Volume 10, Issue 35, September 18, 2018

CDC Science Clips: Volume 10, Issue 35, September 18, 2018

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

  1. CDC Public Health Grand Rounds
    • Maternal and Child Health – Surveillance for Emerging Threats
      1. Protecting mothers and babies – a delicate balancing actExternal
        Rasmussen SA, Barfield W, Honein MA.
        N Engl J Med. 2018 Sep 6;379(10):907-909.

        [No abstract]

      2. The 2014 to 2016 Ebola virus disease (EVD) outbreak in West Africa devastated local health systems and caused thousands of deaths. Historical reports from Zaire ebolavirus outbreaks suggested pregnancy was associated with an increased risk of severe illness and death, with mortality rates from 74 to 100%. In total, 111 cases of pregnant patients with EVD are reported in the literature, with an aggregate maternal mortality of 86%. Pregnancy-specific data published from the recent outbreak include four small descriptive cohort studies and five case reports. Despite limitations including reporting bias and small sample size, these studies suggest mortality in pregnant women may be lower than previously reported, with five of 13 (39%) infected women dying. Optimal treatments for pregnant women, and differences in EVD course between pregnant women and nonpregnant individuals, are major scientific gaps that have not yet been systematically addressed. Ebola virus may be transmitted from mother to baby in utero, during delivery, or through contact with maternal body fluids after birth including breast milk. EVD is almost universally fatal to the developing fetus, and limited fetal autopsy data prevent inferences on risk of birth defects. Decisions about delivery mode and other obstetric interventions should be individualized. WHO recommends close monitoring of survivors who later become pregnant, but does not recommend enhanced precautions at subsequent delivery. Although sexual transmission of Ebola virus has been documented, birth outcomes among survivors have not been published and will be important to appropriately counsel women on pregnancy outcomes and inform delivery precautions for healthcare providers. Birth Defects Research 109:353-362, 2017. (c) 2017 Wiley Periodicals, Inc.

      3. Public health approach to addressing the needs of children affected by congenital Zika syndromeExternal
        Broussard CS, Shapiro-Mendoza CK, Peacock G, Rasmussen SA, Mai CT, Petersen EE, Galang RR, Newsome K, Reynolds MR, Gilboa SM, Boyle CA, Moore CA.
        Pediatrics. 2018 Feb;141(Suppl 2):S146-s153.

        We have learned much about the short-term sequelae of congenital Zika virus (ZIKV) infection since the Centers for Disease Control and Prevention activated its ZIKV emergency response in January 2016. Nevertheless, gaps remain in our understanding of the full spectrum of adverse health outcomes related to congenital ZIKV infection and how to optimize health in those who are affected. To address the remaining knowledge gaps, support affected children so they can reach their full potential, and make the best use of available resources, a carefully planned public health approach in partnership with pediatric health care providers is needed. An essential step is to use population-based data captured through surveillance systems to describe congenital Zika syndrome. Another key step is using collected data to investigate why some children exhibit certain sequelae during infancy and beyond, whereas others do not, and to describe the clustering of anomalies and the timing of when these anomalies occur, among other research questions. The final critical step in the public health framework for congenital Zika syndrome is an intervention strategy with evidence-based best practices for longer-term monitoring and care. Adherence to recommended evaluation and management procedures for infants with possible congenital ZIKV infection, including for those with less obvious developmental and medical needs at birth, is essential. It will take many years to fully understand the effects of ZIKV on those who are congenitally infected; however, the lifetime medical and educational costs as well as the emotional impact on affected children and families are likely to be substantial.

      4. Population-based pregnancy and birth defects surveillance in the era of Zika virusExternal
        Gilboa SM, Mai CT, Shapiro-Mendoza CK, Cragan JD, Moore CA, Meaney-Delman DM, Jamieson DJ, Honein MA, Boyle CA.
        Birth Defects Res. 2017 Mar 15;109(5):372-378.

        BACKGROUND: Zika virus is a newly recognized human teratogen; monitoring its impact on the birth prevalence of microcephaly and other adverse pregnancy outcomes will continue to be an urgent need in the United States and worldwide. METHODS: When the Centers for Disease Control and Prevention (CDC) activated the Emergency Operations Center for the Zika virus outbreak response in January of 2016, public health leadership recognized that a joint, coordinated effort was required between activities focused on the effects of the infection among pregnant women and those focused on birth defects in fetuses and infants. Before the introduction of Zika virus in the Americas, population-based birth defects surveillance occurred independently of pregnancy surveillance activities. RESULTS: The coordination of pregnancy surveillance and birth defects surveillance implemented through the CDC Zika virus response represents a paradigm shift. CONCLUSION: Coordination of these surveillance systems provides an opportunity to capture information from both a prospective and retrospective approach. This relatively modest investment in the public health infrastructure can continue to protect pregnant women and their infants during the ongoing response to Zika virus and in the next emergent threat to maternal and child health. Birth Defects Research 109:372-378, 2017. (c) 2017 Wiley Periodicals, Inc.

      5. Opioid use disorder documented at delivery hospitalization – United States, 1999-2014External
        Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 10;67(31):845-849.

        Opioid use by pregnant women represents a significant public health concern given the association of opioid exposure and adverse maternal and neonatal outcomes, including preterm labor, stillbirth, neonatal abstinence syndrome, and maternal mortality (1,2). State-level actions are critical to curbing the opioid epidemic through programs and policies to reduce use of prescription opioids and illegal opioids including heroin and illicitly manufactured fentanyl, both of which contribute to the epidemic (3). Hospital discharge data from the 1999-2014 Healthcare Cost and Utilization Project (HCUP) were analyzed to describe U.S. national and state-specific trends in opioid use disorder documented at delivery hospitalization. Nationally, the prevalence of opioid use disorder more than quadrupled during 1999-2014 (from 1.5 per 1,000 delivery hospitalizations to 6.5; p<0.05). Increasing trends over time were observed in all 28 states with available data (p<0.05). In 2014, prevalence ranged from 0.7 in the District of Columbia (DC) to 48.6 in Vermont. Continued national, state, and provider efforts to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women are needed. Efforts might include improved access to data in Prescription Drug Monitoring Programs, increased substance abuse screening, use of medication-assisted therapy, and substance abuse treatment referrals.

      6. BACKGROUND: Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts and (2) develop a classification framework to better describe why reported cases were not averted. METHODS: We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days before delivery, as well as the proportion of potential congenital syphilis cases averted. RESULTS: Among the 2508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days before delivery, 89.4% were tested for syphilis at least 30 days before delivery, and 76.9% received an adequate treatment regimen that began at least 30 days before delivery. Overall, an estimated 1928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%. CONCLUSIONS: Although the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.

      7. Emerging infections and pregnancy: assessing the impact on the embryo or fetusExternal
        Rasmussen SA, Hayes EB, Jamieson DJ, O’Leary DR.
        Am J Med Genet A. 2007 Dec 15;143a(24):2896-903.

        The teratogenicity of several infections when acquired during pregnancy is well documented. However, for emerging infections (defined as those for which the incidence has risen in the past two decades or threatens to rise in the near future), the prenatal effects are often unknown, raising concern among women and their health care providers. Investigation of these effects is essential to ensure that pregnant women are appropriately assessed, advised, and treated, but such investigation is often challenging. The impact of emerging infections on the embryo or fetus is difficult to predict and varies depending on the agent and gestational timing of infection. Some women might be asymptomatic or have only mild or nonspecific symptoms, and thus, not be identified as infected, even when the embryo or fetus is severely affected. In addition, diagnosing congenital infection is often complicated. This article will discuss challenges to studying the teratogenicity of emerging infections, advantages, and disadvantages of different study designs, and examples of previous studies of the effects of emerging infections on the embryo or fetus.

      8. Preparing for influenza after 2009 H1N1: special considerations for pregnant women and newbornsExternal
        Rasmussen SA, Kissin DM, Yeung LF, MacFarlane K, Chu SY, Turcios-Ruiz RM, Mitchell EW, Williams J, Fry AM, Hageman J, Uyeki TM, Jamieson DJ.
        Am J Obstet Gynecol. 2011 Jun;204(6 Suppl 1):S13-20.

        Pregnant women and their newborn infants are at increased risk for influenza-associated complications, based on data from seasonal influenza and influenza pandemics. The Centers for Disease Control and Prevention (CDC) developed public health recommendations for these populations in response to the 2009 H1N1 pandemic. A review of these recommendations and information that was collected during the pandemic is needed to prepare for future influenza seasons and pandemics. The CDC convened a meeting entitled “Pandemic Influenza Revisited: Special Considerations for Pregnant Women and Newborns” on August 12-13, 2010, to gain input from experts and key partners on 4 main topics: antiviral prophylaxis and therapy, vaccine use, intrapartum/newborn (including infection control) issues, and nonpharmaceutical interventions and health care planning. Challenges to communicating recommendations regarding influenza to pregnant women and their health care providers were also discussed. After careful consideration of the available information and individual expert input, the CDC updated its recommendations for these populations for future influenza seasons and pandemics.

      9. Vital Signs: Zika-associated birth defects and neurodevelopmental abnormalities possibly associated with congenital Zika virus infection – U.S. territories and freely associated states, 2018External
        Rice ME, Galang RR, Roth NM, Ellington SR, Moore CA, Valencia-Prado M, Ellis EM, Tufa AJ, Taulung LA, Alfred JM, Perez-Padilla J, Delgado-Lopez CA, Zaki SR, Reagan-Steiner S, Bhatnagar J, Nahabedian JF, Reynolds MR, Yeargin-Allsopp M, Viens LJ, Olson SM, Jones AM, Baez-Santiago MA, Oppong-Twene P, VanMaldeghem K, Simon EL, Moore JT, Polen KD, Hillman B, Ropeti R, Nieves-Ferrer L, Marcano-Huertas M, Masao CA, Anzures EJ, Hansen RL, Perez-Gonzalez SI, Espinet-Crespo CP, Luciano-Roman M, Shapiro-Mendoza CK, Gilboa SM, Honein MA.
        MMWR Morb Mortal Wkly Rep. 2018 Aug 10;67(31):858-867.

        INTRODUCTION: Zika virus infection during pregnancy causes serious birth defects and might be associated with neurodevelopmental abnormalities in children. Early identification of and intervention for neurodevelopmental problems can improve cognitive, social, and behavioral functioning. METHODS: Pregnancies with laboratory evidence of confirmed or possible Zika virus infection and infants resulting from these pregnancies are included in the U.S. Zika Pregnancy and Infant Registry (USZPIR) and followed through active surveillance methods. This report includes data on children aged >/=1 year born in U.S. territories and freely associated states. Receipt of reported follow-up care was assessed, and data were reviewed to identify Zika-associated birth defects and neurodevelopmental abnormalities possibly associated with congenital Zika virus infection. RESULTS: Among 1,450 children of mothers with laboratory evidence of confirmed or possible Zika virus infection during pregnancy and with reported follow-up care, 76% had developmental screening or evaluation, 60% had postnatal neuroimaging, 48% had automated auditory brainstem response-based hearing screen or evaluation, and 36% had an ophthalmologic evaluation. Among evaluated children, 6% had at least one Zika-associated birth defect identified, 9% had at least one neurodevelopmental abnormality possibly associated with congenital Zika virus infection identified, and 1% had both. CONCLUSION: One in seven evaluated children had a Zika-associated birth defect, a neurodevelopmental abnormality possibly associated with congenital Zika virus infection, or both reported to the USZPIR. Given that most children did not have evidence of all recommended evaluations, additional anomalies might not have been identified. Careful monitoring and evaluation of children born to mothers with evidence of Zika virus infection during pregnancy is essential for ensuring early detection of possible disabilities and early referral to intervention services.

      10. Preparing for biological threats: Addressing the needs of pregnant womenExternal
        Watson AK, Ellington S, Nelson C, Treadwell T, Jamieson DJ, Meaney-Delman DM.
        Birth Defects Res. 2017 Mar 15;109(5):391-398.

