Volume 10, Issue 45, November 27, 2018

CDC Science Clips: Volume 10, Issue 45, November 27, 2018

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

  1. CDC 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. Making strides in type 2 diabetes preventionExternal
        Albright AL.
        Diabetes Spectr. 2018 ;31(4):299-302.

        [No abstract]

      2. Addressing childhood obesity for type 2 diabetes prevention: Challenges and opportunitiesExternal
        Galuska DA, Gunn JP, O’Connor AE, Petersen R.
        Diabetes Spectr. 2018 ;31(4):330-335.

        [No abstract]

      3. OBJECTIVES: To determine whether declining trends in lower extremity amputations have continued into the current decade. RESEARCH DESIGN AND METHODS: We calculated hospitalization rates for nontraumatic lower extremity amputation (NLEA) for the years 2000-2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes. RESULTS: Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women. CONCLUSIONS: After a two-decade decline in lower extremity amputations, the U.S. may now be experiencing a reversal in the progress particularly in young and middle-aged adults.

      4. Co-occurrence of early diabetes-related complications in adolescents and young adults with type 1 diabetes: an observational cohort studyExternal
        Sauder KA, Stafford JM, Mayer-Davis EJ, Jensen ET, Saydah S, Mottl A, Dolan LM, Hamman RF, Lawrence JM, Pihoker C, Marcovina S, D’Agostino RB, Dabelea D.
        Lancet Child Adolesc Health. 2018 Nov 5.

        BACKGROUND: One in three adolescents and young adults with type 1 diabetes have at least one early diabetes-related complication or comorbidity. We aimed to examine the prevalence and pattern of co-occurring complications in this population, as well as the related risk factors. METHODS: This observational cohort study includes data from individuals diagnosed with type 1 diabetes before age 20 years who participated in the SEARCH for Diabetes in Youth Study across five sites in the USA. We assessed sociodemographic and metabolic risk factors at baseline and at follow-up, and diabetes complications at follow-up. A frequency analysis was done to examine the difference in observed versus expected prevalence (calculated using a contingency table assuming independence across cells) of co-occurring complications or comorbidities. A cluster analysis was done to identify unique clusters of participants based on demographic characteristics and metabolic risk factors. FINDINGS: 1327 participants who completed the follow-up visit were included in the frequency analysis. The mean age was 10.1 (SD 3.9) years at the time of type 1 diabetes diagnosis and 18.0 (4.1) years at follow-up. At a mean diabetes duration of 7.8 [SD 1.9] years, co-occurrence of any two or more complications was observed in 78 (5.9%) participants, more frequently than expected by chance alone (58 [4.4%], p=0.015). Specifically, the complications that co-occurred more frequently than expected were retinopathy and diabetic kidney disease (11 [0.8%] vs three [0.2%]; p=0.0007), retinopathy and arterial stiffness (13 [1.0%] vs four [0.3%]; p=0.0016), and arterial stiffness and cardiovascular autonomic neuropathy (24 [1.8%] vs 13 [1.0%]; p=0.015). We identified four unique clusters characterised by progressively worsening metabolic risk factor profiles (longer duration of diabetes and higher glycated haemoglobin, non-HDL cholesterol, and waist-to-height ratio). The prevalence of at least two complications increased across the clusters (six [2.3%] of 261 in the low-risk cluster, 32 [6.3%] of 509 in the moderate-risk cluster, 28 [8%] of 348 in the high-risk cluster, and five [20.8%] of 24 in the highest-risk cluster). Compared with the low-risk and moderate-risk clusters, the high-risk and highest-risk clusters were characterised by a lower proportion of participants who were non-Hispanic white, and a higher proportion of participants who had a household income below US$50 000 and did not have private health insurance. INTERPRETATION: Early complications co-occur in adolescents and young adults with type 1 diabetes more frequently than expected. Identification of individuals with adverse risk factors could enable targeted behavioural or medical interventions that reduce the likelihood of early development of lifelong diabetes-related morbidity. FUNDING: US Centers for Disease Control and Prevention, US National Institutes of Health.

      5. Nudging to change: Using behavioral economics theory to move people and their health care partners toward effective type 2 diabetes preventionExternal
        Soler RE, Proia K, Jackson MC, Lanza A, Klein C, Leifer J, Darling M.
        Diabetes Spectr. 2018 ;31(4):310-319.

        [No abstract]

      6. BACKGROUND: The study aimed to examine racial/ethnic differences in chemotherapy utilization by breast cancer subtype. METHODS: Data on female non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic stage I-III breast cancer patients diagnosed in 2011 were obtained from a project to enhance population-based National Program of Cancer Registry data for Comparative Effectiveness Research. Hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) were used to classify subtypes: HR+/HER2-; HR+/HER2+; HR-/HER2-; and HR-/HER2 + . We used multivariable logistic regression models to examine the association of race/ethnicity with three outcomes: chemotherapy (yes, no), neo-adjuvant chemotherapy (yes, no), and delayed chemotherapy (yes, no). Covariates included patient demographics, tumor characteristics, Charlson Comorbidity Index, other cancer treatment, and participating states/areas. RESULTS: The study included 25,535 patients (72.1% NHW, 13.7% NHB, and 14.2% Hispanics). NHB with HR+/HER2- (adjusted odds ratio [aOR] 1.22, 95% CI 1.04-1.42) and Hispanics with HR-/HER2- (aOR 1.62, 95% CI 1.15-2.28) were more likely to receive chemotherapy than their NHW counterparts. Both NHB and Hispanics were more likely to receive delayed chemotherapy than NHW, and the pattern was consistent across each subtype. No racial/ethnic differences were found in the receipt of neo-adjuvant chemotherapy. CONCLUSIONS: Compared to NHW with the same subtype, NHB with HR+/HER2- and Hispanics with HR-/HER2- have higher odds of using chemotherapy; however, they are more likely to receive delayed chemotherapy, regardless of subtype. Whether the increased chemotherapy use among NHB with HR+/HER2- indicates overtreatment needs further investigation. Interventions to improve the timely chemotherapy among NHB and Hispanics are warranted.

    • Communicable Diseases
      1. Better outcomes among HIV-infected Rwandan children 18-60 months following the implementation of “treat all”External
        Arpadi S, Lamb M, Isaie Nzeyimana N, Vandebriel G, Anyalechi G, Wong M, Smith R, Rivadeneira ED, Kayirangwa E, Malamba SS, Musoni C, Koumans EH, Braaten M, Nsanzimana S.
        J Acquir Immune Defic Syndr. 2018 Nov 12.

        BACKGROUND: In 2012, Rwanda introduced a Treat All approach for HIV-infected children under age 5. We compared antiretroviral therapy (ART) initiation, outcomes, and retention, before and after this change. METHODS: We conducted a retrospective study of children enrolled into care between June 2009-December 2011 (Before Treat All cohort [BTA]) and between July 2012-April 2015 (Treat All cohort [TA]). SETTING: Medical records of a nationally representative sample were abstracted for all eligible aged 18-60 months from 100 Rwandan public health facilities. RESULTS: We abstracted 374 medical records: 227 in the BTA and 147 in the TA cohorts. Mean (SD) age at enrollment was (3 years [1.1]). Among BTA, 59% initiated ART within one year, vs. 89% in the TA cohort. Median time to ART initiation was 68 days (IQR 14-494) for BTA and 9 days (IQR 0-28) for TA (p<0.0001), with 9 (5%) undergoing same-day initiation in BTA compared to 50 (37%) in TA (p < 0.0001).Before ART initiation, 59% in the BTA reported at least one health condition compared to 35% in the TA cohort (p < 0.0001).While overall loss to follow-up (LTFU) was similar between cohorts (BTA: 13%, TA: 8%, p = 0.18), LTFU prior to ART was significantly higher in the BTA (8%) compared to the TA cohort (2%) (p = 0.02). CONCLUSIONS: Nearly 90% of Rwandan children started on ART within one year of enrollment; most within 1 month, with greater than 90% retention following implementation of TA. TA was also associated with fewer morbidities.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

      2. Discrimination in healthcare settings among adults with recent HIV diagnosesExternal
        Baugher AR, Beer L, Fagan JL, Mattson CL, Luke Shouse R.
        AIDS Care. 2018 Nov 15:1-6.

        The prevalence of discrimination in healthcare settings among HIV patients in the United States is unknown. The Medical Monitoring Project (MMP) is a complex sample survey of adults receiving HIV medical care in the United States. We analyzed nationally representative MMP data collected 2011-2015. We assessed the prevalence of self-reported healthcare discrimination, perceived reasons for discrimination, and factors associated with discrimination among persons with HIV diagnoses </=5 years before interview (n = 3,770). Overall, 14.1% of patients living with HIV (PLWH) experienced discrimination, of whom 82.2% attributed the discrimination to HIV. PLWH reporting poverty, homelessness, or attending a non-Ryan White HIV/AIDS Program (RWHAP) facility were more likely to report discrimination compared with other groups. Of patients attending non-RWHAP facilities, discrimination was higher among those in poverty (27.5%) vs. not in poverty (15.1%). Discrimination was associated with homelessness regardless of facility type, and was highest among homeless persons attending non-RWHAP facilities. Healthcare discrimination was commonly reported among PLWH, and was most often attributed to HIV status. Discrimination was higher among those reporting poverty or homelessness, particularly those attending non-RWHAP facilities. Incorporating practices, such as anti-discrimination training, in facilities may reduce healthcare discrimination.

      3. Linking HIV and viral hepatitis surveillance data: Evaluating a standard, deterministic matching algorithm using data from 6 US health jurisdictionsExternal
        Bosh KA, Coyle JR, Muriithi NW, Ramaswamy C, Zhou W, Brantley AD, Stockman LJ, VanderBusch L, Westheimer EF, Tang T, Green TA, Hall HI.
        Am J Epidemiol. 2018 Nov 1;187(11):2415-2422.

        Accurate interpretations and comparisons of record linkage results across jurisdictions require valid and reliable matching methods. We compared existing matching methods used by 6 US state and local health departments (Houston, Texas; Louisiana; Michigan; New York, New York; North Dakota; and Wisconsin) to link human immunodeficiency virus and viral hepatitis surveillance data with a 14-key automated, hierarchical deterministic matching method. Applicable years of study varied by disease and jurisdiction, ranging from 1979 to 2016. We calculated percentage agreement and Cohen’s kappa coefficient to compare the matching methods used within each jurisdiction. We calculated sensitivity, specificity, and positive predictive value for each matching method, as compared with a new standard that included manual review of discrepant cases. Agreement between the existing matching method and the deterministic matching method was 99.6% or higher in all jurisdictions; Cohen’s kappa values ranged from 0.87 to 0.98. The sensitivity of the deterministic matching method ranged from 97.4% to 100% in the 6 jurisdictions; specificity ranged from 99.7% to 100%; and positive predictive value ranged from 97.4% to 100%. Although no gold standard exists, prior assessments of existing methods and review of discrepant classifications suggest good accuracy and reliability of our deterministic matching method, with the advantage that our method reduces the need for manual review and allows for standard comparisons across jurisdictions when linking human immunodeficiency virus and viral hepatitis data.

      4. HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland’s Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged >/=13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland’s Central Region with initial CD4 counts </=500 cells/mm(3) (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness.

