Volume 10, Issue 34, September 11, 2018

CDC Science Clips: Volume 10, Issue 34, September 11, 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.
    • Communicable Diseases
      • Bacterial factors that predict relapse after tuberculosis therapyExternal
        Colangeli R, Jedrey H, Kim S, Connell R, Ma S, Chippada Venkata UD, Chakravorty S, Gupta A, Sizemore EE, Diem L, Sherman DR, Okwera A, Dietze R, Boom WH, Johnson JL, Mac Kenzie WR, Alland D.
        N Engl J Med. 2018 Aug 30;379(9):823-833.

        BACKGROUND: Approximately 5% of patients with drug-susceptible tuberculosis have a relapse after 6 months of first-line therapy, as do approximately 20% of patients after 4 months of short-course therapy. We postulated that by analyzing pretreatment isolates of Mycobacterium tuberculosis obtained from patients who subsequently had a relapse or were cured, we could determine any correlations between the minimum inhibitory concentration (MIC) of a drug below the standard resistance breakpoint and the relapse risk after treatment. METHODS: Using data from the Tuberculosis Trials Consortium Study 22 (development cohort), we assessed relapse and cure isolates to determine the MIC values of isoniazid and rifampin that were below the standard resistance breakpoint (0.1 mug per milliliter for isoniazid and 1.0 mug per milliliter for rifampin). We combined this analysis with clinical, radiologic, and laboratory data to generate predictive relapse models, which we validated by analyzing data from the DMID 01-009 study (validation cohort). RESULTS: In the development cohort, the mean (+/-SD) MIC of isoniazid below the breakpoint was 0.0334+/-0.0085 mug per milliliter in the relapse group and 0.0286+/-0.0092 mug per milliliter in the cure group, which represented a higher value in the relapse group by a factor of 1.17 (P=0.02). The corresponding MIC values of rifampin were 0.0695+/-0.0276 and 0.0453+/-0.0223 mug per milliliter, respectively, which represented a higher value in the relapse group by a factor of 1.53 (P<0.001). Higher MIC values remained associated with relapse in a multivariable analysis that included other significant between-group differences. In an analysis of receiver-operating-characteristic curves of relapse based on these MIC values, the area under the curve (AUC) was 0.779. In the development cohort, the AUC in a multivariable model that included MIC values was 0.875. In the validation cohort, the MIC values either alone or combined with other patient characteristics were also predictive of relapse, with AUC values of 0.964 and 0.929, respectively. The use of a model score for the MIC values of isoniazid and rifampin to achieve 75.0% sensitivity in cross-validation analysis predicted relapse with a specificity of 76.5% in the development cohort and a sensitivity of 70.0% and a specificity of 100% in the validation cohort. CONCLUSIONS: In pretreatment isolates of M. tuberculosis with decrements of MIC values of isoniazid or rifampin below standard resistance breakpoints, higher MIC values were associated with a greater risk of relapse than lower MIC values. (Funded by the National Institute of Allergy and Infectious Diseases.).

      • Low HIV testing rates among U.S. women who report anal sex and other HIV sexual risk behaviors, 2011-2015External
        Evans ME, Tao G, Porter SE, Gray SC, Huang YA, Hoover KW.
        Am J Obstet Gynecol. 2018 Aug 22.

        OBJECTIVE: In 2016, 19% of HIV diagnoses were in women. About 40% of HIV infections in women aged 18-34 years have been attributed to anal sex, suggesting that women who report high risk behaviors such as anal sex might benefit from HIV testing and prevention with pre-exposure prophylaxis (PrEP). In this analysis, we estimated HIV testing rates among women who reported anal sex. METHODS: We analyzed data from the 2011-2015 National Survey of Family Growth to estimate the proportion of sexually active, nonpregnant U.S. women aged 15-44 years who had an HIV test within the past year, stratified by those who reported anal sex and other risk factors, including >/=2 sexual partners, condomless sex with a new partner or multiple partners, gonorrhea in the past year, or any history of syphilis. RESULTS: Overall, 7.9 million (18.7%) of 42.4 million sexually active, nonpregnant U.S. women reported an HIV test within the past year. Among 42.4 million sexually active women, 9.0 million (20.1%) reported they had anal sex in the past year. Among these 9.0 million women, 19.2% reported that their providers asked about their type of intercourse and 20.1% reported an HIV test within the past year. Overall, HIV testing was higher among women who reported anal sex and reported that their providers asked about type of sex than those whose provider did not ask (37.8% vs. 15.9%; p-value<0.001). HIV testing in the past year was higher for women with other risk behaviors compared to anal sex, ranging from 35.8% to 47.2%. CONCLUSIONS: Overall, HIV testing rates within the past year were low among women with sexual behaviors that increase their risk of acquiring HIV, and especially low among those who reported anal sex. Early detection and treatment of HIV, and HIV prevention with PrEP, are effective health services that protect women’s health and well-being, but that can only be offered based on HIV testing results. Women’s healthcare providers are uniquely poised to assess risk for acquiring HIV, including taking a sexual history that asks about anal sex, and performing HIV testing to identify women who need HIV treatment or might benefit from PrEP.

    • Disaster Control and Emergency Services
      • US Centers For Disease Control and Prevention experience in the joint external evaluation process – radiation emergencies technical areaExternal
        Whitcomb RC, Ansari AJ, Salame-Alfie A, McCurley MC, Buzzell J, Chang A, Jones RL.
        Radiat Prot Dosimetry. 2018 Aug 25.

        In 2015-16, the US Department of Health and Human Services led 23 US Government (USG) agencies including the Centers for Disease Control and Prevention (CDC), and more than 120 subject matter experts in conducting an in-depth review of the US core public health capacities and evaluation of the country’s compliance with the International Health Regulations using the Joint External Evaluation (JEE) methodology. This two-part process began with a detailed ‘self-assessment’ followed by a comprehensive independent, external evaluation conducted by 15 foreign assessors. In the Radiation Emergencies Technical Area, on a scale from 1-lowest to 5-highest, the assessors concurred with the USG self-assessed score of 3 in both of the relevant indicators. The report identified five priority actions recommended to improve the USG capacity to handle large-scale radiation emergencies. CDC is working to implement a post-JEE roadmap to address these priority actions in partnership with national and international partners.

    • Disease Reservoirs and Vectors
      • Impact of wearing and washing/drying of permethrin-treated clothing on their contact irritancy and toxicity for nymphal Ixodes scapularis (Acari: Ixodidae) ticksExternal
        Connally NP, Rose DA, Breuner NE, Prose R, Fleshman AC, Thompson K, Wolfe L, Broeckling CD, Eisen L.
        J Med Entomol. 2018 Aug 27.

        Permethrin-treated clothing is available as consumer products to prevent bites by tick and insect pests. We used bioassays to examine the impact of wearing and washing/drying of permethrin-treated shirts, pants, and socks, and wearing of treated shoes, on their contact irritancy and toxicity for nymphal Ixodes scapularis Say (Acari: Ixodidae) ticks, the primary vectors in the eastern United States of the causative agents of Lyme disease, human anaplasmosis, and human babesiosis. Pristine permethrin-treated clothing displayed strong contact irritancy and toxicity toward I. scapularis nymphs, with 0-30% of ticks across clothing types and tick sources displaying normal movement 1 h after forced contact for 30-120 s with treated textile. Following 16 d of wear and 16 rounds of machine washing and drying, we recorded reduced concentrations (by 50-90%) of permethrin, compared with pristine treated clothing, from shirts, pants, and socks. This loss of permethrin was associated with reduced contact irritancy and toxicity for ticks after forced contact with worn and washed/dried treated clothing: 31-67% of ticks displayed normal movement 1 h after contact. Nevertheless, the worn and washed/dried treated clothing was still superior to nontreated textile, for which 90-100% of ticks displayed normal movement. Treated shoes, which were worn but not washed, remained as toxic to the ticks as pristine treated shoes. We caution that these laboratory bioassay results should not be interpreted as being directly indicative of the outcome of using washed/worn permethrin-treated clothing in daily life. Although wear and washing/drying did reduce the irritancy and toxicity of permethrin-treated clothing for I. scapularis nymphs more than we had expected, the remaining effect might still reduce the risk of tick bites in a real-life scenario.

    • Injury and Violence
      • Protective factors for sexual violence: Understanding how trajectories relate to perpetration in high schoolExternal
        Basile KC, Rostad WL, Leemis RW, Espelage DL, Davis JP.
        Prev Sci. 2018 Aug 27.

        Adolescent sexual violence (SV) perpetration is a significant public health problem. Many risk factors for perpetration are known, but less is known about what protects youth from perpetration, or how protective factors change over time. This longitudinal study reports trajectories of four potential protective factors for SV perpetration (empathy, parental monitoring, social support, and school belonging) across middle and high school and examines their relationship to SV perpetration in high school. Findings reveal that youth who identified as SV perpetrators had significantly lower mean empathy scores (d = – 0.18, 95 % CI [-0.26, -0.10]) and social support scores (d = – 0.05, 95 % CI [-0.14, -0.03]) at the beginning of middle school than non-perpetrators. We also found that youth who identified as SV perpetrators had a quicker deceleration in parental monitoring (slopes) and empathy from middle to high school, compared to non-perpetrators. Within-sex differences emerged; significant differences in slopes were detected for school belonging between male perpetrators and male non-perpetrators (Wald test = 3.76 (1), p = .05) and between female perpetrators and female non-perpetrators (Wald test = 3.95(1), p = .04). Significant differences in slopes for empathy between female perpetrators and female non-perpetrators (Wald test = 4.76(1), p = .03) were also detected. No differences were found between male and female SV perpetrators for either empathy or school belonging. These findings have implications for the content and timing of adolescent SV prevention efforts. Intervention in adolescence, involving parents and schools in a comprehensive, multi-level approach, may be effective in preventing SV perpetration.

      • Violence-related disparities experienced by black youth and young adults: Opportunities for preventionExternal
        Sheats K, Irving SM, Mercy J, Simon TR, Crosby A, Ford DC, Merrick M, Annor F, Morgan RE.
        Am J Prev Med. 2018 Aug 20.

        INTRODUCTION: The purpose of this study is to characterize violence-related disparities experienced by young blacks in the U.S. Reducing violence experienced by blacks, particularly youth, who are at substantially higher risk, is essential to improving the health of blacks in the U.S. METHODS: Data from four independent data sets for youth and adults were analyzed to examine rates of homicide, assault, injury from a physical fight, bullying victimization, and missing school because of safety concerns for non-Hispanic blacks and whites aged 10-34 years between 2010 and 2015. Disparities in adverse childhood experiences (e.g., exposure to violence and household challenges) and physical/mental health outcomes in adulthood were examined. Data were analyzed in 2017. RESULTS: Black adolescents and young adults are at higher risk for the most physically harmful forms of violence (e.g., homicides, fights with injuries, aggravated assaults) compared with whites. In addition, black adults reported exposure to a higher number of adverse childhood experiences than whites. These adverse childhood experiences were positively associated with increased odds of self-reported coronary heart disease, fair or poor physical health, experiencing frequent mental distress, heavy drinking, and current smoking. CONCLUSIONS: Disproportionate exposure to violence for blacks may contribute to disparities in physical injury and long-term mental and physical health. Understanding the violence experiences of this age group and the social contexts surrounding these experiences can help improve health for blacks in the U.S. Communities can benefit from the existing evidence about policies and programs that effectively reduce violence and its health and social consequences.

