Volume 10, Issue 32, August 28, 2018

CDC Science Clips: Volume 10, Issue 32, August 28, 2018

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
    • Communicable Diseases
      • CMV on surfaces in homes with young children: results of PCR and viral culture testingExternal
        Amin MM, Stowell JD, Hendley W, Garcia P, Schmid DS, Cannon MJ, Dollard SC.
        BMC Infect Dis. 2018 Aug 13;18(1):391.

        BACKGROUND: Caring for young children is a known risk factor for cytomegalovirus (CMV) infection mainly through exposure to their saliva and urine. In a previous study, 36 CMV-seropositive children 2 mo. to 4 years old were categorized as CMV shedders (n = 23) or non-shedders (n = 13) based on detection of CMV DNA in their saliva and urine. The current study evaluated the presence of CMV on surfaces in homes of the children. METHODS: Study staff made 4 visits to homes of the 36 enrolled children over 100 days. Saliva was collected by swabbing the mouth and urine was collected on filter paper inserted into diapers. In addition, five surface specimens were collected: three in contact with children’s saliva (spoon, child’s cheek, washcloth) and two in contact with children’s urine (diaper changing table, mother’s hand). Samples were tested by PCR and viral culture to quantify the presence of CMV DNA and viable virus. RESULTS: A total of 654 surface samples from 36 homes were tested; 136 were CMV DNA positive, 122 of which (90%) were in homes of the children shedding CMV (p < 0.001). Saliva-associated samples were more often CMV positive with higher viral loads than urine-associated samples. The higher the CMV viral load of the child in the home, the more home surfaces that were PCR positive (p = 0.01) and viral culture positive (p = 0.05). CONCLUSIONS: The main source for CMV on surfaces in homes was saliva from the child in the home. Higher CMV viral loads shed by children correlated with more viable virus on surfaces which could potentially contribute to viral transmission.

      • Improving STD service delivery: Would American patients and providers use self-tests for gonorrhea and chlamydia?External
        Pearson WS, Kreisel K, Peterman TA, Zlotorzynska M, Dittus PJ, Habel MA, Papp JR.
        Prev Med. 2018 Aug 7;115:26-30.

        Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) are the most frequently reported notifiable diseases in the United States and costs for diagnosis and treatment of these two infections are approximately $700 million per year. A proposed new method for screening for these two infections is self-tests; similar to at-home pregnancy and HIV tests which do not include sending collected specimens to a laboratory for diagnosis. However, no such self-tests for sexually transmitted diseases (STD) have been approved by the Food and Drug Administration (FDA). To determine the acceptability of such a test, we used three surveys, conducted in 2017, including the American Men’s Internet Survey, the SummerStyles survey, and the DocStyles survey to ask potential users about their interest in this type of test and how they might use it. Among our sampled population of men who have sex with men, 79.5% said they would prefer to take this type of test at home and 73.9% said they would be willing to pay at least $20 for the test. Among young adults (18-29years), 54.1% indicated that they would like to take this test at home and 64.5% were willing to pay more than $10 for such a test. Among sampled physicians, 85.1% were “likely” or “very likely” to use an FDA-approved STD self-test in their office to screen for CT or GC. Self-tests for STDs are on our horizon and we need to be prepared to integrate these tests into our healthcare systems.

      • Resource utilization for multidrug-resistant tuberculosis household contact investigations (A5300/I2003)External
        Swindells S, Gupta A, Kim S, Hughes MD, Sanchez J, Mave V, Dawson R, Kumarasamy N, Comins K, Smith B, Rustomjee R, Naini L, Shah NS, Hesseling A, Churchyard G.
        Int J Tuberc Lung Dis. 2018 Sep 1;22(9):1016-1022.

        BACKGROUND: Current guidelines recommend evaluation of the household contacts (HHCs) of individuals with multidrug-resistant tuberculosis (MDR-TB); however, implementation of this policy is challenging. OBJECTIVE: To describe the resource utilization and operational challenges encountered when identifying and characterizing adult MDR-TB index cases and their HHCs. DESIGN: Cross-sectional study of adult MDR-TB index cases and HHCs at 16 clinical research sites in eight countries. Site-level resource utilization was assessed with surveys. RESULTS: Between October 2015 and April 2016, 308 index cases and 1018 HHCs were enrolled. Of 280 index cases with sputum collected, 94 were smear-positive (34%, 95%CI 28-39), and of 201 with chest X-rays, 87 had cavitary disease (43%, 95%CI 37-50) after a mean duration of treatment of 8 weeks. Staff required 512 attempts to evaluate the 308 households, with a median time per attempt of 4 h; 77% (95%CI 73-80) of HHCs were at increased risk for TB: 13% were aged <5 years, 8% were infected with the human immunodeficiency virus, and 79% were positive on the tuberculin skin test/interferon-gamma release assay. One hundred and twenty-one previously undiagnosed TB cases were identified. Issues identified by site staff included the complexity of personnel and participant transportation, infection control, personnel safety and management of stigma. CONCLUSION: HHC investigations can be high yield, but are labor-intensive.

    • Disease Reservoirs and Vectors
      • BACKGROUND: Pathogen colonization inside tick tissues is a significant aspect of the overall competence of a vector. Amblyomma maculatum is a competent vector of the spotted fever group rickettsiae, Rickettsia parkeri. When R. parkeri colonizes its tick host, it has the opportunity to dynamically interact with not just its host but with the endosymbionts living within it, and this enables it to modulate the tick’s defenses by regulating tick gene expression. The microbiome in A. maculatum is dominated by two endosymbiont microbes: a Francisella-like endosymbiont (FLE) and Candidatus Midichloria mitochondrii (CMM). A range of selenium-containing proteins (selenoproteins) in A. maculatum ticks protects them from oxidative stress during blood feeding and pathogen infections. Here, we investigated rickettsial multiplication in the presence of tick endosymbionts and characterized the functional significance of selenoproteins during R. parkeri replication in the tick. RESULTS: FLE and CMM were quantified throughout the tick life stages by quantitative PCR in R. parkeri-infected and uninfected ticks. R. parkeri infection was found to decrease the FLE numbers but CMM thrived across the tick life cycle. Our qRT-PCR analysis indicated that the transcripts of genes with functions related to redox (selenogenes) were upregulated in ticks infected with R. parkeri. Three differentially expressed proteins, selenoprotein M, selenoprotein O, and selenoprotein S were silenced to examine their functional significance during rickettsial replication within the tick tissues. Gene silencing of the target genes was found to impair R. parkeri colonization in the tick vector. Knockdown of the selenogenes triggered a compensatory response from other selenogenes, as observed by changes in gene expression, but oxidative stress levels and endoplasmic reticulum stress inside the ticks were also found to have heightened. CONCLUSIONS: This study illustrates the potential of this new research model for augmenting our understanding of the pathogen interactions occurring within tick hosts and the important roles that symbionts and various tick factors play in regulating pathogen growth.

      • Susceptibility and vectorial capacity of American Aedes albopictus and Aedes aegypti (Diptera: Culicidae) to American Zika virus strainsExternal
        Lozano-Fuentes S, Kenney JL, Varnado W, Byrd BD, Burkhalter KL, Savage HM.
        J Med Entomol. 2018 Aug 9.

        The rapid expansion of Zika virus (ZIKV), following the recent outbreaks of Chikungunya virus, overwhelmed the public health infrastructure in many countries and alarmed many in the scientific community. Aedes aegypti (L.) (Diptera: Culicidae) and Aedes albopictus (Skuse) (Diptera: Culicidae) have previously been incriminated as the vectors of these pathogens in addition to dengue virus. In our study, we challenged low generation Ae. aegypti (Chiapas, Mexico) and Ae. albopictus (North Carolina, Mississippi), with three strains of ZIKV, Puerto Rico (GenBank: KU501215), Honduras (GenBank: KX694534), and Miami (GenBank: MF988743). Following an oral challenge with 107.5 PFU/ml of the Puerto Rico strain, we observed high infection and dissemination rates in both species (95%). We report estimated transmission rates for both species (74 and 33%, for Ae. aegypti (L.) (Diptera: Culicidae) and Ae. albopictus (Skuse) (Diptera: Culicidae), respectively), and the presence of a probable salivary gland barrier in Ae. albopictus to Zika virus. Finally, we calculated vectorial capacity for both species and found that Ae. albopictus had a slightly lower vectorial capacity when compared with Ae. aegypti.Second Language Abstract: La rapida expansion del virus Zika, poco despues de las epidemias de chikungunya, rebaso la infraestructura de salud publica en muchos paises y sorprendio a muchos en la comunidad cientifica. Notablemente, Aedes aegypti y Aedes albopictus transmiten estos patogenos ademas del virus del dengue. En este estudio se expusieron con tres cepas americanas de virus Zika a grupos de Aedes aegypti y Aedes albopictus de generacion reciente. Encontramos altos porcentajes de infeccion y diseminacion en ambas especies (95%). Se reporta, la transmision viral en ambas especies (74 y 33%, para Aedes aegypti and Aedes albopictus, respectivamente) y una probable barrera a nivel de glandulas salivarias. Finalmente, calculamos la capacidad vectorial para ambas especies.

    • Genetics and Genomics
      • BMScan: using whole genome similarity to rapidly and accurately identify bacterial meningitis causing speciesExternal
        Topaz N, Boxrud D, Retchless AC, Nichols M, Chang HY, Hu F, Wang X.
        BMC Infect Dis. 2018 Aug 15;18(1):405.

        BACKGROUND: Bacterial meningitis is a life-threatening infection that remains a public health concern. Bacterial meningitis is commonly caused by the following species: Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes, Haemophilus influenzae and Escherichia coli. Here, we describe BMScan (Bacterial Meningitis Scan), a whole-genome analysis tool for the species identification of bacterial meningitis-causing and closely-related pathogens, an essential step for case management and disease surveillance. BMScan relies on a reference collection that contains genomes for 17 focal species to scan against to identify a given species. We established this reference collection by supplementing publically available genomes from RefSeq with genomes from the isolate collections of the Centers for Disease Control Bacterial Meningitis Laboratory and the Minnesota Department of Health Public Health Laboratory, and then filtered them down to a representative set of genomes which capture the diversity for each species. Using this reference collection, we evaluated two genomic comparison algorithms, Mash and Average Nucleotide Identity, for their ability to accurately and rapidly identify our focal species. RESULTS: We found that the results of Mash were strongly correlated with the results of ANI for species identification, while providing a significant reduction in run-time. This drastic difference in run-time enabled the rapid scanning of large reference genome collections, which, when combined with species-specific threshold values, facilitated the development of BMScan. Using a validation set of 15,503 genomes of our species of interest, BMScan accurately identified 99.97% of the species within 16 min 47 s. CONCLUSIONS: Identification of the bacterial meningitis pathogenic species is a critical step for case confirmation and further strain characterization. BMScan employs species-specific thresholds for previously-validated, genome-wide similarity statistics compiled from a curated reference genome collection to rapidly and accurately identify the species of uncharacterized bacterial meningitis pathogens and closely related pathogens. BMScan will facilitate the transition in public health laboratories from traditional phenotypic detection methods to whole genome sequencing based methods for species identification.

    • Healthcare Associated Infections
    • Immunity and Immunization
      • A bovine adenoviral vector-based H5N1 influenza -vaccine provides enhanced immunogenicity and protection at a significantly low doseExternal
        Sayedahmed EE, Hassan AO, Kumari R, Cao W, Gangappa S, York I, Sambhara S, Mittal SK.
        Mol Ther Methods Clin Dev. 2018 Sep 21;10:210-222.

        Several human and nonhuman adenovirus (AdV) vectors including bovine AdV type 3 (BAdV-3) were developed as gene delivery vectors to supplement and/or elude human AdV (HAdV)-specific neutralizing antibodies (vector immunity). Here we evaluated the vaccine immunogenicity and efficacy of BAdV-3 vector (BAd-H5HA) expressing hemagglutinin (HA) of a H5N1 influenza virus in a dose escalation study in mice with the intranasal (IN) or intramuscular (IM) route of inoculation in comparison with the HAdV type C5 (HAdV-C5) vector (HAd-H5HA) expressing HA of a H5N1 influenza virus. Dose-related increases in the immune responses were clearly noticeable. A single IM inoculation with BAd-H5HA resulted in enhanced cellular immune responses compared with that of HAd-H5HA and conferred complete protection following challenge with a heterologous H5N1 virus at the dose of 3 x 10(7) plaque-forming units (PFUs), whereas a significant amount of influenza virus was detected in the lungs of mice immunized with 1 x 10(8) PFUs of HAd-H5HA. Similarly, compared with that of HAd-H5HA, a single IN inoculation with BAd-H5HA produced significantly enhanced humoral (HA-specific immunoglobulin [IgG] and its subclasses, as well as HA-specific IgA) and cellular immune responses, and conferred complete protection following challenge with a heterologous H5N1 virus. Complete protection with BAd-H5HA was observed with the lowest vaccine dose (1 x 10(6) PFUs), but similar protection with HAd-H5HA was observed at the highest vaccine dose (1 x 10(8) PFUs). These results suggest that at least 30-fold dose sparing can be achieved with BAd-H5HA vector compared with HAd-H5HA vaccine vector.

    • Occupational Safety and Health – Mining
      • Early fire detection for underground diesel fuel storage areasExternal
        Yuan L, Thomas RA, Rowland JH, Zhou L.
        Process Saf Environ Prot. 2018 ;119:69-74.

        With the increased use of mobile diesel-powered equipment in underground mines, the fire risk posed by underground diesel fuel storage areas is a concern. To reduce the risk associated with the storage and transfer of large quantities of diesel fuel in permanent underground mine storage areas, an experimental study was conducted to investigate the responses of different sensors for early detection of diesel fuel fires in a storage area. Fire sensors tested in this study were four carbon monoxide (CO) sensors, two smoke sensors, and one flame sensor. A series of fire tests were conducted in the NIOSH Safety Research Coal Mine, Bruceton, PA, using various fire sizes at different ventilation airflow velocities and fire locations. Response times for different sensors were analyzed, and the results suggest that the flame sensor and smoke sensors resulted in shorter response times in most tests compared to the CO sensors. Based on the test results, the appropriate sensor locations for early fire detection in a diesel fuel storage area were identified. The results of this study can help mining companies to select appropriate fire sensors for underground diesel fuel storage areas and improve the deployment of these sensors to ensure the safety of underground miners.

