Volume 10, Issue 38, October 9, 2018

CDC Science Clips: Volume 10, Issue 38, October 9, 2018

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

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Selected occupational characteristics and change in leukocyte telomere length over 10 years: The Multi-Ethnic Study of Atherosclerosis (MESA)External
        Fujishiro K, Needham BL, Landsbergis PA, Seeman T, Jenny NS, Diez Roux AV.
        PLoS One. 2018 ;13(9):e0204704.

        Telomere length (TL) is considered as a marker of cell senescence, but factors influencing the rate of TL attrition are not well understood. While one previous study reported the association of occupation and TL, many subsequent studies have failed to find the association. This may be due to heterogeneity within the samples and cross-sectional designs. This longitudinal study examines two occupational characteristics, occupational complexity and hazardous conditions, as predictors of TL attrition in gender- and race/ethnicity-stratified analysis. Leukocyte TL (expressed as T/S ratio) was measured twice over a 10-year period in a multi-racial sample (n = 914). Linear mixed effect models were used to estimate TL attrition associated with occupational complexity and hazardous conditions. Analysis was stratified by gender and race/ethnicity (white, African American, and Latino) and controlled for baseline age, baseline TL, and time since baseline. Higher occupational complexity was associated with slower rates of TL attrition only among white men. Hazardous conditions were not associated with TL attrition for any gender-and-race/ethnicity stratified group. Occupational complexity may influence TL attrition, but the different findings for white men and other groups suggest that a more comprehensive framework is needed to better understand the potential link between occupational characteristics and biological aging.

    • Environmental Health
      • Quantification of 19 aldehydes in human serum by Headspace SPME/GC/high-resolution mass spectrometryExternal
        Silva LK, Hile GA, Capella KM, Espenship MF, Smith MM, De Jesus VR, Blount BC.
        Environ Sci Technol. 2018 Sep 18;52(18):10571-10579.

        Sources of human aldehyde exposure include food additives, combustion of organic matter (tobacco smoke), water disinfection byproducts via ozonation, and endogenous processes. Aldehydes are potentially carcinogenic and mutagenic, and chronic human aldehyde exposure has raised concerns about potential deleterious health effects. To aid investigations of human aldehyde exposure, we developed a novel method to measure 19 aldehydes released from Schiff base protein adducts in serum using controlled acid hydrolysis, solid-phase microextraction (SPME), gas chromatography (GC), and high-resolution mass spectrometry (HRMS). Aldehydes are released from Schiff base protein adducts through acid hydrolysis, and are quantified in trace amounts (mug/L) using stable isotope dilution. Detection limits range from 0.1 to 50 mug/L, with calibration curves spanning 3 orders of magnitude. The analysis of fortified quality control material over a three-month period showed excellent precision and long-term stability (3-22% CV) for samples stored at -70 degrees C. The intraday precision is also excellent (CV, 1-10%). The method accuracy ranges from 89 to 108% for all measured aldehydes, except acrolein and crotonaldehyde, two aldehydes present in tobacco smoke; their analysis by this method is not considered robust due in part to their reactivity in vivo. However, results strongly suggest that propanal, butanal, isobutanal, and isopentanal levels in smokers are higher than levels in nonsmokers, and thus may be useful as biomarkers of tobacco smoke exposure. This method will facilitate large epidemiological studies involving aldehyde biomonitoring to examine nonoccupational environmental exposures.

    • Genetics and Genomics
      • Use of whole genome sequencing to complement characterisation of a typhoid fever outbreak among a Marshallese community: Oklahoma, 2015External
        Burnsed LJ, Kovar LD, Angelo KM, Trees EK, Concepcion-Acevedo J, McDermott MD, Wagner D, Bradley KK.
        Epidemiol Infect. 2018 Sep 21:1-7.

        Typhoid fever is an illness caused by Salmonella enterica serotype Typhi. In developing regions, it affects an estimated 20 million people annually, causing 200 000 deaths. Although uncommon, cases occur in the USA each year, predominantly due to international travel. During February 2015, the Oklahoma State Department of Health (OSDH) detected an outbreak of typhoid fever among residents of northwestern Oklahoma. OSDH conducted case-patient interviews to identify the source and symptomatic contacts. Whole genome sequencing (WGS) was performed to characterise the genetic relatedness of isolates among the four outbreak-associated pulsed-field gel electrophoresis (PFGE) patterns. We identified 38 cases, 25 confirmed and 13 probable, in two states. WGS revealed a 0-10 single-nucleotide polymorphism variation between isolates. Although we were unable to determine the source, almost all case-patients were members of the Marshallese community that attended a common event in Oklahoma, or were contacts to a confirmed case. This is the largest outbreak of typhoid fever in the USA since 1989, and first to apply WGS to complement interpretation of PFGE results during a typhoid fever outbreak investigation. This investigation illustrates the potential risk of outbreaks among communities comprised of international populations from regions where typhoid fever remains endemic.

      • Direct RNA sequencing of the coding complete influenza A virus genomeExternal
        Keller MW, Rambo-Martin BL, Wilson MM, Ridenour CA, Shepard SS, Stark TJ, Neuhaus EB, Dugan VG, Wentworth DE, Barnes JR.
        Sci Rep. 2018 Sep 26;8(1):14408.

        For the first time, a coding complete genome of an RNA virus has been sequenced in its original form. Previously, RNA was sequenced by the chemical degradation of radiolabeled RNA, a difficult method that produced only short sequences. Instead, RNA has usually been sequenced indirectly by copying it into cDNA, which is often amplified to dsDNA by PCR and subsequently analyzed using a variety of DNA sequencing methods. We designed an adapter to short highly conserved termini of the influenza A virus genome to target the (-) sense RNA into a protein nanopore on the Oxford Nanopore MinION sequencing platform. Utilizing this method with total RNA extracted from the allantoic fluid of influenza rA/Puerto Rico/8/1934 (H1N1) virus infected chicken eggs (EID50 6.8 x 10(9)), we demonstrate successful sequencing of the coding complete influenza A virus genome with 100% nucleotide coverage, 99% consensus identity, and 99% of reads mapped to influenza A virus. By utilizing the same methodology one can redesign the adapter in order to expand the targets to include viral mRNA and (+) sense cRNA, which are essential to the viral life cycle, or other pathogens. This approach also has the potential to identify and quantify splice variants and base modifications, which are not practically measurable with current methods.

    • Immunity and Immunization
      • The objective of this study was to assess the persistence of antibodies after a single dose of quadrivalent HPV vaccine (4vHPV) and the effect of a dose of nonavalent HPV vaccine (9vHPV) given 3-8 years later. Such data might be of interest in the decision-making process regarding the 2-dose course completion in non-compliant vaccinees in jurisdictions which switched from 4vHPV to 9vHPV. Girls who previously received a single dose of 4vHPV were eligible to participate. Blood specimens were collected just before and one month post-9vHPV administration. The specimens were tested by ELISA for the presence of antibodies to 9 HPV types included in the 9vHPV. Thirty-one girls aged 13-18 years (mean 15.5 years) participated in the study. Pre-9vHPV administration, all participants were seropositive to 4 HPV types included in 4vHPV and 58%-87% were seropositive to the five other HPV types included in the 9vHPV. GMTs were 6.1 AU/ml, 7.7 AU/ml, 20.1 IU/ml and 6.3 IU/ml to HPV6, HPV11, HPV16 and HPV18, respectively. The GMTs for the other five HPV types varied from 1.0 to 2.9 AU/ml. One month post-9vHPV administration all 31 participants were seropositive to all 9 HPV types with a 36.1 to 89.1-fold increase of GMTs. High seropositivity rates observed several years after a single dose of 4vHPV and 100% seropositivity after a dose of 9vHPV suggest that this schedule might be used in non-compliant vaccinees or when switching immunization programs from 4vHPV to 9vHPV.

    • Injury and Violence
      • Pediatric traumatic brain injury (TBI) is a growing health concern, with over half a million TBI-related emergency department (ED) visits annually. However, this is likely an underestimate of the true incidence, with many children presenting to their pediatrician. The Centers for Disease Control and Prevention (CDC) published a guideline on the diagnosis and management of pediatric mild traumatic brain injury (mTBI). We outline key points and a decision checklist for pediatricians based on this evidence-based guideline.

      • Implementation of the Stopping Elderly Accidents, Deaths, and Injuries Initiative in Primary Care: An outcome evaluationExternal
        Johnston YA, Bergen G, Bauer M, Parker EM, Wentworth L, McFadden M, Reome C, Garnett M.
        Gerontologist. 2018 Sep 20.

        Background and Objectives: Older adult falls pose a growing burden on the U.S. health care system. The Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative was developed as a multifactorial approach to fall prevention that includes screening for fall risk, assessing for modifiable risk factors, and prescribing evidence-based interventions to reduce fall risk. The purpose of this study was to determine the impact of a STEADI initiative on medically treated falls within a large health care system in Upstate New York. Research Design and Methods: This cohort study classified older adults who were screened for fall risk into 3 groups: (a) At-risk and no Fall Plan of Care (FPOC), (b) At-risk with a FPOC, and (c) Not-at-risk. Poisson regression examined the group’s effect on medically treated falls when controlling for other variables. The sample consisted of 12,346 adults age 65 or older who had a primary care visit at one of 14 outpatient clinics between September 11, 2012, and October 30, 2015. A medically treated fall was defined as a fall-related treat-and-release emergency department visit or hospitalization. Results: Older adults at risk for fall with a FPOC were 0.6 times less likely to have a fall-related hospitalization than those without a FPOC (p = .041), and their postintervention odds were similar to those who were not at risk. Discussion and Implications: This study demonstrated that implementation of STEADI fall risk screening and prevention strategies among older adults in the primary care setting can reduce fall-related hospitalizations and may lower associated health care expenditures.

      • Importance: Early adversity is associated with leading causes of adult morbidity and mortality and effects on life opportunities. Objective: To provide an updated prevalence estimate of adverse childhood experiences (ACEs) in the United States using a large, diverse, and representative sample of adults in 23 states. Design, Setting, and Participants: Data were collected through the Behavioral Risk Factor Surveillance System (BRFSS), an annual, nationally representative telephone survey on health-related behaviors, health conditions, and use of preventive services, from January 1, 2011, through December 31, 2014. Twenty-three states included the ACE assessment in their BRFSS. Respondents included 248934 noninstitutionalized adults older than 18 years. Data were analyzed from March 15 to April 25, 2017. Main Outcomes and Measures: The ACE module consists of 11 questions collapsed into the following 8 categories: physical abuse, emotional abuse, sexual abuse, household mental illness, household substance use, household domestic violence, incarcerated household member, and parental separation or divorce. Lifetime ACE prevalence estimates within each subdomain were calculated (range, 1.00-8.00, with higher scores indicating greater exposure) and stratified by sex, age group, race/ethnicity, annual household income, educational attainment, employment status, sexual orientation, and geographic region. Results: Of the 214157 respondents included in the sample (51.51% female), 61.55% had at least 1 and 24.64% reported 3 or more ACEs. Significantly higher ACE exposures were reported by participants who identified as black (mean score, 1.69; 95% CI, 1.62-1.76), Hispanic (mean score, 1.80; 95% CI, 1.70-1.91), or multiracial (mean score, 2.52; 95% CI, 2.36-2.67), those with less than a high school education (mean score, 1.97; 95% CI, 1.88-2.05), those with income of less than $15000 per year (mean score, 2.16; 95% CI, 2.09-2.23), those who were unemployed (mean score, 2.30; 95% CI, 2.21-2.38) or unable to work (mean score, 2.33; 95% CI, 2.25-2.42), and those identifying as gay/lesbian (mean score 2.19; 95% CI, 1.95-2.43) or bisexual (mean score, 3.14; 95% CI, 2.82-3.46) compared with those identifying as white, those completing high school or more education, those in all other income brackets, those who were employed, and those identifying as straight, respectively. Emotional abuse was the most prevalent ACE (34.42%; 95% CI, 33.81%-35.03%), followed by parental separation or divorce (27.63%; 95% CI, 27.02%-28.24%) and household substance abuse (27.56%; 95% CI, 27.00%-28.14%). Conclusions and Relevance: This report demonstrates the burden of ACEs among the US adult population using the largest and most diverse sample to date. These findings highlight that childhood adversity is common across sociodemographic characteristics, but some individuals are at higher risk of experiencing ACEs than others. Although identifying and treating ACE exposure is important, prioritizing primary prevention of ACEs is critical to improve health and life outcomes throughout the lifespan and across generations.