    • Laboratory Sciences
      • Comparative in vitro and in vivo analysis of H1N1 and H1N2 variant influenza viruses isolated from humans between 2011 and 2016External
        Pulit-Penaloza JA, Pappas C, Belser JA, Sun X, Brock N, Zeng H, Tumpey TM, Maines TR.
        J Virol. 2018 Aug 29.

        Influenza A virus pandemics are rare events caused by novel viruses which have the ability to spread in susceptible human populations. With respect to H1 subtype viruses, swine H1N1 and H1N2 viruses occasionally cross the species barrier to cause human infection. Recently isolated from humans (termed variants), swine viruses were shown to display great genetic and antigenic diversity, hence posing considerable public health risk. Here, we utilized in vitro and in vivo approaches to provide characterization of H1 subtype variant viruses isolated since the 2009 pandemic and discuss the findings in context with previously studied H1 subtype human isolates. The variant viruses were well adapted to replicate in human respiratory cell line, Calu-3, and the respiratory tracts of mice and ferrets. However, with respect to HA activation pH, the variant viruses had fusion pH thresholds closer to that of most classical swine and triple reassortant H1 isolates rather than viruses that had adapted to humans. Consistent with previous observations for swine isolates, the tested variant viruses were capable of efficient transmission between co-housed ferrets but could transmit via respiratory droplets to differing degrees. Overall, this investigation demonstrates that swine H1 viruses that infected humans possess adaptations required for robust replication and, in some cases, efficient respiratory droplet transmission in a mammalian model, and therefore, need to be closely monitored for additional molecular changes that could facilitate transmission among humans. This work highlights the need for risk assessments of emerging H1 viruses as they continue to evolve and cause human infections.IMPORTANCE Influenza A virus is a continuously evolving respiratory pathogen. Endemic in swine, H1 and H3 subtype viruses sporadically cause human infections. As each zoonotic infection represents an opportunity for human adaptation, the emergence of a transmissible influenza virus to which there is little or no pre-existing immunity is an ongoing threat to public health. Recently isolated variant H1 subtype viruses were shown to display extensive genetic diversity and in many instances were antigenically distinct from seasonal vaccine strains. In this study, we provide characterization of representative H1N1v and H1N2v viruses isolated since the 2009 pandemic. Our results show that, although recent variant H1 viruses possess some adaptation markers of concern, these viruses have not fully adapted to humans and require further adaptation to present a pandemic threat. This investigation highlights the need for close monitoring of emerging variant influenza viruses for molecular changes that could facilitate efficient transmission among humans.

    • Statistics as Topic
      • On a scale as a sum of manifest variablesExternal
        Shin HC.
        Ann Epidemiol. 2018 Aug 9.

        The most common approach for a scale construction is to create a scale as a sum of manifest variables (a “sum scale”). When we use the sum scale for analysis, we implicitly assume that there is a one-dimensional latent structure representing the manifest data on a multidimensional space. In this commentary, we review basics of identifying a latent structure using measured variables with a minimum linear algebra. We demonstrate the technique using Fisher’s iris data as an illustration. We examine the relationships between resulting latent variables and the sum scale to evaluate goodness of the sum scale. As a practical solution, in general, we could create a sum scale using a set of positively and highly correlated measured variables. More care is needed when the data are not unidimensional.

    • Substance Use and Abuse
      • Trends in unit sales of flavored and menthol electronic cigarettes in the United States, 2012-2016External
        Kuiper NM, Loomis BR, Falvey KT, Gammon DG, King BA, Wang TW, Rogers T.
        Prev Chronic Dis. 2018 Aug 23;15:E105.

        INTRODUCTION: The use of flavored tobacco products, including electronic cigarettes (e-cigarettes), is common in the United States, and flavored products are particularly appealing to young people. The objective of this study was to describe national and state trends in flavored and menthol e-cigarette unit sales. METHODS: We examined data on 4 types of e-cigarette products (rechargeables, disposables, prefilled cartridges, and e-liquid refills). We used Universal Product Code retail scanner data from 2 sources: 1) convenience stores and 2) all other outlets combined, including supermarkets, drug stores, mass merchandisers (including Walmart), dollar stores, club stores, and US Department of Defense commissaries. We aggregated data in 4-week periods for the 48 contiguous states and the District of Columbia for the 5-year period from 2012 through 2016. Data from vape shops and internet sales were not available. We used Joinpoint regression to assess trends. RESULTS: From 2012 through 2016, flavored e-cigarette sales as a percentage of all e-cigarette sales increased nationally (from 2.4% to 19.8%) and in all but 4 states (North Dakota, South Dakota, Utah, and Vermont). Nationally, flavored disposable and prefilled cartridge sales increased. Menthol e-cigarette sales were stable nationally at 35% to 40%, while the percentage of menthol disposable, prefilled cartridge, and e-liquid refill sales decreased. By state, menthol e-cigarette sales increased in 2 states (Idaho and Nebraska) and decreased in 7 states. During 2015-2016, the percentage of flavored sales decreased in one state (Rhode Island) and increased in 29 states. CONCLUSION: These findings demonstrate that sales of flavored e-cigarette products have increased dramatically since 2012, with variations by product type and state. Continued monitoring of sales trends at all retail outlets can inform federal, state, and local efforts to address flavored tobacco product use, including e-cigarettes, in the United States.

    • Zoonotic and Vectorborne Diseases
      • Readiness for an increase in congenital Zika virus infections in the United States: Geographic distance to pediatric subspecialist careExternal
        Bertolli J, Holbrook J, Dutton ND, Jones B, Dowling NF, Peacock G.
        Disaster Med Public Health Prep. 2018 Aug 24:1-11.

        OBJECTIVE: The study’s purpose was to investigate readiness for an increase in the congenital Zika infection (CZI) by describing the distribution of pediatric subspecialists needed for the care of children with CZI. METHODS: We applied county-level subspecialist counts to US maps, overlaying the geocoded locations of children’s hospitals to assess the correlation of hospital and subspecialist locations. We calculated travel distance from census tract centroids to the nearest in-state children’s hospital by state (with/without > 100 reported adult Zika virus cases) and by regions corresponding to the likely local Zika virus transmission area and to the full range of the mosquito vector. Travel distance percentiles reflect the population of children 100 miles. CONCLUSION: The travel distance to pediatric subspecialty care varies widely by state and is likely to be an access barrier in some areas, particularly states bordering the Gulf of Mexico, which may have increasing numbers of CZI cases. (Disaster Med Public Health Preparedness. 2018 page 1 of 11).

  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. Obesity and mortality after locoregional breast cancer diagnosisExternal
        Moore AH, Trentham-Dietz A, Burns M, Gangnon RE, Greenberg CC, Vanness DJ, Hampton J, Wu XC, Anderson RT, Lipscomb J, Kimmick GG, Cress R, Wilson JF, Sabatino SA, Fleming ST.
        Breast Cancer Res Treat. 2018 Aug 29.

        PURPOSE: Higher mortality after a breast cancer diagnosis has been observed among women who are obese. We investigated the relationships between body mass index (BMI) and all-cause or breast cancer-specific mortality after a diagnosis of locoregional breast cancer. METHODS: Women diagnosed in 2004 with AJCC Stage I, II, or III breast cancer (n = 5394) were identified from a population-based National Program of Cancer Registries (NPCR) patterns of care study (POC-BP) drawing from registries in seven U.S. states. Differences in overall and breast cancer-specific mortality were investigated using Cox proportional hazards regression models adjusting for demographic and clinical covariates, including age- and stage-based subgroup analyses. RESULTS: In women 70 or older, higher BMI was associated with lower overall mortality (HR for a 5 kg/m(2) difference in BMI = 0.85, 95% CI 0.75-0.95). There was no significant association between BMI and overall mortality for women under 70. BMI was not associated with breast cancer death in the full sample, but among women with Stage I disease; those in the highest BMI category had significantly higher breast cancer mortality (HR for BMI >/= 35 kg/m(2) vs. 18.5-24.9 kg/m(2) = 4.74, 95% CI 1.78-12.59). CONCLUSIONS: Contrary to our hypothesis, greater BMI was not associated with higher overall mortality. Among older women, BMI was inversely related to overall mortality, with a null association among younger women. Higher BMI was associated with breast cancer mortality among women with Stage I disease, but not among women with more advanced disease.

      2. Development and implementation of policy, systems, and environmental (PSE) change is a commonly used public health approach to reduce disease burden. The Centers for Disease Control and Prevention’s National Comprehensive Cancer Control Program conducted a demonstration with 13 programs to determine whether and to what extent dedicated resources would enhance the adoption of PSE strategies. This paper describes results of the qualitative portion of a longitudinal, mixed-methods evaluation of this demonstration. Case studies were conducted with a diverse subset of the 13 programs, and 106 in-depth interviews were completed with state/tribal program staff, community partners, and decision makers. Interviews addressed PSE change planning and capacity building, partnerships, local context, and how programs achieved PSE change. Dedicated PSE resources, including a policy analyst, helped increase PSE change capacity, intensify focus on PSE change overall, and accomplish specific PSE changes within individual jurisdictions. Stakeholders described PSE change as a gradual process requiring preparation and prioritization, strategic collaboration, and navigation of local context. Findings suggest that the demonstration program, including PSE-dedicated funds and a policy analyst, was successful in both increasing PSE change capacity and achieving PSE change itself. These results may be useful to other state, tribal, territorial, and public health organizations planning or implementing PSE change strategies.

    • Communicable Diseases
      1. Burden of HIV-associated histoplasmosis compared with tuberculosis in Latin America: a modelling studyExternal
        Adenis AA, Valdes A, Cropet C, McCotter OZ, Derado G, Couppie P, Chiller T, Nacher M.
        Lancet Infect Dis. 2018 Aug 23.

