Volume 10, Issue 4, February 6, 2018

CDC Science Clips: Volume 10, Issue 4, February 6, 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!

This week, Science Clips is pleased to collaborate with CDC Vital Signs by featuring scientific articles from the latest issue (www.cdc.gov/vitalsigns). The articles marked with an asterisk are general review articles which may be of particular interest to clinicians and public health professionals seeking background information in this area.

  1. CDC Vital Signs
    • Chronic Diseases and Conditions – Asthma in Children
      1. *National surveillance of asthma: United States, 2001-2010External
        Moorman JE, Akinbami LJ, Bailey CM, Zahran HS, King ME, Johnson CA, Liu X.
        Vital Health Stat 3. 2012 Nov(35):1-58.

        BACKGROUND: Asthma is prevalent but treatable: adherence to evidence-based treatment lessens impairment and lowers the risk of future exacerbations. OBJECTIVE: This report details recent trends in asthma prevalence, health care use, and mortality since 2001 and presents an overview of trends since 1980. METHODS: Asthma prevalence estimates were obtained from the National Health Interview Survey (2001-2010). Physician office visit data were obtained from the National Ambulatory Medical Care Survey, hospital outpatient department and emergency department (ED) visit data from the National Hospital Ambulatory Medical Care Survey, hospitalization data from the National Hospital Discharge Survey, and death data from the National Vital Statistics System (2001-2009). Two types of rates were calculated: population-based rates based on the total population and risk-based rates based on the population with asthma. RESULTS: Current asthma prevalence increased from 2001 to 2010. There were no significant changes in rates for hospital outpatient department visits, ED visits, or hospitalizations, whereas risk-based rates for private physician office visits declined. Asthma death rates decreased from 2001 to 2009. Over the long term, asthma prevalence rose more slowly after 2001 than during 1980-1996, asthma hospitalizations declined since 1984 and deaths declined since 1999. Disparities by race and sex for adverse outcomes remained high despite these declines. CONCLUSION: Since 2001, asthma prevalence increased, risk-based rates for visits to private physician offices and deaths declined, and risk-based rates for other types of ambulatory visits and for hospitalizations showed no clear trend.

      2. *Trends in childhood asthma: prevalence, health care utilization, and mortalityExternal
        Akinbami LJ, Schoendorf KC.
        Pediatrics. 2002 Aug;110(2 Pt 1):315-22.

        OBJECTIVES: Our objective was to use national data to produce a comprehensive description of trends in childhood asthma prevalence, health care utilization, and mortality to assess changes in the disease burden among US children. METHODS: Five data sources from the National Center for Health Statistics were used to describe trends in asthma for children aged 0 to 17 years from 1980 to the most recent year for which data were available. These included the National Health Interview Survey (NHIS), the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, the National Hospital Discharge Survey, and the Mortality Component of the National Vital Statistics System. RESULTS: Asthma prevalence increased by an average of 4.3% per year from 1980 to 1996, from 3.6% to 6.2%. The peak prevalence was 7.5% in 1995. In 1997, asthma attack prevalence was 5.4%, but changes in the NHIS design in 1997 preclude comparison to previous estimates. Asthma attack prevalence remained level from 1997 to 2000. After a decrease between 1980 and 1989, the asthma office visit rate increased by an average of 3.8% per year from 1989 to 1999. The asthma hospitalization rate grew by 1.4% per year from 1980 to 1999. Although childhood asthma deaths are rare, the asthma death rate increased by 3.4% per year from 1980 to 1998. Children aged 0 to 4 years had the largest increase in prevalence and had greater health care use, but adolescents had the highest mortality. The asthma burden was borne disproportionately by black children throughout the period. Racial disparities were largest for asthma hospitalizations and mortality: compared with white children, in 1998-1999, black children were >3 times as likely to be hospitalized and in 1997-1998 >4 times as likely to die from asthma. CONCLUSIONS: Recent data suggest that the burden from childhood asthma may have recently plateaued after several years of increasing, although additional years of data collection are necessary to confirm a change in trend. Racial and ethnic disparities remain large for asthma health care utilization and mortality.

      3. Changing trends in asthma prevalence among childrenExternal
        Akinbami LJ, Simon AE, Rossen LM.
        Pediatrics. 2016 Jan;137(1).

        BACKGROUND: Childhood asthma prevalence doubled from 1980 to 1995 and then increased more slowly from 2001 to 2010. During this second period, racial disparities increased. More recent trends remain to be described. METHODS: We analyzed current asthma prevalence using 2001-2013 National Health Interview Survey data for children ages 0 to 17 years. Logistic regression with quadratic terms was used to test for nonlinear patterns in trends. Differences between demographic subgroups were further assessed with multivariate models controlling for gender, age, poverty status, race/ethnicity, urbanicity, and geographic region. RESULTS: Overall, childhood asthma prevalence increased from 2001 to 2009 followed by a plateau then a decline in 2013. From 2001 to 2013, multivariate logistic regression showed no change in prevalence among non-Hispanic white and Puerto Rican children and those in the Northeast and West; increasing prevalence among 10- to 17-year-olds, poor children, and those living in the South; increasing then plateauing prevalence among 5- to 9-year-olds, near-poor children, and non-Hispanic black children; and increasing then decreasing prevalence among 0- to 4-year-olds, nonpoor, and Mexican children and those in the Midwest. Non-Hispanic black-white disparities stopped increasing, and Puerto Rican children remained with the highest prevalence. CONCLUSIONS: Current asthma prevalence ceased to increase among children in recent years and the non-Hispanic black-white disparity stopped increasing due mainly to plateauing prevalence among non-Hispanic black children.

      4. Socioeconomic, family, and pediatric practice factors that affect level of asthma controlExternal
        Bloomberg GR, Banister C, Sterkel R, Epstein J, Bruns J, Swerczek L, Wells S, Yan Y, Garbutt JM.
        Pediatrics. 2009 Mar;123(3):829-35.

        BACKGROUND: Multiple issues play a role in the effective control of childhood asthma. OBJECTIVE: To identify factors related to the level of asthma control in children receiving asthma care from community pediatricians. PATIENTS AND METHODS: Data for 362 children participating in an intervention study to reduce asthma morbidity were collected by a telephone-administered questionnaire. Level of asthma control (well controlled, partially controlled, or poorly controlled) was derived from measures of recent impairment (symptoms, activity limitations, albuterol use) and the number of exacerbations in a 12-month period. Data also included demographic characteristics, asthma-related quality of life, pediatric management practices, and medication usage. Univariable and multivariable analyses were used to identify factors associated with poor asthma control and to explore the relationship between control and use of daily controller medications. RESULTS: Asthma was well controlled for 24% of children, partially controlled for 20%, and poorly controlled for 56%. Medicaid insurance, the presence of another family member with asthma, and maternal employment outside the home were significant univariable factors associated with poor asthma control. Medicaid insurance had an independent association with poor control. Seventy-six percent of children were reported by parents as receiving a daily controller medication. Comparison of guideline recommended controller medication with current level of asthma control indicated that a higher step level of medication would have been appropriate for 74% of these children. Significantly lower overall quality-of-life scores were observed in both parents and children with poor control. CONCLUSIONS: Despite substantial use of daily controller medication, children with asthma continue to experience poorly controlled asthma and reduced quality of life. Although Medicaid insurance and aspects of family structure are significant factors associated with poorly controlled asthma, attention to medication use and quality-of-life indicators may further reduce morbidity.

      5. Impact of physician asthma care education on patient outcomesExternal
        Cabana MD, Slish KK, Evans D, Mellins RB, Brown RW, Lin X, Kaciroti N, Clark NM.
        Pediatrics. 2006 Jun;117(6):2149-57.

        OBJECTIVE: We evaluated the effectiveness of a continuing medical education program, Physician Asthma Care Education, in improving pediatricians’ asthma therapeutic and communication skills and patients’ health care utilization for asthma. METHODS: We conducted a randomized trial in 10 regions in the United States. Primary care providers were recruited and randomly assigned by site to receive the program provided by local faculty. The program included 2 interactive seminar sessions (2.5 hours each) that reviewed national asthma guidelines, communication skills, and key educational messages. Format included short lectures, case discussions, and a video modeling communication techniques. We collected information on parent perceptions of physicians’ communication, the child’s asthma symptoms, and patients’ asthma health care utilization. We used multivariate regression models to determine differences between control and intervention groups. RESULTS: A total of 101 primary care providers and a random sample of 870 of their asthma patients participated. After 1 year, we completed follow-up telephone interviews with the parents of 731 of the 870 patients. Compared to control subjects, parents reported that physicians in the intervention group were more likely to inquire about patients’ concerns about asthma, encourage patients to be physically active, and set goals for successful treatment. Patients of physicians that attended the program had a greater decrease in days limited by asthma symptoms (8.5 vs 15.6 days), as well as decreased emergency department asthma visits (0.30 vs 0.55 visits per year). CONCLUSIONS: The Physician Asthma Care Education program was used in a range of locations and was effective in improving parent-reported provider communication skills, the number of days affected by asthma symptoms, and asthma health care use. Patients with more frequent asthma symptoms and higher health care utilization at baseline were more likely to benefit from their physician’s participation in the program.

      6. Respiratory Syncytial Virus (RSV) and Human Metapneumovirus InfectionsExternal
        Caserta M.
        Merck Manuals. Professional version. 2017 .

        [No abstract]

      7. Effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity: a Community Guide systematic reviewExternal
        Crocker DD, Kinyota S, Dumitru GG, Ligon CB, Herman EJ, Ferdinands JM, Hopkins DP, Lawrence BM, Sipe TA.
        Am J Prev Med. 2011 Aug;41(2 Suppl 1):S5-32.

        CONTEXT: Asthma exacerbations are commonly triggered by exposure to allergens and irritants within the home. The purpose of this review was to evaluate evidence that interventions that target reducing these triggers through home visits may be beneficial in improving asthma outcomes. The interventions involve home visits by trained personnel to conduct two or more components that address asthma triggers in the home. Intervention components focus on reducing exposures to a range of asthma triggers (allergens and irritants) through environmental assessment, education, and remediation. EVIDENCE ACQUISITION: Using methods previously developed for the Guide to Community Preventive Services, a systematic review was conducted to evaluate the evidence on effectiveness of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. The literature search identified over 10,800 citations. Of these, 23 studies met intervention and quality criteria for inclusion in the final analysis. EVIDENCE SYNTHESIS: In the 20 studies targeting children and adolescents, the number of days with asthma symptoms (symptom-days) was reduced by 0.8 days per 2 weeks, which is equivalent to 21.0 symptom-days per year (range of values: reduction of 0.6 to 2.3 days per year); school days missed were reduced by 12.3 days per year (range of values: reduction of 3.4 to 31.2 days per year); and the number of asthma acute care visits were reduced by 0.57 visits per year (interquartile interval: reduction of 0.33 to 1.71 visits per year). Only three studies reported outcomes among adults with asthma, finding inconsistent results. CONCLUSIONS: Home-based, multi-trigger, multicomponent interventions with an environmental focus are effective in improving overall quality of life and productivity in children and adolescents with asthma. The effectiveness of these interventions in adults is inconclusive due to the small number of studies and inconsistent results. Additional studies are needed to (1) evaluate the effectiveness of these interventions in adults and (2) determine the individual contributions of the various intervention components.

      8. Objective. Asthma education programs have been shown to decrease healthcare utilization and improve disease control and management. The purpose of our study was to evaluate the impact of an outpatient adult asthma education program in an inner city hospital caring for patients with low socioeconomic and educational status. Methods. An asthma education program was implemented in September 2014. Patients who received education from September 2014 to July 2015 were evaluated. Outcomes were compared for the same group of patients before and after education. Primary outcomes were emergency room (ER) visits and hospital admissions. Secondary outcomes were change in Asthma Control Test (ACT) score and number of pulmonary clinic visits. Results. Asthma education significantly decreased number of patients requiring ER visits and hospital admissions (p = 0.0005 and p = 0.0015, resp.). Asthma control as per ACT score >/= 20 improved with education (p = 0.0001) with an increase in clinic visits (p = 0.0185). Conclusions. Our study suggests that implementation of a structured asthma education program in an inner city community hospital has a positive impact on reduction of ER visits and hospital admissions with improvement in asthma control. Institutional Review Board Clinical Study registration number is 01081507.

      9. Expert Panel Report 3: Guidelines for the Diagnosis and Management of AsthmaExternal
        National Asthma Education and Prevention Program , Third Expert Panel on the Diagnosis and Management of Asthma .
        Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. 2007 Aug.

