Volume 10, Issue 11, March 27, 2018

CDC Science Clips: Volume 10, Issue 11, March 27, 2018

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Importance: Monitoring sun protection and sunburn over time at the population level can provide valuable information about progress toward skin cancer prevention goals and inform future intervention efforts. Objective: To examine the prevalence of sun protection use (shade, sunscreen, and clothing) and sunburn and the association between sunburn and individual characteristics and health behaviors in the US population. Design, Setting, and Participants: In this cross-sectional study using a nationally representative sample of 31 162 US adults from the 2015 National Health Interview Survey-Cancer Control Supplement, household interviews of civilian, noninstitutionalized US adults were conducted throughout 2015 in person and completed on the telephone when necessary. Data analysis was performed from August 16, 2016, to September 6, 2017. Main Outcomes and Measures: The prevalence of sunburn and use of sun protection and their association with demographic characteristics, sun sensitivity, and health-related behaviors and conditions using multivariable logistic regression modeling. Results: A total of 31162 respondents (mean [SD] age, 47.0 [0.36] years; 13 932 male [44.7%] and 17 230 female [55.3%]) were included in the analyses, with 34.2% experiencing sunburn in 2015. Sunburn prevalence was higher among younger age groups (51.2% in adults 18-29 years old; 95% CI, 48.8%-53.7%), non-Hispanic white individuals (42.5%; 95% CI, 41.2%-43.9%), and those with sun-sensitive skin (50.2%). However, sunburn was also prevalent among black (13.2%; 95% CI, 11.6%-15.1%) and Hispanic (29.7%; 95% CI, 27.6%-31.9%) individuals, demographic groups that are often considered to be at low risk of skin cancer. The most frequent sun protection behaviors were staying in the shade (37.1%; 95% CI, 36.3%-38.0%) and using sunscreen (31.5%; 95% CI, 30.7%-32.3%) followed by wearing long clothing to the ankles (28.4%; 95% CI, 27.6-29.1). Sun avoidance behaviors (seeking shade and not going in the sun) were significantly (39.5% vs 35.1%; P < .001) associated with a lower prevalence of sunburn. Those who used self-applied sunless tanning products (45.0% of users vs 36.1% of nonusers; P < .001), those who engaged in aerobic activity (37.9% of aerobic exercisers vs 32.8% of non-aerobic exercisers; P < .001), binge drinkers (45.1% of binge drinkers vs 35.0% of non-binge drinkers; P < .001), and overweight or obese individuals (37.9% of overweight or obese individuals vs 34.4% of non-overweight or obese individuals; P < .001) were more likely to experience sunburn compared with the respective comparison groups. Conclusions and Relevance: Sun sensitivity was significantly associated with a higher sunburn prevalence, independent of race/ethnicity, suggesting a need to consider sun sensitivity when identifying target demographic groups for sun safety interventions. Efforts to improve vigilance and consistency with use of sun protection are needed. In addition, those who engage in physical activity, use sunless tanners, or use sunscreen for tanning purposes may require additional intervention strategies to address the unique barriers they face in staying adequately protected.

      • Improved understanding of the natural history of cervical cancer has led to changes in screening recommendations, including the addition of the human papillomavirus (HPV) testing as an option in routine screening. Most studies of screening trends have used national self-reported survey data. To better understand recent trends in cervical cancer screening, including cytology (Papanicolaou, or Pap, tests) and human papillomavirus co-tests (HPV+Pap test), we used healthcare claims data to examine screening practices and trends. We analyzed screening among commercially-insured females ages 18-65 during 2005-2014 who were continuously enrolled during three or more contiguous calendar years, to identify those who received cervical cancer screening with a Pap test or co-test. We examined screening prevalence by age group and year. During the latter years of our study period, screening prevalence (regardless of screening method) declined significantly for women in all age groups examined. Despite declines in overall screening, the prevalence of co-testing increased in all age groups except those aged 18-20. In 2014, women aged 30-39 had the highest overall screening uptake (77.5%) and the highest use of co-testing (44.4%); this group also had the lowest overall declines in screening over the time period (-4.5%). These screening measures from healthcare claims were lower than self-reported screening from national surveys of the general population. More research to explore the reasons for these differences is needed to ensure that women are receiving appropriate screening, and to better understand why screening prevalence is declining among this population of commercially insured women.

    • Environmental Health
      • Surveillance of carbon monoxide-related incidents – implications for prevention of related illnesses and injuries, 2005-2014External
        Mukhopadhyay S, Hirsch A, Etienne S, Melnikova N, Wu J, Sircar K, Orr M.
        Am J Emerg Med. 2018 Feb 13.

        BACKGROUND: Carbon monoxide (CO) is an insidious gas responsible for approximately 21,000 emergency department visits, 2300 hospitalizations, and 500 deaths in the United States annually. We analyzed 10 combined years of data from two Agency for Toxic Substances and Disease Registry acute hazardous substance release surveillance programs to evaluate CO incident-related injuries. METHODS: Seventeen states participated in these programs during 2005-2014. RESULTS: In those 10years, the states identified 1795 CO incidents. Our analysis focused on 897 CO incidents having injured persons. Of the 3414 CO injured people, 61.0% were classified as general public, 27.7% were employees, 7.6% were students, and 2.2% were first responders. More than 78% of CO injured people required hospital or pre-hospital treatment and 4.3% died. The location for most injured people (39.9%) were homes or apartments, followed by educational facilities (10.0%). Educational services had a high number of people injured per incident (16.3%). The three most common sources of CO were heating, ventilation, and air conditioning systems; generators; and motor vehicles. Equipment failure was the primary contributing factor for most CO incidents. CONCLUSIONS: States have used the data to evaluate trends in CO poisoning and develop targeted public health outreach. Surveillance data are useful for setting new policies or supporting existing policy such as making CO poisoning a reportable condition at the state level and requiring CO alarms in all schools and housing. Public health needs to remain vigilant to the sources and causes of CO to help reduce this injury and death.

    • Epidemiology and Surveillance
      • Trends in mortality among females in the United States, 1900-2010: Progress and challengesExternal
        Hahn RA, Chang MH, Parrish RG, Teutsch SM, Jones WK.
        Prev Chronic Dis. 2018 Mar 8;15:E30.

        INTRODUCTION: We analyzed trends in US female mortality rates by decade from 1900 through 2010, assessed age and racial differences, and proposed explanations and considered implications. METHODS: We conducted a descriptive study of trends in mortality rates from major causes of death for females in the United States from 1900 through 2010. We analyzed all-cause unadjusted death rates (UDRs) for males and females and for white and nonwhite males and females from 1900 through 2010. Data for blacks, distinct from other nonwhites, were available beginning in 1970 and are reported for this and following decades. We also computed age-adjusted all-cause death rates (AADRs) by the direct method using age-specific death rates and the 2000 US standard population. Data for the analysis of decadal trends in mortality rates were obtained from yearly tabulations of causes of death from published compilations and from public use computer data files. RESULTS: In 1900, UDRs and AADRs were higher for nonwhites than whites and decreased more rapidly for nonwhite females than for white females. Reductions were highest among younger females and lowest among older females. Rates for infectious diseases decreased the most. AADRs for heart disease increased 96.5% in the first 5 decades, then declined by 70.6%. AADRs for cancer rose, then decreased. Stroke decreased steadily. Unintentional motor vehicle injury AADRs increased, leveled off, then decreased. Differences between white and nonwhite female all-cause AADRs almost disappeared during the study period (5.4 per 100,000); differences in white and black AADRs remained high (121.7 per 100,000). CONCLUSION: Improvements in social and environmental determinants of health probably account for decreased mortality rates among females in the early 20th century, partially offset by increased smoking. In the second half of the century, other public health and clinical measures contributed to reductions. The persistent prevalence of risk behaviors and underuse of preventive and medical services indicate opportunities for increased female longevity, particularly in racial minority populations.

    • Food Safety
      • Multistate outbreak of Salmonella Virchow infections linked to a powdered meal replacement product – United States, 2015-2016External
        Gambino-Shirley KJ, Tesfai A, Schwensohn CA, Burnett C, Smith L, Wagner JM, Eikmeier D, Smith K, Stone JP, Updike D, Hines J, Shade LN, Tolar B, Fu TJ, Viazis S, Seelman SL, Blackshear K, Wise ME, Neil KP.
        Clin Infect Dis. 2018 Mar 7.

        Background: Nontyphoidal Salmonella is the leading cause of bacterial gastroenteritis in the United States. Meal replacement products containing raw and ‘superfood’ ingredients have gained increasing popularity among consumers in recent years. In January 2016, we investigated a multistate outbreak of infections with a novel strain of Salmonella Virchow. Methods: Cases were defined using molecular subtyping procedures. Commonly reported exposures were compared with responses from healthy people interviewed in the 2006-2007 FoodNet Population Survey. Firm inspections and product traceback and testing were performed. Results: Thirty-five cases from 24 states were identified; 6 hospitalizations and no deaths were reported. Thirty-one (94%) of 33 ill people interviewed reported consuming a powdered supplement in the week before illness; of these, 30 (97%) reported consuming Product A, a raw organic powdered shake product consumed as a meal replacement. Laboratory testing isolated the outbreak strain of Salmonella Virchow from: leftover Product A collected from ill people’s homes, organic moringa leaf powder (an ingredient in Product A), and finished product retained by the firm. Firm inspections at three facilities linked to Product A production did not reveal contamination at the facilities. Traceback identified that the contaminated moringa leaf powder was imported from South Africa. Conclusions: This investigation identified a novel outbreak vehicle and highlighted the potential risk with similar products not intended to be cooked by consumers before consuming. The company issued a voluntary recall of all implicated products. As this product has a long shelf-life, the recall likely prevented additional illnesses.

    • Health Economics
      • The economic burden of child sexual abuse in the United StatesExternal
        Letourneau EJ, Brown DS, Fang X, Hassan A, Mercy JA.
        Child Abuse Negl. 2018 Mar 10;79:413-422.

        The present study provides an estimate of the U.S. economic impact of child sexual abuse (CSA). Costs of CSA were measured from the societal perspective and include health care costs, productivity losses, child welfare costs, violence/crime costs, special education costs, and suicide death costs. We separately estimated quality-adjusted life year (QALY) losses. For each category, we used the best available secondary data to develop cost per case estimates. All costs were estimated in U.S. dollars and adjusted to the reference year 2015. Estimating 20 new cases of fatal and 40,387 new substantiated cases of nonfatal CSA that occurred in 2015, the lifetime economic burden of CSA is approximately $9.3 billion, the lifetime cost for victims of fatal CSA per female and male victim is on average $1,128,334 and $1,482,933, respectively, and the average lifetime cost for victims of nonfatal CSA is of $282,734 per female victim. For male victims of nonfatal CSA, there was insufficient information on productivity losses, contributing to a lower average estimated lifetime cost of $74,691 per male victim. If we included QALYs, these costs would increase by approximately $40,000 per victim. With the exception of male productivity losses, all estimates were based on robust, replicable incidence-based costing methods. The availability of accurate, up-to-date estimates should contribute to policy analysis, facilitate comparisons with other public health problems, and support future economic evaluations of CSA-specific policy and practice. In particular, we hope the availability of credible and contemporary estimates will support increased attention to primary prevention of CSA.

    • Laboratory Sciences
      • UPLC-ESI-MS/MS method for the quantitative measurement of aliphatic diamines, trimethylamine N-oxide, and beta-methylamino-l-alanine in human urineExternal
        Bhandari D, Bowman BA, Patel AB, Chambers DM, De Jesus VR, Blount BC.
        J Chromatogr B Analyt Technol Biomed Life Sci. 2018 Mar 2;1083:86-92.

