Volume 10, Issue 16, May 8, 2018

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CDC Science Clips: Volume 10, Issue 16, May 8, 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!

The report consists of these components:

  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

    • Communicable Diseases
      • Unhealthy substance use is associated with increased rates of STDs, including HIV. Within three high-risk New York City (NYC) sexual health clinics between 2008 and 2012 (n=146,657), 17% of patients screened positive for a current SUD but only 5.3% ever received prior treatment. The goal of Project Renew was to expand the reach of substance use early intervention services within and across sexual health clinics citywide and decrease substance use, poor mental health, and risky sexual behavior. To accomplish this goal, Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based substance use early intervention model, was implemented in all eight NYC sexual health clinics February 2012-January 2015. Clinic patients were screened for substance misuse using the AUDIT/DAST-10, and those who screened positive were eligible for on-site brief intervention. Overall, 130,597 substance misuse screenings were conducted (66,989, or 51%, positive), and 17,474 on-site brief interventions and 1238 referrals were provided (not unique to individual patients). A 10% sample of 14,709 unique patients who screened positive were interviewed using a federal data collection tool at baseline and six months later to assess changes in substance use, sexual risk behaviors, mental health, and health status (n=1328). At six-month follow-up, patients reported reduced substance use, less sexual activity, improved overall health, and fewer days of depression and anxiety compared to measures at baseline (p<0.05). Based on positive results, Project Renew SBIRT services have been sustained, ensuring essential care which may help prevent acquisition of HIV/STDs among a large population of high-risk New Yorkers.

      • Prevalence of drug-resistant tuberculosis and imputed burden in South Africa: a national and sub-national cross-sectional surveyExternal
        Ismail NA, Mvusi L, Nanoo A, Dreyer A, Omar SV, Babatunde S, Molebatsi T, van der Walt M, Adelekan A, Deyde V, Ihekweazu C, Madhi SA.
        Lancet Infect Dis. 2018 Apr 20.

        BACKGROUND: Globally, per-capita, South Africa reports a disproportionately high number of cases of multidrug-resistant (MDR) tuberculosis and extensively drug-resistant (XDR) tuberculosis. We sought to estimate the prevalence of resistance to tuberculosis drugs in newly diagnosed and retreated patients with tuberculosis provincially and nationally, and compared these with the 2001-02 estimates. METHODS: A cross-sectional survey was done between June 15, 2012-June 14, 2014, using population proportionate randomised cluster sampling in the nine provinces in South Africa. 343 clusters were included, ranging between 31 and 48 per province. A patient was eligible for inclusion in the survey if he or she presented as a presumptive case during the intake period at a drug resistance survey enrolling facility. Consenting participants (>/=18 years old) completed a questionnaire and had a sputum sample tested for resistance to first-line and second-line drugs. Analysis was by logistic regression with robust SEs, inverse probability weighted against routine data, and estimates were derived using a random effects model. FINDINGS: 101 422 participants were tested in 2012-14. Nationally, the prevalence of MDR tuberculosis was 2.1% (95% CI 1.5-2.7) among new tuberculosis cases and 4.6% (3.2-6.0) among retreatment cases. The provincial point prevalence of MDR tuberculosis ranged between 1.6% (95% CI 0.9-2.9) and 5.1% (3.7-7.0). Overall, the prevalence of rifampicin-resistant tuberculosis (4.6%, 95% CI 3.5-5.7) was higher than the prevalence of MDR tuberculosis (2.8%, 2.0-3.6; p=0.01). Comparing the current survey with the previous (2001-02) survey, the overall MDR tuberculosis prevalence was 2.8% versus 2.9% and prevalance of rifampicin-resistant tuberculosis was 3.4% versus 1.8%, respectively. The prevalence of isoniazid mono-resistant tuberculosis was above 5% in all provinces. The prevalence of ethionamide and pyrazinamide resistance among MDR tuberculosis cases was 44.7% (95% CI 25.9-63.6) and 59.1% (49.0-69.1), respectively. The prevalence of XDR tuberculosis was 4.9% (95% CI 1.0-8.8). Nationally, the estimated numbers of cases of rifampicin-resistant tuberculosis, MDR tuberculosis, and isoniazid mono-resistant tuberculosis for 2014 were 13 551, 8249, and 17 970, respectively. INTERPRETATION: The overall prevalence of MDR tuberculosis in South Africa in 2012-14 was similar to that in 2001-02; however, prevalence of rifampicin-resistant tuberculosis almost doubled among new cases. Furthermore, the high prevalence of isoniazid mono-resistant tuberculosis, not routinely screened for, and resistance to second-line drugs has implications for empirical management. FUNDING: President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention under the terms of 1U19GH000571.

      • Risk factors and incidence of syphilis in HIV-infected persons, the HIV Outpatient Study, 1999-2015External
        Novak RM, Ghanem A, Hart R, Ward D, Armon C, Buchacz K.
        Clin Infect Dis. 2018 Apr 24.

        Background: Since 2000, the incidence of syphilis has been increasing, especially among gay, bisexual and other men who have sex with men (MSM) in the United States (U.S.). We assessed temporal trends and associated risk factors for newly diagnosed syphilis infections among HIV-infected patients during a 16-year period. Methods: We analyzed data from the HIV Outpatient Study (HOPS) cohort participants seen at ten U.S. HIV clinics during 1999 – 2015. New syphilis cases were defined based on laboratory parameters and clinical diagnoses. We assessed incidence rates of syphilis and performed Cox proportional hazards regression analyses of sociodemographic, clinical and behavioral risk factors for new syphilis infections. Results: We studied 6888 HIV-infected participants; 641 had one or more new syphilis diagnoses during a median follow-up of 5.2 years. Most participants were male (78%), aged 31-50 years, and 56% were MSM. There were 799 syphilis diagnoses for an overall incidence of 1.8 per 100 person-years (py) (95% Confidence Interval [CI] 1.6-1.9); incidence rate increased from 0.4 (CI 0.2-0.8) to 2.2 (CI 1.4-3.5) per 100 py during 1999 – 2015. In multivariable analyses adjusting for calendar year, risk factors for syphilis included: being aged 18-30 years (hazard ratio [HR] 1.3, CI 1.1-1.6) vs. 31-40 years, being MSM (HR 3.1, CI 2.4-4.1) vs. heterosexual male, and being non-Hispanic black (HR 1.6, CI 1.4-1.9) vs. non-Hispanic white. Conclusions: The increases in the syphilis incidence rate through 2015, reflect ongoing sexual risk, and highlight the need for enhanced prevention interventions among HIV-infected patients in care.

    • Drug Safety

      • National estimates of emergency department visits for antibiotic adverse events among adults – United States, 2011-2015External
        Geller AI, Lovegrove MC, Shehab N, Hicks LA, Sapiano MR, Budnitz DS.
        J Gen Intern Med. 2018 Apr 20.

        BACKGROUND: Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention. OBJECTIVE: Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs. DESIGN: Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015. PATIENTS: Antibiotic-treated adults (>/= 20 years) seeking ED care. MAIN MEASURES: Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics. KEY RESULTS: Based on 10,225 cases, US adults aged >/= 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged >/= 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group. CONCLUSIONS: Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

    • Maternal and Child Health

      • Epidemiology and impact of health care provider-diagnosed anxiety and depression among US childrenExternal
        Bitsko RH, Holbrook JR, Ghandour RM, Blumberg SJ, Visser SN, Perou R, Walkup JT.
        J Dev Behav Pediatr. 2018 Apr 24.

        OBJECTIVE: This study documents the prevalence and impact of anxiety and depression in US children based on the parent report of health care provider diagnosis. METHODS: National Survey of Children’s Health data from 2003, 2007, and 2011-2012 were analyzed to estimate the prevalence of anxiety or depression among children aged 6 to 17 years. Estimates were based on the parent report of being told by a health care provider that their child had the specified condition. Sociodemographic characteristics, co-occurrence of other conditions, health care use, school measures, and parenting aggravation were estimated using 2011-2012 data. RESULTS: Based on the parent report, lifetime diagnosis of anxiety or depression among children aged 6 to 17 years increased from 5.4% in 2003 to 8.4% in 2011-2012. Current anxiety or depression increased from 4.7% in 2007 to 5.3% in 2011-2012; current anxiety increased significantly, whereas current depression did not change. Anxiety and depression were associated with increased risk of co-occurring conditions, health care use, school problems, and having parents with high parenting aggravation. Children with anxiety or depression with effective care coordination or a medical home were less likely to have unmet health care needs or parents with high parenting aggravation. CONCLUSION: By parent report, more than 1 in 20 US children had current anxiety or depression in 2011-2012. Both were associated with significant comorbidity and impact on children and families. These findings may inform efforts to improve the health and well-being of children with internalizing disorders. Future research is needed to determine why child anxiety diagnoses seem to have increased from 2007 to 2012.

    • Substance Use and Abuse

      • Effects of a prior authorization policy for extended-release/long-acting opioids on utilization and outcomes in a state Medicaid programExternal
        Keast SL, Kim H, Deyo RA, Middleton L, McConnell KJ, Zhang K, Ahmed SM, Nesser N, Hartung DM.
        Addiction. 2018 Apr 20.

        BACKGROUND AND AIMS: In response to the opioid overdose epidemic, USA state Medicaid programs have adopted restrictive policies for opioid analgesics, yet effects on prescribing patterns and health outcomes are uncertain. This study aimed to examine effects of a prior authorization policy for extended-release/long-acting (ER/LA) opioids on opioid use in the Oklahoma, USA state Medicaid program. DESIGN: Retrospective difference-in-differences design study comparing changes in opioid use in Oklahoma Medicaid to control (Oregon Medicaid). SETTING: Oklahoma and Oregon, USA. PARTICIPANTS: Medicaid beneficiaries in the Oklahoma and Oregon fee-for-service Medicaid programs between July 2007 and June 2009 (33,724 in Oklahoma and 13,520 in Oregon) MEASUREMENTS: The primary outcome was incident opioid-naive ER/LA opioid use. Secondary outcomes included other opioid and non-opioid pain medication use. We also examined indicators of high-risk prescribing (e.g. high dosage opioid use) and opioid-related hospitalizations or emergency department (ED) visits. FINDINGS: The prior authorization policy was associated with 0.7 percentage point reduction in likelihood of incident opioid-naive ER/LA opioid use (95% confidence interval [CI]: -1.16 to -0.33 percentage points; 70% pre-policy mean reduction), 1.4 percentage point decrease in likelihood of any new ER/LA opioid prescriptions (95% CI: -2.1 to -0.7 percentage points; 33% pre-policy mean reduction), and decline of 0.16 in total ER/LA opioid prescriptions per enrollee (PPE) (95% CI:-0.29 to -0.04 PPE). There was significant increase in number of short-acting opioids filled after the policy (0.36; 95% CI: 0.22 to 0.50 PPE), increases in likelihood of having overlapping opioids and benzodiazepines, but significant reductions in likelihood of having overlapping opioids. No significant changes in opioid-related hospitalizations or ED visits were observed. CONCLUSIONS: Oklahoma, USA’s July 2008 prior authorization policy for extended-release/long-acting (ER/LA) opioids appears to have reduced the number of opioid-naive patients initiating ER/LA opioid use by more than half, but may also have increased short-acting opioid prescriptions by 7%.

      • E-cigarette openness, curiosity, harm perceptions and advertising exposure among U.S. middle and high school studentsExternal
        Margolis KA, Donaldson EA, Portnoy DB, Robinson J, Neff LJ, Jamal A.
        Prev Med. 2018 Apr 17;112:119-125.

        Understanding factors associated with youth e-cigarette openness and curiosity are important for assessing probability of future use. We examined how e-cigarette harm perceptions and advertising exposure are associated with openness and curiosity among tobacco naive youth. Findings from the 2015 National Youth Tobacco Survey (NYTS) were analyzed. The 2015 NYTS is a nationally representative survey of 17,711 U.S. middle and high school students. We calculated weighted prevalence estimates of never users of tobacco products (cigarettes, cigars/cigarillos/little cigars, waterpipe/hookah, smokeless tobacco, bidis, pipes, dissolvables, e-cigarettes) who were open to or curious about e-cigarette use, by demographics. Weighted regression models examined how e-cigarette harm perceptions and advertising exposure were associated with openness using e-cigarettes and curiosity about trying e-cigarettes. Among respondents who never used tobacco products, 23.8% were open to using e-cigarettes and 25.4% were curious. Respondents that perceived e-cigarettes cause a lot of harm had lower odds of both openness (OR=0.10, 95% CI=0.07, 0.15) and curiosity about e-cigarettes (OR=0.10, 95% CI=0.07, 0.13) compared to those with lower harm perception. Respondents who reported high exposure to e-cigarette advertising in stores had greater odds of being open to e-cigarette use (OR=1.22, 95% CI=1.03, 1.44) and highly curious (OR=1.25, 95% CI=1.01, 1.53) compared to those not highly exposed. These findings demonstrate that youth exposed to e-cigarette advertising are open and curious to e-cigarette use. These findings could help public health practitioners better understand the interplay of advertising exposure and harm perceptions with curiosity and openness to e-cigarette use in a rapidly changing marketplace.

    • Zoonotic and Vectorborne Diseases

      • Zika virus shedding in semen of symptomatic infected menExternal
        Mead PS, Duggal NK, Hook SA, Delorey M, Fischer M, Olzenak McGuire D, Becksted H, Max RJ, Anishchenko M, Schwartz AM, Tzeng WP, Nelson CA, McDonald EM, Brooks JT, Brault AC, Hinckley AF.
        N Engl J Med. 2018 Apr 12;378(15):1377-1385.

        BACKGROUND: Zika virus (ZIKV) is an emerging mosquito-borne flavivirus that has been linked to adverse birth outcomes. Previous reports have shown that person-to-person transmission can occur by means of sexual contact. METHODS: We conducted a prospective study involving men with symptomatic ZIKV infection to determine the frequency and duration of ZIKV shedding in semen and urine and to identify risk factors for prolonged shedding in these fluids. Specimens were obtained twice per month for 6 months after illness onset and were tested by real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay for ZIKV RNA and by Vero cell culture and plaque assay for infectious ZIKV. RESULTS: A total of 1327 semen samples from 184 men and 1038 urine samples from 183 men were obtained 14 to 304 days after illness onset. ZIKV RNA was detected in the urine of 7 men (4%) and in the semen of 60 (33%), including in semen samples from 22 of 36 men (61%) who were tested within 30 days after illness onset. ZIKV RNA shedding in semen decreased substantially during the 3 months after illness onset but continued for 281 days in 1 man (1%). Factors that were independently associated with prolonged RNA shedding included older age, less frequent ejaculation, and the presence of certain symptoms at the time of initial illness. Infectious ZIKV was isolated from 3 of 78 semen samples with detectable ZIKV RNA, all obtained within 30 days after illness onset and all with at least 7.0 log10 ZIKV RNA copies per milliliter of semen. CONCLUSIONS: ZIKV RNA was commonly present in the semen of men with symptomatic ZIKV infection and persisted in some men for more than 6 months. In contrast, shedding of infectious ZIKV appeared to be much less common and was limited to the first few weeks after illness onset. (Funded by the Centers for Disease Control and Prevention.).

