Volume 10, Issue 42, November 6, 2018

CDC Science Clips: Volume 10, Issue 42, November 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!

  1. Top Articles of the Week

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

    The names of CDC authors are indicated in bold text.
    • Chronic Diseases and Conditions
      • Clinical implementation of self-measured blood pressure monitoring, 2015-2016External
        Jackson SL, Ayala C, Tong X, Wall HK.
        Am J Prev Med. 2018 Oct 11.

        INTRODUCTION: Self-measured blood pressure monitoring (SMBP) plus additional clinical support is an evidence-based strategy that improves blood pressure control. Despite national recommendations for SMBP use and potential cost savings, insurance coverage for implementation is limited in the U.S. and little is known regarding clinical implementation. METHODS: In 2017, using 2015 and 2016 DocStyles survey data from 1,590 primary care physicians and nurse practitioners in U.S. outpatient facilities, SMBP-related clinical practices and provider roles were assessed. RESULTS: Almost all (97%) respondents reported using SMBP. Among 1,539 who used SMBP, more than half (60%) used SMBP for a combination of diagnostic and treatment purposes, whereas 24% used SMBP for diagnosis only and 16% used SMBP for treatment only. The most common methods for patients to share SMBP results with clinical staff were paper log (68%); during appointments (66%); by telephone (37%); by secure website (22%); or by secure e-mail (19%). Nearly all (98%) respondents reported that medication adjustments were provided to patients based on SMBP readings. About 15% did not counsel patients regarding cuff size, and 8% did not validate patient devices. Only 13% of respondents reported having monitor loaner programs, and availability did not vary by the financial status of the patient population (p=0.59). CONCLUSIONS: SMBP is used widely in outpatient facilities as reported in the survey, although provider roles and SMBP-related practices vary, and gaps exist regarding patient counseling, device validation, and loaner program availability. As part of efforts to improve hypertension control, healthcare professionals can promote increased use of best practices for SMBP, whereas insurers can implement standardization and support of SMBP.

    • Communicable Diseases
      • Outbreak of Neisseria meningitidis serogroup C outside the meningitis belt-Liberia, 2017: an epidemiological and laboratory investigationExternal
        Bozio CH, Vuong J, Dokubo EK, Fallah MP, McNamara LA, Potts CC, Doedeh J, Gbanya M, Retchless AC, Patel JC, Clark TA, Kohar H, Nagbe T, Clement P, Katawera V, Mahmoud N, Djingarey HM, Perrocheau A, Naidoo D, Stone M, George RN, Williams D, Gasasira A, Nyenswah T, Wang X, Fox LM.
        Lancet Infect Dis. 2018 Oct 15.

        BACKGROUND: On April 25, 2017, a cluster of unexplained illnesses and deaths associated with a funeral was reported in Sinoe County, Liberia. Molecular testing identified Neisseria meningitidis serogroup C (NmC) in specimens from patients. We describe the epidemiological investigation of this cluster and metagenomic characterisation of the outbreak strain. METHODS: We collected epidemiological data from the field investigation and medical records review. Confirmed, probable, and suspected cases were defined on the basis of molecular testing and signs or symptoms of meningococcal disease. Metagenomic sequences from patient specimens were compared with 141 meningococcal isolate genomes to determine strain lineage. FINDINGS: 28 meningococcal disease cases were identified, with dates of symptom onset from April 21 to April 30, 2017: 13 confirmed, three probable, and 12 suspected. 13 patients died. Six (21%) patients reported fever and 23 (82%) reported gastrointestinal symptoms. The attack rate for confirmed and probable cases among funeral attendees was 10%. Metagenomic sequences from six patient specimens were similar to a sequence type (ST) 10217 (clonal complex [CC] 10217) isolate genome from Niger, 2015. Multilocus sequencing identified five of seven alleles from one specimen that matched ST-9367, which is represented in the PubMLST database by one carriage isolate from Burkina Faso, in 2011, and belongs to CC10217. INTERPRETATION: This outbreak featured high attack and case fatality rates. Clinical presentation was broadly consistent with previous meningococcal disease outbreaks, but predominance of gastrointestinal symptoms was unusual compared with previous African meningitis epidemics. The outbreak strain was genetically similar to NmC CC10217, which caused meningococcal disease outbreaks in Niger and Nigeria. CC10217 had previously been identified only in the African meningitis belt. FUNDING: US Global Health Security.

      • The use of technology for sexually transmitted disease partner services in the United States: A structured reviewExternal
        Kachur R, Hall W, Coor A, Kinsey J, Collins D, Strona FV.
        Sex Transm Dis. 2018 Nov;45(11):707-712.

        BACKGROUND: Since the late 1990s, health departments and sexually transmitted disease (STD) programs throughout the United States have used technologies, such as the Internet and mobile phones, to provide services to persons with a sexually transmitted infection, including human immunodeficiency virus (HIV), and their sex partners, also known as partner services. This study reviewed the published literature to assess and compare partner services outcomes as a result of using technology and to calculate cost savings through cases averted. METHODS: We conducted a structured literature review of all US studies that examined the use of technology to notify persons exposed to an STD (syphilis, chlamydia, gonorrhea), including HIV, by health care professionals in the United States from 2000 to 2017. Outcome measures, including the number of partners notified, screened or tested; and new positives identified, were captured and cost savings were calculated, when data were available. RESULTS: Seven studies were identified. Methods used for partner services differed across studies, although email was the primary mode in 6 (83%) of the 7 studies. Only 2 of the 7 studies compared use of technology for partner services to traditional partner services. Between 10% and 97% of partners were successfully notified of their exposure through the use of technology and between 34% and 81% were screened or tested. Five studies reported on new infections identified, which ranged from 3 to 19. Use of technology for partner serves saved programs between US $22,795 and US $45,362 in direct and indirect medical costs. CONCLUSIONS: Use of technology for partner services increased the number of partners notified, screened or tested, and new infections found. Importantly, the use of technology allowed programs to reach partners who otherwise would not have been notified of their exposure to an STD or HIV. Improved response times and time to treatment were also seen as was re-engagement into care for previous HIV positive patients. Data and outcome measures across the studies were not standardized, making it difficult to generalize conclusions. Although not a replacement for traditional partner services, the use of technology enhances partner service outcomes.

      • Improved treatment completion with shorter treatment regimens for latent tuberculous infectionExternal
        Macaraig MM, Jalees M, Lam C, Burzynski J.
        Int J Tuberc Lung Dis. 2018 Nov 1;22(11):1344-1349.

        SETTING: Four New York City (NYC) Health Department tuberculosis (TB) clinics. OBJECTIVE: To assess the effectiveness of preferentially offering two shorter treatment regimens-4 months of daily rifampin (4R) and 3 months of once-weekly isoniazid and rifapentine (3HP)-as an alternative to 9 months of daily isoniazid (9H) for the treatment of latent tuberculous infection (LTBI). DESIGN: Retrospective analysis of patients treated for LTBI from January to June 2015. Poisson regression with robust standard error was used to examine the factors associated with treatment completion. RESULTS: Of the patients on 9H, 49% (27/55) completed treatment compared with 70% (187/269) of patients on 4R (P = 0.003) and 79% (99/125) of patients on 3HP (P < 0.001). When adjusting for age, sex, and TB risk factors, patients on 4R (adjusted risk ratio [aRR] 1.39, 95%CI 1.07-1.81) and 3HP (aRR 1.67, 95%CI 1.27-2.19) were more likely to complete treatment than patients on 9H. Treatment was discontinued due to side effects in 1% (3/269) of patients on 4R, 2% (2/125) of patients on 3HP, and 4% (2/55) of patients on 9H. CONCLUSIONS: Most patients were placed on shorter regimens for LTBI treatment, and higher treatment completion was observed. Encouraging community providers to use shorter regimens for LTBI treatment would reduce the TB disease burden in NYC.

    • Health Economics
      • Effectiveness and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in Washington stateExternal
        Kemper KE, Glaze BL, Eastman CL, Waldron RC, Hoover S, Flagg T, Tangka FK, Subramanian S.
        Cancer. 2018 Oct 25.

        BACKGROUND: It has been demonstrated that fecal immunochemical test (FIT) mailing programs are effective for increasing colorectal cancer (CRC) screening. The objectives of the current study were to assess the magnitude of uptake that could be achieved with a mailed FIT program in a federally qualified health center and whether such a program can be implemented at a reasonable cost to support sustainability. METHODS: The Washington State Department of Health’s partner HealthPoint implemented a direct-mail FIT program at 9 medical clinics, along with a follow-up reminder letter and automated telephone calls to those not up-to-date with recommended screening. Supplemental outreach events at selected medical clinics and a 50th birthday card screening reminder program also were implemented. The authors collected and analyzed process, effectiveness, and cost measures and conducted a systematic assessment of the short-term cost effectiveness of the interventions. RESULTS: Overall, 5178 FIT kits were mailed with 4009 follow-up reminder letters, and 8454 automated reminder telephone calls were made over 12 months. In total, 1607 FIT kits were returned within 3 months of the end of the implementation period: an overall return rate of 31% for the mailed FIT program. The average total intervention cost per FIT kit returned was $39.81, and the intervention implementation cost per kit returned was $18.76. CONCLUSIONS: The mailed FIT intervention improved CRC screening uptake among HealthPoint’s patient population. This intervention was implemented for less than $40 per individual successfully screened. The findings and lessons learned can assist other clinics that serve disadvantaged populations to increase their CRC screening adherence. Cancer 2018;124:000-000.

    • Healthcare Associated Infections
      • Mycobacterium chimaera hepatitis: A new disease entityExternal
        Shafizadeh N, Hale G, Bhatnagar J, Alshak NS, Nomura J.
        Am J Surg Pathol. 2018 Oct 20.

        Mycobacterium chimaera was identified as a species within the Mycobacterium avium complex in 2004. Until recently, it was predominantly seen in immunocompromised patients. In 2015, an outbreak of disseminated M. chimaera disease was described in European patients after undergoing open-heart surgery in which contaminated heater-cooler water units were used. Using whole genomic sequencing and phylogenetic analysis, investigators found a highly clonal outbreak from the German manufacturing site of the heater-cooler water units. This outbreak has now proven to be world-wide. Patients present with fever, fatigue, and weight loss months to many years after surgery. They are found to have systemic manifestations, including endocarditis, pancytopenia, renal dysfunction, chorioretinitis, and hepatitis. Preliminary reports suggest a high mortality rate despite aggressive treatment. In some patients, the predominant laboratory abnormalities are elevations in liver function tests, leading to diagnostic hepatobiliary work-ups, including liver biopsy. The pathologic changes in the liver have not yet been described. Herein, we report the clinicopathologic findings of the largest series of M. chimaera liver disease in the United States to date: 7 cases within a large, multihospital health care network. Five (71%) patients died of disease, despite aggressive treatment. Liver function test abnormalities were predominantly biliary: mean values of alkaline phosphate 288 U/L, aspartate aminotransferase 79 U/L, alanine aminotransferase 64 U/L. All 7 biopsies showed a consistent and characteristic dual pattern of injury: small, ill-formed collections of sinusoidal histiocytes with rare multinucleated giant cells, and scattered architectural changes of venous outflow obstruction. Two (29%) cases showed mild pericellular fibrosis. Nodular regenerative hyperplasia was seen in 2 (29%) cases, consistent with a sinusoidal/venous obstructive pattern of injury. We postulate that the sinusoidal location of the granulomas contributes to the venous obstructive changes. Recognition of this characteristic dual pattern of injury can allow pathologists to suggest the diagnosis and prompt the appropriate diagnostic and therapeutic interventions.

    • Immunity and Immunization
    • Injury and Violence
      • RISING SUN: Prioritized outcomes for suicide prevention in the ArcticExternal
        Collins PY, Delgado RA, Apok C, Baez L, Bjerregaard P, Chatwood S, Chipp C, Crawford A, Crosby A, Dillard D, Driscoll D, Ericksen H, Hicks J, Larsen CV, McKeon R, Partapuoli PJ, Phillips A, Pringle B, Rasmus S, Sigurethardottir S, Silviken A, Stoor JP, Sumarokov Y, Wexler L.
        Psychiatr Serv. 2018 Oct 24:appips201700505.

        The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

    • Laboratory Sciences
      • Accuracy and reliability of a low-cost, handheld 3D imaging system for child anthropometryExternal
        Conkle J, Suchdev PS, Alexander E, Flores-Ayala R, Ramakrishnan U, Martorell R.
        PLoS One. 2018 ;13(10):e0205320.

        The usefulness of anthropometry to define childhood malnutrition is undermined by poor measurement quality, which led to calls for new measurement approaches. We evaluated the ability of a 3D imaging system to correctly measure child stature (length or height), head circumference and arm circumference. In 2016-7 we recruited and measured children at 20 facilities in and around metro Atlanta, Georgia, USA; including at daycare, higher education, religious, and medical facilities. We selected recruitment sites to reflect a generally representative population of Atlanta and to oversample newborns and children under two years of age. Using convenience sampling, a total of 474 children 0-5 years of age who were apparently healthy and who were present at the time of data collection were included in the analysis. Two anthropometrists each took repeated manual measures and repeated 3D scans of each child. We evaluated the reliability and accuracy of 3D scan-derived measurements against manual measurements. The mean child age was 26 months, and 48% of children were female. Based on reported race and ethnicity, the sample was 42% Black, 28% White, 8% Asian, 21% multiple races, other or race not reported; and 16% Hispanic. Measurement reliability of repeated 3D scans was within 1 mm of manual measurement reliability for stature, head circumference and arm circumference. We found systematic bias when analyzing accuracy-on average 3D imaging overestimated stature and head circumference by 6 mm and 3 mm respectively, and underestimated arm circumference by 2 mm. The 3D imaging system used in this study is reliable, low-cost, portable, and can handle movement; making it ideal for use in routine nutritional assessment. However, additional research, particularly on accuracy, and further development of the scanning and processing software is needed before making policy and clinical practice recommendations on the routine use of 3D imaging for child anthropometry.

      • Field evaluation of SD BIOLINE HIV/Syphilis Duo assay among pregnant women attending routine antenatal care in Juba, South SudanExternal
        Lodiongo DK, Bior BK, Dumo GW, Katoro JS, Mogga JJ, Lokore ML, Abias AG, Carter JY, Deng LL.
        PLoS One. 2018 ;13(10):e0205383.

        The SD BIOLINE HIV/Syphilis Duo assay is the first World Health Organization prequalified dual rapid diagnostic test for simultaneous detection of HIV and Treponema pallidum antibodies in human blood. Prior to introducing the test into antenatal clinics across South Sudan, a field evaluation of its clinical performance in diagnosing both HIV and syphilis in pregnant women was conducted. SD Bioline test performance on venous blood samples was compared with (i) Vironostika HIV1/2 Uniform II Ag/Ab reference standard and Alere Determine HIV 1/2 non-reference standard for HIV diagnosis, and (ii) Treponema pallidum hemagglutination reference standard and Rapid plasma reagin non-reference standard for syphilis. Sensitivity, specificity, positive predictive value (PPN), negative predictive value (NPV) and kappa (kappa) value were calculated for each component against the reference standards within 95% confidence intervals (CIs); agreements between Determine HIV 1/2 and SD Bioline HIV tests were also calculated. Of 442 pregnant women recruited, eight (1.8%) were HIV positive, 22 (5.0%) had evidence of syphilis exposure; 14 (3.2%) had active infection. For HIV diagnosis, the sensitivity, specificity, PPV and NPV were 100% (95% CI: 63.1-100), 100% (95% CI: 99.2-100), 100% (95% CI: 63.1-100) and 100% (95% CI: 99.2-100) respectively with kappa value of 1 (95% CI: 0.992-1.000). Overall agreement of the Duo HIV component and Determine test was 99.1% (95% CI: 0.977-0.998) with 66.7% (95% CI: 34.9-90.1) positive and 100% (95% CI: 0.992-1.000) negative percent agreements. For syphilis, the Duo assay sensitivity was 86.4% (95% CI: 65.1-97.1) and specificity 100% (95% CI: 99.1-100) with PPV 100% (95% CI: 82.4-100), NPV 99.2% (95% CI: 97.9-99.9) and kappa value 0.92 (95% CI: 0.980-0.999). Our findings suggest the SD Bioline HIV/Syphilis Duo Assay could be suitable for HIV and syphilis testing in women attending antenatal services across South Sudan. Women with positive syphilis results should receive treatment immediately, whereas HIV positive women should undergo confirmatory testing following national HIV testing guidelines.

      • Heteroresistance to the model antimicrobial peptide polymyxin B in the emerging Neisseria meningitidis linage 11.2 urethritis clade: mutations in the pilMNOPQ operonExternal
        Tzeng YL, Berman Z, Toh E, Bazan JA, Turner AN, Retchless AC, Wang X, Nelson DE, Stephens DS.
        Mol Microbiol. 2018 Oct 18.

