Volume 10, Issue 44, November 20, 2018

CDC Science Clips: Volume 10, Issue 44, November 20, 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.
    • Disease Reservoirs and Vectors
      • Transcriptomics reveal antiviral gene induction in the Egyptian rousette bat is antagonized in vitro by Marburg virus infectionExternal
        Arnold CE, Guito JC, Altamura LA, Lovett SP, Nagle ER, Palacios GF, Sanchez-Lockhart M, Towner JS.
        Viruses. 2018 Nov 2;10(11).

        The Egyptian rousette bat (ERB) is the only known Marburg virus (MARV) reservoir host. ERBs develop a productive MARV infection with low viremia and shedding but no overt disease, suggesting this virus is efficiently controlled by ERB antiviral responses. This dynamic would contrast with humans, where MARV-mediated interferon (IFN) antagonism early in infection is thought to contribute to the severe, often fatal disease. The newly-annotated ERB genome and transcriptome have now enabled us to use a custom-designed NanoString nCounter ERB CodeSet in conjunction with RNA-seq to investigate responses in a MARV-infected ERB cell line. Both transcriptomic platforms correlated well and showed that MARV inhibited the antiviral program in ERB cells, while an IFN antagonism-impaired MARV was less efficient at suppressing the response gene induction, phenotypes previously reported for primate cells. Interestingly, and despite the expansion of IFN loci in the ERB genome, neither MARV showed specific induction of almost any IFN gene. However, we detected an upregulation of putative, unannotated ERB antiviral paralogs, as well as an elevated basal expression in uninfected ERB cells of key antiviral genes.

    • Environmental Health
      • Environmental observation, social media, and One Health action: A description of the Local Environmental Observer (LEO) NetworkExternal
        Mosites E, Lujan E, Brook M, Brubaker M, Roehl D, Tcheripanoff M, Hennessy T.
        One Health. 2018 Dec;6:29-33.

        As a result of the close relationships between Arctic residents and the environment, climate change has a disproportionate impact on Arctic communities. Despite the need for One Health responses to climate change, environmental monitoring is difficult to conduct in Arctic regions. The Local Environmental Observer (LEO) Network is a global social media network that recruits citizen scientists to collect environmental observations on social media. We examined the processes of the LEO Network, numbers of members and observations, and three case studies that depict One Health action enabled by the system. From February 2012 to July 2017, the LEO Network gained 1870 members in 35 countries. In this time period, 670 environmental observations were posted. Examples that resulted in One Health action include those involving food sources, wild fire smoke, and thawing permafrost. The LEO network is an example of a One Health resource that stimulates action to protect the health of communities around the world.

    • Health Economics
      • BACKGROUND: Human-capital based lifetime productivity estimates are frequently used in cost-of-illness (COI) analyses and, less commonly, in cost-effectiveness analyses (CEAs). Previous US estimates assumed that labor productivity and real earnings both grow by 1% per year. OBJECTIVES: We present estimates of annual and lifetime productivity for 2016 using data from the American Community Survey, the American Time Use Survey, and the Current Population Survey and with varying assumptions about real earnings growth. METHODS: We estimated the sum of market productivity (gross annual personal labor earnings adjusted for employer-paid benefits) and the imputed value of non-market time spent in household, caring, and volunteer services. The present value of lifetime productivity at various ages was calculated for synthetic cohorts using annual productivity estimates, life tables, discount rates, and assumptions about future earnings growth rates. RESULTS: Mean annual productivity was $57,324 for US adults in 2016, including $36,935 in market and $20,389 in non-market productivity. Lifetime productivity at birth, using a 3% discount rate, is roughly $1.5 million if earnings grow by 1% per year and $1.2 million if future earnings growth averages 0.5% per year. CONCLUSIONS: Inclusion of avoidable productivity losses in societal-perspective CEAs of health interventions is recommended in new US cost-effectiveness guidelines. However, estimates vary depending on whether analysts choose to estimate total productivity or just market productivity and on assumptions made about growth in future productivity and earnings.

    • Injury and Violence
    • Laboratory Sciences
      • Efficacy of vaginally administered gel containing emtricitabine and tenofovir against repeated rectal simian human immunodeficiency virus exposures in macaquesExternal
        Dobard CW, Makarova N, West-Deadwyler R, Taylor A, Dinh C, Martin A, Lipscomb J, Mitchell J, Khalil G, Garcia-Lerma G, Heneine W.
        J Infect Dis. 2018 Sep 8;218(8):1284-1290.

        Vaginal microbicides containing antiretrovirals (ARVs) have shown to prevent vaginally acquired human immunodeficiency virus (HIV), but these products may not protect women who engage in anal sex. Intravaginal dosing with ARVs has shown to result in drug exposures in rectal tissues, thus raising the possibility of dual compartment protection. To test this concept, we investigated whether intravaginal dosing with emtricitabine (FTC)/tenofovir (TFV) gel, which fully protected macaques against repeated vaginal exposures to simian human immunodeficiency virus (SHIV), protects against rectal SHIV exposures. Pharmacokinetic studies revealed rapid distribution of FTC and TFV to rectal tissues and luminal fluids, albeit at concentrations 1-2 log10 lower than those in the vaginal compartment. Efficacy measurements against repeated rectal SHIV challenges demonstrated a 4.5-fold reduction in risk of infection in macaques that received intravaginal FTC/TFV compared to placebo gel (P = .047; log-rank test). These data support the concept of dual compartment protection by vaginal dosing and warrants developing ARV-based vaginal products with improved bidirectional dosing.

      • An ELISA-based method for detection of rabies virus nucleoprotein-specific antibodies in human antemortem samplesExternal
        Realegeno S, Niezgoda M, Yager PA, Kumar A, Hoque L, Orciari L, Sambhara S, Olson VA, Satheshkumar PS.
        PLoS One. 2018 ;13(11):e0207009.

        Rabies is a fatal encephalitic disease in humans and animals caused by lyssaviruses, most commonly rabies virus (RABV). Human antemortem diagnosis of rabies is a complex process involving multiple sample types and tests for the detection of antibodies, antigen (protein), and nucleic acids (genomic RNA). Serological diagnosis of human rabies includes the detection of either neutralizing or binding antibodies in the cerebrospinal fluid (CSF) or serum samples from unimmunized individuals without prior rabies vaccination or passive immunization with purified immunoglobulins. While neutralizing antibodies are targeted against the surface-expressed glycoprotein (G protein), binding antibodies to viral antigens are predominantly against the nucleoprotein (N protein), although there can be antibodies against all RABV-expressed proteins. To determine N protein-specific antibody responses in the CSF and serum during RABV infection, we developed an enzyme-linked immunosorbent assay (ELISA) with purified recombinant N protein expressed in E. coli. N protein-specific immunoglobulin (Ig) subtypes IgG and IgM were detected in the CSF or serum of previously diagnosed human rabies cases. In addition, anti-N protein seroconversion was demonstrated over the course of illness in individual rabies cases. We compared the N protein ELISA results to those of an indirect fluorescent antibody (IFA) test, the current binding antibody assay used in diagnosis, and show that our ELISA is consistent with the IFA test. Sensitivity and specificity of the N protein ELISA ranged from 78.38-100% and 75.76-96.77% with respect to the IFA results. Our data provide evidence for the use of an N protein ELISA as an additional option for the detection of RABV-specific IgG or IgM antibodies in human CSF or serum specimens.

    • Nutritional Sciences
      • One menu please: Parents want affordable, right-sized portions for their children in restaurantsExternal
        Lee-Kwan SH, Park S, Maynard L, Blanck HM.
        Clin Nutr Res. 2018 Oct;7(4):241-247.

        One contributing factor to the obesity epidemic is the large portion sizes served in restaurants. However, no study has looked at the parents’ desire for smaller-portioned meals for their children at restaurants in the U.S. This study examined parents’ preference for restaurants to offer smaller, lower-priced child portions for their children and reasons for the preference. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for the association between preference for child portions and variables on parental sociodemographic characteristics and weight status. About 70% of parents said they would prefer that restaurants offer smaller, lower-priced child portions of all menu offerings. The adjusted odds of preferring child portions were significantly higher among Hispanic parents (OR, 1.95 vs. non-Hispanic whites) but significantly lower among parents with lower education (</= high school, OR, 0.64; some college, OR, 0.69 vs. college graduate) and parents residing in the Midwest or West (Midwest, OR, 0.61; West, OR, 0.58 vs. South). The most common reason for preferring child portions of all meals was “wanting my child to eat healthier foods that are not offered on the children’s menu” (72%). These findings can be used to encourage restaurants and other venues to consider offering child portions of healthier menu items.

    • Occupational Safety and Health
      • Evaluation of toolbox safety training in construction: The impact of narrativesExternal
        Eggerth DE, Keller BM, Cunningham TR, Flynn MA.
        Am J Ind Med. 2018 Nov 2.

        BACKGROUND: Construction is a dangerous industry with a large number of small businesses. Because they require minimal resources to deliver, toolbox talks may be an ideal training format for small construction contractors. METHODS: Eight toolbox talks were developed, each with two versions. One version of each toolbox talk was standard and one version included a narrative and discussion questions. Participants were randomly assigned to receive the standard or the narrative version. Pre- and post-intervention surveys measured demographics, workplace safety climate, and knowledge. The post-intervention survey also measured training impact. RESULTS: Including narratives with discussion questions significantly increased knowledge gain and led to increased training impact. Less experienced workers were more likely to gain knowledge and training impact compared to more experienced workers. There were no significant changes in workplace safety climate. CONCLUSIONS: The results suggest that including a narrative and discussion questions increases toolbox talk effectiveness.

      • Objectives: Workers using flavoring formulations containing diacetyl and 2,3-pentanedione may be at risk of inhalational exposure, as these volatile hazardous chemicals are emitted from the bulk material, especially at elevated temperatures. However, flavoring formulations that contain diacetyl and 2,3-pentanedione might not list these ingredients because they are generally recognized as safe to ingest, may be part of a proprietary mixture deemed a trade secret, or may not be required to be listed if they are present at <1% composition. The objective of this study was to investigate whether potential inhalational hazards present in flavoring samples were reported as chemical ingredients on their corresponding safety data sheets (SDSs). Methods: A convenience sample of 26 bulk liquid flavorings obtained from two coffee roasting and packaging facilities in the USA was analyzed for 20 volatile organic chemicals present in the headspaces of vials containing flavoring liquids using gas chromatography-mass spectrometry. Flavoring samples were included in the study if headspace analysis results and SDSs were available. Flavoring samples included hazelnut, French vanilla, amaretto, chocolate, and caramel as well as some flavoring mixtures containing added fruit flavors such as cherry and raspberry. The presence of a chemical in the flavoring formulation was then compared to the ingredient list on the SDSs. Results: All the flavoring SDSs contained trade secret designations. None of the SDSs listed diacetyl or 2,3-pentanedione. Headspace analyte concentrations revealed that diacetyl was present in 21 of 26 samples (81%) with a maximum concentration of 5.84 x 104 microg m-3 in flavor 18 (caramel). 2,3-Pentanedione was present in 15 flavors (58%) with a maximum concentration of 3.79 x 105 microg m-3 in flavor 24 (oatmeal cookies). Conclusions: A majority of the flavorings tested had diacetyl, 2,3-pentanedione, or both as volatile constituents in the headspace. These chemicals were not listed on the SDSs, but inclusion of diacetyl and 2,3-pentanedione on SDSs would serve to protect downstream users from unrecognized exposure and potential respiratory disease. The headspace technique presented here is a viable tool to rapidly screen for volatile hazardous chemicals that may be present in flavoring formulations. Facilities that use flavorings should be aware that constituents in flavorings may present a potential inhalational hazard even if not identified as such by the SDS. A precautionary approach is warranted when working with flavorings, including exposure monitoring and effective exposure control strategies such as containment and local exhaust ventilation.

    • Zoonotic and Vectorborne Diseases
      • Purified inactivated Zika vaccine candidates afford protection against lethal challenge in miceExternal
        Baldwin WR, Livengood JA, Giebler HA, Stovall JL, Boroughs KL, Sonnberg S, Bohning KJ, Dietrich EA, Ong YT, Danh HK, Patel HK, Huang CY, Dean HJ.
        Sci Rep. 2018 Nov 7;8(1):16509.

        In response to the 2016 global public health emergency of international concern announced by the World Health Organization surrounding Zika virus (ZIKV) outbreaks, we developed a purified inactivated Zika virus vaccine (PIZV) candidate from ZIKV strain PRVABC59, isolated during the outbreak in 2015. The virus isolate was plaque purified, creating six sub-isolated virus stocks, two of which were selected to generate PIZV candidates for preclinical immunogenicity and efficacy evaluation in mice. The alum-adjuvanted PIZV candidates were highly immunogenic in both CD-1 and AG129 mice after a 2-dose immunization. Further, AG129 mice receiving 2 doses of PIZV formulated with alum were fully protected against lethal ZIKV challenge and mouse immune sera elicited by the PIZV candidates were capable of neutralizing ZIKVs of both African and Asian genetic lineages in vitro. Additionally, passive immunization of naive mice with ZIKV-immune serum showed strong positive correlation between neutralizing ZIKV antibody (NAb) titers and protection against lethal challenge. This study supported advancement of the PIZV candidate toward clinical development.