  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. OBJECTIVES: To examine associations between four health behaviors (smoking, physical inactivity, heavy alcohol drinking, and obesity) and three health indices (health-related quality of life, life expectancy, and quality-adjusted life expectancy (QALE)) among US adults with depression. METHODS: Data were obtained from the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System data. The EuroQol five-dimensional questionnaire (EQ-5D) health preference scores were estimated on the basis of extrapolations from the Centers for Disease Control and Prevention’s healthy days measures. Depression scores were estimated using the eight-item Patient Health Questionnaire. Life expectancy estimates were obtained from US life tables, and QALE was estimated from a weighted combination of the EQ-5D scores and the life expectancy estimates. Outcomes were summarized by depression status for the four health behaviors (smoking, physical inactivity, heavy alcohol drinking, and obesity). RESULTS: For depressed adults, current smokers and the physically inactive had significantly lower EQ-5D scores (0.040 and 0.171, respectively), shorter life expectancy (12.9 and 10.8 years, respectively), and substantially less QALE (8.6 and 10.9 years, respectively). For nondepressed adults, estimated effects were similar but smaller. Heavy alcohol drinking among depressed adults, paradoxically, was associated with higher EQ-5D scores but shorter life expectancy. Obesity was strongly associated with lower EQ-5D scores but only weakly associated with shorter life expectancy. CONCLUSIONS: Among depressed adults, physical inactivity and smoking were strongly associated with lower EQ-5D scores, life expectancy, and QALE, whereas obesity and heavy drinking were only weakly associated with these indices. These results suggest that reducing physical inactivity and smoking would improve health more among depressed adults.

      2. PURPOSE: Current literature shows different findings on the contemporary trends of distant-stage prostate cancer incidence, in part, due to low study population coverage and wide age groupings. This study aimed to examine the stage-specific incidence rates and trends of prostate cancer by age (5-year grouping), race, and ethnicity using nationwide cancer registry data. METHODS: Data on prostate cancer cases came from the 2004-2014 United States Cancer Statistics data set. We calculated stage-specific incidence and 95% confidence intervals by age (5-year age grouping), race, and ethnicity. To measure the changes in rates over time, we calculated annual percentage change (APC). RESULTS: We identified 2,137,054 incident prostate cancers diagnosed during 2004-2014, with an age-adjusted incidence rate of 453.8 per 100,000. Distant-stage prostate cancer incidence significantly decreased during 2004-2010 (APC = -1.2) and increased during 2010-2014 (APC = 3.3). Significant increases in distant prostate cancer incidence also occurred in men aged older than or equal to 50 years except men aged 65-74 and older than or equal to 85 years, in men with white race (APC = 3.9), and non-Hispanic ethnicity (APC = 3.5). CONCLUSIONS: Using data representing over 99% of U.S. population, we found that incidence rates of distant-stage prostate cancer significantly increased during 2010-2014 among men in certain ages, in white, and with non-Hispanic ethnicity.

      3. Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth studyExternal
        Reynolds K, Saydah SH, Isom S, Divers J, Lawrence JM, Dabelea D, Mayer-Davis EJ, Imperatore G, Bell RA, Hamman RF.
        J Diabetes Complications. 2018 Apr 4.

        AIMS: To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20years from the SEARCH for Diabetes in Youth study. METHODS: We included 8358 individuals newly-diagnosed with type 1 (n=6840) or type 2 (n=1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study. RESULTS: During 44,893person-years (PY) of observation (median follow-up=5.3years), 41 individuals died (91.3 deaths/100,000PY); 26 with type 1 (70.6 deaths/100,000PY) and 15 with type 2 (185.6 deaths/100,000PY) diabetes. The expected mortality rate was 70.9 deaths/100,000PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4). CONCLUSIONS: Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

    • Communicable Diseases

      1. Swipe right: Dating website and app use among men who have sex with menExternal
        Badal HJ, Stryker JE, DeLuca N, Purcell DW.
        AIDS Behav. 2018 Apr;22(4):1265-1272.

        This study explored the frequency of dating website and app usage among MSM to understand sub-group differences in use. Web-based survey data (N = 3105) were analyzed to assess the use of dating websites and apps. More than half (55.7%) of MSM in this sample were frequent users of dating websites and apps. Two-thirds (66.7%) of frequent users had casual partners only in the past 12 months and reported a high average number of casual sexual partners in the past 12 months (Mdn = 5.0) compared to never users (Mdn = 0.0; chi (2)(2) = 734.94, adj. p < .001). The most frequently used dating website or app was Grindr, with 60.2% of the sample reporting some or frequent use. Adam4Adam (23.5%), Jack’d (18.9%) and Scruff (18.7%) were also frequently used. Dating websites and apps may be effective channels to reach a diverse group of MSM with HIV prevention messages.

      2. Three rotavirus outbreaks in the postvaccine era – California, 2017External
        Burke RM, Tate JE, Barin N, Bock C, Bowen MD, Chang D, Gautam R, Han G, Holguin J, Huynh T, Pan CY, Quenelle R, Sallenave C, Torres C, Wadford D, Parashar U.
        MMWR Morb Mortal Wkly Rep. 2018 Apr 27;67(16):470-472.

        Before the introduction of rotavirus vaccine in 2006, rotavirus was the most common cause of severe diarrhea among U.S. children (1). Currently, two rotavirus vaccines are licensed for use in the United States, both of which have demonstrated good field effectiveness (78%-89%) against moderate to severe rotavirus illness (2), and the use of these vaccines has substantially reduced the prevalence of rotavirus in the United States (3). However, the most recent national vaccine coverage estimates indicate lower full rotavirus vaccine-series completion (73%) compared with receipt of at least 3 doses of vaccines containing diphtheria, tetanus, and pertussis antigens (95%), given on a similar schedule to rotavirus vaccines (4). In the postvaccine era in the United States, rotavirus activity persists in a biennial pattern (3). This report describes three rotavirus outbreaks that occurred in California in 2017. One death was reported; however, the majority of cases were associated with mild to moderate illness, and illness occurred across the age spectrum as well as among vaccinated children. Rotavirus vaccines are designed to mimic the protective effects of natural infection and are most effective against severe rotavirus illness (2). Even in populations with high vaccination coverage, some rotavirus infections and mild to moderate illnesses will occur. Rotavirus vaccination should continue to be emphasized as the best means of reducing disease prevalence in the United States.

      3. Prevalence of rectal chlamydial and gonococcal infections: A systematic reviewExternal
        Dewart CM, Bernstein KT, DeGroote NP, Romaguera R, Turner AN.
        Sex Transm Dis. 2018 May;45(5):287-293.

        We undertook a systematic review to examine rectal Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng) infections in women and men who have sex with men (MSM). English-language publications measuring rectal Ct or Ng prevalence using nucleic acid amplification tests were eligible. Searching multiple electronic databases, we identified 115 eligible reports published between January 2000 and November 2016. Overall, the prevalence of rectal Ct (9%) was higher than that of rectal Ng (4.7%). Rectal Ct prevalence was similar in MSM (9%) and women (9.2%), whereas rectal Ng prevalence was higher in MSM (6.1%) than in women (1.7%). Generally, rectal Ct prevalence was similar in sexually transmitted disease clinics (9.1%) and nonsexual health clinics (8.6%), whereas rectal Ng prevalence was somewhat lower in sexually transmitted disease clinics (4.5%) than in nonsexual health clinics (6%). These infections seem to be relatively common across a range of populations and clinical settings, highlighting the need for additional research on these preventable, treatable conditions.

      4. The influence of religion and spirituality (R/S) on HIV prevention has been understudied, especially for Black and/or Latino men who have sex with men (BLMSM), who bear a disproportionate burden of HIV, and who are part of racial/ethnic communities with high engagement in R/S. The specific aim of this study was to explore perspectives about R/S among BLMSM to inform HIV prevention strategies and reduce HIV-related health disparities. Data from 105 qualitative interviews with BLMSM were analyzed; 58 (55%) stated that R/S had no personal influence on HIV prevention. For those reporting any R/S influence, main themes were: (1) R/S positively influenced decision-making and self-respect, (2) perceived judgment and stigma by religious communities, (3) belief in a higher power, and (4) altruism. These findings can inform faith-based HIV prevention interventions for BLMSM.

      5. The changing landscape of HIV prevention in the United States: Health department experiences and local adaptations in response to the National HIV/AIDS Strategy and High-Impact Prevention ApproachExternal
        Fisher HH, Essuon A, Hoyte T, Shapatava E, Shelley G, Rios A, Beane S, Bourgeois S, Dunbar E, Sapiano T.
        J Public Health Manag Pract. 2018 May/Jun;24(3):225-234.

        OBJECTIVE: HIV prevention has changed substantially in recent years due to changes in national priorities, biomedical advances, and health care reform. Starting in 2010, motivated by the National HIV/AIDS Strategy (NHAS) and the Centers for Disease Control and Prevention’s (CDC’s) High-Impact Prevention (HIP), health departments realigned resources so that cost-effective, evidence-based interventions were targeted to groups at risk in areas most affected by HIV. This analysis describes how health departments in diverse settings were affected by NHAS and HIP. METHODS: We conducted interviews and a consultation with health departments from 16 jurisdictions and interviewed CDC project officers who monitored programs in 5 of the jurisdictions. Participants were asked to describe changes since NHAS and HIP and how they adapted. We used inductive qualitative analysis to identify themes of change. RESULTS: Health departments improved their HIV prevention practices in different ways. They aligned jurisdictional plans with NHAS and HIP goals, increased local data use to monitor program performance, streamlined services, and strengthened partnerships to increase service delivery to persons at highest risk for infection/transmission. They shifted efforts to focus more on the needs of people with diagnosed HIV infection, increased HIV testing and routine HIV screening in clinical settings, raised provider and community awareness about preexposure prophylaxis, and used nontraditional strategies to successfully engage out-of-care people with diagnosed HIV infection. However, staff-, provider-, and data-related barriers that could slow scale-up of priority programs were consistently reported by participants, potentially impeding the ability to meet national goals. CONCLUSION: Findings suggest progress toward NHAS and HIP goals has been made in some jurisdictions but highlight the need to monitor prevention programs in different contexts to identify areas for improvement and increase the likelihood of national success. Health departments and federal funders alike can benefit from the routine sharing of successes and challenges associated with local policy implementation, considering effects on the overall portfolio of programs.

      6. Chromobacterium violaceum is a rare, potentially serious pathogen. Most clinicians have no experience with its clinical appearance or treatment. We describe a case of a child presenting with necrotizing pneumonia caused by C. violaceum. We describe case complexities, including the need for a multidisciplinary approach to diagnosis and treatment.

      7. Impact of improved HIV care and treatment on PrEP effectivenesss in the United States, 2016-2020External
        Khurana N, Yaylali E, Farnham PG, Hicks KA, Allaire BT, Jacobson E, Sansom SL.
        J Acquir Immune Defic Syndr. 2018 Apr 20.

        BACKGROUND: The effect of improving diagnosis, care, and treatment of persons living with HIV (PLWH) on PrEP effectiveness in the United States has not be well established. METHODS: We used a dynamic, compartmental model that simulates the sexually active US population. We investigated the change in cumulative HIV incidence from 2016 to 2020 for three HIV care continuum levels, and the marginal benefit of PrEP compared with each. We also explored the marginal benefit of PrEP for individual risk groups, and as PrEP adherence, coverage and dropout rates varied. RESULTS: Delivering PrEP in 2016 to persons at high risk of acquiring HIV resulted in an 18.1% reduction in new HIV infections from 2016 to 2020 under current care continuum levels. Achieving HIV national goals of 90% of PLWH with diagnosed infection, 85% of newly diagnosed PLWH linked to care at diagnosis, and 80% of diagnosed PLWH virally suppressed reduced cumulative incidence by 34.4%. Delivery of PrEP in addition to this scenario resulted in a marginal benefit of 11.1% additional infections prevented. When national goals were reached, PrEP prevented an additional 15.2% cases among men who have sex with men (MSM), 3.9% among heterosexuals, and 3.8% among persons who inject drugs. CONCLUSIONS: The marginal benefit of PrEP was larger when current HIV care continuum percentages were maintained, but continued to be substantial even when national care goals were met. The high-risk MSM population was the chief beneficiary of PrEP.

      8. The prevalence of hepatitis C virus antibody in HIV-negative persons in Kenya, 2007External
        Ly KN, Kim AA, Drobenuic J, Kodani M, Montgomery JM, Fields BS, Teshale EH.
        Am J Trop Med Hyg. 2018 Apr 23.

        The prevalence of hepatitis C virus (HCV) infection in the Kenyan population has not been previously determined. We estimated the Kenyan HCV prevalence in HIV-negative persons aged 15-64 years. This is a retrospective cross-sectional study using data from the 2007 Kenya AIDS Indicator Survey-a nationally representative sample of 15,853 persons aged 15-64 years who completed a health interview and provided a blood specimen. Of the 1,091 randomly selected participants, 50 tested positive for HCV antibody using the automated chemiluminescence immunoassay, corresponding to a weighted HCV antibody positivity rate of 4.4% (95% confidence interval: 3.3-5.9%) or 848,000 (range: 634,000-1,100,000) persons. Hepatitis C virus RNA, a marker for current infection, was not detected in any of the tested antibody-positive specimens. The high HCV antibody prevalence together with no current infection suggests that some HCV antibody serologic testing in Kenya may result in false positives whereas others may be because of spontaneous viral clearance.

      9. Adverse fetal and infant outcomes among HIV-infected women who received either NNRTI- or PI-based ART for PMTCTExternal
        Masaba R, Borkowf CB, Girde S, Zeh C, Ndivo R, Nyang’au I, Achola K, Thomas TK, Lecher SL.
        Aids. 2018 Apr 19.

        BACKGROUND: For HIV-infected pregnant and breastfeeding women, antiretroviral therapy (ART) is known to reduce the mother’s risk of passing the infection to her child. However, concerns remain about possible associations between various components of different ART regimens and adverse fetal and infant outcomes. As part of a clinical trial in western Kenya for the prevention of mother-to-child transmission (PMTCT) of HIV, pregnant women received one of two different ART regimens. METHODS: The original PMTCT study conducted in Kenya enrolled 522 HIV-infected, ART-naive pregnant women. These women were assigned to receive an ART regimen that included either nevirapine, a nonnucleoside reverse transcriptase inhibitor (NNRTI), or nelfinavir, a protease inhibitor. This substudy involves 384 women from the original study who had baseline CD4 counts at least 250 cells/mul, and compares the risks of adverse fetal and infant outcomes between the two ART regimens. RESULTS: There were 386 live births (including multiples) and 7 (1.8%) stillbirths. Among live births, there were 67 preterm deliveries, 37 low-birth weight infants, and 14 infant deaths by 6 months. There were no statistically significant differences between the two ART regimens for any of the reported adverse outcomes. CONCLUSION: Although these data do not show significant differences between the NNRTI-based or protease inhibitor-based regimens in serious adverse fetal and infant outcomes, more studies need to be done and careful vigilance is needed to ensure infant safety.