        Clusters of Neisseria meningitidis (Nm) urethritis among primarily heterosexual males in multiple United States cities have been attributed to a unique non-encapsulated meningococcal clade (the U.S. Nm urethritis clade, US_NmUC) within the hypervirulent clonal complex 11. Resistance to antimicrobial peptides (AMPs) is a key feature of urogenital pathogenesis of the closely related species, N. gonorrhoeae. The US_NmUC isolates were found to be highly resistant to the model AMP, polymyxin B (PmB, MICs 64-256 mug/ml). The isolates also demonstrated stable subpopulations of heteroresistant colonies that showed near total resistant to PmB (MICs 384-1024 mug/ml) and colistin (MIC 256 mug/ml) as well as enhanced LL-37 resistance. This is the first observation of heteroresistance in N. meningitidis. Consistent with previous findings, overall PmB resistance in US_NmUC isolates was due to active Mtr efflux and LptA-mediated lipid A modification. However, whole genome sequencing, variant analyses and directed mutagenesis revealed that the heteroresistance phenotypes and very high level AMP resistance were the result of point mutations and IS1655 element movement in the pilMNOPQ operon, encoding the type IV pilin biogenesis apparatus. Cross-resistance to other classes of antibiotics was also observed in the heteroresistant colonies. High-level resistance to AMPs may contribute to the pathogenesis of US_NmUC. This article is protected by copyright. All rights reserved.

    • Nutritional Sciences
    • Occupational Safety and Health
      • Lead exposure among workers at a shipyard – Wisconsin, 2015 to 2016External
        Weiss D, Baertlein LA, Yendell SJ, Christensen KY, Tomasallo CD, Creswell PD, Camponeschi JL, Meiman JG, Anderson HA.
        J Occup Environ Med. 2018 Oct;60(10):928-935.

        OBJECTIVE: In March 2016, the state health departments of Wisconsin and Minnesota learned of three shipyard workers with blood lead levels (BLLs) more than 40 mug/dL. An investigation was conducted to determine the extent of and risk factors for the exposure. METHODS: We defined a case as an elevated BLL more than or equal to 5 mug/dL in a shipyard worker. Workers were interviewed regarding their symptoms and personal protective equipment (PPE) use. RESULTS: Of 357 workers, 65.0% had received more than or equal to 1 BLL test. Among tested workers, 171 (73.7%) had BLLmax more than or equal to 5 mug/dL. Workers who received respirator training or fit testing had a median BLLmax of 18.0 mug/dL, similar to the median BLLmax of workers who did not receive such training (22.6 mug/dL, P = 0.20). CONCLUSIONS: Our findings emphasize the importance of adequate provision and use of PPE to prevent occupational lead exposure.

    • Physical Activity
      • Geographic and urban-rural differences in walking for leisure and transportationExternal
        Carlson SA, Whitfield GP, Peterson EL, Ussery EN, Watson KB, Berrigan D, Fulton JE.
        Am J Prev Med. 2018 Oct 18.

        INTRODUCTION: Walking can serve many purposes, such as transportation (to get some place) or leisure (for fun, relaxation, or exercise); therefore, it provides many opportunities for people to be physically active. This study examines geographic and urban-rural differences in walking in the U.S. METHODS: Adult respondents (aged >/=18 years) to the 2015 National Health Interview Survey reported participation in and time spent (minutes per week) walking for transportation and leisure in the past week. In 2017, prevalence and time spent walking (among walkers) for any, leisure, and transportation walking were estimated by nine expanded regions and urban-rural designation. RESULTS: Prevalence of any walking ranged from 50.8% (East South Central) to 72.4% (Pacific); for leisure walking 43.9% (East South Central) to 60.6% (Pacific); and transportation walking 17.8% (East South Central) to 43.5% (New England). Among walkers, mean minutes spent walking per week ranged from 77.4 (East South Central) to 101.6 (Pacific); for leisure walking 70.5 (West South Central) to 85.9 (Mountain); and for transportation walking 47.4 (East South Central) to 66.4 (Middle Atlantic). Overall, there were urban-rural differences in prevalence of walking; however, differences depended on walking purpose and expanded region. Time spent walking was similar in urban and rural areas. CONCLUSIONS: Regional differences in walking prevalence and time spent walking exist. Urban-rural differences in prevalence of walking differ based on region and purpose; however, rural areas had a lower prevalence of walking than urban areas regardless of purpose in southern regions. Opportunities exist to improve walking, particularly among southern regions with a focus on rural areas.

    • Substance Use and Abuse
      • Factors associated with obtaining sterile syringes from pharmacies among persons who inject drugs in 20 US citiesExternal
        Zlotorzynska M, Weidle PJ, Paz-Bailey G, Broz D.
        Int J Drug Policy. 2018 Oct 22;62:51-58.

        BACKGROUND: Increased access to sterile syringes has been shown to reduce HIV risk among people who inject drugs (PWID). Where syringe services programs (SSPs) are limited, pharmacies are an important sterile syringe source. We assessed factors associated with using pharmacies as the primary source of syringes among PWID from 20 US cities. METHODS: PWID ages >/=18 years were recruited for the 2015 National HIV Behavioral Surveillance using respondent-driven sampling. Using generalized estimating equation (GEE) models, we assessed demographic characteristics independently associated with participant-reported primary syringe source: pharmacies vs. SSPs. We calculated associations between primary syringe source and various behavioural outcomes, adjusted for participant characteristics. RESULTS: PWID who were <30 years old, female, white, and less frequent injectors were more likely have used pharmacies as their primary syringe source. Accessing syringes primarily from pharmacies, as compared to SSPs, was associated with receptive syringe sharing and unsafe syringe disposal; using sterile syringes, recent HIV testing and participation in an HIV behavioural intervention were negatively associated with primary pharmacy use. CONCLUSIONS: Pharmacies can play an important role in comprehensive HIV prevention among PWID. Linkage to HIV interventions and syringe disposal services at pharmacies could strengthen prevention efforts for PWID who cannot access or choose not to utilize SSPs.

  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. Adult leukemia survival trends in the United States by subtype: A population-based registry study of 370,994 patients diagnosed during 1995-2009External
        Bailey C, Richardson LC, Allemani C, Bonaventure A, Harewood R, Moore AR, Stewart SL, Weir HK, Coleman MP.
        Cancer. 2018 Oct 21.

        BACKGROUND: The lifetime risk of developing leukemia in the United States is 1.5%. There are challenges in the estimation of population-based survival using registry data because treatments and prognosis vary greatly by subtype. The objective of the current study was to determine leukemia survival estimates in the United States from 1995 to 2009 according to subtype, sex, geographical area, and race. METHODS: Five-year net survival was estimated using data for 370,994 patients from 43 registries in 37 states and in 6 metropolitan areas, covering approximately 81% of the adult (15-99 years) US population. Leukemia was categorized according to principal subtype (chronic lymphocytic leukemia, acute myeloid leukemia, and acute lymphocytic leukemia), and subcategorized in accordance with the HAEMACARE protocol. We analyzed age-standardized 5-year net survival by calendar period (1995-1999, 2000-2004, and 2005-2009), leukemia subtype, sex, race, and US state. RESULTS: The age-standardized 5-year net survival estimates increased from 45.0% for patients diagnosed during 1995-1999 to 49.0% for those diagnosed during 2000-2004 and 52.0% for those diagnosed during 2005-2009. For patients diagnosed during 2005-2009, 5-year survival was 18.2% (95% confidence interval [95% CI], 17.8%-18.6%) for acute myeloid leukemia, 44.0% (95% CI, 43.2%-44.8%) for acute lymphocytic leukemia, and 77.3% (95% CI, 76.9%-77.7%) for chronic lymphocytic leukemia. For nearly all leukemia subtypes, survival declined in successive age groups above 45 to 54 years. Men were found to have slightly lower survival than women; however, this discrepancy was noted to have fallen in successive calendar periods. Net survival was substantially higher in white than black patients in all calendar periods. There were large differences in survival noted between states and metropolitan areas. CONCLUSIONS: Survival from leukemia in US adults improved during 1995-2009. Some geographical differences in survival may be related to access to care. We found disparities in survival by sex and between black and white patients.

      2. Breast cancer risk among women under 55 years of age by joint effects of usage of oral contraceptives and hormone replacement therapyExternal
        Brinton LA, Brogan DR, Coates RJ, Swanson CA, Potischman N, Stanford JL.
        Menopause. 2018 Nov;25(11):1195-1200.

        OBJECTIVE: To assess effects on breast cancer risk of exposure to both oral contraceptives and menopausal hormones, an increasingly common exposure. DESIGN: A case-control study of breast cancer among women under the age of 55 years in Atlanta, GA involving 1,031 cases and 919 population controls was conducted. RESULTS: Ever use of oral contraceptives was associated with a relative risk of 1.1 (95% 0.9-1.4), whereas the relative risk for hormone replacement therapy was 0.9 (95% CI 0.7-1.2). Seventeen percent of the cases versus 19% of the population controls reported exposure to both agents, resulting in a relative risk of 1.0 (95% CI 0.7-1.4) relative to those unexposed to either preparation. Although there was little variation in risk associated with joint effects by either age or race, there were statistically nonsignificant elevations in risk for this exposure among women who had experienced a natural menopause (relative risk = 2.0, 95% CI 0.7-5.6), were relatively thin (relative risk = 1.5, 0.8-3.0), or who had a first degree relative with breast cancer (relative risk = 2.0, 0.6-7.0). When joint effects of longer term use of both agents were considered, subjects who reported use of oral contraceptives for 10 or more years and hormone replacement for 3 or more years had a relative risk of 3.2 (95% CI 1.4-7.4) compared with nonusers of either preparation. CONCLUSIONS: Although our results must be cautiously interpreted given small numbers within subgroups, they raise concern and emphasize the need for further evaluation on breast cancer risk of the increasingly common exposure to both oral contraceptives and hormone replacement therapy.

      3. Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and Hispanic men and womenExternal
        Buchanan Lunsford N, Berktold J, Holman DM, Stein K, Prempeh A, Yerkes A.
        Preventive Medicine Reports. 2018 December;12:203-209.

        Black and Hispanic populations perceive their skin cancer risk to be low and are less likely to use sun protection strategies. We conducted formative research to understand knowledge, awareness, beliefs, and behaviors among these groups. In 2017, eighteen focus groups were conducted with black and Hispanic respondents(18-44 years) in four US cities. Groups were segmented by participant characteristics associated with elevated or lower risk for skin cancer, by race/ethnicity, gender, and age. A professional moderator followed a semi-structured discussion guide, and focus group transcripts were analyzed using conventional content analysis and NVIVO 11 Software. Most participants perceived themselves to be at low skin cancer risk due to their “darker skin tone” and/or “lack of family history.” Skin cancer signs and symptoms were more inconsistently reported by blacks than Hispanics. Few participants reported regular sun protection behaviors. Those who did used sunscreen, wore protective clothing, and had elevated risk based on sun sensitivity or UV exposure. While most participants recalled family discussions (as youth) about sunscreen and sun protection, the understood intent was to warn against “further skin darkening” or to “prevent aging,” not to reduce sun burns or skin cancer risk. Tanning bed use was low across all segments, especially among black respondents. Tailored skin cancer prevention campaigns need to address misperceptions about risks and benefits of skin cancer prevention behaviors among black and Hispanic populations. Families, peer groups, and healthcare providers need to be engaged in the creation of educational interventions and messaging efforts that target these populations.

      4. Evaluation of patient-focused interventions to promote colorectal cancer screening among New York state Medicaid managed care patientsExternal
        Dacus HL, Wagner VL, Collins EA, Matson JM, Gates M, Hoover S, Tangka FK, Larkins T, Subramanian S.
        Cancer. 2018 Oct 25.

        BACKGROUND: The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population. METHODS: Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized. RESULTS: In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region. CONCLUSIONS: Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries. Cancer 2018;124:000-000.

      5. Shade as an environmental design tool for skin cancer preventionExternal
        Holman DM, Kapelos GT, Shoemaker M, Watson M.
        Am J Public Health. 2018 Oct 25:e1-e6.

        Little work has been done to explore the use of shade for skin cancer prevention in the context of the built environment. In an effort to address this gap and draw attention to the intersection between architectural and public health practice, we reviewed research on shade design, use, and policies published from January 1, 1996, through December 31, 2017. Our findings indicate that various features influence the sun-protective effects of shade, including the materials, size, shape, and position of the shade structure; the characteristics of the surrounding area; and weather conditions. Limited research suggests that shade provision in outdoor spaces may increase shade use. Shade audit and design tools are available to inform shade planning efforts. Shade policies to date have mostly been setting specific, and information on the implementation and effects of such policies is limited. Integrating shade planning into community design, planning, and architecture may have a substantial impact and will require a multidisciplinary approach. (Am J Public Health. Published online ahead of print October 25, 2018: e1-e6. doi:10.2105/AJPH.2018.304700).

      6. Physical function following a long-term lifestyle intervention among middle aged and older adults with type 2 diabetes: The Look AHEAD StudyExternal
        Houston DK, Neiberg RH, Miller ME, Hill JO, Jakicic JM, Johnson KC, Gregg EW, Hubbard VS, Pi-Sunyer X, Rejeski WJ, Wing RR, Bantle JP, Beale E, Berkowitz RI, Cassidy-Begay M, Clark JM, Coday M, Delahanty LM, Dutton G, Egan C, Foreyt JP, Greenway FL, Hazuda HP, Hergenroeder A, Horton ES, Jeffery RW, Kahn SE, Kure A, Knowler WC, Lewis CE, Martin CK, Michaels S, Montez MG, Nathan DM, Patricio J, Peters A, Pownall H, Regensteiner J, Steinburg H, Wadden TA, White K, Yanovski SZ, Zhang P, Kritchevsky SB.
        J Gerontol A Biol Sci Med Sci. 2018 Oct 8;73(11):1552-1559.

        Background: Lifestyle interventions have been shown to improve physical function over the short term; however, whether these benefits are sustainable is unknown. The long-term effects of an intensive lifestyle intervention (ILI) on physical function were assessed using a randomized post-test design in the Look AHEAD trial. Methods: Overweight and obese (body mass index >/= 25 kg/m2) middle-aged and older adults (aged 45-76 years at enrollment) with type 2 diabetes enrolled in Look AHEAD, a trial evaluating an ILI designed to achieve weight loss through caloric restriction and increased physical activity compared to diabetes support and education (DSE), underwent standardized assessments of performance-based physical function including a 4- and 400-m walk, lower extremity physical performance (expanded Short Physical Performance Battery, SPPBexp), and grip strength approximately 11 years postrandomization and 1.5 years after the intervention was stopped (n = 3,783). Results: Individuals randomized to ILI had lower odds of slow gait speed (<0.8 m/s) compared to those randomized to DSE (adjusted OR [95% CI]: 0.84 [0.71 to 0.99]). Individuals randomized to ILI also had faster gait speed over 4- and 400-m (adjusted mean difference [95% CI]: 0.019 [0.007 to 0.031] m/s, p = .002, and 0.023 [0.012 to 0.034] m/sec, p < .0001, respectively) and higher SPPBexp scores (0.037 [0.011 to 0.063], p = .005) compared to those randomized to DSE. The intervention effect was slightly larger for SPPBexp scores among older versus younger participants (0.081 [0.038 to 0.124] vs 0.013 [-0.021 to 0.047], p = .01). Conclusions: An intensive lifestyle intervention has modest but significant long-term benefits on physical function in overweight and obese middle-aged and older adults with type 2 diabetes. ClinicalTrials.gov Identifier: NCT00017953.

      7. Psychometric evaluation of the NIH Patient-Reported Outcomes Measurement Information System (PROMIS((R)) ) in a multi-racial, multi-ethnic systemic lupus erythematosus (SLE) cohortExternal
        Katz P, Yazdany J, Trupin L, Rush S, Helmick CG, Murphy LB, Lanata C, Criswell LA, Dall’Era M.
        Arthritis Care Res (Hoboken). 2018 Oct 24.

        BACKGROUND: We examined psychometric performance of PROMIS measures in a racially/ethnically, linguistically diverse SLE cohort. METHODS: Data were from the California Lupus Epidemiology Study (CLUES), a multi-racial/ethnic cohort of individuals with physician-confirmed SLE. The majority (n=332) attended in-person research visits that included interviews conducted in English, Spanish, Cantonese, or Mandarin. Up to 12 PROMIS short-forms were administered (depending on language availability). An additional 99 completed the interview by phone only. Internal consistency was examined with Cronbach’s alpha and item-total correlations. Correlations with SF-36 subscales and both self-reported and physician-assessed disease activity assessed convergent validity. All analyses were repeated within each racial/ethnic group. Differences in scores by race/ethnicity were examined in bivariate analyses and by multiple regression analyses controlling for age, sex, disease duration, and disease damage and activity. RESULTS: The total sample was 30.0% white, 22.3% Hispanic, 10.9% Black, 33.7% Asian, and 3.0% other race/ethnicity. 77.0% of interviews were conducted in-person. Among Hispanics and Asians, 26.0% and 18.6%, respectively, were non-English interviews. Each scale demonstrated adequate reliability and validity overall and within racial/ethnic groups. Minimal floor effects were observed, but ceiling effects were noted. Missing item responses were minimal for most scales, except for items related to work. No differences were noted by mode of administration or by language of administration among Hispanics and Asians. After accounting for differences in disease status, age, and sex, few differences in mean scores between whites and other racial/ethnic groups were noted. CONCLUSION: PROMIS measures appear reliable and valid in lupus across racial/ethnic groups. This article is protected by copyright. All rights reserved.

      8. The importance of addressing depression and diabetes distress in adults with type 2 diabetesExternal
        Owens-Gary MD, Zhang X, Jawanda S, Bullard KM, Allweiss P, Smith BD.
        J Gen Intern Med. 2018 Oct 22.

        People with type 2 diabetes often experience two common mental health conditions: depression and diabetes distress. Both increase a patient’s risk for mortality, poor disease management, diabetes-related complications, and poor quality of life. The American Diabetes Association and the U.S. Preventive Services Task Force recommend routine evaluations for these conditions in adults for optimal disease management and prevention of life-threatening complications. However, barriers exist within primary care and specialty settings that make screening for depression and diabetes distress challenging. Depression and diabetes distress influence diabetes self-care and diabetes control and barriers in clinical care practice that can hinder detection and management of psychosocial issues in diabetes care. This paper highlights opportunities to increase mental health screenings and provides strategies to help providers address depression and diabetes distress in patients with type 2 diabetes.