      5. Moderate to high levels of pre-treatment HIV drug resistance in KwaZulu-Natal Province, South AfricaExternal
        Chimukangara B, Kharsany AB, Lessells RJ, Naidoo K, Rhee SY, Manasa J, Graf T, Lewis L, Cawood C, Khanyile D, Diallo K, Ayalew KA, Shafer R, Hunt G, Pillay D, Abdool SK, de Oliveira T.
        AIDS Res Hum Retroviruses. 2018 Nov 15.

        INTRODUCTION: There is evidence of increasing levels of pre-treatment HIV drug resistance (PDR) in Southern Africa. We used data from two large population-based HIV surveillance studies to estimate prevalence of PDR in KwaZulu-Natal, the province with the highest HIV prevalence in South Africa. METHODS: Sanger sequencing was performed on samples obtained from a longitudinal HIV surveillance programme (study A, 2013-2014) and the HIV Incidence Provincial Surveillance System (study B, 2014-2015). Sequences were included for adult HIV positive participants (age >/=15 years for study A, age 15-49 years for study B) with no documented prior exposure to ART. Overall and drug class-specific PDR was estimated using the World Health Organization 2009 surveillance drug resistance mutation (SDRM) list and phylogenetic analysis was performed to establish evidence of drug resistance transmission linkage. RESULTS: One thousand eight hundred and forty-five (1845) sequences were analysed (611 study A; 1234 study B). An overall PDR prevalence of 9.2% (95% confidence interval (CI): 7.0-11.7) was observed for study A and 11.0% (95% CI 8.9-13.2) for study B. In study B, the prevalence of non-nucleoside reverse-transcriptase inhibitor (NNRTI) PDR exceeded 10% for sequences collected in 2014 (10.2%, 95% CI 7.5-12.9). The most prevalent SDRMs were K103NS (7.5%), M184VI (2.4%) and V106AM (1.4%). There was no evidence of large transmission chains of drug-resistant virus. CONCLUSION: High level NNRTI-PDR (>10%) suggests a need to modify the standard first-line ART regimen and to focus attention on improving the quality of HIV prevention, treatment and care.

      6. Disseminated gonococcal infections in patients receiving eculizumab: a case seriesExternal
        Crew PE, Abara WE, McCulley L, Waldron PE, Kirkcaldy RD, Weston EJ, Bernstein KT, Jones SC, Bersoff-Matcha SJ.
        Clin Infect Dis. 2018 Nov 12.

        Background: Gonorrhea is the second most commonly reported notifiable condition in the United States (U.S.). Infrequently, Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI). Eculizumab, a monoclonal antibody, inhibits terminal complement activation which impairs the ability of the immune system to respond effectively to Neisseria infections. This series describes cases of N. gonorrhoeae infection among patients receiving eculizumab. Methods: Pre- and postmarketing safety reports of N.gonorrhoeae infection in patients receiving eculizumab worldwide were obtained from FDA safety databases and the medical literature, including reports from the start of pivotal clinical trials in 2004 through December 31, 2017. Included patients had at least one eculizumab dose within the three months prior to N. gonorrhoeae infection. Results: Nine cases of N. gonorrhoeae infection were identified; eight were classified as disseminated (89%). Of the disseminated cases, eight patients required hospitalization, seven had positive blood cultures, and two required vasopressor support. One patient required mechanical ventilation. N. gonorrhoeae may have contributed to complications prior to death in one patient; however, the fatality was attributed to underlying disease per the reporter. Conclusion: Patients receiving eculizumab may be at higher risk for DGI than the general population. Prescribers are encouraged to educate patients receiving eculizumab on their risk for serious gonococcal infections and perform screening for sexually transmitted diseases (STDs) per Centers for Disease Control and Prevention STD treatment guidelines or in suspect cases. If antimicrobial prophylaxis is used during eculizumab therapy, prescribers should consider trends in gonococcal antimicrobial susceptibility due to emerging resistance concerns.

      7. Despite the high HIV prevalence among men who have sex with men (MSM) and transgender women (TGW), there are limited data on progress on their respective HIV antiretroviral treatment (ART) cascades to identify progress and gaps in meeting UNAIDS 90-90-90 targets. We conducted a respondent-driven sampling survey of MSM and TGW in Bamako, Mali from October 2014 to February 2015. We describe the HIV treatment cascade for MSM and TGW, identify correlates of being unaware of HIV-infected status and having unsuppressed viral load levels, and estimate proportion of recent infections. We enrolled 387 MSM and 165 TGW. HIV prevalence was 13.7%. Of those living with HIV, 10.4% were aware of their serostatus, 61.2% of them self-reported being on treatment, and of them, 100% were virally suppressed. In multivariate analysis, factors associated with being unaware of HIV infection included not using free condoms in the last six months (aOR: 5.7, 95% CI: 1.1-29.5) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.4-29.9). Having unsuppressed viral load was associated with identifying as a transgender woman (aOR: 4.8, 95% CI: 1.1-20.7) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.0-40.9). Of the 79 HIV-positive participants, 5.1% had recent infections. While the proportion aware of their HIV status was low despite adjusting for viral load biomarkers, all MSM and TGW on treatment were virally suppressed. Improved testing strategies are urgently needed to achieve the first 90 of the HIV cascade among MSM and TGW in Bamako.

      8. Increasing prevalence of self-reported HIV preexposure prophylaxis use in published surveys: a systematic review and meta-analysisExternal
        Kamitani E, Wichser ME, Adegbite AH, Mullins MM, Johnson WD, Crouch PC, Sipe TA.
        Aids. 2018 Nov 13;32(17):2633-2635.

        When combining results from all published surveys, about one in nine global study participants (10.7%) reported ever using preexposure prophylaxis (PrEP) by 2017, a significant increase since US FDA approval in 2012 [odds ratio (OR) = 1.6/year, P < 0.00001]. Moreover, nearly one in six US-based study participants (17.3%) and nearly one in four MSM who met the Centers for Disease Control and Prevention’s PrEP indications (24.5%) reported ever using PrEP by 2016. The odds of reporting PrEP use are approximately doubling each year (OR = 1.8/year, P < 0.00001; OR = 2.0/year, P < 0.00001).

      9. Risk factors for childhood enteric infection in urban Maputo, Mozambique: A cross-sectional studyExternal
        Knee J, Sumner T, Adriano Z, Berendes D, de Bruijn E, Schmidt WP, Nala R, Cumming O, Brown J.
        PLoS Negl Trop Dis. 2018 Nov 12;12(11):e0006956.

        BACKGROUND: Enteric infections are common where public health infrastructure is lacking. This study assesses risk factors for a range of enteric infections among children living in low-income, unplanned communities of urban Maputo, Mozambique. METHODS & FINDINGS: We conducted a cross-sectional survey in 17 neighborhoods of Maputo to assess the prevalence of reported diarrheal illness and laboratory-confirmed enteric infections in children. We collected stool from children aged 1-48 months, independent of reported symptoms, for molecular detection of 15 common enteric pathogens by multiplex RT-PCR. We also collected survey and observational data related to water, sanitation, and hygiene (WASH) characteristics; other environmental factors; and social, economic, and demographic covariates. We analyzed stool from 759 children living in 425 household clusters (compounds) representing a range of environmental conditions. We detected >/=1 enteric pathogens in stool from most children (86%, 95% confidence interval (CI): 84-89%) though diarrheal symptoms were only reported for 16% (95% CI: 13-19%) of children with enteric infections and 13% (95% CI: 11-15%) of all children. Prevalence of any enteric infection was positively associated with age and ranged from 71% (95% CI: 64-77%) in children 1-11 months to 96% (95% CI: 93-98%) in children 24-48 months. We found poor sanitary conditions, such as presence of feces or soiled diapers around the compound, to be associated with higher risk of protozoan infections. Certain latrine features, including drop-hole covers and latrine walls, and presence of a water tap on the compound grounds were associated with a lower risk of bacterial and protozoan infections. Any breastfeeding was also associated with reduced risk of infection. CONCLUSIONS: We found a high prevalence of enteric infections, primarily among children without diarrhea, and weak associations between bacterial and protozoan infections and environmental risk factors including WASH. Findings suggest that environmental health interventions to limit infections would need to be transformative given the high prevalence of enteric pathogen shedding and poor sanitary conditions observed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02362932.

      10. Respiratory viruses in returning Hajj & Umrah pilgrims with acute respiratory illness in 2014-2015External
        Koul PA, Mir H, Saha S, Chadha MS, Potdar V, Widdowson MA, Lal RB, Krishnan A.
        Indian J Med Res. 2018 Sep;148(3):329-333.

        Background & objectives: Respiratory tract infections are common among Hajj and Umrah pilgrims which pose a public health risk of spread of respiratory infections. Influenza has been reported from Indian Hajj and Umrah returning pilgrims, but data on other respiratory pathogens are sparse in India. Here we report the presence of common respiratory viral pathogens in returning Hajj and Umrah pilgrims suffering from acute respiratory illness (ARI) in 2014-2015. Methods: Respiratory specimens (nasopharyngeal and throat swabs) were collected from 300 consenting pilgrims with ARI in the past one week and tested for influenza and Middle East Respiratory Syndrome coronavirus (MERS-CoV) and other respiratory viruses using in-house standardized quantitative real-time reverse-transcription polymerase chain reaction. Clinical features among the pathogen positive and negative patients were compared. The patients received symptomatic treatment and antivirals where appropriate and were followed telephonically to collect data on illness outcome. Results: Ninety seven (32.3%) of the 300 participants were tested positive for any virus, most common being influenza viruses (n=33, 11%). Other respiratory viruses that were detected included human coronaviruses [n=26, 8.7%; OC43 (n=19, 6.3%) and C229E (n=7, 2.3%)], rhinovirus (n=20, 6%), adenoviruses (n=8, 2.6%), parainfluenza viruses (n=7, 2.3%), respiratory syncytial virus (n=3, 1%) and bocaviruses (n=2, 0.6%). Clinical features observed in pathogen positive and pathogen negative patients did not differ significantly. Eighteen influenza positive patients were treated with oseltamivir. Interpretation & conclusions: Pilgrims returning from mass gatherings are often afflicted with respiratory pathogens with a potential to facilitate transmission of respiratory pathogens across international borders. The study reinforces the need for better infection prevention and control measures such as vaccination, health education on cough etiquette and hand hygiene.

      11. The impact of home-based HIV testing services on progress towards the UNAIDS 90-90-90 targets in a hyperendemic area of South AfricaExternal
        Lewis L, Maughan-Brown B, Grobler A, Cawood C, Khanyile D, Glenshaw M, Bm Kharsany A.
        J Acquir Immune Defic Syndr. 2018 Oct 29.