    • Physical Activity
      • Prevalence of master plans supportive of active living in US municipalitiesExternal
        Peterson EL, Carlson SA, Schmid TL, Brown DR.
        Prev Med. 2018 Aug 9.

        Community planning documents can play an important role in promoting the design and maintenance of walkable communities. This study estimates the prevalence among US municipalities of (1) community wide planning documents and (2) inclusion of plan objectives supportive of active living within these documents. Data from the 2014 National Survey of Community-Based Policy and Environmental Supports for Healthy Eating and Active Living (CBS HEAL), a survey of local officials, were analyzed (n=2005). Prevalence of comprehensive or general plans, 3 specific plan types, and 3 objectives supportive of active living were analyzed using survey weights to create national estimates. Overall, 64% of municipalities had a comprehensive/general plan, 46% had a transportation plan, 48% had a bicycle or pedestrian plan and 76% had a land use plan. Of municipalities with a plan, 78% included at least one of the three objectives measured supportive of active living. Differences in presence of plans and objectives were observed by population size of the municipality, urban status, region, and median education. Helping communities, especially smaller or rural municipalities and those with lower median education levels, create and adopt planning documents supportive of active living may be an important step in creating more walkable communities.

    • Zoonotic and Vectorborne Diseases
      • Recurrent anthrax outbreaks in humans, livestock, and wildlife in the same locality, Kenya, 2014-2017External
        Muturi M, Gachohi J, Mwatondo A, Lekolool I, Gakuya F, Bett A, Osoro E, Bitek A, Thumbi SM, Munyua P, Oyas H, Njagi ON, Bett B, Njenga MK.
        Am J Trop Med Hyg. 2018 Aug 13.

        Epidemiologic data indicate a global distribution of anthrax outbreaks associated with certain ecosystems that promote survival and viability of Bacillus anthracis spores. Here, we characterized three anthrax outbreaks involving humans, livestock, and wildlife that occurred in the same locality in Kenya between 2014 and 2017. Clinical and epidemiologic data on the outbreaks were collected using active case finding and review of human, livestock, and wildlife health records. Information on temporal and spatial distribution of prior outbreaks in the area was collected using participatory epidemiology. The 2014-2017 outbreaks in Nakuru West subcounty affected 15 of 71 people who had contact with infected cattle (attack rate = 21.1%), including seven with gastrointestinal, six with cutaneous, and two with oropharyngeal forms of the disease. Two (13.3%) gastrointestinal human anthrax cases died. No human cases were associated with infected wildlife. Of the 54 cattle owned in 11 households affected, 20 died (attack rate = 37%). The 2015 outbreak resulted in death of 10.5% of the affected herbivorous wildlife at Lake Nakuru National Park, including 745 of 4,500 African buffaloes (species-specific mortality rate = 17%) and three of 18 endangered white rhinos (species-specific mortality rate = 16%). The species mortality rate ranged from 1% to 5% for the other affected wildlife species. Participatory epidemiology identified prior outbreaks between 1973 and 2011 in the same area. The frequency and severity of outbreaks in this area suggests that it is an anthrax hotspot ideal for investigating risk factors associated with long-term survival of anthrax spores and outbreak occurrence.

  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. BACKGROUND AND AIMS: National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies. METHODS: The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent. RESULTS: Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate >/=20%. CONCLUSIONS: In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

      2. In recent decades, public health awareness of health disparities among lesbian, gay, bisexual, and transgender (LGBT) populations has increased (1). Healthy People 2020 included objectives to improve health of LGBT persons. Five key health-related behaviors were found to be likely associated with reduced all-cause mortality: never smoking, performing regular physical activity, consuming no or moderate amounts of alcohol, having a normal body weight, and obtaining sufficient sleep daily (2). CDC estimated these five health-related behaviors among adults aged >/=21 years by sexual orientation and transgender status using data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) in 25 U.S. states and Guam. Patterns of these five health-related behaviors varied by sexual orientation among men and women, and among transgender adults. Lesbian and bisexual women were less likely to engage in all five health-related behaviors than were heterosexual women (5.4% and 6.9%, respectively, versus 10.6%). Compared with cisgender( section sign) adults, male-to-female transgender adults were less likely to engage in any two of five health-related behaviors (12.3% versus 18.6%). Male-to-female transgender adults, however, were more likely to engage in any three of five health-related behaviors than were female-to-male transgender adults (47.2% versus 28.2%). The number of health-related behaviors did not differ between gay or bisexual men and heterosexual men. Continued efforts are needed to target LGBT populations for overall well-being, including strategies for health promotion and engagement in health-related behaviors.

      3. Percentage of ingested sodium excreted in 24-hour urine collections: A systematic review and meta-analysisExternal
        Lucko AM, Doktorchik C, Woodward M, Cogswell M, Neal B, Rabi D, Anderson C, He FJ, MacGregor GA, L’Abbe M, Arcand J, Whelton PK, McLean R, Campbell NR.
        J Clin Hypertens (Greenwich). 2018 Aug 12.

        [No abstract]

      4. Physician nonprofessional cancer experience and ovarian cancer screening practices: Results from a national survey of primary care physiciansExternal
        Ragland M, Trivers KF, Andrilla CH, Matthews B, Miller J, Lishner D, Goff B, Baldwin LM.
        J Womens Health (Larchmt). 2018 Aug 10.

        OBJECTIVE: Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians’ screening practices. This study examines the association between physicians’ nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines. MATERIALS AND METHODS: A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence. RESULTS: In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73-0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience. CONCLUSIONS: Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience.

    • Communicable Diseases
      1. Vulnerabilities at first sex and their association with lifetime gender-based violence and HIV prevalence among adolescent girls and young women engaged in sex work, transactional sex, and casual sex in KenyaExternal
        Becker ML, Bhattacharjee P, Blanchard JF, Cheuk E, Isac S, Musyoki HK, Gichangi P, Aral S, Pickles M, Sandstrom P, Ma H, Mishra S.
        J Acquir Immune Defic Syndr. 2018 Aug 10.

        BACKGROUND: Adolescent girls and young women (AGYW) experience high rates of HIV early in their sexual life-course. We estimated the prevalence of HIV-associated vulnerabilities at first sex, and their association with lifetime gender-based violence (GBV) and HIV. METHODS: We conducted a cross-sectional bio-behavioural survey among AGYW (14-24 years) in Mombasa, Kenya in 2015. We compared the prevalence of first sex vulnerabilities across AGYW who self-identified as engaging in sex work (N=408), transactional sex (N=177) or casual sex (N=714); and used logistic regression to identify age-adjusted associations between first sex vulnerabilities and outcomes (GBV after first sex; HIV). RESULTS: The median age at first sex was 16 years (IQR 14 – 18). 43.6% received gifts or money at first sex; 41.2% and 11.2% experienced a coerced and forced first sex respectively. First sex vulnerabilities were generally more common among AGYW in sex work. GBV (prevalence 23.8%) and HIV (prevalence 5.6%) were associated with first sex before age 15 (GBV AOR 1.4, 95% CI 1.0-1.9; HIV AOR 1.9, 95% CI 1.1-1.3); before or within 1 year of menarche (GBV AOR 1.3, 95% CI 1.0-1.7; HIV AOR 2.1, 95% CI 1.3-3.6); and receipt of money (GBV AOR 1.9, 95% CI 1.4-2.5; HIV AOR 2.0, 95% CI 1.2-3.4). CONCLUSION: HIV-associated vulnerabilities begin at first sex and potentially mediate an AGYW’s trajectory of risk. HIV prevention programmes should include structural interventions that reach AGYW early, and screening for a history of first sex vulnerabilities could help identify AGYW at risk of ongoing GBV and HIV.This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

      2. Developing a topology of syphilis in the United StatesExternal
        Bernstein KT, Grey J, Bolan G, Aral SO.
        Sex Transm Dis. 2018 Sep;45(9S Suppl 1):S1-s6.

        BACKGROUND: In the United States, reported rates of syphilis continue to increase. Co-occurring epidemics of syphilis among men who have sex with men (MSM) and heterosexual populations create challenges for the prioritization of resources and the implementation of context-specific interventions. METHODS: State was the unit of analysis and was restricted to the 44 states with the most complete data of sex or sex partners for their reported adult syphilis cases. States were classified as high, medium, or low for reported congenital syphilis (CS) and MSM primary and secondary (P&S) syphilis rates. Average values of a range of ecologic state level variables were examined among the 9 categories created through the cross-tabulation of CS and MSM P&S syphilis rates. Patterns among ecologic factors were assessed across the 9 categories of states’ syphilis rates. RESULTS: Among the 44 states categorized, 4 states had high rates of both CS and MSM P&S syphilis in 2015, whereas 12 states fell into the medium/medium category and 7 into the low category. Six states had high CS and medium MSM syphilis and 4 states had medium CS but high MSM syphilis. Several area-level factors, including violent crime, poverty, insurance status, household structure and income, showed qualitative patterns with higher rates of CS and MSM P&S syphilis. Higher proportions of urban population were found among states with higher CS rates; no trend was seen with respect to urbanity and MSM P&S syphilis. CONCLUSIONS: Several area-level factors were associated with CS and MSM P&S syphilis in similar ways, whereas other ecologic factors functioned differently with respect to the 2 epidemics. Explorations of community and area-level factors may shed light on novel opportunities for population specific prevention of syphilis.

      3. Linking HIV and viral hepatitis surveillance data: Evaluating a standard, deterministic matching algorithm – 6 US health jurisdictionsExternal
        Bosh KA, Coyle JR, Muriithi NW, Ramaswamy C, Zhou W, Brantley AD, Stockman LJ, VanderBusch L, Westheimer EF, Tang T, Green TA, Hall HI.
        Am J Epidemiol. 2018 Aug 7.

        Accurate interpretations and comparisons of linkage results across jurisdictions require valid and reliable matching methods. We compared existing matching methods used by 6 US state and local health departments (Houston, Texas; Louisiana; Michigan; New York City, New York; North Dakota; and Wisconsin) to link human immunodeficiency virus and viral hepatitis surveillance data with a 14-key automated, hierarchical deterministic matching method. Applicable years varied by disease and jurisdiction, ranging from 1979 to 2016. We calculated percentage agreement and Cohen’s kappa coefficient to compare the matching methods used within each jurisdiction. We calculated sensitivity, specificity, and positive predictive value of each matching method, compared with a new standard that included manual review of discrepant cases. Agreement between the existing matching method and the deterministic matching method was 99.6% or higher in all jurisdictions; Cohen’s kappa values ranged from 0.87 to 0.98. Sensitivity of the deterministic matching method ranged from 97.4% to 100% in the 6 jurisdictions; specificity ranged from 99.7% to 100%; and positive predictive value ranged from 97.4% to 100%. Although no gold standard exists, prior assessments of existing methods and review of discrepant classifications suggest good accuracy and reliability of our deterministic matching method, with the advantage that our method reduces the need for manual review and allows for standard comparisons across jurisdictions when linking human immunodeficiency virus and viral hepatitis data.

      4. Corneal infections associated with sleeping in contact lenses – six cases, United States, 2016-2018External
        Cope JR, Konne NM, Jacobs DS, Dhaliwal DK, Rhee MK, Yin J, Steinemann TL.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 17;67(32):877-881.

        Contact lenses, when worn and cared for properly, are a safe and effective form of vision correction used by an estimated 45 million Americans. However, contact lens wearers are at risk for contact lens-related eye infections, especially when wearers do not practice proper contact lens wear and care habits. These infections, affecting the cornea and known as microbial keratitis (Figure), can lead to serious adverse health outcomes. Because contact lenses are regulated by the Food and Drug Administration (FDA) as medical devices, contact lens-related corneal infections should be reported to FDA as an adverse event. To illustrate their serious health implications, six cases of contact lens-related corneal infection, in which sleeping in lenses was reported as the main risk factor, are presented. Consequences of infection reported among the identified cases included the need for frequent administration of antibiotic eye drops, multiple follow-up medical appointments, and permanent eye damage. Health education measures directed toward contact lens wearers should emphasize raising awareness of the risks of sleeping in contact lenses as well as adherence to all recommendations for the wear and care of contact lenses. Additional measures are needed to educate eye care professionals about the need to report contact lens-related corneal infections to MedWatch, the FDA Safety Information and Adverse Event Reporting program (https://www.fda.gov/MedWatch/).

      5. BACKGROUND: Health departments (HDs) cite state laws as barriers to billing third parties for sexually transmitted disease (STD) services, but the association between legal/policy barriers and third-party HD billing has not been examined. This study investigates the relationship between laws that may limit HDs’ ability to bill, clinic perceptions of billing barriers, and billing practices. METHODS: Two surveys, (1) clinic managers (n = 246), (2) STD program managers (n = 63), conducted via a multiregional needs assessment of federally funded HD clinics’ capacity to bill for STD services, billing/reimbursement practices, and perceived barriers were combined with an analysis of state laws regarding third-party billing for STD services. Statistical analyses examined relationships between laws that may limit HDs’ ability to bill, clinic perceptions, and billing practices. RESULTS: Clinic managers reported clinics were less likely to bill Medicaid and other third parties in jurisdictions with a state law limiting their ability to bill compared with respondents who billed neither or 1 payer (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.10-0.97) and cited practical concerns as a primary barrier to billing (OR, 2.83; 95% CI, 1.50-5.37). The STD program managers report that the staff believed that STD services should be free (OR, 0.34; 95% CI, 0.13-0.90) was associated with not billing (not sure versus no resistance to billing); confidentiality concerns was not a reported barrier to billing among either sample. CONCLUSIONS: Practical concerns and clinic staff beliefs that STD services should be free emerged as possible barriers to billing, as were laws to a lesser extent. Attempts to initiate HD billing for STD services may benefit from staff education as well as addressing perceived legal barriers and staff concerns.

      6. Polio priority countries and the 2018 Hajj: Leveraging an opportunityExternal
        Elachola H, Chitale RA, Ebrahim SH, Wassilak SG, Memish ZA.
        Travel Med Infect Dis. 2018 Aug 7.

        [No abstract]

      7. The relationship between census tract poverty and Shiga toxin-producing E. coli risk, analysis of FoodNet data, 2010-2014External
        Hadler JL, Clogher P, Huang J, Libby T, Cronquist A, Wilson S, Ryan P, Saupe A, Nicholson C, McGuire S, Shiferaw B, Dunn J, Hurd S.
        Open Forum Infect Dis. 2018 ;5(7).