      9. A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening programExternal
        Subramanian S, Hoover S, Tangka FK, DeGroff A, Soloe CS, Arena LC, Schlueter DF, Joseph DA, Wong FL.
        Cancer. 2018 Oct 25.

        BACKGROUND: Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS: The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention’s Colorectal Cancer Control Program. RESULTS: Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS: Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality. Cancer 2018;124:000-000.

      10. [No abstract]

      11. Modeling the impact of obesity on the lifetime risk of chronic kidney disease in the United States using updated estimates of GFR progression from the CRIC studyExternal
        Yarnoff BO, Hoerger TJ, Shrestha SS, Simpson SK, Burrows NR, Anderson AH, Xie D, Chen HY, Pavkov ME.
        PLoS One. 2018 ;13(10):e0205530.

        RATIONALE & OBJECTIVE: As the prevalence of obesity continues to rise in the United States, it is important to understand its impact on the lifetime risk of chronic kidney disease (CKD). STUDY DESIGN: The CKD Health Policy Model was used to simulate the lifetime risk of CKD for those with and without obesity at baseline. Model structure was updated for glomerular filtration rate (GFR) decline to incorporate new longitudinal data from the Chronic Renal Insufficiency Cohort (CRIC) study. SETTING AND POPULATION: The updated model was populated with a nationally representative cohort from National Health and Nutrition Examination Survey (NHANES). OUTCOMES: Lifetime risk of CKD, highest stage and any stage. MODEL, PERSPECTIVE, & TIMEFRAME: Simulation model following up individuals from current age through death or age 90 years. RESULTS: Lifetime risk of any CKD stage was 32.5% (95% CI 28.6%-36.3%) for persons with normal weight, 37.6% (95% CI 33.5%-41.7%) for persons who were overweight, and 41.0% (95% CI 36.7%-45.3%) for persons with obesity at baseline. The difference between persons with normal weight and persons with obesity at baseline was statistically significant (p<0.01). Lifetime risk of CKD stages 4 and 5 was higher for persons with obesity at baseline (Stage 4: 2.1%, 95% CI 0.9%-3.3%; stage 5: 0.6%, 95% CI 0.0%-1.1%), but the differences were not statistically significant (stage 4: p = 0.08; stage 5: p = 0.23). LIMITATIONS: Due to limited data, our simulation model estimates are based on assumptions about the causal pathways from obesity to CKD, diabetes, and hypertension. CONCLUSIONS: The results of this study indicate that obesity may have a large impact on the lifetime risk of CKD. This is important information for policymakers seeking to set priorities and targets for CKD prevention and treatment.

      12. Effect of health information technologies on glycemic control among patients with type 2 diabetesExternal
        Yoshida Y, Boren SA, Soares J, Popescu M, Nielson SD, Simoes EJ.
        Curr Diab Rep. 2018 Oct 18;18(12):130.

        PURPOSE OF REVIEW: This study was to present meta-analysis findings across selected clinical trials for the effect of health information technologies (HITs) on glycemic control among patients with type 2 diabetes. RECENT FINDINGS: HITs may be promising in diabetes management. However, findings on effect size of glycated hemoglobin level (HbA1c) yielded from HITs varied across previous studies. This is likely due to heterogeneity in sample size, adherence to standard quantitative method, and/or searching criteria (e.g., type of HITs, type of diabetes, specification of patient population, randomized vs. nonrandomized trials). We systematically searched Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane Library for peer-reviewed randomized control trials that studied the effect of HITs on HbA1c reduction. We also used Google Scholar and a hand search to identify additional studies. Thirty-four studies (40 estimates) met the criteria and were included in the analysis. Overall, introduction of HITs to standard diabetes treatment resulted in a statistically and clinically reduced HbA1c. The bias adjusted HbA1c reduction due to the combined HIT interventions was – 0.56 [Hedges’ g = – 0.56 (- 0.70, – 0.43)]. The reduction was significant across each of the four types of HIT intervention under review, with mobile phone-based approaches generating the largest effects [Hedges’ g was – 0.67 (- 0.90, – 0.45)]. HITs can be an effective tool for glycemic control among patients with type 2 diabetes. Future studies should examine long-term effects of HITs and explore factors that influence their effectiveness.

    • Communicable Diseases
      1. Estimating weekly call volume to a national nurse telephone triage line in an influenza pandemicExternal
        Adhikari BB, Koonin LM, Mugambi ML, Sliger KD, Washington ML, Kahn EB, Meltzer MI.
        Health Secur. 2018 Sep/Oct;16(5):334-340.

        Telephone nurse triage lines, such as the Centers for Disease Control and Prevention’s (CDC) Flu on Call((R)), a national nurse triage line, may help reduce the surge in demand for health care during an influenza pandemic by triaging callers, providing advice about clinical care and information about the pandemic, and providing access to prescription antiviral medication. We developed a Call Volume Projection Tool to estimate national call volume to Flu on Call((R)) during an influenza pandemic. The tool incorporates 2 influenza clinical attack rates (20% and 30%), 4 different levels of pandemic severity, and different initial “seed numbers” of cases (10 or 100), and it allows variation in which week the nurse triage line opens. The tool calculates call volume by using call-to-hospitalization ratios based on pandemic severity. We derived data on nurse triage line calls and call-to-hospitalization ratios from experience with the 2009 Minnesota FluLine nurse triage line. Assuming a 20% clinical attack rate and a case hospitalization rate of 0.8% to 1.5% (1968-like pandemic severity), we estimated the nationwide number of calls during the peak week of the pandemic to range from 1,551,882 to 3,523,902. Assuming a more severe 1957-like pandemic (case hospitalization rate = 1.5% to 3.0%), the national number of calls during the peak week of the pandemic ranged from 2,909,778 to 7,047,804. These results will aid in planning and developing nurse triage lines at both the national and state levels for use during a future influenza pandemic.

      2. The national and provincial burden of medically attended influenza-associated influenza-like illness and severe acute respiratory illness in the Democratic Republic of Congo, 2013-2015External
        Babakazo P, Lubula L, Disasuani W, Manya LK, Nkwembe E, Mitongo N, Kavunga-Membo H, Changachanga JC, Muhemedi S, Ilunga BK, Wemakoy EO, Tamfum JM, Kabamba-Tshilobo J, Tempia S.
        Influenza Other Respir Viruses. 2018 Nov;12(6):695-705.

        BACKGROUND: Estimates of influenza-associated outpatient consultations and hospitalizations are severely limited in low- and middle-income countries, especially in Africa. METHODS: We conducted active prospective surveillance for influenza-like illness (ILI) and severe acute respiratory illness (SARI) at 5 healthcare facilities situated in Kinshasa Province during 2013-2015. We tested upper respiratory tract samples for influenza viruses using a reverse transcription-polymerase chain reaction assay. We estimated age-specific numbers and rates of influenza-associated ILI outpatient consultations and SARI hospitalizations for Kinshasa Province using a combination of administrative and influenza surveillance data. These estimates were extrapolated to each of the remaining 10 provinces accounting for provincial differences in prevalence of risk factors for pneumonia and healthcare-seeking behavior. Rates were reported per 100 000 population. RESULTS: During 2013-2015, the mean annual national number of influenza-associated ILI outpatient consultations was 1 003 212 (95% Confidence Incidence [CI]: 719 335-1 338 050 – Rate: 1205.3; 95% CI: 864.2-1607.5); 199 839 (95% CI: 153 563-254 759 – Rate: 1464.0; 95% CI: 1125.0-1866.3) among children aged <5 years and 803 374 (95% CI: 567 772-1 083 291 – Rate: 1154.5; 95% CI: 813.1-1556.8) among individuals aged >/=5 years. The mean annual national number of influenza-associated SARI hospitalizations was 40 361 (95% CI: 24 014-60 514 – Rate: 48.5; 95% CI: 28.9-72.7); 25 452 (95% CI: 19 146-32 944 – Rate: 186.5; 95% CI: 140.3-241.3) among children aged <5 years and 14 909 (95% CI: 4868-27 570 – Rate: 21.4; 95% CI: 28.9-72.7) among individuals aged >/=5 years. CONCLUSIONS: The burden of influenza-associated ILI outpatient consultations and SARI hospitalizations was substantial and was highest among hospitalized children aged <5 years.

      3. Where do people go for gonorrhea and chlamydia tests: A cross-sectional view of the central Indiana population, 2003-2014External
        Batteiger TA, Dixon BE, Wang J, Zhang Z, Tao G, Tong Y, Tu W, Hoover SA, Arno JN.
        Sex Transm Dis. 2018 Oct 16.

        BACKGROUND: Despite major efforts to control their spread, reported sexually transmitted infections (STI) are increasing. Using data from a mid-sized Midwest metropolitan area, we examined the settings in which individuals are tested for gonorrhea and chlamydia in relation to demographics and test result to determine where interventions may best be focused. METHODS: A de-identified and integrated registry, containing records from all patients tested for an STI from 2003-2014, was created by combining data from a large health information exchange and the reporting district’s STI Program located in Indianapolis, IN. Individual characteristics and visit settings where gonorrhea and chlamydia testing was performed were analyzed. RESULTS: We identified 298,946 individuals with 1,062,369 visits where testing occurred at least once between the ages of 13 and 44 years. Females were tested significantly more often than males and received testing more often in outpatient clinics whereas males were most often tested in the STI clinic. Individuals who utilized both STI and non-STI settings were more likely to have a positive test at an STI or ED visit (6.4% – 20.8%) than outpatient or inpatient setting (0.0-11.3%) (p<.0001). Test visits increased over the study period particularly in emergency departments, which showed a substantial increase in the number of positive test visits. CONCLUSIONS: The most frequent testing sites remain STI clinics for men and outpatient clinics for women. Yet, emergency departments are increasingly a source of testing and morbidity. This makes them a valuable target for public health interventions that could improve care and population health.

      4. Sensitivity of joint contagiousness and susceptibility-based dynamic optimal control strategies for HIV preventionExternal
        Bulla I, Spickanll IH, Gromov D, Romero-Severson EO.
        PLoS One. 2018 ;13(10):e0204741.

        Predicting the population-level effects of an infectious disease intervention that incorporate multiple modes of intervention is complicated by the joint non-linear dynamics of both infection transmission and the intervention itself. In this paper, we consider the sensitivity of Dynamic Optimal Control Profiles (DOCPs) for the optimal joint investment in both a contagiousness and susceptibility-based control of HIV to bio-behavioral, economic, and programmatic assumptions. The DOCP is calculated using recently developed numerical algorithms that allow controls to be represented by a set of piecewise constant functions that maintain a constant yearly budget. Our transmission model assumes multiple stages of HIV infection corresponding to acute and chronic infection and both within- and between-individual behavioral heterogeneity. We parameterize a baseline scenario from a longitudinal study of sexual behavior in MSM and consider sensitivity of the DOCPs to deviations from that baseline scenario. In the baseline scenario, the primary determinant of the dominant control were programmatic factors, regardless of budget. In sensitivity analyses, the qualitative aspects of the optimal control policy were often robust to significant deviation in assumptions regarding transmission dynamics. In addition, we found several conditions in which long-term joint investment in both interventions was optimal. Our results suggest that modeling in the service of decision support for intervention design can improve population-level effects of a limited set of economic resources. We found that economic and programmatic factors were as important as the inherent transmission dynamics in determining population-level intervention effects. Given our finding that the DOCPs were robust to alternative biological and behavioral assumptions it may be possible to identify DOCPs even when the data are not sufficient to identify a transmission model.

      5. Update: Influenza activity – United States and worldwide, May 20-October 13, 2018External
        Chow EJ, Davis CT, Abd Elal AI, Alabi N, Azziz-Baumgartner E, Barnes J, Blanton L, Brammer L, Budd AP, Burns E, Davis WW, Dugan VG, Fry AM, Garten R, Grohskopf LA, Gubareva L, Jang Y, Jones J, Kniss K, Lindstrom S, Mustaquim D, Porter R, Rolfes M, Sessions W, Taylor C, Wentworth DE, Xu X, Zanders N, Katz J, Jernigan D.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 26;67(42):1178-1185.

        During May 20-October 13, 2018,* low levels of influenza activity were reported in the United States, with a mix of influenza A and B viruses circulating. Seasonal influenza activity in the Southern Hemisphere was low overall, with influenza A(H1N1)pdm09 predominating in many regions. Antigenic testing of available influenza A and B viruses indicated that no significant antigenic drift in circulating viruses had emerged. In late September, the components for the 2019 Southern Hemisphere influenza vaccine were selected and included an incremental update to the A(H3N2) vaccine virus used in egg-based vaccine manufacturing; no change was recommended for the A(H3N2) component of cell-manufactured or recombinant influenza vaccines. Annual influenza vaccination is the best method for preventing influenza illness and its complications, and all persons aged >/=6 months who do not have contraindications should receive influenza vaccine, preferably before the onset of influenza circulation in their community, which often begins in October and peaks during December-February. Health care providers should offer vaccination by the end of October and should continue to recommend and administer influenza vaccine to previously unvaccinated patients throughout the 2018-19 influenza season (1). In addition, during May 20-October 13, a small number of nonhuman influenza “variant” virus infections(dagger) were reported in the United States; most were associated with exposure to swine. Although limited human-to-human transmission might have occurred in one instance, no ongoing community transmission was identified. Vulnerable populations, especially young children and other persons at high risk for serious influenza complications, should avoid swine barns at agricultural fairs, or close contact with swine.

      6. Clinical features and outcomes of immunocompromised children hospitalized with laboratory-confirmed influenza in the United States, 2011-2015External
        Collins JP, Campbell AP, Openo K, Farley MM, Cummings CN, Kirley PD, Herlihy R, Yousey-Hindes K, Monroe ML, Ladisky M, Lynfield R, Baumbach J, Spina N, Bennett N, Billing L, Thomas A, Schaffner W, Price A, Garg S, Anderson EJ.
        J Pediatric Infect Dis Soc. 2018 Oct 25.

        Background: Existing data on the clinical features and outcomes of immunocompromised children with influenza are limited. Methods: Data from the 2011-2012 through 2014-2015 influenza seasons were collected as part of the Centers for Disease Control and Prevention (CDC) Influenza Hospitalization Surveillance Network (FluSurv-NET). We compared clinical features and outcomes between immunocompromised and nonimmunocompromised children (<18 years old) hospitalized with laboratory-confirmed community-acquired influenza. Immunocompromised children were defined as those for whom >/=1 of the following applies: human immunodeficiency virus/acquired immunodeficiency syndrome, cancer, stem cell or solid organ transplantation, nonsteroidal immunosuppressive therapy, immunoglobulin deficiency, complement deficiency, asplenia, and/or another rare condition. The primary outcomes were intensive care admission, duration of hospitalization, and in-hospital death. Results: Among 5262 hospitalized children, 242 (4.6%) were immunocompromised; receipt of nonsteroidal immunosuppressive therapy (60%), cancer (39%), and solid organ transplantation (14%) were most common. Immunocompromised children were older than the nonimmunocompromised children (median, 8.8 vs 2.8 years, respectively; P < .001), more likely to have another comorbidity (58% vs 49%, respectively; P = .007), and more likely to have received an influenza vaccination (58% vs 39%, respectively; P < .001) and early antiviral treatment (35% vs 27%, respectively; P = .013). In multivariable analyses, immunocompromised children were less likely to receive intensive care (adjusted odds ratio [95% confidence interval], 0.31 [0.20-0.49]) and had a slightly longer duration of hospitalization (adjusted hazard ratio of hospital discharge [95% confidence interval], 0.89 [0.80-0.99]). Death was uncommon in both groups. Conclusions: Immunocompromised children hospitalized with influenza received intensive care less frequently but had a longer hospitalization duration than nonimmunocompromised children. Vaccination and early antiviral use could be improved substantially. Data are needed to determine whether immunocompromised children are more commonly admitted with milder influenza severity than are nonimmunocompromised children.

      7. The impact of Hurricane Sandy on HIV testing rates: An interrupted time series analysis, January 1, 2011 – December 31, 2013External
        Ekperi LI, Thomas E, LeBlanc TT, Adams EE, Wilt GE, Molinari NA, Carbone EG.
        PLoS Curr. 2018 Sep 13;10.

        BACKGROUND: Hurricane Sandy made landfall on the eastern coast of the United States on October 29, 2012 resulting in 117 deaths and 71.4 billion dollars in damage. Persons with undiagnosed HIV infection might experience delays in diagnosis testing, status confirmation, or access to care due to service disruption in storm-affected areas. The objective of this study is to describe the impact of Hurricane Sandy on HIV testing rates in affected areas and estimate the magnitude and duration of disruption in HIV testing associated with storm damage intensity. METHODS: Using MarketScan data from January 2011December 2013, this study examined weekly time series of HIV testing rates among privately insured enrollees not previously diagnosed with HIV; 95 weeks pre- and 58 weeks post-storm. Interrupted time series (ITS) analyses were estimated by storm impact rank (using FEMA’s Final Impact Rank mapped to Core Based Statistical Areas) to determine the extent that Hurricane Sandy affected weekly rates of HIV testing immediately and the duration of that effect after the storm. RESULTS: HIV testing rates declined significantly across storm impact rank areas. The mean decline in rates detected ranged between -5% (95% CI: -9.3, -1.5) in low impact areas and -24% (95% CI: -28.5, -18.9) in very high impact areas. We estimated at least 9,736 (95% CI: 7,540, 11,925) testing opportunities were missed among privately insured persons following Hurricane Sandy. Testing rates returned to baseline in low impact areas by 6 weeks post event (December 9, 2012); by 15 weeks post event (February 10, 2013) in moderate impact areas; and by 17 weeks after the event (February 24, 2013) in high and very high impact areas. CONCLUSIONS: Hurricane Sandy resulted in a detectable and immediate decline in HIV testing rates across storm-affected areas. Greater storm damage was associated with greater magnitude and duration of testing disruption. Disruption of basic health services, like HIV testing and treatment, following large natural and man-made disasters is a public health concern. Disruption in testing services availability for any length of time is detrimental to the efforts of the current HIV prevention model, where status confirmation is essential to control disease spread.

