Volume 10, Issue 19, May 29, 2018

CDC Science Clips: Volume 10, Issue 19, May 29, 2018

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • State indoor tanning laws and prevalence of indoor tanning among US high school students, 2009-2015External
        Qin J, Holman DM, Jones SE, Berkowitz Z, Guy GP.
        Am J Public Health. 2018 May 17:e1-e6.

        OBJECTIVES: To examine the association between state indoor tanning laws and indoor tanning behavior using nationally representative samples of US high school students younger than 18 years. METHODS: We combined data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveys (n = 41 313) to analyze the association between 2 types of state indoor tanning laws (age restriction and parental permission) and the prevalence of indoor tanning during the 12 months before the survey, adjusting for age, race/ethnicity, and survey year, and stratified by gender. RESULTS: Age restriction laws were associated with a 47% (P < .001) lower indoor tanning prevalence among female high school students. Parental permission laws were not found to be associated with indoor tanning prevalence among either female or male high school students. CONCLUSIONS: Age restriction laws could contribute to less indoor tanning, particularly among female high school students. Such reductions may reduce the health and economic burden of skin cancer. (Am J Public Health. Published online ahead of print May 17, 2018: e1-e6. doi:10.2105/AJPH.2018.304414).

    • Communicable Diseases
      • Using HIV surveillance data to link people to HIV medical care, 5 US states, 2012-2015External
        Beltrami J, Dubose O, Carson R, Cleveland JC.
        Public Health Rep. 2018 Jan 1.

        INTRODUCTION: From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended. MATERIALS AND METHODS: We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care. RESULTS: Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended. PRACTICE IMPLICATIONS: Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

      • Prospects for tuberculosis elimination in the United States: Results of a transmission dynamic modelExternal
        Menzies NA, Cohen T, Hill AN, Yaesoubi R, Galer K, Wolf E, Marks SM, Salomon JA.
        Am J Epidemiol. 2018 May 14.

        We estimated long-term tuberculosis (TB) trends in the US population and assessed prospects for TB elimination. We used a detailed simulation model allowing for changes in TB transmission, immigration, and other TB risk determinants. We evaluated 5 hypothetical scenarios from 2017 to 2100: 1) maintain current TB prevention and treatment activities (base-case), 2) provision of latent TB infection testing and treatment for new legal immigrants, 3) increased uptake of latent TB infection screening and treatment among high-risk populations, including a 3-month isoniazid-rifapentine regimen, 4) improved TB case detection, 5) improved TB treatment quality. Under the base-case, we estimate that by 2050 TB incidence will decline to 14 cases per million, a 52% (95% interval: 35, 67) reduction from 2016, and 82% (78, 86) of incident TB will be among non-US-born persons. Intensified TB control could reduce incidence by 77% (66, 85) by 2050. By 2100, we predict TB may be eliminated in the US-born but not the non-US-born. Results were sensitive to numbers entering the US with latent or active TB, and robust to alternative interpretations of epidemiologic evidence. TB elimination in the US remains a distant goal. However, strengthening TB prevention and treatment could produce important health benefits.

      • Risk and timing of tuberculosis among close contacts of persons with infectious tuberculosisExternal
        Reichler MR, Khan A, Sterling TR, Zhao H, Moran J, McAuley J, Bessler P, Mangura B.
        J Infect Dis. 2018 May 15.

        Background: The risk and timing of tuberculosis (TB) among recently exposed close contacts of patients with infectious TB is not well established. Methods: We prospectively enrolled culture-confirmed pulmonary TB patients >/=15 years of age and their close contacts at nine health departments in the United States and Canada. Close contacts were screened and cross-matched with TB registries to identify those who developed TB. Results: TB was diagnosed in 158 (4%) of 4490 contacts to 718 index TB patients. Of those with TB, cumulative totals of 81 (51%), 119 (75%), 128 (81%) and 145 (92%) were diagnosed by 1, 3, 6, and 12 months after index case diagnosis, respectively. TB rates among contacts were 2644, 115, 46, 69, and 25 per 100,000 persons, respectively, in the five consecutive years after index patient diagnosis. Of the TB cases among contacts, 121 (77%) were identified by contact investigation and 37 (23%) by TB registry cross-match. Conclusions: Close contacts to infectious TB patients had high rates of TB, with most disease diagnosed before or within 3 months after index patient diagnosis. Contact investigations need to be prompt to detect TB and maximize the opportunity to identify and treat latent infection in order to prevent disease.

    • Environmental Health
      • Urinary metabolites of volatile organic compounds of infants in the neonatal intensive care unitExternal
        El-Metwally D, Chain K, Stefanak MP, Alwis U, Blount BC, LaKind JS, Bearer CF.
        Pediatr Res. 2018 May 16.

        BackgroundPreterm infants (PTI) in the NICU are often placed in incubators that may increase their exposure to volatile organic chemicals (VOCs). To determine whether PTI in incubators have higher urinary concentrations of VOC metabolites compared with infants in cribs.MethodsUrine from 40 PTI in incubators and 40 infants in cribs was collected and analyzed for 28 urinary VOC biomarkers. Differences in metabolite concentrations between the two groups were compared.ResultsTwenty two of the VOC metabolites were detected in at least one urine sample. All urine samples tested had measurable levels of six VOC metabolites. Biomarkers for acrolein, acrylonitrile, carbon disulfide, cyanide, N-dimethylformamide, ethylbenzene, ethylene oxide, propylene oxide, styrene, toluene/benzyl alcohol, vinyl chloride, and xylene were higher in the incubator group. The geometric means of five VOC metabolites were 2-fold higher than those reported for NHANES children 6-11 years of age in one or both of the groups with benzyl mercapturic acid being 7-fold and 12-fold greater than NHANES in the crib and incubator group, respectively.ConclusionAll infants were exposed to VOCs. PTI in incubators have a different VOC exposure profile compared with infants in cribs. The health implications associated with these exposures require further study.Pediatric Research advance online publication, 16 May 2018; doi:10.1038/pr.2018.52.

    • Health Economics
      • Estimating the economic burden related to older adult falls by stateExternal
        Haddad YK, Bergen G, Florence CS.
        J Public Health Manag Pract. 2018 May 5.

        OBJECTIVE: Unintentional falls in older adults (persons 65 years of age and older) impose a significant economic burden on the health care system. Methods for calculating state-specific health care costs are limited. This study describes 2 methods to estimate state-level direct medical spending due to older adult falls and explains their differences, advantages, and limitations. DESIGN: The first method, partial attributable fraction, applied a national attributable fraction to the total state health expenditure accounts in 2014 by payer type (Medicare, Medicaid, and private insurance). The second method, count applied to cost, obtained 2014 state counts of older adults treated and released from an emergency department and hospitalized because of a fall injury. The counts in each state were multiplied by the national average lifetime medical costs for a fall-related injury from the Web-based Injury Statistics Query and Reporting System. Costs are reported in 2014 US dollars. SETTING: United States. PARTICIPANTS: Older adults. MAIN OUTCOME MEASURE: Health expenditure on older adult falls by state. RESULTS: The estimate from the partial attributable fraction method was higher than the estimate from the count applied to cost method for all states compared, except Utah. Based on the partial attributable fraction method, in 2014, total personal health care spending for older adult falls ranged from $48 million in Alaska to $4.4 billion in California. Medicare spending attributable to older adult falls ranged from $22 million in Alaska to $3.0 billion in Florida. For the count applied to cost method, available for 17 states, the lifetime medical costs of 2014 fall-related injuries ranged from $68 million in Vermont to $2.8 billion in Florida. CONCLUSIONS: The 2 methods offer states options for estimating the economic burden attributable to older adult fall injuries. These estimates can help states make informed decisions about how to allocate funding to reduce falls and promote healthy aging.

    • Healthcare Associated Infections
      • Large outbreak of hepatitis C virus associated with drug diversion by a healthcare technicianExternal
        Alroy-Preis S, Daly ER, Adamski C, Dionne-Odom J, Talbot EA, Gao F, Cavallo SJ, Hansen K, Mahoney JC, Metcalf E, Loring C, Bean C, Drobeniuc J, Xia GL, Kamili S, Montero JT.
        Clin Infect Dis. 2018 May 14.

        Background: In May 2012, the New Hampshire (NH) Division of Public Health Services (DPHS) was notified of 4 persons with newly diagnosed hepatitis C virus (HCV) infection at hospital X. Initial investigation suggested a common link to the hospital cardiac catheterization laboratory (CCL) because the infected persons included 3 CCL patients and a CCL technician. NH DPHS initiated an investigation to determine the source and control the outbreak. Methods: NH DPHS conducted site visits, case patient and employee interviews, medical record and medication use review, and employee and patient HCV testing using enzyme immunoassay for anti-HCV, reverse-transcription polymerase chain reaction for HCV RNA, nonstructural 5B (NS5B) and hypervariable region 1 (HVR1) sequencing, and quasispecies analysis. Results: HCV HVR1 analysis of the first 4 cases confirmed a common source of infection. HCV testing identified 32 of 1074 CCL patients infected with the outbreak strain, including 3 patients coinfected with >1 HCV strain. The epidemiologic investigation revealed evidence of drug diversion by the HCV-infected technician, evidenced by gaps in controlled medication control, higher fentanyl use during procedures for confirmed cases, and building card key access records documenting the presence of the technician during days when transmission occurred. The employee’s status as a traveling technician led to a multistate investigation, which identified additional cases at prior employment sites. Conclusions: This is the largest laboratory-confirmed drug diversion-associated HCV outbreak published to date. Recommendations to reduce drug diversion risk and to conduct outbreak investigations are provided.

    • Injury and Violence
      • Unmet rehabilitation needs after hospitalization for traumatic brain injuryExternal
        Fuentes MM, Wang J, Haarbauer-Krupa J, Yeates KO, Durbin D, Zonfrillo MR, Jaffe KM, Temkin N, Tulsky D, Bertisch H, Rivara FP.
        Pediatrics. 2018 May;141(5).

        OBJECTIVES: In this study, we describe unmet service needs of children hospitalized for traumatic brain injury (TBI) during the first 2 years after injury and examine associations between child, family, and injury-related characteristics and unmet needs in 6 domains (physical therapy, occupational therapy, speech therapy, mental health services, educational services, and physiatry). METHODS: Prospective cohort study of children age 8 to 18 years old admitted to 6 hospitals with complicated mild or moderate to severe TBI. Service need was based on dysfunction identified via parent-report compared with retrospective baseline at 6, 12, and 24 months. Needs were considered unmet if the child had no therapy services in the previous 4 weeks, no physiatry services since the previous assessment, or no educational services since injury. Analyses were used to compare met and unmet needs for each domain and time point. Generalized multinomial logit models with robust SEs were used to assess factors associated with change in need from pre-injury baseline to each study time point. RESULTS: Unmet need varied by injury severity, time since injury, and service domain. Unmet need was highest for physiatry, educational services, and speech therapy. Among children with service needs, increased time after TBI and complicated mild TBI were associated with a higher likelihood of unmet rather than met service needs. CONCLUSIONS: Children hospitalized for TBI have persistent dysfunction with unmet needs across multiple domains. After initial hospitalization, children with TBI should be monitored for functional impairments to improve identification and fulfillment of service needs.

      • Injuries from physical abuse: National Survey of Children’s Exposure to Violence I-IIIExternal
        Simon TR, Shattuck A, Kacha-Ochana A, David-Ferdon CF, Hamby S, Henly M, Merrick MT, Turner HA, Finkelhor D.
        Am J Prev Med. 2018 Jan;54(1):129-132.

        INTRODUCTION: Official data sources do not provide researchers, practitioners, and policy makers with complete information on physical injury from child abuse. This analysis provides a national estimate of the percentage of children who were injured during their most recent incident of physical abuse. METHODS: Pooled data from three cross-sectional national telephone survey samples (N=13,052 children) included in the National Survey of Children’s Exposure to Violence completed in 2008, 2011, and 2014 were used. RESULTS: Analyses completed in 2016 indicate that 8.4% of children experienced physical abuse by a caregiver. Among those with injury data, 42.6% were injured in the most recent incident. No differences in injury were observed by sex, age, race/ethnicity, or disability status. Victims living with two parents were less likely to be injured (27.1%) than those living in other family structures (53.8%-59%, p<0.001). Incidents involving an object were more likely to result in injury (59.3% vs 38.5%, p<0.05). Injured victims were significantly more likely to experience substantial fear (57.3%) than other victims (34.4%, p<0.001). CONCLUSIONS: A substantial percentage of physical abuse victims are physically hurt to the point that they still feel pain the next day, are bruised, cut, or have a broken bone. Self-report data indicate this is a more common problem than official data sources suggest. The lack of an object in an incident of physical abuse does not protect a child from injury. The results underscore the impact of childhood physical abuse and the importance of early prevention activities.

    • Zoonotic and Vectorborne Diseases
      • Guillain-Barre syndrome risk among individuals infected with Zika virus: a multi-country assessmentExternal
        Mier-y-Teran-Romero L, Delorey MJ, Sejvar JJ, Johansson MA.
        BMC Med. 2018 May 15;16(1):67.

        BACKGROUND: Countries with ongoing outbreaks of Zika virus have observed a notable rise in reported cases of Guillain-Barre syndrome (GBS), with mounting evidence of a causal link between Zika virus infection and the neurological syndrome. However, the risk of GBS following a Zika virus infection is not well characterized. In this work, we used data from 11 locations with publicly available data to estimate the risk of GBS following an infection with Zika virus, as well as the location-specific incidence of infection and the number of suspect GBS cases reported per infection. METHODS: We built a mathematical inference framework utilizing data from 11 locations that had reported suspect Zika and GBS cases, two with completed outbreaks prior to 2015 (French Polynesia and Yap) and nine others in the Americas covering partial outbreaks and where transmission was ongoing as of early 2017. RESULTS: We estimated that 2.0 (95% credible interval 0.5-4.5) reported GBS cases may occur per 10,000 Zika virus infections. The frequency of reported suspect Zika cases varied substantially and was highly uncertain, with a mean of 0.11 (95% credible interval 0.01-0.24) suspect cases reported per infection. CONCLUSIONS: These estimates can help efforts to prepare for the GBS cases that may occur during Zika epidemics and highlight the need to better understand the relationship between infection and the reported incidence of clinical disease.

  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. Trends in chronic diseases reported by refugees originating from Burma resettling to the United States from camps versus urban areas during 2009-2016External
        Bardenheier BH, Phares CR, Simpson D, Gregg E, Cho P, Benoit S, Marano N.
        J Immigr Minor Health. 2018 May 15.

        We examined changes in the prevalence of chronic health conditions among US-bound refugees originating from Burma resettling over 8 years by the type of living arrangement before resettlement, either in camps (Thailand) or in urban areas (Malaysia). Using data from the required overseas medical exam for 73,251 adult (>/= 18 years) refugees originating from Burma resettling to the United States during 2009-2016, we assessed average annual percent change (AAPC) in proportion >/= 45 years and age- and sex-standardized prevalence of obesity, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and musculoskeletal disease, by camps versus urban areas. Compared with refugees resettling from camps, those coming from urban settings had higher prevalence of obesity (mean 18.0 vs. 5.9%), diabetes (mean 6.5 vs. 0.8%), and hypertension (mean 12.7 vs. 8.1%). Compared with those resettling from camps, those from urban areas saw greater increases in the proportion with COPD (AAPC: 109.4 vs. 9.9) and musculoskeletal disease (AAPC: 34.6 vs. 1.6). Chronic conditions and their related risk factors increased among refugees originating from Burma resettling to the United States whether they had lived in camps or in urban areas, though the prevalence of such conditions was higher among refugees who had lived in urban settings.

      2. Obesity, physical activity, and dietary behaviors in an ethnically-diverse sample of cancer survivors with early onset diseaseExternal
        Glenn BA, Hamilton AS, Nonzee NJ, Maxwell AE, Crespi CM, Ryerson AB, Chang LC, Deapen D, Bastani R.
        J Psychosoc Oncol. 2018 May 15:1-19.