        This work describes a quantitative high-throughput analytical method for the simultaneous measurement of small aliphatic nitrogenous biomarkers, i.e., 1,6-hexamethylenediamine (HDA), isophoronediamine (IPDA), beta-methylamino-l-alanine (BMAA), and trimethylamine N-oxide (TMAO), in human urine. Urinary aliphatic diamines, HDA and IPDA, are potential biomarkers of environmental exposure to their corresponding diisocyanates. Urinary BMAA forms as a result of human exposure to blue-green algae contaminated food. And, TMAO is excreted in urine due to the consumption of carnitine- and choline-rich diets. These urinary biomarkers represent classes of small aliphatic nitrogen-containing compounds (N-compounds) that have a high aqueous solubility, low logP, and/or high basic pKa. Because of the highly polar characteristics, analysis of these compounds in complex sample matrices is often challenging. We report on the development of ion-pairing chemistry based ultra-performance liquid chromatography-electrospray ionization-tandem mass spectrometry (UPLC-ESI-MS/MS) method for the simultaneous measurement of these biomarkers in human urine. Chromatographic separation was optimized using heptafluorobutyric acid-(HFBA-) based mobile phase and a reversed-phase C18 column. All four analytes were baseline separated within 2.6min with an overall run time of 5min per sample injection. Sample preparation involved 4h of acid hydrolysis followed by automated solid phase extraction (SPE) performed using strong cation exchange sorbent bed with 7N ammonia solution in methanol as eluent. Limits of detection ranged from 0.05ng/mL to 1.60ng/mL. The inter-day and intra-day accuracy were within 10%, and reproducibility within 15%. The method is accurate, fast, and well-suited for biomonitoring studies within targeted groups, as well as larger population-based studies such as the U. S. National Health and Nutrition Examination Survey (NHANES).

    • Maternal and Child Health
      • ADHD medication use during pregnancy and risk for selected birth defects: National Birth Defects Prevention Study, 1998-2011External
        Anderson KN, Dutton AC, Broussard CS, Farr SL, Lind JN, Visser SN, Ailes EC, Shapira SK, Reefhuis J, Tinker SC.
        J Atten Disord. 2018 Mar 1:1087054718759753.

        OBJECTIVE: The objective of this study was to examine the prevalence of, and maternal characteristics associated with, ADHD medication use before and during pregnancy, and associations between early pregnancy ADHD medication use and risk for 12 selected birth defects. METHOD: We used data from the National Birth Defects Prevention Study (1998-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects. RESULTS: There was an increase in ADHD medication use from 1998-1999 (0.2%) to 2010-2011 (0.5%; p < .001). Early pregnancy ADHD medication use was more commonly reported by mothers of infants/fetuses with gastroschisis (crude odds ratio [cOR]: 2.9, 95% confidence interval [CI] = [1.2, 6.9]), omphalocele (cOR: 4.0, 95% CI = [1.2, 13.6]), and transverse limb deficiency (cOR: 3.3, 95% CI = [1.1, 9.6]). CONCLUSION: ADHD medication use before and during pregnancy was rare, but the prevalence of use has increased over time. In this analysis, early pregnancy ADHD medication use was associated with three of 12 selected birth defects.

    • Parasitic Diseases
      • Schistosomiasis remains a major public health problem in Kenya. The World Health Organization recommends preventive chemotherapy with praziquantel (PZQ) to control morbidity due to schistosomiasis. Morbidity is considered linked to intensity of infection, which along with prevalence is used to determine the frequency of mass drug administration (MDA) to school-age children. We determined the impact of annual school-based MDA on children across all primary and high school years using a repeated cross-sectional study design in five schools near Lake Victoria in western Kenya, an area endemic for Schistosoma mansoni. At baseline and for the following four consecutive years, between 897 and 1,440 school children in Grades 1-12 were enrolled and evaluated by Kato-Katz for S. mansoni and soil-transmitted helminths (STH), followed by annual MDA with PZQ and albendazole. Four annual rounds of MDA with PZQ were associated with reduced S. mansoni prevalence in all school children (44.7-14.0%; P < 0.001) and mean intensity of infection by 91% (90.4 to 8.1 eggs per gram [epg] of stool; P < 0.001). Prevalence of high-intensity infection (>/= 400 epg) decreased from 6.8% at baseline to 0.3% by the end of the study. Soil-transmitted helminth infections, already low at baseline, also decreased significantly over the years. In this high prevalence area, annual school-based MDA with high coverage across all Grades (1-12) resulted in rapid and progressive declines in overall prevalence and intensity of infection. This decrease was dramatic in regard to heavy infections in older school-attending children.

    • Substance Use and Abuse

  2. CDC Authored Publications
    The names of CDC authors are indicated in bold text.
    Articles published in the past 6-8 weeks authored by CDC or ATSDR staff.
    • Chronic Diseases and Conditions
      1. Geographic variations in arthritis prevalence, health-related characteristics, and management – United States, 2015External
        Barbour KE, Moss S, Croft JB, Helmick CG, Theis KA, Brady TJ, Murphy LB, Hootman JM, Greenlund KJ, Lu H, Wang Y.
        MMWR Surveill Summ. 2018 Mar 16;67(4):1-28.

        PROBLEM/CONDITION: Doctor-diagnosed arthritis is a common chronic condition affecting an estimated 23% (54 million) of adults in the United States, greatly influencing quality of life and costing approximately $300 billion annually. The geographic variations in arthritis prevalence, health-related characteristics, and management among states and territories are unknown. Therefore, public health professionals need to understand arthritis in their areas to target dissemination of evidence-based interventions that reduce arthritis morbidity. REPORTING PERIOD: 2015. DESCRIPTION OF SYSTEM: The Behavioral Risk Factor Surveillance System is an annual, random-digit-dialed landline and cellular telephone survey of noninstitutionalized adults aged >/=18 years residing in the United States. Self-reported data are collected from the 50 states, the District of Columbia, Guam, and Puerto Rico. Unadjusted and age-standardized prevalences of arthritis, arthritis health-related characteristics, and arthritis management were calculated. County-level estimates were calculated using a validated statistical modeling method. RESULTS: In 2015, in the 50 states and the District of Columbia, median age-standardized prevalence of arthritis was 23.0% (range: 17.2%-33.6%). Modeled prevalence of arthritis varied considerably by county (range: 11.2%-42.7%). In 13 states that administered the arthritis management module, among adults with arthritis, the age-standardized median percentage of participation in a self-management education course was 14.5% (range: 9.1%-19.0%), being told by a health care provider to engage in physical activity or exercise was 58.5% (range: 52.3%-61.9%), and being told to lose weight to manage arthritis symptoms (if overweight or obese) was 44.5% (range: 35.1%-53.2%). Respondents with arthritis who lived in the quartile of states with the highest prevalences of arthritis had the highest percentages of negative health-related characteristics (i.e., arthritis-attributable activity limitations, arthritis-attributable severe joint pain, and arthritis-attributable social participation restriction; >/=14 physically unhealthy days during the past 30 days; >/=14 mentally unhealthy days during the past 30 days; obesity; and leisure-time physical inactivity) and the lowest percentage of leisure-time walking. INTERPRETATION: The prevalence, health-related characteristics, and management of arthritis varied substantially across states. The modeled prevalence of arthritis varied considerably by county. PUBLIC HEALTH ACTION: The findings highlight notable geographic variability in prevalence, health-related characteristics, and management of arthritis. Targeted use of evidence-based interventions that focus on physical activity and self-management education can reduce pain and improve function and quality of life for adults with arthritis and thus might reduce these geographic disparities.

      2. Race/ethnicity, dietary acid load, and risk of end-stage renal disease among US adults with chronic kidney diseaseExternal
        Crews DC, Banerjee T, Wesson DE, Morgenstern H, Saran R, Burrows NR, Williams DE, Powe NR.
        Am J Nephrol. 2018 Mar 9;47(3):174-181.

        BACKGROUND: Dietary acid load (DAL) contributes to the risk of CKD and CKD progression. We sought to determine the relation of DAL to racial/ethnic differences in the risk of end-stage renal disease (ESRD) among persons with CKD. METHODS: Among 1,123 non-Hispanic black (NHB) and non-Hispanic white (NHW) National Health and Nutrition Examination Survey III participants with estimated glomerular filtration rate 15-59 mL/min/1.73 m2, DAL was estimated using the Remer and Manz net acid excretion (NAEes) formula and 24-h dietary recall. ESRD events were ascertained via linkage with Medicare. A competing risk model (accounting for death) was used to estimate the hazard ratio (HR) for treated ESRD, comparing NHBs with NHWs, adjusting for demographic, clinical and nutritional factors (body surface area, total caloric intake, serum bicarbonate, protein intake), and NAEes. Additionally, whether the relation of NAEes with ESRD risk varied by race/ethnicity was tested. RESULTS: At baseline, NHBs had greater NAEes (50.9 vs. 44.2 mEq/day) than NHWs. It was found that 22% developed ESRD over a median of 7.5 years. The unadjusted HR comparing NHBs to NHWs was 3.35 (95% CI 2.51-4.48) and adjusted HR (for factors above) was 1.68 (95% CI 1.18-2.38). A stronger association of NAE with risk of ESRD was observed among NHBs (adjusted HR per mEq/day increase in NAE 1.21, 95% CI 1.12-1.31) than that among NHWs (HR 1.08, 95% CI 0.96-1.20), p interaction for race/ethnicity x NAEes = 0.004. CONCLUSIONS: Among US adults with CKD, the association of DAL with progression to ESRD is stronger among NHBs than NHWs. DAL is worthy of further investigation for its contribution to kidney outcomes across race/ethnic groups.

      3. The impact of combining human and online supportive resources for prostate cancer patientsExternal
        Hawkins R. P., Pingree S, Van Bogaert D, McDowell H, Jarrard D, Carmack C, Salner A.
        J Community Support Oncol. 2017 Dec;15(6):e321-e329.

        Background: Prostate cancer patients’ needs for information and support have been previously addressed by both mentoring and interactive services. Objective: To determine whether combining computer-based support with a human cancer mentor would benefit prostate cancer patients more than either intervention alone. Methods: Newly diagnosed prostate cancer patients from 3 centers were randomly assigned to receive either: a web-based system of information and support; or telephone and e-mail support from a trained cancer information mentor; or both interventions. Results: The combined condition improved several quality-of-life outcomes more than the individual interventions alone, but these results were few and scattered. Limitations: Offering Internet (computer) access to all potential subjects may have made some computer nonusers less likely to participate, biasing the sample toward relatively advantaged men. Conclusions: Combining human and computer-based interventions did not produce the expected much stronger benefits to patients. Given the costs involved, the computer-based system alone is likely preferable. Funding/sponsorship Grant R01CA114539 from the National Cancer Institute.

      4. Trends in hospitalizations for acute kidney injury – United States, 2000-2014External
        Pavkov ME, Harding JL, Burrows NR.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):289-293.

        Acute kidney injury is a sudden decrease in kidney function with or without kidney damage, occurring over a few hours or days. Diabetes, hypertension, and advanced age are primary risk factors for acute kidney injury. It is increasingly recognized as an in-hospital complication of sepsis, heart conditions, and surgery (1,2). Its most severe stage requires treatment with dialysis. Acute kidney injury is also associated with higher likelihood of long-term care, incidence of chronic kidney disease and hospital mortality, and health care costs (1,2). Although a number of U.S. studies have indicated an increasing incidence of dialysis-treated acute kidney injury since the late 1990s (3), no data are available on national trends in diabetes-related acute kidney injury. To estimate diabetes- and nondiabetes-related acute kidney injury trends, CDC analyzed 2000-2014 data from the National Inpatient Sample (NIS) (4) and the National Health Interview Survey (NHIS) (5). Age-standardized rates of acute kidney injury hospitalizations increased by 139% (from 23.1 to 55.3 per 1,000 persons) among adults with diagnosed diabetes, and by 230% (from 3.5 to 11.7 per 1,000 persons) among those without diabetes. Improving both patient and provider awareness that diabetes, hypertension, and advancing age are frequently associated with acute kidney injury might reduce its occurrence and improve management of the underlying diseases in an aging population.