    • Laboratory Sciences
      • Griffithsin carrageenan fast dissolving inserts prevent SHIV HSV-2 and HPV infections in vivoExternal
        Derby N, Lal M, Aravantinou M, Kizima L, Barnable P, Rodriguez A, Lai M, Wesenberg A, Ugaonkar S, Levendosky K, Mizenina O, Kleinbeck K, Lifson JD, Peet MM, Lloyd Z, Benson M, Heneine W, O’Keefe BR, Robbiani M, Martinelli E, Grasperge B, Blanchard J, Gettie A, Teleshova N, Fernandez-Romero JA, Zydowsky TM.
        Nat Commun. 2018 Sep 24;9(1):3881.

        Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) strategies with proven in vivo efficacy rely on antiretroviral drugs, creating the potential for drug resistance and complicated treatment options in individuals who become infected. Moreover, on-demand products are currently missing from the PrEP development portfolio. Griffithsin (GRFT) is a non-antiretroviral HIV entry inhibitor derived from red algae with an excellent safety profile and potent activity in vitro. When combined with carrageenan (CG), GRFT has strong activity against herpes simplex virus-2 (HSV-2) and human papillomavirus (HPV) in vitro and in vivo. Here, we report that GRFT/CG in a freeze-dried fast dissolving insert (FDI) formulation for on-demand use protects rhesus macaques from a high dose vaginal SHIV SF162P3 challenge 4 h after FDI insertion. Furthermore, the GRFT/CG FDI also protects mice vaginally against HSV-2 and HPV pseudovirus. As a safe, potent, broad-spectrum, on-demand non-antiretroviral product, the GRFT/CG FDI warrants clinical development.

    • Zoonotic and Vectorborne Diseases
      • CD4 T cells, CD8 T cells, and monocytes coordinate to prevent Rift Valley fever virus encephalitisExternal
        Harmon JR, Spengler JR, Coleman-McCray JD, Nichol ST, Spiropoulou CF, McElroy AK.
        J Virol. 2018 Sep 26.

        Rift Valley fever virus (RVFV) is an arbovirus that causes disease in livestock and humans in Africa and the Middle East. While human disease is typically mild and self-limiting, some individuals develop severe manifestations, such as hepatitis, hemorrhagic fever or encephalitis. Encephalitis occurs 2-3 weeks after acute illness; therefore, we hypothesized that it was a result of an inadequate adaptive immunity. To test this hypothesis in vivo, we used an attenuated virus (DelNSsRVFV) that does not typically cause disease in mice. We first characterized the normal immune response to infection with DelNSsRVFV in immune-competent mice and noted expansion of natural killer cells and monocytes, as well as activation of both CD8 and CD4 T cells. Depleting C57BL/6 mice of CD4 T cells prior to DelNSsRVFV infection resulted in encephalitis in 30% of the mice; in encephalitic mice, we noted infiltration of T cells and inflammatory monocytes into the brain. CD4 and CD8 co-depletion in C57Bl/6 mice, as well as CD4 depletion in CCR2 knock-out mice increased the frequency of encephalitis, demonstrating that these cell types normally contributed to the prevention of disease. Encephalitic mice had similar viral RNA loads in the brain regardless of which cell types were depleted, suggesting that CD4 T cells, CD8 T cells, and inflammatory monocytes did little to control viral replication in the brain. CD4-depleted mice exhibited diminished humoral and T cell memory responses, suggesting that these immune mechanisms contributed to peripheral control of virus, thus preventing infection of the brain.Importance:RVFV is found in Africa and the Middle East and is transmitted by mosquitos or through contact with infected animals. Infected individuals can develop mild disease or more severe forms such as hepatitis or encephalitis. In order to understand why some individuals develop encephalitis, we first need to know which immune functions protect those who do not develop this form of disease. In this study, we used a mouse model of RVFV infection to demonstrate that CD4 T cells, CD8 T cells, and monocytes all contribute to prevention of encephalitis. Their likely mechanism of action is preventing RVFV from ever reaching the brain.

  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. State-level diabetes-attributable mortality and years of life lost in the United StatesExternal
        Alva ML, Hoerger TJ, Zhang P, Cheng YJ.
        Ann Epidemiol. 2018 Sep 7.

        PURPOSE: To estimate state-level diabetes-attributable deaths and years of life lost (YLL) in the Unites States. METHODS: We estimated diabetes-attributable all-cause and cardiovascular disease (CVD) deaths by age, sex, and state, using the attributable fraction approach. Data on diabetes prevalence were collected from Behavioral Risk Factor Surveillance System. Relative risks for people with and without diabetes were estimated using the National Health Interview Survey. State-sex-age-specific deaths were obtained from CDC WONDER. YLL were calculated by multiplying the number of people with diabetes by the difference in life expectancy between people with and without diabetes using the life table approach. RESULTS: Nationally, estimated diabetes-attributable all-cause deaths and CVD deaths were 293,224 and 90,953, respectively. Diabetes resulted in a total of 109,707,000 YLL with an average 4.4 years of life lost per person with diabetes. Most state variation in total deaths was explained by state population size and diabetes prevalence. All-cause deaths ranged from 415 in Alaska to 28,538 in California, and CVD deaths ranged from 113 in Alaska to 8908 in California. Across all states, the average diabetes-attributable death rate per 100,000 was 125 for males and 105 for females for all-cause deaths and 40 for males and 31 for females for CVD deaths. CONCLUSIONS: Mortality attributable to diabetes is greatly underestimated when looking only at diabetes listed as an underlying cause of death. These results can be used to track state differences in deaths due to diabetes and to monitor the success of public health activities.

      2. Perspectives on strengthening cancer research and control in Latin America through partnerships and diplomacy: Experience of the National Cancer Institute’s Center for Global HealthExternal
        Frech S, Muha CA, Stevens LM, Trimble EL, Brew R, Perin DP, Luciani S, Mohar A, Pineros M, Vidaurre T, Morgan DR, Hawk ET, Schmeler KM, Foxhall LE, Rabadan-Diehl C, Duran D, Rendler-Garcia M, Cazap EL, Santini L, Zoss W, Delgado LB, Pearlman PC, Given L, Hohman K, Lopez MS, Kostelecky B.
        J Glob Oncol. 2018 Sep(4):1-11.

        According to the Pan American Health Organization, noncommunicable diseases, including cancer, are the leading causes of preventable and premature death in the Americas. Governments and health care systems in Latin America face numerous challenges as a result of increasing morbidity and mortality from cancer. Multiple international organizations have recognized the need for collaborative action on and technical support for cancer research and control in Latin America. The Center for Global Health at the US National Cancer Institute (NCI-CGH) is one entity among many that are working in the region and has sought to develop a strategy for working in Latin America that draws on and expands the collaborative potential of engaged, skilled, and diverse partners. NCI-CGH has worked toward developing and implementing initiatives in collaboration with global partners that share the common objectives of building a global cancer research community and translating research results into evidence-informed policy and practice. Both objectives are complementary and synergistic and are additionally supported by an overarching strategic framework that is focused on partnerships and science diplomacy. This work highlights the overall strategy for NCI-CGH engagement in Latin America through partnerships and diplomacy, and highlights selected collaborative efforts that are aimed at improving cancer outcomes in the region.

      3. Executive summary of the 2018 KDIGO Hepatitis C in CKD Guideline: welcoming advances in evaluation and managementExternal
        Jadoul M, Berenguer MC, Doss W, Fabrizi F, Izopet J, Jha V, Kamar N, Kasiske BL, Lai CL, Morales JM, Patel PR, Pol S, Silva MO, Balk EM, Gordon CE, Earley A, Di M, Martin P.
        Kidney Int. 2018 Oct;94(4):663-673.

        Infection with the hepatitis C virus (HCV) has adverse liver, kidney, and cardiovascular consequences in patients with chronic kidney disease (CKD), including those on dialysis therapy and in those with a kidney transplant. Since the publication of the original Kidney Disease: Improving Global Outcomes (KDIGO) HCV Guideline in 2008, major advances in HCV management, particularly with the advent of direct-acting antiviral therapies, have now made the cure of HCV possible in CKD patients. In addition, diagnostic techniques have evolved to enable the noninvasive diagnosis of liver fibrosis. Therefore, the Work Group undertook a comprehensive review and update of the KDIGO HCV in CKD Guideline. This Executive Summary highlights key aspects of the guideline recommendations.

      4. Training the twenty-first century cancer epidemiologistExternal
        Lam TK, Lavigne JA, Qadir X, Khoury MJ, Schully SD.
        J Cancer Educ. 2018 Sep 24.

        To assess and advance training of twenty-first century cancer epidemiologists, the National Cancer Institute (NCI) sought to obtain a snapshot of the cancer epidemiology training landscape by conducting a survey across academic institutions and cancer centers, focusing on four key training areas driving current cancer epidemiology research (“drivers”): (1) collaboration, (2) novel methods/technologies, (3) multilevel analysis, and (4) knowledge integration. Complementary to the survey, we conducted a portfolio analysis of active NCI-funded training grants. In the present report, we provide our findings from this effort and contribute to the on-going conversation regarding the training of next-generation cancer epidemiologists. Analyses and insights gained from conversations with leaders/educators across 24 academic institutions/cancer centers and the portfolio analysis of training grants echoed contemporaneous conversation that cancer epidemiology training must adapt to meet the needs of the changing research environment. Currently, with the exception of novel methods/technologies, cancer epidemiology trainees receive the majority of their training in collaboration, multilevel approaches, and knowledge integration/translation either informally, ad hoc, or not at all; exposure to these identified drivers varied considerably by institution, mentor, and other external as well as internal factors.

      5. Increased dental use may affect changes in treated and untreated dental caries in young childrenExternal
        Lin M, Thornton-Evans G, Griffin SO, Wei L, Junger M, Espinoza L.
        JDR Clin Trans Res. 2018 .