        BACKGROUND: In several sub-groups of South Africa, the percentage of HIV-positive individuals aware of their status falls well below the UNAIDS 90% target. This study examined the impact that home-based HIV testing services (HBHTS) had on knowledge of status in a hyperendemic area of South Africa. METHODS: We analysed data from the second cross-sectional HIV Incidence Provincial Surveillance System survey (2015/2016), a representative sample (n=10236) of individuals aged 15-49 years. Participants completed a questionnaire, provided blood samples for laboratory testing (used to estimate HIV prevalence) and were offered HBHTS. The proportion of people living with HIV (n=3870) made aware of their status through HBHTS was measured and factors associated with HBHTS uptake were identified. RESULTS: Knowledge of HIV-positive status at the time of the survey was 62.9% among men and 73.4% among women. Through HBHTS, the percentage of HIV-positive men and women who knew their status rose to 74.2% and 80.5% respectively. The largest impact was observed among youth (15-24 years). Knowledge of status increased from 36.6% to 59.3% and from 50.8% to 64.8% among young men and women respectively. Additionally, 51.4% of those who had previously never tested received their first test. Key reasons for declining HBHTS among undiagnosed HIV-positive individuals included fear and self-report of a HIV-negative status. CONCLUSIONS: HBHTS was effective in increasing awareness of HIV-positive status, particularly among youth, men and those who had never tested. HBHTS could have a marked impact on progress towards the UNAIDS 90-90-90 targets within these sub-groups.

      12. Increase in acute flaccid myelitis – United States, 2018External
        McKay SL, Lee AD, Lopez AS, Nix WA, Dooling KL, Keaton AA, Spence-Davizon E, Herlihy R, Clark TA, Hopkins SE, Pastula DM, Sejvar J, Oberste MS, Pallansch MA, Patel M, Routh JA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1273-1275.

        In August 2018, CDC noted an increased number of reports of patients having symptoms clinically compatible with acute flaccid myelitis (AFM), a rare condition characterized by rapid onset of flaccid weakness in one or more limbs and spinal cord gray matter lesions, compared with August 2017. Since 2014, CDC has conducted surveillance for AFM using a standardized case definition (1,2). An Epi-X* notice was issued on August 23, 2018, to increase clinician awareness and provide guidance for case reporting.

      13. Is HIV patient navigation associated with HIV care continuum outcomes?External
        Mizuno Y, Higa DH, Leighton CA, Roland KB, Deluca JB, Koenig LJ.
        Aids. 2018 Nov 13;32(17):2557-2571.

        OBJECTIVE: To provide the first systematic review on the associations between HIV patient navigation and HIV care continuum outcomes (i.e. linkage to care, retention in care, antiretroviral therapy (ART) uptake, medication adherence, and viral suppression) in the United States. We identified primary research studies that addressed these associations and qualitatively assessed whether provision of patient navigation was positively associated with these outcomes, including strength of the evidence. METHODS: A systematic review, including both electronic [MEDLINE (OVID), EMBASE (OVID), PsycINFO (OVID), and CINAHL (EBSCOhost)] online databases and manual searches, was conducted to locate studies published from 1 January 1996 through 23 April 2018. RESULTS: Twenty studies met our inclusion criteria. Of these, 17 found positive associations. Patient navigation was more likely to be positively associated with linkage to care (five of six studies that assessed this association), retention in care (10 of 11), and viral suppression (11 of 15) than with ART uptake (one of four) or ART adherence (two of four). However, almost two-thirds of the 17 studies were of weak study quality, and only three used a randomized controlled trial design. CONCLUSION: Available evidence suggests that patient navigation is a potentially effective strategy to enhance engagement in care among persons with HIV. However encouraging, the evidence is still weak. Studies with more rigorous methodological designs, and research examining characteristics of navigators or navigational programs associated with better outcomes, are warranted given the current interest and use of this strategy.

      14. Risk factors and incidence of syphilis in human immunodeficiency virus (HIV)-infected persons: The HIV Outpatient Study, 1999-2015External
        Novak RM, Ghanem A, Hart R, Ward D, Armon C, Buchacz K.
        Clin Infect Dis. 2018 Nov 13;67(11):1750-1759.

        Background: Since 2000, the incidence of syphilis has been increasing, especially among gay, bisexual, and other men who have sex with men (MSM) in the United States. We assessed temporal trends and associated risk factors for newly diagnosed syphilis infections among human immunodeficiency virus (HIV)-infected patients during a 16-year period. Methods: We analyzed data from the HIV Outpatient Study (HOPS) cohort participants at 10 US HIV clinics during 1999-2015. New syphilis cases were defined based on laboratory parameters and clinical diagnoses. We performed Cox proportional hazards regression analyses of sociodemographic, clinical, and behavioral risk factors for new syphilis infections. Results: We studied 6888 HIV-infected participants; 641 had 1 or more new syphilis diagnoses during a median follow-up of 5.2 years. Most participants were male (78%), aged 31-50 years, and 57% were MSM. The overall incidence was 1.8 (95% confidence interval [CI], 1.6-1.9) per 100 person-years (PY) and it increased from 0.4 (95% CI, .2-.8) to 2.2 (95% CI, 1.4-3.5) per 100 PY during 1999-2015. In multivariable analyses adjusting for calendar year, risk factors for syphilis included age 18-30 years (hazard ratio [HR], 1.3 [95% CI, 1.1-1.6]) vs 31-40 years, being MSM (HR, 3.1 [95% CI, 2.4-4.1]) vs heterosexual male, and being non-Hispanic black (HR, 1.6 [95% CI, 1.4-1.9]) vs non-Hispanic white. Conclusions: The increases in the syphilis incidence rate through 2015 reflect ongoing sexual risk and highlight the need for enhanced prevention interventions among HIV-infected patients in care.

      15. Preexposure prophylaxis for human immunodeficiency virus (HIV) prevention among HIV-uninfected pregnant women: Estimated coverage using risk-based versus regional prevalence approachesExternal
        Pintye J, Singa B, Wanyonyi K, Itindi J, Kinuthia J, Langat A, Nganga L, Katana A, Baeten JM, McGrath CJ, John-Stewart G.
        Sex Transm Dis. 2018 Dec;45(12):e98-e100.

        Antenatal register data from 62 clinics in 5 regions of Kenya were used to estimate women with human immunodeficiency virus (HIV) risk (partner HIV status, syphilis). With individual risk-guided preexposure prophylaxis (PrEP) offer in all regions, 39% of pregnant women would be offered PrEP nationally. Offering PrEP to all women in high-prevalence regions reached 26% of the pregnant women.

      16. Variation in identifying sepsis and organ dysfunction using administrative versus electronic clinical data and impact on hospital outcome comparisonsExternal
        Rhee C, Jentzsch MS, Kadri SS, Seymour CW, Angus DC, Murphy DJ, Martin GS, Dantes RB, Epstein L, Fiore AE, Jernigan JA, Danner RL, Warren DK, Septimus EJ, Hickok J, Poland RE, Jin R, Fram D, Schaaf R, Wang R, Klompas M.
        Crit Care Med. 2018 Nov 13.

        OBJECTIVES: Administrative claims data are commonly used for sepsis surveillance, research, and quality improvement. However, variations in diagnosis, documentation, and coding practices for sepsis and organ dysfunction may confound efforts to estimate sepsis rates, compare outcomes, and perform risk adjustment. We evaluated hospital variation in the sensitivity of claims data relative to clinical data from electronic health records and its impact on outcome comparisons. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of 4.3 million adult encounters at 193 U.S. hospitals in 2013-2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sepsis was defined using electronic health record-derived clinical indicators of presumed infection (blood culture draws and antibiotic administrations) and concurrent organ dysfunction (vasopressors, mechanical ventilation, doubling in creatinine, doubling in bilirubin to >/= 2.0 mg/dL, decrease in platelets to < 100 cells/microL, or lactate >/= 2.0 mmol/L). We compared claims for sepsis prevalence and mortality rates between both methods. All estimates were reliability adjusted to account for random variation using hierarchical logistic regression modeling. The sensitivity of hospitals’ claims data was low and variable: median 30% (range, 5-54%) for sepsis, 66% (range, 26-84%) for acute kidney injury, 39% (range, 16-60%) for thrombocytopenia, 36% (range, 29-44%) for hepatic injury, and 66% (range, 29-84%) for shock. Correlation between claims and clinical data was moderate for sepsis prevalence (Pearson coefficient, 0.64) and mortality (0.61). Among hospitals in the lowest sepsis mortality quartile by claims, 46% shifted to higher mortality quartiles using clinical data. Using implicit sepsis criteria based on infection and organ dysfunction codes also yielded major differences versus clinical data. CONCLUSIONS: Variation in the accuracy of claims data for identifying sepsis and organ dysfunction limits their use for comparing hospitals’ sepsis rates and outcomes. Using objective clinical data may facilitate more meaningful hospital comparisons.

      17. Infectious disease threats and opportunities for preventionExternal
        Silk BJ.
        J Public Health Manag Pract. 2018 Nov/Dec;24(6):503-505.

        [No abstract]

      18. The first year of the global Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in Bangkok, Thailand, 2015-2016External
        Sirivongrangson P, Girdthep N, Sukwicha W, Buasakul P, Tongtoyai J, Weston E, Papp J, Wi T, Cherdtrakulkiat T, Dunne EF.
        PLoS One. 2018 ;13(11):e0206419.

        Antimicrobial-resistant Neisseria gonorrhoeae (NG) infection is a global public health threat, and there is a critical need to monitor patterns of resistance and risk factors. In collaboration with the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (CDC), and the Thailand Department of Disease Control (DDC), Ministry of Public Health (MoPH) implemented the first Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) in November 2015. Men presenting with urethritis at two clinical settings in Bangkok, Thailand (Bangrak Hospital [BH] and Silom Community Clinic @TropMed [SCC @TropMed]) provided demographic and behavioral information and had a urethral swab for Gram’s stain and NG culture collected. The NG isolates were evaluated for antimicrobial susceptibility by the Epsilometer test (Etest) to determine minimum inhibitory concentrations (MICs) for cefixime (CFM), ceftriaxone (CRO), azithromycin (AZI), gentamicin (GEN), and ciprofloxacin (CIP). From November 2015 -October 2016, 1,102 specimens were collected from 1,026 symptomatic men; 861 (78.1%) specimens were from BH and 241 (21.9%) specimens were from SCC @TropMed. Among the 1,102 specimens, 582 (52.8%) had intracellular Gram-negative diplococci and 591 (53.6%) had NG growth (i.e., NG infection); antimicrobial susceptibility testing (AST) was performed on 590 (99.8%) NG isolates. Among all symptomatic men, 293 (28.6%) had sex with men only, 430 (41.9%) were ages 18-29 years, 349 (34.0%) had antibiotic use in the last 2 weeks, and 564 (55.0%) had NG infection. Among 23 men with repeat NG infection during this first year of surveillance, 20 (87.0%) were infected twice, 2 (8.7%) were infected three times, and 1 (4.3%) was infected more than four times. All NG isolates were susceptible to CFM and CRO, and had MICs below 2 mug/mL for AZI and below 16 mug/mL for GEN. Overall, 545 (92.4%) isolates were resistant to CIP. This surveillance activity assessed individual patients, and included demographic and behavioral data linked to laboratory data. The inclusion of both individual and laboratory information in EGASP could help identify possible persistent infection and NG treatment failures. Expansion of EGASP to additional global settings is critical to assess trends and risk factors for NG, and to monitor for the emergence of resistance.

      19. Replacement of neuraminidase inhibitor-susceptible influenza A(H1N1) with resistant phenotype in 2008 and circulation of susceptible influenza A and B viruses during 2009-2013, South AfricaExternal
        Treurnicht FK, Buys A, Tempia S, Seleka M, Cohen AL, Walaza S, Glass AJ, Rossouw I, McAnerney J, Blumberg L, Cohen C, Venter M.
        Influenza Other Respir Viruses. 2018 Sep 14.