    • Communicable Diseases
      1. Latent classes of sexual risk among black men who have sex with men and womenExternal
        Dangerfield DT, Harawa NT, Smith LR, Jeffries WL, Baezconde-Garbanati L, Bluthenthal R.
        Arch Sex Behav. 2018 Mar 14.

        Black men who have sex with men and women (BMSMW) are at high risk for HIV and other sexually transmitted infections (STIs). Despite knowing that HIV/STI risk varies by sexual positioning practices, limited data have characterized the risk profiles of BSMW. This study utilized latent class analysis (LCA) to explore BMSMW’s sexual risk profiles regarding condomless sexual positioning practices. Participants were BMSMW in intervention studies in Los Angeles, Chicago, and Philadelphia. LCA was used to characterize their sexual risk profiles. Age, study location, HIV status, social support, and internalized homophobia were used as covariates in a multinomial regression model predicting the likelihood of class membership. Among the 546 participants, three latent classes of risk were identified: Seropositive Serosorters, Seronegative/unknown Serosorters, and Main Partners Only. All groups had the greatest probabilities of condomless sex with main partners. Seropositive Serosorters had the highest probabilities of condomless sex with HIV-positive partners. Seronegative/unknown Serosorters had the highest probabilities of condomless sex with HIV-negative or unknown status partners. HIV-positive BMSMW had 87% lower odds of being classified as Seronegative/unknown Serosorters than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.13, 95% CI 0.06, 0.28). HIV-positive BMSMW had 71% lower odds of being classified as Main Partners Only than Seropositive Serosorters than HIV-negative/unknown status BMSMW (AOR = 0.29, 95% CI 0.16, 0.51). Findings highlight opportunities for clinicians to promote condom use and risk reduction among BMSMW with differing sexual risk profiles. Increased understanding of sexual positioning practices among BMSMW might help address HIV/STIs among this group.

      2. A pragmatic approach to monitor and evaluate implementation and impact of differentiated ART delivery for global and national stakeholdersExternal
        Ehrenkranz PD, Calleja JM, El-Sadr W, Fakoya AO, Ford N, Grimsrud A, Harris KL, Jed SL, Low-Beer D, Patel SV, Rabkin M, Reidy WJ, Reinisch A, Siberry GK, Tally LA, Zulu I, Zaidi I.
        J Int AIDS Soc. 2018 Mar;21(3).

        INTRODUCTION: The World Health Organization’s (WHO) recommendation of “Treat All” has accelerated the call for differentiated antiretroviral therapy (ART) delivery, a method of care that efficiently uses limited resources to increase access to HIV treatment. WHO has further recommended that stable individuals on ART receive refills every 3 to 6 months and attend clinical visits every 3 to 6 months. However, there is not yet consensus on how to ensure that the quality of services is maintained as countries strive to meet these standards. This commentary responds to this gap by defining a pragmatic approach to the monitoring and evaluation (M&E) of the scale up of differentiated ART delivery for global and national stakeholders. DISCUSSION: Programme managers need to demonstrate that the scale up of differentiated ART delivery is achieving the desired effectiveness and efficiency outcomes to justify continued support by national and global stakeholders. To achieve this goal, the two existing global WHO HIV treatment indicators of ART retention and viral suppression should be augmented with two broad aggregate measures. The addition of indicators measuring the frequency of (1) clinical and (2) refill visits by PLHIV per year will allow evaluation of the pace of scale up while monitoring its overall effect on the quality and efficiency of services. The combination of these four routinely collected aggregate indicators will also facilitate the comparison of outcomes among facilities, regions or countries implementing different models of ART delivery. Enhanced monitoring or additional assessments will be required to answer other critical questions on the process of implementation, acceptability, effectiveness and efficiency. CONCLUSIONS: These proposed outcomes are useful markers for the effectiveness and efficiency of the health system’s attempts to deliver quality treatment to those who need it-and still reserve as much of the available resource pool as possible for other key elements of the HIV response.

      3. Efficacy of a small-group intervention for post-incarcerated black men who have sex with men and women (MSMW)External
        Harawa NT, Guentzel-Frank H, McCuller WJ, Williams JK, Millet G, Belcher L, Joseph HA, Bluthenthal RN.
        J Urban Health. 2018 Mar 14.

        We conducted a randomized controlled trial of a six-session behavioral intervention designed to reduce frequency of condomless sex and numbers of sex partners among recently incarcerated, bisexual Black men. One hundred participants were assigned to the small-group intervention, Men in Life Environments (MILE), and 112 were assigned to the control condition. Among those assigned to MILE, 69% attended at least one session, 88% of whom attended all sessions. At 3-months’ follow-up, large reductions in risk behaviors were reported by both groups. Means for episodes of condomless sex in the previous 3 months declined from 27.7 to 8.0 for the intervention and 25.6 to 6.7 for the control group. Reductions were not greater for the intervention than those of the control group. Regression to the mean, respondent burden, and implementation issues, such as moving from office-based to field-based survey administration at follow-up, may have contributed to the large declines reported by both groups.

      4. Notes from the field: False-negative hepatitis B surface antigen test results in a hemodialysis patient – Nebraska, 2017External
        Hendrickson B, Kamili S, Timmons T, Iwen PC, Pedati C, Safranek T.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):311-312.

        [No abstract]

      5. Cross-sectional HIV incidence surveillance: A benchmarking of approaches for estimating the ‘mean duration of recent infection’External
        Kassanjee R, De Angelis D, Farah M, Hanson D, Labuschagne JP, Laeyendecker O, Le Vu S, Tom B, Wang R, Welte A.
        Stat Commun Infect Dis. 2017 Mar;9(1).

        The application of biomarkers for ‘recent’ infection in cross-sectional HIV incidence surveillance requires the estimation of critical biomarker characteristics. Various approaches have been employed for using longitudinal data to estimate the Mean Duration of Recent Infection (MDRI) – the average time in the ‘recent’ state. In this systematic benchmarking of MDRI estimation approaches, a simulation platform was used to measure accuracy and precision of over twenty approaches, in thirty scenarios capturing various study designs, subject behaviors and test dynamics that may be encountered in practice. Results highlight that assuming a single continuous sojourn in the ‘recent’ state can produce substantial bias. Simple interpolation provides useful MDRI estimates provided subjects are tested at regular intervals. Regression performs the best – while ‘random effects’ describe the subject-clustering in the data, regression models without random effects proved easy to implement, stable, and of similar accuracy in scenarios considered; robustness to parametric assumptions was improved by regressing ‘recent’/’non-recent’ classifications rather than continuous biomarker readings. All approaches were vulnerable to incorrect assumptions about subjects’ (unobserved) infection times. Results provided show the relationships between MDRI estimation performance and the number of subjects, inter-visit intervals, missed visits, loss to follow-up, and aspects of biomarker signal and noise.

      6. Characteristics of persons with repeat syphilis – Idaho, 2011-2015External
        Kassem AM, Bartschi J, Carter KK.
        Sex Transm Dis. 2018 Mar 14.

        During 2011-2015 in Idaho, 14 (7%) of 193 persons with early syphilis had repeat syphilis. Persons with repeat infections were more likely to have had secondary or early latent syphilis (P = 0.037) and be infected with HIV (P < 0.001) compared with those having one infection.

      7. The first session at the 2016 Syphilis Summit provided an opportunity for laboratory researchers and clinicians to comment on gaps in biomedical knowledge and technologies. Predominant themes in the presentations and discussion included the need for optimization of existing diagnostic tests, commercial availability and FDA approval of nucleic acid amplification tests for primary and secondary syphilis, development of sensitive and specific new blood tests for diagnosis of active (vs. treated) syphilis infection, clarification of the best measures for adequacy of response to treatment, continued study of complications of syphilis including neuro- and ocular syphilis, and development of a safe and effective vaccine that will protect against transmission and complications of disseminated infection (including congenital and neurosyphilis). Renewed and sustained support of biomedical syphilis research and an influx of talent could move the needle in the fight against this re-emerging ancient disease.

      8. BACKGROUND: Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts, and (2) develop a classification framework to better describe why reported cases were not averted. METHODS: We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days prior to delivery, as well as the proportion of potential congenital syphilis cases averted. RESULTS: Among the 2,508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days prior to delivery, 89.4% were tested for syphilis at least 30 days prior to delivery, and 76.9% received an adequate treatment regimen that began at least 30 days prior to delivery. Overall, an estimated 1,928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%. CONCLUSIONS: While the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.

      9. Increasing prevalence of nontuberculous mycobacteria in respiratory specimens from US-affiliated Pacific island jurisdictionsExternal
        Lin C, Russell C, Soll B, Chow D, Bamrah S, Brostrom R, Kim W, Scott J, Bankowski MJ.
        Emerg Infect Dis. 2018 Mar;24(3):485-491.

        Nontuberculous mycobacteria (NTM) respiratory infections represent a growing public health problem in many countries. However, there are limited published epidemiologic studies for the Western Pacific region. We reviewed respiratory specimens submitted to Diagnostic Laboratory Services in Hawaii, USA, for culture of Mycobacterium tuberculosis during August 2007-December 2011 to determine the NTM isolation rate. We observed a statistically significant increase in the rate of specimens with NTM isolated in respiratory culture (adjusted rate ratio per year 1.65, 95% CI 1.54-1.77; p<0.01). In contrast, the number of patients with respiratory cultures positive for M. tuberculosis showed no increase (adjusted rate ratio per year 0.98, 95% CI 0.94-1.01; p = 0.19). A 6-month subset of NTM isolates was identified by using a nucleic acid probe or 16S rRNA sequencing. M. avium complex and M. fortuitum were the most common NTM identified.

      10. Varicella outbreak surveillance in schools in sentinel jurisdictions, 2012-2015External
        Lopez AS, LaClair B, Buttery V, Zhang Y, Rosen J, Taggert E, Robinson S, Davis M, Waters C, Thomas CA, Rodriguez C, Thomas E, Tuttle J, Brantley T, Perella D, Del Rosario M, Marin M.
        J Pediatric Infect Dis Soc. 2018 Mar 7.

        Background: In 2007, a routine second dose of varicella vaccine was recommended in the United States for children aged 4 to 6 years to better control varicella-zoster virus circulation and outbreaks. Sentinel varicella outbreak surveillance was established to assess feasibility of surveillance and describe outbreaks that are occurring. Methods: Through the Centers for Disease Control and Prevention Epidemiology Laboratory Capacity funding, health departments conducted active surveillance for varicella outbreaks in schools from 2012 to 2015. Outbreaks of varicella were defined as >/=5 cases in a school within at least 1 incubation period (21 days). School nurses, healthcare providers, or laboratories reported cases and outbreaks of varicella to health departments; demographic, vaccination, and clinical data were collected. Results: Georgia, Houston, Maine, Minnesota, New York City, and Philadelphia participated in all 3 years; Puerto Rico and West Virginia participated in 2012 to 2013; and Kansas and Arkansas participated in 2014 to 2015. Twenty-nine outbreaks including 262 cases were reported. The median size of the outbreaks was 7 cases (range, 5-31 cases), and the median duration was 31 days (range, 4-100 days). Of the case-patients associated with larger outbreaks (>/=8 cases), 55.4% were unvaccinated, and 15.7% and 18.1% had received 1 or 2 doses of vaccine, respectively. In small outbreaks (5-7 cases), 33.3% of case-patients were unvaccinated, and 16.7% and 38.5% had received 1 or 2 doses of vaccine, respectively. Conclusions: The majority of cases associated with outbreaks occurred in undervaccinated children (unvaccinated and 1-dose vaccine recipients). Outbreaks with a greater proportion of 2-dose vaccine recipients were smaller. Varicella outbreak surveillance is feasible, and continued monitoring of outbreaks remains important for describing the epidemiology of varicella during the 2-dose varicella vaccination program.