      10. Pediatric tuberculosis consultations across 5 CDC regional tuberculosis training and medical consultation CentersExternal
        Mase A, Ryan S, Mader G, Alvarez A, Armitige L, Chen L, McSherry G, Wilson J, Mase S, Banerjee R.
        J Clin Tuberc Other Mycobact Dis. 2018 ;11:23-27.

        Background: The U.S. Centers for Disease Control and Prevention (CDC) funds five Regional Tuberculosis Training and Medical Consultation Centers (RTMCCs) that provide training and consultation for tuberculosis (TB) control and management. RTMCC utilization for assistance with diagnosis and management of TB in children has not been described. We analyzed pediatric TB consultations performed across all RTMCCs in terms of question type, provider type, and setting. Methods: The CDC medical consultation database was queried for consultations regarding patients </= 18 years provided between 1/1/13-4/22/15 by all RTMCCs (Curry International TB Center, Heartland National TB Center, Mayo Clinic Center for TB, New Jersey Medical School Global TB Institute, Southeastern National TB Center). Each query was categorized into multiple subject areas based on provider type, setting, consultation topic, and patient age. Results: The 5 RTMCCs received 1164 pediatric consultation requests, representing approximately 20% of all consultations performed by the centers during the study period. Providers requesting consults were primarily physicians (46.3%) or nurses (45.0%). The majority of pediatric consult requests were from state and local public health departments (679, 58.3%) followed by hospital providers (199, 17.1%); fewer requests came from clinicians in private practice (84, 7.2%) or academic institutions (40, 3.4%). Consults addressed 14 different topics, most commonly management of children with TB disease (19.1%), latent TB infection (LTBI) (18.2%), diagnosis or laboratory testing (18.7%), and pharmacology (9.2%). Discussion: Pediatric consultations accounted for approximately 20% of all consultations performed by RTMCCs during the study period. RTMCCs were utilized primarily by public health departments regarding management of TB disease, LTBI, and diagnosis or laboratory testing. The relative underutilization of the RTMCCs by clinicians in non-public health settings, who often manage children with TB exposure or infection, warrants further study. As US TB case rates decline and providers become less experienced with childhood TB, medical consultation support may become increasingly important.

      11. Non-disclosure to male partners and incomplete PMTCT regimens associated with higher risk of mother-to-child HIV transmission: a national survey in KenyaExternal
        McGrath CJ, Singa B, Langat A, Kinuthia J, Ronen K, Omolo D, Odongo BE, Wafula R, Muange P, Katana A, Ng’anga L, John-Stewart GC.
        AIDS Care. 2018 Jun;30(6):765-773.

        Health worker experience and community support may be higher in high HIV prevalence regions than low prevalence regions, leading to improved prevention of mother-to-child HIV transmission (PMTCT) programs. We evaluated 6-week and 9-month infant HIV transmission risk (TR) in a high prevalence region and nationally. Population-proportionate-to-size sampling was used to select 141 clinics in Kenya, and mobile teams surveyed mother-infant pairs attending 6-week and 9-month immunizations. HIV DNA testing was performed on HIV-exposed infants. Among 2521 mother-infant pairs surveyed nationally, 2423 (94.7%) reported HIV testing in pregnancy or prior diagnosis, of whom 200 (7.4%) were HIV-infected and 188 infants underwent HIV testing. TR was 8.8% (4.0%-18.3%) in 6-week and 8.9% (3.2%-22.2%) in 9-month cohorts including mothers with HIV diagnosed postpartum, of which 53% of infant infections were due to previously undiagnosed mothers. Of 276 HIV-exposed infants in the Nyanza survey, TR was 1.4% (0.4%-5.3%) at 6-week and 5.1% (2.5%-9.9%) at 9-months. Overall TR was lower in Nyanza, high HIV region, than nationally (3.3% vs. 7.2%, P = 0.02). HIV non-disclosure to male partners and incomplete ARVs were associated with TR in both surveys [aOR = 12.8 (3.0-54.3); aOR = 5.6 (1.2-27.4); aOR = 4.5 (1.0-20.0), aOR = 2.5, (0.8-8.4), respectively]. TR was lower in a high HIV prevalence region which had better ARV completion and partner HIV disclosure, possibly due to programmatic efficiencies or community/peer/partner support. Most 9-month infections were among infants of mothers without prior HIV diagnosis. Strategies to detect incident or undiagnosed maternal infections will be important to achieve PMTCT.

      12. Resilience is an understudied intrapersonal factor that may reduce HIV risk among men who have sex with men (MSM). Multivariable Poisson regression models were used to estimate the prevalence ratio (PR) of sexual risk behaviors, HIV prevalence, and history of sexually transmitted infections (STIs) with resilience scores in a population-based study among 364 black MSM in the Deep South. Participants with higher resilience scores had a lower prevalence of condomless anal sex with casual sexual partners in past 12 months (PR = 0.80, p value = 0.001) and during their last sexual encounter (PR = 0.81; p value = 0.009). Resilience was inversely associated with a lower prevalence of condomless anal sex with main sexual partners, participating in a sex party/orgy and having a STI in the past 12 months. Resilience may have a protective effect on HIV among black MSM, especially in the Deep South, and should be further explored in studies with prospective designs.

      13. Lessons from the domestic Ebola response: Improving health care system resilience to high consequence infectious diseasesExternal
        Meyer D, Kirk Sell T, Schoch-Spana M, Shearer MP, Chandler H, Thomas E, Rose DA, Carbone EG, Toner E.
        Am J Infect Control. 2018 May;46(5):533-537.

        BACKGROUND: The domestic response to the West Africa Ebola virus disease (EVD) epidemic from 2014-2016 provides a unique opportunity to distill lessons learned about health sector planning and operations from those individuals directly involved. This research project aimed to identify and integrate these lessons into an actionable checklist that can improve health sector resilience to future high-consequence infectious disease (HCID) events. METHODS: Interviews (N = 73) were completed with individuals involved in the domestic EVD response in 4 cities (Atlanta, Dallas, New York, and Omaha), and included individuals who worked in academia, emergency management, government, health care, law, media, and public health during the response. Interviews were transcribed and analyzed qualitatively. Two focus groups were then conducted to expand on themes identified in the interviews. Using these themes, an evidence-informed checklist was developed and vetted for completeness and feasibility by an expert advisory group. RESULTS: Salient themes identified included health care facility issues-specifically identifying assessment and treatment hospitals, isolation and treatment unit layout, waste management, community relations, patient identification, patient isolation, limitations on treatment, laboratories, and research considerations-and health care workforce issues-specifically psychosocial impact, unit staffing, staff training, and proper personal protective equipment. CONCLUSIONS: The experiences of those involved in the domestic Ebola response provide critical lessons that can help strengthen resilience of health care systems and improve future responses to HCID events.

      14. Many studies of persons who exchange sex for money or drugs have focused on their HIV acquisition risk, and are often limited to select populations and/or geographical locations. National estimates of exchange sex among people living with HIV (PLWH) who are in medical care, and its correlates, are lacking. To address these gaps, we analyzed data from the Medical Monitoring Project, a surveillance system that produces nationally representative estimates of behavioral and clinical characteristics of PLWH receiving medical care in the United States, to estimate the weighted prevalence of exchange sex overall, and by selected socio-demographic, behavioral and clinical characteristics. We found 3.6% of sexually active adults reported exchange sex in the past 12 months. We found a higher prevalence of exchange sex among transgender persons, those who experienced homelessness, and those with unmet needs for social and medical services. Persons who exchanged sex were more likely to report depression and substance use than those who did not exchange sex. We found a higher prevalence of sexual behaviors that increase the risk of HIV transmission and lower viral suppression among persons who exchanged sex. PLWH who exchanged sex had a higher prevalence of not being prescribed ART, and not being ART adherent than those who did not exchange sex. We identify several areas for intervention, including: provision of or referral to services for unmet needs (such as housing or shelter), enhanced delivery of mental health and substance abuse screening and treatment, risk-reduction counseling, and ART prescription and adherence support services.

      15. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae infection among asymptomatic men who have sex with men in Bangkok, ThailandExternal
        Pattanasin S, Dunne EF, Wasinrapee P, Tongtoyai J, Chonwattana W, Sriporn A, Luechai P, Mock PA, Chitwarakorn A, Holtz TH, Curlin ME.
        Int J STD AIDS. 2018 May;29(6):577-587.

        We report positivity rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection at each anatomic site among asymptomatic men who have sex with men (MSM). We calculated the number needed to screen (NNS) to detect CT and NG infection at each anatomic site. From 2006 to 2010, we enrolled Thai MSM, age >/= 18 years into the Bangkok MSM Cohort Study. Participants underwent physical examination and had rectal, urethral, and pharyngeal screening for CT and NG infection using nucleic acid amplification tests (NAATs). Of 1744 enrollees, 1696 (97.2%) had no symptoms of CT and NG infection. The positivity rates of CT and NG infection at any site were 14.3% (rectum, urethra, pharynx) and 6.4% (rectum, urethra), respectively. The NNS to detect rectal CT and rectal NG infections was 10 and 16, respectively (p < 0.05). For urethral infection, the NNS of CT was lower than the NNS of NG (22, 121: p < 0.05). The lowest NNS found for rectal CT infection was in HIV-infected MSM (6, 5-8). Asymptomatic CT and NG infection were common among MSM in Bangkok, Thailand and frequently detected in the rectum. In setting where screening in all specimens using NAAT is not feasible, rectal screening should be a priority.

      16. Many health care facilities (HCFs) and households in low-and-middle-income countries have inadequate access to water for hygiene and consumption. To address these problems, handwashing and drinking water stations were installed in 53 HCFs with prevention-of-mother-to-child-transmission of HIV programs in Kenya in 2005, and hygiene education was provided to health workers and clinic clients. To assess this program, we selected a random sample of 30 HCFs, observed the percentage of handwashing and drinking water stations that were functional and in use, and after that interviewed health providers and clients about hygiene and water treatment. Results indicated that, six years after implementation, 80.0% of HCFs had at least one functional handwashing station and 83.3% had at least one functional drinking water station. In addition, 60% of HCFs had soap at >/= one handwashing stations, and 23.3% had >/= one container with detectable free chlorine. Of 299 clients (mothers with >/= one child under five), 57.2% demonstrated proper water treatment knowledge, 93.3% reported ever using water treatment products, 16.4% had detectable chlorine residual in stored water, and 89.0% demonstrated proper handwashing technique. Six years after program implementation, although most HCFs had water stations and most clients could demonstrate proper handwashing technique, water stored in most clinics and homes was not treated.

      17. Estimation of community-level influenza-associated illness in a low resource rural setting in IndiaExternal
        Saha S, Gupta V, Dawood FS, Broor S, Lafond KE, Chadha MS, Rai SK, Krishnan A.
        PLoS One. 2018 ;13(4):e0196495.

        OBJECTIVE: To estimate rates of community-level influenza-like-illness (ILI) and influenza-associated ILI in rural north India. METHODS: During 2011, we conducted household-based healthcare utilization surveys (HUS) for any acute medical illness (AMI) in preceding 14days among residents of 28villages of Ballabgarh, in north India. Concurrently, we conducted clinic-based surveillance (CBS) in the area for AMI episodes with illness onset </=3days and collected nasal and throat swabs for influenza virus testing using real-time polymerase chain reaction. Retrospectively, we applied ILI case definition (measured/reported fever and cough) to HUS and CBS data. We attributed 14days of risk-time per person surveyed in HUS and estimated community ILI rate by dividing the number of ILI cases in HUS by total risk-time. We used CBS data on influenza positivity and applied it to HUS-based community ILI rates by age, month, and clinic type, to estimate the community influenza-associated ILI rates. FINDINGS: The HUS of 69,369 residents during the year generated risk-time of 3945 person-years (p-y) and identified 150 (5%, 95%CI: 4-6) ILI episodes (38 ILI episodes/1,000 p-y; 95% CI 32-44). Among 1,372 ILI cases enrolled from clinics, 126 (9%; 95% CI 8-11) had laboratory-confirmed influenza (A (H3N2) = 72; B = 54). After adjusting for age, month, and clinic type, overall influenza-associated ILI rate was 4.8/1,000 p-y; rates were highest among children <5 years (13; 95% CI: 4-29) and persons>/=60 years (11; 95%CI: 2-30). CONCLUSION: We present a novel way to use HUS and CBS data to generate estimates of community burden of influenza. Although the confidence intervals overlapped considerably, higher point estimates for burden among young children and older adults shows the utility for exploring the value of influenza vaccination among target groups.

      18. Adherence to CDC Recommendations for the Treatment of Uncomplicated Gonorrhea – STD Surveillance Network, United States, 2016External
        Weston EJ, Workowski K, Torrone E, Weinstock H, Stenger MR.
        MMWR Morb Mortal Wkly Rep. 2018 Apr 27;67(16):473-476.

        Gonorrhea, the sexually transmitted disease (STD) caused by Neisseria gonorrhoeae, is the second most common notifiable disease in the United States after chlamydia; 468,514 cases were reported to state and local health departments in 2016, an increase of 18.5% from 2015 (1). N. gonorrhoeae has progressively developed resistance to most antimicrobials used to treat the infection (2). As a result, CDC recommends two antimicrobials (250 mg of ceftriaxone [IM] plus 1 g of azithromycin [PO]) for treating uncomplicated gonorrhea to improve treatment efficacy and, potentially, to slow the emergence and spread of antimicrobial resistance. To monitor adherence to the current CDC-recommended regimen for uncomplicated gonorrhea, CDC reviewed enhanced data collected on a random sample of reported cases of gonorrhea in seven jurisdictions participating in the STD Surveillance Network (SSuN) and estimated the proportion of patients who received the CDC-recommended regimen for uncomplicated gonorrhea, by patient characteristics and diagnosing facility type. In 2016, the majority of reported patients with gonorrhea (81%) received the recommended regimen. There were no differences in the proportion of patients receiving the recommended regimen by age or race/ethnicity; however, patients diagnosed with gonorrhea in STD (91%) or family planning/reproductive health (94%) clinics were more likely to receive this regimen than were patients diagnosed in other provider settings (80%). These data document high provider adherence to CDC gonorrhea treatment recommendations in specialty STD clinics, indicating high quality of care provided in those settings. Local and state health departments should monitor adherence with recommendations in their jurisdictions and consider implementing interventions to improve provider and patient compliance with gonorrhea treatment recommendations where indicated.

    • Disaster Control and Emergency Services

      1. Research participation among state and local public health emergency preparedness and response programsExternal
        Yusuf H, Ekperi L, Groseclose S, Siegfried A, Meit M, Carbone E.
        Public Health. 2018 Apr 16.