        BACKGROUND: Data on the susceptibility of influenza viruses from South Africa to neuraminidase inhibitors (NAIs) are scarce, and no extensive analysis was done. OBJECTIVES: We aimed to determine oseltamivir and zanamivir susceptibility of influenza A and B virus neuraminidases (NAs), 2007-2013, South Africa. PATIENTS/METHODS: We enrolled participants through national influenza-like illness surveillance, 2007-2013. Influenza diagnosis was by virus isolation and quantitative polymerase chain reaction (qPCR). Drug susceptibility was determined by chemiluminescence-based NA-STAR/NA-XTD assay. Sanger sequencing was used to determine molecular markers of NAI resistance. RESULTS: Forty percent (6341/15 985) of participants were positive for influenza viruses using virus isolation (2007-2009) and qPCR (2009-2013) methods. A total of 1236/6341 (19.5%) virus isolates were generated of which 307/1236 (25%) were tested for drug susceptibility. During 2007-2008, the median 50% inhibitory concentration (IC50 ) of oseltamivir for seasonal influenza A(H1N1) increased from of 0.08 nmol/L (range 0.01-3.60) in 2007 to 73 nmol/L (range 1.56-305 nmol/L) in 2008. Influenza A isolates from 2009 to 2013 were susceptible to oseltamivir [A(H3N2) median IC50 = 0.05 nmol/L (range 0.01-0.08); A(H1N1)pdm09 = 0.11 nmol/L (range 0.01-0.78)] and zanamivir [A(H3N2) median IC50 = 0.56 nmol/L (range 0.47-0.66); A(H1N1)pdm09 = 0.35 nmol/L (range 0.27-0.533)]. Influenza B viruses were susceptible to both NAIs. NAI resistance-associated substitutions H275Y, E119V, and R150K (N1 numbering) were not detected in influenza A viruses that circulated in 2009-2013. CONCLUSIONS: We confirm replacement of NAI susceptible by resistant phenotype influenza A(H1N1) in 2008. Influenza A and B viruses (2009-2013) remained susceptible to NAIs; therefore, these drugs are useful for treating influenza-infected patients.

    • Disaster Control and Emergency Services
      1. We discuss challenges to implementing evidence-based practice within the broad field of public health preparedness and response. We discuss the progress of public health preparedness and response in building and translating evidence to practice since the World Trade Center attacks of 9/11/2001. We briefly describe analogies to struggles that other professional disciplines face, and we highlight key factors that facilitate and impede the implementation of evidence-based practice. We recommend a partnership led by funding agencies and closely involving research organizations and professional associations as a means to ensure that the public health preparedness and response field continues to develop an evidence-based culture and practice.

      2. OBJECTIVES: The US Centers for Disease Control and Prevention (CDC)-funded Preparedness and Emergency Response Research Centers (PERRCs) conducted research from 2008 to 2015 aimed to improve the complex public health emergency preparedness and response (PHEPR) system. This paper summarizes PERRC studies that addressed the development and assessment of criteria for evaluating PHEPR and metrics for measuring their efficiency and effectiveness. METHODS: We reviewed 171 PERRC publications indexed in PubMed between 2009 and 2016. These publications derived from 34 PERRC research projects. We identified publications that addressed the development or assessment of criteria and metrics pertaining to PHEPR systems and describe the evaluation methods used and tools developed, the system domains evaluated, and the metrics developed or assessed. RESULTS: We identified 29 publications from 12 of the 34 PERRC projects that addressed PHEPR system evaluation criteria and metrics. We grouped each study into 1 of 3 system domains, based on the metrics developed or assessed: (1) organizational characteristics (n = 9), (2) emergency response performance (n = 12), and (3) workforce capacity or capability (n = 8). These studies addressed PHEPR system activities including responses to the 2009 H1N1 pandemic and the 2011 tsunami, as well as emergency exercise performance, situational awareness, and workforce willingness to respond. Both PHEPR system process and outcome metrics were developed or assessed by PERRC studies. CONCLUSIONS: PERRC researchers developed and evaluated a range of PHEPR system evaluation criteria and metrics that should be considered by system partners interested in assessing the efficiency and effectiveness of their activities. Nonetheless, the monitoring and measurement problem in PHEPR is far from solved. Lack of standard measures that are readily obtained or computed at local levels remains a challenge for the public health preparedness field. (Disaster Med Public Health Preparedness. 2018;page 1 of 13).

    • Disease Reservoirs and Vectors
      1. Restriction of Zika virus infection and transmission in Aedes aegypti mediated by an insect-specific flavivirusExternal
        Romo H, Kenney JL, Blitvich BJ, Brault AC.
        Emerg Microbes Infect. 2018 Nov 15;7(1):181.

        Previous studies demonstrated an insect-specific flavivirus, Nhumirim virus (NHUV), can suppress growth of West Nile virus (WNV) and decrease transmission rates in NHUV/WNV co-inoculated Culex quinquefasciatus. To assess whether NHUV might interfere with transmission of other medically important flaviviruses, the ability of NHUV to suppress viral growth of Zika virus (ZIKV) and dengue-2 virus (DENV-2) was assessed in Aedes albopictus cells. Significant reductions in ZIKV (100,000-fold) and DENV-2 (10,000-fold) were observed in either cells concurrently inoculated with NHUV or pre-inoculated with NHUV. In contrast, only a transient 10-fold titer reduction was observed with an alphavirus, chikungunya virus. Additionally, restricted in vitro mosquito growth of ZIKV was associated with lowered levels of intracellular ZIKV RNA in NHUV co-inoculated cultures. To assess whether NHUV could modulate vector competence for ZIKV, NHUV-inoculated Aedes aegypti were orally exposed to ZIKV. NHUV-inoculated mosquitoes demonstrated significantly lower ZIKV infection rates (18%) compared to NHUV unexposed mosquitoes (51%) (p < 0.002). Similarly, lower ZIKV transmission rates were observed for NHUV/ZIKV dually intrathoracically inoculated mosquitoes (41%) compared to ZIKV only inoculated mosquitoes (78%) (p < 0.0001), suggesting that NHUV can interfere with both midgut infection and salivary gland infection of ZIKV in Ae. aegypti. These results indicate NHUV could be utilized to model superinfection exclusion mechanism(s) and to study the potential for the mosquito virome to impact transmission of medically important flaviviruses.

    • Drug Safety
      1. Advances in optimizing the prescription of antibiotics in outpatient settingsExternal
        King LM, Fleming-Dutra KE, Hicks LA.
        Bmj. 2018 Nov 12;363:k3047.

        The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.

      2. Anticoagulation across care transitions: Identifying minimum data to maximize drug safetyExternal
        Shehab N, Greenwald JL, Budnitz DS.
        Jt Comm J Qual Patient Saf. 2018 Nov;44(11):627-629.

        [No abstract]

    • Environmental Health
      1. Community-wide recreational water-associated outbreak of cryptosporidiosis and control strategies – Maricopa County, Arizona, 2016External
        Iverson SA, Fowle N, Epperson G, Collins J, Zusy S, Narang J, Matthews J, Hlavsa MC, Roellig D, Sylvester T, Klein R, Sunenshine R.
        J Environ Health. 2018 ;81(4):14-21.

        We describe a 2016 community-wide recreational water-associated cryptosporidiosis outbreak investigation and response in Maricopa County, Arizona. Persons with a laboratory-confirmed illness were interviewed using a standardized questionnaire that assessed exposures 2 weeks before symptom onset. A convenience sample of managers and operators of chlorine-treated public aquatic facilities was surveyed regarding permanent supplemental treatment systems for Cryptosporidium. Among 437 cases identified (median age 12, range <1-75 years), 260 persons were interviewed. Public-treated recreational water was the most frequently reported exposure (177, 68%) of interviewed persons; almost 1 in 5 (43, 17%) swam when diarrhea was ongoing. After the 2016 outbreak, managers of some facilities expressed intentions to install supplementary water treatment systems, and by May 2017, at least one large facility installed an ultraviolet light system. Strategies to prevent additional illness included community messaging, education, and targeted remediation of affected facilities on the basis of interviews. Challenges to remediation during a cryptosporidiosis outbreak in a large jurisdiction with primarily outdoor pools underscore the importance of promoting healthy swimming practices that help prevent contamination from occurring.

    • Healthcare Associated Infections
      1. State health department validations of central line-associated bloodstream infection events reported via the National Healthcare Safety NetworkExternal
        Bagchi S, Watkins J, Pollock DA, Edwards JR, Allen-Bridson K.
        Am J Infect Control. 2018 Nov;46(11):1290-1295.

        BACKGROUND: Numerous state health departments (SHDs) have validated central line-associated bloodstream infection (CLABSI) data, and results from these studies provide important insights into the accuracy of CLABSI reporting to the National Healthcare Safety Network (NHSN) and remediable shortcomings in adherence to the CLABSI definition and criteria. METHODS: State CLABSI validation results were obtained from peer-reviewed publications, reports on SHD Web sites, and via personal communications with the SHD health care-associated infections coordinator. Data accuracy measures included pooled mean sensitivity, specificity, positive predictive value, and negative predictive value. Total CLABSI error rate was computed as the proportion of mismatches among total records reviewed. When available, reasons for CLABSI misclassification reported by SHDs were reviewed. RESULTS: At least 23 SHDs that have completed CLABSI validations indicated sensitivity (pooled mean, 82.9%), specificity (pooled mean, 98.5%), positive predictive value (pooled mean, 94.1%), and negative predictive value (pooled mean, 95.9%) of CLABSI reporting. The pooled error rate of CLABSI reporting was 4.4%. Reasons for CLABSI misclassification included incorrect secondary bloodstream infection attribution, misapplication of CLABSI definition, missed case finding, applying clinical over surveillance definitions, misapplication of laboratory-confirmed bloodstream infection 2 definition, and misapplication of general NHSN definitions. CONCLUSIONS: CLABSI underreporting remains a major concern; validations conducted by SHDs provide an important impetus for improved reporting. SHDs are uniquely positioned to engage facilities in collaborative validation reviews that allow transparency, education, and relationship building.

      2. Evaluation of the National Healthcare Safety Network Hemovigilance Module for transfusion-related adverse reactions in the United StatesExternal
        Edens C, Haass KA, Cumming M, Osinski A, O’Hearn L, Passanisi K, Eaton L, Visintainer P, Savinkina A, Kuehnert MJ, Basavaraju SV, Andrzejewski C.
        Transfusion. 2018 Nov 14.