        BACKGROUND: Fungal infections remain a major contributor to the opportunistic infections that affect people living with HIV. Among them, histoplasmosis is considered neglected, often being misdiagnosed as tuberculosis, and is responsible for numerous deaths in Latin America. The objective of this study was to estimate the burden of HIV-associated histoplasmosis compared with tuberculosis in Latin American countries. METHODS: For this modelling study, we estimated prevalence of previous exposure to Histoplasma capsulatum, HIV-associated histoplasmosis annual incidence, and number of deaths in 2012 in Latin American countries based on historical histoplasmin skin test studies in the general population, with an antigen dilution level of more than 1/10. Studies were identified in a literature search. Data on HIV-associated tuberculosis were extracted from the WHO notifications and outcomes tables and data on people living with HIV were extracted from the UNAIDS report for the year 2012. We systematically propagated uncertainty throughout all the steps of the estimation process. FINDINGS: Among 1310 articles identified as of June 1, 2015, 24 articles were included in the study, representing 129 histoplasmin skin test studies led in the general population of Latin American countries. For the year 2012, we estimated a range of 6710 (95% CI 5680-7867) to 15 657 (13 254-18 357) cases of symptomatic HIV-associated histoplasmosis in Latin America. Hotspot areas for histoplasmosis prevalence (>30%) and incidence (>1.5 cases per 100 people living with HIV) were Central America, the northernmost part of South America, and Argentina. According to realistic scenarios, we estimated a range of 671 (95% CI 568-787) to 9394 (7952-11 014) deaths related to histoplasmosis, compared with 5062 (3777-6405) deaths related to tuberculosis reported in Latin America. INTERPRETATION: Our estimates of histoplasmosis incidence and deaths are high and consistent with published data. For the first time, the burden of histoplasmosis is estimated to be equivalent in incidence and even higher in deaths when compared with tuberculosis among people living with HIV in Latin America. FUNDING: None.

      2. Sexually transmitted infections in the Delta Regional Authority: significant disparities in the 252 counties of the eight-state Delta Region AuthorityExternal
        Barger AC, Pearson WS, Rodriguez C, Crumly D, Mueller-Luckey G, Jenkins WD.
        Sex Transm Infect. 2018 Aug 27.

        OBJECTIVE: Chlamydia, gonorrhoea and syphilis (primary and secondary) are at high levels in the USA. Disparities by race, gender and sexual orientation have been characterised, but while there are indications that rural poor populations may also be at distinct risk this has been subjected to little study by comparison. The federally designated Delta Regional Authority, similar in structure to the Appalachian Regional Commission, oversees 252 counties within eight Mississippi Delta states experiencing chronic economic and health disparities. Our objective was to identify differences in infection risk between Delta Region (DR)/non-DR counties and examine how they might vary by rurality, population density, primary care access and education attainment. METHODS: Reported chlamydia/gonorrhoea/syphilis data were obtained from the Centers for Disease Control and Prevention AtlasPlus, county demographic data from the Area Health Resource File and rurality classifications from the Department of Agriculture. Data were subjected to analysis by t-test, chi(2) and linear regression to assess geographical disparities in incidence and their association with measures of rurality, population and primary care density, and education. RESULTS: Overall rates for each infection were significantly higher in DR versus non-DR counties (577.8 vs 330.1/100 000 for chlamydia; 142.8 vs 61.8 for gonorrhoea; 3.6 vs 1.7 for syphilis; all P<0.001) and for nearly every infection for every individual state. DR rates for each infection were near-universally significantly increased for every level of rurality (nine levels) and population density (quintiles). Regression found that primary care and population density and HS graduation rates were significantly associated with each, though model predictive abilities were poor. CONCLUSIONS: The nearly 10 million people living in the DR face significant disparities in the incidence of chlamydia, gonorrhoea and syphilis-in many instances a near-doubling of risk. Our findings suggest that resource-constrained areas, as measured by rurality, should be considered a priority for future intervention efforts.

      3. Importance of 1918 virus reconstruction to current assessments of pandemic riskExternal
        Belser JA, Maines TR, Tumpey TM.
        Virology. 2018 Aug 21;524:45-55.

        Reconstruction of the 1918 influenza virus has facilitated considerable advancements in our understanding of this extraordinary pandemic virus. However, the benefits of virus reconstruction are not limited to this one strain. Here, we provide an overview of laboratory studies which have evaluated the reconstructed 1918 virus, and highlight key discoveries about determinants of virulence and transmissibility associated with this virus in mammals. We further discuss recent and current pandemic threats from avian and swine reservoirs, and provide specific examples of how reconstruction of the 1918 pandemic virus has improved our ability to contextualize research employing novel and emerging strains. As influenza viruses continue to evolve and pose a threat to human health, studying past pandemic viruses is key to future preparedness efforts.

      4. High rates of repeat chlamydial infections among young women – Louisiana, 2000-2015External
        Cha S, Newman DR, Rahman M, Peterman TA.
        Sex Transm Dis. 2018 Aug 24.

        BACKGROUND: Chlamydial infections are common among young women and can lead to serious reproductive health complications. We assessed the risk of reported repeat chlamydial infection among young women in Louisiana and time interval between infections by age and race/ethnicity. METHODS: We analyzed surveillance data on chlamydial infections reported among women in Louisiana from January 1, 2000 to December 31, 2015. Multiple reports for the same person were matched using unique codes. Chlamydial infections reported more than 30 days after a previous positive test were considered new infections. Women aged 15-34 years at first infection during 2000-2012 were censored after three years or after they had a repeat infection. Cumulative incidence and incidence rate of repeat chlamydial infection among women were determined by year of first infection. Race- and age-specific results were obtained using stratified analyses. RESULTS: One in four women diagnosed with a chlamydial infection at 15-34 years of age in Louisiana had a reported repeat infection in three years or less. Risk of repeat infection increased for younger women, racial/ethnic minorities, and women in more recent cohorts. Young black women aged 15-19 years in 2012 had the highest risk (44%). Black women also had shorter intervals between infections than white women. CONCLUSIONS: Repeat chlamydial infections were common, especially among young black women. The true number is likely higher because surveillance data only count infections that were detected and reported. Comprehensive prevention strategies are needed to address high rates of repeat chlamydial infections among women.

      5. Cholera outbreak in Dadaab refugee camp, Kenya – November 2015-June 2016External
        Golicha Q, Shetty S, Nasiblov O, Hussein A, Wainaina E, Obonyo M, Macharia D, Musyoka RN, Abdille H, Ope M, Joseph R, Kabugi W, Kiogora J, Said M, Boru W, Galgalo T, Lowther SA, Juma B, Mugoh R, Wamola N, Onyango C, Gura Z, Widdowson MA, DeCock KM, Burton JW.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 31;67(34):958-961.

        Dadaab Refugee camp in Garissa County, Kenya, hosts nearly 340,000 refugees in five subcamps (Dagahaley, Hagadera, Ifo, Ifo2, and Kambioos) (1). On November 18 and 19, 2015, during an ongoing national cholera outbreak (2), two camp residents were evaluated for acute watery diarrhea (three or more stools in </=24 hours); Vibrio cholerae serogroup O1 serotype Ogawa was isolated from stool specimens collected from both patients. Within 1 week of the report of index cases, an additional 45 cases of acute watery diarrhea were reported. The United Nations High Commissioner for Refugees and their health-sector partners coordinated the cholera response, community outreach and water, sanitation, and hygiene (WASH) activities; Medecins Sans Frontieres and the International Rescue Committee were involved in management of cholera treatment centers; CDC performed laboratory confirmation of cases and undertook GIS mapping and postoutbreak response assessment; and the Garissa County Government and the Kenya Ministry of Health conducted a case-control study. To prevent future cholera outbreaks, improvements to WASH and enhanced disease surveillance systems in Dadaab camp and the surrounding area are needed.

      6. Men who have sex with men and women (including bisexual men) comprise 35% of all men who have sex with men (MSM) in the U.S. It is estimated that 121,800 men who have been bisexually active within the past year are living with HIV in the U.S. Communication about HIV may result in risk-reduction behaviors. However, little is known about the nature or context for HIV prevention communication among bisexual men, particularly for blacks and Hispanic/Latinos who are disproportionately at greater HIV risk. Therefore, we explored patterns and contexts of HIV-related communications occurring within personal social networks among bisexual black and Hispanic/Latino men. Using respondent-driven sampling methods, we conducted semi-structured interviews from 2011 to 2012 among 36 participants living in New York City. We examined interview responses from participants for main themes using computer-assisted thematic analyses. The three main themes identified were: (1) communication strategies (e.g., “You can tell a lot from how a person responds just by the tone of their voice”), (2) barriers (e.g., “My sexuality…it creates a stress”), and (3) motivations for these communications (e.g., “I know that’s a(n) issue in the black community…if I could help another brother, I will do it”). Our findings can inform HIV prevention efforts such as social messaging campaigns and other risk-reduction interventions designed for bisexual men.

      7. A swimming pool-associated outbreak of pharyngoconjunctival fever caused by human adenovirus type 4 in Beijing, ChinaExternal
        Li J, Lu X, Sun Y, Lin C, Li F, Yang Y, Liang Z, Jia L, Chen L, Jiang B, Wang Q.
        Int J Infect Dis. 2018 Aug 22.

        Patients with swimming pool-acquired Human adenovirus (HAdV) infections usually manifest characteristic clinical features that include fever, pharyngitis and conjunctival inflammation, syndromically referred to as pharyngoconjunctival fever (PCF). HAdV types 3, 4 and 7 are most commonly associated with PCF. We reported an outbreak of pharyngoconjunctival fever occurred among 55 students and staff of a university in Beijing, China. Fifty patients had used the same swimming pool two weeks before the onset of symptoms. Human adenovirus type 4 was identified from patient eye and throat swabs and concentrated swimming pool water samples. Partial hexon gene sequences obtained from water samples were 100% identical to the sequences obtained from swab samples, which clustered with HAdV-4 within species E. HAdV-4-contaminated swimming pool water was the most likely source of infection, although one instance of likely person-to-person transmission was noted.

      8. H. pylori-associated pathologic findings among Alaska native patientsExternal
        Nolen LD, Bruden D, Miernyk K, McMahon BJ, Sacco F, Varner W, Mezzetti T, Hurlburt D, Tiesinga J, Bruce MG.
        Int J Circumpolar Health. 2018 Dec;77(1):1510715.

        Helicobacter pylori infection is common among Alaska native (AN) people, however scant gastric histopathologic data is available for this population. This study aimed to characterise gastric histopathology and H. pylori infection among AN people. We enrolled AN adults undergoing upper endoscopy. Gastric biopsy samples were evaluated for pathologic changes, the presence of H. pylori, and the presence of cag pathogenicity island-positive bacteria. Of 432 persons; two persons were diagnosed with gastric adenocarcinoma, two with MALT lymphoma, 40 (10%) with ulcers, and 51 (12%) with intestinal metaplasia. Fifty-five per cent of H. pylori-positive persons had cag pathogenicity island positive bacteria. The gastric antrum had the highest prevalence of acute and chronic moderate-severe gastritis. H. pylori-positive persons were 16 and four times more likely to have moderate-severe acute gastritis and chronic gastritis (p < 0.01), respectively. An intact cag pathogenicity island positive was correlated with moderate-severe acute antral gastritis (53% vs. 31%, p = 0.0003). H. pylori-positive persons were more likely to have moderate-severe acute and chronic gastritis compared to H. pylori-negative persons. Gastritis and intestinal metaplasia were most frequently found in the gastric antrum. Intact cag pathogenicity island positive was correlated with acute antral gastritis and intestinal metaplasia.

