Volume 10, Issue 26, July 17, 2018

CDC Science Clips: Volume 10, Issue 26, July 17, 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. CDC Public Health Grand Rounds
    • CDC Grand Rounds Summary
      1. CDC Grand Rounds: Public Health Strategies to Prevent Neonatal Abstinence SyndromeExternal
        Ko JY, Wolicki S, Barfield WD, Patrick SW, Broussard CS, Yonkers KA, Naimon R, Iskander J.
        MMWR Morb Mortal Wkly Rep. 2017 Mar 10;66(9):242-245.

        Neonatal abstinence syndrome (NAS) is a drug withdrawal syndrome that most commonly occurs in infants after in utero exposure to opioids, although other substances have also been associated with the syndrome (1). NAS usually appears within 48-72 hours of birth with a constellation of clinical signs, including central nervous system irritability (e.g., tremors), gastrointestinal dysfunction (e.g., feeding difficulties), and temperature instability (1) (Box 1). Opioid exposure during pregnancy might result from clinician-approved use of prescription opioids for pain relief; misuse or abuse of prescription opioids; illicit use (e.g., heroin); or medication-assisted treatment (MAT) of opioid use disorder (2) (Box 2).

    • NAS Prevalence and Trends
      1. Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014External
        Winkelman TN, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW.
        Pediatrics. 2018 Apr;141(4).

        OBJECTIVES: To describe incidence, health care use, and cost trends for infants with neonatal abstinence syndrome (NAS) who are covered by Medicaid compared with other infants. METHODS: We used 2004-2014 hospital birth data from the National Inpatient Sample, a nationally representative sample of hospital discharges in the United States (N = 13 102 793). Characteristics and trends among births impacted by NAS were examined by using univariate statistics and logistic regression. RESULTS: Medicaid covered 73.7% of NAS-related births in 2004 (95% confidence interval [CI], 68.9%-77.9%) and 82.0% of NAS-related births in 2014 (95% CI, 80.5%-83.5%). Among infants covered by Medicaid, NAS incidence increased more than fivefold during our study period, from 2.8 per 1000 births (95% CI, 2.1-3.6) in 2004 to 14.4 per 1000 births (95% CI, 12.9-15.8) in 2014. Infants with NAS who were covered by Medicaid were significantly more likely to be transferred to another hospital and have a longer length of stay than infants without NAS who were enrolled in Medicaid or infants with NAS who were covered by private insurance. Adjusting for inflation, total hospital costs for NAS births that were covered by Medicaid increased from $65.4 million in 2004 to $462 million in 2014. The proportion of neonatal hospital costs due to NAS increased from 1.6% in 2004 to 6.7% in 2014 among births that were covered by Medicaid. CONCLUSIONS: The number of Medicaid-financed births that are impacted by NAS has risen substantially and totaled $462 million in hospital costs in 2014. Improving affordable health insurance coverage for low-income women before pregnancy would expand access to substance use disorder treatment and could reduce NAS-related morbidity and costs.

      2. Incidence of neonatal abstinence syndrome – 28 states, 1999-2013External
        Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD.
        MMWR Morb Mortal Wkly Rep. 2016 Aug 12;65(31):799-802.

        Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction (1). During 2000-2012, the incidence of NAS in the United States significantly increased (2,3). Several recent publications have provided national estimates of NAS (2,3); however, data describing incidence at the state level are limited. CDC examined state trends in NAS incidence using all-payer, hospital inpatient delivery discharges compiled in the State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) during 1999-2013. Among 28 states with publicly available data in HCUP during 1999-2013, the overall NAS incidence increased 300%, from 1.5 per 1,000 hospital births in 1999, to 6.0 per 1,000 hospital births in 2013. During the study period, significant increases in NAS incidence occurred in 25 of 27 states with at least 3 years of data, with annual incidence rate changes ranging from 0.05 (Hawaii) to 3.6 (Vermont) per 1,000 births. In 2013, NAS incidence ranged from 0.7 cases per 1,000 hospital births (Hawaii) to 33.4 cases per 1,000 hospital births (West Virginia). The findings underscore the importance of state-based public health programs to prevent unnecessary opioid use and to treat substance use disorders during pregnancy, as well as decrease the incidence of NAS.

    • Clinical Guidelines and/or Evidence Related to Prescribing Opioids and Management of Opioid Use Disorder during Pregnancy
      1. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016External
        Dowell D, Haegerich TM, Chou R.
        MMWR Recomm Rep. 2016 Mar 18;65(1):1-49.

        This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.

      2. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancyExternal
        American College of Obstetricians and Gynecologists .
        Obstet Gynecol. 2012 May;119(5):1070-6.

        Opioid use in pregnancy is not uncommon, and the use of illicit opioids during pregnancy is associated with an increased risk of adverse outcomes. The current standard of care for pregnant women with opioid dependence is referral for opioid-assisted therapy with methadone, but emerging evidence suggests that buprenorphine also should be considered. Medically supervised tapered doses of opioids during pregnancy often result in relapse to former use. Abrupt discontinuation of opioids in an opioid-dependent pregnant woman can result in preterm labor, fetal distress, or fetal demise. During the intrapartum and postpartum period, special considerations are needed for women who are opioid dependent to ensure appropriate pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies. Patient stabilization with opioid-assisted therapy is compatible with breastfeeding. Neonatal abstinence syndrome is an expected and treatable condition that follows prenatal exposure to opioid agonists.

      3. Opioid detoxification during pregnancy: A systematic reviewExternal
        Terplan M, Laird HJ, Hand DJ, Wright TE, Premkumar A, Martin CE, Meyer MC, Jones HE, Krans EE.
        Obstet Gynecol. 2018 May;131(5):803-814.

        OBJECTIVE: To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy. DATA SOURCES: PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016. METHODS OF STUDY SELECTION: English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration’s tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale. TABULATION, INTEGRATION, AND RESULTS: Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9-100%) and illicit drug relapse (0-100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]). CONCLUSIONS: Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.

    • Clinical Guidelines and/or Evidence Related to Neonatal Abstinence Syndrome
      1. Neonatal drug withdrawalExternal
        Hudak ML, Tan RC, Committee on Drugs , Committee on Fetus and Newborn .
        Pediatrics. 2012 Feb;129(2):e540-60.

        Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.

      2. Neonatal abstinence syndrome: Advances in diagnosis and treatmentExternal
        Wachman EM, Schiff DM, Silverstein M.
        Jama. 2018 Apr 3;319(13):1362-1374.

        Importance: Neonatal abstinence syndrome, which occurs as a result of in utero opioid exposure, affects between 6.0 and 20 newborns per 1000 live US births. There is substantial variability in how neonatal abstinence syndrome is diagnosed and managed. Objective: To summarize key studies examining the diagnosis and management (both pharmacologic and nonpharmacologic) of neonatal abstinence syndrome published during the past 10 years. Evidence Review: PubMed, Web of Science, and CINAHL were searched for articles published between July 1, 2007, and December 31, 2017. Abstracts were screened and included in the review if they pertained to neonatal abstinence syndrome diagnosis or management and were judged by the authors to be clinical trials, cohort studies, or case series. Findings: A total of 53 articles were included in the review, including 9 randomized clinical trials, 35 cohort studies, 1 cross-sectional study, and 8 case series-representing a total of 11905 unique opioid-exposed mother-infant dyads. Thirteen studies were identified that evaluated established or novel neonatal abstinence syndrome assessment methods, such as brief neonatal abstinence syndrome assessment scales or novel objective physiologic measures to predict withdrawal. None of the new techniques that measure infant physiologic parameters are routinely used in clinical practice. The most substantial number of studies of neonatal abstinence syndrome management pertain to nonpharmacologic care-specifically, interventions that promote breastfeeding or encourage parents to room-in with their newborns. Although these nonpharmacologic interventions appear to decrease the need for pharmacologic treatment and result in shorter hospitalizations, the interventions are heterogeneous and there are no high-quality clinical trials to support them. Regarding pharmacologic interventions, only 5 randomized clinical trials with prespecified sample size calculations (4 infant, 1 maternal treatment) have been published. Each of these trials was small (from 26 to 131 participants) and tested different therapies, limiting the extent to which results can be aggregated. There is insufficient evidence to support an association between any diagnostic or treatment approach and differential neurodevelopmental outcomes among infants with neonatal abstinence syndrome. Conclusions and Relevance: Evidence pertaining to the optimal diagnosis and treatment strategies for neonatal abstinence syndrome is based on small or low-quality studies that focus on intermediate outcomes, such as need for pharmacologic treatment or length of hospital stay. Clinical trials are needed to evaluate health and neurodevelopmental outcomes associated with objective diagnostic approaches as well as pharmacologic and nonpharmacologic treatment modalities.

    • Improving NAS Surveillance and Use of Prescription Drug Monitoring Programs (PDMP) at State-level
      1. Implementation of a statewide surveillance system for neonatal abstinence syndrome – Tennessee, 2013External
        Warren MD, Miller AM, Traylor J, Bauer A, Patrick SW.
        MMWR Morb Mortal Wkly Rep. 2015 Feb 13;64(5):125-8.

        Over the last decade, rates of opioid pain reliever prescribing grew substantially in the United States, affecting many segments of the population, including pregnant women. Nationally, Tennessee ranks second in the rate of prescriptions written for opioid pain relievers, with 1.4 per person in 2012. The rising prevalence of opioid pain reliever use and misuse in Tennessee led to an increase in adverse outcomes in the state, including neonatal abstinence syndrome (NAS). NAS is a withdrawal syndrome experienced by infants shortly after birth. The syndrome most commonly occurs after antenatal exposure to opioids, although other medications have also been implicated. From 2000 to 2009, the incidence rate of NAS in Tennessee increased from 0.7 to 5.1 per 1,000 births, exceeding the national average, which increased from 1.2 to 3.4 per 1,000 births. NAS is associated with numerous morbidities for the infant, including low birth weight, poor feeding, and respiratory problems. Previous population-based analyses of NAS relied on hospital discharge data, which typically become available for analysis only after substantial delay. In Tennessee, the rising incidence of NAS and its associated public health burden created an urgent need for timelier incidence figures to drive policy and prevention efforts. Beginning January 1, 2013, the Tennessee Department of Health (TDH) made NAS reporting mandatory. A total of 921 cases were reported in 2013 (among 79,954 births), with the most cases clustered in eastern Tennessee; 63% of cases occurred to mothers who were reported to be using at least one substance prescribed by a health care provider (e.g., opioid pain relievers or maintenance medications for opioid dependency), and 33% of cases occurred among women using illicit or diverted substances (e.g., heroin or medications prescribed for someone else). The first year’s surveillance results highlight the need for primary prevention activities focused on reducing dependence/addiction among women of childbearing age and preventing unintended pregnancy among female opioid users.

      2. Implementation of prescription drug monitoring programs associated with reductions in opioid-related death ratesExternal
        Patrick SW, Fry CE, Jones TF, Buntin MB.
        Health Aff (Millwood). 2016 Jul 1;35(7):1324-32.