        Intentional release of infectious agents and biological weapons to cause illness and death has the potential to greatly impact pregnant women and their fetuses. We review what is known about the maternal and fetal effects of seven biological threats: Bacillus anthracis (anthrax); variola virus (smallpox); Clostridium botulinum toxin (botulism); Burkholderia mallei (glanders) and Burkholderia pseudomallei (melioidosis); Yersinia pestis (plague); Francisella tularensis (tularemia); and Rickettsia prowazekii (typhus). Evaluating the potential maternal, fetal, and infant consequences of an intentional release of an infectious agent requires an assessment of several key issues: (1) are pregnant women more susceptible to infection or illness compared to the general population?; (2) are pregnant women at increased risk for severe illness, morbidity, and mortality compared to the general population?; (3) does infection or illness during pregnancy place women, the fetus, or the infant at increased risk for adverse outcomes and how does this affect clinical management?; and (4) are the medical countermeasures recommended for the general population safe and effective during pregnancy? These issues help frame national guidance for the care of pregnant women during an intentional release of a biological threat. Birth Defects Research 109:391-398, 2017.(c) 2017 Wiley Periodicals, Inc.

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

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

      12. Neural-tube defects with dolutegravir treatment from the time of conceptionExternal
        Zash R, Makhema J, Shapiro RL.
        N Engl J Med. 2018 Sep 6;379(10):979-981.

        [No abstract]

  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. Global trends in diabetes complications: a review of current evidenceExternal
        Harding JL, Pavkov ME, Magliano DJ, Shaw JE, Gregg EW.
        Diabetologia. 2018 Aug 31.

        In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

      2. Vital Signs: State-level variation in nonfatal and fatal cardiovascular events targeted for prevention by Million Hearts 2022External
        Ritchey MD, Wall HK, Owens PL, Wright JS.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):974-982.

        INTRODUCTION: Despite its preventability, cardiovascular disease remains a leading cause of morbidity, mortality, and health care costs in the United States. This study describes the burden, in 2016, of nonfatal and fatal cardiovascular events targeted for prevention by Million Hearts 2022, a national initiative working to prevent one million cardiovascular events during 2017-2021. METHODS: Emergency department (ED) visits and hospitalizations were identified using Healthcare Cost and Utilization Project databases, and deaths were identified using National Vital Statistics System data. Age-standardized Million Hearts-preventable event rates and hospitalization costs among adults aged >/=18 years in 2016 are described nationally and across states, as data permit. Expected 2017-2021 event totals and hospitalization costs were estimated assuming 2016 values remain unchanged. RESULTS: Nationally, in 2016, 2.2 million hospitalizations (850.9 per 100,000 population) resulting in $32.7 billion in costs, and 415,480 deaths (157.4 per 100,000) occurred. Hospitalization and mortality rates were highest among men (989.6 and 172.3 per 100,000, respectively) and non-Hispanic blacks (211.6 per 100,000, mortality only) and increased with age. However, 805,000 hospitalizations and 75,245 deaths occurred among adults aged 18-64 years. State-level variation occurred in rates of ED visits (from 56.4 [Connecticut] to 274.8 per 100,000 [Kentucky]), hospitalizations (484.0 [Wyoming] to 1670.3 per 100,000 [DC]), and mortality (111.2 [Vermont] to 267.3 per 100,000 [Mississippi]). Approximately 16.3 million events and $173.7 billion in hospitalization costs could occur during 2017-2021 without preventive intervention. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Million Hearts-preventable events place a considerable health and economic burden on the United States. With coordinated efforts, many of these events could be prevented in every state to achieve the initiative’s goal.

      3. Vital Signs: Prevalence of key cardiovascular disease risk factors for Million Hearts 2022 – United States, 2011-2016External
        Wall HK, Ritchey MD, Gillespie C, Omura JD, Jamal A, George MG.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):983-991.

        INTRODUCTION: Despite decades-long reductions in cardiovascular disease (CVD) mortality, CVD mortality rates have recently plateaued and even increased in some subgroups, and the prevalence of CVD risk factors remains high. Million Hearts 2022, a 5-year initiative, was launched in 2017 to address this burden. This report establishes a baseline for the CVD risk factors targeted for reduction by the initiative during 2017-2021 and highlights recent changes over time. METHODS: Risk factor prevalence among U.S. adults was assessed using data from the National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, and National Health Interview Survey. Multivariate analyses were performed to assess differences in prevalence during 2011-2012 and the most recent cycle of available data, and across subgroups. RESULTS: During 2013-2014, the prevalences of aspirin use for primary and secondary CVD prevention were 27.4% and 74.9%, respectively, and of statin use for cholesterol management was 54.5%. During 2015-2016, the average daily sodium intake was 3,535 mg/day and the prevalences of blood pressure control, combustible tobacco use, and physical inactivity were 48.5%, 22.3%, and 29.1%, respectively. Compared with 2011-2012, significant decreases occurred in the prevalences of combustible tobacco use and physical inactivity; however, a decrease also occurred for aspirin use for primary or secondary prevention. Disparities in risk factor prevalences were observed across age groups, genders, and racial/ethnic groups. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Millions of Americans have CVD risk factors that place them at increased risk for having a cardiovascular event, despite the existence of proven strategies for preventing or managing CVD risk factors. A concerted effort to implement these strategies will be needed to prevent one million acute cardiovascular events during the 5-year initiative.

      4. From 95,196 sample adults in the combined 2010, 2013, and 2015 U.S. National Health Interview Survey, we estimated the association between histories of epilepsy and heart disease after accounting for sociodemographic characteristics and behavioral risk factors. Adults 18years old or older with an epilepsy history reported heart disease (21%) about nine percentage points more often than those without such a history (12%), overall and within levels of characteristics and risk factors. These increases in heart disease history for adults with an epilepsy history compared with adults without such a history were greater in those 45-64 years old or at the lowest family income levels. These increases of heart disease in adults with an epilepsy history highlight two needs-to prevent the occurrence of heart disease and to reduce its consequences. Because comorbidity from heart disease can complicate epilepsy management, physicians caring for those with epilepsy should be aware of these increased risks, identify risk factors for heart disease, and recommend to their patients with epilepsy ways to diminish these risks.

    • Communicable Diseases
      1. Men who have sex with men (MSM) who have not previously tested for HIV: Results from the MSM Testing Initiative, United States (2012-2015)External
        Clark HA, Oraka E, DiNenno EA, Wesolowski LG, Chavez PR, Pitasi MA, Delaney KP.
        AIDS Behav. 2018 Sep 1.

        The Centers for Disease Control and Prevention recommends annual HIV tests for men who have sex with men (MSM), yet some have never tested. We analyzed data from the MSM Testing Initiative. Of 68,185 HIV tests, 8% were with MSM who never previously tested (“first-time testers”). Among tests with first-time testers, 70.7% were with MSM from racial or ethnic minorities; 66.5% were with MSM younger than 30 years. Tests with MSM who reported female partners only during the past year (compared to male partners only) or were recruited for at-home testing (compared to venue-based recruitment) were 4 times (prevalence ratio [PR] 3.62, 95% CI 3.15-4.15) and 5 times as likely (PR 4.69, 95% CI 4.22-5.21) to be associated with first-time testing. At-home testing and focusing on MSM who have sex with women may be effective methods for reaching MSM who are first-time testers.

      2. Ocular syphilis and HIV coinfection among syphilis patients in North Carolina, 2014-2016External
        Cope AB, Mobley VL, Oliver SE, Larson M, Dzialowy N, Maxwell J, Rinsky JL, Peterman TA, Fleischauer A, Samoff E.
        Sex Transm Dis. 2018 Aug 31.

        BACKGROUND: Ocular syphilis (OS) has been associated with HIV coinfection previously. We compared demographic and clinical characteristics of syphilis patients with and without HIV to identify risk factors for developing OS. METHODS: We reviewed all syphilis cases (early and late) reported to the North Carolina (NC) Division of Public Health during 2014-2016 and categorized HIV status (positive, negative, unknown) and OS status based on report of ocular symptoms with no other defined etiology. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) for OS by HIV status. Among syphilis patients with HIV, we compared viral loads and CD4 cell counts by OS status. We compared symptom resolution by HIV status for a subset of OS patients. RESULTS: Among 7,123 confirmed syphilis cases, 2,846 (39.9%) were living with HIV, 109 (1.5%) had OS, and 59 (0.8%) had both. OS was more prevalent in syphilis patients with HIV compared to HIV-negative/unknown-status patients (PR: 1.8; 95% CI: 1.2, 2.6). Compared to other patients with HIV, the prevalence of OS was higher in patients with viral loads >200 copies/mL (1.7; 1.0, 2.8) and in patients with a CD4 count </=200 cells/mL (2.3; 1.3, 4.2). Among 11 patients with severe OS, 9 (81.8%) were HIV-positive. Among 39 interviewed OS patients, OS symptom resolution was similar for HIV-positive (70.0%) and HIV-negative/unknown-status (68.4%) patients. CONCLUSION: Syphilis patients with HIV were nearly twice as likely to report OS symptoms as were patients without documented HIV. HIV-related immunodeficiency possibly increases the risk of OS development in co-infected patients.

      3. Progress in voluntary medical male circumcision for HIV prevention supported by the US President’s Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme dataExternal
        Davis SM, Hines JZ, Habel M, Grund JM, Ridzon R, Baack B, Davitte J, Thomas A, Kiggundu V, Bock N, Pordell P, Cooney C, Zaidi I, Toledo C.
        BMJ Open. 2018 Sep 1;8(8):e021835.

        OBJECTIVE: This article provides an overview and interpretation of the performance of the US President’s Emergency Plan for AIDS Relief’s (PEPFAR’s) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017. DESIGN: Longitudinal collection of routine programme data and disaggregations. SETTING: 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes. PARTICIPANTS: Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above. MAIN OUTCOME MEASURES: Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance. RESULTS: PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision. CONCLUSIONS: Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.

      4. INTRODUCTION: Estimating the incidence of antiretroviral discontinuations due to adverse drug reactions (ADRs) is important to inform antiretroviral treatment (ART) regimen recommendations, and to guide prescribing and monitoring policies. Routinely collected clinical data is a useful source of pharmacovigilance data. We estimated the incidences of first-line antiretroviral discontinuations due to ADRs using routine clinical data, and compared them with incidences estimated using data enhanced by folder review, in two South African cohorts. METHODS: We included patients 16 years and older on first-line ART. We selected a stratified random sample of 25% for checking of ART prescription data and reasons for antiretroviral discontinuations retrospectively, including folders reviews where required (enhanced-data sample). We estimated the incidence of antiretroviral discontinuations using Kaplan-Meier and competing risk analyses. RESULTS: In 15396 patients, 40% had a first-line antiretroviral discontinuation by three years on ART. We could determine the reason for 65% of discontinuations using routine data only, and 84% of discontinuations, in the enhanced-data sample of 3837 patients. ADR was the most common reason for discontinuations. In the enhanced-data sample, the cumulative incidence of discontinuations due to ADRs by three years was 30.4% (95% CI: 24.4-36.6) for stavudine; 2.0% (95% CI: 1.5-2.6) for tenofovir, and 1.3% (95% CI: 0.8-2.1) for efavirenz. Using routine data only, the cumulative incidences of discontinuations due to ADRs by three years for stavudine, tenofovir, and efavirenz respectively were 23.9% (95% CI: 20.3-27.7), 1.2% (95% CI: 0.9-1.4) and 0.5% (95% CI: 0.3-0.7). CONCLUSIONS: Although the relative rankings were similar using routine or enhanced data, lack of checking for missing reasons for discontinuation resulted in underestimates of the incidence of antiretroviral discontinuations due to ADRs. Systems to improve data collection of reasons for regimen changes prospectively would increase the capacity of routine data to answer pharmacovigilance questions.

      5. Perinatal transmission of hepatitis C virus: Defining the cascade of careExternal
        Epstein RL, Sabharwal V, Wachman EM, Saia KA, Vellozzi C, Hariri S, Linas BP.
        J Pediatr. 2018 Aug 28.

        OBJECTIVES: The US National Viral Hepatitis Action Plan calls for major efforts to expand hepatitis C virus (HCV) diagnosis and treatment; prenatal care settings are potential venues for expanding HCV testing. We aimed to characterize the HCV diagnostic cascade for women and infants and investigate factors associated with linkage and follow-up. STUDY DESIGN: We used electronic health records for a 10-year cohort of 879 women with opioid use disorder from an obstetric clinic serving women with substance use disorders. RESULTS: Altogether, 744 women (85%) were screened for HCV; 510 (68%) were seropositive, of whom 369 (72%) had nucleic acid testing performed and of these 261 (71%) were viremic. Of 404 infants born to HCV-seropositive women, 273 (68%) were tested at least once for HCV, 180 (45%) completed the American Academy of Pediatrics-recommended perinatal HCV screening, and 5 (2.8%) were diagnosed with HCV infection and linked to care. More recent delivery date (2014-2015) was associated with maternal linkage to care (aOR, 2.5; 95% CI, 1.4-4.7). Maternal coinfection with HIV (aOR, 9.0; 95% CI, 1.1-72.8) and methadone maintenance therapy, compared with buprenorphine (aOR, 1.5; 95% CI, 0.9-2.5), were associated with higher rates of infant HCV testing. CONCLUSIONS: HCV prevalence among pregnant women with opioid use is high and infant HCV screening is imperfect. Programmatic changes to improve both mother and infant follow-up may help to bridge identified gaps in the cascade to cure.