      • Care of Ebola survivors and factors associated with clinical sequelae – Monrovia, LiberiaExternal
        de St Maurice A, Ervin E, Orone R, Choi M, Dokubo EK, Rollin PE, Nichol ST, Williams D, Brown J, Sacra R, Fankhauser J, Knust B.
        Open Forum Infect Dis. 2018 Oct;5(10):ofy239.

        Background: The Eternal Love Winning Africa (ELWA) Clinic was the first clinic to provide free, comprehensive care to Ebola virus disease (EVD) survivors in Liberia. The objectives of this analysis were to describe the demographics and symptoms of EVD survivors at ELWA from January 2015 through March 2017 and to identify risk factors for development of sequelae. Methods: Patients’ demographic and clinical information was collected by chart review in June 2016 and March 2017. Associations with clinical sequelae were analyzed using the chi-square test, t test, and multivariate logistic regression. Results: From January 2015 to March 2017, 329 EVD survivors were evaluated at ELWA. Most survivors experienced myalgia/arthralgia (73%; n = 239) and headache (53%; n = 173). The length of time from Ebola Treatment Unit (ETU) discharge to first clinic visit ranged from 0 to 30 months. Many visits (30%) occurred 24 or more months after ETU discharge. The proportion of visits for headache, weight loss, joint pain, visual problems, insomnia, fatigue, memory loss, decreased libido, depression, and uveitis decreased over time. More men than women had visits for depression; however, these differences were not significant. Symptom prevalence differed in adults and children; significantly more adults experienced myalgia/arthralgia (77% vs 44%), visual problems (41% vs 12%), post-EVD-related musculoskeletal pain (42% vs 15%), and insomnia (17% vs 2%). Conclusions: EVD survivors frequented ELWA for EVD-related symptoms many months after ETU discharge, indicating a long-term need for care. Reported symptoms changed over time, which may reflect eventual resolution of some sequelae.

  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. Prevalence of arthritis among adults with prediabetes and arthritis-specific barriers to important interventions for prediabetes – United States, 2009-2016External
        Sandoval-Rosario M, Nayeri BM, Rascon A, Boring M, Aseret-Manygoats T, Helmick CG, Murphy LB, Hootman JM, Imperatore G, Barbour KE.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1238-1241.

        An estimated 54.4 million U.S. adults have doctor-diagnosed arthritis (arthritis), and this number is projected to rise to 78.4 million by 2040 (1,2). Physical inactivity and obesity are two factors associated with an increased risk for developing type 2 diabetes,* and arthritis has been determined to be a barrier to physical activity among adults with obesity (3). The prevalence of arthritis among the 33.9% (estimated 84 million)(dagger) of U.S. adults with prediabetes and how these conditions are related to physical inactivity and obesity are unknown. To examine the relationships among arthritis, prediabetes, physical inactivity, and obesity, CDC analyzed combined data from the 2009-2016 National Health and Nutrition Examination Surveys (NHANES). Overall, the unadjusted prevalence of arthritis among adults with prediabetes was 32.0% (26 million). Among adults with both arthritis and prediabetes, the unadjusted prevalences of leisure-time physical inactivity and obesity were 56.5% (95% confidence intervals [CIs] = 51.3-61.5) and 50.1% (CI = 46.5-53.6), respectively. Approximately half of adults with both prediabetes and arthritis are either physically inactive or have obesity, further increasing their risk for type 2 diabetes. Health care and public health professionals can address arthritis-specific barriers( section sign) to physical activity by promoting evidence-based physical activity interventions.( paragraph sign) Furthermore, weight loss and physical activity promoted though the National Diabetes Prevention Program can reduce the risk for type 2 diabetes and reduce pain from arthritis.

      2. Using 3 health surveys to compare multilevel models for small area estimation for chronic diseases and health behaviorsExternal
        Wang Y, Holt JB, Xu F, Zhang X, Dooley DP, Lu H, Croft JB.
        Prev Chronic Dis. 2018 Nov 1;15:E133.

        BACKGROUND: We used a multilevel regression and poststratification approach to generate estimates of health-related outcomes using Behavioral Risk Factor Surveillance System 2013 (BRFSS) data for the 500 US cities. We conducted an empirical study to investigate whether the approach is robust using different health surveys. METHODS: We constructed a multilevel logistic model with individual-level age, sex, and race/ethnicity as predictors (Model I), and sequentially added educational attainment (Model II) and area-level poverty (Model III) for 5 health-related outcomes using the nationwide BRFSS, the Massachusetts BRFSS 2013 (a state subset of nationwide BRFSS), and the Boston BRFSS 2010/2013 (an independent survey), respectively. We applied each model to the Boston population (2010 Census) to predict each outcome in Boston and compared each with corresponding Boston BRFSS direct estimates. RESULTS: Using Model I for the nationwide BRFSS, estimates of diabetes, high blood pressure, physical inactivity, and binge drinking fell within the 95% confidence interval of corresponding Boston BRFSS direct estimates. Adding educational attainment and county-level poverty (Models II and III) further improved their accuracy, particularly for current smoking (the model-based estimate was 15.2% by Model I and 18.1% by Model II). The estimates based on state BRFSS and Boston BRFSS models were similar to those based on the nationwide BRFSS, but area-level poverty did not improve the estimates significantly. CONCLUSION: The estimates of health-related outcomes were similar using different health surveys. Model specification could vary by surveys with different geographic coverage.

    • Communicable Diseases
      1. Hospitalization following outpatient medical care for influenza: US Influenza Vaccine Effectiveness Network, 2011-12-2015-16External
        Appiah GD, Chung JR, Flannery B, Havers F, Zimmerman RK, Nowalk MP, Monto AS, Martin ET, Gaglani M, Murthy K, Jackson LA, Jackson ML, McLean HQ, Belongia EA, Fry AM.
        Influenza Other Respir Viruses. 2018 Nov 8.

        Over five seasons, we determined the proportion of outpatients with laboratory-confirmed, influenza-associated illness who were hospitalized within 30 days following the outpatient visit. Overall, 136 (1.7%) of 7,813 influenza-positive patients were hospitalized a median of 4 days after an outpatient visit. Patients aged >/=65 years and those with high-risk conditions were at increased risk of hospitalization. After controlling for age and high-risk conditions, vaccination status and infecting influenza virus type were not associated with hospitalization risk among adults. This article is protected by copyright. All rights reserved.

      2. Persistence of endothelial thrombomodulin in a patient with infectious purpura fulminans treated with protein C concentrateExternal
        Bendapudi PK, Robbins A, LeBoeuf N, Pozdnyakova O, Bhatt A, Duke F, Sells R, McQuiston J, Humrighouse B, Rouaisnel B, Colling M, Stephenson KE, Saavedra A, Losman JA.
        Blood Adv. 2018 Nov 13;2(21):2917-2921.

        [No abstract]

      3. Notes from the Field: Increase in Coccidioidomycosis – Arizona, October 2017-March 2018External
        Bezold CP, Khan MA, Adame G, Brady S, Sunenshine R, Komatsu K.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1246-1247.

        [No abstract]

      4. Neisseria gonorrhoeae – rising infection rates, dwindling treatment optionsExternal
        Blank S, Daskalakis DC.
        N Engl J Med. 2018 Nov 8;379(19):1795-1797.

        [No abstract]

      5. Trends in human immunodeficiency virus diagnoses among men who have sex with men in North America, Western Europe, and Australia, 2000-2014External
        Chapin-Bardales J, Schmidt AJ, Guy RJ, Kaldor JM, McGregor S, Sasse A, Archibald C, Rank C, Casabona Barbara J, Folch C, Vives N, Cowan SA, Cazein F, Velter A, An der Heiden M, Gunsenheimer-Bartmeyer B, Marcus U, Op de Coul EL, van Sighem A, Aldir I, Cortes Martins H, Berglund T, Velicko I, Gebhardt M, Delpech V, Hughes G, Nardone A, Hall HI, Johnson AS, Sullivan PS.
        Ann Epidemiol. 2018 Oct 9.

        PURPOSE: The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia. METHODS: Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively. RESULTS: Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM. CONCLUSIONS: Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends.

      6. Assessment of sexual health services at US colleges and universities, 2001 and 2014External
        Coor A, Esie P, Dittus PJ, Koumans EH, Kang J, Habel MA.
        Sex Health. 2018 Sep 27.

        Background: Approximately 19 million students attend post-secondary institutions in the US. With rates of sexually transmitted infections (STIs) at unprecedented highs, the college and university setting can provide the opportunity to engage young adults in their sexual health and deliver recommended services. The purpose of this study was to compare the provision of sexual health services at US college and university health centres across studies conducted in 2001 and 2014. Methods: We compared data from nationally representative surveys administered by the Centers for Disease Control and Prevention (2001, n=736 schools; 2014, n=482 schools), assessing the provision of services, including STI diagnosis and treatment, contraception, STI education, condom distribution and availability of health insurance. Results: Compared with 2001, statistically significant increases were observed in 2014, including in the provision of contraceptive services (56.1% vs 65.0%), HIV testing (81.5% vs 92.3%) and gonorrhoea testing (90.7% vs 95.8%). Significant decreases were found in the number of schools offering health plans (65.5% vs 49.4%) and specific modes of offering STI education, such as health fairs (82.3% vs 69.9%) and orientation presentations (46.5% vs 29.8%; all P<0.001). Conclusions: From 2001 to 2014, there have been some improvements in sexual health services at colleges and universities, but there are areas that require additional access to services. Schools may consider regular assessments of service provision in order to further promote sexual health services on college campuses.

      7. Unusual Neisseria species as a cause of infection in patients taking eculizumabExternal
        Crew PE, McNamara L, Waldron PE, McCulley L, Jones SC, Bersoff-Matcha SJ.
        J Infect. 2018 Nov 5.

        BACKGROUND: Non-meningococcal, non-gonococcal Neisseria spp. are typically commensal and rarely cause invasive disease. Eculizumab is a terminal complement inhibitor that increases susceptibility to meningococcal disease, but data on disease caused by typically-commensal Neisseria spp. are lacking. This series describes postmarketing reports of typically-commensal Neisseria spp. disease in patients receiving eculizumab. METHODS: We searched the FDA Adverse Event Reporting System (FAERS) and medical literature for reports of commensal Neisseria spp. disease in patients receiving eculizumab, from eculizumab U.S. approval (2007) through January 31, 2018. RESULTS: We identified seven FAERS reports (including one case also reported in the literature) of non-meningococcal, non-gonococcal Neisseria disease, including N. sicca (mucosa)/subflava (n=2), N. cinerea (n=2), N. sicca (mucosa) (n=1), N. mucosa (n=1, with concurrent alpha-hemolytic Streptococcus bacteremia), and N. flavescens (subflava) (n=1). Four cases had sources of patient immunosuppression in addition to eculizumab. Three patients had sepsis (n=2) or septic shock (n=1). Five patients were bacteremic. All patients were hospitalized; the infections resolved with antibiotics. CONCLUSIONS: Our search identified seven cases of disease from typically commensal Neisseria spp. in eculizumab recipients. These findings suggest that any Neisseria spp. identified from a normally sterile site in an eculizumab recipient could represent true infection warranting prompt treatment.

      8. Estimating effects of HIV sequencing data completeness on transmission network patterns and detection of growing HIV transmission clustersExternal
        Dasgupta S, France AM, Brandt MG, Reuer J, Zhang T, Panneer N, Hernandez AL, Oster AM.
        AIDS Res Hum Retroviruses. 2018 Nov 7.

        OBJECTIVES: HIV nucleotide sequence data can identify clusters of persons with genetically similar strains suggesting transmission. We simulated the effect of lowered data completeness, defined by the percent of persons with diagnosed HIV with a reported sequence, on transmission patterns and detection of growing HIV transmission clusters. METHODS: We analyzed HIV surveillance data for persons with HIV diagnosed during 2008-2014 who resided in Michigan or Washington. We calculated genetic distances, constructed the inferred transmission network for each jurisdiction, and compared transmission network characteristics and detection of growing transmission clusters in the full dataset with artificially reduced datasets. RESULTS: Simulating lower levels of completeness resulted in decreased percentages of persons linked to a cluster from high completeness (full dataset) to low completeness (5%) (Michigan: 54% to 18%; Washington, 46% to 16%). Patterns of transmission between certain populations remained robust as data completeness level was reduced. As data completeness was artificially decreased, sensitivity of cluster detection substantially diminished in both states. In Michigan, sensitivity decreased from 100% with the full dataset, to 62% at 50% completeness and 21% at 25% completeness. In Washington, sensitivity decreased from 100% with the full dataset, to 71% at 50% completeness and 29% at 25% completeness. CONCLUSIONS: Lower sequence data completeness limits the ability to detect clusters that may benefit from investigation; however, inferences can be made about transmission patterns even with low data completeness, given sufficient numbers. Data completeness should be prioritized, as lack of or delays in detection of transmission clusters could result in additional infections.

      9. Burkholderia thailandensis isolated from infected wound, Arkansas, USAExternal
        Gee JE, Elrod MG, Gulvik CA, Haselow DT, Waters C, Liu L, Hoffmaster AR.
        Emerg Infect Dis. 2018 Nov;24(11):2091-2094.

        The bacterium Burkholderia thailandensis, a member of the Burkholderia pseudomallei complex, is generally considered nonpathogenic; however, on rare occasions, B. thailandensis infections have been reported. We describe a clinical isolate of B. thailandensis, BtAR2017, recovered from a patient with an infected wound in Arkansas, USA, in 2017.