        Using the 1997 EPR 2 guidelines and the 2004 update of EPR 2 as the framework, the expert panel organized the literature review and final guidelines report around four essential components of asthma care, namely: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. The updated guidelines emphasize the importance of asthma control. Asthma control is the degree to which the manifestations of asthma are minimized by therapeutic intervention and the goals of therapy are met. Because asthma is highly variable, the level of control must be monitored on a periodic basis to determine whether therapy should be maintained or adjusted (stepped up if necessary, stepped down if possible). On the other hand, asthma severity is the intrinsic intensity of the disease process, most easily and directly measured in a patient not receiving long-term control therapy. For managing asthma, the recommendation is to assess severity to initiate therapy and assess control to adjust therapy. Recommendations for managing asthma include an expanded section on childhood asthma with addition of an age group 5 to 11 years old (earlier guidelines combined this group with adults). The guidelines provide new recommendations on patient education in settings beyond the physician’s office, and new advice for controlling environmental factors that can cause asthma symptoms

      10. Written action plan use in inner-city children: is it independently associated with improved asthma outcomes?External
        Sunshine J, Song L, Krieger J.
        Ann Allergy Asthma Immunol. 2011 Sep;107(3):207-13.

        BACKGROUND: Guidelines from the National Asthma Education and Prevention Program stipulate that multicomponent self-management interventions for asthma should include a written action plan (WAP). However the specific, independent effect of WAPs in improving outcomes remains unclear. OBJECTIVE: To measure the association between WAP use during the previous year and improved asthma outcomes. METHODS: We conducted a longitudinal quasi-experimental study using data from the Healthy Homes II (HH-II) randomized controlled trial in Seattle, WA. Action plan use during the previous year was measured at exit of HH-II. A participant was a WAP user if he used his action plan every day, almost every day, or once per week, and non-user if he did not meet these criteria. Sensitivity analyses explored less stringent criteria for WAP user designation. Prespecified outcomes were baseline-to-exit changes in asthma control in the previous 2 weeks, Pediatric Asthma Caregiver Quality of Life Scale score, and urgent health services utilization. We used robust linear and logistic regression to compare outcomes across groups. RESULTS: Two hundred fifty-one patients participated: 112 WAP users; 139 non-users. After adjustment, no significant differences in outcomes were observed between WAP users and non-users. Among a subgroup of participants with recent urgent health services utilization, WAP users had better asthma control than non-users. Changing WAP user criteria to include those who simply owned an action plan, irrespective of use, did not alter our results. CONCLUSION: WAP use during the previous year was not associated with improved outcomes compared with non-use. Additional studies are needed to assess the long-term, independent benefit of this universally recommended intervention.

  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. Diagnoses and ordering practices driving blood demand for treatment of anemia in TanzaniaExternal
        Apata IW, Drammeh B, De AK, Bjork A, Pathak S, Lyimo M, Juma A, Kutaga R, Mahmoud M, Nkya E, Kuehnert M, Marfin A.
        Transfusion. 2018 Jan 19.

        BACKGROUND: Resource-limited countries in Africa experience blood shortages. Understanding clinical drivers of blood demand can inform strategies to increase blood availability. STUDY DESIGN AND METHODS: From a national representative sample of 42 hospitals in Tanzania, patient records and requests for whole blood (WB) and red blood cells (RBCs) to treat anemia were analyzed using data collected prospectively from June through September 2013. Abstracted data included cause of anemia, number of requested units, clinical signs, and pretransfusion hemoglobin (Hb) levels. Weighted projections of nationwide drivers of blood demand for the year, 2013, were calculated. Mean posttransfusion Hb levels were estimated, and blood requests were assessed for clinical appropriateness. RESULTS: Malaria was the leading driver of blood demand for anemia among children, accounting for 67% (55,949 units; standard deviation [SD], 1911 units) of projected units requested for children in 2013. Maternal hemorrhage was the leading driver of blood demand for anemia among adults, accounting for 21% (31,321 units; SD, 963 units) of projected units requested. Seventeen percent (26,133 units; SD, 1013 units) of projected requested units were deemed inappropriate. Adults with severe anemia had a mean Hb level of 3.7 g/dL and a mean of 1.6 WB or RBC units per request, resulting in an estimated mean posttransfusion Hb level of 5.3 g/dL. CONCLUSIONS: Strategies to prevent and treat underlying causes of anemia and decrease inappropriate blood requests will likely increase blood availability. Restrictive blood ordering practices seen in adults with severe anemia suggests undertreatment of anemia and may result in an underestimation of the national blood demand.

      2. Body mass index at age 18 years and recent body mass index in relation to risk of breast cancer overall and ER/PR/HER2-defined subtypes in white women and African-American women: a pooled analysisExternal
        Ma H, Ursin G, Xu X, Lee E, Togawa K, Malone KE, Marchbanks PA, McDonald JA, Simon MS, Folger SG, Lu Y, Sullivan-Halley J, Deapen DM, Press MF, Bernstein L.
        Breast Cancer Res. 2018 Jan 22;20(1):5.

        BACKGROUND: Although it has been well-documented that obesity is associated with decreased risk of premenopausal breast cancer and increased risk of postmenopausal breast cancer, it is unclear whether these associations differ among breast cancer subtypes defined by the tumor protein expression status of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). METHODS: We evaluated the associations of body mass index (BMI) at age 18 years and recent BMI in relation to risk of breast cancer overall and ER/PR/HER2-defined subtypes, in 6320 women (3934 case-patient participants, 2386 control participants) aged 35-64 years, who participated in one of three population-based case-control studies. We estimated multivariable-adjusted odd ratios (ORs) and corresponding 95% confidence intervals (CIs) using polychotomous unconditional logistic regression methods for case-control comparisons in premenopausal women and postmenopausal women. RESULTS: BMI at age 18 years was inversely associated with risk of breast cancer, particularly among premenopausal women (>/= 25 vs. < 20 kg/m(2), OR = 0.72, 95% CI = 0.53-0.96; per 5 kg/m(2) increase, OR = 0.83, 95% CI = 0.73-0.95). This inverse association did not differ across ER/PR/HER2-defined subtypes or by race (white women, African-American women). Recent BMI was not associated with risk of premenopausal breast cancer after adjustment for BMI at age 18 years; nevertheless, the analysis for the joint effects of BMI at age 18 years and recent BMI showed that premenopausal women in the highest categories of the two BMI measures (>/= 25 kg/m(2) at age 18 years and >/= 30 kg/m(2) for recent BMI) had 46% lower risk of breast cancer than premenopausal women in the lowest categories of the two BMI measures (< 20 kg/m(2) at age 18 years and < 25 kg/m(2) for recent BMI; OR = 0.54, 95% CI = 0.38-0.78). Neither measure of BMI was statistically significantly associated with risk of postmenopausal breast cancer. CONCLUSION: Our findings indicate that high BMI near the end of adolescence decreases risk of all ER/PR/HER2-defined subtypes of premenopausal breast cancer and also suggest that this benefit could be maximized among premenopausal women who consistently have high BMI during their premenopausal years.

      3. PurposeGiven the importance of family history in the early detection and prevention of type 2 diabetes, we quantified the public health impact of reported family health history on diagnosed diabetes (DD), undiagnosed diabetes (UD), and prediabetes (PD) in the United States.MethodsWe used population data from the National Health and Nutrition Examination Survey 2009-2014 to measure the association of reported family history of diabetes with DD, UD, and PD.ResultsUsing polytomous logistic regression and multivariable adjustment, family history prevalence ratios were 4.27 (confidence interval (CI): 3.57, 5.12) for DD, 2.03 (CI: 1.56, 2.63) for UD, and 1.26 (CI: 1.09, 1.44) for PD. In the United States, we estimate that 10.1 million DD cases, 1.4 million UD cases, and 3.9 million PD cases can be attributed to having a family history of diabetes.ConclusionThese findings confirm that family history of diabetes has a major public health impact on diabetes in the United States. In spite of the recent interest and focus on genomics and precision medicine, family health history continues to be an integral component of public health campaigns to identify persons at high risk for developing type 2 diabetes and early detection of diabetes to prevent or delay complications.GENETICS in MEDICINE advance online publication, 25 January 2018; doi:10.1038/gim.2017.238.

      4. Implementing key drivers for diabetes self-management education and support programs: Early outcomes, activities, facilitators, and barriersExternal
        Morgan JM, Mensa-Wilmot Y, Bowen SA, Murphy M, Bonner T, Rutledge S, Rutledge G.
        Prev Chronic Dis. 2018 Jan 25;15:E15.

        [No abstract]

      5. [No abstract]

      6. The National Diabetes Education Program at 20 years: Lessons learned and plans for the futureExternal
        Siminerio LM, Albright A, Fradkin J, Gallivan J, McDivitt J, Rodriguez B, Tuncer D, Wong F.
        Diabetes Care. 2018 Feb;41(2):209-218.

        The National Diabetes Education Program (NDEP) was established to translate findings from diabetes research studies into clinical and public health practice. Over 20 years, NDEP has built a program with partnership engagement that includes science-based resources for multiple population and stakeholder audiences. Throughout its history, NDEP has developed strategies and messages based on communication research and relied on established behavior change models from health education, communication, and social marketing. The program’s success in continuing to engage diverse partners after 20 years has led to time-proven and high-quality resources that have been sustained. Today, NDEP maintains a national repository of diabetes education tools and resources that are high quality, science- and audience-based, culturally and linguistically appropriate, and available free of charge to a wide variety of audiences. This review looks back and describes NDEP’s evolution in transforming and communicating diabetes management and type 2 diabetes prevention strategies through partnerships, campaigns, educational resources, and tools and identifies future opportunities and plans.

      7. Short sleep duration among middle school and high school students – United States, 2015External
        Wheaton AG, Jones SE, Cooper AC, Croft JB.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):85-90.

        Insufficient sleep among children and adolescents is associated with increased risk for obesity, diabetes, injuries, poor mental health, attention and behavior problems, and poor academic performance (1-4). The American Academy of Sleep Medicine has recommended that, for optimal health, children aged 6-12 years should regularly sleep 9-12 hours per 24 hours and teens aged 13-18 years should sleep 8-10 hours per 24 hours (1). CDC analyzed data from the 2015 national, state, and large urban school district Youth Risk Behavior Surveys (YRBSs) to determine the prevalence of short sleep duration (<9 hours for children aged 6-12 years and <8 hours for teens aged 13-18 years) on school nights among middle school and high school students in the United States. In nine states that conducted the middle school YRBS and included a question about sleep duration in their questionnaire, the prevalence of short sleep duration among middle school students was 57.8%, with state-level estimates ranging from 50.2% (New Mexico) to 64.7% (Kentucky). The prevalence of short sleep duration among high school students in the national YRBS was 72.7%. State-level estimates of short sleep duration for the 30 states that conducted the high school YRBS and included a question about sleep duration in their questionnaire ranged from 61.8% (South Dakota) to 82.5% (West Virginia). The large percentage of middle school and high school students who do not get enough sleep on school nights suggests a need for promoting sleep health in schools and at home and delaying school start times to permit students adequate time for sleep.

    • Communicable Diseases
      1. The 1918 flu, 100 years laterExternal
        Belser JA, Tumpey TM.
        Science. 2018 Jan 19;359(6373):255.

        [No abstract]

      2. The important role of co-infections in patients with AIDS and progressive disseminated histoplasmosis (PDH): A cohort from ColombiaExternal
        Caceres DH, Tobon A, Restrepo A, Chiller T, Gomez BL.
        Medical Mycology Case Reports. 2018 ;19:41-44.

        A total of 23/45 (51%) patients with AIDS and histoplasmosis from Medellin, Colombia had other infections. Tuberculosis was the most common (n = 16/23, 70%). Pneumocystosis and cryptococcosis were found in three patients each (13%), bacterial infection and cytomegalovirus occurred each in two patients (9%) while toxoplasmosis, herpes virus and esophageal candidiasis were recorded in one patient each (4%). Of all co-infected patients, 18/23 (78%) had one, four (17%) had two and one (4%) had three additional opportunistic infections.

      3. Assessment of poliovirus antibody seroprevalence in polio high risk areas of West AfricaExternal
        Guindo O, Mach O, Doumbia S, Ekra DK, Beavogui AH, Weldon WC, Oberste MS, Sutter RW.
        Vaccine. 2018 Jan 18.