      6. Prenatal HIV testing and the impact of state HIV testing laws, 2004 to 2011External
        FitzHarris LF, Johnson CH, Nesheim SR, Oussayef NL, Taylor AW, Harrison AT, Ruffo N, Burley K, House L, Koumans EH.
        Sex Transm Dis. 2018 Sep;45(9):583-587.

        OBJECTIVE: This study aimed to analyze prenatal human immunodeficiency virus (HIV) testing rates over time and describe the impact of state HIV testing laws on prenatal testing. METHODS: During 2004-2011, self-reported prenatal HIV testing data for women with live births in 35 states and New York City were collected. Prevalence of testing was estimated overall and by state and year. An annual percent change was calculated in states with at least 6 years of data to analyze testing changes over time. An attorney-coder used WestlawNext to identify states with laws that direct prenatal care providers to screen all pregnant women or direct all women to be tested for HIV and document changes in laws to meet this threshold. RESULTS: The overall prenatal HIV testing rate for 2004 through 2011 combined was 75.7%. State-level data showed a wide range of testing rates (43.2%-92.8%) for 2004 through 2011 combined. In areas with 6 years of data, 4 experienced an annual drop in testing (Alaska, Arkansas, Colorado, and Illinois). States that changed laws to meet the threshold generally had the highest testing rates, averaging 80%, followed by states with a preexisting law, at approximately 70%. States with no law, or no law meeting the threshold, had an average prenatal testing rate of 65%. CONCLUSIONS: Prenatal HIV testing remained stable between 2004 and 2011 but remained below universal recommendations. Testing varied widely across states and was generally higher in areas that changed their laws to meet the threshold or had preexisting prenatal HIV testing laws, compared with those with no or limited prenatal HIV testing language.

      7. Progress toward poliovirus containment implementation – worldwide, 2017-2018External
        Fournier-Caruana J, Previsani N, Singh H, Boualam L, Swan J, Llewellyn A, Sutter RW, Zaffran M.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):992-995.

        Substantial progress has been made since the World Health Assembly (WHA) resolved to eradicate poliomyelitis in 1988 (1). Among the three wild poliovirus (WPV) types, type 2 (WPV2) was declared eradicated in 2015, and type 3 (WPV3) has not been reported since 2012 (1). In 2017 and 2018, only Afghanistan and Pakistan have reported WPV type 1 (WPV1) transmission (1). When global eradication of poliomyelitis is achieved, facilities retaining poliovirus materials need to minimize the risk for reintroduction of poliovirus into communities and reestablishment of transmission. Poliovirus containment includes biorisk management requirements for laboratories, vaccine production sites, and other facilities that retain polioviruses after eradication; the initial milestones are for containment of type 2 polioviruses (PV2s). At the 71st WHA in 2018, World Health Organization (WHO) Member States adopted a resolution urging acceleration of poliovirus containment activities globally, including establishment by the end of 2018 of national authorities for containment (NACs) to oversee poliovirus containment (2). This report summarizes containment progress since the previous report (3) and outlines remaining challenges. As of August 2018, 29 countries had designated 81 facilities to retain PV2 materials; 22 of these countries had established NACs. Although there has been substantial progress, intensification of containment measures is needed.

      8. Pneumonia-associated hospitalizations, New York City, 2001-2014External
        Gu CH, Lucero DE, Huang CC, Daskalakis D, Varma JK, Vora NM.
        Public Health Rep. 2018 Sep/Oct;133(5):584-592.

        OBJECTIVES: Death certificate data indicate that the age-adjusted death rate for pneumonia and influenza is higher in New York City than in the United States. Most pneumonia and influenza deaths are attributed to pneumonia rather than influenza. Because most pneumonia deaths occur in hospitals, we analyzed hospital discharge data to provide insight into the burden of pneumonia in New York City. METHODS: We analyzed data for New York City residents discharged from New York State hospitals with a principal diagnosis of pneumonia, or a secondary diagnosis of pneumonia if the principal diagnosis was respiratory failure or sepsis, during 2001-2014. We calculated mean annual age-adjusted pneumonia-associated hospitalization rates per 100 000 population and 95% confidence intervals (CIs). We examined data on pneumonia-associated hospitalizations by sociodemographic characteristics and colisted conditions. RESULTS: During 2001-2014, a total of 495 225 patients residing in New York City were hospitalized for pneumonia, corresponding to a mean annual age-adjusted pneumonia-associated hospitalization rate of 433.8 per 100 000 population (95% CI, 429.3-438.3). The proportion of pneumonia-associated hospitalizations with in-hospital death was 12.0%. The mean annual age-adjusted pneumonia-associated hospitalization rate per 100 000 population increased as area-based poverty level increased, whereas the percentage of pneumonia-associated hospitalizations with in-hospital deaths decreased with increasing area-based poverty level. The proportion of pneumonia-associated hospitalizations that colisted an immunocompromising condition increased from 18.7% in 2001 to 33.1% in 2014. CONCLUSION: Sociodemographic factors and immune status appear to play a role in the epidemiology of pneumonia-associated hospitalizations in New York City. Further study of pneumonia-associated hospitalizations in at-risk populations may lead to targeted interventions.

      9. Reduced nevirapine concentrations among HIV-positive women receiving mefloquine for intermittent preventive treatment for malaria control during pregnancyExternal
        Haaland R, Otieno K, Martin A, Katana A, Dinh C, Slutsker L, Menendez C, Gonzalez R, Williamson J, Heneine W, Desai M.
        AIDS Res Hum Retroviruses. 2018 Sep 1.

        Clinical trials demonstrated intermittent preventive treatment in pregnancy (IPTp) with mefloquine (MQ) reduced malaria rates among pregnant women, yet an unexpected higher risk of mother to child transmission (MTCT) of HIV among HIV-positive women receiving MQ has also been observed. To determine if interactions between antiretroviral drugs (ARVs) and MQ could contribute to the increased MTCT observed in women receiving MQ, we performed a retrospective cross-sectional analysis of ARVs in peripheral blood plasma (maternal plasma) and cord blood plasma (cord plasma) collected at delivery from 186 mothers participating in a randomized clinical trial of MQ compared to placebo in Kenya. Plasma zidovudine (AZT), lamivudine (3TC) and nevirapine (NVP) concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry. ARVs were detected in maternal plasma and cord plasma specimens in similar proportions between the two study arms. Median concentrations of AZT and 3TC were not significantly lower in the MQ arm compared to the placebo arm for maternal plasma and cord plasma (p > 0.05). However, median NVP concentrations were significantly lower in the MQ study arm compared to the placebo study arm in both maternal plasma (1597 ng/mL vs. 2353 ng/mL, Mann-Whitney Rank Sum, p = 0.023) and cord plasma (2038 ng/mL vs. 2434 ng/mL, p = 0.048). Reduced NVP concentrations in maternal and cord plasma of women receiving MQ suggest MQ may affect NVP metabolism for both mother and infant. These results highlight the need to evaluate potential drug-drug interactions between candidate antimalarials and ARVs for use in pregnant women.

      10. Viral etiology of acute gastroenteritis in <2-year-old US children in the post-rotavirus vaccine eraExternal
        Hassan F, Kanwar N, Harrison CJ, Halasa NB, Chappell JD, Englund JA, Klein EJ, Weinberg GA, Szilagyi PG, Moffatt ME, Oberste MS, Nix WA, Rogers S, Bowen MD, Vinje J, Wikswo ME, Parashar UD, Payne DC, Selvarangan R.
        J Pediatric Infect Dis Soc. 2018 Sep 3.

        Background: The rotavirus disease burden has declined substantially since rotavirus vaccine was introduced in the United States in 2006. The aim of this study was to determine the viral etiology of acute gastroenteritis (AGE) in US children aged <2 years. Methods: The New Vaccine Surveillance Network (NVSN) of geographically diverse US sites conducts active pediatric population-based surveillance in hospitals and emergency departments. Stool samples were collected from children aged <2 years with symptoms of AGE (n = 330) and age-matched healthy controls (HCs) (n = 272) between January and December 2012. Samples were tested by real-time reverse-transcriptase polymerase chain reaction assays {adenovirus (type 40 and 41), norovirus, parechovirus A, enterovirus, sapovirus, and astrovirus} and an enzyme immunoassay (rotavirus). All samples that tested positive were genotyped. Results: Detection rates of pathogens in children with AGE versus those of HCs were, respectively, 23.0% versus 6.6% for norovirus (P < .01), 23.0% versus 16.0% for adenovirus (P = .08), 11.0% versus 16.0% for parechovirus A (P = .09), 11.0% versus 9.0% for enterovirus (P = .34), 7.0% versus 3.0% for sapovirus (P = .07), 3.0% versus 0.3% for astrovirus (P = .01), and 3.0% versus 0.4% for rotavirus (P = .01). A high prevalence of adenovirus was detected at 1 surveillance site (49.0% for children with AGE and 43.0% for HCs). Norovirus GII.4 New Orleans was the most frequently detected (33.0%) norovirus genotype. Codetection of >1 virus was more common in children with AGE (16.0%) than in HCs (10.0%) (P = .03). Conclusions: Norovirus, astrovirus, sapovirus, and rotavirus were detected significantly more in children with AGE than in HCs, and norovirus was the leading AGE-causing pathogen in US children aged <2 years during the year 2012.

      11. Characteristics of persons with repeat syphilis – Idaho, 2011 to 2015External
        Kassem AM, Bartschi JL, Carter KK.
        Sex Transm Dis. 2018 Sep;45(9):e68-e71.

        During 2011 through 2015 in Idaho, 14 (7%) of 193 persons with early syphilis had repeat syphilis. Persons with repeat infections were more likely to have had secondary or early latent syphilis (P = 0.037) and be infected with human immunodeficiency virus (P < 0.001) compared with those having 1 infection.

      12. As part of the global response to the HIV/AIDS epidemic, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is committed to the provision of high-quality services and ensuring testing accuracy. Two recently published papers focusing on HIV testing and misdiagnosis in sub-Saharan Africa by Kosack et al. report on evaluations of HIV rapid diagnostic tests (RDTs) and found lower than expected specificity and sensitivity on some tests when used in certain geographic locations. The magnitude of PEPFAR’s global HIV response has been possible due to the extensive use of RDTs, which have made HIV diagnosis accessible all over the world. We take the opportunity to address concerns raised about the potential implications that these findings could have on real-world HIV testing accuracy. PEPFAR supported countries adhere to the normative guidance by World Health Organization (WHO) supporting algorithms which require sequential positive tests for diagnostic accuracy. An analysis of Medecins Sans Frontieres (MSF) RDT site-specific data applied to PEPFAR in-country protocols demonstrate a variation in the diagnostic accuracy of the testing algorithms, but with a very small population-level effect. The data demonstrate, with the use of these algorithms, that the RDT outcomes found in the study by Kosack et al. would be largely mitigated and would not be expected to have a significant impact on diagnostic accuracy and overall programming in most countries. Avoiding any misdiagnosis is a priority for PEPFAR, and it remains vital to gain a deeper understanding of the causes and the extent of diagnostic errors and any misclassification. Extensive quality control mechanisms and continued research are essential. With a focus on epidemic control and ensuring diagnostic accuracy, PEPFAR recommends that all countries use WHO pre-qualified RDTs within the recommended strategies and algorithms for HIV testing. We also support validation of HIV testing algorithms using in-country specimens to determine optimal performance, and the reverification testing of all people diagnosed with HIV prior to starting treatment as an essential quality assurance measure.

      13. Notes from the field: Acquisition of delamanid under a compassionate use program for extensively drug-resistant tuberculosis – United States, 2017External
        Lardizabal AA, Khan AN, Bamrah Morris S, Goswami ND.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):996-997.

