Black, C. L. Singleton, J. A.

      2. Acceptability, feasibility, and validity of detecting respiratory pathogens during acute respiratory illness in participant-collected swabs in a low-income, community sample
        Thind P, Vargas CY, Reed C, Wang L, Alba LR, Larson EL, Saiman L, Stockwell MS.
        Open Forum Infect Dis. 2023 ;10(3):ofad068.
        BACKGROUND: Community surveillance for acute respiratory illness (ARI) can include unsupervised participant-collected nasal swabs. Little is known about use of self-swabs in low-income populations or among households including extended family members and the validity of self-collected swabs. We assessed the acceptability, feasibility, and validity of unsupervised participant-collected nasal swabs in a low-income, community sample. METHODS: This was a substudy of a larger prospective community-based ARI surveillance study in 405 households in New York City. Participating household members self-collected swabs on the day of a research home visit for an index case, and for 3-6 subsequent days. Demographics associated with agreement to participate and swab collection were assessed, and index case self-collected versus research staff-collected swab results were compared. RESULTS: Most households (n = 292 [89.6%]) agreed to participate, including 1310 members. Being <18 years old, female, and the household reporter or member of the nuclear family (parents and children) were associated with both agreement to participate and self-swab collection. Being born in the United States or immigrating ≥10 years ago was associated with participation, and being Spanish-speaking and having less than a high school education were associated with swab collection. In all, 84.4% collected at least 1 self-swabbed specimen; self-swabbing rates were highest during the first 4 collection days. Concordance between research staff-collected swabs and self-swabs was 88.4% for negative swabs, 75.0% for influenza, and 69.4% for noninfluenza pathogens. CONCLUSIONS: Self-swabbing was acceptable, feasible, and valid in this low-income, minoritized population. Some differences in participation and swab collection were identified that could be noted by future researchers and modelers.

        Reed, C.

    • Genetics and Genomics
      1. Improving biomarker-based HIV incidence estimation in the treatment era
        Fellows IE, Hladik W, Eaton JW, Voetsch AC, Parekh BS, Shiraishi RW.
        Epidemiology. 2023 .
        BACKGROUND: Estimating HIV-1 incidence using biomarker assays in cross-sectional surveys is important for understanding the HIV pandemic. However, the utility of these estimates has been limited by uncertainty about what input parameters to use for false recency rate (FRR) and mean duration of recent infection (MDRI) after applying a recent infection testing algorithm (RITA). METHODS: This article shows how testing and diagnosis reduce both FRR and mean duration of recent infection compared to a treatment-naive population. A new method is proposed for calculating appropriate context-specific estimates of FRR and mean duration of recent infection. The result of this is a new formula for incidence that depends only on reference FRR and mean duration of recent infection parameters derived in an undiagnosed, treatment-naive, nonelite controller, non-AIDS-progressed population. RESULTS: Applying the methodology to eleven cross-sectional surveys in Africa results in good agreement with previous incidence estimates, except in 2 countries with very high reported testing rates. CONCLUSIONS: Incidence estimation equations can be adapted to account for the dynamics of treatment and recent infection testing algorithms. This provides a rigorous mathematical foundation for the application of HIV recency assays in cross-sectional surveys.

        Fellows, I. E. Hladik, W. Voetsch, A. C. Parekh, B. S.

      2. Genome sequences from a reemergence of vibrio cholerae in Haiti, 2022 reveal relatedness to previously circulating strains
        Walters C, Chen J, Stroika S, Katz LS, Turnsek M, Compère V, Im MS, Gomez S, McCullough A, Landaverde C, Putney J, Caidi H, Folster J, Carleton HA, Boncy J, Lee CC.
        J Clin Microbiol. 2023 :e0014223.

      3. Total and subgenomic RNA viral load in patients infected with SARS-CoV-2 Alpha, Delta, and Omicron variants
        Dimcheff DE, Blair CN, Zhu Y, Chappell JD, Gaglani M, McNeal T, Ghamande S, Steingrub JS, Shapiro NI, Duggal A, Busse LW, Frosch AE, Peltan ID, Hager DN, Gong MN, Exline MC, Khan A, Wilson JG, Qadir N, Ginde AA, Douin DJ, Mohr NM, Mallow C, Martin ET, Johnson NJ, Casey JD, Stubblefield WB, Gibbs KW, Kwon JH, Talbot HK, Halasa N, Grijalva CG, Baughman A, Womack KN, Hart KW, Swan SA, Surie D, Thornburg NJ, McMorrow ML, Self WH, Lauring AS.
        J Infect Dis. 2023 .
        BACKGROUND: SARS-CoV-2 genomic and subgenomic RNA levels are frequently used as a correlate of infectiousness. The impact of host factors and SARS-CoV-2 lineage on RNA viral load is unclear. METHODS: Total nucleocapsid (N) and subgenomic N (sgN) RNA levels were measured by RT-qPCR in specimens from 3,204 individuals hospitalized with COVID-19 at 21 hospitals. RT-qPCR cycle threshold (Ct) values were used to estimate RNA viral load. The impact of time of sampling, SARS-CoV-2 variant, age, comorbidities, vaccination, and immune status on N and sgN Ct values were evaluated using multiple linear regression. RESULTS: Ct values at presentation for N (mean ±standard deviation) were 24.14±4.53 for non-variants of concern, 25.15±4.33 for Alpha, 25.31±4.50 for Delta, and 26.26±4.42 for Omicron. N and sgN RNA levels varied with time since symptom onset and infecting variant but not with age, comorbidity, immune status, or vaccination. When normalized to total N RNA, sgN levels were similar across all variants. CONCLUSIONS: RNA viral loads were similar among hospitalized adults, irrespective of infecting variant and known risk factors for severe COVID-19. Total N and subgenomic RNA N viral loads were highly correlated, suggesting that subgenomic RNA measurements adds little information for the purposes of estimating infectivity.

        Surie, D. Thornburg, N. J. McMorrow, M. L.

    • Health Behavior and Risk
      1. Treatment as prevention (TasP) is an effective HIV prevention strategy. Our objectives were to explore TasP attitudes and beliefs among people with HIV (PWH) who are not engaged in care and to examine attitudes and beliefs by selected characteristics. We sampled PWH who had participated in the Medical Monitoring Project (MMP), a structured interview survey, from June 2018-May 2019 to participate in 60-minute semi-structured telephone interviews. We obtained sociodemographic and behavioral quantitative data from the MMP structured interview. We used applied thematic analysis to analyze the qualitative data and integrated the qualitative and quantitative data during analysis. Negative attitudes and beliefs, especially skepticism and mistrust, about TasP were pervasive. Only one participant who identified as female, was not sexually active, and had not heard of TasP held positive attitudes and beliefs about TasP. TasP messages should use clear and unambiguous language, address mistrust, and reach people who are not engaged in medical care.

        Padilla, M. Gutierrez, M. Basu, M. Fagan, J.

      2. Chemsex drug use among a national sample of sexually active men who have sex with men, - American Men's Internet Survey, 2017-2020
        Ivey K, Bernstein KT, Kirkcaldy RD, Kissinger P, Edwards OW, Sanchez T, Abara WE.
        Subst Use Misuse. 2023 :1-7.
        Background: Chemsex is the intentional use of drugs to enhance sexual activity. Chemsex drug use among men who have sex with men (MSM) is associated with sexual behaviors that increase sexually transmitted infection (STI) risks and adverse mental health outcomes. However, published data are largely based on MSM recruited from STI clinics. There are limited data about use of chemsex drugs among national samples of MSM in the United States. Using data from the American Men's Internet Survey (AMIS), we assessed the prevalence and correlates of use of chemsex drugs among sexually active MSM in the United States. Methods: We used data from the 2017 to 2020 AMIS cycles to examine the prevalence of chemsex drug use in the past 12 months among MSM. We calculated prevalence ratios (PR) and 95% confidence intervals (CI) to compare chemsex drug use across demographic, behavioral, and mental health factors. Results: Of 30,294 MSM, 3,113 (10.3%) reported chemsex drug use in the past 12 months. Of the 3,113 MSM who reported chemsex drug use, 65.1% reported ecstasy use, 42.5% reported crystal methamphetamine use, and 21.7% reported GHB use. Factors associated with chemsex drug use included condomless anal sex (PR = 1.93, 95%=1.69-2.20), problem drinking (PR = 2.36, 95% = 2.13-2.61), bacterial STI test (1.84, 95% CI = 1.68-2.02) and probable serious mental illness (PR = 1.92, 95% = 1.76-2.09). Conclusion: Chemsex drug use is associated with behaviors that increase STI risk and mental distress among MSM. Health programs that serve MSM can consider screening for chemsex drug use and offering sexual and mental health promotion and risk reduction interventions when necessary.