        OBJECTIVES: The objective of our study was to assess whether state and local health staff participated in public health emergency preparedness research activities and what partner organizations they collaborated with on research. STUDY DESIGN: This is a cross-sectional study. METHODS: Data were derived from a 2014 web-based survey of state, territorial, and local health departments conducted by the Centers for Disease Control and Prevention and NORC at the University of Chicago as part of a larger project to assess the public health emergency preparedness and response research priorities of state and local health departments. RESULTS: Overall, 30% of survey respondents indicated that health department staff were involved in public health preparedness and response research-related activities. Thirty-four percent indicated that they were extremely or moderately familiar with emergency preparedness research and literature. Approximately 67% of respondents reported interest in receiving additional information and/or training related to the preparedness research and literature. The most frequently reported partners for collaboration in preparedness research-related activities were schools of public health (34%). CONCLUSIONS: Our findings suggest that there is health department interest in learning more about preparedness and response science and that additional efforts are needed to increase health department participation in public health emergency preparedness and response research-related activities.

    • Disease Reservoirs and Vectors

      1. A bead-based flow cytometric assay for monitoring Yersinia pestis exposure in wildlifeExternal
        Chandler JC, Baeten LA, Griffin DL, Gidlewski T, DeLiberto TJ, Petersen JM, Pappert R, Young JW, Bevins SN.
        J Clin Microbiol. 2018 Apr 25.

        Yersinia pestis is the causative agent of plague, and is considered a category A priority pathogen due to its potential for high transmissibility and the significant morbidity and mortality it causes in humans. Y. pestis is endemic to the Western United States and much of the world, necessitating programs to monitor for this pathogen on the landscape. Elevated human risk of plague infection has been spatially correlated with spikes in seropositive wildlife numbers, particularly rodent-eating carnivores which are frequently in contact with the enzootic hosts and the associated arthropod vectors of Y. pestis In this study, we describe a semi-automated bead-based flow cytometric assay developed for plague monitoring in wildlife called the F1-Luminex Plague Assay (F1-LPA). Based upon Luminex/Bio-Plex technology, the F1-LPA targets serological responses to the F1 capsular antigen of Y. pestis and was optimized to analyze antibodies eluted from wildlife blood samples preserved on Nobuto filter paper strips. In comparative evaluations using wildlife samples with passive hemagglutination, the gold standard tool for wildlife plague serodiagnosis, the F1-LPA demonstrated as much as 64x improvement in analytical sensitivity to F1-specific IgG detection, and allowed for unambiguous classification of IgG status. The functionality of the F1-LPA was demonstrated for coyotes and other canids, which are the primary sentinels in wildlife plague monitoring, as well as felids and raccoons. Additionally, assay formats that do not require species-specific immunological reagents, which are not routinely available for several wildlife species used in plague monitoring, were determined to be functional in the F1-LPA.

      2. Modeling climate suitability of the western blacklegged tick in CaliforniaExternal
        Eisen RJ, Feirer S, Padgett KA, Hahn MB, Monaghan AJ, Kramer VL, Lane RS, Kelly M.
        J Med Entomol. 2018 Apr 25.

        Ixodes pacificus Cooley & Kohls (Acari: Ixodidae), the primary vector of Lyme disease spirochetes to humans in the far-western United States, is broadly distributed across Pacific Coast states, but its distribution is not uniform within this large, ecologically diverse region. To identify areas of suitable habitat, we assembled records of locations throughout California where two or more I. pacificus were collected from vegetation from 1980 to 2014. We then employed ensemble species distribution modeling to identify suitable climatic conditions for the tick and restricted the results to land cover classes where these ticks are typically encountered (i.e., forest, grass, scrub-shrub, riparian). Cold-season temperature and rainfall are particularly important abiotic drivers of suitability, explaining between 50 and 99% of the spatial variability across California among models. The likelihood of an area being classified as suitable increases steadily with increasing temperatures >0 degrees C during the coldest quarter of the year, and further increases when precipitation amounts range from 400 to 800 mm during the coldest quarter, indicating that areas in California with relatively warm and wet winters typically are most suitable for I. pacificus. Other consistent predictors of suitability include increasing autumn humidity, temperatures in the warmest month between 23 and 33 degrees C, and low-temperature variability throughout the year. The resultant climatic suitability maps indicate that coastal California, especially the northern coast, and the western Sierra Nevada foothills have the highest probability of I. pacificus presence.

      3. Genotypic characterization of Rickettsia bellii reveals distinct lineages in the United States and South AmericaCdc-pdfExternal
        Krawczak FS, Labruna MB, Hecht JA, Paddock CD, Karpathy SE.
        BioMed Research International. 2018 :1-8.

        The bacterium Rickettsia bellii belongs to a basal group of rickettsiae that diverged prior to the pathogenic spotted fever group and typhus group Rickettsia species. Despite a diverse representation of R. bellii across more than 25 species of hard and soft ticks in the American continent, phylogeographical relationships among strains of this basal group-Rickettsia species are unknown; the work described here explores these relationships. DNA was extracted from 30 R. bellii tick isolates: 15 from the United States, 14 from Brazil, and 1 from Argentina. A total of 2,269 aligned nucleotide sites of 3 protein coding genes (gltA, atpA, and coxA) and 2 intergenic regions (rpmE-tRNAfmet and RC1027-xthA2) were concatenated and subjected to phylogenetic analysis by Bayesian methods. Results showed a separation of almost all isolates between North and South Americas, suggesting that they have radiated within their respective continents. Phylogenetic positions of the 30 isolates could be a result of not only their geographical origin but also the tick hosts they have coevolved with. Whether R. bellii originated with ticks in North or South America remains obscure, as our analyses did not show evidence for greater genetic divergence of R. bellii in either continent.

      4. Enhanced surveillance for Rift Valley Fever in livestock during El Nino rains and threat of RVF outbreak, Kenya, 2015-2016External
        Oyas H, Holmstrom L, Kemunto NP, Muturi M, Mwatondo A, Osoro E, Bitek A, Bett B, Githinji JW, Thumbi SM, Widdowson MA, Munyua PM, Njenga MK.
        PLoS Negl Trop Dis. 2018 Apr;12(4):e0006353.

        BACKGROUND: In mid-2015, the United States’ Pandemic Prediction and Forecasting Science and Technical Working Group of the National Science and Technology Council, Food and Agriculture Organization Emergency Prevention Systems, and Kenya Meteorological Department issued an alert predicting a high possibility of El-Nino rainfall and Rift Valley Fever (RVF) epidemic in Eastern Africa. METHODOLOGY/PRINCIPAL FINDINGS: In response to the alert, the Kenya Directorate of Veterinary Services (KDVS) carried out an enhanced syndromic surveillance system between November 2015 and February 2016, targeting 22 RVF high-risk counties in the country as identified previously through risk mapping. The surveillance collected data on RVF-associated syndromes in cattle, sheep, goats, and camels from >1100 farmers through 66 surveillance officers. During the 14-week surveillance period, the KDVS received 10,958 reports from participating farmers and surveillance officers, of which 362 (3.3%) had at least one syndrome. The reported syndromes included 196 (54.1%) deaths in young livestock, 133 (36.7%) abortions, and 33 (9.1%) hemorrhagic diseases, with most occurring in November and December, the period of heaviest rainfall. Of the 69 herds that met the suspect RVF herd definition (abortion in flooded area), 24 (34.8%) were defined as probable (abortions, mortalities in the young ones, and/or hemorrhagic signs) but none were confirmed. CONCLUSION/SIGNIFICANCE: This surveillance activity served as an early warning system that could detect RVF disease in animals before spillover to humans. It was also an excellent pilot for designing and implementing syndromic surveillance in animals in the country, which is now being rolled out using a mobile phone-based data reporting technology as part of the global health security system.

    • Environmental Health

      1. Liver disease in a residential cohort with elevated polychlorinated biphenyl exposuresExternal
        Clair HB, Pinkston CM, Rai SN, Pavuk M, Dutton ND, Brock G, Prough RA, Falkner KC, McClain CJ, Cave MC.
        Toxicol Sci. 2018 Apr 19.

        Endocrine and metabolism disrupting chemicals (EDCs/MDCs) have been associated with environmental liver diseases including toxicant-associated steatohepatitis (TASH). TASH has previously been characterized by hepatocellular necrosis, disrupted intermediary metabolism, and liver inflammation. Polychlorinated biphenyls (PCBs) are environmental EDCs/MDCs associated with the genesis and progression of steatohepatitis in animal models and human liver injury in epidemiology studies. The cross-sectional Anniston Community Health Survey (ACHS) investigates ortho-substituted PCB exposures and health effects near a former PCB manufacturing complex. The rates of obesity, diabetes, and dyslipidemia were previously determined to be high in ACHS. In this study, 738 ACHS participants were categorized by liver disease status using the serum cytokeratin 18 biomarker. Associations between PCB exposures and mechanistic biomarkers of intermediary metabolism, inflammation, and hepatocyte death were determined. The liver disease prevalence was high (60.2%), and 80.7% of these individuals were categorized as having TASH. Sex and race/ethnicity differences were noted. TASH was associated with increased exposures to specific PCB congeners, insulin resistance, dyslipidemia, pro-inflammatory cytokines, and liver necrosis. These findings are consistent with PCB-related steatohepatitis. SigmaPCBs was inversely associated with insulin resistance/production, leptin, and hepatocyte apoptosis, while other adipocytokines were increased. This is possibly the largest environmental liver disease study applying mechanistic biomarkers ever performed and the most comprehensive analysis of PCBs and adipocytokines. It provides insight into the mechanisms of PCB-related endocrine and metabolic disruption in liver disease and diabetes. In the future, associations between additional exposures and liver disease biomarkers will be evaluated in the ACHS and follow-up ACHS-II studies.

      2. A nested case-control study of polychlorinated biphenyls, organochlorine pesticides, and thyroid cancer in the Janus Serum Bank cohortExternal
        Lerro CC, Jones RR, Langseth H, Grimsrud TK, Engel LS, Sjodin A, Choo-Wosoba H, Albert P, Ward MH.
        Environ Res. 2018 Apr 23;165:125-132.

        BACKGROUND: Polychlorinated biphenyls (PCBs) and organochlorine pesticides have been associated with altered thyroid hormone levels in humans, but their relationship with thyroid cancer is unknown. METHODS: We conducted a nested case-control study of thyroid cancer in the Norwegian Janus Serum Bank cohort using pre-diagnostic blood samples from 1972 to 1985. Incident thyroid cancer (n=108) was ascertained through 2008. Controls were matched 2:1 by age, date of blood draw, gender, and county. We used gas chromatography/mass spectrometry to quantify 36 PCB congeners and metabolites of pesticides DDT, chlordane, hexachlorocyclohexane, and hexachlorobenzene. PCBs and pesticide metabolites were evaluated individually and summed by degree of chlorination and parent compound, respectively. Odds ratios (OR) and 95% confidence intervals (CI) were computed using conditional logistic regression per specified increase in lipid-adjusted concentration. We additionally stratified analyses by birth cohort (1923-1932, 1933-1942, 1943-1957). RESULTS: Increasing concentration of DDT metabolites (ORper 1000ng/g = 0.80, 95%CI = 0.66-0.98) was inversely associated with thyroid cancer. Associations for PCBs were null or in inverse direction. We observed interactions for total PCBs, moderately-chlorinated PCBs, and chlordane metabolites with birth cohort (p</=0.04). Among participants born 1943-1957, total PCBs (ORper 100ng/g = 1.25, 95%CI = 1.00-1.56), moderately-chlorinated PCBs (ORper 100ng/g = 1.31, 95%CI = 1.01-1.70), and chlordane metabolites (ORper 10ng/g = 1.78, 95%CI = 1.09-2.93) were positively associated with thyroid cancer. For individuals born before 1943, associations were generally null or in the inverse direction. CONCLUSIONS: Emissions of PCBs and OC pesticides varied over time. Different risk patterns by birth cohort suggest the potential importance of timing of exposure in thyroid cancer risk. Further evaluation of these associations is warranted.

      3. BACKGROUND: Most US studies of mortality and air pollution have been conducted on largely non-Hispanic white study populations. However, many health and mortality outcomes differ by race and ethnicity, and non-Hispanic white persons experience lower air pollution exposure than those who are non-Hispanic black or Hispanic. This study examines whether associations between air pollution and heart disease mortality differ by race/ethnicity. METHODS: We used data from the 1997 to 2009 National Health Interview Survey linked to mortality records through December 2011 and annual estimates of fine particulate matter (PM2.5) by census tract. Proportional hazards models were used to estimate hazard ratios and 95% confidence intervals between PM2.5 (per 10 microg/m(3)) and heart disease mortality using the full sample and the sample adults, which have information on additional health variables. Interaction terms were used to examine differences in the PM2.5-mortality association by race/ethnicity. RESULTS: Overall, 65 936 of the full sample died during follow-up, and 22 152 died from heart disease. After adjustment for several factors, we found a significant positive association between PM2.5 and heart disease mortality (hazard ratio, 1.16; 95% confidence interval, 1.08-1.25). This association was similar in sample adults with adjustment for smoking and body mass index (hazard ratio, 1.18; 95% confidence interval, 1.06-1.31). Interaction terms for non-Hispanic black and Hispanic groups compared with the non-Hispanic white group were not statistically significant. CONCLUSIONS: Using a nationally representative sample, the association between PM2.5 and heart disease mortality was elevated and similar to previous estimates. Associations for non-Hispanic black and Hispanic adults were not statistically significantly different from those for non-Hispanic white adults.

      4. Prenatal exposure to polychlorinated biphenyls and fetal growth in British girlsExternal
        Patel JF, Hartman TJ, Sjodin A, Northstone K, Taylor EV.
        Environ Int. 2018 Apr 17;116:116-121.

        Polychlorinated biphenyls (PCBs) are synthetic chemicals that bioaccumulate in the food chain. PCBs were used primarily for industrial applications due to their insulating and fire retardant properties, but were banned in the 1970s in the United States and in the 1980s in the United Kingdom, as adverse health effects following exposure were identified. Previous studies of populations with high PCB exposure have reported inverse associations with birth weight and gestational length. Birth weight is a powerful predictor of infant survival, and low birth weight can predispose infants to chronic conditions in adult life such as diabetes and cardiovascular diseases. Using data from the Avon Longitudinal Study of Parents and Children, we investigated the association between prenatal exposure to PCBs and fetal growth in a sample of 448 mother-daughter dyads. Concentrations of three common PCB analytes, PCB-118, PCB-153 and PCB-187, were measured in maternal serum collected during pregnancy, and fetal growth was measured by birth weight and birth length. Multivariable linear regression was used to examine the associations between PCB analytes and measures of fetal growth, after adjusting for parity, maternal age, pre-pregnancy BMI, educational status, tobacco use and gestational age of infant at sample collection. Birth length, ponderal index and gestational age were not associated with any of the PCB analytes. Mothers’ educational status modified associations for PCB analytes with birthweight. We observed significant inverse associations with birth weight only among daughters of mothers with less education. Daughter’s birth weight was -138.4g lower (95% CI: -218.0, -58.9) for each 10ng/g lipid increase in maternal serum PCB-118. Similarly, every 10ng/g lipid increase in maternal serum PCB-153 was associated with a -41.9g (95% CI: -71.6, -12.2) lower birth weight. Every 10ng/g lipids increase in maternal serum PCB-187, was associated with a -170.4g (95% CI: -306.1, -34.7) lower birth weight, among girls with mothers in the lowest education group. Our findings suggest that prenatal exposure to PCBs is inversely associated with daughters’ birth weight and that mothers’ education, which is a possible marker for socioeconomic status, significantly modified the association between maternal PCB concentrations and birth weight in female newborns.