        INTRODUCTION: The National Healthcare Safety Network (NHSN) Hemovigilance Module (HM) collects data on the frequency, severity, and imputability of transfusion-associated adverse events. These events contribute to significant morbidity and mortality among transfusion patients. We report results from the first systematic assessment of eight attributes of the HM. MATERIALS AND METHODS: Standard methods were used to assess the HM. Evaluation data included training materials, system modification history, and facility survey information. A concordance analysis was performed using data from the Baystate Medical Center’s (Boston, MA) electronic transfusion reporting system. RESULTS: In 2016, system representativeness remained low, with 6% (277 of 4690) of acute care facilities across 43 jurisdictions enrolled in the HM. In 2016, 48% (2147 of 4453) and 89% (3969 of 4,453) of adverse reactions were reported within 30 and 90 days of the reaction date, respectively, compared to 21% (109 of 511) and 56% (284 of 511) in 2010, demonstrating improved reporting timeliness. Data quality from most reactions was adequate, with 10% (45 of 442) misclassified transfusion-associated circulatory overload reactions, and no incomplete transfusion-transmitted infection data reported from 2010 to 2013. When compared to the Baystate system to assess concordance, 43% (24 of 56) of NHSN-reported febrile reactions were captured in both systems (unweighted kappa value, 0.47; confidence interval, 0.33-0.61). CONCLUSION: Since the 2010 HM pilot, improvements have led to enhanced simplicity, timeliness, and strengthened data quality. The HM serves an important and unique role despite incomplete adoption nationwide. Facility efforts to track and prevent transfusion-associated adverse events through systems like the NHSN HM are a key step toward improving transfusion safety in the United States.

    • Immunity and Immunization
      1. Preparing for safety monitoring after rotavirus vaccine introduction – assessment of baseline epidemiology of intussusception among children < 2 years of age in four Asian countriesExternal
        Burnett E, Van Trang N, Rayamajhi A, Yousafzai MT, Satter SM, Anh DD, Thapa A, Qazi SH, Heffelfinger JD, Hung PH, Rayamajhi AK, Saddal N, Flora MS, Canh TM, Ali SA, Gurley ES, Tate JE, Yen C, Parashar UD.
        Vaccine. 2018 Nov 7.

        Intussusception is the invagination of one segment of the bowel into a distal segment, characterized by symptoms of bloody stool, vomiting, and abdominal pain. Previous studies have found regional differences in incidence but the etiology of most intussusception cases is unknown. Rotavirus vaccines were associated with a slightly of increased risk of intussusception in post-licensure evaluations in high- and middle-income countries, but not in low income African countries. To describe the baseline epidemiology of intussusception in young children prior to rotavirus vaccine implementation, active sentinel hospital surveillance for intussusception in children<2years of age was conducted in 4 low income Asian countries (Bangladesh, Nepal, Pakistan and Vietnam). Over a 24-month period, 15 sites enrolled 1,415 intussusception cases, of which 70% were enrolled in Vietnam. Overall, 61% of cases were male and 1% (n=16) died, ranging from 8% in Pakistan to 0% in Vietnam. The median age of cases enrolled ranged from 6months in Bangladesh and Pakistan to 12months in Vietnam. The proportion of cases receiving surgical management was 100% in Bangladesh, 88% in Pakistan, 61% in Nepal, and 1% in Vietnam. The high proportion of males and median age of cases around 6months of age found in this regional surveillance network are consistent with previous descriptions of the epidemiology of intussusception in these countries and elsewhere. Differences in management and the fatality rate of cases between the countries likely reflect differences in access to healthcare and availability of diagnostic modalities. These baseline data will be useful for post-rotavirus vaccine introduction safety monitoring.

      2. The Advisory Committee on Immunization Practices (ACIP)* is a federal advisory committee that provides expert advice to the Director of CDC and the Secretary of the U.S. Department of Health and Human Services in the form of recommendations on the use of vaccines and related agents for control of vaccine-preventable diseases in the U.S. civilian population (1,2). Work groups that gather, analyze, and prepare scientific information assist in the recommendation formulation process and present options for recommendations based on the scientific evidence they have assessed. Recommendations that are approved by a majority of ACIP’s voting members are then reviewed by the Director of CDC and published in MMWR if approved by the director. This report briefly summarizes an update to the ACIP process for developing evidence-based recommendations that ACIP adopted at its February 2018 meeting.

      3. Influenza vaccine effectiveness among patients with high-risk medical conditions in the United States, 2012-2016External
        Shang M, Chung JR, Jackson ML, Jackson LA, Monto AS, Martin ET, Belongia EA, McLean HQ, Gaglani M, Murthy K, Zimmerman RK, Nowalk MP, Fry AM, Flannery B.
        Vaccine. 2018 Nov 9.

        BACKGROUND: Annual influenza vaccination has been recommended for persons with high-risk conditions since the 1960s. However, few estimates of influenza vaccine effectiveness (VE) for persons with high-risk conditions are available. METHODS: Data from the U.S. Influenza Vaccine Effectiveness Network from 2012 to 2016 were analyzed to compare VE of standard-dose inactivated vaccines against medically-attended influenza among patients aged >/=6months with and without high-risk medical conditions. Patients with acute respiratory illness were tested for influenza by RT-PCR. Presence of high-risk conditions and vaccination status were obtained from medical records. VE by influenza virus type/subtype and age group was calculated for patients with and without high-risk conditions using the test-negative design. Interaction terms were used to test for differences in VE by high-risk conditions. RESULTS: Overall, 9643 (38%) of 25,369 patients enrolled during four influenza seasons had high-risk conditions; 2213 (23%) tested positive for influenza infection. For all ages, VE against any influenza was lower among patients with high-risk conditions (41%, 95% CI: 35-47%) than those without (48%, 95% CI: 43-52%; P-for-interaction=0.02). For children aged <18years, VE against any influenza was 51% (95% CI: 39-61%) and 52% (95% CI: 39-61%) among those with and without high-risk conditions, respectively (P-for-interaction=0.54). For adults aged >/=18years, VE against any influenza was 38% (95% CI: 30-45%) and 44% (95% CI: 38-50%) among those with and without high-risk conditions, respectively (P-for-interaction=0.21). For both children aged <18 and adults aged >/=18years, VEs against illness related to influenza A(H3N2), A(H1N1)pdm09, and influenza B virus infection were similar among those with and without high-risk conditions. CONCLUSIONS: Influenza vaccination provided protection against medically-attended influenza among patients with high-risk conditions, at levels approaching those observed among patients without high-risk conditions. Results from our analysis support recommendations of annual vaccination for patients with high-risk conditions.

      4. Global routine vaccination coverage – 2017External
        VanderEnde K, Gacic-Dobo M, Diallo MS, Conklin LM, Wallace AS.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1261-1264.

        Endorsed by the World Health Assembly in 2012, the Global Vaccine Action Plan 2011-2020 (GVAP) (1) calls on all countries to reach >/=90% national coverage with all vaccines in the country’s national immunization schedule by 2020. This report updates previous reports (2,3) and presents global, regional, and national vaccination coverage estimates and trends as of 2017. It also describes the number of infants surviving to age 1 year (surviving infants) who did not receive the third dose of diphtheria and tetanus toxoids and pertussis-containing vaccine (DTP3), a key indicator of immunization program performance (4,5), with a focus on the countries with the highest number of children who did not receive DTP3 in 2017. Based on the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) estimates, global DTP3 coverage increased from 79% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). In 2017, among the 19.9 million children who did not receive DTP3 in the first year of life, 62% (12.4 million) lived in 10 countries. From 2007 to 2017, the number of children who had not received DTP3 decreased in five of these 10 countries and remained stable or increased in the other five. Similar to DTP3 coverage, global coverage with the first measles-containing vaccine dose (MCV1) increased from 80% in 2007 to 84% in 2010, and has remained stable from 2010 to 2017 (84% to 85%). Coverage with the third dose of polio vaccine (Pol3) has remained stable at 84%-85% since 2010. From 2007 to 2017, estimated global coverage with the second MCV dose (MCV2) increased from 33% to 67%, as did coverage with the completed series of rotavirus (2% to 28%), pneumococcal conjugate (PCV) (4% to 44%), rubella (26% to 52%), Haemophilus influenzae type b (Hib) (25% to 72%) and hepatitis B (HepB) (birth dose: 24% to 43%; 3-dose series: 63% to 84%) vaccines. Targeted, context-specific strategies are needed to reach and sustain high vaccination coverage, particularly in countries with the highest number of unvaccinated children.

    • Informatics
      1. The Nigerian health information system policy review of 2014 – the need, content, expectations and progressExternal
        Meribole EC, Makinde OA, Oyemakinde A, Oyediran KA, Atobatele A, Fadeyibi FA, Azeez A, Ogbokor D, Adebayo O, Adebayo W, Abatta E, Adoghe A, Adebayo SB, Mahmoud Z, Ashefor G, Adebayo SB, Yisa IO, Balogun A, Chukwujekwu O, Dalhatu I, Jahun I, Bamidele S, Johnson DO, Ibrahim M, Akpan F, Aiyenigba B, Omaha OI, Terpase A, Ottih C, Adelakin O, Mullen S, Orobaton N.
        Health Info Libr J. 2018 Nov 12.

        BACKGROUND: Nigeria’s national health information system (HIS) data sources are grouped into institutional and population based data that traverse many government institutions. Communication and collaboration between these institutions are limited, fraught with fragmentation and challenges national HIS functionality. OBJECTIVES: The objective of this paper was to share insights from and the implications of a recent review of Nigeria’s HIS policy in 2014 that resulted in its substantial revision. We also highlight some subsequent enactments. REVIEW PROCESS AND OUTCOMES: In 2013, Nigeria’s Federal Ministry of Health launched an inter-ministerial and multi-departmental review of the National Health Management Information System policy of 2006. The review was guided by World Health Organization’s ‘Framework and Standards for Country Health Information Systems’. The key finding was a lack of governance mechanisms in the execution of the policy, including an absent data management governance process. The review also found a multiplicity of duplicative, parallel reporting tools and platforms. CONCLUSION: Recommendations for HIS Policy revisions were proposed to and implemented by the Federal Government of Nigeria. The revised HIS policy now provides for a strong framework for the leadership and governance of the HIS with early results.

    • Injury and Violence
      1. Suicide rates by major occupational group – 17 states, 2012 and 2015External
        Peterson C, Stone DM, Marsh SM, Schumacher PK, Tiesman HM, McIntosh WL, Lokey CN, Trudeau AT, Bartholow B, Luo F.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1253-1260.

        During 2000-2016, the suicide rate among the U.S. working age population (persons aged 16-64 years) increased 34%, from 12.9 per 100,000 population to 17.3 (https://www.cdc.gov/injury/wisqars). To better understand suicide among different occupational groups and inform suicide prevention efforts, CDC analyzed suicide deaths by Standard Occupational Classification (SOC) major groups for decedents aged 16-64 years from the 17 states participating in both the 2012 and 2015 National Violent Death Reporting System (NVDRS) (https://www.cdc.gov/violenceprevention/nvdrs). The occupational group with the highest male suicide rate in 2012 and 2015 was Construction and Extraction (43.6 and 53.2 per 100,000 civilian noninstitutionalized working persons, respectively), whereas the group with the highest female suicide rate was Arts, Design, Entertainment, Sports, and Media (11.7 [2012] and 15.6 [2015]). The largest suicide rate increase among males from 2012 to 2015 (47%) occurred in the Arts, Design, Entertainment, Sports, and Media occupational group (26.9 to 39.7) and among females, in the Food Preparation and Serving Related group, from 6.1 to 9.4 (54%). CDC’s technical package of strategies to prevent suicide is a resource for communities, including workplace settings (1).

      2. Proportion of violent injuries unreported to law enforcementExternal
        Wu DT, Moore JC, Bowen DA, Mercer Kollar LM, Mays EW, Simon TR, Sumner SA.
        JAMA Intern Med. 2018 Nov 12.