        We conducted a serological survey of anti-polio antibodies in polio high-risk areas of Mali, Guinea and Cote d’Ivoire to assess risk of future poliovirus outbreaks. Random community sampling of children 6-11 and 36-48months-old was conducted; neutralizing antibodies against poliovirus were detected using microneutralization assay. We analysed 1059/1064 (99.5%) of enrolled children. Seroprevalence to poliovirus type 1 (PV1) across all age groups and locations ranged between 92 and 100%, for PV2 it was 77-100%, and 89-95% for PV3. PV2 seroprevalence in the younger age group in Guinea and Cote d’Ivoire was<80%. History of<4 polio vaccine doses and acute malnutrition were associated with seronegativity (OR=2.1 CI95%=1.5-3.1, OR=1.8 CI95%=1.1-3.3 respectively). The risk of poliovirus outbreak following importation is low because of high population immunity to PV1, however, due to large cohort of PV2 seronegative children any future detection of vaccine-derived poliovirus type 2 requires urgent response to arrest rapid spread.

      4. Moving forward with treatment of gonorrhea for users of HIV preexposure prophylaxis given the threat of antimicrobial resistanceExternal
        Jenness SM, Weiss KM, Goodreau SM, Gift T, Chesson H, Hoover KW, Smith DK, Liu AY, Sullivan PS, Rosenberg ES.
        Clin Infect Dis. 2018 Jan 23.

        [No abstract]

      5. Hepatitis B virus infection and hepatitis C virus treatment in a large cohort of hepatitis C-infected patients in the United StatesExternal
        Moorman AC, Xing J, Rupp LB, Gordon SC, Spradling PR, Boscarino JA, Schmidt MA, Daida YG, Teshale EH, Holmberg SD.
        Gastroenterology. 2018 Jan 19.

        [No abstract]

      6. Association of maternal KIR gene content polymorphisms with reduction in perinatal transmission of HIV-1External
        Omosun YO, Blackstock AJ, Williamson J, van Eijk AM, Ayisi J, Otieno J, Lal RB, Ter Kuile FO, Slutsker L, Shi YP.
        PLoS One. 2018 ;13(1):e0191733.

        The role of killer cell immunoglobulin-like receptors (KIRs) in the transmission of HIV-1 has not been extensively studied. Here, we investigated the association of KIR gene content polymorphisms with perinatal HIV-1 transmission. The KIR gene family comprising 16 genes was genotyped in 313 HIV-1 positive Kenyan mothers paired with their infants. Gene content polymorphisms were presented as presence of individual KIR genes, haplotypes, genotypes and KIR gene concordance. The genetic data were analyzed for associations with perinatal transmission of HIV. There was no association of infant KIR genes with perinatal HIV-1 transmission. After adjustment for gravidity, viral load, and CD4 cell count, there was evidence of an association between reduction in perinatal HIV-1 transmission and the maternal individual KIR genes KIR2DL2 (adjusted OR = 0.50; 95% CI: 0.24-1.02, P = 0.06), KIR2DL5 (adjusted OR = 0.47; 95% CI: 0.23-0.95, P = 0.04) and KIR2DS5 (adjusted OR = 0.39; 95% CI: 0.18-0.80, P = 0.01). Furthermore, these maternal KIR genes were only significantly associated with reduction in perinatal HIV transmission in women with CD4 cell count >/= 350 cells/ mul and viral load <10000 copies/ml. Concordance analysis showed that when both mother and child had KIR2DS2, there was less likelihood of perinatal HIV-1 transmission (adjusted OR = 0.44; 95% CI: 0.20-0.96, P = 0.039). In conclusion, the maternal KIR genes KIR2DL2, KIR2DL5, KIR2DS5, and KIR2DS2 were associated with reduction of HIV-1 transmission from mother to child. Furthermore, maternal immune status is an important factor in the association of KIR with perinatal HIV transmission.

      7. HIV RNA suppression during and after pregnancy among women in the HIV Outpatient Study, 1996 to 2015External
        Patel M, Tedaldi E, Armon C, Nesheim S, Lampe M, Palella F, Novak R, Sutton M, Buchacz K.
        J Int Assoc Provid AIDS Care. 2018 Jan-Dec;17:2325957417752259.

        OBJECTIVE: To examine HIV viral suppression during/after pregnancy. DESIGN: Prospective observational cohort. METHODS: We identified pregnancies from 1996 to 2015. We examined HIV RNA viral load (VL), VL suppression (</=500 copies/mL), and antiretroviral therapy (ART) status at pregnancy start, end, and 6 months postpartum. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) for VL nonsuppression. RESULTS: Among 253 pregnancies analyzed, 34.8% of women exhibited VL suppression at pregnancy start, 60.1% at pregnancy end, and 42.7% at 6 months postpartum. Median VL (log10 copies/mL) was 2.80 (interquartile range [IQR]: 1.40-3.85) at pregnancy start, 1.70 (IQR: 1.40-2.82) at pregnancy end, and 2.30 (IQR: 1.40-3.86) at postpartum. Risk of postpartum VL nonsuppression was also lower among women on ART and with VL suppression at pregnancy end (versus those not; adjusted RR = 0.30, 95% CI: 0.17-0.53). CONCLUSIONS: Maintaining VL suppression among US women remains a challenge, particularly during postpartum. Achieving VL suppression earlier during pregnancy benefits women subsequently.

      8. Comparison of outpatient medically attended and community level influenza-like illness – New York City, 2013-2015External
        Russell KE, Fowlkes A, Stockwell MS, Vargas CY, Saiman L, Larson EL, LaRussa P, Di Lonardo S, Popowich M, St George K, Steffens A, Reed C.
        Influenza Other Respir Viruses. 2018 Jan 19.

        BACKGROUND: Surveillance of influenza-like illness (ILI) in the United States is primarily conducted through medical settings despite a significant burden of non-medically attended ILI. OBJECTIVES: To assess consistency between surveillance for respiratory viruses in outpatient and community settings using ILI surveillance from the Centers for Disease Control and Prevention Influenza Incidence Surveillance Project (IISP) and the Mobile Surveillance for Acute Respiratory Infections (ARI) and Influenza-Like Illness in the Community (MoSAIC) Study. METHODS: IISP conducts ILI surveillance in 3 primary care clinics in New York City, and MoSAIC conducts community-based ILI/ARI surveillance through text messaging among a cohort of New York City residents. Both systems obtain respiratory specimens from participants with ILI/ARI and test for multiple pathogens. We conducted a retrospective review of ILI cases in IISP and MoSAIC from January 2013 – May 2015 with descriptive analyses of clinical and laboratory data. RESULTS: Five-hundred twelve MoSAIC and 669 IISP participants met an ILI criteria (fever with cough or sore throat) and were included. Forty percent of MoSAIC participants sought care; the majority primary care. Pathogens were detected in 63% of MoSAIC and 70% of IISP cases. The relative distribution of influenza and other respiratory viruses detected were similar; however, there were statistically significant differences in the frequency that were not explained by care-seeking. CONCLUSIONS: Outpatient and community-based surveillance in the one found similar timing and relative distribution of respiratory viruses, but community surveillance in a single neighborhood may not fully capture the variations in ILI etiology that occur more broadly. This article is protected by copyright. All rights reserved.

      9. Invasive bacterial disease trends and characterization of group B streptococcal isolates among young infants in southern Mozambique, 2001-2015External
        Sigauque B, Kobayashi M, Vubil D, Nhacolo A, Chauque A, Moaine B, Massora S, Mandomando I, Nhampossa T, Bassat Q, Pimenta F, Menendez C, Carvalho MD, Macete E, Schrag SJ.
        PLoS One. 2018 ;13(1):e0191193.

        BACKGROUND: Maternal group B streptococcal (GBS) vaccines under development hold promise to prevent GBS disease in young infants. Sub-Saharan Africa has the highest estimated disease burden, although data on incidence and circulating strains are limited. We described invasive bacterial disease (IBD) trends among infants <90 days in rural Mozambique during 2001-2015, with a focus on GBS epidemiology and strain characteristics. METHODS: Community-level birth and mortality data were obtained from Manhica’s demographic surveillance system. IBD cases were captured through ongoing surveillance at Manhica district hospital. Stored GBS isolates from cases underwent serotyping by multiplex PCR, antimicrobial susceptibility testing, and whole genome sequencing. RESULTS: There were 437 IBD cases, including 57 GBS cases. Significant declines in overall IBD, neonatal mortality, and stillbirth rates were observed (P<0.0001), but not for GBS (P = 0.17). In 2015, GBS was the leading cause of young infant IBD (2.7 per 1,000 live births). Among 35 GBS isolates available for testing, 31 (88.6%) were highly related serotype III isolates within multilocus sequence types (STs) 17 (68.6%) or 109 (20.0%). All seven ST109 isolates (21.9%) had elevated minimum inhibitory concentration (MIC) to penicillin (>/=0.12 mug/mL) associated with penicillin-binding protein (PBP) 2x substitution G398A. Epidemiologic and molecular data suggest this is a well-established clone. CONCLUSION: A notable young infant GBS disease burden persisted despite improvements in overall maternal and neonatal health. We report an established strain with pbp2x point mutation, a first-step mutation associated with reduced penicillin susceptibility within a well-known virulent lineage in rural Mozambique. Our findings further underscores the need for non-antibiotic GBS prevention strategies.

      10. INTRODUCTION: With the rapid scale-up of antiretroviral treatment (ART) in the “Treat All” era, there has been increasing emphasis on using differentiated models of HIV service delivery. The gaps within the clinical cascade for mothers and their infants suggest that current service delivery models are not meeting families’ needs and prompt re-consideration of how services are provided. This article will explore considerations for differentiated care and encourage the ongoing increase of ART coverage through innovative strategies while also addressing the unique needs of mothers and infants. DISCUSSION: Service delivery models should recognize that the timing of the mother’s HIV diagnosis is a critical aspect of determining eligibility. Women newly diagnosed with HIV require a more intensive approach so that adequate counselling and monitoring of ART initiation and response can be provided. Women already on ART with evidence of virologic failure are also at high risk of transmitting HIV to their infants and require close follow-up. However, women stable on ART with a suppressed viral load before conception have a very low likelihood of HIV transmission and thus are strong candidates for multi-month ART dispensing, community-based distribution of ART, adherence clubs, community adherence support groups and longer intervals between clinical visits. A number of other factors should be considered when defining eligibility of mothers and infants for differentiated care, including location of services, viral load monitoring and duration on ART. To provide differentiated care that is client-centred and driven while encompassing a family-based approach, it will be critical to engage mothers, families and communities in models that will optimize client satisfaction, retention in care and quality of services. CONCLUSIONS: Differentiated care for mothers and infants represents an opportunity to provide client-centred care that reduces the burden on clients and health systems while improving the quality and uptake of services for families. However, with decreasing funding, stable HIV incidence, and aspirations for sustainability, it is critical to consider efficient, customized and cost-effective models of care for these populations as we aspire to eliminate mother-to-child transmission of HIV.

      11. Comparison of HIV testing among children and adults with tuberculosis, VietnamExternal
        Volkmann T, Nguyen B, Anyalechi EG, Chapman Hedges KN, Van Anh H, Tue PQ, Nhung NV, Click ES.
        J Tuberc Res. 2017 Dec;5(4):292-297.

        HIV testing among persons with tuberculosis (TB) results in high-yield identification of persons infected with HIV. To evaluate differences in HIV testing among children versus adults with TB in Vietnam, we collected and analyzed age-disaggregated facility and aggregated provincial data from the National Tuberculosis Program. HIV testing was incompletely documented for >70% of children, whereas adult testing data were >90% complete. Standardized training of personnel for universal HIV testing and documentation for children with TB could improve HIV case-detection and permit linking of children with HIV to antiretroviral treatment to prevent morbidity and mortality.

    • Disaster Control and Emergency Services
      1. NCRP Program Area Committee 3: Nuclear and Radiological Security and SafetyExternal
        Ansari A, Buddemeier B.
        Health Physics. 2018 ;114(2):248-250.

        The National Council on Radiation Protection and Measurements (NCRP) Program Area Committee (PAC) 3 covers the broad subject of nuclear and radiological security and safety and provides guidance and recommendations for response to nuclear and radiological incidents of both an accidental and deliberate nature. In 2017, PAC 3 Scientific Committee 3-1 completed the development of Guidance for Emergency Responder Dosimetry and began development of a companion commentary on operational aspects of that guidance. PAC 3 members also organized the technical program for the 2017 Annual Meeting of NCRP on “Assessment of National Efforts in Emergency Preparedness for Nuclear Terrorism: Is There a Need for Realignment to Close Remaining Gaps.” Based on discussions and presentations at the annual meeting, PAC 3 is working to develop a commentary on the subject that could serve as a roadmap for focusing our national efforts on the most pressing needs for preparing the nation for nuclear and radiological emergencies. PAC 3 is also engaged in active discussions exploring the landscape of priority issues for its future activities. An important consideration in this discussion is the extent of NCRP’s present and potential future resources to support the work of its scientific committees.