        [No abstract]

      14. Laboratory and epidemiologic data are vital to identify a novel influenza A virus and inform the public health response, whether it be to a localized outbreak or pandemic. The Centers for Disease Control and Prevention (CDC) developed the Pandemic Influenza Readiness Assessment (PIRA) to evaluate the state of the nation’s preparedness for the next influenza pandemic. Representatives from all 62 Public Health Emergency Preparedness (PHEP) awardee jurisdictions were requested to complete the web-based questionnaire in July 2015. The PIRA consists of 7 modules covering key components of pandemic preparedness; this article summarizes results from the laboratory and epidemiology modules. Many of the jurisdictions reported they had the capacity to fulfill most of the laboratory and epidemiology tasks, including the ability to differentiate novel influenza A viruses from seasonal influenza viruses and electronically transfer laboratory, surveillance, and case investigation data. Pandemic preparedness includes transfer of electronic death records and conducting surveillance for influenza-associated mortality in adults. Although most jurisdictions self-reported that they had the epidemiologic and laboratory capabilities that were assessed, additional planning and technical assistance are needed to ensure all states and territories have and maintain all critical capacities. The results from this PIRA can inform how CDC and federal partners focus future training and outreach.

      15. Preventing congenital syphilis – opportunities identified by congenital syphilis case review boardsExternal
        Rahman MM, Hoover A, Johnson C, Peterman TA.
        Sex Transm Dis. 2018 Aug 31.

        BACKGROUND: Louisiana has had the highest rates of congenital syphilis (CS) in the nation since 2012. CS Case Review Boards were established statewide in 2016 to study CS cases and identify interventions. METHODS: We summarized the findings of CS review boards, assessed which cases were preventable by prenatal care providers, reviewed recommended interventions, and assessed subsequent improvement in provider practices. RESULTS: All 79 CS cases reported January 2016-July 2017 were reviewed by boards during August 2016-August 2017.Twenty-six cases (33%) that could have been prevented by prenatal care providers had: lack of rescreening at 28-32 weeks (n=15), lack of any screening (n=5), treatment delay (n=4), or incorrect interpretation of test results (n=2).Twenty-one cases (27%) were possibly preventable by providers including: mother did not return for follow-up and treatment (n=19), late third trimester reactive test with premature delivery (n=1), or incomplete treatment and lack of follow-up by health department staff (n=1).Thirty-two cases (40%) that were unlikely to be prevented by providers had: non-reactive test at 28-32 weeks then reactive test <30 days before delivery (n=10), no prenatal care (n=9), mother adequately treated, case by infant criteria (n=8), first/second trimester non-reactive, reactive at preterm delivery (n=4), or mother adequately treated, reinfected before delivery (n=1). Providers were advised to adhere to CDC recommended syphilis screening and treatment protocols and rapidly report pregnant women with syphilis. Many providers changed their procedures. CONCLUSIONS: CS case review boards identified practices with inadequate screening, treatment, or reporting. Sharing these findings with providers changed practices and may prevent future cases.

      16. Diffusion of handwashing knowledge and water treatment practices from mothers in an antenatal hygiene promotion program to nonpregnant friends and relatives, Machinga District, MalawiExternal
        Rajasingham A, Routh JA, Loharikar A, Chemey E, Ayers T, Gunda AW, Russo ET, Wood S, Quick R.
        Int Q Community Health Educ. 2018 Sep 5:272684×18797063.

        Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases in low- and middle-income countries. Integrating water treatment and hygiene products into antenatal clinic care can motivate water treatment and handwashing among pregnant women. Free water hygiene kits (water storage containers, sodium hypochlorite water treatment solution, and soap) and refills of water treatment solution and soap were integrated into antenatal care and delivery services in Machinga District, Malawi, resulting in improved water treatment and hygiene practices in the home and increased maternal health service use. To determine whether water treatment and hygiene practices diffused from maternal health program participants to friends and relatives households in the same communities, we assessed the practices of 106 nonpregnant friends and relatives of these new mothers at baseline and 1-year follow-up. At follow-up, friends and relatives were more likely than at baseline to have water treatment products observable in the home (33.3% vs. 1.2%, p < 0.00001) and detectable free chlorine residual in their water, confirming water treatment (35.7% vs. 1.4%; p < 0.00001). Qualitative data from in-depth interviews also suggested that program participants helped motivate adoption of water treatment and hygiene behaviors among their friends and relatives.

      17. Screening Peter to save Paul: The population-level effects of screening men who have sex with men for gonorrhea and chlamydiaExternal
        Ridpath AD, Chesson H, Marcus JL, Kirkcaldy RD, Torrone EA, Aral SO, Bernstein KT.
        Sex Transm Dis. 2018 Sep;45(9):623-625.

        [No abstract]

      18. Background: Despite successful vaccination programs, pertussis remains endemic in the United States and increasing incidence has been reported. We used national surveillance data to describe pertussis epidemiology, including patient demographic characteristics, geographic distribution, and temporal trends. Methods: We included cases reported through the National Notifiable Diseases Surveillance System between January 1, 2000 and December 31, 2016. Differences in case characteristics were compared using Pearson’s 2. Average annual incidence (cases per 100,000 population) was calculated overall, and by age (<1 year, 1-6 years, 7-10 years, 11-18 years, 19-39 years, 30-64 years, and >/=65 years) and geographic subgroup. Negative binomial regression was used to calculate annual percent change. Results: During 2000-2016, 339,420 pertussis cases were reported. The majority were in white (88.2%) and non-Hispanic (81.3%) persons, 9.9% resulted in hospitalization, and 0.1% were fatal; however, differences existed by age. Infants had the highest incidence (75.3/100,000 population), accounting for 88.8% of deaths. Incidence increased significantly over time (p=0.0019), with baseline rates rising 1.7-fold between 2000-2008 and 2009-2016; increases were observed for all groups except persons aged <1 year and 19-64 years. Elevated case counts among persons aged 7-10 and 11-18 years coincided with the aging of acellular-primed birth cohorts. Incidence varied by geographic region, with some similarities in disease cyclicity. Conclusions: Increasing baseline incidence and changing age distribution of pertussis suggest a central role of the transition to acellular vaccines in the U.S. disease resurgence. Continued monitoring of national surveillance data is important to evaluate and optimize pertussis prevention and control strategies.

      19. The Leprosy Post-Exposure Prophylaxis (LPEP) programme: Update and interim analysisCdc-pdfExternal
        Steinmann P, Cavaliero A, Aerts A, Anand S, Arif M, Ay SS, Aye TM, Barth-Jaeggi T, Banstola NL, Bhandari CM, Blaney D, Bonenberger M, Van Brakel W, Cross H, Das VK, Fahrudda A, Fernando N, Gani Z, Greter H, Ignotti E, Kamara D, Kasang C, Komm B, Kumar A, Lay S, Mieras L, Mirza F, Mutayoba B, Njako B, Pakasi T, Saunderson P, Shengelia B, Smith CS, Staheli R, Suriyarachchi N, Shwe T, Tiwari A, D Wijesinghe MS, Van Berkel J, Plaetse BV, Virmond M, Richardus JH.
        Leprosy Review. 2018 ;89(2):102-116.

        Innovative approaches are required to further enhance leprosy control, reduce the number of people developing leprosy, and curb transmission. Early case detection, contact screening, and chemoprophylaxis currently is the most promising approach to achieve this goal. The Leprosy Post-Exposure Prophylaxis (LPEP) programme generates evidence on the feasibility of integrating contact tracing and single-dose rifampicin (SDR) administration into routine leprosy control activities in different settings. The LPEP programme is implemented within the leprosy control programmes of Brazil, Cambodia, India, Indonesia, Myanmar, Nepal, Sri Lanka and Tanzania. Focus is on three key interventions: tracing the contacts of newly diagnosed leprosy patients; screening the contacts for leprosy; and administering SDR to eligible contacts. Country-specific protocol adaptations refer to contact definition, minimal age for SDR, and staff involved. Central coordination, detailed documentation and rigorous supervision ensure quality evidence. Around 2 years of field work had been completed in seven countries by July 2017. The 5,941 enrolled index patients (89.4% of the registered) identified a total of 123,311 contacts, of which 99.1% were traced and screened. Among them, 406 new leprosy patients were identified (329/100,000), and 10,883 (8.9%) were excluded from SDR for various reasons. Also, 785 contacts (0.7%) refused the prophylactic treatment with SDR. Overall, SDR was administered to 89?0% of the listed contacts. Post-exposure prophylaxis with SDR is safe; can be integrated into the routines of different leprosy control programmes; and is generally well accepted by index patients, their contacts and the health workforce. The programme has also invigorated local leprosy control.

      20. Challenges and opportunities for outreach workers in the Prevention of Mother to Child Transmission of HIV (PMTCT) program in IndiaExternal
        Suryavanshi N, Mave V, Kadam A, Kanade S, Sivalenka S, Kumar VS, Harvey P, Gupta R, Hegde A, Gupte N, Gupta A, Bollinger RC, Shankar A.
        PLoS One. 2018 ;13(9):e0203425.

        BACKGROUND: The Prevention of Mother-to-Child Transmission of HIV (PMTCT) program in India is one of the largest in the world. It uses outreach workers (ORWs) to facilitate patient uptake of services, however, the challenges faced by the ORWs, and their views about the effectiveness of this program are unknown. METHODS: The COMmunity-Home Based INDia (COMBIND) Prevention of Mother to Child Transmission of HIV study evaluated an integrated mobile health and behavioral intervention to enhance the capacity of ORWs in India. To understand the challenges faced by ORWs, and their perceptions of opportunities for program improvement, four group discussions were conducted among 60 ORW from four districts of Maharashtra, India, as part of the baseline assessment for COMBIND. Data were qualitatively analyzed using a thematic approach. RESULTS: Numerous personal-, social-, and structural-level challenges existed for ORW as they engaged with their patients. Personal-level challenges for ORWs included disclosure of their own HIV status and travelling costs for home visits. Personal-level challenges for patients included financial costs of travelling to ART centers, non-adherence to ART, loss of daily wages, non-affordability of infant formula, lack of awareness of the baby’s needs, financial dependence on family, four time points (6weeks, 6 months, 12 months and 18 months) for HIV tests, and need for nevirapine (NVP) prophylaxis. Social-level challenges included lack of motivation by patients and/or health care staff, social stigma, and rude behavior of health care staff and their unwillingness to provide maternity services to women in the PMTCT programme. Structural-level challenges included cultural norms around infant feeding, shortages of HIV testing kits, shortages of antiretroviral drugs and infant NVP prophylaxis, and lack of training/knowledge related to PMTCT infant feeding guidelines by hospital staff. The consensus among ORWs was that there was a critical need for tools and training to improve their capacity to effectively engage with patients, and deliver appropriate care, and for motivation through periodic feedback. CONCLUSIONS: Given the significant challenges in PMTCT programme implementation reported by ORW, novel strategies to address these challenges are urgently needed to improve patient engagement, and access to and retention in care.

      21. Epidemiology of influenza in Ethiopia: findings from influenza sentinel surveillance and respiratory infection outbreak investigations, 2009-2015External
        Woyessa AB, Mengesha M, Belay D, Tayachew A, Ayele W, Beyene B, Kassa W, Zemelak E, Demissie G, Amare B, Boulanger L, Granados C, Williams T, Tareke I, Rajatonirina S, Jima D.
        BMC Infect Dis. 2018 Sep 3;18(1):449.

        BACKGROUND: Influenza is an acute viral disease of the respiratory tract which is characterized by fever, headache, myalgia, prostration, coryza, sore throat and cough. Globally, an estimated 3 to 5 million cases of severe influenza illness and 291 243-645 832 seasonal influenza-associated respiratory deaths occur annually. Although recent efforts from some African countries to describe burden of influenza disease and seasonality, these data are missing for the vast majority, including Ethiopia. Ethiopia established influenza sentinel surveillance in 2008 aiming to determine influenza strains circulating in the country and know characteristics, trend and burden of influenza viruses. METHODS: We used influenza data from sentinel surveillance sites and respiratory disease outbreak investigations from 2009 to 2015 for this analysis. We obtained the data by monitoring patients with influenza-like illness (ILI) at three health-centers, severe acute respiratory infection (SARI) at five hospitals and investigating patients during different respiratory infection outbreaks. Throat-swab specimens in viral transport media were transported to the national reference laboratory within 72 h of collection using a cold-chain system. We extracted viral RNA from throat-swabs and subjected to real-time PCR amplification. We further subtyped and characterized Influenza A-positive specimens using CDC real-time reverse transcription PCR protocol. RESULTS: A total of 4962 throat-swab samples were collected and 4799 (96.7%) of them were tested. Among them 988 (20.6%) were influenza-positive and of which 349 (35.3%) were seasonal influenza A(H3N2), 321 (32.5%) influenza A(H1N1)pdm2009 and 318 (32.0%) influenza B. Positivity rate was 29.5% in persons 5-14 years followed by 26.4% in 15-44 years, 21.2% in > 44 years and 6.4% in under five children. The highest positivity rate observed in November (37.5%) followed by March (27.6%), December (26.4%), October (24.4%) and January (24.3%) while the lowest positivity rate was in August (7.7%). CONCLUSION: In Ethiopia, seasonal Influenza A(H3N2), Influenza A(H1N1)pdm2009 and Influenza B viruses were circulating during 2009-2015. Positivity rate and number of cases peaked in November and December. Influenza is one of public health problems in Ethiopia and the need to introduce influenza vaccine and antivirus is important to prevent and treat the disease in future.