        [No abstract]

    • Laboratory Sciences
      1. Group II innate lymphoid cells and microvascular dysfunction from pulmonary titanium dioxide nanoparticle exposureExternal
        Abukabda AB, McBride CR, Batchelor TP, Goldsmith WT, Bowdridge EC, Garner KL, Friend S, Nurkiewicz TR.
        Part Fibre Toxicol. 2018 Nov 9;15(1):43.

        BACKGROUND: The cardiovascular effects of pulmonary exposure to engineered nanomaterials (ENM) are poorly understood, and the reproductive consequences are even less understood. Inflammation remains the most frequently explored mechanism of ENM toxicity. However, the key mediators and steps between lung exposure and uterine health remain to be fully defined. The purpose of this study was to determine the uterine inflammatory and vascular effects of pulmonary exposure to titanium dioxide nanoparticles (nano-TiO2). We hypothesized that pulmonary nano-TiO2 exposure initiates a Th2 inflammatory response mediated by Group II innate lymphoid cells (ILC2), which may be associated with an impairment in uterine microvascular reactivity. METHODS: Female, virgin, Sprague-Dawley rats (8-12 weeks) were exposed to 100 mug of nano-TiO2 via intratracheal instillation 24 h prior to microvascular assessments. Serial blood samples were obtained at 0, 1, 2 and 4 h post-exposure for multiplex cytokine analysis. ILC2 numbers in the lungs were determined. ILC2s were isolated and phosphorylated nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) levels were measured. Pressure myography was used to assess vascular reactivity of isolated radial arterioles. RESULTS: Pulmonary nano-TiO2 exposure was associated with an increase in IL-1ss, 4, 5 and 13 and TNF- alpha 4 h post-exposure, indicative of an innate Th2 inflammatory response. ILC2 numbers were significantly increased in lungs from exposed animals (1.66 +/- 0.19%) compared to controls (0.19 +/- 0.22%). Phosphorylation of the transactivation domain (Ser-468) of NF-kappaB in isolated ILC2 and IL-33 in lung epithelial cells were significantly increased (126.8 +/- 4.3% and 137 +/- 11% of controls respectively) by nano-TiO2 exposure. Lastly, radial endothelium-dependent arteriolar reactivity was significantly impaired (27 +/- 12%), while endothelium-independent dilation (7 +/- 14%) and alpha-adrenergic sensitivity (8 +/- 2%) were not altered compared to control levels. Treatment with an anti- IL-33 antibody (1 mg/kg) 30 min prior to nano-TiO2 exposure resulted in a significant improvement in endothelium-dependent dilation and a decreased level of IL-33 in both plasma and bronchoalveolar lavage fluid. CONCLUSIONS: These results provide evidence that the uterine microvascular dysfunction that follows pulmonary ENM exposure may be initiated via activation of lung-resident ILC2 and subsequent systemic Th2-dependent inflammation.

      2. Trends in Q fever serologic testing by immunofluorescence from four large reference laboratories in the United States, 2012-2016External
        Miller HK, Binder AM, Peterson A, Theel ES, Volpe JM, Couturier MR, Cherry CC, Kersh GJ.
        Sci Rep. 2018 Nov 12;8(1):16670.

        Laboratory testing for Q fever (Coxiella burnetii) is essential for a differential diagnosis, yet little is known about Q fever diagnostic testing practices in the United States. We retrospectively analyzed Q fever immunoglobulin G (IgG) indirect immunofluorescence assay (IFA) testing data between 1/1/2012-10/31/2016 from ARUP, LabCorp, Mayo Medical Laboratories, and Quest Diagnostics. Data included IgG phase I and phase II titers, patient age and sex, and state and date of specimen collection. On average, 12,821 specimens were tested for Q fever annually by the participating laboratories. Of 64,106 total specimens, 84.1% tested negative for C. burnetii-specific antibodies. Positive titers ranged from 16 to 262,144 against both phase I and phase II antigens. Submission of specimens peaked during the summer months, and more specimens were submitted from the West North Central division. Testing occurred more frequently in males (53%) and increased with age. In conclusion, few U.S. Q fever cases are reported, despite large volumes of diagnostic specimens tested. Review of commercial laboratory data revealed a lack of paired serology samples and patterns of serology titers that differ from case reporting diagnostic criteria.

      3. Triplex real-time PCR assay for the detection of Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae directly from clinical specimens without extraction of DNAExternal
        Ouattara M, Whaley MJ, Jenkins LT, Schwartz SB, Traore RO, Diarra S, Collard JM, Sacchi CT, Wang X.
        Diagn Microbiol Infect Dis. 2018 Oct 16.

        This study presents a triplex real-time PCR assay that allows for the direct detection of Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae in one reaction without DNA extraction, with similar sensitivity and specificity to singleplex assays. This approach saves time, specimen volume and reagents while achieving a higher testing throughput.

      4. Comparison of multi-walled carbon nanotube and nitrogen-doped multi-walled carbon nanotube effects on lung function and airway reactivity in ratsExternal
        Russ KA, Thompson JA, Kashon M, Porter DW, Friend SA, McKinney W, Fedan JS.
        Toxicol Appl Pharmacol. 2018 Nov 10.

        Incorporation of multi-wall carbon nanotubes (MWCNT) into materials has raised concerns about their potential hazards to manufacturing workers. In animal models, airway inflammation and lung fibrosis follow aspiration, instillation, and inhalation exposures to MWCNT. However, the effects of MWCNT on pulmonary function, airway reactivity and airway epithelium function following inhalation exposure has not been studied. We investigated whether inhaled MWCNT affects lung resistance (RL) and dynamic compliance (Cdyn), reactivity to inhaled methacholine (MCh), epithelial regulation of airway reactivity to MCh in vitro, and airway epithelial ion transport. Male rats were exposed by whole body inhalation for 6h to air or aerosolized MWCNT (0.5, 1 or 5mg/m(3)) for one or nine days. Eighteen h after 1 d exposure to 5mg/m(3) MWCNT, basal RL was increased and basal Cdyn was decreased; changes did not persist for 7 d. Reactivity to MCh (RL) was increased and Cdyn responses were decreased at 18h, but not 7 d after exposure to 1 and 5mg/m(3) MWCNT. The effects of i.t.-instilled MWCNT and nitrogen-doped MWCNT (N-MWCNT) on pulmonary function and reactivity to MCh at doses comparable to deposition after inhalation of 5mg/m(3) at 1 d and 0.5, 1, and 5mg/m(3) MWCNT 9 d-exposures were compared. Both nanoparticles increased airway reactivity (RL); N-MWCNT did not affect Cdyn responses. Lung function and airway reactivity are altered following a single MWCNT inhalation and generally subside over time. Given i.t., MWCNT’s and N-MWCNT’s effects were comparable, but N-MWCNT evoke smaller changes in Cdyn responses.

      5. Concordance analysis between different methodologies used for identification of oral isolates of Candida speciesExternal
        Zuluaga A, Arango-Bustamante K, Caceres DH, Sanchez-Quitian ZA, Velasquez V, Gomez BL, Parra-Giraldo CM, Maldonado N, Cano LE, de Bedout C, Rivera RE.
        Colomb Med (Cali). 2018 Sep 30;49(3):193-200.

        Background: The yeasts species determination is fundamental not only for an accurate diagnosis but also for establishing a suitable patient treatment. We performed a concordance study of five methodologies for the species identification of oral isolates of Candida in Colombia. Methods: Sixty-seven Candida isolates were tested by; API(R) 20C-AUX, Vitek(R)2 Compact, Vitek(R)MS, Microflex(R) and a molecular test (panfungal PCR and sequencing). The commercial cost and processing time of the samples was done by graphical analysis. Results: Panfungal PCR differentiated 12 species of Candida, Vitek(R)MS and Microflex(R) methods identified 9 species, and API(R) 20C-AUX and Vitek(R)2 Compact methods identified 8 species each. Weighted Kappa (wK) showed a high agreement between Panfungal PCR, Vitek(R)MS, Microflex(R) and API(R) 20C-AUX (wK 0.62-0.93). The wK that involved the Vitek(R)2 Compact method presented moderate or good concordances compared with the other methods (wK 0.56-0.73). Methodologies based on MALDI TOF MS required 4 minutes to generate results and the Microflex(R) method had the lowest selling price. Conclusion: The methods evaluated showed high concordance in their results, being higher for the molecular methods and the methodologies based on MALDI TOF. The latter are faster and cheaper, presenting as promising alternatives for the routine identification of yeast species of the genus Candida.

    • Maternal and Child Health
      1. Prevalence and characteristics of autism spectrum disorder among children aged 8 years – Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2012External
        Christensen DL, Braun KV, Baio J, Bilder D, Charles J, Constantino JN, Daniels J, Durkin MS, Fitzgerald RT, Kurzius-Spencer M, Lee LC, Pettygrove S, Robinson C, Schulz E, Wells C, Wingate MS, Zahorodny W, Yeargin-Allsopp M.
        MMWR Surveill Summ. 2018 Nov 16;65(13):1-23.

        PROBLEM/CONDITION: Autism spectrum disorder (ASD). PERIOD COVERED: 2012. DESCRIPTION OF SYSTEM: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system that provides estimates of the prevalence and characteristics of ASD among children aged 8 years whose parents or guardians reside in 11 ADDM Network sites in the United States (Arkansas, Arizona, Colorado, Georgia, Maryland, Missouri, New Jersey, North Carolina, South Carolina, Utah, and Wisconsin). Surveillance to determine ASD case status is conducted in two phases. The first phase consists of screening and abstracting comprehensive evaluations performed by professional service providers in the community. Data sources identified for record review are categorized as either 1) education source type, including developmental evaluations to determine eligibility for special education services or 2) health care source type, including diagnostic and developmental evaluations. The second phase involves the review of all abstracted evaluations by trained clinicians to determine ASD surveillance case status. A child meets the surveillance case definition for ASD if one or more comprehensive evaluations of that child completed by a qualified professional describes behaviors that are consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder-not otherwise specified (including atypical autism), or Asperger disorder. This report provides ASD prevalence estimates for children aged 8 years living in catchment areas of the ADDM Network sites in 2012, overall and stratified by sex, race/ethnicity, and the type of source records (education and health records versus health records only). In addition, this report describes the proportion of children with ASD with a score consistent with intellectual disability on a standardized intellectual ability test, the age at which the earliest known comprehensive evaluation was performed, the proportion of children with a previous ASD diagnosis, the specific type of ASD diagnosis, and any special education eligibility classification. RESULTS: For 2012, the combined estimated prevalence of ASD among the 11 ADDM Network sites was 14.5 per 1,000 (one in 69) children aged 8 years. Estimated prevalence was significantly higher among boys aged 8 years (23.4 per 1,000) than among girls aged 8 years (5.2 per 1,000). Estimated ASD prevalence was significantly higher among non-Hispanic white children aged 8 years (15.3 per 1,000) compared with non-Hispanic black children (13.1 per 1,000), and Hispanic (10.2 per 1,000) children aged 8 years. Estimated prevalence varied widely among the 11 ADDM Network sites, ranging from 8.2 per 1,000 children aged 8 years (in the area of the Maryland site where only health care records were reviewed) to 24.6 per 1,000 children aged 8 years (in New Jersey, where both education and health care records were reviewed). Estimated prevalence was higher in surveillance sites where education records and health records were reviewed compared with sites where health records only were reviewed (17.1 per 1,000 and 10.4 per 1,000 children aged 8 years, respectively; p<0.05). Among children identified with ASD by the ADDM Network, 82% had a previous ASD diagnosis or educational classification; this did not vary by sex or between non-Hispanic white and non-Hispanic black children. A lower percentage of Hispanic children (78%) had a previous ASD diagnosis or classification compared with non-Hispanic white children (82%) and with non-Hispanic black children (84%). The median age at earliest known comprehensive evaluation was 40 months, and 43% of children had received an earliest known comprehensive evaluation by age 36 months. The percentage of children with an earliest known comprehensive evaluation by age 36 months was similar for boys and girls, but was higher for non-Hispanic white children (45%) compared with non-Hispanic black children (40%) and Hispanic children (39%). INTERPRETATION: Overall estimated ASD prevalence was 14.5 per 1,000 children aged 8 years in the ADDM Network sites in 2012. The higher estimated prevalence among sites that reviewed both education and health records suggests the role of special education systems in providing comprehensive evaluations and services to children with developmental disabilities. Disparities by race/ethnicity in estimated ASD prevalence, particularly for Hispanic children, as well as disparities in the age of earliest comprehensive evaluation and presence of a previous ASD diagnosis or classification, suggest that access to treatment and services might be lacking or delayed for some children. PUBLIC HEALTH ACTION: The ADDM Network will continue to monitor the prevalence and characteristics of ASD among children aged 8 years living in selected sites across the United States. Recommendations from the ADDM Network include enhancing strategies to 1) lower the age of first evaluation of ASD by community providers in accordance with the Healthy People 2020 goal that children with ASD are evaluated by age 36 months and begin receiving community-based support and services by age 48 months; 2) reduce disparities by race/ethnicity in identified ASD prevalence, the age of first comprehensive evaluation, and presence of a previous ASD diagnosis or classification; and 3) assess the effect on ASD prevalence of the revised ASD diagnostic criteria published in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