        Bernstein, K. T. Kirkcaldy, R. D. Abara, W. E.

    • Health Economics
      1. Cost analysis of the positive health check intervention to suppress HIV viral load and retain patients in HIV clinical care
        Shrestha RK, Galindo CA, Courtenay-Quirk C, Harshbarger C, Abdallah I, Marconi VC, DallaPiazza M, Swaminathan S, Somboonwit C, Lewis MA, Khavjou OA.
        J Public Health Manag Pract. 2023 .
        CONTEXT: Digital video-based behavioral interventions are effective tools for improving HIV care and treatment outcomes. OBJECTIVE: To assess the costs of the Positive Health Check (PHC) intervention delivered in HIV primary care settings. DESIGN, SETTING, AND INTERVENTION: The PHC study was a randomized trial evaluating the effectiveness of a highly tailored, interactive video-counseling intervention delivered in 4 HIV care clinics in the United States in improving viral suppression and retention in care. Eligible patients were randomized to either the PHC intervention or the control arm. Control arm participants received standard of care (SOC), and intervention arm participants received SOC plus PHC. The intervention was delivered on computer tablets in the clinic waiting rooms. The PHC intervention improved viral suppression among male participants. A microcosting approach was used to assess the program costs, including labor hours, materials and supplies, equipment, and office overhead. PARTICIPANTS: Persons with HIV infection, receiving care in participating clinics. MAIN OUTCOME MEASURES: The primary outcome was the number of patients virally suppressed, defined as having fewer than 200 copies/mL by the end of their 12-month follow-up. RESULTS: A total of 397 (range across sites [range], 95-102) participants were enrolled in the PHC intervention arm, of whom 368 participants (range, 82-98) had viral load data at baseline and were included in the viral load analyses. Of those, 210 (range, 41-63) patients were virally suppressed at the end of their 12-month follow-up visit. The overall annual program cost was $402 274 (range, $65 581-$124 629). We estimated the average program cost per patient at $1013 (range, $649-$1259) and the cost per patient virally suppressed at $1916 (range, $1041-$3040). Recruitment and outreach costs accounted for 30% of PHC program costs. CONCLUSIONS: The costs of this interactive video-counseling intervention are comparable with other retention in care or reengagement interventions.

        Shrestha, R. K. Galindo, C. A. Courtenay-Quirk, C. Harshbarger, C.

    • Health Equity and Health Disparities
      1. HIV prevention services for Hispanic/Latino persons in THRIVE, 2015-2020
        Bonacci RA, Tanner MR, Zhu W, Hayes T, Dominguez KL, Iqbal K, Wiener J, Drezner K, Jennings JM, Tsoi B, Wendell D, Hoover KW.
        Am J Prev Med. 2023 .
        INTRODUCTION: Hispanic/Latino men who have sex with men (MSM) and transgender women (TGW) are disproportionately affected by HIV in the U.S. This study evaluated HIV prevention services and outcomes among Hispanic/Latino MSM and TGW in the targeted highly effective interventions to reduce the HIV epidemic (THRIVE) demonstration project and consider lessons learned. METHODS: The authors described the THRIVE demonstration project services provided to Hispanic/Latino MSM and TGW in 7 U.S. jurisdictions from 2015 to 2020. HIV prevention service outcomes were compared between 1 site with (2,147 total participants) and 6 sites without (1,129 total participants) Hispanic/Latino-oriented pre-exposure prophylaxis clinical services, and Poisson regression was used to estimate the adjusted RR between sites and pre-exposure prophylaxis outcomes. Analyses were conducted from 2021 to 2022. RESULTS: The THRIVE demonstration project served 2,898 and 378 Hispanic/Latino MSM and TGW, respectively, with 2,519 MSM (87%) and 320 TGW (85%) receiving ≥1 HIV screening test. Among 2,002 MSM and 178 TGW eligible for pre-exposure prophylaxis, 1,011 (50%) MSM and 98 (55%) TGW received pre-exposure prophylaxis prescriptions, respectively. MSM and TGW were each 2.0 times more likely to be linked to pre-exposure prophylaxis (95% CI=1.4, 2.9 and 95% CI=1.2, 3.6, respectively) and 1.6 and 2.1 times more likely to be prescribed pre-exposure prophylaxis (95% CI=1.1, 2.2 and 95% CI=1.1, 4.1), respectively, at the site providing Hispanic/Latino-oriented pre-exposure prophylaxis clinical services than at other sites and adjusted for age group. CONCLUSIONS: The THRIVE demonstration project delivered comprehensive HIV prevention services to Hispanic/Latino MSM and TGW. Hispanic/Latino-oriented clinical settings may improve HIV prevention service delivery to persons in Hispanic/Latino communities.

        Bonacci, R. A. Tanner, M. R. Zhu, W. Iqbal, K. Wiener, J. Hoover, K. W.

      2. INTRODUCTION: Studies characterizing differences in youth flavored tobacco product use prevalence, curiosity/susceptibility, and harm perceptions by race and ethnicity are limited. This study comprehensively examines flavored tobacco product use and harm perceptions among U.S. middle and high school students, by race and ethnicity. METHODS: Data came from the 2019 (N=19,018) and 2020 (N=14,531) National Youth Tobacco Surveys (NYTS). Weighted prevalence estimates of flavored tobacco product use and curiosity, susceptibility, and harm perception are reported by race and ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, or NH Other). t-Tests assessed differences in prevalence by years and racial/ethnic groups. RESULTS: Among youth with past 30-day tobacco use, use of most flavored tobacco products increased across all racial/ethnic groups; the largest increase was observed among Hispanic youth using other flavored tobacco products (30.3%). The group with the highest susceptibility to future electronic cigarette (e-cigarette) use was Hispanic students (42.3%). Hispanic students had the highest curiosity about and susceptibility to future use of cigarettes and cigars as well. CONCLUSIONS: Increases in the use of and higher susceptibility to other flavored tobacco products, particularly among Hispanic youth, suggest a need for additional changes in environmental conditions and possibly targeted or tailored tobacco control interventions for Hispanic youth. IMPLICATIONS: Given that flavored tobacco use is prevalent among youth and aggressively marketed more to racial/ethnic minority populations, it is important to understand how susceptibility and perceptions relate to tobacco use. Our results suggest a need for a better understanding of social and environmental factors that drive tobacco use behaviors and perceptions, particularly among Hispanic youth, to address the root causes of these differences and create more equitable tobacco control interventions.

        Watson, C. V. Puvanesarajah, S. Hawkins, N. A. Trivers, K. F.

      3. Elevated colorectal cancer incidence among American Indian/Alaska native persons in Alaska compared to other populations worldwide
        Haverkamp D, Redwood D, Roik E, Vindigni S, Thomas T.
        Int J Circumpolar Health. 2023 ;82(1):2184749.
        Colorectal cancer (CRC) is a leading cancer worldwide; incidence varies greatly by country and racial group. We compared 2018 American Indian/Alaska Native (AI/AN) CRC incidence rates in Alaska to other Tribal, racial, and international population rates. AI/AN persons in Alaska had the highest CRC incidence rate among US Tribal and racial groups (61.9/100,000 in 2018). AI/AN persons in Alaska also had higher rates than those reported for any other country in the world in 2018 except for Hungary, where males had a higher CRC incidence rate than AI/AN males in Alaska (70.6/100,000 and 63.6/100,000 respectively). This review of CRC incidence rates from populations in the United States and worldwide showed that AI/AN persons in Alaska had the highest documented incidence rate of CRC in the world in 2018. It is important to inform health systems serving AI/AN persons in Alaska about policies and interventions that can support CRC screening to reduce the burden of this disease.

        Haverkamp, D.