        Over the past two decades the number of opioid pain relievers sold in the United States rose dramatically. This rise in sales was accompanied by an increase in opioid-related overdose deaths. In response, forty-nine states (all but Missouri) created prescription drug monitoring programs to detect high-risk prescribing and patient behaviors. Our objectives were to determine whether the implementation or particular characteristics of the programs were effective in reducing opioid-related overdose deaths. In adjusted analyses we found that a state’s implementation of a program was associated with an average reduction of 1.12 opioid-related overdose deaths per 100,000 population in the year after implementation. Additionally, states whose programs had robust characteristics-including monitoring greater numbers of drugs with abuse potential and updating their data at least weekly-had greater reductions in deaths, compared to states whose programs did not have these characteristics. We estimate that if Missouri adopted a prescription drug monitoring program and other states enhanced their programs with robust features, there would be more than 600 fewer overdose deaths nationwide in 2016, preventing approximately two deaths each day.

  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. Racial disparities in fifth-grade sun protection: Evidence from the Healthy Passages studyExternal
        Correnti CM, Klein DJ, Elliott MN, Veledar E, Saraiya M, Chien AT, Schwebel DC, Mrug S, Tortolero SR, Cuccaro PM, Schuster MA, Chen SC.
        Pediatr Dermatol. 2018 Jul 2.

        BACKGROUND/OBJECTIVES: Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS: Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS: Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P < .001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P < .001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. CONCLUSION: Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.

      2. Influence of improvement or worsening of glucose tolerance on risk of stroke in persons with impaired glucose toleranceExternal
        Shen X, Zhang P, Wang J, An Y, Gregg EW, Zhang B, Li H, Gong Q, Chen Y, Shuai Y, Engelgau MM, Hu Y, Bennett PH, Li G.
        Int J Stroke. 2018 Jan 1:1747493018784432.

        Background and aim We sought to determine the effect of regression to normal glucose tolerance (NGT) or progression to diabetes in early years of impaired glucose tolerance (IGT) on subsequent risk of stroke. Methods In 1986, 576 adults aged 25 years and older with impaired glucose tolerance in Da Qing, China, were randomly assigned by clinic to control, diet, exercise, or diet plus exercise intervention groups for a six-year period. Subsequently participants received medical care in their local clinics. We tracked participants for additional 17 years to ascertain stroke events and other outcomes. Results At the end of 23-year follow-up, 272 (50.2%) had progressed to diabetes, 169 (31.2%) regressed to normal glucose tolerance, and 101 (18.6%) remained impaired glucose tolerance. During the subsequent 17-year follow-up, 173 (31.9%) developed a stroke, 26.7% of normal glucose tolerances, 30.7% of impaired glucose tolerances, and 36.1% of those with diabetes. After controlling for age, sex, baseline blood pressure, smoking, total cholesterol, previous cardiovascular disease and intervention group, those who developed diabetes in the first six years had a higher incidence of stroke than those who reverted to normal glucose tolerance (HR = 1.49, 95% CI 1.01-2.19, p = 0.04), whereas for those who remained impaired glucose tolerance compared to those who regressed to normal glucose tolerance the HR was 1.25 (95% CI 0.80-1.93; p = 0.30). A 1-mmol/L increase in both fasting and 2-h post-load plasma glucose from entry to end of the six-year trial was significantly associated with a higher risk of development of stroke in the subsequent 17 years, respectively (HR = 1.07, 95% CI 1.03-1.11, p < 0.0001 for fasting glucose, HR = 1.05, 95% CI 1.02-1.09, p = 0.007 for 2-h post-load plasma glucose). Conclusions Among Chinese adults with impaired glucose tolerance, early progression to diabetes predicted a higher risk of stroke, compared those who regressed to normal glucose tolerance.

    • Communicable Diseases
      1. Characteristics associated with delivery of an infant with congenital syphilis and missed opportunities for prevention – California, 2012 to 2014External
        Biswas HH, Chew Ng RA, Murray EL, Chow JM, Stoltey JE, Watt JP, Bauer HM.
        Sex Transm Dis. 2018 Jul;45(7):435-441.

        BACKGROUND: Congenital syphilis (CS), the transmission of Treponema pallidum from mother to fetus during pregnancy, can cause adverse birth outcomes. In 2012 to 2014, the CS rate in California increased more than 200% from 6.6 to 20.3 cases per 100,000 live births. Our objectives were to identify characteristics associated with delivering an infant with CS and missed opportunities for prevention among syphilis-infected pregnant women in California. METHODS: We linked California Department of Public Health syphilis surveillance records from women aged 15 to 45 years-diagnosed from March 13, 2012, to December 31, 2014-to birth records. We compared characteristics among mothers who delivered an infant with CS (CS mothers) with mothers who delivered an infant without CS (non-CS mothers) by using chi or Fisher exact tests. To visualize gaps in prevention among syphilis-infected pregnant women, we constructed a CS prevention cascade, a figure that shows steps to prevent CS. RESULTS: During the selected period, 2498 women were diagnosed as having syphilis, and 427 (17%) linked to birth records; 164 (38%) were defined as CS mothers and 263 (62%) as non-CS mothers. Mothers with CS were more likely than non-CS mothers to have their first prenatal care visit in the third trimester. High proportions of mothers in both groups reported high-risk sexual behaviors, methamphetamine use, or incarceration (13%-29%). The CS prevention cascade showed decrements of 5% to 11% in prenatal care receipt, testing, and treatment steps; only 62% of potential CS births were prevented. CONCLUSIONS: Multifaceted efforts are needed to address gaps in the CS prevention cascade and reduce CS cases in California.

      2. Heterosexual anal and oral sex in adolescents and adults in the United States, 2011-2015External
        Habel MA, Leichliter JS, Dittus PJ, Spicknall IH, Aral SO.
        Sex Transm Dis. 2018 Jun 29.

        BACKGROUND: Heterosexual anal and oral sex are related to the acquisition and transmission of STDs. As common reportable STDs (chlamydia, gonorrhea, and syphilis) in the U.S. are increasing, it is important to understand recent oral and anal sexual behaviors. METHODS: We examined the prevalence and correlates of heterosexual anal and oral sex, associated condom use, and having multiple partners among men and women 15-44 years. RESULTS: Approximately one-third of women and men had ever engaged in anal sex including 11% of adolescents (15-19 years). Most women and men had ever received or given oral sex, at >75%. Six and seven percent of women and men respectively, used a condom at last oral sex compared to 20% and 30% who used a condom at last anal sex. Having multiple sex partners in the past year was most common among adolescents, never or formerly married persons, and those who had a nonmonogamous partner. Less than 10% reported multiple anal sex partners in the past year. A substantial minority had multiple oral or anal sex partners; black women and men had highest reports of oral sex partners by race/ethnicity. CONCLUSIONS: Anal and oral sex are common sexual practices. Given the low rates of condom use during these behaviors, it is important that recommendations for sexual risk assessments are followed. Tailored messaging regarding risk for STD and HIV acquisition during oral and anal sex may benefit adolescents, singles, and divorced individuals. Future discussions regarding the benefits of extragenital STD testing for heterosexuals may be useful.

      3. Self-reported chlamydia and gonorrhea testing and diagnosis among men who have sex with men – 20 US cities, 2011 and 2014External
        Hoots BE, Torrone EA, Bernstein KT, Paz-Bailey G.
        Sex Transm Dis. 2018 Jul;45(7):469-475.

        BACKGROUND: Annual screening for chlamydia and gonorrhea is recommended for sexually active men who have sex with men (MSM) at anatomical sites of contact, regardless of condom use. METHODS: We assessed differences in self-reported chlamydia and gonorrhea testing and diagnosis in the past 12 months among MSM using National HIV Behavioral Surveillance data from 2011 and 2014. Men who have sex with men who had 1 or more partners in the past 12 months were included in analyses. Analyses of chlamydia and gonorrhea diagnosis data were limited to participants who reported past 12 months chlamydia and gonorrhea testing, respectively. Differences in testing and diagnosis over time were assessed using Poisson regression models with robust standard errors separately for chlamydia and gonorrhea. RESULTS: Analyses included data from 18,896 MSM (2011, n = 9256; 2014, n = 9640). Testing for chlamydia was 37% in 2011 and 47% in 2014 (prevalence ratio [PR], 1.25; 95% confidence interval [CI], 1.20-1.30) and 38% and 47% for gonorrhea (PR, 1.24; 95% CI, 1.19-1.29). Testing was higher in 2014 among most demographic subgroups. Prevalence of chlamydia diagnoses was 8% in 2011 and 11% in 2014 (PR, 1.37; 95% CI, 1.18-1.59) and of gonorrhea diagnoses was 10% in 2011 and 14% in 2014 (adjusted PR: 1.40, 95% CI, 1.23-1.60). Larger changes in diagnoses were observed among MSM in the white and “other” racial categories and those who disclosed same-sex behavior to their health care provider. CONCLUSIONS: Self-reported testing and diagnoses among MSM increased from 2011 to 2014. Increased efforts are needed to meet annual sexually transmitted disease screening recommendations among MSM at high HIV risk.

      4. Notes from the field: HIV testing in health care facilities – Lesotho, 2017External
        Isavwa T, Letsie M, Ramphalla P.
        MMWR Morb Mortal Wkly Rep. 2018 Jul 6;67(26):748-749.

        [No abstract]

      5. Characteristics associated with lack of HIV testing during pregnancy and delivery in 36 U.S. states, 2004-2013External
        Koumans EH, Harrison A, House LD, Burley K, Ruffo N, Smith R, FitzHarris L, Johnson CH, Taylor AW, Nesheim SR.
        Int J STD AIDS. 2018 Jan 1:956462418780053.

        The Centers for Disease Control and Prevention and the American Congress of Obstetricians and Gynecologists recommend universal prenatal HIV testing to prevent perinatal HIV transmission in the U.S.; since the 1990s perinatal HIV transmission has declined. In 2006, 74% of women with a recent live birth reported testing for HIV prenatally or at delivery. We used Pregnancy Risk Assessment Monitoring System data from 36 states and New York City from 2004 to 2013 (N = 387,424) to assess characteristics associated with lack of self-reported testing and state-to-state variability in these associations. Overall, 75.2% (95% confidence interval [CI] 75.0-75.5) of women with a recent live birth reported an HIV test. There were significant differences in testing prevalence by state, ranging from 91.8% (95% CI 91.0-92.6) in New York to 42.3% (95% CI 41.7-43.5) in Utah. In adjusted analysis, characteristics associated with no reported testing included being married, white, non-Hispanic, multiparous, not smoking during pregnancy, and having neither Medicaid nor Special Supplemental Nutritional Program for Women, Infants, and Children. White married women were 57% (adjusted prevalence ratio [aPR] 1.57, 95% CI 1.52-1.63) more likely to report no test compared to white unmarried women. Multiparous married women were 57% (aPR 1.57, 95% CI 1.51-1.64) more likely to report no test compared to multiparous unmarried women. Women who were married, white, non-Hispanic, and multiparous women were 23% less likely to be tested than other women combined. Marital status was significantly associated with lower prevalence of testing in 35 of the 37 reporting areas, and race was significant in 30 of 35 states with race information. The prevalence of reported HIV testing during pregnancy or at delivery remains below 80%. Opportunities exist to increase HIV testing among pregnant women, particularly among certain subpopulations.