      8. Integrating standardized whole genome sequence analysis with a global Mycobacterium tuberculosis antibiotic resistance knowledgebaseExternal
        Ezewudo M, Borens A, Chiner-Oms A, Miotto P, Chindelevitch L, Starks AM, Hanna D, Liwski R, Zignol M, Gilpin C, Niemann S, Kohl TA, Warren RM, Crook D, Gagneux S, Hoffner S, Rodrigues C, Comas I, Engelthaler DM, Alland D, Rigouts L, Lange C, Dheda K, Hasan R, McNerney R, Cirillo DM, Schito M, Rodwell TC, Posey J.
        Sci Rep. 2018 Oct 18;8(1):15382.

        Drug-resistant tuberculosis poses a persistent public health threat. The ReSeqTB platform is a collaborative, curated knowledgebase, designed to standardize and aggregate global Mycobacterium tuberculosis complex (MTBC) variant data from whole genome sequencing (WGS) with phenotypic drug susceptibility testing (DST) and clinical data. We developed a unified analysis variant pipeline (UVP) ( https://github.com/CPTR-ReSeqTB/UVP ) to identify variants and assign lineage from MTBC sequence data. Stringent thresholds and quality control measures were incorporated in this open source tool. The pipeline was validated using a well-characterized dataset of 90 diverse MTBC isolates with conventional DST and DNA Sanger sequencing data. The UVP exhibited 98.9% agreement with the variants identified using Sanger sequencing and was 100% concordant with conventional methods of assigning lineage. We analyzed 4636 publicly available MTBC isolates in the ReSeqTB platform representing all seven major MTBC lineages. The variants detected have an above 94% accuracy of predicting drug based on the accompanying DST results in the platform. The aggregation of variants over time in the platform will establish confidence-graded mutations statistically associated with phenotypic drug resistance. These tools serve as critical reference standards for future molecular diagnostic assay developers, researchers, public health agencies and clinicians working towards the control of drug-resistant tuberculosis.

      9. Staffing reductions in state and local health departments in fiscal year 2012 were concentrated in disease investigation specialists and clinicians (local) and disease investigation specialists and administrative staff (state). Local health departments with budget cuts were significantly more likely to report reduced partner services if they had staffing reductions.

      10. Association of male circumcision with women’s knowledge of its biomedical effects and with their sexual satisfaction and function: A systematic reviewExternal
        Grund JM, Bryant TS, Toledo C, Jackson I, Curran K, Zhou S, Del Campo JM, Yang L, Kivumbi A, Li P, Bock N, Taliano J, Davis SM.
        AIDS Behav. 2018 Oct 24.

        Male circumcision (MC) is a key HIV prevention intervention for men in countries with high HIV prevalence. Women’s understanding of MC is important but poorly understood. We conducted a systematic review including women’s knowledge of MC’s biomedical impacts and its association with female sexual satisfaction and function through October 2017. Thirty-eight articles were identified: thirty-two with knowledge outcomes, seven with sexual satisfaction, and four with sexual function (N = 38). Respondent proportions aware MC protects men from HIV were 9.84-91.8% (median 60.0%). Proportions aware MC protects men from STIs were 14.3-100% (72.6%). Proportions aware MC partially protects men from HIV were 37.5-82% (50.7%). Proportions aware MC is not proven to protect women from infection by an HIV-positive partner were 90.0-96.8% (93.0%). No increases over time were noted. Women’s MC knowledge is variable. Education could help women support MC and make better-informed sexual decisions.

      11. Epidemiologic and genotypic distribution of noroviruses among children with acute diarrhea and healthy controls in a low-income rural settingExternal
        Hossain ME, Rahman R, Ali SI, Islam MM, Rahman MZ, Ahmed S, Faruque AS, Barclay L, Vinje J, Rahman M.
        Clin Infect Dis. 2018 Oct 23.

        Background: Noroviruses are the most common cause of epidemic and endemic acute gastroenteritis (AGE) worldwide. The burden of norovirus disease in low-income settings is poorly understood. Methods: We tested stool samples from children less than 5 years of age with diarrhea who were admitted in a rural hospital in Bangladesh from 2010-2012 and from matched healthy controls from the same catchment area. Results: Norovirus was detected in 109 (18%) of 613 children with diarrhea and in 30 (15%) of 206 healthy controls. Most (n=118; 85%) norovirus infections belonged to genogroup II (GII). Of these, GII.4 viruses were identified in 36 (33%) of the cases and in 6 (21%) of the controls. Other major genotypes included GII.3 (13%), GII.6 (11%), and GII.13 (11%) in cases and GII.6 (17%) and GII.2 (14%) in controls. Greatest risk of severe norovirus disease (Vesikari score >/=11) was associated to GII.4 infections. GII.4 viruses were the predominant genotype detected during the winter (55%) and rainy season (23%) while GII.3 (19%) and GII.13 (19%) viruses were the most prevalent genotypes during the summer. Vomiting was significantly associated with GII.4 infection, while longer duration of diarrhea with GI.3 infection. Conclusions: Future studies are needed to understand the high rates of virus shedding in children without AGE symptoms.

      12. HIV preexposure prophylaxis, by race and ethnicity – United States, 2014-2016External
        Huang YA, Zhu W, Smith DK, Harris N, Hoover KW.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1147-1150.

        Preexposure prophylaxis (PrEP) with a daily, oral pill containing antiretroviral drugs is highly effective in preventing acquisition of human immunodeficiency virus (HIV) infection (1-4). The combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) is the only medication approved by the Food and Drug Administration (FDA) for PrEP. PrEP is indicated for men and women with sexual or injection drug use behaviors that increase their risk for acquiring HIV (5). CDC analyzed 2014-2016 data from the IQVIA Real World Data – Longitudinal Prescriptions (IQVIA database) to estimate the number of persons prescribed PrEP (users) in the United States and to describe their demographic characteristics, including sex and race/ethnicity. From 2014 to 2016, the annual number of PrEP users aged >/=16 years increased by 470%, from 13,748 to 78,360. In 2016, among 32,853 (41.9%) PrEP users for whom race/ethnicity data were available, 68.7% were white, 11.2% were African American or black (black), 13.1% were Hispanic, and 4.5% were Asian. Approximately 7% of the estimated 1.1 million persons who had indications for PrEP were prescribed PrEP in 2016, including 2.1% of women with PrEP indications (6). Although black men and women accounted for approximately 40% of persons with PrEP indications (6), this study found that nearly six times as many white men and women were prescribed PrEP as were black men and women. The findings of this study highlight gaps in effective PrEP implementation efforts in the United States.

      13. Increasing protection of dialysis patients against influenzaExternal
        Lindley MC, Kim DK.
        Clin J Am Soc Nephrol. 2018 Oct 23.

        [No abstract]

      14. Mumps outbreak in a Marshallese community – Denver Metropolitan Area, Colorado, 2016-2017External
        Marx GE, Burakoff A, Barnes M, Hite D, Metz A, Miller K, Davizon ES, Chase J, McDonald C, McClean M, Miller L, Albanese BA.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1143-1146.

        In January 2017, the Colorado Department of Public Health and Environment (CDPHE) identified four epidemiologically linked cases of mumps among persons from a Marshallese community who were members of the same church in the Denver metropolitan area. During 2016-2017, sizable outbreaks of mumps reported in Arkansas, Hawaii, and Washington also affected the Marshallese population (1). CDPHE, the Tri-County Health Department (TCHD), and Denver Public Health collaborated to conduct an outbreak investigation during January-March 2017 using active and passive surveillance that identified 17 confirmed and 30 probable cases. Public health actions included conducting measles-mumps-rubella (MMR) vaccination clinics at local Marshallese churches; these resulted in the vaccination of 126 persons with >/=1 doses of MMR vaccine. Implementation of active surveillance and support from local Marshallese church leaders in promoting vaccination programs likely contributed to interruption of the outbreak.

      15. Cross-sectional estimates revealed high HIV incidence in Botswana rural communities in the era of successful ART scale-up in 2013-2015External
        Moyo S, Gaseitsiwe S, Mohammed T, Pretorius Holme M, Wang R, Kotokwe KP, Boleo C, Mupfumi L, Yankinda EK, Chakalisa U, van Widenfelt E, Gaolathe T, Mmalane MO, Dryden-Peterson S, Mine M, Lebelonyane R, Bennett K, Leidner J, Wirth KE, Tchetgen Tchetgen E, Powis K, Moore J, Clarke WA, Lockman S, Makhema JM, Essex M, Novitsky V.
        PLoS One. 2018 ;13(10):e0204840.

        BACKGROUND: Botswana is close to reaching the UNAIDS “90-90-90” HIV testing, antiretroviral treatment (ART), and viral suppression goals. We sought to determine HIV incidence in this setting with both high HIV prevalence and high ART coverage. METHODS: We used a cross-sectional approach to assessing HIV incidence. A random, population-based sample of adults age 16-64 years was enrolled in 30 rural and peri-urban communities as part of the Botswana Combination Prevention Project (BCPP), from October 2013 -November 2015. Data and samples from the baseline household survey were used to estimate cross-sectional HIV incidence, following an algorithm that combined Limiting-Antigen Avidity Assay (LAg-Avidity EIA), ART status (documented or by testing ARV drugs in plasma) and HIV-1 RNA load. The LAg-Avidity EIA cut-off normalized optical density (ODn) was set at 1.5. The HIV-1 RNA cut-off was set at 400 copies/mL. For estimation purposes, the Mean Duration of Recent Infection was 130 days and the False Recent Rate (FRR) was evaluated at values of either 0 or 0.39%. RESULTS: Among 12,610 individuals participating in the baseline household survey, HIV status was available for 12,570 participants and 3,596 of them were HIV positive. LAg-Avidity EIA data was generated for 3,581 (99.6%) of HIV-positive participants. Of 326 participants with ODn </=1.5, 278 individuals were receiving ART verified through documentation and were considered to represent longstanding HIV infections. Among the remaining 48 participants who reported no use of ART, 14 had an HIV-1 RNA load </=400 copies/mL (including 3 participants with ARVs in plasma) and were excluded, as potential elite/viremic controllers or undisclosed ART. Thus, 34 LAg-Avidity-EIA-recent, ARV-naive individuals with detectable HIV-1 RNA (>400 copies/mL) were classified as individuals with recent HIV infections. The annualized HIV incidence among 16-64 year old adults was estimated at 1.06% (95% CI 0.68-1.45%) with zero FRR, and at 0.64% (95% CI 0.24-1.04%) using a previously defined FRR of 0.39%. Within a subset of younger individuals 16-49 years old, the annualized HIV incidence was estimated at 1.29% (95% CI 0.82-1.77%) with zero FRR, and at 0.90% (95% CI 0.42-1.38%) with FRR set to 0.39%. CONCLUSIONS: Using a cross-sectional estimate of HIV incidence from 2013-2015, we found that at the time of near achievement of the UNAIDS 90-90-90 targets, ~1% of adults (age 16-64 years) in Botswana’s rural and peri-urban communities became HIV infected annually.

      16. Complexities and dilemmas in community consultation on the design of a research project logo in MalawiExternal
        Nyirenda D, Gooding K, Lora W, Kumwenda M, McMorrow M, Everett D, Desmond N.
        PLoS One. 2018 ;13(10):e0205737.

        BACKGROUND: Community engagement on research design is widely highlighted as an important approach for ethical research. This article reports the experience of consulting with communities on the logo used for an influenza study in Malawi. The logo was designed for use on badges worn by study researchers, participant information sheets and other project documents, and could affect perceptions of the study and consequent engagement in the research. METHODS: Four focus group discussions were conducted with populations targeted by the influenza study: pregnant women, people with HIV, mothers and community members. The focus groups incorporated a participatory matrix exercise focusing on key themes emerging from the discussions such as: attractiveness, comprehension, acceptability and suggestions for improvement. Findings from the focus groups were analyzed according to these key themes. RESULTS: The consultation highlighted important benefits of discussion with communities on research design, including providing new perspectives and helping to avoid harm. For example, people living with HIV felt that one of the possible logos could increase stigma within communities. The experience also indicated potential challenges of consultation. In particular, there were contrasting perspectives among the groups, such that the consultation did not provide a clear answer about which logo should be selected. CONCLUSIONS: Our experience adds to current evidence on community engagement by reporting on an area where there is less discussion of community consultation for design of a study logo. The consultation exercise reaffirmed the value of community engagement, but also the difficulty of relying on a brief consultation for decision-making in research design. Further ethical guidance is required on how to negotiate contradictory views during consultations.

      17. Community perceptions and personal accounts of HIV discordance in rural western KenyaExternal
        Ondenge K, Odero I, Awuonda E, Omoro T, Kibogo M, Otieno G, Ongwena P, Gust DA.
        Afr J AIDS Res. 2018 Sep;17(3):281-290.

        Among HIV-discordant couples, the literature is sparse regarding issues related to stigma, relationships and coping. Objectives were to explore: 1) perceptions about discordant HIV status; 2) understanding of HIV discordancy; 3) effects of discordancy on couples; and 4) adaptation and coping strategies for discordant HIV status. A survey was administered to 202 members of heterosexual discordant couples in rural western Kenya. In addition, to understand the community perspective, in-depth interviews (IDI) (n = 26) and focus group discussions (FGD) (n = 10) were conducted with community opinion leaders, healthcare workers and members of discordant couples. More than 70% of men (73.4%) and women (80.4%) surveyed agreed that their relationship changed for the worse when they disclosed their HIV status to their partner. Participants of IDIs and FGDs provided several explanations for discordancy including the perception that discordancy is a lie, the negative partner has “thick blood”, HIV infection is a punishment for sexual promiscuity or cultural disobedience, and that HIV is a punishment from God. Members of discordant couples reported experiencing tension and fear, stigma and rejection, and changes in partner support. Adaptation and coping strategies included counselling, sero-sorting and pursuing concordancy with the uninfected partner. HIV discordancy in a relationship can potentially cause long-term negative emotional and physical consequences. There is an acute need to develop and disseminate locally sensitive HIV-discordant couple counselling messages, and to provide couple-centred HIV care and treatment. Communication can help couples rebuild and rebalance their relationship and adjust to a new normal.

      18. Completeness of patient-held records: observations of the Road-to-Health Booklet from two national facility-based surveys at 6 weeks postpartum, South AfricaExternal
        Ramraj T, Goga AE, Larsen A, Ramokolo V, Bhardwaj S, Chirinda W, Jackson D, Nsibande D, Ayalew K, Pillay Y, Lombard CJ, Ngandu NK.
        J Glob Health. 2018 Dec;8(2):020901.

        Background: Continuity of care is important for child well-being in all settings where postnatal retention of mother-infant pairs in care remains a challenge. This analysis reports on completeness of patient-held infant Road to Health Booklets (RtHBs), amongst HIV exposed and unexposed infants during the first two years after the RtHB was launched country-wide in South Africa. Methods: Secondary data were analysed from two nationally representative, cross-sectional surveys, conducted in 2011-12 and 2012-13. These surveys aimed to measure early effectiveness of the national programme for preventing vertical HIV transmission. Participants were eligible for this analysis if they were 4-8 weeks old, receiving their six-week immunisation, not needing emergency care and had their RtHBs reviewed. Caregivers were interviewed and data abstracted from RtHBs. RtHB completeness across both surveys was defined as the proportion of RtHBs with any of the following indicators recorded: infant birth weight, BCG immunisation, maternal syphilis results and maternal HIV status. A partial proportional odds logistic regression model was used to identify factors associated with completeness. Survey sampling weights were included in all analyses. Results: Data from 10 415 (99.6%) participants in 2011-12 and 9529 (99.2%) in 2012-13 were analysed. Overall, recording of all four indicators increased from 23.1% (95% confidence interval (CI) = 22.2-24.0) in 2011-12 to 43.3% (95% CI = 42.3-44.4) in 2012-13. In multivariable models, expected RtHB completeness (ie, recording all four indicators vs recording of <4 indicators), was significantly (P<0.05) associated with survey year, marital status, socio-economic status, maternal antenatal TB screening, antenatal infant feeding counselling, delivery at a clinic or hospital and type of birth attendant. Conclusions: Routine patient-held infant health RtHB, a critical tool for continuity of care in high HIV/TB prevalence settings, was poorly completed, with less than 50% of the RtHB showing expected completeness. However, government efforts for improved usage of the booklet were evidenced by the near doubling of completeness from 2011 to 2013. Education about its importance and interventions aiming at optimising its use without violating user privacy should be continued.

      19. Hepatitis C virus in women of childbearing age, pregnant women, and childrenExternal
        Schillie SF, Canary L, Koneru A, Nelson NP, Tanico W, Kaufman HW, Hariri S, Vellozzi CJ.
        Am J Prev Med. 2018 Nov;55(5):633-641.