        Introduction: From 1999-2004 to 2011-2014, untreated dental caries prevalence decreased among US children aged 2 to 5 y, regardless of family income. Policies were concurrently initiated for children to increase access to preventive dental services in dental, primary, and community settings and to restorative care in dental settings. Objectives: We aimed to examine 1) whether changes in prevalence and severity of untreated and treated caries between the periods varied by family income and 2) to what degree increased past-year dental visit (PYDV) contributed to the changes. Methods: We used data for 3,822 children in the National Health and Nutrition Examination Survey 1999 to 2004 and 2011 to 2014. Caries prevalence included prevalence of untreated caries with >/= 1 decayed teeth (dt) and prevalence of treated caries with >/= 1 filled teeth (ft). Caries severity included number of dt and ft among those with >/=1 dt or ft. We estimated changes in caries outcomes among low- and higher-income children with models?one controlling for sociodemographics and another controlling for sociodemographics and PYDV. Significant changes (P < 0.05) becoming insignificant after controlling for PYDV provide insight on the contribution of PYDV to changes in outcomes. Results: Prevalence of untreated caries decreased for low- and higher-income children, with a slightly larger decrease for low-income children; dt decreased only for low-income children; and estimated decreases did not vary by model. An increase in prevalence of treated caries was observed only among low-income children but became minimized and insignificant after controlling for PYDV. Similarly, after controlling for PYDV, the increase in ft among low-income children lost significance, whereas the increase among higher-income children remained. Conclusion: Untreated caries among children aged 2 to 5 y declined from 1999-2004 to 2011-2014, with larger declines among low-income children. While changes in PYDV contributed to increases in treated caries, particularly for low-income children, additional factors appear to have contributed to decreased untreated caries. Knowledge Transfer Statement: For young children, the degree and direction of changes in caries over the last decade varied by outcome measure (e.g., untreated or treated) and family poverty status. Examining the effect of increased dental utilization on changes in untreated and treated caries outcomes can help identify those policies that contribute to changes in these outcomes and highlight the potential role of the different caries assessment criteria used in dental offices versus those in a population-based survey.

      6. Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015-2060) in adults aged >/=65 yearsExternal
        Matthews KA, Xu W, Gaglioti AH, Holt JB, Croft JB, Mack D, McGuire LC.
        Alzheimers Dement. 2018 Sep 17.

        INTRODUCTION: Alzheimer’s disease and related dementias (ADRD) cause a high burden of morbidity and mortality in the United States. Age, race, and ethnicity are important risk factors for ADRD. METHODS: We estimated the future US burden of ADRD by age, sex, and race and ethnicity by applying subgroup-specific prevalence among Medicare Fee-for-Service beneficiaries aged >/=65 years in 2014 to subgroup-specific population estimates for 2014 and population projection data from the US Census Bureau for 2015 to 2060. RESULTS: The burden of ADRD in 2014 was an estimated 5.0 million adults aged >/=65 years or 1.6% of the population, and there are significant disparities in ADRD prevalence among population subgroups defined by race and ethnicity. ADRD burden will double to 3.3% by 2060 when 13.9 million Americans are projected to have the disease. DISCUSSION: These estimates can be used to guide planning and interventions related to caring for the ADRD population and supporting caregivers.

      7. Arthritis prevalence: which case definition for surveillance?External
        Murphy LB, Sacks JJ, Helmick CG, Brady TJ, Boring MA, Moss S, Barbour KE, Guglielmo D, Hootman JM, Theis KA.
        Arthritis Rheumatol. 2018 Sep 24.

        In the article titled “Updated Estimates Suggest a Much Higher Prevalence of Arthritis in United States Adults than Previous Ones”, Jafarzadeh and Felson present an alternative estimate of arthritis prevalence. (1) Specifically, using a new case definition for arthritis and applying Bayesian methods to correct for misclassification, Jafarzadeh and Felson analyzed National Health Interview Survey (NHIS) data and estimated that in 2015, 91.2 million US adults had arthritis. In contrast, CDC had estimated from the 2013-2015 NHIS that 54.4 million US adults had doctor-diagnosed arthritis. (2) In this letter, we make two observations about their methods and discuss implications for public health surveillance of arthritis. This article is protected by copyright. All rights reserved.

      8. Modeled state-level estimates of hypertension prevalence and undiagnosed hypertension among US adults during 2013-2015External
        Park S, Gillespie C, Baumgardner J, Yang Q, Valderrama AL, Fang J, Loustalot F, Hong Y.
        J Clin Hypertens (Greenwich). 2018 Sep 24.

        Hypertension affects about one in three US adults, from recent surveillance, or four in nine based on the 2017 ACC/AHA Hypertension Guideline; about half of them have their blood pressure controlled, and nearly one in six are unaware of their hypertension status. National estimates of hypertension awareness, treatment, and control in the United States are traditionally based on measured BP from National Health and Nutrition Examination Survey (NHANES); however, at the state level, only self-reported hypertension awareness and treatment are available from BRFSS. We used national- and state-level representative samples of adults (>/=20 years) from NHANES 2011-2014 and BRFSS 2013 and 2015, respectively. The authors generated multivariable logistic regression models using NHANES to predict the probability of hypertension and undiagnosed hypertension and then applied the fitted model parameters to BRFSS to generate state-level estimates. The predicted prevalence of hypertension was highest in Mississippi among adults (42.4%; 95% CI: 41.8-43.0) and among women (42.6%; 41.8-43.4) and highest in West Virginia among men (43.4%; 42.2-44.6). The predicted prevalence was lowest in Utah 23.7% (22.8-24.6), 26.4% (25.0-27.7), and 21.0% (20.0-22.1) for adults, men, and women, respectively. Hypertension predicted prevalence was higher in most Southern states and higher among men than women in all states except Mississippi and DC. The predicted prevalence of undiagnosed hypertension ranged from 4.1% (3.4-4.8; Kentucky) to 6.5% (5.5-7.5; Hawaii) among adults, from 5.0% (4.0-5.9; Kentucky) to 8.3% (6.9-9.7; Hawaii) among men, and from 3.3% (2.5-4.1; Kentucky) to 4.8% (3.4-6.1; Vermont) among women. Undiagnosed hypertension was more prevalent among men than women in all states and DC.

      9. [No abstract]

    • Communicable Diseases
      1. Diarrhea-associated mortality in children less than 5 years of age in the United States, 2005-2016External
        Aliabadi N, Pham H, Curns AT, Rha B, Tate JE, Parashar UD.
        Pediatr Infect Dis J. 2018 Sep 19.

        Diarrheal disease morbidity decreased after the 2006 US introduction of rotavirus vaccine. We calculated diarrheal death rates for children who were <5 years of age during 2005-2016. Death rates declined from 2.3/100,000 (2005-2006) to 1.7/100,000 (2014-2016). Declines were seen among 1-23 month olds, white and black children. Further exploration of the role of rotavirus vaccine in decreasing deaths among children is warranted.

      2. Trends in pelvic inflammatory disease among American Indian and Alaska Native Women, Indian Health Service, 2001-2015External
        Apostolou A, Chapman C, Person M, Kreisel K, McCollum J.
        Am J Public Health. 2018 Sep 25:e1-e8.

        OBJECTIVES: To describe trends in rates of pelvic inflammatory disease (PID) encounters among American Indian/Alaska Native (AI/AN) women aged 15 to 44 years in the United States receiving care within the Indian Health Service (IHS). METHODS: We analyzed IHS discharge data sets for PID encounters during 2001 to 2015 with International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes. We calculated rates of PID encounters per 100 000 women overall and stratified by age group, region, and health care setting. We used regression to identify trends in the total, annual, and average annual percent changes in the rate of PID encounters. RESULTS: There were 44 042 PID encounters during 2001 to 2015 (rate = 825 per 100 000). The highest rates were among women aged 20 to 24 years (1104) and from the Alaska region (1556). Rates significantly decreased overall (2001: 1084; 2015: 512; P < .001) and within all age groups and health care settings. There was variability in Alaska, with large increases during 2001 to 2010 followed by large decreases during 2010 to 2015. CONCLUSIONS: We observed decreasing trends in PID encounters among AI/AN women aged 15 to 44 years during 2001 to 2015, with the exception of increases in the Alaska region. (Am J Public Health. Published online ahead of print September 25, 2018: e1-e8. doi:10.2105/AJPH.2018.304676).

      3. Closing the book on Category II: time for individualized regimens for patients with recurrent tuberculosisExternal
        Auld SC, Gandhi NR, Shah NS.
        Int J Tuberc Lung Dis. 2018 Oct 1;22(10):1113-1114.

        [No abstract]

      4. Meningococcal disease surveillance in men who have sex with men – United States, 2015-2016External
        Bozio CH, Blain A, MacNeil J, Retchless A, Weil LM, Wang X, Jenkins LT, Rodriguez-Rivera LD, Jarashow C, Ngo V, Hariri S, Mbaeyi SA, Oliver S.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1060-1063.

        Meningococcal disease is a rare, but serious, bacterial infection that progresses rapidly and can be life-threatening, even with prompt antibiotic treatment. Men who have sex with men (MSM) have previously been reported to be at increased risk for meningococcal disease compared with other men, and recent outbreaks of serogroup C meningococcal disease among MSM have occurred (1). However, the epidemiology of meningococcal disease among MSM in the United States is not well described, in part, because information about MSM has not historically been collected as part of routine meningococcal disease surveillance. To better characterize and identify risk factors for meningococcal disease in general, supplementary data and isolates have been collected since 2015 through enhanced meningococcal disease surveillance activities. During 2015-2016, 271 cases of meningococcal disease in men aged >/=18 years were reported to the National Notifiable Diseases Surveillance System (NNDSS) in 45 states participating in this enhanced surveillance. Forty-eight (17.7%) cases were in men identified as MSM, including 17 (37.8%) with human immunodeficiency virus (HIV) infection. Among MSM, 39 (84.8%) cases were caused by Neisseria meningitidis serogroup C, whereas this serogroup was responsible for only 16.4% of cases among men who were not known to be MSM (non-MSM). Despite improvements in surveillance, MSM likely remain underascertained among men with meningococcal disease. Improved surveillance data are needed to understand the prevalence of and risk for meningococcal disease among MSM and inform policy and prevention strategies. Vaccination with quadrivalent meningococcal conjugate (MenACWY) vaccine is recommended for the control of meningococcal disease outbreaks caused by serogroups A, C, W, or Y, including during outbreaks among MSM; in addition, all persons aged >/=2 months with HIV infection should receive MenACWY vaccine because of the increased risk for meningococcal disease.

      5. Patterns of seasonal influenza activity in U.S. core based statistical areas, described using prescriptions of oseltamivir in Medicare claims dataExternal
        Dahlgren FS, Shay DK, Izurieta HS, Forshee RA, Wernecke M, Chillarige Y, Lu Y, Kelman JA, Reed C.
        Epidemics. 2018 Aug 29.

        Using Medicare claims data on prescriptions of oseltamivir dispensed to people 65 years old and older, we present a descriptive analysis of patterns of influenza activity in the United States for 579 core based statistical areas (CBSAs) from the 2010-2011 through the 2015-2016 influenza seasons. During this time, 1,010,819 beneficiaries received a prescription of oseltamivir, ranging from 45,888 in 2011-2012 to 380,745 in 2014-2015. For each season, the peak weekly number of prescriptions correlated with the total number of prescriptions (Pearson’s r >/= 0.88). The variance in peak timing decreased with increasing severity (p < 0.0001). Among these 579 CBSAs, neither peak timing, nor relative timing, nor severity of influenza seasons showed evidence of spatial autocorrelation (0.02 </= Moran’s I </= 0.23). After aggregating data to the state level, agreement between the seasonal severity at the CBSA level and the state level was fair (median Cohen’s weighted kappa = 0.32, interquartile range = 0.26-0.39). Based on seasonal severity, relative timing, and geographic place, we used hierarchical agglomerative clustering to join CBSAs into influenza zones for each season. Seasonal maps of influenza zones showed no obvious patterns that might assist in predicting influenza zones for future seasons. Because of the large number of prescriptions, these data may be especially useful for characterizing influenza activity and geographic distribution during low severity seasons, when other data sources measuring influenza activity are likely to be sparse.

      6. The Pregnancy and Influenza Multinational Epidemiologic (PRIME) study: a prospective cohort study of the impact of influenza during pregnancy among women in middle-income countriesExternal
        Dawood FS, Hunt D, Patel A, Kittikraisak W, Tinoco Y, Kurhe K, Soto G, Hombroek D, Garg S, Chotpitayasunondh T, Gonzales O, Bhargav S, Thompson MG, Chotpitayasunondh B, Florian R, Prakash A, Arriola S, Macareo L, Das P, Cabrera S, La Rosa S, Azziz-Baumgartner E.
        Reprod Health. 2018 Sep 21;15(1):159.