      10. Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016External
        Hofmeister MG, Rosenthal EM, Barker LK, Rosenberg ES, Barranco MA, Hall EW, Edlin BR, Mermin J, Ward JW, Blythe Ryerson A.
        Hepatology. 2018 Nov 6.

        Hepatitis C virus (HCV) infection is the most commonly reported bloodborne infection in the United States, causing substantial morbidity and mortality and costing billions of dollars annually. To update the estimated HCV prevalence among all adults aged >/=18 years in the United States, we analyzed 2013-2016 data from the National Health and Nutrition Examination Survey (NHANES) to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches to estimate the HCV prevalence and population sizes for four additional populations: incarcerated people, unsheltered homeless people, active-duty military personnel, and nursing home residents. We estimated that during 2013-2016 1.7% (95% confidence interval [CI], 1.4-2.0%) of all adults in the United States, approximately 4.1 (3.4-4.9) million persons, were HCV antibody-positive (indicating past or current infection) and that 1.0% (95% CI, 0.8-1.1%) of all adults, approximately 2.4 (2.0-2.8) million persons, were HCV RNA-positive (indicating current infection). This includes 3.7 million noninstitutionalized civilian adults in the United States with HCV antibodies and 2.1 million with HCV RNA and an estimated 0.38 million HCV antibody-positive persons and 0.25 million HCV RNA-positive persons not part of the 2013-2016 NHANES sampling frame. Conclusion: Over 2 million people in the United States had current HCV infection during 2013-2016; compared to past estimates based on similar methodology, HCV antibody prevalence may have increased, while RNA prevalence may have decreased, likely reflecting the combination of the opioid crisis, curative treatment for HCV infection, and mortality among the HCV-infected population; efforts on multiple fronts are needed to combat the evolving HCV epidemic, including increasing capacity for and access to HCV testing, linkage to care, and cure.

      11. Comparison of hepatitis C virus testing recommendations in high-income countriesExternal
        Irvin R, Ward K, Agee T, Nelson NP, Vellozzi C, Thomas DL, Millman AJ.
        World J Hepatol. 2018 Oct 27;10(10):743-751.

        AIM: To investigate hepatitis C virus (HCV) testing recommendations from the United States and other high-income countries. METHODS: A comprehensive search for current HCV testing recommendations from the top quartile of United Nations Human Development Index (HDI) countries (very high HDI) was performed using Google and reviewed from May 1 – October 30, 2014 and re-reviewed April 1 – October 2, 2017. RESULTS: Of the 51 countries identified, 16 had HCV testing recommendations from a government body or recommendations issued collaboratively between a government and a medical organization. Of these 16 countries, 15 had HCV testing recommendations that were primarily risk-based and highlight behaviors, exposures, and conditions that are associated with HCV transmission in that region. In addition to risk-based testing, the HCV Guidance Panel (United States) incorporates recommendations for a one-time test for individuals born during 1945-1965 (the birth cohort) without prior ascertainment of risk into their guidance. In addition to the United States, six other countries either have an age-based testing recommendation or recommend one-time testing for all adults independent of risk factors typical of the region. CONCLUSION: This review affirmed the similarities of the HCV Guidance Panel’s guidance with those of recommendations from very high HDI countries.

      12. Progress towards elimination of measles in Kenya, 2003-2016External
        Kisangau N, Sergon K, Ibrahim Y, Yonga F, Langat D, Nzunza R, Borus P, Galgalo T, Lowther SA.
        Pan Afr Med J. 2018 ;31 (65).

        Introduction: Measles is targeted for elimination in the World Health Organization African Region by the year 2020. In 2011, Kenya was off track in attaining the 2012 pre-elimination goal. We describe the epidemiology of measles in Kenya and assess progress made towards elimination. Methods: We reviewed national case-based measles surveillance and immunization data from January 2003 to December 2016. A case was confirmed if serum was positive for anti-measles IgM antibody, was epidemiologically linked to a laboratory-confirmed case or clinically compatible. Data on case-patient demographics, vaccination status, and clinical outcome and measles containing vaccine (MCV) coverage were analyzed. We calculated measles surveillance indicators and incidence, using population estimates for the respective years. Results: The coverage of first dose MCV (MCV1) increased from 65% to 86% from 2003-2012, then declined to 75% in 2016. Coverage of second dose MCV (MCV2) remained < 50% since introduction in 2013. During 2003-2016, there were 26,188 suspected measles cases were reported, with 9043(35%) confirmed cases, and 165 deaths (case fatality rate, 1.8%). The non-measles febrile rash illness rate was consistently > 2/100,000 population, and “80% of the sub-national level investigated a case in 11 of the 14 years. National incidence ranged from 4 to 62/million in 2003-2006 and decreased to 3/million in 2016. The age specific incidence ranged from 1 to 364/million population and was highest among children aged < 1 year. Conclusion: Kenya has made progress towards measles elimination. However, this progress remains at risk and the recent declines in MCV1 coverage and the low uptake in MCV2 could reverse these gains.

      13. Fomite-mediated transmission as a sufficient pathway: a comparative analysis across three viral pathogensExternal
        Kraay AN, Hayashi MA, Hernandez-Ceron N, Spicknall IH, Eisenberg MC, Meza R, Eisenberg JN.
        BMC Infect Dis. 2018 Oct 29;18(1):540.

        BACKGROUND: Fomite mediated transmission can be an important pathway causing significant disease transmission in number of settings such as schools, daycare centers, and long-term care facilities. The importance of these pathways relative to other transmission pathways such as direct person-person or airborne will depend on the characteristics of the particular pathogen and the venue in which transmission occurs. Here we analyze fomite mediated transmission through a comparative analysis across multiple pathogens and venues. METHODS: We developed and analyzed a compartmental model that explicitly accounts for fomite transmission by including pathogen transfer between hands and surfaces. We consider two sub-types of fomite-mediated transmission: direct fomite (e.g., shedding onto fomites) and hand-fomite (e.g., shedding onto hands and then contacting fomites). We use this model to examine three pathogens with distinct environmental characteristics (influenza, rhinovirus, and norovirus) in four venue types. To parameterize the model for each pathogen we conducted a thorough literature search. RESULTS: Based on parameter estimates from the literature the reproductive number ([Formula: see text]) for the fomite route for rhinovirus and norovirus is greater than 1 in nearly all venues considered, suggesting that this route can sustain transmission. For influenza, on the other hand, [Formula: see text] for the fomite route is smaller suggesting many conditions in which the pathway may not sustain transmission. Additionally, the direct fomite route is more relevant than the hand-fomite route for influenza and rhinovirus, compared to norovirus. The relative importance of the hand-fomite vs. direct fomite route for norovirus is strongly dependent on the fraction of pathogens initially shed to hands. Sensitivity analysis stresses the need for accurate measurements of environmental inactivation rates, transfer efficiencies, and pathogen shedding. CONCLUSIONS: Fomite-mediated transmission is an important pathway for the three pathogens examined. The effectiveness of environmental interventions differs significantly both by pathogen and venue. While fomite-based interventions may be able to lower [Formula: see text] for fomites below 1 and interrupt transmission, rhinovirus and norovirus are so infectious ([Formula: see text]) that single environmental interventions are unlikely to interrupt fomite transmission for these pathogens.

      14. Reflexive laboratory-based cryptococcal antigen screening and preemptive fluconazole therapy for cryptococcal antigenemia in HIV-infected individuals with CD4 <100 cells/microL: a stepped-wedge, cluster-randomized trialExternal
        Meya DB, Kiragga AN, Nalintya E, Morawski BM, Rajasingham R, Park BJ, Mubiru A, Kaplan JE, Manabe YC, Boulware DR.
        J Acquir Immune Defic Syndr. 2018 Nov 5.

        BACKGROUND: HIV-infected persons with cryptococcal antigenemia (CrAg) are at high risk for meningitis or death. We evaluated the effect of CrAg screening and pre-emptive fluconazole therapy, as an adjunct to antiretroviral therapy (ART), on six-month survival among persons with advanced HIV disease. METHODS: We enrolled HIV-infected, ART-naive eligible participants with <100 CD4 cells/microL, in a stepped-wedge, cluster-randomized trial from July 2012 – December 2014 at 17 Ugandan clinics. Clinics participated in a prospective observational phase, followed by an interventional phase with lab-based, reflexive CrAg screening of residual CD4 count plasma. Asymptomatic CrAg-positive participants received preemptive fluconazole therapy for ten weeks. We assessed six-month survival using Cox-regression, adjusting for nadir CD4, calendar time, and stepped-wedge steps. RESULTS: We included 1,280 observational and 2,108 interventional participants, of whom 9.3% (195/2,108) were CrAg-positive. CD4-, time-, and stepped-wedge-adjusted analyses demonstrated no difference in survival in the observational vs the interventional arms (HR = 1.34; 95% CI, 0.86-2.10; P = 0.20), including when the analysis was limited to persons who started ART (HR=1.11; 95% CI, 0.62 – 1.79, P=0.86) However, six-month mortality of participants with CrAg titers <1:160 and CrAg-negative patients did not differ. Patients with CrAg titers >/=1:160 had 2.6-fold higher six-month mortality than patients with titers <1:160. CONCLUSION: We observed no overall survival benefit of the lab-based reflexive CrAg screen-and-treat intervention. However, preemptive antifungal therapy for asymptomatic cryptococcosis appeared to be effective in patients with CrAg titer <1:160. A more aggressive approach may be required for persons with CrAg titer >/=1:160.This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

      15. Disclosure and clinical outcomes among young adolescents living with HIV in KenyaExternal
        Ngeno B, Waruru A, Inwani I, Nganga L, Wangari EN, Katana A, Gichangi A, Mwangi A, Mukui I, Rutherford GW.
        J Adolesc Health. 2018 .

        Purpose: Informing adolescents of their own HIV infection is critical as the number of adolescents living with HIV increases. We assessed the association between HIV disclosure and retention in care and mortality among adolescents aged 10-14 years in Kenya’s national program. Methods: We abstracted routinely collected patient-level data for adolescents enrolled into HIV care in 50 health facilities from November 1, 2004, through March 31, 2010. We defined disclosure as any documentation that the adolescent had been fully or partially made aware of his or her HIV status. We compared weighted proportions for categorical variables using chi2 and weighted logistic regression to identify predictors of HIV disclosure; we estimated the probability of LTFU using Kaplan-Meier methods and dying using Cox regression-based test for equality of survival curves. Results: Of the 710 adolescents aged 10-14 years analyzed; 51.3% had severe immunosuppression, 60.3% were in WHO stage 3 or 4, and 36.6% were aware of their HIV status. Adolescents with HIV-infected parents, histories of opportunistic infections (OIs), and enrolled in support groups were more likely to be disclosed to. At 36 months, disclosure was associated with lower mortality [1.5% (95% CI.6%-4.1%) versus 5.4% (95% CI 3.6.6%-8.0%, p <.001)] and lower LTFU [6.2% (95% CI 3.0%-12.6%) versus 33.9% (95% CI 27.3%-41.1%) p <.001]. Conclusions: Only one third of HIV-infected Kenyan adolescents in treatment programs had been told they were infected, and knowing their HIV status was associated with reduced LTFU and mortality. The disclosure process should be systematically encouraged and organized for HIV-infected adolescents.

      16. Seroprevalence of herpes simplex virus types 1 and 2 among pregnant women and sexually active, nonpregnant women in the United StatesExternal
        Patton ME, Bernstein K, Liu G, Zaidi A, Markowitz LE.
        Clin Infect Dis. 2018 Oct 30;67(10):1535-1542.

        Background: Neonatal herpes is a rare, devastating consequence of herpes simplex virus type 1 (HSV-1) or 2 (HSV-2) infection during pregnancy. The risk of neonatal infection is higher among pregnant women seronegative for HSV-1 or HSV-2 who acquire their first HSV infection near delivery. Methods: We estimated HSV-1 and HSV-2 seroprevalence among pregnant women aged 20-39 years in 1999-2014, assessed HSV seroprevalence changes between 1999-2006 and 2007-2014, and compared HSV seroprevalence between pregnant women and sexually active, nonpregnant women aged 20-39 years in 2007-2014 using National Health and Nutrition Examination Survey data. Results: Among pregnant women in 1999-2014, HSV-1 seroprevalence was 59.3%, HSV-2 seroprevalence was 21.1%, and HSV seronegativity was 30.6%. Between 1999-2006 and 2007-2014, HSV-1 and HSV-2 seroprevalence among pregnant women remained stable. However, among pregnant women with </=3 sex partners (approximately 40% of all pregnant women), seronegativity for both HSV-1 and HSV-2 increased from 35.6% to 51.4% (P < .05). In 2007-2014, nonpregnant women who were (1) unmarried, (2) living below poverty level, or (3) had >/=4 sex partners were more likely than pregnant women to be seronegative for both HSV-1 and HSV-2 (P < .05). Conclusions: HSV-1 and HSV-2 seroprevalence among US pregnant women remained stable between 1999 and 2014. However, pregnant women with fewer sex partners were increasingly seronegative for both HSV-1 and HSV-2, indicating an increasing proportion of pregnant women who are vulnerable to primary HSV acquisition in pregnancy, which confers an increased risk of transmitting HSV to their neonates.