        PURPOSE: To assess weight status, physical activity, and dietary behaviors in an ethnically-diverse sample of breast and colorectal cancer survivors with early onset disease (</= 50 years). METHODS: Breast and colorectal cancer survivors, diagnosed between 1999 and 2009 with early-stage cancer diagnosed by 50 years of age, were identified through a population-based cancer registry and surveyed. Descriptive and regression analyses were conducted to characterize the sample and identify correlates of lifestyle behaviors. FINDINGS: The majority of participants (n = 156) were female (83%), insured (84%), and racial/ethnic minorities (29% Asian, 24% Latino, 15% African American). Participants’ mean age at response was 50 years and mean time since diagnosis was 9 years. Over half of survivors were overweight or obese. Few participants reported engaging in regular physical activity (31%) and adhering to minimum guidelines for fruit and vegetable consumption (32%). A substantial proportion of survivors consumed fast food in the past week (75%) and nearly half (48%) reported daily consumption of sugar-sweetened beverages. Lower income was associated with inadequate fruit and vegetable intake. Fast food and sugar-sweetened beverage consumption was significantly higher among racial/ethnic minority survivors compared to non-Latino whites. CONCLUSIONS: High prevalence of overweight and suboptimal adherence to recommended nutrition and physical activity behaviors were observed among cancer survivors with early onset disease. Cancer survivors diagnosed at a young age may benefit from targeted interventions to address overweight and suboptimal nutrition and physical activity.

      3. Breast cancer related perceptions and practices of health professionals working in Brazil’s network of primary care unitsExternal
        Hallowell BD, Puricelli Perin DM, Simoes EJ, Paez DC, Parra DC, Brownson RC, Saraiya M.
        Prev Med. 2018 Jan;106:216-223.

        In 2004 the Brazilian National Cancer Institute (INCA) established breast cancer screening guidelines for women in Brazil: annual clinical breast exam for women age 40-49 and biennial mammogram for women age 50-69. Healthcare provider’s adherence to these guidelines is currently unknown. The objective of this study is to describe the perceptions and practices related to breast cancer screening among physicians, nurses, and health unit coordinators working in the network of primary healthcare units (HCUs) in Brazil. In 2011, 1600 primary HCUs were randomly sampled from all regions in Brazil. At each HCU the coordinator and one health professional were asked to participate in a telephone survey to gathered information on their knowledge, attitudes, and practices related to breast cancer screening. Participation rates for coordinators, physicians, and nurses were 78%, 34%, and 65% respectively. Health unit coordinators identified numerous barriers that prevent patients from receiving appropriate screening, many (44%) were unaware of INCA cancer screening guidelines. Despite a high perceived impact of INCA guidelines, a majority of physicians and nurses did not follow them. Most physicians and nurses recommended mammograms on an annual basis (~75%) and 50.9% of nurses and 25.1% of physicians initiated routine breast cancer screening in women under age 40. Physicians and nurses in Brazil screen at younger ages and more frequently than recommended by INCA guidelines. Given that primary HCUs are the source of health care for many women, interventions that educate healthcare providers on the appropriate ages and intervals for breast cancer screening may prove useful.

      4. OBJECTIVE: Agreement between administrative and survey data has been shown to vary by the condition of interest and there is limited research dedicated to parental report of asthma among children. The current study assesses the concordance between parent-reported asthma from the National Health Interview Survey (NHIS) with Medicaid administrative claims data among linkage eligible children from the NHIS. METHODS: Medicaid Analytic eXtract (MAX) files from the Centers for Medicare & Medicaid Services (CMS) (years 2000-2005) were linked to participants of the NHIS (years 2001-2005). Concordance measures were calculated to assess overall agreement between a claims-based asthma diagnosis and a survey-based asthma diagnosis. Structural equation modeling was used to assess the association between demographic, service utilization, and co-occurring conditions factors and agreement. RESULTS: Percent agreement between the two data sources was high (90%) with a prevalence-adjusted bias-adjusted kappa of 0.80 and Cohen’s kappa of 0.55. Agreement varied by demographic characteristics, service utilization characteristics, and the presence of allergies and other health conditions. Structural equation modeling results found the presence of a series of co-occurring conditions, namely allergies, resulted in significantly lower agreement after controlling for demographics and service utilization. CONCLUSIONS: There was general agreement between asthma diagnoses reported in the NHIS when compared to medical claims. Discordance was greatest among children with co-occurring conditions.

    • Communicable Diseases
      1. Expanding severe acute respiratory infection (SARI) surveillance beyond influenza: The process and data from 1 year of implementation in VietnamExternal
        Alroy KA, Do TT, Tran PD, Dang TQ, Vu LN, Le NT, Dang AD, Ngu ND, Ngo TH, Hoang PM, Phan LT, Nguyen TV, Nguyen LT, Nguyen TV, Vien MQ, Le HX, Dao AT, Nguyen TB, Pham DT, Nguyen VT, Pham TN, Phan BH, Whitaker B, Do TT, Dao PA, Balajee SA, Mounts AW.
        Influenza Other Respir Viruses. 2018 May 13.

        BACKGROUND: In 2016, as a component of the Global Health Security Agenda, the Vietnam Ministry of Health expanded its existing influenza sentinel surveillance for severe acute respiratory infections (SARI) to include testing for 7 additional viral respiratory pathogens. This article describes the steps taken to implement expanded SARI surveillance in Vietnam and reports data from 1 year of expanded surveillance. METHOD: The process of expanding the suite of pathogens for routine testing by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) included laboratory trainings, procurement/distribution of reagents, and strengthening and aligning SARI surveillance epidemiology practices at sentinel sites and regional institutes (RI). RESULTS: Surveillance data showed that of 4,003 specimens tested by the RI laboratories, 20.2% (n = 810) were positive for influenza virus. Of the 3,193 influenza-negative specimens, 41.8% (n = 1,337) were positive for at least 1 non-influenza respiratory virus, of which 16.2% (n = 518), 13.4% (n = 428), and 9.6% (n = 308) tested positive for respiratory syncytial virus, rhinovirus, and adenovirus, respectively. CONCLUSIONS: The Government of Vietnam has demonstrated that expanding respiratory viral surveillance by strengthening and building upon an influenza platform is feasible, efficient, and practical. This article is protected by copyright. All rights reserved.

      2. Trends in antiretroviral therapy eligibility and coverage among children aged <15 years with HIV infection – 20 PEPFAR-supported sub-Saharan African countries, 2012-2016External
        Burrage A, Patel M, Mirkovic K, Dziuban E, Teferi W, Broyles L, Rivadeneira E.
        MMWR Morb Mortal Wkly Rep. 2018 May 18;67(19):552-555.

        Rapid disease progression and associated opportunistic infections contribute to high mortality rates among children aged <15 years with human immunodeficiency virus (HIV) infection (1). Antiretroviral therapy (ART) has decreased childhood HIV-associated morbidity and mortality rates over the past decade (2). As accumulating evidence revealed lower HIV-associated mortality with early ART initiation, the World Health Organization (WHO) guidelines broadened ART eligibility for children with HIV infection (2). Age at ART initiation for children with HIV infection expanded sequentially in the 2010, 2013, and 2016 WHO guidelines to include children aged <2, <5, and <15 years, respectively, regardless of clinical or immunologic status (3-5). The United States President’s Emergency Plan for AIDS Relief (PEPFAR) has supported ART for children with HIV infection since 2003 and, informed by the WHO guidelines and a growing evidence base, PEPFAR-supported countries have adjusted their national pediatric guidelines. To understand the lag between guideline development and implementation, as well as the ART coverage gap, CDC assessed national pediatric HIV guidelines and analyzed Joint United Nations Programme on HIV and AIDS (acquired immunodeficiency syndrome; UNAIDS) data on children aged <15 years with HIV infection and the numbers of these children on ART. Timeliness of WHO pediatric ART guideline adoption varied by country; >50% of children with HIV infection are not receiving ART, underscoring the importance of strengthening case finding and linkage to HIV treatment in pediatric ART programs.

      3. Assessing sexually transmitted disease partner services in state and local health departmentsExternal
        Cuffe KM, Leichliter JS, Gift TL.
        Sex Transm Dis. 2018 Jun;45(6):e33-e37.

        State and local health department sexually transmitted disease (STD) programs provide several partner services to reduce disease transmission. Budget cuts and temporary staff reassignments for public health emergencies may affect the provision of partner services. Determining the impact of staffing reductions on STD rates and public health response should be further assessed.

      4. Reactivation of a vaccine escape hepatitis B virus mutant in a Cambodian patient during anti-hepatitis C virus therapyExternal
        Fusco DN, Ganova-Raeva L, Khudyakov Y, Punkova L, Mohamed A, Cheon SS, Koirala P, Andersson KL, Jourdain G, Sureau C, Chung RT, Lauer G.
        Front Med (Lausanne). 2018 ;5:97.

        A 76-year-old Cambodian man co-infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) 6c-1 presented for care. HBV DNA was intermittently detectable despite anti-HBs levels being above the protective threshold. During treatment for HCV, HBV DNA levels increased. Sequencing revealed multiple mutations including vaccine escape mutation and mutations predicted to enhance fitness. This case represents exacerbation of an HBV vaccine escape mutant during a direct-acting antiviral therapy.

      5. Community-based services to improve testing and linkage to care among non-U.S.-born persons with chronic hepatitis B virus infection – three U.S. programs, October 2014-September 2017External
        Harris AM, Link-Gelles R, Kim K, Chandrasekar E, Wang S, Bannister N, Pong P, Chak E, Chen MS, Bowlus C, Nelson NP.
        MMWR Morb Mortal Wkly Rep. 2018 May 18;67(19):541-546.

        Among an estimated 850,000 to 2.2 million persons with chronic hepatitis B virus (HBV) infection in the United States, 70% are non-U.S.-born (1,2). All patients require linkage to care, and approximately 20%-40% require antiviral treatment (3). Without treatment, one in four persons chronically infected with HBV will die prematurely from liver failure, liver cirrhosis, or hepatocellular carcinoma (4). To mitigate morbidity and mortality, CDC funded a cooperative agreement to develop hepatitis B testing and linkage-to-care programs serving non-U.S.-born persons during October 2014-September 2017. This report describes each program’s operational services and partnerships with primary care centers, community-based organizations, and public health departments to recruit non-U.S.-born persons for HBV testing using the hepatitis B surface antigen (HBsAg) and link those whose test results were positive to HBV-directed care (medical visit attendance with monitoring of HBV DNA and liver enzyme tests). Among 10,152 program participants, 757 (7.5%) were HBsAg-positive, indicative of chronic HBV infection; among these, 643 (85%) attended >/=1 medical visit, 587 (78%) received HBV-directed care, and 137 (18%) were prescribed antiviral treatment. Among 273 household contacts of HBsAg-positive persons, 39 (14%) had positive test results for HBsAg. Prevalence of current HBV infection was high in this non-U.S.-born population and among household and sexual contacts of HBV-infected persons. HBV testing and linkage to care can be achieved through partnerships with community organizations, health centers, and public health departments.

      6. Outbreaks associated with treated recreational water – United States, 2000-2014External
        Hlavsa MC, Cikesh BL, Roberts VA, Kahler AM, Vigar M, Hilborn ED, Wade TJ, Roellig DM, Murphy JL, Xiao L, Yates KM, Kunz JM, Arduino MJ, Reddy SC, Fullerton KE, Cooley LA, Beach MJ, Hill VR, Yoder JS.
        MMWR Morb Mortal Wkly Rep. 2018 May 18;67(19):547-551.

        Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires’ disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis [“hot tub rash”] and otitis externa [“swimmers’ ear”]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC’s Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water.

      7. Staphylococcus aureus bacteremia incidence and methicillin resistance in rural Thailand, 2006-2014External
        Jaganath D, Jorakate P, Makprasert S, Sangwichian O, Akarachotpong T, Thamthitiwat S, Khemla S, Defries T, Baggett HC, Whistler T, Gregory CJ, Rhodes J.
        Am J Trop Med Hyg. 2018 May 14.

        Staphylococcus aureus is a common cause of bloodstream infection and methicillin-resistant S. aureus (MRSA) is a growing threat worldwide. We evaluated the incidence rate of S. aureus bacteremia (SAB) and MRSA from population-based surveillance in all hospitals from two Thai provinces. Infections were classified as community-onset (CO) when blood cultures were obtained </= 2 days after hospital admission and as hospital-onset (HO) thereafter. The incidence rate of HO-SAB could only be calculated for 2009-2014 when hospitalization denominator data were available. Among 147,524 blood cultures, 919 SAB cases were identified. Community-onset S. aureus bacteremia incidence rate doubled from 4.4 (95% confidence interval [CI]: 3.3-5.8) in 2006 to 9.3 per 100,000 persons per year (95% CI: 7.6-11.2) in 2014. The highest CO-SAB incidence rate was among adults aged 50 years and older. Children less than 5 years old had the next highest incidence rate, with most cases occurring among neonates. During 2009-2014, there were 89 HO-SAB cases at a rate of 0.13 per 1,000 hospitalizations per year (95% CI: 0.10-0.16). Overall, MRSA prevalence among SAB cases was 10% (90/911) and constituted 7% (55/736) of CO-SAB and 20% (22/111) of HO-SAB without a clear temporal trend in incidence rate. In conclusion, CO-SAB incidence rate has increased, whereas MRSA incidence rate remained stable. The increasing CO-SAB incidence rate, especially the burden on older adults and neonates, underscores the importance of strong SAB surveillance to identify and respond to changes in bacteremia trends and antimicrobial resistance.

      8. Survival of children living with human immunodeficiency virus on antiretroviral therapy in Andhra Pradesh, IndiaExternal
        Jha UM, Dhingra N, Raj Y, Rewari BB, Jeyaseelan L, Harvey P, Chavan L, Saggurti N, Reddy DC.
        Indian Pediatrics. 2018 ;55(4):301-305.

        Objectives: To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India. Methods: The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability. Results: The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the &lt;5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ?200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ?350/mm3. Conclusion: Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

      9. The use of technology for STD partner services in the United States: A structured reviewExternal
        Kachur R, Hall W, Coor A, Kinsey J, Collins D, Strona FV.
        Sex Transm Dis. 2018 May 1.

        BACKGROUND: Since the late 1990s, health departments and STD programs throughout the U.S. have used technologies, such as the internet and mobile phones, to provide services to persons with a sexually transmitted infection, including HIV, and their sex partners, also known as partner services. This study reviewed the published literature to assess and compare partner services outcomes as a result of using technology and to calculate cost savings through cases averted. METHODS: We conducted a structured literature review of all U.S. studies that examined the use of technology to notify persons exposed to an STD (syphilis, chlamydia, gonorrhea), including HIV, by health care professionals in the U.S. from 2000 to 2017. Outcome measures, including the number of the number of partners notified, screened or tested; and new positives identified, were captured and cost savings were calculated, when data were available. RESULTS: Seven studies were identified. Methods used for partner services differed across studies, although email was the primary mode in 6 (83%) of the 7 studies. Only 2 of the 7 studies compared use of technology for partner services to traditional partner services. Between 10% and 97% of partners were successfully notified of their exposure through the use of technology and between 34% and 81% were screened or tested. Five studies reported on new infections identified, which ranged from 3-19. Use of technology for partner serves saved programs between $22,795 and $45,362 in direct and indirect medical costs. CONCLUSIONS: Use of technology for partner services increased the number of partners notified, screened or tested, and new infections found. Importantly, the use of technology allowed programs to reach partners who otherwise would not have been notified of their exposure to an STD or HIV. Improved response times and time to treatment were also seen as was re-engagement into care for previous HIV positive patients. Data and outcome measures across the studies were not standardized, making it difficult to generalize conclusions. Although not a replacement for traditional partner services, the use of technology enhances partner service outcomes.