      6. BACKGROUND: Black women who are positive for human immunodeficiency virus (HIV) are more likely than other HIV-positive women to experience poor health outcomes. Given these disparities, we compared receipt of HIV testing and other preventive services among Black, White, and Hispanic women participating in HIV prevention programs funded by the Centers for Disease Control and Prevention in 2015. METHODS: Data came from 61 health department jurisdictions and 123 community-based organizations. Using Wald chi(2) tests, we assessed racial/ethnic differences in HIV testing by demographic characteristics, risk factors, HIV status, HIV service delivery, and (using unlinked data) participation in evidence-based HIV prevention interventions among women. We also assessed temporal changes in Black women’s receipt of preventive services (2012-2015). RESULTS: In 2015, there were 1,326,589 HIV testing events (single sessions in which one or more HIV tests are performed to determine HIV status) that occurred among Black, White, and Hispanic women, resulting in 4,868 positive diagnoses. Proportionally fewer Black (vs. White and Hispanic) women were linked to HIV medical care within 90 days (64.4% vs. 69.1% and 73.7%), interviewed for partner services (50.4% vs. 54.4% and 63.5%), and referred to risk reduction services (55.5% vs. 57.7% and 59.8%). From 2012 to 2015, HIV testing events among Black women decreased by 15.2%, but linkage to care within 90 days increased by 30.6% and participation in one or more evidence-based intervention increased by 46.8% among HIV-positive Black women. CONCLUSIONS: Black HIV-positive women were less likely than White and Hispanic women to receive services that prevent HIV-related morbidity and mortality. Additional programmatic efforts are needed to increase the proportion of HIV-positive Black women who are linked to services to reduce HIV disparities among women.

      7. The role of HIV in influenza- and respiratory syncytial virus-associated hospitalizations in South African children, 2011-2016External
        McMorrow ML, Tempia S, Walaza S, Treurnicht FK, Moyes J, Cohen AL, Pretorius M, Hellferscee O, Wolter N, von Gottberg A, Nguweneza A, McAnerney JM, Naby F, Mekgoe O, Venter M, Madhi SA, Cohen C.
        Clin Infect Dis. 2018 Jun 29.

        Background: Few data describe influenza- or respiratory syncytial virus (RSV)-associated hospitalized illness in children aged <5 years in sub-Saharan Africa. Methods: During 2011-2016, we conducted prospective surveillance for severe respiratory illness (SRI) in children aged <5 years in three South African hospitals. Nasopharyngeal aspirates were tested for influenza and RSV by real-time reverse transcription polymerase chain reaction. We estimated rates of influenza- and RSV-associated hospitalized SRI by HIV status and compared children who tested positive for influenza versus RSV using multivariable penalized logistic regression. Results: Among 3650 hospitalized children, 203 (5.6%) tested positive for influenza viruses, 874 (23.9%) for RSV, and 19 (0.5%) for both. The median age of children hospitalized with influenza was 13.9 months versus 4.4 months for RSV (p<0.01). Annual influenza-associated hospitalization rates per 100,000 were highest among infants aged 6-11 months (545, 95% Confidence Interval (CI): 409-703), while RSV-associated hospitalization rates were highest in infants aged 0-2 months (6593, 95% CI: 5947-7217). HIV exposure was associated with increased incidence of influenza- and RSV-associated hospitalization in infants aged 0-5 months, Relative Risk (RR) 2.2 (95% CI: 1.4-3.4) and 1.4 (95% CI: 1.3-1.6), respectively. HIV infection was associated with increased incidence of influenza- and RSV-associated hospitalization in all age groups; RR 2.7 (95% CI: 2.0-3.5) and 3.8 (95% CI: 3.1-4.8), respectively. The case-fatality rate was 0.8% among children hospitalized with influenza or RSV. Conclusions: Influenza- and RSV-associated hospitalization are common among South African infants. HIV infection, and HIV exposure in infants, increase risk of influenza- and RSV-associated hospitalization.

      8. Time spent with HIV viral load >1500 copies/mL among patients in HIV care, 2000-2014External
        Mendoza MC, Gardner L, Armon C, Rose C, Palella FJ, Novak R, Tedaldi E, Buchacz K.
        Aids. 2018 Jun 28.

        OBJECTIVE: Sexual HIV transmission is more likely to occur when plasma HIV RNA level (viral load, VL) exceeds 1,500 copies/mL. We assessed the percentage of person-time spent with VL >1,500 copies/mL (pPT>1500) among adults with HIV in care. DESIGN: Observational cohort in eight United States HIV clinics. METHODS: Participants had >/=1 HIV Outpatient Study (HOPS) clinic visit and >/=2 VLs during 2000-2014. We assessed pPT>1500 in time intervals between consecutive VL pairs, overall and by ART status. Trends in pPT>1500 and associations between pPT>1500 and chosen baseline demographics and clinical characteristics were analyzed using generalized estimating equations. RESULTS: There were 5,873 patients contributing 37,794 person-years [py]; 86.0% py were prescribed ART, with increasing coverage over time. Over 2000-2014 pPT>1500 was 24.2%, decreasing from 38.3% in 2000-2002 to 11.3% in 2012-2014. During observation time with ART prescribed, pPT>1500 was 16.4% overall, decreasing from 29.9% in 2000-2002 to 8.0% in 2012-2014. pPT>1500 was higher in patients <35 vs. >/=50 years old (31.5% vs. 15.6%), women vs. men (30.8% vs. 22.3%), and black vs. white and Latino/Hispanic patients (32.7% vs. 19.9% and 23.7%, respectively). Multivariable correlates of higher pPT>1,500 included no prescribed ART, being younger, non-Hispanic black vs. white, baseline VL >1,500 copies/mL or lower CD4+ count, and baseline public vs. private insurance. CONCLUSIONS: pPT>1500 declined during 2000-2014. Results support decreasing HIV transmission risk from persons in HIV care over the last decade, and the need to focus interventions on patient groups more consistently viremic.

      9. Antimicrobial resistance among Helicobacter pylori isolates in Alaska, 2000-2016External
        Mosites E, Bruden D, Morris J, Reasonover A, Rudolph K, Hurlburt D, Hennessy T, McMahon B, Bruce M.
        J Glob Antimicrob Resist. 2018 Jun 30.

        OBJECTIVES: Alaska Native people experience a high burden of Helicobacter pylori infection and concomitant high rates of gastric cancer. Additionally, the prevalence of antimicrobial resistant strains of H. pylori has been shown to be high in Alaska. We evaluated antimicrobial resistance over time among sentinel surveillance isolates and assessed risk factors for carrying resistant H. pylori. METHODS: Through Alaska’s H. pylori sentinel surveillance system, we collected and cultured antral and fundal biopsies from Alaska Native patients undergoing esophagogastroduodenoscopy for clinical indications during 2000-2016. For positive cultures, we performed minimum inhibitory concentration (MIC) testing for metronidazole, amoxicillin, clarithromycin, tetracycline, and levofloxacin. RESULTS: We tested 800H. pylori isolates obtained from 763 patients. Metronidazole resistance was most common (342/800; 43%), followed by clarithromycin resistance (238/800; 30%), resistance to both clarithromycin and metronidazole (128/800; 16%), and levofloxacin resistance (113/800; 15%). Low proportions of isolates were resistant to amoxicillin and tetracycline. Levofloxacin resistance increased between 2000 and 2016 (p <0.001), but resistance to other antimicrobials did not change over time. Metronidazole and clarithromycin resistance were more common among women (p <0.001 for both), while levofloxacin resistance was more common among those with an urban residence (p=0.003). Metronidazole resistance and levofloxacin resistance were more common among older patients (p=0.004, p=0.012). CONCLUSION: Between 2000 and 2016, a large percentage of the H. pylori isolates received by the Alaska Sentinel Surveillance System demonstrated resistance to common antimicrobial agents. The surveillance system provides valuable information for clinicians to make informed treatment choices for patient with H. pylori.

      10. Prolonged and large outbreak of invasive group A Streptococcus disease within a nursing home: repeated intrafacility transmission of a single strainExternal
        Nanduri SA, Metcalf BJ, Arwady MA, Edens C, Lavin MA, Morgan J, Clegg W, Beron A, Albertson JP, Link-Gelles R, Ogundimu A, Gold J, Jackson D, Chochua S, Stone N, Van Beneden C, Fleming-Dutra K, Beall B.
        Clin Microbiol Infect. 2018 May 18.

        OBJECTIVES: Multiple invasive group A Streptococcus (GAS) infections were reported to public health by a skilled nursing facility (facility A) in Illinois between May 2014 and August 2016. Cases continued despite interventions including antibiotic prophylaxis for all residents and staff. Two other geographically close facilities reported contemporaneous outbreaks of GAS. We investigated potential reasons for ongoing transmission. METHODS: We obtained epidemiologic data from chart review of cases and review of facility and public health records from previous investigations into the outbreak. Infection control practices at facility A were observed and evaluated. Whole genome sequencing followed by phylogenetic analysis was performed on available isolates from the three facilities. RESULTS: From 2014 to 2016, 19 invasive and 60 noninvasive GAS infections were identified at facility A occurring in three clusters. Infection control evaluations during clusters 2 and 3 identified hand hygiene compliance rates of 14% to 25%, appropriate personal protective equipment use in only 33% of observed instances, and deficient wound-care practices. GAS isolates from residents and staff of all three facilities were subtype emm89.0; on phylogenetic analysis, facility A isolates were monophyletic and distinct. CONCLUSIONS: Inadequate infection control and improper wound-care practices likely led to this 28-month-long outbreak of severe infections in a skilled nursing facility. Whole genome sequencing and phylogenetic analysis suggested that intrafacility transmission of a single highly transmissible GAS strain was responsible for the outbreak in facility A. Integration of genomic epidemiology tools with traditional epidemiology and infection control assessments was helpful in investigation of a facility-wide outbreak.

      11. Spatial patterns of extensively drug-resistant tuberculosis (XDR-tuberculosis) transmission in KwaZulu-Natal, South AfricaExternal
        Nelson KN, Shah NS, Mathema B, Ismail N, Brust JC, Brown TS, Auld SC, Omar SV, Morris N, Campbell A, Allana S, Moodley P, Mlisana K, Gandhi NR.
        J Infect Dis. 2018 Jun 28.

        Background: Transmission is driving the global drug-resistant tuberculosis epidemic; nearly three-quarters of drug-resistant tuberculosis cases are attributable to transmission. Geographic patterns of disease incidence, combined with information on probable transmission links, can define the spatial scale of transmission and generate hypotheses about factors driving transmission patterns. Methods: We combined whole-genome sequencing data with home GPS coordinates from 344 participants with extensively drug-resistant (XDR) tuberculosis in KwaZulu-Natal, South Africa diagnosed from 2011-2014. We aimed to determine if genomically linked (</=5 single nucleotide polymorphisms [SNP] differences) cases lived close to one another, which would suggest a role for local community settings in transmission. Results: 182 study participants were genomically linked, comprising 1084 case-pairs. The median distance between case-pairs’ homes was 108 km (IQR: 64-162 km). Between-district, as compared to within-district, links accounted for the majority (912/1084, 84%) of genomic links. Half (526, 49%) of genomic links involved a case from Durban, the urban center of KwaZulu-Natal. Conclusions: The high proportions of between-district links with Durban provide insight into possible drivers of province-wide XDR-tuberculosis transmission, including urban-rural migration. Further research should focus on characterizing the contribution of these drivers to overall XDR-tuberculosis transmission in KwaZulu-Natal to inform design of targeted strategies to curb the drug-resistant tuberculosis epidemic.