        Background. The relationship between socioeconomic status and Shiga toxin-producing Escherichia coli (STEC) is not well understood. However, recent studies in Connecticut and New York City found that as census tract poverty (CTP) decreased, rates of STEC increased. To explore this nationally, we analyzed surveillance data from laboratory-confirmed cases of STEC from 2010-2014 for all Foodborne Disease Active Surveillance Network (FoodNet) sites, population 47.9 million. Methods. Case residential data were geocoded and linked to CTP level (2010-2014 American Community Survey). Relative rates were calculated comparing incidence in census tracts with < 20% of residents below poverty with those with ?20%. Relative rates of age-adjusted 5-year incidence per 100 000 population were determined for all STEC, hospitalized only and hemolytic-uremic syndrome (HUS) cases overall, by demographic features, FoodNet site, and surveillance year. Results. There were 5234 cases of STEC; 26.3% were hospitalized, and 5.9% had HUS. Five-year incidence was 10.9/100 000 population. Relative STEC rates for the < 20% compared with the >/= 20% CTP group were > 1.0 for each age group, FoodNet site, surveillance year, and race/ethnic group except Asian. Relative hospitalization and HUS rates tended to be higher than their respective STEC relative rates. Conclusions. Persons living in lower CTP were at higher risk of STEC than those in the highest poverty census tracts. This is unlikely to be due to health care-seeking or diagnostic bias as it applies to analysis limited to hospitalized and HUS cases. Research is needed to better understand exposure differences between people living in the lower vs highest poverty-level census tracts to help direct prevention efforts.

      8. Epidemiology of measles in the metropolitan setting, Addis Ababa, Ethiopia, 2005-2014: a retrospective descriptive surveillance data analysisExternal
        Hassen MN, Woyessa AB, Getahun M, Beyene B, Buluanger L, Ademe A, Bekele A, Addissie A, Kebede A, Jima D.
        BMC Infect Dis. 2018 Aug 14;18(1):400.

        BACKGROUND: Measles is a highly infectious and serious respiratory viral disease which caused by a virus. It is a significant cause of illness and death worldwide. This data analysis was conducted to describe the trend and determine the reporting rate of measles cases in Addis Ababa to make recommendation for the government of the city to strengthening measles control interventions. METHODS: We obtained and extracted ten years (2005-2014) Addis Ababa city’s measles surveillance data from national database. We carried out retrospective descriptive data analysis by time, place and person variables. We calculated cumulative and specific reporting rates by dividing measles cases (lab confirmed, epidemiologically linked and compatible cases) to respective population and multiplying by 100,000. We divided average of ten years measles cases to midyear population and multiplied by 100,000 to calculate annualized reporting rate. We analyzed non-measles febrile rash rate by dividing laboratory negative cases to total population and multiplying by 100,000. RESULTS: A total of 4203 suspected measles cases were identified. Among them 1154 (27.5%) were laboratory confirmed, 512 (12.2%) were clinically compatible, 52 (1.2%) were epidemiologically linked cases and the rest 2485 (59.1%) were IgM negative for measles which makes total measles cases 1718 (40.9%). Median age was 5 years with 2-18 years interquartile-range. The annualized measles reporting rate was 5.9, which was 40.2 among > 1 year, 11.5 among 1-4 years, 6.0 among 5-14 years, 4.1 among 15-44 years and 0.01 among >/= 45 years per 100,000 population. Among the total measles cases; 380 (22%) were received at least one dose of measles containing vaccine (MCV) while 415 (24%) cases were not vaccinated and the vaccination status of 923 (54%) cases were not known. CONCLUSION: Our analysis revealed that the reporting rate was higher among young children than older age group. Among all the patients 22% were received at least one dose of measles vaccine whereas 13% were not vaccinated against measles antigen. Routine immunization should be strengthened to reach all children through well monitored vaccine cold chain management.

      9. Readiness for responding to a severe pandemic 100 years after 1918External
        Jester B, Uyeki T, Jernigan D.
        Am J Epidemiol. 2018 Aug 9.

        The 1918 H1N1 pandemic caused unprecedented mortality worldwide. The tools to deal with the global emergency were limited with insufficient surveillance systems and a dearth of diagnostic, treatment, and prevention options. With continuing focus on pandemic planning, technologic advances in surveillance, vaccine capabilities, and 21st century medical care and countermeasures, we are more prepared for a severe pandemic than 100 years ago; however, notable gaps remain.

      10. When combining results from all published surveys, about one in nine global study participants (10.7%) reported ever using PrEP by 2017, a significant increase since U.S. FDA approval in 2012 (OR = 1.6/year, p < 0.00001). Moreover, nearly one in six US-based study participants (17.3%) and nearly one in four MSM who met the CDC’s PrEP indications (24.5%) reported ever using PrEP by 2016. The odds of reporting PrEP use are approximately doubling each year (OR = 1.8/year, p < 0.00001; OR = 2.0/year, p < 0.00001).

      11. Rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among women reporting anal intercourseExternal
        Llata E, Braxton J, Asbel L, Chow J, Jenkins L, Murphy R, Pathela P, Schumacher C, Torrone E.
        Obstet Gynecol. 2018 Aug 6.

        OBJECTIVE: To examine the prevalence and treatment of rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among women reporting receptive anal intercourse in a network of sexually transmitted disease or sexual health clinics and estimate the proportion of missed infections if women were tested at the genital site only. METHODS: We conducted a cross-sectional analysis of C trachomatis and N gonorrhoeae test results from female patients reporting receptive anal intercourse in the preceding 3 months during visits to 24 sexually transmitted disease clinics from 2015 to 2016. Primary outcomes of interest were 1) anatomic site-specific C trachomatis and N gonorrhoeae testing and positivity among women attending selected U.S. sexually transmitted disease clinics who reported receptive anal intercourse and 2) the proportion of rectal infections that would have remained undetected if only genital sites were tested. RESULTS: Overall, 7.4% (3,743/50,785) of women reported receptive anal intercourse during the 2 years. Of the 2,818 women tested at both the genital and rectal sites for C trachomatis, 292 women were positive (61 genital only, 60 rectal only, and 171 at both sites). Of the 2,829 women tested at both the genital and rectal sites for N gonorrhoeae, 128 women were positive (31 genital only, 23 rectal only, and 74 at both sites). Among women tested at both anatomic sites, the proportion of missed C trachomatis infections would have been 20.5% and for N gonorrhoeae infections, 18.0%. CONCLUSION: Genital testing alone misses approximately one fifth of C trachomatis and N gonorrhoeae infections in women reporting receptive anal intercourse in our study population. Missed rectal infections may result in ongoing transmission to other sexual partners and reinfection.

      12. Is HIV patient navigation associated with HIV care continuum outcomes? A systematic reviewExternal
        Mizuno Y, Higa DH, Leighton CA, Roland KB, Deluca JB, Koenig LJ.
        Aids. 2018 Aug 9.

        OBJECTIVE: To provide the first systematic review on the associations between HIV patient navigation and HIV care continuum outcomes (i.e., linkage to care, retention in care, ART uptake, medication adherence, and viral suppression) in the United States (U.S.). We identified primary research studies that addressed these associations and qualitatively assessed whether provision of patient navigation was positively associated with these outcomes, including strength of the evidence. METHODS: A systematic review, including both electronic (MEDLINE [OVID], EMBASE [OVID], PsycINFO [OVID], and CINAHL [EBSCOhost]) online databases and manual searches, was conducted to locate studies published from January 1, 1996 through April 23, 2018. RESULTS: Twenty studies met our inclusion criteria. Of these, 17 found positive associations. Patient navigation was more likely to be positively associated with linkage to care (5 of 6 studies that assessed this association), retention in care (10 of 11), and viral suppression (11 of 15) than with antiretroviral (ART) uptake (1 of 4) or ART adherence (2 of 4). However, almost two-thirds of the 17 studies were of weak study quality, and only three used a randomized controlled trial (RCT) design. CONCLUSIONS: Available evidence suggests that patient navigation is a potentially effective strategy to enhance engagement in care among persons with HIV (PWH). However encouraging, the evidence is still weak. Studies with more rigorous methodological designs, and research examining characteristics of navigators or navigational programs associated with better outcomes, are warranted given the current interest and use of this strategy.

      13. Emergence of localized serogroup W meningococcal disease in the United States – Georgia, 2006-2016External
        Moore AE, MacNeil JR, Wang X, Joseph SJ, Lorentzson L, Thomas S, Tunali A, Parrott T, Farley MM, Tobin-D’Angelo M.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 17;67(32):894-897.

        Several countries in Europe and Australia are reporting an increasing incidence of Neisseria meningitidis serogroup W (NmW) as a consequence of the rapid expansion of a single NmW clone belonging to clonal complex 11 (1-5). Because this clone is reported to be associated with more severe disease, unusual clinical presentations, and a high case fatality ratio (CFR), it is considered a hypervirulent strain (1,6). In the United States, NmW accounts for approximately 5% of meningococcal disease reported each year, and this proportion has remained stable for several years (7). However, localized increases in NmW have been reported, most notably in Florida during 2008-2009 (8). In Georgia, NmW accounted for only 3% of meningococcal disease cases reported during 2006-2013; however, between January 2014 and December 2016, 42% of all reported cases were NmW. Surveillance data from Georgia were analyzed to describe the epidemiology and clinical characteristics of NmW cases, and whole-genome sequencing of NmW isolates was performed for comparison with NmW strains circulating in the United States and worldwide. These data indicate that the U.S. NmW strains might have evolved from the same ancestor as the hypervirulent strain that is circulating globally. Genetic analysis demonstrates that these strains are closely related, which would suggest that genetic variation led to the rise of different strains from the same ancestor. Given the recent global expansion of this potentially hypervirulent NmW lineage, clinicians and public health officials need to remain vigilant in obtaining isolates to monitor changes in circulating strains.

      14. Equity of antiretroviral treatment use in high HIV burden countries: Analyses of data from nationally-representative surveys in Kenya and South AfricaExternal
        Moyo S, Young PW, Gouws E, Naidoo I, Wamicwe J, Mukui I, Marsh K, Igumbor EU, Kim AA, Rehle T.
        PLoS One. 2018 ;13(8):e0201899.

        OBJECTIVE: To assess changes and equity in antiretroviral therapy (ART) use in Kenya and South Africa. METHODS: We analysed national population-based household surveys conducted in Kenya and South Africa between 2007 and 2012 for factors associated with lack of ART use among people living with HIV (PLHIV) aged 15-64 years. We considered ART use to be inequitable if significant differences in use were found between groups of PLHIV (e.g. by sex). FINDINGS: ART use among PLHIV increased from 29.3% (95% confidence interval [CI]: 22.8-35.8) to 42.5% (95%CI: 37.4-47.7) from 2007 to 2012 in Kenya and 17.4% (95%CI: 14.2-20.9) to 30.3% (95%CI: 27.2-33.6) from 2008 to 2012 in South Africa. In 2012, factors independently associated with lack of ART use among adult Kenyan PLHIV were rural residency (adjusted odds ratio [aOR] 1.98, 95%CI: 1.23-3.18), younger age (15-24 years: aOR 4.25, 95%CI: 1.7-10.63, and 25-34 years: aOR 5.16, 95%CI: 2.73-9.74 versus 50-64 years), nondisclosure of HIV status to most recent sex partner (aOR 2.41, 95%CI: 1.27-4.57) and recent recreational drug use (aOR 2.50, 95%CI: 1.09-5.77). Among South African PLHIV in 2012, lack of ART use was significantly associated with younger age (15-24 years: aOR 4.23, 95%CI: 2.56-6.70, and 25-34 years: aOR 2.84, 95%CI: 1.73-4.67, versus 50-64 years), employment status (aOR 1.61, 95%CI: 1.16-2.23 in students versus unemployed), and recent recreational drug use (aOR 4.56, 95%CI: 1.79-11.57). CONCLUSION: Although we found substantial increases in ART use in both countries over time, we identified areas needing improvement including among rural Kenyans, students in South Africa, and among young people and drug users in both countries.

      15. Building a network for multicenter, prospective research of central nervous system infections in South America: Process and lessons learnedExternal
        Nelson C, Mori N, Ton T, Zunt J, Kochel T, Romero A, Gadea N, Tilley D, Ticona E, Soria J, Celis V, Huanca D, Delgado A, Rivas M, Stiglich M, Sihuincha M, Donayre G, Celis J, Romero R, Tam N, Tipismana M, Espinoza I, Rozas M, Peralta A, Sanchez E, Vasquez L, Munoz P, Ramirez G, Reyes I.
        eNeurologicalSci. 2018 .

        Multicenter collaborative networks are essential for advancing research and improving clinical care for a variety of conditions. Research networks are particularly important for central nervous system infections, which remain difficult to study due to their sporadic occurrence and requirement for collection and testing of cerebrospinal fluid. Establishment of long-term research networks in resource-limited areas also facilitates diagnostic capacity building, surveillance for emerging pathogens, and provision of appropriate treatment where needed. We review our experience developing a research network for encephalitis among twelve hospitals in five Peruvian cities since 2009. We provide practical suggestions to aid other groups interested in advancing research on central nervous system infections in resource-limited areas.

      16. BACKGROUND: The number of categorical sexually transmitted disease (STD) clinics is declining in the United States. Federally qualified health centers (FQHCs) have the potential to supplement the needed sexually transmitted infection (STI) services. In this study, we describe the spatial distribution of FQHC sites and determine if reported county-level nonviral STI morbidity were associated with having FQHC(s) using spatial regression techniques. METHODS: We extracted map data from the Health Resources and Services Administration data warehouse on FQHCs (ie, geocoded health care service delivery [HCSD] sites) and extracted county-level data on the reported rates of chlamydia, gonorrhea and, primary and secondary (P&S) syphilis (2008-2012) from surveillance data. A 3-equation seemingly unrelated regression estimation procedure (with a spatial regression specification that controlled for county-level multiyear (2008-2012) demographic and socioeconomic factors) was used to determine the association between reported county-level STI morbidity and HCSD sites. RESULTS: Counties with HCSD sites had higher STI, poverty, unemployment, and violent crime rates than counties with no HCSD sites (P < 0.05). The number of HCSD sites was associated (P < 0.01) with increases in the temporally smoothed rates of chlamydia, gonorrhea, and P&S syphilis, but there was no significant association between the number of HCSD per 100,000 population and reported STI rates. CONCLUSIONS: There is a positive association between STI morbidity and the number of HCSD sites; however, this association does not exist when adjusting by population size. Further work may determine the extent to which HCSD sites can meet unmet needs for safety net STI services.