      17. BACKGROUND: Early (including acute) HIV infection is associated with viral loads higher than those in later stages. OBJECTIVE: This study aimed to examine the association between acute infection and viral loads near the time of diagnosis using data reported to the US National HIV Surveillance System. METHODS: We analyzed data on infections diagnosed in 2012-2016 and reported through December 2017. Diagnosis and staging were based on the 2014 US surveillance case definition for HIV infection. We divided early HIV-1 infection (stage 0) into two subcategories. Subcategory 0alpha: a negative or indeterminate HIV-1 antibody test was </=60 days after the first confirmed positive HIV-1 test or a negative or indeterminate antibody test or qualitative HIV-1 nucleic acid test (NAT) was </=180 days before the first positive test, the latter being a NAT or detectable viral load. Subcategory 0beta: a negative or indeterminate antibody or qualitative NAT was </=180 days before the first positive test, the latter being an HIV antibody or antigen/antibody test. We compared median earliest viral loads for each stage and subcategory in each of the first 6 weeks after diagnosis using only the earliest viral load for each individual. RESULTS: Of 203,392 infections, 56.69% (115,297/203,392) were reported with a quantified earliest viral load within 6 weeks after diagnosis and criteria sufficient to determine the stage at diagnosis. Among 5081 infections at stage 0, the median earliest viral load fell from 694,000 copies/mL in week 1 to 125,022 in week 2 and 43,473 by week 6. Among 30,910 infections in stage 1, the median earliest viral load ranged 15,412-17,495. Among 42,784 infections in stage 2, the median viral load declined from 44,973 in week 1 to 38,497 in week 6. Among 36,522 infections in stage 3 (AIDS), the median viral load dropped from 205,862 in week 1 to 119,000 in week 6. The median earliest viral load in stage 0 subcategory 0alpha fell from 1,344,590 copies/mL in week 1 to 362,467 in week 2 and 47,320 in week 6, while that in subcategory 0beta was 70,114 copies/mL in week 1 and then 32,033 to 44,067 in weeks 2-6. The median viral load in subcategory 0alpha was higher than that in subcategory 0beta in each of the first 6 weeks after diagnosis (P<.001). CONCLUSIONS: In the 1st week after diagnosis, viral loads in early infections are generally several times higher than those in later stages at diagnosis. By the 3rd week, however, most are lower than those in stage 3. High viral loads in early infection are much more common in subcategory 0alpha than in subcategory 0beta, consistent with 0alpha comprising mostly acute infections and 0beta comprising mostly postacute early infections. These findings may inform the prioritization of interventions for prevention.

      18. Notes from the Field: Cronobacter sakazakii meningitis in a full-term neonate fed exclusively with breast milk – Indiana, 2018External
        Sundararajan M, Enane LA, Kidwell LA, Gentry R, Danao S, Bhumbra S, Lehmann C, Teachout M, Yeadon-Fagbohun J, Krombach P, Schroeder B, Martin H, Winkjer J, Waltz T, Strysko J, Cope JR.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1248-1249.

        [No abstract]

      19. Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause 1.3 million deaths annually. To prevent over 7 million deaths by 2030, the World Health Organization set goals to eliminate HBV and HCV, defined as a 90% reduction in new infections and a 65% reduction in deaths, and prevent more than 7 million related deaths by 2030. Elimination of HBV and HCV is feasible because of characteristics of the viruses, reliable diagnostic tools, and available cost-effective or cost-saving interventions. Broad implementation of infant immunization against HBV, blood safety and infection-control programs have greatly reduced the burden of HBV and HCV infections. To achieve elimination, priorities include implementation of HBV vaccine-based strategies to prevent perinatal transmission, safe injection practices and HCV treatment for persons who inject drugs, and testing and treatment for HBV- and HCV-infected persons. With sufficient capacity, HBV and HCV elimination programs can meet their goals.

    • Disaster Control and Emergency Services
      1. Perspective on improving environmental monitoring of biothreatsExternal
        Dunbar J, Pillai S, Wunschel D, Dickens M, Morse SA, Franz D, Bartko A, Challacombe J, Persons T, Hughes MA, Blanke SR, Holland R, Hutchison J, Merkley ED, Campbell K, Branda CS, Sharma S, Lindler L, Anderson K, Hodge D.
        Front Bioeng Biotechnol. 2018 ;6:147.

        For more than a decade, the United States has performed environmental monitoring by collecting and analyzing air samples for a handful of biological threat agents (BTAs) in order to detect a possible biological attack. This effort has faced numerous technical challenges including timeliness, sampling efficiency, sensitivity, specificity, and robustness. The cost of city-wide environmental monitoring using conventional technology has also been a challenge. A large group of scientists with expertise in bioterrorism defense met to assess the objectives and current efficacy of environmental monitoring and to identify operational and technological changes that could enhance its efficacy and cost-effectiveness, thus enhancing its value. The highest priority operational change that was identified was to abandon the current concept of city-wide environmental monitoring because the operational costs were too high and its value was compromised by low detection sensitivity and other environmental factors. Instead, it was suggested that the focus should primarily be on indoor monitoring and secondarily on special-event monitoring because objectives are tractable and these operational settings are aligned with likelihood and risk assessments. The highest priority technological change identified was the development of a reagent-less, real-time sensor that can identify a potential airborne release and trigger secondary tests of greater sensitivity and specificity for occasional samples of interest. This technological change could be transformative with the potential to greatly reduce operational costs and thereby create the opportunity to expand the scope and effectiveness of environmental monitoring.

      2. Medical countermeasures for children in radiation and nuclear disasters: Current capabilities and key gapsExternal
        Gardner AH, Dziuban EJ, Griese S, Berrios-Cartagena N, Buzzell J, Cobham-Owens K, Peacock G, Kazzi Z, Prasher JM.
        Disaster Med Public Health Prep. 2018 Nov 2:1-8.

        OBJECTIVE: Despite children’s unique vulnerability, clinical guidance and resources are lacking around the use of radiation medical countermeasures (MCMs) available commercially and in the Strategic National Stockpile to support immediate dispensing to pediatric populations. To better understand the current capabilities and shortfalls, a literature review and gap analysis were performed. METHODS: A comprehensive review of the medical literature, Food and Drug Administration (FDA)-approved labeling, FDA summary reviews, medical references, and educational resources related to pediatric radiation MCMs was performed from May 2016 to February 2017. RESULTS: Fifteen gaps related to the use of radiation MCMs in children were identified. The need to address these gaps was prioritized based upon the potential to decrease morbidity and mortality, improve clinical management, strengthen caregiver education, and increase the relevant evidence base. CONCLUSIONS: Key gaps exist in information to support the safe and successful use of MCMs in children during radiation emergencies; failure to address these gaps could have negative consequences for families and communities. There is a clear need for pediatric-specific guidance to ensure clinicians can appropriately identify, triage, and treat children who have been exposed to radiation, and for resources to ensure accurate communication about the safety and utility of radiation MCMs for children. (Disaster Med Public Health Preparedness. 2018;page 1 of 8).

      3. Experimental studies on performance of ventilators stored in the Strategic National StockpileExternal
        Mehrabi A, Dillon P, Kelly K, Hitchins K, Malatino E, Gorman S, Nambiar M, Scharen H.
        J Emerg Manag. 2018 Sep/Oct;16(5):321-336.

        BACKGROUND: The Center for Devices and Radiological Health, Food and Drug Administration (FDA) launched a collaborative initiative with Centers for Disease Control and Prevention (CDC) to gain a better understanding of ventilators that are used during national emergencies. This initiative was intended to test reliability of ventilator devices stored long term in the CDC Strategic National Stockpile (SNS) and also used by the Department of Defense. These ventilators are intended to be used by trained operators to provide ventilatory support to adult and pediatric populations under diverse environmental conditions. The authors evaluated device performance and possible effects of long-term storage. METHODS: Three SNS ventilator models: Impact Uni-Vent 754 Eagle, Covidien (Puritan Bennett) LP10, and CareFusion LTV 1200 were used in this study. A total of 36 ventilators, 12 per model, were evaluated for performance in simulated adult populations using a test lung. The parameters evaluated included battery charge status and capability, battery longevity, positive end expiratory pressure consistency, device performance on AC and DC (battery) power, and device durability testing. RESULTS: The out-of-the-box run time was equal to or higher than the manufacturer’s specifications for fully charged batteries for all ventilators except 58 percent of the Impact 754 ventilators. No significant ventilator performance issues were observed in terms of tidal volume consistency, proximal pressure, oxygen consumption, and a 2000-hour run test in LP10 models. CONCLUSIONS: These findings provide information about the long-term storage of ventilators that have regular maintenance, and their ability to perform reliably during a public health emergency.

    • Disease Reservoirs and Vectors
      1. Zoonotic Cryptosporidium species and subtypes in lambs and goat kids in AlgeriaExternal
        Baroudi D, Hakem A, Adamu H, Amer S, Khelef D, Adjou K, Dahmani H, Chen X, Roellig D, Feng Y, Xiao L.
        Parasit Vectors. 2018 Nov 6;11(1):582.

        BACKGROUND: Little is known on the occurrence and identity of Cryptosporidium species in sheep and goats in Algeria. This study aimed at investigating the occurrence of Cryptosporidium species in lambs and goat kids younger than 4 weeks. METHODS: A total of 154 fecal samples (62 from lambs and 92 from kid goats) were collected from 13 sheep flocks in Medea, Algeria and 18 goat flocks across Algiers and Boumerdes. They were screened for Cryptosporidium spp. by nested-PCR analysis of a fragment of the small subunit (SSU) rRNA gene, followed by restriction fragment length polymorphism and sequence analyses to determine the Cryptosporidium species present. Cryptosporidium parvum and C. ubiquitum were further subtyped by sequence analysis of the 60 kDa glycoprotein gene. RESULTS: Cryptosporidium spp. were detected in 17 fecal samples (11.0%): 9 from lambs (14.5%) and 8 from goat kids (8.7%). The species identified included C. parvum in 3 lambs, C. xiaoi in 6 lambs and 6 goat kids, and C. ubiquitum in 2 goat kids. Cryptosporidium infections were detected mostly in animals during the first two weeks of life (7/8 for goat kids and 7/9 for lambs) and in association with diarrhea occurrence (7/17 or 41.2% goat kids and 7/10 or 70.0% lambs with diarrhea were positive for Cryptosporidium spp.). Subtyping of C. parvum and C. ubiquitum isolates identified the zoonotic IIaA13G2R1 and XIIa subtype families, respectively. Minor differences in the SSU rRNA gene sequences were observed between C. xiaoi from sheep and goats. CONCLUSIONS: Results of this study indicate that three Cryptosporidium species occur in lambs and goat kids in Algeria, including zoonotic C. parvum and C. ubiquitum. They are associated with the occurrence of neonatal diarrhea.

      2. Detection of tickborne relapsing fever spirochete, Austin, Texas, USAExternal
        Bissett JD, Ledet S, Krishnavajhala A, Armstrong BA, Klioueva A, Sexton C, Replogle A, Schriefer ME, Lopez JE.
        Emerg Infect Dis. 2018 Nov;24(11):2003-2009.

        In March 2017, a patient became febrile within 4 days after visiting a rustic conference center in Austin, Texas, USA, where Austin Public Health suspected an outbreak of tickborne relapsing fever a month earlier. Evaluation of a patient blood smear and molecular diagnostic assays identified Borrelia turicatae as the causative agent. We could not gain access to the property to collect ticks. Thus, we focused efforts at a nearby public park, <1 mile from the suspected exposure site. We trapped Ornithodoros turicata ticks from 2 locations in the park, and laboratory evaluation resulted in cultivation of 3 B. turicatae isolates. Multilocus sequencing of 3 chromosomal loci (flaB, rrs, and gyrB) indicated that the isolates were identical to those of B. turicatae 91E135 (a tick isolate) and BTE5EL (a human isolate). We identified the endemicity of O. turicata ticks and likely emergence of B. turicatae in this city.

      3. A decade of vector control activities: Progress and limitations of Chagas disease prevention in a region of Guatemala with persistent Triatoma dimidiata infestationExternal
        Juarez JG, Pennington PM, Bryan JP, Klein RE, Beard CB, Berganza E, Rizzo N, Cordon-Rosales C.
        PLoS Negl Trop Dis. 2018 Nov 6;12(11):e0006896.

        INTRODUCTION: Chagas disease, a neglected tropical disease that affects millions of Latin Americans, has been effectively controlled in Guatemala after multiple rounds of indoor residual insecticide spraying (IRS). However, a few foci remain with persistent Triatoma dimidiata infestation. One such area is the municipality of Comapa, Department of Jutiapa, in the southeastern region of Guatemala, where control interventions appear less effective. We carried out three cross sectional entomological and serological surveys in Comapa to evaluate a decade of vector control activities. Baseline serological (1999) and entomological (2001-2) surveys were followed by three rounds of insecticide applications (2003-2005) and intermittent focal spraying of infested houses, until approximately 2012. Household inspections to determine entomological indices and construction materials were conducted in 2001, 2007 and 2011. Seroprevalence surveys were conducted in school-age children in 1999, 2007 and 2015, and in women of child bearing age (15-44 years) only in 2015. After multiple rounds of indoor residual sprayings (IRS), the infestation index decreased significantly from 39% (2001-2) to 27% (2011). Household construction materials alone predicted <10% of infested houses. Chagas seroprevalence in Comapa declined in school-aged children by 10-fold, from 10% (1999) to 1% (2015). However, seroprevalence in women of child bearing age remains >10%. CONCLUSION: After a decade of vector control activities in Comapa, there is evidence of significantly reduced transmission. However, the continued risk for vector-borne and congenital transmission pose a threat to the 2022 Chagas disease elimination goal. Systematic integrated vector control and improved Chagas disease screening and treatment programs for congenital and vector-borne disease are needed to reach the elimination goal in regions with persistent vector infestation.