      9. Participant satisfaction with clinical trial experience and post-trial transitioning to HIV care in KenyaExternal
        Odero I, Ondeng’e K, Mudhune V, Okola P, Oruko J, Otieno G, Akelo V, Gust DA.
        Int J STD AIDS. 2018 Aug 29:956462418791946.

        We conducted an exploratory analysis of former HIV Prevention Trials Network 052 (HPTN 052) clinical trial participants in 2016 to assess their (1) satisfaction with the HPTN 052 clinical trial care and treatment, and reasons for joining the trial; and (2) perspectives about the post-trial transition to public HIV care centers. Quantitative data showed that, of the 70 survey participants, 94.3% (n = 66) reported being very satisfied with the care and treatment they received while participating in the clinical trial and 51.4% (n = 36) reported they joined the study because they would receive information to improve their own or their partner’s health. Qualitative data (five in-depth interviews and two focus group discussions) analysis revealed the following themes: transition experiences; perceived superior clinical trial care; study benefits not offered at public HIV care centers; and the public HIV care centers’ indifference to the uninfected partner. For some HPTN 052 participants, transition to HIV care clinics was disappointing. Clinical trial investigators and local Institutional Review Boards should consider the need for safeguards and oversight of post-trial health care for trial participants after the trial ends, especially in resource-constrained settings, to avoid negative health outcomes.

      10. Notes from the Field: Fatal Vibrio anguillarum infection in an immunocompromised patient – Maine, 2017External
        Sinatra JA, Colby K.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 31;67(34):962-963.

        [No abstract]

      11. Infectious disease-specific health literacy in Tibet, ChinaExternal
        Yang P, Dunzhu C, Widdowson MA, Wu S, Ciren P, Duoji D, Pingcuo W, Dun B, Ma C, Li J, Pang X, Wang Q.
        Health Promot Int. 2018 Feb 1;33(1):84-91.

        This study was aimed to develop an instrument to assess infectious disease-specific health literacy (IDSHL) in the general population of Tibet, China and identify the association between IDSHL and reported infectious disease-related symptoms. A survey using a standardized questionnaire, which included 25 questions on knowledge, behaviors and skills regarding infectious diseases, was conducted in the general population of Tibet, China between September 2011 and November 2011. The 25 questions formed the index system of the instrument assessing IDSHL (total scores: 25 scores). Factors associated with index scores of IDSHL were identified by general linear model. The association between the index score of IDSHL and the occurrence of the five selected infectious disease symptoms (fever, diarrhea, rash, jaundice or conjunctivitis) were investigated using multivariate unconditional logistic regression. Among 5717 eligible participants in the survey, 4631 participants completed all of the 25 questions in the instrument. The instrument was reliable and valid as measured by the Cronbach’s alpha coefficient and split-half coefficient, and the confirmatory factor analysis. Only 1.0% (48/4631) answered >/=80% of the 25 questions correctly (score >/= 20). Significant factors associated with lower health literacy score included female gender, older age, Tibetan group, lower education level, underlying diseases and more undeveloped area. For each increasing score of IDSHL, reports of fever, diarrhea or jaundice in the prior year were significantly decreased by 3% (p = 0.015), 4% (p = 0.004) and 16% (p < 0.001), respectively. Accurately measuring IDSHL could help identify those individuals with poor IDSHL, who could be targeted with specific interventions to improve health.

      12. Influenza-associated hospitalization in children younger than five years of age in Suzhou, China, 2011- 2016External
        Yu J, Zhang X, Shan W, Gao J, Hua J, Tian J, Ding Y, Zhang J, Chen L, Song Y, Zhou S, Iuliano AD, Greene CM, Zhang T, Zhao G.
        Pediatr Infect Dis J. 2018 Aug 27.

        BACKGROUND: Studying the burden and risk factors associated with severe illness from influenza infection in young children in eastern China will contribute to future cost-effectiveness analyses of local influenza vaccine programs. METHODS: We conducted prospective, severe acute respiratory infection (SARI) surveillance at Suzhou University Affiliated Children’s Hospital (SCH) to estimate influenza-associated hospitalizations in SCH by month in children younger than 5 years of age from October 2011 to September 2016. SARI was defined as fever (measured axillary temperature >/=38 degrees C) and cough or sore throat or inflamed/red pharynx in the 7 days preceding hospitalization. We combined SARI surveillance data with healthcare utilization survey data to estimate and characterize the burden of influenza-associated SARI hospitalizations in Suzhou within this age group in the 5-year period. RESULTS: Of 36,313 SARI cases identified, 2,297 from respiratory wards were systematically sampled; of these, 259 (11%) were influenza positive. Estimated annual influenza-associated SARI hospitalization rates per 1,000 children younger than 5 years of age ranged from 4 (95% Confidence Interval [CI]: 2-5) in the 2012-2013 season to 16 (95% CI: 14-19) in the 2011-2012 season. The predominant viruses were A/H3N2 (59%) in 2011-12, both A/H1N1pdm09 (42%) and B (46%) in 2012-13, A/H3N2 (71%) in 2013-14, A/H3N2 (55%) in 2014-15 and both A/H1N1pdm09 (50%) and B (50%) in 2015-16. The age-specific influenza-associated SARI hospitalization rates for the 5-year period were 11 (95% CI: 8-15) per 1,000 children aged 0-5 months; 8 (95% CI: 7-10) per 1,000 children aged 6-23 months; and 5 (95% CI: 4-5) per 1,000 children aged 24-59 months respectively. CONCLUSIONS: From 2011-2016, influenza-associated SARI hospitalization rates in children aged younger than 5 years of age in Suzhou, China were high, particularly among children aged 0-5 months. Higher hospitalization rates were observed in years where the predominant circulating virus was influenza A/H3N2. Immunization for children >6 months, and maternal and caregiver immunization for those <6 months, could reduce influenza-associated hospitalizations in young children in Suzhou.

    • Disease Reservoirs and Vectors
      1. Flanders hapavirus in western North AmericaExternal
        Golnar AJ, Langevin S, Panella NA, Solberg OD, Reisen WK, Komar N.
        Arch Virol. 2018 Aug 29.

        Flanders virus (FLAV; family Rhabdoviridae) is a mosquito-borne hapavirus with no known pathology that is frequently isolated during arbovirus surveillance programs. Here, we document the presence of FLAV in Culex tarsalis mosquitoes and a Canada goose (Branta canadensis) collected in western North America, outside of the currently recognized range of FLAV. Until now, FLAV-like viruses detected in the western United States were assumed to be Hart Park virus (HPV, family Rhabdoviridae), a closely related congener. A re-examination of archived viral isolates revealed that FLAV was circulating in California as early as 1963. FLAV also was isolated in Nebraska, Colorado, South Dakota, North Dakota, and Saskatchewan, Canada. Phylogenetic analysis of the U1 pseudogene for 117 taxa and eight nuclear genes for 15 taxa demonstrated no distinct clustering between western FLAV isolates. Assuming the range of FLAV has been expanding west, these results indicate that FLAV likely spread west following multiple invasion events. However, it remains to be determined if the detection of FLAV in western North America is due to expansion or is a result of enhanced arbovirus surveillance or diagnostic techniques. Currently, the impact of FLAV infection remains unknown.

    • Environmental Health
      1. Pre-pubertal and pubertal endocrine disrupting chemicals exposure and breast density among Chilean adolescentsExternal
        Binder AM, Corvalan C, Pereira A, Calafat AM, Ye X, Shepherd J, Michels KB.
        Cancer Epidemiol Biomarkers Prev. 2018 Aug 29.

        BACKGROUND: During puberty, mammary tissue undergoes rapid development, which provides a window of heightened susceptibility of breast composition to the influence of endogenous and exogenous hormones. Exposure to endocrine disrupting chemicals (EDCs) may affect breast development and composition and the risk of developing breast cancer in adulthood. METHODS: We evaluated the associations between breast density and urinary concentrations of phenols and phthalates collected at Tanner 1 (B1) and Tanner 4 (B4) in 200 Chilean girls. Total breast volume (BV), fibroglandular volume (FGV), and percent dense breast (%FGV) were evaluated at B4 using dual x-ray absorptiometry. Generalized estimating equations were used to analyze the association between concentrations of EDC biomarkers across puberty and breast density. RESULTS: The geometric mean %FGV was 7% higher among girls in the highest relative to the lowest tertile of monocarboxyisooctyl phthalate (1.07; 95% CI: 1.01-1.14). Monoethyl phthalate concentrations at B4 were positively associated with FGV (highest vs lowest tertile: 1.22; 95% CI: 1.06-1.40). Bisphenol A displayed a u-shaped association with FGV; girls in the middle tertile had at least 10% lower FGV than girls in the lowest or highest tertiles. Monocarboxyisononyl phthalate showed a non-linear association with BV. No other statistically significant associations were observed. CONCLUSIONS: Our results suggest that the developing breast tissue is susceptible to select EDCs during childhood and adolescence. IMPACT: This study may spur further investigations into environmental influences on breast development during puberty, and how shifts in pubertal breast density track through the life course to modify breast cancer risk.

      2. Biomonitoring programs in Michigan, Minnesota and New York to assess human exposure to Great Lakes contaminantsExternal
        Wattigney WA, Irvin-Barnwell E, Li Z, Davis SI, Manente S, Maqsood J, Scher D, Messing R, Schuldt N, Hwang SA, Aldous KM, Lewis-Michl EL, Ragin-Wilson A.
        Int J Hyg Environ Health. 2018 Aug 25.

        Over the past century, industrialization and urban practices have resulted in the contamination of the Great Lakes ecosystem-the world’s largest surface freshwater system-that provides drinking water and recreation to more than 40 million residents. In 2010, the Great Lakes Restoration Initiative was launched to accelerate efforts to protect and restore the Great Lakes and surrounding areas. Funded by GLRI, the Agency for Toxic Substances and Disease Registry initiated the Biomonitoring of Great Lakes Populations (BGLP) program. The objective of the program is to assess human exposure to legacy and emerging contaminants in the Great Lakes by measuring the body burden of contaminants in potentially susceptible populations. The BGLP program consists of a series of cross-sectional studies carried out collaboratively with states that are funded through ATSDR. The first BGLP Program (BGLP-I) began in 2010 and was completed in September 2015 through cooperative agreements with state health departments in Michigan, Minnesota, and New York. The three state programs targeted susceptible adult populations living in designated areas of contamination. Contaminants measured in all populations include mercury, lead, mirex, hexachlorobenzene, dichlorodiphenyltrichloroethane, and selected polychlorinated biphenyl congeners. In addition, some chemicals of emerging concern, such as per- and polyfluoroalkyl substances, were measured in several populations. The biomonitoring results helped guide public health actions to mitigate chemical exposures in these vulnerable Great Lakes populations. We provide an overview of the BGLP-I program’s study populations, designs, and general methods. This overview provides a lead-in for subsequent manuscripts that present human biomonitoring data for legacy and emerging contaminants in culturally diverse susceptible populations-i.e., shoreline anglers, sport anglers, American Indians, and Burmese immigrants-residing in seven areas of concern.