      10. Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in Ethiopia: A cluster-randomised non-inferiority trialExternal
        Kallander K, Alfven T, Funk T, Abebe A, Hailemariam A, Getachew D, Petzold M, Steinhardt LC, Gutman JR.
        PLoS Med. 2018 Apr;15(4):e1002553.

        BACKGROUND: With declining malaria prevalence and improved use of malaria diagnostic tests, an increasing proportion of children seen by community health workers (CHWs) have unclassified fever. Current community management guidelines by WHO advise that children seen with non-severe unclassified fever (on day 1) should return to CHWs on day 3 for reassessment. We compared the safety of conditional follow-up reassessment only in cases where symptoms do not resolve with universal follow-up on day 3. METHODS AND FINDINGS: We undertook a 2-arm cluster-randomised controlled non-inferiority trial among children aged 2-59 months presenting with fever and without malaria, pneumonia, diarrhoea, or danger signs to 284 CHWs affiliated with 25 health centres (clusters) in Southern Nations, Nationalities, and Peoples’ Region, Ethiopia. The primary outcome was treatment failure (persistent fever, development of danger signs, hospital admission, death, malaria, pneumonia, or diarrhoea) at 1 week (day 8) of follow-up. Non-inferiority was defined as a 4% or smaller difference in the proportion of treatment failures with conditional follow-up compared to universal follow-up. Secondary outcomes included the percentage of children brought for reassessment, antimicrobial prescription, and severe adverse events (hospitalisations and deaths) after 4 weeks (day 29). From December 1, 2015, to November 30, 2016, we enrolled 4,595 children, of whom 3,946 (1,953 universal follow-up arm; 1,993 conditional follow-up arm) adhered to the CHW’s follow-up advice and also completed a day 8 study visit within +/-1 days. Overall, 2.7% had treatment failure on day 8: 0.8% (16/1,993) in the conditional follow-up arm and 4.6% (90/1,953) in the universal follow-up arm (risk difference of treatment failure -3.81%, 95% CI -infinity, 0.65%), meeting the prespecified criterion for non-inferiority. There were no deaths recorded by day 29. In the universal follow-up arm, 94.6% of caregivers reported returning for reassessment on day 3, in contrast to 7.5% in the conditional follow-up arm (risk ratio 22.0, 95% CI 17.9, 27.2, p < 0.001). Few children sought care from another provider after their initial visit to the CHW: 3.0% (59/1,993) in the conditional follow-up arm and 1.1% (22/1,953) in the universal follow-up arm, on average 3.2 and 3.4 days later, respectively, with no significant difference between arms (risk difference 1.79%, 95% CI -1.23%, 4.82%, p = 0.244). The mean travel time to another provider was 2.2 hours (95% CI 0.01, 5.3) in the conditional follow-up arm and 2.6 hours (95% CI 0.02, 4.5) in the universal follow-up arm (p = 0.82); the mean cost for seeking care after visiting the CHW was 26.5 birr (95% CI 7.8, 45.2) and 22.8 birr (95% CI 15.6, 30.0), respectively (p = 0.69). Though this study was an important step to evaluate the safety of conditional follow-up, the high adherence seen may have resulted from knowledge of the 1-week follow-up visit and may therefore not transfer to routine practice; hence, in an implementation setting it is crucial that CHWs are well trained in counselling skills to advise caregivers on when to come back for follow-up. CONCLUSIONS: Conditional follow-up of children with non-severe unclassified fever in a low malaria endemic setting in Ethiopia was non-inferior to universal follow-up through day 8. Allowing CHWs to advise caregivers to bring children back only in case of continued symptoms might be a more efficient use of resources in similar settings. TRIAL REGISTRATION: www.clinicaltrials.gov, identifier NCT02926625.

      11. Comparison of incidence and cost of influenza between healthy and high-risk children <60 months old in Thailand, 2011-2015External
        Kittikraisak W, Suntarattiwong P, Kanjanapattanakul W, Ditsungnoen D, Klungthong C, Lindblade KA, Fernandez S, Dawood FS, Chotpitayasunondh T, Olsen SJ.
        PLoS One. 2018 ;13(5):e0197207.

        INTRODUCTION: Thailand recommends influenza vaccination for children aged 6 months to <36 months, but investment in vaccine purchase is limited. To inform policy decision with respect to influenza disease burden and associated cost in young children and to support the continued inclusion of children as the recommended group for influenza vaccination, we conducted a prospective cohort study of children in Bangkok hospital to estimate and compare influenza incidence and cost between healthy and high-risk children. METHODS: Caregivers of healthy children and children with medical conditions (‘high-risk’) aged <36 months were called weekly for two years to identify acute respiratory illness (ARI) episodes and collect illness-associated costs. Children with ARI were tested for influenza viruses by polymerase chain reaction. Illnesses were categorized as mild or severe depending on whether children were hospitalized. Population-averaged Poisson models were used to compare influenza incidence by risk group. Quantile regression was used to examine differences in the median illness expenses. RESULTS: During August 2011-September 2015, 659 healthy and 490 high-risk children were enrolled; median age was 10 months. Incidence of mild influenza-associated ARI was higher among healthy than high-risk children (incidence rate ratio [IRR]: 1.67; 95% confidence interval [CI]: 1.13-2.48). Incidence of severe influenza-associated ARI did not differ (IRR: 0.40; 95% CI: 0.11-1.38). The median cost per mild influenza-associated ARI episode was $22 among healthy and $25 among high-risk children (3-4% of monthly household income; difference in medians: -$1; 95% CI for difference in medians: -$9 to $6). The median cost per severe influenza-associated ARI episode was $232 among healthy and $318 among high-risk children (26-40% and 36-54% of monthly household income, respectively; difference in medians: 110; 95% CI for difference in medians: -$352 to $571). CONCLUSIONS: Compared to high-risk children, healthy children had higher incidence of mild influenza-associated ARI but not severe influenza-associated ARI. Costs of severe influenza-associated ARI were substantial. These findings support the benefit of annual influenza vaccination in reducing the burden of influenza and associated cost in young children.

      12. Notes from the Field: Outbreak of Vibrio cholerae associated with attending a funeral – Chegutu District, Zimbabwe, 2018External
        McAteer JB, Danda S, Nhende T, Manamike P, Parayiwa T, Tarupihwa A, Tapfumanei O, Manangazira P, Mhlanga G, Garone DB, Martinsen A, Aubert RD, Davis W, Narra R, Balachandra S, Tippett Barr BA, Mintz E.
        MMWR Morb Mortal Wkly Rep. 2018 May 18;67(19):560-561.

        [No abstract]

      13. Undisclosed antiretroviral drug use in Botswana: implication for national estimatesExternal
        Moyo S, Gaseitsiwe S, Powis KM, Pretorius Holme M, Mohammed T, Zahralban-Steele M, Yankinde EK, Maphorisa C, Abrams W, Lebelonyane R, Manyake K, Sekoto T, Mmalane M, Gaolathe T, Wirth KE, Makhema J, Lockman S, Clarke W, Essex M, Novitsky V.
        Aids. 2018 May 11.

        Among 3596 HIV-positive participants enrolled in Botswana Combination Prevention Project who self-reported no prior antiretroviral (ARV) therapy use and were tested for viral load (n = 951; 27% of all participants), 136 (14%) had HIV-1 RNA less than 400 copies/ml. ARV drugs were detected in 52 (39%) of 134 participants tested. Adjusting for undisclosed ARV use increased the overall estimate of virally suppressed individuals on ARV therapy by 1.4% from 70.2 to 71.6%.

      14. Lack of virological suppression among young HIV-positive adults in BotswanaExternal
        Novitsky V, Gaolathe T, Mmalane M, Moyo S, Chakalisa U, Kadima Yankinda E, Marukutira T, Pretorius Holme M, Sekoto T, Gaseitsiwe S, Musonda R, van Widenfelt E, Powis KM, Khan N, Dryden-Peterson S, Bennett K, Wirth KE, Tchetgen Tchetgen E, Bachanas P, Mills LA, Lebelonyane R, Shenaaz EH, Makhema J, Lockman S, Essex M.
        J Acquir Immune Defic Syndr. 2018 Apr 27.

        BACKGROUND: HIV-1 RNA load is the best biological predictor of HIV transmission and treatment response. The rate of virologic suppression among key sub-populations can guide HIV prevention programs. METHODS: The Botswana Combination Prevention Project performed a population-based household survey among adults in 30 communities in Botswana. Data collected included knowledge of HIV-positive status, ART coverage and virologic suppression (HIV-1 RNA </=400 copies/mL). Individuals aged 16-29 years were considered young adults. RESULTS: Among 552 young people living with HIV (PLHIV) enrolled with RNA load data and ART status available, 51% (n=279) had undetectable HIV-1 RNA, including 54% of young women and 32% of young men (gender PR: 0.53; 95% CI: 0.43-0.80; p<0.001). Compared with older adults (30-64 years old), young HIV-infected adults were significantly less likely to have undetectable HIV-1 RNA (PR: 0.65; 95%CI: 0.59-0.70; p<0.0001), including both men (PR: 0.43; 95%CI: 0.34-0.56; p<0.0001) and women (PR: 0.67; 95%CI: 0.62-0.74; p<0.0001). Among a subset of PLHIV receiving ART, young adults also were less likely to have undetectable HIV-1 RNA load than older adults (PR: 0.93; 95%CI: 0.90-0.95; p=<0.0001). Analysis of the care continuum revealed that inferior HIV diagnosis and sub-optimal linkage to care are the primary reasons for low virologic suppression among young adults. CONCLUSIONS: Young adults in Botswana are significantly less likely to have undetectable HIV-1 RNA load compared with older adults. In the era of broad scale-up of ART, interventions able to diagnose young adults living with HIV and link them to effective therapy are urgently needed.

      15. High uptake of antiretroviral therapy among HIV-positive TB patients receiving co-located services in SwazilandExternal
        Pathmanathan I, Pasipamire M, Pals S, Dokubo EK, Preko P, Ao T, Mazibuko S, Ongole J, Dhlamini T, Haumba S.
        PLoS One. 2018 ;13(5):e0196831.

        BACKGROUND: Swaziland has the highest adult HIV prevalence and second highest rate of TB/HIV coinfection globally. Recently, the Ministry of Health and partners have increased integration and co-location of TB/HIV services, but the timing of antiretroviral therapy (ART) relative to TB treatment-a marker of program quality and predictor of outcomes-is unknown. METHODS: We conducted a retrospective analysis of programmatic data from 11 purposefully-sampled facilities to evaluate timely ART provision for HIV-positive TB patients enrolled on TB treatment between July-November 2014. Timely ART was defined as within two weeks of TB treatment initiation for patients with CD4<50/muL or missing, and within eight weeks otherwise. Descriptive statistics were estimated and logistic regression used to assess factors independently associated with timely ART. RESULTS: Of 466 HIV-positive TB patients, 51.5% were male, median age was 35 (interquartile range [IQR]: 29-42), and median CD4 was 137/muL (IQR: 58-268). 189 (40.6%) were on ART prior to, and five (1.8%) did not receive ART within six months of TB treatment initiation. Median time to ART after TB treatment initiation was 15 days (IQR: 14-28). Almost 90% started ART within eight weeks, and 45.5% of those with CD4<50/muL started within two weeks. Using thresholds for “timely ART” according to baseline CD4 count, 73.3% of patients overall received timely ART after TB treatment initiation. Patients with CD4 50-200/muL or >/=200/muL had significantly higher odds of timely ART than patients with CD4<50/muL, with adjusted odds ratios of 11.5 (95% confidence interval [CI]: 5.0-26.6) and 9.6 (95% CI: 4.6-19.9), respectively. TB cure or treatment completion was achieved by 71.1% of patients at six months, but this was not associated with timely ART. CONCLUSIONS: This study demonstrates the relative success of integrated and co-located TB/HIV services in Swaziland, and shows that timely ART uptake for HIV-positive TB patients can be achieved in resource-limited, but integrated settings. Gaps remain in getting patients with CD4<50/muL to receive ART within the recommended two weeks post TB treatment initiation.

      16. Rates of prevalent and new HIV diagnoses by race and ethnicity among men who have sex with men, U.S. states, 2013-2014External
        Rosenberg ES, Purcell DW, Grey JA, Hankin-Wei A, Hall E, Sullivan PS.
        Ann Epidemiol. 2018 Apr 30.

        PURPOSE: Men who have sex with men (MSM) bear a disproportionate burden of new and existing HIV infections in the United States, with black and Hispanic MSM facing the highest rates. A lack of data on MSM population sizes has precluded the understanding of state-level variations in these rates. METHODS: Using a recently developed model for estimating state-level population sizes of MSM by race that synthesizes data from the American Community Survey and the National Health and Nutrition Examination Survey, in conjunction with Centers for Disease Control and Prevention-based HIV diagnosis data, we estimated rates of living with an HIV diagnosis (2013) and new diagnosis among MSM (2014) by state and race. RESULTS: Nationally, state-level median prevalence of living with an HIV diagnosis was 10.6%. White MSM had lower prevalence in all but five states; black MSM were higher in all but three. Hispanic MSM had highest concentrations in Northeast and Mississippi Delta states. Patterns were similar for new diagnoses rates. CONCLUSIONS: Results suggest that racial disparities in HIV infection among MSM are more prominent than geographic ones. Interventions should be differentially tailored to areas of high proportionate and absolute burden. Continued efforts to understand and address racial differences in HIV infection are needed.

      17. Cholera epidemic – Lusaka, Zambia, October 2017-May 2018External
        Sinyange N, Brunkard JM, Kapata N, Mazaba ML, Musonda KG, Hamoonga R, Kapina M, Kapaya F, Mutale L, Kateule E, Nanzaluka F, Zulu J, Musyani CL, Winstead AV, Davis WW, N’Cho H S, Mulambya NL, Sakubita P, Chewe O, Nyimbili S, Onwuekwe EV, Adrien N, Blackstock AJ, Brown TW, Derado G, Garrett N, Kim S, Hubbard S, Kahler AM, Malambo W, Mintz E, Murphy J, Narra R, Rao GG, Riggs MA, Weber N, Yard E, Zyambo KD, Bakyaita N, Monze N, Malama K, Mulwanda J, Mukonka VM.
        MMWR Morb Mortal Wkly Rep. 2018 May 18;67(19):556-559.

        On October 6, 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of Vibrio cholerae O1, biotype El Tor, serotype Ogawa, from stool specimens from two patients with acute watery diarrhea. The two patients had gone to a clinic in Lusaka, the capital city, on October 4. Cholera cases increased rapidly, from several hundred cases in early December 2017 to approximately 2,000 by early January 2018 (Figure). In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples. In late December 2017, a number of water-related preventive actions were initiated, including increasing chlorine levels throughout the city’s water distribution system and placing emergency tanks of chlorinated water in the most affected neighborhoods; cholera cases declined sharply in January 2018. During January 10-February 14, 2018, approximately 2 million doses of oral cholera vaccine were administered to Lusaka residents aged >/=1 year. However, in mid-March, heavy flooding and widespread water shortages occurred, leading to a resurgence of cholera. As of May 12, 2018, the outbreak had affected seven of the 10 provinces in Zambia, with 5,905 suspected cases and a case fatality rate (CFR) of 1.9%. Among the suspected cases, 5,414 (91.7%), including 98 deaths (CFR = 1.8%), occurred in Lusaka residents.

      18. Risk factors associated with preterm delivery and low delivery weight among HIV-exposed neonates in ChinaExternal
        Wang L, Zhao H, Cai W, Tao J, Zhao Q, Sun L, Fan Q, Kourtis AP, Shepard C, Zhang F.
        Int J Gynaecol Obstet. 2018 May 17.