        BACKGROUND: The World Health Organization identifies pregnant women as at high-risk for severe influenza, but influenza vaccines are underutilized among pregnant women. Data on influenza burden during pregnancy are largely limited to high-income countries and data on the impact of influenza on birth and perinatal outcomes are scarce. METHODS/DESIGN: This prospective, longitudinal cohort study of pregnant women in middle-income countries is designed to address three primary objectives: 1) to evaluate the effect of laboratory-confirmed influenza during pregnancy on pregnancy and perinatal outcomes; 2) to estimate the incidences of all-cause acute respiratory illness and laboratory-confirmed influenza during pregnancy; and 3) to examine the clinical spectrum of illness associated with influenza viruses. Through a multi-country network approach, three sites aim to enroll cohorts of 1500-3000 pregnant women just before local influenza seasons. Women aged >/= 18 years with expected delivery dates >/= 8 weeks after the start of the influenza season are eligible. Women are followed throughout pregnancy through twice weekly surveillance for influenza symptoms (>/= 1 of myalgia, cough, runny nose, sore throat, or difficulty breathing) and have mid-turbinate nasal swabs collected for influenza virus testing during illness episodes. Primary outcomes include relative risk of preterm birth and mean birth weight among term singleton infants of women with and without reverse transcription polymerase chain reaction-confirmed influenza during pregnancy. Gestational age is determined by ultrasound at < 28 weeks gestation and birth weight is measured by digital scales using standardized methods. Sites are primarily urban in Bangkok, Thailand; Lima, Peru; and Nagpur, India. All sites recruit from antenatal clinics at referral hospitals and conduct surveillance using telephone calls, messaging applications, or home visits. Nasal swabs are self-collected by participants in Thailand and by study staff in Peru and India. During the first year (2017), sites enrolled participants during March-May in Peru and May-July in India and Thailand; 4779 women were enrolled. DISCUSSION: This study aims to generate evidence of the impact of influenza during pregnancy to inform decisions by Ministries of Health, healthcare providers, and pregnant women in middle-income countries about the value of influenza vaccination during pregnancy.

      7. Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in ZimbabweExternal
        Feldacker C, Bochner AF, Murenje V, Makunike-Chikwinya B, Holec M, Xaba S, Balachandra S, Mandisarisa J, Sidile-Chitimbire V, Barnhart S, Tshimanga M.
        PLoS One. 2018 ;13(9):e0203292.

        BACKGROUND: Timing of routine follow-up visits after adult male circumcision (MC) differs by country and method. Most men do not attend all routine follow-up visits. This cross-sectional study aimed to further understanding of AE timing within a large-scale, routine, MC program to improve patient safety. METHODS: From 2013-2017, ZAZIC consortium performed 192,575 MCs in Zimbabwe; the reported adverse event (AE) rate was 0.3%. Three scheduled, routine, follow-up visits intend to identify AEs. For surgical MC, visits were days 2, 7 and 42 post-procedure. For PrePex (device-based), visits were days 7, 14 and 49. Descriptive statistics explored characteristics of those patients with AEs. For each MC method, chi-square tests were used to evaluate associations between AE timing (days from MC to AE diagnosis) and factors of interest (age, AE type, severity). RESULTS: Of 421 AEs, 290 (69%) were surgical clients: 55 (19%) AEs were </=2 days post-MC; 169 (58%) between 3-7 days; 47 (16%) between days 8-14; and 19 (7%) were >/=15 post-MC. Among surgical clients, bleeding was most common AE on/before Day 2 while infections predominated in other follow-up periods (p<0.001). Younger surgical MC patients with AEs experienced AEs later than older clients (p<0.001). Among 131 (31%) PrePex clients with AEs, 46 (35%) were </=2 days post-MC; 59 (45%) between 3-7 days; 16 (12%) between days 8-14; and 10 (7%) >/=15 post-MC. For PrePex clients, device displacements were more likely to occur early while late AEs were most commonly infections (p<0.001). CONCLUSION: Almost 23% of surgical and 8% of PrePex AEs occurred after Visit 2. Later AEs were likely infections. Clinicians, clients, and caregivers should be more effectively counseled that complications may arise after initial visits. Messages emphasizing attention to wound care until complete healing could help ensure client safety. Younger boys, ages 10-14, and their caregivers would benefit from improved, targeted, post-operative counseling.

      8. Correlates of undiagnosed HIV infection and retesting among voluntary HIV testing clients at Mildmay Clinic, UgandaExternal
        Hakim AJ, Mukasa B, Hundley L, Odiit M, Ogwal M, Sendagala S, Karamagi Y, Sande E, Hladik W.
        AIDS Behav. 2018 Sep 25.

        Increasing HIV diagnosis is important for combatting HIV. We invited individuals aged >/= 13 years seeking voluntary HIV testing at Mildmay Clinic in Uganda to undertake a computer or audio-computer-assisted self-interview to facilitate post-test counseling. We evaluated first-visit data from 12,233 consenting individuals between January 2011 and October 2013. HIV prevalence was 39.0%. Of those with HIV, 37.2% already knew they were infected. Undiagnosed infection was associated with not being single, screening positive for depression (aOR 1.16, 95% CI 1.04-1.28), and screening for harmful drinking behavior (aOR 1.23, 95% CI 1.10-1.39). The odds of retesting subsequent to HIV diagnosis were lower for males (aOR 0.80, 95% CI 0.70-0.92) and those screening positive for harmful drinking behavior (aOR 0.77, 95% CI 0.66-0.88). Retesting was also associated with higher education and perceived social status below ‘better off’. Our findings reiterate the value of population-based HIV surveys to provide estimates of testing coverage.

      9. 100 years of medical countermeasures and pandemic influenza preparednessExternal
        Jester BJ, Uyeki TM, Patel A, Koonin L, Jernigan DB.
        Am J Public Health. 2018 Sep 25:e1-e4.

        The 1918 influenza pandemic spread rapidly around the globe, leading to high mortality and social disruption. The countermeasures available to mitigate the pandemic were limited and relied on nonpharmaceutical interventions. Over the past 100 years, improvements in medical care, influenza vaccines, antiviral medications, community mitigation efforts, diagnosis, and communications have improved pandemic response. A number of gaps remain, including vaccines that are more rapidly manufactured, antiviral drugs that are more effective and available, and better respiratory protective devices. (Am J Public Health. Published online ahead of print September 25, 2018: e1-e4. doi:10.2105/AJPH.2018.304586).

      10. Notes from the Field: Blastomycosis cases occurring outside of regions with known endemicity – New York, 2007-2017External
        McDonald R, Dufort E, Jackson BR, Tobin EH, Newman A, Benedict K, Blog D.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1077-1078.

        [No abstract]

      11. Mumps outbreak investigation in Jaisalmer, Rajasthan, India, June-September 2016External
        Moghe CS, Goel P, Singh J, Nayak NR, Dhuria M, Jain R, Yadav R, Saroha E, Sodha SV, Aggarwal CS, Venkatesh S.
        J Med Virol. 2018 Sep 25.

        Mumps, a vaccine-preventable disease, causes inflammation of salivary glands and may cause severe complications such as encephalitis, meningitis, deafness, and orchitis/oophoritis. In India, mumps vaccine is not included in the universal immunization program and during 2009-2014, 72 outbreaks with >1500 cases were reported. In August 2016, a suspected mumps outbreak was reported in Jaisalmer block, Rajasthan. We investigated to confirm the etiology, describe epidemiology, and recommend prevention and control measures. We defined a case as swelling in the parotid region in a Jaisalmer block resident between June 23 and September 10, 2016. We searched for cases in health facilities and house-to-house in affected villages and hamlets. We tested blood samples of cases for mumps IgM ELISA. We found 162 cases (60% males) with median age of 9.4 years (range: 7 month-38 years) and 65 (40%) were females. Symptoms included fever (70%) and bilateral swelling in neck (65%). None were vaccinated against mumps. Most (84%) cases were school-going children (3-16 years old). The overall attack rate was 2%. Village A, with two hamlets, had the highest attack rate (hamlet 1=13% and hamlet 2=12%). School A of village A, hamlet 1 which accommodated 200 children in two classrooms had an attack rate of 55%. Of 18 blood samples from cases, 11 tested positive for mumps IgM ELISA. This was a confirmed mumps outbreak in Jaisalmer bl0ock that disproportionately affected school-going children. We recommended continued surveillance, five-day absence from school, and vaccination. This article is protected by copyright. All rights reserved.

      12. Predictors of male condom use among sexually active heterosexual young women in South Africa, 2012External
        Ntshiqa T, Musekiwa A, Mlotshwa M, Mangold K, Reddy C, Williams S.
        BMC Public Health. 2018 Sep 24;18(1):1137.

        BACKGROUND: In South Africa, young women are at disproportionate risk of HIV infection with about 2363 new infections per week in 2015. Proper condom use is one of the most effective HIV/AIDS prevention strategies among sexually active persons. Understanding factors associated with male condom use in this key population group is important to curb the spread of HIV. This study determined practices and predictors of male condom use among sexually active young women in South Africa. METHODS: The 2012 National HIV Communication Survey measured the extent of exposure to communication activities for HIV prevention among men and women aged 16-55 years in South Africa. We performed a secondary data analysis on a subset of this survey, focussing on 1031 women aged 16-24 years who reported having had sex in the past 12 months. We determined predictors of male condom use using the unconditional multivariable logistic regression model. RESULTS: Of the 1031 young women, 595 (57.8%) reported using a male condom at last sex, 68.4% in women aged 16-19 years and 54.5% in women aged 20-24 years (p < 0.001). Delayed sexual debut [20 years or above] (Adjusted Odds Ratio [aOR] 2.1, 95% CI: 1.2 to 3.7, p = 0.006); being a student (aOR 1.6, 95% CI: 1.2 to 2.3, p = 0.005); and exposure to HIV communication programmes (aOR 3.1, 95% CI: 1.2 to 8.6, p = 0.025) were significantly associated with male condom use at last sex. CONCLUSION: Male condom use was a common practice among young women and was associated with delayed sexual debut and exposure to HIV communication programmes. Behavioral interventions and HIV communication programmes should therefore encourage young women to delay initiation of sex and promote usage of male condoms.

      13. Azithromycin susceptibility in Neisseria gonorrhoeae and seasonal macrolide useExternal
        Olesen SW, Torrone EA, Papp JR, Kirkcaldy RD, Lipsitch M, Grad YH.
        J Infect Dis. 2018 Sep 15.

        Rising azithromycin nonsusceptibility among Neisseria gonorrhoeae threatens current treatment recommendations, but the cause of this rise is not well understood. We performed an ecological study of seasonal patterns in macrolide use and azithromycin resistance in N. gonorrhoeae, finding that population-wide macrolide use is associated with increased azithromycin nonsusceptibility. These results, indicative of “bystander” selection, have implications for antibiotic prescribing guidelines.

      14. Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, KenyaExternal
        Quilter LA, Obondi E, Kunzweiler C, Okall D, Bailey RC, Djomand G, Otieno-Nyunya B, Otieno F, Graham SM.
        Sex Transm Infect. 2018 Sep 21.

        OBJECTIVES: In settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men. METHODS: Anorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection. RESULTS: Overall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18-24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point >/=3, and the NNT was 12. CONCLUSIONS: A model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.