    • Epidemiology and Surveillance

      1. Evaluation of syndromic surveillance systems in 6 US state and local health departmentsExternal
        Thomas MJ, Yoon PW, Collins JM, Davidson AJ, Mac Kenzie WR.
        J Public Health Manag Pract. 2018 May/Jun;24(3):235-240.

        OBJECTIVE: Evaluating public health surveillance systems is critical to ensuring that conditions of public health importance are appropriately monitored. Our objectives were to qualitatively evaluate 6 state and local health departments that were early adopters of syndromic surveillance in order to (1) understand the characteristics and current uses, (2) identify the most and least useful syndromes to monitor, (3) gauge the utility for early warning and outbreak detection, and (4) assess how syndromic surveillance impacted their daily decision making. DESIGN: We adapted evaluation guidelines from the Centers for Disease Control and Prevention and gathered input from the Centers for Disease Control and Prevention subject matter experts in public health surveillance to develop a questionnaire. PARTICIPANTS: We interviewed staff members from a convenience sample of 6 local and state health departments with syndromic surveillance programs that had been in operation for more than 10 years. RESULTS: Three of the 6 interviewees provided an example of using syndromic surveillance to identify an outbreak (ie, cluster of foodborne illness in 1 jurisdiction) or detect a surge in cases for seasonal conditions (eg, influenza in 2 jurisdictions) prior to traditional, disease-specific systems. Although all interviewees noted that syndromic surveillance has not been routinely useful or efficient for early outbreak detection or case finding in their jurisdictions, all agreed that the information can be used to improve their understanding of dynamic disease control environments and conditions (eg, situational awareness) in their communities. CONCLUSION: In the jurisdictions studied, syndromic surveillance may be useful for monitoring the spread and intensity of large outbreaks of disease, especially influenza; enhancing public health awareness of mass gatherings and natural disasters; and assessing new, otherwise unmonitored conditions when real-time alternatives are unavailable. Future studies should explore opportunities to strengthen syndromic surveillance by including broader access to and enhanced analysis of text-related data from electronic health records. Health departments may accelerate the development and use of syndromic surveillance systems, including the improvement of the predictive value and strengthening the early outbreak detection capability of these systems. These efforts support getting the right information to the right people at the right time, which is the overarching goal of CDC’s Surveillance Strategy.

    • Genetics and Genomics

      1. A proposed approach to accelerate evidence generation for genomic-based technologies in the context of a learning health systemExternal
        Lu CY, Williams MS, Ginsburg GS, Toh S, Brown JS, Khoury MJ.
        Genet Med. 2018 Apr;20(4):390-396.

        Genomic technologies should demonstrate analytical and clinical validity and clinical utility prior to wider adoption in clinical practice. However, the question of clinical utility remains unanswered for many genomic technologies. In this paper, we propose three building blocks for rapid generation of evidence on clinical utility of promising genomic technologies that underpin clinical and policy decisions. We define promising genomic tests as those that have proven analytical and clinical validity. First, risk-sharing agreements could be implemented between payers and manufacturers to enable temporary coverage that would help incorporate promising technologies into routine clinical care. Second, existing data networks, such as the Sentinel Initiative and the National Patient-Centered Clinical Research Network (PCORnet) could be leveraged, augmented with genomic information to track the use of genomic technologies and monitor clinical outcomes in millions of people. Third, endorsement and engagement from key stakeholders will be needed to establish this collaborative model for rapid evidence generation; all stakeholders will benefit from better information regarding the clinical utility of these technologies. This collaborative model can create a multipurpose and reusable national resource that generates knowledge from data gathered as part of routine care to drive evidence-based clinical practice and health system changes.

    • Health Economics

      1. A comprehensive examination of own- and cross-price elasticities of tobacco and nicotine replacement products in the U.SExternal
        Huang J, Gwarnicki C, Xu X, Caraballo RS, Wada R, Chaloupka FJ.
        Prev Med. 2018 Apr 21.

        While much is known about the demand for cigarettes, research on the demand for non-cigarette tobacco products and the cross-price impacts among those products is limited. This study aims to comprehensively examine the own- and cross-price elasticities of demand for tobacco and nicotine replacement products (NRPs) in the U.S. We analyzed market-level quarterly data on sales and prices of 15 different types of tobacco products and NRPs from 2007 to 2014, compiled from retail store scanner data. Fixed effects models with controls were used to estimate their own-price elasticities and cross-price elasticities between cigarettes and the other 14 products. Our results show that, except for cigars, the demand for combustible tobacco products was generally elastic, with the estimated own-price elasticity >1 (10% increase in prices reduces sales by >10%). The own-price elasticities for smokeless tobacco products were smaller than those for combustible tobacco, although not always significant. The demand for electronic cigarettes and NRPs was found to be elastic. The cross-price elasticities with respect to cigarettes were positive for cigarillos, little cigars, loose tobacco, pipe tobacco, electronic cigarettes and NRPs, but only results for little cigars, loose tobacco, pipe tobacco, and dissolvable lozenges were consistently significant. Our findings suggest demand for tobacco products and NRPs was responsive to changes in their own prices. Substitutions or positive cross-price impacts between cigarettes and certain other products exist. It is important that tobacco control policies take into account both own- and cross-price impacts among tobacco products and NRTs.

      2. Costs of community-based interventions from the Community Transformation GrantsExternal
        Khavjou OA, Honeycutt AA, Yarnoff B, Bradley C, Soler R, Orenstein D.
        Prev Med. 2018 Apr 18;112:138-144.

        Limited data are available on the costs of evidence-based community-wide prevention programs. The objective of this study was to estimate the per-person costs of strategies that support policy, systems, and environmental changes implemented under the Community Transformation Grants (CTG) program. We collected cost data from 29 CTG awardees and estimated program costs as spending on labor; consultants; materials, travel, and services; overhead activities; partners; and the value of in-kind contributions. We estimated costs per person reached for 20 strategies. We assessed how per-person costs varied with the number of people reached. Data were collected in 2012-2015, and the analysis was conducted in 2015-2016. Two of the tobacco-free living strategies cost less than $1.20 per person and reached over 6 million people each. Four of the healthy eating strategies cost less than $1.00 per person, and one of them reached over 6.5 million people. One of the active living strategies cost $2.20 per person and reached over 7 million people. Three of the clinical and community preventive services strategies cost less than $2.30 per person, and one of them reached almost 2 million people. Across all 20 strategies combined, an increase of 10,000 people in the number of people reached was associated with a $0.22 reduction in the per-person cost. Results demonstrate that interventions, such as tobacco-free indoor policies, which have been shown to improve health outcomes have relatively low per-person costs and are able to reach a large number of people.

    • Healthcare Associated Infections

      1. Emerging multidrug-resistant Candida duobushaemulonii infections in Panama hospitals: importance of laboratory surveillance and accurate identificationExternal
        Ramos R, Caceres DH, Perez M, Garcia N, Castillo W, Santiago E, Borace J, Lockhart SR, Berkow EL, Hayer L, Espinosa-Bode A, Moreno J, Jackson BR, Moran J, Chiller T, de Villarreal G, Sosa N, Vallabhaneni S.
        J Clin Microbiol. 2018 Apr 25.

        Candida duobushaemulonii, a yeast closely related to Candida auris, is thought to rarely cause infections, and is often misidentified. In October 2016, the Panamanian Ministry of Health implemented laboratory surveillance for C. auris Suspected C. auris isolates were forwarded to the national reference laboratory for identification by Matrix Assisted Laser Desorption Ionization-Time of Flight mass spectrometry and antifungal susceptibility testing. During November 2016-May 2017, 17 of 36 (47%) isolates suspected to be C. auris were identified as C. duobushaemulonii. These 17 isolates were obtained from 14 patients at six hospitals. Ten patients, including three children, had bloodstream infections, MICs for fluconazole, voriconazole, and amphotericin B were elevated. No resistance to echinocandins was observed. C. duobushaemulonii causes more invasive infections than previously appreciated, and poses a substantial problem given it is resistant to multiple antifungals. Expanded laboratory surveillance is an important step in the detection and control of such emerging pathogens.

    • Immunity and Immunization

      1. Tolerability of trivalent inactivated influenza vaccine among pregnant women, 2015External
        Asavapiriyanont S, Kittikraisak W, Suntarattiwong P, Ditsungnoen D, Kaoiean S, Phadungkiatwatana P, Srisantiroj N, Chotpitayasunondh T, Dawood FS, Lindblade KA.
        BMC Pregnancy Childbirth. 2018 Apr 23;18(1):110.

        BACKGROUND: Thailand recommends influenza vaccination among pregnant women. We conducted a cohort study to determine if the prevalence of adverse events following immunization (AEFIs) with influenza vaccine among Thai pregnant women was similar to that often cited among healthy adults. METHODS: Women who were >/=17 gestational weeks and >/=18 years of age were recruited. Demographic and health history data were collected using structured questionnaires. Women were provided with symptom diary, ruler to measure local reaction(s), and thermometer to measure body temperature. AEFIs were defined as any new symptom/abnormality occurring within four weeks after vaccination. The diaries were abstracted for frequency, duration, and level of discomfort/inconvenience of the AEFIs. Serious adverse events (SAEs) and the likelihood of AEFIs being associated with vaccination were determined using standard definitions. RESULTS: Among 305 women enrolled between July-November 2015, median age was 29 years. Of these, 223 (73%) were in their third trimester, 271 (89%) had completed secondary school or higher, and 20 (7%) reported >/=1 pre-existing conditions. AEFIs were reported in 134 women (44%; 95% confidence interval [CI] 38-50%). Soreness at the injection site (74, 24%; CI 19-29%), general weakness (50, 16%; CI 12-21%), muscle ache (49, 16%; CI 12-21%), and headache (45, 15%; CI 1-19%) were most common. Of those with AEFIs, 120 (89%) reported symptom/abnormality occurred on day 0 or day 1 following vaccination. Ten women (7%) reported the AEFIs affected daily activities. The AEFIs generally spontaneously resolved within 24 h of onset. There were two vaccine-unrelated SAEs. Of 294 women with complete follow-up, 279 (95%) had term deliveries, 12 (4%) had preterm deliveries, and 3 (1%) had miscarriage or stillbirth. CONCLUSION: In our cohort, AEFIs with influenza vaccine occurred with similar frequency to those reported among healthy adults in other studies, and were generally mild and self-limited. No influenza vaccine-associated SAEs were identified.

      2. Receipt and effectiveness of influenza vaccination reminders for adults, 2011-2012 season, United StatesExternal
        Benedict KM, Santibanez TA, Kahn KE, Pabst LJ, Bridges CB, Kennedy ED.
        Influenza Other Respir Viruses. 2018 Apr 22.

        BACKGROUND: Reminders for influenza vaccination improve influenza vaccination coverage. The purpose of this study was to describe the receipt of reminders for influenza vaccination during the 2011-12 influenza season among U.S. adults. METHODS: We analyzed data from the March 2012 National Flu Survey (NFS), a random digit dial telephone survey of adults in the United States. Relative to July 1, 2011, respondents were asked if they received a reminder for influenza vaccination and the source and type of reminder they received. The association with reminder receipt and demographic variables, and the association between influenza vaccination coverage and receipt of reminders were also examined. RESULTS: Of adults interviewed, 17.2% reported receiving a reminder since July 1, 2011. More than half (65.2%) of the reminders were sent by doctor offices. Hispanics and non-Hispanic blacks were more likely than non-Hispanic whites to report receiving a reminder. Adults who reported having a usual health care provider, health insurance, or a high-risk condition were more likely to report receiving reminders than the respective reference group. Adults reporting receipt of reminders were 1.15 times more likely (adjusted prevalence ratio, 95% CI: 1.06-1.25) to report being vaccinated for influenza than adults reporting not receiving reminders. CONCLUSIONS: Differences exist in receipt of influenza vaccination reminders among adults. Reminders are important tools to improve adult influenza vaccination coverage. Greater use of reminders may lead to higher rates of adult influenza vaccination coverage and reductions in influenza-related morbidity. This article is protected by copyright. All rights reserved.

      3. CONTEXT: Before participating in a project funded by the Centers for Disease Control and Prevention, most state and local health departments (LHDs) were not seeking reimbursement or being fully reimbursed by insurance plans for the cost of immunization services (including vaccine costs and administration fees) they provided to insured patients. Centers for Disease Control and Prevention’s Billables Project was designed to enable state and LHDs to bill public and private insurance plans for immunization services provided to insured patients. OBJECTIVE: Identify and describe key barriers state and LHDs may encounter while planning and implementing a billing program, as well as possible solutions for overcoming those barriers. DESIGN: This study used reports from Billables Project participants to explore barriers they encountered when planning and implementing a billing program and steps taken to address those barriers. SETTING AND PARTICIPANTS: Thirty-eight state immunization programs. RESULTS: Based on project participants’ reports, barriers were noted in 7 categories: (1) funding and costs, (2) staff, (3) health department characteristics, (4) third-party payers and insurance plans, (5) software, (6) patient insurance status, and (7) other barriers. Possible solutions for overcoming those barriers included hiring or seeking external help, creating billing guides and training modules, streamlining workflows, and modifying existing software systems. CONCLUSION: Overcoming barriers during planning and implementation of a billing program can be challenging for state and LHDs, but the experiences and suggestions of past Billables Project participants can help guide future billing program efforts.

      4. Knowledge and attitudes regarding category B ACIP recommendations among primary care providers for childrenExternal
        Kempe A, Allison MA, MacNeil JR, O’Leary ST, Crane LA, Beaty BL, Hurley LP, Brtnikova M, Lindley MC, Liang JL, Albert AP, Smith JC.
        Acad Pediatr. 2018 Apr 17.