        INTRODUCTION: Perinatal transmission is an increasingly important mode of hepatitis C virus transmission. The authors characterized U.S. births among hepatitis C virus-infected women and evaluated trends in hepatitis C virus testing and positivity in women of childbearing age, pregnant women, and children aged less than 5years. METHODS: In 2017, National Center for Health Statistics birth certificate data (48 states and District of Columbia) were analyzed to assess the number of hepatitis C virus-infected women delivering live births in 2015, and commercial laboratory data were analyzed to assess hepatitis C virus testing and positivity among women of childbearing age, pregnant women, and children aged <5years from 2011 to 2016. RESULTS: In 2015, a total of 0.38% (n=14,417) of live births were delivered by hepatitis C virus-infected women. Births delivered by hepatitis C virus-infected women, compared with births overall, occurred more often in women who were aged 20-29years (60.7% vs 50.9%); white, non-Hispanic (80.2% vs 52.8%); covered by Medicaid or other government insurance (79.2% vs 43.9%); and had rural residence (26.0% vs 14.0%). From 2011 to 2016 laboratory data, among women of childbearing age, hepatitis C virus testing increased by 39%, from 6.1% to 8.4%, and positivity increased by 36%, from 4.4% to 6.0%. Among pregnant women, hepatitis C virus testing increased by 135%, from 5.7% to 13.4%, and positivity increased by 39%, from 2.6% to 3.6%. Among children, hepatitis C virus testing increased by 25%, from 0.47% to 0.59%, and positivity increased by 13%, from 3.6% to 4.0%. CONCLUSIONS: The potential for perinatal hepatitis C virus transmission exists. Expanded hepatitis C virus testing guidelines may address the burden of disease in this population.

      20. We examined Medicaid claims data during 2004 to 2013. The proportion of sexually active females aged 15 to 25 years who had Papanicolaou testing or were pregnant significantly decreased during 2004 to 2013 (67.0% to 43.9%, P < 0.05), resulting in a slowed increasing trend in overall chlamydia screening rates. Structural-level interventions for improving chlamydia screening are urgently needed.

    • Disease Reservoirs and Vectors
      1. Impact of indoor residual spraying on malaria parasitaemia in the Bunkpurugu-Yunyoo District in northern GhanaExternal
        Abuaku B, Ahorlu C, Psychas P, Ricks P, Oppong S, Mensah S, Sackey W, Koram KA.
        Parasit Vectors. 2018 Oct 23;11(1):555.

        BACKGROUND: Since 2008 indoor residual spraying (IRS) has become one of the interventions for malaria control in Ghana. Key partners in the scale-up of IRS have been the US President’s Malaria Initiative (PMI) and AngloGold Ashanti (AGA). This study was designed to assess the impact of IRS on malaria parasitaemia among children less than 5 years-old in Bunkpurugu-Yunyoo, one of PMI-sponsored districts in northern Ghana, where rates of parasitaemia significantly exceeded the national average. METHODS: Two pre-IRS cross-sectional surveys using microscopy were conducted in November 2010 and April 2011 to provide baseline estimates of malaria parasitaemia for the high and low transmission seasons, respectively. IRS for the entire district was conducted in May/June to coincide with the beginning of the rains. Alpha-cypermethrin was used in 2011 and 2012, and changed to pirimiphos-methyl in 2013 and 2014 following declining susceptibility of local vectors to pyrethroids. Post-IRS cross-sectional surveys were conducted between 2011 and 2014 to provide estimates for the end of high (2011-2014) and the end of low (2012-2013) transmission seasons. RESULTS: The end of high transmission season prevalence of asexual parasitaemia declined marginally from 52.4% (95% CI: 50.0-54.7%) to 47.7% (95% CI: 45.5-49.9%) following 2 years of IRS with alpha-cypermethrin. Prevalence declined substantially to 20.6% (95% CI: 18.4-22.9%) following one year of IRS with pirimiphos-methyl. CONCLUSIONS: The use of a more efficacious insecticide for IRS can reduce malaria parasitaemia among children less than 5 years-old in northern Ghana.

    • Environmental Health
      1. Prenatal high molecular weight phthalates and bisphenol A, and childhood respiratory and allergic outcomesExternal
        Berger K, Eskenazi B, Balmes J, Kogut K, Holland N, Calafat AM, Harley KG.
        Pediatr Allergy Immunol. 2018 Oct 18.

        BACKGROUND: Asthma and allergy prevalence is increasing in United States children. In utero exposure to chemicals used in personal care products and plastics may contribute to increase in these diseases. METHODS: We quantified urinary concentrations of eight phthalate metabolites and bisphenol A in mothers twice during pregnancy in 1999-2000 in Salinas, California. We assessed probable asthma, aeroallergies, eczema, and spirometry in their age 7 children, and measured T helper 1 and T helper 2 cells in blood at ages 2, 5, and 7 (N=392). We employed Bayesian Model Averaging to select confounders from additional biomarkers measured in this population and controlled for them in logistic and linear regressions. RESULTS: Monocarboxyisooctyl phthalate was associated with increased odds for probable asthma (odds ratio: 1.54, 95% CI: 1.12, 2.12), and with lower forced expiratory volume in one second (beta: -0.09 liters, 95% CI: -0.15, -0.03) and forced expiratory flow from 25-75% of forced vital capacity (beta: -7.06 liters/second, 95% CI: -11.04, -2.90). Several other associations were attenuated in final models that controlled for additional biomarkers. CONCLUSION: Monocarboxyisooctyl phthalate was associated with lower respiratory health after controlling for related chemical exposure, which suggests that confounding by multiple chemical exposures should be considered in future research. This article is protected by copyright. All rights reserved.

      2. Use of personal hearing protection devices at loud athletic or entertainment events among adults – United States, 2018External
        Eichwald J, Scinicariello F, Telfer JL, Carroll YI.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1151-1155.

        Tens of millions of U.S. residents have a range of adverse health outcomes caused by noise exposure (1). During 2011-2012, 21 million U.S. adults who reported no exposure to loud or very loud noise at work exhibited hearing damage suggestive of noise-induced hearing loss (2). In addition to the known risk for hearing damage, nonauditory adverse health outcomes and health risks from excessive environmental sound exposure can include effects on the cardiovascular system, metabolism, blood pressure, body weight, cognition, sleep, mental health, quality of life, and overall well-being (1,3,4). CDC analyzed a representative sample of the U.S. adult population (aged >/=18 years) from a 2018 national marketing survey (50 states and the District of Columbia) that included questions about use of hearing protection devices (HPDs) (e.g., ear plugs or ear muffs) during recreational exposure to loud athletic and entertainment events; approximately 8% of respondents reported consistent use of an HPD at these types of events. Among those adults more likely to wear an HPD, 63.8% had at least some college education, and 49.1% had higher income levels. Women and older adults were significantly less likely to use HPDs. These findings suggest a need to strengthen a public health focus on the adverse health effects of excessive noise exposure at home and in recreational settings as well as a need for continued efforts to raise public awareness about the protective value of HPDs.

      3. BACKGROUND: There is limited information regarding isothiazolinone content in residential wall paints in the United States. OBJECTIVE: The aim of this study was to evaluate the prevalence of 5 isothiazolinones-methylisothiazolinone (MI), methylchloroisothiazolinone, benzisothiazolinone (BIT), butyl BIT, and octylisothiazolinone-in US residential wall paints. METHODS: Forty-seven paints were obtained from retailers in Minneapolis/St Paul, Minnesota. Paint samples were assessed for the presence of the 5 isothiazolinones using high-performance liquid chromatographic-mass spectrometry. RESULTS: At least 1 isothiazolinone was detected in all 47 paints. However, no paint contained butyl BIT, and only 1 paint had octylisothiazolinone. The MI and BIT were found in 96% and 98% of the paints, respectively. Methylisothiazolinone ranged in concentration from 17 to 358 ppm, whereas BIT varied from 29 to 1111 ppm. Methylchloroisothiazolinone was found solely in oil-based paints. Isothiazolinones were declared in 15% of Safety Data Sheets but did not correlate with high-performance liquid chromatographic-mass spectrometry. One “preservative-free” paint had BIT at 71.5 ppm. Paint sheen was not statistically associated with BIT or MI concentrations. Unpigmented paints and paints with volatile organic compound claims had significantly lower concentrations of MI, but not BIT. CONCLUSIONS: All paints contained at least 1 isothiazolinone. Methylisothiazolinone and BIT were the most common. Safety Data Sheets are insufficient for ascertaining isothiazolinone content in US paints.

      4. Regression analysis was used to estimate and test for relationships between the blood lead concentration and the concentrations of serum thyroid stimulating hormone and serum total thyroxine in adults, 20 years and older, participating in the third National Health and Nutrition Examination Survey. No relationship was found between the blood lead level and the concentration of serum thyroid stimulating hormone. The serum total thyroxine concentration decreased as the blood lead level increased in women, but not in men. The lowest concentration of blood lead at which a relationship could be detected was 2.1 ?g/dL and 3.9 ?g/dL for the non-pregnant and pregnant women, respectively. Hypothetical mechanisms of the action of lead are discussed.

    • Genetics and Genomics
      1. Fast estimation of genetic relatedness between members of heterogeneous populations of closely related genomic variantsExternal
        Tsyvina V, Campo DS, Sims S, Zelikovsky A, Khudyakov Y, Skums P.
        BMC Bioinformatics. 2018 Oct 22;19(Suppl 11):360.

        BACKGROUND: Many biological analysis tasks require extraction of families of genetically similar sequences from large datasets produced by Next-generation Sequencing (NGS). Such tasks include detection of viral transmissions by analysis of all genetically close pairs of sequences from viral datasets sampled from infected individuals or studying of evolution of viruses or immune repertoires by analysis of network of intra-host viral variants or antibody clonotypes formed by genetically close sequences. The most obvious naieve algorithms to extract such sequence families are impractical in light of the massive size of modern NGS datasets. RESULTS: In this paper, we present fast and scalable k-mer-based framework to perform such sequence similarity queries efficiently, which specifically targets data produced by deep sequencing of heterogeneous populations such as viruses. It shows better filtering quality and time performance when comparing to other tools. The tool is freely available for download at https://github.com/vyacheslav-tsivina/signature-sj CONCLUSION: The proposed tool allows for efficient detection of genetic relatedness between genomic samples produced by deep sequencing of heterogeneous populations. It should be especially useful for analysis of relatedness of genomes of viruses with unevenly distributed variable genomic regions, such as HIV and HCV. For the future we envision, that besides applications in molecular epidemiology the tool can also be adapted to immunosequencing and metagenomics data.

    • Health Disparities
      1. Income disparities and cardiovascular risk factors among adolescentsExternal
        Jackson SL, Yang EC, Zhang Z.
        Pediatrics. 2018 Oct 17.

        BACKGROUND AND OBJECTIVES: Socioeconomic disparities in cardiovascular health among adults have been documented, but disparities during adolescence are less understood. In this study, we examined secular trends in cardiovascular risk factors and disparities among US adolescents. METHODS: We analyzed NHANES data from 1999 to 2014, including 11 557 (4854 fasting) participants aged 12 to 19 years. To examine trends in cardiovascular risk factors, adolescents were stratified into 3 groups on the basis of family poverty-income ratio: low income (poverty-income ratio, <1.3), middle income (>/=1.3 and <3.5), and high income (>/=3.5). RESULTS: From 1999 to 2014, the prevalence of obesity increased (16.3%-20.9%, P = .001) but only among low- and middle-income adolescents, with significant disparities in prevalence by income (21.6% vs 14.6% among low- versus high-income adolescents, respectively, in 2011-2014). In addition, there were significant and persistent disparities in the prevalence of smoking (20.7% vs 7.3% among low- versus high-income adolescents, respectively, in 2011-2014), low-quality diet (68.9% vs 55.4%), and physical inactivity (25.6% vs 17.0%). No significant disparities were observed in the prevalence of prediabetes and diabetes, hypertension, or hypercholesterolemia, although the prevalence of prediabetes and diabetes nearly doubled (11.9%-23.1%, P < .001) among all adolescents from 1999 to 2014. Overall, the prevalence of adolescents with 2 or more risk factors declined, but this decline was only significant for high-income adolescents (44.1%-29.1%, P = .02). CONCLUSIONS: Recent improvements in cardiovascular health have not been equally shared by US adolescents of varying socioeconomic status.

      2. Racial and ethnic differences in survival of pediatric patients with brain and central nervous system cancer in the United StatesExternal
        Siegel DA, Li J, Ding H, Singh SD, King JB, Pollack LA.
        Pediatr Blood Cancer. 2018 Oct 23:e27501.

        BACKGROUND: Brain and central nervous system (CNS) cancer is the leading cause of cancer death among children and adolescents in the United States. Data from earlier studies suggested racial and ethnic differences in survival among pediatric patients with brain tumor. This study examined racial/ethnic difference in survival using national data and considered the effects of demographic and clinical factors. METHODS: Using National Program of Cancer Registries data, 1-, 3-, and 5-year relative survival (cancer survival in the absence of other causes of death) was calculated for patients with brain and CNS cancer aged < 20 years diagnosed during 2001-2008 and followed up through 2013. Racial and ethnic differences in survival were measured by sex, age, economic status, stage, anatomic location, and histology. Adjusted racial and ethnic difference in 5-year cancer specific survival was estimated using multivariable Cox regression analysis. RESULTS: Using data from 11 302 patients, 5-year relative survival was 77.6% for non-Hispanic white patients, 69.8% for non-Hispanic black patients, and 72.9% for Hispanic patients. Differences in relative survival by race/ethnicity existed within all demographic groups. Based on multivariable analysis, non-Hispanic black patients had a higher risk of death at 5 years after diagnosis compared to non-Hispanic white patients (adjusted hazard ratio = 1.2, 95% confidence interval, 1.1-1.4). CONCLUSIONS: Pediatric brain and CNS cancer survival differed by race/ethnicity, with non-Hispanic black patients having a higher risk of death than non-Hispanic white patients. Future investigation of access to care, social and economic barriers, and host genetic factors might identify reasons for disparities in survival.

      3. Cardiometabolic dysfunction among U.S. adolescents and area-level poverty: Race/ethnicity-specific associationsExternal
        Williams AD, Shenassa E, Slopen N, Rossen L.
        J Adolesc Health. 2018 Nov;63(5):546-553.

        PURPOSE: To examine race/ethnicity-specific associations between area-level poverty and cardiometabolic dysfunction among U.S. adolescents. METHODS: Data were from 10,415 adolescents aged 12-19 in the National Health and Nutrition Examination Survey (1999-2012), linked with census tract data on area-level poverty (the percent population living in poverty, grouped into race/ethnicity-specific quartiles). Cardiometabolic dysfunction was parameterized by summing z-scores of six cardiometabolic biomarkers, grouped into quintiles. Hierarchical ordinal models estimated overall and race/ethnicity specific associations. Posthoc analysis explored associations between area-level poverty and family poverty-to-income ratio. RESULTS: Overall, compared to adolescents residing in areas with the lowest area-level poverty (i.e., first quartile), residents in third (OR 1.32, 95% CI 1.13, 1.53) and fourth (OR 1.27, 95% CI 1.08, 1.50) quartiles of area-level poverty experienced elevated odds of cardiometabolic dysfunction. Area-level poverty predicted cardiometabolic dysfunction between non-Hispanic white and Mexican American adolescents, but not between non-Hispanic black adolescents. CONCLUSIONS: We found race/ethnicity-specific associations between area-level poverty and cardiometabolic dysfunction among U.S. adolescents, highlighting the moderating effect of race-ethnicity. Among non-Hispanic black adolescents, neither higher area-level nor family-level socioeconomic status is associated with cardiometabolic health, in contrast to non-Hispanic white adolescents. Similar associations among non-Hispanic white and Mexican American groups aligns with evidence of the Hispanic Paradox. Future studies of effect of area-level determinants of cardiometabolic dysfunction may consider race/ethnicity-specific associations.

    • Health Economics
      1. Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical CenterExternal
        Kim KE, Randal F, Johnson M, Quinn M, Maene C, Hoover S, Richmond-Reese V, Tangka FK, Joseph DA, Subramanian S.
        Cancer. 2018 Oct 25.

        BACKGROUND: This report details the cost effectiveness of a non-nurse patient navigation (PN) program that was implemented at the University of Chicago Medical Center to increase colonoscopy-based colorectal cancer (CRC) screening. METHODS: The authors investigated the impact of the PN intervention by collecting process measures. Individuals who received navigation were compared with a historic cohort of non-navigated patients. In addition, a previously validated data-collection instrument was tailored and used to collect all costs related to developing, implementing, and administering the program; and the incremental cost per patient successfully navigated (the cost of the intervention divided by the change in the number who complete screening) was calculated. RESULTS: The screening colonoscopy completion rate was 85.1% among those who were selected to receive PN compared with 74.3% when no navigation was implemented. With navigation, the proportion of no-shows was 8.2% compared with 15.4% of a historic cohort of non-navigated patients. Because the perceived risk of noncompletion was greater among those who received PN (previous no-show or cancellation, poor bowel preparation) than that in the historic cohort, a scenario analysis was performed. Assuming no-show rates between 0% and 50% and using a navigated rate of 85%, the total incremental program cost per patient successfully navigated ranged from $148 to $359, whereas the incremental intervention-only implementation cost ranged from $88 to $215. CONCLUSIONS: The current findings indicate that non-nurse PN can increase colonoscopy completion, and this can be achieved at a minimal incremental cost for an insured population at an urban academic medical center.