        OBJECTIVE: To examine the relationship between combination antiretroviral therapy (cART) and preterm delivery (PTD) or low delivery weight among pregnant Chinese women with HIV. METHODS: The present retrospective cross-sectional medical chart review enrolled pregnant women with HIV who delivered at five tertiary hospitals in China between January 1, 2009, and December 31, 2014. Generalized linear mixed modeling was used to explore PTD (<37 weeks of pregnancy) and low delivery weight (<2500 g) risk factors. RESULTS: Among 731 mother-neonate pairs, 93 (12.7%) mothers had PTD and 133 (18.2%) neonates had low delivery weight. Use of cART pre-conception or its initiation in the first trimester was associated with PTD (adjusted odds ratio [aOR] 2.82; P=0.002) and low delivery weight (aOR 1.92; P=0.026). First-trimester cART initiation was associated with PTD for lopinavir/ritonavir (aOR 2.59; P=0.006) and nevirapine (aOR, 2.64; P=0.003) regimens compared with later; the same was not true for efavirenz-based cART (P=0.197). Low maternal body mass index (</=23.5) before delivery was independently associated with an increased likelihood of low delivery weight (aOR 1.60; P=0.038) but not PTD. CONCLUSION: Early use of cART was associated with increased likelihood of PTD and low delivery weight. Efavirenz-based cART appear to be favorable for women with HIV regardless of the timing of cART initiation. Good nutritional status is essential to prevent low delivery weight. This article is protected by copyright. All rights reserved.

      19. Cutaneous melanoma risk among people with HIV in the United States and CanadaExternal
        Yanik EL, Hernandez-Ramirez RU, Qin L, Lin H, Leyden W, Neugebauer RS, Horberg MA, Moore RD, Mathews WC, Justice AC, Hessol NA, Mayor AM, Gill MJ, Brooks JT, Sun J, Althoff KN, Engels EA, Silverberg MJ, Dubrow R.
        J Acquir Immune Defic Syndr. 2018 Apr 27.

        BACKGROUND: Cutaneous melanoma incidence may be modestly elevated in people with HIV (PWH) versus people without HIV. However, little is known about the relationship of immunosuppression, HIV replication, and antiretroviral treatment (ART) with melanoma risk. METHODS: PWH of white race in the North American AIDS Cohort Collaboration on Research and Design were included. A standardized incidence ratio (SIR) was calculated comparing risk with the white general population, standardizing by age, sex, and calendar period. Associations between melanoma incidence and current, lagged, and cumulative measures of CD4 count, HIV RNA level, and ART use were estimated with Cox regression, adjusting for established risk factors such as age and annual residential ultraviolet B (UVB) exposure. RESULTS: Eighty melanomas were diagnosed among 33,934 white PWH (incidence=40.75 per 100,000 person-years). Incidence was not elevated compared with the general population (SIR=1.15, 95% confidence interval [95%CI]=0.91-1.43). Higher melanoma incidence was associated with older age (adjusted hazard ratio [aHR] per decade increase=1.50, 95%CI=1.20-1.89) and higher UVB exposure (aHR for exposure >/=35 vs. <35 mW/m=1.62, 95%CI=0.99-2.65). Current, lagged, and cumulative CD4 and HIV RNA were not associated with melanoma incidence. Melanoma incidence was higher among people ART-treated for a larger proportion of time in the prior 720 days (aHR per 10% increase=1.16, 95%CI=1.03-1.30). CONCLUSIONS: These results suggest that HIV-induced immune dysfunction does not influence melanoma development. The association between ART and melanoma risk may be due to increased skin surveillance among PWH engaged in clinical care. Associations with age and UVB confirmed those established in the general population.

      20. Optimal allocation of HIV prevention funds for state health departmentsExternal
        Yaylali E, Farnham PG, Cohen S, Purcell DW, Hauck H, Sansom SL.
        PLoS One. 2018 ;13(5):e0197421.

        OBJECTIVE: To estimate the optimal allocation of Centers for Disease Control and Prevention (CDC) HIV prevention funds for health departments in 52 jurisdictions, incorporating Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program funds, to improve outcomes along the HIV care continuum and prevent infections. METHODS: Using surveillance data from 2010 to 2012 and budgetary data from 2012, we divided the 52 health departments into 5 groups varying by number of persons living with diagnosed HIV (PLWDH), median annual CDC HIV prevention budget, and median annual HRSA expenditures supporting linkage to care, retention in care, and adherence to antiretroviral therapy. Using an optimization and a Bernoulli process model, we solved for the optimal CDC prevention budget allocation for each health department group. The optimal allocation distributed the funds across prevention interventions and populations at risk for HIV to prevent the greatest number of new HIV cases annually. RESULTS: Both the HIV prevention interventions funded by the optimal allocation of CDC HIV prevention funds and the proportions of the budget allocated were similar across health department groups, particularly those representing the large majority of PLWDH. Consistently funded interventions included testing, partner services and linkage to care and interventions for men who have sex with men (MSM). Sensitivity analyses showed that the optimal allocation shifted when there were differences in transmission category proportions and progress along the HIV care continuum. CONCLUSION: The robustness of the results suggests that most health departments can use these analyses to guide the investment of CDC HIV prevention funds into strategies to prevent the most new cases of HIV.

    • Disease Reservoirs and Vectors
      1. Pyrethroid insecticides maintain repellent effect on knock-down resistant populations of Aedes aegypti mosquitoesExternal
        Bowman NM, Akialis K, Cave G, Barrera R, Apperson CS, Meshnick SR.
        PLoS One. 2018 ;13(5):e0196410.

        Pyrethroid-treated clothing is commonly worn for protection against mosquitoes; pyrethroids are both insecticides and repellents. Pyrethroid resistance has become increasingly common in Aedes aegypti, the vector of dengue, Zika, and other arboviruses, but it is not clear whether resistance is associated with reductions in repellency. In order to determine whether long-lasting permethrin impregnated (LLPI) clothing is protective, we used Aedes aegypti from New Orleans, LA (pyrethroid-sensitive) and San Juan, PR (resistant) to measure both lethality and repellency. PCR and Sanger sequencing were used to confirm resistance status by detecting mutations in the kdr gene at positions 1016 and 1534. Arm-in-cage trials of 100 Aedes aegypti females from both populations were performed for 10 minutes to bare arm or an arm clothed in untreated military camouflage or military camouflage impregnated with deltamethrin, permethrin, or etofenprox. Trials were repeated 4-5 times on different days. Number of landings, number of blood meals, and immediate and 24-hour mortality were recorded. Mortality was extremely low in all trials. Compared to untreated cloth, mosquitoes demonstrated a trend towards a 2%-63% reduction in landings and a statistically significant 78-100% reduction in blood feeding on pyrethroid-treated cloth for most insecticides. Effects were observed in both pyrethroid-sensitive and pyrethroid-resistant mosquito populations. Our data show that kdr mutations are associated with pyrethroid resistance but are likely not the only contributors. Pyrethroids appear to maintain repellent effect against resistant mosquitoes. This finding suggests that even in places where pyrethroid resistance is widespread, permethrin still has a role for use as a repellent on clothing to protect against mosquito bites.

      2. An evaluation of removal trapping to control rodents inside homes in a plague-endemic region of rural Northwestern UgandaExternal
        Eisen RJ, Atiku LA, Boegler KA, Mpanga JT, Enscore RE, MacMillan K, Gage KL.
        Vector Borne Zoonotic Dis. 2018 May 16.

        Rodents pose a significant threat to human health, particularly in rural subsistence farming communities in Africa, where rodents threaten food security and serve as reservoirs of human pathogens, including the agents of plague, leptospirosis, murine typhus, rat-bite fever, Lassa fever, salmonellosis, and campylobacteriosis. Our study focused on the plague-endemic West Nile region of Uganda, where a majority of residents live in Uganda government-defined poverty, rely on subsistence farming for a living, and frequently experience incursions of rodents into their homes. In this study, we show that rodent removal was achieved in a median of 6 days of intensive lethal trapping with multiple trap types (range: 0-16 days). However, rodent abundance in 68.9% of homesteads returned to pretreatment levels within a median of 8 weeks (range 1-24 weeks), and at least a single rodent was captured in all homesteads by a median of 2 weeks (range 1-16 weeks) after removal efforts were terminated. Results were similar between homesteads that practiced rodent control whether or not their neighbors implemented similar strategies. Overall, intensive lethal trapping inside homes appears to be effective at reducing rodent abundance, but control was short lived after trapping ceased.

      3. Prevalence of Rickettsia species (Rickettsiales: Rickettsiaceae) in Dermacentor variabilis ticks (Acari: Ixodidae) in North CarolinaExternal
        Kakumanu ML, Ponnusamy L, Sutton H, Meshnick SR, Nicholson WL, Apperson CS.
        J Med Entomol. 2018 May 16.

        The American dog tick, Dermacentor variabilis (Say), is a vector of spotted fever group (SFG) rickettsiae, including Rickettsia rickettsii the causative organism of Rocky Mountain spotted fever (RMSF). In North Carolina, SFG rickettsioses (including RMSF) are a leading cause of tick-borne illness. Knowledge of the infection rate and geographic distribution of D. variabilis ticks infected with Rickettsia spp. provides information on the spatial distribution of public health risk. Accordingly, we extracted genomic DNA from adult D. variabilis collected from field habitats in 32 North Carolina counties from 2009 to 2013. A nested PCR assay of the 23S-5S intergenic spacer (IGS) region of Rickettsia coupled with reverse line blot hybridization (RLBH) with species-specific probes was used to detect and identify rickettsiae to species. Approximately half of the 532 tick DNA samples exhibited a band of the expected size on agarose gels, indicating infection with Rickettsia spp. RLBH analyses showed R. amblyommatis (formerly ‘Candidatus R. amblyommii’), R. parkeri, and R. montanensis were predominant, while other Rickettsia species detected included R. conorii-like, R. massiliae, R. rhipicephali, R. canadensis, R. bellii, and some unknown Rickettsia spp. Some ticks were infected with more than one Rickettsia species. Notably, several Rickettsia-positive ticks harbored R. rickettsii. DNA sequencing was performed on a portion of the 23S-5S IGS amplicons and the results were concordant with RLB assay results. We conclude that Rickettsia spp. are common in D. variabilis in North Carolina. Geographic patterns in the occurrence of Rickettsia-infected D. variabilis ticks across the counties sampled are discussed.

      4. Drivers of flea (Siphonaptera) community structure in sympatric wild carnivores in northwestern MexicoExternal
        Lopez-Perez AM, Gage K, Rubio AV, Montenieri J, Orozco L, Suzan G.
        J Vector Ecol. 2018 Jun;43(1):15-25.

        Host identity, habitat type, season, and interspecific interactions were investigated as determinants of the community structure of fleas on wild carnivores in northwestern Mexico. A total of 540 fleas belonging to seven species was collected from 64 wild carnivores belonging to eight species. We found that the abundances of some flea species are explained by season and host identity. Pulex irritans and Echidnophaga gallinacea abundances were significantly higher in spring than in fall season. Flea communities on carnivore hosts revealed three clusters with a high degree of similarity within each group that was explained by the flea dominance of E. gallinacea, P. simulans, and P. irritans across host identity. Flea abundances did not differ statistically among habitat types. Finally, we found a negative correlation between the abundances of three flea species within wild carnivore hosts. Individual hosts with high loads of P. simulans males usually had significantly lower loads of P. irritans males or tend to have lower loads of E. gallinacea fleas and vice-versa. Additionally, the logistic regression model showed that the presence of P. simulans males is more likely to occur in wild carnivore hosts in which P. irritans males are absent and vice-versa. These results suggest that there is an apparent competitive exclusion among fleas on wild carnivores. The study of flea community structure on wild carnivores is important to identify the potential flea vectors for infectious diseases and provide information needed to design programs for human health and wildlife conservation.

    • Environmental Health
      1. In this study, we examined associations between serum concentrations of 35 polychlorinated biphenyl (PCB) congeners, pesticides, and indicators of thyroid function in participants of the Anniston Community Health Survey (ACHS). Study subjects lived in the vicinity of a former PCB production facility and had PCB concentrations 2 to 3 times higher than similar age and race groups from the general population. We investigated associations among serum levels of thyroid hormones (thyroxin [T4], free thyroxin [fT4], triiodothyronine [T3], thyroid stimulation hormone [TSH]) and auto-antibodies (thyroglobulin antibody [TgAb] or thyroperoxidase antibody [TPOAb]) and combined indicators of thyroid function with the sum of PCBs, varying PCB groups, individual PCB congeners, and 8 pesticides. Logistic and linear regression models were adjusted for log10 transformed total lipids, age, sex, ethnicity, BMI, smoking, and family history of thyroid disease. We also performed analyses stratified by ethnicity and sex. Linear regression showed inverse associations between TT3 and thyroid-like PCBs (sum of PCBs 28, 52, 74, 101, 105, and 118; p = .0004), two pesticides (hexachlorobenzene, and pp’-DDE), and individual congeners (PCBs 74, 105). Null associations were observed between PCBs, pesticides, TSH, TT4, and fT4. Logistic regression analyses did not provide support for TT3 findings and found no association with other thyroid hormones, antibodies, or combined indicator of thyroid function. These results suggest there is little evidence that these chemicals have any major clinical effect on thyroid function in this highly PCB exposed population.

      2. Urinary concentrations of phthalate metabolites, bisphenols and personal care product chemical biomarkers in pregnant women in IsraelExternal
        Machtinger R, Berman T, Adir M, Mansur A, Baccarelli AA, Racowsky C, Calafat AM, Hauser R, Nahum R.
        Environ Int. 2018 May 10;116:319-325.

        Mounting evidence suggests possible adverse effects of intrauterine exposure to certain phenols and phthalates, two classes of endocrine disruptor chemicals, on the developing fetus, with consequences into later life. These findings have contributed to the replacement of some chemicals, such as di2ethylhexyl phthalate (DEHP) and bisphenol A (BPA), in consumer products. For the current study we quantified urinary concentrations of biomarkers of exposure among 50 pregnant women in Israel to several phthalates, bisphenols and personal care product chemicals, as well as DEHP and BPA alternatives. We detected 14 of the 31 biomarkers in more than 90% of the women. We detected biomarkers of 1,2cyclohexane dicarboxylic acid, diisononyl ester (DINCH), bisphenol S, and bisphenol F not as frequently (27-56%). This study is the first to evaluate exposure to triclosan, bisphenols, parabens, and phthalates and BPA alternatives among Israeli pregnant women.

      3. Exposure of dioxin-like chemicals in participants of the Anniston Community Health Survey follow-upExternal
        Yang E, Pavuk M, Sjodin A, Lewin M, Jones R, Olson J, Birnbaum L.
        Sci Total Environ. 2018 May 12;637-638:881-891.

        The 2014 follow-up of the Anniston Community Health Survey (ACHS II) consisted of 338 surviving participants from the 2005-2007 baseline study (ACHS) who had previous polychlorinated biphenyl (PCB) measurements, were not pregnant, and were not institutionalized. Questionnaires and blood samples provided the demographic, personal history, and chemical concentration data of the Anniston residents. Approximately 51% of participants were African American, 72% were female, and the mean age was 63years old. The objectives of this study were to provide an exposure assessment of dioxin-like chemicals in the ACHS II participants and compare the measurements with the general United States (U.S.) population via the National Health and Nutrition Examination Survey (NHANES). Stratified analyses revealed significantly higher average total dioxin toxic equivalencies (TEQs) among African Americans compared to Whites (33.1 vs. 19.2pg/g lipid), and in females compared to males (29.8 vs. 17.0pg/g lipid). When adjusting for age, sex, and race in linear regression, we found ACHS II participants to have significantly higher total dioxin TEQ than the general 2014 U.S. population that we estimated for using half-life and NHANES 2003/04 data (most recent NHANES individual samples data), by 16.7pg/g lipid. Principal component analyses showed that non-ortho and mono-ortho PCBs were separated from the other dioxin-like chemicals among the Anniston residents, whereas the chemicals were all clustered together for estimated NHANES 2014. The concentrations of dioxin-like chemicals, especially non-ortho and mono-ortho PCBs, in Anniston residents who resided near the former PCB production plant were higher than those in the general U.S. POPULATION: Although data strongly supported this difference, these inferences are limited because NHANES 2013/14 data were unavailable and we used estimated NHANES 2014 levels that we imputed from NHANES 2003/04 data in conjunction with half-life values estimated from Milbrath et al., 2009.