        OBJECTIVE: In 2015, the Advisory Committee on Immunization Practices (ACIP) made a category B recommendation for use of serogroup B meningococcal (MenB) vaccines, meaning individual clinical decision-making should guide recommendations. This was the first use of a category B recommendation pertaining to a large population and the first such recommendation for adolescents. As part of a survey regarding MenB vaccine, our objectives were to assess among pediatricians (Peds) and family physicians (FPs) nationally: 1) knowledge of the meaning of category A versus B recommendations and insurance coverage implications; and 2) attitudes about category A and B recommendations. DESIGN/METHODS: We surveyed a nationally representative sample of Peds and FPs by e-mail and mail from 10-12/2016. RESULTS: The response rate was 72% (660/916). Although >80% correctly identified the definition of a category A recommendation, only 24% were correct about the definition for category B. Fifty-five percent didn’t know that private insurance would pay for vaccines recommended as category B, and 51% didn’t know that category B-recommended vaccines would be covered by the Vaccines for Children program. Fifty-nine percent found it difficult to explain category B recommendations to patients; 22% thought ACIP should not make category B recommendations; and 39% were in favor of category B recommendations because they provide leeway in decision-making. CONCLUSIONS: For category B recommendations to be useful in guiding practice, primary care clinicians will need to have a better understanding of their meaning, their implications for insurance payment and guidance on how to discuss them with parents and patients.

      5. Prevalence and incidence of anal and cervical high-risk human papillomavirus (HPV) types covered by current HPV vaccines among HIV-infected women in the SUN StudyExternal
        Kojic EM, Conley L, Bush T, Cu-Uvin S, Unger ER, Henry K, Hammer J, Escota G, Darragh TM, Palefsky JM, Brooks JT, Patel P.
        J Infect Dis. 2018 Apr 23;217(10):1544-1552.

        Background: Nonavalent (9v) human papilloma virus vaccine targets high-risk human papillomavirus (HR-HPV) types 16, 18, 31, 33, 45, 52, 58, and low-risk 6, 11. We examined prevalence, incidence, and clearance of anal and cervical HR-HPV in HIV-infected women. Methods: The SUN Study enrolled 167 US women in 2004-2006. Anal and cervical specimens were collected annually for cytology and identification of 37 HPV types: 14 HR included: 9v 16, 18, 31, 33, 45, 52, 58; non-9v 35, 39, 51, 56, 59, 66, 68. Results: Baseline characteristics of 126 women included: median age 38 years; 57% non-Hispanic black; 67% HIV RNA < 400 copies/mL; 90% CD4 counts >/=200 cells/mm3. HPV prevalence at anus and cervix was 90% and 83%; for 9v HR-HPV types, 67% and 51%; non-9v HR-HPV, 54% and 29%, respectively. The 9v and non-9v HR-HPV incidence rates/100 person-years were similar (10.4 vs 9.5; 8.5 vs 8.3, respectively); 9v clearance rates were 42% and 61%; non-9v 46% and 59%, in anus and cervix, respectively. Conclusions: Anal HR-HPV prevalence was higher than cervical, with lower clearance; incidence was similar. Although prevalence of non-9v HR-HPV was substantial, 9v HR-HPV types were generally more prevalent. These findings support use of nonavalent vaccine in HIV-infected women.

      6. INTRODUCTION: Hepatitis A can cause widespread outbreaks. Until 2018, postexposure prophylaxis (PEP) in the United States for individuals >40years consisted of immune globulin (IG) administered as soon as possible after exposure, ideally within 14days whereas those aged </=40 should receive hepatitis A (HepA) vaccine. However, state health departments reporting difficulty quickly accessing and administering IG, costs of higher IG doses and importance of long-term HAV protection prompted CDC to review immunogenicity data for use of HepA vaccine for PEP in older adults. We reviewed literature on use of HepA vaccine in adults >40years and existing recommendations for HepA vaccine for use as PEP in other countries. METHODS: We searched PubMed and EMBASE from January 1, 1992-January 7, 2017 using the terms “hepatitis A vaccine *” and “HAV vaccine *.” Two reviewers read each abstract and articles were preserved if they included results (seroprotection, mean titers) within 28days of HepA vaccine administration in adults >40years. Additionally, we reviewed PEP recommendations from six other jurisdictions. RESULTS: A total of 1,039 unique articles were identified, of which eight were retained and two added from references. Three studies included direct comparisons between individuals aged >40years and those </=40years and one other study included three age groups over 40years, finding lowest immunogenicity in the oldest adults. All found higher proportions seroprotected (definition varied by study) in younger age groups (ages varied by study) at 15days post-vaccination but similar seroprotection at 30days. Most other jurisdictions reviewed recommended vaccine alone or in conjunction with IG for PEP in older adults. CONCLUSIONS: Immunogenicity of HepA vaccine may be diminished in older adults, especially in the very oldest age groups. HepA vaccine should be administered as soon as possible within 14days after exposure to achieve the best possible immune response.

    • Informatics

      1. Intelligent mortality reporting with FHIRExternal
        Hoffman RA, Wu H, Venugopalan J, Braun P, Wang MD.
        IEEE J Biomed Health Inform. 2018 ;05.

        One pressing need in the area of public health is timely, accurate, and complete reporting of deaths and the diseases or conditions leading up to them. Fast Healthcare Interoperability Resources (FHIR) is a new HL7 interoperability standard for electronic health record (EHR), while Sustainable Medical Applications and Reusable Technologies (SMART)-on- FHIR enables third-party app development that can work “out of the box”. This research demonstrates the feasibility of developing SMART-on-FHIR applications to enable medical professionals to perform timely and accurate death reporting within multiple different jurisdictions of US. We explored how the information on a standard certificate of death can be mapped to resources defined in the FHIR standard (DSTU2) and common profiles. We also demonstrated analytics for potentially improving the accuracy and completeness of mortality reporting data. Copyright OAPA

      2. Evaluating a mobile application for improving clinical laboratory test ordering and diagnosisExternal
        Meyer AN, Thompson PJ, Khanna A, Desai S, Mathews BK, Yousef E, Kusnoor AV, Singh H.
        J Am Med Inform Assoc. 2018 Apr 20.

        Objective: Mobile applications for improving diagnostic decision making often lack clinical evaluation. We evaluated if a mobile application improves generalist physicians’ appropriate laboratory test ordering and diagnosis decisions and assessed if physicians perceive it as useful for learning. Methods: In an experimental, vignette study, physicians diagnosed 8 patient vignettes with normal prothrombin times (PT) and abnormal partial thromboplastin times (PTT). Physicians made test ordering and diagnosis decisions for 4 vignettes using each resource: a mobile app, PTT Advisor, developed by the Centers for Disease Control and Prevention (CDC)’s Clinical Laboratory Integration into Healthcare Collaborative (CLIHC); and usual clinical decision support. Then, physicians answered questions regarding their perceptions of the app’s usefulness for diagnostic decision making and learning using a modified Kirkpatrick Training Evaluation Framework. Results: Data from 368 vignettes solved by 46 physicians at 7 US health care institutions show advantages for using PTT Advisor over usual clinical decision support on test ordering and diagnostic decision accuracy (82.6 vs 70.2% correct; P < .001), confidence in decisions (7.5 vs 6.3 out of 10; P < .001), and vignette completion time (3:02 vs 3:53 min.; P = .06). Physicians reported positive perceptions of the app’s potential for improved clinical decision making, and recommended it be used to address broader diagnostic challenges. Conclusions: A mobile app, PTT Advisor, may contribute to better test ordering and diagnosis, serve as a learning tool for diagnostic evaluation of certain clinical disorders, and improve patient outcomes. Similar methods could be useful for evaluating apps aimed at improving testing and diagnosis for other conditions.

    • Injury and Violence
      1. OBJECTIVE: Explore healthcare providers’ experiences managing mTBI and better understand their use of mTBI assessment tools and guidelines. Cross-sectional Methods: A random sample of 1,760 healthcare providers responded to the web-based DocStyles survey between June 18 and 30, 2014. The sample included family/general practitioners, internists, pediatricians, and nurse practitioners who reported seeing pediatric patients. We examined their experiences with mTBI to identify opportunities to increase preparedness and improve management of mTBI. RESULTS: Fifty-nine percent of healthcare providers reported that they diagnosed or managed pediatric patients with mTBI within the last 12 months. Of those, 44.4% felt ‘very prepared’ to make decisions about when pediatric patients can safety return to activities, such as school and sports after a mTBI. When asked how often they use screening or assessment tools to assess pediatric patients with mTBI, almost half reported that they ‘seldom’ or ‘never’ use those resources (24.6% and 22.0%, respectively). CONCLUSION: Most healthcare providers reported seeing pediatric patients with mTBI, yet most feel only somewhat prepared to manage this injury in their practise. Broader use of screening tools and guidelines, that include clinical decision support tools, may be useful for healthcare providers who care for pediatric patients with mTBI.

    • Laboratory Sciences
      1. RSV continues to be a high priority for vaccine and antiviral drug development. Unfortunately, no safe and effective RSV vaccine is available and treatment options are limited. Over the past decade, several studies have focused on the role of RSV G protein on viral entry, viral neutralization, and RSV-mediated pathology. Anti-G murine monoclonal antibody (mAb) 131-2G treatment has been previously shown to reduce weight loss, bronchoalveolar lavage (BAL) cell number, airway reactivity, and Th2-type cytokine production in RSV-infected mice more rapidly than a commercial humanized monoclonal antibody (mAb) against RSV F protein (Palivizumab). In this study, we have tested two human anti-RSV G mAbs, 2B11 and 3D3, by both prophylactic and therapeutic treatment for RSV in the BALB/c mouse model. Both anti-G mAbs reduced viral load, leukocyte infiltration and IFN-gamma and IL-4 expression in cell-free BAL supernatants emphasizing the potential of anti-G mAbs as anti-inflammatory and antiviral strategies.

      2. High-throughput, simultaneous quantitation of hemoglobin adducts of acrylamide, glycidamide, and ethylene oxide using UHPLC-MS/MSExternal
        Yang M, Frame T, Tse C, Vesper HW.
        J Chromatogr B Analyt Technol Biomed Life Sci. 2018 Apr 3;1086:197-205.

        Ethylene oxide (EO), acrylamide (AA) and glycidamide (GA) exposures are associated with mammary tumors in animals. Currently available information about human exposure to these chemicals is limited creating the need for analytical methods to assess their exposure. We developed a sensitive ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method to simultaneously quantitate hemoglobin (Hb) N-terminal valine adducts of AA (HbAA), GA (HbGA), and EO (HbEO) using modified Edman reaction. The limits of detection of this method were 3.9, 4.9 and 12.9 in pmol/g Hb for HbAA, HbGA and HbEO, respectively. The among-day and within-day precision for all analytes determined with three levels of quality control pools ranged from 2.2-13.0% in percent coefficient of variation (%CV). The accuracy determined by standard addition was between 94 and 111% among all analytes. The median HbAA, HbGA and HbEO values in 34 self-reported non-smokers were 64.9, 45.3 and 113.6pmol/g Hb and in 70 self-reported smokers were 127.8, 69.6 and 237.1pmol/g Hb, respectively. HbAA, HbGA, and HbEO were detectable in all samples suggesting that the described method is suitable for measuring hemoglobin adducts of AA, GA and EO in the general population. This high throughput method can process 148 samples in 8h. The HbEO/HbGA ratio appears independent of the HbAA levels in non-smokers and decreases with increasing HbAA concentration in smokers. This new method is suitable for measuring human exposure to AA, GA and EO and can provide further insight into the metabolism of these chemicals in humans.

    • Maternal and Child Health

      1. Relevance of abusive head trauma to intracranial hemorrhages and bleeding disordersExternal
        Anderst JD, Carpenter SL, Presley R, Berkoff MC, Wheeler AP, Sidonio RF, Soucie JM.
        Pediatrics. 2018 Apr 25.

        BACKGROUND: Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT. METHODS: We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder. RESULTS: Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT. CONCLUSIONS: In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a “mimic” of AHT.

      2. BACKGROUND: Counseling for appropriate medication use and folic acid consumption are elements of preconception care critical for improving pregnancy outcomes. Hispanic women receive less preconception care than women of other race/ethnic groups. The objective of this analysis is to describe differences in these two elements of preconception care among Hispanic subsegments. MATERIALS AND METHODS: Porter Novelli’s 2013 Estilos survey was sent to 2,609 U.S. Hispanic adults of the Offerwise QueOpinas Panel. Surveys were completed by 1,000 individuals (calculated response rate 42%), and results were weighted to the 2012 U.S. Census Hispanic proportions for sex, age, income, household size, education, region, country of origin, and acculturation. Responses were analyzed with weighted descriptive statistics, linear regression, and Rao-Scott chi-square tests. RESULTS: Of the 499 female respondents, 248 had a child under the age of 18 years and were asked about healthcare provider discussions concerning medication use before or during their last pregnancy. Timing of discussions varied by maternal age, marital status, income, youngest child’s country of birth, and acculturation. Discussions before pregnancy were reported by 47% of the female respondents; high acculturated women more often reported never having such discussions. Among female respondents, 320 were of reproductive age, and 27% of those reported daily multivitamin use. Multivitamin use varied by pregnancy intention and youngest child’s country of birth, but did not vary significantly by acculturation. CONCLUSIONS: Differences in discussions concerning medication use in pregnancy and multivitamin use exist among Hispanic subsegments based on pregnancy intention, marital status, income, youngest child’s country of birth, and level of acculturation.

      3. Trends and characteristics of fetal and neonatal mortality due to congenital anomalies, Colombia 1999-2008External
        Roncancio CP, Misnaza SP, Pena IC, Prieto FE, Cannon MJ, Valencia D.
        J Matern Fetal Neonatal Med. 2018 Jul;31(13):1748-1755.

        OBJECTIVE: To describe fetal and neonatal mortality due to congenital anomalies in Colombia. METHODS: We analyzed all fetal and neonatal deaths due to a congenital anomaly registered with the Colombian vital statistics system during 1999-2008. RESULTS: The registry included 213,293 fetal deaths and 7,216,727 live births. Of the live births, 77,738 (1.08%) resulted in neonatal deaths. Congenital anomalies were responsible for 7321 fetal deaths (3.4% of all fetal deaths) and 15,040 neonatal deaths (19.3% of all neonatal deaths). The fetal mortality rate due to congenital anomalies was 9.9 per 10,000 live births and fetal deaths; the neonatal mortality rate due to congenital anomalies was 20.8 per 10,000 live births. Mortality rates due to congenital anomalies remained relatively stable during the study period. The most frequent fatal congenital anomalies were congenital heart defects (32.0%), central nervous system anomalies (15.8%), and chromosomal anomalies (8.0%). Risk factors for fetal and neonatal death included: male or undetermined sex, living in villages or rural areas, mother’s age >35 years, low and very low birthweight, and <28 weeks gestation at birth. CONCLUSIONS: Congenital anomalies are an important cause of fetal and neonatal deaths in Colombia, but many of the anomalies may be preventable or treatable.

    • Occupational Safety and Health

      1. Carbon nanotube and nanofiber exposure and sputum and blood biomarkers of early effect among U.S. workersExternal
        Beard JD, Erdely A, Dahm MM, de Perio MA, Birch ME, Evans DE, Fernback JE, Eye T, Kodali V, Mercer RR, Bertke SJ, Schubauer-Berigan MK.
        Environ Int. 2018 Apr 23;116:214-228.