      2. Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectivenessExternal
        Lara CL, Means KL, Morwood KD, Lighthall WR, Hoover S, Tangka FK, French C, Gayle KD, DeGroff A, Subramanian S.
        Cancer. 2018 Oct 25.

        BACKGROUND: The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment’s Clinic Quality Improvement for Population Health initiative. METHODS: Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems. RESULTS: CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened. CONCLUSIONS: In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

    • Healthcare Associated Infections
      1. Multistate outbreak of Burkholderia cepacia complex bloodstream infections after exposure to contaminated saline flush syringes – United States, 2016-2017External
        Brooks RB, Mitchell PK, Miller JR, Vasquez AM, Havlicek J, Lee H, Quinn M, Adams E, Baker D, Greeley R, Ross K, Daskalaki I, Walrath J, Moulton-Meissner H, Crist MB.
        Clin Infect Dis. 2018 Oct 22.

        Background: Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of four Bcc bloodstream infections (BSIs) in patients residing at a single skilled nursing facility (SNF) within one week led to an epidemiological investigation to identify additional cases and the outbreak source. Methods: A case was initially defined as a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after August 1, 2016. Multistate notifications were issued to identify additional cases. Public health authorities performed site visits at facilities with cases to conduct chart reviews and identify possible sources. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from cases and suspect products. Facilities involved in manufacturing suspect products were inspected to assess possible root causes. Results: An outbreak of 162 Bcc BSIs across 59 nursing facilities in 5 states occurred during September 2016-January 2017. Isolates from patients and pre-filled saline flush syringes were closely related by PFGE, identifying contaminated flushes as the outbreak source and prompting a nationwide recall. Inspection of facilities at the saline flush manufacturer identified deficiencies which might have led to the failure to sterilize a specific case containing a partial lot of product. Conclusions: Communication and coordination among key stakeholders, including healthcare facilities, public health authorities, and state and federal agencies, led to the rapid identification of an outbreak source and likely prevented many additional infections. Effective processes to ensure the sterilization of injectable products are essential to prevent similar outbreaks in the future.

      2. Prevalence of hepatitis B virus infection and uptake of hepatitis B vaccine among healthcare workers, Makueni County, Kenya 2017External
        Kisangau EN, Awour A, Juma B, Odhiambo D, Muasya T, Kiio SN, Too R, Lowther SA.
        J Public Health (Oxf). 2018 Oct 23.

        Background: Hepatitis B virus (HBV) is a vaccine-preventable infection that can spread in healthcare setting. Data on HBV infections and vaccine in African healthcare workers (HCWs) are limited. We estimated HBV infection prevalence, hepatitis B vaccination status and identified factors associated with vaccination in one Kenyan county. Methods: Randomly selected HCWs completed a questionnaire about HBV exposure and self-reported immunization histories, and provided blood for testing of selected HBV biomarkers to assess HBV infection and vaccination status: HBV core antibodies (anti-HBc), HBV surface antigen (HBsAg) and HBV surface antibodies (anti-HBs). Prevalence odds ratios (OR) with 95% confidence intervals (95% CI) were calculated to identify factors associated with vaccination. Results: Among 312 HCWs surveyed, median age was 31 years (range: 19-67 years). Of 295 blood samples tested, 13 (4%) were anti-HBc and HBsAg-positive evidencing chronic HBV infection; 139 (47%) had protective anti-HBs levels. Although 249 (80%) HCWs received >/=1 HBV vaccine dose, only 119 (48%) received all three recommended doses. Complete vaccination was more likely among those working in hospitals compared to those working in primary healthcare facilities (OR = 2.5; 95% CI: 1.4-4.3). Conclusion: We recommend strengthening county HCW vaccination, and collecting similar data nationally to guide HBV prevention and control.

    • Immunity and Immunization
      1. Rotavirus vaccine take in infants is associated with secretor statusExternal
        Armah GE, Cortese MM, Dennis FE, Yu Y, Morrow AL, McNeal MM, Lewis KD, Awuni DA, Armachie J, Parashar UD.
        J Infect Dis. 2018 Oct 24.

        Rotaviruses bind to enterocytes in a genotype-specific manner via histo-blood group antigens (HBGAs), which are also detectable in saliva. We evaluated antirotavirus immunoglobulin A seroconversion (‘vaccine take”) among 166 Ghanaian infants after 2-3 doses of G1P[8] rotavirus vaccine during a vaccine trial, by HBGA status from saliva collected at age 4.1 years. Only secretor status was associated with seroconversion: 41% seroconversion for secretors vs 13% for nonsecretors; relative risk, 3.2 (95% confidence interval, 1.2-8.1; P = .016). Neither Lewis antigen nor salivary antigen blood type was associated with seroconversion. Likelihood of “take” for any particular rotavirus vaccine may differ across populations based on HBGAs.

      2. Initial validation of a simulation model for estimating the impact of serogroup A Neisseria meningitidis vaccination in the African meningitis beltExternal
        Jackson ML, Diallo AO, Medah I, Bicaba BW, Yameogo I, Koussoube D, Ouedraogo R, Sangare L, Mbaeyi SA.
        PLoS One. 2018 ;13(10):e0206117.

        We previously developed a mathematical simulation of serogroup A Neisseria meningitidis (NmA) transmission in Burkina Faso, with the goal of forecasting the relative benefit of different vaccination programs. Here, we revisit key structural assumptions of the model by comparing how accurately the different assumptions reproduce observed NmA trends following vaccine introduction. A priori, we updated several of the model’s parameters based on recently published studies. We simulated NmA disease under different assumptions about duration of vaccine-induced protection (including the possibility that vaccine-induced protection may last longer than natural immunity). We compared simulated and observed case counts from 2011-2017. We then used the best-fit model to forecast the impact of different vaccination strategies. Our updated model, with the assumption that vaccine-induced immunity lasts longer than immunity following NmA colonization, was able to reproduce observed trends in NmA disease. The updated model predicts that, following a mass campaign among persons 1-29 years of age, either routine immunization of 9 month-old children or periodic mini-campaigns among children 1-4 years of age will lead to sustained control of epidemic NmA in Burkina Faso. This validated model can help public health officials set policies for meningococcal vaccination in Africa.

      3. Update on vaccine-derived polioviruses – worldwide, January 2017-June 2018External
        Jorba J, Diop OM, Iber J, Henderson E, Zhao K, Sutter RW, Wassilak SG, Burns CC.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 26;67(42):1189-1194.

        Since the Global Polio Eradication Initiative was launched in 1988 (1), the number of polio cases worldwide has declined by >99.99%. Among the three wild poliovirus (WPV) serotypes, only type 1 (WPV1) has been detected since 2012. This decline is attributable primarily to use of the live, attenuated oral poliovirus vaccine (OPV) in national routine immunization schedules and mass vaccination campaigns. The success and safety record of OPV use is offset by the rare emergence of genetically divergent vaccine-derived polioviruses (VDPVs), whose genetic drift from the parental OPV strains indicates prolonged replication or circulation (2). Circulating VDPVs (cVDPVs) can emerge in areas with low immunization coverage and can cause outbreaks of paralytic polio. In addition, immunodeficiency-associated VDPVs (iVDPVs) can emerge in persons with primary immunodeficiencies and can replicate and be excreted for years. This report presents data on VDPVs detected during January 2017-June 2018 and updates previous VDPV summaries (3). During this reporting period, new cVDPV outbreaks were detected in five countries. Fourteen newly identified persons in nine countries were found to excrete iVDPVs. Ambiguous VDPVs (aVDPVs), isolates that cannot be classified definitively, were found among immunocompetent persons and environmental samples in seven countries.

      4. Multiple introductions and antigenic mismatch with vaccines may contribute to increased predominance of G12P[8] rotaviruses in the United StatesExternal
        Ogden KM, Tan Y, Akopov A, Stewart LS, McHenry R, Fonnesbeck CJ, Piya B, Carter MH, Fedorova NB, Halpin RA, Shilts MH, Edwards KM, Payne DC, Esona MD, Mijatovic-Rustempasic S, Chappell JD, Patton JT, Halasa NB, Das SR.
        J Virol. 2018 Oct 17.

        Rotavirus is the leading global cause of diarrheal mortality for unvaccinated children under five years of age. The outer capsid of rotavirus virions consists of VP7 and VP4 proteins, which determine viral G and P types, respectively, and are primary targets of neutralizing antibodies. Successful vaccination depends upon generating broadly protective immune responses following exposure to rotaviruses presenting a limited number of G and P type antigens. Vaccine introduction resulted in decreased rotavirus disease burden but also coincided with emergence of uncommon G and P genotypes, including G12. To gain insight into the recent predominance of G12P[8] rotaviruses in the U.S., we evaluated 142 complete rotavirus genome sequences and metadata from 151 clinical specimens collected in Nashville, TN from 2011-2013 through the New Vaccine Surveillance Network. Circulating G12P[8] strains were found to share many segments with other locally circulating strains but to have distinct constellations. Phylogenetic analyses of G12 sequences and their geographic sources provided evidence for multiple separate introductions of G12 segments into Nashville, TN. Antigenic epitopes of VP7 proteins of G12P[8] strains circulating in Nashville, TN differ markedly from those of vaccine strains. Fully vaccinated children were found to be infected with G12P[8] strains more frequently than with other rotavirus genotypes. Multiple introductions and significant antigenic mismatch may in part explain the recent predominance of G12P[8] strains in the U.S. and emphasize need for continued monitoring of rotavirus vaccine efficacy against emerging rotavirus genotypes.IMPORTANCERotavirus is an important cause of childhood diarrheal disease worldwide. Two immunodominant proteins of rotavirus, VP7 and VP4, determine G and P genotypes, respectively. Recently, G12P[8] rotaviruses have become increasingly predominant. By analyzing rotavirus genome sequences from stool specimens obtained in Nashville, TN from 2011-2013 and globally circulating rotaviruses, we found evidence of multiple introductions of G12 genes into the area. Based on sequence polymorphisms, VP7 proteins of these viruses are predicted to present themselves very differently to the immune system compared to those of vaccine strains. Many of the sick children with G12P[8] rotavirus in their diarrheal stools also were fully vaccinated. Our findings emphasize the need for continued monitoring of circulating rotaviruses and the effectiveness of the vaccines against strains with emerging G and P genotypes.

      5. OBJECTIVES: To determine the proportion of children whose parents prefer them to receive live, attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV), examine reasons for preferences, and determine what percentage of vaccinated children receive other than the preferred type of vaccine and why. METHODS: Parental-reported data for the 2014-15 and 2015-16 influenza seasons from the National Immunization Survey-Flu (NIS-Flu), a random-digit-dialed, dual frame (landline and cellular telephone) survey of households with children, were analyzed. We calculated the proportions of vaccinated children aged 2-17years whose parents preferred LAIV, IIV, or had no preference, and the proportions that were vaccinated with other than the preferred type of vaccine. RESULTS: For the 2014-15 and 2015-16 seasons, 55.2% and 53.7%, respectively, of vaccinated children had parents who reported no preference for either IIV or LAIV. The percentage who preferred LAIV was 22.7% and 21.7%, and IIV was 22.1% and 24.7%. The most common reason given by parents for preferring LAIV was the child’s fear of needles (70.9%) and for preferring IIV was belief that the shot is more effective (29.0%). Approximately one-third of vaccinated children whose parents preferred LAIV received IIV only. CONCLUSIONS: The main finding of this study was that most parents do not have a vaccine type preference for their children. The lack of overwhelming preference is advantageous for the maintenance of vaccination coverage levels during times when one vaccine type is not available or not recommended such as in the 2016-17 and 2017-18 seasons when there was a temporary recommendation not to administer LAIV.

    • Injury and Violence
      1. BACKGROUND: Non-fatal self-inflicted (SI) injuries may be underidentified in administrative medical data sources. OBJECTIVE: Compare patients with SI versus undetermined intent (UI) injuries according to patient characteristics, incidence of subsequent SI injury and risk factors for subsequent SI injury. METHODS: Truven Health MarketScan was used to identify patients’ (aged 10-64) first SI or UI injury in 2015 (index injury). Patient characteristics and subsequent SI within 1 year were assessed. A logistic regression model examined factors associated with subsequent SI. RESULTS: Among analysed patients (n=44 806; 36% SI, 64% UI), a higher proportion of patients with SI index injury were female, had preceding comorbidities (eg, depression), Medicaid (vs commercial insurance), treatment in an ambulance or hospital and cut/pierce or poisoning injuries compared with patients with UI index injury. Just 1% of patients with UI had subsequent SI</=1 year vs 16% of patients with SI. Among patients with UI index injury, incidence of and risk factors for subsequent SI injury were similar across assessed age groups (10-24 years, 25-44 years, 45-64 years). Severe injuries (eg, treated in emergency department), cut/pierce or poisoning injuries, mental health and substance use disorder comorbidities and Medicaid (among adult patients) were risk factors for subsequent SI among patients with UI index injuries. CONCLUSIONS: Regardless of circumstances that influence clinicians’ SI vs UI coding decisions, information on incidence of and risk factors for subsequent SI can help to inform clinical treatment decisions when SI injury is suspected as well as provide evidence to support the development and implementation of self-harm prevention activities.

    • Laboratory Sciences
      1. Yersinia pseudotuberculosis exploits CD209 receptors for promoting host dissemination and infectionExternal
        He YX, Ye CL, Zhang P, Li Q, Park CG, Yang K, Jiang LY, Lv Y, Ying XL, Ding HH, Huang HP, Tembo JM, Li AY, Cheng B, Zhang SS, Zheng GX, Chen SY, Li W, Xia LX, Kan B, Wang X, Jing HQ, Yang RF, Peng H, Fu YX, Klena JD, Skurnik M, Chen T.
        Infect Immun. 2018 Oct 22.

        Yersinia pseudotuberculosis is a Gram-negative enteropathogen and causes gastrointestinal infections. It disseminates from gut to mesenteric lymph nodes (MLNs), spleen and liver of infected humans and animals. Although the molecular mechanisms for dissemination and infection are unclear, many Gram-negative enteropathogens presumably invade into the small intestine via the Peyer’s patches to initiate dissemination. In this study, we demonstrate that Y. pseudotuberculosis utilizes its lipopolysaccharide (LPS) core to interact with CD209 receptors, leading to invasion of human dendritic cells (DCs) and murine macrophages. These Y. pseudotuberculosis-CD209 interactions result in bacterial dissemination to MLNs, spleens and livers of both wild-type and Peyer’s patch-deficient mice. The blocking of the Y. pseudotuberculosis-CD209 interactions by expression of O-antigen and with oligosaccharides reduces infectivity. Based on the well-documented studies, in which HIV-CD209 interaction leads to the viral dissemination, we therefore propose an infection route for Y. pseudotuberculosis where this pathogen after penetrating the intestinal mucosal membrane hijacks via the Y. pseudotuberculosis-CD209 interaction antigen presenting cells (APCs) to reach their target destinations, MLNs, spleens and livers.

      2. Genomic heterogeneity differentiates clinical and environmental subgroups of Legionella pneumophila sequence type 1External
        Mercante JW, Caravas JA, Ishaq MK, Kozak-Muiznieks NA, Raphael BH, Winchell JM.
        PLoS One. 2018 ;13(10):e0206110.

        Legionella spp. are the cause of a severe bacterial pneumonia known as Legionnaires’ disease (LD). In some cases, current genetic subtyping methods cannot resolve LD outbreaks caused by common, potentially endemic L. pneumophila (Lp) sequence types (ST), which complicates laboratory investigations and environmental source attribution. In the United States (US), ST1 is the most prevalent clinical and environmental Lp sequence type. In order to characterize the ST1 population, we sequenced 289 outbreak and non-outbreak associated clinical and environmental ST1 and ST1-variant Lp strains from the US and, together with international isolate sequences, explored their genetic and geographic diversity. The ST1 population was highly conserved at the nucleotide level; 98% of core nucleotide positions were invariant and environmental isolates unassociated with human disease (n = 99) contained ~65% more nucleotide diversity compared to clinical-sporadic (n = 139) or outbreak-associated (n = 28) ST1 subgroups. The accessory pangenome of environmental isolates was also ~30-60% larger than other subgroups and was enriched for transposition and conjugative transfer-associated elements. Up to ~10% of US ST1 genetic variation could be explained by geographic origin, but considerable genetic conservation existed among strains isolated from geographically distant states and from different decades. These findings provide new insight into the ST1 population structure and establish a foundation for interpreting genetic relationships among ST1 strains; these data may also inform future analyses for improved outbreak investigations.

      3. Corticosterone and pyridostigmine/DEET exposure attenuate peripheral cytokine expression: supporting a dominant role for neuroinflammation in a mouse model of Gulf War IllnessExternal
        Michalovicz LT, Locker AR, Kelly KA, Miller JV, Barnes Z, Fletcher MA, Miller DB, Klimas NG, Morris M, Lasley SM, O’Callaghan JP.
        Neurotoxicology. 2018 Oct 16.

        Gulf War Illness (GWI) is a chronic multi-symptom disorder experienced by as many as a third of the veterans of the 1991 Gulf War; the constellation of “sickness behavior” symptoms observed in ill veterans is suggestive of a neuroimmune involvement. Various chemical exposures and conditions in theater have been implicated in the etiology of the illness. Previously, we found that GW-related organophosphates (OPs), such as the sarin surrogate, DFP, and chlorpyrifos, cause neuroinflammation. The combination of these exposures with exogenous corticosterone (CORT), mimicking high physiological stress, exacerbates the observed neuroinflammation. The potential relationship between the effects of OPs and CORT on the brain versus inflammation in the periphery has not been explored. Here, using our established GWI mouse model, we investigated the effects of CORT and DFP exposure, with or without a chronic application of pyridostigmine bromide (PB) and N,N-diethyl-meta-toluamide (DEET), on cytokines in the liver and serum. While CORT primed DFP-induced neuroinflammation, this effect was largely absent in the periphery. Moreover, the changes found in the peripheral tissues do not correlate with the previously reported neuroinflammation. These results not only support GWI as a neuroimmune disorder, but also highlight the separation between central and peripheral effects of these exposures.