      15. BACKGROUND: HIV is a major driver of the tuberculosis epidemic in sub-Saharan Africa. The population-level impact of antiretroviral therapy (ART) scale-up on tuberculosis rates in this region has not been well studied. We conducted a descriptive analysis to examine evidence of population-level effect of ART on tuberculosis by comparing trends in estimated tuberculosis notification rates, by HIV status, for countries in sub-Saharan Africa. METHODS: We estimated annual tuberculosis notification rates, stratified by HIV status during 2010-2015 using data from WHO, the Joint United Nations Programme on HIV/AIDS, and the United Nations Population Division. Countries were included in this analysis if they had >/=4 years of HIV prevalence estimates and >/= 75% of tuberculosis patients with known HIV status. We compared tuberculosis notification rates among people living with HIV (PLHIV) and people without HIV via Wilcoxon rank sum test. RESULTS: Among 23 included countries, the median annual average change in tuberculosis notification rates among PLHIV during 2010-2015 was -5.7% (IQR -6.9 to -1.7%), compared to a median change of -2.3% (IQR -4.2 to -0.1%) among people without HIV (p-value = 0.0099). Among 11 countries with higher ART coverage, the median annual average change in TB notification rates among PLHIV was -6.8% (IQR -7.6 to -5.7%) compared to a median change of -2.1% (IQR -6.0 to 0.7%) for PLHIV in 12 countries with lower ART coverage (p = 0.0106). CONCLUSION: Tuberculosis notification rates declined more among PLHIV than people without HIV, and have declined more in countries with higher ART coverage. These results are consistent with a population-level effect of ART on decreasing TB incidence among PLHIV. To further reduce TB incidence among PLHIV, additional scale-up of ART as well as greater use of isoniazid preventive therapy and active case-finding will be necessary.

      16. Measles outbreak at a privately operated detention facility – Arizona, 2016External
        Venkat H, Briggs G, Brady S, Komatsu K, Hill C, Leung J, Patel M, Livar E, Su CP, Kassem A, Sowers SB, Mercader S, Rota PA, Elson D, Timme E, Robinson S, Fitzpatrick K, Franco J, Hickman C, Gastanaduy PA.
        Clin Infect Dis. 2018 Sep 26.

        Background: We describe a measles outbreak and the control measures implemented at a privately operated detention facility housing U.S. Immigration and Customs Enforcement detainees in 2016. Methods: Case-patients reported fever and rash and were either laboratory-confirmed or had an epidemiological link to a laboratory-confirmed case-patient. IgG avidity and plaque reduction neutralization tests were performed to distinguish between primary acute and reinfection case-patients. Measles-specific immunoglobulin G (IgG) was measured to assess immunity levels among detainees. We compared attack rates (ARs) among detainees and staff, IgG-negative and IgG-positive detainees, and by detainee housing unit and sex. Results: We identified 32 measles case-patients (23 detainees, 9 staff); rash onsets were during May 6-June 26. High IgG avidity and neutralizing antibody titers >40,000 to measles (indicating reinfection) were identified in 18 (95%) and 15 (84%) of 19 tested case-patients, respectively. Among 205 detainees in unit A tested for presumptive immunity, 186 (91%) had detectable IgG. Overall, AR was 1.65%. ARs were significantly higher among detainees in unit A (7.05%) compared with units B-F (0.59%), and among male (2.33%) compared with female detainees (0.38%); however, not significantly different between detainees and staff or between IgG-negative and IgG-positive detainees. Control measures included vaccination of 1,424 of 1,425 detainees and 190 of 510 staff, immunity verification for 445 staff, case-patient isolation, and quarantining of affected units. Conclusions: Although ARs were low, measles outbreaks can occur in intense exposure settings despite high population immunity, underscoring the importance of high vaccination coverage and containment in limiting measles transmission.

      17. Human adenoviruses (HAdVs) were previously detected at high prevalence by real-time RT-PCR (rRT-PCR) in the upper respiratory tract of residents of two Kenyan refugee camps under surveillance for acute respiratory illness (ARI) between October 2006 and April 2008. We sought to confirm this finding and characterize the HAdVs detected. Of 2148 respiratory specimens originally tested, 511 (23.8%) screened positive for HAdV and 510 were available for retesting. Of these, 421 (82.4%) were confirmed positive by repeat rRT-PCR or PCR and sequencing. Other respiratory viruses were co-detected in 55.8% of confirmed HAdV-positive specimens. Species B and C viruses predominated at 82.8% and HAdV-C1, -C2, and -B3 were the most commonly identified types. Species A, D and F HAdVs, that are rarely associated with ARI, comprised the remainder. Viral loads were highest among species B HAdVs, particularly HAdV-B3. Species C showed the widest range of viral loads and species A, D and F were most often present at low loads and more often with co-detections. These findings suggest that many HAdV detections were incidental and not a primary cause of ARI among camp patients. Species/type, co-detections and viral load determinations may permit more accurate HAdV disease burden estimates in these populations. This article is protected by copyright. All rights reserved.

    • Disaster Control and Emergency Services
      1. We provide an overview of a Centers for Disease Control and Prevention-funded public health preparedness and response (PHPR) research and training initiative to improve public health practice. Our objectives were to accelerate the translation, dissemination, and implementation (TDI) of promising PHPR evidence-based tools and trainings developed by the Preparedness and Emergency Response Research Centers (PERRC) or the Preparedness and Emergency Response Learning Centers (PERLC) between 2008 and 2015. Nine competitive awards were made to seven academic centers to achieve predetermined TDI objectives. The outputs attained by the initiative included: user-friendly online repositories of PERRC and PERLC tools and trainings; training courses that addressed topics; a community resilience manual to synthesize, translate, and implement evidence-based programs; and Web applications that supported legal preparedness, exercise evaluation, and immunization education. The evaluation identified several best practices and potential barriers to implementation. As illustrated by the work in this supplement, the broader awareness and implementation of PERRC preparedness products and PERLC trainings and the continued evaluation of their impact could enhance the PHPR capacity and capability of the nation, which could lead to improved health security. (Am J Public Health. Published online ahead of print September 27, 2018: e1-e8. doi:10.2105/AJPH.2018.304709).

    • Disease Reservoirs and Vectors
      1. Nonhuman primates across sub-Saharan Africa are infected with the yaws bacterium Treponema pallidum subsp. pertenueExternal
        Knauf S, Gogarten JF, Schuenemann VJ, De Nys HM, Dux A, Strouhal M, Mikalova L, Bos KI, Armstrong R, Batamuzi EK, Chuma IS, Davoust B, Diatta G, Fyumagwa RD, Kazwala RR, Keyyu JD, Lejora IA, Levasseur A, Liu H, Mayhew MA, Mediannikov O, Raoult D, Wittig RM, Roos C, Leendertz FH, Smajs D, Nieselt K, Krause J, Calvignac-Spencer S.
        Emerg Microbes Infect. 2018 Sep 19;7(1):157.

        [No abstract]

    • Drug Safety
      1. Characteristics of dual drug benefit use among veterans with dementia enrolled in the Veterans Health Administration and Medicare Part DExternal
        Schleiden LJ, Thorpe CT, Cashy JP, Gellad WF, Good CB, Hanlon JT, Mor MK, Niznik JD, Pleis JR, Van Houtven CH, Thorpe JM.
        Res Social Adm Pharm. 2018 Sep 8.

        BACKGROUND: Obtaining prescription medications from multiple health systems may complicate coordination of care. Older Veterans who obtain medications concurrently through Veterans Affairs (VA) benefits and Medicare Part D benefits (dual users) are at higher risk of unintended negative outcomes. OBJECTIVE: To explore characteristics predicting dual drug benefit use from both VA and Medicare Part D in a national sample of older Veterans with dementia. METHODS: Administrative data were obtained from the VA and Medicare for a national sample of 110,828 Veterans with dementia ages 68 and older in 2010. Veterans were classified into three drug benefit user groups based on the source of all prescription medications they obtained in 2010: VA-only, Part D-only, and Dual Use. Multinomial logistic regression was used to examine predictors of drug benefit user group. The source of prescriptions was described for each of the ten most frequently used drug classes and opioids. RESULTS: Fifty-six percent of Veterans received all of their prescription medications from VA-only, 28% from Part D-only, and 16% from both VA and Part D. Veterans who were eligible for Medicaid or who had a priority group score conferring less generous drug benefits within the VA were more likely to be Part D-only or dual users. Nearly one fourth of Veterans taking opioids concurrently received opioid prescriptions from dual sources (24.7%). CONCLUSIONS: Medicaid eligibility and Veteran priority group status, which largely decrease copayments for drugs obtained outside versus within the VA, respectively, were the main factors predicting drug user benefit group. Policies to encourage single-system prescribing and enhance communication across health systems are crucial to preventing negative health outcomes related to care fragmentation.

    • Environmental Health
      1. Multidrug-resistant Aspergillus fumigatus carrying mutations linked to environmental fungicide exposure – three states, 2010-2017External
        Beer KD, Farnon EC, Jain S, Jamerson C, Lineberger S, Miller J, Berkow EL, Lockhart SR, Chiller T, Jackson BR.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1064-1067.

        The environmental mold Aspergillus fumigatus is the primary cause of invasive aspergillosis. In patients with high-risk conditions, including stem cell and organ transplant recipients, mortality exceeds 50%. Triazole antifungals have greatly improved survival (1); however, triazole-resistant A. fumigatus infections are increasingly reported worldwide and are associated with increased treatment failure and mortality (2). Of particular concern are resistant A. fumigatus isolates carrying either TR34/L98H or TR46/Y121F/T289A genetic resistance markers, which have been associated with environmental triazole fungicide use rather than previous patient exposure to antifungals (3,4). Reports of these triazole-resistant A. fumigatus strains have become common in Europe (2,3), but U.S. reports are limited (5). Because of the risk posed to immunocompromised patients, understanding the prevalence of such isolates in patients is important to guide clinical and public health decision-making. In 2011, CDC initiated passive laboratory monitoring for U.S. triazole-resistant A. fumigatus isolates through outreach to clinical laboratories. This system identified five TR34/L98H isolates collected from 2016 to 2017 (6), in addition to two other U.S. isolates collected in 2010 and 2014 and reported in 2015 (5). Four of these seven isolates were reported from Pennsylvania, two from Virginia, and one from California. Three isolates were collected from patients with invasive pulmonary aspergillosis, and four patients had no known previous triazole exposure. A. fumigatus resistant to all triazole medications is emerging in the United States, and clinicians and public health personnel need to be aware that resistant infections are possible even in patients not previously exposed to these medications.

      2. Prenatal exposure to perfluoroalkyl substances and adipocytokines: the HOME StudyExternal
        Buck CO, Eliot MN, Kelsey KT, Calafat AM, Chen A, Ehrlich S, Lanphear BP, Braun JM.
        Pediatr Res. 2018 Sep 13.

        OBJECTIVE: Gestational perfluoroalkyl substances exposure has been associated with decreased birthweight. We determined if gestational perfluoroalkyl substances exposure was associated with fetal metabolic markers using data from the HOME Study, a prospective birth cohort of pregnant women and their children in Cincinnati, Ohio. METHODS: Maternal serum concentrations of perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS), perfluorononanoic acid, and perfluorohexane sulfonic acid were quantified. We measured neonatal adipocytokine (leptin and adiponectin) concentrations in umbilical cord serum, and estimated percent differences with a 2-fold increase in maternal perfluoroalkyl substances concentrations among 230 mother-infant pairs. RESULTS: Median maternal serum PFOA and PFOS concentrations were 5.6 ng/mL and 14 ng/mL, respectively. Leptin was positively correlated with infant birthweight (p < 0.001). There were no statistically significant associations between maternal perfluoroalkyl substances and neonatal adipocytokine concentrations; each 2-fold increase in PFOA was associated with a non-significant increase in leptin (5%; 95% CI: -10, 22) and adiponectin (7%; 95% CI: -4, 19). CONCLUSION: Despite known associations with reduced birthweight, gestational serum perfluoroalkyl substances concentrations were not associated with neonatal adipocytokine concentrations. Further exploration of pathways of perfluoroalkyl substances associated changes in birthweight may help identify biomarkers that could be used to identify at-risk populations and develop interventions.