      4. To explain the patchy distribution of West Nile virus (WNV), we propose that avian immunity encountered by Culex vectors regulates WNV transmission, particularly at communal bird roosts. To test this hypothesis, we selected two test sites with communally roosting American robins (Turdus migratorius) and two control sites that lacked communal roosts. The density of vector-vertebrate contacts, represented by engorged Culex pipiens, was 23-fold greater at test sites compared to control sites, and the density of blood-engorged Cx. pipiens measured in resting mosquito traps correlated positively with the presence of robins and negatively with the presence of other birds, confirming an attraction to robins for blood feeding. WNV transmission was alternately up-regulated (amplification) and down-regulated (suppression) at both test sites. At one test site, infection in resting Cx. pipiens surged from zero to 37.2 per thousand within four weeks, and robin immunity rose from 8.4% to 64% before reducing to 33%. At this site, ten potentially infectious contacts between vector and vertebrates (including nine robins and a mourning dove [Zenaida macroura]) were documented. Infectious vector-vertebrate contacts were absent from control sites. The use of infectious vector-vertebrate contacts, rather than infected mosquitoes, to evaluate a transmission focus is novel.

    • Drug Safety
      1. Variation in outpatient antibiotic dispensing for respiratory infections in children by clinician specialty and treatment settingExternal
        Agiro A, Gautam S, Wall E, Hackell J, Helm M, Barron J, Zaoutis T, Fleming-Dutra KE, Hicks LA, Rosenberg A.
        Pediatr Infect Dis J. 2018 Dec;37(12):1248-1254.

        BACKGROUND: Antibiotics are commonly prescribed for children with acute respiratory infections (ARIs). This study describes the distribution of ARI diagnoses and specifically quantifies antibiotic dispensing for bronchitis and upper respiratory infection (URI) by treatment setting and specialty. METHODS: This retrospective, observational cross-sectional study used data from the HealthCore Integrated Research Environment containing claims from 14 commercial health plans for 2012 to 2014. Children (2-17 years) with first-episode ARI were identified by diagnosis of acute otitis media (AOM), sinusitis, pharyngitis, bronchitis or URI with no competing infections or chronic illnesses. Treatment setting was where diagnoses were made: primary care offices, urgent care centers (UCC), retail health clinics (RHCs) or emergency departments. Primary outcome measure was antibiotic prescription fills from pharmacies within 2 days of start of ARI episode. RESULTS: For URI, the highest proportions in antibiotic dispensing were ordered by office-based or UCC family physicians (28% and 30%, respectively) and office-based or UCC nurse practitioners/physician assistants (30% and 29%, respectively). Across all settings and specialties, there was high proportion of antibiotic dispensing for bronchitis (75%). Overall, 48% of 544,531 children diagnosed with ARI filled antibiotics. Nurse practitioners/physician assistants in RHC made the most diagnoses of AOM (24%) and streptococcal pharyngitis (22%). CONCLUSIONS: Outreach efforts to decrease antibiotic dispensing for URI can be focused on office-based and UCC family physicians and nurse practitioners/physician assistants. All specialties need widespread interventions to reduce antibiotic dispensing for bronchitis. RHC nurse practitioners/physician assistants can be targeted to reduce high proportion of AOM and streptococcal pharyngitis diagnoses.

      2. Antibiotic prescriptions associated with dental-related emergency department visitsExternal
        Roberts RM, Hersh AL, Shapiro DJ, Fleming-Dutra KE, Hicks LA.
        Ann Emerg Med. 2018 Nov 1.

        STUDY OBJECTIVE: The frequency of antibiotic prescribing and types of antibiotics prescribed for dental conditions presenting to the emergency department (ED) is not well known. The objective of this study is to quantify how often and which dental diagnoses made in the ED resulted in an antibiotic prescription. METHODS: From 2011 to 2015, there were an estimated 2.2 million (95% confidence interval [CI] 1.9 to 2.5 million) ED visits per year for dental-related conditions, which accounted for 1.6% (95% CI 1.5% to 1.7%) of ED visits. This is based on an unweighted 2,125 observations from the National Hospital Ambulatory Medical Care Survey in which a dental-related diagnosis was made. RESULTS: An antibiotic, most often a narrow-spectrum penicillin or clindamycin, was prescribed in 65% (95% CI 61% to 68%) of ED visits with any dental diagnosis. The most common dental diagnoses for all ages were unspecified disorder of the teeth and supporting structures (44%; 95% CI 41% to 48%; International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] code 525.9), periapical abscess without sinus (21%; 95% CI 18% to 25%; ICD-9-CM code 522.5), and dental caries (18%; 95% CI 15% to 22%; ICD-9-CM code 521.0). Recommended treatments for these conditions are usually dental procedures rather than antibiotics. CONCLUSION: The common use of antibiotics for dental conditions in the ED may indicate the need for greater access to both preventive and urgent care from dentists and other related specialists as well as the need for clearer clinical guidance and provider education related to oral infections.

    • Environmental Health
      1. [No abstract]

    • Epidemiology and Surveillance
      1. Comparing the performance of 2 health utility measures in the Medicare Health Outcome Survey (HOS)External
        Jia H, Lubetkin EI, DeMichele K, Stark DS, Zack MM, Thompson WW.
        Med Decis Making. 2018 Nov;38(8):983-993.

        BACKGROUND: The Medicare Health Outcomes Survey (HOS), a nationwide annual survey of Medicare beneficiaries, includes the Centers for Disease Control and Prevention’s HRQOL-4 questionnaire and Veterans RAND 12-item Health Survey (VR-12). This study compared EQ-5D scores derived from the HRQOL-4 (dEQ-5D) to SF-6D scores derived from VR-12. METHODS: Data were from Medicare HOS Cohort 15 (2012 baseline; 2014 follow-up). We included participants aged 65+ ( n = 105,473). We compared score distributions, evaluated known-groups validity, assessed each index as a predictor for mortality, and estimated quality-adjusted life years (QALYs) using the dEQ-5D and SF-6D. RESULTS: Compared to the SF-6D, the dEQ-5D had a higher mean score (0.787 v. 0.691) and larger standard deviation (0.310 v. 0.101). The decreases in estimated scores associated with chronic conditions were greater for the dEQ-5D than for the SF-6D. For example, dEQ-5D scores for persons with depression decreased 0.456 points compared to 0.141 points for the SF-6D. The dEQ-5D strongly predicted mortality, as adjusted hazard ratios for the first to fourth quintiles, relative to the fifth quintile, were 2.2, 1.7, 1.8, and 1.5, respectively, while the association between SF-6D and mortality was weaker or nonexistent (adjusted hazard ratios were 1.3, 1.1, 1.0, and 0.6, respectively). Compared to the SF-6D, QALYs estimated using the dEQ-5D were higher overall (5.6 v. 4.9 years), higher for persons with less debilitating conditions (e.g., hypertension, 5.0 v. 4.4 years), and lower for more debilitating conditions (e.g. depression, 2.5 v. 2.8 years). CONCLUSIONS: Compared to the SF-6D, the dEQ-5D was better able to measure individuals’ overall health; detect the differential impact of chronic conditions, particularly among persons in poorer health; and predict mortality. The HRQOL-4 questionnaire may be valuable for monitoring and improving health outcomes for the Medical HOS data set.

    • Genetics and Genomics
      1. PacBio genome sequences of Escherichia coli serotype O157:H7, diffusely adherent E. coli, and Salmonella enterica strains, all carrying plasmids with an mcr-1 resistance geneExternal
        Lindsey RL, Batra D, Smith P, Patel PN, Tagg KA, Garcia-Toledo L, Loparev VN, Juieng P, Sheth M, Joung YJ, Rowe LA.
        Microbiol Resour Announc. 2018 ;7(14).

        We report here Illumina-corrected PacBio whole-genome sequences of an Escherichia coli serotype O157:H7 strain (2017C-4109), an E. coli serotype O[undetermined]:H2 strain (2017C-4173W12), and a Salmonella enterica subsp. enterica serovar Enteritidis strain (2017K-0021), all of which carried the mcr-1 resistance gene on an IncI2 or IncX4 plasmid. We also determined that pMCR-1-CTSe is identical to a previously published plasmid, pMCR-1-CT.

      2. Timing the origin of Cryptococcus gattii sensu stricto, southeastern United StatesExternal
        Lockhart SR, Roe CC, Engelthaler DM.
        Emerg Infect Dis. 2018 Nov;24(11):2095-2097.

        We conducted molecular clock analysis of whole-genome sequences from a set of autochthonous isolates of Cryptococcus gattii sensu stricto from the southeastern United States. Our analysis indicates that C. gattii arrived in the southeastern United States approximately 9,000-19,000 years ago, long before its arrival in the Pacific Northwest.

    • Health Disparities
      1. Rural cancer control: Bridging the chasm in geographic health inequityExternal
        Henley SJ, Jemal A.
        Cancer Epidemiol Biomarkers Prev. 2018 Nov;27(11):1248-1251.

        [No abstract]

    • Health Economics
      1. Background: Treatment of noncommunicable diseases (NCDs) in low-income countries can entail large out-of-pocket (OOP) medical expenditures, which can increase the likelihood of household impoverishment and perpetuate the poverty cycle. This paper studies the implications of NCDs on household medical expenditure, household financial stress (e.g. selling assets or borrowing for treatment financing), catastrophic OOP expenditure, and impoverishment in Bangladesh. Methods: We used self-reported health status and household expenditure survey data from 12,240 households in Bangladesh. NCD-afflicted households were defined by presence of at least one of the following conditions within the household – heart disease, hypertension, asthma, diabetes, cancer, or kidney disease. Using linear regression models, we examined whether NCD households incur more medical expenditures, allocate a larger budget share on medical expenditures, and have greater probability of experiencing catastrophic medical expenditure or financial stress from OOP spending than non-NCD households. Finally, using survey weights, we extrapolated how NCD-attributable medical expenditure can result in impoverishment and downward movement in net consumption status at the population level. Results: NCD-afflicted households allocate a greater share of household expenditures for medical care than households without NCDs, and their probability of incurring catastrophic medical expenditure is higher by 6.7 percentage points compared to the households with no reported conditions. NCD households are 85% more likely to sell assets or borrow from informal sources to finance treatment cost. Household spending on NCD care is estimated to account for the impoverishment of 0.66 million persons in Bangladesh in 2010, and for reducing the net consumption status of 7.63 million persons on both sides of the poverty line after accounting for NCD-related OOP expenditures. Conclusion: NCD-related household medical expenditure is associated with experiencing financial distress and aggravating poverty in Bangladesh.

    • Immunity and Immunization
      1. Study of Healthcare Personnel with Influenza and other Respiratory Viruses in Israel (SHIRI): study protocolExternal
        Hirsch A, Katz MA, Laufer Peretz A, Greenberg D, Wendlandt R, Shemer Avni Y, Newes-Adeyi G, Gofer I, Leventer-Roberts M, Davidovitch N, Rosenthal A, Gur-Arie R, Hertz T, Glatman-Freedman A, Monto AS, Azziz-Baumgartner E, Ferdinands JM, Martin ET, Malosh RE, Neyra Quijandria JM, Levine M, Campbell W, Balicer R, Thompson MG.
        BMC Infect Dis. 2018 Nov 6;18(1):550.

        BACKGROUND: The Study of Healthcare Personnel with Influenza and other Respiratory Viruses in Israel (SHIRI) prospectively follows a cohort of healthcare personnel (HCP) in two hospitals in Israel. SHIRI will describe the frequency of influenza virus infections among HCP, identify predictors of vaccine acceptance, examine how repeated influenza vaccination may modify immunogenicity, and evaluate influenza vaccine effectiveness in preventing influenza illness and missed work. METHODS: Cohort enrollment began in October, 2016; a second year of the study and a second wave of cohort enrollment began in June 2017. The study will run for at least 3 years and will follow approximately 2000 HCP (who are both employees and members of Clalit Health Services [CHS]) with routine direct patient contact. Eligible HCP are recruited using a stratified sampling strategy. After informed consent, participants complete a brief enrollment survey with questions about occupational responsibilities and knowledge, attitudes, and practices about influenza vaccines. Blood samples are collected at enrollment and at the end of influenza season; HCP who choose to be vaccinated contribute additional blood one month after vaccination. During the influenza season, participants receive twice-weekly short message service (SMS) messages asking them if they have acute respiratory illness or febrile illness (ARFI) symptoms. Ill participants receive follow-up SMS messages to confirm illness symptoms and duration and are asked to self-collect a nasal swab. Information on socio-economic characteristics, current and past medical conditions, medical care utilization and vaccination history is extracted from the CHS database. Information about missed work due to illness is obtained by self-report and from employee records. Respiratory specimens from self-collected nasal swabs are tested for influenza A and B viruses, respiratory syncytial virus, human metapneumovirus, and coronaviruses using validated multiplex quantitative real-time reverse transcription polymerase chain reaction assays. The hemagglutination inhibition assay will be used to detect the presence of neutralizing influenza antibodies in serum. DISCUSSION: SHIRI will expand our knowledge of the burden of respiratory viral infections among HCP and the effectiveness of current and repeated annual influenza vaccination in preventing influenza illness, medical utilization, and missed workdays among HCP who are in direct contact with patients. TRIAL REGISTRATION: NCT03331991 . Registered on November 6, 2017.