      4. Possible undetected Mpox infection among persons accessing homeless services and staying in encampments - San Francisco, California, October-November 2022
        Waddell CJ, Filardo TD, Prasad N, Pellegrini GJ, Persad N, Carson WC, Navarra T, Townsend MB, Satheshkumar PS, Lowe D, Borne D, Janssen J, Okoye N, Bejarano A, Marx GE, Mosites E.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(9):227-231.
        Monkeypox (mpox) is a disease caused by an Orthopoxvirus. The 2022 multinational outbreak, which began in May 2022, has spread primarily by close skin-to-skin contact, including through sexual contact. Persons experiencing homelessness have been disproportionately affected by severe mpox (1). However, mpox prevalence and transmission pathways among persons experiencing homelessness are not known, and persons experiencing homelessness have not been specifically recommended to receive mpox vaccine during the 2022 outbreak (2,3). During October 25-November 3, 2022, a CDC field team conducted an orthopoxvirus seroprevalence survey among persons accessing homeless services or staying in encampments, shelters, or permanent supportive housing in San Francisco, California that had noted at least one case of mpox or served populations at risk. During field team visits to 16 unique sites, 209 participants completed a 15-minute survey and provided a blood specimen. Among 80 participants aged <50 years who did not report smallpox or mpox vaccination or previous mpox infection, two (2.5%) had detectable antiorthopoxvirus immunoglobulin (Ig) G antibody. Among 73 participants who did not report mpox vaccination or previous mpox infection and who were tested for IgM, one (1.4%) had detectable antiorthopoxvirus IgM. Together, these results suggest that three possible undetected mpox infections occurred among a sample of persons experiencing homelessness, highlighting the need to ensure that community outreach and prevention interventions, such as vaccination, are accessible to this population.

        Waddell, C. J. Filardo, T. D. Prasad, N. Pellegrini, G. J., Jr. Persad, N. Carson, W. C. Navarra, T. Townsend, M. B. Satheshkumar, P. S. Lowe, D. Marx, G. E. Mosites, E.

    • Healthcare Associated Infections
      1. Bacterial and viral infections among adults hospitalized with COVID-19, COVID-NET, 14 states, March 2020-April 2022
        Shah MM, Patel K, Milucky J, Taylor CA, Reingold A, Armistead I, Meek J, Anderson EJ, Weigel A, Reeg L, Como-Sabetti K, Ropp SL, Muse A, Bushey S, Shiltz E, Sutton M, Talbot HK, Chatelain R, Havers FP.
        Influenza Other Respir Viruses. 2023 ;17(3):e13107.
        BACKGROUND: Bacterial and viral infections can occur with SARS-CoV-2 infection, but prevalence, risk factors, and associated clinical outcomes are not fully understood. METHODS: We used the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance system, to investigate the occurrence of bacterial and viral infections among hospitalized adults with laboratory-confirmed SARS-CoV-2 infection between March 2020 and April 2022. Clinician-driven testing for bacterial pathogens from sputum, deep respiratory, and sterile sites were included. The demographic and clinical features of those with and without bacterial infections were compared. We also describe the prevalence of viral pathogens including respiratory syncytial virus, rhinovirus/enterovirus, influenza, adenovirus, human metapneumovirus, parainfluenza viruses, and non-SARS-CoV-2 endemic coronaviruses. RESULTS: Among 36 490 hospitalized adults with COVID-19, 53.3% had bacterial cultures taken within 7 days of admission and 6.0% of these had a clinically relevant bacterial pathogen. After adjustment for demographic factors and co-morbidities, bacterial infections in patients with COVID-19 within 7 days of admission were associated with an adjusted relative risk of death 2.3 times that of patients with negative bacterial testing. Staphylococcus aureus and Gram-negative rods were the most frequently isolated bacterial pathogens. Among hospitalized adults with COVID-19, 2766 (7.6%) were tested for seven virus groups. A non-SARS-CoV-2 virus was identified in 0.9% of tested patients. CONCLUSIONS: Among patients with clinician-driven testing, 6.0% of adults hospitalized with COVID-19 were identified to have bacterial coinfections and 0.9% were identified to have viral coinfections; identification of a bacterial coinfection within 7 days of admission was associated with increased mortality.

        Shah, M. M. Patel, K. Milucky, J. Taylor, C. A.

      2. Clinical course associated with aseptic meningitis induced by intravenous immunoglobulin for the treatment of multisystem inflammatory syndrome in children
        Young CC, LaRovere KL, Newhams MM, Kucukak S, Gertz SJ, Maddux AB, Halasa NB, Crandall H, Kong M, Fitzgerald JC, Irby K, Randolph AG, Campbell AP, Son MB.
        J Pediatr. 2023 .
        Aseptic meningitis is a rare but potentially serious complication of intravenous immunoglobulin (IVIG) treatment. In this case series, meningitic symptoms following IVIG initiation in patients with multisystem inflammatory syndrome were rare (7/2,086 [0.3%]). However, they required the need for additional therapy and/or readmission.

        Campbell, A. P.

      3. Risk factors associated with Hepatitis E virus infection in kidney transplant recipients in a single tertiary Center in the United States
        Sakulsaengprapha V, Wasuwanich P, Thawillarp S, Ingviya T, Phimphilai P, Sue PK, Jackson AM, Kraus ES, Teshale EH, Kamili S, Karnsakul W.
        Transpl Immunol. 2023 :101809.
        BACKGROUND: Hepatitis E virus (HEV), the causative agent of hepatitis E, is a common but self-limiting disease. However, in immunosuppressed kidney transplant 47 recipients (KTRs), HEV infection can become chronic. We investigated risk factors associated with HEV infection among 271 KTRs at the Johns Hopkins Hospital transplanted between 1988 and 2012. METHODS: HEV infection was defined as having positive anti-HEV IgM, anti-HEV IgG, or HEV RNA. The risk factors included: age at transplant, sex, hemodialysis/peritoneal dialysis, plasmapheresis, transfusions, community urbanization, and other socioeconomic factors. Logistic regression was used to determine independent risk factors associated with HEV infection. RESULTS: Out of 271 KTRs, 43 (16%) had HEV infection though not active disease. HEV infection in KTRs was associated with older age (≥45 years; OR = 4.04; 95% CI = 1.81-57 10.03; p = 0.001) and living in communities with low proportions of minorities (OR = 0.22; 95% 58 CI = 0.04-0.90; p = 0.046). CONCLUSION: KTRs who had HEV infection may be at an increased risk of developing chronic HEV.

        Teshale, E. H. Kamili, S.

    • Immunity and Immunization
      1. Increases in COVID-19 vaccination among NYC municipal employees after implementation of vaccination requirements
        Rubenstein BL, Amiel PJ, Ternier A, Helmy H, Lim S, Chokshi DA, Zucker JR.
        Health Aff (Millwood). 2023 ;42(3):357-365.
        In July 2021 New York City (NYC) instituted a requirement for all municipal employees to be vaccinated against COVID-19 or undergo weekly testing. The city eliminated the testing option November 1 of that year. We used general linear regression to compare changes in weekly primary vaccination series completion among NYC municipal employees ages 18-64 living in the city and a comparison group of all other NYC residents in this age group during May-December 2021. The rate of change in vaccination prevalence among NYC municipal employees was greater than that of the comparison group only after the testing option was eliminated (employee slope = 12.0; comparison slope = 5.3). Among racial and ethnic groups, the rate of change in vaccination prevalence among municipal employees was higher than the comparison group for Black and White people. The requirements were associated with narrowing the gap in vaccination prevalence between municipal employees and the comparison group overall and between Black municipal employees and employees from other racial and ethnic groups. Workplace requirements are a promising strategy for increasing vaccination among adults and reducing racial and ethnic disparities in vaccination uptake.

        Rubenstein, B. L.

      2. Effectiveness of first and second COVID-19 mRNA vaccine monovalent booster doses during a period of circulation of Omicron variant sublineages: December 2021-July 2022
        Petrie JG, King JP, McClure DL, Rolfes MA, Meece JK, Pattinson D, Neumann G, Kawaoka Y, Belongia EA, McLean HQ.
        Influenza Other Respir Viruses. 2023 ;17(3):e13104.
        BACKGROUND: US recommendations for COVID-19 vaccine boosters have expanded in terms of age groups covered and numbers of doses recommended, whereas evolution of Omicron sublineages raises questions about ongoing vaccine effectiveness. METHODS: We estimated effectiveness of monovalent COVID-19 mRNA booster vaccination versus two-dose primary series during a period of Omicron variant virus circulation in a community cohort with active illness surveillance. Hazard ratios comparing SARS-CoV-2 infection between booster versus primary series vaccinated individuals were estimated using Cox proportional hazards models with time-varying booster status. Models were adjusted for age and prior SARS-CoV-2 infection. The effectiveness of a second booster among adults ≥50 years of age was similarly estimated. RESULTS: The analysis included 883 participants ranging in age, from 5 to >90 years. Relative effectiveness was 51% (95% CI: 34%, 64%) favoring the booster compared with primary series vaccination and did not vary by prior infection status. Relative effectiveness was 74% (95% CI: 57%, 84%) at 15 to 90 days after booster receipt, but declined to 42% (95% CI: 16%, 61%) after 91 to 180 days, and to 36% (95% CI: 3%, 58%) after 180 days. The relative effectiveness of a second booster compared to a single booster was 24% (95% CI: -40% to 61%). CONCLUSIONS: An mRNA vaccine booster dose added significant protection against SARS-CoV-2 infection, but protection decreased over time. A second booster did not add significant protection for adults ≥50 years of age. Uptake of recommended bivalent boosters should be encouraged to increase protection against Omicron BA.4/BA.5 sublineages.