      17. PURPOSE: With HIV and sexually transmitted disease (STD) rates disproportionately high among adolescent sexual minority males (ASMM), it is important to understand how school-based sexual health education may relate to sexual risk-related behavior among this population. This analysis explores reported HIV/AIDS- and condom-related education and sexual risk-related behaviors among ASMM and their adolescent non-sexual-minority male (non-ASMM) peers. METHODS: Students (n = 11,681) from seven Florida high schools completed paper-and-pencil questionnaires. A matched analytic sample of ASMM and non-ASMM students was created by using propensity score-matching techniques (n = 572). Logistic regressions controlling for individual and school characteristics examined reporting having been taught about AIDS or HIV in school, having been taught in school about using condoms, condom use at last sex, HIV/STD testing, and associations between these variables. RESULTS: Compared with matched non-ASMM peers, ASMM students were less likely to report having been taught about AIDS or HIV in school (odds ratio [OR] = 0.58, P = 0.04) and having used a condom at last sex (OR = 0.39, P < 0.01), but were more likely to report having been tested for HIV or STDs (OR = 1.88, P = 0.02). There were no significant differences for reporting having been taught in school about using condoms. Among non-ASMM, reporting having been taught in school about using condoms was associated with a greater likelihood of condom use at last sex (OR = 4.78, P < 0.01); this was not seen for ASMM. CONCLUSIONS: Differential reports of receiving HIV/AIDS education and differential associations between condom-related education and condom use in ASMM and non-ASMM suggest that sexual health education in schools may not be resonating with ASMM and non-ASMM in the same way.

      18. Advances in emerging and neglected infectious diseases 2018External
        Spencer CT, Vasconcelos JR, Thornburg NJ, Zimmer SL.
        Biomed Res Int. 2018 ;2018:4619282.

        [No abstract]

      19. HIV viral suppression and longevity among a cohort of children initiating antiretroviral therapy in Eastern Cape, South AfricaExternal
        Teasdale CA, Sogaula N, Yuengling KA, Wang C, Mutiti A, Arpadi S, Nxele M, Pepeta L, Mogashoa M, Rivadeneira ED, Abrams EJ.
        J Int AIDS Soc. 2018 Aug;21(8):e25168.

        INTRODUCTION: There are limited data on viral suppression (VS) in children with HIV receiving antiretroviral therapy (ART) in routine care in low-resource settings. We examined VS in a cohort of children initiating ART in routine HIV care in Eastern Cape Province, South Africa. METHODS: The Pediatric Enhanced Surveillance Study enrolled HIV-infected ART eligibility children zero to twelve years at five health facilities from 2012 to 2014. All children received routine HIV care and treatment services and attended quarterly study visits for up to 24 months. Time to VS among those starting treatment was measured from ART start date to first viral load (VL) result <1000 and VL <50 copies/mL using competing risk estimators (death as competing risk). Multivariable sub-distributional hazards models examined characteristics associated with VS and VL rebound following suppression among those with a VL >30 days after the VS date. RESULTS: Of 397 children enrolled, 349 (87.9%) started ART: 118 (33.8%) children age <12 months, 122 (35.0%) one to five years and 109 (31.2%) six to twelve years. At study enrolment, median weight-for-age z-score (WAZ) was -1.7 (interquartile range (IQR):-3.1 to -0.4) and median log VL was 5.6 (IQR: 5.0 to 6.2). Cumulative incidence of VS <1000 copies/mL at six, twelve and twenty-four months was 57.6% (95% CI 52.1 to 62.7), 78.7% (95% CI 73.7 to 82.9) and 84.0% (95% CI 78.9 to 87.9); for VS <50 copies/mL: 40.3% (95% CI 35.0 to 45.5), 63.9% (95% CI 58.2 to 69.0) and 72.9% (95% CI 66.9 to 78.0). At 12 months only 46.6% (95% CI 36.6 to 56.0) of children <12 months had achieved VS <50 copies/mL compared to 76.9% (95% CI 67.9 to 83.7) of children six to twelve years (p < 0.001). In multivariable models, children with VL >1 million copies/mL at ART initiation were half as likely to achieve VS <50 copies/mL (adjusted sub-distributional hazards 0.50; 95% CI 0.36 to 0.71). Among children achieving VS <50 copies/mL, 37 (19.7%) had VL 50 to 1000 copies/mL and 31 (16.5%) had a VL >1000 copies/mL. Children <12 months had twofold increased risk of VL rebound to VL >1000 copies/mL (adjusted relative risk 2.03, 95% CI: 1.10 to 3.74) compared with six to twelve year olds. CONCLUSIONS: We found suboptimal VS among South African children initiating treatment and high proportions experiencing VL rebound, particularly among younger children. Greater efforts are needed to ensure that all children achieve optimal outcomes.

      20. [No abstract]

      21. Risk stratification with coccidioidal skin test to prevent Valley Fever among inmates, California, 2015External
        Wheeler C, Lucas KD, Derado G, McCotter O, Tharratt RS, Chiller T, Mohle-Boetani JC.
        J Correct Health Care. 2018 Aug 13:1078345818792679.

        Two California state prisons (A and B) have very high rates of coccidioidomycosis (Valley Fever). The prison health care service sought to improve their prevention strategy by risk stratification with a newly available spherulin-based Coccidioides delayed-type hypersensitivity test. Of the 36,789 voluntarily screened inmates, 4.7% experienced adverse reactions. A positive test (8.6% of those tested) was independently associated with (1) incarceration at prisons A and B, (2) admission to prison from a Coccidioides-endemic county, (3) length of stay at prisons A and B, and (4) increasing age. These findings suggest that the test is safe and performing well at risk stratification; the prison system now restricts inmates with negative tests from prisons A and B. This novel use of the test might benefit other coccidioidomycosis prevention programs.

    • Disease Reservoirs and Vectors
      1. New opportunities for malaria vector controlExternal
        Gimnig JE, Ochomo E.
        Lancet. 2018 Aug 10.

        [No abstract]

      2. Although Dermacentor spp. ticks are considered the primary vectors of Rickettsia rickettsii in the United States, other North American tick species are also capable of transmitting the agent, including the lone star tick-Amblyomma americanum. The lone star tick is an aggressive human-biting tick abundant in the South, Central, and Mid-Atlantic United States, which has been shown to be a competent vector of R. rickettsii in laboratory studies. However in nature, A. americanum frequently carry Rickettsia amblyommatis-another member of the spotted fever group-with the prevalence of infection reaching 84% in some populations. It has been postulated that the presence of an endosymbiotic Rickettsia in a significant proportion of a vector population would diminish or even block transmission of pathogenic Rickettsia in ticks from generation to generation due to transovarial interference. We measured the ability of R. amblyommatis-infected A. americanum to acquire R. rickettsii from an infected host with a bloodmeal, and transmit it transstadially, horizontally (to a susceptible host), and vertically to the next generation. Larvae from both the R. amblyommatis-infected and R. amblyommatis-free cohorts acquired R. rickettsii from infected guinea pigs, but the presence of the symbiont diminished the ability of coinfected engorged larvae to transmit R. rickettsii transstadially. Conversely, acquisition of R. rickettsii by cofeeding was unaffected in R. amblyommatis-infected nymphs and adults; prevalence of R. rickettsii in engorged adults reached 97% in both R. amblyommatis-infected and R. amblyommatis-free cohorts. In guinea pigs exposed to dually infected nymphs, R. rickettsii infection was milder than in those fed upon nymphs infected with R. rickettsii only. The frequency of transovarial transmission of R. rickettsii in the R. amblyommatis-infected cohort (31%) appeared lower than that in the R. amblyommatis-free cohort (48%), but the difference was not statistically significant. Larval progenies of dually infected A. americanum females transmitted R. rickettsii to naive guinea pigs confirming viability of the pathogen. Thus, the vector competence of A. americanum for R. rickettsii was not significantly affected by R. amblyommatis.

    • Environmental Health
      1. Variability of indoor fungal microbiome of green and non-green low-income homes in Cincinnati, OhioExternal
        Coombs K, Taft D, Ward DV, Green BJ, Chew GL, Shamsaei B, Meller J, Indugula R, Reponen T.
        Sci Total Environ. 2018 Jan 1;610-611:212-218.

        “Green” housing is designed to use low-impact materials, increase energy efficiency and improve occupant health. However, little is known about the indoor mycobiome of green homes. The current study is a subset of a multicenter study that aims to investigate the indoor environment of green homes and the respiratory health of asthmatic children. In the current study, the mycobiome in air, bed dust and floor dust was compared between green (study site) and non-green (control site), low-income homes in Cincinnati, Ohio. The samples were collected at baseline (within four months following renovation), and 12months after the baseline at the study site. Parallel sample collection was conducted in non-green control homes. Air samples were collected by PM2.5 samplers over 5-days. Bed and floor dust samples were vacuumed after the air sampling was completed. The DNA sample extracts were analyzed using ITS amplicon sequencing. Analysis indicated that there was no clear trend in the fungal communities between green and non-green homes. Instead, fungal community differences were greatest between sample types – air, bed, and floor. Microbial communities also changed substantially between sampling intervals in both green and non-green homes for all sample types, potentially indicating that there was very little stability in the mycobiomes. Research gaps remain regarding how indoor mycobiome fluctuates over time. Longer follow-up periods might elucidate the effect of green renovation on microbial load in buildings.

      2. Childhood polybrominated diphenyl ether (PBDE) exposure and executive function in children in the HOME StudyExternal
        Vuong AM, Yolton K, Poston KL, Xie C, Webster GM, Sjodin A, Braun JM, Dietrich KN, Lanphear BP, Chen A.
        Int J Hyg Environ Health. 2018 Jan;221(1):87-94.

        Prenatal exposure to polybrominated diphenyl ethers (PBDEs) have been reported to impair executive function in children, but little is known whether childhood PBDE exposures play a role. Using the Health Outcomes and Measures of the Environment (HOME) Study, a prospective birth cohort in the greater Cincinnati area, we investigated the association between repeated measures of PBDEs during childhood and executive function at 8 years in 208 children and whether effect modification by child sex was present. We used child serum collected at 1, 2, 3, 5, and 8 years to measure PBDEs. The Behavior Rating Inventory of Executive Function was completed by parents to assess executive function at 8 years. We used multiple informant models to examine childhood PBDEs during several exposure windows. Null associations were observed between early childhood PBDEs and executive function. However, we observed significant adverse associations between a 10-fold increase in concurrent concentrations of BDE-28 (beta=4.6, 95% CI 0.5, 8.7) and BDE-153 (beta=4.8, 95% CI 0.8, 8.8) with behavioral regulation. In addition, PBDEs at 8 years were significantly associated with poorer emotional and impulse control. No associations were noted between childhood PBDEs and metacognition or global executive function. However, child sex significantly modified the associations, with significantly poorer executive function among males with higher concurrent BDE-153, and null associations in females. Our study findings suggest that concurrent PBDE exposures during childhood may be associated with poorer executive function, specifically behavior regulation. Males may also be more sensitive to adverse associations of concurrent PBDEs on executive function.

      3. Per- and polyfluoroalkyl substances in sera from children 3 to 11 years of age participating in the National Health and Nutrition Examination Survey 2013-2014External
        Ye X, Kato K, Wong LY, Jia T, Kalathil A, Latremouille J, Calafat AM.
        Int J Hyg Environ Health. 2018 Jan;221(1):9-16.

        Several per- and polyfluoroalkyl substances (PFAS) have been measured in U.S. National Health and Nutrition Examination Survey (NHANES) participants 12 years of age and older since 1999-2000, but PFAS data using NHANES individual samples among children younger than 12 years do not exist. To obtain the first nationally representative PFAS exposure data in U.S. children, we quantified serum concentrations of 14 PFAS including perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), perfluorohexane sulfonic acid (PFHxS), and perfluorononanoic acid (PFNA), in a nationally representative subsample of 639 3-11year old participants in NHANES 2013-2014. We used on-line solid-phase extraction coupled to isotope dilution-high performance liquid chromatography-tandem mass spectrometry; limits of detection were 0.1ng/mL for all analytes. We calculated geometric mean concentrations, determined weighted Pearson correlations, and used linear regression to evaluate associations of sex, age (3-5 vs 6-11 years), race/ethnicity (Hispanic vs non-Hispanic), household income, and body mass index with concentrations of PFAS detected in more than 60% of participants. We detected PFOS, PFOA, PFHxS, and PFNA in all children at concentrations similar to those of NHANES 2013-2014 adolescents and adults, suggesting prevalent exposure to these PFAS or their precursors among U.S. 3-11year old children, most of whom were born after the phase out of PFOS in the United States in 2002. PFAS concentration differences by sex, race/ethnicity, and age suggest lifestyle differences that may impact exposure, and highlight the importance of identifying exposure sources and of studying the environmental fate and transport of PFAS.

    • Food Safety
      1. A population-based surveillance study of shared genotypes of Escherichia coli isolates from retail meat and suspected cases of urinary tract infectionsExternal
        Yamaji R, Friedman CR, Rubin J, Suh J, Thys E, McDermott P, Hung-Fan M, Riley LW.
        mSphere. 2018 Aug 15;3(4).

        There is increasing evidence that retail food may serve as a source of Escherichia coli that causes community-acquired urinary tract infections, but the impact of this source in a community is not known. We conducted a prospective, population-based study in one community to examine the frequency of recovery of uropathogenic E. coli genotypes from retail meat samples. We analyzed E. coli isolates from consecutively collected urine samples of patients suspected to have urinary tract infections (UTIs) at a university-affiliated health service and retail meat samples from the same geographic region. We genotyped all E. coli isolates by multilocus sequence typing (MLST) and tested them for antimicrobial susceptibility. From 2016 to 2017, we cultured 233 E. coli isolates from 230 (21%) of 1,087 urine samples and 177 E. coli isolates from 120 (28%) of 427 retail meat samples. Urine samples contained 61 sequence types (STs), and meat samples had 95 STs; 12 STs (ST10, ST38, ST69, ST80, ST88, ST101, ST117, ST131, ST569, ST906, ST1844, and ST2562) were common to both. Thirty-five (81%) of 43 meat isolates among the 12 STs were from poultry. Among 94 isolates in the 12 STs, 26 (60%) of 43 retail meat isolates and 15 (29%) of 51 human isolates were pan-susceptible (P < 0.005). We found that 21% of E. coli isolates from suspected cases of UTIs belonged to STs found in poultry. Poultry may serve as a possible reservoir of uropathogenic E. coli (UPEC). Additional studies are needed to demonstrate transmission pathways of these UPEC genotypes and their food sources.IMPORTANCE Community-acquired urinary tract infection caused by Escherichia coli is one of the most common infectious diseases in the United States, affecting approximately seven million women and costing approximately 11.6 billion dollars annually. In addition, antibiotic resistance among E. coli bacteria causing urinary tract infection continues to increase, which greatly complicates treatment. Identifying sources of uropathogenic E. coli and implementing prevention measures are essential. However, the reservoirs of uropathogenic E. coli have not been well defined. This study demonstrated that poultry sold in retail stores may serve as one possible source of uropathogenic E. coli This finding adds to a growing body of evidence that suggests that urinary tract infection may be a food-borne disease. More research in this area can lead to the development of preventive strategies to control this common and costly infectious disease.