      11. BACKGROUND: Before searching prior records, sexually transmitted disease (STD) programs use syphilis reactor grids to exclude some reactive non-treponemal test results (RNTs) based on patient age, sex, and test titer. We propose a new algorithm that starts with comparing RNTs to previous syphilis non-treponemal tests and current treponemal test results. METHODS: De-duplicated RNTs from Florida’s surveillance system (2006-2015) were extracted and stratified on morbidity. An algorithm was developed to triage RNTs. Sensitivity and specificity of the algorithm and the current reactor grid were estimated using reported syphilis cases. A random sample of cases missed by the proposed algorithm, stratified by stage of disease, were reviewed to verify case classification. RESULTS: Reported RNTs increased 58% from 2006 (n=34,808) to 2015 (n=55,001) (total=372,902). The current reactor grid removed 91,518 (24.5%) RNTs and missed 1,149 potential cases. Strictly following the reactor grid would result in a sensitivity of 97.4% and a specificity of 27.5%. The proposed algorithm would remove 242,078 (64.9%) RNTs and miss 2,768 potential cases. This results in a slightly lower sensitivity of 93.8%, but nearly triples the specificity, 72.9%. A review of a random sample of the 2,768 cases estimated that 72.7% would not have met the syphilis surveillance case definition resulting in an adjusted sensitivity of 98.4%. CONCLUSIONS: In Florida, an algorithm that starts by searching previous syphilis test results vastly improved specificity and slightly improved sensitivity compared to the current reactor grid. Implementing an automated algorithm could increase case ascertainment efficiency and further prioritize likely cases for investigation.

      12. Prevalence of Helicobacter pylori among Alaskans: Factors associated with infection and comparison of urea breath test and anti-Helicobacter pylori IgG antibodiesExternal
        Miernyk KM, Bulkow LR, Gold BD, Bruce MG, Hurlburt DH, Griffin PM, Swerdlow DL, Cook K, Hennessy TW, Parkinson AJ.
        Helicobacter. 2018 Mar 14.

        BACKGROUND: Helicobacter pylori is one of the most common human infections in the world, and studies in Alaska Native people, as well as other Indigenous peoples, have shown a high prevalence of this gastric infection. This study was undertaken to determine the prevalence of H. pylori infection by urea breath test (UBT) and anti- H. pylori IgG among Alaskans living in four regions of the state and to identify factors associated with infection. METHODS: A convenience sample of persons > 6 months old living in five rural and one urban Alaskan community were recruited from 1996 to 1997. Participants were asked about factors possibly associated with infection. Sera were collected and tested for anti- H. pylori IgG antibodies; a UBT was administered to participants > 5 years old. RESULTS: We recruited 710 people of whom 571 (80%) were Alaska Native and 467 (66%) were from rural communities. Rural residents were more likely to be Alaska Native compared with urban residents (P < .001). Of the 710 people, 699 (98%) had a serum sample analyzed, and 634 (97%) persons > 5 years old had a UBT performed. H. pylori prevalence was 69% by UBT and 68% by anti- H. pylori IgG. Among those with a result for both tests, there was 94% concordance. Factors associated with H. pylori positivity were Alaska Native racial status, age >/= 20 years, rural region of residence, living in a crowded home, and drinking water that was not piped or delivered. CONCLUSIONS: Helicobacter pylori prevalence is high in Alaska, especially in Alaska Native persons and rural residents. Concordance between UBT and serology was also high in this group. Two socioeconomic factors, crowding and drinking water that was not piped or delivered, were found to be associated with H. pylori positivity.

      13. Saksenaea vasiformis orbital cellulitis in an immunocompetent child treated with posaconazoleExternal
        Reich P, Shute T, Lysen C, Lockhart SR, Kelly Keating M, Custer P, Orscheln R.
        J Pediatric Infect Dis Soc. 2018 Mar 7.

        An 11-year-old immunocompetent girl presented with two and a half months of progressive right orbital cellulitis, which did not respond to multiple courses of antibiotics or prednisone. A panfungal polymerase chain reaction primer was positive for Saksenaea vasiformis, and she completed 5 months of oral posaconazole therapy after debridement. Saksenaea vasiformis is a rare cause of zygomycosis, and it typically causes skin and soft tissue infection in immunocompetent hosts, particularly after a traumatic injury. The diagnosis should be considered in cases with a protracted course that fail to respond to typical antibiotic therapy. Treatment includes surgical debridement, in additional to antifungal therapy with amphotericin B or posaconazole.

      14. Triazole resistance surveillance in Aspergillus fumigatusExternal
        Resendiz Sharpe A, Lagrou K, Meis JF, Chowdhary A, Lockhart SR, Verweij PE.
        Med Mycol. 2018 Apr 1;56(suppl_1):83-92.

        Triazole resistance is an increasing concern in the opportunistic mold Aspergillus fumigatus. Resistance can develop through exposure to azole compounds during azole therapy or in the environment. Resistance mutations are commonly found in the Cyp51A-gene, although other known and unknown resistance mechanisms may be present. Surveillance studies show triazole resistance in six continents, although the presence of resistance remains unknown in many countries. In most countries, resistance mutations associated with the environment dominate, but it remains unclear if these resistance traits predominately migrate or arise locally. Patients with triazole-resistant aspergillus disease may fail to antifungal therapy, but only a limited number of cohort studies have been performed that show conflicting results. Treatment failure might be due to diagnostic delay or due to the limited number of alternative treatment options. The ISHAM/ECMM Aspergillus Resistance Surveillance working group was set up to facilitate surveillance studies and stimulate international collaborations. Important aims are to determine the resistance epidemiology in countries where this information is currently lacking, to gain more insight in the clinical implications of triazole resistance through a registry and to unify nomenclature through consensus definitions.

      15. [No abstract]

    • Disease Reservoirs and Vectors
      1. House screening with insecticide-treated netting provides sustained reductions in domestic populations of Aedes aegypti in Merida, MexicoExternal
        Che-Mendoza A, Medina-Barreiro A, Koyoc-Cardena E, Uc-Puc V, Contreras-Perera Y, Herrera-Bojorquez J, Dzul-Manzanilla F, Correa-Morales F, Ranson H, Lenhart A, McCall PJ, Kroeger A, Vazquez-Prokopec G, Manrique-Saide P.
        PLoS Negl Trop Dis. 2018 Mar 15;12(3):e0006283.

        BACKGROUND: There is a need for effective methods to control Aedes aegypti and prevent the transmission of dengue, chikungunya, yellow fever and Zika viruses. Insecticide treated screening (ITS) is a promising approach, particularly as it targets adult mosquitoes to reduce human-mosquito contact. METHODOLOGY/PRINCIPAL FINDINGS: A cluster-randomised controlled trial evaluated the entomological efficacy of ITS based intervention, which consisted of the installation of pyrethroid-impregnated long-lasting insecticide-treated netting material fixed as framed screens on external doors and windows. A total of 10 treatment and 10 control clusters (100 houses/cluster) were distributed throughout the city of Merida, Mexico. Cross-sectional entomological surveys quantified indoor adult mosquito infestation at baseline (pre-intervention) and throughout four post-intervention (PI) surveys spaced at 6-month intervals corresponding to dry/rainy seasons over two years (2012-2014). A total of 844 households from intervention clusters (86% coverage) were protected with ITS at the start of the trial. Significant reductions in the indoor presence and abundance of Ae. aegypti adults (OR = 0.48 and IRR = 0.45, P<0.05 respectively) and the indoor presence and abundance of Ae. aegypti female mosquitoes (OR = 0.47 and IRR = 0.44, P<0.05 respectively) were detected in intervention clusters compared to controls. This high level of protective effect was sustained for up to 24 months PI. Insecticidal activity of the ITS material declined with time, with ~70% mortality being demonstrated in susceptible mosquito cohorts up to 24 months after installation. CONCLUSIONS/SIGNIFICANCE: The strong and sustained entomological impact observed in this study demonstrates the potential of house screening as a feasible, alternative approach to a sustained long-term impact on household infestations of Ae. aegypti. Larger trials quantifying the effectiveness of ITS on epidemiological endpoints are warranted and therefore recommended.

    • Genetics and Genomics
      1. Genetic analysis of virulence potential of Escherichia coli O104 serotypes isolated from cattle feces using whole genome sequencingExternal
        Shridhar PB, Patel IR, Gangiredla J, Noll LW, Shi X, Bai J, Elkins CA, Strockbine NA, Nagaraja TG.
        Frontiers in Microbiology. 2018 01 Mar;9 (MAR) (341).

        Escherichia coli O104:H4, a Shiga toxin-producing hybrid pathotype that was implicated in a major foodborne outbreak in Germany in 2011, has not been detected in cattle. However, serotypes of O104, other than O104:H4, have been isolated from cattle feces, with O104:H7 being the most predominant. In this study, we investigated, based on whole genome sequence analyses, the virulence potential of E. coli O104 strains isolated from cattle feces, since cattle are asymptomatic carriers of E. coli O104. The genomes of ten bovine E. coli O104 strains (six O104:H7, one O104:H8, one O104:H12, and two O104:H23) and five O104:H7 isolated from human clinical cases were sequenced. Of all the bovine O104 serotypes (H7, H8, H12, and H23) that were included in the study, only E. coli O104:H7 serotype possessed Shiga toxins. Four of the six bovine O104:H7 strains and one of the five human strains carried stx1c. Three human O104 strains carried stx2, two were of subtype 2a, and one was 2d. Genomes of stx carrying bovine O104:H7 strains were larger than the stx-negative strains of O104:H7 or other serotypes. The genome sizes were proportional to the number of genes carried on the mobile genetic elements (phages, prophages, transposable elements and plasmids). Both bovine and human strains were negative for intimin and other genes associated with the type III secretory system and non-LEE encoded effectors. Plasmid-encoded virulence genes (ehxA, epeA, espP, katP) were also present in bovine and human strains. All O104 strains were negative for antimicrobial resistance genes, except one human strain. Phylogenetic analysis indicated that bovine E. coli O104 strains carrying the same flagellar antigen clustered together and STEC strains clustered separately from non-STEC strains. One of the human O104:H7 strains was phylogenetically closely related to and belonged to the same sequence type (ST-1817) as the bovine O104:H7 STEC strains. This suggests that the bovine feces could be a source of human illness caused by E. coli O104:H7 serotype. Because bovine O104:H7 strains carried virulence genes similar to human clinical strains and one of the human clinical strains was phylogenetically related to bovine strains, the serotype has the potential to be a diarrheagenic pathogen in humans. Copyright ? 2018 Shridhar, Patel, Gangiredla, Noll, Shi, Bai, Elkins, Strockbine and Nagaraja.

      2. Genetic diversity within dominant Enterocytozoon bieneusi genotypes in pre-weaned calvesExternal
        Tang C, Cai M, Wang L, Guo Y, Li N, Feng Y, Xiao L.
        Parasit Vectors. 2018 Mar 12;11(1):170.