      12. Women have always been part of the HIV/AIDS epidemic. As with other populations affected by HIV, for many years the only prevention strategy available was behavior change. Behavioral interventions for women were developed and evaluated, with some success. Because women did not control the use of male condoms, efficacious interventions needed to build skills for partner negotiation. Woman-controlled technologies such as the female condom and vaginal spermicide were unable to solve the problem of male control of the condom and enable the development of safe methods for women to protect themselves. The modern era of HIV prevention has produced biomedical solutions based on highly active retroviral chemoprophylaxis, which can be hidden from the male partner and thus eliminate his possible negative reactions. Pre-exposure prophylaxis holds promise for HIV prevention among women. This article reviews the literature on HIV prevention for women, including both successes and challenges.

      13. Correlates of rectal douching practices among men who have sex with men in KenyaExternal
        Saleska JL, Turner AN, Syvertsen J, Nakhumwa J, Soo L, Ohaga S, Agot K.
        Sex Transm Dis. 2018 Jun 29.

        BACKGROUND: Among men who have sex with men (MSM), rectal douching (RD) has been associated with increased prevalence of HIV and other sexually transmitted infections. Substances commonly used for RD, especially water-based solutions, could disrupt the rectal epithelium and increase susceptibility to infection. The few existing reports on RD among MSM are primarily in middle- and high-income settings, and to date, no study has focused on RD among MSM in Africa. METHODS: We conducted a secondary data analysis of programmatic data from key population service centers in western Kenya. Data were extracted from records of clients who identified as MSM and accessed services between January 1, 2014 and September 1, 2016. We compared demographic and behavioral characteristics of men who did and did not practice RD. Logistic regression assessed associations with RD. RESULTS: Of the 202 MSM in this analysis, 63% engaged in RD. All who engaged in RD used water-based substances. Those who engaged in receptive anal intercourse (RAI) in the last 3 months were more likely to report RD (Odds Ratio (OR): 3.19, 95% Confidence Interval (CI): 1.67-6.07). Among MSM who engaged in sex work, those who practiced RD reported more regular clients per week (2.8 vs. 1.3 clients, p=0.01). RD practices did not vary by other sexual risk practices. CONCLUSIONS: RD is common in this population of Kenyan MSM, especially among those who have recently engaged in RAI, suggesting that a rectal douche that delivers microbicides could be a potential intervention to reduce HIV/STI infection within this population.

      14. Identifying which place characteristics are associated with the odds of recent HIV testing in a large sample of people who inject drugs in 19 US Metropolitan AreasExternal
        Tempalski B, Cooper HL, Kelley ME, Linton SL, Wolfe ME, Chen YT, Ross Z, Des Jarlais DC, Friedman SR, Williams LD, Semaan S, DiNenno E, Wejnert C, Broz D, Paz-Bailey G.
        AIDS Behav. 2018 Jul 3.

        This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC’s 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

      15. Antiviral treatment for outpatient use during an influenza pandemic: a decision tree model of outcomes averted and cost-effectivenessExternal
        Venkatesan S, Carias C, Biggerstaff M, Campbell AP, Nguyen-Van-Tam JS, Kahn E, Myles PR, Meltzer MI.
        J Public Health (Oxf). 2018 Jun 28.

        Background: Many countries have acquired antiviral stockpiles for pandemic influenza mitigation and a significant part of the stockpile may be focussed towards community-based treatment. Methods: We developed a spreadsheet-based, decision tree model to assess outcomes averted and cost-effectiveness of antiviral treatment for outpatient use from the perspective of the healthcare payer in the UK. We defined five pandemic scenarios-one based on the 2009 A(H1N1) pandemic and four hypothetical scenarios varying in measures of transmissibility and severity. Results: Community-based antiviral treatment was estimated to avert 14-23% of hospitalizations in an overall population of 62.28 million. Higher proportions of averted outcomes were seen in patients with high-risk conditions, when compared to non-high-risk patients. We found that antiviral treatment was cost-saving across pandemic scenarios for high-risk population groups, and cost-saving for the overall population in higher severity influenza pandemics. Antiviral effectiveness had the greatest influence on both the number of hospitalizations averted and on cost-effectiveness. Conclusions: This analysis shows that across pandemic scenarios, antiviral treatment can be cost-saving for population groups at high risk of influenza-related complications.

      16. BACKGROUND: Opportunistic diseases cause morbidity and mortality among human immunodeficiency virus (HIV) infected persons. There is dearth of evidence on the magnitude and predictors of opportunistic diseases among PLHIV in Ethiopia. This study was conducted to determine the magnitude and predictors of opportunistic diseases among adults enrolled in the national HIV/AIDS care and treatment services and generate information for program planning and medicine quantification in the country. METHODS: A health facility-based cross-sectional study was conducted. Probability proportional to size and random sampling methods were employed to select health facilities and medical records of adult HIV-infected patients respectively. A total of 7826 medical records were reviewed from 60 health facilities nationwide. Socio-demographic and clinical data including diagnosis of opportunistic diseases were collected from the medical records. Period prevalence of opportunistic diseases over one year period was determined. Bivariate and multivariate logistic regression was used to measure associations between independent variables and the dependent variable, occurrence of opportunistic diseases. RESULTS: Of the total of 7826 study participants, 3748 (47.9%) were from hospitals and 4078 were from health centers. The majority (61.8%) were female. The median age was 32 years with interquartile range (IQR) of 27-40. The median duration of stay in HIV care was 56 (IQR = 28-80) months; 7429 (94.9%) were on antiretroviral treatment. A total of 1665 cases of opportunistic diseases were recorded with an overall prevalence estimated at 21.3% (95% confidence interval (CI): 20.36, 22.18%). Skin diseases (4.1%), diarrhea (4.1%), bacterial pneumonia (3.6%), recurrent upper respiratory tract infections (3.1%) and tuberculosis (2.7%) were the leading opportunistic diseases. Isoniazid preventive therapy coverage among eligible patients was 24.8%. Persons with a CD4 count < 200 cells/mm(3) [adjusted odds ratio (AOR) 1.80, 95% CI: 1.45, 2.23]; and who were bed ridden or ambulatory functional status [AOR (95% CI) = 3.19 (2.32, 4.39)] were independent predictors of diagnosis of opportunistic diseases. CONCLUSION: Opportunistic diseases were found to be pervasive among HIV infected adults in Ethiopia. Proactive identification and management, and prevention of opportunistic diseases should be strengthened especially among females, ambulatory or bed-ridden, and patients with low CD4 cell count.

      17. BACKGROUND: Homelessness significantly affects health and well-being. Homeless adults often experience co-occurring and debilitating physical, psychological, and social conditions. These determinants are associated with disproportionate rates of infectious disease among homeless adults, including tuberculosis, HIV, and hepatitis. Less is known about sexually transmitted infection (STI) prevalence among homeless adults. METHODS: We systematically searched 3 databases and reviewed the 2000-2016 literature on STI prevalence among homeless adults in the United States. We found 59 articles of US studies on STIs that included homeless adults. Of the 59 articles, 8 met the inclusion criteria of US-based, English-language, peer-reviewed articles, published in 2000 to 2016, with homeless adults in the sample. Descriptive and qualitative analyses were used to report STI prevalence rates and associated risk factors. RESULTS: Overall, STI prevalence ranged from 2.1% to 52.5%. A composite STI prevalence was most often reported (n = 7), with rates ranging from 7.3% to 39.9%. Reported prevalence of chlamydia/gonorrhea (7.8%) was highest among younger homeless adult women. Highest reported prevalence was hepatitis C (52.5%) among older homeless men. Intimate partner violence, injection and noninjection substance use, incarceration history, and homelessness severity are associated with higher STI prevalence. CONCLUSIONS: Homeless adults are a vulnerable population. Factors found to be associated with sexual risk were concurrently associated with housing instability and homelessness severity. Addressing STI prevention needs of homeless adults can be enhanced by integrating sexual health, and other health services where homeless adults seek or receive housing and other support services.

    • Environmental Health
      1. WIC participation and blood lead levels among children 1-5 years: 2007-2014External
        Aoki Y, Brody DJ.
        Environ Health Perspect. 2018 Jun;126(6):067011.

        BACKGROUND: The CDC recommends a targeted strategy for childhood blood lead screening based on participation in federal programs, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Yet, there is scarcity of data on blood lead levels (BLLs) among WIC participants. OBJECTIVE: Our objective was to investigate whether children participating in WIC and not enrolled in Medicaid, who have not been targeted in the historical Medicaid-focused screening strategy, have higher BLLs than children in neither of these programs. METHODS: The analysis included 3,180 children 1-5 y of age in the National Health and Nutrition Examination Surveys conducted in 2007-2014. Log-binomial regression, which allows direct estimation of prevalence ratios, was used to examine associations between WIC participation (in conjunction with Medicaid enrollment) and having BLLs >/=5 mug/dL with adjustment for age (1-2 vs. 3-5 y). RESULTS: The percentage of children participating in “WIC only,” “Medicaid only,” “both WIC and Medicaid,” and “neither” were 18.9%, 10.8%, 25.4%, and 44.9%, respectively. “WIC only,” “Medicaid only,” and “both WIC and Medicaid” children were more likely to have BLLs >/=5 mug/dL than children who were not enrolled in either program, with adjusted prevalence ratios of 3.29 [95% confidence interval (CI): 1.19, 9.09], 4.56 (95% CI: 2.18, 9.55), and 2.58 (95% CI: 1.18, 5.63). CONCLUSIONS: Children participating in WIC but not Medicaid were more likely to have BLLs >/=5 mug/dL than children who were not enrolled in either program. These findings may inform public health recommendations and clinical practice guidelines.

      2. Radon is a naturally occurring, radioactive, colorless, odorless gas, and the second leading cause of lung cancer. The 1990-1991 National School Radon Survey estimated that more than 70,000 schoolrooms nationwide had “high short-term radon levels.” Using data from a nationally representative survey of schools in the United States ( N = 568; response rate = 69%), we examined the location and demographic characteristics of U.S. schools that had ever been tested for radon and whether having been tested varied by radon zone, which predicts average indoor radon levels in U.S. counties. Overall, 46.0% (95% confidence interval [39.8%, 52.4%]) of schools reported that they had ever been tested for radon. Testing significantly varied by region, percentage of minority students, and radon zone. These findings highlight the need for improved awareness of radon testing in schools, as testing is the only way to identify when remediation is needed.

      3. Alternaria is associated with asthma symptoms and exhaled NO among NYC childrenExternal
        Soffer N, Green BJ, Acosta L, Divjan A, Sobek E, Lemons AR, Rundle AG, Jacobson JS, Goldstein IF, Miller RL, Perzanowsk MS.
        J Allergy Clin Immunol. 2018 Jun 28.

        Among NYC children, Alternaria sensitization, even at low IgE concentrations, was associated with asthma morbidity. Domestic Alternaria exposure, which was common, was associated with exhaled NO, specifically among children with higher neighborhood-level combustion air pollution.

    • Health Economics
      1. Communicating the financial burden of treatment with patientsExternal
        Nipp RD, Sonet EM, Guy GP.
        Am Soc Clin Oncol Educ Book. 2018 ;38:524-531.