    • Healthcare Associated Infections
      1. BACKGROUND: As the US population ages, the number of hip and knee arthroplasties is expected to increase. Because surgical site infections (SSIs) following these procedures contribute substantial morbidity, mortality, and costs, we projected SSIs expected to occur from 2020 through 2030. METHODS: We used a stochastic Poisson process to project the number of primary and revision arthroplasties and SSIs. Primary arthroplasty rates were calculated using annual estimates of hip and knee arthroplasty stratified by age and gender from the 2012-2014 Nationwide Inpatient Sample and standardized by census population data. Revision rates, dependent on time from primary procedure, were obtained from published literature and were uniformly applied for all ages and genders. Stratified complex SSI rates for arthroplasties were obtained from 2012-2015 National Healthcare Safety Network data. To evaluate the possible impact of prevention measures, we recalculated the projections with an SSI rate reduced by 30%, the national target established by the US Department of Health and Human Services (HHS). RESULTS: Without a reduction in SSI rates, we projected an increase in complex SSIs following hip and knee arthroplasty of 14% between 2020 and 2030. We projected a total burden of 77,653 SSIs; however, meeting the 30% rate reduction could prevent 23,297 of these SSIs. CONCLUSIONS: Given current SSI rates, we project that complex SSI burden for primary and revision arthroplasty may increase due to an aging population. Reducing the SSI rate to the national HHS target could prevent 23,000 SSIs and reduce subsequent morbidity, mortality, and Medicare costs.

    • Immunity and Immunization
      1. Evaluation of mass vaccination clinics in response to a serogroup B meningococcal disease outbreak at a large, public university – Oregon, 2015External
        Fisher EA, Poissant T, Luedtke P, Leman R, Young C, Cieslak P.
        J Adolesc Health. 2018 Aug;63(2):151-156.

        PURPOSE: Between January and May 2015, seven people at a large, public university developed invasive serogroup B meningococcal disease. One case was fatal. Attack rates were highest among freshmen and members of sororities, and fraternities (Greek organizations). Mass vaccination clinics using newly licensed serogroup B vaccine were held in March, May, and October 2015. No cases occurred after the second mass vaccination clinic. METHODS: We surveyed vaccine recipients at each clinic from March to October 2015 to determine preferred methods for notification about vaccination clinics, assess motivations for attending, and evaluate the clinic attendee population. RESULTS: Vaccination rates were low; 15% of undergraduates received one vaccine dose. An additional 11% received two doses of the three-dose MenB-FHbp series, and 4% completed a serogroup B meningococcal vaccine series at a mass vaccination clinic. University freshmen were 2.3 times as likely (confidence interval: 2.2-2.9) and Greek members 1.3 times as likely (confidence interval: 1.2-1.4) to attend a mass vaccination clinic as nonfreshmen or non-Greek members, respectively. Attendees reported e-mail as their preferred communication method (90%). Concerns about developing meningococcal disease (66%) and parental request (56%) were the most commonly cited motivations for attending a vaccination clinic. CONCLUSIONS: The serogroup B meningococcal outbreak at this large, public university disproportionately affected freshmen and students affiliated with Greek organizations. Despite low overall vaccination rates, the vaccination campaign did reach the populations at risk. In future outbreaks at large universities, we recommend focusing vaccination efforts on specific at-risk populations to maximize vaccination of those most at risk for this deadly disease.

      2. This report updates the 2017-18 recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding the use of seasonal influenza vaccines in the United States (MMWR Recomm Rep 2017;66[No. RR-2]). Routine annual influenza vaccination is recommended for all persons aged >/=6 months who do not have contraindications. A licensed, recommended, and age-appropriate vaccine should be used. Inactivated influenza vaccines (IIVs), recombinant influenza vaccine (RIV), and live attenuated influenza vaccine (LAIV) are expected to be available for the 2018-19 season. Standard-dose, unadjuvanted, inactivated influenza vaccines will be available in quadrivalent (IIV4) and trivalent (IIV3) formulations. Recombinant influenza vaccine (RIV4) and live attenuated influenza vaccine (LAIV4) will be available in quadrivalent formulations. High-dose inactivated influenza vaccine (HD-IIV3) and adjuvanted inactivated influenza vaccine (aIIV3) will be available in trivalent formulations.Updates to the recommendations described in this report reflect discussions during public meetings of ACIP held on October 25, 2017; February 21, 2018; and June 20, 2018. New and updated information in this report includes the following four items. First, vaccine viruses included in the 2018-19 U.S. trivalent influenza vaccines will be an A/Michigan/45/2015 (H1N1)pdm09-like virus, an A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus, and a B/Colorado/06/2017-like virus (Victoria lineage). Quadrivalent influenza vaccines will contain these three viruses and an additional influenza B vaccine virus, a B/Phuket/3073/2013-like virus (Yamagata lineage). Second, recommendations for the use of LAIV4 (FluMist Quadrivalent) have been updated. Following two seasons (2016-17 and 2017-18) during which ACIP recommended that LAIV4 not be used, for the 2018-19 season, vaccination providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, RIV4, or LAIV4). LAIV4 is an option for those for whom it is appropriate. Third, persons with a history of egg allergy of any severity may receive any licensed, recommended, and age-appropriate influenza vaccine (IIV, RIV4, or LAIV4). Additional recommendations concerning vaccination of egg-allergic persons are discussed. Finally, information on recent licensures and labeling changes is discussed, including expansion of the age indication for Afluria Quadrivalent (IIV4) from >/=18 years to >/=5 years and expansion of the age indication for Fluarix Quadrivalent (IIV4), previously licensed for >/=3 years, to >/=6 months.This report focuses on the recommendations for use of vaccines for the prevention and control of influenza during the 2018-19 season in the United States. A Background Document containing further information and a brief summary of these recommendations are available at https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html.These recommendations apply to U.S.-licensed influenza vaccines used within Food and Drug Administration-licensed indications. Updates and other information are available at CDC’s influenza website (https://www.cdc.gov/flu). Vaccination and health care providers should check CDC’s influenza website periodically for additional information.

      3. Understanding FDA-approved labeling and CDC recommendations for use of vaccinesExternal
        Meissner HC, Farizo K, Pratt D, Pickering LK, Cohn AC.
        Pediatrics. 2018 Aug 23.

        Adherence to recommendations for the use of licensed vaccines ensures maximum individual and societal benefits from the national immunization program. The US Food and Drug Administration (FDA) licenses a vaccine once it determines that data submitted by the manufacturer reveal that the vaccine is safe and effective for its intended use. For each US-licensed vaccine, the FDA-approved prescribing information contains detailed information for health care providers to ensure safe and effective use. Centers for Disease Control and Prevention recommendations for the use of a licensed vaccine often are based on additional considerations, such as disease epidemiology, public acceptance, vaccine supply, and cost. Our objective in this article is to explain the reasons for the differences between FDA-approved prescribing information and Centers for Disease Control and Prevention recommendations for vaccine use.

      4. [No abstract]

    • Injury and Violence
      1. Injury prevention and health promotion: A global perspectiveExternal
        Franklin RC, Sleet DA.
        Health Promot J Austr. 2018 Aug;29(2):113-116.

        [No abstract]

      2. Texting/emailing while driving among high school students in 35 states, United States, 2015External
        Li L, Shults RA, Andridge RR, Yellman MA, Xiang H, Zhu M.
        J Adolesc Health. 2018 Aug 17.

        PURPOSE: Determine the prevalence and explore individual- and state-level factors associated with texting/emailing while driving (TWD) among adolescent drivers in the United States. METHODS: Data from 35 states that administered the 2015 state Youth Risk Behavior Survey were analyzed. We used Poisson regression models with robust error variance to estimate prevalence ratios (PRs) for TWD. RESULTS: Among the 101,397 high school students aged >/= 14 years who had driven a vehicle during the past 30 days, 38% reported TWD at least once. TWD prevalence ranged from 26% in Maryland to 64% in South Dakota. TWD prevalence was higher in states with a lower minimum learner’s permit age and in states where a larger percentage of students drove. Multivariable analyses revealed that the likelihood of TWD increased substantially with age, and white students were more likely to engage in TWD than students of all other races/ethnicities. Infrequent seatbelt users were 21% more likely to engage in TWD compared with frequent seatbelt users (adjusted PR=1.21, 95% confidence interval: 1.16-1.26), and students who reported drinking and driving were almost twice as likely to TWD as compared to students who did not (adjusted PR=1.91, 95% confidence interval: 1.79-2.04). CONCLUSIONS: Prevalence of TWD among US high school students varied by more than two-fold across states. TWD prevalence was higher in states with lower minimum learner’s permit ages and in states where a larger percentage of students drove. Older age, white race/ethnicity, and other risky driving behaviors were associated with TWD.

    • Laboratory Sciences
      1. Characterization of 108 genomic DNA reference materials for 11 human leukocyte antigen loci: A GeT-RM Collaborative ProjectExternal
        Bettinotti MP, Ferriola D, Duke JL, Mosbruger TL, Tairis N, Jennings L, Kalman LV, Monos D.
        J Mol Diagn. 2018 Sep;20(5):703-715.

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

      2. Infection of cultured mammalian cells with aerosolized influenza virusExternal
        Creager HM, Tumpey TM, Maines TR, Belser JA.
        Methods Mol Biol. 2018 ;1836:387-399.

        Inoculation of animals via inhaled aerosols has long been used to study the infectivity and pathogenesis of both influenza virus and other respiratory pathogens in a context that mimics natural infection. In contrast, traditional in vitro studies of cellular tropism have been limited to the use of liquid inocula. We have recently shown that cultured cells can become successfully infected after exposure to aerosolized influenza virus. In this chapter, we describe the methodology employed, including the operation of aerosolization instrumentation and calculation of infectious dose, both in experimental planning and after exposure occurs.

      3. Neutralizing antibodies inhibit chikungunya virus budding at the plasma membraneExternal
        Jin J, Galaz-Montoya JG, Sherman MB, Sun SY, Goldsmith CS, O’Toole ET, Ackerman L, Carlson LA, Weaver SC, Chiu W, Simmons G.
        Cell Host Microbe. 2018 Aug 18.