      4. Laboratory evaluation of a rapid IgG4 antibody test (BLF Rapid) for Bancroftian filariasisExternal
        Noordin R, Yunus MH, Robinson K, Won KY, Babu S, Fischer PU, Hisam S, Mahmud R.
        Am J Trop Med Hyg. 2018 Oct 22.

        At the end phase of the Global Programme to Eliminate Lymphatic Filariasis, antibody testing may have a role in decision-making for bancroftian filariasis-endemic areas. This study evaluated the diagnostic performance of BLF Rapid(), a prototype immunochromatographic IgG4-based test using BmSXP recombinant protein, for detection of bancroftian filariasis. The test was evaluated using 258 serum samples, comprising 96 samples tested at Universiti Sains Malaysia (in-house) and 162 samples tested independently at three international laboratories in the USA and India, and two laboratories in Malaysia. The independent testing involved 99 samples from Wuchereria bancrofti microfilaria or antigen positive individuals and 63 samples from people who were healthy or had other infections. The in-house evaluation showed 100% diagnostic sensitivity and specificity. The independent evaluations showed a diagnostic sensitivity of 84-100% and 100% specificity (excluding non-lymphatic filarial infections). BLF Rapid has potential as a surveillance diagnostic tool to make “Transmission Assessment Survey”-stopping decisions and conduct post-elimination surveillance.

      5. Purification of Cyclospora cayetanensis oocysts obtained from human stool specimens for whole genome sequencingExternal
        Qvarnstrom Y, Wei-Pridgeon Y, Van Roey E, Park S, Srinivasamoorthy G, Nascimento FS, Moss DM, Talundzic E, Arrowood MJ.
        Gut Pathog. 2018 ;10:45.

        Background: Cyclospora cayetanensis is a food-borne intestinal human parasite that causes outbreaks of diarrhea. There is a need for efficient laboratory methods for strain-level characterization to assist in outbreak investigations. By using next generation sequencing, genomic sequences can be obtained and compared to identify potential genotyping markers. However, there is no method available to propagate this parasite in the laboratory. Therefore, genomic DNA must be extracted from oocysts purified from human stool. The objective of this study was to apply optimized methods to purify C. cayetanensis oocysts and extract DNA in order to obtain high-quality whole genome sequences with minimum contamination of DNA from other organisms. Results: Oocysts from 21 human stool specimens were separated from other stool components using discontinuous density gradient centrifugation and purified further by flow cytometry. Genomic DNA was used to construct Ovation Ultralow libraries for Illumina sequencing. MiSeq sequencing reads were taxonomically profiled for contamination, de novo assembled, and mapped to a draft genome available in GenBank to assess the quality of the resulting genomic sequences. Following all purification steps, the majority (81-99%) of sequencing reads were from C. cayetanensis. They could be assembled into draft genomes of around 45 MB in length with GC-content of 52%. Conclusions: Density gradients performed in the presence of a detergent followed by flow cytometry sorting of oocysts yielded sufficient genomic DNA largely free from contamination and suitable for whole genome sequencing of C. cayetanensis. The methods described here will facilitate the accumulation of genomic sequences from various samples, which is a prerequisite for the development of typing tools to aid in outbreak investigations.

      6. Automated quality control for a molecular surveillance systemExternal
        Sims S, Longmire AG, Campo DS, Ramachandran S, Medrzycki M, Ganova-Raeva L, Lin Y, Sue A, Thai H, Zelikovsky A, Khudyakov Y.
        BMC Bioinformatics. 2018 Oct 22;19(Suppl 11):358.

        BACKGROUND: Molecular surveillance and outbreak investigation are important for elimination of hepatitis C virus (HCV) infection in the United States. A web-based system, Global Hepatitis Outbreak and Surveillance Technology (GHOST), has been developed using Illumina MiSeq-based amplicon sequence data derived from the HCV E1/E2-junction genomic region to enable public health institutions to conduct cost-effective and accurate molecular surveillance, outbreak detection and strain characterization. However, as there are many factors that could impact input data quality to which the GHOST system is not completely immune, accuracy of epidemiological inferences generated by GHOST may be affected. Here, we analyze the data submitted to the GHOST system during its pilot phase to assess the nature of the data and to identify common quality concerns that can be detected and corrected automatically. RESULTS: The GHOST quality control filters were individually examined, and quality failure rates were measured for all samples, including negative controls. New filters were developed and introduced to detect primer dimers, loss of specimen-specific product, or short products. The genotyping tool was adjusted to improve the accuracy of subtype calls. The identification of “chordless” cycles in a transmission network from data generated with known laboratory-based quality concerns allowed for further improvement of transmission detection by GHOST in surveillance settings. Parameters derived to detect actionable common quality control anomalies were incorporated into the automatic quality control module that rejects data depending on the magnitude of a quality problem, and warns and guides users in performing correctional actions. The guiding responses generated by the system are tailored to the GHOST laboratory protocol. CONCLUSIONS: Several new quality control problems were identified in MiSeq data submitted to GHOST and used to improve protection of the system from erroneous data and users from erroneous inferences. The GHOST system was upgraded to include identification of causes of erroneous data and recommendation of corrective actions to laboratory users.

      7. PoSE: visualization of patterns of sequence evolution using PAML and MATLABExternal
        Zhao K, Henderson E, Bullard K, Oberste MS, Burns CC, Jorba J.
        BMC Bioinformatics. 2018 Oct 22;19(Suppl 11):364.

        BACKGROUND: Determining patterns of nucleotide and amino acid substitution is the first step during sequence evolution analysis. However, it is not easy to visualize the different phylogenetic signatures imprinted in aligned nucleotide and amino acid sequences. RESULTS: Here we present PoSE (Pattern of Sequence Evolution), a reliable resource for unveiling the evolutionary history of sequence alignments and for graphically displaying their contents. Substitutions are displayed by category (transitions and transversions), codon position, and phenotypic effect (synonymous and nonsynonymous). Visualization is accomplished using MATLAB scripts wrapped around PAML (Phylogenetic Analysis by Maximum Likelihood), implemented in an easy-to-use graphical user interface. The application displays inferred substitutions estimated by baseml or codeml, two programs included in the PAML software package. PoSE organizes patterns of substitution in eleven plots, including estimated non-synonymous/synonymous ratios (dN/dS) along the sequence alignment. In addition, PoSE provides visualization and annotation of patterns of amino acid substitutions along groups of related sequences that can be graphically inspected in a phylogenetic tree window. CONCLUSIONS: PoSE is a useful tool to help determine major patterns during sequence evolution of protein-coding sequences, hypervariable regions, or changes in dN/dS ratios. PoSE is publicly available at https://github.com/CDCgov/PoSE.

    • Maternal and Child Health
      1. A review of MD STAR net’s research contributions to pediatric-onset dystrophinopathy in the United States; 2002-2017External
        Sahay KM, Smith T, Conway KM, Romitti PA, Lamb MM, Andrews J, Pandya S, Oleszek J, Cunniff C, Valdez R.
        J Child Neurol. 2018 Oct 22:883073818801704.

        Population studies of rare disorders, such as Duchenne and Becker muscular dystrophies (dystrophinopathies), are challenging due to diagnostic delay and heterogeneity in disorder milestones. To address these challenges, the Centers for Disease Control and Prevention established the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STAR net) in 2002 in the United States. From 2002 to 2012, MD STAR net longitudinally tracked the prevalence, clinical, and health care outcomes of 1054 individuals born from 1982 to 2011 with pediatric-onset dystrophinopathy through medical record abstraction and survey data collection. This article summarizes 31 MD STAR net peer-reviewed publications. MD STAR net provided the first population-based prevalence estimates of childhood-onset dystrophinopathy in the United States. Additional publications provided insights into diagnostic delay, dystrophinopathy-specific growth charts, and health services use. Ongoing population-based surveillance continually improves our understanding of clinical and diagnostic outcomes of rare disorders.

      2. Effects of prenatal marijuana exposure on neuropsychological outcomes in children aged 1-11 years: A systematic reviewExternal
        Sharapova SR, Phillips E, Sirocco K, Kaminski JW, Leeb RT, Rolle I.
        Paediatr Perinat Epidemiol. 2018 Oct 18.

        BACKGROUND: Normalisation of medicinal and recreational marijuana use has increased the importance of fully understanding effects of marijuana use on individual-and population-level health, including prenatal exposure effects on child development. We undertook a systematic review of the literature to examine the long-term effects of prenatal marijuana exposure on neuropsychological function in children aged 1-11 years. METHODS: Primary research publications were searched from Medline, Embase, PsychInfo, CINAHL EbscoHost, Cochrane Library, Global Health and ERIC (1980-2018). Eligible articles documented neuropsychological outcomes in children 1-11 years who had been prenatally exposed to marijuana. Studies of exposure to multiple prenatal drugs were included if results for marijuana exposure were reported separately from other substances. Data abstraction was independently performed by two reviewers using a standardised protocol. RESULTS: The eligible articles (n = 21) on data from seven independent longitudinal studies had high quality based on the Newcastle-Ottawa Scale. Some analyses found associations (P < 0.05) between prenatal marijuana exposure and decreased performance on memory, impulse control, problem-solving, quantitative reasoning, verbal development and visual analysis tests; as well as increased performance on attention and global motion perception tests. Limitations included concurrent use of other substances among study participants, potential under-reporting and publication biases, non-generalisable samples and limited published results preventing direct comparison of analyses. CONCLUSIONS: The specific effects of prenatal marijuana exposure remain unclear and warrant further research. The larger number of neuropsychological domains that exhibit decreased versus increased psychological and behavioural functions suggests that exposure to marijuana may be harmful for brain development and function.

      3. A population-based case-control study of the association between weather-related extreme heat events and orofacial cleftsExternal
        Soim A, Sheridan SC, Hwang SA, Hsu WH, Fisher SC, Shaw GM, Feldkamp ML, Romitti PA, Reefhuis J, Langlois PH, Browne ML, Lin S.
        Birth Defects Res. 2018 Oct 19:e1385.

        BACKGROUND: Limited epidemiologic research exists on the association between weather-related extreme heat events (EHEs) and orofacial clefts (OFCs). We estimated the associations between maternal exposure to EHEs in the summer season and OFCs in offspring and investigated the potential modifying effect of body mass index on these associations. METHODS: We conducted a population-based case-control study among mothers who participated in the National Birth Defects Prevention Study for whom at least 1 day of their first two post-conception months occurred during summer. Cases were live-born infants, stillbirths, and induced terminations with OFCs; controls were live-born infants without major birth defects. We defined EHEs using the 95th and the 90th percentiles of the daily maximum universal apparent temperature distribution. We used unconditional logistic regression with Firth’s penalized likelihood method to estimate adjusted odds ratios and 95% confidence intervals, controlling for maternal sociodemographic and anthropometric variables. RESULTS: We observed no association between maternal exposure to EHEs and OFCs overall, although prolonged duration of EHEs may increase the risk of OFCs in some study sites located in the Southeast climate region. Analyses by subtypes of OFCs revealed no associations with EHEs. Modifying effect by BMI was not observed. CONCLUSIONS: We did not find a significantly increased risk of OFCs associated with maternal exposure to EHEs during the relevant window of embryogenesis. Future studies should account for maternal indoor and outdoor activities and for characteristics such as hydration and use of air conditioning that could modify the effect of EHEs on pregnant women.

    • Nutritional Sciences
      1. There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross-sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6-23 months in two districts in Nepal that were part of a post-pilot scale-up of a IYCF-MNP programme. Multivariable log-binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length-for-age z-score <-2), wasting (weight-for-length z-score <-2), underweight (weight-for-age z-score <-2), anaemia (altitude-adjusted haemoglobin <110 mug/L), moderate or severe anaemia (altitude-adjusted haemoglobin <100 g/L), iron deficiency (inflammation-adjusted ferritin <12 mug/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers’ interactions with female community health volunteers (FCHVs; >1x per month or monthly vs. <1x per month) and MNP coverage (1 or >/=2 distributions vs. none among children 12-23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable-adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal-FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF-MNP programmes to improve children’s nutritional status.

      2. Iodine status of pregnant women and women of reproductive age in the United StatesExternal
        Perrine CG, Herrick KA, Gupta PM, Caldwell K.
        Thyroid. 2018 Oct 23.

        [No abstract]

    • Occupational Safety and Health
      1. CDC Grand Rounds: New frontiers in workplace healthExternal
        Fischer LS, Lang JE, Goetzel RZ, Linnan LA, Thorpe PG.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1156-1159.

        [No abstract]

    • Occupational Safety and Health – Mining
      1. [No abstract]

    • Physical Activity
      1. The 24-hour activity cycle: A new paradigm for physical activityExternal
        Rosenberger ME, Fulton JE, Buman MP, Troiano RP, Grandner MA, Buchner DM, Haskell WL.
        Med Sci Sports Exerc. 2018 Oct 18.

        The physiologic mechanisms by which the four activities of sleep, sedentary behavior, light-intensity physical activity (LIPA), and moderate-to-vigorous physical activity (MVPA) affect health are related, but these relationships have not been well explored in adults. Research studies have commonly evaluated how time spent in one activity affects health. Because one can only increase time in one activity by decreasing time in another, such studies cannot determine the extent that a health benefit is due to one activity versus due to reallocating time among the other activities. For example, interventions to improve sleep possibly also increase time spent in MVPA. If so, the overall effect of such interventions on risk of premature mortality is due to both more MVPA and better sleep. Further, the potential for interaction between activities to affect health outcomes is largely unexplored. For example, is there a threshold of MVPA minutes per day, above which adverse health effects of sedentary behavior are eliminated? This paper considers the 24-Hour Activity Cycle (24-HAC) model as a paradigm for exploring inter-relatedness of health effects of the four activities. It discusses how to measure time spent in each of the four activities, as well as the analytical and statistical challenges in analyzing data based upon the model, including the inevitable challenge of confounding among activities. The potential usefulness of this model is described by reviewing selected research findings that aided in the creation of the model and discussing future applications of the 24-HAC model.

    • Reproductive Health
      1. Prevalence of and risk factors for abnormal vaginal flora and its association with adverse pregnancy outcomes in a rural district in north-east BangladeshExternal
        Baqui AH, Lee AC, Koffi AK, Khanam R, Mitra DK, Dasgupta SK, Uddin J, Ahmed P, Rafiqullah I, Rahman M, Quaiyum A, Koumans EH, Christian P, Saha SK, Mullany LC, Labrique A.
        Acta Obstet Gynecol Scand. 2018 Oct 22.

        INTRODUCTION: The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes. MATERIAL AND METHODS: Pregnant women (n=4,221) <19 weeks of gestation provided self-administered mid-vaginal swabs; smears were Nugent scored. AVF was treated with oral clindamycin; if AVF was present 3 weeks after treatment, persistent AVF was re-treated. We examined risk factors for AVF and the association of persistent AVF with adverse pregnancy outcomes. RESULTS: The prevalence of AVF was 16.5%; 9.8% of women had bacterial vaginosis and 6.8% had intermediate flora. Lower economic and educational status of women were associated with increased risk of AVF. One-third of women with AVF had persistent abnormal flora; these women had higher risk of a composite measure of adverse pregnancy outcomes from 20 to < 37 weeks (preterm live birth, preterm still birth, late miscarriage) [RR 1.33, 95% CI; 1.07 to 1.65)], and of late miscarriage alone [RR 4.15, 95% CI; 2.12 to 8.12)] compared to women without AVF. CONCLUSIONS: In this study in Sylhet District, Bangladesh, rates of AVF and persistent AVF were high and persistent AVF was associated with adverse pregnancy outcomes, with an especially high associated risk for late miscarriage. Further characterization of the microbiome and relative bacterial species density associated with persistent AVF is needed. This article is protected by copyright. All rights reserved.

      2. Youth-friendly family planning services for young people: A systematic review updateExternal
        Brittain AW, Loyola Briceno AC, Pazol K, Zapata LB, Decker E, Rollison JM, Malcolm NM, Romero LM, Koumans EH.
        Am J Prev Med. 2018 Nov;55(5):725-735.

        CONTEXT: Youth-friendly family planning services may improve youth reproductive health outcomes. A systematic review conducted in 2011 was updated in 2016 to incorporate recent data examining the effects of youth-friendly family planning services on reproductive health outcomes and the facilitators and barriers facing young people in accessing family planning services. EVIDENCE ACQUISITION: PubMed, POPLINE, EMBASE, and other databases were used to identify relevant articles published from March 2011 through April 2016. EVIDENCE SYNTHESIS: Eighteen studies met inclusion criteria and were added to 19 studies from the review conducted in 2011. Of these, seven assessed the effect of youth-friendly services on outcomes: two showed a positive effect on reducing teen pregnancy, three on contraceptive use, and three on knowledge and patient satisfaction (not mutually exclusive). Facilitators or barriers were described in 32 studies. However, none were RCTs and most were at high risk for bias due to selection, self-report, and recall bias among others. CONCLUSIONS: The studies in this review suggest some positive effects of youth-friendly family planning services on reproductive health outcomes, but the need for more rigorous research persists. This review identified numerous factors relevant to young people’s access to family planning services, reaffirming findings from the initial review: young people value confidentiality, supportive provider interaction, specialized provider training, and the removal of logistic barriers. Further, it illuminates the importance young people place on receiving comprehensive, client-centered family planning counseling. These findings should be considered when developing, implementing, and evaluating reproductive health services for young people. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      3. Client preferences for contraceptive counseling: A systematic reviewExternal
        Fox E, Reyna A, Malcolm NM, Rosmarin RB, Zapata LB, Frederiksen BN, Moskosky SB, Dehlendorf C.
        Am J Prev Med. 2018 Nov;55(5):691-702.