    • Genetics and Genomics
      1. [No abstract]

    • Health Communication and Education
      1. Background: The topic of breast cancer genetics entered the public discourse following Angelina Jolie’s 2013 announcement that she carries the BRCA1 mutation and underwent a prophylactic double mastectomy to reduce her breast cancer risk. A year prior to Jolie’s announcement, the teen drama 90210 ran an eight-episode story arc on the BRCA gene mutations. This study focuses on an evaluation of the impact of this particular media text within the broader context of research on the persuasive effects of entertainment narratives (i.e. entertainment education). Method: The evaluation consisted of two complementary studies of adult women: a pre-test/post-test study using a panel sample of regular television viewers who were directed to watch a particular episode (Study 1), and a cross-sectional study using a convenience sample of frequent 90210 viewers (Study 2). Results: In both studies, storyline exposure was associated with increased knowledge (familiarity with the BRCA gene, knowledge about mastectomy). Study 1 additionally saw evidence of increased fears regarding the consequences of the BRCA gene and intentions to talk to a doctor. In Study 2, the number of episodes viewed was positively related to both knowledge and behavior (finding out about one’s family history of breast cancer). Conclusions: These findings suggest that despite unprecedented changes in the ways audiences engage with and consume entertainment media, television narratives remain a powerful method of educating viewers about health risks and inspiring them to take action.

    • Health Disparities
      1. Prevalence of disabilities and health care access by disability status and type among adults – United States, 2016External
        Okoro CA, Hollis ND, Cyrus AC, Griffin-Blake S.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 17;67(32):882-887.

        Persons with disabilities face greater barriers to health care than do those without disabilities (1). To identify characteristics of noninstitutionalized adults with six specific disability types (hearing, vision, cognition, mobility, self-care, and independent living),* and to assess disability-specific disparities in health care access, CDC analyzed 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalences of disability overall and by disability type, and access to health care by disability type, were estimated. Analyses were stratified by three age groups: 18-44 years (young adults), 45-64 years (middle-aged adults), and >/=65 years (older adults). Among young adults, cognitive disability (10.6%) was the most prevalent type. Mobility disability was most prevalent among middle-aged (18.1%) and older adults (26.9%). Generally, disability prevalences were higher among women, American Indians/Alaska Natives (AI/AN), adults with income below the federal poverty level (FPL), and persons in the South U.S. Census region. Disability-specific disparities in health care access were prevalent, particularly among young and middle-aged adults. These data might inform public health programs of the sociodemographic characteristics and disparities in health care access associated with age and specific disability types and guide efforts to improve access to care for persons with disabilities.

    • Health Economics
      1. Cost-of-illness (COI) studies often include the ‘indirect’ cost of lost production resulting from disease, disability, and premature death, which is an important component of the economic burden of chronic conditions assessed from the societal perspective. In most COI studies, productivity costs are estimated primarily as the economic value of production forgone associated with loss of paid employment (foregone gross earnings); some studies include the imputed value of lost unpaid work as well. This approach is commonly but imprecisely referred to as the human capital approach (HCA). However, there is a lack of consensus among health economists as to how to quantify loss of economic productivity. Some experts argue that the HCA overstates productivity losses and propose use of the friction cost approach (FCA) that estimates societal productivity loss as the short-term costs incurred by employers in replacing a lost worker. This review sought to identify COI studies published during 1995-2017 that used the FCA, with or without comparison to the HCA, and to compare FCA and HCA estimates from those studies that used both approaches. We identified 80 full COI studies (of which 75% focused on chronic conditions), roughly 5-8% of all COI studies. The majority of those studies came from three countries, Canada, Germany, and the Netherlands, that have officially endorsed use of the FCA. The FCA results in smaller productivity loss estimates than the HCA, although the differential varied widely across studies. Lack of standardization of HCA and FCA methods makes productivity cost estimates difficult to compare across studies.

    • Healthcare Associated Infections
      1. Burden of invasive methicillin-resistant Staphylococcus aureus infections in nursing home residentsExternal
        Grigg C, Palms D, Stone ND, Gualandi N, Bamberg W, Dumyati G, Harrison LH, Lynfield R, Nadle J, Petit S, Ray S, Schaffner W, Townes J, See I.
        J Am Geriatr Soc. 2018 Aug 10.

        OBJECTIVES: To describe the epidemiology and incidence of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections in nursing home (NH) residents, which has previously not been well characterized. DESIGN: Retrospective analysis of public health surveillance data. SETTING: Healthcare facilities in 33 U.S. counties. PARTICIPANTS: Residents of the surveillance area. MEASUREMENTS: Counts of NH-onset and hospital-onset (HO) invasive MRSA infections (cultured from sterile body sites) identified from the Centers for Disease Control and Prevention Emerging Infections Program (EIP) population-based surveillance from 2009 to 2013 were compared. Demographic characteristics and risk factors of NH-onset cases were analyzed. Using NH resident-day denominators from the Centers for Medicare and Medicaid Services Skilled Nursing Facility Cost Reports, incidence of NH-onset invasive MRSA infections from facilities in the EIP area was determined. RESULTS: A total of 4,607 NH-onset and 4,344 HO invasive MRSA cases were reported. Of NH-onset cases, median age was 74, most infections were bloodstream infections, and known risk factors for infection were common: 1,455 (32%) had previous MRSA infection or colonization, 1,014 (22%) had decubitus ulcers, 1,098 (24%) had recent central venous catheters, and 1,103 (24%) were undergoing chronic dialysis; 2,499 (54%) had been discharged from a hospital in the previous 100 days. The in-hospital case-fatality rate was 19%. The 2013 pooled mean incidence of NH-onset invasive MRSA infections in the surveillance area was 2.4 per 100,000 patient-days. CONCLUSION: More NH-onset than HO cases occurred, primarily in individuals with known MRSA risk factors. These data reinforce the importance of infection prevention practices during wound and device care in NH residents, especially those with a history of MRSA infection or colonization.

      2. OBJECTIVE To describe pathogen distribution and antimicrobial resistance patterns for healthcare-associated infections (HAIs) reported to the National Healthcare Safety Network (NHSN) from pediatric locations during 2011-2014. METHODS Device-associated infection data were analyzed for central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP), and surgical site infection (SSI). Pooled mean percentage resistance was calculated for a variety of pathogen-antimicrobial resistance pattern combinations and was stratified by location for device-associated infections (neonatal intensive care units [NICUs], pediatric intensive care units [PICUs], pediatric oncology and pediatric wards) and by surgery type for SSIs. RESULTS From 2011 to 2014, 1,003 hospitals reported 20,390 pediatric HAIs and 22,323 associated pathogens to the NHSN. Among all HAIs, the following pathogens accounted for more than 60% of those reported: Staphylococcus aureus (17%), coagulase-negative staphylococci (17%), Escherichia coli (11%), Klebsiella pneumoniae and/or oxytoca (9%), and Enterococcus faecalis (8%). Among device-associated infections, resistance was generally lower in NICUs than in other locations. For several pathogens, resistance was greater in pediatric wards than in PICUs. The proportion of organisms resistant to carbapenems was low overall but reached approximately 20% for Pseudomonas aeruginosa from CLABSIs and CAUTIs in some locations. Among SSIs, antimicrobial resistance patterns were similar across surgical procedure types for most pathogens. CONCLUSION This report is the first pediatric-specific description of antimicrobial resistance data reported to the NHSN. Reporting of pediatric-specific HAIs and antimicrobial resistance data will help identify priority targets for infection control and antimicrobial stewardship activities in facilities that provide care for children. Infect Control Hosp Epidemiol 2018;39:1-11.

      3. INTRODUCTIONIn 2017, the Journal of Clinical Microbiology published a Point-Counterpoint on the laboratory diagnosis of Clostridium difficile infection (CDI). At that time, Ferric C. Fang, Christopher R. Polage, and Mark H. Wilcox discussed the strategies for diagnosing Clostridium difficile colitis in symptomatic patients (J Clin Microbiol 55:670-680, 2017, https://doi.org/10.1128/JCM.02463-16). Since that paper, new guidelines from the Infectious Diseases Society of America and the Society for Health Care Epidemiology have been published (L. C. McDonald, D. N. Gerding, S. Johnson, J. S. Bakken, K. C. Carroll, et al., Clin Infect Dis 66:987-994, 2018, https://doi.org/10.1093/cid/ciy149) and health care systems have begun to explore screening asymptomatic patients for C. difficile colonization. The theory behind screening selected patient populations for C. difficile colonization is that these patients represent a substantial reservoir of the bacteria and can transfer the bacteria to other patients. Hospital administrators are taking note of institutional CDI rates because they are publicly reported. They have become an important metric impacting hospital safety ratings and value-based purchasing, and hospitals may have millions of dollars of reimbursement at risk. In this Point-Counterpoint, Cliff McDonald of the U.S. Centers for Disease Control and Prevention discusses the value of asymptomatic C. difficile screening, while Dan Diekema of the University of Iowa discusses why caution should be used.

      4. Approach to the investigation and management of patients with Candida auris, an emerging multidrug-resistant yeastExternal
        Tsay S, Kallen A, Jackson BR, Chiller TM, Vallabhaneni S.
        Clin Infect Dis. 2018 Jan 6;66(2):306-311.

        Candida auris is an emerging, multidrug-resistant yeast that can spread in healthcare settings. It can cause invasive infections with high mortality and is difficult to identify using traditional yeast identification methods. Candida auris has been reported in more than a dozen countries, and as of August 2017, 112 clinical cases have been reported in the United States. Candida auris can colonize skin and persist in the healthcare environment, allowing for transmission between patients. Prompt investigation and aggressive interventions, including notification to public health agencies, implementation of contact precautions, thorough environmental cleaning and disinfection, infection control assessments, contact tracing and screening of contacts to assess for colonization, and retrospective review of microbiology records and prospective surveillance for cases at laboratories are all needed to limit the spread of C. auris. This review summarizes the current recommended approach to manage cases and control transmission of C. auris in healthcare facilities.

    • Immunity and Immunization
      1. Impact of monovalent rotavirus vaccine on diarrhoea-associated post-neonatal infant mortality in rural communities in Malawi: a population-based birth cohort studyExternal
        Bar-Zeev N, King C, Phiri T, Beard J, Mvula H, Crampin AC, Heinsbroek E, Lewycka S, Tate JE, Parashar UD, Costello A, Mwansambo C, Heyderman RS, French N, Cunliffe NA.
        Lancet Glob Health. 2018 Sep;6(9):e1036-e1044.

        BACKGROUND: Rotavirus is a major contributor to child mortality. The effect of rotavirus vaccine on diarrhoea mortality has been estimated in middle-income but not low-income settings, where mortality is high and vaccine effectiveness in reducing admissions to hospital is lower. Empirical population-based mortality studies have not been done in any setting. Malawi introduced monovalent rotavirus vaccine (RV1) in October, 2012. We aimed to investigate the impact and effectiveness of the RV1 vaccine in reducing diarrhoea-associated mortality in infants aged 10-51 weeks. METHODS: In this population-based cohort study, we included infants born between Jan 1, 2012, and June 1, 2015, in Mchinji, Central Malawi and analysed data on those surviving 10 weeks. Individual vaccination status was extracted from caregiver-held records or report at home visits at 4 months and 1 year of age. Survival to 1 year was confirmed at home visit, or cause of death ascertained by verbal autopsy. We assessed impact (1 minus mortality rate ratio following vs before vaccine introduction) using Poisson regression. Among vaccine-eligible infants (born from Sept 17, 2012), we assessed effectiveness (1 minus hazard ratio) using Cox regression. FINDINGS: Between Jan 1, 2012, and June 1, 2015, we recruited 48 672 livebirths in Mchinji, among whom 38 518 were vaccine-eligible and 37 570 survived to age 10 weeks. Two-dose versus zero-dose effectiveness analysis included 28 141 infants, of whom 101 had diarrhoea-associated death before 1 year of age. Diarrhoea-associated mortality declined by 31% (95% CI 1-52; p=0.04) after RV1 introduction. Effectiveness against diarrhoea-mortality was 34% (95% CI -28 to 66; p=0.22). INTERPRETATION: RV1 was associated with substantial reduction in diarrhoea-associated deaths among infants in this rural sub-Saharan African setting. These data add considerable weight to evidence showing the impact of rotavirus vaccine programmes. FUNDING: Wellcome Trust and GlaxoSmithKline Biologicals.

      2. Progress on Norovirus vaccine research: Public health considerations and future directionsExternal
        Mattison CP, Cardemil CV, Hall AJ.
        Expert Rev Vaccines. 2018 Aug 9.

        INTRODUCTION: Noroviruses are the leading cause of foodborne illness worldwide, account for approximately one-fifth of acute gastroenteritis cases globally and cause a substantial economic burden. Candidate norovirus vaccines are in development, but there is currently no licensed vaccine. Areas covered: Noroviruses cause approximately 684 million cases and 212,000 deaths per year across all age groups, though burden estimates vary by study and region. Challenges to vaccine research include substantial and rapidly evolving genetic diversity, short-term and homotypic immunity to infection, and the absence of a single, well-established correlate of protection. Nonetheless, several norovirus vaccine candidates are currently in development, utilizing virus-like particles (VLPs), P particles, and recombinant adenoviruses. Of these, a bivalent GI.1/GII.4 VLP-based intramuscular vaccine (Phase IIb) and GI.1 oral vaccine (Phase I) are in clinical trials. Expert Commentary: A norovirus vaccine should target high risk populations, including the young and the elderly and protect against the most common circulating norovirus strains. A norovirus vaccine would be a powerful tool in the prevention and control of norovirus while lessening the burden of AGE worldwide. However, more robust burden and cost estimates are needed to justify investments in and guide norovirus vaccine development.