    • Disaster Control and Emergency Services
      1. Global health security agenda implementation: A case for community engagementExternal
        Armstrong-Mensah EA, Ndiaye SM.
        Health Security. 2018 ;16(4):217-223.

        In today’s interconnected world, infectious diseases can spread rapidly within and between countries. The 2014-2016 Ebola epidemic in Guinea, Liberia, and Sierra Leone underscored the inability of countries with limited capacities and weak public health systems to respond effectively to outbreaks. To mitigate future health threats, nations and international organizations launched the Global Health Security Agenda (GHSA) to accelerate compliance with the WHO’s International Health Regulations, so as to enhance global protection from infectious disease threats. To advance GHSA’s mandate to build capacity to prevent, detect, and respond to infectious diseases, and thereby contain threats at their source, community engagement is needed. This article advocates for community engagement in GHSA implementation, using examples from 3 GHSA action packages. A country’s ability to prevent a local disease outbreak from becoming an epidemic often rests with the level of knowledge about the situation and the actions taken at the community level.

    • Drug Safety
      1. Effectiveness of an educational intervention to improve antibiotic dispensing practices for acute respiratory illness among drug sellers in pharmacies, a pilot study in BangladeshExternal
        Chowdhury F, Sturm-Ramirez K, Mamun AA, Iuliano AD, Chisti MJ, Ahmed M, Bhuiyan MU, Hossain K, Haider MS, Aziz SA, Rahman M, Azziz-Baumgartner E.
        BMC Health Serv Res. 2018 Aug 31;18(1):676.

        BACKGROUND: Inappropriate dispensing of antibiotics for acute respiratory illness (ARI) is common among drug sellers in Bangladesh. In this study, we evaluated the impact of an educational intervention to promote guidelines for better ARI management among drug sellers. METHODS: From June 2012 to December 2013, we conducted baseline and post-intervention surveys on dispensing practices in 100 pharmacies within Dhaka city. In these surveys, drug sellers participated in 6 standardized role-playing scenarios led by study staffs acting as caregivers of ARI patients and drug sellers were blinded to these surveys. After the baseline survey, we developed ARI guidelines and facilitated a one-day educational intervention about ARI management for drug sellers. Our guidelines only recommended antibiotics for children with complicated ARI. Finally, we conducted the six month post-intervention survey using the same scenarios to record changes in drug dispensing practices. RESULTS: Only 2/3 of participating pharmacies were licensed and few (11%) of drug sellers had pharmacy training. All the drug sellers were male, had a median age of 34 years (IQR 28-41). For children, dispensing of antibiotics for uncomplicated ARI decreased (30% baseline vs. 21% post-intervention; p = 0.04), but drug sellers were equally likely to dispense antibiotics for complicated ARI (15% baseline vs. 17% post-intervention; p = 0.6) and referrals to physicians for complicated ARIs decreased (70% baseline vs. 58% post-intervention; p = 0.03). For adults, antibiotic dispensing remained similar for uncomplicated ARI (48% baseline vs. 40% post-intervention; p = 0.1) but increased among those with complicated ARI (44% baseline vs. 78% post-intervention; p < 0.001). Although our evidence-based guidelines recommended against prescribing antihistamines for children, drug sellers continued to sell similar amounts for uncomplicated ARI (33% baseline vs. 32% post-intervention; p = 0.9). CONCLUSIONS: Despite the intervention, drug sellers continued to frequently dispense antibiotics for ARI, except for children with uncomplicated ARI. Pairing educational interventions among drug sellers with raising awareness about proper antibiotic use among general population should be further explored. In addition, annual licensing and an reaccreditation system with comprehensive monitoring should be enforced, using penalties for non-compliant pharmacies as possible incentives for appropriate dispensing practices.

    • Environmental Health
      1. Effect of residential lead-hazard interventions on childhood blood lead concentrations and neurobehavioral outcomes: A randomized clinical trialExternal
        Braun JM, Hornung R, Chen A, Dietrich KN, Jacobs DE, Jones R, Khoury JC, Liddy-Hicks S, Morgan S, Vanderbeek SB, Xu Y, Yolton K, Lanphear BP.
        JAMA Pediatr. 2018 Aug 27.

        Importance: Childhood lead exposure is associated with neurobehavioral deficits. The effect of a residential lead hazard intervention on blood lead concentrations and neurobehavioral development remains unknown. Objective: To determine whether a comprehensive residential lead-exposure reduction intervention completed during pregnancy could decrease residential dust lead loadings, prevent elevated blood lead concentrations, and improve childhood neurobehavioral outcomes. Design, Setting, and Participants: This longitudinal, community-based randomized clinical trial of pregnant women and their children, the Health Outcomes and Measures of the Environment (HOME) Study, was conducted between March 1, 2003, and January 31, 2006. Pregnant women attending 1 of 9 prenatal care clinics affiliated with 3 hospitals in the Cincinnati, Ohio, metropolitan area were recruited. Of the 1263 eligible women, 468 (37.0%) agreed to participate and 355 women (75.8%) were randomized in this intention-to-treat analysis. Participants were randomly assigned to receive 1 of 2 interventions designed to reduce residential lead or injury hazards. Follow-up on children took place at 1, 2, 3, 4, 5, and 8 years of age. Data analysis was performed from September 2, 2017, to May 6, 2018. Main Outcomes and Measures: Residential dust lead loadings were measured at baseline and when children were 1 and 2 years of age. At 1, 2, 3, 4, 5, and 8 years of age, the children’s blood lead concentrations as well as behavior, cognition, and executive functions were assessed. Results: Of the 355 women randomized, 174 (49.0%) were assigned to the intervention group (mean [SD] age at delivery, 30.1 (5.5) years; 119 [68.3%] self-identified as non-Hispanic white) and 181 (50.9%) to the control group (mean [SD] age at delivery, 29.2 [5.7] years; 123 [67.9%] self-identified as non-Hispanic white). The intervention reduced the dust lead loadings for the floor (24%; 95% CI, -43% to 1%), windowsill (40%; 95% CI, -60% to -11%), and window trough (47%; 95% CI, -68% to -10%) surfaces. The intervention did not statistically significantly reduce childhood blood lead concentrations (-6%; 95% CI, -17% to 6%; P = .29). Neurobehavioral test scores were not statistically different between children in the intervention group than those in the control group except for a reduction in anxiety scores in the intervention group (beta = -1.6; 95% CI, -3.2 to -0.1; P = .04). Conclusions and Relevance: Residential lead exposures, as well as blood lead concentrations in non-Hispanic black children, were reduced through a comprehensive lead-hazard intervention without elevating the lead body burden. However, this decrease did not result in substantive neurobehavioral improvements in children. Trial Registration: ClinicalTrials.gov identifier: NCT00129324.

      2. [No abstract]

      3. Land reuse site screening tool cohorts: Creating land reuse site inventoriesExternal
        Perlman GD, Berman L, Alameda M, Arias E, Pawlowicz G, Yogerst E.
        J Environ Health. 2018 ;81(2):40-43.

        [No abstract]

    • Epidemiology and Surveillance
      1. Event-based surveillance at community and healthcare facilities, Vietnam, 2016-2017External
        Clara A, Do TT, Dao AT, Tran PD, Dang TQ, Tran QD, Ngu ND, Ngo TH, Phan HC, Nguyen TT, Lai AT, Nguyen DT, Nguyen MK, Nguyen HT, Becknell S, Bernadotte C, Nguyen HT, Nguyen QC, Mounts AW, Balajee SA.
        Emerg Infect Dis. 2018 Sep;24(9):1649-1658.

        Surveillance and outbreak reporting systems in Vietnam required improvements to function effectively as early warning and response systems. Accordingly, the Ministry of Health of Vietnam, in collaboration with the US Centers for Disease Control and Prevention, launched a pilot project in 2016 focusing on community and hospital event-based surveillance. The pilot was implemented in 4 of Vietnam’s 63 provinces. The pilot demonstrated that event-based surveillance resulted in early detection and reporting of outbreaks, improved collaboration between the healthcare facilities and preventive sectors of the ministry, and increased community participation in surveillance and reporting.

    • Food Safety
      1. [No abstract]

    • Genetics and Genomics
      1. Morphometric and genetic variation in eight breeds of Ethiopian camels (Camelus dromedarius)External
        Legesse YW, Dunn CD, Mauldin MR, Garza NO, Rowden GR, Mekasha Y, Kurtu MY, Mohammed SA, Whibesilassie WD, Ballou M, Tefera M, Perry G, Bradley RD.
        J Anim Sci. 2018 Sep 5.

        Dromedary camels (Camelus dromedarius) are a domesticated and closely guarded economic staple of indigenous people located throughout Ethiopian territorial states. Seventeen morphometric variables were examined to determine intraspecific variation among 8 pastoralist-designated breeds of camels. Additionally, DNA sequences from mitochondrial cytochrome-b gene and genotyping of 6 nuclear microsatellite loci were examined to assess genetic diversity and phylogenetic relationship of Ethiopian camels. Examination of 525 individuals revealed significant morphometric differentiation in Afar as compared with the remaining 7 breeds. Analysis of cytochrome-b sequences failed to recover monophyletic groups associated with pastoralist-recognized breeds. Analysis of 6 microsatellite loci from 104 individuals depicted no resolution of distinct genetic lineages in accordance to geographical or designated breeds. Overall, separation of 2 ecotypes based on the morphometric data was supported; however, genetic analysis of cytochrome-b and microsatellite data failed to support any unique genetic lineage or statistically significant population structure.

    • Health Disparities
      1. Relationship of racial residential segregation to newly diagnosed cases of HIV among black heterosexuals in US metropolitan areas, 2008-2015External
        Ibragimov U, Beane S, Adimora AA, Friedman SR, Williams L, Tempalski B, Stall R, Wingood G, Hall HI, Johnson AS, Cooper HL.
        J Urban Health. 2018 Sep 4.

        Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton’s isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV.

    • Healthcare Associated Infections
      1. Investigation of a case of suspected transfusion-transmitted malariaExternal
        Anand A, Mace KE, Townsend RL, Madison-Antenucci S, Grimm KE, Espina N, Losco P, Lucchi NW, Rivera H, Breen K, Tan KR, Arguin PM, White JL, Stramer SL.
        Transfusion. 2018 Sep 3.

        BACKGROUND: Transfusion-transmitted malaria (TTM) is a rare occurrence with serious consequences for the recipient. A case study is presented as an example of best practices for conducting a TTM investigation. CASE REPORT: A 15-year-old male with a history of sickle cell disease developed fever after a blood transfusion. He was diagnosed with Plasmodium falciparum malaria and was successfully treated. The American Red Cross, New York State Department of Health, and the Centers for Disease Control and Prevention investigated the eight donors who provided components to the transfusion. The investigation to identify a malaria-positive donor included trace back of donors, serologic methods to identify donor(s) with a history of malaria exposure, polymerase chain reaction (PCR) testing, microsatellite analysis to identify the parasite in a donor and match its genotype to the parasite in the recipient, and reinterview of all donors to clarify malaria risk factors. RESULTS: One donor had evidence of infection with P. falciparum by PCR, elevated antibody titers, and previously undisclosed malaria risk factors. Reinterview revealed that the donor immigrated to the United States from Togo just short of 3 years before the blood donation. The donor was treated for asymptomatic low parasitemia infection. CONCLUSION: This investigation used standard procedures for investigating TTM but also demonstrated the importance of applying sensitive laboratory techniques to identify the infected donor, especially a donor with asymptomatic infection with low parasitemia. Repeat interview of all donors identified as having contributed to the transfused component provides complementary epidemiologic information to confirm the infected donor.