        BACKGROUND: Cattle are commonly infected with the microsporidian parasite Enterocytozoon bieneusi. Sequence characterization of E. bieneusi in these animals at the ribosomal internal transcribed spacer (ITS) locus had identified I, J and BEB4 as the dominant genotypes. However, current studies on E. bieneusi in dairy cattle are mostly on infection rates and genotype distribution. This study aims to examine the intragenotypic diversity within dominant E. bieneusi genotypes in pre-weaned dairy calves in Shanghai, China. METHODS: Enterocytozoon bieneusi genotypes and subtypes were identified by PCR sequence analysis of ITS and multilocus sequence typing (MLST), based on material from farms. Chi-square test was used to examine differences in E. bieneusi infection rates between farms or age groups. RESULTS: The overall infection rate of E. bieneusi was 26.5% (214/809), ranging from 12.6% (Farm 5) to 38.5% (Farm 4). Infection rates increased with age during early life, with the peak infection rate (43.0%; 43/100) occurring at six weeks. Four genotypes were present, including J (n = 145, 67.8%), BEB4 (n = 59, 27.6%), CHN4 (n = 4, 1.9%) and CHN15 (n = 1, 0.5%), with the former two belonging to Group 2 and the latter two belonging to Group 1. Differences were detected in the distribution of the dominant genotypes J and BEB4 among five study farms. Altogether, 10 multilocus genotypes (MLGs) were identified in the two dominant ITS genotypes, including MLG-J1 to MLG-J8 of genotype J and MLG-B1 to MLG-B2 of genotype BEB4. MLG-B1 and MLG-B2 were recovered in Farms 1, 2 and 5, whereas MLG-J1 to MLG-J5 and MLG-J6 to MLG-J8 were found in Farms 3 and 4, respectively. CONCLUSIONS: There is extensive genetic heterogeneity within the dominant E. bieneusi genotypes J and BEB4 in dairy calves in Shanghai, China, and MLST should be used in molecular epidemiological studies of E. bieneusi in cattle.

      3. Development of a reverse genetics system for Sosuga virus allows rapid screening of antiviral compoundsExternal
        Welch SR, Chakrabarti AK, Wiggleton Guerrero L, Jenks HM, Lo MK, Nichol ST, Spiropoulou CF, Albarino CG.
        PLoS Negl Trop Dis. 2018 Mar 9;12(3):e0006326.

        Sosuga virus (SOSV) is a recently discovered zoonotic paramyxovirus isolated from a single human case in 2012; it has been ecologically and epidemiologically associated with transmission by the Egyptian rousette bat (Rousettus aegyptiacus). Bats have long been recognized as sources of novel zoonotic pathogens, including highly lethal paramyxoviruses like Nipah virus (NiV) and Hendra virus (HeV). The ability of SOSV to cause severe human disease supports the need for studies on SOSV pathogenesis to better understand the potential impact of this virus and to identify effective treatments. Here we describe a reverse genetics system for SOSV comprising a minigenome-based assay and a replication-competent infectious recombinant reporter SOSV that expresses the fluorescent protein ZsGreen1 in infected cells. First, we used the minigenome assay to rapidly screen for compounds inhibiting SOSV replication at biosafety level 2 (BSL-2). The antiviral activity of candidate compounds was then tested against authentic viral replication using the reporter SOSV at BSL-3. We identified several compounds with anti-SOSV activity, several of which also inhibit NiV and HeV. Alongside its utility in screening for potential SOSV therapeutics, the reverse genetics system described here is a powerful tool for analyzing mechanisms of SOSV pathogenesis, which will facilitate our understanding of how to combat the potential public health threats posed by emerging bat-borne paramyxoviruses.

    • Immunity and Immunization
      1. Vaccine-derived poliovirus outbreaks and events – three provinces, Democratic Republic of the Congo, 2017External
        Alleman MM, Chitale R, Burns CC, Iber J, Dybdahl-Sissoko N, Chen Q, Van Koko DR, Ewetola R, Riziki Y, Kavunga-Membo H, Dah C, Andriamihantanirina R.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):300-305.

        The last confirmed wild poliovirus (WPV) case in Democratic Republic of the Congo (DRC) had paralysis onset in December 2011 (1). DRC has had cases of vaccine-derived polioviruses (VDPVs) documented since 2004 (Table 1) (1-6). After an outbreak of 30 circulating VDPV type 2 (cVDPV2) cases during 2011-2012, only five VDPV2 cases were reported during 2013-2016 (Table 1) (1-6). VDPVs can emerge from oral poliovirus vaccine (OPV types 1, 2, or 3; Sabin) polioviruses that have genetically mutated resulting in reversion to neurovirulence. This process occurs during extensive person-to-person transmission in populations with low immunity or after extended replication in the intestines of immune-deficient persons following vaccination (1-6). During 2017 (as of March 8, 2018), 25 VDPV cases were reported in three provinces in DRC: in Tanganyika province, an emergence with one VDPV2 case (pending final classification) in Kabalo health zone and an emergence with one ambiguous VDPV type 1 (aVDPV1) case in Ankoro health zone; in Maniema province, an emergence with two cVDPV2 cases; and in Haut Lomami province, an emergence with 20 cVDPV2 cases that originated in Haut Lomami province and later spread to Tanganyika province (hereafter referred to as the Haut Lomami outbreak area) and an emergence with one aVDPV type 2 (aVDPV2) case in Lwamba health zone (Table 1) (Figure) (6). Outbreak response supplementary immunization activities (SIAs) were conducted during June-December 2017 (Table 2) (6). Because of limitations in surveillance and suboptimal SIA quality and geographic scope, cVDPV2 circulation is likely continuing in 2018, requiring additional SIAs. DRC health officials and Global Polio Eradication Initiative (GPEI) partners are increasing human and financial resources to improve all aspects of outbreak response.

      2. Nasal delivery of H5N1 avian influenza vaccine formulated with GenJet or in vivo-jetPEI((R)) induces enhanced serological, cellular and protective immune responsesExternal
        Cao W, Mishina M, Amoah S, Mboko WP, Bohannon C, McCoy J, Mittal SK, Gangappa S, Sambhara S.
        Drug Deliv. 2018 Nov;25(1):773-779.

        Avian influenza virus infection is a serious public health threat and preventive vaccination is the most cost-effective public health intervention strategy. Unfortunately, currently available unadjuvanted avian influenza vaccines are poorly immunogenic and alternative vaccine formulations and delivery strategies are in urgent need to reduce the high risk of avian influenza pandemics. Cationic polymers have been widely used as vectors for gene delivery in vitro and in vivo. In this study, we formulated H5N1 influenza vaccines with GenJet or in vivo-jetPEI((R)), and showed that these formulations significantly enhanced the immunogenicity of H5N1 vaccines and conferred protective immunity in a mouse model. Detailed analyses of adaptive immune responses revealed that both formulations induced mixed TH1/TH2 antigen-specific CD4 T-cell responses, antigen-specific cytotoxic CD8 T-cell and memory B-cell responses. Our findings suggest that cationic polymers merit future development as potential adjuvants for mucosal delivery of poorly immunogenic vaccines.

      3. Predicting the susceptibility of meningococcal serogroup B isolates to bactericidal antibodies elicited by bivalent rLP2086, a novel prophylactic vaccineExternal
        McNeil LK, Donald RG, Gribenko A, French R, Lambert N, Harris SL, Jones TR, Li S, Zlotnick G, Vogel U, Claus H, Abad R, Vazquez JA, Borrow R, Findlow J, Taha MK, Deghmane AE, Caugant DA, Kriz P, Musilek M, Wang X, Vuong J, Mayer LW, Pride MW, Jansen KU, Anderson AS.
        MBio. 2018 Mar 13;9(2).

        Bivalent rLP2086 (Trumenba), a vaccine for prevention of Neisseria meningitidis serogroup B (NmB) disease, was licensed for use in adolescents and young adults after it was demonstrated that it elicits antibodies that initiate complement-mediated killing of invasive NmB isolates in a serum bactericidal assay with human complement (hSBA). The vaccine consists of two factor H binding proteins (fHBPs) representing divergent subfamilies to ensure broad coverage. Although it is the surrogate of efficacy, an hSBA is not suitable for testing large numbers of strains in local laboratories. Previously, an association between the in vitro fHBP surface expression level and the susceptibility of NmB isolates to killing was observed. Therefore, a flow cytometric meningococcal antigen surface expression (MEASURE) assay was developed and validated by using an antibody that binds to all fHBP variants from both fHBP subfamilies and accurately quantitates the level of fHBP expressed on the cell surface of NmB isolates with mean fluorescence intensity as the readout. Two collections of invasive NmB isolates (n = 1,814, n = 109) were evaluated in the assay, with the smaller set also tested in hSBAs using individual and pooled human serum samples from young adults vaccinated with bivalent rLP2086. From these data, an analysis based on fHBP variant prevalence in the larger 1,814-isolate set showed that >91% of all meningococcal serogroup B isolates expressed sufficient levels of fHBP to be susceptible to bactericidal killing by vaccine-induced antibodies.IMPORTANCE Bivalent rLP2086 (Trumenba) vaccine, composed of two factor H binding proteins (fHBPs), was recently licensed for the prevention of N. meningitidis serogroup B (NmB) disease in individuals 10 to 25 years old in the United States. This study evaluated a large collection of NmB isolates from the United States and Europe by using a flow cytometric MEASURE assay to quantitate the surface expression of the vaccine antigen fHBP. We find that expression levels and the proportion of strains above the level associated with susceptibility in an hSBA are generally consistent across these geographic regions. Thus, the assay can be used to predict which NmB isolates are susceptible to killing in the hSBA and therefore is able to demonstrate an fHBP vaccine-induced bactericidal response. This work significantly advances our understanding of the potential for bivalent rLP2086 to provide broad coverage against diverse invasive-disease-causing NmB isolates.

      4. Assessment of temporally-related acute respiratory illness following influenza vaccinationExternal
        Rikin S, Jia H, Vargas CY, Castellanos de Belliard Y, Reed C, LaRussa P, Larson EL, Saiman L, Stockwell MS.
        Vaccine. 2018 Mar 7.

        BACKGROUND: A barrier to influenza vaccination is the misperception that the inactivated vaccine can cause influenza. Previous studies have investigated the risk of acute respiratory illness (ARI) after influenza vaccination with conflicting results. We assessed whether there is an increased rate of laboratory-confirmed ARI in post-influenza vaccination periods. METHODS: We conducted a cohort sub-analysis of children and adults in the MoSAIC community surveillance study from 2013 to 2016. Influenza vaccination was confirmed through city or hospital registries. Cases of ARI were ascertained by twice-weekly text messages to household to identify members with ARI symptoms. Nasal swabs were obtained from ill participants and analyzed for respiratory pathogens using multiplex PCR. The primary outcome measure was the hazard ratio of laboratory-confirmed ARI in individuals post-vaccination compared to other time periods during three influenza seasons. RESULTS: Of the 999 participants, 68.8% were children, 30.2% were adults. Each study season, approximately half received influenza vaccine and one third experienced >/=1 ARI. The hazard of influenza in individuals during the 14-day post-vaccination period was similar to unvaccinated individuals during the same period (HR 0.96, 95% CI [0.60, 1.52]). The hazard of non-influenza respiratory pathogens was higher during the same period (HR 1.65, 95% CI [1.14, 2.38]); when stratified by age the hazard remained higher for children (HR 1.71, 95% CI [1.16, 2.53]) but not for adults (HR 0.88, 95% CI [0.21, 3.69]). CONCLUSION: Among children there was an increase in the hazard of ARI caused by non-influenza respiratory pathogens post-influenza vaccination compared to unvaccinated children during the same period. Potential mechanisms for this association warrant further investigation. Future research could investigate whether medical decision-making surrounding influenza vaccination may be improved by acknowledging patient experiences, counseling regarding different types of ARI, and correcting the misperception that all ARI occurring after vaccination are caused by influenza.