        Rolfes, M. A.

      3. Healthy vaccinee bias and MenB-FHbp vaccine effectiveness against gonorrhea
        Abara WE, Bernstein KT, Lewis FM, Pathela P, Islam A, Eberhart M, Cheng I, Ternier A, Sanderson Slutsker J, Madera R, Kirkcaldy R.
        Sex Transm Dis. 2023 .
        Observational studies demonstrated 30-40% effectiveness of OMV meningococcal serogroup-B vaccines against gonorrhea. To explore whether healthy vaccinee bias influenced such findings, we examined effectiveness of MenB-FHbp, a non-OMV vaccine that is not protective against gonorrhea. MenB-FHbp was ineffective against gonorrhea. Healthy vaccinee bias likely did not confound earlier studies of OMV vaccines.

        Abara, W. E. Bernstein, K. T. Kirkcaldy, R.

      4. Assessing country compliance with circulating vaccine-derived poliovirus type 2 outbreak response standard operating procedures: April 2016 to December 2020
        Darwar R, Biya O, Greene SA, Jorba J, Al Safadi M, Franka R, Wiesen E, Durry E, Pallansch MA.
        Vaccine. 2023 .
        BACKGROUND: Trivalent oral poliovirus vaccine (tOPV) was globally replaced with bivalent oral poliovirus vaccine (bOPV) in April 2016 ("the switch"). Many outbreaks of paralytic poliomyelitis associated with type 2 circulating vaccine-derived poliovirus (cVDPV2) have been reported since this time. The Global Polio Eradication Initiative (GPEI) developed standard operating procedures (SOPs) to guide countries experiencing cVDPV2 outbreaks to implement timely and effective outbreak response (OBR). To assess the possible role of compliance with SOPs in successfully stopping cVDPV2 outbreaks, we analyzed data on critical timelines in the OBR process. METHODS: Data were collected on all cVDPV2 outbreaks detected for the period April 1, 2016 and December 31, 2020 and all outbreak responses to those outbreaks between April 1, 2016 and December 31, 2021. We conducted secondary data analysis using the GPEI Polio Information System database, records from the Anonymized Institution Poliovirus Laboratory, and meeting minutes of the monovalent OPV2 (mOPV2) Advisory Group. Date of notification of circulating virus was defined as Day 0 for this analysis. Extracted process variables were compared with indicators in the GPEI SOP version 3.1. RESULTS: One hundred and eleven cVDPV2 outbreaks resulting from 67 distinct cVDPV2 emergences were reported during April 1, 2016-December 31, 2020, affecting 34 countries across four World Health Organization Regions. Out of 65 OBRs with the first large-scale campaign (R1) conducted after Day 0, only 12 (18.5%) R1s were conducted by the target of 28 days after Day 0. Of the 89 OBRs with the second large-scale campaign (R2) conducted after Day 0, 30 (33.7%) R2s were conducted by the target of 56 days after Day 0. Twenty-three (31.9%) of the 72 outbreaks with isolates dated after Day 0 were stopped within the 120-day target. CONCLUSION: Since "the switch", delays in OBR implementation were evident in many countries, which may be related to the persistence of cVDPV2 outbreaks >120 days. To achieve timely and effective response, countries should follow GPEI OBR guidelines.

        Darwar, R. Biya, O. Greene, S. A. Jorba, J. Franka, R. Wiesen, E. Durry, E. Pallansch, M. A.

    • Informatics
      1. Using real-world electronic health record data to assess chronic disease screening in children: A case study of non-alcoholic fatty liver disease
        Kraus EM, Pierce SL, Porter R, Kompaniyets L, Vos MB, Blanck HM, King RJ, Goodman AB.
        Child Obes. 2023 .
        Background: Data sources for assessing pediatric chronic diseases and associated screening practices are rare. One example is non-alcoholic fatty liver disease (NAFLD), a common chronic liver disease prevalent among children with overweight and obesity. If undetected, NAFLD can cause liver damage. Guidelines recommend screening for NAFLD using alanine aminotransferase (ALT) tests in children ≥9 years with obesity or those with overweight and cardiometabolic risk factors. This study explores how real-world data from electronic health records (EHRs) can be used to study NAFLD screening and ALT elevation. Research Design: Using IQVIA's Ambulatory Electronic Medical Record database, we studied patients 2-19 years of age with body mass index ≥85th percentile. Using a 3-year observation period (January 1, 2019 to December 31, 2021), ALT results were extracted and assessed for elevation (≥1 ALT result ≥22.1 U/L for females and ≥25.8 U/L for males). Patients with liver disease (including NAFLD) or receiving hepatotoxic medications during 2017-2018 were excluded. Results: Among 919,203 patients 9-19 years of age, only 13% had ≥1 ALT result, including 14% of patients with obesity and 17% of patients with severe obesity. ALT results were identified for 5% of patients 2-8 years of age. Of patients with ALT results, 34% of patients 2-8 years of age and 38% of patients 9-19 years of age had ALT elevation. Males 9-19 years of age had a higher prevalence of ALT elevation than females (49% vs. 29%). Conclusions: EHR data offered novel insights into NAFLD screening: despite screening recommendations, ALT results among children with excess weight were infrequent. Among those with ALT results, ALT elevation was common, underscoring the importance of screening for early disease detection.

        Kraus, E. M. Pierce, S. L. Porter, R. Kompaniyets, L. Blanck, H. M. King, R. J. Goodman, A. B.

    • Injury and Violence
      1. Association of recent violence encounters with suicidal ideation among adolescents with depression
        Wang J, Harrer S, Zwald ML, Leemis RW, Holland KM, Stone DM, McDavid Harrison K, Swedo EA.
        JAMA Netw Open. 2023 ;6(3):e231190.
        IMPORTANCE: Suicide prevention is an important component of depression management. Knowledge about depressed adolescents with increased risk for suicide can inform suicide prevention efforts. OBJECTIVE: To describe the risk of documented suicidal ideation within a year following a diagnosis of depression and to examine how the risk of documented suicidal ideation differed by recent violence encounter status among adolescents with new depression diagnoses. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in clinical settings including outpatient facilities, emergency departments, and hospitals. Using IBM's Explorys database containing electronic health records from 26 US health care networks, this study observed a cohort of adolescents with new depression diagnoses from 2017 to 2018 for up to 1 year. Data were analyzed from July 2020 to July 2021. EXPOSURES: Recent violence encounter was defined by a diagnosis of child maltreatment (physical, sexual, or psychological abuse or neglect) or physical assault within 1 year before depression diagnosis. MAIN OUTCOMES AND MEASURES: The main outcome was diagnosis of suicidal ideation within 1 year following depression diagnosis. Multivariable adjusted risk ratios of suicidal ideation were calculated for overall recent violence encounters and for individual forms of violence. RESULTS: Among a total of 24 047 adolescents with depression, 16 106 (67.0%) were female and 13 437 (55.9%) were White. A total of 378 had experienceda violence (hereafter, encounter group) and 23 669 had not (hereafter, nonencounter group). Following the diagnosis of depression, 104 adolescents with any past-year violence encounter (27.5%) documented suicidal ideation within 1 year. In contrast, 3185 adolescents in the nonencounter group (13.5%) experienced thoughts of suicide following the diagnosis of depression. In multivariable analyses, those with any violence encounter had 1.7 times (95% CI 1.4-2.0) higher risk of documented suicidal ideation compared with those in the nonencounter group (P < .001). Among different forms of violence, sexual abuse (risk ratio, 2.1; 95% CI, 1.6-2.8) and physical assault (risk ratio, 1.7; 95% CI, 1.3-2.2) were associated with significantly increased risk of suicidal ideation. CONCLUSIONS AND RELEVANCE: Among adolescents with depression, persons who experienced past-year violence encounters showed a higher rate of suicidal ideation than those who had not. These findings highlight the importance of identifying and accounting for past violence encounters when treating adolescents with depression to reduce risk of suicide. Public health approaches to prevent violence may help to avert morbidity associated with depression and suicidal ideation.