      3. Temporal trends in serum polybrominated diphenyl ether concentrations in the Australian population, 2002-2013External
        Toms LL, Sjodin A, Hobson P, Harden FA, Aylward LL, Mueller JF.
        Environ Int. 2018 Sep 19;121(Pt 1):357-364.

        In Australia, systematic biomonitoring of persistent organic pollutants (POPs) in pooled serum samples stratified by age and sex has occurred every two years between 2002/03 and 2012/13. Multiple regression modeling on log10-transformed serum pool concentrations of BDEs 47, 99, 100 and 153 and on the sum of these (Sigma4PBDE) was conducted to examine trends by sex and time since baseline, stratified by age group. Temporal trends were age- and congener-specific, with the largest changes per year of observation in the 0-4year old group, with beta (SE)=-0.098 (0.013) for log10BDE47; -0.119 (0.012) for log10BDE99; -0.084 (0.014) for log10BDE100, and -0.053 (0.013) for log10BDE153, all p<0.001. Adults over age 16 showed much smaller decreasing temporal trends for BDE47 and BDE99, no significant changes in BDE100, and, for the oldest age groups, slight increases in BDE153. As a result, Sigma4PBDE concentrations were stable over the entire time period in adults older than 16. Concentrations of each BDE in pools from females aged 31-60 were significantly lower compared to males. Relative proportions of BDE47 declined, while BDE153 accounted for a greater share of Sigma4PBDE over time. Whereas previously we saw a large elevation in the youngest age groups compared to older children and adults, this is no longer the case. This may be due to a decline in infant and toddler exposures in the indoor environment as use of PBDEs in consumer products has been phased out, suggesting temporal changes in the relative sources of exposure for young children in Australia.

    • Health Disparities
      1. Promoting health equity is a fundamental public health objective, yet health disparities remain largely overlooked in studies of vectorborne diseases, especially those transmitted by ticks. We sought to identify health disparities associated with Lyme disease and human monocytic ehrlichiosis, two of the most pervasive tickborne diseases within the United States. We used general linear mixed models to measure associations between county-level disease incidence and six variables representing racial/ethnic and socioeconomic characteristics of counties (percent white non-Hispanic; percent with a bachelors degree or higher; percent living below the poverty line; percent unemployed; percent of housing units vacant; per capita number of property crimes). Two ecological variables important to tick demography (percent forest cover; density of white-tailed deer) were included in secondary analyses to contextualize findings. Analyses included data from 2,695 counties in 37 states and the District of Columbia during 2007-2013. Each of the six variables was significantly associated with the incidence of one or both diseases, but the direction and magnitude of associations varied by disease. Results suggested that the incidence of Lyme disease was highest in counties with relatively higher proportions of white and more educated persons and lower poverty and crime rates; the incidence of human monocytic ehrlichiosis was highest in counties with relatively higher proportions of white and less educated persons, higher unemployment rates and lower crime rates. The percentage of housing units vacant was a strong positive predictor for both diseases with a magnitude of association comparable to those between incidence and the ecological variables. Our findings indicate that racial/ethnic and socioeconomic disparities in disease incidence appear to be epidemiologically important features of Lyme disease and human monocytic ehrlichiosis in the United States. Steps to mitigate encroachment of wild flora and fauna into areas with vacant housing might be warranted to reduce disease risk.

    • Health Economics
      1. PURPOSE: Measure the preferences of decision makers and researchers associated with the Advisory Committee on Immunization Practices (ACIP) regarding the recommended format for presenting health economics studies to the ACIP. METHODS: We conducted key informant interviews and an online survey of current ACIP work group members, and current and previous ACIP voting members, liaison representatives, and ex-officio members to understand preferences for health economics presentations. These preferences included the presentation of results and sensitivity analyses, the role of health economics studies in decision making, and strategies to improve guidelines for presenting health economics studies. Best-worst scaling was used to measure the relative value of seven attributes of health economics presentations in vaccine decision making. RESULTS: The best-worst scaling survey had a response rate of 51% (n=93). Results showed that summary results were the most important attribute for decision making (mean importance score: 0.69) and intermediate outcomes and disaggregated results were least important (mean importance score: -0.71). Respondents without previous health economics experience assigned sensitivity analysis lower importance and relationship of the results to other studies higher importance than the experienced group (sensitivity analysis scores: -0.15 vs. 0.15 respectively; relationship of the results: 0.13 vs. -0.12 respectively). Key informant interviews identified areas for improvement to include additional information on the quality of the analysis and increased role for liaisons familiar with health economics. CONCLUSION: Additional specificity in health economics presentations could allow for more effective presentations of evidence for vaccine decision making.

      2. Trends and factors associated with hospitalization costs for inflammatory bowel disease in the United StatesExternal
        Xu F, Liu Y, Wheaton AG, Rabarison KM, Croft JB.
        Appl Health Econ Health Policy. 2018 Sep 27.

        BACKGROUND: Few studies have addressed recent trends in hospitalization costs for inflammatory bowel disease (IBD). OBJECTIVE: We explored trends and described patient and hospital factors associated with hospitalization costs for IBD. METHODS: Using data from the 2003-2014 National Inpatient Sample for adults aged >/= 18 years, we estimated costs using multivariable linear models and assessed linear trends by time periods using piecewise linear regressions. RESULTS: In 2014, there were an estimated 56,290 hospitalizations for Crohn’s disease (CD), with a mean cost of US$11,345 and median cost of US$7592; and 33,585 hospitalizations for ulcerative colitis (UC), with a mean cost of US$13,412 and median cost of US$8873. Higher costs were observed among Hispanic [adjusted cost ratio (ACR) = 1.07; 95% confidence interval (CI) = 1.00-1.14; p = 0.04] or other non-Hispanic (ACR = 1.09; 95% CI = 1.02-1.17; p = 0.01) CD patients than for non-Hispanic White CD patients. For UC patients, higher costs were observed among men (ACR = 1.09; 95% CI = 1.05-1.13; p < 0.001) compared with women and among patients aged 35-44 years, 45-54 years, and 55-64 years compared with those aged 18-24 years. Among all patients, factors associated with higher costs included higher household income, more comorbidities, and hospitals that were government nonfederal versus private, were large versus small, and were located in the West versus Northeast regions. From 2003 to 2008, total costs increased annually by 3% for CD (1.03; 95% CI = 1.02-1.05; p < 0.001) and 4% for UC (1.04; 95% CI = 1.02-1.06; p < 0.001), but remained unchanged from 2008 to 2014. CONCLUSIONS: The findings are important to identify IBD patients with higher hospitalization costs and to inform policy plans on hospital resource allocation.

    • Healthcare Associated Infections
      1. [No abstract]

    • Immunity and Immunization
      1. Influenza vaccination coverage among health care personnel – United States, 2017-18 influenza seasonExternal
        Black CL, Yue X, Ball SW, Fink RV, de Perio MA, Laney AS, Williams WW, Graitcer SB, Fiebelkorn AP, Lu PJ, Devlin R.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1050-1054.

        The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel receive an annual influenza vaccination to reduce influenza-related morbidity and mortality among health care personnel and their patients and to reduce absenteeism among health care personnel (1-4). CDC conducted an opt-in Internet panel survey of 2,265 U.S. health care personnel to estimate influenza vaccination coverage among these persons during the 2017-18 influenza season. Overall, 78.4% of health care personnel reported receiving influenza vaccination during the 2017-18 season, similar to reported coverage in the previous four influenza seasons (5). As in previous seasons, coverage was highest among personnel who were required by their employer to be vaccinated (94.8%) and lowest among those working in settings where vaccination was not required, promoted, or offered on-site (47.6%). Health care personnel working in long-term care settings, the majority of whom work as assistants or aides, have lower influenza vaccination coverage than do health care personnel working in all other health care settings, which puts the elderly in long-term settings at increased risk for severe complications for influenza. Implementing workplace strategies shown to improve vaccination coverage among health care personnel, including vaccination requirements and active promotion of on-site vaccinations at no cost, can help ensure health care personnel and patients are protected against influenza (6). CDC’s long-term care web-based toolkit* provides resources, strategies, and educational materials for increasing influenza vaccination among health care personnel in long-term care settings.

      2. Some 50 years ago, Edgar Hope-Simpson published his hypothesis regarding the interactions between varicella and herpes zoster. As part of this hypothesis, Hope-Simpson postulated that reactivation of varicella zoster virus (VZV) was under immunological control, and that this immunological control could be boosted “endogenously” due to reactivation of latent VZV, and “exogenously” due to exposure to varicella. This hypothesis has important policy implications and remains a source of debate today; namely, does reducing VZV circulation through effective pediatric varicella vaccination programs lead to unintended increases in herpes zoster (HZ) incidence? This article provides 2 very different perspectives on this issue. The first perspective (Rafael Harpaz: Evidence Against an Effect) highlights the empiric experience of the United States, with its population of >300 million, a highly effective national varicella vaccination program lasting >20 years, and with several credible sources of data regarding HZ incidence. The US data have shown an increase in HZ incidence that preceded the availability of varicella vaccination by decades; indeed, HZ rates appear to have plateaued among older adults since varicella vaccination was introduced. Furthermore, HZ rates are not different in states having higher vs lower preschool varicella vaccination rates. The second perspective (Albert J. van Hoek: Evidence for an Effect) cites data that persons with close exposure to children appear to be at lower risk of HZ before universal VZV vaccination, but not so thereafter. Due to historic demographic changes, exogenous boosting could play a role in explaining the observed increase in HZ before varicella vaccination. Thus, it might be difficult to separate declines in exogenous boosting due to demographic changes from those caused by the varicella vaccination program. Additional data will be needed to conclusively rule out an impact of varicella vaccination on HZ.

      3. Influenza and Tdap vaccination coverage among pregnant women – United States, April 2018External
        Kahn KE, Black CL, Ding H, Williams WW, Lu PJ, Fiebelkorn AP, Havers F, D’Angelo DV, Ball S, Fink RV, Devlin R.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1055-1059.

        Vaccinating pregnant women with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines can reduce the risk for influenza and pertussis for themselves and their infants. The Advisory Committee on Immunization Practices (ACIP) recommends that all women who are or might be pregnant during the influenza season receive influenza vaccine, which can be administered any time during pregnancy (1). The ACIP also recommends that women receive Tdap during each pregnancy, preferably from 27 through 36 weeks’ gestation (2). To assess influenza and Tdap vaccination coverage among women pregnant during the 2017-18 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 10, 2018. Among 1,771 survey respondents pregnant during the peak influenza vaccination period (October 2017-January 2018), 49.1% reported receiving influenza vaccine before or during their pregnancy. Among 700 respondents who had a live birth, 54.4% reported receiving Tdap during their pregnancy. Women who reported receiving a provider offer of vaccination had higher vaccination coverage than did women who received a recommendation but no offer and women who did not receive a recommendation. Reasons for nonvaccination included concern about effectiveness of the influenza vaccine and lack of knowledge regarding the need for Tdap vaccination during every pregnancy. Provider offers or referrals for vaccination in combination with patient education could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

      4. Effectiveness of monovalent rotavirus vaccine in the PhilippinesExternal
        Lopez AL, Daag JV, Esparagoza J, Bonifacio J, Fox K, Nyambat B, Parashar UD, Ducusin MJ, Tate JE.
        Sci Rep. 2018 Sep 24;8(1):14291.