    • Epidemiology and Surveillance
      1. Evaluating behavioral health surveillance systemsExternal
        Azofeifa A, Stroup DF, Lyerla R, Largo T, Gabella BA, Smith CK, Truman BI, Brewer RD, Brener ND.
        Prev Chronic Dis. 2018 May 10;15:E53.

        In 2015, more than 27 million people in the United States reported that they currently used illicit drugs or misused prescription drugs, and more than 66 million reported binge drinking during the previous month. Data from public health surveillance systems on drug and alcohol abuse are crucial for developing and evaluating interventions to prevent and control such behavior. However, public health surveillance for behavioral health in the United States has been hindered by organizational issues and other factors. For example, existing guidelines for surveillance evaluation do not distinguish between data systems that characterize behavioral health problems and those that assess other public health problems (eg, infectious diseases). To address this gap in behavioral health surveillance, we present a revised framework for evaluating behavioral health surveillance systems. This system framework builds on published frameworks and incorporates additional attributes (informatics capabilities and population coverage) that we deemed necessary for evaluating behavioral health-related surveillance. This revised surveillance evaluation framework can support ongoing improvements to behavioral health surveillance systems and ensure their continued usefulness for detecting, preventing, and managing behavioral health problems.

    • Genetics and Genomics
      1. Genetic diversity of human sapovirus across the AmericasExternal
        Diez-Valcarce M, Castro CJ, Marine RL, Halasa N, Mayta H, Saito M, Tsaknaridis L, Pan CY, Bucardo F, Becker-Dreps S, Lopez MR, Magana LC, Ng TF, Vinje J.
        J Clin Virol. 2018 May 6;104:65-72.

        BACKGROUND: Sapoviruses are responsible for sporadic and epidemic acute gastroenteritis worldwide. Sapovirus typing protocols have a success rate as low as 43% and relatively few complete sapovirus genome sequences are available to improve current typing protocols. OBJECTIVE/STUDY DESIGN: To increase the number of complete sapovirus genomes to better understand the molecular epidemiology of human sapovirus and to improve the success rate of current sapovirus typing methods, we used deep metagenomics shotgun sequencing to obtain the complete genomes of 68 sapovirus samples from four different countries across the Americas (Guatemala, Nicaragua, Peru and the US). RESULTS: VP1 genotyping showed that all sapovirus sequences could be grouped in the four established genogroups (GI (n=13), GII (n=30), GIV (n=23), GV (n=2)) that infect humans. They include the near-complete genome of a GI.6 virus and a recently reported novel GII.8 virus. Sequences of the complete RNA-dependent RNA polymerase gene could be grouped into three major genetic clusters or polymerase (P) types (GI.P, GII.P and GV.P) with all GIV viruses harboring a GII polymerase. One (GII.P-GII.4) of the new 68 sequences was a recombinant virus with the hotspot between the NS7 and VP1 regions. CONCLUSIONS: Analyses of this expanded database of near-complete sapovirus sequences showed several mismatches in the genotyping primers, suggesting opportunities to revisit and update current sapovirus typing methods.

      2. Genome sequences of Akhmeta virus, an early divergent old world orthopoxvirusExternal
        Gao J, Gigante C, Khmaladze E, Liu P, Tang S, Wilkins K, Zhao K, Davidson W, Nakazawa Y, Maghlakelidze G, Geleishvili M, Kokhreidze M, Carroll DS, Emerson G, Li Y.
        Viruses. 2018 May 12;10(5).

        Annotated whole genome sequences of three isolates of the Akhmeta virus (AKMV), a novel species of orthopoxvirus (OPXV), isolated from the Akhmeta and Vani regions of the country Georgia, are presented and discussed. The AKMV genome is similar in genomic content and structure to that of the cowpox virus (CPXV), but a lower sequence identity was found between AKMV and Old World OPXVs than between other known species of Old World OPXVs. Phylogenetic analysis showed that AKMV diverged prior to other Old World OPXV. AKMV isolates formed a monophyletic clade in the OPXV phylogeny, yet the sequence variability between AKMV isolates was higher than between the monkeypox virus strains in the Congo basin and West Africa. An AKMV isolate from Vani contained approximately six kb sequence in the left terminal region that shared a higher similarity with CPXV than with other AKMV isolates, whereas the rest of the genome was most similar to AKMV, suggesting recombination between AKMV and CPXV in a region containing several host range and virulence genes.

      3. High-quality whole-genome sequences for 77 Shiga toxin-producing Escherichia coli strains generated with PacBio sequencingExternal
        Patel PN, Lindsey RL, Garcia-Toledo L, Rowe LA, Batra D, Whitley SW, Drapeau D, Stoneburg D, Martin H, Juieng P, Loparev VN, Strockbine N.
        Genome Announc. 2018 May 10;6(19).

        Shiga toxin-producing Escherichia coli (STEC) is an enteric foodborne pathogen that can cause mild to severe illness. Here, we report the availability of high-quality whole-genome sequences for 77 STEC strains generated using the PacBio sequencing platform.

    • Health Disparities
      1. Implementation research to address the United States health disadvantage: Report of a National Heart, Lung, and Blood Institute WorkshopExternal
        Engelgau MM, Narayan KM, Ezzati M, Salicrup LA, Belis D, Aron LY, Beaglehole R, Beaudet A, Briss PA, Chambers DA, Devaux M, Fiscella K, Gottlieb M, Hakkinen U, Henderson R, Hennis AJ, Hochman JS, Jan S, Koroshetz WJ, Mackenbach JP, Marmot MG, Martikainen P, McClellan M, Meyers D, Parsons PE, Rehnberg C, Sanghavi D, Sidney S, Siega-Riz AM, Straus S, Woolf SH, Constant S, Creazzo TL, de Jesus JM, Gavini N, Lerner NB, Mishoe HO, Nelson C, Peprah E, Punturieri A, Sampson U, Tracy RL, Mensah GA.
        Glob Heart. 2018 Apr 28.

        Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

    • Health Economics
      1. [No abstract]

      2. Drivers of patient costs in accessing HIV/AIDS services in TanzaniaExternal
        Mnzava T, Mmari E, Berruti A.
        J Int Assoc Provid AIDS Care. 2018 Jan-Dec;17:2325958218774775.

        BACKGROUND: Patient costs pose a challenge in accessing antiretroviral therapy for people living with HIV in sub-Saharan Africa. The study aimed at identifying drivers for out-of-pocket (OOP) costs in Tanzania. METHODS: In 2009, 500 adult patients who attended 10 HIV clinics across 7 regions of Tanzania were asked about time and resources consumed to access HIV services. Bivariate and multivariate median regression models were used to determine the main drivers for OOP costs. RESULTS: Male and female patients have a median OOP costs of $40.37 and $28.01 per year, respectively ( P = .01). Males spend significantly more on travel ($26.51) than females ($19.68; P = .02). Living in rural areas and poor social economic status (SES) are associated with greater OOP costs ( P = .001) for both sexes. CONCLUSION: Poor SES and rural residence are main drivers of OOP costs. Patients are less likely to seek health care unless they are in dire need, leading to expensive services.

      3. Diabetes-attributable nursing home costs for each U.S. stateExternal
        Neuwahl SJ, Honeycutt AA, Poehler DC, Shrestha SS, Zhang P, Hoerger TJ.
        Diabetes Care. 2018 May 14.

        OBJECTIVE: To estimate the diabetes-attributable nursing home costs for each state. RESEARCH DESIGN AND METHODS: We used a diabetes-attributable fraction (AF) approach to estimate nursing home costs attributable to diabetes (in 2013 $) in aggregate and per person with diabetes in each state. We calculated the AFs as the difference in diabetes prevalence between nursing homes and the community. We used the Centers for Medicare and Medicaid’s 2013-2015 Minimum Data Set to estimate the prevalence of diabetes in nursing homes and to adjust for the intensity of care among people with diabetes in nursing homes. Community prevalence was estimated using the Behavioral Risk Factor Surveillance System (BRFSS). State nursing home expenditures were from the 2013 State Health Expenditure Accounts. RESULTS: The fraction of total nursing home expenditures attributable to diabetes ranged from 12.3% (Illinois) to 22.5% (Washington, DC; median AF of 15.6%, New Jersey). The median AF was highest in the 19-64 years age-group and lowest in the 85 years or older age-group. Nationally, diabetes-attributable nursing home costs were $18.6 billion. State-level diabetes-attributable costs ranged from $21 million in Alaska to $2.0 billion in California. Diabetes-attributable nursing home costs per person ranged from $374 in New Mexico to $1,610 in Washington, DC (median of $799 in Maine). CONCLUSIONS: Our estimates provide state policymakers with an improved understanding of the economic burden of diabetes in each state’s nursing homes. These estimates could serve as critical inputs for planning and evaluating diabetes prevention and management interventions that can keep people healthier and living longer in their communities.

    • Healthcare Associated Infections
      1. Hydrogel delivery of lysostaphin eliminates orthopedic implant infection by Staphylococcus aureus and supports fracture healingExternal
        Johnson CT, Wroe JA, Agarwal R, Martin KE, Guldberg RE, Donlan RM, Westblade LF, Garcia AJ.
        Proc Natl Acad Sci U S A. 2018 May 14.

        Orthopedic implant infections are a significant clinical problem, with current therapies limited to surgical debridement and systemic antibiotic regimens. Lysostaphin is a bacteriolytic enzyme with high antistaphylococcal activity. We engineered a lysostaphin-delivering injectable PEG hydrogel to treat Staphylococcus aureus infections in bone fractures. The injectable hydrogel formulation adheres to exposed tissue and fracture surfaces, ensuring efficient, local delivery of lysostaphin. Lysostaphin encapsulation within this synthetic hydrogel maintained enzyme stability and activity. Lysostaphin-delivering hydrogels exhibited enhanced antibiofilm activity compared with soluble lysostaphin. Lysostaphin-delivering hydrogels eradicated S. aureus infection and outperformed prophylactic antibiotic and soluble lysostaphin therapy in a murine model of femur fracture. Analysis of the local inflammatory response to infections treated with lysostaphin-delivering hydrogels revealed indistinguishable differences in cytokine secretion profiles compared with uninfected fractures, demonstrating clearance of bacteria and associated inflammation. Importantly, infected fractures treated with lysostaphin-delivering hydrogels fully healed by 5 wk with bone formation and mechanical properties equivalent to those of uninfected fractures, whereas fractures treated without the hydrogel carrier were equivalent to untreated infections. Finally, lysostaphin-delivering hydrogels eliminate methicillin-resistant S. aureus infections, supporting this therapy as an alternative to antibiotics. These results indicate that lysostaphin-delivering hydrogels effectively eliminate orthopedic S. aureus infections while simultaneously supporting fracture repair.

    • Immunity and Immunization
      1. BACKGROUND: Nicaragua implemented an influenza vaccination program for pregnant women with high-risk obstetric conditions in 2007. In 2014, the recommendation of influenza vaccination expanded to include all pregnant women. Given the expansion in the recommendation of vaccination, we evaluated knowledge, attitudes and practices of pregnant women and their healthcare providers towards influenza vaccination and its recommendation. METHODS: We conducted surveys among pregnant women and their healthcare providers from June to August 2016 at two hospitals and 140 health facilities in Managua. The questions were adapted from the U.S. national CDC influenza survey and related to knowledge, attitudes and practices about influenza vaccination and barriers to vaccination. We analyzed reasons for not receiving vaccination among pregnant women as well as receipt of vaccination recommendation and offer by their healthcare providers. RESULTS: Of 1,303 pregnant women enrolled, 42% (545) reported receiving influenza vaccination in the 2016 season. Of those who reported not receiving vaccination, 46% indicated barriers to vaccination. Pregnant women who were vaccinated were more likely to be aware of the recommendation for vaccination and the risks of influenza illness during pregnancy and to perceive the vaccine as safe and effective, compared to unvaccinated pregnant women (p-values<0.001). Of the 619 health workers enrolled, over 89% recalled recommending influenza vaccination to all pregnant women, regardless of obstetric risk. Of the 1,223 women who had a prenatal visit between the start date of the influenza vaccination and the time of interview, 44% recalled receiving a recommendation for influenza vaccination and 43% were offered vaccination. Vaccination rates were higher for those receiving a recommendation and offer of vaccination compared with those who received neither (95% vs 5%, p-value<0.001). CONCLUSION: Pregnant women in Managua had positive perceptions of influenza vaccine and were receptive to receiving influenza vaccination, especially after the offer and recommendation by their healthcare providers.

      2. Sustained impact of rotavirus vaccine introduction on rotavirus gastroenteritis hospitalizations in children <5 years of age, Ghana, 2009-2016External
        Enweronu-Laryea CC, Armah G, Sagoe KW, Ansong D, Addo-Yobo E, Diamenu SK, Mwenda JM, Parashar UD, Tate JE.
        Vaccine. 2018 May 8.

        INTRODUCTION: Ghana introduced monovalent rotavirus vaccine in April 2012. We sought to determine the long-term impact of routine rotavirus vaccination on rotavirus gastroenteritis hospitalizations in Ghana during the first 4years following rotavirus vaccine introduction. METHODS: Active sentinel surveillance for acute gastroenteritis hospitalizations among children <5years of age was conducted at two sites from July 2009 through June 2016. Stool specimens were collected from enrolled children and tested by enzyme immunoassay. Changes in the proportion of all-cause gastroenteritis hospitalizations due to rotavirus pre- (July 2009-June 2012) and post-vaccine introduction (July 2012-June 2016) were compared using chi-square test. RESULTS: The proportion of acute gastroenteritis hospitalizations due to rotavirus among children <5years of age significantly declined by 42% from a pre-vaccine median of 50% (343/684) to a post-vaccine median of 29% (118/396) (p<0.001). The age distribution of rotavirus hospitalizations shifted toward older ages with 64% (759/1197) of rotavirus hospitalizations occurring in children <12months of age pre-vaccine introduction to 47% (212/453) occurring in children <12months of age post-vaccine introduction (p<0.001). DISCUSSION: The decline in rotavirus hospitalizations following rotavirus vaccine introduction have been sustained over the first 4years of the vaccination program in Ghana. Continued vaccination against rotavirus will ensure that this burden remains low.

      3. BACKGROUND: Provider recommendation is associated with influenza vaccination receipt. The objectives of this study were to estimate the percentage of children 6months-17years for whom a provider recommendation for influenza vaccination was received, identify factors associated with receipt of provider recommendation, and evaluate the association between provider recommendation and influenza vaccination status among children. METHODS: National Immunization Survey-Flu (NIS-Flu) parentally reported data for the 2013-14, 2014-15, and 2015-16 seasons were analyzed. Tests of association between provider recommendation and demographic characteristics were conducted using Wald chi-square tests and pairwise comparison t-tests. Multivariable logistic regression was used to determine variables independently associated with receiving provider recommendation and the association between provider recommendation and influenza vaccination status. RESULTS: Approximately 70% of children had a parent report receiving a provider recommendation for influenza vaccination for their child. The strongest association between receipt of provider recommendation and demographic characteristics was with child’s age, with younger children (6-23months, 2-4years, and 5-12years) being more likely to have a provider recommendation than older children (13-17years). In addition, children living in a household above poverty with household income >$75,000 were more likely to have a parent report receipt of a provider recommendation than children living below poverty. Children with a provider recommendation were twice as likely to be vaccinated than those without. CONCLUSIONS: This study affirms the importance of provider recommendation for influenza vaccination among children. Ensuring that parents of all children receive a provider recommendation may improve vaccination coverage.