        In recent years, high health care costs and the financial burden of cancer care have received increased attention. In response to the financial burden of cancer care, patients may jeopardize their health outcomes by not properly adhering to prescribed therapies or even forgoing and delaying care in an effort to defray costs. In addition, the financial burden experienced by patients with cancer may negatively impact clinical outcomes, such as quality of life, physical and psychological symptoms, and potentially, even survival. Notably, in the current era of targeted treatment and immunotherapies for patients with cancer, the rising costs of cancer continue to remain at the forefront of patient concerns. Therefore, a critical need exists to determine how best to assist patients with the cost burden of cancer diagnosis and treatment.

    • Healthcare Associated Infections
      1. Human factors and systems engineering: The future of infection prevention?External
        Patel PR, Kallen AJ.
        Infect Control Hosp Epidemiol. 2018 Jul;39(7):849-851.

        [No abstract]

    • Immunity and Immunization
      1. The relative invasive disease potential of Streptococcus pneumoniae among children after PCV introduction: a systematic review and meta-analysisExternal
        Balsells E, Dagan R, Yildirim I, Gounder PP, Steens A, Munoz-Almagro C, Mameli C, Kandasamy R, Lavi NG, Daprai L, van der Ende A, Trzcinski K, Nzenze S, Meiring S, Foster D, Bulkow LR, Rudolph K, Valero-Rello A, Ducker S, Vestrheim DF, von Gottberg A, Pelton SI, Zuccotti G, Pollard AJ, Sanders EA, Campbell H, Madhi SA, Nair H, Kyaw MH.
        J Infect. 2018 Jun 29.

        OBJECTIVES: Burden of pneumococcal disease depends on the prevalence and invasive disease potential of serotypes. We aimed to estimate the invasive disease potential of serotypes in children under 5 years of age by combining data from different settings with routine immunisation with pneumococcal conjugate vaccines (PCV). METHODS: We conducted a systematic review, supplemented by unpublished data, to identify data on the frequency of pneumococcal serotypes in carriage and invasive pneumococcal disease (IPD). We estimated the invasive disease potential of serotypes as the ratio of IPD in relation to carriage (odds ratio and 95%CI) compared with 19A (reference serotype) by meta-analysis. We report results based on a random effects model for children aged 0-23, 24-29, and 0-59 months and by invasive clinical syndromes. RESULTS: In comparison with 19A, serotypes 1, 7F, and 12F had a significantly higher invasive disease potential in children aged 0-23 and 0-59 months for all IPD and clinical syndromes (OR>5). Several non-vaccine types (NVTs) (6C, 15A, 15BC, 16F, 23B, in these two age groups) had a lower invasive disease potential than 19A (OR 0*1-0*3). NVTs 8, 12F, 24F, and 33F were at the upper end of the invasiveness spectrum. CONCLUSIONS: There is substantial variation among pneumococcal serotypes in their potential to cause IPD and disease presentation, which is influenced by age and time after PCV introduction. Surveillance of IPD and carriage is critical to understand the expected effectiveness of current PCVs (in the longer term) and guide the development of future vaccines.

      2. Measles-rubella supplementary immunization activity readiness assessment – India, 2017-2018External
        Gurnani V, Haldar P, Khanal S, Bhatnagar P, Singh B, Ahmed D, Samiuddin M, Kumar A, Negi Y, Gupta S, Harvey P, Bahl S, Dabbagh A, Alexander JP, Goodson JL.
        MMWR Morb Mortal Wkly Rep. 2018 Jul 6;67(26):742-746.

        In 2013, during the 66th session of the Regional Committee of the World Health Organization (WHO) South-East Asia Region (SEAR), the 11 SEAR countries* adopted goals to eliminate measles and control rubella and congenital rubella syndrome by 2020(dagger) (1). To accelerate progress in India (2,3), a phased( section sign) nationwide supplementary immunization activity (SIA)( paragraph sign) using measles-rubella vaccine and targeting approximately 410 million children aged 9 months-14 years commenced in 2017 and will be completed by first quarter of 2019. To ensure a high-quality SIA, planning and preparation were monitored using a readiness assessment tool adapted from the WHO global field guide** (4) by the India Ministry of Health and Family Welfare. This report describes the results and experience gained from conducting SIA readiness assessments in 24 districts of three Indian states (Andhra Pradesh, Kerala, and Telangana) during the second phase of the SIA. In each selected area, assessments were conducted 4-6 weeks and 1-2 weeks before the scheduled SIA. At the first assessment, none of the states and districts were on track with preparations for the SIA. However, at the second assessment, two (67%) states and 21 (88%) districts were on track. The SIA readiness assessment identified several preparedness gaps; early assessment results were immediately communicated to authorities and led to necessary corrective actions to ensure high-quality SIA implementation.

      3. Population structure of invasive Neisseria meningitidis in the United States, 2011-15External
        Potts CC, Joseph SJ, Chang HY, Chen A, Vuong J, Hu F, Jenkins LT, Schmink S, Blain A, MacNeil JR, Harrison LH, Wang X.
        J Infect. 2018 Jun 28.

        OBJECTIVES: Meningococcal conjugate vaccines (MenACWY) were licensed in the United States in 2005. We assessed the population structure of invasive Neisseria meningitidis (Nm) ten years after recommended use of MenACWY among adolescents. METHODS: Meningococcal isolates obtained through Active Bacterial Core surveillance (ABCs) from 2000-05, 2006-10, and 2011-15 underwent whole genome or Sanger sequencing. Genome phylogenies were completed using maximum likelihood methods; and distribution of multilocus sequence typing (MLST) sequence type (ST) and clonal complex (CC), and PorA and FetA types were assessed. RESULTS: Prevalent serogroups (B, C, Y and W), CCs, and PorA and FetA types were detected in all three time periods, but dynamic changes were observed. The proportion of serogroup W CC11 isolates increased in 2011-15 and were most related to South American strains. Changes in CC distribution were also observed in serogroup C and serogroup Y. Phylogenetic analysis showed that U.S. serogroup W CC11s are closely related to a subset of U.S. serogroup C isolates; combined global analysis demonstrated that some CCs, including CC11, exhibit regional clustering. CONCLUSIONS: Overall, the Nm population structure has remained stable after MenACWY introduction. Dynamic changes in genotypes, unlikely related to vaccination, also occurred, highlighting the need for continued whole genome-based surveillance.

      4. Use of the revised World Health Organization cluster survey methodology to classify measles-rubella vaccination campaign coverage in 47 counties in Kenya, 2016External
        Subaiya S, Tabu C, N’Ganga J, Awes AA, Sergon K, Cosmas L, Styczynski A, Thuo S, Lebo E, Kaiser R, Perry R, Ademba P, Kretsinger K, Onuekwusi I, Gary H, Scobie HM.
        PLoS One. 2018 ;13(7):e0199786.

        INTRODUCTION: To achieve measles elimination, two doses of measles-containing vaccine (MCV) are provided through routine immunization services or vaccination campaigns. In May 2016, Kenya conducted a measles-rubella (MR) vaccination campaign targeting 19 million children aged 9 months-14 years, with a goal of achieving >/=95% coverage. We conducted a post-campaign cluster survey to estimate national coverage and classify coverage in Kenya’s 47 counties. METHODS: The stratified multi-stage cluster survey included data from 20,011 children in 8,253 households sampled using the recently revised World Health Organization coverage survey methodology (2015). Point estimates and 95% confidence intervals (95% CI) of national campaign coverage were calculated, accounting for study design. County vaccination coverage was classified as ‘pass,’ ‘fail,’ or ‘intermediate,’ using one-sided hypothesis tests against a 95% threshold. RESULTS: Estimated national MR campaign coverage was 95% (95% CI: 94%-96%). Coverage differed significantly (p < 0.05) by child’s school attendance, mother’s education, household wealth, and other factors. In classifying coverage, 20 counties passed (>/=95%), two failed (<95%), and 25 were intermediate (unable to classify either way). Reported campaign awareness among caretakers was 92%. After the 2016 MR campaign, an estimated 93% (95% CI: 92%-94%) of children aged 9 months to 14 years had received >/=2 MCV doses; 6% (95% CI: 6%-7%) had 1 MCV dose; and 0.7% (95% CI: 0.6%-0.9%) remained unvaccinated. CONCLUSIONS: Kenya reached the MR campaign target of 95% vaccination coverage, representing a substantial achievement towards increasing population immunity. High campaign awareness reflected the comprehensive social mobilization strategy implemented in Kenya and supports the importance of including strong communications platforms in future vaccination campaigns. In counties with sub-optimal MR campaign coverage, further efforts are needed to increase MCV coverage to achieve the national goal of measles elimination by 2020.

      5. Development of a relative potency test using ELISA for human rabies vaccinesExternal
        Wang Z, Sun Y, Wu X, Carroll DS, Lv W, You L, Ji Y, Shi J, Yan J, Xu G, Meng S.
        Biologicals. 2018 Jun 30.

        The NIH potency test for human rabies vaccines has disadvantages for use, especially in developing countries where rabies is endemic and prophylaxis needs ample, rapid, and reliable vaccine supplies. In China, 60-75 million doses of human rabies vaccines are administered each year. Vaccine quality control is of paramount importance, as is the release of potency-validated vaccines. We intended to design an alternative to the NIH in vivo method, and developed a relative potency test using an ELISA. Using Pearson’s correlation analysis, we found a close relationship between the rabies vaccine glycoprotein content in vitro and the potency values in vivo. We suggest the relative potency test developed here as a simplified method for human rabies vaccine quality control in China and a possible alternative to the NIH method.

    • Injury and Violence
      1. Reducing fall risk in older adultsExternal
        Haddad YK, Bergen G, Luo F.
        Am J Nurs. 2018 Jul;118(7):21-22.

        : Evidence supports addressing medication management.

    • Laboratory Sciences
      1. Multi-laboratory comparison of three commercially available Zika IgM enzyme-linked immunosorbent assaysExternal
        Basile AJ, Goodman C, Horiuchi K, Sloan A, Johnson BW, Kosoy O, Laven J, Panella AJ, Sheets I, Medina F, Mendoza EJ, Epperson M, Maniatis P, Semenova V, Steward-Clark E, Wong E, Biggerstaff BJ, Lanciotti R, Drebot M, Safronetz D, Schiffer J.
        J Virol Methods. 2018 Jun 28.

        [No abstract]

      2. Characterization of 108 Genomic DNA Reference Materials for 11 Human Leukocyte Antigen (HLA) Loci: A GeT-RM Collaborative ProjectExternal
        Bettinotti MP, Ferriola D, Duke JL, Mosbruger TL, Tairis N, Jennings L, Kalman LV, Monos D.
        J Mol Diagn. 2018 Jun 26.