    • Immunity and Immunization
      1. Cluster anxiety-related adverse events following immunization (AEFI): An assessment of reports detected in social media and those identified using an online search engineExternal
        Suragh TA, Lamprianou S, MacDonald NE, Loharikar AR, Balakrishnan MR, Benes O, Hyde TB, McNeil MM.
        Vaccine. 2018 Aug 29.

        BACKGROUND: Adverse events following immunization (AEFI) arising from anxiety have rarely been reported as a cluster(s) in the setting of a mass vaccination program. Reports of clusters of anxiety-related AEFIs are understudied. Social media and the web may be a resource for public health investigators. METHODS: We searched Google and Facebook separately from Atlanta and Geneva to identify reports of cluster anxiety-related AEFIs. We reviewed a sample of reports summarizing year, country/setting, vaccine involved, patient symptoms, clinical management, and impact to vaccination programs. RESULTS: We found 39 reports referring to 18 unique cluster events. Some reports were only found based on the geographic location from where the search was performed. The most common vaccine implicated in reports was human papillomavirus (HPV) vaccine (48.7%). The majority of reports (97.4%) involved children and vaccination programs in school settings or as part of national vaccination campaigns. Five vaccination programs were reportedly halted because of these cluster events. In this study, we identified 18 cluster events that were not published in traditional scientific peer-reviewed literature. CONCLUSIONS: Social media and online search engines are useful resources for identifying reports of cluster anxiety-related AEFIs and the geographic location of the researcher is an important factor to consider when conducting these studies. Solely relying upon traditional peer-reviewed journals may seriously underestimate the occurrence of such cluster events.

    • Injury and Violence
      1. Alcohol, prescription drug misuse, sexual violence, and dating violence among high school youthExternal
        Espelage DL, Davis JP, Basile KC, Rostad WL, Leemis RW.
        J Adolesc Health. 2018 Aug 29.

        PURPOSE: Sexual violence (SV), teen dating violence (TDV), and substance use are significant public health concerns among U.S. adolescents. This study examined whether latent classes of baseline alcohol and prescription drug misuse longitudinally predict SV and TDV victimization and perpetration (i.e., verbal, relational, physical/threatening, and sexual) 1 year later. METHODS: Students from six Midwestern high schools (n=1,875; grades 9-11) completed surveys across two consecutive spring semesters. Latent class analysis was used to identify classes of individuals according to four substance use variables. A latent class regression and a manual three-step auxiliary approach were used to assess concurrent and distal relationships between identified classes and SV and TDV victimization and perpetration. RESULTS: Three classes of substance use were identified: low/no use (41% of sample), alcohol only use (45%), and alcohol and prescription drug misuse (APD) (14%). Youth in the APD class experienced greater SV and TDV victimization and perpetration than the alcohol only class at baseline. At Time 2 (one year later), youth in the baseline APD class experienced significantly higher SV and TDV victimization and perpetration outcomes than youth in the alcohol only class with the exception of sexual and physical TDV perpetration. CONCLUSIONS: The misuse of both alcohol and prescription drugs emerged as a significant risk factor for later SV and TDV among adolescents. As such, it would be beneficial if future research continued to assess the nature of these associations and incorporate prescription drug use and misuse into heath education, substance use, and violence prevention programs.

      2. Lifetime economic burden of intimate partner violence among U.S. adultsExternal
        Peterson C, Kearns MC, McIntosh WL, Estefan LF, Nicolaidis C, McCollister KE, Gordon A, Florence C.
        Am J Prev Med. 2018 Aug 17.

        INTRODUCTION: This study estimated the U.S. lifetime per-victim cost and economic burden of intimate partner violence. METHODS: Data from previous studies were combined with 2012 U.S. National Intimate Partner and Sexual Violence Survey data in a mathematical model. Intimate partner violence was defined as contact sexual violence, physical violence, or stalking victimization with related impact (e.g., missed work days). Costs included attributable impaired health, lost productivity, and criminal justice costs from the societal perspective. Mean age at first victimization was assessed as 25 years. Future costs were discounted by 3%. The main outcome measures were the mean per-victim (female and male) and total population (or economic burden) lifetime cost of intimate partner violence. Secondary outcome measures were marginal outcome probabilities among victims (e.g., anxiety disorder) and associated costs. Analysis was conducted in 2017. RESULTS: The estimated intimate partner violence lifetime cost was $103,767 per female victim and $23,414 per male victim, or a population economic burden of nearly $3.6 trillion (2014 US$) over victims’ lifetimes, based on 43 million U.S. adults with victimization history. This estimate included $2.1 trillion (59% of total) in medical costs, $1.3 trillion (37%) in lost productivity among victims and perpetrators, $73 billion (2%) in criminal justice activities, and $62 billion (2%) in other costs, including victim property loss or damage. Government sources pay an estimated $1.3 trillion (37%) of the lifetime economic burden. CONCLUSIONS: Preventing intimate partner violence is possible and could avoid substantial costs. These findings can inform the potential benefit of prioritizing prevention, as well as evaluation of implemented prevention strategies.

      3. The impact of the low-income housing tax credit on children’s health and wellbeing in GeorgiaCdc-pdfExternal
        Ports KA, Rostad WL, Luo F, Putnam M, Zurick E.
        Child Youth Serv Rev. 2018 ;93:390-396.

        Housing instability is a risk factor for child abuse and neglect (CAN). Thus, policies that increase availability of affordable housing may reduce CAN rates. The Low Income Housing Tax Credit (LIHTC) program is the largest affordable housing policy initiative in the country. This study used fixed-effects models to estimate the relationship between LIHTC units and county-level CAN reports in Georgia from 2005 to 2015, controlling for county demographic characteristics. One-way fixed-effects models (including only county fixed-effects) demonstrated significant negative associations between number of LIHTC units and substantiated cases of CAN and total reports of sexual abuse. In two-way fixed-effects models (including county and year fixed-effects), LIHTC units were not associated with any of the outcomes. The findings are subject to limitations, including voluntary provision of CAN data, suppressed data for counties with <10 CAN cases, and no assessment of the quality of LIHTC neighborhood. LIHTC may be a promising prevention strategy, but more research is needed.

      4. The global challenge of child injury preventionExternal
        Sleet DA.
        Int J Environ Res Public Health. 2018 Sep 4;15(9).

        [No abstract]

    • Laboratory Sciences
      1. BACKGROUND: Laboratory tests to detect respiratory syncytial virus (RSV) vary in sensitivity and specificity. Diagnostic testing practices can impact RSV disease diagnosis and burden estimates. OBJECTIVES: We surveyed a sample of laboratories that participated in the National Respiratory and Enteric Virus Surveillance System (NREVSS) in 2015-2016 to understand RSV testing, diagnostic capabilities, and practices. STUDY DESIGN: We distributed surveys in fall 2016 to NREVSS laboratories using an internet survey platform. We conducted a descriptive analysis of survey responses and stratified results by self-identified children’s hospital laboratories (CHL, i.e. laboratories affiliated with or in a children’s hospital) or general hospital laboratories (GHL, i.e. laboratories that performed analysis on specimens from only adults or adults and children). RESULTS: We sampled 367 (82.5%) of 445 eligible NREVSS laboratories with a 35.7% response rate; 11.5% (n = 15) were CHLs. All CHLs had PCR-based assay capability to test for RSV compared to 48.7% of GHLs (p < 0.001), and it was the most frequent method used by CHLs (n = 9, 75.0%). GHLs used rapid antigen detection tests most frequently (n = 65, 60.2%) to detect RSV compared to CHLs (p = 0.02, n = 3, 25.0%). Almost half (n = 41, 48.2%) of GHLs reported specimen submission from adults >/=50 years for RADTs. CONCLUSIONS: Laboratory testing and diagnostic capabilities differed by whether laboratories self-identified as a CHL or GHL. Many GHLs reported use of RADTs in adults >/=50 years, a less sensitive diagnostic method for this population compared to PCR-based assays. RADT use in adults might miss RSV cases and affect diagnoses and disease burden estimates.

      2. Implementation of the laboratory quality management system (ISO 15189): Experience from Bugando Medical Centre Clinical Laboratory – Mwanza, TanzaniaExternal
        Beyanga M, Gerwing-Adima L, Jackson K, Majaliwa B, Shimba H, Ezekiel S, Massambu C, Majige D, Mwasegaka M, Mtotela W, Mateta P, Kasang C.
        Afr J Lab Med. 2018 ;7(1):657.

        Background: Use of laboratory evidence-based patient health care in Tanzania remains a complex problem, as with many other countries in sub-Saharan Africa. As at 2010, 39 African countries, including Tanzania, had no clinical laboratories that met the minimum requirements for international laboratory standards (International Organization for Standardization [ISO] 15189). Objective: The aim of this article is to share experience from Bugando Medical Centre laboratory’s milestones in reaching ISO 15189 accreditation. Methods: Mentors to address the laboratory management and technical requirements performed a gap analysis using the Southern African Development Community Accreditation system checklist. Several non-conformances were detected. System and technical procedures were developed, approved and communicated. Quality indicators were established to measure laboratory improvement and to identify issues which require immediate and preventive actions. Results: The departments’ external quality assessment performance increased after ISO 15189 implementation (e.g. Parasitology from 45% to 100%, Molecular Biology from no records to 100%, Biochemistry 50% to 95%, Tuberculosis Microscopy 60% to 100%, and Microbiology from 48.1% to 100%). There was a reduction in complaints, from eight to two per week. Rejected samples were reduced from 7.2% to 1.2%. Turn-around time was not recorded before implementation but reached 92% (1644/1786) of the defined targets, and the proportion of contamination in blood cultures decreased from 16% to 4%. Conclusion: Our experience suggests that the implementation of a quality management system is possible in resource-limited countries like Tanzania. Mentorship is necessary and should be done by professional laboratory mentors trained in quality management systems. Financial resources and motivated staff are key to achieving ISO 15189 accreditation.

      3. Measurement of skin surface pHExternal
        du Plessis JL, Stefaniak AB, Wilhelm KP.
        Curr Probl Dermatol. 2018 ;54:19-25.

        The acidic nature of the skin surface was recognised more than a century ago and has been measured since 1928. Several non-invasive methods for measuring skin surface pH have been developed ever since and have contributed to our understanding of healthy and diseased skin. This chapter summarises the endogenous physiological, exogenous and environmental factors that influence skin surface pH and its measurement as well as the different measurement methods for skin surface pH, with specific emphasis on the classic planar glass electrode method. Also, practical guidance for measurement of skin surface pH using the planar glass electrode method is provided. Adherence to practical skin surface pH measurement (method) guidelines with due consideration and practicable control of all factors that may affect skin surface pH will ensure credible pH measurement results in our continuous pursuit of understanding especially diseased skin.

      4. Mycoplasma hyopneumoniae and Mycoplasma flocculare are genetically similar. However, M. hyopneumoniae causes porcine enzootic pneumonia, while M. flocculare is a commensal bacterium. M. hyopneumoniae and M. flocculare do not penetrate their host cells, and secreted proteins are important for bacterium-host interplay. Thus, the secretomes of a swine trachea cell line (NPTr) infected with M. hyopneumoniae 7448 (a pathogenic strain), M. hyopneumoniae J (a non-pathogenic strain) and M. flocculare were compared to shed light in bacterium-host interactions. Medium from the cultures was collected, and secreted proteins were identified by a LC-MS/MS. Overall numbers of identified host and bacterial proteins were, respectively, 488 and 58, for NPTr/M. hyopneumoniae 7448; 371 and 67, for NPTr/M. hyopneumoniae J; and 203 and 81, for NPTr/M. flocculare. The swine cells revealed different secretion profiles in response to the infection with each M. hyopneumoniae strain or with M. flocculare. DAMPs and extracellular proteasome proteins, secreted in response to cell injury and death, were secreted by NPTr cells infected with M. hyopneumoniae 7448. All three mycoplasmas secreted virulence factors during NPTr infection, but M. hyopneumoniae 7448 secreted higher number of adhesins and hypothetical proteins, that may be related with pathogenicity. SIGNIFICANCE: The enzootic pneumonia caused by mycoplasmas of swine respiratory tract has economic loss consequences in pig industry due to antibiotic costs and pig weight loss. However, some genetically similar mycoplasmas are pathogenic while others, such as Mycoplasma hyopneumoniae and Mycoplasma flocculare, are non-pathogenic. Here, we conducted an infection assay between swine cells and pathogenic and non-pathogenic mycoplasmas to decipher secreted proteins during host-pathogen interaction. Mycoplasma response to cell infection was also observed. Our study provided new insights on secretion profile of swine cells in response to the infection with pathogenic and non-pathogenic mycoplasmas. It was possible to observe that pathogenic M. hyopneumoniae 7448 secreted known virulence factors and swine cells responded by inducing cell death. Otherwise, M. hyopneumoniae J and M. flocculare, non-pathogenic mycoplasmas, secreted a different profile of virulence factors in response to swine cells. Consequently, swine cells altered their secretome profile, but the changes were not sufficient to cause disease.