        Neutralizing antibodies (NAbs) are traditionally thought to inhibit virus infection by preventing virion entry into target cells. In addition, antibodies can engage Fc receptors (FcRs) on immune cells to activate antiviral responses. We describe a mechanism by which NAbs inhibit chikungunya virus (CHIKV), the most common alphavirus infecting humans, by preventing virus budding from infected human cells and activating IgG-specific Fcgamma receptors. NAbs bind to CHIKV glycoproteins on the infected cell surface and induce glycoprotein coalescence, preventing budding of nascent virions and leaving structurally heterogeneous nucleocapsids arrested in the cytosol. Furthermore, NAbs induce clustering of CHIKV replication spherules at sites of budding blockage. Functionally, these densely packed glycoprotein-NAb complexes on infected cells activate Fcgamma receptors, inducing a strong, antibody-dependent, cell-mediated cytotoxicity response from immune effector cells. Our findings describe a triply functional antiviral pathway for NAbs that might be broadly applicable across virus-host systems, suggesting avenues for therapeutic innovation through antibody design.

      4. Proposed epidemiological cutoff values for ceftriaxone, cefepime, and colistin in SalmonellaExternal
        Tyson GH, Bodeis-Jones S, Caidi H, Cook K, Dessai U, Haro J, McCullough AE, Meng J, Morales CA, Lawrence JP, Tillman GE, Winslow A, Miller RA.
        Foodborne Pathog Dis. 2018 Aug 28.

        We tested a diverse set of 500 isolates of nontyphoidal Salmonella enterica subsp. enterica from various animal, food, and human clinical sources for susceptibility to antimicrobials currently lacking epidemiological cutoff values (ECOFFs) set by the European Committee on Antimicrobial Susceptibility Testing. A consortium of five different laboratories each tested 100 isolates, using broth microdilution panels containing twofold dilutions of ceftriaxone, cefepime, and colistin to determine the minimum inhibitory concentrations of each drug when tested against the Salmonella isolates. Based on the resulting data, new ECOFFs of 0.25 microg/mL for ceftriaxone, 0.12 microg/mL for cefepime, and 2 microg/mL for colistin have been proposed. These thresholds will aid in the identification of Salmonella that have phenotypically detectable resistance mechanisms to these important antimicrobials.

      5. Characterization of unknown orthobunya-like viruses from IndiaExternal
        Whitmer SL, Yadav PD, Sarkale P, Chaubal GY, Francis A, Klena J, Nichol ST, Stroher U, Mourya DT.
        Viruses. 2018 Aug 24;10(9).

        Next-generation sequencing (NGS) of agents causing idiopathic human diseases has been crucial in the identification of novel viruses. This study describes the isolation and characterization of two novel orthobunyaviruses obtained from a jungle myna and a paddy bird from Karnataka State, India. Using an NGS approach, these isolates were classified as Cat Que and Balagodu viruses belonging to the Manzanilla clade of the Simbu serogroup. Closely related viruses in the Manzanilla clade have been isolated from mosquitos, humans, birds, and pigs across a wide geographic region. Since Orthobunyaviruses exhibit high reassortment frequency and can cause acute, self-limiting febrile illness, these data suggest that human and livestock infections of the Oya/Cat Que/Manzanilla virus may be more widespread and/or under-reported than anticipated. It therefore becomes imperative to identify novel and unknown viruses in order to understand their role in human and animal pathogenesis. The current study is a step forward in this regard and would act as a prototype method for isolation, identification and detection of several other emerging viruses.

    • Maternal and Child Health
      1. Surgeries and health outcomes among patients with spina bifidaExternal
        Alabi NB, Thibadeau J, Wiener JS, Conklin MJ, Dias MS, Sawin KJ, Valdez R.
        Pediatrics. 2018 Aug 29.

        BACKGROUND AND OBJECTIVES: Patients with spina bifida (SB) typically develop serious secondary conditions and undergo surgical procedures related to neurologic disorders, orthopedic abnormalities, bladder and bowel dysfunction, and skin breakdown. In this study, we describe the age distribution of common surgical procedures and health outcomes in patients with SB. METHODS: Using serial cross-sectional data from the National Spina Bifida Patient Registry (2009-2013; n = 4664), we examined surgical procedures (gastrointestinal, neurologic, orthopedic, skin, urologic, and other) and health outcomes (fecal continence, urinary continence, skin breakdown, and ambulation status) of patients with SB by age and SB type (myelomeningocele and nonmyelomeningocele). RESULTS: All patients who were enrolled had available health outcome data, and 81.5% (n = 3801) of patients had complete surgical procedure data, which totaled 18 891 procedures across their lifetimes. Almost all procedures (91.4%) occurred among participants with myelomeningocele SB. For both types of SB, the distribution of procedures varied by age. The most frequent procedures were neurologic, with approximately half (53%) occurring in patients <1 year of age; orthopedic and urologic procedures followed in frequency but tended to occur at older ages. The health outcomes for patients with myelomeningocele SB revealed lower frequencies of positive health outcomes than those for patients with nonmyelomeningocele SB across all age groups. Overall, the rates of fecal and urinary continence and skin breakdown increased with age whereas the ability to ambulate declined with age. CONCLUSIONS: Understanding the surgical procedures and health outcome variations by age and SB type can help clinicians and populations that are affected set expectations regarding the occurrence of these procedures and the outcomes throughout the patients’ life spans.

      2. Public health implications of very preterm birthExternal
        Barfield WD.
        Clin Perinatol. 2018 Sep;45(3):565-577.

        With advanced perinatal care and technology, survival among infants born very preterm (<32 weeks gestation) has improved dramatically over the last several decades. However, adverse medical and neurodevelopmental outcomes for those born very preterm remains high, particularly at the lowest gestational ages. Public health plays a critical role in providing data to assess population-based risks associated with very preterm birth, addressing disparities, and identifying opportunities for prevention, including improving the health of reproductive-age women, before, during, and after pregnancy.

      3. Background: Participation in epidemiologic studies has declined, raising concerns about selection bias. While estimates derived from epidemiologic studies have been shown to be robust under a wide range of scenarios, additional empiric study is needed. The Georgia Study to Explore Early Development (GA SEED), a population-based case-control study of risk factors for autism spectrum disorder (ASD), provided an opportunity to explore factors associated with non-participation and potential impacts of non-participation on association studies. Methods: GA SEED recruited preschool-aged children residing in metropolitan-Atlanta during 2007-2012. Children with ASD were identified from multiple schools and healthcare providers serving children with disabilities; children from the general population (POP) were randomly sampled from birth records. Recruitment was via mailed invitation letter with follow-up phone calls. Eligibility criteria included birth and current residence in study area and an English-speaking caregiver. Many children identified for potential inclusion could not be contacted. We used data from birth certificates to examine demographic and perinatal factors associated with participation in GA SEED and completion of the data collection protocol. We also compared ASD-risk factor associations for the final sample of children who completed the study with the initial sample of all likely ASD and POP children invited to potentially participate in the study, had they been eligible. Finally, we derived post-stratification sampling weights for participants who completed the study and compared weighted and unweighted associations between ASD and two factors collected via post-enrollment maternal interview: infertility and reproductive stoppage. Results: Maternal age and education were independently associated with participation in the POP group. Maternal education was independently associated with participation in the ASD group. Numerous other demographic and perinatal factors were not associated with participation. Moreover, unadjusted and adjusted odds ratios for associations between ASD and several demographic and perinatal factors were similar between the final sample of study completers and the total invited sample. Odds ratios for associations between ASD and infertility and reproductive stoppage were also similar in unweighted and weighted analyses of the study completion sample. Conclusions: These findings suggest that effect estimates from SEED risk factor analyses, particularly those of non-demographic factors, are likely robust.

      4. The frequency of joint hemorrhages and procedures in nonsevere hemophilia A vs BExternal
        Soucie JM, Monahan PE, Kulkarni R, Konkle BA, Mazepa MA.
        Blood Adv. 2018 Aug 28;2(16):2136-2144.

        Data are needed on minimal factor activity (FA) levels required to prevent bleeding in hemophilia. We aimed to evaluate associations between hemophilia type and FA level and joint bleeding and orthopedic procedures using longitudinal data. Data were collected over an 11-year period on males with nonsevere hemophilia A or B without inhibitors who were receiving on-demand factor replacement therapy. Data on the number of joint bleeds in the previous 6 months and data on procedures from clinical records were analyzed using regression models. Data were collected on 4771 patients (hemophilia A, 3315; hemophilia B, 1456) from 19 979 clinic visits. Ages ranged from 2 to 91 years and baseline FA level ranged from 1% to 49% with a mean of 9.4%. Joint bleeding rates were heterogeneous across the FA range and were highest among men age 25 to 44 years. Adjusted for FA level, the mean number of joint bleeds per 6 months was 1.4 and 0.7 for patients with hemophilia A and B, respectively (P < .001). Regression models predicted 1.4 and 0.6 bleeds per year for hemophilia A and B patients, respectively, at an FA level of 15%. Patients with hemophilia B were 30% less likely than those with hemophilia A to have undergone an orthopedic procedure. We conclude that joint bleed rates for any given FA level were higher among hemophilia A than hemophilia B patients, and target FA levels of 15% are unlikely to prevent all joint bleeding in US males with hemophilia.

    • Nutritional Sciences
      1. Thiamine deficiency disorders: diagnosis, prevalence, and a roadmap for global control programsExternal
        Whitfield KC, Bourassa MW, Adamolekun B, Bergeron G, Bettendorff L, Brown KH, Cox L, Fattal-Valevski A, Fischer PR, Frank EL, Hiffler L, Hlaing LM, Jefferds ME, Kapner H, Kounnavong S, Mousavi MP, Roth DE, Tsaloglou MN, Wieringa F, Combs GF.
        Ann N Y Acad Sci. 2018 Aug 27.

        Thiamine is an essential micronutrient that plays a key role in energy metabolism. Many populations worldwide may be at risk of clinical or subclinical thiamine deficiencies, due to famine, reliance on staple crops with low thiamine content, or food preparation practices, such as milling grains and washing milled rice. Clinical manifestations of thiamine deficiency are variable; this, along with the lack of a readily accessible and widely agreed upon biomarker of thiamine status, complicates efforts to diagnose thiamine deficiency and assess its global prevalence. Strategies to identify regions at risk of thiamine deficiency through proxy measures, such as analysis of food balance sheet data and month-specific infant mortality rates, may be valuable for understanding the scope of thiamine deficiency. Urgent public health responses are warranted in high-risk regions, considering the contribution of thiamine deficiency to infant mortality and research suggesting that even subclinical thiamine deficiency in childhood may have lifelong neurodevelopmental consequences. Food fortification and maternal and/or infant thiamine supplementation have proven effective in raising thiamine status and reducing the incidence of infantile beriberi in regions where thiamine deficiency is prevalent, but trial data are limited. Efforts to determine culturally and environmentally appropriate food vehicles for thiamine fortification are ongoing.