        The highly polymorphic human leukocyte antigen (HLA) genes, located in the human major histocompatibility complex, encode the class I and II antigen-presenting molecules which are centrally involved in the immune response. HLA typing is used for several clinical applications such as transplantation, pharmacogenetics, and diagnosis of autoimmune disease. HLA typing is highly complex due to the homology of HLA genes and pseudogenes and the extensive polymorphism in the population. The Centers for Disease Control and Prevention (CDC) established the Genetic Testing Reference Materials Coordination Program (GeT-RM) in partnership with the genetics community to improve the availability of genomic DNA reference materials necessary to assure the quality of genetic laboratory testing. The GeT-RM together with three clinical laboratories and the Coriell Cell Repositories have characterized genomic DNA obtained from a panel of 108 cell lines for all HLA classical polymorphic loci: HLA-A, B, C, DRB1, DRB3, DRB4, DRB5, DQA1, DQB1, DPA1, and DPB1. The goal was to develop a publicly available and renewable source of well-characterized genomic DNA reference materials to support molecular HLA typing assay development, validation, and verification, quality control, and proficiency testing. These genomic DNA samples are publicly available from the National Institutes of General Medical Science (NIGMS) Repository at the Coriell Cell Repositories.

      3. Headspace analysis for screening of volatile organic compound profiles of electronic juice bulk materialExternal
        LeBouf RF, Burns DA, Ranpara A, Attfield K, Zwack L, Stefaniak AB.
        Anal Bioanal Chem. 2018 Jul 4.

        The use of electronic nicotine delivery systems continues to gain popularity, and there is concern for potential health risks from inhalation of aerosol and vapor produced by these devices. An analytical method was developed that provided quantitative and qualitative chemical information for characterizing the volatile constituents of bulk electronic cigarette liquids (e-liquids) using a static headspace technique. Volatile organic compounds (VOCs) were screened from a convenience sample of 146 e-liquids by equilibrating 1 g of each e-liquid in amber vials for 24 h at room temperature. Headspace was transferred to an evacuated canister and quantitatively analyzed for 20 VOCs as well as tentatively identified compounds using a preconcentrator/gas chromatography/mass spectrometer system. The e-liquids were classified into flavor categories including brown, fruit, hybrid dairy, menthol, mint, none, tobacco, and other. 2,3-Butanedione was found at the highest concentration in brown flavor types, but was also found in fruit, hybrid dairy, and menthol flavor types. Benzene was observed at concentrations that are concerning given the carcinogenicity of this compound (max 1.6 ppm in a fruit flavor type). The proposed headspace analysis technique coupled with partition coefficients allows for a rapid and sensitive prediction of the volatile content in the liquid. The technique does not require onerous sample preparation, dilution with organic solvents, or sampling at elevated temperatures. Static headspace screening of e-liquids allows for the identification of volatile chemical constituents which is critical for identifying and controlling emission of potentially hazardous constituents in the workplace.

      4. Mass spectral detection of diethoxyphospho-tyrosine adducts on proteins from HEK293 cells using monoclonal antibody depY for enrichmentExternal
        Onder S, Schopfer LM, Tacal O, Blake TA, Johnson RC, Lockridge O.
        Chem Res Toxicol. 2018 Jun 18;31(6):520-530.

        Chronic illness from exposure to organophosphorus toxicants is hypothesized to involve modification of unknown proteins. Tyrosine in proteins that have no active site serine readily reacts with organophosphorus toxicants. We developed a monoclonal antibody, depY, that specifically recognizes diethoxyphospho-tyrosine in proteins and peptides, independent of the surrounding amino acid sequence. Our goal in the current study was to identify diethoxyphosphorylated proteins in human HEK293 cell lysate treated with chlorpyrifos oxon. Cell lysates treated with chlorpyrifos oxon were recognized by depY antibody in ELISA and capillary electrophoresis based Western blot. Tryptic peptides were analyzed by liquid chromatography tandem mass spectrometry. Liquid chromatography tandem mass spectrometry identified 116 diethoxyphospho-tyrosine peptides from 73 proteins in immunopurified samples, but found only 15 diethoxyphospho-tyrosine peptides from 12 proteins when the same sample was not immunopurified on depY. The most abundant proteins in the cell lysate, histone H4, heat shock 70 kDa protein 1A/1B, heat shock protein HSP 90 beta, and alpha-enolase, were represented by several diethoxyphospho-tyrosine peptides. It was concluded that use of immobilized depY improved the number of diethoxyphospho-tyrosine peptides identified in a complex mixture. The mass spectrometry results confirmed the specificity of depY for diethoxyphospho-tyrosine peptides independent of the context of the modified tyrosine, which means depY could be used to analyze modified proteins in any species. Use of the depY antibody could lead to an understanding of chronic illness from organophosphorus pesticide exposure.

      5. Host-viral interaction occurring throughout the infection process between the influenza A virus (IAV) and bronchial cells determines the success of infection. Our previous studies showed that the apoptotic pathway triggered by the host cells was repressed by IAV facilitating prolonged survival of infected cells. A detailed understanding on the role of IAV in altering the cell death pathway during early stage infection of human bronchial epithelial cells (HBEpCs) is still unclear. We investigated the gene expression profiles of IAV-infected versus mock-infected cells at the early stage of infection using a PCR array for death receptor (DR) pathway. At early stages infection (2h) with IAV significantly upregulated DR pathway genes in HBEpCs, whereas 6h exposure to IAV resulted in downregulation of same genes. IAV replication in HBEpCs decreased the levels of DR pathway genes including TNF-receptor super family1, Fas-associated Death Domain, caspase-8, and caspase-3, by 6h, resulting in increased survival of cells. The apoptotic cell population decreased in 6h compared to the 2h exposure to IAV. The PCR array data was imported into Ingenuity pathway analysis software, resulting in confirmation of the model showing significant modulation of the DR pathway. Our data indicate that a significant transcriptional regulation of apoptotic, necrotic and DR genes occur at early and late hours of infection that are vital in modulating the survival of host cells and replication of IAV. These data intuitively may have provided a likely roadmap for translational approaches targeting the DR pathway to enhance apoptosis and inhibit replication of the virus.

      6. Background: Measurement of folate monoglutamates by HPLC-tandem mass spectrometry (HPLC-MS/MS) in whole-blood lysate (WBL) requires lengthy incubation before analysis, risking degradation of labile folate vitamers. Objective: We explored whether the addition of a commercially available recombinant exogenous gamma-glutamyl hydrolase (exoGGH) enzyme reduced the required incubation time of WBL for measurement of folate as monoglutamates. Methods: For conventional deglutamylation of polyglutamates, WBL was incubated for 4 h at 37 degrees C. Alternatively, we added exoGGH to WBL at varying concentrations (1-10 microg/mL) and incubation times (0-90 min). We also investigated modifications to the sample diluent (pH, ascorbic acid compared with sodium ascorbate, and ascorbate concentration). Finally, we tested the effect of the enzyme in different sample types: WBL from frozen whole blood compared with frozen WBL or with frozen washed RBCs. Samples (n </= 15/experiment) were analyzed by HPLC-MS/MS for 6 folate monoglutamates and 5-methyltetrahydrofolate diglutamate. Results: Optimal deconjugation of folate polyglutamates was achieved by using 1% ascorbic acid and 5 microg enzyme/mL WBL, requiring </=30 min incubation time to achieve complete folate recovery as monoglutamates. This treatment resulted in similar folate concentrations as conventional deglutamylation (4 h at 37 degrees C). The exoGGH enzyme was effective in samples stored frozen as whole blood and as WBL. However, the extended thaw time of whole blood resulted in 5-methyltetrahydrofolate loss and unacceptable changes to the non-methyl folate concentration. Total folate (with exoGGH) measured in washed RBCs was approximately 15% lower than RBC folate calculated from WBL concentrations (conventional deglutamylation). Conclusions: The use of exoGGH minimized incubation time and thus may avoid degradative losses of labile folate forms during sample preparation. The lower folate results in washed RBCs may be due to inadequate packing of RBCs, among other unidentified factors. A larger study is required to confirm the lack of differences in folate concentrations determined with and without the use of exoGGH.

      7. The effects of inhaled multi-walled carbon nanotubes on blood pressure and cardiac functionExternal
        Zheng W, McKinney W, Kashon ML, Pan D, Castranova V, Kan H.
        Nanoscale Res Lett. 2018 Jul 3;13(1):189.

        BACKGROUND: Heart rate variability (HRV) as a marker reflects the activity of the autonomic nervous system. The prognostic significance of HRV for cardiovascular disease has been reported in clinical and epidemiological studies. Our laboratory has reported alterations in rat heart rate variability (HRV) due to increasing activity of both sympathetic and parasympathetic nervous system after pulmonary exposure to multi-walled carbon nanotubes (MWCNTs). This suggests that pulmonary inhalation of engineered nanoparticles (ENs) may lead to functional changes in the cardiovascular system. The present study further investigated the effects of inhaled MWCNTs on the cardiovascular system and evaluated the correlation between the alterations in HRV and changes in cardiovascular function. METHODS: Male Sprague-Dawley rats were pre-implanted with a telemetry device and exposed by inhalation to MWCNTs for 5 h at a concentration of 5 mg/m(3). The electrocardiogram (EKG) and blood pressure were recorded in real time by the telemetry system at pre-exposure, during exposure, and 1 and 7 days post-exposure. In vivo cardiac functional performance in response to dobutamine was determined by a computerized pressure-volume loop system. RESULTS: Inhalation of MWCNTs significantly increased both systolic and diastolic blood pressure and decreased heart rate in awake freely moving rat. Additionally, inhalation of MWCNTs also reduced cardiac stroke work, stroke volume, and output in response to dobutamine in anesthetized rats. CONCLUSIONS: Inhalation of MWCNTs altered cardiovascular performance, which was associated with MWCNT exposure-induced alterations in the sympathetic and parasympathetic nervous system. These findings suggest the need to further investigate the cardiovascular effects of inhaled MWCNTs.

    • Maternal and Child Health
      1. Building community support for pregnant and parenting teenagers using a modified World Cafe method in Forsyth County, North CarolinaExternal
        Johnson SM, Trejo G, Beck KL, Worsley C, Tranberg H, Plax KL, Linton JM.
        J Pediatr Adolesc Gynecol. 2018 Jun 27.

        STUDY OBJECTIVE: To identify community priorities, foster awareness of existing supports, and recognize barriers and opportunities to enhance support services for pregnant and parenting teens (PPT). DESIGN: and Setting: A modified World Cafe event incorporated parallel, rotating focus groups with semi-structured, case-based discussions of salient issues. The event was organized and took place in Forsyth County, North Carolina. PARTICIPANTS: Seventy-eight local health and social service professionals and fifteen PPT representatives INTERVENTIONS AND MAIN OUTCOME MEASURES: Qualitative coding was used to thematically analyze transcript data. Quantitative data pre-/post-event comparisons were made using Fisher’s exact test. RESULTS: Key community-based support services for PPT were identified. Qualitative analysis yielded 10 key codes regarding barriers and opportunities to enhance community-based support services, resulting in 4 themes. Themes included maximizing access and efficient delivery of high-quality healthcare, engaging a three-generation approach to meet the current and future needs of at-risk families, focusing efforts to meet the unique needs of each teen and his/her family, and emphasizing teen self-advocacy. Pre/post survey responses were overwhelmingly positive regarding use of the modified World Cafe format for discussion and network building. CONCLUSION: The modified World Cafe Method offered a platform to collaboratively identify challenges and opportunities and to develop networks to improve health and wellbeing of PPT. Engaging multiple stakeholders in meaningful dialogue may foster multidisciplinary, cross-sector collaboration that mitigates risk and enhances resilience among PPT and their children.