    • Injury and Violence
      1. Sex differences in school safety and bullying experiences among sexual minority youthExternal
        Rose ID, Sheremenko G, Rasberry CN, Lesesne CA, Adkins SN.
        J Sch Nurs. 2018 Jan 1:1059840518762536.

        Schools play an integral role in creating safe, supportive environments for students, especially for sexual minority youth (SMY). Using 2016 questionnaire data from seven high schools in a Florida school district, we obtained a sample of 1,364 SMY. Logistic regressions controlling for sex (as applicable), age, grade, race/ethnicity, and school explored differences between SMY and nonsexual minority youth (non-SMY). Sex differences related to school environment perceptions and experiences related to safety, bullying, and hearing homophobic remarks were also explored. SMY were more likely than non-SMY to report several negative school environment perceptions and experiences. Where differences existed within SMY, male SMY were more likely than female SMY to have missed school in the past 30 days (odds ratio [ OR] = 1.66, p = .03), report avoiding spaces at school due to safety concerns ( OR = 1.38, p = .02), and report hearing homophobic remarks from teachers ( OR = 2.00, p = .01). Implications for school nursing are discussed.

    • Laboratory Sciences
      1. Hepatitis E virus (HEV) genotype (gt) 3 infection is food-borne causing sporadic infections in older individuals and gt1 infection is water-borne, often causing epidemics affecting primarily young adults. Although HEV infection causes self-limited disease, gt3 induces chronic infection in immunocompromised individuals. Hepatic host gene expression against gt3 infection remains unknown. Host gene expression profiles for HEV gt1 (n=3) and gt3 (n=7) infections were analyzed in the livers of experimentally infected rhesus macaques. HEV RNA was detected from 2 to 24 days after inoculation (DAI) in stool and serum, elevated alanine aminotransferase (ALT) activity was detected from 7 to 31 DAI, and anti-HEV antibody became detectable between 12 and 42 DAI. All 10 animals cleared the infection between 34 to 68 DAI. We found that 24%, 48%, and 41% of hepatic immune response genes against gt3 infection were upregulated during the early, peak, and decline phases of HEV RNA replication. For gt1 infection, 25% of hepatic immune response-related genes were downregulated during early viremia, but 6%, 34%, and 37% of genes were upregulated at the early, peak and during decline of HEV RNA replication, respectively. Our study demonstrated distinct differences in the expression profiles of host immune response-related genes of HEV gt3 and gt1 infections in experimentally infected rhesus macaques. This article is protected by copyright. All rights reserved.

      2. Sexual transmission of Zika virus enhances in utero transmission in a mouse modelExternal
        Duggal NK, McDonald EM, Ritter JM, Brault AC.
        Sci Rep. 2018 Mar 14;8(1):4510.

        Zika virus (ZIKV) is an emerging mosquito-borne virus that can cause ZIKV congenital syndrome when a pregnant woman is infected. Sexual transmission has also been described for ZIKV, though the relationship between sexual transmission and vertical transmission has not been investigated. Here, viral dissemination to the female reproductive tract and fetuses was assessed in immunodeficient (AG129) female mice that were exposed to ZIKV by subcutaneous (s.c.) inoculation, intravaginal (ivag.) inoculation, or sexual transmission from infected male AG129 mice. Pregnant females had significantly increased ZIKV dissemination to the female reproductive tract compared to non-pregnant females when exposed by s.c. or ivag. inoculation. Sexual transmission resulted in significantly greater morbidity and mortality in females and higher ZIKV titers in the female reproductive tract than s.c. or ivag. inoculation. Ovaries from females infected sexually contained ZIKV RNA within the ovarian follicles. Furthermore, ZIKV titers were significantly higher in fetuses from dams exposed sexually compared to fetuses from dams exposed by s.c. or ivag. inoculation. These results demonstrate that sexual transmission enhances dissemination of ZIKV to the female reproductive tract and developing fetuses in a mouse model.

      3. A high throughput whole blood assay for analysis of multiple antigen-specific T cell responses in human Mycobacterium tuberculosis infectionExternal
        Whatney WE, Gandhi NR, Lindestam Arlehamn CS, Nizam A, Wu H, Quezada MJ, Campbell A, Allana S, Kabongo MM, Khayumbi J, Muchiri B, Ongalo J, Tonui J, Sasser LE, Fergus TJ, Ouma GS, Ouma SG, Beck AA, Mulligan MJ, Oladele A, Kaushal D, Cain KP, Waller L, Blumberg HM, Altman JD, Ernst JD, Rengarajan J, Day CL.
        J Immunol. 2018 Mar 14.

        Antigen-specific CD4 and CD8 T cells are important components of the immune response to Mycobacterium tuberculosis, yet little information is currently known regarding how the breadth, specificity, phenotype, and function of M. tuberculosis-specific T cells correlate with M. tuberculosis infection outcome in humans. To facilitate evaluation of human M. tuberculosis-specific T cell responses targeting multiple different Ags, we sought to develop a high throughput and reproducible T cell response spectrum assay requiring low blood sample volumes. We describe here the optimization and standardization of a microtiter plate-based, diluted whole blood stimulation assay utilizing overlapping peptide pools corresponding to a functionally diverse panel of 60 M. tuberculosis Ags. Using IFN-gamma production as a readout of Ag specificity, the assay can be conducted using 50 mul of blood per test condition and can be expanded to accommodate additional Ags. We evaluated the intra- and interassay variability, and implemented testing of the assay in diverse cohorts of M. tuberculosis-unexposed healthy adults, foreign-born adults with latent M. tuberculosis infection residing in the United States, and tuberculosis household contacts with latent M. tuberculosis infection in a tuberculosis-endemic setting in Kenya. The M. tuberculosis-specific T cell response spectrum assay further enhances the immunological toolkit available for evaluating M. tuberculosis-specific T cell responses across different states of M. tuberculosis infection, and can be readily implemented in resource-limited settings. Moreover, application of the assay to longitudinal cohorts will facilitate evaluation of treatment- or vaccine-induced changes in the breadth and specificity of Ag-specific T cell responses, as well as identification of M. tuberculosis-specific T cell responses associated with M. tuberculosis infection outcomes.

      4. Latent class modeling to compare testing platforms for detection of antibodies against the Chlamydia trachomatis antigen Pgp3External
        Wiegand RE, Cooley G, Goodhew B, Banniettis N, Kohlhoff S, Gwyn S, Martin DL.
        Sci Rep. 2018 Mar 9;8(1):4232.

        Latent class modeling can be used to combine the results of multiple tests to compare the sensitivity and specificity of those tests in the absence of a gold standard. Seroepidemiology for chlamydia infection may be useful for determining the cumulative risk of infection within a population. Initial studies using the Chlamydia trachomatis immunodominant antigen Pgp3 have shown utility for seroepidemiology of sexually transmitted chlamydia and the eye disease trachoma. We present our latent class modeling results for comparison of antibody data obtained from three different Pgp3-based platforms – multiplex bead array, ELISA, and lateral flow assay. Sensitivity and specificity estimates from the best fitting latent class models were similar to estimates derived from those previously obtained using a nucleic acid amplification test as a gold standard for sensitivity and non-endemic pediatric specimens for specificity, although the estimates from latent class models had wider confidence intervals. The modeling process and evaluation highlighted the importance of including as many antibody tests as possible when fitting a latent class model to ensure that as many patterns as possible are available for evaluation. Future studies designed to evaluate antibody test performance in the absence of a gold standard should utilize as many tests as possible.

      5. Disparities in detection of antibodies against hepatitis E virus in US blood donor samples using commercial assaysExternal
        Zafrullah M, Zhang X, Tran C, Nguyen M, Kamili S, Purdy MA, Stramer SL.
        Transfusion. 2018 Mar 9.

        BACKGROUND: Reported hepatitis E virus (HEV) antibody assay performance characteristics are variable. Using a subset of surplus US blood donation samples, we compared assays for detecting anti-HEV immunoglobulin M (Ig)M and IgG or total anti-HEV antibodies. STUDY DESIGN AND METHODS: Samples from 5040 random blood donations, all HEV-RNA negative, collected primarily in the midwestern United States in 2015 were tested for anti-HEV IgM and IgG or total anti-HEV using assays manufactured by Diagnostic Systems, Wantai, and MP Biomedicals. RESULTS: Overall, the percentage of detection for anti-HEV IgG and total anti-HEV was 11.4%, and for anti-HEV IgM was 1.8%. Nine samples were reactive for anti-HEV IgM by all assays, giving a recent infection rate of 0.18%. Anti-HEV IgG/total anti-HEV detection rates increased with age. Interassay agreement was higher among the IgG anti-HEV/total anti-HEV assays (84%) than the IgM assays (22%). Regression analyses of signal-to-cutoff ratios from IgG/total antibody assay were heteroskedastic, indicating no constant variance among these assays, suggesting they may detect different epitopes or were affected by waning or less avid antibodies in the US donor population. CONCLUSIONS: Although similar percentages of IgG anti-HEV/total anti-HEV detection were observed across the three commercial assays, each assay detected a unique sample subpopulation and was heteroskedastic when compared pairwise. Discordance was higher among anti-HEV IgM assays, but a recent HEV infection rate of at least 0.18% was estimated based on assay concordance.

    • Maternal and Child Health
      1. Neonatal and pediatric candidemia: Results from population-based active laboratory surveillance in four US locations, 2009-2015External
        Benedict K, Roy M, Kabbani S, Anderson EJ, Farley MM, Harb S, Harrison LH, Bonner L, Wadu VL, Marceaux K, Hollick R, Beldavs ZG, Zhang AY, Schaffner W, Graber CR, Derado G, Chiller TM, Lockhart SR, Vallabhaneni S.
        J Pediatric Infect Dis Soc. 2018 Mar 7.

        Introduction: Candida is a leading cause of healthcare-associated bloodstream infections in the United States. Infants and children have unique risk factors for candidemia, and the Candida species distribution in this group is different that among adults; however, candidemia epidemiology in this population has not been described recently. Methods: We conducted active population-based candidemia surveillance in 4 US metropolitan areas between 2009 and 2015. We calculated incidences among neonates (0-30 days old), infants (0-364 days old), and noninfant children (1-19 years old), documented their clinical features and antifungal drug resistance. Results: We identified 307 pediatric candidemia cases. Incidence trends varied according to site, but overall, the incidence in neonates decreased from 31.5 cases/100000 births in 2009 to 10.7 to 11.8 cases/100000 births between 2012 and 2015, the incidence in infants decreased from 52.1 cases/100000 in 2009 to 15.7 to 17.5 between 2012 and 2015, and the incidence in noninfant children decreased steadily from 1.8 cases/100000 in 2009 to 0.8 in 2014. Common underlying conditions were prematurity in neonates (78%), surgery in nonneonate infants (38%), and malignancy in noninfant children (28%). Most neonate cases were caused by C albicans (67%), whereas non-C. albicans species accounted for 60% of cases in nonneonate infants and noninfant children. Fluconazole and echinocandin resistance rates were low overall. Thirty-day crude mortality was 13%. Conclusions: The incidence of candidemia among neonates and infants declined after 2009 but remained stable from 2012 to 2015. Antifungal drug resistance is uncommon. Reasons for the lack of recent declines in neonatal and infant candidemia deserve further exploration. In this article, we describe the epidemiology of candidemia in children in the United States and on the basis of data collected as part of US Centers for Disease Control and Prevention active population-based surveillance. Trends in incidence, clinical characteristics, species distribution, and resistance rates are presented.