        Wang, J. Zwald, M. L. Leemis, R. W. Holland, K. M. Stone, D. M. McDavid Harrison, K. Swedo, E. A.

    • Laboratory Sciences
      1. A rapid point-of-care assay for cysticercosis antigen detection in urine samples
        Toribio L, Handali S, Marin Y, Perez E, Castillo Y, Bustos JA, O'Neal SE, Garcia HH.
        Am J Trop Med Hyg. 2023 ;108(3):578-580.
        We report a proof-of-concept study using a dipstick assay to detect Taenia solium antigen in urine samples of 30 patients with subarachnoid neurocysticercosis and 10 healthy control subjects. Strips were read in blind by two readers. The assay detected antigen in 29 of 30 cases and was negative in all 10 control samples. Although this study was performed in samples from individuals with subarachnoid neurocysticercosis who likely had high circulating antigen levels, it provides the proof of concept for a functional urine antigen point-of-care assay that detects viable cysts. Such an assay could serve to support a clinical diagnosis of suspect neurocysticercosis or to identify patients at risk of developing severe disease in areas where medical resources are limited, providing evidence to refer these individuals for imaging and specialized care as needed.

        Handali, S.

      2. Editorial: Current research on serological analyses of infectious diseases
        Rogier EW, Giorgi E, Tetteh K, Sepúlveda N.
        Front Med (Lausanne). 2023 ;10:1154584.

      3. Serine 970 of RNA helicase MOV10 is phosphorylated and controls unfolding activity and fate of mRNAs targeted for AGO2-mediated silencing
        Nawaz A, Kenny PJ, Shilikbay T, Reed M, Stuchlik O, Pohl J, Ceman S.
        J Biol Chem. 2023 :104577.
        MOV10 is an RNA helicase that is required for organismal development and is highly expressed in postnatal brain. MOV10 was identified as an AGO2 associated protein that is also necessary for AGO2-mediated silencing. AGO2 is the primary effector of the miRNA pathway. MOV10 has been shown to be ubiquitinated, leading to its degradation and release from bound mRNAs but no other post-translational modifications with functional implications have been described. Using mass spectrometry, we show that MOV10 is phosphorylated in cells at the C-terminus, specifically at serine 970 (S970). Substitution of S970 to phospho-mimic aspartic acid (S970D) blocked unfolding of an RNA G-quadruplex, similar to when the helicase domain was mutated (K531A). In contrast, the alanine substitution (S970A) of MOV10 unfolded the model RNA G-quadruplex. To examine its role in cells, our RNA-seq analysis showed that the expression of S970D causes decreased expression of MOV10 enhanced Cross-Linking Immunoprecipitation (eCLIP) targets compared to WT. Introduction of S970A had an intermediate effect, suggesting that S970 was protective of mRNAs. In whole cell extracts, MOV10 and its substitutions bound AGO2 comparably; however, knockdown of AGO2 abrogated the S970D-induced mRNA degradation. Thus, MOV10 activity protects mRNA from AGO2; phosphorylation of S970 restricts this activity resulting in AGO2-mediated mRNA degradation. S970 is positioned C-terminal to the defined MOV10-AGO2 interaction site and is proximal to a disordered region that likely modulates AGO2 interaction with target mRNAs upon phosphorylation. In summary, we provide evidence for a model whereby MOV10 phosphorylation facilitates AGO2 association with the 3'UTR of translating mRNAs that leads to their degradation.

        Reed, M. Stuchlik, O. Pohl, J.

      4. Modelling the impact of CD4 testing on mortality from TB and cryptococcal meningitis among patients with advanced HIV disease in nine countries
        Oboho IK, Paulin H, Corcoran C, Hamilton M, Jordan A, Kirking HL, Agyemang E, Podewils LJ, Pretorius C, Greene G, Chiller T, Desai M, Bhatkoti R, Shiraishi RW, Shah NS.
        J Int AIDS Soc. 2023 ;26(3):e26070.
        INTRODUCTION: Despite antiretroviral therapy (ART) scale-up among people living with HIV (PLHIV), those with advanced HIV disease (AHD) (defined in adults as CD4 count <200 cells/mm(3) or clinical stage 3 or 4), remain at high risk of death from opportunistic infections. The shift from routine baseline CD4 testing towards viral load testing in conjunction with "Test and Treat" has limited AHD identification. METHODS: We used official estimates and existing epidemiological data to project deaths from tuberculosis (TB) and cryptococcal meningitis (CM) among PLHIV-initiating ART with CD4 <200 cells/mm(3) , in the absence of select World Health Organization recommended diagnostic or therapeutic protocols for patients with AHD. We modelled the reduction in deaths, based on the performance of screening/diagnostic testing and the coverage and efficacy of treatment/preventive therapies for TB and CM. We compared projected TB and CM deaths in the first year of ART from 2019 to 2024, with and without CD4 testing. The analysis was performed for nine countries: South Africa, Kenya, Lesotho, Mozambique, Nigeria, Uganda, Zambia, Zimbabwe and the Democratic Republic of Congo. RESULTS: The effect of CD4 testing comes through increased identification of AHD and consequent eligibility for protocols for AHD prevention, diagnosis and management; algorithms for CD4 testing avert between 31% and 38% of deaths from TB and CM in the first year of ART. The number of CD4 tests required per death averted varies widely by country from approximately 101 for South Africa to 917 for Kenya. CONCLUSIONS: This analysis supports retaining baseline CD4 testing to avert deaths from TB and CM, the two most deadly opportunistic infections among patients with AHD. However, national programmes will need to weigh the cost of increasing CD4 access against other HIV-related priorities and allocate resources accordingly.

        Oboho, I. K. Paulin, H. Corcoran, C. Jordan, A. Kirking, H. L. Agyemang, E. Podewils, L. J. Greene, G. Chiller, T. Desai, M. Bhatkoti, R. Shiraishi, R. W. Shah, N. S.

    • Maternal and Child Health
      1. Acceptability and usability of a paediatric HIV screening tool in high-volume outpatient settings in Malawi, perspectives from caregivers and healthcare workers
        Katirayi L, Maphosa T, Kudiabor K, Kayira D, Gross J, Hrapcak S, Chamanga R, Nkhoma H, Puleni P, Maida A, Ahimbisibwe A, Woelk G.
        BMJ Paediatr Open. 2023 ;7(1).
        BACKGROUND: Using an HIV pretest screening tool to identify children most at risk for HIV infection may be a more efficient and cost-effective approach to identify children living with HIV in resource-limited settings. These tools seek to reduce overtesting of children by increasing the positive predictive value while ensuring a high negative predictive value for those screened for HIV. METHODS: This qualitative study in Malawi evaluated acceptability and usability of a modified version of the Zimbabwe HIV screening tool to identify children aged 2-14 years most-at-risk. The tool included additional questions about previous hospitalisations due to malaria and prior documented diagnoses. Sixteen interviews were conducted with expert clients (ECs), trained peer-supporters, which administered the screening tool and 12 interviews with biological and non-biological caregivers of screened children. All interviews were audiorecorded, transcribed and translated. Transcripts were analysed manually using a short-answer analysis, compiling responses for each question by study participant group. Summary documents were generated, identifying common and outlier perspectives. RESULTS: The HIV paediatric screening tool was generally accepted by caregivers and ECs, with both groups seeing the benefit of the tool and promoting its use. The ECs who were primarily responsible for implementing the tool initially struggled with acceptance of the tool but started to accept it after additional training and mentorship was provided. Overall, caregivers accepted having their children tested for HIV, although non-biological caregivers expressed hesitancy in giving consent for HIV testing. ECs reported challenges with the ability for non-biological caregivers to answer some questions. CONCLUSION: This study found general acceptance of paediatric screening tools in children in Malawi and identified some minor challenges that raise important considerations for tool implementation. These include the need for a thorough orientation of the tools for the healthcare workers and caregivers, appropriate space at the facility, and adequate staffing and commodities.

        Kayira, D. Gross, J. Hrapcak, S. Maida, A.