    • Occupational Safety and Health
      1. Carbon monoxide emission rates from roasted whole bean and ground coffeeExternal
        LeBouf RF, Aldridge M.
        J Air Waste Manag Assoc. 2018 Aug 27.

        Carbon monoxide (CO) emitted from roasted coffee is a potential occupational respiratory exposure hazard to workers within the coffee industry. The current study objective was to estimate CO emission factors from commercially-available roasted whole and ground coffee measured in loose-form, not packaged, and to assess the utility of CO monitoring in non-ventilated storage spaces such as within coffee roasting and packaging facilities, transport vessels, and cafes. Determinants affecting CO emissions from coffee were investigated including form (whole vs. ground), roast level (Light, Medium, Medium-Dark, Dark), and age (time since the package was opened). CO emissions factors were estimated for roasted coffee samples from a variety of manufacturers purchased from local grocery stores and online. Emissions tests were performed on 36 brands of coffee with more than one sample per brand and with various roast levels. Decaying source equations or smoothing functions were fitted to the CO concentration measurements. Maximum observed emission factors at the peak of the predicted concentration curve were adjusted by the time required to reach the maximum CO concentration, and reported as emissions factors (EFbuildup). Ground coffee had a significantly increased EFbuildup (p < 0.0001) compared to whole bean. Roast level did not significantly affect emissions for whole bean coffee (p = 0.72), but did for ground (p < 0.001) coffee. For ground coffee, Medium-Dark and Dark roasts had significantly higher emissions than Medium and Light roasts. Worst-case emissions factors from commercially-available whole and ground coffee measured in loose-form, not packaged, showed that roasted coffee can rapidly emit CO. CO concentrations should be monitored in storage spaces in service and manufacturing facilities as well as transport vessels to ensure exposures do not exceed occupational exposure limits. Storage spaces may need to be ventilated to control CO concentrations to safe levels.

    • Parasitic Diseases
      1. An important component of malaria control programs is the ability to assess the effectiveness of the insecticide in insecticide-treated nets (ITNs) during normal usage. The standard technique to measure insecticidal activity is the World Health Organization (WHO) cone test, which in many circumstances, may be difficult to implement. We have evaluated an alternative technique, the colorimetric field test (CFT) on a group of 24-month-old Permanet((R)) 2.0 nets collected in Colombia. The CFT, which measures surface levels (SL) of deltamethrin is compared with standard high-performance liquid chromatography (HPLC) and the WHO cone test. Effective concentrations of deltamethrin for 80% mortality (EC80) were determined from the CFT and HPLC results. Distribution of insecticide SL after 24 months of use reveal that sampling of the midsection best represents the condition of the entire net. We conclude that the CFT is a practical alternative to the WHO cone test for assessing ITN efficacy.

      2. Rapid epidemiological and entomological survey for validation of reported indicators and characterization of local malaria transmission in Guinea, 2017External
        Camara A, Guilavogui T, Keita K, Dioubate M, Barry Y, Camara D, Loua Z, Kaba I, Bah I, Haba MP, Koivogui Z, Conde M, Fofana A, Loua E, Camara S, Sarr A, Irish SR, Plucinski MM.
        Am J Trop Med Hyg. 2018 Aug 20.

        To confirm and investigate possible explanations for unusual trends in malaria indicators, a protocol for rapid, focal assessment of malaria transmission, and control interventions was piloted in N’Zerekore and Macenta Prefectures, which each reported surprisingly low incidence of malaria during the peak transmission months during 2017 in holoendemic Forested Guinea. In each prefecture, epidemiological, and entomological cross-sectional surveys were conducted in two sub-prefectures reporting high incidence and one sub-prefecture reporting low incidence. Investigators visited six health facilities and 356 households, tested 476 children, performed 14 larval breeding site transects, and conducted 12 nights of human landing catches during the 2-week investigation. Rapid diagnostic test positivity in the community sample of children under five ranged from 23% to 68% by subprefecture. Only 38% of persons with fever reported seeking care in the public health sector; underutilization was confirmed by verification of health facility and community healthcare worker (CHW) registries. High numbers of Anopheles mosquitoes were collected in human landing collections in N’Zerekore (38 per night in combined indoor and outdoor collections) and Macenta (87). Most of the detected breeding sites positive for Anopheles larvae (83%) were shallow roadside puddles. In the investigated prefectures, malaria rates remain high and the low reported incidence likely reflects low utilization of the public health-care sector. Strengthening the CHW program to rapidly identify and treat malaria cases and elimination of roadside puddles as part of routine cleanup campaigns should be considered. Systematic joint epidemiological/entomological investigations in areas reporting anomalous signals in routine data can allow control programs to respond with tailored local interventions.

    • Physical Activity
      1. Secular changes in physical education attendance among U.S. high school students, 1991-2015External
        Clennin MN, Demissie Z, Michael SL, Wright C, Silverman S, Chriqui J, Pate RR.
        Res Q Exerc Sport. 2018 Aug 28:1-8.

        PURPOSE: The purpose of this study was to examine changes in school-based physical education (PE) attendance over time among nationally representative samples of U.S. high school students and how changes in PE attendance have varied across demographic subgroups. METHOD: Student demographic information and PE attendance data were obtained from 13 biennial cycles (1991-2015) of the national Youth Risk Behavior Survey (YRBS). Physical education variables derived from YRBS data included PE attendance, daily PE, average PE days/week, and PE frequency. Logistic regression models examined trends in PE attendance, daily PE, and PE frequency for the overall sample and demographic subgroups. Linear regression models examined trends in average PE days/week in the overall sample only. RESULTS: Overall, there was no significant change in the percentage of students reporting PE attendance during 1991 to 2015. However, daily PE and average PE days/week declined significantly from 1991 to 1995 (41.6% to 25.4% and 4.64 days to 3.64 days, respectively) and then remained stable through 2015 (29.8% and 4.11 days, respectively). The percentage of students reporting a PE frequency of 3 days per week increased significantly from 1991 to 1995 (1.5% to 19.0%) before stabilizing through 2015 (9.1%). Trends across demographic subgroups revealed notable differences in PE attendance. CONCLUSIONS: Study findings showed that U.S. schools have not substantially reduced PE amounts in recent years. Still, the prevalence of PE attendance among U.S. high school students is well below recommendations. For PE to contribute to increased adolescent compliance with national physical activity guidelines, significant policy actions are needed to improve PE access for all students.

      2. Transportation and leisure walking among U.S. adults: Trends in reported prevalence and volume, National Health Interview Survey 2005-2015External
        Ussery EN, Carlson SA, Whitfield GP, Watson KB, Berrigan D, Fulton JE.
        Am J Prev Med. 2018 Aug 20.

        INTRODUCTION: Promotion of walking is a promising strategy for increasing physical activity levels in the U.S. The proportion of adults who report walking for either transportation or leisure has increased in recent years, but evidence on trends in walking for specific purposes is limited. METHODS: The 2005, 2010, and 2015 National Health Interview Survey assessed self-reported participation in and volume (minutes/week) of walking for transportation and leisure in the past week among adults aged >/=18 years. Linear and quadratic trends in the prevalence and mean volume of walking for each purpose were evaluated using logistic and linear regression. Analyses were performed in 2017. RESULTS: The prevalence of transportation walking increased from 28.4% (2005) to 31.7% (2015) (linear trend: p<0.05). Leisure walking prevalence increased from 42.1% (2005) to 52.1% (2015), but the increased stalled from 2010 to 2015 with only a 2.3 percentage point increase (linear and quadratic trends: p<0.05). Across purposes, the mean walking volume decreased from 2005 to 2015, with no significant changes between 2010 and 2015 (linear and quadratic trends: p<0.05). The proportion of adults who walked for both transportation and leisure in the past week increased steadily (linear trend: p<0.05), and this group reported the greatest total volume of walking. CONCLUSIONS: Although the prevalence of self-reported transportation and leisure walking increased during the last decade, the time spent walking has decreased. Strategies that encourage walking for multiple purposes may present an opportunity for increasing both participation in walking and the amount of time spent walking.

    • Reproductive Health
      1. FDA Public Meeting Report on “Drug Interactions With Hormonal Contraceptives: Public Health and Drug Development Implications”External
        Akbar M, Berry-Bibee E, Blithe DL, Day RS, Edelman A, Hochel J, Jamshidi R, Kim MJ, Li L, Purohit VS, Turpin JA, Scott PE, Strauss DG, Sun H, Tepper NK, Zhang L, Yu C.
        J Clin Pharmacol. 2018 Aug 24.

        Potential drug interactions with hormonal contraceptives are an important public health concern. A public meeting on “Drug Interactions With Hormonal Contraceptives: Public Health and Drug Development Implication” was hosted by the United States Food and Drug Administration (FDA). The meeting endeavored to provide an opportunity for the FDA to seek input from experts on the public health concerns associated with the use of hormonal contraceptives and interacting drugs that might affect efficacy and safety, including pharmacokinetic/pharmacodynamic considerations, in the design of drug interaction studies of hormonal contraceptives for drug development and approaches to translating the results of drug interaction information into informative labeling and communication. The input received could be used to refine FDA’s thinking on hormonal contraceptives drug interaction study design and interpretation and labeling communication of drug interaction risk. This meeting benefited from strong and diverse participation from the Center for Drug Evaluation and Research at the FDA, Centers for Disease Control and Prevention, National Institutes of Health, Swedish Medical Products Agency, pharmaceutical industry, and representatives of academia. This report provides a summary of the key discussion based on the presentations and panel discussion.

      2. Building community support using a modified World Cafe method for pregnant and parenting teenagers in Forsyth County, North CarolinaExternal
        Johnson SM, Trejo G, Beck KL, Worsley C, Tranberg H, Plax KL, Linton JM.
        J Pediatr Adolesc Gynecol. 2018 Jun 28.

        STUDY OBJECTIVE: To identify community priorities, foster awareness of existing supports, and recognize barriers and opportunities to enhance support services for pregnant and parenting teens (PPTs). DESIGN AND SETTING: A modified World Cafe event incorporated parallel, rotating focus groups with semistructured, case-based discussions of salient issues. The event was organized and took place in Forsyth County, North Carolina. PARTICIPANTS: Seventy-eight local health and social service professionals and 15 PPT representatives. INTERVENTIONS AND MAIN OUTCOME MEASURES: Qualitative coding was used to thematically analyze transcript data. Quantitative data pre-/post-event comparisons were made using Fisher exact test. RESULTS: Key community-based support services for PPTs were identified. Qualitative analysis yielded 10 key codes regarding barriers and opportunities to enhance community-based support services, resulting in 4 themes. Themes included maximizing access and efficient delivery of high-quality health care, engaging a 3-generation approach to meet the current and future needs of at-risk families, focusing efforts to meet the unique needs of each teen and his/her family, and emphasizing teen self-advocacy. Pre/post survey responses were overwhelmingly positive regarding use of the modified World Cafe format for discussion and network building. CONCLUSION: The modified World Cafe Method offered a platform to collaboratively identify challenges and opportunities and to develop networks to improve health and well-being of PPTs. Engaging multiple stakeholders in meaningful dialogue might foster multidisciplinary, cross-sector collaboration that mitigates risk and enhances resilience among PPTs and their children.