        Rotavirus (RV) is an important cause of diarrheal disease particularly in children aged under 5 years. Monovalent RV vaccine (RVV) was selectively introduced in 2012 in the Philippines and in July 2014 was introduced in the public health program of a province. Two RVV doses are recommended at 6 and 10 weeks of age. We conducted a test negative case-control evaluation to assess the effectiveness of RVV when given in a routine public health program in the Philippines. From September 2014 to August 2017, 967 children aged <5 years were hospitalized with diarrhea and of these, we enrolled 600 who were eligible to have received RVV and provided stool specimens for testing. Among children >/=8 months of age who were age-eligible to have received RVV, at least one dose of RVV had an adjusted vaccine effectiveness (VE) against RV hospitalization of 60% (95% confidence interval, CI: 24%, 79%), and against severe rotavirus diarrhea, VE was 64% (95% CI: 11%, 85%). These findings support the introduction of RVV into routine public health use in the Philippines. However, other factors such as costs, cost-effectiveness and operational issues must be considered prior to adoption of the vaccine into the countries’ public immunization program.

      5. U.S. clinicians’ and pharmacists’ reported barriers to implementation of the Standards for Adult Immunization PracticeExternal
        Srivastav A, Black CL, Lutz CS, Fiebelkorn AP, Ball SW, Devlin R, Pabst LJ, Williams WW, Kim DK.
        Vaccine. 2018 Sep 19.

        BACKGROUND: The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians’ (physicians, physician assistants, nurse practitioners) and pharmacists’ reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients’ attitudes toward vaccines were evaluated. METHODS: Data from non-probability-based Internet panel surveys of U.S. clinicians (n=1714) and pharmacists (n=261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated. RESULTS: High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians’ and 38.4% pharmacists’ submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS. CONCLUSION: Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers’ reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.

    • Informatics
      1. In the US Federal government, an analysis of alternatives (AoA) is required for a significant investment of resources. The AoA yields the recommended alternative from a set of viable alternatives for the investment decision. This paper presents an integrated AoA and project management framework for analyzing new or emerging alternatives (e.g., Cloud computing), as may be driven by an information system strategy that incorporates a methodology for analyzing the costs, benefits, and risks of each viable alternative. The case study in this paper, about a business improvement project to provide public health and safety services to citizens in a US Federal agency, is a practical application of this integrated framework and reveals the benefits of this integrated approach for an investment decision. The decision making process in the framework-as an integrated, organized, and adaptable set of management and control practices-offers a defensible recommendation and provides accountability to stakeholders.

    • Injury and Violence
      1. Introduction to the special issue: The role of public policies in preventing IPV, TDV, and SVExternal
        D’Inverno AS, Kearns MC, Reidy DE.
        J Interpers Violence. 2018 Nov;33(21):3259-3266.

        [No abstract]

      2. Surveillance for violent deaths – National Violent Death Reporting System, 27 states, 2015External
        Jack SP, Petrosky E, Lyons BH, Blair JM, Ertl AM, Sheats KJ, Betz CJ.
        MMWR Surveill Summ. 2018 Sep 28;67(11):1-32.

        PROBLEM/CONDITION: In 2015, approximately 62,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC’s National Violent Death Reporting System (NVDRS) regarding violent deaths from 27 U.S. states for 2015. Results are reported by sex, age group, race/ethnicity, location of injury, method of injury, circumstances of injury, and other selected characteristics. REPORTING PERIOD: 2015. DESCRIPTION OF SYSTEM: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 27 states that collected statewide data for 2015 (Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident. RESULTS: For 2015, NVDRS captured 30,628 fatal incidents involving 31,415 deaths in the 27 states included in this report. The majority (65.1%) of deaths were suicides, followed by homicides (23.5%), deaths of undetermined intent (9.5%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term “legal intervention” is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns varied by manner of death. Suicide rates were highest among males, non-Hispanic American Indian/Alaska Natives, non-Hispanic whites, adults aged 45-54 years, and men aged >/=75 years. The most common method of injury was a firearm. Suicides often were preceded by a mental health, intimate partner, substance abuse, or physical health problem, or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged <1 year and 20-34 years. Among males, non-Hispanic blacks accounted for the majority of homicides and had the highest rate of any racial/ethnic group. Homicides primarily involved a firearm, were precipitated by arguments and interpersonal conflicts, were related to intimate partner violence (particularly for females), or occurred in conjunction with another crime. When the relationship between a homicide victim and a suspected perpetrator was known, an acquaintance/friend or an intimate partner frequently was involved. Legal intervention death rates were highest among males and persons aged 20-54 years; rates among non-Hispanic black males were approximately double the rates of those among non-Hispanic white males. Precipitating circumstances for legal intervention deaths most frequently were an alleged criminal activity in progress, the victim reportedly using a weapon in the incident, a mental health or substance abuse problem (other than alcohol abuse), an argument or conflict, or a recent crisis (during the previous or upcoming 2 weeks). Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 10-24 years; these deaths most often occurred while the shooter was playing with a firearm and most often were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. Deaths of undetermined intent were more frequent among males, particularly non-Hispanic black and American Indian/Alaska Native males, and persons aged 30-54 years. Substance abuse, mental health problems, physical health problems, and a recent crisis were the most common circumstances preceding deaths of undetermined intent. In 2015, approximately 3,000 current or former military personnel died by suicide. The majority of these decedents were male, non-Hispanic white, and aged 45-74 years. Most suicides among military personnel involved a firearm and were precipitated by mental health, physical health, and intimate partner problems, as well as a recent crisis. INTERPRETATION: This report provides a detailed summary of data from NVDRS for 2015. The results indicate that deaths resulting from self-inflicted or interpersonal violence most frequently affect males and certain age groups and minority populations. Mental health problems, intimate partner problems, interpersonal conflicts, and general life stressors were primary precipitating events for multiple types of violent deaths, including suicides among current or former military personnel. PUBLIC HEALTH ACTION: NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Virginia VDRS data are used to help identify suicide risk factors among active duty service members, Oregon VDRS suicide data are used to coordinate information and activities across community agencies that support veterans and active duty service members, and Arizona VDRS data are used to develop recommendations for primary care providers who deliver care to veterans. The continued development and expansion of NVDRS to include all 50 states, U.S. territories, and the District of Columbia are essential to public health efforts to reduce deaths due to violence.

    • Maternal and Child Health
      1. Children with heart conditions and their special health care needs – United States, 2016External
        Chen MY, Riehle-Colarusso T, Yeung LF, Smith C, Farr SL.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1045-1049.

        Children with heart conditions often use more health care services and specialized care than children without a heart condition (1); however, little is known about the number of U.S. children with heart conditions and their special health care needs. CDC used data from the 2016 National Survey of Children’s Health (NSCH) to estimate the prevalence of heart conditions among U.S. children aged 0-17 years, which indicated that 1.3% had a current heart condition and 1.1% had a past heart condition (representing approximately 900,000 and 755,000 children, respectively). Sixty percent and 40% of children with current and past heart conditions, respectively, had one or more special health care needs, compared with 18.7% of children without a heart condition (adjusted prevalence ratios [aPRs] = 3.1 and 2.1, respectively). Functional limitations were 6.3 times more common in children with current heart conditions (30.7%) than in those without heart conditions (4.6%). Among children with current heart conditions, males, children with lower family income, and children living in other than a two-parent household had an increased prevalence of special health care needs. These findings highlight the importance of developmental surveillance and screening for children with heart conditions and might inform public health resource planning.

      2. Behavioral problems in children with autism spectrum disorder with and without co-occurring intellectual disabilityExternal
        Kurzius-Spencer M, Pettygrove S, Christensen D, Pedersen AL, Cunniff C, Meaney FJ, Soke GN, Harrington RA, Durkin M, Rice S.
        Res Autism Spectr Disord. 2018 December;56:61-71.

        Background: Autism spectrum disorder (ASD), intellectual disability (ID), and behavioral problems commonly co-occur, leading to increased impairment, diagnostic confusion, and treatment delays. Using data from a large surveillance population of children with ASD, the objectives of the present study were to compare the relative risk of common behavioral problems in children with ASD, with and without co-occurring intellectual disability. Methods: Data from the Autism and Developmental Disabilities Monitoring (ADDM) Network (2006-2010) on 9378 8-year-old children who met case definition for ASD and had cognitive test scores and information on behavioral problems were analyzed using frequency measures, risk ratios, chi-squared tests, and trend tests. Results: Children with ASD with and without ID had on average six co-occurring behavioral problems. The relative risk (RR) of self-injurious behaviors, unusual fear responses, and eating abnormalities increased with increasing cognitive impairment among children with ASD and ID (all p<0.001). Conversely, RR of mood (p<0.001) and sleep abnormalities (p=0.013) declined with increasing levels of cognitive impairment. Conclusions: Children with ASD and ID are at greater risk of some behavioral problems and lower risk of others as compared to children with ASD only. Successful interventions depend on understanding the complex interactions between co-occurring neurodevelopmental and behavioral problems.

      3. The effect of steroid treatment on weight in nonambulatory males with Duchenne muscular dystrophyExternal
        Lamb MM, Cai B, Royer J, Pandya S, Soim A, Valdez R, DiGuiseppi C, James K, Whitehead N, Peay H, Venkatesh SY, Matthews D.
        Am J Med Genet A. 2018 Sep 26:e40517.

        To describe the long-term effect of steroid treatment on weight in nonambulatory males with Duchenne Muscular Dystrophy (DMD), we identified 392 males age 7-29 years with 4,512 weights collected after ambulation loss (176 steroid-naive and 216 treated with steroids >/=6 months) from the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet). Comparisons were made between the weight growth curves for steroid-naive males with DMD, steroid-treated males with DMD, and the US pediatric male population. Using linear mixed-effects models adjusted for race/ethnicity and birth year, we evaluated the association between weight-for-age and steroid treatment characteristics (age at initiation, dosing interval, cumulative duration, cumulative dose, type). The weight growth curves for steroid-naive and steroid-treated nonambulatory males with DMD were wider than the US pediatric male growth curves. Mean weight-for-age z scores were lower in both steroid-naive (mean = -1.3) and steroid-treated (mean = -0.02) nonambulatory males with DMD, compared to the US pediatric male population. Longer treatment duration and greater cumulative dose were significantly associated with lower mean weight-for-age z scores. Providers should consider the effect of steroid treatment on weight when making postambulation treatment decisions for males with DMD.

    • Nutritional Sciences
      1. Global folate status in women of reproductive age: a systematic review with emphasis on methodological issuesExternal
        Rogers LM, Cordero AM, Pfeiffer CM, Hausman DB, Tsang BL, De-Regil LM, Rosenthal J, Razzaghi H, Wong EC, Weakland AP, Bailey LB.
        Ann N Y Acad Sci. 2018 Sep 21.

        Inadequate folate status in women of reproductive age (WRA) can lead to adverse health consequences of public health significance, such as megaloblastic anemia (folate deficiency) and an increased risk of neural tube defect (NTD)-affected pregnancies (folate insufficiency). Our review aims to evaluate current data on folate status of WRA. We queried eight databases and the World Health Organization Micronutrients Database, identifying 45 relevant surveys conducted between 2000 and 2014 in 39 countries. Several types of folate assays were used in the analysis of blood folate, and many surveys used folate cutoffs not matched to the assay. To allow better comparisons across surveys, we attempted to account for these differences. The prevalence of folate deficiency was >20% in many countries with lower income economies but was typically <5% in countries with higher income economies. Only 11 surveys reported the prevalence of folate insufficiency, which was >40% in most countries. Overall, folate status data for WRA globally are limited and must be carefully interpreted due to methodological issues. Future surveys would benefit from using the microbiologic assay to assess folate status, along with assay-matched cutoffs to improve monitoring and evaluation of folic acid interventions, thus informing global efforts to prevent NTDs.