      2. Cronobacter sakazakii infections in two infants linked to powdered infant formula and breast pump equipment - United States, 2021 and 2022
        Haston JC, Miko S, Cope JR, McKeel H, Walters C, Joseph LA, Griswold T, Katz LS, Andújar AA, Tourdot L, Rounds J, Vagnone P, Medus C, Harris J, Geist R, Neises D, Wiggington A, Smith T, Im MS, Wheeler C, Smith P, Carleton HA, Lee CC.
        MMWR Morb Mortal Wkly Rep. 2023 ;72(9):223-226.
        Cronobacter sakazakii, a species of gram-negative bacteria belonging to the Enterobacteriaceae family, is known to cause severe and often fatal meningitis and sepsis in young infants. C. sakazakii is ubiquitous in the environment, and most reported infant cases have been attributed to contaminated powdered infant formula (powdered formula) or breast milk that was expressed using contaminated breast pump equipment (1-3). Previous investigations of cases and outbreaks have identified C. sakazakii in opened powdered formula, breast pump parts, environmental surfaces in the home, and, rarely, in unopened powdered formula and formula manufacturing facilities (2,4-6). This report describes two infants with C. sakazakii meningitis reported to CDC in September 2021 and February 2022. CDC used whole genome sequencing (WGS) analysis to link one case to contaminated opened powdered formula from the patient's home and the other to contaminated breast pump equipment. These cases highlight the importance of expanding awareness about C. sakazakii infections in infants, safe preparation and storage of powdered formula, proper cleaning and sanitizing of breast pump equipment, and using WGS as a tool for C. sakazakii investigations.

        Haston, J. C. Miko, S. Cope, J. R. McKeel, H. Walters, C. Joseph, L. A. Griswold, T. Katz, L. S. Andújar, A. A. Smith, T. Im, M. S. Wheeler, C. Smith, P. Carleton, H. A. Lee, C. C.

    • Occupational Safety and Health
      1. Paid sick leave among U.S. healthcare personnel, April 2022
        de Perio MA, Srivastav A, Razzaghi H, Laney AS, Black CL.
        Am J Prev Med. 2023 .
        INTRODUCTION: Healthcare personnel (HCP) are at risk for acquiring and transmitting respiratory infections in the workplace. Paid sick leave benefits allow workers to stay home and visit a healthcare provider when ill. The objectives of this study were to quantify the percentage of HCP reporting paid sick leave, identify differences across occupations and settings, and determine factors associated with having paid sick leave. METHODS: In a national nonprobability Internet panel survey of HCP in April 2022, respondents were asked, "Does your employer offer paid sick leave?." Responses were weighted to the U.S. HCP population by age, sex, race/ethnicity, work setting, and census region. The weighted percentage of HCP who reported paid sick leave was calculated by occupation, work setting, and type of employment. Using multivariable logistic regression, factors associated with having paid sick leave were identified. RESULTS: In April 2022, 73.2% of 2,555 responding HCP reported having paid sick leave, similar to 2020 and 2021 estimates. The percentage of HCP reporting paid sick leave varied by occupation, ranging from 63.9% (assistants/aides) to 81.2% (non-clinical personnel). Female HCP and those working as licensed independent practitioners, in the Midwest, and in the South were less likely to report paid sick leave. CONCLUSIONS: The majority of HCP from all occupational groups and healthcare settings reported having paid sick leave. However, differences by sex, occupation, type of work arrangement, and Census region exist and highlight disparities. Increasing HCP access to paid sick leave may decrease presenteeism and subsequent transmission of infectious diseases in healthcare settings.

        de Perio, M. A. Razzaghi, H. Laney, A. S. Black, C. L.

      2. Relationship between telework experience and presenteeism during COVID-19 pandemic, United States, March-November 2020
        Shafer L, Ahmed F, Kim S, Wernli KJ, Jackson ML, Nowalk MP, Bear T, Zimmerman RK, Martin ET, Monto AS, Gaglani M, Reis M, Chung JR, Flannery B, Uzicanin A.
        Emerg Infect Dis. 2023 ;29(2):278-285.
        Persons with COVID-19-like illnesses are advised to stay home to reduce the spread of SARS-CoV-2. We assessed relationships between telework experience and COVID-19 illness with work attendance when ill. Adults experiencing fever, cough, or loss of taste or smell who sought healthcare or COVID-19 testing in the United States during March-November 2020 were enrolled. Adults with telework experience before illness were more likely to work at all (onsite or remotely) during illness (87.8%) than those with no telework experience (49.9%) (adjusted odds ratio 5.48, 95% CI 3.40-8.83). COVID-19 case-patients were less likely to work onsite (22.1%) than were persons with other acute respiratory illnesses (37.3%) (adjusted odds ratio 0.36, 95% CI 0.24-0.53). Among COVID-19 case-patients with telework experience, only 6.5% worked onsite during illness. Telework experience before illness gave mildly ill workers the option to work and improved compliance with public health recommendations to stay home during illness.

        Shafer, L. Ahmed, F. Kim, S. Chung, J. R. Flannery, B. Uzicanin, A.

      3. Occupational safety and health of women in mining
        Eiter BM, Dugdale ZJ, Robinson T, Nixon CT, Lawson H, Halldin CN, Stazick C.
        J Womens Health (Larchmt). 2023 .
        The mining industry plays a critical role in the U.S. economy, with active mines in every state producing materials such as those used to construct houses and roads, make medicines, and manufacture cars and electronics. Throughout its history, mining has been a male-dominated industry. Recent estimates indicate that between 10% and 17% of miners are women. Previous occupational safety and health (OSH) research has focused primarily on the male experience. In more recent years, the mining industry has engaged in efforts to increase workforce diversity through the recruitment and retention of women miners. To meet the needs of a diverse workforce, it is critically important to identify OSH concerns that are unique to populations that have been understudied and to develop work-related policies and practices that improve their work experiences and health outcomes. The purpose of this article is to describe the specific OSH challenges women as miners face and to discuss how the National Institute for Occupational Safety and Health's (NIOSH) Mining Program is situated to address these challenges through its Mining Program Strategic Plan.

        Eiter, B. M. Dugdale, Z. J. Robinson, T. Nixon, C. T. Lawson, H. Halldin, C. N. Stazick, C.

      4. A new resource to protect temporary workers
        Rosemberg MS, Menger-Ogle LM.
        Workplace Health Saf. 2023 ;71(3):152.

    • Public Health Leadership and Management
      1. CONTEXT: A trained and diverse public health workforce is needed to respond to public health threats. The Epidemic Intelligence Service (EIS) is an applied epidemiology training program. Most EIS officers are from the United States, but some are from other countries and bring unique perspectives and skills. OBJECTIVES/EVALUATION: To characterize international officers who participated in the EIS program and describe their employment settings after training completion. DESIGN: International officers were people who participated in EIS and who were not US citizens or permanent residents. We analyzed data from EIS's application database during 2009-2017 to describe officers' characteristics. We used data from the Centers for Disease Control and Prevention's (CDC's) workforce database for civil servants and EIS exit surveys to describe jobs taken after program completion. MAIN OUTCOME MEASURES: We described the characteristics of the international officers, jobs taken immediately after program completion, and duration of employment at CDC. RESULTS: Among 715 officers accepted in EIS classes of 2009-2017, 85 (12%) were international applicants, with citizenships from 40 different countries. Forty (47%) had 1 or more US postgraduate degrees, and 65 (76%) were physicians. Of 78 (92%) international officers with available employment data, 65 (83%) reported taking a job at CDC after program completion. The remaining took a public health job with an international entity (6%), academia (5%), or other jobs (5%). Among 65 international officers who remained working at CDC after graduation, the median employment duration was 5.2 years, including their 2 years in EIS. CONCLUSIONS: Most international EIS graduates remain at CDC after program completion, which strengthens the diversity and capacity of CDC's epidemiological workforce. Further evaluations are needed to determine the effects of pulling away crucial talent from other countries needing experienced epidemiologists and to what extent retaining those persons can benefit public health globally.

        Temate-Tiagueu, Y. Winquist, A. Davis, M. Dietz, S. Robinson, B. Pevzner, E. Arvelo, W.

    • Social and Behavioral Sciences
      1. Trust in US federal, state, and local public health agencies during COVID-19: Responses and policy implications
        SteelFisher GK, Findling MG, Caporello HL, Lubell KM, Vidoloff Melville KG, Lane L, Boyea AA, Schafer TJ, Ben-Porath EN.
        Health Aff (Millwood). 2023 ;42(3):328-337.
        Public health agencies' ability to protect health in the wake of COVID-19 largely depends on public trust. In February 2022 we conducted a first-of-its-kind nationally representative survey of 4,208 US adults to learn the public's reported reasons for trust in federal, state, and local public health agencies. Among respondents who expressed a "great deal" of trust, that trust was not related primarily to agencies' ability to control the spread of COVID-19 but, rather, to beliefs that those agencies made clear, science-based recommendations and provided protective resources. Scientific expertise was a more commonly reported reason for "a great deal" of trust at the federal level, whereas perceptions of hard work, compassionate policy, and direct services were emphasized more at the state and local levels. Although trust in public health agencies was not especially high, few respondents indicated that they had no trust. Lower trust was related primarily to respondents' beliefs that health recommendations were politically influenced and inconsistent. The least trusting respondents also endorsed concerns about private-sector influence and excessive restrictions and had low trust in government overall. Our findings suggest the need to support a robust federal, state, and local public health communications infrastructure; ensure agencies' authority to make science-based recommendations; and develop strategies for engaging different segments of the public.