      2. This summary of the 53rd Annual Meeting of the National Council on Radiation Protection and Measurements (NCRP) captures the highlights of the presentations including the Warren K. Sinclair Keynote Address and the five scientific sessions and wrap-up summary and panel discussion of “Assessment of National Efforts in Emergency Preparedness for Nuclear Terrorism: Is There a Need for Realignment to Close Remaining Gaps?” The issue of radiological emergency preparedness has evolved in the last 20 y from a primarily nuclear power plant focus to a wider, more comprehensive approach that includes response to all types of radiological and nuclear emergencies, including terrorism. The meeting took an introspective look at the advances in radiological emergency preparedness in the last 15 y and focused on four major topic areas: Plans and guidance, training and exercising for both the first responder and the first receiver communities, recovery and return, and communication. In each area, the speakers reflected on the current state of that specific area and provided three to five practicable priority actions/initiatives for future work. As a result of the meeting, NCRP has made a commitment to create a committee to write a commentary that will go into more detail in each of the proposed priority areas discussed in the meeting and provide a roadmap for future work.

      3. NEHA strives to provide up-to-date and relevant information on environmental health and to build partnerships in the profession. In pursuit of these goals, we feature a column from the Environmental Health Services Branch (EHSB) of the Centers for Disease Control and Prevention (CDC) in every issue of the Journal. In these columns, EHSB and guest authors share insights and information about environmental health programs, trends, issues, and resources. The conclusions in this column are those of the author(s) and do not necessarily represent the official position of CDC. CDR Jill Shugart is a senior environmental health specialist and the Emergency Responder Health Monitoring and Surveillance System coordinator for the National Institute for Occupational Safety and Health, Emergency Preparedness and Response Office in Atlanta GA. ERHMS is a framework that allows an organization to monitor the health and safety of emergency responders throughout the predeployment, deployment, and post-deployment phases of a response. The goal of ERHMS is to prevent short- and long-term illness and injury in emergency responders.

    • Disease Reservoirs and Vectors
      1. Multiflora rose invasion amplifies prevalence of Lyme disease pathogen, but not necessarily Lyme disease riskExternal
        Adalsteinsson SA, Shriver WG, Hojgaard A, Bowman JL, Brisson D, D’Amico V, Buler JJ.
        Parasit Vectors. 2018 Jan 23;11(1):54.

        BACKGROUND: Forests in urban landscapes differ from their rural counterparts in ways that may alter vector-borne disease dynamics. In urban forest fragments, tick-borne pathogen prevalence is not well characterized; mitigating disease risk in densely-populated urban landscapes requires understanding ecological factors that affect pathogen prevalence. We trapped blacklegged tick (Ixodes scapularis) nymphs in urban forest fragments on the East Coast of the United States and used multiplex real-time PCR assays to quantify the prevalence of four zoonotic, tick-borne pathogens. We used Bayesian logistic regression and WAIC model selection to understand how vegetation, habitat, and landscape features of urban forests relate to the prevalence of B. burgdorferi (the causative agent of Lyme disease) among blacklegged ticks. RESULTS: In the 258 nymphs tested, we detected Borrelia burgdorferi (11.2% of ticks), Borrelia miyamotoi (0.8%) and Anaplasma phagocytophilum (1.9%), but we did not find Babesia microti (0%). Ticks collected from forests invaded by non-native multiflora rose (Rosa multiflora) had greater B. burgdorferi infection rates (mean = 15.9%) than ticks collected from uninvaded forests (mean = 7.9%). Overall, B. burgdorferi prevalence among ticks was positively related to habitat features (e.g. coarse woody debris and total understory cover) favorable for competent reservoir host species. CONCLUSIONS: Understory structure provided by non-native, invasive shrubs appears to aggregate ticks and reservoir hosts, increasing opportunities for pathogen transmission. However, when we consider pathogen prevalence among nymphs in context with relative abundance of questing nymphs, invasive plants do not necessarily increase disease risk. Although pathogen prevalence is greater among ticks in invaded forests, the probability of encountering an infected tick remains greater in uninvaded forests characterized by thick litter layers, sparse understories, and relatively greater questing tick abundance in urban landscapes.

      2. The recently described Lyme disease spirochete Borrelia mayonii is associated with human illness in the Upper Midwest of the United States. Experimental laboratory studies and field observations on natural infection indicate that B. mayonii is maintained by horizontal transmission between tick vectors and vertebrate reservoirs. While maintaining a colony of Ixodes scapularis Say (Acari: Ixodidae) ticks infected with the B. mayonii type strain (MN14-1420), we had an opportunity to examine whether infected females may pass this spirochete transovarially to their offspring. We found no evidence of B. mayonii infection in subsets of larvae originating from 18 infected I. scapularis females (grand total of 810 larvae tested), or in mice exposed to larval feeding.

      3. Borrelia miyamotoi is an increasingly recognized human pathogen transmitted by Ixodes ticks in the Northern Hemisphere. In North America, infection prevalences of B. miyamotoi are characteristically low (<10%) in Ixodes scapularis (Say; Acari: Ixodidae) and Ixodes pacificus (Cooley & Kohls; Acari: Ixodidae), both of which readily bite humans. We tested 3,255 host-seeking I. pacificus nymphs collected in 2004 from 79 sites throughout Mendocino County in north-coastal California for presence of B. miyamotoi. The collection sites represented a variety of forest types ranging from hot, dry oak woodlands in the southeast, to coastal redwoods in the west, and Ponderosa pine and Douglas fir-dominated areas in the northern part of the county. We found that B. miyamotoi was geographically widespread, but infected I. pacificus nymphs infrequently (cumulative prevalence of 1.4%). Infection prevalence was not significantly associated with geographic region or woodland type, and neither density of host-seeking nymphs, nor infection with Borrelia burgdorferi sensu stricto was associated with B. miyamotoi infection status in individual ticks. Because B. burgdorferi prevalence at the same sites was previously associated with woodland type and nymphal density, our results suggest that despite sharing a common vector, the primary modes of enzootic maintenance for the two pathogens are likely different.

      4. Introduction and establishment of raccoon rabies on islands: Jekyll Island, Georgia as a case studyExternal
        Ortiz S, Hernandez SM, Yabsley MJ, Becker TI, Carswell B, Moore Y, Fenton H, Bahnson CS, Niedringhaus K, Elsmo E, Orciari L, Yager P, Stedman NL, Nelson SE, Norton TM.
        J Wildl Dis. 2018 Jan 25.

        The introduction of rabies virus (RABV) to barrier islands, which are often popular tourist destinations with resource-rich habitats and connectivity and proximity to the mainland, is especially concerning because it can easily become endemic due to factors like dense rabies-vector populations (e.g., raccoons [ Procyon lotor]), high inter- and intraspecies contact rates, and anthropogenic activities such as supplemental feeding of feral cats ( Felis catus). In January 2013, a neurologic raccoon found on the Jekyll Island (JI), Georgia causeway tested positive for rabies. Mortality investigations of 29 raccoons have been conducted between December 2012-May 2017. The two most-common diagnoses were RABV ( n=11) and canine distemper virus (CDV; n=8). Parvoviral enteritis was diagnosed in four raccoons but no coinfections were diagnosed. There was no apparent seasonality for rabies cases, but all CDV cases occurred in spring-fall. Most (64%) rabies submissions came from residential or recreational use areas located near feral cat feeding stations. Jekyll Island is a popular destination where tourists engage in numerous outdoor activities which facilitate human-wildlife interactions. Concerns regarding public and animal health highlight the importance of rabies surveillance, prevention, and control on islands. This is the first report of rabies on JI and emphasizes the importance of disease investigations because the assumption that neurologic raccoons have CDV, an endemic pathogen, can miss the establishment of novel pathogens such as RABV.

      5. Surveillance for tick-borne viruses near the location of a fatal human case of Bourbon virus (Family Orthomyxoviridae: Genus Thogotovirus) in Eastern Kansas, 2015External
        Savage HM, Godsey MS, Panella NA, Burkhalter KL, Manford J, Trevino-Garrison IC, Straily A, Wilson S, Bowen J, Raghavan RK.
        J Med Entomol. 2018 Jan 20.

        Bourbon virus (Family Orthomyxoviridae: Genus Thogotovirus) was first isolated from a human case-patient residing in Bourbon County, Kansas, who subsequently died. Before becoming ill in late spring of 2014, the patient reported several tick bites. In response, we initiated tick surveillance in Bourbon County and adjacent southern Linn County during spring and summer of 2015. We collected 20,639 host-seeking ticks representing four species from 12 sites. Amblyomma americanum (L.) (Acari: Ixodidae) and Dermacentor variabilis (Say) (Acari: Ixodidae) accounted for nearly all ticks collected (99.99%). Three tick pools, all composed of adult A. americanum ticks collected in Bourbon County, were virus positive. Two pools were Heartland virus (Family Bunyaviridae: Genus Phlebovirus) positive, and one was Bourbon virus positive. The Bourbon virus positive tick pool was composed of five adult females collected on a private recreational property on June 5. Detection of Bourbon virus in the abundant and aggressive human-biting tick A. americanum in Bourbon County supports the contention that A. americanum is a vector of Bourbon virus to humans. The current data combined with virus detections in Missouri suggest that Bourbon virus is transmitted to humans by A. americanum ticks, including both the nymphal and adult stages, that ticks of this species become infected as either larvae, nymphs or both, perhaps by feeding on viremic vertebrate hosts, by cofeeding with infected ticks, or both, and that Bourbon virus is transstadially transmitted. Multiple detections of Heartland virus and Bourbon virus in A. americanum ticks suggest that these viruses share important components of their transmission cycles.

    • Drug Safety
      1. Opioid prescribing in the United StatesExternal
        Guy GP, Shults RA.
        Am J Nurs. 2018 Feb;118(2):19-20.

        Evidence-based information for nurses on the risks and benefits of prescription opioids.

    • Environmental Health
      1. Relationship between serum trimethylamine N-oxide and exposure to dioxin-like pollutantsExternal
        Petriello MC, Charnigo R, Sunkara M, Soman S, Pavuk M, Birnbaum L, Morris AJ, Hennig B.
        Environ Res. 2018 Jan 16;162:211-218.

        Trimethylamine N-oxide (TMAO) is a diet and gut microbiota-derived metabolite that has been linked to cardiovascular disease risk in human studies and animal models. TMAO levels show wide inter and intra individual variability in humans that can likely be accounted for by multiple factors including diet, the gut microbiota, levels of the TMAO generating liver enzyme Flavin-containing monooxygenase 3 (FMO3) and kidney function. We recently found that dioxin-like (DL) environmental pollutants increased FMO3 expression to elevate circulating diet-derived TMAO in mice, suggesting that exposure to this class of pollutants might also contribute to inter-individual variability in circulating TMAO levels in humans. To begin to explore this possibility we examined the relationship between body burden of DL pollutants (reported by serum lipid concentrations) and serum TMAO levels (n = 340) in the Anniston, AL cohort, which was highly exposed to polychlorinated biphenyls (PCBs). TMAO concentrations in archived serum samples from the Anniston Community Health Survey (ACHS-II) were measured, and associations of TMAO with 28 indices of pollutant body burden, including total dioxins toxic equivalent (TEQ), were quantified. Twenty-three (22 after adjustment for multiple comparisons) of the 28 indices were significantly positively associated with TMAO. Although the design of ACHS-II does not enable quantitative assessment of the contributions of previously known determinants of TMAO variability to this relationship, limited multivariate modeling revealed that total dioxins TEQ was significantly associated with TMAO among females (except at high BMIs) but not among males. Our results from this cross-sectional study indicate that exposure to DL pollutants may contribute to elevated serum TMAO levels. Prospective longitudinal studies will be required to assess the joint relationship between DL pollutant exposures, other determinants of TMAO, and health outcomes.

    • Genetics and Genomics
      1. Dating the Cryptococcus gattii dispersal to the North American Pacific NorthwestExternal
        Roe CC, Bowers J, Oltean H, DeBess E, Dufresne PJ, McBurney S, Overy DP, Wanke B, Lysen C, Chiller T, Meyer W, Thompson GR, Lockhart SR, Hepp CM, Engelthaler DM.
        mSphere. 2018 Jan-Feb;3(1).