      5. Antibiotic-resistant Escherichia coli and class 1 integrons in people, domestic animals, and wild primates in rural UgandaExternal
        Weiss D, Wallace RM, Rwego IB, Gillespie TR, Chapman CA, Singer RS, Goldberg TL.
        Appl Environ Microbiol. 2018 Aug 31.

        Antibiotic resistance is a global concern, although it has been studied most extensively in developed countries. We studied Escherichia coli and class 1 integrons in western Uganda by analyzing 1,685 isolates from people, domestic animals, and wild non-human primates near two national parks. Overall, 499 isolates (29.6%) were resistant to at least one of 11 antibiotic tested. The frequency of resistance reached 20.3% of isolates for trimethoprim/sulfamethoxazole but was nearly zero for the less commonly available antibiotics ciprofloxacin (0.4%), gentamicin (0.2%) and ceftiofur (0.1%). The frequency of resistance was 57.4% in isolates from people, 19.5% in isolates from domestic animals, and 16.3% in isolates from wild non-human primates. Isolates of livestock and primate origin displayed multidrug resistance patterns identical to those of human-origin isolates. The percentage of resistant isolates in people was higher near Kibale National Park (64.3%) than near Bwindi Impenetrable National Park (34.6%), perhaps reflecting local socioeconomic or ecological conditions. Across antibiotics, resistance correlated negatively with the local price of the antibiotic, with the most expensive antibiotics (nalidixic acid and ciprofloxacin) showing near-zero resistance. Among phenotypically resistant isolates, 33.2% harbored class 1 integrons containing 11 common resistance genes arranged into nine distinct gene cassettes, five of which were present in isolates from multiple host species. Overall, these results show that phenotypic resistance and class 1 integrons are distributed broadly among E. coli isolates from different host species in this region, where local socioeconomic and ecological conditions may facilitate widespread diffusion of bacteria or resistance-conferring genetic elements.Importance Antibiotic resistance is a global problem. This study, conducted in rural western Uganda, describes antibiotic resistance patterns in E. coli bacteria near two forested national parks. Resistance was present not only in people, but also in their livestock and in wild non-human primates nearby. Multidrug resistance and class 1 integrons containing genes that confer resistance were common and similar in people and animals. The percent of resistant isolates decreased with increasing local price of the antibiotic. Antibiotic resistance in this setting likely reflects environmental diffusion of bacteria or their genes, perhaps facilitated by local ecological and socioeconomic conditions.

    • Maternal and Child Health
      1. Educational disabilities among children born with neonatal abstinence syndromeExternal
        Fill MA, Miller AM, Wilkinson RH, Warren MD, Dunn JR, Schaffner W, Jones TF.
        Pediatrics. 2018 Sep;142(3).

        BACKGROUND: Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that can occur after intrauterine opioid exposure. Adverse neurobehavioral outcomes have been documented in infants with NAS; however, educational outcomes have not been thoroughly examined. We analyzed Tennessee data to understand the need for special educational services among infants who are born with NAS. METHODS: By using Tennessee Medicaid and birth certificate data, infants who were born in Tennessee between 2008 and 2011 with a history of NAS were matched (1:3) to infants who were born during the same period without a history of NAS. Groups were matched on the basis of sex, race and/or ethnicity, age, birth region of residence, and Medicaid enrollment status. Data were linked to Tennessee Department of Education special education data during early childhood (3-8 years of age). Conditional multivariable logistic regression was used to assess associations between NAS and selected special education outcomes. RESULTS: A total of 1815 children with a history of NAS and 5441 children without NAS were assessed. Children with NAS were significantly more likely to be referred for a disability evaluation (351 of 1815 [19.3%] vs 745 of 5441 [13.7%]; P < .0001), to meet criteria for a disability (284 of 1815 [15.6%] vs 634 of 5441 [11.7%]; P < .0001), and to require classroom therapies or services (278 of 1815 [15.3%] vs 620 of 5441 [11.4%]; P < .0001). These findings were sustained in a multivariable analysis, with multiple models controlling for maternal tobacco use, maternal education status, birth weight, gestational age, and/or NICU admission. CONCLUSIONS: Results of this novel analysis linking health and education data revealed that children with a history of NAS were significantly more likely to have a subsequent educational disability.

    • Occupational Safety and Health
      1. Healthcare personnel exposure in an emergency department during influenza seasonExternal
        Rule AM, Apau O, Ahrenholz SH, Brueck SE, Lindsley WG, de Perio MA, Noti JD, Shaffer RE, Rothman R, Grigorovitch A, Noorbakhsh B, Beezhold DH, Yorio PL, Perl TM, Fisher EM.
        PLoS One. 2018 ;13(8):e0203223.

        INTRODUCTION: Healthcare personnel are at high risk for exposure to influenza by direct and indirect contact, droplets and aerosols, and by aerosol generating procedures. Information on air and surface influenza contamination is needed to assist in developing guidance for proper prevention and control strategies. To understand the vulnerabilities of healthcare personnel, we measured influenza in the breathing zone of healthcare personnel, in air and on surfaces within a healthcare setting, and on filtering facepiece respirators worn by healthcare personnel when conducting patient care. METHODS: Thirty participants were recruited from an adult emergency department during the 2015 influenza season. Participants wore personal bioaerosol samplers for six hours of their work shift, submitted used filtering facepiece respirators and medical masks and completed questionnaires to assess frequency and types of interactions with potentially infected patients. Room air samples were collected using bioaerosol samplers, and surface swabs were collected from high-contact surfaces within the adult emergency department. Personal and room bioaerosol samples, surface swabs, and filtering facepiece respirators were analyzed for influenza A by polymerase chain reaction. RESULTS: Influenza was identified in 42% (53/125) of personal bioaerosol samples, 43% (28/ 96) of room bioaerosol samples, 76% (23/30) of pooled surface samples, and 25% (3/12) of the filtering facepiece respirators analyzed. Influenza copy numbers were greater in personal bioaerosol samples (17 to 631 copies) compared to room bioaerosol samples (16 to 323 copies). Regression analysis suggested that the amount of influenza in personal samples was approximately 2.3 times the amount in room samples (Wald chi2 = 16.21, p<0.001). CONCLUSIONS: Healthcare personnel may encounter increased concentrations of influenza virus when in close proximity to patients. Occupations that require contact with patients are at an increased risk for influenza exposure, which may occur throughout the influenza season. Filtering facepiece respirators may become contaminated with influenza when used during patient care.

    • Occupational Safety and Health – Mining
      1. Design and experimental evaluation of a flooded-bed dust scrubber integrated into a longwall shearerExternal
        Arya S, Sottile J, Rider JP, Colinet JF, Novak T, Wedding C.
        Powder Technology. 2018 ;339:487-496.

        Continuous mining machines operating in U.S. underground coal mines have, for decades, utilized flooded-bed dust scrubbers for capturing and removing respirable dust generated at the production face. However, the application of dust scrubbers to longwall mining systems has not yet been successful. Considering that nearly 60% of U.S. underground coal production is from longwall mines, the successful application of dust scrubbers to longwall mining systems could have a significant impact on miner health. A full-scale mock-up of a longwall shearer was constructed and equipped with a flooded-bed dust scrubber designed to capture dust produced by the headgate cutting drum. The mockup was installed at the National Institute for Occupational Safety and Health (NIOSH) Longwall Dust Gallery and a series of 40 experiments was conducted to evaluate the scrubber’s performance. Results show that the scrubber achieved a 56% reduction of respirable dust in the return airway and a 74% reduction of respirable dust in the walkway area near the shearer. Although these tests were conducted under a controlled environment, the results suggest that a similar scrubber design could be very effective at achieving a significant reduction in respirable dust in longwall mining systems.

    • Physical Activity
      1. Policy and practice-relevant youth Physical Activity Research Center agendaExternal
        Botchwey N, Floyd MF, Pollack Porter K, Cutter CL, Spoon C, Schmid TL, Conway TL, Hipp JA, Kim AJ, Umstattd Meyer MR, Walker AL, Kauh TJ, Sallis JF.
        J Phys Act Health. 2018 Aug 1;15(8):626-634.

        BACKGROUND: The Physical Activity Research Center developed a research agenda that addresses youth physical activity (PA) and healthy weight, and aligns with the Robert Wood Johnson Foundation’s Culture of Health. This paper summarizes prioritized research studies with a focus on youth at higher risk for inactive lifestyles and childhood obesity in urban and rural communities. METHODS: Systematic literature reviews, a survey, and discussions with practitioners and researchers provided guidance on research questions to build evidence and inform effective strategies to promote healthy weight and PA in youth across race, cultural, and economic groups. RESULTS: The research team developed a matrix of potential research questions, identified priority questions, and designed targeted studies to address some of the priority questions and inform advocacy efforts. The studies selected examine strategies advocating for activity-friendly communities, Play Streets, park use, and PA of youth in the summer. A broader set of research priorities for youth PA is proposed. CONCLUSION: Establishing the Physical Activity Research Center research agenda identified important initial and future research studies to promote and ensure healthy weight and healthy levels of PA for at-risk youth. Results will be disseminated with the goal of promoting equitable access to PA for youth.

      2. Creating walkable communities: Understanding trade-offsExternal
        Carlson SA, Omura JD, Watson KB, Fulton JE.
        Prev Chronic Dis. 2018 Aug 30;15:E107.

        Implementing community design strategies can offer benefits related to walkability; however, they may also come with trade-offs to other community needs and desires. We examined public sentiment for 2 trade-offs among 2014 SummerStyles survey respondents (n = 3,995). About 33% of adults reported strongly favoring safer street design even if driving is slower; only 19% reported strongly favoring community design with walkable destinations even if homes are closer together. Walking frequency was positively associated with strongly favoring trade-offs, while differences by other demographic characteristics depended on the trade-off. Addressing public sentiment for potential trade-offs may be important when promoting walkable design strategies.

      3. Investigating best practices of district-wide physical activity programmatic efforts in US schools- a mixed-methods approachExternal
        Economos CD, Mueller MP, Schultz N, Gervis J, Miller GF, Pate RR.
        BMC Public Health. 2018 Aug 30;18(1):992.

        BACKGROUND: The majority of US children do not meet physical activity recommendations. Schools are an important environment for promoting physical activity in children, yet most school districts do not offer enough physical activity opportunities to meet recommendations. This study aimed to identify school districts across the country that demonstrated exemplary efforts to provide students with many physical activity opportunities and to understand the factors that facilitated their programmatic success. METHODS: A total of 59 districts were identified as model districts by members of the Physical Activity and Health Innovation Collaborative, an ad hoc activity associated with the Roundtable on Obesity Solutions at the National Academies of Sciences, Engineering, and Medicine. Semi-structured interviews were conducted with consenting stakeholders from 23 school districts to understand physical education and activity efforts and elucidate factors that led to the success of these districts’ physical activity programming. Districts were geographically and socioeconomically diverse and varied in their administrative and funding structure. RESULTS: Most districts did not offer the recommended 150 or 225 min of physical activity a week through physical education alone; yet all districts offered a range of programs outside of physical education that provided additional opportunities for students to be physically active. The average number of school-based physical activity programs offered was 5.5, 3.5 and 2.1 for elementary, middle and high schools, respectively. Three overarching and broadly relevant themes were identified that were associated with successfully enhancing physical activity opportunities for students: soliciting and maintaining the support of champions, securing funding and/or tangible support, and fostering bi-directional partnerships between the district and community organizations and programs. Not only were these three themes critical for the development of physical activity opportunities, but they also remained important for the implementation, evaluation and sustainability of programs. These themes also did not differ substantially by the socioeconomic status of districts. CONCLUSIONS: These findings demonstrate the success of school districts across the nation in providing ample opportunities for physical activity despite considerable variability in socioeconomic status and resources. These results can inform future research and provide actionable evidence for school districts to enhance physical activity opportunities to students.