        Lubell, K. M. Lane, L.

    • Substance Use and Abuse
      1. Isolating the effect of COVID-19-related disruptions on HIV diagnoses in the United States in 2020
        Viguerie A, Song R, Johnson AS, Lyles CM, Hernandez A, Farnham PG.
        J Acquir Immune Defic Syndr. 2023 ;92(4):293-299.
        BACKGROUND: Diagnoses of HIV in the United States decreased by 17% in 2020 due to COVID-related disruptions. The extent to which this decrease is attributable to changes in HIV testing versus HIV transmission is unclear. We seek to better understand this issue by analyzing the discrepancy in expected versus observed HIV diagnoses in 2020 among persons who acquired HIV between 2010 and 2019 because changes in diagnosis patterns in this cohort cannot be attributed to changes in transmission. METHODS: We developed 3 methods based on the CD4-depletion model to estimate excess missed diagnoses in 2020 among persons with HIV (PWH) infected from 2010 to 2019. We stratified the results by transmission group, sex assigned at birth, race/ethnicity, and region to examine differences by group and confirm the reliability of our estimates. We performed similar analyses projecting diagnoses in 2019 among PWH infected from 2010 to 2018 to evaluate the accuracy of our methods against surveillance data. RESULTS: There were approximately 3100-3300 (approximately 18%) fewer diagnoses than expected in 2020 among PWH infected from 2010 to 2019. Females (at birth), heterosexuals, persons who inject drugs, and Hispanic/Latino PWH missed diagnoses at higher levels than the overall population. Validation and stratification analyses confirmed the accuracy and reliability of our estimates. CONCLUSIONS: The substantial drop in number of previously infected PWH diagnosed in 2020 suggests that changes in testing played a substantial role in the observed decrease. Levels of missed diagnoses differed substantially across population subgroups. Increasing testing efforts and innovative strategies to reach undiagnosed PWH are needed to offset this diagnosis gap. These analyses may be used to inform future estimates of HIV transmission during the COVID-19 pandemic.

        Viguerie, A. Song, R. Johnson, A. S. Lyles, C. M. Hernandez, A. Farnham, P. G.

      2. Suspected nonfatal cocaine-involved overdoses overall and with co-involvement of opioids
        Scholl L, Liu S, Pickens CM.
        J Public Health Manag Pract. 2023 .
        CONTEXT: The Centers for Disease Control and Prevention (CDC) developed a syndrome definition for detection of suspected nonfatal cocaine-involved overdoses. The definition can be used to monitor trends and detect anomalies in emergency department (ED) syndromic surveillance data at the national, state, and local levels. OBJECTIVE: This study describes the development of the nonfatal, unintentional/undetermined intent cocaine-involved overdose (UUCOD) definition and analysis of trends over time. DESIGN/SETTING: CDC developed the UUCOD definition to query ED data in CDC's National Syndromic Surveillance Program (NSSP). Data between 2018 and 2021 were analyzed from 29 states sharing data access in the Drug Overdose Surveillance and Epidemiology (DOSE) System via NSSP. Using Joinpoint regression, trends were analyzed for UUCOD overall, by sex and age group, and for UUCOD co-involving opioids. MEASURES: Time trends between 2018 and 2021 were analyzed by examining average monthly percentage change. Individual trend segments and trend inflection points were analyzed by examining monthly percentage change. RESULTS: During 2018-2021, a total of 27 240 UUCOD visits were identified by the syndrome definition. Analyses identified different patterns in trends for males and females, with largely similar trends for persons aged 15 to 44 years and 45 years or older. Analyses also identified seasonal patterns with increases in spring/summer months in UUCOD overall and UUCOD co-involving opioids and declines for both in fall/winter months. CONCLUSION: This UUCOD syndrome definition will be useful for ongoing monitoring of suspected nonfatal overdoses involving cocaine and co-involving cocaine and opioids. Ongoing assessment of cocaine-involved overdose trends might identify anomalies requiring further investigation and inform deployment of resources.

        Scholl, L. Liu, S. Pickens, C. M.

    • Zoonotic and Vectorborne Diseases
      1. Geostatistical modeling and prediction of Rift Valley fever seroprevalence among livestock in Uganda
        Telford C, Nyakarahuka L, Waller L, Kitron U, Shoemaker T.
        Am J Trop Med Hyg. 2023 .
        Uganda reported cases of Rift Valley fever virus (RVFV) for the first time in almost 50 years in 2016, following an outbreak of Rift Valley fever (RVF) that caused four human infections, two of which resulted in death. Subsequent outbreak investigation serosurveys found high seroprevalence of IgG antibodies without evidence of acute infection or IgM antibodies, suggesting the possibility of undetected RVFV circulation prior to the outbreak. After the 2016 outbreak investigation, a serosurvey was conducted in 2017 among domesticated livestock herds across Uganda. Sampling data were incorporated into a geostatistical model to estimate RVF seroprevalence among cattle, sheep, and goats. Variables resulting in the best fit to RVF seroprevalence sampling data included annual variability in monthly precipitation and enhanced vegetation index, topographic wetness index, log human population density percent increase, and livestock species. Individual species RVF seroprevalence prediction maps were created for cattle, sheep, and goats, and a composite livestock prediction was created based on the estimated density of each species across the country. Seroprevalence was greater in cattle compared with sheep and goats. Predicted seroprevalence was greatest in the central and northwestern quadrant of the country, surrounding Lake Victoria, and along the Southern Cattle Corridor. We identified areas that experienced conditions conducive to potential increased RVFV circulation in 2021 in central Uganda. An improved understanding of the determinants of RVFV circulation and locations with high probability of elevated RVF seroprevalence can guide prioritization of disease surveillance and risk mitigation efforts.

        Telford, C. Shoemaker, T.

      2. Bartonella spp. infections identified by molecular methods, United States
        McCormick DW, Rassoulian-Barrett SL, Hoogestraat DR, Salipante SJ, SenGupta D, Dietrich EA, Cookson BT, Marx GE, Lieberman JA.
        Emerg Infect Dis. 2023 ;29(3):467-476.
        Molecular methods can enable rapid identification of Bartonella spp. infections, which are difficult to diagnose by using culture or serology. We analyzed clinical test results of PCR that targeted bacterial 16S rRNA hypervariable V1-V2 regions only or in parallel with PCR of Bartonella-specific ribC gene. We identified 430 clinical specimens infected with Bartonella spp. from 420 patients in the United States. Median patient age was 37 (range 1-79) years; 62% were male. We identified B. henselae in 77%, B. quintana in 13%, B. clarridgeiae in 1%, B. vinsonii in 1%, and B. washoensis in 1% of specimens. B. quintana was detected in 83% of cardiac specimens; B. henselae was detected in 34% of lymph node specimens. We detected novel or uncommon Bartonella spp. in 9 patients. Molecular diagnostic testing can identify Bartonella spp. infections, including uncommon and undescribed species, and might be particularly useful for patients who have culture-negative endocarditis or lymphadenitis.

        McCormick, D. W. Dietrich, E. A. Marx, G. E.

      3. Increase in Colorado tick fever virus disease cases and effect of COVID-19 pandemic on behaviors and testing practices, Montana, 2020
        Soto RA, Baldry E, Vahey GM, Lehman J, Silver M, Panella A, Brault AC, Hughes HR, Fitzpatrick KA, Velez J, Biggerstaff BJ, Wolff B, Randolph J, Ruth LJ, Staples JE, Gould CV.
        Emerg Infect Dis. 2023 ;29(3):561-568.
        In 2020, Montana, USA, reported a large increase in Colorado tick fever (CTF) cases. To investigate potential causes of the increase, we conducted a case-control study of Montana residents who tested positive or negative for CTF during 2020, assessed healthcare providers' CTF awareness and testing practices, and reviewed CTF testing methods. Case-patients reported more time recreating outdoors on weekends, and all reported finding a tick on themselves before illness. No consistent changes were identified in provider practices. Previously, only CTF serologic testing was used in Montana. In 2020, because of SARS-CoV-2 testing needs, the state laboratory sent specimens for CTF testing to the Centers for Disease Control and Prevention, where more sensitive molecular methods are used. This change in testing probably increased the number of CTF cases detected. Molecular testing is optimal for CTF diagnosis during acute illness. Tick bite prevention measures should continue to be advised for persons doing outdoor activities.