      2. Progress toward poliomyelitis eradication – Pakistan, January 2017-September 2018External
        Hsu C, Mahamud A, Safdar M, Nikulin J, Jorba J, Bullard K, Agbor J, Kader M, Sharif S, Ahmed J, Ehrhardt D.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1242-1245.

        Among the three wild poliovirus (WPV) serotypes, only WPV type 1 (WPV1) has been reported in polio cases or detected from environmental surveillance globally since 2012. Pakistan remains one of only three countries worldwide (the others are Afghanistan and Nigeria) that has never had interrupted WPV1 transmission. This report documents Pakistan’s activities and progress toward polio eradication during January 2017-September 2018 and updates previous reports (1,2). In 2017, Pakistan reported eight WPV1 cases, a 60% decrease from 20 cases in 2016. As of September 18, 2018, four cases had been reported, compared with five cases at that time in 2017. Nonetheless, in 2018, WPV1 continues to be isolated regularly from environmental surveillance sites, primarily in the core reservoir areas of Karachi, Quetta, and Peshawar, signifying persistent transmission. Strategies to increase childhood immunity have included an intense schedule of supplemental immunization activities (SIAs), expanding and refining deployment of community-based vaccination implemented by community health workers recruited from the local community in reservoir areas, and strategic placement of permanent transit points where vaccination is provided to mobile populations. Interruption of WPV1 transmission will require further programmatic improvements throughout the country with a focus on specific underperforming subdistricts in reservoir areas.

    • Injury and Violence
      1. Firearm homicides and suicides in major metropolitan areas – United States, 2012-2013 and 2015-2016External
        Kegler SR, Dahlberg LL, Mercy JA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1233-1237.

        Firearm homicides and suicides represent a continuing public health concern in the United States. During 2015-2016, a total of 27,394 firearm homicides (including 3,224 [12%] among persons aged 10-19 years) and 44,955 firearm suicides (including 2,118 [5%] among persons aged 10-19 years) occurred among U.S. residents (1). This report updates an earlier report (2) that provided statistics on firearm homicides and suicides in major metropolitan areas during 2006-2007 and 2009-2010, and places continued emphasis on youths, in recognition of the importance of early prevention efforts. Firearm homicide and suicide rates were determined for the 50 most populous U.S. metropolitan statistical areas (MSAs)* during 2012-2013 and 2015-2016 using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. In contrast to the earlier report, which indicated that firearm homicide rates among persons of all ages had been declining both nationally and in large MSAs overall, current findings show that rates have returned to levels comparable to those observed during 2006-2007. Consistent with the earlier report, these findings show that firearm suicide rates among persons aged >/=10 years have continued to increase, both nationally and in large MSAs overall. Although firearm suicide rates among youths remain notably lower than those among persons of all ages, youth rates have also increased both nationally and in large MSAs collectively. These findings can inform ongoing development and monitoring of strategies directed at reducing firearm-related violence.

    • Laboratory Sciences
      1. Tobacco use classification by inexpensive urinary cotinine immunoassay test stripsExternal
        Achilihu H, Feng J, Wang L, Bernert JT.
        J Anal Toxicol. 2018 Nov 3.

        Urinary cotinine is one of the most commonly measured biomarkers reflecting recent exposure to nicotine. In some cases a simple qualitative dichotomization of smokers and non-smokers is all that is required. NicAlert(R) test strips have been evaluated for this purpose, but other recently introduced, inexpensive single-line test strips have not. In this study we evaluated two such strips with nominal cutoffs of 200 and 10 ng/mL. A total of 800 urine samples with known cotinine concentrations determined by an LC-MS-MS method were examined, including 400 urine samples ranging from 0.23 to more than 24,000 ng/mL by the 200 ng/mL strip, and 400 samples with concentrations <200 ng/mL by the 10 ng/mL cutoff strip. Both test strips performed well in these evaluations. Classification relative to LC-MS-MS by the 200 ng/mL strips had a sensitivity of 99.5% and specificity of 92%, with 95.8% accuracy. The 10 ng/mL strips had a sensitivity of 98.7% and specificity of 90.1%, with 93.3% accuracy. The positive predictive value for the 200 ng/mL strips was 92.6% and the negative predictive value was 99.5%. For the 10 ng/mL strips, the corresponding values were 85.4 and 99.2%, respectively. The prevalence of positive samples was 50% in the 200 ng/mL group, and 37% in the 10 ng/mL set. Each strip was read by two readers with an overall agreement of >98%. Our results suggest that these simple and inexpensive lateral flow immunoassay test strips can provide useful qualitative estimates of nicotine exposures for appropriate applications within the inherent limitations of sensitivity and precision of the immunoassay test strip format.

      2. Analysis of erythrocyte dynamics in Rhesus macaque monkeys during infection with Plasmodium cynomolgiExternal
        Fonseca LL, Joyner CJ, Saney CL, Moreno A, Barnwell JW, Galinski MR, Voit EO.
        Malar J. 2018 Nov 6;17(1):410.

        BACKGROUND: Malaria is a major mosquito transmitted, blood-borne parasitic disease that afflicts humans. The disease causes anaemia and other clinical complications, which can lead to death. Plasmodium vivax is known for its reticulocyte host cell specificity, but many gaps in disease details remain. Much less is known about the closely related species, Plasmodium cynomolgi, although it is naturally acquired and causes zoonotic malaria. Here, a computational model is developed based on longitudinal analyses of P. cynomolgi infections in nonhuman primates to investigate the erythrocyte dynamics that is pertinent to understanding both P. cynomolgi and P. vivax malaria in humans. METHODS: A cohort of five P. cynomolgi infected Rhesus macaques (Macaca mulatta) is studied, with individuals exhibiting a plethora of clinical outcomes, including varying levels of anaemia. A discrete recursive model with age structure is developed to replicate the dynamics of P. cynomolgi blood-stage infections. The model allows for parasitic reticulocyte preference and assumes an age preference among the mature RBCs. RBC senescence is modelled using a hazard function, according to which RBCs have a mean lifespan of 98 +/- 21 days. RESULTS: Based on in vivo data from three cohorts of macaques, the computational model is used to characterize the reticulocyte lifespan in circulation as 24 +/- 5 h (n = 15) and the rate of RBC production as 2727 +/- 209 cells/h/microL (n = 15). Analysis of the host responses reveals a pre-patency increase in the number of reticulocytes. It also allows the quantification of RBC removal through the bystander effect. CONCLUSIONS: The evident pre-patency increase in reticulocytes is due to a shift towards the release of younger reticulocytes, which could result from a parasite-induced factor meant to increase reticulocyte availability and satisfy the parasite’s tropism, which has an average value of 32:1 in this cohort. The number of RBCs lost due to the bystander effect relative to infection-induced RBC losses is 62% for P. cynomolgi infections, which is substantially lower than the value of 95% previously determined for another simian species, Plasmodium coatneyi.

      3. Comparative cytotoxicity of respirable surface-treated/untreated calcium carbonate rock dust particles in vitroExternal
        Khaliullin TO, Kisin ER, Yanamala N, Guppi S, Harper M, Lee T, Shvedova AA.
        Toxicol Appl Pharmacol. 2018 Oct 25;362:67-76.

        Calcium carbonate rock dust (RD) is used in mining to reduce the explosivity of aerosolized coal. During the dusting procedures, potential for human exposure occurs, raising health concerns. To improve RD aerosolization, several types of anti-caking surface treatments exist. The aim of the study was to evaluate cytotoxicity of four respirable RD samples: untreated/treated limestone (UL/TL), untreated/treated marble (UM/TM), and crystalline silica (SiO2) as a positive control in A549 and THP-1 transformed human cell lines. Respirable fractions were generated and collected using FSP10 high flow-rate cyclone samplers. THP-1 cells were differentiated with phorbol-12-myristate-13-acetate (20ng/ml, 48h). Cells were exposed to seven different concentrations of RD and SiO2 (0-0.2mg/ml). RD caused a slight decrease in viability at 24 or 72h post-exposure and were able to induce inflammatory cytokine production in A549 cells, however, with considerably less potency than SiO2. In THP-1 cells at 24h, there was significant dose-dependent lactate dehydrogenase, inflammatory cytokine and chemokine release. Caspase-1 activity was increased in SiO2- and, on a lesser scale, in TM- exposed cells. To test if the increased toxicity of TM was uptake-related, THP-1 cells were pretreated with Cytochalasin D (CytD) or Bafilomycin A (BafA), followed by exposure to RD or SiO2 for 6h. CytD blocked the uptake and significantly decreased cytotoxicity of all particles, while BafA prevented caspase-1 activation but not cytotoxic effects of TM. Only TM was able to induce an inflammatory response in THP-1 cells, however it was much less pronounced compared to silica.

      4. Potential inhalation of fibrous carbon nanomaterials depends on the manufacturing/handling process and their tendency for air dispersion. Because of the large variety of carbon nanotube and nanofiber (CNT and CNF) products, with varying physical and chemical properties, characterization of these materials and their associated exposure risks is challenging. In this study, we aerosolized different types of CNT and CNF materials using an acoustic generator (AG) and characterized their aerodynamic and physical properties. The generation characteristics of the AG for the different CNT and CNF materials were investigated by measuring aerosol number concentrations and its decay properties with time. Airborne particle properties such as mobility and aerodynamic diameters were measured using mobility and aerodynamic particle sizers. The bulk and effective densities of the powder and aerosol were obtained by measuring the mass and volume of the bulk material and aerosol particles, where effective density was calculated by a tandem mobility-mass technique. The relationship between the aerosol properties (i.e., particle size, concentration, and dustiness) and bulk density of the material was also investigated to understand the potential for dispersion in air. The results showed that the aerosol concentration decay for each nanomaterial has a unique time constant, and that the rate of decay is positively correlated with the bulk density of the powder: the lower the bulk density, the slower the concentration decay. The aerodynamic diameter increased with increasing bulk density, while the mobility diameter showed the opposite trend. In general, bulk density is smaller than the particle effective density, and the effective density tends to approach the bulk density as particle size increases. Also, the bulk density of the fibrous nanomaterials tested in this study showed a reasonable correlation with dustiness data obtained from both our measurements and the literature, which was relatively weak for non-fibrous powders. This study indicates that more loosely agglomerated CNT powders, with lower bulk densities, would be more readily dispersed, and the dispersed particles remain airborne for longer periods. Depending on particle size, such materials can pose higher exposure risks due to their ease of dispersion and longer residence times.

      5. Microvascular dysfunction following multiwalled carbon nanotube exposure is mediated by thrombospondin-1 receptor CD47External
        Mandler WK, Nurkiewicz TR, Porter DW, Kelley EE, Olfert IM.
        Toxicol Sci. 2018 Sep 1;165(1):90-99.

        Pulmonary exposure to multiwalled carbon nanotubes (MWCNTs) disrupts peripheral microvascular function. Thrombospondin-1 (TSP-1) is highly expressed during lung injury and has been shown to alter microvascular reactivity. It is unclear exactly how TSP-1 exerts effects on vascular function, but we hypothesized that the TSP-1 receptor CD47 may mediate changes in vasodilation. Wildtype (WT) or CD47 knockout (CD47 KO) C57B6/J-background animals were exposed to 50 microg of MWCNT or saline control via pharyngeal aspiration. Twenty-four hours postexposure, intravital microscopy was performed to assess arteriolar dilation and venular leukocyte adhesion and rolling. To assess tissue redox status, electron paramagnetic resonance and NOx measurements were performed, while inflammatory biomarkers were measured via multiplex assay.Vasodilation was impaired in the WT + MWCNT group compared with control (57 +/- 9 vs 90 +/- 2% relaxation), while CD47 KO animals showed no impairment (108 +/- 8% relaxation). Venular leukocyte adhesion and rolling increased by >2-fold, while the CD47 KO group showed no change. Application of the antioxidant apocynin rescued normal leukocyte activity in the WT + MWCNT group. Lung and plasma NOx were reduced in the WT + MWCNT group by 47% and 32%, respectively, while the CD47 KO groups were unchanged from control. Some inflammatory cytokines were increased in the CD47 + MWCNT group only. In conclusion, TSP-1 is an important ligand mediating MWCNT-induced microvascular dysfunction, and CD47 is a component of this dysregulation. CD47 activation likely disrupts nitric oxide (*NO) signaling and promotes leukocyte-endothelial interactions. Impaired *NO production, signaling, and bioavailability is linked to a variety of cardiovascular diseases in which TSP-1/CD47 may play an important role.

      6. Evaluation of performance characteristics of hepatitis B e antigen serologic assaysExternal
        Mixson-Hayden T, Purdy MA, Ganova-Raeva L, McGovern D, Forbi JC, Kamili S.
        J Clin Virol. 2018 Oct 13;109:22-28.