    • Military Medicine and Health
      1. The multiple hit hypothesis for Gulf War Illness: Self-reported chemical/biological weapons exposure and mild traumatic brain injuryExternal
        Janulewicz P, Krengel M, Quinn E, Heeren T, Toomey R, Killiany R, Zundel C, Ajama J, O’Callaghan J, Steele L, Klimas N, Sullivan K.
        Brain Sci. 2018 Nov 13;8(11).

        The Gulf War Illness Consortium (GWIC) was designed to identify objective biomarkers of Gulf War Illness (GWI) in 1991 Gulf War veterans. The symptoms of GWI include fatigue, pain, cognitive problems, gastrointestinal, respiratory, and skin problems. Neurotoxicant exposures during deployment, such as pesticides, sarin, and pyridostigmine bromide pills have been identified as contributors to GWI. We have also found an association between mild traumatic brain injury (mTBI) and increased rates of GWI. However, the combined impact of these physical and chemical exposures has not yet been explored in GWI. The objective of this study was to examine both self-reported mTBI and exposure to chemical/biological weapons (CBW) as a multiple or two hit model for increased risk of GWI and other chronic health conditions. The study population included 125 Gulf War (GW) veterans from the Boston GWIC. Exposure to CBW was reported in 47.2% of the study population, and 35.2% reported sustaining a mTBI during the war. Results confirmed that those with both exposures (mTBI and CBW) had higher rates of comorbid chronic health conditions while rates of GWI were equivalent for mTBI and CBW or mTBI alone. The timing of exposure to mTBI was found to be strikingly different between those with GWI and those without it. Correspondingly, 42.3% of GWI cases reported experiencing a mTBI during military service while none of the controls did (p = 0.0002). Rates of mTBI before and after the war did not differ between the cases and controls. In addition, 54% of cases compared to 14.3% of controls (p = <0.001) reported being exposed to CBW during military service. The current study examined the relation of the separate and combined effects of exposure to mTBI and CBW in 1991 GW veterans. The findings from this study suggest that both exposure to mTBI and CBW are associated with the development of GWI and multiple chronic health conditions and that combined exposure appears to lead to higher risk of chronic health effects.

    • Nutritional Sciences
      1. The dietary supplement label database: Recent developments and applicationsExternal
        Dwyer JT, Bailen RA, Saldanha LG, Gahche JJ, Costello RB, Betz JM, Davis CD, Bailey RL, Potischman N, Ershow AG, Sorkin BC, Kuszak AJ, Rios-Avila L, Chang F, Goshorn J, Andrews KW, Pehrsson PR, Gusev PA, Harnly JM, Hardy CJ, Emenaker NJ, Herrick KA.
        J Nutr. 2018 01 Aug;148(8 Supplement):1428S-1435S.

        Although many Americans use dietary supplements, databases of dietary supplements sold in the United States have not been widely available. The Dietary Supplement Label Database (DSLD), an easily accessible public-use database, was created in 2008 to provide information on dietary supplement composition for use by researchers and consumers. We describe in this article the history, key features, recent enhancements, and common applications of the DSLD. Accessing current information easily and quickly is crucial for documenting exposures to dietary supplements because they contain nutrients and other bioactive ingredients that may have beneficial or adverse effects on human health. This article details recent developments with the DSLD to achieve this goal, and provides examples of how the DSLD has been used. With periodic updates to track changes in product composition and capture new products entering the market, the DSLD currently contains >71,000 dietary supplement labels. Following usability testing with consumer and researcher user groups completed in 2016, improvements to the DSLD interface were made. As of 2018, both a desktop and mobile device version are available. Since its inception in 2008, the DSLD has been used for research, exposure monitoring, and for other purposes by users in the public and private sectors. Further refinement of the user interface and search features is planned to facilitate ease of use for stakeholders. The DSLD can be used to track changes in product composition and capture new products entering the market. With >71,000 dietary supplement labels, it is a unique resource that policymakers, researchers, clinicians, and consumers may find valuable for multiple applications.

      2. Federal monitoring of dietary supplement use in the resident, civilian, noninstitutionalized US Population: National Health and Nutrition Examination SurveyExternal
        Gahche JJ, Bailey RL, Potischman N, Ershow AG, Herrick KA, Ahluwalia N, Dwyer JT.
        J Nutr. 2018 ;148(8):1436S-1444S.

        This review summarizes the current and previous data on dietary supplement (DS) use collected from participants in the NHANES, describes the NHANES DS database used to compute nutrient intakes from DSs, discusses recent developments and future directions, and describes many examples to show the utility of these data in informing nutrition research and policy. Since 1971, NHANES has been collecting information on the use of DSs from participants. These data are critical to national nutrition surveillance and have been used to characterize usage patterns, examine trends over time, assess the percentage of the population meeting or exceeding nutrient recommendations, and help to elucidate the sources contributing nutrients to the diet of the US population. More than half of adults and approximately one-third of children in the United States currently use ?1 DS in the course of 30 d. DSs contribute to the dietary intake of nutrients and bioactive compounds in the United States and therefore need to be assessed when monitoring nutritional status of the population and when studying diet-health associations. With the recent development and availability of the Dietary Supplement Label Database, a comprehensive DS database that will eventually contain labels for all products marketed in the United States, NHANES DS data will be more easily linked to product information to estimate nutrient intake from DSs. NHANES provides a rich source of nationally representative data on the usage of dietary supplements in the United States. Over time, NHANES has both expanded and improved collection methods. The continued understanding of sources of error in collection methods will continue to be explored and is critical to improved accuracy.

    • Occupational Safety and Health
      1. Characterization and workplace exposure assessment of nanomaterial released from a carbon nanotube-enabled anti-corrosive coatingExternal
        Brame JA, Alberts EM, Schubauer-Berigan MK, Dunn KH, Babik KR, Barnes E, Moser R, Poda AR, Kennedy AJ.
        NanoImpact. 2018 ;12:58-68.

        Improvement of methods to quantify the release and characterization of engineered nanomaterials (ENMs) from nano-enabled products is essential to enhance the accuracy and usability of environmental health and safety evaluations. An anticorrosive coating containing multi-wall carbon nanotubes (MWCNTs) was analyzed for nano-scale material and workplace exposure potential. Worker breathing zone measurements for elemental carbon (EC) and electron-microscopy-based structure counts showed negligible MWCNT exposure to workers during laboratory and spray-painting operations over the course of two 8-hour shifts (arithmetic mean inhalable EC and electron microscopy structure count concentrations were 6.47 g/m3 and 0.084 structures/cm3 respectively). UV weathering prior to abrasion testing increased the nano-size fraction of released material as measured by a fast mobility particle sizer (FMPS) and visual inspection by SEM indicated increased presence of exposed MWCNTs embedded in the polymer matrix. However, no free MWCNTs were identified, despite evidence of MWCNTs embedded in airborne particles. TiO2, used as a pigment in the coating and not anticipated as a candidate for nano-specific scrutiny, contained a small fraction (3.5% in number) of nano-sized constituents (100 nm). This work emphasizes need for rigorous characterization of additive materials to properly assess potential health hazards and to better our understanding of what qualifies as nano.

      2. Firefighter hood contamination: Efficiency of laundering to remove PAHs and FRsExternal
        Mayer AC, Fent KW, Bertke S, Horn GP, Smith DL, Kerber S, La Guardia MJ.
        J Occup Environ Hyg. 2018 Nov 14:1-32.

        Firefighters are occupationally exposed to products of combustion containing polycyclic aromatic hydrocarbons (PAHs) and flame retardants (FRs), potentially contributing to their increased risk for certain cancers. Personal protective equipment (PPE), including firefighter hoods, helps to reduce firefighters’ exposure to toxic substances during fire responses by providing a layer of material on which contaminants deposit prior to reaching the firefighters skin. However, over time hoods that retain some contamination may actually contribute to firefighters’ systemic dose. We investigated the effectiveness of laundering to reduce or remove contamination on the hoods, specifically PAHs and three classes of FRs: polybrominated diphenyl ethers (PBDEs), non-PBDE flame retardants (NPBFRs), and organophosphate flame retardants (OPFRs). Participants in the study were grouped into crews of 12 firefighters who worked in pairs by job assignment while responding to controlled fires in a single family residential structure. For each pair of firefighters, one hood was laundered after every scenario and one was not. Bulk samples of the routinely laundered and unlaundered hoods from five pairs of firefighters were collected and analyzed. Residual levels of OPFRs, NPBFRs, and PAHs were lower in the routinely laundered hoods, with total levels of each class of chemicals being 56-81% lower, on average, than the unlaundered hoods. PBDEs, on average, were 43% higher in the laundered hoods, most likely from cross contamination. After this initial testing, four of the five unlaundered exposed hoods were subsequently laundered with other heavily exposed (unlaundered) and unexposed (new) hoods. Post-laundering evaluation of these hoods revealed increased levels of PBDEs, NPBFRs, and OPFRs in both previously exposed and unexposed hoods, indicating cross contamination. For PAHs, there was little evidence of cross contamination and the exposed hoods were significantly less contaminated after laundering (76% reduction; p = 0.011). Further research is needed to understand how residual contamination on hoods could contribute to firefighters’ systemic exposures.