        Soto, R. A. Vahey, G. M. Lehman, J. Silver, M. Panella, A. Brault, A. C. Hughes, H. R. Fitzpatrick, K. A. Velez, J. Biggerstaff, B. J. Wolff, B. Randolph, J. Ruth, L. J. Staples, J. E. Gould, C. V.

      4. BACKGROUND: Allergic airway disease (AAD) is a growing concern in industrialized nations and can be influenced by fungal exposures. Basidiomycota yeast species such as Cryptococcus neoformans are known to exacerbate allergic airway disease; however, recent indoor assessments have identified other Basidiomycota yeasts, including Vishniacozyma victoriae (syn. Cryptococcus victoriae), to be prevalent and potentially associated with asthma. Until now, the murine pulmonary immune response to repeated V. victoriae exposure was previously unexplored. OBJECTIVE: This study aimed to compare the immunological impact of repeated pulmonary exposure to Cryptococcus yeasts. METHODS: Mice were repeatedly exposed to an immunogenic dose of C. neoformans or V. victoriae via oropharyngeal aspiration. Bronchoalveolar lavage fluid (BALF) and lungs were collected to examine airway remodeling, inflammation, mucous production, cellular influx, and cytokine responses at 1 day and 21 days post final exposure. The responses to C. neoformans and V. victoriae were analyzed and compared. RESULTS: Following repeated exposure, both C. neoformans and V. victoriae cells were still detectable in the lungs 21 days post final exposure. Repeated C. neoformans exposure initiated myeloid and lymphoid cellular infiltration into the lung that worsened over time, as well as an IL-4 and IL-5 response compared to PBS-exposed controls. In contrast, repeated V. victoriae exposure induced a strong CD4(+) T cell-driven lymphoid response that started to resolve by 21 days post final exposure. DISCUSSION: C. neoformans remained in the lungs and exacerbated the pulmonary immune responses as expected following repeated exposure. The persistence of V. victoriae in the lung and strong lymphoid response following repeated exposure were unexpected given its lack of reported involvement in AAD. Given the abundance in indoor environments and industrial utilization of V. victoriae, these results highlight the importance to investigate the impact of frequently detected fungal organisms on the pulmonary response following inhalational exposure. Moreover, it is important to continue to address the knowledge gap involving Basidiomycota yeasts and their impact on AAD.

        Rush, R. E. Blackwood, C. B. Lemons, A. R. Green, B. J. Croston, T. L.

      5. Rabies surveillance in the United States during 2021
        Ma X, Bonaparte S, Corbett P, Orciari LA, Gigante CM, Kirby JD, Chipman RB, Fehlner-Gardiner C, Thang C, Cedillo VG, Aréchiga-Ceballos N, Rao A, Wallace RM.
        J Am Vet Med Assoc. 2023 :1-9.
        OBJECTIVE: To provide epidemiological information on the occurrence of animal and human rabies in the US during 2021 and summaries of 2021 rabies surveillance for Canada and Mexico. PROCEDURES: State and territorial public health departments and USDA Wildlife Services provided data on animals submitted for rabies testing in 2021. Data were analyzed temporally and geographically to assess trends in domestic animal and wildlife rabies cases. RESULTS: During 2021, 54 US jurisdictions reported 3,663 rabid animals, representing an 18.2% decrease from the 4,479 cases reported in 2020. Texas (n = 456 [12.4%]), Virginia (297 [8.1%]), Pennsylvania (287 [7.8%]), North Carolina (248 [6.8%]), New York (237 [6.5%]), California (220 [6.0%]), and New Jersey (201 [5.5%]) together accounted for > 50% of all animal rabies cases reported in 2021. Of the total reported rabid animals, 3,352 (91.5%) involved wildlife, with bats (n = 1,241 [33.9%]), raccoons (1,030 [28.1%]), skunks (691 [18.9%]), and foxes (314 [8.6%]) representing the primary hosts confirmed with rabies. Rabid cats (216 [5.9%]), cattle (40 [1.1%]), and dogs (36 [1.0%]) accounted for 94% of rabies cases involving domestic animals in 2021. Five human rabies deaths were reported in 2021. CLINICAL RELEVANCE: The number of animal rabies cases reported in the US decreased significantly during 2021; this is thought to be due to factors related to the COVID-19 pandemic.

        Ma, X. Bonaparte, S. Corbett, P. Orciari, L. A. Gigante, C. M. Rao, A. Wallace, R. M.

      6. Zika virus knowledge, attitudes and prevention behaviors among pregnant women in the ZEN cohort study, Colombia, 2017-2018
        Burkel VK, Newton SM, Acosta J, Valencia D, Benavides M, Tong VT, Daza M, Sancken C, Gonzalez M, Polen K, Rodriguez H, Borbón M, Rao CY, Gilboa SM, Honein MA, Ospina ML, Johnson CY.
        Trans R Soc Trop Med Hyg. 2023 .
        BACKGROUND: Zika virus (ZIKV) infection during pregnancy can cause severe birth defects in the fetus and is associated with neurodevelopmental abnormalities in childhood. Our objective was to describe ZIKV knowledge and attitudes among pregnant women in Colombia while ZIKV was circulating and whether they predicted the adoption of behaviors to prevent ZIKV mosquito-borne and sexual transmission. METHODS: We used self-reported data from Zika en Embarazadas y Niños (ZEN), a cohort study of women in early pregnancy across three regions of Colombia during 2017-2018. We used Poisson regression to estimate associations between knowledge, attitudes and previous experience with mosquito-borne infection and preventative behaviors. RESULTS: Among 1519 women, knowledge of mosquito-borne transmission was high (1480; 97.8%) and 1275 (85.5%) participants were worried about ZIKV infection during pregnancy. The most common preventive behavior was wearing long pants (1355; 89.4%). Regular mosquito repellent use was uncommon (257; 17.0%). While ZIKV knowledge and attitudes were not associated with the adoption of ZIKV prevention behaviors, previous mosquito-borne infection was associated with increased condom use (prevalence ratio 1.4, 95% CI 1.1 to 1.7). CONCLUSIONS: Participants were well informed about ZIKV transmission and its health consequences. However, whether this knowledge resulted in behavior change is less certain.

        Burkel, V. K. Newton, S. M. Valencia, D. Tong, V. T. Sancken, C. Polen, K. Rao, C. Y. Gilboa, S. M. Honein, M. A. Johnson, C. Y.

      7. Pathogenesis of Kasokero virus in experimentally infected Egyptian rousette bats (Rousettus aegyptiacus)
        Kirejczyk SG, Schuh AJ, Zhang J, Amman BR, Guito JC, Sealy TK, Graziano JC, Brown CC, Towner JS.
        Vet Pathol. 2023 :3009858231158076.
        Egyptian rousette bats (ERBs; Rousettus aegyptiacus; family Pteropodidae) are associated with a growing number of bunyaviruses of public health importance, including Kasokero virus (KASV), which was first identified as a zoonosis in Uganda in 1977. In this study, formalin-fixed paraffin-embedded tissues from a previous experiment in which KASV infection was confirmed in 18 experimentally infected ERBs were used for an in-depth analysis using histopathology, in situ hybridization (ISH) for detection of viral RNA, immunohistochemistry (IHC) to assess the mononuclear phagocyte system response, and quantitative digital image analysis to investigate virus clearance from the liver and spleen within a spatial context. Significant gross and histological lesions were limited to the liver, where KASV-infected bats developed mild to moderate, acute viral hepatitis, which was first observed at 3 days postinfection (DPI), peaked at 6 DPI, and was resolved by 20 DPI. A subset of bats had glycogen depletion (n = 10) and hepatic necrosis (n = 3), rarely with intralesional bacteria (n = 1). Virus replication was confirmed by ISH in the liver, spleen, lymph nodes, and tongue. In the liver, KASV replicated in the cytoplasm of hepatocytes, to a lesser extent in mononuclear phagocytes, and rarely in presumptive endothelial cells. Most KASV RNA, as detected by ISH, was cleared from the spleen and liver by 6 DPI. It is concluded that ERBs have effective mechanisms to respond to this virus, clearing it without evidence of clinical disease.

        Kirejczyk, S. G. M. Schuh, A. J. Amman, B. R. Guito, J. C. Sealy, T. K. Graziano, J. C. Towner, J. S.

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