      3. Use of secondary contraception following vasectomy: insights from the Pregnancy Risk Assessment Monitoring System, 2007-2011External
        Patel DP, Williams L, Warner L, O’Neil ME, Aston K, Carrell DT, Grigorescu V, Jamieson DJ, Gannon JR, Eisenberg ML, Walsh TJ, Hotaling JM.
        Transl Androl Urol. 2018 Jul;7(Suppl 3):S264-s270.

        Background: To assess postpartum use of secondary contraception with vasectomy within Pregnancy Risk Assessment Monitoring System (PRAMS). Methods: Secondary contraception and type of method used were assessed among married women reporting partner vasectomy 4 months after a recent live birth in female residents of 15 US states and New York City who participated in the 2007-2011 PRAMS. Results: Between 2007 and 2011, 1,004 married women who had a recent live birth participating in PRAMS reported they and their partners relied on vasectomy for postpartum contraception. Among these couples, 57.8% reported not using additional forms of contraception postpartum. Of those reporting additional contraception, condoms were most commonly used (50.0%), followed by oral contraceptive pills (26.5%), and withdrawal (9.5%). Multivariable modeling showed that use of secondary contraception was twice as high among women reporting a second birth versus women reporting a fourth or higher birth [adjusted prevalence odds ratio (POR) =2.0 (1.1-3.2)]. No other sociodemographic characteristics (maternal age, maternal race, parental education, household income) were significantly associated with use of secondary contraception with vasectomy. Conclusions: Most couples within PRAMS reporting partner vasectomy as postpartum contraception did not use secondary contraception in the months immediately after vasectomy, and, of those who did, most relied on less effective methods. Clinicians need to better understand reasons for limited use of secondary contraception with vasectomy to improve counseling strategies for reducing unintended pregnancy.

    • Social and Behavioral Sciences
      1. Outcomes of an individual counselling programme in Grozny, Chechnya: a randomised controlled studyExternal
        Lenglet A, Lopes-Cardozo B, Shanks L, Blanton C, Feo C, Tsatsaeva Z, Idrisov K, Bolton PA, Pintaldi G.
        BMJ Open. 2018 Aug 23;8(8):e019794.

        OBJECTIVES: To evaluate the effectiveness of individual counselling on functioning of clients participating in a mental health intervention in a humanitarian setting. DESIGN: Randomised controlled trial. SETTING: Mental health programme implemented by Medecins Sans Frontieres in Grozny, Republic of Chechnya. PARTICIPANTS: 168 eligible clients were randomly assigned to the intervention and waitlisted (2 months) arms between November 2014 and February 2015. INTERVENTION: Individual counselling sessions. MAIN OUTCOME MEASURES: Change in functioning was measured using the Short Form 6 (SF6) and gender-specific locally adapted Chechen functioning instruments in the intervention group at the end of counselling and the waitlisted group after their waitlisted period. Unadjusted differences in gain scores (DGSs) between intervention and waitlisted groups were calculated with effect size (Cohen’s d) for both tools. Linear regression compared the mean DGS in both groups. RESULTS: The intervention group (n=78) improved compared with waitlisted controls (n=80) on the SF6 measures with moderate to large effect sizes: general health (DGS 12.14, d=0.52), body pain (DGS 10.26, d=0.35), social support (DGS 16.07, d=0.69) and emotional functioning (DGS 16.87, d=0.91). Similar improvement was seen using the Chechen functioning instrument score (female DGS -0.33, d=0.55; male DGS -0.40, d=0.99). Adjusted analysis showed significant improvement (p<0.05) in the intervention group for all SF6 measures and for the Chechen functioning instrument score in women but not men (p=0.07). CONCLUSIONS: Individual counselling significantly improved participants’ ability to function in the intervention group compared with the waitlisted group. Further research is needed to determine whether similar positive results can be shown in other settings and further exploring the impact in male clients’ population. TRIAL REGISTRATION NUMBER: NTR4689.

    • Substance Use and Abuse
      1. Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016-June 2017External
        Mattson CL, O’Donnell J, Kariisa M, Seth P, Scholl L, Gladden RM.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 31;67(34):945-951.

        In 2016, 63,632 drug overdose deaths occurred in the United States, 42,249 (66.4%) of which involved opioids (1). The development of prevention programs are hampered by a lack of timely data on specific substances contributing to and circumstances associated with fatal overdoses. This report describes opioid overdose deaths (referred to as opioid deaths) for decedents testing positive for prescription opioids (e.g., oxycodone and hydrocodone), illicit opioids (e.g., heroin, illicitly manufactured fentanyl, and fentanyl analogs), or both prescription and illicit opioids, and describes circumstances surrounding the overdoses, in 11 states participating in CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program.* During July 2016-June 2017, among 11,884 opioid overdose deaths, 17.4% of decedents tested positive for prescription opioids only, 58.7% for illicit opioids only, and 18.5% for both prescription and illicit opioids (type of opioid could not be classified in 649 [5.5%] deaths). Approximately one in 10 decedents had been released from an institutional setting in the month preceding the fatal overdose. Bystanders were reportedly present in approximately 40% of deaths; however, naloxone was rarely administered by a layperson. Enhanced surveillance data from 11 states provided more complete information on the substances involved in and circumstances surrounding opioid overdose deaths. Consistent with other emerging evidence and recommendations,(dagger) these data suggest prevention efforts should prioritize naloxone distribution to persons misusing opioids or using high dosage prescription opioids and to their family members and friends. In addition, these data suggest a need to expand treatment and support for persons who have experienced a nonfatal overdose and to expand treatment in detention facilities and upon release.

      2. Racial/ethnic disparities in tobacco product use among middle and high school students – United States, 2014-2017External
        Odani S, Armour BS, Agaku IT.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 31;67(34):952-957.

        During the past few decades, wide disparities in tobacco product use have been documented among the largest racial/ethnic groups in the United States (1,2); however, little is known about tobacco product use among youths from racial/ethnic groups other than whites, blacks, and Hispanics. Surveillance reports typically aggregate these racial/ethnic minorities into a single category because of small sample sizes (3). To assess tobacco product use among U.S. middle and high school students from seven racial/ethnic groups (non-Hispanic whites [whites], non-Hispanic blacks [blacks], Hispanics, non-Hispanic Asians [Asians], non-Hispanic American Indian/Alaska natives [AI/ANs], non-Hispanic Native Hawaiians/Other Pacific Islanders [NHOPIs], and non-Hispanic multiracial persons [multiracial]), CDC analyzed pooled data from the 2014-2017 National Youth Tobacco Surveys (NYTS). Prevalence of ever (>/=1 time in lifetime) and current (>/=1 time in past 30 days) use of seven tobacco products (cigarettes, cigars, smokeless tobacco, electronic cigarettes [e-cigarettes], hookahs, pipes, and bidis) was assessed; any tobacco product use was defined as use of one or more tobacco products, including hand-rolled cigarettes. During 2014-2017, ever-use of any tobacco product among U.S. middle and high school students was as follows: NHOPIs (45.1%), AI/ANs (43.8%), multiracial persons (38.2%), Hispanics (35.1%), blacks (32.3%), whites (32.0%), and Asians (16.3%). Current use of any tobacco product was as follows: NHOPIs (23.4%), AI/ANs (20.6%), multiracial persons (16.5%), whites (15.3%), Hispanics (14.6%), blacks (11.5%), and Asians (5.0%). Among black middle and high school students, cigars were the most common product currently used, whereas e-cigarettes were the most commonly used product for all other racial/ethnic groups. Comprehensive and sustained implementation of evidence-based, population-level tobacco control interventions could reduce prevalence and disparities in tobacco product use among U.S. youths.

    • Zoonotic and Vectorborne Diseases
      1. Reassessing serosurvey-based estimates of the Zika symptomatic proportionExternal
        Mitchell PK, Mier-Y-Teran-Romero L, Biggerstaff BJ, Delorey MJ, Aubry M, Cao-Lormeau VM, Lozier MJ, Cauchemez S, Johansson MA.
        Am J Epidemiol. 2018 Aug 28.

        Since the 2007 Zika epidemic in Yap, it has been apparent that not all people infected with Zika virus (ZIKV) experience symptoms. However, the proportion of infections that result in symptoms remains unclear. Existing estimates varied in their interpretation of symptoms due to other causes and the case definition used, and assumed perfect test sensitivity and specificity. Using a Bayesian model and data from ZIKV serosurveys in Yap (2007), French Polynesia (2013-14), and Puerto Rico (2016), we found that assuming perfect sensitivity and specificity generally led to lower estimates of the symptomatic proportion. Incorporating reasonable assumptions for assay sensitivity and specificity, we estimated that 27% (95% Credible Interval: 15-37%) (Yap), 44% (26-66%) (French Polynesia), and 50% (34-92%) (Puerto Rico) of infections were symptomatic, with variation due to differences in study populations, study designs, and case definitions. The proportion of ZIKV infections causing symptoms is critical for surveillance system design and impact assessment. Here, we accounted for key uncertainties in existing seroprevalence data and found that estimates for the symptomatic proportion ranged from 27% to 50%, suggesting that while the majority of infections are asymptomatic or mildly symptomatic, symptomatic infections might be more common than previously estimated.

      2. A large leptospirosis outbreak following successive severe floods in Fiji, 2012External
        Togami E, Kama M, Goarant C, Craig SB, Lau C, Ritter JM, Imrie A, Ko A, Nilles E.
        Am J Trop Med Hyg. 2018 Aug 20.

        Severe flooding has been linked to outbreaks of leptospirosis. Two sequential extreme flood events in Western Fiji caused the largest outbreak of leptospirosis recorded in the South Pacific, with 1,217 total suspected cases, of which 314 were probable and confirmed. Most (83%) cases occurred within 6 weeks of the flood events, displaying a biphasic epidemic curve associated with the floods. Given the temporal proximity of cases to flooding events, most of the transmission appeared to occur during or immediately after the floods; therefore, prevention of exposure to contaminated environments is a priority in the immediate flood and post-flood period. In addition, genotyping studies suggest that multiple animal reservoirs were implicated in the outbreak, reaffirming the importance of integrated human and animal health strategies for leptospirosis control.

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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