        BACKGROUND: Carbon nanotubes and nanofibers (CNT/F) are increasingly used for diverse applications. Although animal studies suggest CNT/F exposure may cause deleterious health effects, human epidemiological studies have typically been small, confined to single workplaces, and limited in exposure assessment. OBJECTIVES: We conducted an industrywide cross-sectional epidemiological study of 108 workers from 12 U.S. sites to evaluate associations between occupational CNT/F exposure and sputum and blood biomarkers of early effect. METHODS: We assessed CNT/F exposure via personal breathing zone, filter-based air sampling to measure background-corrected elemental carbon (EC) (a CNT/F marker) mass and microscopy-based CNT/F structure count concentrations. We measured 36 sputum and 37 blood biomarkers. We used factor analyses with varimax rotation to derive factors among sputum and blood biomarkers separately. We used linear, Tobit, and unconditional logistic regression models to adjust for potential confounders and evaluate associations between CNT/F exposure and individual biomarkers and derived factors. RESULTS: We derived three sputum and nine blood biomarker factors that explained 78% and 67%, respectively, of the variation. After adjusting for potential confounders, inhalable EC and total inhalable CNT/F structures were associated with the most sputum and blood biomarkers, respectively. Biomarkers associated with at least three CNT/F metrics were 72kDa type IV collagenase/matrix metalloproteinase-2 (MMP-2), interleukin-18, glutathione peroxidase (GPx), myeloperoxidase, and superoxide dismutase (SOD) in sputum and MMP-2, matrix metalloproteinase-9, metalloproteinase inhibitor 1/tissue inhibitor of metalloproteinases 1, 8-hydroxy-2′-deoxyguanosine, GPx, SOD, endothelin-1, fibrinogen, intercellular adhesion molecule 1, vascular cell adhesion protein 1, and von Willebrand factor in blood, although directions of associations were not always as expected. CONCLUSIONS: Inhalable rather than respirable CNT/F was more consistently associated with fibrosis, inflammation, oxidative stress, and cardiovascular biomarkers.

      2. Fatal falls overboard in commercial fishing – United States, 2000-2016External
        Case SL, Lincoln JM, Lucas DL.
        MMWR Morb Mortal Wkly Rep. 2018 Apr 27;67(16):465-469.

        Commercial fishing is one of the most dangerous jobs in the United States, with a 2016 work-related fatality rate (86.0 deaths per 100,000 full-time equivalent workers) 23 times higher than that for all U.S. workers (3.6) (1). Sinking vessels cause the most fatalities in the industry; however, falling from a fishing vessel is a serious hazard responsible for the second highest number of commercial fishing-associated fatalities (2,3). CDC’s National Institute for Occupational Safety and Health (NIOSH) analyzed data on unintentional fatal falls overboard in the U.S. commercial fishing industry to identify gaps in the use of primary, secondary, and tertiary prevention strategies. During 2000-2016, a total of 204 commercial fishermen died after unintentionally falling overboard. The majority of falls (121; 59.3%) were not witnessed, and 108 (89.3%) of these victims were not found. Among 83 witnessed falls overboard, 56 rescue attempts were made; 22 victims were recovered but were not successfully resuscitated. The circumstances, rescue attempts, and limited use of lifesaving and recovery equipment indicate that efforts to reduce these preventable fatalities are needed during pre-event, event, and post-event sequences of falls overboard. Vessel owners could consider strategies to prevent future fatalities, including lifeline tethers, line management, personal flotation devices (PFDs), man-overboard alarms, recovery devices, and rescue training.

      3. Training employers to implement health promotion programs: Results from the CDC Work@Health(R) ProgramExternal
        Cluff LA, Lang JE, Rineer JR, Jones-Jack NH, Strazza KM.
        Am J Health Promot. 2018 May;32(4):1062-1069.

        PURPOSE: Centers for Disease Control and Prevention (CDC) initiated the Work@Health Program to teach employers how to improve worker health using evidence-based strategies. Program goals included (1) determining the best way(s) to deliver employer training, (2) increasing employers’ knowledge of workplace health promotion (WHP), and (3) increasing the number of evidence-based WHP interventions at employers’ worksites. This study is one of the few to examine the effectiveness of a program designed to train employers how to implement WHP programs. DESIGN: Pre- and posttest design. SETTING: Training via 1 of 3 formats hands-on, online, or blended. PARTICIPANTS: Two hundred six individual participants from 173 employers of all sizes. INTERVENTION: Eight-module training curriculum to guide participants through building an evidence-based WHP program, followed by 6 to 10 months of technical assistance. MEASURES: The CDC Worksite Health ScoreCard and knowledge, attitudes, and behavior survey. ANALYSIS: Descriptive statistics, paired t tests, and mixed linear models. RESULTS: Participants’ posttraining mean knowledge scores were significantly greater than the pretraining scores (61.1 vs 53.2, P < .001). A year after training, employers had significantly increased the number of evidence-based interventions in place (47.7 vs 35.5, P < .001). Employers’ improvements did not significantly differ among the 3 training delivery formats. CONCLUSION: The Work@Health Program provided employers with knowledge to implement WHP interventions. The training and technical assistance provided structure, practical guidance, and tools to assess needs and select, implement, and evaluate interventions.

      4. Mental health in the workplace: A call to action proceedings from the Mental Health in the Workplace-Public Health SummitExternal
        Goetzel RZ, Roemer EC, Holingue C, Fallin MD, McCleary K, Eaton W, Agnew J, Azocar F, Ballard D, Bartlett J, Braga M, Conway H, Crighton KA, Frank R, Jinnett K, Keller-Greene D, Rauch SM, Safeer R, Saporito D, Schill A, Shern D, Strecher V, Wald P, Wang P, Mattingly CR.
        J Occup Environ Med. 2018 Apr;60(4):322-330.

        OBJECTIVE: The aim of the study was to declare a call to action to improve mental health in the workplace. METHODS: We convened a public health summit and assembled an Advisory Council consisting of experts in the field of occupational health and safety, workplace wellness, and public policy to offer recommendations for action steps to improve health and well-being of workers. RESULTS: The Advisory Council narrowed the list of ideas to four priority projects. CONCLUSIONS: The recommendations for action include developing a mental health in the workplace (1) “how to” guide, (2) scorecard, (3) recognition program, and (4) executive training.

      5. The relationships between hand coupling force and vibration biodynamic responses of the hand-arm systemExternal
        Pan D, Xu XS, Welcome DE, McDowell TW, Warren C, Wu J, Dong RG.
        Ergonomics. 2018 Jun;61(6):818-830.

        This study conducted two series of experiments to investigate the relationships between hand coupling force and biodynamic responses of the hand-arm system. In the first experiment, the vibration transmissibility on the system was measured as a continuous function of grip force while the hand was subjected to discrete sinusoidal excitations. In the second experiment, the biodynamic responses of the system subjected to a broadband random vibration were measured under five levels of grip forces and a combination of grip and push forces. This study found that the transmissibility at each given frequency increased with the increase in the grip force before reaching a maximum level. The transmissibility then tended to plateau or decrease when the grip force was further increased. This threshold force increased with an increase in the vibration frequency. These relationships remained the same for both types of vibrations. The implications of the experimental results are discussed. Practitioner Summary: Shocks and vibrations transmitted to the hand-arm system may cause injuries and disorders of the system. How to take hand coupling force into account in the risk assessment of vibration exposure remains an important issue for further studies. This study is designed and conducted to help resolve this issue.

      6. Melanoma, thyroid cancer, and gynecologic cancers in a cohort of female flight attendantsExternal
        Pinkerton LE, Hein MJ, Anderson JL, Christianson A, Little MP, Sigurdson AJ, Schubauer-Berigan MK.
        Am J Ind Med. 2018 Apr 24.

        BACKGROUND: Flight attendants may have an increased risk of some cancers from occupational exposure to cosmic radiation and circadian disruption. METHODS: The incidence of thyroid, ovarian, and uterine cancer among approximately 6000 female flight attendants compared to the US population was evaluated via life table analyses. Associations of these cancers, melanoma, and cervical cancer with cumulative cosmic radiation dose and metrics of circadian disruption were evaluated using Cox regression. RESULTS: Incidence of thyroid, ovarian, and uterine cancer was not elevated. No significant, positive exposure-response relations were observed. Weak, non-significant, positive relations were observed for thyroid cancer with cosmic radiation and time zones crossed and for melanoma with another metric of circadian disruption. CONCLUSIONS: We found little evidence of increased risk of these cancers from occupational cosmic radiation or circadian disruption in female flight attendants. Limitations include few observed cases of some cancers, limited data on risk factors, and misclassification of exposures.

      7. Social avoidance in policing: Associations with cardiovascular disease and the role of social supportExternal
        Violanti JM, Ma CC, Gu JK, Fekedulegn D, Mnatsakanova A, Andrew ME.
        Policing. 2018 .

        Purpose: The purpose of this paper is to examine the association of social avoidance among police, cardiovascular disease (CVD) (metabolic syndrome (MetSyn)), and social support. Design/methodology/approach: Participants were officers from the Buffalo Cardio-Metabolic Occupational Police Stress study (n=289). Social avoidance (defined as the tendency to avoid social contact) and other subscales from the Cook-Medley Hostility Scale were analyzed. The mean number of MetSyn components across tertiles of the Cook-Medley scales was computed using analysis of variance and analysis of covariance. Social support was measured with the Social Provisions Scale, categorized as high or low based on the median. Findings: The mean number of MetSyn components increased significantly across tertiles of social avoidance (1.51 +/- 0.18, 1.52 +/-0.12, and 1.81+/- 0.12); the only Cook-Medley subscale that remained significantly associated with MetSyn following adjustment for age and gender. Participants high in social avoidance reported significantly lower social support (79.9 +/- 8.5 vs 85.8 +/- 8.6; p=0.001). Research limitations/implications: The study is cross-sectional and therefore precludes causality. The authors were unable to determine the direction of associations between social avoidance and MetSyn. The measure of social support was unidimensional, including only perceived support; additional types of social support measures would be helpful. Practical implications: This study suggests that occupational-based police social isolation is associated with health outcomes and lower support. Several suggestions are made which will help to improve communication between the police and public. Examples are the use of social media, training in communication techniques, and changing the police role to one of public guardians. Originality/value: Social avoidance is the least studied the Cook-Medley subscale associated with CVD. It is important for the health of officers to maintain a social connection with others.

    • Parasitic Diseases

      1. Safety of single-dose primaquine in G6PD-deficient and G6PD-normal males in Mali without malaria: An open-label, phase 1, dose-adjustment trialExternal
        Chen I, Diawara H, Mahamar A, Sanogo K, Keita S, Kone D, Diarra K, Djimde M, Keita M, Brown J, Roh ME, Hwang J, Pett H, Murphy M, Niemi M, Greenhouse B, Bousema T, Gosling R, Dicko A.
        J Infect Dis. 2018 Mar 28;217(8):1298-1308.

        Background: The World Health Organization recommendation on the use of a single low dose of primaquine (SLD-PQ) to reduce Plasmodium falciparum malaria transmission requires more safety data. Methods: We conducted an open-label, nonrandomized, dose-adjustment trial of the safety of 3 single doses of primaquine in glucose-6-phosphate dehydrogenase (G6PD)-deficient adult males in Mali, followed by an assessment of safety in G6PD-deficient boys aged 11-17 years and those aged 5-10 years, including G6PD-normal control groups. The primary outcome was the greatest within-person percentage drop in hemoglobin concentration within 10 days after treatment. Results: Fifty-one participants were included in analysis. G6PD-deficient adult males received 0.40, 0.45, or 0.50 mg/kg of SLD-PQ. G6PD-deficient boys received 0.40 mg/kg of SLD-PQ. There was no evidence of symptomatic hemolysis, and adverse events considered related to study drug (n = 4) were mild. The mean largest within-person percentage change in hemoglobin level between days 0 and 10 was -9.7% (95% confidence interval [CI], -13.5% to -5.90%) in G6PD-deficient adults receiving 0.50 mg/kg of SLD-PQ, -11.5% (95% CI, -16.1% to -6.96%) in G6PD-deficient boys aged 11-17 years, and -9.61% (95% CI, -7.59% to -13.9%) in G6PD-deficient boys aged 5-10 years. The lowest hemoglobin concentration at any point during the study was 92 g/L. Conclusion: SLD-PQ doses between 0.40 and 0.50 mg/kg were well tolerated in G6PD-deficient males in Mali. Clinical Trials Registration: NCT02535767.

      2. Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort studyExternal
        Kleinschmidt I, Bradley J, Knox TB, Mnzava AP, Kafy HT, Mbogo C, Ismail BA, Bigoga JD, Adechoubou A, Raghavendra K, Cook J, Malik EM, Nkuni ZJ, Macdonald M, Bayoh N, Ochomo E, Fondjo E, Awono-Ambene HP, Etang J, Akogbeto M, Bhatt RM, Chourasia MK, Swain DK, Kinyari T, Subramaniam K, Massougbodji A, Oke-Sopoh M, Ogouyemi-Hounto A, Kouambeng C, Abdin MS, West P, Elmardi K, Cornelie S, Corbel V, Valecha N, Mathenge E, Kamau L, Lines J, Donnelly MJ.
        Lancet Infect Dis. 2018 Apr 9.

        BACKGROUND: Scale-up of insecticide-based interventions has averted more than 500 million malaria cases since 2000. Increasing insecticide resistance could herald a rebound in disease and mortality. We aimed to investigate whether insecticide resistance was associated with loss of effectiveness of long-lasting insecticidal nets and increased malaria disease burden. METHODS: This WHO-coordinated, prospective, observational cohort study was done at 279 clusters (villages or groups of villages in which phenotypic resistance was measurable) in Benin, Cameroon, India, Kenya, and Sudan. Pyrethroid long-lasting insecticidal nets were the principal form of malaria vector control in all study areas; in Sudan this approach was supplemented by indoor residual spraying. Cohorts of children from randomly selected households in each cluster were recruited and followed up by community health workers to measure incidence of clinical malaria and prevalence of infection. Mosquitoes were assessed for susceptibility to pyrethroids using the standard WHO bioassay test. Country-specific results were combined using meta-analysis. FINDINGS: Between June 2, 2012, and Nov 4, 2016, 40 000 children were enrolled and assessed for clinical incidence during 1.4 million follow-up visits. 80 000 mosquitoes were assessed for insecticide resistance. Long-lasting insecticidal net users had lower infection prevalence (adjusted odds ratio [OR] 0.63, 95% CI 0.51-0.78) and disease incidence (adjusted rate ratio [RR] 0.62, 0.41-0.94) than did non-users across a range of resistance levels. We found no evidence of an association between insecticide resistance and infection prevalence (adjusted OR 0.86, 0.70-1.06) or incidence (adjusted RR 0.89, 0.72-1.10). Users of nets, although significantly better protected than non-users, were nevertheless subject to high malaria infection risk (ranging from an average incidence in net users of 0.023, [95% CI 0.016-0.033] per person-year in India, to 0.80 [0.65-0.97] per person year in Kenya; and an average infection prevalence in net users of 0.8% [0.5-1.3] in India to an average infection prevalence of 50.8% [43.4-58.2] in Benin). INTERPRETATION: Irrespective of resistance, populations in malaria endemic areas should continue to use long-lasting insecticidal nets to reduce their risk of infection. As nets provide only partial protection, the development of additional vector control tools should be prioritised to reduce the unacceptably high malaria burden. FUNDING: Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development.