      2. BACKGROUND: Invasive orthopaedic interventions (IOI) are often used to control recurrent haemarthrosis, pain and loss of joint function, in males with haemophilia (Factor VIII and Factor IX deficiency). AIM: Identify risk factors associated with IOIs in males with haemophilia enrolled in the Universal Data Collection (UDC) surveillance program from 2000 until 2010. METHODS: Data were collected on IOIs performed on patients receiving care in 130 haemophilia treatment centers in the United States annually by health care providers using standardized forms. IOIs included in this study are as follows: 1) synovectomy and 2) arthrodesis or arthroplasty (A/A). Information about potential risk factors was obtained from the preceding UDC visit if available, or from the same visit if not. Patients with no reported IOI at any of their UDC visits were the reference group for the analysis. Multivariate analyses were conducted to identify independent risk factors for synovectomies and arthrodesis/arthroplasty. RESULTS: Risk factors significantly associated with the two IOI categories were age, student status, haemophilia severity, number of joint bleeds within the last 6 months, HIV or hepatitis C (HCV) status. Multivariate analyses showed patients on continuous prophylaxis were 50% less likely to have had a synovectomy and were 40% less likely to have an A/A. CONCLUSIONS: This study shows modifiable risk factors, including management of bleeding episodes with a continuous prophylactic treatment schedule are associated with a decreased likelihood of IOIs in males with haemophilia.

    • Nutritional Sciences
      1. Change in US adult consumer knowledge, attitudes, and behaviors related to sodium intake and reduction: SummerStyles 2012 and 2015External
        John KA, Cogswell ME, Zhao L, Tong X, Odom EC, Ayala C, Merritt R.
        Am J Health Promot. 2018 Jul;32(6):1357-1364.

        PURPOSE: To describe changes in consumer knowledge, attitudes, and behaviors related to sodium reduction from 2012 to 2015. DESIGN: A cross-sectional analysis using 2 online, national research panel surveys. SETTING: United States. PARTICIPANTS: A total of 7796 adults (18+ years). MEASURES: Sodium-related knowledge, attitudes, and behaviors. ANALYSIS: Data were weighted to match the US population survey proportions using 9 factors. Wald chi(2) tests were used to examine differences by survey year and hypertensive status. RESULTS: Despite the lack of temporal changes observed in respondent characteristics (mean age: 46 years, 67% were non-Hispanic white, and 26% reported hypertension), some changes were found in the prevalence of sodium-related knowledge, attitudes, and behaviors. The percentage of respondents who recognized processed foods as the major source of sodium increased from 54% in 2012 to 57% in 2015 ( P = .04), as did the percentage of respondents who buy or choose low/reduced sodium foods, from 33% in 2012 to 37% in 2015 ( P = .016). In contrast, the percentage of self-reported receipt of health professional advice among persons with hypertension decreased from 59% in 2012 to 45% in 2015 ( P < .0001). Other sodium-related knowledge, attitudes, and behaviors did not change significantly during 2012 to 2015. CONCLUSION: In recent years, some positive changes were observed in sodium-related knowledge and behaviors; however, the decrease in reported health professional advice to reduce sodium among respondents with hypertension is a concern.

      2. Review of grain fortification legislation, standards, and monitoring documentsExternal
        Marks KJ, Luthringer CL, Ruth LJ, Rowe LA, Khan NA, Maria De-Regil L, Lopez X, Pachon H.
        Glob Health Sci Pract. 2018 Jun 27;6(2):354-369.

        OBJECTIVE: Analyze the content of documents used to guide mandatory fortification programs for cereal grains. METHODS: Legislation, standards, and monitoring documents, which are used to mandate, provide specifications for, and confirm fortification, respectively, were collected from countries with mandatory wheat flour (n=80), maize flour (n=11), and/or rice (n=6) fortification as of January 31, 2015, yielding 97 possible country-grain combinations (e.g., Philippines-wheat flour, Philippines-rice) for the analysis. After excluding countries with limited or no documentation, 72 reviews were completed, representing 84 country-grain combinations. Based on best practices, a criteria checklist was created with 44 items that should be included in fortification documents. Two reviewers independently scored each available document set for a given country and food vehicle (a country-grain combination) using the checklist, and then reached consensus on the scoring. We calculated the percentage of country-grain combinations containing each checklist item and examined differences in scores by grain, region, and income level. RESULTS: Of the 72 country-grain combinations, the majority of documentation came from countries in the Americas (46%) and Africa (32%), and most were from upper and lower middle-income countries (73%). The majority of country-grain combinations had documentation stating the food vehicle(s) to be fortified (97%) and the micronutrients (e.g., iron) (100%), fortificants (e.g., ferrous fumarate) (88%), and fortification levels required (96%). Most (78%) stated that labeling is required to indicate a product is fortified. Many country-grain combinations described systems for external (64%) monitoring, and stated that industry is required to follow quality assurance/quality control (64%), though detailed protocols (33%) and roles and responsibilities (45%) were frequently not described. CONCLUSIONS: Most country-grain combinations have systems in place for internal, external, and import monitoring. However, documentation of other important items that would influence product compliance to national standard, such as roles and responsibilities between agencies, the cost of regulating fortification, and enforcement strategies, are often lacking. Countries with existing mandatory fortification can improve upon these items in revisions to their documentation while countries that are beginning fortification can use the checklist to assist in developing new policies and programs.

    • Occupational Safety and Health
      1. Preventing emergency vehicle crashes: Status and challenges of human factors issuesExternal
        Hsiao H, Chang J, Simeonov P.
        Hum Factors. 2018 Jul 1:18720818786132.

        OBJECTIVE: This study reports current status of knowledge and challenges associated with the emergency vehicle (police car, fire truck, and ambulance) crashes, with respect to the major contributing risk factors. BACKGROUND: Emergency vehicle crashes are a serious nationwide problem, causing injury and death to emergency responders and citizens. Understanding the underlying causes of these crashes is critical for establishing effective strategies for reducing the occurrence of similar incidents. METHOD: We reviewed the broader literature associated with the contributing factors for emergency vehicle crashes: peer-reviewed journal papers; and reports, policies, and manuals published by government agencies, universities, and research institutes. RESULTS: Major risk factors for emergency vehicle crashes identified in this study were organized into four categories: driver, task, vehicle, and environmental factors. Also, current countermeasures and interventions to mitigate the hazards of emergency vehicle crashes were discussed, and new ideas for future studies were suggested. CONCLUSION: Risk factors, control measures, and knowledge gaps relevant to emergency vehicle crashes were presented. Six research concepts are offered for the human factors community to address. Among the topics are emergency vehicle driver risky behavior carryover between emergency response and return from a call, distraction in emergency vehicle driving, in-vehicle driver assistance technologies, vehicle red light running, and pedestrian crash control. APPLICATION: This information is helpful for emergency vehicle drivers, safety practitioners, public safety agencies, and research communities to mitigate crash risks. It also offers ideas for researchers to advance technologies and strategies to further emergency vehicle safety on the road.

      2. Evaluation of occupational exposure limits for heat stress in outdoor workers – United States, 2011-2016External
        Tustin AW, Lamson GE, Jacklitsch BL, Thomas RJ, Arbury SB, Cannon DL, Gonzales RG, Hodgson MJ.
        MMWR Morb Mortal Wkly Rep. 2018 Jul 6;67(26):733-737.

        Heat stress, an environmental and occupational hazard, is associated with a spectrum of heat-related illnesses, including heat stroke, which can lead to death. CDC’s National Institute for Occupational Safety and Health (NIOSH) publishes recommended occupational exposure limits for heat stress (1). These limits, which are consistent with those of the American Conference of Governmental Industrial Hygienists (ACGIH) (2), specify the maximum combination of environmental heat (measured as wet bulb globe temperature [WBGT]) and metabolic heat (i.e., workload) to which workers should be exposed. Exposure limits are lower for workers who are unacclimatized to heat, who wear work clothing that inhibits heat dissipation, and who have predisposing personal risk factors (1,2). These limits have been validated in experimental settings but not at outdoor worksites. To determine whether the NIOSH and ACGIH exposure limits are protective of workers, CDC retrospectively reviewed 25 outdoor occupational heat-related illnesses (14 fatal and 11 nonfatal) investigated by the Occupational Safety and Health Administration (OSHA) from 2011 to 2016. For each incident, OSHA assessed personal risk factors and estimated WBGT, workload, and acclimatization status. Heat stress exceeded exposure limits in all 14 fatalities and in eight of 11 nonfatal illnesses. An analysis of Heat Index data for the same 25 cases suggests that when WBGT is unavailable, a Heat Index screening threshold of 85 degrees F (29.4 degrees C) could identify potentially hazardous levels of workplace environmental heat. Protective measures should be implemented whenever the exposure limits are exceeded. The comprehensive heat-related illness prevention program should include an acclimatization schedule for newly hired workers and unacclimatized long-term workers (e.g., during early-season heat waves), training for workers and supervisors about symptom recognition and first aid (e.g., aggressive cooling of presumed heat stroke victims before medical professionals arrive), engineering and administrative controls to reduce heat stress, medical surveillance, and provision of fluids and shady areas for rest breaks.

    • Physical Activity
      1. PURPOSE: The US Preventive Services Task Force recommends that adults at risk for cardiovascular disease (CVD) be offered or referred to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. We assessed primary care providers’ (PCPs) awareness of local physical activity-related behavioral counseling services, whether this awareness was associated with referring eligible patients, and the types and locations of services to which they referred. DESIGN: Cross-sectional survey. SETTING: Primary care providers practicing in the United States. SUBJECTS: 1256 respondents. MEASURES: DocStyles 2016 survey assessing PCPs’ awareness of and referral to physical activity-related behavioral counseling services. ANALYSIS: Calculated prevalence and adjusted odds ratios (aORs). RESULTS: Overall, 49.9% of PCPs were aware of local services. Only 12.6% referred many or most of their at-risk patients and referral was associated with awareness of local services (aOR = 2.81, [95% confidence interval: 1.85-4.25]). Among those referring patients, services ranged from a health-care worker within their practice or group (25.4%) to an organized program in a medical facility (41.2%). Primary care providers most often referred to services located outside their practice or group (58.1%). CONCLUSION: About half of PCPs were aware of local behavioral counseling services, and referral was associated with awareness. Establishing local resources and improving PCPs’ awareness of them, especially using community-clinical linkages, may help promote physical activity among adults at risk for CVD.

    • Public Health Leadership and Management
      1. Health education workforce: Opportunities and challengesExternal
        Bruening RA, Coronado F, Auld ME, Benenson G, Simone PM.
        Prev Chronic Dis. 2018 Jun 28;15:E89.