      3. Rubella virus neutralizing antibody response after a third dose of measles-mumps-rubella vaccine in young adultsExternal
        McLean HQ, Fiebelkorn AP, Ogee-Nwankwo A, Hao L, Coleman LA, Adebayo A, Icenogle JP.
        Vaccine. 2018 Aug 11.

        BACKGROUND: Third doses of measles-mumps-rubella (MMR) vaccine have been administered during mumps outbreaks and in various non-outbreak settings. The immunogenicity of the rubella component has not been evaluated following receipt of a third dose of MMR vaccine. METHODS: Young adults aged 18-31years with documented two doses of MMR vaccine received a third dose of MMR vaccine between July 2009 and October 2010. Rubella neutralizing antibody titers were assessed before, 1month, and 1year after receipt of a third dose of MMR vaccine. RESULTS: Among 679 participants, 1.8% had rubella antibody titers less than 10 U/ml, immediately before vaccination, approximately 15years after receipt of a second dose of MMR vaccine. One month after receipt of a third dose of MMR vaccine, average titers were 4.5 times higher and >50% of participants had a 4-fold boost. Response was highest among those with titers less than 10 U/ml prior to vaccination (geometric mean titer ratio=18.8; 92% seroconversion) and decreased with increasing pre-vaccination titers. Average titers declined 1year postvaccination but remained significantly higher than pre-vaccination levels. The proportion classified as low-positive antibody levels increased from 3% 1month postvaccination to 24% 1year postvaccination. CONCLUSIONS: Vaccination with a third dose of MMR vaccine resulted in a robust boosting of rubella neutralizing antibody response that remained elevated 1year later. Young adults with low rubella titers are more likely to benefit from a third dose of MMR vaccine.

    • Laboratory Sciences
      1. A diagnostic evaluation of a molecular assay used for testing and treating anorectal chlamydia and gonorrhoea infections at the point-of-care in Papua New GuineaExternal
        Badman SG, Willie B, Narokobi R, Gabuzzi J, Pekon S, Amos-Kuma A, Hakim AJ, Weikum D, Gare J, Silim S, Guy RJ, Donovan B, Cunningham P, Kaldor JM, Vallely AJ, Whiley D, Kelly-Hanku A.
        Clin Microbiol Infect. 2018 Aug 11.

        OBJECTIVES: Papua New Guinea (PNG) has among the highest prevalences of sexually transmissible infections (STIs) globally with no services able to accurately test for anorectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections. Here we prospectively evaluated the diagnostic performance of a molecular CT/NG assay used at the point-of-care (POC) with the aim of enhancing anorectal STI screening and same day treatment. METHODS: Men who have sex with men (MSM), Transgender women (TGW) and female sex workers (FSW) taking part in PNG’s first large-scale biobehavioural study were enrolled and asked to provide a self-collected anorectal swab for POC GeneXpert CT/NG testing. Same day treatment was offered if positive. A convenience sample of 396 unique and randomly selected samples were transported to Australia for comparison using the Cobas 4800 CT/NG test (Roche Molecular Diagnostics, Pleasanton, CA). RESULTS: A total of 326 samples provided valid results by Cobas whereas 70 samples provided invalid results suggesting inhibition. The positive, negative and overall percentage agreements of GeneXpert CT/NG for the detection of CT were 96.7% (CI: 92.3, 98.9%), 95.5% (CI: 91.3, 98.0%) and 96.0% (93.3, 97.8%), and for NG were 93.0% (CI: 86.1, 97.1%), 100.0%, (CI: 98.3%, 100.0%) and 97.8% (CI: 95.6%, 99.1%), respectively. CONCLUSIONS: The overall rate of agreement between the GeneXpert and Cobas CT/NG assays was high with 96.0% for CT and 97.8% for NG. Results from this study data suggest the GeneXpert CT/NG assay is suitable for testing self-collected anorectal specimens at the point-of-care and same day treatment was feasible.

      2. Laboratory comparison of new high flow rate respirable size-selective samplerExternal
        Lee T, Thorpe A, Cauda E, Tipton L, Sanderson WT, Echt A.
        J Occup Environ Hyg. 2018 Aug 10:1-26.

        A newly developed high flow rate respirable size-selective cyclone sampler (GK4.162-also known as the Respirable Air Sampling Cyclone Aluminum Large (RASCAL)) was calibrated to determine its optimum operating flow rate. The Health and Safety Laboratory in the United Kingdom and two laboratories from the National Institute for Occupational Safety and Health in the United States conducted experiments using two different methods: (1) polydisperse aerosol and time-of-flight direct reading instrument (Aerodynamic Particle Sizer (APS)) and (2) monodisperse aerosol and APS. The measured performance data for the cyclone was assessed against the international respirable convention using the bias map approach. Although the GK4.162 cyclone was tested using different aerosols and detection methods, the results from the three laboratories were generally similar. The recommended flow rate based on the agreement of results from the laboratories was 9.0 L/min.

      3. Syphilis, caused by the bacterium Treponema pallidum, is on the rise in the United States particularly among men who have sex with men. The disease is complex with varied clinical manifestations and challenges remain in the laboratory diagnostic setting because T. pallidum is noncultivable and no single test can accurately diagnose all stages of the disease. There are missed opportunities for the use of direct detection tests in primary and secondary syphilis. The increasing use of different reverse sequence algorithms for serology testing without validation in populations with varying risks for syphilis makes the interpretation of test results difficult; this has led to concerns about diagnostic errors or overtreatment. On the other hand, the traditional algorithm may miss some early primary syphilis cases, which is of concern in high-risk populations. The potential utility of rapid syphilis serology tests in different settings or populations remains to be determined. The implementation of better tests and appropriate testing algorithms together with laboratory guidelines for test use in general will lead to better diagnostic options for syphilis.

      4. Malaria diagnostic practices in U.S. laboratories in 2017External
        Prestel C, Tan KR, Abanyie F, Jerris R, Gutman JR.
        J Clin Microbiol. 2018 Aug;56(8).

        In the United States, the gold standard for malaria diagnosis is microscopic blood smear examination. Because malaria is not endemic in the United States, diagnostic capabilities may be limited, causing delays in diagnosis and increased morbidity and mortality. A survey of the malaria diagnostic practices of U.S. laboratories was conducted from June to July 2017; members of the American Society for Microbiology’s listserv received a questionnaire inquiring about malaria diagnostic test availability, techniques, and reporting. Results were assessed using the Clinical and Laboratory Standards Institute (CLSI) guidelines for malaria diagnostics. After excluding incomplete and duplicate responses, responses representing 175 laboratories were included. Most labs (99%) received at least one specimen annually for malaria diagnosis, and 31% reported receiving only 1 to 10 specimens. The majority (74%) diagnosed five or fewer cases of malaria per year. Most (90%) performed blood smears on-site. Two-thirds (70%) provided initial blood smear results within 4 h. Although diagnostic testing for malaria was available 24/7 at 74% (141) of responding laboratories, only 12% (17) met criteria for analysis and reporting of malaria testing, significantly more than reported in a similar survey in 2010 (3%; P < 0.05). The majority of laboratories surveyed had the capability for timely diagnosis of malaria; few comply with CLSI guidelines. Inexperience may factor into this noncompliance; many laboratories see few to no cases of malaria per year. Although reported adherence to CLSI guidelines was higher than in 2010, there is a need to further improve laboratory compliance with recommendations.

      5. Photo-induced electron transfer real-time PCR for detection of Plasmodium falciparum plasmepsin 2 gene copy numberExternal
        Souza SS, L’Episcopia M, Severini C, Udhayakumar V, Lucchi NW.
        Antimicrob Agents Chemother. 2018 Aug;62(8).

        Piperaquine is an important partner drug used in artemisinin-based combination therapies (ACTs). An increase in the plasmepsin 2 and 3 gene copy numbers has been associated with decreased susceptibility of Plasmodium falciparum to piperaquine in Cambodia. Here, we developed a photo-induced electron transfer real-time PCR (PET-PCR) assay to quantify the copy number of the P. falciparumplasmepsin 2 gene (PfPM2) that can be used in countries where P. falciparum is endemic to enhance molecular surveillance.

      6. 3-dimensional printing with nano-enabled filaments releases polymer particles containing carbon nanotubes into airExternal
        Stefaniak AB, Bowers LN, Knepp AK, Virji MA, Birch EM, Ham JE, Wells JR, Qi C, Schwegler-Berry D, Friend S, Johnson AR, Martin SB, Qian Y, LeBouf RF, Birch Q, Hammond D.
        Indoor Air. 2018 Aug 13.

        Fused deposition modeling (FDM() ) 3-dimensional printing uses polymer filament to build objects. Some polymer filaments are formulated with additives, though it is unknown if they are released during printing. Three commercially-available filaments that contained carbon nanotubes (CNTs) were printed with a desktop FDM() 3-D printer in a chamber while monitoring total particle number concentration and size distribution. Airborne particles were collected on filters and analyzed using electron microscopy. Carbonyl compounds were identified by mass spectrometry. The elemental carbon content of the bulk CNT-containing filaments was 1.5 to 5.2 wt%. CNT-containing filaments released up to 10(10) ultrafine (d <100 nm) particles/g printed and 10(6) to 10(8) respirable (d ~0.5 to 2 mum) particles/g printed. From microscopy, 1% of the emitted respirable polymer particles contained visible CNTs. Carbonyl emissions were observed above the limit of detection (LOD) but were below the limit of quantitation (LOQ). Modeling indicated that for all filaments, the average proportional lung deposition of CNT-containing polymer particles was 6.5%, 5.7%, and 7.2% for the head airways, tracheobronchiolar, and pulmonary regions, respectively. If CNT-containing polymer particles are hazardous, it would be prudent to control emissions during use of these filaments. This article is protected by copyright. All rights reserved.

      7. In vitro evaluation of the toxicity and underlying molecular mechanisms of Janus Fe3 O4 -TiO2 nanoparticles in human liver cellsExternal
        Su H, Li Z, Lazar L, Alhamoud Y, Song X, Li J, Wang Y, Fiati Kenston SS, Lqbal MZ, Wu A, Li Z, Hua Q, Ding M, Zhao J.
        Environ Toxicol. 2018 Aug 11.

        Recent studies show that Janus Fe3 O4 -TiO2 nanoparticles (NPs) have potential applications as a multifunctional agent of magnetic resonance imaging (MRI) and photodynamic therapy (PDT) for the diagnosis and therapy of cancer. However, little work has been done on their biological effects. To evaluate the toxicity and underlying molecular mechanisms of Janus Fe3 O4 -TiO2 nanoparticles, an in vitro study using a human liver cell line HL-7702 cells was conducted. For comparison, the Janus Fe3 O4 -TiO2 NPs parent material TiO2 NPs was also evaluated. Results showed that both Fe3 O4 -TiO2 NPs and TiO2 NPs decreased cell viability and ATP levels when applied in treatment, but increased malonaldehyde (MDA) and reactive oxygen species (ROS) generation. Mitochondria JC-1 staining assay showed that mitochondrial membrane permeability injury occurred in both NPs treated cells. Cell viability analysis showed that TiO2 NPs induced slightly higher cytotoxicity than Fe3 O4 -TiO2 NPs in HL7702 cells. Western blotting indicated that both TiO2 NPs and Fe3 O4 -TiO2 NPs could induce apoptosis, inflammation, and carcinogenesis related signal protein alterations. Comparatively, Fe3 O4 -TiO2 NPs induced higher signal protein expressions than TiO2 NPs under a high treatment dose. However, under a low dose (6.25 mug/cm(2) ), neither NPs had any significant toxicity on HL7702 cells. In addition, our results suggest both Fe3 O4 -TiO2 NPs and TiO2 NPs could induce oxidative stress and have a potential carcinogenetic effect in vitro. Further studies are needed to elaborate the detailed mechanisms of toxicity induced by a high dose of Fe3 O4 -TiO2 NPs.

    • Maternal and Child Health
      1. Family history of immune conditions and autism spectrum and developmental disorders: Findings from the Study to Explore Early DevelopmentExternal
        Croen LA, Qian Y, Ashwood P, Daniels JL, Fallin D, Schendel D, Schieve LA, Singer AB, Zerbo O.
        Autism Res. 2018 Aug 10.

        Numerous studies have reported immune system disturbances in individuals with autism and their family members; however, there is considerable variability in findings with respect to the specific immune conditions involved, their timing, and the family members affected and little understanding of variation by autism subphenotype. Using data from the Study to Explore Early Development (SEED), a multi-site case-control study of children born 2003-2006 in the United States, we examined the role of family history of autoimmune diseases, asthma, and allergies in autism spectrum disorder (ASD) as well as other developmental disorders (DD). We investigated maternal immune conditions during the pregnancy period, as well as lifetime history of these conditions in several family members (mother, father, siblings, and study child). Logistic regression analyses included 663 children with ASD, 984 children with DD, and 915 controls ascertained from the general population (POP). Maternal history of eczema/psoriasis and asthma was associated with a 20%-40% increased odds of both ASD and DD. Risk estimates varied by specific ASD subphenotypes in association with these exposures. In addition, children with ASD were more likely to have a history of psoriasis/eczema or allergies than POP controls. No association was observed for paternal history or family history of these immune conditions for either ASD or DD. These data support a link between maternal and child immune conditions and adverse neurodevelopmental outcomes, and further suggest that associations may differ by ASD phenotype of the child. Autism Res 2018., (c) 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Using data from a large multi-site study in the US-the Study to Explore Early Development-we found that women with a history of eczema/psoriasis and asthma are more likely to have children with ASD or DD. In addition, children with ASD are more likely to have a history of psoriasis/eczema or allergies than typically developing children. These data support a link between maternal and child immune conditions and adverse neurodevelopmental outcomes.

      2. Improving quality measurement while reducing costs helps public health programs identify and better support critical aspects of the care and services delivered to the patients they serve. This is true for state-based early hearing detection and intervention (EHDI) programs as they strive to develop robust clinical quality measures to help track the quality of hearing health services provided during the EHDI processes. Leveraging today’s electronic health records and public health surveillance system functionalities, state reporting requirements facilitate and yield efficient collection and analysis of data for quality measurement. In this study, we tested three EHDI quality measures endorsed by the National Quality Forum using a retrospective sample of more than 1,100,000 newborns from 3 states using electronic health data available in the state EHDI Information Systems (EHDI-IS). The results of the analysis reported herein from a large multi-state cohort provide a “real life” benchmark for future quality improvement projects and of where EHDI stands today. Reflecting on these findings, suggestions are posed for enhancing the EHDI quality measures in future updates.