      4. Impact of routine rotavirus vaccination on all-cause and rotavirus hospitalizations during the first four years following vaccine introduction in RwandaExternal
        Sibomana H, Rugambwa C, Mwenda JM, Sayinzoga F, Iraguha G, Uwimana J, Parashar UD, Tate JE.
        Vaccine. 2018 May 10.

        BACKGROUND: Rwanda introduced pentavalent rotavirus vaccine into its national immunization program in 2012. To determine the long-term impact of rotavirus vaccine on disease burden in a high burden setting, we examined trends in rotavirus and all-cause diarrhea hospitalizations in the first four years following rotavirus vaccine introduction. METHODS: We used data from an active surveillance system, from a review of pediatric ward registries, and from the Health Management Information System to describe trends in rotavirus and all-cause diarrhea hospitalizations from January 2009 through December 2016. Percent reductions were calculated to compare the number of all-cause and rotavirus diarrhea hospitalizations pre- and post-rotavirus vaccine introduction. RESULTS: The proportion of diarrhea hospitalizations due to rotavirus declined by 25-44% among all children <5years of age during 2013-2015 with a shift in rotavirus hospitalizations to older age groups. The proportion of total hospitalizations due to diarrhea among children <5years of age decreased from 19% pre-vaccine introduction to 12-13% post-vaccine introduction. In the national hospital discharge data, substantial decreases were observed in all-cause diarrhea hospitalizations among children <5years of age in 2013 and 2014 but these gains lessened in 2015-2016. DISCUSSION: Continued monitoring of long-term trends in all-cause diarrhea and rotavirus hospitalizations is important to ensure that the impact of the vaccination program is sustained over time and to better understand the changing age dynamics of diarrhea and rotavirus hospitalizations in the post-vaccine introduction era.

    • Laboratory Sciences
      1. Virulent PB1-F2 residues: effects on fitness of H1N1 influenza A virus in mice and changes during evolution of human influenza A virusesExternal
        Alymova IV, McCullers JA, Kamal RP, Vogel P, Green AM, Gansebom S, York IA.
        Sci Rep. 2018 May 10;8(1):7474.

        Specific residues of influenza A virus (IAV) PB1-F2 proteins may enhance inflammation or cytotoxicity. In a series of studies, we evaluated the function of these virulence-associated residues in the context of different IAV subtypes in mice. Here, we demonstrate that, as with the previously assessed pandemic 1968 (H3N2) IAV, PB1-F2 inflammatory residues increase the virulence of H1N1 IAV, suggesting that this effect might be a universal feature. Combining both inflammatory and cytotoxic residues in PB1-F2 enhanced virulence further, compared to either motif alone. Residues from these virulent motifs have been present in natural isolates from human seasonal IAV of all subtypes, but there has been a trend toward a gradual reduction in the number of virulent residues over time. However, human IAV of swine and avian origin tend to have more virulent residues than do the human-adapted seasonal strains, raising the possibility that donation of PB1 segments from these zoonotic viruses may increase the severity of some seasonal human strains. Our data suggest the value of surveillance of virulent residues in both human and animal IAV to predict the severity of influenza season.

      2. Identification and characterization of Salmonella enterica serotype Newport isolates with decreased susceptibility to ciprofloxacin in the United StatesExternal
        Campbell D, Tagg K, Bicknese A, McCullough A, Chen J, Karp BE, Folster JP.
        Antimicrob Agents Chemother. 2018 May 14.

        Nontyphoidal Salmonella (NTS) causes an estimated 1.2 million illnesses, 23,000 hospitalizations, and 450 deaths each year in the United States. Decreased susceptibility to ciprofloxacin (DSC) has historically been associated with chromosomal mutations (QRDR), but plasmid-mediated quinolone resistance (PMQR) genes are increasing. To investigate DSC among serotype Newport, we examined 40 isolates with DSC from 1996-2016. Thirty isolates (71%) contained the PMQR gene, qnrB, and eight isolates (19%) contained a QRDR…..

      3. Schistosomiasis induces persistent DNA methylation and tuberculosis-specific immune changesExternal
        DiNardo AR, Nishiguchi T, Mace EM, Rajapakshe K, Mtetwa G, Kay A, Maphalala G, Secor WE, Mejia R, Orange JS, Coarfa C, Bhalla KN, Graviss EA, Mandalakas AM, Makedonas G.
        J Immunol. 2018 May 11.

        Epigenetic mechanisms, such as DNA methylation, determine immune cell phenotype. To understand the epigenetic alterations induced by helminth coinfections, we evaluated the longitudinal effect of ascariasis and schistosomiasis infection on CD4(+) T cell DNA methylation and the downstream tuberculosis (TB)-specific and bacillus Calmette-Guerin-induced immune phenotype. All experiments were performed on human primary immune cells from a longitudinal cohort of recently TB-exposed children. Compared with age-matched uninfected controls, children with active Schistosoma haematobium and Ascaris lumbricoides infection had 751 differentially DNA-methylated genes, with 72% hypermethylated. Gene ontology pathway analysis identified inhibition of IFN-gamma signaling, cellular proliferation, and the Th1 pathway. Targeted real-time quantitative PCR after methyl-specific endonuclease digestion confirmed DNA hypermethylation of the transcription factors BATF3, ID2, STAT5A, IRF5, PPARg, RUNX2, IRF4, and NFATC1 and cytokines or cytokine receptors IFNGR1, TNFS11, RELT (TNF receptor), IL12RB2, and IL12B (p < 0.001; Sidak-Bonferroni). Functional blockage of the IFN-gamma signaling pathway was confirmed, with helminth-infected individuals having decreased upregulation of IFN-gamma-inducible genes (Mann-Whitney p < 0.05). Hypomethylation of the IL-4 pathway and DNA hypermethylation of the Th1 pathway was confirmed by Ag-specific multidimensional flow cytometry demonstrating decreased TB-specific IFN-gamma and TNF and increased IL-4 production by CD4+ T cells (Wilcoxon signed-rank p < 0.05). In S. haematobium-infected individuals, these DNA methylation and immune phenotypic changes persisted at least 6 mo after successful deworming. This work demonstrates that helminth infection induces DNA methylation and immune perturbations that inhibit TB-specific immune control and that the duration of these changes are helminth specific.

      4. A cynomolgus macaque model for Crimean-Congo haemorrhagic feverExternal
        Haddock E, Feldmann F, Hawman DW, Zivcec M, Hanley PW, Saturday G, Scott DP, Thomas T, Korva M, Avsic-Zupanc T, Safronetz D, Feldmann H.
        Nat Microbiol. 2018 May;3(5):556-562.

        Crimean-Congo haemorrhagic fever (CCHF) is the most medically significant tick-borne disease, being widespread in the Middle East, Asia, Africa and parts of Europe (1) . Increasing case numbers, westerly movement and broadly ranging case fatality rates substantiate the concern of CCHF as a public health threat. Ixodid ticks of the genus Hyalomma are the vector for CCHF virus (CCHFV), an arbovirus in the genus Orthonairovirus of the family Nairoviridae. CCHFV naturally infects numerous wild and domestic animals via tick bite without causing obvious disease(2,3). Severe disease occurs only in humans and transmission usually happens through tick bite or contact with infected animals or humans. The only CCHF disease model is a subset of immunocompromised mice(4-6). Here, we show that following CCHFV infection, cynomolgus macaques exhibited hallmark signs of human CCHF with remarkably similar viral dissemination, organ pathology and disease progression. Histopathology showed infection of hepatocytes, endothelial cells and monocytes and fatal outcome seemed associated with endothelial dysfunction manifesting in a clinical shock syndrome with coagulopathy. This non-human primate model will be an invaluable asset for CCHFV countermeasures development.

      5. A digital microfluidic system for serological immunoassays in remote settingsExternal
        Ng AH, Fobel R, Fobel C, Lamanna J, Rackus DG, Summers A, Dixon C, Dryden MD, Lam C, Ho M, Mufti NS, Lee V, Asri MA, Sykes EA, Chamberlain MD, Joseph R, Ope M, Scobie HM, Knipes A, Rota PA, Marano N, Chege PM, Njuguna M, Nzunza R, Kisangau N, Kiogora J, Karuingi M, Burton JW, Borus P, Lam E, Wheeler AR.
        Sci Transl Med. 2018 Apr 25;10(438).

        Serosurveys are useful for assessing population susceptibility to vaccine-preventable disease outbreaks. Although at-risk populations in remote areas could benefit from this type of information, they face several logistical barriers to implementation, such as lack of access to centralized laboratories, cold storage, and transport of samples. We describe a potential solution: a compact and portable, field-deployable, point-of-care system relying on digital microfluidics that can rapidly test a small volume of capillary blood for disease-specific antibodies. This system uses inexpensive, inkjet-printed digital microfluidic cartridges together with an integrated instrument to perform enzyme-linked immunosorbent assays (ELISAs). We performed a field validation of the system’s analytical performance at Kakuma refugee camp, a remote setting in northwestern Kenya, where we tested children aged 9 to 59 months and caregivers for measles and rubella immunoglobulin G (IgG). The IgG assays were determined to have sensitivities of 86% [95% confidence interval (CI), 79 to 91% (measles)] and 81% [95% CI, 73 to 88% (rubella)] and specificities of 80% [95% CI, 49 to 94% (measles)] and 91% [95% CI, 76 to 97% (rubella)] (measles, n = 140; rubella, n = 135) compared with reference tests (measles IgG and rubella IgG ELISAs from Siemens Enzygnost) conducted in a centralized laboratory. These results demonstrate a potential role for this point-of-care system in global serological surveillance, particularly in remote areas with limited access to centralized laboratories.

      6. Effects of gel volume on pharmacokinetics for vaginal and rectal applications of combination DuoGel-IQB4012, a dual chamber-dual drug HIV microbicide gel, in pigtailed macaquesExternal
        Pereira LE, Singletary T, Martin A, Dinh CT, Deyounks F, Holder A, McNicholl J, Buckheit KW, Buckheit RW, Ham A, Katz DF, Smith JM.
        Drug Deliv Transl Res. 2018 May 14.

        This study evaluated effects of differing gel volumes on pharmacokinetics (PK). IQB4012, a gel containing the non-nucleoside reverse transcriptase inhibitor IQP-0528 and tenofovir (TFV), was applied to the pigtailed macaque vagina and rectum. Vaginal gel volumes (1% loading of both drugs) were 0.5 or 1.5 ml; following wash-out, 1 or 4 ml of gel were then applied rectally. Blood, vaginal, and rectal fluids were collected at 0, 2, 4, and 24 h. Vaginal and rectal tissue biopsies were collected at 4 and 24 h. There were no statistically significant differences in concentrations for either drug between gel volumes within compartments at matched time points. After vaginal gel application, median IQP-0528 concentrations were ~ 10(4)-10(5) ng/g, 10(5)-10(6) ng/ml, and 10(3)-10(5) ng/ml in vaginal tissues, vaginal fluids, and rectal fluids, respectively (over 24 h). Median vaginal TFV concentrations were 1-2 logs lower than IQP-0528 levels at matched time points. After rectal gel application, median IQP-0528 and TFV concentrations in rectal fluids were ~ 10(3)-10(5) ng/ml and ~ 10(2)-10(3) ng/ml, respectively. Concentrations of both drugs sampled in rectal tissues were low (~ 10(1)-10(3) ng/g). For 1 ml gel, half of sampled rectal tissues had undetectable concentrations of either drug, and over half of sampled rectal fluids had undetectable TFV concentrations. These results indicate differences in drug delivery between the vaginal and rectal compartments, and that smaller vaginal gel volumes may not significantly compromise microbicide PK and prophylactic potential. However, effects of rectal gel volume on PK for both drugs were less definitive.

    • Maternal and Child Health
      1. Women’s periconceptional diet and risk of biliary atresia in offspringExternal
        Carmichael SL, Ma C, Van Zutphen AR, Moore CA, Shaw GM.
        Birth Defects Res. 2018 May 15.

        INTRODUCTION: We examined the association of biliary atresia with maternal dietary intake, using National Birth Defects Prevention Study (NBDPS) data from 152 cases and 11,112 nonmalformed controls born 1997-2011. METHODS: NBDPS is a multisite, population-based case-control study. Exposure data were from maternal telephone interviews, which included a food frequency questionnaire. Odds ratios (OR) and 95% confidence intervals (CI) were generated from logistic regression models that included nutritional factors as continuous variables and were adjusted for energy intake only or energy intake plus covariates (maternal race-ethnicity, education, age, prepregnancy body mass index, vitamin/mineral supplement intake, conception during summer). Models included a quadratic term for the nutrient if p < 0.10. ORs reflect odds of having biliary atresia for nutrient values at the 75th compared to 25th percentile values of each nutrient, based on distributions among controls. RESULTS: ORs for which the 95% CI excluded 1.00 were energy-adjusted ORs for calcium (0.63), protein (0.65), riboflavin (0.71), and diet quality index (0.69), and fully adjusted ORs for calcium (0.68) and vitamin E (0.72). ORs that were fully adjusted for covariates tended to be closer to 1.0 than ORs adjusted only for energy intake. ORs for the other studied nutrients had 95% CIs that included 1.00. CONCLUSIONS: NBDPS is the first study to include detailed information on maternal dietary intake and risk of biliary atresia. Our results suggest reduced risks associated with some nutrients, which may provide etiologic clues but should be interpreted with caution given the small number of cases and novelty of the investigation.

      2. Background: The US CDC and the Institute of Medicine recommend that women capable of becoming pregnant consume >/=400 microg synthetic folic acid/d to prevent neural tube defects (NTDs). The United States has 3 sources of folic acid: fortified enriched cereal grain products (ECGPs), fortified ready-to-eat (RTE) cereals, and dietary supplements. Objective: Our objectives were as follows: 1) to estimate the usual daily folic acid intake and distributions of red blood cell (RBC) folate concentrations among women consuming folic acid from different sources; 2) to assess the usual daily total folic acid intake associated with optimal RBC folate concentrations for NTD prevention; 3) to predict NTD prevalence; and 4) to estimate the number of preventable folate-sensitive NTDs. Design: NHANES data (2007-2012) for nonpregnant women of reproductive age (12-49 y) were used to estimate usual daily intakes of synthetic folic acid and natural food folate. We applied existing models of the relation between RBC folate concentrations and NTD risk to predict NTD prevalence. Results: Based on the distribution of overall RBC folate concentrations (4783 women), the predicted NTD prevalence was 7.3/10,000 live births [95% uncertainty interval (UI): 5.5-9.4/10,000 live births]. Women consuming folic acid from ECGPs as their only source had lower usual daily total folic acid intakes (median: 115 microg/d; IQR: 79-156 microg/d), lower RBC folate concentrations (median: 881 nmol/L; IQR: 704-1108 nmol/L), and higher predicted NTD prevalence (8.5/10,000 live births; 95% UI: 6.4-10.8/10,000 live births) compared with women consuming additional folic acid from diet or supplements. If women who currently consume folic acid from ECGPs only (48% of women) consumed additional folic acid sources, 345 (95% UI: 0-821) to 701 (95% UI: 242-1189) additional NTDs/y could be prevented. Conclusions: This analysis supports current recommendations and does not indicate any need for higher intakes of folic acid to achieve optimal NTD prevention. Ensuring 400 microg/d intake of folic acid prior to pregnancy has the potential to increase the number of babies born without an NTD.

      3. Uptake of skilled attendance along the continuum of care in rural Western Kenya: selected analysis from Global Health Initiative Survey – 2012External
        Mwangi W, Gachuno O, Desai M, Obor D, Were V, Odhiambo F, Nyaguara A, Laserson KF.
        BMC Pregnancy Childbirth. 2018 May 16;18(1):175.