        [No abstract]

    • Reproductive Health
      1. Objective: The prevalence of sub-dermal contraceptive implant use in Jamaica is low, despite growing international acceptance of long-acting reversible contraception. This study assessed the availability, effectiveness, side-effects and utilization of sub-dermal contraceptive implants and described the characteristics of users over a one-year period. Methods: We reviewed the medical records of women aged 15-45 years who utilized contraceptive implant-related services at any of the six included public health centres in Jamaica during 2013, and surveyed 20 available reproductive healthcare providers. Results: In 2013, 738 women attended a Jamaican public health centre for contraceptive implant services: 493 (66.8%) for insertion, 202 (27.4%) for removal and 53 (7.2%) for follow- up visits (10 women had the same implant inserted and removed in 2013). The women’s median age was 26.0 years, 24.3% were <= 18 years, and 85.9% had >= 1 child. Most women (68.5%) did not have documented side-effects; irregular bleeding, the most commonly documented side-effect, was recorded for 24%. Of the 493 women who had implants inserted, three (0.6%) were identified to be pregnant within three months of insertion. Among the 202 women who had implants removed, 11 (5.4%) experienced complications with removal. Reproductive healthcare providers highlighted the need for an expansion of contraceptive implant availability and provider training. Conclusion: Sub-dermal implants have few insertion complications and side-effects and are effective, but were underutilized in Jamaica. Increased implant availability and enhanced reproductive healthcare provider training may improve implant utilization and reduce unintended pregnancy rates in Jamaica.

    • Substance Use and Abuse
      1. Social aspects of hookah smoking among US youthExternal
        Agaku I, Odani S, Armour B, Glover-Kudon R.
        Pediatrics. 2018 Jul 2.

        BACKGROUND: We investigated 3 social dimensions of youth hookah smoking: frequency, places smoked, and descriptive social norms. METHODS: Data were from the 2016 National Youth Tobacco Survey of US sixth- to 12th-graders (n = 20 675). Hookah smoking frequency was classified as never, former, current occasional, and current frequent. Places where past 30-day hookah smoking occurred and students’ perceptions of their classmates’ hookah smoking prevalence were assessed. Descriptive and multivariable analyses were performed (P < .05). RESULTS: Overall, 10.5% reported smoking hookah >/=1 time in their lifetime. Of these, 65.8% were former, 26.3% were current occasional, and 7.9% were current frequent smokers. Overall, 59.3% of students overestimated hookah smoking prevalence in their grade. Current occasional smoking was predicted by female sex (adjusted odds ratio [aOR] = 1.54) and peer hookah-smoking overestimation (aOR = 9.30). Current frequent smoking was most strongly predicted by living with a hookah smoker (aOR = 20.56), speaking a second language other than English (aOR = 2.17), and co-use of mentholated cigarettes (aOR = 19.94) or other flavored noncigarette tobacco products (aOR = 17.59). The top 3 places hookah was smoked were a friend’s house (47.7%), the respondent’s own house (31.8%), and another family member’s house (20.8%). CONCLUSIONS: The home environment was the most common place for youth hookah smoking. Home-tailored interventions that encourage voluntary smoke-free rules and warn about the dangers of social smoking could help denormalize hookah smoking.

      2. Federal response to the opioid crisisExternal
        Johnson K, Jones C, Compton W, Baldwin G, Fan J, Mermin J, Bennett J.
        Curr HIV/AIDS Rep. 2018 Jul 3.

        PURPOSE OF REVIEW: In light of the current crisis in opioid involved overdose deaths, the federal Department of Health and Human Services operating divisions are working together to implement a data-driven, research-based strategy to reduce opioid misuse and its consequences. RECENT FINDINGS: The strategy has five elements: (1) strengthening public health data collection and reporting; (2) advancing the practice of pain management; (3) improving access to addiction prevention, treatment, and recovery support services; (4) increasing availability of overdose-reversing drugs; and (5) supporting cutting-edge research in treatment of pain, opioid use disorder, and associated conditions. The Department of Health and Human Services has developed a concerted, coordinated evidence-based effort across department divisions to reduce opioid misuse, prevalence of opioid use disorder, and reduce deaths due to opioid use.

      3. US hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015External
        Peterson C, Xu L, Mikosz CA, Florence C, Mack KA.
        J Subst Abuse Treat. 2018 September;92:35-39.

        Background: Understanding more about circumstances in which patients receive an opioid use disorder (OUD) diagnosis might illuminate opportunities for intervention and ultimately prevent opioid overdoses. This study aimed to describe patient and clinical characteristics of hospital discharges documenting OUD among patients not being treated for opioid overdose, detoxification, or rehabilitation. Methods: We assessed patient, payer, and clinical characteristics of nationally-representative 2011-2015 National Inpatient Sample discharges documenting OUD, excluding opioid overdose, detoxification, and rehabilitation. Discharges were clinically classified by Diagnostic Related Group (DRG) for analysis. Results: Annual discharges grew 38%, from 347,137 (2011) to 478,260 (2015), totaling 2 million discharges during the study period. The annual discharge rate increased among all racial/ethnic groups, but was highest among the non-Hispanic black population until 2015, when non-Hispanic whites had a slightly higher rate (164 versus 162 per 100,000 population). Female patients and Medicaid and Medicare as primary payer accounted for an increasing annual proportion of discharges. Just 14 DRGs accounted for nearly 50% of discharges over the study period. The most prevalent primary treatment received during OUD inpatient stays was for psychoses (DRG 885; 16% of discharges) and drug and alcohol abuse or dependence symptoms (including withdrawal) or (non-opioid) poisoning (DRG 894, 897, 917, 918; 12% of discharges). Conclusions: Now nearly half a million yearly US hospital discharges for a range of primary treatment include patients’ diagnosis of OUD without opioid overdose, detoxification, or rehabilitation services. Inpatient stays present an important opportunity to link OUD patients to treatment to reduce opioid-related morbidity and mortality.

    • Zoonotic and Vectorborne Diseases
      1. Chagas disease surveillance activities – seven states, 2017External
        Bennett C, Straily A, Haselow D, Weinstein S, Taffner R, Yaglom H, Komatsu K, Venkat H, Brown C, Byers P, Dunn J, Moncayo A, Mayes BC, Montgomery SP.
        MMWR Morb Mortal Wkly Rep. 2018 Jul 6;67(26):738-741.

        Chagas disease, a potentially life-threatening disease caused by the protozoan parasite Trypanosoma cruzi, has become a concern in the United States as a result of human emigration from Latin America where Chagas disease is endemic (1). It is estimated that as many as 8 million people living in Mexico, and Central and South America have Chagas disease.* Most cases of Chagas disease in the United States are chronic infections; however, rare cases of acute congenital infections and autochthonous vectorborne transmission have been reported (2). To understand how data are collected and used, a review of state-level public health surveillance for Chagas disease was conducted through semistructured interviews with health officials in six states (Arizona, Arkansas, Louisiana, Mississippi Tennessee, and Texas) where Chagas disease is reportable and one (Massachusetts) where it was previously reportable. States implemented surveillance in response to blood donor screening for Chagas disease and to identify the route of disease transmission. Many states reported primarily chronic cases and had limited ability to respond to local transmission because acute cases were infrequently reported. Surveillance remains important in states with large populations of immigrants or frequent travelers from countries with endemic disease and for states with a risk for local transmission. Surveillance efforts can also help increase awareness among providers and assist in linking patients with Chagas disease to treatment to help prevent cardiac and gastrointestinal complications.

      2. Notes from the field: Adverse event associated with unintentional exposure to the Brucella abortus RB51 vaccine – Oregon, December 2017External
        Hatcher SM, Shih D, Holderman J, Cossaboom C, Leman R, DeBess E.
        MMWR Morb Mortal Wkly Rep. 2018 Jul 6;67(26):747.

        [No abstract]

      3. Confirmation of Zika virus infection through hospital-based sentinel surveillance of acute febrile illness in Uganda, 2014-2017External
        Kayiwa JT, Nankya AM, Ataliba IJ, Mossel EC, Crabtree MB, Lutwama JJ.
        J Gen Virol. 2018 Jul 5.

        Zika virus (ZIKV), transmitted by Aedes species mosquitoes, was first isolated in Uganda in 1947. From February 2014 to October 2017, the Uganda Virus Research Institute, in collaboration with the US Centers for Diseases Control and Prevention, conducted arbovirus surveillance in acute febrile illness (AFI) patients at St Francis hospital in Nkonkonjeru. Three hundred and eighty-four serum samples were collected and tested for IgM antibodies to yellow fever virus (YFV), West Nile virus (WNV), dengue virus (DENV), chikungunya virus (CHIKV) and ZIKV. Of the 384 samples, 5 were positive for ZIKV IgM. Of these five, three were confirmed by plaque reduction neutralization test (PRNT) to be ZIKV infections. Of the remaining two, one was determined to be a non-specific flavivirus infection and one was confirmed to be alphavirus-positive by reverse transcriptase polymerase chain reaction (RT-PCR). This study provides the first evidence of laboratory-confirmed ZIKV infection in Uganda in five decades, and emphasizes the need to enhance sentinel surveillance.

      4. Human biomarkers of outcome following Rift valley fever virus infectionExternal
        McElroy AK, Harmon JR, Flietstra T, Nichol ST, Spiropoulou CF.
        J Infect Dis. 2018 Jun 28.

        Rift Valley fever virus is an arbovirus found in Africa and the Middle East. Most infected individuals experience a mild self-limiting illness; however, some develop severe disease including hepatitis, hemorrhagic fever, or encephalitis. The biological reasons for these marked differences in disease manifestation are unknown. In this study, we evaluate 32 biomarkers in serum of 26 patients from an outbreak that occurred in Saudi Arabia in 2000-2001. Eleven biomarkers correlated with viral RNA. Thirteen biomarkers were associated with a fatal outcome. No associations of biomarkers and hemorrhage or central nervous system disease were identified in this cohort.

      5. Assessment of human-to-human transmissibility of avian influenza A(H7N9) virus across five waves by analyzing clusters of case-patients in mainland China, 2013-2017External
        Wang X, Wu P, Pei Y, Tsang TK, Gu D, Wang W, Zhang J, Horby PW, Uyeki TM, Cowling BJ, Yu H.
        Clin Infect Dis. 2018 Jun 29.

        Background: The 2016-17 epidemic of human infections with avian influenza A(H7N9) virus was alarming due to the surge in reported cases across a wide geographic area and the emergence of highly pathogenic A(H7N9) viruses. Our study aimed to assess whether human-to-human transmission risk of A(H7N9) virus has changed across the five waves since 2013. Methods: Data on human cases and clusters of A(H7N9) virus infection were collected from WHO, national and provincial reports, informal online sources and published literature. We compared the epidemiological characteristics and clinical severity of sporadic and cluster cases, estimated the relative risk (RR) of infection in blood-relatives and non-blood relatives, and estimated the bounds on the effective reproductive number (Re) across waves from 2013 through September 2017. Results: 40 human clusters of A(H7N9) virus infection were identified, with a median cluster size of 2 (range 2-3). The overall RR of infection in blood-relatives versus non-blood relatives was 1.65 (95% CI 0.88, 3.09), and was not significantly different across waves (chi2=2.66, P=0.617). The upper and lower limits of Re for A(H7N9) virus were 0.12 (95% CI 0.10, 0.14) and 0.03 (95% CI 0, 0.14), respectively. Re estimates were not significantly different across waves (chi2=1.52, P=0.822 for upper limit; chi2=6.58, P=0.160 for lower limit). Conclusions: The small cluster size and low Re suggest that human-to-human transmissibility of A(H7N9) virus has not changed over time and remains limited to date. Continuous assessment of A(H7N9) virus infections and human case clusters is of crucial importance for public health.

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  • Onnalee Gomez, MS, Health Scientist
  • Jarvis Sims, MIT, MLIS, Librarian


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

Page last reviewed: January 31, 2019