      3. Workers’ compensation injury claims among workers in the private ambulance services industry – Ohio, 2001-2011External
        Reichard AA, Al-Tarawneh IS, Konda S, Wei C, Wurzelbacher SJ, Meyers AR, Bertke SJ, Bushnell PT, Tseng CY, Lampl MP, Robins DC.
        Am J Ind Med. 2018 Nov 12.

        BACKGROUND: Ambulance service workers frequently transfer and transport patients. These tasks involve occupational injury risks such as heavy lifting, awkward postures, and frequent motor vehicle travel. METHODS: We examined Ohio workers’ compensation injury claims among state-insured ambulance service workers working for private employers from 2001 to 2011. Injury claim counts and rates are presented by claim types, diagnoses, and injury events; only counts are available by worker characteristics. RESULTS: We analyzed a total of 5882 claims. The majority were medical-only (<8 days away from work). The overall injury claim rate for medical-only and lost-time cases was 12.1 per 100 full-time equivalents. Sprains and strains accounted for 60% of all injury claims. Overexertion from patient handling was the leading injury event, followed by motor vehicle roadway incidents. CONCLUSIONS: Study results can guide the development or improvement of injury prevention strategies. Focused efforts related to patient handling and vehicle incidents are needed.

    • Parasitic Diseases
      1. Progress toward global eradication of dracunculiasis – January 2017-June 2018External
        Hopkins DR, Ruiz-Tiben E, Weiss AJ, Roy SL, Zingeser J, Guagliardo SA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1265-1270.

        Dracunculiasis (Guinea worm disease), caused by the parasite Dracunculus medinensis, is acquired by drinking water containing copepods (water fleas) infected with its larvae. The worm typically emerges through the skin on a lower limb approximately 1 year after infection, causing pain and disability (1). The worldwide eradication campaign began at CDC in 1980. In 1986, the World Health Assembly called for dracunculiasis elimination, and the global Guinea Worm Eradication Program (GWEP), led by the Carter Center in partnership with the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), CDC, and others, began assisting ministries of health in countries with dracunculiasis. There is no vaccine or medicine to treat the disease; the GWEP relies on case containment* to prevent water contamination and other interventions to prevent infection, including health education, water filtration, chemical treatment of water, and provision of safe drinking water (1,2). In 1986, an estimated 3.5 million cases(dagger) occurred each year in 20( section sign) African and Asian countries (3,4). This report, based on updated health ministry data (3), describes progress during January 2017-June 2018 and updates previous reports (1,4). In 2017, 30 cases were reported from Chad and Ethiopia, and 855 infected animals (mostly dogs) were reported from Chad, Ethiopia, and Mali, compared with 25 cases and 1,049 animal infections reported in 2016. During January-June 2018, the number of cases declined to three cases each in Chad and South Sudan and one in Angola, with 709 infected animals reported, compared with eight cases and 547 animal infections during the same period of 2017. With only five affected countries, the eradication goal is near, but is challenged by civil unrest, insecurity, and lingering epidemiologic and zoologic questions.

      2. Specificity of the IgG antibody response to Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, and Plasmodium ovale MSP119 subunit proteins in multiplexed serologic assaysExternal
        Priest JW, Plucinski MM, Huber CS, Rogier E, Mao B, Gregory CJ, Candrinho B, Colborn J, Barnwell JW.
        Malar J. 2018 Nov 9;17(1):417.

        BACKGROUND: Multiplex bead assays (MBA) that measure IgG antibodies to the carboxy-terminal 19-kDa sub-unit of the merozoite surface protein 1 (MSP119) are currently used to determine malaria seroprevalence in human populations living in areas with both stable and unstable transmission. However, the species specificities of the IgG antibody responses to the malaria MSP119 antigens have not been extensively characterized using MBA. METHODS: Recombinant Plasmodium falciparum (3D7), Plasmodium malariae (China I), Plasmodium ovale (Nigeria I), and Plasmodium vivax (Belem) MSP119 proteins were covalently coupled to beads for MBA. Threshold cut-off values for the assays were estimated using sera from US citizens with no history of foreign travel and by receiver operator characteristic curve analysis using diagnostic samples. Banked sera from experimentally infected chimpanzees, sera from humans from low transmission regions of Haiti and Cambodia (N = 12), and elutions from blood spots from humans selected from a high transmission region of Mozambique (N = 20) were used to develop an antigen competition MBA for antibody cross-reactivity studies. A sub-set of samples was further characterized using antibody capture/elution MBA, IgG subclass determination, and antibody avidity measurement. RESULTS: Total IgG antibody responses in experimentally infected chimpanzees were species specific and could be completely suppressed by homologous competitor protein at a concentration of 10 mug/ml. Eleven of 12 samples from the low transmission regions and 12 of 20 samples from the high transmission area had antibody responses that were completely species specific. For 7 additional samples, the P. falciparum MSP119 responses were species specific, but various levels of incomplete heterologous competition were observed for the non-P. falciparum assays. A pan-malaria MSP119 cross-reactive antibody response was observed in elutions of blood spots from two 20-30 years old Mozambique donors. The antibody response from one of these two donors had low avidity and skewed almost entirely to the IgG3 subclass. CONCLUSIONS: Even when P. falciparum, P. malariae, P. ovale, and P. vivax are co-endemic in a high transmission setting, most antibody responses to MSP119 antigens are species-specific and are likely indicative of previous infection history. True pan-malaria cross-reactive responses were found to occur rarely.

    • Physical Activity
      1. Prevalence of children walking to school and related barriers – United States, 2017External
        Omura JD, Hyde ET, Watson KB, Sliwa SA, Fulton JE, Carlson SA.
        Prev Med. 2018 Oct 25;118:191-195.

        Children and adolescents can engage in an active lifestyle by walking to school; however, several barriers may limit this behavior. This study estimates the prevalence of walking to school and related barriers as reported by U.S. parents. Data from the 2017 SummerStyles, a Web-based survey conducted on a nationwide sample of U.S. adults, were analyzed in 2017. Parents of children aged 5-18years (n=1137) were asked whether their youngest child walked to or from school during a usual school week and what barriers make this difficult. Frequencies are presented overall and by parent characteristics. About 1 in 6 parents (16.5%) reported their youngest child walks to or from school at least once during a usual week. Prevalence differed by parental race/ethnicity, marital status, region, and distance from school. The most common barrier was living too far away (51.3%), followed by traffic-related danger (46.2%), weather (16.6%), “other” barrier (14.7%), crime (11.3%), and school policy (4.7%). The frequency at which parents reported certain barriers varied by their child’s walking status, distance to school, age of youngest child, race/ethnicity, education level, household income, and metropolitan statistical area status. However, the relative ranking of barriers did not differ by these characteristics. Prevalence of walking to school is low in the U.S., and living too far away and traffic-related danger are common barriers reported by parents. Implementing Safe Routes to School programs and other initiatives that utilize strategies to overcome locally-relevant barriers could help increase the prevalence of children walking to school.

      2. The Physical Activity Guidelines for AmericansExternal
        Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD.
        Jama. 2018 Nov 12.

        Importance: Approximately 80% of US adults and adolescents are insufficiently active. Physical activity fosters normal growth and development and can make people feel, function, and sleep better and reduce risk of many chronic diseases. Objective: To summarize key guidelines in the Physical Activity Guidelines for Americans, 2nd edition (PAG). Process and Evidence Synthesis: The 2018 Physical Activity Guidelines Advisory Committee conducted a systematic review of the science supporting physical activity and health. The committee addressed 38 questions and 104 subquestions and graded the evidence based on consistency and quality of the research. Evidence graded as strong or moderate was the basis of the key guidelines. The Department of Health and Human Services (HHS) based the PAG on the 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Recommendations: The PAG provides information and guidance on the types and amounts of physical activity to improve a variety of health outcomes for multiple population groups. Preschool-aged children (3 through 5 years) should be physically active throughout the day to enhance growth and development. Children and adolescents aged 6 through 17 years should do 60 minutes or more of moderate-to-vigorous physical activity daily. Adults should do at least 150 minutes to 300 minutes a week of moderate-intensity, or 75 minutes to 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. They should also do muscle-strengthening activities on 2 or more days a week. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week. Adults with chronic conditions or disabilities, who are able, should follow the key guidelines for adults and do both aerobic and muscle-strengthening activities. Recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Additional benefits occur with more physical activity. Both aerobic and muscle-strengthening physical activity are beneficial. Conclusions and Relevance: The Physical Activity Guidelines for Americans, 2nd edition, provides information and guidance on the types and amounts of physical activity that provide substantial health benefits. Health professionals and policy makers should facilitate awareness of the guidelines and promote the health benefits of physical activity and support efforts to implement programs, practices, and policies to facilitate increased physical activity and to improve the health of the US population.

    • Substance Use and Abuse
      1. Notes from the field: Use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011-2018External
        Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA.
        MMWR Morb Mortal Wkly Rep. 2018 Nov 16;67(45):1276-1277.

        [No abstract]

    • Zoonotic and Vectorborne Diseases
      1. [No abstract]

      2. Rabies vaccine initiation and adherence among animal-bite patients in Haiti, 2015External
        Tran CH, Kligerman M, Andrecy LL, Etheart MD, Adrien P, Blanton JD, Millien M, Wallace RM.
        PLoS Negl Trop Dis. 2018 Nov 13;12(11):e0006955.

        BACKGROUND: Approximately 59,000 people die from rabies worldwide annually. Haiti is one of the last remaining countries in the Western Hemisphere with endemic canine rabies. Canine-mediated rabies deaths are preventable with post-exposure prophylaxis (PEP): wound treatment, immunoglobulin, and vaccination. In countries where PEP is available, variability in healthcare seeking behaviors and lack of adherence to recommended treatment guidelines could also contribute to these deaths. Yet, few studies have addressed these issues. METHODS: We examined animal-bite reporting and assessed adherence to treatment guidelines at nine healthcare facilities in Haiti. We analyzed individual-level, de-identified patient data (demographic characteristics, geographic location, healthcare facility type, vaccine administration, and bite injury information) using descriptive analyses and logistic regression to examine factors associated with receiving PEP. FINDINGS: During the 6 month study period, we found 2.5 times more animal-bite case-patients than reported by the national surveillance system (690 versus 274). Of the 690 animal-bite patients identified, 498 (72%) sought care at six PEP providing facilities. Of the case-patients that sought care, 110 (22%) received at least one rabies vaccine. Of the 110 patients, 60 (55%) received all five doses. Delays were observed for three events: when patients presented to a facility after an animal-bite (3.0 days, range: 0-34 days), when patients received their fourth dose (16.1 days, range: 13-52 days), and when patients received their fifth dose (29 days, range: 26-52). When comparing vaccination status and patient characteristics, we found a significant association for bite location (p < .001), severity rank score (p < .001), geographic location (p < .001), and healthcare facility type (p = .002) with vaccination. CONCLUSION: High levels of underreporting identified here are of concern since vaccine distribution may, in part, be based on the number of animal-bite cases reported. Given that the Haitian government provides PEP to the population for free and we found animal-bite victims are seeking care in a timely manner horizontal line reducing rabies deaths is an achievable goal.

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CDC Science Clips Production Staff

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  • 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