        The emergence of Cryptococcus gattii, previously regarded as a predominantly tropical pathogen, in the temperate climate of the North American Pacific Northwest (PNW) in 1999 prompted several questions. The most prevalent among these was the timing of the introduction of this pathogen to this novel environment. Here, we infer tip-dated timing estimates for the three clonal C. gattii populations observed in the PNW, VGIIa, VGIIb, and VGIIc, based on whole-genome sequencing of 134 C. gattii isolates and using Bayesian evolutionary analysis by sampling trees (BEAST). We estimated the nucleotide substitution rate for each lineage (1.59 x 10(-8), 1.59 x 10(-8), and 2.70 x 10(-8), respectively) to be an order of magnitude higher than common neutral fungal mutation rates (2.0 x 10(-9)), indicating a microevolutionary rate (e.g., successive clonal generations in a laboratory) in comparison to a species’ slower, macroevolutionary rate (e.g., when using fossil records). The clonal nature of the PNW C. gattii emergence over a narrow number of years would therefore possibly explain our higher mutation rates. Our results suggest that the mean time to most recent common ancestor for all three sublineages occurred within the last 60 to 100 years. While the cause of C. gattii dispersal to the PNW is still unclear, our research estimates that the arrival is neither ancient nor very recent (i.e., <25 years ago), making a strong case for an anthropogenic introduction. IMPORTANCE The recent emergence of the pathogenic fungus Cryptococcus gattii in the Pacific Northwest (PNW) resulted in numerous investigations into the epidemiological and enzootic impacts, as well as multiple genomic explorations of the three primary molecular subtypes of the fungus that were discovered. These studies lead to the general conclusion that the subtypes identified likely emerged out of Brazil. Here, we conducted genomic dating analyses to determine the ages of the various lineages seen in the PNW and propose hypothetical causes for the dispersal events. Bayesian evolutionary analysis strongly suggests that these independent fungal populations in the PNW are all 60 to 100 years old, providing a timing that is subsequent to the opening of the Panama Canal, which allowed for more direct shipping between Brazil and the western North American coastline, a possible driving event for these fungal translocation events.

    • Health Disparities
      1. Sub-county life expectancy: A tool to improve community health and advance health equityExternal
        Boothe VL, Fierro LA, Laurent A, Shih M.
        Prev Chronic Dis. 2018 Jan 25;15:E11.

        Compared with people in other developed countries, Americans live shorter lives, have more disease and disability, and lag on most population health measures. Recent research suggests that this poor comparative performance is primarily driven by profound local place-based disparities. Several initiatives successfully used sub-county life expectancy estimates to identify geographic disparities, generate widespread interest, and catalyze multisector actions. To explore the feasibility of scaling these efforts, the Centers for Disease Control and Prevention and the Council of State and Territorial Epidemiologists initiated a multiphase project – the Sub-County Assessment of Life Expectancy. Phase I participants reviewed the literature, assessed and identified appropriate tools, calculated locally relevant estimates, and developed methodological guidance. Phase I results suggest that most state and local health departments will be able to calculate actionable sub-county life expectancy estimates despite varying resources, expertise, and population sizes, densities, and geographies. To accelerate widespread scaling, we describe several successful case examples, identify user-friendly validated tools, and provide practical tips that resulted from lessons learned.

      2. Histologic lung cancer incidence rates and trends vary by race/ethnicity and residential countyExternal
        Houston KA, Mitchell KA, King J, White A, Ryan BM.
        J Thorac Oncol. 2018 Jan 19.

        INTRODUCTION: Lung cancer incidence is higher among NH blacks compared with NH white and Hispanic populations in the U.S. However, national cancer estimates may not always reflect the cancer burden in terms of disparities and incidence in small geographic areas, especially urban-rural disparities. Moreover, there is a gap in the literature regarding rural-urban disparities in terms of cancer histology. METHODS: Using population-based cancer registry data-Surveillance, Epidemiology and End Results (SEER) and National Program of Cancer Registries (NPCR)-we present age-adjusted histologic rates and trends by race/ethnicity, and residential county location at the time of first cancer diagnosis. Rate ratios were calculated to examine racial/ethnic differences in rates. Annual percent change (APC) was calculated to measure changes in rates over time. RESULTS: We find that declines in squamous cell carcinoma (SCC) are occurring fastest in metropolitan counties, while rates of adenocarcinoma increased fastest in counties non-adjacent to metropolitan areas. Further, while NH black men have increased lung cancer incidence compared with NH white and Hispanic men in all geographic locations, we find that the degree of the disparity increases with increasing rurality of residence. Finally, we report that among women diagnosed at less than 55 years of age, the incidence of SCC and adenocarcinoma was higher for NH blacks compared with NH whites. CONCLUSIONS: Our results highlight disparities among NH blacks in non-adjacent rural areas. These findings may have significant impact for the implementation of smoking cessation and lung cancer screening programs.

    • Health Economics
      1. Vaccine financing and billing in practices serving adult patients: A follow-up surveyExternal
        Lindley MC, Hurley LP, Beaty BL, Allison MA, Crane LA, Brtnikova M, Snow M, Bridges CB, Kempe A.
        Vaccine. 2018 Jan 20.

        BACKGROUND: Financial concerns are often cited by physicians as a barrier to administering routinely recommended vaccines to adults. The purpose of this study was to assess perceived payments and profit from administering recommended adult vaccines and vaccine purchasing practices among general internal medicine (GIM) and family medicine (FM) practices in the United States. METHODS: We conducted an interviewer-administered survey from January-June 2014 of practices stratified by specialty (FM or GIM), affiliation (standalone or>/=2 practice sites), and level of financial decision-making (independent or larger system level) in FM and GIM practices that responded to a previous survey on adult vaccine financing and provided contact information for follow-up. Practice personnel identified as knowledgeable about vaccine financing and billing responded to questions about payments relative to vaccine purchase price and payment for vaccine administration, perceived profit on vaccination, claim denial, and utilization of various purchasing strategies for private vaccine stocks. Survey items on payment and perceived profit were assessed for various public and private payer types. Descriptive statistics were calculated and responses compared by physician specialty, practice affiliation, and level of financial decision-making. RESULTS: Of 242 practices approached, 43% (n=104) completed the survey. Reported payment levels and perceived profit varied by payer type. Only for preferred provider organizations did a plurality of respondents report profiting on adult vaccination services. Over half of respondents reported losing money vaccinating adult Medicaid beneficiaries. One-quarter to one-third of respondents reported not knowing about Medicare Part D payment levels for vaccine purchase and vaccine administration, respectively. Few respondents reported negotiating with manufacturers or insurance plans on vaccine purchase prices or payments for vaccination. CONCLUSIONS: Practices vaccinating adults may benefit from education and technical assistance related to vaccine financing and billing and greater use of purchasing strategies to decrease upfront vaccine cost.

      2. Quantifying the risk and cost of active monitoring for infectious diseasesExternal
        Reich NG, Lessler J, Varma JK, Vora NM.
        Sci Rep. 2018 Jan 18;8(1):1093.

        During outbreaks of deadly emerging pathogens (e.g., Ebola, MERS-CoV) and bioterror threats (e.g., smallpox), actively monitoring potentially infected individuals aims to limit disease transmission and morbidity. Guidance issued by CDC on active monitoring was a cornerstone of its response to the West Africa Ebola outbreak. There are limited data on how to balance the costs and performance of this important public health activity. We present a framework that estimates the risks and costs of specific durations of active monitoring for pathogens of significant public health concern. We analyze data from New York City’s Ebola active monitoring program over a 16-month period in 2014-2016. For monitored individuals, we identified unique durations of active monitoring that minimize expected costs for those at “low (but not zero) risk” and “some or high risk”: 21 and 31 days, respectively. Extending our analysis to smallpox and MERS-CoV, we found that the optimal length of active monitoring relative to the median incubation period was reduced compared to Ebola due to less variable incubation periods. Active monitoring can save lives but is expensive. Resources can be most effectively allocated by using exposure-risk categories to modify the duration or intensity of active monitoring.

    • Healthcare Associated Infections
      1. Acanthamoeba endophthalmitis during treatment for cutaneous disease in a renal transplant patientExternal
        Kutner A, Aldrich M, Patel S, Kang JJ, Amin B, Mann R, Ali IK, Brasil Martines R, Cope JR, De Boccardo GO, Puius YA.
        Transpl Infect Dis. 2018 Jan 23.

        Acanthamoeba infections are difficult to diagnose and treat. We present a renal transplant patient who developed Acanthamoeba endophthalmitis on therapy with posaconazole and miltefosine for cutaneous acanthamobiasis. The patient was maintained on intracameral voriconazole injections, and oral azithromycin, fluconazole, and flucytosine. This case highlights novel presentations and treatments for acanthamoebic infection. This article is protected by copyright. All rights reserved.

    • Immunity and Immunization
      1. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccinesExternal
        Dooling KL, Guo A, Patel M, Lee GM, Moore K, Belongia EA, Harpaz R.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):103-108.

        On October 20, 2017, Zoster Vaccine Recombinant, Adjuvanted (Shingrix, GlaxoSmithKline, [GSK] Research Triangle Park, North Carolina), a 2-dose, subunit vaccine containing recombinant glycoprotein E in combination with a novel adjuvant (AS01B), was approved by the Food and Drug Administration for the prevention of herpes zoster in adults aged >/=50 years. The vaccine consists of 2 doses (0.5 mL each), administered intramuscularly, 2-6 months apart (1). On October 25, 2017, the Advisory Committee on Immunization Practices (ACIP) recommended the recombinant zoster vaccine (RZV) for use in immunocompetent adults aged >/=50 years.

      2. Influence of birth cohort on effectiveness of 2015-2016 influenza vaccine against medically attended illness due to 2009 pandemic influenza A(H1N1) virus in the United StatesExternal
        Flannery B, Smith C, Garten RJ, Levine MZ, Chung JR, Jackson ML, Jackson LA, Monto AS, Martin ET, Belongia EA, McLean HQ, Gaglani M, Murthy K, Zimmerman R, Nowalk MP, Griffin MR, Keipp Talbot H, Treanor JJ, Wentworth DE, Fry AM.
        J Infect Dis. 2018 Jan 18.

        Background: The effectiveness of influenza vaccine during 2015-2016 was reduced in some age groups as compared to that in previous 2009 pandemic influenza A(H1N1) virus (A[H1N1]pdm09 virus)-predominant seasons. We hypothesized that the age at first exposure to specific influenza A(H1N1) viruses could influence vaccine effectiveness (VE). Methods: We estimated the effectiveness of influenza vaccine against polymerase chain reaction-confirmed influenza A(H1N1)pdm09-associated medically attended illness from the 2010-2011 season through the 2015-2016 season, according to patient birth cohort using data from the Influenza Vaccine Effectiveness Network. Birth cohorts were defined a priori on the basis of likely immunologic priming with groups of influenza A(H1N1) viruses that circulated during 1918-2015. VE was calculated as 100 x [1 – adjusted odds ratio] from logistic regression models comparing the odds of vaccination among influenza virus-positive versus influenza test-negative patients. Results: A total of 2115 A(H1N1)pdm09 virus-positive and 14 696 influenza virus-negative patients aged >/=6 months were included. VE was 61% (95% confidence interval [CI], 56%-66%) against A(H1N1)pdm09-associated illness during the 2010-2011 through 2013-2014 seasons, compared with 47% (95% CI, 36%-56%) during 2015-2016. During 2015-2016, A(H1N1)pdm09-specific VE was 22% (95% CI, -7%-43%) among adults born during 1958-1979 versus 61% (95% CI, 54%-66%) for all other birth cohorts combined. Conclusion: Findings suggest an association between reduced VE against influenza A(H1N1)pdm09-related illness during 2015-2016 and early exposure to specific influenza A(H1N1) viruses.

      3. Notes from the field: Errors in administration of an excess dosage of yellow fever vaccine – United States, 2017External
        McNeil MM, Hibbs BF, Miller ER, Cano MV.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):109-110.

        [No abstract]

      4. Exploring facilitators and barriers to initiation and completion of the human papillomavirus (HPV) vaccine series among parents of girls in a safety net systemExternal
        O’Leary ST, Lockhart S, Barnard J, Furniss A, Dickinson M, Dempsey AF, Stokley S, Federico S, Bronsert M, Kempe A.
        Int J Environ Res Public Health. 2018 Jan 23;15(2).

        Objective: To assess, among parents of predominantly minority, low-income adolescent girls who had either not initiated (NI) or not completed (NC) the HPV vaccine series, attitudes and other factors important in promoting the series, and whether attitudes differed by language preference. Design/Methods: From August 2013-October 2013, we conducted a mail survey among parents of girls aged 12-15 years randomly selected from administrative data in a Denver safety net system; 400 parents from each group (NI and NC) were targeted. Surveys were in English or Spanish. RESULTS: The response rate was 37% (244/660; 140 moved or gone elsewhere; 66% English-speaking, 34% Spanish-speaking). Safety attitudes of NIs and NCs differed, with 40% NIs vs. 14% NC’s reporting they thought HPV vaccine was unsafe (p < 0.0001) and 43% NIs vs. 21% NCs that it may cause long-term health problems (p < 0.001). Among NCs, 42% reported they did not know their daughter needed more shots (English-speaking, 20%, Spanish-speaking 52%) and 39% reported that “I wasn’t worried about the safety of the HPV vaccine before, but now I am” (English-speaking, 23%, Spanish-speaking, 50%). Items rated as very important among NIs in the decision regarding vaccination included: more information about safety (74%), more information saying it prevents cancer (70%), and if they knew HPV was spread mainly by sexual contact (61%). Conclusions: Safety concerns, being unaware of the need for multiple doses, and low perceived risk of infection remain significant barriers to HPV vaccination for at-risk adolescents. Some parents’ safety concerns do not appear until initial vaccination.