    • Occupational Safety and Health
      1. [No abstract]

      2. Emerging insights into the occupational mycobiomeExternal
        Green BJ.
        Curr Allergy Asthma Rep. 2018 Sep 27;18(11):62.

        PURPOSE OF REVIEW: The evolution of molecular-based methods over the last two decades has provided new approaches to identify and characterize fungal communities or “mycobiomes” at resolutions previously not possible using traditional hazard identification methods. The recent focus on fungal community assemblages within indoor environments has provided renewed insight into overlooked sources of fungal exposure. In occupational studies, internal transcribed spacer (ITS) region sequencing has recently been utilized in a variety of environments ranging from indoor office buildings to agricultural commodity and harvesting operations. RECENT FINDINGS: Fungal communities identified in occupational environments have been primarily placed in the phylum Ascomycota and included classes typically identified using traditional fungal exposure methods such as the Eurotiomycetes, Dothideomycetes, Sordariomycetes, and Saccharomycetes. The phylum Basidiomycota has also been reported to be more prevalent than previously estimated and ITS region sequences have been primarily derived from the classes Agaricomycetes and Ustilaginomycetes. These studies have also resolved sequences placed in the Basidiomycota classes Tremellomycetes and Exobasidiomycetes that include environmental and endogenous yeast species. These collective datasets have shown that occupational fungal exposures include a much broader diversity of fungi than once thought. Although the clinical implications for occupational allergy are an emerging field of research, establishing the mycobiome in occupational environments will be critical for future studies to determine the complete spectrum of worker exposures to fungal bioaerosols and their impact on worker health.

      3. Feasibility assessment of a new surveillance tool for respiratory protective devices used in U.S. healthcareExternal
        Wizner K, Radonovich L, Bell A, Oke C, Yarbrough M.
        J Int Soc Respir Prot. 2018 Jul;35(1):26-35.

        Background: Respiratory protective devices (RPDs) are used for infection prevention in healthcare settings during routine patient care and public health emergencies. In recent years, healthcare systems have experienced shortages of RPDs during outbreaks of infectious diseases, in part due to a lack of information about their availability. New tools to track RPD inventories may improve accessibility during an emergency. Investigators at Vanderbilt University have identified four major themes that influence RPD use for infection prevention: hospital preparedness, responsiveness to airborne pathogens, potential exposure outcomes, and infection control practices related to respirator effectiveness. Based on these findings, an RPD surveillance tool (RST) was developed to collect and share near real-time data about RPD supplies in healthcare facilities. The objective of this study was to conduct a feasibility assessment of this RST. Methods: The new online surveillance tool was implemented at four large, urban, acute care U.S. hospitals in January 2014; data was collected about RPD inventory, tracking systems, hospital characteristics, and utility of gathered information. Results: The RST was implemented successfully and without difficulty at hospitals that had 78 to 90 percent occupancy rates. Participating hospitals reported that the RST (1) provided value for benchmarking their RPD supply, (2) promoted understanding about RPD accessibility among hospital systems engaged in infection control, and (3) served as a means to assess RPD program quality. Conclusion: Implementation of this newly developed RST is feasible and appears to have utility in U.S. hospitals for tracking and understanding RPD use for routine healthcare delivery and public health emergencies.

    • Parasitic Diseases
      1. The epidemiology and clinical features of Balamuthia mandrillaris disease in the United States, 1974 – 2016External
        Cope JR, Landa J, Nethercut H, Collier SA, Glaser C, Moser M, Puttagunta R, Yoder JS, Ali IK, Roy SL.
        Clin Infect Dis. 2018 Sep 20.

        Background: Balamuthia mandrillaris is a free-living ameba that causes rare, nearly always fatal disease in humans and animals worldwide. B. mandrillaris has been isolated from soil, dust, and water. Initial entry of Balamuthia into the body is likely via the skin or lungs. To date, only individual case reports and small case series have been published. Methods: The Centers for Disease Control and Prevention (CDC) maintains a free-living ameba (FLA) registry and laboratory. To be entered into the registry, a Balamuthia case must be laboratory-confirmed. Several sources were used to complete entries in the registry, including case report forms, CDC laboratory results, published case reports, and media information. SAS(c) version 9.3 software was used to calculate descriptive statistics and frequencies. Results: We identified 109 case reports of Balamuthia disease between 1974 and 2016. Most (99%) had encephalitis. The median age was 36 years (range 4 months to 91 years). Males accounted for 68% of the case patients. California had the highest number of case reports followed by Texas and Arizona. Hispanics constituted 55% for those with documented ethnicity. Exposure to soil was commonly reported. Among those with a known outcome, 90% of patients died. Conclusions: Balamuthia disease in the United States is characterized by a highly fatal encephalitis that affects patients of all ages. Hispanics were disproportionately affected. The southwest region of the U.S. reported the most cases. Clinician awareness of Balamuthia as a cause of encephalitis might lead to earlier diagnosis and initiation of treatment, resulting in better outcomes.

    • Reproductive Health
      1. Policy, law and post-abortion care services in KenyaExternal
        Mutua MM, Manderson L, Musenge E, Achia TN.
        PLoS One. 2018 ;13(9):e0204240.

        BACKGROUND: Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy. METHODS: A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality. RESULTS: The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge. DISCUSSION: Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination. CONCLUSION: Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.

    • Substance Use and Abuse
      1. Current tobacco smoking, quit attempts, and knowledge about smoking risks among persons aged >/=15 years – Global Adult Tobacco Survey, 28 countries, 2008-2016External
        Ahluwalia IB, Smith T, Arrazola RA, Palipudi KM, Garcia de Quevedo I, Prasad VM, Commar A, Schotte K, Garwood PD, Armour BS.
        MMWR Morb Mortal Wkly Rep. 2018 Sep 28;67(38):1072-1076.

        Each year, tobacco use causes approximately 7 million deaths worldwide, including approximately 6 million among tobacco users and an estimated 890,000 among nonsmokers exposed to secondhand smoke (1). Tobacco use is a leading preventable cause of disease globally and has been determined to cause adverse health outcomes such as coronary heart disease, stroke, and multiple types of cancer, including lung cancer (2-4). Approximately 80% of the world’s 1.1 billion tobacco smokers reside in low- and middle-income countries (4). Some persons do not fully understand the health risks associated with tobacco smoking (5-9), and studies have indicated that increasing knowledge about the adverse health effects of smoking can contribute to decreases in smoking, increases in cessation attempts, and increases in successful cessation (3,7,10). CDC analyzed 2008-2016 Global Adult Tobacco Survey (GATS) data from 28 countries to assess tobacco smoking prevalence, quit attempts, and knowledge about tobacco smoking risks among persons aged >/=15 years. Across countries, the median prevalence of tobacco smoking was 22.5%, and a median of 42.5% of tobacco smokers had made a quit attempt in the preceding 12 months. The median prevalences of knowing that tobacco smoking causes stroke, heart attack, and lung cancer were 73.6%, 83.6%, and 95.2%, respectively. Implementation of proven tobacco control interventions, including strategies that increase knowledge about the health risks posed by tobacco use, might help to reduce tobacco use and tobacco-related disease, including heart disease, stroke, and lung cancer (3-5).

      2. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016External
        Jalal H, Buchanich JM, Roberts MS, Balmert LC, Zhang K, Burke DS.
        Science. 2018 Sep 21;361(6408).

        Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.

      3. Prevalence of cannabis use in electronic cigarettes among US youthExternal
        Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ.
        JAMA Pediatr. 2018 Sep 17.

        [No abstract]

      4. Impact of U.S. antismoking tv ads on Spanish-language quitline callsExternal
        Zhang L, Babb S, Johns M, Mann N, Thompson J, Shaikh A, Lavinghouze R, Rodes R, Malarcher A.
        Am J Prev Med. 2018 Oct;55(4):480-487.

        INTRODUCTION: Cigarette smoking is a major preventable cause of disease and death among U.S. Hispanics. Tobacco-cessation quitlines have been shown to increase quitting among Hispanics. However, the use of quitlines by this population remains low, especially among Spanish-speaking Hispanics. This study evaluates the promotion of 1-855-DEJELO-YA (a quitline portal that routes callers to state-specific Spanish-language services) implemented as part of the Centers for Disease Control and Prevention’s national Tips From Former Smokers((R)) (Tips((R))) campaign. Additionally, this study examines how media content impacted calls to 1-855-DEJELO-YA. METHODS: Using National Cancer Institute data on calls to 1-855-DEJELO-YA from February 2013 to December 2014, multivariate linear regressions were conducted of weekly area code-level call volume as a function of media market-level Gross Rating Points for Tips Spanish-language TV ads tagged with 1-855-DEJELO-YA. The models were adjusted for covariates, including market-level population characteristics and state fixed effects. The data were analyzed from October 2017 through April 2018. RESULTS: Greater exposure to Tips Spanish-language ads was associated with increased calls to 1-855-DEJELO-YA (p<0.001). On average, each additional 100 Tips Gross Rating Points per media market increased calls by 0.56 (95% CI=0.45, 0.67) calls/week/area code, representing congruent with 974 additional calls beyond the baseline. Media messages highlighting health consequences of smoking had a greater effect size than messages highlighting health effects of secondhand smoke. CONCLUSIONS: A national Spanish-language quitline number could be a useful cessation resource for Spanish-speaking cigarette smokers. Opportunities exist to increase use of this number through a national Spanish-language media campaign, particularly by focusing campaign messages on the health consequences of smoking.

    • Zoonotic and Vectorborne Diseases
      1. Impacts of misclassification on Lyme disease surveillanceExternal
        Rutz H, Hogan B, Hook S, Hinckley A, Feldman K.
        Zoonoses Public Health. 2018 Sep 21.

        In Maryland, Lyme disease (LD) is the most widely reported tickborne disease. All laboratories and healthcare providers are required to report LD cases to the local health department. Given the large volume of LD reports, the nuances of diagnosing and reporting LD, and the effort required for investigations by local health department staff, surveillance for LD is burdensome and subject to underreporting. To determine the degree to which misclassification occurs in Maryland, we reviewed medical records for a sample of LD reports from 2009. We characterized what proportion of suspected and “not a case” reports could be reclassified as confirmed or probable once additional information was obtained from medical record review, explored the reasons for misclassification, and determined multipliers for a more accurate number of LD cases. We reviewed medical records for reports originally classified as suspected (n = 44) and “not a case” (n = 92). Of these 136 records, 31 (23%) suspected cases and “not a case” reports were reclassified. We calculated multipliers and applied them to the case counts from 2009, and estimate an additional 269 confirmed and probable cases, a 13.3% increase. Reasons for misclassification fell into three general categories: lack of clinical or diagnostic information from the provider; surveillance process errors; and incomplete information provided on laboratory reports. These multipliers can be used to calculate a better approximation of the true number of LD cases in Maryland, but these multipliers only account for underreporting due to misclassification, and do not account for cases that are not reported at all (e.g., LD diagnoses based on erythema migrans alone that are not reported) or for cases that are not investigated. Knowing that misclassification of cases occurs during the existing LD surveillance process underscores the complexities of LD surveillance, which further reinforces the need to find alternative approaches to LD surveillance.

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

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