      3. Early life influences on child weight outcomes in the Study to Explore Early DevelopmentExternal
        Kral TV, Chittams J, Bradley CB, Daniels JL, DiGuiseppi CG, Johnson SL, Pandey J, Pinto-Martin JA, Rahai N, Ramirez A, Schieve LA, Thompson A, Windham G, York W, Young L, Levy SE.
        Autism. 2018 Aug 13:1362361318791545.

        We examined associations between child body mass index at 2-5 years and maternal pre-pregnancy body mass index, gestational weight gain, and rapid weight gain during infancy in children with autism spectrum disorder, developmental delays, or population controls. The Study to Explore Early Development is a multi-site case-control study of children, aged 2-5 years, classified as autism spectrum disorder ( n = 668), developmental delays ( n = 914), or population controls ( n = 884). Maternal gestational weight gain was compared to the Institute of Medicine recommendations. Rapid weight gain was a change in weight-for-age z-scores from birth to 6 months > 0.67 standard deviations. After adjusting for case status, mothers with pre-pregnancy overweight/obesity were 2.38 times (95% confidence interval: 1.96-2.90) more likely, and mothers who exceeded gestational weight gain recommendations were 1.48 times (95% confidence interval: 1.17-1.87) more likely, to have an overweight/obese child than other mothers ( P < 0.001). Children with autism spectrum disorder showed the highest frequency of rapid weight gain (44%) and were 3.47 times (95% confidence interval: 1.85-6.51) more likely to be overweight/obese as children with autism spectrum disorder without rapid weight gain ( P < 0.001). Helping mothers achieve a healthy pre-pregnancy body mass index and gestational weight gain represent important targets for all children. Healthy infant growth patterns carry special importance for children at increased risk for an autism spectrum disorder diagnosis.

      4. Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case studyExternal
        Sami S, Amsalu R, Dimiti A, Jackson D, Kenyi S, Meyers J, Mullany LC, Scudder E, Tomczyk B, Kerber K.
        BMC Pregnancy Childbirth. 2018 Aug 10;18(1):325.

        BACKGROUND: Targeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework. METHODS: We used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period. RESULTS: Key bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns. CONCLUSIONS: Improving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.

    • Occupational Safety and Health
      1. An interactive tutorial on using a mouse for first-time computer users was developed as part of a training CD-ROM tailored for Latino immigrant workers in trenching and excavation. It was designed for Spanish-speaking users with varying levels of formal education. The tutorial was tested in focus groups with workers who had little or no previous experience using a computer. Findings revealed that while users with less than a fourth-grade education and/or low proficiency in Spanish had some difficulties with the tutorial, they still scored above 67 percent on the performance evaluation; participants with at least a fourth-grade education (the majority) completed it with minimal assistance and scored 80%-100% on the performance evaluation. Feedback from participant focus groups following the computer sessions supported these findings. The results of this study suggest that computer-based training may be able to be made accessible for low computer literacy Latino immigrant workers, if it is tailored to their needs.

      2. Introduction: Workers’ compensation (WC) insurers offer services and programs for prospective client selection and insured client risk control (RC) purposes. Toward these aims, insurers collect employer data that may include information on types of hazards present in the workplace, safety and health programs and controls in place to prevent injury/illness, and return-to-work programs to reduce injury/illness severity. Despite the potential impact of RC systems on workplace safety and health and the use of RC data in guiding prevention efforts, few research studies on the types of RC services provided to employers or the RC data collected have been published in the peer-reviewed literature. Methods: Researchers conducted voluntary interviews with nine private and state-fund WC insurers to collect qualitative information on RC data and systems. Results: Insurers provided information describing their RC data, tools, and practices. Unique practices as well as similarities including those related to RC services, policyholder goals, and databases were identified. Conclusions: Insurers collect and store extensive RC data, which have utility for public health research for improving workplace safety and health. Practical applications: Increased public health understanding of RC data and systems and an identification of key collaboration opportunities between insurers and researchers will facilitate increased use of RC data for public health purposes.

      3. Occupational traumatic injuries among offshore seafood processors in Alaska, 2010-2015External
        Syron LN, Lucas DL, Bovbjerg VE, Case S, Kincl L.
        J Safety Res. 2018 ;66:169-178.

        Introduction: The U.S. Coast Guard and Federal Occupational Safety and Health Administration have identified the Alaskan offshore seafood processing industry as high-risk. This study used Coast Guard injury reports to describe patterns of traumatic injury among offshore seafood processors, as well as identify modifiable hazards. Methods: From the reports, we manually reviewed and abstracted information on the incident circumstances, injury characteristics and circumstances, and vessel. Traumatic injury cases were coded using the Occupational Injury and Illness Classification System, and a Work Process Classification System. Descriptive statistics characterized worker demographics, injuries, and fleets. Results: One fatal and 304 nonfatal injuries among processors were reported to the Coast Guard during 2010-2015 across multiple fleets of catcher-processor and mothership vessels. The most frequently occurring injuries were: by nature of injury, sprains/strains/tears (75, 25%), contusions (50, 16%), and fractures (45, 15%); by body part affected, upper extremities (121, 40%), and trunk (75, 25%); by event/exposure resulting in injury, contact with objects and equipment (150, 49%), and overexertion and bodily reaction (76, 25%); and by source of injury, processing equipment and machinery (85, 28%). The work processes most frequently associated with injuries were: processing seafood on the production line (68, 22%); stacking blocks/bags of frozen product (50, 17%); and repairing/maintaining/cleaning factory equipment (28, 9%). Conclusions: Preventing musculoskeletal injuries, particularly to workers’ upper extremities and trunks, is paramount. Some injuries, such as serious back injuries, intracranial injuries, and finger crushing or amputations, had the potential to lead to disability. Practical applications: Safety professionals and researchers can use the study findings to inform future intervention efforts in this industry. Hazard control measures should target: (a) overexertion from lifting and lowering objects and equipment; (b) equipment and boxes falling and striking workers; (c) workers being caught in running machinery during regular operations; and (d) slips, trips, and falls.

    • Occupational Safety and Health – Mining
      1. Refuge alternatives provide shelter to miners trapped underground during a disaster. Manufacturers must demonstrate that their refuge alternatives meet the U.S. Mine Safety and Health Administration (MSHA) requirements for oxygen supply, carbon dioxide removal, and management of heat from the occupants and mechanical/chemical systems. In this study, miner size and activity level were used to determine the metabolic heat rate, oxygen requirements and carbon dioxide generation that are representative of miners in a refuge situation. A convenience sample of 198 male miners was used for the distribution of current U.S. coal miners, and the composite 95th percentile height and weight were determined to be 193 cm (76 in.) and 133 kg (293 lb). The resting metabolic rate (RMR) was determined to be representative of activity level in a refuge alternative. The highest likely metabolic heat generation ranged from 113 to 134 W, depending on occupancy. The highest required oxygen supply and carbon dioxide removal were estimated to be 23 L (0.81 cu ft) of oxygen per hour per person and 20 L (0.71 cu ft) of carbon dioxide per hour per person, which means the margin of safety is 50 percent or more compared with the MSHA requirements. The information on metabolic heat generation can be used to assess refuge alternative thermal environments by testing or simulation. The required oxygen supply and carbon dioxide removal can be used to assess refuge alternative requirements.

      2. Diesel particulate matter (DPM) is an occupational health hazard in underground mines. It generally occurs in the submicrometer size range and is often present in the mine atmosphere with significant concentrations of dust particles that tend to occur in the supramicrometer size range. As dust can interfere with analytical methods to measure DPM, it is often removed from a sample stream using an impactor-type size selector such as the DPM impactor (DPMI). Because the DPMI physically removes oversized particles from the stream, its performance may be gradually reduced with aging. Sharp-cut cyclones (SCCs) are an alternative size selector for DPM sampling applications, with a major advantage that, by design, they should not be susceptible to rapid aging. This paper presents the results of a field study designed to compare the performance of aged versus new/clean DPMIs and SCCs in an underground mine. DPMI aging resulted in clogging of the device and, eventually, a reduction of its effective particle cut size, but when sample flow rate was maintained, DPM sample mass collection was not affected until significant aging had occurred. Under the conditions of this study, the effects of SCC aging were observed to be minimal at the end of the study period.

    • Parasitic Diseases
      1. Seroprevalence of antibodies to Toxocara species in the United States and associated risk factors, 2011-2014External
        Liu EW, Chastain HM, Shin SH, Wiegand RE, Kruszon-Moran D, Handali S, Jones JL.
        Clin Infect Dis. 2018 Jan 6;66(2):206-212.

        Background: Toxocariasis results from infection with larval stages of a dog and cat intestinal nematode and causes human morbidity. The current United States estimate of Toxocara exposure is 13.9% (National Health and Nutrition Examination Survey [NHANES] III [1988-1994]). Methods: We used a multiplex bead-based assay (Tc-CTL-1MBA) with purified Toxocara canis antigen to estimate Toxocara antibody seroprevalence in serum of 13 509 persons aged >/=6 years from NHANES 2011-2014 and identified seropositivity risk factors. We tested a subset of 500 samples with the T. canis enzyme immunoassay used in NHANES III to estimate prior seroprevalence had samples from NHANES III been tested by Tc-CTL-1MBA. Results: The age-standardized estimate of Toxocara seroprevalence was 5.0% (95% confidence interval [CI], 4.2%-5.8%), lower than previously reported even after adjusting for increased Tc-CTL-1MBA specificity. Risk factors for seropositivity from multiple logistic regression were older age, non-Hispanic black/Hispanic origin, male sex, living below poverty level, households with >/=0.5 persons per room, less than college education, and birth outside of the United States. Conclusions: Toxocara seroprevalence estimates in 2011-2014 were lower than in a study from NHANES III (1988-1994), but seropositivity risk factors remained the same and should continue to be the focus of prevention efforts.

    • Physical Activity
      1. Environmental supports for physical activity, National Health Interview Survey-2015External
        Whitfield GP, Carlson SA, Ussery EN, Watson KB, Adams MA, James P, Brownson RC, Berrigan D, Fulton JE.
        Am J Prev Med. 2018 Feb;54(2):294-298.

        INTRODUCTION: The Guide to Community Preventive Services recommends combined built environment approaches to increase physical activity, including new or enhanced transportation infrastructure (e.g., sidewalks) and land use and environmental design interventions (e.g., close proximity of local destinations). The aim of this brief report is to provide nationally representative estimates of two types of built environment supports for physical activity: near-home walkable infrastructure and destinations, from the 2015 National Health Interview Survey. METHODS: Adults (n=30,453) reported the near-home presence of walkable transportation infrastructure (roads, sidewalks, paths, or trails where you can walk; and whether most streets have sidewalks) and four walkable destination types (shops, stores, or markets; bus or transit stops; movies, libraries, or churches; and places that help you relax, clear your mind, and reduce stress). The prevalence of each, and the count of destination types, was calculated (in 2017) and stratified by demographic characteristics. RESULTS: Overall, 85.1% reported roads, sidewalks, paths, or trails on which to walk, and 62.6% reported sidewalks on most streets. Among destinations, 71.8% reported walkable places to relax; followed by shops (58.0%); transit stops (53.2%); and movies, libraries, or churches (47.5%). For most design elements, prevalence was similar among adults aged 18-24 and 25-34 years, but decreased with age >35 years. Adults in the South reported a lower prevalence of all elements compared with those in other Census regions. CONCLUSIONS: Many U.S. adults report walkable built environment elements near their home; future efforts might target areas with many older adult residents or those living in the South.

    • Public Health Leadership and Management
      1. Developing a public health pipeline: Key components of a public health leadership programExternal
        Flores AL, Risley K, Quintana K.
        Prev Med Community Health. 2018 ;2018.

        Thirty percent of federal public health employees were retirement eligible in September 2017. Further, at the state public health level, as indicated in the recent Public Health Workforce Interests and Needs Survey (PH WINS), an estimated 25% of employees are planning to retire before 2020 with an additional 18% intending to leave their organizations within one year. Due to these workforce changes, there is an urgent need for public health organizations to examine how they are ensuring a talent pool from which leaders can emerge. As a large federal public health agency, the Centers for Disease Control and Prevention (CDC) faces the challenge of providing leadership development to staff. Factors were examined that agency leaders identified as key components of a leadership development program to transition scientific public health staff into supervisory leadership roles. While many factors contribute to leadership development, participants more often identified training, provision of opportunities, mentors, and identification of high potential employees as key components of a leadership develop program. With the need to develop organizational leaders to be ready when vacancies become available, findings from this study can inform the development and implementation of public health leadership development programs.

      2. CONTEXT: Leaders of government agencies are responsible for stewardship over taxpayer investments. Stewardship strengthens agency performance that is critical to improving population health. Most industries, including health care, and public enterprises, such as education, have policies for uniform data reporting and financial systems for the application of theoretical analytical techniques to organizations and entire systems. However, this is not a mainstreamed practice in local and state government public health. PROGRAM: The Public Health Uniform National Data System (PHUND$) is a financial information system for local health departments that advances the application of uniform practices to close financial analytical gaps. A 10-year retrospective overview on the development, implementation, and utility of PHUND$ is provided and supported by documented program and agency improvements to validate the analytical features and demonstrate a best practice. RESULTS: Benefits found from utilizing PHUND$ included reducing financial risks, supporting requests for increased revenues, providing comparative analysis, isolating drivers of costs and deficits, increasing workforce financial management skills, enhancing decision-making processes, and fostering agency sustainability to support continuous improvements in quality and population health. The PHUND$ financial data definitions in the data dictionary provided the structure needed for standardized data collection and confirmed the feasibility of a standardized public health chart of accounts. CONCLUSION: PHUND$ analysis provided evidence on the relationship between financial and operational performance, as well as informing strategies for managing risks and improving quality. Such analysis is critical to identifying financial and operational problems and essential to mitigating financial crisis, avoiding disruption of services, and fostering agency sustainability. PHUND$ additionally serves as an instrument that can guide development of standards that measure for agency sound financial management systems.

    • Reproductive Health
      1. Stakeholder education for community-wide health initiatives: A focus on teen pregnancy preventionExternal
        Finley C, Suellentrop K, Griesse R, House LD, Brittain A.
        Health Promot Pract. 2018 Jan;19(1):38-50.