    • Public Health Leadership and Management
      1. Community health workers (CHWs) are becoming a well-recognized workforce to help reduce health disparities and improve health equity. Although evidence demonstrates the value of engaging CHWs in health care teams, there is a need to describe best practices for integrating CHWs into US health care settings. The use of existing health promotion and implementation theories could guide the research and implementation of health interventions conducted by CHWs. We conducted a standard 5-step scoping review plus stakeholder engagement to provide insight into this topic. Using PubMed, EMBASE, and Web of Science, we identified CHW intervention studies in health care settings published between 2000 and 2017. Studies were abstracted by 2 researchers for characteristics and reported use of theory. Our final review included 50 articles published between January 2000 and April 2017. Few studies used implementation theories to understand the facilitators and barriers to CHW integration. Those studies that incorporated implementation theories used RE-AIM, intervention mapping, cultural tailoring, PRECEDE-PROCEED, and the diffusion of innovation. Although most studies did not report using implementation theories, some constructs of implementation such as fidelity or perceived benefits were assessed. In addition, studies that reported intervention development often cited specific theories, such as the transtheoretical or health belief model, that helped facilitate the development of their program. Our results are consistent with other literature describing poor uptake and use of implementation theory. Further translation of implementation theories for CHW integration is recommended.

      2. INTRODUCTION: Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs’ engagement in activities to meet these standards. OBJECTIVES: To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program. METHODS: Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey. RESULTS: Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent). CONCLUSIONS: LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs’ participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

    • Statistics as Topic
      1. Data from the National Health and Nutrition Examination Survey have been linked to the Center for Medicare and Medicaid Services’ Medicaid Enrollment and Claims Files for the survey years 1999-2004. The linked data are produced by the National Center for Health Statistics’ (NCHS) Data Linkage Program and are available in the NCHS Research Data Center. This project compares the usefulness of multiple imputation to account for data linkage ineligibility and other survey nonresponse with currently recommended weight adjustment procedures. Estimated differences in environmental smoke exposure across Medicaid/Children’s Health Insurance Program (CHIP) enrollment status among children ages 3-15 years are examined as a motivating example. Comparisons are drawn across the three different estimates: one that uses MI to impute the administrative Medicaid/CHIP status of those who are ineligible for linkage, a second that uses the linked data restricted to linkage eligible participants with a basic weight adjustment, and a third that uses self-reported Medicaid/CHIP status from the survey data. The results indicate that estimates from the multiple imputation analysis were comparable to those found when using weight adjustment procedures and had the added benefit of incorporating all survey participants (linkage eligible and linkage ineligible) into the analysis. We conclude that both multiple imputation and weight adjustment procedures can effectively account for survey participants who are ineligible for linkage.

    • Substance Use and Abuse
      1. Background: In response to adverse outcomes from prescription opioids, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain in March 2016. Objective: To test the hypothesis that the CDC guideline release corresponded to declines in specific opioid prescribing practices. Design: Interrupted time series analysis of monthly prescribing measures from the IQVIA transactional data warehouse and Real-World Data Longitudinal Prescriptions population-level estimates based on retail pharmacy data. Population size was determined by U.S. Census monthly estimates. Setting: United States, 2012 to 2017. Patients: Persons prescribed opioid analgesics. Measurements: Outcomes included opioid dosage, days supplied, overlapping benzodiazepine prescriptions, and the overall rate of prescribing. Results: The rate of high-dosage prescriptions (>/=90 morphine equivalent milligrams per day) was 683 per 100 000 persons in January 2012 and declined by 3.56 (95% CI, -3.79 to -3.32) per month before March 2016 and by 8.00 (CI, -8.69 to -7.31) afterward. Likewise, the percentage of patients with overlapping opioid and benzodiazepine prescriptions was 21.04% in January 2012 and declined by 0.02% (CI, -0.04% to -0.01%) per month before the CDC guideline release and by 0.08% (CI, -0.08% to -0.07%) per month afterward. The overall opioid prescribing rate was 6577 per 100 000 persons in January 2012 and declined by 23.48 (CI, -26.18 to -20.78) each month before the guideline release and by 56.74 (CI, -65.96 to -47.53) per month afterward. Limitation: No control population; inability to determine the appropriateness of opioid prescribing. Conclusion: Several opioid prescribing practices were decreasing before the CDC guideline, but the time of its release was associated with a greater decline. Guidelines may be effective in changing prescribing practices. Primary Funding Source: CDC.

    • Zoonotic and Vectorborne Diseases
      1. St. Louis encephalitis virus disease in the United States, 2003-2017External
        Curren EJ, Lindsey NP, Fischer M, Hills SL.
        Am J Trop Med Hyg. 2018 Sep 4.

        St. Louis encephalitis virus (SLEV), an arthropod-borne flavivirus, can cause disease presentations ranging from mild febrile illness through severe encephalitis. We reviewed U.S. national SLEV surveillance data for 2003 through 2017, including human disease cases and nonhuman infections. Over the 15-year period, 198 counties from 33 states and the District of Columbia reported SLEV activity; 97 (49%) of those counties reported SLEV activity only in nonhuman species. A total of 193 human cases of SLEV disease were reported, including 148 cases of neuroinvasive disease. A median of 10 cases were reported per year. The national average annual incidence of reported neuroinvasive disease cases was 0.03 per million. States with the highest average annual incidence of reported neuroinvasive disease cases were Arkansas, Arizona, and Mississippi. No large outbreaks occurred during the reporting period. The most commonly reported clinical syndromes were encephalitis (N = 116, 60%), febrile illness (N = 35, 18%), and meningitis (N = 25, 13%). Median age of cases was 57 years (range 2-89 years). The case fatality rate was 6% (11/193) and all deaths were among patients aged > 45 years with neuroinvasive disease. Nonhuman surveillance data indicated wider SLEV activity in California, Nevada, and Florida than the human data alone suggested. Prevention depends on community efforts to reduce mosquito populations and personal protective measures to decrease exposure to mosquitoes.

      2. Assessment of state, local, and territorial Zika planning and preparedness activities – United States, June 2016-July 2017External
        Murthy BP, Vagi S, Desamu-Thorpe R, Avchen R.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 7;67(35):969-973.

        The emergency response to Zika virus disease required coordinated efforts and heightened collaboration among federal, state, local, and territorial public health jurisdictions. CDC activated its Emergency Operations Center on January 21, 2016, with seven task forces to support the national response. The State Coordination Task Force, which functions as a liaison between jurisdictions and federal operations during a response, coordinated the development of CDC Guidelines for Development of State and Local Risk-based Zika Action Plans, which included a Zika Preparedness Checklist (1). The checklist summarized recommendations covering topics from the seven task forces. In July 2016, CDC’s Office of Public Health Preparedness and Response (OPHPR) awarded $25 million in supplemental funding to 53 jurisdictions (41 states, eight territories, and four metropolitan areas) to support Zika preparedness and response activities. In December 2016, CDC awarded an additional $25 million to 21 of the 53 jurisdictions at the greatest risk for seeing Zika in their communities based on the presence of the mosquito responsible for spreading Zika, history of local transmission, or a high volume of travelers from Zika-affected areas. The additional $25 million was part of the $350 million in Zika supplemental funding provided to CDC by Congress in 2016* (2,3). Funded jurisdictions reported progress through the checklist at five quarterly points throughout the response. Data were analyzed to assess planning and response activities. Among the 53 jurisdictions, the percentage that reported having a Zika virus readiness, response, and recovery plan increased from 26% in June 2016 to 64% in July 2017. Overall, Zika planning and response activities increased among jurisdictions from June 2016 to July 2017. The recent Zika virus outbreak underscores the importance of strengthening state, local, and territorial health department capacity for rapid response to emerging threats.

      3. Preventing human Salmonella infections resulting from live poultry contact through interventions at retail storesExternal
        Nichols M, Stevenson L, Whitlock L, Pabilonia K, Robyn M, Basler C, Gomez T, Behravesh CB.
        J Agric Saf Health. 2018 ;24(3):155-166.

        The number of outbreaks of Salmonella infections linked to live poultry contact increased from 1990 to 2016. In 2016, the number of human illnesses linked to live poultry was the highest reported, with more than 900 cases, including 209 hospitalizations and three deaths. Live poultry harboring Salmonella typically appear healthy but can intermittently shed bacteria in their droppings, contaminating their feathers, beaks, and the areas where they live and roam. Thus, both direct contact with poultry and indirect contact with anything in areas where animals live and roam can result in human Salmonella infection. To prevent Salmonella infections linked to live poultry, a One Health approach for control and prevention is required. This approach unifies animal and human health needs and takes into account the environments at the hatcheries where poultry are produced, the agricultural retail stores where poultry are sold, and the customers who own and raise poultry. Agricultural retail stores are the main point of sale for backyard poultry in the U.S. Therefore, stores can play a vital role in preventing infections by sourcing poultry from hatcheries that take steps to reduce Salmonella in the environment, by displaying poultry in areas that can be easily cleaned, and by using barriers that allow customers to view, but not touch, poultry from a distance. Retail store employees also have a role in preventing illnesses and contamination after the sale by educating customers about appropriate housing for live poultry in outdoor coops, barns, or other designated areas.

      4. Demonstration of efficient vertical and venereal transmission of dengue virus type-2 in a genetically diverse laboratory strain of Aedes aegyptiExternal
        Sanchez-Vargas I, Harrington LC, Doty JB, Black WC, Olson KE.
        PLoS Negl Trop Dis. 2018 Aug 31;12(8):e0006754.

        Aedes aegypti is the primary mosquito vector of dengue viruses (DENV; serotypes 1-4). Human-mosquito transmission cycles maintain DENV during epidemics but questions remain regarding how these viruses survive when human infections and vector abundance are minimal. Aedes mosquitoes can transmit DENV within the vector population through two alternate routes: vertical and venereal transmission (VT and VNT, respectively). We tested the efficiency of VT and VNT in a genetically diverse laboratory (GDLS) strain of Ae. aegypti orally infected with DENV2 (Jamaica 1409). We examined F1 larvae from infected females generated during the first and second gonotrophic cycles (E1 and E2) for viral envelope (E) antigen by amplifying virus in C6/36 cells and then performing an indirect immunofluorescence assay (IFA). RT-PCR/nested PCR analyses confirmed DENV2 RNA in samples positive by IFA. We observed VT of virus to larvae and adult male progeny and VNT of virus to uninfected virgin females after mating with males that had acquired virus by the VT route. We detected no DENV2 in 30 pools (20 larvae/pool) of F1 larvae following the first gonotrophic cycle, suggesting limited virus dissemination at 7 days post-infection. DENV2 was detected by IFA in 27 of 49 (55%) and 35 of 51 (68.6%) F1 larval pools (20 larvae/pool) from infected E2 females that received a second blood meal without virus at 10 or 21 days post-infection (E2-10d-F1 and E2-21-F1), respectively. The minimum filial infection rates by IFA for E2-10d-F1 and E2-21d-F1 mosquitoes were 1:36 and 1:29, respectively. The VNT rate from E2-10d-F1 males to virgin (uninfected) GDLS females was 31.6% (118 of 374) at 8 days post mating. Twenty one percent of VNT-infected females receiving a blood meal prior to mating had disseminated virus in their heads, suggesting a potential pathway for virus to re-enter the human-mosquito transmission cycle. This is the first report of VNT of DENV by male Ae. aegypti and the first demonstration of sexual transmission in Aedes by naturally infected males. Our results demonstrate the potential for VT and VNT of DENV in nature as mechanisms for virus maintenance during inter-epidemic periods.

      5. Zika virus seropositivity in 1-4-year-old children, Indonesia, 2014External
        Sasmono RT, Dhenni R, Yohan B, Pronyk P, Hadinegoro SR, Soepardi EJ, Ma’roef CN, Satari HI, Menzies H, Hawley WA, Powers AM, Rosenberg R, Myint KS, Soebandrio A.
        Emerg Infect Dis. 2018 Sep;24(9).

        We assessed Zika virus seroprevalence among healthy 1-4-year-old children using a serum sample collection assembled in 2014 representing 30 urban sites across Indonesia. Of 662 samples, 9.1% were Zika virus seropositive, suggesting widespread recent Zika virus transmission and immunity. Larger studies are needed to better determine endemicity in Indonesia.

Back to Top

CDC Science Clips Production Staff

  • John Iskander, MD MPH, Editor
  • Gail Bang, MLIS, Librarian
  • Kathy Tucker, Librarian
  • William (Bill) Thomas, MLIS, Librarian
  • Onnalee Gomez, MS, Health Scientist
  • Jarvis Sims, MIT, MLIS, Librarian


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

Page last reviewed: January 31, 2019