      3. Functional studies of T regulatory lymphocytes in human schistosomiasis in Western KenyaExternal
        Ondigo BN, Ndombi EM, Nicholson SC, Oguso JK, Carter JM, Kittur N, Secor WE, Karanja DM, Colley DG.
        Am J Trop Med Hyg. 2018 Apr 23.

        Immunoregulation is considered a common feature of Schistosoma mansoni infections, and elevated levels of T regulatory (Treg) lymphocytes have been reported during chronic human schistosomiasis. We now report that the removal of Treg (CD4+/CD25(hi)/CD127(low) lymphocytes) from peripheral blood mononuclear cells (PBMCs) of S. mansoni-infected individuals leads to increased levels of phytohemagglutinin (PHA)-stimulated interferon gamma (IFNgamma) production and decreased interleukin-10 (IL-10) responses. Exposure to schistosome antigens did not result in measurable IFNgamma by either PBMC or Treg-depleted populations. Interleukin-10 responses to soluble egg antigens (SEA) by PBMC were unchanged by Treg depletion, but the depletion of Treg greatly the decreased IL-10 production to soluble worm antigenic preparation (SWAP). Proliferative responses to PHA increased upon Treg removal, but responses to SEA or SWAP did not, unless only initially low responders were evaluated. Addition of anti-IL-10 increased PBMC proliferative responses to either SEA or SWAP, but did not alter responses by Treg-depleted cells. Blockade by anti-TGF-beta increased SEA but not SWAP proliferative responses by PBMC, whereas anti-TGF-beta increased both SEA- and SWAP-stimulated responses by Treg-depleted cultures. Addition of both anti-IL-10 and anti-TGF-beta to PBMC or Treg-depleted populations increased proliferation of both populations to either SEA or SWAP. These studies demonstrate that Treg appear to produce much of the antigen-stimulated IL-10, but other cell types or subsets of Treg may produce much of the TGF-beta. The elevated levels of Treg seen in chronic schistosomiasis appear functional and involve IL-10 and TGF-beta in antigen-specific immunoregulation perhaps leading to regulation of immunopathology and/or possibly decreased immunoprotective responses.

    • Public Health Leadership and Management

      1. Local boards of health characteristics influencing support for health department accreditationExternal
        Shah GH, Sotnikov S, Leep CJ, Ye J, Corso L.
        J Public Health Manag Pract. 2018 May/Jun;24(3):263-270.

        BACKGROUND: Local boards of health (LBoHs) serve as the governance body for 71% of local health departments (LHDs). PURPOSE: To assess the impact of LBoH governance functions and other characteristics on the level of LBoH support of LHD accreditation. METHODS: Data from 394 LHDs that participated in the 2015 Local Boards of Health Survey were used for computing summative scores for LBoHs for domains of taxonomy and performing logistic regression analyses in 2016. RESULTS: Increased odds of an LBoH directing, encouraging, or supporting LHD accreditation activities were significantly associated with (a) a higher overall combined score measuring performance of governance functions and presence of other LBoH characteristics (adjusted odds ratio [AOR] = 1.05; P < .001); (b) a higher combined score for the Governance Functions subscale (AOR = 1.06; P < .01); (c) the “continuous improvement” governance function (AOR = 1.15; P < .001); and (d) characteristics and strengths such as board composition (eg, LBoH size, type of training, elected vs nonelected members), community engagement and input, and the absence of an elected official on the board (AOR = 1.14; P = .02). CONCLUSIONS: LBoHs are evenly split by thirds in their attention to Public Health Accreditation Board accreditation among the following categories: (a) encouraged or supported, (b) discussed but made no recommendations, and (c) did not discuss. This split might indicate that they are depending on the professional leadership of the LHD to make the decision or that there is a lack of awareness. The study findings have policy implications for both LBoHs and initiatives aimed at strengthening efforts to promote LHD accreditation.

    • Reproductive Health

      1. Foreword: Maternal mortality and severe maternal morbidityExternal
        Callaghan WM.
        Clin Obstet Gynecol. 2018 Jun;61(2):294-295.

        [No abstract]

      2. Do health promotion messages integrate unintended pregnancy and STI prevention? A content analysis of online information for adolescents and young adultsExternal
        Steiner RJ, Rasberry CN, Sales JM, Gaydos LM, Pazol K, Kramer M, Swartzendruber A.
        Contraception. 2018 Apr 20.

        OBJECTIVE: Recently there have been calls to strengthen integration of unintended pregnancy and sexually transmitted infection (STI) prevention messages, spurred by increasing use of long-acting reversible contraception. To assess the extent to which public health/clinical messages about unintended pregnancy prevention also address STI prevention, we conducted a content analysis of web-based health promotion information for young people. STUDY DESIGN: Websites identified through a systematic Google search were eligible for inclusion if they were operated by a United States-based organization with a mission related to public health/clinical services and the URL included: 1) original content; 2) about sexual and reproductive health; 3) explicitly for adolescents and/or young adults. Using defined protocols, URLs were screened and content was selected and analyzed thematically. RESULTS: Many of the 32 eligible websites presented information about pregnancy and STI prevention separately. Concurrent discussion of the two topics was often limited to statements about (1) strategies that can prevent both outcomes (abstinence, condoms only, condoms plus moderate or highly effective contraceptive methods) and (2) contraceptive methods that confer no STI protection. We also identified framing of condom use with moderate or highly effective contraceptive method for back-up pregnancy prevention but not STI prevention. STI prevention methods in addition to condoms, such as STI/HIV testing, vaccination, or pre-exposure or post-exposure prophylaxis, were typically not addressed with pregnancy prevention information. CONCLUSIONS: There may be missed opportunities for promoting STI prevention online in the context of increasing awareness of and access to a full range of contraceptive methods. IMPLICATIONS: Strengthening messages that integrate pregnancy and STI prevention may include: describing STI prevention strategies when noting that birth control methods do not prevent STIs; promoting a full complement of STI prevention strategies; and always connecting condom use to STI prevention, even when promoting condoms for back-up contraception.

    • Substance Use and Abuse
      1. IMPORTANCE: Two components of social norms-descriptive (estimated prevalence) and injunctive (perceived acceptability)-can influence youth tobacco use. OBJECTIVE: To investigate electronic cigarettes (e-cigarette) and cigarette descriptive norms and measure the associations between overestimation of e-cigarette and cigarette prevalence and tobacco-related attitudes and behaviours. DESIGN: Cross-sectional. SETTING: School-based, using paper-and-pencil questionnaires. PARTICIPANTS: US 6th-12th graders participating in the 2015 (n=17 711) and 2016 (n=20 675) National Youth Tobacco Survey. EXPOSURE: Students estimated the percent of their grade-mates who they thought used e-cigarettes and cigarettes; the discordance between perceived versus grade-specific actual prevalence was used to categorise students as overestimating (1) neither product, (2) e-cigarettes only, (3) cigarettes only or (4) both products. OUTCOMES: Product-specific outcomes were curiosity and susceptibility (never users), as well as ever and current use (all students). Descriptive and multivariable logistic regression analyses were performed. Statistical significance was at P<0.05. Data were weighted to be nationally representative. RESULTS: More students overestimated cigarette (74.0%) than e-cigarette prevalence (61.0%; P<0.05). However, the associations between e-cigarette-only overestimation and e-cigarette curiosity (adjusted OR (AOR)=3.29), susceptibility (AOR=2.59), ever use (AOR=5.86) and current use (AOR=8.15) were each significantly larger than the corresponding associations between cigarette-only overestimation and cigarette curiosity (AOR=1.50), susceptibility (AOR=1.54), ever use (AOR=2.04) and current use (AOR=2.52). Despite significant declines in actual e-cigarette use prevalence within each high school grade level during 2015-2016, perceived prevalence increased (11th and 12th grades) or remained unchanged (9th and 10th grades). CONCLUSIONS: Four of five US students overestimated peer e-cigarette or cigarette use. Counter-tobacco mass media messages can help denormalise tobacco use.

    • Zoonotic and Vectorborne Diseases
      1. Most Zika disease cases diagnosed in the continental US have been associated with travel to areas with risk of Zika transmission, mainly the Caribbean and Latin America. Limited information has been published about the demographic and travel characteristics of Zika case-patients in the United States, besides their age and gender. During 2016-2017 the County of San Diego Health and Human Services Agency, California, expanded the scope and completeness of demographic and travel information collected from Zika case-patients for public health surveillance purposes. The majority (53.8%) of travel-related Zika virus infection case-patients (n = 78) in the county were Hispanic, significantly higher (p </= 0.05) than the 33.0% of Hispanics in the county. Foreign-born residents, mainly from Mexico, were also overrepresented among cases compared to their share in the county population (33.3 vs. 23.0%; p </= 0.05). Seventeen (21.8%) patients reported a primary language other than English (14 Spanish). Most case-patients traveled for tourism (54%) or to visit friends and relatives (36%). This surveillance information helps identify higher-risk populations and implement culturally targeted interventions for Zika prevention and control.

      2. A 2015 outbreak of flea-borne rickettsiosis in San Gabriel Valley, Los Angeles County, CaliforniaExternal
        Nelson K, Maina AN, Brisco A, Foo C, Croker C, Ngo V, Civen R, Richards AL, Fujioka K, Wekesa JW.
        PLoS Negl Trop Dis. 2018 Apr 20;12(4):e0006385.

        Although flea-borne rickettsiosis is endemic in Los Angeles County, outbreaks are rare. In the spring of 2015 three human cases of flea-borne rickettsiosis among residents of a mobile home community (MHC) prompted an investigation. Fleas were ubiquitous in common areas due to presence of flea-infested opossums and overabundant outdoor cats and dogs. The MHC was summarily abated in June 2015, and within five months, flea control and removal of animals significantly reduced the flea population. Two additional epidemiologically-linked human cases of flea-borne rickettsiosis detected at the MHC were suspected to have occurred before control efforts began. Molecular testing of 106 individual and 85 pooled cat fleas, blood and ear tissue samples from three opossums and thirteen feral cats using PCR amplification and DNA sequencing detected rickettsial DNA in 18.8% of the fleas. Seventeen percent of these cat fleas tested positive for R. felis-specific DNA compared to under two (<2) percent for Candidatus R. senegalensis-specific DNA. In addition, serological testing of 13 cats using a group-specific IgG-ELISA detected antibodies against typhus group rickettsiae and spotted fever group rickettsiae in six (46.2%) and one (7.7%) cat, respectively. These results indicate that cats and their fleas may have played an active role in the epidemiology of the typhus group and/or spotted fever group rickettsial disease(s) in this outbreak.

      3. Zoonotic origin and transmission of Middle East respiratory syndrome coronavirus in the UAEExternal
        Paden CR, Yusof M, Al Hammadi ZM, Queen K, Tao Y, Eltahir YM, Elsayed EA, Marzoug BA, Bensalah OK, Khalafalla AI, Al Mulla M, Khudhair A, Elkheir KA, Issa ZB, Pradeep K, Elsaleh FN, Imambaccus H, Sasse J, Weber S, Shi M, Zhang J, Li Y, Pham H, Kim L, Hall AJ, Gerber SI, Al Hosani FI, Tong S, Al Muhairi SS.
        Zoonoses Public Health. 2018 May;65(3):322-333.

        Since the emergence of Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012, there have been a number of clusters of human-to-human transmission. These cases of human-to-human transmission involve close contact and have occurred primarily in healthcare settings, and they are suspected to result from repeated zoonotic introductions. In this study, we sequenced whole MERS-CoV genomes directly from respiratory samples collected from 23 confirmed MERS cases in the United Arab Emirates (UAE). These samples included cases from three nosocomial and three household clusters. The sequences were analysed for changes and relatedness with regard to the collected epidemiological data and other available MERS-CoV genomic data. Sequence analysis supports the epidemiological data within the clusters, and further, suggests that these clusters emerged independently. To understand how and when these clusters emerged, respiratory samples were taken from dromedary camels, a known host of MERS-CoV, in the same geographic regions as the human clusters. Middle East respiratory syndrome coronavirus genomes from six virus-positive animals were sequenced, and these genomes were nearly identical to those found in human patients from corresponding regions. These data demonstrate a genetic link for each of these clusters to a camel and support the hypothesis that human MERS-CoV diversity results from multiple zoonotic introductions.

      4. Notes from the Field: Identification of tourists from Switzerland exposed to rabies virus while visiting the United States – January 2018External
        Pieracci EG, Stanek D, Koch D, Kohl KS, Blanton JD, Harder T, O’Brien M, Leon H, Colarusso P, Baker B, Brown C, Stauffer KE, Petersen BW, Wallace RM.
        MMWR Morb Mortal Wkly Rep. 2018 Apr 27;67(16):477-478.

        [No abstract]

      5. Orientia tsutsugamushi (Ots) is an obligate, intracellular, mite-transmitted human pathogen which causes scrub typhus. Understanding the diversity of Ots antigens is essential for designing specific diagnostic assays and efficient vaccines. The protective immunodominant type-specific 56 kDa antigen (TSA) of Ots varies locally and across its geographic distribution. TSA contains four hypervariable domains. We bioinformatically analyzed 345 partial sequences of TSA available from India, most of which contain only the three variable domains (VDI-III) and three spacer conserved domains (SVDI, SVDII/III, SVDIII). The total number (152) of antigenic types (amino acid variants) varied from 14-36 in the six domains of TSA that we studied. Notably, 55% (787/1435) of the predicted CD4 T-cell epitopes (TCEs) from all the six domains had high binding affinities (HBA) to at least one of the prevalent Indian human leukocyte antigen (HLA) alleles. A surprisingly high proportion (61%) of such TCEs were from spacer domains; indeed 100% of the CD4 TCEs in the SVDI were HBA. TSA sequences from India had more antigenic types (AT) than TSA from Korea. Overall, >90% of predicted CD4 TCEs from spacer domains were predicted to have HBA against one or more prevalent HLA types from Indian, Korean, Asia-Pacific region or global population data sets, while only <50% of CD4 TCEs in variable domains exhibited such HBA. The phylogenetically and immunologically important amino acids in the conserved spacer domains were identified. Our results suggest that the conserved spacer domains are predicted to be functionally more important than previously appreciated in immune responses to Ots infections. Changes occurring at the TCE level of TSA may contribute to the wide range of pathogenicity of Ots in humans and mouse models. CD4 T-cell functional experiments are needed to assess the immunological significance of these HBA spacer domains and their role in clearance of Ots from Indian patients.

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

Page last reviewed: January 31, 2019
Content source: Centers for Disease Control and Prevention