        BACKGROUND: Examining skilled attendance throughout pregnancy, delivery and immediate postnatal period is proxy indicator on the progress towards reduction of maternal and neonatal mortality in developing countries. METHODS: We conducted a cross-sectional baseline survey of households of mothers with at least 1 child under-5 years in 2012 within the KEMRI/CDC health and demographic surveillance system (HDSS) area in rural western Kenya. RESULTS: Out of 8260 mother-child pairs, data on antenatal care (ANC) in the most recent pregnancy was obtained for 89% (n = 8260); 97% (n = 7387) reported attendance. Data on number of ANC visits was available for 89% (n = 7140); 52% (n = 6335) of mothers reported >/=4 ANC visits. Data on gestation month at first ANC was available for 94% (n = 7140) of mothers; 14% (n = 6690) reported first visit was in1(st)trimester (0-12 weeks), 73% in 2nd trimester (14-28 weeks) and remaining 13% in third trimester. Forty nine percent (n = 8259) of mothers delivered in a Health Facility (HF), 48% at home and 3% en route to HF. Forty percent (n = 7140) and 63% (n = 4028) of mothers reporting ANC attendance and HF delivery respectively also reported receiving postnatal care (PNC). About 36% (n = 8259) of mothers reported newborn assessment (NBA). Sixty eight percent (n = 3966) of mothers that delivered at home reported taking newborn for HF check-up, with only 5% (n = 2693) doing so within 48 h of delivery. Being </=34 years (OR 1.8; 95% CI 1.4-2.4) and at least primary education (OR 5.3; 95% CI 1.8-15.3) were significantly associated with ANC attendance. Being </=34 years (OR 1.7; 95% CI 1.5-2.0), post-secondary vs primary education (OR 10; 95% CI 4.4-23.4), ANC attendance (OR 4.5; 95% CI 3.2-6.1), completing >/=4 ANC visits (OR 2.0; 95% CI 1.8-2.2), were strongly associated with HF delivery. The continuum of care was such that 97% (n = 7387) mothers reported ANC attendance, 49% reported both ANC and HF delivery attendance, 34% reported ANC, HF delivery and PNC attendance and only 18% reported ANC, HF delivery, PNC and NBA attendance. CONCLUSION: Uptake of services drastically declined from antenatal to postnatal period, along the continuum of care. Age and education were key determinants of uptake.

      4. Nongenetic risk factors for holoprosencephaly: An updated review of the epidemiologic literatureExternal
        Summers AD, Reefhuis J, Taliano J, Rasmussen SA.
        Am J Med Genet C Semin Med Genet. 2018 May 15.

        Holoprosencephaly (HPE) is a major structural birth defect of the brain that occurs in approximately 1 in 10,000 live births. Although some genetic causes of HPE are known, a substantial proportion of cases have an unknown etiology. Due to the low birth prevalence and rarity of exposure to many potential risk factors for HPE, few epidemiologic studies have had sufficient sample size to examine risk factors. A 2010 review of the literature identified several risk factors that had been consistently identified as occurring more frequently among cases of HPE, including maternal diabetes, twinning, and a predominance of females, while also identifying a number of potential risk factors that had been less widely studied. In this article, we summarize a systematic literature review conducted to update the evidence for nongenetic risk factors for HPE.

    • Mining
      1. Ideas from the fieldExternal
        Connor BP, Gallick J.
        Coal Age. 2018 ;123(3):32-34.

        [No abstract]

      2. Electromagnetic interference from personal dust monitors and other electronic devices with proximity detection systemsExternal
        Noll J, Matetic RJ, Zhou JL, DuCarme J, Reyes M, Srednicki J.
        Mining Engineering. 2018 ;70(5):61-68.

        In April 2016, the U.S. Mine Safety and Health Administration (MSHA) began requiring the use of continuous personal dust monitors to monitor and measure respirable mine dust exposures to underground coal miners. Mines are currently using the PDM3700 personal dust monitor to comply with this regulation. After the PDM3700’s implementation, mine operators discovered that it interfered with proximity detection systems, thus exposing miners to potential striking and pinning hazards from continuous mining machines. Besides the PDM3700, other electronic devices were also previously reported to interfere with proximity detection systems. MSHA sought the aid of the U.S. National Institute for Occupational Safety and Health (NIOSH) and mining industry stakeholders to determine how the PDM3700 and some other electronic devices and proximity detection systems interact with each other. Accordingly, NIOSH investigated existing standards, developed test protocols, designed experiments and conducted laboratory evaluations. Some interferences were observed to be caused by electromagnetic interference from some electronic devices, including the PDM3700. Results showed that there was no significant interference when the PDM3700, as well as other electronic devices, and the miner-wearable component of the proximity detection system were separated by distances of 15 cm (6 in.) or greater. In the present study, it was found that the PDM3700 and the personal alarm device needed to be at least 15 cm (6 in.) apart in order for them to be used simultaneously and reduce potential interference.

      3. Dust control by air-blocking shelves and dust collector-to-bailing airflow ratios for a surface mine drill shroudExternal
        Zheng Y, Reed WR, Potts JD, Li M, Rider JP.
        Mining Engineering. 2018 ;70(5):69-74.

        The National Institute for Occupational Safety and Health (NIOSH) recently developed a series of validated models utilizing computational fluid dynamics (CFD) to study the effects of air-blocking shelves on airflows and respirable dust distribution associated with medium-sized surface blasthole drill shrouds as part of a dry dust collector system. Using validated CFD models, three different air-blocking shelves were included in the present study: a 15.2-cm (6-in.)-wide shelf; a 7.6-cm (3-in.)-wide shelf; and a 7.6-cm (3-in.)-wide shelf at four different shelf heights. In addition, the dust-collector-to-bailing airflow ratios of 1.75:1, 1.5:1, 1.25:1 and 1:1 were evaluated for the 15.2-cm (6-in.)-wide air-blocking shelf. This paper describes the methodology used to develop the CFD models. The effects of air-blocking shelves and dust collector-to-bailing airflow ratios were identified by the study, and problem regions were revealed under certain conditions.

    • Nutritional Sciences
      1. Knowledge of health conditions associated with sugar-sweetened beverage intake is low among US Hispanic adultsExternal
        Park S, Ayala GX, Sharkey JR, Blanck HM.
        Am J Health Promot. 2018 Jan 1:890117118774206.

        PURPOSE: To examine associations between knowledge of health conditions and sugar-sweetened beverage (SSB) intake among Hispanic adults. DESIGN: Quantitative, cross-sectional study. SETTING: The 2015 Estilos survey data. PARTICIPANTS: One thousand US Hispanic adults (>/=18 years). MEASURES: The outcome variable was frequency of SSB intake (regular soda, fruit drink, sports/energy drink, and sweetened coffee/tea drink). Exposure variables were knowledge of 6 SSB-related health conditions (weight gain, diabetes, dental caries, high cholesterol, heart disease, and hypertension). ANALYSIS: Six multinomial logistic regression models were used to estimate adjusted odds ratios for consuming SSBs >/=3 times/day (high intake), in relation to knowledge of SSB-related health conditions. RESULTS: Overall, 58% of Hispanic adults consumed SSBs >/=2 times/day and 36% consumed SSBs >/=3 times/day. Although most identified that weight gain (75%) and diabetes (76%) were related to drinking SSBs, only half identified this relation with dental caries (57%) and hypertension (41%). Even fewer identified high cholesterol (32%) and heart disease (32%) as related. In crude analyses, SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, dental caries, and heart disease; however, after adjusting for sociodemographics and acculturation, associations were no longer significant. CONCLUSIONS: Although SSB intake was very high, knowledge of SSB-related health conditions was low and was not related to high SSB intake among US Hispanic adults. Education efforts alone may not be adequate for Hispanic adults to change their behaviors.

    • Occupational Safety and Health
      1. Exploring workplace TB interventions with foreign-born Latino workersExternal
        Eggerth DE, Keller BM, Flynn MA.
        Am J Ind Med. 2018 May 15.

        BACKGROUND: Persons born outside the United States are more likely to be diagnosed with tuberculosis disease (TB) than native-born individuals. Foreign-born Latinos at risk of TB may be difficult to reach with public health interventions due to cultural and institutional barriers. Workplaces employing large concentrations of foreign-born Latinos may be useful locations for TB interventions targeting this high-risk population. METHOD: This study used a two-phase approach to investigate the feasibility of workplace TB interventions. The first phase investigated employer knowledge of TB and receptiveness to allowing TB interventions in their businesses through 5 structured interviews. The second phase investigated foreign-born workers’ knowledge of TB and their receptiveness to receiving TB interventions in their places of employment through 12 focus groups stratified by gender and education. RESULTS: Phase 1: Only 1 of the 5 employers interviewed had a high level of knowledge about TB, and three had no knowledge other than that TB was a disease that involved coughing. They were receptive to workplace TB interventions, but were concerned about lost productivity and customers finding out if an employee had TB. Phase 2: There was no observed differences in responses between gender and between the bottom two education groups, so the final analysis took place between a gender-combined lower education group and higher education group. The higher education group tended to have knowledge that was more accurate and to view TB as a disease associated with poverty. The lower education group tended to have more misconceptions about TB and more often expressed concern that their employers would not support worksite interventions. CONCLUSIONS: The results from both phases indicate that more TB education is needed among both foreign-born Latino workers and their employers. Obstacles to implementing workplace TB interventions include knowledge, potential productivity loss, employer liability, and perceived customer response.

      2. Association of pulmonary, cardiovascular, and hematologic metrics with carbon nanotube and nanofiber exposure among U.S. workers: a cross-sectional studyExternal
        Schubauer-Berigan MK, Dahm MM, Erdely A, Beard JD, Eileen Birch M, Evans DE, Fernback JE, Mercer RR, Bertke SJ, Eye T, de Perio MA.
        Part Fibre Toxicol. 2018 May 16;15(1):22.

        BACKGROUND: Commercial use of carbon nanotubes and nanofibers (CNT/F) in composites and electronics is increasing; however, little is known about health effects among workers. We conducted a cross-sectional study among 108 workers at 12 U.S. CNT/F facilities. We evaluated chest symptoms or respiratory allergies since starting work with CNT/F, lung function, resting blood pressure (BP), resting heart rate (RHR), and complete blood count (CBC) components. METHODS: We conducted multi-day, full-shift sampling to measure background-corrected elemental carbon (EC) and CNT/F structure count concentrations, and collected induced sputum to measure CNT/F in the respiratory tract. We measured (nonspecific) fine and ultrafine particulate matter mass and count concentrations. Concurrently, we conducted physical examinations, BP measurement, and spirometry, and collected whole blood. We evaluated associations between exposures and health measures, adjusting for confounders related to lifestyle and other occupational exposures. RESULTS: CNT/F air concentrations were generally low, while 18% of participants had evidence of CNT/F in sputum. Respiratory allergy development was positively associated with inhalable EC (p=0.040) and number of years worked with CNT/F (p=0.008). No exposures were associated with spirometry-based metrics or pulmonary symptoms, nor were CNT/F-specific metrics related to BP or most CBC components. Systolic BP was positively associated with fine particulate matter (p-values: 0.015-0.054). RHR was positively associated with EC, at both the respirable (p=0.0074) and inhalable (p=0.0026) size fractions. Hematocrit was positively associated with the log of CNT/F structure counts (p=0.043). CONCLUSIONS: Most health measures were not associated with CNT/F. The positive associations between CNT/F exposure and respiratory allergies, RHR, and hematocrit counts may not be causal and require examination in other studies.

      3. Exploring respiratory protection practices for prominent hazards in healthcare settingsExternal
        Wizner K, Nasarwanji M, Fisher E, Steege AL, Boiano JM.
        J Occup Environ Hyg. 2018 May 11:1-26.

        The use of respiratory protection, an important component of personal protective equipment (PPE) in healthcare, is dependent on the hazard and environmental conditions in the workplace. This requires the employer and healthcare worker (HCW) to be knowledgeable about potential exposures and their respective protective measures. However, the use of respirators is inconsistent in healthcare settings, potentially putting HCWs at risk for illness or injury. To better understand respirator use, barriers, and influences, the National Institute for Occupational Safety and Health (NIOSH) Health and Safety Practices Survey of Healthcare Workers provided an opportunity to examine self-reported use of respirators and surgical masks for targeted hazards. The hazards of interest included aerosolized medications, antineoplastic drugs, chemical sterilants, high-level disinfectants, influenza-like illness (ILI), and surgical smoke. Of the 10,383 HCWs who reported respiratory protection behaviors, 1,904 (18%) reported wearing a respirator for at least one hazard. Hazard type, job duties, site characteristics, and organizational factors played a greater role in the likelihood of respirator use than individual factors. The proportion of respirator users was highest for aerosolized medications and lowest for chemical sterilants. Most respondents reported using a surgical mask for at least one of the hazards, with highest use for surgical smoke generated by electrosurgical techniques and ILI. The high proportion of respirator non-users who used surgical masks is concerning because HCWs may be using a surgical mask in situations that require a respirator, specifically for surgical smoke. Improved guidance on hazard recognition, risk evaluation, and appropriate respirator selection could potentially help HCWs better understand how to protect themselves at work.

    • Parasitic Diseases
      1. An assessment of false positive rates for malaria rapid diagnostic tests caused by non-Plasmodium infectious agents and immunological factorsExternal
        Gatton ML, Ciketic S, Barnwell JW, Cheng Q, Chiodini PL, Incardona S, Bell D, Cunningham J, Gonzalez IJ.
        PLoS One. 2018 ;13(5):e0197395.

        BACKGROUND: Malaria rapid diagnostic tests (RDTs) can produce false positive (FP) results in patients with human African trypanosomiasis and rheumatoid factor (RF), but specificity against other infectious agents and immunological factors is largely unknown. Low diagnostic specificity caused by cross-reactivity may lead to over-estimates of the number of malaria cases and over-use of antimalarial drugs, at the cost of not diagnosing and treating the true underlying condition. METHODS: Data from the WHO Malaria RDT Product Testing Programme was analysed to assess FP rates of 221 RDTs against four infectious agents (Chagas, dengue, Leishmaniasis and Schistosomiasis) and four immunological factors (anti-nuclear antibody, human anti-mouse antibody (HAMA), RF and rapid plasma regain). Only RDTs with a FP rate against clean negative samples less than 10% were included. Paired t-tests were used to compare product-specific FP rates on clean negative samples and samples containing non-Plasmodium infectious agents and immunological factors. RESULTS: Forty (18%) RDTs showed no FP results against any tested infectious agent or immunological factor. In the remaining RDTs significant and clinically relevant increases in FP rates were observed for samples containing HAMA and RF (P<0.001). There were significant correlations between product-matched FP rates for RF and HAMA on all RDT test bands (P<0.001), and FP rates for each infectious agent and immunological factor were also correlated between test bands of combination RDTs (P</=0.002). CONCLUSIONS: False positive results against non-Plasmodium infectious agents and immunological factors does not appear to be a universal property of malaria RDTs. However, since many malaria RDTs have elevated FP rates against HAMA and RF positive samples practitioners may need to consider the possibility of false positive results for malaria in patients with conditions that stimulate HAMA or RF.

      2. A survey on outcomes of accidental atovaquone-proguanil exposure in pregnancyExternal
        Tan KR, Fairley JK, Wang M, Gutman JR.
        Malar J. 2018 May 15;17(1):198.

        BACKGROUND: Malaria chemoprophylaxis options in pregnancy are limited, and atovaquone-proguanil (AP) is not recommended because of insufficient safety evidence. An anonymous, internet-based survey was disseminated to describe outcomes of pregnancies accidentally exposed to AP. Outcomes of interest included miscarriage (defined as pregnancy loss before 20 weeks), stillbirth (defined as pregnancy loss at or after 20 weeks), preterm birth or live birth prior to 37 weeks, and the presence of congenital anomalies. RESULTS: A total of 487 women responded and reported on 822 pregnancies. Of the 807 pregnancies with information available on exposure and outcomes, 10 (1.2%) had atovaquone-proguanil exposure, all in the first trimester, and all resulted in term births with no birth defects. CONCLUSIONS: Use of an anti-malarial not recommended in pregnancy is likely to occur before the woman knows of her pregnancy. This study adds to the limited evidence of the safety of AP in pregnancy. Further study on use of AP in pregnancy should be a high priority, as an alternative option for the prevention of malaria in pregnancy in non-immune travellers is urgently needed.