      5. When administered as standard three-dose schedules, the licensed HPV prophylactic vaccines have demonstrated extraordinary immunogenicity and efficacy. We summarize the immunogenicity of these licensed vaccines and the most commonly used serology assays, with a focus on key considerations for one-dose vaccine schedules. Although immune correlates of protection against infection are not entirely clear, both preclinical and clinical evidence point to neutralizing antibodies as the principal mechanism of protection. Thus, immunogenicity assessments in vaccine trials have focused on measurements of antibody responses to the vaccine. Non-inferiority of antibody responses after two doses of HPV vaccines separated by 6months has been demonstrated and this evidence supported the recent WHO recommendations for two-dose vaccination schedules in both boys and girls 9-14years of age. There is also some evidence suggesting that one dose of HPV vaccines may provide protection similar to the currently recommended two-dose regimens but robust data on efficacy and immunogenicity of one-dose vaccine schedules are lacking. In addition, immunogenicity has been assessed and reported using different methods, precluding direct comparison of results between different studies and vaccines. New head-to-head vaccine trials evaluating one-dose immunogenicity and efficacy have been initiated and an increase in the number of trials relying on immunobridging is anticipated. Therefore, standardized measurement and reporting of immunogenicity for the up to nine HPV types targeted by the current vaccines is now critical. Building on previous HPV serology assay standardization and harmonization efforts initiated by the WHO HPV LabNet in 2006, new secondary standards, critical reference reagents and testing guidelines will be generated as part of a new partnership to facilitate harmonization of the immunogenicity testing in new HPV vaccine trials.

      6. Screening and genomic characterization of filamentous hemagglutinin-deficient Bordetella pertussisExternal
        Weigand MR, Pawloski LC, Peng Y, Ju H, Burroughs M, Cassiday PK, Davis JK, DuVall M, Johnson T, Juieng P, Knipe K, Loparev VN, Mathis MH, Rowe LA, Sheth M, Williams MM, Tondella ML.
        Infect Immun. 2018 Jan 22.

        Despite high vaccine coverage, pertussis cases in the United States (US) have increased over the last decade. Growing evidence suggests that disease resurgence results, in part, from genetic divergence of circulating strain populations away from vaccine references. The US exclusively employs acellular vaccines and current Bordetella pertussis isolates are predominantly deficient in at least one immunogen, pertactin (Prn). First detected in the US retrospectively in a 1994 isolate, the rapid spread of Prn deficiency is likely vaccine driven, raising concerns about whether other acellular vaccine immunogens experience similar pressures as further antigenic changes could potentially threaten vaccine efficacy. We developed an electrochemiluminescent antibody capture assay to monitor production of the acellular vaccine immunogen filamentous hemagglutinin (Fha). Screening 722 US surveillance isolates collected from 2010-2016 identified two that were both Prn- and Fha-deficient. Three additional Fha-deficient laboratory strains were also identified from a historic collection of 65 isolates dating back to 1935. Whole-genome sequencing of deficient isolates revealed putative, underlying genetic changes. Only four isolates harbored mutation to known genes involved in Fha production, highlighting the complexity of its regulation. The chromosomes of two Fha-deficient isolates included unexpected structural variation that did not appear to influence Fha production. Furthermore, insertion sequence disruption of fhaB was also detected in a previously identified pertussis toxin-deficient isolate that still produced normal levels of Fha. These results demonstrate the genetic potential for additional vaccine immunogen deficiency and underscore the importance of continued surveillance of circulating B. pertussis evolution in response to vaccine pressure.

    • Informatics
      1. The Public Health Community Platform, electronic case reporting, and the digital bridgeExternal
        Cooney MA, Iademarco MF, Huang M, MacKenzie WR, Davidson AJ.
        J Public Health Manag Pract. 2018 Mar/Apr;24(2):185-189.

        At the intersection of new technology advancements, ever-changing health policy, and fiscal constraints, public health agencies seek to leverage modern technical innovations and benefit from a more comprehensive and cooperative approach to transforming public health, health care, and other data into action. State health agencies recognized a way to advance population health was to integrate public health with clinical health data through electronic infectious disease case reporting. The Public Health Community Platform (PHCP) concept of bidirectional data flow and knowledge management became the foundation to build a cloud-based system connecting electronic health records to public health data for a select initial set of notifiable conditions. With challenges faced and lessons learned, significant progress was made and the PHCP grew into the Digital Bridge, a national governance model for systems change, bringing together software vendors, public health, and health care. As the model and technology advance together, opportunities to advance future connectivity solutions for both health care and public health will emerge.

    • Laboratory Sciences
      1. IFCC Working Group Recommendations for Assessing Commutability Part 3: Using the calibration effectiveness of a reference materialExternal
        Budd JR, Weykamp C, Rej R, MacKenzie F, Ceriotti F, Greenberg N, Camara JE, Schimmel H, Vesper HW, Keller T, Delatour V, Panteghini M, Burns C, Miller WG.
        Clin Chem. 2018 Jan 18.

        A process is described to assess the commutability of a reference material (RM) intended for use as a calibrator based on its ability to fulfill its intended use in a calibration traceability scheme to produce equivalent clinical sample (CS) results among different measurement procedures (MPs) for the same measurand. Three sources of systematic error are elucidated in the context of creating the calibration model for translating MP signals to measurand amounts: calibration fit, calibrator level trueness, and commutability. An example set of 40 CS results from 7 MPs is used to illustrate estimation of bias and variability for each MP. The candidate RM is then used to recalibrate each MP, and its effectiveness in reducing the systematic error among the MPs within an acceptable level of equivalence based on medical requirements confirms its commutability for those MPs. The RM is declared noncommutable for MPs for which, after recalibration, the CS results do not agree with those from other MPs. When a lack of agreement is found, other potential causes, including lack of calibration fit, should be investigated before concluding the RM is noncommutable. The RM is considered fit for purpose for those MPs where commutability is demonstrated.

      2. Delta hepatitis: Toward improved diagnosticsExternal
        Kamili S, Drobeniuc J, Mixson-Hayden T, Kodani M.
        Hepatology. 2017 Dec;66(6):1716-1718.

        [No abstract]

      3. INTRODUCTION: The loop-mediated isothermal amplification (LAMP) technique holds substantial promise as an alternative easy-to-use molecular test for malaria parasite detection. Several modifications to the initial malaria LAMP assay have been made in an effort to make the LAMP platform more field-friendly. Areas covered: A PubMed literature search was performed using the following search terms: “malaria,” “loop mediated isothermal amplification”, “LAMP”, “molecular tests” and “diagnostics”. The authors review the currently reported malaria LAMP assays and discuss what requirements would be needed to make malaria LAMP assays field-usable, especially in the context of malaria elimination. Expert Commentary: Expanding the malaria LAMP tests as options for use in malaria control programs will require addressing some important challenges such as the need for simplified sample preparation steps; ready to use kits that require no cold chain; the use of a non-subjective results readout and preferably cost-effectiveness. Two malaria LAMP kits are now CE-marked and commercially available: the Loopamp MALARIA kit and the Illumigene malaria LAMP. Malaria LAMP tests, like other molecular tests, will likely be utilized in very specific studies such as: to evaluate “detect and treat” strategies; in controlled malaria infection trials or drug efficacy trials and as confirmatory test in reference laboratories.

      4. IFCC Working Group Recommendations for Assessing Commutability Part 1: General experimental designExternal
        Miller WG, Schimmel H, Rej R, Greenberg N, Ceriotti F, Burns C, Budd JR, Weykamp C, Delatour V, Nilsson G, MacKenzie F, Panteghini M, Keller T, Camara JE, Zegers I, Vesper HW.
        Clin Chem. 2018 Jan 18.

        Commutability is a property of a reference material (RM) that relates to the closeness of agreement between results for an RM and results for clinical samples (CSs) when measured by >/=2 measurement procedures (MPs). Commutability of RMs used in a calibration traceability scheme is an essential property for them to be fit for purpose. Similarly, commutability of trueness controls or external quality assessment samples is essential when those materials are used to assess trueness of results for CSs. This report is part 1 of a 3-part series describing how to assess commutability of RMs. Part 1 defines commutability and addresses critical components of the experimental design for commutability assessment, including selection of individual CSs, use of pooled CSs, qualification of MPs for inclusion, establishing criteria for the determination that an RM is commutable, generalization of commutability conclusions to future measurements made with the MPs included in the assessment, and information regarding commutability to be included in the certificate for an RM. Parts 2 and 3 in the series present 2 different statistical approaches to commutability assessment that use fixed criteria related to the medical decisions that will be made using the laboratory test results.

      5. Macrophage sensing of single-walled carbon nanotubes via Toll-like receptorsExternal
        Mukherjee SP, Bondarenko O, Kohonen P, Andon FT, Brzicova T, Gessner I, Mathur S, Bottini M, Calligari P, Stella L, Kisin E, Shvedova A, Autio R, Salminen-Mankonen H, Lahesmaa R, Fadeel B.
        Sci Rep. 2018 Jan 18;8(1):1115.

        Carbon-based nanomaterials including carbon nanotubes (CNTs) have been shown to trigger inflammation. However, how these materials are ‘sensed’ by immune cells is not known. Here we compared the effects of two carbon-based nanomaterials, single-walled CNTs (SWCNTs) and graphene oxide (GO), on primary human monocyte-derived macrophages. Genome-wide transcriptomics assessment was performed at sub-cytotoxic doses. Pathway analysis of the microarray data revealed pronounced effects on chemokine-encoding genes in macrophages exposed to SWCNTs, but not in response to GO, and these results were validated by multiplex array-based cytokine and chemokine profiling. Conditioned medium from SWCNT-exposed cells acted as a chemoattractant for dendritic cells. Chemokine secretion was reduced upon inhibition of NF-kappaB, as predicted by upstream regulator analysis of the transcriptomics data, and Toll-like receptors (TLRs) and their adaptor molecule, MyD88 were shown to be important for CCL5 secretion. Moreover, a specific role for TLR2/4 was confirmed by using reporter cell lines. Computational studies to elucidate how SWCNTs may interact with TLR4 in the absence of a protein corona suggested that binding is guided mainly by hydrophobic interactions. Taken together, these results imply that CNTs may be ‘sensed’ as pathogens by immune cells.

      6. IFCC Working Group Recommendations for Assessing Commutability Part 2: Using the difference in bias between a reference material and clinical samplesExternal
        Nilsson G, Budd JR, Greenberg N, Delatour V, Rej R, Panteghini M, Ceriotti F, Schimmel H, Weykamp C, Keller T, Camara JE, Burns C, Vesper HW, MacKenzie F, Miller WG.
        Clin Chem. 2018 Jan 18.

        A process is described to assess the commutability of a reference material (RM) intended for use as a calibrator, trueness control, or external quality assessment sample based on the difference in bias between an RM and clinical samples (CSs) measured using 2 different measurement procedures (MPs). This difference in bias is compared with a criterion based on a medically relevant difference between an RM and CS results to make a conclusion regarding commutability. When >2 MPs are included, the commutability is assessed pairwise for all combinations of 2 MPs. This approach allows the same criterion to be used for all combinations of MPs included in the assessment. The assessment is based on an error model that allows estimation of various random and systematic sources of error, including those from sample-specific effects of interfering substances. An advantage of this approach is that the difference in bias between an RM and the average bias of CSs at the concentration (i.e., amount of substance present or quantity value) of the RM is determined and its uncertainty estimated. An RM is considered fit for purpose for those MPs for which commutability is demonstrated.

      7. Use of hupresin to capture red blood cell acetylcholinesterase for detection of soman exposureExternal
        Onder S, Schopfer LM, Cashman JR, Tacal O, Johnson RC, Blake TA, Lockridge O.
        Anal Chem. 2018 Jan 2;90(1):974-979.