      2. We compared the prevalence of various medical and behavioral co-occurring conditions/symptoms between 4- and 8-year-olds with autism spectrum disorder (ASD) from five sites in the Autism and Developmental Disabilities Monitoring Network during the 2010 survey year, accounting for sociodemographic differences. Over 95% of children had at least one co-occurring condition/symptom. Overall, the prevalence was higher in 8- than 4-year-olds for 67% of co-occurring conditions/symptoms examined. Further, our data suggested that co-occurring conditions/symptoms increased or decreased the age at which children were first evaluated for ASD. Similarly, among the 8-year-olds, the prevalence of most co-occurring conditions/symptoms was higher in children with a previous ASD diagnosis documented in their records. These findings are informative for understanding and screening co-occurring conditions/symptoms in ASD.

    • Mining
      1. Refuge alternatives relief valve testing and design with updated test standExternal
        Lutz T, Bissert P, Homce G, Yonkey J.
        Mining Engineering. 2018 ;70(3):46-50.

        Underground refuge alternatives require an air source to supply breathable air to the occupants. This requires pressure relief valves to prevent unsafe pressures from building up within the refuge alternative. The U.S. Mine Safety and Health Administration (MSHA) mandates that pressure relief valves prevent pressure from exceeding 1.25 kPa (0.18 psi), or as specified by the manufacturer, above mine atmospheric pressure when a fan or compressor is used for the air supply. The U.S. National Institute for Occupational Safety and Health (NIOSH) tested a variety of pressure relief valves using an instrumented test fixture consisting of data acquisition equipment, a centrifugal blower, ductwork and various sensors to determine if the subject pressure relief valves meet the MSHA requirement. Relief pressures and flow characteristics, including opening pressure and flow rate, were measured for five different pressure relief valves under a variety of conditions. The subject pressure relief valves included two off-the-shelf modified check valves, two check valves used in MSHA-approved built-in-place refuge alternatives, and a commercially available valve that was designed for a steel refuge alternative and is currently being used in some built-in-place refuge alternatives. The test results showed relief pressures ranging from 0.20 to 1.53 kPa (0.03 to 0.22 psi) and flow rates up to 19.3 m3/min (683 scfm). As tested, some of the pressure relief valves did not meet the 1.25 kPa (0.18 psi) relief specification.

    • Nutritional Sciences
      1. Effect of infant feeding practices on iron status in a cohort study of Bolivian infantsExternal
        Burke RM, Rebolledo PA, Aceituno AM, Revollo R, Iniguez V, Klein M, Drews-Botsch C, Leon JS, Suchdev PS.
        BMC Pediatr. 2018 Mar 12;18(1):107.

        BACKGROUND: Iron deficiency (ID) is the most common micronutrient deficiency worldwide, with potentially severe consequences on child neurodevelopment. Though exclusive breastfeeding (EBF) is recommended for 6 months, breast milk has low iron content. This study aimed to estimate the effect of the length of EBF on iron status at 6 – 8 months of age among a cohort of Bolivian infants. METHODS: Mother-infant pairs were recruited from 2 hospitals in El Alto, Bolivia, and followed from one through 6 – 8 months of age. Singleton infants > 34 weeks gestational age, iron-sufficient at baseline, and completing blood draws at 2 and 6 – 8 months of age were eligible for inclusion (N = 270). Ferritin was corrected for the effect of inflammation. ID was defined as inflammation-corrected ferritin < 12 mug/L, and anemia was defined as altitude-corrected hemoglobin < 11 g/dL; IDA was defined as ID plus anemia. The effect of length of EBF (infant received only breast milk with no other liquids or solids, categorized as < 4, 4 – 6, and > 6 months) was assessed for ID, IDA, and anemia (logistic regression) and ferritin (Fer) and hemoglobin (Hb, linear regression). RESULTS: Low iron status was common among infants at 6 – 8 months: 56% of infants were ID, 76% were anemic, and 46% had IDA. EBF of 4 months and above was significantly associated with ID as compared with EBF < 4 months (4 – 6 months: OR 2.0 [1.1 – 3.4]; > 6 months: 3.3 [1.0 – 12.3]), but not with IDA (4 – 6 months: OR 1.4 [0.8 – 2.4]; > 6 months: 2.2 [0.7 – 7.4]), or anemia (4 – 6 months: OR 1.4 [0.7 – 2.5]; > 6 months: 1.5 [0.7 – 7.2]). Fer and Hb concentrations were significantly lower with increasing months of EBF. CONCLUSIONS: Results suggest a relationship between prolonged EBF and ID, but are not sufficient to support changes to current breastfeeding recommendations. More research is needed in diverse populations, including exploration of early interventions to address infant IDA.

    • Occupational Safety and Health
      1. BACKGROUND: The purpose of this study was to estimate the prevalence of occupational noise exposure, hearing difficulty and cardiovascular conditions within US industries and occupations, and to examine any associations of these outcomes with occupational noise exposure. METHODS: National Health Interview Survey data from 2014 were examined. Weighted prevalence and adjusted prevalence ratios of self-reported hearing difficulty, hypertension, elevated cholesterol, and coronary heart disease or stroke were estimated by level of occupational noise exposure, industry, and occupation. RESULTS: Twenty-five percent of current workers had a history of occupational noise exposure (14% exposed in the last year), 12% had hearing difficulty, 24% had hypertension, 28% had elevated cholesterol; 58%, 14%, and 9% of these cases can be attributed to occupational noise exposure, respectively. CONCLUSIONS: Hypertension, elevated cholesterol, and hearing difficulty are more prevalent among noise-exposed workers. Reducing workplace noise levels is critical. Workplace-based health and wellness programs should also be considered.

      2. Elements of a workplace culture of health, perceived organizational support for health, and lifestyle riskExternal
        Payne J, Cluff L, Lang J, Matson-Koffman D, Morgan-Lopez A.
        Am J Health Promot. 2018 Jan 1:890117118758235.

        PURPOSE: We investigated the impact of elements of a workplace culture of health (COH) on employees’ perceptions of employer support for health and lifestyle risk. DESIGN: We used 2013 and 2015 survey data from the National Healthy Worksite Program, a Centers for Disease Control and Prevention (CDC)-led initiative to help workplaces implement health-promoting interventions. SETTING: Forty-one employers completed the CDC Worksite Health Scorecard to document organizational changes. PARTICIPANTS: Eight hundred twenty-five employees provided data to evaluate changes in their health and attitudes. MEASURES: We defined elements of a COH as environmental, policy, and programmatic supports; leadership and coworker support; employee engagement (motivational interventions); and strategic communication. Outcomes included scores of employees’ perceptions of employer support for health and lifestyle risk derived from self-reported physical activity, nutrition, and tobacco use. ANALYSIS: We estimated effects using multilevel regression models. RESULTS: At the employee level and across time, regression coefficients show positive associations between leadership support, coworker support, employee engagement, and perceived support for health ( P < .05). Coefficients suggest a marginally significant negative association between lifestyle risk and the presence of environmental and policy supports ( P < .10) and significant associations with leadership support in 2015 only ( P < .05). CONCLUSION: Relational elements of COH (leadership and coworker support) tend to be associated with perceived support for health, while workplace elements (environmental and policy supports) are more associated with lifestyle risk. Employers need to confront relational and workplace elements together to build a COH.

    • Parasitic Diseases
      1. Comparison of antigen and antibody responses in repeat lymphatic filariasis transmission assessment surveys in American SamoaExternal
        Won KY, Robinson K, Hamlin KL, Tufa J, Seespesara M, Wiegand RE, Gass K, Kubofcik J, Nutman TB, Lammie PJ, Fuimaono S.
        PLoS Negl Trop Dis. 2018 Mar 9;12(3):e0006347.

        BACKGROUND: Current WHO recommendations for lymphatic filariasis (LF) surveillance advise programs to implement activities to monitor for new foci of transmission after stopping mass drug administration (MDA). A current need in the global effort to eliminate LF is to standardize diagnostic tools and surveillance activities beyond the recommended transmission assessment survey (TAS). METHODOLOGY: TAS was first conducted in American Samoa in 2011 (TAS 1) and a repeat TAS was carried out in 2015 (TAS 2). Circulating filarial antigen (CFA) and serologic results from both surveys were analyzed to determine whether interruption of LF transmission has been achieved in American Samoa. PRINCIPAL FINDINGS: A total of 1,134 and 864 children (5-10 years old) were enrolled in TAS 1 and TAS 2, respectively. Two CFA-positive children were identified in TAS 1, and one CFA-positive child was identified in TAS 2. Results of both surveys were below the threshold for which MDA was warranted. Additionally, 1,112 and 836 dried blood spots from TAS 1 and TAS 2, respectively were tested for antibodies to Wb123, Bm14 and Bm33 by luciferase immunoprecipitation system (LIPS) assay and multiplex bead assay. In 2011, overall prevalence of responses to Wb123, Bm14, and Bm33 was 1.0%, 6.8% and 12.0%, respectively. In 2015, overall prevalence of positive Bm14 and Bm33 responses declined significantly to 3.0% (p<0.001) and 7.8% (p = 0.013), respectively. CONCLUSIONS/SIGNIFICANCE: Although passing TAS 1 and TAS 2 and an overall decline in the prevalence of antibodies to Bm14 and Bm33 between these surveys suggests decreased exposure and infection among young children, there were persistent responses in some schools. Clustering and persistence of positive antibody responses in schools may be an indication of ongoing transmission. There is a need to better understand the limitations of current antibody tests, but our results suggest that serologic tools can have a role in guiding programmatic decision making.

    • Public Health Leadership and Management
      1. A review of public health training needs assessment approaches: Opportunities to move forwardExternal
        Joly BM, Coronado F, Bickford BC, Leider JP, Alford A, McKeever J, Harper E.
        J Public Health Manag Pract. 2018 Mar 7.

        CONTEXT: Assessing training needs of the public health workforce is crucial for creating professional development opportunities to improve knowledge, competence, and effectiveness of this workforce. DISSEMINATION: Regional Public Health Training Centers (RPHTCs) assess workforce training needs and deliver training based on identified needs. To determine training priorities, several needs assessment surveys have been administered by RPHTCs and national public health member organizations. EVALUATION: This study identified the types of training questions being asked to public health practitioners in the various assessment surveys implemented by RPHTCs and national membership organizations. Although the surveys measured similar overarching constructs, multiple approaches with limited consistency were used to measure training needs. DISCUSSION: Although successful in responding to the needs of their targeted constituents, the limited consistency among survey types makes generalization of findings difficult. Disseminating common metrics and aggregate survey findings would increase efficiency in determining workforce training needs and developing targeted training.

    • Reproductive Health
      1. Preterm birth and small-for-gestational age in singleton in vitro fertilization births using donor oocytesExternal
        Boulet SL, Kawwass JF, Crawford S, Davies MJ, Kissin DM.
        Am J Epidemiol. 2018 Mar 9.

        We used 2006-2015 US National Assisted Reproductive Technology Surveillance System data to compare preterm birth and fetal growth for livebo n singletons (24-42 week gestation) following donor versus autologous oocyte in vitro fertilization (IVF). Using binary and multinomial logistic regressi n, we computed adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between use of donor oocytes and preterm delivery, small-f r-gestational-age (SGA), and large-for-gestational age (LGA), stratified by fresh and thawed embryo status and accounting for maternal characteristics and year of birth. There were 204,855 singleton births from fresh embryo transfers and 106,077 from thawed embryo transfers. Among fresh embryo transfers, donor oocyte births had higher odds of preterm (aOR 1.32, 95% CI 1.27-1.38) and LGA (aOR 1.27, 95% CI 1.21-1.33) but lower odds of SGA (aOR 0.81, 95% CI 0.77-0.85). Among thawed embryo transfers, donor oocyte births had higher odds of preterm (aOR 1.57, 95% CI 1.48-1.65) and SGA (aRR 1.22, 95% CI 1.14-1.31), but lower odds of LGA (aOR 0.87, 95% CI 0.82-0.92). Use of donor oocytes was associated with increased odds of preterm delivery irrespective of embryo status; odds of SGA were increased for donor versus autologous oocyte births among thawed embryo transfers only.