        Teen pregnancies and births continue to decline due in part to implementation of evidence-based interventions and clinical strategies. While local stakeholder education is also thought to be critical to this success, little is known about what types of strategies work best to engage stakeholders. With the goal of identifying and describing evidence-based or best practice strategies for stakeholder education in community-based public health initiatives, we conducted a systematic literature review of strategies used for effective stakeholder education. Over 400 articles were initially retrieved; 59 articles met inclusion criteria. Strategies were grouped into four steps that communities can use to support stakeholder education efforts: identify stakeholder needs and resources, develop a plan, develop tailored and compelling messaging, and use implementation strategies. These strategies lay a framework for high-quality stakeholder education. In future research, it is important to prioritize evaluating specific activities taken to raise awareness, educate, and engage a community in community-wide public health efforts.

      2. Severe maternal morbidity at delivery and risk of hospital encounters within 6 weeks and 1 year postpartumExternal
        Harvey EM, Ahmed S, Manning SE, Diop H, Argani C, Strobino DM.
        J Womens Health (Larchmt). 2018 Feb;27(2):140-147.

        BACKGROUND: Little is known about the impact of severe maternal morbidity (SMM) after delivery. We examined the risk of rehospitalization in the first year postpartum among deliveries to women with and without SMM. MATERIALS AND METHODS: We used the Pregnancy to Early Life Longitudinal data system, in which vital birth/fetal death records were linked with hospital delivery discharge data and subsequent nondelivery hospitalization data, including observational stays (OSs) and in-patient stays (hospital discharge [HD]) for Massachusetts residents during 2002-2011. We excluded deliveries to women with preexisting chronic conditions: hypertension, diabetes, asthma, and autoimmune conditions for a final sample of 685,228 deliveries. Multivariable log binomial regression with generalized estimating equations modeled the relative risk (RR) of hospital encounters 6 weeks and 1 year postpartum. RESULTS: The rate of SMM was 99 per 10,000 deliveries. In the first year postpartum, 2.8% of deliveries to women without chronic medical conditions experienced at least one HD encounter and 1.0% at least one OS encounter. The adjusted relative risk (aRR) of any HD encounter for deliveries with SMM was 2.48 (95% confidence interval [CI]: 2.20-2.80) within 6 weeks postpartum and 2.04 (95% CI: 1.87-2.23) within 1 year. For OS encounters, aRRs among deliveries with SMM at delivery were 2.47 (95% CI: 1.94-3.14) in the first 6 weeks and 1.69 (95% CI: 1.43-2.01) in 1 year. CONCLUSIONS: In Massachusetts, SMM increased the risk of rehospitalization in the first year postpartum among deliveries to women without chronic medical conditions.

      3. Missed opportunities to address pregnancy prevention with young men in primary careExternal
        Wheeler NJ, Pilgrim N, Jennings JM, Sanders R, Page KR, Loosier PS, Dittus PJ, Marcell AV.
        Clin Pediatr (Phila). 2018 Aug 10:9922818793351.

        Young men (aged 15-24 years) have pregnancy prevention needs, yet little is known about whether they perceive they learn about pregnancy prevention in primary care. A sample of 190 young men seen in primary care in one city from April 2014 to September 2016 were assessed on perceived learning about pregnancy prevention, background and visit characteristics, pregnancy prevention care receipt, and contraception needs at last sex. The majority of participants were non-Hispanic black (92%), aged 15 to 19 years (54%), seen for a physical examination (52%), and established patients (87%). Few participants perceived they learned about pregnancy prevention (32%), regardless of sexual activity (33% among sexually active participants, 26% among never sexually active). Poisson regression models determined that perceived learning about pregnancy prevention was independently associated with young men’s pregnancy prevention care receipt and contraception needs at last sex. Findings highlight the need to improve providers’ delivery of pregnancy prevention services to young men.

    • Social and Behavioral Sciences
      1. Because little is known about the mental health status of Syrian refugees in the United States, we conducted a survey among a convenience sample of those resettled in Atlanta between March 2011 and 2017. Though home visits, we delivered a questionnaire including standardized instruments (HSCL25 and PTSD-8) to assess symptoms of anxiety, depression and Posttraumatic Stress Disorder. We found high rates of anxiety (60%), depression (44%) and Posttraumatic Stress Disorder (84%) symptoms; however, only 20% of participants had seen a mental health professional. Reported reasons for not seeking professional help were lack of transportation and access to information. Findings of this survey indicate the high burden of mental health symptoms and the need for services to the study population. A longitudinal study with a larger sample size would improve the understanding of mental health needs and resilience factors of Syrian refugees resettled in the US.

    • Substance Use and Abuse
      1. Patterns of e-cigarette use frequency – National Adult Tobacco Survey, 2012-2014External
        Sharapova SR, Singh T, Agaku IT, Kennedy SM, King BA.
        Am J Prev Med. 2018 Feb;54(2):284-288.

        INTRODUCTION: Accounting for occasional or intermittent e-cigarette use has yielded higher estimates of current use among U.S. adults. However, frequency of e-cigarette use by population subgroups is not well described. This study assessed e-cigarette use frequency by sociodemographic characteristics and other tobacco product use among U.S. adults. METHODS: This study analyzed combined data from the 2012-2013 (n=60,192) and 2013-2014 (n=75,233) National Adult Tobacco Survey, a telephone-based survey of U.S. adults aged >/=18 years, to assess frequency of e-cigarette use (daily, some days, rarely) by sex, age, race/ethnicity, education, annual household income, U.S. region, marital status, sexual orientation, and cigarette smoking and other tobacco product use (cigars, cigarillos, little filtered cigars; traditional pipes; water pipes; and chewing tobacco, snuff, dip, snus, and dissolvable tobacco products). Analyses took place in 2016. RESULTS: Among current e-cigarette users, 19.3% used daily, 29.3% used some days, and 51.4% used rarely. Daily use was lowest among younger adults, Hispanics, and those who were single, never married, or not living with a partner; and greatest among non-Hispanic Asians (p<0.0001). Among current e-cigarette users, 25.3% were cigarette-only smokers, 52.8% smoked cigarettes and used other tobacco products, 5.5% used other tobacco products only, 6.5% were former cigarette-only smokers, 6.7% were former users of cigarettes and other tobacco products, 1.3% were former other tobacco product users only, and 1.8% never used cigarettes or other tobacco products. CONCLUSIONS: E-cigarette use frequency varies by sociodemographic characteristics and other tobacco use. Further surveillance, particularly related to frequency of e-cigarette use and its impact on cigarette cessation, could inform public health policy, planning, and practice.

      2. Screening for alcohol misuse: Practices among U.S. primary care providers, DocStyles 2016External
        Tan CH, Hungerford DW, Denny CH, McKnight-Eily LR.
        Am J Prev Med. 2018 Feb;54(2):173-180.

        INTRODUCTION: Excessive alcohol use is associated with car crashes, violence, and multiple disease conditions, including fetal alcohol spectrum disorders. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care providers screen all adults and conduct brief counseling interventions with those who misuse alcohol. The USPSTF prefers use of three screening tools that measure alcohol consumption (Alcohol Use Disorders Identification Test, Alcohol Use Disorders Identification Test-Consumption, and National Institute on Alcohol Abuse and Alcoholism Single Question) because these tools detect the full spectrum of alcohol misuse in adults. This study estimated the prevalence of primary care provider screening practices for alcohol misuse and examined factors associated with using a USPSTF-preferred screening tool. METHODS: In 2016, a cross-sectional analysis was conducted on self-reported 2016 DocStyles data to estimate the prevalence of different screening tools used by 1,506 primary care providers-family practitioners, internists, obstetrician/gynecologists, and nurse practitioners. Adjusted prevalence ratios were calculated using logistic regression to examine the association between provider attributes and use of USPSTF-preferred screening tools. RESULTS: In this study, 96% of providers reported screening patients for alcohol misuse. Among those that screened, 38% used a USPSTF-preferred screening tool. Provider specialty, awareness of USPSTF guidelines, and mode of administering screening tool were associated with using a preferred screening tool. CONCLUSIONS: Although most primary care providers reported screening for alcohol misuse, about two thirds did not use a tool capable of detecting the full spectrum of alcohol misuse. Using suitable screening tools will better identify patients who misuse alcohol and increase the opportunity for appropriate intervention, ultimately helping to reduce the burden from the many conditions associated with excessive alcohol consumption.

    • Veterinary Medicine
      1. Pathology in practiceExternal
        Edwards EE, Birch SM, Hoppes SM, Keating MK, Stoica G.
        J Am Vet Med Assoc. 2018 Aug 15;253(4):423-426.

        [No abstract]

    • Zoonotic and Vectorborne Diseases
      1. Zika virus as a sexually transmitted pathogenExternal
        Mead PS, Hills SL, Brooks JT.
        Curr Opin Infect Dis. 2018 Feb;31(1):39-44.

        PURPOSE OF REVIEW: Zika virus has recently emerged from an obscure mosquito-borne pathogen to an international public health concern. It is the first viral agent newly demonstrated to cause birth defects in several decades, and it is the only arbovirus now known to be transmitted sexually. The purpose of this review is to provide an overview of current understanding of sexual transmission of Zika virus and its possible clinical and public health consequences. RECENT FINDINGS: Sexual transmission of Zika virus has been reported from at least 13 countries without simultaneous mosquito-borne transmission; it is undoubtedly also occurring in countries with active arthropod transmission. Most published cases involve transmission from symptomatically infected men to women partners. Nevertheless, transmission from a symptomatic man to another man, from a symptomatic woman to a man, and from an asymptomatic man to a woman has also been reported. Sexual transmission has occurred before symptom onset, during illness, and after resolution of the source partner’s symptoms. With the exception of a woman who developed symptomatic infection 44 days after onset of her husband’s illness, nearly all instances reported to date have occurred within 20 days of the source partner’s illness. Zika virus RNA has been detected in semen, saliva, blood, urine, and vaginal and cervical secretions; the length of time during which RNA can be detected varies widely across different body fluids but is especially lengthy in semen. Although semen has been found to contain ZIKV RNA for more than 180 days after illness onset, only a small proportion of samples with detectable RNA yield replicative virus whenever cultured. SUMMARY: Public health agencies have promulgated interim recommendations to prevent sexual transmission of Zika virus; however, much remains unknown regarding the duration of contagiousness and risk factors for transmission. Given the risk for birth defects, the greatest concern is for transmission of the virus to women who are pregnant or attempting to become pregnant. To prevent sexual transmission in general, couples are advised to use condoms or not have sex for at least 6 months from the start of the male partner’s symptoms or the date he was diagnosed with Zika or after he has returned from an area with risk of ZIKV infection. Women who have symptomatic ZIKV infection or have traveled to an area of risk are advised to use condoms or avoid sex for 8 weeks from the start of the woman’s symptoms or the date she was diagnosed with Zika or after the woman returns from the area of risk.

      2. Sero-prevalence of yellow fever and related Flavi viruses in Ethiopia: a public health perspectiveExternal
        Mengesha Tsegaye M, Beyene B, Ayele W, Abebe A, Tareke I, Sall A, Yactayo S, Shibeshi ME, Staples E, Belay D, Lilay A, Alemu A, Alemu E, Kume A, H. Mariam A, Ronveaux O, Tefera M, Kassa W, Bekele Weyessa A, Jima D, Kebede A, Tayachew A.
        BMC Public Health. 2018 Aug 14;18(1):1011.

        BACKGROUND: Yellow fever (YF) is a viral hemorrhagic fever, endemic in the tropical forests of Africa and Central and South America. The disease is transmitted by mosquitoes infected with the yellow fever virus (YFV). Ethiopia was affected by the largest YF outbreak since the vaccination era during 1960-1962. The recent YF outbreak occurred in 2013 in Southern part of the country. The current survey of was carried out to determine the YF seroprevalence so as to make recommendations from YF prevention and control in Ethiopia. METHODOLOGY: A multistage cluster design was utilized. Consequently, the country was divided into 5 ecological zones and two sampling towns were picked per zone randomly. A total of 1643 serum samples were collected from human participants. The serum samples were tested for IgG antibody against YFV using ELISA. Any serum sample testing positive by ELISA was confirmed by plaque reduction neutralization test (PRNT). In addition, differential testing was performed for other flaviviruses, namely dengue, Zika and West Nile viruses. RESULT: Of the total samples tested, 10 (0.61%) were confirmed to be IgG positive against YFV and confirmed with PRNT. Nine (0.5%) samples were antibody positive for dengue virus, 15(0.9%) forWest Nile virus and 7 (0.4%) for Zika virus by PRNT. Three out of the five ecological zones namely zones 1, 3 and 5 showed low levels (< 2%) of IgG positivity against YFV. A total of 41(2.5%) cases were confirmed to be positive for one of flaviviruses tested. CONCLUSION: Based on the seroprevalence data, the level of YFV activity and the risk of a YF epidemic in Ethiopia are low. However additional factors that could impact the likelihood of such an epidemic occurring should be considered before making final recommendations for YF prevention and control in Ethiopia. Based on the results of the serosurvey and other YF epidemic risk factors considered, a preventive mass vaccination campaign is not recommended, however the introduction of YF vaccine in routine EPI is proposed nationwide, along with strong laboratory based YF surveillance.

      3. Identification of urine metabolites as biomarkers of early Lyme diseaseExternal
        Pegalajar-Jurado A, Fitzgerald BL, Islam MN, Belisle JT, Wormser GP, Waller KS, Ashton LV, Webb KJ, Delorey MJ, Clark RJ, Molins CR.
        Sci Rep. 2018 Aug 15;8(1):12204.

        Metabolites detectible in human biofluids are attractive biomarkers for the diagnosis of early Lyme disease (ELD), a vector-borne infectious disease. Urine represents an easily obtained clinical sample that can be applied for diagnostic purposes. However, few studies have explored urine for biomarkers of ELD. In this study, metabolomics approaches were applied to evaluate small molecule metabolites in urine from patients with ELD (n = 14), infectious mononucleosis (n = 14) and healthy controls (n = 14). Metabolic biosignatures for ELD versus healthy controls and ELD versus infectious mononucleosis were generated using untargeted metabolomics. Pathway analyses and metabolite identification revealed the dysregulation of several metabolic processes in ELD as compared to healthy controls or mononucleosis, including metabolism of tryptophan. Linear discriminant analyses demonstrated that individual metabolic biosignatures can correctly discriminate ELD from the other patient groups with accuracies of 71 to 100%. These data provide proof-of-concept for use of urine metabolites as biomarkers for diagnostic classification of ELD.

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

Page last reviewed: January 31, 2019