    • Reproductive Health
      1. Unplanned pregnancies and contraceptive use among HIV- positive women in careExternal
        Sutton MY, Zhou W, Frazier EL.
        PLoS One. 2018 ;13(5):e0197216.

        Among 230,360 women with diagnosed HIV in the United States (U.S.), ~ 8,500 give birth annually, and unplanned pregnancies (as with HIV-negative women) are prevalent. However, unplanned pregnancies and contraceptive use among HIV-positive women have been understudied. To examine unplanned pregnancies and contraceptive use among HIV-positive women, we used 2013-2014 data from the Medical Monitoring Project (MMP), an HIV surveillance system that produces national estimates for HIV-positive adults in care in the U.S. (Pregnancy outcome dates were from years 1986-2015 for this cohort of women who were interviewed during 2013-2014; median year of reported pregnancy outcome was year 2003). Women in HIV care and diagnosed with HIV before age 45 (reproductive age) were included. We calculated adjusted prevalence ratios (aPR) of unplanned pregnancies with 95% confidence intervals (CI). For women who were aged 18-44 years at time of interview, we computed weighted prevalences of contraceptive use (previous 12 months) by method, including permanent (i.e., sterilization), short-acting (i.e., pills, depo-progesterone acetate (DMPA)), long-acting reversible contraceptives (LARC) (i.e., implants), and barriers (i.e., condoms). Six hundred seventy-one women met criteria for the unplanned pregnancy analysis; median age at HIV diagnosis = 24.6 years, and 78.1% (CI:74.5-81.7) reported >/= 1 unplanned pregnancy. Women reporting unplanned pregnancies were more likely to be non-Hispanic white (aPR = 1.20; CI 1.05-1.38) or non-Hispanic black (aPR = 1.14; CI 1.01-1.28) than Hispanic, to be above the poverty level (aPR = 1.09; CI 1.01-1.18), and to have not received care from an OB/GYN in the year before interview (aPR = 1.13; CI 1.04-1.22). Among 1,142 total pregnancies, 795 (69.6%) were live births; 70 (7.8%) were born HIV-positive; 42 (60%) of those born HIV-positive were unplanned pregnancies. For the contraceptives analysis (n = 957 women who were aged 18-44 at time of interview), 90.5% reported using at least one contraceptive, including 59.7% reporting barrier methods, 29.9% reporting permanent sterilization, and 22.8% reporting short-term methods in the previous year. LARC was used by only 5.3% of women. Women who reported use of LARC or DMPA were more likely to be aged 18-29 years (aPR = 3.08; CI 1.61-5.89) or 30-39 years (aPR = 2.86; CI 1.76-4.63) compared with women aged 40-44 years. Unplanned pregnancies were prevalent and LARC use was low; prevention efforts should strengthen pregnancy planning and contraceptive awareness for HIV-positive women during clinical visits.

    • Substance Use and Abuse
      1. eHealth Familias Unidas: Efficacy trial of an evidence-based intervention adapted for use on the internet with Hispanic familiesExternal
        Estrada Y, Lee TK, Wagstaff R, M. Rojas L, Tapia MI, Velazquez MR, Sardinas K, Pantin H, Sutton MY, Prado G.
        Prev Sci. 2018 May 10.

        While substance use and sexual risk behaviors among Hispanic youth continue to be public health concerns, few evidence-based preventive interventions are developed for and implemented with Hispanic/Latino youth. The objective of this study was to evaluate the efficacy of eHealth Familias Unidas, an Internet adaptation of an evidence-based family intervention for Hispanics. A randomized controlled trial design (n = 230) was used to evaluate intervention effects on substance use and condomless sex among a sample of Hispanic eighth graders with behavioral problems. Participants were randomized to eHealth Familias Unidas (n = 113) or prevention as usual (n = 117) and assessed at baseline and 3 and 12 months post baseline. We trained mental health school personnel and community mental health professionals to recruit and deliver the Internet-based intervention with Hispanic families. It was hypothesized that, over time, eHealth Familias Unidas would be more efficacious than prevention as usual in reducing drug use (marijuana, cocaine, inhalants, and other drugs), prescription drug use, cigarette use, alcohol use, and condomless sex and that these changes would be mediated by family functioning. Significant intervention effects were found across time for drug use, prescription drug use, and cigarette use. While eHealth Familias Unidas positively affected family functioning, mediation effects were not found. This study demonstrated that family-based eHealth interventions can be efficacious among Hispanic populations when delivered in community settings.

      2. Attitudes toward smokeless tobacco use at all public sports venues among U.S. adults, 2016External
        Odani S, O’Flaherty K, Veatch N, Tynan MA, Agaku IT.
        Prev Med. 2018 Jun;111:397-401.

        Policies prohibiting smokeless tobacco (SLT) use at sports venues have been enacted in California and nine U.S. cities. We measured opposition toward SLT use at all public sports venues and its correlates among U.S. adults. Data were from the 2016 SummerStyles, a web-based survey of U.S. adults aged >/=18years (n=4203). Weighted estimates of opposition (“strongly” or “somewhat”) SLT use were computed overall and by selected characteristics. Multivariable Poisson regression analyses were performed to identify determinants of opposition toward SLT use overall and among current tobacco product users. Overall, 81.8% of U.S. adults opposed SLT use at all public sports venues. Opposition varied by tobacco product use status: 85.9%, 86.9% and 60.4% among never, former, and current tobacco product users, respectively. Among all adults, the likelihood of opposition was higher among females than males (Adjusted Prevalence Ratio [APR]=1.05; 95%CI=1.01-1.08) and increased with every 10-year increase in age (APR=1.01; 95%CI=1.00-1.02). Likelihood was lower among persons with a high school diploma (APR=0.92; 95%CI=0.88-0.96) than those with college degree or higher; persons widowed/divorced/separated (APR=0.92; 95%CI=0.87-0.97) than those married; and current tobacco product users (APR=0.70; 95%CI=0.65-0.76) than never users. Among current tobacco product users, likelihood was lower among persons living in the Midwest (APR=0.81; 95%CI=0.66-0.98) and South (APR=0.78; 95%CI=0.65-0.94) than the Northeast. Most U.S. adults, including three-fifths of current tobacco product users, oppose SLT use at all public sports venues. Complete tobacco-free policies for sports venues that prohibit all forms of tobacco product use can help reduce the social acceptability of SLT use.

      3. Aluminum in tobacco products available in the United StatesExternal
        Pappas RS, Watson CH, Valentin-Blasini L.
        J Anal Toxicol. 2018 May 10.

        A quantitative method for the analysis of aluminum in tobacco products was developed, validated and applied to select samples. Samples were prepared using standard microwave digestion of tobacco from various products. Detection and quantification utilized sector field inductively coupled plasma-mass spectrometry. Method applicability to analyze aluminum in a range of tobacco products was demonstrated with quantitative analyses of smokeless tobacco products, cigarette tobacco, little cigar tobacco and roll-your-own/pipe tobacco. Though these products represent a convenience sampling, we observed that smokeless tobacco products, as a category, had the lowest average aluminum concentrations. Roll-your-own or pipe tobacco and little cigar tobacco had higher median and ranges of aluminum concentrations than cigarette and smokeless tobacco samples.

      4. Attitudes toward smoke-free public housing among U.S. adults, 2016External
        Wang TW, Lemos PR, McNabb S, King BA.
        Am J Prev Med. 2018 Jan;54(1):113-118.

        INTRODUCTION: Effective February 2017, the U.S. Department of Housing and Urban Development published a rule requiring each public housing agency to implement a smoke-free policy within 18 months. This study assessed the prevalence and determinants of favorability toward smoke-free public housing among U.S. adults. METHODS: Data from 2016 Summer Styles, a nationally representative web-based survey conducted among adults (N=4,203) were analyzed in 2017. Participants were asked: Do you favor or oppose prohibiting smoking in public housing, including all indoor areas of living units, common areas, and office buildings, as well as in all outdoor areas within 25 feet of buildings? Multivariate Poisson regression was used to calculate adjusted prevalence ratios of favorability (strongly or somewhat). RESULTS: Overall, 73.7% of respondents favored smoke-free public housing. Favorability was 44.3% among current cigarette smokers, 73.2% among former smokers, and 80.4% among never smokers. The adjusted likelihood of favorability was greater among non-Hispanic, non-black racial/ethnic minorities than whites, and among those in the West than the Northeast (p<0.05). Favorability was lower among adults with a high school education or less compared with those with a college degree, adults with annual household income <$15,000 than those with income >/=$60,000, multiunit housing residents than non-multiunit housing residents, current cigarette smokers than never smokers, and current non-cigarette tobacco product users than never users (p<0.05). CONCLUSIONS: Most U.S. adults favor prohibiting smoking in public housing. These data can inform the implementation and sustainment of smoke-free policies to reduce the public health burden of tobacco smoking in public housing.

    • Zoonotic and Vectorborne Diseases
      1. Detection of an avian lineage influenza A(H7N2) virus in air and surface samples at a New York city feline quarantine facilityExternal
        Blachere FM, Lindsley WG, Weber AM, Beezhold DH, Thewlis RE, Mead KR, Noti JD.
        Influenza Other Respir Viruses. 2018 May 16.

        BACKGROUND: In December 2016, an outbreak of low pathogenicity avian influenza (LPAI) A(H7N2) occurred in cats at a New York City animal shelter and quickly spread to other shelters in New York and Pennsylvania. The A(H7N2) virus also spread to an attending veterinarian. In response, 500 cats were transferred from these shelters to a temporary quarantine facility for continued monitoring and treatment. OBJECTIVES: The objectives of this study was to assess the occupational risk of A(H7N2) exposure among emergency response workers at the feline quarantine facility. METHODS: Aerosol and surface samples were collected from inside and outside the isolation zones of the quarantine facility. Samples were screened for A(H7N2) by quantitative RT-PCR and analyzed in embryonated chicken eggs for infectious virus. RESULTS: H7N2 virus was detected by RT-PCR in 28 of 29 aerosol samples collected in the high-risk isolation (hot) zone with 70.9% on particles with aerodynamic diameters >4 mum, 27.7% in 1-4 mum, and 1.4% in <1 mum. Seventeen of 22 surface samples from the high-risk isolation zone were also H7N2-positive with an average M1 copy number of 1.3 x 10(3) . Passage of aerosol and surface samples in eggs confirmed that infectious virus was present throughout the high-risk zones in the quarantine facility. CONCLUSIONS: By measuring particle size, distribution, and infectivity, our study suggests that the A(H7N2) virus had the potential to spread by airborne transmission and/or direct contact with viral-laden fomites. These results warranted continued A(H7N2) surveillance and transmission-based precautions during the treatment and care of infected cats. This article is protected by copyright. All rights reserved.

      2. Leptospirosis among returned travelers: A GeoSentinel site survey and multicenter analysis – 1997-2016External
        de Vries SG, Visser BJ, Stoney RJ, Wagenaar JF, Bottieau E, Chen LH, Wilder-Smith A, Wilson M, Rapp C, Leder K, Caumes E, Schwartz E, Hynes NA, Goorhuis A, Esposito DH, Hamer DH, Grobusch MP, For The GeoSentinel Surveillance N.
        Am J Trop Med Hyg. 2018 May 14.

        Leptospirosis is a potentially fatal emerging zoonosis with worldwide distribution and a broad range of clinical presentations and exposure risks. It typically affects vulnerable populations in (sub)tropical countries but is increasingly reported in travelers as well. Diagnostic methods are cumbersome and require further improvement. Here, we describe leptospirosis among travelers presenting to the GeoSentinel Global Surveillance Network. We performed a descriptive analysis of leptospirosis cases reported in GeoSentinel from January 1997 through December 2016. We included 180 travelers with leptospirosis (mostly male; 74%; mostly tourists; 81%). The most frequent region of infection was Southeast Asia (52%); the most common source countries were Thailand (N = 52), Costa Rica (N = 13), Indonesia, and Laos (N = 11 each). Fifty-nine percent were hospitalized; one fatality was reported. We also distributed a supplemental survey to GeoSentinel sites to assess clinical and diagnostic practices. Of 56 GeoSentinel sites, three-quarters responded to the survey. Leptospirosis was reported to have been most frequently considered in febrile travelers with hepatic and renal abnormalities and a history of freshwater exposure. Serology was the most commonly used diagnostic method, although convalescent samples were reported to have been collected infrequently. Within GeoSentinel, leptospirosis was diagnosed mostly among international tourists and caused serious illness. Clinical suspicion and diagnostic workup among surveyed GeoSentinel clinicians were mainly triggered by a classical presentation and exposure history, possibly resulting in underdiagnosis. Suboptimal usage of available diagnostic methods may have resulted in additional missed, or misdiagnosed, cases.

      3. Multi-site evaluation of the LN34 pan-lyssavirus real-time RT-PCR assay for post-mortem rabies diagnosticsExternal
        Gigante CM, Dettinger L, Powell JW, Seiders M, Condori RE, Griesser R, Okogi K, Carlos M, Pesko K, Breckenridge M, Simon EM, Chu M, Davis AD, Brunt SJ, Orciari L, Yager P, Carson WC, Hartloge C, Saliki JT, Sanchez S, Deldari M, Hsieh K, Wadhwa A, Wilkins K, Peredo VY, Rabideau P, Gruhn N, Cadet R, Isloor S, Nath SS, Joseph T, Gao J, Wallace R, Reynolds M, Olson VA, Li Y.
        PLoS One. 2018 ;13(5):e0197074.

        Rabies is a fatal zoonotic disease that requires fast, accurate diagnosis to prevent disease in an exposed individual. The current gold standard for post-mortem diagnosis of human and animal rabies is the direct fluorescent antibody (DFA) test. While the DFA test has proven sensitive and reliable, it requires high quality antibody conjugates, a skilled technician, a fluorescence microscope and diagnostic specimen of sufficient quality. The LN34 pan-lyssavirus real-time RT-PCR assay represents a strong candidate for rabies post-mortem diagnostics due to its ability to detect RNA across the diverse Lyssavirus genus, its high sensitivity, its potential for use with deteriorated tissues, and its simple, easy to implement design. Here, we present data from a multi-site evaluation of the LN34 assay in 14 laboratories. A total of 2,978 samples (1,049 DFA positive) from Africa, the Americas, Asia, Europe, and the Middle East were tested. The LN34 assay exhibited low variability in repeatability and reproducibility studies and was capable of detecting viral RNA in fresh, frozen, archived, deteriorated and formalin-fixed brain tissue. The LN34 assay displayed high diagnostic specificity (99.68%) and sensitivity (99.90%) when compared to the DFA test, and no DFA positive samples were negative by the LN34 assay. The LN34 assay produced definitive findings for 80 samples that were inconclusive or untestable by DFA; 29 were positive. Five samples were inconclusive by the LN34 assay, and only one sample was inconclusive by both tests. Furthermore, use of the LN34 assay led to the identification of one false negative and 11 false positive DFA results. Together, these results demonstrate the reliability and robustness of the LN34 assay and support a role for the LN34 assay in improving rabies diagnostics and surveillance.

      4. Notes from the Field: Investigation of an outbreak OF Salmonella paratyphi B Variant L(+) tartrate + (Java) associated with ball python exposure – United States, 2017External
        Krishnasamy V, Stevenson L, Koski L, Kellis M, Schroeder B, Sundararajan M, Ladd-Wilson S, Sampsel A, Mannell M, Classon A, Wagner D, Hise K, Carleton H, Trees E, Schlater L, Lantz K, Nichols M.
        MMWR Morb Mortal Wkly Rep. 2018 May 19;67(19):562-563.

        [No abstract]

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