        CONTEXT: Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients’ preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive. EVIDENCE ACQUISITION: This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011. EVIDENCE SYNTHESIS: In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered. CONCLUSIONS: Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      4. Clinic-based programs to prevent repeat teen pregnancy: A systematic reviewExternal
        Frederiksen BN, Rivera MI, Ahrens KA, Malcolm NM, Brittain AW, Rollison JM, Moskosky SB.
        Am J Prev Med. 2018 Nov;55(5):736-746.

        CONTEXT: The purpose of this paper is to synthesize and evaluate the evidence on the effectiveness of repeat teen pregnancy prevention programs offered in clinical settings. EVIDENCE ACQUISITION: Multiple databases were searched for peer-reviewed articles published from January 1985 to April 2016 that included key terms related to adolescent reproductive health services. Analysis of these studies occurred in 2017. Studies were excluded if they focused solely on sexually transmitted disease/HIV prevention services, or occurred outside of a clinic setting or the U.S., Canada, Europe, Australia, or New Zealand. Inclusion and exclusion criteria further narrowed the studies to those that included information on at least one short-term (e.g., increased knowledge); medium-term (e.g., increased contraceptive use); or long-term (e.g., decreased repeat teen pregnancy) outcome, or identified contextual barriers or facilitators for providing adolescent-focused family planning services. Standardized abstraction methods and tools were used to synthesize the evidence and assess its quality. Only studies of clinic-based programs focused on repeat teen pregnancy prevention were included in this review. EVIDENCE SYNTHESIS: The search strategy identified 27,104 citations, 940 underwent full-text review, and 120 met the adolescent-focused family planning services inclusion criteria. Only five papers described clinic-based programs focused on repeat teen pregnancy prevention. Four studies found positive (n=2) or null (n=2) effects on repeat teen pregnancy prevention; an additional study described facilitators for helping teen mothers remain linked to services. CONCLUSIONS: This review identified clinic-based repeat teen pregnancy prevention programs and few positively affect factors that may reduce repeat teen pregnancy. Access to immediate postpartum contraception or home visiting programs may be opportunities to meet adolescents where they are and reduce repeat teen pregnancy. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      5. Impact of contraceptive education on knowledge and decision making: An updated systematic reviewExternal
        Pazol K, Zapata LB, Dehlendorf C, Malcolm NM, Rosmarin RB, Frederiksen BN.
        Am J Prev Med. 2018 Nov;55(5):703-715.

        CONTEXT: Educational interventions can help individuals increase their knowledge of available contraceptive methods, enabling them to make informed decisions and use contraception correctly. This review updates a previous review of contraceptive education. EVIDENCE ACQUISITION: Multiple databases were searched for articles published March 2011-November 2016. Primary outcomes were knowledge, participation in and satisfaction/comfort with decision making, attitudes toward contraception, and selection of more effective methods. Secondary outcomes included contraceptive behaviors and pregnancy. Excluded articles described interventions that had no comparison group, could not be conducted feasibly in a clinic setting, or were conducted outside the U.S. or similar country. EVIDENCE SYNTHESIS: A total of 24,953 articles were identified. Combined with the original review, 37 articles met inclusion criteria and described 31 studies implementing a range of educational approaches (interactive tools, written materials, audio/videotapes, and text messages), with and without healthcare provider feedback, for a total of 36 independent interventions. Of the 31 interventions for which knowledge was assessed, 28 had a positive effect. Fewer were assessed for their effect on attitudes toward contraception, selection of more effective methods, contraceptive behaviors, or pregnancy-although increased knowledge was found to mediate additional outcomes (positive attitudes toward contraception and contraceptive continuation). CONCLUSIONS: This systematic review is consistent with evidence from the broader healthcare field in suggesting that a range of interventions can increase knowledge. Future studies should assess what aspects are most effective, the benefits of including provider feedback, and the extent to which educational interventions can facilitate behavior change and attainment of reproductive health goals. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      6. Community education and engagement in family planning: Updated systematic reviewExternal
        Sharma AE, Frederiksen BN, Malcolm NM, Rollison JM, Carter MW.
        Am J Prev Med. 2018 Nov;55(5):747-758.

        CONTEXT: Community education and engagement are important for informing family planning projects. The objective of this study was to update two prior systematic reviews assessing the impact of community education and engagement interventions on family planning outcomes. EVIDENCE ACQUISITION: Sixteen electronic databases were searched for studies relevant to a priori determined inclusion/exclusion criteria in high development settings, published from March 2011 through April 2016, updating two reviews that included studies from 1985 through February 2011. EVIDENCE SYNTHESIS: Nine relevant studies were included in this updated review related to community education, in addition to 17 from the prior review. No new community engagement studies met inclusion criteria, as occurred in the prior review. Of new studies, community education modalities included mass media, print/mail, web-based, text messaging, and interpersonal interventions. One study on mass media intervention demonstrated a positive impact on reducing teen and unintended pregnancies. Three of four studies on interpersonal interventions demonstrated positive impacts on medium-term family planning outcomes, such as contraception and condom use. Three new studies demonstrated mostly positive, but inconsistent, results on short-term family planning outcomes. CONCLUSIONS: Findings from this systematic review update are in line with a previous review showing the positive impact of community education using traditional modalities on short-term family planning outcomes, identifying additional impacts on long-term outcomes, and highlighting new evidence for education using modern modalities, such as text messaging and web-based education. More research is necessary to provide a stronger evidence base for directing community education and engagement efforts in family planning contexts. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      7. Contraceptive counseling in clinical settings: An updated systematic reviewExternal
        Zapata LB, Pazol K, Dehlendorf C, Curtis KM, Malcolm NM, Rosmarin RB, Frederiksen BN.
        Am J Prev Med. 2018 Nov;55(5):677-690.

        CONTEXT: The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings. EVIDENCE ACQUISITION: Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016. EVIDENCE SYNTHESIS: The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest. CONCLUSIONS: Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

      8. Family planning reminder systems: An updated systematic reviewExternal
        Zapata LB, Pazol K, Rollison JM, Loyola Briceno AC.
        Am J Prev Med. 2018 Nov;55(5):716-724.

        CONTEXT: The objective of this systematic review was to update a prior review and summarize the evidence on the impact of family planning reminder systems (e.g., daily text messages reminding oral contraception users to take a pill). EVIDENCE ACQUISITION: Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016, describing studies of reminder systems. EVIDENCE SYNTHESIS: The search strategy identified 24,953 articles, of which two studies met the inclusion criteria. In total with the initial review, four studies (including two RCTs) examined reminder systems among oral contraception users, with two of three that examined correct use finding a statistically significant positive impact, and one RCT finding a positive impact on knowledge and continuation. Of three studies (including two RCTs) that examined reminder systems among depot medroxyprogesterone acetate users, one of three that examined correct use found a statistically significant positive impact on timely injections at 3 months, and one study found no effect on continued use at 12 months. CONCLUSIONS: Although this review found mixed support for the effectiveness of reminder systems on family planning behaviors, the highest quality evidence yielded null findings related to correct use of oral contraception and timely depot medroxyprogesterone acetate injections beyond 3 months, and found positive findings related to oral contraception continuation and knowledge. Future studies would be strengthened by objectively measuring outcomes and examining additional contraceptive methods and outcomes at least 12 months post-intervention. THEME INFORMATION: This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

    • Zoonotic and Vectorborne Diseases
      1. Evaluation of in vivo expressed Borrelia burgdorferi antigens for improved IgM serodiagnosis of early Lyme diseaseExternal
        Brandt KS, Ullmann AJ, Molins CR, Horiuchi K, Biggerstaff BJ, Gilmore RD.
        Diagn Microbiol Infect Dis. 2018 Oct 3.

        Improved serologic tests are needed for accurate diagnosis and proper treatment of early stage Lyme disease. We evaluated the 3 antigens currently used for 2-tiered IgM immunoblot testing (FlaB, OspC, and BmpA) in combination with 3 additional antigens (BBA65, BBA70, and BBA73) and measured the sensitivity and specificity against a serum repository of positive and negative controls. Using 3 statistical methods for positivity cutoff determinations and scoring criteria, we found increased sensitivities for early Lyme disease when 2 of 6 antigens were positive as compared with the 2 of 3 antigen IgM criteria currently used for second-tier immunoblot scoring. Specificities for negative controls were comparable or superior to using 2 of 3 antigens. These results indicate that IgM sensitivity and specificity of serological testing for Lyme disease in the early stages of illness can be improved by employing antigens that target the initial host antibody responses.

      2. Notes from the field: Reference laboratory investigation of patients with clinically diagnosed Lyme disease and babesiosis – Indiana, 2016External
        Brown JA, Allman R, Herwaldt BL, Gray E, Rivera HN, Qvarnstrom Y, Kwit N, Schriefer ME, Hinckley A, Pontones P.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1160-1161.

        [No abstract]

      3. West Nile virus and other nationally notifiable arboviral diseases – United States, 2017External
        Curren EJ, Lehman J, Kolsin J, Walker WL, Martin SW, Staples JE, Hills SL, Gould CV, Rabe IB, Fischer M, Lindsey NP.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1137-1142.

        Arthropodborne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes or ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the continental United States (1). Other arboviruses, including Jamestown Canyon, La Crosse, Powassan, St. Louis encephalitis, and eastern equine encephalitis viruses, cause sporadic cases of disease and occasional outbreaks. This report summarizes surveillance data reported to CDC from U.S. states in 2017 for nationally notifiable arboviruses. It excludes dengue, chikungunya, and Zika viruses because, in the continental United States, these viruses are acquired primarily through travel. In 2017, 48 states and the District of Columbia (DC) reported 2,291 cases of domestic arboviral disease, including 2,097 (92%) WNV disease cases. Among the WNV disease cases, 1,425 (68%) were classified as neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis), for a national rate of 0.44 cases per 100,000 population. More Jamestown Canyon and Powassan virus disease cases were reported in 2017 than in any previous year. Because arboviral diseases continue to cause serious illness, maintaining surveillance is important to direct and promote prevention activities.

      4. Influenza A(H3N2) variant virus outbreak at three fairs – Maryland, 2017External
        Duwell MM, Blythe D, Radebaugh MW, Kough EM, Bachaus B, Crum DA, Perkins KA, Blanton L, Davis CT, Jang Y, Vincent A, Chang J, Abney DE, Gudmundson L, Brewster MG, Polsky L, Rose DC, Feldman KA.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 26;67(42):1169-1173.

        On September 17, 2017, the Maryland Department of Agriculture (MDA) was notified by fair and 4-H officials of ill swine at agricultural fair A, held September 14-17. That day, investigation of the 107 swine at fair A revealed five swine with fever and signs of upper respiratory tract illness. All five respiratory specimens collected from these swine tested positive for influenza A virus at the MDA Animal Health Laboratory, and influenza A(H3N2) virus was confirmed in all specimens by the U.S. Department of Agriculture National Veterinary Services Laboratory (NVSL). On September 18, MDA was notified by fair and 4-H officials that swine exhibitors were also ill. MDA alerted the Maryland Department of Health (MDH). A joint investigation with MDH and the local health department was started and later broadened to Maryland agricultural fairs B (September 13-17) and C (September 15-23). In total, 76 persons underwent testing for variant influenza, and influenza A(H3N2) variant (A(H3N2)v) virus infection was identified in 40 patients with exposure to swine at these fairs (Figure), including 30 (75%) who had more than one characteristic putting them at high risk for serious influenza complications; 24 (60%) of these were children aged <5 years. Twenty-six (65%) patients reported direct contact with swine (i.e., touching swine or swine enclosure), but 14 (35%) reported only indirect contact (e.g., walking through a swine barn). Two children required hospitalization; all patients recovered. This outbreak highlights the risk, particularly among children, for contracting variant influenza virus at agricultural fairs after direct or indirect swine contact. Publicizing CDC’s recommendation that persons at high risk for serious influenza complications avoid pigs and swine barns might help prevent future variant influenza outbreaks among vulnerable groups (1).

      5. Notes from the Field: Contact tracing investigation after first case of Andes virus in the United States – Delaware, February 2018External
        Kofman A, Eggers P, Kjemtrup A, Hall R, Brown SM, Morales-Betoulle M, Graziano J, Zufan SE, Whitmer SL, Cannon DL, Chiang CF, Choi MJ, Rollin PE, Cetron MS, Yaglom HD, Duwell M, Kuhar DT, Kretschmer M, Knust B, Klena JD, Alvarado-Ramy F, Shoemaker T, Towner JS, Nichol ST.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 19;67(41):1162-1163.

        [No abstract]

      6. Persistence of yellow fever virus-specific neutralizing antibodies after vaccination among U.S. travelersExternal
        Lindsey NP, Horiuchi KA, Corey Fulton D, Panella AJ, Kosoy OI, Velez JO, Krow-Lucal ER, Fischer M, Staples JE.
        J Travel Med. 2018 Oct 20.

        Background: Few studies have assessed the duration of humoral immunity following yellow fever (YF) vaccination in a non-endemic population. We evaluated seropositivity among U.S. resident travelers based on time post-vaccination. Methods: We identified serum samples from U.S. travelers with YF virus-specific plaque reduction neutralization testing (PRNT) performed at CDC from 1988-2016. Analyses were conducted to assess the effect of time since vaccination on neutralizing antibody titer counts. Results: Among 234 travelers who had neutralizing antibody testing performed on a specimen obtained >/=1 month after vaccination, 13 received multiple YF vaccinations and 221 had one dose of YF vaccine reported. All 13 who received more than one dose of YF vaccine had a positive PRNT regardless of the amount time since most recent vaccination. Among the 221 travelers with one reported dose of YF vaccine, 155 (70%) were vaccinated within 10 years (range 1 month-9 years) and 66 (30%) were vaccinated >/=10 years (range 10-53 years) prior to serum collection. Among the 155 individuals vaccinated <10 years prior to serum collection, 146 (94%) had a positive PRNT compared to 82% (54/66) of individuals vaccinated >/=10 years prior to serum collection (p = 0.01). Post-vaccination PRNT titers showed a time-dependent decrease. Individuals with immunocompromising conditions were less likely to have a positive PRNT (77%) compared to those who were not immunocompromised (92%; p = 0.04). Conclusion: Although the percentage of vaccinees with a positive PRNT and antibody titers decreased over time, a single dose of YF vaccine provided long-lasting protection in the majority of U.S. travelers. A booster dose could be considered for certain travelers who are planning travel to a high risk area based on immune competence and time since vaccination.

      7. From recognition to action: A strategic approach to foster sustainable collaborations for rabies eliminationExternal
        Octaria R, Salyer SJ, Blanton J, Pieracci EG, Munyua P, Millien M, Nel L, Wallace RM.
        PLoS Negl Trop Dis. 2018 Oct;12(10):e0006756.

        [No abstract]

      8. Notes from the Field: Recurrence of a multistate outbreak of Salmonella enteritidis infections linked to contact with guinea pigs – eight states, 2015-2017External
        Robertson S, Burakoff A, Stevenson L, Tompkins B, Patel K, Tolar B, Whitlock L, House J, Schlater L, Mackie T, Morningstar-Shaw B, Nichols M, Basler C.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 26;67(42):1195-1196.

        [No abstract]

      9. Translocation of a stray cat infected with rabies from North Carolina to a terrestrial rabies-free county in Ohio, 2017External
        Singh AJ, Chipman RB, de Fijter S, Gary R, Haskell MG, Kirby J, Yu L, Condori RE, Orciari L, Wallace R.
        MMWR Morb Mortal Wkly Rep. 2018 Oct 26;67(42):1174-1177.

        On July 24, 2017, the Ohio Department of Health (ODH) was notified of a positive rabies test result from a domestic cat in Summit County, a county considered free from terrestrial rabies. Oral rabies vaccination (ORV) of raccoons, in the form of consumable bait, is conducted each year along the Ohio-Pennsylvania border to prevent the westward expansion of the raccoon rabies virus variant (RVV). In the United States, several distinct rabies virus variants exist; raccoon RVV is enzootic along the eastern parts of the United States (from Florida to Maine), including several counties in northeast Ohio (1). Animal rabies vaccination is protective against all rabies virus variants. The rabid cat (cat A) was located west of the ORV barrier, raising concern that it had acquired the infection from a raccoon and suggesting a possible breach in the ORV barrier (Figure 1). ODH initiated an investigation to identify persons and animals exposed to the rabid cat during its viral shedding period and collaborated with CDC to determine the likely origin of the virus (Figure 2). Public health investigators later discovered that the cat originated in North Carolina. Phylogenetic analysis confirmed that the virus was most similar to the raccoon RVV that circulates in North Carolina (Figure 3); therefore, this ORV breach was likely the result of human-mediated movement of a rabid animal rather than natural expansion of the raccoon rabies virus enzootic area. This report summarizes the investigation and highlights the importance of owner compliance regarding rabies vaccination.

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

Page last reviewed: January 31, 2019