        Toxicity from acute exposure to nerve agents and organophosphorus toxicants is due to irreversible inhibition of acetylcholinesterase (AChE) in the nervous system. AChE in red blood cells is a surrogate for AChE in the nervous system. Previously we developed an immunopurification method to enrich red blood cell AChE (RBC AChE) as a biomarker of exposure. The goal of the present work was to provide an alternative RBC AChE enrichment strategy, by binding RBC AChE to Hupresin affinity gel. AChE was solubilized from frozen RBC by addition of 1% Triton X-100. Insoluble debris was removed by centrifugation. The red, but not viscous, RBC AChE solution was loaded on a Hupresin affinity column. Hemoglobin and other proteins were washed off with 3 M NaCl, while retaining AChE bound to Hupresin. Denatured AChE was eluted with 1% trifluoroacetic acid. The same protocol was used for 20 mL of RBC AChE inhibited with a soman model compound. The acid denatured protein was digested with pepsin and analyzed by liquid chromatography tandem mass spectrometry on a 6600 Triple-TOF mass spectrometer. A targeted method identified the aged soman adduct on serine 203 in peptide FGESAGAAS. It was concluded that Hupresin can be used to enrich soman-inhibited AChE solubilized from 8 mL of frozen human erythrocytes, yielding a quantity sufficient for detecting soman exposure.

    • Maternal and Child Health
      1. Recognition of clinical characteristics for population-based surveillance of fetal alcohol syndromeExternal
        Andrews JG, Galindo MK, Meaney FJ, Benavides A, Mayate L, Fox D, Pettygrove S, O’Leary L, Cunniff C.
        Birth Defects Res. 2018 Jan 25.

        BACKGROUND: The diagnosis of fetal alcohol syndrome (FAS) rests on identification of characteristic facial, growth, and central nervous system (CNS) features. Public health surveillance of FAS depends on documentation of these characteristics. We evaluated if reporting of FAS characteristics is associated with the type of provider examining the child. METHODS: We analyzed cases aged 7-9 years from the Fetal Alcohol Syndrome Surveillance Network II (FASSNetII). We included cases whose surveillance records included the type of provider (qualifying provider: developmental pediatrician, geneticist, neonatologist; other physician; or other provider) who evaluated the child as well as the FAS diagnostic characteristics (facial dysmorphology, CNS impairment, and/or growth deficiency) reported by the provider. RESULTS: A total of 345 cases were eligible for this analysis. Of these, 188 (54.5%) had adequate information on type of provider. Qualifying physicians averaged more than six reported FAS characteristics while other providers averaged less than five. Qualifying physicians reported on facial characteristics and developmental delay more frequently than other providers. Also, qualifying physicians reported on all three domains of characteristics (facial, CNS, and growth) in 97% of cases while others reported all three characteristics on two thirds of cases. CONCLUSIONS: Documentation in medical records during clinical evaluations for FAS is lower than optimal for cross-provider communication and surveillance purposes. Lack of documentation limits the quality and quantity of information in records that serve as a major source of data for public health surveillance systems.

      2. Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016External
        Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ.
        J Clin Child Adolesc Psychol. 2018 Jan 24:1-14.

        The purpose of this study is to estimate the national prevalence of parent-reported attention deficit/hyperactivity disorder (ADHD) diagnosis and treatment among U.S. children 2-17 years of age using the 2016 National Survey of Children’s Health (NSCH). The NSCH is a nationally representative, cross-sectional survey of parents regarding their children’s health that underwent a redesign before the 2016 data collection. It included indicators of lifetime receipt of an ADHD diagnosis by a health care provider, whether the child currently had ADHD, and receipt of medication and behavioral treatment for ADHD. Weighted prevalence estimates were calculated overall and by demographic and clinical subgroups (n = 45,736). In 2016, an estimated 6.1 million U.S. children 2-17 years of age (9.4%) had ever received an ADHD diagnosis. Of these, 5.4 million currently had ADHD, which was 89.4% of children ever diagnosed with ADHD and 8.4% of all U.S. children 2-17 years of age. Of children with current ADHD, almost two thirds (62.0%) were taking medication and slightly less than half (46.7%) had received behavioral treatment for ADHD in the past year; nearly one fourth (23.0%) had received neither treatment. Similar to estimates from previous surveys, there is a large population of U.S. children and adolescents who have been diagnosed with ADHD by a health care provider. Many, but not all, of these children received treatment that appears to be consistent with professional guidelines, though the survey questions are limited in detail about specific treatment types received. The redesigned NSCH can be used to annually monitor diagnosis and treatment patterns for this highly prevalent and high-impact neurodevelopmental disorder.

      3. Severe maternal morbidity during delivery hospitalizationsExternal
        Gibson C, Rohan AM, Gillespie KH.
        Wmj. 2017 Dec;116(5):215-220.

        INTRODUCTION: Severe maternal morbidities include 25 complications resulting from, or exacerbated by, pregnancy. Nationally, in the last decade, these rates have doubled. OBJECTIVE: This study describes trends in the rates of severe maternal morbidities at the time of hospitalization for delivery among different groups of Wisconsin women. METHODS: Hospital discharge data and ICD-9-CM diagnosis and procedure codes were used to identify delivery hospitalizations and rates of severe maternal morbidity among Wisconsin women from 2000 to 2014. Subsequent analyses focused on recent years (2010-2014). Rates of severe maternal morbidity were calculated per 10,000 delivery hospitalizations for all 25 severe maternal morbidity conditions as well as 24 conditions (excluding blood transfusions). Rates and rate ratios were calculated overall and for racial/ethnic groups, age groups, public health region of residence, and hospital payer. Median hospital length of stay and median hospital charges were compared for delivery hospitalizations with increasing severe maternal morbidities. RESULTS: Severe maternal morbidity rates increased 104% from 2000 to 2014 (P for trend <0.01). After excluding blood transfusions, rates increased 15% (P for trend <0.05). From 2010 to 2014, overall rates were stable over time, but varied by maternal age, race/ethnicity, payer, and public health region of residence. Median hospital charges and length of stay increased as the number of morbidities increased. CONCLUSIONS: Monitoring severe maternal morbidities adds valuable information to understanding perinatal health and obstetric complications in order to identify opportunities for prevention of severe morbidities and improvements in the quality of maternity care.

      4. Maternal occupational cadmium exposure and nonsyndromic orofacial cleftsExternal
        Suhl J, Romitti PA, Cao Y, Rocheleau CM, Burns TL, Conway K, Rajaraman P, Agopian AJ, Stewart P.
        Birth Defects Res. 2018 Jan 23.

        BACKGROUND: Cigarette smoking is a well-studied risk factor for orofacial clefts (OFCs). Little is known about which constituents in cigarette smoke contribute to this teratogenicity in humans. One constituent, cadmium, has been associated with OFCs in animal studies; in humans, the role of maternal cadmium exposure on OFCs, independent of cigarette smoke, is unclear. In particular, the relation between maternal occupational cadmium exposure and OFCs is largely unexplored. METHODS: Using data from a large, population-based case-control study, we compared expert rater assessed maternal occupational cadmium exposure from self-reported occupational histories during the period 1 month before through 3 months after conception between OFC cases (n = 1,185) and unaffected controls (n = 2,832). Multivariable logistic regression analyses were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals for any (yes/no) and cumulative (no, low, high exposure) occupational cadmium exposures and all OFCs, cleft lip +/- cleft palate (CL/P) and cleft palate (CP). RESULTS: Overall, 45 mothers (cases = 13, controls = 32) were rated as having occupational cadmium exposure. Comparing all OFCs to controls, we observed inverse, nonsignificant aORs for any or low exposure, and positive, nonsignificant aORs for high exposure. Where data were available, aORs for CL/P and CP tended to parallel those for all OFCs. CONCLUSION: To our knowledge, this is the first study to specifically examine maternal occupational cadmium exposure and OFCs, using expert rater exposure assessment. The small numbers of exposed mothers observed, however, led to imprecise estimates. Continued research using more detailed occupational exposure assessment and increased sample sizes is recommended.

    • Nutritional Sciences
      1. Parental characteristics and reasons associated with purchasing kids’ meals for their childrenExternal
        Lee-Kwan SH, Park S, Maynard LM, Blanck HM, McGuire LC, Collins JL.
        Am J Health Promot. 2018 Feb;32(2):264-270.

        PURPOSE: Characteristics of parents who purchased kids’ meals, reasons for the purchase, and desire for healthy options were examined. DESIGN: Quantitative, cross-sectional study. SETTING: National. PARTICIPANTS: The SummerStyles survey data of 1147 parents (>/=18 years). MEASURES: Self-reported outcome variables were purchase of kids’ meals (yes/no), reasons for the purchase (13 choices), and desire for healthy options (yes/no). ANALYSIS: We used multivariable logistic regression to estimate odds ratios (ORs) for purchasing kids’ meals based on parental sociodemographic and behavioral characteristics. RESULTS: Over half (51%) of parents reported purchasing kids’ meals in the past month. The adjusted OR of purchasing kids’ meals were significantly higher among younger parents (OR = 3.44 vs >/=50 years) and among parents who consumed sugar-sweetened beverages (SSBs) daily (OR = 2.70 vs none). No differences were found for race/ethnicity, income, and education. Parents who purchased kids’ meals reported that the top 3 reasons for purchase were (1) because their children asked for kids’ meals, (2) habit, and (3) offering of healthier sides such as fruits or fruit cups. Thirty-seven percent of parents who did not purchase kids’ meals expressed willingness to purchase kids’ meals if healthy options were available; this willingness was highest among younger parents (47%; P < .05). CONCLUSIONS: Kids’ meal purchases were somewhat common. Our findings on characteristics of parents who frequently bought kids’ meals (ie, younger parents and SSB consumers), common reasons for purchasing kids’ meals, and willingness to buy healthier kids’ meal can be used to inform intervention efforts to improve quality of kids’ meals.

    • Occupational Safety and Health
      1. The materials and methods used in manufacturing are changing rapidly and dramatically. So are the business management and product delivery models that have been part of the global manufacturing economy for decades. An informed and proactive industrial hygiene community can act now to embrace and influence the new challenges and opportunities that advanced manufacturing is creating. The current, traditional model of manufacturing includes large-scale production facilities that ship finished goods to strategically placed warehouses and distribution centers, where they are held until orders for these goods are received; the evolving 21st-century manufacturing model focuses on producing smaller, more distributed ”batches” of products or individual product components that meet specific customer demands.

      2. Microbial hazards during harvesting and processing at an outdoor United States cannabis farmExternal
        Green BJ, Couch JR, Lemons AR, Burton NC, Victory KR, Nayak AP, Beezhold DH.
        J Occup Environ Hyg. 2018 Jan 25:0.

        Cannabis cultivation is an emerging industry within the United States. Organic dust derived in part from naturally occurring microorganisms is known to cause byssinosis in the hemp industry. In this pilot study, bacteria and fungi encountered by workers at an outdoor cannabis farm that utilized organic practices were elucidated by 1625% shaded blockS ribosomal RNA (rRNA) and Internal Transcribed Spacer (ITS) region sequencing, respectively. Area (n = 14) and personal air samples (n = 12) were collected during harvesting and processing activities. 1625% shaded blockS rRNA and ITS regions of extracted bacterial and fungal genomic DNA were amplified and sequenced using Sanger sequencing. Bacterial sequencing resolved 1077 sequences that were clustered into 639 operational taxonomic units (OTUs) and predominantly placed in the phylum, Actinobacteria (46%). Personal air samples revealed higher bacterial and Actinobacteria diversity compared to outdoor area samples collected within the facility (p<0.05). A high degree of dissimilarity between bacteria was identified within and between samples. Fungal sequences (n = 985) were identified and predominantly clustered in the phylum Ascomycota (53%). Of the 216 fungal OTUs elucidated, the cannabis plant pathogenic species, Botrytis cinerea, was the most prevalent and accounted for 34% of all fungal sequences. The relative abundance of B. cinerea was highest in personal air samples (59%) compared to area samples collected in the drying room (19%), greenhouse (18%) and outdoor environment (6%). There was 49% sample similarity between fungi identified within personal air samples, but higher dissimilarity coefficients were observed within and between greenhouse, drying room, and outdoor area air samples. The results of this pilot study suggest that the cannabis farm workers are potentially exposed to Actinobacteria as well as the cannabis plant pathogen, B. cinerea during harvesting, bud stripping, and hand trimming processes.

      3. Development of a taxonomy of practice-related stressors experienced by veterinarians in the United StatesExternal
        Vande Griek OH, Clark MA, Witte TK, Nett RJ, Moeller AN, Stabler ME.
        J Am Vet Med Assoc. 2018 Jan 15;252(2):227-233.