        BACKGROUND: Hepatitis B e antigen (HBeAg) is considered an indicator of high hepatitis B virus (HBV) replication. Performance characteristics of commercially available HBeAg assays have not been determined, thus it is unknown whether lack of HBeAg detection is because of test sensitivity or HBV basal core promoter and precore mutations. OBJECTIVES: We studied the correlation between HBeAg reactivity with HBV DNA levels in three commercially available HBeAg assays using 335 HBsAg and HBV DNA positive serum/plasma samples. STUDY DESIGN: Diagnostic sensitivity was determined by serial dilutions of a WHO HBeAg standard. The limit of HBeAg detection estimated through regression was 1 IU/mL (Centaur), 97 IU/mL (DiaSorin) and 129 IU/mL (Vitros). Of these 335 samples, enough sample volume remained in 253 samples for head-to-head comparison of the assays. RESULTS: 81 (32%), 41 (16%) and 36 (14%) of the samples were HBeAg positive by the Centaur, DiaSorin and Vitros assays, respectively. Compared to the FDA-approved Centaur assay the specificity of the other two assays was 98%, while sensitivity was 47% for the DiaSorin assay and 41% for the Vitros assay. Significant association was found between HBeAg positive samples and HBV DNA levels >20,000 IU/mL; 31% of HBeAg negative samples (Centaur) had HBV DNA levels >20,000 IU/mL, 26% of HBeAg positive samples had HBV DNA levels <20,000 IU/mL and 5 HBeAg positive samples had HBV DNA levels <2000 IU/mL. CONCLUSION: Discordance was seen between these HBeAg assays, indicating reliance on HBeAg alone as a marker of high HBV replication can be misleading. Detection and quantification of HBV DNA remains the accurate and reliable marker of HBV replication.

      7. Proficiency of WHO Global Foodborne Infections Network External Quality Assurance System participants in identification and susceptibility testing of thermotolerant Campylobacter spp. from 2003 to 2012External
        Pedersen SK, Wagenaar JA, Vigre H, Roer L, Mikoleit M, Aidara-Kane A, Cawthorne AL, Aarestrup FM, Hendriksen RS.
        J Clin Microbiol. 2018 Nov;56(11).

        Campylobacter spp. are foodborne and waterborne pathogens. While rather accurate estimates for these pathogens are available in industrialized countries, a lack of diagnostic capacity in developing countries limits accurate assessments of prevalence in many regions. Proficiency in the identification and susceptibility testing of these organisms is critical for surveillance and control efforts. The aim of the study was to assess performance for identification and susceptibility testing of thermotolerant Campylobacter spp. among laboratories participating in the World Health Organization (WHO) Global Foodborne Infections Network (GFN) External Quality Assurance System (EQAS) over a 9-year period. Participants (primarily national-level laboratories) were encouraged to self-evaluate their performance as part of continuous quality improvement. The ability to correctly identify Campylobacter spp. varied by year and ranged from 61.9% (2008) to 90.7% (2012), and the ability to correctly perform antimicrobial susceptibility testing (AST) for Campylobacter spp. appeared to steadily increase from 91.4% to 93.6% in the test period (2009 to 2012). The poorest performance (60.0% correct identification and 86.8% correct AST results) was observed in African laboratories. Overall, approximately 10% of laboratories reported either an incorrect identification or antibiogram. As most participants were supranational reference laboratories, these data raise significant concerns regarding capacity and proficiency at the local clinical level. Addressing these diagnostic challenges is critical for both patient-level management and broader surveillance and control efforts.

      8. An evaluation of the contact forces on the fingers when squeezing a spherical rehabilitation ballExternal
        Wu JZ, Sinsel EW, Warren CM, Welcome DE.
        Biomed Mater Eng. 2018 ;29(5):629-639.

        The rehabilitation squeeze ball is a popular device to help strengthen the hand, fingers and forearm muscles. The distributions of the contact pressure in the interface between the therapy ball and hand/fingers can affect the joint moment of each of the individual fingers, thereby affecting rehabilitation effects. In the current study, we evaluated the contact force distributions on the fingers when gripping a spherical object. Eight female adults [age 29 (9.1) years, mass 64.6 (7.1) kg, height 163.5 (1.9) cm, hand length 17.2 (0.7) cm] participated in the study. Contact force sensors were attached to the middle of the palmar surfaces of the distal, middle, and proximal phalanges of the four fingers in the longitudinal direction. In order to evaluate the effects of the ball stiffness on the contact force distributions on the fingers, subjects were requested to perform quasi-static gripping on a standard tennis ball and on a rehabilitation ball. The tennis ball is much stiffer and experiences smaller deformation under compression compared to the rehabilitation ball. We analyzed the force share among the distal, middle, and proximal finger segments, when subjects gripping balls of different stiffnesses (tennis ball vs. rehabilitation ball) and at three different grip efforts. Our results indicated that the grip force is contributed about 60% and 40% by the middle/ring fingers and by the index/little fingers, respectively. These characteristics are independent of the grip force levels and stiffness of the contact surface.

    • Maternal and Child Health
      1. BACKGROUND: Hospitals that provide maternity care can play an important role in providing or directing mothers to postdischarge breastfeeding support, which improves breastfeeding duration especially when providing multiple support modes. This study described 2007-2015 national trends in postdischarge breastfeeding supports among United States maternity care hospitals. METHODS: Data were from the Maternity Practices in Infant Nutrition and Care survey, a biennial census of maternity care hospitals in the United States and territories. Hospitals reported whether they provided nine support types, which we categorized into three support modes: physical contact (eg, return visits), active reaching out (eg, telephone calls), and referrals (eg, to lactation consultants). We calculated prevalence of each support type, each support mode, and providing all three support modes for each survey year and examined trends over 2007-2015. For 2015, we assessed differences by hospital- and area-level characteristics. RESULTS: Prevalence of providing all three support modes increased from 24% (2007) to 31% (2015). Nearly all (99%) hospitals provided referrals in each survey year. Fewer offered physical contact and active reaching out. However, from 2007 to 2015, the prevalence of physical contact increased from 39% to 46%; active reaching out increased from 54% to 64%. In 2015, smaller and rural hospitals were more likely to provide all three discharge supports. CONCLUSIONS: Prevalence of offering referrals was high, but there is room for improvement in providing physical contact and active reaching out to ensure multiple modes of support are available to help mothers reach their breastfeeding goals.

      2. Population-based surveillance of congenital heart defects among adolescents and adults: surveillance methodologyExternal
        Glidewell J, Book W, Raskind-Hood C, Hogue C, Dunn JE, Gurvitz M, Ozonoff A, McGarry C, Van Zutphen A, Lui G, Downing K, Riehle-Colarusso T.
        Birth Defects Res. 2018 Nov 5.

        BACKGROUND: Improved treatment of congenital heart defects (CHDs) has increased survival of persons with CHDs; however, no U.S. population-based systems exist to assess prevalence, healthcare utilization, or longer-term outcomes among adolescents and adults with CHDs. METHODS: Novel approaches identified individuals aged 11-64 years who received healthcare with ICD-9-CM codes for CHDs at three sites: Emory University in Atlanta, Georgia (EU), Massachusetts Department of Public Health (MA), New York State Department of Health (NY) between January 1, 2008 (2009 for MA) and December 31, 2010. Case-finding sources included outpatient clinics; Medicaid and other claims data; and hospital inpatient, outpatient, and emergency visit data. Supplemental information came from state vital records (EU, MA), and birth defects registries (EU, NY). Demographics and diagnostic and procedural codes were linked, de-duplicated, and shared in a de-identified dataset. Cases were categorized into one of five mutually exclusive CHD severity groups; non-cardiac comorbidity codes were grouped into broad categories. RESULTS: 73,112 individuals with CHD codes in healthcare encounters were identified. Primary data source type varied: clinics (EU, NY for adolescents), claims (MA), hospital (NY for adults). There was a high rate of missing data for some variables and data varied in format and quality. Some diagnostic codes had poor specificity for CHD ascertainment. CONCLUSIONS: To our knowledge, this is the first population-based, multi-site CHD surveillance among adolescents and adults in the U.S. Identification of people living with CHDs through healthcare encounters using multiple data sources was feasible, though data quality varied and linkage/de-duplication was labor-intensive.

      3. Maternal genitourinary infections and risk of birth defects in the National Birth Defects Prevention StudyExternal
        Howley MM, Feldkamp ML, Papadopoulos EA, Fisher SC, Arnold KE, Browne ML.
        Birth Defects Res. 2018 Nov 6.

        BACKGROUND: Genitourinary infections (GUIs) are common among sexually active women. Yet, little is known about the risk of birth defects associated with GUIs. METHODS: Using data from the National Birth Defects Prevention Study, a multisite, population-based, case-control study, we assessed self-reported maternal GUIs in the month before through the third month of pregnancy (periconception) from 29,316 birth defect cases and 11,545 unaffected controls. We calculated odds ratios (ORs) and 95% confidence intervals to estimate the risk of 52 major structural birth defects associated with GUIs. We also calculated risk of birth defects associated with each type of GUI: urinary tract infection (UTI) and sexually transmitted infection (STI). RESULTS: In our analysis, 10% (n = 2,972) of case and 9% (n = 1,014) of control mothers reported a periconceptional GUI. A GUI was significantly associated with 11 of the 52 birth defects examined (ORs ranging from 1.19 to 2.26): encephalocele, cataracts, cleft lip, esophageal atresia, duodenal atresia/stenosis, small intestinal atresia/stenosis, colonic atresia/stenosis, transverse limb deficiency, conoventricular septal defect, atrioventricular septal defect, and secundum atrial septal defect. A periconceptional UTI was significantly associated with nine birth defects (ORs from 1.21 to 2.48), and periconceptional STI was significantly associated with four birth defects (ORs ranging from 1.63 to 3.72). CONCLUSIONS: While misclassification of GUIs in our analysis is likely, our findings suggest GUIs during the periconceptional period may increase the risk for specific birth defects.

      4. Study of selected birth defects among American Indian/Alaska Native population: A multi-state population-based retrospective study, 1999-2007External
        Marengo LK, Flood TJ, Ethen MK, Kirby RS, Fisher S, Copeland G, Meyer RE, Dunn J, Canfield MA, Anderson T, Yazzie D, Mai CT.
        Birth Defects Res. 2018 Nov 6.

        BACKGROUND: Higher prevalence of selected birth defects has been reported among American Indian/Alaska Native (AI/AN) newborns. We examine whether known risk factors for birth defects explain the higher prevalence observed for selected birth defects among this population. METHODS: Data from 12 population-based birth defects surveillance systems, covering a birth population of 11 million from 1999 to 2007, were used to examine prevalence of birth defects that have previously been reported to have elevated prevalence among AI/ANs. Prevalence ratios (PRs) were calculated for non-Hispanic AI/ANs and any AI/ANs (regardless of Hispanic ethnicity), adjusting for maternal age, education, diabetes, and smoking, as well as type of case-finding ascertainment surveillance system. RESULTS: After adjustment, the birth prevalence of two of seven birth defects remained significantly elevated among AI/ANs compared to non-Hispanic whites (NHWs): anotia/microtia was almost threefold higher, and cleft lip +/- cleft palate was almost 70% higher compared to NHWs. Excluding AI/AN subjects who were also Hispanic had only a negligible impact on adjusted PRs. CONCLUSIONS: Additional covariates accounted for some of the elevated birth defect prevalences among AI/ANs compared to NHWs. Exclusion of Hispanic ethnicity from the AI/AN category had little impact on birth defects prevalences in AI/ANs. NHWs serve as a viable comparison group for analysis. Birth defects among AI/ANs require additional scrutiny to identify modifiable risk and protective factors.

      5. Levels of maternal care verification pilot: Translating guidance into practiceExternal
        Zahn CM, Remick A, Catalano A, Goodman D, Kilpatrick SJ, Menard MK.
        Obstet Gynecol. 2018 Nov 5.

        Development of systems for perinatal regionalization and for the provision of risk-appropriate maternal care is a key strategy to decrease maternal morbidity and mortality. Regionalized systems pertaining to neonatal care are broadly implemented in many states, but networks for risk-appropriate maternal care are lacking. In response to increases in maternal morbidity and mortality over the past decade, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) developed and published the levels of maternal care guidelines in 2015. The guidelines are designed to promote collaboration among maternal facilities and health care providers with the goal that pregnant women receive care at a facility appropriate for their risk. The Centers for Disease Control and Prevention (CDC) developed the Levels of Care Assessment Tool in 2013 to assist states and jurisdictions in assessing maternal and neonatal levels of care in alignment with the national guidelines published by ACOG and SMFM and the American Academy of Pediatrics, respectively. With the goal of promoting levels of maternal care, ACOG and SMFM developed and piloted the levels of maternal care verification program. Fourteen facilities across three states (Georgia, Illinois, and Wyoming) participated in the pilot. A multidisciplinary team representing organizations with expertise in maternal risk-appropriate care performed an onsite comprehensive review of the maternal services available in each facility using the results from the CDC Levels of Care Assessment Tool as a previsit screening. A verification program that could be implemented on a local, state, or regional scale is being developed leveraging the lessons learned from the pilot.

    • Occupational Safety and Health
      1. National estimates of youth and injuries on U.S. farms, 2012External
        Hendricks KJ, Layne LA, Goldcamp EM.
        J Agric Saf Health. 2018 Oct;24(4):261-269.