      2. Policy change is not enough: Engaging provider champions on immediate postpartum contraceptionExternal
        Okoroh EM, Kane DJ, Gee RE, Kieltyka L, Frederiksen BN, Baca KM, Rankin KM, Goodman DA, Kroelinger CD, Barfield WD.
        Am J Obstet Gynecol. 2018 Mar 9.

        Rates of short interval pregnancies resulting in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception (LARC) methods have annual failure rates of less than 1% compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to LARCs in the immediate postpartum period, several State Medicaid programs, including those in Iowa (IA) and Louisiana (LA), recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum LARC insertion. We used a mixed-methods approach, to analyze 2013-2015 linked Medicaid and vital records data from both IA and LA, to describe trends in immediate postpartum LARC provision one year prior to and following the Medicaid reimbursement policy change. We also used data from key informant interviews with State program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in IA increased from 4.6 per month prior to the policy to 6.6 per month post policy, and in LA, the average increased from 2.6 per month prior to the policy to 45.2 per month. In both states, the majority of insertions occurred at one academic/teaching hospital. In LA, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of State-level Medicaid payment reform policies that allow reimbursement for immediate postpartum LARC insertions.

    • Statistics as Topic
      1. Hierarchical Bayes models have been used in disease mapping to examine small scale geographic variation. State level geographic variation for less common causes of mortality outcomes have been reported however county level variation is rarely examined. Due to concerns about statistical reliability and confidentiality, county-level mortality rates based on fewer than 20 deaths are suppressed based on Division of Vital Statistics, National Center for Health Statistics (NCHS) statistical reliability criteria, precluding an examination of spatio-temporal variation in less common causes of mortality outcomes such as suicide rates (SRs) at the county level using direct estimates. Existing Bayesian spatio-temporal modeling strategies can be applied via Integrated Nested Laplace Approximation (INLA) in R to a large number of rare causes of mortality outcomes to enable examination of spatio-temporal variations on smaller geographic scales such as counties. This method allows examination of spatiotemporal variation across the entire U.S., even where the data are sparse. We used mortality data from 2005-2015 to explore spatiotemporal variation in SRs, as one particular application of the Bayesian spatio-temporal modeling strategy in R-INLA to predict year and county-specific SRs. Specifically, hierarchical Bayesian spatio-temporal models were implemented with spatially structured and unstructured random effects, correlated time effects, time varying confounders and space-time interaction terms in the software R-INLA, borrowing strength across both counties and years to produce smoothed county level SRs. Model-based estimates of SRs were mapped to explore geographic variation.

    • Substance Use and Abuse
      1. Exposure to electronic cigarette advertising among middle and high school students – United States, 2014-2016External
        Marynak K, Gentzke A, Wang TW, Neff L, King BA.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):294-299.

        Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among U.S. middle and high school students (1). Exposure to e-cigarette advertisements is associated with higher odds of current e-cigarette use among middle and high school students (2-4). To assess patterns of self-reported exposure to four e-cigarette advertising sources (retail stores, the Internet, television, and newspapers and magazines), CDC analyzed data from the 2014, 2015, and 2016 National Youth Tobacco Surveys (NYTSs). Overall, exposure to e-cigarette advertising from at least one source increased each year during 2014-2016 (2014: 68.9%, 18.3 million; 2015: 73.0%, 19.2 million; 2016: 78.2%, 20.5 million). In 2016, exposure was highest for retail stores (68.0%), followed by the Internet (40.6%), television (37.7%), and newspapers and magazines (23.9%). During 2014-2016, youth exposure to e-cigarette advertising increased for retail stores (54.8% to 68.0%), decreased for newspapers and magazines (30.4% to 23.9%), and did not significantly change for the Internet or television. A comprehensive strategy to prevent and reduce youth use of e-cigarettes and other tobacco products includes efforts to reduce youth exposure to e-cigarette advertising from a range of sources, including retail stores, television, the Internet, and print media such as newspapers and magazines (5).

    • Zoonotic and Vectorborne Diseases
      1. Spatio-temporal coherence of dengue, chikungunya and Zika outbreaks in Merida, MexicoExternal
        Bisanzio D, Dzul-Manzanilla F, Gomez-Dantes H, Pavia-Ruz N, Hladish TJ, Lenhart A, Palacio-Vargas J, Gonzalez Roldan JF, Correa-Morales F, Sanchez-Tejeda G, Kuri Morales P, Manrique-Saide P, Longini IM, Halloran ME, Vazquez-Prokopec GM.
        PLoS Negl Trop Dis. 2018 Mar 15;12(3):e0006298.

        Response to Zika virus (ZIKV) invasion in Brazil lagged a year from its estimated February 2014 introduction, and was triggered by the occurrence of severe congenital malformations. Dengue (DENV) and chikungunya (CHIKV) invasions tend to show similar response lags. We analyzed geo-coded symptomatic case reports from the city of Merida, Mexico, with the goal of assessing the utility of historical DENV data to infer CHIKV and ZIKV introduction and propagation. About 42% of the 40,028 DENV cases reported during 2008-2015 clustered in 27% of the city, and these clustering areas were where the first CHIKV and ZIKV cases were reported in 2015 and 2016, respectively. Furthermore, the three viruses had significant agreement in their spatio-temporal distribution (Kendall W>0.63; p<0.01). Longitudinal DENV data generated patterns indicative of the resulting introduction and transmission patterns of CHIKV and ZIKV, leading to important insights for the surveillance and targeted control to emerging Aedes-borne viruses.

      2. Notes from the field: Assessing rabies risk after a mass bat exposure at a research facility in a national park – Wyoming, 2017External
        Cote A, Guagliardo SA, Tran CH, Said MA, Pickens V, Musgrave K, Wallace R.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):313-314.

        [No abstract]

      3. Emergence of monkeypox – West and Central Africa, 1970-2017External
        Durski KN, McCollum AM, Nakazawa Y, Petersen BW, Reynolds MG, Briand S, Djingarey MH, Olson V, Damon IK, Khalakdina A.
        MMWR Morb Mortal Wkly Rep. 2018 Mar 16;67(10):306-310.

        The recent apparent increase in human monkeypox cases across a wide geographic area, the potential for further spread, and the lack of reliable surveillance have raised the level of concern for this emerging zoonosis. In November 2017, the World Health Organization (WHO), in collaboration with CDC, hosted an informal consultation on monkeypox with researchers, global health partners, ministries of health, and orthopoxvirus experts to review and discuss human monkeypox in African countries where cases have been recently detected and also identify components of surveillance and response that need improvement. Endemic human monkeypox has been reported from more countries in the past decade than during the previous 40 years. Since 2016, confirmed cases of monkeypox have occurred in Central African Republic, Democratic Republic of the Congo, Liberia, Nigeria, Republic of the Congo, and Sierra Leone and in captive chimpanzees in Cameroon. Many countries with endemic monkeypox lack recent experience and specific knowledge about the disease to detect cases, treat patients, and prevent further spread of the virus. Specific improvements in surveillance capacity, laboratory diagnostics, and infection control measures are needed to launch an efficient response. Further, gaps in knowledge about the epidemiology and ecology of the virus need to be addressed to design, recommend, and implement needed prevention and control measures.

      4. Recognizing the global impact of Zika virus infection during pregnancyExternal
        Honein MA.
        N Engl J Med. 2018 Mar 15;378(11):1055-1056.

        [No abstract]

      5. Prolonged detection of Zika virus nucleic acid among symptomatic pregnant women: a cohort studyExternal
        Lozier MJ, Rosenberg ES, Doyle K, Adams L, Klein L, Munoz-Jordan J, Alvarado LI, Sharp TM, Paz-Bailey G.
        Clin Infect Dis. 2018 Mar 9.

        A prospective cohort of women with RT-PCR confirmed Zika virus infection aged 18-39 years in Puerto Rico found that pregnant women have about a three-fold longer estimated median detection of Zika virus RNA in serum, which can increase definitive diagnosis of infection and facilitate timely and appropriate clinical management.

      6. Antigenically diverse swine-origin H1N1 variant influenza viruses exhibit differential ferret pathogenesis and transmission phenotypesExternal
        Pulit-Penaloza JA, Jones J, Sun X, Jang Y, Thor S, Belser JA, Zanders N, Creager HM, Ridenour C, Wang L, Stark TJ, Garten R, Chen LM, Barnes J, Tumpey TM, Wentworth DE, Maines TR, Davis CT.
        J Virol. 2018 Mar 14.

        Influenza A(H1) viruses circulating in swine represent an emerging virus threat as zoonotic infections occur sporadically following exposure to swine. A fatal infection caused by an H1N1 variant (H1N1v) virus was detected in a patient with reported exposure to swine and who presented with pneumonia, respiratory failure, and cardiac arrest. To understand the genetic and phenotypic characteristics of the virus, genome sequence analysis, antigenic characterization, and ferret pathogenesis and transmissibility experiments were performed. Antigenic analysis of the virus isolated from the fatal case, A/Ohio/09/2015, demonstrated significant antigenic drift away from classical swine H1N1 variant viruses and H1N1 pandemic 2009 viruses. A substitution in the H1 hemagglutinin (G155E) was identified that likely impacted antigenicity, and reverse genetics was employed to understand the molecular mechanism of antibody escape. Reversion of the substitution to 155G, in a reverse genetics A/Ohio/09/2015 virus, showed that this residue was central to the loss of hemagglutination inhibition by ferret antisera raised against a prototypical H1N1 pandemic 2009 virus (A/California/07/2009), as well as gamma lineage classical swine H1N1 viruses, demonstrating the importance of this residue for antibody recognition of this H1 lineage. When analyzed in the ferret model, A/Ohio/09/2015 and another H1N1v virus (A/Iowa/39/2015), as well as A/California/07/2009, replicated efficiently in the respiratory tract of ferrets. The two H1N1v viruses transmitted efficiently among cohoused ferrets, but respiratory droplet transmission studies showed that A/California/07/2009 transmitted through the air more efficiently. Pre-existing immunity to A/California/07/2009 did not fully protect ferrets from challenge with A/Ohio/09/2015.IMPORTANCE Human infections with classical swine influenza A(H1N1) viruses that circulate in pigs continue to occur in the United States following exposure to swine. To understand the genetic and virologic characteristics of a virus (A/Ohio/09/2015) associated with a fatal infection and a virus associated with a non-fatal infection (A/Iowa/39/2015), we performed genome sequence analysis, antigenic testing, and pathogenicity and transmission studies in a ferret model. Reverse genetics was employed to identify a single antigenic site substitution (HA G155E) responsible for antigenic variation of A/Ohio/09/2015 compared to related classical swine influenza A(H1N1) viruses. Ferrets with pre-existing immunity to the pandemic A(H1N1) virus were challenged with A/Ohio/09/2015 demonstrating decreased protection. This data illustrates the potential for currently circulating swine influenza viruses to infect and cause illness in humans with pre-existing immunity to H1N1 pandemic 2009 viruses and a need for ongoing risk assessment and development of candidate vaccine viruses for improved pandemic preparedness.

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  • John Iskander, MD MPH, Editor
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  • Kathy Tucker, Librarian
  • William (Bill) Thomas, MLIS, Librarian
  • Onnalee Gomez, MS, Health Scientist
  • Jarvis Sims, MIT, MLIS, Librarian


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

Page last reviewed: January 31, 2019