        OBJECTIVE To develop a comprehensive taxonomy of practice-related stressors experienced by US veterinarians. DESIGN Cross-sectional survey. SAMPLE A subset of 1,422 US veterinarians who provided written (vs selected) responses to a question in a previous survey regarding practice-related stressors. PROCEDURES Using grounded theory analysis, 3 researchers inductively analyzed written survey responses concerning respondents’ main practice-related stressors. In 5 iterations, responses were individually coded and categorized, and a final list of practice-related stressor categories and subcategories was iteratively and collaboratively developed until theoretical and analytic saturation of the data was achieved. RESULTS A taxonomy of 15 categories of broad practice-related stressors and 40 subcategories of more specific practice-related stressors was developed. The most common practice-related stressor categories included financial insecurity (n = 289 [20.3%]), client issues (254 [17.9%]), coworker or interpersonal issues (181 [12.7%]), and work-life balance (166 [11.7%]). The most common subcategories were clients unwilling to pay (118 [8.3%]), low income (98 [6.9%]), cost of maintaining practice (56 [3.9%]), and government or state board policies (48 [3.4%]). CONCLUSIONS AND CLINICAL RELEVANCE This study provided a comprehensive list of the types of practice-related stressors experienced by US veterinarians, building a foundation for future research into relationships between job stress and mental health in this population. Frequency data on the various stressors provided an initial understanding of factors that might be contributing to high stress rates among US veterinarians.

    • Occupational Safety and Health – Mining
      1. Industrial Internet of Things: (IIoT) applications in underground coal minesExternal
        Zhou C, Damiano N, Whisner B, Reyes M.
        Min Eng. 2017 Dec;69(12):50-56.

        The Industrial Internet of Things (IIoT), a concept that combines sensor networks and control systems, has been employed in several industries to improve productivity and safety. U.S. National Institute for Occupational Safety and Health (NIOSH) researchers are investigating IIoT applications to identify the challenges of and potential solutions for transferring IIoT from other industries to the mining industry. Specifically, NIOSH has reviewed existing sensors and communications network systems used in U.S. underground coal mines to determine whether they are capable of supporting IIoT systems. The results show that about 40 percent of the installed post-accident communication systems as of 2014 require minimal or no modification to support IIoT applications. NIOSH researchers also developed an IIoT monitoring and control prototype system using low-cost microcontroller Wi-Fi boards to detect a door opening on a refuge alternative, activate fans located inside the Pittsburgh Experimental Mine and actuate an alarm beacon on the surface. The results of this feasibility study can be used to explore IIoT applications in underground coal mines based on existing communication and tracking infrastructure.

    • Parasitic Diseases
      1. Infant and child mortality in relation to malaria transmission in KEMRI/CDC HDSS, Western Kenya: validation of verbal autopsyExternal
        Amek NO, Van Eijk A, Lindblade KA, Hamel M, Bayoh N, Gimnig J, Laserson KF, Slutsker L, Smith T, Vounatsou P.
        Malar J. 2018 Jan 18;17(1):37.

        BACKGROUND: Malaria transmission reduction is a goal of many malaria control programmes. Little is known of how much mortality can be reduced by specific reductions in transmission. Verbal autopsy (VA) is widely used for estimating malaria specific mortality rates, but does not reliably distinguish malaria from other febrile illnesses. Overall malaria attributable mortality includes both direct and indirect deaths. It is unclear what proportion of the deaths averted by reducing malaria transmission are classified as malaria in VA. METHODS: Both all-cause, and cause-specific mortality reported by VA for children under 5 years of age, were assembled from the KEMRI/CDC health and demographic surveillance system in Siaya county, rural Western Kenya for the years 2002-2004. These were linked to household-specific estimates of the Plasmodium falciparum entomological inoculation rate (EIR) based on high resolution spatio-temporal geostatistical modelling of entomological data. All-cause and malaria specific mortality (by VA), were analysed in relation to EIR, insecticide-treated net use (ITN), socioeconomic status (SES) and parameters describing space-time correlation. Time at risk for each child was analysed using Bayesian geostatistical Cox proportional hazard models, with time-dependent covariates. The outputs were used to estimate the diagnostic performance of VA in measuring mortality that can be attributed to malaria exposure. RESULTS: The overall under-five mortality rate was 80 per 1000 person-years during the study period. Eighty-one percent of the total deaths were assigned causes of death by VA, with malaria assigned as the main cause of death except in the neonatal period. Although no trend was observed in malaria-specific mortality assessed by VA, ITN use was associated with reduced all-cause mortality in infants (hazard ratio 0.15, 95% CI 0.02, 0.63) and the EIR was strongly associated with both all-cause and malaria-specific mortality. 48.2% of the deaths could be attributed to malaria by analysing the exposure-response relationship, though only 20.5% of VAs assigned malaria as the cause and the sensitivity of VAs was estimated to be only 26%. Although VAs assigned some deaths to malaria even in areas where there was estimated to be no exposure, the specificity of the VAs was estimated to be 85%. CONCLUSION: Interventions that reduce P. falciparum transmission intensity will not only significantly reduce malaria-diagnosed mortality, but also mortality assigned to other causes in under-5 year old children in endemic areas. In this setting, the VA tool based on clinician review substantially underestimates the number of deaths that could be averted by reducing malaria exposure in childhood, but has a reasonably high specificity. This suggests that malaria transmission-reducing interventions such as ITNs can potentially reduce overall child mortality by as much as twice the total direct malaria burden estimated from VAs.

    • Reproductive Health
      1. Access to long-acting reversible contraception among US publicly funded health centersExternal
        Bornstein M, Carter M, Zapata L, Gavin L, Moskosky S.
        Contraception. 2017 Dec 15.

        OBJECTIVES: Access to a full range of contraceptive methods, including long-acting reversible contraception (LARC), is central to providing quality family planning services. We describe health center-related factors associated with LARC availability, including staff training in LARC insertion/removal and approaches to offering LARC, whether onsite or through referral. STUDY DESIGN: We analyzed nationally representative survey data collected during 2013-2014 from administrators of publicly funded U.S. health centers that offered family planning. The response rate was 49.3% (n=1615). In addition to descriptive statistics, we used multivariable logistic regression to identify health center characteristics associated with offering both IUDs and implants onsite. RESULTS: Two-thirds (64%) of health centers had staff trained in all three LARC types (hormonal IUD, copper IUD, implant); 21% had no staff trained in any of those contraceptive methods. Half of health centers (52%) offered IUDs (any type) and implants onsite. After onsite provision, informal referral arrangements were the most common way LARC methods were offered. In adjusted analyses, Planned Parenthood (AOR=9.49) and hospital-based (AOR=2.35) health centers had increased odds of offering IUDs (any type) and implants onsite, compared to Health Departments, as did Title X-funded (AOR=1.55) compared to non-Title X-funded health centers and centers serving a larger volume of family planning clients. Centers serving mostly rural areas compared to those serving urbans areas had lower odds (AOR 0.60) of offering IUD (any type) and implants. CONCLUSIONS: Variation in LARC access remains among publicly funded health centers. In particular, Health Departments and rural health centers have relatively low LARC provision. IMPLICATIONS: For more women to be offered a full range of contraceptive methods, additional efforts should be made to increase availability of LARC in publicly-funded health centers, such as addressing provider training gaps, improving referrals mechanisms, and other efforts to strengthen the health care system.

    • Substance Use and Abuse
      1. State-specific prevalence of tobacco product use among adults – United States, 2014-2015External
        Odani S, Armour BS, Graffunder CM, Willis G, Hartman AM, Agaku IT.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):97-102.

        Despite recent declines in cigarette smoking prevalence, the tobacco product landscape has shifted to include emerging tobacco products* (1,2). Previous research has documented adult use of smokeless tobacco and cigarettes by state (3); however, state-specific data on other tobacco products are limited. To assess tobacco product use in the 50 U.S. states and the District of Columbia (DC), CDC and the National Cancer Institute analyzed self-reported use of six tobacco product types: cigarettes, cigars, regular pipes, water pipes, electronic cigarettes (e-cigarettes), and smokeless tobacco products among adults aged >/=18 years using data from the 2014-2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Prevalence of ever-use of any tobacco product ranged from 27.0% (Utah) to 55.4% (Wyoming). Current (every day or some days) use of any tobacco product ranged from 10.2% (California) to 27.7% (Wyoming). Cigarettes were the most common currently used tobacco product in all states and DC. Among current cigarette smokers, the proportion who currently used one or more other tobacco products ranged from 11.5% (Delaware) to 32.3% (Oregon). Differences in tobacco product use across states underscore the importance of implementing proven population-level strategies to reduce tobacco use and expanding these strategies to cover all forms of tobacco marketed in the United States. Such strategies could include comprehensive smoke-free policies, tobacco product price increases, anti-tobacco mass media campaigns, and barrier-free access to clinical smoking cessation resources (1,4).

    • Zoonotic and Vectorborne Diseases
      1. Population-based surveillance of birth defects potentially related to Zika virus infection – 15 states and U.S. territories, 2016External
        Delaney A, Mai C, Smoots A, Cragan J, Ellington S, Langlois P, Breidenbach R, Fornoff J, Dunn J, Yazdy M, Scotto-Rosato N, Sweatlock J, Fox D, Palacios J, Forestieri N, Leedom V, Smiley M, Nance A, Lake-Burger H, Romitti P, Fall C, Prado MV, Barton J, Bryan JM, Arias W, Brown SV, Kimura J, Mann S, Martin B, Orantes L, Taylor A, Nahabedian J, Akosa A, Song Z, Martin S, Ramlal R, Shapiro-Mendoza C, Isenburg J, Moore CA, Gilboa S, Honein MA.
        MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67(3):91-96.

        Zika virus infection during pregnancy can cause serious birth defects, including microcephaly and brain abnormalities (1). Population-based birth defects surveillance systems are critical to monitor all infants and fetuses with birth defects potentially related to Zika virus infection, regardless of known exposure or laboratory evidence of Zika virus infection during pregnancy. CDC analyzed data from 15 U.S. jurisdictions conducting population-based surveillance for birth defects potentially related to Zika virus infection.* Jurisdictions were stratified into the following three groups: those with 1) documented local transmission of Zika virus during 2016; 2) one or more cases of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents; and 3) less than one case of confirmed, symptomatic, travel-associated Zika virus disease reported to CDC per 100,000 residents. A total of 2,962 infants and fetuses (3.0 per 1,000 live births; 95% confidence interval [CI] = 2.9-3.2) (2) met the case definition.(dagger) In areas with local transmission there was a non-statistically significant increase in total birth defects potentially related to Zika virus infection from 2.8 cases per 1,000 live births in the first half of 2016 to 3.0 cases in the second half (p = 0.10). However, when neural tube defects and other early brain malformations (NTDs)( section sign) were excluded, the prevalence of birth defects strongly linked to congenital Zika virus infection increased significantly, from 2.0 cases per 1,000 live births in the first half of 2016 to 2.4 cases in the second half, an increase of 29 more cases than expected (p = 0.009). These findings underscore the importance of surveillance for birth defects potentially related to Zika virus infection and the need for continued monitoring in areas at risk for Zika.

      2. Chlamydia psittaci in feral rosy-faced lovebirds (Agapornis roseicollis) and other backyard birds in Maricopa County, ArizonaExternal
        Dusek RJ, Justice-Allen A, Bodenstein B, Knowles S, Grear DA, Adams L, Levy C, Yaglom HD, Shearn-Bochsler VI, Ciembo PG, Gregory CR, Pesti D, Ritchie BW.
        J Wildl Dis. 2018 Jan 25.

        In 2013, a mortality event of nonnative, feral Rosy-faced Lovebirds ( Agapornis roseicollis) in residential backyards in Maricopa County, Arizona, USA was attributed to infection with Chlamydia psittaci. In June 2014, additional mortality occurred in the same region. Accordingly, in August 2014 we sampled live lovebirds and sympatric bird species visiting backyard bird feeders to determine the prevalence of DNA and the seroprevalence of antibodies to C. psittaci using real-time PCR-based testing and elementary body agglutination, respectively. Chlamydia psittaci DNA was present in conjunctival-choanal or cloacal swabs in 93% (43/46) of lovebirds and 10% (14/142) of sympatric birds. Antibodies to C. psittaci were detected in 76% (31/41) of lovebirds and 7% (7/102) of sympatric birds. Among the sympatric birds, Rock Doves ( Columba livia) had the highest prevalence of C. psittaci DNA (75%; 6/8) and seroprevalence (25%; 2/8). Psittacine circovirus 1 DNA was also identified, using real-time PCR-based testing from the same swab samples in 69% (11/16) of species sampled, with a prevalence of 80% (37/46) in lovebirds and 27% (38/142) in sympatric species. The presence of either Rosy-faced Lovebirds or Rock Doves at residential bird feeders may be cause for concern for epizootic and zoonotic transmission of C. psittaci in this region.

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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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