        The National Institute for Occupational Safety and Health (NIOSH), in order to provide injury surveillance for youth on farms in the U.S., partnered with the USDA to conduct the Childhood Agricultural Injury Survey (CAIS). CAIS data for all farm youth less than 20 years of age have been collected intermittently since 1998. CAIS data from 2012 indicated that an estimated 25.9 million youth lived on, worked on, or visited U.S. farms. These youth experienced almost 14,000 injuries while on the farm. The majority of these injuries occurred to males (7,290) and youth between the ages of 10 and 15 years (5,766). Approximately 20% (2,739) of the injuries were related to work being done on the farm. Youth living on the farm incurred 56% (7,784) of the injuries. An additional 5,771 injuries occurred to hired and visiting youth. Although youth injuries on farms have declined, the numbers are still unacceptably high. Additional research and detailed assessments of subsets of the youth population would help to better direct safety intervention programs and focus future research activities.

      2. Research methodologies for Total Worker Health(R): Proceedings from a workshopExternal
        Tamers SL, Goetzel R, Kelly KM, Luckhaupt S, Nigam J, Pronk NP, Rohlman DS, Baron S, Brosseau LM, Bushnell T, Campo S, Chang CC, Childress A, Chosewood LC, Cunningham T, Goldenhar LM, Huang TT, Hudson H, Linnan L, Newman LS, Olson R, Ozminkowski RJ, Punnett L, Schill A, Scholl J, Sorensen G.
        J Occup Environ Med. 2018 Nov;60(11):968-978.

        OBJECTIVE: There is growing interest in the NIOSH Total Worker Health program, specifically in the process of designing and implementing safer, health-promoting work and workplaces. A Total Worker Health (TWH) Research Methodology Workshop was convened to discuss research methods and future needs. METHODS: Twenty-six experts in occupational safety and health and related fields reviewed and discussed current methodological and measurement issues and those showing promise. RESULTS: TWH intervention studies face the same challenges as other workplace intervention studies and some unique ones. Examples are provided of different approaches and their applications to TWH intervention studies, and desired developments in the TWH literature. CONCLUSIONS: This report discusses and outlines principles important to building the TWH intervention research base. Rigorous, valid methodologic, and measurement approaches are needed for TWH intervention as well as for basic/etiologic, translational, and surveillance research.

      3. It is accepted in industries that an industrial helmet should be disposed of when it is subjected to a significant impact. There is no scientific evidence that supports this well-accepted belief. The current study was intended to evaluate the shock absorption performance of industrial helmets under repeated impacts. Common industrial or construction helmets are categorized as Type I according to ANSI Z89.1 and they are designed to mainly protect top impacts. A representative basic Type I construction helmet model was selected in the study. Helmets were repeatedly impacted ten times using a commercial drop tower tester with an impactor (mass 3.6?kg) at different drop heights from 0.30 to 2.03?m. A total of 80 impact trials were performed in the study. The relationships of the transmitted force with the drop height and with impact number were analyzed. A new parameter – the endurance limit – was proposed to evaluate the shock absorption performance of a helmet. The helmets were observed to experience cumulative structural damage with increasing impact number, resulting in a degrading shock absorption performance, when being impacted repeatedly with magnitudes greater than the endurance limit. Repeated impacts with magnitudes smaller than the endurance limit did not cause measurable cumulative structural damage to the helmets in our study.

    • Occupational Safety and Health – Mining
      1. Emerging ergonomics issues and opportunities in miningExternal
        Dempsey PG, Kocher LM, Nasarwanji MF, Pollard JP, Whitson AE.
        Int J Environ Res Public Health. 2018 Nov 3;15(11).

        Ergonomics is the scientific discipline that investigates the interactions between humans and systems to optimize both human and system performance for worker safety, health, and productivity. Ergonomics is frequently involved either in the design of emerging technologies or in strategies to alleviate unanticipated human performance problems with emerging technologies. This manuscript explores several such emerging issues and opportunities in the context of the mining sector. In mining, the equipment, tools, and procedures have changed considerably and continue to change. Body-worn technology provides a number of opportunities to advance the safety and health of miners, while teleoperation and autonomous mining equipment stand to benefit significantly from ergonomics applications in other sectors. This manuscript focuses on those issues and opportunities that can impact the safety and health of miners in the near term.

    • Reproductive Health
      1. State-identified implementation strategies to increase uptake of immediate postpartum long-acting reversible contraception policiesExternal
        Kroelinger CD, Morgan IA, DeSisto CL, Estrich C, Waddell LF, Mackie C, Pliska E, Goodman DA, Cox S, Velonis A, Rankin KM.
        J Womens Health (Larchmt). 2018 Nov 2.

        BACKGROUND: In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation. MATERIALS AND METHODS: Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified. RESULTS: The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities. CONCLUSIONS: Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

      2. PURPOSE: Adolescents may encounter many barriers to initiating contraception. ‘Quick Start’ is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to ‘Quick Start’ provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents. METHODS: We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n=2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) ‘Quick Start’ provision of CHC and DMPA to adolescents in the past year. RESULTS: The prevalence of considering ‘Quick Start’ as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent ‘Quick Start’ provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered ‘Quick Start’ unsafe or were uncertain about its safety had lower odds of frequent ‘Quick Start’ provision compared with those who considered it safe (public-sector providers: CHC aOR=0.09 95% CI 0.06-0.13, DMPA aOR=0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR=0.06 95% CI 0.02-0.22, DMPA aOR=0.07 95% CI 0.02-0.20). CONCLUSIONS: While most providers reported that ‘Quick Start’ initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent ‘Quick Start’ provision in this population, particularly among office-based physicians.

    • Substance Use and Abuse
      1. Tobacco product use among adults – United States, 2017External
        Wang TW, Asman K, Gentzke AS, Cullen KA, Holder-Hayes E, Reyes-Guzman C, Jamal A, Neff L, King BA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 9;67(44):1225-1232.

        Cigarette smoking harms nearly every organ of the body and causes adverse health consequences, including heart disease, stroke, and multiple types of cancer (1). Although cigarette smoking among U.S. adults has declined considerably, tobacco products have evolved in recent years to include various combustible, noncombustible, and electronic products (1,2). To assess recent national estimates of tobacco product use among U.S. adults aged >/=18 years, CDC, the Food and Drug Administration (FDA), and the National Institutes of Health’s National Cancer Institute analyzed data from the 2017 National Health Interview Survey (NHIS). In 2017, an estimated 47.4 million U.S. adults (19.3%) currently used any tobacco product, including cigarettes (14.0%; 34.3 million); cigars, cigarillos, or filtered little cigars (3.8%; 9.3 million); electronic cigarettes (e-cigarettes) (2.8%; 6.9 million); smokeless tobacco (2.1%; 5.1 million); and pipes, water pipes, or hookahs (1.0%; 2.6 million). Among current tobacco product users, 86.7% (41.1 million) smoked combustible tobacco products, and 19.0% (9.0 million) used >/=2 tobacco products. By univariate analyses, the prevalence of current use of any tobacco product was higher among males than among females; adults aged <65 years than among those aged >/=65 years; non-Hispanic American Indian/Alaska Natives, whites, blacks, or multiracial adults than among Hispanics or non-Hispanic Asians; adults who lived in the South or Midwest than among those in the West or Northeast; adults who had a general educational development certificate (GED) than among those with other levels of education; adults who earned an annual household income of <$35,000 than among those with those with higher income; lesbian, gay, or bisexual adults than among heterosexual/straight adults; and adults who were divorced/separated/widowed or single/never married/not living with a partner than among those who were married/living with a partner. Prevalence was also higher among those who were uninsured, insured by Medicaid, or had some other public insurance than among those with private insurance or Medicare only; those who had a disability/limitation than among those who did not; and those who had serious psychological distress than among those who did not. Full implementation of evidence-based tobacco control interventions that address the diversity of tobacco products used by U.S. adults, in coordination with regulation of tobacco product manufacturing, marketing, and sales, can reduce tobacco-related disease and death in the United States (1-3).

      2. Identifying opioid overdose deaths using vital statistics dataExternal
        Warner M, Hedegaard H.
        Am J Public Health. 2018 Dec;108(12):1587-1589.

        [No abstract]

    • Zoonotic and Vectorborne Diseases
      1. Time to harmonize dengue nomenclature and classificationExternal
        Cuypers L, Libin PJ, Simmonds P, Nowe A, Munoz-Jordan J, Alcantara LC, Vandamme AM, Santiago GA, Theys K.
        Viruses. 2018 Oct 18;10(10).

        Dengue virus (DENV) is estimated to cause 390 million infections per year worldwide. A quarter of these infections manifest clinically and are associated with a morbidity and mortality that put a significant burden on the affected regions. Reports of increased frequency, intensity, and extended geographical range of outbreaks highlight the virus’s ongoing global spread. Persistent transmission in endemic areas and the emergence in territories formerly devoid of transmission have shaped DENV’s current genetic diversity and divergence. This genetic layout is hierarchically organized in serotypes, genotypes, and sub-genotypic clades. While serotypes are well defined, the genotype nomenclature and classification system lack consistency, which complicates a broader analysis of their clinical and epidemiological characteristics. We identify five key challenges: (1) Currently, there is no formal definition of a DENV genotype; (2) Two different nomenclature systems are used in parallel, which causes significant confusion; (3) A standardized classification procedure is lacking so far; (4) No formal definition of sub-genotypic clades is in place; (5) There is no consensus on how to report antigenic diversity. Therefore, we believe that the time is right to re-evaluate DENV genetic diversity in an essential effort to provide harmonization across DENV studies.

      2. Outbreak of yellow fever in central and southwestern Uganda, February-May 2016External
        Kwagonza L, Masiira B, Kyobe-Bosa H, Kadobera D, Atuheire EB, Lubwama B, Kagirita A, Katushabe E, Kayiwa JT, Lutwama JJ, Ojwang JC, Makumbi I, Ario AR, Borchert J, Zhu BP.
        BMC Infect Dis. 2018 Nov 3;18(1):548.

        BACKGROUND: On 28 March, 2016, the Ministry of Health received a report on three deaths from an unknown disease characterized by fever, jaundice, and hemorrhage which occurred within a one-month period in the same family in central Uganda. We started an investigation to determine its nature and scope, identify risk factors, and to recommend eventually control measures for future prevention. METHODS: We defined a probable case as onset of unexplained fever plus >/=1 of the following unexplained symptoms: jaundice, unexplained bleeding, or liver function abnormalities. A confirmed case was a probable case with IgM or PCR positivity for yellow fever. We reviewed medical records and conducted active community case-finding. In a case-control study, we compared risk factors between case-patients and asymptomatic control-persons, frequency-matched by age, sex, and village. We used multivariate conditional logistic regression to evaluate risk factors. We also conducted entomological studies and environmental assessments. RESULTS: From February to May, we identified 42 case-persons (35 probable and seven confirmed), of whom 14 (33%) died. The attack rate (AR) was 2.6/100,000 for all affected districts, and highest in Masaka District (AR = 6.0/100,000). Men (AR = 4.0/100,000) were more affected than women (AR = 1.1/100,000) (p = 0.00016). Persons aged 30-39 years (AR = 14/100,000) were the most affected. Only 32 case-patients and 128 controls were used in the case control study. Twenty three case-persons (72%) and 32 control-persons (25%) farmed in swampy areas (ORadj = 7.5; 95%CI = 2.3-24); 20 case-patients (63%) and 32 control-persons (25%) who farmed reported presence of monkeys in agriculture fields (ORadj = 3.1, 95%CI = 1.1-8.6); and 20 case-patients (63%) and 35 control-persons (27%) farmed in forest areas (ORadj = 3.2; 95%CI = 0.93-11). No study participants reported yellow fever vaccination. Sylvatic monkeys and Aedes mosquitoes were identified in the nearby forest areas. CONCLUSION: This yellow fever outbreak was likely sylvatic and transmitted to a susceptible population probably by mosquito bites during farming in forest and swampy areas. A reactive vaccination campaign was conducted in the affected districts after the outbreak. We recommended introduction of yellow fever vaccine into the routine Uganda National Expanded Program on Immunization and enhanced yellow fever surveillance.

      3. Detection of avian influenza A(H7N2) virus infection among animal shelter workers using a novel serological approach-New York City, 2016-2017External
        Poirot E, Levine MZ, Russell K, Stewart RJ, Pompey JM, Chiu S, Fry AM, Gross L, Havers FP, Li ZN, Liu F, Crossa A, Lee CT, Boshuizen V, Rakeman JL, Slavinski S, Harper S, Gould LH.
        J Infect Dis. 2018 Nov 5.

        Background: In 2016, an influenza A(H7N2) virus outbreak occurred in cats in New York City’s municipal animal shelters. One human infection was initially detected. Methods: We conducted a serological survey using a novel approach to rule out cross-reactive antibodies to other seasonal influenza viruses to determine whether additional A(H7N2) human infections had occurred and to assess exposure risk. Results: Of 121 shelter workers, one had serological evidence of A(H7N2) infection, corresponding to a seroprevalence of 0.8% (95% confidence interval, .02%-4.5%). Five persons exhibited low positive titers to A(H7N2) virus, indicating possible infection; however, we could not exclude cross-reactive antibody responses to seasonal influenza viruses. The remaining 115 persons were seronegative. The seropositive person reported multiple direct cat exposures without using personal protective equipment and mild illness with subjective fever, runny nose, and sore throat. Conclusions: We identified a second case of A(H7N2) infection from this outbreak, providing further evidence of cat-to-human transmission of A(H7N2) virus.

Back to Top

CDC Science Clips Production Staff

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


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

Page last reviewed: January 31, 2019